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Get involved: It's here the UK Government’s Consultation on Mandatory Fortification of Flour with Folic Acid

Briefing: UK Government’s 2019 Consultation on Mandatory Fortification of Flour with Folic Acid:

bowl of flour and wheat

What’s this all about?

The issue here is whether the UK Government should enact legislation, covering all four nations, making it a legal requirement that folic acid (Vitamin B9) to be added to most flour produced in the UK.

The UK Government has now launched a public consultation on this topic. Views in favour or against this legislation (or offering advice/evidence) must be submitted before noon on Monday 9 September 2019.

Both Spina Bifida Hydrocephalus Scotland (SBH Scotland) and the Queen’s Nursing Institute Scotland (QNIS) are in favour of mandatory Vitamin B9 fortification of flour. So, too, are the:

  • Scientific Advisory Committee on Nutrition of the Food Standards Agency;
  • Food Standards Scotland;
  • UK’s Chief Medical Officers;
  • Scottish and Welsh Governments;
  • Relevant Royal Colleges & professional associations; as well as,
  • Leading public health & maternal and child health experts across the UK.

There is no equivalent, organised opposition to mandatory folic acid (Vitamin B9) fortification. It is not a party-political issue. However, it is still uncertain whether such legislation will actually be enacted and implemented by this Parliament. There is concern that folic acid (Vitamin B9) legislation will be ‘kicked into the long grass’, given Westminster’s preoccupation with Brexit and other higher priority matters.

The best way to overcome inaction on this legislation at Westminster is to create a groundswell of support for fortification. Most individuals and organisations will not choose to spend the time and energy needed to submit a full consultation response here. However, the choice is not between a full response and none at all. It would be sufficient – and very helpful – for you to submit a message expressing support. More information about how to do so can be found at the end of this Briefing.

What are the essential points?

About Neural Tube Defects (NTDs):

  • When all goes well, neural tubes are what eventually develop into a person’s spine and brain. They are fully formed (or malformed) by the fifth week of pregnancy. This is before most women are even aware that they are pregnant.
  • If the neural tube of any fetus does not close properly by the 28th day of pregnancy, then it is classified as a neural tube defect (NTD). It cannot be closed or corrected later.
  • Sometimes, this NTD is detected by the woman’s own body and the fetus is rejected. That is why NTDs are a leading cause of both miscarriages and stillbirths. While the data are imprecise, it is estimated that more NTDs result in pregnancy loss than in live births. There are at least 1,000 NTD-affected pregnancies in the UK each year.
  • If the pregnancy continues until a live birth (approximately 1 in 1,000 births), then the NTD causes a spectrum of life-long conditions, including (but not limited to) spina bifida, hydrocephalus and anencephaly (a fatal condition in which part of the brain is missing).
  • All pregnant women are offered free screening for NTDs on the NHS. This non-invasive screening is optional. The point is to offer an informed choice about whether to continue the pregnancy or decide to have it terminated. Many (but not all) women choose to have the pregnancy terminated if a neural tube defect is discovered.

About Folic Acid (Vitamin B9):

  • More than thirty years of extensive, internationally validated research has proven that Vitamin B9 can prevent more than half of all neural tube defects, as well as having other health benefits. The cornerstone study on the preventive power of folic acid was led by Professor Sir Nicholas Wald and the results have been widely known since 1991.
  • Vitamin B9 is necessary for the healthy development of cells and DNA/RNA. It is available naturally by eating certain green vegetables, e.g. spinach and broccoli. A synthetic version – that is, folic acid -- also provides the Vitamin B9 every body needs.
  • People with a healthy, folate-filled diet can acquire the level of Vitamin B9 normally needed by most people. However, the reality is that only a small proportion of people in Scotland have such a diet (even with the tiny amount voluntarily added to cereals and other products), so folate levels tend to be very low among women of childbearing age. Across the UK, 91% of women of childbearing age have blood folate levels below the thresholds indicating elevated risks of pregnancies affected by neural tube defects.
  • The level of Vitamin B9 required to prevent NTDs cannot be attained by eating green vegetables. Effective prevention depends upon additional Vitamin B9 from folic acid before and during the first trimester of pregnancy. At the other end of the spectrum, there is no plausible upper limit, after which too much folic acid could become harmful.

About voluntary supplementation:

  • Voluntary supplementation with folic acid – i.e. taking folic acid tablets every day on an optional, individual basis – has been strongly advocated and tried throughout the UK for more than a decade. This voluntary strategy has failed to significantly reduce the occurrence of neural tube defects.
  • Worse, the voluntary supplementation schemes increased health inequalities. That’s because the women most likely to take adequate amounts of folic acid regularly, and far enough in advance of becoming pregnant, tended to be in the upper half of the socioeconomic spectrum. So, those in the lower half also are likely to have the lowest Vitamin B9 levels when becoming pregnant.
  • Timing is crucial to benefit from the preventative effect of Vitamin B9. It takes many weeks for anyone to build up the amount of Vitamin B9 that will greatly lower the risk of NTDs. So, folic acid must be taken regularly at least three months before conceiving and continued daily at least through the first month of pregnancy. Waiting to take folic acid supplements until pregnancy has been confirmed is simply too late to prevent NTDs; a health version of ‘closing the stable door after the horse has bolted’.
  • Another major pitfall for voluntary supplementation is that nearly half of all pregnancies across the UK are unintended/unplanned. Reaching health goals – such as increasing Vitamin B9 levels – during the preconception period is almost impossible when it is unknown when (or if) a pregnancy will begin.

About mandatory fortification:

  • Adding folic acid to most UK manufactured flour is the most inexpensive, effective, efficient and egalitarian way to achieve the Vitamin B9 level needed for NTD prevention to have a chance.
  • Years of continuing scientific research and evaluations of the lived experience in over 80 countries already fortifying flour (for decades in some nations) have demonstrated there are no significant ill-effects or negative consequences of folic acid fortification.
  • For more than half a century, most flour produced in the UK has already been – and still is -- fortified with four other healthy ingredients: calcium, iron, niacin and thiamine. In fact, two of these helpful ingredients are also B vitamins; thiamine is Vitamin B1, while niacin (nicotinic acid) is Vitamin B3 – just as folic acid is Vitamin B9. Each performs a different, non-duplicative function in improving nutrition and preventing deficiencies. The addition of folic acid merely replaces the natural folate extracted during the milling process.
  • There are detailed issues remaining to be resolved when enacting and enforcing legislation requiring folic acid fortification. For instance, determining how much folic acid to add to have the desired preventative effect - or deciding which flours (or other foods) will be included/excluded - are now under consideration. The current consultation is meant to gather views and evidence addressing such specialised matters.

The most fundamental goal of this UK Government consultation is to solicit views about whether to implement folic acid fortification at all. That is where most individuals and organisations reading this Briefing will fit into the picture.

To make your and/or your organisation’s views known, please write a letter or email expressing them. While you are welcome to use any of the information contained in this Briefing (including other sources listed at the end), please remember that it should be in your own words, rather than copied. Individual, bespoke messages are usually taken seriously. However, ‘cut and paste’ ones tend to be dismissed.

If you do not want to contact the key people directly, then you are welcome to send your message to Andrew H D Wynd MBE, MIoD, Chief Executive, SBH Scotland or to Dr Jonathan Sher, Deputy Director, QNIS

They will send it on your behalf, along with others received, to the following relevant officials:

***********

At Westminster

Matt Hancock MP, Secretary of State for Health and Social Care

Chris Skidmore MP, Minister of State for Health

Jo Churchill MP, Permanent Under Secretary of State for Health and Social Care

Baroness Blackwood, Permanent Under Secretary of State for Public Health (Lords)

Members of the All Party Parliamentary Group (APPG) on Folic Acid Fortification, Westminster

Owen Smith, Chair; Nigel Dodds, Co-Chair; Lord Rooker, Lord Baffe, Vice Chair; and, Lord Rooker, Vice Chair (former head, UK Food Standards Agency), plus Kate Steele (APPG Secretariat and Chief Executive, Shine charity)

Health Spokespeople in the House of Commons for other parties

SNP: Dr Philippa Whitford, MP; Labour: Jonathan Ashworth MP; Lib Dems: Judith Jolly MP and Jo Swinson MP (Leader); DUP: Jim Shannon MP; Greens: Caroline Lucas MP; Independent: Dr Sarah Wollaston (Chair, House of Commons Health Committee)

In Scotland:

Minister for Public Health – Joe FitzPatrick, MSP

Chief Medical Officer – Dr Catherine Calderwood

Other reference sources:

Spina Bifida Hydrocephalus Scotland Fortification Campaign

Tommys: https://www.tommys.org/pregnancy-information/im-pregnant/pregnancy-news-and-blogs/consulatation-begins-folic-acid-being-added-flour-uk

RCOG: https://www.rcog.org.uk/en/news/rcog-response-to-government-consultation-on-fortifying-flour-with-folic-acid/

BMA

British Dietetic Association: https://www.bda.uk.com/dt/articles/folic_acid_fortification_uk

Faculty of Public Health: https://www.fph.org.uk/media/1384/position-statement-folic-acid.pdf

SACN (for Food Standards Scotland): https://www.gov.uk/government/publications/folic-acid-updated-sacn-recommendations

Shine: https://www.shinecharity.org.uk/spina-bifida/the-fortification-campaign

Articles by Dr Linda de Caestecker and Dr Jonathan Sher: https://www.holyrood.com/articles/comment/folic-acid-bread-barn-gates-and-neural-tubes

https://www.thenational.scot/news/16066494.heres-how-scotland-can-lead-the-uk-in-preventing-birth-defects/

and with Prof John Frank and Dr Larry Doi: https://academic.oup.com/jpubhealth/article/41/2/e209/5076112

New stats reveal 91% of UK women have insufficient folate levels to support a reduction in neural tube defects

A study carried out on behalf of Public Health England and the Food Standards Agency which has been published today (16 March 2018), has revealed as many as 91% of women of childbearing age (16 – 49) in the UK are at increased risk of a neural tube defect (NTD) affected pregnancy due to a folic acid deficiency.

image of flour and wheatFolic acid has been found to be essential in the reduction of NTDs such as spina bifida in unborn babies. The report, which assessed the diet, nutrient intake and nutritional status of the general population, supports this by stating that increased folic acid intake through supplementation has been shown to reduce the risk of pregnancies affected by NTDs, if taken before birth.

Spina Bifida Hydrocephalus Scotland (SBH Scotland) has long advocated for the fortification of flour with folic acid to help reduce the number of NTDs. The charity welcomes the findings and calls on the UK Government to take steps to introduce legislation which makes fortification of flour with folic acid mandatory.

Chief Executive of Spina Bifida Hydrocephalus Scotland Andy Wynd MBE said; “With this report finding there’s a further increase (91%) in the number of women in the UK not receiving the adequate levels of folic acid, it again supports our ongoing calls for the mandatory fortification of flour.

“Foods such as lentils and dark green vegetables produce naturally high levels of folate, and it is already added to some foods, including breakfast cereals. However, it is through the fortification of flour where the real benefits are seen, with other countries recording up to 70% reduction in NTD pregnancies following the mandatory fortification process.

“We believe flour fortification would produce similar results in the UK and with overwhelming evidence to support it, we, once again, ask the UK Government to make fortification of flour a reality.”

Scotland specific issues

Scotland has more live births per head of population with spina bifida than anywhere else in the UK. Possibly due to religious and cultural differences, only 45% of pregnancies are terminated in Scotland as compared with around 80% in the rest of the UK.

Taking daily folic acid supplements, at the correct recommended dose* (0.4mg) three months prior to conception, could reduce up to 70% of these pregnancies from being affected and lower both the number of those born with the condition and the number of pregnancies terminated.

Children born with spina bifida often have paralysis in the lower limbs, urological, neurological and orthopedic problems which often become more significant throughout life. Fortification of flour would reduce the number of babies born with this lifelong disability. Find out more about folic acid and flour fortification on the Spina Bifida Hydrocephalus Scotland website www.sbhscotland.org.uk/folic-acid

*Some females have an increased risk of a pregnancy being affected by an NTD and should be taking a higher dosage of folic Acid

Find out more about our flour fortification campaign

Summary of results from National Diet and Nutrition Survey Rolling Programme.

Those affected by any of the issues associated with spina bifida or hydrocephalus, can call the SBH Scotland Family Support Service helpline on 03455 211 300 or email them.

UK Government urged to add folic acid to flour after new study

A study published in Public Health Reviews has revealed previous data showing the set upper limit of folate was flawed. The experts involved are now urging the Department of Health to approve the fortification of flour with folic acid in order to help reduce neural tube defects (NTD), such as spina bifida, in unborn babies.

This follows the Scottish and Welsh Governments recently writing joint letters to the UK Health Secretary urging him to make the fortification of flour with folic acid mandatory on a UK wide basis.

Make time for folic acid image

Recent figures show folate levels in Scotland are particularly low compared to international standards. In Scotland, 81% of women of childbearing age are more at risk of an NTD affected pregnancy because they don’t have enough folic acid – which is 6% higher than the UK as a whole.

Chief Executive of Spina Bifida Hydrocephalus Scotland Andy Wynd MBE said; “We welcome this new evidence published in the Public Health Reviews which shows there is no medical reason to stop folic acid being added to flour. As a charity we have long advocated for mandatory flour fortification in order to reduce the number of children born with neural tube defects such as spina bifida. In light of this new evidence, we believe the UK Government should be actively taking steps to introduce legislation to ensure that mandatory fortification of flour becomes a reality in the UK.”

“In Scotland, the issue of flour fortification is particularly relevant as more children are born with spina bifida than anywhere else in the UK. Flour fortification in other countries has resulted in up to 70% reductions in pregnancies according to recent studies and we believe this would produce similar results in Scotland.”

Scotland specific issues

Scotland has more live births per head of population with spina bifida than anywhere else in the UK. Possibly due to religious and cultural differences, only 45% of pregnancies are terminated in Scotland as compared with 80% in the rest of the UK.

Taking daily folic acid supplements, at the correct recommended dose (0.4mg) three months prior to conception, could reduce up to 70% of these pregnancies from being affected and lower both the number of those born with the condition and the number of pregnancies terminated.

Children born with spina bifida often have paralysis in the lower limbs, urological, neurological and orthopedic problems which often become more significant throughout life. Fortification of flour would reduce the number of babies born with this lifelong disability. Find out more about folic acid and flour fortification on the Spina Bifida Hydrocephalus Scotland website www.sbhscotland.org.uk/folic-acid

Parents in Scotland are offered impartial and non-judgmental advice by SBH Scotland to enable them to make informed decisions about their pregnancy. Whatever their final decision, SBH Scotland will always be there for support and advice whenever needed. Those affected by any of the issues associated with spina bifida or hydrocephalus, can call the SBH Scotland Family Support Service helpline on 03455 211 300, email: support@sbhscotland.org.uk or visit www.sbhscotland.org.uk

Could you be the new Folic Acid Man?

Spina Bifida Hydrocephalus Scotland are looking for the next Folic Acid Man to be the face of our national health awareness campaign. Do you have what it takes

Model Aron supports launch of Folic Acid Man Competition

Held in association with The All Talent Agency, we're looking for physically fit men (18 and over) across Scotland who would like to be the model leading our important campaign forward for the next 12 months. So if you fancy a future in modelling or you'd like the opportunity to work in tv and film then apply today.

Get your families and friends involved! Once we've chosen the semi-finalists we'll be asking everyone to go online and 'like' their favourites to help us chose the finalists.

The competition

The lucky winner of this competition will be the face of the new 'Are you getting enough?' campaign but they'll also win:

  • A modelling contract with All Talent Agency
  • A photo shoot with award winning photographer Alan Peebles
  • Being the face of SBH Scotland's important folic acid campaign
  • £100 Slater Menswear Vouchers
  • 1 month Glasgow Nuffield Health Gym membership plus 2 personal training sessions
  • Hair cut and style at the Rainbow Rooms International

To Apply

Fill in our Application form attaching a current photo of you (without sunglasses or hats).

Deadline for entries is Wednesday 11th May at 5pm.

The winner will be announced live at the SBH Scotland Ladies Lunch on Sunday 5th June 2016 in Glasgow.

Are Scotland taking the next step?

Folic acid in flour - Ministers ask for advice on next steps.

Public Health Minister Maureen Watt has written to Food Standards Scotland for advice on how Scotland could fortify flour with folic acid.

The advice will be used to help ministers decide how to pursue the policy on a Scotland only basis. The Scottish Government’s preference is for a UK wide solution, but the UK Government has so far failed to commit to the measure despite repeated requests.

The Welsh and Northern Irish governments have also publically backed the fortification of flour.

The Scottish Government believes mandatory fortification of flour with folic acid is the best way to reduce neural tube defects like spina bifida in unborn babies. Folate levels are low across the UK by international standards – particularly so in Scotland.

Ms Watt wrote again to UK Public Health Minister Jane Ellison on November 11 last year to ask the UK Government to consider mandatory fortification. However, she again failed to commit to the step.

Ms Watt said:

“Our consistent position is that UK-wide mandatory fortification of flour is the best way to reduce neural tube defects. However, despite repeated requests it’s clear that the UK Government has no intention of doing so at this time.

“I have therefore asked Food Standards Scotland to provide some detailed advice on how we could do this on a Scotland-only basis. This advice will then be used to allow us to make a decision on what our next steps should be.

“There are far too many babies being born with Spina Bifida in Scotland – particularly in our more deprived communities. Folic acid is tasteless, entirely safe within recommended intake levels and is already included in many foods like breakfast cereals.

“There are 78 countries around the world that already have mandatory fortification of flour. The USA has done it for the past eight years, with no adverse effects on health. By joining them we can help to save many families from the heartbreak of being told their baby has Spina Bifida.”

Ross Finnie, Chair of Food Standards Scotland said:

“As Scotland’s independent public food body, we will be happy to provide the Scottish Government with the advice that has been requested. Such advice will fit well with our statutory duty to improve the diet of the Scottish population. The advice we provide will enable the Scottish Government to determine the best way forward to reduce neural tube defects. In doing so, we will draw on the previous body of advice provided by the Food Standards Agency as well as taking account of any new evidence and advice from the Scientific Advisory Committee on Nutrition.”

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