Give us this day…

MANDATORY fortification of bread with folic acid would reduce the number of children born with spina bifida – but is mass medication safe or ethical, asks Dani Garavelli

MELANIE Chambers had endured a 15-hour labour and an emergency caesarian and was just celebrating the successful delivery of a baby girl when the consultant came in bearing bad news. Her beautiful new daughter Ella had spina bifida and hydrocephalus (excess fluid on the brain). She was paralysed from the waist down, and would need shunts fitted to her head before she could lift it.

Today, Ella is a bright, chatty five-year-old, the centre of attention at her mainstream primary school, but there are still days when her mother wishes she had the chance to go to ballet lessons like her friends. And if she had her time again, she would certainly take the folic acid supplements that might have prevented Ella's condition in the run-up to her conception.

Hide Ad
Hide Ad

"My husband Cy and I had been married five years and we'd been thinking about having a baby and more or less decided, if it happens, it happens," says Melanie, 38.

"Well, it did happen. I found out at around four weeks and I did start taking a supplement for pregnant women which included folic acid. But by then, I guess it was too late. We were told the news about 20 minutes after Ella was born – and it was devastating."

Spina bifida is a birth defect caused by the failure of the neural tube to close during the first month of embryonic development. It affects 700-900 pregnancies in the UK every year (40-50 in Scotland). Doctors believe taking 400 micrograms a day of folic acid – a synthetic alternative to the folates found in leafy vegetables and fruit – can reduce the number of spina bifida pregnancies by up to 75 per cent.

But, like Melanie, who works for the Royal College of Physicians and Surgeons, many women are not aware that, because the body can't store folates, they need to start taking the supplements as much as 12 weeks before they conceive. And, since 50 per cent of pregnancies in this country are unplanned, it wouldn't necessarily solve the problem if they were.

In the late 1990s, the US, Canada and Chile introduced the mandatory fortification of flour with folic acid, resulting in a drop of around 50 per cent in spina bifida pregnancies. And last week, the Food Standards Agency said the Scientific Advisory Committee on Nutrition (SACN) had examined new reports on alleged links between folic acid and bowel cancer and found nothing to persuade it that the UK should not follow suit. It put its recommendation to Liam Donaldson, chief medical officer for England and Wales, and his Scottish counterpart Harry Burns, who are now considering their own stance.

If the UK does introduce mandatory fortification, it will become the first country in Europe to take that step. The logic of the move is obvious: 30 million people in the UK do not consume enough folates, which help prevent cardiovascular disease and cancer, and most of us eat at least two slices of bread a day.

British consumers are accustomed to added vitamins in their breakfast cereals, milk and energy drinks and Omega 3 in a wide range of food products. And yet – as the first example of compulsory mass medication since the fluoridation programmes in the 1960s – mandatory fortification of bread (or flour) is proving extremely controversial, with some scientists claiming excessive consumption of folic acid could be as damaging as inadequate consumption, and health choice campaigners objecting to the principle of being forced to consume an additive aimed at helping a relatively small proportion of the population.

So is this a sensible way to cut down the number of spina bifida pregnancies and ensure we all consume enough folic acid? Or a potential threat to our well-being and a step too far in the medicalisation of our diet?

Hide Ad
Hide Ad

Forty years ago, people ate chiefly to sustain themselves. If they were worried about their children not getting enough vitamins they force fed them malt extract and cod liver oil. As the "You are what you eat" maxim has taken hold, however, there has been far more focus on making sure our diets contain exactly the right balance of nutrients.

With that has come a trend for health-enhancing products such as pro-biotic yoghurts (the friendly bacteria) and cholesterol-busting spreads. In some cases vitamins are added simply because they have been stripped out during processing: vitamin D in low fat milk, for example, or B complex vitamins in cereals. But as manufacturers struggle to compete in a crowded marketplace, many try to make their products stand out by giving them extra health benefits: calcium in orange juice for children who don't drink milk, for example, or energy drinks with group B vitamins.

For a while, Omega 3 was so popular with parents who believed it would improve their children's behaviour and concentration it was being added to hundreds more food items – from yoghurt to tinned spaghetti – every month (even though the amount of Omega 3 in most of them was just a fraction of that contained in one portion of salmon).

But when it comes to staples such as food and water – and to making consumption compulsory rather than voluntary – consumers tend to be a bit more squeamish about what's added.

Controversy has raged over the fluoridation of water since the first programmes were introduced in the West Midlands and parts of the North-East of England in the Sixties. Although there is no doubt the move reduces tooth decay, there are arguments over possible side-effects – it can cause fluorosis, an unsightly spotting on the teeth – and of the ethics of mass medicating for a problem that could be overcome through proper dental care.

Likewise, there is a degree of resistance to mandatory fortification of bread, particularly among consumer organisations such as Consumer Focus Scotland. Yesterday, its senior policy advocate Liz Macdonald said one of the organisation's predecessor bodies – the Scottish Consumer Council – had come out against the move in 2000 because it believed there was not enough evidence to suggest the benefits outweighed the risks, and there was nothing in the latest report to suggest that situation had changed.

"We would oppose it firstly because it is mass medication and deprives the consumer of choice," she said. "But there is also the issue of dosage. If it's being put into flour, but is also in some breakfast cereals and then a proportion of people are taking supplements over and above that, you have to ensure they don't start ingesting too much and then it's a question of information and labelling and it can get very difficult for the consumer to know if they are taking safe levels. Finally, SACN has conceded that there are still uncertainties about the links between folic acid and cancer risk. It suggests that concerns about these links would be allayed by monitoring the situation. This is a worrying stance and not one which we could endorse."

Andrew Wynd, chief executive of the Scottish Spina Bifida Association, acknowledges these concerns, but believes many of them have been addressed within the recommendation.

Hide Ad
Hide Ad

"We could have gone hell for leather calling for a high dose, but we took a more reasoned approach in our lobbying," he says. "We realise there is an issue of consumer choice, so we suggested it should only be added to white bread, so those who don't want it can opt for wholemeal – a proposal that appears to have been taken on board.

"And the FSA have made clear that mandatory fortification should be accompanied by controls over voluntary fortification and advice on supplements to prevent people consuming too much. As for the potential risks to health, it's ten years since it was introduced in the US and Canada and no-one seems to have taken action yet, which is always a good sign."

But at the Institute of Food Research, experts are not so confident. Research scientist Dr Sian Astley says she recognised folic acid plays a part in reducing – although not eliminating – the number of children born with neural tube defects – but stressed folic acid was not as effectively processed by the body as folates.

"Folic acid is metabolised in the liver rather than the stomach and the liver is very easily saturated, which means there might be excess floating around in the bloodstream," says Astley. "We are very much aware that – like many other things – folic acid has a U-shaped risk curve: too little can be dangerous, but then so can too much."

She says studies have shown too much folic acid may place those with a family history of bowel cancer, or an existing tumour at higher risk. Excess folic acid is thought to speed up cognitive decline in old people with poor vitamin B status and mask the existence of pernicious anaemia. In addition, it is said to increase the chances of a multiple birth in women who are undergoing IVF treatment.

Whatever the potential health risks, one thing is beyond doubt: mandatory fortification does reduce the incidence of neural tube defect pregnancies – by up to 50 per cent in the US, Canada and Chile. So clear are the benefits to pregnant women, Wynd would like the Government in Scotland to press ahead as soon as possible.

Back at her home in Glasgow Melanie Chambers says she's not an expert on the issue, but anything that will prevent other children suffering from the same condition that affects Ella is worth looking at.

"Ella is a fabulous girl who brightens up the day of everyone she meets. So much so that when she arrives at school there is a queue of children waiting to push her in.

Hide Ad
Hide Ad

"But when I was first told the news, well, there was no time to prepare for it and I admit I found it difficult to bond at first. In fact, if it hadn't been for my husband Cy, and his amazingly positive attitude, I don't know if I'd still be here. There have been hard times – particularly in the first year when she needed the operations. It's hard to lift her up and down stairs, and though most people are great, there are some who stare. And of course it would be better for her if she could run around."

Some people may see the move to put folic acid in bread as just one more step towards what Bad Science writer Ben Goldacre calls the "medicalisation of everyday life". But for Melanie and families like hers that must seem a small price to pay for a better chance of a healthy child.