Folic acid failure is scandal in the making

Actions have consequences, but so too does a failure to act. When it comes to Ireland’s failure to ensure that women of childbearing age take enough folic acid, those consequences can include the death or disablement of their babies.

Our laissez-faire approach to folic acid supply has all the makings of a health scandal of considerable proportions. A slew of recent research points to the need for urgent action. These studies show: The incidence of severe birth defects, known as neural tube defects, is on the rise;

Fewer and fewer food products are being fortified by manufacturers with folic acid, a simple vitamin that helps prevent most of these defects; Only a small minority of women are taking folic acid supplements prior to becoming pregnant;

As few as one-quarter of women (in one study by the Coombe Women’s Hospital) are taking supplements while pregnant.

What this means is that women are not getting enough folic acid passively – through the food they eat – or actively – by taking supplements – before they become pregnant. Since up to half of pregnancies are unplanned, that means many women lack the protection afforded by folic acid intake.

While many do take supplements once they are pregnant, not enough are doing so. In any case, by then it may be too late, as the baby’s neural tube develops in the first month after conception.

Neural tube defects are severe congenital disorders that inevitably have a profound impact on both mother and baby. The most common is spina bifida (which means “split spine”) and involves major physical and/or neurological complications. Another is anencephaly, where a major part of the brain is absent. It stands to reason that our society should be doing everything to reduce the incidence of such awful defects.

It is hard then to understand why so little is being done to ensure that women get the folic acid they need to provide protection against neural tube defects. About 50 countries in the world operate a policy of mandatory fortification of foodstuff as a way of increasing the intake of folic acid.

Usually, one common food item is chosen for fortification – say, bread or flour – and the level of fortification is set at a percentage of the recommended daily intake needed by women.

Ireland follows a policy of voluntary fortification, effectively leaving it to food manufacturers to decide whether to add folic acid to their products.

During the boom years, this worked well enough. People became more health conscious and they had more money, so they could afford more upmarket food choices. Foodmakers used the addition of folic acid as a marketing device to consumers, and were able to charge more for the health premium offered.

And as the number of products containing folic acid increased, and those products contained higher levels of the vitamin, so the incidence of neural tube defects dropped. More folic acid meant fewer babies with severe birth defects.

This model fell apart when the recession came along. Manufacturers’ margins shrank, leading them to save costs by eliminating folic acid from their products. Consumers had less money, and started shopping in discount stores where fewer products were fortified in the first place. Folic acid-specific labelling disappeared.

Almost immediately, the incidence of neural tube defects started rising again from 2009 and has continued to increase.

It has taken a few years for this trend to show up in research but, even so, the official response has been slow. Ireland now has a choice; either introduce mandatory fortification or focus awareness campaigns on women of childbearing age to ensure they take enough folic acid.

‘Hit and miss’ affair

Dr Mary Flynn, chief specialist in public health nutrition at the

Food Safety Authority of Ireland

(FSAI), admits voluntary fortification is a “hit and miss” affair but says the only way to make it mandatory is through the EU.

She says the authority was about to recommend mandatory fortification a number of years ago but put this “on hold” when research showed that non-target groups – the very young and very old – were getting too much folic acid in their diet, and after a small number of studies suggested this could have negative health consequences.

So while the benefits from folic acid far exceed any negatives, “you have to be very careful”, says Flynn.

“We had to make sure we had the evidence.”

The authority would like to see the introduction of mandatory fortification, she says, but this is probably for the long term. “In the short term, there should be an awareness programme advising women to take supplements.

“We could even be providing folic acid on the medical card.”

Safefood, the all-Ireland food promotion body, says it is planning a “digital media awareness campaign” in the coming months on the issue. It has also commissioned research to examine folate levels in women, but this will take at least a year to complete.

As Flynn points out, fortified foods are more expensive, and supplements are dearer still. That means women from deprived areas are least likely to be taking enough folic acid and, therefore, are most at risk.

Lidl was singled out in one of the recent pieces of research for selling virtually no fortified foods – two, compared with more than 100 in larger supermarket chains.

Contacted by The Irish Times, the company said it worked closely with the FSAI to ensure all legislation and guidelines were adhered to. "Previously, it was decided by the authority not to introduce mandatory folic acid fortification. Lidl will continue to liaise with the FSAI on matters of this kind."

There is another reason, specific to Ireland, why this issue is so important. Historically, because of our laws on termination, the percentage of pregnancies involving a neural tube defect that results in a live birth is far higher here than in other European countries.

If we are serious about public health, it should be a priority to reduce this appalling burden of suffering, one which is so easily and cheaply prevented.