Model essay answer.

Critically evaluate the statement: “fortification of flour is overdue in the UK”.

Background.

A decision on fortification of flour by the government is expected.

So, if this essay is ever to appear, it will be soon.

Although, I suppose, you could get an essay asking for justification of the policy.

It would be a killer if it did come up, so at least read the following so that you have some facts in your head.

And some understanding of the arguments for and against fortification.

Lucy Wills showed that a yeast extract (Marmite) could correct megaloblastic anaemia of pregnancy in the 1930s.

The active ingredient was extracted from spinach in 1941 and named folate.

In the 1960s & 70s Hibbard and Smithells looked at women from poor socio-economic groups.

And linked their low folate levels to a variety of pregnancy problems such as abruption and neural tube defect, (NTD).

I remember hearing Hibbard talking on the subject, particularly in relation to abruption.

The response among the senior doctors present was unenthusiastic.

Smithells treated women who had had a baby with NTD with multivitamins including folic acid and showed a reduced risk of recurrence from 5% to 0.6%.

The Medical Research Council (MRC) published a trial in 1991 using 4mg. prophylaxis in women who had had an affected baby.

The incidence reduced by 72% and was due to folic acid, not other vitamins.

The next year Czeizel reported a study from Hungary using 800 micrograms prophylaxis in low-risk women.

The control group of about 2,000 had the expected 6 cases of NTD, the treated group none.

Other research has shown a reduced incidence of other abnormalities such as facial clefts and cardiovascular anomalies.

Bukowski et al published a sensational paper in 2009, showing that pre-conception folic acid for at least a year reduced the incidence of premature labour by up to 70%.

PLoS Med. 2009 May 5;6(5):e1000061

If other studies validate this, it will make the case for fortification of flour even stronger.

Surén et al from the Mother and Child Cohort Study published a paper that suggested a link to reduced risk of autism. JAMA. 2013;309(6):570-577

Answer.

It is now accepted that peri-conceptual folic acid supplementation decreases the risk of neural tube defect in the baby.

It may reduce the risk of other anomalies, such as facial clefts and cardiovascular abnormalities and of premature labour.

A paper from the Norwegian Mother and Child Cohort Study suggested a reduced risk of autism.

The Medical Research Council (MRC) published a trial in 1991 using 4mg. prophylaxis in women who had had an affected baby.

The incidence reduced by 72% and was due to folic acid, not other vitamins.

Other studies have supported this finding.

The Dublin group showed an inverse relationship between maternal blood folate levels and the risk of NTD.

They proposed a level of 400 micrograms per litre as optimal.

They demonstrated that this could not be achieved by increasing intake of natural folate in food.

They argued that only supplementation with folic acid or fortification of a food staple could work.

Most industrial countries introduced health education programmes to encourage women to take periconceptual folic acid (PFA) in the early 1990s.

In the UK the dose was 400 micrograms for low-risk women.

And 5 mg. (the only available preparation close to the 4mg. dose of the MRC trial) for high-risk women, such as:

    those with a NTD,

    those with a baby with NTD,

    and those who have diabetes or take anti-epileptic medicines.

No country saw a fall in the incidence of NTD.

Clearly, health education programmes do not deal with the issue.

There are various reasons.

In the UK most pregnancies are unplanned.

The neural tube closes early, by day 28.

Few women will have seen a midwife by this time and been advised to take folic acid.

Also, those who take PFA tend to be from high socio-economic groups with a low incidence of NTD.

Mandatory fortification of flour with folic acid (FFFA) was introduced in the USA in 1998.

NTD incidence fell by more than 20% with no perceptible adverse outcomes.

The rates of stroke and coronary artery events also fell, probably due to a beneficial effect on homocysteine levels.

Canadian experience was similar with a remarkable 78% reduction in NTD in Newfoundland, a high-incidence area.

Other countries, such as Brazil, have introduced FFFA with similar results.

FFFA has been resisted by the Department of Health in the UK.

There is concern that it may mask B₁₂ deficiency and cause sub-acute combined degeneration of the cord.

Some people already have high intakes of folic acid from supplemented breakfast cereals and food spreads.

FFFA might take them over recommended daily maximum intakes.

There have been concerns that the incidence of twins might increase and that the reduction of NTDs is due to terathanasia – these have been disproved.

There is also the libertarian argument about choice, as with fluoridation of water.

The RCOG has argued in favour of FFFA since 1997.

The DOH’s Scientific Advisory Committee on Nutrition (SACN) researched the subject.

It reported in favour to the Food Standards Agency (FSA) in 2006.

It recommended a dosage of 300 micrograms / 100 gm.

It looked at a large list of possible adverse effects:

        that it might increase the risk of cancer,

        act against phenytoin,

        cause depression etc.,

        but found no evidence of significant risk.

The FSA came out in favour in 2007 and advised the DOH accordingly.

The decision by the Minister and the DOH is awaited.

If introduced, fortification of cereals and spreads will cease.

And people will be advised not to take additional folic acid in vitamin supplements.

Women will still be encouraged to take PFA in the same way as now.

Bukowski et al published a paper in 2009 showing a reduction in the risk of premature labour of up to 70% when folic acid was taken for at least a year before conception.

It this is proven by other studies, it will make the case for fortification even stronger.

Terathanasia = “selective abortion of abnormal fetuses”.

The concern was that folic acid was not preventing NTDs, but making fetuses with NTD abort.

Those with ethical objections to termination would not be happy with folic acid fortification of flour if it worked by producing TOP.

Return to the answer.

It took me 19 minutes to plan and write this essay from scratch.

But I know the subject quite well.

I have put all you need to know in MCQ7, answer 23.

It would also be worth reading the RCOG's SAC opinion paper 4 on the subject.