Folic acid in bread: barn gates and neural tubes

Bread - credit Slice of Chic

Last year, one out of every six known pregnancies in Scotland did not end with the birth of a live baby. If present trends continue, then more than 100,000 conceptions over the next five years will result in a termination, miscarriage or stillbirth. Terminations account for the majority. But, women do not become pregnant because they are motivated by a desire to experience any of these three outcomes.

Our focus today is on the reality that a large proportion of miscarriages and stillbirths are not inevitable. One cause is a foetus with malformed neural tubes that the body rejects as not viable. In addition, a small number of babies are born with Spina Bifida and even more severe neural tube defects (NTDs) that compromise, or prematurely end, their young lives.

Many miscarriages, stillbirths and birth defects are preventable by intentionally building up adequate levels of folic acid (Vitamin B9) prior to pregnancy. The public announcements made earlier in 2016 by Scotland’s Public Health Minister and Chief Medical Officer in favour of fortifying flour offer an effective, inexpensive way for Scotland to prevent many (but not all) miscarriages, stillbirths and NTDs are worthy of support and action.

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That would be a blessing for everyone who suffers the consequences of too little folic acid too late to make any difference to the outcome.

Sometimes in life, timing is everything. Although not farmers, we understand the meaning of ‘closing the barn gate after the horse has bolted’. Among midwives, obstetricians and GPs, the equivalent is ‘starting to take folic acid supplements after the foetus has already developed neural tubes’.

The neural tubes are essential to our lives and wellbeing because they are what eventually become – if all goes well – our central nervous system (our brain and spinal cord). If they do not grow normally, then the result is a miscarriage, a stillbirth or, among babies born alive, Spina Bifida or other neural tube defects.

As we have all learned this year, Zika virus can cause severe microcephaly (babies born with pitiably small heads and brains). Besides Spina Bifida, neural tube defects include four types of ‘cephaly’. These are rare, but include the worst one: anencephaly (born with no, or almost no, brain).

Here is why timing matters so much. For better or worse, neural tube development is basically complete before the fifth week of pregnancy – that is, before most women even know they are pregnant. Despite this fixed biological reality, the current social reality across Scotland is that many women arrive at first booking (8-12 weeks pregnant) enquiring about whether they should start taking folic acid supplements. Barn gates, horses . . .

This is not just random medical information. It is an emerging Scottish political issue in which knowledge about the timing of neural tube development is crucial. The issue is whether to fortify Scotland’s flour supply with folic acid.

This is a good news, bad news story. The good news is that most neural tube defects are preventable. Adequate levels of folates/Vitamin B9/folic acid in a woman’s system before conception reduce the incidence of NTDs by up to 72 per cent, according to the latest international evidence.

This does not happen overnight; just like developing a six-pack requires more than a few workouts. Human bodies do not store Vitamin B9 well, so it usually takes three months of daily folic acid supplements and healthy eating to reach the level at which prevention works. Eating lots more spinach and other folate-rich foods during pregnancy is sound nutritional advice, but it is too little too late to prevent NTDs.

The bad news is that current UK-wide strategies for increasing folic acid supplementation are not working equitably. They are based on educating women about the advantages of daily doses of folic acid and then counting on each individual to change her preconception behaviours by buying and taking folic acid supplements every day for months before pregnancy -- and continuing during the first trimester.

In practical terms, it has resulted in a health inequality gap. Relatively well-educated, well-informed, well-off women tend to follow the advice, while their less advantaged sisters often do not. The gap has also grown between women with well-planned and well-timed pregnancies and the large percentage of Scottish women who become pregnant unintentionally, unexpectedly or with minimal preparation.

Adding folic acid to flour is only one piece of the larger jigsaw puzzle of helping the next generation of prospective parents to be healthier and better prepared (whether for their first or their next pregnancy). However, Vitamin B9 fortification is a piece that can only be added by government.

For more than a decade, the UK Food Standards Agency, and its associated scientific panels – and the new Food Standards Scotland -- have done their homework and endorsed the value of fortifying the grain supply with folic acid. This step already has been taken in Canada, Australia and more than 70 other nations. Last year, all four of the UK’s Chief Medical Officers (CMOs) agreed to advocate for folate fortification.

Taking this step is now a devolved power. Scotland’s CMO, Dr. Catherine Calderwood, is an obstetrician who knows this is the right public health action. The benefits of preventing NTDs by fortifying flour will be distributed universally across Scotland’s women. The Minister of Public Health publicly announced her intention for Scotland to act independently without waiting for the other UK nations. The planning is now underway. Scotland’s women health leaders should be strongly supported by the Scottish Parliament to make prevention real in this tangible way.

There is no serious, evidence-based, scientific case against folate fortification. It is a great opportunity to be the first nation in the UK to leave the starting gate and bolt toward a future of fewer miscarriages and stillbirths; more social justice for Scottish mothers and fathers; and, babies less likely to be burdened with birth defects that could have been prevented.

The Holyrood baby – Kirsty – and her parents were lucky enough to have averted this danger. Surely, all of us want as many babies, mothers and fathers as possible to be equally fortunate. Adding Vitamin B9 (folic acid) to Scotland’s flour will allow everyone to stop being hostages to this misfortune.

Dr Linda de Caestecker is Public Health Director of NHS Greater Glasgow and Clyde. She was on secondment last year as Deputy Director of the International Federation of Gynecology and Obstetrics. Dr Jonathan Sher is an Edinburgh-based Independent Consultant on preconception health, education and care.