Science in practice

Posted by Andrew Wadge on May 18th 2007 in Science, safety and health

It’s been a busy week and this is my first full day back in the office. I’ve spent an away day working on leadership behaviours with my heads of division and team leaders, then a day at the Federation of Bakers annual conference, where the Agency’s Chair Deirdre Hutton praised the Federation for their work on salt reduction. And of course then there was yesterday’s FSA Board Meeting in Nottingham.

There has been a buzz of anticipation all week about the Board discussion on whether to recommend to ministers the mandatory fortification of flour with folic acid. Of course, this was of considerable interest to the bakers and millers at the FoB conference. Coming just a day before the debate, I could not predict what the Board would recommend, but I was able to talk about the process by which this issue was addressed. And in many ways I think the folate issue is an exemplar of how the Agency works.

The starting point for folate and other issues is the science. In the other substantive item for discussion at the Board meeting, I presented my Annual Report on Science in the Agency. We have a good story to tell, with a strong level of in-house expertise, access to 140 independent experts via our scientific advisory committees and a research budget of about £20m to fund work to plug gaps in our knowledge and, importantly, track our progress towards meeting key strategic targets on food safety and dietary health.

I am delighted for all of the scientists in the Agency that the Board recognised what a strong position we are in – one that I want to build on over the next year. The strength of our work on science does not rest on one individual, but is based on good people and good processes. And the fact that we conduct our work in an open and transparent manner, engaging with consumers, food industry, academics and others, helps build trust in what we do, even if people disagree with our conclusions. I firmly believe that the Agency’s science is in a stronger position now than it ever has been.

Moving back to folate, I recommend that you look at the Board paper. It sets out clearly all of the arguments and the results of our consultations with experts, ethical advisers, business sectors and consumer groups. The debate focused firstly on the science: is there good evidence that mandatory fortification will help reduce the incidence of Neural Tube Defects (NTDs)? The answer is yes. The debate then moved on to a discussion about possible adverse effects. We are rarely in the position of having a complete picture of the risks and benefits on any issue and folate was no exception. But although there are some uncertainties about possible adverse effects, the weight of evidence on benefits was much stronger than on any theoretical risks. As always, however, we will continue to monitor the science for developments.

The recommendation for mandatory fortification is something that could really make a positive difference to people’s lives, as has been demonstrated by the reduction in NTDs in countries such as the US, Canada and Chile. Because, as the Board Members pointed out, when we talk about science and broad issues of public health, we do have to remember the very human side – and the emotional impact of developmental problems in pregnancy can’t be underestimated.

I’m sure that readers of the blog will all have their own views – so do respond with what you think.

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Folic Acid added to food

Posted by Bruce Osborne (not verified) on 14/12/2007 - 05:22

I agree folic acid should be added to some flours but I ask that we also be given the choice to buy bread, etc where it has not been added. Please don't 'mass medicate'; instead let those people who are interested and care enough about their food to control their own diets.
Thanks for the opportunity to comment.
Bruce

Adding folic acid to flour

Posted by Oriole Hall (not verified) on 20/06/2007 - 09:47

I am really concerned that yet again my liberties are being eroded. There are far too many additives in flour nowadays which is why so many people have a wheat intolerance. I make my own bread using organic spelt flour and have absolutely no desire or need to have folic acid added.
I can see the point to some extent in adding it to the white flour which goes into so much of the pappy bread that the majority eats but please let us have a choice.

I am also concerned that there may be an impact on the elderly and on pregnant women who are B12 deficient and potentially on those with certain genetic cancers.

Folic acid supplementation

Posted by Andrew Wadge on 13/06/2007 - 17:41

Thanks Morton, that’s very interesting, particularly ahead of the discussion our Board is going to have tomorrow morning about the best vehicle for folic acid fortification (having agreed at last month’s meeting that fortification is the right way forward in the UK).

For me, you have hit three nails on the head. First, that the consumer comes first. Whether you are a regulator or a food business, we share the same boss.

Second, when it comes to food regulation, rarely is anything as straightforward as it first looks. Bread’s place in the diet makes it an obvious choice for folic acid fortification, but there are pros and cons to be weighed up before deciding to fortify bread itself, or the flour from which it is baked (which may go into many other food products).

And that leads me to the third point, which is that the experience and expertise that resides in the food industry is invaluable when it comes to making judgments around the practicalities of food production and the impact of any changes on the market. That’s why we always look to work with the industry on issues like this one.

Folic Acid Supplementation

Posted by Morton Satin (not verified) on 12/06/2007 - 14:09

Please note that the first large-scale supplementation of folic acid and biotin took place in Canada in 1977.

Following the 1975 Nutrition Canada Survey, it was clear that the population in general and pregnant women in particular would benefit from folic acid and biotin supplementation in bread. I was Research Director of the Steinberg Bakery in Montreal (one of the largest in the world at the time) and made the decision that we should supplement all our breads.

When we informed the Government of our decision, they threatened to take us to court, because folic acid and biotin were not in the bread standard. However, we believed that the science behind supplementation was sound and decided to risk the suit in the interests of our customers (we felt confident we could refer to the government's own Nutrition Canada Survey, if we had to).

We did not charge extra for the bread and absorbed the extra costs ourselves. We made no great advertising claims, but made sure to indicate these new ingredients were on the ingredient list (with a reference to the Nutrition Canada Survey). We had a large flour mill but decided not to supplement the flour because, at the time, we only wanted the breads and no other baked goods to contain folic acid and biotin.

Thus, 20 years before it became mandatory in the US and Canada and 30 years before it became mandatory in the UK, our clients enjoyed the health benefits of folic acid supplementation.

An excellent example of private sector initiative in an organization where the customer always came first.

Morton Satin

Folic Acid fortification

Posted by Claudia (not verified) on 26/05/2007 - 17:00

I am delighted to see the FSA have finally decided to support the fortification of Folic Acid to help prevent the incidence of Neural Tube defects which can have devastating effects on the person born with conditions such as Spina Bifida and their family. In the UK we have the highest rate of teenage pregnancy who would not routinely have the opportunity to take supplements. Equally many adults do not plan their pregnancies and may have to make the difficult choice of whether to continue a pregnancy or have a termination. It is I think sensible to take preventative measures to reduce the risk of NTD's.

Thanks for the comments ...

Posted by Andrew Wadge on 25/05/2007 - 14:11

Thanks to everyone who has responded so far (and please keep the comments coming) – you have demonstrated that mandatory fortification is a controversial issue.

Rob questioned whether there are risks as well as benefits to mandatory fortification with folic acid. The Board’s decision was only made after an extensive and scientifically robust process. This included analysis and advice from the Scientific Advisory Committee on Nutrition (SACN), which is an independent committee of scientific experts. SACN conducted a thorough and comprehensive assessment of the scientific evidence on the benefits and possible risks of mandatory fortification. All the scientific evidence considered by SACN is detailed in its report, Folate and Disease Prevention (December 2006) and is available on the SACN website.

Choice has been raised by a few of you, specifically what the options would be if someone wanted to buy bread that didn’t contain added folic acid. No decision has been taken on exactly how mandatory fortification would be achieved. The discussions so far have been in relation to fortifying some types of flour or bread and the Board will debate this at its Open Board Meeting in June.

If, as SACN has suggested, white and brown wheat flour were fortified, there would be no added folic acid in bread made from wholemeal wheat flour, or rye and other types of flour. So people wishing to avoid bread fortified with folic acid could choose to buy these. And bread and flour imported from countries that don't have mandatory fortification would probably be free from added folic acid as well. Effective labelling will also be important for consumer choice. The Board will discuss labelling at its next meeting.

One of you expresses concern that mandatory fortification is 'treating' the whole population when the intended benefits are for just a small group. The Board did take this into account and considered a range of views, including an expert view on the ethical issues regarding the policy options for improving folate intake to reduce pregnancies affected by neural tube defects (NTDs). I strongly believe that if we know we can help a section of our society, however small, without causing harm to others then we have a responsibility to do so. Experience has shown that trying to specifically target the at-risk group, by advising women to take folic acid supplements, has not been effective in reducing NTDs anywhere in the world, despite active promotion campaigns. Hence the need for fortification, although the Board did recognise that this would need to be part of a package of measures.

Also, lots of other people stand to benefit from fortification. Folate is a vitamin that is essential for everyone’s health. It is required for normal cell division, which means that if you have a deficiency it affects processes in your body such as growth and red blood cell production (the latter causing anaemia). Data from the National Diet and Nutrition Surveys (NDNS) show that overall 23% of the population, 34% of women of child-bearing age and 37% of those aged over 65 have folate intakes below the recommended levels of 200 micrograms a day. So folic acid fortification would also benefit large sections of the UK population with intakes below dietary recommendations.

Giselle asked about the recording of NTD-affected pregnancies. In the UK, women are offered diagnostic screening for NTDs during antenatal care. We don't have complete data on the number of NTDs. But SACN estimated that there are about 700-900 NTD-affected pregnancies each year, not taking into account miscarriages that occur as a result of the condition. Most women who are diagnosed opt for an abortion, which is available in all countries except Northern Ireland. And about 160 babies are born with NTDs each year.

Peter implies that the next step after folic acid fortification could be to add ‘every known chemical to every known ill’ to bread. I don't think that adding a vitamin (albeit a synthetic form of that vitamin) at the levels envisaged – which would increase average daily intakes by less than 100 micrograms per day – is analogous to adding drugs for cholesterol etc, which are required at much higher doses. Furthermore, doctors have been able to target successfully the ‘at-risk’ group for cholesterol and give advice and treatment as necessary. As mentioned earlier, attempts to do this for the 'at-risk' group for NTDs have failed.

Finally, thanks to Roger for your positive comments about my blog – I'm glad you like it.

simply amazing!

Posted by A (not verified) on 22/05/2007 - 20:38

I am really amazed about the way how people have reacted to the fact that there will be suplements of folic acid in bread in the future...
It is particularly annoying the woman, that so keenly describes herself as in the "at risk group" who does not seem to believe that preventing children to be born disabled is more important than her choice on what type of bread she want to eat.
Sometimes , when I read some people I believe that they may live on a different planet. Comparing the adition of fluor to the drinking water with using folic acid to suplement bread is more evidence of the lack of knowledge on nutrition of the people making such statements.
The fact , wether those people like it or not ,is that food production has become an industrial process. As such , we have lost some things in the process .... and we shall need to suplement them on some short of form to be able to balance our diet with our nutritional requirements of those elements. If food available on the market , naturally have those elements , they will not be suplemented...got it? and they use bread because is easy and something that almost anyone can eat.
If you can't understand it , you must stay in the caves and let the rest of the world to lead a healthier life.

Folic Acid - Manditory Fortification

Posted by Anonymous (not verified) on 21/05/2007 - 12:34

We are constantly being told that as human beings we are unique, our DNA is particular to us as individuals. The way we react to circumstances both emotional and physcal are unique to us. If this is the case, should we as humans not be treated en mass, as reations will differ from person to person. Therefore I would not think it appropriate to 'treat' the population as whole and would rather be responsible for my own body as far as possible. For examply I have an intollerance to yeast and therefore do not eat yeast based products, and avoid processed foods as far as possible.

But what about choice?

Posted by Giselle (not verified) on 21/05/2007 - 11:49

I've decided that adding 'produced' vitamins and minerals to foods is not the best idea. Maybe it works, maybe it doesn't, and maybe it has long term health effects. As a result, I (personally) try to avoid them.

I'm already annoyed that I can't get white bread flour without the other added vitamins excluded; despite the fact that I've gone and bought a breadmaker so I can make things without additives/preservatives etc. Now you want to add folate to that? And yes, as a young woman I am in the at-risk group.

There are 60-million odd people in the UK - so you want to load ALL white bread with folate where you could rather target young women in the at-risk group? For the sake of a small reduction (not elimination!) in the number of babies born disabled? yes, I know that you might leave wholewheat bread without added folate, but sometimes it's nice to eat some white bread as well!

I will admit I have not yet read the board paper, but did do a quick overview of some of the medical evidence. The reduction is small, in one case (possibly due to increased sample size) there was actually an increase in the number of NTD's. Also, I remain unconvinced by the recording of NTD pregnancies that are terminated. Was this taken into account or were all the statistics done on a 'live birth' basis?

Folic Acid

Posted by Peter Coleman (not verified) on 21/05/2007 - 09:24

Clearly with such well-researched and proven data enabling everyone in our country to be subjected to forcible and mandatory consumption of chemicals whatever their view might be, why stop there? Can you not include chemicals which lower cholesterol (a significant problem for over 60% of the population), high blood pressure (75% of the population?) Type 2 diabetes (50% of the population, and very few even know it)………etc. etc.

Why not make life simple for all of us, and magically solve all known illnesses, life limiting situations, and diseases by hollowing out the centre of all loaves of bread and stuffing the cavity full of every known chemical to cure every known ill.

Obviously the time-honoured tradition of individuals taking medication to prevent certain illnesses is now unacceptable in this progressive, equality-obsessed society of ours. Remove choice, prevent the ignorant, un-educated hoi-polloi having any ability to decide, make it compulsory, force it on us…set stiff prison sentences for all those who fail to obey to orders, or try to avoid being poisoned…..

Choice

Posted by Rob (not verified) on 20/05/2007 - 07:04

I understand the benefits for pregnant women but have been led to believe there are risks as well as benefits. Will the public be able to choose to buy non fortified bread just as it can buy bottled water with no Flourine?

FSA blog

Posted by Roger Darlington (not verified) on 19/05/2007 - 11:25

Andrew, Your blog is an exemplar for how regulators should be reaching out to and engaging with consumers.

I've blogged about it here.