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Health: Birth Defects

Volume 749: debated on Wednesday 6 November 2013

Question for Short Debate

Asked by

To ask Her Majesty’s Government what assessment they have made of the impact of fortifying white flour with folic acid on the number of pregnancies affected by neural tube defects.

My Lords, I am very pleased to have the opportunity to raise the subject of fortifying white flour with folic acid in the interests of public health.

Deficiencies in folic acid have been found to lead to neural tube birth defects, including spina bifida and hydrocephalus. It is both a national and an international issue. Public health policy has been to encourage those planning to become pregnant to ensure a voluntary input of folates, either by supplement or by folate-rich foods, in that crucial period covering conception and the first 12 weeks. However, this policy is known to fall on deaf ears in some socioeconomic groups, and does not cover the issue of unplanned or unintended pregnancies. In some countries, where bread is part of the staple diet, it has been found that fortifying bread flour with folic acid can cover both the issues of the target group and unplanned pregnancy.

Bread has been a staple food in the UK for centuries. Consumption has fallen a little but it still contains more than 10% of our daily intake of key nutrients and remains a major source of them. Since the 1940s, just after the war, most of our bread flour has been fortified with four added nutrients, and that is still the case today. On 5 August this year, at the start of the Recess, Defra announced the result of the consultation on the bread and flour regulations, which was that the mandatory fortification of flour will continue on health and scientific grounds.

The idea of folic acid fortification has been around for many years. I can confirm from my own personal experience that in 1999, as Minister for food safety—before my Food Standards Agency days—I was lobbied on the issue by a leading scientist during a journey to a food conference. My initial reaction was, “It’s mass medication”. But I soon realised it was not then, and it is not now. By 2007, Her Majesty’s Government had been advised by the independent Scientific Advisory Committee on Nutrition and the Food Standards Agency to go down the route of mandatory fortification. This advice was reinforced in 2009-10, during my term as chair of the Food Standards Agency.

Scientists involved in the research, such as Professor Nicholas Wald of the Wolfson Institute of Preventive Medicine, have chased the issue up over the years. Others, such as Professor Colin Blakemore, have raised more generally the issue of the lack of feedback from government on advice from scientists, where there seems to be no clear decision on policy or action to be taken, or not taken, on the basis of the advice. He cited folic fortification as a recent example.

Delay has been caused by some scientific doubts regarding the effect of too much folate in the diet, which might be the cause of some rare cancers. Justifiably, Ministers and Chief Medical Officers required reassurance on this aspect. I believe—and this is why I am raising the issue now, after leaving the FSA—that the publication in March this year of the paper by Vollset et al in the Lancet puts the concerns to rest. The study analysed data on 49,621 individuals in 13 evenly randomised trials and found that there was no significant effect of folic acid supplementation on the incidence of cancer of the large intestine, prostate, lung, breast or any specific site. Furthermore, in interpretation, the scientists pointed out that the fortification of flour and cereal products involves doses of folic acid that are on average an order of magnitude smaller than the doses used in the trials they examined.

On 1 July the noble Earl, Lord Howe, the Health Minister for England, told Parliament that Ministers were “taking stock”. Has that included talking to Ministers in the other three countries of the UK? More than 50 countries are fortifying flour with folic acid, including the United States, Canada, Iran, Argentina and South Africa. So far, none in Europe are, due to the concerns I have mentioned, which are no longer justified.

Australia introduced mandatory folic fortification in September 2009. It has been found, in a paper by Brown et al in the Medical Journal of Australia in January 2011, that,

“the introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in woman of childbearing age”.

A study in the American Journal of Medical Genetics in 2010 found that food fortification with folic acid prevents neural tube defects but not other types of congenital abnormalities. The study covered more than 3 million births in Chile, Argentina and Brazil over a 25-year period, according to the authors, Lopez-Camelo et al. The paper by Blencowe et al in 2010 in the International Journal of Epidemiology concluded:

“The evidence supports both folic acid supplementation and fortification as effective in reducing neonatal mortality from NTDs”.

So it works.

The latest study, published earlier in the year in the Lancet, clears the way to vastly improve the health position in the UK. We start from a low position. England has the highest rate of unintended or unplanned pregnancies after the USA—well in excess of 200,000. As such, the women concerned will see no need for supplementation. So far as the pregnancies that are affected by neural tube defects are concerned, there are hidden and avoidable family tragedies involved.

The best figures I have—they are a little old but I am advised they are the best—are those used by SACN, the Scientific Advisory Committee on Nutrition, in its report, drawn to my attention by the Shine charity. In England and Wales, there were 178 neural tube defect-affected births from 853 neural tube defect-affected pregnancies. That means that there were 675 terminations. In Northern Ireland, there were 11 affected births and no terminations. In Scotland, there were 49 affected pregnancies with 50% terminations. That means that there were more or less 238 neural tube defect-affected births and 913 affected pregnancies, with around 700 terminations. These will be late, following the 20-week scan, when neural tube defects show. In summary, therefore, there are 150 to 200 babies born with neural tube defects leading to spina bifida and other conditions, with a total of 750 to 1,000 pregnancies. Eighty per cent of the neural tube defect-affected pregnancies are terminated.

Nothing I say diminishes my life-long support for a woman's right to chose, but it is self-evident that decisions for termination based on neural tube defect-affected pregnancies would decline with folate increases. More than one in 1,000 pregnancies in the UK is affected each year. Folic fortification has been shown in the countries that have a mandatory policy to have prevented between 27% and 50% of cases of neural tube defects. Based on these figures, we have a potential to save 100-plus neural tube defect-affected births per year in UK; and significantly we could prevent hundreds of late terminations every year. Putting it crudely, the current reduction in the number of babies born with neural tube defects is actually brought about by the termination of pregnancies. I do not like the idea that in the past some DoH officials have claimed that NTD is well managed.

The Prime Minister said at PMQs on 27 February that,

“conditions such as spina bifida have come down and that folic acid has an important role to play”.—[Official Report, Commons, 27/2/13; col. 311.]

They have “come down” as terminations go up, due to the rate of diagnosis getting more accurate. What we need is primary prevention. Putting folic acid in white bread flour is not mass medication. Those who wish to avoid it just avoid white sliced bread. It gets to the groups of women most difficult to get to.

I want to hear what assessment the Government have made of the impact over the past seven months while they have been taking stock of the operation in England and what discussions have taken place with the devolved Administrations and their Chief Medical Officers. It is better to have a UK solution, as I know that flour mills are not always in the most convenient locations for four separate policies.

The science policy advice to government is to do it. Scientific concerns have been raised and cleared. It is not mass medication; it saves lives and misery, and it saves money. It reduces the hidden cost of the present policy, namely the costs of terminations as a management tool. It produces more healthy babies and improves public health.

My Lords, one speaker has scratched. That will allow us to stretch speaking times from seven to nine minutes, provided that the next four speakers all observe that when 9 comes up on the clock, they stop.

My Lords, I do not think I am likely to get to nine minutes. I am very grateful to the noble Lord, Lord Rooker, for bringing this subject to our attention this evening.

Under normal circumstances, I would prefer that young women should all have a good balanced diet with plenty of fresh fruit and leafy vegetables, regardless of whether or not they were considering pregnancy, to give them sufficient folic acid to prevent neural tube defects and, come to that, a very large number of other subclinical conditions linked with folic acid deficiency. Unfortunately, life does not work like that. Many young people—women and girls in particular—lead rather frenetic lives and tend to eat on the hoof. Food which takes little preparation and cooking is the easiest way for them to get their calories. Many have little idea of the nutritional values of the food they eat and cooking a good, balanced meal comes very low in their order of priorities. Others simply cannot afford to buy fresh green vegetables and fruit on a regular basis. While some cereal and snack manufacturers fortify their products with folic acid, these too might be out of range for those on benefits. No amount of education or health promotion material can overcome these problems.

As a mother and grandmother of healthy girls, I find it hard to imagine the anguish and grief that a pregnant woman suffers when told that she is bearing a baby with neural tube defects. The noble Lord, Lord Rooker, has pointed out the abortion rates for this condition. She and her partner have to decide whether they wish to continue with the pregnancy. She has the added knowledge, and the guilt that would accompany it, that if she had taken folic acid before she became pregnant, or immediately she knew that there was a possibility that she was pregnant, she might have prevented potential disaster.

There are people who object on principle to what they regard as mass medication. The noble Lord, Lord Rooker, again has made very clear that it is not without consent. We are all aware of the objections to fluoridation of drinking water. I know that there have been discussions about removing calcium fortification in flour, although these seem to have stalled. Few people realise that, as well as calcium, our white flour is already fortified with thiamine, iron and niacin. They also ask why they should have to have their products made with flour fortified to prevent disease in a very small minority. I believe very strongly that, in the case of folic acid, flour should be fortified. This belief is endorsed by researchers at the Institute for Science and Society at the University of Nottingham in their 2007 report The Ethical Implications of Options for Improving the Folate Intake of Women of Reproductive Age.

The prevalence of neural tube defects started to fall before folic acid supplementation was introduced in the 1970s. Perhaps the abortion laws that came in around that time had some effect. When I was newly married I was told to avoid eating green potatoes because these were seen as the cause of spina bifida. The prevalence fell quite steeply for about 20 years but it has remained stubbornly at between eight and 15 per 10,000 pregnancies since the 1990s. One possible reason could be that nearly half of pregnancies are unplanned; by the time a woman finds she is pregnant it is too late for the supplements to have the greatest benefit.

Most of the UK population eats white flour in some form or another as part of their staple diet, although we must not forget those who are gluten sensitive and do not eat wheat for medical or other reasons. A standard loaf of bread is relatively cheap and filling. It tends to be a substantial part of the diet of those who cannot afford fresh fruit and vegetables or other foods rich in folic acid, such as offal and pulses. It seems likely that fortified bread has a better chance of reaching the target than education or promotional campaigns to encourage this group of women to take folic acid as a precautionary measure. It would also catch those who have unplanned pregnancies.

As well as preventing neural tube defects, folic acid may have a role in reducing congenital heart defects, cleft lips, limb defects and urinary tract abnormalities. It may also help to protect the unborn infant from disease in the mother. It seems to be important that vitamin B12 levels are checked as there is concern that high prenatal levels of folic acid combined with low B12 may cause epigenetic changes. There is a complex interaction between B12, folic acid and iron. As our flour is already fortified with iron we would need to ensure that B12 deficiency would not be masked by the other two.

As the noble Lord, Lord Rooker, has already said, concerns have been voiced about the possibility that folic acid fortification might mask vitamin B12 deficiencies in the elderly and that it might cause bowel cancer, but recent research would appear to negate both these concerns, particularly for the elderly. There would appear to be very little, if any, risk from fortified bread to the general population—indeed, it might even prevent a number of subclinical conditions which could become serious, particularly in the elderly.

The one small concern that I have is that, if white flour is fortified, it will be difficult to determine the folic acid status of women who want to become pregnant or who are pregnant because we will not know their average daily intake. The Department of Health recommends that,

“‘all women who could become pregnant should take 400 microgrammes”—

that is, 0.4 milligrams—

“of folic acid per day as a medicinal or food supplement prior to conception until the twelfth week of pregnancy”.

The RDA for folate equivalents is 600 micrograms. The BMA suggests that the guidance level set for the UK of 1 milligram a day is satisfactory,

“provided there are appropriate controls on mandatory fortification to ensure that individuals do not exceed the upper intake level of 1mg per day”.

There must be huge variations in the amount of white bread and other white flour products that UK consumers eat on an average daily basis. How are we to ensure that young women get enough folic acid to protect their unborn children, or that the elderly do not get too much? What advice about additional supplements will be given to women of child-bearing age who do not eat a lot of bread and to those who have had a previous pregnancy with neural tube defects or who have a genetic risk? We need to be cautious about depending too much upon fortification of white flour with folic acid to solve all the problem of neural tube defects. Nevertheless, that is not an excuse for not doing it.

I support the noble Lord, Lord Rooker, who is himself supported by the BMA, the Scientific Advisory Committee on Nutrition, the Department of Health’s Committee on Medical Aspects of Food and Nutrition Policy and the Food Standards Agency. I hope that the Government will listen to him.

My Lords, I thank the noble Lord, Lord Rooker, for tabling this interesting debate. As ever, your Lordships’ Chamber gives us a wonderful opportunity to think about certain topics in more detail and to challenge ourselves and our opinions.

Until this debate was tabled I had not previously considered other methods of taking folic acid apart from the pills that were available over the counter. My first thought was that I was not sure that it was a terribly good idea—mass medication, as the noble Lord, Lord Rooker, has said. However, I thought of other areas where there is fortification, such as fluoride in the water, mentioned by my noble friend Lady Mar who raises some good points on the level of folic acid that should be taken. I came to realise that it is probably a reasonable idea if it can be done in the right way and not cause any other issues.

I felt compelled to speak because I have spina bifida—that is why I am a wheelchair user—and perhaps if the benefits of folic acid had been known when my parents were planning a family, my life might have been very different. Many of the opportunities that I have experienced are due to the fact that there was little knowledge in this area, whether it was around supplementation or various scans that are now routinely available. For me personally, it is kind of hard to regret that there was no knowledge at that time.

When I was born, my parents were told that I had spina bifida. I do not think that they really knew what it meant. There was little education and disabled people were not as visible in society as they are now. My parents were also told that if I had been born just a few years earlier, because of my condition, I would have been taken away and not fed.

My parents were also given a whole host of reasons why I had spina bifida. My mother was blamed. She was told that she had not eaten enough vegetables, even though she was virtually a vegetarian. My father was then blamed because of other family conditions or illnesses which were then a precursor. The final reason we were given was that it was more common in areas of coal mining or industry, so therefore the figures were much higher for the Welsh mining valleys, Nottingham and Newcastle. I grew up in Cardiff; I do not know whether that is good or bad.

I am very pleased that there is better knowledge today. Although everything I have read says that spina bifida was not hereditary, I and other family members were told that there could be a slightly higher incidence of the condition, and I was advised to take a double dose of folic acid. Obviously I was able to take it because my daughter was part of a planned pregnancy, but we must consider unplanned pregnancies and, indeed, women taking folic acid for the correct amount of time. When I was pregnant, it was not made that clear that it was meant to be for 12 weeks of pregnancy. I know that, in my own case, I experienced dreadful day sickness—I dreamed that it might just become morning sickness—and, as a result, I was never entirely sure of the amounts I had taken or whether it had remained in my body. I took several pills a day, just hoping that some of it would benefit me. I treated taking folic acid in the same way as I thought about my diet; I do not drink or smoke. It was about doing the best I could for my unborn child.

I read with interest the documents produced by the British Medical Association in April this year about the falling rates of spina bifida. Like my noble friend Lady Mar, I believe that part of it is about scanning and the opportunity to discuss and offer termination in a different way. That certainly was not available when I was born. Certainly, it appears that the best medical advice is that taking folic acid will contribute to preventing this condition.

This is a difficult subject to discuss because it would be so easy to move into a wider discussion on scanning and termination, but that is not what this debate is about. In a note which I received from Jackie Bland, the chief executive of Shine—the charity for people with spina bifida and hydrocephalus—she indicated that we might well have a situation where it seems many of us are more comfortable managing the occurrence of spina bifida through scanning and termination, when fortification combined with more robust public health information could reduce occurrence by up to 72%. This is really interesting.

Perhaps there is also a failure to acknowledge the extremely traumatic consequences of a late-pregnancy termination. I do not believe that termination is an easy option. I also know of several people who, knowing that they are having a child with spina bifida, have chosen to carry on. Shine’s health advisers have also said that many parents have reported a strong pressure to terminate and a sense of guilt if they choose to continue. That is a consequence of the acceptance of management by termination. We must recognise that whatever people choose, these are hard decisions that families have to take.

When I was pregnant I was asked so many times what I would do if I knew I was going to have a child with spina bifida or who would become a wheelchair user. I think that people were expecting me to give a definite, immediate answer. My response was that I would ensure that my child had the best self-propelling wheelchair on the market from the age that they were meant to be crawling. It is about managing it, and the choices that you make.

I have only one question. I was wondering, when researching this area, whether consideration had been given to including folic acid in other food products. I do not eat a lot of bread and am not planning on having another child. It is about understanding the right amount of folic acid that should be taken.

Finally, I reiterate that I am strongly in support of prevention, in the way that I support things like the seat-belt law, which had a significant impact on the rate at which people experienced traumatic spinal cord injuries, or something like cycle safety. Prevention is a positive step forward. I look forward to debating this again in the future.

My Lords, I, too, am grateful to my noble friend Lord Rooker for bringing the subject to our attention and for introducing it in his usual robust and forthright way. It is a privilege, too, of course, to follow the noble Baroness, Lady Grey-Thompson, who spoke so movingly of her personal experiences.

It is pretty obvious that spina bifida in its severe form is indeed a nasty disorder. It affects one or two in every 1,000 pregnancies, causes paralysis of the legs, problems with bladder and bowel control and, in some children, learning difficulties. It can cause serious lifetime problems and distress both for the children and their families. On top of all that, it poses a considerable economic burden on the families and on the health service.

Yet we can prevent—according to my figures—about 70% of cases with a simple dietary manoeuvre; that is, by increasing the intake of folic acid in women before they become pregnant. It was in 1991, 22 years ago, that a study by the Medical Research Council was the first to show that we could prevent these neural tube defects by giving mothers 4 milligrams of folic acid a day, before and during their pregnancy. The incidence went down by about 70% which was a remarkable discovery first made here in the UK. Even much smaller doses were shown to be equally effective. Since then, it has been more or less routine practice to recommend that folic acid should be given to all pregnant women.

However, the problem that soon arose was that simply prescribing it to women who were already pregnant did little or nothing to prevent the disorder. It had to be given before they were pregnant, because the defect arises very early in pregnancy. The neural tube closes at 23 to 27 days after conception; that is before the first period is missed. By the time a woman realises she is pregnant, it is usually too late. She has to take the folic acid before she is pregnant for it to be effective and that immediately eliminates all those women who do not plan their pregnancies. That is particularly the case, for example, in single women and it is exacerbated in those with poor dietary habits whose intake of green vegetables, the natural source of folic acid, is limited. In fact, there is a linear relationship between the level of folic acid in the red cells and plasma and the incidence of neural tube defects. The higher the folate level, the lower the incidence—that is a clear relationship.

So how can we make sure that all women take it before they become pregnant? We inevitably come to the conclusion that we should fortify our food. The Government’s own Expert Advisory Group and COMA, the Committee on Medical Aspects of Nutrition, have been repeatedly recommending that we fortify our flour with folic acid over many years. The idea is that everyone eating average amounts of bread will take about 280 micrograms, about a quarter of a milligram, of folate per day. It is a very small amount but sufficient to prevent spina bifida in a majority of cases. We in the UK have unfortunately not taken that advice, even though more than 70 other countries around the world, including the USA and Canada, supplement their flour with folic acid.

Of course, there is always a reluctance to add things to the diet that everyone is going to eat. Noble Lords have talked about this. Worries about side-effects and unexpected adverse events are always raised and it is usually wise to be cautious. In the case of folic acid there were worries about the possibility of two sorts of danger: that it could cause cancer; and that it might cause a peripheral neuropathy in those elderly people who were also deficient in vitamin B12. This is a disorder of the nerves going to the arms and legs, a condition caused by a combination of B12 deficiency and folic acid excess. So delay in taking up the recommendations of COMA was inevitable until these dangers could be eliminated.

Now we know from a huge number of studies that they have indeed been eliminated. In the meta-analysis that noble Lords have referred to of a large number of trials by Vollset and his colleagues in the last year, trials covered almost 50,000 individuals given a largish dose of 5 milligrams a day for five years or more and there was no sign of an increase in the overall number of all cancers or of any individual specific type of cancer. Incidentally, these trials were done largely in the belief that folic acid might prevent coronary artery disease. It did not show that, but it did show that cancers did not increase, which was a useful side-effect. Nor has there been any sign that the B12 deficient neuropathy I mentioned has increased in the population of America or Canada where they have been fortifying their flour since 1998, 15 years ago. Incidentally, the manufacturers of breakfast cereals—All-Bran and the like—routinely fortify them with a range of vitamins, including folic acid. Perhaps the noble Baroness, Lady Grey-Thompson, could take breakfast cereals; that might help her.

It is hard now to refute the scientific evidence, gathered from huge populations, that supplementing the diet of everyone by an average of 280 micrograms a day of this vitamin is harmless to the population at large. It clearly reduces the incidence of this nasty and burdensome disease in our children. It is more than 20 years since we discovered that we could prevent neural tube defects by this simple measure. The discovery was made here in the UK and it is high time we caught up with much of the rest of the world and took advantage of what we now know.

My Lords, I am delighted again to applaud my noble friend for raising this matter and I hope that we can look forward to a positive response from the Minister. My noble friend Lord Turnberg explained the science and it is clear that there is very credible support for my noble friend’s position. The Scientific Advisory Committee on Nutrition’s 2006 report recommended mandatory fortification of flour to the Government. That was endorsed in 2007 by the Food Standards Agency board. More recently we have all, I think, had a briefing from the British Medical Association which also supports folic acid fortification of flour. I thought that the BMA was very much to the point when it argued that the current guidance to women to take folic acid supplements has a number of limitations. As the noble Countess, Lady Mar, said it does not take account of unplanned pregnancies and, given that almost half of all pregnancies in the UK are unplanned, it is clearly an inadequate response. It is also a fact that poor compliance with the advice to take supplements means that women planning a pregnancy only marginally increase their compliance with folic acid supplement use. The noble Baroness, Lady Grey-Thompson, made some very powerful points about this and about the very hard decisions parents subsequently have to make.

Noble Lords have already dealt very effectively with the concerns that have been raised about the links between folic acid and cancer. The Scientific Advisory Committee on Nutrition, which advises the Food Standards Agency, said that the evidence in relation to bowel cancer was insubstantial and that any increase in cases could be down to improved screening. It recommended that those deemed to be at greater risk of colon cancer should receive precautionary advice on taking extra supplements containing folic acid and that the situation should be monitored. The Chief Medical Officer then requested further investigation by the Scientific Advisory Committee on Nutrition into the potential link between folic acid and colorectal cancer. The committee upheld its previous recommendation, with an amended recommendation to clarify the advice on supplement use for particular population groups.

We roll forward to January 2013, when the noble Earl, Lord Howe, told the House:

“Additional advice on folic acid and cancer risk was requested by the then Chief Medical Officer and provided by SACN in 2009. The papers underpinning the advice from SACN have not yet all been peer-reviewed and published in a scientific journal. Ministers need to very carefully consider this complicated issue and would like to see all information in the public domain before making any decision”.—[Official Report, 8/1/13; col. WA 44.]

I am a great admirer of the Department of Health, having enjoyed many happy years there, but I recognise long-grass briefing when I see it and that is the kiss of death. I hope that the Minister, if she cannot say that the Government are going to go down this route, will at least give a timetable for when the Government will make a definitive decision, or must we wait, month after month, for every single paper to be peer-reviewed? I think that that would be a great pity.

In conclusion, I shall ask the Minister a rather more general question coming back to the issue of advice given by health visitors and midwives in relation to vitamins and minerals generally. The reason I do so is that in September 2012 in another place my honourable friend Kate Green secured a Westminster Hall debate about the rise in the incidence of rickets. She talked about vitamin D deficiency across large sections of the population and quoted a study by the Clinical Effectiveness Unit at Stockport which found a surprising lack of awareness among health professionals about vitamin D across eight acute and six primary care trusts in the north-west. Only 24% of health visitors and just 11% of midwives reported having had training in vitamin D supplementation. I realise that this is a little distant from folic acid, but since the Government now put such reliance on advice given to women, does the Minister think that, as part of a wider response to the issues raised by my noble friend tonight, more needs to be done to ensure that midwives and health visitors are adequately trained in providing advice in relation to vitamins and minerals in pregnancy and before?

That is not a substitute for the action that my noble friend wants, and I very much hope that the Government will recognise that this would be the right thing to do. I hope that the Minister will be able to make a happy announcement.

I am grateful to the noble Lord for securing this debate on this very important issue, and I thank all noble Lords for this thoughtful and informative debate. The department is considering this issue very seriously. We know that approximately one in every 1,000 pregnancies is affected by a neural tube defect, which can result in miscarriage, neonatal death or lifelong disability. We also know that poor folate status is an established cause of neural tube defect-affected pregnancies, and therefore how important folic acid is for women of childbearing age. I will take your Lordships briefly through the detail of how the Government are currently taking action to reduce the risk of women having insufficient levels of folate—a risk that may result in potential neural tube defects such as spina bifida in unborn children.

It is possible to get all the folate you need from food in a healthy diet, but for women who are trying to conceive or are newly pregnant, getting enough particularly matters. That is why, since the 1990s, the Department of Health has advised women who can become pregnant to take folic acid supplements before conception and for the first 12 weeks of pregnancy, and to increase their intake of folate-rich foods. That advice is promoted as strongly as possible through all the channels we use to communicate with women and health professionals. NICE guidance ensures that health professionals are equipped with comprehensive advice on folic acid and on action to take with women who may become pregnant.

For women, advice is disseminated through a variety of sources such as the NHS Choices website, which sets out why folic acid is important for pregnancy and gives guidance on taking supplements. The Department of Health also provides funds to the charity Tommy’s to produce The Young Woman’s Guide to Pregnancy, which advises young women to take folic acid. Start4Life, a campaign to give the best start in life to nought to two year-olds, gives information on five key healthy behaviours during pregnancy, one of which is taking folic acid and vitamin D supplements. Their leaflets are written in a friendly and accessible style and are very popular with healthcare professionals as a tool to facilitate conversation with parents and expectant parents. The NHS Information Service for Patients offers to send e-mails and texts to women and their partners in the fifth week of pregnancy to remind women to take their folic acid.

Folic acid supplements are widely available and cost as little as £1 for a month’s supply, but are also available on NHS prescription. Pregnant women and women who have had a child in the previous 12 months are exempt from prescription charges, as are people on certain benefits or those who qualify through the NHS low-income scheme. We also offer free vitamin supplements containing folic acid without an NHS prescription to pregnant women and new mothers in very low-income families throughout the UK who are supported by the Healthy Start scheme. More than 150,000 pregnant women and new mothers are eligible to claim vitamins through that scheme. However, we know that some women do not take supplements, and of those that do, some start too late. That is of real concern to the Government and health professionals, and an area on which the Chief Medical Officer is keen to see action, as she set out in her recent annual report.

In 2000 the Committee on Medical Aspects of Food Policy first recommended the fortification of flour with folic acid to reduce the risk of NTD-affected births. Your Lordships will be familiar with the developments of the scientific advice since then. The Government are very grateful for the full advice which has been provided by consecutive expert committees and for the rigour and scrutiny with which the Scientific Advisory Committee on Nutrition—better known as SACN—considered the issue for its report in 2006 and its subsequent reviews of evidence. The noble Lord, Lord Rooker, will know that SACN sought to understand and clarify the risks of fortification carefully as it sought to make clear the benefits of its recommendation.

The advisory committee concluded in 2006 that mandatory fortification of flour with folic acid would reduce the risk of NTD-affected pregnancies, but that there was a potential risk to some population groups, particularly older people, including a potential increased risk of bowel cancer. In 2007, the then CMO asked SACN to further consider the evidence in this regard. In 2009, SACN’s majority view was that the new evidence did not provide a substantial basis for changing the original recommendation. However, it recommended fortification only if accompanied by a number of other actions, including restricting voluntary fortification of foods with folic acid, developing guidance on supplement use for particular population groups, and implementing measures to monitor evidence of long-term exposure to intakes of folic acid above the guideline upper limit per day.

SACN’s recommendation about monitoring and review explicitly reflected concerns around the potential for the numbers of people consuming levels of folic acid above the guideline upper limit. Health Ministers considered it prudent to ensure that all available evidence on the risk of colon cancer was peer-reviewed and in the public domain, which noble Lords referred to earlier, and the evidence was published in the Lancet this January. Following publication, Ministers confirmed earlier this year that they were taking stock of the issue. I assure the noble Lord who, as former chair of the Food Standards Agency, will understand this better than many, that because of the complexity of the issue it is essential that we weigh up carefully the risks and benefits in coming to a decision, and that we fully think through the implications of the other recommendations made by SACN. We are now doing that, and, thanks to the expert scientific committees and the consideration of this by the FSA and others, there is a wide range of evidence and advice to consider.

I pay tribute to the work of the voluntary sector, and in particular to one organisation mentioned earlier in this debate, Shine, which supports individuals and families as they face the challenges arising from spina bifida. It works tirelessly to raise awareness of the importance of folic acid and in May this year held the first ever national Folic Awareness Day.

Noble Lords have asked many questions, and I will work through them in the time I have available. However, if there are any still outstanding I will be happy to write to noble Lords after the debate. The noble Lord, Lord Rooker, asked whether we had talked to Ministers in Scotland, Wales and Northern Ireland. As noble Lords are aware, food and health policies are devolved issues and discussions on fortification outside England are for those Administrations. However, the views of those authorities will be taken into consideration by Ministers.

I am sorry to interrupt, but this dismissal of devolution is symptomatic of Westminster; it just does not do devolution. Rather than simply saying that it is a matter for them, it would be better to have a UK-wide policy. Is the Minister admitting that Ministers in England—this is what we are talking about here—have not discussed the matter with Ministers in Scotland, who may take their own route, as they are free to do, and that the four chief medical offices have not discussed the issue among themselves?

My Lords, I am telling noble Lords what I have been briefed. I am more than happy to write to noble Lords and, if they are happy for me to do so, leave the letter in the Library for everyone to check. I will also need to respond to the noble Lord, Lord Rooker, on his question regarding terminations.

The noble Countess, Lady Mar, asked about the risks and benefits, and assessing impacts, of fortification, giving due consideration to the implications of additional recommendations by SACN. We will take into account the views of the Chief Medical Officer, who raised the issue in her annual report, and of the devolved Administrations. The other point raised by the noble Countess was on ensuring that NTDs are avoided in pregnancy and on preventing vitamin B12 masking. We need to get this right. SACN considered the amount of folic acid to recommend and also recommended developing guidance on supplement use for particular population groups, along with implementing measures to monitor evidence of long-term exposure to intakes of folic acid. We are carefully weighing the benefits and risks of SACN’s recommendations and will take account of all views.

The noble Baroness, Lady Grey-Thompson, asked what foods would be considered for fortification. Currently, breakfast cereals are voluntarily fortified with folic acid in the UK. The FSA considered other foods, including soft drinks, fruit juice, milk and chewing gum, when it made that recommendation, but the consumption rate of these products is not considered to be universal across women of child-bearing age and would therefore not be suitable for fortification. Other foods were also considered. Bread was finally decided upon as the universal food as—to answer a point raised by both noble Baronesses—it is universally consumed across the population and all socioeconomic groups: more than 90% of households eat bread. Fortification of wheat flour would also include other wheat-based products such as pizzas, pastries and biscuits.

I think I have replied to several points that were raised.

My Lords, will the Minister write to noble Lords—clearly the Government will have to consider this—and set out a timetable on when they will come back to Parliament with an answer?

That sounds eminently sensible. I am happy to write to noble Lords to give them that information. I hope that I have provided reassurance—I am not convinced that I have—that the Government are committed to reaching the right decision on the fortification of flour with folic acid, doing proper justice to the work of SACN and others and ensuring that, while seeking to deliver the benefits, we minimise the potential risks. In the mean time the Government will continue to raise awareness of the need to take folic acid supplements and are supportive of all those who are raising awareness of this issue. I thank the noble Lord for securing the debate.

Sitting suspended.