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Fortified Flour

Volume 641: debated on Wednesday 16 May 2018

I beg to move,

That this House has considered the mandatory fortification of flour with folic acid to prevent spina bifida and anencephaly.

I am delighted to serve under your chairmanship, Mr Hanson, in this important debate on the potential for the mandatory fortification of flour with folic acid to prevent neural tube defects. Every week in this country two children are born with a neural tube defect, most commonly spina bifida and anencephaly, and every day two pregnancies are terminated as a result of the diagnosis of such conditions in the womb.

The neural tube is the structure in the embryo that becomes the brain and the spinal cord. It should close between the 18th and 28th days after conception. Failure of the neural tube to close completely and properly leads to conditions such as spina bifida, affecting brain development, mobility, and bladder and bowel dysfunction—other right hon. and hon. Members have personal experience of that and will talk with great knowledge about it—and anencephaly, a fatal condition in which the brain does not develop.

In 1991 a seminal piece of research on prevention of neural tube defects for the vitamin study group of the Medical Research Council by Professor Sir Nicholas Wald showed conclusively that supplementing the diets of women with folic acid, a naturally occurring nutrient found in spinach, liver or Marmite, prior to conception and during the first trimester of pregnancy could reduce the incidence of NTDs by up to 70%. In response to the data, the Conservative Government at the time introduced new guidelines that recommended that all women should take supplements of folic acid prior to conception and during the first 12 weeks of pregnancy.

Eighty-one other countries around the world, however, including the United States, Brazil, Australia, South Africa, Nigeria, Indonesia, Argentina and Canada, took a far bolder position, mandating the fortification of flour and flour-based products in their countries with folic acid as a public health intervention for whole societies. They did so having recognised the data and the long-established fact that at least 40% of pregnancies are unplanned, so NTDs might develop in the womb often even before those women realise that they are pregnant.

The recommendation of voluntary supplementation in our country led to an initial increase in the number of women taking folic acid before conception. The proportion went up to 35% in 1999,but by 2012 it had started to fall back, to just 31%, with much lower numbers seen in the more deprived socioeconomic sectors of society and in black and minority ethnic communities. Among pregnant women aged less than 20, on average just 6% supplement their diet before conception.

In short, the position that we have taken in our country under successive Governments has led to increasing health inequalities, with poorer, more marginalised and younger women having greater risk of their children being born with spina bifida or other conditions. By contrast, in the United States, which in 1998 started mandatory fortification of rye and wheat flour, and in 2016 introduced a new programme to fortify corn flour so as to target the Hispanic population, we have seen a reduction in NTD pregnancies of almost 30%. In Canada, one study of the prevalence of NTDs showed a drop from 4.56 births per 1,000 to 0.76 per 1,000 after fortification. Had we in this country followed the same route as Canada or the US, we would have seen 2,000 fewer pregnancies with a neural tube defect between 1998 and 2012. That is a sobering thought for the advisory committee in the UK to consider.

In fact, the scientific evidence in the case for fortification is not really contested. That is why the Scientific Advisory Committee on Nutrition to this Government and previous ones—it used to be called COMA, the Committee on the Medical Aspects of Food Policy, but understandably changed its name—back in 2000 responded to the evidence and to the US move by recommending that our country should go down the route of mandatory fortification. SACN repeated that recommendation in 2006, in 2009 and in July of last year.

The most recent SACN report, surveying all the evidence available around the world about the benefits and the possible adverse consequences of folic acid fortification, stated:

“Conclusive evidence from randomised controlled trials…has shown that folic acid supplementation during the early stages of pregnancy can reduce the risk of the fetus developing neural tube defects”.

It goes on to maintain its view, expressed consistently by scores of scientific advisers to the committee over the years, that Britain should be fortifying our flour to prevent NTDs. The key question as far as I am concerned—not as a clinician or expert, but as someone who understands the value of evidence-based policy making—is this: why have this Government and previous Governments not acted on the advice and the evidence to take similar steps in our country?

The principal excuse offered by Ministers is that the evidence is mixed and that some studies have shown some possible risks associated with having higher levels of folic acid or folates in our bodies. In particular, two risks have been talked about: first, that higher levels of folates may mask vitamin B12 deficiencies in individuals, possibly leading to anaemia and neurological damage; and secondly, that higher doses of folic acid might run the risk of increasing the likelihood of certain cancers. As far as I can see, however, all the evidence and the science produced over the intervening 25 years have largely debunked such concerns.

The SACN has looked at all the evidence in last year’s review and previous ones and stated, on the issue of B12, that folic acid intakes up to 1 mg per day are not associated with neurological impairment in older people with low vitamin B12 status. The most recent SACN review stated that

“studies of folic acid supplementation and observational studies, indicate either no relationship with cognitive decline or a lower risk associated with higher folate status.”

It goes on to note:

“The prevalence of vitamin B12 deficiency with or without anaemia did not increase after mandatory fortification in the USA.”

Since the SACN provided that evidence, a further, critical study has been done by Professor Sir Nicholas Wald, who produced the original research suggesting the use of folic acid in flour, and Professor Sir Colin Blakemore, who is well known to right hon. and hon. Members. The study shows definitively that there is no evidential base for the suggestion of a maximum tolerable level for folic acid. The question of it masking vitamin B12 is therefore no longer taken seriously by the scientific community in our country or overseas as a reason for not introducing folic acid into flour.

On the potential connection between high folate levels and overall cancer risk, again I quote the SACN’s latest review:

“Findings from the different study types are inconsistent but overall do not suggest an adverse association. RCTs”—

randomised controlled trials—

“show no effect of folic acid supplementation on overall cancer risk. The MTHFR genetic studies suggest higher folate concentrations reduce overall cancer risk.”

Again, observed data from America, Canada and other societies do not show any adverse effects of increased cancer risk.

Support for the notion of mandatory fortification comes not just from our country or the SACN, but from a volume of organisations that I shall reference at some length: Shine, the brilliant spina bifida and hydrocephalus charity in this country; the Royal College of Obstetricians and Gynaecologists; the Royal College of Paediatrics and Child Health; the Royal College of Midwives; the British Maternal and Fetal Medicine Society; the Faculty of Sexual and Reproductive Healthcare; the British Dietetic Association; the Governments in Wales, Northern Ireland and Scotland, where only last year the Scottish Government said that they wished to introduce mandatory fortification but were unable to do so on a Scotland-only basis; the chief medical officers in England, Wales, Northern Ireland and Scotland; Public Health England; Public Health Wales; NHS Health Scotland; Health and Social Care in Northern Ireland; the Faculty of Public Health; the Food Standards Agency; Food Standards Scotland; Colin Blakemore; Nick Wald; Jeff Rooker; and me.

There are many people who think this is a very clear case where the evidence should lead to a policy change. Why do the Government not agree with their own advisers and with the overwhelming majority of scientific opinion? Why, in the light of the evidence, do they appear to have dragged their feet—not just this Government, but the previous Labour Government and, indeed, the Conservative Administration before that?

On 2 May, in response to a written question from my hon. Friend the Member for Coventry South (Mr Cunningham) on the case of mandatory fortification, the Minister said:

“No assessment has been made of potential merits of adding folic acid to flour on pregnant women or children.”

That seems to be slightly at odds with what I have been saying for the past 10 minutes—that there seems to be a lot of evidence in support of it. He went on to say that the recent SACN report, which was published in July 2017,

“made recommendations in respect of folate levels and developing foetuses. Ministers are currently considering the issue of mandatory fortification and will set out their position in due course.”

We find ourselves here because I am looking for the Minister to set out the Government’s position in due course. They have had a quarter of a century to mull over the position, in the light of the evidence. I know the Minister, who I have great regard for, is a man of action. I look forward to him setting out the Government’s case and getting on with it.

It is a pleasure to be here under your chairmanship, Mr Hanson. I congratulate the hon. Member for Pontypridd (Owen Smith) on securing this important debate and on the eloquent and cogent way that he set out the case for the fortification of flour with folic acid.

When the facts are set out and the evidence is adduced, it is a very compelling case. It is all the more surprising, when one hears the weighted evidence of the arguments in favour of it, that something has not yet been done in this country to ensure the mandatory fortification of flour with folic acid. The hon. Gentleman said that that has happened in many major countries across the world with vast populations. He mentioned Brazil, the United States and Canada; they are big countries with very strong regulatory regimes in which this practice has been carried out. Therefore, there have been multiple opportunities to have all the scientific evidence evaluated and to have all the upsides and downsides considered. It is very clear that the upsides are so massive that they require this country to follow suit. It is a shame that we are not yet in a position in this country to have mandatory fortification of flour.

It has been 27 years since the Medical Research Council published its research demonstrating that supplementing women’s diets with folic acid before the early stages of pregnancy reduced the chances of the pregnancy being affected by neural tube defects. That was in 1991. It was in 1990 that my son, Andrew, was born with spina bifida. Very soon after he was born, we became experts in the whole area of spina bifida: the reasons for it, how it develops and all the rest of it. Even back then, the great Professor Norman Nevin, who was an expert in the field in Belfast and did a lot of research, was a massive advocate for the mandatory fortification of flour, even before it was widely known about. He wanted to ensure that young parents who were planning to have children were better educated about the need to take folic acid and the general low levels of folates in the adult population and young people generally, because it was a massive problem and would store up big problems in future.

The reality is that as a result of not taking those measures, children are born with spina bifida or anencephaly. Children need not be born with those conditions if the parents have the right information and the mothers take folic acid at the appropriate time. The evidence shows, and it has been spelled out already, that it is too late once pregnancy has started. Many pregnancies are unplanned; many people even today, in 2018—never mind back in 1990 when my son was born—have no awareness of the need to take folic acid. They think it is something rather exotic—why on earth would they even consider such a thing? Even the name sounds a little strange.

People do not take the necessary steps and, as a result, children are born with severe disabilities. That presents great challenges to them, and often life-changing effects on their families. Often, as sadly was the case for my son, these children do not live a long life. Our boy died when he was eight years of age. In the process of his short but extremely rewarding and rich life, he underwent numerous procedures in hospital and numerous hospitalisations, sometimes lengthy. That had an impact on him, his family and his siblings.

The reality is that for all those children who are born with spina bifida and who live with it and are treated, many other children in the womb who are diagnosed with having a neural tube defect are never born. The hon. Member for Pontypridd and I recently hosted an excellent meeting in Portcullis House, which a lot of people attended. One of the things that came out of that was that, sadly, it appears that in this country we effectively deal with this problem simply by terminating foetuses that are diagnosed with a neural tube defect. That is how the vast bulk of these foetuses are treated.

It is a terrible thing that otherwise healthy babies and foetuses are in this situation as a result of a lack of action by society, successive Governments and by all of us, who have not done what other countries have done, which could be done at very little cost with no scientific downside, and which would reap enormous benefits for everybody. This is something that we need to take very seriously.

Over the years, my wife and I have done some work to try to educate people about the need to take folic acid. My wife, very bravely, did a number of television interviews when Andrew was alive. He even appeared on the television programmes. The process of education and telling people is not cutting through. It is not doing the job. It is not reaching the people it needs to reach at the time it needs to reach them, before they fall pregnant. We need to step up to the plate.

I will not repeat the scientific evidence, which has been laid out well by the hon. Gentleman and the groups that support this necessary move. There is a lack of understanding. People sometimes get nervous about the idea of adding things to food for public health purposes. I understand all that, but we already add things to flour and to water—we already make interventions where that is important and necessary. A lot of scientific evidence has been produced. I was struck that Professor Blakemore and the other experts who came to the event we held in Portcullis House said that, scientifically, absolutely nothing more needs to be proved or evaluated. All the evidence is there; we now require action on the basis of that evidence.

I simply add my voice to the plea for the Government to act on the advice of their own Scientific Advisory Committee on Nutrition and listen to the voices of all those who speak in favour of this measure. They should listen in particular to the voice of Shine which, as the hon. Gentleman rightly said, is a fantastic organisation that does tremendous work to help kids with spina bifida and hydrocephalus, and parents who have lost children. As I learned over those many years of intense engagement with clinicians and others, who often said, “Well, you tell us how Andrew’s feeling, because you know better,” parents do know. The Government need to listen to parents and potential parents—people who lost children in the womb or, totally understandably, felt unable to have a child with that condition.

This is a very important issue. It does not seem to me to be taken seriously enough, primarily because, relatively speaking, not a lot of children are born with spina bifida nowadays in the United Kingdom. As I said, I think that is partly because a lot of children with the condition are simply terminated in the womb. If it prevents even one or two children from being born with spina bifida who otherwise would have been born with the condition, this will have been a step well worth taking.

Order. I intend to call the Scottish National party spokesperson, the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), at 5.10 pm. Three hon. Members wish to speak before that, so will they split the remaining time accordingly? I call Stuart C. McDonald.

It is a pleasure to serve under your chairmanship, Mr Hanson. I thank the hon. Member for Pontypridd (Owen Smith) for introducing this debate and for setting out the facts and the science so comprehensively. I entered the ballot to try to secure a debate on this topic, and I was unsuccessful in persuading the Leader of the House to allow a debate in Government time, so I am pleased that he came up trumps. I also thank both him and the right hon. Member for Belfast North (Nigel Dodds), who made an incredibly powerful speech, for hosting the recent Folic Acid Awareness Day event in conjunction with Shine. I was very sorry to miss that.

Both hon. Members mentioned Shine’s fantastic work, but let me mention another charity. I recently battled through the heat of the London marathon to raise funds for two charities, one of which was Spina Bifida Hydrocephalus Scotland. SBH Scotland is a fantastic charity based in Cumbernauld whose specialist staff work across Scotland and are committed to providing a lifetime of information, support and projects to all those affected by spina bifida, hydrocephalus and allied conditions. It, too, is a strong champion of mandatory fortification of flour with folic acid.

Like pretty much everyone else in the Chamber, I believe we are a long way past the point at which mandatory fortification became the right option. Intake of folic acid has been proven to reduce the number of pregnancies affected by neural tube defects, of which spina bifida is the most common. The Government themselves recommend that women who are planning a pregnancy or are within the first 12 weeks of their pregnancy should take a daily 400 microgram supplement of folic acid. However, only 31% of women take the correct dosage, and many do not begin until they are pregnant, when it is too late. We must keep in mind that 45% of pregnancies are unplanned—in those cases, there is no possibility to plan ahead. Overall, 75% of women of childbearing age across the UK are at increased risk of having a pregnancy affected by a neural tube defect due to having lower than the recommended level of folic acid.

There is no evidence to suggest that mandatory fortification would be anything other than beneficial, given that recent research, which the hon. Member for Pontypridd expertly set out, shows there is no longer a basis for setting an upper limit on folic acid intake. As we have heard, the argument is further strengthened by the experience in at least 81 countries, including the USA, Canada and Australia. Importantly, as I understand it, no country that has taken the step of mandating the fortification of flour has gone on to reverse it. It is clearly time for the UK to follow suit.

The issue is particularly pressing in Scotland, where proportionately more children are born with spina bifida than in other parts of the UK and folic acid levels are particularly low—lower than in the UK as a whole, which itself has low levels by international standards. As we have heard, the Scottish Government have supported compulsory fortification of flour for many years. Unfortunately, although power over the issue is devolved to Scotland, the advice from Food Standards Scotland is that realistically, given the way in which the flour and milling industries are structured, a response is better delivered UK-wide. That is what we unite to call for today.

The Holyrood Government, the Welsh Government, the Northern Ireland Department of Health, the Food Standards Agency, Public Health England, the British Medical Association, the Scientific Advisory Committee on Nutrition and all the royal colleges under the sun are on board. The science points overwhelmingly in favour of mandatory fortification, but surely, when we listen to the individuals and families affected by neural tube defects—spina bifida and allied conditions, of which the right hon. Member for Belfast North gave an example—that overwhelming case becomes undeniable. I hope that the Government listen to the science and to the families affected, and act quickly.

I congratulate my hon. Friend the Member for Pontypridd (Owen Smith) on securing this important debate and, as always, making an excellent case in favour of the fortification of flour and the science behind it. I also thank him and the right hon. Member for Belfast North (Nigel Dodds) for organising the recent event in Parliament with the charity Shine, among others. Shine has worked for many years alongside my constituents, the Walbyoffs, on whose behalf I speak.

I will use my short contribution to give a voice to Paul and Liz, whose eldest daughter, Sara, lives with spina bifida. My hon. Friend for Pontypridd explained comprehensively how the conditions caused by a low level of folic acid during a mother’s pregnancy cause neural tube defects in an unborn child. Sara was diagnosed with the condition weeks before the birth of the family’s second child, Alis. Paul and Liz tell me that, had they known that earlier, Liz would have increased her dosage of folic acid during her pregnancy. Indeed, mums such as Liz would have benefited from the extra folic acid boost that would have come from the fortification of flour. The evidence suggests that, in as many as three out of four cases, that could be the difference between a baby being born with a neural tube defect and not.

Like many families across the country with a personal connection to the debate, Paul and Liz cannot understand why the UK has not introduced mandatory fortification of flour. Other food products, such as cereal, are fortified with folic acid; the rationale for excluding flour from fortification is unclear. There is clearly strong support for that among members of the medical profession. David Bailey, the chair of the BMA council in Wales, described mandatory fortification to prevent spina bifida as

“an important and cost effective public health measure.”

On behalf of Paul and Liz, I urge the Government to look at this sensible proposal carefully and to act. As the right hon. Member for Belfast North said, all the evidence is there; all that is needed is action. I hope that the Government listen to this debate.

I, too, congratulate the hon. Member for Pontypridd (Owen Smith) on bringing this debate to Westminster Hall. I congratulate him on presenting his case so well, as he did at the awareness day that some of us were able to get down to. As the Democratic Unionist party spokesperson for health, I am aware of this issue and very supportive of the fortification of flour.

All the speeches we have heard were tremendous. I commend my right hon. Friend the Member for Belfast North (Nigel Dodds) for telling a very personal story. Personal stories in these debates always carry substantial weight. His was a story that he and his wife have walked, and although we might have known something about this issue, we have heard a whole lot more. I commend him on that and assure him of our support. He knows that it has always been there for him, but on days when we tell personal stories we feel it a bit more.

When my parliamentary aide was pregnant, we got a surprise. In the mornings when she was under a little pressure, instead of shouts of “coffee” coming from her desk she would ask for water. By the time of her second baby, we all knew what “no coffee” meant—baby on board. You can imagine the apprehension I felt, Mr Hanson, on a Friday morning when I said to the staff in the office, “Girls, who’s for coffee?” If they said no, I knew they did not want coffee, but was there anything they wanted to tell me? That, however, is by the way. Why did my aide do that? It is simple: she told me, “Coffee makes the baby’s heart beat faster, so I need to stay away from it.” I wanted to make a contribution to the debate because she has lived through this.

Almost every mother I have ever known, as soon as they have that pregnancy test, has made changes to their lifestyle. They do it automatically, and in many cases right away, for the sake of the baby. They stop having alcohol and start on vitamins, reduce caffeine and increase their fruit and veg. By doing that, they naturally create—to use an Ulsterism—a better wee home for their child, which is what the mother is trying to achieve.

This is a personal story from my aide. They are told by the doctor to take folic acid, and of course they do, because it is important, but the problem is that ladies who have been on contraceptive pills find their folic acid store completely depleted. If they have not taken folic acid before pregnancy, it may be too late. With approximately 40% of UK pregnancies estimated to be unplanned, that is certainly an issue, so we look to the Minister for a good response. I mean this respectfully: larger ladies who have a higher body mass index should be taking more folic acid than the usual pregnancy dose. That is not talked about widely, but it is important to put on record how important folic acid is for anyone who is pregnant, and perhaps those showing signs more than others.

I read an excerpt from the NHS Choices website regarding flour and folic acid that made things very clear to me. It describes how a randomised controlled trial from 1991 first indicated that taking 4 mg of folic acid during pregnancy—10 times the current recommended dose—could prevent about 80% of neural tube defects. On the basis of that trial, it was concluded that such defects are due to a vitamin deficiency that needs correcting before pregnancy. However, it said that, despite campaigns, a study of nearly half a million women in England showed that less than a third took folic acid supplements before pregnancy. That tells me clearly that action is needed, and it is needed now.

On adding folic acid to flour, we have potentially been putting fluoride into water, and that has virtually no health benefits. That has only dental benefits, which are about lifestyle choice, and that is different from those suffering because they are not getting folic acid through their diet. It is great that this issue has been brought forward, and we should look to put folic acid into flour and ensure that everyone gets it, because there are no negative sides to that.

I wholeheartedly agree with my hon. Friend. We are already putting additives into many products we eat, to our benefit, and that is what we should be doing.

To return to taking folic acid supplements before pregnancy, of the half a million women in England surveyed, less than a third did so. The figures varied by age, with the highest use in women aged 35 to 39, of whom 38% took it before pregnancy, compared with only 13% of those aged 20 to 24 and 7% of those under 20. There was also a marked ethnic variation, with 35% of white women taking it compared with 20% of south Asian women and 18% of Afro-Caribbean women.

Just under two thirds of all women took supplements in early pregnancy, but the researchers say that that is already too late. The current strategy of encouraging women to take folic acid before pregnancy is inadequate and, in particular, putting younger women and minority groups at a disadvantage. People always talk about stats, but the fact of the matter is that they tell a story—and these stats tell a clear story. When women take folic acid before and during pregnancy, it makes a difference. However, there is clearly either no knowledge or not enough information about it. We look to the Minister and the Government to step forward and do what is right.

I would also like to mention that whenever people come to my office for benefit claims and I see what medication they are on, as we need to do—it must be the same for everybody’s offices—I find it surprising how many are, for different reasons, in receipt of folic acid. That is because folic acid helps to get their bodies back into kilter. That is important: folic acid has benefits not just for those who are pregnant but for those who are in ill health.

While I understand the Government’s reluctance to become a nanny state who enforce rather than guide, we should remember that flour fortification is not new. To white flour, the UK adds calcium, iron, thiamine and niacin to replace the nutrients stripped and discarded when the bran and germ are removed from the wheat grain. That was introduced after world war two to help improve the nation’s heath. We did it then for that purpose, so why in 2018 can we not do it for the purposes we are presenting to the House today? I do not agree with the nanny state argument. Sometimes, Governments have to take the initiative and do things that are important.

Today, milling is even more efficient at stripping the nourishing layers from the endosperm, which means that even less natural folate is left in white flour than there was when replacing other lost B vitamins was deemed necessary. There is, therefore, a greater need today for folic acid than there was in the past—even after world war two, when that was seen to be important.

I will conclude, because I am conscious of the timescale you gave us, Mr Hanson. The Government must consider this issue. I give my full support to the hon. Member for Pontypridd for bringing the debate forward, and to my right hon. Friend the Member for Belfast North and other speakers. We have all come here with the same message, in an attempt to highlight this issue to the Government. Anything we can do to bring healthy babies into this world should be done without any delay. This seems to be a cost-effective way of helping mothers and their babies from the earliest opportunity. I am fond of the Minister, and he knows that. I look to him for a substantial response—no pressure whatsoever—on what we have proposed, with reasons.

It is a pleasure to serve under your chairmanship, Mr Hanson, and to take part in this debate, which has been profound and poignant so far. I thank the hon. Member for Pontypridd (Owen Smith), who gave an extremely good, well-researched, evidence-based case for the fortification of flour with folic acid. There is scientific evidence, and when we know that we can do the right thing, there is no reason not to do so. His case was strong, clinically based and backed by the royal colleges and practitioners we should be listening to.

We heard that every week two children are born with spinal neural tube defects and that, as a result of potential defects, many terminations occur. As someone who has experienced a number of miscarriages in my life, there is nothing more horrendous than losing a baby: you question every single thing that you have done and everything that you could have done. If something like this could make a difference for those individuals who find themselves in that traumatic situation and do not seek terminations and for those who have unexplained miscarriages, we should be doing it.

There is absolutely no cost that can be put on losing a baby that you very much want to have. Often the tragedy of it is that it is unexplained. It is not until it has happened four times—another issue that we must address—that there is even any research into why it might have happened, or happened repeatedly. There are many individuals who may be or have been affected, who might not even know that a simple step such as this could have made the difference. That is certainly a step we must take.

As we have heard, the scientific basis is there. The countries that are leading now and protecting their populations by fortifying their flour with folic acid—I say again, such a simple step—have found no adverse consequences. Those countries have implemented the policy over a long period of time; they are looking at the health benefits and finding that any concerns about health costs were unfounded. The research is unequivocal in that regard and must be listened to.

As has been noted, the Scottish and Welsh Governments have both written to the UK Health Secretary, urging him to take action and introduce mandatory fortification of flour with folic acid on a UK-wide basis, because that is what is required. I am often in debates where there is little consensus across the four nations, but this seems to be one of those unique debates in which we are all saying, “This has to happen,” from across parties and across nations. There seems absolutely no logical reason for not taking this matter forward timeously, to protect families from the trauma of that unexplained miscarriage or of finding out that they have a baby who is very sick, and perhaps having to have a termination that they never wanted, or a difficult discussion regarding how to care for a young child who they want to see reach their full potential and want to give all the love in the world to, but who will have medical complications throughout their life.

I thank the right hon. Member for Belfast North (Nigel Dodds) for an extremely profound and personal account in memory of Andrew. We must pay heed to people’s personal accounts. That is what must guide policy. They are real people who are being affected; we are talking about families, and we must do the right thing. I also thank my hon. Friend the Member for Cumbernauld, Kilsyth and Kirkintilloch East (Stuart C. McDonald), who has done a lot of fundraising in this regard—even running a marathon, which is something I commend him for doing, and unfortunately not something I will ever be able to do myself. The hon. Member for Strangford (Jim Shannon), who is a health spokesperson for his party, made a good speech and asked important questions of the Minister, and the hon. Member for Newport East (Jessica Morden) advocated excellently for her constituents. For once, we are singing from the same hymn sheet. These are small nudges that we can make—small changes that make such a great difference. I urge the Minister to act.

It is a pleasure to serve under your chairmanship, Mr Hanson; I think it is the first time I have had such a pleasure.

I thank my hon. Friend the Member for Pontypridd (Owen Smith) for securing the debate and for his eloquent speech. As always, he showed his knowledge and passion on this important topic. I also thank the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), who speaks for the Scottish National party and mentioned that the Scottish Government have looked at this policy and, as I understand the situation, concluded that it was impossible to bring in fortified flour on a Scotland-only basis because of the fluid nature of the UK food industry and the very fluid nature of flour. I therefore think it is definitely time that the UK Government looked at this issue again.

I thank the right hon. Member for Belfast North (Nigel Dodds) for his brave and personal speech, and I thank my hon. Friend the Member for Newport East (Jessica Morden) and the hon. Members for Cumbernauld, Kilsyth and Kirkintilloch East (Stuart C. McDonald) and for Strangford (Jim Shannon) for their excellent contributions to the debate. Finally, I add my thanks to my hon. Friend the Member for Redcar (Anna Turley), who raised this matter last week during Health and Social Care questions.

As we have heard, this issue has been on the table for decades now, and it is only right that it continues to be brought up at every possible opportunity. The UK Government continue their policy of voluntary folic acid supplementation for women of childbearing age, despite the evidence and the fact that the latest National Diet and Nutrition Survey states that 91% of women of childbearing age have a red blood cell folate level below the level estimated to lower the risk of NTDs. I therefore ask the Minister what he is doing to encourage women of childbearing age to take folic acid supplements. Additionally, what steps is his Department taking to ensure that women of childbearing age even know that they should take those supplements?

Incidentally, this was something that I was aware of when I was having my children 25 years ago. We think things have moved on, but my young researcher in my office said that she only found out about it when she was researching for this speech. So, the message is not out there—not everybody knows this information. The voluntary approach means that, more often than not, those who do not need the supplements will take them, whilst those most at risk will miss out. Young mothers and those from the most socioeconomically deprived areas are least likely to take supplements. What steps are the Government taking to ensure that these groups of women are included and reached?

I am sure that it will not come as a surprise to the Minister that as many as 40% of pregnancies are unplanned, and that means that many women will not have been taking supplements during the crucial phase, just before or just after conception. It therefore makes sense for flour to be fortified with folic acid, to ensure that women get the nutrients that they need in order to reduce the risk of NTDs. That already happens in over 80 countries worldwide, including the United States, Canada and Australia.

Currently, no countries in the European Union fortify their flour with folic acid. However, there is no legislation preventing any of them from doing so. Given the UK’s research on this matter, I believe that they are waiting for us to lead the way, and as we have heard, I believe Scotland is probably doing just that. Why are the Government not therefore taking the opportunity to lead the way and reduce NTDs, not only in the UK but, in turn, across Europe? I understand and sympathise with concerns about adverse effects that this may have on the population. However, there really is no evidence to suggest that from other countries that have fortified their flour with folic acid for many years.

I also note the response of the Parliamentary Under Secretary of State for Mental Health and Inequalities from Health and Social Care questions last week:

“We have advice that if the intake of folic acid exceeds given levels, that can also bring health problems”.—[Official Report, 8 May 2018; Vol. 640, c. 537.]

However, the modelling undertaken by Food Standards Scotland in 2017 indicated that fortification at the recommended levels, with a capping of voluntary fortification and supplements, can achieve the reductions in NTD risk without increasing the number of people consuming the upper recommended limit. Has the Minister made any assessment of that finding, and could he stipulate where his advice is from? Finally, has the Minister’s Department made any assessment in the last five years of the benefits of fortifying flour with folic acid?

From this afternoon’s debate it is clear that there are benefits to the mandatory fortification of flour with folic acid. I really do hope that the Minister will take all of this away with him today back to his Department and reconsider this policy—unless, of course, he is going to announce that he is going to fortify flour forthwith.

Thank you, Mr Hanson. Should that be the miller, Steve Brine? I like the notion from the shadow Minister that the European Union is waiting for us to lead. That is a new concept.

It is a pleasure to serve under your chairmanship for the first time, Mr Hanson. I congratulate the hon. Member for Pontypridd (Owen Smith) on securing the debate and I thank him for devoting it to an issue that I know he cares about. He works closely with Shine, which he mentioned and which was mentioned by others, and is based in his constituency. It does some fantastic work supporting people with spina bifida and anencephaly and their families. I have asked my officials to see if Shine will come in and see me as soon as possible. It is not a charity that I know, so I want to speak to and get to know its staff.

I hope I can reassure hon. Members a little bit—I suspect it will not be a lot—that the Government and those who provide us with expert independent advice are looking incredibly closely at all of this, as I will set out. I will say at the outset that I am sorry to disappoint the shadow Minister, but I cannot give the House an exclusive announcement today, I am afraid. However, I may be able to give some encouragement.

Part of the pregnancy advice currently provided to women is of course to take folic acid supplements. The consequences of folate deficiency in the general population are that pregnant women are at greater risk of giving birth to low birth-weight, premature babies with neural tube defects. Unless someone is pregnant or is thinking of having a baby, they should be able to get all the folate they need by eating a generally varied and balanced diet. Women who are trying to conceive, or who are likely to become pregnant, are advised to take a daily supplement of, we say, 400 micrograms of folic acid until the 12th week of pregnancy. They are also advised to increase their daily intake of folate by eating more folate-rich foods such as spinach and broccoli, which sounds lovely, and foods that are voluntarily fortified with folic acid such as, as has been said, a wide range of breakfast cereals.

As has been said by pretty much every Member who has spoken, around half of pregnancies are unplanned. Of those that are planned, it has been estimated that only half of all mothers take folic acid supplements or modify their diet to increase their folate intake. That is one of the main reasons behind the calls for mandatory fortification and is one of the reasons why the debate was called.

UK wheat flour is currently fortified with calcium, iron, niacin and thiamine in accordance with the Bread and Flour Regulations 1998—introduced under the last Labour Government—which apply in England, Scotland and Wales, with parallel regulations in Northern Ireland. This mandatory fortification is a domestic, not an EU, requirement and is done for public health reasons. It has the primary objective of restoring those nutrients lost during the milling process, with the exception of calcium, which is added in larger amounts than that lost.

To date, successive Governments have not considered that the mandatory fortification of flour with folic acid is the best way of protecting public health and have instead promoted the use of supplements as part of a wide range of pre and post-conception advice to women of childbearing age. That may be merely stating the obvious of where we have come from, but it does not necessarily need to mean where we are headed.

While it may appear straightforward to just add folic acid to the existing mandatory flour fortification measures, a problem that arises with the proposal to move from the current advice of taking a measured supplement is of how to ensure that women are able to assess their folate intake if getting it from foods made from flour instead. Women in the targeted age group may not eat the relevant products in sufficient quantities.

We also want to consider the population’s wider dietary advice, and to educate women to encourage them to achieve a greater folate intake by way of eating those folate-rich vegetables that I mentioned earlier, rather than relying on flour-containing foods, which may not be the best contributor to a balanced diet. It will be necessary to consider properly women’s consumption of all wheat flour-containing products to fully understand the impact of any mandatory fortification on diet and folate intake levels. Additionally, we are aware that the universal fortification of flour with folic acid may not be readily accepted by the general public, especially when the measure is intended to benefit only a specific section of the population.

The aforementioned Scientific Advisory Committee on Nutrition—SACN; it was indeed called COMA—is a committee of independent experts on nutrition that provides advice to Public Health England, for which I have ministerial responsibility, and other Government agencies and Departments across the UK. It has recently updated the evidence on folic acid in response to a request from Food Standards Scotland, which was prompted by Scottish Ministers expressing a desire to proceed unilaterally with the mandatory folic acid fortification of flour north of the border.

In its most recent July 2017 report, SACN saw no reason to change its previous recommendations, made in 2006 and 2009, for mandatory folic acid fortification, to improve the folate status of women most at risk of NTD-affected pregnancies, provided that this is accompanied by restrictions on voluntary dietary fortification with folic acid. Again, this emphasises the need to fully understand all the sources of folate intake by women, to ensure that their health is protected as well as to protect their unborn children. The Wald paper, which is a new scientific paper published on 31 January this year in Public Health Reviews, has again raised this issue. However, the paper suggests that there should be no upper limit on folate intake, which would remove some of SACN’s concerns.

The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment—COT—is another independent scientific committee that provides advice to the Government on, among other things, the safe upper levels for vitamins and minerals. The Wald paper was brought to the attention of COT by its chairman, and COT agreed to take forward for further consideration the issue of tolerable upper limits for folate. COT discussed a scoping paper in March this year and will have its first detailed discussion in July to see whether Wald’s analysis of the data is correct and whether the original tolerable upper level recommendation is not appropriate. COT will then receive a second paper in September considering all of that and is hoping to be able to report its findings towards the end of this year.

I wanted to put that on the record because it is the advice I have been given, but I have to say that, frankly, I am the Minister, and that is not good enough for me. I want it sooner than that, so I have asked COT to come and see me by the end of this month to explain itself and to see whether we can move forward more quickly.

To conclude, I am moved by the testimonies given today. The right hon. Member for Belfast North (Nigel Dodds) is a gentleman and an excellent parliamentarian, and his speech about his son, Andrew, cannot have been an easy one to make. I thank him for putting those personal things on the record in the way he did. There are many issues to consider, but I wholeheartedly agree with the sentiment of the debate. I will do my utmost as the public health Minister, working with other colleagues across Government—this impacts on other Departments as well—to work through the issues to give the best effect to the aim of the debate as soon as we possibly can.

I thank the Minister for his response, but I have to say that I am disappointed by it. I am disappointed principally because I do not think he has taken the action that he could have on the basis of the evidence that has been presented both today and, more importantly, by the scientific community in our country and around the world over the past 25 years, as well as the lived experience of the 80-odd communities, societies and Governments around the world that have undertaken mandatory fortification with no evidence recorded in any studies of any of the potential adverse events in their populations that have been referred to in a few scientific papers.

The Minister concedes that the current process is not working because of low uptake of the advice and because so many pregnancies are unplanned. I am pleased that COT is looking at the Wald paper on tolerable upper limits and the evidence it presents that there is not one, because excess folic acid is excreted. However, I am intrigued to know—I will write to the Minister on this—whether COT has advised the Government not to introduce mandatory fortification and not to follow the advice from their other advisory body, SACN, formerly known as COMA. If it has not offered advice to that effect, I cannot understand where Ministers are getting the advice that tells them not to introduce mandatory fortification.

The only formal advice that Ministers have had from 2000 to 2017 is to do what all Members here and the scientific community have recommended and to get on with mandatory fortification. It is a mystery to me why the Government continue to suggest that there are serious scientific reasons for not doing it. I do not believe that the Government have illustrated that and I do not think that the Minister illustrated that today; unfortunately, I do not think successive Ministers in all Governments have illustrated that.

Today has been a missed opportunity. However, I leave the Minister under no illusion that we will continue to raise this issue and to push for mandatory fortification. I look forward to debating it with him again in the future.

Question put and agreed to.


That this House has considered the mandatory fortification of flour with folic acid to prevent spina bifida and anencephaly.

Sitting adjourned.