Wednesday, 4 May 2016

A scientific report published today by the Food Safety Authority of Ireland (FSAI) highlights the need for women of childbearing age to have higher intakes of folic acid, in order to reduce the incidence of severe birth defects in Ireland. Produced by the FSAI’s Scientific Committee, the report provides a comprehensive update on folic acid nutrition and the efforts to reduce Irish rates of neural tube defects (NTDs) such as spina bifida and anencephaly, which are among the highest in the world. The report examines the effectiveness of increasing women’s folic acid intakes through food supplements and food fortification. This report summarises the options for further reducing the risk of NTD-affected pregnancies in Ireland.

The achievement of optimal folate status is an important public health goal for Ireland, as it is for populations worldwide. Taking folic acid before conception and during the very early stages of pregnancy can prevent up to 70% of NTDs. It is currently estimated that only 36% of women of childbearing age in Ireland have blood folate levels that are adequate for optimal protection against NTDs. One in five young women in Ireland do not consume folic acid at all (non-consumers of supplements or fortified food) and very few of these women have the level of blood folate required to protect against the development of NTDs should they become pregnant.

Since 1993, the policy in Ireland has been to advise all women of childbearing age to take 400 micrograms (µg) of folic acid daily as a supplement, whether they are planning to become pregnant or not. In practice, very few women in Ireland take folic acid supplements as recommended. There is particular concern that women from disadvantaged backgrounds are least likely to follow folic acid recommendations. Voluntary fortification of food with folic acid by manufacturers, which was introduced in the early 1980s, has made a significant contribution to reducing the risk of NTD-affected pregnancies in Ireland. However, the approach has been shown to be less effective than mandatory fortification schemes in countries such as the US, where rates of NTDs are significantly lower than in Ireland.

The report by the FSAI’s Scientific Committee proposes that one of two options should be implemented to reduce risk of NTD-affected pregnancies in Ireland. Both options have been presented to an expert group on folic acid set up by the Minister for Health:

Option 1: Mandatory fortification together with voluntary fortification and advice on supplementation Mandatory fortification of bread or flour in Ireland to provide about 150µg of folic acid per day in women of childbearing age could reduce the prevalence of NTDs by approximately 30%. This should be accompanied by advice to all women of childbearing age who are capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement. Voluntary fortification of foods with folic acid would continue. Mandatory fortification of flour or bread with folic acid would require legislation. Compared to the other option, this option has stronger evidence to support its effectiveness in further reducing the rate of NTD-affected pregnancies from the current rate.

Option 2: Voluntary fortification together with advice on supplementation Continuation of current policy to advise all women of childbearing age who are capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement. Voluntary fortification of foods with folic acid would continue and there is potential to improve its effectiveness by providing guidance on voluntary fortification of selected foods with folic acid by manufacturers, e.g. for levels of fortification and the range of foods fortified, in conjunction with a voluntary labelling scheme. Compared to Option 1, this approach has weaker evidence to support its possible effectiveness in further reducing rates of NTD-affected pregnancies from the current rate.

Commenting on the report, Dr Mary Flynn, Chief Specialist in Public Health Nutrition, FSAI states that the low folate status of women of childbearing age remains a significant problem in Ireland, contributing to an unacceptably high rate of NTDs.

    “There is conclusive scientific evidence linking low levels of folate with spina bifida and related birth defects, and this a major challenge given the low levels of folic acid in the Irish diet which needs to be addressed,” says Dr Flynn. “Today’s report looks at ways to increase folate levels either through a system of mandatory fortification of food staples, such as bread and flour, or through improvements in the current voluntary approach. In addition to dietary intake, we continue to advise that the most effective way to protect against NTDs is for all women of childbearing age to take 400µg of folic acid every day through a supplement. Unfortunately, this advice is not being followed by most women in the target group and this is a particular concern given the link with birth defects. Ongoing and sustained information campaigns are therefore required to promote the use of folic acid supplements as part of a national strategy to reduce birth defects.”

Additional recommendations outlined in the report:

• Guidance should be provided to food manufacturers for voluntary food fortification with folic acid to support the effectiveness of the chosen national policy.

• Advice to women of childbearing age capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement should be actively promoted and its effectiveness monitored.

• A comprehensive nationwide register of pregnancies affected by congenital birth defects including NTDs, underpinned by specific legislation, needs to be introduced in Ireland. In addition, a national retrospective study on the incidence of NTDs in Ireland since 2012, should be undertaken.

• There should be on-going monitoring, informed by international best practice, of dietary intake and blood levels of folate, including folic acid in the food supply, total folate intake and corresponding blood folate status for the target group (women of childbearing age) in addition to other population sub-groups.

• The policy should be reviewed on a regular basis to assess its effectiveness and safety.

Update Report on Folic Acid and the Prevention of Birth Defects in Ireland