Blog: What next for fortifying flour in Northern Ireland to help prevent birth defects?

15 Jan, 2024

The UK is in line to be the first country in Europe to fortify flour in a bid to reduce the occurrence of certain birth defects.

In this blog, Dr Jenny Mack, Consultant in Public Health Medicine, shares some insights on why this measure is being introduced in the UK and what this may mean for Northern Ireland.

Why has this measure been agreed by the UK government?

Folic acid plays a very important role in the development of the brain, skull, and spinal cord of the foetus. Despite decades of efforts to enhance the use of folic acid supplements, there are still many women in the UK who do not have enough folic acid in early pregnancy. Being deficient in folic acid means the woman’s developing baby is at risk of a neural tube defect (NTD). This is important, as NTDs can lead to serious health problems, including long-term damage to the nervous system, disability and unfortunately, death.

Evidence reviews conclude that more NTDS could be prevented if broader population health measures were introduced, specifically if flour was fortified with folic acid. This measure will help ensure that women with unplanned pregnancy, and those that have not taken supplements before they discover they are pregnant, can also be offered some protection for their baby. Adding folic acid to food products, a process known as ‘fortification’, has been implemented in around 80 countries across the world. In countries where folate fortification has been rolled out, NTDs have fallen.

In the USA, folic acid fortification of cereal grains was mandated in 1998. This was associated with a decline in NTDs which was maintained for more than a decade. At the same time, fortification led to an increase in folate levels amongst women of a childbearing age in the general population. This video produced by the CDC tells the story of how evidence influenced the policy decision in the USA.

A study in the British Medical Journal estimated that 2,000 pregnancies associated with NTDs would have been prevented by 2012 if the UK has adopted the same fortification regimen as the USA in 1998.

What is the potential benefit to health in Northern Ireland?

The UK government and devolved administrations have proposed the addition of 250µg of folic acid per 100g of non-wholemeal wheat flour. If these regulations are enacted fully, this would be a major step towards the prevention of a substantial proportion of NTDs. This is particularly important for Northern Ireland, where the population is at higher risk of NTDs due to higher levels of social deprivation, evidence of a less nutritious diet among women of childbearing age and some evidence of lower levels of folate in women who may become pregnant, when compared to other regions in the UK and in comparison to Ireland. Estimates of the incidence of neural tube defects are not routinely published in Northern Ireland, in part due to the absence of a standardised congenital anomaly register in the region. Estimates from Hospital Information Branch suggest that there were around 48 admissions, and tragically 6 stillbirths, attributable to NTDs in the region in 2018. However, due to small population size in Northern Ireland and no bespoke register, developing appropriate incidence estimates and assessment of trend needs further careful epidemiological analysis.

So why hasn’t this been implemented in Northern Ireland?

The UK government agreed to fortify flour with folic acid in an announcement in September 2021. Devolved governments in Northern Ireland need to amend their regional Bread and Flour Regulations to see the measure implemented in the region. It is now over a year since interested parties, including IPH, submitted a response to the Department for Environment Food and Rural Affairs (DEFRA) consultation on Northern Ireland’s ‘Bread and Flour’ regulations. A consultation report detailing the responses received and the government response was released on 17 January 2024. There were 23 responses from Northern Ireland to this consultation.
The report states that the UK government and devolved administrations have carefully considered the responses received and intend to proceed with the proposals as set out in the consultation, with the exception of the proposal to exempt flour used as a minor ingredient (less than 10% of the final product). A UK-wide monitoring group has been set up to develop an evaluation of the proposed implementation of amendments to the Bread and Flour Regulations, relating to micronutrient levels. The monitoring group is chaired by Food Standards Scotland and comprises colleagues from the Department of Health and Social Care; the Department of Health Northern Ireland; Welsh Government; Scottish Government; the Department for Environment, Food and Rural Affairs; and the Food Standards Agency in Northern Ireland. The group is considering monitoring at a UK level as standard and at the devolved administrations level where feasible, for both positive and postulated negative impacts of the policy. Political support for this measure exists, with Lord Dodds of Duncairn particularly active on the issue in the House of Lords and in the All-party Parliamentary Group on Folic Acid Fortification at Westminster.

What about Ireland?

In Ireland the topic of NTDs recently came into the spotlight with concerns over outcomes for children with spina bifida undergoing surgery. There has been some, but limited, discussion on issues of prevention, data monitoring and surveillance. The Minister for Health recently responded to a parliamentary question on the fortification and the prevention of NTDs. The Minister’s response indicated that before any policy position is reached on folic acid fortification, stakeholder consultation would be required, and that in the short-term other measures would need to be optimised, such as folic acid supplementation and dietary folate intake.

What measures are needed to further reduce NTDS on the island of Ireland?

Alongside fortification, IPH suggested the development of a Northern Ireland strategy to reduce NTDs at a population level. A strategy could help to co-ordinate a suite of preventative actions, including fortification, but also optimise the use of supplements, monitor incidence and enhance preventive approaches for higher risk pregnancies. IPH recommended investment in a monitoring system to assess levels of fortification, adequacy of folate levels in women who may become pregnant and incidence of NTDs. Baseline estimates have recently been established in other regions of the UK which will enable the impact of fortification to be evaluated.

There is much to learn from the New Zealand experience. Despite some failed attempts to progress the measure in 2007, Manatu Hauora (New Zealand Ministry of Health fully introduced mandatory fortification in August 2023, within two years of announcing government support in 2021. The government championed the legislation as a health inequity investment – capturing learning from fortification in Australia to show the additional benefit to indigenous women and protecting women, babies and families in underserved communities.