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Westminster Hall

Wednesday 19 October 2005

[Mr. David Amess in the Chair]

Spina Bifida and Folic Acid

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Coaker.]

9.30 am

Mr. Stewart Jackson (Peterborough) (Con): I am delighted to have the opportunity to debate such a vital issue. I shall endeavour to keep my remarks reasonably brief, and without having recourse to a welter of scientific data.

At the outset, I pay tribute to the Association for Spina Bifida and Hydrocephalus, the national charity that is located in my constituency, to its staff and volunteers, and to the thousands of families who have coped with that terrible disability over the years with love, compassion and fortitude.

The Government have the opportunity to prevent thousands of pregnancy terminations and severe disability for hundreds of children and young people, and so improve the nation's health, by fortifying flour with folic acid. Since the landmark Medical Research Council international study of 1991, the efficacy of fortifying foods with folic acid to prevent the most common neural tube defect, spina bifida, has been proven beyond doubt. Lost opportunities since then fly in the face of the UK's strong tradition in preventive medicine and public health. In short, the condition is as preventable as polio was—and is.

Spina bifida is a neural tube defect and one of the UK's most common congenital malformations, leading to paralysis and incontinence. A major secondary complication is hydrocephalus—excess fluid on the brain that can lead to brain damage if untreated. It occurs early in pregnancy, at about four weeks, when the spine and the brain are being formed. One or more of the bones fail to develop properly, leaving the spinal cord exposed and the cord and nerves damaged to a variable extent.

Although the incidence of neural tube defects has been reduced over the past 30 years from 3.8 per 1,000 births to approximately 1.8 per 1,000, due mainly to better antenatal screening, about 1,400 pregnancies still occur each year in the UK which result in about 1,200 elective terminations and 200 live births. Sadly, our rate of neural tube defects ranks among the highest in the world.

I turn first to the detailed evidence in favour of fortifying with folic acid enriched products such as flour and bread. Folic acid is the synthetic form of folate, a water-soluble vitamin in the B-complex group, which occurs in a variety of foods such as green vegetables, beans, pulses and grains, yeast and beef extracts.

Following the 1991 Medical Research Council vitamin study, which found that more than 70 per cent. of neural tube defects were preventable, the Department of Health's expert committee recommended in 1992 that
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women planning pregnancy should increase their intake of folic acid by eating foods high in folate, by taking a 4 mg folic acid supplement daily, and by eating foods fortified with folic acid, such as certain types of bread and breakfast cereal. Academic studies have also shown that if the supplement intake were increased to 5 mg a day, up to 85 per cent. of neural tube defects could be prevented.

The most recent evidence for that can be found in the British Medical Journal of 12 March 2005. The Health Education Authority launched a campaign promoting the benefits of folic acid in 1996, and it remains of the same view today. In January 2000, the Committee on Medical Aspects of Food and Nutrition Policy published a report under the auspices of the working group on folic acid, in which it recommended mandatory universal flour fortification at 240 micrograms per 100 g flour in the UK. That would have

The then Minister for Public Health, the hon. Member for Pontefract and Castleford (Yvette Cooper), welcomed the report's findings and promised a wide-ranging public consultation on its conclusions. The results of that consultation showed that 59 per cent. of those consulted who expressed an opinion supported the fortification of wheat flour with folic acid, with 30 per cent. against it and 11 per cent. expressing reservations.

In 2005, in the American journal Pediatrics, a mammoth study of 11 million births and 4,468 cases of spina bifida showed that the incidence of neural tube defects in infants fell by up to a third in some ethnic groups following the increased enrichment of grain products with folic acid throughout the 1990s.

In 2002, against that background of strong empirical evidence, the Food Standards Agency decided, perversely, not to recommend the mandatory fortification of flour with folic acid, and that approach was confirmed by the Department of Health in June 2004. That is despite the experience in countries such as Canada, Chile, South Africa and, of course, the United States, where recommendations regarding the need for folic acid in early pregnancy are integral to a policy of promoting the widespread fortification of flour. The entire population receives at least a small additional amount of folic acid, with evidence showing that such a population-wide approach is effective in reducing the incidence of neural tube defects. Since 1998, at the direction of the US Food and Drug Administration, enriched cereal grains have been fortified with synthetic folic acid throughout the United States.

Above all, we must remember that taking pills cannot prevent or ameliorate neural tube defects per se, because many pregnancies are unplanned, and if prevention is to be effective, the women's folate status has to be high, not after she falls pregnant, but at the time of conception and immediately afterwards.

Unfortunately, awareness of such issues among women is declining, despite the laudable efforts of various public health campaigns, recent Department of Health advice in its leaflet, "Thinking of having a baby: Folic acid—an essential ingredient in making babies", and the work of the National Institute for Health and Clinical Excellence. A MORI poll for Action Medical
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Research in October 2000 showed that only 56 per cent. of women of childbearing age—those between 15 and 55—were aware of the health benefits of folic acid for unborn babies.

In analysing preventive strategies against neural tube defects across Europe, the British Medical Journal study of March 2005 that I quoted earlier specifically discounts the efficacy of recommending the peri-conceptional supplementation of folic acid in planned pregnancies as "not effective enough". Supplementation simply does not work. In addition, studies show that the relatively poor bio-availability of natural food folate, as a result, for example, of cooking, leads to a degree of deficiency in any case. The report also stated:

That is because such defects disproportionately affect poorer people. Poor diet and poor education continue to account for the fact that lower socio-economic groups are more susceptible to neural tube defects.

Let us turn briefly to the safety issues sometimes cited by participants in the debate on this issue. Research studies using folic acid at high doses have shown no evidence whatever of toxicity. Folic acid is safe, even at levels very much higher than those advocated to prevent neural tube defects, such as those recommended by COMA. In particular, and unrelated to toxicity, there is a concern that the "masking" of vitamin B12 deficiency has arisen—that folic acid could delay the diagnosis of that deficiency—but there is no evidence of that occurring, even in countries with fortified flour, as a recent US study concluded. The COMA report expressly dismissed those concerns in 2000. Indeed, there is evidence that older people would in any case benefit from folic acid fortification.

Let us briefly examine the possible technical obstacles to fortifying flour. There are none. There are issues in the marketplace relating to labelling and trade, but that is all. Not unreasonably, the baking and milling industry has indicated that it requires a Government directive before implementation across the board. Voluntary fortification has increased, but applies to only a very small proportion of the bread market.

We have reached a crossroads, and public policy on this issue is in a state of inertia. It is sad to note that the rate of neural tube defects remains at 1.8 per 1,000 pregnancies and has been at that level for 17 years, since 1988. We await with interest the detailed report and recommendations from the Scientific Advisory Committee on Nutrition, which the Minister advised me in a written answer on 12 September would be published later this year. We shall see. Unfortunately, judging by past performance, we are likely to see obfuscation, evasion and delay, particularly from the Food Standards Agency. Why? The facts are clear for all to see.

About three quarters of neural tube defects could be prevented if all women took a daily dose of 4 or 5 mg of folic acid before pregnancy. Flour fortification at the COMA-recommended level, resulting in an increase in folic acid of about 0.2 mg a day, would prevent 300
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neural tube defects annually in the United Kingdom. There is a need for an effective public health strategy based on folic acid fortification of flour to an effective level. No other single public health measure could prevent as many serious congenital defects and the tragedy of so many pregnancy terminations. Folic acid fortification would be practical, feasible and safe and would even deliver benefits for cardiovascular health, as some studies have found.

Even as a libertarian, I confess that I have no truck with the arcane debates about the state versus the individual. We must be pragmatic and practical, as we have been in the past. If we had not been, we would still have a country full of children disfigured by polio, despite the fact that a vaccine was available to lift that terrible burden from them. The Minister can help to lift a terrible burden today from the hundreds of families who may in future endure heartache and be required to care for their loved ones in a way that goes beyond the bounds of most people's experience and endurance. Let us remember that we are talking about a congenital condition that is largely if not wholly preventable. We have seen the evidence from across the world. We now require the political will and the courage to take the tough decisions needed to improve the lives of our fellow citizens. I hope and trust that the Minister will rise to that challenge.

9.44 am

David Simpson (Upper Bann) (DUP): Will the Minister tell us how much finance the Government have put aside for the current financial year for research into spina bifida?

Mr. David Amess (in the Chair): Order. I had been advised that the hon. Gentleman wanted to make a speech. Is that the case?

David Simpson : No.

Mr. David Amess (in the Chair): No other Members want to speak, so Opposition spokesmen may now speak.

9.45 am

Sandra Gidley (Romsey) (LD): There is a limited amount to be said on the subject, and I do not intend to repeat what the hon. Member for Peterborough (Mr. Jackson) has already said. I congratulate him on securing the debate. I note with interest the fact that we have discussed the subject before. Four years ago, the previous Member for Peterborough also called for an Adjournment debate on this matter. Depressingly, we do not seem to have moved on very much in those four years. I shall return to the final remarks of the then Minister in a moment.

It is worth discussing briefly the sort of advice that women receive these days when planning their pregnancy. Given that many pregnancies are unplanned, there is clearly a problem, because the folate status of many women will not be at the required level. Someone might not want to take medication. Moreover, it is quite difficult to reach the required level simply by eating a diet rich in folates. One needs to drink about
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10 glasses of orange juice a day or to eat a perfectly obscene amount of Brussels sprouts, neither of which is probably very good for you.

The National Institute for Health and Clinical Excellence confirmed that all women should be advised to take supplements preferably for about a month before they start trying to conceive, and to continue to take them for the first three months of pregnancy. I remember that when I worked as a pharmacist, women were put on a higher dose of 5 mg of folic acid if they were considered to be at risk. That advice was revised more generally for the wider population to say that a 400 microgram-a-day supplement should be sufficient.

Studies have shown that, apart from the period when quite a high-profile campaign was run about this, only about a third of women have any idea that they should be doing something about their folate status. Most women do not see a midwife before they become pregnant. That simply does not happen, so it is too late to act on that advice by the time one has one's first appointment with the midwife—an appointment made despite the shortages.

The current situation has, I believe, been outlined, but I should point out that recent research shows that 1,420 pregnancies were affected by neural tube defects, 90 per cent. of which resulted in a termination. One can argue whichever way one wants, but the NHS can ill afford the cost. There is certainly a cost to the women who must cope with terminating a pregnancy that may have been much wanted. We should not underestimate that cost, because this is not only about pounds, shillings and pence, but about women's lives and about something that could easily be prevented.

The long and the short of the issue is this: should we be fortifying flour because, as has already been pointed out, by the time most women know they are pregnant, it is too late to start taking the supplements? I was a little uneasy about the idea to start with. The Liberal Democrats consulted on it in a recent review of health policy. Some people were quite against the fortification of foods in the same way they are against the fluoridation of water. The difference with flour is that we do not have to fortify everything; we can make sure that an alternative is available, if one is needed for some reason. It can, for example, be a problem if epileptics have too much folic acid, so there could be an alternative available for them.

The situation is much the same with salt; most people do not realise that, years ago, iodine was put into salt in many parts of the world to help counter certain deficiencies. There are many precedents of putting substances and vitamins into products. Nearly every breakfast cereal is fortified in some way. Margarine—for those who eat that disgusting stuff—is fortified with vitamins A and D. At the time, these changes were all regarded as public health measures. It seems clear that we should seriously consider the fortification of flour and flour products, as long as there is an alternative.

The evidence from the United States seems to show that the fears about masking B12 deficiency and potentially pernicious anaemia in older people were unfounded. We would do well to consider that. We should also bear it in mind that 38 other countries have adopted the measure.
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Looking back at the last time we had such a debate, I see that the then Minister said the Government took the issue seriously and were looking into it, and that various recommendations were coming out. However, we have not heard anything on the subject from the Government since. This is a timely opportunity for the current Minister to tell us what the Government will do to address the problem.

9.51 am

Dr. Andrew Murrison (Westbury) (Con): I congratulate my hon. Friend the Member for Peterborough (Mr. Jackson) on raising this topic for debate. Having spoken to him, I know that he feels passionately about it. The debate is timely, as we really ought to be reviewing what progress the Government have made. I commend ASBAH, which has done a great deal to raise the issue.

First, I shall set some context. As part of my preparation for this debate, I looked into our country's performance as regards child health and perinatal mortality. I must say that we do not do particularly well compared with European countries such as France, Germany, Italy and Spain. Indeed, the rise in stillbirths recently reported by the confidential inquiry into maternal and child death is alarming and, when we are talking about spina bifida and neural tube defects, we need to set that in a wider context. I hope that when the Minister speaks, she will spare just a couple of minutes of the ample time that will be available to her to let us know what her Government are doing to improve the health of children, particularly the very young.

UNICEF figures on low birth weight for this country are particularly revealing. The latest figures available, which are for 2004, show that 8 per cent. of children in this country have low birth weight, compared with 6 per cent. in Spain and Italy, and 7 per cent. in Germany and France. We appear to be at the lower end of the European batting order. Most people in this country would find that unacceptable. We hope that a Health Minister will address those adverse comparisons when making policy.

In a similar vein, we looked at what the European health report of 2005 said about the burden of disease for young children in the European region. We found that the figures for disability-adjusted life years per 1,000 births for conditions early in life were unflattering—those for neonatal mortality were even more so—with the European average for countries that pretty well approximate to our own at about 4, with France at 4.2, Holland at 4.9, Spain at 4 and Germany at 4.8, while Poland is at 5.3 and the UK at 7.2. It is unacceptable for our country to have figures that tend towards the eastern European average rather than that in comparable countries.

I shall deal now with the specifics of spina bifida. We are understandably reluctant to introduce compulsion in this country in place of informed choice. My hon. Friend has mentioned the Health Education Authority's campaign in 1996, which appeared to have been successful in raising the prominence of spina bifida awareness. Since the campaign ended about five years ago, we have seen a decline in the understanding of neural tube defects. Although I understand the Government's reluctance to introduce compulsion, and
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I share some of those sentiments, I think that much more could have been done in the interim to revisit the authority's campaign.

Sandra Gidley : Does the hon. Gentleman agree that the problem with a campaign is that it must be ongoing? The cohort of women who are interested in the subject is perpetually renewing itself. Women who become pregnant today may have been teenagers when the campaign was running, so they may not have been aware of it. The subject is not one about which mothers talk to their daughters. There is a continued need for education which is not being fulfilled.

Dr. Murrison : The hon. Lady is quite right. I disagree only in so far as to say that mothers do talk to their daughters about such issues. I hope that those mothers will remember some of those education campaigns. From my relatively recent experience, there is a memory among women of the need for folate. It has entered into our lexicography in a way that it previously perhaps had not, so the campaign did have value. However, I agree entirely with the hon. Lady that it must be revisited. The issue must be on the agenda all the time. The level of risk, sadly, has not changed, so we must ensure that women are constantly aware of the need for folate. There is no doubt about that. I hope that when the Minister makes her remarks she will be able to give us some encouragement that a campaign of the type that was carried out in the mid-1990s will be reintroduced. That would be very useful.

The hon. Member for Romsey (Sandra Gidley) mentioned the analogy—if it is an analogy—between the fluoridation of water and the addition of folate to flour and bread. I think that there is an analogy, and I shall probably annoy dentists by saying that there is a substantial difference between dental caries and neural tube defects. Neural tube defects are potentially devastating, and we must do what we can, in public health terms, to reduce their incidence.

Another difference, as the hon. Lady pointed out, is that we have an element of choice with bread products, or an element of choice can at least be introduced. Fluoridation of water, however, means that most people have no choice. There is a stark difference between the two. It is perhaps slightly ironic that the Government seem to be quite keen on the fluoridation of water, yet that enthusiasm has not been matched to date in their views on the addition of folate to flour products. It would be interesting to hear the Minister's thoughts on that.

I am old enough to remember at medical school the axiom that one did not give folate before checking an elderly person's B12 status. Twenty years on, that debate obviously continues. I am interested in recent research that suggests that the risk to an elderly person is more hypothetical than real. Nevertheless, those who specialise in health care for the elderly are concerned that, in providing folate in flour products, we may mask B12 deficiency. The pernicious anaemia will be treated, but the neurological consequences of B12 deficiency, which are the serious consequences of that deficiency, will not. I imagine that the Minister has that in mind and it may have informed some of her reluctance to take action up to this point.
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We have also heard that certain anti-convulsants and folate do not really mix and that folate affects the efficacy of sodium valproate in particular. Those groups that champion people with epilepsy are concerned, perhaps, that the addition of folate to food might have adverse consequences. That can be managed, and strategies would allow it to be managed reasonably well. It is probably not an insurmountable obstacle, but it is a factor.

COMA's recommendations in 2000 were fairly unequivocal, yet the Government decided that the Food Standards Agency should look at the matter. One wonders sometimes whether the agency is scratching around for things to do. I will make no further comment than that. Having the FSA look at the matter seems to have been kicked it into the long grass; the agency has been considering it since 2002. I hope that the Minister will be able to tell us where it has got to.

We need a definitive plan. It is no good passing the proposal on to agencies so that no action is taken. The Government need to decide whether they are going to do it or whether they will pursue a libertarian line, which would be perfectly understandable. We need a statement from the Minister about which route she intends to take.

I hope that the hon. Lady will also look at ways of encouraging food manufacturers to add folic acid in a way that stops short of compulsion. Notwithstanding the remarks of the industry, I am sure that that might be achieved through the various interventions open to the Minister. Perhaps she has some thoughts as to how we can get around the sticky issue of introducing compulsion. In this country we are naturally reluctant to have things added to our food. We all enjoy watching "Big Brother", but we do not particularly want Big Brother ordaining what we shall eat, and most people in this country have little choice about the bread that they eat. Perhaps the Minister will consider the possibility that wholemeal flour might not have folate added if she is minded to ask manufacturers to add folic acid into bread more generally. People need to have an element of choice in their diet.

I hope that the Minister agrees that it is highly desirable that foods are labelled in a way that is accessible to people so that they can make their own choice. There will be those who decide, for whatever reason, that they do not want that substance, and they need to be able to make the choice. Some will hold that folic acid may have long-term adverse consequences for their health, although I can see no evidence for that, and they are entitled to their view. They may choose not to take foods to which folic acid has been added.

The Government might look slightly foolish if we found in 10, 20 or 30 years that there was a public health issue about the addition of folic acid and they had ordained it without giving people a choice. That would be a bad thing. The Minister has ages to talk about the subject, so I hope that she will be able to cover most of the points.

10.3 am

The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I am pleased to be able to respond to the debate this morning. I pay tribute to the hon. Member for Peterborough (Mr. Jackson) for raising the issue and to his predecessor, Helen Clark,
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who, as ASBAH is based in Peterborough, saw this as an important part of her constituency work and secured the last Adjournment debate on the subject.

I appreciate the points made by all hon. Members this morning. As with any public health matter, particularly a move to adopt a universal approach to tackling different issues—whether through fluoridation or through the food supply—there are often convincing arguments for the proposal. The issues that have been raised are important, because we need to make sure that we have explored all the evidence, including emerging evidence, to ensure that the benefits outweigh the potential harm to others in the population who might be affected. I do not, however, rule out the universal approach. I am in favour of water fluoridation, so it would be hypocritical of me to rule out the idea of seeking better mass campaigns or initiatives in other areas of health.

More than 500 pregnancies a year are affected by neural tube defects, of which spina bifida is the most common. However, the issue is complex. Universal fortification of any food, such as wheat flour, as a public health measure, needs the fullest consideration. In the 1960s it was suggested that the risk of a woman giving birth to a child with a neural tube defect might be affected by her intake of the vitamin folate. Definitive evidence emerged in 1991 that supplementation with folic acid, the artificial form of the naturally occurring vitamin folate, significantly reduced the risk of NTDs in women who had already had an NTD-affected pregnancy.

At that time the Government issued guidance advising supplementation with 4 mg of folic acid to prevent reoccurrence of NTDs. That guidance was later expanded to cover the prevention of first-time NTDs, with the recommendation that all women planning a pregnancy should take 400 micrograms as a daily dietary supplement from when they began to try to conceive until the 12th week of pregnancy, and that they should consume folate-rich foods—green leafy vegetables and folate-fortified foods.

I take the point made by the hon. Member for Romsey (Sandra Gidley) about Brussels sprouts. I asked officials the other day about other folate-rich foods, and broccoli was mentioned. I was told that one would need to eat 2 kg of broccoli to get the recommended amount. I know that broccoli is a superfood, and it is one of my favourite vegetables, but that is a pretty tall order for any individual on a daily basis.

Our policy, and that of previous Governments, has been to try to ensure that women of childbearing age are aware of the need to take folic acid supplements before and at the time of conception, to minimise the risk of an NTD in their offspring. In 1995 the Health Education Authority ran a national integrated campaign that targeted women of childbearing age, health and other professionals, such as teachers and journalists, and the commercial sector, including food retailers and manufacturers.

I give credit to that campaign for achieving some heartening success. Unprompted awareness among women increased from 9 per cent. in 1995 to 49 per cent. in 1998, and prompted awareness has risen from 51 per cent. to 89 per cent. I am pleased to inform hon.
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Members that the last infant feeding survey, published in 2002, reported that 73 per cent. of mothers had taken supplements or modified their diets in early pregnancy.

Mr. Stewart Jackson : Does the Minister concede that supplementation does not work with respect to the absolute desire to reduce the number of neural tube defects each year, as represented by the scientific data over the past 13 years?

Caroline Flint : Clearly, there is still a problem. More than 500 pregnancies a year are affected and, as I was going to say, there is of course still a problem with the number of unplanned pregnancies. About half of all pregnancies in the UK are unplanned and by the time a woman knows she is pregnant it may be too late for folic acid to be effective.

Sandra Gidley : Will the Minister, for clarification, confirm that in speaking of supplementation she is referring specifically to folate, and not just general supplementation with a wider vitamin product?

Caroline Flint : I was referring to supplementation of folate.

As to reaching those women whose pregnancies have not been prepared for, I welcome any support and encouragement from those in this Chamber to the Government over widening access to contraception services. The issue of women's and girls' sex education, and their awareness of contraception, was raised earlier. These are important things for young women, and men, to learn. I take it that hon. Members will give full support for some of our work in our sexual health campaign in the months and years ahead. Those issues are tied together in the context of how people can best plan pregnancies, and they have implications in other areas besides the one that we are focusing on today.

In 2000, the Department's advisory committee, the Committee on Medical Aspects of Food and Nutrition Policy, concluded that universal fortification of flour at   240 micrograms per 100 g in food products as consumed would have a significant effect in preventing NTD-affected births and pregnancies, without resulting in unacceptably high intakes in any group of the population. It was estimated that this would reduce the incidence of NTD-affected pregnancies by 41 per cent. and would have prevented 38 of the 93 NTD-affected births in England and Wales in 1998.

We consulted on the recommendations in the report in 2000. Views were sought in particular on whether universal fortification of bread or flour was desirable; whether any such fortification should be mandatory or voluntary; the practicalities of fortification; the impact of the recommendations on consumers and consumer choice; and food labelling and technical issues for industry. The hon. Member for Westbury (Dr. Murrison) mentioned food labelling, which is extremely important in food safety and better health.

The consultation was therefore complex and the responses raised a number of issues. As the hon. Member for Peterborough mentioned, the majority of respondents—59 per cent.—were in favour of fortification. However, that was not overwhelming. The most common concerns related to the potential risks of
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fortification, in particular the risk of B12 deficiency among older adults. A significant number felt that there was still not sufficient information available about the possible adverse effects. Almost 80 per cent. of respondents felt that consumer choice would be lost if all flour were fortified. Respondents from the industry also stated that there may be technical problems associated with any mandatory policy.

All those concerns demanded further exploration and the Department of Health and the Food Standards Agency commissioned relevant research and undertook further work to develop a sound policy. I should remind the hon. Member for Westbury that one of the reasons this Government had support across the House for the creation and establishment of the agency was the knock-on effect of the disaster with BSE which was caused by a previous Tory Government and the issue of the quality of independent advice to Government on the safety of our food. The agency's public remit may not be exactly as some people might wish, but its remit is to advise the Government independently on the safety of food and to enable the consumer to make clear choices about the food they purchase.

Mr. Jackson : I am trying to avoid the overtly partisan nature of some of the Minister's comments. I fully concede that both Conservative and Labour Governments have not acted with due alacrity over the last few years, so we do not need to stray into political point-scoring. Can the Minister tell me what single piece of detailed, definitive scientific research the Department is using to militate against a policy of fortification with folic acid?

Caroline Flint : I will send the hon. Gentleman details of the research.

In answer to the question that the hon. Member for Upper Bann (David Simpson) raised about research spending, I can tell the Chamber that approximately £1 million a year has been spent on research on folate during the past three to four years. I am happy to provide details of that research.

Sandra Gidley : In the previous Adjournment debate, the then Minister of State, Department of Health, the right hon. Member for Redditch (Jacqui Smith) said:

Quite a lot of the argument against fortification seems to relate to B12 in older people. Will the hon. Lady tell us about the findings of the cost-benefit analysis?

Caroline Flint : I am happy to write to the hon. Lady with more detail. In the next part of my speech I shall explore the issue of B12 deficiency a little more. There is a balance to be struck. Sometimes we do not have enough information to hand about the potential adverse effects. It is a difficult and complex area. The findings in the United States have been cited this morning; there are sometimes difficulties in comparing different countries' practices, like with like. I like to think that we, with our health service that is free at the point of service, have a
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lot to teach America, although I do not say that we cannot learn from the Americans. There are clear issues about access to health services, particularly for older people, and the problem of identifying whether folic acid masks B12 deficiency and thus affects the ability of the health service to ascertain whether an older person suffers from it.

The benefits for women of childbearing age of taking folic acid are well established, but many feel that the potential risk of vitamin B12 deficiency, particularly for older people, is not. Many hon. Members agree with that. High levels of folic acid can make it difficult to diagnose B12 deficiency, which can, if undetected for a long time, cause damage to the nerves and spinal cord, leading to severe disability. The anaemia that usually appears first allows early detection of B12 deficiency before any nerve damage occurs. Older adults are at the greatest risk of B12 deficiency, because they are less able to absorb vitamins from foods—we will all have to adjust to that as we get older. There is, therefore, legitimate concern that the fortification of foods with folic acid could increase the number of older people at risk of undetected B12 deficiency.

Information on the true prevalence of B12 deficiency in the UK was unknown in 2000, and we felt that it was not right to make a decision at that time without further work on that and other issues. Recent research funded by the Department indicates that 10 per cent. of people aged over 65—approximately 5,000 to 6,000 people—could be at risk of undetected B12 deficiency.

As has been mentioned, fortification was introduced in the US in 1998, from which there seem to be some good outcomes. No other European country has implemented a mandatory fortification policy; countries that have include the United States, Canada and Chile. Although a number of respondents to the consultation suggested that we could use the American policy to inform our policy, it is difficult to compare the situations there and here. I acknowledge that there are no adverse reports in America, so far, about B12 deficiency, but the Americans have not focused on unidentified B12 deficiency. For all we know, it could be that people there have suffered from B12 deficiency that has led to more severe problems, but the situation with the American health systems means that it has not been picked up.

Mr. Jackson : Is the hon. Lady aware of the paper that Professor A.V. Hoffbrand gave to the ASBAH symposium on 10 May, in which he quoted four academic studies from the United States that failed to show any empirical, clinical evidence linking folic acid intake with B12 vitamin deficiency in young or old people?

Caroline Flint : That is interesting. I am happy to consider the paper and to make sure that our officials are aware of any developments in the United States, but it is important to consider the differences between health services, particularly in relation to the ability of the poorest people in society to access them. We in this country have something to be proud of in that regard.

Dr. Murrison : I would like to clear up a small point. Is the Minister saying that because she disagrees with the
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health care delivery system in the United States, she believes that the public health surveillance system there is defective? That is the implication of her remarks.

Caroline Flint : No, it is not. I am saying that the health services of other countries cannot necessarily be compared, like with like. The United States has some examples of extremely good health care, but I am advised that the problem of B12 deficiency does not have a particularly high priority when trying to identify whether fortification poses a risk. The FSA and the Department of Health believe that that matter needs further consideration. As I said, I shall ensure that our officials are made aware of recent research, and that it informs all discussions on fortification.

The FSA has also been addressing other issues of concern to consumers, such as the labelling of fortified foods, an issue mentioned by the hon. Member for Westbury; the legal position; and the technical aspects of fortification, such as problems with the fortification of wholemeal flour to which no vitamins or minerals are added, and the additional amounts required to overcome loss of folic acid during processing. The FSA has conducted detailed discussions with industry to ensure that any proposed action is feasible. If we are to make a recommendation for change, we must ensure that that important work has been done.

The FSA board subsequently concluded that it would not recommend the mandatory fortification of flour with folic acid, and it wished further to review emerging evidence on the impact of fortification on B12 deficiency in older people. I understand that that work is ongoing. We agreed with the board's advice and asked the Scientific Advisory Committee on Nutrition to consider the implications of folic acid fortification and any emerging evidence on the benefits and risks. I shall check that the papers cited by the hon. Member for Peterborough have been taken into account.

The SACN has been considering the risks and benefits of fortification, not only in connection with the prevention of spina bifida but because of its potential to reduce blood homocysteine levels and thereby the risk of heart disease. The hon. Gentleman mentioned circulatory disease. Those interesting developments may lead to fortification having more than one added value.

Mr. Jackson : I promise that this will be my last intervention—probably. I am anxious to press the point before the Minister concludes her remarks. Will she give an undertaking that the results and recommendations of the SACN will be considered promptly by the Food Standards Agency; that is at least within 12 months, and preferably within six months? That is not an unreasonable request, given that it is now 14 years since the Medical Research Council's landmark report. With all respect, ASBAH and the families who are suffering and will suffer as a result of that congenital disease have waited long enough.

Caroline Flint : I am certainly looking into what progress has been made, and I understand that the SACN is hoping to finalise its report early next year. It is meeting tomorrow, and its decisions on timetabling will be reported to me. I have also asked officials to raise the question of the level of fortification to ensure that it is
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considered by the committee; it is an important aspect of the discussion. The committee will be finalising its report early next year, after publishing it for external consultation with stakeholders. The Food Standards Agency and my colleagues in Scotland, Wales and Northern Ireland will consider the SACN recommendations carefully.

The hon. Member for Westbury made a number of statements on health, low-weight births and so on. Those are important issues. The Labour Government were the first to recognise that there is something called health inequality. Conservative Governments called it "variations in health". Over the past few years, we have been trying to understand why, despite the available evidence, we are not reaching people in poorer communities as well as we should. That has been happening for decades.

Dr. Murrison : Will the Minister give way?

Caroline Flint : No, I should like to develop my argument. We are debating important issues.

We know that public health and people's choice of lifestyle are often affected by social and economic factors. That is why, for example, we have some 88 spearhead health communities; we have identified them as some of our poorest, and we have identified better ways to reach them. Most Members of Parliament, and their families, feel confident enough to access the latest information on the internet about how they should look after themselves and what vitamins they should take. For some in our communities, that is not the case, partly because our health services have been structured so that they focus only on treating people when they are ill rather than trying to prevent them from falling ill in the first place.

"Choosing Health", which was published last year, is the first comprehensive White Paper dealing with public health which recognises that Government have a role. Clearly, the health service has a role, and local government has a role in matters such as the quality of the environment. Tackling crime is important as well, but how can we allow individuals to make choices—choosing health—for themselves? I shall give one example relating to low-weight birth, which I was interested by when I read about it. We have made enormous progress in England in addressing some of the issues concerning smoking, particularly in raising to a high level the awareness of the dangers of smoking while pregnant among women who are or who want to become pregnant. I am proud to have helped to establish the first service of its kind for pregnant women in Doncaster, which then became the national Quitline service to support pregnant women wishing to give up or reduce smoking.

Despite good evidence that smoking rates have gone down while this Government have been in power, tremendously so among pregnant women, there is a smaller group of pregnant women, often very young and often of low educational attainment, who have a confusion in their minds. Some of them weigh up the consequences of smoking against those of having a heavier baby, thinking that a low-weight baby would be less painful in childbirth.

That is one example showing how, when we are talking about public health, within and between communities, with men and women, older and younger
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people, and people from different ethnic backgrounds, we must understand where they are coming from if we are to make some progress in reducing health inequality. For too long, the health service has been quite traditional and has focused on hospital services rather than on what happens in communities and how we can work together.

Dr. Murrison : Will the Minister give way?

Caroline Flint : In a moment; I have plenty of time, as the hon. Gentleman told me earlier.

We introduced the Sure Start programme. I was pleased to be able to sit on the board of the trailblazing Sure Start unit in my constituency. I have seen it grow over the last few years because of the help and support that it gives to people and their families—men and women, grandparents and others. They also use the outreach services. I have seen a transformation in the role of health visitors and community midwives, who are working much more with families on issues that are wider than the conventional issues of antenatal care.

Mr. David Amess (in the Chair): Order. I hesitate to interrupt the Minister because the debate is very interesting. However, I am reminded that it is confined to spina bifida and folic acid. I gently ask her, and all those seeking to intervene, to confine their remarks to the subject of the debate.

Caroline Flint : I heed your advice, Mr. Amess, but I am sure that you will not have begrudged me the chance to respond to a rather open contribution from the hon. Member for Westbury. I shall bring those remarks to a close.

A point was made by, I think, the hon. Member for Peterborough, about the fact that it is often those families from lower groups and poorer backgrounds who are most at risk of being deficient and experiencing problems such as spina bifida. I reiterate my point that we must find better ways to reach those groups who often lack the confidence or the awareness needed to access health services that some of us take for granted.

Dr. Murrison rose—

Caroline Flint : I shall take the hon. Gentleman's intervention, as long as it is strictly within the terms of the debate.

Dr. Murrison : I am grateful to the Minister for allowing me to intervene in that qualified way. She mentioned health inequalities, and I was wondering whether she had read her Department's figures on them. If so, could she tell us what they reveal?

Mr. David Amess (in the Chair): Order. Obviously, the hon. Gentleman felt that he had to read that into the
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record, but I ask the Minister not to be tempted to reply, because we are talking specifically about spina bifida and folic acid.

Caroline Flint : I will say one word—progress.

Dr. Murrison : On a point of order, Mr. Amess. Would it be appropriate for you to ask the Minister to reconsider her last remark and for you gently to suggest—

Mr. David Amess (in the Chair): Order. The hon. Gentleman must desist from giving me advice, although I know that he has the best of intentions. I ask the Minister to proceed with her remarks.

Caroline Flint : Thank you, Mr. Amess. I hope that we will make progress on the core subject of today's Adjournment debate.

We all agree that universal fortification is a complex issue and raises all sorts of questions about the scientific evidence base and about what is publicly acceptable. We have touched not only on the health outcomes, but on how we make fortification work, how we keep people informed and how the industry can respond technically. I hope that, after careful consideration of the benefits and of how we manage any risks, we can make progress.

The Government continue to encourage women of childbearing age who might become pregnant to increase their folate intake, including through the use of supplements. We are also promoting the use of pre-conceptional supplements and increased dietary intakes of folic acid through the "healthy start" and "five a day" programmes, for example. In addition, we are considering ways of addressing concerns about the prevalence and about the identification of vitamin B12 deficiency among older people in its own right. We are also supporting the folic acid flash scheme, which helps consumers to identify foods that manufacturers have voluntarily fortified with folic acid. I shall have a look at what further work can be done with industry on voluntary change.

I hope that I have reassured Members that we are taking this issue seriously. After the previous agreement with the FSA not to recommend fortification, we have not simply let the issue drift. We constantly consider reviewing the situation and updating our approach, based on any evidence that comes forward. We shall be considering the issue in great depth.

I welcome today's debate. We shall endeavour to find the best public health solution, taking account of the benefits and risks to all sections of the population. I say to the hon. Member for Peterborough that I certainly hope that it will not be 12 months before we reach conclusions on this issue.

10.32 am
Sitting suspended.
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