Updated childhood obesity plan: But how does it measure up?

Updated childhood obesity plan: But how does it measure up?

The government recently announced new measures to halve rates of childhood obesity by 2030 and significantly reduce the health inequalities that persist – closing the gap in obesity rates between children from the most and least deprived areas.

This proposal builds upon the first chapter of the Childhood Obesity Plan, which was widely criticised at the time as lacking the breadth and depth of initiatives needed to effectively tackle such a widespread and entrenched issue.

Steve Brine, Public Health Minister has stated: “One in three children are now overweight or obese by the time they leave primary school. Overconsumption, combined with reduced activity, is having a catastrophic effect on our children’s health. As both a parent and minister, I am committed to driving today’s pledge of halving obesity over the next 12 years with bold new action.”

“Our updated plan will put parents in charge, providing more information and support. Our aim is to help families make healthier choices, which will in turn provide a better chance at a longer, healthier life for our children.”

Obesity – A systems issue

The financial burden of obesity is too great to ignore: it’s estimated that the NHS in England spent £6.1 billion on overweight and obesity-related ill-health in 2017/18, which, to put into context is more than was spent on the police, fire service and judicial system combined. The wider costs to society of these conditions are around £27 billion a year, if not higher.

Ever since the Foresight report was published over a decade ago, it has been recognised that obesity is a systems issue and one that therefore requires reform at many points, to deliver change. This idea and the fact that no plan to date has sought to address childhood obesity in a multi-sector way, was reiterated in the recent inquiry by the parliamentary Health and Social Care Committee into childhood obesity. Childhood Obesity: Time for Action argued for a change in narrative, making clear that obesity is everyone’s business and “an effective childhood obesity plan demands a holistic, joined-up, ‘whole systems’ approach with clear and effective leadership”.

How does the Childhood Obesity Strategy measure up?

This update to the Childhood Obesity Strategy is a welcome step forward. It contains a raft of proposed measures that seek to tackle the issue using a co-ordinated range of policy levers. What is also good to see is that this new plan takes a firm but fair approach in how it will deliver change: using voluntary measures in the first instance but being clear that a harder tact with the likes of regulatory and fiscal measures will be considered where progress is deemed insufficient, or where a level playing field is required.

Here at Nutrilicious, we’ve taken a closer look at what’s in store and benchmarked the new childhood obesity plan against the World Cancer Research Fund’s NOURISHING framework, as well as the recommendations from the Health and Social Care Committee’s report mentioned earlier.

The NOURISHING framework

The NOURISHING Framework sets out that policies are needed within three core areas to improve diets: the food environment, food system and behaviour change communication.

N – Nutrition label standards and regulations on the use of claims and implied claims on food
O – Offer healthy food and set standards in public institutions and other specific settings
U – Use economic tools to address food affordability and purchase incentives
R – Restrict food advertising and other forms of commercial promotion
I – Improve nutritional quality of the whole food supply
S – Set incentives and rules to create a healthy retail and food service environment
H – Harness food supply chain and actions across sectors to ensure coherence with health
I – Inform people about food and nutrition through public awareness
N – Nutrition advice and counselling in health care settings
G – Give nutrition education and skills

Bearing in mind that some policies and actions targeting childhood obesity were in place prior to this strategy update, overlaying the new measures show how broad their impact alone intends to be:

New measures N O U R I S H I N G Nutrilicious notes
Improved food labelling to display ‘world-leading, simple nutritional information’ as well as information on origin and welfare standards following Brexit X
Strengthen School Food Standards to reduce sugar consumption X X We would like to see these universally applied and close the loophole that exists for some academies
Strengthen Government Buying Standards for Food and Catering Services* X X
Ban price promotions such as buy one get one free, multibuys or unlimited refills of unhealthy foods and drinks in the retail and out of home sector* X It is good to see a mandatory approach applied here, as this is what is undoubtedly needed when policies will impact businesses’ bottom line.
Ban the sale of energy drinks to children* X
Ban promotion of unhealthy food and drink by location e.g. positioning – checkouts, end of aisles and store entrances, in retail and out of home sector* X
Introduce a 9pm watershed on unhealthy food and drink advertising and similar protection online* X We would like to see similar controls applied to sports advertising
Review governance arrangements for advertising rules (currently overseen by the Committee of Advertising Practice and Advertising Standards Authority) X
Potentially bring ‘sugary milk drinks’ into the soft drinks levy if insufficient action on sugar reduction takes place X X
Introduce mandatory calorie labelling for out of home sector in England* X X
Sugar reduction plan for products aimed exclusively at babies and young children due in 2019* X
Calorie reduction plan due mid-2019* X
Develop trailblazer programme with local authority partners to highlight what can be done within existing powers X We would like to see greater powers for local authorities and health services
Develop plan to use Healthy Start vouchers to provide additional support to children from lower income families* X
Ofsted will review school curriculum to understand how it can better support healthy behaviours, including food choices X X We would like to see improved early years education for parents to support a healthy first 1000 days and compulsory home economics with healthy cooking skills at the core in both primary and secondary schools

*Proposal for further consultation

Is it enough?

While we applaud this latest round of the childhood obesity plan, we would also draw attention to the fact that there is still some way to go.

By mapping the proposed policy options against the NOURISHING framework, we can see that in this latest iteration of the plan much more focus has been given to shaping an environment that enables and supports healthier choices, which is great to see.

However, what is noticeably absent is the ‘I’ in terms of improving food and health literacy of the population. In a ‘post truth’ world where consumers are increasingly sceptical of messages coming from the scientific community, and when social media influencers are capturing the hearts and minds of the masses with questionable dietary advice, never has it been more important to provide clear, simple and authoritative information and advice. As such, we’d like to the see the government step-up their efforts on social marketing and educational campaigns.

What is more, a number of recommendations made in the Health and Social Care Committee are notably absent, including:

  • Establishing a Cabinet-level committee to review the implementation of the plan, ensuring it gets the high-level traction it requires
  • Proposing further measures around early years and the first 1,000 days of life, including targets to improve rates of breastfeeding
  • Banning the advertising and promotion of follow-on formula milk
  • Providing local authorities with further powers to limit unhealthy food and drink advertising near schools (the only powers available to local authorities extend to the positioning of the billboards themselves, not the content of the advertising)
  • Introducing services for children living with obesity

Finally, while this plan is overtly focussed on limiting unhealthy foods and drinks and making processed, packaged foods a little better through reformulation (lower in salt etc), we would also like to see equal attention given to measures that work improve the quantity and quality of foods that we do want people to eat more of. Changing the dietary landscape will require strong efforts to provide families with the tools and knowledge to instil these healthier behaviours in a sustainable way.

The full plan for action can be viewed here:

https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action

 

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Latest advice on infant feeding: has anything changed?

Latest advice on infant feeding: has anything changed?

The final ‘Feeding in the First Year of Life’ report published by the Scientific Advisory Committee on Nutrition (SACN) supports current government recommendations including breast is best, introduction of allergenic foods from six months and the importance of variety and textures.

Covering infant feeding from birth to 12 months, it provides its recommendations to government based on the best available evidence for the short- and long-term health outcomes for infants and mothers.

The one note of significant difference to existing advice is the recommendation that vitamin A supplements for infants should be discontinued. This will cause some inconvenience as most infant vitamin drops, which were developed on government advice, include vitamin A.

What is the SACN recommending to government?

  • More strategies and support to help mums breast feed exclusively for the first six months of the infant’s life and to continue breast feeding alongside weaning for the first year.
  • Where breast feeding is not possible, infant formulae based on either cows’ or the more recent goats’ milk are the only suitable alternative options. Soya-based formulae should only be introduced under medical advice.
  • Only breast milk, formula or water as a drink should be offered between six and 12 months.
  • Solids should be introduced from around six months of age, ‘having achieved developmental readiness’. The SACN found no evidence for the critical window of opportunity (four-six months) for increased acceptance of solids.
  • Reducing risk of ‘fussy eaters’. Based on the evidence available, it is recommended that perseverance with repeated exposure of a variety of textures and flavours should be encouraged.
  • Introduction of textures is critical for the development of munching and chewing. Textures should be introduced incrementally depending on the infant’s individual development rate.
  • Baby-led weaning: due to too few studies, the SACN could not make any recommendations. However, it did make the point that the limited evidence to date is promising for earlier self-feeding and less food fussiness.
  • All allergenic foods should be introduced from six months in small quantities and one at a time. This is of course for infants not at high risk of or diagnosed with an allergy. It is particularly important for peanuts and hen’s eggs, where the evidence is strong that delayed introduction increases the risk of allergy later in life. Additionally, nuts such as peanuts should not be given whole until the age of five years to prevent choking risk.
  • Vitamin D intakes remain a concern for infants who are being breast fed or on less than 500ml formula daily. The SACN acknowledges the poor update of vitamin drops for babies but continues to emphasise the importance of encouraging breast feeding mums to use vitamin D supplements from birth.
  • Iron continues to be an issue beyond six months of age and greater emphasis should be placed on the introduction of iron rich foods, rather than supplements, from the start of weaning.
  • Vitamin A supplementation should no longer be encouraged as risk of deficiency is low and advises the government to review its current baby vitamin drop recommendations.
  • Energy intakes remain too high and infant weights exceed standard weight charts. There is a need to better monitor overweight and obesity in infants.
  • Salt and sugars intakes remain high in infants, with commercial baby foods, especially fruit purees, being the main contributors.
  • Throughout the report, the SACN make no distinction in their advice between commercial or home-made complementary foods – could this be a sign that reality and practicality has been taken into consideration?

The Public Health England (PHE) sugar reduction programme for complementary foods will be far more controversial than the new SACN recommendations.

We have heard this week that PHE have just finished their scoping work for their sugar reduction programme of complementary foods for infants and are preparing for discussions with industry, NGOs and other interested parties.

Setting sugar reduction targets for this category will be challenging, to say the least.

  1. The complementary foods’ regulation, which PHE cannot over-ride, permits significantly high levels of sugars: up to 20g total sugars per 100g for ‘fruit only’ products and up to 25g per 100g for desserts and puddings.
  2. There are huge discrepancies between PHE’s classification of ‘free sugars’ and regulatory and labelling classifications of ‘added sugars’. Sugars naturally present in fruit and vegetable purees are classified as ‘free sugars’ by PHE but not as ‘added sugars’ by foods or labelling regulations.
  3. Some will argue that pureed formats of fruit and vegetable are essential as first foods, especially by those from the ever-exploding pouch market, and as such should be excluded from the ‘free sugars’ classification. However, there should be a strong opposition from health experts and very active pressure groups:
    • There is a growing consensus that fruit and sweet tastes should no longer be recommended as first foods in order to reduce the infants’ continued preference for sweetness.
    • Additionally, with the SACN’s affirmation that complementary feeding should start around six months, purees are no longer essential. At that age the infant is ready, and should be encouraged, to develop their munching and chewing skills which means the need for textures. Pureed food on the other hand only rely on an infant’s innate skills of sucking and swallowing.

Interesting times…let’s wait and see.

Complementary foods regulation update – will this rock the boat?

The updated version of the 2006 regulation on processed cereal-based foods and baby foods for infants and young children has yet to be published. The revised regulation was rejected last year for numerous reasons, including pesticide and sugar upper limits being too high.

The next version should be with us this year and it will be interesting to see how it aligns with the SACN’s and PHE’s recommendations – especially with regard to sugars and when solid foods should be introduced. Currently, the regulation (and the failed 2017 revision) permitted solid food introduction from four months.

Welcoming the findings

Only recently, the BBC reported the potential benefits of feeding solids as early as three months, which is likely to have caused confusion for parents.

So we’re pleased that this new SACN report helps to give support for the current advice in the UK: babies should ideally be exclusively breastfed for six months, and solid foods should be introduced after this. Or, as Dr Alison Tedstone, Chief Nutritionist at Public Health England (PHE) put it: “SACN’s robust advice puts to bed any arguments about a beneficial effect of early introduction of solid foods.”

We do however notice the very precise wording of ‘around six months’.

There is some concern amongst dietetic paediatric experts that setting a specific time for solid food introduction is unrealistic, may place some infants at risk and is an added pressure for mums on top of guilt faced by those who do not wish to or cannot breast feed.

The important factor is that solid foods should only be introduced when an infant is developmentally ready: when they can sit with minimal support and hold their head steady; can co-ordinate eyes, hands and mouth; and are able to reach out to pick up food and bring it to their mouth. Some infants may be ready before six months; a few may not be ready yet at that stage.

It’s important government advice should ensure mums understand that there is flexibility ‘around’ the six months.

Further advice on early feeding and breastfeeding
In the UK we have some of the lowest breastfeeding rates in the world, so it is important to provide help and support to mothers wishing to breastfeed. The NHS gives information about where to get help.

See also:

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New review concludes omega-3 fats have no benefits for heart health… or does it?

New review concludes omega-3 fats have no benefits for heart health… or does it?

An extensive detailed analysis of the current scientific evidence into omega-3 seems to have thrown a spanner in the works for heart health dietary advice.

Conducted by Cochrane, the review concludes that there is no correlation between cardiovascular health and intakes of the long chain omega-3 fats eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) over a one- to six-year period.

Long chain omega-3 fats have long been associated with reductions in blood triglycerides, blood pressure and thrombosis; producing anti-inflammatory and anti-arrhythmia effects as well as improving endothelial function and insulin sensitivity.

This most recent publication will raise many eyebrows within the heart health professional arena and likely to be taken up by media editors who seem to enjoy questioning the trustworthiness of public health guidelines. These recommend a diet including omega-3, especially found in oil-rich fish such as salmon, tuna and mackerel.

So, do we need to change dietary guidelines on the importance of omega-3 and oil-rich fish?

Before we jump the gun, it’s important to put things into context:

1. The shortcomings of the review

a. The studies investigated in this review predominantly used omega-3 supplements. Thus the outcomes cannot be related to oil-rich fish consumption which is the main dietary source of EPA and DHA.

b. The studies were also of one to six years’ duration, which is a relatively short period to assess disease and mortality risk. And conclusions cannot be reached for a lifetime consumption of foods rich in EPA or DHA.

c. Many of the studies may not have used adequate number pf subjects in the studies to elicit a result. This is especially the case for studies conducted in healthy individuals (and therefore low risk of heart disease), which would require very high numbers to demonstrate a difference in the omega-3 and non-omega-3 study groups.

d. Any studies conducted over the last two decades of people at risk of cardiovascular disease (CVD) will be in individuals already medicated with statins and other cardio-protective drugs, which may mask the effect, if any, of additional omega-3.

2. Omega-3 benefits go beyond heart health

Long chain omega-3 fats are critical for eye and brain development of the foetus and young children. Therefore, food sources should be included in a healthy balanced diet of children and adults planning for a family.

3. Oil-rich fish is not just omega-3. It offers so many health benefits.

a. Unlike omega-3 supplements, oil-rich fish is a rich source of not only the long chain omega-3 fats but also of selenium, zinc, vitamin D and iodine; woefully lacking in the UK diet.

b. Oil-rich fish has a healthier fat profile when compared to red meat and other animal proteins. Replacing saturated fat with unsaturated fat in the diet has been proven to have a positive effect on blood lipids and cardiovascular health (as confirmed by Cochrane’s 2015 review and the SACN’s & the WHO’s draft 2018 reports). See our saturated fat blog

Indeed, the authors themselves remind us of the other nutritional benefits of oil-rich fish and that this review does not negate public health advice that consuming oil-rich fish is beneficial to health.

The Nutrilicious view

Taking vitamin and mineral supplements as a substitute for eating a healthy balanced diet has never been encouraged by health professionals. However, dietitians recognise that when demands for specific nutrients are high, or when an individual’s nutritional intake is at proven risk of being compromised, supplements can play an important role. For example, pregnancy and folic acid; under-5 year olds and vitamins C and D; or sufferers of osteoporosis and calcium and vitamin D.

Therefore, these findings do not come as any surprise: omega-3 supplements are not a solution to better heart health. There are numerous dietary and lifestyle factors that impact on heart health. It should always be about food rather than the benefits of single nutrients.

As Linda Main, Dietitian and dietary advisor for cholesterol charity HEART UK, explains: “We continue to advise the lifelong consumption of a heart healthy diet centred around eating whole foods rather than the emphasis being on nutrients.

“Eating patterns such as the Mediterranean, DASH or the UCLP© diets result in the consumption of a nutritionally appropriate diet. This is characterised by eating plenty of vegetables, fruits, wholegrains, vegetable proteins such as nuts and soya, seeds, vegetable oils and spreads. In those who consume animal proteins, the inclusion of low fat dairy, lean and largely unprocessed meat and white and oily fish and seafood are recommended.

“Omega-3 supplements are not currently advised by HEART UK and would not be our first choice, except when prescribed by a recognised qualified health professional or when needed to safeguard the intake of the essentially fatty acid – alpha-linolenic acid.”

As oil-rich fish is an excellent low saturated fat protein source, and the main dietary source of long-chain omega-3 fats as well as other crucial nutrients, it should continue to be part of dietary guidelines.

Additionally, for those wishing to follow a more plant-based diet, it’s reassuring that the report finds consumption of the shorter chain omega-3 fats found in plant foods (like rapeseed and soya oil) has cardio-protective qualities. This supports findings from population studies that vegetarians and vegans have a lower incidence of cardiovascular events and mortality compared to non-vegetarians.

Current UK heart health dietary advice remains unchanged:

  • Lower the amount of food eaten which is high in saturated fat and replace it with foods high in unsaturated fats (which Cochrane’s 2015 review supports, SACN 2017 Saturated fat draft guidance).
  • Increase our intake of fibre (especially from beans, pulses, oats and barley), nuts.
  • Consume at least five servings of fruit and vegetables daily.
  • Reduce intakes of red meat and avoid/limit processed meat.
  • Consume two portions of fish weekly – one of which should be oil rich.
  • Increase intakes of leaner and plant-sources of protein.
  • Use sterol or stanol fortified products (if blood cholesterol is raised after other dietary changes have been made).

It’s interesting to note that, unlike the US, the UK does not (and has never) recommended taking dietary supplements of omega-3 fish oil.

For up to date expert advice on heart health visit: heartuk.org.uk

Further references

Saturated fat and heart health reports

Supplements for specific groups
NHS UK: Vitamins for children; Vitamins, supplements and nutrition in pregnancy

 Vegetarian and vegan diets and health outcomes

  • Rizzo N, Jaceldo-Siegl K, Sabate J et al. Nutrient profiles of vegetarian and non-vegetarian dietary patterns. J Acad Nutr Diet.. 2013;113(12):1610-9.
  • Sobiecki J, Appleby P, Bradbury K et al. High compliance with dietary recommendations in a cohort of meat eaters, fish eaters, vegetarians, and vegans: results from the European Prospective Investigation into Cancer and Nutrition-Oxford study. Nutr Res.. 2016;36(5):464-77.
  • Springmann M, Godfray H, Rayner M et al. Analysis and valuation of the health and climate change cobenefits of dietary change. Proc Natl Acad Sci U S A.. 2016;113(15):4146-51.
  • Clarys P, Deliens T, Huybrechts I et al. Comparison of nutritional quality of the vegan, vegetarian, semi-vegetarian, pesco-vegetarian and omnivorous diet. Nutrients.. 2014;6(3):1318-32.

Cochrane is an established body of researchers, health professionals and patients across the globe renowned for their high quality scientific reviews of nutrition and health evidence.

 

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Can specific foods provide health benefits?

Can specific foods provide health benefits?

This month, the British Medical Journal (BMJ) published a review on dietary patterns and chronic disease prevention. It aimed to answer questions including whether specific foods actually provide health benefits; and whether exclusion diets – vegetarian, vegan, avoidance of gluten or lactose – are the key to good health.

Here we put it in the context of the advice we’re being by government as to what we should eat to be healthy.

Key messages from the BMJ review:

  • Prioritise eating fruits, vegetables, whole grains and fish to best help prevent chronic disease risk. Equally, lower consumption of red and processed meats and sugar-sweetened drinks.
  • Eating more nuts, legumes, vegetable oils, fermented dairy products and coffee are further likely to provide benefit.
  • Evidence comes from prospective observational and intervention studies, each study design having different strengths and limitations. Both types of studies should contribute to the evidence base.
  • New analytical approaches are still needed for nutrition research.

How do the findings fit in with current advice?

The key messages promoted from the review support the government’s advice for healthy eating, the Eatwell Guide.

  1. Fruit and vegetables

BMJ: Found that fruit and vegetables were associated with lower risk of cancer, coronary heart disease and stroke.

GUIDANCE: It’s recommended we eat at least five portions of fruit and vegetables per day. See this factsheet (https://www.bda.uk.com/foodfacts/FruitVeg.pdf) from the British Dietetic Association (BDA) on how to help achieve this.

  1. Whole grains

BMJ: Wholegrain consumption was related to lower risk for most diseases studied (the endpoints).

GUIDANCE: We are advised to have at least 30 grams of fibre per day. Wholegrains can certainly help us achieve this. See the British Dietetic Association fibre fact sheet for more information https://www.bda.uk.com/foodfacts/fibrefoodfactsheet.pdf.

  1. Fish

BMJ: Fish consumption was found to reduce the risk of coronary heart disease and stroke.

GUIDANCE: The government recommend we consume 2 portions of fish per week (one portion is around 140g), one of which should be oily. Find out more from the National Health Service.

  1. Red and processed meat

BMJ: Consumption of red and processed meats increased the risk for most of the endpoints.

GUIDANCE: This supports the latest review by the World Cancer Research Fund (WCRF) discussed in our previous blog.

Their report recommends we consume no more than about three portions per week, which is around 350–500g cooked weight (or 525–750g raw weight) a week. To help give you an idea of what that means:

  • One pork chop is 75g cooked weight (110g raw)
  • One medium steak is 145g (210g raw)
  • A portion of beef mince in Bolognese averages about 140g cooked weight (200g raw).

WCRF recommend that for cancer protection we eat little or no processed meats (e.g. sausages, ham, bacon).

  1. Sugar sweetened drinks

BMJ: Drinking sugar-sweetened drinks was associated with increased risk of type 2 diabetes, coronary heart disease and stroke.

GUIDANCE: Excessive sugar intake (for which sugar-sweetened drinks are a major contributor of) remains a major problem in the UK. Just a couple of months ago, the UK sugar tax was introduced as one of the many strategies employed to help combat this public health issue.

The government’s advice for limiting free sugars supports BMJ’s findings.

  1. Nuts, fermented dairy products, coffee and others

The review states that higher consumption of nuts, legumes and vegetable oils are likely to confer further benefits. This helps support the benefits behind a more plant-based diet. For more information see the BDA’s factsheet (https://www.bda.uk.com/foodfacts/plant-based_diet).

Fermented dairy products (such as yogurt, kefir) were also mentioned because links were found between these foods and a reduced risk of cardiometabolic disease. Whilst fermented dairy foods can form part of a balanced diet, the research is inconclusive at this stage. The British Nutrition Foundation discuss the area of fermented foods and why it can be difficult to draw conclusions at this stage.

Finally, studies found a reduced risk of many endpoints by drinking 3-5 cups of coffee per day. We often see headlines focusing on negative effects of coffee, when in fact there is a lot of research for beneficial effects.

Coffee can certainly help meet our daily fluid requirements and should not be discouraged. We must bear in mind that due to the caffeine, it should be limited to two cups per day (instant coffee) for pregnant women.

The review also goes through the studies found for specific dietary patterns, highlighting that most reliable evidence for chronic disease prevention lies with following a Mediterranean diet. This type of diet generally refers to a diet encouraging high intake of fruits, nuts and seeds, vegetables, fish, legumes and cereals and reducing intake of meat and dairy products. Moderate intakes of alcohol and olive oil are also components of this diet.

Summary
This latest BMJ review supports the government’s messages for healthy eating. A significant proportion of the foods shown to be of benefit (such as fruit and vegetables, wholegrains, legumes, nuts and vegetable oils) are plant-based and these should be encouraged as part of our whole diets for both health and environmental reasons.

Remember:
– There are often flaws to research in the field of nutrition, as discussed the BMJ review.
– Concentrate on the whole diet rather than just focusing on individual foods or groups.

 

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Folic acid in pregnancy – what’s new and what’s next?

Folic acid in pregnancy – what’s new and what’s next?

The latest National Diet and Nutrition Survey (NDNS) highlighted that 91% of women of childbearing age (16 to 49 years) in the UK have folate levels that are too low.

It’s in the early stages of pregnancy that the foetus rapidly develops spine and nerve cells. Low folate levels increase the risk of foetal Neural Tube Defects (NTDs), such as spina bifida, so folic acid is recommended as a supplement.

Yet a recent survey of 750 pregnant women carried out by baby charity Tommy’s showed that:

  • One in five women started taking folic acid before contraception
  • One in six women did not take folic acid at all

Previous large studies have seen similar low levels of folic acid intake. For example, a study of nearly half a million women in England and the Isle of Man found less than 1 in 3 women had taken folic acid supplements before pregnancy.

 

What is the current advice for folic acid supplements?

Women planning a pregnancy (ideally two to three months before conception) are advised to take a 400-microgram supplement of folic acid until the 12th week of pregnancy.

Women with diabetes and those who have had a pregnancy previously affected by NTDs may need a 500-microgram supplement. For more information on who may need higher doses, see the National Health Service.

The advice for taking a supplement is in addition to eating foods rich in folate, the natural form of folic acid. Top sources of folate include green leafy vegetables, citrus fruits, beans and legumes, yeast extract and fortified foods. Eating these foods alone will not meet the demands of a pregnant women and their developing baby.

For more information, the British Dietetic Association (BDA) have produced a factsheet on folic acid.

 

Folic acid fortification: the UK needs to get up to speed

Over 80 countries have introduced mandatory fortification of flour with folic acid, to help reduce the number of babies affected with NTDs.

The UK hasn’t yet followed suit. In 2002, the Food Standards Agency (FSA) advised against mandatory fortification because folic acid supplements were believed to mask the anaemia caused by B12 deficiency (which causes ongoing nerve damage) and lead to an increased risk of colon cancer in certain groups.

However, more recent research has found no significant links between high doses of folic acid and cancer. In addition, countries that already have mandatory folic acid flour fortification in place haven’t seen an increase in people developing nerve damage as a result of B12 deficiency.

Highlighting the benefits, the US has seen a 23% fall in pregnancies with NTDs since the policy was introduced in 1998. A 2016 study published in the British Medical Journal estimated that 2,000 pregnancies associated with NTDs would have been prevented if the UK had adopted the same fortification as the US from 1998.

The most recent update from the Scientific Advisory Committee on Nutrition, which considers all the evidence for and against folic acid supplementation, echoed previous advice they had given supporting mandatory fortification of flour with folic acid in the UK. The FSA also now support mandatory fortification. Unfortunately, the UK government has remained unwilling to introduce regulation.

The BDA have information on how their members can help support the introduction of folic acid fortification to put pressure on the UK government.

 

What’s next for folic acid intake?

Folic acid plays a crucial role for the prevention of NTDs in babies but many women are not taking the recommended supplement before pregnancy.

In response to their findings, Tommy’s have created a new online tool, Planning for Pregnancy, which helps women plan for healthy pregnancies. It was created alongside the Royal College of Obstetricians and Gynaecologists, Public Health England and the UCL Institute for Women’s Health. The tool provides advice on folic acid and other factors involved for a healthy pregnancy and will hopefully prove to be a useful resource for women planning to become pregnant. Dietitians, nutritionists and all involved in food and health communications have a role in promoting such resources.

At a policy level, we hope to see the UK government enforce mandatory fortification of flour in the UK as a simple way to increase folic acid for everyone, in light of the wealth of evidence to support the measure.

Of course, in addition to taking folic acid pre-conception, there are other points to be aware of to help ensure a healthy pregnancy including avoidance of smoking, avoiding alcohol, being a healthy weight before pregnancy (BMI between 18.5kg/m2 and 24.9kg/m2) and engaging in regular moderate exercise.

 

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