“Europe has an epidemic of spina bifida and anencephaly compared with countries with mandatory folic acid fortification policy,” said researchers from Europe and the US.
They said Europe’s prevalence was 1.6 times higher than in countries with folic acid food fortification programmes.
“Between years 2000 through 2010, a total of 7478 pregnancies with spina bifida and anencephaly out of approximately nine million births were caused by the failure of European governments to introduce folic acid fortification on a population level,” they wrote in the journal Birth Defects Research.
For all neural tube defects this stood at about 8,400 cases.
These figures were based on the European Surveillance of Congenital Anomalies (EUROCAT) database, which only covered nine million births or about 20% of the EU population. This meant the real figures could be much higher than estimated in the paper, the researchers said.
They said promoting voluntary folic acid supplements for women of reproductive age had proven ineffective in lowering the risk of NTDs in Europe – with prevalence per 10,000 births still high in many EU countries like Denmark (13.84 per 10,000), UK (12), Netherlands (11.38) and France (10.62).
Instead mandatory fortification was needed to “save lives and significant public health costs”.
In Germany alone there would have been 293 fewer pregnancies affected with spina bifida each year and up to €32.9 million saved in additional direct lifetime medical costs among children born alive with spina bifida compared with the general population.
Neural tube defects are caused by the incomplete development of the brain, spinal cord and/or their protective coverings and occur when the foetus’ spine fails to close properly.
The cost of NTDs
They said fortification should be considered within the context of Europe’s ten-year economic growth strategy, which aimed to keep people healthy and active for longer.
The social and actual cost of NTDs was huge. A Dutch study estimated the total direct and indirect lifetime expenditures for an individual with NTD was €242,948.
Meanwhile a German study using health insurance data estimated an average annual health care expenditure of €4532 for an individual with spina bifida, which was substantially higher than the general population. Health costs for one year olds with spina bifida were five times higher than children without the condition.
The mandatory debate
Mandatory flour fortification with folic acid has already been imposed in Canada and the US – yet no European countries have followed suit.
However in June this year the UK government put forward a bill proposing folic acid be added to the list of mandatory micronutrients used to fortify wheat flour under the Bread and Flour Regulations 1998 - movement seen after decades of debate.
The issue was first raised back in the 1990s when a UK Medical Research Council trial suggested folic acid (vitamin B9) could help reduce the risk of neural tube defects by up to 72%.
The supplement debate
Last year the European Food Safety Authority (EFSA) approved a health claim for 400 microgram-dose supplements for women of child-bearing age, stating: “Low maternal folate status is a risk factor in the development of neural tube defects in the developing foetus.”
The trade groups and charities behind the claim hailed it as a communication game changer.
At the time the Council for Responsible Nutrition (CRN) said supplements offered a targeted strategy, unlike mandatory flour fortification that would include the whole population and may not account for changing consumption patterns.
Last month Safefood, the Irish public body responsible for raising consumer awareness on food safety and healthy eating, launched a campaign to encourage women of child bearing age to take folic acid supplements.
It said to achieve the daily 600 mcg dose of folic acid needed for pregnant women they would need to eat something like 1.2 kg of broccoli every day.
This latest paper was compiled by researchers from the Aarhus University in Denmark, Emory University in the US, Zurich University of Applied Sciences in Switzerland and the University Hospital of Bonn and Rheinische Friedrich-Wilhelms University in Germany.
It was supported by grants from Sophie's Voice Foundation, a charity founded by US actors Boris Kodjoe and Nicole Ari Parker in honour of their daughter Sophie who was diagnosed with Spina Bifida at birth.
In 2011 the foundation established the Centre for Spina Bifida Research, Prevention and Policy (CSB) at Emory University in Georgia.
Source: Birth Defects Research
Published online ahead of print, DOI: 10.1002/bdra.23400
“Preventable spina bifida and anencephaly in Europe”
Authors: R. Obeid, K. Pietrzik, G. P. Oakley Jr., V. Kancherla, W. Holzgreve and S. Wieser