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Wednesday, July 20, 2016

Filling the Gaps on Folic Acid Insufficiency:Legislation, Implementation, and Intervention

PRESS RELEASE
NAST-DOST*

The National Academy of Science and Technology, Philippines (NAST PHL) gathered stakeholders from the health and nutrition sector, representatives from the legislative body and other concerned government agencies, the academe, the private sector, and the pharmaceutical industry on June 28 at Hotel Jen Manila for a Science Legislative Forum (SLF) on Folic Acid. 


Resource persons, speakers and guests of the SLF on Folic Acid. (Photo: NAST-PHL @NASTPHL)

The objectives of the SLF were to review the global and Philippine burden of neural tube defects; review the burden of folic acid deficiency and insufficiency in the Philippines; review evidence for, impacts of, and safety of increasing folic acid intake; review experiences in increasing folic acid intake globally and in the Philippines; to orient the various stakeholders on the proposed legislations on folic acid supplementation and fortification; and discuss the role of government agencies, the academe, and the private sector.

The participants of the legislative forum were welcomed by Academician (Acd.) Fabian M. Dayrit, acting president of NAST PHL. One of the mandates of NAST PHL is to serve as an adviser to the government and the scientific community on policy formulation. Through the initiatives of Acd. Carmencita D. Padilla, member of the Health Sciences Division (HSD) of NAST PHL and focal person of the SLF on Folic Acid, the Rare Disease Act or the Republic Act No. 10747 was signed into law by President Benigno Aquino III. Its stakeholders can be traced from a successful legislative forum that captured cohesive inputs for the advocacy of the said act.

As there no are existing folic acid fortification efforts in the Philippines and supplementation efforts have achieved low coverage, there is a need to put a comprehensive policy in place not only to increase the awareness and knowledge on how folic acid can prevent NTDs but also to improve the maternal health of every Filipino mother and woman of child-bearing age; hence the conduct of a legislative forum for folic acid fortification and supplementation, Acd. Dayrit stressed.

Folate is a B-vitamin that plays a significant role in preventing birth defects particularly of the baby’s brain and spine, which are collectively known as neural tube defects (NTDs). Folic acid is the synthetic form of folate that occurs in fortification and supplementation.


Dr. Marissa B. Lukban, head of Section of Pediatric Neurology, Departments of Pediatrics and Neurosciences at the Philippine General Hospital (PGH), Manila, discussed the burden of neural tube defects in the Philippines. According to the data she presented, the occurrence of NTDs in the Philippines General Hospital is 23 per 10,000 live births; there is no available national data. She emphasized on the underreporting of cases in the Institute of Human Genetics Birth Defects Registry and the discrepancy among the regions, primarily because of varied reporting by the hospitals. 

Dr. Robert John Berry, medical epidemiologist of Prevention Research Branch, National Center on Birth Defects and Developmental Disabilities, US Centers for Disease Control, discussed the evidence for reduction of NTDs, other benefits, and safety of increasing folic acid intake. He clarified that there is a difference between folate deficiency and insufficiency – that folate deficiency commonly results to clinical anemia and homocysteine deficiency while folate insufficiency is attributed to the occurrence of NTDs. According to the data derived from numerous studies, as red-blood cell folate concentration increases, the NTD risk decreases. Despite the positive result of clinical studies on folic acid and folate, it is important to consider and identify potential adverse effects of folate because science, as Dr. Berry emphasized, is incapable of proving safety. He demonstrated however that reviews of high quality data show no adverse effects of folic acid and hence the evidence of the benefits of folic acid currently far outweigh any evidence of risk.

Dr. Helena Pachon, senior nutrition scientist of Food Fortification Initiative, discussed the global experience in increasing folic acid intake. Her presentation can be summarized into the following main statements: 1) fortification with folic acid reduces the risk of NTDs, 2) fortification with folic acid is more effective than supplementation or dietary diversification for reducing the risk of NTDs, 3) mandatory fortification with folic acid is more effective than voluntary fortification, and 4) fortification with folic acid can also reduce folate deficiency and folate-deficiency anemia. She mentioned that the Philippines is one of the only five countries that mandates the fortification of wheat flour but does not require folic acid and this is an opportunity for reducing the occurrence of NTDs in the Philippines. Based on estimates of NTDs in the Philippines, and impacts that have been achieved by other countries, fortification with folic acid could prevent between 3,000 and 3,500 babies from being born with a neural tube defect per year. She also presented data from the 2008 National Nutrition Survey of the Food and Nutrition Research Institute which suggests that 40-60% of reproductive age women in the Philippines are folate deficient; a substantially larger proportion are therefore folate insufficient and at risk of NTDs.

Ms. Maria Lourdes A. Vega, chief of Nutrition Policy and Planning Division, National Nutrition Council, discussed fortification efforts in the Philippines: its successes and challenges. She emphasized on the importance of food fortification as a global strategy for preventing micronutrient deficiencies and a cost-effective means to address malnutrition. The Philippines, as she stated,  has already legislated fortification of salt, wheat flour, cooking oil, rice and sugar but implementation, especially of salt, rice and sugar is not optimal. One of the major constraints is non-compliance to standards. The National Nutrition Council is therefore considering changes to the legislation, including the inclusion of folic acid fortification of flour.

Dr. Gerardo D. Legaspi, director and neurosurgeon of PGH, Manila, discussed the surgical management of patients with neural tube defects (NTDs). He discussed the epidemiology, pathophysiology, and treatment of several types of NTDs such as encephalocele, spina bifida, myelomeningocele, and anencephaly. He shared information on the extremely high costs of surgery for NTDs in private hospitals and impacts to quality of life to patients and their families.

Academician Padilla, Chancellor of the University of the Philippines (UP) Manila, presented the highlights of the proposed legislation on folic acid. Is there a need for legislation? Asked Dr. Padilla. She gave an overview of the journey of the Newborn Screening Act of 2004 or the Republic Act 9288; highlighting the importance and impact of a legislation in implementing a healthcare program. 

Among the highlights of the proposed bill are:

  • to ensure that every woman of reproductive age has access to food and food products containing folate and folic acid and folic acid supplements to reduce the risk of having babies with neural tube defects and other birth defects; 
  • to ensure that there is adequate supply of folic acid-fortified food and food products and folic acid tablets at an affordable price; 
  • to ensure that there is sufficient and correct information on the role of folate and folic acid for women of reproductive age and their children; 
  • to ensure the creation of a sustained inter-agency collaboration for the aggressive implementation and monitoring of this Act; and 
  • to foster collaborative undertakings in continuous research on folic acid food fortification and supplementation. 

Dr. Paulyn Jean B. Rosell-Ubial, incoming Secretary and Assistant Secretary of Health, Office for Health Regulations, Department of Health, expressed her support for the bill to be included as one of the priorities of the incoming Duterte administration. 

Ms. Maria Lourdes M. Sanchez, Committee Secretary, Committee on Health, House of Representatives is optimistic that the legislation of folic acid will be one of the banner programs of the 17th congress, alongside with education. She mentioned that a relatively significant bill has been submitted for enactment since the 12th congress up to the 16th congress, through the efforts of Representative Rufus Rodriguez.

Dr. Eva Maria Cutiongco-De La Paz, Outstanding Young Scientist 2002, vice chancellor for research of UP Manila, and executive director of UP National Institutes of Health gave a synthesis of the discussions. She reminded the audience-turned-folic acid advocates of their responsibility as stakeholders and frontrunners of the proposed legislation on folic acid fortification and supplementation, which is to watch the State of the Nation Address that will be delivered by President-elect Rodrigo Duterte and to promote the public health significance of folic acid especially for child-bearing women.


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*The National Academy of Science and Technology, Philippines (NAST PHL) is an attached agency of the Department of Science and Technology (DOST) and the country’s highest recognition and advisory body to the government and science community on issues concerning science and technology.

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