Response to letter from Mrs Kathleen Dawson, Department of Health, 24th December 1999
Comment on document entitled Scientific Review of the Welfare Food Scheme
Comment on proposal that vitamin A be omitted from the Welfare Food vitamin supplement for pregnant women
1. The reason given for omitting vitamin A (section 7.2.1i) is the teratogenic potential in early pregnancy. The health consequences of omitting Vitamin A are not discussed. Vitamin A requirements can be met by intake of retinol or of some carotenes. Retinol is teratogenic at high intakes but carotene is not. (1) (2) (3) (4). No irreversible effects of intakes of betacarotene have been found with daily intakes up to 180 mg/d. Pregnacare capsules recommended by the Royal College of Obstetricians and Gynecologists contain no retinol but 4.2 mg per capsule of betacarotene, providing 700 mcg of vitamin A by physiological biosynthesis as required (5) (6). If supplements do not contain retinol but only betacarotene the teratogenic potential ceases to be relevant. The COMA Review (Section 4.1.1 Table 1) leaves it unclear whether the Welfare Food vitamin supplements contain retinol or carotene and in the light of the discussion of teratogenicity prompt the suspicion that they contain retinol.
2. The Welfare Foods are available to women receiving benefits who are by definition the poorest women in our society but the COMA Review does not discuss whether vitamin A intakes below recommended levels are at all common among these recipients of the supplements. The current RNIs for vitamin A are 600 mcg/d for all women not pregnant, 700 mcg/d for pregnancy and 950 mcg/d for lactation (7). The survey of the diet of British adults (8) reports that the median intake of vitamin A of poor women ( in receipt of benefits) was 633 mcg/d (retinol equivalent). The lower 2.5 percentile for all women aged 25 to 34 was 177 mcg/d. This indicates that there are a large number of women with vitamin A intakes between 177 and 633 mcg/d and a small percentage below 177 mcg/d. Thus nearly one half of all poor women have vitamin A intakes below the RNI of 600 mcg/d.
3. There is a substantial literature describing the consequences of a low vitamin A intake and as a result different countries have recommendations for vitamin A conceived to maximise human health. A classic study published by the WHO in 1968 said (9):
"Vitamin A deficiency shows synergism with almost every known infectious disease. Table 5 lists nearly fifty investigations on diseases of bacterial, viral and protozoal origin in which this deficiency resulted in greater frequency, severity and fatality."
Vitamin A passes the placenta and poor pregnant women who already have low reserves of vitamin A will be further depleted. The omission of vitamin A from the Welfare Food vitamin supplement would further increase their susceptibility to most kinds of infection.
4. The synergism of vitamin A deficiency and infectious disease prompted research on the role of vitamin A in the immune system and the effect of vitamin A on the immune response (10) (11). Vitamin A has been shown to increase the number of antibody forming cells and to enhance the antibody response of B cells (12) and T cells (13) It has been shown that vitamin A can influence the growth and differentiation of the progenitor cells of macrophages and can stimulate the production of cytotoxic cells in the presence of an immunogen (14) (15). There is now an extensive literature on vitamin A and the immune system.
5. This immunological research led quickly to the study of the role of vitamin A deficiency in the development of cancer. For example in 1988 the Surgeon General of the USA said (16):
"A large body of evidence suggests that foods high in vitamin A and carotenoids are protective against a variety of epithelial cancers". (17) (18) (19) (20)
It seems reasonable to fear that the omission of vitamin A from the Welfare Food supplements would increase vulnerability to infections and cancer among the poor women who receive them. Low vitamin A intake is one of the causes of the inferior health of the poor.
6. Studies in farm animals and in rats show an association between vitamin A intake and intrauterine growth from early in pregnancy. Winick in his classic study entitled Malnutrition and Brain Development says (21):
"Reduced levels of vitamin A have long been known to be teratogenic in the rat. Experiments in our laboratory have demonstrated that marginal vitamin A deficiency in the mother will retard growth in the fetus. By 16 days of gestation the earliest effects of the growth failure can be detected." (p 111)
Vitamin A deficiency in utero depresses fetal cell replication but does so differentially, affecting some cells or organs more than others, resulting in morphological anomalies. For example a deficiency of vitamin A in pregnant rats causes serious respiratory problems in the fetus caused by loss of ciliae and disrupted microvilli and by keratinizing metaplasia (22)(23). Similar anomalies caused by vitamin A deficiency have been reported in animal experiments in the digestive tract, salivary gland, the genitourinary tract and in the vagina.
7. The animal experiments establish hypotheses for the effects of vitamin A deficiency in human pregnancy but no studies have been found which enable the effects of this deficiency to be distinguished from the effect of low maternal intake of other vitamins and minerals acting at the same time.
Welfare Food supplements should continue to supply vitamin A but as carotenes and should be so described. The amount of carotenes should provide 700 mcg vitamin A as in Pregnacare capsules.
Comment on the proposal to limit Welfare Food supplements for pregnant women to vitamins D, C and folic acid.
8. Welfare Food supplements, containing only three vitamins, contrast with the supplements for prepregnancy and pregnancy sold quite widely which contain many vitamins and also minerals. For example Pregnacare one-a-day capsules approved by the Royal College of Obstetricians and Gynaecologists contains 11 vitamins and 5 minerals as shown in Table 1.
Table 1
Percentage of British children aged 1½ to 4½ with plasma retinol below threshold of 0.75 mcmol/l
| age and sex | |||||
| percent with | all aged | all aged | 3.5 to 4.5 | all age | |
| plasma retinol | 1.5-2.5 | 2.5-3.5 | boys | girls | and sex |
| below 0.75 mcmol/l | 12 | 11 | 15 | 14 | 12 |
| Source: see reference 24. |
There are also other such pregnancy supplements on sale:
Boots: Pregnancy Daily Supplement Superdrug: Natal Supplement
Vega: Prenatal Formula Solgar: Prenatal Nutrition Tablets
Lanes: Preconceive
The content, presentation and price vary between these products but whatever is right or wrong the contrast with the proposed Welfare Food supplements looks unfortunately too much like one supplement for the poor and one supplement for the rich, or a big supplement for the rich and a little supplement for the poor!
9. The difference between the daily intake of nutrients of women in Social Classes I & II and women in receipt of benefits for whom the Welfare Foods are intended is shown in Table 2. The 14 nutrients are ranked in order of apparent effect of poverty on intake (8 ). Vitamin C, one of the Welfare Food Scheme favourites is seen to be top of Table 2. The present Welfare Food Scheme ( Review para 4.4.1) provides 21.4 mg/d of vitamin C for pregnant women. This is seen to be substantially less than the difference between the median intake of women in columns A and B.
Table 2
Association of women's poverty and reduced intake of essential nutrients; median intake of 14 essential nutrients by women in Social Class I & II and women in receipt of benefits
| women in SC I & II | women in receipt of benefits | 100 x B/A | |
| vitamin C mg/d | 70.4 | 39.5 | 56.1 |
| vitamin A (ret equiv) mcg/d | 1,019 | 633 | 62.1 |
| riboflavin B2 mg/d | 1.7 | 1.2 | 70.6 |
| vitamin D mcg/d | 2.5 | 1.8 | 72.0 |
| vitamin E mg/d | 7.5 | 5.6 | 74.7 |
| iodine mcg/d | 178 | 138 | 77.5 |
| magnesium mg/d | 248 | 193 | 77.8 |
| phosphorus mg/d | 1,132 | 885 | 78.2 |
| thiamine B1 mg/d | 1.4 | 1.1 | 78.6 |
| folate B 9 mcg/d | 229 | 180 | 78.6 |
| potassium mg/d | 2,546 | 2,043 | 80.21 |
| zinc mg/d | 8.81 | 7.1 | 80.6 |
| iron mg/d | 11.0 | 9.0 | 81.8 |
| pyridoxine B6 mg/d | 1.7 | 1.4 | 82.3 |
| protein | 65.8 | 53.9 | 81.9 |
Source: see reference
10. Vitamin C is essential for the synthesis of collagen, the connective and structural protein needed for the growth and repair of blood vessels, bone , cartilage and teeth, with an extra requirement for wound healing. An intake of vitamin C of 75 mg/d was suggested by the US Surgeon General to be necessary to maintain the body pool and plasma level in the average woman as shown in Table 3. A lower intake and lower plasma level slows down collagen synthesis. An intake of 75 mg/d does not take into account any special requirements, for example smoking greatly increases the intake needed to maintain serum levels. Collagen synthesis is only one of the important roles of vitamin C.
Table 3
Vitamin C for women
| mg/day | |
| French Apports Nutritionnels Conseilles (ANC) - pregnant women ( ) | 90 |
| French Apports Nutritionnels Conseilles - women not pregnant | 80 |
| US Surgeon General - to maintain plasma level ( ) | 75 |
| US Recommended Dietary Allowance (RDA) - pregnant women ( ) | 70 |
| Royal College of Obstetricians &; Gynaecologists - Pregnacare tablets ( ) | 70 |
| US Recommended Dietary Allowance (RDA) - women not pregnant | 60 |
| US Surgeon General - needed to ensure iron absorption | 60 |
| UK Reference Nutrient Intake (RNI) - pregnant women ( ) | 50 |
| UK Reference Nutrient Intake - women over 15 | 40 |
| UK dietary survey of adults - median intake of women receiving benefits ( ) | 39.5 |
11. How much vitamin C should the Welfare Food supplement contain? Median intakes are used in Table 2. One half, therefore, of women in receipt of benefits have vitamin C intakes below 39.5 mg/d and the survey shows that some women have intakes below 12.0 mg/d. The content of the Pregnacare capsules looks reasonable to bring intakes up to the 75 mg/d for women plus 10 mg/d extra for pregnant women which is necessary to maintain an optimum body pool of vitamin C as suggested by the US Surgeon General. However human variability must be taken into account and 70 mg/d is certainly inadequate for women who smoke or have special requirements for other reasons.
Welfare Food supplements should supply at least 75 mg/d of vitamin C and the Review
should include a study of the literature on other vitamins with a view to their inclusion.
The political danger of the gap between commercial supplements and what may be seen
as "poor persons vitamins" should be taken into account. Welfare Food must not carry
a stigma.
12. Since welfare foods were first established over 50 years ago the reasons for these supplements have changed. Fifty years ago the prevalence of low birthweight and its significance was not the preoccupation it is today. It is seen in Table 4 that the United Kingdom has the highest percentage of babies born too small (< 2,500g and below) of 12 European countries. Furthermore, the percentage is rising as shown in Table 5. The reduction in this percentage is one aim of public policy as part of the Sure Start program. There is an economics literature showing that low birthweight is very expensive in the short term to health services and families, in the longer term to educational services, to the social security budget and to the economy in loss of earning power and tax revenue.
The prevention of low birthweight should be one of the purposes of the Review of the Welfare Food Scheme.
Comment on the omission of minerals from Welfare Food supplements except for iodine supplement for breast feeding mothers
13. The prevention of low birthweight requires an adequate intake of minerals as well as vitamins before conception and during pregnancy. The welfare supplements listed on page 20 of the Scientific Review do not include any minerals for pregnant women but the Review recommends 0.13 mg/d potassium iodide ( equivalent to 100 mcg/d iodine ) in tablets for breast feeding mothers only. A report of the WHO says (24):
"Iodine deficiency affects reproductive function leading to increased rates of abortion, still births, congenital anomalies, low birthweight and infant and young child mortality."
A book of 492 pages entitled Iodine Deficiency in Europe: a continuing concern was published in 1993 reporting a conference of UNICEF, WHO and 6 other governmental organisations (25). European countries are no longer troubled by iodine deficiency severe enough to cause cretinism, but are still troubled by lesser degrees of maternal iodine deficiency resulting in losses of mental ability in children recorded at school age. Another important motive for the European conference was the realisation that iodine deficiency has a damaging effect on a woman's thyroid gland during pregnancy. Thyroiditis and hypothyroidism can continue for a lifetime following overstimulation of the thyroid gland in a mother who is iodine deficient during her pregnancy. US health surveys show about 5 per cent of American women with such chronic post-pregnancy thyroid dysfunction. British GPs have reported 5 to 10 percent of woman patients with this disorder (26). Some local studies report over 20 per cent (27).
14. The survey of adult diet showed that 32 per cent of women have intakes of iodine below the UK RNI of 140 mcg/d. The RNI provides no increases in iodine intake for pregnancy or lactation. More than half of all women receiving benefits have iodine intakes below the RNI and an appreciable number have intakes as low as 30 mcg/d. Again the Pregnacare supplement of 140 mcg/d of iodine for women anticipating pregnancy seems reasonable both for the infant and for their own health. The WHO recommends intakes for women of 150 mcg/d with an increment of 50 mcg/d totalling 200 mcg/d for pregnancy and lactation (28)..
Welfare Food supplements for pregnant women should contain about 150 mcg/d of iodine in line with WHO recommendations.
15. A number of countries have reported an association between birthweight and maternal magnesium intake (29). In a study of London women magnesium intake had the highest correlation with birthweight of 7 different minerals. The Welfare Food supplements contain no magnesium in contrast to Pregnacare which contains 150 mg per tablet. A double-blind controlled trial in Switzerland on a comparatively healthy population recorded a substantial and highly significant reduction in low birthweight and a substantial reduction in hospital workload was emphasised in the report (30). Following trials in Germany failure of mothers to take magnesium supplements is listed as a pregnancy risk factor to be assessed during antenatal care (29). The UK Reference Nutrient Intake for magnesium is 270 mg/d. The median intake of all British women is only 226 mg/d and in the 25 to 34 age bracket magnesium intake ranges down to under 100 mg/d.
16. The prevention of heart disease is one of the government's priority targets. The steep income and social class correlation of magnesium intake is relevant not only to prevention of low birthweight but to prevention of heart disease .A prospective study of nutritional factors causing heart disease used 4-yearly records of 58,218 American female registered nurses and found that low magnesium intake had the highest correlation with raised blood pressure and heart disease (31). Low magnesium intake has also been shown to produce both low birthweight and raised blood pressure in animals (32). Magnesium , which is the second most important mineral within all human and animal cells, influences the level of the hormones, prostacyclin and thromboxane, which control blood pressure.
17. There is also substantial research literature showing low birthweight and pregnancy pathology can be caused by inadequate maternal intakes notably of zinc (33) and iron (34).
Welfare Food supplements for pregnant women should contain magnesium and consideration should be given to the inclusion of other minerals
How could the Welfare Food Scheme contribute to the prepregnancy nutrition of women ?
18. The Review stresses the importance of good nutrition before pregnancy. The WHO published a monograph in 1995 based on a metaanalysis from 20 countries which supports this view (35).An international conference hosted by the New York Academy of Sciences in 1993 entitled Maternal Nutrition and Pregnancy Outcome concluded (36):
"A major area of consensus of this conference is that prepregnancy nutritional status significantly affects pregnancy outcome."
A substantial body of research has shown the importance of nutritional status during the follicular phase before and around ovulation and conception and the damaging effect of maternal malnutrition at this time on hormone levels, on the size of the corpus luteum and on the development of the embryo.
19. How can the Welfare Food vitamin supplement be made more acceptable and the take up before pregnancy be achieved? A mother can collect milk tokens at the Post Office when she collects her Income Support or Jobseekers Allowance. She may choose from nine branded baby milks like any other mother. There is no DoH plain packaged "National Dried" suggesting an only-for-the-poor product. The Welfare Food vitamins are not the same as any woman can buy in her chemist's shop. Moreover any woman hoping to be pregnant can buy her folate tablets or pregnancy formulated vitamins and minerals tablets including folate without having to confide in a doctor or midwife or anyone else what her hopes are. She cannot be "asked for proof that you are entitled" as the booklet Welfare milk and vitamins: a guide for families warns her. Women entitled to benefits must be trusted to know their own intentions and obtain entitlement to the vitamin pills without consulting anyone. The vitamin pills should be brands available to any woman . The Panel reviewing the Welfare Food Scheme should examine the contents of pregnancy pills now available and exclude any not approved in the same way as soya and other baby milks are excluded from the choice available for bottle feeding.
20. Suppose a woman asks for the vitamin pills before conception and then does not have a baby? Is this not a waste of public money? On the contrary it is in the public interest for as many poor women as possible to consume such supplements whether or not they become pregnant, or even change their minds. Poor women, that is to say women receiving benefits, from ages 18 to 50 have more than twice the number of hospital admissions as their more prosperous contemporaries. Recent studies have also shown that up to 40 per cent of hospital
admissions for men and women are a consequence of secondary malnutrition superimposed on a primary illness (37). The cost of hospitalisation is such that if a vitamin supplement reduced the risk of admission by only 1 per cent it would still be highly profitable.
A choice of vitamin supplements before conception should be available to any woman receiving benefits and no requirement to confide in any professional should be imposed on her.
References
1. Bendich A, Langseth L. Safety of vitamin A. Am J Clin Nutr 1989;49 :358 - 371.
2. Greenberg RE. A clinical trial of vitamins to prevent colorectal adenoma. N Eng J Med 1994; 331: 141 - 7.
3. Hathcock JN, Hattan DG, Jenkins MY, et al. Evaluation of vitamin A toxicity. Am J Clin Nutr 1990; 52: 183 - 202.
4.The alpha-tocopherol, beta-carotene cancer prevention study group. The effect of vitamin E and beta-carotene on the incidence of lung cancer and other cancers in male smokers. N Eng J Med 1994; 330: 1029 - 1035.
5. WellBeing, Royal College of Obstetricians and Gynaecologists. Preparing for pregnancy.
Pregnancy and birth. London, 1999.
6. Introduction to Pregnacare. London: Vitabiotics, 1999
7. Department of Health. Dietary reference values for food energy and nutrients for the United Kingdom. London: HMSO, 1991.
8. Gregory J, Foster K, Tyler K, Wiseman M. The dietary and nutritional survey of British adults. OPCS 1990. London: HMSO.
9. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. World Health Organisation, 1968. Geneva: WHO.
10. Demert G. Retinoids and the immune system: immunostimulation by vitamin A. In: Sporn MB, ed. Retinoids, vol 2 pp 373 - 390. New York: Academic Press, 1984.
11. Demert G. Immunostimulation by retinoic acid. In: CIBA Foundation, Retinoids, differentiation and disease ,1985;113:117-131. London: Pitman.
12. Sidell N, Famatiga E, Golub SH. Immunological aspects of retinoids in humans. Cell Immunol 1984;88:374 - 3 81.
13. Lotan R. Stimulating effects of vitamin A analogs on induction of cell-mediated cytotoxicity in vivo. Cancer Res 1979; 39: 55 - 38.
14. Dover D, Koeffler HP. Retinoic acid enhances colony stimulating factor- induced clonal growth of normal human myeloid progenitor cells in vivo. Exp Cell Res 1982;138: 193 - 198.
15. Rhodes J, Oliver S. Retinoids as regulators of macrophage function. Immunology 1980; 40; 467-4 72.
16. US Department of Health and Human Services. The Surgeon General's Report on Nutrition and Health. Washington: Government Publishing Office, No 88-50210 1988.
17 Mettlin C. Epidemiologic studies on vitamin A and cancer. Advances Nutr Res,1984; 6: 47-64.
18. Kummet T, Moon TE, Meystens FL. Vitamin A: evidence for its preventive role in human cancer. Nutr Cancer 1983; 5: 96- 106.
19. Bertram JS, Kolanel LM, Meyskens FL. Rational and strategies for the chemo prevention of cancer in humans. Cancer Research 1987; 47: 3012- 31.
20. Palgi A. Vitamin A and lung cancer; a perspective. Nutr Cancer 1984; 6: 105 - 20.
21. Winick M. Malnutrition and brain development. New York, London: Oxford University Press, 1976.
22. Wong YC, Buck RC. An electron microscope study of metaplasia of the rat tracheal epithelium in vitamin A deficiency. Lab Invest 1971; 24: 55 - 66.
23. Biesalski HK, Stofft E, Wellner U et al. Vitamin A and ciliated cells of respiratory epithelia. Zeitschrift fur Ernahrungswissenshaft 1986;25 :114-121.
24. World Health Organisation. Global prevalence of iodine deficiency disorders. Geneva: WHO, 1993.
25. Delange F, Dunn JT, Glinoer D. Iodine deficiency in Europe: a contemporary concern. Vol 241. New York: Plenum Press, 1993.
26. Durrant-Peatfield BJ. Aspects of common missed diagnosis: thyroid dysfunction and management. J Nutr Environ Med 1996; 6:371-8
27. Othman S, Phillips AP, Parkes AB. A long-term follow up of postpartum thyroiditis. Clin Endocrinol 1990; 30: 559- 64.
28. World Health Organisation. Trace elements in human nutrition and health. Geneva: WHO, 1996.
29. Wynn M, Wynn A. Magnesium and other nutrient deficiencies as possible causes of hypertension and low birthweight. Nutr Health 1988; 6: 69-88.
30. Spatling L, Spatling G. magnesium supplementation in pregnancy: a double-blind study. Br J Obstet Gynaecol 1988; 95: 120 - 5.
31. Jacqueline CM, Witteman MS, Willett WC et al. A prospective study of nutritional factors and hypertension among US women. Circulation 1989; 80;1320 -132 6.
32. Weaver K. Pregnancy induced hypertension and low birthweight in magnesium deficient ewes. Magnesium 1986; 5: 191 - 200.
33. Prasad AS. Zinc deficiency in women, infants and children. J Am Coll Nutr 1996;15: 113 - 120.
34. US Institute of Medicine. Nutrition during pregnancy. Washington DC: National Academy Press, 1990, 468 pages.
35. WHO. Maternal anthropometry and pregnancy outcome. WHO Bnulletin 1995;73: 1 - 98.
36. Keen CL, Bendich A, Willhite CC. Maternal nutrition and pregnancy outcome. Ann NY Acad Sci 1993; 678: 372 pages.
37. Davis AM, Bristow A. Managing nutrition in hospital. Nuffield Trust 1999, 118 pages.
Table 6
Example of vitamin mineral supplement on sale for children aged 3 to 12 years.*
| content per tablet | |
| vitamin A | 750 mcg |
| vitamin D | 5 mcg |
| vitamin E | 10 mg |
| vitamin C | 60 mg |
| thiamin B1 | 1.4 mg |
| riboflavin B2 | 1.6 mg |
| niacin B3 | 9 mg |
| pyridoxine B6 | 2 mg |
| folic acid | 200 mcsg |
| vitamin B 12 | 1 mcg |
| biotin | 25 mcg |
| pantothenic acid | 1 mg |
| betacarotene | 400 mcg |
| calcium | 133 mg |
| phosphorus | 70 mg |
| iron | 4 mg |
| magnesium | 50 mg |
| zinc | 2.5 mg |
| iodine | 150 mcg |
* Produced by Sanatogen, Roche Consumer Health. Recommended intake: one tablet daily.