Professor Michael Turner:

Up until 2009, the women had not been weighed at their first visit. We reintroduced weighing in 2009. There is a lot of good data internationally on obesity levels outside of pregnancy but there is a paucity of information about obesity during pregnancy itself. This has implications not just for folic acid. We know that obese women are more likely to have congenital malformations. We know they are more likely to have babies with neural tube defects. We also know that, technically, because of their obesity it is harder to make the diagnosis of neural tube defects because when one comes to do the scan, the baby is further away from the probe. The obesity crisis is another issue that merits attention.

I will now deal with the cost of supplementation. The costs of fortification for the food industry are extremely low, I read a figure of the order of 19 cent per individual per annum. It is a pittance. One can buy folic acid supplements over the counter. The cost varies from pharmacy to pharmacy and one can get better deals from some pharmacists compared to others.

Again, this is in the order of €4 or €5 per month. My concern about the decrease is that it is a discretionary spend and the demographic of women in their 20s and 30s who should be spending money on supplementation are also those who are struggling to make ends meet with their mortgages and trying to feed their families. They prioritise the nutrition of the children they already have without planning for the children they might have in future. This may explain the regional differences with regard to Dublin. We do not know precisely why there are differences between Dublin and the rest of Ireland, but we know from the Central Statistics Office that people in Dublin spend 20% more on food than people outside Dublin. This highlights the importance of doing national audits. In the past, many of the audits on neural tube defects were Dublin-centric because of the excellent data collection in the three Dublin maternity hospitals. We need to audit outcomes throughout the country and not just in Dublin.

Senator Crown asked about the side effects. There are concerns, and he would probably know more about it than I do, about whether excessive folic acid may be associated with cancer, particularly bowel cancer. I do not find the evidence particularly compelling in terms of risk. It is weak. There is also evidence that cancer is associated with folic depletion. Folic acid may have benefits other than preventing neural tube defects. The evidence suggests that it also prevents cardiac congenital abnormalities and cleft lip and palate abnormalities. It may prevent cardiac disease and stroke in adults. Having lots of folic acid in one's diet and taking folic acid supplements has benefits which go beyond preventing neural tube defects.

All pregnancy outcomes have a social gradient, and this is very important. It is those women who need folic acid supplementation the most who do not avail of it. When it comes to the planning of pregnancy, there is a very strong social gradient. This is important not just in terms of folic acid supplementation but with regard to preparation for pregnancy generally, including losing weight, increasing physical exercise and stopping smoking.

If we had complete compliance with folic acid supplementation - in other words, if every woman took it for three months before she became pregnant - it is estimated that two thirds of cases of neural tube defects would be prevented. To put this in context, approximately 50 to 60 families every year have a baby who must come to Temple Street for surgery, which corrects the defect rather than the neurological issue, so 40 families would be spared this trauma. There is no good data as to the cost to the health services of neural tube defects in Ireland, other than to say that a big review was published four years ago which estimated that each case of spina bifida costs €500,000 over the lifetime of the person concerned. If one takes this €500,000 and multiplies it by 60, it is €30 million. We could do a lot with €30 million in maternity services.

In terms of the consistency of our guidelines, we need to get our house in order nationally. Some guidelines say that folic acid should be taken when one is planning pregnancy, while others say it should be taken one month beforehand and others say three months beforehand. In general, most European guidelines were published after the landmark studies of the 1990s, but the more recent research suggests that folic acid should be taken for three months beforehand. The European guidelines need to be updated. The Canadians and Australians have updated their guidelines and they are advanced. If we get our house in order there is something that could be done at EU level in terms of aligning guidelines, particularly now with women in their 20s and 30s moving more freely between EU countries. We need to have consistency.

The demographic in question uses social media a lot. This has advantages because we know from our work in the Coombe that 95% of pregnant women use their smartphones for pregnancy-related information. Interestingly, those who are socially disadvantaged also use it a lot. It has advantages in that it is inexpensive. We can measure its use, we can archive it, we can update it very quickly and we know what parts of it are used. We cannot do this with traditional communication channels. Not just on the issue of folic acid, but on the issue of providing information to women who are pregnant or contemplating pregnancy, we need to have a national e-health strategy when it comes to maternity services. I am pleased to report that I was at a meeting recently at which I learned that safefood is planning to launch a social media campaign in July on folic acid supplementation.

Senator Burke asked about childhood obesity and whether it was an issue. If a mother or father is obese the child is three to four times more likely to be obese. This is why, when we speak about maternal obesity, we see it not just in terms of the mother; it is a family issue. If mothers have a healthy lifestyle and diet, we hope the fathers will improve. We know that one in six fathers-to-be in the Coombe are also obese. We hope that if the parents have a healthy diet the children will have a healthy diet. There is concern about obesity begetting obesity. Nationally we need a strategy on breaking the intergenerational cycle of obesity.

I agree with Deputy Byrne on the regional differences. Transition year is a great opportunity across the board to educate girls and boys on what they should do to modify their risks subsequently in life. There are huge educational opportunities that we are not taking as a country at present.