Colin Michie (Zimbabwe & University 1980) is a paediatrician at the Institute of Child Health, University College, London
My interest in nutrition reaches back to junior clinical training, when I also volunteered as a rowing coach in Oxford. Several children and families I helped in these different roles suffered enormous challenges living with spina bifida. This established my interest in embryonic nutrition.
Folic acid or vitamin B9 ensures that the embryonic nerve cord zips together and seals successfully. Notochord problems and some fetal losses can therefore be prevented. A large Medical Research Council trial in the UK, published while I was starting paediatrics in the 1980s, supported the benefits of folic acid. In over 80 countries fortification of staple foods with folic acid has since been employed. The UK was, ironically, exceptional in not fortifying any staples following the second world war.
As a paediatrician in training I worked with various teams in the Royal College of Paediatrics and Child Health, outside agencies and charities to try to change this position. Data from historical sources and overseas clinics, collated through collaborations, demonstrated positive values and no significant negative public health impacts of fortification. I became chair of the nutrition committee in the College and joined with an All Party Parliamentary Group to examine the problem, collaborating with representatives from the milling and baking industries. Legislation permitting fortification was passed in 2024; fortification is to commence by the end of this year, 2026. Predictions suggest this will prevent 200 cases of spina bifida every year in the UK.
The B vitamins are all essential nutrients. Historically they were classified together because they were water soluble and were thought to prevent beri-beri. Biochemical analysis subsequently separated them into 8 distinct molecules. Vitamins B1 (thiamine), B6 (pyridoxine) B9 (folate) and B12 (cobalamin) have specific roles in neurological development and function. Deficiencies of each have been described and defined; daily doses for sufficiency are available. A pioneer of vitamin science, Jack Drummond, led a team to design and deliver the British “National Loaf” of bread, together with several distinguished nutritionists, to ensure adequate provision of vitamins and other micronutrients to the British population during rationing (Fig 1). Drummond was also cited in his early career for observing that during pregnancy a mother will have considerably greater requirements for many micronutrients, given the high rates of fetal growth, including their brains!
Vitamin B12 merits particular mention because this vitamin is almost exclusively of animal origin. It is a protein build around cobalt: its complete description was the result of a distinguished Oxford chemist and crystallographer, Dorothy Crowfoot Hodgkin, who received the 1964 Nobel Prize in Chemistry for employing X-ray crystallography to identifying its ring design (Figure 2). It is difficult for those taking a vegetarian or vegan diets to obtain sufficient B12 during pregnancy, a subject often discussed by paediatricians and obstetricians. Many mothers in developing countries are B12 deficient: the shortage of this vitamin can compromise the neurological development of their infants. Early studies showed that treating infants after birth with vitamin B12 was less effective than treating mothers. Together with teams of colleagues in Nepal and India I have assisted with a trial to supplement mothers, the outcome of which was published recently. This showed that higher doses of B12 supplementation during pregnancy and lactation improved newborn developmental outcomes.
These comments need to be put into context. Other micronutrients, including iron, zinc, magnesium, vitamin D and omega 3 fatty acids are critical components of neurological development too. However the larger challenge is now to establish whether increasing doses might promote neurological ‘improvements’. For instance, could B vitamins be used to improve neurological outcomes, or would these compromise pregnancies in terms of placental function, risks of maternal diabetes, or perhaps other complications? Early genomic studies show that genetic variation between mothers and their infants can modulate the effects of folate and B12 supplements.
Mechanisms by which vitamin Bs work are many and varied. They include single carbon metabolisms, synaptic signalling, neurotransmitters and the dynamics of neuroinflammation. Their respective roles in the changing brains of newborn infants are not clear, neither is their genetic regulation, or ideal dosing and timing related to various neurodevelopmental skills and capacities.
So should mothers on vegan or vegetarian diets be recommended to receive a broader supplement or fortification of B vitamins, in some fashion? As medical and ecological drivers encourage all of us to eat more plants and less meat, such findings are likely to impact on the neurological potentials at those crucial bookends of life: our newborn and our elderly.