The Centers for Disease Control and Prevention (CDC) currently recommends that women of reproductive age consume folic acid each day to help prevent neural tube defects (NTDs), including spina bifida. Two public health interventions are associated with this recommendation: mandatory fortification of enriched flour and grains and voluntary fortification of mesa flour. While the work of many people led to these interventions, I sat down with Professor Shirley Beresford, PhD, ahead of her retirement and learned more about her contributions to the field of folic acid research, which have made an immeasurable impact on the health and well-being of many children and families.
From our conversation, it became clear that this story is one of several opportunities Dr. Beresford has seized throughout her career to shape public health research, policy, methods, and education. Dr. Beresford retired in November, from her roles as Senior Associate Dean in the UW School of Public Health (SPH), professor of epidemiology, and adjunct professor of health services, and was appointed as professor emeritus of epidemiology.
Your background is in mathematics and statistics. What initially piqued your interest in epidemiology?
I grew up in Kent, on the outskirts of London in the Southeast of England. The British educational system encourages you to concentrate in a field of study early, so by 15 years old, the only things I was studying were mathematics and physics. I went on to study mathematics at the University of Cambridge. Natural considerations of where mathematics could be applied, led to my interest in statistics as a postgraduate. Most people with a math degree go on to teach mathematics, but I was interested in exploring other, lesser known, opportunities, which led me to where math and statistics could be applied.
My first research appointment was attached to a medical school at the University of London, working in what was then called social medicine. I taught statistics, but most of what we did in the research unit involved collaborative studies between clinical epidemiology, statistics, and social science. Soon, I realized I wanted to play a more primary role, running some of my own studies, which required me to get a PhD in epidemiology, so that’s where it started.
Your research career has spanned a wide and diverse spectrum of public health topics. How would you describe your research interests and how have they evolved over time?
Family circumstance was responsible for one research area that became quite important. After our son Alistair was born with spina bifida, I became involved as a professional advisor to the Spina Bifida Association of America. In that capacity, I was invited to attend CDC advisory group meetings, which brought together experts from different disciplines to explore causes of neural tube defects (NTDs), including spina bifida. When the vitamin nutritional element emerged as a potential contributing factor to NTDs, the CDC began planning a randomized control trial (RCT) to explore the effects of multivitamins on women newly registered for marriage in Northern China.
As I listened to scientists from vastly different backgrounds explaining the evidence they had uncovered of potential relevance to NTD etiology, I noticed the role of the micronutrient folic acid came up in in several different presentations. It became clear to me that while folic acid was included as part of the CDC’s RCT with other multivitamins, it needed to be evaluated separately. After I raised this observation, the CDC group took notice and it influenced the design of the study, which moved forward in the planning stage as a factorial design. Soon afterwards, the results of the Medical Research Council (MRC) trial of women with a history of a NTD-affected pregnancy came out, forming a solid basis for intervention planning. The collaborative study in Northern China was reformulated as a demonstration intervention (quasi-experimental design).
The results from the MRC trial demonstrated the importance of the mother having good folic status before conception. Later, the CDC invited me to join them as a consultant in an effort to advise the FDA of ways to make folic acid commonly available to all women of childbearing age regardless of their ability to pay for a pill.
I was very privileged to be at the table, and together we were able to make it clear that the importance of folic acid needed urgent attention. Since then, I’ve had several opportunities to contribute to the design and conduct of interventions for the general population, designed to improve public health. Looking back now has helped me recognize what tremendous opportunities they really were!
Not only did you have the opportunity, but you voiced your opinion and it clearly made an impact! What are other areas of research you are proud of?
Another big opportunity involved dietary behavior interventions. When interest in this area of research began to emerge, there were a number RCTs looking to try and reduce diseases relevant to men, like heart disease. Around the same time, dietary fat intake and hormone therapy post menopause were two areas that were clearly ready to have interventions evaluated for their impact on the health of women.
Because I had been doing some epidemiological observational work in each of these areas, I was able to persuade colleagues at the Fred Hutchinson Cancer Research Center that I could help with the Seattle Clinical Center as one of the investigators for the Women’s Health Initiative (WHI) trials. While I initially started out with responsibility to recruit women to the trials, I ended up taking on a leadership role in the Clinical Center and in the Dietary Modification Trial implementation, after a senior colleague retired.
This work was another example where I was a part of something big, and the WHI has been very big—in terms of policy on the hormone therapy front, and in terms of developing the methods used to measure diet and dietary information.
I think we take it for granted that the tools to assess and measure dietary behavior had to be created. Can you say more about your involvement in this type of methods development?
There were a couple of critical methodological pieces that trace back to my work in London. At that time, I was working alongside a team of scientists, including another mathematical statistician and a nutritional scientist, and we were collaboratively looking at a whole series of studies, grappling with the question: Is diet associated with chronic disease?
Within the context of WHI, and in relation to my teaching graduate students nutritional epidemiology for more than 30 years, I was able to draw back on some of that work and, with colleagues, distill another major question you run into when interpreting self-assessment of diet: How do you measure a specific dietary factor as an outcome of an intervention? For example, should it be measured in relation to the total diet, or as a dietary factor per se, in absolute terms?
I am pretty passionate about these concepts. Establishing appropriate methodology helps to avoid making inferences from imperfect tools. This is particularly important for dietary intake in a health context to assess benefits or evaluate a behavioral intervention.
How have interdisciplinary collaborations played a part in your career?
Well, all of my research work has relied on collaborations and partnerships with people from other disciplines. Let me give you one example from my work in social epidemiology. Harking back to my PhD studies around water quality in different areas and industrialization, it was very clear then that employment and income opportunities and where you live (by affordability, choice or social constraints), tend to cluster together geographically. This research is what initially sparked my interest in social epidemiology, so I was excited when a group of Epi PhD students identified we needed more work on social epidemiology. We pulled together some symposia, with several other Health Sciences Schools, on the social determinants of health and health disparities. Ultimately, that led to a journal club which led to a course in social epidemiological methods. We also got a lot of help from biostatistics faculty in the teaching the methods needed in evaluating the association between income inequalities, poor working conditions, and environmental factors, and the individual effects on poor health consequences.
More recently, my partner, Donald Patrick, and I established a fund, the Patrick-Beresford Fellowship in Social Epidemiology, to support students who are interested in pursuing a career in social epidemiology. It was important to us to support students who are interested in both the social science part and the epi part. We’re very excited that more donors have been inspired to contribute and that the fund continues to get more visibility as interest in this area of research grows.
Reflecting on the many hats you’ve worn as Senior Associate Dean for the School of Public Health, and faculty member in epidemiology and health services departments, what have you enjoyed about these roles?
It’s been enormously exciting to be part of the iterative process to re-envision the Master in Public Health (MPH) degree. The efforts to evolve this degree program have helped codify the appreciation for interdisciplinary work. The committee, and everyone involved, have set up the MPH common core courses in the co-teaching model and student-centered learning strategies that I believe will help foster respect for other disciplines.
What advice do you have for students?
While a lot of what you’ll do is luck in a sense, you have to have your eyes open for opportunities. Some people know what they want to study and they become an expert on that subject, but that’s not the only way. You can start with what you’re interested in and where there is opportunity, and then tie the multiple threads linking them together.
What are you looking forward to the most in retirement? Do you have any plans or projects?
I’m hoping I’ll be able to identify a meaningful set of volunteer opportunities. I look forward to continuing to pursue my longstanding hobby of singing. I currently sing regularly with Seattle Pro Musica, and sing with the choir at the University Unitarian church.
I’m looking forward to continuing some of my work in evaluating health disparities. I’ve had a long-standing collaboration with a horticultural scientist colleague at New Mexico State University as part of a U54 grant to look at where gardening and health intersect. As part of that project, we’re working with investigators from the Navajo nation, to look at strategies for improving healthy eating and increasing access to vegetables through gardening and elementary school curriculum. I’m excited to help see that project through to the next phase.