Report calls for mandatory folic acid fortification in bread – Expert reaction

A joint report commissioned by the Ministry of Health has found compelling evidence that the benefits of adding folic acid to packaged bread outweigh the risks. 

The report, co-authored by former chief science advisor Sir Peter Gluckman and the Royal Society Te Apārangi, has found mandatory folic acid fortification is linked to lower rates of birth defects, and that taking folic acid supplements at the recommended doses in pregnancy has no adverse effects on pregnancy outcome or the child’s health.

The Science Media Centre gathered expert commentary on the review. Please feel free to use these comments in your reporting.

The report and press material are available on Scimex.

Associate Professor Barry Borman, Associate Director, Centre for Public Health Research (CPHR) Massey University, comments:

“Congratulations to the authors for confirming the long-held international view that the evidence is compelling for mandatory folic acid fortification to reduce the risk of neural tube defects.

“The myths of any risks have been comprehensively and emphatically laid to rest. There has been no scientific reason for New Zealand not to have joined more than 80 other countries in implementing a mandatory programme.

“Despite the accumulating evidence of the success of these programmes in Australia and elsewhere, New Zealand’s response since the 2000s has been snail-paced and politically and industry driven.

“The unsubstantiated theoretical risks and the need to appease the industry have held sway over the proven benefits of a mandatory programme. Meanwhile, about 30 babies per year continue to be born with a defect which could easily have been averted by a programme of mandatory folic acid fortification.

“At last, the sterling efforts of many individuals and organisations who have championed tirelessly for the implementation of mandatory folic acid fortification will be realised. Babies and families will no longer have to endure the trials and tribulations of having to cope with an easily preventable neural tube defect.

“Come on, New Zealand, we can do this.”

Dr Andrew Marshall, Paediatrician at Wellington Regional Hospital for Capital & Coast District Health Board, comments: 

“I strongly support the mandatory fortification of flour (or bread) with folic acid to prevent cases of neural tube defects such as anencephaly and spina bifida.

“The scientific evidence overwhelmingly favoured the safety and efficacy of mandatory fortification in 2006-2008, which is why NZ and Australia agreed to implement mandatory fortification in 2009. The New Zealand Government of the time pulled back from that commitment, and ever since we have had a regime of voluntary fortification which was never going to deliver the potential health outcome desired.

“This report is of the highest standard of expert analysis, and reaffirms that mandatory fortification is safe and effective.

“I call on the current government to implement mandatory folic acid fortification in New Zealand, joining the 80 countries who already do this.

“Every year that goes by, there are estimated to be between 5-15 new cases of NTD in New Zealand that would have been prevented by the mandatory fortification regime implemented as planned in 2009. These children would have been born without disability, if mandatory fortification had been introduced. I believe it is urgent that this situation is reversed. Those of us working at the coal-face see the chronic pain and degree of disability of children who have spina bifida, the impact on their whānau, and the high preventable costs of multiple surgeries, medical, educational and social supports required for them.

“Due to declining consumption of packaged breads in NZ, fortifying flour rather than bread, as in Australia, is likely to be a more cost efficient and effective strategy.”

Conflict of interest statement: No financial conflicts. I have been a member of the MPI Folic Acid Fortification Group as representative for the Paediatric Society of NZ for a number of years.

Professor Elaine Rush, Professor of Nutrition, AUT, comments:

“The report presents compelling evidence that the prevalence of neural tube defects would reduce if food/ bread was fortified with folic acid, ensuring improved folate status at the time of conception.

“We know that mandatory fortification of bread with iodine has improved iodine status of the NZ population. But we also know women of child bearing age, in general, are eating less bread so other measures are also needed.

“Folate, vitamin B9, was first found in green leafy foods and was named after its foliage sources. Ideally, in our ‘green’ country, adequate folate, and other nutrients, would be derived, every day, from wholesome foods including green leafy vegetables such as silverbeet and lentils, dried beans and whole grain flours. Whole grain bread has more folate than white bread. So other system- measures are also needed to improve nutrient status.

“Food security – access to affordable and nutritious food – is an increasing problem in New Zealand. Environmental measures in addition to the fortification of bread, that would reach the most vulnerable in society, could include removing the GST on fruit and vegetables, building more community gardens, paying a living wage and reducing homelessness, overcrowding and child poverty.

“All of these are intergenerational investments in the future for New Zealand children and the environment.”

No conflict of interest.

Professor Jim Mann, Professor in Medicine & Human Nutrition, University of Otago, and Director, Healthier Lives National Science Challenge, comments:

“Fortunately neural tube defects (NTDs) are uncommon but the cost to the child, the family and society are enormous.

“It has been established beyond doubt that adequate levels of folate in the blood of women of childbearing age can radically reduce the risk of NTDs. Folate occurs naturally in food but it seems that most people do not achieve protective levels on an ordinary diet. In order to achieve blood levels of folate which will achieve this risk reduction, it is necessary to either take folic acid supplements (in tablet form) or to fortify some food.

“In New Zealand the approach to date has been to recommend supplementation when women are planning a family (ie prior to conception and during pregnancy) and to permit voluntary fortification of flour.

“While supplementation has the potential to achieve adequate folate levels, it is universally acknowledged that pregnancies are frequently unplanned and that many (notably the socio-economically disadvantaged) are unaware or do not heed advice from the Ministry of Health and other sources.This is the reason why so many countries (including Australia) have opted for mandatory fortification.

“The reason given for New Zealand not following the practice of Australia and other countries was that more information was required on risks and benefits – an argument that seemed difficult to sustain in the light of the decisions of other countries. Not wishing to impose regulations which might be described as ‘nanny state’ would seem to be a more likely underlying explanation. This in-depth report, which takes into account the totality of evidence confirms the benefits of mandatory fortification in terms of reducing NCD risk and that the theoretical possible small effect of folic acid on some cancers (prostate and colon) did not provide a justification for withholding mandatory fortification.

“With this evidence supporting similar findings from many other countries, it is hoped that the current government will heed this advice and proceed with mandatory fortification at the earliest opportunity.”

Conflict of interest statement: I was a peer reviewer of the report.

Associate Professor Lisa Houghton, Head of Department, Human Nutrition, University of Otago, comments:

“Eighty-one countries including the United States and Canada since 1998, have introduced mandatory folic acid fortification of flour which has been found to reduce neural tube defects without any evidence of harm.

“Folic acid fortification of flour or a commonly consumed food product is a simple, highly effective public health measure. Bread fortification in both NZ and Australia was made mandatory in 2009 but as the deadline neared, political and manufacturer opposition in NZ gave rise to concerns about costs and harmful effects. Where Australia preceded with fortification of bread-making flour, New Zealand withdrew and replaced the mandatory policy with a targeted approach aimed at encouraging bread manufacturers to voluntarily fortify their products.

“Today, it is clear that this targeted approach has not been effective. Despite an increase in breads containing folic acid, there has been no improvement in the folate status of women. Of equal importance, nearly 10 years on since the programme was withdrawn – there is no additional evidence of any adverse effect of folic acid. In fact, new research has suggested removing the need for upper limit of folate intake.”

Conflict of interest statement: I was a member of the expert panel for the report.