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Mandatory folic acid in bread to reduce birth defects – Expert Reaction

All non-organic bread-making wheat flour in New Zealand will be fortified with folic acid within the next two years.

The supplement has been proven to prevent birth defects like spina bifida. Food Safety Minister Ayesha Verrall said more than half of pregnancies in New Zealand are unplanned, so it’s not practical for all women to take a folic acid supplement a month before they conceive.

The SMC asked experts to comment on the announcement.

Dr Kathryn Bradbury, Senior Research Fellow, National Institute for Health Innovation, School of Population Health, University of Auckland, comments:

“The discovery that folic acid prevents spina bifida and other Neural Tube Defects is probably the greatest nutrition science breakthrough of the past 40 years. With the announcement that folic acid will be added to bread-making flour, New Zealand will join over 70 countries that already require folic acid to be added to a food staple to prevent Neural Tube Defects.

“Adding folic acid to bread-making flour levels the playing field and allows all women who could become pregnant to increase their intake of folic acid and reduce their risk of having a pregnancy affected by a Neural Tube Defect.

“In 2009, Australia went ahead with mandatory fortification while we backed out. They have since reported a striking decrease (60 to 80%) in Neural Tube Defect rates among teenage and Aboriginal and Torres Strait Islander mothers.

“The latest data we have from randomised controlled trials shows no significant effect of high-dose folic acid supplements on cancer risk – and the amount of folic acid that we will get from a fortification programme is around 10 times less than the amount used in the trials.”

No conflict of interest.

Professor Barry Borman, Professor of Epidemiology, Massey University; and Director, New Zealand Congenital Anomalies Registry, comments:

“There is no doubt that 8 July 2021 will be remembered as a momentous day for public health for NZ. At last, after many consultations, much prevarication and hand wringing, and opposition, NZ has joined the growing list of countries to have implemented mandatory folic acid fortification to reduce the risk of neural tube defects.

“In a rare instance in public health, the science to support the decision has been unequivocal and emphatic since 1992. Minister Verrall, the patient staff of MPI, and many people across the health system, are to be congratulated for their persistence, advocacy and determination in achieving this milestone in the history of public health in New Zealand. All have done a major service to improving the child health of this country.”

No conflict of interest declared.

Emeritus Professor Elaine Rush, Professor of Nutrition, Auckland University of Technology, comments:

“At present New Zealand does not have mandatory fortification of any foods with folate. The mandatory fortification of bread-making flour with folic acid is supported by strong evidence that lower rates of neural tube defects will result. It is the right thing to do. Folate is a water soluble vitamin and as such should be consumed every day; at least 400 micrograms a day.

“Why it is necessary is an indictment of New Zealand’s ability to feed its own well, according to its eating and activity guidelines. Folate is naturally found in many foods, including dark green leafy vegetables (silverbeet, puha, spinach), cabbage, lentils, chickpeas, soy and other beans, AND in whole wheat flour.

“White bread is cheaper than wholegrain bread, and will keep longer. Whole grains do not have the bran and germ removed and contain more fibre, minerals and vitamins than refined, white flour.

“We know what New Zealanders should be eating but sadly many do not have enough money or resources to be able to buy these foods, this is the problem that we all should be working towards so that New Zealand is a more equitable place to live.”

No conflict of interest.

Rhodi Bulloch, New Zealand Registered Dietitian; and PhD candidate (folic acid supplementation in pregnancy), University of Auckland, comments:

“I welcome the Government’s decision, particularly from an equity perspective. Folic acid supplementation in pregnancy and woman of childbearing age is an equity issue in New Zealand. With half of pregnancies unplanned, women often realise they’re pregnant after the neural tube has closed.

“We see lower rates of folic acid supplementation pre- and during pregnancy in our priority groups such as Māori and Pacific women. Mandatory folic acid fortification will not only improve neural tube defect rates, but also help to reduce inequities in folic acid intake in New Zealand, and help give our New Zealand tamariki a better start in life.”

No conflict of interest declared.

Dr Louise Brough, Senior Lecturer in Nutrition Science, School of Food and Advanced Technology, Massey University, comments:

“The mandatory addition of folic acid to all bread will reduce neural tube defects (NTDs) and inequity in health outcomes for pregnant women and their infants. Critics will suggest women who intend to get pregnant should simply take a folic acid supplement.  However, around 50% of pregnancies which result in a live birth are unplanned, but not unwanted. Women who are not preparing for pregnancy are unlikely to be using a prenatal supplement. The neural tube closes within one month of conception and by the time many women realise they are pregnant the time to take the supplement has passed.

“Adequate folate intake in pregnancy is an equity issue as far as supplement use is concerned. Māori, Pacifica, young mothers and those on lower incomes are less likely to take folic acid supplements, especially pre-pregnancy. However, bread is widely consumed by the NZ population, with bread intake being higher among those on lower incomes, this makes bread an excellent vehicle.

“In the US flour has been fortified with folic acid for two decades which has reduced NTDs and there is no evidence of adverse outcomes in the population. Folic acid fortification is safe and will enable more equitable health outcomes.”

No conflict of interest.

Professor Clare Wall, Head of the Discipline of Nutrition and Dietetics, Faculty of Medical and Health Sciences, University of Auckland, comments:

“Information collected by Growing Up in New Zealand, this country’s largest contemporary longitudinal study, was an important contributor to the development of the new policy announced today that all non-organic bread-making wheat flour in New Zealand will be fortified with folic acid within the next two years.

“Published research from Growing Up demonstrated that 92% of pregnant women were not taking folic acid supplements according to the national recommendation (4 weeks before until 12 weeks after conception), with 69% taking insufficient folic acid, and 57% extending use of the supplement past 13 weeks’ gestation.

“This study also indicated that there were important sociodemographic inequities in the rates of inadequate use of folic acid. The risk of having insufficient folic acid use during pregnancy was higher among mothers: under 30, with lower level of education, of non-European/Pakeha ethnicities, unemployed, who smoked cigarettes, whose pregnancy was unplanned, living in more deprived households or who had older children. In contrast, there was decreased risk of extended use of folic acid (past the 12th week after conception) among mothers: of Pacific ethnicity (versus European) and for whom this was not a first pregnancy.

“Then, a subsequent study, using Growing Up dietary data collected from mothers antenatally, enabled us to explore the impact of different scenarios of folic acid fortification of foods on women`s dietary intake of folate. This study demonstrated that the current voluntary fortification of food with folic acid in NZ is not providing equal access to folate intake among its ethnically diverse population of women of childbearing age. It also showed that if food products made with wheat flour and rice were mandatorily fortified with folic acid in New Zealand, ethnic inequities in women’s folate intakes would be potentially reduced.

“The findings of both studies are of relevance for New Zealand, as it used contemporary data and which are nationally generalizable.”

Main findings from study 1:

  • 13% did not use folic acid at all;
  • 22% did not take sufficient supplements during the recommended period (4 weeks before until 12 weeks after conception);
  • 33% did not take sufficient supplements during the recommended period but extended folic acid use beyond the first trimester of pregnancy;
  • Only 8% used folic acid supplements according to the recommendation;
  • 23% achieved the recommendation and kept using this supplement past the 12th week after conception.

No conflict of interest declared.