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International Experience

Codex Alimentarius

Considers mandatory fortification with folic acid is inconsistent with Codex Alimentarius fortification principles in that bread consumption by the target group is variable and not stable, consumption of fortified bread will not provide sufficient folic acid for optimum NTD prevention, and fortification will result in 3-6% of children.
Considers no country is currently fortifying all bread-making flour. ReadyBake Canada has confirmed that white flour is the only flour enriched. ReadyBake estimate that 60% of their products are made with enriched white flour. Intake of grain products is rising.

Refers to the recent report of the National Committee on Folic Acid Fortification by the Food Safety Authority of Ireland which recommends bread rather than flour or all flour containing foods as the vehicle of choice for mandatory folic acid fortification in Ireland.

Notes in the UK a decision on mandatory fortification has been delayed due to the risks associated with masking of B12 deficiency and interaction with epileptic drugs.
No other country has introduced mandatory fortification with an upper limit for addition. The levels of fortification are also lower than those proposed by FSANZ.
Does not believe there is strong evidence from other countries that mandatory fortification will be appropriate for Australia.
Does not believe US and Canadian rates can be compared with Australia and NZ because we don’t have an accurate national register, the US decline in rates is not due to mandatory fortification alone, Canada had higher rates of NTDs than Australia and NZ at baseline, and Chilean rates do not include terminations.

Supplements

Concerned that women may believe they are getting sufficient folic acid from mandatory and voluntary fortification.
Lack of knowledge and awareness among women of child-bearing age with regard to folic acid supplements is a significant issue. Important to target those capable of becoming pregnant not just those planning a pregnancy.
Notes an increase in supplement use in south Australia after a campaign in 1994.
Promotes a targeted sustained national education campaign, promotion of supplements and range of voluntarily fortified foods targeted to women of child-bearing age. Notes the lack of a publicly funding campaign in NZ, and questionable monitoring of Australian campaigns.
Notes folic acid supplements are highly bioavailable, therefore the most effective way to increase folic acid intake.

Voluntary fortification

Considers there is a lack of evidence for market failure.

Notes the recommendations of the Australian Food and Nutrition Monitoring Unit’s report (Abraham & Webb 2001) recommended that the implementation of the folate fortification programme be improved and that there be a coordinated strategy for monitoring and evaluation.

Considers the impact of voluntary fortification coupled with supplement promotion and education has been positive, (references given), and further improvements could be made.

Use of the folate health claim has been limited. There is a need for a simpler claim that is more easily understood by consumers.

Questions data on voluntary fortification permissions uptake. Believes there would be increased uptake of voluntary permissions if the Code allowed wider voluntary permissions.
Notes increases in folate intake are higher in women than men with voluntary fortification, which suggests this strategy is better targeted to women than men.
Supplies a table of GWF folic acid fortified breads and the levels of fortification.
Considers removal of voluntary permission for bread and replacement with mandatory fortification will result in lower levels of folic acid in bread.

Health risks

Considers there is reasonable evidence to warrant concern over negative health effects including cancer, cognitive decline, unmetabolised folic acid and masking of B12 deficiency (references supplied for all). Notes the UK is undertaking further analysis of nutrition data for fortification even though they have more accurate and current information than Australia.
Believes the masking of vitamin B12 deficiency is a concern and presents data from a number on references on the prevalence of vitamin B12 deficiency and lack of direct assessment of risk associated with increased folic acid intake in older individuals or children (references provided).
Believes there is concern in the scientific literature regarding the increased risk of cancer from higher folate levels (Kim 2004 and Van Guelpen 2006).
Believes there is definite cause for concern at the potential impact of an increased intake of synthetic folic acid on unmetabolised circulating folic acid. Notes a number of researchers have expressed concern.
Food vehicle

Does not believe there is one food vehicle that will deliver effective amounts of folic acid to the target population.

Does not believe bread-making flour is a suitable vehicle. Notes bread consumption in the target group (see below).
Sub-groups of the target market will not be reached by the fortification e.g. those who cannot eat wheat products, cultures who eat rice as their staple, those who do not eat bread because of a perception that it is unhealthy and causes weight gain, and those who choose grain breads will receive lower levels of folic acid than those who consume white bread.

Considers using thiamine fortification as a justification for choosing flour as the food vehicle was not appropriate because thiamine is added at higher levels than the dose suggested for folic acid, NZ does not fortify with thiamine, has no infrastructure, and new dosing equipment would be required for folic acid in order to meet the upper limit.

Australian National Nutrition Survey data was conducted 11 years ago and does not represent current bread intakes amongst women of child breading age. From five sets of bread consumption data collected by GWF, the total daily average bread consumption is two slices per day. Between 25-33% of women of child-bearing age are consuming equal to or less than one slice (average 30g) per day (summary of surveys provided).
Impact on Industry