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Most Bread And Flour Now Fortified With Folic Acid - Expert Reaction

As of tomorrow, all non-organic bread-making wheat flour in New Zealand will be fortified with folic acid.

The supplement has been proven to prevent neural tube defects, such as spina bifida, which affect on average 64 pregnancies a year in New Zealand and are incredibly costly to the health system. Folic acid supplements must be taken before conception to be fully effective, but more than half of pregnancies in New Zealand are unplanned.

The SMC asked experts to comment.

Dr Kathryn Bradbury, Senior Research Fellow, Department of Epidemiology and Biostatistics, 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 has joined over 70 countries that already require folic acid to be added to a food staple to prevent Neural Tube Defects.

"Folic acid is a B vitamin and some foods in NZ, including many breakfast cereals and some breads, are already fortified with folic acid. Adding folic acid to all 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. This is important because women need to be having extra folic acid very early on in pregnancy in order to be protected, ideally before they even become pregnant.

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"In 2009, Australia went ahead with mandatory fortification while we backed out. They have since reported a major 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 average amount used in the trials."

No conflict of interest.

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

"We know that fortification of foods with essential nutrients increases consumption of that nutrient if the foods are consumed. In 2009 the addition of iodised salt for fortification of bread with iodine became mandatory for most breads. In August 2023 folic acid fortification will be a requirement for non organic wheat flour that is sold as suitable for bread making. From conception it is critical that essential nutrients are available to the mother to the child for optimal growth and development. Fortification is one way to do this.

"But there are a number of reasons these nutrients may not get to those who need it:

"An increasing proportion of the population are choosing or needing to consume a gluten free diet which means that they do not eat any foods that contain wheat, let alone fortified wheat flour.

"In 2008/2009, the last national nutrition survey, bread was the food most frequently consumed, and was 11% of the energy intake, and 10% of the protein intake of NZ adults. However there has not been another national dietary survey since, so we do not know how many people are consuming bread 15 years later.

"Pizza bases and doughs, pastries, pastas, and non-yeast leavened flat breads (e.g. wraps), do not need to made from flour fortified with folate.

"In 2019 a food focus survey found that 11% of those surveyed were consuming a gluten-free diet. Asian peoples were more likely to consume rice than bread and rice was considered more sustaining than bread.

"In 2018 an analysis of food exports and imports of New Zealand determined that the equivalent of 300g/day/person of wheat was imported into New Zealand. In the same time 33g/day/person of rice was imported. Rice triples in weight when it is cooked so this is 100g of cooked rice.

"The cost of bread has increased more than rice. The value of wheat imported has more than doubled since 2018 but the cost of imported rice has gone up less than 15%. Some will remember the supermarket $1 loaves of bread available between 2015 and 2019. In July 2009 a 600g loaf of white sliced bread cost $1.55, in 2018 the cost of a loaf was less at $1.10 but from 2020 the cost rose to $1.32 and in 2023 the cost was $1.52. It is likely that it will continue to increase which means less bread and more rice may be consumed.

"The question is: will the fortification of bread with folic acid reach the target consumers (women of child-bearing age)?

"A national nutrition survey, now, is vital to answer this question so that the policy can be adapted to have its intended impact on health and inform the fortification of other foods such as rice.

"In the big picture a variety of adequate nutritious wholesome foods as recommended by the food based dietary guidelines should be available even to those without financial resources. The nutrition of women during pregnancy is a priority to ensure the best start to life for the next generation. Foods such as dark green leafy vegetables, peas, beans and lentils are good dietary sources of folates and many other nutrients necessary for life. But we do not grow enough in New Zealand to feed the whole population."

No conflicts of interest.

Associate Professor Lynne Chepulis, He Huataki Waiora School of Health, University of Waikato, comments:

"Folate, also known as vitamin B9, is an important vitamin that many of us do not get enough of. It occurs naturally in many foods, including dark leafy green vegetables, fresh fruits, eggs, beans and liver, but a lot of people still do not get as much as they should – often as a result of dietary patterns. Folic acid is the supplement form of folate/Vitamin B9 and it is actually absorbed nearly twice as much as that from food sources.

"As with any vitamin deficiency, a lack of folate can have negative effects on health. During pregnancy, a lack of folate can lead to the development of neural tube defects in developing embryos, and large studies have shown that folic acid supplements can reduce the occurrence of these neural tube defects during pregnancy by up to 70%. In NZ, it has been standard policy for some time that women planning pregnancy should take folic acid supplementation before and during pregnancy for a healthy baby.

"However, there is good evidence that folic acid supplementation is still highly beneficial outside of pregnancy. Studies show the important role of folic acid supplementation in reducing the risk of cardiovascular disease and even some cancers. Folate helps to form DNA and RNA inside body cells and is involved in protein metabolism in the body. Specifically, it helps to break down an amino acid called homocysteine which can be harmful if present in higher amounts (homocysteine, for example, is associated with dementia and Alzheimer’s disease). Folate is also needed to produce healthy red blood cells. Hence, optimal folate levels are needed throughout life, but particularly, during periods of rapid growth.

"Fortification of food products such as bread with folic acid is a way of providing people with a suitable intake of folate, thereby reducing the health risks associated with deficiency. It’s particularly useful for those with reduced fruit and vegetable intake, and has the advantage that it has positive impacts on the population regardless of gender, age, knowledge levels or socioeconomic status. Folic acid / folate is also water-soluble so your body doesn’t hold onto it for long. If not needed by your body, you simply pee it out.

"Folate and folic acid are not the same thing. Folate is the naturally occurring vitamin and the way it occurs in food. Folic acid is ‘man made’. After ingestion it needs to be converted to folate in the liver or other tissues. This process is generally quite slow.

"There is no consistent evidence to suggest that folic acid has any harmful effects when added to foods at the recommended level. Long story short is that high levels of folic acid intake can be harmful - i.e. may associate with some cancers. However, the levels have to be HIGH and this is well beyond the levels achieved by fortifying bread.

"The benefits well and truly outweigh any risk - particularly for Maori, Pacific and low socioeconomic status communities."

No conflicts of interest declared.

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

"From Monday 14th August it will become mandatory in New Zealand for folic acid to be added to all bread (excluding organic bread). This regulation will reduce the number of neural tube defect affected pregnancies which will benefit women, their infants and families.

"Opponents will argue that women planning pregnancy should simply take a folic acid supplement. However, it is essential that folic acid supplementation starts preconception, as the neural tube closes within one month of conception, and yet in New Zealand around half of pregnancies which result in a live birth are unplanned (although unwanted). Many women are not preparing for pregnancy and by the time many women realise they are pregnant the time to take the supplement has passed. It has been suggested that this initiative could also prevent many miscarriages.

"Adequate folate intake in pregnancy is also a health equity issue. Māori, Pasifika, young mothers and those on lower incomes are less likely to take folic acid supplements, especially preconception due to high levels of unplanned pregnancy. Bread is an excellent vehicle for providing folate as it is widely consumed throughout New Zealand, with higher intakes among those on lower incomes. Fortification of bread with folic acid became mandatory in Australia in 2009, and it is estimated that neural tube defects were reduced by 14% among all women, but by 74% among Aboriginal Australians.

"There are also concerns around ‘mass medication’ and the effects of higher folic acid intake on other population groups. However, flour has been fortified with folic acid in the US for over two decades and neural tube defect affected pregnancies have reduced, without any demonstrable adverse outcomes in the population. Folic acid fortification has been shown to be safe and will enable more equitable health outcomes within the New Zealand population."

Conflict of interest statement: Associate Professor Louise Brough has worked with Vitabiotics Limited, London, UK and Bayer Australia Limited.

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

Neural tube defects

"Neural tube defects are a fatal or disabling birth defect that affects the brain and spine of the baby. They occur when the neural tube, which forms the nervous system, does not close properly during early pregnancy.

"Neural tube defects, which include spina bifida, anencephaly, and encephalocele, are estimated to affect 10.6 per 10,000 births in New Zealand. There is an average of 64 neural tube defect-affected pregnancies recorded a year; of which, 60% of cases resulted in elective termination or stillbirths.

"The prevalence of neural tube defect live births are higher for wāhine Māori and Pasifika compared to European and Other women."

Folate

"Folate is a B vitamin, and is critical in cell growth and reproduction. As such, is very important during pregnancy.

"Folate comes in many different forms. Folic acid is the synthetic form of folate, that is used in dietary supplements and fortified foods and beverages.

"Studies over 25 years ago showed that folic acid can prevent neural tube defects by ensuring that the neural tube closes correctly. Folic acid works best if it is taken before conception and during the first 12 weeks of pregnancy, when the neural tube is forming."

Folic acid for the prevention of neural tube defects

"The New Zealand Ministry of Health recommends that women planning a pregnancy take 0.8 mg of folic acid daily for at least four weeks prior to conception and for 12 weeks after conceiving to reduce the risk of neural tube defects.

"In Aotearoa New Zealand, just over half of pregnancies are unplanned, meaning that a substantial number of women do not take folic acid supplements during the critical period before and shortly after pregnancy.

"In addition, not all women are able to follow the supplementation advice for various reasons such as lack of awareness, access, affordability, or compliance. For example, a 2011 NZ survey showed only one-third of women consumed folic acid supplements prior to pregnancy."

Mandatory folic acid fortification of food

"There is compelling evidence that mandatory folic acid fortification is associated with lower rates of neural tube defects.

"Over 80 countries have introduced mandatory folic acid fortification of food staples. Countries like Canada and the USA in 1998 and Australia in 2009 decided to add folic acid to some staple foods, such as flour or bread. This has been shown to reduce the rates of neural tube defects, in some cases to a substantial degree.

"Mandatory folic acid fortification results in an average consumption of about 0.15 mg of folic acid per day, and this is not known to be associated with any risks.

"A 2018 report by Prime Minister’s Chief Science Advisor and the Royal Society Te Apārangi found no evidence to link folic acid fortification to increased risk of harmful effects."

No conflict of interest declared.

Sylvia North, Lecturer, School of Sport and Recreation, AUT University; and New Zealand Registered Dietitian, comments:

"Folic acid supplementation is known to prevent a class of birth defects that are known as neural tube defects. In New Zealand, these occur in about 10.6 per 10,000 live births and are associated with lifelong disability. For folic acid supplementation to be beneficial, it's usually recommended to be taken three months prior and two months post conception.

"Because most pregnancies are unplanned, many women miss this critical window where folic acid supplementation could be protective against neural tube defects in the offspring. Adding folic acid to bread aims to address this gap, and as a result, food fortification strategies like this have been shown to reduce the incidences of neural tube defects in other parts of the world.

"Folic acid fortification is a controversial topic in nutrition because it's the only widely used example of a population-wide food fortification strategy which is intended to only directly benefit a very small population group - women who are about to and have just become pregnant.

"The topic is controversial because it means that the majority of the population are exposed to this synthetic form of vitamin B9. There are concerns that excessive folic acid exposure in other population groups can "mask" vitamin B12 deficiency which could lead to irreversible neurological damage and cognitive impairment in older adults. Folic acid is a synthetic vitamin which is metabolised slightly differently and there are concerns surrounding the potential downsides of unmetabolised folic acid accumulating in the blood.

"Folic acid has a reasonably good safety profile, as this approach has been replicated in other parts of the world. However, there concerns about people having excessive and long-term exposure due to the reasons above.

"Fortifying bread means that people will get exposed to different levels of folic acid because of their consumption patterns. This is something that can't necessarily be controlled.

"On a public health level, if this is the way to reduce the incidences of babies being born with the defect, then it could be a good thing for our population. I think the greatest challenge is that it may not necessarily capture the target population all that well. There are a lot of unknowns around the impact of dosing people with folic acid when they don't necessarily need it. An important detail is that folic acid is not the same as natural folate, and there is where a lot of the unknowns are."

No conflicts of interest declared.

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