Folic acid: Why mandatory fortification is vital

On Monday we published a comment, “Folic acid: Old women and children first!” which supported the argument that mandatory fortification was unnecessary given current voluntary initiatives by manufacturers. We also strongly recommended that ‘controlled voluntary fortification’ involving government and manufacturers agreeing on which products to fortify should be considered as a compromise between mandatory and purely voluntary fortification.

To read the commentary, ‘Folic acid: Old women and children first!’​ please click here​.

Response​

In a response to our comment, Professor Sir Nicholas Wald from Barts & The London, Queen Mary’s School of Medicine and Dentistry in London argues against voluntary fortification.

Sir Nicholas told NutraIngredients: “The commentary entitled ‘Folic acid: Old women and children first!’​ dated 24th August 2009 proposed relying on voluntary fortification and consumer knowledge to ensure that people get enough folic acid in their daily diet. Voluntary food fortification programs are just that – voluntary. They can begin or end at the food manufacturers’ discretion and often sections of the community that are most in need are not protected.

The best way to achieve safe folic acid levels is a well-planned, efficiently monitored mandatory fortification program. It is inconsistent to rely on people doing something deliberately to safely prevent a serious medical disorder but at the same time argue that doing so generally is unsafe or undesirable.

If voluntary fortification is acceptable, there is no reason not to support mandatory fortification. Unfortified flour products could still be sold provided they are labelled accordingly.

The argument favouring voluntary fortification is that consumers will make good choices regarding folic acid. This policy has not worked. Many pregnancies are unplanned. Even after a health awareness campaign no more than about 50 per cent of women took folic acid supplements before pregnancy. Voluntary fortification with folic acid can improve a population’s folate status, but most voluntary programs do not reach all the population.

Safety net​

Mandatory fortification provides a population safety net. The level of fortification proposed is generally low but could prevent about a quarter of pregnancies with spina bifida and ancephaly. Women still need to be encouraged to take folic acid supplements to achieve a higher level of prevention.

The suggestion that folic acid could cause negative side effects is unwarranted in my opinion. Hypothetical links between folic acid and cancer have been raised but do not bear scrutiny. As I shared during a presentation with the Food Standards Agency in Uppsala, Sweden, in January 2009, the possibility of harm is small and remote and insufficient to stop fortification.

Some may argue that even a remote and hypothetical risk is too great to take when the public’s heath is at stake. But denying a benefit is causing harm; there is no doubt that failure to fortify will cause harm. Typically wheat flour is centrally produced in large mills, which means government regulatory agencies are easily able to monitor compliance. Most modern mills are already equipped to handle fortification, and if the country requires flour fortification, the ongoing cost of buying folic acid for fortification is shared equally by everyone in the industry.

Most importantly, mandatory fortification means that women who need folic acid the most will receive an adequate amount of this essential nutrient without having to change their behavior. We should not accept the needless burden of disability from birth defects such as spina bifida when a proven method for reducing their incidence is available.”

Sir Nicholas Wald is Professor of Environmental and Preventive Medicine at the Wolfson Institute of Preventive Medicine, Barts & The London, Queen Mary’s School of Medicine and Dentistry.​

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Reader comments:​

I would like to wholeheartedly support Sir Nicholas Wald regarding his stance on mandatory fortification of folic acid.

As a consultant with over a decade of experience in advocating and implementing fortification of staple foods (wheat, maize/corn, vegetable oils, sugar and rice) in ECSA with a range of vitamins and minerals (A, B complex, Folic acid, iron and zinc) I can assure your readers that voluntary fortification, whilst laudable, is fraught with difficulties.

Major producers often use the addition of micronutrients as a marketing tool - and it can be argued that this is a valid and effective tool - but all too often it leaves the consumer unaware of the beneftits of that intervention and few producers have the necessary background information that will enable them to set the fortification levels at a point which will have the desired health impact. Frequently levels are set too low to have any significant impact.

In South Africa we have had mandatory fortification of wheat flour and maize meal since 2003 as part of an intergrated nutrition intervention which includes activities such as improving sanitation etc (don't feed the worms, feed the children) and are already seeing a significant decrease in incidents of NTD for example.

This success has been due to the commitment of the milling industry to the programme and whilst we have had our fair share of problems in monitoring and enforcement, due to lack of capacity with inspectors and focussing more on health safety issues i.e. the recent cholera outbreak, we have had a high degree of compliance.

It has also been interesting to note that throughout ECSA industry has usually required fortification to mandatory (arguing it keeps a level playing field) as opposed to voluntary fortification in which they could make some marketing mileage. Further, the fact that the fortification is mandatory, industry can be assured that Government gets involved in the essential components of any fortification programme - those of educating the consumer regarding the benefits of the intervention and of monitoring both the level of compliance by industry and the level of impact the intervetion is having on the consumer.

Mandatory fortification does have its problems as it usually requires extensive and widespread consultation with interested parties (academia, heath professionals, consumer groups, industry, legislature etc) which, by its very nature, causes considerable delays in implementation (in South Africa it took over 8 years to get the intervention off the ground).
Nevertheless concensus was finally reached (albeit a compromise rather than an optimised solution) due to the persistance and support of key decision makers.

It must also be realised that fortification is not a curative intervention but a preventative one. It has a cost implication but fortification is widely recognised as being the most cost effective means of improving the nutritional status of the population. The cost is so low that I have not encountered a situation over the past 10 years in which the added cost of the micronutrients in a typical consumer pack of fortified product has exceeded the value of the smallest unit of currency in that country.

- Philip Randall PhD
Fortification Consultant
South Africa