Relying on voluntary fortification of grain products with folic acid is not sufficient to ensure adequate intakes and relieve the burden of birth defects, says an eminent British professor.
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 .
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.
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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