leheartedly 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