| 2005 |
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YEAR BOOK |
Food Safety Authority of Ireland
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The case for considering folic acid food fortification
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In Ireland, since 1993, women of childbearing age have been advised by the Department of Health and Children to take folic acid supplements and also to eat foods which are rich in folate or fortified with folic acid, if there is any chance that they may become pregnant. However, similar to the experience in other countries, this policy has not proved to be effective in reducing the number of pregnancies affected by NTDs in Ireland. The main reason the supplement advice policy fails is that as many as 50% of pregnancies are unplanned and by the time these women realise they are pregnant, it is too late to take preventive action. Cost of supplements and lack of awareness about the importance of folic acid are other barriers to the uptake of advice to take folic acid supplements. These factors particularly affect women from socio-economically disadvantaged backgrounds who are at highest risk of having a pregnancy affected by NTDs.
In the late 1990s, this situation led some countries, including Canada and the USA, to implement a national policy of fortification of cereal grains/flour with folic acid � a step that ensures an increased intake of folic acid by all women at time of conception. Despite the fact that the amount of folic acid added into the food supply does not provide enough to fully protect unborn children, recent reports from Canada and the USA indicate fortification of cereal grains has been very effective. When all affected pregnancies are accounted for (i.e. live births, stillbirths and terminations), reductions in NTDs by between 50% and 70% are evident.
The situation regarding NTDs in Ireland is quite different to that of other countries. Firstly, there is evidence that as many as 50% of all pregnancies in Ireland have a genetic vulnerability towards the development of these defects. Another issue concerns the lack of options when an affected pregnancy is diagnosed. The option of secondary prevention through termination of pregnancies affected by NTDs, which is used in most other countries, is not available in Ireland. As a consequence, the proportion of NTD pregnancies that are delivered as live births is much higher in Ireland than elsewhere. For example 81% in Dublin, compared with 10% in parts of Britain and 20% in a region of Spain. Notwithstanding that, such an approach to secondary prevention is traumatic and heartbreaking for families involved, the fact that termination of affected pregnancies is not practised means that NTDs have a considerably greater impact in Irish society than elsewhere. It has been argued that this places a greater onus on Ireland to maximise the primary prevention of these conditions by choosing a national food fortification approach.
For all of these reasons, the Food Safety Authority of Ireland (FSAI) and the Department of Health and Children, working together through the National Committee on Folic Acid Food Fortification, are overseeing the consideration of folic acid food fortification in Ireland to reduce NTDs. The Committee process included a public consultation on the following three options, two of which consider food fortification:
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1.�Structured Voluntary Fortification � flour millers and bakers would be permitted to add specified levels of folic acid voluntarily to bread, which would then carry a special logo and a health claim.
2.�Mandatory Fortification � (a) of bread-making flour to ensure a targeted level of folic acid is present in all breads, or (b) of all flour to ensure a targeted level of folic acid in all flour-containing foods. 3.�Continue with the Current Practice � intermittent health promotion campaigns to raise public awareness of the need for women to take a folic acid supplement and have a diet rich in folates, while the background diet in Ireland would permit the unstructured voluntary fortification of foods with folic acid. |
The issue of safety for all people in Ireland who would be exposed to folic acid, should a national food fortification programme be implemented, was a primary consideration of the National Committee. Available evidence indicates the only established risk associated with high intakes of folic acid is the masking of undiagnosed vitamin B12 deficiency, which is a particular issue for the elderly. However, folate deficiency is also prevalent among the elderly. Therefore, the level of additional folic acid proposed by the National Committee was chosen with a view to the eradication of folate deficiency in all population groups, rather than a level that would provide women with the optimal level to reduce NTDs. Eradicating folate deficiency among women of childbearing age will impact on the prevalence of NTDs, however as in Canada and the USA, women will continue to be advised to take folic acid supplements to optimise protection of their future pregnancies.
Finally, there is a considerable body of evidence that increasing folate status throughout the population may reduce the risk of cardiovascular disease, neuropsychiatric disorders � such as dementia, Alzheimer's disease � colon cancer and other cancers. These issues are the subject of intensive ongoing research internationally. However, in contrast to the proven effect of folic acid in preventing NTDs, the evidence is as yet insufficient to conclude that folate status influences the development of these conditions.
Contact: Dr Mary A.T. Flynn,
Food Safety Authority of Ireland,
Abbey Court, Lower Abbey Street, Dublin 1;
Tel: 01 817 1300; Fax: 01 817 1301;
E-mail: [email protected] ; Web: www.fsai.ie