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Folic Acid - Industry Divided

It became Mandatory for all non-organic bread-making flour to be fortified with folic acid in September 2010. This article looks at the health benefits, risks and implications folic acid will have on the industry.

Thirty-year-old mother of three Rachel Power buys her bread from a bakery and supermarket in Gungahlin, Canberra. Shopping for daughters Jasmine and Jemma and three-month-old son Teddy, she will buy thinly sliced multigrain bread, or perhaps a vienna loaf for herself. If she's in the mood, she may treat herself to cheese and bacon rolls or twists.

While pregnant with her children, Rachel maintained a fairly good diet and increased her intake of leafy vegetables and folate rich foods. Her doctor and her sister, a nurse, both highly recommended she take folic acid and iron supplements in order to prevent neural tube defects (NTD). She tried taking them, but found the iron made her sick and so changed to a straight folate supplement.
"I would say that I am a fairly aware mother and did read many books about pregnancy while pregnant with my first,' Mrs Power said.
While Mrs Power followed her doctor's recommendations and took the necessary precautions for the sake of her health, the Government is concerned many women will not have the same initiative. Based on scientific research and industry consultation, Food Standards Australia and New Zealand (FSANZ) selected non-organic bread-making flour as the food vehicle for mandatory folic acid fortification, which went into effect 13 September.

"I feel that with it added to bread it may make mothers complacent and may actually be detrimental. I also feel that doctors are still going to suggest supplements as they do not know how much folate rich foods a new mother consumes, and a supplement gives what is needed regardless of diet," Mrs Power said.

Folic acid is important for the healthy development of babies early in pregnancy. A baby's growth is the most rapid in the first weeks of life. often before a woman is aware she is pregnant. The neural tube closes and fuses very early in pregnancy; and if it doesn't close, can result in spina bifida.

In Australia, women of child bearing age are advised to consume 400 micrograms (a microgram is a millionth of a gram) of folic acid a day to minimise the risk of their unborn child being affected by an NTD. Folic acid taken at recommended levels for at least one month before and three months after conception can prevent the occurrence of most NTDs.

University of Sydney human nutrition Associate Professor Samir Samman provided evidence to FSANZ during the folic acid fortification consultation process, and doesn't have any objections to fortification.

Based on the published evaluation of fortification programs around the world, rates of neural tube defects are likely to come down to about five cases per 10,000 births, which is great news. Getting improvements below that rate may require other or additional interventions," Mr Samman said.

Despite the benefits, some scientists are concerned fortification may have a negative impact on the rates of cancers such as colorectal, prostate and breast.

In September's Current opinion in clinical nutrition and metabolic care publication, Mark Lucock and Zoe Yate agree there is a consensus view that folic acid supplementation has numerous health benefits, but are concerned about new research showing potential health issues.

"Emerging evidence suggests that increased population exposure to folic acid may also have a negative impact with respect to certain developmental and degenerative disorders," the publication states.

In the March 2008 issue of American Journal of Clinical Nutrition, David Smith, Young-In Kim and Helga Refsum looked at the 10 years since mandatory folic acid fortification was introduced in the US and Canada. The article said folate has a dual effect on cancer protecting against cancer initiation but facilitating progression and growth of certain cells and cancers. and a high folic acid intake may be harmful for some people.

"Nations considering fortification should be cautious and stimulate further research to identify the effects, good and bad, caused by a high intake of folic acid from fortified food or dietary supplements. Only then can authorities develop the right strategies for the population as a whole," the article states.

Deakin University Associate Professor Mark Lawrence published an article in 2007 in response to the food standard review of mandatory fortification. The article states that mandatory folic acid fortification is associated with many scientific and ethical uncertainties.

"There continues to be evidence emerging about a possible relationship between folic acid and the progression of certain cancers, e.g. colo-rectal cancer," Mir Lawrence told Baking Business.

"FSANZ appears to have backed itself into a corner and gone into denial over the risks - the point I would make is that they are at odds with a number of other countries (Ireland, UK, and NZ) on this matter, all of whom now have adopted a more responsible and cautious approach and decided to wait until more is known about the risks before launching into a population-wide experiment," he said.

This scientific uncertainty has launched industry leaders such as Australian Society of Baking's executive assistant Margaret Davey into action, who has been actively representing the industry during the consultation process.

'A mandated policy takes away the ability of the consumer to choose what they consume," Mrs Davey said.

According to Mrs Davey, the legislation was rushed through without full disclosure and consultation with industry and with "set agenda's from some within FSANZ", "It all sums up the fact that the whole process was handled very badly. They should revise their way forward because of more recent information questioning the policy and its benefits/harms to society at large," she said.

"Any woman who is or about to become pregnant in this country will see a GP and the first thing they will be told is to start taking folate. How may women of child bearing age are going to eat seven to 10 slices of bread every day, it's ridiculous. We are bakers, not chemists." Mr MacLennan said, "I don't believe bakers should be in the medication business. I hope common sense will prevail," he said.

According to the 2006 Mandatory Folic Acid Fortification report. FSANZ spent several years looking at folic acid scientific studies available, consulted with Australian and international health expert groups and drew on international experience. From a practical perspective, it considered bread-making flour as a feasible vehicle due to the existing mandatory fortification requirement with thiamin in Australia.

University of South Australia health economics sciences Professor Leonie Segal was a part of the consultation process in 2007 and conducted economic modelling for FSANZ. Her research team looked at the costs and benefits of adding folic acid to bread, and the alternative of a public health campaign to women. Their recommendation was that there should be a high-profile public campaign focused on encouraging the use of prescribed folic acid rather than the mandatory fortification of breadĀ­making flour.

"The first priority should be to promote women taking folic acid supplements," Professor Segal said.

The proposed alternative to fortification of bread was to perform baseline data collection to establish reliably the number of people taking supplements, and then launching and monitoring a campaign to determine who might be missing out on the supplements. This would be followed by a more targeted response of those with low supplement usage. According to Professor Segal's modelling, this option was not only cost-effective, but could save just as many lives as the more costly system of fortifying bread-making flour now in place.

"Evidence suggests campaigns can be quite effective and can be reasonably targeted at particular populations that are known to be low users of supplements," she said.

University of Queensland School of Chemistry and Molecular Biosciences Honorary Reader, Dr Peter Nixon is an expert on folic acid metabolism and pharmacology. He made a submission to the consultation process, which he said was "generally ignored".

"It is apparent that the fortification process was driven politically and in imitation of policies adopted in other countries. To a large extent the assessment has been driven exclusively by nutritionists, and few Australian nutritionists have hands-on experience of folate chemistry or biology," Dr Nixon said.

Baking Business contacted numerous bakeries prior to the mandatory introduction of folic acid and found there was limited knowledge on the subject.

Western Australia's Noonan's Bakery owner, Paul Noonan said the addition of folic acid has been forced on the industry.
"The general concern is that it is good for some, but not for others.