The repeating history of objections to the fortification of bread and alcohol: from iron filings to folic acid

Abstract

The recent viewpoint by Kamien is timely, given Food Standards Australia New Zealand is currently advocating for the mandatory fortification of all bread-making flour with folic acid (80–180μg per 100g of bread). The proposal is now before the Australia and New Zealand Food Regulation Ministerial Council, and a decision is imminent. In 1991, the Medical Research Council Vitamin Study Research Group reported a randomised double-blind trial conducted at 33 centres in seven countries. Periconceptual folic acid supplementation had a 72% protective effect against neural tube defects (relative risk, 0.28; 95% CI, 0.12– 0.71). Because folic acid supplementation is ineffective when started after the pregnancy is confirmed, fortification of staple foods such as bread remains best practice. The United States started mandatory fortification of enriched cereal-grain products a decade ago. As expected, there has been an increase in the population geometric mean concentrations of serum folate and red blood cell folate, and a corresponding reduction in the number of babies born with debilitating neural tube defects. The benefits are clear and the risks are vague. Historical concerns that folic acid supplementation could mask pernicious anaemia and cause cancer have not been substantiated by international experience in more than 50 countries. Australian health professionals have a brief window of opportunity to join Maberly and Stanley and advocate for mandatory fortification in spite of commercial objections, which are based on marketshare concerns for existing “designer” products. If we educate and inform our patients and the community at large, the decisionmakers should finally get the message and this cheap, safe and effective public health policy would be implemented — a decade overdue.