Mandatory folate fortification - will benefits outweigh risks?

The article considers the concerns raised about the implementation of mandatory food fortification in Australia. Mandatory food fortification, the compulsory addition of nutrients to food products, is a powerful policy approach for public health nutrition. The danger in exposing every Australians to increased amounts of nutrients is discussed. Mandate folate fortification is being assessed by Food Standards Australia New Zealand due to the increased cases of neural tube defects in Australia.

Examination of selected national policies towards mandatory folic acid fortification

The purpose of this paper is to present an examination of the contrasting policies towards mandatory folic acid fortification in six countries from different regions of the world. Three questions are addressed: 1) What is the policy of the country? 2) Why was the policy adopted? 3) What lessons have been learned? Policy contrasts among countries were assessed as reflecting different interpretations of the potential risks and benefits associated with folic acid fortification. Although commonalities were identified, it was considered unlikely that there could be a standard policy response for all countries. Instead, a country-by-country policy response based on national circumstances is indicated.

Folate fortification : a case study of public health policy-making

Introducing Evidence Based Health Policy: Problems and Possibilities, Section 1: What is the Problem?, 1: Competing Rationalities: Evidence based Health Policy, 2: Beyond Two Communities, Section 2: What does Evidence Mean?, 3: Evidence based Medicine - The Medical Profession and Health Policy, 4: Mind The Gap: Assessing the Quality of Evidence for Public Health Problems, 5: Health Policy and Normative Analysis: Ethics, Evidence and Politics, 6: What is New in Health Information? Evidence for Health Consumers and Policy Making, 7: From Evidence based Medicine to Evidence based Public Health, Section 3: Policy Case Studies, 8: The Viagra Affair: Evidence as the Terrain for Competing Partners, 9: Folate Fortification: A Case Study of Public Health Policy-Making in a Food Regulation Setting, 10: The Supply and Safety of Blood and Blood Products - Evidence, Risk and Policy, 11: The Development of Nurse Practitioner Policy, 12: Creating Healthy Public Policy for Oral Health: How was the Evidence Used?, 13: Regulation of Traditional Chinese Medicine in Victoria, 14: The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making, 15: Evidence-based Practice in the Australian Drug Policy Community, 16: Challenging the Evidence - Women's Health Policy in Australia, 17: Evidence and Aboriginal Health Policy, 18: The Limits to Technical Rationality in the Health Inequalities Policy Process, 19: Evidence-based policy: A Technocratic Wish in a Political World, Section 4: Is the transfer of evidence into policy possible?, 20: The Community Model of Research Transfer, 21: Getting Research Transfer into Policy and Practice in Maternity Care, 22: Improving the Research and Policy Partnership: An Agenda for Research Transfer and Governance, 23: Framing and Taming 'Wicked' Problems

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Protecting legal rights when things go wrong : legal recourse if mandatory fortification of a food were to harm human health

Food laws can encompass considerations that extend beyond food safety. The recent food standard mandating the fortification of flour with folic acid in Australia illustrates the legal problems and legal risks when governments introduce food standards that aim to medicinalise the population through the food supply despite a lack of scientific consensus. Legal analysis of the process by which the folic acid fortification was introduced into flour in Australia demonstrates legal inadequacies, administrative and policy failures, as well as flaws in safety assumptions. An analysis of the restrictions on legal rights and remedies for any adversely affected consumers seeking legal redress, and the existence of statutory immunities for governments, demonstrates a need for legal reform and changes in policy development processes.

Estimating the impact of mandatory folic acid fortification on the folic acid intake of Australian women of childbearing age

Objective: The primary aim of this study was to estimate the impact of mandatory folic acid (FA) fortification of bread-making flour on the FA intake of Australian women of childbearing age (16-44 years). The secondary objective was to investigate the relationship between estimated FA intake and socio-economic status (SES) and age.

Method: Dietary modelling was used to estimate FA intake under four mandatory fortification scenarios – no supplement use, supplement use unrelated to FA intake, supplement use only among the highest consumers of bread, and increased supplement use. Data were obtained from the 1995 National Nutrition Survey for food intake patterns, the 2007 Victorian Population Health Survey for FA supplement use, and a marketplace survey.

Results: It is estimated that the National Health and Medical Research Council (NHMRC) recommendation for an additional 400 mg/day FA will be achieved by a minimum of 3.9, 25.4, 21.7 and 30% of the target population under scenarios 1-4, respectively. The FA upper level of intake is exceeded by a maximum of 0.1, 1.7, 6.1 and 4.1% of the target population for scenarios 1-4, respectively.

Conclusions: Mandatory FA fortification is not sufficient for the NHMRC recommendations for minimum and maximum intakes to be met by all of the target population under a number of plausible behaviour scenarios.

Implications: Targeted nutrition education campaigns are needed for SES and age sub-groups and research of this nature should be extended to other population groups. Monitoring and evaluation of this policy will be important to ensure appropriate FA intake.

Food fortification : the evidence, ethics and politics of adding nutrients to food

This research book presents a critical analysis of mandatory food fortification as a technology for protecting and promoting public health. Increasing numbers of foods fortified with novel amounts and combinations of nutrients are being introduced into the food supplies of countries around the world to raise populations’ nutrient intakes. Three topical food fortification case studies representing the different public health rationales for adding nutrients to food were assessed for their public health benefits, risks and ethical considerations: Universal salt iodisation (USI) to help prevent iodine deficiency disorders; mandatory flour fortification with folic acid (MFFFA) to help prevent neural tube defects; and mandatory milk fortification with vitamin D (MMFVD) to help prevent vitamin D deficiency. These assessments found that whereas USI performs strongly as a public health intervention, MFFFA and MMFVD are associated with more risks and less ethical justification than an alternative policy option. Food fortification can be a blunt policy response to complex policy problems. The findings highlight that the primary predictor of a mandatory food fortification policy’s benefits, risks and ethics is its ability to address the underlying cause of the policy problem. The analysis of the policy-making processes for each case study found that certain powerful actors use their influence to determine what counts as evidence in policy processes to privilege food fortification activities over alternative policy options. Policy-making frequently was notable for the low prominence it afforded ethical considerations and its lack of public engagement. Priority activities to help strengthen policy processes and outcomes are suggested.

Fortification. Folic acid and spina bifida. Is it safe? Is it wise? Is it right?

Food fortification takes many forms. The example discussed here is unusual, because in many countries now it is required by law: the fortification of flour with the B vitamin folic acid, or MFFFA for short. Voluntary fortification of various food products was first used to help prevent and control child and maternal anaemia associated with folate deficiency (1). In the mid-1990s, policy-makers in various countries began considering using mandatory fortification under a novel policy paradigm, that fortification was needed to increase the folic acid intake and protect the health status of people who had a special requirement for this nutrient, irrespective of the folate status of the population as a whole.

Profiling national mandatory folic acid fortification policy around the world

Mandatory food fortification “occurs when governments legally oblige food producers to fortify particular foods or categories of foods with specified micronutrients” [1]. Because mandatory food fortification exposes everyone in the population who consumes the fortified food(s) to raised levels of the specified micronutrient, it is one of the most powerful policy instruments available to influence dietary intake and population health outcomes. Many national food regulatory authorities have established policy guidance on mandatory food fortification. From an international perspective, the Codex Alimentarius Commission (Codex) provides principles for the addition of essential nutrients to foods [2]. According to these Codex principles, mandatory food fortification with additional vitamins and minerals is recommended where there is proven public health and nutrition need (Note: these principles are under review at the time of writing).

Effect of fortification of drinking water with iron plus ascorbic acid or with ascorbic acid alone on hemoglobin values and anthropometric indicators in preschool children in day-care centers in Southeast Brazil

Background. Iron-deficiency anemia currently is the most frequently occurring nutritional disorder worldwide. Previous Brazilian studies have demonstrated that drinking water fortified with iron and ascorbic acid is an adequate vehicle for improving the iron supply for children frequenting day-care centers. Objective. The objective of this study was to clarify the role of ascorbic acid as a vehicle for improving iron intake in children in day-care centers in Brazil. Methods. A six-month study was conducted on 150 children frequenting six day-care centers divided into two groups of three day-care centers by drawing lots: the iron-C group (3 day-care centers, n = 74), which used water fortified with 10 mg elemental iron and 100 mg ascorbic acid per liter, and the comparison group (3 day-care centers, n = 76), which used water containing only 100 mg ascorbic acid per liter. Anthropometric measurements and determinations of capillary hemoglobin were performed at the beginning of the study and after six months of intervention. The food offered at the day-care centers was also analyzed. Results. The fo od offered at the day-care center was found to be deficient in ascorbic acid, poor in heme iron, and adequate in non-heme iron. Supplementation with fortified drinking water resulted in a decrease in the prevalence of anemia and an increase in mean hemoglobin levels associated with height gain in both groups. Conclusions. Fortification of drinking water with iron has previously demonstrated effectiveness in increasing iron supplies. This simple strategy was confirmed in the present study. The present study also demonstrated that for populations receiving an abundant supply of non-heme iron, it is possible to control anemia in a simple, safe, and inexpensive manner by adding ascorbic acid to drinking water. © 2005, The United Nations University.