Australia introduced mandatory folic acid fortification of wheat flour for making bread in 2009. The Australia and New Zealand Food Regulation Ministerial Council (now the Legislative and Governance Forum on Food Regulation) committed to a comprehensive and independent review of the program to begin two years after implementation.
Since implementation, the Commonwealth and state/territory food regulatory authorities have undertaken a number of projects to monitor mandatory folic acid fortification. The findings of these projects have contributed to the planned review with the most recent report being from the Australian Institute of Health and Welfare (AIHW) on monitoring the health impact of mandatory folic acid and iodine fortification. The review report includes information on the nutrient content of bread, nutrient intakes, nutritional status, health benefits and possible adverse effects.
As part of its role in monitoring the Australian food supply FSANZ conducted surveys of post mandatory fortification levels of folic acid in commonly eaten breads on the Australian market. It also estimated the mean daily intake of folic acid by Australians of all age groups, particularly the target group for mandatory folic acid fortification (females of child-bearing age). The FSANZ report on folic acid fortification in Australia provides information on the national bread surveys undertaken and the estimated intake of folic acid by the population (including target group) before and after mandatory folic acid fortification.
Survey of folic acid content of bread
FSANZ analysed commonly consumed breads on the Australian market in June and July 2010, and in March to April 2012 following implementation of mandatory folic acid fortification in late 2009. Samples for both surveys were bought from representative food retail outlets in the capital cities of all states and territories.
The samples were chemically analysed by the National Measurement Institute of Australia laboratories in Melbourne. The survey provided data for the amount of folic acid in breads consumed by Australians at the two time periods after implementation of mandatory folic acid fortification. The post-fortification amounts of folic acid in the bread samples were similar to those predicted during the standard development process.
The survey results together with food consumption data from the two available national nutrition surveys were used to estimate the Australian population's intake of dietary folic acid before and after implementation of the mandatory folic acid fortification standard. FSANZ undertook dietary intake assessment using internationally accepted procedures and its custom built computer modelling program. Data from the 1995 Australian National Nutrition Survey and the 2007 National Children's Nutrition and Physical Activity Survey were used because they were the best available national data at the time of the analyses.
Estimates of folic acid intake
The intake estimates indicated a substantial increase in mean daily intake of dietary folic acid by Australians after mandatory folic acid fortification of bread.
The increase was observed in the target population (females of child-bearing age) and the general adult population, resulting in an increase in the proportion of the population that met intake requirements for the nutrient. The expected health outcome from the increased mean daily intake of dietary folic acid by females of child-bearing age is a reduction in the incidence of neural tube defects, which are serious birth defects. However, as currently advised by FSANZ and health authorities, pregnant women and women planning pregnancy still need to continue to take folic acid supplements.
The estimates also provided evidence of the importance of bread as the main food in the Cereal and Cereal Products food group that contributed to the Australian population's increased intake of dietary folic acid. Although the analyses in the report used previous national nutrition survey data, the recent 2011-2013 National Nutrition and Physical Activity Survey by the Australian Bureau of Statistics showed regular bread and bread rolls continue to be the commonly eaten food of the Cereal and Cereal Products food group. The current food consumption information indicates the continuing relevance of consumption of folic acid fortified bread to improve the Australian population's intake of dietary folic acid.
In 2010 Australian state and territory food regulatory authorities conducted a survey of Australian flour millers to assess compliance with the mandatory folic acid fortification standard.
In total, 21 flour mills throughout Australia took part in the study, and all showed they had arrangements in place to demonstrate compliance with mandatory folic acid fortification. These arrangements included review of documents to support implementation, sampling protocols and auditing processes.
The survey also included analyses of folic acid concentrations in flour samples taken from the mills. The levels of folic acid were within the correct limits for 16 of the mills. There was some variance at the other mills (with some slightly over or under the limits). These mills continue to work with food regulatory authorities to ensure the levels remain within the correct limits for fortification.
The Department of Health provides the following survey from 2011: National mandatory folic acid fortification of wheat flour for making bread compliance survey
A survey of Australia and New Zealand consumers' awareness, attitudes and behavior towards fortified foods was undertaken by FSANZ as part of monitoring mandatory fortification of some foods in the food supply chain.
A qualitative survey of representative samples of consumers in both countries was commissioned in 2009 to research the topic. The qualitative work helped to design the quantitative component of the consumer survey of food fortification.
In 2011, FSANZ commissioned Newspoll to conduct the quantitative component of the consumer fortification research using a computer assisted telephone interview survey. Data was again collected from representative samples of consumers in the two countries, analysed and the report finalised in 2013.
Review of mandatory folic acid fortification
The Department of Health is managing an independent review of mandatory fortification (folic acid and iodine) in a three phase process.
- Phase 1 is an independent report on the food industry's level of compliance with the mandatory fortification standard and the impact on enforcement agencies' compliance which is completed.
- Phase 2 is the completed AIHW report on monitoring the health impact of mandatory fortification (folic acid and iodine) to which the FSANZ report contributes information.
- Phase 3 is the independent evaluation of the effectiveness of the mandatory fortification program and the adequacy and the adequacy of the framework. This phase has commenced.
Folic acid and disease outcomes
In 2013, FSANZ published a systematic review and meta-analysis examining the effects on cancers and death from all causes in randomised controlled trials that had used folic acid. Since then, the trial by Sato et al which appeared in the analysis of deaths has been retracted. Therefore FSANZ has re-analysed these data. In the paper we reported that the relative risk for death from all causes was 0.99 (95% CI: 0.92-1.05). Because Sato et al was a small trial compared to others in the analysis, removing their data had little effect on the results: relative risk=0.98 (95% CI: 0.92-1.05). The following figure replaces Figure 8 in the paper:
State, territory and Commonwealth food regulatory and health authorities agreed to a wide range of data collection and reporting to monitor mandatory folic acid fortification, including the activities mentioned above. Available national pre-fortification data was published by the AIHW in three reports; a baseline report, a supplementary data report, and a report on monitoring neural tube defects.
The web addresses for the three AIHW publications in the order in which they are listed above are: