Dialogue: Add a lifesaver to our nation's daily bread

PAUL HUTCHISON* says fortifying flour with folic acid is a simple and cheap way to significantly reduce cases of spine and brain birth defects, stroke and heart disease.

Forget the health restructuring and put folic acid in our flour - by doing this the Government could save a significant number of lives at minimal cost.

If all flour and baked goods were fortified with folic acid, more than 30 cases of severe spine and brain defects (neural tube defects) could be prevented each year in New Zealand. There may also be a profound benefit in reducing stroke and cardiovascular conditions.

To satisfy the concerns of civil libertarians, there could be (initially) voluntary fortification of bread with appropriate labelling. If, however, fortification was not near-universal within six months, I would advocate making it a requirement, with manufacturers allowed to opt out.

As an obstetrician and a politician, I believe that the Government should act now to ensure this happens.

In 1993, an American epidemiologist, Professor Oakley, said in the Journal of the American Medical Association that one of the most exciting medical findings of the last part of the 20th century was that folic acid - a widely available, water-soluble vitamin - can prevent spina bifida and anencephaly.

Not since the rubella vaccine became available 30 years ago have we had a comparable opportunity for primary prevention of such common and serious birth defects.

In Britain, the committee on medical aspects of food and nutrition policy has recommended fortifying flour with folic acid.

Its report concluded that on scientific, medical and public health grounds, universal fortification of flour at 240 mcg for every 100gm would have a significant effect in preventing neural tube defects (NTDs).

In New Zealand, milling and baking industry leaders have discussed ways their industry might assist to advance this initiative. Already both Sanitarium and Kelloggs fortify with folic acid.

Four months ago Professor Oakley wrote to Health Minister Annette King and challenged her to implement a fortification programme which could lead to New Zealand becoming the first country to prevent all folic acid-preventable birth defects and cardiovascular disease.

In New Zealand 50 babies are born with an NTD every year, either stillborn or with a significant disability. Many more are identified early in pregnancy and are now aborted.

Anencephaly is characterised by a large brain defect, and those infants who are live-born usually die within hours of birth. Spina bifida includes a range of defects affecting closure of the spinal column.

Most infants with spina bifida are live-born and may have associated birth defects. Minor and mild cases can lead good quality lives, but severe cases may suffer significant ongoing disability.

A small proportion will not be prevented by folic acid intake.

Dr Barry Borman and Sheldon Brown published an authoritative survey last December of the folic acid situation in New Zealand.

The scientific committee of the National Heart Foundation reviewed the evidence linking folate intake and heart disease. They agreed with Dr Borman's evidence suggesting that high intake of folate causes reduction in homocysteine levels and thereby a reduction in cardiovascular disease.

While the link is not absolutely certain, the consistency of the evidence in the size of the heart disease problem in New Zealand means that the public health potential of fortification of bread folate could be substantial. It is relevant to men as well as women.

There are three mechanisms available to increase folate to levels which prevent NTDs: fortification, supplementation and diet.

Fortification of all grain products appears the most effective mechanism for improving the folate status of women. The United States fortified in 1998, Canada has, and many countries are following suit.

Voluntary supplements are an effective method of taking folic acid, but many pregnancies are unplanned, and neural tube defects are formed in the first month, before many women are aware they are pregnant.

It is difficult for women to raise their level of folate sufficiently through folate-rich food alone. Natural folate that occurs in food is less stable than synthetic folic acid and has a lower bio-availability.

For a woman to receive an extra 400 mcg of folic acid each day, she would have to consume more than eight glasses of orange juice, 10 servings of broccoli, three servings of brussels sprouts, or appropriate combinations of such foods.

The 1997 New Zealand Nutrition Survey found that the usual daily median intake of folate from food was 212 mcg for females. But people from deprived areas, and young females, are likely to have an inadequate intake of folate.

A major objection to fortification of a staple food, such as bread, with folic acid is that all members of society are exposed to folic acid in larger amounts than is usual. Instances in public health where fortification has been effective includes rickets (vitamin D), thyroid disease, goitre (iodine) and dental caries (fluoride).

There are no known toxic effects from the ingestion of folic acid either by diet supplementation or fortification. And by labelling food as fortified, objectors could make other product choices.

The evidence for universal fortification of flour and baked goods in New Zealand is compelling.

This is an opportunity for all parliamentarians to lend their support to an inexpensive public health initiative that is highly likely to reduce the incidence of NTDs in New Zealand by 70 per cent and may also have a profound, positive effect on cardiovascular disease.

I, too, challenge the Health Minister to get on with it.

* Dr Paul Hutchison is MP for Port Waikato, Opposition associate spokesman on health and Opposition spokesman on crown research institutes. He is an obstetrician and gynaecologist.