The Politics of Prevention: the long journey to mandate folic acid fortification in New Zealand

Imagine if you could prevent a serious birth defect in your baby by simply eating about two slices of bread. Sounds too good to be true, right? Well, that is what folic acid fortification is all about.

Folic acid is a synthetic form of folate, a B vitamin that is essential for cell growth and reproduction. It is more bioavailable (more readily absorbed and used in the body) than naturally occurring food folate. And, folic acid is the only form of folate shown to help prevent neural tube defects in randomised controlled trials.

Neural tube defects (NTDs) are conditions that affect the brain and spine of the developing foetus. Spina bifida and anencephaly are the most common types of NTDs. Spina bifida causes paralysis and bowel and bladder problems in some children. Anencephaly causes underdeveloped brains and skulls in babies, who usually die soon after birth.

Like many countries, the New Zealand Ministry of Health recommend that women who plan to become pregnant take a folic acid supplement for at least four weeks prior to conception and for 12 weeks after conceiving to reduce the risk of NTDs. However, only about a third of women follow the recommendation to take folic acid supplements before and during pregnancy. The issue of compliance is compounded by the fact that about half of pregnancies in New Zealand are not planned.

Folic acid fortification is one solution to overcome the challenges of supplementation. It can reach more women of childbearing age, especially those who have unplanned pregnancies or do not take folic acid supplements as recommended. By adding folic acid to a staple food like bread, more women will be consuming sufficient amounts at the critical time of neural tube development without changing their dietary habits or relying on their awareness and compliance.

One of the first countries to mandate folic acid fortification was the United States, which did so over 25 years ago. Between 1996 to 2006, this policy prevented 10,000 NTD-affected pregnancies, saved US$4.7 billion and was praised as one of the greatest public health achievements. Today more than 80 countries have implemented mandatory folic acid fortification, mostly in wheat flour.

This week, New Zealand finally puts into action the mandatory folic acid fortification of non-organic flour for bread making, after a lengthy and drawn-out delay.

But not everyone has been happy with this approach. There has been a long and heated debate over whether to make folic acid fortification mandatory or not. Some people were worried about the safety and effectiveness of folic acid in food. They feared that folic acid may have negative effects on health, such as masking vitamin B12 deficiency, increasing cancer risk, or interfering with some medications (however, these risks have been inflated!). Some also preferred to have the option to choose whether to consume folic acid or not.

These challenges have delayed and complicated the implementation of mandatory folic acid fortification in New Zealand for over a decade. However, the scientific evidence that folic acid fortification protects babies against NTDs has been overwhelming.

The number of babies born with brain and spinal cord defects is higher in New Zealand than other comparable countries such as Australia, Canada and the United States who now have mandatory folic acid fortification.

NTDs are estimated to affect 10.6 per 10,000 births in New Zealand, with an average of 64 NTD-affected pregnancies recorded each year. Of these, 60% of cases resulted in elective termination or stillbirths.

The possible association of folic acid fortification with increased risks, are not supported by strong or consistent evidence. Most studies have used high doses of folic acid supplements or observational data that cannot establish causality. Besides, the level of folic acid added to food is much lower than the amount used in supplements or clinical trials.

While the safety concerns were the main focus of the media, they were not the only reason for the delay. There was also political resistance and industry opposition to the programme.

In 2007, New Zealand and Australia agreed to a joint mandatory folic acid fortification standard under the Australia New Zealand Food Standards Code. However, as the 2009 deadline drew near, political and manufacturer opposition to mandatory fortification in New Zealand gave rise to concerns about costs and consumer choice. As a result, New Zealand did not implement mandatory fortification, unlike Australia, which did. This has led to a difference in the rates of NTDs between the two countries.

This major change in New Zealand’s fortification trajectory occurred when the newly elected National-led government decided to defer mandatory fortification fortification for three years, followed by an indefinite extension of the deferral. The National government claimed that ‘it was a matter of consumer choice, not science’. They argued that consumers should have the right to decide whether they want to consume folic acid or not, and that mandatory fortification would take away that choice.

These arguments were challenged by many health experts and consumer advocates, who pointed out that the scientific evidence for the benefits of folic acid fortification was strong and consistent, and that the risks were minimal and uncertain. They also argued that consumer choice was not a valid reason to deny a public health intervention that could prevent serious birth defects and reduce health inequalities.

Strong advocacy continued for and against mandatory fortification. The Ministry of Primary Industries estimated that the average lifetime cost of each spina bifida case in New Zealand was NZ$4.8 million in 2010. This included the costs of health care, education, social services, productivity losses, and intangible costs such as pain and suffering. In contrast, the additional costs to consumers to add folic acid to bread was 1c per loaf.

To add fuel to the fire, mandatory folic acid fortification in Australia has resulted in a 14% reduction in NTDs (from 10.2 to 8.7 per 10,000 conceptions that resulted in a birth) in the general population and 77% reduction in indigenous populations.

It is estimated that if New Zealand had followed Australia’s lead on mandatory fortification since 2009, between 162 to 240 NTDs could have been prevented. This would have spared many families from the the emotional and financial hardships of having a baby with a serious birth defect.

After a change (once again) of government and an updated review of the evidence, New Zealand finally approved mandatory fortification of bread-making flour with folic acid. Millers were given two years from July 2021 to make the necessary changes to comply with the new regulations.

The science was clear, and the decision was welcomed by many healthprofessionals, researchers, policy makers and consumer groups.

As of 14 August 2023, 14 years after the implementation of folic acid fortification in Australia, the lives of many New Zealand babies and families are no longer at stake.