Folic acid fortification in Europe

1
Folic acid fortification in Europe
3 IC BDD DWJune 17-21 2007Rio de Janeiro

• Pierpaolo Mastroiacovo
• Professor of Pediatrics
• ICBDSR Centre, Director

2
Situation in Europe
Rarely used No serious discussion on
fortification
Source UKs Scientific Advisory Committee on
Nutrition SACN Report 2005
3 Countries
3
The Netherlands

• 1996
• Fortification with vitamins of various type of
  food, approved. No folic acid in the list
• 2000, Nov 15
• Committee from the Health Council advises that
  the fortification of food products with folic
  acid should for the time being be limited to
  those foods wich are specifically aimed at the
  target group with the appropriate advice and
  labelling
• 2003, May 10
• Committee from the Health Council gives
  references for dietary intakes, endorses the
  recommendation of supplementation, no single word
  on fortification
• 2004, Nov 9
• RIVM Report on Neurotoxicity of FA (1)
  Conclusion masking by FA of pernicious
  anaemia due to B12 deficiency is no argument to
  renounce the fortification of food with FA. Data
  claiming that FA may precipitate neurological
  damage is of limited scientific value, and remain
  unproven.

(1) JGC vam Amsterdam et al. For account of Dpt
Nutrition and Health protection, Ministry of
Welfare, Public Health and Sport
4
Ireland (1)

• 1997 1998
• The discussion on food fortification starts in
  the Parliament
• 2003, March
• Nutrition sub-committee of FSAI () in
  association with its FA working group made a
  document for consideration by the FSAI Scientific
  Committee
• http//www.fsai.ie/publications/other/Folic_Acid_R
  eport.pdf
• 2004
• Minister for Health and Children (MHC) set up a
  National Committee on FA Fortification,
  established under the secretariat of FSAI
• 2005, March
• National Committee on FA Fortification prepared a
  document and launched for public consultation
• 2005, June 24
• Deadline for a public consultation on possible
  options for the fortification

() Food Safety Authority of Ireland
5
Ireland (2)

• 2006, July 18
• National Committee on FA Fortification,
  established by the Minister for Health and
  Children, under the secretariat of FSAI propose
  mandatory fortification at a level of 120mg per
  100g of bread (1,2)
• The proposal has been supported by the Health
  Ministry who decided to establish an implemention
  group to develop a detailed implementation
  process for mandatory fortification of bread

• Full Report available www.fsai.ie/publications/rep
  orts/folic_acid.pdf
• Power Point presentation www.bfr.bund.de/cm/232/m
  andatory_folic_acid_food_fortification_in_ireland.
  pdf

6
United Kingdom (1)

• 2000 January 13
• Committee on Medical Aspects of Nutrition Policy
  (COMA) Report did not recommend the mandatory
  fortification
• 2004 June 14
• Health Ministers agreed with FSA not to recommend
  the introduction of mandatory fortification
  because of concerns about potential health risks
  to the elderly
• 2005 November 23
• Scientific Advisory Committee on Nutrition (SACN)
  published a new report and launched a public
  consultation
• 2006 December
• SACN Consultation deadline

7
United Kingdom (2)

• 2007 May 17
• The Scientific Advisory Committee on Nutrition
  (SACN) of the UKs Food Standard Agency agreed
  unanimously to recommend mandatory fortification
  of some foods with FA, but whether it is bread or
  flour is still up for debate
• 2007 May 21
• The Federation of Bakers and the Medical Research
  Council signalled their support for the move

8
Expert Discussion Forum at Bundesinstitut fur
Risikobewertung

• 2007 January 12
• Representatives (public health) from 14 EU
  countries Switzerland
• Conclusions
• Primary prevention is ethically more acceptable
  than secondary prevention (prenatal diagnosis and
  ToPs)
• Promote periconceptional supplements regardless
  fortification measures
• While considering the voluntary or mandatory
  fortification, fortification levels should be
  kept as low as possible, effective but safe
• Regular monitoring of impact is essential
• Another meeting on safety, especially the issue
  of cancer, is desirable

9
My understanding why fortification has not yet
been implemented

• Cultural unjustified beliefs
• NTDs prevalence is considered low in some EU
  countries except than in Ireland and UK
• In some countries (e.g. Italy) the common belief
  is that daily nutrition is rich in folic acid
• Any fortification of food is considered an
  artificial anti-ecological action
• Personal choices (supplementation) are more
  important
• Safety seems to be the most critical issue
• Possible side effects are felt more important
  than evidence based efficacy and effectiveness
• Papers on side effects had more attention and
  visibility than the papers on efficacy

10
My understanding why fortification has not yet
been implemented

• Most important so called secondary prevention
  (ToPs after PD) is considered the standard
  preventive measure
• HCP and womens common feelings
• prevention of birth defects is prenatal
  diagnosis and ToPs
• birth defects cannot be prevented by primary
  prevention
• In some EU countries the ToPs proportion is
  reaching almost 100 of anencephaly and 70-80 of
  spina bifida cases

11
Proportion (and CI 95) of ToPs out of all cases
of SB in some countries ICBDSR 2000-2004
R registries, cumulated when homogeneous
Spain, 3 EUROCAT registries estimates 75.0
12
Thanks
13
AknowledgementsThanks to two giants experts for
their advices and informationAndrew Czeizel
Godfrey Oakley