Outcomes of folic acid fortification in Australia

Mandatory folic acid fortification in Australia has increased the level of folic acid in the food supply, and thereby increased folic acid intakes and folate status among women of child-bearing age (the target population) (Table 1). The rate of neural tube defects has decreased following mandatory folic acid fortification by 14.4%, in line with predictions. The decrease in neural tube defects has been most substantial for teenagers and Aboriginal and Torres Strait Islander women.

Table 1: Key mandatory folic acid fortification outcomes in Australia
Key monitoring question and measurement Pre-mandatory fortification Post-mandatory fortification Further details Outcome

Has the level of folic acid in our food supply increased?
Mean folic acid level of bread

20–29 µg/100 g

134–200 µg/100 g

The predicted post-fortification estimate was 120 µg/100 g in bread.

Desired outcome achieved

Are the food industries adequately complying with the mandatory fortification standards?

Not applicable

Mills and baking businesses have systems in place to ensure compliance.


Desired outcome achieved

Have folic acid intakes of women of child-bearing age increased?
Mean folic acid intakes in women aged 16–44

102 µg/day

247 µg/day (145 µg/day increase; 142%)

The predicted post-fortification predicted increase was 100 µg/day.

Desired outcome achieved

Has the folate status of women of child-bearing age improved?
Mean red blood cell and serum folate

Serum folate data are available for limited assessment.
No adequate red blood cell folate baseline data are available.

Red blood cell folate
All women aged 16–44: 1,647 nmol/L
Pregnant women aged 16–44: 1,958 nmol/L
Breastfeeding women aged 16–44: 1,775 nmol/L

Mean serum folate levels post‑fortification were higher than at baseline; however, results must be interpreted with caution because different methodologies were used (see Section 2.4).

Not applicable

Has the incidence of neural tube defects (NTDs) decreased?
NTD incidence per 10,000 conceptions that resulted in a birth

Total study population
All women: 10.2
Indigenous women: 19.6
Teenagers: 14.9
Population omitting NSW residents(a)
All women: 12.8
Indigenous women: 22.8
Teenagers: 18.6

Total study population
All women: 8.7 (14.4% decrease)
Indigenous women: 5.1 (74.2% decrease)
Teenagers: 6.7 (54.8% decrease)
Population omitting NSW residents(a)
All women: 11.2 (12.5% decrease)
Indigenous women: 4.5 (80.2% decrease)
Teenagers: 7.0 (62.6% decrease)

The predicted post-fortification predicted average decrease in NTDs was 14%.
Ongoing monitoring of NTDs is required to confirm whether these reductions will be sustained.

Desired outcome achieved

Does mandatory folic acid fortification result in adverse health effects for the population?
Proportion of the population with folic acid intakes above the upper level of intake (UL)

Women aged 16–44: 0%
Persons aged 19 and over: 0%
Children aged 4–8: 3%
Children aged 2–3: 5%

Women aged 16–44: 0%
Persons aged 19 and over: <1%
Children aged 4–8: 15%
Children aged 2–3: 21%

Minimal change in adults exceeding the UL. A higher proportion of children aged 2–16 exceeded the UL but is not considered a health risk. The UL incorporates a fivefold safety margin and is based on an end point for high intakes in older adults.

Not applicable

Cancer and all-cause mortality


No increase in cancer or all-cause mortality can be directly associated with increase in folic acid intakes in adults.


Desired outcome achieved

 Desired outcome achieved
Partial achievement Partial achievement
  Not applicable: data did not support an overall assessment or a rating was not appropriate.

µg microgram
NTD neural tube defect
UL upper level of intake (for more information, see the Nutrient Reference Values for Australia and New Zealand website)

  1. Analysis omitting New South Wales from the study population was undertaken as a sensitivity analysis to assess the potential bias of missing data from the state. Inclusion of New South Wales provided a much larger population and improved the study power.