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.
|
|
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Are the food industries adequately complying with the mandatory fortification standards?
|
Not applicable |
Mills and baking businesses have systems in place to ensure compliance.
|
|
|
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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.
|
|
|
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).
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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)
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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.
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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%
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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.
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Cancer and all-cause mortality
|
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No increase in cancer or all-cause mortality can be directly associated with increase in folic acid intakes in adults.
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Desired outcome achieved
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)
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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.