ࡱ> G ,bjbjَ *hG(]$$$$$$$88888p,8:(&&& Ha } $!#.$ "  $$&& $&$&88$$$$   y$$&288 :"THE PAEDIATRIC SOCIETY OF NEW ZEALAND Secretariat: Email: Denise Tringham P O Box 22 234 Wellington Tel: (04) 938 4827 Fax: (04) 976 4827  HYPERLINK "mailto:psnz@paradise.net.nz" psnz@paradise.net.nz  31 July 2006 FSANZ Consultation July 2006 Mandatory Folic Acid Fortification Standard. Draft Assessment Report July 2006. (Proposal P295) Submission from: The Paediatric Society of New Zealand The Paediatric Society of New Zealand strongly supports the mandatory fortification of the food supply with folic acid. The opportunity to reduce the number of individuals affected by neural tube defects and congenital heart disease, as well as the number of women affected by therapeutic termination of pregnancy must not be missed. The following points are made in support of our submission: There is good evidence that interventions such as voluntary fortification, periconceptual supplementation and dietary modification with folate-rich foods do not, either alone or in combination, produce the desired public health outcome. Voluntary supplementation is not effective in achieving adequate folic acid levels in the target population. It is unlikely that voluntary fortification plus pre-conception folic acid supplementation will significantly reduce the incidence of neural tube defect even with a sustained publicity campaign. This is because of the high rate of unplanned pregnancy (50%) and the likelihood that Many women will not be reached by whatever publicity campaign is conducted. Many women even if informed will not take supplements consistently. Women in already disadvantaged socio-economic groups are less likely to be reached and respond to a campaign, or may be disadvantaged by the cost of purchasing supplements. These women are at highest risk of having a diet low in folic acid. The most recent (1997) Adult Diet Survey showed that virtually all women in New Zealand have dietary folate intakes below the 400 micrograms (mcg)/day recommended in pregnancy. Therefore all women require supplements if they are to achieve even that modest pregnancy intake level. The usual daily median intake of folate from food for the New Zealand population was 242 mcg (males 278 mcg, females 212 mcg). Intakes varied little across age group. Females living in NZDep96 quartile I areas had higher levels of intake (227 mcg) compared with those living in quartile IV areas (201 mcg). The benefits of folic acid fortification have been known for many years. So far 52 countries have recognised the value of folic acid fortification for their population and proceeded with this. There is overwhelming evidence that folic acid fortification of flour is a safe and effective public health measure. The benefits are not confined to a reduction in incidence of a preventable birth defect - Neural Tube Defects (NTD) but also include improving serum folate concentrations in the adult population and reducing levels of serum homocysteine (a risk factor for stroke and heart attack). Mandatory fortification is also likely to reduce the incidence (and cost) of serious congenital heart disease. There is now an impressive body of research documenting the efficacy of mandatory fortification of flour with folic acid in achieving the desired public health outcome, reduction in the true incidence of Neural Tube Defects. International experience has now demonstrated that wheat flour and wheat products are the ideal vehicles for increasing folic acid consumption in the whole population, not just the target group (reproductive age females). This initiative has previously been embraced by industry groups. A level of 240-285 micrograms (mcg) folic acid per 100g of flour is likely to be most effective, both in reaching the target group and reducing the true incidence of Neural Tube Defects in the New Zealand and Australian populations. Even at this level of fortification, the target groups will still need to be exposed to a continuing public education programme, as they will also need to take some level of supplementation and/or consume more folate-rich foods. The target groups are : Women who have had a previous child with NTD, or have a family history of NTD (and thus have a higher risk of NTD recurrence than the general population). Women planning a pregnancy. Neural Tube Defects The true incidence of Neural Tube Defects is not known for New Zealand as the cases which are terminated in pregnancy are not recorded. Most of the data available refers only to live births and still births. Thus, claims that the overall incidence is low are fallacious and should be clearly identified as such. However, improved data collection in 2004 allowed for recording of virtually all Neural Tube Defects in terminations of pregnancy by the Abortion Supervisory Committee in New Zealand. Preliminary analysis of this data indicates that, in 2004, the number of second trimester terminations for NTD/CNS malformation was 41 and the number of live births 12 (stillbirth figure outstanding). This clearly indicates that the true population incidence is likely to be between 50 and 60 per annum, and that the documented live birth prevalence now represents only a minority of affected cases. Thus, primary prevention by folic acid fortification of flour, in combination with public education and supplementation in the target group (reproductive females) could produce a substantial drop in the number of affected pregnancies, and thus the terminations for Neural Tube Defects. This reduction in the number of terminations has implications for reducing hospital care costs, and more importantly reducing morbidity associated with termination in these women and improving their reproductive health. This could be achieved with no evidence of harm to the NZ population from folic acid fortification of flour. A surveillance system is now in place to monitor the incidence of Neural Tube Defects in NZ live births, stillbirths and terminations of pregnancy. The emotional and financial consequences to an affected individual, to his/her family, and to society, of spina bifida and other neural tube defects are enormous. The opportunity to reduce the number of affected individuals by PRIMARY prevention (that is, ensuring those individuals are born in good health without disability) rather than SECONDARY prevention (that is, terminating the lives of those individuals found to be affected) must not be missed. Consumer issues. Many other countries have now fortified their flour with folic acid. In those countries there is no evidence to suggest an adverse reaction from consumers to this public health initiative. Other such public good initiatives like immunisation and fluoridation likewise are accepted by consumers in general. There will always be small, vocal minorities who object to such initiatives. In this case, if they wish not to consume products with folic acid fortification then they will have choices from other non-mainstream producers. The Paediatric Society of New Zealand strongly supports the mandatory fortification of the food supply with folic acid. The opportunity to reduce the number ofindividuals affected by neural tube defects and congenital heart disease, as well as the number of women affected by therapeutic termination of pregnancy must not be missed. This submission prepared by Rosemary Marks, MB ChB, FRACP, Chair of the Child Development Special Interest Group of the Paediatric Society of New Zealand, in consultation with the membership of the Paediatric Society of New Zealand References. Adams, J. (Grain Foods Foundation, Denver) (2005). Anonymous. Newsletter article. (The Canadian Wheat Board, Winnipeg) (2005). Botto LD et al. International retrospective cohort studies of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ 330, 12 (2005). Bower C. Primary prevention of neural tube defects with folate in Western Australia: the value of the Western Australia Birth Defects Registry. Congenit Anom (Kyoto) 46, 118-121 (2001). Chan A, Haan E. Universal periconceptual folate supplementation: chasing the dream? [letter,comment]. Medical Journal of Australia, 173, 223 (2000). Chan A, et al. Folate before pregnancy: the impact on women and health professionals of a population-based health promotion campaign in South Australia. Medical Journal of Australia, 174, 631-6 (2001). Davey Smith G, Ebrahim S. Folate supplementation and cardiovascular disease. Lancet, 366, 1679-81 (2005). Folic Acid and Prevention of Spina Bifida and Anencephaly 10 Years After the U.S. Public Health Service Recommendation MMWR Recommendations and Reports September 13, 2002 / Vol. 51 / No. RR-13 CDC  HYPERLINK "https://mail.adhb.govt.nz/exchweb/bin/redir.asp?URL=http://www.cdc.gov/mmwr/PDF/rr/rr5113.pdf" \t "_blank" http://www.cdc.gov/mmwr/PDF/rr/rr5113.pdf Grosse SD, Hopkins DP, Mulinare J, Lianos A, Hertrampf E. Folic acid fortification and birth defects prevention: lessons from the Americas. AGROFood industry hi-tech 17 (2006). 10. Improving Folate Intake in New Zealand: Policy implications. Wellington: Ministry of Health. Published in August 2003 by the Ministry of Health PO Box 5013, Wellington, New Zealand ISBN 0-478-25663-9 (Book) ISBN 0-478-25664-7 (Website) Lawrence JM, Petitti DB, Watkins M, Umekubo MA. Trends in serum folate after food fortification. Lancet 354, 915-6 (1999). NZ Food: NZ People Key results of the 1997 National Nutrition Survey, Ministry of Health 1999 ISBN 0-478-23572-0 (Document) ISBN 0-478-23573-9 (Internet) Oakley GP, Weber MB, Bell KN, Colditz P. Scientific evidence supporting folic acid fortification of flour in Australia and New Zealand. Birth Defects Research 70, 838-41 (2004). Personal Communication (Dixon, J, Borman, B) Trends in spina bifida and anencephalus in the United States, 19912000. Centers for Disease Control and Prevention. National Center for Health StatisticsHealth E Stats. National Vital Statistics System.  HYPERLINK "" http://www.cdc.gov/nchs/products/pubs/pubd/hestats/spine_anen.htm November 2001. Yang Q. Improvement in stroke mortality in Canada and the United States. 1990-2002. Circulation, 113,1335-43 (2006).  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Submissions

The Paediatric Society believes all children and youth should, by right, attain optimal physical, mental and social health and wellbeing.  By working as a coordinated national network of health professionals the Society dedicates its efforts and resources to making official submissions to both Government and Non-Government organisations on issues that will impact on the health and wellbeing of children and young people.

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