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Purpose: To present a case study of the considerations of mandatory fortification with folic acid in Australia and New Zealand., Methods: Review of published reports and consumer advocacy views., Results: Australia and New Zealand jointly approved mandatory fortification of flour with folic acid to prevent neural tube defects in 2007. Fortification was fully implemented in Australia in 2009 and has resulted in reduction in NTD. At the last minute, industry lobbying led to the New Zealand government not proceeding with fortification. With continued consumer advocacy, mounting scientific evidence, and a change of government, approval was given in 2021 for mandatory fortification of flour with folic acid., Conclusion: In large part as a response to consumer pressure, New Zealand has now joined with Australia (and around 70 other countries) in fortifying flour with folic acid for the prevention of NTD., (© 2023. The Author(s).)

Since the early 1990s, maternal folic acid supplementation has been recommended prior  to and during the first trimester of pregnancy, to reduce the risk of infant neural tube defects. In  addition, many countries have also implemented the folic acid fortification of staple foods, in order  to promote sufficient intakes amongst women of a childbearing age, based on concerns surrounding  variable dietary and supplementation practices. As many women continue to take folic acid  supplements beyond the recommended first trimester, there has been an overall increase in folate  intakes, particularly in countries with mandatory fortification. This has raised questions on the  consequences for the developing fetus, given that folic acid, a methyl donor, has the potential to  epigenetically modify gene expression. In animal studies, folic acid has been shown to promote an  allergic phenotype in the offspring, through changes in DNA methylation. Human population  studies  have  also  described  associations  between  folate  status  in  pregnancy  and  the  risk  of  subsequent childhood allergic disease. In this review, we address the question of whether ongoing  maternal folic acid supplementation after neural tube closure, could be contributing to the rise in  early life allergic diseases.

Background: Mandatory fortification of wheat flour for bread-making was introduced in Australia in September 2009, to assist in the prevention of neural tube defects (NTD). NTD are twice as common in Aboriginal compared with non-Aboriginal infants, and folate levels are lower in the Aboriginal population., Aims: This study was undertaken to compare folate status and NTD in the Aboriginal population before and after fortification., Methods: Postfortification, 95 Aboriginal men and nonpregnant women aged 16-44 years in metropolitan and regional Western Australia (WA) completed a rapid dietary assessment tool and had blood taken to measure red cell folate. Measures were compared with prefortification values obtained in an earlier study using the same methods. Data on NTD in Aboriginal infants were obtained from the WA Register of Developmental Anomalies., Results: No participant was folate deficient. The mean red cell folate increased after fortification to 443 ng/mL for males and 567 ng/mL for females. The mean difference between red cell folate after fortification compared with before was 129 ng/mL for males (95% CI 81-177); t = 5.4; P < 0.0001) and 186 ng/mL for females (95% CI 139-233); t = 7.9; P < 0.0001). Most participants ate fortified shop-bought bread at least weekly, resulting in an estimated additional folate intake per day of 178 (males) and 145 (females) dietary folate equivalents. NTD prevalence fell by 68% following fortification (prevalence ratio 0.32 (CI 0.15-0.69))., Conclusions: The population health intervention of mandatory fortification of wheat flour for bread-making has had the desired effect of increasing folate status and reducing NTD in the Australian Aboriginal population., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Recent research suggests that maternal folic acid supplementation is associated with a reduced risk of childhood brain tumors (CBT); polymorphisms in folate pathway genes could modify this association or directly influence CBT risk., Methods: Associations between risk of CBT and folate pathway polymorphisms were investigated in a population-based case-control study in Australia (2005-2010). Cases were recruited through all Australian pediatric oncology centers and controls by national random digit dialing. Data were available from 321 cases and 552 controls. Six polymorphisms were genotyped in children and parents (MTHFR 677C>T, MTHFR 1298A>C, MTRR 66A>G, MTR 2756A>G, MTR 5049C>A, and CBS 2199 T>C). Maternal folic acid use was ascertained via questionnaire. ORs were estimated using unconditional logistic regression. Case-parent trio analyses were also undertaken., Results: There was weak evidence of a reduced risk of CBT for the MTRR 66GG genotype in the child or father: ORs 0.71 [95% confidence interval (CI), 0.48-1.07]; 0.54 (95% CI, 0.34-0.87), respectively. Maternal prepregnancy folic acid supplementation showed a stronger negative association with CBT risk where the child, mother, or father had the MTRR 66GG genotype (Pinteraction = 0.07, 0.10, and 0.18, respectively)., Conclusions: Evidence for an association between folate pathway genotypes and CBT is limited in this study. There was possible protection by the MTRR 66GG genotype, particularly when combined with maternal prepregnancy folic acid supplementation; these results are novel and require replication., Impact: The possible interaction between folic acid supplementation and MTRR 66A>G, if confirmed, would strengthen evidence for prepregnancy folate protection against CBT., (©2015 American Association for Cancer Research.)

Purpose: The etiology of childhood brain tumors (CBT) is poorly understood, but dietary factors could be involved. In this case-control study of CBT, the possible associations of childhood intake of dietary and supplemental folate, vitamin B6, and vitamin B12 with the risk of CBT were investigated, along with various food groups., Methods: Cases diagnosed between 2005 and 2010 were identified from 10 pediatric oncology centers in Australia and controls by nationwide random-digit dialling. For study children of ages 3-14 years, diet in the year before diagnosis (or recruitment) was assessed using food frequency questionnaires. Folate intake was adjusted for bioavailability, and dietary micronutrient intake was energy-adjusted. Micronutrients and food groups were analyzed using logistic regression adjusting for relevant confounders. Principal components analysis was conducted to assess food group intake patterns for analysis., Results: Food and micronutrient data were available for 216 cases and 523 controls. Folate intake was associated with a reduced risk of CBT overall (odds ratio for highest tertile vs. lowest: 0.63, 95% confidence interval 0.41, 0.97) and particularly low-grade gliomas (odds ratio for highest tertile vs. lowest: 0.52, 95% confidence interval 0.29, 0.92). Vitamin B6 and B12 intake was not associated with CBT risk, nor was processed meat., Conclusions: High folate intake during childhood may reduce the risk of CBT. This potentially important finding needs to be corroborated in other studies. If replicated, these results could have important implications for public health recommendations regarding diet during childhood.

It is biologically plausible that a paternal preconception diet low in nutrients related to DNA integrity could affect sperm DNA and subsequently risk of cancer in the offspring. The aim of this analysis was to investigate whether paternal preconception dietary folate, B6, or B12 intake was associated with the risk of childhood brain tumors (CBT) in an Australian case-control study. Cases <15 years of age were recruited from 10 Australian pediatric oncology centers between 2005 and 2010, and controls from random-digit dialing, frequency-matched to cases on age, sex, and state of residence. Paternal dietary information was obtained by food-frequency questionnaires. Nutrient values were energy adjusted and divided into tertiles for analysis by unconditional logistic regression. In fathers with relevant data (237 cases and 629 controls), no association with dietary folate and B6 and risk of CBT was seen; high B12 intake was associated with an increased risk of CBT (odds ratio highest vs. lowest tertile: 1.74, 95% confidence interval: 1.14, 2.66) without an increasing trend. These results do not support the hypothesis that paternal dietary folate intake influences the risk of CBT. The increased OR observed between dietary B12 intake and risk of CBT is without any certain explanation.

Background: Several studies suggest that maternal folic acid supplementation before or during pregnancy protects against childhood acute lymphoblastic leukemia (ALL). We investigated associations between ALL risk and folate pathway gene polymorphisms, and their modification by maternal folic acid supplements, in a population-based case-control study (2003-2007)., Methods: All Australian pediatric oncology centers provided cases; controls were recruited by national random digit dialing. Data from 392 cases and 535 controls were included. Seven folate pathway gene polymorphisms (MTHFR 677C>T, MTHFR 1298A>C, MTRR 66A>G, MTR 2756 A>G, MTR 5049 C>A, CBS 844 Ins68, and CBS 2199 T>C) were genotyped in children and their parents. Information on prepregnancy maternal folic acid supplement use was collected. ORs were estimated with unconditional logistic regression adjusted for frequency-matched variables and potential confounders. Case-parent trios were also analyzed., Results: There was some evidence of a reduced risk of ALL among children who had, or whose father had, the MTRR 66GG genotype: ORs 0.60 [95% confidence interval (CI) 0.39-0.91] and 0.64 (95% CI, 0.40-1.03), respectively. The ORs for paternal MTHFR 677CT and TT genotypes were 1.41 (95% CI, 1.02-1.93) and 1.81 (95% CI, 1.06-3.07). ORs varied little by maternal folic acid supplementation., Conclusions: Some folate pathway gene polymorphisms in the child or a parent may influence ALL risk. While biologically plausible, underlying mechanisms for these associations need further elucidation., Impact: Folate pathway polymorphisms may be related to risk of childhood ALL, but larger studies are needed for conclusive results., (©2014 American Association for Cancer Research.)

Childhood brain tumors (CBT) are the second most common childhood cancers, yet their etiology is largely unknown. We investigated whether maternal gestational intake of folate and vitamins B6 and B12 was associated with CBT risk in a nationwide case-control study conducted 2005-2010. Case children 0-14 years were recruited from all 10 Australian pediatric oncology centers. Control children were recruited by national random digit dialing, frequency matched to cases on age, sex, and state of residence. Dietary intake was ascertained using food frequency questionnaires and adjusted for total energy intake. Data from 293 case and 726 control mothers were analyzed using unconditional logistic regression. The odds ratio (OR) for the highest versus lowest tertile of folate intake was 0.70 [95% confidence interval (CI): 0.48, 1.02]. The ORs appeared lower in mothers who drank alcohol during pregnancy (OR = 0.45, 95% CI: 0.22, 0.93), mothers who took folic acid (OR = 0.67, 95% CI: 0.42, 1.06) or B6/B12 supplements (OR = 0.51, 95% CI: 0.25, 1.06) and in children younger than 5 years (OR = 0.50, 95% CI: 0.27, 0.93). These findings are consistent with folate's crucial role in maintenance of genomic integrity and DNA methylation. Dietary intake of B6 and B12 was not associated with risk of CBT.

Background: Interest in a possible protective effect of maternal vitamin use before or during pregnancy against childhood brain tumors (CBT) and other childhood cancers has grown over the past decade. Our Australian study of CBTs, conducted between 2005 and 2011, investigated whether maternal use folic acid and other supplements was protective., Methods: Case children were identified through the 10 Australian pediatric oncology centers and controls were recruited by national random digit dialing. Mothers of 327 cases and 867 control children provided information on supplement use before and during the index pregnancy, including brand name, dose, and timing. Data were analyzed using multivariable unconditional logistic regression., Results: The OR for any maternal use of folic acid, use of folic acid without iron or vitamins B6, B12, C, or A, and any vitamin use before pregnancy, were: 0.68 [95% confidence interval (CI), 0.46-1.00; 0.55 (95% CI, 0.32-0.93) and 0.68 (95% CI, 0.46-1.01), respectively. The ORs for use of these supplements during pregnancy were also below unity, but generally closer to the null than those for the prepregnancy period. There was some evidence of an inverse dose-response during each time period., Conclusions: These results suggest that folic acid supplements before and possibly during pregnancy may protect against CBT. Such associations are biologically plausible through established mechanisms., Impact: This study provides evidence of a specific protective effect of prenatal folic acid supplementation against the risk of CBT that is not attributable to the actions of the other micronutrients investigated., (©2012 AACR.)

Background: Neural tube defects arise during the development of the brain and spinal cord., Objectives: The objective of this review was to assess the effects of increased consumption of folate or multivitamins on the prevalence of neural tube defects periconceptionally (that is before pregnancy and in the first two months of pregnancy)., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: April 2001., Selection Criteria: Randomised and quasi-randomised trials comparing periconceptional supplementation by multivitamins with placebo, folate with placebo, or multivitamins with folate; different dosages of multivitamins or folate; prepregnancy dietary advice and counselling in primary care settings to increase the consumption of folate-rich foods, or folate-fortified foods, with standard care; increased intensity of information provision with standard public health dissemination., Data Collection and Analysis: Two reviewers assessed trial quality and extracted data., Main Results: Four trials of supplementation involving 6425 women were included. The trials all addressed the question of supplementation and they were of variable quality. Periconceptional folate supplementation reduced the incidence of neural tube defects (relative risk 0.28, 95% confidence interval 0.13 to 0.58). Folate supplementation did not significantly increase miscarriage, ectopic pregnancy or stillbirth, although there was a possible increase in multiple gestation. Multivitamins alone were not associated with prevention of neural tube defects and did not produce additional preventive effects when given with folate.One dissemination trial, a community randomised trial, was identified involving six communities, matched in pairs, and where 1206 women of child-bearing age were interviewed following the dissemination intervention. This showed that the provision of printed material increased the awareness of the folate/neural tube defects association by 4%, (odds ratio 1.37, 95% confidence interval 1.33 to 1.42)., Authors' Conclusions: Periconceptional folate supplementation has a strong protective effect against neural tube defects. Information about folate should be made more widely available throughout the health and education systems. Women whose fetuses or babies have neural tube defects should be advised of the risk of recurrence in a subsequent pregnancy and offered continuing folate supplementation. The benefits and risks of fortifying basic food stuffs, such as flour, with added folate remain unresolved.

Objective: To establish baseline prevalence of neural tube defects (NTDs) prior to mandatory folic acid fortification in Australia., Method: Retrospective population based study. Data from the Australian Congenital Anomalies Monitoring System, for 1998-2005 were used to calculate birth prevalence including live/stillbirths of at least 20 weeks gestation or 400 g birthweight. Total prevalence and trends of NTD including terminations of pregnancy (TOPs) before 20 weeks were established using data from South Australia, Victoria and Western Australia because of the incomplete ascertainment in other states., Results: The birth prevalence of NTDs from 1998-2005, was 5/10,000 births. The total prevalence including TOPs was 13/10,000 births. A 26% declining trend in total prevalence was seen from 1992-2005, but the main decline occurred prior to 1998. Women who were Indigenous, socially disadvantaged, young, living in remote areas and had multiple gestations were more likely to give birth to babies with NTDs., Conclusion: The prevalence of NTD has been stable since 1998. Reporting of the birth prevalence alone underestimates the actual prevalence of NTD., Implications: From a public health perspective, future monitoring of NTD following implementation of fortification of bread-making flour with folic acid should include a mixed methods approach; reporting birth prevalence on national data and total prevalence on tri-state data.

Background: After randomized, controlled trials established that consumption of folic acid before pregnancy and during the early weeks of gestation reduces the risk of a neural tube defect (NTD)-affected pregnancy, the United States Public Health Service recommended in 1992 that all women capable of becoming pregnant consume 400 microg folic acid daily. In 1998, folic acid fortification of all enriched cereal grain product flour was fully implemented in the United States and Canada., Objective: To provide guidance on national fortification of wheat and maize flours to prevent 50 to 70% of the estimated 300,000 NTD-affected pregnancies worldwide., Methods: An expert workgroup reviewed the latest evidence of effectiveness of folic acid flour fortification and the safety of folic acid., Results: Recent estimates show that in the United States and Canada, the additional intake of about 100 to 150 microg/day of folic acid through food fortification has been effective in reducing the prevalence of NTDs at birth and increasing blood folate concentrations in both countries. Most potential adverse effects associated with folic acid are associated with extra supplement use not mandatory fortification. Fortification of wheat flour has a proven record of prevention in other developed countries. In 2009, 51 countries had regulations written for mandatory wheat flour fortification programs that included folic acid., Conclusions: NTDs remain an important cause of perinatal mortality and infantile paralysis worldwide. Mandatory fortification of flour with folic acid has proved to be one of the most successful public health interventions in reducing the prevalence of NTD-affected pregnancies. Most developing countries have few, if any, common sources of folic acid, unlike many developed countries, which have folic acid available from ready-to-eat cereals and supplements. Expanding the number of developed and developing countries with folic acid flour fortification has tremendous potential to safely eliminate most folic acid-preventable NTDs.

Objectives: Prior to the introduction of mandatory folic acid fortification in September 2009, this study collected baseline data on folate awareness, knowledge of pregnancy-relevant public health messages and consumer behaviours in Western Australia., Methods: One thousand residents aged 18 years or older participated in a cross sectional telephone survey in September 2006. Respondents were recruited randomly from the electronic residential telephone directory., Results: Most respondents reported knowing little or nothing about folate (86%). Women of childbearing age were more likely than other adults to know the association between folate intake and birth defects (82% v 56%) but 41% did not know that folate should be consumed periconceptionally to reduce the risk of spina bifida. Overall, half the respondents did not take supplements and two-thirds did not know if the food products they ate were fortified with folic acid. Associations were detected between knowledge, consumer behaviours and socio-economic indicators such as age, income, highest level of education, area of residence and parental status., Implications: A mix of public health strategies that includes mandatory fortification and the promotion of supplement use should improve the timely and sufficient intake of folate across all socio-economic strata of the Australian population. Strategies that support the introduction of mandatory fortification, such as awareness and education campaigns should be built on a solid understanding of the drivers and barriers to knowledge acquisition and desired consumer behaviours.

Background: Use of periconceptional folic acid supplementation has been promoted in Western Australia since late 1992, and voluntary fortification of some foods with folic acid has been permitted in Australia since 1996. Reduced rates of neural tube defects (NTDs) have been observed since 1995. Aboriginal infants have a higher rate of NTDs, but no fall in rates has been documented. Encephaloceles have not been examined separately., Methods: Data on anencephaly, spina bifida, and encephalocele were obtained from the Western Australian Birth Defects Registry. The prevalence ratio for each type of NTD was calculated, comparing 1993 to 1995 (promotion of supplements, no fortification) and 1996 to 2006 (promotion of supplements and voluntary fortification) with 1980 to 1992 (no promotion or fortification)., Results: From 1996 to 2006, there was a 32% reduction in anencephaly, 23% in spina bifida, and 34% in encephalocele compared with 1980 to 1992. There were no differences seen from 1993 to 1995 compared with 1980 to 1992. For Aboriginal infants, the rates were higher than for non-Aboriginal infants, for each type of NTD. The prevalence ratios, comparing 1996 to 2006 with 1980 to 1995, were 0.70 (CI, 0.61-0.79) for non-Aboriginal infants and 0.90 (CI, 0.61-1.32) for Aboriginal infants., Conclusions: Overall, the rates of encephalocele, anencephaly, and spina bifida have fallen to a similar extent in association with promotion of folic acid supplements and voluntary fortification. No such falls were seen for Aboriginal infants. These data will provide a useful baseline against which to monitor the effects of mandatory fortification on NTDs when it is introduced in Australia in September 2009., ((c) 2009 Wiley-Liss, Inc.)

Background: In response to the proposal that mandatory fortification be introduced in Australia to reduce the incidence of NTDs, the purpose of this study was to establish, for the adult community, baseline data on knowledge, attitudes, and behaviors towards the fortification of foods with folic acid., Methods: A cross-sectional, Computer Assisted Telephone Interviewing survey with respondents recruited randomly from the electronic version of the Western Australian telephone directory was used. One thousand members of the community aged 18 years or older were interviewed for the study., Results: Interviews were conducted in September 2006, with a response rate of 76%. Half the respondents were aware folate is currently added to some breakfast cereals (59%) and some breads (53%), but awareness of other food types that may be voluntarily fortified with folate was much lower. Only 13% of respondents were concerned about folate being added to bread, 10% believed folate should not be added to foods, and 9% said they would avoid foods with added folate. Generally, around half the respondents were uncertain about the benefits of fortifying foods with folate and around a quarter were uncertain about any risks or concerns with this practice., Conclusions: The community appears no more concerned about the fortification of bread with folate than they are about other existing fortification programs in Australia, and appear more likely to support rather than oppose the fortification of foods with folate, particularly if they are informed of the benefits of such a program.

Background: Two crucial issues relative to the benefits and impact of folic acid in the prevention of birth defects are whether supplementation recommendations alone, without fortification, are effective in reducing the population-wide rates of neural tube defects (NTDs), and whether such policies can reduce the occurrence of other birth defects. Using data from 15 registries, we assessed rates and trends of 14 major defects, including NTDs, in areas with official recommendations or fortification to assess the effectiveness of recommendations and fortification on a wide range of major birth defects., Methods: We evaluated surveillance data through 2003 on major birth defects from population-based registries from Europe, North America, and Australia. All included ascertainment of pregnancy terminations (where legal). Trends before and after policies or fortification were assessed via Poisson regression and were compared via rate ratios., Results: Significant changes in trends were seen for NTDs in areas with fortification but not in areas with supplementation recommendations alone. For other major birth defects, there was an overall lack of major trend changes after recommendations or fortification. However, some significant declines were observed for select birth defects in individual areas., Conclusions: Recommendations alone remain an ineffective approach in translating the known protective effect of folic acid in population-wide decline in NTD rates. Fortification appears to be effective in reducing NTDs. The effect on other birth defects remains unclear., ((c) 2006 Wiley-Liss, Inc.)

Objective: To estimate the number of neural tube defects that could be prevented in Australia and New Zealand by increasing levels of folic acid intake., Methods: Available data on prevalence of neural tube defects in Australia and New Zealand, folic acid supplement use and serum folate were used in a published model to estimate the number of neural tube defects that could be prevented in Australia and New Zealand for increments of folic acid intake from 0.1 mg daily to 1 mg daily., Results: An increase of 0.2 mg folic acid per day was estimated to result in the prevention of 49 (95% CI 27-84) neural tube defects per year in Australia and 11 (95% CI 6-18) in New Zealand. A separate estimation for Indigenous Australians found that 0.2 mg of folic acid daily could prevent 7 (95% CI 4-11) neural tube defects in Indigenous infants per year., Conclusions: These data should be useful in considering primary preventive strategies for neural tube defects, including the possible introduction of mandatory fortification of food with folic acid. The estimates are imprecise because of limitations in the data used in the model., Implications: More representative and precise data on neural tube defects, serum folate levels and use of folic acid supplements from all Australian States and New Zealand are needed to refine the output from the model and to provide a baseline assessment of folate status against which to measure the effects of any future interventions to prevent neural tube defects.

Objectives: To investigate whether maternal periconceptional folate intake is associated with a reduction in selected non-neural birth defects in Western Australia (WA)., Methods: Case-control study of folate intake in women whose infants had orofacial clefts (62); congenital heart defects (151); urinary tract defects (117); limb reduction defects (26); or other major birth defects (119); and 578 control women., Results: Neither folic acid supplements nor dietary folate intake in women not using supplements was significantly associated with a reduction in risk in any of the case groups. In contrast to neural tube defects, WA population data for orofacial clefts, heart defects, limb reduction defects and urinary tract defects showed no fall in prevalence since the introduction of folate promotion and voluntary food fortification., Conclusions: This study provides no evidence of folate being an important factor in the prevention of birth defects other than neural tube defects.

Since the publication of randomised trials showing firm evidence of prevention of neural tube defects with periconceptional folic acid, there have been population health promotion programmes to encourage women to take folic acid supplements, and the introduction of voluntary fortification of some foods with folic acid in Australia. In order to evaluate these two strategies, we collected data by self-administered questionnaire from a random sample of recently pregnant women in Western Australia between September 1997 and March 2000. Response to health promotion was measured in three ways: (1) knowledge of the association between periconceptional folate and prevention of spina bifida (the 'correct message'); (2) use of periconceptional vitamin supplements of folic acid daily in the periconceptional period; and (3) daily folate intake from fortified foods in the 6 months before pregnancy. We examined the relationship of maternal demographic and behavioural characteristics with these three measures. Overall, 62.3% of women were aware of the correct message before pregnancy, 28.5% reported taking 200 microg or more of folic acid from supplements daily in the periconceptional period and 56.6% of women obtained 100 microg or more of folic acid from fortified foods. Women who first became aware of the correct message during pregnancy or who were unaware of the correct message before or during pregnancy were more likely than women aware before pregnancy to be younger, having their first pregnancy, be single or in a de facto relationship, have no tertiary education, and be a public patient. Similar associations were seen for women taking either no folic acid or < 200 microg of folic acid in supplements daily in the periconceptional period. There were no significant associations between these demographic variables and amount of folate obtained from fortified foods. Women who were unaware of the correct message and did not take folic acid supplements were more likely to have smoked, not to have engaged in exercise, and not to have planned their pregnancy, whereas there was no association with these behavioural characteristics and intake of folate from fortified foods. These results indicate that health promotion strategies have not reached all segments of the target population equally, but there is no such disparity with folate-fortified foods, and they suggest that mandatory fortification of a staple food is likely to reach all women regardless of demographic and behavioural characteristics, and hence provide improved opportunity for prevention of neural tube defects in Australia.

Background: Since the publication of randomized controlled trials demonstrating the prevention of neural tube defects (NTDs) with periconceptional folate, several Australian states have promoted an increase in periconceptional use of folic acid supplements. Since 1996, voluntary fortification of food with folate has been allowed in Australia and New Zealand for the purpose of preventing NTDs., Methods: For this report, we synthesized published and unpublished data on folic acid supplement use, voluntary fortification, and trends in NTDs., Results: There has been an increase in the proportion of women (up to 30-40%) taking periconceptional folic acid supplements in Australia, and many foods (mainly breakfast cereals) are fortified. Supplement use is strongly correlated with educational and socioeconomic status; consumption of voluntarily fortified foods is not. There has been a fall in NTDs of about 30% in the non-Aboriginal population, but no change has been seen in the Aboriginal population., Conclusions: These data support mandatory fortification of food as a more equitable approach to achieving sufficient folate intake in the periconceptional period for all women in Australia and New Zealand to prevent the majority of NTDs in their offspring. In May 2004, based on these and other considerations, the Australia and New Zealand Food Regulation Ministerial Council agreed that mandatory fortification of food with folate should be considered as a priority.

Objectives: We conducted a case-control study to investigate the effectiveness of efforts to increase folate intake in Western Australia (WA) for the prevention of neural tube defects (NTD)., Methods: Case (36) and control (578) mothers completed questionnaires, from which their intake of folate from supplements and food (including fortified foods) was estimated., Results: Almost one-third of women took folic acid supplements periconceptionally. Supplement use was associated with a non-significant 4% reduction in risk. For women not taking supplements, dietary sources of folate were protective, and most women obtained at least some folate from fortified food., Conclusions: For the two-thirds of WA women not taking supplements, fortified food is an important source of folate for the prevention of NTD., Implications: Greater promotion of foods currently allowed to be fortified with folate, or mandatory fortification, is needed to maximise prevention of NTD in Australia.

Firm evidence from randomized, controlled trials that maternal periconceptional folic acid reduced the risk of neural-tube defects was published in the early 1990s. Despite promotion of periconceptional folic acid supplement use, no more than 50% of women take them and so mandatory fortification of a staple food has been considered by many countries as an important adjunct to any public-health approach for the prevention of neural-tube defects. Even 15 years after the confirming evidence, some countries have yet to commit to mandatory fortification and, in those that have, there is limited and poorly coordinated monitoring and evaluation of its effectiveness and safety. [ABSTRACT FROM AUTHOR]

The objectives of this study were: to inform health professionals and women of childbearing age about the prevention of neural tube defects by folate; to recommend that all women of childbearing age increase their intake of folate; and to evaluate the effectiveness of the strategies used to achieve these aims. The study took place in Western Australia. The Folate and Neural Tube Defects Prevention Project is a health promotion project using written material, presentations and unpaid media. Surveys were carried out of general practitioners, child health nurses and women of childbearing age before the project began and 12 months later. The main outcome measures were: knowledge of folate and prevention of neural tube defects and exposure to and effectiveness of promotional material. Knowledge of folate and the prevention of neural tube defects increased amongst general practitioners and child health nurses, and most displayed the promotional material and made changes in their practice to promote an increased folate intake for women planning a pregnancy. In women of childbearing age, the knowledge of folate, of spina bifida, and of the association between the two, increased over the study period. Women who had seen the promotional pamphlet were over seven times more likely to know that increased folate helps prevent spina bifida. The Project has been effective in raising awareness amongst health professionals and women of the prevention of neural tube defects by folate. Further evaluation is needed to determine the extent to which folate intake has increased, and its effectiveness in reducing the birth prevalence of neutral tube defects. [ABSTRACT FROM PUBLISHER]

Historically, neural tube defects (NTD) in Australia affected around 1 in every 1000 births; 42% higher for Aboriginal births. Following firm evidence of the protective effect of periconceptional folate, health promotion activities encouraged increased folate intake through diet and supplements and limited voluntary food fortification. A 30% reduction in NTD was observed in non-Aboriginal but not Aboriginal infants, widening the disparity between Aboriginal and non-Aboriginal rates. Mandatory flour fortification with folic acid in 2009, led to further reductions in overall NTD, and greater reduction among Aboriginal infants, such that rates in Aboriginal and non-Aboriginal infants were similar by 2010–2014. Elimination of this disparity will make a small but important contribution to the Australian government's Closing the Gap initiative to reduce disadvantage among Aboriginal people. Long-term, complete, high-quality surveillance data on NTD have been of great value in monitoring trends in and evaluation of public health interventions for NTD in Australia. [ABSTRACT FROM AUTHOR]