The Healthy Ireland Framework has brought a new focus on the importance of health promotion and the need for cross-Government and cross-sectoral co-operation to prevent ill-health. The Healthy Ireland Framework has enshrined the principles of prevention and early intervention within all policies, with a particular emphasis on the early years.
Following the publication of healthy eating guidelines for the general population in 2016, it was recognised that dietary intake of folate remains sub optimal In Ireland. A multidisciplinary Committee was established by the Department of Health to review the evidence in support of folic acid supplementation to prevent neural tube defects (NTD). Recommendations published in the 2019 report “Folic Acid Supplementation” by the Department of Health, outline several mechanisms to improve folic acid intake for women of child-bearing age and thereby reduce the risk of neural tube defects.
One key recommendation given at the time was to consider the requirements for food fortification with folate. The Committee recognised that this option is dependent on a range of issues including food consumption patterns and preferences, supply chain issues, implications of Brexit, as well as the significant undertaking in terms of resources and timing involved. These issues would need to be worked through before any further consideration could be given to mandatory food fortification.
Ireland does not have any national mills and relies on the UK for up to eighty per cent of its flour supply. After undertaking a public consultation on the proposal to introduce mandatory fortification of UK flour with folic acid, the UK Government and devolved administrations decided to proceed with the mandatory fortification of non-wholemeal wheat flour and legislate on this basis in 2021.
Up to this point fortification of flour was conducted on a voluntary basis. The voluntary addition of vitamins and minerals to foods is regulated by means of Regulation (EC) No 1925/2006, which aims to ensure that fortified foods are safe, and to allow for the proper functioning of the internal market. This regulation permits the addition of folic acid to foods in compliance with its rules.
The ‘mandatory addition’ of vitamins and minerals for public health reasons, such as the fortification of staple foods with folic acid, is not covered by this regulation. The European Commission does not envisage the harmonisation of the mandatory addition of nutrients, such as folic acid, across the EU. It is up to Member States to decide if they wish to introduce alternative measures such as mandatory food fortification with folic acid.
In addition, the labelling of a compound food containing a fortified ingredient must comply with the provisions of Regulation (EU) No 1169/2011, to ensure that it shall not be misleading for the consumer.
In the event of any proposal to revise existing legislation a regulatory impact analysis would need to be conducted. Before any policy position is finalised on folic acid fortification, stakeholder consultation would need to be carried out on a national basis. Once a policy position has been formed, the Department would need to notify the Commission via the Technical Regulation Information System (TRIS) system of Ireland’s intention to introduce fortification of flour with folic acid. Ireland would be required to demonstrate that evidence-based analysis, public stakeholder consultation and cross Government collaboration had taken place to justify why Ireland is considering mandatory fortification. To give an estimation of predicted timelines, the consultation process is still ongoing in the UK, two years post announcement of mandatory fortification.
With this in mind, other actions are needed to optimise both Folic Acid supplement use and dietary folate in the short-term. It is recommended that all women considering pregnancy take a 400-microgram (mcg) supplement of folic acid per day when planning a pregnancy and for the first 12 weeks of pregnancy and this is described in The Nutrition in Pregnancy, national clinical guideline that was developed in 2019 to promote the link between good nutrition during pregnancy and a favourable pregnancy outcome.
Under the phase 2 of the First 5 strategy implementation plan, it has been identified that parents, families and communities will be supported to engage in and promote positive health behaviours among babies and young children, starting from the pre-conception period. Enhanced integration and communication of Folic Acid supplement advice will continue under several relevant programmes being operated by the Health and Wellbeing Division, Primary Care, Obstetrics and Gynaecology and Sexual Health services.
