Editor—The European governments were criticised by Oakley for failing to mandate the universal fortification of flour with folic acid, a public health action that can prevent neural tube defects and other congenital abnormalities in fetuses, as well as cardiovascular disorders in adults, including elderly people.1,2 However, we would like to remind Oakley and the readers of the BMJ that a bread fortification programme was launched in Hungary in August 1998.3 This public health project had three differences from the flour fortification initiative in the United States.
Firstly, bread was fortified because it is the national basic food, average daily intake being 200 g. The consumption of bread can generally be measured or estimated much more easily than that of flour, and our pilot study showed that quality control in Hungarian mills could not be guaranteed. Fortified bread could be produced by adding yeast fortified with vitamins to bread dough. Flour is 75% of Hungarian bread and 20% of vitamins are lost during production.
Secondly, we fortified bread with three B vitamins. Fortification with 330 μg folic acid would mean that 1-2% of the Hungarian population would exceed the tolerable upper intake of folic acid for healthy people (1000 μg).4 Vitamin B12 is an independent risk factor for neural tube defects and may be useful in neutralising the possible adverse effect of high doses of folic acid in patients with pernicious anaemia. However, only 1-3% of oral vitamin B12 can be absorbed via non-physiological mass action, thus it is necessary to use a high dose (25 μg) of vitamin B12. Vitamin B12 has no toxic effect under 1000 μg. Vitamin B6 is also important in preventing homocysteine related vascular diseases.
Thirdly, the Hungarian bread fortification programme was not compulsory because consumers should be able to decide whether they want to buy fortified bread.
The Hungarian project had a good start, but there was no official support. With the election of a new government this year, bread fortification has become among the highest priorities of the public health programme. This commitment is exemplified by the fact that one of us (MK) is state secretary in the government.
References
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