Risk–benefit assessment of different scenarios of bread fortification and supplementation with folic acid in Portugal

The Portuguese population exhibits inadequate levels of folate intake. This study aimed to assess the impact of scenarios of fortification of bread with folic acid and supplementation on the health of the Portuguese population. We applied a risk–benefit approach to assess the potential risks associated with increased exposure to folate/folic acid and the potential benefits associated with a reduction in the incidence of neural tube defects in newborns and in the likelihood of developing megaloblastic anaemia. Based on intake data from the National Food and Physical Activity Survey (2015–2016), we created scenarios with different levels of fortification and use of dietary supplements. We applied a probabilistic stochastic model to calculate the incidence of each health effect, using Monte Carlo simulations to quantify uncertainties. The overall health impact of each scenario was quantified in disability-adjusted life years (DALYs) and compared with the reference scenario. The results showed that the most beneficial scenario entailed the supplementation of 400 μg/day to women of childbearing age, without fortification, which resulted in a reduction of 1,285 DALYs compared to the reference scenario. We concluded that supplementation aimed at women of childbearing age should be favoured over mandatory fortification of bread with folic acid.