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Application A588 – Voluntary addition of fluoride to packaged waters – Initial Assessment Report

30 April 2008

Dear Sir/Madam

Thank you for the opportunity to comment on this application. The comments contained in this submission are intended to represent the views of NZFSA and/or the Ministry of Health either singly or combined (‘we’) where appropriate.

The Ministry of Health recommends tap water for drinking wherever safe supplies are available. However, as the Application acknowledges, the fluoridation of drinking water in New Zealand varies by region with approximately one half of the population not having access to a fluoridated community water supply. As such, we see obvious merit in adding fluoride to bottled water. This can give consumers access to fluoridated water in regions that are currently not on a fluoridated community water supply (Whangarei, Tauranaga, Wanganui, Napier, Nelson, Blenheim, Christchurch, Timaru and Oamaru) and further access to fluoridated water among consumers in regions that currently fluoridate their community water supply. Along with brushing twice a day, eating healthy foods and timely check-ups with a dental provider, water fluoridation can decrease an individual’s risk of dental caries. Therefore, we believe the Application for consent to add fluoride to packaged water can be supported if the following points are addressed in response to the Application:

We agree with FSANZ that under policy guidance on the addition of vitamins and minerals to food that “nutritional equivalence” is used as basis for assessment of this Application.

We believe that the limit for the addition of fluoride should be equivalent to, and no greater than, the optimal level in fluoridated tap water (0.7 – 1.0 mg/l). This is because this water will be available across all areas and the fluoride levels should be equivalent to what can be obtained by using fluoridated tap water. This concentration would also be consistent with FSANZ’s approach to be considering this Application on the basis of nutritional equivalence.

We also recommend the Application is limited to still, plain, unadulterated mineral or spring water (as defined in Standard 2.6.2), which can have added fluoride and that the flavoured waters with added sugars are not permitted to add fluoride and make nutrient/health claims. This is important because carbonated beverages with or without sugar may cause significant dental erosion because of the acidity and it is important that consumers are not confused thinking that they are equivalent to still water (1).

While there is no doubt that fluoride protects against dental caries, the World Health Organisation reports ‘convincing’ evidence that excess fluoride is associated with enamel developmental defects (2). The maximum claimable amount that the Applicant has applied for is consistent with maximum acceptable value for fluoride in ‘The Drinking-water Standards for New Zealand 2005’ (1.5mg/l) however we believe that consumers purchasing packaged drinking water with added fluoride should have access to water at the optimal level for the health benefit of reducing dental decay and minimising the potential for enamel developmental defects e.g. fluorosis (white flecking of the tooth enamel) (3). This level is established in New Zealand as between 0.7 and 1.0 mg/l. This optimal level of 1.0 mg/l also addresses the use of this water for young children so that there is no potential to increase their intake beyond what is occurring at present. Recent New Zealand evidence affirms that enamel fluorosis is acceptably controlled at current levels of water fluoridation (4).

Regarding consumption and substitution, it is unclear to us whether individuals will substitute unfluoridated water for fluoridated water or further whether individuals will substitute fluoridated community water with packaged fluoridated water in the future. This is clearly an important distinction when modeling exposure to dietary fluoride and considering public health and safety.

If consumers are to be provided with adequate information to enable informed choice regarding fluoridated packaged water, all packaged water should be clearly labelled as to the level of fluoride in the water whether it is added intentionally or naturally present. Common public perception is that packaged water does not contain fluoride despite the fact that it is naturally occurring in some water sources or that some bottled water is sourced from fluoridated reticulated water supplies. Any labelling should not infer that bottled water containing fluoride is superior or has any additional benefits to fluoridated tap water.

Given both of the compounds proposed to be used to add the fluoride to the water are sodium based compounds, we are interested in the effect this may have on the sodium content of the water and whether any significant difference to the concentration of sodium would occur as a result of this Application.

Yours sincerely

References

(1) Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutr. 2004 Feb;7(1A):201-226.

(2) World Health Organisation. Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation. 2003;916.

(3) Ministry of Health. Drinking-water Standards for New Zealand 2005. 2005;HP 4124.

(4) Mackay TD, Thomson WM. Enamel defects and dental caries among Southland children. N.Z.Dent.J. 2005 Jun;101(2):35-43.