Folic acid both before and during early pregnancy is extremely important. This feature explains why.
What Is Folic Acid?
Folic acid, also known as folate, is a B vitamin. Folic acid is significant to the production of red blood cells and the development of a baby’s neural tube into the spinal cord and brain. (1) Folic acid is necessary for producing and repairing DNA. This is the body’s genetic map and the basic method of building cells. For that reason, folic acid is essential for the rapid cell growth of the placenta and the development of the baby. (7)
The body requires folic acid to prevent a certain kind of anemia and some research believes that taking folic acid daily can reduce the risk of developing pre-eclampsia. This is a multifaceted disorder that can affect the mother’s health as well as the baby’s health. (4) The CDC (Centres for Disease Control USA) suggests taking folic acid daily when pregnant and a month prior to becoming pregnant.
The CDC also recommends that any women of a childbearing age begin taking folic acid daily whether planning pregnancy or not. (10) This is due to the fact, that more than half of the pregnancies in the United States are unplanned. Taking this vitamin can help prevent birth defects that typically occur during the first 3-4 weeks of pregnancy. Having folic acid in the system during the early stages of development, when the baby’s brain and spinal cord are developing, is essential. One study proved that women who took folic acid for a year prior to getting pregnant decreased the chance of early delivery by 50% or more. (3) The neural tube begins forming around three weeks after conception; this is why it is important to receive a daily dose of folic acid prior to conception and during the first trimester. (4) In most cases, women that consult with a doctor when trying to conceive are told to begin taking folic acid with prenatal vitamins.
It is important to remember that when personally selecting prenatal vitamins, women should consult with their medical team. This ensures the vitamins have the recommended amount of everything needed during pregnancy, including folic acid. Prenatal vitamins can vary significantly and some may not have the proper amount of folic acid needed during pregnancy. (4)
How Much Folic Acid Is Needed?
The recommended dose for a woman planning a pregnancy is 400 mcg daily. Those who take multivitamins daily should confirm that the recommended dosage of folic acid is included. For anyone that does not want to take multivitamins, folic acid is also available as a supplement. However, the supplement and the multivitamins should never be combined. (3) The March of Dimes, The U.S. Public Health Service, and the American College of Obstetricians and Gynecologists (ACOG) strongly suggest that any woman of childbearing age, whether pregnant or not, take at least 400 mcg of folic acid daily. (4)
Below is the daily recommended amount of folic acid (in terms of pregnancy): (3) When attempting to conceive: 400 mcg When Breastfeeding: 500 mcg (12) During the first three months of pregnancy: 400 mcg During months four through nine of pregnancy: 600 mcg It is important to note that taking more than 1,000 mcg per day of folic acid can be dangerous, unless prescribed by a healthcare professional. However, this mainly applies to vegans. Vegans are at a higher risk of being deficient in vitamin B12, as a result of the lack of meat and dairy in their diets. Taking an excess of folic acid can make a diagnosis of deficiency difficult for healthcare professionals. (4)
What Are The Benefits Of Taking Folic Acid?
It is suggested that folic acid can protect a baby from neural tube defects by at least 50%. (1)(2) The Centres for Disease Control and Prevention (CDC) states that women who take the suggested dose of folic acid daily, beginning one month prior to conception and during the first trimester, help reduce the baby’s chance of neural tube defects by 50 to 70 percent. (5)
Mothers who have given birth to a baby with a neural tube defect can reduce the risk of having another child with a neural tube defect by as much as 70% by taking folic acid. (2) (8) When taken before and during pregnancy, folic acid can protect a baby against: (7)(10)
- Low birth weight
- Cleft lip and palate
- Premature birth
Folic acid is also recommended to reduce the risk of other pregnancy complications that include:
- Several types of cancers
- Heart disease
- Alzheimer’s disease
What Can Happen When There Is Insufficient Folic Acid?
An insufficient amount of folic acid in the body may cause the baby’s neural tube to close incorrectly and this could develop health issues known as neural tube defects or NTDs. These defects include: (11)( 12) Spina bifida: occurs when the spinal cord or the vertebrae do not develop correctly Anencephaly: occurs when major parts of the brain do not develop correctly.
Babies with anencephaly generally do not live long; while babies with spina bifida are permanently disabled. These serious health issues may be preventable with the use of folic acid (12). Neural tube defects, or NTDs, can begin at an early stage in development. In some cases, this is before the woman realises she may be pregnant. This affects more than 3,000 pregnancies per year in the United States. (4)
Folic Acid & Neural Tube Defects – The Irish Context
folic acid IrelandThe Report of the National Committee on Folic Acid Food Fortification which was published by the Food Safety Authority of Ireland showed that: (13) Ireland has one of the highest incidences of NTD’s in Europe. Every year between 49 and 93 Irish babies are affected each year, most commonly with spina bifida. Between 70%* of NTDs can be prevented by taking the recommended amount of folic acid – we have known this since 1991. *Other studies refer to 50% or between 50% and 70% Some of the more recent Irish studies show the following (14): McGuire et al, 2010 85% took FA at some point during the peri-conceptional period but only 28% took folic acid (FA) – antenatal and delivery records in the Coombe Women and Infants University Hospital between 1 January 2000 and 31 December 2007 Tarrant et al, 2011 88% of women took FA during pregnancy and 44% of them took a supplement before conception/during the 1st month of pregnancy (n=450). McNulty et al, 2011 84% took FA during pregnancy, but only 19% before pregnancy (n=296); ‘Red cell folate concentrations in women not complying with recommendations were suboptimal in relation to NTD risk’
Why Some Irish Women Don’t Take The Recommended Intake of Folic Acid?
Although the scientific evidence that folic acid can play a part in preventing NTDs came to light in the early 1990s, today there are still lots of Irish women of childbearing age who don’t take folic acid as recommended. One big issue as pointed out in the The Report of the National Committee on Folic Acid Food Fortification (13) is that 50% of pregnancies are not planned – therefore unless women of childbearing age appreciate that without taking supplements they are unlikely to consumed the recommended amount, this leaves a large group of women at risk, straight away.
In fact this study also found that more than one third of Irish women of childbearing age consumed no folic acid at all (35%). Although some foods in Ireland are fortified with folic acid, not everyone eats these foods. There has been an ongoing debate about fortifying flour, and therefore bread, however at the time of writing this still hasn’t been implemented. Additionally it is not possible to add the full recommended amount to bread as this would result in excesses for other members of the population.
The most important reasons why some Irish women don’t take folic acid are:
- 50% of pregnancies are unplanned
- Lack of education regarding the importance of taking folic acid before conceiving and during the first trimester
- Financial barriers to buying supplements
Who May Be At Higher Risk?
- Women with certain genotypes that are associated with a higher risk of NTDs
- Women with prior pregnancies resulting in NTDs or a family history of NTDs
- Women with certain malabsorption disorders (such as inflammatory bowel disease)
- Women suffering from obesity with a Body Mass Index > 35 kg/m2
- Women diagnosed with diabetes
- Women diagnosed with liver disease
- Women diagnosed with sickle cell disease (12)
- Women dealing with lifestyle and compliance issues – these women are also at an increased risk of developing NTDs and may benefit from receiving higher dosages of folic acid: (2)
- Women who use anti epileptic drugs
- Women who take folate antagonists (such sulfonamides, asmethotrexate)
- Women who consume more than one alcoholic drink per day (12)
- Women who smoke regularly
In most cases, women suffering from obesity are more likely to have a baby with a neural tube defect. Although the reason remains vague; some studies suggest that women with a higher Body Mass Index (BMI) usually have lower levels of folate in their blood. Significantly overweight women should consult with a healthcare professional prior to conceiving. This is primarily because the healthcare professional may prescribe more than 400 mcg of folic acid daily. (2)(4) If the mother has had a previous baby with a neural tube defect, it is important to alert the healthcare professional before attempting conception.
Without the assistance of a professional, women in this particular situation are at a higher risk of experiencing another pregnancy complicated by an NTD. However, the risk can be reduced significantly by taking a larger dose of folic acid. (1) Women that have been diagnosed with diabetes or women taking anti-seizure medications for epilepsy are at a higher risk of having a baby with an NTD. Seeking the help of a healthcare professional at least a month prior to conception can help reduce the risk of having a baby with NTD.
The professional can recommend the proper amount of folic acid and safely monitor the condition. (2) Research has shown that the body absorbs the synthetic form of folic acid easier than the form that is available naturally in foods. (12) Generally, grain products and enriched cereals are fortified with the synthetic form.
However, the majority of women don’t eat these types of foods enough to depend on them as the main source of folic acid.
Foods that are rich in folate include: (12)
- Citrus fruits and Juice
- Dried beans
- Enriched white rice
- Dark green vegetables such as asparagus, spinach, collard or turnip greens, broccoli, and okra
- Enriched flour and pastas
- Baked potatoes
- Yeast extract
However, these foods are not a permanent solution for the daily doses of folic acid. These foods are considered a partner to the supplement. This is mainly because the body absorbs all of the folic acid in the supplement, but only absorbs some of the folate in the enriched foods. More importantly, folate can be destroyed when cooking it. Most folates dissolve easily in water. This is why steaming or microwaving vegetables works better than boiling them. Overcooking these type of foods can destroy the folates that are contained inside. (4)(12)
(1) Folic Acid for the Prevention of Neural Tube Defects http://pediatrics.aappublications.org/content/104/2/325.full
(2) Identifying women who might benefit from higher doses of folic acid in pregnancy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325450/
(3) Folic acid supplementation before and during pregnancy in the Newborn Epigenetics Study (NEST)http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038155/
(4) Folic acid: Why you need it before and during pregnancy http://www.babycenter.com/0_folic-acid-why-you-need-it-before-and-during-pregnancy_476.bc?page=1
(5) Folic acid: influence on the outcome of pregnancy http://ajcn.nutrition.org/content/71/5/1295s.full
(6) Folic acid supplementation, dietary folate intake during pregnancy and risk for spontaneous preterm delivery: a prospective observational cohort study http://www.biomedcentral.com/1471-2393/13/160
(7) Effect of folate intake on health outcomes in pregnancy: a systematic review and meta-analysis on birth weight, placental weight and length of gestation http://www.nutritionj.com/content/11/1/75
(8) Folic acid use in pregnant Women presenting to the emergency department http://www.intjem.com/content/4/1/38 (9) Patterns and predictors of folic acid supplement use among pregnant women: the Norwegian Mother and Child Cohort Study http://ajcn.nutrition.org/content/84/5/1134.full
(10) Pregnancy Qs & As https://www.cdc.gov/ncbddd/folicacid/index.html
(11) The Importance of Folic Acid: Anifa’s Story http://www.cdc.gov/features/folicacidstory/index.html
(12) Folic Acid Fact Sheet https://www.womenshealth.gov/files/documents/folic-acid-factsheet.pdf
(13) Report of the National Committee on Folic Acid Food Fortification http://www.fsai.ie/uploadedfiles/folic_acid.pdf
(14) Growing Up in Ireland – Peri-conceptual Folic Acid Use In Ireland http://www.growingup.ie/fileadmin/user_upload/documents/Conference/2011/Session_F_Paper_2_McNally__Bourke__McCrory.pdf
All articles on the blog and website are intended as information only. Please do not consider any of the information provided here as a substitute for medical advice. At all times seek medical advice directly with your own doctor and medical team.