Folate and Folic Acid Requirements During Pregnancy

Folic acid, also known as folate or Vitamin B9 is a group of B Vitamins that is crucial during pregnancy. The need for folic acid is not only important during pregnancy but should also be taken in the months leading up to conception if you are actively trying to conceive.

• It helps prevent neural tube defects in the baby.
• It prevents serious brain abnormalities in the baby
• It prevents spinal cord abnormalities in the baby
• It decreases the risk of premature birth During Pregnancy,

It is recommended that women consume anywhere between 400 – 800mcg a day of folate or folic acid.  This can be done through diet, supplementation, and a combination of both. Foods such as spinach and wheatgerm are particularly high in folate.  When you see the term ‘folic acid’ what you are seeing is the synthetic version of folate.  It is a man-made substance and sold in supplement form or added to fortified foods such as breads and cereals. Both have the same effect.

Supplementing with Folic Acid

Many women will already be taking folic acid supplements and all prenatal vitamins will include the standard requirements as recommended above. In conjunction with ensuring you take your prenatal vitamins, its important to focus on the folate rich foods as well to ensure a healthy pregnancy. Folate is especially important in aiding rapid cell division and growth, particularly during pregnancy and during early childhood. Children and adults require folate to produce healthy red blood cells and to prevent anaemia. Humans cannot synthesise folates within their body.  Therefore, folates are essential nutrients that must be supplied through the diet on a regular basis to meet the body’s requirements. Folic acid is the synthetic form of folate and it is found in supplements and in fortified foods.

Natural folate is rather unstable and quite a bit of contents in food are lost during cooking and food preparation. Also, natural folates have a low bio-availability meaning that only about 50%, or half of the natural folates consumed from foods are absorbed and taken up into the body.

In contrast, the synthetic form, folic acid is rather stable and almost the entire intake is absorbed into the body.

To account for these differences in stability and bio-availability, dietary intake of folate is described using a dietary folate equivalent or DFE. One microgram of DFE is equal to one microgram of food folate or half a microgram of folic acid, if taken on an empty stomach or 0.6 microgram of folic acid if supplied with meals. 

In 2015, the World Health Organisation established population specific cut-off values for red blood cell folate concentration to determine adequate folate status in women of reproductive age. The aim was to effectively prevent the occurrence of neural tube defects in population. On a population level, red blood cell folate levels in women of reproductive age should be above 906 nanomole per litre, to achieve an optimal reduction in neural tube defects or NTDs.

Folate for cell division

There is no established serum folate threshold for pregnant women. And the red blood cell threshold only applies to determine population folate status, but not the individual risk.

The amount of folate-rich food required per day to meet the requirements is so great, that where possible, the WHO as well as many international recommendations stipulate folic acid supplementation in addition to a folate-rich diet. Folate and folic acid derive their names from the Latin word, folium, which means leaf. 

Folates occur naturally in many foods and are especially plentiful in dark green leafy vegetables, in legumes, citrus foods and juices. Folates are also common in breads and cereals that contain flour enriched with folic acid. 

Folate is required for cell division and it plays a major role in the prevention of Neural Tube Defects. NTD are serious congenital malformations that results from failure of a neural tube to close during the early embryogenesis, between 18 and 26 days after conception. It is therefore paramount that an adequate amount of folic acid is already consumed prior to conception to achieve adequate tissue concentrations at the very beginning of pregnancy.

The timely intake of folic acid supplementation before conception

Is emphasised by the number of unplanned pregnancies. Folic acid supplementation after the diagnosis of pregnancy is far less effective and usually too late to really effectively reduce the risk of NTDs because the closure of the neural tube is completed usually by the time a woman starts to know that she’s expecting a child. 

The protective effects of folic acid in the prevention of neural tube defects is well proven and has been established by several randomised controlled trials. In 2010 a Cochrane review of folic acid in the pre-conception and early pregnancy period, looking into the prevention of neural tube defects, and other defects such as cleft palate concluded that the folic acid was beneficial without any evidence of harm for the mother and baby. It’s thought that around 72% of neural tube defects could be prevented by folic acid during this period either alone, or in combination with other vitamins and minerals. 

An excellent example of the benefits of folic acid fortification of flour comes from the United States. And here, folic acid fortification was first introduced in 1996 followed by mandatory fortification from 1998, with 140 micrograms of folic acid, per 100 grams of flour.

Following the introduction of this, the prevalence of neural tube defect births began to decline.  It is thought that folic acid fortification of flour is now estimated to prevent around 1,000 affected neural tube defect births annually.

International regulations in place

This success has led to other countries globally introducing mandatory folic acid fortification, and 86 countries worldwide now have such legislation in place.  Because the increased needs in early pregnancy are exceedingly difficult to meet with dietary intake alone the most widespread strategy used is a supplement of multivitamin preparation containing 400 to 800 micrograms of folic acid, even in the case of fortified foods.

Many national and international nutrient requirement setting bodies recommend the intake of 600 microgram per day of dietary folate, during pregnancy. However, for the purpose of reducing the risk of NTDs, it is recommended that women in addition to the dietary folate intake, also consume at least 400 microgram per day of folic acid in the form of a supplement or with fortified foods. 

Start taking at least a month prior to conception

This should be started at least one month prior to conception. and continued until at least 12 weeks of pregnancy. After the twelfth week of pregnancy, women should increase their folic acid supplement dosage to about 800 microgram per day. Globally, more and more guidelines are suggesting that not only pregnant women, but all women of reproductive age should take a daily folic acid supplement. 

This is an attempt to reduce the risk of neural tube defects in unplanned pregnancies as well as in planned pregnancies. For women with a history of children with neural tube defects, for women with diabetes, or for women who receive anti-convulsant treatment as well as for obese women, the recommended dose is four to five milligram of folic acid per day. High risk women should consult their doctor to ensure the correct guidelines for folic acid supplementation are followed. Folic acid supplementation in the pre-conception period effectively reduces the risk of recurrent NTDs by about 70%. 

Therefore, its inclusion in pre-conception preparation as well as for all women of childbearing age should be considered an essential part of pre-natal counselling.

Dietary sources of Folate include the following