Folic Acid (Folate) Supplementation
Written By:
Dr. Maria Dolores Mercado, OB-GYNE
One of the advances that changed the understanding of vitamins was the discovery that folic acid deficiency is linked to birth defects specifically neural tube defects like spina bifida and anencephaly. Evidence suggests that folic acid insufficiency has a global effect on brain development (Ars, 2016). Fifty years ago, the cause of these birth defects are unknown. More than 30 years ago, British researchers found that mothers of children with spina bifida had low vitamin levels.[1] Eventually, two large, randomized trials about folic acid supplementation vs placebo showed that folic acid deficiency increased a woman’s chances of having a baby with spina bifida or anencephaly compared to women who get enough folic acid greatly reduces the incidence of these birth defects. [2,3]
Aside from neural tube defects, a deficiency of this vitamin leads to megaloblastic anemia during pregnancy. In developed countries, megaloblastic anemia is relatively unusual. A report by Marzan states that 15-20 percent of Filipinos have a folic acid deficiency. According to him, this deficiency is not usually of such degree as to bring about megaloblastosis. The lowering of folic acid stores is attributed to folic acid high requirements during pregnancy.[4]
The terms “ folic acid” or “folate” are often used interchangeably, even though they are different. Folate is a general term to describe a different natural form of vitamin B9, which are water-soluble and naturally found in many foods. Lontok, et al, analyzed the folate content of some Philippine foods and found that deep green colored leafy vegetables, such as mustard and Philippine spinach, as well as animal liver contain very high amounts (100ug/100 grams and above) of the vitamins. [5] Folic acid is a specific type of folate that does not generally occur naturally. It is sold as a supplement in the form of folic acid. This oral form, actually, has a better absorption of 85% compared to food sources of 5%, respectively.[6] Folic acid is also the ideal form of folate to use for food fortification. The overall benefits of fortifying basic foods such grains with added folic acihaveas been associated wi an increase in supplementation of 140-200mcg/day and a 20-50% decrease incidence of NTDs.[7] Folate helps to form DNA and RNA and is involved in protein metabolism. It plays a key role in breaking done homocysteine, an amino acid that can exert harmful effects in the bo if it is present in high amounts. Folate is also needed to produce healthy red blood cells and is critical during periods of rapid growth, such as during pregnan and fetal development.[8]
The timing of folic acid supplementation is critical. Given that 50% of pregnancies are unplanned and conception tends to be unpredictable, it is recommended that all reproductive-age women should be on folic acid supplementation from menarche to menopause. The preconception intervention with folic acid supplementation has the most evidence-based data to support its efficacy. Supplementation should start at least 1 month before conception and continue until at least 28 days after conception. This is the time of neural tube closure.[9]
Folic acid supplementation can be started at a minimum of 400ug/day for all patients with 93% decrease in neural tube defects(NTD), and 4 mg/day for patients with prior children with NTDs or those on epileptic medications with a 69% decrease in recurrent NTDs.[10] Patients with homozygous methylenehydrofolate reductase(MTHFR) enzyme mutations or those who are obese may also need higher doses of folic acid supplementation. Folic acid supplementation has also been associated with a decrease in the risk of congenital anomalies other than NTD like cardiac and facial clefts.[11-12]
The recommended options for folic acid supplementation in pregnancy are as follows:
Options | Population | Folic acid dose | Duration of supplementation |
|---|---|---|---|
A. | High Risk Population | 1. Folate-rich foods, with supplementation with 4 mg per day of folic acid | 1. Begin at least 30 days before conception and continue throughout first trimester pregnancy |
2. Daily supplementation with 0.4-1 mg folic acid | 2. From 12 weeks preconception throughout pregnancy and the postpartum(4-6 weeks or as long as breastfeeding continues) | ||
B. | Low Risk Population | Good diet of | At least 30 days before pregnancy and to continue daily throughout the first trimester |
C. | All other | Folate rich foods with daily supplementation with 0.4-0.8 mg folic acid | Counsel about folic acid supplementation to prevent birth defects Advise during wellness visits especially if without consistent birth control |
⏤ FIGO Working Group on Best Practice in Maternal Fetal Medicine, 2015
Some experts have advocated 5 mg of folic acid per day as optimal universal supplementation because the increase in the serum baseline folic acid levels is directly proportional to a decreased incidence of NTD.[13] One RCT study showed that folic acid supplementation has been associated with a decrease in severe language delay at 3 years of age.[14]
Education, counseling and learner-centered nutrition education all increase the awareness of the folate/NTDs association and the use of folic acid supplements. These interventions may be effective in increasing prophylactic use of additional preconception care activities as well as prenatal care.[10,15,16]. Proper supplementation of women will help improve the first 1,000 days of a child’s life.
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