*Updated 10/2022
The rise of the "designer prenatal vitamin"...
Extra folate is required for pregnancy. The best way to get folate is through your diet with foods like vegetables (especially dark green leafy vegetables), fruits and fruit juices, nuts, beans, peas, seafood, eggs, dairy products, meat, poultry, grains, liver, asparagus, and brussel sprouts. Although it is important to eat a balanced diet rich in natural food folate to get the required amounts necessary for pregnancy, it is very difficult to get the recommended amount of folate from food alone. In fact, studies have shown that most reproductive aged persons do not consume enough dietary folate, which is why folate supplementation is recommended.
Over the past few years as expensive designer prenatal vitamins have popped onto the market, a public health problem has been growing. While these prenatal vitamins might provide good supplementation for some essential vitamins and minerals for those TTC and who are pregnant, they are leaving out a critical component- folic acid (FA)! Folic acid is the only form of folate proven to help prevent neural tube defects (NTDs) in the fetus. This leaves those who are TTC or pregnant at risk for having babies with neural tube defects (NTDs), including spina bifida and anencephaly.
As the CDC says in its ‘Facts About Neural Tube Defects’ information page, “Neural tube defects are severe birth defects of the brain and spine… NTDs occur when the neural tube does not close properly. The neural tube forms the early brain and spine. These types of birth defects develop very early during pregnancy, often before a woman knows she is pregnant.” Because the neural tube of the fetus closes at approximately 6 weeks of gestation, taking FA before even becoming pregnant is ideal. As a result, numerous major national medical organizations and public health authorities recommend that all persons of childbearing potential, not just those who are TTC, receive a once daily FA supplement of 400-800 mcg.
These medical organizations and public health authorities include:
- ACOG: The American College of Obstetricians and Gynecologists
- SMFM: The Society of Maternal-Fetal Medicine
- USPSTF: US Preventive Services Task Force
- ACMG: American College of Medical Genetics
- CDC: Centers for Disease Control and Prevention
- FDA: Food and Drug Administration
- AAFP: American Academy of Family Physicians
- AAP: American Academy of Pediatrics
- AAN: American Academy of Neurology
- SOGC: The Society of Obstetricians and Gynaecologists of Canada
- RCOG: The Royal College of Obstetricians and Gynaecologists
- The Academy of Nutrition and Dietetics (FORMERLY the American Dietetics Association)
- The Food and Nutrition Board (FNB) of the National Academies of Sciences, Engineering, and Medicine, Health, and Medicine Division
How does folic acid differ from folate?
Folate is the general term used to describe the various forms of vitamin B9. There are over 20 different forms of folate. The different forms of folate most commonly found in supplements and prenatal vitamins include:
- Dihydrofolate (DHF)
- Tetrahydrofolate (THF)
- 5, 10-methylenetetrahydrofolate (5, 10-Methylene-THF)
- 5-methyltetrahydrofolate (5-Methyl-THF or 5-MTHF), AKA methyfolate
- Folinic acid
- Folic acid
Who is a candidate for extra FA?
ACOG recommends higher dose of periconceptional/first-trimester FA supplementation of 4000mcg (4mg) in those those with a history of one of the following:
- neural tube defect in themselves or their partner
- a prior offspring with a neural tube defect
This amount should start 3 moths prior to conceiving and continue throughout the first trimester.
There are other indications that could require extra FA. UpToDate has an easy to reference table for recommendations on extra FA supplementation by indication:
How you can ensure that you get enough folic acid!
The critical period for FA supplementation starts at least 1 month before conception and continues through the end of the first trimester of pregnancy. This is why taking a supplement with 400 mcg of FA even if you are not yet pregnant is so important- you want to already have the proper level in your body to help prevent NTDs in the developing fetus.
You can get FA by taking a prenatal vitamin or supplement with FA in it, eating foods fortified with FA, or a combination of the two, in addition to eating a balanced diet. Studies have shown that a person who consumes 400 mcg/0.4mg of FA each day generally has enough folate in their blood to help prevent NTDs, regardless of MTHFR C677T genotype (CC, CT, or TT) status--this will be discussed in more detail below.
A commonly used argument by designer prenatal vitamin companies against the use of FA in prenatal vitamins is that it is synthetic and cheap, and therefore of lesser quality or inferior. This is WRONG! In fact, the other types of folate found in some vitamins or supplements (such as 5-MTHF or folinic acid) are different from the folate found in foods, even if the nutrition label claims “natural food folate." If the nutrition label says “natural food folate” or contains another form of folate, it is still man-made, just like FA. To ensure that your prenatal vitamin has FA, the label must specifically say “folic acid” followed by an amount in micrograms. Check out "Folate and Folic Acid on the Nutrition and Supplement Facts Labels", where the FDA explains how to look for FA on the Nutrition Facts or Supplement Facts label.
Why FA is ideal for supplementation in pregnancy compared to other available forms of folate
- Folic acid has been proven to be effective at preventing NTDs in randomized controlled trials.
- FA is not cost prohibitive. Prenatal vitamins with FA are accessible and affordable, which makes them ideal for persons who are TTC and pregnant, especially those who are socioeconomically disadvantaged. Effective public health measures achieve health equality and EQUITY! For example, Hispanic pregnant persons are more likely to have a child with a NTD compared to non-Hispanic white persons. Although the reasons for the disparity are not well understood, they have been found to have lower intake of FA overall compared to non-Hispanic whites. As a result, the FDA recently approved fortification of corn masa with FA in an effort to help curb the incidence of NTDs in this population. They DID NOT choose to fortify with the better/expensive methylfolate or folinic acid.
- The body has an easier the absorbing FA than natural food folate. FA is about twice as bioavailable as food folate, especially when administered on an empty stomach.
- L-methylfolate is more difficult, and therefore more costly, to make into a supplement and is less stable than FA. As a result, it can be hard to know exactly how much someone is getting if it's been sitting on the shelf, since over-the-counter supplements are largely unregulated by the FDA and are exempt from requirements demonstrating that their ingredients are made carefully — or that they even work.
- Folic acid is more heat-and light-stable than natural food folate, which is broken down easily by heat and light; therefore, folic acid is better suited for food fortification because many fortified products, such as bread, are baked. Furthermore, FA is not degraded in cooking, which can decrease or degrade natural folate.
MTHFR gene variants & folate
It is commonly reported on social media by influencers, nutritionists, dieticians, naturopaths and functional medicine doctors that FA is not safe or you need an alternative form of folate if you have one or two copies of the MTHFR C677T variant, but THIS IS NOT TRUE. If you have one or two copies of the C677T variant, your body can safely and effectively process FA. There have been no recommendations to increase FA supplementation, alter the type of folate supplementation, or to perform additional screening based on MTHFR genotype alone.
Suggestions to change your folate supplementation while TTC or in pregnancy should be interpreted with caution because no scientific studies exist that show that supplements containing other types of folate (i.e. 5-MTHF) can help prevent NTD, whereas it has been shown conclusively that FA supplementation reduces the risk of NTDs across diverse populations. Daily consumption of 400 mcg of FA increases a person's blood folate concentration to an adequate amount to help prevent a NTD regardless of their MTHFR genotype (CC, CT, or TT).
Regarding MTHFR variants, here is what major medical organizations say:
ACOG
•Testing for MTHFR mutations is not recommended for recurrent pregnancy loss, as only antiphospholipid syndrome has shown consistent associations
MTHFR variants in isolation do not confer additional risk for thrombosis in either pregnant or nonpregnant women and therefore testing for MTHFR variants or fasting homocysteine levels in not recommended for the work up of venous thromboembolism.
•There is lack of association between heterozygosity or homozygosity for 677C>T and any negative pregnancy outcomes
SMFM
•Don’t test women for MTHFR gene variants.
ASRM and NSGC
•Testing for MTHFR variants for recurrent pregnancy loss is not recommended.
ACMG/CAP
•MTHFR polymorphism genotyping should not be ordered as part of the clinical evaluation for thrombophilia or recurrent pregnancy loss or for at-risk family members
•Do not adjust preventative folic acid supplementation dose for NTDs based on MTHFR results.
Thrombosis Canada
•Due to lack of clinical utility and available data, treating hyperhomocysteinemia in patients with cardiovascular disease or VTE is not recommended, nor is vitamin supplementation for primary prevention of cardiovascular disease recommended.
Joint Statement on Expanded Carrier Screening (ACOG/ACMG/NSGC/PQF/SMFM)
•It may be preferable not to include variants on expanded prenatal genetic carrier panels that have high allele frequencies and low penetrance of a phenotype such as MTHFR.
AHA
•There is no indication for MTHFR mutation testing in routine clinical practice in any patient group.
***Please be cautious if anyone recommends that you get tested for MTHFR gene variants. This could potentially delay you receiving an accurate medical diagnosis for your medical condition!
Beware of online misinformation!
In this article, Online Misinformation Fuels a Fight Over Folic Acid, by Christina Szalinski, it is noted that “despite the scientific consensus, some nutritionists and dietitians, along with complementary health practitioners including naturopaths, chiropractors, and functional medicine doctors, are causing many people, and not just those who are or may become pregnant, to question whether they should be consuming any FA at all.” This is problematic because we now have individuals urging people who could become pregnant to avoid vital FA supplementation, potentially putting unborn babies at unnecessary risk for NTDs.
Watch this video where I debunk some commonly spread misinformation about FA and MTHFR gene variants.
What to do next:
Take a supplement that has 400 mcg of FA in it. When you buy a prenatal vitamin, be sure that it says “folic acid” on the supplement label and not any other form of folate. You must be your own advocate and guardian on this matter as many alternative companies use this as a marketing tactic at the benefit of their own company profits and the expense of your baby’s health.