The Truth Designer Prenatal Vitamin

By
Shannon M. Clark, MD
|
April 22, 2022
The Truth Designer Prenatal Vitamin

The rise of the "designer prenatal vitamin"...

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! 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.” As a result, all persons who can become pregnant should get 400 micrograms of folic acid every day, especially if you are actively trying to conceive (TTC) or are pregnant. Because the neural tube of the fetus closes at approximately 6 weeks of gestation, taking folic acid before even becoming pregnant is ideal.

How does folic acid differ from folate?

Folate is the general term used to describe vitamin B9 that naturally occurs in foods. The different forms of folate 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

You can find natural food folate in 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 of folate 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 folic acid supplementation is recommended. In addition, folic acid is more stable than natural food folate, which can be broken down by heat and light. As a result, FA is ideal for both prenatal vitamin supplementation and food fortification.

Most 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. A few of these medical organizations include: USPSTF, ACOG, ACMG, ASRM, CDC, AAFP, AAP, Health and Medicine Division of the National Academies, US Public Health Service, American Academy of Neurology, The Academy of Nutrition and Dietetics and FDA. Why do all of these medical organizations recommend folic acid supplementation? Well, no other form of folate has been proven to help reduce the risk of neural tube defects!

Who is a candidate for extra FA?

A higher dose of periconceptional/first-trimester FA supplementation should be considered for 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
  • a first- or second-degree relative with neural tube defect, cleft lip/palate, congenital heart defects, limb reduction defects, or urinary tract defects

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.

You can get FA supplementation by taking a vitamin with FA in it, eating fortified foods, or a combination of the two. 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.

The commonly used argument that FA is synthetic and cheap and therefore of lesser quality or inferior 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” it is 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". Here, the FDA explains how to look for folic acid on the Nutrition Facts or Supplement Facts label.

Folic acid IS effective at preventing neural tube defects and IS NOT cost prohibitive. Prenatals with folic acid are accessible and affordable, which further 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 about 20 percent more likely to have a child with a neural tube defect (NTD), which includes spina bifida and anencephaly, 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 folic acid overall compared to non-Hispanic whites. As a result, the FDA recently approved fortification of corn masa with FOLIC ACID in an effort to help curb the incidence of neural tube defects in this population. They DID NOT choose to fortify with your better/expensive methylfolate or folinic acid.

MTHFR gene variants & folate

It is commonly reported on social media 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 folic acid supplementation, alter the type of folic acid supplementation, or to perform additional screening based on MTHFR genotype alone.

Suggestions to change your folic acid intake 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, this what a few 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.

MTHFR gene variants have also been the subject of more than 3,000 research articles, some of which study whether the common variations may be linked to over 600 disorders, including autism, anxiety, infertility, as well as NTDs. The links between MTHFR and the majority of the disorders are weak, according to Barry Shane, a nutrition researcher and professor emeritus at the University of California, Berkeley, who has been studying folate metabolism for over 45 years.

Watch this video that I made debunking some common misinformation spread about folic acid and MTHFR gene variants.

What to do next:

Take a supplement that has 400 mcg of folic acid in it. When you buy a prenatal vitamin, be sure that it says “folic acid” on the nutrition 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.

Please go to my instagram highlights on folic acid and MTHFR gene variants for numerous resources!

Shannon M. Clark, MD

Shannon M. Clark, MD

Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.

Follow Shannon on TikTok @tiktokbabydoc, Facebook @babiesafter35, and Instagram @babiesafter35.

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