Rewriting the script on folate
Imagine if we gave women the whole story and allowed them to make an informed decision for themselves when it comes to the folate vs folic acid debate?
The conversation with your health care provider could look like this instead.
Care provider to client:
Why folate is important
“It is really important that your folate status is optimised before pregnancy. Have you heard of spina bifida or a neural tube defect? The term neural tube defect refers to issues that arise early in pregnancy where your baby’s spine and spinal cord do not develop properly. This occurs in about 300-350 pregnancies in Australia each year, so 0.1% of pregnancies. We know that several factors make a neural tube defect more likely including:
- A previous pregnancy affected by a neural tube defect
- Maternal diabetes (type 1)
- Maternal use of anti-seizure medication
- Maternal obesity
- Exposure to high temperatures early in pregnancy (prolonged fever, hot-tub use)
- Race/ethnicity - more common among Anglo-saxons than others
- Low socioeconomic status
Despite all of these factors, we know that an adequate folate intake before conception and through the first trimester of pregnancy reduces the risk.
Do you have any questions so far?
What is the recommendation?
Based on this, it is recommended that women who are planning for a pregnancy consume 600mcg/day of folate containing foods - I’ll provide you with a list of these before you leave today - as well as an additional 400mcg/day of folic acid from supplements or fortified foods for the 1st month before pregnancy and the first trimester only. After the first trimester, when your baby's brain and spinal cord have completed their cellular division and closure, we recommend you go back to consuming only the 600mcg of folate from foods.
The difference between folate and folic acid
I’d like to talk to you about the difference between folate and folic acid and explain how you might achieve these increased folate/folic acid requirements in a way that works best for you and your situation. I also have all of this on an information sheet for you to take home and read.
The most common approach is to increase your intake of folate containing foods, green leafy vegetables, legumes and citrus fruits and take a tablet containing the synthetic form of folate, called folic acid. The tablet is convenient and you will meet the guidelines for reducing your risk of having a baby with a neural tube defect, as well as a cleft lip or palate. Folic acid is considered safe at low doses and is routinely taken by many women around the world. As folic acid is a synthetic vitamin there is evidence that exceeding the safe upper limit can be harmful to you including general toxicity, increased risk of cancer and adverse reproductive and developmental effects (https://www.nrv.gov.au/nutrients/folate). Based on these data, the recommended upper level of folic acid intake is 1000mcg/day during pregnancy (800mcg/day for a pregnant woman aged 14-18 years).
How much will you need?
To help us work out how much folic acid supplementation you might need to meet the recommendation, it is important to know that some of our food supply has been supplemented with folic acid, including all non-organic bread making wheat flour. About 2-3mg of folic acid has been added to every 1 kg of wheat flour. A typical intake of bread products for an Australian woman is 72g of bread each day which provides approximately ~210mg of folic acid. So if this is you, then you only need to take an additional 190mg of folic acid/day to meet the guidelines. Many of the major prenatal multivitamins and folic acid supplements available on the market actually provide higher than the recommended levels of folic acid, some prenatal vitamins include double (800mcg), so it is important that we understand how much folic acid you are getting from other sources, before we make a decision which supplement to take. There are also some people who have a gene variation that impacts on their folate status and their ability to absorb and metabolise folic acid. This is something for us to keep in mind and discuss further.
There are alternative folate supplements that are becoming available, these address some of the limitations of folic acid, although they are less well studied/researched in pregnancy. If this is something you’d like to consider I can provide you with some options and we can talk about dosing.
The other way of meeting the guidelines is to eat even more folate containing foods. Despite being a synthetic form of folate, folic acid is considered to be more bioavailable than folate in foods. There is a calculation we use to determine the dietary folate equivalents (DFE) of a food or supplement. Folate from food (1mcg) scores a 1mcg DFE, 1mcg folic acid scores a 0.6mcg DFE, because you actually get more ‘folate’ from the same amount of folic acid.
So, taking a 400mcg folic acid supplement, which is the recommendation, is the equivalent of 680mcg dietary folate equivalents or 680mcg of folate from food. This would mean eating 1280mcg of folate from foods to meet the recommended dietary folate intake (600mcg), as well as the supplemental folic acid intake (400mcg or 680mcg DFE) before pregnancy and during the first trimester. This is quite a lot, but it is definitely achievable once you know which foods contain folate.
What foods contain folate?
Here are some foods you could eat each day to help you achieve this. The added benefit of this approach is that you are achieving many other nutritional targets with these foods as well.
1.5 cups raw Chinese flowering cabbage (think coleslaw) - 425mcg
2 handfuls of peanuts - 240mcg
1 cup raw spinach / rocket / watercress (think side salad) - 160-280mcg
1 cup cooked broccoli - 154mcg
1 handful hazelnuts - 113mcg
1 baked beetroot - 107mcg
½ avocado - 90mcg
½ cup of haricot or kidney beans - 130mcg
1 cup muesli with dried fruit - 130mcg
½ cup quandong - 180mcg
½ cup asparagus - 125mcg
Importantly, folate, (or any vitamins or minerals for that matter), doesn’t work alone, it works closely with vitamin B12 to ensure that both vitamins are activated and available for our body to use. So let’s make sure that we are achieving your vitamin B12 requirements too…...
Do you have any more questions?”
The real deal
In writing this script, we know the barriers. Low health literacy, insufficient time and an absence of training and knowledge for care providers to have this conversation make it difficult. We can also see our bias - clearly slanted toward eating whole foods - how radical!
But, and this is a big but, that shouldn’t mean we don’t try. It shouldn’t mean that those that do have adequate health literacy aren’t even given a chance to make this decision for themselves and their family. And, it is up to those of us that do have health literacy, to share it and offer it as a gift to those that don’t.
So we believe it is time for a more personalised approach to pregnancy nutritional guidelines. A blanket recommendation for the entire population simply does not work. We must admit to those we are providing care for that we don’t have the complete story. We must share what we do know with them, the good and the not so good, and guide them to make their own informed choices.
As it stands now, only recommending a supplement as an option for a woman, when there are real whole food options available too, misses an incredible opportunity for the health of future generations. Mothers are the greatest influence on their children’s eating habits. If we truly nourished our mothers, with real whole foods throughout pregnancy and beyond, we would stand to revolutionise the food choices and habits of the next generation. This is why Eat for You is here. To offer choice. To tell the more complete story. To empower all women to choose their own adventure and to leave a legacy of good health for generations to come.
Share this story with your friends and family. Have the conversation with your care providers. Ask questions. Take back your power and choose what works for you.
Looking for recipes that contain folate rich foods? We've got you covered in our pregnancy recipes e-book.
Dr Hayley Dickinson, PhD and Kendall Macdowell