The folate debate
Most women I see in my practice who are trying to fall pregnant know they need folate. All parents-to-be want to do all they can to have a healthy baby and many have sought out relevant information and done extensive reading. However, in questioning them further, I find most are unaware of why they need to take folate and, most importantly, when they need to take it.
Folate is needed in pregnancy to prevent neural tube defects (NTDs), a group of birth defects that includes spina bifida and anencephaly. Despite public health campaigns, there are still a number of babies affected by NTDs every year, which has led authorities to consider the feasibility and the desirability of adding folate to certain foods to ensure mums-to-be are getting enough and to reduce the incidence of these distressing and sometimes catastrophic birth defects.
What is folate?
One of the B-complex vitamins, folate is the naturally occurring form of B9, the one that is present in foods. Folic acid, which you’ll see on your supplement labels, is the most common synthetic form.
In our bodies, folate is involved in the production of new cells and assists in the replication of DNA, so it’s needed to make new genetic material. It also plays a role in the maintenance of existing cells by helping in protein production. It’s an important nutrient that everyone needs, all the time and during life stages where a lot of growth occurs. In childhood and pregnancy, for example, this need increases.
Folate is also needed to make red blood cells. Deficiency causes a type of anaemia called megaloblastic anaemia whereby the red blood cells are unable to mature properly. A lack of vitamin B12 can also cause this type of anaemia.
Where do I get it from?
Folate is found in a number of different foods. Green leafy vegetables such as spinach, broccoli and silverbeet are good sources, as are legumes such as chickpeas, lentils and beans. Some meats, including liver, also contain folate. See the accompanying table for a list of the top folate-containing foods.
Folate was originally identified in yeast, and yeast extracts are one of the richest sources. In fact, during the early 2000s, US authorities banned the import of Vegemite in jars larger than 113g (much to the consternation of many expat Australians!). It was considered such a rich source of folate, there was the potential for people to eat too much.
How much do I need?
Everyone, at every life stage, needs folate — no exceptions. Its role in cell replication and growth as well as the formation of red blood cells means we all need it on a regular basis. The recommended daily intake (RDI) is:
- 100mcg per day for children 1-7 years
- 150mcg per day for children 8-11 years
- 200mcg per day for children above 12 and adults
- 400mcg per day for pregnant women.
On average, you absorb only about 50 per cent of the folate contained in the foods you eat. So to get the RDI of 200mcg of folate you need to eat foods containing double that amount (ie 400mcg). If you’re wanting to fall pregnant you need to eat 800mcg of folate every day.
Folic acid — the synthetic form of folate — on the other hand, is more easily absorbed: you’ll absorb about 85 per cent of the folic acid contained in fortified foods and 100 per cent from supplements.
Deficiencies of folate are common. It has been estimated that 50 per cent of women of childbearing age eat only about half the RDI. Indeed, eating foods containing 800mcg of folate every day (to get the RDI of 400mcg) is a big ask. Dietary intake alone is seldom enough to meet the needs of pregnancy, so women wanting to fall pregnant should start taking folate supplements at least one month before and for the first three months of pregnancy. This is the best way to insure against NTDs.
How do I get more folate?
Folate is very sensitive to heat, light and air, so how you store and cook foods makes a difference to their folate content. Folate levels are reduced by long-term storage and also by extensive cooking, especially boiling.
To get more folate from your diet, you first need to choose more folate-containing foods. Have a look at the accompanying table and try to choose two rich sources to include in your diet every day. A handful of chickpeas or other legumes can be added to salads. Spinach, sprouted mung beans, sunflower seeds, asparagus and broccoli can go in salads and stirfries. Try baking some corn cobs in the oven. Chickpeas and spinach can be added at the last minute to soups and casseroles. Have the fruits and vegetables raw or lightly cooked (steaming and stirfrying are best).
Can I have too much folate?
It is possible to have too much folate, though this is very rare. Excess folate can affect how your body uses zinc and also lead to sleep disturbances. Potentially, it may react with conventional medications, such as those used in epilepsy, rheumatoid arthritis and asthma. There is also a concern that too much folate can mask a B12 deficiency. Much is unknown about the consequences of long-term high levels of folate, and overdose is extremely rare.
Given the rate of absorption of folate from food, you’re unlikely to get too much from diet and there has never been a case of folate toxicity from food alone. The concern about excess folate is mainly directed towards the use of folic acid in supplements and food fortification.
What about in pregnancy?
Folate is needed all the time, but it’s particularly vital in pregnancy. As the foetus grows, cell division is occurring at a rapid rate and folate is needed for the cells to reproduce and growth to occur. More significantly, folate is needed to prevent NTDs.
NTDs are a group of central nervous system problems. The neural tube is formed in the very early stages of pregnancy when a band of cells on the back of the foetus develops into a hollow tube. As the foetus continues to grow, this hollow tube — the neural tube — becomes the brain and spinal column. NTDs occur when this tube fails to close properly, leaving the spinal cord exposed or just covered in skin. Babies born with NTDs often die early in life and those who survive have lifelong physical and often intellectual disabilities.
It’s important to note that development and closure of the neural tube occurs in the very early stages of pregnancy. The neural tube should be closed off 25 to 29 days after conception. At this time, most women are unaware they are pregnant, or are only just investigating the possibility of pregnancy. Starting folate supplementation when pregnancy is confirmed is therefore too late to safeguard against NTDs.
How often do NTDs occur?
Since the 1980s, there has been a marked reduction in the number of babies born with NTDs. Improved prenatal screening techniques can show up the presence of NTDs early in pregnancy. In Australia, it’s thought about 500 pregnancies are affected each year, though the final figure is uncertain as NTDs often go unreported.
It’s estimated that up to 70 per cent of NTDs are preventable through increasing the mother’s intake of folate. Since 1993, medical authorities have recommended women who are trying to conceive top up their dietary intake of folate with supplements. Health practitioners across the board recommend folate supplements to all women wanting to fall pregnant and there’s a number of brands available in healthfood shops, chemists and supermarkets. These all contain between 400mcg and 500mcg of folate — the RDI for a woman wanting to fall pregnant.
However, despite these measures, the majority of women in Australia are not taking folate supplements when they fall pregnant. The primary problem is that about half of all pregnancies are unplanned, so individuals are not taking folate supplements to protect against NTDs.
Moreover, despite the health campaigns, there is still a lack of knowledge of the timing and benefits of folate in pregnancy and many mistakenly believe they only need to take folic acid once pregnant.
Finally, as with any health measure requiring people to take supplements, there is a problem of people simply forgetting to take the tablets or not being able to afford them.
What is fortification?
This problem has led medical authorities in many countries to propose fortification of the food supply with folic acid. Fortification is where vitamins or minerals are added to a foodstuff to increase the nutritional value of that food. At present in Australia, there is no mandatory fortification of any nutrient, though voluntary fortification codes do exist.
For fortification to be effective, the chosen food must:
- be eaten often by the target audience
- have a widespread use
- be available to the target audience regardless of their income, ethnicity and geographical location.
In other countries that have introduced mandatory fortification, flour is seen as the ideal foodstuff, as bread is a staple in most people’s diet. In this way, it’s possible to achieve the kind of widespread usage required to make a fortification program successful.
What’s the situation in Australia?
At present in Australia, fortification of food with folate is allowed, but it’s a purely voluntary thing. Manufacturers can choose to add folic acid to their foods at a level of 50 per cent of the adult RDI (ie up to 100mcg) per serve of that food. They can then include a health claim on their packaging that the product contains folic acid and there is an established link between adequate maternal dietary intake and a reduced risk of NTDs developing in pregnancy.
So far folic acid has been added to some breakfast cereals, flour, savoury biscuits, breads, pasta, fruit and vegetable juices, fruit cordials and some other beverages. Interestingly, despite the health claims on the packaging and the public health promotion of the importance of folate in pregnancy, there has been very little change in the sales of folate-rich foods since the voluntary code was introduced.
Since May 2004, Food Standards Australia New Zealand (FSANZ) has been considering changing this from a voluntary code to a mandatory one whereby manufacturers would be legally required to add folic acid at a certain ratio to certain foodstuffs.
So has this been done elsewhere? A number of other countries have both mandatory and voluntary folic acid fortification programs. Canada, the US and Indonesia, along with a number of South American and African countries, have mandatory fortification of flour with folic acid. The UK is currently considering a proposal for mandatory fortification along the lines of the US model.
Positives and negatives of fortification
The issue of NTDs is a highly difficult and emotive one and it must be heartbreaking to be a parent of a child affected by NTDs. Given the majority of NTDs are preventable, steps should be taken to reduce the incidence of these devastating conditions. This is a complex issue, especially given the large number of unplanned pregnancies.
Fortifying the food supply with a specific nutrient is an effective way to increase the population’s intake of that nutrient. Public health campaigns aimed at changing people’s diets are expensive and difficult to implement. Many find it hard to make changes to their diet. Fortification bypasses these problems.
However, adding a nutrient such as folate to the food supply via a commonly used food such as flour does not just reach the target audience of women trying to fall pregnant — it reaches the whole population. While one group benefits, it will be difficult for those who wish to avoid fortified foods to do so. And, while there are few known cases of folate toxicity, the long-term effects of high levels of folic acid are, at present, unknown.
Fortifying foods with folate leads to a loss of control about who receives the extra folate. If flour is the vehicle, then folic acid will not only be in bread but also pasta, cakes, biscuits, muffins, pancakes, pastries, scones, crackers, doughnuts and so on (ie in many different foods). And while one person may limit or exclude these foods from their diet, another might eat them constantly. If you’re a person who has toast for breakfast, a sandwich for lunch, a couple of biscuits in the afternoon and then pasta in the evening, you’ll be getting many times your RDI. And children also have the potential to be eating many times their RDI of folate.
A potential problem with folic acid fortification, raised by the Australian Consumers’ Association (ACA), is the possibility of high doses of folate masking B12 deficiencies, especially among the elderly. B12 deficiency can cause significant and irreversible neurological damage, though the first sign, before any neurological damage occurs, is megaloblastic anaemia. This is easily spotted and diagnosed by a blood test and can then be treated before more serious damage occurs. However, a high folate intake could mask this anaemia, meaning the B12 deficiency is not spotted early, thereby increasing the risk of neurological damage. The ACA has called for any fortification program to be accompanied by increased screening of the elderly.
Fortification also means manufacturers have to purchase folic acid and new equipment, as well as undergo further product testing and quality control. These increases in costs may well be passed on to consumers.
Fortification vs supplementation and education
Since fortification was introduced in the US in 1998, there has been a 25 per cent reduction in the number of birth defects. However, this means there is only a quarter reduction in the number of NTDs and, despite mandatory fortification, women can still be folate-deficient at the time they fall pregnant.
A new US study suggests pregnant women who don’t take folic acid supplements are eight times more likely to have low serum folate levels, despite eating folic acid-fortified foods. It’s now being suggested by some that the level of folic acid fortification be increased, while others are calling for the reintroduction of programs that promote folic acid supplementation on top of fortification.
So it seems that no one measure alone is the solution. While food fortification is likely to be introduced in Australia, education programs to promote folate-rich foods, folic acid supplementation and the importance of folate in pregnancy will still be needed. As the ACA has noted, consumer education is the heart and foundation of any attempt to reduce the number of NTDs in Australia. Moreover, such a campaign must be long term and include clear and consistent messages, promoted Australia-wide by the media, GPs, naturopaths, pharmacists, other health professionals, nutrition education and food labelling.
There is also a case that information about folate-rich foods is important as part of total diet education. Many of the folate-rich foods are packed with vitamins, minerals and antioxidants. The country with the lowest incidence of NTDs in the world is France, which is primarily attributable to their folate-rich Mediterranean diet, not to any food fortification or supplementation program.
Folate content of foods, per common measure
| Food | Measure | Folate content |
| lentils, black-eyed peas, cooked | 1 cup | 358mcg |
| spinach, cooked | 1 cup | 263mcg |
| chickpeas, pinto beans, cooked | 1 cup | 280mcg |
| beef liver, cooked | 85g | 221mcg |
| broccoli, cooked | 1 cup | 168mcg |
| rice, white | 1 cup | 153mcg |
| beetroot, cooked | 1 cup | 136mcg |
| papaya | 1 papaya (300g) | 116mcg |
| Vegemite | 1 serve, 5g | 100mcg |
| parsnips, cooked | 1 cup | 90mcg |
| asparagus, cooked | 4 spears | 89mcg |
| sunflower seeds | ¼ cup | 76mcg |
| raspberries | 1 cup | 65mcg |
| mung beans, sprouted | 1 cup | 63mcg |
| corn | 1 cup | 57mcg |
| orange | 1 orange | 54mcg |
| tofu | 100g | 50mcg |
Source: US Department of Agriculture
References
‘Folate’, Australian Consumers’ Association, www.choice.com.au, Oct 2004
‘Folic acid’, Wikipedia Encyclopedia, http://en.wikipedia.org/wiki/Folate
‘Folic acid food fortification works’, www.nutraingredients.com/news/ng.asp?id=54960, 27 Sept 2004
Australian Consumers’ Association, Submission to Food Standards Australia New Zealand on the Initial Assessment Report Proposal P295: Consideration of Mandatory Fortification with Folic Acid, www.choice.com.au, Dec 2004
Food Standards Australia New Zealand (FSANZ), Initial Assessment Report Proposal P295: Consideration of Mandatory Fortification with Folic Acid, 17 Dec 2004
Lawrence, J.M., et al, ‘Do racial and ethnic differences in serum folate values exist after food fortification with folic acid?’ American Journal of Obstetrics & Gynecology 194, No. 2 (Feb 2006): 520-6.=
O’Conner, V., and G. Kovacs, Obstetrics, Gynaecology and Women’s Health, Cambridge University Press, 2003
Kathryn Elliott is a nutritionist and herbalist (www.strandnatural.com). When she’s not seeing clients and cooking, Kathryn is a verging-on-obsessive blogger and her writings, recipes and opinions can be found at www.kathrynelliott.com.au/blog.
