One-third of pregnant and lactating women may not be meeting their folate requirements from diet alone based on mandated levels of folic acid fortification

Women in Canada are consuming above the upper intake level of folic acid but few are meeting dietary choline recommendations in the second trimester of pregnancy: data from the CHILD cohort study

There is concern that during a low-risk pregnancy, women are consuming more than recommended (400 µg/day) supplemental folic acid and may not meet recommendations for other nutrients. The objective of this study was to determine folic acid supplement use and dietary folate intakes in the second trimester (week 18) of pregnancy in women (n = 2996) in the Canadian CHILD cohort study. Vitamin B12 and choline intakes were also assessed because they are metabolically related to folate. The majority of participants (71.6%) were consuming a daily prenatal supplement. Twenty-eight percent of women (n = 847) reported consuming a folic acid supplement and of these women, 45.3% had daily supplemental folic acid intakes above the upper intake level (UL; 1000 µg/day). Daily dietary folate intakes were (mean (SD)) 575 (235) DFE µg/day. In contrast, only 24.8% of women met the dietary choline adequate intake (AI) recommendation (AI ≥ 450 mg/day) with a mean (SD) intake of 375 (151) mg/day. Further understanding of the impact of supplemental folic acid intake above the UL and low choline intake during pregnancy requires further investigation.

Pattern of dietary supplement use and its psychosocial predictors among females visiting fitness centers in Saudi Arabia: Findings from a cross-sectional study

Background

Establishing a balanced diet is necessary for obtaining the required daily micronutrients and macronutrients. However, the importance of using dietary supplements to complement one's diet is a significant aspect to consider. While studies have reported the prevalence and patterns of dietary supplements in Saudi Arabia, most focused on university students, women in their reproductive life-particularly during pregnancy-or male athletes. Hence, the objective of this study is to estimate the prevalence and patterns of dietary supplement usage, along with the associated sociodemographic and psychiatric predictors among women attending fitness centers in Saudi Arabia.

Methods

A cross-sectional design was utilized using a structured questionnaire to collect data on dietary intakes such as consumption, nutrition supplements, type of nutrition supplements, and reason for consuming dietary supplements. Data collection occurred in female fitness centers, with participants accessing the questionnaires through QR codes linked to online Google forms. The dietary usage was assessed using a structured questionnaire developed by the study authors, and depressive and anxiety symptoms were assessed using the PHQ-9 and the GAD-7 scales, respectively. SPSS 23.0 was utilized to analyze the data, and a multivariable logistic regression analysis was performed to determine the association between sociodemographic and psychiatric predictors and patterns of dietary supplement usage. The results were presented by reporting an unadjusted and adjusted odds ratio (AOR) with 95 % Confidence Intervals (CIs).

Results

The total number of participants in this study was 453 women. Half of the 453 women (46.1 %) consumed dietary supplements, and (84.0 %) reported taking proteins, caffeine, creatinine, mineral salts, fish oil, and/or amino acids or a combination of these dietary supplements. A considerable number of women (41.0 %) reported that a doctor, dietitian, or trainer motivated them to take the dietary supplement, and (38.0 %) of women self-prescribed dietary supplements. More than half (51 %) of the women consumed dietary supplements to compensate for nutrient deficiency, and 48 % used them to improve their health. Women who did not work to earn were 53 % less likely to consume dietary supplements (AOR = 0.47; [95 % CI: 0.30-0.72]) than women who reported working to earn either in the private or government sector. Depressed women were (42 %) less likely to consume dietary supplements than non-depressed women (AOR = 0.58; [95 % CI: 0.33-0.99]) after adjusting for sociodemographic variables and other medical conditions.

Conclusion

It has been evident that a large proportion of women enrolled in the fitness center report consuming dietary supplements, mostly to compensate for energy and to improve overall health. The findings highlight that non-working and depressed women were less likely to use dietary supplements than their counterparts. By understanding these patterns, the community can tailor health interventions and policies to ensure equitable access to proper dietary support, especially for those facing challenges like depression and unemployment. Future research on a larger sample of women outside fitness centers is encouraged to explore further dietary supplement consumption and patterns among diverse population groups, and to ultimately develop health guidelines for the appropriate use of supplements.

Association between Mediterranean diet and metal mixtures concentrations in pregnant people from the New Hampshire Birth Cohort Study

Diet is a primary source of nutrients but also toxic metal exposure. In pregnancy, balancing essential metal exposure while reducing non-essential ones is vital for fetal and maternal health. However, the effect of metal mixtures from diets like the Mediterranean, known for health benefits, remains unclear. This study aimed to explore the association between Mediterranean diet adherence and metals exposure, both individually and as mixtures. The study involved 907 pregnant participants from the New Hampshire Birth Cohort Study. We calculated the relative Mediterranean diet score (rMED) through a validated food frequency questionnaire, which includes 8 traditional Mediterranean dietary components. Also, at ~24-28 weeks of gestation, we used ICP-MS to measure speciation of Al, Cd, Co, Cu, Fe, Hg, Mo, Ni, Sb, Se, Sn, Zn, and As in urine, as well as Pb, Hg, As, Ni, and Se in toenails. We used multiple linear regression and Weighted Quantile Sum regression to analyze the association between rMED and metal mixtures. The models were adjusted for age, pre-pregnancy BMI, smoking during pregnancy, and educational level. High adherence to the Mediterranean diet was associated with increased urinary Al (® = 0.26 (95 % confidence interval (CI) = 0.05; 0.46)), Cd (β = 0.12 (95%CI = 0.00; 0.24)), Mo (β = 0.10 (95%CI = 0.00; 0.20)), and AsB (β = 0.88 (95%CI = 0.49; 1.27)) as well as toenail Hg (β = 0.44 (95%CI = 0.22; 0.65)), Ni (β = 0.37 (95%CI = 0.06; 0.67)), and Pb (β = 0.22 (95%CI = 0.03; 0.40)) compared to those with low adherence. The intake of fruits and nuts, fish and seafood, legumes, cereals, meat, and olive oil were found to be related to the metal biomarkers within the rMED. In conclusion, the Mediterranean diet enhances essential metal intake but may also increase exposure to harmful ones.

Supplementation with (6S)-5-methyltetrahydrofolic acid appears as effective as folic acid in maintaining maternal folate status while reducing unmetabolised folic acid in maternal plasma: a randomised trial of pregnant women in Canada

Folic acid supplementation is recommended during pregnancy to support healthy fetal development; (6S)-5-methyltetrahydrofolic acid ((6S)-5-MTHF) is available in some commercial prenatal vitamins as an alternative to folic acid, but its effect on blood folate status during pregnancy is unknown. To address this, we randomised sixty pregnant individuals at 8-21 weeks' gestation to 0·6 mg/d folic acid or (6S)-5-MTHF × 16 weeks. Fasting blood specimens were collected at baseline and after 16 weeks (endline). Erythrocyte and serum folate were quantified via microbiological assay (as globally recommended) and plasma unmetabolised folic acid (UMFA) via LC-MS/MS. Differences in biochemical folate markers between groups were explored using multivariable linear/quantile regression, adjusting for baseline concentrations, dietary folate intake and gestational weeks. At endline (n 54), the mean values and standard deviations (or median, inter-quartile range) of erythrocyte folate, serum folate and plasma UMFA (nmol/l) in those supplemented with (6S)-5-MTHF v. folic acid, respectively, were 1826 (sd 471) and 1998 (sd 421); 70 (sd 13) and 78 (sd 17); 0·5 (0·4, 0·8) and 1·3 (0·9, 2·1). In regression analyses, erythrocyte and serum folate did not differ by treatment group; however, concentrations of plasma UMFA in pregnancy were 0·6 nmol/l higher (95 % CI 0·2, 1·1) in those supplementing with folic acid as compared with (6S)-5-MTHF. In conclusion, supplementation with (6S)-5-MTHF may reduce plasma UMFA by ∼50 % as compared with supplementation with folic acid, the biological relevance of which is unclear. As folate is currently available for purchase in both forms, the impact of circulating maternal UMFA on perinatal outcomes needs to be determined.

Associations between folic acid supplement use and folate status biomarkers in the first and third trimesters of pregnancy in the Maternal-Infant Research on Environmental Chemicals (MIREC) Pregnancy Cohort Study

BACKGROUND

Achieving optimal folate status during early gestation reduces the risk of neural tube defects (NTDs). While inadequate folate intake remains a concern, it is becoming increasingly common for individuals to consume higher than recommended doses of folic acid (FA) with minimal additional benefit.

OBJECTIVE

Here, we sought to investigate the determinants, including FA supplement dose and use, of plasma total and individual folate vitamer concentrations in the first and third trimesters of pregnancy.

METHODS

Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort exposed to mandatory FA fortification, we measured plasma total folate and individual folate vitamer [5-methyltetrahydrofolate (5-methylTHF), unmetabolized FA (UMFA), and non-methyl folates (sum of THF, 5-formylTHF, 5,10-methenyl-THF)] concentrations in the first and third trimesters (n = 1,893). Using linear mixed models, we estimated associations between plasma folate concentrations, total daily supplemental FA intake, plasma vitamin B-12 concentrations, and multiple demographic, maternal, and reproductive factors.

RESULTS

Almost 95% of MIREC study participants met or exceeded the recommended daily supplemental FA intake from supplements (≥400 μg/d), with approximately 25% consuming more than the Tolerable Upper Intake Level (>1000 μg/d). Over 99% of MIREC participants had a plasma total folate status indicative of maximal NTD risk reduction (25.5 nmol/L) regardless of FA supplement dose. UMFA was detected in almost all participants, with higher concentrations associated with higher FA doses. Determinants of adequate FA supplement intake and folate status associated with reduced NTD risk included indicators of higher socioeconomic position, higher maternal age, nulliparity, and lower prepregnancy BMI.

CONCLUSIONS

In the context of mandatory FA fortification, our data indicate that higher-than-recommended FA doses are unwarranted, with the exception of individuals at higher risk for NTDs. Ideally, prenatal supplements would contain 400 rather than 1000 µg FA, thereby enabling the consumption of optimal and safe FA doses.

Gestational Folate and Folic Acid Intake among Women in Canada at Higher Risk of Pre-Eclampsia

BACKGROUND

Periconceptional folic acid (FA) supplementation is recommended to prevent neural tube defects; however, the extent to which recommendations are met through dietary sources and supplements is not clear.

OBJECTIVES

Our objective was to evaluate the dietary and supplemental intakes of FA in a Canadian pregnancy cohort and to determine the proportions of pregnant women exceeding the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL).

METHODS

FACT (the Folic Acid Clinical Trial) was an international multicenter, randomized, double-blinded, placebo-controlled, phase III trial investigating FA for the prevention of pre-eclampsia in high-risk pregnancies. Participants were enrolled from Canadian sites at 8-16 weeks of gestation. Dietary and supplemental FA intake data were collected through participant interviews and FFQs at the time of FACT enrollment. Categorical data were summarized as n (%) and continuous data as median (IQR).

RESULTS

This study included 1198 participants. Participants consumed 485 μg dietary folate equivalents (DFE)/d (IQR: 370-630 μg DFE/d) from dietary sources of folate and FA. Through diet alone, 43.4% of participants consumed ≥520 μg DFE/d, the EAR for pregnant individuals. Of the 91.9% of participants who consumed daily FA supplements, 0.4% consumed <400 μg FA/d and 96.0% consumed ≥1000 μg/d, the UL for FA. Median (IQR) total folate intake was 2167 μg DFE/d (2032-2325 μg DFE/d); 95.3% of participants met or exceeded the EAR from all sources, but 1069 (89.2%) participants exceeded the UL.

CONCLUSIONS

The majority of participants in this Canadian pregnancy cohort did not consume the recommended amount of folate from dietary sources. However, most prenatal supplements contained 1000 μg FA, resulting in the majority of women exceeding the UL. With no additional benefit associated with FA intakes beyond the UL for most women, modification of prenatal supplement formulations may be warranted to ensure women meet but do not exceed recommended FA intakes.FACT was registered at clinicaltrials.gov as NCT01355159 and at isrctn.com as ISRCTN23781770.

Nutritional adequacy and the role of supplements in the diets of Indigenous Australian women during pregnancy

OBJECTIVE

To determine sources of key nutrients contributing towards nutritional adequacy during pregnancy (fibre, calcium, iron, zinc and folate) in a cohort of women carrying an Indigenous child.

DESIGN

Analysis of cross-sectional data from a prospective longitudinal cohort study that followed Indigenous women through pregnancy.

SETTING

Women recruited via antenatal clinics in regional and remote locations in NSW, Australia as part of the Gomeroi gaaynggal project.

PARTICIPANTS

One hundred and fifty-two pregnant Australian women who identified as Indigenous or carrying an Indigenous child.

MEASUREMENTS AND FINDINGS

Measurement outcomes included demographic information, smoking status, anthropometrics (weight and height,), self-reported pre-pregnancy weight, health conditions and dietary information (24-hour food recall). Findings indicate the inadequate intake of key pregnancy nutrients in this cohort. Supplements contributed to the nutrient adequacy of the cohort with 53% reporting use. As expected, predominant sources of fibre were from core food groups, whereas calcium was attained from a range of sources including food and beverages, with small amounts from supplementation. Importantly, supplements contributed significant amounts of iron, zinc and folate.

KEY CONCLUSIONS

There is limited literature on Indigenous Australian maternal nutrition. This study highlights the key dietary contributors of nutritional adequacy during pregnancy for the cohort and that supplementation may be considered a viable source of nutrients during pregnancy for these women. Few women met national nutrient recommendations. The findings present an opportunity to optimise nutrient intakes of Indigenous pregnant women.

IMPLICATIONS FOR PRACTICE

Culturally appropriate targeted interventions to optimise dietary intakes of Indigenous Australian pregnant women is required. Collaborative support of health workers, Indigenous Australian communities, dietitians, and researchers to raise awareness of nutrition during pregnancy is imperative to achieving nutrient targets and optimising pregnancy outcomes. Targeted interventions provide positive opportunities to achieve improvements.

Safety evaluation of calcium L-methylfolate

Calcium L-methylfolate (L-5-MTHF-Ca; CAS Number 151533-22-1) is a source of folate and an alternative to folic acid for use in human food and food supplements. The safety of L-5-MTHF-Ca was evaluated by testing for genotoxicity, subchronic and prenatal developmental toxicity. In in vitro assays L-5-MTHF-Ca was not mutagenic and did not induce other chromosomal events. Additionally, L-5-MTHF-Ca was not genotoxic in the in vivo micronucleus test nor did it induce DNA damage in rat liver cells. In a subchronic toxicity study, rats administered up to 400 mg/kg bw/day of L-5-MTHF-Ca via oral gavage for 13 weeks had no treatment-related mortalities, and no treatment-related effects were identified on behaviour, body weight, food consumption, ophthalmology, haematology, or organ weights. No treatment-related macroscopic or histopathological findings were observed. Calcium and sodium levels increased with increasing dosage, however the slight increases were within historical control ranges and reversible after the recovery period. L-5-MTHF-Ca is neither teratogenic nor embryotoxic. Based on the results of the in vitro and in vivo studies, the safe use of L-5-MTHF-Ca as an ingredient in foods is supported. The no observed adverse effect level was the highest dose in the subchronic toxicity study, i.e. 400 mg/kg bw/day for male and female rats.

Diet in Early Pregnancy: Focus on Folate, Vitamin B12, Vitamin D, and Choline

Purpose: Prenatal multivitamins are recommended in pregnancy. This study assessed food and supplement intakes of folate, vitamin B12 (B12), vitamin D, and choline in pregnant women living in Southern Ontario in comparison with current recommendations. Methods: Women recruited to the Be Healthy in Pregnancy RCT (NCT01693510) completed 3-day diet/supplement records at 12-17 weeks gestation. Intakes of folate, B12, vitamin D, and choline were quantified and compared with recommendations for pregnant women. Results: Folate intake (median (min, max)) was 1963 μg/day dietary folate equivalents (153, 10 846); 90% of women met the Estimated Average Requirement (EAR) but 77% exceeded the Tolerable Upper Intake Level (UL) (n = 232). B12 intake was 12.1 μg/day (0.3, 2336); 96% of women met the EAR with 7% exceeding the EAR 100-fold (n = 232). Vitamin D intake was 564 IU/day (0.0, 11 062); 83% met the EAR, whereas 1.7% exceeded the UL (n = 232). Choline intake was 338 mg/day (120, 1016); only 18% met the Adequate Intake and none exceeded the UL (n = 158). Conclusion: To meet the nutrient requirements of pregnancy many women rely on prenatal vitamins. Reformulating prenatal multivitamin supplements to provide doses of vitamins within recommendations to complement a balanced healthy diet would ensure appropriate micronutrient intakes for pregnant women.

The MTHFR 677C>T polymorphism is associated with unmetabolized folic acid in breast milk in a cohort of Canadian women

BACKGROUND

Maternal nutrition and genetics are determinants of breast-milk nutrient composition and, as such, are determinants of the nutritional exposure of breastfed infants.

OBJECTIVES

The aim of this study was to determine whether common maternal single nucleotide polymorphisms (SNPs) in folate-dependent enzymes are associated with breast-milk folate content in a cohort of mothers enrolled in the Maternal-Infant Research on Environmental Chemicals (MIREC) study.

METHODS

The MIREC study is a Canadian prospective pregnancy cohort study that recruited 2001 participants between 2008 and 2011. Five folate-related SNPs-MTHFR 677C>T (rs1801133), MTHFR 1298A>C (rs1801131), MTHFR 1793G>A (rs2274976), MTR 2756A>G (rs1805087), and MTRR 66A>G (rs1801394)-were genotyped. Breast milk was sampled ∼1 mo postpartum, and tetrahydrofolate (THF), 5-methyl-THF, 5-formyl-THF, 5,10-methenyl-THF, and unmetabolized folic acid (UMFA) were measured using liquid chromatography-tandem mass spectrometry in a subset of participants (n = 551). Associations were assessed using Wald's test. Associations were considered significant if P ≤ 0.01 (Bonferroni correction for multiple testing).

RESULTS

None of the SNPs were associated with total breast-milk folate. However, the MTHFR 677C>T SNP was associated with breast-milk UMFA (R2 = 0.01; unadjusted P = 0.004), explaining a small portion of total variance; this association remained significant when adjusted for other covariates, including supplemental folic acid consumption. The MTHFR 1793G>A and MTRR 66A>G SNPs tended to be associated with 5-methyl-THF (R2 = 0.008, P = 0.04) and reduced folates (THF + 5-methyl-THF + 5-formyl-THF + 5,10-methenyl-THF; R2 = 0.01, P = 0.02), respectively.

CONCLUSIONS

We found that total breast-milk folate content was not associated with any of the folate-related SNPs examined. The association between the MTHFR 677C>T SNP and breast-milk UMFA, albeit modest, highlights the need to better understand the determinants of breast-milk folate and the impact they might have on milk folate bioavailability.

Periconceptional intake of folic acid among low-risk women in Canada: summary of a workshop aiming to align prenatal folic acid supplement composition with current expert guidelines

The Government of Canada and the Society of Obstetricians and Gynaecologists of Canada both recommend a daily multivitamin supplement containing 400 µg folic acid (FA) for the primary prevention of neural tube defects among low-risk women from before conception and throughout lactation. Prenatal supplements marketed and prescribed in Canada typically exceed the recommended dose, usually providing ≥1000 µg FA/d. This high daily dose, coupled with staple-food FA fortification, has resulted in the observation of very high blood folate concentrations among reproductive-aged women consuming FA-containing supplements. The long-term consequences of high folate status on fetal development are unknown; however, evidence from animal studies and some human epidemiologic data suggest potential adverse consequences. To address this issue, a workshop was convened with the overall goal to identify challenges and solutions to aligning supplemental FA intakes with current evidence-based recommendations. Thirty-eight stakeholders from academia, industry, government, and health professional groups participated. Group discussions facilitated the identification and prioritization of 5 key challenges for which solutions and implementation strategies were proposed. The 5 themes encompassed clarity and harmonization of evidence-based guidelines, reformulation or relabeling of FA-containing supplements, access to FA for all women, knowledge dissemination strategies and education of the public and health care professionals, and attitude change to overcome the perception of "more is better." A combination of the proposed implementation strategies involving all key stakeholders and directed to health care professionals and the public may enable a sustainable change to align FA intake during the periconceptional period with evidence-based recommendations.

Lactating Canadian Women Consuming 1000 µg Folic Acid Daily Have High Circulating Serum Folic Acid Above a Threshold Concentration of Serum Total Folate

Background

Consumption of high-dose folic acid supplements is common throughout pregnancy and lactation in several countries, including Canada, Brazil, and the United States, and may lead to high levels of circulating unmetabolized folic acid.

Objective

The objective of the study was to characterize serum and whole-blood folate forms in Canadian lactating women regularly consuming a daily high-dose folic acid supplement.

Methods

One-hundred and seventeen Canadian lactating women aged between 18 and 42 y, with a geometric mean ± SD prepregnancy body mass index (kg/m2) of 23.1 ± 1.2, were enrolled in a vitamin D supplementation trial between 13 and 22 wk of gestation. As part of the trial, the women received a daily multivitamin containing 1000 µg folic acid throughout pregnancy and lactation until 8 wk postpartum. At 8 wk postpartum, serum folate forms, including folic acid and RBC total folate, were determined from nonfasted blood samples. Differences in median folate vitamer concentrations among quintiles of serum total folate status were assessed by the Wald test and quantile regression methods. A breakpoint in the relation between serum folic acid and serum total folate was modeled with the use of the segmented package in R.

Results

Median serum total folate concentration among participants was 79.3 nmol/L (5th-95th percentile 30.7-186 nmol/L) and median RBC folate concentration was 2790 nmol/L (5th-95th percentile 1330-4850 nmol/L). There was a breakpoint in the relation between serum total folate and serum folic acid at 78.5 nmol/L (95% CI: 67.9, 89.1 nmol/L), below which serum folic acid was not associated with serum total folate, and above which serum folic acid increased 0.78 nmol/L (95% CI: 0.70, 0.86 nmol/L; P < 0.001) for each 1 nmol/L increase in serum total folate.

Conclusions

These data demonstrate the potential for high serum folic acid concentrations proportional to overall folate concentrations in lactating women with serum total folate >80 nmol/L taking high-dose supplemental folic acid. This study was registered at clinicaltrials.gov as NCT01112891.

Folate Deficiency and Anemia Among Women of Reproductive Age (15-49 Years) in Senegal: Results of a National Cross-Sectional Survey

Background:

Widely spread throughout the world, folate and iron deficiencies are risk factors for many diseases. However, contrary to iron deficiency and anemia, which have been documented in depth, the prevalence of folate deficiency among women has not been well-studied.

Objective:

The aim of this study is to determine the prevalence of folate deficiency and anemia and their association among Senegalese women of reproductive age.

Methods:

A national cross-sectional survey using a stratified 2-stage cluster sampling was conducted. Data were collected from 1012 women (aged 15-49 years). Plasma folate and hemoglobin (Hb), as well as protein markers of subclinical infections, were equally measured.

Results:

The mean folate concentration was 8.50 nmol/L (8.16-8.85 nmol/L), and 54.8% of the women were folate deficient (<10 nmol/L). Plasma folate concentration of rural women (7.27 nmol/L [6.89-7.68 nmol/L]) and urban women (10.45 nmol/L [9.88-11.05 nmol/L]) was significantly different ( P < .0001), the highest concentration being observed in women living in Dakar, the capital of Senegal. The breastfeeding women showed lower plasma folate concentration compared to nonbreastfeeding ones: 6.97 nmol/L (6.37-7.63 nmol/L) versus 9.03 nmol/L (8.61-9.46 nmol/L). Overall, 27% of the women were suffering from inflammation/infections. Mean Hb concentration was 116.86 (1.18) g/L, and 47.63% of the women involved in the study were anemic (pregnant women Hb <110 g/L; nonpregnant Hb <120 g/L). Also, a positive and significant correlation was found between plasma folate and Hb concentrations ( r = .07; P = .0167).

Conclusions:

This study showed a high prevalence of folate deficiency and anemia among Senegalese women (15-49 years), particularly those living in rural settings and breastfeeding women.

Adequacy of nutritional intake from food and supplements in a cohort of pregnant women in Québec, Canada: the 3D Cohort Study (Design, Develop, Discover)

Background: Assessments of the dietary intakes in various populations suggest that pregnant women have difficulty meeting all their nutritional requirements through diet alone. Few large-scale studies have considered both food sources and supplements in assessing the adequacy of nutritional intakes during pregnancy.Objective: Our study aimed to assess nutritional intakes during pregnancy by examining dietary sources and supplements. It then compared these findings with Dietary Reference Intakes.Design: We conducted a nutrition study in a large pregnancy cohort using a 3-d food record during the second trimester of pregnancy. Detailed information about supplement consumption was obtained by interview at each prenatal visit. We estimated the distribution of total usual intakes for energy, macronutrients, and micronutrients for 1533 pregnant women.Results: A third of the participants had total fat intakes that exceeded the Acceptable Micronutrient Distribution Range. A majority of women (85%) had sodium intakes above the Tolerable Upper Intake Level (UL). Median intakes for fiber and potassium were lower than Adequate Intakes. Dietary intakes of vitamin B-6, magnesium, and zinc were below the Estimated Average Requirements (EARs) for 10-15% of the women. A majority of the women had dietary intakes below the EARs for iron (97%), vitamin D (96%), and folate (70%). When we considered micronutrient intakes from both food and supplements, we found that the prevalence of inadequate intake was <10% for all nutrients except vitamin D (18%) and iron (15%), whereas 32% and 87% of the women had total intakes above the ULs for iron and folic acid, respectively.Conclusions: The level of intake of some nutrients from food alone remains low in the diets of pregnant women. Supplement use reduces the risk of inadequate intake for many micronutrients, but diet-related issues during pregnancy remain and deserve to be addressed in public health interventions. This trial was registered at clinicaltrials.gov as NCT03113331.

Total folate and unmetabolized folic acid in the breast milk of a cross-section of Canadian women

Background: Folate requirements increase during pregnancy and lactation. It is recommended that women who could become pregnant, are pregnant, or are lactating consume a folic acid (FA)-containing supplement.Objectives: We sought to determine breast-milk total folate and unmetabolized folic acid (UMFA) contents and their relation with FA-supplement use and doses in a cohort of Canadian mothers who were enrolled in the MIREC (Maternal-Infant Research on Environmental Chemicals) study.Design: Breast-milk tetrahydrofolate (THF), 5-methyl-THF, 5-formyl-THF, 5,10-methenyl-THF, and UMFA were measured with the use of liquid chromatography-tandem mass spectrometry (n = 561). Total daily supplemental FA intake was based on self-reported FA-supplement use.Results: UMFA was detectable in the milk of 96.1% of the women. Total daily FA intake from supplements was associated with breast folate concentration and species. Breast-milk total folate was 18% higher (P < 0.001) in supplement users (n = 401) than in nonusers (n = 160), a difference driven by women consuming >400 μg FA/d (P ≤ 0.004). 5-Methyl-THF was 19% lower (P < 0.001) and UMFA was 126% higher (P < 0.001) in supplement users than in nonusers. Women who consumed >400 μg FA/d had proportionally lower 5-methyl-THF and higher UMFA than did women who consumed ≤400 μg FA/d.Conclusions: FA-supplement use was associated with modestly higher breast-milk total folate. Detectable breast-milk UMFA was nearly ubiquitous, including in women who did not consume an FA supplement. Breast-milk UMFA was proportionally higher than 5-methyl-THF in women who consumed >400 μg FA/d, thereby suggesting that higher doses exceed the physiologic capacity to metabolize FA and result in the preferential uptake of FA in breast milk. Therefore, FA-supplement doses >400 μg may not be warranted, especially in populations for whom FA fortification is mandatory.

Energy and nutrients in self-reported diet before and at week 18–22 of pregnancy

Background

Objective

Design

Results

Conclusions

Pre-conception Folic Acid and Multivitamin Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital Anomalies

OBJECTIVE

To provide updated information on the pre- and post-conception use of oral folic acid with or without a multivitamin/micronutrient supplement for the prevention of neural tube defects and other congenital anomalies. This will help physicians, midwives, nurses, and other health care workers to assist in the education of women about the proper use and dosage of folic acid/multivitamin supplementation before and during pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, Medline, CINAHL, and the Cochrane Library in January 2011 using appropriate controlled vocabulary and key words (e.g., folic acid, prenatal multivitamins, folate sensitive birth defects, congenital anomaly risk reduction, pre-conception counselling). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from 1985 and June 2014. Searches were updated on a regular basis and incorporated in the guideline to June 2014 Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Costs, risks, and benefits: The financial costs are those of daily vitamin supplementation and eating a healthy folate-enriched diet. The risks are of a reported association of dietary folic acid supplementation with fetal epigenetic modifications and with an increased likelihood of a twin pregnancy. These associations may require consideration before initiating folic acid supplementation. The benefit of folic acid oral supplementation or dietary folate intake combined with a multivitamin/micronutrient supplement is an associated decrease in neural tube defects and perhaps in other specific birth defects and obstetrical complications.

VALUES

The quality of evidence in the document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Summary Statement In Canada multivitamin tablets with folic acid are usually available in 3 formats: regular over-the-counter multivitamins with 0.4 to 0.6 mg folic acid, prenatal over-the-counter multivitamins with 1.0 mg folic acid, and prescription multivitamins with 5.0 mg folic acid. (III) Recommendations 1. Women should be advised to maintain a healthy folate-rich diet; however, folic acid/multivitamin supplementation is needed to achieve the red blood cell folate levels associated with maximal protection against neural tube defect. (III-A) 2. All women in the reproductive age group (12-45 years of age) who have preserved fertility (a pregnancy is possible) should be advised about the benefits of folic acid in a multivitamin supplementation during medical wellness visits (birth control renewal, Pap testing, yearly gynaecological examination) whether or not a pregnancy is contemplated. Because so many pregnancies are unplanned, this applies to all women who may become pregnant. (III-A) 3. Folic acid supplementation is unlikely to mask vitamin B12 deficiency (pernicious anemia). Investigations (examination or laboratory) are not required prior to initiating folic acid supplementation for women with a risk for primary or recurrent neural tube or other folic acid-sensitive congenital anomalies who are considering a pregnancy. It is recommended that folic acid be taken in a multivitamin including 2.6 ug/day of vitamin B12 to mitigate even theoretical concerns. (II-2A) 4. Women at HIGH RISK, for whom a folic acid dose greater than 1 mg is indicated, taking a multivitamin tablet containing folic acid, should be advised to follow the product label and not to take more than 1 daily dose of the multivitamin supplement. Additional tablets containing only folic acid should be taken to achieve the desired dose. (II-2A) 5. Women with a LOW RISK for a neural tube defect or other folic acid-sensitive congenital anomaly and a male partner with low risk require a diet of folate-rich foods and a daily oral multivitamin supplement containing 0.4 mg folic acid for at least 2 to 3 months before conception, throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues. (II-2A) 6. Women with a MODERATE RISK for a neural tube defect or other folic acid-sensitive congenital anomaly or a male partner with moderate risk require a diet of folate-rich foods and daily oral supplementation with a multivitamin containing 1.0 mg folic acid, beginning at least 3 months before conception. Women should continue this regime until 12 weeks' gestational age. (1-A) From 12 weeks' gestational age, continuing through the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (II-2A) 7. Women with an increased or HIGH RISK for a neural tube defect, a male partner with a personal history of neural tube defect, or history of a previous neural tube defect pregnancy in either partner require a diet of folate-rich foods and a daily oral supplement with 4.0 mg folic acid for at least 3 months before conception and until 12 weeks' gestational age. From 12 weeks' gestational age, continuing throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (I-A). The same dietary and supplementation regime should be followed if either partner has had a previous pregnancy with a neural tube defect. (II-2A).

Pregnant Canadian Women Achieve Recommended Intakes of One-Carbon Nutrients through Prenatal Supplementation but the Supplement Composition, Including Choline, Requires Reconsideration

BACKGROUND

Folate, vitamin B-6, vitamin B-12, and choline are involved in one-carbon metabolism and play critical roles in pregnancy including prevention of birth defects and promotion of neurodevelopment. However, excessive intakes may adversely affect disease susceptibility in offspring. Intakes of these nutrients during pregnancy are not well characterized.

OBJECTIVE

Our aim was to determine dietary and supplemental intakes and major dietary sources of one-carbon nutrients during pregnancy.

METHODS

In pregnant women (n = 368) at ≤16 wk postconception, supplement use >30 d before pregnancy was assessed by maternal recall and supplement and dietary intakes in early (0-16 wk) and late pregnancy (23-37 wk) were assessed by food-frequency questionnaire.

RESULTS

Preconception, 60.1% (95% CI: 55.8, 64.3) of women used B vitamin-containing supplements. This increased to 92.8% (95% CI: 89.6, 95.2) in early and 89.0% (95% CI: 85.0, 92.3) in late pregnancy. Median supplemental folic acid, vitamin B-12, and vitamin B-6 were 1000 μg/d, 2.6 μg/d, and 1.9 mg/d, respectively. Forty-one percent and 50% of women had dietary intakes of folate and vitamin B-6 less than the estimated average requirement (520 mg/d dietary folate equivalents and 1.6 mg/d, respectively). Eight-seven percent of women had choline intakes less than the Adequate Intake (450 mg/d). Dietary intakes did not change appreciably during pregnancy. Fruits and vegetables and fortified foods contributed ∼57% to total dietary folate intake. Fruits and vegetables contributed ∼32% to total dietary vitamin B-6 intake and dairy and egg products contributed ∼37% to total dietary vitamin B-12 intake.

CONCLUSIONS

Vitamin supplements were an important source of one-carbon nutrients during pregnancy in our sample. Without supplements, many women would not have consumed quantities of folate and vitamin B-6 consistent with recommendations. Given the importance of choline in pregnancy, further research to consider inclusion in prenatal supplements is warranted. This trial was registered at clinicaltrials.gov as NCT02244684.

The Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study: rationale and methods

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Benefits of docosahexaenoic acid, folic acid, vitamin D and iodine on foetal and infant brain development and function following maternal supplementation during pregnancy and lactation

Scientific literature is increasingly reporting on dietary deficiencies in many populations of some nutrients critical for foetal and infant brain development and function.

PURPOSE

To highlight the potential benefits of maternal supplementation with docosahexaenoic acid (DHA) and other important complimentary nutrients, including vitamin D, folic acid and iodine during pregnancy and/or breast feeding for foetal and/or infant brain development and/or function.

METHODS

English language systematic reviews, meta-analyses, randomised controlled trials, cohort studies, cross-sectional and case-control studies were obtained through searches on MEDLINE and the Cochrane Register of Controlled Trials from January 2000 through to February 2012 and reference lists of retrieved articles. Reports were selected if they included benefits and harms of maternal supplementation of DHA, vitamin D, folic acid or iodine supplementation during pregnancy and/or lactation.

RESULTS

Maternal DHA intake during pregnancy and/or lactation can prolong high risk pregnancies, increase birth weight, head circumference and birth length, and can enhance visual acuity, hand and eye co-ordination, attention, problem solving and information processing. Vitamin D helps maintain pregnancy and promotes normal skeletal and brain development. Folic acid is necessary for normal foetal spine, brain and skull development. Iodine is essential for thyroid hormone production necessary for normal brain and nervous system development during gestation that impacts childhood function.

CONCLUSION

Maternal supplementation within recommended safe intakes in populations with dietary deficiencies may prevent many brain and central nervous system malfunctions and even enhance brain development and function in their offspring.

Circulating unmetabolized folic Acid: relationship to folate status and effect of supplementation

There are increasing concerns that exposure to unmetabolized folic acid, which results from folic acid intakes that overwhelm the liver's metabolic capacity, may be associated with adverse effects. In this paper, we examined the folic acid status of women of reproductive age in relation to dietary intake and the effect of folic acid supplementation (1.1 mg or 5 mg). Plasma unmetabolized folic acid was not significantly correlated with folate intake estimated by food frequency questionnaire or biomarkers. The proportion of women with detectable levels of unmetabolized folic acid increased from 65% to 100% after twelve weeks of supplementation (P < 0.05); however, the increase in concentrations did not reach statistical significance and the effect was not sustained. Moreover, there were no significant differences between the two doses. This suggests that there are mechanisms by which the body adapts to high folic acid intakes to limit exposure to unmetabolized folic acid.

Folic acid fortification above mandated levels results in a low prevalence of folate inadequacy among Canadians

BACKGROUND

Understanding folate intakes after folic acid fortification of the food supply will help to establish dietary and supplement recommendations that balance health benefits and risks.

OBJECTIVES

The objectives were to estimate the prevalence of folate inadequacy (POFI) and intakes above the Tolerable Upper Intake Level (UL) among Canadians and to estimate the supplemental dose that, with diet, provides reproductive-aged women with 400 μg folic acid/d to prevent neural tube defects.

DESIGN

Twenty-four-hour recall and supplement (prior 30 d) data from the 2004 Canadian Community Health Survey (n = 35,107) were used to calculate the POFI and intakes above the UL with and without adjustment for fortification overages. POFI was also estimated by risk factors thought to be related to low folate intake. The Software for Intake Distribution Evaluation (SIDE program; Department of Statistics and Center for Agricultural and Rural Development, Iowa State University) was used to estimate usual dietary intakes in all analyses.

RESULTS

Except for women aged >70 y, POFI was <20% after adjustment for fortification overages. For children aged <14 y, POFI approached zero, even when supplement use was excluded. POFI among adults was unaffected by supplement use, except for women aged >70 y. Only 18% of reproductive-aged women consumed 400 μg folic acid/d from diet and supplements. Modeling showed that supplements containing 325-700 μg folic acid would provide adult women with 400 μg/d but not more than the UL. Diabetes was associated with POFI.

CONCLUSIONS

Innovative strategies are needed to ensure that the subgroups of Canadians who could still benefit from improved folate intake are targeted. Consideration should be given to removing folic acid from supplements designed for young children and men.

How much folate is in Canadian fortified products 10 years after mandated fortification?

OBJECTIVE

In 1998, the Canadian government mandated folic acid fortification of white flour and enriched grain products to lower the prevalence of neural tube defects. There is now growing concern over the potential harmful effects of too much folic acid on some segments of the population. Given that the actual amount of folate in Canadian foods is unknown, the objective of this study was to measure the folate content in selected fortified foods.

METHODS

Using data from the 2001 Food Expenditure Survey and the ACNielsen Company, 95 of the most commonly purchased folic acid-fortified foods in Canada were identified. Folate concentrations in these foods were determined using tri-enzyme digestion followed by microbiological assay. Analyzed values were compared to those in the Canadian Nutrient File (2007b, CNF) and to label values.

RESULTS

The analyzed folate content of foods was, on average, 151% +/- 63 of the CNF values. Analyzed values as a percent of CNF values ranged from 116% in the "rolls and buns" category to 188% in "ready-to-eat cereals". Analyzed values were higher than label values for "breads", "rolls and buns" and "ready-to-eat cereals" (141%, 118% and 237%, respectively [p < 0.05]).

CONCLUSIONS

Ten years after folic acid fortification of the food supply, neither the CNF nor label values accurately reflect actual amounts of folate in foods. Further, overage differences by food category hinder the development of future strategies designed to strike the right balance between health benefits and risks; monitoring of fortified foods for their nutrient content is required.

Perinatal depression: prevalence, risks, and the nutrition link--a review of the literature

The purpose of this review is to examine the role of nutrition in perinatal depression. Perinatal (maternal) depression refers to major and minor episodes during pregnancy (termed antenatal) and/or within the first 12 months after delivery (termed postpartum or postnatal). Prevalence of antenatal depression can be as high as 20%, while approximately 12% to 16% of women experience postpartum depression. These are probably conservative estimates, as cases of maternal depression are underreported or underdiagnosed. Risk factors for depression include genetic predisposition and environmental factors, as well as a number of social, psychological, and biological factors. One biological factor given increasing consideration is inadequate nutrition. Credible links between nutrient deficiency and mood have been reported for folate, vitamin B-12, calcium, iron, selenium, zinc, and n-3 fatty acids. For maternal depression, the nutrient that has received the most attention from nutrition researchers has been the n-3 essential fatty acids. Numerous studies, such as randomized controlled trials, cohort studies, and ecological studies, have found a positive association between low n-3 levels and a higher incidence of maternal depression. In addition, nutrient inadequacies in pregnant women who consume a typical western diet might be much more common than researchers and clinicians realize. A number of studies have reported inadequate intakes of n-3, folate, B vitamins, iron, and calcium in pregnant women. Depletion of nutrient reserves throughout pregnancy can increase a woman's risk for maternal depression.

Folic acid food fortification prevents inadequate folate intake among preschoolers from Ontario

Objective

Folic acid food fortification has successfully reduced neural tube defect-affected pregnancies across Canada. The effect of this uncontrolled public health intervention on folate intake among Canadian children is, however, unknown. Our objectives were to determine folic acid intake from food fortification and whether fortification promoted adequate folate intakes, and to describe folic acid-fortified food usage among Ontario preschoolers.

Design

Cross-sectional data were used from the NutriSTEP™ validation project with preschoolers recruited using convenience sampling. Mean daily total folate and folic acid intakes were estimated from 3 d food records, which included multivitamin supplement use. Comparisons were made to Dietary Reference Intakes, accounting for and excluding fortificant folic acid, to determine the prevalence of inadequate and excessive intakes.

Setting

Canada.

Subjects

Two hundred and fifty-four preschoolers (aged 3–5 years).

Results

All participants (130 girls, 124 boys) ate folic acid-fortified foods and 30 % (n76) used folic acid-containing supplements. Mean (se) fortificant folic acid intake was 83 (2) μg/d, which contributed 30 % and 50 % to total folate intake for supplement users and non-users, respectively. The prevalence of total folate intakes below the Estimated Average Requirement was <1 %; however, excluding fortificant folic acid, the prevalence was 32 %, 54 % and 47 % for 3-, 4- and 5-year-olds, respectively. The overall prevalence of folic acid (fortificant and supplemental) intakes above the Tolerable Upper Intake Level was 2 % (7 % among supplement users).

Conclusions

Folic acid food fortification promotes dietary folate adequacy and did not appear to result in excessive folic acid intake unless folic acid-containing supplements were consumed.

Dietary intake and nutritional adequacy prior to conception and during pregnancy: a follow-up study in the north of Portugal

Objective

To assess maternal diet and nutritional adequacy prior to conception and during pregnancy.

Design

Follow-up of a cohort of pregnant women with collection of questionnaire data throughout pregnancy and after delivery.

Setting

Antenatal clinics at two public hospitals in Porto, Portugal.

Subjects

Two hundred and forty-nine pregnant women who reported a gestational age below 13 weeks at the time they attended their first antenatal visit.

Results

Intakes of energy and macronutrients were within recommended levels for most women. Pregnancy was accompanied by increases in the dietary intake of vitamins A and E, riboflavin, folate, Ca and Mg, but declines in the intake of alcohol and caffeine. The micronutrients with higher inadequacy prevalences prior to pregnancy were vitamin E (83 %), folate (58 %) and Mg (19 %). These three micronutrients, together with Fe, were also those with the highest inadequacy prevalences during pregnancy (91 %, 88 %, 73 % and 21 %, respectively, for folate, Fe, vitamin E and Mg). Ninety-seven per cent of the women reported taking supplements of folic acid during the first trimester, but the median gestational age at initiation was 6·5 (interquartile range 5, 9) weeks. Self-reported prevalences of Fe and Mg supplementation were high, and increased throughout pregnancy.

Conclusion

The study identified low dietary intakes of vitamin E, folate and Mg both in the preconceptional period and during pregnancy, and low intake of Fe during pregnancy only. The low dietary intake of folate and the late initiation of supplementation indicate that current national guidelines are unlikely to be effective in preventing neural tube defects.

Steady state folate concentrations achieved with 5 compared with 1.1 mg folic acid supplementation among women of childbearing age

BACKGROUND

Synthetic folic acid (0.4-1.0 mg) consumed during the periconceptional period has been shown to reduce the risk of neural tube defects. Women with poor supplement adherence or a previous pregnancy affected by a neural tube defect may need to take higher doses of folic acid (4-5 mg). However, there are limited data on the pharmacokinetics of higher folic acid doses.

OBJECTIVE

Our aim was to compare steady state folate concentrations in women of childbearing age who took 5 or 1.1 mg folic acid daily for 30 wk.

DESIGN

Forty nonpregnant women aged between 18 and 45 y, who did not take folic acid supplements, were enrolled in the study. Subjects were randomly assigned to take either 5 or 1.1 mg folic acid daily for 30 wk. Plasma and red blood cell (RBC) folate concentrations were measured at baseline and at weeks 2, 4, 6, 12, and 30.

RESULTS

There was no significant difference in baseline RBC folate concentrations between the 2 groups (1121 +/- 410 and 1035 +/- 273 nmol/L for the 5- and 1.1-mg folic acid groups, respectively). Significant differences in RBC folate were detected between groups at weeks 4, 6, 12, and 30. RBC folate concentrations by week 30 were 2339 +/- 782 and 1625 +/- 339 nmol/L for the 5- and 1.1-mg folic acid groups, respectively.

CONCLUSION

The use of 5 mg folic acid among women of childbearing age produced higher blood folate concentrations, with a faster rate of folate accumulation, compared with 1.1 mg folic acid.

How well do blood folate concentrations predict dietary folate intakes in a sample of Canadian lactating women exposed to high levels of folate? An observational study

Background

In 1998, mandatory folic acid fortification of white flour and select cereal grain products was implemented in Canada with the intention to increase dietary folate intakes of reproducing women. Folic acid fortification has produced a dramatic increase in blood folate concentrations among reproductive age women, and a reduction in neural tube defect (NTD)-affected pregnancies. In response to improved blood folate concentrations, many health care professionals are asking whether a folic acid supplement is necessary for NTD prevention among women with high blood folate values, and how reliably high RBC folate concentrations predict folate intakes shown in randomized controlled trials to be protective against NTDs. The objective of this study was to determine how predictive blood folate concentrations and folate intakes are of each other in a sample of well-educated lactating Canadian women exposed to high levels of synthetic folate.

Methods

The relationship between blood folate concentrations and dietary folate intakes, determined by weighed food records, were assessed in a sample of predominantly university-educated lactating women (32 ± 4 yr) at 4-(n = 53) and 16-wk postpartum (n = 55).

Results

Median blood folate concentrations of all participants were well above plasma and RBC folate cut-off levels indicative of deficiency (6.7 and 317 nmol/L, respectively) and all, except for 2 subjects, were above the cut-off for NTD-risk reduction (>906 nmol/L). Only modest associations existed between total folate intakes and plasma (r = 0.46, P < 0.001) and RBC (r = 0.36, P < 0.01) folate concentrations at 16-wk postpartum. Plasma and RBC folate values at 16-wk postpartum correctly identified the quartile of folate intake of only 26 of 55 (47%) and 18 of 55 (33%) of subjects, respectively. The mean RBC folate concentration of women consuming 151–410 μg/d of synthetic folate (2^nd quartile of intake) did not differ from that of women consuming >410 μg/d (3^rd and 4^th quartile).

Conclusion

Folate intakes, estimated by food composition tables, and blood folate concentrations are not predictive of each other in Canadian lactating women exposed to high levels of folate. Synthetic intakes > 151–410 μg/d in these women produced little additional benefit in terms of maximizing RBC content. More studies are needed to examine the relationship between blood folate concentration and NTD risk. Until data from such studies are available, women planning a pregnancy should continue to consume a daily folic acid supplement of 400 μg.

Folate during reproduction: the Canadian experience with folic acid fortification

Folate has received international attention regarding its role in the risk-reduction of birth defects, specifically neural tube defects (NTDs). In 1998, health officials in Canada, like the United States, mandated the addition of folic acid to white flour and select grain products to increase the folate intake of reproductive-aged women. Subsequent to this initiative there has been an increase in blood folate concentrations in Canada and a 50% reduction in NTDs. Many countries, including Korea, have not mandated folic acid fortification of their food supply. Reasons vary but often include concern over the masking of vitamin B₁₂ deficiency, a belief that folate intakes among womenare adequate, low priority relative to other domestic issues, and the philosophy that individuals have the right not to consume supplemental folic acid if they so choose. Prior to folic acid fortification of the food supply in Canada, the folate intakes of women were low, and their blood folate concentrations while not sufficiently low to produce overt signs of folate deficiency (eg. anemia) were inconsistent with a level known to reduce the risk of an NTD-affected pregnancy. The purpose of this article is to describe the role of folate during the periconceptional period, pregnancy, and during lactation. The rationale for, and history of recommending folic acid-containing supplements during the periconceptional period and pregnancy is described as is folic acid fortification of the food supply. The impact of folic acid fortification in Canada is discussed, and unresolved issues associated with this policy described. While the incidence of NTDs in Canada pre-folic acid fortification were seemingly higherthan that of Korea today, blood folate levels of Korean women are strikingly similar. We will briefly explore these parallels in an attempt to understand whether folic acid fortification of the food supply in Korea might be worth consideration