Cork doctor: What women need to know about folic acid

There are many things that women will do to make sure they are in their best shape to carry a child. Eating right and regular exercise are top of the list but there are a few other essentials that are just as important.

Food helps us to get most of the minerals and nutrients we need, but there are some that the body needs just a bit more of, and one supplement is an absolute must to prepare the body for a new baby.

In recent years, celebrities have been lining up to share their supplement routine to keep them in tip top condition. Miley Cyrus and Rihanna say they are big fans of daily supplements. Kate Middleton prepared for pregnancy with Vitamin B6 prenatally to help alleviate a severe pregnancy-induced vomiting condition called hyperemesis gravidarum.

But top of the list for pregnancy preparation is folic acid.

Now, Minister for Public Health, Wellbeing and the National Drugs Strategy, Jennifer Murnane O’Connor has taken the first step towards all non-wholemeal flour being fortified with folic acid, to help reduce the incidence of neural tube defects in Ireland.

Neural tube defects (NTDs) such as spina bifida, anencephaly and encephalocele, can occur when the spinal cord does not develop properly during pregnancy. Anencephaly is fatal, while spina bifida and encephalocele cause serious disability in survivors.

Ireland has a higher-than-average rate of neural tube defects - 1.05 per 1,000 births, compared with the rate in Europe of 0.36 per 1,000 births.

The good news is that up to two-thirds of neural tube defects can be prevented by consuming folic acid before and during the early stages of pregnancy. Women typically cannot get enough folic acid through diet alone, so fortified foods and folic acid supplements are needed to help reach the required levels.

“We hope to reduce the incidence of neural tube defects in Ireland in the future by increasing dietary intake of foods which have been fortified with folic acid, and by encouraging folic acid supplementation,” said Murnane O’Connor.

She emphasised the profound impact of neural tube defects on patients, their families and the health service.

Thirty-five years ago, in 1991, the Medical Research Council Vitamin Study confirmed that the majority of NTDs could be prevented if the mother took folic acid prior to conception as well as in the first trimester of pregnancy.

But the reality is that many women do not take supplements prior to conception.

The spinal cord begins forming in the embryonic stage, as early as the first 3 to 4 weeks of pregnancy. Cells fold inwards to form the neural tube that later develops into the perfectly intact brain and spinal cord. The tube is typically closed by the sixth week. The embryo is about 2mm long – about the size of an apple seed.

Because the crucial stages for formation of the spinal cord occur so early on, many countries worldwide have introduced mandatory fortification of flour with folic acid.

To date, 80 countries worldwide have introduced mandatory fortification policies with the addition of folic acid to staple foods like wheat flour, including the US, Canada, Australia and New Zealand. There is evidence of reductions in NTD rates in the US and Canada following mandatory fortification in 1998.

The UK is introducing mandatory fortification of non-wholemeal flour from December 13, 2026. This also means that products like breads, biscuits, cakes and pastries entering the Irish market from the UK will be fortified with folic acid.

And it’s not just unplanned pregnancies that gain from adding folic acid to flour. Many elderly people consume nutritionally incomplete meals for a variety of reasons – smaller appetites, poor dentition and a weaker swallow, while patients recovering from surgery or receiving chemotherapy need a nutrient-dense diet for cell growth and repair.

What is folic acid?

Folic acid is the synthetic form of folate or vitamin B9 which is an essential vitamin for making DNA.

Folate is the form that is found naturally in foods and folic acid is the form that is added to foods and food supplements. It plays an important role in forming red blood cells, cell growth and repair, maintaining brain health as well as playing a critical role in lowering the risk of NTDs.

Ireland currently imports the majority (70%) of its flour from the UK (49% from Great Britain and 21% from Northern Ireland).

After fortification, non-wholemeal flour will contain 0.25mg (250µg) folic acid per 100g.

Are there any negative effects of consuming too much folic acid?

A key question is whether people can consume too much folic acid.

Large doses of folic acid can mask Vitamin B12 deficiency in older people, leading to potential health impacts caused by delayed diagnosis.

The Food Safety Advisory Authority (FSAI) investigated this a decade ago and found the risk with the small doses being used to fortify food, to be negligible.

If food is fortified with folic acid – do I still need to take a folic acid supplement?

A critical question for women of childbearing age is if food is fortified with folic acid, should they continue to take a daily folic acid supplement?

The answer is a resounding yes.

The FSAI advises that intake resulting from folic acid in food containing fortified flour will not be sufficient to lower the risk of birth defects alone. It is recommended that all women of childbearing age should take a 400µg supplement daily.

The HSE advice if you are a woman of childbearing age and do not take folic acid already, it’s best to start taking it at least three months before you become pregnant and continue taking it throughout your pregnancy.

While you cannot get the amount of folate you need from food alone, it’s still important to include foods high in folate in your diet. This includes green leafy vegetables, legumes, or citrus foods. Some foods are also voluntarily fortified with folic acid such as breakfast cereals, yogurts, dairy spreads, fruit juices and some milks.

What does all of this mean?

Fortification of non-wholemeal flour is not the whole answer – rather just one part of a three-pronged approach to reducing NTDs. Diets high in leafy vegetables and citrus fruits; folate supplementation before and during pregnancy; and the mandatory fortification of non-wholemeal flour will all work together to reduce the incidence of a potentially fatal or complicated condition with life-long ramifications.

The bottom line is, if you are a woman of childbearing age and there is a chance you could become pregnant, make sure you are taking a folic acid supplement.

• Submissions on the publication consultation on the mandatory fortification of flour with folic acid can be made until October 5.
• See https://www.gov.ie/en/department-of-health/consultations/mandatory-fortification-of-flour-with-folic-acid-public-consultation/
• Dr Catherine Conlon is a public health doctor in Cork and former Director of Human Health and Nutrition, safefood.