The latest National Diet and Nutrition Survey (NDNS) highlighted that 91% of women of childbearing age (16 to 49 years) in the UK have folate levels that are too low.
It’s in the early stages of pregnancy that the foetus rapidly develops spine and nerve cells. Low folate levels increase the risk of foetal Neural Tube Defects (NTDs), such as spina bifida, so folic acid is recommended as a supplement.
Yet a recent survey of 750 pregnant women carried out by baby charity Tommy’s showed that:
- One in five women started taking folic acid before contraception
- One in six women did not take folic acid at all
Previous large studies have seen similar low levels of folic acid intake. For example, a study of nearly half a million women in England and the Isle of Man found less than 1 in 3 women had taken folic acid supplements before pregnancy.
What is the current advice for folic acid supplements?
Women planning a pregnancy (ideally two to three months before conception) are advised to take a 400-microgram supplement of folic acid until the 12th week of pregnancy.
Women with diabetes and those who have had a pregnancy previously affected by NTDs may need a 500-microgram supplement. For more information on who may need higher doses, see the National Health Service.
The advice for taking a supplement is in addition to eating foods rich in folate, the natural form of folic acid. Top sources of folate include green leafy vegetables, citrus fruits, beans and legumes, yeast extract and fortified foods. Eating these foods alone will not meet the demands of a pregnant women and their developing baby.
For more information, the British Dietetic Association (BDA) have produced a factsheet on folic acid.
Folic acid fortification: the UK needs to get up to speed
Over 80 countries have introduced mandatory fortification of flour with folic acid, to help reduce the number of babies affected with NTDs.
The UK hasn’t yet followed suit. In 2002, the Food Standards Agency (FSA) advised against mandatory fortification because folic acid supplements were believed to mask the anaemia caused by B12 deficiency (which causes ongoing nerve damage) and lead to an increased risk of colon cancer in certain groups.
However, more recent research has found no significant links between high doses of folic acid and cancer. In addition, countries that already have mandatory folic acid flour fortification in place haven’t seen an increase in people developing nerve damage as a result of B12 deficiency.
Highlighting the benefits, the US has seen a 23% fall in pregnancies with NTDs since the policy was introduced in 1998. A 2016 study published in the British Medical Journal estimated that 2,000 pregnancies associated with NTDs would have been prevented if the UK had adopted the same fortification as the US from 1998.
The most recent update from the Scientific Advisory Committee on Nutrition, which considers all the evidence for and against folic acid supplementation, echoed previous advice they had given supporting mandatory fortification of flour with folic acid in the UK. The FSA also now support mandatory fortification. Unfortunately, the UK government has remained unwilling to introduce regulation.
The BDA have information on how their members can help support the introduction of folic acid fortification to put pressure on the UK government.
What’s next for folic acid intake?
Folic acid plays a crucial role for the prevention of NTDs in babies but many women are not taking the recommended supplement before pregnancy.
In response to their findings, Tommy’s have created a new online tool, Planning for Pregnancy, which helps women plan for healthy pregnancies. It was created alongside the Royal College of Obstetricians and Gynaecologists, Public Health England and the UCL Institute for Women’s Health. The tool provides advice on folic acid and other factors involved for a healthy pregnancy and will hopefully prove to be a useful resource for women planning to become pregnant. Dietitians, nutritionists and all involved in food and health communications have a role in promoting such resources.
At a policy level, we hope to see the UK government enforce mandatory fortification of flour in the UK as a simple way to increase folic acid for everyone, in light of the wealth of evidence to support the measure.
Of course, in addition to taking folic acid pre-conception, there are other points to be aware of to help ensure a healthy pregnancy including avoidance of smoking, avoiding alcohol, being a healthy weight before pregnancy (BMI between 18.5kg/m2 and 24.9kg/m2) and engaging in regular moderate exercise.