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Improving folic acid intake

In the Republic of Ireland, 236 babies with a neural tube defect (NTD) were born between 2009 and 2011, a reverse in the trend from the previous decade. On average, around 80 babies are born every year with a NTD — taking folic acid daily as a supplement could potentially prevent 70 per cent of these cases.

However, folic acid intake in women planning to have a child or already pregnant is suboptimal in Ireland.

A new scientific report, published by the Food Safety Authority of Ireland (FSAI) in May, highlights the need for women of child-bearing age to have higher intakes of folic acid, in order to reduce the incidence of severe birth defects in Ireland. Produced by the FSAI’s Scientific Committee, the Update Report on Folic Acid and the Prevention of Birth Defects in Ireland provides a comprehensive update on folic acid nutrition and the efforts to reduce Irish rates of NTDs such as spina bifida and anencephaly, which are among the highest in the world. 

The report examines the effectiveness of increasing women’s folic acid intakes through food supplements and food fortification. This report summarises the options for further reducing the risk of NTD-affected pregnancies in Ireland.

The achievement of optimal folate status is an important public health goal for Ireland, as it is for populations worldwide. 

While taking folic acid before conception and during the very early stages of pregnancy can prevent up to 70 per cent of NTDs, it is currently estimated that only 36 per cent of women of child-bearing age in Ireland have blood folate levels that are adequate for optimal protection against NTDs. One-in-five young women in Ireland do not consume folic acid at all (non-consumers of supplements or fortified food) and very few of these women have the level of blood folate required to protect against the development of NTDs, should they become pregnant.

Since 1993, the policy in Ireland has been to advise all women of child-bearing age to take 400µg of folic acid daily as a supplement, whether they are planning to become pregnant or not. In practice, very few women in Ireland take folic acid supplements as recommended. There is particular concern that women from disadvantaged backgrounds are least likely to follow folic acid recommendations. Voluntary fortification of food with folic acid by manufacturers, which was introduced in the early 1980s, has made a significant contribution to reducing the risk of NTD-affected pregnancies in Ireland. However, the approach has been shown to be less effective than mandatory fortification schemes in countries such as the US, where rates of NTDs are significantly lower than in Ireland, the FSAI has pointed out.

The report proposes that one of two options should be implemented to reduce risk of NTD-affected pregnancies in Ireland. Both options have been presented to an expert group on folic acid set up by the Minister for Health.

Option one: Mandatory fortification, together with voluntary fortification and advice on supplementation

Mandatory fortification of bread or flour in Ireland to provide about 150µg of folic acid per day in women of child-bearing age could reduce the prevalence of NTDs by approximately 30 per cent. This should be accompanied by advice to all women of child-bearing age who are capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement. Voluntary fortification of foods with folic acid would continue. Mandatory fortification of flour or bread with folic acid would require legislation. Compared to the other option, this option has stronger evidence to support its effectiveness in further reducing the rate of NTD-affected pregnancies from the current rate, according to the FSAI.

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Option two: Voluntary fortification together with advice on supplementation

Continuation of current policy to advise all women of child-bearing age who are capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement. Voluntary fortification of foods with folic acid would continue and there is potential to improve its effectiveness by providing guidance on voluntary fortification of selected foods with folic acid by manufacturers, eg, for levels of fortification and the range of foods fortified, in conjunction with a voluntary labelling scheme. Compared to option one, this approach has weaker evidence to support its possible effectiveness in further reducing rates of NTD-affected pregnancies from the current rate, according to the FSAI.

‘Babies know the facts about folic’

The safefood campaign ‘Babies know the facts about folic’ has been developed to encourage women to take folic acid supplements and help address Ireland’s high incidence rate of NTDs.

Speaking at the launch of the campaign last year, Prof Michael Turner, UCD Professor of Obstetrics and Gynaecology at the Coombe Women and Infants University Hospital, said: “We know from recently-published Irish research that three out of four women who attend for antenatal care have not taken folic acid supplements before they become pregnant. Taking folic acid daily as a supplement could potentially prevent two-thirds of NTDs every year — on average, that’s approximately 50 fewer babies affected every year.”

Dr Rhona Mahony, Master, National Maternity Hospital, Holles Street, added: “We know that women are somewhat aware of folic acid but with up to 50 per cent of all pregnancies being unplanned, it’s so important that all women who are sexually active start taking the vitamin daily, even if a baby is the last thing on their mind. That’s because a baby’s neural tube develops in the first few weeks of pregnancy when many women may be unaware they are pregnant.”

Consumer research conducted by safefood for the campaign found that young adult women are misinformed, with less than 10 per cent of women surveyed taking folic acid routinely, while a further one-in-10 wrongly believed they got enough folic acid from the food they ate.

A new research project being funded by safefood will also look at folic acid levels in women during the first trimester of pregnancy on the island of Ireland and will help inform future policy and practice around folic acid.

For more information, visit www.safefood.eu/folicacid.

Challenges

Commenting on the report, Dr Mary Flynn, Chief Specialist in Public Health Nutrition, FSAI, states that the low folate status of women of child-bearing age remains a significant problem in Ireland, contributing to an unacceptably high rate of NTDs.

“There is conclusive scientific evidence linking low levels of folate with spina bifida and related birth defects, and this a major challenge given the low levels of folic acid in the Irish diet, which needs to be addressed,” says Dr Flynn. 

“The report looks at ways to increase folate levels either through a system of mandatory fortification of food staples, such as bread and flour, or through improvements in the current voluntary approach. In addition to dietary intake, we continue to advise that the most effective way to protect against NTDs is for all women of child-bearing age to take 400µg of folic acid every day through a supplement. Unfortunately, this advice is not being followed by most women in the target group and this is a particular concern, given the link with birth defects. Ongoing and sustained information campaigns are therefore required to promote the use of folic acid supplements as part of a national strategy to reduce birth defects.”

Higher-risk women should consult GPs

Some women may be at a higher risk of having a baby with an NTD and should consult with their GP first about whether there is a need for a higher dose of folic acid.

The risk categories:

• If they or their child have an NTD, for example, spina bifida or hydrocephalus.

• If they or their partner’s family have a history of NTDs.

• If they are overweight or obese.

• If they have type 1 or type 2 diabetes.

• Folic acid can also affect certain medications pregnant women may be taking, for example for epilepsy, so if they are unsure for any reason it is recommended they consult their GP for medical advice and discuss the options, given their own personal circumstances.

For more information, visit www.safefood.eu/folicacid.

Additional recommendations outlined in the report include:

Guidance should be provided to food manufacturers for voluntary food fortification with folic acid to support the effectiveness of the chosen national policy.

Advice to women of child-bearing age capable of becoming pregnant to take an additional 400µg folic acid daily as a food supplement should be actively promoted and its effectiveness monitored.

A comprehensive nationwide register of pregnancies affected by congenital birth defects including NTDs, underpinned by specific legislation, needs to be introduced in Ireland. In addition, a national retrospective study on the incidence of NTDs in Ireland since 2012 should be undertaken.

There should be ongoing monitoring, informed by international best practice, of dietary intake and blood levels of folate, including folic acid in the food supply, total folate intake and corresponding blood folate status for the target group (women of child-bearing age) in addition to other population sub-groups.

The policy should be reviewed on a regular basis to assess its effectiveness and safety.

A copy of the Update Report on Folic Acid and the Prevention of Birth Defects in Ireland is available on the FSAI website: www.fsai.ie/publications_folic_acid_update/.

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