Folic Acid

In North Carolina, about 200 pregnancies per year are affected by a neural tube defect (NTD). More than half of these babies will never be born. The others may be born with some degree of disability ranging from mild to severe. In some cases, the disability causes the baby to be stillborn or die within days after birth. If all women in the U.S. consumed adequate amounts of folic acid throughout their childbearing years, the incidence of NTDs could be reduced by up to 70 percent. Recent studies show that periconceptional multivitamin use may also reduce the risk of other major birth defects, such as orofacial clefts, congenital heart defects and urinary defects. In addition, some studies show that folic acid may help reduce the risk for heart disease, stroke and colon cancer.

“One of the most exciting medical findings of the last part of the 20th century is that folic acid, a simple, widely available, water-soluble vitamin, can prevent spina bifida and anencephaly. Not since the rubella vaccine became available 30 years ago have we had a comparable opportunity for primary prevention of such common and serious birth defects.” – G. Oakley, MD, JAMA, March 10, 1993

The North Carolina Preconception Health Campaign has found that encouraging women to take a multivitamin instead of a folic acid pill is more effective in producing a behavior change. Focus group testing in North Carolina revealed that young women are not interested in hearing about pregnancy, NTDs or folic acid unless they are actively contemplating a pregnancy. They are interested, however, in discussing weight, diet, nutrition, energy, exercise and their body in general terms. They state that they take multivitamins for non-pregnancy-related health issues and that they are unlikely to take a folic acid pill alone. These sentiments are reflected in our materials and on other sections of this website.

As a health professional, you are an important motivator to change patient behavior. Studies have shown that a simple recommendation from a health professional is a major reason why women take supplements. According to a study conducted by the Gallup Organization and March of Dimes Foundation, almost 90 percent of women say they’d take multivitamins at their doctor’s recommendation. Additionally, 99 percent of Latina women surveyed in North Carolina stated they would take a multivitamin if their health care provider recommended it. However, only 33 percent of women ages 18-45 who say they are aware of folic acid actually heard about folic acid from their health care provider.1

Patients value the opinion of their health care provider. Tell your patients, even those not planning a pregnancy, to take a multivitamin with folic acid daily. The North Carolina Preconception Health Campaign provides free in-service presentations to health care providers in North Carolina. For more information about our folic acid trainings, please contact us.

A provider training on folic acid is also available from the NC Department of Public Health. Click here to download the slides.

What you need to know about folic acid

Folic acid (pteroylglutamic acid) is a B vitamin that acts as a coenzyme in single-carbon transfers. It is involved in many reactions, especially those in cell division, including:

  • DNA synthesis as part of a coenzyme for pyrimidine nucleotide synthesis and purine synthesis
  • Amino acid conversions, most notably the conversion of homocysteine to methionine

Folate is the natural form of folic acid found in food. Food folates are pteroylpolyglutamates, which contain one to six additional glutamates compared to folic acid. These polyglutamate derivatives must be hydrolyzed to monoglutamate forms prior to absorption in the proximal small intestine. In addition, dietary folates are heat-liable, thus easily destroyed by storage and cooking. It is estimated that the bioavailability of dietary folate is approximately 50 percent. Thus, it is almost impossible to obtain the recommended 400 mcg of folic acid from food sources alone.

Only folic acid supplementation, along with a healthy diet, has been proven to reduce the incidence of NTDs. This is true even when women are counseled about increasing dietary folates. Liver, most dried beans, peas, oranges and some green vegetables are good sources of folate. Yet, one would need to eat four cups of black beans or 16 oranges to obtain the equivalent of 400 mcg of folic acid.

Folic acid’s role in the prevention of birth defects is well documented and supported by scientific evidence. This includes observational and randomized control trials.

Recent research suggests that folic acid supplementation may play a role in reducing the risk of other congenital conditions, such as orofacial clefts, congenital heart defects and defects of the urinary tract. For adults, it may play a role in reducing the risks for heart disease, stroke, vascular diseases, poor cognitive function in the elderly and colorectal cancer. Due to its ubiquitous role in coenzymes and DNA synthesis, folic acid continues to be a topic of research.

What women know about folic acid

Many women state they know about folic acid and its role in preventing birth defects. According to data obtained through the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) survey and the Behavioral Risk Factor Surveillance System (BRFSS) survey, the majority of women know the following information.

In North Carolina:

  • About 82 percent of women know that folic acid can help prevent some birth defects. Women under the age of 20 are least likely to know that folic acid can prevent some birth defects.2
  • About 60 percent of women of childbearing age (18-44) correctly identified birth defect prevention as the reason why health experts recommend 400 mcg of folic acid.3
  • Eighty-two percent of women get information about folic acid from a doctor, nurse or other health care provider.4

What women do regarding folic acid

There is a disconnect between what women know about folic acid and how they behave. Recent data show that only 38 percent of women ages 18-44 in North Carolina take a multivitamin or vitamin pills/supplements containing folic acid daily.5 Nationally, women’s folic acid-taking behavior is not much different. A national survey conducted by the Gallup Organization and March of Dimes Foundation shows that only 39 percent of women take folic acid daily (2008).6

In addition, the same survey reported that 89 percent of women who do not currently take any multivitamin supplements on a daily basis report they would be likely to take a daily multivitamin if advised to do so by their physician or other health care provider.7

Sources:

  1. Gallup Organization and March of Dimes Foundation (2008). Improving Preconception Health: Women’s Knowledge and Use of Folic Acid.
  2. PRAMS, 2005. PRAMS is an ongoing, population-based, randomized survey of North Carolina resident women who have recently given birth. Information is collected on pregnancy risk factors, access to health care services and other issues related to improving the health of both the mother and the baby. It is conducted by the NC State Center for Health Statistics.
  3. BRFSS, 2006. BRFSS is an ongoing, population-based, randomized survey of state residents aged 18 and older in households with telephones. Information is collected on a variety of health behaviors and preventive health practices related to the leading causes of death and disability such as cardiovascular disease, cancer, diabetes and injuries. It is conducted by the NC State Center for Health Statistics.
  4. PRAMS, 2005
  5. BRFSS, 2008
  6. Gallup Organization and March of Dimes Foundation (2008). Improving Preconception Health: Women’s Knowledge and Use of Folic Acid.
  7. Ibid.