What is folate/folic acid?
Folate is an essential B vitamin and is found naturally in leafy vegetables, citrus fruits, wholemeal bread, yeast, liver and legumes.
Folic acid refers to pteroylmonoglutamic acid and is the synthetic (‘man made’) form of folate. Folic acid is used in dietary supplements and fortified foods and beverages. It is more bio-available (more readily absorbed and used in the body) and stable, than naturally occurring food folate.
Why we need folate
Folate is important in cell growth and reproduction. Folate deficiency can result in a type of anaemia called ‘megaloblastic anaemia’ which is a blood disorder characterised by the presence of enlarged immature and dysfunctional red blood cells (megablasts).
Studies from the 1980s and 1990s showed that folic acid can help ensure healthy development of babies in early pregnancy. In 1999 Berry et al conclusively found that a daily dose of 400 µg of folic acid alone resulted in a reduction in neural tube defect risk (first occurrence) similar to that reported in earlier studies, when taken at least one month before conception and for 12 weeks after conceiving.
More information can be found about this research in the publication Improving Folate Intake in New Zealand: Policy Implications [in the Ministry's Library Catalogue].
Neural tube defects (NTD)
Neural tube defects (NTDs) are major birth defects where the brain, spinal cord, or the covering of these organs has not developed properly. Spina bifida and anencephaly are the most common types of NTDs.
Spina bifida is the most common NTD. It results from the failure of the spine to close properly during the first month of pregnancy. Children with spina bifida can have varying degrees of paralysis of their lower limbs – some children can be confined to a wheelchair whereas others have almost no symptoms at all. The condition can also cause bowel and bladder problems.
Babies born with anencephaly have underdeveloped brains and incomplete skulls. Most infants born with anencephaly do not survive more than a few hours after birth.
Between 2011 and 2015, the estimated NTD prevalence was 10.6 per 10,000 total births (live births, foetal deaths and terminated pregnancies). There was an average of 64 recorded NTD-affected pregnancies a year, 26 of which were live births.
The prevalence of NTD live births for wāhine Māori, Pasifika and European/other women was 4.58, 4.09 and 2.81 per 10,000 births respectively.
Aotearoa New Zealand's policy for folic acid supplementation
- Women at low risk of a NTD affected pregnancy who plan to become pregnant, are recommended to take a 800 µg tablet of folic acid daily for at least four weeks prior to conception and for 12 weeks after conceiving to reduce the risk of NTDs. More information can be found in the Health Education resource Folic Acid and Iodine.
- Women who are themselves affected with a NTD, or who have had a child with a NTD, a close family member who has had a NTD, or whose partner is affected or had a family history of NTD, are recommended to take a higher dose of 5000 µg (5 mg) of folic acid daily with subsequent pregnancies for at least four weeks prior to conception and for 12 weeks after conceiving to reduce the risk of NTDs.
- A daily folic acid tablet of 5 mg is also recommended for women who are on insulin treatment for diabetes for at least four weeks prior to conception and for 12 weeks after conception to reduce the risk of NTDs.
- A daily folic acid tablet of 5 mg is also recommended for women who are taking medicines known to affect folate metabolism such as anti-epileptics (eg, carbamazepine, sodium valproate). This tablet should be taken for at least four weeks prior to conception and for 12 weeks after conception to reduce the risk of NTDs.
Currently an 800 µg and 5 mg folic acid tablet are the only approved medicines available in New Zealand. These folic acid tablets can be obtained at a lower cost (subsidised) on a prescription or purchased over the counter from a pharmacy. These folic acid-only tablets are what the Ministry of Health recommends for women for at least four weeks prior to conception and for 12 weeks after conception to reduce the risk of NTDs.
Folic acid fortification
In Aotearoa New Zealand, just over half of pregnancies are unplanned, meaning that a significant number of women do not take folic acid supplementation during the critical period (one month before and for the first three months following conception). Fortification of a food is therefore the only other approach that reaches such a large group of women. It is an internationally, well-accepted and safe public health approach.
On 8 July 2021, the Government announced its decision for mandatory folic acid fortification of non-organic wheat flour that is used in making bread. Flour millers will have two years to make the necessary changes.
Until the flour is fortified with folic acid, bread-makers continue to add folic acid to bread on a voluntary basis. Other foods, such as breakfast cereals, fruit and vegetable juices, milk alternatives (eg, soy milk) and certain food drinks (eg, liquid meal supplements) may also contain added folic acid.
For more information on the regulation of folic acid fortification, see the Ministry for Primary Industries website.
Health benefits and risks of folic acid fortification of food
In April 2017, the Ministry of Health commissioned Sir Peter Gluckman, at that time the Prime Minister’s Chief Science Advisor (PMCSA), and the Royal Society Te Apārangi to review the health benefits and risks of folic acid fortification of food.
This involved a literature review and analysis of the available scientific evidence from Aotearoa New Zealand and internationally on the health benefits and risks of folic acid fortification.
An expert panel was appointed to oversee the review which included one lay member as an Observer. This follows the approach taken with previous scientific reviews conducted by the PMCSA and the Royal Society for the Ministry of Health on water fluoridation and exposure to asbestos.
Findings and conclusions
The report finds that there is compelling evidence that mandatory folic acid fortification is associated with lower rates of neural tube defects, and that taking folic acid supplements at the recommended doses in pregnancy has no adverse effects on pregnancy outcome or the child’s health.
No evidence was found to link the use of folic acid supplements or fortification to increased risks of neurological/cognitive decline, diabetes, or cardiovascular disease; nor was there evidence that unmetabolised folic acid is harmful.
Increasing folate naturally
Folate is found naturally in green leafy vegetables (such as spinach and broccoli), citrus fruits and juices, wholemeal bread and legumes. Animal liver is also a rich source of folate. However, it is difficult to get enough folate from natural sources to reduce the risk of a NTD affected pregnancy.
For example, if women relied on green leafy vegetables and fruit to increase their folate intake, they would have to eat the equivalent of 500 g of raw spinach or 900 g of boiled spinach or raw broccoli daily to get the amount needed to reduce the risk of having a baby with a neural tube defect.
Further information on eating well for pregnancy can be found the Health Education resource Eating for Healthy Pregnant Women or your local public health unit.
What other countries do with folic acid
Mandatory fortification with folic acid
- USA – has had mandatory fortification of all cereal/grain flours with folic acid since 1998.
- Canada – white flour and pasta has been mandatorily fortified since 1998.
- Chile – introduced mandatory fortification of flour in 2000.
- Australia – introduced mandatory fortification of non-organic bread-making wheat flour in late 2009.
Food Standards Australia New Zealand (FSANZ) develops food standards for both New Zealand and Australia.
Voluntary fortification with folic acid
- European countries – to date, none have introduced mandatory fortification with folic acid.
- UK and Ireland – continue to permit voluntary fortification of certain foods with folic acid.
Recommendations for women planning a pregnancy
USA, Canada, Australia, UK and Ireland recommend women planning a pregnancy take a folic acid tablet in the range of 400–500 µg for women at low risk of a NTD affected pregnancy.