Folic Acid Supplementation

Folic acid is vital for pregnant women especially during early pregnancy to prevent neural tube defects and spine and brain defects in the unborn baby.

Worldwide governments and health organizations have made recommendations concerning folic acid ''supplementation'' for women intending to become pregnant. Despite recommendations, many women miss out on their folic acid supplements.

This has led to the fortification or addition of folates to regularly consumed foods like bread, cereals, grains, flour and breakfast cereals with the intention of everyone benefiting from the associated rise in blood folate levels.

Advantages and impact of fortification of foods with folic acid

Investigations on effects of folate fortification on blood levels showed that over years fortification of cereals and foods with folic acid will progressively:

  • Reduce the risk of neural tube defects in babies. The studies estimated that 77 to 162 cases of babies born with neural tube defects could be prevented each year. This is a 11 to 18% risk reduction. This means that women at greatest risk of neural tube defect affected pregnancies, i.e. those with the lowest folate intakes, would be reached through mandatory fortification.
  • Normalize the proportion of people in the population with folic acid intakes above the upper limit per day. The number of people with folic acid intakes above the upper limit per day would be reduced by 12,000.
  • Normalize the number of people aged 65 years and over with low vitamin B12 status consuming more than 1mg/day of folic acid. Studies showed that there would be no change in the number of adults aged 65 years and over, with low vitamin B12 status, exceeding intakes of 1mg/day.

Disadvantages of folic acid fortification

Folate fortification, if not accompanied by vitamin B 12, can unmask vitamin B12 mediated nerve damage. This is especially true in older individuals.

Clinical signs of vitamin B12 deficiency are anaemia and/or neurological impairment. Treatment with folic acid can alleviate or mask the anaemia and therefore delay the diagnosis of vitamin B12 deficiency, which can lead to the irreversible and serious nerve damage.

In addition, folic acid can also chemically interact with the pharmacokinetics of phenytoin, an anti- epileptic drug, and may lower serum phenytoin concentrations leading to poorer seizure control. Certain drugs like Methotrexate are anti-folate agents and their efficacy may be affected with mandatory fortification.

Countries that have opted for mandatory folic acid fortification

Flour fortification with folic acid is opted by several western countries. A number of Middle Eastern countries, Indonesia, Mongolia and a number of ex-Soviet republics have opted for fortification. Australia and New Zealand had jointly agreed to fortification though the Food Standards Australia New Zealand.

Australia has fortified all flour from 18 September 2009. The requirement is 0.135 mg of folate per 100g of bread. In the United Kingdom the Food Standards Agency has recommended fortification.

The United States Public Health Service recommends an extra 0.4 mg/day, which can be taken as a pill. Approximately 53% of the US population uses dietary supplements and 35% uses dietary supplements containing folic acid.

Men consume more folate (in dietary folate equivalents) than women and non-Hispanic whites have higher folate intakes than Mexican Americans and non-Hispanic blacks. As a result of the folic acid fortification program, fortified foods have become a major source of folic acid in the American diet.

How is food fortified with folates?

Folates can be produced by engineering Lactococcus lactis strains and using bioassay techniques. These engineered folates can potentially help alleviate the effects of folate deficiency in the diet.

Blood studies show that administration of these folates can show an improvement in megaloblastic or macrocytic anemia.

Further Reading


Last Updated: Jun 21, 2023

Dr. Ananya Mandal

Written by

Dr. Ananya Mandal

Dr. Ananya Mandal is a doctor by profession, lecturer by vocation and a medical writer by passion. She specialized in Clinical Pharmacology after her bachelor's (MBBS). For her, health communication is not just writing complicated reviews for professionals but making medical knowledge understandable and available to the general public as well.


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