Folate - information for health professionals

Page content: Why promote folate to Victorian women? | Who does it affect? | What is folate? | Why all women of child bearing age? | How to promote folate to Victorian women | What are neural tube defects? | High risk groups | Who needs folate? | Current advice on folate and the prevention of neural tube defects | Suggested way to use the resources | For more information | Further references

Why promote folate to Victorian women?

Over the past few years the National Health and Medical Research Council (NHMRC) and the Federal Government have both acknowledged the connection between increased intake of folate and the prevention of neural tube defects. Research indicates that increased folate intake can prevent seven out of 10 births of babies affected by a neural tube defect.

The Victorian Department of Human Services has acknowledged this and embarked on a statewide folate awareness campaign. Some other Australian states have also acknowledged this need and organised similar awareness campaigns.

The NHMRC policy statement (1993) emphasises the need for women who are capable of getting pregnant, or who are planning a pregnancy to be advised about folate and the importance of increasing folate intake to 0.4 - 0.5mg daily. This is supported by the Australian College of Paediatrics and the Public Health Association of Australia.

In Victoria, the range of 0.4 - 0.5mg has been adopted to take into account the variation in products available on the market. It is common for 0.5mg folate supplements to be available, however there are some manufacturers which produce 0.4mg supplements or multivitamins with 0.4mg folate content. Both of these amounts are acceptable.

The issue of folate has also been highlighted in the Australian and New Zealand Food Authority (ANZFA) pilot health claims project which has included the involvement of food manufacturers and a major supermarket chain. The pilot project may result in a monitored program through which food processors and manufacturers will be able to promote the link between approved foods and specific health benefits on food labels.

Other intiatives to raise awareness of folate have also been conducted by commercial organisations, such as vitamin and cereal manufacturers.

top of page

The findings of the latest National Nutrition Survey show that out of all Australian women surveyed, Victorian women are the least likely to be aware of the need to take a folate supplement daily. The recent work done by Consumer Information Group on Pregnancy and Childbirth based at the Royal Women's Hospital also showed that the levels of awareness of the role of folate in risk reduction of neural tube defects can be increased when a number of awareness raising interventions are undertaken in certain targeted groups in the community.

Precampaign surveys done for Victoria's campaign showed:

• 77.5% of women had heard of the term 'folate' or 'folic acid'
• 42.8% did not know what it was and a further 31% gave an incorrect response
• 24% knew folate could prevent birth defects and just over half of these could name what type (spina bifida or neural tube defects)
• 1.5% thought folate could help them get pregnant
• 40% of women surveyed thought that folate should be taken prior to pregnancy. 9% thought it should be taken during pregnancy and 4% thought 'during a menstrual period'. 38% did not know.
• of the women surveyed for this campaign, 4% were taking a folate supplement. This and other data on folate supplementation show that Victorian women are the least likely in the country to take a supplement.

Who does it affect?

Any woman of child bearing age has the potential to have a baby affected by a neural tube defect. Absence of a family history or previous birth of unaffected children are not protective factors.

There is no evidence to suggest that the age of the mother (or father) is a risk factor.

There is also no evidence to suggest that the risk of neural tube defects are linked with socio-economic status, specific ethnic groups or races.

There are, however, some factors which would put a woman at 'high risk' of experiencing a neural tube defect affected pregnancy.

top of page

What is folate?

Folate (also called 'folic acid') is a B group vitamin found in a variety of foods. It is added to many vitamin and mineral supplements as folic acid, a synthetic form of folate.

Food sources of folate include green leafy vegetables such as brussels sprouts and spinach, potatoes, bananas, strawberries and legumes. Some pastas, breads and cereals have been fortified with folate and have labels to indicate this. Diets that are generally rich in other B vitamins and vitamin C are usually rich in folate.

Folate is vulnerable to heat and dissolves in water - so cooking can reduce the levels of folate in foods. Prolonged storage of certain foods is also thought to reduce their folate levels. It can be misleading to advise women that a certain amount of food contains a certain amount of folate because of this. For this reason, this document does not give specific guidance on quantities of food and measured folate content, however the following table can be used as a reference.

Special note: One food which is high in folate is liver. However, it should be noted that liver should not be recommended to women who are, or could be, pregnant because of its high Vitamin A content and risk of listeriosis. Both pose a risk to a developing foetus.

top of page

Why 'all women of child bearing age'?

There are two major reasons why 'all women of child bearing age' are a target of this campaign and should be advised to increase their folate intake.

The first is that research indicates that about half of all pregnancies are not planned. This does not mean they are not wanted, but it does mean that many women did not anticipate or plan the pregnancy. For this reason it is unwise to link increased folate intake too closely with pregnancy, because it assumes that most are planned. This is clearly not the case.

The second is based on the fact that the neural tube develops before a woman knows or suspects she is pregnant, making it difficult to gauge when 'one month prior to conception' actually will be.

How to promote folate to Victorian women

• Raise the issue of folate in general consultations or discussions with women who use your service.
• Find out more about the issue by phoning for information on 1800 013 952

There are a range of materials you can access for your patients or clients that have been researched, developed and evaluated for the purposes of this campaign. The research showed that two types of approaches needed to be developed. One approach is aimed at women who do not consider pregnancy an issue for them and might therefore discount the relevance of increasing their folate intake. The other approach acknowledges that there are many women who are open to the possibility of parenthood - whether they are actively planning a pregnancy, have already had children and want more, or simply consider the issue relevant to them as future mothers.

A range of resources has been developed to appeal to each of these groups:

• Two posters and a brochure for use in health settings. The brochure text is available in some languages other than English. Phone Family Planning Victoria to find out what is currently available on 1800 013 952.
• A portable display has been produced which can be borrowed from Family Planning Victoria to highlight the issue in your community or service.
• A checklist of women's health issues has been developed to guide your discussions. The checklist is in the form of a double-sided notepad so that you can use it as a prompt and then provide women with the tear off sheet to remind them of the information you discussed.

Other ways for you to promote the folate issue include:

• Write a media release based on the information in this document for your local media;
• Ask school counsellors, nurses or welfare co-ordinators in your area if they are aware of the folate issue and inform them of the information available to young women through accessing Family Planning Victoria;
• Assist in promoting folate at local health fairs or festivals using the display, posters and brochures;
• Talk to the local chemist or health food shop about having a display to promote the folate message and folate supplements in local shops.

  top of page

What are neural tube defects?

One in every 600 pregnancies in Victoria is affected by a neural tube defect. Neural tube defects include anencephaly, encephalocoele and spina bifida.

The closure of the neural tube is complete at about the 26th day of pregnancy - often before a woman suspects she is pregnant.

Spina bifida is the most common form of neural tube defect resulting in continued life after birth. It occurs when the lower part of the neural tube, which develops into the spinal cordand the bones that enclose them, does not close properly, leaving the spinal cord exposed or covered only with skin. Babies born with spina bifida may have a wide range of physical disabilities, such as loss of bladder and bowel control, paralysis of the legs and associated hydrocephalus.

Anencephaly is a fatal condition in which the upper end of the neural tube does not close and the brain fails to completely develop or is entirely absent. Pregnancies affected by anencephaly often result in miscarriages, stillbirth or neonatal death.

Encephalocoele is when part of the brain or surrounding membranes protrude through a defect in the skull. It is very rare.

top of page

High risk groups

While the focus is on risk factors being associated with the mother, fathers might be considered 'high risk.'

A pregnancy is considered at higher risk if the mother or father have:

• already had a baby with a neural tube defect (that is, spina bifida or anencephaly)
• a neural tube defect themselves
• a blood relative affected by a neural tube defect (that is, spina bifida or anencephaly).

Another important risk indicator is when the mother takes medicine for epilepsy or seizures (some medications can affect the absorption of folate).

Women at risk need to have a folate intake about 10 times higher than the average recommended daily dose of 0.4 - 0.5mg daily, that is high risk women need a dose of 5mg per day.

There is no evidence to show that men need to take folate pre-conceptually.

Who needs folate?

Everyone needs folate in their diet (0.2mg), however the optimum level is higher for women of childbearing age (between 0.4-0.5mg) because of the evidence which shows it can lower the risk of neural tube defects in babies.

Ideally, folate intake should be increased at least one month prior to conception and maintained for the first trimester of a pregnancy. However, most women do not seek pre-pregnancy counselling where the issue of folate would ideally be raised.

Women who are already pregnant should be advised to take a folate supplement if they are in their first trimester. Those in a later stage of pregnancy should be given reassurance that the incidence of neural tube defects is still relatively small. If appropriate, they can be advised of the availability of ultrasound screening and other tests. They should be advised of the importance of increasing their folate intake for any subsequent pregnancies.

top of page

Current advice on folate and the prevention of neural tube defects

There are three ways a woman can increase her daily intake of folate and this campaign recommends that all three are adopted. The campaign is placing a particular emphasis on the need for women to take a folate supplement because this is the easiest way of being certain that folate levels are adequate.

Women who are able to get pregnant need to consume between 0.4-0.5mg daily. They can be advised to do this by doing all of the following:

1. taking a daily folate supplement (0.4-0.5mg) which is cheap and readily available from the supermarket, chemist or health food shop;
2. choosing foods that have added folate (or are 'fortified' with folate) - usually breakfast cereals and breads (advise them to read the labels of products);
3. eating more foods which are naturally rich in folate.

It is not possible to consume 'too much' folate. Using folate over many years appears to be safe and is not addictive - it is the same as taking any other water soluble vitamin supplement.

The range 0.4-0.5mg is offered to reflect what is available on the market. While most folate supplements are 0.5mg, many multivitamins and some supplements contain 0.4mg. Both amounts are sufficient. The reason that this campaign offers the range in its official advice to health professionals and women is to prevent any concern for women who are taking a 0.4mg supplement.

A 5mg supplement is available for women who are considered high risk. (See the previous definition).

A note on supplements: Not all supplements and multivitamins contain the optimum level of folate for women of childbearing age. Many multivitamins contain only 0.2 milligrams. It is important to clearly advise women of the level they should be looking for in a supplement. That is, 0.4 - 0.5mg.

top of page

Suggested ways to use the resources

• Make a habit of using the women's health checklist;
• Put the posters in waiting rooms, foyers, outpatient departments, clinic areas and community health centres;
• Make the brochure clearly visible and available to women.

For more information

For further information about folate and neural tube defects, contact Family Planning Victoria Information Hotline on 1800 013 952.

Other useful numbers:

Spina Bifida Association - (61 3) 9362 6111
Victorian Clinical Genetic Service - (61 3) 8341 6201

Further references

Riley & Halliday. Congenital malformations in Victoria 1983 - 1994, Victorian Perinatal Data Collection Unit

Henshaw SK. Abortion incidence and services in the United States, 1995-1996.

Fam Plann Perspect. 1998 Nov-Dec;30(6): 263-70, 287.

Czeizel AE, Dudas I. Prevention of the first occurrence on neural-tube defects by periconceptional vitamin supplementation. N Engl J Med 1992; 327: 1832-1835.

Sauberlich HE. 1995. Folate Status of US Population Groups. In Bailey: LB (Ed) folate in health & Disease. Dekker, new York, pp 171-194

Harper PS. Practical genetic counselling. 4th ed. Oxford: Butterworth-Heinemann, 1993; 177.

National Health and Medical Research Council. Revised statement on the relationship between dietary folic acid and neural tube defects such as spina bifida. Canberra: NHMRC, 1993.

top of page