What is the difference between folate and folic acid?

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Supplementation with vitamin B9 is recommended for pregnant women to prevent complications related to pregnancy, chiefly neural tube defects. While the terms “Folate” and “Folic acid” are used interchangeably to refer to vitamin B9, they are not the same. In this article, we address the most frequently asked questions about folate and folic acid and the importance of this supplement during pregnancy.

Pregnant women require vitamins and minerals to support the growth and development of the fetus along with maintaining good health during this period. Folate and folic acid are vitamin B9 forms that should be taken during pregnancy to prevent pregnancy-related complications.  

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What is the difference between Folate and Folic acid?

The terms “Folate” and “Folic acid” are often used analogously, however, they are not synonymous. Folate is a natural form of vitamin B9 present in beans, peanuts, sunflower seeds, fresh fruits, liver, seafood, eggs, leafy green vegetables, and citrus fruits. Naturally occurring vitamin B9 preparations include the following:1,2,3 

  • Dihydrofolate (DHF)
  • Tetrahydrofolate (THF)
  • 5-methyltetrahydrofolate (5-MTHF)
  • 5, 10-methylenetetrahydrofolate (5, 10-MTHF)

Folic acid on the other hand is a synthetic form of vitamin B9 found in fortified products and supplements.1,2,3 

Both folate and folic acid have the same role in the body but have different mechanisms. Folate is the more bioavailable form as it is easily converted into an active form of vitamin B9 in the gut and is involved in several metabolic functions. Folic acid on the other hand initially gets converted into dihydrofolate (DHF) followed by tetrahydrofolate (THF) before getting absorbed. However, folic acid is more heat stable thus making it the better option for food fortification.1,2,3 

What is the importance of folate during pregnancy?

The need for folate increases substantially during pregnancy. Folate is essential for fetal development as it facilitates cell growth, cell division and functioning. Aside from this, it is needed for the production of healthy red blood cells, DNA, and RNA and is vital for protein metabolism. Folate also assists in alleviating pain and inflammation in the body and breaks down homocysteine which could be toxic to the body in large amounts.3,4  

Folate is an important element to support periods of rapid growth and is required to prevent birth defects such as congenital deformities of the brain or spine, including neural tube defects (NTDs). Thus, folate deficiency during pregnancy can be detrimental to the baby, as it may result in neural tube defects in the newborn.2,3 

How can we identify a folate deficiency?

A folate deficiency could affect several metabolic and body functions. The symptoms include reduced appetite, fatigue, mouth ulcers, diarrhea, irritability, and pallor.5  

What is the recommended amount of folic acid?

Vitamin B9 can be procured from regular dietary sources. However, pregnant women may need an additional amount to support the growth of the fetus and prevent complications. Folic acid supplementation can help in bridging the gaps in pregnant women and should be taken before conception, during pregnancy, and in the postpartum period.3  

Recommendations may vary depending on the country and their policies, and on the nutrient status and risk factors of the mother. Some are detailed below:  

  • CDC recommends 400 mcg of folic acid/day along with dietary sources for women of reproductive age2  
  • US public health service (1992), Institute of Medicine (1998), US preventive services task force (2009), TGA, 18 European countries recommend 400 mcg/day of folic acid during pregnancy6 
  • In the Netherlands, the recommended intake is 500 mcg/day6 
  • Canadian recommendations for folic acid in pregnancy are as follows:4 
     
Population Folic acid dose 
Patients having no personal health risks, planned pregnancy 
  • 0.4 to 1 mg/day along with dietary sources of folate months before conception (at least 2 to 3), all-round pregnancy as well as the postpartum period 
Patients having health risks, family history of NTD, an ethnic group with high risk 
  • 5 mg folic acid along with dietary sources of folate starting at least 3 months before conception and continued till 10 to 12 weeks after conception 
  • 0.4 to 1 mg/day from 12 weeks post-conception and continuation throughout pregnancy and the postpartum period 

*Postpartum period: (4–6 weeks or as long as breastfeeding continues). 

is the difference between dietary folate equivalent (DFE) and micrograms of folic acid?

Folic acid can be measured as DFE or mcg. The recommended quantity in DFE and mcg are provided below.2 

 Recommended DFE (mcg) as per CDC Recommended Folic Acid (mcg) as per CDC 
To Prevent Anemia 400 mcg DFE 240 mcg folic acid 
To Prevent NTDs 667 mcg DFE 400 mcg folic acid 
In Lactating women 500 mcg DFE 300 mcg folic acid 

Do folic acid requirements change in mothers with a history of NTD pregnancy?

A high-risk pregnancy is marked by raised health risks for the pregnant woman and fetus. Risk factors include high blood pressure, diabetes, obesity, HIV infection, old or young maternal age, or a history of multiple births. Women who previously had an NTD-affected pregnancy are also considered at high risk and should consult a doctor if they are planning a pregnancy.7  

The current CDC recommendation is that women with high-risk pregnancies consume 4,000 mcg/day 1 month before conception and through the first 3 months of pregnancy. CDC also recommends consuming 400 mcg/day even when not planning pregnancy.8 

Conclusion:

Neural tube defects are one of the most serious complications encountered in pregnancy. Folic acid supplementation is an evidence-based recommendation to prevent neural tube defects, either alone or with other micronutrient supplementation. It is recommended to replenish the folate concentrations in women of reproductive age, women planning pregnancy, and during pregnancy. 

References

  1. Folate and folic acid for use in listed medicines. Available at: https://www.tga.gov.au/folate-and-folic-acid-use-listed-medicines Accessed on 23 March 2022
  2. General Information About NTDs, Folic Acid, and Folate. Available at: https://www.cdc.gov/ncbddd/folicacid/faqs/faqs-general-info.html Accessed on 2w March 2022
  3. Greenberg JA, Bell SJ, Guan Y, Yu YH. Folic Acid supplementation and pregnancy: more than just neural tube defect prevention. Rev Obstet Gynecol. 2011 Summer;4(2):52-9.
  4. Prenatal nutrition guidelines for health professionals. Available at: https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_forma… Accessed on 14 June 2022
  5. Folate Deficiency. Available at: https://my.clevelandclinic.org/health/diseases/22198-folate-deficiency#:~:text=Folate%20deficiency%20occurs%20when%20your,in%20foods%20that%20contain%20folate.
  6. Cawley S, Mullaney L, McKeating A, Farren M, McCartney D, Turner MJ. A review of European guidelines on periconceptional folic acid supplementation. Eur J Clin Nutr. 2016 Feb;70(2):143-54.
  7. What is high-risk pregnancy? Available at: https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/high-ri… Accessed on 14 June 2022
  8. MTHFR Gene, Folic Acid, and Preventing Neural Tube Defects. Available at: https://www.cdc.gov/ncbddd/folicacid/mthfr-gene-and-folic-acid.html Accessed on 2w March 2022