A guide to understanding the importance of Folic Acid, Vitamin B9 and Folate

I recently heard a story of a young woman going to see a doctor about a number of problems. She was about 30 years old, and complained of weakness, headaches, certain pains, and other very non-specific symptoms which could mean anything. She also had some general questions about healthy diets, alternative treatments, and some others. The doctor listened patiently, and then gave her an answer. The doctor replied that she should forget about everything she came for, though if there was one thing that this doctor wanted to convey to the patient, it was that she should be taking folic acid regularly. Although it’s a bit of a silly story, I thought it might be a good transition to start talking about folic acid. Although folic acid is known to treat a number of situations including certain types of anemia, or prevention for stroke or cardiovascular disease, this post will only focus on some of the benefits pertaining to pregnancy and child birth.

What is folic acid, folate, and Vitamin B9?

Folic acid, folate, and vitamin B9 are 3 names for the same thing. Without diving too deep into the world of chemistry, folic acid is a compound that is used in one of the important stages of DNA synthesis, our genetic material. This is also true for RNA synthesis, which is the middle stage between DNA and proteins. Its most prominent jobs occur during cell division and replication. The implications of which are that a folic acid deficiency hits us in the most sensitive areas of cell replication, being bone marrow (where our blood is created and renewed) and fetal development during pregnancy. Anemia (low red blood cell count) is a common outcome of folic acid deficiency, and pregnant women with deficiency have much higher risks of abnormal fetal development, which can be expressed in a number of ways.

When/where did we find out about it?

The initial suggestion that folic acid deficiency is related to congenital birth defects was in 1965, when a pair of scientists named Hibbard and Smithells sought to explain the correlation of higher chances of birth defects with lower socioeconomic areas. The hypothesis was that a poor diet had to do with the matter, and so they provided periconceptional multivitamin supplementation to those areas. This paved the way for much more research to be provided on the matter.

Neural tube defects are often pointed to as the main problem.

Neural tube defects are considered the main complication of folic acid deficiency in pregnant women. These are a group of abnormalities of the nervous system, which can include defects of the brain, spine, or or spinal cord. A large study done in 1992 randomly assigned more than 4000 women with either a trace-element supplement, or a vitamin supplement which contained folic acid. The women in the group that received the vitamins had almost half of the chances of giving birth to a child with neural tube defects than the other group. Much larger studies since have been performed in China, showing that a 400 microgram daily supplement of folic acid reduces the risk of neural tube defects by 85%. Since those results have been published, it is unethical to continue to study such a topic by actively giving a group of women something that does not contain folic acid.

A large population based study in Hungary had results that indicated a significant reduction in preterm births after supplementation of folic acid in the second and third trimester of pregnancy.

Twins? Some studies tried to show correlation between women who took folic acid supplements and the chance of giving birth to twins. The largest and most convincing study however was done in China with more than 240,000 participants, and was published in 2003. They found that women taking 400 micrograms of folic acid on a daily basis before and during pregnancy did not have a higher risk for twin pregnancies compared to women not taking folic acid.

6 large studies reviewing the chances of miscarriage were combined and review, concluding that there was no evidence of any difference in the risk of total fetal loss, early or late miscarriage, or stillbirth between women who took folic acid with or without iron or multivitamins, compared to women who did not take folic acid. However, preliminary data from a large study in China are showing that women taking folic acid have almost a 45% lower odds of having a miscarriage.

Is it all good? What are the skeptics saying?

There was a report out of Johns Hopkins Bloomberg School of Public Health that suggested that women who had very high levels of Folic Acid in their blood had higher chances of giving birth to a child who would be diagnosed on the autism spectrum. Although I haven’t been able to find the research itself (if anyone could share a link I would appreciate it), a number of interviews and publications have helped me understand the facts behind it. 10% of women at birth had higher folic acid and B12 levels, and those women had higher chances of giving birth to child who would later be diagnosed with autism spectrum disorder. There was no correlation between supplements of folic acid and autism, and nothing has been proven so far with this preliminary data. We are going to have to wait until more research is performed to confirm or deny these findings, in order to start drawing conclusions.


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Here are some references of articles referred to in this post. I am happy to provide more information to those who seek, please send us a message and we’ll be happy to get back to you.

Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med. 1992;327(26):1832-1835.

Smithells RW, Sheppard S, Schorah CJ, et al. Apparent prevention of neural tube defects by periconceptional vitamin supplementation. Arch Dis Child. 1981;56(12):911-918.

Zheng JS, Guan Y, Zhao Y, et al. Pre-conceptional intake of folic acid supplements is inversely associated with risk of preterm birth and small-for-gestational-age birth: a prospective cohort study. Br J Nutr. 2016;115(3):509-516.


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