Tag Archives: folic acid

Thoughts on Choosing a Prenatal Vitamin

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“Are you taking a prenatal?”

Picking a prenatalIdeally, we would all get our nutrients from foods.  However, with food intolerances, food aversions, soil depletion, lack of access to high quality food sources, and food processing, some argue that this just isn’t possible in today’s world.  I won’t argue either way.  All I know is that doctors like it when women who are trying to conceive, pregnant, or nursing take a prenatal vitamin, but they aren’t always helpful in recommending one or up to date on the latest nutrient information.

I have delivered four babies in four different states, and my four different obstetricians never once had a firm prenatal vitamin recommendation.  Often, I just cycled through samples they gave me at different visits or some Walgreen’s over-the-counter product.  The question at OB check-ups always was, “Are you taking a prenatal?”  And my answer usually was, “Yes.”  The doctor’s simple response was, “Okay.”   (Or–“No, I am not taking a prenatal.  I feel too sick.”  “Well, just make sure and get some folic acid.”)  End of conversation.  Never once did the OB request, “What kind?  Let me see it.”  However, I think obstetricians/practitioners need to know of any supplement put in their patients’ mouths so they can have the opportunity to offer guidance.  They may even have some great recommendations and samples based on a patient’s health history needs.  (Or not.)

Anyhow, after the last few folic acid/folate posts, I received a few questions and comments about choosing a supplement for pregnancy.  So I put my fingers to the keyboard and was reminded of what I already knew from my search many months ago for myself at the beginning of our surprise pregnancy.  Choosing a prenatal vitamin supplement is a real bear.  A real maze.  A twisted, contorted game.

The Dilemma

If you read my recent posts on folic acid versus folate, you probably think that it’s probably high time to ditch folic acid in favor of a natural folate in prenatal vitamins (and vitamins in general).  Great.  Now you know.  Now I know.  But what good is knowledge if you don’t know how to act on it in real life?  I tried to pinpoint a good prenatal vitamin with L-methylfolate for myself to take many months ago, but it wasn’t as easy as that.  Let me say it again.  It was not as easy as that.  If I liked the vitamin content profile, then I didn’t like the extra ingredients, for example the use of soy, oats, artificial colors, or vanillin (an artificial vanilla flavor).  If I liked the clean ingredient profile, it didn’t meet the minimum recommended iodine requirements.  Or it didn’t have any DHA.  Or it used ergocalciferol (a plant-based vitamin D) rather than cholecalciferol (the better utilized animal based).  Or the vitamin B 12 was not the methylcobalamin form.  Or it didn’t have any vitamin K2.

What do you do?  You do the best you can.  You choose the best you can.  (And you make EVERY BITE COUNT.  More on my personal experience with that in a subsequent post.)  There is no perfect prenatal out there.  There just isn’t.  I’ll tell you what I looked for.  But this is the story of my thoughts and learning.  Not my medical advice.  Please don’t use my blog posts as medical advice.   You’ll have to figure out for yourself with your practitioner’s help what you need for sure and also where you’re willing to compromise on your prenatal vitamin.

Things I looked for in my prenatal vitamin:

  • Does it use folate or folic acid?  I prefer L-methylfolate or another biological folate.
  • Does it have the recommended dose of iodine?  What is the source of iodine?  I prefer it to have iodine since my iodine sources are limited (I don’t tolerate eggs and dairy well.) and haven’t yet sorted through which source I feel is best for iodine.
  • Does it have selenium to accompany the iodine?  If iodine is taken, then selenium needs to be sufficient as well.
  • Is the vitamin D source from ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3)?  I prefer vitamin D3 (cholecalciferol).
  • Does it have any vitamin K2 in it?  Vitamin K2 is difficult to consume from foods, especially on a dairy-free diet, yet it is very important for health and fetal development.  Many supplements lack this.
  • Does it have the methylated form of vitamin B12 (methylcobalamin)?  I prefer this.
  • Does it have any DHA?  (A type of omega-3)  None of the prenatals I looked at contained DHA.  I made a point to eat DHA-rich foods, and if that wasn’t happening, I supplemented.
  • Does it have biotin?
  • Does it have choline?
  • What extra ingredients does it have?  I don’t see any reason for artificial colors and artificial flavors (like vanillin).  In addition, I am always on the lookout for soy, dairy, and gluten in any supplements due to some sensitivities.  I scan ingredients, also, for added probiotics or FOSs which may not agree with tummy issues.
  • What are the amounts and types of other minerals, like iron, calcium, and magnesium?  Many prenatals don’t have the recommended allowances of these, which can be okay.  However, women need to make sure they know how much of these minerals are in their prenatal vitamins so they can get their needs elsewhere if required.  Some women rely on their vitamins because of food aversions and nausea.
  • What is the vitamin A source and how much is in there?  Striking a middle ground here would probably be wise.  Not too much.  Not too little.  If you eat a lot of vitamin A rich foods, lean on the lower end in the supplement.
  • How many pills need to be taken?  Sure.  One is ideal but probably not optimal for absorption and maximizing nutrients.  For example, the calcium needs of the body cannot be absorbed in one sitting.  It needs to be spread out through the day.

Putting Criteria into Reality

I don’t have a good prenatal to recommend.  Like I said, nothing met all of my criteria.  My most recent obstetrician didn’t mind that I didn’t take a prenatal vitamin as long as I took a “folic acid” supplement.  This was a surprise pregnancy, and by the time I started looking for a prenatal, I was overcome with pregnancy maladies.  (Read:  I am making excuses for not selecting a good prenatal.)

Initially, I took a vitamin B complex with an active form of L-methylfolate made by Designs for Health along with some fermented cod liver oil since we were in the dead of a brutal winter (which would provide vitamin D, vitamin A, and DHA/EPA).  Then, I switched to a Designs for Health multi-vitamin that I already had in my cupboard which would provide some vitamin K2, iodine, zinc, biotin, and choline for baby and me, but it recommended 6 pills per day!  Right.  I was not very compliant with that.  So I eventually picked up a pre-natal from the local health food store, Rainbow Light, and made do with it, but it did not meet all my criteria.  My nutrition overall was strong and well thought out, and I felt the prenatal was more of a safety blanket for me.  Like perhaps to cover my low intake of iodine until I recognized a weak area in my diet.

I went back this week and looked at some prenatal vitamins after reading up on folic acid/folate, and I wished I had had the energy to investigate them all early in that first trimester.  But I didn’t.  So here are some of the vitamins I looked at this week that met a lot of criteria I find important.  I also listed Rainbow Light since I took it and saw a lot of women commenters on other sites mention it.

Do not use this list as a recommendation list.  Use it as a place to start looking, comparing, and contrasting which vitamin might fit you best, and always enlist the help of your physician to make sure you’re not overlooking something.

Nutrient 950 with Vitamin K by Pure Encapsulations

This is not the prenatal from the same company.  The prenatal has folic acid, not folate.

 

Emerald Labs Multi Vit-A-Min Prenatal

  • This has L-5-methyl tetrahydrofolate (L-5-MTHF), vitamin D3, iodine (although a lower amount), selenium, methylcobalamin, and biotin.
  • No DHA or choline.
  • The dose is 4 capsules.
  • With the recommended dose, one does not obtain the recommended daily doses of magnesium and calcium.
  • The ingredient list should be inspected for a person to see if there are any sensitivities to included ingredients, like quinoa and FOS.
  • One source of vitamin A is vitamin A palmitate, rather than simply relying on beta-carotene.  A reader may want to research this a bit.  Especially if they eat many food sources of vitamin A.
  • http://www.ultralaboratories.com/emeraldlabs/Prenatal%20Multi/index.php

 

Thorne Research Basic Prenatal

  • This has calcium folinate and L-5-methyltetrahydrofolate (L-5-MTHF), both biological folates. It also uses vitamin D3, iodine, selenium, methylcobalimin, and biotin.
  • There is no vitamin K2.
  • Calcium and magnesium do not reach the recommended daily doses.
  • The source of vitamin A is also palmitate (and carotenes).
  • The dose is 3 capsules.
  • https://shop.thorne.com/products/womens-health/basic-prenatal

Designs for Health DFH Complete Multi

  • Designs for Health Complete Multi has vitamin D3 (cholecalciferol), vitamin K2, natural folates (5-MTHF and 5-FTHF), methylcobalamin, biotin, choline, iodine, and selenium.
  • The calcium and magnesium are less than recommended allowances.
  • There is NO iron and no copper.
  • Its vitamin A source is carotenoids.
  • The dose is 6 capsules.
  • http://catalog.designsforhealth.com/DFH-Complete-Multi

Optimal Prenatal Vitamin/Vitamin Powder

This vitamin is out of stock reportedly due to popularity, but there is a protein powder designed to be interchangeable.  They are working to get the vitamin back in stock.

Rainbow Light

Rainbow Light is a food-based multivitamin, vegan compliant.  It is what I landed on for a prenatal vitamin due to chance, and it gets good reviews on-line.  It misses some of my criteria.  I landed on it, but I don’t think it’s the best.

  • It’s vitamin D source is D2 (ergocalciferol).
  • It has no vitamin K2.
  • It does not have the methylated form of vitamin B12.
  • It uses folic acid.
  • On the other hand, it does have iodine, choline, and biotin.  It also contains iron.
  • The calcium and magnesium content, like the other brands, is less than the recommended daily doses.
  • It has some added ingredients, like red raspberry leaf, ginger, spirulina, probiotics, and digestive enzymes for readers to investigate.
  • http://www.rainbowlight.com/multivitamins-prenatal-one-multivitamin.aspx

 Conclusion

I think this is a good list of prenatal vitamins/multi-vitamins to start to check out.  Do readers have any others (and thanks to those who gave suggestions)?  Remember, it’s all a game of checks and balances.  Start with a good, strong, well-planned pregnancy diet and make sure your supplement does that–supplements the gaps in your diet.  Run all of your supplements by your doctor.

All the best to you for a happy, healthy family!

~~Terri

 

 

 

Two Follow-Up Articles to Read on Folic Acid in Pregnancy

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Pregnant belly in black and whiteChoosing a supplement for pregnancy, lactation, and trying to conceive is daunting!  Dozens and dozens of prenatal vitamins exist!  How do you choose?  One important way to narrow it down is to choose one with a “natural folate.”  Recently, I ran two posts on folate/folic acid (here and here) and why people may want to steer away from folic acid use in foods and vitamins–but NOT folate in general–just the folic acid form.

Today I will post two really readable articles regarding folic acid versus folate in prenatals that readers may be interested in.  Remember, my blog is a story of what I am learning.  It is absolutely not to be used as medical advice.

Two Fairly Easy to Read Articles on Folic Acid in Pregnancy

“Should you skip prenatal vitamins with folic acid?“

(Click on article title to link to the article.)

This is a nice overview article from the news written in common language.  I think it summarizes the thoughts from my second post on folic acid versus folate (click here to read it).  Basically, those people with MTHFR (methyltetrahydrofolate reductase) issues would benefit from L-methylfolate rather than folic acid.  But how do you know if you’re “one of those people?”  Unless you’re tested, you don’t.  And in this article, it states that about 50% of women can be affected.  So you’re playing a guessing game.  Am I good with folic acid?  Or would I be better off with L-methylfolate?

If you’re trying to conceive, pregnant, or taking folic acid, this would be a good article to read to help you understand whether or not taking folic acid (versus folate) is best for you.

“Multi-vitamin Supplementation During Pregnancy:  Emphasis on Folic Acid and L-methylfolate.“

(Click on article title to link to the article.)

This is a nice little interview between an obstetrician and a nutritionist regarding L-methylfolate, folic acid, and MTHFR issues.  The conclusion is very similar to the article first listed (and similar to what I concluded), but rather than being in the general news, it is from an obstetrical journal.

Closing

The next post will discuss what I look for in a prenatal vitamin along with some vitamins that I looked at, but the take-away message that I learned is this:  If you don’t know your MTHFR status, it might be wise to stay away from folic acid supplements (but not folate).

~~Terri

 

Continued. Folic acid or folate? What’s in your vitamin? What’s in your food? What makes a difference?

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wpid-IMAG0802.jpgFortification can never replace real, whole foods and all the natural co-nutrients that go hand in hand.  You are lying to yourself, or letting somebody lie to you if you believe that processed, fortified food consumption can lead to health and prevention.  Let them continue their studies on isolated nutrients.  Meanwhile, let’s get on in the knowledge that health is an intricate web that starts with real, whole foods–not isolated supplements and fortification.

Today we will continue our discussion of how folic acid (used in fortified foods and vitamins) is different from folates found in real food.  Our continuation is going to get a bit technical, and I’m sorry.  But I think this could be a very valuable read and lead for somebody who has had a standard medical work-up that is normal yet is still struggling with particular health issues nobody can explain to them.  Listing only a sampling of problems possibly related to folate metabolism disorders:  depression, schizophrenia, bipolar disorder, Down’s Syndrome, stroke, Alzheimer’s Disease, Parkinson’s Disease.  autism,  migraine, and infertility, both male and female. (1)  Please note that there seems to be mostly correlation and not hard and fast causation.  Still.  Blows the mind that eating your greens and avoiding synthetic folic acid could play a role in these and other conditions.

Folate or folic acid?  Terminology reminder.

Remember from the last post that they are both types of vitamin B-9.  The term folic acid (which is not naturally occurring) should be reserved for discussion of the synthetic form of vitamin B-9.  The term folate usually refers to forms of vitamin B-9 which occur naturally, particularly in foods.  BUT many times the terms “folic acid” and “folate” are just lumped together simply as “folates,” with “folate” just being a generic term.

My nutshell overview.

My blog posts are a story of what I am learning from alternative health exploration, trying to align it with my conventional health training.  Posts are not intended for diagnosis or self-treatment.  Don’t use them that way.

What I am taking away from my research on folic acid versus natural folates is:Cute orange snack

  1. For some people, folic acid may be fine and does not appear to disrupt their overall folate biochemistry.
  2. However, in today’s processed food world where everything seems supplemented with folic acid, even these people whose chemistry is suitable for using folic acid may be getting folic acid levels which are too high.  And folic acid as it is is unusable.  It is possible, although not yet definitively proven, that there are detrimental effects to unmetabolized folic acid in circulation.  If you’re interested, you should definitely keep an eye on studies relating to this.  They are popping up the last several years.  Excess folic acid binds preferentially over active folates in reactions, and it could downregulate intestinal folate uptake receptors, so a person absorbs less food folates.
  3. Unfortunately, many people unknowingly have defects in the enzymes needed to process folic acid!  Despite having enough circulating folic acid, these people are functioning with a “folate” deficiency because they cannot convert folic acid to necessary forms of “folate” adequately.  This can lead to high levels of an amino acid called homocysteine.  High homocysteine levels create all kinds of problems in the body.  Folate metabolism disorders are moderately new discoveries in the medical field and so this is not common knowledge.  I think if more doctors were aware of this, there would be less use of folic acid for supplementation (and more use of another type of biological folate to be discussed later).
  4. Better than folic acid is to eat real food rich in folates.  Real food folates are absorbed in forms which are already suited to be used in our body’s folate pathways. To get enough through diet, folate-rich foods must be eaten in abundance nearly every day of the week.  Indulge (yep, indulge!) in foods like lentils, beans, sunflower seeds, broccoli, spinach, asparagus, collard greens, Romaine lettuce, avocado, oranges, orange juice, and mangoes.  And of course, liver.  No supplement can ever give you the benefits of real food.  Eat real food.  Shun processed food.
  5. If you cannot eat enough folate-rich foods or supplementation is needed, then there are vitamins with the biologically occurring forms of folate which can be used which may offer benefits over the standard folic acid.

Continuing on from the previous post…

 

1. Folic acid is better absorbed from the imagegastrointestinal tract than natural forms of folate.  Yes.  True.  But it requires more processing by the body to be used in cellular pathways.

Studies show that folic acid is actually better absorbed from the gastrointestinal tract than folate from foods.  Somewhere around 80-100% of folic acid is consistently absorbed (more is absorbed on an empty stomach).   A highly variable 50-90% of natural food folate is absorbed. (2)  Folic acid’s reliably better absorption sounds like a positive thing, right?!  Let’s see.  Let’s look beyond absorption.

Processing of folates found naturally in foods:

Food-based folates usually come with these “tails”  attached on their structures which have to be hacked off in the Finishedlumen of the GI tract before entering cells.  The “tails” are made up of strings of glutamates called polyglutamate tails, and enzymes in the brush border of the intestine cut off all but one of the glutamates.  Once the tail is hacked off and only one glutamate is left intact, the natural forms of folate can be transported by transporters into the GI cells to be used and also sent off to the liver–then off to the rest of the body.  These dietary monoglutamates are commonly 5-methyltetrahydrofolate (5-MTHF) and 5-formyltetrahydrofolate (5-FTHF). Monoglutamates are readily funneled into the folate pathways of the body!  Off they go!

Can glitches happen?  Of course!  If the GI tract is damaged, like in celiac disease or inflammatory bowel disease, then the enzymes can’t take off the tails of the natural folates and they cannot be abosrbed by the transporters.  Or if there are defects in the transporters to move the monoglutamate folates into the GI cells.  I have denoted these potential glitch points by underlining the affected area in the figure.

Processing of Folic Acid:

Folic acid can enter the GI cell as is.  It doesn’t have to have its tail cut like natural folates, so it is more bioavailable.  However, on the flip side, once it is absorbed, folic acid must be acted on by special enzymes inside the GI or liver cell to get it to a usable state.  The natural food folates, once abosrbed are mostly in a highly usable state–when the natural folate makes it into the GI cell, it is already teed up for action and ready to go.  Folic acid, on the other hand, is not and can get hung up in the system.  It is absorbed as folic acid into the GI cells where it can stay or get shuttled to the liver.  In both places, it must be acted on by a series of enzymes to get it to the usable 5-MTHF we mentioned already.  Let’s look at glitch points for folic acid.

folic acid metabolism (darker image)One possible glitch is that the ingested amount of folic acid can overcome the ability of the GI and liver cells to act on it, and it will then go straight into circulation unchanged.  So there is free, unusable folic acid circulating.  Usually the kidney will take care of excess folic acid, but too much can overwhelm the kidney’s ability to get rid of it.  This can easily happen in a person who eats processed foods, like enriched bread and cereals, and also takes a multi-vitamin with folic acid.

Another glitch is that some people lack properly functioning enzymes in the pathway needed to get folic acid converted to its usable form.  So if you take in too much AND you have enzyme issues, you can really get some build-up of folic acid.  People can have deficient dihydrofolate reductase (DHFR) and deficient 5, 10-methyl tetrahydrofolate reductase (MTHFR).  (I will go into a little more detail on MTHFR deficiency later, but it is a huge topic beyond the scope of these two posts.)  In addition, to optimally convert folic acid to the much desired MTHF there must be adequate vitamin B-6 (pyridoxine) and vitamin B-2 (riboflavin) in the body.  So other vitamin deficiencies can block folic acid utilization.

So you can see there are more roadblocks in folic acid use than there is in the natural folate use.  There are concerns that this excess folic acid floating around may modify health risks, like allowing cancer to progress; masking or negatively impacting vitamin B12 deficiency neurologic symptoms; altered immune function;and increased obesity, insulin resistance, and asthma in children whose moms supplemented folic acid during pregnancy. (3, 4)

2.  Genetic variations which interfere with folate metabolism occur fairly commonly.  In the United States, up to 60% of people have folate metabolism deficiencies. Folic acid metabolism will be more problematic for these people than naturally occurring folates.(5)

I hope you can hang with all the acronyms and terminology as I try to break this down to understandable language.  One reason that folic acid is a concern is due to the fact that a pretty significant number of people lack full functionality of an wpid-IMAG1044.jpgenzyme called 5, 10-methylenetetrahydrofolate reductase.  It has several ways to name it, so don’t be confused; 5, 10-MTHFR can be shortened to MTHFR.  These people aren’t so good at creating natural, productive forms of folate out of folic acid!  The enzyme MTHFR is needed to get folic acid to the active form.  (That’s not all it does, but due to scope issues, we’ll stop there.)  Although some people have a severe form of MTHFR deficiency and are very sick, some people have milder forms that cause more of a non-specific health picture not readily attributable to MTHFR deficiency.  So unless a person is aware of it or their doctor is really on top of things, it can be neglected.

MTHFR (5,10-methylenetetrahydrofolate reductase) deficiency:  There is a gene called the MTHFR gene.  We all have two genes, one from mom and one from dad.  The genes code for an enzyme which kindly has the same name as the gene, the MTHFR enzyme.  The MTHFR enzyme helps make active, usable forms of folate for the body, particularly 5-methyltetrahydrofolate–see schematic diagram shown in previous section.  5-methyltetrahydrofolate goes by many names, too:   5-MTHF, L-methylfolate, [6s]-5-MTHF, L-MTHF, MTHF or L-5-MTHF.  Regardless, it is a highly usable and active form of folate, which is what we get when we eat food folates, and which we have to make when we ingest folic acid.

Whole, real food (not processed, enriched grain foods) usually contains 5-MTHF, but folic acid has to be turned into it!  If an MTHFR gene produces a faulty enzyme, then the person can’t use the folic acid that is being consumed to make the needed folate derivatives for cellular pathways.  Usually this doesn’t occur in an all or none fashion.  It depends on the defective error (because many have been identified, although two are much more common than others–the C677T and the A1298C)) and if you got just one defective gene from either your mom and dad–or if you got defective ones from mom AND dad.  Usually a person produces some enzyme that is still active, but maybe only at 70% or 40% its normal activity level.  Up to 60% of the US population has one copy of a gene (heterozygotes) that does not make MTHFR properly.  Up to 25% of certain US populations have two copies of a gene (homozygotes), which dramatically interferes with MTHFR production and function and folate/folic acid metabolism.  (6)

Many conditions are beginning to be associated with MTHFR genetic polymorphisms.  These include, but are not limited wpid-IMAG1155.jpgto, conditions like high homocysteine, risk of cardiovascular disease, increased blood clots, neural tube defects (like spina bifida or anencephaly), glaucoma, psychiatric disorders (schizophrenia, bipolar, and depression), cancers, and preeclampsia (high blood pressure in pregnancy).

 3.  “Okay.  I see some of the issues with folic acid.  But my doctor still wants me to take it.  What are people doing for supplementation?”  Well, besides folic acid, a physiologic version of a folate involved in cellular pathways is available.  It is L-methylfolate.  You will recognize it as the 5-MTHF discussed above. 

Technically, if you’re taking L-methylfolate (5-MTHF) in a supplement form, it is synthetic too (like folic acid).  However, the difference is that L-methylfolate directly enters the folate metabolic pathways and doesn’t require precursor steps to be used, like folic acid does.  L-methylfolate is the main folate in human circulation.  Taking a folate form which doesn’t need converted first like folic acid is likely important for people with 5-MTHFR issues, DHFR issues and with aging.

Folic acid vitaimin edited photoI’ve already talked about L-methylfolate above and how it can go by many names.  No matter what name it goes by, just know that it is the main folate from food ingestion.  So whatever claim is made for Deplin and Metafolin (marketing names) can be first and foremost said about L-methylfolate from food.  An exception would be in those people with damaged small intestinal tracts who can’t de-glutamate food folates.  I have listed the many names for L-methylfolate (and probably still missed some).  Unfortunately, it is important to know whether the L-methylfolate is an isomer that is naturally made by the body.  That’s where the “s” and “L” that you see below comes into play.  This takes you back to chemistry and how structures can have the same formulas, but how they are put together spatially is different.  To be active, methylfolate needs to be denoted by an “L” or “s.”  You may need to call the manufacturer to find this little piece of information out.  Should things really be this difficult?  (No.  But they are.)

  • L-methylfolate
  • Methylfolate
  • Methyltetrahydrofolate
  • MTHF
  • L-MTHF
  • 5-MTHF
  • [6s]-5-MTHF
  • [6s]-5-methyltetrahydrofolic acid
  • L-5-MTHF
  • Deplin (Prescription form, usually prescribed in depression along with an anti-depressant.  It is simply L-methylfolate in higher doses.  L-methylfolate, unlike unmetabolized folic acid, can cross the blood brain barrier and be utilized in neurotransmitter production.)  (7)
  • Metafolin (This is a trade name.  It is used certain OTC products.  It is the calcium salt of [6s]-5-methyltetrahdrofolic acid.  My vitamin B complex vitamin and multi-vitamin have Metafolin in it.)
  • …and other name variations I missed!

Closing

That’s it.  I know I left things out.  There was a lot to learn and cover.  Some readers actually know they have folate metabolism disorders and can provide critical feedback to us about what I have written about my understanding of folic acid, folate, and enzyme deficiency disorders.  It was good to research this topic and finally see what all the hubbub was about regarding folic acid and MTHFR deficiencies.  (If you kind of get this post, you’re set up for understanding methylation disorders.) I don’t know if I have one of these disorders or not, but overall I’m feeling well.  I will continue with eating greens nearly daily, broccoli, and liver.  If supplementation seems indicated, then I will use a biological folate rather than folic acid.

Regards–

Terri

Sources and Citations:

Lots of good reading here!  Although I noticed some of the links look like they won’t work in all my copying and pasting.  Try using Google Chrome to search these links.  If you just act like you’re going to copy it and then choose “Search Google for…” then you can use Google to get you to the site.  If that fails, let me know in the comments, and I’ll comment back with the active link.

1. Hickey, Curry, Toriello.  ACMG Practice Guideline:  lack of evidence for MTHFR polymorphism testing.  Genetics in Medicine (2013).  Volume: 15, 153–156. doi:10.1038/gim.2012.165 (Link)

2.  Overview of folic acid/folate.  Project Healthy Children.  http://projecthealthychildren.org/wp-content/uploads/2012/03/2012-06-19-PHC-Folic-Acid-FINAL-FINAL.pdf

3.  Smith, Kim, and Refsum.  Is folic acid good for everyone? Am J Clin Nutr March 2008 vol. 87 no. 3 517-533.  (http://ajcn.nutrition.org/content/87/3/517.full)                  

4.  Tam, O’Connor, and Koren.  Circulating Unmetabolized Folic Acid: Relationship to Folate Status and Effect of Supplementation.  Obstetrics and Gynecology International.  Volume 2012 (2012)       

5.  Greenberg and Bell.  Multivitamin Supplementation During Pregnancy:  Emphasis on Folic Acid and l-Methylfolate.  Rev Obstet Gynecol. 2011; 4(3-4): 126–127.  (Link)

 6.  Greenberg, Bell, Guan, and Yu.  Folic Acid Supplementation and Pregnancy:  More Than Just Neural Tube Defect Prevention.  Rev Obstet Gynecol. 2011 Summer; 4(2): 52–59.  (Link)

7.  http://www.deplin.com/

8.  https://tspace.library.utoronto.ca/bitstream/1807/30137/1/Lakoff_Alanna_D_201006_MSc_thesis.pdf

9.  http://www.hindawi.com/journals/ogi/2012/485179/

10.  http://www.fao.org/docrep/004/y2809e/y2809e0a.htm

11.  Prinz-Langenohl, Bramswig, Tobolski, Smulders, Smith, Finglas, Pietrzik.  [6S]-5-methyltetrahydrofolate increases plasma folate more effectively than folic acid in women with the homozygous or wild-type 677C –>polymorphism of methylenetetrahydrofolate reductase.  Br J Pharmacol. Dec 2009; 158(8): 2014–2021.  (Link)

12.  Smith, David.  Folic acid fortification:  the good, the bad, and the puzzle of vitamin B-12.  Am J Clin Nutr. January 2007 vol. 85 no. 1 3-5.

13.  Ueland and Rozen.  MTHFR Polymorphisms and disease. 2005.  Eureka.com.

Click to access Ueland_9781587063978.pdf

 

 

Folic acid or folate? What’s in your vitamin? What’s in your food? What makes a difference?

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Someone is not right.  (Ding. Ding. Ding. Ding.)

Folate versus folic acid.  What was I taught as a medical doctor and pharmacist?  No difference.  So alert bells chimed in myFolic acid vitaimin edited photo head two years ago when I started reading alternative takes on medicine in the effort to fix my gastrointestinal tract (which led to many more benefits in myself and my family than I ever expected) and seeing the “naturalists” crying out against folic acid.

Ding.  Ding.  Ding.  Ding.  Discrepancy alert.  Need real story.  These alternative views felt there was a difference and started slinging around acronyms I had long buried in my medical student past, like MTHF and MTHFR, and referring to tests which could be ordered for diagnosis of disorders revolving around MTHFR deficiencies.  They fear-mongered with increased risks of cancer with folic acid intake.  With complete honesty and openness, my thoughts at the time were:  1) Geesh, where do they come up with this stuff and these tests?  Egads they’re feeding the neuroticism.  Getting vulnerable people all worked up.  AND 2)  My mom always said there’s a bit of truth in every rumor.  I really need to look into this.  Chuck it on the list to research.

Well, I have finally made it to the “Folate vs. Folic acid” boxing match.  I see and relate to the good intentions behind the use of folic acid in our supplemented foods and vitamins, and yet I see and admit the potential failures of folic acid compared to folate.  As I’m finding in so many areas I’m reading about now with alternative medical views, medical research is beginning to perhaps support folic acid’s shortcomings too, but it seems to take many decades before things trickle down to the doctors in trenches and the public.  Frustrating but true.

Join me as I summarize what I have learned regarding folate and folic acid.  My blog posts are a collection of what I have learned.  A story.  They are not intended for medical advice.  Don’t use them that way.

1.  Folic acid and folate are both types of vitamin B-9.  FOLIC ACID is synthetically made and does not naturally occur in our bodies or in foods.  FOLATE usually refers to naturally occuring forms of vitamin B-9, although it can be a wastebasket term to include both folic acid and naturally occuring forms of vitamin B-9.

You really need to read well and scrutinize to figure out how the term “folate” is being used when you see it.  Technically, it looks like the term “folate” is used to include ALL forms of vitamin B-9, both natural and artificial.  Kind of like a wastebasket, generic term.  (You know.  Like not all kleenexes are Kleenexes!)   However, some sources specify that “folate” is natural and “folic acid” is artificial.  In many places, you’ll see the terms folate and folic acid used interchangeably, without regard for any distinction.

Why the terminology looseness across sources?  All folates (generic term) share a common structural core.  Natural folates and folic acid are structurally and functionally similar and feed into the same pathways in the body–so some sources don’t see a need to differentiate.  Don’t take it for granted that an article you’re reading or a vitamin you’re taking is referring to a naturally occurring, physiologic type of vitamin B-9 (folate).  If it says “folic acid,” you can be sure it’s the artificial stuff.  If it says “folate,” you need to get more details.

In the remainder of this post and the next folate/folic acid post, I’ll use folic acid to refer strictly to folic acid and try to clarify which folates I’m talking about, food-based or otherwise.  Due to amount of content, folate/folic acid will take two posts.

2.  Real foods contain natural folates, and processed foods (and most vitamins) contain folic acid.  The folate in real foods is not as shelf-stable as the folic acid added to foods and vitamins.

Real foods which contain good amounts of natural folates:

  • Leafy greens like spinach
  • Beans and lentils
  • Asparagus
  • Broccoli
  • Romaine lettuce
  • Broccoli
  • Mango fruit
  • Oranges
  • Liver
  • Egg yolks
  • Wheat germ

Broccoli grouchThe longer fresh, real food sits exposed to air, disconnected from its living source, the more the natural folate breaks down, making the folate content much lower with time.  So the closer you are from garden to mouth, the better in regard to natural folates.  In addition, cooking will diminish the folate content as well, sometimes quite significantly!  So the less you cook foods, the higher the natural folate amount. (Eat a little cooked…eat a little raw…)

On a science note, the forms of folate found in natural foods are primarily tetrahydrofolate (THF), 5-methyltetrahydrofolate (5-MTHF), and 5-formyltetrahydrofolate (5-FTHF).  So when people use the term “folate” regarding foods with intrinsic folate content, please know that it’s not just one form.  It’s not just “folate.”  There are several forms of “folate,” and these three are the most common, with 5-MTHF being the most common.  This tidbit of information will come into play later when I talk about why some people won’t do well with synthetic folic acid.

Processed foods with folic acid added include:

  • Fortified breakfast cereals
  • Enriched bread
  • Enriched flours
  • White, enriched rice
  • Enriched pasta
  • Enriched crackers

When grain products are processed, they are stripped of virtually all their naturally occurring folates.  In the 1990s, the United States began mandating the addition of synthetic folic acid to processed foods to boost women’s levels of folate in the body and drive down the incidence of neural tube defects (abnormalities in the brain and spinal cord).  It worked.

Folic acid is an oxidized form of vitamin B-9 and is used because it is very shelf-stable and inexpensive to make.  Folic acid levels won’t diminish as much in processed foods as they sit on the shelf, and it is easily absorbed from the gastrointestinal tract.  (And experts thought it was similar enough to natural folates to not cause any problems in the general population…)

3.  Back up.  What’s vitamin B-9 (folate/folic acid) for anyhow?

If you remember chemistry class, maybe you’ll remember the one carbon group called a “methyl” group.  Well, folates carry methyl groups for transfer in cellular reactions in the body.  They are involved in “methylation.”  This is very important for making our DNA and RNA; for turning off and on genes; for recycling some of our enzymes that are used for “detoxifying;” for reducing our homocysteine (and therefore cutting down heart disease and stroke levels) to recycle methionine; for our red and white blood cells; for production of a fetus; and for neurotransmitter production.  This just gives you a basic insight to just how valuable folate is.  It’s critical, and you can’t store folates up, so you need a fairly steady supply daily.

4.  What does folate/folic acid do in pregnant women?

My own pregnancy is what moved the folate versus folic acid debate up on my “to-research” list.  I’m just finally getting around to putting it all together in a post.

Folate (generic term) is important for the developing fetus, and demands for it increase during pregnancy.  Without it, there is an increased risk of neural tube defects like spina bifida (an opening in the spine) and anencephaly (lack of brain formation), congenital heart defects, and possibly preterm birth.  For reduction of neural tube defects, enough folate/folic acid needs to be present at conception and very early in pregnancy, often before a woman knows she is pregnant!  (A plug to eat good nutrition lifelong!)

Adding folic acid to the US and Canadian processed food supply in the 1990s decreased the occurrence of neural tube defects (NTD).  The authorities didn’t feel it was possible or reliable to get enough folate through diet to diminish the risks of these serious birth defects.  However, supplementation of folic acid may not be adequate for women with a disorder known as methyltetrahydrofolate reductase deficiency (MTHFR deficiency), which is actually pretty common!  I’ll talk about this next post and also address alternative forms of folate supplementation which could be considered.  Women with a personal history of NTD, prior birth history of NTD, or family history of neural tube defects may have a higher incidence of 5-MTHFR deficiency and will want to know about this.

Closing

Thanks for reading.  Eat lots of folate-rich natural foods!  Next post we will explore much more deeply why folic acid may not be “as good as” natural folates and may even be detrimental for people!  After researching, I’m a big fan now of natural folates.  I work very hard to eat leafy greens daily and liver weekly, both great sources of natural folate.  Folate is now a word we use commonly in the house to teach the kids about the food they eat.  The more they understand WHY we eat, the better they actually WILL eat.  (This post is just a precursor to what I think is such an interesting and fascinating second post, which will describe more why folic acid is demonized.)

~~Terri

Links to Sources:

1.  https://tspace.library.utoronto.ca/bitstream/1807/30137/1/Lakoff_Alanna_D_201006_MSc_thesis.pdf

2.  http://projecthealthychildren.org/wp-content/uploads/2012/03/2012-06-19-PHC-Folic-Acid-FINAL-FINAL.pdf

3.  http://www.fao.org/docrep/004/y2809e/y2809e0a.htm