Given the high number of unplanned pregnancies, should certain foods be fortified with folic acid to protect against neural tube defects, asks Andrea Mara.

AVOID blue cheese, don’t eat rare steak and take care with tuna — there’s plenty of information about nutritional do’s and don’ts when you’re pregnant, but what about before conception? 

Are there certain foods you need if you’re planning to become pregnant, and why is it so important to take folic acid?

“Rather than focusing on foods, I suggest future mums and dads look at the nutrients needed to support a healthy pregnancy,” says senior paediatric dietitian Cathy Monaghan ( ).

“In order for a mother to be well-nourished from the time of conception and throughout pregnancy, pre-pregnancy nutritional status is very important. Recent data would suggest that many pregnant women are not reaching their requirements for several essential nutrients.”

Indeed a study published this year in the European Journal of Clinical Nutrition showed that 56% of women surveyed in the Coombe hospital did not take folic acid before pregnancy. 

Folic acid provides folate — a key nutrient required before and during pregnancy.

“Folate helps prevent neural tube defects,” explains one of the study’s authors, Michael Turner, professor of obstetrics and gynaecology at the UCD Centre in the Coombe, Dublin.

“It’s important to note that it doesn’t prevent all neural tube defects — only about two thirds. The other third are genetically related. But neural tube defects are the commonest major congenital malformation that is preventable, and the number of neural tube defects has gone back up.

“There’s about a case a week in Ireland— and particularly with spina bifida — it has huge lifelong consequences.”

So when should you start taking folic acid?

“Folic acid is very important for the growth and development of cells, which happens over weeks, not minutes,” explains Professor Turner.

“You need to build up to a certain level to get into cells. So women should be should be taking folic acid for three months before becoming pregnant.”

And therein lies the problem — not all pregnancies are planned. 

The Coombe study showed that of the women who did not take folic acid before conception, more than three quarters said it was because they didn’t expect to become pregnant.

There is also a general lack of awareness about when women should take folic acid.

“In Ireland we’ve not been giving consistent advice – people think you only need to take it if you’re pregnant,”says Professor Turner.

“And women who came into the country from the rest of the world in recent years have missed previous public health campaigns. We believe that what we need is a sustained, consistent public health message.”

Cathy Monaghan is also clear in her advice on folic acid. “Neural tube defects arise at the very early stages of pregnancy, when many women don’t realise they are pregnant,” she says.

“Since 1993 all women of childbearing age are advised to consume a daily folic acid supplement of 400mg per day prior to conception and for a minimum of 12 weeks after. Even if you’re not planning a pregnancy, if you are sexually active, consider taking a folic acid supplement.”

Another hot topic is food fortification.

“Flour and rice are fortified with folic acid in North America,” says Professor Turner. 

“But there hasn’t been mandatory food fortification in any of the European countries, and I believe it needs to be examined here — I think there’s a strong case to be made for mandatory food fortification.”

The FSAI also says that food fortification should be looked at, suggesting two options: either mandatory fortification (together with voluntary fortification and advice on supplementation), or a continuation of voluntary fortification but with guidelines to improve effectiveness.

“In May of this year, we published a report of our scientific committee, which proposes that one of two options should be implemented to reduce risk of NTD-affected pregnancies in Ireland,” says Jane Ryder, FSAI communications manager.

“Both options were presented to an expert group on folic acid set up by the Minister for Health and this is a matter for it.”

But it’s not as simple as it sounds. “It’s complicated because it’s governed by EU law,” says Professor Turner.

“And you have to decide what food to fortify — for example, if you fortify flour it means that someone who has Coeliac disease won’t get it. But you don’t want to fortify at such a high level that it poses a risk to elderly people - the problem with the elderly is that if they are also deficient in vitamin B 12, too much folic acid could cause pernicious anaemia.

“A lot of our food comes from abroad so it would be very difficult to regulate. And it would need to be monitored, which brings a cost.”

Food fortification is certainly a complex matter, but taking folic acid isn’t, especially when the outcomes are so serious says Professor Turner.

“We can deal with the problem when it arises but it has such an impact, it makes much more sense to try to modify behaviour before the woman becomes pregnant at all.”

Top nutrients

Nutritional information for wannabe and expecting parents

Cathy Monaghan advises on top nutrients to include as part of a balanced diet if planning a baby:

* Folic acid supplement daily (400 µg/d)

* Vitamin D3 supplement.

* Good iron sources in the diet —lean red meat, green leafy vegetables, some dried fruits.

* Two to three portions of quality protein per day - meat, fish, eggs, lentils, legumes, nuts and seeds.

* Oily fish 1-2 times per week — if you do not eat oily fish consider a DHA supplement.

* Avoid highly processed foods as these can contain added salt, sugar and unhealthy fats.

* Try to cook healthy meals using lots of fresh fruit and vegetables from scratch as much as possible.


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