Folic Acid vs Natural folate

Why do I need to take folic acid?

Folic acid is recommended from when you start trying to conceive and for the first 3 months of pregnancy. This is because there is good evidence that this reduces the risks of spina bifida. Spina bifida is a serious birth defect, also known as a ‘neural tube defect’. 

All the international national health authorities,  including WHO, NICE, CDC and USPSTF recommend folic acid, rather than other forms of folate. Folic acid was used in these big studies and it showed a benefit. Folic acid is added to flour in some countries too for this reason.

The best study so far, which is a Cochrane review of all the best studies showed that folic acid reduced the risk of neural tube defects by around 70% (De Regil 2015). 

Why might I take natural folate instead?

There are many doctors who instead recommend a different version, sometimes called ‘natural’ folate, methyl folate or 5 methyltetrahydrafolate.

This is because when you take folic acid, the body needs to convert it to methyl folate (5 methyltetrahydrafolate). There are a small number of people who are unable to do this conversion for genetic reasons. Therefore, if you are one of these people, there is a chance that taking folic acid won’t be helpful as you can’t do this conversion. The only way to know if you have this is to have a test of your genes. The NHS won’t do this test and it is quite expensive to get done privately as part of a wider genetic screening test.

Some people also think that it is just better to take the version of the vitamin that the body can most easily use. However, when it comes to preventing neural tube defects, most of the studies are of folic acid and no studies have shown that taking methyl folate, or natural folate, is any better. In theory, it should be as effective and indeed, it may be better, but we don’t know for sure and the evidence is that folic acid is effective.

Which is the best to take?

For this reason, folic acid rather than any other version of folate is the recommended way to reduce the risk of spina bifida. It is also cheap and easy to buy  at the correct pregnancy dose (400mcg) in supermarkets, and, in the UK, the midwife will give you healthy start vitamins for free in pregnancy. It is the version that is in Pregnacare, and most pregnancy multi-vitamins because we have big studies showing that it is both effective and safe.  For example, at the time of writing folic acid is available in Boots for £2 for 60 tablets (roughly 2 months). It is probably much cheaper in supermarkets.

In contrast, natural folate, or methyl folate, is more expensive and more difficult to obtain. You can usually only get it online, and the price difference is quite big. For example, at the time of writing, it cost 13.50 from a well known health retailer for 60 tablets. 

What dose is best?

If you are in a higher risk group, such as if you have a raised body mass index of greater than 30, or if you have had a baby affected by a neural tube defect previously, 5mg of folic acid is recommended. This higher dose needs to be prescribed by a doctor in the UK. Therefore, when you think you want to start to try for a baby, it is a good idea to get this prescribed so you have it ready at home to start taking it.

Whatever form of folic acid or folate you decide to take, start it when you start trying to conceive and continue if for the first 3 months of pregnancy. 

References

https://www.who.int/tools/elena/interventions/folate-periconceptional, https://cks.nice.org.uk/topics/pre-conception-advice-management/management/advice-for-all-women/#advice-on-folic-acid, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication, 

De Regil et al (2015) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007950.pub3/full