Folic Acid, a synthetic form of Folate, is a B vitamin found in a variety of foods and added to many vitamin and mineral supplements. Folate is needed both before and in the first weeks of pregnancy and can help reduce the risk of certain serious and common birth defects called neural tube defects, which affect the brain and spinal cord.

The tricky part is that neural tube defects can occur in an embryo before a woman realizes she's pregnant. That's why it's important for all women of childbearing age (15 to 45) to include folate in their diets: If they get pregnant, it reduces the chance of the baby having a birth defect of the brain or spinal cord.

"Adequate folate should be eaten daily and throughout the childbearing years," said Elizabeth Yetley, Ph.D., a registered dietitian and director of FDA's Office of Special Nutritionals.

Folate's potential to reduce the risk of neural tube defects is so important that the Food and Drug Administration requires food manufacturers to fortify enriched grain products with folic acid. This will give women one way to get sufficient folate: by eating fortified breads and other grain products, such as enriched pasta, rice, waffles and cereal bars.

Other ways to do this are:

• Eat fruits, dark-green leafy vegetables, dried beans and peas, and other foods that are natural sources of folate.
• Eat folic acid-fortified enriched cereal grain products and breakfast cereals.
• Take a vitamin supplement containing folic acid.

Nutrition information on food and dietary supplement labels can help women determine whether they are getting enough folate, which is 400 micrograms (0.4 milligrams) a day before pregnancy and 800 micrograms a day during pregnancy.

Neural Tube Birth Defects

The technical names of the two major neural tube birth defects reduced by adequate folate intake are anencephaly and spina bifida. Babies with anencephaly do not develop a brain and are stillborn or die shortly after birth. Those with spina bifida have a defect of the spinal column that can result in varying degrees of handicap, from mild and hardly noticeable cases of scoliosis (a sideways bending of the spine) to paralysis and bladder or bowel incontinence. With proper medical treatment, most babies born with spina bifida can survive to adulthood. But they may require leg braces, crutches, and other devices to help them walk, and they may have learning disabilities. About 30 percent have slight to severe mental retardation.

The national Centers for Disease Control and Prevention estimate that about 2,500 infants with spina bifida and anencephaly are born each year in the United States.

Other maternal factors also may contribute to the development of neural tube defects. These include:

• family history of neural tube defects
• prior neural tube defect-affected pregnancy
• use of certain antiseizure medications
• severe overweight
• hot tub use in early pregnancy
• fever during early pregnancy
• diabetes.

Folate Link

Scientists first suggested a link between neural tube birth defects and diet in the 1950s. The incidence of these conditions has always been higher in low socioeconomic groups in which women may have poorer diets. Also, babies conceived in the winter and early spring are more likely to be born with spina bifida, perhaps because the mother's diet lacks fresh fruits and vegetables--which are good sources of folate--during the early weeks of pregnancy.

In 1991, British researchers found that 72 percent of women who had one pregnancy with a neural tube birth defect had a lower risk of having another child with this birth defect when they took prescription doses of folic acid before and during early pregnancy.

Another study looked at folic acid intake in Hungarian women. The evidence indicated that mothers who had never given birth to babies with neural tube defects and who took a multivitamin and mineral supplement with folic acid had less risk in subsequent pregnancies for having babies with neural tube defects than women given a placebo.

These studies led the U.S. Public Health Service in September 1992 to recommend that all women of childbearing age capable of becoming pregnant consume 0.4 mg of folate daily to reduce their risk of having a pregnancy affected with spina bifida or other neural tube defects.

That corresponds to FDA's Daily Value for folic acid, which is 400 micrograms for nonpregnant women, as well as children 4 and older and adult men. For pregnant women, the Daily Value jumps to 800 micrograms. Daily Values are dietary reference numbers used on the Nutrition Facts panel on food labels to show the amounts of various nutrients in a serving of food.

Many women between 19 and 50 consume much less than 400 micrograms of folate a day, according to the U.S. Department of Agriculture.

Sources of Folate

Folate occurs naturally in a variety of foods, including liver; dark-green leafy vegetables such as collards, turnip greens, and Romaine lettuce; broccoli and asparagus; citrus fruits and juices; whole-grain products; wheat germ; and dried beans and peas, such as pinto, navy and lima beans, and chickpeas and black-eyed peas.

Under FDA's folic acid fortification program, which became effective January 1998, the agency requires manufacturers to add from 0.43 mg to 1.4 mg of folic acid per pound of product to enriched flour, bread, rolls and buns, farina, corn grits, cornmeal, rice, and noodle products. A serving of each product will provide about 10 percent of the Daily Value for folic acid. Whole-grain products do not have to be enriched because they contain natural folate. Some of the natural folate in non-whole-grain products is lost in the process of refining whole grains.

Folate also can be obtained from dietary supplements, such as folic acid tablets and multivitamins with folic acid, and from fortified breakfast cereals.

A report recently released by the Institute of Medicine indicates that the evidence suggests that folic acid, the synthetic form of folate, may be better absorbed than folate found naturally in foods. The report also points out that, if taken in adequate amounts, food folate may eventually be demonstrated to be as effective as folic acid.

Foods Containing Folate

Food	Serving Size	Amount (Micrograms)	%Daily Value*
Chicken liver	3.5 oz	770	193
Breakfast cereals	1/2 to 1 1/2 cup	100 to 400	25 to 100
Braised beef liver	3.5 oz	217	54
Lentils, cooked	1/2 cup	180	45
Chickpeas	1/2 cup	141	35
Asparagus	1/2 cup	132	33
Spinach, cooked	1/2 cup	131	33
Black beans	1/2 cup	128	32
Burrito with beans	2	118	30
Pasta	2 oz.	100-120	25-30
Kidney beans	1/2 cup	115	29
Cereal bars	1 bar	40-100	10-25
Baked beans with pork	1 cup	92	23
Lima beans	1/2 cup	78	20
White rice, cooked	3/4 cup	60	15
Tomato juice	1 cup	48	12
Brussels sprouts	1/2 cup	47	12
Orange	1 medium	47	12
Broccoli, cooked	1/2 cup	39	10
Fast-food French fries	large order	38	10
Wheat germ	2 tbsp	38	10
Fortified white bread	1 slice	38	10

* based on Daily Value for folate of 400 micrograms
(Source: Food Values of Portions Commonly Used, 16th edition)

How to Find Foods Containing Folate or Folic Acid

Certain information on food and dietary supplement labels can help women spot foods containing substantial amounts of folate. Some labels may claim that the product is "high in folate or folic acid," which means a serving of the food provides 20 percent or more of the Daily Value for folic acid. Or the label may say the food is a "good source" of folate, which means a serving of the food provides 10 to 19 percent of the Daily Value for folic acid. The exact amount will be given in the label's Nutrition Facts panel.

Some food and dietary supplement labels may carry a longer claim that says adequate folate intake may reduce the risk of neural tube birth defects. Products carrying this claim must:

• provide 10 percent or more of the Daily Value for folic acid per serving
• not contain more than 100 percent of the Daily Value for vitamins A and D per serving because high intakes of these vitamins are associated with other birth defects
• carry a caution on the label about excess folic acid intake, if a serving of food provides more than 100 percent of the Daily Value for folic acid. FDA has set 1 mg (or 1,000 micrograms) of folate daily as the maximum safe level. There are limited data on the safety of consuming more than 1 mg daily, and there may be a risk for people with low amounts of vitamin B₁₂ in their bodies--for example, older people with malabsorption problems, and people on certain anticancer drugs or drugs for epilepsy whose effectiveness can diminish when taken with high intakes of folate.
• list on the label's Nutrition or Supplement Facts panel the amount by weight in micrograms and the %Daily Value of folate per serving of the product. This information, which appears toward the bottom of the panel, along with the listing of other vitamins and minerals, can be used to compare folate levels in various foods and supplements.

More Considerations

The claim about folate cannot imply that adequate folate intake alone will ensure a healthy baby, since so many factors can affect a pregnancy.

Women should bear this in mind when contemplating pregnancy, advises Jeanne Latham, a registered dietitian and consumer safety officer in FDA's Office of Special Nutritionals. "Folate can make a significant contribution," she said, "many factors, including an overall good diet, are involved in having a healthy baby."

Genetics plays a role, as do other healthful prenatal practices, such as eating an all-around good diet. But unlike genetics, diet is a risk factor women can modify to their--and their baby's--advantage, said Jeanne Rader, Ph.D., director of the division of science and applied technology in FDA's Office of Food Labeling.

"Folic acid is one of many nutrients needed in a healthy diet for women of childbearing age," she said. "A well-balanced diet with a variety of foods can provide all those nutrients, including adequate amounts of folate."

Women have options for reaching the folate intake goal: They can get the necessary nutrients and calories both before and during pregnancy by eating a well-balanced diet, keeping in mind folate-rich foods, nutrition experts say. Folic acid-fortified grain products, including breakfast cereals, will help, too. Dietary supplements are another source of folate. Any one or a combination of these options for ensuring adequate folate can help assure women of childbearing age that, if they become pregnant, their babies will be off to a healthy start.