Folic acid influences fetal health
In Brazil, 52% of women get pregnant without planning it. The data comes from the Birth in Brazil - National survey on labor and birth, carried out by the Oswaldo Cruz Foundation (Fiocruz) in 2014. In other words, more than half of the country's babies do not benefit from the protective effect of periconceptional supplementation (prior to pregnancy) of folic acid or vitamin B9. This is because the recommendation is that the daily dose of 400 micrograms (or 0.4 milligrams) should be started 30 days before pregnancy and continue throughout the first trimester of pregnancy. The benefit of using this B-complex vitamin to prevent neural tube defects (NTDs) - such as anencephaly, spina bifida and encephalocele - has already been well documented and consolidated in studies that began more than 50 years ago.
New research, however, extends the protective effect of vitamin B9 on children's health. Antonio Carlos Vieira Cabral, professor of obstetrics at the Federal University of Minas Gerais (UFMG) School of Medicine, says that folic acid supplementation prevents other anomalies, such as cleft lip and cleft palate. "In addition to the facial effects, it protects the fetus against congenital heart disease and against the negative effects of drugs that the mother needs to use during pregnancy - depression and epilepsy, for example. In these cases, folic acid antagonizes the actions of these drugs in pregnancy," he says.
New approaches also suggest protection against autism and obesity. "We have been researching the importance of folic acid supplementation in preventing disorders such as autism and growing disorders among children, such as obesity. This is a field that has not yet reached its limits and it is likely that over the next few years we will discover even more benefits in this relationship," says the expert.
Cabral says that folic acid began to be used empirically. "Pregnant women would take it and researchers would observe the results and then look for an explanation as to why it had a positive effect on preventing NTDs. Over the last 20 years, research has aimed to understand the benefits of supplementation in preventing other anomalies. Recently, studies have attested to folic acid's ability to form DNA. As well as helping the genetic code, this vitamin promotes gene expression, i.e. it makes it easier for genes to express themselves properly. Today we know that folic acid is directly related to genetics," he explains. In this new approach, according to him, it is already known that folate has an effect on the maturation of neurodevelopment in fetuses.
IMPORTANCE OF CORRECT DOSAGE
President of the Perinatology Commission of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and professor at the Federal University of Paraíba (UFPB), Eduardo Borges da Fonseca says that folic acid prevents between 70% and 80% against neural tube defects. According to him, the protocol of 400 micrograms (or 0.4 milligrams) of folic acid 30 days before pregnancy and in the first trimester of pregnancy is defended by the main health organizations in the world and he cites the International Federation of Gynecology and Obstetrics (Figo), the American College of Obstetricians and Gynecologists (Acog) and the Royal College Of Obstetricians and Gynecologists (RCOG).
In Brazil, according to him, the biggest problem - apart from the lack of family planning which prevents periconceptional supplementation of vitamin B9 - is the dose provided by the Unified Health System (SUS), which does not follow the international prescription. "The National List of Medicines (Rename) determines that the medicine is available in drops in the public health network in a dosage of 0.2mg/ml - an amount that would be suitable for use by pregnant women. However, basic health units offer the supplement at a dose of 5mg. Folic acid is not available in the public network to prevent neural tube defects, but rather to treat anemia," he points out. Eduardo Fonseca also warns that overdosing on folic acid also has negative repercussions on the health of the fetus. "There are already studies that associate high doses of this vitamin with alterations in the child's neuropsychomotor development," he says.
UFMG professor Antonio Carlos Vieira Cabral also points out that the 5mg dose of folic acid offered by SUS cannot be taken daily. "The ideal is to use the right dose - 0.4 milligrams daily - to avoid overdosing. Otherwise, supplementation can have a paradoxical effect on the child, impairing neurodevelopment or even causing malformations. You should never use too many vitamins. We need to put an end to this misconception that 'the more vitamins, the better'. An overdose is just as harmful as a lack of it," he observes.
As well as stressing that the minimum period for periconceptional supplementation is 30 days, the specialist explains that the maximum period can be years (as long as the dosage is correct). "If the woman doesn't get pregnant within 30 days, she can continue with the daily dose of 400 micrograms." Cabral adds that the use of folic acid can be extended throughout pregnancy and not just in the first three months. "In the second and third trimesters, supplementation aims to act on other structures. From the point of view of maturation, brain formation doesn't end at three months, but lasts until the end of pregnancy. At any time during the 40 weeks, there is a risk of these structures being compromised. Thus, folic acid will have fulfilled its full purpose: both in preventing abnormalities and in helping neurodevelopmental maturation," he says.
LACK OF INFORMATION
Eduardo Borges da Fonseca conducted a study at UFPB that evaluated the use of folic acid in 500 women who gave birth in public and private maternity hospitals. "Half became pregnant unplanned and didn't get the protection of folic acid for the health of the fetus. In these cases, it's common for women to go to the doctor after their periods are late, i.e. at six weeks gestation, when the baby's neural tube is formed between 57 and 60 days. In other words, if you don't take it beforehand, the vast majority miss this formation window," he points out.
Another alarming finding is that, in the group of women who planned their pregnancies, 30% used folic acid, but only 10% used the correct dosage. "The main determining factor found in the survey was socioeconomic status. The higher the socioeconomic level, the greater the adherence to the correct use of folic acid supplementation. This shows us that information is a preponderant factor in preventing NTDs," says Fonseca.
It's also important to know that neural tube defects are multifactorial and result from the combined action of genes and the environment. "In this case, the environmental factor that is important is folic acid which, used in small doses, reduces the overall incidence of NTDs. When a couple has a child with a neural tube defect, the risk of the second child having the same problem is approximately 4%. With the use of folic acid, the risk drops to 1%," says Fonseca. Thus, according to him, this B-complex vitamin acts in two ways: to prevent the occurrence and to reduce recurrence.
The specialist adds that the repercussions for the child's life can be more serious or less serious depending on where the tube opens. "When the neural tube defect is in the upper part (or upper torso), the impairment is greater. If it's lower down, i.e. in the lumbosacral region, it affects the legs and sphincters," he explains. In this case, the child may have problems with urinary and fecal incontinence, as well as difficulty walking.
FOODS RICH IN FOLIC ACID
A resolution by the National Health Surveillance Agency (Anvisa/RDC 344, of December 13, 2002) made it compulsory to fortify wheat and corn flour with folic acid and iron due to the high rates of anemia in the country, as well as other diseases caused by a deficiency of these substances. Since then, every 100 grams of wheat or corn flour must contain 4.2 milligrams of iron and 150 micrograms of folic acid.
The president of Febrasgo's Perinatology Commission, Eduardo Borges da Fonseca, says that this fortification minimizes the unplanned pregnancy in relation to the periconceptional protective effect of folic acid supplementation. "But it must be made clear that this fortification does not replace the need for supplementation," he warns.
Antonio Carlos Cabral stresses that the prescription recommended by the main health organizations around the world already takes into account the fortification of flours. "With flour, women absorb approximately 70% of the necessary vitamin," he says. For him, the big problem with relying on fortification is that it's not possible to know if what's on the label is really being offered. "Folic acid is not cheap and not all food companies have strict quality control," he adds.
It is also important to remember that folic acid is not only significant for pregnant women and their babies. Oba Hortifruti nutritionist Lívia Nogueira explains that folate also plays an important role in the bodies of adults and children. "Folic acid acts in the production of hemoglobin in the blood and its deficiency in the body can cause anemia, inflammation of the tongue, mental deterioration and even problems related to the gastrointestinal system, such as diarrhea," she explains. According to her, the preparation of foods rich in folic acid must be careful, because around 50% to 95% of this vitamin is easily modified in prolonged contact with oxygen in the air or high temperatures, which impairs its action in the body.
NEURAL TUBE DEFECTS
The incidence of neural tube defects is one person per thousand births: 40% is anencephaly (incompatible with life), 40% spina bifida (the child may not walk, have fecal and urinary incontinence and developmental delay) and 20% encephalocele. Professor of pediatrics at UFMG's School of Medicine and coordinator of the Genetics Service at Hospital das Clínicas, Marcos Aguiar explains that the central nervous system begins as an open tube and then closes, and it is in this closure that folic acid acts.
- Anencephaly: complete or partial absence of the brain and skull. The anomaly is incompatible with life and is one of the cases in which abortion is guaranteed by law in Brazil.
- Spina bifida: a defect in the posterior bone closure of the spine. The congenital abnormality can present itself in different ways. It can be hidden and asymptomatic (spina bifida occulta), with the meninges exposed (meningocele) or, in addition to the meninges, the spinal cord and nerve roots can be exposed (myelomeningocele).
- Encephalocele: similar to a defect in the closure of the spinal column, except that it occurs in the skullcap. In other words, the brain and meninges herniate (become exposed) through this opening in the skullcap. It's as if a person had suffered a traffic accident with loss of brain mass.
WHAT TO EAT
See what to include in your diet and how to prepare it
- Broccoli: To preserve folic acid, it's best to steam the vegetable quickly.
- Kale: Eat raw or steamed in salads, soups and broths.
- Spinach: Can be eaten raw or steamed. It enhances salads, pies, quiches, soups and broths.
- Liver: To make the most of the nutrients contained in this food, it should be eaten fresh.
- Beans: It's important to consume not only the beans, but also the broth, which concentrates a large part of the folic acid during cooking.