nikaLIVE: Folic acid – why is it so important for women?

Folic acid is routinely recommended to women planning to enlarge their family and those who are already pregnant. However, the awareness of future mothers that not every supplement or even medicine containing folic acid can be absorbed by them due to human genetic predispositions is still low. We talked on nikaLIVE on Instagram with Dr. about which folic acid to choose for pregnancy (and not only). n. med. Maciej Socha, specialist in obstetrics and gynecology, clinical andrologist, oncological gynecologist and perinatologist. You can watch and listen to the recording at this link .

Below is a text version of this conversation.

Typically, women start thinking about folic acid in the context of pregnancy. Why is it so important in this period?

This is one of my favorite topics because folic acid is one of the few substances that for us, obstetricians and gynecologists, has an almost magical function . Let's start with the simplest thing. Well, folic acid helps prevent open neural tube defects . I know that this is a very tired topic, everyone thinks that a lot has already been said about it, everyone knows that folic acid should be taken. However, there is a big "but" that reminds us that supplementation with folic acid in the appropriate dose is extremely important. The progress of medicine has recently caused us to hear more and more often about open neural tube defects, encephalocele, meningocele, and myelomeningocele. These are all preventable defects . We can reduce their percentage.

The situation with folic acid is strange, because when the patient finds out that she is pregnant, it is already too late . Because the neural tube is initially like a characteristic cup or gutter, if we tried to imagine it. Before it closes into the tube, i.e. the neural tube, it needs folic acid. The neural tube closes around age 6-7. week of pregnancy - this is the time when women most often find out that they are pregnant. What we, obstetrician-gynecologists, postulate, what the Polish Society of Gynecologists and Obstetricians and, in fact, most organizations in the world recommend - the patient should think about folic acid supplementation +/- 3 months before getting pregnant . If we would like to get pregnant spontaneously and romantically (which is, of course, beautiful), we will be exposed to certain risks. To reduce these risks, and, among others, also the risk of neural tube defects, you should think about it much earlier.

Does this mean that every woman of childbearing age who is considering possibly expanding her family will be better off taking folic acid just in case?

Exactly. This is the so-called universal prevention . It applies to all women of childbearing age or thinking women who are currently trying to get pregnant . If someone wants to get pregnant or if there is a possibility of getting pregnant, supplementation should be considered. And not only due to neural tube defects. An extremely important element of the hematological economy, i.e. everything related to the formation of blood cells and the function of a single erythrocyte, is how it will function depending on the level of folic acid. We often forget that anemia is one of the risk factors for miscarriage . Without delving into any complicated mechanisms and strange disease entities - simply, those patients who have anemia are patients who are at increased risk of problems with getting pregnant, the risk of open neural tube defects and, finally, an increased risk of miscarriage . Miscarriages are very common events. If we can do anything to reduce this risk by at least one permille, we should think about it. Meanwhile, patients realize that iron is the only element that reduces the risk of anemia. Yes, iron builds the heme molecule, which is contained in a single erythrocyte. However, I will say it very loudly - in order for iron to be properly incorporated into the blood cell, to build the heme molecule, it needs, among other things, also folic acid . The level of iron, the level of folic acid, the level of hormones that govern their metabolism are very important and affect, among others: whether or not a miscarriage will occur.

B vitamins (including folic acid) are most often talked about in the context of their impact on the nervous system, but it is rarely mentioned in the public space that they are important for blood formation and that the cause of anemia may not only be iron deficiency, but also a deficiency of B vitamins.

Both folic acid and the recently "fashionable" (and extremely important) inositols, and the entire group of B vitamins play a very important role, are of great importance for the body and are related to fertility . Today we know that the proper function of the hypothalamic-pituitary-ovarian axis and the proper endocrine function, which influences how the patient ovulates, how pregnancy occurs, and how the pregnancy is maintained in the early stages - depends on the entire group of vitamins from group B , including, among others, is related to the function of folic acid and its final metabolite methylenetetrahydrofolate . Many of my patients already know this complicated name.

Since you started talking about forms of folic acid, let's move on to products with folic acid available on the Polish market. What should we pay attention to when choosing folic acid for ourselves?

Maybe I'll start with what this methylenetetrahydrofolate (MTHF) is all about. Patients very often already know the term MTHFR . This "R" stands for reductase, an enzyme that, when we deal with folic acid, turns it into the active form 5-methylenetetrahydrofolate (5-MTHF). Reductase is an enzyme that is created as a result of the action of appropriate genes . But it turns out that at least half of us, and perhaps as many as 60 to 70% of people (some believe 75-80% of people) produce slightly different forms of reductase . You can even say that it is not a mutation, because a mutation is an incorrect arrangement of genes, and here we are dealing with different variants of the structure of the MTHFR gene itself . Some of us are better at this activity, others are worse at it. Roughly speaking, every second person in the general population has a differently functioning gene for this MTHF reductase. Does this mean there is something wrong with us? NO. Some people, among those with incorrectly constructed genes, will be able to cope somehow if we simply add more ordinary folic acid.

However, in this situation, I usually remind my students of such a metaphor. Imagine that you are asking your father to throw the coal that a dump truck dumped in front of the house into the basement. And at that moment it turns out that dad breaks his arm. And what's happening? If we add more coal, will he get it into the basement faster? NO. Same with folic acid. If, due to a defective or non-normal structure of this gene, it does not function perfectly, then for me it is a rather vulgar idea to add more coal (i.e. folic acid) when my father has a broken arm and I have no way of throwing this coal into the basement. So what can we do about it? We can provide our body with an already active, bioavailable , properly constructed, perfect molecule of methylenetetrahydrofolate, i.e. the active form of folic acid .

ESPHGAN, the European Association of Pediatric Gastroenterology, Hepatology and Nutrition in Germany (headed by the famous Professor Koletzko), recommends that all dietary supplements contain the active form of folic acid . I don't know if this is the right time and if I'm the right person, but I would like to appeal to everyone. Take supplements containing the active form of folic acid . Nothing can replace it. It just has to be well constructed, because it is not squeezed from some vegetable or fruit. Only a properly constructed molecule. And it can work wonders. The active form of folic acid taken even just before the idea of ​​getting pregnant or just after the expected "romantic failure" is certainly a better idea than taking popular supplements with ordinary folic acid.

However, many women still take dietary supplements with this plain, inactive folic acid. And doctors often recommend taking such products. Why is it like that?

I don't think I'm qualified to answer these questions (laughter). Each of us has our own idea for life, for health, for medicine, for recovery. If it is the idea of ​​a patient who is not an expert in a given field, I can accept everything if the patient hears the pros and cons of such a solution . However, the fact that the doctor may not have updated his knowledge for 20 years and came up with certain recommendations should be considered malpractice in the light of current medical knowledge . We should not use preparations or agents that do not have a well-established scientific position. The characteristics of some medicinal products (i.e. the so-called leaflets) were often created a long time ago, as were the products. And now we are dealing with such flowers that the doctor says: "No, you don't need to use any vitamin D3, why do you need iodine?" Let's give up on these ideas about the active form of folic acid. I can only beat my chest for my environment and say that I am extremely sorry that such things are happening. But this has no scientific support . Happily, I only admit that sometimes patients are smarter than us doctors, and kudos to them for that.

For example, if the patient has already stocked up on supplements with synthetic inactive folic acid and now thinks: "It's too bad, I've already bought it, I'll take it anyway, maybe it will be available to me." Can this approach harm her?

It sounded so light, but I wish it sounded a little stronger. We in medicine, especially in perinatology, very often devote enormous amounts of our energy to reducing, for example, the risk of perinatal hypoxia by 1 case in 10,000. When we perform screening for various diseases, e.g. pre-eclampsia, we do it to select just one out of thousands of patients. So if we're talking about someone having such a risk appetite that they're willing to risk fifty-fifty, that sounds like madness . I leave no room for juggling, especially when we are talking about the health of the fetus and the pregnant woman. What both Polish, European and international decent scientific organizations are currently saying, that with the help of proper supplementation we are able to improve perinatal results .

Imagine that a mother with anemia sometimes has larger blood cells. MCV is an indicator in morphology that shows the volume of this blood cell. When we add the wrong supplements, such a large blood cell has no way of squeezing through the small vessels in the so-called utero-fetal-placental unit. What we said so lightly, that if instead of "normal" folic acid (because I use that term) I take some random synthetic one (because my mother and grandmother took it and everyone remembers its characteristic name), it is worth considering realize that it is not based on truth and scientific facts , on anything that would be consistent with current medical knowledge. And my patients know that we work together so intensively to ensure that the end point of treatment, i.e. the child taken home, is a healthy child . We have a scale that allows us to assess the cognitive abilities of a child in the second year of life. And when we look at the results of these studies, it turns out that children of mothers who did not have anemia and elevated homocysteine ​​levels, and who had adequate folate levels , function better . If the patient is going to take a risk because she has already bought something there, she must understand that the other possibility may be that the child will get an "A" in the "environment" in the 4th grade of primary school, and not a C.

Should only pregnant women pay attention to folic acid? Or maybe also women of other ages or men?

Sometimes I wonder if it is out of love, from the bottom of my heart that I am a fan of folates, or simply out of common sense. But my head keeps telling me that folate is needed. The appropriate level of folates will reduce the risk of cardiovascular diseases , will be important for patients with polycystic ovary syndrome , and will affect the functioning of patients with metabolic syndrome , with a spectrum of autoimmune diseases that affect the ovaries, thyroid and vascular endothelium . So let's imagine a patient with PCOS, additionally hypothyroidism, or in fact Hashimoto's disease , she will develop obesity, abnormal glycemia levels, and carbohydrate metabolism disorders. Folates are also used for this purpose . And since half of us have improperly functioning MTHF reductase, which we talked about earlier, it is worth thinking about folate supplementation .

I work as a clinical andrologist and when men ask what supplement to use, I list the classics that come up, but I often tell them: "If my wife has her supplements and there will be vitamin D3, iodine, magnesium, the active form of folic acid, then it's really please take this pill.” Then, of course, there is a lot of laughter, because what, a supplement for a pregnant woman, for someone trying to get pregnant? I have no hesitation in recommending it to men . Supplements for pregnant women are well designed and I recommend them to men in the "period of pregnancy" period, so that they know that active folic acid will also be useful for them . Although, of course, the peri-pregnancy period and recommendations for folic acid supplementation during this time are the main period I focus on when working with my patients.

Some people think that a varied diet rich in green vegetables and broccoli will help provide enough folate. Is this a good solution?

This is not even a matter of my opinion, but a matter of scientific doctrine, medical knowledge and simply research results . They indicate that even the most balanced and properly prepared diet (regardless of whether vegan or omnivorous) is not able to provide us with the appropriate level of folates . Some patients say that they would like to do without any supplements, without any pills, so that it would be super natural. However, let's look at the research on the so-called "raw population", i.e. a general group of people. Let's say the miscarriage rate is X in this group. Using such an "unnatural" approach, as supplementation in addition to a varied diet is sometimes considered, may allow us to make the risk either X minus some points, or X divided by some. And the surprised patient asks: "Really?" Yes, quite seriously. Nutritional societies also mention various other supplements, there are few of them, but they change the history of what we can do to maximize the chances of a normal pregnancy and its happy ending . We must supplement active folic acid. And there should actually be a huge dot over the i. There should be no discussion about this.