the importance of folic acid in pregnancy plus our special folic acid recipes-by merrion fetal...

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THE IMPORTANCE OF

FOLIC ACID IN PREGNANCY

Plus Our Special Folic Acid Recipes

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CONTENTS

What is folic acid?

How much folic acid do you need?

What are the benefits?

What happens when you don't take enough?

The Irish context

Who may be at higher risk?

Food that can partner folic acid supplements

Asparagus & Ricotta Tarts

Halloumi Burgers

Lamb & Lentil Shepherd’s Pie

Pasta Primavera

Vegetable Gratin

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12.

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FOREWORD

Folic acid plays a vital role in contributing to a healthy pregnancy, and a healthy baby.

This magazine has been produced by Merrion Fetal Health - the medically led, midwife facilitated ultrasound clinic in Dublin, Ireland.

It incorporates the information that you need to know about folic acid, as well as looking at the Irish context.

The research references a number of medical studies which are included in the bibliography.

Merrion Fetal Health has also commissioned a chef & nutritionist to create a small selection of folic acid rich recipes for you.

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1. What is folic acid?

Folic acid, also known as folate, is a B vitamin, in its synthetic form. Folic acid is significant for the production of red blood cells and the development of a baby’s neural tube into the spinal cord and brain (1).

Folic acid is necessary for producing and repairing DNA. This is the

body’s genetic map and the basic method of building cells. For that rea-

son, folic acid is essential for the rapid cell growth of the placenta and

the development of the baby. (7)

The body requires folic acid to prevent a certain kind of anemia and

some research believes that taking folic acid daily can reduce the risk

of developing pre-eclampsia. This is a multifaceted disorder that can af-

fect the mother’s health as well as the baby’s health. (4)

The CDC (Centres for Disease Control USA) suggests taking folic acid

daily when pregnant and a month prior to becoming pregnant. The

CDC also recommends that any women of a childbearing age begin tak-

ing folic acid daily whether planning pregnancy or not. (10) This is due

to the fact, that more than half of the pregnancies in the United States

are unplanned.


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Helps Prevents Birth Defects

Taking this vitamin can help prevent

birth defects that typically occur dur-

ing the first 3-4 weeks of pregnancy.

Having folic acid in the system dur-

ing the early stages of development,

when the baby’s brain and spinal

cord are developing, is essential. One

study proved that women who took

folic acid for a year prior to getting

Decreases Chance Of Early Delivery

pregnant decreased the chance of

early delivery by 50% or more. (3)

The neural tube begins forming

around three weeks after concep-

tion; this is why it is important to

receive a daily dose of folic acid

prior to conception and during

the first trimester. (4)

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2. How much folic acid do you need?

A daily supplement of 400 micrograms (400μg/0.4mg) folic acid as recommended prior to conception and for the first 12 weeks of pregnancy, has been shown to help prevent neural tube defects (NTDμs) (FSAI, 2006). (15)

The above data is relevant to the majority of women, but there are

some exceptions, such as when there is a family history of either neu-

ral tube defects (NTDs) or pre-existing diabetes. Women who fall into

these categories will be recommended a higher dose both before con-

ception and during the first trimester.

There is medical evidence that suggests that obese women can also

benefit from a higher dose of folic acid during these periods.

Please note however, that higher dosages must be administered with

care and only by your healhtcare provider.

The March of Dimes, The U.S. Public Health Service, and the American

College of Obstetricians and Gynecologists (ACOG) strongly suggest that

any woman of childbearing age, whether pregnant or not, take at least

400 mcg of folic acid daily. (4)


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Pre-Natal Vitamins

When women consult with a doctor

when trying to conceive, they are

told to begin taking folic acid, and

perhaps additionally pre-natal vita-

mins.

It is important to remember that

when personally selecting pre-natal

vitamins, women should consult with

their medical team.

Pre-Natal Vitamins

This ensures that the chosen vi-

tamins have the recommended

amount of everything needed

during pregnancy, including folic

acid.

Pre-natal vitamins can vary sig-

nificantly and some may not have

the proper amount of folic acid

needed during pregnancy. (4)

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3. What are the benefits?

It is suggested that folic acid can protect a baby from neural tube defects by at least 50%. (1) (2)

The Centres for Disease Control and Prevention (CDC) states that

women who take the suggested dose of folic acid daily, beginning one

month prior to conception and during the first trimester, help reduce

the baby’s chance of neural tube defects by 50 to 70 percent. (5)

Mothers who have given birth to a baby with a neural tube defect can

reduce the risk of having another child with a neural tube defect by as

much as 70% by taking folic acid. (2) (8)

A 2015 British Medical Journal study said:

"In the absence of mandatory fortification, the prevalence of NTD has

not decreased in Europe despite longstanding recommendations aimed

at promoting peri-conceptional folic acid supplementation and exis-

tence of voluntary folic acid fortification."


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Folic Acid Also Helps:

When taken before and during preg-

nancy, folic acid can protect a baby

against: (7)(10)

- Low birth weight

- Cleft lip and palate

- Premature birth

Other Benefits

Folic acid may also aid those who

take it in reducing the risk of:

- Several types of cancers

- Heart disease

- Alzheimer's disease

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4. What happens when you don't take enough?

An insufficient amount of folic acid in the body may cause the baby’s neural tube to close in-correctly and this could develop health issues known as neural tube defects or NTDs

These defects include: (11)( 12)

Spina bifida:

This occurs when the spinal cord or the vertebrae do not develop cor-

rectly

Anencephaly:

This occurs when major parts of the brain do not develop correctly.

Babies with anencephaly generally do not live long; while babies with

spina bifida are permanently disabled. These serious health issues may

be preventable with the use of folic acid (12).

Neural tube defects, or NTDs, can begin at an early stage in develop-

ment. In some cases, this is before the woman realises she may be preg-

nant. This affects more than 3,000 pregnancies per year in the United

States. (4)

5. The Irish context

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Ireland & NTDs

The Report of the National Commit-

tee on Folic Acid Food Fortification

showed that (13):

- Ireland has one of the highest inci-

dences of NTD’s in Europe.

- Every year between 49 and 93 Irish

babies are affected each year, most

commonly with spina bifida.

Prevention

Between 70%* of NTDs can be

prevented by taking the recom-

mended amount of folic acid – we

have known this since 1991.

*Other studies refer to 50% or be-

tween 50% and 70%:

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50% of pregnancies in Ireland are not planned.

The most important reasons why some Irish women don’t take folic acid are:

- 50% of pregnancies are unplanned

- Lack of education regarding the importance of taking folic acid before conceiving and during the first trimester

- Financial barriers to buying supplements


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One big issue as pointed out in the

The Report of the National Com-

mittee on Folic Acid Food Fortifica-

tion (13) is that 50% of pregnancies

are not planned – therefore unless

women of childbearing age appreci-

ate that without taking supplements

they are unlikely to consumed the

recommended amount, this leaves

a large group of women at risk,

straight away.

In fact this study also found that more than one third of Irish women of childbearing age consumed no folic acid at all (35%).

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6. Who is at higher risk?

Higher risk categories include those who smoke regularly, drink more than one alcoholic drink per day......read on to disccover a number of other groups.

- Women with certain genotypes that are associated with a higher risk

of NTDs

- Women with prior pregnancies resulting in NTDs or a family history

of NTDs

- Ladies with certain malabsorption disorders (such as inflammatory -

bowel disease)

- Those suffering from obesity with a Body Mass Index > 35 kg/m2

- Women diagnosed with diabetes

- Women diagnosed with liver disease

- Women diagnosed with sickle cell disease (12)

- Those dealing with lifestyle and compliance issues – these women are

also at an increased risk of developing NTDs and may benefit from re-

ceiving higher dosages of folic acid: (2)

- Women who use anti epileptic drugs

- Those who take folate antagonists (such sulfonamides, asmethotrex-

ate)

- Women who consume more than one alcoholic drink per day (12)

- Women who smoke regularly


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In most cases, women suffering from

obesity are more likely to have a

baby with a neural tube defect. Al-

though the reason remains vague;

some studies suggest that women

with a higher Body Mass Index (BMI)

usually have lower levels of folate in

their blood.

Significantly overweight women

should consult with a healthcare pro-

fessional prior to conceiving.

This is primarily because the

healthcare professional may pre-

scribe more than 400 mcg of folic

acid daily. (2)(4)

If the mother has had a previous

baby with a neural tube defect, it

is important to alert the health-

care professional before attempt-

ing conception.

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If a woman has given birth to a baby with a neural tube defect previously, she needs to talk to her doctor before trying to conceive.

Without the assistance of a professional, women in this particular situ-

ation are at a higher risk of experiencing another pregnancy compli-

cated by an NTD. However, the risk can be reduced significantly by tak-

ing a larger dose of folic acid. (1)

Women that have been diagnosed with diabetes or women taking anti-

seizure medications for epilepsy are at a higher risk of having a baby

with an NTD. Seeking the help of a healthcare professional at least a

month prior to conception can help reduce the risk of having a baby

with NTD. The professional can recommend the proper amount of folic

acid and safely monitor the condition. (2)

Research has shown that the body absorbs the synthetic form of folic

acid easier than the form that is available naturally in foods. (12) Gen-

erally, grain products and enriched cereals are fortified with the syn-

thetic form. However, the majority of women don’t eat these types of

foods enough to depend on them as the main source of folic acid.

7. Foods that can partner folic acid supplements

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AsparagusBaked potatoesBroccoliBrussels sproutsCabbageChickpeasCitrus fruits & juicesCollardDried beans

Enriched flour and pastaFortified breakfast cerealsKalePeasOkraSpinachTurnip greensYeast Extract

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Before you check out the selection of recipes which we have created for you, please note the following advice:

The ingredients of the following recipes, as well as the foods mentioned on the previous page are not a permanent solution for the daily re-quired intake of folic acid.

These foods are considered a partner to the supplement. This is mainly because the body absorbs all of the folic acid in the supplement, but only absorbs some of the folate in the en-riched foods.

It is also very important to know that folate can be destroyed when cooking it. Most folates dis-solve easily in water. This is why steaming or microwaving vegetables works better than boil-ing them. Overcooking these type of foods can destroy the folates that are contained inside. (4)(12)


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Although some foods in Ireland are fortified with folic acid, not everyone eats these foods.

There has been an on-going debate about forti-fying flour, and therefore bread, however at the time of writing this still hasn’t been implement-ed.

Additionally it is not possible to add the full recommended amount to bread, as this would result in an excess of folic acid for other members of the population.

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Time & ServingsPrep time: > 15 minutes.

Cook time: 30 minutes

Serves 2

Nutritional Analysis:Calories 423

Fat 28g

Carbs 29g

Protein 16g

Folate 164µg

Ingredients:200g ready-rolled puff pastry

150g ricotta cheese

20g grated parmesan cheese

6 sun-dried tomatoes, finely

chopped

10-12 asparagus spears, trimmed


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These stunning little tarts are perfect for a romantic night in. They are easy to prepare and use only a few good-quality ingredients. The dish contains a good amount of folate, calcium and vitamin K - all essential for baby’s growth and for your own health.

1 Pre-heat the oven to 190°C/170°C (fan).

2 Unroll the puff pastry and cut two rectangles, widthways. Score an-other rectangle inside these - leaving a border of about 1cm. Be sure not to cut through the pastry.

3 Line a baking tray with parchment (or use the parchment the pastry was rolled in) and place the pastry rectangles on top. Score a criss-cross pattern around the borders, if you like.

4 Place the pastry in the oven and cook for 15 minutes. Remove from the oven, cool slightly, and then gently depress the inside windows with your fingers.

5 While the pastry is cooking, mix the ricotta with the parmesan and sun-dried tomatoes.

6 Carefully spread the mixture into the windows of the pastry - it helps to put little ‘dollops’ of the mixture all over - and then top with the as-paragus spears.

7 Using a pastry brush, use the oil from your jar of sun-dried tomatoes to glaze the asparagus spears. Place the tarts back into the oven for a further 15 minutes. Serve warm or at room temperature, with a green salad.

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Halloumi BurgersHalloumi Burgers

Time & ServingsPrep time: 10 minutes.

Cook time: 8-10 minutes

Serves 2


Fat 11g

Carbs 34g

Protein 13g

Folate 122 µg

Ingredients:1 block halloumi

5-6 sprouts, very finely shredded

2 spring onions, very finely

shredded

30g chopped dried cranberries

1 egg

Small handful dried breadcrumbs

1 tsp crushed garlic

2-3 tsp cranberry sauce

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Halloumi Burgers

A nice variation from the simple grilled hal-loumi, these burgers are a cinch to prepare and can be done a day in advance if necessary. Sprouts have been included in the burger mix for a folate hit, while cranberries, good for the urinary system, provide a hint of sweetness..

1 Rinse the halloumi well to remove excess salt and pat dry with kitch-en towel. Finely grate into a mixing bowl.

2 Add the shredded sprouts, spring onions, cranberries, breadcrumbs, egg and garlic and mix until well combined.

3 With your hands, check the mixture is right by taking a small amount and scrunching into a ball - it should just about stick together, with a little moisture oozing out. If it is too crumbly, add a little more egg. Too wet, add more breadcrumbs. Bear in mind the mixture will firm up in the fridge.

4 Form into patties and place on a plate, then cover with cling film and chill for at least half an hour.

5 When ready to cook, heat a little olive oil in a frying pan over a me-dium heat.

6 Cook the patties for 3-4 minutes each side - be careful when you turn them - until golden brown and heated through.

7 Serve in buns with mayo on the bottom and a spoonful of cranberry sauce on the top, and a side salad..

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Lamb & Lentil Shepherd’s PieLamb & Lentil Shepherd’s Pie


Cook time: 1 to 1.5 hours

Serves 4


Fat 16g

Carbs 42g

Protein 34g

Folate 240 µg

Ingredients:400g lean lamb mince

1 onion, chopped

2 carrots, peeled and finely diced

1 tbsp. tomato puree

200ml beef or chicken stock

2 bay leaves

1 sprig thyme

100g peas

150g ready cooked lentils (e.g.

from a pouch)

4-5 large potatoes, peeled

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Lamb & Lentil Shepherd’s Pie

This hearty and warming dish is perfect for cold nights, and can be made ahead and reheated as well as frozen for later. The lamb’s liver is op-tional, but it is worth including as it gives a rich depth to the dish - as well as being an excellent source of folic acid.

1. Preheat the oven to 180°C (fan). Put a pan of water on to boil and place a large, deep frying or sauté pan over a medium heat.

2. In the sauté pan, dry-fry the lamb mince until browned, then add the onion and carrots. Cook, stirring, for 5-7 minutes until the onion and carrot are beginning to soften.

3. Add the lambs liver, if using, and cook a further two minutes before adding the tomato puree. Stir well.

4. Add the stock, thyme and bay leaves and lower the heat. Simmer for 15-20 minutes.

5. Meanwhile, chop the potatoes into even-sized chunks and add to the pan of boiling water. Cook for 10-15 minutes until very tender, then drain and mash with a generous knob of butter.

6. Once the potatoes are cooked and mashed, add the lentils and peas to the lamb mixture and pour or ladle this into an oven-proof casserole dish.

7. Top with the mashed potato and spread into an even layer. Pop the casserole into the oven and cook for 20-30 minutes, until turning gold-en brown on the top. Leave to rest for 5 minutes, then serve with green vegetables such as broccoli..

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Pasta PrimaveraPasta Primavera


Cook time: 15 minutes

Serves 2-3


Fat 3g

Carbs 84g

Protein 24g

Folate 211 µg

Ingredients:200g pasta shapes of your choice

A small onion, chopped

6-8 asparagus tips

75g sugar snap peas, trimmed

120g sprouting broccoli, trimmed

75g frozen or freshly-shelled peas

Splash white wine

2 tbsp. crème fraiche

Mixed soft herbs, such as parsley,

dill, chives.

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Pasta Primavera

A lovely summery dish teeming with fresh vegetables, this is a cinch to prepare and cook. The broccoli, peas and asparagus are all good sources of folic acid and make this a perfect lunch or supper for vegetarians. Look out, also, for fortified pastas on the supermarket shelves, or just use whole-wheat.

1. Bring a saucepan of water to the boil, and heat a sauté pan over a me-dium heat.

2. Add a splash of olive oil to the sauté pan and gently fry the onions until softened but not coloured.

3. Cook the pasta according to the pack instructions. When there are only 3 minutes left of cooking time, throw in the broccoli to the same pan.

4. At this point, add a splash of white wine to the pan with the onions, and bubble for two minutes before adding the frozen peas and crème fraiche. Turn down the heat.

5. For the final minute of pasta cooking time, add the sugar snaps and asparagus. Blanch for one minute then drain everything through a sieve, reserving about half a cup of pasta water.

6. Mix the pasta and veggies into the onion, pea and crème fraiche mix and stir gently to combine. Stir through your chosen herbs, then serve..

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Vegetable GratinVegetable Gratin


Cook time: 35-40 minutes

Serves 2-4


Fat 48g

Carbs 26g

Protein 23g

Folate 281 µg

Ingredients:One medium head broccoli

10-12 sprouts, blemished leaves

removed and halved if large

300ml double cream

150g finely grated Emmental or

cheddar cheese

10g each parsley and chives

Pinch salt and pepper

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Vegetable Gratin

A very simple dish which is great alone with a side salad, or as an accompaniment alongside grilled chicken or fish. This dish is quite high in fat, so If you are watching the calories feel free to swap to low-fat cream and cheese.

1. Bring a saucepan of water to the boil, and heat a sauté pan over a me-dium heat.

2. Add a splash of olive oil to the sauté pan and gently fry the onions until softened but not coloured.

3. Cook the pasta according to the pack instructions. When there are only 3 minutes left of cooking time, throw in the broccoli to the same pan.

4. At this point, add a splash of white wine to the pan with the onions, and bubble for two minutes before adding the frozen peas and crème fraiche. Turn down the heat.

5. For the final minute of pasta cooking time, add the sugar snaps and asparagus. Blanch for one minute then drain everything through a sieve, reserving about half a cup of pasta water.

6. Mix the pasta and veggies into the onion, pea and crème fraiche mix and stir gently to combine. Stir through your chosen herbs, then serve.

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Bibliography

(1) Folic Acid for the Prevention of Neural Tube Defects

http://pediatrics.aappublications.org/content/104/2/325.full

(2) Identifying women who might benefit from higher doses of

folic acid in pregnancy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325450/

(3) Folic acid supplementation before and during pregnancy in

the Newborn Epigenetics Study (NEST)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038155/

(4) Folic acid: Why you need it before and during pregnancy

http://www.babycenter.com/0_folic-acid-why-you-need-it-be-

fore-and-during-pregnancy_476.bc?page=1

(5) Folic acid: influence on the outcome of pregnancy

http://ajcn.nutrition.org/content/71/5/1295s.full

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Bibliography

(6) Folic acid supplementation, dietary folate intake during preg-

nancy and risk for spontaneous preterm delivery: a prospective

observational cohort study

http://www.biomedcentral.com/1471-2393/13/160

(7) Effect of folate intake on health outcomes in pregnancy: a

systematic review and meta-analysis on birth weight, placental

weight and length of gestation

http://www.nutritionj.com/content/11/1/75

(8) Folic acid use in pregnant Women presenting to the emergen-

cy department

http://www.intjem.com/content/4/1/38

(9) Patterns and predictors of folic acid supplement use among

pregnant women: the Norwegian Mother and Child Cohort Study

http://ajcn.nutrition.org/content/84/5/1134.full

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MERRION FETAL HEALTH

Conveniently located in Dublin 2, Merrion Fetal Health is a medically led ultrasound clinic, that offers the reassurance of medi-cal excellence in obstetric, gynaecological

and fertility ultrasound.

To book an appointment or make an enquiry:

Call: (01) 663 5060

Website: www.merrionfetalhealth.ie

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