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Folate and folic acid in the periconceptional period: recommendations from official health organizations in thirty-six countries worldwide and WHO

  • Sandra Gomes (a1) (a2), Carla Lopes (a1) (a2) and Elisabete Pinto (a2) (a3)

To summarize the recommendations on folate intake and folic acid supplementation and fortification in the periconceptional period, aimed at prevention of neural tube defects (NTD), provided by official health organizations in different countries worldwide and WHO.


Information on recommendations for folate and folic acid intake in the periconceptional period was gathered from the websites of official national health organizations of several countries worldwide and from the WHO website.


WHO, selected developed countries and emerging economies, totalling thirty-six countries worldwide (some European, BRICS, G8, Asian Tiger/Asian Dragon and Australia).


Recommendations differ between countries, although the majority (69·4 %) recommend a healthy diet plus a folic acid supplement of 400 µg/d from preconception (4–12 weeks) until the end of the first trimester of pregnancy (8–12 weeks). The same recommendation is issued by the WHO. Dosages for women at high risk of NTD are up to 4–5 mg/d (for 41·7 % of studied countries). The recommended intake for folate is in the range of 300–400 µg/d for women of childbearing age and 500–600 µg/d for pregnant women in different countries and WHO. Five countries emphasize the importance of a healthy diet rendering supplementation needless. By contrast, five others advise a healthy diet and supplementation plus mandatory fortification. Only one mentions the importance of ensuring an adequate folate status and refers to checking with a health-care provider on the need for supplements.


Different recommendations regarding folate and folic acid, seeking NTD prevention, are available worldwide; however, most countries and WHO focus on a healthy diet and folic acid supplementation of 400 µg/d periconceptionally.

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1. Rosano, A, Botto, LD, Botting, B et al. (2000) Infant mortality and congenital anomalies from 1950 to 1994: an international perspective. J Epidemiol Community Health 54, 660666.
2. Institute of Medicine (1998) Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academies Press.
3. Herrmann, W & Obeid, R (2011) The mandatory fortification of staple foods with folic acid: a current controversy in Germany. Dtsch Arztebl Int 108, 249254.
4. MRC Vitamin Study Research Group (1991) Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 338, 131137.
5. Czeizel, AE & Dudas, I (1992) Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med 327, 18321835.
6. Institute of Medicine (2006) Dietary Reference Intakes: The Essential Guide to Nutrient Requirements [JJ Otten, JP Hellwig and LD Meyers, editors]. Washington, DC: The National Academies Press.
7. Wilcox, AJ, Lie, RT, Solvoll, K et al. (2007) Folic acid supplements and risk of facial clefts: national population based case–control study. BMJ 334, 464.
8. Kelly, D, O’Dowd, T & Reulbach, U (2012) Use of folic acid supplements and risk of cleft lip and palate in infants: a population-based cohort study. Br J Gen Pract 62, e466e472.
9. De-Regil, LM, Fernandez-Gaxiola, AC, Dowswell, T et al. (2010) Effects and safety of periconceptional folate supplementation for preventing birth defects. Cochrane Database Syst Rev issue 10, CD007950.
10. Rozendaal, AM, van Essen, AJ, Te Meerman, GJ et al. (2013) Periconceptional folic acid associated with an increased risk of oral clefts relative to non-folate related malformations in the Northern Netherlands: a population based case–control study. Eur J Epidemiol 28, 875887.
11. Charles, DH, Ness, AR, Campbell, D et al. (2005) Folic acid supplements in pregnancy and birth outcome: re-analysis of a large randomised controlled trial and update of Cochrane review. Paediatr Perinat Epidemiol 19, 112124.
12. de Benoist, B (2008) Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food Nutr Bull 29, 2 Suppl, S238S244.
13. Fekete, K, Berti, C, Trovato, M et al. (2012) Effect of folate intake on health outcomes in pregnancy: a systematic review and meta-analysis on birth weight, placental weight and length of gestation. Nutr J 11, 75.
14. Lassi, ZS, Salam, RA, Haider, BA et al. (2013) Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes. Cochrane Database Syst Rev 3, CD006896.
15. European Food Safety Authority (2009) Folic acid: an update on scientific developments. (accessed March 2015).
16. Botto, LD, Lisi, A, Robert-Gnansia, E et al. (2005) International retrospective cohort study of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ 330, 571.
17. Pinto, E, Barros, H & dos Santos Silva, I (2009) Dietary intake and nutritional adequacy prior to conception and during pregnancy: a follow-up study in the north of Portugal. Public Health Nutr 12, 922931.
18. World Health Organization (2012) WHO Guidelines Approved by the Guidelines Review Committee. Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva: WHO.
19. World Health Organization (2006) Prevention of Neural Tube Defects. Standards for Maternal and Neonatal Care. Geneva: WHO, Department of Making Pregnancy Safer.
20. Singh, S, Sedgh, G & Hussain, R (2010) Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann 41, 241250.
21. Butterworth, CE Jr & Tamura, T (1989) Folic acid safety and toxicity: a brief review. Am J Clin Nutr 50, 353358.
22. United Nations (2012) Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings. (accessed October 2013).
23. EUROCAT (2013) World map of countries having mandatory fortification of food with folic acid. (accessed September 2013).
24. Williams, LJ, Rasmussen, SA, Flores, A et al. (2005) Decline in the prevalence of spina bifida and anencephaly by race/ethnicity: 1995–2002. Pediatrics 116, 580586.
25. De Wals, P, Tairou, F, Van Allen, MI et al. (2007) Reduction in neural-tube defects after folic acid fortification in Canada. N Engl J Med 357, 135142.
26. Kondo, A, Kamihira, O & Ozawa, H (2009) Neural tube defects: prevalence, etiology and prevention. Int J Urol 16, 4957.
27. Osterhues, A, Ali, NS & Michels, KB (2013) The role of folic acid fortification in neural tube defects: a review. Crit Rev Food Sci Nutr 53, 11801190.
28. Food and Agriculture Organization of the United Nations & World Health Organization (2001) Human Vitamin and Mineral Requirements. Report of a Joint FAO/WHO Expert Consultation, Bangkok, Thailand. Rome: FAO; available at
29. Cole, BF, Baron, JA, Sandler, RS et al. (2007) Folic acid for the prevention of colorectal adenomas: a randomized clinical trial. JAMA 297, 23512359.
30. Ebbing, M, Bonaa, KH, Nygard, O et al. (2009) Cancer incidence and mortality after treatment with folic acid and vitamin B12 . JAMA 302, 21192126.
31. Kennedy, DA, Stern, SJ, Moretti, M et al. (2011) Folate intake and the risk of colorectal cancer: a systematic review and meta-analysis. Cancer Epidemiol 35, 210.
32. Vollset, SE, Clarke, R, Lewington, S et al. (2013) Effects of folic acid supplementation on overall and site-specific cancer incidence during the randomised trials: meta-analyses of data on 50,000 individuals. Lancet 381, 10291036.
33. National Center for Biotechnology Information (2013) MeSH – Pregnancy Outcome. (accessed October 2013).
34. Yajnik, CS, Deshpande, SS, Jackson, AA et al. (2008) Vitamin B12 and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study. Diabetologia 51, 2938.
35. Burdge, GC & Lillycrop, KA (2012) Folic acid supplementation in pregnancy: are there devils in the detail? Br J Nutr 108, 19241930.
36. Whitrow, MJ, Moore, VM, Rumbold, AR et al. (2009) Effect of supplemental folic acid in pregnancy on childhood asthma: a prospective birth cohort study. Am J Epidemiol 170, 14861493.
37. European Commission (2013) Trustworthy websites on ‘Population groups’. (accessed October 2013).
38. European Food Safety Authority (2009) ESCO report prepared by the EFSA Scientific Cooperation Working Group on Analysis of Risks and Benefits of Fortification of Food with Folic Acid. (accessed October 2013).
39. Theodosiou, L & Green, J (2003) Emerging challenges in using health information from the internet. Adv Psychiatr Treat 9, 387396.
40. Mo, P (2012) The use of internet for health education. J Biosafety Health Educ 1, e102.
41. Houston, TK & Allison, JJ (2002) Users of Internet health information: differences by health status. J Med Internet Res 4, E7.
42. World Health Organization & Food and Agriculture Organization of the United Nations (2004) Vitamin and Mineral Requirements in Human Nutrition, 2nd ed. Geneva: WHO; available at
43. United Nations University/World Health Organization/Food and Agriculture Organization of the United Nations (2004) Human Energy Requirements: Report of a Joint FAO/WHO/UNU Expert Consultation, Rome, 17–24 October 2001. Rome: FAO; available at
44. Steegers-Theunissen, RP, Twigt, J, Pestinger, V et al. (2013) The periconceptional period, reproduction and long-term health of offspring: the importance of one-carbon metabolism. Hum Reprod Update 19, 640655.
45. Institute of Medicine (2006) Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. In Dietary Reference Intakes Research Synthesis Workshop Summary, pp. 35–38 [CW Suitor and LD Meyers, rapporteurs]. Washington, DC: The National Academies Press.
46. Commission of the European Communities (1993) Reports of the Scientific Committee on Food (Thirty-first Series) Nutrition and Energy Intakes for the European Community. Luxembourg: Office for Official Publications of the European Communities.
47. McKillop, DJ, Pentieva, K, Daly, D et al. (2002) The effect of different cooking methods on folate retention in various foods that are amongst the major contributors to folate intake in the UK diet. Br J Nutr 88, 681688.
48. Sotres-Alvarez, D, Siega-Riz, AM, Herring, AH et al. (2013) Maternal dietary patterns are associated with risk of neural tube and congenital heart defects. Am J Epidemiol 177, 12791288.
49. Chandler, AL, Hobbs, CA, Mosley, BS et al. (2012) Neural tube defects and maternal intake of micronutrients related to one-carbon metabolism or antioxidant activity. Birth Defects Res A Clin Mol Teratol 94, 864874.
50. Vujkovic, M, Ocke, MC, van der Spek, PJ et al. (2007) Maternal Western dietary patterns and the risk of developing a cleft lip with or without a cleft palate. Obstet Gynecol 110, 378384.
51. Krapels, IP, van Rooij, IA, Ocke, MC et al. (2004) Maternal nutritional status and the risk for orofacial cleft offspring in humans. J Nutr 134, 31063113.
52. Sumiyoshi, Y (2007) How do we react on folic acid deficiency? Brain Spinal Cord 14, 13.
53. Kennedy, D & Koren, G (2012) Identifying women who might benefit from higher doses of folic acid in pregnancy. Can Fam Physician 58, 394397.
54. Talaulikar, VS & Arulkumaran, S (2011) Folic acid in obstetric practice: a review. Obstet Gynecol Surv 66, 240247.
55. Heseker, HB, Mason, JB, Selhub, J et al. (2009) Not all cases of neural-tube defect can be prevented by increasing the intake of folic acid. Br J Nutr 102, 173180.
56. Kim, YI (2004) Will mandatory folic acid fortification prevent or promote cancer? Am J Clin Nutr 80, 11231128.
57. Troen, AM, Mitchell, B, Sorensen, B et al. (2006) Unmetabolized folic acid in plasma is associated with reduced natural killer cell cytotoxicity among postmenopausal women. J Nutr 136, 189194.
58. Kelly, P, McPartlin, J, Goggins, M et al. (1997) Unmetabolized folic acid in serum: acute studies in subjects consuming fortified food and supplements. Am J Clin Nutr 65, 17901795.
59. Bailey, RL, Mills, JL, Yetley, EA et al. (2010) Unmetabolized serum folic acid and its relation to folic acid intake from diet and supplements in a nationally representative sample of adults aged ≥60 y in the United States. Am J Clin Nutr 92, 383389.
60. Lunet, N, Rodrigues, T, Correia, S et al. (2008) Adequacy of prenatal care as a major determinant of folic acid, iron, and vitamin intake during pregnancy. Cad Saude Publica 24, 11511157.
61. National Health and Medical Research Council (2013) Australian Dietary Guidelines. (accessed December 2014).
62. National Health and Medical Research Council (2005) Nutrient Reference Values for Australia and New Zealand. (accessed December 2014).
63. Food Standards Australia New Zealand (2013) Folic acid/folate and pregnancy. (accessed December 2014).
64. Federal Ministry of Health, Austria – Public Health Portal (2014) Folat. Ernährung in der Schwangerschaft, (accessed December 2014).
65. D-A-CH (2013) Referenzwerte für die Nährstoffzufuhr Folat., (accessed December 2014).
66. Hoppenbrouwers, K, Roelants, M, Guérin, C et al. (2010) Preventie van spina bifida en andere neuralebuisdefecten door foliumzuursuppletie tijdens de zwangerschap. (accessed December 2014).
67. Flemish Government – Child and Family Support Centre for Policy Research – Welfare, Health and Family (2014) Foliumzuur. (accessed December 2014).
68. Ministério da Saúde (2012) Cadernos de Atenção Básica, nº 32 – Atenção ao pré-natal de baixo risco. Normas e Manuais Técnicos. (accessed December 2014).
69. Ministério da Saúde (2006) Caderno nº 5–Manual Técnico – Pré-natal e puerpério – Atenção qualificada e humanizada. Série Direitos Sexuais e Direitos Reprodutivos. (accessed December 2014).
71. Health Canada (2009) Prenatal Nutrition Guidelines for Health Professionals – Folate Contributes to a Healthy Pregnancy. (accessed December 2014).
72. Health Canada (2010) High Dose Folic Acid Supplementation – Questions and Answers for Health Professionals. (accessed December 2014).
73. Agence de la santé publique du Canada (2002) Pourquoi toutes les femmes qui pourraient devenir enceintes devraient prendre de l’acide folique. (accessed December 2014).
74. Health Canada (2010) Dietary Reference Intakes – Definitions. (accessed December 2014).
75. (E-health – Shanghai Jing’an District Health Promotion Board – Ministry of Health) (2014), (accessed December 2014).
76. (Chinese Nutrition Society) (2007) (accessed December 2014).
77. Danish Health and Medicines Authority (2014) Graviditet: Spis folsyre, jern, D-vitamin og eventuelt kalk som kosttilskud.,-jern,-d-vitamin-og-eventuelt-kalk (accessed December 2014).
78. Sundhedsstyrelsen (National Board of Health) (2010) Healthy habits before, during and after pregnancy. (accessed December 2014).
79. Nordic Council of Ministers (2014) Nordic Nutrition Recommendations 2012: Integrating nutrition and physical activity. (accessed December 2014).
80. Tervise Arengu Instituut, Eesti Toitumisteaduse Selts (2006) Eesti toitumis – ja toidusoovitused. (accessed December 2014).
81. Tervise Arengu Instituut, Eesti Ämmaemandate Ühing (2008) Rasedate ja imetavate toitumis – ja toidusoovitused. (accessed December 2014).
82. Health Information Network (2011) Фолиевая кислота – что это и для чего?. (accessed December 2014).
83. Ravijuhend (2014) Foolhape – mis ja milleks? Foolhappe osatähtsus terve beebi sündimisel. (accessed December 2014).
84. Hasunen, K, Kalavainen, M, Keinonen, H et al. (2004) Lapsi, perhe ja ruoka. (accessed December 2014).
85. Programme National Nutrition Santé (2007) Le guide nutrition pendant et après la grossesse. (accessed December 2014).
86. Institute national de prévention et d'éducation pour la santé (2014) Vous avez un projet de bébé? Pensez dès maintenant à la vitamine B9. (accessed December 2014).
87. Institute national de prévention et d'éducation pour la santé (2011) Folates et désir de grossesse: informer et prescrire au bon moment. Les essentiels de l’INPES. (accessed December 2014).
88. Manger Bouger – Programme National Nutrition Santé (2014) Les folates. (accessed December 2014).
89. Familienplanung – Bundeszentrale für gesundheitliche Aufklärung (2014) Lexikon – Folsäure-Prophylaxe. (accessed December 2014).
90. (Department of Health) (2013) Healthy eating during pregnancy and breastfeeding. (accessed December 2014).
91. The Hong Kong College of Obstetricians and Gynaecologists (2008) HKCOG Guidelines – Guidelines on Antenatal Care (Part I). (accessed December 2014).
92. Agoston, H, Bıcs, E, Domonkos, A et al. (2005) Táplálkozási ajánlások várandós és szoptató anyáknak. (accessed December 2014).
93. Directorate of Health (2007) Fólat. (accessed December 2014).
94. Directorate of Health (2004) Forvarnir með fólasíni. (accessed December 2014).
95. Health Service Executive (2006) Training Programme for Public Health Nurses and Doctors in Child Health Screening, Surveillance and Health Promotion. Unit 7: Food & Nutrition. (accessed December 2014).
97. Ministero della Salute (2009) 7 Azioni per la vita del tuo bambino. Genitori Più – Prendiamoci più cura della loro vita–Materiale informativo per gli operatori. (accessed December 2014).
98. Ministry of Health Labour and Welfare (2009) (Folate). (accessed December 2014).
99. Medicine – Latvijas veselibas portals (2013) Folijskābe grūtniecības laikā. (accessed December 2014).
100. Ministère de la Santé (2009) L’Alimentation saine pendant la grossesse. (accessed December 2014).
101. Ministry for Health – Malta (2013) Registries. Birth defects. Malta Congenital Anomalies Registry. (accessed December 2014).
102. National Institute for Public Health and Environment – Ministry of Health, Welfare and Sport (2014) Toolkits voor publiekscommunicatie. (accessed December 2014).
103. Voedingscentrum (2014) Zwanger. (accessed December 2014).
104. Folkehelseinstituttet (2014) Folat – Folattilskudd og svangerskap faktaark.,6665&MainContent_6263=6464:0:25,6667&List_6212=6218:0:25,6685:1:0:0:::0:0 (accessed December 2014).
105. Ministerstwo Zdrowia (2011) Żywienie w ciąży – porady żywieniowe dla przyszłych mam. (accessed December 2014).
106. Direcção-Geral da Saúde (2006) Circular Normativa nº 2/DSMIA de 16/01/2006. (accessed December 2014).
107. Societatea de Nutritie din Romania (2006) Ghid pentru alimentatia sanatoasa. (accessed December 2014).
108. здоровая россия (Healthy Russia) (2013) Фолиевая кислота. (accessed December 2014).
109. Health Promotion Board (2012) Preganacy and diet, Conception to Birth: Eating For A Healthy Baby, Recommended Dietary Allowances, (accessed December 2014).
110. Institute za Varovanje Zdravja – Republike Slovenije (2013) Referencne vrednosti za vnos vitaminov in mineralov. (accessed December 2014).
112. Department of Health (2003) Human genetics policy guidelines for the management and prevention of genetic disorders, birth defects and disabilities. (accessed December 2014).
113. National Nutrition Week (2012) Nutritional tips before and during pregnancy. (accessed December 2014).
114. Ministerio de Sanidad Política Social e Igualdad (2011) Estrategia Nacional de Salud Sexual y Reproductiva. (accessed December 2014).
115. Ministerio de Sanidad Política Social e Igualdad (2006) Guía para la Prevención de Defectos Congénitos. (accessed December 2014).
116. Swedish National Food Administration (2008) Advice about food for you who are pregnant. (accessed December 2014).
117. Livsmedelsverket (2014) Råd om folsyra. (accessed December 2014).
118. Schweizerische Gesellschaft für Ernährung, Société Suisse de Nutrition, Società Svizzera di Nutrizione (2012) L’alimentation de la femme enceinte. (accessed December 2014).
120. Health Promotion Administration – Ministry of Health and Welfare (2009) (Maternal Health Handbook). (accessed December 2014).
121. (Food and Drug Administration) (2010) (accessed December 2014).
122. (Food and Drug Administration) (2009) (accessed December 2014).
123. NHS (2014) Vitamins and nutrition in pregnancy. (accessed December 2014).
125. Centers for Disease Control and Prevention (2010) Folic Acid: Questions and Answers. (accessed December 2014).
126. Centers for Disease Control and Prevention (2014) Folic Acid Reccomendations. (accessed December 2014).
127. Women’s Health (2014) Folic acid fact sheet. (accessed December 2014).
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