Table 1.
Folate and folic acid recommendations for women in the periconceptional period from official websites of national health organizations of some countries worldwide (n 36) and WHO
| Folic acid fortification | Folic acid supplementation for NTD risk reduction | Folate | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Country/entity | Is it mandatory?( 23 ) | Dosage | Begin | End | UL | Dosage for high risk of NTD | Is a healthy diet and folate-rich food recommended? | Recommended folate intake | Recommended DFE intake | Official entities |
| Australia | Yes | 400 µg/d (supplements)/at least 400 µg/d by health-care provider | Woman capable of, or planning, pregnancy at least 4 weeks/1 month before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | Higher dosages, to discuss with physician | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | National Health and Medical Research Council( 61 , 62 ) Food Standards Australia New Zealand( 63 ) |
| Austria | No | 400 µg/d | At least 4 weeks/1 month before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | To discuss with physician | Yes | – | Pregnant: 550 µg/d Women: 300 µg/d | Federal Ministry of Health, Austria – Public Health Portal( 64 ) D-A-CH( 65 ) |
| Belgium – Flanders | No | 400 µg/d | When the contraceptive is stopped | 12 weeks/3 months of pregnancy | 1 mg/d for adults | 4 mg/d | Yes | – | – | Flemish Government – Child and Family Support Centre for Policy Research – Welfare, Health and Family( 66 , 67 ) |
| Brazil* | Yes | 5 mg/d especially in women with history of NTD | 8–12 weeks/2–3 months before conception | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes | – | – | Ministry of Health( 68 , 69 ) |
| Bulgaria | No | 400 µg/d | At least 12 weeks/3 months before conception | 12 weeks/3 months of pregnancy | – | – | Yes | – | – | Official Bulgarian Patient Organization ‘Conception’( 70 ) |
| Canada | Yes | 400 µg/d (supplements) | Before conception by all women capable of becoming pregnant/at least 12 weeks/3 months before conception | Throughout pregnancy or early pregnancy/12 weeks/3 months of pregnancy | 1 mg/d for adults | 4–5 mg/d (higher dosages) | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | Health Canada( 71 – 74 ) |
| China* | No | 400 µg/d | At least 4 weeks/3 months before conception | Throughout the pregnancy | 1 mg/d for adults | – | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | E-health – Shanghai Jing’an District Health Promotion Board – Ministry of Health( 75 ) Chinese Nutrition Society( 76 ) |
| Denmark | No | 400 µg/d | When you start thinking about getting pregnant/for those who plan to become pregnant | 12 weeks/3 months after conception or 8 weeks/2 months (for high risk of NTD) | Not exceed recommendation | 5 mg prescribe by the physician | Yes | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | Danish Health and Medicines Authority( 77 , 78 ) Nordic Nutrition Recommendations( 79 ) |
| Estonia | No | 400 µg/d | At least 12 weeks/3 months before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | 4 mg/d | Yes | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | National Institute for Health Development( 80 , 81 ) Health Information Network( 82 ) Treatment Guide( 83 ) |
| Finland | No | 400 µg/d for woman with an unhealthy diet† | When the contraceptive is stopped/for those who plan to become pregnant | 12 weeks/3 months of pregnancy | 1 mg/d for adults | 4 mg/d | Yes† | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | Ministry of Social Affairs and Health( 84 ) Nordic Nutrition Recommendations( 79 ) |
| France* | No | 400 µg/d may be prescribed by health-care provider‡ | At pregnancy project | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes‡ | – | – | National Institute for Prevention and Health Education( 85 – 87 ) National Nutrition and Health Program( 88 ) |
| Germany | No | 400 µg/d | At least 4 weeks/1 month before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | To discuss with physician | Yes | – | Pregnant: 550 µg/d Women: 300 µg/d | Federal Centre for Health Education – Family Planning( 89 ) German Nutrition Society/D-A-CH( 65 ) |
| Hong Kong | No | 400 µg/d | 4 weeks/1 month before conception/when planning for pregnancy | 12 weeks/3 months of pregnancy (throughout pregnancy in women carrying thalassaemia trait) | – | – | Yes | – | – | Department of Health( 90 ) The Hong Kong College of Obstetricians and Gynaecologist( 91 ) |
| Hungary | No | 400 µg/d | At least 4 weeks/1 month before conception | 12 weeks/3 months of pregnancy | – | – | Yes | – | – | National Centre for Food Safety and Nutrition( 92 ) |
| Iceland | No | 400 µg/d | At least 4 weeks before conception/all women able to get pregnant | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | Directorate of Health( 93 , 94 ) Nordic Nutrition Recommendations( 79 ) |
| Ireland | No | 400 µg/d | 12 weeks/3 months before conception/all women of childbearing age | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes | – | – | Health Service Executive( 95 ) |
| Italy | No | 400 µg/d | Before conception | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes | – | – | Ministry of Health( 96 , 97 ) |
| Japan* | No | 400 µg/d | 12 weeks/3 months before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | – | Yes | – | – | Ministry of Health, Labour and Welfare( 98 ) |
| Latvia* | No | 400 µg/d | While trying to get pregnant | 12 weeks/3 months of pregnancy | – | – | Yes | – | – | Latvian Health Portal( 99 ) |
| Luxembourg | No | 400 µg/d | 4 weeks/1 month before conception | 12 weeks/3 months of pregnancy | – | Higher dosages (>400 µg/d) | Yes | – | – | Ministry of Health( 100 ) |
| Malta | No | 400 µg/d | Women who are planning a pregnancy/prior to conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | – | Yes | – | Women: 400 µg/d | Ministry for Health( 101 ) |
| Netherlands | No | 400 or 500 µg/d | 4 weeks/1 month before conception/when there is a chance of becoming pregnant | 10 weeks/2 months of pregnancy | – | Higher dosages (>400 or 500 µg/d) | Yes | – | – | National Institute for Public Health and Environment – Ministry of Health, Welfare and Sport( 102 ) Nutrition Centre( 103 ) |
| Norway | No | 400 µg/d | 4 weeks/1 month before conception/women who are planning to conceive | 8–12 weeks/2–3 months of pregnancy | – | 4 mg/d | Yes | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | National Institute of Public Health( 104 ) Nordic Nutrition Recommendations( 79 ) |
| Poland | No | 400 µg/d | While trying to get pregnant | 12 weeks/3 months of pregnancy | – | – | Yes | – | – | Ministry of Health( 105 ) |
| Portugal | No | – | At least 8 weeks/2 months before stopping using contraception | – | – | – | Yes | – | – | Ministry of Health( 106 ) |
| Romania* | No | 400 µg/d | – | – | 1 mg/d for adults | 5 mg/d | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | Ministry of Health – Romanian Nutrition Society( 107 ) |
| Russia* | No | – | – | – | – | – | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | Ministry of Health of the Russian Federation( 108 ) |
| Singapore* | No | Check with health-care provider‡ | Before conception/when trying to become pregnant | 12 weeks/3 months of pregnancy | – | – | Yes‡ | – | Pregnant: 600 µg/d Women: 400 µg/d | Health Promotion Board – Singapore Government( 109 ) |
| Slovenia | No | – | – | – | – | – | Yes | – | Pregnant, 2nd and 3rd trimester: 600 µg/d Women: 400 µg/d | Institute of Public Health of the Republic of Slovenia( 110 ) Ministry of Health( 111 ) |
| South Africa* | Yes | Recommended by health-care provider | When planning for pregnancy | – | Not exceed recommendation | – | Yes | – | – | The National Department of Health( 112 ) Association for Dietetics in South Africa( 113 ) |
| Spain | No | 400 µg/d | 12 weeks/3 months before stopping contraception/4–8 weeks/1–2 months before conception | 12 weeks/3 months of pregnancy | 1 mg/d for adults | 5 mg/d | Yes | – | – | Ministry of Health, Social Services and Equality – National Health System( 114 , 115 ) |
| Sweden | No | 400 µg/d except for women with high folate intake§ | 4 weeks/1 month before conception/woman who may get pregnant | 12 weeks/3 months of pregnancy | 1 mg/d for adults | – | Yes§ | Pregnant: 500 µg/d Women 18–30 years or childbearing age: 400 µg/d Women: 300 µg/d | – | National Food Agency( 116 , 117 ) Nordic Nutrition Recommendations( 79 ) European Food Safety Authority( 15 ) |
| Switzerland | No | 400 µg/d | At least 4 weeks/1 month before conception/women who wish or may fall pregnant | 12 weeks/3 months of pregnancy | 1 mg/d for adults | To discuss with physician/higher dosages (>400 µg/d) | Yes | – | Pregnant: 550 µg/d Women: 300 µg/d Women: 400 µg/d | Swiss Society of Nutrition( 118 )/D-A-CH( 65 ) Swiss Federal Office of Public Health( 119 ) |
| Taiwan* | No | –‡ | – | – | 1 mg/d for adults | – | Yes‡ | Pregnant: 600 µg/d Women: 400 µg/d | – | Health Promotion Administration, Ministry of Health and Welfare( 120 ) Food and Drug Administration( 121 , 122 ) |
| UK | No | 400 µg/d | While trying to get pregnant | 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes | – | – | National Health Service( 123 ) |
| USA | Yes | 400 µg/d (supplements or fortified foods) or 400–800 µg/d (supplements) to discuss with physician | Before conception by all women capable of becoming pregnant/at least 4 weeks/1 month before conception (for high risk of NTD) | 12 weeks/3 months of pregnancy(for high risk of NTD) or throughout pregnancy | 1 mg/d or adults | 4 mg/d | Yes | – | Pregnant: 600 µg/d Women: 400 µg/d | Institute of Medicine of the National Academies( 124 ) Centers for Disease Control and Prevention( 125 , 126 ) Women’s health – Department of Health and Human Services( 127 ) |
| WHO* | – | 400 µg/d | As early as possible (periconceptionally) or women trying to conceive/8 weeks/2 months before the planned pregnancy | Throughout pregnancy or 12 weeks/3 months of pregnancy | – | 5 mg/d | Yes (high risk of NTD) | – | Pregnant: 600 µg/d Women: 400 µg/d | WHO( 18 , 19 , 28 , 42 ) |
NTD, neural tube defects; UL, tolerable upper intake level; DFE, dietary folate equivalents; D-A-CH, Deutschland–Austria–Confoederatio Helvetica (reference values for nutrient intake by German Nutrition Society, Austrian Nutrition Society, Swiss Society for Nutrition Research and Swiss Society for Nutrition). – means that no information was available.
*
Without official validation.
†
‘Unhealthy diet means having less than 400 µg of folate.’
‡
‘A varied diet may be enough’ (France)/‘Keep up your folate status by eating a healthy diet’ (Singapore)/‘A balanced diet is assumed to be enough to achieve the recommendations’ (Taiwan).
§
‘For women with a high intake of folate-rich foods, such as vegetarians and vegans eating large quantities of pulses and vegetables, folate intake from food may happen to be enough. For them there is no need for extra folic acid supplementation’.