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Counseling Patients on Preconception Care: Folate and Beyond

Download a PDFPreconception counseling as life-long health promotion

Preconception counseling for all women of reproductive age can improve the chances of a successful pregnancy, especially counseling on how:

Figure 1: Sources of Folate and Folic Acid

Folate can be found in:

  • Lentils
  • Asparagus
  • Spinach
  • Romaine lettuce
  • Black beans
  • Broccoli
  • Peanuts
  • Orange Juice
  • Enriched breads
  • Enriched pastas

Folic Acid can be found in:

  • Fortified breakfast cereals
  • Enriched breads
  • Enriched pastas
  • Prenatal vitamins
  • Multivitamins
  • Some oral contraceptives (e.g., Drospirenon, Ethinylestradion, Methyltetrahydrofolate)
Figure 2: Folate and Folic Acid Recommendations7

Women capable of becoming pregnant:

  • Healthy diet
  • 600 mcg folate
  • Folic acid supplement of 400 mcg/day (0.4mg/d)

Women with previous NTD pregnancy:

  • Healthy diet
  • Folic acid supplement of 4 mg/day
Figure 3: Limiting exposure to BPA


  • Plastic food containers and packaging (PVC #3, Styrofoam #6 and BPA #7)
  • Hard plastic water
    bottles that don't
    specify "BPA-free"
  • Canned foods, such as vegetables, soups, fruits, meat products, fish, and desserts
  • Certain canned
    beverages, such as meal replacement shakes


  • Glass containers,
    especially for
    microwaving food
  • Non-polycarbonate plastic or glass bottles
  • Fresh or frozen fruits and vegetables
Figure 4: Reducing exposure to methylmercury and polychlorinated biphenyls (PCBs)


  • Limit the amount of fish you eat on a weekly basis
  • Trim fat from fish
    before cooking
  • Eat fish that are known to have low or no levels of methylmercury—trout, salmon, tilapia, sardines


  • Eat fish that are known to have high levels of methylmercury—shark, swordfish, king mackerel and tilefish
    Eat more than 2 cans of light tuna per week
  • Eat more than 2/3 can per week of white albacore tuna
  • Folate intake and folic acid supplementation reduce neural tube defects (NTDs)
  • Alcohol ingestion during pregnancy can cause fetal alcohol syndrome (FAS)
  • Exposure to environmental contaminants affects reproductive health

Neural tube defects, folate and folic acid

Folate intake and folic acid supplementation are important for all women of reproductive age because 1:1000 pregnancies are affected by a NTD.1

  • Both folate (naturally occurring in food) and folic acid (synthetically produced) have a major impact on the reduction of NTDs
  • The neural tube closes by day 28 of gestation, before many women realize they are pregnant
  • Folic acid supplementation is estimated to reduce the risk of NTDs by:
    • 50% for women who have never had a child with a NTD2
    • 70% for women who have had a child with a NTD
  • It is important to make sure that all women, even those with normal folate levels, supplement their diets with folic acid. This is because some women with serum folate levels in the normal range are still at risk for having a child with a NTD through:
    • Genetic predisposition
    • Certain medications (e.g. anti-seizure drugs such as valproic acid and carbamazepine)
    • Certain pathological states3

Folate intake and folic acid supplementation

All women of childbearing age should be encouraged to take a folic acid supplement, even those with a healthy diet, because:

  • Most women do not get enough folate in their diet4
    • Cooking reduces folate in many foods
    • Low carbohydrate diets may reduce folic acid intake5
  • Many women are ambivalent about pregnancy, and may have contraceptive gaps6


  • Drinking alcohol during pregnancy increases the risk for fetal alcohol syndrome (FAS)8
  • Current guidelines encourage women to avoid drinking any alcohol during pregnancy (including beer and wine coolers)9

Environmental contaminants

Some chemicals in the environment end up in certain foods and drinks and can be harmful to reproductive health.

Bisphenol A (BPA) interferes with the normal function of hormones in the body and is especially harmful during the first three months of pregnancy. While we can't fully eliminate our risk of BPA exposure, since BPA can be in our carpets, pipes and other household items, we can take smart steps to lower our exposure.

Methylmercury and polychlorinated biphenyls (PCBs) are found in ocean and freshwater fish. If a developing fetus is exposed to methylmercury, there may be long term health consequences. These consequences include delays in development, blindness, and cerebral palsy.10 Research has shown that PCBs alter the normal function of hormones and contribute to low birth weight in children of women who eat contaminated fish.

Additional Resources:

Folic Acid Supplementation:


Food Contaminants:


  1. Matthews TJ. Trends in Spina Bifida and Anencephalus in the United States, 1991-2005. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2007.
  2. Centers for Disease Control. Recommendations for the use of folic acid treduce the number of cases of spina bifida and other neural tube defects. MMWR 1992;41(N. RR-14).
  3. U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:626-631.
  4. Quinlivan EP, Gregory JF 3rd. Reassessing folic acid consumption patterns in the United States (1999 2004): potential effect on neural tube defects and overexposure to folate Am J Clin Nutr. 2007;86:1773-9.
  5. Quinlivan EP, Gregory JF 3rd. Reassessing folic acid consumption patterns in the United States (1999 2004): potential effect on neural tube defects and overexposure to folate Am J Clin Nutr. 2007;86:1773-9.
  6. Frost JJ, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007;39(2):90-9.
  7. Institute of Medicine. Dietary Reference Intakes For Thiamine, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin and Choline. National Academy Press. Washington, DC. 1998:220-240.
  8. Bertrand J, Floyd RL, Weber MK, 'Connor M, Riley EP, Johnson KA, et al. National Task Force on FAS/FAE. Fetal alcohol syndrome: guidelines for referral and diagnosis. Atlanta , GA: Centers for Disease Control and Prevention. 2004.
  9. Floyd, RL, 'Connor, MJ, Sokol, RJ, et al. Recognition and Prevention of Fetal Alcohol Syndrome. Obstet Gynecol. 2005; 106:1059.
  10. Mahaffey KR, Clickner RP, Jeffries RA. Adult women's blood mercury concentrations vary regionally in the United States: association with patterns of fish consumption (NHANES 1999-2004). Environ Health Perspect. 2009;117:47-53.