Article: The Folate Decision I Spent the Most Time On
The Folate Decision I Spent the Most Time On
When I was formulating The Prenatal, the folate decision was the one I spent the most time on. Not because the research is unclear, but because the gap between what the research says and what most prenatal vitamins actually contain is genuinely significant. Most Australian prenatals still use folic acid, the synthetic form that requires a multi-step conversion in the liver before your body can use it. Meanwhile, up to 40% of the population carries a gene variant that impairs that exact conversion process.
That is the reason moode contains calcium folinate, an active form of folate, not folic acid. And it is the reason this article exists: because the form of folate in your prenatal matters more than most labels make clear.
What is folate and why does it matter in pregnancy?
Folate is vitamin B9 in its naturally occurring form, found in food sources including green leafy vegetables, liver, eggs and legumes. It is essential for red blood cell production, DNA replication and cell growth and repair, all processes that are operating at extraordinary speed during pregnancy.
The most critical window for folate is the first 28 days after conception, when the neural tube, the structure that becomes the brain and spinal cord, closes. Neural tube defects including spina bifida occur when folate is insufficient at this stage. Because this window happens before most women know they are pregnant, adequate folate levels at conception, not just after a positive test, is what actually matters.
Raising folate levels in the preconception phase has also been shown to reduce the risk of preterm birth, and folate deficiency in pregnancy has been associated with anaemia in the mother and congenital abnormalities in the baby.
What is the difference between folic acid and folate?
These terms are used interchangeably, but they are not the same thing.
Folate is the naturally occurring form of vitamin B9, found in whole foods. Your body absorbs it directly without significant conversion.
Folic acid is the synthetic form of folate. It is the version most commonly added to fortified foods in Australia (including bread flour, which is mandatory under Australian food standards) and the form found in most standard prenatal vitamins. Folic acid does not exist in nature and must be converted by the body before it can be used.
The conversion of folic acid to its active, usable form (5-methyltetrahydrofolate, or 5-MTHF) happens in the liver. This process is not instant, it puts a metabolic load on the liver, and in some individuals it does not happen efficiently at all.
What is folinic acid and how is it different?
Folinic acid, also called calcium folinate, is an activated form of folate. It has already undergone the conversion that folic acid requires, which means the liver does not need to process it before the body can use it.
This is the distinction that matters clinically. Folinic acid provides the body with a readily usable form of folate, bypassing the conversion step entirely. It is more bioavailable, more directly usable, and does not carry the same risk of accumulation in the body that unconverted folic acid does.
You will see folinic acid written on labels as:
- Folinic acid
- Calcium folinate
- A specific isomer designation
All refer to the same activated form.
What is methylfolate and how does it compare?
Methylfolate (also called L-MTHF, 5-MTHF or levomefolic acid) is the other active form of folate. It is the form that actually circulates in the blood and crosses into cells. Like folinic acid, it does not require liver conversion before the body can use it.
Both folinic acid and methylfolate are considered active forms and are more bioavailable than folic acid. The clinical debate between them is ongoing, and both are considered appropriate choices for prenatal supplementation. Some practitioners prefer one over the other based on the patient's specific clinical picture, including MTHFR gene status and individual biochemistry.
What is MTHFR and why does it affect which folate you should take?
MTHFR (methylenetetrahydrofolate reductase) is an enzyme involved in the conversion of folic acid to its active form. Variants in the MTHFR gene, which affect approximately 40% of the population, can impair this conversion to varying degrees.
For women with an MTHFR variant, supplementing with folic acid may be significantly less effective than supplementing with an active form, because the conversion step that would normally convert folic acid into usable folate is impaired. There is also evidence that unconverted folic acid can accumulate in the body when conversion is impaired, which may have its own downstream effects including increased homocysteine levels and reduced vitamin B12 availability.
It is worth noting that MTHFR variants exist on a spectrum. Some variants impair conversion significantly, others have a modest effect. If you know you carry an MTHFR variant, or suspect you might based on a history of miscarriage, neural tube defects in the family, or other relevant history, an active form of folate is the more reliable choice regardless of the degree of impairment.
If you are unsure of your MTHFR status, MTHFR gene testing is available through your GP. For a broader explanation of how to interpret MTHFR results in the context of fertility, see A Fertility Nutritionist's Guide to Preconception Preparation.
Which form of folate should my prenatal contain?
The honest answer from four years of formulating and reviewing prenatal labels: if a prenatal contains folic acid as its only source of folate, that is a meaningful limitation, particularly for the 40% of women who may not convert it efficiently.
An active form of folate (calcium folinate or methylfolate) is the more reliable choice for most women, regardless of whether they know their MTHFR status, because it does not rely on the conversion step to be usable. It is not more expensive to take. It is simply more directly available to the body.
The Prenatal by moode contains calcium folinate at 500 micrograms, the Australian recommended daily intake for pregnancy as established in national nutrient reference standards. It does not contain folic acid. Always read the label and follow directions for use.
How much folate do I actually need?
The Australian recommended daily intake of folate during pregnancy is 500 micrograms per day, as established in the Nutrient Reference Values for Australia and New Zealand. For breastfeeding, the recommendation increases to 600 micrograms per day.
This dose should be coming from a prenatal supplement rather than relying on diet alone during preconception and pregnancy, because dietary folate intake is highly variable and the timing of adequate levels at conception is too important to leave to chance.
Health practitioners recommend starting folate supplementation at least three months before trying to conceive. The neural tube closes at four weeks from conception, before most women have confirmed a pregnancy, which is why preconception supplementation is the standard recommendation rather than starting after a positive test.
For more on when to start taking a prenatal, see When Should I Start Taking a Prenatal Vitamin?
What does hyperhomocysteinemia actually mean and why does it matter?
Hyperhomocysteinemia is an elevated level of homocysteine in the blood. Homocysteine is a byproduct of normal amino acid metabolism that is typically converted to other compounds through a folate-dependent process. When folate is deficient, or when folic acid is not being converted efficiently, homocysteine can accumulate.
Elevated homocysteine in pregnancy has been associated with a range of adverse outcomes including neural tube defects, pregnancy loss and placental complications. It is one of the mechanisms through which inadequate or poorly absorbed folate can affect pregnancy outcomes beyond the neural tube specifically.
Ensuring adequate, bioavailable folate through preconception is one of the most direct dietary interventions available to reduce homocysteine levels before pregnancy begins.
The form of folate in your prenatal matters more than most labels make clear.
moode answers your questions about folate in pregnancy
Is folic acid the same as folate?
No. Folate is the naturally occurring form of vitamin B9 found in food. Folic acid is the synthetic form added to supplements and fortified foods. Folic acid requires conversion in the liver before the body can use it, whereas food-form folate and active forms like folinic acid and methylfolate are more directly usable.
What is the best form of folate in a prenatal vitamin?
An active form: either calcium folinate (folinic acid) or methylfolate (5-MTHF, L-MTHF). Both bypass the liver conversion step required for folic acid and are usable by the body regardless of MTHFR gene status. If your prenatal contains only folic acid and no active folate form, that is worth considering when choosing your supplement.
Do I need to know my MTHFR status before choosing a folate?
No. Taking an active form of folate is appropriate for all women regardless of MTHFR status, because it is more directly available to the body whether or not the conversion enzyme is functioning optimally. Knowing your MTHFR status is useful additional information but not required to make a better folate choice.
Can I get enough folate from food alone during pregnancy?
Dietary folate from green leafy vegetables, eggs and liver contributes meaningfully, but reaching the recommended 500 micrograms per day consistently through food alone is difficult, and the timing of adequate levels at the point of conception is too important to rely on diet alone. A quality prenatal supplement ensures consistent, measured dosing through the preconception period.
How long before pregnancy should I start taking folate?
At least three months before trying to conceive. Neural tube closure happens at four weeks from conception, before most women know they are pregnant. Starting folate at conception is too late to provide the protective effect the research demonstrates. Three months preconception is the standard clinical recommendation.
What is calcium folinate?
Calcium folinate is the calcium salt form of folinic acid, an activated form of folate. It is the form of folate in The Prenatal by moode. It does not require conversion by the liver and is usable by the body regardless of MTHFR gene status.
Does fortified bread contain enough folate for pregnancy?
No. Australian bread flour is mandatorily fortified with folic acid, which contributes to background dietary intake. But the amounts provided by fortified bread are not sufficient to meet the recommended 500 micrograms per day for pregnancy, and the form (folic acid) carries the limitations described above. Fortified foods are a useful dietary background, not a prenatal supplement substitute.
Jess Rosenberg is the founder of moode and trained in Nutrition and Naturopathy. The decision to use calcium folinate rather than folic acid in The Prenatal was one of the founding formulation decisions she made before the brand launched. Learn more about moode.
