Periconceptional intake of folic acid among low-risk women in Canada: summary of a workshop aiming to align prenatal folic acid supplement composition with current expert guidelines

The Government of Canada and the Society of Obstetricians and Gynaecologists of Canada both recommend a daily multivitamin supplement containing 400 µg folic acid (FA) for the primary prevention of neural tube defects among low-risk women from before conception and throughout lactation. Prenatal supplements marketed and prescribed in Canada typically exceed the recommended dose, usually providing ≥1000 µg FA/d. This high daily dose, coupled with staple-food FA fortification, has resulted in the observation of very high blood folate concentrations among reproductive-aged women consuming FA-containing supplements. The long-term consequences of high folate status on fetal development are unknown; however, evidence from animal studies and some human epidemiologic data suggest potential adverse consequences. To address this issue, a workshop was convened with the overall goal to identify challenges and solutions to aligning supplemental FA intakes with current evidence-based recommendations. Thirty-eight stakeholders from academia, industry, government, and health professional groups participated. Group discussions facilitated the identification and prioritization of 5 key challenges for which solutions and implementation strategies were proposed. The 5 themes encompassed clarity and harmonization of evidence-based guidelines, reformulation or relabeling of FA-containing supplements, access to FA for all women, knowledge dissemination strategies and education of the public and health care professionals, and attitude change to overcome the perception of “more is better.” A combination of the proposed implementation strategies involving all key stakeholders and directed to health care professionals and the public may enable a sustainable change to align FA intake during the periconceptional period with evidence-based recommendations.