Periconceptional folate supplementation, in addition to a balanced diet, has consistently been shown to significantly reduce the NTD risk. Therefore women planning a pregnancy are recommended to take daily folic acid supplements at levels of 400 µg or higher, in order to help reach optimal red blood cell (RBC)–folate levels (>906 nmol/L). Yet a major problem is low adherence to the folic acid supplement recommendation, as reported in many countries.
Globally, 84 countries had mandatory fortification in 2019 but an estimated 215,000 NTD-affected pregnancies still occurred as a result of inadequate or nonexistent fortification policies.
Pre- and peri-conceptional folic acid supplementation is the main recommended public health measure in Switzerland, complemented by the availability of folic acid fortified food products. A first national survey of folate status conducted in pregnant women (PW) in Switzerland (2001, n = 381), showed 63% of women took a supplement of folic acid, but women were not asked when they started taking the supplements.
In a later survey (2009) conducted in over 22,000 women in 18 European countries including Switzerland, 70% of respondents (77% in Switzerland) had heard of folate or folic acid but only 17% (33% in Switzerland) were aware of its preventive effects against NTDs.
The current study is the first to report data on folate status in women of reproductive age (WRA) in Switzerland and data on folate awareness in the general Swiss population, leading to critical discussion of the overall folate landscape.
Researchers aimed to: assess folate red blood cell concentration in WRA and PW in Switzerland; and investigate the awareness of the importance of dietary folate and pre- and peri-conceptional folate supplementation in the general Swiss population.
The team conducted a cross–sectional study in April 2015–January 2016. They contacted 346 obstetric/prenatal care clinics/hospitals throughout Switzerland by e-mail and 29 clinics/hospitals agreed to participate.
A total of 937 participants accessed the survey and 784 completed questionnaires. Of these respondents, 482 were female and 302 were male, with an average age of 34.4 ± 12.2 years.
In total, 61% of respondents (66% of women and 52% of men) correctly identified folate as an important vitamin when asked “What is folate?”.
In contrast, the question on natural sources of folate in food was answered correctly by only 2% of respondents. Nevertheless, 37%, 41% and 53% of respondents correctly identified vegetables, wheat germ, and pulses, respectively, as foods rich in folate, while only 13% were aware that fruits are good folate sources.
In total, 74% of respondents correctly identified at least one natural source of folate, and women more often correctly identified the sources.
A notable 88% and 93% identified a positive effect regarding risk reduction of spina bifida and the normal development of the fetus in the uterus, respectively.
Of all PW and women who already have children (n = 200), 38% started taking folate supplements at least one month before conception. However, 20% of the women did not take any folate supplements and 44% started taking them at a later point than the recommended one month prior to conception.
Class and education
Education was an important predictor of the timing of supplements - 41% of women with tertiary degree reported taking supplements ≥1 month prior to conception compared to only 16% of women without a tertiary degree.
Similarly, women in the higher income class were more likely to take the supplements at the recommended time (43%) compared to those in the lower income class (21%).
Around a quarter of women reported that they were informed about folate deficiency and the risk of birth defects by their gynecologist before pregnancy (25%) and during pregnancy (21%), whereas 54% were not informed at all.
What's more, 30% were never provided with any information about the relationship between folate levels and neural tube defects.
The report concludes: "A high proportion of inadequate folate intake in both WRA and PW in Switzerland, along with low adherence to supplementation recommendations. Furthermore, the awareness of folate’s essential role before and during a pregnancy was low, especially in the younger adults and groups with low education level.
"These results highlight the need to strengthen public health strategies and foster better co-ordination for existing measures aimed to improve awareness and ensure adequate folate intake, especially in women planning pregnancy.
"New approaches might be needed to reach the younger population, such as the use of digital media or by introducing the topic at an earlier age through the school curriculum. There seems to be high potential for raising the awareness of folate requirements and nutrition during pregnancy at the routine check-ups with the gynecologist, which are attended by a majority of women.
"To facilitate reaching targeted periconceptional RBC folate levels, improvements in the present system of voluntary folic acid fortification might be achieved by increased control and monitoring, or by considering mandatory fortification of targeted staple foods."
Sych. J., et al
"Inadequate Status and Low Awareness of Folate in Switzerland—A Call to Strengthen Public Health Measures to Ensure Sufficient Intakes"
https://doi.org/10.3390/nu12123729 (registering DOI)