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The Folate Fortification Story – How we fixed one problem…but may have created another

By: Mary Scourboutakos

Neural tube defects are a type of birth defect—affecting the brain, spine or spinal cord—that result from suboptimal folate status.
Folate is a B vitamin that’s naturally found in legumes (like chickpeas, lentils, pinto and kidney beans), seeds, leafy greens (like spinach, collard greens and romaine lettuce) and other vegetables such as asparagus, brussels sprouts and broccoli.

The problem is, people don’t eat enough of these foods. As a result, for many years, pregnant women were at risk for folate deficiency and hence, neural tube defects.

Prenatal supplements were the original solution to this problem as one of their prime ingredients is folic acid, the synthetic form of folate. However, they’re not a fool proof solution because neural tube defects form within four weeks of conception, often before women know they’re pregnant, and thus, before they start taking their supplements.

As a result, in the late 1990s folic acid was mandatorily added to white flour and enriched grain products to ensure that pregnant women would get enough folate, irrespective of whether they take a supplement.

Problem solved? Sort of…

Back in the early 1990s when discussions regarding the addition of folic acid to the food supply were taking place, it was suggested that after fortification was implemented, the dose of folic acid in prenatal supplements should be revised to prevent excessive intakes. The new problem is…the doses were never revised.

Currently, marketed prenatal supplements usually contain 1000 micrograms of folic acid, which is the daily upper limit for folic acid. Meanwhile, it’s recommended that pregnant women should consume about 400 micrograms of folic acid per day for neural tube defect prevention.

With mandatory fortification, three-quarters of a cup of cereal can provide greater than 400 micrograms of folic acid. So if you add a prenatal supplement to a bowl of cereal at breakfast, some bread at lunch, and pasta for dinner, you’re consuming a lot of folic acid!

According to Dr. Deborah O’Connor, a Professor from the University of Toronto who has spent decades studying folate and infant health, this could be a problem. She explained that in animal models, it has been shown that folate can make changes to the genes that are transcribed during development. And while similar data have not been done on humans, she said “if you’re not getting any benefit from those high levels, it would be prudent to cut back given the current status…(because) if there’s no benefit, there’s only a risk.”

From a regulatory point-of-view, she says there’s nothing stopping the industry from changing the amount of folic acid in the supplements. She suggested that the industry’s reluctance to modify the dose in prenatal supplements is probably due to inertia and the fact that “with nutrition you’re always fighting against the more is better philosophy.”

In the meantime, what should women do? In their 2015 clinical practice guidelines, the Society of Obstetrics and Gynecologists recommended a multivitamin containing 400 to 1000 micrograms of folic acid. But currently, there are no prenatal vitamins available with less than 1000. Hence, Dr. O’Connor’s recommendation is “do not use the prenatal, just use a regular multi-vitamin and maybe add a little iron.” Furthermore, she added “care must be taken to ensure vitamin A intakes do not exceed 3,000 mcg retinol activity equivalents (RAE) or 10,000 IU during pregnancy.”

Alas, it’s a classic story, you try to fix one problem, but in doing so, you create another. Hopefully prenatal supplements will be adjusted soon, but in the meantime, prudent folic acid intakes are probably a good idea.

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Nutritional Interventions in Treatment of Major Depressive Disorder

By Chris Sovey, RN, BSN

Do you know someone who is depressed? You probably do, whether you realize it or not. Major Depression is a crippling mood disorder currently affecting over 26.2% of the adult population in the United States (U.S.) (NIMH, 2005, NIMH 2008). The prevalence of Major Depression in the U.S. has increased by a factor of ten fold in the last two decades (Ilardi, 2009). It is expected to continue to rise. The National Institute of Mental Health estimates that 1 in 4 Americans will meet the diagnostic criteria for major depression during their lifetime (NIMH, 2008). Medicare claims of those suffering with depression tend to incur charges an average of $2,409 greater per medical incident than their non-depressed counterparts (NIMH, 2009).

There is a significant body of literature supporting the use of nutritional interventions in the treatment of depression. Because of the increasing prevalence of this troublesome disorder, my goal is to briefly outline four nutritional supplements that have demonstrated safety and at least some efficacy in research. Keep in mind that research surrounding these particular items is still controversial.

Omega-3’s– Omega-3 supplementation comes highly recommended by a growing number of practitioners as an integral part of depression treatment. Dr. Neil Nedley, MD and Stephen S. Ilardi, PhD claim that diets high in omega-3’s may assist in the treatment of both major depression and bipolar disorder. Because the Western American Diets tend to lack foods containing omega-3’s, it may be beneficial to find a supplemental source, such as fish oil or flaxseed. Some authors claim that the alpha-linolenic acid (ALA) found in flax is not a bio-available source of Omega-3 fatty acids. Fish oil may be another viable option. Walnuts also contain a relatively high level of Omega-3’s. Regardless of source, omega-3 supplementation has consistently demonstrated a reduction in depressive symptoms in the literature (Riediger, et al 2009).

Folate and Vitamin B-12 – Depressed patients tend to demonstrate higher deficiency levels of vitamin B-12. Folate levels typically are lower in depressed patients (Bodner, 2005). It has been suggested that a deficiency in either of these vitamins may impair methylation in the central nervous system that is necessary to produce monoamine neurotansmitters (Penninx, 2000). This may in turn lead to the impaired mood symptoms evident in depression.

Vitamin D – Serum 25-hydoxyvitamin D levels tend to be low among depressed individuals. Some authors argue that there may be a causal link between depression and Vitamin D deficiency (Jorde, et. al 2008), while others maintain that the evidence is not strong enough at this point. Even more confusing is the lack of an established dosage to treat various disorders. This includes depression. Some studies suggest a dose of 2000 IUs / day for general intake (Vieth, 1999). In the treatment of depression, some studies have used dosages as high as 20,000 – 40,000 IUs / day! (Jorde, et. al 2008) Regardless of whether or not there is a direct causal relationship, it appears that some studies are yielding positive results in reducing depressive symptoms.

St. John’s Wort – Hypericum perforatum L. (St. John’s Wort) is currently a hotspot for research. It is widely popular in Europe, and used as a front-line treatment for mild to moderate depression. The United States is a little more hesitant to adopt this herb into the realm of psychotherapy, as it comes with several drug interactions. Many systematic reviews present confusing and contradictory results. A meta-analysis by Linde, et al. found Hypericum to be as effective as standard antidepressants to decrease depressive symptoms in mild to moderately severe depression (Linde, 1996). It is likely that more research will need to be completed before St. John’s Wort becomes an accepted treatment for depression in the U.S.

I want to stress that when applied correctly, an appropriate regimen of nutritional interventions in addition to other therapies for depression may yield profound results in mood and other symptoms. You must work the details out with your healthcare provider.

Lastly, if you’re reading this out of sheer curiosity, pass this information on to someone who is struggling with depression. Maybe it is a family member. Maybe it is you. Sometimes things can seem pretty hopeless in our darkest moments. But there is always hope. Finding the correct information and acting upon it is the first step to recovery.

Disclaimer: These interventions are not meant to serve as medical advice. Please consult with your healthcare provider. Supplements, and even foods, may cause interactions with your current medications.


Bodnar, L., & Wisner, K. (2005). Nutrition and depression: Implications for improving mental health among childbearing-aged women.Biological Psychology, 58, 679-685. Retrieved from

Ilardi, S. (2010). The depression cure. Da Capo Press. 1999. Philadelphia, PA.

Jorde, R., Sneve, M., Figenschau, Y., Svartberg, J., & Waterloo, K. (2008). Effects of vitamin d supplementation on symptoms of depression in overweight and obese subjects: randomized double blind trial. Journal of Internal Medicine,264(6), 599-609. Retrieved from

Linde, K., Ramirez, G., Mulrow, C., Pauls, A., Weidenhammer, W., & Melchart, D. (1996). St john’s wort for depression—an overview and meta-analysis of randomised clinical trials. British Medical Journal, 313(253), Retrieved from

NIMH. (2009, February 13). Health care costs much higher for older adults with depression plus other medical conditions. Retrieved from

NIMH. (2005). Major depressive disorder among adults. Retrieved from

NIMH. (2008, June 26). The numbers count: Mental disorders in america. Retrieved from

Penninx, B., Guralnik, J., Ferrucci, L., Fried, L., Allen, R., & Stabler, S. (2000). Vitamin b12 deficiency and depression in physically disabled older women: Epidemiologic evidence from the women’s health and aging study. American Journal of Psychiatry, 157, 715-721. Retrieved from

Riediger, N., Othman, R., Miyoung, S., & Moghadasian, M. (2009). A systemic review of the roles of n-3 fatty acids in health and disease. American Dietetic Association, 109, 668-679.

Vieth, R. (1999). Vitamin d supplementation, 25-hydroxyvitamin d concentrations, and safety.American Journal of Clinical Nutrition, 69(5), 842-856. Retrieved from