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If you\u2019re planning to get pregnant, one of the first things your doctor will tell you<\/a> is to take a daily prenatal vitamin with folic acid. That\u2019s because folic acid<\/a> \u2014\u00a0the synthetic form of folate, or vitamin B9 \u2014\u00a0has been shown to help prevent neural-tube defects, including anencephaly and spina bifida. In a healthy pregnancy, the neural tube forms in the early weeks of gestation, eventually developing into the brain and spinal cord. If the neural tube doesn\u2019t close properly, the results can be catastrophic<\/a>. Many of these pregnancies end in miscarriage or stillbirth. In other cases, babies are born missing parts of the brain and skull and die within days of being born. Those who do survive are likely to contend with a wide range of serious disabilities, including paralysis.<\/p>\n The World Health Organization estimates<\/a> that around 300,000 babies are born with neural-tube defects each year. However, in many cases these birth defects are preventable<\/a> with folic-acid supplementation. In fact, folic acid is so effective at preventing neural-tube defects that since 1998, the U.S. has required that it be added to certain \u201cenriched\u201d grain products \u2014\u00a0including flour, bread, pasta, and breakfast cereal \u2014\u00a0to help ensure that women who become pregnant are getting enough of it. According to the CDC<\/a>, fortifying grains with folic acid helps prevent around 1,300 babies from being born with neural-tube defects every year.<\/p>\n Supplements are a gigantic industry<\/a>, despite the fact that, in most cases<\/a>, they don\u2019t do much for our health. Folic acid is a rare exception. Adding it to everyday foods<\/a> has saved lives. But lately, as wellness influencers grow increasingly suspicious of the synthetic chemicals lurking in our food supply<\/a>, many of them have turned on folic acid. Instagram is full of videos warning that folic acid is toxic<\/a>, blaming it for everything from miscarriages<\/a> to autism<\/a> \u2014\u00a0and supplement companies are lining up to sell women an unproven alternative. Now, a growing number of popular brands \u2014\u00a0including Ritual, Thorne, Needed, and Perelel \u2014\u00a0are selling prenatal vitamins that don\u2019t include folic acid at all.<\/p>\n Appearing on The Skinny Confidential Him and Her podcast earlier this year, the biohacker Gary Brecka told<\/a> co-hosts Lauryn and Michael Bosstick that prenatal vitamins containing folic acid are \u201cthe leading cause of postpartum depression.\u201d A few months later, Bosstick, pregnant with her third child, posted a video<\/a> gushing about Ritual\u2019s prenatal vitamins, noting that, instead of folic acid, their formulation includes \u201ca specific methylated form\u201d of folate that Brecka recommends to avoid postpartum depression and anxiety. She\u2019s not the only one. Influencers like Hannah Bronfman<\/a> and Danielle Brown<\/a> (also known as Healthy Girl Kitchen<\/a>) swear by Ritual\u2019s prenatal vitamins, and Serena Williams recently joined the company<\/a> as a \u201cWomen\u2019s Health Advisor.\u201d \u201cRitual has been challenging industry norms since day one,\u201d Williams said in a promo video<\/a>, adding that she \u201ctrusts the products\u201d because they\u2019re \u201cbacked by science.\u201d<\/p>\n In their marketing copy, Ritual and its competitors claim that folic acid is an inferior form of folate<\/a>\u00a0because it\u2019s synthetic. Instead of folic acid, these brands use methylfolate. Both folic acid and methylfolate are forms of folate, a nutrient found in leafy green vegetables and legumes. Typically, when you consume folic acid, your body converts it into methylfolate through a process called methylation. Ritual argues<\/a> that because methylfolate has already been chemically reduced to the \u201cactive form\u201d of folate, it\u2019s a better choice \u2014\u00a0especially since, it claims<\/a>, \u201cup to one-third of adults have a genetic variation that makes it difficult to efficiently utilize folic acid.\u201d<\/p>\n This is where things get even more confusing\u00a0and contentious. For the pro-methylfolate camp, everything comes back to MTHFR gene variants. This isn\u2019t new: Over the past 15 years, as direct-to-consumer genetic tests have become more popular, alternative-medicine practitioners have seized on MTHFR variants as a catchall diagnosis<\/a>, claiming they\u2019re responsible for everything from infertility and pregnancy loss<\/a> to ADHD, OCD, bipolar disorder, hypertension, thyroid disease, and poor gut health. The naturopathic doctor Ben Lynch helped pave the way for this, claiming that if you have an MTHFR gene variant \u2014\u00a0or as he likes to call it, \u201cmutation\u201d \u2014 your body can\u2019t metabolize folic acid<\/a>. Conveniently, he had a solution. In 2011, he founded Seeking Health, a supplement company that sells a vast array of vitamins designed to be \u201cbioavailable\u201d<\/a> for people with MTHFR variants \u2014\u00a0and one of the first<\/a> to market a prenatal vitamin using methylfolate instead of folic acid.<\/p>\n According to 23andMe<\/a>, MTHFR is the \u201cmost-asked about gene\u201d by customers. That\u2019s probably because variants of this gene are incredibly common; according to the CDC<\/a>, more than half the population has one. And while they have become fertile ground for speculation and medical misinformation, there\u2019s no definitive evidence<\/a> that they cause any significant health effects, says Shannon M. Clark, an OBGYN and maternal-fetal medicine specialist. For that reason, medical organizations generally\u00a0recommend against<\/a> testing for MTHFR variants. The OBGYN Jen Gunter has called<\/a> MTHFR testing \u201cmeaningless\u201d and \u201ca scam.\u201d<\/p>\n That said, having an MTHFR variant does impact how your body processes folate \u2014 it just means that, because you\u2019re more likely to have lower blood-folate levels, you need more folic acid to protect against neural-tube defects, according to Martha Field, a professor of nutrition at Cornell.<\/p>\n There\u2019s also no credible evidence that consuming folic acid at the recommended dosage has any negative effects on health. While some influencers claim<\/a> that taking folic acid increases the chance of miscarriage, studies show the opposite<\/a>. And contrary to what Brecka says<\/a>, studies show that folic-acid supplementation helps reduce perinatal depression symptoms<\/a>, too. While supplement companies that use methylfolate like to emphasize the risks of taking too much folic acid<\/a>, the amount added to fortified foods is actually pretty conservative. Evidence shows most people consume less than 150 micrograms of folic acid<\/a> a day from fortified food. Unless you\u2019re taking multiple supplements that contain folic acid, it\u2019s unlikely you\u2019d exceed the recommended limit, says Field.<\/p>\n The problem with replacing folic acid in prenatal vitamins is that there haven\u2019t been any clinical trials showing that methylfolate prevents neural-tube defects, Field says. According to the CDC<\/a>, folic acid is the only form of folate that has been proven to help prevent neural-tube defects. It\u2019s so effective that doing a trial comparing the efficacy of folic acid and methylfolate in early pregnancy would be unethical \u201cbecause you can\u2019t withhold folic acid from a pregnant woman,\u201d says Field. While Ritual claims to be<\/a> \u201cthe only leading prenatal backed by its own human clinical trial,\u201d that trial had only 62 participants and it hasn\u2019t been published in a journal. Ritual also didn\u2019t exactly show that its vitamin prevents neural-tube defects, because it looked only at women in the second and third trimester of pregnancy \u2014\u00a0after the neural tube has already closed, says Kevin C. Klatt, a metabolism researcher at the University of California, Berkeley. (Ritual declined to comment for this story, and none of the other supplement companies mentioned in this story responded to a request for comment.)<\/p>\n Ritual suggests<\/a> that because methylfolate has been shown to raise blood-folate levels, it would presumably support neural-tube development, which happens in the first month of pregnancy. \u201cThat\u2019s a totally valid hypothesis, but they haven\u2019t shown that,\u201d says Klatt. And there are reasons to be skeptical that\u2019s the case. Folic acid is much more chemically stable than methylfolate, says Klatt. It holds up well in food and supplements, and it\u2019s actually more bioavailable<\/a> than folate found in food. On the other hand, methylfolate degrades more easily when it\u2019s exposed to light and oxygen. \u201cSo when you put a certain amount of methylfolate in a bottle of prenatal vitamins, you don\u2019t know how much a patient is getting,\u201d says Clark.<\/p>\n Methylfolate is also more expensive. Ritual spins this into a selling point to help justify the fact that it charges three times as much<\/a> as supermarket prenatals<\/a>. \u201cThey have the beautiful website and the beautiful marketing, and they can make all these bullshit claims because there\u2019s no regulation,\u201d says Clark. Because the FDA classifies prenatal vitamins as dietary supplements, they are not required to include certain ingredients<\/a>, nor are they evaluated for safety or effectiveness before they hit the market.<\/p>\n \u201cThese brands are preying on the fact that people don\u2019t trust institutions or official recommendations, and then they\u2019re selling the solution,\u201d Klatt believes \u2014\u00a0and if that\u2019s the intent, it appears to be working. Ritual made more than $250 million<\/a> last year, and its prenatals routinely make it into popular roundups<\/a> of \u201cbest prenatal vitamins<\/a>,\u201d which neglect to mention that they don\u2019t include the only ingredient that has been shown to prevent neural-tube defects. Clark says she sees patients all the time who are taking a fancy prenatal vitamin without realizing it isn\u2019t what their doctor would recommend.<\/p>\n The risk of having a pregnancy affected by a neural-tube defect is low, Klatt says, and many women don\u2019t start taking a prenatal vitamin until after they find out that they\u2019re pregnant \u2014\u00a0and after the crucial window for neural-tube development \u2014\u00a0which is why the U.S. fortifies grains with folic acid. \u201cBut now you\u2019ve got trad moms making TikToks about how they\u2019re making bread that\u2019s folic-acid free,\u201d Klatt says. As folic-acid misinformation spreads online, \u201cit\u2019s making the everyday mom turn away from what\u2019s probably the most evidence-based thing in maternal child nutrition \u2014\u00a0and have to shell out tons of money.\u201d Any case of a neural-tube defect that could have been prevented is a tragedy. \u201cWe know folic acid works. We have the evidence,\u201d says Clark. \u201cWhy take that risk?\u201d<\/p>\n Stay in touch.<\/p>\n Get the Cut newsletter delivered daily<\/p>\n Vox Media, LLC Terms and Privacy Notice<\/p>\n