174 | Folate, Choline & the Fertility Supplement Hype

If you were at the Today's Dietician Conference this spring, you may have stopped by one of the cutest booths there, all covered in strawberries. That was my first introduction to Fullwealth, a dietitian-founded supplement company focused on prenatal and reproductive health. I loved getting to know the brand and the philosophy behind it, and that conversation eventually turned into today's episode, which is sponsored by Fullwealth. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA, a dietitian, and today I'm talking with Fullwealth's founder, formulator, and CEO, Ayla Farmer. Ayla is also a registered dietitian who has spent more than 20 years working in reproductive health and nutrition. Now, since I'm on the other side of fertility over here in pediatrics, I was especially excited to hear her take on some of the hot topics showing up everywhere right now. Folic acid versus methylfolate, where inosetol may fit for patients with PMOS, and why choline probably deserves a lot more attention than it gets. So grab your coffee or drive safe and enjoy my conversation with Ayla. Ayla, thank you so much for coming onto the podcast. I'm really excited to chat with you today. Welcome to the show. Thank you so much for having me. So if a patient comes in to us and she says that she's trying to conceive, what are some of the nutrition priorities that you address first?

You know, no, no two journeys are the same. But the first thing that I'm gonna do is I I like to have a conversation and kind of get to know my uh clients in front of me and see what's going on with them. You know, what kind of things are they concerned about? And so one of the things that we'll do is we'll kind of go through a questionnaire, we'll look at um what is going on uh symptom-wise, what are they experiencing and how does digestion feel for them? And I do often start there because we can't really get the benefit of what we're eating and what we're taking supplement-wise, unless we're able to really absorb it and process it right through the gut. Um, so a digestive assessment is a big one. Um, but I I will also kind of step back and look at, all right, what does your typical diet look like? You know, what does the cadence of it look like? Um, you know, from timing of the meals and snacks to the composition of them, to the variability between a weekday and a weekend day, um work schedules and all of that. And another area, I'll always ask about what kind of dietary supplements are you taking so we can factor that in. And then the other big piece that I will look at is as a registered dietitian, I can order nutrition labs to kind of look at what's going on. So a complete iron panel is is huge. And by complete, I mean not just a hemoglobin, not just a CBC, right? Uh, you know, a ferritin and even a um a transferritin. And then vitamin D. Vitamin D affects ovulation, um, it affects egg quality. Um, it is, it plays a profound role in fertility and early pregnancy. Some other places I'm gonna look will actually be a TSH, you know, a thyroid a complete thyroid panel if we can do it. Not because I'm going to diagnose and treat a thyroid condition, but because I can screen for something that may be going on, since that's such a common reason for pregnancy loss.

Yeah, that first visit is a lot of investigating. It's a lot of question asking. And so along those lines, what are some of the most common misconceptions about like nutrition and preconception that you've seen, whether it be on social media or just from your patients?

The the number one biggest misconception that I see is that we don't really need to worry about nutrition at all until you are pregnant. A lot of times, um, you know, I find that women are not starting a prenatal multivitamin or um even really addressing nutrition at all until they've gone for that first visit to confirm their pregnancy at an OB or a PCP. Um, it feels like, you know, it all starts once pregnancy is confirmed. But the reality is we've we got to back it up. Um, the things that both women and men do in the three to six months prior to conception have a really big impact on conceiving, but also the health of the pregnancy. So we and in long-term health of baby. And so it's it's really important that we we do pay attention to that preconception period because while it feels like nothing's going on right there, there's actually a lot going on. Um, and a lot that will ultimately influence the pregnancy. And in fact, you know, some of the most important things that happen in the very early stages of pregnancy are really dependent on nutrient intake, nutrient stores, and status prior to pregnancy. A good example is folate status, as well as choline, vitamin B12. Um, that's another thing I see being a misconception, is that um, you know, it's all about folate, and that somehow is the only nutrient that we need uh, you know, for conception and pregnancy, when in reality, there's a lot of nutrients. There's a lot of resources in general that are needed for supporting conception, supporting pregnancy. It is a very energy-intensive, you know, kind of amazing process that the body goes through, right?

It is a miracle, like a true miracle what women's bodies are capable of doing and that we can grow a human life inside of us. Now, I want to hit the pause button on folates because it has become surprisingly confusing over, I would say maybe the last year, I don't know, maybe more, but social media has made it quite controversial now, which is um very upsetting to myself and I'm sure people like you. And so I would love if you could walk us through folate, folic acid, and methylfolate, because we are hearing those three things kind of thrown around on social media and clarify some of those misconceptions and what should we actually be telling patients?

I would love to dig into this a bit because it is really confusing. So here's the reality the folate that we find in food naturally is 80% methylfolate. The other 20% is a mix of types of folate, including folitic acid and other types of folate. None of that is folic acid. That doesn't mean folic acid is bad, but what happened is folic acid was created in the 90s as a tool to fortify the food supply. This was a big public health campaign and effort that was very largely successful by all measures, um, where there was a recognized increase in neural tube defects happening throughout the population. And what that was really traced back to was the fact that we were processing the folate out of grains. You know, we were stripping them down in the refining process, getting rid of that outer bran, a lot of fiber and good stuff, including B vitamins like folic acid or folate, um, were naturally present. So we were getting rid of that. And so that was in turn causing a, in part, a spike in neural tube defects, which are very serious pregnancy complications. And so the government, through research and um a really enormous, if you think about it, public health initiative to make this happen, um required that the industry replace what was stripped with back with folate in the form of folic acid. Now, I think that they ultimately landed on folic acid instead of a methylfolate or another form of folate because one, it's very stable. So um when you put it into food, it's going to stay folic acid and remain in that form. And two, it's a lot less expensive, like hundreds of times less expensive than methylfolate. Um, and so realistically, this was a very good way to get the foods, the food industry to adopt this type of fortification program, right? And it was it was successful in reducing neural tube defects because folic acid is very well absorbed in our intestines. It's absorbed very well. It will raise our serum levels of folate. However, that doesn't tell us how well our body is utilizing that. So, um to some extent, I mean, everybody, regardless of genetics, can handle some folic acid. I mean, um, we do again see it working really well. But what has become more prevalent, more prominent in the research that I find concerning is that is what happens to the folic acid that our body cannot metabolize, can't use. And that that becomes what's called unmetabolized folic acid. It's exactly what it sounds like it is, right? And if you look into the research in that, you see some of the negative impact um on other areas of the body, like decreasing natural killer cell activity and other things. And so that's where I think some of the concern comes in from other providers. And while um I don't think many of us, although it does get really extreme out there, I don't think many of us are completely hardcore anti-folic acid, because we recognize the utility of it, the benefit, the effectiveness of it. You know, the the current guideline from some of the more conventional organizations like ACOG, right, is still folic acid. Though even ACOG recognizes that methylfolate is comparable. The FDA recognizes that methylfolate is comparable to folic acid. It's why you'll see on a label something called DFE, dietary folic acid equivalent, um, to kind of convert and make things apples to apples, sort of. My recommendation is go for the methylfolate if it's within budget, if you could find a formula that works for you that is going to be superior, hands down. I mean, I just don't think you can argue with that because it's the form that we naturally stripped out of food. Um, it is very stable in supplement form. It may not be as stable when we're putting it back into like a food, like a flour, but it is very stable in supplements and it's it's not going to require any conversion by your body. As you can see, I think that's about as brief as I could be because there's a lot involved in this conversation.

Yeah, that was really helpful. Thank you for that deep dive. And we could probably do like a full hour episode on this topic alone. But I have other questions, questions for you. Now, for an individual with PMOS, which my audience will know used to be PCOS, who's trying to conceive, talk to me about Eno Citol because we're seeing this, I'm seeing it pop up a little bit more on social media, and I really didn't learn about it in school. So maybe what is it? Who would benefit from it? And then how are the response rates to it?

Yeah, so PMOS, which was previously called PCOS, it is the number one endocrine disorder worldwide. It's very common. There's lots of different phenotypes, lots of different ways that PMOS can present. But one of the underlying hallmarks of this condition is metabolic dysfunction. And how that shows up is insulin resistance. And that insulin resistance is really the driver behind irregular ovulation, irregular cycles, some a lot of the um the elevated androgen levels. So when you see things like acne and facial hair and um hair loss on your head, you know, these are things that we can trace back to insulin resistance and um androgen dominance. Uh and so, really, a lot of the best efforts and best strategies to manage the symptoms of PMOS and support regularity of cycles is to go after this metabolic dysfunction. And it doesn't look exactly the same as it does for someone that's like a pre-diabetic or diabetic. It's it's a little bit more nuanced and specific to PMOS. There is a compound, a natural uh compound that we find in foods like beans and legumes, um, that is a B vitamin-like compound. It's called inocitol, as you mentioned. And this is something that has been shown in the clinic in clinical trials to really support metabolic health and increase insulin sensitivity in those with PMOS. But there's some nuance to it, like everything. Um, you know, uh inocitol really ideally is taken in a ratio that mirrors what our body best wants and uses. And that's referred to as a 40 to 1 ratio. So the 40 referencing myoinocitol, the the one referencing D chironostol, just two different kinds of inocital. What inocitol really does is, like I said, it kind of supports that metabolic function and insulin sensitivity. Um, however, the the the other piece to consider here is that many women, I think this is actually up to 20% of women, do not absorb inocital well in the gut. And so one of the things that we can do to enhance the absorption is combine it with a compound called alpha lactalbumin, which I really love. It's quite, it's it's novel, but it's it's really just a whey-derived protein that's very well tolerated, even if you don't tolerate dairy. And it helps enhance inocital absorption by up to 30%. And just my last note on this is that, you know, the it really does matter to take things in the form that your body can best utilize, but also to take it in the dose that your body that really matches the evidence, right? Because otherwise it you may just be taking something that's not not going to do anything. It's kind of a pixie dust ingredient where you see it on the label, but it's not in enough quantity that is um going to be efficacious. So uh it's it's two grams twice daily of that 40 to one ratio. So four grams daily and divided doses.

I'm really glad that you brought that up because I feel like PMOS is one of those populations that I feel there's a lot of predatory marketing going on. So I appreciate that caveat that you had mentioned. Ayla, you mentioned uh choline earlier, and I want to come back to that nutrient because you're right, it often gets overlooked. Folate is like the top dog when we are talking about pregnancy with our patients, but choline is something not often on a lot of people's radar. So why should we be thinking about it and talking about it with our patients?

Choline is so important when it comes to pregnancy and even conception. And um, it is there's kind of this trifecta, I really um, I really uh see in the research, you know, and what in physio physiologically, what it's going on in our body between um, you know, vitamin B12, folate, and choline. All three of them are part of cellular processes, methylation, um, things that are happening at a very, very basic level that go into overdrive during the early embryo development implantation, and then ultimately pregnancy. And so needs go up. Um, and choline is one that's tricky. It's a tricky nutrient because, you know, in the US, we are not getting in nearly enough. In fact, most women, most, the vast majority of women, upwards of 95% of women, are not even meeting the adequate intake level for choline. And that adequate intake level has not been updated for a long time. It certainly doesn't reflect the newest research, which puts puts the adequate intake level at almost double what it is. So the AI is around 450 milligrams of choline in pregnancy, 550 milligrams breastfeeding because your needs go up even more if you're breastfeeding. And neural research really puts that at more like 900 milligrams. So we're um 95% aren't even meeting that minimum. We we really aren't getting there. So supplementation makes a lot of sense. Um, it's choline is involved, like I said, in neural tube uh formation. It's also involved very heavily in um brain development, cognitive health. You find it in food in more animal-based products. Um, egg yolk is a really rich source, organ meats, which are not as commonly part of people's diets. And then oysters, like canned smoked oysters. I don't recommend um raw oysters in pregnancy, but you know, canned is is an option. Very rich in choline. Your plant-based sources exist. So, like peanut butter, legumes, they just are not as concentrated. So it becomes, it's really difficult. Like I said, most people are not doing it to get to your needs without supplementing. So I find that a lot of folks look in looking at the delta between what they're getting in diet-wise and what they need, it tends to be around 300 milligrams. Um, and it's hard to go higher than that in a supplement form because choline is a large nutrient. It takes up a ton of room in the capsule. And so if you have a one-a-day prenatal, a two, or even a three-a-day prenatal, I guarantee if you look at that label, there's going to be negligible amounts of choline, nowhere near 300 milligrams, um, because it does take up quite a lot of room. And so that's um, that's something that I would really look for in a prenatal uh and to really consider taking supplementally because it is so hard to get consistently in diet.

You've mentioned that you were the owner of the supplement company Fullwell. So I would love to hear more about that company and specifically like your approach to fertility nutrition and how that shows up in the products that you offer.

Yes. So so full well was something I founded out of a need that I saw in practice. You know, I was a practitioner for, you know, over a decade, uh, working primarily in fertility and pregnancy nutrition, postpartum, through that perenatal stage of life and with other reproductive health concerns. And over and over again, I just kept looking for formulas that really met my patient's needs. And so, like most things, I could do it myself, you know, right? And rather naively decided to embark on it, which took three, four years before I actually finally had met the requirements. But ultimately, I wanted formulas that made sense, that really truly complemented typical diets and based on the best available evidence for dosing, but also forms for tolerance. And so I, my practitioner experience has been invaluable and really the way the company has been built. To me, there's no point in doing any of this unless you're gonna do it the right way.

Can you talk to me about a product you may be especially excited or proud of?

Yeah, so I absolutely love our prenatal stick packs that launched this year. They are our prenatal multivitamin, which is in capsules, and make it in a much more convenient format. And the the thing that I'm most proud of with that formula too is that we were really able to achieve the quality and keep that first and foremost in mind. And so that's why they're in stick packs and it's not in a giant tub or bag. You know, that's just not a great idea. Um, when there's inconsistent scooping, there's different sizes of nutrients that can settle um in different ways. And so the stick packs, they taste really good. And I think that they um they mix really well, they incorporate into life really well, and um, they also maintain that quality. So there's no compromise there.

So, where can people purchase, learn more, send their patients, and learn more about Fullwell?

Yes, so you can find us at Fullwell Fertility um on Instagram, on social media. Uh, fullwellfertility.com is our URL, and you'll see um all of our products there.

Um, you can find me at Ayla Barber on Instagram. Well, I will link down to all of that in the show notes. Definitely check them out. Ayla, thank you so much for being here. I appreciate the gift of your time today. Thank you so much for having me. And thank you guys for carving out some time for nutrition. I will see you next week.