Sep 12, 2025
Dietary folate intake and folate status of women following a gluten free diet: a scoping review protocol
- Deanna Park1,
- Rachael Thurecht2,
- Kay Gibbons1
- 1Charles Darwin University, Australia;
- 2School of health, University of the Sunshine Coast, Australia
Protocol Citation: Deanna Park, Rachael Thurecht, Kay Gibbons 2025. Dietary folate intake and folate status of women following a gluten free diet: a scoping review protocol. protocols.io https://dx.doi.org/10.17504/protocols.io.x54v95171l3e/v1
License: This is an open access protocol distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Protocol status: Working
We use this protocol and it's working
Created: September 12, 2025
Last Modified: September 12, 2025
Protocol Integer ID: 227170
Keywords: Adult, celiac, dietary quality, folic acid, micronutrient, risk of inadequate folate intake, dietary folate intake, evidence available on the folate status, folate status, adequate folate status, inadequate folate intake, folate intake, measurement of folate intake, adequacy of folate intake, implications for folic acid fortification initiative, folate, folic acid fortification initiative, gluten free diet, unplanned pregnancy, intake of women, fortified grain product, exclusion of fortified grain product, risk of neural tube defect, data on female, health implication, important during preconception
Abstract
Objective: To scope the evidence available on the folate status and folate intake of women on a gluten free diet (GFD) and compare this against established reference ranges and recommended intake values.
Introduction: Folate is essential for cell division, DNA synthesis and amino acid metabolism. Adequate folate status is important during preconception to reduce the risk of neural tube defects. Individuals following a GFD may be at risk of inadequate folate intake due to the exclusion of fortified grain products. As women represent the majority of GFD followers, this may have health implications in cases of unplanned pregnancy.
Inclusion criteria: Eligible studies will include data on females of any age following a GFD and reporting a measurement of folate intake or folate status. There will be no restriction on language or year of publication. Peer-reviewed and grey literature sources will be included.
Methods: Following the Joanna Briggs Institute guidelines for scoping reviews, a comprehensive search for peer-reviewed literature will be conducted using specified search terms in PubMed, CINAHL Ultimate and Scopus. Other databases (ProQuest, Cochrane Library, Clinical Trials Gov and Google Scholar) will be utilised to search for grey literature. Title and abstract and then full-text screening will occur with additional backwards citation searching. Data extraction will focus on folate status and/or intake and study characteristics. Findings will be discussed in relation to gaps in the literature, adequacy of folate intake and status and implications for folic acid fortification initiatives.
Troubleshooting
Introduction
“Gluten” is the collective name for several plant-storage proteins found in wheat, rye, barley and sometimes oats (1). These grains are used to make staple foods like bread, pasta, noodles, flour and
breakfast cereals worldwide (1). Although most people consume these staple foods and hence
gluten frequently, a significant proportion of the world’s population follows a gluten free diet (GFD)
(1). For example, in Australia it has been found that between 2.5% and 24.2% of survey respondents
were avoiding gluten (2-4). People follow a GFD for a variety of reasons such as for the treatment of
Coeliac disease, management of dermatitis herpetiformis, non-coeliac gluten sensitivity and wheat
allergy, lactose intolerance, irritable bowel syndrome and gastrointestinal symptoms, to aid weight
loss and for general health reasons (3, 5-9). Overall, more women follow the GFD than men do and
this has been confirmed worldwide (4, 10-18).
Several studies have examined the nutritional quality of the GFD and have demonstrated that it is not nutritionally adequate (19, 20). A nutrient of specific concern for those following the GFD is the
micronutrient folate (19, 20). Folate plays an important role in DNA synthesis, cell division and the
metabolism of amino acids (21). Furthermore, it is important for women of reproductive age (WRA,
16-44 years) as it enables the development of the foetus’ neural tube in early pregnancy; in the
context of folate deficiency there is an increased risk of neural tube defects (22-25). To ensure
adequate folate intake and status during pregnancy, all WRA planning pregnancy, including those
following a GFD, are recommended to take supplements containing 400-500 micrograms of folic acid
(the synthetic form of folate) daily prior to conception (23, 26). Additionally, WRA are recommended
to consume a folate-rich diet containing high-folate foods like green leafy vegetables, legumes, some
fruits, eggs, tofu and foods fortified with folic acid (23, 26). In Australia, most adults consume only 3
serves of vegetables per day with folate-rich vegetables (i.e. green leafy vegetables and legumes)
comprising approximately 45% or 1.35 serves daily (27). To address the low consumption of folate
and folate-rich dietary sources, the Australian government mandated folic acid fortification of wheat
flour for bread making in 2009 (28). This public health intervention resulted in a significant increase
in population folate and folic acid intake (28). Many other governments worldwide have also
encouraged or mandated public health measures to fortify wheat-based and maize-based staple
foods with folic acid to good effect (29, 30). One study found that in countries with folic acid
fortification, mean plasma folate levels were 50-100% higher and neural tube defect prevalence was
25-50% lower when compared to countries without folic acid fortification (30).
Around half of pregnancies are unplanned and therefore many women may miss the opportunity to
select folate-rich foods and take folic acid supplements to ensure adequate folate status and intake
during early pregnancy (26, 31, 32). For those following a gluten-containing diet, the fortification of
wheat based staple foods with folic acid has proven to be beneficial in this case (28, 30). However,
for women following a GFD, their folate intake and status may be at risk more so than the general
population. As previously mentioned, folate has been identified as a nutrient of concern for those
following a GFD (19, 20). This could potentially be due to many common GF (gluten free) foods and
commonly used GF ingredients in staple GF foods being naturally poor in micronutrients like folate
(33, 34). Furthermore, folic acid fortification strategies usually require fortification of staple foods
containing wheat flour and not GF staple foods (29, 35). As such, those following a GFD, especially
WRA, may not be benefiting from public health initiatives to increase the folate content of their
habitual diets at the population level.
A preliminary search has revealed that there are some primary studies and a small number of
reviews which examine the folate intake and folate status of people following the GFD. However,
these investigations were included as part of wider investigations into the overall nutritional intake
and status of those on the GFD rather than investigations particularly into folate intake and/or status
alone (15, 19, 36-40). Furthermore, most of the literature does group men’s and women’s folate
status and intake together despite clear gender-based differences in the dietary patterns of the two
genders while following the GFD (18, 36). Therefore, this scoping review will be the first of its kind to
examine the effect of the GFD with a specific focus on women’s folate intake and status with
consideration of reproductive health and public health policy.
The scoping review method was chosen to investigate the folate intake and status of women
following a GFD as it is ideal for investigating research topics which have not been studied in depth,
like this topic (41). Furthermore, due to the lack of studies on this research topic and the fact that
the published data is heterogenous and complex, it will be important to first identify and map what
body of evidence is available and scoping reviews are ideal for this purpose (41). Additionally,
scoping reviews are informed by peer-reviewed and non-peer-reviewed material to ensure high
search sensitivity in a context of limited evidence (41). This relates well to the chosen research topic
as there is a limited availability of peer-reviewed evidence and some relevant grey literature does
exist on the topic which would be remiss to be excluded. Finally, an in-depth analysis and quality
appraisal of sources are generally not a characteristic of scoping reviews due to their utilisation in
emerging research fields without extensive and/or reliable data available (41). As the preliminary
search provided only a small body of evidence around this research topic, it was determined that an
in-depth methodological analysis and bias assessment of the data would not be possible and thus
the scoping review method was deemed more suitable than other types of reviews.
The aim of this scoping review is to 1) identify and map the international evidence on the folate
status and intake of women following the GFD, and 2) compare the reported values against
established reference ranges and recommended intake values.
Review questions
1. What is the scope and depth of evidence internationally reporting on folate status and
folate intake of women following a GFD?
2. What are the reported folate status and folate intake values of women following a GFD
and are these adequate in relation to established reference values and recommended
intake values?
Inclusion criteria
The inclusion criteria will be based on participants, concept, context and different types of sources as detailed below.
Participants
Sources to be included in this scoping review must meet two participant-related criteria: 1) following
a GFD, and 2) females aged ≥ 18 years of age. Sources excluded are those investigating only men
following a GFD or studies that do not provide disaggregated data across sex, age group or life stage
(i.e., children, adolescents, WRA, pregnant etc). Furthermore, any studies or materials which
investigate non-human participants or topics will be excluded from this scoping review.
Concept
In addition to fulfilling the participant criteria, sources must investigate one or both of the following
criteria: 1) participant dietary folate intake or 2) participant folate status. Folate status measures can
include any relevant folate status tests including serum folate or red blood cell (erythrocyte) folate
(42). Dietary intake is inclusive of reported quantification of folate from natural dietary sources and
folic acid from fortified products and supplementation. Experimental studies without a control group
following a habitual GFD will be excluded unless baseline folate status or intake measures are
recorded prior to the intervention period.
Context
This scoping review will review data at the international level, from all settings and from any point in
time. Therefore, no context-specific restrictions have been set regarding geographical location,
cultural factors or the type of study setting.
Types of sources
This scoping review will include both observational and experimental studies of any research design.
Published as well as ongoing or unpublished evidence will be considered where relevant if the data is
able to be adequately sourced. Grey literature such as dissertations and theses, conference
materials (including conference papers and proceedings), clinical trials and any reports or other
relevant publications will also be included. Reviews will be included if the data is relevant to this
scoping review. No date restriction will be applied to allow for a view overtime of the available
evidence. Finally, no language restriction will be applied to the search and non-English sources will
be translated were feasible.
Methods
The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI)
methodology for scoping reviews (41).
Search strategy
A three-step search strategy will be utilized in this review. First an initial preliminary search was
conducted in CINAHL Ultimate to identify relevant articles on the topic. This initial search used
several search terms established using the PCC (‘population’, ‘concept’ and ‘context’) mnemonic
recommended for scoping reviews and based on the research questions (41). The titles, abstracts,
index terms and some of the full texts of relevant studies were examined to generate additional
search terms. This enabled the refinement of the PCC mnemonic, condensing of the search terms
and the development of the full search strategy (41).
The full search strategy (refer to Appendix I) will be used to locate peer-reviewed sources and
reviews in PubMed, CINAHL Ultimate and Scopus. Additionally, the search will be conducted in
ProQuest, Cochrane Library, Clinical Trials Gov and Google Scholar to further locate sources including grey literature. Minor changes to the full search strategy will be necessary to adapt accordingly to
the requirements of each database. Any relevant incomplete, partially published or full-text not
available sources will be sourced where possible by utilizing interlibrary requests or by contacting
the corresponding author. Finally, the backwards citation searching of included sources will be
conducted to check for missed citations.
Study/Source of evidence selection
After the full search has been completed, all identified citations will be collated and uploaded
into Endnote version 21 (Clarivate Analytics, PA, USA). Duplicates will be removed first through
Endnote’s ‘find duplicates’ function and then manually by title and author. After deduplication, all
remaining sources will be imported into the JBI System for the Unified Management, Assessment
and Review of Information (JBI SUMARI) (JBI, Adelaide, Australia) (43).
Titles and abstracts will then be screened by two independent reviewers for assessment against the
inclusion criteria. The remaining sources will have their full text retrieved and imported into JBI
SUMARI. At full text screening, each source will be assessed in detail against the inclusion criteria by
two or more independent reviewers. Sources which meet the inclusion criteria after full text
screening will be used in the final scoping review. The details for exclusion of any sources will be
recorded and reported in the scoping review. Any disagreements regarding inclusion or exclusion of
sources between the reviewers will be resolved through a discussion between the researchers. A
backwards citation search of the included sources will be undertaken with suitable sources sought
for full text review.
The results of the full search, deduplication, title and abstract screening, full text screening and
backwards citation searching and related screening will be reported in full in the final scoping review
and presented in a PRISMA flow diagram (44).
Data extraction
The research team identified the study characteristics and data to be obtained from the sources to
answer the research questions. A data extraction form was then created and piloted using the full
texts of three studies which were identified as highly relevant for this scoping review (18, 39, 45).
Modifications were made to the original data extraction form during piloting to ensure that the data
required to answer the research questions would be adequately captured. The data extraction form
will obtain the following data:
• Source characteristics: including title, authors, year of publication, key words, name of
journal (if applicable), publishing language, correspondence information, years of data
collection (if applicable), country in which the study was conducted, study type or grey
literature type, aim and/or purpose, funding, conflicts of interest and research methodology.
• Sample characteristics: including sample size, sample recruitment details, sample
demographics (including age of participants, participant population, presence of Coeliac
disease and diagnostic methodology (if relevant), length of time on a GFD and details related
to GFD adherence) and participant inclusion and exclusion criteria.
• Research findings and analysis: including details around which data was included in the
analysis, findings related to folate intake and/or folate status data, data related to folate
intake recommendations (if applicable), data related to folate status reference ranges (if
applicable).
• Potential confounders and study strengths and limitations.
For any sources that do not adequately provide the information required to be obtained for this
scoping review (for example, number of participants in the sample or folate status reference ranges),
the authors will be contacted to obtain the missing information.
The data extraction form is shown in Appendix II and will be modified and reviewed throughout the
data extraction process where required. Any modifications made to the extraction form during data
extraction will be detailed in the scoping review.
Data analysis and presentation
The data extracted from the sources will be analysed to identify key patterns and differences.
Dominant trends, outliers and gaps in the evidence will also be identified. If required, folate intake
recommendations or folate status reference ranges may be sought from the relevant bodies to
enable a comparison between the data contained within the sources and the recommendations. The
analysis will enable an overview of the body of evidence, the data around folate intake or status
contained within the body of evidence and how this relates to folate status or intake
recommendations.
The findings of this scoping review will be presented both graphically and in tabular form. In addition
to this, the results will be presented in a thesis format and this will include a narrative description of
the findings and how the findings of this scoping review relate to the objectives and research
questions. There will be three specific areas of discussion including characteristics and mapping of
the body of evidence, data located within the body of evidence and finally a discussion of how the
data found relates to folate intake and status recommendations.
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Acknowledgements
This scoping review will contribute toward DP’s Masters of Public Health thesis. DP, KG and RT contributed to the conceptualization of this scoping review. DP created and finalised the search strategy with inputs from KG and RT. DP will conduct the full search, obtain the sources and conduct deduplication. DP and KG will contribute to the title and abstract screening and all authors will contribute to full text screening. DP will extract the data from the sources and perform the analysis with supervision from KG and RT. DP will write the thesis in which the narrative description and graphic and tabular presentation of the data will be contained within. KG and RT will provide critical guidance and feedback during the thesis writing stage.
Special thanks to Ingrid Freshwater of Charles Darwin University’s library who provided guidance in the early stages of the search strategy formulation.
No funding was used for this project and there are no conflicts of interest.