Folate Deficiency

A deficiency of folate can occur when an increased need for folate is not matched by an increased intake, when dietary folate intake does not meet recommended needs, or when folate loss increases. Medications that interfere with the metabolism of folate may also increase the need for this vitamin and the risk of deficiency.

The following medical conditions increase the need for folate or result in increased loss of folate:

• Pregnancy and lactation (breastfeeding)
• Alcohol abuse
• Malabsorption
• Kidney dialysis
• Liver disease
• Certain anemias

The following medications interfere with folate utilization:

• Anticonvulsant medications (e.g., dilantin, phenytoin, primidone)
• Metformin (sometimes prescribed to control blood sugar in type 2 diabetes)
• Sulfasalazine (used to control inflammation associated with Crohn's disease and ulcerative colitis)
• Triamterene (a diuretic)
• Methotrexate (used for cancer and other diseases)
• Barbiturates (used as sedatives)

What are some common signs and symptoms of folate deficiency?

• Folate-deficient women who become pregnant are at greater risk of giving birth to babies with low birth weight, prematurity, and/or neural tube defects.
• In infants and children, folate deficiency can slow overall growth rate.
• In adults, a particular type of anemia can result from long-term folate deficiency.
• Other signs of folate deficiency are often subtle. Digestive disorders, such as diarrhea and loss of appetite and weight, can occur, as can weakness, sore tongue, headaches, heart palpitations, irritability, forgetfulness, and behavioral disorders. An elevated level of homocysteine in the blood, a risk factor for cardiovascular disease, can also result from folate deficiency.

Many of these subtle symptoms are nonspecific and can be caused by a variety of medical conditions other than folate deficiency. A physician must evaluate these symptoms so that appropriate medical care can be given.

Do women of childbearing age and pregnant women have a special need for folate?

Folic acid is very important for all women who may become pregnant. Adequate folate intake during the periconceptual period (the time just before and just after a woman becomes pregnant) protects against neural tube defects. Neural tube defects result in malformations of the spine (spina bifida), skull, and brain (anencephaly). The risk of neural tube defects is significantly reduced when supplemental folic acid is consumed in addition to a healthful diet prior to and during the first month following conception.

Since January 1, 1998, when the folate food fortification program took effect, data suggest that there has been a significant reduction in neural tube birth defects. Women who could become pregnant are advised to eat foods fortified with folic acid or take a folic acid supplement in addition to eating folate-rich foods to reduce the risk of some serious birth defects. For this population, researchers recommend a daily intake of 400 mcg of synthetic folic acid per day from fortified foods and/or dietary supplements .

Who else may need extra folic acid to prevent a deficiency?

People who abuse alcohol; those taking medications that may interfere with the action of folate (including, but not limited to those listed previously); individuals diagnosed with anemia from folate deficiency; and those with malabsorption, liver disease, or who are receiving kidney dialysis treatment may benefit from a folic acid supplement.

Folate deficiency has been observed in alcoholics. A 1997 review of the nutritional status of chronic alcoholics found low folate status in more than 50% of those surveyed. Alcohol interferes with the absorption of folate and increases the amount of folate the kidney gets rid of. In addition, many people who abuse alcohol have poor-quality diets that do not provide the recommended intake of folate. Increasing folate intake through diet, or folic acid intake through fortified foods or supplements, may improve the health of alcoholics.

Anticonvulsant medications such as dilantin increase the need for folate. Anyone taking anticonvulsants and other medications that interfere with the body's ability to use folate should consult with a physician about the need to take a folic acid supplement.

Anemia is a condition that occurs when there is insufficient hemoglobin in red blood cells to carry enough oxygen to cells and tissues. It can result from a wide variety of medical problems, including folate deficiency. With folate deficiency, your body may make large red blood cells that do not contain adequate hemoglobin, the substance in red blood cells that carries oxygen to your body's cells. Your physician can determine whether an anemia is associated with folate deficiency and whether supplemental folic acid is indicated.

Several medical conditions increase the risk of folic acid deficiency. Liver disease and kidney dialysis increase the loss of folic acid. Malabsorption can prevent your body from using folate in food. Physicians treating individuals with these disorders will evaluate the need for a folic acid supplement.