Dr. Axe > Nutrition > Vitamins & Minerals

9 Signs of Folate Deficiency & How to Reverse It

November 4, 2017

Folate, also known vitamin B9, is one of many essential vitamins needed for copying and synthesizing DNA, producing new cells, and supporting nerve and immune functions. As a water-soluble B vitamin, it’s naturally present in some foods, added to others and available as a dietary supplement in the form of folic acid.

Studies show that a diet high in folate-rich foods can help prevent cancer, heart disease, birth defects, anemia and cognitive decline. Are you getting enough folate from your diet?

Symptoms of Folate Deficiency

Folate deficiency can be a serious problem, although in most developed nations it’s not nearly as common of a nutrient deficiency as some others. According to USDA analyses of data in 2006, the National Health and Nutrition Examination Survey found that most people in the United States obtain adequate amounts of folate, although some groups are still at risk of obtaining insufficient amounts.

Mean dietary intakes of folate (including food folate and folic acid from fortified foods and supplements) range from 454 to 652 micrograms per day in U.S. adults and from 385 to 674 micrograms in children. Keep in mind that adults need about 400 micrograms daily, and children need roughly 300 micrograms.

Here are nine common signs that you might be suffering from a folate deficiency:

Poor immune function; frequently getting sick
Chronic low energy (including chronic fatigue syndrome)
Poor digestion; issues like constipation, bloating and IBS
Developmental problems during pregnancy and infancy, including stunted growth
Anemia
Canker sores in the mouth and a tender, swollen tongue
Changes in mood, including irritability
Pale skin
Premature hair graying

Keep in mind that some people are at higher risks of experiencing folate deficiency than others. Groups who should be particularly careful to get enough folate naturally from their diets include:

Pregnant women or women looking to become pregnant
Breast-feeding mothers
Alcoholics
Anyone with liver disease
Anyone on kidney dialysis
Anyone taking medications for diabetes
Those frequently using diuretics or laxatives
Anyone taking methotrexate

How to Prevent Folate Deficiency: Recommended Daily Intakes

Folate is largely found in plant foods, so the best way to get adequate folate and prevent folate deficiency is to eat five or more servings of whole foods like fruits and vegetables daily. Green vegetables (nutritious Brussel sprouts, broccoli and peas, for example), especially all types of leafy greens, along with beans and citrus fruits are particularly important for preventing folate deficiency. Folate is also naturally found in some animal products, including liver and poultry.

Generally speaking, it should be pretty easy to prevent folate deficiency by eating a well-balanced diet. But studies have shown that folate absorption varies widely from person to person. There are several factors that influence how much folate someone can absorb from the foods they eat, including their levels of zinc and health of their kidneys, liver and gut.

The total body content of folate is estimated to be 10 to 30 milligrams, about half of which is stored in the liver. The remainder is found in the blood and body tissues. To test for folate deficiency, a doctor might conduct a serum folate concentration test (a value above 3 nanograms (ng)/mL indicates deficiency). However, a more reliable approach is testing erythrocyte folate concentrations, which provides a longer-term measure of folate intakes and is a better indicator of stored folate within tissues.

According to the National Institute of Health, the recommended dietary allowances (RDAs) for folate are as follows:

Infants and babies: 65 micrograms/day
Children ages 1–8: 80–150 micrograms/day
Teens ages 8–13: 300 micrograms/day
Adult men and women (above age 14): 400 micrograms/day
Pregnant women: 600 micrograms/day (which is about 50 percent higher than the non-pregnant women’s recommendation)
Women who are breast-feeding: 500 micrograms/day

Folate vs. Folic Acid: An Important Difference!

Let’s talk about folate vs. folic acid — do you know the difference between the two?

It’s estimated that about 35 percent of adults and 28 percent of all children in the United States use supplements containing folic acid. Folate and folic acid are usually used interchangeably, but they definitely have some noteworthy differences. While folate is a naturally occurring and essential vitamin, folic acid is a synthetic B vitamin found in supplements and fortified foods.

Folate is easily and naturally absorbed and utilized by the body when it’s metabolized in the small intestines. On the other hand, folic acid — which was only first introduced around the 1940s — requires the presence of a specific enzyme named dihydrofolate reductase, which is relatively rare in the body.

What’s the harm in supplementing with folic acid? Because many of us, particularly women who are of “child-bearing age,” cannot metabolize folic acid well, elevated levels of unmetabolized folic acid enter and remain in the bloodstream. Side effects of folic acid remaining in the body include changes in sex hormones, trouble concentrating, inability to sleep, mood changes and deficiencies in certain nutrients like vitamin B12.

High levels of lingering folic acid in the blood is even tied to cancer development, according to some research. Several studies have found a link between supplementing with high levels of folic acid or obtaining it from fortified foods (like cereal grains, breads, etc.) in fostering the growth of pre-cancerous cells and tumors.

This is definitely unfortunate considering folic acid remains on the FDA’s list of mandatory food fortifications first developed in 1998. According to the U.S Department of Health and Human Services, in 1998 the FDA began requiring food manufacturers to add folic acid to enriched grain products — including all breads, cereals, flours, cornmeals, pastas, rice and other packaged goods. Other countries, including Canada, Costa Rica, Chile and South Africa, have also established mandatory folic acid fortification programs. The FDA’s fortification program was projected to increase folic acid intakes in the average American’s diet by approximately 100 micrograms/day, but the program actually increased mean folic acid intakes by almost double this amount — about 190 micrograms/day.

The USDA clams that there is a higher level of bioavailability of folic acid than that of food-found folate. At least 85 percent of folic acid is estimated to be bioavailable when taken with food, whereas only about 50 percent of folate naturally present in food is bioavailable. There are pros and cons to this, because it means folic acid can easily remain elevated, but it also might help prevent certain symptoms of deficiency.

6 Health Benefits of Folate

1. Supports a Healthy Pregnancy

Folate is known to be one of the most critical vitamins for a healthy and vibrant pregnancy, which is why it’s added synthetically to nearly all prenatal vitamins. For pregnant women, a folate deficiency is especially risky because it can potentially lead to neural tube defects, including spina bifida, anencephaly, malformations of the limbs and heart complications.

Spina bifida is a defect of the fetus’s spine in which part of the spinal cord and its meninges are exposed through a gap in the underdeveloped backbone. Anencephaly is the absence of a major portion of the fetus’s brain, skull and scalp that occurs during embryonic development early into pregnancies. Folic acid supplementation has been shown to lengthen mean gestational age of the fetus and lower the risk of preterm births (although it comes with other risks).

Folate functions as a coenzyme (or cosubstrate) in single-carbon transfers in the synthesis of nucleic acids (DNA and RNA) and metabolism of amino acids. Because folate is needed for DNA copying and building new cells, you can see why low levels result in various types of developmental issues, even some that remain an issue once the baby is born and continuing to grow.

In order to prevent neural tube defects, the FDA supplements many processed grains with folic acid, knowing that grain products make up a large percentage of the average American’s diet. According to the FDA, the recommended daily value in order to prevent folate deficiency is set at 400 micrograms and 600 micrograms for pregnant women, however, we know that obtaining this level from synthetic folic acid is not as beneficial as getting natural folate from folate-rich foods. Some superfoods for a healthy pregnancy that provide folate include leafy greens, sprouted beans, avocados and citrus.

2. Helps the Body Utilize Iron, Vitamin B12 and Amino Acids

A folate deficiency can contribute to anemia, which is a condition that develops when red blood cells are improperly formed. An important folate-dependent reaction in the body is the conversion of the methylation of deoxyuridylate to thymidylate in the formation of DNA, which is required for proper cell division. When this process is impaired, this initiates megaloblastic anemia, one of the hallmarks of folate deficiency.

Folate also helps vitamn B12 to be absorbed, so some experts are therefore concerned that high folic acid intakes might “mask” vitamin B12 deficiency until its neurological consequences become irreversible. Vitamin B12 benefits the body in many ways, including helping with nutrient absorption, energy expenditure and brain function — therefore, undiagnosed deficiency can be very risky.

3. Might Help Prevent Cancer

Low blood folate levels are associated with an increased risk of cervical, breast, colon, brain and lung cancer. Epidemiologic evidence generally indicates that a high intake of folate-rich foods offers protection against the development of some common cancers, but the relationship between folic acid and cancer is complicated, as you’ve learned.

In the NIH-AARP Diet and Health Study, a cohort study of more than 525,000 people aged 50 to 71 years in the U.S., individuals with total folate intakes of 900 micrograms/day or higher had a 30 percent lower risk of developing colorectal cancer than those with intakes less than 200 micrograms/day.

On the other hand, observations in animal and human studies demonstrate that an overly abundant intake of folate among those who harbor existing foci of neoplasia might do the opposite and raise risk of certain cancers. The pharmaceutical form of the vitamin is distinct from natural forms of the vitamin and, therefore, the most protection comes from eating real foods!

4. Supports Heart Health

Just like other B vitamins, folate plays an important role in reducing high levels of homocysteine in the blood. Homocysteine is a compound that has been linked to an increased risk of heart attacks and strokes when it lingers in the blood.

Homocysteine is an amino acid (the building blocks of proteins). It’s not possible to get homocysteine from the diet — instead, it must be made internally from methionine, another amino acid that is found in meat, fish and dairy products. Vitamins B6, B12 and folate are needed to make this reaction occur.

One of the most important folate-dependent reactions in the body is the conversion of homocysteine to methionine that occurs during the synthesis of important methyl donors. This helps normalize homocysteine levels and plays a positive role in the process of metabolizing minerals and antioxidant activities.

Generally, studies show that people who consume higher levels of folate have a lower risk of cardiovascular disease than those who have a lower intake. Although folic acid (and vitamin B12) supplements can lower homocysteine levels, research indicates that these supplements do not actually decrease the risk of cardiovascular disease, although they might provide protection from stroke.

Since we know that a diet high in plant foods like vegetables and fruits can help lower heart disease risk, this seems like the safest way to obtain folate and also benefit cardiovascular health.

5. Protects Cognitive Function and Might Help Prevent Dementia and Alzheimer’s

Most observational studies show a relationship between elevated homocysteine levels and a greater risk for Alzheimer’s disease and dementia. Some observational studies have also found correlations between low folate concentrations and poor cognitive function.

However, even though increasing folic acid through supplementing can help reduce homocysteine concentrations, this hasn’t been shown to improve cognitive function and prevent disease. A better natural Alzheimer’s treatment is to focus on obtaining plenty of nutrients, including natural folate from a variety of unprocessed whole foods.

6. Can Help Prevent Depression

While folate alone might not prevent depression, it appears that a balanced diet with plenty of veggies and plant foods might act like a natural remedy for depression. In clinical and observational studies, folate status has been linked to depression and poor response to antidepressants. In study involving 2,948 people aged 1 to 39 years in the U.S., folate concentrations were significantly lower in individuals with major depression than in those who had never been depressed.

Results from a study of 52 men and women with major depressive disorder showed that only one of 14 subjects with low folate levels responded to antidepressant treatment compared with 17 of 38 subjects with normal folate levels.

Top 12 Folate Food Sources

Increasing your intake of natural folate-rich foods is the best way to protect yourself from deficiency along with complications of folic acid supplementation. The USDA lists the following folate levels found in natural foods:

1. Spinach — 1 cup cooked: 262 mcg (66 percent DV)

2. Beef Liver — 3 oz: 215 mcg (54 percent DV)

3. Black Eyed Peas — 1 cup cooked: 210 mcg (52 percent DV)

4. Asparagus — 8 spears: 178 mcg (44 percent DV)

5. Broccoli — 1 cup cooked: 104 mcg (26 percent DV)

6. Brussel Sprouts— 1 cup cooked: 156 mcg (40 percent DV)

7. Mustard Greens— 1 cup cooked: 104 mcg (26 percent DV)

8. Kidney Beans — 92 mcg (24 percent DV)

9. Romaine Lettuce — 1 cup raw: 64 mg (16 percent DV)

10. Avocado — ½ cup: 59 mcg (15 percent DV)

11. Wheat Germ — 2 tablespoons: 40 mcg (10 percent DV)

12. Orange — 1 medium: 29 mcg (7 percent)

How to Add More Folate to Your Diet

Folate can be found naturally in these recipes that contain folate-rich foods, such as broccoli, spinach, beans and oranges.

Interactions and Side Effects of Folate

Folate from whole food sources doesn’t pose much of a risk, but folic acid supplements can interact with several medications and aggravate health conditions as mentioned earlier. Aside from posing a risk of cancer and autoimmune problems, anyone taking Methotrexate, a medication used to treat cancer and autoimmune diseases, is at risk for compilations when taking folic acid since this medication impacts folate absorbability.

Taking antiepileptic medications used to treat epilepsy or psychiatric diseases along with folic acid supplements might cause a reduction in serum levels of these medications. The same goes for medications like Sulfasalazine used primarily to treat ulcerative colitis.