Folate Deficiency: Symptoms, Causes, and Remedies

Dr. Group
by Dr. Edward Group DC, NP, DACBN, DCBCN, DABFM
Published on

Kale can help with folate deficiency.

If you’re feeling weak or like you have low energy, folate deficiency might be to blame. Folate is one of the essential B vitamins – B9 to be exact. This water-soluble vitamin is essential for making red blood cells and keeping levels of the amino acid homocysteine low. Lack of sufficient folate is linked to a variety of problems, including anemia, memory loss, bone fractures, and hearing loss. Folate is also critical for developing fetuses.

While folate is found in many foods, not everyone gets enough of it in their diets And even if they do, not everyone can absorb it due to issues like poor digestion (specifically malabsorption disorders). Or, they have a genetic problem that makes it harder to convert the dietary folate and supplemental folic acid that they do consume into a form their body can use.

Read on to learn more about the signs of folate deficiency, the health benefits of folate, common causes of folate deficiency, top folate-containing whole foods, and recommended doses of folic acid supplements.

Signs of Folate Deficiency

There are several common folate deficiency symptoms:

  • Fatigue and low energy
  • Hearing loss
  • Anemia
  • Shortness of breath
  • Memory loss
  • Pale skin

Fatigue & Low Energy

Do you ever feel tired or weak or have unexplained fatigue? Maybe you feel like your get up and go has got up and went away. Whatever the case, your energy reserves are low, and you’re not sure why. While there are many causes of low energy, it’s possible folate deficiency is to blame. That’s because fatigue is a common problem with anemia, and folate deficiency can cause anemia.

Hearing Loss

A 2010 study[1] found that age-related hearing loss is associated with significantly lower levels of folate in the blood. If you’re over the age of 60 and experiencing hearing loss without a clear medical diagnosis, it could be from a folate deficiency, which is common in older people.

Anemia

Anemia is a shortage of red blood cells in your body. Because red blood cells are responsible for transporting oxygen and energy to the cells throughout your body, anemia can make you feel tired and weak. Without sufficient red blood cells to carry oxygen through your body, you may feel short of breath – and your heart rate may go up as it tries to get more oxygen to your cells. Your hands and feet may feel cold, and your skin may be paler than normal.

Anemia can have many different causes. Internal bleeding, heavy menstruation, serious illnesses, and genetic diseases (such as sickle cell anemia) are all factors. But anemia is more commonly caused by nutritional deficiencies, particularly low iron, low B-12, and low folate.

Shortness of Breath

If you have trouble catching your breath, or if you feel winded after even mild exertion, the cause may be a folate deficiency. That’s because anemia, an aforementioned common problem in people with folate deficiencies, can lead to shortness of breath.

Memory Loss

Cognitive impairment, including poor memory and dementia, is associated with lower levels of folate in the blood, especially in older adults that need special care. A couple of small studies[2] have indicated that folic acid supplementation can lead to improvement in cognitive function for some patients.

Pale Skin

If your skin looks significantly paler than normal, you may have a folate deficiency. That’s because pale skin is a symptom of anemia, and anemia can be caused by folate deficiency.

If you are experiencing symptoms of folate deficiency, make sure you are getting adequate folate in your diet and consider taking a folic acid supplement to get the U.S. Recommended Daily Allowance (RDA) for this vitamin. If your symptoms persist, see your doctor.

Folate vs. Folic Acid

You may hear people talk about folate and folic acid. So what’s the difference? While folate and folic acid are both forms of the water-soluble vitamin B9, the difference is their source. Folate is the natural form of this vitamin. You get it by eating natural foods, especially nuts, green leafy vegetables (such as kale and spinach), and other fruits and vegetables.

By contrast, folic acid, also known as folacin, is the synthetic form of vitamin B9. Since 1998, the FDA has required food producers to fortify enriched cereal and flour with folic acid. Many brands of nutritional yeast are also fortified with folic acid. Food manufacturers use synthetic folic acid rather than the natural form of this vitamin, folate, because folic acid is less expensive and folate is not shelf-stable.

It is not necessary to eat fortified foods or take folic acid supplements to get enough vitamin B9. You can get enough folate through your regular diet alone, provided you follow a healthy, whole-food diet rich in fruit, vegetables, beans, and nuts.

Folate and Folic Acid Benefits

There are many health benefits to consuming sufficient folate and folic acid. Adequate amounts of this water-soluble B vitamin help your body produce new blood cells and reduce the risk of stroke in people with high blood pressure. Folic acid can also help promote bone health. During pregnancy, getting enough folate through a healthy diet or enough folic acid through supplements and fortified foods helps to protect your developing baby’s health and prevent certain birth defects.

Facilitates New Cell Production

Adequate folate doesn’t just enable your body to build more red blood cells, it’s also important for producing and maintaining all new cells in the body. That’s because folate is required for DNA replication (to copy DNA for new cells) and for the DNA within each cell to be used to create new proteins.

Promotes Normal Blood Pressure

In people with high blood pressure, adequate folic acid intake may help prevent strokes. A 2015 study published in the Journal of the American Medical Association[3] followed more than 20,000 adults with high blood pressure in China over 4.5 years. Those participants who received folic acid supplements, rather than a placebo, were less likely to have a stroke during that time.

Keep in mind, China doesn’t require folate fortification of grains the way the U.S. does, so it’s likely that the China-based study saw a more dramatic benefit due to the lower folate levels of people in the study. But these findings may be relevant to people in the U.S. who do not consume a lot of fortified grains, either because their main source of dietary carbohydrates is corn masa (which isn’t fortified) or because they are on a gluten-free diet due to celiac or other health issues.

Helps Healthy Development of Fetus During Pregnancy

Getting enough folic acid in pregnancy is critical to protecting the developing fetus from neural tube defects (NTDs). One type of NTD is spina bifida, where the neural tube of the spine doesn’t close completely. With the more severe forms of spina bifida, part of the infant’s spine is exposed at birth, and the child will experience minor to major disabilities. Other types of NTD affect the developing fetus’s brain and can lead to stillbirth (due to the failure of the brain to develop) or part of the infant’s brain being exposed at birth.

The good news is that women can help protect their developing babies by consuming enough folic acid before and during pregnancy. According to the CDC, since mandatory folic acid fortification of cereals and flours began, the percentage of infants in the U.S. who were born with a neural tube defect has fallen by 35 percent.[4]

While getting enough folic acid is important throughout a woman’s entire pregnancy, it’s especially critical during the early weeks, since NTDs can occur as early as three to four weeks into pregnancy. That’s why the CDC recommends that women of childbearing age consume at least 400 micrograms of folic acid, even when they’re not pregnant. By the time a woman finds out she’s pregnant and starts taking prenatal supplements, she may already be six weeks pregnant – or more.

At the very least, folic acid supplementation should begin at least one month before conception, to ensure that blood levels are adequate before conception.

Encourages a Healthy Heart

One marker for heart disease risk is the level of the amino acid homocysteine in the blood. Elevated levels of homocysteine can cause inflammation of the blood vessels, which can lead to a buildup of plaque in the arteries of the heart.

The body needs sufficient amounts of B vitamins – specifically, B6, B9 (folic acid) and B-12 – to convert homocysteine into methionine, an essential amino acid. While studies of those who already have heart disease showed no benefit from B vitamin supplementation, the Nurses’ Health Study[5] found that woman with no history of heart disease and high levels of dietary B6 and folate had a lower risk of heart disease.

Helps Protect Your Bones

Folate deficiency can lead to higher levels of the amino acid homocysteine. Elevated homocysteine levels can increase the rate of bone fractures.[6] Ensuring you get adequate folic acid through diet and supplements can bring down homocysteine levels, potentially protecting your bones.

What Causes Folate Deficiency

The most common cause of folate deficiency in the U.S. is eating too little of the foods that contain folate. But even people who are eating enough folate can still be at risk. Here are some common risk factors:

A Defect of the MTHFR Gene

Those with a common defect of the MTHFR gene have trouble converting both dietary folate and folic acid supplements into a form that can be used by the body. So even with sufficient intake, they are still deficient. People who have a genetic defect with their MTHFR gene should avoid taking folic acid supplements and instead speak with their healthcare provider about methylated folate.

Poor Digestion Due to a Malabsorption Disorder

A malabsorption disorder (like celiac disease) that prevents nutrients from being adequately absorbed into the blood from the small intestines can also cause folate deficiency, even in those who consume enough dietary folate or take folic acid supplements.

Alcoholism

Alcoholics are also more at risk of folate deficiency because long-term consumption of high amounts of alcohol can affect the digestive system’s ability to absorb nutrients. It can also cause more folate to be excreted in the urine. Plus, the long-term impact of alcohol on the liver makes it harder for the liver to take up and store folate, and roughly half of the body’s folate is typically stored in the liver.

Pregnancy and Breastfeeding

Pregnancy and breastfeeding can also lead to folate deficiency due to the increased demand for folic acid in women’s bodies during these times.

Medications

Finally, certain medications – including metformin (for diabetes) and birth control pills – can cause folate deficiency.

Top Foods High in Folate

  • Kale
  • Spinach
  • Collard greens
  • Lentils
  • Asparagus
  • Brussels sprouts
  • Nuts

It’s easy to get enough natural folate by following a well-balanced, whole food diets – especially if you eat some high-folate foods every day. It’s probably no surprise that nutrient-dense dark-green leafy vegetables, such as kale, are one of the best natural sources of folate. Just one cup of spinach contains 263 micrograms of folate – or 65 percent of the U.S. RDA. Collard greens come in a close second, with 177 micrograms or 44 percent of the U.S. RDA, for a one cup serving.

Legumes are also a great natural source of folate. Most beans contain between 200 and 300 micrograms of folate (50 percent to 75 percent of the U.S. RDA) per cup. When it comes to folate, though, lentils are the clear leaders – just one cup of lentils contains a whopping 358 micrograms of folate – or 90 percent of the U.S. RDA!

Other good sources of dietary folate include nuts, peas, citrus fruits, Brussels sprouts, avocados, asparagus, broccoli, corn, and carrots. It’s not just nuts, beans, fruits, and vegetables that are high in folate. Unexpected sources of natural folate include egg yolks and organ meats, such as liver and kidney.

How Much Folic Acid Should You Take?

Life Stage RDA
Infants birth-6 months 65 mcg
Infants 7-12 months 80 mcg
1–3 years 150 mcg
4–8 years 200 mcg
9–13 years 300 mcg
Individuals 14+ 400 mcg
Pregnant women 600 mcg
Breastfeeding women 500 mcg

The U.S. RDA for folic acid is 400 micrograms for adults, 600 micrograms for pregnant women and 500 micrograms for lactating women.[7] While most adults get enough folate in their diet and don’t need a supplement, the CDC recommends[8] that all women of childbearing age take 400 micrograms of folic acid daily to prevent birth defects, particularly spina bifida and anencephaly (where part of skull and brain are missing).

Supplementation is also recommended if you are not consuming a lot of folate-rich foods, if you have a malabsorption disorder that prevents you from adequately absorbing the folate you do eat or if you are taking medication that negatively impacts your folate stores.

Points to Remember

If you’re dealing with unexplained weakness and fatigue, shortness of breath, memory loss, or age-related hearing loss, it’s possible that folate deficiency is causing it. The best way to prevent a folic acid deficiency is to get enough folate in your diet by eating ample amounts of dark leafy greens and beans, and also nuts, citrus fruits, and other foods that are high in folate.

But diet alone may not be enough. If you have a defect in your MTHFR gene, you should consider taking methylated folate, which doesn’t require conversion to be used by your body. And if you are a woman of childbearing age, you should strongly consider taking a high-quality folic acid supplement, even if you’re not trying to conceive, to ensure you have adequate levels of folate in your blood to support a healthy pregnancy.

But the benefits of folic acid supplementation go beyond ensuring a healthy pregnancy. Adequate folate can help boost your energy and decrease your risk of having a stroke. It can also help protect your bones, hearing, and memory as you age.

References (8)
  1. Medpage Today. "Hearing Loss Linked to Folate, B12 Deficiencies." 2010.
  2. Reynolds EH. "Folic acid, ageing, depression, and dementia." BMJ 2002;324:1512.
  3. Corliss J. "Folic Acid, a B Vitamin, Lowers Stroke Risk in People with High Blood Pressure." Harvard Health Blog, 2016.
  4. "Folic Acid." Centers for Disease Control and Prevention. 2017.
  5. Rimm EB. "Folate and Vitamin B6 From Diet and Supplements in Relation to Risk of Coronary Heart Disease Among Women." JAMA Internal Medicine, American Medical Association, 1998.
  6. Swart KM, et al. "Vitamin B12, Folic Acid, and Bone." Advances in Pediatrics, U.S. National Library of Medicine. Sept. 2013.
  7. "Office of Dietary Supplements - Dietary Supplement Fact Sheet: Folate." NIH Office of Dietary Supplements, U.S. Department of Health and Human Services.
  8. "Folic Acid." Centers for Disease Control and Prevention. 2018.

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