Folate deficiency: risk factors, consequences & testing

As a Nutritional Therapy Practitioner and an AIP Certified Coach, folate deficiency — a deficiency in vitamin B9 — is one of the most common nutritional deficiencies I see in my practice. It’s most common among clients with malabsorption issues — including those with celiac disease and inflammatory bowel disease (IBD) — and often occurs alongside other nutrient deficiencies such as iron deficiency with or without anaemia. 

The reason for this is individuals with celiac disease, IBD, and other malabsorptive conditions absorb fewer vitamins and minerals from the food they eat. This increases their risk of developing deficiencies in one or more nutrients such as folate, vitamin B12, vitamin D, iron, calcium, magnesium, iodine, and zinc. In fact, between 20 and 60 per cent of IBD patients have low folate levels and up to 85 per cent of adults with celiac disease may have a folate deficiency. 

In this blog, we’ll look at some other potential risk factors for folate deficiency and discuss what you can do if you suspect your folate levels may be low. 

Sources of dietary folate

Aside from those with malabsorption issues such as celiac disease and IBD, inadequate folate status is relatively rare (but still possible) in countries that fortify foods with folic acid (synthetic folate). Examples of these foods include grain products, fortified cereals, and some fruit juices. Gluten-free grain products, however, are less likely to be fortified with folate and other nutrients.  

Folate is also found naturally in many whole foods such as fruits, vegetables, legumes, nuts, and animal foods including beef liver. Just 85 grams of braised beef liver provides 215 micrograms of dietary folate: about 54 per cent of the daily value for adults! 

Even vegetarians and vegans can get enough natural folate from whole food sources, as other high-folate foods include spinach, asparagus, brussels sprouts, lentils, and pinto beans. One cup of raw spinach provides about 58 micrograms of dietary folate, while a cup of boiled lentils provides about 358 micrograms of natural folate. 

What about folic acid supplements?

Many supplements provide folate in either the synthetic form, folic acid, or the biologically active form, methylfolate. Both are generally more bioavailable than folate from food sources, but methylfolate has an advantage: it doesn’t require conversion to be absorbed by the body. In contrast, folic acid must be converted to its active form, a process that can be slow and inefficient for some people, leading to a buildup of unmetabolized folic acid in the bloodstream, which may increase cancer risk. Additionally, for individuals with MTHFR gene mutations, the methylated form of folate is often more effective at raising folate levels.

That said, keep in mind that high doses of folic acid supplements can lead to negative health consequences such as immune dysfunction, cognitive impairment, and an increased risk of colorectal cancer. Excess folate from high-dose folic acid supplements can also mask and exacerbate symptoms of a vitamin B12 deficiency, potentially leading to irreversible neurological damage. 

Before supplementing with folate, I recommend testing your folate and B12 levels. Book your free inquiry call to learn more about functional nutrition testing. 

Importance of folate among reproductive-age women

Despite the increase in folic acid fortification, research suggests that folate insufficiency is still prevalent among reproductive-age women. One study found that 17 per cent of women aged 19 to 30 weren’t meeting their recommended daily allowance (RDA) for folate, in addition to 19 per cent of women aged 14 to 18. The study looked at folate intake from all sources, including diet and supplements. 

Because of folate’s role in foetal growth and development, reproductive-age women who are capable of becoming pregnant must ensure they’re getting enough folate from food and/or supplements — even if they don’t plan on becoming pregnant. Adequate folate status — especially during the first trimester of pregnancy — is needed to support foetal development and prevent neural tube defects, congenital anomalies, premature labour, and other pregnancy complications. 

Maintaining adequate folate levels during pregnancy can also prevent megaloblastic anaemia, a type of anaemia that develops as a result of deficiencies in vitamin B9 or vitamin B12. Megaloblastic anaemia is not the same as iron deficiency anaemia but can cause similar symptoms.

The recommended dietary allowance (RDA) for reproductive-age women is:

• 400 micrograms of folate (or folic acid) daily. 
• 600 micrograms of folate (or folic acid) daily during pregnancy.
• 500 micrograms of folate (or folic acid) daily while breastfeeding.

Other benefits of B9 (folate) adequacy

Of course, folate is essential outside of pregnancy as well. It plays a role in producing DNA and RNA, metabolising amino acids, regulating homocysteine levels, supporting cardiovascular health, and producing haemoglobin. Its role in forming haemoglobin means that low folate levels can cause megaloblastic anaemia (folate-deficiency anaemia). 

Folate sufficiency seems to support thyroid function as well, as folate deficiency has been shown to increase thyroid-stimulating hormone (TSH) levels and elevate thyroid antibodies: two risk factors for hypothyroidism. Adequate folate intake may also reduce the risk of cancer, stroke, and depression — though excess folic acid from supplements can be harmful.

Additional factors that affect folate status

Those with other autoimmune diseases such as rheumatoid arthritis (RA) and type 1 diabetes may have an increased risk of folate deficiency as well. This is because increased intestinal permeability (leaky gut) is shown to precede autoimmunity — and leaky gut can impair nutrient absorption and increase the risk of nutritional deficiencies. 

Furthermore, some medications used to treat autoimmune diseases deplete folate levels and can lead to a deficiency. For example, methotrexate — a drug used to treat RA — has been shown to interfere with the metabolism of folate.

Other factors that increase the risk of folate deficiency include smoking, excess alcohol consumption, MTHFR gene variants, overcooking fruits and vegetables, and eating a poorly balanced diet that lacks dietary folate in its natural or synthetic form (folic acid). 

Should you take a folate supplement?

Depending on your specific situation, folate supplementation may be recommended — especially if you’re hoping to become pregnant or you have celiac disease, IBD, or another condition that impairs nutrient absorption. Supplementation may also be needed if you’re having trouble getting enough folate from food sources alone.

Several folate deficiency symptoms to watch for include:

• Severe fatigue.
• Weakness.
• Shortness of breath.
• Mouth sores.
• Memory loss.
• Concentration issues. 
• Depression.
• Weight loss.

Potential signs that may point to a folate deficiency or insufficiency include megaloblastic anaemia, elevated homocysteine levels, and low serum folate levels. Some research suggests that serum folate levels should be at least 13 ng/mL to prevent neural tube defects. 

Test your vitamin B9 and B12 levels before supplementing with folate

Keep in mind that differentiating between low levels of vitamin B12 and folate can be challenging since the two nutrient insufficiencies share many of the same symptoms. For example, both deficiencies can also cause megaloblastic anaemia, a type of anaemia that causes symptoms like fatigue, shortness of breath, and weakness. 

Because of their shared symptoms and close relationship, it’s best to test B12 and folate levels before supplementing when either type of deficiency is suspected. Some functional lab tests can be ordered through me, while others may be ordered through your GP. 

Book your nutritional therapy appointment

If you suspect you could be dealing with one or more nutrient deficiencies, nutritional therapy can help. Book your free 20-minute inquiry call to get started!