What is Folic Acid Deficiency?
Folate is a vital vitamin that dissolves in water and is naturally found in certain foods, namely fruits, green leafy vegetables, and liver. Folic acid is the man-made version of folate found in enriched foods and supplements and is more easily used by the body than folate that naturally occurs in food. In the United States, folate is added to grains to prevent birth defects, particularly ones that affect the brain and spine. This is because folate plays a crucial role in the formation of various important substances in many of our body’s systems, especially for creating components of DNA and RNA, and helping to form and maintain red blood cells.
Like vitamin B12, folate helps to provide parts needed for the creation of DNA and RNA. The most effective form of folic acid is known as tetrahydrofolate. Recent studies show that a lack of folic acid can cause various health issues:
There might be a connection between high levels of a substance called homocysteine (which is a sign of an increased risk for hardening of the arteries) and a lack of folate. Lowering the levels of homocysteine with folic acid reduces the risk of stroke, but not heart-related problems. Women who take folic acid supplements during pregnancy have a lower chance of having a baby with brain or spine defects. Not having enough folic acid during pregnancy might increase the risk of birth defects in children of mothers with diabetes and autism. Taking folic acid during pregnancy may decrease the chance of the child developing leukemia. However, taking folic acid supplements might increase the risk of cancer.
What Causes Folic Acid Deficiency?
Folic acid deficiency can happen due to many reasons, one of which is not getting enough of it in your diet. Cooking food can destroy folic acid, a type of vitamin important for bodily functions. This vitamin is absorbed in a part of the small intestine called the jejunum.
Various illnesses like celiac disease, tropical sprue, short bowel syndrome, amyloidosis, gastric bypass surgery, or problems with blood vessels supplying the small intestine can hinder the body’s ability to absorb folate. This could lead to a shortage of the vitamin. Also, a higher than normal pH level in the stomach, which may happen in a condition called achlorhydria, can make it hard for the body to absorb folate.
There are certain medications including methotrexate, phenytoin, sulfasalazine, and trimethoprim that can interfere with how folic acid is absorbed or processed in the body, resulting in a shortage. Sometimes, people are born with a lack of certain enzymes needed to process folate, leading to its deficiency.
A vitamin B-12 deficiency can also set off a folic acid deficiency. This is because vitamin B-12 is needed for an enzyme called methionine synthase, which is important for using folic acid properly. If there’s not enough vitamin B-12, folic acid can get trapped in a form called methyltetrahydrofolate and it starts to build up in the bloodstream, which leads to increased excretion of folate in urine. This is known as the ‘folate trap’.
Excessive drinking of alcohol can also lead to folic acid deficiency. Other circumstances such as pregnancy, hemolytic anemia (where red blood cells are destroyed faster than they can be made), and dialysis (a treatment for kidney failure) can also result in a shortage of folic acid.
Risk Factors and Frequency for Folic Acid Deficiency
The National Health and Nutrition Examination Survey (NHANES) study found that women of childbearing age and non-black Hispanic women are more likely to have insufficient levels of folic acid, which can lead to a deficiency. This is generally because of not consuming enough folic acid in their diet.
Due to the risk of folic acid deficiency, many developed countries now require flour to be fortified with folic acid. Additionally, in most European countries, folic acid supplements are recommended before and during the early months of pregnancy.
But it’s not only women of childbearing age who can be at risk. People with low social-economic status and older people living in care facilities can also face an increased chance of folic acid deficiency. The contributing factors include not eating enough green leafy vegetables, malnutrition, and changes in mental status.
Interestingly, recent observations have shown that consuming too much folate may increase the risk of developing malignancies.
Signs and Symptoms of Folic Acid Deficiency
When a patient has a deficiency, some clues from their personal and medical history may help identify why this is happening. This can include their diet, any medications they are taking, and how much alcohol they drink. Certain conditions like pregnancy, breastfeeding, hemolytic anemia, and some skin disorders could increase the body’s need for nutrients. Also, some medications like methotrexate, phenytoin, and trimethoprim can cause a deficiency in folate. These symptoms are often similar to vitamin B-12 deficiency, but B-12 deficiency also includes specific neurological symptoms.
During a physical exam, signs like a painful, bright red tongue and anorexia might be noticeable. The neurological exam may find issues like mental impairment, depression, and dementia.
- Dietary history
- Medication history
- Alcohol consumption
- Pregnancy or breastfeeding
- Hemolytic anemia or certain skin disorders
- Painful, bright red tongue
- Signs of anorexia
- Mental impairment, depression, or dementia
Testing for Folic Acid Deficiency
If your doctor suspects that you might be lacking in folic acid, they will also check for a deficiency in vitamin B12. This is because both can lead to a certain type of anemia called macrocytic anemia, which involves having larger-than-normal red blood cells.
To investigate this, your doctor will initially conduct a series of blood tests which include a complete blood count (CBC) and a peripheral smear (PS). The CBC helps to quantify the blood cells in your body, while the PS gives a visual representation of the cells themselves.
If you have a folic acid deficiency, the tests would typically reveal low levels of hemoglobin and hematocrit – both important components of your red blood cells. This condition is also known as anemia. An abnormal increase in the size of your red blood cells, known as ‘Mean Corpuscular Volume’ (MCV), would also suggest anemia. In addition, the peripheral smear may show large red blood cells, referred to as macrocytes or megaloblasts, and white blood cells with too many lobes, called hypersegmented neutrophils.
Additionally, the doctor might order tests to measure the levels of vitamin B12 and folic acid (also known as folate) in your blood to help differentiate between the two deficiencies. Folate levels below 2 ng/mL generally point to a deficiency, while levels above 4 ng/mL are considered normal. If your folate levels are in the range of 2 to 4 ng/mL, further tests may be ordered to measure the levels of two substances called methylmalonic acid (MMA) and homocysteine in your blood. Elevated homocysteine levels coupled with normal B12 and MMA readings confirm a folate deficiency, whereas low B12 levels alongside high MMA and homocysteine readings suggest a B12 deficiency.
The folate level in your red blood cells can also provide useful information about the body’s folate stores and how long the deficiency has been there. In general, a bone marrow test is not necessary for assessing vitamin B12 or folate deficiency, but if performed for other reasons, this test could show an increase in the number and size of red blood cells, a condition known as megaloblastic erythroid hyperplasia.
Once the underlying cause of the folic acid deficiency is found and addressed, future deficiencies can be prevented.
Treatment Options for Folic Acid Deficiency
People with a folate deficiency should consider taking folic acid to help correct this problem. Normally, folic acid can be taken orally, with doses varying from 1 to 5 mg per day. However, if you have trouble with oral medications, you can look into forms of the supplement that can be injected either via an intravenous line, under the skin, or into a muscle.
Folinic acid, a particular type of folate, is mainly used to counter the side effects of a drug called methotrexate. How long you will need to take the supplement depends on the root cause of your deficiency. For instance, people with conditions such as malabsorption or short gut syndrome, which affect the body’s ability to absorb nutrients, may need to take folic acid for a long time.
Worth noting that if you have a vitamin B12 deficiency along with the folate deficiency, it is crucially important to also include more of this vitamin in your treatment plan. Just taking folic acid won’t improve any neurological symptoms caused by vitamin B12 deficiency, which, if left untreated, can progress and potentially cause permanent neurological damage.
You should also try to maintain a diet that’s rich in fruits and vegetables as they are good natural sources of these important vitamins.
What else can Folic Acid Deficiency be?
Conditions such as a deficiency in vitamin B12, alcoholic liver disease, underactive thyroid (hypothyroidism), and a condition where your body stops producing new blood cells (aplastic anemia) can all lead to health problems.
What to expect with Folic Acid Deficiency
The outlook is generally good when treating a folic acid deficiency. Most physical symptoms and results from medical tests indicating the deficiency are likely to improve. However, if you don’t have enough folic acid, you can develop a condition called macrocytic anemia, which is when your body produces fewer and larger than normal red blood cells.
A lack of folic acid also increases the level of homocysteine in the body. High levels of homocysteine are linked to a disease called atherosclerosis, which is the hardening and narrowing of the arteries.
If you’re pregnant and don’t have enough folic acid, it can cause various issues including complications with the placenta, miscarriages, birth defects in the baby’s brain and spine known as neural tube defects, and severe speech and language problems in the child as they grow.
Possible Complications When Diagnosed with Folic Acid Deficiency
Not treating a folic acid deficiency can result in larger than normal red blood cells, a condition known as megaloblastic anemia. It can also lead to a decrease in the number of all types of blood cells, a condition referred to as pancytopenia. Other physical effects can include inflammation of the tongue, sores in the corners of the mouth, and mouth ulcers.
Certain emotional and mental health conditions can also be triggered by a folic acid deficiency. These could range from mood disorders such as depression and irritability, to difficulty sleeping, mental decline, feelings of extreme tiredness, and even mental conditions such as psychosis.
Common Effects:
- Megaloblastic anemia (overly large red blood cells)
- Pancytopenia (reduced number of all blood cells)
- Glossitis (inflammation of the tongue)
- Angular stomatitis (sores in the mouth corners)
- Oral ulcers (mouth sores)
- Depression
- Irritability
- Insomnia
- Cognitive decline
- Fatigue
- Psychosis
Preventing Folic Acid Deficiency
People with a lack of folic acid – a type of vitamin that is critical for our bodies to function properly – should start including more green leafy vegetables and fruits in their diet. Taking a supplement with 1mg of folic acid every day can generally help to prevent a deficiency, especially for those who might be at higher risk. This includes people who’ve had weight-loss surgery, those suffering from malnutrition, chronic alcohol users, people with a condition that breaks down red blood cells too quickly (chronic hemolytic anemia), and conditions with high cell turnover.
It’s important for women who can become pregnant to also eat foods rich in folic acid and to take at least 0.4 mg of a supplemental folic acid daily. This can help to prevent complications during pregnancy and prevent the development of severe birth defects of the baby’s brain or spine, known as neural tube defects.
However, unless you fall into one of these specific categories, there’s generally no need for routine supplementation of folic acid. It’s always better to discuss with your doctor about your personal needs before starting on any supplements.
