What Happens If You Do Not Have Enough Folate? A Guide to Deficiency

While uncommon in countries with fortified food programs, marginal folate status is still a concern, especially among women of childbearing age. Failing to get enough of this essential B vitamin can lead to a range of severe health problems, some of which develop over a period of months.

Quick Summary

Insufficient folate intake can cause megaloblastic anemia, extreme fatigue, and oral problems like a sore tongue or mouth ulcers. Long-term deficiency is linked to severe birth defects and neurological issues.

Key Points

• Megaloblastic Anemia: A deficiency in folate can cause a specific type of anemia characterized by abnormally large red blood cells that cannot function properly.

• Risks in Pregnancy: Inadequate folate before and during pregnancy significantly increases the risk of neural tube defects like spina bifida, preterm birth, and low birth weight.

• Neurological Consequences: Symptoms can include extreme fatigue, irritability, cognitive difficulties, and, if complicated by B12 deficiency, permanent nerve damage.

• Common Causes: The main causes are poor dietary intake, alcohol abuse, certain medications, malabsorption diseases (like celiac disease), and increased bodily demand during pregnancy.

• Treatment is Effective: Treatment with oral folic acid supplements is highly effective and can reverse most symptoms within a few months, provided there is no underlying vitamin B12 deficiency.

• Prevention through Diet: Incorporating folate-rich foods like dark leafy greens, legumes, and fortified cereals into your diet is the best way to prevent a deficiency.

What is Folate and Why Is It So Important?

Folate, also known as vitamin B9, is a water-soluble vitamin that plays a crucial role in many bodily functions. It is essential for producing new red blood cells, synthesizing and repairing DNA, and maintaining neurological health. Because the body stores only a small amount of folate, regular intake from dietary sources or supplements is necessary to prevent deficiency. The synthetic form of folate, called folic acid, is often added to fortified foods like cereal, bread, and pasta to help ensure adequate intake.

Signs and Symptoms of Folate Deficiency

Symptoms of a folate deficiency can develop gradually, but they can be severe if the condition remains untreated. The most recognizable sign is megaloblastic anemia, a blood disorder where red blood cells become abnormally large and are less effective at carrying oxygen.

Anemia-Related Symptoms

• Fatigue and weakness: This is often the earliest and most common symptom due to the lack of oxygen-carrying capacity in the blood.
• Pale skin: A noticeably pale complexion can indicate low red blood cell counts.
• Shortness of breath: The body's inability to transport enough oxygen can lead to feeling breathless.
• Irritability: A result of the body not functioning optimally.
• Heart palpitations: The heart may beat faster or irregularly to compensate for the lack of oxygen.

Other Physical Symptoms

• Oral discomfort: A red, sore, or swollen tongue is a common sign, sometimes accompanied by mouth ulcers.
• Gastrointestinal issues: Diarrhea and weight loss can occur in more severe cases.
• Hair and skin changes: Rarely, changes in hair and skin pigmentation may be observed.

Neurological and Cognitive Symptoms

While typically associated with vitamin B12 deficiency, folate deficiency can also cause mental and emotional changes. These can include:

• Memory loss
• Difficulty concentrating
• Confusion and impaired judgment
• Depression and other psychological problems

Common Causes of Folate Deficiency

There are several reasons a person may not have enough folate. Poor dietary intake is the most frequent cause, but other factors also play a significant role.

Dietary Causes

• Inadequate consumption: A diet low in fresh fruits, leafy greens, and fortified grains can quickly lead to low folate levels, as the body's stores are limited.
• Overcooking food: Heat can destroy folate in food, so overcooking vegetables can reduce the amount available.
• Alcohol consumption: Excessive alcohol intake interferes with folate absorption and increases its excretion from the body.

Malabsorption Issues

• Digestive diseases: Conditions like celiac disease, Crohn's disease, and other malabsorptive disorders can prevent the body from properly absorbing folate from food.

Medical Conditions and Medications

• Increased demand: Pregnancy, breastfeeding, and chronic conditions like sickle cell anemia increase the body's need for folate.
• Certain medications: Some anti-seizure drugs (e.g., phenytoin), methotrexate, and sulfasalazine can interfere with folate metabolism.

Genetic Factors

• Some individuals have a genetic mutation in the MTHFR gene that impairs their body's ability to convert folate into its active form, potentially increasing their risk of deficiency.

The Serious Health Risks of Low Folate

Risks During Pregnancy

Folate's role in early fetal development makes deficiency particularly dangerous for pregnant women. Inadequate intake is strongly linked to:

• Neural tube defects (NTDs): These are severe birth defects affecting the baby's brain and spinal cord, such as spina bifida and anencephaly.
• Preterm birth and low birth weight: Insufficient folate during pregnancy is also associated with these adverse outcomes.

Risks for General Health

Beyond pregnancy, a chronic folate deficiency poses other health threats:

• Cardiovascular concerns: Elevated homocysteine levels, a consequence of folate deficiency, have been linked to an increased risk of cardiovascular disease and stroke.
• Cognitive decline: Low folate levels are associated with a higher risk of depression, dementia, and reduced cognitive function.

Diagnosis, Treatment, and Prevention

If a deficiency is suspected, a healthcare provider will conduct a blood test to measure serum and red blood cell folate levels. It is critical to also measure vitamin B12 levels, as treating a B12 deficiency with folate alone can mask the anemia while allowing neurological damage to progress.

Treatment and Prevention Methods

• Supplements: Oral folic acid supplements are the primary treatment for deficiency, with dosages determined by a healthcare provider.
• Dietary changes: Increasing consumption of folate-rich foods is crucial for prevention. These include leafy greens, legumes, eggs, nuts, and fortified cereals.
• Fortification: Many countries fortify staple foods like flour with folic acid, a public health measure that has significantly reduced deficiency rates.

Folate vs. Vitamin B12 Deficiency: Key Differences

Both folate and vitamin B12 deficiencies can cause megaloblastic anemia, making diagnosis challenging. However, a key differentiator is the presence of neurological symptoms.

Feature	Folate Deficiency	Vitamin B12 Deficiency
Megaloblastic Anemia	Yes, common	Yes, common
Fatigue	Common	Common
Sore Tongue/Mouth Ulcers	Common	Common
Memory & Cognitive Issues	Possible, but less prominent	Common and more severe
Neurological Damage	Generally absent, but can worsen if B12 is deficient	Prominent, including nerve damage (tingling, numbness)
Homocysteine Levels	Elevated	Elevated
Methylmalonic Acid (MMA)	Normal	Elevated

Conclusion

While serious, folate deficiency is a manageable condition with effective treatment and prevention strategies. The symptoms, particularly fatigue, can often be mistaken for less severe issues, but the risks, especially for pregnant women, are significant. The best defense is a balanced diet rich in natural folate and fortified foods. For those at higher risk due to diet, genetics, or health conditions, supplementation is a safe and effective way to ensure adequate levels. If symptoms of deficiency appear, consulting a healthcare provider is essential to determine the correct diagnosis and treatment plan, which should always include checking for a coexisting vitamin B12 deficiency.

For more detailed information on folate and its health implications, please visit the NIH Office of Dietary Supplements.

Frequently Asked Questions

What is the main cause of folate deficiency?

The most common cause is a poor or imbalanced diet lacking in folate-rich foods such as green leafy vegetables, fresh fruits, and fortified grains.

What are the first signs of low folate levels?

The earliest and most prominent signs of folate deficiency are often a feeling of extreme tiredness (fatigue), muscle weakness, and overall lethargy.

Can folate deficiency affect mental health?

Yes, a lack of folate is associated with psychological issues, including depression, confusion, and memory problems. However, these symptoms are often more severe in a vitamin B12 deficiency.

How is folate deficiency diagnosed?

A doctor can diagnose a folate deficiency with a simple blood test that measures the amount of folate in your blood. They will also check your vitamin B12 levels to rule out a dual deficiency.

What is the difference between folate and folic acid?

Folate is the form of vitamin B9 that is found naturally in food, while folic acid is the synthetic, man-made form added to supplements and fortified foods.

How long does it take to recover from folate deficiency?

With proper treatment, which typically involves folic acid supplements, hematological recovery usually begins within a couple of weeks, and most symptoms resolve within four to eight weeks.

Is folate deficiency a risk during pregnancy?

Yes, folate deficiency during pregnancy is a significant risk factor for serious birth defects of the brain and spinal cord, known as neural tube defects.

Can certain medications cause a folate deficiency?

Yes, some medications, including specific anti-seizure drugs, methotrexate for arthritis, and sulfasalazine for ulcerative colitis, can interfere with folate absorption.