What Happens if Your Folic Acid is Really Low?

The human body does not store large reserves of folate, a key B vitamin, so a consistently low dietary intake can lead to a deficiency in just a few months. This rapid depletion means that knowing what happens if your folic acid is really low is crucial for health, especially for vulnerable populations like pregnant women and those with malabsorption issues.

Quick Summary

A severe deficiency of folic acid can lead to megaloblastic anemia, which causes fatigue, weakness, and shortness of breath. It can also cause neurological issues and, for pregnant women, increases the risk of neural tube defects in the fetus. Prompt treatment with supplements and dietary changes is vital.

Key Points

• Megaloblastic Anemia: A really low folic acid level impairs red blood cell production, leading to megaloblastic anemia with symptoms like extreme fatigue and weakness.

• Neurological Consequences: Severe deficiency can cause serious neurological issues, including memory loss, depression, confusion, and peripheral neuropathy.

• Pregnancy Risks: For pregnant women, critically low folate significantly increases the risk of severe neural tube defects (NTDs) like spina bifida in the baby.

• Diagnosis and Treatment: A simple blood test can diagnose the deficiency, which is typically treated effectively with oral folic acid supplements and dietary changes.

• Underlying Causes: Common causes include poor diet, alcoholism, malabsorption disorders like celiac disease, and certain medications.

• Long-term Complications: Left untreated, prolonged folate deficiency can lead to cardiovascular problems and ongoing neurological damage.

Understanding the Role of Folic Acid

Folic acid, or vitamin B9, is a water-soluble vitamin essential for numerous bodily functions. Its primary role involves DNA synthesis and repair, as well as the production of red blood cells. A consistent and adequate supply is necessary to produce healthy red blood cells, which are responsible for carrying oxygen throughout the body. When levels are really low, this process is severely impaired, leading to a range of serious health problems.

The Onset of Megaloblastic Anemia

One of the most significant consequences of a severe folic acid deficiency is megaloblastic anemia. This condition is characterized by the production of abnormally large, immature, and improperly functioning red blood cells called megaloblasts. These cells are unable to carry oxygen effectively, resulting in a number of symptoms, including:

• Fatigue and Weakness: As oxygen delivery to tissues is compromised, a lack of energy becomes a prominent and persistent symptom.
• Shortness of Breath: The body attempts to compensate for the lack of oxygen-carrying red blood cells by increasing respiration, leading to breathlessness.
• Pallor: A visibly pale complexion can occur as a result of the reduced number of healthy red blood cells circulating in the body.
• Heart Palpitations: The heart may beat faster or irregularly to pump more blood in an effort to meet the body's oxygen demands.

Serious Complications of Low Folate

Beyond anemia, extremely low folic acid levels can affect various other body systems, with potentially irreversible consequences if left untreated.

Neurological and Cognitive Damage

Folate is vital for the nervous system. When levels plummet, individuals may experience a range of neurological and psychological issues. These can include:

• Cognitive Issues: Problems with memory, concentration, and judgment are common.
• Psychological Problems: A severe deficiency can cause mood disturbances ranging from mild depression and anxiety to more severe confusion and dementia-like symptoms.
• Peripheral Neuropathy: Some individuals may experience numbness, tingling, or a 'pins and needles' sensation in their hands and feet, which indicates nerve damage.

Impact on Pregnancy and Fetal Development

The risk is particularly high for pregnant women, where low folic acid levels are a major concern. During early pregnancy, folate is critical for the development of the fetal brain and spinal cord.

• Neural Tube Defects (NTDs): A severe deficiency can lead to NTDs such as spina bifida and anencephaly. Spina bifida involves incomplete development of the spinal cord, while anencephaly is a fatal condition where the baby is born without parts of the brain and skull.
• Other Pregnancy Complications: Low folate status has also been linked to increased risk of preterm delivery, low birth weight, and placental abruption.

Other Systemic Issues

Other potential complications from really low folic acid include:

• Oral Manifestations: A severely inflamed, red, and sore tongue (glossitis) along with mouth ulcers can develop.
• Gastrointestinal Problems: Digestive issues like diarrhea and decreased appetite are frequently reported.
• Increased Homocysteine Levels: Low folate can lead to elevated homocysteine, an amino acid linked to an increased risk of cardiovascular disease and stroke.
• Potential Link to Cancer: Some research suggests a link between long-term folate deficiency and an increased risk of certain cancers, though the relationship is complex.

Comparison of Folate Deficiency Symptoms by Severity

To illustrate the progression, here is a comparison of symptoms between moderate and severe folic acid deficiency.

Symptom	Moderate Folate Deficiency	Severe Folate Deficiency
Fatigue	Mild to moderate tiredness.	Extreme, debilitating fatigue and weakness.
Cardiovascular	Mild breathlessness, irritability.	Noticeable palpitations, severe shortness of breath.
Oral Health	Minor mouth sores may occur.	Sore, red, and swollen tongue (glossitis) and persistent mouth ulcers.
Neurological	Mood changes like irritability or mild depression.	Confusion, memory loss, anxiety, and potentially dementia.
Gastrointestinal	Reduced appetite.	Diarrhea, significant weight loss.
Pregnancy Risk	Increased risk of complications, though severity varies.	Significantly higher risk of severe neural tube defects and other issues.

Causes and Treatment

What Causes Critically Low Levels?

Several factors can contribute to a severe drop in folic acid:

• Inadequate Diet: The most common cause is not eating enough folate-rich foods like leafy greens, citrus fruits, and fortified cereals.
• Malabsorption Disorders: Conditions like celiac disease and inflammatory bowel disease (IBD) can interfere with folate absorption in the small intestine.
• Excessive Alcohol Use: Alcohol interferes with the absorption and metabolism of folate and increases its excretion through the kidneys.
• Certain Medications: Some drugs, including methotrexate (for autoimmune diseases) and certain anticonvulsants, can lower folate levels.
• Increased Demand: Pregnancy and certain blood disorders, like hemolytic anemia, increase the body's need for folate, which can lead to a deficiency if intake isn't increased.

Treatment Options for Severe Deficiency

Treatment for severe folic acid deficiency is usually straightforward and highly effective once diagnosed:

• Folic Acid Supplements: Your doctor will prescribe oral folic acid tablets to quickly restore levels. In severe cases or for individuals with absorption problems, injections may be necessary initially. Treatment typically lasts several months, or longer if the underlying cause persists.
• Dietary Changes: Increasing consumption of folate-rich foods is crucial for long-term management and prevention. Excellent sources include asparagus, spinach, broccoli, beans, and fortified grains.
• Address the Underlying Cause: Treating the root cause, such as managing a malabsorption disorder or adjusting medication, is essential for a complete recovery.

Conclusion

Ignoring a severely low folic acid level can lead to debilitating and potentially permanent health problems, affecting everything from blood cell production to neurological function and fetal development. Megaloblastic anemia is often the most recognizable symptom, but cognitive and neurological damage represents an even greater risk, particularly for those with an undiagnosed vitamin B12 deficiency. Fortunately, diagnosis via a simple blood test and treatment with dietary adjustments and supplements are highly effective. If you experience persistent symptoms like fatigue, weakness, or unexplained changes in mood, consulting a healthcare provider for a proper diagnosis is the most important step.

Visit the NIH website for detailed fact sheets on Folate and other vitamins.

Frequently Asked Questions

What are the first signs that my folic acid is really low?

The initial signs of a really low folic acid level often include fatigue, weakness, and irritability. These are followed by more specific symptoms like a sore tongue, mouth ulcers, and shortness of breath as megaloblastic anemia develops.

Can low folic acid cause permanent damage?

Yes, if left untreated for a prolonged period, very low folic acid can cause irreversible neurological damage. It can also lead to complications during pregnancy, such as neural tube defects, that have permanent consequences.

How quickly can folic acid deficiency be treated?

Folic acid deficiency can typically be corrected with oral supplements within a few months. However, the duration depends on the severity and underlying cause, and ongoing supplementation or treatment may be required.

Is it possible to have low folic acid without knowing?

Yes, a mild or moderate folic acid deficiency can develop gradually with subtle, non-specific symptoms, or sometimes no symptoms at all. A deficiency is often discovered during routine blood tests.

Can alcohol affect folic acid levels?

Yes, chronic and excessive alcohol consumption is a major cause of dangerously low folic acid levels. Alcohol interferes with folate absorption and increases its excretion from the body.

What foods are rich in folate?

Foods naturally rich in folate include dark leafy green vegetables (spinach, kale), legumes (beans, chickpeas), nuts, citrus fruits, and liver. Many grain products like cereals and bread are also fortified with folic acid.

Why is it important to check for B12 deficiency when treating low folate?

It is crucial to check vitamin B12 levels because supplements for folate can mask an underlying B12 deficiency. If B12 is also low, treating only with folate can worsen the neurological complications associated with B12 deficiency.