What Population Is Deficient in Folic Acid? A Comprehensive Guide

November 16, 2025 •

5 min read

According to studies, folate insufficiency—levels inadequate to prevent neural tube defects—affects over 40% of women of reproductive age globally, highlighting the urgent public health need to understand what population is deficient in folic acid. This article explores the various demographic, lifestyle, and medical factors that put certain groups at a higher risk of deficiency.

Quick Summary

This guide outlines the demographic groups and factors that contribute to folic acid deficiency, such as pregnancy, chronic alcohol use, malabsorption issues, certain medications, and genetic variants.

Key Points

Women of Reproductive Age: Due to increased demands during pregnancy and fetal development, women of childbearing age have a higher risk of folic acid deficiency, which can cause neural tube defects in infants.
Geographic Location: Deficiency is more prevalent in low- and middle-income countries and regions without mandatory folic acid fortification of grain products.
Chronic Alcohol Use: Excessive alcohol consumption disrupts folate absorption, metabolism, and storage, making chronic alcoholics a significant population at risk.
Malabsorption Issues: Individuals with gastrointestinal conditions like celiac or Crohn's disease, or those who have had bariatric surgery, are prone to deficiency because their bodies cannot absorb folate efficiently.
Advanced Age and Institutionalization: Older adults, especially those in institutional care, are vulnerable due to limited dietary intake and underlying health conditions.
Certain Medications: Drugs such as methotrexate and some anticonvulsants can interfere with the body's folate utilization, increasing the risk of deficiency.
Genetic Factors: Specific genetic mutations, like in the MTHFR gene, can impair the body's ability to process folate, contributing to lower folate levels.

Key Demographics with Higher Risk

Certain demographic groups face a heightened risk of folic acid deficiency due to increased physiological demands, limited dietary intake, or socioeconomic factors. Understanding these groups is the first step toward effective prevention and intervention strategies.

Women of Childbearing Age

This group, particularly those who are pregnant or planning to become pregnant, is highly susceptible. The rapid cell division during early pregnancy increases the body's need for folate. Low levels can lead to neural tube defects (NTDs) like spina bifida. Fortification of grains has reduced NTD rates in some countries, but deficiency remains a concern globally and for those not taking supplements.

Individuals in Countries Without Fortification

Folic acid deficiency is more common in countries without mandatory food fortification programs, which significantly lower deficiency rates. Rates can be much higher compared to countries with fortification. Lack of fortified foods and limited dietary diversity contribute to poor folate status in these regions.

Older Adults

Older adults, especially those institutionalized or isolated, are more likely to have folate deficiency due to poor diet, malnutrition, and other health issues. Difficulties with eating and physiological changes also play a role.

Lifestyle and Medical Factors Contributing to Deficiency

Certain lifestyle choices and health conditions can interfere with folate absorption, use, or storage.

Chronic Alcoholism

Heavy alcohol consumption significantly contributes to folic acid deficiency by hindering absorption and metabolism. Alcohol can also lead to poor nutrition and increases folate excretion.

Malabsorption Disorders

Conditions affecting the gastrointestinal tract can prevent proper nutrient absorption, including folate. These include:

Celiac disease
Crohn's disease
Inflammatory Bowel Disease (IBD)
Tropical sprue
Gastric bypass surgery

Genetic Variations

A common genetic change in the MTHFR gene can reduce the body's ability to convert folate into its active form. Individuals with this mutation may benefit from supplements containing L-5-Methyltetrahydrofolate.

Chronic Medical Conditions and Dialysis

Patients with conditions involving rapid cell turnover, such as some anemias or cancers, need more folate. Kidney dialysis can also cause folate loss. These individuals often need higher doses of supplements.

Medications That Affect Folate Levels

Some medications can interfere with folate, raising the risk of deficiency. These include:

Methotrexate: Used for conditions like rheumatoid arthritis.
Phenytoin: An anti-seizure drug.
Sulfasalazine: Used for inflammatory bowel disease.
Trimethoprim: An antibiotic.

A Comparison of Fortification Programs and Deficiency Rates


Feature	Fortified Countries (e.g., USA, Canada)	Non-Fortified Countries (e.g., many in Europe, low-income nations)
Prevalence of Deficiency	Typically less than 5% due to widespread fortification.	Rates can be significantly higher, often exceeding 20% in some populations.
Primary Source of Folic Acid	Fortified grain products (bread, cereal, rice, pasta) and supplements, in addition to natural sources.	Relies heavily on dietary intake of naturally occurring folate, which is susceptible to cooking heat.
Effect on NTD Rates	Significant reduction in neural tube defects following the introduction of mandatory fortification.	Higher incidence of neural tube defects due to lower folate intake and insufficiency in women of reproductive age.
Risk Mitigation	Public health campaigns and widespread access to fortified foods help mitigate risk across the general population.	Requires targeted education and individual supplementation for at-risk groups, which may face access barriers.

How to Prevent Folic Acid Deficiency

Prevention involves diet and, for high-risk individuals, supplements. Here is a list of ways to increase folate and folic acid intake:

Eat folate-rich foods: Include dark green leafy vegetables, legumes, citrus fruits, and liver.
Choose fortified products: Look for cereals, breads, rice, and pasta fortified with folic acid, especially in countries with mandatory fortification.
Cook carefully: Folate is heat-sensitive. Steaming or microwaving vegetables preserves more nutrients than boiling.
Take supplements: Pregnant women or those planning pregnancy should take a daily folic acid supplement. A doctor may recommend a specific dosage for others with risk factors.
Moderate alcohol consumption: Limiting alcohol intake improves folate absorption and liver function.
Manage underlying conditions: Address malabsorption disorders or other chronic conditions with a healthcare provider.

Conclusion

Folic acid deficiency affects various individuals, including women of childbearing age, the elderly, and those with specific medical conditions or lifestyle factors. Food fortification has reduced deficiency in many countries, but challenges remain in regions without these programs and for high-risk groups. Prevention involves education, diet, and targeted supplementation. Consult reliable health resources like the CDC for more information on preventing neural tube defects.

Keypoints

Women of Reproductive Age: This group is at high risk for folic acid deficiency, which can cause neural tube defects, due to increased demands during pregnancy.
Global Disparities: Deficiency is more prevalent in countries without mandatory folic acid fortification programs.
Chronic Alcohol Use: Excessive alcohol consumption disrupts folate absorption and metabolism, increasing risk.
Malabsorption Syndromes: Conditions like celiac disease impair folate absorption.
Genetic Factors: Mutations in the MTHFR gene can hinder the body's ability to metabolize folate.
Older Adults: The elderly, especially those institutionalized, are vulnerable due to diet and health conditions.
Medication-Related Risk: Certain medications interfere with folate utilization.

FAQs

Q: How does folic acid deficiency affect pregnant women? A: Deficiency in early pregnancy can cause neural tube defects (NTDs) like spina bifida. Adequate intake is vital for fetal development.

Q: Can a poor diet be the sole cause of folic acid deficiency? A: Yes, a diet low in folate-rich foods can lead to deficiency within months.

Q: What symptoms might indicate a folic acid deficiency? A: Symptoms include fatigue, pale skin, a sore tongue, mouth ulcers, diarrhea, and irritability, often linked to megaloblastic anemia.

Q: What is the MTHFR gene mutation and how does it relate to folic acid deficiency? A: This mutation affects the conversion of folic acid to its active form, 5-MTHF. Individuals may need specific folate supplements.

Q: How do certain medications, like methotrexate, affect folate levels? A: Drugs like methotrexate interfere with folate use. Patients on these medications need monitoring and possible supplementation.

Q: Why are people who consume large amounts of alcohol at risk? A: Chronic alcohol use disrupts folate absorption and storage, and heavy drinkers often have poor diets.

Q: Does food fortification eliminate all risk of folic acid deficiency? A: No, while fortification reduces risk, some high-risk individuals like pregnant women or those with malabsorption may still need supplements.

Q: What is the difference between folate and folic acid? A: Folate is natural vitamin B9 in food; folic acid is the synthetic form in fortified foods and supplements. Folic acid is generally more easily absorbed.

Citations

Folic Acid Deficiency - StatPearls - NCBI Bookshelf. (June 25, 2025). https://www.ncbi.nlm.nih.gov/books/NBK535377/
Folic Acid Deficiency - StatPearls - NCBI Bookshelf. (June 25, 2025). https://www.ncbi.nlm.nih.gov/books/NBK535377/
Folate Deficiency: Symptoms, Causes & Prevention. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22198-folate-deficiency
Folate Deficiency: Symptoms, Causes & Prevention. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22198-folate-deficiency
Folate, Alcohol, and Liver Disease - PMC - PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC3736728/

Frequently Asked Questions

The most vulnerable populations include pregnant and breastfeeding women, individuals living in countries without food fortification, people with chronic alcoholism, older adults, and those with malabsorption issues like celiac disease.

Pregnancy significantly increases the body's demand for folate to support rapid fetal growth and development. If a woman's folate intake is insufficient before and during early pregnancy, it can lead to serious birth defects, such as neural tube defects.

Mandatory folic acid fortification of grain products has been proven highly effective in lowering deficiency rates across the general population. In countries with these programs, prevalence is typically low, contrasting with higher rates in non-fortified countries.

Yes, several medications can interfere with folate metabolism. Examples include methotrexate (used for rheumatoid arthritis) and certain anticonvulsants, which inhibit the body's ability to use or absorb folate effectively.

Older adults are at higher risk due to potential dietary limitations, underlying medical conditions, or changes in nutrient absorption with age. Institutionalized or socially isolated elderly individuals are particularly vulnerable.

A common genetic variant in the MTHFR gene impairs the body's ability to convert folate into its active form. This can lead to functional folate deficiency and may require specific types of folate supplementation, rather than standard folic acid.

To prevent deficiency, consume plenty of folate-rich foods like leafy green vegetables, legumes, and citrus fruits. Additionally, choose fortified grain products where available, and be mindful that overcooking can destroy folate.

Folate is the naturally occurring form of vitamin B9 found in foods, while folic acid is the synthetic form used in fortified foods and supplements. Folic acid is generally more bioavailable than naturally occurring folate.