Who is at High Risk for Folate Deficiency?

December 3, 2025 •

4 min read

According to the CDC, mandatory folic acid fortification has reduced neural tube defects by 35% since 1998, but not all populations are equally protected. Many factors beyond diet can increase an individual's vulnerability, making it crucial to know who is at high risk for folate deficiency.

Quick Summary

This article outlines the key populations highly susceptible to folate deficiency, such as pregnant women, individuals with chronic alcohol use, those with malabsorption disorders, and people taking specific medications. It details the reasons behind their heightened risk and the potential consequences.

Key Points

High-Risk Groups: Pregnant women, chronic alcohol users, and individuals with malabsorption disorders are at significantly higher risk for folate deficiency.
Medication Interference: Certain drugs, including methotrexate and some anticonvulsants, can disrupt folate metabolism and utilization.
Genetic Factors: A mutation in the MTHFR gene can impair the body's ability to convert folate into its active form, leading to functional deficiency.
Gastrointestinal Health: Conditions like celiac disease and Inflammatory Bowel Disease (IBD) interfere with the absorption of folate in the small intestine.
Alcohol Abuse: Chronic alcohol consumption hampers folate absorption, storage in the liver, and increases its excretion.
Socioeconomic Barriers: Low income and limited dietary diversity can restrict access to folate-rich foods and supplements in vulnerable populations, including the elderly.
Pregnancy Complications: Folate deficiency during early pregnancy is a leading cause of neural tube defects (NTDs) in newborns.

Understanding the Role of Folate

Folate, also known as vitamin B9, is a water-soluble vitamin essential for numerous bodily functions. It is crucial for cell growth and division, DNA synthesis, and red blood cell formation. A shortfall in this vital nutrient can lead to a range of health issues, most notably megaloblastic anemia, where red blood cells become abnormally large and inefficient at carrying oxygen. While food fortification has significantly lowered deficiency rates in some countries, specific populations remain highly susceptible due to increased physiological demand, poor absorption, genetic factors, and certain lifestyle choices.

Pregnant Women and Those of Childbearing Age

Pregnant women have significantly higher folate requirements to support the rapid cell growth and division of both the fetus and the placenta. A deficiency during the early stages of pregnancy can cause severe birth defects known as neural tube defects (NTDs), which affect the brain, spinal cord, or spine. Since NTDs often develop before a woman even knows she is pregnant, health experts recommend that all women of childbearing age take folic acid supplements. In the U.S., studies show that women, particularly those of certain ethnic backgrounds like Hispanic and non-Hispanic Black women, have persistently suboptimal folate levels despite food fortification.

Individuals with Chronic Alcoholism

Chronic alcohol use is one of the most common causes of folate deficiency. The mechanisms are multifaceted, impacting several stages of folate's journey through the body. Chronic alcohol consumption can:

Reduce dietary intake of folate-rich foods due to a poor diet.
Interfere with the absorption of folate in the intestine.
Impair the liver's ability to store and release folate.
Increase the excretion of folate by the kidneys.

These combined effects can rapidly deplete the body's folate reserves, predisposing individuals to severe deficiency and its complications.

People with Malabsorption Disorders

Conditions that affect the small intestine, where folate is absorbed, can lead to deficiency regardless of dietary intake. Malabsorption syndromes and other gastrointestinal diseases interfere with the body’s ability to properly absorb nutrients from food. Key conditions include:

Celiac Disease: An autoimmune disorder where consuming gluten damages the small intestine lining, impeding nutrient absorption.
Inflammatory Bowel Disease (IBD): Chronic inflammation of the digestive tract, including Crohn's disease, can impair absorption, especially in patients with small bowel involvement.
Bariatric Surgery: Procedures like gastric bypass alter the digestive tract, potentially leading to malabsorption of vitamins and minerals, including folate.
Tropical Sprue: A condition that causes damage to the small intestine, resulting in malabsorption.

Individuals Taking Certain Medications

Some medications can interfere with folate absorption, metabolism, or utilization, thereby increasing deficiency risk. Patients on long-term therapy may require supplementation. These drugs include:

Methotrexate: A folate antagonist used to treat cancer and autoimmune conditions like rheumatoid arthritis.
Certain Anticonvulsants: Drugs like phenytoin, carbamazepine, and phenobarbital can interfere with folate levels.
Trimethoprim and Sulfasalazine: Antibiotics that can impact folate metabolism.
Metformin: A medication for type 2 diabetes that can affect folate levels over time.

Individuals with Specific Genetic Mutations

A genetic polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene can affect the body's ability to convert folate into its active, usable form, L-methylfolate. This can lead to elevated homocysteine levels and reduced methylation capacity, increasing the risk of both folate deficiency and related health complications. Individuals with this mutation may have adequate dietary intake but still be functionally deficient. Supplementation with the active form, L-methylfolate, is sometimes recommended.

Elderly and Socioeconomically Disadvantaged Populations

Older adults, particularly those in institutions or with limited dietary diversity, are at risk for folate deficiency. Factors include poor appetite, inadequate food intake, and co-existing medical conditions. Similarly, low socioeconomic status can be a barrier to accessing nutritious, folate-rich foods or fortified products, increasing the prevalence of deficiency in vulnerable communities.

Comparison of Risk Factors


Risk Factor	Primary Cause	Impact on Folate Status	Population Affected
Pregnancy	Increased physiological demand for cell growth	Increases need for folate up to 600 mcg/day	Women who are pregnant or may become pregnant
Chronic Alcoholism	Impaired absorption, reduced intake, and increased excretion	Interferes with folate metabolism and storage	Individuals with long-term, heavy alcohol consumption
Malabsorption	Damage or changes to the small intestine	Prevents proper absorption from food	People with celiac disease, IBD, or post-bariatric surgery
Certain Medications	Interference with folate's metabolic pathways	Inhibits absorption or utilization	Patients on long-term methotrexate, anticonvulsants, etc.
Genetic Mutation (MTHFR)	Impaired conversion to active folate	Reduces usable folate, raising homocysteine levels	Individuals with the MTHFR gene polymorphism

Conclusion

While public health initiatives have made significant strides in combating widespread folate deficiency through food fortification, several populations remain highly susceptible. Identifying these at-risk groups—including pregnant women, chronic alcoholics, individuals with malabsorption issues or genetic predispositions, and those on specific medications—is critical for targeted prevention and management. For many, a balanced diet is sufficient, but those in high-risk categories should consult a healthcare provider about potential supplementation. Awareness of these risk factors is the first step toward preventing the serious health complications associated with inadequate folate levels.

For more information on the critical role of folic acid in pregnancy, see the Office on Women's Health.

Frequently Asked Questions

Chronic alcoholism can cause folate deficiency through several mechanisms: poor diet resulting in low folate intake, impaired intestinal absorption, reduced storage in the liver, and increased excretion by the kidneys.

Pregnant women have increased folate requirements to support the rapid cell division and growth of the developing fetus and the placenta. Insufficient folate can lead to severe birth defects like neural tube defects.

Some medications, such as methotrexate and trimethoprim, are folate antagonists that interfere with the body's utilization of folate by inhibiting key enzymes. Others, like some anticonvulsants, can affect absorption.

Yes, celiac disease can cause folate deficiency because the inflammation and damage it causes to the small intestine lining can significantly impair the absorption of nutrients, including folate.

A mutation in the MTHFR gene can prevent the body from efficiently converting folate into its active, usable form (L-methylfolate). This can lead to a functional folate deficiency, despite adequate intake.

Yes, aside from pregnancy, conditions involving rapid cell turnover can increase folate demand. This includes chronic hemolytic anemias, exfoliative skin disorders, and certain cancers.

Folate deficiency can be a risk for older adults, particularly those in institutional care, due to factors like poor nutritional intake, reduced appetite, and limited access to varied diets.