Who Needs a Folate Supplement? A Guide to Key Indicators and At-Risk Groups

October 8, 2025 •

4 min read

According to the Centers for Disease Control and Prevention (CDC), folic acid fortification of grain products has played a significant role in reducing the prevalence of neural tube defects since the late 1990s. However, some individuals and groups may require a targeted folate supplement, particularly those with increased nutritional needs or specific health conditions.

Quick Summary

This article outlines the specific groups and medical conditions that necessitate folate supplementation. It details the critical role of folic acid during pregnancy, identifies risk factors for deficiency, explains the difference between folate and folic acid, and discusses genetic factors and dietary considerations.

Key Points

Pregnant Women and Pre-conception: All women of childbearing age and those who are pregnant should take a folic acid supplement to prevent neural tube defects.
Folate Deficiency Anemia: A diagnosed deficiency often requires a therapeutic approach involving folic acid to correct megaloblastic anemia and its symptoms.
Absorption Issues: Individuals with conditions like Crohn's disease, celiac disease, or those undergoing kidney dialysis may need supplementation due to impaired absorption.
MTHFR Mutation: A specific genetic variant can affect folate metabolism, and some people may benefit from a supplement containing the active form, L-methylfolate.
Drug Interactions: Certain medications, such as methotrexate and some anti-seizure drugs, can increase the need for folate supplementation.
B12 Deficiency Risk: High intake of folic acid can mask a vitamin B12 deficiency, so it's critical to have B12 levels checked, especially for vegans and older adults.

The Difference Between Folate and Folic Acid

Before determining who requires a supplement, it's essential to understand the distinction between folate and folic acid. Folate is the naturally occurring form of vitamin B9 found in foods like leafy greens, legumes, and citrus fruits. In contrast, folic acid is the synthetic, man-made version used in dietary supplements and to fortify processed foods such as bread, cereal, and pasta. Folic acid is actually better absorbed by the body than natural food folate. This higher bioavailability is why it is the form recommended for supplementation, especially for pregnancy. Folate is crucial for DNA synthesis and repair, cell growth, and the production of healthy red blood cells.

Who Needs a Folate Supplement? Key Groups and Conditions

While most healthy adults can meet their daily folate needs through diet alone, several populations and health scenarios significantly increase the need for supplementation. Consulting a healthcare provider is always the best first step to determine if a supplement is right for you.

Women Planning a Pregnancy or Who Are Pregnant

This is perhaps the most well-known group recommended to take a supplement. Folic acid is vital for the prevention of neural tube defects (NTDs), which are serious birth defects of the brain and spine (e.g., spina bifida and anencephaly). The CDC advises that all women of childbearing age consume folic acid daily. This is because NTDs occur very early in pregnancy, often before a woman knows she is pregnant. For those with a history of an NTD-affected pregnancy or other risk factors, a healthcare provider may recommend a higher intake.

Individuals with Folate Deficiency Anemia

Folate deficiency can lead to a type of megaloblastic anemia, where red blood cells are abnormally large and immature. This impairs the blood's ability to carry oxygen, causing symptoms like fatigue, paleness, irritability, and shortness of breath. Treatment typically involves folic acid. For individuals with a long-term absorption problem, this may require ongoing treatment.

People with Conditions Affecting Nutrient Absorption

Certain digestive disorders and medical treatments can interfere with the body's ability to absorb nutrients from food, including folate. These include:

Malabsorption syndromes: Conditions like celiac disease, inflammatory bowel disease (Crohn's disease, ulcerative colitis), and gastric bypass surgery can all lead to poor folate absorption.
Kidney dialysis: Patients undergoing dialysis often require folate supplements.

Individuals with the MTHFR Gene Mutation

The methylenetetrahydrofolate reductase (MTHFR) gene provides instructions for an enzyme that helps process folate. A common genetic variant can make it harder for the body to convert folate into its active form, 5-MTHF. While many people with this mutation do not experience health problems, some may benefit from a supplement containing the active form (L-methylfolate). For pregnancy, however, standard folic acid is still the form recommended to prevent NTDs, even with the mutation.

People Taking Certain Medications

Some medications can deplete the body of folate or interfere with its metabolism. These include:

Methotrexate: This medication, used for conditions like severe arthritis and psoriasis, requires supplemental folic acid to reduce its side effects.
Anti-seizure drugs: Some epilepsy medications can disrupt folate absorption.

Others at an Increased Risk

Other factors can increase a person's risk of folate deficiency, prompting the need for a supplement:

Heavy alcohol consumption: Alcohol can interfere with folate absorption and metabolism.
Poor diet: The elderly, institutionalized individuals, or those with very limited or poor diets may not consume enough folate-rich foods.

Folate vs. Folic Acid: Which Supplement is Best?


Feature	Folate (Natural)	Folic Acid (Synthetic)
Source	Found naturally in foods.	Produced in a lab for supplements and fortified foods.
Absorption Rate	Variable; can be easily destroyed by cooking.	High; more readily absorbed by the body.
Bioavailability	Lower than folic acid due to processing.	Higher; body uses it more efficiently.
Fortification	Not used for fortification.	Used to fortify grain products (e.g., cereals, breads).
Medical Use	Supplementation is more often with the synthetic form due to higher absorption.	Recommended for pregnancy and treating deficiency.

Important Considerations and Risks

While a folate supplement is beneficial and necessary for certain groups, it is not without risks, especially if you have an undiagnosed vitamin B12 deficiency. Taking folic acid can mask the hematological symptoms (anemia) of a B12 deficiency while allowing the nerve damage to progress, potentially leading to irreversible neurological problems. Therefore, it is crucial to test for B12 deficiency before supplementing with folic acid, and to take a balanced approach with a healthcare provider's guidance. Some research also suggests a potential link between very high folic acid intake over the long term and an increased risk of certain cancers, though more studies are needed.

The Role of a Nutritious Diet

For those not in the at-risk categories, prioritizing a diet rich in naturally occurring folate and fortified foods is the best strategy. Foods high in folate include:

Dark green leafy vegetables (spinach, kale, romaine lettuce)
Legumes (beans, peas, lentils)
Citrus fruits and juices
Fortified breakfast cereals
Asparagus and Brussels sprouts
Eggs
Liver (however, avoid during pregnancy)

Conclusion

While a balanced diet is the best source of nutrients for most people, a folate supplement is a crucial preventive measure for certain populations. Women of childbearing age, pregnant women, and individuals with specific medical conditions like anemia, malabsorption issues, or genetic variants are the primary candidates for supplementation. Because high doses of folic acid can mask a potentially dangerous vitamin B12 deficiency, it is vital to consult a healthcare professional to determine if a supplement is needed and at what amount. This ensures safe and effective management of your nutritional health and supports overall well-being. For more in-depth nutritional information, visit the Office of Dietary Supplements at the National Institutes of Health.

Disclaimer: This information is for general knowledge and should not be taken as medical advice. Consult with a healthcare professional before starting any new supplement regimen.

Frequently Asked Questions

Folate is the natural form of Vitamin B9 found in food, while folic acid is the synthetic form used in supplements and fortified foods. Folic acid is generally more easily absorbed by the body.

The CDC recommends that all women of childbearing age take folic acid daily. This should be continued during the first 12 weeks of pregnancy to help prevent neural tube defects.

For most healthy people, a balanced diet rich in leafy greens, legumes, and fortified grains can provide enough folate. However, heat can destroy natural folate, and certain conditions increase the need, making supplements necessary for some.

Common symptoms include fatigue, weakness, pale skin, shortness of breath, irritability, and a sore or red tongue. Deficiency can lead to megaloblastic anemia.

A common MTHFR genetic variant can reduce the body's ability to process folic acid. While most people with this mutation do not have health problems, some may benefit from supplementing with L-methylfolate, the active form of folate. For preventing NTDs in pregnancy, standard folic acid is still effective.

Yes, taking excessive folic acid can mask a vitamin B12 deficiency, which can cause permanent nerve damage if left untreated. It is important to stay within recommended limits unless advised otherwise by a doctor.

If you suspect a folate deficiency, it is important to speak with a healthcare provider. They can perform a blood test to confirm the deficiency and rule out a co-existing vitamin B12 deficiency before recommending a treatment plan.

Foods rich in folate include dark green leafy vegetables, legumes, citrus fruits, fortified cereals, asparagus, Brussels sprouts, and eggs.

Folic acid is crucial for proper development of the baby's brain and spine. Taking it before and during early pregnancy significantly reduces the risk of neural tube defects.