Who needs folate the most? Identifying key groups and risks

October 8, 2025 •

4 min read

According to the Centers for Disease Control and Prevention (CDC), since the U.S. began fortifying grain products with folic acid, the number of babies born with neural tube defects has significantly decreased. Understanding who needs folate the most is crucial, as this essential B vitamin is vital for cell growth, DNA synthesis, and red blood cell formation. While many get enough from their diet, specific populations have higher needs and greater risks of deficiency.

Quick Summary

Folate is a critical nutrient, with pregnant women and those planning a pregnancy having the highest requirements to prevent birth defects. Other high-risk groups include people with malabsorption issues, genetic mutations, liver disease, and individuals with alcohol use disorders. Supplementation and dietary strategies are key for these populations.

Key Points

Pregnant and planning women: The highest risk group for folate deficiency, often requiring daily folic acid consideration to prevent neural tube defects.
Malabsorption issues: Conditions like Celiac and Crohn's disease hinder folate absorption, necessitating careful management and potentially higher intake strategies.
MTHFR gene mutation: Individuals with this mutation have reduced ability to process synthetic folic acid and may benefit from active L-methylfolate considerations.
Chronic alcohol use: Heavy drinking impairs folate absorption and metabolism, increasing the risk of deficiency and its complications.
Liver and kidney disease: These conditions can disrupt the body's folate storage and utilization, requiring dietary adjustments and monitoring.
Certain medications: Drugs like methotrexate and some anti-seizure medications can interfere with folate, making its careful consideration necessary.
Prevention of anemia: Ensuring adequate folate intake helps prevent megaloblastic anemia, a type of deficiency that causes fatigue and weakness.

The critical role of folate in the body

Folate, or vitamin B9, is an essential water-soluble vitamin that plays a foundational role in numerous bodily processes. It is critical for producing DNA and other genetic material, and for creating healthy new cells. These functions make it especially important during periods of rapid cell division and growth, such as during fetal development. Folate also works with vitamin B12 to produce red blood cells and to regulate homocysteine levels, a byproduct of protein metabolism.

Low folate levels can lead to a condition called megaloblastic anemia, where the body produces abnormally large, immature red blood cells that cannot function effectively. This can cause symptoms such as fatigue, weakness, and shortness of breath. Given its crucial role in cell and tissue formation, deficiency poses significant health risks for various groups.

Women of childbearing age and pregnant women

Women who are pregnant or may become pregnant are, without a doubt, the population with the greatest need for adequate folate intake. This is primarily due to folate's ability to prevent major birth defects of the baby’s brain and spine, known as neural tube defects (NTDs), including spina bifida and anencephaly.

The neural tube develops in the very first weeks of pregnancy, often before a woman even knows she is pregnant. To protect against NTDs, health authorities often recommend that all women of childbearing age—not just those actively trying to conceive—take a daily folic acid supplement in addition to dietary intake. For women with a history of NTD-affected pregnancies or a family history of NTDs, a higher dosage may be prescribed by a doctor.

After the first trimester, the requirement remains high to support continued fetal growth.

Other high-risk groups for folate deficiency

While pregnant women receive the most attention, several other groups require special attention to their folate status:

Individuals with malabsorption disorders: Conditions that affect the small intestine, such as Crohn's disease, celiac disease, and irritable bowel syndrome (IBS), can impair the body's ability to absorb nutrients, including folate.
People with liver or kidney disease: Liver disease can disrupt folate storage, while kidney dialysis can cause folate to be removed from the body, increasing the risk of deficiency.
Individuals with a specific genetic mutation: A significant portion of the population has a mutation in the MTHFR gene, which impairs the body's ability to convert folate into its active, usable form. For these individuals, supplementation with the active form, L-methylfolate, may be more effective.
People with chronic alcohol use: Alcohol interferes with folate absorption and increases its excretion from the body. Individuals with heavy alcohol use often have poor dietary intake, compounding the risk.
Those taking certain medications: Some medications, such as methotrexate (used for rheumatoid arthritis and psoriasis) and certain anti-seizure drugs, can interfere with folate metabolism. In these cases, doctors often discuss strategies to counteract the drug's effects, which may include folate.

Dietary sources of folate

To ensure adequate intake, a balanced diet rich in folate-containing foods is essential. Folate is found naturally in many foods, while folic acid is the synthetic form used to fortify certain grain products.

Naturally occurring folate:
- Leafy greens: Spinach, kale, romaine lettuce
- Legumes: Lentils, chickpeas, black-eyed peas
- Fruits: Oranges, bananas, papayas
- Organ meats: Beef liver
- Other vegetables: Asparagus, broccoli, Brussels sprouts
Folic acid (fortified foods):
- Enriched bread and pasta
- Fortified breakfast cereals
- White rice and cornmeal

Supplementation versus fortified foods

Many people can get their daily folate needs through a combination of natural food sources and fortified products. However, for high-risk individuals, supplementation with folic acid or L-methylfolate is often necessary and recommended by healthcare providers. The absorption of synthetic folic acid from supplements and fortified foods is higher than that of naturally occurring folate. For this reason, supplementation can be a reliable way to ensure consistent intake, particularly for women trying to prevent neural tube defects.

Comparison of folate needs by demographic


Demographic Group	Primary Reason for High Need	Special Considerations
Women of childbearing age	Crucial for preventing neural tube defects in case of pregnancy.	Important to consider daily intake, even if not actively trying to conceive, due to unplanned pregnancies.
Pregnant women	Supports rapid cell growth and fetal development, preventing birth defects.	Higher intake may be recommended for high-risk cases.
Breastfeeding women	Supports both the mother's needs and the high folate demand for milk production.	Ensuring adequate intake supports nutrient-rich breast milk for the infant.
People with malabsorption	Conditions like Celiac or Crohn's disease interfere with nutrient absorption.	May require supplementation under medical supervision.
Individuals with MTHFR mutation	Impaired ability to convert synthetic folic acid to the active form.	Requires consideration of supplement form for effective absorption and use.
Individuals with chronic alcohol use	Alcohol impairs folate absorption and increases breakdown and excretion.	Dietary intake is often low, necessitating focused dietary improvement and potential supplementation.

Conclusion

While a sufficient folate intake is important for everyone to maintain general health, certain populations bear a greater burden of risk associated with deficiency. Women who are or may become pregnant are the most prominent group needing consistent and deliberate folate focus to prevent serious birth defects. Additionally, individuals with specific health conditions, such as malabsorption issues, liver or kidney disease, and those with certain genetic factors or on particular medications, have heightened needs. By understanding these unique requirements and risks, targeted dietary and supplementation strategies can be implemented, promoting better health outcomes for those who need folate the most. Consulting a healthcare provider is the best way to determine individual folate needs and ensure they are met safely and effectively.

Frequently Asked Questions

The primary reason is to prevent neural tube defects (NTDs), which are serious birth defects of the brain and spine that occur in the first few weeks of pregnancy, often before a woman knows she is pregnant.

Folate is the natural form of vitamin B9 found in food, while folic acid is the synthetic, man-made form found in supplements and fortified foods. Folic acid is often more easily absorbed by the body than natural folate.

For the general population, a balanced diet can often provide enough folate. However, for high-risk groups, such as women of childbearing age, focusing on folic acid intake is often recommended to ensure adequate and consistent levels.

Common symptoms of folate deficiency can include fatigue, weakness, shortness of breath, a sore tongue, mouth ulcers, pale skin, and irritability.

Excellent natural sources of folate include dark leafy greens like spinach, legumes such as lentils and chickpeas, fruits like oranges, and beef liver.

Women who could become pregnant are often advised to prioritize folic acid intake from a supplement or fortified food, in addition to folate from natural sources.

It is not possible to consume too much natural folate from food. However, excessively high amounts of synthetic folic acid from supplements can potentially mask a vitamin B12 deficiency, which can lead to nerve damage. There are recommended upper limits for synthetic folic acid intake.