Are you getting enough folate in your diet?

Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food. Folic acid is synthetic and is found in supplements and fortified foods.

Folate is important in the production and maintenance of new cells. This is especially important during periods of rapid cell division and growth such as infancy and pregnancy. Folate is needed to make DNA and RNA, the building blocks of cells. It also helps prevent changes to DNA that may lead to cancer. Both adults and children need folate to make normal red blood cells and prevent anemia.

In what foods is folate found?

Leafy, dark greens such as spinach and turnip greens, dry beans and peas, fortified cereals and grain products, and some fruits and vegetables are rich food sources of folate. Some breakfast cereals (ready-to-eat and others) are fortified with 25%-100% of the Daily Value (DV) for folic acid.

Since 1998, food manufacturers have been required to add folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products. These regulations specifically target a reduction in the risk of neural tube birth defects in newborns. Since this program took effect, fortified foods have become a major source of folic acid in the North American diet. Synthetic folic acid that is added to fortified foods and dietary supplements has a simpler chemical make-up than the natural form of folate, and is absorbed more easily by the body. After digestion and absorption however, the two forms are identical and function in exactly the same manner.

How much folate do we need?

The 1998 Recommended Dietary Allowances for folate for adult men and women (aged 19 years and older) is 400 mcg. During pregnancy the daily intake should be increased to 500 mcg, and the RDA for breastfeeding women is 500 mcg.

The National Health and Nutrition Examination Survey (NHANES III 1988-91) and the Continuing Survey of Food Intakes by Individuals (1994-96 CSFII) indicated that most adults did not consume an adequate amount of folate. However, the folic acid fortification program has increased folic acid content of commonly eaten foods such as cereals and grains, and as a result diets of most adults now provide recommended amounts of folate equivalents.

When can deficiency occur?

A deficiency of folate can occur when your need for it is increased, when dietary intake of folate is inadequate, and when your body loses more folate than usual. Medications that interfere with your body’s ability to use folate may also increase the need for this vitamin. Some situations that increase the need for folate include:

• Pregnancy and lactation (breastfeeding)
• Alcohol abuse
• Malabsorption
• Kidney dialysis
• Liver disease
• Certain anemias

Some medications interfere with the body’s ability to use folate, including:

• Dilantin, phenytoin, and primidone
• Metformin
• Sulfasalazine
• Triamterene
• Methotrexate

The signs of folic acid deficiency are often subtle. Diarrhea, loss of appetite, and weight loss can occur. Additional signs are weakness, sore tongue, headaches, heart palpitations, irritability, and behavioral disorders. Women with folate deficiency who become pregnant are more likely to give birth to low birth weight and premature infants, and infants with neural tube defects. In adults, anemia is a sign of advanced folate deficiency.

In infants and children, folate deficiency can decrease growth rate. Some of these symptoms can also result from a variety of medical conditions other than folate deficiency. It is important to have a physician evaluate these symptoms so that appropriate medical care can be given.

Who may need extra folic acid to prevent a deficiency?

• Women of childbearing age
• People who abuse alcohol
• Anyone taking anti-convulsants or other medications that interfere with the action of folate
• Individuals diagnosed with anemia from folate deficiency
• Individuals with malabsorption, liver disease, or who are receiving kidney dialysis treatment may benefit from a folic acid supplement

It is recommended that women who may become pregnant take folic acid. Adequate folate intake during the time just before and just after pregnancy protects against a number of congenital malformations including neural tube defects. Neural tube defects result in malformations of the spine called spina bifida, and of the skull, and brain anencephaly. The risk of neural tube defects is significantly reduced when supplemental folic acid is consumed in addition to a healthful diet prior to and during the first month following conception.

Women who could become pregnant are advised to eat foods fortified with folic acid or take supplements in addition to eating folate-rich foods to reduce the risk of some serious birth defects.

Research also shows that folate deficiency can be found in alcholics. In 1997 a review of the nutritional status of chronic alcoholics found low folate status in more than 50% of those surveyed. Alcohol messes with the absorption of folate and increases excretion of folate by the kidney. Additionally, many alcoholics have poor diets that do not provide the recommended intake of folate. Increasing folate intake through diet, or folic acid intake through fortified foods or supplements, may be beneficial to the health of alcoholics.

Taking anti-convulsants like dilantin has been found to increase the need for folate in the diet. If you are using an anti-convulsant or other drugs that may interfere with your body’s ability to use folate consult your doctor about possibly taking a folic acid supplement.

Anemia is a condition that occurs when red blood cells cannot carry enough oxygen. It can result from a wide variety of medical problems, including folate deficiency. Folate deficiency can result in the formation of large red blood cells that do not contain adequate hemoglobin, the substance in red blood cells that carries oxygen to your body’s cells. Your doctor can determine whether an anemia is associated with folate deficiency and whether supplemental folic acid is needed.

Liver disease and kidney dialysis boost excretio
n (loss) of folic acid. Malabsorption can hinder your body from using folate in food. Here again, your doctor will evaluate the need for a folic acid supplement.

Is there a health risk associated with too much folic acid?

The risk of toxicity from folic acid is low. The Institute of Medicine has established an upper intake level for folate of 1,000 mcg (micrograms) for adult men and women, and an upper intake level of 800 mcg for pregnant and breast-feeding women less than 18 years of age. Supplemental folic acid should not exceed the upper intake level to prevent folic acid from masking symptoms of vitamin B12 deficiency.

What should I know about folic acid supplements?

• Be cautious of the interaction between vitamin B12 and folic acid.
• Folic acid supplements will not correct changes in the nervous system that result from vitamin B12 deficiency.
• Permanent nerve damage can occur if vitamin B12 deficiency is not treated.
• Intake of supplemental folic acid should not exceed 1,000 micro grams per day to prevent folic acid from masking symptoms of vitamin B12 deficiency.
• Older adults must be made aware of the relationship between folic acid and vitamin B12 because they are at greater risk of having a vitamin B12 deficiency. If you are 50 years of age or older, ask your physician to check your B12 status before you take a supplement that contains folic acid.

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