Folate deficiency anemia occurs when a person has a low level of folate, or vitamin B-9, in their body. Folate plays a vital role in many bodily processes, such as creating red blood cells and preventing congenital disabilities.

When a person does not have enough folate, they develop anemia, the symptoms of which include fatigue, weakness, and pale skin. People can meet their daily folate needs by eating folate-rich roods or taking vitamin supplements.

In this article, we explore the causes, symptoms, and complications relating to folate deficiency anemia. We also discuss how to prevent and treat this condition.

What is folate deficiency anemia?

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A person may become anemic if they do not have sufficient folate in their body.

Folate is necessary for creating red blood cells, which carry oxygen to the body’s tissues.

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A lack of folate leads to anemia, a condition in which the body cannot create a sufficient number of red blood cells. Folate deficiency anemia is one of many different types of anemia.

If a person does not have enough red blood cells, their organs and tissues do not get enough oxygen, and their body cannot function efficiently.

As a result, they may experience classic anemia symptoms, such as fatigue, muscle weakness, and pale skin.

Getting enough folate through the diet and supplements is the best way to prevent folate deficiency anemia. The synthetic form of folate is called folic acid. Folic acid is present in many prenatal vitamins, multivitamins, and B complex vitamins, and it is also available as a separate vitamin supplement.

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What causes folate deficiency?

Folate deficiency may occur if a person does not consume enough foods that contain folate. However, even people who eat a healthful, balanced diet can develop folate deficiency.

The causes of folate deficiency anemia include:

  • not eating enough folate-rich foods
  • having a disease or condition that interferes with vitamin absorption, such as celiac disease or inflammatory bowel disease (IBD)
  • having alcohol use disorder, as alcohol interferes with folate absorption and causes the body to remove folate too quickly
  • being pregnant, which increases the body’s demand for folate
  • taking a medication that interferes with folate absorption or lowers folate levels
  • having a methylenetetrahydrofolate reductase (MTHFR) gene variant, as this interferes with the body’s ability both to convert folate to its active form in the body and to use it

Like all vitamin Bs, folate dissolves in water, and this means that the body cannot store it. The kidneys excrete any excess folate in the urine.

As a result, people can become deficient in folate within just a few weeks if their diet does not include enough folate or if they have a health condition that interferes with its absorption.

Everyone needs to get the recommended amount of folate each day because the body cannot store it. It is especially important for women who are pregnant or who could become pregnant.

Major health organizations, including the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists, recommend that women of childbearing age take a folic acid supplement every day. They offer this advice because low levels of folate increase the risk of having a baby with serious congenital disabilities of the brain and spinal cord.

Symptoms

At first, a person may not have obvious symptoms of folate deficiency anemia, but as it becomes more severe, people may notice:

  • weakness
  • feeling lightheaded
  • fatigue
  • trouble concentrating
  • irritability
  • headaches
  • a sore tongue
  • sores in the mouth or on the tongue
  • in pregnant women, having a baby with specific neural tube defects

Symptoms in pregnancy

Women need higher amounts of folate during pregnancy because folate is necessary for DNA formation as the fetus develops. Folate deficiency can interfere with normal cell division and growth in the fetus and placenta, leading to birth abnormalities.

If a woman does not get enough folate before and during pregnancy, her baby may develop serious neural tube defects, which are problems with the brain and spinal cord.

Neural tube defects include:

  • anencephaly, in which the fetus is missing parts of the brain and skull
  • spina bifida, which results in abnormalities of the spine, the nerves, or both

Folate deficiency can also cause the low birth weight of a baby. The CDC state that every woman of childbearing age should get 400 micrograms (mcg) of folic acid in addition to eating folate-rich foods.

Even women who do not plan to become pregnant should take a folic acid supplement because:

  • nearly half of all pregnancies in the U.S. are unintentional, according to the CDC
  • birth abnormalities resulting from folate deficiency occur very early on in pregnancy, often before a woman even knows that she is pregnant
  • it can be difficult to get the recommended amount of folate through the diet alone

Risk factors

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Pregnancy can be a risk factor for folate deficiency.

Risk factors for folate deficiency include:

  • malnutrition or not eating a varied diet that includes fruits, vegetables, and fortified foods
  • having alcohol use disorder or drinking large amounts of alcohol regularly
  • being a woman of childbearing age
  • being pregnant
  • having a malabsorptive disorder
  • having the MTHFR polymorphism gene variation that interferes with how the body uses folate
  • taking certain medications, including methotrexate, antiseizure medicines, and some medicines that treat ulcerative colitis

Diagnosis

Doctors cannot diagnose folate deficiency anemia from its symptoms alone. Many different types of anemia exist, including anemia that results from low iron or low vitamin B-12 levels, and they can have similar symptoms.

Usually, doctors will need to use a blood test to diagnose folate deficiency anemia. Measuring the folate concentration in the blood can reveal whether a person has enough folate in their body.

In a person with folate deficiency anemia, a blood test may also reveal abnormally shaped and immature blood cells called megaloblasts. These immature red blood cells are oversized and cannot deliver oxygen to the body efficiently. If a blood test shows that the person has megaloblasts, this is a strong indication that the person is deficient in either folate or vitamin B-12.

Complications

Folate deficiency may lead to problems with red blood cells, such as megaloblastic anemia, which can deprive the body’s organs and tissues of necessary oxygen.

Folate deficiency anemia in women during pregnancy may lead to problems in a developing fetus, including serious abnormalities of the brain and spinal cord or low birth weight.

Treatment

People who are deficient in folate may need to take folic acid supplements. A doctor might prescribe pills or injections, depending on the person’s needs.

Women of childbearing age who have folate deficiency anemia may wish to speak to a doctor if they plan to try getting pregnant. In some cases, a woman may decide to postpone pregnancy until her folate levels are normal.

It is important to speak to a healthcare professional before taking any supplements.

Some researchers have suggested that taking excessive amounts of folic acid can mask a vitamin B-12 deficiency. For this reason, do not take more than 1,000 mcg per day unless a doctor recommends a higher dose.

Prevention

man cooking with asparagus
A person may prevent folate deficiency anemia by eating foods that contain folate.

Taking a folic acid supplement and eating a healthful diet will prevent many cases of folate deficiency anemia.

People who have risk factors for folate deficiency should ask a doctor about the right amount of folic acid to take.

A person may also prevent folate deficiency anemia by eating foods that are rich in folate or that manufacturers have fortified with folic acid.

Folate occurs naturally in many foods, including:

  • spinach
  • romaine lettuce
  • Brussels sprouts
  • asparagus
  • avocado
  • beans

To make it easier for people to meet their folic acid requirements, as of 1998, the Food and Drug Administration (FDA) require food manufacturers to add folic acid to standardized enriched cereal grain products, such as enriched bread.

Products that manufacturers often fortify with folic acid include flours, breakfast cereals, and other grain products. These fortified foods are a good source of folic acid in the diet.

Outlook

If a person diagnoses and treats folate deficiency anemia in the early stages, they will not usually experience any long-term problems.

People can usually treat and prevent folate deficiency by either getting enough folate from their diet or taking vitamin supplements. People can choose multivitamins that contain folic acid or just take folic acid supplements.

People can find folic acid supplements in drug stores or choose between brands online:

To prevent complications, women should ensure that they meet their folic acid requirements before and during pregnancy. Although treatments exist for spina bifida, it often causes some degree of physical or mental disability in the baby. There is no treatment for anencephaly, and the CDC state that most babies who have this condition die shortly after birth.

Women of childbearing age should consider taking a prenatal vitamin each day. Doing this will ensure that they get adequate amounts of folic acid along with other nutrients that they need if they become pregnant.