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Folate Status – Levels, Deficiency & Health

Folate status describes how well the body is supplied with folic acid (vitamin B9). It is determined through blood tests and is especially important during pregnancy.

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Folate status describes how well the body is supplied with folic acid (vitamin B9). It is determined through blood tests and is especially important during pregnancy.

What Is Folate Status?

Folate status refers to the level of folate – also known as folic acid or vitamin B9 – in the body. Folate is a water-soluble B vitamin that plays a critical role in many essential body functions. Folate status is typically assessed through a blood test that measures folate levels in the serum or in red blood cells (erythrocytes).

Biological Functions of Folate

Folate performs several key functions in the body:

Cell division and growth: Folate is essential for DNA synthesis, which is required for the production of new cells.
Blood cell formation: Together with vitamin B12, folate is involved in the maturation of red blood cells.
Neural tube development: Adequate folate intake during early pregnancy is critical for proper development of the nervous system in the unborn child.
Homocysteine metabolism: Folate helps regulate homocysteine levels in the blood – elevated levels are considered a risk factor for cardiovascular disease.

Reference Values and Assessment of Folate Status

Folate status is assessed based on measured blood values:

Serum folate: Reflects short-term intake. Normal range: 6–20 ng/mL (may vary by laboratory).
Red blood cell (erythrocyte) folate: Reflects longer-term folate stores over the past 2–3 months. Normal range: 150–700 ng/mL.

Values below these reference ranges may indicate folate deficiency, while very high values can occur with excessive supplementation.

Causes of Impaired Folate Status

Deficiency

Low folate status can result from several factors:

Poor diet low in vegetables and legumes
Increased requirements during pregnancy and breastfeeding
Malabsorption syndromes (e.g., Crohn's disease, celiac disease)
Chronic alcohol consumption
Use of certain medications (e.g., methotrexate, antiepileptics)
Genetic variants such as the MTHFR polymorphism, which affects folate metabolism

Excess

Very high folate levels occur almost exclusively due to high-dose supplementation. Excessive intake through food alone is practically impossible.

Symptoms of Folate Deficiency

Insufficient folate status can cause the following symptoms:

Fatigue and general weakness
Megaloblastic anemia (a form of anemia involving enlarged, immature red blood cells)
Mucosal changes (e.g., mouth ulcers, inflamed tongue)
Difficulty concentrating and memory problems
In pregnant individuals: increased risk of neural tube defects in the baby (e.g., spina bifida)

At-Risk Groups

Certain groups are at higher risk of poor folate status:

Pregnant individuals and those planning a pregnancy
Older adults
People with chronic intestinal diseases
Individuals with high alcohol consumption
Vegans and vegetarians with a one-sided diet
People taking certain long-term medications

Diagnosis

Folate status is determined through a blood test ordered by a healthcare professional. Both serum folate and red blood cell folate levels can be measured. Additionally, homocysteine levels may be assessed, as elevated homocysteine is frequently associated with folate deficiency.

Dietary Sources and Recommended Intake

Folate occurs naturally in many foods:

Green leafy vegetables (spinach, broccoli, lamb's lettuce)
Legumes (lentils, chickpeas, beans)
Whole grain products
Liver (use is restricted during pregnancy)
Eggs and dairy products

The World Health Organization (WHO) and most national nutrition authorities recommend a daily folate intake of 400 µg for healthy adults. Requirements increase during pregnancy (up to 600 µg) and breastfeeding (up to 500 µg).

Supplementation

In cases of confirmed deficiency or increased need, physicians typically recommend folic acid supplements. Supplementation is especially important for individuals planning a pregnancy: it is recommended to begin taking at least 400 µg of synthetic folic acid daily at least 4 weeks before conception and throughout the first trimester. People with the MTHFR polymorphism may benefit more from the active form 5-methyltetrahydrofolate (5-MTHF).

References

Bailey LB et al.: Biomarkers of Nutrition for Development – Folate Review. Journal of Nutrition, 2015; 145(7):1636S–1680S. PubMed PMID: 26063472.
World Health Organization (WHO): Guideline: Daily iron and folic acid supplementation in pregnant women. WHO, Geneva, 2012. Available at: https://www.who.int
Institute of Medicine (US): Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academies Press, Washington DC, 1998.

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