|Folic acid, a precursor of active B9|
Folate deficiency is a low level of folic acid and derivatives in the body. Also known as vitamin B9, folate is involved in adenosine, guanine, and thymidine synthesis (part of DNA synthesis). Signs of folate deficiency are often subtle. Anemia is a late finding in folate deficiency and folate deficiency anemia is the term given for this medical condition. It is characterized by the appearance of large-sized, abnormal red blood cells (megaloblasts), which form when there are inadequate stores of folic acid within the body.
Signs and symptoms
Loss of appetite and weight loss can occur. Additional signs are weakness, sore tongue, headaches, heart palpitations, irritability, and behavioral disorders. In adults, anemia (macrocytic, megaloblastic anemia) can be a sign of advanced folate deficiency.
Women with folate deficiency who become pregnant are more likely to give birth to low birth weight premature infants, and infants with neural tube defects. In infants and children, folate deficiency can lead to failure to thrive or slow growth rate, diarrhea, oral ulcers, megaloblastic anemia, neurological deterioration. Microcephaly, irritability, developmental delay, seizures, blindness and cerebellar ataxia can also be observed.
A deficiency of folate can occur when the body's need for folate is increased, when dietary intake or absorption of folate is inadequate, or when the body excretes (or loses) more folate than usual. Medications that interfere with the body's ability to use folate may also increase the need for this vitamin. Some research indicates that exposure to ultraviolet light, including the use of tanning beds, can lead to a folate deficiency. The deficiency is more common in pregnant women, infants, children, and adolescents. May also be due to poor diet or a consequence of alcoholism.
Additionally, a defect in homocysteine methyltransferase or a deficiency of B-12 may lead to a so-called "methyl-trap" of tetrahydrofolate (THF), in which THF is converted to a reservoir of methyl-THF which thereafter has no way of being metabolized, and serves as a sink of THF that causes a subsequent deficiency in folate. Thus, a deficiency in B-12 can generate a large pool of methyl-THF that is unable to undergo reactions and will mimic folate deficiency.
Folate (pteroylmonoglutamate) is absorbed throughout the small intestine, though mainly in the Jejunum, binding to specific receptor proteins. Diffuse inflammatory or degenerative diseases of the small intestine, such as Crohn's disease, coeliac disease, chronic enteritis or entero-enteric fistulae, may reduce the activity of pteroyl polyglutamase (PPGH), a specific hydrolase required for folate absorption, and thereby leading to folate deficiency.
Some situations that increase the need for folate include the following:
- kidney dialysis
- liver disease
- malabsorption, including celiac disease and fructose malabsorption
- pregnancy and lactation (breastfeeding)
- tobacco smoking
- alcohol consumption
Medications can interfere with folate utilization, including:
- anticonvulsant medications (such as phenytoin, primidone, carbamazepine or valproate)
- metformin (sometimes prescribed to control blood sugar in type 2 diabetes)
- methotrexate, an anti-cancer drug also used to control inflammation associated with Crohn's disease, ulcerative colitis and rheumatoid arthritis.
- sulfasalazine (used to control inflammation associated with Crohn's disease, ulcerative colitis and rheumatoid arthritis)
- triamterene (a diuretic)
- birth control pills
When methotrexate is prescribed, folic acid supplements are sometimes given with the methotrexate. The therapeutic effects of methotrexate are due to its inhibition of dihydrofolate reductase and thereby reduce the rate de novo purine and pyrimidine synthesis and cell division. Methotrexate inhibits cell division and is particularly toxic to fast dividing cells, such as rapidly dividing cancer cells and the progenitor cells of the immune system. Folate supplementation is beneficial in patients being treated with long-term, low-dose methotrexate for inflammatory conditions, such as rheumatoid arthritis (RA) or psoriasis, to avoid macrocytic anemia caused by folate deficiency. Folate is often also supplemented before some high dose chemotherapy treatments in an effort to protect healthy tissue. However, it may be counterproductive to take a folic acid supplement with methotrexate in cancer treatment.
Folate deficiency is diagnosed with a blood test.
Prevention and treatment
Folate is found in leafy green vegetables. Multi-vitamins also tend to include Folate as well as many other B vitamins. B vitamins, such as Folate, are water-soluble and excess is excreted in the urine.
Folate deficiency during human pregnancy has been associated with an increased risk of infant neural tube defects. Such deficiency during the first four weeks of gestation can result in structural and developmental problems. NIH guidelines recommend oral B vitamin supplements to decrease these risks near the time of conception and during the first month of pregnancy.
Folate deficiency during gestation or infancy due to development by the fetus or infant of autoantibodies to the folate receptor might result in various developmental disorders including autism spectrum disorders.
Studies suggest that insufficient folate and vitamin B12 status may contribute to major depressive disorder and that supplementation might be useful in this condition. The role of vitamin B12 and folate in depression is due to their role in transmethylation reactions, which are crucial for the formation of neurotransmitters (e.g. serotonin, epinephrine, nicotinamides, purines, phospholipids). The proposed mechanism, is that low levels of folate or vitamin B12 can disrupt transmethylation reaction, leading to an accumulation of homocysteine (hyperhomocisteinemia) and to impaired metabolism of neurotransmitters (especially the hydroxylation of dopamine and serotonin from tyrosine and tryptophan), phospholipids, myelin, and receptors. High homocysteine levels in the blood can lead to vascular injuries by oxidative mechanisms which can contribute to cerebral dysfunction. All of these can lead to the development of various disorders, including depression.
- Huether, Sue; McCance, Kathryn (2004). "20". Understanding Pathophysiology (3rd ed.). Mosby. p. 543. ISBN 0-323-02368-1.
- Tamparo, Carol. Diseases of the Human Body (Fifth ed.). Philadelphia, PA. p. 337. ISBN 978-0-8036-2505-1.
- Haslam N, Probert CS (1998). "An audit of the investigation and treatment of folate deficiency". Journal of the Royal Society of Medicine. 91 (2): 72–3. PMC . PMID 9602741.
- Kliegman, Robert M.; Stanton, Bonita M.D.; Geme, Joseph St.; Schor, Nina F (eds.). Nelson Textbook of Pediatrics (20th ed.). pp. 317–320. ISBN 978-1-4557-7566-8.
- Oakley GP Jr; Adams MJ; Dickinson CM (1996). "More folic acid for everyone, now". Journal of Nutrition. 126 (3): 751S–755S. PMID 8598560.
- McNulty H (1995). "Folate requirements for health in different population groups". British Journal of Biomedical Science. 52 (2): 110–9. PMID 8520248.
- Stolzenberg R (1994). "Possible folate deficiency with postsurgical infection". Nutrition in Clinical Practice. 9 (6): 247–50. doi:10.1177/0115426594009006247. PMID 7476802.
- Pietrzik KF, Thorand B (1997). "Folate economy in pregnancy". Nutrition. 13 (11–12): 975–7. doi:10.1016/S0899-9007(97)00340-7. PMID 9433714.
- Kelly GS (1998). "Folates: Supplemental forms and therapeutic applications". Altern Med Rev. 3 (3): 208–20. PMID 9630738.
- Cravo ML, Gloria LM, Selhub J, Nadeau MR, Camilo ME, Resende MP, Cardoso JN, Leitao CN, Mira FC (1996). "Hyperhomocysteinemia in chronic alcoholism: correlation with folate, vitamin B-12, and vitamin B-6 status". The American Journal of Clinical Nutrition. 63 (2): 220–4. PMID 8561063.
- "Pregnancy and Tanning". American Pregnancy Association. January 2014. Retrieved January 11, 2015.
- Borradale D, Isenring E, Hacker E, Kimlin MG (February 2014). "Exposure to solar ultraviolet radiation is associated with a decreased folate status in women of childbearing age". Journal of Photochemistry and Photobiology B: Biology. 131: 90–95. doi:10.1016/j.jphotobiol.2014.01.002.
- Tamparo, Carol (2011). Fifth Edition: Diseases of the Human Body. Philadelphia, PA: F. A. Davis Company. p. 337. ISBN 978-0-8036-2505-1.
- Hoffbrand, AV; Weir, DG (2001). "The history of folic acid". Br J Haematol. 113 (3): 579–589. doi:10.1046/j.1365-2141.2001.02822.x. PMID 11380441.
- "Folate: Evidence". Mayo Clinic. Retrieved January 11, 2015.
- Nutrient Data Laboratory (December 2007). "USDA Table of Nutrient Retention Factors, Release 6" (PDF). USDA.
- O’connor, Anahad (2006-10-17). "The Claim: Microwave Ovens Kill Nutrients in Food". The New York Times. ISSN 0362-4331. Retrieved 2017-07-10.
spinach retained nearly all its folate when cooked in a microwave, but lost about 77 percent when cooked on a stove
- McKillop, Derek J.; Pentieva, Kristina; Daly, Donna; McPartlin, Joseph M.; Hughes, Joan; Strain, J. J.; Scott, John M.; McNulty, Helene (2002). "The effect of different cooking methods on folate retention in various foods that are amongst the major contributors to folate intake in the UK diet". British Journal of Nutrition. 88 (6): 681–688. doi:10.1079/bjn2002733. ISSN 1475-2662.
other forms of cooking ... that minimise the direct contact of food with the cooking water such as pressure cooking ... and microwave cooking (Chen et al. 1983; Klein, 1989) have been found to be preferable to boiling in terms of folate retention.
- Czeizel AE, Dudás I, Vereczkey A, Bánhidy F (2013). "Folate deficiency and folic acid supplementation: the prevention of neural-tube defects and congenital heart defects". Nutrients. 5 (11): 4760–75. doi:10.3390/nu5114760. PMC . PMID 24284617.
- "Dietary Supplement Fact Sheet: Folate". National Institutes of Health. Retrieved January 11, 2015.
- Desai, A; Sequeira, JM; Quadros, EV (July 2016). "The metabolic basis for developmental disorders due to defective folate transport". Biochimie. 126: 31–42. doi:10.1016/j.biochi.2016.02.012. PMID 26924398.
- Coppen A, Bolander-Gouaille C (2005). "Treatment of depression: time to consider folic acid and vitamin B12". J Psychopharmacol. 19 (1): 59–65. doi:10.1177/0269881105048899. PMID 15671130.
- Karakuła H, Opolska A, Kowal A, Domański M, Płotka A, Perzyński J (2009). "Does diet affect our mood? The significance of folic acid and homocysteine". Pol Merkur Lekarski. 26 (152): 136–41. PMID 19388520.