Folate deficiency anaemia

Folate is a B vitamin. You need folate for many important processes inside your body, including making red blood cells. If you don’t have enough folate, your body won't make as many red blood cells as normal. They will also be abnormally large and won't last as long as they should.

If you don't have enough red blood cells, your tissues and organs may not get enough oxygen. This leads to the symptoms of anaemia.

Common symptoms of all types of anaemia include:

• feeling tired
• looking pale
• increased breathlessness on exertion
• feeling your heart racing or thumping (called palpitations)

If you have folate deficiency anaemia, you may also develop problems, such as:

• a sore tongue
• indigestion
• a reduced sense of taste
• diarrhoea

These symptoms may be caused by problems other than folate deficiency anaemia. If you have any of these symptoms, see your GP for advice.

If you have anaemia, your heart has to work harder to get oxygen to your vital organs. If left untreated it can lead to problems with your heart and lungs. Having a deficiency in folate can also increase your risk of certain cancers.

There are a number of causes of folate deficiency. Some of the most common causes are listed below.

• Poor diet. Your body can't store folate, so you need to eat foods every day that contain folate to make sure your body has sufficient levels.
• Medicines. Certain epilepsy medicines and methotrexate, which is used to treat rheumatoid arthritis, can interfere with the way that folate is used in your body.
• Alcohol. Drinking too much alcohol can reduce your body's ability to absorb and use folate.
• Bowel disease. Coeliac disease or an inflammatory bowel disease, such as Crohn's disease, can interfere with how your body absorbs folate.
• Chronic haemolytic anaemias. These include certain inherited conditions such as thalassaemia and sickle cell anaemia, which cause red blood cells to break down too quickly. This increases your body’s need for folate and can lead to a deficiency if you don’t get enough in your diet.
• Pregnancy. If you’re a woman and become pregnant, you require more folate to meet the needs of your developing baby. If you don’t have sufficient folate intake, you may become deficient and your unborn baby may develop a neural tube defect. This happens when your unborn baby's nerves and spinal cord don't develop properly in the first months of pregnancy.

Your GP will ask about your symptoms, and examine you. He or she may also ask you about your medical history. If your GP suspects you have anaemia, you will be asked to have a blood test. Your blood will be sent to a laboratory to be tested for the following.

• A full blood count. This is to check the level of haemoglobin in your blood, how many of each of the different types of blood cell you have, the size of your red cells and the amount of haemoglobin in each red cell.
• A blood film. This involves looking at your blood under a microscope to check the size and shape of your red blood cells and to assess the different white cells that are present.
• Vitamin B12, iron and folate. The levels of each of these will be measured.

If your blood tests show that you have anaemia with enlarged red blood cells and low levels of folate, you could have folate deficiency anaemia.

You may need to have further tests to help identify the cause of your anaemia. Your GP may refer you to a haematologist (a doctor who specialises in identifying and treating conditions of the blood) or a gastroenterologist (a doctor who specialises in identifying and treating conditions that affect the digestive system).

Your GP will try to identify why you’re deficient in folate so that any underlying cause can be treated.

Self-help
If you’re not getting enough folate in your diet, your GP will give you advice on how to adjust it, or refer you to a dietitian. If your alcohol intake is excessive, he or she will suggest you reduce this.

Medicines

Your GP will also prescribe folic acid tablets. Before you start, he or she will check the levels of vitamin B12 in your blood. This is because although the treatment helps you to feel better, it may hide an underlying vitamin B12 deficiency. If this happens, you may develop problems with your nervous system.

Folate comes in a synthetic (artificial) form called folic acid. This is a water-soluble vitamin that your body can use instead of folate. You will usually need to take 5 milligrams per day, for at least four months. Some people may need to take folic acid for a long time, sometimes for life. Always read the patient information leaflet that comes with your supplements and if you have any questions, ask your GP or pharmacist for advice.

If you're taking folic acid to treat anaemia, your GP will monitor your blood count and folate level. You will be asked to have a blood test shortly after you start taking the supplements and again about eight weeks later to confirm that you’re responding to the treatment.

Special considerations
If you're pregnant and don't get enough folate in your diet, there is an increased risk of your baby developing a neural tube defect. It can result in spina bifida, which is where your baby's spine doesn’t form properly.

If you're planning to have a baby, you should take a supplement of 400 micrograms of folic acid before you become pregnant, and also in the first 12 weeks of pregnancy. This will help to reduce the risk of your baby having a neural tube defect. If you have previously had a child with this problem, ask your GP for advice as you may need to increase your intake of folic acid during your pregnancy. See our common questions for more information.

It's also important to eat folate-rich foods, such as broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice. Although liver is a good source of folate, pregnant women shouldn't eat liver or liver pâté because it contains lots of vitamin A. Large intakes of vitamin A during pregnancy are linked to an increased risk of birth defects.

You can reduce your risk of developing folate deficiency anaemia by eating a healthy, balanced diet that contains enough folate. The recommended daily amount for adults is 200 micrograms. For most people, having enough vegetables, fruit and grains will be sufficient without the need to take supplements.

Good sources of folate include broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice. It's also found in small amounts in leafy green vegetables like spinach, watercress and curly kale, some fruits (especially oranges and satsumas) and liver. Folate is damaged by heat, so fruit and vegetables will contain more folate when they are raw compared to when they are cooked. Breads or breakfast cereals that have been fortified with vitamins also contain a good source of folate. Fortified means that folic acid has been added during manufacturing.

If you have a condition that affects how well you absorb nutrients, or if you’re pregnant, you may need to take supplements. Ask your GP for advice.

Why do women who are pregnant need to take a higher dose of folic acid?

Answer
If you're pregnant, or are planning to have a baby, you will need to take folic acid supplements. This is to reduce the risk of your child having a neural tube defect.

Explanation
It's important to start taking folic acid supplements early, preferably as soon as you start trying for a baby, and for at least the first 12 weeks of your pregnancy. This will reduce the risk of your baby having a neural tube defect. A neural tube defect is when your unborn baby's nerves and spinal cord don't develop properly in the first months of pregnancy. It can result in spina bifida (where your baby’s spine doesn’t close properly) or anencephaly (where your baby’s brain and skull don’t close properly).

If you're at a particularly high risk of having a child with a neural tube defect, you will need to take a higher dose of folic acid. For example, your unborn baby may be at greater risk if you or your partner has a neural tube defect, such as spina bifida, or if you have previously had a pregnancy affected by a neural tube defect. Your unborn baby may also be at greater risk of having a neural tube defect if you have coeliac disease, diabetes, sickle cell anaemia, thalassaemia, or if you take anti-epilepsy medicines.

The recommended dose of folic acid for women at normal risk of having a baby with a neural tube defect is 400 micrograms daily. If you're at a high risk of having a baby with a neural tube defect, you will need to take a dose of 5 milligrams daily.

It's also important to make sure you get enough folate from the food you eat. Good sources of folate include broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice. It's also found in small amounts in leafy green vegetables like spinach, watercress and curly kale, some fruits (especially oranges and satsumas) and breads or breakfast cereals that have been fortified with vitamins. Fortified means that folic acid has been added during manufacturing.

Although liver is a good source of folate, pregnant women shouldn't eat liver or liver pâté because it contains a lot of vitamin A. Large intakes of vitamin A during pregnancy are linked with an increased risk of birth defects.

For more information about folic acid supplements, talk to your GP.

Do men need to take folic acid supplements when planning for a baby?

Answer
No, men don't need to take folic acid supplements when trying for a baby. However, men should eat a healthy, balanced diet and may wish to make some lifestyle changes to improve their fertility.

Explanation
There is limited evidence to suggest that men should increase their folate intake when trying for a baby, so it isn’t usually advised.

However, if you and your partner are planning to have a baby, it’s important for both of you to make some lifestyle adjustments to increase your chances of conceiving. Eating a healthy, balanced diet is a good start. The recommended daily amount of folate for adults is 200 micrograms per day. If you eat a balanced diet, you should get all the folate you need. Folate is found in foods such as broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice.

Is there a difference between folate and folic acid?

Answer
Yes, both are terms used for vitamin B9 but they come from different sources.

Explanation
Folate is the natural form of the vitamin B9 and is found in fresh green vegetables such as broccoli, Brussels sprouts, asparagus and peas. It's also found in some fruits (especially oranges and satsumas), as well as in liver.

Folic acid is a synthetic (artificial) type of the B vitamin used in supplements and is added to fortified foods such as breakfast cereals and spreads. Your body absorbs folic acid more efficiently because it's water-soluble and doesn't need to be broken down before it can be absorbed.

Further Information

• British Nutrition Foundation - 020 7404 6504 - www.nutrition.org.uk

Sources

• Anaemia – vitamin B12 and folate deficiency. Prodigy. www.prodigy.clarity.co.uk, published January 2011
• Vitamin B12 and folate deficiency. Lab Tests Online UK. www.labtestsonline.org.uk, published 20 October 2011
• Pre-conception – advice and management. Prodigy. www.prodigy.clarity.co.uk, published September 2010
• Joint Formulary Committee. British National Formulary. 62nd ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2011
• Your health in pregnancy. Department of Health. www.dh.gov.uk, published October 2009
• Folic acid – food factsheet. The British Dietetic Association. www.dba.uk.com, published May 2010
• Neural tube defects – factsheet 59. Centre for Genetics Education.