(This article was first printed in the April, 2001 issue of the Harvard Women's Health
Watch. For more information or to order, please go to http://health.harvard.edu/women.)
In general, folate means the naturally occurring form of the vitamin that is in foods or in
the blood; folic acid usually refers to the synthetic form of the vitamin found in
supplements and fortified foods. Folacin refers to both forms. These terms are often used
interchangeably. Amounts are listed in either milligrams (mg) or micrograms (mcg): 0.4
mg = 400 mcg.Folate is an important vitamin, but not just for the reason we know best.
Most of us know that women of childbearing age need to get enough folate to help
prevent birth defects involving the brain and spinal cord. But if we focus on this benefit
alone, we may vastly underestimate folate's broader effect on our health. Mounting
evidence suggests that adequate intake of this nutrient may help prevent an astonishing
variety of health problems at all stages of life—from conception through old age.
Folic Acid and The Heart
Folate is considered a key nutrient in heart health because of its effect on blood levels of
homocysteine. This amino acid is found at high levels in as many as 50% of people with
cardiovascular disease, but only 5% of the general population. Since 1984, dozens of
studies have reported an association between high levels of homocysteine and severe
atherosclerosis, involving the heart, brain, or legs. Homocysteine is thought to promote
vascular problems by damaging blood-vessel linings and making the blood more likely to
clot. Research has shown that homocysteine levels are influenced by the action of the B
vitamins: folic acid and vitamins B6 and B12.
More information is needed from randomized controlled trials before we know whether
lowering homocysteine levels with folic acid supplements will lower the risk of heart
disease and what the optimal dose might be. But evidence so far hints strongly that folate
supplementation may afford women some protection against heart disease. Nurses' Health
Study researchers have evaluated the impact of vitamins on heart disease in 80,082 study
participants. The risk for coronary heart disease was 20–30% lower in women in the
study who were getting at least 400 mcg of folic acid daily (the amount in most
multivitamins) than in women who got less. Women with the highest intake of both folate
and vitamin B6 had a 45% lower risk than the women with the lowest intake.
Dietary changes and treatment with folic acid have been shown to lower homocysteine
levels and may even reverse some cardiovascular damage. In a study reported in
Circulation (Aug. 22, 2000), eight weeks on a low-fat diet rich in fruits, vegetables, and
low-fat dairy products (and including whole grains, poultry, fish, and nuts) increased
folate levels and lowered homocysteine levels. A study of 101 patients with vascular
disease, reported in the American Journal of Hypertension (January 2000), found that
high-dose folic acid caused shrinkage of carotid-artery plaques that had been growing
slowly larger. Both patients with low and those with high homocysteine levels benefited,
but only if they consumed exceptionally large doses of folic acid.
The American Heart Association (AHA) is awaiting the results of large treatment trials
before deciding whether to recommend that everyone take folic acid supplements to
prevent heart disease. Meanwhile, the AHA advocates a diet rich in folate and vitamins
B6 and B12. It also suggests that homocysteine measurements might help clinicians assess
risk in people with a personal or family history of heart disease who do not themselves
have any well-established risk factors, such as high cholesterol or diabetes. Other experts
believe that everyone should raise the subject of folic acid supplements with their
Possible Protection Against Cancer
Folate also plays a vital role in normal cell division and the repair of DNA damage.
Scientists have observed that patients with many types of cancer have low folate levels,
and there is intriguing evidence that folic acid may help prevent colon and breast cancer.
The Nurses' Health Study found that folic acid intake has no impact on breast-cancer risk,
with one exception. In a study confirming that alcohol raises breast cancer risk, the
researchers also found that women who drank alcohol did not have a higher risk if they
consumed at least 600 mcg/day of folic acid from diet and supplements. Alcohol is
known to lower folate levels.
The Nurses' Health Study also showed that women taking folic acid-containing
multivitamins for at least 15 years were 75% less likely to develop colon cancer than
women who did not take multivitamins. The reduction was statistically significant only
with long-term use. A modest decrease in colon cancer incidence occurred among women
who took no supplements but whose diets contained at least 400 mcg of folate per day.
Folic acid supplements also lower the risk of colon cancer in people with ulcerative
colitis. In one study, the incidence of abnormal new cell growth was 46% lower in
patients taking 1,000 mcg/day of folic acid than in people who did not receive
supplements. Those taking 400 mcg/day also benefited, but not as much. If you have
ulcerative colitis or Crohn's disease, ask your physician whether you should take a
standard multivitamin with folic acid or a higher dose.
Folate's Link to Diseases of Aging
Researchers have found connections between folic acid and several common diseases of
aging. In one study that evaluated the brains of deceased elderly nuns, low levels of blood
folate were significantly correlated with the extent of atrophy in the cerebral cortex of the
brain. The link was twice as strong in nuns who had been diagnosed with Alzheimer's
disease. This correlation did not exist with any other nutritional marker. A British study
found that Alzheimer's disease was 3.3 times more likely among subjects with the lowest
serum folate levels than in those with the highest levels. Austrian researchers have
recently reported similar findings in the American Journal of Clinical Nutrition .
Age-related hearing loss affects about 1 in 4 women over age 65. In the first study linking
vitamins to hearing loss, researchers found that in a group of 55 women ages 60–71,
those with impaired hearing had 31% lower serum folate levels—and 38% lower serum
B12—than the women with normal hearing.
Folate Deficiency and Who's at Risk
Anemia, producing fatigue, weakness, irritability, and shortness of breath, is the classic
sign of folate deficiency. These symptoms come on gradually and are caused by a
reduction in the blood's oxygen-carrying capacity. Folic acid deficiency can also cause a
sore tongue, indigestion, and diarrhea. Low levels of folate are common in people with
intestinal disorders, alcoholism, or any other condition that compromises nutrient
Some medications interfere with the absorption of folic acid or disrupt the process by
which it is metabolized into a usable form. These actions may explain some of their side
effects, and folic acid supplements may make them more tolerable. If you are taking any
of the following drugs, ask your doctor whether extra folic acid might reduce drug side
effects or improve your health without interfering with the medication's intended
—an antiinflammatory drug used to treat Crohn's disease, ulcerative colitis, and
rheumatoid arthritis. The Crohn's and Colitis Foundation encourages patients who
take sulfasalazine to ask about a prescription supplement if they cannot get
adequate folic acid through diet alone.
—frequently prescribed for rheumatoid arthritis (RA) and psoriasis. The National
Psoriasis Foundation advises people who are taking methotrexate for severe
psoriasis that between 1,000 and 5,000 mcg/day of folic acid, as recommended by
a physician, may reduce treatment-related nausea.
—used to treat urinary tract infections, eye infections, and pneumocystis
—a diuretic used in combination with hydrochlorothiazide to treat hypertension,
congestive heart failure, and liver or kidney disorders.
—used to treat epilepsy, trigeminal neuralgia, and some mental illnesses.
Various other anticonvulsants,
including phenytoin, primidone, and phenobarbital.
A Sampling of Food Folate Sources
The serving sizes of the following foods will give you about 100 mcg of folate:
1 cup Brussels sprouts
1 cup cooked collard greens, mustard greens, or green peas
1½ cups cooked broccoli
5 spears asparagus
½ cup cooked spinach
½ cup avocado
1½ cups shredded romaine lettuce
1¼ cups orange juice or 2 oranges
1½ cups firm tofu
2 ounces dry-roasted sunflower seeds
½ cup dry roasted peanuts
¼ cup cooked lentils
½ cup cooked black beans, kidney beans, or chickpeas
½ cup non-fat plain yogurt
1 cup low-fat buttermilk
Check food labels for the amount of folic acid in servings of fortified breakfast cereal.
Labels on enriched flour, rice, and noodle products will not list a specific amount of the
nutrient. According to the FDA, if a product is labeled "high in folate" a serving must
contain at least 20% of the daily value; a "good source" provides 10–19%. Folate in foods
is easily destroyed. To maintain folate, store fruits and vegetables in the refrigerator, and
do not overcook them.
Getting Enough Folic Acid
The synthetic folic acid in supplements and fortified foods is easier for the body to absorb
than naturally occurring folate is. Once in the body, the two are identical in their actions,
but the bioavailability of natural folate is roughly half that of folic acid from supplements
and fortified foods. Consequently, you have to eat about 800 mcg of natural folate to get
the amount of folic acid—400 mcg—typically found in a multivitamin.
All women of reproductive age who might become pregnant should take a supplement or
eat fortified foods to get 400 mcg/day of folic acid, in addition to a varied diet. Pregnant
women should increase their total intake to 1,000 mcg/day, as supplied in prescription
prenatal vitamins. Some physicians recommend staying on prenatal vitamins throughout
All other adults should get at least 400 mcg/day of folic acid from supplements or
fortified foods. They should also be sure to get enough vitamins B6 and B12. Vitamin
supplements are a good way to get enough of all three nutrients. Postmenopausal
women—particularly those not on hormone replacement therapy—are more likely to
have lower folate and higher homocysteine levels and should pay close attention to their
folic acid intake.
Critics of folic acid supplements and fortified foods once argued that these products
could mask pernicious anemia, a condition related to B12 deficiency. A person who took
large amounts of folic acid could suffer permanent nervous system damage because there
would be no anemia to signal the B12 deficiency. To avoid this problem, the Institute of
Medicine (IOM) advises that you limit folic acid from supplementation and fortified
foods to 1,000 mcg/day. The IOM also recommends that people over 50 take 2.4 mcg/day
of vitamin B12 in a supplement.
--- In TheHypnoBirthingNest@yahoogroups.com, "Carol Keene" <carolkeene@...>
> Hello Heera & Welcome to the HB Nest!
> At 33 weeks into her pregnancy, it is a little late in the game for your
> mom to be concerned enough to bring up the state of her nutrition with
> you & this problem taking her supplements is something she should have
> talked over long ago with her OB & also should have made him/her aware
> that she is a vegetarian. Then, the mom should have taken steps on her
> own to solve the dilemma & run them past her OB.
> As a vegetarian who was about to become pregnant or was newly pregnant,
> it was encumbent upon her to educate herself well enough about nutrition
> in pregnancy that she should have been able to find a way to deal with
> her problem of not being able to tolerate her supplements. Many women
> (my daughter included) experience the same problems as she did but
> perservere & find a way to make sure they get adequate Folate & other
> nutrients before, during & after pregnancy - and especially if they are
> going to be breastfeeding. It is easy to say, "oh well, I just can't do
> it". A big part of HypnoBirthing is about owning your power - if she
> has gone this far & hasn't seen the need to find out how she can
> adequately nourish herself & her unborn child, what are you as a
> HypnoBirthing Practitioner supposed to say to her??? Just give her the
> information & let her decide on her own how to improve the situation.
> Every women owes it to her unborn child to see that it has the best
> possible start in life.
> the following information is from:
> .html> and
> Having a healthy baby means making sure you're healthy, too. One of the
> most important things you can do to help prevent serious birth defects
> in your baby is to get enough folic acid every day - especially before
> conception and during early pregnancy.
> What Is Folic Acid?
> Folic acid, sometimes called folate, is a B vitamin (B9) found mostly in
> dark leafy green vegetables like kale and spinach, orange juice, nuts,
> and enriched grains. (SOUNDS LIKE A VEGETARIAN'S DREAM TO ME).
> Repeated studies have shown that women who get 400 micrograms (0.4
> milligrams) daily prior to conception and during early pregnancy reduce
> the risk that their baby will be born with a serious neural tube defect
> (a birth defect involving incomplete development of the brain and spinal
> cord) by up to 70%.
> The most common neural tube defects are spina bifida (an incomplete
> closure of the spinal cord and spinal column), anencephaly (severe
> underdevelopment of the brain), and encephalocele (when brain tissue
> protrudes out to the skin from an abnormal opening in the skull). All of
> these defects occur during the first 28 days of pregnancy - usually
> before a woman even knows she's pregnant.
> That's why it's so important for all women of childbearing age to get
> enough folic acid - not just those who are planning to become pregnant.
> Only 50% of pregnancies are planned, so any woman who could become
> pregnant should make sure she's getting enough folic acid.
> Doctors and scientists still aren't completely sure why folic acid has
> such a profound effect on the prevention of neural tube defects, but
> they do know that this vitamin is crucial in the development of DNA. As
> a result, folic acid plays a large role in cell growth and development,
> as well as tissue formation.
> Getting Enough Folic Acid
> The U.S. Centers for Disease Control and Prevention (CDC) recommends
> that all women of childbearing age - and especially those who are
> planning a pregnancy - consume about 400 micrograms (0.4 milligrams) of
> folic acid every day. Adequate folic acid intake is very important 1
> month before conception and at least 3 months afterward to potentially
> reduce the risk of having a fetus with a neural tube defect.
> So, how can you make sure you're getting enough folic acid? In 1998, the
> Food and Drug Administration mandated that folic acid be added to
> enriched grain products - so you can boost your intake by looking for
> breakfast cereals, breads, pastas, and rice containing 100% of the
> recommended daily folic acid allowance. But for most women, eating
> fortified foods isn't enough. To reach the recommended daily level,
> you'll probably need a vitamin supplement.
> During pregnancy, you require more of all of the essential nutrients
> than you did before you became pregnant. Although prenatal vitamins
> shouldn't replace a well-balanced diet, taking them can give your body -
> and, therefore, your baby - an added boost of vitamins and minerals.
> Some health care providers even recommend taking a folic acid supplement
> in addition to your regular prenatal vitamin. Talk to your doctor about
> your daily folic acid intake and ask whether he or she recommends a
> prescription supplement, an over-the-counter brand, or both.
> Also talk to your doctor if you've already had a pregnancy that was
> affected by a neural tube defect. He or she may recommend that you
> increase your daily intake of folic acid (even before getting pregnant)
> to lower your risk of having another occurrence.
> Nutrition information on food and dietary supplement labels can help
> women determine whether they are getting enough folate, which is 400
> micrograms (0.4 milligrams) a day before pregnancy and 800 micrograms a
> day during pregnancy.
> Additional resources for vegetarian moms: this information is all
> readily accesible on the internet for anyone who choosed to educate
> themselves. You can refer her to resources like this for her next
> <http://www.vrg.org/journal/vj2000sep/2000sepfolate.htm> etc., etc.,