Biomark
Feb 15, 2018

All there is to know about vitamin B9 and folic acid

The Biomarker Handbook is a curated series that seeks to provide readers with insights on each biomarker we cover in our blood test packages and its relation to our body.


There is a total of eight types of B vitamins, amongst which folic acid, or vitamin B9, holds special importance. Like all other members of the vitamin B-complex family, the primary action of folic acid is in the synthesis of several different essential compounds in the body. Folic acid deficiency is one of the most common vitamin deficiencies , particularly affecting pregnant females and people with heavy alcohol consumption.

Folic Acid: The Biochemistry

Folic acid, also known as folate, is a water-soluble vitamin. Its activated form is tetrahydrofolate (THF) which participates in the various biological functions in the cells of the body. This activated form is made during a multi-step process in which folic acid is first converted into dihydrofolate and then subsequently into tetrahydrofolate. This multi-step conversion is catalysed by different enzymes, the deficiency of which can cause folic acid deficiency.

The Nutritional Importance of Folic Acid

According to the British Dietetic Association (BDA), folic acid is vital for

  1. Making red blood cells
  2. The synthesis and repair of DNA and RNA
  3. Aiding rapid cell division and growth
  4. Enhancing brain health
  5. Age-related hearing loss.

It is particularly important for women who are pregnant to consume enough folic acid. This helps prevent the fetus from developing major congenital deformities of the brain or spine, including neural tube defects, such as spina bifida and anencephaly.

The daily recommended intake of folic acid is 0.4mg for an adult. For pregnant women, the daily requirement is 0.6mg.

Several physiological and pathological conditions can affect the serum levels of folate in the blood. Inadequate levels of folic acid can cause serious symptoms discussed later. An increased demand of this vitamin is seen in pregnancy and lactation, in people with poor intestinal absorption caused by certain diseases (Crohn’s disease, celiac disease, cancers etc), in people with chronic alcoholism and in those taking certain anti-folate drugs (such as methotrexate).

Low levels of this vitamin causes diminished DNA synthesis, which manifests itself in the form of brain defects and anemia.

There is also evidence of folic acid preventing the incidence of heart disease and lowering the risk of preeclampsia.

Clinical Signs and Symptoms of Reduced Folate in the Blood

Folic acid deficiency can cause various signs and symptoms, some of which are listed as follows:

  • Lethargy and fatigue
  • Weakness
  • Breathlessness
  • Skin pallor
  • Diarrhea
  • Forgetfulness
  • Mouth sores and inflammation
  • Greying of hair
  • Anxiety and irritability

Consequences of Folic Acid Deficiency

Since a lack of folate affects the normal production of DNA in the body, it can have serious adverse effects on one’s body, especially for pregnant women.

Anaemia: Nutritional anaemia is one of the first manifestations of folate deficiency. This anaemia is of a macrocytic type in which incomplete red blood cell formation results in abnormally large and immature RBC precursors in the blood. These immature, giant red blood cells are sometimes referred to megaloblasts and this type of folate-deficiency anaemia is therefore called a megaloblastic anaemia.

Leukopenia: Low levels of folic acid also cause a reduction in white blood cells and platelets in the body. They also cause neutrophils, a subtype of white blood cells, to change its morphology and appear hyper-segmented under the microscope.

Birth Defects: In pregnancy, folic acid deficiency can lead to potentially serious birth defects. Neural tube defects or defects in the development of the spinal cord and brain could occur. This is especially probable if the woman is folate deficient at the time of conception since crucial folate-dependent development takes place during the first few weeks of pregnancy. These neural tube defects include spina bifida and anencephaly, which can cause the death of the fetus.

Folic Acid Toxicity

Oral folic acid is safe and not toxic to humans even at high levels but it may cause adverse neurological symptoms in patients that suffer from pernicious anaemia. Folate supplements can also interact with drugs like anti-seizure medication.

Mild side effects of taking too much folic acid may include nausea, insomnia, bloating and flatulence.

Preventing Folic Acid Deficiency

A number of foods can help combat falling levels of folate in the body. Including these foods in your everyday diet can help maintain the daily requirement of folic acid.

A nutritious diet that includes green leafy vegetables, peas, citrus fruits, legumes, eggs, beans, milk, salmon, and liver meat are all great sources of folic acid. In many countries including the United States, grains and cereals are fortified with folic acid to provide the daily nutritional dose.

Apart from consuming a natural folate-rich diet, you can take multivitamins to meet the requirement as well. These vitamins come in an oral chewable form or liquid drops. Pregnant women need to include these important supplements to their diet as merely natural folic acid rich foods will not be able to meet the daily requirement for them.

When to See a Doctor

If you’re not conceiving or of a child-bearing age, folic acid deficiency can easily be overcome. However, if the symptoms of folate deficiency begin to worry you, book an appointment with your doctor for expert advice.

For women that are conceiving or plan to conceive, it is important to check in with your doctor and get your tests done to ensure you are receiving the recommended intake of folic acid. Even if you do not experience the symptoms, it is important to get a full nutrition plan during the period of your pregnancy.

Tests to Diagnose Folate Levels

While a direct folic acid test exists to measure the amount of folic acid in your blood, a reliable diagnosis can also be reached after a complete blood count test and microscopic examination of your blood. Decreased number of red blood cells, white blood cells and platelets are common in folic acid deficiency. Under the microscope, red blood cells will appear large (megaloblasts) and irregular with scanty cytoplasm.

Maintaining adequate levels of this vitamin will ensure the DNA in cells is being synthesized properly and red blood cells are maturing. Pregnant women need to be especially cautious about their folate intake to avoid unforeseen consequences like brain and spinal cord defects.

Folic acid is one of the most essential vitamins required by our bodies, so make sure that you are aware of your body’s needs to prevent any undesirable consequences!


Interested in other biomarkers, check out the rest of The Biomarker Handbook.

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