Common symptoms of all types of anaemia include:
- feeling tired
- feeling short of breath
- feeling your heart racing or thumping, which is called palpitations
If you have folate deficiency anaemia, you may also develop symptoms, such as:
- a sore tongue
- losing your appetite
These symptoms may be caused by problems other than folate deficiency anaemia. If you have any of these symptoms, see your GP for advice.
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, he or she will ask you 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 and how many of each of the different types of blood cell you have. It will also check the size of your red cells.
- Vitamin B12, iron and folate. The levels of each of these will be measured to see if you have reduced levels.
- A blood film. This involves looking at your blood under a microscope to check the size and shape of your red blood cells. It will also assess the different white cells that are present.
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 your GP may refer you to see 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 he or she can treat any underlying cause.
If you’re not getting enough folate in your diet, your GP will give you advice on how to get more. He or she may refer you to see a dietitian. Good sources of folate include:
- green vegetables, such as spinach, kale and broccoli
- beans, such as blackeye beans
- poultry and pork
- brown rice
If you're drinking too much alcohol, your GP will suggest you reduce your intake and may offer you support to achieve this.
Your GP may advise you to take folic acid supplements. You can buy supplements over-the-counter from a pharmacy or your GP may prescribe them for you. Before you start, he or she will check your levels of vitamin B12 in your blood. This is because although folic acid supplements can help you to feel better, they 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 (mg) per day, for at least four months. Some people may need to take folic acid for a long time, sometimes for the rest of their 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 take folic acid to treat anaemia, your GP will monitor your blood count and folate level. You will have a blood test about eight weeks after you start taking supplements. You will then have another blood test at the end of your treatment to confirm that you responded to it.
There are a number of possible causes of a folate deficiency, the most common of which are listed below.
- Poor diet. Your body can't store folate so you need to eat foods that contain folate every day to make sure you have sufficient levels.
- Medicines. Certain epilepsy medicines and methotrexate, a medicine 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 pregnant, you need more folate to meet the needs of your developing baby.
If you have anaemia, your heart has to work harder to deliver oxygen to your vital organs. If you have severe folate deficiency anaemia, it may lead to heart failure. This means your heart doesn’t pump blood around your body as well as it should do.
If you don't get treatment, folate deficiency anaemia can increase your risk of cardiovascular disease and affect your fertility. Having a deficiency in folate can also increase your risk of developing certain types of cancer.
If you’re pregnant and don’t get enough folate during the first few months of pregnancy, your unborn baby may develop a neural tube defect. This can lead to a condition called spina bifida, and happens when your unborn baby's nerves and spinal cord don't develop properly.
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. This can result in a condition called spina bifida, which is when your baby's spine doesn’t form properly.
If you're trying to get pregnant, take a supplement of 400 micrograms (μg) of folic acid every day from when you start trying. Continue to take it in the first 12 weeks of your 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. You will need to increase your intake of folic acid during your pregnancy. See our FAQs for more information.
It's also important to eat folate-rich foods but don't eat liver. Although it's a good source of folate, it's not suitable for pregnant women because it contains lots of vitamin A, which can harm your baby.
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 (μg). Most people get enough folate from eating enough vegetables, fruit and grains, and don't need to take supplements.
Folate is damaged by heat, so fruit and vegetables contain more folate when they are raw compared to when they are cooked. Breads or breakfast cereals that have been fortified with vitamins are also a good source of folate. Fortified means that folic acid has been added during manufacturing.
If you have a condition that affects how 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?
If you're pregnant, or are planning to have a baby, it’s recommended that you take folic acid supplements. This is to reduce the risk of your child having a neural tube defect.
It's important to start taking folic acid supplements early if you’re trying to get pregnant. Take them 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 greater risk of having a child with a neural tube defect, you will need to take a higher dose of folic acid. For example, your baby may be at greater risk if you or your partner has a neural tube defect, such as spina bifida. Your baby may also be at greater risk of a neural tube defect if you have previously had a pregnancy affected by one. The risk is also increased if you have coeliac disease, diabetes, sickle cell anaemia or 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 (μg) daily. If you're at high risk of having a baby with a neural tube defect, you will be advised to take a dose of 5 milligrams (mg) 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, fruits (especially oranges) and cereals fortified with vitamins. Fortified means that folic acid has been added during manufacturing.
Although liver is a good source of folate, don't eat liver or liver products if you're pregnant 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?
No, men don't need to take folic acid supplements when trying for a baby. However, it's important for men to eat a healthy, balanced diet and they may wish to make some lifestyle changes to improve their fertility.
There is limited evidence to suggest that men should consume more foods that contain folate if they are trying for a baby. However, since there isn't a lot of good quality evidence, your doctor won't usually advise you to do this.
It's still important for both you and your partner to make some lifestyle adjustments to increase your chances of conceiving. And if you're both making the changes, you can support each other.
Eating a healthy, balanced diet is a good start. The recommended daily amount of folate for adults is 200 micrograms (μg) 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?
Yes, both are terms used for vitamin B9 but they come from different sources.
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), as well as in liver.
Folic acid is a synthetic (artificial) type of the B vitamin used in supplements and 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.
- British Nutrition Foundation
020 7557 7930
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- Anaemia – B12 and folate deficiency. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published February 2013
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- Vitamin B12 and folate deficiency. Map of Medicine. www.mapofmedicine.com, published 28 March 2012
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- Pre-conception – advice and management. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published June 2012
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- Fertility: assessment and treatment for people with fertility problems. National Institute for Health and Care Excellence (NICE), February 2013. www.nice.org.uk
- Young SS, Eskenazi B, Marchetti FM, et al. The association of folate, zinc and antioxidant intake with sperm aneuploidy in healthy non-smoking men. Hum Reprod 2008; 23(5):1014–22. doi: 10.1093/humrep/den036.
- British Nutrition Foundation
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