Folic acid

What are folic acid and folate?

Folic acid is the man-made form of folate, a B vitamin. Folate is found naturally in certain fruits, vegetables, and nuts. Folic acid is found in vitamins and fortified foods.

Folic acid and folate help the body make healthy new red blood cells. Red blood cells carry oxygen to all the parts of your body. If your body does not make enough red blood cells, you can develop anemia. Anemia happens when your blood cannot carry enough oxygen to your body, which makes you pale, tired, or weak. Also, if you do not get enough folic acid, you could develop a type of anemia called folate-deficiency anemia.

Why do women need folic acid?

Everyone needs folic acid to be healthy. But it is especially important for women:

• Before and during pregnancy. Folic acid protects unborn children against serious birth defects called neural tube defects. These birth defects happen in the first few weeks of pregnancy, often before a woman knows she is pregnant. Folic acid might also help prevent other types of birth defects and early pregnancy loss (miscarriage). Since about half of all pregnancies in the United States are unplanned¹, experts recommend all women get enough folic acid even if you are not trying to get pregnant.
• To keep the blood healthy by helping red blood cells form and grow. Not getting enough folic acid can lead to a type of anemia called folate-deficiency anemia. Folate-deficiency anemia is more common in women of childbearing age than in men.

How do I get folic acid?

You can get folic acid in two ways.

1. Through the foods you eat. Folate is found naturally in some foods, including spinach, nuts, and beans. Folic acid is found in fortified foods (called “enriched foods”), such as breads, pastas, and cereals. Look for the term “enriched” on the ingredients list to find out whether the food has added folic acid.
2. As a vitamin. Most multivitamins sold in the United States contain 400 micrograms, or 100% of the daily value, of folic acid. Check the label to make sure.

How much folic acid do women need?

All women need 400 micrograms of folic acid every day. Women who can get pregnant should get 400 to 800 micrograms of folic acid from a vitamin or from food that has added folic acid, such as breakfast cereal.² This is in addition to the folate you get naturally from food.

Are some women at risk for not getting enough folic acid?

Yes, certain groups of women do not get enough folic acid each day.4

• Women who can get pregnant need more folic acid (400 to 800 micrograms).²
• Nearly one in three African-American women does not get enough folic acid each day.
• Spanish-speaking Mexican-American women often do not get enough folic acid. However, Mexican-Americans who speak English usually get enough folic acid.⁵

Not getting enough folic acid can cause health problems, including folate-deficiency anemia, and problems during pregnancy for you and your unborn baby.

What can happen if I do not get enough folic acid during pregnancy?

If you do not get enough folic acid before and during pregnancy, your baby is at higher risk for neural tube defects.

Neural tube defects are serious birth defects that affect the spine, spinal cord, or brain and may cause death. These include:

• Spina bifida.⁶ This condition happens when an unborn baby’s spinal column does not fully close during development in the womb, leaving the spinal cord exposed. As a result, the nerves that control the legs and other organs do not work. Children with spina bifida often have lifelong disabilities. They may also need many surgeries.
• Anencephaly.⁷ This means that most or all of the brain and skull does not develop in the womb. Almost all babies with this condition die before or soon after birth.

Do I need to take folic acid every day even if I’m not planning to get pregnant?

Yes. All women who can get pregnant need to take 400 to 800 micrograms of folic acid every day, even if you’re not planning to get pregnant.2 There are several reasons why:

• Your birth control may not work or you may not use birth control correctly every time you have sex. In a survey by the Centers for Disease Control and Prevention, almost 40% of women with unplanned pregnancies were using birth control.⁸
• Birth defects of the brain and spine can happen in the first few weeks of pregnancy, often before you know you are pregnant. By the time you find out you are pregnant, it might be too late to prevent the birth defects.
• You need to take folic acid every day because it is a water soluble B-vitamin. Water soluble means that it does not stay in the body for a long time. Your body metabolizes (uses) folic acid quickly, so your body needs folic acid each day to work properly.

What foods contain folate?

Folate is found naturally in some foods. Foods that are naturally high in folate include:

• Spinach and other dark green, leafy vegetables
• Oranges and orange juice
• Nuts
• Beans
• Poultry (chicken, turkey, etc.) and meat
• Whole grains

What foods contain folic acid?

Folic acid is added to foods that are refined or processed (not whole grain):

• Breakfast cereals (Some have 100% of the recommended daily value — or 400 micrograms — of folic acid in each serving.)
• Breads and pasta
• Flours
• Cornmeal
• White rice

Since 1998, the Food and Drug Administration (FDA) has required food manufacturers to add folic acid to processed breads, cereals, flours, cornmeal, pastas, rice, and other grains.9 For other foods, check the Nutrition Facts label on the package to see if it has folic acid. The label will also tell you how much folic acid is in each serving. Sometimes, the label will say “folate” instead of folic acid.

How can I be sure I get enough folic acid?

You can get enough folic acid from food alone. Many breakfast cereals have 100% of your recommended daily value (400 micrograms) of folic acid.

If you are at risk for not getting enough folic acid, your doctor or nurse may recommend that you take a vitamin with folic acid every day. Most U.S. multivitamins have at least 400 micrograms of folic acid. Check the label on the bottle to be sure. You can also take a pill that contains only folic acid.

If swallowing pills is hard for you, try a chewable or liquid product with folic acid.

What should I look for when buying vitamins with folic acid?

Look for “USP” or “NSF” on the label when choosing vitamins. These “seals of approval” mean the pills are made properly and have the amounts of vitamins it says on the label. Also, make sure the pills have not expired. If the bottle has no expiration date, do not buy it.

Ask your pharmacist for help with selecting a vitamin or folic acid-only pill. If you are pregnant and already take a daily prenatal vitamin, you probably get all the folic acid you need. Check the label to be sure.

Vitamin label

Check the “Supplement Facts” label to be sure you are getting 400 to 800 micrograms (mcg) of folic acid.2

Can I get enough folic acid from food alone?

Yes, many people get enough folic acid from food alone. Some foods have high amounts of folic acid. For example, many breakfast cereals have 100% of the recommended daily value (400 micrograms) of folic acid in each serving. Check the label to be sure.

Some women, especially women who could get pregnant, may not get enough folic acid from food. African-American women and Mexican Americans are also at higher risk for not getting enough folic acid each day. Talk to your doctor or nurse about whether you should take a vitamin to get the 400 micrograms of folic acid you need each day.

What is folate-deficiency anemia?

Folate-deficiency anemia is a type of anemia that happens when you do not get enough folate. Folate-deficiency anemia is most common during pregnancy. Other causes of folate-deficiency anemia include alcoholism and certain medicines to treat seizures, anxiety, or arthritis.

The symptoms of folate-deficiency anemia include:

• Fatigue
• Headache
• Pale skin
• Sore mouth and tongue

If you have folate-deficiency anemia, your doctor may recommend taking folic acid vitamins and eating more foods with folate.

Can I get too much folic acid?

Yes, you can get too much folic acid, but only from man-made products such as multivitamins and fortified foods, such as breakfast cereals. You can’t get too much from foods that naturally contain folate.

You should not get more than 1,000 micrograms of folic acid a day, unless your doctor prescribes a higher amount. Too much folic acid can hide signs that you lack vitamin B12, which can cause nerve damage.10

Do I need folic acid after menopause?

Yes. Women who have gone through menopause still need 400 micrograms of folic acid every day for good health. Talk to your doctor or nurse about how much folic acid you need.

Are folic acid pills covered under insurance?

Yes. Under the Affordable Care Act (the health care law), all Health Insurance Marketplace plans and most other insurance plans cover folic acid pills for women who could get pregnant at no cost to you. Check with your insurance provider to find out what’s included in your plan.

References

1. Finer, L.B., Zolna, M.R. (2016). Declines in unintended pregnancy in the United States, 2008-2011. The New England Journal of Medicine; 374(9):843–52.
2. U.S. Preventive Services Task Force. (2016). Final Recommendation Statement: Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication.
3. CDC. (2016). Folic Acid Recommendations.
4. Bailey, R.L., Dodd, K.W., Gahche, J.J., Dwyer, J.T., McDowell, M.A., Yetley, E.A., et al. (2010). Total folate and folic acid intake from foods and dietary supplements in the United States: 2003–2006. American Journal of Clinical Nutrition; 91(1): 231–237.
5. Hamner, H.C., Cogswell, M.E., Johnson, M.A. (2011). Acculturation factors are associated with folate intakes among Mexican American women. The Journal of Nutrition; 141(10): 1889–97.
6. CDC. (2016). Spina Bifida.
7. CDC. (2015). Facts about Anencephaly.
8. Mosher, W.D., Jones, J., Abma, J.C. (2012). Intended and Unintended Births in the United States: 1982–2010 (PDF, 404 KB). National Health Statistics Reports; no. 55.
9. U.S. Government Printing Office. (1996). Food Standards: Amendment of Standards of Identity For Enriched Grain Products to Require Addition of Folic Acid (PDF, 215 KB). Federal Register; 61(44): 8781.
10. Morris, M.S., Jacques, P.F., Rosenberg, I.H., et al. (2007).  Folate and vitamin B12 status in relation to anemia, macrocytosis and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr; 85(1):193–200.