Folate Versus Folic Acid: Are They Equal?

folate vs folic

Will the Real Vitamin B9 Please Stand Up?

This may shock you: Folic acid is NOT a vitamin. A vitamin is a “vital amine” meaning you can’t live without it.  Folic acid may become a vitamin (folate), but its fate is dependent on your genes and metabolism. 

In the case of folate, the true vitamin B9, terminology and form really do matter.

In recent years, quality research is highlighting how synthetic nutrients are never as good as the natural forms of nutrients.  The research with synthetic vitamin E was fraught with these issues in the 90’s.

Now we are seeing issues with folic acid, the synthetic form of folate.

Somehow correct terminology has gotten lost, even in the world of research. And lost in the headlines. And lost in respected journals.

So how is the public supposed to know what to do?

What is the correct term for vitamin B9?  It is folate, NOT folic acid. 

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Folate and Folic Acid History and Fate

Folate was discovered in 1931 by Dr. Lucy Wills, when she discovered that pregnant women became anemic without it [1].

It was first discovered in brewer’s yeast.

In 1943, Bob Stockstad successfully made artificial folate, also known as folic acid or pteroylmonoglutamic acid.

Although very close structurally to folate, folic acid has a key difference that requires a gene in your body to convert it to the active form.

It also requires a conversion in your gut.  As it turns out, up to half the population has a variant in this gene so folic acid gets “jammed up” in the body if you will. 

 

What Does Folate Do?

This is a topic that at glance is confusing, but it can be simplified. 

One of the most important folate-dependent reactions is the conversion of homocysteine to methionine. To do this, folate donates methyl. 

It then becomes S-adenosyl-methionine (SAMe), an important mood-stabilizing and anti-inflammatory compound.

In our body, we need to deal with homocysteine (via folate) or we end up with increased rates of disease. 

What Are Symptoms of Deficiency?

Symptoms of deficiency of folate include:

  • Anemia

  • Fatigue

  • Mood changes

  • Depression

  • Digestive distress

  • Pale skin

  • Impaired immunity

  • Pregnancy complications

Where Do I Get Folate?

Folate comes from the word “foliage” so as you might guess, green leafy vegetables are the best sources of folate. 

Foods rich in folate are

  • Leafy greens

  • Asparagus 

  • Citrus fruits 

  • Papaya 

  • Broccoli 

  • Beets 

  • Brussels sprouts 

  • Legumes

  • Potatoes cooked with the skin

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Am I Deficient In Folate (not folic acid)?

Many people don’t eat the healthy foods required to get adequate folate in their bodies. In addition, many drugs deplete folate, including:

  • Alchohol

  • Methotrexate

  • Diuretic pills

  • Laxatives

  • Mood stabilizers

  • Antidepressants

  • Anticonvulsants

How Do I Supplement Natural Folate?

Other names for natural folate in supplements are:

  • Methylfolate

  • L-Methylfolate calcium (refers to the calcium salt molecule it is attached to)

  • Metafolin and Deplin

  • 5-MTHF and L-5-MTHF (in this article 5-MTHF refers to L-5-MTHF)

  • Levomefolic acid

  • 5-methyltetrahydrofolate

  • (6S)-5-methyltetrahydrofolate and Quatrefolic.

The active form of folate in the body is called levomefolic acid or 5-methyltetrahydrofolate (5-MTHF).

Natural folate also works to lower homocysteine and correcting nutrient deficiency equally or better than folic acid [2]. 

The Fate of Folate and Folic Acid

Current research suggests that folic acid may not be used in the body (metabolized) correctly, and leave unwanted, possibly damaging substances in the body [3]. 

Folic acid must also be converted by the liver into active folate, and this process doesn’t always go smoothly.

Even more importantly, folate from our diet is very efficiently changed into its healthy form in the gut, but folic acid is not;

Folic acid’s fate is also dependent on the liver, which is not a certain fate [4].

Other nutrients may help the use of synthetic folic acid, such as other B-vitamins [5]. 

Food sources of folate improve blood folate status by 60% more than the equivalent folic acid in supplemental form [6]. 

Folic Acid Risks

How is this folic acid in our blood, then, a problem?  New research is linking higher folic acid levels to an increased cancer risk, including colorectal cancer [7]. 

Folic acid increased the risk of all-cause cancer [8]. 

Folic acid also increased risk of prostate cancer while dietary sources of folate were associated with reduced risk of prostate cancer [9].

High folic acid intake can also mask a B12 deficiency.

Side effects: watch out for your body’s signs.  If you get nausea, irritability or other symptoms, it could be a sign you aren’t metabolizing folic acid correctly.

I’m Pregnant or Planning to Get Pregnant, Now What?

We are all familiar with the big emphasis to get folic acid during pregnancy.  While good advice generally, there are issues.

Folic acid does indeed reduce the risk of neural tube defects [10]. 

However, it is important to know that a large percentage of the population, even pregnant women, who do not use folic acid correctly due to a mutation in a gene called MTHFR.  It is as common as 50% of the population. 

This does not mean that folic acid causes damage in all pregnancies with this gene, but it may affect some. 

Notably, women with MTHFR variant had higher rates of pregnancy losses [11,12]

For example, when women who had multiple pregnancy losses and the MTHFR gene variant, were given a natural form of folate called methylfolate, it had positive effects on pregnancy outcome in women who had this gene defect or gene variant [13]. 

Not long ago, folic acid supplementation was strongly recommended for all women, especially during their first trimester of pregnancy.

While this advice still seems to reduce chances of neural tube defects, there are several reasons to consider adding natural folate or methylfolate instead.

Further, women who had this gene and took folic acid during pregnancy was related to a reduction in lung function in their babies [14]. 

Although it is too soon to generalize these findings to the public, what we do know is that use of natural folate or methylfolate is safe and as effective as folic acid during pregnancy [15]. 

It may be prudent for women to check with their doctors about gene testing for MTHFR variants if there is concern for miscarriage or other known risk factors for this gene, which include.

Over half of babies born have folic acid in their cord blood that is not metabolized [16]. 

What About Older Adults?

Further, in older adults, folic acid blood levels are associated with worsening mental function, while natural folate is associated with improved mental function [17]. 

And about 1/3rd of older Americans have non-metabolized folic acid in their blood.

What about Cost? 

Natural folate supplements are substantially more money than folic acid.  You do get what you pay for. 

However, folic acid isn’t likely bad for all people and is a better alternative than nothing when cost is a factor.  Unless of course, you have had multiple pregnancy losses, or arguably, if you have cancer. 

If you take any of the drugs mentioned above or don’t eat folate-rich foods, you need to carefully consider taking some form of folate at a minimum. 

Always make sure to balance out natural folate with other B vitamins for correct metabolism.

What about that folic acid in your bread and grains?

Click here for more details from a good friend and colleague of mine, Jeanette Kimszal, RD

Mandatory fortification of folic acid  started in 1998; the government requires that cereal products be enriched with 140 micrograms of folic acid per 100 grams of cereal [18].

Neural tube defects have gone down but have not gone away, this is likely because of MTHFR genes, and of concern, may have contributed to increased miscarriage risk.

B12 deficiency also increases risk of neural tube defects in babies [19]. 

Can you get too much natural folate?

In supplemental  forms, yes. 

Some people react poorly to supplements in excess of their body’s needs.  The results can be side effect like any other substances taken in excess.  For example, nervousness, anxiety, nausea, headaches or skin rash can occur. 

Side effects are much less likely to occur if taken with a balance of other vitamins and minerals. 

Methylfolate is available both over-the-counter and with a prescription from your doctor.

Most importantly.  Folate is found in green, leafy vegetables, and eating a lot of these can help get more folate.

The Problem with Testing for Folate Status

In a nutshell, un-metabolized folic acid can falsely show adequacy of folate or even excessive blood levels of folate, despite not EVER being able to function as folate in the body.

These folate lab tests aren’t accurate in the presence of MTHFR gene mutations, in at least 30-50% of the population.

Summary

I personally choose to avoid intake of synthetic folic acid at this time based on the mounting data that for people my age, it probably has more risk than benefit. 

I do take a well-rounded and natural supplement with natural folate. Many people can benefit from natural folate supplementation. 

The information on this website has not been evaluated by the Food & Drug Administration or any other medical body and is shared for educational purposes only. Consult your doctor or healthcare provider before making changes to your supplement regimen or lifestyle.

April 8, 2018 | Heidi Moretti, MS, RD