Folate Deficiency Anemia: Symptoms, Causes, and Management
Updated: 3 days ago
Medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: October 2026
Quick Answer
Folate deficiency anemia is a condition in which a lack of vitamin B9 (folate) keeps the bone marrow from making healthy red blood cells. Symptoms include fatigue, weakness, paler skin and shortness of breath. It is diagnosed with blood tests and treated with folic acid and folate-rich foods. The outlook is good, though symptoms may take months to resolve. [4]
What the research says
Anemia in older adults is often nutritional. A review of anemia in clinical practice reports that in about one third of older adults with anemia, the cause is a nutritional deficiency, including iron, folate or vitamin B12 deficiency. Another third is anemia of chronic disease, and about one third cannot be explained (Cappellini and Motta, Seminars in Hematology, 2015).
Folic acid around conception lowers the risk of neural tube defects. A Cochrane review of 5 trials (7,391 women) found that daily folic acid, alone or with other vitamins and minerals, reduced the risk of neural tube defects (RR 0.31, 95% CI 0.17 to 0.58; 6,708 births; high-quality evidence). It also reduced recurrence in women with a previously affected pregnancy (RR 0.34, 95% CI 0.18 to 0.64), with no clear effect on other birth defects (De-Regil et al., Cochrane Database of Systematic Reviews, 2015).
Folic acid can hide a vitamin B12 deficiency. A review explains that high-dose folic acid (more than 5 mg a day) was once used to reverse the megaloblastic anemia of B12 deficiency, which masked the underlying B12 deficiency and possibly worsened nerve damage. The evidence that excess folic acid worsens B12 deficiency is mostly correlative, but the authors call for more vigilance in identifying B12 deficiency in at-risk people, including older adults (Miller et al., Food and Nutrition Bulletin, 2024).
What Is Folate Deficiency Anemia?
Folate deficiency anemia happens when your body doesn't have enough folate (vitamin B9) to make healthy red blood cells. A severe folate deficiency may also affect your white blood cells and platelets [4].
Folate drives red blood cell production. Without it, your bone marrow makes abnormal red blood cells. These cells either become trapped in your bone marrow or die soon after entering your bloodstream. Eventually your red blood cell level becomes so low that you have anemia [4].
Component | Role in folate deficiency | Effect on the body |
|---|---|---|
Red blood cells | The main cells affected; they become abnormal or die early | Less oxygen delivery, causing fatigue and weakness |
Hemoglobin | The protein in red blood cells that carries oxygen | Lower levels contribute to shortness of breath |
Bone marrow | The factory for blood cells | Makes abnormal cells without enough folate |
White blood cells and platelets | May be affected in severe deficiency | Possible effects on the immune system and clotting |
Symptoms and Warning Signs
Red blood cells carry oxygen, so most symptoms come from the body struggling to get oxygen to tissues and organs. You may have [4]:
Fatigue and weakness: feeling very tired and weak
Lightheadedness: feeling dizzy or like you might faint
Skin changes: skin that is paler than usual
Heart signs: a very fast heartbeat
Breathing difficulty: shortness of breath
Causes and Risk Factors
Why folate deficiency happens
You may have this condition if the food you eat doesn't contain enough vitamin B9 or folic acid. It can also happen if a medical condition means you need more folate than you get from food, or if your body doesn't absorb folate. Causes include [4]:
Alcohol use disorder
Digestive disorders, such as celiac disease
Dialysis treatment for kidney failure
Hemolytic anemia
Certain skin conditions
Hereditary folate malabsorption, an inherited disorder that affects your body's ability to absorb folate
Medications that treat seizures, infections or immune system disorders
Pregnancy, which increases the need for folate
Risk factors
Risk category | Details |
|---|---|
Age | People age 60 and older are more likely to have this condition |
Access to food | People without regular access to folate-rich food have a higher risk |
Medical conditions | Alcohol use disorder, digestive disorders, hemolytic anemia and kidney failure treated with dialysis |
Medications | Drugs that treat seizures, infections or immune system disorders |
Genetics | Hereditary folate malabsorption (rare) |
Complications
Without treatment, folate deficiency anemia can cause heart problems such as angina, heart attack and heart failure [4].
How Folate Deficiency Anemia Is Diagnosed
A healthcare provider will ask about your symptoms and health history and do a physical exam. They may also order blood tests [4]:
Complete blood count (CBC): measures the number of red blood cells, white blood cells and platelets, and checks the amount of hemoglobin.
Folate and homocysteine levels: blood tests to check your folate level and your homocysteine level.
Peripheral blood smear: shows the size and shape of your blood cells.
Reticulocyte count: measures the number of immature red blood cells in your blood.
Your provider may also check your vitamin B12 level, since you can have vitamin B9 and B12 deficiency at the same time [4].
Treatment and Management
Vitamin B9 supplements
Treatment involves vitamin B9 or folic acid supplements. You may take the supplement as a pill, a shot or through an intravenous (IV) line. Your healthcare provider may also recommend adding folate-rich foods to your meals [4].
Folate-rich foods
Leafy greens: for example spinach and kale
Legumes: black-eyed peas, kidney beans and lentils
Beef liver: a highly concentrated source of folate
Fortified foods: many cereals and grains have folic acid added
Folate-rich foods listed by Cleveland Clinic include beef liver, leafy greens and legumes such as black-eyed peas and kidney beans [4].
Prevention
It's hard to say whether this condition can be prevented, especially if you have a condition that affects how your body absorbs folate. In general, these steps may reduce your risk [4]:
Eat well: include folate-rich foods in your meals.
Know your needs: folate needs change as we age, and females who plan to become pregnant, are pregnant or are breastfeeding should boost their folate intake. Talk to a healthcare provider before taking any supplement.
Cut back on alcohol: drinking a lot of alcohol makes it hard for your body to absorb folate.
Outlook
The outlook is good. Your anemia symptoms will become less noticeable, but it takes time for your bone marrow to make enough healthy red blood cells to ease them. It may be several months before your symptoms go away. An underlying condition, such as a digestive disorder, will affect your prognosis, so ask your healthcare provider what to expect if that applies to you [4].
When to See a Healthcare Provider
Talk to your healthcare provider if you have [4]:
Anemia symptoms such as fatigue, weakness or feeling short of breath
A condition like celiac disease that affects how your body absorbs folate
Anemia symptoms that don't go away even when you take vitamin B9 supplements as prescribed
Conclusion
Folate deficiency anemia is very treatable. If you feel tired no matter how much you rest, or you are short of breath, see a healthcare provider. Blood tests can confirm the cause, and vitamin B9 supplements together with a folate-rich diet usually restore healthy red blood cells and ease symptoms [4].
Your next step: if these symptoms sound familiar, book an appointment with your healthcare provider rather than starting supplements on your own, because B12 levels may need to be checked at the same time.
Frequently Asked Questions
What is the difference between folate and folic acid?
Folate is the form of vitamin B9 found naturally in food. Folic acid is the lab-made version used in supplements and added to some foods. [4]
How long does it take to recover from folate deficiency anemia?
The outlook is good, but it takes time for the bone marrow to make enough healthy red blood cells. It may be several months before your symptoms go away, and an underlying condition such as a digestive disorder can affect your outlook. [4]
Can I have both folate and B12 deficiency?
Yes. You can have vitamin B9 and B12 deficiency at the same time, so your provider may also check your B12 level. This matters because high-dose folic acid can mask an underlying B12 deficiency, so talk with your provider before starting a supplement. [4][3]
Why does folate matter in pregnancy?
Pregnancy increases the body's need for folate. Females who plan to become pregnant, are pregnant or are breastfeeding should boost their folate intake, after talking with a healthcare provider about supplements. [4] In a Cochrane review of 5 trials (7,391 women), daily folic acid around conception reduced the risk of neural tube defects (RR 0.31, 95% CI 0.17 to 0.58). [2]
Can alcohol cause folate deficiency?
Yes. Alcohol use disorder is a cause of folate deficiency anemia, and drinking a lot of alcohol makes it hard for your body to absorb folate. Cutting back can reduce your risk. [4]
What are the heart complications of untreated folate deficiency anemia?
Without treatment, the condition can cause heart problems such as angina (chest pain), heart attack and heart failure. [4]
Are there medications that cause folate deficiency?
Medications that treat seizures, infections or immune system disorders can contribute to folate deficiency anemia. Ask your provider before changing any medicine. [4]
Who is most at risk for folate deficiency anemia?
People age 60 and older, people without regular access to folate-rich food, people with conditions that affect folate absorption (such as celiac disease or alcohol use disorder), people on dialysis and pregnant people. [4]
Can I get too much folate from food?
It is very hard to get too much folate from natural food sources. Talk with a healthcare provider before taking a vitamin B9 or any other supplement. [4]
What should I do if my symptoms don't improve with supplements?
Talk to your healthcare provider if anemia symptoms don't go away even when you take vitamin B9 supplements as prescribed. They may do more tests to check for other issues. [4]
Related Reading
Learn more in our guide to MCV Blood Test: Normal Range and What Low or High MCV Means.
Learn more in our guide to Reticulocyte Count: Normal Range, Low and High Results Explained.
Homocysteine Test: Normal Levels, Causes of High Homocysteine and What It Means for Your Heart explains the blood test linked to B vitamins and heart and stroke risk.
References
Cappellini MD, Motta I. Anemia in clinical practice: definition and classification: does hemoglobin change with aging? Seminars in Hematology. 2015;52(4):261-269. PMID 26404438. https://doi.org/10.1053/j.seminhematol.2015.07.006
De-Regil LM, Peña-Rosas JP, Fernández-Gaxiola AC, et al. Effects and safety of periconceptional oral folate supplementation for preventing birth defects. Cochrane Database of Systematic Reviews. 2015;(12):CD007950. PMID 26662928. https://doi.org/10.1002/14651858.CD007950.pub3
Miller JW, Smith A, Troen AM, et al. Excess folic acid and vitamin B12 deficiency: clinical implications? Food and Nutrition Bulletin. 2024;45(1_suppl):S67-S72. PMID 38987872. https://doi.org/10.1177/03795721241229503
Cleveland Clinic. Folate deficiency anemia. Cleveland Clinic. November 24, 2025. https://my.clevelandclinic.org/health/diseases/24196-folate-deficiency-anemia
Medical disclaimer
This article was prepared for general information only and is not a substitute for professional medical advice.
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