Folate (Vitamin B9) Deficiency In Africa: Symptoms And Treatment


By: Victoria Iyeduala (Freelance Health and Wellness Writer). Medically reviewed bythe DLHA Team


Folate deficiency in Africa. Causes, Symptoms and Treatment

Pregnant black woman holding a bottle of vitamin supplements






Folate (vitamin B9) deficiency means your body doesn't have sufficient folate. When your body doesn't have enough nutrients to function well, you start being ill.


Vitamin B9, or folate, is an essential nutrient for forming critical components of cells and tissues in the body like DNA, RNA, proteins and red blood cells. It is necessary for proper growth and development, particularly in pregnancy and infancy.


You can get natural folate from eating vegetables, fruits, nuts, seeds, beans and animal products. Folic acid is a synthetic folate found in supplements and fortified foods.


Folate is easily passed out through urine because it's a water-soluble vitamin. So, you'll have to continually replenish lost folate.



 What is folate (vitamin B9) deficiency?


Folate or vitamin B9 deficiency is when your body lacks enough folate to stay healthy. It could take about 8-16 weeks before you notice the signs.



What are the signs and symptoms of folate deficiency?


Folate deficiency symptoms can show up as a special type of anaemia called megaloblastic anaemia, mental health (neuropsychiatric) problems and oral health issues.


The diverse signs and symptoms of folate deficiency may include:

  • Anaemia symptoms
  • A red and painful swollen tongue (glossitis)
  • Cracks in the corners of your mouth (angular stomatitis)
  • Mouth sores
  • Diarrhoea
  • Weight loss
  • Depression
  • Crankiness
  • Insomnia
  • Cognitive decline, such as confusion, memory loss and concentration problems
  • Fatigue
  • Psychosis    



What are the risk factors and causes of folate deficiency?


Certain factors cause or increase your risk of folate insufficiency, including:

  • A diet low in folate-rich foods
  • Overcooking your meals
  • Drinking excessively
  • Pregnancy and lactation
  • Medical condition
  • Treatment and medication side effects
  • Genetics


Having a diet low in vitamin B9-rich foods

Your diet may be limited because you're a picky eater or you don't eat often. It could also be because of your medical condition, belief or financial situation. However, if your diet doesn't contain lots of fruits and vegetables and you don't take folate supplements, you're probably getting less than you need.


Overcooking your meals

Maybe you eat folate-rich foods (e.g. lots of vegetables) but often overcook them. Heat destroys natural folate found in food. So, overcooking your meals will reduce the amount of folate (and possibly other nutrients) that goes into your body.


Excessive alcohol consumption

Excess alcohol consumption depletes the nutrients in your body, including folate. Alcohol reduces the absorption of folate. It also increases the number of times you urinate, removing more folate from your body than you can replenish.

Additionally, people with alcohol use disorder may neglect their diet by eating less or hardly eating healthy food.


Pregnancy and lactation

Although research data is limited, the occurrence of folate deficiency in pregnant women goes up from almost 1% to 57.7% in different African countries.

Pregnant and breastfeeding women need an increased supply of nutrients for themselves and their babies. When they don't get enough from food, the mother and child may develop nutrient deficiencies, including folate.


Medical conditions

Some diseases can affect the way your body absorbs and uses folate.

Examples of some conditions that can reduce folate absorption and usage are:

  • Coeliac disease – an inherited autoimmune disease of the digestive system
  • Hemolytic anaemia – a condition where red blood cells are destroyed faster than they're produced
  • Mesenteric vascular insufficiency – a condition associated with a reduced supply of blood to the intestines
  • Achlorhydria – inability to produce hydrochloric acid (HCL in the stomach
  • Short bowel syndrome – a condition where the small intestine is damaged or shortened
  • Vitamin B12 deficiency – a lack of sufficient vitamin B12 (cobalamin) in your body


Side effects of certain treatments and medications

Some medicines can interfere with how your body absorbs, processes and uses folate.

Examples are:

  • Sulfasalazine (a drug for inflammatory bowel diseases and rheumatoid arthritis)
  • Trimethoprim (an antibiotic)
  • Phenytoin (an anti-seizure medication)
  • Methotrexate (a cancer drug)

Treatments, such as gastric bypass surgery and kidney dialysis, can also cause folate deficiency.


MTHFR gene mutation

A gene in the body produces the MTHFR (methylenetetrahydrofolate reductase) enzyme, a crucial chemical your body needs to process folate to its usable form. Some people are born with an alteration (mutation) of this gene, which can affect this process and result in low blood folate levels.



What does folate deficiency cause?


When left untreated, folate deficiency can cause various health complications including:

  • Vitamin deficiency anaemia (megaloblastic anaemia)
  • Pancytopenia (Low red blood ells, white blood cells and platelets )
  • Pregnancy and birth complications
  • Hyperhomocysteinemia

Folate deficiency is also linked with infertility and cancer.


Folate deficiency anaemia (megaloblastic anaemia)

Insufficient folate levels in your blood can cause folate deficiency anaemia. Folate and vitamin B12 deficiencies both cause vitamin deficiency anaemia.

Vitamin deficiency anaemia occurs when you have fewer red blood cells because your body produces abnormally large-sized red blood cells. Fewer healthy red blood cells means less oxygen goes round your body. This type of anaemia is called megaloblastic anaemia.

Symptoms of folate deficiency anaemia may start showing only when it gets serious. Significant signs include:

  • Weakness
  • Shortness of breath, particularly after an energetic activity 
  • Irregular heartbeat
  • Dizziness
  • Pale skin
  • Smooth, red, swollen and painful tongue (glossitis)
  • Inability to taste food
  • Jaundice (yellow skin)


Pancytopenia (low levels of red blood cells, white blood cells and platelets in the body)

Untreated folate deficiency can cause pancytopenia, where your body makes fewer red blood cells, white blood cells and platelets than you need. It means you have a combination of anaemia (low red blood cells), leukopenia (low white blood cells) and thrombocytopenia (low blood platelets).

The anaemia causes reduced oxygen in the body, leukopenia increases your risk of infections, and thrombocytopenia makes you bruise easily and bleed excessively. People with pancytopenia have a combination of symptoms specific to each blood cell deficiency.


Pregnancy and birth complications

"Pregnant women who are deficient in folic acid can have babies with abnormally developed brain, skull, and backbone. These are serious conditions referred to as anencephaly and spina bifida. All women of childbearing age should keep this in mind and ensure they get healthy, balanced nutrition and folic acid supplements", says Dr Temitope Obafemi, a Medical Doctor at Afe Babalola University Multi-system Hospital, Ekiti, Nigeria.

Anencephaly and spina bifida are neural tube defects (NTDs). NTDs are congenital disorders of the brain and spine that can cause disabilities and death in affected babies.

Folic acid deficiency during pregnancy can also cause placental abruption (placenta separates from the womb), miscarriage, premature birth, low birth weight and folate deficiency in newborns. Children may also develop severe language disorders, such as problems with expressing themselves and understanding others.


Hyperhomocysteinemia (a state of too much homocysteine, an intermediate amino acid in the body)

Homocysteine plays a vital role in vitamin metabolism, and high levels may mean that you have vitamin deficiency. It's a chemical that helps your body process some important proteins. A lack of folate in your blood raises levels of homocysteine.

Hyperhomocysteinemia can damage your arteries and cause blood clots that block your blood vessels. These increase your chance of having heart disease and stroke.

Elevated levels of homocysteine is also associated with atherosclerosis or atherosclerotic disease. Atherosclerosis causes heart disease, heart attack, stroke, dementia, erectile dysfunction, disability and death.



How can you prevent folate deficiency?


You can prevent folate deficiency in three ways:

  • Eating a nutritious diet
  • Taking folic acid supplements
  • Drinking less alcohol


Eat a healthful diet

“You can prevent vitamin B9 deficiency by eating a healthy diet. Most of our typical diet, such as green leafy vegetables, beans, mushrooms, eggs and oranges, contain a good amount of folic acid", says Dr Obafemi.

Wash and eat your fruits fresh. Ensure you cook your meals carefully, especially your vegetables. Adding vegetables to your food when it's ready to be taken down from the stove is one way to ensure they don't overcook – for example, adding sliced leafy vegetables to your rice, soup or stew.


Take a folate supplement

Although folate is available in many foods, some people don't get enough from their diet. Taking folate (vitamin B9) supplements, such as folic acid, can help increase your folate stores and prevent deficiency.

It's crucial for females of childbearing age and pregnant women to take a folic acid supplement daily, at least 0.4mg, in addition to a folate-rich diet to prevent folic acid deficiency during pregnancy.

"Supplements are beneficial for pregnant women or women of childbearing age generally since there's a higher need and demand for folic acid to prevent their babies from developing abnormally and also to make sure they don't develop megaloblastic anaemia themselves", Dr Obafemi explains.

Sick people, people with medical conditions, using medications or undergoing treatments that reduce folate levels, people with diet restrictions and people with MTHFR gene mutation may need to take folic acid supplements to compensate for any inadequacy.


Drink less alcohol

You should avoid too much alcohol intake. Additionally, you should seek professional help if you've got a drinking problem, as excess alcohol consumption causes many health problems.



How do doctors diagnose folate deficiency?


Dr Obafemi says, "Usually, doctors don't start out to test for folic acid/vitamin B9 deficiency. If a patient manifests symptoms of anaemia (reduced red blood cells in the body), such as easily getting tired, shortness of breath, growth problems, or features of folate deficiency like swollen tongue, confusion, and prematurely greying hair, then a blood test called a full blood count is done. Alternatively, a peripheral blood film could also be done."

Healthcare providers use a full blood count to detect abnormalities in your blood and a peripheral blood film to examine the abnormalities and ascertain why they're there. Dr Obafemi explains that these procedures will help doctors determine the cause of the anaemia.

"If required, a specific folic acid blood test can be done to ascertain the levels of the nutrient in the body", he adds.



 How is folate deficiency treated?


Treatment for folate deficiency depends on the cause.

  • Treating underlying cause

Dr Obafemi explains, "In some cases, something other than poor nutrition is responsible for the deficiency. These might include excessive alcohol intake, diseases like Crohn's disease and coeliac disease that prevent the nutrients from getting absorbed from the intestines, and some medications like septrin, phenytoin and others. So, a proper assessment must be done for people with the symptoms I've already mentioned. This will guide the kind of treatment they'll receive."

If an underlying medical condition is causing the folate deficiency, your doctor will treat the condition and the deficiency.


 ·Improving your dietary intake of folate

Improving your diet to contain more folate is the treatment for folate deficiency. You can achieve this by eating more natural folate-rich foods and folic acid-fortified foods and taking folic acid supplements.

"Vitamin B9 and B12 deficiencies can be treated with a good diet and vitamin supplements commonly available as Vitamin B Complex, which is relatively cheap to obtain in pharmacies without even needing a prescription in most places", says Dr Obafemi

Your doctor will recommend the best dose, duration of use and method of administration of folic acid supplement based on your needs.

Green leafy vegetables, citrus fruits and animal-derived products are excellent sources of folate.

Examples of folate-rich African foods are:

  • Leafy greens, such as pumpkin leaves, waterleaf, scent leaf/clove basil, bitter leaf, spinach, lettuce and moringa
  • Citrus fruits, such as oranges, grapefruits and tangerines
  • Fruits, such as apples, papayas, mangoes and avocados
  • Animal products, such as meat, fish, eggs and milk
  • Nuts, seeds and beans
  • Spices and other vegetables

You can also get folic acid from fortified foods, such as cereals, bread, flour, milk and pasta.


 ·Making certain lifestyle changes

In addition to increasing your dietary intake of folate, you need to reduce alcohol consumption because alcohol depletes your body's folate stores.





Folate or vitamin B9 deficiency can cause various health complications if left untreated. Although it may take some time to notice the signs, you can get treatment and recover well. So, see your doctor immediately if you have symptoms of folate insufficiency.

Ultimately, to avoid folate deficiency, you need to eat a healthy diet, drink less alcohol and take folic acid supplements as directed by your doctor.




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Published: Octobe 7, 2023

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