Folate

Folate is one of the few supplements where Australian guidance gives clear directions, so the questions our naturopaths ask in store are mostly about matching you to the right form and the right conversation.

A good fit if

• You're pregnant, planning a pregnancy or could become pregnant. Australian guidance recommends a folic acid supplement for this group specifically
• You don't eat many vegetables, legumes and leafy greens, or you avoid wheat bread and so miss out on the fortified flour
• You want to understand the folate versus folic acid question before you choose an activated form
• You have a diagnosed absorption problem such as coeliac disease and your health team has raised folate with you
• You're already on a pregnancy or B-complex formula and want to know how its folate counts towards the Australian limit

Check with us first if

• You've had a pregnancy affected by a neural tube defect, have a family history of one, have diabetes, have a BMI over 30, have a condition that affects nutrient absorption, or take epilepsy medicine. Australian guidance describes a much higher dose for these situations, and that's a decision for your doctor, not something to buy off the shelf.
• You're over 50, vegan or vegetarian, on long-term metformin or a proton pump inhibitor (a reflux medicine), or otherwise at risk of low vitamin B12. Get your B12 checked before taking folate supplements, because folate can make your blood test look better while a B12 problem carries on underneath.
• You take methotrexate. Folate interacts with it directly, and whether you should take it, and how much, depends entirely on why you're on methotrexate. Talk to your prescriber before starting anything.
• You take epilepsy medicines such as phenytoin, carbamazepine or valproate. These lower your folate levels, and folate supplements may in turn make the medicine work less well. This needs your doctor.
• You take sulfasalazine. It blocks folate absorption in your gut and can cause folate deficiency.
• You've had an MTHFR test, or you're thinking about one. Bring the result in and we'll talk you through what it does and doesn't change.
• You have, or have had, a cancer diagnosis. Whether high folic acid intake matters when precancerous changes are present is still an open question in the research, so talk to your treating team.
• You're on kidney dialysis, have liver disease or drink heavily. All of these raise your folate needs and need medical input.
• You take any prescription medicine. Check with your doctor, pharmacist or our naturopaths before starting.

• Food folate (naturally occurring folates). Best known for: The form in leafy greens, legumes, avocado and citrus. It's several folates bound as polyglutamates rather than one compound. Absorption: Around 50 per cent is absorbed. Your gut has to trim the polyglutamate tail first, and folate is damaged by heat, so boiling loses some. Typical use: The baseline everyone gets from meals. Dietary folate equivalents exist so food folate and folic acid can be counted on the same scale.
• Folic acid (pteroylmonoglutamic acid). Best known for: The synthetic form used in supplements and in mandatory flour fortification, and the form Australian pregnancy guidance names. Absorption: About 85 per cent is absorbed with food and close to 100 per cent on an empty stomach, making it the most reliably absorbed of the group. Typical use: Standard in Australian pregnancy and pre-pregnancy products, almost always at 500 micrograms, which is the most a listed medicine can provide.
• Levomefolate calcium (L-methylfolate, 5-MTHF). Best known for: The activated form, sold as the answer to MTHFR variants. Schedule 1 item 3013. Absorption: Raises blood folate at least as well as folic acid, and skips the MTHFR conversion step because it's already 5-MTHF. Typical use: Marketed heavily for MTHFR. Capped at the same 500 micrograms as folic acid, and counted towards the same combined total.
• Levomefolate glucosamine (Quatrefolic-type salt). Best known for: The same activated 5-MTHF, paired with a different salt for stability. Schedule 1 item 3014. Absorption: Delivers the same active folate as levomefolate calcium; the salt affects how well the raw material keeps, not the vitamin itself. Typical use: Common in practitioner and premium pre-pregnancy formulas. Same 500 microgram cap and same combined total.
• Calcium folinate (folinic acid, 5-formyl-THF). Best known for: A reduced folate that enters the folate cycle one step before methylfolate. Schedule 1 item 1077. Absorption: Well absorbed and readily converted. Its high-dose use in hospital medicine is a completely different job from a supplement's microgram dose. Typical use: Uncommon on retail shelves and more often seen in practitioner formulas. Same 500 microgram cap and same combined total.

Reference values. The NHMRC sets the recommended folate intake in micrograms of dietary folate equivalents: 400 µg/day for all adults from 19 years, 600 µg/day in pregnancy and 500 µg/day when breastfeeding. For children it's 150 µg/day at 1 to 3 years, 200 µg at 4 to 8, 300 µg at 9 to 13 and 400 µg from 14. Babies have Adequate Intakes of 65 µg/day up to 6 months and 80 µg/day from 7 to 12 months, measured as folate rather than dietary folate equivalents.

Typical supplemental range. Australian supplements almost all contain 500 micrograms, because that's the most a listed medicine can provide in its maximum daily dose. Pregnancy and preconception products nearly all sit at that figure, and the 400 micrograms in Australian pregnancy guidance is the minimum rather than the target. Some products split the total between folic acid and an activated form, which Australian rules allow as long as the combined total stays at 500 micrograms.

Upper level. The NHMRC upper limit is 1,000 µg/day for adults, 800 µg for 14 to 18 year olds, 600 µg for 9 to 13, 400 µg for 4 to 8 and 300 µg for 1 to 3 years. Importantly, the upper limit applies only to folic acid from supplements and fortified foods, not to folate from everyday food. The NHMRC says no side effects have been linked to the amounts normally found in foods or fortified foods. No upper limit for supplemental folic acid could be set for babies under 12 months, and the advice is that their intake should come from milk, formula and food only.

Worth knowing. Doses above 500 micrograms are more than an Australian listed complementary medicine can provide, so if you've been advised to take a higher dose before pregnancy, you'll get it through a doctor or pharmacist rather than off the shelf. What you need depends on your age, diet and health, so talk to one of our naturopaths.

Food first, where the diet allows it.

• Beef liver, braised: by a distance the richest ordinary source, though it is also very high in vitamin A and is not recommended in pregnancy: 3 oz (about 85 g): 215 µg DFE
• Spinach, boiled: 1/2 cup: 131 µg DFE
• Legumes: black-eyed peas, lentils, chickpeas and kidney beans: 1/2 cup boiled black-eyed peas: 105 µg DFE; 1/2 cup canned kidney beans: 46 µg DFE
• Asparagus, boiled: 4 spears: 89 µg DFE
• Avocado, raw: 1/2 cup sliced: 59 µg DFE
• Bread made from Australian bread-making flour, which must contain added folic acid: 100 g, about three slices: an average of 120 µg of folic acid

If any of these sound like you, talk to one of our naturopaths or your doctor before you start.

• You have anaemia that hasn't been diagnosed. Folate can fix the blood signs of vitamin B12 deficiency while nerve damage keeps progressing, so find the cause first.
• You have, or are at risk of, vitamin B12 deficiency: over 50, vegan or vegetarian, or on metformin or a proton pump inhibitor long term. Check your B12 before taking folate.
• You take methotrexate. This is a direct interaction; folate supplements may interfere with its anticancer effect. Only your prescriber can decide.
• You take epilepsy medicines such as phenytoin, carbamazepine or valproate. These lower blood folate, and folate supplements may make them less effective.
• You take sulfasalazine. It blocks folate absorption in the gut and can cause folate deficiency.
• You take trimethoprim or another folate antagonist. Talk to your doctor or pharmacist before taking folate.
• You have, or have had, cancer. The effect of high folic acid intake on existing precancerous changes isn't settled, so this belongs with your treating team.
• Your pregnancy is higher risk: a previous pregnancy affected by a neural tube defect, family history, diabetes, a BMI over 30, malabsorption or epilepsy medicines. Australian guidance describes a much higher dose that must come from a doctor.
• Babies under 12 months. No Upper Level for supplemental folic acid could be set, so intake should come from breast milk, formula and food only.
• Doses above the NHMRC Upper Level of 1,000 µg/day of folic acid from supplements and fortified food, which is also more than an Australian listed medicine can provide.
• You're on kidney dialysis, have liver disease or drink heavily. All of these raise your needs and call for medical input.
• You notice new numbness, pins and needles, unsteadiness or memory changes. Stop and get a medical assessment promptly.
• If you take prescription medicines, check with your doctor, pharmacist or our naturopaths before starting.