I have yet to have a doctor's appointment that did not include a recommendation that I take folic acid supplements. Low levels of folic acid is proven to cause severe neural tube birth defects and all doctors are trained to repeat this advice to females of childbearing age. The problem is that folic acid is not the same as folate and the difference may be causing you harm.
Folic acid is not the same as Folate
So what is the difference? Both are termed Vitamin B9 but folic acid is the synthetic form and is made in a laboratory, whereas folate is the natural form commonly found in whole foods. After ingesting folic acid (the synthetic form), the body must go through a complex metabolic pathway in order to turn it into the useable form, folate.
So what's the big deal if both end up as folate? Well here is why it matters:
Reason #1. A large subset of the population with certain variations in the MTHFR gene are unable to breakdown folic acid (the synthetic form) properly. That means you may not be getting enough folate even when taking folic acid supplements. The easiest way to find out if you have a MTHFR mutation is to ask your doctor to run a panel or to do it on your own have your DNA sequenced by 23andme and then follow these instructions. I recently did both and found out that I have a compound heterozygous mutation in this gene which simply means that I have a 50% reduction in my ability to break down folic acid into folate.
Reason #2. When you can't metabolize folic acid properly, it stays around in the body and many scientists are finding that it causes cancer. Vitamin supplementation with folic acid has been found in scientific studies to be associated with an increased risk of breast cancer (1). Another study found a higher rate of prostate cancer in those supplementing with folic acid (2). In 2012 a study found a correlation between the childhood eye cancer called Retinoblastoma with folic acid intake of the child's parents. Mothers who took folic acid supplements while pregnant and had the genetic MTHFR mutation in which they could not turn folic acid into folate, were 4 times more likely to have a child with Retinoblastoma than the control. The study found that “both insufficient folate intake and increased folic acid intake have been associated with the development of carcinomas in adults and with the promotion of neoplastic lesions and genetic damage in rodent models" (3).
It turns out that while too little folate can cause terrible birth defects, too much of folic acid may have serious consequences as well, like cancer. What’s disturbing is that doctors do not seem to know any of this! From my own encounters, most of them do not even know the difference between folate and folic acid and that's because the vast majority of doctors do not receive nutrition education in medical school. After explaining to one of my doctors the reasons why I would not take folic acid supplements and showing him the studies, he responded saying "I need to learn more about nutrition".
Unfortunately saying no to folic acid supplements is not enough to avoid it. If you eat any breads, pastas, rice, cereals, or flours, they are all fortified heavily with folic acid. Since 1998 the FDA has been fortifying with folic acid mandatory with the goal of reducing birth defects. But it is likely that too much folic acid in our diets is causing harm especially if you are eating these things everyday (4). A 2009 study looked at colon cancer in Chile before and after the start of the flour fortification program with folic acid and found that "fortification programs could be associated with an additional risk of colon cancer" (5).
So what do you do when too little folate causes birth defects and too much folic acid may increase your risk of cancer?
What you can do
1. Avoid folic acid and get as much folate from whole foods as you can. There is no danger in eating too much natural folate like there is with folic acid. Folate helps the development of red blood cells, reduces levels of homocysteine in the blood which supports cardiovascular health, and it supports nervous system function.
The Wholesome app can help you get know if you're getting enough folate in your diet. It allows you to track toward the USDA's recommended goal based on your age and gender. It also has an easy access list of the foods with the most folate.
If you are pregnant or trying to get pregnant you will need need to increase the amount of folate in your diet from 400mcg to 600mcg (source: NIH). In the Wholesome app settings, simply update your profile to 'pregnant' and the app will set your goal to 600mcg per day.
2. Have a blood test performed by your doctor to measure your actual level of folate. I had this done recently and found out mine were way above the recommended amount (finally some validation that I don’t need those pills!). Your doctor may also run your homocysteine level which is an amino acid that can be elevated when you are deficient in folate. High homocysteine levels can put you at risk for cardiovascular disease (source).
3. Find a better folate supplement. If your levels of folate are low or you are trying to get pregnant find a supplement that says 'folate', '5-methyltetrahydrofolate', or '5-MTHF' on the label and avoid anything that says 'folic acid'. I recommend mykind organics found at Whole Foods Stores. Watch out because most multivitamins contain folic acid.
4. Assuming you are getting enough folate, avoid packaged goods with folic acid listed on the label – that probably means less cereal and energy bars. Sometimes the labels are confusing, for example, cliff energy bars list “folate” under vitamins but then in the ingredients it says “folic acid”.
5. Find out if you have a MTHFR mutation that can impact your ability to metabolize folic acid and puts you more at risk. See my post on this here.
At a minimum, do your best to get natural folate from whole foods rather than simply relying on folic acid supplementation.
About the author
Jessica Glago is the CoFounder of the Wholesome App. After having two different cancers in her childhood she developed the app with the help of her husband to get more healthfulness out of her diet. To date, Wholesome for iOS has had over 250,000 downloads and over 1.5 million whole foods tracked. The app has been featured on BuzzFeed, LikeHacker, CultofMac, and The Seattle Times.