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Folate deficiency: why it happens and how it feels | CION Cancer Clinics
Folate deficiency usually comes from too little fresh food, a higher need in pregnancy, regular heavy drinking, gut conditions that block absorption, or certain medicines. It shows up as tiredness, breathlessness, a sore red tongue, mouth ulcers and low mood, with large red cells on a blood test. It is usually simple to correct once found, but vitamin B12 should be checked at the same time. At CION Cancer Clinics, our haematologist cares for anaemia, bleeding, clotting and inherited blood disorders, with ArogyaSri, CGHS and cashless insurance accepted.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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On this page
- What is folate deficiency, and why does it make you tired?
- What are the symptoms of low folate?
- Who is most likely to run low on folate?
- How does a doctor find out whether it is folate?
- What do families often get wrong about folate?
- What can this page not tell you?
- Common questions about folate deficiency
The short answer
What is folate deficiency, and why does it make you tired?
Folate deficiency means your body does not have enough folate, a B vitamin found in green leafy vegetables, pulses and some fruit. Without it, the bone marrow cannot make healthy red cells, so you end up with fewer, larger red cells that carry oxygen poorly.
Why it can happen quickly
Your body keeps only a small store of folate. Vitamin B12 stores can last for years, but folate runs down within a few months if intake falls or need rises. A spell of poor eating, heavy drinking, a stomach illness or a pregnancy can be enough to use it up.
What it looks like on a blood test
The full blood count usually shows a low haemoglobin and a high MCV, which means the red cells are bigger than usual. The doctor then checks folate and vitamin B12 levels together, because both shortages produce the same large red cells and they often occur side by side.
Reference ranges differ between laboratories. A single result is always read alongside your symptoms and, often, a repeat test.What you may notice
What are the symptoms of low folate?
Symptoms build slowly, so many people put them down to work, age or a busy household. Some people have none at all.
Tiredness and breathlessness
The most common signs. You may feel drained after ordinary tasks, get out of breath on the stairs or notice your heart racing.
Also seen
- Pale skin or pale inner eyelids
- Headaches
- Feeling faint when standing up
Mouth and tongue
A sore, smooth, red tongue and mouth ulcers that keep coming back. Some people find food tastes less than it used to.
Appetite and digestion
Loss of appetite, weight loss without trying and loose motions. These can be a sign of low folate, and they can also be the cause of it when a gut problem stops folate being absorbed.
Mood and memory
Low mood, irritability, poor concentration and forgetfulness. In older people these changes are easily mistaken for ageing.
Tingling, numb feet or unsteady walking point more towards low B12. Tell your doctor about them.Not sure whether this applies to you?
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When this cannot wait for an appointment
If someone with a low haemoglobin becomes very breathless at rest, has chest pain, faints or is confused, go to the nearest emergency department the same day or call 108. Take the latest blood report with you. Do not wait to see whether a tablet or a better diet settles it first.
Causes
Who is most likely to run low on folate?
Usually more than one of these is at work at the same time.
A diet short on fresh greens
Folate comes from spinach, methi, other leafy vegetables, dal, chickpeas and oranges. Long boiling and reheating destroy much of it, so a diet of overcooked food can fall short.
Pregnancy and breastfeeding
A growing baby needs a lot of folate, and so does a mother who is feeding. Twins, closely spaced pregnancies and severe morning sickness raise the risk further.
Regular heavy drinking
Alcohol reduces how much folate you absorb and how well the liver stores it. Heavy drinkers also tend to eat poorly.
Gut conditions
Coeliac disease, Crohn's disease and tropical sprue damage the lining where folate is absorbed, so even a good diet is not enough.
Conditions that use up red cells
When red cells break down early and the marrow works harder, folate is used faster.
For example
- Sickle cell disease and thalassaemia
- Long-term kidney dialysis
- Severe skin conditions such as psoriasis
Some medicines
Methotrexate, some medicines for fits such as phenytoin, trimethoprim and sulfasalazine can lower folate. Never stop one of these yourself. Ask the doctor who prescribed it.
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Confirming it
How does a doctor find out whether it is folate?
A full blood count
This shows your haemoglobin and the MCV, the average size of your red cells. A low haemoglobin with large red cells makes the doctor think of folate or B12 first.
Folate and B12 levels together
Both are measured from the same blood sample. A recent meal can push a serum folate result up, so some labs also check red cell folate, which reflects the past few months.
Looking for the reason
The doctor asks about diet, alcohol, pregnancy, loose motions and medicines. A test for coeliac disease or a kidney and liver check may follow if the cause is not obvious.
Checking that treatment works
A repeat blood count after treatment starts shows whether the haemoglobin is climbing. If it is not, the doctor looks again for a second cause.
Commonly believed
What do families often get wrong about folate?
"It is just weakness. A tonic from the chemist will
do."
Tiredness with large red cells has more than one cause. A tonic can hide the problem without finding out why it started, and a gut condition or a medicine effect can be missed for months.
"Folic acid tablets are harmless, so everyone at home
can take them."
Folic acid on its own can lift the blood count while a hidden B12 shortage keeps damaging the nerves. That is why doctors check B12 before or alongside folate treatment. Ask before starting any tablet.
"We are vegetarian, so we cannot be short of
folate."
Vegetarian food is rich in folate when it is fresh and lightly cooked. Vegetables boiled for a long time, or cooked in the morning and reheated at night, lose much of it.
"Folic acid only matters once you know you are
pregnant."
The baby's spine and brain form in the first weeks, often before a pregnancy is confirmed. Official advice is to take folic acid while trying to conceive and through the first three months of pregnancy, at the amount your doctor advises.
Being straight with you
What can this page not tell you?
This page cannot tell you whether your own tiredness comes from folate. The symptoms overlap with thyroid problems, iron shortage, B12 shortage, poor sleep and depression. Only a blood test read by a doctor who knows your history can sort them out.
It cannot set your treatment
Most people are treated with folic acid tablets for a few months and advice on food. How much, for how long and whether B12 is needed too is decided by your doctor. Do not change a prescribed medicine to protect your folate level without speaking to the person who prescribed it.
When a haematologist is worth seeing
Most folate shortages are managed by a family doctor or physician. A haematologist, a blood specialist, is worth seeing if the count does not improve with treatment, if white cells or platelets are also low, or if large red cells remain without a clear reason. At CION, the haematology team reviews these reports and tells you what to ask next.
Bring every blood report you have, including older ones. A trend over time says far more than one result.Questions we are asked
Common questions about folate deficiency
Is folate deficiency serious?
It is usually simple to correct once found, and most people feel better within weeks of treatment. It becomes serious when it is left for a long time, when it occurs in pregnancy, or when it hides a B12 shortage or a gut condition. That is why the reason behind it matters as much as the tablet.
Is folate the same as folic acid?
Nearly. Folate is the natural form found in food. Folic acid is the man-made form used in tablets and added to some flours and cereals. Your body uses both in the same way. When a report says "serum folate", it is measuring the level of this vitamin in your blood.
Can eating more greens fix it without tablets?
A better diet helps prevent it from coming back, but once your level is low, food alone is usually too slow to correct it. Your doctor will normally advise tablets for a period and food changes for the long term. Fresh, lightly cooked vegetables keep more folate than food that is boiled for long.
My B12 is normal but folate is low. What does that mean?
It points to a folate problem on its own, which is common with poor diet, alcohol, pregnancy or gut conditions. Your doctor will still look for the reason. A borderline B12 result may be repeated, because the two shortages can occur together and treating only one can leave the other behind.
Could low folate be a sign of cancer?
Usually it is not. Most folate shortages come from diet, drinking, pregnancy, gut conditions or medicines. Large red cells that do not improve with treatment, or low white cells and platelets alongside, need a closer look by a haematologist. This page cannot rule anything in or out for you.
I take methotrexate. Should I worry about folate?
Methotrexate works partly by blocking folate, so your doctor may already have planned folic acid alongside it and will check your blood count regularly. Do not start, stop or change the timing of either medicine yourself. If you feel unusually tired or get mouth ulcers, tell the prescribing doctor.
Can children and older people get it?
Yes. Children with sickle cell disease or thalassaemia use folate faster, and fussy eaters may not get enough. Older people living alone, eating little fresh food or drinking regularly are also at higher risk. In both groups, tiredness and poor concentration are easy to overlook.
Which doctor should I see first?
Start with your family doctor or a physician, who can arrange the blood tests and treat most cases. Ask for a haematology opinion if the count does not recover, if other blood counts are low, or if the cause stays unclear. Bring your old reports and a list of every medicine you take.
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Dr. Basudev Pokhrel reviews blood counts, transfusion needs and blood disorders, and works with the CION tumour board on blood cancers.
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Sources
- NHS — Vitamin B12 or folate deficiency anaemia
- NHS — Vitamins, supplements and nutrition in pregnancy
- NICE Clinical Knowledge Summaries — Anaemia - B12 and folate deficiency
- NHS — Folic acid
- World Health Organization — Anaemia
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
B12 and folate guideThe full guide to large red cells and the vitamins behind themB12 Deficiency ExplainedThe shortage that looks like folate on a blood countLarge red cells with a normal haemoglobinWhen the MCV is high but haemoglobin is still normalB12, Folate and PregnancyWhy need rises before and during pregnancy
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