Low Folate Levels Can Indicate Malnutrition in Hospital Patients

Folate deficiency, also known as vitamin B9 deficiency, is a low level of folate and derivatives in the body. Signs of folate deficiency are often subtle. A low number of red blood cells (anemia) are a late finding in folate deficiency and folate deficiency anemia is the term given for this medical condition.

About 10% of patients who come to complex care hospitals may have low levels of folate and other indicators of malnutrition. To ensure those patients are identified and helped, those who present with gastrointestinal problems, chronic kidney disease or sepsis, all associated with malnutrition, need to have their folate levels tested on admission.


Scientists at the Medical College of Georgia (Augusta, GA, USA) reviewed the medical records of 1,019 patients with serum folate less than 7.0 ng/mL, 301 patients with serum folate of 15 ng/mL, and 300 patients with serum folate more than 23 ng/mL.

The investigators reported that serum pre-albumin levels were subnormal in 54.8% of patients with serum folate less than 7.0 ng/mL. Vitamin B12, hemoglobin, and serum albumin levels were significantly lower in the less than 7.0 ng/mL folate group. One or more markers of malnutrition were present in 62.4% of patients with serum folate less than 7.0 ng/mL. The low-folate group had a significantly higher prevalence of gastrointestinal (GI) disorders, sepsis, and abnormal serum creatinine level. There were no significant differences in the two groups regarding diabetes; behavioral/neurological disorders, including drug and alcohol abuse; bariatric surgery; or a diagnosis of malnutrition.

A complicating factor was that as many as 60% of the patients the team reviewed had received a folic acid supplement before they were tested, which meant that low folate levels could be even more prevalent. That finding and other indicators of nutritional deficiency prompted the AU Health System to urge medical staff to do folic acid testing before any supplements or blood products were given, even before patients eat a hospital meal. The health system's Medical Executive Board also approved automatic testing for prealbumin and B12 in those found to have a folate level of less than 7ng/mL.

Gurmukh Singh, MD, PhD, MBA, vice chair of pathology and senior author of the study, said, “We looked at people who had low levels and relatively normal folate levels. The people with low levels had a higher incidence of gastrointestinal disorders like chronic diarrhea as well as sepsis and kidney disease. The other piece was that people who had low levels also had other markers of malnutrition.”

The authors concluded that the prevalence of folate deficiency depends on what is considered a normal serum folate level. Approximately 10% of tertiary-care patients have level less than 7.0 ng/mL and exhibit other markers of malnutrition. It is recommended that patients with GI disorders, chronic kidney disease, and sepsis be routinely tested for serum folate levels, before administration of vitamin supplements. Patients with serum folate levels less than 7.0 ng/mL should be evaluated for malnutrition and Folate supplementation should be administered only after excluding coexisting vitamin B12 deficiency. The study was published on Januarys 30, 2020 in the Laboratory Medicine.

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Medical College of Georgia