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Folate (Folic Acid)

Folic acid is the synthetic form of folate used in dietary supplements and food fortification. It needs to be converted into biologically active folate to be available in the synthesis of DNA and RNA [7]. Folate is also critical in HCY and vitamin B12 metabolism. Folate is essential in cardiovascular, dermatological, neurological, and psychological conditions ranging from atherosclerosis, psoriasis, migraine headaches to depression.

Absorption of folic acid/folate requires gastric hydrochloric acid [17] with bioavailability of folic acid supplements approximately, 100% when assessed in healthy volunteers [18] but the folate present in food is only one-third to one-half bioavailable [19]. Individuals with MTHFR genetic factors are encouraged to select methylfolate products (also called Optimized Folate, FolaPro or 5-MTHFR).

The supplement label must read folate NOT folic acid. Higher dose prescription products—Deplin and Metanx—are available especially for those taking high dose niacin or for treating depression.

The supplement label must read L-form of folate, not the D-form, an example: l-methyltetrahydrofolate. The U.S. Food and Drug Administration is proposing a rule on vitamin labels that only folic acid can be used on supplements because folate is found in foods. Hopefully this designation will not be forthcoming due to the confusion it would cause.

Megaloblastic anemia is the best recognized sign of folate deficiency. Other symptoms usually associated with insufficiency are depression, anxiety, fatigue, apathy, confusion, and dementia [20]. Severe folate deficiency may cause neurological disorders similar to those in vitamin B12 deficiency. Low folate can also lead to malabsorption of other nutrients, which can be of concern in bariatric surgery patients [21].

The absence of macrocytic anemia should not rule out folate deficiency. Serum folate laboratory testing fluctuates according to dietary intake. The RBC folate levels are the more stable form to access but may be influenced by vitamin B12 deficiency and/or iron deficiency.

Food sources of folate include leafy green vegetables, legumes, and citrus fruits. Foods highly processed or overcooked have reduced availability of folate. For increased bioavailability, raw or lightly steamed vegetables need to be consumed because the conjugase enzymes in the vegetables cause inactivation of the folates from heat [22].

B Complex Vitamins

Vitamin B complex includes a group of eight vitamins.

Thiamin is a vital part of coenzyme thiamine pyrophosphate for energy metabolism. Major food sources include whole grains and pork [23].

Riboflavin serves as a coenzyme in many reactions for energy metabolism. Food sources include liver, eggs, and dairy products [23].

Niacin, also known as niacinamide, participates in numerous metabolic actions, especially glucose, fat, and alcohol metabolism. Food sources include meat, chicken, tuna, and liver [23].

Biotin is critical as a coenzyme for gluconeogenesis and fatty acid synthesis. Food sources include egg yolk, fish, and whole grains [23].

Pantothenic acid is a B vitamin with involvement in more than 100 metabolic pathways such as lipid metabolism and neurotransmitter, hemoglobin, and hormone functions. Food sources include beef, whole grains, tomatoes, broccoli, and avocado [23].

Vitamin B6 occurs in three forms—pyridoxal, pyridoxine, and pyridoxamine—which is needed for amino acid metabolism. Deficiency causes neurotransmitter issues that include depression, confusion, and abnormal brain wave patterns. It is easily destroyed by heat with primary food sources being meat, fish, poultry, legumes, and liver [23].

Due to limited consumption from bariatric surgery, patients may need to consider supplementation.

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