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Folate: What is it?
What foods provide folate?
What are the Dietary Reference Intakes for folate?
When can folate deficiency occur?
What are some common signs and symptoms of folate deficiency?
Do women of childbearing age and pregnant women have a special need for folate?
Who else may need extra folic acid to prevent a deficiency?
What are some current issues and controversies about folate?
Caution About Folic Acid Supplements
What is the health risk of too much folic acid?
Selecting a healthful diet
References
Reviewers

Folate: What is it?
Folate is a water-soluble B vitamin that occurs naturally in food. Folic acid is the synthetic form of folate that is found in supplements and added to fortified foods [1].

Folate gets its name from the Latin word "folium" for leaf. A key observation of researcher Lucy Wills nearly 70 years ago led to the identification of folate as the nutrient needed to prevent the anemia of pregnancy. Dr. Wills demonstrated that the anemia could be corrected by a yeast extract. Folate was identified as the corrective substance in yeast extract in the late 1930s, and was extracted from spinach leaves in 1941.

Folate helps produce and maintain new cells [2]. This is especially important during periods of rapid cell division and growth such as infancy and pregnancy. Folate is needed to make DNA and RNA, the building blocks of cells. It also helps prevent changes to DNA that may lead to cancer [3]. Both adults and children need folate to make normal red blood cells and prevent anemia [4]. Folate is also essential for the metabolism of homocysteine, and helps maintain normal levels of this amino acid.

What foods provide folate?
Leafy green vegetables (like spinach and turnip greens), fruits (like citrus fruits and juices), and dried beans and peas are all natural sources of folate [5].

In 1996, the Food and Drug Administration (FDA) published regulations requiring the addition of folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products [6-9]. Since cereals and grains are widely consumed in the U.S., these products have become a very important contributor of folic acid to the American diet. The following table suggests a variety of dietary sources of folate.

Table 1: Selected Food Sources of Folate and Folic Acid [5]


Food

Micrograms (μg)

% DV^

*Breakfast cereals fortified with 100% of the DV, ¾ cup

400

100

Beef liver, cooked, braised, 3 ounces

185

45

Cowpeas (blackeyes), immature, cooked, boiled, ½ cup

105

25

*Breakfast cereals, fortified with 25% of the DV, ¾ cup

100

25

Spinach, frozen, cooked, boiled, ½ cup

100

25

Great Northern beans, boiled, ½ cup

90

20

Asparagus, boiled, 4 spears

85

20

*Rice, white, long-grain, parboiled, enriched, cooked, ½ cup

65

15

Vegetarian baked beans, canned, 1 cup

60

15

Spinach, raw, 1 cup

60

15

Green peas, frozen, boiled, ½ cup

50

15

Broccoli, chopped, frozen, cooked, ½ cup

50

15

*Egg noodles, cooked, enriched, ½ cup

50

15

Broccoli, raw, 2 spears (each 5 inches long)

45

10

Avocado, raw, all varieties, sliced, ½ cup sliced

45

10

Peanuts, all types, dry roasted, 1 ounce

40

10

Lettuce, Romaine, shredded, ½ cup

40

10

Wheat germ, crude, 2 Tablespoons

40

10

Tomato Juice, canned, 6 ounces

35

10

Orange juice, chilled, includes concentrate, ¾ cup

35

10

Turnip greens, frozen, cooked, boiled, ½ cup

30

8

Orange, all commercial varieties, fresh, 1 small

30

8

*Bread, white, 1 slice

25

6

*Bread, whole wheat, 1 slice

25

6

Egg, whole, raw, fresh, 1 large

25

6

Cantaloupe, raw, ¼ medium

25

6

Papaya, raw, ½ cup cubes

25

6

Banana, raw, 1 medium

20

6


* Items marked with an asterisk (*) are fortified with folic acid as part of the Folate Fortification Program.

^ DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for folate is 400 micrograms (μg). Most food labels do not list a food's magnesium content. The percent DV (%DV) listed on the table indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

What are the Dietary Reference Intakes for folate?
Recommendations for folate are given in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine of the National Academy of Sciences [10]. Dietary Reference Intakes is the general term for a set of reference values used for planning and assessing nutrient intake for healthy people. Three important types of reference values included in the DRIs are Recommended Dietary Allowances(RDA), Adequate Intakes(AI), and Tolerable Upper Intake Levels(UL). The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group [10]. An AI is set when there is insufficient scientific data available to establish a RDA. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members of a specific age and gender group. The UL, on the other hand, is the maximum daily intake unlikely to result in adverse health effects [10].

The RDAs for folate are expressed in a term called the Dietary Folate Equivalent. The Dietary Folate Equivalent (DFE) was developed to help account for the differences in absorption of naturally occurring dietary folate and the more bioavailable synthetic folic acid [10-11]. Table 2 lists the RDAs for folate, expressed in micrograms (μg) of DFE, for children and adults [10].

Table 2: Recommended Dietary Allowances for Folate for Children and Adults [10]


Age
(years)

Males and Females
(μg/day)

Pregnancy
(μg/day)

Lactation
(μg/day)

1-3

150

N/A

N/A

4-8

200

N/A

N/A

9-13

300

N/A

N/A

14-18

400

600

500

19+

400

600

500


*1 DFE = 1 μg food folate = 0.6 μg folic acid from supplements and fortified foods

There is insufficient information on folate to establish an RDA for infants. An Adequate Intake (AI) has been established that is based on the amount of folate consumed by healthy infants who are fed breast milk [10]. Table 3 lists the Adequate Intake for folate, in micrograms (μg), for infants.

Table 3: Adequate Intake for folate for infants [10]


Age
(months)

Males and Females
(μg/day)

0 to 6

65

7 to 12

80



The National Health and Nutrition Examination Survey (NHANES III 1988-94) and the Continuing Survey of Food Intakes by Individuals (1994-96 CSFII) indicated that most individuals surveyed did not consume adequate folate [12-13]. However, the folic acid fortification program, which was initiated in 1998, has increased folic acid content of commonly eaten foods such as cereals and grains, and as a result most diets in the United States (US) now provide recommended amounts of folate equivalents [14].

When can folate deficiency occur?
A deficiency of folate can occur when an increased need for folate is not matched by an increased intake, when dietary folate intake does not meet recommended needs, and when folate loss increases. Medications that interfere with the metabolism of folate may also increase the need for this vitamin and risk of deficiency [1,15-19].

Medical conditions that increase the need for folate or result in increased loss of folate include:

Medications that interfere with folate utilization include:

What are some common signs and symptoms of folate deficiency?
  Folate deficient women who become pregnant are at greater risk of giving birth to low birth weight, premature, and/or infants with neural tube defects.
  In infants and children, folate deficiency can slow overall growth rate.
  In adults, a particular type of anemia can result from long term folate deficiency.
  Other signs of folate deficiency are often subtle. Digestive disorders such as diarrhea, loss of appetite, and weight loss can occur, as can weakness, sore tongue, headaches, heart palpitations, irritability, forgetfulness, and behavioral disorders [1,20]. An elevated level of homocysteine in the blood, a risk factor for cardiovascular disease, also can result from folate deficiency.

Many of these subtle symptoms are general and can also result from a variety of medical conditions other than folate deficiency. It is important to have a physician evaluate these symptoms so that appropriate medical care can be given.

Do women of childbearing age and pregnant women have a special need for folate?
Folic acid is very important for all women who may become pregnant. Adequate folate intake during the periconceptual period, the time just before and just after a woman becomes pregnant, protects against neural tube defects [21]. Neural tube defects result in malformations of the spine (spina bifida), skull, and brain (anencephaly) [10]. The risk of neural tube defects is significantly reduced when supplemental folic acid is consumed in addition to a healthful diet prior to and during the first month following conception [10,22-23]. Since January 1, 1998, when the folate food fortification program took effect, data suggest that there has been a significant reduction in neural tube birth defects [24]. Women who could become pregnant are advised to eat foods fortified with folic acid or take a folic acid supplement in addition to eating folate-rich foods to reduce the risk of some serious birth defects. For this population, researchers recommend a daily intake of 400 μg of synthetic folic acid per day from fortified foods and/or dietary supplements [10].

Who else may need extra folic acid to prevent a deficiency?
People who abuse alcohol, those taking medications that may interfere with the action of folate (including, but not limited to those listed above), individuals diagnosed with anemia from folate deficiency, and those with malabsorption, liver disease, or who are receiving kidney dialysis treatment may benefit from a folic acid supplement.

Folate deficiency has been observed in alcoholics. A 1997 review of the nutritional status of chronic alcoholics found low folate status in more than 50% of those surveyed [25]. Alcohol interferes with the absorption of folate and increases the amount of folate the kidney gets rid of. In addition, many people who abuse alcohol have poor quality diets that do not provide the recommended intake of folate [17]. Increasing folate intake through diet, or folic acid intake through fortified foods or supplements, may be beneficial to the health of alcoholics.

Anti-convulsant medications such as dilantin increase the need for folate [26-27]. Anyone taking anti-convulsants and other medications that interfere with the body's ability to use folate should consult with a medical doctor about the need to take a folic acid supplement [28-30].

Anemia is a condition that occurs when there is insufficient hemoglobin in red blood cells to carry enough oxygen to cells and tissues. It can result from a wide variety of medical problems, including folate deficiency. With folate deficiency, your body may make large red blood cells that do not contain adequate hemoglobin, the substance in red blood cells that carries oxygen to your body's cells [4]. Your physician can determine whether an anemia is associated with folate deficiency and whether supplemental folic acid is indicated.

Several medical conditions increase the risk of folic acid deficiency. Liver disease and kidney dialysis increase the loss of folic acid. Malabsorption can prevent your body from using folate in food. Medical doctors treating individuals with these disorders will evaluate the need for a folic acid supplement [1].

What are some current issues and controversies about folate?
Folic Acid and Cardiovascular Disease
Cardiovascular disease involves any disorder of the heart and blood vessels that make up the cardiovascular system. Coronary heart disease occurs when blood vessels which supply the heart become clogged or blocked, increasing the risk of a heart attack. Vascular damage can also occur to blood vessels supplying the brain, and can result in a stroke.

Cardiovascular disease is the most common cause of death in industrialized countries such as the US, and is on the rise in developing countries. The National Heart, Lung, and Blood Institute of the National Institutes of Health has identified many risk factors for cardiovascular disease, including an elevated LDL-cholesterol level, high blood pressure, a low HDL-cholesterol level, obesity, and diabetes [31]. In recent years, researchers have identified another risk factor for cardiovascular disease, an elevated homocysteine level. Homocysteine is an amino acid normally found in blood, but elevated levels have been linked with coronary heart disease and stroke [32-44]. Elevated homocysteine levels may impair endothelial vasomotor function, which determines how easily blood flows through blood vessels [45]. High levels of homocysteine also may damage coronary arteries and make it easier for blood clotting cells called platelets to clump together and form a clot, which may lead to a heart attack [38].

A deficiency of folate, vitamin B12 or vitamin B6 may increase blood levels of homocysteine, and folate supplementation has been shown to decrease homocysteine levels and to improve endothelial function [46-48]. At least one study has linked low dietary folate intake with an increased risk of coronary events [49]. The folic acid fortification program in the U. S. has decreased the prevalence of low levels of folate and high levels of homocysteine in the blood in middle-aged and older adults [50]. Daily consumption of folic-acid fortified breakfast cereal and the use of folic acid supplements has been shown to be an effective strategy for reducing homocysteine concentrations [51].

Evidence supports a role for supplemental folic acid for lowering homocysteine levels, however this does not mean that folic acid supplements will decrease the risk of cardiovascular disease. Clinical intervention trials are underway to determine whether supplementation with folic acid, vitamin B12, and vitamin B6 can lower risk of coronary heart disease. It is premature to recommend folic acid supplementation for the prevention of heart disease until results of ongoing randomized, controlled clinical trials positively link increased folic acid intake with decreased homocysteine levels AND decreased risk of cardiovascular disease.

Folic Acid and Cancer
Some evidence associates low blood levels of folate with a greater risk of cancer [52]. Folate is involved in the synthesis, repair, and function of DNA, our genetic map, and there is some evidence that a deficiency of folate can cause damage to DNA that may lead to cancer [52]. Several studies have associated diets low in folate with increased risk of breast, pancreatic, and colon cancer [53-54]. Over 88,000 women enrolled in the Nurses' Health Study who were free of cancer in 1980 were followed from 1980 through 1994. Researchers found that women ages 55 to 69 years in this study who took multivitamins containing folic acid for more than 15 years had a markedly lower risk of developing colon cancer [54]. Findings from over 14,000 subjects followed for 20 years suggest that men who do not consume alcohol and whose diets provide the recommended intake of folate are less likely to develop colon cancer [55]. However, associations between diet and disease do not indicate a direct cause. Researchers are continuing to investigate whether enhanced folate intake from foods or folic acid supplements may reduce the risk of cancer. Until results from such clinical trials are available, folic acid supplements should not be recommended to reduce the risk of cancer.

Folic Acid and Methotrexate for Cancer
Folate is important for cells and tissues that rapidly divide [2]. Cancer cells divide rapidly, and drugs that interfere with folate metabolism are used to treat cancer. Methotrexate is a drug often used to treat cancer because it limits the activity of enzymes that need folate.

Unfortunately, methotrexate can be toxic, producing side effects such as inflammation in the digestive tract that may make it difficult to eat normally [56-58]. Leucovorin is a form of folate that can help "rescue" or reverse the toxic effects of methotrexate [59]. There are many studies underway to determine if folic acid supplements can help control the side effects of methotrexate without decreasing its effectiveness in chemotherapy [60-61]. It is important for anyone receiving methotrexate to follow a medical doctor's advice on the use of folic acid supplements.

Folic Acid and Methotrexate for Non-Cancerous Diseases
Low dose methotrexate is used to treat a wide variety of non-cancerous diseases such as rheumatoid arthritis, lupus, psoriasis, asthma, sarcoidosis, primary biliary cirrhosis, and inflammatory bowel disease [62]. Low doses of methotrexate can deplete folate stores and cause side effects that are similar to folate deficiency. Both high folate diets and supplemental folic acid may help reduce the toxic side effects of low dose methotrexate without decreasing its effectiveness [63-64]. Anyone taking low dose methotrexate for the health problems listed above should consult with a physician about the need for a folic acid supplement.

Caution About Folic Acid Supplements
Beware of the interaction between vitamin B12 and folic acid
Intake of supplemental folic acid should not exceed 1,000 micrograms (μg) per day to prevent folic acid from triggering symptoms of vitamin B12 deficiency [10]. Folic acid supplements can correct the anemia associated with vitamin B12 deficiency. Unfortunately, folic acid will not correct changes in the nervous system that result from vitamin B12 deficiency. Permanent nerve damage can occur if vitamin B12 deficiency is not treated.

It is very important for older adults to be aware of the relationship between folic acid and vitamin B12 because they are at greater risk of having a vitamin B12 deficiency. If you are 50 years of age or older, ask your physician to check your B12 status before you take a supplement that contains folic acid. If you are taking a supplement containing folic acid, read the label to make sure it also contains B12 or speak with a physician about the need for a B12 supplement.

What is the health risk of too much folic acid?
Folate intake from food is not associated with any health risk. The risk of toxicity from folic acid intake from supplements and/or fortified foods is also low [65]. It is a water soluble vitamin, so any excess intake is usually lost in the urine. There is some evidence that high levels of folic acid can provoke seizures in patients taking anti-convulsant medications [1]. Anyone taking such medications should consult with a medical doctor before taking a folic acid supplement.

The Institute of Medicine has established a tolerable upper intake level (UL) for folate from fortified foods or supplements (i.e. folic acid) for ages one and above. Intakes above this level increase the risk of adverse health effects. In adults, supplemental folic acid should not exceed the UL to prevent folic acid from triggering symptoms of vitamin B12 deficiency [10]. It is important to recognize that the UL refers to the amount of synthetic folate (i.e. folic acid) being consumed per day from fortified foods and/or supplements. There is no health risk, and no UL, for natural sources of folate found in food. Table 4 lists the Upper Intake Levels (UL) for folate, in micrograms (μg), for children and adults.

Table 4: Tolerable Upper Intake Levels for Folate for Children and Adults [10]


Age
(years)

Males and Females
(μg/day)

Pregnancy
(μg/day)

Lactation
(μg/day)

1-3

300

N/A

N/A

4-8

400

N/A

N/A

9-13

600

N/A

N/A

14-18

800

800

800

19 +

1000

1000

1000

Selecting a healthful diet
As the 2000 Dietary Guidelines for Americans states, "Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need" [66]. As indicated in Table 1, green leafy vegetables, dried beans and peas, and many other types of vegetables and fruits provide folate. In addition, fortified foods are a major source of folic acid. It is not unusual to find foods such as some ready-to-eat cereals fortified with 100% of the RDA for folate. The variety of fortified foods available has made it easier for women of childbearing age in the US to consume the recommended 400 mcg of folic acid per day from fortified foods and/or supplements [6]. The large numbers of fortified foods on the market, however, also raises the risk of exceeding the UL. This is especially important for anyone at risk of vitamin B12 deficiency, which can be triggered by too much folic acid. It is important for anyone who is considering taking a folic acid supplement to first consider whether their diet already includes adequate sources of dietary folate and fortified food sources of folic acid.

For more information about building a healthful diet, refer to the Dietary Guidelines for Americans (http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2000/2000DGProfessionalBooklet.pdf) [66] and the US Department of Agriculture's Food Guide Pyramid (http://www.nal.usda.gov/fnic/Fpyr/pyramid.html) [67].

 

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Glossary
absorption - In nutrition, the process of moving protein, carbohydrates, fats, and other nutrients from the digestive system into the bloodstream. Most absorption occurs in the small intestine.
Adequate Intake - AI. The recommended daily intake of a nutrient estimated by the Institute of Medicine to meet or exceed the amount needed to maintain adequate nutrition for most people in a particular life stage and gender group. An AI is established when not enough information is available from scientific research to determine a Recommended Dietary Allowance (a dietary intake level that is sufficient to meet the nutrient requirements of most people).
adverse event - An unwanted medical problem that occurs during treatment. Adverse events may be unrelated to the treatment or they may be caused by the therapy or procedure. For example, an adverse event may be caused by the toxic effects of a particular drug or dietary supplement or by an interaction with another therapy. Also called adverse effect and side effect.
alcoholic - A person who is not able to stop drinking once he or she has begun, needs to drink larger amounts of alcohol to get high, and suffers withdrawal symptoms (such as nausea, sweating, shakiness, and anxiety) after stopping drinking.
amino acid - A chemical building block of protein.
anemia - A condition in which the number of red blood cells in the blood, or the amount of hemoglobin in them, is lower than normal, causing a condition in which red blood cells are not able to supply enough oxygen to all the tissues in the body. Hemoglobin is the substance in red blood cells that carries oxygen to your body's cells.
anencephaly - A condition in which a baby is born without most of a brain and skull. The brain may not be covered by bone or skin. Babies born with this condition do not survive more than a few hours or days. Anencephaly belongs to the group of disorders called neural tube defects.
anticonvulsant - A drug that prevents, reduces, or stops convulsions or seizures.
association - A relationship between two conditions or states such that if one is present, the other is likely to be present as well. An association between two conditions or states, however, does not necessarily imply a cause and effect relationship. The terms association and relationship are often used interchangeably.
asthma - A long-lasting disease in which the airways that carry air in and out of the lungs sometimes become narrower, limiting the amount of air that can flow through them, and causing wheezing, coughing, chest tightness, and trouble breathing (called a spasm). Cells in the airways may also make more mucus than usual, which narrows the airways even more. Asthma can also cause death, but can usually be controlled with regular treatment. It may be caused by allergies (such as to pet hair, dust, mold, pollen, or cockroaches), respiratory infections, vigorous exercise, environmental factors (such as cigarette smoke, certain foods, or pollution), stress, and genetics (a child is more likely to have asthma if one or both parents have asthma).
B vitamin - A nutrient that is important for cell function. The B vitamins are biotin, folate, niacin, pantothenic acid, riboflavin (vitamin B2), thiamin, vitamin B6, and vitamin B12. The B vitamins make up the vitamin B complex.
barbiturate - A category of drug used to treat seizure disorders, insomnia, and anxiety and to calm patients before surgery. It belongs to the family of drugs called central nervous system depressants.
bioavailability - The amount of a nutrient that reaches the body’s tissues after it is eaten.
blood sugar - The main source of energy used by the body's cells. Blood sugar comes from food and is made by the liver, and is carried to the cells through the bloodstream. Also called blood glucose.
blood vessel - A tube through which blood circulates in the body. Blood vessels include a network of arteries, arterioles, capillaries, venules, and veins.
cancer - A group of diseases in which cells divide abnormally and without control, and spread to nearby tissues and other parts of the body. Without treatment, cancer can stop organs from working normally, damage body systems, and cause the patient to die. The main types of cancer include carcinoma (cancer that begins in the skin or in tissues that line or cover internal organs), sarcoma (cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue), leukemia (cancer that starts in the bone marrow and causes large numbers of abnormal blood cells to move into the bloodstream), and lymphoma and multiple myeloma (cancers that begin in the cells that protect the body against infection and disease). Cancer may be caused by multiple factors, such as radiation, sunlight, tobacco, certain viruses, and poisonous chemicals; however, the cause of many cancers is unknown.
cardiovascular disease - CVD. A general term referring to disorders of the heart and blood vessels. CVD includes coronary artery disease, heart failure, atherosclerosis, high blood pressure, peripheral artery disease, and stroke.
cardiovascular system - The heart, blood, and blood vessels.
cell - The individual unit that makes up the tissues of the body. All living things are made up of one or more cells, which are the smallest units of living structure capable of independent existence.
cell division - The method by which a single cell divides to create two cells. This is a continuous process that allows a population of cells to increase in number or remain the same in number.
chemotherapy - A chemical that kills bacteria, viruses, fungi, or tumor cells. It usually refers to drugs used in cancer treatment.
chronic - Happening for a long time, persistently, or repeatedly.
clinical trial - A type of research study that uses volunteers to test the safety and efficacy (the ability to produce a beneficial effect) of new methods of screening (checking for disease when there are no symptoms), prevention, diagnosis, or treatment of a disease. Also called a clinical study.
colon cancer - Uncontrolled growth of abnormal cells in the large intestine (the tube-like organ connected to the small intestine at one end and the anus at the other).
conception - In biology, the fertilization of an egg by a sperm that begins a pregnancy.
Continuing Survey of Food Intakes by Individuals - CSFII. A nationwide survey conducted by the US Department of Agriculture that collects information about the kinds and amounts of foods Americans eat. The information is used to study the nation's food supply, including learning whether the foods available to consumers contain enough of the nutrients needed to maintain a healthy diet, finding out how much the foods provided by food assistance programs (such as Food Stamps) contribute to a person's nutrition needs, and calculating the amount of a pesticide that can be used on a crop while providing a safe food product. In 2002, CSFII was incorporated into the ongoing National Health and Nutrition Examination Survey.
coronary heart disease - A disease in which the blood vessels (coronary arteries) that carry blood and oxygen to the heart are narrowed or blocked, which can cause chest pain, shortness of breath, and heart attack. It is usually caused by a build-up of fat and cholesterol deposits inside the arteries (atherosclerosis). Also called heart disease.
Crohn's disease - A long-lasting (chronic) disease that causes severe irritation in the gastrointestinal tract. It usually affects the lower small intestine (called the ileum) or the colon, but it can affect any part of the digestive tract from the mouth to the anus. It is painful, causing severe watery or bloody diarrhea, and may lead to life-threatening complications. Crohn's disease is a form of inflammatory bowel disease.
Daily Value - DV. A term used on a food or dietary supplement product label to describe the recommended levels of intake of a nutrient. The percent Daily Value (% DV) represents how much of a nutrient is provided in one serving of the food or dietary supplement. For example, the DV for calcium is 1,000 mg (milligrams); a food that has 200 mg of calcium per serving would state on the label that the % DV for calcium is 20%.
deficiency - An insufficient amount, a shortage, or an inadequacy.
deoxyribonucleic acid - DNA. The molecules inside cells that carry genetic information and pass it from one generation to the next.
diabetes - A disease in which blood sugar (glucose) levels are high because the body is unable to use glucose properly. Diabetes occurs when the body does not make enough insulin, which helps the cells use glucose, or when the body no longer responds to insulin.
diagnose - The process of using signs and symptoms to identify a disease.
dialysis - The process of filtering the blood when the kidneys are not able to cleanse it.
diarrhea - Frequent and watery bowel movements.
Dietary Folate Equivalent - DFE. A term used to describe the Recommended Dietary Allowance of folate. DFE accounts for the easier absorption of folate in supplements and fortified foods compared with folic acid found naturally in foods, which is absorbed only about half as well. One DFE = 1 microgram (μg) food folate = 0.6 μg folic acid from supplements and fortified foods.
Dietary Guidelines for Americans - Advice from the federal government to promote health and reduce the chance (risk) of long-lasting (chronic) diseases through nutrition and physical activity. The Guidelines are updated and published every 5 years by the US Department of Health and Human Services and the US Department of Agriculture.
Dietary Reference Intake - DRI. A term developed by the Institute of Medicine that refers to a set of recommendations used to plan and evaluate the nutrient intake of healthy people. The DRIs include the Estimated Average Requirement (an intake value estimated to meet the nutrient requirements of half of all people), the Recommended Dietary Allowance (a dietary intake level that is sufficient to meet the nutrient requirements of most people), Adequate Intake (a recommended nutrient intake that meets or exceeds the amount needed to maintain adequate nutrition in most people), and the Tolerable Upper Intake Level (the largest daily intake of a nutrient that is considered unlikely to cause harmful side effects for most people).
dietary supplement - A product that is intended to supplement the diet. A dietary supplement contains one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and other substances) or their components; is intended to be taken by mouth as a pill, capsule, tablet, or liquid; and is identified on the front label of the product as being a dietary supplement.
digestive tract - The large, muscular tube that extends from the mouth to the anus, in which hormones, enzymes, and the movement of muscles work together to digest food. Also called the gastrointestinal (GI) tract.
diuretic - A drug or other substance that increases the amount of urine made by the body.
dose - The amount of medicine or other substance taken at one time or over a specific period of time.
effectiveness - In medicine, the ability of an intervention (for example, a drug, surgery, or a dietary supplement) to produce the desired beneficial effect under the usual conditions of care by a health care provider.
enrichment - In food, the replacement of important nutrients (such as vitamins and minerals) that may be lost during processing or storage. For example, white flour is enriched with thiamin, niacin, and riboflavin because those vitamins are lost when grain is made into flour.
enzyme - A protein that speeds up chemical reactions in the body.
evidence - Information used to support the use of a particular screening procedure, treatment, or preventive measure. In medicine, evidence needed to determine effectiveness is provided by laboratory research, clinical trials, and other studies.
folate - A general term for the various forms of folic acid, a B vitamin. Folate is needed to make DNA, RNA, and amino acids. It occurs naturally in foods and is found in leafy green vegetables (such as spinach and turnip greens), fruits (such as citrus fruits and juices), and dried beans and peas. The synthetic (manufactured) form of folate used in supplements and fortified foods is called folic acid.
folic acid - The form of folate (a B vitamin occurring naturally in food) that is manufactured and used in supplements and fortified foods.
Food and Drug Administration - FDA, Department of Health and Human Services. FDA is the Federal government agency responsible for ensuring that foods and dietary supplements are safe, wholesome and sanitary, and that drugs, medical devices, cosmetics, and food are honestly, accurately and informatively represented to the public. FDA regulates dietary supplements under a different set of regulations than those covering conventional foods and drug products (prescription and over-the-counter). The dietary supplement manufacturer is responsible for ensuring that a dietary supplement is safe before it is marketed. FDA is responsible for taking action against any unsafe dietary supplement product after it reaches the market. Generally, manufacturers do not need to get FDA approval before producing or selling dietary supplements.
fortify - To add nutrients to a food during food processing or to replace nutrients lost when a food product is produced or stored that may be lacking in the overall diet (such as folate, vitamins A and D, and calcium). This process is sometimes called enrichment. For example, when calcium is added to processed orange juice, the orange juice is said to be "fortified with calcium." Another example is adding folic acid to flour.
HDL cholesterol - High-density lipoprotein cholesterol. A type of protein that carries excess cholesterol through the blood to the liver to be excreted in the bile. Also called good cholesterol.
heart attack - The blockage of an artery supplying blood and oxygen to the heart, resulting in the damage or death of a section of heart muscle.
heart palpitation - Forceful and irregular beating of the heart.

hemoglobin - The substance inside red blood cells that carries oxygen from the lungs to the body's tissues.
high blood pressure - A blood pressure measurement of 140/90 mmHg (millimeters of mercury) or higher is considered high blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries. Blood pressure measurements are written as two numbers, for example 120/80. The first number (the systolic pressure) measures the pressure when the heart beats and pumps out blood into the arteries. The second number (the diastolic pressure) measures the pressure when the heart is at rest between beats. High blood pressure is a condition that occurs when a person's blood pressure often measures above 140/90 or regularly stays at that level or higher. This condition usually has no symptoms but can be life-threatening. It damages the arteries and increases the chance of stroke, heart attack, kidney failure, and blindness. Also called hypertension.
homocysteine - An amino acid (a building block of protein). At high blood levels, it may increase the risk of developing coronary heart disease, heart attack, stroke, and Alzheimer's disease. Elevated homocysteine may also increase the risk of developing osteoporosis and bone fractures.
infant - A child younger than 12 months old.
inflammation - Redness, swelling, pain, and/or a feeling of heat in an area of the body. It is a protective reaction to injury, disease, or irritation of tissues.
inflammatory bowel disease - IBD. Long-lasting (chronic) problems that cause irritation and ulcers in the digestive tract. The most common disorders are ulcerative colitis and Crohn's disease.
Institute of Medicine - IOM. A private nongovernmental organization that issues reports on biomedical science, medicine, and health as requested by government agencies, private industry, and foundations.
interaction - In pharmacy, the effect that results from combining two or more drugs or dietary supplements that neither drug nor dietary supplement produces when taken individually. Such interactions can increase or decrease the absorption, metabolism, effectiveness, and safety of a drug or dietary supplement.
kidney - One of two organs in the abdomen. Kidneys remove waste from the blood (as urine), produce erythropoietin (a substance that stimulates red blood cell production), and play a role in blood pressure regulation.
LDL cholesterol - Low-density lipoprotein cholesterol. A type of protein that carries cholesterol to many tissues throughout the body. High levels of LDL cholesterol increase the risk of coronary heart disease. Also called bad cholesterol.
leucovorin - A form of folate that is used as a medicine to help prevent or treat severe side effects of some chemotherapy drugs (such as methotrexate, which makes a cell unable to use folic acid, preventing DNA from being made, and stopping cells from dividing). Leucovorin also is used in the prevention or treatment of some types of anemia and in the treatment of colorectal cancer.
lupus - A long-lasting autoimmune disease in which the body attacks its own healthy cells and tissues, causing inflammation (swelling, redness, pain, and warmth), and tissue damage. It can affect the skin, joints, kidneys, heart, lungs, blood vessels, and/or brain, and affects each person differently. Symptoms may include sore or swollen joints, persistent high fever, extreme fatigue, skin rashes, pain in the chest, anemia, sensitivity to sunlight, hair loss, seizures, and mouth or nose sores.
malabsorption - A reduced ability to properly absorb nutrients. It can be caused by injury to the digestive tract, a genetic disease, or other conditions. Malabsorption can lead to malnutrition.
malformation - A defect in the physical shape or structure of an organ or body part, caused by abnormal development before birth. Examples include spina bifida (in which part of the spinal cord is on the outside of the body) and cleft palate (an opening in the roof of the mouth). Also called a deformity.
metabolism - All chemical changes that take place in a cell or an organism. These changes produce energy and basic materials needed for important life processes.
methotrexate - A drug that blocks the body’s ability to use folic acid, which is needed by growing cells such as those making up the skin, blood, digestive tract, and the cells that protect the body against infection and disease. Methotrexate is used to treat some types of cancer, arthritis, and severe skin disorders. It belongs to the group of drugs called antimetabolites.
National Heart, Lung, and Blood Institute - NHLBI. An organization in the federal government that plans, conducts and supports research related to the prevention, diagnosis, treatment, and rehabilitation of patients suffering from diseases of the heart, blood vessels, and lungs; blood diseases; and sleep disorders. It also supports research on the clinical use of blood and management of blood resources. NHLBI is one of 27 Institutes and Centers that make up the National Institutes of Health.
National Institutes of Health - NIH. The main organization in the federal government responsible for conducting and supporting medical research. It is composed of 27 Institutes and Centers that provide financial support to researchers in the United States and throughout the world to investigate ways to prevent, treat, and cure common and rare diseases. NIH is part of the US Department of Health and Human Services.
nervous system - The brain and spinal cord, including the network of nerves that carry messages back and forth between the brain and all parts of the body. The nervous system controls what the body does.
neural tube defect - A disorder in which the brain, spinal cord, or the tissues protecting the brain or spine do not develop properly during pregnancy. Examples of neural tube defects include anencephaly (most of the skull and brain are missing), spina bifida (part of the spine may be on the outside of the body), and encephalocele (part of the brain is on the outside of the skull). It is a common cause of infant death and disability.
neuron - A nerve cell. Neurons send chemical and electrical messages throughout the nervous system that direct the body to function, move, think, and have emotions.
Nurses' Health Study - An ongoing long-term study of diet, nutrition, and risk factors for major chronic disease in a large number of women in the United States.
nutrient - A chemical compound (such as protein, fat, carbohydrate, a vitamin, or mineral) that is found in food. Nutrients are used by the body to function and maintain health.
nutritional - Having to do with nutrition (eating, digesting, and absorbing the nutrients in food, and the health and disease consequences).
obesity - A condition characterized by an excessive amount of body fat. Obesity can be determined by calculating the body mass index (BMI). (BMI is a number that estimates the amount of body fat on a person, based on his or her weight and height. It is calculated by multiplying weight [in pounds] by 703, dividing the answer by height [in inches] and dividing that answer by height [in inches]). In adults, a BMI of 30 or higher indicates obesity. Some people, such as bodybuilders or other athletes with a lot of muscle, can be overweight without being obese. See: overweight.
platelet - Fragments of bone marrow cells (megakaryocytes) that help prevent bleeding by causing blood clots to form. Also called a thrombocyte.
population - All individuals who share something in common (such as geographic location, ethnicity, gender, age, or disease). In statistics, conclusions are made about the population by studying smaller sample groups of individuals who are representative of the larger group.
prescription - A written order from a health care provider for medicine, other therapy, or tests.
prevalence - In medicine, the percentage of a population that is affected with a specific disease at any one time.
prevent - To stop from happening.
prevention - In medicine, action taken to decrease the chance (risk) of developing a disease.
primary biliary cirrhosis - A long-lasting disease that slowly destroys bile ducts in the liver. Bile, a substance that helps digest fat, leaves the liver through these ducts. When the ducts are damaged, bile builds up and harms the liver. Over time, the disease can cause cirrhosis (scar tissue that replaces healthy tissue) and may cause the liver to stop working. Symptoms of primary biliary cirrhosis include itchy skin, fatigue, jaundice (yellowing of the eyes and skin), cholesterol deposits on the skin, bloating (fluid retention), and dry eyes or mouth.
psoriasis - A chronic inflammatory disease in which the skin becomes swollen, red, and itchy, with patches of silvery-white scales.
randomization - When referring to an experiment or clinical trial, the process by which animal or human subjects are assigned by chance to separate groups that compare different treatments or other therapies. Randomization gives each participant an equal chance of being assigned to any of the groups.
Recommended Dietary Allowance - RDA. The daily dietary intake level estimated by the Institute of Medicine to meet the nutrient requirements of most healthy individuals in a particular life stage and gender group. For example, the RDA for vitamin C is 75 mg/day for women older than 18 years.
red blood cell - A cell that carries oxygen to and removes carbon dioxide from all parts of the body.
rheumatoid arthritis - An inflammatory disease that causes aching and throbbing pain, swelling, stiffness, and loss of function in the linings of the joints (places in the body where two bones connect). It often affects the wrists, fingers, knees, feet, and ankles. Usually, if one knee or hand is involved, the other one is too. The surrounding tissues and organs may also be affected. People with rheumatoid arthritis may develop anemia, neck pain, dry eyes and mouth, fever, feel tired and weak, lose appetite and weight, and generally not feel well. Rheumatoid arthritis may last a few months, a year or two, or a lifetime. Symptoms may come and go, or be severe, leading to serious joint damage, deformity, and disability. It is an autoimmune disease, in which the body attacks its own tissue as if it were a foreign substance.
ribonucleic acid - RNA. A substance that tells cells how to make proteins.
risk - The chance or probability that a harmful event will occur.
risk factor - Something that may increase the chance of developing a disease. For example, a diet that is low in calcium and vitamin D is a risk factor for osteoporosis; smoking is a risk factor for lung cancer.
sarcoidosis - A disease in which tiny lumps (granulomas) form in cells on the inside or outside of the body. It often starts in the lungs or lymph nodes, but can occur in the skin, eyes, liver, or any organ. There may be no symptoms, or it can cause shortness of breath, fatigue, rash, pain, or death.
sedative - A drug or other substance that helps cause relaxation, calmness, and sleepiness.

seizure - Sudden changes in behavior caused by excessive electrical activity in the brain.
sign - An indication of disease that can be seen and/or measured. Examples include high fever, high blood pressure, infection, and coughing up blood.
spina bifida - A disorder in which a fetus's spine does not close properly during the first month of pregnancy. It may result in permanent damage to the nerves and spinal cord, causing paralysis of the legs and feet, bowel and bladder problems, learning problems, or hydrocephalus (too much fluid on the brain).
statistically significant - In medicine, a mathematical measure of difference between two or more groups receiving different treatments that is greater than what might be expected to happen by chance alone.
status - The state or condition.
stroke - A loss of blood flow to part of the brain. Strokes are caused by blood clots or broken blood vessels in the brain, and result in damage to a section of brain tissue. Symptoms include dizziness, numbness, weakness on one side of the body, and problems with talking or understanding language. The chance (risk) of stroke is increased by high blood pressure, older age, smoking, diabetes, high cholesterol, heart disease, a family history of stroke, and a build-up of fatty material inside the coronary arteries (atherosclerosis). See also NIH publication: Know Stroke. Know the Signs. Act in Time. http://www.ninds.nih.gov/disorders/stroke/knowstroke.htm
supplement - A nutrient that may be added to the diet to increase the intake of that nutrient. Sometimes used as a synonym of dietary supplement.
symptom - An indication of disease that an individual can feel, but that cannot be measured objectively by a health care professional. Examples include headache, fatigue, indigestion, depression, and pain.
synthetic - Made by combining parts to make a whole; usually having to do with substances that are artificial or manufactured.
tissue - A group or layer of cells in a living organism that work together to perform a specific function.
Tolerable Upper Intake Level - UL. The largest daily intake of a nutrient that is considered unlikely to cause harmful side effects for most people in a particular life stage and gender group. Taking more than the UL is not recommended and may be harmful. The amount is established by the Institute of Medicine. For example, the UL for vitamin A is 3,000 micrograms/day. Women who consume more than this amount every day shortly before or during pregnancy have an increased chance (risk) of giving birth to an infant with a birth defect.
toxic - Having to do with poison or something harmful to the body. Toxic substances usually cause unwanted health effects.
toxicity - The state of being poisonous (toxic).
treat - To care for a patient with a disease by using medicine, surgery, or other approaches.
ulcerative colitis - A serious disease that causes inflammation (swelling, redness, pain, and warmth) and sores (ulcers) in the lining of the colon and rectum, increases the risk of colon cancer, and can cause death. Ulcers form where inflammation has killed the cells that usually line the colon, then bleed and produce pus. Inflammation also causes the colon to empty frequently, causing diarrhea. Symptoms include abdominal pain, bloody diarrhea, anemia, fatigue, weight loss, rectal bleeding, loss of appetite, loss of body fluids and nutrients, and joint pain. Ulcerative colitis is an inflammatory bowel disease (IBD).
US Department of Agriculture - USDA promotes America's health through food and nutrition, and advances the science of nutrition by monitoring food and nutrient consumption and updating nutrient requirements and food composition data. USDA is responsible for food safety, improving nutrition and health by providing food assistance and nutrition education, expanding markets for agricultural products, managing and protecting US public and private lands, and providing financial programs to improve the economy and quality of rural American life.
vascular - Having to do with blood vessels.
vasomotor - Having to do with the narrowing and widening of blood vessels.
vitamin B12 - A group of chemical compounds that contain cobalt and are needed for certain chemical reactions in the body. Vitamin B12 is involved in maintaining healthy nerve cells and red blood cells. It is needed to make DNA (the genetic material in all cells), and is required for the metabolism (chemical changes that take place in the tissues to produce energy and the basic materials needed by the body) of carbohydrate, fat, and protein. Also called cobalamin. For more information see the NIH Office of Dietary Supplements Vitamin B12 fact sheet.
vitamin B6 - A group of water-soluble chemical compounds, including pyridoxine, pyridoxal, and pyridoxamine. It is involved in protein metabolism, is needed for the nervous system and immune system to work efficiently, and is needed to make hemoglobin (a molecule within red blood cells that carries oxygen to tissues). It also helps maintain blood glucose (sugar) within a normal range. For more information see the NIH Office of Dietary Supplements Vitamin B6 fact sheet.
water soluble vitamin - A vitamin that dissolves in water and is excreted in the urine. Foods that supply water-soluble vitamins need to be eaten regularly because they cannot be stored in the body. Water-soluble vitamins include vitamin C, biotin, folate, niacin, pantothenic acid, riboflavin (vitamin B2), thiamin, and vitamin B6.

Disclaimer
Reasonable care has been taken in preparing this document and the information provided herein is believed to be accurate. However, this information is not intended to constitute an "authoritative statement" under Food and Drug Administration rules and regulations.

About ODS
The mission of the Office of Dietary Supplements (ODS) is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results, and educating the public to foster an enhanced quality of life and health for the U.S. population.

General Safety Advisory
Health professionals and consumers need credible information to make thoughtful decisions about eating a healthful diet and using vitamin and mineral supplements. To help guide those decisions, registered dietitians at the NIH Clinical Center developed a series of Fact Sheets in conjunction with ODS. These Fact Sheets provide responsible information about the role of vitamins and minerals in health and disease. Each Fact Sheet in this series received extensive review by recognized experts from the academic and research communities.

The information is not intended to be a substitute for professional medical advice. It is important to seek the advice of a physician about any medical condition or symptom. It is also important to seek the advice of a physician, registered dietitian, pharmacist, or other qualified health professional about the appropriateness of taking dietary supplements and their potential interactions with medications.

Reviewers
The Clinical Nutrition Service and the ODS thank the expert scientific reviewers for their role in ensuring the scientific accuracy of the information discussed in these fact sheets:
Lynn B. Bailey, Ph.D., University of Florida
Jesse F. Gregory, III, Ph.D., University of Florida
Mary Frances Picciano, Ph.D., NIH, Office of Dietary Supplements
Irwin H. Rosenberg, M.D., USDA Human Nutrition Research Center on Aging, Tufts University
Richard J. Wood, Ph.D., USDA Human Nutrition Research Center on Aging, Tufts University

Information Provided By:
Office of Dietary Supplements
National Institutes of Health
Bethesda, Maryland 20892 USA
Web: http://ods.od.nih.gov
E-mail: ods@nih.gov