Correspondence of folate dietary intake and biomarker data

Am J Clin Nutr. 2017 Jun;105(6):1336-1343. doi: 10.3945/ajcn.116.148775. Epub 2017 Apr 26.


Background: Public health concerns with regard to both low and high folate status exist in the United States. Recent publications have questioned the utility of self-reported dietary intake data in research and monitoring.Objectives: The purpose of this analysis was to examine the relation between self-reported folate intakes and folate status biomarkers and to evaluate their usefulness for several types of applications.Design: We examined usual dietary intakes of folate by using the National Cancer Institute method to adjust two 24-h dietary recalls (including dietary supplements) for within-person variation and then compared these intakes with serum and red blood cell (RBC) folate among 4878 men and nonpregnant, nonlactating women aged ≥19 y in NHANES 2011-2012, a nationally representative, cross-sectional survey, with respect to consistency across prevalence estimates and rank order comparisons.Results: There was a very low prevalence (<1%) of folate deficiency when serum (<7 nmol/L) and RBC (<305 nmol/L) folate were considered, whereas a higher proportion of the population reported inadequate total dietary folate intakes (6%). Similar patterns of change occurred between intakes and biomarkers of folate status when distributions were examined (i.e., dose response), particularly when diet was expressed in μg. Intakes greater than the Tolerable Upper Intake Level greatly increased the odds of having high serum folate (OR: 17.6; 95% CI: 5.5, 56.0).Conclusions: When assessing folate status in the United States, where fortification and supplement use are common, similar patterns in the distributions of diet and biomarkers suggest that these 2 types of status indicators reflect the same underlying folate status; however, the higher prevalence estimates for inadequate intakes compared with biomarkers suggest, among other factors, a systematic underestimation bias in intake data. Caution is needed in the use of dietary folate data to estimate the prevalence of inadequacy among population groups. The use of dietary data for rank order comparisons or to estimate the potential for dietary excess is likely more reliable.

Keywords: NHANES; dietary assessment; folate; folic acid; measurement error; prevalence.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biomarkers / blood
  • Cross-Sectional Studies
  • Diet
  • Dietary Supplements
  • Energy Intake*
  • Erythrocytes / metabolism
  • Feeding Behavior*
  • Female
  • Folic Acid / administration & dosage
  • Folic Acid / blood*
  • Folic Acid Deficiency / blood*
  • Folic Acid Deficiency / epidemiology
  • Humans
  • Male
  • Mental Recall
  • Middle Aged
  • Nutrition Surveys
  • Prevalence
  • Self Report
  • United States / epidemiology
  • Young Adult


  • Biomarkers
  • Folic Acid