Research Article| Volume 1, ISSUE 4, P775-796, December 1981

Laboratory Assessment of Folate Status

  • Neville Colman
    Corresponding author: Veterans Administration Medical Center, 130 West Kingsbridge Road, Bronx, New York, 10468
    Director, Hematology Laboratory and Blood Bank, and Chief, Hematopathology Research, Veterans Administration Medical Center, Bronx, New York

    Assistant Professor of Pathology, Mount Sinai School of Medicine, New York, New York
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.
      Clinical situations in which folate deficiency should be suspected and clinical evidence of folate deficiency are described. Laboratory tests used to assess folate status are primarily based on the developing sequence of events in the peripheral blood and bone marrow, and include determinations of serum folate, neutrophil hypersegmentation, urinary excretion of metabolites, erythrocyte folate, macrocytosis, and megaloblastic changes in bone marrow. The deoxyuridine suppression test is especially valuable in defining the presence of megaloblastosis and in differentiating between folate and vitamin B12 deficiencies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribers receive full online access to your subscription and archive of back issues up to and including 2002.

      Content published before 2002 is available via pay-per-view purchase only.


      Subscribe to Clinics in Laboratory Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Blakley R.L.
        The Biochemistry of Folic Acid and Related Pteridines.
        North-Holland Publishing Company, Amsterdam1969: 4-6
        • Scott J.M.
        • Weir D.G.
        Folate composition, synthesis and function in natural materials.
        Clin. Haematol. 1976; 5: 547
        • Herbert V.
        • Bertino J.R.
        Folic acid.
        in: Gyorgy P. Pearson W.N. The Vitamins: Chemistry, Physiology, Pathology, Methods. Edition 2. Vol. 7. Academic Press, New York1967: 243-269
        • Houlihan C.M.
        • Scott J.M.
        The identification of pteroylpentaglutamate as the major folate derivative in rat liver and the demonstration of its biosynthesis from exogenous 3H-pteroylglutamate.
        Biochem. Biophys. Res. Comm. 1972; 48: 1675-1681
        • Eto I.
        • Krumdieck C.L.
        Determination of three different pools of reduced one-carbon-substituted folates.
        Anal. Biochem. 1980; 109: 167-184
        • Halsted C.H.
        The intestinal absorption of folates.
        Am. J. Clin. Nutr. 1979; 32: 845-855
        • Colman N.
        • Hettiarachchy N.
        • Herbert V.
        Detection of a milk factor that facilitates folate uptake by intestinal cells.
        Science. 1981; 211: 1427-1429
        • Steinberg S.E.
        • Campbell C.L.
        • Hillman R.S.
        Kinetics of the normal folate enterohepatic cycle.
        J. Clin. Invest. 1979; 64: 83-88
        • Hillman R.S.
        • McGuffin R.
        • Campbell C.
        Alcohol interference with the folate enterohepatic cycle.
        Trans. Assoc. Am. Physicians. 1977; 90: 145-156
        • Herbert V.
        • Zalusky R.
        Interrelations of vitamin B12 and folic acid metabolism: Folic acid clearance studies.
        J. Clin. Invest. 1962; 41: 1263
        • Scott J.M.
        • Dinn J.J.
        • Wilson P.
        • et al.
        Pathogenesis of sub-acute combined degeneration — A result of methyl-group deficiency.
        Lancet. 1981; 2: 334-337
        • Colman N.
        • Herbert V.
        Folate metabolism in brain.
        in: Kumar S. Biochemistry of Brain. Pergamon Press, New York1980: 103-125
        • Hoffbrand A.V.
        • Peters T.J.
        The subcellular localization of pteroypolyglutamate hydrolase and folate in guinea pig intestinal mucosa.
        Biochim. Biophys. Acta. 1969; 192: 479
        • Laskowski M.
        • Mims V.
        • Day P.L.
        Studies on the enzyme which produces the streptococcus lactis R-stimulating from inactive precursor substance in yeast.
        J. Biol. Chem. 1945; 157: 731-739
        • Kmmdieck C.L.
        • Botts L.R.
        • Cornwell P.E.
        • et al.
        Cyclic variations in folate composition and pteroylglutamate hydrolase (conjugase) activity of the rat uterus.
        Am. J. Clin. Nutr. 1976; 29: 288-294
        • Herbert V.
        Megaloblastic anemias.
        in: Beeson P.B. McDermott W. Wyngaarden J.B. Cecil Textbook of Medicine. Edition 15. W. B. Saunders Co., Philadelphia1979: 1719-1729
        • Colman N.
        Folate deficiency in humans.
        in: Draper H.H. Advances in Nutritional Research. Vol. 1. Plenum Publishing, New York1977: 77-124
        • Butterworth C.E.
        • Krumdieck C.L.
        Intestinal absorption of folic acid monoglutamates and polyglutamates: A brief review of some recent developments.
        Br. J. Haematol. (Suppl.). 1975; 31: 111
        • Rosenberg I.H.
        Absorption and malabsorption of folates.
        Clin. Haematol. 1976; 5: 589
        • Reisenauer A.M.
        • Krumdieck C.L.
        • Halsted C.L.
        Folate conjugase: Two separate activities in human jejunum.
        Science. 1977; 198: 196-197
        • Kelly D.
        • Weir D.
        • Reed B.
        • et al.
        Effect of anticonvulsant drugs on the rate of folate catabolism in mice.
        J. Clin. Invest. 1979; 64: 1089-1096
        • Krumdieck C.L.
        • Fukushima K.
        • Fukushima T.
        • et al.
        A long term study of the excretion of folate and pterins in a human subject after ingestion of (14C) folic acid, with observations on the effect of diphenylhydantoin administration.
        Am. J. Clin. Nutr. 1978; 31: 88-93
        • Tamura T.
        • Shin Y.S.
        • Buehring K.U.
        • et al.
        The availability of folates in man: Effect of orange juice supplement on intestinal conjugase.
        Br. J. Haematol. 1976; 32: 123
        • Benn A.
        • Swann C.H.J.
        • Cooke W.T.
        • et al.
        Effect of intraluminal pH on the absorption of pteroylmonoglutamic acid.
        Br. Med. J. 1971; 1: 148
        • Colman N.
        • Green R.
        • Metz J.
        Prevention of folate deficiency in food fortification. II. Absoiption of folic acid from fortified staple foods.
        Am. J. Clin. Nutr. 1975; 28: 459
        • Jennette J.C.
        • Goldman I.E.
        Inhibition of the membrane transport of folates by anions retained in uremia.
        J. Lab. Clin. Med. 1975; 86: 834
      1. Hines, J. D., Kamen, B., and Caston, D.: Abnormal folate binding proteins in azotemic patients. Proc. 16th Annual Mtg., Amer. Soc. Hematol., 1973, p. 57.

        • Colman N.
        • Herbert V.
        Measurement of total folate binding capacity (TFBC) of serum after removal of endogenous folate at acid pH.
        Clin. Res. 1974; 22: 700A
        • Colman N.
        • Herbert V.
        Total folate binding capacity of normal human plasma and variations in uremia, cirrhosis and pregnancy.
        Blood. 1976; 48: 911
        • Metz J.
        Folate deficiency conditioned by lactation.
        Am. J. Clin. Nutr. 1970; 23: 843
        • Channing W.
        Notes on anhaemia, principally in its connections with the puerperal state and with functional disease of the uterus; with cases.
        N. Engl. Quart. J. Med. Surg. 1842; 1: 157
        • Osler W.
        The severe anaemias of pregnancy and the post-partum state.
        Br. Med. J. 1919; 1: 1
        • Wills L.
        Treatment of “pernicious anaemia of pregnancy” and “tropical anaemia,” with special reference to yeast extract as curative agent.
        Br. Med. J. 1931; 1: 1059
        • Moore C.V.
        • Bierbaum O.S.
        • Welch A.D.
        • et al.
        Activity of synthetic Lactobacillus casei factor (“folic acid”) as antipernicious anemia substance: Observations on four patients, two with Addisonian pernicious anemia, one with nontropical sprue, and one with pernicious anemia of pregnancy.
        J. Lab. Clin. Med. 1945; 30: 1056
        • Colman N.
        • Barker E.A.
        • Barker M.
        • et al.
        Prevention of folate deficiency by food fortification: IV. Identification of target groups in addition to pregnant women in an adult rural population.
        Am. J. Clin. Nutr. 1975; 28: 471
        • Herbert V.
        • Colman N.
        • Spivack M.
        • et al.
        Folic acid deficiency in the United States: Folate assay in a prenatal clinic.
        Am. J. Obstet. Gynecol. 1975; 123: 175
        • Herbert V.
        Folate metabolism; Folate deficiency in developing populations.
        XIV International Congress of Hematology, Sao Paulo, Brazil, Lectures1972: 6
        • Colman N.
        • Larsen J.V.
        • Barker M.
        • et al.
        Prevention of folate deficiency by food fortification. III. Effect in pregnant subjects of varying amounts of added folic acid.
        Am. J. Clin. Nutr. 1975; 28: 465
        • Metz J.
        • Zalusky R.
        • Herbert V.
        Folic acid binding by serum and milk.
        Am. J. Clin. Nutr. 1968; 22: 289
        • Sevitt L.H.
        • Hoffbrand A.V.
        Serum folate and vitamin B12 levels in acute and chronic renal disease. Effect of peritoneal dialysis.
        Br. Med. J. 1969; 2: 18
        • Murphy M.
        • Keating M.
        • Boyle P.
        • et al.
        The elucidation of the mechanism of folate catabolism in the rat.
        Biochim. Biophys. Res. Comm. 1976; 71: 1017
        • O’Broin J.D.
        • Temperley E.J.
        • Scott J.M.
        Erythrocyte, plasma and serum folate: Specimen stability before microbiological assay.
        Clin. Chem. 1980; 26 (letter): 522-524
        • Rothman D.
        Folic acid in pregnancy.
        Am. J. Obstet. Gynecol. 1970; 108: 149
        • Baumslag N.
        • Edelstein T.
        • Metz J.
        Reduction of incidence of prematurity by folic acid supplementation in pregnancy.
        J. Nutr. 1970; 105: 80
        • Harrison D.K.
        • Ibeziak’o P.A.
        Maternal anaemia and fet al birth weight.
        J. Obstet. Gynaecol. Brit. Commonw. 1973; 80: 798
        • Iyengar L.
        • Rajalakshmi K.
        Effect of folic acid supplement on birth weights of infants.
        Am. J. Obstet. Gynecol. 1975; 122: 332
        • Whitehead N.
        • Reyner F.
        • Lindenbaum J.
        Megaloblastic changes in the cervical epithelium. Association with oral contraceptives therapy and reversible with folic acid.
        J.A.M.A. 1973; 226: 1421
        • Butterworth C.E.
        • Hatch K.D.
        • Gore H.
        Folate-induced regression of cervical intraepithelial neoplasia (CIN) in users of oral contraceptive agents (OCA).
        Clin. Res. 1980; 28: 593A
        • Rosensweig N.S.
        Diet and intestinal enzyme adaptation: Implications for gastrointestinal disorders.
        Am. J. Clin. Nutr. 1975; 28: 648
        • Vogel R.I.
        • Fink R.A.
        • Scheider L.C.
        • et al.
        Effect of folic acid on gingival health.
        J. Periodontol. 1976; 47: 259A
        • Reynolds E.H.
        Neurological aspects of folate and vitamin B12 metabolism.
        Clin. Haematol. 1976; 5: 661
        • Botez M.I.
        • Reynolds E.H.
        Folic Acid in Neurology, Psychiatry and Internal Medicine.
        Raven Press, New York1979
        • Shorvon S.D.
        • Carney M.W.P.
        • Chanarin I.
        • et al.
        The neuropsychiatry of megaloblastic anaemia.
        Br. Med. J. 1980; 281: 1036-1038
        • Herbert V.
        Experimental nutritional folate deficiency in man.
        Trans. Assoc. Am. Physicians. 1962; 75: 307
        • Herbert V.
        The assay and nature of folic acid activity in human serum.
        J. Clin. Invest. 1961; 40: 81
        • Scott J.M.
        • Ghanta V.
        • Herbert V.
        Trouble-free microbiologic serum and red cell folate assays.
        Am. J. Med. Technol. 1974; 40: 1225
        • Waxman S.
        • Schreiber C.
        • Herbert V.
        Radioisotopic assay for measurement of serum folate levels.
        Blood. 1971; 38: 219
        • Archibald E.L.
        • Mincey E.K.
        • Morrison R.T.
        Estimation of serum folate levels by competitive protein binding assay.
        Clin. Biochem. 1972; 5: 232-241
        • Rothenberg S.P.
        • DaCosta M.
        • Rosenberg Z.
        A radioassay for serum folate: Use of-a two-phase sequential-incubation ligand-binding system.
        N. Engl. I. Med. 1973; 286: 232-241
        • Miney E.K.
        • Wilcox E.
        • Morrison R.T.
        Estimation of serum and red cell folate by a simple radiometric technique.
        Clin. Biochem. 1973; 6: 274-284
        • Colman N.
        Technological factors affecting use of radioassays in the assessment of the nutritional anemias.
        Ligand Quart. 1981; 4: 31-36
        • Longo D.L.
        • Herbert V.
        Radioassay for serum and red cell folate.
        J. Lab. Clin. Med. 1976; 87: 138
        • Colman N.
        • Longo D.
        • Herbert V.
        Folate radioassay and crude milk binder.
        Blood. 1976; 48: 626-627
        • Thoebald R.A.
        • Batcheider M.
        • Sturgeon M.F.
        Evaluation of pteroylglutamic acid and N-5-methyltetrahydrofolic acid reference standards in a new “no-boil” radioassay for serum folate.
        Clin. Chem. 1981; 27: 553-555
        • Jacob E.
        • Colman N.
        • Herbert V.
        Evaluation of simultaneous radioassay for two vitamins: Folate and vitamin B12.
        Am. J. Clin. Nutr. 1977; 30: 6165
        • Herbert V.
        The Megaloblastic Anemias.
        Grune and Stratton, New York1959
        • Nath B.J.
        • Lindenbaum J.
        Persistence of neutrophil hypersegmentation during recovery from megaloblastic granulopoiesis.
        Ann. Intern. Med. 1979; 90: 757-760
        • Lindenbaum J.
        • Nath B.J.
        Megaloblastic anemia and hypersegmentation.
        Br. J. Haematol. 1980; 44: 511-513
        • Das K.C.
        • Herbert V.
        • Colman N.
        • et al.
        Unmasking covert folate deficiency in iron-deficient subjects with neutrophil hypersegmentation: dU suppression tests on lymphocytes and bone marrow.
        Br. J. Haematol. 1978; 39: 357-375
        • Herbert V.
        Studies of folate deficiency in man.
        Proc. R. Soc. Med. 1964; 57: 377
        • Herbert V.
        • Zalusky R.
        Interrelations of vitamin B12 and folic acid metabolism: Folic acid clearance studies.
        J. Clin. Invest. 1962; 41: 1263
        • Gutcho S.
        Source of error in determination of erythrocyte folate by competitive binding radioassay—Comments.
        Clin. Chem. 1978; 24: 388-389
        • Shane B.
        • Tamura T.
        • Stokstad E.L.R.
        Folate assay: A comparison of radioassay and microbiological methods.
        Clin. Chem. Acta. 1980; 100: 13-19
        • Lessin L.S.
        • Bessis M.
        Morphology of the erythron.
        in: Williams W.J. Beutler E. Erslev A.J. Hematology. Edition 2. McGraw-Hill, New York1977: 103-135
        • Chanarin I.
        Investigation and management of megaloblastic anemias.
        Clin. Haematol. 1976; 5: 747
        • Wu A.
        • Chanarin I.
        • Slavin G.
        • et al.
        Folate deficiency in the alcoholic — Its relationship to clinical and haematologic abnormalities, liver disease and folate stores.
        Br. J. Haematol. 1975; 29: 469
        • Lindenbaum J.
        Folate and vitamin B12 deficiencies in alcoholism.
        Semin. Hematol. 1980; 17: 119-129
        • Clarkson D.R.
        • Moore E.M.
        Reticulocyte size in nutritional anemias.
        Blood. 1976; 48: 669
        • Balias S.K.
        • Saidi P.
        • Constantino M.
        Reduced erythrocyte deformability in megaloblastic anemia.
        Am. J. Clin. Pathol. 1976; 66: 953
        • Metz J.
        • Kelly A.
        • Swett V.C.
        • et al.
        Deranged DNA synthesis by bone marrow from vitamin B12-deficient humans.
        Br. J. Haematol. 1968; 14: 575
        • Herbert V.
        • Tisman G.
        • Go L.T.
        • et al.
        The dU suppression test using 125I-UdR to define biochemical megaloblastosis.
        Br. J. Haematol. 1973; 24: 713
        • Das K.C.
        • Hoffband A.V.
        Studies of folate uptake by phytohaemagglutinin-stimulated lymphocytes.
        Br. J. Haematol. 1970; 19: 203
        • Das K.C.
        • Hoffband A.V.
        Lymphocyte transformation in megaloblastic anemia. Morphology and DNA synthesis.
        Br. J. Haematol. 1970; 19: 459
        • Das K.C.
        • Herbert V.
        The lymphocyte as a marker of past nutritional status: Persistence of abnormal deoxyuridine suppression test and chromosomes in patients with past deficiency of folate and vitamin B12.
        Br. J. Haematol. 1978; 38: 219-233
        • Das K.C.
        • Manusselis C.
        • Herbert V.
        Simplifying lymphocyte culture and the deoxyuridine supression test by using whole blood (0.1 ml) instead of separated lymphocytes.
        Clin. Chem. 1980; 26: 72-77
        • Colman N.
        • Herbert V.
        Abnormal lymphocyte deoxyuridine suppression test: A reliable indicator of decreased lymphocyte folate levels.
        Am. J. Hematol. 1980; 8: 169-174
        • Williams R.C.
        • Baker D.R.
        • Schmit E.
        Analysis of water-soluble vitamins by high-speed ion-exchange chromatography.
        J. Chromatogr. Sei. 1973; 11: 618-624
        • Reed L.S.
        • Archer M.C.
        Separation of folic acid derivatives by high-performance liquid chromatography.
        J. Chromatogr. 1976; 121: 100
        • Clifford C.K.
        • Clifford A.J.
        High pressure liquid chromatographic analysis of food for folates.
        J. Assoc. Off. Anal. Chem. 1977; 60: 1248
        • Reingold R.N.
        • Picciano M.F.
        Separation of folate derivatives by in situ paired-ion high-pressure liquid chromatography.
        J. Chromatogr. Sei. 1980; 190: 237-240
        • Allen B.A.
        • Newman R.A.
        High-performance liquid chromatographic separation of clinically important folic acid derivatives using ion-pair chromatography.
        J. Chromatogr. Sei. 1980; 190: 241-245
        • Lankelma J.
        • van der Kleijn E.
        • Jansen M.J.T.
        Determination of 5-methyltetrahydrofolic acid in plasma and spinal fluid by high-performance liquid chromatography, using on-column concentration and electrochemical detection.
        J. Chromatogr. 1980; 182: 35-45
        • Dine M.E.
        • Snyder L.M.
        Iron deficiency and PMN segmentation.
        N. Engl. J. Med. 1970; 282: 691
        • Herbert V.
        • Colman N.
        • Jacob E.
        Folic acid and vitamin B12.
        in: Goodhart R.S. Shils M.E. Modern Nutrition in Health and Disease. Lea and Febiger, Philadelphia1980: 229-259