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Bronberg R, Martinez J, Morales L, Ruderman A, Taire D, Ramallo V, Dipierri J. "Prevalence and secular trend of neural tube defects in fetal deaths in Argentina, 1994-2019". Birth Defects Res 2023; 115:1737-1745. [PMID: 37715338 DOI: 10.1002/bdr2.2248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Fetal deaths are a major source of information on the epidemiology of neural tube defects (NTDs; anencephaly and myelomeningocele). We analyzed NTDs prevalence and secular trend using fetal death records between 1994 and 2019 in Argentina. MATERIALS AND METHODS Data were obtained from the Department of Statistics and Information of the Ministry of Health (DEIS). Using the number of fetal deaths due to anencephaly and myelomeningocele, we estimated the proportion of all fetal deaths due to anencephaly, myelomeningocele, and NTDs (anencephaly + myelomeningocele) during pre- and post-fortification period in Argentina. We also estimated the ratio of fetal deaths due to anencephaly, myelomeningocele, and NTDs (anencephaly + myelomeningocele) to 10,000 live births. Secular trend in the outcomes was analyzed using a Poisson model and Joinpoint regression analysis. RESULTS In the entire period analyzed, the NTD proportion on fetal deaths was 1.32. In 1994, NTDs accounted for 34.7% of congenital malformations fetal deaths (CM) and 1.7% of all fetal deaths, whereas in 2019, these percentages were 9.4% and 0.5%, respectively. NTDs present a negative secular trend (p < .05). The risk of fetal death due to anencephaly and myelomeningocele decreases between 2005 and 2019 by 67% and 51% respectively (p < .05) in comparison to the period between 1994 and 2004 before the effective fortification of wheat flour used in the food industry destined for the domestic market. DISCUSSION AND CONCLUSION We found a significant decrease in the risk of all fetal deaths due to NTDs, particularly anencephaly, in Argentina over the study period, with most reduction observed during the mandatory flour fortification era (introduced in Argentina in 2002). The inclusion of fetal deaths in NTD surveillance, coupled or uncoupled with other pregnancy outcomes, is essential for monitoring preventive supplementation measures.
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Affiliation(s)
- Ruben Bronberg
- Medical and Population Genetics Area, Ramos Mejía Hospital, Buenos Aires, Argentina
- Buenos Aires Government Research Committee, Buenos Aires, Argentina
| | - Jorge Martinez
- Institute of Ecoregions of the Andes, National Scientific and Technical Research Council (CONICET), Jujuy, Argentina
| | - Leonardo Morales
- Patagonian Institute of Social and Human Sciences (IPCSH CCT CONICET-CENPAT) and Department of Informatics, Faculty of Engineering National University of Patagonia San Juan Bosco (UNPSJB), Argentina
| | - Anahi Ruderman
- Patagonian Institute of Social and Human Sciences (IPCSH CCT CONICET-CENPAT), Argentina
| | - Damian Taire
- Andrés Ísola Zonal Hospital, Puerto Madryn-Patagonian Institute of Social and Human Sciences (IPCSH CCT CONICET-CENPAT), Argentina
| | - Virginia Ramallo
- Patagonian Institute of Social and Human Sciences (IPCSH CCT CONICET-CENPAT), Argentina
| | - Jose Dipierri
- Institute of Ecoregions of the Andes, National Scientific and Technical Research Council (CONICET), Jujuy, Argentina
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Finkelstein JL, Guetterman HM, Fothergill A, Johnson CB, Qi YP, Jabbar S, Zhang M, Pfeiffer CM, Rose CE, Yeung LF, Williams JL, Krisher JT, Ruth C, Roy Choudhury D, Venkatramanan S, Haas JD, Kuriyan R, Mehta S, Bonam W, Crider KS. A Randomized Trial of Quadruple-Fortified Salt for Anemia and Birth Defects Prevention in Southern India: Protocol Design and Methods. Curr Dev Nutr 2023; 7:100052. [PMID: 37181934 PMCID: PMC10111605 DOI: 10.1016/j.cdnut.2023.100052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
Background Women of reproductive age are at an increased risk of anemia and micronutrient deficiencies. Evidence supports the role of periconceptional nutrition in the development of neural tube defects (NTDs) and other pregnancy complications. Vitamin B12 deficiency is a risk factor for NTDs and may modify folate biomarkers that predict NTD risk at the population level. There is an interest in mandatory fortification with vitamin B12 and folic acid for anemia and birth defect prevention. However, there are limited population-representative data needed to inform policy and guidelines. Objectives This randomized trial will be conducted to evaluate the efficacy of quadruple-fortified salt (QFS; iron, iodine, folic acid, vitamin B12) in 1,000 households in Southern India. Methods Women 18 to 49 y who are not pregnant or lactating and reside within the catchment area of our community-based research site in Southern India will be screened and invited to participate in the trial. After informed consent, women and their households will be randomized to receive one of the following 4 interventions: 1) double-fortified salt (DFS; iron, iodine), 2) DFS + folic acid (iron, iodine, folic acid), 3) DFS + vitamin B12 (iron, iodine, vitamin B12), or 4) DFS + folic acid and vitamin B12 (QFS; iron, iodine, folic acid, vitamin B12) for 12 mo. Structured interviews will be conducted by trained nurse enumerators to collect sociodemographic, anthropometric, dietary, health, and reproductive history data. Biological samples will be collected at baseline, midpoint, and endpoint. Whole blood will be analyzed for hemoglobin using Coulter Counter. Total vitamin B12 will be measured by chemiluminescence; red blood cell folate and serum folate will be evaluated using the World Health Organization-recommended microbiologic assay. Conclusions The results of this randomized trial will help to evaluate the efficacy of QFS to prevent anemia and micronutrient deficiencies. Clinical trial registration numbers: NCT03853304 and Clinical Trial Registry of India REF/2019/03/024479. Registration number NCT03853304 and REF/2019/03/024479.
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Affiliation(s)
- Julia L. Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- St. John’s Research Institute, Bangalore, Karnataka, India
| | | | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Yan Ping Qi
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Shameem Jabbar
- The National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mindy Zhang
- The National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M. Pfeiffer
- The National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles E. Rose
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Lorraine F. Yeung
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jennifer L. Williams
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jesse T. Krisher
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Caleb Ruth
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Dripta Roy Choudhury
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- St. John’s Research Institute, Bangalore, Karnataka, India
| | | | - Jere D. Haas
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | | | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- St. John’s Research Institute, Bangalore, Karnataka, India
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Krista S. Crider
- The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
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3
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Mai CT, Evans J, Alverson CJ, Yue X, Flood T, Arnold K, Nestoridi E, Denson L, Adisa O, Moore CA, Nance A, Zielke K, Rice S, Shan X, Dean JH, Ethen M, Hansen B, Isenburg J, Kirby RS. Changes in Spina Bifida Lesion Level after Folic Acid Fortification in the US. J Pediatr 2022; 249:59-66.e1. [PMID: 35772508 PMCID: PMC10250025 DOI: 10.1016/j.jpeds.2022.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/30/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess whether the severity of cases of spina bifida changed after the institution of mandatory folic acid fortification in the US. STUDY DESIGN Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (prefortification period) and 1999-2016 (postfortification period). The programs contributed varying years of data. Case information included both a medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing the prefortification and postfortification periods, aORs for case severity (upper-level lesions [cervical, thoracic] vs lower-level lesions [lumbar, sacral]) and prevalence ratios (PRs) were estimated. RESULTS A total of 2593 cases of spina bifida (out of 7 816 062 live births) met the inclusion criteria, including 573 cases from the prefortification period and 2020 cases from the postfortification period. Case severity decreased by 70% (aOR, 0.30; 95% CI, 0.26-0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic White mothers. Overall spina bifida prevalence declined by 23% (PR, 0.77; 95% CI, 0.71-0.85), with similar reductions seen across the early, mid, and recent postfortification periods. A statistically significant decrease in upper-level lesions occurred in the postfortification period compared with the prefortification period (PR, 0.28; 95% CI, 0.22-0.34), whereas the prevalence of lower-level lesions remained relatively similar (PR, 0.94; 95% CI, 0.84-1.05). CONCLUSIONS The severity of spina bifida cases decreased after mandatory folic acid fortification in the US. Further examination is warranted to better understand the potential effect of folic acid on spina bifida severity.
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Affiliation(s)
- Cara T Mai
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Jane Evans
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Clinton J Alverson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xin Yue
- Eagle Global Scientific, Atlanta, GA
| | - Timothy Flood
- Bureau of Public Health Statistics, Arizona Department of Health Services, Phoenix, AZ
| | - Kathryn Arnold
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eirini Nestoridi
- Center for Birth Defects Research and Prevention, Bureau of Family Health and Nutrition, Massachusetts Department of Public Health, Boston, MA
| | - Lindsay Denson
- Oklahoma Birth Defects Registry, Oklahoma State Department of Health, Oklahoma City, OK
| | | | - Cynthia A Moore
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amy Nance
- Utah Birth Defect Network, Office of Children with Special Health Care Needs, Utah Department of Health and Human Services, Salt Lake City, UT
| | - Katherine Zielke
- South Carolina Birth Defects Program, South Carolina Department of Health and Environmental Control, Columbia, SC
| | | | - Xiaoyi Shan
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock, AK
| | | | - Mary Ethen
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX
| | - Brenda Hansen
- California Birth Defects Monitoring Program, Genetic Disease Screening Program/Center for Family Health, California Department of Public Health, Sacramento, CA
| | - Jennifer Isenburg
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Russell S Kirby
- College of Public Health, University of South Florida, Tampa, FL
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Yasmin S, Siddiqa A, Rockliffe L, Miyan J. Knowledge of Neural Tube Defects and Prevention Through Folic Acid Use Among Women in Faisalabad, Punjab, Pakistan: A Cross-Sectional Survey. Int J Womens Health 2022; 14:425-434. [PMID: 35386938 PMCID: PMC8978686 DOI: 10.2147/ijwh.s347887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Neural tube defects (NTDs) are one of the most common congenital abnormalities of the central nervous system and are associated with significant mortality, morbidity, and major life-long disability. Periconceptional folic acid reduces the risk of NTDs by up to 70%; however, in Pakistan, no public information program exists concerning the risks of NTDs or promoting folic acid use. As such, the aim of this study was to assess levels of knowledge about NTDs and folic acid use among women attending the gynaecology department of DHQ Hospital, Faisalabad, Pakistan. Design A cross-sectional survey. Setting The gynaecology department of the District Head Quarter (DHQ) Hospital in Faisalabad, Pakistan. Participants Three hundred and fifty-five married women. Primary and Secondary Outcome Measures Primary outcome measures included knowledge of NTDs and knowledge of folic acid use. Results About 85.4% of participants had no knowledge of neural tube defects and 76.7% reported no knowledge about folic acid use. The majority of participants (86.2%) were unaware that folic acid protects against NTDs. Lack of knowledge of NTDs was significantly associated with education (P = 0.001), husband’s education (P = 0.002), planned pregnancy (P = 0.002), sources of antenatal care (P = 0.003), knowledge of folic acid (P = 003), knowledge that folic acid protects against NTDs (P = 0.002), and health decision-making (P = 0.003). Knowledge of folic acid use was significantly associated with age (P = 0.000), education (P = 0.004), husband’s education (P = 0.002), monthly income (P = 0.003), planned pregnancy (P = 0.003), pregnancy trimester (P < 0.001), sources of antenatal care (P < 0.001), knowledge of NTDs (P = 0.002), knowledge that folic acid protects against NTDs (P < 0.001), use of folic acid (P < 0.001), sources of vitamin information (P < 0.001), and health decision-making (P = 0.002). Conclusion These findings highlight extremely low levels of knowledge about NTDs and folic acid use of women in Pakistan. There is an urgent need to increase knowledge and awareness of the risks of NTDs and preventative approaches, through health education programs delivered by trusted health professionals.
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Affiliation(s)
- Shazia Yasmin
- Department of Rural Sociology, Faculty of Social Sciences, University of Agriculture, Faisalabad, Pakistan.,Faculty of Biology, Medicine & Health, School of Biological Sciences, The University of Manchester, Manchester, M13 9PT, UK
| | - Ayesha Siddiqa
- Department of Sociology and Criminology, University of Sargodha, Punjab, Pakistan
| | - Lauren Rockliffe
- Manchester Centre for Health Psychology, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jaleel Miyan
- Faculty of Biology, Medicine & Health, School of Biological Sciences, The University of Manchester, Manchester, M13 9PT, UK
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5
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Zhou Y, Crider KS, Yeung LF, Rose CE, Li Z, Berry RJ, Li S, Moore CA. Periconceptional folic acid use prevents both rare and common neural tube defects in China. Birth Defects Res 2022; 114:184-196. [PMID: 35098705 PMCID: PMC11091954 DOI: 10.1002/bdr2.1983] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neural tube defects (NTDs) encompass a variety of distinct types. We assessed if the preventive effect of folic acid (FA) varied by NTD type and infant sex. METHODS We examined all pregnancies with NTD status confirmation from a pregnancy-monitoring system in selected locations in northern and southern regions of China between 1993 and 1996. Women who took 400 μg of FA daily during 42 days after last menstrual period were considered FA users. We analyzed NTD prevalence by FA use status, NTD type, geographic region, and infant sex. RESULTS Among 626,042 pregnancies, 700 were affected by an NTD. Among FA nonusers, 65 pregnancies (8.8 per 10,000) in the north and 51 pregnancies (1.2 per 10,000) in the south were affected by one of the two rare NTDs, that is, craniorachischisis, iniencephaly. FA use prevented occurrence of these two rare NTDs and reduced the prevalence of spina bifida (SB) by 78% (from 17.9 to 3.9 per 10,000) in the north and 51% (from 2.4 to 1.2 per 10,000) in the south. Among FA users, SB prevalence, including SB with high lesion level, was significantly reduced in both geographic regions. FA use reduced prevalence of anencephaly and encephalocele by 85% and 50%, respectively in the north, while it did not reduce the prevalence of these two NTDs in the south. There was a greater reduction in NTD prevalence in female than in male infants and fetuses. CONCLUSIONS This is the first study to show that FA prevents the entire spectrum of NTD types.
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Affiliation(s)
- Ying Zhou
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Krista S. Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lorraine F. Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Charles E. Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zhu Li
- Institute of Reproductive and Child Health, School of Public Health, Peking University, Beijing, China
| | - Robert J. Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Song Li
- Peking University Third Hospital, Beijing, China
| | - Cynthia A. Moore
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Pardo R, Vilca M, Villarroel L, Davalji T, Obrycki JF, Mazumdar M, Avila C, Mellado C. Neural tube defect prevalence does not increase after modification of the folic acid fortification program in Chile. Birth Defects Res 2022; 114:259-266. [PMID: 35218603 DOI: 10.1002/bdr2.1994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/04/2022] [Accepted: 02/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND In 2000, Chile's Ministry of Health mandated fortification of wheat flour with folic acid at a concentration of 2.2 mg/kg to prevent neural tube defects (NTDs), resulting in a 50% reduction in NTD prevalence. Concerns about possible collateral effects of high folic acid intake led, in 2009, to decrease the folic acid fortification to 1.8 mg/kg of flour. Our study evaluated the impact of this modification on the prevalence of NTDs in Santiago. METHODS This study measured the prevalence of NTDs in live births and stillbirths born in Santiago. We calculated prevalence ratios (PR) and 95% confidence intervals (CI) between pre-folic acid fortification (1999-2000), post-folic acid fortification (2001-2009), and post-modified folic acid fortification (2010-2015) periods for all NTDs and their specific types. We used chi-square tests to analyze proportions, and a Joinpoint regression to visualize prevalence time trends. RESULTS The NTD prevalence for the period 2001-2015 was 8.9 per 10,000 births, which represents a 48% reduction (PR = 0.52; 95% CI = 0.45-0.61; p < .001) from the pre-folic acid fortification period. During 2010-2015, the NTD prevalence was 9.5/10,000 births, which was higher, but not statistically significantly different from 2001 to 2009 prevalence of 8.6/10,000 (PR = 1.11; 95% CI = 0.96-1.30, p = .17). CONCLUSIONS Decreasing the concentration of folic acid fortification was not associated with a statistically significant change in the prevalence of NTDs. Mandatory folic acid fortification continues to be a safe and highly effective policy to prevent NTDs. Future studies should evaluate the prevalence of NTDs across Chile and adherence to folic acid fortification mandates.
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Affiliation(s)
- Rosa Pardo
- Genetics Unit, Pediatrics Service, Complejo Asistencial Dr. Sótero del Río, Puente Alto, Chile.,Genetics Section, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Neonatology Unit, Department of Obstetrics and Gynecology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Marcela Vilca
- Neonatology Unit, Department of Obstetrics and Gynecology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Luis Villarroel
- Department of Public Health, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tahera Davalji
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - John F Obrycki
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Claudia Avila
- Neonatology Unit, Complejo Hospitalario San José, Santiago, Chile
| | - Cecilia Mellado
- Genetics Unit, Pediatrics Service, Complejo Asistencial Dr. Sótero del Río, Puente Alto, Chile.,Genetics Unit, Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Irvine N, England-Mason G, Field CJ, Dewey D, Aghajafari F. Prenatal Folate and Choline Levels and Brain and Cognitive Development in Children: A Critical Narrative Review. Nutrients 2022; 14:nu14020364. [PMID: 35057545 PMCID: PMC8778665 DOI: 10.3390/nu14020364] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 01/13/2023] Open
Abstract
Women’s nutritional status during pregnancy can have long-term effects on children’s brains and cognitive development. Folate and choline are methyl-donor nutrients and are important for closure of the neural tube during fetal development. They have also been associated with brain and cognitive development in children. Animal studies have observed that prenatal folate and choline supplementation is associated with better cognitive outcomes in offspring and that these nutrients may have interactive effects on brain development. Although some human studies have reported associations between maternal folate and choline levels and child cognitive outcomes, results are not consistent, and no human studies have investigated the potential interactive effects of folate and choline. This lack of consistency could be due to differences in the methods used to assess folate and choline levels, the gestational trimester at which they were measured, and lack of consideration of potential confounding variables. This narrative review discusses and critically reviews current research examining the associations between maternal levels of folate and choline during pregnancy and brain and cognitive development in children. Directions for future research that will increase our understanding of the effects of these nutrients on children’s neurodevelopment are discussed.
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Affiliation(s)
- Nathalie Irvine
- O’Brien Centre for the Bachelor of Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada;
| | - Gillian England-Mason
- Owerko Centre, Alberta Children’s Hospital Research Institute, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada; (G.E.-M.); (D.D.)
- Department of Pediatrics, Cumming School of Medicine, Alberta Children’s Hospital, 28 Oki Drive NW, Calgary, AB T3B 6A8, Canada
| | - Catherine J. Field
- Department of Agricultural, Food and Nutritional Science, University of Alberta, 4-126C Li Ka Shing Centre for Research, 11203-87th Ave NW, Edmonton, AB T6G 2H5, Canada;
| | - Deborah Dewey
- Owerko Centre, Alberta Children’s Hospital Research Institute, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada; (G.E.-M.); (D.D.)
- Department of Pediatrics, Cumming School of Medicine, Alberta Children’s Hospital, 28 Oki Drive NW, Calgary, AB T3B 6A8, Canada
- Hotchkiss Brain Institute, Health Research Innovation Centre, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada
| | - Fariba Aghajafari
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, G012, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
- Correspondence:
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8
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Kancherla V, Ma C, Grant G, Lee HC, Hintz SR, Carmichael SL. Factors Associated with Early Neonatal and First-Year Mortality in Infants with Myelomeningocele in California from 2006 to 2011. Am J Perinatol 2021; 38:1263-1270. [PMID: 32473597 PMCID: PMC7704777 DOI: 10.1055/s-0040-1712165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study is to examine factors associated with early neonatal (death within first 7 days of birth) and infant (death during the first year of life) mortality among infants born with myelomeningocele. STUDY DESIGN We examined linked data from the California Perinatal Quality Care Collaborative, vital records, and hospital discharge records for infants born with myelomeningocele from 2006 to 2011. Survival probability was calculated using Kaplan-Meier Product Limit method and 95% confidence intervals (CI) using Greenwood's method; Cox proportional hazard models were used to estimate unadjusted and adjusted hazard ratios (HR) and 95% CI. RESULTS Early neonatal and first-year survival probabilities among infants born with myelomeningocele were 96.0% (95% CI: 94.1-97.3%) and 94.5% (95% CI: 92.4-96.1%), respectively. Low birthweight and having multiple co-occurring birth defects were associated with increased HRs ranging between 5 and 20, while having congenital hydrocephalus and receiving hospital transfer from the birth hospital to another hospital for myelomeningocele surgery were associated with HRs indicating a protective association with early neonatal and infant mortality. CONCLUSION Maternal race/ethnicity and social disadvantage did not predict early neonatal and infant mortality among infants with myelomeningocele; presence of congenital hydrocephalus and the role of hospital transfer for myelomeningocele repair should be further examined. KEY POINTS · Mortality in myelomeningocele is a concern. · Social disadvantage was not associated with death. · Hospital-based factors should be further examined.
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Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Chen Ma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gerald Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Henry C. Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California,California Perinatal Quality Care Collaborative, Stanford, California
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California,California Perinatal Quality Care Collaborative, Stanford, California
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Kancherla V, Mowla S, Räisänen S, Gissler M. Early Neonatal Mortality among Babies Born with Spina Bifida in Finland (2000-2014). Am J Perinatol 2021. [PMID: 34428829 DOI: 10.1055/s-0041-1733957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We examined early neonatal mortality risk, temporal trends, and selected infant and maternal factors associated with early neonatal mortality among all spina bifida-affected live births in Finland. STUDY DESIGN We linked multiregistry population-based data from the national registers in Finland for infants born with spina bifida from 2000 to 2014. Early neonatal mortality was defined as death in 0 to 6 days after birth. Early neonatal mortality risk and 95% confidence intervals (CI) was estimated by using the Poisson approximation of binomial distribution. Poisson regression was used to examine temporal trend in early neonatal mortality from 2000 to 2014 for spina bifida cases and all births in Finland. Selected infant and maternal characteristics were compared between cases that experienced early neonatal mortality and cases that did not. Exact logistic regression was used to estimate unadjusted odds ratios (uORs) and 95% confidence intervals (CIs). RESULTS A total of 181 babies were born alive with spina bifida in Finland during the study period; 61% had isolated spina bifida. Pooling all study years, 7.2% (95% CI: 4.2-12.4%) of all live-born cases experienced early neonatal death. There was a significant increase in early neonatal mortality among spina bifida births over the study period (p < 0.0001). Low gestational age (<37 weeks; uOR = 6.96; 95% CI: 1.86-29.01), cases occurring as a part of a syndrome (uOR = 125.67; 95% CI: 14.90 to >999.999), and advanced maternal age at gestation (≥35 years; uOR = 5.33; 95% CI: 1.21-21.87) were positively associated with early neonatal mortality. CONCLUSION Using national data from Finland, we found high early neonatal mortality with increasing trend over birth period spanning 15 years (2000-2014), and unadjusted positive associations with some infant and maternal factors. Future studies should pool data from Nordic countries to increase study size allowing multivariable analysis. KEY POINTS · Early neonatal mortality in babies affected by spina bifida is 7% in Finland.. · Early neonatal mortality trend showed a significant increase from 2000 to 2014.. · Low gestational age, syndrome case status, and advanced maternal age increased early neonatal mortality risk in spina bifida..
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Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sanjida Mowla
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sari Räisänen
- School of Health, Tampere University of Applied Sciences, Tampere, Finland
| | - Mika Gissler
- Information Services Department, THL Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden, Academic Primary Health Care Centre, Region Stockholm, Sweden
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Sensory and Physicochemical Properties and Stability of Folic Acid in a Pineapple Ready-to-Serve Beverage Fortified with Encapsulated Folic Acid. J FOOD QUALITY 2021. [DOI: 10.1155/2021/9913884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fortification of food and beverages with folic acid is carried out frequently as a remedy to folic acid deficiency which causes serious health issues. This study was carried out to investigate the effect of incorporation of folic acid encapsulated alginate submicron particles in pineapple ready-to-serve (RTS) beverages. The encapsulation efficiency and loading capacity of the particles were 91.54 ± 0.45% and 1.02 ± 0.01%, respectively. The photostability and thermal stability studies of folic acid revealed that encapsulation poses a protective effect on folic acid and that dark and refrigerated conditions contribute to higher stability of folic acid. In this study, sensory evaluation of the RTS beverages was carried out through both ranking tests and acceptance tests using a five-point hedonic scale. The sensory panel showed the highest preference to pineapple RTS with incorporated encapsulated folic acid at a quantity of its recommended daily intake (400 µg/200 mL) before heat treatment. Shelf-life evaluations were carried out through measuring physicochemical properties, and pH, titratable acidity, and total soluble solids showed negligible or acceptable changes over two months. Folic acid degradation occurred due to heat treatment, but encapsulation in alginate submicron particles provided heat stability to folic acid. Thus, microencapsulated folic acid may be a successful carrier of folic acid which can be incorporated in beverages such as fortified pineapple RTS.
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11
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A scoping review of research on policies to address child undernutrition in the Millennium Development Goals era. Public Health Nutr 2021; 24:4346-4357. [PMID: 33926609 DOI: 10.1017/s1368980021001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The breadth of research on the impact of nutrition-specific policies to address child undernutrition is not well documented. This review maps the evidence base and identifies gaps on such policies. DESIGN We systematically searched Medline, Embase, PAIS Index for public policy, Scopus and Web of Science databases to identify eligible studies. Key study characteristics, including research design, type of policy, time span of policy before impact assessment, child age at outcome assessment and types of outcomes assessed, were abstracted in duplicate. SETTING Low-, middle- and high-income countries. PARTICIPANTS Studies were eligible for inclusion if they aimed to assess the impact of population-level nutrition-specific policies on undernutrition among children under 10 years of age. RESULTS Of the 5646 abstracts screened, eighty-three studies were included. A range of policies to address child undernutrition were evaluated; the majority were related to micronutrient fortification. Most studies were observational, reported on mandatory regional or sub-national polices, were conducted in high-income countries and evaluated policies within 1 year of implementation. A narrow set of health outcomes were evaluated, most commonly iodine deficiency disorders and neural tube defects. CONCLUSIONS Nutrition policies were commonly associated with improved child nutritional status and health. However, this evidence is primarily based on limited settings and on a limited number of outcomes. Further research is needed to assess the longer-term impact of a broader range of nutrition policies on child health, particularly in low- and middle-income countries.
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Ortiz-Cruz G, Aguayo-Gómez A, Luna-Muñoz L, Muñoz-Téllez LA, Mutchinick OM. Myelomeningocele genotype-phenotype correlation findings in cilia, HH, PCP, and WNT signaling pathways. Birth Defects Res 2021; 113:371-381. [PMID: 33470056 DOI: 10.1002/bdr2.1872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/27/2020] [Accepted: 01/09/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Myelomeningocele (MMC) is the most severe and frequent type of spina bifida. Its etiology remains poorly understood. The Hedgehog (Hh), Wnt, and planar cell polarity (PCP) signaling pathways are essential for normal tube closure, needing a structural-functional cilium for its adequate function. The present study aimed to investigate the impact of different gene variants (GV) from those pathways on MMC genotype-subphenotype correlations. METHODS The study comprised 500 MMC trios and 500 controls, from 16 Telethon centers of 16 Mexican states. Thirty-four GVs of 29 genes from cilia, Hh, PCP, and Wnt pathways, were analyzed, by an Illumina on design microarray. The total sample (T-MMC) was stratified in High-MMC (H-MMC) when thoracic and Low-MMC (L-MMC) when lumbar-sacral vertebrae affected. STATA/SE-12.1 and PLINK software were used for allelic association, TDT, and gene-gene interaction (GGI) analyses, considering p value <.01 as statistically significant differences (SSD). RESULTS Association analysis showed SSD for COBL-rs10230120, DVL2-rs2074216, PLCB4-rs6077510 GVs in T-MMC and L-MMC, and VANGL2-rs120886448 in T-MMC and H-MMC, and INVS-rs7024375 exclusively in L-MMC. TDT assay showed SSD preferential transmissions of C2CD3-rs826058 in H-MMC, and LRP5-rs3736228, and BBS2-rs1373 in L-MMC. Statistically significant GGI was observed in four in T-MMC, four completely different in L-MMC, and one in H-MMC. Interestingly, no one repeated in subphenotypes. CONCLUSIONS Our results support an association of GVs in Hh, Wnt, PCP, and cilia pathways, with MMC occurrence location, although further validation is needed. Furthermore, present results show a distinctive panel of gene-variants in H-MMC and LMMC subphenotypes, suggesting a feasible genotype-phenotype correlation.
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Affiliation(s)
- Gabriela Ortiz-Cruz
- Department of Genetics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Adolfo Aguayo-Gómez
- Department of Genetics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Leonora Luna-Muñoz
- Department of Genetics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Luis A Muñoz-Téllez
- Department of Genetics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Osvaldo M Mutchinick
- Department of Genetics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
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Shlobin NA, LoPresti MA, Du RY, Lam S. Folate fortification and supplementation in prevention of folate-sensitive neural tube defects: a systematic review of policy. J Neurosurg Pediatr 2020; 27:294-310. [PMID: 33338998 DOI: 10.3171/2020.7.peds20442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neural tube defects (NTDs) are common congenital neurological defects, resulting in mortality, morbidity, and impaired quality of life for patients and caregivers. While public health interventions that increase folate consumption among women who are or plan to become pregnant are shown to reduce folate-sensitive NTDs, public health policy reflecting the scientific evidence lags behind. The authors aimed to identify the types of policies applied, associated outcomes, and impact of folate fortification and supplementation on NTDs worldwide. By identifying effective legislation, the authors aim to focus advocacy efforts to more broadly effect change, reducing the burden of NTDs in neurosurgery. METHODS A systematic review was conducted exploring folate fortification and supplementation policies using the PubMed and Scopus databases. Titles and abstracts from articles identified were read and selected for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes. RESULTS Of 1637 resultant articles, 54 were included. Mandatory folate fortification was effective at reducing folate-sensitive NTDs. Mandatory fortification also decreased hospitalization rates and deaths after discharge and increased 1st-year survival for infants with NTDs. Recommended folate supplementation also resulted in decreased NTDs; however, issues with compliance and adherence were a concern and impacted effectiveness. Folate fortification and/or supplementation resulted in decreased NTD prevalence, although more change was attributed to fortification. Dual policies may hold the most promise. Furthermore, reductions in NTDs were associated with significant cost savings over time. CONCLUSIONS Both mandatory folate fortification and recommended supplementation policies were found to effectively decrease folate-sensitive NTD rates when applied. A comprehensive approach incorporating mandatory folate fortification, appropriate folate supplementation, and improved infrastructure and access to prenatal care may lead to decreased NTDs worldwide. This approach should be context-specific, emphasize education, and account for regional access to healthcare and social determinants of health. With wide implications for NTDs, associated health outcomes, quality of life of patients and caregivers, and economic impacts, policy changes can drastically improve global NTD outcomes. As caretakers of children with NTDs, the authors as neurosurgeons advocate for a comprehensive policy, the engagement of stakeholders, and a broader global impact.
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Affiliation(s)
- Nathan A Shlobin
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois; and
| | | | - Rebecca Y Du
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois; and
| | - Sandi Lam
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois; and
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Pruthi V, Abbasi N, Ryan G, Drake J, Kulkarni AV, Kwan-Wong T, Phillips J, Thakur V, Church P, Diambomba Y, Kelly E, Vermeersch L, Pollard L, Carvalho JCA, Van Mieghem T. Fetal Surgery for Open Spina Bifida in Canada: Initial Results. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:733-739.e1. [PMID: 33227419 DOI: 10.1016/j.jogc.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. METHODS We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017-2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. RESULTS Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R² = 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. CONCLUSION Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.
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Affiliation(s)
- Vagisha Pruthi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Greg Ryan
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - James Drake
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Abhaya V Kulkarni
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Terence Kwan-Wong
- Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON
| | - John Phillips
- Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON
| | - Varsha Thakur
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Cardiology, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Paige Church
- Department of Paediatrics, Holland-Bloorview, Sunnybrook Health Centre and University of Toronto, Toronto, ON
| | - Yenge Diambomba
- Department of Neonatology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Edmond Kelly
- Department of Neonatology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Leslie Vermeersch
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Lindsay Pollard
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Jose C A Carvalho
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Anesthesia and Pain Management, Mount Sinai Hospital and University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON.
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Kancherla V, Wagh K, Pachón H, Oakley GP. A 2019 global update on folic acid-preventable spina bifida and anencephaly. Birth Defects Res 2020; 113:77-89. [PMID: 33124747 DOI: 10.1002/bdr2.1835] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mandatory folic acid fortification of staples is a proven intervention to prevent spina bifida and anencephaly, two life-threatening and disabling neural tube defects. We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented through mandatory folic acid fortification of wheat and/or maize flour in 2019. METHODS Using data from the Global Fortification Data Exchange, we identified countries with mandatory fortification policies that required at least 1.0 ppm folic acid be added to wheat and/or maize flour and had information on percentage of industrially milled flour that is fortified. We built FAP SBA prevention models assuming mandatory folic acid fortification at 200 μg/day of folic acid fully protects against FAP SBA and would lower the prevalence neural tube defects to 0.5 per 1,000 live births. RESULTS In 2019, 56 countries met our criteria for mandatory folic acid fortification of wheat (n = 56 countries) and/or maize (n = 15 countries) flour and with complete data for our modeling. Overall, our prevention model estimated that 65,380 FAP SBA cases were prevented in 2019 through folic acid fortification of wheat and/or maize flour. We estimated the current global prevention proportion of all preventable FAP SBA cases worldwide to be at 23% of total possible prevention. CONCLUSION Global prevention efforts for FAP SBA are slow and have stalled. Mandatory fortification should be urgently implemented in all countries to prevent epidemics of FAP SBA, and to achieve health-related Sustainable Development Goals for year 2030 by reducing child mortality due to preventable FAP SBA.
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
| | - Kaustubh Wagh
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
| | - Helena Pachón
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA.,Food Fortification Initiative, Atlanta, Georgia, USA
| | - Godfrey P Oakley
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
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Finkelstein JL, Fothergill A, Johnson CB, Guetterman HM, Bose B, Jabbar S, Zhang M, Pfeiffer CM, Qi YP, Rose CE, Krisher JT, Ruth CJ, Mehta R, Williams JL, Bonam W, Crider KS. Periconceptional surveillance for prevention of anaemia and birth defects in Southern India: protocol for a biomarker survey in women of reproductive age. BMJ Open 2020; 10:e038305. [PMID: 33122315 PMCID: PMC7597478 DOI: 10.1136/bmjopen-2020-038305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Women of reproductive age (WRA) are a high-risk population for anaemia and micronutrient deficiencies. Evidence supports the role of periconceptional nutrition in the development of adverse pregnancy complications. However, in India, there are limited population-based data to guide evidence-based recommendations and priority setting. The objective of this study is to conduct a population-based biomarker survey of anaemia and vitamin B12 and folate status in WRA as part of a periconceptional surveillance programme in Southern India. METHODS WRA (15-40 years) who are not pregnant or lactating and reside within 50 km2 of our community research site in Southern India will be screened and invited to participate in the biomarker survey at our research facility at Arogyavaram Medical Centre. After informed consent/assent, structured interviews will be conducted by trained nurse enumerators to collect sociodemographic, dietary, anthropometry, health and reproductive history data. Venous blood samples will be collected at enrolment; whole blood will be analysed for haemoglobin. Plasma, serum and red blood cells (RBCs) will be processed and stored <-80°C until batch analysis. Vitamin B12 concentrations will be measured via chemiluminescence, and RBC and serum folate concentrations will be evaluated using the World Health Organisation (WHO)-recommended microbiological assay at our laboratory in Bangalore. A WHO surveillance system will also be established to determine the baseline prevalence of birth defects in this setting. ETHICS AND DISSEMINATION This study has obtained clearance from the Health Ministry Screening Committee of the Indian Council of Medical Research. The study protocol was reviewed and approved by the Institutional Review Board at Cornell University and the Institutional Ethics Committees at Arogyavaram Medical Centre and St. John's Research Institute. Findings from this biomarker survey will establish the burden of anaemia and micronutrient deficiencies in WRA and directly inform a randomised trial for anaemia and birth defects prevention in Southern India. The results of this study will be disseminated at international research conferences and as published articles in peer-reviewed journals. TRIAL REGISTRATION NUMBERS Clinical trials registration number NCT04048330, NCT03853304 and Clinical Trials Registry of India (CTRI) registration number REF/2019/03/024479.
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Affiliation(s)
- Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
- St. John's Research Institute, Bangalore, Karnataka, India
| | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | | | | | - Beena Bose
- St. John's Research Institute, Bangalore, Karnataka, India
| | - Shameem Jabbar
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mindy Zhang
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jesse T Krisher
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Caleb J Ruth
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Rajesh Mehta
- World Health Organization Regional Office for South-East Asia, New Delhi, Delhi, India
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wesley Bonam
- Arogyavaram Medical Centre, Madanapalle, Andhra Pradesh, India
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Kancherla V, Tsang B, Wagh K, Dixon M, Oakley GP. Modeling shows high potential of folic acid-fortified salt to accelerate global prevention of major neural tube defects. Birth Defects Res 2020; 112:1461-1474. [PMID: 32738033 DOI: 10.1002/bdr2.1769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/27/2020] [Accepted: 06/30/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) potentially prevented through mandatory double fortification of iodized salt with folic acid. METHODS Using United Nations Children's Fund (UNICEF) and Global Fortification Data Exchange (GFDx) data sets, we modeled country-specific number of FAP SBA cases prevented annually using (a) current coverage of the salt in households worldwide and (b) expected daily amount of folic acid intake from folic acid-fortified iodized salt. Our evidence-based modeling strategy assumed mandatory folic acid fortification of salt at 20 ppm, and that at 200 μg/day intake of folic acid through fortified salt, should achieve 100% prevention of all FAP SBA in countries. RESULTS One hundred countries that have data on percent of households consuming iodized salt globally were examined; 55 of them have ≥80% households consuming iodized salt. Our model estimated approximately 180,000 cases of FAP SBA could be prevented in these 100 countries through folic acid-fortified iodized salt, and 150,000 of them would be in countries where ≥80% households consuming iodized salt that can be potentially fortified with folic acid. Salt fortification with folic acid could contribute to the prevention of about 65% global FAP SBA cases annually. CONCLUSIONS Our evidence-based model shows that there is high potential to prevent FAP SBA using folic acid-fortified iodized salt. Prevention will reach countries where there is a limited reach of centrally processed folic acid-fortified wheat or maize flour. If this intervention is made feasible by the salt industry, it can accelerate the prevention of FAP SBA significantly.
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Becky Tsang
- Food Fortification Initiative, Atlanta, Georgia, USA
| | - Kaustubh Wagh
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Meredith Dixon
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Godfrey P Oakley
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Samson KLI, Loh SP, Khor GL, Mohd Shariff Z, Yelland LN, Leemaqz S, Makrides M, Hutcheon JA, Sulistyoningrum DC, Yu JJ, Roche ML, De-Regil LM, Green TJ, Karakochuk CD. Effect of once weekly folic acid supplementation on erythrocyte folate concentrations in women to determine potential to prevent neural tube defects: a randomised controlled dose-finding trial in Malaysia. BMJ Open 2020; 10:e034598. [PMID: 32029499 PMCID: PMC7044827 DOI: 10.1136/bmjopen-2019-034598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Folic acid (0.4 mg) taken prior to and during early pregnancy reduces the risk of neural tube defects (NTDs). Because these birth defects occur early in pregnancy, before women may know they are pregnant, many countries have mandated the addition of folic acid to food staples. In countries where fortification is not possible, and weekly iron folic acid programmes exist to reduce anaemia, the WHO recommends that 2.8 mg (7×0.4 mg) folic acid be given instead of the current weekly practice of 0.4 mg. Currently, there is a lack of evidence to support if the 2.8 mg folic acid per week dose is sufficient to raise erythrocyte folate concentrations to a level associated with a reduced risk of a NTD-affected pregnancy. We aim to conduct a three-arm randomised controlled trial to determine the effect of weekly folic acid with iron on erythrocyte folate, a biomarker of NTD risk. METHODS AND ANALYSIS We will recruit non-pregnant women (n=300; 18-45 years) from Selangor, Malaysia. Women will be randomised to receive either 2.8, 0.4 or 0.0 (placebo) mg folic acid with 60 mg iron weekly for 16 weeks, followed by a 4-week washout period. The primary outcome will be erythrocyte folate concentration at 16 weeks and the mean concentration will be compared between randomised treatment groups (intention-to-treat) using a linear regression model adjusting for the baseline measure. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of British Columbia (H18-00768) and Universiti Putra Malaysia (JKEUPM-2018-255). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS ACTRN12619000818134 and NMRR-19-119-45736.
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Affiliation(s)
- Kaitlyn L I Samson
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Su Peng Loh
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Geok Lin Khor
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Zalilah Mohd Shariff
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Lisa N Yelland
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Shalem Leemaqz
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Jennifer A Hutcheon
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dian C Sulistyoningrum
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica J Yu
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marion L Roche
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Luz Maria De-Regil
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Tim J Green
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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19
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Claridge EA, Bloemen MAT, Rook RA, Obeid J, Timmons BW, Takken T, Van Den Berg-Emons RJG, De Groot JF, Gorter JW. Physical activity and sedentary behaviour in children with spina bifida. Dev Med Child Neurol 2019; 61:1400-1407. [PMID: 31468507 DOI: 10.1111/dmcn.14333] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 01/10/2023]
Abstract
AIM To describe active and sedentary time in children with spina bifida and to compare their physical activity on weekdays versus weekends. METHOD In this exploratory cross-sectional study, data from 13 Canadian and 22 Dutch children with spina bifida (14 females, 21 males; mean age 10y 11mo, standard deviation [SD] 3y 6mo, range 5y 6mo-18y; Hoffer classification distribution: community [n=28], household [n=3], non-functional [n=3], and non-ambulator [n=1]) were analysed. Objective measures of physical activity and sedentary behaviour were obtained by using ActiGraph or Actiheart activity monitors. Data for the participants wearing the ActiGraph were compared with age- and sex-matched controls that were developing typically using independent-samples t-tests. Activity data collected on weekdays was compared to those on weekends. RESULTS ActiGraph data demonstrated children with spina bifida spent more time sedentary (mean [SD] 49.5min/h [5.78]) and less time in moderate to vigorous physical activity (mean [SD] 2.33min/h [1.61]) compared with the typically developing group (mean [SD] 41.0min/h [5.76] and 5.46min/h [2.13], p=0.001 and p<0.001 respectively). For both ActiGraph- and Actiheart-derived data, physical activity and sedentary time were not significantly different between weekdays and weekends. INTERPRETATION Children with spina bifida have reduced levels of physical activity and increased sedentary behaviour, with no statistical differences seen between weekdays and weekends. Several methodological issues related to activity monitoring warrant consideration when choosing the appropriate method to quantify physical activity and sedentary behaviour. WHAT THIS PAPER ADDS Reduced levels of physical activity and sedentary time were quantified in children with spina bifida. Objective quantification of physical behaviour in ambulatory and non-ambulatory school-aged children with spina bifida is possible.
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Affiliation(s)
- Everett A Claridge
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada
| | - Manon A T Bloemen
- Research Group Lifestyle and Health, HU University of Applied Health Sciences Utrecht, Utrecht, the Netherlands.,Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rosanne A Rook
- Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joyce Obeid
- Child Health & Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Brian W Timmons
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada.,Child Health & Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Tim Takken
- Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Janke F De Groot
- Research Group Lifestyle and Health, HU University of Applied Health Sciences Utrecht, Utrecht, the Netherlands.,Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.,Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Jan Willem Gorter
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada
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20
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Levy MA, McKinnon T, Goldfine H, Enomoto A, Schneider E, Cuomo J. Consumption of a multivitamin/multimineral supplement for 4 weeks improves nutritional status and markers of cardiovascular health. J Funct Foods 2019. [DOI: 10.1016/j.jff.2019.103511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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21
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Kehoe L, Walton J, Hopkins SM, McNulty BA, Nugent AP, Flynn A. Modelling the impact of mandatory folic acid fortification of bread or flour in Ireland on the risk of occurrence of NTD-affected pregnancies in women of childbearing age and on risk of masking vitamin B 12 deficiency in older adults. Eur J Nutr 2019; 59:2631-2639. [PMID: 31646387 DOI: 10.1007/s00394-019-02111-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/04/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The rate of neural tube defects (NTDs) in Europe has remained similar since the 1990s despite folic acid supplement recommendations (400 µg/day) for women of childbearing age. Mandatory folic acid fortification of staple foods has proved effective for reducing the prevalence of NTDs in over 80 countries. This study estimated the impact of addition of folic acid to bread or flour in the Republic of Ireland on reducing the risk of occurrence of NTD-affected pregnancies and the possible risk of masking (undiagnosed) vitamin B12 deficiency in older adults. METHODS Analyses were based on the Irish National Adult Nutrition Survey (2008-2010). Folic acid fortification was modelled using DaDiet© software. Estimates were made of the increase in average daily folic acid intake in women (18-50 years) and the risk of exceeding the tolerable upper intake level (UL) of 1000 µg for folic acid in adults over 50 years of age. RESULTS The fortification scenarios examined would reduce the risk of NTD-affected pregnancies by 8-32%, corresponding to an increase of 39-152 μg in the mean daily folic acid intake of WCBA. The risk of masking anaemia associated with vitamin B12 deficiency in older adults would be negligible as the probability of exceeding the UL for folic acid, even by a small amount, is very low (≤ 0.2%). CONCLUSIONS These levels of addition of folic acid to bread or flour would effectively reduce the risk of NTDs while allowing safe consumption of folic acid at current levels from other fortified foods and supplements.
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Affiliation(s)
- Laura Kehoe
- School of Food and Nutritional Sciences, University College Cork, Cork, Republic of Ireland.
| | - Janette Walton
- School of Food and Nutritional Sciences, University College Cork, Cork, Republic of Ireland
- Department of Biological Sciences, Cork Institute of Technology, Cork, Republic of Ireland
| | - Sinead M Hopkins
- UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Breige A McNulty
- UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Anne P Nugent
- UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
- Institute for Global Food Security, Queens University Belfast, Belfast, Northern Ireland, UK
| | - Albert Flynn
- School of Food and Nutritional Sciences, University College Cork, Cork, Republic of Ireland
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22
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Agopian AJ, Cabrera R. Summary of the 10th international conference on neural tube defects. Birth Defects Res 2019; 111:945-946. [PMID: 31215175 DOI: 10.1002/bdr2.1519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Affiliation(s)
- A J Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Robert Cabrera
- Center for Precision Environmental Health, Baylor College of Medicine, Houston, Texas
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23
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Majumdar I, Kundu R, Das J, Mukherjee D. Dorsal dermal sinus presenting as quadriparesis. BMJ Case Rep 2019; 12:12/6/e228503. [PMID: 31256046 DOI: 10.1136/bcr-2018-228503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dorsal dermal sinus (DDS) represents the spectrum of spinal dysraphism. Children may present with features of meningitis. A 13-month male child presented with features of meningitis and quadriparesis. Clinical examination revealed a small pit over the thoracic spine. MRI was suggestive of a DDS. Initially, the patient responded to antibiotics and methylprednisolone, which was given for resolving the mass effect. However, he had a recurrence of symptoms and underwent surgical exploration and resection of DSS with resolution of symptoms. Careful examination of the back is extremely essential in children with meningitis. Radiological investigation helps in visualisation of the DSS. Although rare in children, they may present with recurrent meningitis.
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Affiliation(s)
| | | | - Joydeep Das
- Pediatrics, Institute of Child Health, Kolkata, India
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24
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Obrycki JF, Lee JJ, Kapur K, Paul L, Hasan MOSI, Mia S, Quamruzzaman Q, Christiani DC, Mazumdar M. A case-control analysis of maternal diet and risk of neural tube defects in Bangladesh. Birth Defects Res 2019; 111:967-981. [PMID: 30989821 DOI: 10.1002/bdr2.1505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Mothers need a nutrient-rich diet for healthy neural tube development. Neural tube defect risk can be reduced through fortifying grain products with folic acid and taking folic acid supplements. Fortification is not required in Bangladesh. Maternal supplement use rates are low, similar to other countries. This study evaluates maternal dietary intake during pregnancy to identify possible interventions. METHODS A food frequency questionnaire (FFQ) assessed maternal diet. The primary aim compared dietary intake (calories, fat, carbohydrate, protein, fiber, vitamins, and minerals) between mothers of infants with myelomeningocele (cases) and mothers of controls. Secondary aims included (i) comparing foods consumed and (ii) evaluating if rice intake correlated with arsenic exposure. Paired t-tests, Wilcoxon signed rank tests, McNemar's chi-squared test, and linear regression were used. RESULTS This study included 110 matched mother-infant pairs (55 cases/55 controls). Mothers of cases and mothers of controls had similar caloric intake [median 2406 kcal/day vs. 2196 kcal/day (p = 0.071)]. Mothers in both groups consumed less than half the daily recommended 600 μg of folate. Diets were potentially deficient in vitamins A, D, E, potassium, sodium, and iron. Steamed rice was the primary food consumed for both groups, and this rice intake was not associated with toenail arsenic. CONCLUSIONS Dietary interventions should increase folate, vitamins A, D, E, potassium, sodium, and iron intake in Bangladeshi mothers. Folic acid fortification of grain products maybe the only viable strategy to achieve adequate folate intake for mothers. Given the central role of rice to the Bangladeshi diet, fortifying rice may be a viable option.
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Affiliation(s)
- John F Obrycki
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Jane J Lee
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Ligi Paul
- Jean Mayer United States Department of Agriculture (USDA) Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | | | - Selim Mia
- Dhaka Community Hospital, Dhaka, Bangladesh
| | | | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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25
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Liu S, Evans J, MacFarlane AJ, Ananth CV, Little J, Kramer MS, Joseph KS. Association of maternal risk factors with the recent rise of neural tube defects in Canada. Paediatr Perinat Epidemiol 2019; 33:145-153. [PMID: 30920008 DOI: 10.1111/ppe.12543] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/17/2018] [Accepted: 01/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND We sought to assess the recent trend in NTD prevalence at birth in the post-folic acid food fortification era and to identify the maternal risk factors associated with that trend. METHODS We carried out a population-based study of all livebirths and stillbirths (including late pregnancy terminations) delivered in hospitals in Canada (excluding Quebec) from 2004 to 2015 (n = 3 439 330). We examined NTD birth prevalence by year, multiple pregnancy, maternal age, parity, pregestational diabetes, chronic illness, and problematic substance use. Poisson regression was used to quantify the association between spina bifida and cranial defects and maternal characteristics and other risk factors. RESULTS We identified 1517 non-chromosomal NTDs, yielding a birth prevalence of 4.4 per 10 000 total births. NTD prevalence rose from 3.6 in 2004 to 4.6 per 10 000 in 2015 (Ptrend = 0.03). Among NTD subtypes, only spina bifida showed a temporal increase (Ptrend = 0.03). Birth prevalence of spina bifida was higher among younger mothers, those with type 2 diabetes (rate ratio (RR) 3.74, 95% confidence interval (CI) 2.21, 6.35), chronic illness (RR 3.16, 95% CI 1.97, 5.07), and problematic substance use (RR 1.88, 95% CI 1.31, 2.71). Adjusting for risk factors attenuated the significant temporal trend in spina bifida (unadjusted average annual prevalence ratio (aAAPR) 1.016, 95% CI 1.001, 1.032; adjusted AAPR 1.014, 95% CI 0.998, 1.029). CONCLUSIONS Increases in the frequency of maternal risk factors such as pregestational diabetes mellitus, substance use, and chronic illness may be partly responsible for the recent rise in NTDs, particularly spina bifida.
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Affiliation(s)
- Shiliang Liu
- Maternal, Child and Youth Health Division, Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jane Evans
- Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanda J MacFarlane
- Nutrition Research Division, Bureau of Nutritional Sciences, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael S Kramer
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology and the School of Population and Public Health, University of British Columbia and the Children's and Women's Hospital of British Columbia, Vancouver, British Columbia, Canada
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26
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Crider KS, Devine O, Qi YP, Yeung LF, Sekkarie A, Zaganjor I, Wong E, Rose CE, Berry RJ. Systematic Review and Bayesian Meta-analysis of the Dose-response Relationship between Folic Acid Intake and Changes in Blood Folate Concentrations. Nutrients 2019; 11:nu11010071. [PMID: 30609688 PMCID: PMC6356991 DOI: 10.3390/nu11010071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/22/2018] [Accepted: 12/28/2018] [Indexed: 11/25/2022] Open
Abstract
The threshold for population-level optimal red blood cell (RBC) folate concentration among women of reproductive age for the prevention of neural tube defects has been estimated at 906 nmol/L; however, the dose-response relationship between folic acid intake and blood folate concentrations is uncharacterized. To estimate the magnitude of blood folate concentration increase in response to specific dosages of folic acid under steady-state conditions (as could be achieved with food fortification), a systematic review of the literature and meta-analysis was conducted. Of the 14,002 records we identified, 533 were selected for full-text review, and data were extracted from 108 articles. The steady-state concentrations (homeostasis) of both serum/plasma and RBC folate concentrations were estimated using a Bayesian meta-analytic approach and one-compartment physiologically-based pharmacokinetic models. RBC folate concentrations increased 1.78 fold (95% credible interval (CI): 1.66, 1.93) from baseline to steady-state at 375–570 µg folic acid/day, and it took a median of 36 weeks of folic acid intake (95% CI: 27, 52) to achieve steady-state RBC folate concentrations. Based on regression analysis, we estimate that serum/plasma folate concentrations increased 11.6% (95% CI: 8.4, 14.9) for every 100 µg/day folic acid intake. These results will help programs plan and monitor folic acid fortification programs.
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Affiliation(s)
- Krista S Crider
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Owen Devine
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
- Karna, LLC, Atlanta, GA 30329, USA.
- G²S Corporation, San Antonio, TX 78216, USA.
| | - Yan Ping Qi
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Lorraine F Yeung
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Ahlia Sekkarie
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Doctoral Program in Nutrition Health Sciences, Laney Graduate School, Emory University, Atlanta, GA 30322, USA.
| | - Ibrahim Zaganjor
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Department of Epidemiology, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Eugene Wong
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Department of Epidemiology, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Charles E Rose
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Robert J Berry
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
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27
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Lowry RB, Bedard T, MacFarlane AJ, Crawford S, Sibbald B, Agborsangaya BC. Prevalence rates of spina bifida in Alberta, Canada: 2001–2015. Can we achieve more prevention? Birth Defects Res 2018; 111:151-158. [DOI: 10.1002/bdr2.1438] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/30/2018] [Accepted: 11/17/2018] [Indexed: 12/14/2022]
Affiliation(s)
- R. Brian Lowry
- Alberta Congenital Anomalies Surveillance System, Clinical Genetics, Alberta Health Services Calgary Alberta Canada
- Departments of Pediatrics and Medical GeneticsUniversity of Calgary and Alberta Children's Hospital Calgary Alberta Canada
- Alberta Children's Hospital Research Institute Calgary Alberta Canada
| | - Tanya Bedard
- Alberta Congenital Anomalies Surveillance System, Clinical Genetics, Alberta Health Services Calgary Alberta Canada
| | | | - Susan Crawford
- Alberta Perinatal Health Program, Alberta Health Services Calgary Alberta Canada
| | - Barbara Sibbald
- Alberta Congenital Anomalies Surveillance System, Clinical Genetics, Alberta Health Services Calgary Alberta Canada
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28
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AlRefai A, Drake J, Kulkarni AV, Connor KL, Shannon P, Toi A, Chitayat D, Blaser S, Church PT, Abbasi N, Ryan G, Van Mieghem T. Fetal myelomeningocele surgery: Only treating the tip of the iceberg. Prenat Diagn 2018; 39:10-15. [PMID: 30536580 DOI: 10.1002/pd.5390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fetal myelomeningocele (fMMC) surgery improves infant outcomes when compared with postnatal surgery. Surgical selection criteria and the option of pregnancy termination, however, limit the number of cases that are eligible for prenatal surgery. We aimed to quantify what proportion of cases could ultimately benefit from fetal therapy. METHODS We retrospectively reviewed all cases of fMMC referred to a large tertiary care center over a 10-year period and assessed their eligibility for fetal surgery, pregnancy termination rates, and actual uptake of the surgery. RESULTS Of 158 cases, 67 (42%) were ineligible for fetal surgery based on surgical exclusion criteria. Eleven fetuses (7%) had chromosomal anomalies, 10 of which (91%) had other anomalies on ultrasound. Thirty-four patients had a combination of maternal and fetal contraindications. Of the remaining 91 eligible cases (58%), 45 (49%) pregnancies were terminated, leaving only 46 (29% of initial 158 cases) as potential candidates for fetal repair. Actual uptake of fetal surgery was 15% (n = 14 of 91), but this increased after a national program was started. CONCLUSION Only a minority of fMMC cases will ultimately undergo fetal surgery. These numbers support the centralization of care in expert centers.
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Affiliation(s)
- Alyaa AlRefai
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - James Drake
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kristin L Connor
- Department of Health Sciences, Carleton University, Ottawa, Canada
| | - Patrick Shannon
- Department of Pathology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ants Toi
- Department of Radiology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - David Chitayat
- Department of Medical Genetics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Susan Blaser
- Department of Radiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paige T Church
- Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital and University of Toronto, Toronto, Canada
| | - Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
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29
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Kancherla V, Wagh K, Johnson Q, Oakley GP. A 2017 global update on folic acid-preventable spina bifida and anencephaly. Birth Defects Res 2018; 110:1139-1147. [DOI: 10.1002/bdr2.1366] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/14/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology; Rollins School of Public Health of Emory University; Atlanta Georgia
| | - Kaustubh Wagh
- Hubert Department of Global Health; Rollins School of Public Health of Emory University; Atlanta Georgia
| | | | - Godfrey P. Oakley
- Center for Spina Bifida Prevention, Department of Epidemiology; Rollins School of Public Health of Emory University; Atlanta Georgia
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30
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Eldridge C, Bandlamuri S, Andrews JG, Galindo MK, Contreras D, Flood TJ, Rice S. Postfolate spina bifida lesion level change. Birth Defects Res 2018; 110:949-955. [PMID: 29575817 DOI: 10.1002/bdr2.1221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/24/2017] [Accepted: 02/20/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Spina bifida accounts for a large proportion of birth defects in the United States. Studies have evaluated the decrease in prevalence at birth after folate fortification of food grains, but little is known about neurologic functional changes related to fortification. This study assesses the functional level of lesions in the prefortification and postfortification eras. METHODS Data were collected through retrospective review of medical records from a regional multispecialty clinic in Arizona. This study included individuals born between 1981-1995 (prefortification) and 1999-2013 (postfortification). Patients were included if they had a primary diagnosis of spina bifida with or without hydrocephalus. RESULTS There was a significant difference in functional lesion level with an 85% reduction in thoracic level lesions in the postfortification era (p < .005). There were no differences in gender or ethnicity across eras; however, Hispanic ethnicity had a higher number of cases overall (51.7%). The most common lesion level in both eras was mid-lumbar, accounting for 35.7 and 34.4% of cases in the prefolate and postfolate eras, respectively. CONCLUSIONS This study demonstrates a significant difference in the distribution of lesion level of spina bifida patients born in the postfortification era, based on neurologic function. Further research with a larger sample size is needed to determine if this observation holds true nationally.
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Affiliation(s)
- Carin Eldridge
- School of Medicine, University of Arizona, Tucson, Arizona
| | - Sruti Bandlamuri
- Department of Pediatrics, University of Arizona, Tucson, Arizona
| | | | | | - Dianna Contreras
- Arizona Birth Defects Monitoring Program, Arizona Department of Health Services, Phoenix, Arizona
| | - Timothy J Flood
- Arizona Birth Defects Monitoring Program, Arizona Department of Health Services, Phoenix, Arizona
| | - Sydney Rice
- Department of Pediatrics, University of Arizona, Tucson, Arizona
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31
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Crider KS, Qi YP, Devine O, Tinker SC, Berry RJ. Modeling the impact of folic acid fortification and supplementation on red blood cell folate concentrations and predicted neural tube defect risk in the United States: have we reached optimal prevention? Am J Clin Nutr 2018; 107:1027-1034. [PMID: 29767673 PMCID: PMC6980262 DOI: 10.1093/ajcn/nqy065] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/16/2018] [Indexed: 01/10/2023] Open
Abstract
Background The US CDC and the Institute of Medicine recommend that women capable of becoming pregnant consume ≥400 µg synthetic folic acid/d to prevent neural tube defects (NTDs). The United States has 3 sources of folic acid: fortified enriched cereal grain products (ECGPs), fortified ready-to-eat (RTE) cereals, and dietary supplements. Objective Our objectives were as follows: 1) to estimate the usual daily folic acid intake and distributions of red blood cell (RBC) folate concentrations among women consuming folic acid from different sources; 2) to assess the usual daily total folic acid intake associated with optimal RBC folate concentrations for NTD prevention; 3) to predict NTD prevalence; and 4) to estimate the number of preventable folate-sensitive NTDs. Design NHANES data (2007-2012) for nonpregnant women of reproductive age (12-49 y) were used to estimate usual daily intakes of synthetic folic acid and natural food folate. We applied existing models of the relation between RBC folate concentrations and NTD risk to predict NTD prevalence. Results Based on the distribution of overall RBC folate concentrations (4783 women), the predicted NTD prevalence was 7.3/10,000 live births [95% uncertainty interval (UI): 5.5-9.4/10,000 live births]. Women consuming folic acid from ECGPs as their only source had lower usual daily total folic acid intakes (median: 115 µg/d; IQR: 79-156 µg/d), lower RBC folate concentrations (median: 881 nmol/L; IQR: 704-1108 nmol/L), and higher predicted NTD prevalence (8.5/10,000 live births; 95% UI: 6.4-10.8/10,000 live births) compared with women consuming additional folic acid from diet or supplements. If women who currently consume folic acid from ECGPs only (48% of women) consumed additional folic acid sources, 345 (95% UI: 0-821) to 701 (95% UI: 242-1189) additional NTDs/y could be prevented. Conclusions This analysis supports current recommendations and does not indicate any need for higher intakes of folic acid to achieve optimal NTD prevention. Ensuring 400 µg/d intake of folic acid prior to pregnancy has the potential to increase the number of babies born without an NTD.
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Affiliation(s)
- Krista S Crider
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA
| | - Yan Ping Qi
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA
| | - Owen Devine
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA,Chestatee Solutions, Dahlonega, GA
| | - Sarah C Tinker
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA
| | - Robert J Berry
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA,GS Corporation, San Antonio, TX
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Trends in incidence and long-term outcomes of myelomeningocele in British Columbia. Childs Nerv Syst 2018; 34:717-724. [PMID: 29236131 DOI: 10.1007/s00381-017-3685-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 11/29/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Myelomeningocele is typically a disabling condition that results in neurologic, orthopedic, and urologic morbidity. The aim of this study was to examine the trends over time in both incidence and outcomes of myelomeningocele (MMC) in British Columbia (BC). METHODS A retrospective chart review was performed of all children with MMC followed in the British Columbia Children's Hospital (BCCH) Spinal Cord Clinic between 1971 and 2016. The incidence of new MMC cases and the long-term outcomes of MMC were compared between two 10-year cohorts. The first cohort comprised children born with MMC between 1971 and 1981, and the second cohort comprised children born with MMC between 1996 and 2006. RESULTS A total of 309 children with MMC were followed in the BCCH Spinal Cord Clinic between 1971 and 2016. There were 101 and 46 children with MMC in the two-time cohorts, respectively. Between the earlier and later cohorts, there was a significant difference in the following: MMC incidence [2.5/10,000 births vs 1.1/10,000 births, respectively (p = 0.0002)], mortality [18 vs 0% (p = 0.0009)], and the proportion of cases repaired in under 48 h [56 vs 98% (p < 0.0001)]. For surviving children, the proportion of children attending special classes was significantly different between the earlier and later cohorts [16 vs 46%, respectively (p = 0.0002)], whereas all other outcome measures, including the proportion with hydrocephalus, kyphoscoliosis, Chiari II surgery, bowel and bladder continence, recreation participation, obesity, and ambulation, were not significantly different. CONCLUSIONS In BC, the incidence of new cases of MMC has decreased between 1971 and 2016, while the probability of survival for these patients has increased. Despite earlier and more universal post-natal repair, long-term outcomes have not improved significantly over time. Future research should focus on developing ways of reducing disability and improving quality of life for MMC patients and their families.
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Kancherla V. Countries with an immediate potential for primary prevention of spina bifida and anencephaly: Mandatory fortification of wheat flour with folic acid. Birth Defects Res 2018. [PMID: 29532629 DOI: 10.1002/bdr2.1222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Mandatory fortification of flour with folic acid has been proven to be a highly effective way to prevent spina bifida and anencephaly. Yet, over 100 countries worldwide do not implement this intervention. Our objectives were to identify countries with an immediate potential for mandatory fortification of wheat flour with folic acid and to estimate the number of preventable cases of spina bifida and anencephaly that would be averted each year through the intervention. METHODS We examined folic acid fortification characteristics in countries as of September 2017. Country selection criteria included current fortification status, existing industrial capacity for flour production, fortification coverage, and daily grams of per capita wheat flour available for human consumption. We estimated the country-specific number of preventable cases of spina bifida and anencephaly by calculating the difference between the observed prevalence (prefortification) and expected prevalence that can be achieved postfortification (0.5 per 1,000 live births). RESULTS We identified 71 countries with an immediate potential for mandatory fortification of 145 million metric tons of wheat flour with folic acid. Fortification in identified countries would avert approximately 57,000 live births associated with folic acid-preventable spina bifida and anencephaly annually and increase global prevention from the current rate of 13% to a new rate of 34%. CONCLUSIONS Fortification can be achieved immediately in many countries with existing industrial milling infrastructure. Effective fortification interventions can accelerate global primary prevention efforts of folic acid-preventable spina bifida and anencephaly, especially in developing countries with a high prevalence of neural tube defects and associated morbidity and mortality.
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
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Bailey LB, Hausman DB. Folate status in women of reproductive age as basis of neural tube defect risk assessment. Ann N Y Acad Sci 2017; 1414:82-95. [PMID: 29139138 DOI: 10.1111/nyas.13511] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/31/2017] [Accepted: 09/09/2017] [Indexed: 12/31/2022]
Abstract
Reliable folate status data for women of reproductive age (WRA) to assess global risk for neural tube defects (NTDs) are needed. We focus on a recent recommendation by the World Health Organization that a specific "optimal" red blood cell (RBC) folate concentration be used as the sole indicator of NTD risk within a population and discuss how to best apply this guidance to reach the goal of assessing NTD risk globally. We also emphasize the importance of using the microbiologic assay (MBA) as the most reliable assay for obtaining comparable results for RBC folate concentration across time and countries, the need for harmonization of the MBA through use of consistent key reagents and procedures within laboratories, and the requirement to apply assay-matched cutoffs for folate deficiency and insufficiency. To estimate NTD risk globally, the ideal scenario would be to have country-specific population-based surveys of RBC folate in WRA determined utilizing a harmonized MBA, as was done in recent studies in Guatemala and Belize. We conclude with guidance on next steps to best navigate the road map toward the goal of generating reliable folate status data on which to assess NTD risk in WRA in low- and middle-income countries.
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Affiliation(s)
- Lynn B Bailey
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, Georgia
| | - Dorothy B Hausman
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, Georgia
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Arth A, Kancherla V, Pachón H, Zimmerman S, Johnson Q, Oakley GP. A 2015 global update on folic acid-preventable spina bifida and anencephaly. ACTA ACUST UNITED AC 2017; 106:520-9. [PMID: 27418029 DOI: 10.1002/bdra.23529] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 04/14/2016] [Accepted: 04/27/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Spina bifida and anencephaly are two major neural tube defects. They contribute substantially to perinatal, neonatal, infant, and under-five mortality and life-long disability. To monitor the progress toward the total prevention of folic acid-preventable spina bifida and anencephaly (FAP SBA), we examined their global status in 2015. METHODS Based on existing data, we modeled the proportion of FAP SBA that are prevented in the year 2015 through mandatory folic acid fortification globally. We included only those countries with mandatory fortification that added at least 1.0 ppm folic acid as a fortificant to wheat and maize flour, and had complete information on coverage. Our model assumed mandatory folic acid fortification at 200 μg/day is fully protective against FAP SBA, and reduces the rate of spina bifida and anencephaly to a minimum of 0.5 per 1000 births. RESULTS Our estimates show that, in 2015, 13.2% (35,500 of approximately 268,700 global cases) of FAP SBA were prevented in 58 countries through mandatory folic acid fortification of wheat and maize flour. Most countries in Europe, Africa, and Asia were not implementing mandatory fortification with folic acid. CONCLUSION Knowledge that folic acid prevents spina bifida and anencephaly has existed for 25 years, yet only a small fraction of FAP SBA is being prevented worldwide. Several countries still have 5- to 20-fold epidemics of FAP SBA. Implementation of mandatory fortification with folic acid offers governments a proven and rapid way to prevent FAP SBA-associated disability and mortality, and to help achieve health-related Sustainable Development Goals. Birth Defects Research (Part A) 106:520-529, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Annelise Arth
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Helena Pachón
- Food Fortification Initiative, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | | | | | - Godfrey P Oakley
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia
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Donnan J, Walsh S, Sikora L, Morrissey A, Collins K, MacDonald D. A systematic review of the risks factors associated with the onset and natural progression of spina bifida. Neurotoxicology 2017; 61:20-31. [DOI: 10.1016/j.neuro.2016.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 12/14/2022]
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Agha MM, Glazier RH, Moineddin R, Booth G. Congenital abnormalities in newborns of women with pregestational diabetes: A time-trend analysis, 1994 to 2009. ACTA ACUST UNITED AC 2016; 106:831-839. [DOI: 10.1002/bdra.23548] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Mohammad M. Agha
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Centre for Research on Inner City Health, St. Michael's Hospital, University of Toronto; Canada
- Paediatric Oncology Group of Ontario, University of Toronto; Toronto Canada
- Dalla Lana School of Public Health, University of Toronto; Toronto Canada
| | - Richard H. Glazier
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Centre for Research on Inner City Health, St. Michael's Hospital, University of Toronto; Canada
- Dalla Lana School of Public Health, University of Toronto; Toronto Canada
- Department of Family and Community Medicine; University of Toronto; Toronto Canada
| | - Rahim Moineddin
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Centre for Research on Inner City Health, St. Michael's Hospital, University of Toronto; Canada
- Department of Family and Community Medicine; University of Toronto; Toronto Canada
| | - Gillian Booth
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Centre for Research on Inner City Health, St. Michael's Hospital, University of Toronto; Canada
- University of Toronto, Department of endocrinology; Toronto Canada
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Hua X, Zhang J, Guo Y, Shen M, Gaudet L, Janoudi G, Walker M, Wen SW. Effect of folic acid supplementation during pregnancy on gestational hypertension/preeclampsia: A systematic review and meta-analysis. Hypertens Pregnancy 2016; 35:447-460. [PMID: 27315401 DOI: 10.1080/10641955.2016.1183673] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the effect of folic acid supplementation during pregnancy on the risk of gestational hypertension/preeclampsia. METHODS A systematic review and meta-analysis were conducted. Medline, Embase, Scopus, and the Web of Science were searched from inception to December 2014. RESULTS Out of 1224 potentially relevant studies, 13 studies met our inclusion criteria (2 randomized controlled trials (RCTs), 10 cohort studies, and 1 case-control study). The pooled relative risk (RR) and 95% confidence interval (CI) of the two RCTs were 0.62 (0.45-0.87) in the trial arm as compared with the placebo arm. The pooled RR was 0.92 (95% CI: 0.79-1.08) for nine cohort studies with available data on folic acid supplementation in pregnancy and gestational hypertension/preeclampsia. Pooled RR was 0.88 (95% CI: 0.76-1.02) for eight cohort studies with available data on folic acid supplementation and preeclampsia. CONCLUSION Whether folic acid supplementation in pregnancy can prevent the occurrence of gestational hypertension/preeclampsia remains uncertain.
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Affiliation(s)
- Xiaolin Hua
- a Department of Obstetrics , Xinhua Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China.,b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Jiewen Zhang
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,d Department of Obstetrics and Gynecology , Beijing Friendship Hospital, Capital Medical University , Beijing , China
| | - Yanfang Guo
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Minxue Shen
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,e School of Public Health , Central South University , Changsha , China
| | - Laura Gaudet
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Ghayath Janoudi
- f Canadian Agency for Drugs and Technologies in Health , Ottawa , Ontario , Canada
| | - Mark Walker
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,g School of Epidemiology, Public Health, and Preventive Medicine , University of Ottawa Faculty of Medicine , Ottawa , Ontario , Canada
| | - Shi Wu Wen
- b Department of Obstetrics and Gynecology, Faculty of Medicine , OMNI Research Group, University of Ottawa , Ottawa , Ontario , Canada.,c Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,e School of Public Health , Central South University , Changsha , China.,g School of Epidemiology, Public Health, and Preventive Medicine , University of Ottawa Faculty of Medicine , Ottawa , Ontario , Canada
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Grosse SD, Berry RJ, Mick Tilford J, Kucik JE, Waitzman NJ. Retrospective Assessment of Cost Savings From Prevention: Folic Acid Fortification and Spina Bifida in the U.S. Am J Prev Med 2016; 50:S74-S80. [PMID: 26790341 PMCID: PMC4841731 DOI: 10.1016/j.amepre.2015.10.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 10/12/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Although fortification of food with folic acid has been calculated to be cost saving in the U.S., updated estimates are needed. This analysis calculates new estimates from the societal perspective of net cost savings per year associated with mandatory folic acid fortification of enriched cereal grain products in the U.S. that was implemented during 1997-1998. METHODS Estimates of annual numbers of live-born spina bifida cases in 1995-1996 relative to 1999-2011 based on birth defects surveillance data were combined during 2015 with published estimates of the present value of lifetime direct costs updated in 2014 U.S. dollars for a live-born infant with spina bifida to estimate avoided direct costs and net cost savings. RESULTS The fortification mandate is estimated to have reduced the annual number of U.S. live-born spina bifida cases by 767, with a lower-bound estimate of 614. The present value of mean direct lifetime cost per infant with spina bifida is estimated to be $791,900, or $577,000 excluding caregiving costs. Using a best estimate of numbers of avoided live-born spina bifida cases, fortification is estimated to reduce the present value of total direct costs for each year's birth cohort by $603 million more than the cost of fortification. A lower-bound estimate of cost savings using conservative assumptions, including the upper-bound estimate of fortification cost, is $299 million. CONCLUSIONS The estimates of cost savings are larger than previously reported, even using conservative assumptions. The analysis can also inform assessments of folic acid fortification in other countries.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia.
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia
| | - J Mick Tilford
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James E Kucik
- Office of the Associate Director for Policy, CDC, Atlanta, Georgia
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Rosenthal J, Reeve ME, Ramirez N, Crider KS, Sniezek J, Vellozzi C, Devine O, Lopez-Pazos E. Red Blood Cell Folate Insufficiency among nonpregnant Women of Childbearing age in Guatemala 2009 to 2010: Prevalence and predicted Neural Tube Defects risk. ACTA ACUST UNITED AC 2016; 106:587-95. [PMID: 27010602 DOI: 10.1002/bdra.23499] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The World Health Organization recently released recommendations stating that red blood cell (RBC) folate concentrations should be above 400 ng/L (906 nmol/L) for optimal prevention of folate-sensitive neural tube defects (NTDs). The objective of this study was to determine the distribution of folate insufficiency (FI) (<906 nmol/L) and potential risk of NTDs based on RBC folate concentrations among nonpregnant women of child-bearing age in Guatemala. METHODS A national and regional multistage cluster probability survey was completed during 2009 to 2010 among Guatemalan women of child-bearing age 15 to 49 years of age. Demographic and health information and blood samples for RBC folate analyses were collected from 1473 women. Prevalence rate ratios of FI and predicted NTD prevalence were estimated based on RBC folate concentrations comparing subpopulations of interest. RESULTS National FI prevalence was 47.2% [95% confidence interval, 43.3-51.1] and showed wide variation by region (18-81%). In all regions, FI prevalence was higher among indigenous (27-89%) than among nonindigenous populations (16-44%). National NTD risk based on RBC folate concentrations was estimated to be 14 per 10,000 live births (95% uncertainty interval, 11.1-18.6) and showed wide regional variation (from 11 NTDS in the Metropolitan region to 26 NTDs per 10,000 live births in the Norte region). CONCLUSION FI remains a common problem in populations with limited access to fortified products, specifically rural, low income, and indigenous populations. However, among subpopulations that are most likely to have fortified food, the prevalence of FI is similar to countries with well-established fortification programs. Birth Defects Research (Part A) 106:587-595, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jorge Rosenthal
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Nicte Ramirez
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joe Sniezek
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Claudia Vellozzi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Owen Devine
- Carter Consulting, Inc, Atlanta, Georgia, USA
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Huot PSP, Ly A, Szeto IMY, Reza-López SA, Cho D, Kim YI, Anderson GH. Maternal and postweaning folic acid supplementation interact to influence body weight, insulin resistance, and food intake regulatory gene expression in rat offspring in a sex-specific manner. Appl Physiol Nutr Metab 2015; 41:411-20. [PMID: 26989972 DOI: 10.1139/apnm-2015-0503] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal intake of multivitamins or folic acid above the basal dietary requirement alters the growth and metabolic trajectory of rat offspring. We hypothesized that a modest increase in the folic acid content of maternal diets would alter the offspring's metabolic phenotype, and that these effects could be corrected by matching the folic acid content of the offspring's diet with that of the maternal diet. Female Sprague-Dawley rats were placed on a control or a 2.5× folic acid-supplemented diet prior to mating and during pregnancy and lactation. At weaning, pups from each maternal diet group were randomized to the control or to the 2.5× folic acid-supplemented diet for 25 weeks. Male pups from dams fed the folic acid-supplemented diet were 3.7% heavier than those from control-fed dams and had lower mRNA expression for leptin receptor Obrb isoform (Lepr) (11%) and Agouti-related protein (Agrp) (14%). In contrast, female pups from folic acid-supplemented dams were 5% lighter than those from control-fed dams and had lower proopiomelanocortin (Pomc) (42%), Lepr (32%), and Agrp (13%), but higher neuropeptide Y (Npy) (18%) mRNA expression. Folic acid supplementation ameliorated the alterations induced by maternal folic acid supplementation in male pups and led to the lowest insulin resistance, but the effects were smaller in female pups and led to the highest insulin resistance. In conclusion, maternal folic acid supplementation at 2.5× the control level was associated with alterations in body weight and hypothalamic gene expression in rat offspring in a sex-specific manner, and some of these effects were attenuated by postweaning folic acid supplementation.
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Affiliation(s)
- Pedro S P Huot
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Anna Ly
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Ignatius M Y Szeto
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Sandra A Reza-López
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Daniel Cho
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
| | - Young-In Kim
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada.,b Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON M5G 2C4, Canada.,c Keenan Research Centre for Biomedical Sciences of St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.,d Division of Gastroenterology, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada
| | - G Harvey Anderson
- a Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 3E2, Canada
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Bergman JEH, Otten E, Verheij JBGM, de Walle HEK. Folic acid supplementation influences the distribution of neural tube defect subtypes: A registry-based study. Reprod Toxicol 2015; 59:96-100. [PMID: 26627544 DOI: 10.1016/j.reprotox.2015.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/05/2015] [Accepted: 11/20/2015] [Indexed: 11/19/2022]
Abstract
Periconceptional folic acid (FA) reduces neural tube defect (NTD) risk, but seems to have a varying effect per NTD subtype. We aimed to study the effect of FA supplementation on NTD subtype distribution using data from EUROCAT Northern Netherlands. We included all birth types with non-syndromal NTDs born in 1997-2012. By Fisher's exact test we analyzed possible differences in NTD subtype distribution between a correct FA supplementation group and incorrect FA supplementation group. We found proportionally fewer cervical/thoracic spina bifida cases and more lumbar/sacral spina bifida cases in the correct FA supplementation group, irrespective of the presence of the main NTD risk factors. The effect on NTD subtype distribution was only seen when FA supplementation was started before conception. We conclude that FA not only prevents the occurrence of a significant proportion of NTDs, but might also decrease the severity of NTDs, as long as supplementation is started before conception.
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Affiliation(s)
- J E H Bergman
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - E Otten
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J B G M Verheij
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H E K de Walle
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Plumptre L, Masih SP, Ly A, Aufreiter S, Sohn KJ, Croxford R, Lausman AY, Berger H, O'Connor DL, Kim YI. High concentrations of folate and unmetabolized folic acid in a cohort of pregnant Canadian women and umbilical cord blood. Am J Clin Nutr 2015; 102:848-57. [PMID: 26269367 DOI: 10.3945/ajcn.115.110783] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mandatory fortification, prevalent supplement use, and public health guidelines recommending periconceptional supplementation have increased folic acid intakes in North American pregnant women. However, the effects of increased folic acid intakes during pregnancy on maternal and cord blood folate concentrations have not been well established. OBJECTIVES In this prospective study, we determined maternal and cord blood concentrations of folate and unmetabolized folic acid (UMFA) in a cohort of pregnant Canadian women and their newborns and examined the effect of maternal intakes of folate and folic acid and fetal genetic variants in folate metabolism on folate status. DESIGN Folate and folic acid intakes of 368 Canadian pregnant women were assessed in early (0-16 wk) and late (23-37 wk) pregnancy. Blood concentrations of folate and UMFA were measured with the use of immunoassays and liquid chromatography-mass spectrometry, respectively, in maternal samples in early pregnancy (12-16 wk), at delivery (28-42 wk), and in cord blood. Four fetal genetic variants of the 5,10-methylenetetrahydrofolate reductase (MTHFR) and dihydrofolate reductase (DHFR) genes were assessed for their association with cord blood concentrations of folate and UMFA. RESULTS Geometric mean (95% CI) maternal red blood cell (RBC) folate concentrations were 2417 nmol/L (2362, 2472 nmol/L ) and 2793 nmol/L (2721, 2867 nmol/L ) in early pregnancy and at delivery, respectively. The mean (95% CI) cord RBC folate concentration was 2689 nmol/L (2614, 2765 nmol/L). UMFA was detectable in >90% of maternal and cord plasma samples. Although 3 fetal MTHFR and DHFR genetic variants had no effect, the fetal MTHFR 677TT genotype was associated with significantly lower cord serum (P = 0.03) and higher cord RBC (P = 0.02) folate concentrations than those of the wild type. CONCLUSIONS Notwithstanding differences in assays, maternal and cord RBC folate and plasma UMFA concentrations were higher than previously reported values. Functional ramifications of high folate and UMFA concentrations in maternal and fetal circulation warrant additional investigation because an excess folate status may affect long-term health outcomes of the offspring. This study was registered at www.clinicaltrials.gov as NCT02244684.
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Affiliation(s)
- Lesley Plumptre
- Departments of Nutritional Sciences and Keenan Research Center for Biomedical Science and
| | - Shannon P Masih
- Departments of Nutritional Sciences and Keenan Research Center for Biomedical Science and
| | - Anna Ly
- Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susanne Aufreiter
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kyoung-Jin Sohn
- Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center for Biomedical Science and
| | - Ruth Croxford
- Freelance statistics consultant, Toronto, Ontario, Canada; and
| | - Andrea Y Lausman
- Department of Obstetrics and Gynecology, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Howard Berger
- Department of Obstetrics and Gynecology, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Deborah L O'Connor
- Departments of Nutritional Sciences and Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Young-In Kim
- Departments of Nutritional Sciences and Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center for Biomedical Science and Division of Gastroenterology, Department of Medicine, St. Michael's Hospital, Toronto, Canada;
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Chakraborty H, Nyarko KA, Goco N, Moore J, Moretti-Ferreira D, Murray JC, Wehby GL. Folic Acid Fortification and Women's Folate Levels in Selected Communities in Brazil - A First Look. INT J VITAM NUTR RES 2015; 84:286-94. [PMID: 26255550 DOI: 10.1024/0300-9831/a000215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Several countries have implemented mandatory folic acid fortification of wheat flour and selected grain products to increase the folate intake of reproductive-aged women. Brazil implemented a folic acid fortification program in 2004. No previous studies have examined folate differences among Brazilian women following the mandate. OBJECTIVE We evaluate differences in serum and red blood cell (RBC) folate concentrations between two samples of women of childbearing age from selective communities in Brazil, one tested before (N = 116) and the other after the mandate (N = 240). METHODS We compared the baseline folate levels of women enrolled in a prevention study shortly before the fortification mandate was implemented, to baseline levels of women from the same communities enrolled in the same study shortly after fortification began. The participants were women enrolled in a folate supplementation clinical trial, at a hospital specializing in treating craniofacial anomalies in the city of Bauru from January 29, 2004 to April 27, 2005. We only compared baseline folate levels before the women received oral cleft prevention program (OCPP) folic acid supplements. RESULTS Women enrolled after the fortification mandate had higher means of serum folate (20.3 versus 11.2 nmol/L; p < 0.001) and RBC folate (368.3 versus 177.6 nmol/L; p < 0.001) than women enrolled before the mandate. Differences in folate levels between the two groups remained after adjusting for several co-variables. CONCLUSIONS The results suggest that serum and RBC folate levels among women of childbearing age increased after implementing the folic acid fortification mandate in Brazil.
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Affiliation(s)
- Hrishikesh Chakraborty
- 1 Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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Obeid R, Pietrzik K, Oakley GP, Kancherla V, Holzgreve W, Wieser S. Preventable spina bifida and anencephaly in Europe. ACTA ACUST UNITED AC 2015; 103:763-71. [PMID: 26178749 DOI: 10.1002/bdra.23400] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/15/2015] [Accepted: 05/29/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Promotion of voluntary folic acid supplement use among women of reproductive age has been proven to be ineffective in lowering the risk of neural tube defects in Europe. METHODS Using surveillance data from all births covered by the full member countries of the European Surveillance of Congenital Anomalies (EUROCAT), we estimated the total prevalence of spina bifida and anencephaly per 10,000 births between 2000 and 2010. We also estimated additional lifetime direct medical costs among individuals with spina bifida, compared with those without, in Germany for the year 2009. RESULTS During the study period, there were 7478 documented cases of spina bifida and anencephaly among the 9,161,189 births, with an estimated average combined prevalence of 8.16 per 10,000 births (95% confidence interval, 7.98 - 8.35). For the 241 spina bifida-affected live births in 2009 in Germany, the estimated additional lifetime direct medical costs compared with non-spina bifida affected births were €65.5 million. Assuming a 50% reduction in the prevalence if folic acid has been provided to all women before pregnancy, 293 spina bifida cases could have been prevented in Germany in 2009. The estimated lifetime direct medical cost saving for the live births in 2009 was €32.9 million assuming a 50% reduction, or €26.1 million assuming a 40% risk reduction. CONCLUSION Europe has an epidemic of spina bifida and anencephaly compared with countries with mandatory folic acid fortification policy. Primary prevention through mandatory folic acid fortification would considerably reduce the number of affected pregnancies, and associated additional costs.
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Affiliation(s)
- Rima Obeid
- AIAS, Aarhus Institute for Advanced Studies, Aarhus University, Høegh-Guldbergs Gade 6B, Aarhus C, Denmark
| | - Klaus Pietrzik
- Department of Nutrition and Food Science, Rheinische Friedrich-Wilhelms University, Bonn, Bonn, Germany
| | - Godfrey P Oakley
- Center for Spina Bifida Research, Prevention and Policy, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Vijaya Kancherla
- Center for Spina Bifida Research, Prevention and Policy, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Wolfgang Holzgreve
- Chair of the Board of Directors of the University Bonn Medical Center, University Hospital of Bonn, Bonn, Germany
| | - Simon Wieser
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
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Al Rakaf MS, Kurdi AM, Ammari AN, Al Hashem AM, Shoukri MM, Garne E, Majeed-Saidan MA. Patterns of folic acid use in pregnant Saudi women and prevalence of neural tube defects - Results from a nested case-control study. Prev Med Rep 2015; 2:572-6. [PMID: 26844119 PMCID: PMC4721389 DOI: 10.1016/j.pmedr.2015.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although the role of folic acid (FA) in preventing neural tube defects (NTDs) is well documented, its optimal intake in pregnant women is still low in many countries. Here, we prospectively studied the prevalence of NTDs in the newborns and the patterns of FA intake in pregnant Saudi mothers. METHODS This case-control study was nested within a 3-year project (July 2010 to June 2013) to study the patterns of birth defects in the offspring of Saudi women who received their antenatal care and delivered at Prince Sultan Military Medical City, Riyadh-Saudi Arabia. Enrolled mothers were divided into 4 groups: group 1 (FA taken before pregnancy and continued regularly after conception), group 2 (FA taken post-conception), group 3 (no FA intake), and group 4 (did not remember or were unsure of taking FA). Control mothers were randomly selected from those with normal first obstetrical ultrasound scan at 18-22 weeks of gestation. RESULTS The cohort included 30,531 mothers giving birth to 28,646 infants. We studied 1179 mothers of babies with birth defects (BDs) and 1262 control mothers. There were 237 (9.7%) mothers in-group 1; 2001 (82%) in-group 2; 154 (6.3%) in-group 3; and 49 (2%) in-group 4. There were 49 babies with NTDs, a prevalence of 1.7/1000 total births. Among the studied mothers 2274 (93%) took FA either full or partial course. CONCLUSION The high prevalence of NTDs and the low optimal FA intake highlight the need for a strict implementation of staple food fortification and health education program for Saudi women.
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Affiliation(s)
- Maha S. Al Rakaf
- Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed M. Kurdi
- Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Amer N. Ammari
- Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Amal M. Al Hashem
- Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | | | - Ester Garne
- Hospital Lillebaelt-Kolding, Kolding, Denmark
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Colapinto CK, O'Connor DL, Dubois L, Tremblay MS. Prevalence and correlates of high red blood cell folate concentrations in the Canadian population using 3 proposed cut-offs. Appl Physiol Nutr Metab 2015; 40:1025-30. [PMID: 26319565 DOI: 10.1139/apnm-2015-0191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A distinct shift towards higher folate concentrations has emerged in Canada. These higher concentrations have known benefits, including prevention of neural tube defects, but concerns have been raised regarding potential associations with adverse health outcomes. The aim of this research was to propose cut-offs for high red blood cell (RBC) folate concentrations and identify their correlates. RBC folate was measured in a nationally representative cross-sectional sample of Canadians (N = 5248) aged 6 to 79 years. RBC folate concentrations were adjusted from the IMMULITE 2000 immunoassay to a microbiologic assay. The population was characterized at 3 RBC folate cut-offs: 1450 nmol/L, 1800 nmol/L, and 2150 nmol/L. We used t tests to examine differences by age, sex, income, and body mass index (BMI) at each cut-off and logistic regression to explore associations with folic acid supplement intake. The prevalence of high RBC folate was 16%, 6%, and 2% at thresholds of 1450 nmol/L, 1800 nmol/L, and 2150 nmol/L, respectively. Females, those aged 60 to 79 years, and overweight or obese participants had the greatest prevalence of having high RBC folate at each cut-off. Folic acid supplement users were more likely than non-users to have high RBC folate concentrations. Older age, higher BMI, and folic acid supplement use were identified as correlates of high folate status. A high RBC folate concentration cut-off will advance the field towards consistent measurement and reporting of high folate status. This may facilitate future investigation of associations between RBC folate concentrations at the upper end of the distribution and health outcomes.
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Affiliation(s)
- Cynthia K Colapinto
- a Institute of Population Health, University of Ottawa, Ottawa, ON K1N 6N5, Canada.,b Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Deborah L O'Connor
- c Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 3E2, Canada.,d Physiology and Experimental Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Lise Dubois
- a Institute of Population Health, University of Ottawa, Ottawa, ON K1N 6N5, Canada.,e School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Mark S Tremblay
- b Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada.,f Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada
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Bisaro DL, Bidonde J, Kane KJ, Bergsma S, Musselman KE. Past and current use of walking measures for children with spina bifida: a systematic review. Arch Phys Med Rehabil 2015; 96:1533-1543.e31. [PMID: 25944500 DOI: 10.1016/j.apmr.2015.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/16/2015] [Accepted: 04/21/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe walking measurement in children with spina bifida and to identify patterns in the use of walking measures in this population. DATA SOURCES Seven medical databases-Medline, PubMed, Embase, Scopus, Web of Science, CINAHL, and AMED-were searched from the earliest known record until March 11, 2014. Search terms encompassed 3 themes: (1) children; (2) spina bifida; and (3) walking. STUDY SELECTION Articles were included if participants were children with spina bifida aged 1 to 17 years and if walking was measured. Articles were excluded if the assessment was restricted to kinematic, kinetic, or electromyographic analysis of walking. A total of 1751 abstracts were screened by 2 authors independently, and 109 articles were included in this review. DATA EXTRACTION Data were extracted using standardized forms. Extracted data included study and participant characteristics and details about the walking measures used, including psychometric properties. Two authors evaluated the methodological quality of articles using a previously published framework that considers sampling method, study design, and psychometric properties of the measures used. DATA SYNTHESIS Nineteen walking measures were identified. Ordinal-level rating scales (eg, Hoffer Functional Ambulation Scale) were most commonly used (57% of articles), followed by ratio-level, spatiotemporal measures, such as walking speed (18% of articles). Walking was measured for various reasons relevant to multiple health care disciplines. A machine learning analysis was used to identify patterns in the use of walking measures. The learned classifier predicted whether a spatiotemporal measure was used with 77.1% accuracy. A trend to use spatiotemporal measures in older children and those with lumbar and sacral spinal lesions was identified. Most articles were prospective studies that used samples of convenience and unblinded assessors. Few articles evaluated or considered the psychometric properties of the walking measures used. CONCLUSIONS Despite a demonstrated need to measure walking in children with spina bifida, few valid, reliable, and responsive measures have been established for this population.
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Affiliation(s)
- Derek L Bisaro
- School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Julia Bidonde
- School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kyra J Kane
- School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Shane Bergsma
- Department of Computer Science, College of Arts and Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kristin E Musselman
- School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Nasri K, Ben Fradj MK, Aloui M, Ben Jemaa N, Masmoudi A, Elmay MV, Marrakchi R, Siala Gaigi S. An increase in spina bifida cases in Tunisia, 2008-2011. Pathol Res Pract 2015; 211:369-73. [PMID: 25617140 DOI: 10.1016/j.prp.2014.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/01/2014] [Accepted: 12/16/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The term spina bifida refers to a group of neural tube defects that result in malformations of the spinal cord and the surrounding vertebrae. Though the etiologies of spina bifida remain largely unknown, several risk factors have been identified, including feto-maternal characteristics. AIM OF THE STUDY To discover possible underlying reasons for the increase of spina bifida and identify intervention targets, an investigation was undertaken comparing spina bifida-affected pregnancy notifications in 2008-2011 with notifications in the period 1991-1994. METHODS Characteristics and outcomes of births with spina bifida and pregnancy characteristics of mothers were recorded in the medical chart. Comparisons of pregnancies affected by a spina bifida in 2008-2011 were made with pregnancies affected by a spina bifida in the period 1991-1994. Statistical analysis was undertaken using Poisson regression and Chi-squared tests. RESULTS From 1991 through 1994, the prevalence of identified spina bifida cases was equal to 0.3/10,000 births compared to 1.6/10,000 births in 2008-2011. This increase was statistically significant (P<0.001). The prevalence of females was equal to 0.45 per 10,000 births over the period 1991-1994 compared to 1.88 per 10,000 births during the period 2008-2011. As for males, the prevalence was equal to 0.16 per 10,000 births in 1991-1994 compared to 1.88 in 2008-2011. The difference was statistically significant (P<0.001) between both genders. A mother's age of over 30 years had significant impact on the emergence of spina bifida (P=0.02, OR=3.93, CI=1.23-12.47). As well as, maternal blood type was a significant risk factor for the appearance of spina bifida (P=0.008). Results also had shown that fetal weight and term, gestity and parity were significant risk factors for the occurrence of spina bifida (P<0.05).In this study, results have been interpreted with caution due to analyses not being adjusted. CONCLUSION This analysis highlighted areas where prevention efforts should be strengthened and surveillance data improved.
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Affiliation(s)
- Kaouther Nasri
- Faculté des Sciences de Bizerte, Université de Carthage, 7021 Zarzouna, Bizerte, Tunisia; UR 06/SP14 Troubles du développement embryo-fœtal et placentaire, Service d'embryo-fœtopathologie, Centre de Maternité et de Néonatologie La Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia.
| | - Mohamed Kacem Ben Fradj
- UR05/08-08, Département de biochimie, Hôpital la Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
| | - Mariem Aloui
- Faculté des Sciences de Bizerte, Université de Carthage, 7021 Zarzouna, Bizerte, Tunisia; UR 06/SP14 Troubles du développement embryo-fœtal et placentaire, Service d'embryo-fœtopathologie, Centre de Maternité et de Néonatologie La Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
| | - Nadia Ben Jemaa
- UR 06/SP14 Troubles du développement embryo-fœtal et placentaire, Service d'embryo-fœtopathologie, Centre de Maternité et de Néonatologie La Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
| | - Aida Masmoudi
- UR 06/SP14 Troubles du développement embryo-fœtal et placentaire, Service d'embryo-fœtopathologie, Centre de Maternité et de Néonatologie La Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
| | - Michèle Véronique Elmay
- 01/UR/08-07 Laboratoire d'histologie, embryologie et biologie cellulaire de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
| | - Raja Marrakchi
- Laboratoire de génétique, immunologie et pathologie humaine, faculté des sciences de Tunis, Université El Manar, 2092 Tunis, Tunisia
| | - Soumeya Siala Gaigi
- UR 06/SP14 Troubles du développement embryo-fœtal et placentaire, Service d'embryo-fœtopathologie, Centre de Maternité et de Néonatologie La Rabta et de la Faculté de Médecine de Tunis, Université El Manar II, 1007 Tunis, Tunisia
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Abstract
INTRODUCTION Since Canada began fortifying grain products with folic acid in 1998, the rate of folate deficiency in outpatients has decreased substantially. Limited data exist on the prevalence of folate deficiency in Canadian hospital inpatients. METHODS The electronic patient record at a large urban academic institution was reviewed for all red blood cell folate and vitamin B12 level tests performed on inpatients between January 1 and December 31, 2010. Chart reviews were performed on patients found to have folate deficiency to determine the indication for folate testing and the etiology of deficiency. RESULTS There were 2563 red blood cell folate and 3154 vitamin B12 level tests performed in 2010. Of these, only 4 (0.16%) red blood cell folate levels were in the deficient range (<254 nmol/L), compared with 98 (3.1%) and 426 (13.5%) vitamin B12 levels that were in the deficient (<138 pmol/L) and intermediate (138-221 pmol/L) range, respectively. Of the 4 patients with folate deficiency, the etiology appeared to be alcohol abuse in one, a malabsorption syndrome in the second, decreased oral intake due to schizophrenia in the third, with the final low folate level appearing to be spurious. At a cost of $12.54 per test, $32,140 could be saved each year at this institution if red blood cell folate testing on inpatients was restricted. CONCLUSION Folate deficiency in inpatients is nearly nonexistent, while an appreciable number of patients have low/intermediate vitamin B12 levels. Significant savings could be achieved by eliminating folate testing on inpatients.
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