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Baba A, Aregbesola A, Caldwell PHY, Elliott SA, Elsman EBM, Fernandes RM, Hartling L, Heath A, Kelly LE, Preston J, Sammy A, Webbe J, Williams K, Woolfall K, Klassen TP, Offringa M. Developments in the Design, Conduct, and Reporting of Child Health Trials. Pediatrics 2024:e2024065799. [PMID: 38832441 DOI: 10.1542/peds.2024-065799] [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] [Received: 01/17/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 06/05/2024] Open
Abstract
To identify priority areas to improve the design, conduct, and reporting of pediatric clinical trials, the international expert network, Standards for Research (StaR) in Child Health, was assembled and published the first 6 Standards in Pediatrics in 2012. After a recent review summarizing the 247 publications by StaR Child Health authors that highlight research practices that add value and reduce research "waste," the current review assesses the progress in key child health trial methods areas: consent and recruitment, containing risk of bias, roles of data monitoring committees, appropriate sample size calculations, outcome selection and measurement, and age groups for pediatric trials. Although meaningful change has occurred within the child health research ecosystem, measurable progress is still disappointingly slow. In this context, we identify and review emerging trends that will advance the agenda of increased clinical usefulness of pediatric trials, including patient and public engagement, Bayesian statistical approaches, adaptive designs, and platform trials. We explore how implementation science approaches could be applied to effect measurable improvements in the design, conducted, and reporting of child health research.
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Affiliation(s)
- Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Alex Aregbesola
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Patrina H Y Caldwell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Sarah A Elliott
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Lisa Hartling
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Lauren E Kelly
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmacology and Therapeutics, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer Preston
- National Institute for Health and Care Research (NIHR) Alder Hey Clinical Research Facility, Liverpool, United Kingdom
| | - Adrian Sammy
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - James Webbe
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Katrina Williams
- Department of Paediatrics, Monash University and Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, United Kingdom
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Kinney MO, Craig JJ, Delanty N. Folic acid in women with epilepsy: prescribing advice. Pract Neurol 2024; 24:180-182. [PMID: 38527794 DOI: 10.1136/pn-2023-003829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Michael Owen Kinney
- Queen's University Belfast, Belfast, UK
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - John J Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Norman Delanty
- Department of Neurology, Beaumont Hospital, School of Pharmacy and Biomolecular Sciences, and FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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Sulistyoningrum DC, Sullivan TR, Skubisz M, Palmer DJ, Wood S, Ueland PM, McCann A, Makrides M, Green TJ, Best KP. Maternal serum unmetabolized folic acid concentration following multivitamin and mineral supplementation with or without folic acid after 12 weeks gestation: A randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13668. [PMID: 38783413 DOI: 10.1111/mcn.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/03/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Abstract
Pregnant women are advised to take folic acid (FA) supplements before conception and during the first trimester of pregnancy. Many women continue FA supplementation throughout pregnancy, and concerns have been raised about associations between excessive FA intake and adverse maternal and child health outcomes. Unmetabolized folic acid (UMFA) is found in serum after high FA intakes and is proposed as a biomarker for excessive FA intake. We aimed to determine if removing FA from prenatal micronutrient supplements after 12 weeks of pregnancy reduces serum UMFA concentrations at 36 weeks gestation. In this double-blind, randomized controlled trial conducted in South Australia, 103 women with a singleton pregnancy were randomly assigned at 12-16 weeks gestation to take a micronutrient supplement containing no FA or 800 µg/day FA from enrollment until 36 weeks gestation. Ninety women (0 µg/day FA n = 46; 800 µg/day FA n = 44) completed the study. Mean, UMFA concentration was lower in the women randomized to the 0 µg/day group compared to the 800 µg/day FA group, 0.6 ± 0.7 and 1.4 ± 2.7 nmol/L, respectively. The adjusted mean difference (95% CI) in UMFA between the groups was [-0.85 (-1.62, -0.08) nmol/L, p = 0.03]. Maternal serum and red blood cell folate concentrations were lower in the 0 µg/day FA group than in the 800 µg/day group (median 23.2 vs. 49.3 and 1335 vs. 1914 nmol/L, respectively; p < 0.001). Removing FA at 12-16 weeks gestation from prenatal micronutrient supplements reduced the concentration of UMFA at 36 weeks gestation.
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Affiliation(s)
- Dian C Sulistyoningrum
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas R Sullivan
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia
| | - Monika Skubisz
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Debra J Palmer
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Simon Wood
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Food, Nutrition and Health Program, University of British Columbia, Vancouver, British Columbia, Canada
- InovoBiologic Inc., Calgary, Alberta, Canada
| | | | | | - Maria Makrides
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Timothy J Green
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Karen P Best
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Chen Z, Berger JS, Castellucci LA, Farkouh M, Goligher EC, Hade EM, Hunt BJ, Kornblith LZ, Lawler PR, Leifer ES, Lorenzi E, Neal MD, Zarychanski R, Heath A. A comparison of computational algorithms for the Bayesian analysis of clinical trials. Clin Trials 2024:17407745241247334. [PMID: 38752434 DOI: 10.1177/17407745241247334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Clinical trials are increasingly using Bayesian methods for their design and analysis. Inference in Bayesian trials typically uses simulation-based approaches such as Markov Chain Monte Carlo methods. Markov Chain Monte Carlo has high computational cost and can be complex to implement. The Integrated Nested Laplace Approximations algorithm provides approximate Bayesian inference without the need for computationally complex simulations, making it more efficient than Markov Chain Monte Carlo. The practical properties of Integrated Nested Laplace Approximations compared to Markov Chain Monte Carlo have not been considered for clinical trials. Using data from a published clinical trial, we aim to investigate whether Integrated Nested Laplace Approximations is a feasible and accurate alternative to Markov Chain Monte Carlo and provide practical guidance for trialists interested in Bayesian trial design. METHODS Data from an international Bayesian multi-platform adaptive trial that compared therapeutic-dose anticoagulation with heparin to usual care in non-critically ill patients hospitalized for COVID-19 were used to fit Bayesian hierarchical generalized mixed models. Integrated Nested Laplace Approximations was compared to two Markov Chain Monte Carlo algorithms, implemented in the software JAGS and stan, using packages available in the statistical software R. Seven outcomes were analysed: organ-support free days (an ordinal outcome), five binary outcomes related to survival and length of hospital stay, and a time-to-event outcome. The posterior distributions for the treatment and sex effects and the variances for the hierarchical effects of age, site and time period were obtained. We summarized these posteriors by calculating the mean, standard deviations and the 95% equitailed credible intervals and presenting the results graphically. The computation time for each algorithm was recorded. RESULTS The average overlap of the 95% credible interval for the treatment and sex effects estimated using Integrated Nested Laplace Approximations was 96% and 97.6% compared with stan, respectively. The graphical posterior densities for these effects overlapped for all three algorithms. The posterior mean for the variance of the hierarchical effects of age, site and time estimated using Integrated Nested Laplace Approximations are within the 95% credible interval estimated using Markov Chain Monte Carlo but the average overlap of the credible interval is lower, 77%, 85.6% and 91.3%, respectively, for Integrated Nested Laplace Approximations compared to stan. Integrated Nested Laplace Approximations and stan were easily implemented in clear, well-established packages in R, while JAGS required the direct specification of the model. Integrated Nested Laplace Approximations was between 85 and 269 times faster than stan and 26 and 1852 times faster than JAGS. CONCLUSION Integrated Nested Laplace Approximations could reduce the computational complexity of Bayesian analysis in clinical trials as it is easy to implement in R, substantially faster than Markov Chain Monte Carlo methods implemented in JAGS and stan, and provides near identical approximations to the posterior distributions for the treatment effect. Integrated Nested Laplace Approximations was less accurate when estimating the posterior distribution for the variance of hierarchical effects, particularly for the proportional odds model, and future work should determine if the Integrated Nested Laplace Approximations algorithm can be adjusted to improve this estimation.
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Affiliation(s)
- Ziming Chen
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | | | | | | | | | | | - Eric S Leifer
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Matthew D Neal
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Anna Heath
- The Hospital for Sick Children, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Statistical Science, University College London, London, UK
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Nasri K, Ben Jamaa N, Gaigi SS, Feki M, Marrakchi R. Association of MTHFR (C677T, A1298C) and MTRR A66G polymorphisms with fatty acids profile and risk of neural tube defects. Birth Defects Res 2024; 116:e2333. [PMID: 38716581 DOI: 10.1002/bdr2.2333] [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: 11/16/2023] [Revised: 01/29/2024] [Accepted: 03/22/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE This study aims to determine if 5,10-methylenetetrahydrofolate reductase (MTHFR C677T and A1298C) and methionine synthase reductase (MTRR A66G) gene polymorphisms were associated with fatty acid (FA) levels in mothers of fetuses with neural tube defects (NTDs) and whether these associations were modified by environmental factors. METHODS Plasma FA composition was assessed using capillary gas chromatography. Concentrations of studied FA were compared between 42 mothers of NTDs fetuses and 30 controls as a function of each polymorphism by the Kruskal-Wallis nonparametric test. RESULTS In MTHFR gene C677T polymorphism, cases with (CT + TT) genotype had lower monounsaturated FAs (MUFA) and omega-3 polyunsaturated FA (n-3 PUFA) levels, but higher omega-6 polyunsaturated FAs (n-6 PUFA) and omega-6 polyunsaturated FAs: omega-3 polyunsaturated FAs (n-6:n-3) ratio levels. In MTRR gene A66G polymorphism, cases with (AG + GG) genotype had lower MUFA levels, but higher PUFA and n-6 PUFA levels. Controls with (AG + GG) genotype had lower n-6 PUFA levels. In MTHFR gene C677T polymorphism, cases with smoking spouses and (CT + TT) genotype had lower MUFA and n-3 PUFA levels, but higher PUFA, n-6 PUFA, and n-6:n-3 ratio levels. Cases with (CT + TT) genotype and who used sauna during pregnancy had lower n-3 PUFA levels. In MTRR gene A66G polymorphism, cases with (AG + GG) genotype and who used sauna during pregnancy had higher PUFA and n-6 PUFA levels. CONCLUSIONS Further research is required to clarify the association of FA metabolism and (MTHFR, MTRR) polymorphisms with NTDs.
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Affiliation(s)
- Kaouther Nasri
- Faculty of Sciences of Bizerte, University of Carthage, Bizerte, Tunisia
- Service of Embryo-Fetopathology, Center for Maternity and Neonatology of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Nadia Ben Jamaa
- Department of Histology-Embryology, Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Soumeya Siala Gaigi
- Service of Embryo-Fetopathology, Center for Maternity and Neonatology of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, Rabta Hospital, Tunis El Manar University Jebbari, Tunis, Tunisia
| | - Raja Marrakchi
- Laboratory of Human Genetics, Immunology and Pathology, Faculty of Sciences of Tunis, Tunis El Manar University, Tunis, Tunisia
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Wagh K, Kancherla V, Dorsey A, Pachón H, Oakley GP. A global update on the status of prevention of folic acid-preventable spina bifida and anencephaly in year 2022. Birth Defects Res 2024; 116:e2343. [PMID: 38688860 DOI: 10.1002/bdr2.2343] [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: 12/04/2023] [Revised: 03/13/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Mandatory fortification of staple foods with folic acid is an effective public health strategy to prevent folic acid-preventable spina bifida and anencephaly (FAP SBA). We estimated the global proportion of FAP SBA prevented through mandatory folic acid fortification of cereal grains (i.e., wheat flour, maize flour, and rice). METHODS We used year 2022 data from the Food Fortification Initiative to identify countries (n = 69) with mandatory fortification of grains that includes folic acid. Sixty-eight countries were eligible for analysis with complete data. Proportion of FAP SBA prevention was modeled assuming >150 mcg/day of folic acid fortification protects against FAP SBA, reducing post-fortification prevalence to a lowest achievable level of 0.5 cases per 1000 births. RESULTS Our analysis found that a total of 63,520 cases of FAP SBA were prevented in the year 2022 in 68 countries implementing mandatory folic acid fortification of grains with folic acid. This translated to a 23.7% prevention of all possible FAP SBA prevention globally. An excess of 204,430 cases of FAPSBA still occurred in over 100 countries where mandatory staple food fortification with folic acid is not implemented. CONCLUSION Our study showed that only a quarter of all FAP SBA cases were averted through mandatory folic acid fortification in the year 2022; many countries are not implementing the policy, resulting in a large proportion of FAP SBA cases that can be prevented. Fortification will help countries with achieving 2030 Sustainable Development Goals on neonatal- and under-five mortality, disability, stillbirths, and elective terminations prevention, from FAP SBA.
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Affiliation(s)
- Kaustubh Wagh
- Department of Population Health Sciences, School of Public Health of Georgia State University, Atlanta, Georgia, USA
| | - Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
| | - Amanda Dorsey
- Center for Spina Bifida Prevention, Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
| | - Helena Pachón
- Food Fortification Initiative, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, 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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Qi YP, Crider KS, Williams AM, Tripp K, Mapango C, Rhodes EC, Nyirenda E, Phiri F, Zhang M, Jabbar S, Pfeiffer CM, Pachón H, Zimmerman S, Williams JL. Folate and vitamin B 12 status and predicted neural tube defects risk among nonpregnant women of reproductive age from the Malawi National Micronutrient Survey, 2015-2016. Birth Defects Res 2024; 116:e2329. [PMID: 38526193 DOI: 10.1002/bdr2.2329] [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: 10/03/2023] [Revised: 02/05/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Maternal folate and vitamin B12 deficiency can lead to serious adverse pregnancy outcomes. There are no nationally representative estimates on folate and vitamin B12 status among women of reproductive age (WRA) in Malawi. OBJECTIVE We assessed folate and vitamin B12 status among nonpregnant WRA in Malawi and predicted the risk of folate-sensitive neural tube defects (NTDs) were they to become pregnant. METHODS Using data from the cross-sectional, nationally representative 2015-2016 Malawi Micronutrient Survey, we calculated the proportion of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 778 nonpregnant WRA (15-49 years). We predicted NTD prevalence using red blood cell (RBC) folate distributions and a published Bayesian model of the association between RBC folate and NTD risk. Analyses accounted for complex survey design. RESULTS Among WRA, 8.5% (95% CI: 6.2, 11.6) and 13.3% (10.0, 17.4) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The proportion of vitamin B12 deficiency (<148 pmol/L) and insufficiency (≤221 pmol/L) was 11.8% (8.6, 16.0) and 40.6% (34.1, 47.4), respectively. RBC folate insufficiency (<748 nmol/L, defined as the concentration associated with the threshold for elevated NTD risk: >8 cases per 10,000 births) was widespread: 81.4% (75.0, 86.4). The predicted NTD risk nationally was 24.7 cases per 10,000 live births. RBC folate insufficiency and higher predicted NTD risk were more common among WRA living in urban areas or with higher education. CONCLUSIONS These findings highlight the importance of nutritional and NTD surveillance in Malawi and the opportunity for improving folate and vitamin B12 nutrition among Malawian WRA.
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Affiliation(s)
- Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | | | - Katie Tripp
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia, USA
| | - Carine Mapango
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | - Elizabeth C Rhodes
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Eunice Nyirenda
- Department of Nutrition, HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Felix Phiri
- Department of Nutrition, HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Mindy Zhang
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | - Shameem Jabbar
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | | | - Helena Pachón
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Food Fortification Initiative, Atlanta, Georgia, USA
| | - Sarah Zimmerman
- McKing Consulting Corporation, Atlanta, Georgia, USA
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
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Quinn M, Halsey J, Sherliker P, Pan H, Chen Z, Bennett DA, Clarke R. Global heterogeneity in folic acid fortification policies and implications for prevention of neural tube defects and stroke: a systematic review. EClinicalMedicine 2024; 67:102366. [PMID: 38169713 PMCID: PMC10758734 DOI: 10.1016/j.eclinm.2023.102366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
Background Folic acid (pteroylmonoglutamic acid) supplements are highly effective for prevention of neural tube defects (NTD) prompting implementation of mandatory or voluntary folic acid fortification for prevention of NTDs. We used plasma folate levels in population studies by country and year to compare effects of folic acid fortification types (mandatory or voluntary folic acid fortification policies) on plasma folate levels, NTD prevalence and stroke mortality rates. Methods We conducted systematic reviews of (i) implementation of folic acid fortification in 193 countries that were member states of the World Health Organization by country and year, and (ii) estimated population mean plasma folate levels by year and type of folic acid fortification. We identified relevant English language reports published between Jan 1, 1990 and July 31, 2023 using Google Scholar, Medline, Embase and Global Health. Eligibility criteria were observational or interventional studies with >1000 participants. Studies of pregnant women or children <15 years were excluded. Using an ecological study design, we examined the associations of folic acid fortification types with NTD prevalence (n = 108 studies) and stroke mortality rates (n = 3 countries). Findings Among 193 countries examined up to 31 July 2023, 69 implemented mandatory folic acid fortification, 47 had voluntary fortification, but 77 had no fortification (accounting for 32%, 53% and 15% of worldwide population, respectively). Mean plasma folate levels were 36, 21 and 17 nmol/L in populations with mandatory, voluntary and no fortification, respectively (and proportions with mean folate levels >25 nmol/L were 100%, 15% and 7%, respectively). Among 75 countries with NTD prevalence, mean (95% CI) prevalence per 10,000 population were 4.19 (4.11-4.28), 7.61 (7.47-7.75) and 9.66 (9.52-9.81) with mandatory, voluntary and no folic acid fortification, respectively. However, age-standardised trends in stroke mortality rates were unaltered by the introduction of folic acid fortification. Interpretation There is substantial heterogeneity in folic acid fortification policies worldwide where folic acid fortification are associated with 50-100% higher population mean plasma folate levels and 25-50% lower NTD prevalence compared with no fortification. Many thousand NTD pregnancies could be prevented yearly if all countries implemented mandatory folic acid fortification. Further trials of folic acid for stroke prevention are required in countries without effective folic acid fortification policies. Funding Medical Research Council (UK) and British Heart Foundation.
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Affiliation(s)
- Matthew Quinn
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jim Halsey
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit of University of Oxford, United Kingdom
| | - Hongchao Pan
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit of University of Oxford, United Kingdom
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit of University of Oxford, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Liu H, Ou J, Chen Y, Chen Q, Luo M, Wang T, Qin J. Association of Maternal Folate Intake and Offspring MTHFD1 and MTHFD2 Genes with Congenital Heart Disease. Nutrients 2023; 15:3502. [PMID: 37630697 PMCID: PMC10458540 DOI: 10.3390/nu15163502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Existing evidence supported that congenital heart defect (CHD) was associated with a combination of environmental and genetic factors. Based on this, this study aimed at assessing the association of maternal folic acid supplementation (FAS), genetic variations in offspring methylenetetrahydrofolate dehydrogenase (MTHFD)1 and MTHFD2 genes, and their interactions with CHD and its subtypes. A hospital-based case-control study, including 620 cases with CHD and 620 healthy children, was conducted. This study showed that the absence of FAS was significantly associated with an increased risk of total CHD and its subtypes, such as atrial septal defect (ASD). FAS during the first and second trimesters was associated with a significantly higher risk of CHD in offspring compared to FAS during the three months prior to conception. The polymorphisms of offspring MTHFD1 and MTHFD2 genes at rs2236222, rs11849530, and rs828858 were significantly associated with the risk of CHD. Additionally, a significantly positive interaction between maternal FAS and genetic variation at rs828858 was observed for the risk of CHD. These findings suggested that pregnant women should carefully consider the timing of FAS, and individuals with higher genetic risk may benefit from targeted folic acid supplementation as a preventive measure against CHD.
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Affiliation(s)
- Hanjun Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Jun Ou
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Yige Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Qian Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Manjun Luo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410078, China; (H.L.); (J.O.); (Y.C.); (Q.C.); (M.L.)
- National Health Committee Key Laboratory of Birth Defect for Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha 410028, China
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10
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Dong J, Yin LL, Deng XD, Ji CY, Pan Q, Yang Z, Peng T, Wu JN. Initiation and duration of folic acid supplementation in preventing congenital malformations. BMC Med 2023; 21:292. [PMID: 37545008 PMCID: PMC10405478 DOI: 10.1186/s12916-023-03000-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Folic acid (FA) supplementation is associated with a lower risk of the neural tube and heart defects and is recommended for women of childbearing age. Although there are detailed recommendations, differences in the initiation time and duration of FA supplementation remain poorly studied. METHODS A multicentre prospective study of 17,713 women was conducted. The incidence of congenital malformations in women taking a recommended dosage (e.g. 0.4 or 0.8 mg/day) of FA was compared with that in women without supplementation. The predicted probability of malformations by the initiation time and duration of FA use was estimated to determine optimal options. RESULTS Periconceptional FA supplementation was associated with a lower and insignificant risk of congenital malformations (1.59% vs. 2.37%; odds ratio [OR] 0.69; 95% confidence interval [CI]: 0.44-1.08), heart defects (3.8 vs. 8.0 per 1000 infants; OR, 0.47; 0.21-1.02), and neural tube defects (7.0 vs. 11.5 per 10,000 infants; OR, 0.64; 0.08-5.15). FA use after pregnancy provided greater protection against total malformations. Statistically significant associations were found in women who initiated FA supplementation in the first month of gestation (OR, 0.55; 95% CI: 0.33-0.91) and in those who supplemented for 1 to 2 months (OR, 0.59; 95% CI: 0.36-0.98). Similar results were found for heart defects. The optimal initiation time was 1.5 (optimal range: 1.1 to 1.9) months before pregnancy and a duration of 4.0 (3.7 to 4.4) months was reasonable to achieve the lowest risk of congenital malformations. Heart defect prevention required an earlier initiation (2.2 vs. 1.1 months before pregnancy) and a longer duration (4.7 vs. 3.7 months) than the prevention of other malformations. CONCLUSIONS The timely initiation of FA supplementation for gestation was associated with a decreased risk of congenital malformations, which was mainly attributed to its protection against heart defects. The initiation of FA supplementation 1.5 months before conception with a duration of 4 months is the preferred option for congenital malformation prevention. TRIAL REGISTRATION Chictr.org.cn identifier: ChiCTR-SOC-17010976.
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Affiliation(s)
- Jing Dong
- Medical Center of Diagnosis and Treatment for Cervical Disease, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China
| | - Lin-Liang Yin
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215006, China
| | - Xue-Dong Deng
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215006, China
| | - Chun-Ya Ji
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215006, China
| | - Qi Pan
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215006, China
| | - Zhong Yang
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215006, China
| | - Ting Peng
- Department of Obstetrics, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China.
| | - Jiang-Nan Wu
- Department of Clinical Epidemiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China.
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11
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Kancherla V. Neural tube defects: a review of global prevalence, causes, and primary prevention. Childs Nerv Syst 2023; 39:1703-1710. [PMID: 36882610 DOI: 10.1007/s00381-023-05910-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
Neural tube defects (NTDs) are common birth defects and contribute to life-long disabilities, high medical care costs, and perinatal and child mortality. This review is a primer on prevalence, causes, and evidence-based prevention strategies for NTDs. The estimated average global prevalence of NTDs is two cases per 1000 births, amounting to approximately 214,000-322,000 affected pregnancies worldwide annually. Prevalence and associated adverse outcomes are disproportionately high in developing countries. NTDs have multiple risk factors including genetic and non-genetic (i.e., maternal nutritional status, pre-pregnancy diabetes, early pregnancy exposure to valproic acid (anti-epileptic medication), and a previous pregnancy affected by a NTD) factors. Maternal folate insufficiency before and during early pregnancy is the most common risk factor and is preventable. Folic acid (vitamin B9) is required for formation of the neural tube early in pregnancy, around 28 days after conception, when most women are unaware of their pregnancies. Current guidelines recommend that all women planning or capable of pregnancy take a daily supplement containing 400-800 μg of folic acid. Mandatory folic acid fortification of staple foods (e.g., wheat flour, maize flour, rice) is safe, economical, and the effective intervention for primary prevention of NTDs. Currently, about 60 countries are implementing mandatory folic acid fortification of staple foods, preventing just a quarter of all preventable NTD cases worldwide. There is an urgent need for active champions, including neurosurgeons and other healthcare providers, to generate political will and promote effective mandatory food fortification with folic acid, and reach equitable primary prevention of NTDs in all countries.
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA.
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12
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Kubo Y, Shoji K, Tajima A, Horiguchi S, Fukuoka H, Nishikawa M, Kagawa Y, Kawabata T. Serum 5-Methyltetrahydrofolate Status Is Associated with One-Carbon Metabolism-Related Metabolite Concentrations and Enzyme Activity Indicators in Young Women. Int J Mol Sci 2023; 24:10993. [PMID: 37446171 DOI: 10.3390/ijms241310993] [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: 04/11/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Maintaining optimal one-carbon metabolism (OCM) is essential for health and pregnancy. In this cross-sectional study, folate status was assessed based on 5-methyltetrahydrofolate (5-MTHF) levels, and the association between 5-MTHF and OCM-related metabolites was investigated in 227 female Japanese university students aged 18-25 years. The participants were divided into high and low 5-MTHF groups based on their folate status. Serum samples of the participants were collected while they were fasting, and 18 OCM-related metabolites were measured using stable-isotope dilution liquid chromatography-electrospray tandem mass spectrometry. The association between serum 5-MTHF and OCM-related metabolite concentrations was assessed using Spearman's rank correlation coefficient. Serum 5-MTHF concentrations were negatively correlated with total homocysteine (tHcy) concentrations and positively correlated with S-adenosylmethionine (SAM) and total cysteine (tCys) concentrations. Serum 5-MTHF concentrations demonstrated a stronger negative correlation with tHcy/tCys than with tHcy alone. The negative correlation between betaine and tHcy concentrations was stronger in the low 5-MTHF group than in the high 5-MTHF group. The 5-MTHF status could be linked to Hcy flux into the transsulfuration pathway via SAM. Therefore, the tHcy/tCys ratio may be a more sensitive indicator of the 5-MTHF status than tHcy alone. Furthermore, a low 5-MTHF status can enhance Hcy metabolism via betaine.
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Affiliation(s)
- Yoshinori Kubo
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
- Division of Anatomy and Cell Biology, Department of Anatomy, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu 520-2192, Japan
| | - Kumiko Shoji
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
| | - Akiko Tajima
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
| | - Sayaka Horiguchi
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
| | - Hideoki Fukuoka
- Department of Perinatal Mesenchymal Stem Cell Research, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Masazumi Nishikawa
- Department of Food Management, School of Food, Agricultural and Environmental Sciences, Miyagi University, 2-2-1 Hatadate, Taihaku-ku, Sendai 982-0215, Japan
| | - Yasuo Kagawa
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
| | - Terue Kawabata
- Faculty of Nutrition, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado 350-0288, Japan
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13
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Martinez H, Benavides-Lara A, Arynchyna-Smith A, Ghotme KA, Arabi M, Arynchyn A. Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age. Childs Nerv Syst 2023; 39:1719-1736. [PMID: 37103517 DOI: 10.1007/s00381-023-05913-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/28/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age. METHODS This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification. RESULTS Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition. DISCUSSION We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.
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Affiliation(s)
- Homero Martinez
- Global Technical Services, Nutrition International, 180 Elgin St. suite 1000, ON, Ottawa, Canada.
- Hospital Infantil de México Federico Gómez, Mexico City, Mexico.
| | - Adriana Benavides-Lara
- Costa Rican Birth Defects Register Center (CREC), Costa Rican Institute of Research and Education in Nutrition and Health (INCIENSA), Cartago, Costa Rica
| | - Anastasia Arynchyna-Smith
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kemel A Ghotme
- Translational Neuroscience Research Lab, Faculty of Medicine, Universidad de La Sabana, Chia, Colombia
- Department of Neurosurgery, Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Mandana Arabi
- Global Technical Services, Nutrition International, 180 Elgin St. suite 1000, ON, Ottawa, Canada
| | - Alexander Arynchyn
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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14
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Shane B, Stover PJ. First things first-addressing frank nutrient deficiencies must remain a priority in the age of precision nutrition. Am J Clin Nutr 2023; 117:844-846. [PMID: 37137614 DOI: 10.1016/j.ajcnut.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 05/05/2023] Open
Affiliation(s)
- Barry Shane
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, CA, United States.
| | - Patrick J Stover
- Institute for Advancing Health Through Agriculture Texas A&M University College Station, TX, United States
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15
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Fothergill A, Crider KS, Rose CE, Bose B, Guetterman HM, Johnson CB, Jabbar S, Zhang M, Pfeiffer CM, Qi YP, Williams JL, Kuriyan R, Bonam W, Finkelstein JL. Estimating the serum folate concentration that corresponds to the red blood cell folate concentration threshold associated with optimal neural tube defects prevention: A population-based biomarker survey in Southern India. Am J Clin Nutr 2023; 117:985-997. [PMID: 37137617 PMCID: PMC10356561 DOI: 10.1016/j.ajcnut.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND RBC folate concentrations are monitored at the population level, with a recommended threshold for optimal neural tube defect (NTD) prevention. A corresponding threshold for serum folate has not been established. OBJECTIVES This study aimed to estimate the serum folate insufficiency threshold corresponding to the RBC folate threshold for NTD prevention and examine how this threshold is modified by vitamin B12 status. METHODS Participants were women (15-40 y; not pregnant or lactating; n = 977) from a population-based biomarker survey in Southern India. RBC folate and serum folate were measured via microbiologic assay. RBC folate deficiency (<305 nmol/L) and insufficiency (<748 nmol/L), serum vitamin B12 deficiency (<148 pmol/L) and vitamin B12 insufficiency (<221 pmol/L), elevated plasma MMA (>0.26 μmol/L), elevated plasma homocysteine (>10.0 μmol/L), and elevated HbA1c (≥6.5%) were evaluated. Bayesian linear models were used to estimate unadjusted and adjusted thresholds. RESULTS Compared with adequate vitamin B12 status, the estimated serum folate threshold was higher in participants with serum vitamin B12 deficiency (72.5 vs. 28.1 nmol/L) or vitamin B12 insufficiency (48.7 vs. 24.3 nmol/L) and elevated MMA (55.6 vs. 25.9 nmol/L). The threshold was lower in participants with elevated HbA1c (HbA1c ≥6.5% vs. <6.5%; 21.0 vs. 40.5 nmol/L). CONCLUSIONS The estimated serum folate threshold for optimal NTD prevention was similar to previous reports (24.3 vs. 25.6 nmol/L) among participants with sufficient vitamin B12 status. However, this threshold was more than 2-fold higher in participants with vitamin B12 deficiency and substantially higher across all indicators of insufficient vitamin B12 status (<221 pmol/L, elevated MMA, combined B12, impaired vitamin B12 status), and lower in participants with elevated HbA1c. Findings suggest a serum folate threshold for NTD prevention may be possible in some settings; however, it may not be appropriate in populations with high prevalence of vitamin B12 insufficiency. Am J Clin Nutr 2023;xx:xx-xx. This trial was registered at https://clinicaltrials.gov as NCT04048330.
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Affiliation(s)
- Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Beena Bose
- Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India
| | | | | | - Shameem Jabbar
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mindy Zhang
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca Kuriyan
- Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; Division of Nutrition, St. John's Research Institute, Bangalore, Karnataka, India; Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA.
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16
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Perera N, Rudland VL, Simmons D, Price SAL. Folate Supplementation in Women with Pre-Existing Diabetes. Nutrients 2023; 15:nu15081879. [PMID: 37111098 PMCID: PMC10145371 DOI: 10.3390/nu15081879] [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: 03/20/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Folate supplementation in the periconceptual period is the standard of care for the prevention of neural tube defects. To support dietary folate intake, some countries have introduced mandatory folic acid fortification of food products. Robust evidence supports the additional use of a low-dose folic acid supplement (0.4 mg/day) in all women from 2-3 months preconception until the end of the 12th week of gestation. For women with pre-existing diabetes, high-dose folic acid supplementation (5 mg/day) is recommended in some, but not all international guidelines. The recommendation is made based on consensus opinion and reflects the increased risk of neural tube defects in pregnant women with pre-existing diabetes. However, there is limited evidence to clarify the high-risk groups that benefit from high-dose folic acid versus those that do not. There are also some data to suggest that high-dose folic acid may be harmful to mothers and offspring, although this issue remains controversial. This narrative review explores the evidence that supports the recommendation for women with pre-existing diabetes to take high-dose folic acid in the periconceptual period. It explores the potential benefits of high-dose supplemental folate beyond the prevention of neural tube defects, and also the potential adverse impacts of high-dose folate use. These topics are considered with a specific focus on the issues that are pertinent to women with pre-existing diabetes. Based on the available evidence, a pragmatic approach to the use of folic acid supplements in women with pre-existing diabetes during the periconception period is suggested. The need for comprehensive preconception care that optimises glycaemic control and addresses other modifiable risk factors before pregnancy is emphasized.
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Affiliation(s)
- Nayomi Perera
- Department of Obstetric Medicine, Royal Women's Hospital, Flemington Rd, North Melbourne, VIC 3051, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Grattan St, Parkville, VIC 3010, Australia
| | - Victoria L Rudland
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - David Simmons
- Macarthur Clinical School, Western Sydney University, Campbelltown, NSW 2560, Australia
| | - Sarah A L Price
- Department of Obstetric Medicine, Royal Women's Hospital, Flemington Rd, North Melbourne, VIC 3051, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Grattan St, Parkville, VIC 3010, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Grattan St, Parkville, VIC 3010, Australia
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17
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Wang L, Li X, Montazeri A, MacFarlane AJ, Momoli F, Duthie S, Senekal M, Eguiagaray IM, Munger R, Bennett D, Campbell H, Rubini M, McNulty H, Little J, Theodoratou E. Phenome-wide association study of genetically predicted B vitamins and homocysteine biomarkers with multiple health and disease outcomes: analysis of the UK Biobank. Am J Clin Nutr 2023; 117:564-575. [PMID: 36811473 PMCID: PMC7614280 DOI: 10.1016/j.ajcnut.2023.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Although a number of health outcomes such as CVDs, metabolic-related outcomes, neurological disorders, pregnancy outcomes, and cancers have been identified in relation to B vitamins, evidence is of uneven quality and volume, and there is uncertainty about putative causal relationships. OBJECTIVES To explore the effects of B vitamins and homocysteine on a wide range of health outcomes based on a large biorepository linking biological samples and electronic medical records. METHODS First, we performed a phenome-wide association study (PheWAS) to investigate the associations of genetically predicted plasma concentrations (genetic component of the circulating concentrations) of folate, vitamin B6, vitamin B12, and their metabolite homocysteine with a wide range of disease outcomes (including both prevalent and incident events) among 385,917 individuals in the UK Biobank. Second, 2-sample Mendelian randomization (MR) analysis was used to replicate any observed associations and detect causality. We considered MR P <0.05 as significant for replication. Third, dose-response, mediation, and bioinformatics analyses were carried out to examine any nonlinear trends and to disentangle the underlying mediating biological mechanisms for the identified associations. RESULTS In total, 1117 phenotypes were tested in each PheWAS analysis. After multiple corrections, 32 phenotypic associations of B vitamins and homocysteine were identified. Two-sample MR analysis supported that 3 of them were causal, including associations of higher plasma vitamin B6 with lower risk of calculus of kidney (OR: 0.64; 95% CI: 0.42, 0.97; P = 0.033), higher homocysteine concentration with higher risk of hypercholesterolemia (OR: 1.28, 95% CI: 1.04, 1.56; P = 0.018), and chronic kidney disease (OR: 1.32, 95% CI: 1.06, 1.63; P = 0.012). Significant nonlinear dose-response relationships were observed for the associations of folate with anemia, vitamin B12 with vitamin B-complex deficiencies, anemia and cholelithiasis, and homocysteine with cerebrovascular disease. CONCLUSIONS This study provides strong evidence for the associations of B vitamins and homocysteine with endocrine/metabolic and genitourinary disorders.
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Affiliation(s)
- Lijuan Wang
- School of Public Health and the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Xue Li
- School of Public Health and the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Azita Montazeri
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Susan Duthie
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom
| | - Marjanne Senekal
- Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - Ines Mesa Eguiagaray
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Ron Munger
- Department of Nutrition and Food Sciences and the Center for Epidemiologic Studies, Utah State University, Logan, UT, USA
| | - Derrick Bennett
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Michele Rubini
- Department of Neuroscience and rehabilitation, University of Ferrara, Ferrara, Italy
| | - Helene McNulty
- Nutrition Innovation Centre for Food and Health, Ulster University, Coleraine, Northern Ireland, United Kingdom
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Evropi Theodoratou
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom; Cancer Research UK Edinburgh Centre, The University of Edinburgh MRC Institute of Genetics and Cancer, Edinburgh, United Kingdom.
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18
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Crider KS, Wang A, Ling H, Potischman N, Bailey RL, Lichen Y, Pfeiffer CM, Killian JK, Rose C, Sampson J, Zhu L, Berry RJ, Linet M, Yu W, Su LJ. Maternal Periconceptional Folic Acid Supplementation and DNA Methylation Patterns in Adolescent Offspring. J Nutr 2023; 152:2669-2676. [PMID: 36196007 PMCID: PMC9839994 DOI: 10.1093/jn/nxac184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Folate, including the folic acid form, is a key component of the one-carbon metabolic pathway used for DNA methylation. Changes in DNA methylation patterns during critical development periods are associated with disease outcomes and are associated with changes in nutritional status in pregnancy. The long-term impact of periconceptional folic acid supplementation on DNA methylation patterns is unknown. OBJECTIVES To determine the long-term impact of periconceptional folic acid supplementation on DNA methylation patterns, we examined the association of the recommended dosage (400 μg/d) and time period (periconceptional before pregnancy through first trimester) of folic acid supplementation with the DNA methylation patterns in the offspring at age 14-17 y compared with offspring with no supplementation. METHODS Two geographic sites in China from the 1993-1995 Community Intervention Program of folic acid supplementation were selected for the follow-up study. DNA methylation at 402,730 CpG sites was assessed using saliva samples from 89 mothers and 179 adolescents (89 male). The mean age at saliva collection was 40 y among mothers (range: 35-54 y) and 15 y among adolescents (range: 14-17 y). Epigenome-wide analyses were conducted to assess the interactions of periconceptional folic acid exposure, the 5,10-methylenetetrahydrofolate reductase (MTHFR)-C677T genotype, and epigenome-wide DNA methylation controlling for offspring sex, geographic region, and background cell composition in the saliva. RESULTS In the primary outcome, no significant differences were observed in epigenome-wide methylation patterns between adolescents exposed and those non-exposed to maternal periconceptional folic acid supplementation after adjustment for potential confounders [false discovery rate (FDR) P values < 0.05]. The MTHFR-C677T genotype did not modify this lack of association (FDR P values < 0.05). CONCLUSIONS Overall, there were no differences in DNA methylation between adolescents who were exposed during the critical developmental window and those not exposed to the recommended periconceptional/first-trimester dosage of folic acid.
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Affiliation(s)
- Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Arick Wang
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Hao Ling
- US CDC China Office, Beijing, China
| | | | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Yang Lichen
- National Center for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, US CDC, Atlanta, GA, USA
| | - J Keith Killian
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Charles Rose
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Joshua Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Li Zhu
- School of Public Health, Peking University Health Science Center, Beijing, China (retired)
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Martha Linet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Wang Yu
- Director General (former), Chinese Center for Disease Control and Prevention, Beijing, China
| | - L Joseph Su
- Cancer Prevention and Population Sciences Program, Division of Epidemiology, University of Arkansas, Little Rock, AR, USA
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19
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Patti MA, Braun JM, Arbuckle TE, MacFarlane AJ. Associations between folic acid supplement use and folate status biomarkers in the first and third trimesters of pregnancy in the Maternal-Infant Research on Environmental Chemicals (MIREC) Pregnancy Cohort Study. Am J Clin Nutr 2022; 116:1852-1863. [PMID: 36255373 PMCID: PMC9761751 DOI: 10.1093/ajcn/nqac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/15/2022] [Accepted: 08/19/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Achieving optimal folate status during early gestation reduces the risk of neural tube defects (NTDs). While inadequate folate intake remains a concern, it is becoming increasingly common for individuals to consume higher than recommended doses of folic acid (FA) with minimal additional benefit. OBJECTIVE Here, we sought to investigate the determinants, including FA supplement dose and use, of plasma total and individual folate vitamer concentrations in the first and third trimesters of pregnancy. METHODS Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort exposed to mandatory FA fortification, we measured plasma total folate and individual folate vitamer [5-methyltetrahydrofolate (5-methylTHF), unmetabolized FA (UMFA), and non-methyl folates (sum of THF, 5-formylTHF, 5,10-methenyl-THF)] concentrations in the first and third trimesters (n = 1,893). Using linear mixed models, we estimated associations between plasma folate concentrations, total daily supplemental FA intake, plasma vitamin B-12 concentrations, and multiple demographic, maternal, and reproductive factors. RESULTS Almost 95% of MIREC study participants met or exceeded the recommended daily supplemental FA intake from supplements (≥400 μg/d), with approximately 25% consuming more than the Tolerable Upper Intake Level (>1000 μg/d). Over 99% of MIREC participants had a plasma total folate status indicative of maximal NTD risk reduction (25.5 nmol/L) regardless of FA supplement dose. UMFA was detected in almost all participants, with higher concentrations associated with higher FA doses. Determinants of adequate FA supplement intake and folate status associated with reduced NTD risk included indicators of higher socioeconomic position, higher maternal age, nulliparity, and lower prepregnancy BMI. CONCLUSIONS In the context of mandatory FA fortification, our data indicate that higher-than-recommended FA doses are unwarranted, with the exception of individuals at higher risk for NTDs. Ideally, prenatal supplements would contain 400 rather than 1000 µg FA, thereby enabling the consumption of optimal and safe FA doses.
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Affiliation(s)
- Marisa A Patti
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Joseph M Braun
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Tye E Arbuckle
- Population Studies Division, Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario, Canada (retired)
| | - Amanda J MacFarlane
- Nutrition Research Division, Health Canada, Ottawa, Ontario, Canada
- Department of Biology, Carleton University, Ottawa, Ontario, Canada
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20
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Sun H, Song K, Zhou Y, Ding JF, Tu B, Yang JJ, Sha JM, Zhao JY, Zhang Y, Tao H. MTHFR epigenetic derepression protects against diabetes cardiac fibrosis. Free Radic Biol Med 2022; 193:330-341. [PMID: 36279972 DOI: 10.1016/j.freeradbiomed.2022.10.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetes cardiac fibrosis is associated with altered DNA methylation of fibrogenic genes; however, the underlying mechanisms remain unclear. OBJECTIVES In this study, we investigate the critical role of DNA methylation aberration-associated suppression of MTHFR in diabetes cardiac fibrosis, and the protective effects of folate on diabetes cardiac fibrosis, using cultured cells, animal models, and clinical samples. METHODS AND RESULTS Herein, we report that DNA methylation repression of MTHFR, critically involved in diabetes cardiac fibrosis, mediates the significant protective effects of folate in a mouse model of diabetes cardiac fibrosis induced by STZ. Heart MTHFR expression was markedly suppressed in diabetes cardiac fibrosis patients and mice, accompanied by increased DNMT3A and MTHFR promoter methylation. Knockdown of DNMT3A demethylated MTHFR promoter, recovered the MTHFR loss, and alleviated the diabetes cardiac fibrosis pathology and cardiac fibroblasts pyroptosis. Mechanistically, DNMT3A epigenetically repressed MTHFR expression via methylation of the promoter. Interestingly, folate supplementation can rescue the effect of MTHFR loss in diabetes cardiac fibrosis, suggesting that inactivation of MTHFR through epigenetics is a critical mediator of diabetes cardiac fibrosis. CONCLUSIONS The current study identifies that MTHFR repression due to aberrant DNMT3A elevation and subsequent MTHFR promoter hypermethylation is likely an important epigenetic feature of diabetes cardiac fibrosis, and folate supplementation protects against diabetes cardiac fibrosis.
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Affiliation(s)
- He Sun
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Kai Song
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Yang Zhou
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Ji-Fei Ding
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China; Department of Cardiothoracic Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, 210028, Jiangsu Province, PR China
| | - Bin Tu
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Jing-Jing Yang
- Department of Clinical Pharmacy, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Ji-Ming Sha
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China
| | - Jian-Yuan Zhao
- Institute for Developmental and Regenerative Cardiovascular Medicine, MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, PR China.
| | - Ye Zhang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China.
| | - Hui Tao
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China; Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, 230601, PR China.
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21
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Haas CB, Su YR, Petersen P, Wang X, Bien SA, Lin Y, Albanes D, Weinstein SJ, Jenkins MA, Figueiredo JC, Newcomb PA, Casey G, Le Marchand L, Campbell PT, Moreno V, Potter JD, Sakoda LC, Slattery ML, Chan AT, Li L, Giles GG, Milne RL, Gruber SB, Rennert G, Woods MO, Gallinger SJ, Berndt S, Hayes RB, Huang WY, Wolk A, White E, Nan H, Nassir R, Lindor NM, Lewinger JP, Kim AE, Conti D, Gauderman WJ, Buchanan DD, Peters U, Hsu L. Interactions between folate intake and genetic predictors of gene expression levels associated with colorectal cancer risk. Sci Rep 2022; 12:18852. [PMID: 36344807 PMCID: PMC9640550 DOI: 10.1038/s41598-022-23451-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
Observational studies have shown higher folate consumption to be associated with lower risk of colorectal cancer (CRC). Understanding whether and how genetic risk factors interact with folate could further elucidate the underlying mechanism. Aggregating functionally relevant genetic variants in set-based variant testing has higher power to detect gene-environment (G × E) interactions and may provide information on the underlying biological pathway. We investigated interactions between folate consumption and predicted gene expression on colorectal cancer risk across the genome. We used variant weights from the PrediXcan models of colon tissue-specific gene expression as a priori variant information for a set-based G × E approach. We harmonized total folate intake (mcg/day) based on dietary intake and supplemental use across cohort and case-control studies and calculated sex and study specific quantiles. Analyses were performed using a mixed effects score tests for interactions between folate and genetically predicted expression of 4839 genes with available genetically predicted expression. We pooled results across 23 studies for a total of 13,498 cases with colorectal tumors and 13,918 controls of European ancestry. We used a false discovery rate of 0.2 to identify genes with suggestive evidence of an interaction. We found suggestive evidence of interaction with folate intake on CRC risk for genes including glutathione S-Transferase Alpha 1 (GSTA1; p = 4.3E-4), Tonsuko Like, DNA Repair Protein (TONSL; p = 4.3E-4), and Aspartylglucosaminidase (AGA: p = 4.5E-4). We identified three genes involved in preventing or repairing DNA damage that may interact with folate consumption to alter CRC risk. Glutathione is an antioxidant, preventing cellular damage and is a downstream metabolite of homocysteine and metabolized by GSTA1. TONSL is part of a complex that functions in the recovery of double strand breaks and AGA plays a role in lysosomal breakdown of glycoprotein.
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Affiliation(s)
- Cameron B Haas
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Yu-Ru Su
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paneen Petersen
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Xiaoliang Wang
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Stephanie A Bien
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yi Lin
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Demetrius Albanes
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stephanie J Weinstein
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark A Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jane C Figueiredo
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Preventive Medicine and USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Polly A Newcomb
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- School of Public Health, University of Washington, Seattle, WA, USA
| | - Graham Casey
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | | | - Peter T Campbell
- Behavioral and Epidemiology Research Group, American Cancer Society, Atlanta, GA, USA
| | - Victor Moreno
- Oncology Data Analytics Program, Catalan Institute of Oncology-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona, Spain
- ONCOBEL Program, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - John D Potter
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Center for Public Health Research, Massey University, Wellington, New Zealand
| | - Lori C Sakoda
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Martha L Slattery
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Li Li
- Department of Family Medicine, University of Virginia, Charlottesville, VA, USA
| | - Graham G Giles
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Stephen B Gruber
- Department of Preventive Medicine and USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gad Rennert
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Clalit National Cancer Control Center, Haifa, Israel
| | - Michael O Woods
- Memorial University of Newfoundland, Discipline of Genetics, St. John's, Canada
| | - Steven J Gallinger
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Sonja Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Richard B Hayes
- Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Wen-Yi Huang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alicja Wolk
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Emily White
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hongmei Nan
- IU Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis, IN, USA
| | - Rami Nassir
- Department of Pathology, School of Medicine, Umm Al-Qura'a University, Makkah, Saudi Arabia
| | - Noralane M Lindor
- Department of Health Science Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Juan P Lewinger
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andre E Kim
- Department of Preventive Medicine and USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David Conti
- Department of Preventive Medicine and USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - W James Gauderman
- Department of Preventive Medicine and USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel D Buchanan
- Colorectal Oncogenomics Group, Department of Clinical Pathology, The University of Melbourne, Parkville, VIC, 3010, Australia
- University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, VIC, 3010, Australia
| | - Ulrike Peters
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Li Hsu
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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22
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Kancherla V, Wagh K, Priyadarshini P, Pachón H, Oakley GP. A global update on the status of prevention of folic acid‐preventable spina bifida and anencephaly in year 2020: 30‐Year anniversary of gaining knowledge about folic acid's prevention potential for neural tube defects. Birth Defects Res 2022; 114:1392-1403. [DOI: 10.1002/bdr2.2115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
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
| | - Pretty Priyadarshini
- 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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23
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Antony AC, Vora RM, Karmarkar SJ. The silent tragic reality of Hidden Hunger, anaemia, and neural-tube defects (NTDs) in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 6:100071. [PMID: 37383344 PMCID: PMC10305893 DOI: 10.1016/j.lansea.2022.100071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Hidden Hunger arising from nutritional iron-, folate-, and vitamin-B12-deficiencies is exceedingly common in India and has profound negative impacts on anaemia, on pregnancy, and on embryonic-foetal neurodevelopment in utero, which predisposes to NTDs and psychological-psychiatric manifestations in childhood. Whereas younger-to-middle-aged Indians fail to perform at maximum potential, the elderly are at risk for calamitous neurologic events. However, these micronutrient-deficiencies are eminently correctable through food-fortification. Therefore, the Indian Government can no longer afford the luxury of inaction by either denying or downplaying the gravity of this problem. What is critically needed from India's leaders is an urgent, clear-eyed reappraisal and act of anagnorisis-(an often startling self-recognition and discovery of a profoundly serious error and tragic flaw)-in failing to confront this problem for decades. Only when closely followed by a metanoia-(a transformative change of heart that triggers remedial action)-can they help India avoid a catastrophic tryst with destiny.
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Affiliation(s)
- Aśok C. Antony
- Division of Hematology-Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ravindra M. Vora
- Department of Paediatric Surgery, Paediatric Surgery Centre & Post-Graduate Institute, Implementing The Lancet Commission on Global Surgery in India, Sangli, Maharashtra, India
| | - Santosh J. Karmarkar
- Department of Paediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
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Kumari R, Kumar S, Thakur VK, Singh K, Kumar U. MTHFR C677T and MTR A2756G Gene Polymorphism in Neural Tube Defect Patients and Its Association with Red Blood Cell Folate Level in Eastern Indian Population. J Indian Assoc Pediatr Surg 2022; 27:699-706. [PMID: 36714485 PMCID: PMC9878516 DOI: 10.4103/jiaps.jiaps_29_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/14/2022] [Accepted: 06/27/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Single-nucleotide polymorphism (SNP) is a single-nucleotide change in a deoxyribose nucleic acid (DNA) sequence that occurs in >1% of population. Methylene tetra hydro folate reductase (MTHFR) C677T (rs1801133) and methionine synthase enzyme (MTR) A2756G (rs1805087) are two such SNPs occurring in coding sequence of the respective genes, which are frequently seen with neural tube defects (NTDs). MTHFR and MTR genes are involved in folate metabolism. The folate level in the course of pregnancy is treated as vital in the etiopathogenesis of NTDs. This study aims to explore the association of SNPs of both genes and red blood cell (RBC) folate levels in the predisposition to NTDs. Aims and Objective The purpose of this investigation was to determine the relationship of NTDs with polymorphisms in MTHFR and MTR genotype and to estimate and compare the RBC folate levels in NTD patients and controls. Materials and Methods A total of 397 individuals were enrolled (163 patients and 234 controls) for this observational study. Genotyping to find out MTHFR C677T and MTR A2756G was performed by polymerase chain reaction-restriction fragment length polymorphism technique from DNA extracted from the subject's blood. RBC folate level was estimated by chemiluminescence immunoassay method with the same blood sample. Results The total RBC folate levels were significantly less among cases compared to controls (P = 0.020). A significant difference for RBC folate was observed between case and control groups of various genotypes of MTHFR C677T, except heterozygote CT (P = 0.459). Among MTR A2756G, genotypes with only homozygous AA have significant difference (P = 0.003) for RBC folate levels. Among different types of NTDs, there were no significant differences for RBC folate levels. Among MTHFR C677T, T allele possessed 1.9 times risk compared to C allele for the occurrence of NTDs. In MTR A2756G polymorphism, the odds of developing NTDs were 1.6 times in heterozygous AG compared to homozygous AA. Similarly, the risk for NTDs was three times higher in subjects with both heterozygous AG and CT genotypes compared to wild-type homozygous AA and CC genotypes. Conclusion The total RBC folate levels were significantly less among cases compared to controls, and the genotypes had no such effect in decrease in RBC folate levels. The presence of mutant allele in homozygous or heterozygous condition for both SNPs had increased risk associated with NTDs.
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Affiliation(s)
- Rekha Kumari
- Department of Biochemistry, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Santosh Kumar
- Department of Biochemistry, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Vinit Kumar Thakur
- Department of Pediatric Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Kalpana Singh
- Department of Reproductive Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Uday Kumar
- Department of Biochemistry, Netaji Subhas Medical College and Hospital, Dayalpur Daulatpur, Bihar, India
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Chen H, Zhang Y, Wang D, Chen X, Li M, Huang X, Jiang Y, Dou Y, Wang Y, Ma X, Sheng W, Jia B, Yan W, Huang G. Periconception Red Blood Cell Folate and Offspring Congenital Heart Disease : Nested Case-Control and Mendelian Randomization Studies. Ann Intern Med 2022; 175:1212-1220. [PMID: 35994746 DOI: 10.7326/m22-0741] [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: 11/22/2022] Open
Abstract
BACKGROUND Periconception folic acid supplementation has been suggested to protect against congenital heart disease (CHD), but the association between maternal red blood cell (RBC) folate, the gold-standard biomarker of folate exposure, and subsequent offspring CHD risk is lacking. OBJECTIVE To quantify the association between periconception maternal RBC folate and offspring CHD risk. DESIGN Prospective, nested, case-control study and 1-sample Mendelian randomization. (ClinicalTrials.gov: NCT02737644). SETTING 29 maternity institutions in 12 districts of Greater Shanghai, China. PARTICIPANTS All 197 mothers of offspring with CHD and 788 individually matched mothers of unaffected offspring from the SPCC (Shanghai Preconception Cohort). MEASUREMENTS Maternal RBC folate was measured before or at early pregnancy. Odds ratios [ORs] were estimated using conditional logistic regression after adjustment for covariates. Mendelian randomization was done using the methylenetetrahydrofolate reductase (MTHFR) C677T as the genetic instrument. RESULTS Case patients had lower median maternal RBC folate concentrations than control participants (714 nmol/L [interquartile range, 482 to 1008 nmol/L] vs. 788 nmol/L [557 to 1094 nmol/L]). Maternal RBC folate concentrations were inversely associated with offspring CHD (adjusted OR per 100 nmol/L, 0.93 [95% CI, 0.89 to 0.99]). The adjusted OR for mothers with periconception RBC folate of 906 nmol/L or more (vs. <906 nmol/L) was 0.61 (CI, 0.40 to 0.93). Mendelian randomization showed that each 100-nmol increase in maternal RBC folate concentrations was significantly associated with reduced offspring CHD risk (OR, 0.75 [CI, 0.61 to 0.92]). LIMITATION Potential confounding due to unmeasured covariates in the nested case-control study. CONCLUSION Higher maternal RBC folate is associated with reduced offspring CHD risk. For primary CHD prevention, higher target RBC folate levels than currently recommended for neural tube defect prevention may be needed and warrant further study. PRIMARY FUNDING SOURCE National Key Research and Development Program of China, National Natural Science Foundation of China, China Postdoctoral Science Foundation, and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences.
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Affiliation(s)
- Hongyan Chen
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Yi Zhang
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Dingmei Wang
- Pediatric Heart Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China (D.W., M.L.)
| | - Xiaotian Chen
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Mengru Li
- Pediatric Heart Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China (D.W., M.L.)
| | - Xiangyuan Huang
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China (X.H.)
| | - Yuan Jiang
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Yalan Dou
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Yin Wang
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (H.C., Y.Z., X.C., Y.J., Y.D., Y.W.)
| | - Xiaojing Ma
- Pediatric Heart Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (X.M., B.J.)
| | - Wei Sheng
- Shanghai Key Laboratory of Birth Defects, Shanghai, China (W.S.)
| | - Bing Jia
- Pediatric Heart Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, and Shanghai Key Laboratory of Birth Defects, Shanghai, China (X.M., B.J.)
| | - Weili Yan
- Department of Clinical Epidemiology and Clinical Trial Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, Shanghai Key Laboratory of Birth Defects, Shanghai, and Research Unit of Early Intervention of Genetically Related Childhood Cardiovascular Diseases (2018RU002), Chinese Academy of Medical Sciences, Shanghai, China (W.Y.)
| | - Guoying Huang
- Pediatric Heart Center, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, Shanghai Key Laboratory of Birth Defects, Shanghai, and Research Unit of Early Intervention of Genetically Related Childhood Cardiovascular Diseases (2018RU002), Chinese Academy of Medical Sciences, Shanghai, China (G.H.)
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Crider KS, Qi YP, Yeung LF, Mai CT, Head Zauche L, Wang A, Daniels K, Williams JL. Folic Acid and the Prevention of Birth Defects: 30 Years of Opportunity and Controversies. Annu Rev Nutr 2022; 42:423-452. [PMID: 35995050 PMCID: PMC9875360 DOI: 10.1146/annurev-nutr-043020-091647] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
For three decades, the US Public Health Service has recommended that all persons capable of becoming pregnant consume 400 μg/day of folic acid (FA) to prevent neural tube defects (NTDs). The neural tube forms by 28 days after conception. Fortification can be an effective NTD prevention strategy in populations with limited access to folic acid foods and/or supplements. This review describes the status of mandatory FA fortification among countries that fortify (n = 71) and the research describing the impact of those programs on NTD rates (up to 78% reduction), blood folate concentrations [red blood cell folate concentrations increased ∼1.47-fold (95% CI, 1.27, 1.70) following fortification], and other health outcomes. Across settings, high-quality studies such as those with randomized exposures (e.g., randomized controlled trials, Mendelian randomization studies) are needed to elucidate interactions of FA with vitamin B12 as well as expanded biomarker testing.
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Affiliation(s)
- Krista S Crider
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Yan Ping Qi
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Lorraine F Yeung
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Cara T Mai
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Lauren Head Zauche
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Arick Wang
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | | | - Jennifer L Williams
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
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Affiliation(s)
- Bermans J Iskandar
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
| | - Richard H Finnell
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
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Berhane A, Belachew T. Effect of Picture-based health education and counselling on knowledge and adherence to preconception Iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia: a randomized controlled trial. J Nutr Sci 2022; 11:e58. [PMID: 35912303 PMCID: PMC9305079 DOI: 10.1017/jns.2022.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022] Open
Abstract
The present study examined the effect of picture-based nutrition education on knowledge and adherence to pre-conception iron-folic acid supplement (IFAS) in Ethiopia, a country where there is a high burden of neural tube defects (NTDs) and anaemia. In eastern Ethiopia, a parallel randomised controlled trial design was employed among women planning to get pregnant. The interventional arm (n 122) received a preconception picture-based nutrition education and counselling along with an IFAS and the control arm (n 122) received only a preconception IFAS. The effects of the intervention between-group differences were assessed using a χ 2 and independent sample t-test. Bivariate and multivariable linear regression model was fitted to detect independent variables affecting the outcome. The outcome measures regarding the knowledge and adherence to the IFAS intake during the three months of the intervention period were deteremined. It was observed that large proportion of women in the intervention group (42⋅6 %) had an adherence to IFAS compared to the control group (3⋅3 %); (P < 0⋅0001). Based on bivariate and multivariable linear regression analyses, among NTDs affecting pregnancy, the history of spontaneous abortion and knowledge were independently associated with adherence to the IFAS (P < 0⋅05). Preconception nutrition education with regular follow-ups could be effective in improving knowledge and adherence to the IFAS intake. This intervention is very short, simple, cost-effective and has the potential for adaptation development to a large-scale implementation in the existing healthcare system in Ethiopia to prevent NTDs and adverse birth outcomes among women who plan to get pregnant. This clinical trial was registered on 6 April 2021 under the ClinicalTrials.gov with an identifier number PACTR202104543567379.
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Affiliation(s)
- Anteneh Berhane
- Department of Public Health, College of Medicine and Health Science, Dire Dawa University, Dire Dawa, Ethiopia
- Department of Nutrition and Dietetics, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Tefera Belachew
- Department of Nutrition and Dietetics, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
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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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Silveira JS, Ramires Júnior OV, Schmitz F, Ferreira FS, Rodrigues FC, Silva RC, Savio LEB, Wyse ATS. Folic acid supplementation during pregnancy alters behavior in male rat offspring: nitrative stress and neuroinflammatory implications. Mol Neurobiol 2022; 59:2150-2170. [PMID: 35044624 DOI: 10.1007/s12035-022-02724-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/30/2021] [Indexed: 12/27/2022]
Abstract
Pregnancy diet can impact offspring's neurodevelopment, metabolism, redox homeostasis, and inflammatory status. In pregnancy, folate demand is increased due to the requirement for one-carbon transfer reactions. The present study was proposed to investigate the effect of folic acid supplementation throughout pregnancy on a battery of behavior tests (olfactory preference, motor activity, exploratory capacity, habituation, memory, anxiety- and depression-like behavior). Redox homeostasis and neuroinflammatory status in cerebral cortex were also investigated. After pregnancy confirmation, the pregnant rats were randomly divided into two groups, according to the diet: group 1, (control) standard diet (2 mg/kg diet of folic acid) and group 2, supplemented diet with 4 mg/kg diet of folic acid. Throughout the gestational period, the pregnant rats received experimental diets. Results show that the supplemented diet with 4 mg/kg diet of folic acid throughout pregnancy impaired memory and motricity of the offspring when compared with control (standard diet). It was also observed an increase in anxiety- and depression-like behavior in this group. Nitrite levels increased in cerebral cortex of the offspring, when compared to control group. In contrast, iNOS expression and immunocontent were not altered. Moreover, we identify an increase in TNF-α, IL-1β, IL-6, IL-10, and MCP-1 gene expression in the cerebral cortex. In conclusion, our study showed that the supplemented diet with 4 mg/kg diet of folic acid throughout pregnancy may cause behavioral and biochemical changes in the male offspringGraphical abstract After pregnancy confirmation, the pregnant rats were randomly divided into two groups, according to the diet: group 1, (control) standard diet (2 mg/kg diet of folic acid) and group 2, supplemented diet with 4 mg/kg diet of folic acid. Throughout the gestational period, the pregnant rats received experimental diets. Results show that folic acid supplementation did not impair the mother-pup relationship. We showed that supplemented diet with 4 mg/kg diet of folic acid during pregnancy impairs memory and motricity of the offspring when compared with standard diet. It was also observed an increase in anxiety- and depression-like behavior in this group. Nitrative stress and neuroinflammation parameters were increased in the cerebral cortex of the offspring. ROS, reactive oxygen species.
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Affiliation(s)
- Josiane Silva Silveira
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Laboratório de Neuroproteção E Doenças Metabólicas (Wyse's Lab), Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal Do Rio Grande Do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, Rio Grande do Sul, 90035003, Brazil
| | - Osmar Vieira Ramires Júnior
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Laboratório de Neuroproteção E Doenças Metabólicas (Wyse's Lab), Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal Do Rio Grande Do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, Rio Grande do Sul, 90035003, Brazil
| | - Felipe Schmitz
- Laboratório de Neuroproteção E Doenças Metabólicas (Wyse's Lab), Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal Do Rio Grande Do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, Rio Grande do Sul, 90035003, Brazil
| | - Fernanda Silva Ferreira
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Laboratório de Neuroproteção E Doenças Metabólicas (Wyse's Lab), Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal Do Rio Grande Do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, Rio Grande do Sul, 90035003, Brazil
| | - Fabiana Cristina Rodrigues
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Bloco G. Av. Carlos Chagas Filho, 373. Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Robson Coutinho Silva
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Bloco G. Av. Carlos Chagas Filho, 373. Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Luiz Eduardo Baggio Savio
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Bloco G. Av. Carlos Chagas Filho, 373. Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Angela T S Wyse
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil. .,Laboratório de Neuroproteção E Doenças Metabólicas (Wyse's Lab), Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal Do Rio Grande Do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, Rio Grande do Sul, 90035003, Brazil.
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Li M, Zhang L, Gan L, Li Z. The Impact of Pregnancy Termination before 28 Weeks of Gestation on the Overall Prevalence of Birth Defects — Shaanxi Province, China, 2014–2020. China CDC Wkly 2022; 4:967-973. [DOI: 10.46234/ccdcw2022.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
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Managing folate deficiency implies filling the gap between laboratory and clinical assessment. Clin Nutr 2021; 41:374-383. [PMID: 34999332 DOI: 10.1016/j.clnu.2021.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 11/22/2022]
Abstract
The characterization of folate status in subjects at risk of deficiency and with altered vitamin homeostasis is crucial to endorse preventive intervention health policies, especially in developed countries. Several physiological changes (i.e. pregnancy), clinical situations and diseases have been associated to increased requirement, impaired intake and absorption of folate. However clinical practice guidelines (CPG) endorse folic acid supplementation generally discarding the use of its determination in serum to assess the risk of deficiency and/or its concentration at baseline. Poor confidence on the diagnostic accuracy of serum folate assays still persists in the current CPGs although recent standardization efforts have greatly improved inter-method variability and precision. In this review we critically appraise the methodological issues concerning laboratory folate determination and the evidence on the potential adverse effects of folic acid exposure. The final aim is to build a sound background to promote serum folate-based cost-effective health care policies by optimizing folic acid supplementation in subjects at risk of deficiency and with altered folate homeostasis. Our first result was to adjust in relation to current serum folate assays the thresholds reported by CPGs as index of folate status, defined on the association with metabolic and hematologic indicators. We identify a statistically significant difference between the estimated thresholds and accordingly show that the assessment of folate status actually changes in relation to the assay employed. The use of the method-dependent thresholds here reported may pragmatically endorse the stewardship of folic acid supplementation in clinical practice and increase the cost-effectiveness of health care policies.
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Luo H, Brown KH, Stewart CP, Beckett LA, Clermont A, Vosti SA, Guintang Assiene JM, Engle-Stone R. Review of Existing Models to Predict Reductions in Neural Tube Defects Due to Folic Acid Fortification and Model Results Using Data from Cameroon. Adv Nutr 2021; 12:2401-2414. [PMID: 34280291 PMCID: PMC8634386 DOI: 10.1093/advances/nmab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 12/02/2022] Open
Abstract
Several models have been developed to predict the effects of folic acid fortification programs on prevention of neural tube defects (NTDs), but each relies on different assumptions and data inputs. We identified and reviewed 7 models that predict the effects of folic acid intake or status on NTD risk. We applied 4 of these models [the original and a modified version of the Lives Saved Tool (LiST) and models developed by Arth et al. and Wald et al.] to predict the effect of folic acid fortification of wheat flour on reduction of NTDs using national survey data from Cameroon. The estimated percentage of NTDs averted due to fortified wheat flour (5.0 μg folic acid/g flour) varied by predictive model, with a 21-31% reduction in LiST to 83% in Arth's model, and 15% in Wald's model. As the simulated fortification level was increased from 1.0 to 7.0 μg folic acid/g flour, the pattern of change in estimated numbers of NTDs averted differed due to different model assumptions: the number of NTDs averted increased and then reached a plateau in the modified LiST model (as would be expected in real-world conditions), increased sharply in Arth's model, and increased continuously in Wald's model. This wide variation in predicted effects, and implausible results in some cases, undermines the models' utility for users of model outputs. Concurrent collection of dietary and biomarker data, including plasma and RBC folate concentrations, and NTD outcomes, is necessary to validate these models and monitor change in folic acid intake, folate-related biomarkers, and reduced NTD risk due to fortification. In the meantime, models based on erythrocyte folate concentration are recommended, based on biological plausibility and consistency with empirical evidence. Where erythrocyte folate data are unavailable, sensitivity analyses (using several models) could be conducted to examine the range of possible outcomes.
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Affiliation(s)
- Hanqi Luo
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Christine P Stewart
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
| | - Laurel A Beckett
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Adrienne Clermont
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | | | - Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA, USA
- Institute for Global Nutrition, University of California, Davis, CA, USA
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Bae S, Kamynina E, Guetterman HM, Farinola AF, Caudill MA, Berry RJ, Cassano PA, Stover PJ. Provision of folic acid for reducing arsenic toxicity in arsenic-exposed children and adults. Cochrane Database Syst Rev 2021; 10:CD012649. [PMID: 34661903 PMCID: PMC8522704 DOI: 10.1002/14651858.cd012649.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Arsenic is a common environmental toxin. Exposure to arsenic (particularly its inorganic form) through contaminated food and drinking water is an important public health burden worldwide, and is associated with increased risk of neurotoxicity, congenital anomalies, cancer, and adverse neurodevelopment in children. Arsenic is excreted following methylation reactions, which are mediated by folate. Provision of folate through folic acid supplements could facilitate arsenic methylation and excretion, thereby reducing arsenic toxicity. OBJECTIVES To assess the effects of provision of folic acid (through fortified foods or supplements), alone or in combination with other nutrients, in lessening the burden of arsenic-related health outcomes and reducing arsenic toxicity in arsenic-exposed populations. SEARCH METHODS In September 2020, we searched CENTRAL, MEDLINE, Embase, 10 other international databases, nine regional databases, and two trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the provision of folic acid (at any dose or duration), alone or in combination with other nutrients or nutrient supplements, with no intervention, placebo, unfortified food, or the same nutrient or supplements without folic acid, in arsenic-exposed populations of all ages and genders. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included two RCTs with 822 adults exposed to arsenic-contaminated drinking water in Bangladesh. The RCTs compared 400 µg/d (FA400) or 800 µg/d (FA800) folic acid supplements, given for 12 or 24 weeks, with placebo. One RCT, a multi-armed trial, compared FA400 plus creatine (3 g/d) to creatine alone. We judged both RCTs at low risk of bias in all domains. Due to differences in co-intervention, arsenic exposure, and participants' nutritional status, we could not conduct meta-analyses, and therefore, provide a narrative description of the data. Neither RCT reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Folic acid supplements alone versus placebo Blood arsenic. In arsenic-exposed individuals, FA likely reduces blood arsenic concentrations compared to placebo (2 studies, 536 participants; moderate-certainty evidence). For folate-deficient and folate-replete participants who received arsenic-removal water filters as a co-intervention, FA800 reduced blood arsenic levels more than placebo (percentage change (%change) in geometric mean (GM) FA800 -17.8%, 95% confidence intervals (CI) -25.0 to -9.8; placebo GM -9.5%, 95% CI -16.5 to -1.8; 1 study, 406 participants). In one study with 130 participants with low baseline plasma folate, FA400 reduced total blood arsenic (%change FA400 mean (M) -13.62%, standard error (SE) ± 2.87; placebo M -2.49%, SE ± 3.25), and monomethylarsonic acid (MMA) concentrations (%change FA400 M -22.24%, SE ± 2.86; placebo M -1.24%, SE ± 3.59) more than placebo. Inorganic arsenic (InAs) concentrations reduced in both groups (%change FA400 M -18.54%, SE ± 3.60; placebo M -10.61%, SE ± 3.38). There was little to no change in dimethylarsinic acid (DMA) in either group. Urinary arsenic. In arsenic-exposed individuals, FA likely reduces the proportion of total urinary arsenic excreted as InAs (%InAs) and MMA (%MMA) and increases the proportion excreted as DMA (%DMA) to a greater extent than placebo (2 studies, 546 participants; moderate-certainty evidence), suggesting that FA enhances arsenic methylation. In a mixed folate-deficient and folate-replete population (1 study, 352 participants) receiving arsenic-removal water filters as a co-intervention, groups receiving FA had a greater decrease in %InAs (within-person change FA400 M -0.09%, 95% CI -0.17 to -0.01; FA800 M -0.14%, 95% CI -0.21 to -0.06; placebo M 0.05%, 95% CI 0.00 to 0.10), a greater decrease in %MMA (within-person change FA400 M -1.80%, 95% CI -2.53 to -1.07; FA800 M -2.60%, 95% CI -3.35 to -1.85; placebo M 0.15%, 95% CI -0.37 to 0.68), and a greater increase in %DMA (within-person change FA400 M 3.25%, 95% CI 1.81 to 4.68; FA800 M 4.57%, 95% CI 3.20 to 5.95; placebo M -1.17%, 95% CI -2.18 to -0.17), compared to placebo. In 194 participants with low baseline plasma folate, FA reduced %InAs (%change FA400 M -0.31%, SE ± 0.04; placebo M -0.13%, SE ± 0.04) and %MMA (%change FA400 M -2.6%, SE ± 0.37; placebo M -0.71%, SE ± 0.43), and increased %DMA (%change FA400 M 5.9%, SE ± 0.82; placebo M 2.14%, SE ± 0.71), more than placebo. Plasma homocysteine: In arsenic-exposed individuals, FA400 likely reduces homocysteine concentrations to a greater extent than placebo (2 studies, 448 participants; moderate-certainty evidence), in the mixed folate-deficient and folate-replete population receiving arsenic-removal water filters as a co-intervention (%change in GM FA400 -23.4%, 95% CI -27.1 to -19.5; placebo -1.3%, 95% CI -5.3 to 3.1; 1 study, 254 participants), and participants with low baseline plasma folate (within-person change FA400 M -3.06 µmol/L, SE ± 3.51; placebo M -0.05 µmol/L, SE ± 4.31; 1 study, 194 participants). FA supplements plus other nutrient supplements versus nutrient supplements alone In arsenic-exposed individuals who received arsenic-removal water filters as a co-intervention, FA400 plus creatine may reduce blood arsenic concentrations more than creatine alone (%change in GM FA400 + creatine -14%, 95% CI -22.2 to -5.0; creatine -7.0%, 95% CI -14.8 to 1.5; 1 study, 204 participants; low-certainty evidence); may not change urinary arsenic methylation indices (FA400 + creatine: %InAs M 13.2%, SE ± 7.0; %MMA M 10.8, SE ± 4.1; %DMA M 76, SE ± 7.8; creatine: %InAs M 14.8, SE ± 5.5; %MMA M 12.8, SE ± 4.0; %DMA M 72.4, SE ±7.6; 1 study, 190 participants; low-certainty evidence); and may reduce homocysteine concentrations to a greater extent (%change in GM FA400 + creatinine -21%, 95% CI -25.2 to -16.4; creatine -4.3%, 95% CI -9.0 to 0.7; 1 study, 204 participants; low-certainty evidence) than creatine alone. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that FA supplements may benefit blood arsenic concentration, urinary arsenic methylation profiles, and plasma homocysteine concentration versus placebo. There is low-certainty evidence that FA supplements plus other nutrients may benefit blood arsenic and plasma homocysteine concentrations versus nutrients alone. No studies reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Given the limited number of RCTs, more studies conducted in diverse settings are needed to assess the effects of FA on arsenic-related health outcomes and arsenic toxicity in arsenic-exposed adults and children.
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Affiliation(s)
- Sajin Bae
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Elena Kamynina
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | | | - Adetutu F Farinola
- Faculty of Public Health, Department of Human Nutrition and Dietetics, University of Ibadan, Ibadan, Nigeria
| | - Marie A Caudill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Haggarty P. UK introduces folic acid fortification of flour to prevent neural tube defects. Lancet 2021; 398:1199-1201. [PMID: 34562392 DOI: 10.1016/s0140-6736(21)02134-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Paul Haggarty
- Rowett Institute of Nutrition and Health, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK.
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Martinez H, Pachón H, Kancherla V, Oakley GP. Food Fortification With Folic Acid for Prevention of Spina Bifida and Anencephaly: The Need for a Paradigm Shift in Evidence Evaluation for Policy-Making. Am J Epidemiol 2021; 190:1972-1976. [PMID: 33728445 PMCID: PMC8485149 DOI: 10.1093/aje/kwab061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 01/21/2023] Open
Abstract
Context-specific evidence evaluation is advocated in modern epidemiology to support public health policy decisions, avoiding excessive reliance on experimental study designs. Here we present the rationale for a paradigm shift in evaluation of the evidence derived from independent studies, as well as systematic reviews and meta-analyses of observational studies, applying Hill's criteria (including coherence, plausibility, temporality, consistency, magnitude of effect, and dose-response) to evaluate food fortification as an effective public health intervention against folic acid-preventable (FAP) spina bifida and anencephaly (SBA). A critical appraisal of evidence published between 1983 and 2020 supports the conclusion that food fortification with folic acid prevents FAP SBA. Policy-makers should be confident that with mandatory legislation, effective implementation, and periodic evaluation, food fortification assures that women of reproductive age will safely receive daily folic acid to significantly reduce the risk of FAP SBA. Current evidence should suffice to generate the political will to implement programs that will save thousands of lives each year in over 100 countries.
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Affiliation(s)
- Homero Martinez
- Correspondence to Dr. Homero Martinez, Global Technical Services Unit, Nutrition International, 180 Elgin Street, Suite 1000, Ottawa, ON K2P 2K3, Canada (e-mail: )
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Samson KLI, Loh SP, Lee SS, Sulistyoningrum DC, Khor GL, Shariff ZBM, Ismai IZ, Yelland LN, Leemaqz S, Makrides M, Hutcheon JA, Roche ML, Karakochuk CD, Green TJ. Weekly iron-folic acid supplements containing 2.8 mg folic acid are associated with a lower risk of neural tube defects than the current practice of 0.4 mg: a randomised controlled trial in Malaysia. BMJ Glob Health 2021; 5:bmjgh-2020-003897. [PMID: 33272946 PMCID: PMC7716666 DOI: 10.1136/bmjgh-2020-003897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/05/2020] [Accepted: 11/11/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction Weekly iron–folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is >20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk. Methods We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n=331) were randomised to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks. Results At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7; p<0.0001) more likely to achieve an RBC folate >748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group. Conclusion Weekly IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed. Trail registration number This trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12619000818134).
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Affiliation(s)
- Kaitlyn L I Samson
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada.,Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Su Peng Loh
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Siew Siew Lee
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Dian C Sulistyoningrum
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Geok Lin Khor
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | | | - Irmi Zarina Ismai
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Lisa N Yelland
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shalem Leemaqz
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jennifer A Hutcheon
- Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Crystal D Karakochuk
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada.,Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Timothy J Green
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia .,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Caceres A, Blount JP, Messing-Jünger M, Chatterjee S, Fieggen G, Salomao JF. The International Society for Pediatric Neurosurgery resolution on mandatory folic acid fortification of staple foods for prevention of spina bifida and anencephaly and associated disability and child mortality. Childs Nerv Syst 2021; 37:1809-1812. [PMID: 33942142 DOI: 10.1007/s00381-021-05191-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/25/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Adrian Caceres
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica.
| | - Jeffrey P Blount
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica
| | - Martina Messing-Jünger
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica
| | - Sandip Chatterjee
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica
| | - Graham Fieggen
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica
| | - Jose Francisco Salomao
- Department of Neurosurgery, Hospital Nacional de Ninos ¨Dr. Carlos Saenz Herrera¨, Paseo Colon y Calle 20 Sur, San Jose, 10103, Costa Rica
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Kozman D, Mattox S, Singh G. Serum Folate of Less than 7.0 ng/mL is a Marker of Malnutrition. Lab Med 2021; 51:507-511. [PMID: 31999344 DOI: 10.1093/labmed/lmz101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To identify clinical/laboratory factors associated with folate deficiency in tertiary care patients. METHODS We reviewed the medical records of 1019 patients with serum folate <7.0 ng/mL, 301 patients with serum folate of 15 ng/mL, and 300 patients with serum folate > 23 ng/mL. RESULTS Serum prealbumin levels were subnormal in 54.8% of patients with serum folate <7.0 ng/mL. Vitamin B12, hemoglobin, and serum albumin levels were significantly lower in the <7.0 ng/mL folate group. In 62.4% of patients with serum folate <7.0 ng/mL, 1 or more markers of malnutrition were present. The low-folate group had a significantly higher prevalence of gastrointestinal (GI) disorders, sepsis, and abnormal serum creatinine level. There were no significant differences in the 2 groups regarding diabetes; behavioral/neurological disorders, including drug and alcohol abuse; bariatric surgery; or a diagnosis of malnutrition. The average body mass index (BMI) for the <7.0 ng/mL and 15 ng/mL folate groups was significantly different (28.89 and 28.31, respectively), although the difference does not appear to be clinically meaningful. CONCLUSIONS The prevalence of folate deficiency depends on what is considered a normal serum folate level. Approximately 10% of tertiary-care patients have levels <7.0 ng/mL and exhibit other markers of malnutrition. It is recommended that patients with GI disorders, chronic kidney disease, and sepsis be routinely tested for serum folate levels, before administration of vitamin supplements. Patients with serum folate levels <7.0 ng/mL should be evaluated for malnutrition, despite BMI > 25. Folate supplementation should be administered only after excluding coexisting vitamin B12 deficiency.
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Affiliation(s)
- Diana Kozman
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
| | - Samantha Mattox
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
| | - Gurmukh Singh
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, GA
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Finkelstein JL, Fothergill A, Johnson CB, Guetterman HM, Bose B, Jabbar S, Zhang M, Pfeiffer CM, Qi YP, Rose CE, Williams JL, Bonam W, Crider KS. Anemia and Vitamin B-12 and Folate Status in Women of Reproductive Age in Southern India: Estimating Population-Based Risk of Neural Tube Defects. Curr Dev Nutr 2021; 5:nzab069. [PMID: 34027296 PMCID: PMC8128722 DOI: 10.1093/cdn/nzab069] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Women of reproductive age (WRA) are a high-risk population for anemia and micronutrient deficiencies. However, there are few representative population-level data from India, which could help inform evidence-based recommendations and policy. OBJECTIVE To conduct a population-based biomarker survey of anemia and vitamin B-12 and folate status in WRA as part of a periconceptional surveillance program in southern India. METHODS Participants were WRA (15-40 y) who were not pregnant or lactating. Whole blood (n = 979) was analyzed for hemoglobin via a Coulter counter (Coulter HMX). Plasma, serum, and RBCs were processed and stored at -80°C or less until batch analysis. Vitamin B-12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were evaluated via microbiological assay. Anemia and severe anemia were defined as hemoglobin <12.0 g/dL and <8.0 g/dL, respectively. Vitamin B-12 deficiency and insufficiency were defined as total vitamin B-12 <148 pmol/L and <221 pmol/L, respectively. Folate deficiency and insufficiency were defined as RBC folate <305 nmol/L and <748 nmol/L. A previously developed Bayesian model was used to predict neural tube defect (NTD) prevalence per 10,000 births. RESULTS A total of 41.5% of WRA had anemia and 3.0% had severe anemia. A total of 48.3% of WRA had vitamin B-12 deficiency and 74.3% had vitamin B-12 insufficiency. The prevalence of RBC folate deficiency was 7.6%, and 79.3% of WRA had RBC folate <748 nmol/L, the threshold for optimal NTD prevention. Predicted NTD prevalence per 10,000 births based on RBC folate concentrations was 20.6 (95% uncertainty interval: 16.5-25.5). CONCLUSIONS The substantial burden of anemia, vitamin B-12 deficiency, and RBC folate insufficiency in WRA in this setting suggests an opportunity for anemia and birth defects prevention. Findings will directly inform the development of a randomized trial for anemia and birth defects prevention in southern India.This study was registered at clinicaltrials.gov as NCT04048330.
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Affiliation(s)
- Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- St John's Research Institute, Bangalore, Karnataka, India
| | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, 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, GA, USA
| | - Mindy Zhang
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Wang A, Rose CE, Qi YP, Williams JL, Pfeiffer CM, Crider KS. Impact of Voluntary Folic Acid Fortification of Corn Masa Flour on RBC Folate Concentrations in the U.S. (NHANES 2011-2018). Nutrients 2021; 13:1325. [PMID: 33923768 PMCID: PMC8073626 DOI: 10.3390/nu13041325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Surveillance data have highlighted continued disparities in neural tube defects (NTDs) by race-ethnicity in the United States. Starting in 2016, the Food and Drug Administration (FDA) authorized voluntary folic acid fortification of corn masa flour to reduce the risk of neural tube defects (NTDs) among infants of Hispanic women of reproductive age. To assess the impact of voluntary corn masa fortification, cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011-2018 for Hispanic women of reproductive age with available red blood cell (RBC) folate concentrations were analyzed, with additional analyses conducted among Hispanic women whose sole source of folic acid intake was fortified foods (enriched cereal grain products (ECGP) only), excluding ready-to-eat cereals and supplements. RBC folate concentration (adjusted geometric mean) among Hispanic women of reproductive age did not differ between 2011-2016 and 2017-2018, though RBC folate concentration increased significantly among lesser acculturated Hispanic women consuming ECGP only. Concentrations of RBC folate for those born outside the U.S and residing in the U.S <15 years increased from 894 nmol/L (95% CI: 844-946) in 2011-2016 to 1018 nmol/L (95% CI: 982-1162; p < 0.001) in 2017-2018. Primarily Spanish-speaking Hispanic women of reproductive age who only consumed ECGP saw an increase from 941 nmol/L (95% CI: 895-990) in 2011-2016 to 1034 nmol/L (95% CI: 966-1107; p = 0.03) in 2017-2018. By subpopulation, we observed no significant changes in the proportion at risk of NTDs (<748 nmol/L) and no changes in the model-based estimated NTD rates following voluntary corn masa fortification. This analysis suggests that there is a remaining risk among Hispanics for folate sensitive NTDs, though continued monitoring of folate status in future NHANES data cycles will help inform the long-term efficacy of voluntary fortification of corn masa flour.
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Affiliation(s)
- Arick Wang
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA
| | - Charles E. Rose
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Yan Ping Qi
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Jennifer L. Williams
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Christine M. Pfeiffer
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, GA 30341, USA;
| | - Krista S. Crider
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
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Roche ML, Samson KLI, Green TJ, Karakochuk CD, Martinez H. Perspective: Weekly Iron and Folic Acid Supplementation (WIFAS): A Critical Review and Rationale for Inclusion in the Essential Medicines List to Accelerate Anemia and Neural Tube Defects Reduction. Adv Nutr 2021; 12:334-342. [PMID: 33439978 PMCID: PMC8009743 DOI: 10.1093/advances/nmaa169] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 11/12/2022] Open
Abstract
Weekly iron and folic acid supplementation (WIFAS) is among the 8 key effective actions for improving adolescent nutrition included by the WHO in the 2018 guidelines. However, at present WIFAS in the WHO-recommended formulation is not included in the Model Essential Medicines List (MEML), limiting the potential for countries to import, produce, and prioritize this formulation as part of their national supply management and procurement plans for medicines. The WHO WIFAS guideline presents evidence that the formulation reduces anemia, but not that folic acid reduces neural tube defects (NTDs), because sufficient evidence was unavailable at the time of the last review. Recently, a 3-arm, parallel-group, randomized, double-blind, placebo-controlled folic acid efficacy trial on WIFAS was conducted to address this evidence gap. The study population included 331 women (18-45 y old), randomly assigned to 3 treatment groups, including a supplement with 60 mg Fe as ferrous fumarate and either 0 mg, 0.4 mg, or 2.8 mg of folic acid, to be consumed once weekly for 16 wk, followed by a 4-wk washout period. In this article we critically review how the outcomes of this folic acid efficacy trial, and how the evidence generated, could potentially be used to inform WHO WIFAS guidelines for the potential inclusion of this formulation on the MEML, and how this, in turn, may affect product availability. If the new evidence on weekly folic acid is assessed as adequately reducing the risk of NTDs, a guideline revision could be warranted and WIFAS could be presented to the MEML for the dual benefits of anemia reduction and NTD prevention. This inclusion could enable acceleration of implementing policies and programs to contribute to global anemia and NTD reduction efforts.
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Affiliation(s)
- Marion L Roche
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Kaitlyn L I Samson
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Tim J Green
- Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Homero Martinez
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
- The Children's Hospital of Mexico, Mexico City, Mexico
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Kucuk IG, Eser U, Cevik M, Ongel K. Awareness of Neural Tube Defects in Family Physicians. JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2021. [DOI: 10.29333/jcei/9707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Yacob A, Carr CJ, Foote J, Scullen T, Werner C, Mathkour M, Bui CJ, Dumont AS. The Global Burden of Neural Tube Defects and Disparities in Neurosurgical Care. World Neurosurg 2021; 149:e803-e820. [PMID: 33540098 DOI: 10.1016/j.wneu.2021.01.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite the success of folic acid fortification programs, neural tube defects (NTDs) such as spina bifida, encephalocele, and anencephaly remain among the most substantial causes of childhood morbidity and mortality worldwide. Although these are complicated conditions that require an interdisciplinary approach to care, definitive treatment of survivable NTDs is often neurosurgical. METHODS Using Global Burden of Disease data, we examined the global burden of NTDs as related to a nation's wealth, health care quality, and access to neurosurgical care. We abstracted data for death by cause, years lived with disability (YLD), gross domestic product (GDP), United Nations geoscheme, Food Fortification Initiative participation, and Healthcare Access and Quality Index. We compared means using 1-way analysis of variance and proportions using Fisher exact tests, with statistical significance as α = 0.05. RESULTS Seventeen of 20 (85%) nations with the most deaths caused by NTDs (P < 0.0001) and 15/20 (75%) nations with the highest YLD (P < 0.0001) were in the lowest GDP quartile. Deaths and YLD were negatively correlated with increasing GDP and Healthcare Access and Quality Index (P < 0.0001). The nations with the highest disease burdens also had the fewest neurosurgeons per capita. CONCLUSIONS Despite the success of folic acid fortification programs, greater global public health efforts should be placed on improving access to neurosurgical care in low and middle-income nations through sustainable initiatives such as surgeon exchange programs and the establishment of neurosurgery residency training programs.
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Affiliation(s)
- Alex Yacob
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Christopher J Carr
- Tulane University-Ochsner Clinic Foundation Program, Department of Neurosurgery, Tulane University Medical Center, New Orleans, Louisiana, USA.
| | - Jake Foote
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tyler Scullen
- Tulane University-Ochsner Clinic Foundation Program, Department of Neurosurgery, Tulane University Medical Center, New Orleans, Louisiana, USA
| | - Cassidy Werner
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mansour Mathkour
- Tulane University-Ochsner Clinic Foundation Program, Department of Neurosurgery, Tulane University Medical Center, New Orleans, Louisiana, USA
| | - Cuong J Bui
- Department of Neurosurgery, Ochsner Health System, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane University Medical Center, New Orleans, Louisiana, USA
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Kancherla V, Chadha M, Rowe L, Thompson A, Jain S, Walters D, Martinez H. Reducing the Burden of Anemia and Neural Tube Defects in Low- and Middle-Income Countries: An Analysis to Identify Countries with an Immediate Potential to Benefit from Large-Scale Mandatory Fortification of Wheat Flour and Rice. Nutrients 2021; 13:nu13010244. [PMID: 33467050 PMCID: PMC7830675 DOI: 10.3390/nu13010244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 11/20/2022] Open
Abstract
Using a predetermined set of criteria, including burden of anemia and neural tube defects (NTDs) and an enabling environment for large-scale fortification, this paper identifies 18 low- and middle-income countries with the highest and most immediate potential for large-scale wheat flour and/or rice fortification in terms of health impact and economic benefit. Adequately fortified staples, delivered at estimated coverage rates in these countries, have the potential to avert 72.1 million cases of anemia among non-pregnant women of reproductive age; 51,636 live births associated with folic acid-preventable NTDs (i.e., spina bifida, anencephaly); and 46,378 child deaths associated with NTDs annually. This equates to a 34% reduction in the number of cases of anemia and 38% reduction in the number of NTDs in the 18 countries identified. An estimated 5.4 million disability-adjusted life years (DALYs) could be averted annually, and an economic value of 31.8 billion United States dollars (USD) generated from 1 year of fortification at scale in women and children beneficiaries. This paper presents a missed opportunity and warrants an urgent call to action for the countries identified to potentially avert a significant number of preventable birth defects, anemia, and under-five child mortality and move closer to achieving health equity by 2030 for the Sustainable Development Goals.
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA;
| | - Manpreet Chadha
- Nutrition International, Ottawa, ON K2P 2K3, Canada; (A.T.); (S.J.); (D.W.); (H.M.)
- Correspondence: ; Tel.: +1-613-859-1452
| | - Laura Rowe
- Food Fortification Initiative, Atlanta, GA 30322, USA;
| | - Andrew Thompson
- Nutrition International, Ottawa, ON K2P 2K3, Canada; (A.T.); (S.J.); (D.W.); (H.M.)
| | - Sakshi Jain
- Nutrition International, Ottawa, ON K2P 2K3, Canada; (A.T.); (S.J.); (D.W.); (H.M.)
| | - Dylan Walters
- Nutrition International, Ottawa, ON K2P 2K3, Canada; (A.T.); (S.J.); (D.W.); (H.M.)
| | - Homero Martinez
- Nutrition International, Ottawa, ON K2P 2K3, Canada; (A.T.); (S.J.); (D.W.); (H.M.)
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Pharmacokinetics of Sodium and Calcium Salts of (6S)-5-Methyltetrahydrofolic Acid Compared to Folic Acid and Indirect Comparison of the Two Salts. Nutrients 2020; 12:nu12123623. [PMID: 33255787 PMCID: PMC7760477 DOI: 10.3390/nu12123623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023] Open
Abstract
(6S)-5-Methyltetrahydrofolic acid ((6S)-5-Methyl-THF) salts and folic acid may differ in their abilities to raise plasma (6S)-5-Methyl-THF levels. We compared the area under the curve (AUC), Cmax, and Tmax of plasma (6S)-5-Methyl-THF after intakes of (6S)-5-Methyl-THF-Na salt (Arcofolin®) and folic acid. Moreover, we compared the AUCs after intakes of (6S)-5-Methyl-THF-Na and the calcium salt, (6S)-5-Methyl-THF-Ca, that were tested against folic acid in two independent studies. The study was randomized, double blind, and cross over. Twenty-four adults (12 men and 12 women) received a single oral dose of 436 µg (6S)-5-Methyl-THF-Na and an equimolar dose of folic acid (400 µg) on two kinetic days with two weeks washout period in between. The plasma concentrations of (6S)-5-Methyl-THF were measured at 9 time points between 0 and 8 h. We found that the AUC0–8 h of plasma (6S)-5-Methyl-THF (mean (SD) = 126.0 (33.6) vs. 56.0 (25.3) nmol/L*h) and Cmax (36.8 (10.8) vs. 11.1 (4.1) nmol/L) were higher after administration of (6S)-5-Methyl-THF-Na than after the administration of folic acid (p < 0.001 for both). These differences were present in men and women. Only administration of folic acid resulted in a transient increase in plasma unmetabolized folic acid (2.5 (2.0) nmol/L after 0.5 h and 4.7 (2.9) nmol/L after 1 h). Intake of (6S)-5-Methyl-THF-Na was safe. The ratios of the AUC0–8 h for (6S)-5-Methyl-THF-Na and (6S)-5-Methyl-THF-Ca to the corresponding folic acid reference group and the delta of these AUC0–8 h did not differ between the studies. In conclusion, a single oral dose of (6S)-5-Methyl-THF-Na caused higher AUC0–8 h and Cmax of plasma (6S)-5-Methyl-THF compared to folic acid. The Na- and Ca- salts of (6S)-5-Methyl-THF are not likely to differ in their pharmacokinetics. Further studies may investigate whether supplementation of the compounds for a longer time will lead to differences in circulating or intracellular/tissue folate concentrations.
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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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Stover PJ, Garza C, Durga J, Field MS. Emerging Concepts in Nutrient Needs. J Nutr 2020; 150:2593S-2601S. [PMID: 33000157 PMCID: PMC7527270 DOI: 10.1093/jn/nxaa117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/12/2020] [Accepted: 04/02/2020] [Indexed: 12/14/2022] Open
Abstract
Dietary reference intakes (DRIs) are quantitative, nutrient intake-based standards used for assessing the diets and specific nutrient intakes of healthy individuals and populations and for informing national nutrition policy and nutrition programs. Because nutrition needs vary by age, sex, and physiological state, DRIs are often specified for healthy subgroups within a population. Diet is known to be the leading modifiable risk factor for chronic disease, and the prevalence of chronic disease is growing in all populations globally and across all subgroups, but especially in older adults. It is known that nutrient needs can change in some chronic disease and other clinical states. Disease states and/or disease treatment can cause whole-body or tissue-specific nutrient depletion or excess, resulting in the need for altered nutrient intakes. In other cases, disease-related biochemical dysfunction can result in a requirement for a nonessential nutrient, rendering it as conditionally essential, or result in toxicity for a food component at levels usually tolerated by healthy people, as seen in inborn errors of metabolism. Here we summarize examples from a growing body of literature of disease-altering nutrient requirements, supporting the need to give more consideration to special nutrient requirements in disease states.
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Affiliation(s)
| | - Cutberto Garza
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Jane Durga
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Azaryah H, Verdejo-Román J, Martin-Pérez C, García-Santos JA, Martínez-Zaldívar C, Torres-Espínola FJ, Campos D, Koletzko B, Pérez-García M, Catena A, Campoy C. Effects of Maternal Fish Oil and/or 5-Methyl-Tetrahydrofolate Supplementation during Pregnancy on Offspring Brain Resting-State at 10 Years Old: A Follow-Up Study from the NUHEAL Randomized Controlled Trial. Nutrients 2020; 12:E2701. [PMID: 32899673 PMCID: PMC7551257 DOI: 10.3390/nu12092701] [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] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 01/10/2023] Open
Abstract
Recent studies have shown that maternal supplementation with folate and long-chain polyunsaturated fatty acids (LC-PUFAs) during pregnancy may affect children's brain development. We aimed at examining the potential long-term effect of maternal supplementation with fish oil (FO) and/or 5-methyl-tetrahydrofolate (5-MTHF) on the brain functionality of offspring at the age of 9.5-10 years. The current study was conducted as a follow-up of the Spanish participants belonging to the Nutraceuticals for a Healthier Life (NUHEAL) project; 57 children were divided into groups according to mother's supplementation and assessed through functional magnetic resonance imaging (fMRI) scanning and neurodevelopment testing. Independent component analysis and double regression methods were implemented to investigate plausible associations. Children born to mothers supplemented with FO (FO and FO + 5-MTHF groups, n = 33) showed weaker functional connectivity in the default mode (DM) (angular gyrus), the sensorimotor (SM) (motor and somatosensory cortices) and the fronto-parietal (FP) (angular gyrus) networks compared to the No-FO group (placebo and 5-MTHF groups, n = 24) (PFWE < 0.05). Furthermore, no differences were found regarding the neuropsychological tests, except for a trend of better results in an object recall (memory) test. Considering the No-FO group, the aforementioned networks were associated negatively with attention and speed-processing functions. Mother's FO supplementation during pregnancy seems to be able to shape resting-state network functioning in their children at school age and appears to produce long-term effects on children´s cognitive processing.
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Affiliation(s)
- Hatim Azaryah
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
| | - Juan Verdejo-Román
- Mind, Brain and Behaviour International Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain; (J.V.-R.); (C.M.-P.); (M.P.-G.); (A.C.)
| | - Cristina Martin-Pérez
- Mind, Brain and Behaviour International Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain; (J.V.-R.); (C.M.-P.); (M.P.-G.); (A.C.)
| | - José Antonio García-Santos
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (Ibs-GRANADA), Health Sciences Technological Park, 18012 Granada, Spain
| | - Cristina Martínez-Zaldívar
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
| | - Francisco J. Torres-Espínola
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
| | - Daniel Campos
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
| | - Berthold Koletzko
- Ludwig-Maximiliams-Universität München, Dr. von Hauner Children’s Hospital, University of Munich Hospitals, 80337 Munich, Germany;
| | - Miguel Pérez-García
- Mind, Brain and Behaviour International Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain; (J.V.-R.); (C.M.-P.); (M.P.-G.); (A.C.)
| | - Andrés Catena
- Mind, Brain and Behaviour International Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain; (J.V.-R.); (C.M.-P.); (M.P.-G.); (A.C.)
| | - Cristina Campoy
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain; (H.A.); (J.A.G.-S.); (C.M.-Z.); (F.J.T.-E.); (D.C.)
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (Ibs-GRANADA), Health Sciences Technological Park, 18012 Granada, Spain
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada’s Node, Institute of Health Carlos III, 28029 Madrid, Spain
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