Early initiation of B-vitamin supplementation may reduce symptoms and explain intrafamilial variability: Insights from two sibling pairs from the TANGO2 natural history study

TANGO2-deficiency disorder (TDD) is an autosomal recessive condition arising from pathogenic biallelic variants in the TANGO2 gene. TDD is characterized by symptoms typically beginning in late infancy including delayed developmental milestones, cognitive impairment, dysarthria, expressive language deficits, and gait abnormalities. There is wide phenotypic variability where some are severely affected while others have mild symptoms. This variability has been documented even among sibling pairs who share the same genotype, but reasons for this variability have not been well understood. Emerging data suggest a potential link between B-complex or multivitamin supplementation and decreased metabolic crises in TDD. In this report, we describe two sibling pairs from unreladiagnosed with TDD with marked differences in symptoms. In both families, the older siblings suffered multiple metabolic crises and are clinically more affected than their younger siblings who have very mild to no symptoms; they are the least impaired among 70 other patients in our ongoing international natural history study. Unlike their older siblings, the two younger siblings started taking B-complex vitamins early between 9 and 16 months. This report delineates the mildest presentation of TDD in two families. These data may support a role for early diagnosis and initiation of vitamin supplementation to not only prevent metabolic crises but also improve neurologic outcomes in this life-threatening disorder.

Multivitamin Supplementation Improves Memory in Older Adults: A Randomized Clinical Trial

BACKGROUND

Maintenance of cognitive abilities is of critical importance to older adults, yet few effective strategies to slow cognitive decline currently exist. Multivitamin supplementation is used to promote general health; it is unclear whether it favorably affects cognition in older age.

OBJECTIVES

To examine the effect of daily multivitamin/multimineral supplementation on memory in older adults.

METHODS

The COcoa Supplement and Multivitamin Outcomes Study Web (COSMOS-Web) ancillary study (NCT04582617) included 3562 older adults. Participants were randomly assigned to a daily multivitamin supplement (Centrum Silver) or placebo and evaluated annually with an Internet-based battery of neuropsychological tests for 3 y. The prespecified primary outcome measure was change in episodic memory, operationally defined as immediate recall performance on the ModRey test, after 1 y of intervention. Secondary outcome measures included changes in episodic memory over 3 y of follow-up and changes in performance on neuropsychological tasks of novel object recognition and executive function over 3 y.

RESULTS

Compared with placebo, participants randomly assigned to multivitamin supplementation had significantly better ModRey immediate recall at 1 y, the primary endpoint (t(5889) = 2.25, P = 0.025), as well as across the 3 y of follow-up on average (t(5889) = 2.54, P = 0.011). Multivitamin supplementation had no significant effects on secondary outcomes. Based on cross-sectional analysis of the association between age and performance on the ModRey, we estimated that the effect of the multivitamin intervention improved memory performance above placebo by the equivalent of 3.1 y of age-related memory change.

CONCLUSIONS

Daily multivitamin supplementation, compared with placebo, improves memory in older adults. Multivitamin supplementation holds promise as a safe and accessible approach to maintaining cognitive health in older age. This trial was registered at clinicaltrials.gov as NCT04582617.

The Extent of the Use of Multivitamins and Multimineral Supplements Without Clinically Measurable Benefits Among Adults in Ha'il, Saudi Arabia: A Cross-Sectional Study

Introduction Multivitamins and multiminerals (MVMM) are nutritional supplements that contain a wide range of important nutrients. The use of vitamins and minerals has been showing a tremendous increase over the past few years due to the high demand for supplements to replenish nutritional deficiencies. Purpose This study aimed to assess MVMM usage, the reasons why people chose to use MVMM, and the factors related to this usage. Methodology A cross-sectional study was conducted on adults living in Ha'il, Saudi Arabia. Data were collected between October 31 and December 14, 2022, a self-administered online questionnaire was used, and data were analyzed using SPSS version 25.0 (IBM Corp, Armonk, NY). Results A total of 310 participants enrolled in the study, of which 240 (77.42%) were females and 70 (22.58%) were males. The extent of the use of MVMM supplements without clinically measurable benefits was more than half of the present study participants (58.71%). There was a significant difference between MVMM use and gender or employment status. MVMM usage on a regular basis was found to be associated with satisfaction with the outcomes. The majority of participants used MVMM to promote health. Calcium and vitamin D were found to be the most common types of dietary supplements used. Conclusion The use of MVMM supplements without clinically measurable benefits was more prevalent among females. It is important to promote public health awareness programs about the benefits and risks of overdose.

Vitamin D Supply of Multivitamins Commercialized Online by Amazon in Western and Southern Europe: A Labeling Analysis

Multivitamins are commonly used by the general population, often without medical prescription. The purpose of this report is to inform on the daily vitamin D supply provided by multivitamins containing vitamin D that are commercialized online by Amazon in Western and Southern Europe. We surveyed multivitamins aimed at adults using the following marketplaces: amazon.es®, amazon.de®, amazon.it®, and amazon.fr®. We identified 199 vitamin D3-containing multivitamins sold by Amazon marketplaces: 77 from amazon.es®, 73 from amazon.de®, 33 from amazon.it®, and 16 from amazon.fr®. No multivitamin contained vitamin D2. The daily vitamin D3 supply ranged from 16 to 2000 IU: it was less than 400 IU daily in 108 (54%), 400−800 IU daily in 53 (27%), and more than 800 IU daily in the remaining 38 (19%) products. The vitamin D3 supply of products sold by amazon.it® was on average higher (p < 0.05) than that of products sold by amazon.de®, amazon.fr®, and amazon.es®. In conclusion, the vitamin D supply of multivitamins sold by Amazon may be insufficient, marginally sufficient, or adequate for subjects at high risk of hypovitaminosis D such as subjects 65 years or more of age, pregnant (or lactating) women, or patients on drug treatment or with an underlying disease, where a vitamin D supplementation is advocated.

Erratum: Iodine content of frequently used prenatal and adult multivitamins in Switzerland

[This corrects the article DOI: 10.3389/fendo.2022.1041232.].

Allergic contact dermatitis from vitamins: A systematic review

Background and Aims

Vitamins are bioactive compounds naturally found in many different types of food and required by the human body for many biological functions and enzymatic activities. Due to their antioxidant properties, certain vitamin derivatives have been synthesized for inclusion in many cosmetics, thus leading to an increasing incidence of allergic contact dermatitis (ACD) cases. Therefore, the present review may be helpful to provide an insight into the sensitizing role of at least certain vitamins and may also offer possible patch test alternatives for definitive diagnosis.

Methods

This study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Literature search regarding ACD cases to vitamins was performed using the Medline, PubMed, Scopus, EMBASE, and Google Scholar databases from January 1940 up to June 2021.

Results

A total of 4494 articles matched the keywords used for the researched. Records removed before screening included 15 duplicate articles and 3429 not eligible articles (e.g., not written in English, studies on animals, not relevant to the topic). A total of 1050 articles underwent the screening phase and 258 were therefore excluded as they were not primary studies. Subsequentially, 792 articles were considered eligible for the review and 688 of them were finally excluded as they did not report the outcome of interest. Therefore, 104 articles were definitely included in the present review.

Conclusion

ACD to vitamins is still probably an underestimated issue in cosmetology, as many vitamins are considered "natural" and therefore "safe" ingredients. On the contrary, according to current literature, almost all vitamins contained in topical products are able to induce allergic reactions, with the exception of vitamin B2 and vitamin B9. Patch tests are not standardized, thus leading to difficulties in diagnosis.

Guideline No. 427: Folic Acid and Multivitamin Supplementation for Prevention of Folic Acid-Sensitive Congenital Anomalies

OBJECTIVE

To provide updated guidance on pre-conception folic acid and multivitamin supplementation for primary and secondary (recurrence) prevention of neural tube defects and other folate-sensitive congenital anomalies.

TARGET POPULATION

Women aged 12-45 years who could become pregnant should be aware of the risk of serious birth defects without adequate pre-conception and first-trimester folic acid supplementation.

OPTIONS

Optimizing folic acid supplementation is complex and depends on factors including dosage; type of supplement; bioavailability of folate from food, timing of initiating supplementation; and metabolic and genetic factors. For all women who could become pregnant, a low daily dosage of folic acid is recommended before conception and throughout pregnancy and breastfeeding. High-dosage folic acid supplementation is recommended only for women who can become pregnant and have had a previous pregnancy affected by a neural tube defect or other folate-sensitive congenital anomaly. Directed personalized approaches could be considered and adopted for women who can become pregnant and have complex risks (genetic, medical, or surgical risk factors), using new knowledge of co-factor metabolism and synergy, as well as red blood cell or serum folate testing. Such approaches would require changes to current provincial health care maternal serum folate screening/testing.

OUTCOMES

New approaches to oral folic acid supplementation, including triage tools, need to be considered to optimize the benefits of decreasing risk of neural tube defects and folate-sensitive congenital anomalies.

BENEFITS, HARMS, AND COSTS

Oral folic acid supplementation, or dietary folate intake combined with a multivitamin/micronutrient supplement, is associated with lower rates of neural tube defects, other folate-sensitive birth defects, and obstetrical complications. The costs are those attributable to daily vitamin supplementation and a healthy, folate-rich diet.

EVIDENCE

A literature search was designed and carried in PubMed and the Cochrane Library databases from 1990 to 2021 using following MeSH terms and keywords (and variants): folic acid supplementation; folate food fortification; primary neural tube defect prevention; prevention of recurrence of neural tube defects; folate-sensitive birth defects; folate supplementation benefit; folate supplementation risk; folate pregnant woman physiology; pregnant woman RBC folate level; pregnant woman serum folate levels; folate and epilepsy; folate and obesity. This guideline was based upon expert guidelines or opinions, systematic reviews, randomized controlled clinical trials, and observational case-control studies and case series retrieved, published in English from 1990 to 2021.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternity health care providers (physicians, midwives, nurses) and other providers of pregnancy-related wellness and health counselling.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Periconceptional use of vitamin A and the risk of giving birth to a child with nonsyndromic orofacial clefts-A meta-analysis

BACKGROUND

We conducted a meta-analysis of observational epidemiological studies to evaluate the association between periconceptional use of vitamin A and the risk of giving birth to a child with nonsyndromic orofacial clefts (NSOFCs).

METHODS

We carried out a systematic literature search of Embase, PubMed, Web of Science, Google Scholar, and OpenGrey from inception to June 30, 2021. Two reviewers independently evaluated the studies that met the inclusion criteria and filled out an abstraction form for each study. Study quality was assessed using the Newcastle-Ottawa Assessment Scale (NOS). Adjusted estimates were pooled with an inverse variance weighting using a random-effects model. Heterogeneity and publication bias were assessed using the Cochran's Q test and funnel plot, respectively.

RESULTS

A total of six case-control studies with moderate risk of bias were included. The pooled OR showed a 20% reduction in the risk of NSOFCs for periconceptional use of vitamin A which was not statistically significant (OR = .80; 95% CI .54-1.17, p = .25). For nonsyndromic cleft lip with or without cleft palate (NSCL/P), the studies were homogenous, and the pooled estimate showed a 13% risk reduction, which was significant (OR = .87; 95% CI .77-.99, p = .03). For nonsyndromic cleft palate only (NSCPO), the pooled estimate showed a 33% lower likelihood, which was not statistically significant (OR = .67; 95% CI .42-1.08, p = .10).

CONCLUSION

Our results suggest a possible protective effect for the periconceptional use of vitamin A on the risk of NSCL/P. This finding should be investigated further in prospective studies across multiple populations.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Iodine content of frequently used prenatal and adult multivitamins in Switzerland

BACKGROUND

Iodine is essential for the biosynthesis of thyroid hormones, which are crucial for intrauterine growth and fetal neurocognitive development. Iodine requirements increase during pregnancy and lactation. The World Health Organization and the Swiss Confederation recommend a total daily iodine intake of 250 µg of iodine during preconception, pregnancy and lactation. To assure this goal, several professional organizations recommend complementing the nutritional iodine intake with supplements containing 150 μg of iodine daily.

METHODS

Prenatal and adult multivitamins widely available in Switzerland were compiled to determine their iodine content. Obstetricians verified that the list includes the most frequently prescribed supplements in Switzerland.

RESULTS

A total of 44 adult multivitamin supplements were identified, 23 of which are specifically intended for women planning pregnancy, pregnant, or breastfeeding. Seven out of 23 (30.4%) prenatal multivitamins products, and 12/21 (57.1%) adult multivitamins contained no iodine. Among all the products, only 18/44 (40.9%) contain 150 µg of iodine or more.

CONCLUSION

Several widely used products contain no or insufficient amounts (<150 ug) of iodine. Providers need to be informed about the variability in iodine content of supplements and established recommendations, and manufacturers of prenatal supplements should assure that their products contain iodine in adequate amounts.

Supplemental folic acid and/or multivitamins in pregnancy is associated with a decreased risk of childhood and adolescent nasopharyngeal carcinoma

The aim of this study was to evaluate the association between prenatal and neonatal period exposures and the risk of childhood and adolescent nasopharyngeal carcinoma (NPC). From January 2009 to January 2016, a total of 46 patients with childhood and adolescent NPC (i.e., less than 18 years of age) who were treated at Sun Yat-sen University Cancer Center were screened as cases, and a total of 45 cancer-free patients who were treated at Sun Yat-sen University Zhongshan Ophthalmic Center were selected as controls. The association between maternal exposures during pregnancy and obstetric variables and the risk of childhood and adolescent NPC was evaluated using logistic regression analysis. Univariate analysis revealed that compared to children and adolescents without a family history of cancer, those with a family history of cancer had a significantly higher risk of childhood and adolescent NPC [odds ratios (OR) = 3.15, 95% confidence interval (CI) = 1.02-9.75, P = 0.046], and the maternal use of folic acid and/or multivitamins during pregnancy was associated with a reduced risk of childhood and adolescent NPC in the offspring (OR = 0.07, 95% CI = 0.02-0.25, P < 0.001). After multivariate analysis, only the maternal use of folic acid and/or multivitamins during pregnancy remained statistically significant. These findings suggest that maternal consumption of folic acid and/or multivitamins during pregnancy is associated with a decreased risk of childhood and adolescent NPC in the offspring.

Multivitamin Use and Overall and Site-Specific Cancer Risks in the National Institutes of Health-AARP Diet and Health Study

BACKGROUND

Multivitamins are among the most commonly used supplements in the United States, but their effectiveness in preventing cancer remains unclear.

OBJECTIVES

We prospectively examined the association between multivitamin use and risks of overall and site-specific cancer in a large, well-characterized cohort to ascertain potential preventive or harmful relationships.

METHODS

We examined 489,640 participants ages 50-71 in the NIH-American Association of Retired Persons (AARP) Diet and Health Study who were enrolled from 1995 to 1998. We linked to 11 state cancer registries in order to identify incident cancers. Multivitamin use was assessed by a baseline questionnaire. Cox proportional hazards regression models of multivitamin use were used to estimate HRs and 95% CIs for cancer risks in men and women, adjusted for potential confounders, including age, BMI, smoking, physical activity, the Healthy Eating Index 2015 score, and use of single-vitamin/-mineral supplements.

RESULTS

A slightly higher overall cancer risk was observed in men (but not women) who consumed 1 or more multivitamins daily compared to nonusers [HRs, 1.02 (95% CI: 1.01-1.04) and 1.03 (95% CI: 1.00-1.07), respectively; P-trend = 0.002]. The latter reflected higher risks for prostate cancer (HR, 1.04; 95% CI: 0.98-1.10; P-trend = 0.005), lung cancer (HR, 1.07; 95% CI: 0.96-1.20; P-trend = 0.003), and leukemia (HR, 1.26; 95% CI: 1.02-1.57; P-trend = 0.003). Taking more than 1 multivitamin daily was also strongly positively associated with the risk of oropharyngeal cancer in women (HR, 1.53, 95% CI: 1.04-2.24; P-trend < 0.0001). By contrast, daily multivitamin use was inversely associated with the colon cancer risk in both sexes (HR, 0.82; 95% CI: 0.73-0.93; P-trend = 0.0003).

CONCLUSIONS

We found little evidence to support a cancer-preventive role for multivitamin use, with the exception of colon cancer, in both sexes in the NIH-AARP Diet and Health Study. In addition, slightly higher risks of overall, prostate, and lung cancer, as well as leukemia, were observed for greater multivitamin use in men, with a higher oropharyngeal cancer risk in women.

Preparation and Evaluation of Lipid Emulsion Containing 13 Vitamins for Injection Without Anaphylactoid Reactions

Objective

Multivitamins containing Tween 80 can cause anaphylactoid reactions. The objective of this study was to develop a new lipid emulsion containing 13 fat- and water-soluble vitamins for injection (13V-LE) that were simultaneously dissolved in one bottle and to evaluate the stability of and anaphylactoid reactions to 13V-LE.

Methods

Particle size, ζ-potential, and polydispersity of 13V-LE were assayed with a Zetasizer Nano ZS. Entrapment efficiency of 13V-LE was determined with HPLC. Behavior, histamine, and blood pressure of beagle dogs were investigated by observation, fluorospectrophotometry, and sphygmomanometry.

Results

The 13V-LE with the smallest particles and highest entrapment efficiency with stable ζ-potential was composed of soybean oil, glycerin (2.25%, w:v), egg lecithin (1.2%, w:v), and purified water. There was no obvious change in characteristics of the 13V-LE samples in terms of appearance, size distribution, ζ-potential, pH value, or concentration over 6 months. In anaphylactoid reactions tests, when being administered with the multivitamin Infuvite Adult containing Tween 80, six beagles showed grade IV symptoms (P<0.01 vs control), low blood pressure, and high plasma-histamine concentrations (P<0.05 or P<0.01). However, there were no significant differences in behavior, blood pressure, or histamine concentration in the dogs before and after administration in the 13V-LE group.

Conclusion

The 13V-LE formulation is a suitable intravenous lipid emulsion without anaphylactoid reactions.

Most Effective Combination of Nutraceuticals for Improved Memory and Cognitive Performance in the House Cricket, Acheta domesticus

Background: Dietary intake of multivitamins, zinc, polyphenols, omega fatty acids, and probiotics have all shown benefits in learning, spatial memory, and cognitive function. It is important to determine the most effective combination of antioxidants and/or probiotics because regular ingestion of all nutraceuticals may not be practical. This study examined various combinations of nutrients to determine which may best enhance spatial memory and cognitive performance in the house cricket (Acheta domesticus (L.)). Methods: Based on the 31 possible combinations of multivitamins, zinc, polyphenols, omega-3 polyunsaturated fatty acids (PUFAs), and probiotics, 128 house crickets were divided into one control group and 31 experimental groups with four house crickets in each group. Over eight weeks, crickets were fed their respective nutrients, and an Alternation Test and Recognition Memory Test were conducted every week using a Y-maze to test spatial working memory. Results: The highest-scoring diets shared by both tests were the combination of multivitamins, zinc, and omega-3 fatty acids (VitZncPuf; Alternation: slope = 0.07226, Recognition Memory: slope = 0.07001), the combination of probiotics, polyphenols, multivitamins, zinc, and omega-3 PUFAs (ProPolVitZncPuf; Alternation: slope = 0.07182, Recognition Memory: slope = 0.07001), the combination of probiotics, multivitamins, zinc, and omega-3 PUFAs (ProVitZncPuf; Alternation: slope = 0.06999, Recognition Memory: slope = 0.07001), and the combination of polyphenols, multivitamins, zinc, and omega-3 PUFAs (PolVitZncPuf; Alternation: slope = 0.06873, Recognition Memory: slope = 0.06956). Conclusion: All of the nutrient combinations demonstrated a benefit over the control diet, but the most significant improvement compared to the control was found in the VitZncPuf, ProVitZncPuf, PolVitZncPuf, and ProPolVitZncPuf. Since this study found no significant difference between the performance and improvement of subjects within these four groups, the combination of multivitamins, zinc, and omega-3 fatty acids (VitZncPuf) was concluded to be the most effective option for improving memory and cognitive performance.

Ways to make the right decisions in internal medicine and some specialized fields

The article presents the Choosing wisely (CHW) approach to selected problems of internal medicine, as developed by professional societies in the USA, Great Britain, Canada, Australia and the Federal Republic of Germany. It deals in more detail with issues and procedures in specialized fields of nephrology and rheumatology. There are negative, but also some positive recommendations on how the CHW approach views them.

Associations Between Different Dietary Vitamins and the Risk of Obesity in Children and Adolescents: A Machine Learning Approach

BACKGROUNDS

Simultaneous dietary intake of vitamins is considered as a common and real scenario in daily life. However, limited prospective studies have evaluated the association between multivitamins intake and obesity in children and adolescents.

OBJECTIVES

This study aimed to evaluate the relationship between the intake of different dietary vitamins and the risk of obesity in children (6-11 years) and adolescents (12-19 years).

METHODS

We conducted a cross-sectional study based on data from U.S. National Health and Nutrition Examination Survey, 2013-2016. A total of 3634 children and adolescents were included who had available data on dietary vitamins, obesity and covariates. We analyzed the dietary intake levels of nine vitamins, including vitamin A, vitamin B₁, vitamin B₂, vitamin B₆, vitamin B₁₂, vitamin C, vitamin D, vitamin E, vitamin K. Multivariate logistic regression was used to model the associations between vitamins and obesity. Bayesian kernel machine regression (BKMR) was employed to explore the joint and independent effects of vitamins on obesity among children and adolescents.

RESULTS

In the multivariate logistic regression model, five vitamins (vitamin A, vitamin B₁, vitamin B₂, vitamin B₁₂, and vitamin D) were negatively associated with obesity in children and adolescents. BKMR analysis showed that when the concentration of the nine vitamins was at or above the 55th percentile compared with the median value, the combined intake of these vitamins could significantly reduce the risk of obesity in children and adolescents. Potential interactions between vitamin B₂ and vitamin B₁₂ in increasing the risk of obesity in children and adolescents were observed.

CONCLUSIONS

We determine the combined effects of multivitamins on obesity in children and adolescents, and observe a significant interaction between vitamin B₂ and vitamin B₁₂. Further cohort studies are needed to clarify the health effects of multivitamins intake in a larger population.

Risk and Protective Factors in Autism Spectrum Disorders: A Case Control Study in the Lebanese Population

Autism spectrum disorders (ASD) are among the most common childhood neurodevelopmental disorders. Identification of risk and protective factors are necessary to improve the guidance of prevention and intervention strategies. Our study aims to determine the potential risk and protective factors in ASD in the Lebanese population. Our case-control study included 100 ASD patients and 100 healthy matched controls recruited from all the Lebanese districts. The data collected from the questionnaires was analyzed using SPSS 23.0. Independent Student T-test and Chi-Square test were carried out for the bivariate analysis of the data. In addition, the variables revealing a p-value < 0.05 were used for the multivariate logistic regression analysis. Multivitamins intake, especially omega 3 and vitamin B (Odds Ratio (OR) = 0.257; 95% Confidence Interval (CI) [0.115–0.579]), rich cereal diet (OR = 0.212; 95% CI [0.089–0.510]), and supplementation in iron during pregnancy (OR = 0.229; 95% CI [0.083–0.627]) were identified as protective factors against ASD. On the other hand, stress during pregnancy (OR = 6.339; 95% CI [2.845–14.125]), the presence of ASD patients in the family (OR = 7.878; 95% CI [1.877–33.065]) and the presence of attention deficit hyperactivity disorder (ADHD) patients in the family (OR = 6.981; 95% CI [1.362–35.789]) were associated with ASD. This study shed light on risk and protective factors associated with ASD in the Lebanese population. Further rigorous research, taking into consideration these factors, is needed to assist in early detection, prevention and subsequent intervention targeting ASD and its associated comorbidities, given that our study is not experimental and does not prove causality.

Iron Packaging Regulations in the United States and Pediatric Morbidity: A Retrospective Cohort Study

Iron poisoning was a leading cause of pediatric morbidity and mortality. We sought to assess whether the removal of strict iron packaging requirements in 2003 resulted in an increase in iron-related morbidity and mortality in pediatric exposures. We performed a retrospective cohort study utilizing the National Poison Data System from 2000 to 2017. A total of 4110 exposures met inclusion criteria: 847 from before (2000-2003) and 3263 after removal of unit-dose package regulations (2004-2017). The incidence of any marker of severity (7.2% vs 3.8%; odds ratio = 0.51, 95% confidence interval = 0.37-0.69) and frequency of deferoxamine use were both higher in the early time period (2.6% vs 1.0%; odds ratio = 0.38, 95% confidence interval = 0.22-0.66). There was no difference in the frequency of key serious effects (acidosis, elevated transaminases, hypotension). Despite removal of iron packaging regulations in the United States, there continues to be a decrease in the incidence of severe iron exposures in children.

General public knowledge and use of dietary supplements in Riyadh, Saudi Arabia

Context:

Dietary supplements is a growing industry, pharmaceuticals are having several types of similar supplements and multivitamins as over-the-counter products, a complete diet is necessary for a healthy body which leads to the usage of supplements or multivitamins complementing diets as needed, therefore leading to its encouraged usage among the population worldwide.

Aims:

The study was aimed to determine the public's knowledge and their use of dietary supplements.

Settings and Design:

A cross-sectional study was conducted among the general public of Riyadh, Saudi Arabia.

Methods and Materials:

The sample consisted of 679 participants including 41% males and 59% females. The ethnicity of the participants is 100% Arabs.

Statistical Analysis Used:

SPSS.

Results:

The sociodemographic data showed there were more female participants than males (59.1% vs. 40.9%), most of our participants had at least bachelor degree (64.4%), most of our participants had normal BMI (62.3%). 88.5% had knowledge on supplements and only 11.5% stated they were not aware at all.

Conclusions:

Dietary supplements and multivitamins consumption is prevalent among Saudi Arabian population. Our study suggests the majority of consumers understand the supportive role of dietary supplements and are aware of risks and side effects.

Iodine Content of the Best-Selling United States Adult and Prenatal Multivitamin Preparations

BACKGROUND

Iodine is essential for thyroid hormone production and fetal development. Even mild maternal iodine deficiency in gestation may be associated with impaired child neurodevelopment. Iodine requirements increase during pregnancy and lactation. Supplements containing 150 μg/day are recommended by the American Thyroid Association for all U.S. women who are pregnant, lactating, or planning pregnancy. The contribution of multivitamin supplements as an iodine source for pregnant and nonpregnant US adults has not been well studied. This study aimed to understand better the contribution of the top-selling adult multivitamins (AMV) and prenatal multivitamins (PMV) to iodine nutrition in the United States.

METHODS

Product names, dollar sales, unit and volume sales, and recommended daily intakes of the top-selling 99 AMV and 60 PMV from July 2016 to July 2017 were obtained from Information Resources, Inc. Iodine content and source were determined from product labels. After excluding private-label brands and unavailable product labels, a final sample of 89 AMV and 59 PMV was analyzed.

RESULTS

Of the 89 AMV, 74.2% contained iodine. The median (range) iodine content of AMV was 150 μg (38-150 μg) per daily serving. Over the study period, 8,924,371,955 AMV doses were sold, of which 84.8% contained iodine. Thirty-four (57.6%) of the 59 PMV contained iodine, with a median (range) iodine content of 150 μg (25-290 μg) per daily serving. Over the study period, 466,927,559 PMV doses were sold, of which 76.8% contained iodine. All iodine-containing AMV used potassium iodine as an iodine source. Of iodine-containing PMV, 73.5% used potassium iodide, 23.5% kelp, and 2.9% inactivated Saccharomyces cerevisiae as an iodine source.

CONCLUSIONS

During the one-year study period, a higher proportion of AMV doses than PMV doses contained iodine. Some PMV but no AMV included sources of iodine known to be highly variable. The median iodine content of the top-selling AMV and PMV was at the recommended 150 μg daily intake, but the range remains wide. Twenty-four percent of PMV doses sold did not contain iodine. More effort is needed to ensure adequate iodine content in prenatal vitamins for women who are pregnant, lactating, or planning pregnancy.

Efficacy and safety of Eurycoma longifolia (Physta®) water extract plus multivitamins on quality of life, mood and stress: a randomized placebo-controlled and parallel study

Background

The use of alternative and complementary medicines to alleviate stress has increased to avoid the negative effects of pharmaceutical drugs.

Objective

This study investigated the safety and efficacy of Eurycoma longifolia in combination with multivitamins (EL+MV) versus placebo on improving quality of life (QoL), mood and stress in moderately stressed healthy participants.

Methods

This randomised, double-blind, placebo-controlled 24-week study enrolled 93 participants aged 25-65 years, with a body mass index of 18-30 kg/m², scoring ≤18 in tension and ≤14 in fatigue subscale of Profiles of Mood Scores (POMS) questionnaire and supplemented with EL+MV or placebo. The primary endpoints were QoL measured by 12-Item Short Form Health Survey (SF-12) questionnaire and mood measured by POMS. The secondary endpoint was stress measured by Multi-Modal Stress Questionnaire (MMSQ). The safety of the intervention product was measured by complete metabolic panel, lipid and renal analysis including several immune parameters.

Results

While there were no significant between-group differences, within-group improvements were observed in the SF-12 QoL, POMS and MMSQ domains. In the SF-12 domain, improvements were seen in role limitation due to emotional health (P = 0.05), mental component domain (P < 0.001), emotional well-being (P < 0.001), social functioning (P = 0.002) as well as vitality (P = 0.001) at week 12. An increasing trend in POMS-vigour domain was also observed in the EL+MV group at week 12. A 15% decrease in physical stress domain (P < 0.05) compared with 0.7% in the placebo group was also observed in MMSQ. When the subjects were subgrouped according to age, 25-45 and 46-65 years of age, for primary outcomes, between-group significance was observed in the 25-45 year group in the social functioning domain of SF-12 (P = 0.021) and POMS-vigour (P = 0.036) in the 46-65 year group. No significant changes were observed in vital signs and complete metabolic panel. Regarding immune parameters, the lymphocytes increased significantly in the active group (P≤0.05). In total, 13 adverse events were reported: six on placebo and seven on EL+MV.

Conclusion

EL+MV may support the QoL, mood, stress and immune parameters in healthy participants.

Trial registration

This study has been registered at clinicaltrials.gov (NCT02865863).

Dietary Supplements and Cardiovascular Diseases

The market of nutritional supplements is expected to expand over 6%/year through 2018 due to growing interest in personal health, aging population, and promising personalized care products. The most used dietary supplements are fish oil, multivitamins, Vitamin D, and coenzyme Q10 (CoQ10) in this order, while probiotics is the fastest growing supplement. In the U.S., over 68% of the population use dietary supplements regularly. On the other hand, in the developed countries, cardiovascular diseases (CVDs) are the main cause of death and morbidity from the 1900s. The effects of most dietary supplements on cardiovascular risk and CVD have been studied for a long time. However, despite several studies explored the association of the various supplements to the cardiovascular risk, there is still a lack of consensus. Multivitamin supplementation has been advocated to reduce cardiovascular events; Vitamin D levels have been associated with the occurrence of coronary artery disease, heart failure, and atrial fibrillation; CoQ10 deficiency has been associated with myocardial dysfunction and with statin myopathy; probiotoics has been suggested to lower both blood pressure and circulating lipids. However, the study of the effects of dietary supplementations is not straightforward, since people assuming dietary supplements generally have a healthier diet and lifestyle, and randomized studies are rarely performed. In this review, we will summarize the findings linking dietary supplements to CVD with a special focus on novel insights.

Effects of Multivitamin and Multimineral Supplementation on Blood Pressure: A Meta-Analysis of 12 Randomized Controlled Trials

Previous studies have not drawn a consistent conclusion about effect of multivitamin and multimineral supplementation (MVMS) on blood pressure. A comprehensive search of PubMed, Embase and Cochrane Library (up to May 2018) and references of relevant articles was undertaken. The present meta-analysis included 12 randomized controlled trials (RCTs), of which eight RCTs in 2011 subjects evaluated the effect of MVMS on blood pressure and four RCTs in 21,196 subjects evaluated the effect of MVMS on the risk of hypertension. MVMS had a lowering effect on systolic blood pressure (SBP) and diastolic blood pressure (DBP): the weighted mean difference (WMD) was -1.31 mmHg (95% CI, -2.48 to -0.14 mmHg) and -0.71 mmHg (95% CI, -1.43 to 0.00 mmHg), respectively. Subgroup analysis indicated that the lowering effect of MVMS on blood pressure was only significant in 134 subjects with chronic disease but not in 1580 healthy subjects, and the WMD for systolic blood pressure (SBP) and DBP in subjects with chronic disease was -6.29 mmHg (95% CI, -11.09 to -1.50 mmHg) and -2.32 mmHg (95% CI, -4.50 to -0.13 mmHg), respectively. The effect size of MVMS on SBP in 58 hypertensive subjects (WMD, -7.98 mmHg; 95% CI, -14.95 to -1.02 mmHg) was more than six times of that in 1656 normotensive subjects (WMD, -1.25 mmHg; 95% CI, -2.48 to -0.02 mmHg). However, no significant effect on DBP was observed in both hypertensive and normotensive subgroups. There was no significant effect of MVMS on risk of hypertension in 22,852 subjects with a normal blood pressure at baseline. In conclusion, although MVMS had a significant lowering effect on blood pressure in normotensive subjects, the lowering effect was too small to effectively prevent future hypertension. MVMS may be an effective method for blood pressure control in subjects with chronic disease including hypertension, but the sample size of subjects with hypertension or other chronic disease was too small, and more well-designed RCTs are needed to confirm this result.

A Survey Instrument to Assess Intake of Dietary Supplements, Related Products, and Caffeine in High-Use Populations

Substantial data on the use of dietary supplements by the general adult population are available, but many population subgroups have not been extensively studied. Because military service members and young people consume large amounts of dietary supplements, including for enhancement of physical performance, weight control, and bodybuilding, which can be dangerous, we developed a comprehensive questionnaire to characterize patterns of supplement use in these and other populations. The questionnaire has been used to study >7000 military service members and 1000 college students. This supplement article presents a detailed description of the questionnaire, which contains comprehensive questions on demographic characteristics, exercise habits, attitudes with regard to dietary supplements, and amount of money spent on supplements. Intakes of specific dietary supplements and caffeine, frequency of use, and reasons for use are assessed. The questionnaire was designed for studying dietary supplement and caffeine intake patterns with the use of paper-and-pencil administration to military populations and was modified for use with college students and for computer and Web administration. It is available online at https://go.usa.gov/xn9FP and in the Supplemental File for this publication. It can be used to study other populations if minor modifications are made. The online version of the questionnairewill be updated periodically as newversions become available. In conclusion, a validated, detailed, noncopyrighted questionnaire designed to assess the use of dietary supplements, energy drinks (and related products), and caffeine is available for use in diverse populations. The format of the questionnaire is adaptable to computer administration and scoring, and it can be customized for specific subpopulations, locations, and product categories including updates that reflect changes in the availability of supplements or availability of new products.

Dietary Supplement Ingredient Database (DSID) and the Application of Analytically Based Estimates of Ingredient Amount to Intake Calculations

OBJECTIVE

We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology.

BACKGROUND AND HISTORY

During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES.

RATIONALE

Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations.

RECENT DEVELOPMENTS

We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs.

FUTURE DIRECTIONS

DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs.

CONCLUSIONS

We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.

Discussing Appropriate Medication Use and Multivitamin Intake with a Healthcare Provider: An Examination of Two Elements of Preconception Care Among Latinas

BACKGROUND

Counseling for appropriate medication use and folic acid consumption are elements of preconception care critical for improving pregnancy outcomes. Hispanic women receive less preconception care than women of other race/ethnic groups. The objective of this analysis is to describe differences in these two elements of preconception care among Hispanic subsegments.

MATERIALS AND METHODS

Porter Novelli's 2013 Estilos survey was sent to 2,609 U.S. Hispanic adults of the Offerwise QueOpinas Panel. Surveys were completed by 1,000 individuals (calculated response rate 42%), and results were weighted to the 2012 U.S. Census Hispanic proportions for sex, age, income, household size, education, region, country of origin, and acculturation. Responses were analyzed with weighted descriptive statistics, linear regression, and Rao-Scott chi-square tests.

RESULTS

Of the 499 female respondents, 248 had a child under the age of 18 years and were asked about healthcare provider discussions concerning medication use before or during their last pregnancy. Timing of discussions varied by maternal age, marital status, income, youngest child's country of birth, and acculturation. Discussions before pregnancy were reported by 47% of the female respondents; high acculturated women more often reported never having such discussions. Among female respondents, 320 were of reproductive age, and 27% of those reported daily multivitamin use. Multivitamin use varied by pregnancy intention and youngest child's country of birth, but did not vary significantly by acculturation.

CONCLUSIONS

Differences in discussions concerning medication use in pregnancy and multivitamin use exist among Hispanic subsegments based on pregnancy intention, marital status, income, youngest child's country of birth, and level of acculturation.

Maternal exposures and risk of oral clefts in South Vietnam

BACKGROUND

Oral clefts are among the most common congenital anomalies. Most studies on risk factors of oral clefts have been carried out in developed countries. We investigated the associations between maternal exposures in the first trimester and oral clefts in South Vietnam.

METHODS

We conducted a hospital-based case-control study during October 2014-November 2015. Cases included 170 patients with nonsyndromic cleft lip with or without cleft palate and those with cleft palate only. Controls were 170 children without oral clefts, matched to each case by age and gender. Mothers were interviewed using structured questionnaire. We performed conditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Passive smoking was associated with increased risk of oral clefts in univariate analysis, but not in multivariable analysis (adjusted OR [aOR] = 1.68; 95% CI, 0.53-5.37). No association was observed between liver intake and oral clefts. Compared with nondrinkers, mothers who reported consumption of caffeine-containing beverages were more likely to have an infant with oral cleft (aOR = 5.89; 95% CI, 1.08-32.00). Periconceptional use of folic acid and multivitamins supplementation was associated with reduced risk of oral clefts (aOR = 0.01; 95% CI, 0.00-0.09 and aOR = 0.03; 95% CI, 0.01-0.13, respectively).

CONCLUSIONS

The results suggest no associations of maternal passive smoking or liver intake with oral clefts. Periconceptional use of folic acid or multivitamins may protect against oral clefts. Further studies are warranted to examine the roles of caffeine consumption in pregnant mothers on occurrence of oral clefts in offspring.

Dietary Supplement Use during Preconception: The Australian Longitudinal Study on Women's Health

Worldwide, dietary supplement use among reproductive aged women is becoming increasingly common. The aim of this study was to investigate dietary supplement use among Australian women during preconception. Self-reported data were collected prospectively for the Australian Longitudinal Study on Women’s Health (ALSWH). The sample included 485 women aged 31–36 years, with supplement data, classified as preconception when completing Survey 5 of the ALSWH in 2009. Frequency and contingency tables were calculated and Pearson’s chi-square test for associations between demographic variables and supplementation status was performed. Sixty-three per cent of women were taking at least one dietary supplement during preconception. Multiple-micronutrient supplements were the most commonly reported supplement (44%). Supplements containing folic acid and iodine were reported by 51% and 37% of preconception women, respectively. Folic acid (13%), omega-3 fatty acids (11%), vitamin C (7%), B vitamins (4%), iron (3%), and calcium (3%) were the most common single nutrients supplemented during preconception. Women trying to conceive, with no previous children, and born outside Australia were more likely to take dietary supplements. In Australia, dietary supplement use during preconception is relatively high. However, supplementation of recommended nutrients, including folic acid and iodine, could be improved.

Multivitamin use and risk of stroke incidence and mortality amongst women

BACKGROUND AND PURPOSE

Few studies have examined the association between multivitamin use and the risk of stroke incidence and mortality, and the results remain inconclusive as to whether multivitamins are beneficial.

METHODS

The associations between multivitamin use and the risk of incident stroke and stroke mortality were prospectively examined in 86 142 women in the Nurses' Health Study, aged 34-59 years and free of diagnosed cardiovascular disease at baseline. Multivitamin use and covariates were updated every 2 years and strokes were documented by review of medical records. Hazard ratios of total, ischaemic and hemorrhagic strokes were calculated across categories of multivitamin use (non-user, past, current user) and duration (years), using Cox proportional hazards models.

RESULTS

During 32 years of follow-up from 1980 to 2012, 3615 incident strokes were documented, including 758 deaths from stroke. In multivariate analyses, women who were current multivitamin users did not have a lower risk of incident total stroke compared to non-users [relative risk (RR) 1.02, 95% confidence interval (CI) 0.93-1.11], even those with longer durations of 15 or more years of use (RR 1.08, 95% CI 0.97-1.20) or those with a lower quality diet (RR 0.96, 95% CI 0.80-1.15). There was also no indication of benefit from multivitamin use for incident ischaemic or hemorrhagic strokes or for total stroke mortality.

CONCLUSIONS

Long-term multivitamin use was not associated with reduced risk of stroke incidence or mortality amongst women in the study population, even amongst those with a lower diet quality. An effect in a less well-nourished population cannot be ruled out.

Analytical ingredient content and variability of adult multivitamin/mineral products: national estimates for the Dietary Supplement Ingredient Database

BACKGROUND

Multivitamin/mineral products (MVMs) are the dietary supplements most commonly used by US adults. During manufacturing, some ingredients are added in amounts exceeding the label claims to compensate for expected losses during the shelf life. Establishing the health benefits and harms of MVMs requires accurate estimates of nutrient intake from MVMs based on measures of actual rather than labeled ingredient amounts.

OBJECTIVES

Our goals were to determine relations between analytically measured and labeled ingredient content and to compare adult MVM composition with Recommended Dietary Allowances (RDAs) and Tolerable Upper Intake Levels.

DESIGN

Adult MVMs were purchased while following a national sampling plan and chemically analyzed for vitamin and mineral content with certified reference materials in qualified laboratories. For each ingredient, predicted mean percentage differences between analytically obtained and labeled amounts were calculated with the use of regression equations.

RESULTS

For 12 of 18 nutrients, most products had labeled amounts at or above RDAs. The mean measured content of all ingredients (except thiamin) exceeded labeled amounts (overages). Predicted mean percentage differences exceeded labeled amounts by 1.5-13% for copper, manganese, magnesium, niacin, phosphorus, potassium, folic acid, riboflavin, and vitamins B-12, C, and E, and by ∼25% for selenium and iodine, regardless of labeled amount. In contrast, thiamin, vitamin B-6, calcium, iron, and zinc had linear or quadratic relations between the labeled and percentage differences, with ranges from -6.5% to 8.6%, -3.5% to 21%, 7.1% to 29.3%, -0.5% to 16.4%, and -1.9% to 8.1%, respectively. Analytically adjusted ingredient amounts are linked to adult MVMs reported in the NHANES 2003-2008 via the Dietary Supplement Ingredient Database (http://dsid.usda.nih.gov) to facilitate more accurate intake quantification.

CONCLUSIONS

Vitamin and mineral overages were measured in adult MVMs, most of which already meet RDAs. Therefore, nutrient overexposures from supplements combined with typical food intake may have unintended health consequences, although this would require further examination.

Men's health supplement use and outcomes in men receiving definitive intensity-modulated radiation therapy for localized prostate cancer

BACKGROUND

Approximately 50% of newly diagnosed cancer patients start taking dietary supplements. Men's health supplements (MHSs), which we define as supplements that are specifically marketed with the terms men's health and prostate health (or similar permutations), are often mislabeled as having potential anticancer benefits.

OBJECTIVE

We evaluated the effects of MHSs on patient outcomes and toxicities in patients who were undergoing definitive intensity-modulated radiation therapy (IMRT) for localized prostate cancer.

DESIGN

This retrospective analysis included patients who were being treated at a National Cancer Institute-designated comprehensive cancer center and consented to have information stored in a prospective database. MHSs were queried online. Outcome measures were freedom from biochemical failure (FFBF) (biochemical failure was defined with the use of the prostate-specific antigen nadir + 2-ng/mL definition), freedom from distant metastasis (FFDM), cancer-specific survival (CSS), and overall survival (OS) as well as toxicities. Kaplan-Meier analysis, log-rank tests, Fine and Gray competing-risk regression (to adjust for patient and lifestyle factors), and Cox models were used.

RESULTS

From 2001 to 2012, 2207 patients were treated with IMRT with a median dose of 78 Gy, and a median follow-up of 46 mo. Of these patients, 43% were low risk, 37% were intermediate risk, and 20% were high risk; 10% used MHSs. MHSs contained a median of 3 identifiable ingredients (range: 0-78 ingredients). Patients who were taking an MHS compared with those who were not had improved 5-y OS (97% compared with 92%, respectively; P = 0.01), but there were no differences in the FFBF (94% compared with 89%, respectively; P = 0.12), FFDM (96% compared with 97%, respectively; P = 0.32), or CSS (100% compared with 99%, respectively; P = 0.22). The unadjusted association between MHS use and improved OS was attenuated after adjustment for patient lifestyle factors and comorbidities. There was no difference in toxicities between the 2 groups (late-grade 3-4 genitourinary <3%; gastrointestinal <4%).

CONCLUSION

The use of MHSs is not associated with outcomes or toxicities.

Functional foods: How functional are they? A case report of supplement-induced psychosis

There is rising evidence of patients' use of alternative and complementary medicine. The percentage of the U.S. population who used at least one dietary supplement increased from 42% in 1988-1994 to 53% in 2003-2006. We present a case of an Asian female in her 40s, with no previous psychiatric illness, who presented to the emergency room following a brief psychotic episode, during which she self-amputated the tips of her fingers, after using multivitamins and herbal supplements including ginseng, gui yuan rou (Chinese herb), astaxanthin, goji (Chinese fruit), selenium, saw palmetto, grape seed extract, citrus bioflavanoid, lutein (zeaxantin), resvexatrol, sun chlorella, spirulina powder, phytoceramides, phytoestrogen, glucosatrin, bromelain plus, and American bee pollen. Comprehensive laboratory workup, drug screening, and diagnostic imaging were negative. Vital signs were stable. Other than the amputated finger tips, the remainder of her physical examination was unremarkable. Her mental status improved significantly after treatment with risperidone 1 mg twice daily, during a five-day psychiatric hospitalization. This case draws attention to the fact that supplements have the potential of producing frank psychosis and require close monitoring and study by physicians.

Maternal risk factors involved in specific congenital anomalies of the kidney and urinary tract: A case-control study

BACKGROUND

Congenital anomalies of the kidney and urinary tract (CAKUT) comprise a heterogeneous group of birth defects with a variety of genetic and nongenetic factors suspected of involvement in the etiology. However, little is known about risk factors in specific CAKUT phenotypes. Therefore, we studied potential maternal risk factors in individual phenotypes within the CAKUT spectrum.

METHODS

Questionnaire data were collected from parents of 562 children with CAKUT and 2139 healthy controls within the AGORA data- and biobank. Potential maternal risk factors investigated included folic acid use, overweight and obesity, smoking, alcohol consumption, subfertility, and diabetes mellitus. We performed logistic regression analyses to assess associations between these potential risk factors and CAKUT phenotypes.

RESULTS

Increased risks of CAKUT were observed for folic acid use and maternal obesity, while fertility treatment by in vitro fertilization or intrauterine insemination and diabetes diagnosed during pregnancy also seem to be associated with CAKUT. Use of multivitamins reduced the risk (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-1.0) as opposed to use of folic acid supplements only (OR, 1.3; 95% CI, 1.0-1.8). Folic acid use was associated with duplex collecting systems (OR, 1.8; 95% CI, 1.0-3.4) and vesicoureteral reflux (OR, 1.8; 95% CI, 1.1-2.9) in particular. A relatively strong association was observed between diabetes during pregnancy and posterior urethral valves (OR, 2.6; 95% CI, 1.1-5.9).

CONCLUSION

Use of folic acid only seems to be counterproductive for prevention of CAKUT, in contrast to multivitamin use. Furthermore, we observed differences in risk factor patterns among CAKUT phenotypes, which stress the importance of separate analyses for each phenotype. Birth Defects Research (Part A) 106:596-603, 2016. © 2016 Wiley Periodicals, Inc.

Lifestyle and pregnancy loss in a contemporary cohort of women recruited before conception: The LIFE Study

OBJECTIVE

To estimate pregnancy loss incidence in a contemporary cohort of couples whose lifestyles were measured during sensitive windows of reproduction to identify factors associated with pregnancy loss for the continual refinement of preconception guidance.

DESIGN

Prospective cohort with preconception enrollment.

SETTING

Sixteen counties in Michigan and Texas.

PATIENT(S)

Three hundred forty-four couples with a singleton pregnancy followed daily through 7 postconception weeks of gestation.

INTERVENTION(S)

None. Couples daily recorded use of cigarettes, caffeinated and alcoholic beverages, and multivitamins. Women used fertility monitors for ovulation detection and digital pregnancy tests. Pregnancy loss was denoted by conversion to a negative pregnancy test, onset of menses, or clinical confirmation depending upon gestation. Using proportional hazards regression and accounting for right censoring, we estimated adjusted hazard ratios and 95% confidence intervals (aHR, 95% CI) for couples' lifestyles (cigarette smoking, alcoholic and caffeinated drinks, multivitamins) during three sensitive windows: preconception, early pregnancy, and periconception.

MAIN OUTCOME MEASURE(S)

Incidence and risk factors for pregnancy loss.

RESULT(S)

Ninety-eight of 344 (28%) women with a singleton pregnancy experienced an observed pregnancy loss. In the preconception window, loss was associated with female age ≥35 years (1.96, 1.13-3.38) accounting for couples' ages, women's and men's consumption of >2 daily caffeinated beverages (1.74, 1.07-2.81; and 1.73, 1.10-2.72, respectively), and women's vitamin adherence (0.45, 0.25-0.80). The findings were similar for lifestyle during the early pregnancy and periconception windows.

CONCLUSION(S)

Couples' preconception lifestyle factors were associated with pregnancy loss, although women's multivitamin adherence dramatically reduced risk. The findings support continual refinement and implementation of preconception guidance.

Interaction between MTHFR 677C>T and periconceptional folic acid supplementation in the risk of Hypospadias

BACKGROUND

Hypospadias is a congenital malformation with both environmental factors and genetic predisposition involved in the pathogenesis. The role of maternal periconceptional folic acid supplement use in the development of hypospadias is unclear. As folate levels may also be influenced by the C677T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene, we hypothesize that a gene-environment interaction between this polymorphism and folic acid use is involved in the etiology of hypospadias.

METHODS

We conducted a case-control study among 855 hypospadias cases and 713 population-based controls from the AGORA data- and biobank. Folic acid supplement use was derived from maternal questionnaires and infant and maternal DNA was used to determine the MTHFR C677T polymorphism using Taqman assays. We performed separate analyses for different hypospadias phenotypes (anterior/middle/posterior).

RESULTS

Hypospadias was neither associated with folic acid use or the MTHFR C677T polymorphism, nor with their interaction. However, we did find an association with middle hypospadias when no supplements were used (odds ratio = 1.6; 95% confidence interval, 1.1-2.4), especially in infants carrying the CT/TT genotype (odds ratio = 2.5; 95% confidence interval, 1.4-4.7). In addition, more infants with these genotypes seemed to have posterior hypospadias, regardless of folic acid use.

CONCLUSION

Our study does not suggest a major role for folic acid supplements or the MTHFR C677T polymorphism in the etiology of hypospadias in general, but not using folic acid and/or carrying the MTHFR C677T polymorphism may be associated with middle and posterior hypospadias. Therefore, we stress the importance of studying gene-environment interactions preferably in stratified analyses for different hypospadias phenotypes.

Daily Zinc but Not Multivitamin Supplementation Reduces Diarrhea and Upper Respiratory Infections in Tanzanian Infants: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Although various micronutrient regimens have been shown to prevent and treat common infectious diseases in children, the effects of daily multivitamin (MV) and/or zinc supplementation have not been widely evaluated in young African infants.

OBJECTIVE

The objective was to determine whether daily supplementation of HIV-unexposed Tanzanian infants with MVs or zinc reduces the risk of infectious morbidity compared with placebo.

METHODS

In a 2 × 2 factorial, double-blind, randomized controlled trial, 2400 infants who were 6 wk of age and born to HIV-negative mothers in a low-malaria setting were randomly assigned to receive daily oral supplementation of MVs (vitamin B complex and vitamins C and E), zinc, zinc + MVs, or placebo for 18 mo. Morbidity was assessed by study nurses at monthly visits and by physicians every 3 mo and/or when the child was acutely ill.

RESULTS

No significant differences were found in the percentage of nurse visits during which diarrhea, cough, or any other symptom were reported throughout the previous month when receiving either zinc or MVs. However, physician diagnoses of all types of diarrhea (RR = 0.88; 95% CI: 0.81, 0.96; P = 0.003), dysentery (RR = 0.84; 95% CI: 0.74, 0.95; P = 0.006), and acute upper respiratory infection (RR = 0.92; 95% CI: 0.88, 0.97; P = 0.0005) were significantly lower for infants supplemented with zinc than for those who did not receive zinc. Among the 2360 infants for whom vital status was obtained, there was a nonsignificant increase in all-cause mortality among infants who received zinc (HR = 1.80; 95% CI: 0.98, 3.31; P = 0.06) compared with those who did not receive zinc. MVs did not alter the rates of any recorded physician diagnoses or mortality. Neither zinc nor MVs reduced hospitalizations or unscheduled outpatient visits.

CONCLUSIONS

Daily zinc supplementation of Tanzanian infants beginning at the age of 6 wk may lower the burden of diarrhea and acute upper respiratory infections, but provision of MVs using the regimen in this trial did not confer additional benefit. This trial was registered at clinicaltrials.gov as NCT00421668.

Periconceptional folic acid fortification for the risk of gestational hypertension and pre-eclampsia: a meta-analysis of prospective studies

Published literatures report controversial results about the association of folic acid-containing multivitamins with gestational hypertension and pre-eclampsia. A comprehensive search was performed to identify related prospective studies to assess the effect of folic acid fortification on gestational hypertension and pre-eclampsia. The Q test and I(2) statistic were used to examine between-study heterogeneity. Fixed or random effects models were selected based on study heterogeneity. A funnel plot and modified Egger linear regression test were used to estimate publication bias. Eleven studies conformed to the criteria. Pooled results indicated that folic acid fortification alone was not associated with the occurrence of gestational hypertension [relative risk (RR) = 1.03, 95% confidence interval (CI): 0.98-1.09, P = 0.267] and pre-eclampsia (RR = 0.99, 95% CI: 0.90-1.08, P = 0.738). However, supplementation of multivitamins containing folic acid could prevent gestational hypertension (RR = 0.57, 95% CI: 0.43-0.76, P < 0.001) and pre-eclampsia (RR = 0.64, 95% CI: 0.48-0.84, P = 0.001). The difference between folic acid fortification alone and multivitamins containing folic acid was significant. This meta-analysis suggests that periconceptional multivitamin supplementation with appropriate dose, not folic acid alone, is an appropriate recommendation for pregnant women. The effect should be further confirmed by conducting large-scale randomised controlled trials.

Improved blood biomarkers but no cognitive effects from 16 weeks of multivitamin supplementation in healthy older adults

Supplementation with vitamins, minerals and phytonutrients may be beneficial for cognition, especially in older adults. The aim of this study was to assess the effects of multivitamin supplementation in older adults on cognitive function and associated blood biomarkers. In a randomised, double blind, placebo-controlled trial, healthy women (n = 68) and men (n = 48) aged 55–65 years were supplemented daily for 16 weeks with women’s and men’s formula multivitamin supplements. Assessments at baseline and post-supplementation included computerised cognitive tasks and blood biomarkers relevant to cognitive aging. No cognitive improvements were observed after supplementation with either formula; however, several significant improvements were observed in blood biomarkers including increased levels of vitamins B₆ and B₁₂ in women and men; reduced C-reactive protein in women; reduced homocysteine and marginally reduced oxidative stress in men; as well as improvements to the lipid profile in men. In healthy older people, multivitamin supplementation improved a number of blood biomarkers that are relevant to cognition, but these biomarker changes were not accompanied by improved cognitive function.

No major role for periconceptional folic acid use and its interaction with the MTHFR C677T polymorphism in the etiology of congenital anorectal malformations

BACKGROUND

Both genetic and nongenetic factors are suggested to be involved in the etiology of congenital anorectal malformations (ARM). Maternal periconceptional use of folic acid supplements were inconsistently suggested to play a role in the prevention of ARM. Therefore, we investigated independent associations and interactions of maternal periconceptional folic acid supplement use and the infant and maternal MTHFR (methylenetetrahydrofolate reductase) C677T polymorphisms with the risk of ARM and subgroups of ARM.

METHODS

A case-control study was conducted among 371 nonsyndromic ARM cases and 714 population-based controls born between 1990 and 2012 using maternal questionnaires and DNA samples from mother and child. Cases were treated for ARM at departments of Pediatric Surgery of the Radboud university medical center, Sophia Children's Hospital-Erasmus MC Rotterdam, and the University Medical Center Groningen in The Netherlands and hospitals throughout Germany.

RESULTS

No association with folic acid use was present (odds ratio = 1.1; 95% confidence interval: 0.8-1.4) for ARM as a group. Infant and maternal MTHFR C677T polymorphisms were weakly associated with isolated ARM in particular. Lack of folic acid supplement use in combination with infants or mothers carrying the MTHFR C677T polymorphism did not seem to increase the risk of ARM or subgroups of ARM. The relative excess risks due to interaction did not clearly indicate interaction on an additive scale either.

CONCLUSION

This first study investigating interactions between periconceptional folic acid supplement use and infant and maternal MTHFR C677T polymorphisms in the etiology of ARM did not provide evidence for a role of this gene-environment interaction.

Folate deficiency and folic acid supplementation: the prevention of neural-tube defects and congenital heart defects

Diet, particularly vitamin deficiency, is associated with the risk of birth defects. The aim of this review paper is to show the characteristics of common and severe neural-tube defects together with congenital heart defects (CHD) as vitamin deficiencies play a role in their origin. The findings of the Hungarian intervention (randomized double-blind and cohort controlled) trials indicated that periconceptional folic acid (FA)-containing multivitamin supplementation prevented the major proportion (about 90%) of neural-tube defects (NTD) as well as a certain proportion (about 40%) of congenital heart defects. Finally the benefits and drawbacks of three main practical applications of folic acid/multivitamin treatment such as (i) dietary intake; (ii) periconceptional supplementation; and (iii) flour fortification are discussed. The conclusion arrived at is indeed confirmation of Benjamin Franklin's statement: "An ounce of prevention is better than a pound of care".

Multivitamin supplementation improves haematologic status in children born to HIV-positive women in Tanzania

Introduction

Anaemia is prevalent among children born to HIV-positive women, and it is associated with adverse effects on cognitive and motor development, growth, and increased risks of morbidity and mortality.

Objective

To examine the effect of daily multivitamin supplementation on haematologic status and mother-to-child transmission (MTCT) of HIV through breastfeeding.

Methods

A total of 2387 infants born to HIV-positive women from Dar es Salaam, Tanzania were enrolled in a randomized, double-blind, placebo-controlled trial, and provided a daily oral supplement of multivitamins (vitamin B complex, C and E) or placebo at age 6 weeks for 24 months. Among them, 2008 infants provided blood samples and had haemoglobin concentrations measured at baseline and during a follow-up period. Anaemia was defined as haemoglobin concentrations<11 g/dL and severe anaemia<8.5 g/dL.

Results

Haemoglobin concentrations among children in the treatment group were significantly higher than those in the placebo group at 12 (9.77 vs. 9.64 g/dL, p=0.03), 18 (9.76 vs. 9.57 g/dL, p=0.004), and 24 months (9.93 vs. 9.75 g/dL, p=0.02) of follow-up. Compared to those in the placebo group, children in the treatment group had a 12% lower risk of anaemia (hazard ratio (HR): 0.88; 95% CI: 0.79–0.99; p=0.03). The treatment was associated with a 28% reduced risk of severe anaemia among children born to women without anaemia (HR: 0.72; 95% CI: 0.56–0.92; p=0.008), but not among those born to women with anaemia (HR: 1.10; 95% CI: 0.79–1.54; p=0.57; p for interaction=0.007). One thousand seven hundred fifty three infants who tested HIV-negative at baseline and had HIV testing during follow-up were included in the analysis for MTCT of HIV. No association was found between multivitamin supplements and MTCT of HIV.

Conclusions

Multivitamin supplements improve haematologic status among children born to HIV-positive women. Further trials focusing on anaemia among HIV-exposed children are warranted in the context of antiretroviral therapy.

The Impact of Cigarette Quitting during Pregnancy on Other Prenatal Health Behaviors

Several economic studies have evaluated the effects of cigarette smoking and quitting on other health behaviors such as alcohol use and weight gain. However, there is little research that evaluates the effects of cigarette quitting during pregnancy on other health behaviors such as caloric intake, alcohol consumption, multivitamin use, and caffeine intake. In this paper, we evaluate these effects and employ a genetic variant that predicts cigarette quitting to aid in identification. We find some evidence that cigarette quitting during pregnancy may increase multivitamin use and caloric intake and reduce caffeine consumption.

An assessment of vitamin supplements in the Indian market

We aimed to study the composition and availability of various vitamin preparations in the Indian market, data about which was collected from an annual Drug Compendium. The preparations were assessed for total number, different formulations, constituents and amount of each constituent present in the formulation. A large number of vitamin supplements are available in the Indian market. It includes single-ingredient products and various combinations of vitamins, minerals, and other constituents. Among single products, the maximum number was that of vitamin D3 (n=150). Most of the supplements are available as combinations (76.49%), with vitamin-minerals combinations constituting the maximum number. In a large number of products, amount of the vitamins was not specified. The most common formulation for oral administration was capsules (34.1%). In our research, majority of the supplements contained nutrient amounts higher than the recommended intakes recommended dietary allowance. Unsupervised intake of vitamins can pose a serious health risk in the susceptible population. The composition and amount of each constituent in the dietary supplement should be detailed and properly labelled for each preparation. Availability of a large number of preparations with unknown composition as ‘over the counter’ agents requires a serious review of the legal provisions in India for drug manufacturing and marketing. There is a need for proper guidelines and regulations for the manufacturing, labelling and marketing of dietary supplements in India. Strict enforcement of such provisions is essential to safeguard the health of the population at large.

Effects of lipid emulsion and multivitamins on the growth of microorganisms in peripheral parenteral nutrition solutions

BACKGROUND

Blood stream infections caused by Bacillus cereus or Serratia marcescens in patients receiving peripheral parenteral nutrition (PPN) have occasionally been reported in Japan, but these microorganisms are not major causes of blood stream infections in patients receiving total parenteral nutrition via a central venous catheter. In Japan, commercially available PPN solutions contain amino acids, glucose, and electrolytes, but not contain lipid emulsion (LE) and multivitamins (MV). In this study, the effects of LE and MV on the growth of microorganisms such as Bacillus cereus, Serratia marcescens, Staphylococcus aureus, and Candida albicans in PPN solutions were investigated.

METHODS

A commercial 3% amino acid and 7.5% glucose solution with electrolytes (AF) was used as the base solution to prepare test solutions (LAF, AFV, and LAFV) containing LE, MV, or both. Specifically, 20% LE was added to AF in a ratio of 1:9 to prepare LAF. MV was added to AF and LAF to prepare AFV and LAFV, respectively. A specified number of each microorganism was added to each 100 mL of AF, LAF, AFV, and LAFV in sterile plastic flasks, and all flasks were allowed to stand at room temperature. The number of colony forming units per mL of each microorganism was counted at 0, 24, and 48 hours after the addition of each microorganism.

RESULTS

Both Bacillus cereus and Serratia marcescens increased rapidly in AF as well as in LAF, AFV, and LAFV. Staphylococcus aureus did not increased in AF, but increased slightly in LAF and increased rapidly in AFV and LAFV. Candida albicans increased slightly in AF and increased rapidly in LAF, AFV, and LAFV.

CONCLUSIONS

The results suggest the followings: if microbial contamination occurs, 1) Bacillus cereus and Serratia marcescens can grow rapidly in PPN solutions consisting of amino acids, glucose and electrolytes; 2) Staphylococcus aureus cannot grow without LE and MV, but can grow rapidly with MV; 3) Candida albicans can grow slowly without LE and MV, and the addition of LE or MV accelerates its growth.

Effect of multivitamin supplements on weight gain during pregnancy among HIV-negative women in Tanzania

Multivitamin supplementation has been shown to reduce the risk of low birthweight. This effect could be mediated through gestational weight gain. However, the effect of multivitamin supplementation on weight gain during pregnancy has not been fully studied. The objective of this study was to examine the effects of multivitamins on pregnancy weight gain. We enrolled 8468 HIV-negative women from Dar es Salaam, Tanzania, in a randomised, placebo-controlled trial of multivitamins on birth outcomes. Women were randomly assigned to receive either a daily oral dose of multivitamin tablets or a placebo and were weighed every 4 weeks from enrolment until the last visit before delivery. Intent-to-treat analyses were carried out to examine the effects of multivitamins on pregnancy weight gain. Multivariate linear and binomial regression models with the log-link function were used to examine the association of weight gain during pregnancy to birthweight. The overall total weight gain was 253 g (SE: 69, P: 0.0003) more, while the overall 4 weekly weight gain was 59 g greater (SE: 18, P: 0.005) among women who received multivitamins compared to placebo. Women in the lowest quartile of gestational weight gain had babies with an average birthweight of 3030 g (SD: 524), while women in the highest quartile had babies weighing 3246 g (SD: 486), on average. Prenatal multivitamin supplements increased gestational weight gain, which was a significant predictor of birthweight.

Primary prevention of neural-tube defects and some other congenital abnormalities by folic acid and multivitamins: history, missed opportunity and tasks

The history of intervention trials of periconception folic acid with multivitamin and folic acid supplementation in women has shown a recent breakthrough in the primary prevention of structural birth defects, namely neural-tube defects and some other congenital abnormalities. Recently, some studies have demonstrated the efficacy of this new method in reducing congenital abnormalities with specific origin; for example, in the offspring of diabetic and epileptic mothers, and in pregnancy with high fever. The benefits and drawbacks of four possible uses of periconception folate/folic acid and multivitamin supplementation are discussed: we believe there has been a missed opportunity to implement this preventive approach in medical practice. The four methods are as follows: (i) dietary intake of folate and other vitamins, (ii) periconception folic acid/multivitamin supplementation, (iii) food fortification with folic acid, and (iv) the combination of oral contraceptives with 6S-5-methytetrahydrofolate ('folate').

Vitamin E: maternal concentrations are associated with fetal growth

BACKGROUND

Few data exist on the effects of the 2 most abundant isomers of vitamin E (alpha- and gamma-tocopherols) on fetal growth.

OBJECTIVE

We measured maternal plasma concentrations of alpha- and gamma-tocopherols and examined their relation with measures of fetal growth. We also examined the relation, controlled for associated maternal factors, of diet and supplement use to tocopherol concentrations at week 28 of gestation.

DESIGN

A cohort of 1231 gravid women from Camden, NJ, was studied from entry to care (16.0 +/- 0.15 wk gestation); plasma tocopherol concentrations were measured at entry and at week 28.

RESULTS

Plasma concentrations of alpha-tocopherol at entry and at week 28 were positively related to increased fetal growth (birth weight for gestation), a decreased risk of small-for-gestational-age births, and an increased risk of large-for-gestational-age births. Concentration of alpha-tocopherol at week 28 was positively related to use of prenatal multivitamins and dietary intake of vitamin E; concentration of gamma-tocopherol was related positively to dietary fat intake and negatively to multivitamin use.

CONCLUSION

Early and late circulating concentrations of alpha-tocopherol are positively associated with fetal growth.

The primary prevention of birth defects: Multivitamins or folic acid?

Periconceptional use of folic acid alone or in multivitamin supplements is effective for the primary prevention of neural-tube defects. The Hungarian randomized and two-cohort controlled trials showed that periconceptional multivitamin supplementation can reduce the occurrence of some other structural birth defects, i.e. congenital abnormalities. These findings were supported by many, but not all observational studies. Recently there have been two main debated questions. The first one is whether the use of folic acid alone or folic acid-containing multivitamins is better. The second one is connected with the dilemma of whether high dose of folic acid (e.g. 5 mg) might be better than a daily multivitamin with 0.4 - 0.8 mg of folic acid. Comparison of the pooled data of two Hungarian trials using a multivitamin containing 0.8 mg folic acid and the data of the Hungarian Case-Control Surveillance of Congenital Abnormalities using high dose of folic acid seemed to be appropriate to answer these questions. Multivitamins containing 0.4 - 0.8 mg of folic acid were more effective for the reduction of neural-tube defects than high dose of folic acid. Both multivitamins and folic acid can prevent some part of congenital cardiovascular malformations. Only multivitamins were able to reduce the prevalence at birth of obstructive defects of urinary tract, limb deficiencies and congenital pyloric stenosis. However, folic acid was effective in preventing some part of rectal/anal stenosis/atresia, and high dose of folic acid had effect in preventing some orofacial clefts. The findings are consistent that periconceptional multivitamin and folic acid supplementation reduce the overall occurrence of congenital abnormalities in addition to the demonstrated effect on neural-tube defects.