Teratogenicity of high vitamin A intake

Implication of Wt1 in the pathogenesis of nephrogenic failure in a mouse model of retinoic acid-induced caudal regression syndrome

Renal malformations are common human birth defects that sometimes occur in the context of the caudal regression syndrome. Here, we found that exposure of pregnant mice to all-trans retinoic acid, at a time when the metanephros has yet to form, causes a failure of kidney development along with caudal regression. Maternal treatment with Am580 (retinoic acid receptor alpha agonist) also induced similar patterns of kidney maldevelopment in the fetus. In metanephroi from retinoic acid-treated pregnancies, renal mesenchyme condensed around the ureteric bud but then failed to differentiate into nephrons, instead undergoing involution by fulminant apoptosis to produce a renal agenesis phenotype. Results of whole organ cultures in serum-free medium, and also tissue recombination experiments, showed that the nephrogenic defect was intrinsic to the kidney and that it resided in the metanephric mesenchyme and not the ureteric bud. Renal mesenchyme from control embryos expressed Wilms' tumor 1 (Wt1), but this transcription factor, which is indispensable for kidney development, failed to express in metanephroi of retinoic acid-exposed embryos. Wt1 expression and organogenesis were both restored, however, when metanephroi from retinoic acid-treated pregnancies were grown in serum-containing media. Our data illuminate the pathobiology of a severe, teratogen-induced kidney malformation.

Risk of drug-induced congenital defects

Defects attributable to drug therapy represent about 1% of congenital defects of known aetiology. This means that a precautionary attitude and correct use of drugs in fertile, and especially pregnant, women is a feasible form of prevention. Drugs currently in use with proven teratogenic effect number approximately 25, but new pharmaceutical drugs are constantly in preparation. Recognition of a drug-induced teratogenic effect is a complex procedure taking into account not only experimental animal data but also experience in humans. Considering that 40% of pregnancies are not planned, it follows that any drug with known or suspected teratogenic potential must be used only under strict medical control. Also, adequate knowledge on potential teratogenicity of a drug permits modification of therapy before conception. It goes without saying that any drug should be used during pregnancy only if it is essential, and it would be prudent to use only those where adequate information is provided and prior clinical experience is available. Teratology Information Services can assist both physicians and patients when any doubt exists.

Nutritional Supplements and Upper Respiratory Tract Illnesses in Young Children in the United States

Key Points

In the United States, children have lower blood levels than adults of eicosapentaenoic acid (EPA), an important ω-3 fatty acid that helps decrease inflammation; vitamin A, the “anti-infective” vitamin; and selenium (Se), a trace metal that is an intrinsic part of glutathione peroxidase, an important free-radical scavenging enzyme.

EPA, vitamin A, and Se are important in controlling inflammation and can be supplied by oral nutritional supplements.

Cod liver oil contains EPA (and other important ω-3 fatty acids), and vitamin A as well as vitamin D.

Fish oil contains ω-3 fatty acids (including EPA) but no vitamins.

Our clinical research demonstrates that daily supplementation with a flavored cod liver oil (which meets European purity standards) and a children’s multivitamin-mineral with trace metals, including Se, can decrease morbidity from upper respiratory tract illnesses, otitis media, and sinusitis in young children living in the United States.

These supplements can be used by practitioners on an individual basis, when clinically indicated; the supplements can be purchased in the United States without a prescription.

Socioeconomically disadvantaged children are at risk for micronutrient deficiencies. However, their families may not be able to afford to purchase these supplements, which are not available through Medicaid, The Special Supplemental Nutrition Program for Women, Infants and Children, or the Food Stamp Program.

If our results are confirmed in larger studies, a system change will be needed to provide these supplements to nutritionally vulnerable, socioeconomically disadvantaged children living in the United States.

Maternal nutritional status and the risk for orofacial cleft offspring in humans

Periconceptional folate and folic acid intake prevents orofacial clefts (OFC) in the offspring. It has been suggested that other nutrients also play a role. We investigated the preconceptional intake of macronutrients (protein, fat, carbohydrate, fiber, and cholesterol), vitamins (vitamin A, retinol, beta-carotene, ascorbic acid, and alpha-tocopherol), minerals (calcium, phosphorus, iron, magnesium, and zinc) and food groups in mothers of OFC children and controls. At approximately 14 mo after the index pregnancy, 206 mothers of a child with a nonsyndromic OFC and 203 control mothers completed a FFQ on current food intake and a general questionnaire. After exclusion of pregnant and lactating mothers, mothers who reported a change in diet compared with the preconceptional period, and those for whom periconceptional folic acid supplement use was unclear, 182 OFC mothers and 173 control mothers were evaluated. Macronutrient, vitamin, mineral, and food group intakes were compared. After adjustment for energy, quintiles of dietary nutrient intake and odds ratios with 95% CI were calculated. The preconceptional intake of all macronutrients, vitamins, minerals, and food groups with the exception of milk (products), potatoes, pies/cookies were lower in OFC mothers than in controls. The energy-adjusted intakes of vegetable protein, fiber, beta-carotene, ascorbic acid, alpha-tocopherol, iron, and magnesium were significantly lower in cases compared with controls. Increasing intakes of vegetable protein, fiber, ascorbic acid, iron, and magnesium decreased OFC risk. In conclusion, a higher preconceptional intake of nutrients predominantly present in fruits and vegetables reduces the risk of offspring affected by OFC.

No effect of vitamin A intake on bone mineral density and fracture risk in perimenopausal women

In recent studies from Sweden and the United States, a high vitamin A intake has been associated with low bone mineral density (BMD) and increased fracture risk. In Sweden and the United States, food items such as milk and breakfast cereals are fortified with vitamin A, whereas in Denmark there is no mandatory fortification with vitamin A. In the present study, we investigated relations between vitamin A intake and BMD and fracture risk in a Danish population consuming mostly unfortified food items. Within a population-based cohort study in 2,016 perimenopausal women, associations between BMD and vitamin A intake were assessed at baseline and after 5-year follow-up. Moreover, associations between baseline vitamin A intake and 5-year changes in BMD were studied. Finally, fracture risk was assessed in relation to vitamin A intake. In our cohort, dietary retinol intake (0.53 mg/day) was lower than the intake reported in recent studies form Sweden (0.78 mg/day) and the United States (1.66 mg/day). Cross-sectional and longitudinal analyses showed no associations between intake of vitamin A and BMD of the femoral neck or lumbar spine. Neither did BMD differ between those 5% who had the highest, and those 5% who had the lowest, vitamin A intake. During the 5-year study period, 163 subjects sustained a fracture (cases). Compared to 978 controls, logistic regression analyses revealed no difference in vitamin A intake. Thus, in a Danish population, average vitamin A intake is lower than in Sweden and the United States and not associated with detrimental effects on bone.

Moderate maternal vitamin A deficiency alters myogenic regulatory protein expression and perinatal organ growth in the rat

Vitamin A deficiency is one of the most common dietary deficiencies in the developing world and is a major health concern where it is associated with increased risk of fetal and infant mortality and morbidity. Early studies in the rat demonstrated that, in addition to respiratory problems, neonates showed evidence of mobility problems in response to moderate vitamin A deficiency. This study investigated whether moderate deficiency of this vitamin plays a role in regulating key skeletal muscle regulatory pathways during development. Thirty female rats were fed vitamin A-moderate (VAM) or vitamin A-sufficient diets from weaning and throughout pregnancy. Fetal and neonatal hindlimb and muscle samples were collected on days 13.5, 15.5, 17.5, and 19.5 of pregnancy and 1 day following birth. Mothers fed the VAM diet had reduced retinol concentrations at all time points studied (P < 0.01), and neonates had reduced relative lung weights (P < 0.01). Fetal weight and survival did not differ between groups but neonatal survival was lower in the VAM group where neonates had increased relative heart weights (P < 0.05). Analysis of myogenic regulatory factor expression and calcineurin signaling in fetuses and neonates demonstrated decreased protein levels of myf5 [50% at 17.5 dg (P < 0.05)], myogenin [70% at birth (P < 0.001)], and myosin heavy chain fast [50% at birth (P < 0.05)] in response to moderate vitamin A deficiency. Overall, these changes suggest that vitamin A status during pregnancy may have important implications for fetal muscle development and subsequent muscle function in the offspring.

Epidemiologic approaches to identifying environmental causes of birth defects

Epidemiology can be used to elucidate environmental causes of birth defects. This paper discusses 1) different types of environmental causes; 2) the difficulties in comparing the prevalence of birth defects between populations, including the need for a population base and the implications of prenatal diagnosis; 3) the main study designs for observational epidemiological studies and the various sources of bias; 4) how statistical power can be increased by meta-analysis or multicentric studies, and improved grouping of birth defects into etiologically more homogeneous subgroups; 5) the distinction between association and causation; 6) the interpretation of clusters in time and space in relation to local environmental causes; and 7) the potential of genetic epidemiology to help elucidate environmental causes. While further research continues into the environmental causes of birth defects, the epidemiologic evidence base for policy making and clinical practice is poor in many areas. The epidemiologic approach is important not only to elucidate environmental causes but also to assess the implementation of existing research into policy and practice for the prevention of birth defects.

Cardiac neural crest of the mouse embryo: axial level of origin,migratory pathway and cell autonomy of the splotch(Sp2H) mutant effect

A sub-population of the neural crest is known to play a crucial role in development of the cardiac outflow tract. Studies in avians have mapped the complete migratory pathways taken by `cardiac' neural crest cells en route from the neural tube to the developing heart. A cardiac neural crest lineage is also known to exist in mammals, although detailed information on its axial level of origin and migratory pattern are lacking. We used focal cell labelling and orthotopic grafting, followed by whole embryo culture, to determine the spatio-temporal migratory pattern of cardiac neural crest in mouse embryos. Axial levels between the post-otic hindbrain and somite 4 contributed neural crest cells to the heart, with the neural tube opposite somite 2 being the most prolific source. Emigration of cardiac neural crest from the neural tube began at the 7-somite stage, with cells migrating in pathways dorsolateral to the somite, medial to the somite, and between somites. Subsequently, cardiac neural crest cells migrated through the peri-aortic mesenchyme, lateral to the pharynx, through pharyngeal arches 3, 4 and 6, and into the aortic sac. Colonisation of the outflow tract mesenchyme was detected at the 32-somite stage. Embryos homozygous for the Sp2H mutation show delayed onset of cardiac neural crest emigration, although the pathways of subsequent migration resembled wild type. The number of neural crest cells along the cardiac migratory pathway was significantly reduced in Sp2H/Sp2H embryos. To resolve current controversy over the cell autonomy of the splotchcardiac neural crest defect, we performed reciprocal grafts of premigratory neural crest between wild type and splotch embryos. Sp2H/Sp2H cells migrated normally in the +/+environment, and +/+ cells migrated normally in the Sp2H/Sp2H environment. In contrast, retarded migration along the cardiac route occurred when either Sp2H/+ or Sp2H/Sp2H neural crest cells were grafted into the Sp2H/Sp2Henvironment. We conclude that the retardation of cardiac neural crest migration in splotch mutant embryos requires the genetic defect in both neural crest cells and their migratory environment.

Gene–nutrient interactions: importance of folates and retinoids during early embryogenesis

The role that nutritional factors play in mammalian development has received renewed attention over the past two decades, as the scientific literature exploded with reports of retinoid compounds disrupting craniofacial development, and with other reports that folic acid supplementation in the periconceptional period can protect embryos from highly significant malformations. As was often the case, the situation became far more complicated, as the interaction between nutritional factors with selected genes was recognized. In this review, we attempt to summarize a complex clinical and experimental literature of nutritional factors, their biological transport mechanisms, and the impact that they have during early embryogenesis. Although not exhaustive, our goal was to provide an overview of important gene-nutrient interactions and a framework for their investigation.

Vitamin A intake and the risk of hip fracture in postmenopausal women: the Iowa Women's Health Study

Excessive intake of vitamin A is postulated to have a detrimental effect on bone by inducing osteoporosis. This may lead to an increased risk of fracture, particularly in persons who are already at risk of osteoporosis. However, few studies have specifically examined the association of vitamin A intake through diet and supplement use, with fractures in a cohort of older, community-dwelling women. We prospectively followed a cohort of 34,703 postmenopausal women from the Iowa Women's Health Study to determine if high levels of vitamin A and retinol intake through food and supplement use were associated with an increased risk of hip or all fractures. A semiquantitative food frequency questionnaire was used to obtain the participants' baseline vitamin A and retinol intake. Participants were followed for a mean duration of 9.5 years for incident self-reported hip and nonhip fractures. After multivariate adjustment, it was revealed that users of supplements containing vitamin A had a 1.18-fold increased risk of incident hip fracture (n = 525) compared with nonusers (95% CI, 0.99 to 1.41), but there was no evidence of an increased risk of all fractures (n = 6,502) among supplement users. There was also no evidence of a dose-response relationship in hip fracture risk with increasing amounts of vitamin A or retinol from supplements. Furthermore, our results showed no association between vitamin A or retinol intake from food and supplements, or food only, and the risk of hip or all fractures. In conclusion, we found little evidence of an increased risk of hip or all fractures with higher intakes of vitamin A or retinol among a cohort of older, postmenopausal women.

Are those in need taking dietary supplements? A survey of 21 923 adults

Many people take dietary supplements, but information on characteristics associated with their use is lacking. The relationship between lifestyle behaviours, morbidity and use of dietary supplements has not been examined and earlier studies have limited applicability to a general population. These issues were addressed in the current study. Information was obtained by postal questionnaire sent to a sample of the general population. The questionnaire was completed by 70.5 % of the sample (15 465 from a total sample of 21 923), with at least one-third (35.5 %) taking dietary supplements. In adjusted analyses, supplement users were more likely to be women, white, home-owners, non-smokers and physically active. Use of vitamin, mineral and/or antioxidant supplements was associated with eating more fruits and vegetables, and taking fish-oil supplements was associated with eating oil-rich fish. A history of CVD or risk factors for CVD reduced the risk of taking vitamins, minerals and/or antioxidants or fish-oil supplements. Those reporting musculoskeletal disorders such as arthritis were more likely to take fish-oil supplements For the first time, we have shown that dietary supplement use is related to different types of morbidity. In particular, people at risk of primary or secondary CVD seem less likely to use dietary supplements, despite possible benefits shown in clinical trials. Public health organisations need to develop guidelines for the public and health professionals regarding the uncontrolled use of dietary supplements in the community.

Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations

BACKGROUND

It is well established that an excessive intake of retinol (vitamin A) is toxic; however, it has been > 25 y since the last extensive treatise of case reports on this subject.

OBJECTIVE

The objectives were to identify and evaluate all individual cases of retinol toxicity published in the scientific literature that assessed the thresholds and symptoms induced by high intakes of retinol and to compare the toxicity of different physical forms of retinol preparations.

DESIGN

We performed a meta-analysis of case reports on toxicity claimed to be induced by intakes of excessive amounts of dietary retinol (ie, retinol and retinyl esters in foods or supplements). Using free text and MESH (medical subheading) strategies in PubMed, we identified 248 articles in the scientific literature. From these initial articles we identified other relevant citations. The final database consisted of 259 cases in which individual data on dose, sex, age, time of exposure, and symptoms are reported.

RESULTS

Chronic hypervitaminosis A is induced after daily doses of 2 mg retinol/kg in oil-based preparations for many months or years. In contrast, doses as low as 0.2 mg retinol. kg(-1). d(-1) in water-miscible, emulsified, and solid preparations for only a few weeks caused chronic hypervitaminosis A. Thus, water-miscible, emulsified, and solid preparations of retinol are approximately 10 times as toxic as are oil-based retinol preparations. The safe upper single dose of retinol in oil or liver seems to be approximately 4-6 mg/kg body wt. These thresholds do not vary considerably with age.

CONCLUSIONS

The results of the present study indicate that the physical form of retinol supplements is a major determinant of toxicity. The use of water-miscible, emulsified, and solid preparations of retinol should therefore be carefully considered before being used in supplements and fortifications.

Genetic evidence that retinaldehyde dehydrogenase Raldh1 (Aldh1a1) functions downstream of alcohol dehydrogenase Adh1 in metabolism of retinol to retinoic acid

Vitamin A (retinol) is a nutrient that is essential for developmental regulation but toxic in large amounts. Previous genetic studies have revealed that alcohol dehydrogenase Adh1 is required for efficient clearance of excess retinol to prevent toxicity, thus demonstrating that the mechanism involves oxidation of excess retinol to retinoic acid (RA). Whereas Adh1 plays a dominant role in the first step of the clearance pathway (oxidation of retinol to retinaldehyde), it is unknown what controls the second step (oxidation of retinaldehyde to RA). We now present genetic evidence that aldehyde dehydrogenase Aldh1a1, also known as retinaldehyde dehydrogenase Raldh1, plays a dominant role in the second step of retinol clearance in adult mice. Serum RA levels following a 50 mg/kg dose of retinol were reduced 72% in Raldh1-/- mice and 82% in Adh1-/- mice. This represented reductions in RA synthesis of 77-78% for each mutant after corrections for altered RA degradation in each. After retinol dosing, serum retinaldehyde was increased 2.5-fold in Raldh1-/- mice (indicating defective retinaldehyde clearance) and decreased 3-fold in Adh1-/- mice (indicating defective retinaldehyde synthesis). Serum retinol clearance following retinol administration was decreased 7% in Raldh1-/- mice and 69% in Adh1-/- mice. LD50 studies indicated a small increase in retinol toxicity in Raldh1-/- mice and a large increase in Adh1-/- mice. These observations demonstrate that Raldh1 functions downstream of Adh1 in the oxidative metabolism of excess retinol and that toxicity correlates primarily with accumulating retinol rather than retinaldehyde.

Teratogenia da vitamina A

A vitamina A é essencial à preservação e ao funcionamento normal dos tecidos, assim como, ao crescimento e desenvolvimento. No humano há evidência indireta que a vitamina A em excesso, durante as primeiras semanas de gestação é teratogênica. Do contrário, não há dúvidas sobre os efeitos deletérios, de uma alimentação carente neste micronutriente e sobre a disponibilidade do conhecimento técnico para evitá-los. A preocupação com o fato de que a vitamina A conduziria a teratogenia em humanos, tem retardado a implementação de programas de combate a carência de vitamina A, atingindo principalmente os programas de enriquecimento de alimentos. A literatura é controvertida e dispõe de poucas informações sobre as doses para suplementação de gestantes. Como o retinol circulante materno é controlado homeostaticamente após o consumo de alimentos fonte de vitamina A, espera-se a mesma resposta metabólica após o consumo de alimentos fortificados, indicando que não há risco de teratogenia. Consequentemente, parece altamente improvável que o consumo de alimentos enriquecidos ou de suplementos de vitamina A pré-formada, nas doses unitárias habituais, tenha efeito teratogênico no homem.

Vitamin A and infancy. Biochemical, functional, and clinical aspects

Vitamin A is a very intriguing natural compound. The molecule not only has a complex array of physiological functions, but also represents the precursor of promising and powerful new pharmacological agents. Although several aspects of human retinol metabolism, including absorption and tissue delivery, have been clarified, the type and amounts of vitamin A derivatives that are intracellularly produced remain quite elusive. In addition, their precise function and targets still need to be identified. Retinoic acids, undoubtedly, play a major role in explaining activities of retinol, but, recently, a large number of physiological functions have been attributed to different retinoids and to vitamin A itself. One of the primary roles this vitamin plays is in embryogenesis. Almost all steps in organogenesis are controlled by retinoic acids, thus suggesting that retinol is necessary for proper development of embryonic tissues. These considerations point to the dramatic importance of a sufficient intake of vitamin A and explain the consequences if intake of retinol is deficient. However, hypervitaminosis A also has a number of remarkable negative consequences, which, in same cases, could be fatal. Thus, the use of large doses of retinol in the treatment of some human diseases and the use of megavitamin therapy for certain chronic disorders as well as the growing tendency toward vitamin faddism should alert physicians to the possibility of vitamin overdose.

Short-term (intestinal) and long-term (postintestinal) conversion of beta-carotene to retinol in adults as assessed by a stable-isotope reference method

BACKGROUND

Quantitative information on the conversion of beta-carotene to vitamin A in humans is limited.

OBJECTIVE

We determined the short- and long-term conversion of labeled beta-carotene to vitamin A by using a stable-isotope reference method.

DESIGN

[(2)H(8)]beta-Carotene (11,011 nmol, or 6 mg) in oil was given with a liquid diet (25% of energy from fat) to 22 adult volunteers (10 men, 12 women). Three days after the [(2)H(8)]beta-carotene dose, the volunteers each took a dose of [(2)H(8)]retinyl acetate (8915 nmol, or 3 mg) in oil with the same liquid diet. Blood samples were collected over 56 d.

RESULTS

The 53-d area under the serum [(2)H(4)]retinol response curve (from the [(2)H(8)]beta-carotene dose) was 569 +/- 385 nmol. d, and the 53-d area under the serum [(2)H(8)]retinol response curve (from the [(2)H(8)]retinyl acetate dose) was 1798 +/- 1139 nmol. d. With the use of [(2)H(8)]retinyl acetate as the vitamin A reference, the [(2)H(4)]retinol formed from [(2)H(8)]beta-carotene (11,011 nmol) was calculated to be equivalent to 3413.9 +/- 2298.4 nmol retinol. The conversion factor of beta-carotene to retinol varied from 2.4 to 20.2, and the average conversion factor was 9.1 to 1 by wt or 4.8 to 1 by mol. This conversion factor was positively correlated with body mass index (r = 0.57, P = 0.006). The postabsorption conversion of beta-carotene was estimated as 7.8%, 13.6%, 16.4%, and 19.0% of the total converted retinol at 6, 14, 21, or 53 d after the [(2)H(8)]beta-carotene dose, respectively.

CONCLUSION

The quantitative determination of the conversion of beta-carotene to vitamin A in humans can be accomplished by using a stable-isotope reference method. This approach provides in vivo metabolic information after a physiologic dose of beta-carotene.

Pregnancy and lactation: physiological adjustments, nutritional requirements and the role of dietary supplements

Nutritional needs are increased during pregnancy and lactation for support of fetal and infant growth and development along with alterations in maternal tissues and metabolism. Total nutrient needs are not necessarily the sum of those accumulated in maternal tissues, products of pregnancy and lactation and those attributable to the maintenance of nonreproducing women. Maternal metabolism is adjusted through the elaboration of hormones that serve as mediators, redirecting nutrients to highly specialized maternal tissues specific to reproduction (i.e., placenta and mammary gland). It is most unlikely that the heightened nutrient needs for successful reproduction can always be met from the maternal diet. Requirements for energy-yielding macronutrients increase modestly compared with several micronutrients that are unevenly distributed among foods. Altered nutrient utilization and mobilization of reserves often offset enhanced needs but sometimes nutrient deficiencies are precipitated by reproduction. There are only limited data from well-controlled intervention studies with dietary supplements and with few exceptions (iron during pregnancy and folate during the periconceptional period), the evidence is not strong that nutrient supplements confer measurable benefit. More research is needed and in future studies attention must be given to subject characteristics that may influence ability to meet maternal and infant demands (genetic and environmental), nutrient-nutrient interactions, sensitivity and selectivity of measured outcomes and proper use of proxy measures. Consideration of these factors in future studies of pregnancy and lactation are necessary to provide an understanding of the links among maternal diet; nutritional supplementation; and fetal, infant and maternal health.

Micronutrients and reproductive health issues: an international perspective

Micronutrients may have a role in enhancing reproductive health of women living in the developing world. Two illustrative micronutrients, zinc and vitamin A, have received some attention in this regard. Numerous animal experiments and observational studies suggest the potential role of zinc deficiency in labor and delivery-related complications such as premature rupture of membrane, placental abruption, preterm labor and inefficient uterine contraction. These associations have not been confirmed in supplementation studies. Zinc does not appear to be a limiting factor in intrauterine growth in the developing world, contrary to some evidence of its suggested benefit among women residing in industrialized countries. One study in Nepal found that maternal vitamin A or beta-carotene supplementation reduces pregnancy-related mortality but not infant mortality. These findings are corroborated by observations of the significantly higher risk of mortality among night-blind women compared to non-night-blind women long after the termination of pregnancy and the resolution of night blindness. Maternal multiple micronutrient supplementation needs more careful evaluation before its use in large-scale programs. Two recent trials indicated that a prenatal multiple micronutrient supplement provides no added advantage over iron and folate in reducing outcomes such as low birth weight and probably no survival benefit. Data are also suggestive that adding zinc may negate the beneficial effect of iron and folic acid on birth weight. Research is needed to further our understanding of nutrient-nutrient interactions.

Dietary supplement use by American women: challenges in assessing patterns of use, motives and costs

The 1994 passage of Public Law 103-417, the Dietary Supplement and Health Education Act, resulted in an exponential increase in the number and variety of dietary supplements available for over-the-counter purchase. Surveys conducted on random samples of U.S. residents have shown that approximately half of all American women use dietary supplements regularly, but very little is known about the risks and benefits of long-term and widespread supplement use. To accurately evaluate the health effects of supplement use, it is important to characterize usage patterns, motivations and costs of supplement use. However, this is a considerable challenge because accurate supplement data are difficult to collect, product databases with consistent and reliable information are lacking and survey instruments or interview protocols currently in use may not capture information about product selection for specific health conditions, motivations for use, or out-of-pocket expenditures. Future research would benefit from collaborative efforts among governmental scientists, academic scientists and industry to improve dietary supplement data collection methods and develop appropriate tools for analysis.

Effect of co-administration of retinoids on rat embryo development in vitro

BACKGROUND

Excess retinyl palmitate (vitamin A) induces a variety of malformations in many mammalian species, yet retinyl palmitate is not thought to be the proximate teratogen. Many metabolites are generated after oral dosing several of which are, individually teratogenic. It is not known whether these metabolites when present simultaneously interact in an additive or synergistic manner.

METHODS

Whole rat embryos were cultured with retinol, all-trans retinoic acid (tRA), 4-oxo all-trans retinoic acid (4otRA) or 9-cis retinoic acid (9cRA). Retinoids were added singly or in paired combinations at the start of culture and embryos were examined for evidence of dysmorphogenesis at the end of culture. Retinoids were added at both subthreshold and supra-threshold concentrations.

RESULTS

Co-administration of subthreshold concentrations of tRA and 4otRA, retinol and tRA or 4otRA and 4otRA and 9cRA resulted in a greater frequency of abnormal embryos compared to single administration of each retinoid.

CONCLUSIONS

Knowledge of the way in which retinyl palmitate metabolites interact should refine our ability to predict risk from a potentially teratogenic event e.g., accidental overdose with RP during human pregnancy.

Strenuous work, nutrition and adverse pregnancy outcomes: a brief review

This brief review explores the available epidemiologic data to investigate the question of whether strenuous work by women during pregnancy in developing countries influences micronutrient status and thereby increase risks of adverse pregnancy outcomes. Some data exist on the potential relationship between strenuous work or physical activity and nutrient compromise, strenuous work or physical activity and adverse reproductive outcomes and micronutrient intakes or status and adverse reproductive outcomes. No substantial body of data exists that has directly investigated the potential causal path of whether strenuous work during pregnancy alters micronutrient status leading to adverse reproductive outcome. Search of the literature identified only a few papers from developing countries that provided even remotely related data on the topic. Thus, the available data are insufficient for drawing firm inferences that strenuous work, in a developing country, alters a pregnant woman's nutritional status and therefore affects her risk of an adverse pregnancy outcome. Effects on nutritional status, micronutrients in particular, of pregnant women from strenuous physical activities at work or in other lifestyle events require further study in developing countries.

Effects of liver-supplemented food on the development of embryos in mice

We examined whether dietary intake of cattle liver-supplemented food induces reproductive effects in dams and developmental effects in embryos in the mouse model. Seven groups of 19 to 35 female mice each were given either powdered food or the food supplemented with crude liver homogenate, its lipophilic component, the defatted liver homogenate or vitamin A (retinol palmitate) during a 25-d period spanning from a week prior to mating to gestation day 18 (GD18). Fetal mortality and incidence of external abnormalities of the fetuses whose dams were given the diet supplemented with the crude liver homogenate increased dose-dependently with an increase in the supplemented amount of the crude liver homogenate. On the other hand, the defatted liver homogenate did not induce any reproductive or teratological effect. The vitamin A (VA)-supplemented food (950 IU/5 g food as VA) induced approximately the same levels of the incidence of total external abnormalities appearing at the same affected regions or organs as the foods supplemented with the 700 mg crude liver homogenate (1029 IU/5 g food as VA) and its lipophilic component (950 IU/5 g food as VA). The content of VA (as 1029 IU/5 g food) in the crude liver homogenate was found to be approximately equal to that in the lipophilic component (950 IU/5 g food as VA). Therefore, it was concluded that VA plays an important role in induction of the lethal and teratogenic effects in the fetuses whose dams were given the powdered foods supplemented with the crude liver homogenate and its lipophilic component.

Serum retinol levels and the risk of fracture

BACKGROUND

Although studies in animals and epidemiologic studies have indicated that a high vitamin A intake is associated with increased bone fragility, no biologic marker of vitamin A status has thus far been used to assess the risk of fractures in humans.

METHODS

We enrolled 2322 men, 49 to 51 years of age, in a population-based, longitudinal cohort study. Serum retinol and beta carotene were analyzed in samples obtained at enrollment. Fractures were documented in 266 men during 30 years of follow-up. Cox regression analysis was used to determine the risk of fracture according to the serum retinol level.

RESULTS

The risk of fracture was highest among men with the highest levels of serum retinol. Multivariate analysis of the risk of fracture in the highest quintile for serum retinol (>75.62 microg per deciliter [2.64 micromol per liter]) as compared with the middle quintile (62.16 to 67.60 microg per deciliter [2.17 to 2.36 micromol per liter]) showed that the rate ratio was 1.64 (95 percent confidence interval, 1.12 to 2.41) for any fracture and 2.47 (95 percent confidence interval, 1.15 to 5.28) for hip fracture. The risk of fracture was further increased within the highest quintile for serum retinol. Men with retinol levels in the 99th percentile (>103.12 microg per deciliter [3.60 micromol per liter]) had an overall risk of fracture that exceeded the risk among men with lower levels by a factor of seven (P<0.001). The level of serum beta carotene was not associated with the risk of fracture.

CONCLUSIONS

Our findings, which are consistent with the results of studies in animals, as well as in vitro and epidemiologic dietary studies, suggest that current levels of vitamin A supplementation and food fortification in many Western countries may need to be reassessed.

Anaemia and micronutrient deficiencies

Anaemia in pregnancy is a common and worldwide problem that deserves more attention. For many developing countries, prevalence rates of up to 75% are reported. Anaemia is frequently severe in these situations and can be expected to contribute significantly to maternal mortality and morbidity. After a discussion of definitions, screening for anaemia and prevalence, the relationship between anaemia and maternal mortality and morbidity will be reviewed. Micronutrient deficiency and especially iron deficiency is believed to be the main underlying cause for anaemia. More recently the role of vitamin A deficiency as a contributing factor to anaemia has also been examined. The difficulties of assessment of micronutrient sufficiency or deficiency in pregnancy are described, as is the interaction between infection and micronutrient deficiency states.

A complex deoxyribonucleic acid response element in the rat Ca(2+)/calmodulin-dependent protein kinase IV gene 5'-flanking region mediates thyroid hormone induction and chicken ovalbumin upstream promoter transcription factor 1 repression

Ca(2+)/calmodulin-dependent protein kinase IV (CaMKIV) is regulated by T(3) in a time- and concentration-dependent manner in the developing rat brain and plays an important role in neuronal-specific gene regulation. T(3) treatment, but not retinoic acid (RA), stimulated endogenous CaMKIV mRNA 5-fold in mouse embryonic stem (ES) cells differentiated into neurons. We localized a region -750 to -700 in the CaMKIV gene 5'-flanking region that conferred T(3) responsiveness and bound thyroid hormone receptor (TR), retinoic acid receptor (RAR), and chicken ovalbumin upstream promoter-transcription factor 1 (COUP-TF1). T(3) and RA treatment stimulated the CaMKIV hormone response element. Cotransfection of a COUP-TF1 expression vector repressed the T(3) response and augmented the RA response. Mutational analysis identified three half-sites arranged in a direct repeat (AB) and overlapping inverted repeat (BC), required for functional induction and receptor binding. TR and RAR bound predominantly to the BC portion of the element and COUP-TF1 to the AB region, with a close correlation of binding and functional studies. COUP-TF1 binding did not influence TR/retinoid X receptor binding but modestly augmented RAR/retinoid X receptor binding. A single element confers T(3) and COUP-TF1 regulation of CaMKIV expression.

Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome

It is the position of the American Dietetic Association that women of childbearing potential should maintain good nutritional status through a lifestyle that optimizes maternal health and reduces the risk of birth defects, suboptimal fetal growth and development, and chronic health problems in their children. The key components of a health-promoting lifestyle during pregnancy include appropriate weight gain; consumption of a variety of foods in accordance with the Food Guide Pyramid; appropriate and timely vitamin and mineral supplementation; avoidance of alcohol, tobacco, and other harmful substances; and safe food-handling. Prenatal weight gain within the Institute of Medicine (IOM) recommended ranges is associated with better pregnancy outcomes. The total energy needs during pregnancy range between 2,500 to 2,700 kcal a day for most women, but prepregnancy body mass index, rate of weight gain, maternal age, and physiological appetite must be considered in tailoring this recommendation to the individual. The consumption of more food to meet energy needs and the increased absorption and efficiency of nutrient utilization that occurs in pregnancy are generally adequate to meet the needs for most nutrients. However, vitamin and mineral supplementation is appropriate for some nutrients and situations. This statement also includes recommendations pertaining to use of alcohol, tobacco, caffeine, street drugs, and other substances during pregnancy; food safety; and management of common complaints during pregnancy and specific health problems. In particular for medical nutrition therapy, pregnant women with inappropriate weight gain, hyperemesis, poor dietary patterns, phenylketonuria (PKU), certain chronic health problems, or a history of substance abuse should be referred to a qualified dietetics professional.

Antioxidant vitamins and their influence in diabetes mellitus

Diabetes mellitus is a chronic disease associated with serious complications. A number of studies have suggested that enhanced oxidation is the underlying abnormality responsible for some of the complications of diabetes. It is not known whether the ingestion of antioxidant vitamins could retard or perhaps reverse the oxidative damage. The information regarding the benefit of antioxidant vitamin supplementation is conflicting some trials have demonstrated adverse effects of excessive consumption of vitamin supplements. In this article, we review the available literature on the association of cardiovascular events and ingestion of vitamins with antioxidant properties. Given the lack of data to substantiate the benefit and safety of ingestion of antioxidant vitamins in excess of the recommended dietary allowance, physicians should avoid the recommendation of vitamin supplementation to their patients.

Naso-maxillary deformity due to frontonasal expression of human transthyretin gene in transgenic mice

BACKGROUND

Retinoic acid, a metabolic product of retinol, is essential for craniofacial morphogenesis. Transthyretin (TTR) is a plasma protein delivering retinol to tissues. We produced several transgenic mouse lines using the human mutant TTR (hTTRMet30) gene to establish a mouse model of familial amyloidotic polyneuropathy. One of the lines showed an autosomal dominant inheritance of naso-maxillary deformity termed Nax.

RESULTS

The Nax malformation was characterized by a hypoplastic developmental defect of the frontonasal region. Homozygous mice with higher transgene expressions showed more severe phenotypes, but a subline, in which the copy number and expression of the transgene was reduced, showed a normal phenotype, indicating that the hTTRMet30 expression caused the malformation. Nax mice began to express the hTTRMet30 gene in the nasal placode from embryonic day 10.5 (E10.5), which was 2 days earlier than in the other transgenic lines with a normal phenotype. Excessive cell death was observed in the nasal placode of the E10.5 Nax embryos. In addition, the forced expression of hTTRMet30 in the nasal placode of transgenic mice resulted in similar phenotypes.

CONCLUSION

The expression of the hTTRMet30 gene in the nasal placode at E10.5 induced apoptotic cell death, leading to hypoplastic deformity in the frontonasal region.

Estimating the potential for vitamin A toxicity in women and young children

This paper describes usual intakes of vitamin A from diet plus low dose supplements, reviews methods for assessing vitamin A toxicity and applies a kinetic analysis of vitamin A turnover to estimate the effect of high dose supplements on vitamin A liver stores in infants and young children. In the United States, the 95th percentile of intake by preschoolers from foods and supplements exceeds the tolerable upper level (UL) but is below the no-observed-adverse-effect level (NOAEL). The 95th percentile of vitamin A intake from foods and supplements for nonpregnant, nonlactating women aged 19-30 y also exceeds the UL but is below the NOAEL for women of reproductive age. In low income populations in developing countries, vitamin A intakes of preschoolers and women consuming foods plus low dose supplements can also exceed the UL but are unlikely to exceed the NOAEL. There are few data on which to establish thresholds for excessive vitamin A intake or vitamin A concentrations in tissues. To assess the potential toxicity of the new recommendations (see article by Ross in this issue) for high dose vitamin A supplements for infants and children, we used a kinetic approach to estimate accumulation of the vitamin in liver. The new recommendations are unlikely to result in toxic levels (>300 microg per gram of liver) even if high dose supplements are inadvertently given monthly. The kinetic analysis also illustrates that a constant supply of vitamin A from breast milk (and/or complementary foods) is vital for preventing depletion of liver vitamin A stores between high dose supplements.

Drug-induced congenital defects: strategies to reduce the incidence

Approximately 1% of congenital anomalies relate to pharmacological exposure and are. in theory, preventable. Prevention consists of controlled administration of drugs known to have teratogenic properties (e.g. retinoids, thalidomide). When possible, prevention could take the form of the use of alternative pharmacological therapies during the pre-conception period for certain specific pathologies, selecting the most appropriate agent for use during pregnancy [e.g. haloperidol or a tricyclic antidepressant instead of lithium; anticonvulsant drug monotherapy in place of multitherapy; propylthiouracil instead of thiamazole (methimazole)], and substitution with the most suitable therapy during pregnancy (e.g. insulin in place of oral antidiabetics; heparin in place of oral anticoagulants; alpha-methyldopa instead of ACE inhibitors). Another strategy is the administration of drugs during pregnancy taking into account the pharmacological effects in relation to the gestation period (e.g. avoidance of chemotherapy during the first trimester, avoidance of nonsteroidal anti-inflammatory drugs in the third trimester, and avoidance of high doses of benzodiazepines in the period imminent to prepartum).

Use of US birth certificate data to estimate the risk of maternal cigarette smoking for oral clefting

OBJECTIVE

The purpose of this study was to evaluate the relationship between maternal cigarette smoking and the risk of having an offspring with an oral cleft.

DESIGN

This was a large population-based, matched case-control study derived from the United States Natality database for 1997.

SUBJECTS

The sample consisted of 2029 cases with non-syndromic oral clefts and 4050 non-malformed controls. Controls were matched to cases on mother's and father's race and child's sex, county of birth, and month of birth. This sample was selected from a total of 3,093,821 births in the United States, which represents 80% of all births in this country during 1997.

RESULTS

The association between maternal cigarette smoking and oral clefts in the offspring was close to the null (odds ratio 1.16; 95% confidence interval (CI) 1.01 to 1.33; one-sided Fisher exact test p =.0207). The comparison and pooling of results to those of a similar study that used the U.S. Natality database for 1996 resulted in a common Mantel-Haenszel odds ratio of 1.33 (95% CI 1.21 to 1.46). The dose-response analysis was slightly significant for all levels of maternal smoking.

CONCLUSION

This large study confirms that smoking during pregnancy is only a minor risk factor for oral clefting in the offspring.

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

OBJECTIVE

We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.

DESIGN

Cross-sectional study.

SETTING

Four antenatal clinics in rural northern Tanzania.

SUBJECTS/METHODS

A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70-89 g/l (n=61), Hb=90-109 g/l (n=86), Hb=110-149 g/l (n=105) and Hb> or =150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.

MAIN OUTCOME MEASURES

Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l.

RESULTS

Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90-109 g/l) were similar, but weaker.

CONCLUSIONS

Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.

SPONSORSHIP

The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Porcine intestinal metabolism of excess vitamin a differs following vitamin a supplementation and liver consumption

Vitamin A is a well-established teratogen in all animal species. A number of case reports also suggest a teratogenic potential of vitamin A in humans. A possible teratogenic risk of dietary liver vitamin A intake, the kinetics of vitamin A and its metabolites in humans after intake of either a vitamin A supplement or a liver meal have been studied. Major differences were described for the kinetics of all-trans-retinoic acid (all-trans-RA), which occurred at much higher concentrations after supplementation than after liver consumption. Therefore, we investigated whether the intestine may be responsible for the differences in vitamin A metabolism after supplementation or liver feeding. We found that cytosolic fractions of porcine enterocytes oxidized retinol to all-trans-RA in vitro with a K(m) of 94-96 micromol/L and a V(max) of 7.9-8.6 pmol/(min x mg protein). In an in vivo approach, the portal vein and the central vein (external jugular vein) of a pig were cannulated. In two subsequent experiments, the pig was given a vitamin A supplement or liver. Plasma samples were taken from portal and central veins. Comparison of retinoid levels in these veins indicated that all-trans-RA was already formed from supplemental vitamin A in the intestine and released into the systemic circulation. Two major metabolic pathways were additionally present in the pig, leading to the formation of glucuronides of all-trans-RA and retinol itself. Our results indicate that intestinal metabolism contributes to the elevated levels of all-trans-RA in the systemic circulation after supplementation with vitamin A, but not after consumption of liver.

Vitamin A supplementation during pregnancy

BACKGROUND

Vitamin A supplements have been recommended in pregnancy to improve outcomes that include maternal mortality and morbidity.

OBJECTIVES

To review the effectiveness of vitamin A supplementation during pregnancy, alone or in combination with other supplements, on maternal and newborn clinical and laboratory outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's specialised register of controlled trials (April 2002) and the Cochrane Controlled Trials Register (The Cochrane Library Issue 1, 2002).

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating the effect of vitamin A supplementation in pregnant women. The types of intervention included vitamin A supplementation alone or in combination with other micro-nutrients.

DATA COLLECTION AND ANALYSIS

We assessed trials for methodological quality using the standard Cochrane criteria of adequacy of concealment. At least two reviewers independently assessed the trials for inclusion and extracted data. We collected information on blinding, loss to follow-up, setting, number of women, exclusion after randomisation and follow-up as well as supplementation type, dose and frequency. The outcomes we sought included maternal and neonatal clinical and laboratory outcomes.

MAIN RESULTS

Five trials involving 23,426 women were included. Because the trials were heterogeneous with regard to type of supplement given, duration of supplement use and outcomes measured, pooled results using meta analysis could not be performed. One large population based trial in Nepal showed a possible beneficial effect on maternal mortality after weekly vitamin A supplements. In this study a reduction was noted in all cause maternal mortality up to 12 weeks postpartum with Vitamin A supplementation (RR 0.60, 95% CI 0.37-0.97). Night-blindness was assessed in a nested case-control study within this trial and found to be reduced but not eliminated. Three trials examined the effect of vitamin A supplementation on haemoglobin levels. The trial from Indonesia showed a beneficial effect in women who were anaemic ([Hb] <11.0 g/dl). After supplementation, the proportion of women who became non-anaemic was 35% in the Vitamin A supplemented group, 68% in the iron-supplemented group, 97% in the group supplemented with both Vitamin A and iron and 16% in the placebo group. The two trials from Malawi did not corroborate these positive findings.

REVIEWER'S CONCLUSIONS

Although the two trials from Nepal and Indonesia suggested beneficial effects of vitamin A supplementation, further trials are needed to determine whether vitamin A supplements can reduce maternal mortality and morbidity and by what mechanism.

Embryonic gut anomalies in a mouse model of retinoic Acid-induced caudal regression syndrome: delayed gut looping, rudimentary cecum, and anorectal anomalies

Vitamin A and its derivatives such as retinoic acid (RA) are important signaling molecules for morphogenesis of vertebrate embryos. Little is known, however, about morphogenetic factors controlling the development of the gastrointestinal tract and RA is likely to be involved. In the mouse, teratogenic doses of RA cause truncation of the embryonic caudal body axis that parallel the caudal regression syndrome as described in humans. These changes are often associated with anomalies of the lower digestive tract. Overlapping spatiotemporal expression of retinoic acid receptor-beta (RAR beta) and cellular retinol-binding protein I, CRBPI, with Hoxb5 and c-ret in the gut mesoderm imply possible cooperation required for proper neuromuscular development. To determine susceptibility and responsiveness of the developing gut and its neuromusculature to exogenous retinoids we used a mouse model of RA-induced caudal regression syndrome. The results showed that stage-specific RA treatment both in vivo and in vitro affected gut looping/rotation morphogenesis and growth of asymmetrical structures such as the cecum together with delayed differentiation of the gut mesoderm and colonization of the postcecal gut by neural crest-derived enteric neuronal precursors. These observations demonstrate that RA has a direct effect on gut morphogenesis and innervation.

Retinoic acid metabolites in plasma are higher after intake of liver paste compared with a vitamin A supplement in women

The objectives of the present study were to compare the bioavailability of vitamin A from liver paste and from a vitamin A supplement at three nutritionally relevant levels of intake, and to estimate levels of "safe" intake based on concentrations of retinoic acid and its metabolites in plasma after a single dose of vitamin A from liver paste. Women (n = 35; 19-47 y of age) consumed 3.0, 7.5 or 15 mg vitamin A as liver paste or as a vitamin A supplement with a test meal in a randomized design, with a combined crossover (two sources) and parallel approach (three dosages). Retinyl esters and retinoic acid (RA) metabolites were quantified in blood samples at 2-24 h after dosing. The areas under the time-response curves (AUC) were calculated to evaluate responses in plasma vitamin A after intake of liver paste and the vitamin A supplements. For retinyl esters, the AUC was significantly affected by the dosage, but not by the source. The formation of 13-cis-RA, 13-cis-4-oxo-RA, and to a lesser extent all-trans-RA was significantly higher after consumption of liver paste compared with the supplement, especially at higher dosages. Long-term baseline concentrations of retinol were not affected by a single intake of vitamin A. In conclusion, the bioavailability of vitamin A from single doses of liver paste and a vitamin A supplement does not differ, but the plasma concentrations of RA metabolites are higher after intake of liver paste. Thus, pregnant women should indeed limit the intake of vitamin A from liver products.

Vitamin A and cardiac outflow tract defects

To assess the relationship between maternal intake of vitamin A and cardiac outflow tract defects, we examined data from a population-based case-control study among liveborn infants born from 1987 through 1989 to mothers residing in the Baltimore-Washington area. Case infants (126) had a nonsyndromic cardiac outflow tract defect. Control infants (679) did not have birth defects and were a stratified random sample of liveborn infants from the same area. The main exposure was average daily maternal intake of retinol and provitamin A carotenoids from foods and supplements during the year before conception. Compared with an average intake of less than 10,000 IU, retinol intake of 10,000 IU or more from supplements was associated with a ninefold increased risk for transposition of the great arteries (odds ratio = 9.2; 95% confidence interval = 4.0-21.2), but not for outflow tract defects with normally related arteries (odds ratio = 0.8; 95% confidence interval = 0.1-6.6). Similar intakes of carotenoids and dietary retinol were not associated with an increased risk for either type of outflow tract defect.

Assessment of the food safety issues related to genetically modified foods

International consensus has been reached on the principles regarding evaluation of the food safety of genetically modified plants. The concept of substantial equivalence has been developed as part of a safety evaluation framework, based on the idea that existing foods can serve as a basis for comparing the properties of genetically modified foods with the appropriate counterpart. Application of the concept is not a safety assessment per se, but helps to identify similarities and differences between the existing food and the new product, which are then subject to further toxicological investigation. Substantial equivalence is a starting point in the safety evaluation, rather than an endpoint of the assessment. Consensus on practical application of the principle should be further elaborated. Experiences with the safety testing of newly inserted proteins and of whole genetically modified foods are reviewed, and limitations of current test methodologies are discussed. The development and validation of new profiling methods such as DNA microarray technology, proteomics, and metabolomics for the identification and characterization of unintended effects, which may occur as a result of the genetic modification, is recommended. The assessment of the allergenicity of newly inserted proteins and of marker genes is discussed. An issue that will gain importance in the near future is that of post-marketing surveillance of the foods derived from genetically modified crops. It is concluded, among others that, that application of the principle of substantial equivalence has proven adequate, and that no alternative adequate safety assessment strategies are available.

[Dietary recommendations for pregnant women affected with phenylketonuria]

Prevention of embryopathy due to maternal phenylketonuria is possible thanks to a maternal-specific low-phenylalanine diet, which has to be started before conception and followed during the whole gestation. The setup of this diet implies knowing the recommended dietary allowances for normal pregnant women as well as for women with nutritional deficiencies. Women with phenylketonuria must be considered at risk for nutritional imbalance for two main reasons. First, most adult women with phenylketonuria have been on a vegetarian diet for many years without protein substitutes or medical control. Secondly, the strict diet for pregnant women with phenylketonuria may induce anorexia or nutritional deficits if it is not well tolerated or understood. Protein, iron, calcium, selenium, vitamin B 12 and caloric intakes are the most sensitive parameters. Close cooperation with an experienced medical and dietician team is required.

Dietary guidelines for pregnancy: a review of current evidence

In a successful pregnancy maternal health is maintained, a healthy baby is delivered and the mother is able to nurture her newborn adequately. Despite continued interest in the role and importance of maternal diet in this process, we do not have a clear understanding of how the nutritional status of the mother influences fetal growth and development. Recent epidemiological evidence of an association between poor fetal growth and adult disease highlights the need to reconsider the influences which act on the fetus, and the role maternal nutrition may play. Nutrient needs are increased in pregnancy. For the mother to be solely dependent upon her dietary intake to meet these demands, would represent a very high risk strategy. Hence adequate reserves are important for a successful outcome. Whilst there are numerous observational studies of diet during pregnancy, there are only limited data from well-controlled, randomised supplementation studies. A recent systematic review showed only dietary supplements balanced in energy and protein content to result consistently in improved fetal growth. There is no strong evidence that nutrient supplements confer benefit in women without overt deficiency. To interpret future dietary studies in pregnancy we need to consider metabolic differences between women which may influence their ability to meet fetal nutrient demand, to allow for nutrient-nutrient interactions, and to take account of differences in timing in gestation. Consideration of these factors in studies of pregnancy, will lead to a clearer understanding of the links between maternal diet and fetal growth and development. Until we have this understanding, it is reasonable to expect that women entering pregnancy are provided with a diet which is adequate, based upon our normal understanding of requirements, and it is not acceptable for women to be expected to carry a pregnancy with an obvious or overt nutritional deficiency.

Dietary factors and risk of spontaneous abortion

OBJECTIVE

This study examines the association between dietary habits and risk of spontaneous abortion.

DESIGN

Hospital-based case-control study.

SETTING

Obstetric hospitals in Milan, Italy.

SUBJECTS

Cases were: 912 women admitted for spontaneous abortion (within the 12th week of gestation). Controls were: women who gave birth at term to healthy infants on randomly selected days at the same hospitals where cases had been identified.

RESULTS

The risk of spontaneous abortion was inversely and significantly related to green vegetables, fruit, milk, cheese, eggs and fish consumption. The multivariate odds ratios (OR), for highest versus lowest levels of intake, were 0.3 for fruit, 0.5 for cheese, 0.6 for green vegetables and milk and 0.7 for fish and eggs. The major type of seasoning fats have showed a direct association with risk of miscarriage. Comparing the highest with the lowest intake, the ORs were 2.0 (95% confidence interval, CI 1.1-3.6) and 1.6 (95% CI 1.1-2.3) for butter and oil, respectively. No consistent association emerged between meat, liver, ham and carrots intake and the risk of spontaneous abortion.

CONCLUSIONS

This result suggests that a diet poor in several aspects, including vegetables and fruit, milk and dairy products, but rich in fats, may be a determinant or a correlate of increased risk of spontaneous abortion.