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Santos-Calderón LA, Rojas-Gómez A, Ramos-Rodríguez C, Murphy MM. Indicators of Cobalamin Status During Pregnancy, Pregnancy Outcome and Long-Term Effects on Offspring Health. Food Nutr Bull 2024; 45:S10-S15. [PMID: 38987881 DOI: 10.1177/03795721241229502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND Little attention has been given to prenatal cobalamin insufficiency in settings where dietary cobalamin intake is presumed adequate, such as populations with habitual intake of foods from animal sources. RESULTS However, low cobalamin status in women of fertile age has been reported in Europe, United States, and Canada. In India, where cobalamin deficiency is highly prevalent, it has been associated with an increased risk of miscarriage, intrauterine growth retardation, as well as insulin resistance and lower neurodevelopment scores in the offspring. Low cobalamin status in pregnancy has been associated with similar outcomes as those reported in the Indian studies although the evidence is scant and conflicting. CONCLUSIONS Consideration should be given to maternal cobalamin status in the context of prevention of adverse pregnancy outcomes as well as cobalamin insufficiency both in the mother and the offspring during lactation. Further attention is now justified with the increasing tendency toward plant-based diets. Reference intervals for cobalamin status during each trimester of pregnancy are needed and further investigation of the long-term conse-quences of low cobalamin status during pregnancy for health and development in the offspring is warranted.
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Affiliation(s)
- Luis Adolfo Santos-Calderón
- Unit of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Reus, IISPV, Universitat Rovira i Virgili, Spain
| | - Alejandra Rojas-Gómez
- Unit of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Reus, IISPV, Universitat Rovira i Virgili, Spain
| | - Carla Ramos-Rodríguez
- Unit of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Reus, IISPV, Universitat Rovira i Virgili, Spain
| | - Michelle M Murphy
- Unit of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Reus, IISPV, Universitat Rovira i Virgili, Spain
- CIBERObn (Instituto de Salud Carlos III), Spain
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Monasso GS, Hoang TT, Mancano G, Fernández-Barrés S, Dou J, Jaddoe VW, Page CM, Johnson L, Bustamante M, Bakulski KM, Håberg SE, Ueland PM, Battram T, Merid SK, Melén E, Caramaschi D, Küpers LK, Sunyer J, Nystad W, Heil SG, Schmidt RJ, Vrijheid M, Sharp GC, London SJ, Felix JF. A meta-analysis of epigenome-wide association studies on pregnancy vitamin B12 concentrations and offspring DNA methylation. Epigenetics 2023; 18:2202835. [PMID: 37093107 PMCID: PMC10128528 DOI: 10.1080/15592294.2023.2202835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/22/2022] [Accepted: 01/06/2023] [Indexed: 04/25/2023] Open
Abstract
Circulating vitamin B12 concentrations during pregnancy are associated with offspring health. Foetal DNA methylation changes could underlie these associations. Within the Pregnancy And Childhood Epigenetics Consortium, we meta-analysed epigenome-wide associations of circulating vitamin B12 concentrations in mothers during pregnancy (n = 2,420) or cord blood (n = 1,029), with cord blood DNA methylation. Maternal and newborn vitamin B12 concentrations were associated with DNA methylation at 109 and 7 CpGs, respectively (False Discovery Rate P-value <0.05). Persistent associations with DNA methylation in the peripheral blood of up to 482 children aged 4-10 y were observed for 40.7% of CpGs associated with maternal vitamin B12 and 57.1% of CpGs associated with newborn vitamin B12. Of the CpGs identified in the maternal meta-analyses, 4.6% were associated with either birth weight or gestational age in a previous work. For the newborn meta-analysis, this was the case for 14.3% of the identified CpGs. Also, of the CpGs identified in the newborn meta-analysis, 14.3% and 28.6%, respectively, were associated with childhood cognitive skills and nonverbal IQ. Of the 109 CpGs associated with maternal vitamin B12, 18.3% were associated with nearby gene expression. In this study, we showed that maternal and newborn vitamin B12 concentrations are associated with DNA methylation at multiple CpGs in offspring blood (PFDR<0.05). Whether this differential DNA methylation underlies associations of vitamin B12 concentrations with child health outcomes, such as birth weight, gestational age, and childhood cognition, should be further examined in future studies.
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Affiliation(s)
- Giulietta S. Monasso
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Thanh T. Hoang
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, Durham, NC, USA
| | - Giulia Mancano
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Bristol Medical School Population Health Sciences, University of Bristol, Bristol, UK
| | - Sílvia Fernández-Barrés
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), madrid,Barcelona, Spain
| | - John Dou
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Vincent W.V. Jaddoe
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Christian M. Page
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Mathematics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Laura Johnson
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - Mariona Bustamante
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), madrid,Barcelona, Spain
| | - Kelly M. Bakulski
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Siri E. Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Thomas Battram
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Simon K. Merid
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children’s Hospital, South General Hospital, Stockholm, Sweden
| | - Doretta Caramaschi
- College of Life and Environmental Sciences, Department of Psychology, University of Exeter, Exeter, UK
| | - Leanne K. Küpers
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Jordi Sunyer
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), madrid,Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Wenche Nystad
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Sandra G. Heil
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rebecca J. Schmidt
- Department of Public Health Sciences, School of Medicine, University of California Davis, Davis, USA
- The UC Davis MIND Institute, School of Medicine, University of California Davis, Sacramento, USA
| | - Martine Vrijheid
- ISGlobal, Bacelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), madrid,Barcelona, Spain
| | - Gemma C. Sharp
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Bristol Medical School Population Health Sciences, University of Bristol, Bristol, UK
| | - Stephanie J. London
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, Durham, NC, USA
| | - Janine F. Felix
- The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Tiwari A, Kumar Singh R, Satone PD, Meshram RJ. Metformin-Induced Vitamin B12 Deficiency in Patients With Type-2 Diabetes Mellitus. Cureus 2023; 15:e47771. [PMID: 38034222 PMCID: PMC10688235 DOI: 10.7759/cureus.47771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
Diabetes mellitus (DM) is the most common metabolic disease worldwide. Hence, the prevalence of the disease continues to increase across the globe. Metformin is used as a first-line oral hypoglycemic drug to keep control of type-2 DM (T2DM) in adults. Diabetic patients on metformin have been largely seen to be suffering from a deficiency of vitamin B12. It is a water-soluble vitamin mainly obtained from animal food like meat. At the basic cell level, it acts as a cofactor for enzymes essential for DNA synthesis and neuroprotection. As a result, vitamin B12 deficiency can show clinical effects such as progressive demyelination, peripheral neuropathy and haematological abnormalities (such as macrocytic anaemia and neutrophil hypersegmentation). Various studies also show a relation between vitamin B12 insufficiency and metformin-treated T2DM patients as decreased absorption of vitamin B12. There could be a severe complication of vitamin B12 deficiency in T2DM patients. The use of proton pump inhibitors, gastric bypass surgery, older patients and patients with a higher red blood cell turnover are factors that hasten the depletion of vitamin B12 reserves in the liver. Methylmalonic acid and homocysteine levels can be measured to identify vitamin B12 insufficiency at its early stage if blood vitamin B12 levels are borderline. The action of metformin on vitamin B12 absorption and its potential mechanisms of inhibition will be the main topics of discussion in this review. The review will also discuss how vitamin B12 deficiencies in T2DM patients using metformin affect their clinical results.
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Affiliation(s)
- Aakriti Tiwari
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rakshit Kumar Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Prasiddhi D Satone
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Revat J Meshram
- Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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St-Laurent A, Plante AS, Lemieux S, Robitaille J, MacFarlane AJ, Morisset AS. Higher Than Recommended Folic Acid Intakes is Associated with High Folate Status Throughout Pregnancy in a Prospective French-Canadian Cohort. J Nutr 2023; 153:1347-1358. [PMID: 36848988 DOI: 10.1016/j.tjnut.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND Folate and vitamin B12 status during pregnancy are important for maternal and neonatal health. Maternal intake and prepregnancy body mass index (ppBMI) can influence biomarker status. OBJECTIVES This study aimed to, throughout pregnancy; 1) assess folate and B12 status including serum total folate, plasma total vitamin B12, and homocysteine (tHcy); 2) examine how these biomarkers are associated with intakes of folate and B12 and with ppBMI; and 3) determine predictors of serum total folate and plasma total vitamin B12. METHODS In each trimester (T1, T2, and T3), food and supplement intakes of 79 French-Canadian pregnant individuals were assessed by 3 dietary recalls (R24W) and a supplement use questionnaire. Fasting blood samples were collected. Serum total folate and plasma total vitamin B12 and tHcy were assessed by immunoassay (Siemens ADVIA Centaur XP). RESULTS Participants were 32.1 ± 3.7 y and had a mean ppBMI of 25.7 ± 5.8 kg/m2. Serum total folate concentrations were high (>45.3 nmol/L, T1: 75.4 ± 55.1, T2: 69.1 ± 44.8, T3: 72.1 ± 52.1, P = 0.48). Mean plasma total vitamin B12 concentrations were >220 pmol/L (T1: 428 ± 175, T2: 321 ± 116, T3: 336 ± 128, P < 0.0001). Mean tHcy concentrations were <11 μmol/L across trimesters. Most participants (79.6%-86.1%) had a total folic acid intake above the Tolerable Upper Intake Level (UL, >1000 μg/d). Supplement use accounted for 71.9%-76.1% and 35.3%-41.8% of total folic acid and vitamin B12 intakes, respectively. The ppBMI was not correlated with serum total folate (P > 0.1) but was weakly correlated with and predicted lower plasma total vitamin B12 in T3 (r = -0.23, P = 0.04; r2 = 0.08, standardized beta [sβ] = -0.24, P = 0.01). Higher folic acid intakes from supplements predicted higher serum total folate (T1: r2 = 0.05, sβ = 0.15, P = 0.04, T2: r2 = 0.28, sβ = 0.56, P = 0.01, T3: r2 = 0.19, sβ = 0.44, P < 0.0001). CONCLUSIONS Most pregnant individuals had elevated serum total folate concentrations, reflecting total folic acid intakes above the UL driven by supplement use. Vitamin B12 concentrations were generally adequate and differed by ppBMI and pregnancy stage.
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Affiliation(s)
- Audrey St-Laurent
- School of Nutrition, Laval University, Quebec City, Canada; Endocrinology and Nephrology Unit, CHU of Quebec-Laval University Research Center, Quebec City, Canada; NUTRISS Research Center, Institute of Nutrition and Functional Foods, Laval University, Quebec City, Canada
| | - Anne-Sophie Plante
- School of Nutrition, Laval University, Quebec City, Canada; Endocrinology and Nephrology Unit, CHU of Quebec-Laval University Research Center, Quebec City, Canada
| | - Simone Lemieux
- School of Nutrition, Laval University, Quebec City, Canada; NUTRISS Research Center, Institute of Nutrition and Functional Foods, Laval University, Quebec City, Canada
| | - Julie Robitaille
- School of Nutrition, Laval University, Quebec City, Canada; Endocrinology and Nephrology Unit, CHU of Quebec-Laval University Research Center, Quebec City, Canada; NUTRISS Research Center, Institute of Nutrition and Functional Foods, Laval University, Quebec City, Canada
| | - Amanda J MacFarlane
- Nutrition Research Division, Health Canada, Ottawa, Ontario, Canada; Agriculture, Food, and Nutrition Evidence Center, Texas A&M University, Fort Worth, Texas, USA
| | - Anne-Sophie Morisset
- School of Nutrition, Laval University, Quebec City, Canada; Endocrinology and Nephrology Unit, CHU of Quebec-Laval University Research Center, Quebec City, Canada; NUTRISS Research Center, Institute of Nutrition and Functional Foods, Laval University, Quebec City, Canada.
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Venkata Surekha M, Shravanthi G, Shalini T, Uday Kumar P. Vitamin B12 status in term pregnant women and the cord blood samples of their newborns: A cross-sectional study. Nutr Health 2023:2601060231151720. [PMID: 36803291 DOI: 10.1177/02601060231151720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Background and aim: In India, total vitamin B12 (Vit B12) and its active form (active B12) have not been studied in mother's blood and cord blood. We hypothesized that total and active B12 levels are sufficiently maintained in cord blood despite low levels in mothers. Methods: Two hundred term pregnant mother's blood and cord blood was collected and analyzed for total Vit B12 (radioimmunoassay method) and active B12 levels (enzyme-linked immunosorbent assay). Mean values of constant or continuous variables (hemoglobin (Hb), packed cell volume (PCV), mean corpuscular volume (MCV), white blood cells (WBC), and Vit B12) were compared in mother's blood and newborn cord blood using Student's t-test and multiple comparisons within the groups were carried out with ANOVA. Spearman's correlation (Vit B12) and multivariable backward regression analyses (height, weight, education, body mass index (BMI) and Hb, PCV, MCV, WBC, and Vit B12 levels) were also performed. Results: Total Vit 12 deficiency was highly prevalent at 89% and active B12 deficiency was 36.7% in mothers. Cord blood showed total Vit B12 deficiency prevalence of 53% and active B12 deficiency being 9.3%. Total Vit B12 (p<0.001) and active B12 (p<0.001) levels were significantly higher in cord blood when compared to mother's blood. In multivariate analysis, higher total and active B12 levels in mother's blood predicted higher levels of total and active B12 levels in cord blood. Conclusion: Our study showed higher prevalence of total and active Vit B12 deficiency in mothers compared to cord blood thus indicating their transfer to fetus irrespective of mother's status. Maternal Vit B12 levels affected cord blood Vit B12 levels.
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Affiliation(s)
- Mullapudi Venkata Surekha
- Pathology and Microbiology Division, Indian Council of Medical Research (ICMR) - National Institute of Nutrition, Hyderabad, India
| | | | - Tattari Shalini
- Biochemistry Division, 28603ICMR - National Institute of Nutrition, Hyderabad, India
| | - Putcha Uday Kumar
- Pathology and Microbiology Division, Indian Council of Medical Research (ICMR) - National Institute of Nutrition, Hyderabad, India
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Pregnancy homocysteine and cobalamin status predict childhood metabolic health in the offspring. Pediatr Res 2023; 93:633-642. [PMID: 35641553 DOI: 10.1038/s41390-022-02117-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/08/2022] [Accepted: 05/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inadequate pregnancy cobalamin status has been associated with adverse offspring metabolic health in Indian and Nepalese studies. Studies of pregnancy cobalamin status and mid-childhood health outside of Asia are scarce. METHODS Associations between pregnancy fasting plasma total homocysteine (tHcy), cobalamin status (plasma cobalamin, holotranscobalamin (holoTC), methylmalonic acid (MMA)) and mid-childhood metabolic score (MetSco) ((including fat mass index (zFMI), homeostatic model assessment of insulin resistance (zHOMA-IR) and dyslipidemia (zTG - zHDLc)/2) z-scores)) were investigated in a prospective study of 293 mother-child dyads. RESULTS Highest versus low-mid pregnancy tHcy tertile was associated with higher mid-childhood MetSco, specifically with higher child zFMI. Stratifying by sex, the maternal tHcy-child MetSco association was limited to boys and confirmed for zFMI and zHOMA-IR. The maternal tHcy-child zFMI association was not mediated by birth weight z-score. First trimester plasma cobalamin was not associated with child outcomes, but other indicators of cobalamin status were. Lowest versus mid-high plasma holoTC tertile was associated with MetSco (specifically zFMI and zHOMA-IR) and highest versus low-mid plasma MMA tertile with higher MetSco and dyslipidemia in boys. CONCLUSIONS Moderately elevated pregnancy tHcy and low cobalamin status were associated with mid-childhood metabolic score in boys. The pregnancy tHcy-child zFMI association was not mediated by birth weight. IMPACT Fasting plasma total homocysteine (tHcy) during pregnancy and low cobalamin status during early pregnancy are associated with mid-childhood metabolic score and its components in the offspring. These findings were only significant in male offspring. The study provides new evidence that impaired one carbon metabolism during pregnancy is associated with negative health outcomes in the offspring, in a population with low prevalence of cobalamin deficiency. The maternal-offspring associations were observed in the functional markers of cobalamin status (holotranscobalamin and methylmalonic acid) and tHcy, not with plasma cobalamin concentration. Screening for low pregnancy cobalamin status should be considered.
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Patti MA, Braun JM, Arbuckle TE, MacFarlane AJ. Associations between folic acid supplement use and folate status biomarkers in the first and third trimesters of pregnancy in the Maternal-Infant Research on Environmental Chemicals (MIREC) Pregnancy Cohort Study. Am J Clin Nutr 2022; 116:1852-1863. [PMID: 36255373 PMCID: PMC9761751 DOI: 10.1093/ajcn/nqac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/15/2022] [Accepted: 08/19/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Achieving optimal folate status during early gestation reduces the risk of neural tube defects (NTDs). While inadequate folate intake remains a concern, it is becoming increasingly common for individuals to consume higher than recommended doses of folic acid (FA) with minimal additional benefit. OBJECTIVE Here, we sought to investigate the determinants, including FA supplement dose and use, of plasma total and individual folate vitamer concentrations in the first and third trimesters of pregnancy. METHODS Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort exposed to mandatory FA fortification, we measured plasma total folate and individual folate vitamer [5-methyltetrahydrofolate (5-methylTHF), unmetabolized FA (UMFA), and non-methyl folates (sum of THF, 5-formylTHF, 5,10-methenyl-THF)] concentrations in the first and third trimesters (n = 1,893). Using linear mixed models, we estimated associations between plasma folate concentrations, total daily supplemental FA intake, plasma vitamin B-12 concentrations, and multiple demographic, maternal, and reproductive factors. RESULTS Almost 95% of MIREC study participants met or exceeded the recommended daily supplemental FA intake from supplements (≥400 μg/d), with approximately 25% consuming more than the Tolerable Upper Intake Level (>1000 μg/d). Over 99% of MIREC participants had a plasma total folate status indicative of maximal NTD risk reduction (25.5 nmol/L) regardless of FA supplement dose. UMFA was detected in almost all participants, with higher concentrations associated with higher FA doses. Determinants of adequate FA supplement intake and folate status associated with reduced NTD risk included indicators of higher socioeconomic position, higher maternal age, nulliparity, and lower prepregnancy BMI. CONCLUSIONS In the context of mandatory FA fortification, our data indicate that higher-than-recommended FA doses are unwarranted, with the exception of individuals at higher risk for NTDs. Ideally, prenatal supplements would contain 400 rather than 1000 µg FA, thereby enabling the consumption of optimal and safe FA doses.
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Affiliation(s)
- Marisa A Patti
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Joseph M Braun
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Tye E Arbuckle
- Population Studies Division, Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario, Canada (retired)
| | - Amanda J MacFarlane
- Nutrition Research Division, Health Canada, Ottawa, Ontario, Canada
- Department of Biology, Carleton University, Ottawa, Ontario, Canada
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Mishra A, Bisen AC, Kumar P, Rathore AS, Verma SK, Sanap SN, Kumar M, Godbole MM, Bhatta RS. Simultaneous estimation of total homocysteine and methylmalonic-acid using LC-MS/MS: Clinical application in adult and pediatric. Anal Biochem 2022; 659:114907. [PMID: 36209897 DOI: 10.1016/j.ab.2022.114907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 12/14/2022]
Abstract
Quantitative determination of biomarkers homocysteine (Hcy) and methylmalonic acid (MMA), the regulators of cobalamin (Cbl) and folate levels, together used as a biomarkers to diagnose chemical insufficiency/deficiency of Cbl and folate. We report simultaneous clinical estimation of total Hcy and MMA with efficient clean-up, sensitive and selective LC-MS/MS method. Efficient sample clean-up was achieved by a two-step extraction protocol with 100 μL serum. The validated method was applied to 893 clinical samples from 2 cohorts including pediatrics and mothers, respectively, for identifying their Cbl and folate status. The method shows excellent order of linearity for Hcy (22.2nM-3.7 μM) and MMA (42.34 nM - 5.92 μM), respectively. Complete method validation was performed where intraday-interday accuracy-precision and mean stability recovery data were found within ±15%. The validated method was extended for the quantification of serum total Hcy-MMA levels in clinical samples. The efficient extraction with negligible matrix-effect (ME) has reduced LC-MS/MS chocking and clean-up downtime. The rapid, sensitive and robust LC-MS/MS method has been successfully validated for simultaneous estimation of total Hcy and MMA using only 100 μL serum. The method was applicable to large number of clinical samples and was found to be good throughput with low contamination of mass detector, high sensitivity and selectivity.
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Affiliation(s)
- Anjali Mishra
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India; Academy of Scientific & Innovative Research (AcSIR), CSIR-HRDC Campus, Sector 19, Kamla Nehru Nagar, Ghaziabad, Uttar Pradesh, 201002, India
| | - Amol Chhatrapati Bisen
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India; Academy of Scientific & Innovative Research (AcSIR), CSIR-HRDC Campus, Sector 19, Kamla Nehru Nagar, Ghaziabad, Uttar Pradesh, 201002, India
| | - Praveen Kumar
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Atul Singh Rathore
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Sarvesh Kumar Verma
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Sachin Nashik Sanap
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India; Academy of Scientific & Innovative Research (AcSIR), CSIR-HRDC Campus, Sector 19, Kamla Nehru Nagar, Ghaziabad, Uttar Pradesh, 201002, India
| | - Mukesh Kumar
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - M M Godbole
- Department of Molecular Medicine and Biotechnology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rabi Sankar Bhatta
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India; Academy of Scientific & Innovative Research (AcSIR), CSIR-HRDC Campus, Sector 19, Kamla Nehru Nagar, Ghaziabad, Uttar Pradesh, 201002, India.
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Reischl-Hajiabadi AT, Garbade SF, Feyh P, Weiss KH, Mütze U, Kölker S, Hoffmann GF, Gramer G. Maternal Vitamin B 12 Deficiency Detected by Newborn Screening-Evaluation of Causes and Characteristics. Nutrients 2022; 14:3767. [PMID: 36145143 PMCID: PMC9505342 DOI: 10.3390/nu14183767] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022] Open
Abstract
Vitamin B12 deficiency, mostly of maternal origin in newborns, is a well-treatable condition but can cause severe neurologic sequelae in infants. Early detection of vitamin B12 deficiency allows the pre-symptomatic treatment of affected children. This evaluation assesses the characteristics of maternal vitamin B12 deficiency detected by newborn screening. In a prospective single-center study, a systematic screening strategy for vitamin B12 deficiency using a combination of two second-tier strategies was applied. In addition to confirmatory diagnostics in children, the systematic work-up of vitamin B12 status was also performed for their mothers. Maternal characteristics were assessed including ethnic origin, diet, and vitamin supplementation during pregnancy. For affected mothers, a work-up by internal medicine was recommended. In total, 121 mother-infant couples were analyzed. 66% of mothers adhered to a balanced diet including meat. The cause of maternal vitamin B12 deficiency was unknown in 56% of cases, followed by dietary causes in 32%, and organic causes in 8%. All mothers following a vegan diet and most mothers with a vegetarian diet took vitamin preparations during pregnancy, whereas only 55.8% of mothers with a balanced diet took folic acid or other vitamins. Maternal vitamin B12, folic acid, and homocysteine levels were significantly correlated with the child's folic acid levels, and with homocysteine, methylmalonic, and methylcitric acid levels in first and second NBS dried blood spots. Most children had normal blood counts and showed normocytosis. Although 36.7% of mothers showed anemia, only one presented with macrocytosis. Adherence to vitamin supplementation in pregnancy is low despite the recommendation for supplementation of folic acid. Ideally, the evaluation of mothers for vitamin B12 levels and appropriate therapy should be initiated in early pregnancy. In infants detected through newborn screening, the multidisciplinary assessment and therapy of both children and mothers should be performed.
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Affiliation(s)
- Anna T. Reischl-Hajiabadi
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F. Garbade
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Patrik Feyh
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Ulrike Mütze
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F. Hoffmann
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Gwendolyn Gramer
- Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistraße 52, 20246 Hamburg, Germany
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10
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Sobowale OI, Khan MR, Roy AK, Raqib R, Ahmed F. Prevalence and Risk Factors of Vitamin B 12 Deficiency among Pregnant Women in Rural Bangladesh. Nutrients 2022; 14:1993. [PMID: 35631134 PMCID: PMC9144522 DOI: 10.3390/nu14101993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Vitamin B12 deficiency is associated with an increased risk of pregnancy complications and adverse birth outcomes. However, data on vitamin B12 deficiency in pregnant Bangladeshi women are limited. This study examines vitamin B12 deficiency and marginal deficiency in rural Bangladeshi women during early and late pregnancies. Some 522 women whose gestational age was <20 weeks were recruited. Serum vitamin B12 concentrations were measured at baseline and after 14 weeks of iron-folate supplementation. Logistic regression analysis examined the association of various socio-demographic, dietary, and pregnancy-related factors with vitamin B12 deficiency and marginal deficiency. Overall, 19% of the women during early pregnancy had vitamin B12 deficiency (serum vitamin B12 concentration < 203 pg/mL) and nearly 40% had marginal deficiency (serum vitamin B12 concentration 203 to <300 pg/mL). Vitamin B12 deficiency doubled to 38% during late pregnancy, while marginal deficiency slightly increased to 41.7%. The pregnant women with a gestational age of ≥27 weeks had a higher risk of developing vitamin B12 deficiency (OR = 2.61; 95% CI = 1.096−6.214) than those of a gestational age of <27 weeks. Vitamin B12 deficiency was significantly higher in pregnant women in rented accommodation (OR = 13.32; 95% CI = 1.55−114.25) than in those living in their own house. Vitamin B12 deficiency was significantly higher among women who consumed red or organ meat <3 times a week than in those who consumed it more often (OR = 2.327, 95% CI = 1.194−4.536). None of these factors were significantly associated with marginal vitamin B12 deficiency. In conclusion, vitamin B12 deficiency and marginal deficiency among pregnant rural Bangladeshi women increased as their pregnancies progressed. Increasing gestational age, living in a rented house, and the consumption of red or organ meat <3 times a week were identified as the independent risk factors of vitamin B12 deficiency in this population. Further research with more in-depth assessments of dietary vitamin B12 intakes is needed to develop an intervention program preventing vitamin B12 deficiency in this population.
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Affiliation(s)
| | - Moududur Rahman Khan
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka 1000, Bangladesh;
| | - Anjan Kumar Roy
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka 1212, Bangladesh; (A.K.R.); (R.R.)
| | - Rubhana Raqib
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka 1212, Bangladesh; (A.K.R.); (R.R.)
| | - Faruk Ahmed
- Public Health, School of Medicine and Dentistry, Gold Coast Campus, Griffith University, Gold Coast, QLD 4220, Australia
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11
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Dib MJ, Gumban-Marasigan M, Yoxall R, Andrew T, Harrington DJ, Sobczyńska-Malefora A, Ahmadi KR. Evaluating the Diagnostic Value of a Combined Indicator of Vitamin B12 Status (cB12) Throughout Pregnancy. Front Nutr 2022; 8:789357. [PMID: 35155515 PMCID: PMC8825834 DOI: 10.3389/fnut.2021.789357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background Inadequate provision of vitamin B12 during pregnancy is associated with a number of adverse maternal and fetal outcomes. We set out to (1) suggest pregnancy-specific reference ranges for a range of biomarkers of vitamin B12; (2) assess the temporal behaviors of these markers over the course of pregnancy; and (3) test whether any biomarkers, including the genetic marker HIBCH rs291466 strongly associated with MMA measured early in pregnancy could reliably and significantly predict future B12 status within a healthy UK population of pregnant women. Materials and Methods We used existing biobank samples from the placebo arm of the UK Selenium in PRegnancy Intervention (SPRINT) study, to generate biochemical data for serum folate, B12, holotranscobalamin (HoloTC), total homocysteine (tHcy), and MMA, calculate cB12, and genotyped the polymorphism rs291466 in gene HIBCH on a total of n=114 women across trimesters 1–3 of their pregnancy. We performed a series of exploratory cross-sectional and longitudinal analyses to investigate levels at each trimester, suggest references ranges, evaluate changes and correlations between the B12 biomarkers, and assess the predictive capabilities of each biomarker from 12-weeks to 35-weeks of gestation. Results Significant changes in all vitamin B12 biomarker values were observed over the three trimesters (P < 0.05). Our study shows that cB12 values were largely constant and stable throughout trimester 1 (T1) and T2 (i.e., up to week 20), but declined significantly in T3 (−66% | P < 0.001). Yet, cB12 generally remained within the normal boundaries. We identified pregnancy and trimester-specific reference ranges for each biomarker at each trimester, notably for total serum B12. This marker fell below the recommended cut-offs in 1/3 of the cohort at the third trimester, contrasting other markers (mostly normal). Our multivariate analyses indicated that none of the biomarkers could reliably and accurately predict any other biomarkers than themselves later in pregnancy. Yet, HoloTC seems to be a promising predictor within the limitations of our cohort, constituted of B12-replete individuals. Most notably, cB12 did not significantly predict itself between trimesters. Finally, we show that the HIBCH variant has little predictive power for MMA or cB12 as it does not explain the significant increase in MMA concentrations nor the decline of cB12 throughout pregnancy. Conclusion Trimester-specific reference ranges for biomarkers of vitamin B12 in normal pregnancy are suggested. However, these biomarkers have limited predictive value in identifying mothers at elevated risk of vitamin B12 insufficiency/deficiency during pregnancy.
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Affiliation(s)
- Marie-Joe Dib
- Department of Nutritional Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
- Department of Biostatistics and Epidemiology, School of Public Health, Imperial College, London, United Kingdom
- *Correspondence: Marie-Joe Dib
| | | | - Rozzie Yoxall
- Department of Nutritional Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Toby Andrew
- Department of Genomics of Common Disease, Imperial College, London, United Kingdom
| | - Dominic J. Harrington
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, United Kingdom
- Division of Women's Health, School of Medicine, King's College London, London, United Kingdom
| | - Agata Sobczyńska-Malefora
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, United Kingdom
- Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Kourosh R. Ahmadi
- Department of Nutritional Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
- Kourosh R. Ahmadi
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12
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Obeid R, Eussen SJPM, Mommers M, Smits L, Thijs C. Imbalanced Folate and Vitamin B12 in the Third Trimester of Pregnancy and its Association with Birthweight and Child Growth up to 2 Years. Mol Nutr Food Res 2021; 66:e2100662. [PMID: 34821015 DOI: 10.1002/mnfr.202100662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/12/2021] [Indexed: 01/25/2023]
Abstract
SCOPE Folic acid supplementation during pregnancy may lead to an imbalance when vitamin B12 intake is low (folate trap) and may affect child's growth. METHODS The authors study the association between third trimester maternal intakes of folate and B12 and birthweight and postnatal growth of 2632 infants from the KOALA Birth Cohort Study. Plasma vitamin biomarkers are measured in 1219 women. RESULTS Imbalanced total intakes (folate > 430 µg day-1 combined with B12 < 5.5 µg day-1 ) are not associated with birthweight [β adj (95% CI) = -14.87 (-68.87, 39.13)] compared with high intakes of both. Imbalanced intake is associated with a lower z score of weight at 1-2 years [β adj = -0.14 (-0.25, -0.03)]. Having red blood cell folate > 745 nmol L-1 and plasma B12 < 172 pmol L-1 is not associated with birthweight [β adj = -7.10 (-97.90, 83.71) g]. Maternal dietary B12 intake [β adj = -9.5 (-15.6, -3.3)] and plasma methylmalonic acid [β adj = 234 (43, 426)] are associated with birthweight. CONCLUSION Low maternal dietary B12 intake and elevated methylmalonic acid rather than imbalanced vitamins are associated with higher birthweight, suggesting that low maternal B12 can predispose the infants for later obesity.
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Affiliation(s)
- Rima Obeid
- Department of Clinical Chemistry and Laboratory Medicine, Saarland University Hospital, Kirrberg street, Building 57, Homburg, Saarland, D-66421, Germany
| | - Simone J P M Eussen
- Department of Epidemiology, Maastricht University Medical Centre+, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Monique Mommers
- Department of Epidemiology, Maastricht University Medical Centre+, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Luc Smits
- Department of Epidemiology, Maastricht University Medical Centre+, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Carel Thijs
- Department of Epidemiology, Maastricht University Medical Centre+, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
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13
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Sobczyńska-Malefora A, Yajnik CS, Harrington DJ, Hitman GA, Finer S. Vitamin B12 and Folate Markers Are Associated with Insulin Resistance During the Third Trimester of Pregnancy in South Asian Women, Living in the United Kingdom, with Gestational Diabetes and Normal Glucose Tolerance. J Nutr 2021; 152:163-170. [PMID: 34601603 PMCID: PMC8754569 DOI: 10.1093/jn/nxab352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/21/2021] [Accepted: 09/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) can adversely affect the health of the developing fetus. Women of South Asian origin are particularly at risk of developing GDM. Insulin resistance (IR) contributes to the etiology of GDM, and although studies have shown associations of vitamin B12 (B12) and folate status with GDM and IR, only a limited number of B12 and folate markers have been used. OBJECTIVE We used a comprehensive panel of B12 and folate markers to examine their association with IR in pregnant women with diet-controlled GDM and normal glucose tolerance (NGT). METHODS In this cross-sectional study, 59 British-Bangladeshi women (24 GDM and 35 NGT) with a mean age of 29 y, BMI (in kg/m2) 26.7 and gestational age 33 wk were recruited. Serum total B12, holotranscobalamin, folate, methylmalonic acid, plasma homocysteine, 5-methyltetrahydrofolate, and red cell folate (RCF) were measured along with other parameters. The independent sample t-test and chi-squared test were used to assess differences in markers between GDM and NGT women. Spearman's test was used to look for correlations. A simple multiple regression analysis was used to investigate if markers of B12 and folate status predicted IR, using the HOMA-IR and adjusting for age, GDM status, and BMI. RESULTS There were no differences in concentrations of B12 and folate markers between GDM and NGT women. In Spearman's analysis HOMA-IR correlated negatively with total serum B12 (P < 0.001) and holotranscobalamin (P < 0.05), and positively with BMI (P < 0.001), blood pressure (P < 0.05) and triglycerides (P < 0.05) in all women. MMA did not correlate with any of the B12 markers. In regression analysis, total B12 (β = -0.622, P = 0.004), RCF (β = 0.387, P = 0.018), and BMI (β = 0.024, P < 0.001) were the significant predictors of HOMA-IR variance. CONCLUSIONS Significant associations between markers of B12 and folate status with HOMA-IR were found during the third trimester in British-Bangladeshi women. B12 markers correlated poorly with each other.
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Affiliation(s)
| | | | - Dominic J Harrington
- Nutristasis Unit, Viapath, St. Thomas’ Hospital, London, United Kingdom,Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Graham A Hitman
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Sarah Finer
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom,Barts Health NHS Trust, London, United Kingdom
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14
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Infante M, Leoni M, Caprio M, Fabbri A. Long-term metformin therapy and vitamin B12 deficiency: An association to bear in mind. World J Diabetes 2021; 12:916-931. [PMID: 34326945 PMCID: PMC8311483 DOI: 10.4239/wjd.v12.i7.916] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/21/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
To date, metformin remains the first-line oral glucose-lowering drug used for the treatment of type 2 diabetes thanks to its well-established long-term safety and efficacy profile. Indeed, metformin is the most widely used oral insulin-sensitizing agent, being prescribed to more than 100 million people worldwide, including patients with prediabetes, insulin resistance, and polycystic ovary syndrome. However, over the last decades several observational studies and meta-analyses have reported a significant association between long-term metformin therapy and an increased prevalence of vitamin B12 deficiency. Of note, evidence suggests that long-term and high-dose metformin therapy impairs vitamin B12 status. Vitamin B12 (also referred to as cobalamin) is a water-soluble vitamin that is mainly obtained from animal-sourced foods. At the cellular level, vitamin B12 acts as a cofactor for enzymes that play a critical role in DNA synthesis and neuroprotection. Thus, vitamin B12 deficiency can lead to a number of clinical consequences that include hematologic abnormalities (e.g., megaloblastic anemia and formation of hypersegmented neutrophils), progressive axonal demyelination and peripheral neuropathy. Nevertheless, no definite guidelines are currently available for vitamin B12 deficiency screening in patients on metformin therapy, and vitamin B12 deficiency remains frequently unrecognized in such individuals. Therefore, in this "field of vision" article we propose a list of criteria for a cost-effective vitamin B12 deficiency screening in metformin-treated patients, which could serve as a practical guide for identifying individuals at high risk for this condition. Moreover, we discuss additional relevant topics related to this field, including: (1) The lack of consensus about the exact definition of vitamin B12 deficiency; (2) The definition of reliable biomarkers of vitamin B12 status; (3) Causes of vitamin B12 deficiency other than metformin therapy that should be identified promptly in metformin-treated patients for a proper differential diagnosis; and (4) Potential pathophysiological mechanisms underlying metformin-induced vitamin B12 deficiency. Finally, we briefly review basic concepts related to vitamin B12 supplementation for the treatment of vitamin B12 deficiency, particularly when this condition is induced by metformin.
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Affiliation(s)
- Marco Infante
- UniCamillus, Saint Camillus International University of Health Sciences, Rome 00131, Italy
- Diabetes Research Institute Federation (DRIF), Division of Endocrinology and Diabetes, CTO Alesini Hospital, Department of Systems Medicine, University of Rome Tor Vergata, Rome 00145, Italy
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Rome 00145, Italy
| | - Martina Leoni
- Diabetes Research Institute Federation (DRIF), Division of Endocrinology and Diabetes, CTO Alesini Hospital, Department of Systems Medicine, University of Rome Tor Vergata, Rome 00145, Italy
| | - Massimiliano Caprio
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome 00166, Italy
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome 00166, Italy
| | - Andrea Fabbri
- Diabetes Research Institute Federation (DRIF), Division of Endocrinology and Diabetes, CTO Alesini Hospital, Department of Systems Medicine, University of Rome Tor Vergata, Rome 00145, Italy
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15
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Sobczyńska-Malefora A, Delvin E, McCaddon A, Ahmadi KR, Harrington DJ. Vitamin B 12 status in health and disease: a critical review. Diagnosis of deficiency and insufficiency - clinical and laboratory pitfalls. Crit Rev Clin Lab Sci 2021; 58:399-429. [PMID: 33881359 DOI: 10.1080/10408363.2021.1885339] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vitamin B12 (cobalamin) is an essential cofactor for two metabolic pathways. It is obtained principally from food of animal origin. Cobalamin becomes bioavailable through a series of steps pertaining to its release from dietary protein, intrinsic factor-mediated absorption, haptocorrin or transcobalamin-mediated transport, cellular uptake, and two enzymatic conversions (via methionine synthase and methylmalonyl-CoA-mutase) into cofactor forms: methylcobalamin and adenosylcobalamin. Vitamin B12 deficiency can masquerade as a multitude of illnesses, presenting different perspectives from the point of view of the hematologist, neurologist, gastroenterologist, general physician, or dietician. Increased physician vigilance and heightened patient awareness often account for its early presentation, and testing sometimes occurs during a phase of vitamin B12 insufficiency before the main onset of the disease. The chosen test often depends on its availability rather than on the diagnostic performance and sensitivity to irrelevant factors interfering with vitamin B12 markers. Although serum B12 is still the most commonly used and widely available test, diagnostics by holotranscobalamin, serum methylmalonic acid, and plasma homocysteine measurements have grown in the last several years in routine practice. The lack of a robust absorption test, coupled with compromised sensitivity and specificity of other tests (intrinsic factor and gastric parietal cell antibodies), hinders determination of the cause for depleted B12 status. This can lead to incorrect supplementation regimes and uncertainty regarding later treatment. This review discusses currently available knowledge on vitamin B12, informs the reader about the pitfalls of tests for assessing its deficiency, reviews B12 status in various populations at different disease stages, and provides recommendations for interpretation, treatment, and associated risks. Future directions for diagnostics of B12 status and health interventions are also discussed.
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Affiliation(s)
- Agata Sobczyńska-Malefora
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Edgard Delvin
- Sainte-Justine UHC Research Centre, Montreal, Canada.,Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, Canada
| | | | - Kourosh R Ahmadi
- Department of Nutrition & Metabolism, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Dominic J Harrington
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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16
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Maternal vitamin B12 deficiency and perinatal outcomes in southern India. PLoS One 2021; 16:e0248145. [PMID: 33822790 PMCID: PMC8023483 DOI: 10.1371/journal.pone.0248145] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 02/19/2021] [Indexed: 12/16/2022] Open
Abstract
Background Vitamin B12 deficiency during pregnancy has been associated with adverse maternal and infant health outcomes. Few prospective studies have investigated vitamin B12 status early in pregnancy, and its links to infant vitamin B12 status, particularly in India where the burden of vitamin B12 deficiency is estimated to be the highest globally. The objective of this study was to examine the associations of maternal vitamin B12 biomarkers with neonatal vitamin B12 status. Methods Pregnant women (~12 weeks’ gestation) were enrolled in a perinatal cohort study in Bangalore, India. Total vitamin B12, methylmalonic acid (MMA), and homocysteine concentrations were evaluated in maternal samples at enrollment and in neonates at birth using cord blood. Linear and binomial regression models were used to evaluate the associations of maternal vitamin B12 biomarkers with neonatal vitamin B12 status and perinatal outcomes. Results A total of 63.2% of women had vitamin B12 deficiency (<148 pmol/L), 87.2% had vitamin B12 insufficiency (<221 pmol/L), and 47.3% had impaired vitamin B12 status (vitamin B12<148 pmol/L and MMA>0.26μmol/L) at enrollment; 40.8% of neonates had vitamin B12 deficiency, 65.6% were insufficiency, and 38.1% had impaired vitamin B12 status at birth. Higher maternal vitamin B12 concentrations at enrollment were associated with increased neonatal vitamin B12 concentrations (β(SE): 0.40 (0.05); p<0.0001) and lower risk of neonatal vitamin B12 deficiency (Risk Ratio [RR]: 0.53; 95% CI: [0.43, 0.65]; p<0.0001). Maternal vitamin B12 deficiency (RR: 1.97 [1.43, 2.71]; p<0.001), insufficiency (RR: 2.18 [1.23, 3.85]; p = 0.007), and impaired vitamin B12 status (RR: 1.49 [1.13, 1.97]; p = 0.005) predicted a two-fold increase in the risk of neonatal vitamin B12 deficiency at birth. Conclusions The prevalence of vitamin B12 deficiency was high early in pregnancy and predicted neonatal vitamin B12 status. Future research is needed to determine the role of vitamin B12 in the development of pregnancy and infant outcomes, and to inform screening and interventions to improve maternal and child health.
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17
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Maternal vitamin B 12 status in early pregnancy and its association with birth outcomes in Canadian mother-newborn Dyads. Br J Nutr 2021; 126:1823-1831. [PMID: 33602347 DOI: 10.1017/s0007114521000581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vitamin B12 (B12) is a co-enzyme essential for fetal growth and development. Lower maternal B12 status has been associated with preterm birth (<37 gestational weeks) and low birth weight (<2500 g), which are linked to morbidity and mortality across the lifespan. In Canada, 17-25 % of women in early pregnancy had a serum total B12 concentration <148 pmol/l and maternal total B12 concentration decreased throughout pregnancy. This study aimed to determine the association between maternal B12 status and birth outcomes in Canadian mother-newborn dyads. A secondary analysis of 709 mother-newborn dyads in British Columbia (BC), Canada, was conducted. Bio-banked first- (n 656) and second-trimester (n 709) maternal serum samples of apparently healthy South Asian (50 %) and European (50 %) women from the BC Prenatal Genetic Screening Program were quantified for B12 biomarkers (total B12, holotranscobalamin (holoTC), methylmalonic acid (MMA) and total homocysteine (tHcy)). Obstetric history and birth outcome data were obtained from the BC Perinatal Data Registry. All associations were determined using multiple linear regression. Maternal serum total B12, holoTC, MMA and tHcy had a mean weekly decrease of 3·64 pmol/l, 1·04 pmol/l, 1·44 nmol/l and 0·104 μmol/l, respectively (P < 0·001). Despite a total B12 concentration <148 pmol/l among 20-25 % of the women, maternal B12 biomarker concentrations were not associated with birth weight z-score, head circumference z-score and gestational age at birth (P > 0·05). Additional research in women at high risk of adverse birth outcomes and the association between maternal B12 status and functional, for example, cognitive, outcomes is needed.
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18
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Rashid S, Meier V, Patrick H. Review of Vitamin B12 deficiency in pregnancy: a diagnosis not to miss as veganism and vegetarianism become more prevalent. Eur J Haematol 2021; 106:450-455. [PMID: 33341967 DOI: 10.1111/ejh.13571] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 01/23/2023]
Abstract
Vegetarianism and veganism are increasingly popular. The Food Standards Agency, biennial Food and You Survey of adults aged 16 years and over living in the UK, found that between 2012 and 2018 the proportion of people who reported never consuming dairy products had increased from 2% to 5%. However, veganism risks development of vitamin B12 deficiency as it is not available from plant sources. Moreover, its impact may be slow to be detected because body stores of vitamin B12 can last years. There is currently no published guidance on antenatal diagnosis and management of vitamin B12 deficiency. This paper reviews the metabolism, diagnosis and treatment of vitamin B12 in pregnancy. It concludes that national screening policymakers should consider introducing screening for B12 deficiency into the Antenatal and Newborn Screening Programmes for mothers and their infants if at risk of vitamin B12 deficiency. In the interim, national policy should be developed for prophylactic vitamin B12 supplementation in high-risk groups around the time of pregnancy.
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Affiliation(s)
- Sabia Rashid
- Lewisham and Greenwich NHS Trust, Queen Elizabeth Hospital, London, UK
| | - Violet Meier
- Library and Knowledge Services, University Hospital Lewisham, London, UK
| | - Hannah Patrick
- Lewisham and Greenwich NHS Trust, Queen Elizabeth Hospital, London, UK
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19
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Prevalence and Indicators of Vitamin B12 Insufficiency among Young Women of Childbearing Age. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010001. [PMID: 33374905 PMCID: PMC7792587 DOI: 10.3390/ijerph18010001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Abstract
Vitamin B12 insufficiency is a global health issue among women of childbearing age, yet few studies have investigated its prevalence and risk factors among healthy Middle Eastern populations. This cross-sectional study included 346 Saudi women aged 19–30 years and enrolled at King Saud University, Riyadh, Saudi Arabia. A series of questionnaires were administered to record the study participants’ sociodemographic status, medical history, dietary intake, and physical activity. Participants’ anthropometric data were also recorded and their fasting blood samples were analyzed. The rate of vitamin B12 insufficiency (≤220 pmol/L) was approximately 6% among the study participants. After adjusting for confounding factors, it was observed that the risk factors for vitamin B12 insufficiency included daily sitting time ≥ 7 h, low income (<10,000 Saudi riyal) and increasing age. The recommended dietary allowance of vitamin B12 (>2.4 mcg/day) has been shown to confer reasonable protection against vitamin B12 insufficiency. These study findings highlight that a combination of increased physical activity and dietary vitamin B12 intake above the current recommended dietary allowance may help improve the serum vitamin B12 levels of young women of childbearing age, especially those with a low socioeconomic status. Timely detection and protection against vitamin B12 insufficiency in this subpopulation are important to prevent maternal and fetal health risks.
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20
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Baroni L, Rizzo G, Goggi S, Giampieri F, Battino M. Vegetarian diets during pregnancy: effects on the mother's health. A systematic review. Food Funct 2020; 12:466-493. [PMID: 33306085 DOI: 10.1039/d0fo01991g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
While interest in vegetarian nutrition has been steadily increasing, some aspects have not yet been consistently investigated. One topic requiring evidence-based confirmation is the adoption of a vegetarian diet during pregnancy and lactation. Maternal diet is not only correlated with the fetus's and infant's health, but appears relevant for that of the mother as well. Not only is an adequate delivery of nutrients to the fetus and infant mandatory, but the increased physiological needs of the maternal body require an adequate supply of nutrients and can represent harmful stress events that may lead to well-defined pathological conditions. In this review, we aim to systematically investigate state-of-the-art of vegetarian diets during pregnancy and lactation, focusing on maternal nutritional status and pregnancy outcomes. Data are scarce, often inconsistent and not homogeneous for many of the topics we considered, mainly because only a few studies have been performed in developed countries, whereas other studies have derived from developing countries, where vegetarianism can be a proxy indicator of malnutrition. For this reason, we did not find sufficient data to provide evidence-based information and recommendations. To date, the available literature does not clearly support a negative impact on the mother's health and pregnancy outcomes, but, analogously with the findings in the vegetarian adult population, an improvement in the quality of studies might facilitate finding more information on the possible positive impact of well-planned vegetarian diets during pregnancy and lactation. More epidemiological and interventional studies are warranted, in order to address the question as to whether vegetarian nutrition represents an advantage for the mother or poses nutritional issues that need further attention.
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Affiliation(s)
- Luciana Baroni
- Scientific Society for Vegetarian Nutrition, Venice, Italy
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21
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Schroder TH, Tan A, Mattman A, Sinclair G, Barr SI, Vallance HD, Lamers Y. Reference intervals for serum total vitamin B12 and holotranscobalamin concentrations and their change points with methylmalonic acid concentration to assess vitamin B12 status during early and mid-pregnancy. Clin Chem Lab Med 2020; 57:1790-1798. [PMID: 31085739 DOI: 10.1515/cclm-2018-1337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/05/2019] [Indexed: 11/15/2022]
Abstract
Background Maternal vitamin B12 (B-12) adequacy is important for maternal health and optimal fetal growth. However, pregnancy-specific cut-offs for B-12 biomarkers are lacking. Methods Reference intervals for serum total B-12, holotranscobalamin (holoTC) and methylmalonic acid (MMA) concentrations were calculated following CLSI EP28-A3c guidelines in 723 pregnant women of European (50%) and South Asian (50%) ethnicity, residing in British Columbia, Canada, at median (range) 11.4 (8.3-13.9) and 16.1 (14.9-20.9) weeks of gestation. Change point analyses described relationships between log serum MMA concentration with serum total B-12 and holoTC concentrations, assuming linear-linear relationships. Results The central 95% reference interval limits indicated that serum total B-12 <89.9 and <84.0 pmol/L, holoTC <29.5 and <26.0 pmol/L and MMA >371 and >374 nmol/L, in the first and second trimesters, respectively, may indicate B-12 deficiency in pregnant women. The lower limits of total B-12 and holoTC and the upper limits of MMA significantly differed by ethnicity in both trimesters. According to the change point analysis, total B-12 <186 and <180 pmol/L and holoTC <62.2 and <67.5 pmol/L in the first and second trimesters, respectively, suggested an increased probability of impaired intracellular B-12 status, with no difference between ethnicities. Conclusions We present novel reference limits and change points for B-12 biomarkers, which may be employed to identify possible B-12 deficiency in women during early and mid-pregnancy. Future research is needed to validate these cut-offs and determine the predictors and functional outcomes associated with impaired B-12 status in ethnically diverse populations.
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Affiliation(s)
- Theresa H Schroder
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Amy Tan
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Clinical Chemistry and Laboratory Medicine, St Paul's Hospital, Vancouver, BC, Canada
| | - Graham Sinclair
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital and BC Women's Health Centre, Vancouver, BC, Canada
| | - Susan I Barr
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada
| | - Hilary D Vallance
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital and BC Women's Health Centre, Vancouver, BC, Canada
| | - Yvonne Lamers
- British Columbia Children's Hospital Research Institute, 950 W 28th Ave, Vancouver, BC V5Z 4H4, Canada.,Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, FNH 245, 2205 East Mall, Vancouver, BC V6T 1Z4, Canada
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Al-Musharaf S, Aljuraiban GS, Danish Hussain S, Alnaami AM, Saravanan P, Al-Daghri N. Low Serum Vitamin B12 Levels Are Associated with Adverse Lipid Profiles in Apparently Healthy Young Saudi Women. Nutrients 2020; 12:E2395. [PMID: 32785129 PMCID: PMC7468727 DOI: 10.3390/nu12082395] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/14/2022] Open
Abstract
An abnormal lipid profile is an independent risk factor for cardiovascular diseases. The relationship between vitamin B12 deficiency and lipid profile is inconclusive, with most studies conducted in unhealthy populations. In this study, we aimed to assess the relationship between serum vitamin B12 levels and lipid profiles in a cross-sectional study that included 341 apparently healthy Saudi women, aged 19-30 years, from different colleges at King Saud University, Saudi Arabia. Sociodemographic, anthropometric, biochemical, and lifestyle data were collected, including diet and physical activity. Serum vitamin B12 deficiency was defined as serum B12 level of <148 pmol/L. The prevalence of vitamin B12 deficiency was approximately 0.6%. Using multivariable linear regression models, serum vitamin B12 levels were found to be inversely associated with total cholesterol (B = -0.26; p < 0.001), low-density lipoprotein cholesterol levels (B = -0.30; p < 0.001), and triglyceride (B = -0.16; p < 0.01) after adjusting for potential confounders, while obesity indices of body mass index, central obesity, and fat percentage showed no association. Therefore, we conclude that low serum vitamin B12 levels are independently associated with abnormal lipid profiles in healthy young Saudi women. Further interventional studies are needed to determine whether improving serum vitamin B12 levels in a healthy population can improve lipid profiles.
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Affiliation(s)
- Sara Al-Musharaf
- Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11451, Saudi Arabia;
- Chair for Biomarkers of Chronic Diseases, Riyadh Biochemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (S.D.H.); (A.M.A.); (N.A.-D.)
| | - Ghadeer S. Aljuraiban
- Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Syed Danish Hussain
- Chair for Biomarkers of Chronic Diseases, Riyadh Biochemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (S.D.H.); (A.M.A.); (N.A.-D.)
| | - Abdullah M. Alnaami
- Chair for Biomarkers of Chronic Diseases, Riyadh Biochemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (S.D.H.); (A.M.A.); (N.A.-D.)
| | - Ponnusamy Saravanan
- Population, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV2 2 DX, UK
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK
| | - Nasser Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Riyadh Biochemistry Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (S.D.H.); (A.M.A.); (N.A.-D.)
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23
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Finkelstein JL, Guillet R, Pressman EK, Fothergill A, Guetterman HM, Kent TR, O'Brien KO. Vitamin B 12 Status in Pregnant Adolescents and Their Infants. Nutrients 2019; 11:E397. [PMID: 30781902 PMCID: PMC6413223 DOI: 10.3390/nu11020397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 11/23/2022] Open
Abstract
Vitamin B12 deficiency has been associated with increased risk of adverse pregnancy outcomes. Few prospective studies have investigated the burden or determinants of vitamin B12 deficiency early in life, particularly among pregnant adolescents and their children. The objectives of this study were to determine the prevalence of vitamin B12 deficiency and to examine associations between maternal and neonatal vitamin B12 status in a cohort study of healthy pregnant adolescents. Serum vitamin B12 and folate concentrations were measured in adolescents at mid-gestation (n = 124; 26.4 ± 3.5 weeks) and delivery (n = 131; 40.0 ± 1.3 weeks), and in neonates at birth using cord blood. Linear regression was used to examine associations between maternal and neonatal vitamin B12 status. Although the prevalence of vitamin B12 deficiency (<148.0 pmol/L; 1.6%) in adolescents was low during pregnancy, 22.6% of adolescents were vitamin B12 insufficient (<221.0 pmol/L; 22.6%) at mid-gestation. Maternal vitamin B12 concentrations significantly decreased from mid-gestation to delivery (p < 0.0001), and 53.4% had insufficient vitamin B12 status at delivery. Maternal vitamin B12 concentrations (p < 0.001) and vitamin B12 deficiency (p = 0.002) at delivery were significantly associated with infant vitamin B12 concentrations in multivariate analyses, adjusting for gestational age, maternal age, parity, smoking status, relationship status, prenatal supplement use, pre-pregnancy body mass index, race, and intake of vitamin B12 and folate. Maternal vitamin B12 concentrations significantly decreased during pregnancy and predicted neonatal vitamin B12 status in a cohort of healthy pregnant adolescents.
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Affiliation(s)
- Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
| | - Ronnie Guillet
- University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Eva K Pressman
- University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
| | | | - Tera R Kent
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
| | - Kimberly O O'Brien
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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24
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Allen LH, Miller JW, de Groot L, Rosenberg IH, Smith AD, Refsum H, Raiten DJ. Biomarkers of Nutrition for Development (BOND): Vitamin B-12 Review. J Nutr 2018; 148:1995S-2027S. [PMID: 30500928 PMCID: PMC6297555 DOI: 10.1093/jn/nxy201] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/06/2017] [Accepted: 08/02/2018] [Indexed: 12/31/2022] Open
Abstract
This report on vitamin B-12 (B12) is part of the Biomarkers of Nutrition for Development (BOND) Project, which provides state-of-the art information and advice on the selection, use, and interpretation of biomarkers of nutrient exposure, status, and function. As with the other 5 reports in this series, which focused on iodine, folate, zinc, iron, and vitamin A, this B12 report was developed with the assistance of an expert panel (BOND B12 EP) and other experts who provided information during a consultation. The experts reviewed the existing literature in depth in order to consolidate existing relevant information on the biology of B12, including known and possible effects of insufficiency, and available and potential biomarkers of status. Unlike the situation for the other 5 nutrients reviewed during the BOND project, there has been relatively little previous attention paid to B12 status and its biomarkers, so this report is a landmark in terms of the consolidation and interpretation of the available information on B12 nutrition. Historically, most focus has been on diagnosis and treatment of clinical symptoms of B12 deficiency, which result primarily from pernicious anemia or strict vegetarianism. More recently, we have become aware of the high prevalence of B12 insufficiency in populations consuming low amounts of animal-source foods, which can be detected with ≥1 serum biomarker but presents the new challenge of identifying functional consequences that may require public health interventions.
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Affiliation(s)
- Lindsay H Allen
- USDA, Agricultural Research Service Western Human Nutrition Research Center, University of California, Davis, CA
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ
| | - Lisette de Groot
- Division of Human Nutrition, Wageningen University, Wageningen, Netherlands
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - A David Smith
- Department of Pharmacology, University of Oxford, Oxford, United Kingdom
| | - Helga Refsum
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Bethesda, MD
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25
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Gramer G, Fang-Hoffmann J, Feyh P, Klinke G, Monostori P, Okun JG, Hoffmann GF. High incidence of maternal vitamin B 12 deficiency detected by newborn screening: first results from a study for the evaluation of 26 additional target disorders for the German newborn screening panel. World J Pediatr 2018; 14:470-481. [PMID: 29948967 DOI: 10.1007/s12519-018-0159-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 05/04/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Newborn screening (NBS) in Germany currently includes 15 target disorders. Recent diagnostic improvements suggest an extension of the screening panel. METHODS Since August 2016, a prospective study evaluating 26 additional target disorders (25 metabolic disorders and vitamin B12-deficiency) in addition to the German screening panel is performed at the Newborn Screening Center Heidelberg. First-tier results from tandem-MS screening are complemented by second-tier strategies for 15 of the additional target disorders. NBS results of seven patients diagnosed symptomatically with one of the additional target disorders by selective screening since August 2016 are retrospectively evaluated. RESULTS Over a 13-month period, 68,418 children participated in the study. Second-tier analyses were performed in 5.4% of samples. Only 59 (0.1%) of study participants had abnormal screening results for one of the additional target disorders. Target disorders from the study panel were confirmed in 12 children: 1 3-hydroxy-3-methylglutaryl coenzyme A (CoA)-lyase deficiency, 1 citrullinemia type I, 1 multiple acyl-CoA dehydrogenase-deficiency, 1 methylenetetrahydrofolate reductase-deficiency, and 8 children with maternal vitamin B12-deficiency. In addition, six of seven patients diagnosed symptomatically outside the study with one of the target disorders would have been identified by the study strategy in their NBS sample. CONCLUSIONS Within 13 months, the study "Newborn Screening 2020" identified additional 12 children with treatable conditions while only marginally increasing the recall rate by 0.1%. Maternal vitamin B12-deficiency was the most frequent finding. Even more children could benefit from screening for the additional target disorders by extending the NBS panel for Germany and/or other countries.
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Affiliation(s)
- Gwendolyn Gramer
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| | - Junmin Fang-Hoffmann
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Patrik Feyh
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Glynis Klinke
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Peter Monostori
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Jürgen G Okun
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Neuropediatric and Metabolic Medicine, Department of General Pediatrics, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
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The effect of gestational period on the association between maternal prenatal salivary cortisol and birth weight: A systematic review and meta-analysis. Psychoneuroendocrinology 2018; 94:49-62. [PMID: 29754005 DOI: 10.1016/j.psyneuen.2018.04.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Studies exploring the relations between maternal stress and fetal development show an association between increased maternal stress and adverse birth outcomes. A frequently proposed mechanism linking maternal prenatal stress and adverse birth outcomes is heightened concentrations of maternal cortisol. To date, studies exploring this association have reported conflicting results because of the diverse approaches taken to measuring cortisol and the wide variety of possible birth outcomes explored. To add clarity to the growing body of literature, this systematic review and meta-analysis reports empirical findings on the association between maternal prenatal salivary cortisol and newborn birth weight. METHODS Searches for relevant papers published up until November 2017 were run in MEDLINE, EMBASE, PsycINFO, and CINAHL. Non-English language papers were included and experts were contacted when necessary. We included data from human observational studies that were designed or had an underlying intention to measure maternal prenatal salivary cortisol and newborn birth weight. We only included data from measurements of salivary cortisol to prevent rendering of the review unsuitable for meta-analysis. Two independent reviewers assessed study eligibility and quality. For every maternal-fetal dyad, an area under the curve with respect to ground (AUCg) of maternal cortisol was calculated to determine a Pearson's correlation coefficient with a continuous measure of newborn birth weight. Correlation coefficients were then pooled across all stages of gestation. To examine if there are critical gestational periods in which the fetus may be more susceptible to elevated concentration of maternal salivary cortisol, a meta-analysis was performed on separate correlations calculated from gestational trimesters. RESULTS Nine studies with a total of 1606 maternal-fetal dyads demonstrated a negative correlation between pooled maternal salivary cortisol and birth weight (-0.24, 95% CI -0.28 to -0.20), but there was a high degree of heterogeneity between studies (I2 = 88.9%). To investigate heterogeneity, subgroup analysis by trimester of the pooled correlation between salivary cortisol and birth weight was performed with the following correlations found: first trimester, -0.18 (95% CI -0.32 to -0.03, I2 = 97.3%); second trimester, -0.20 (95% CI -0.28 to -0.12, I2 = 98.3%); and third trimester, -0.30 (95% CI -0.33 to -0.26, I2 = 85.4%). DISCUSSION A consistently negative association was observed between maternal cortisol and infant birth weight. The review highlights specific gaps in the literature on the relationship between maternal prenatal salivary cortisol and newborn birth weight. Although a significant negative correlation was found, substantial heterogeneity of effects and the likelihood of publication bias exist. The third trimester was revealed as a possible critical gestational period for heightened maternal cortisol concentration to affect birth weight. Challenges faced in this body of research and recommendations for future research are discussed.
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Varsi K, Ueland PM, Torsvik IK, Bjørke-Monsen AL. Maternal Serum Cobalamin at 18 Weeks of Pregnancy Predicts Infant Cobalamin Status at 6 Months-A Prospective, Observational Study. J Nutr 2018; 148:738-745. [PMID: 29947806 DOI: 10.1093/jn/nxy028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/30/2018] [Indexed: 02/05/2023] Open
Abstract
Background An adequate maternal cobalamin status is crucial for fetal and infant neurodevelopment. Pregnancy-induced physiologic changes make evaluation of maternal cobalamin status in pregnancy difficult. Objective We have investigated maternal cobalamin status during pregnancy in order to establish a maternal cobalamin concentration which secures an optimal infant cobalamin status during the first 6 mo of life. Methods In an observational, prospective study, markers of cobalamin status including serum cobalamin, plasma total homocysteine (tHcy), and plasma methylmalonic acid (MMA) were assessed in healthy pregnant women (n = 114) from week 18 of pregnancy through 6 mo postpartum and related to infant cobalamin status at 6 mo. Healthy, never-pregnant women aged 18-40 y (n = 123) were included as controls. Results Compared to controls, all markers of cobalamin status were lower in pregnant women. Median serum cobalamin concentration progressively decreased from week 18 to week 36 of pregnancy (356 to 302 pmol/L, P < 0.001) and increased by >40% by 6 wk postpartum (518 pmol/L). The metabolic markers increased from week 18 of pregnancy to 6 wk postpartum: median plasma tHcy 3.9 to 7.7 μmol/L (P < 0.001), and MMA 0.13 to 0.17 μmol/L (P < 0.001). The serum cobalamin concentration of infants at age 6 mo correlated with maternal serum cobalamin concentration during pregnancy and postpartum (rho = 0.36-0.55, P < 0.001). A maternal serum cobalamin concentration <394 pmol/L during week 18 of pregnancy was associated with an increased risk (OR: 4.2; 95% CI: 1.5, 11.5) of infant biochemical cobalamin deficiency at 6 mo (defined as tHcy ≥6.5 μmol/L). Conclusions The maternal serum cobalamin concentration in early pregnancy is a strong predictor for later maternal and infant cobalamin status. To secure an optimal infant cobalamin status during the first 6 mo of life, we recommend a maternal serum cobalamin concentration >394 pmol/L at week 18 of pregnancy. This should be confirmed in an intervention study. This trial was registered at clinicaltrials.gov as NCT03272022.
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Affiliation(s)
- Kristin Varsi
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Per M Ueland
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Ingrid K Torsvik
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Anne-Lise Bjørke-Monsen
- Laboratory of Clinical Biochemistry, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
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28
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Solé-Navais P, Salat-Batlle J, Cavallé-Busquets P, Fernandez-Ballart J, Ueland PM, Ballesteros M, Ornosa-Martín G, Inglès-Puig M, Colomina JM, Murphy MM. Early pregnancy folate-cobalamin interactions and their effects on cobalamin status and hematologic variables throughout pregnancy. Am J Clin Nutr 2018; 107:173-182. [PMID: 29529156 DOI: 10.1093/ajcn/nqx041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/20/2017] [Indexed: 12/21/2022] Open
Abstract
Background Periconception folic acid supplementation is widespread, but how it interacts with cobalamin status is rarely considered. Objective The aim of this study was to investigate whether first-trimester folate-cobalamin interactions affect pregnancy cobalamin status, hematologic variables, and pregnancy outcomes. Design In the longitudinal Reus-Tarragona Birth Cohort study from <12 gestational weeks throughout pregnancy, fasting plasma and red blood cell (RBC) folate, plasma cobalamin, holotranscobalamin (holoTC), methylmalonic acid (MMA), total homocysteine (tHcy), hemoglobin, mean cell volume (MCV), postglucose-load serum glucose, gestational hypertension, gestational age at birth, and birth weight were recorded in 563 participants. Results The highest plasma folate concentrations occurred in the first trimester when folic acid supplement use was extensive. Supplementation beyond the first trimester interacted with time of pregnancy on plasma folate, RBC folate, and tHcy throughout pregnancy (P-interaction <0.001). Plasma folate and RBC folate were higher and tHcy was lower in continued supplement users than in nonusers. Elevated plasma folate (≥30 nmol/L) occurred in 78.9% of women who exceeded the recommended 400 µg folic acid/d. First-trimester folate-cobalamin status interactions were associated with MMA (P-interaction <0.001) throughout pregnancy. When plasma cobalamin was suboptimal (≤221 pmol/L; n = 36), participants with elevated plasma folate (n = 11) had higher MMA concentrations than did those with nonelevated plasma folate (n = 23). First-trimester folate-MMA status interactions were associated with MCV throughout pregnancy (P-interaction <0.01) and with cord plasma holoTC (P-interaction <0.05). The mean difference (95% CI) in MCV (fL) between women with elevated and nonelevated plasma folate status was -2.12 (-3.71, -0.52) for top-quartile plasma MMA (≥0.139 µmol/L) and 0.60 (-0.39, 1.60) for plasma MMA <0.139 µmol/L. Cord plasma holoTC was higher in women with elevated compared with nonelevated plasma folate status only for MMA <0.139 µmol/L. Folate-cobalamin interactions were not associated with the other investigated outcomes. Conclusion First-trimester folate-cobalamin status interactions were associated with plasma MMA and MCV throughout pregnancy. This trial was registered at www.clinicaltrials.gov as NCT01778205.
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Affiliation(s)
- Pol Solé-Navais
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain
| | - Judith Salat-Batlle
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain
| | - Pere Cavallé-Busquets
- Units of Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain.,Units of Obstetrics and Gynecology, University Hospitals Sant Joan, Reus and Joan XXIII, Tarragona, Spain.,Biomedical Research Networking Center for the Pathophysiology of Obesity, Carlos III Institute of Health, Madrid, Spain
| | - Joan Fernandez-Ballart
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain.,Biomedical Research Networking Center for the Pathophysiology of Obesity, Carlos III Institute of Health, Madrid, Spain
| | - Per M Ueland
- Section of Pharmacology, Department of Internal Medicine, University of Bergen, Bergen, Norway
| | - Mónica Ballesteros
- Units of Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain.,Units of Joan XXIII, Tarragona, Spain
| | - Gemma Ornosa-Martín
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain
| | - Montserrat Inglès-Puig
- Units of Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain.,Units of Obstetrics and Gynecology, University Hospitals Sant Joan, Reus and Joan XXIII, Tarragona, Spain
| | - Jose M Colomina
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain
| | - Michelle M Murphy
- Units of Preventive Medicine and Public Health, Department of Basic Medical Sciences and Obstetrics and Gynecology, Department of Medicine and Surgery, Faculty of Medicine and Health Sciences, Pere Virgili Institute of Health Research, Rovira i Virgili University, Reus, Spain.,Biomedical Research Networking Center for the Pathophysiology of Obesity, Carlos III Institute of Health, Madrid, Spain
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Molloy AM. Should vitamin B 12 status be considered in assessing risk of neural tube defects? Ann N Y Acad Sci 2018; 1414:109-125. [PMID: 29377209 PMCID: PMC5887889 DOI: 10.1111/nyas.13574] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/07/2017] [Accepted: 11/11/2017] [Indexed: 02/06/2023]
Abstract
There is a strong biological premise for including vitamin B12 with folic acid in strategies to prevent neural tube defects (NTDs), due to the closely interlinked metabolism of these two vitamins. For example, reduction of B12 deficiency among women of reproductive age could enhance the capacity of folic acid to prevent NTDs by optimizing the cellular uptake and utilization of natural folate cofactors. Vitamin B12 might also have an independent role in NTD prevention, such that adding it in fortification programs might be more effective than fortifying with folic acid alone. Globally, there is ample evidence of widespread vitamin B12 deficiency in low‐ and middle‐income countries, but there is also considerable divergence of vitamin B12 status across regions, likely due to genetic as well as nutritional factors. Here, I consider the evidence that low vitamin B12 status may be an independent factor associated with risk of NTDs, and whether a fortification strategy to improve B12 status would help reduce the prevalence of NTDs. I seek to identify knowledge gaps in this respect and specify research goals that would address these gaps.
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Affiliation(s)
- Anne M Molloy
- School of Medicine and School of Biochemistry and Immunology, Trinity College Dublin, Trinity Biomedical Sciences Institute, Dublin, Ireland
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31
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Obeid R, Murphy M, Solé-Navais P, Yajnik C. Cobalamin Status from Pregnancy to Early Childhood: Lessons from Global Experience. Adv Nutr 2017; 8:971-979. [PMID: 29141978 PMCID: PMC5683008 DOI: 10.3945/an.117.015628] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Low cobalamin intake and status during pregnancy or lactation have been linked to adverse maternal and perinatal health outcomes, whereas low cobalamin status during early childhood is associated with impaired development in children. Women who begin pregnancy with depleted stores (low or very low plasma cobalamin) will give birth to depleted infants who are likely to develop deficiency symptoms during the first few weeks or months postpartum. Newly ingested cobalamin during pregnancy and lactation (from diet or supplements) is transferred to the child and is not likely to correct cobalamin status in depleted women. The prevalence of low cobalamin status is high especially in low-income settings or in populations with a low intake of animal products. Folate and cobalamin play interdependent roles in one-carbon metabolism. Although folic acid supplementation during early pregnancy is widely recommended and practiced, cobalamin supplementation during pregnancy and lactation has received little attention. Furthermore, the intake recommendations for pregnant and lactating women and in early life need reevaluation in the light of newly available evidence in the field.
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Affiliation(s)
- Rima Obeid
- Aarhus Institute of Advanced Studies, University of Aarhus, Aarhus, Denmark
| | - Michelle Murphy
- Area of Preventive Medicine and Public Health, Department of Basic Medical Sciences, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, Pere Virgili Institute for Health Research, Reus, Spain;,Centros de Investigación Biomédica en Red (CB06/03), Instituto de Salud Carlos III; and
| | - Pol Solé-Navais
- Area of Preventive Medicine and Public Health, Department of Basic Medical Sciences, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, Pere Virgili Institute for Health Research, Reus, Spain
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32
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Pregnant women of South Asian ethnicity in Canada have substantially lower vitamin B12 status compared with pregnant women of European ethnicity. Br J Nutr 2017; 118:454-462. [PMID: 28920568 DOI: 10.1017/s0007114517002331] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Maternal vitamin B12 (B12) status has been inversely associated with adverse pregnancy outcomes and positively with fetal growth and infant development. South Asians, Canada's largest ethnic minority, are prone to B12 deficiency. Yet, data are lacking on B12 status in South Asian pregnant women in North America. We sought to determine B12 status, using multiple biomarkers, in 1st and 2nd trimester pregnant women of South Asian and, for comparison, European ethnicity living in Vancouver, Canada. In this retrospective cohort study, total B12, holotranscobalamin (holoTC), methylmalonic acid (MMA), and total homocysteine concentrations were quantified in two routinely collected (mean gestational week: 11·5 (range 8·3-13·9) and 16·5 (range 14·9-20·9)), banked serum samples of 748 healthy pregnant South Asian (n 371) and European (n 377) women. South Asian pregnant women had significantly lower B12 status than European pregnant women at both time points, as indicated by lower serum total B12 and holoTC concentrations, and higher MMA concentrations (all P≤0·001). The largest difference, which was substantial (Cohen's d≥0·5), was observed in mean serum total B12 concentrations (1st trimester: 189 (95 % CI 180, 199) v. 246 (95 % CI 236, 257) pmol/l; 2nd trimester: 176 (95 % CI 168, 185) v. 226 (95 % CI 216, 236) pmol/l). Further, South Asian ethnicity was a significant negative predictor of B12 status during pregnancy. South Asian women living in Vancouver have substantially lower B12 status during early pregnancy. Future research identifying predictors and health consequences of this observed difference is needed to allow for targeted interventions.
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van der Woude DAA, Pijnenborg JMA, de Vries J, van Wijk EM. The distribution of total vitamin B12, holotranscobalamin, and the active vitamin B12 fraction in the first 5 weeks postpartum. Int J Lab Hematol 2017; 40:72-76. [PMID: 28868811 DOI: 10.1111/ijlh.12730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/02/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Total vitamin B12 levels decrease significantly during pregnancy and recover to normal values within 8-week postpartum. Holotranscobalamin (holoTC) reflects the active part of vitamin B12 and has been shown to remain constant during pregnancy and postpartum. A mechanism of redistribution of vitamin B12 is suggested, with a shift toward holoTC if there is insufficient total vitamin B12 available. Our objective was to examine vitamin B12 deficiency and the active vitamin B12 fraction in postpartum women. METHODS Total vitamin B12 and holoTC were measured in 171 women within 48 hours (T0) and at 5 weeks (T5) postpartum. Vitamin B12 deficiency was defined as total vitamin B12 < 180 pmol/L or holoTC <32 pmol/L. The active vitamin B12 fraction was defined as holoTC/total vitamin B12. RESULTS Without intervention, vitamin B12 deficiency based on both serum total vitamin B12 and holoTC changed from 75% and 60%, to respectively 10% and 6% at T5. The fraction of active vitamin B12 was significant higher in vitamin B12 deficient women at both time points and across time (P < .0001 and P = .002). A high fraction of active vitamin B12 was only present in women with total vitamin B12 deficiency at T0. At T5, no high vitamin B12 fraction was found. CONCLUSION The changes in total vitamin B12 levels seem to be based on a physiological changes rather than vitamin B12 deficiency. The results of this study confirm the hypothesis that a shift toward the metabolic active vitamin B12 (holoTC) occurs in women with insufficient available total vitamin B12.
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Affiliation(s)
- D A A van der Woude
- CoRPS, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands.,Department of Gynecology and Obstetrics, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - J M A Pijnenborg
- Department of Gynecology and Obstetrics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J de Vries
- CoRPS, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands.,Department of Medical Psychology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - E M van Wijk
- Laboratory of Clinical Chemistry and Hematology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
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Green R, Allen LH, Bjørke-Monsen AL, Brito A, Guéant JL, Miller JW, Molloy AM, Nexo E, Stabler S, Toh BH, Ueland PM, Yajnik C. Vitamin B 12 deficiency. Nat Rev Dis Primers 2017; 3:17040. [PMID: 28660890 DOI: 10.1038/nrdp.2017.40] [Citation(s) in RCA: 457] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vitamin B12 (B12; also known as cobalamin) is a B vitamin that has an important role in cellular metabolism, especially in DNA synthesis, methylation and mitochondrial metabolism. Clinical B12 deficiency with classic haematological and neurological manifestations is relatively uncommon. However, subclinical deficiency affects between 2.5% and 26% of the general population depending on the definition used, although the clinical relevance is unclear. B12 deficiency can affect individuals at all ages, but most particularly elderly individuals. Infants, children, adolescents and women of reproductive age are also at high risk of deficiency in populations where dietary intake of B12-containing animal-derived foods is restricted. Deficiency is caused by either inadequate intake, inadequate bioavailability or malabsorption. Disruption of B12 transport in the blood, or impaired cellular uptake or metabolism causes an intracellular deficiency. Diagnostic biomarkers for B12 status include decreased levels of circulating total B12 and transcobalamin-bound B12, and abnormally increased levels of homocysteine and methylmalonic acid. However, the exact cut-offs to classify clinical and subclinical deficiency remain debated. Management depends on B12 supplementation, either via high-dose oral routes or via parenteral administration. This Primer describes the current knowledge surrounding B12 deficiency, and highlights improvements in diagnostic methods as well as shifting concepts about the prevalence, causes and manifestations of B12 deficiency.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis, 4400 V Street, PATH Building, Davis, California 95817, USA
| | - Lindsay H Allen
- USDA, ARS Western Human Nutrition Research Center, University of California Davis, Davis, California, USA
| | | | - Alex Brito
- USDA, ARS Western Human Nutrition Research Center, University of California Davis, Davis, California, USA
| | - Jean-Louis Guéant
- Inserm UMRS 954 N-GERE (Nutrition Génétique et Exposition aux Risques Environnementaux), University of Lorraine and INSERM, Nancy, France
| | - Joshua W Miller
- School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Anne M Molloy
- School of Medicine and School of Biochemistry and Immunology, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Ebba Nexo
- Department of Clinical Medicine, Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Sally Stabler
- Department of Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Ban-Hock Toh
- Centre for Inflammatory Diseases, Monash Institute of Medical Research, Clayton, Victoria, Australia
| | - Per Magne Ueland
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.,Section for Pharmacology, Department of Clinical Science, University of Bergen, Bergen, Norway
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35
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Sobczyńska-Malefora A, Ramachandran R, Cregeen D, Green E, Bennett P, Harrington DJ, Lemonde HA. An infant and mother with severe B12 deficiency: vitamin B12 status assessment should be determined in pregnant women with anaemia. Eur J Clin Nutr 2017; 71:1013-1015. [DOI: 10.1038/ejcn.2017.85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 12/18/2022]
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South Asian Ethnicity Is Related to the Highest Risk of Vitamin B12 Deficiency in Pregnant Canadian Women. Nutrients 2017; 9:nu9040317. [PMID: 28333089 PMCID: PMC5409656 DOI: 10.3390/nu9040317] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/12/2017] [Accepted: 03/20/2017] [Indexed: 01/08/2023] Open
Abstract
Vitamin B12 (B12) adequacy during pregnancy is crucial for maternal health and optimal fetal development; however, suboptimal B12 status has been reported in pregnant Canadian women. Methylmalonic acid (MMA) is a sensitive indicator of B12 status. Since few studies have measured MMA during pregnancy in Canadian women, the objective of this study was to evaluate B12 status in pregnant women living in Metro Vancouver, using both plasma total B12 and MMA. We recruited a convenience sample of 320 pregnant women between 20 and 35 gestational weeks from local healthcare facilities. Plasma total B12 concentrations indicative of deficiency (<148 pmol/L) and suboptimal B12 status (148–220 pmol/L) were found in 18% and 33% of the women, respectively. Normal plasma MMA concentration (<210 nmol/L) was observed in 82% of all women. Gestational age was a strong predictor of plasma total B12 and MMA concentration, and South Asian ethnicity of B-12 deficiency and MMA concentrations. Overall, there was a high discrepancy between the prevalence of B12 inadequacy depending on the biomarker used. Independently, however, South Asian women were at particular risk for B12 deficiency, likely due to lower animal source food intake. Further study of this vulnerable group and performance testing of B12 biomarkers is warranted.
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37
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High Prevalence of Vitamin B12 Deficiency and No Folate Deficiency in Young Children in Nepal. Nutrients 2017; 9:nu9010072. [PMID: 28106733 PMCID: PMC5295116 DOI: 10.3390/nu9010072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 02/07/2023] Open
Abstract
Many children in low- and middle-income countries may have inadequate intake of vitamin B12 and folate; data confirming these inadequacies are limited. We used biochemical, demographic, behavioral and anthropometric data to describe the folate and vitamin B12 concentrations among six- to 23-month-old Nepalese children. Vitamin B12 (serum B12 < 150 pmol/L) and folate deficiencies (red blood cell (RBC) folate < 226.5 nmol/L) were assessed. We used logistic regression to identify predictors of vitamin B12 deficiency. The vitamin B12 geometric mean was 186 pmol/L; 30.2% of children were deficient. The mean RBC folate concentration was 13,612 nmol/L; there was no deficiency. Factors associated with vitamin B12 deficiency included: (a) age six to 11 months (adjusted odds ratio (aOR) 1.51; 95% confidence interval (CI): 1.18, 1.92) or 12-17 months (aOR 1.38; 95% CI: 1.10, 1.72) compared to 18-23 months; (b) being stunted (aOR 1.24; 95% CI: 1.03, 1.50) compared to not being stunted; (c) and not eating animal-source foods (aOR 1.85; 95% CI: 1.42, 2.41) compared to eating animal-source foods the previous day. There was a high prevalence of vitamin B12 deficiency, but no folate deficiency. Improving early feeding practices, including the consumption of rich sources of vitamin B12, such as animal-source foods and fortified foods, may help decrease deficiency.
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Choi R, Choi S, Lim Y, Cho YY, Kim HJ, Kim SW, Chung JH, Oh SY, Lee SY. A Prospective Study on Serum Methylmalonic Acid and Homocysteine in Pregnant Women. Nutrients 2016; 8:nu8120797. [PMID: 27941633 PMCID: PMC5188452 DOI: 10.3390/nu8120797] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/15/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate serum methylmalonic acid (MMA) and homocysteine levels and to assess their effects on pregnancy and neonatal outcomes. Serum MMA and homocysteine levels in 278 pregnant Korean women, determined by liquid chromatography–tandem mass spectrometry in each trimester, were compared with those of previous studies in other ethnic groups. We investigated the association between MMA and homocysteine status with pregnancy and neonatal events: gestational diabetes, preeclampsia, gestational age at delivery, preterm birth, small for gestational age, neonatal birth weight, and congenital abnormalities. The median (range) MMA level was 0.142 (0.063–0.446) µmol/L and homocysteine level was 10.6 (4.4–38.0) µmol/L in pregnant women. MMA levels were significantly higher in the third trimester than during other trimesters (p < 0.05), while homocysteine levels were not. No significant association was observed between MMA or homocysteine levels and any of the maternal or neonatal outcomes examined. Future studies are needed to assess the associations among maternal serum concentrations of MMA and homocysteine, and maternal and neonatal outcomes.
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Affiliation(s)
- Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Sunkyu Choi
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Yaeji Lim
- Biostatistics Team, Samsung Biomedical Research Institute, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Hye Jeong Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea.
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Sukumar N, Venkataraman H, Wilson S, Goljan I, Selvamoni S, Patel V, Saravanan P. Vitamin B12 Status among Pregnant Women in the UK and Its Association with Obesity and Gestational Diabetes. Nutrients 2016; 8:nu8120768. [PMID: 27916927 PMCID: PMC5188423 DOI: 10.3390/nu8120768] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/16/2016] [Accepted: 11/22/2016] [Indexed: 01/15/2023] Open
Abstract
Background: To evaluate vitamin B12 and folate status in pregnancy and their relationship with maternal obesity, gestational diabetes mellitus (GDM), and offspring birthweight. Methods: A retrospective case-control study of 344 women (143 GDM, 201 no-GDM) attending a district general hospital and that had B12 and folate levels measured in the early 3rd trimester was performed. Maternal history including early pregnancy body mass index (BMI) and neonatal data (birthweight, sex, and gestational age) was recorded for all subjects. Results: 26% of the cohort had B12 levels <150 pmol/L (32% vs. 22% in the two groups respectively, p < 0.05) while 1.5% were folate deficient. After adjusting for confounders, 1st trimester BMI was negatively associated with 3rd trimester B12 levels. Women with B12 insufficiency had higher odds of obesity and GDM (aOR (95% CI) 2.40 (1.31, 4.40), p = 0.004, and 2.59 (1.35, 4.98), p = 0.004, respectively), although the latter was partly mediated by BMI. In women without GDM, the lowest quartile of B12 and highest quartile of folate had significantly higher adjusted risk of fetal macrosomia (RR 5.3 (1.26, 21.91), p = 0.02 and 4.99 (1.15, 21.62), p = 0.03 respectively). Conclusion: This is the first study from the UK to show that maternal B12 levels are associated with BMI, risk of GDM, and additionally may have an independent effect on macrosomia. Due to the increasing burden of maternal obesity and GDM, longitudinal studies with B12 measurements in early pregnancy are needed to explore this link.
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Affiliation(s)
- Nithya Sukumar
- Warwick Medical School, University of Warwick, Coventry CV2 2DX, UK.
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK.
| | - Hema Venkataraman
- Warwick Medical School, University of Warwick, Coventry CV2 2DX, UK.
| | - Sean Wilson
- Hull York Medical School, Hertford Building, University of Hull, Hull HU6 7RX, UK.
| | - Ilona Goljan
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK.
| | - Selvin Selvamoni
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK.
| | - Vinod Patel
- Warwick Medical School, University of Warwick, Coventry CV2 2DX, UK.
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK.
| | - Ponnusamy Saravanan
- Warwick Medical School, University of Warwick, Coventry CV2 2DX, UK.
- Academic Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital, Nuneaton CV10 7DJ, UK.
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40
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Bjørke-Monsen AL, Ulvik A, Nilsen RM, Midttun Ø, Roth C, Magnus P, Stoltenberg C, Vollset SE, Reichborn-Kjennerud T, Ueland PM. Impact of Pre-Pregnancy BMI on B Vitamin and Inflammatory Status in Early Pregnancy: An Observational Cohort Study. Nutrients 2016; 8:nu8120776. [PMID: 27916904 PMCID: PMC5188431 DOI: 10.3390/nu8120776] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 12/13/2022] Open
Abstract
Maternal nutrition and inflammation have been suggested as mediators in the development of various adverse pregnancy outcomes associated with maternal obesity. We have investigated the relation between pre-pregnancy BMI, B vitamin status, and inflammatory markers in a group of healthy pregnant women. Cobalamin, folate, pyridoxal 5′-phosphate, and riboflavin; and the metabolic markers homocysteine, methylmalonic acid, and 3-hydroxykynurenine/xanthurenic acid ratio (HK/XA); and markers of cellular inflammation, neopterin and kynurenine/tryptophan ratio (KTR) were determined in pregnancy week 18 and related to pre-pregnancy body mass index (BMI), in 2797 women from the Norwegian Mother and Child Cohort Study (MoBa). Pre-pregnancy BMI was inversely related to folate, cobalamin, pyridoxal 5′-phosphate (PLP), and riboflavin (p < 0.001), and associated with increased neopterin and KTR levels (p < 0.001). Inflammation seemed to be an independent predictor of low vitamin B6 status, as verified by low PLP and high HK/XA ratio. A high pre-pregnancy BMI is a risk factor for low B vitamin status and increased cellular inflammation. As an optimal micronutrient status is vital for normal fetal development, the observed lower B vitamin levels may contribute to adverse pregnancy outcomes associated with maternal obesity and B vitamin status should be assessed in women with high BMI before they get pregnant.
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Affiliation(s)
| | | | - Roy M Nilsen
- Centre for Clinical Research, Haukeland University Hospital, 5021 Bergen, Norway.
| | | | - Christine Roth
- The Norwegian Institute of Public Health, 0403 Oslo, Norway.
- Imprints Center for Genetic and Environmental Life Course Studies, Mailman School of Public Health and New York State Psychiatric Institute, Columbia University, New York, NY 10027, USA.
| | - Per Magnus
- The Norwegian Institute of Public Health, 0403 Oslo, Norway.
| | - Camilla Stoltenberg
- The Norwegian Institute of Public Health, 0403 Oslo, Norway.
- Department of Public Health and Primary Health Care, University of Bergen, 5007 Bergen, Norway.
| | - Stein Emil Vollset
- The Norwegian Institute of Public Health, 0403 Oslo, Norway.
- Department of Public Health and Primary Health Care, University of Bergen, 5007 Bergen, Norway.
| | - Ted Reichborn-Kjennerud
- The Norwegian Institute of Public Health, 0403 Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway.
| | - Per Magne Ueland
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, 5021 Bergen, Norway.
- Department of Clinical Science, University of Bergen, 5007 Bergen, Norway.
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41
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Abuyaman O, Torring N, Obeid R, Nexo E. First trimester serum levels of the soluble transcobalamin receptor, holo-transcobalamin, and total transcobalamin in relation to preeclampsia risk. Scandinavian Journal of Clinical and Laboratory Investigation 2016; 76:641-644. [PMID: 27700208 DOI: 10.1080/00365513.2016.1230885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Human placenta expresses CD320, a receptor that ensures the uptake of holo-transcobalamin (holoTC). Soluble CD320 (sCD320) is present in the circulation and its concentration increases during pregnancy. AIMS To investigate a possible association of sCD320, holoTC and total transcobalamin (TC) with the risk of subsequent preeclampsia using serum samples from asymptomatic first trimester pregnant women. Moreover, we aimed to establish reference intervals of the aforementioned biomarkers for first trimester pregnant women who remained healthy throughout pregnancy. STUDY DESIGN This study was a retrospective case-control study that we performed on biobank serum samples. Cases (n = 50) and controls (n = 198) (matched for gestational age and date of sample collection) were asymptomatic women in early pregnancy [median (range) gestational age = 10 (8-12) weeks]. Cases developed preeclampsia while the controls remained normotensive throughout pregnancy. We measured the serum concentration of sCD320, holoTC, and total TC by using in-house ELISA methods. RESULTS First trimester median concentrations of sCD320, holoTC and total TC were not significantly different between cases and controls. The odd ratio for developing preeclampsia based on exposure to low or high levels of sCD320, holoTC or total TC at first trimester was not significant. The reference intervals (2.5-97.5% percentiles (median)) derived from the controls were 50-170 (90) pmol\L for sCD320, 20-140 (70) pmol\L for holoTC and 560-1300 (810) pmol\L for total TC. CONCLUSIONS The risk of preeclampsia is not predicted by first trimester serum concentrations of sCD320, holoTC or total TC. The first trimester reference intervals for the three parameters is reported.
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Affiliation(s)
- Omar Abuyaman
- a Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - Niels Torring
- a Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - Rima Obeid
- b Aarhus Institute for Advanced Studies, Aarhus University , Aarhus , Denmark
| | - Ebba Nexo
- a Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
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Reference interval of methylmalonic acid concentrations in dried blood spots of healthy, term newborns to facilitate neonatal screening of vitamin B12 deficiency. Clin Biochem 2016; 49:973-8. [DOI: 10.1016/j.clinbiochem.2016.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/04/2016] [Accepted: 03/23/2016] [Indexed: 11/18/2022]
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Sukumar N, Adaikalakoteswari A, Venkataraman H, Maheswaran H, Saravanan P. Vitamin B12 status in women of childbearing age in the UK and its relationship with national nutrient intake guidelines: results from two National Diet and Nutrition Surveys. BMJ Open 2016; 6:e011247. [PMID: 27519920 PMCID: PMC4985863 DOI: 10.1136/bmjopen-2016-011247] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To assess serum B12, folate and the associated homocysteine (Hcy) levels among women of childbearing age in the UK and examine their association with dietary intake in relation to the UK Recommended Nutrient Intakes (RNIs) for B12 and folate. DESIGN Cross-sectional study. SETTING Data from two publicly available National Diet and Nutrition Surveys (NDNS 2000/2001 and 2008/2012) were used. These were population-based surveys of randomly selected samples of adults which were carried out in their households. PARTICIPANTS Women of childbearing age (aged 19-39 years), representative of the UK population. Those who were pregnant or breastfeeding were excluded. OUTCOME MEASURES The associations between micronutrient intakes and blood levels of B12, folate and Hcy were assessed by correlation and stepwise linear regression. B12 intake was divided into quintiles and plotted against blood B12 and Hcy concentrations to determine the threshold of any associations. RESULTS 299 women from the first NDNS cohort had complete intake and biomarker data. The prevalence of serum vitamin B12 (≤150 pmol/L) and serum folate (≤10 nmol/L) deficiency and hyperhomocysteinemia (≥12 µmol/L) was 12.4%, 6.4% and 21.2%, respectively, despite seemingly adequate B12 intakes (median 3.8 μg/day, 96% consumed more than the UK RNI of 1.5 μg/day). B12 concentrations increased across all quintiles of intake with serum levels in quintiles 4 and 5 (median intake 4.9 and 7.1 μg/day, respectively) significantly higher than quintile 1. However, Hcy concentrations levelled off between quintiles 4 and 5. Comparison of micronutrient intake between the two surveys found that folate intake has reduced in the more recent cohort. CONCLUSIONS The UK RNI for B12 intake should be increased for women of childbearing age with intakes of around 5-7 μg/day likely to be associated with stable biomarker levels. B12 levels should also be measured in women preconceptionally or in early pregnancy given the high rates of deficiency.
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Affiliation(s)
- Nithya Sukumar
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Diabetes and Metabolism, George Eliot Hospital, Nuneaton, UK
| | | | - Hema Venkataraman
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Diabetes and Metabolism, George Eliot Hospital, Nuneaton, UK
| | | | - Ponnusamy Saravanan
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Diabetes and Metabolism, George Eliot Hospital, Nuneaton, UK
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Vitamin B12 and placental expression of transcobalamin in pregnant adolescents. Placenta 2016; 45:1-7. [PMID: 27577703 DOI: 10.1016/j.placenta.2016.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 06/21/2016] [Accepted: 06/26/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transcobalamin is a key placental protein involved in transport of vitamin B12 to the fetus. However, few data currently exist on the ability of the placenta to modify vitamin B12 transporter expression, particularly in high-risk populations such as pregnant adolescents. OBJECTIVE This study was conducted to determine the impact of maternal and neonatal serum vitamin B12 concentrations on placental transcobalamin (TC) expression in a cohort of healthy pregnant adolescents in the United States. DESIGN Serum vitamin B12 concentrations were measured in maternal blood samples at mid-gestation (26.4 ± 2.8 weeks) and delivery (39.8 ± 1.4 weeks) and infant cord blood samples at birth. Placentas were collected at delivery and TC mRNA expression (ΔΔCt) and TC protein abundance (TC:α-actin) were evaluated. Linear and binomial regression models were used to examine the associations of maternal serum (mid-gestation, delivery) and cord blood vitamin B12 concentrations with placental TC mRNA expression and protein abundance (n = 63). RESULTS Maternal serum vitamin B12 concentrations at mid-gestation or delivery were not significantly associated with placental TC mRNA expression or TC protein abundance (p > 0.05). Higher placental TC protein abundance was associated with increased cord blood vitamin B12 concentrations (p = 0.003). CONCLUSIONS Higher placental TC protein abundance was associated with higher cord blood vitamin B12 concentrations, suggesting a potential role in vitamin B12 transport to the fetus.
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Molloy A, Pangilinan F, Mills J, Shane B, O’Neill M, McGaughey D, Velkova A, Abaan H, Ueland P, McNulty H, Ward M, Strain J, Cunningham C, Casey M, Cropp C, Kim Y, Bailey-Wilson J, Wilson A, Brody L. A Common Polymorphism in HIBCH Influences Methylmalonic Acid Concentrations in Blood Independently of Cobalamin. Am J Hum Genet 2016; 98:869-882. [PMID: 27132595 DOI: 10.1016/j.ajhg.2016.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 03/08/2016] [Indexed: 12/20/2022] Open
Abstract
Methylmalonic acid (MMA) is a by-product of propionic acid metabolism through the vitamin B12 (cobalamin)-dependent enzyme methylmalonyl CoA mutase. Elevated MMA concentrations are a hallmark of several inborn errors of metabolism and indicators of cobalamin deficiency in older persons. In a genome-wide analysis of 2,210 healthy young Irish adults (median age 22 years) we identified a strong association of plasma MMA with SNPs in 3-hydroxyisobutyryl-CoA hydrolase (HIBCH, p = 8.42 × 10(-89)) and acyl-CoA synthetase family member 3 (ACSF3, p = 3.48 × 10(-19)). These loci accounted for 12% of the variance in MMA concentration. The most strongly associated SNP (HIBCH rs291466; c:2T>C) causes a missense change of the initiator methionine codon (minor-allele frequency = 0.43) to threonine. Surprisingly, the resulting variant, p.Met1?, is associated with increased expression of HIBCH mRNA and encoded protein. These homozygotes had, on average, 46% higher MMA concentrations than methionine-encoding homozygotes in young adults with generally low MMA concentrations (0.17 [0.14-0.21] μmol/L; median [25(th)-75(th) quartile]). The association between MMA levels and HIBCH rs291466 was highly significant in a replication cohort of 1,481 older individuals (median age 79 years) with elevated plasma MMA concentrations (0.34 [0.24-0.51] μmol/L; p = 4.0 × 10(-26)). In a longitudinal study of 185 pregnant women and their newborns, the association of this SNP remained significant across the gestational trimesters and in newborns. HIBCH is unique to valine catabolism. Studies evaluating flux through the valine catabolic pathway in humans should account for these variants. Furthermore, this SNP could help resolve equivocal clinical tests where plasma MMA values have been used to diagnose cobalamin deficiency.
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Sukumar N, Rafnsson SB, Kandala NB, Bhopal R, Yajnik CS, Saravanan P. Prevalence of vitamin B-12 insufficiency during pregnancy and its effect on offspring birth weight: a systematic review and meta-analysis. Am J Clin Nutr 2016; 103:1232-51. [PMID: 27076577 DOI: 10.3945/ajcn.115.123083] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 02/24/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vitamin B-12 and folate are micronutrients essential for normal embryogenesis. Vitamin B-12 insufficiency in pregnancy is high in certain parts of the world, such as India, and although this has been linked to low birth weight (LBW) in these populations, the relation between vitamin B-12 and birth weight (BW) elsewhere is unknown. OBJECTIVES We performed a systematic review to assess 1) the worldwide prevalence of vitamin B-12 insufficiency in pregnancy and 2) its association with BW. DESIGN A search of 5 electronic databases was performed to identify eligible articles. Random-effects meta-analysis was conducted according to geographic regions and pregnancy trimesters for the prevalence subreview and by categorical measures of BW. RESULTS A total of 57 and 23 articles were included for the prevalence and BW subreviews, respectively. The pooled estimates of vitamin B-12 insufficiency were 21%, 19%, and 29% in the first, second, and third trimesters, respectively, with high rates for the Indian subcontinent and the Eastern Mediterranean. The large heterogeneity between studies was partially addressed by creating a standardized score for each study (mean vitamin B-12 insufficiency ÷ cutoff value), which internally corrected for geographic region, trimester, and assay type. Twelve of the 13 longitudinal studies included showed a decrease in mean or median vitamin B-12 across trimesters. Pooled analysis showed nonsignificantly lower maternal vitamin B-12 concentrations in LBW than in normal-BW infants and higher odds of LBW with lower vitamin B-12 values (adjusted OR: 1.70; 95% CI: 1.16, 2.50), but studies from India largely contributed to the latter. CONCLUSIONS Our review indicates that vitamin B-12 insufficiency during pregnancy is common even in nonvegetarian populations and that concentrations of vitamin B-12 decrease from the first to the third trimester. There is no consistent association between vitamin B-12 insufficiency and LBW. However, given the long-term risks of LBW, this observation warrants further cohort studies and randomized controlled trials.
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Affiliation(s)
- Nithya Sukumar
- Division of Health Sciences, Populations, Evidence, and Technologies Group, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Snorri B Rafnsson
- Department of Epidemiology and Public Health, University College London, London, United Kingdom; Edinburgh Migration, Ethnicity, and Health Research Group, Centre for Population Health Sciences, Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Ngianga-Bakwin Kandala
- Department of Mathematics and Information Sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, United Kingdom; Health Economics and Evidence Synthesis Unit, Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Raj Bhopal
- Edinburgh Migration, Ethnicity, and Health Research Group, Centre for Population Health Sciences, Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Chittaranjan S Yajnik
- Diabetes Unit, King Edward Memorial Hospital and Research Centre, Rasta Peth, Pune, Maharashtra, India; and
| | - Ponnusamy Saravanan
- Division of Health Sciences, Populations, Evidence, and Technologies Group, Warwick Medical School, The University of Warwick, Coventry, United Kingdom; Academic Department of Diabetes & Endocrinology, George Eliot Hospital, Nuneaton, United Kingdom
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Visentin CE, Masih SP, Plumptre L, Schroder TH, Sohn KJ, Ly A, Lausman AY, Berger H, Croxford R, Lamers Y, Kim YI, O'Connor DL. Low Serum Vitamin B-12 Concentrations Are Prevalent in a Cohort of Pregnant Canadian Women. J Nutr 2016; 146:1035-42. [PMID: 27075906 DOI: 10.3945/jn.115.226845] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/26/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Among Canadian women of reproductive age, 5% and 20% have serum vitamin B-12 concentrations indicative of deficiency (<148 pmol/L) and marginal status (148-220 pmol/L), respectively. Given the association between suboptimal vitamin B-12 and adverse pregnancy outcomes, an understanding of vitamin B-12 status during pregnancy, and factors that influence it, is required. OBJECTIVE This prospective analysis from the PREFORM (PREnatal FOlic acid exposuRe on DNA Methylation in the newborn infant) study investigated 1) vitamin B-12 status in a cohort of Canadian pregnant women and their newborns, 2) the association of maternal dietary vitamin B-12 intake with maternal and cord blood concentrations of vitamin B-12 and its biomarkers, and 3) the association of fetal genetic polymorphisms with cord blood concentrations of vitamin B-12 and its biomarkers. METHODS In pregnant Canadian women (n = 368; mean ± SD age: 32 ± 5 y), vitamin B-12 intakes were assessed in early (0-16 wk) and mid- to late (23-37 wk) pregnancy. Serum vitamin B-12 and plasma total homocysteine (tHcy) and methylmalonic acid (MMA) in maternal blood at 12-16 wk of pregnancy and at delivery (28-42 wk) and in cord blood were measured and compared by using regression analyses. The associations of 28 fetal genetic variants in vitamin B-12 metabolism and cord blood vitamin B-12, tHcy, and MMA concentrations were assessed by using regression analysis, with adjustment for multiple testing. RESULTS A total of 17% and 38% of women had deficient and 35% and 43% had marginal serum vitamin B-12 concentrations at 12-16 wk of pregnancy and at delivery, respectively. Only 1.9-5.3% had elevated MMA (>271 nmol/L), and no women had elevated tHcy (>13 μmol/L). Maternal dietary vitamin B-12 intake during pregnancy was either weakly associated or not associated with maternal and cord blood vitamin B-12 (r(2) = 0.17-0.24, P < 0.0008), tHcy (P = NS) and MMA (r(2) = 0.05-0.11, P < 0.001). Fetal genetic polymorphisms were not associated with cord blood concentrations of vitamin B-12 and its biomarkers. CONCLUSIONS Deficient and marginal serum vitamin B-12 concentrations are prevalent in Canadian pregnant women with the use of traditional cutoffs, despite supplement use. Given the growing interest among women to adhere to a vegetarian diet that may be lower in vitamin B-12, and vitamin B-12's importance in pregnancy, the functional ramifications of these observations need to be elucidated. This trial was registered at clinicaltrials.gov as NCT02244684.
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Affiliation(s)
- Carly E Visentin
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Shannon P Masih
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lesley Plumptre
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Theresa H Schroder
- Food, Nutrition, and Health Program, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Kyoung-Jin Sohn
- Departments of Medicine and Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Anna Ly
- Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrea Y Lausman
- Obstetrics and Gynecology, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Howard Berger
- Obstetrics and Gynecology, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Yvonne Lamers
- Food, Nutrition, and Health Program, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Young-In Kim
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada; Departments of Medicine and Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada;
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48
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Maternal dietary vitamin B 12 intakes during the first trimester of pregnancy. Proc Nutr Soc 2016. [DOI: 10.1017/s0029665116002561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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49
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Solé-Navais P, Cavallé-Busquets P, Fernandez-Ballart JD, Murphy MM. Early pregnancy B vitamin status, one carbon metabolism, pregnancy outcome and child development. Biochimie 2015; 126:91-6. [PMID: 26700149 DOI: 10.1016/j.biochi.2015.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/01/2015] [Indexed: 11/18/2022]
Abstract
Periconception supplementation with folic acid is recommended until 12 gestational weeks to prevent neural tube defects. Doses of folic acid contained in supplements and timing and length of use during pregnancy vary. The effects of status in periconception and pregnancy folate, cobalamin, betaine and their interactions on one carbon metabolism (1C), as well as the global effect of 1C on foetal growth and pregnancy outcome, are reviewed. Results from prospective studies are reviewed. Cessation of folic acid supplement use after the first trimester is associated with a sharp drop in plasma folate status and enhanced conversion of betaine to dimethylglycine. Dimethylglycine production is also higher in mothers with low folate status than in those with normal-high folate status. The effects of high doses of folic acid on one carbon metabolism in mothers with low early pregnancy cobalamin status and on foetal growth are also reviewed. Several studies report that moderately elevated early pregnancy fasting plasma total homocysteine (tHcy) is inversely associated with birth weight and a predictor of intrauterine growth retardation. There is also evidence for increased risk of preterm birth when maternal folate status is low.
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Affiliation(s)
- Pol Solé-Navais
- Area of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili (URV), IISPV, Spain; CIBER (CB06/03) ISCIII, Spain
| | - Pere Cavallé-Busquets
- CIBER (CB06/03) ISCIII, Spain; Area of Obstetrics & Gynaecology, Hospital Universitari Sant Joan, Reus, Spain
| | - Joan D Fernandez-Ballart
- Area of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili (URV), IISPV, Spain; CIBER (CB06/03) ISCIII, Spain
| | - Michelle M Murphy
- Area of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili (URV), IISPV, Spain; CIBER (CB06/03) ISCIII, Spain.
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50
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Bae S, West AA, Yan J, Jiang X, Perry CA, Malysheva O, Stabler SP, Allen RH, Caudill MA. Vitamin B-12 Status Differs among Pregnant, Lactating, and Control Women with Equivalent Nutrient Intakes. J Nutr 2015; 145:1507-14. [PMID: 25995278 DOI: 10.3945/jn.115.210757] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/21/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Limited data are available from controlled studies on biomarkers of maternal vitamin B-12 status. OBJECTIVE We sought to quantify the effects of pregnancy and lactation on the vitamin B-12 status response to a known and highly controlled vitamin B-12 intake. METHODS As part of a 10-12 wk feeding trial, pregnant (26-29 wk gestation; n = 26), lactating (5 wk postpartum; n = 28), and control (nonpregnant, nonlactating; n = 21) women consumed vitamin B-12 amounts of ∼8.6 μg/d [mixed diet (∼6 μg/d) plus a prenatal multivitamin supplement (2.6 μg/d)]. Serum vitamin B-12, holotranscobalamin (bioactive form of vitamin B-12), methylmalonic acid (MMA), and homocysteine were measured at baseline and study-end. RESULTS All participants achieved adequate vitamin B-12 status in response to the study dose. Compared with control women, pregnant women had lower serum vitamin B-12 (-21%; P = 0.02) at study-end, whereas lactating women had higher (P = 0.04) serum vitamin B-12 throughout the study (+26% at study-end). Consumption of the study vitamin B-12 dose increased serum holotranscobalamin in all reproductive groups (+16-42%; P ≤ 0.009). At study-end, pregnant (vs. control) women had a higher holotranscobalamin-to-vitamin B-12 ratio (P = 0.04) with ∼30% (vs. 20%) of total vitamin B-12 in the bioactive form. Serum MMA increased during pregnancy (+50%; P < 0.001) but did not differ by reproductive state at study-end. Serum homocysteine increased in pregnant women (+15%; P = 0.009) but decreased in control and lactating women (-16-17%; P < 0.001). Despite these changes, pregnant women had ∼20% lower serum homocysteine than the other 2 groups at study-end (P ≤ 0.02). CONCLUSION Pregnancy and lactation alter vitamin B-12 status in a manner consistent with enhanced vitamin B-12 supply to the child. Consumption of the study vitamin B-12 dose (∼3 times the RDA) increased the bioactive form of vitamin B-12, suggesting that women in these reproductive states may benefit from vitamin B-12 intakes exceeding current recommendations. This trial was registered at clinicaltrials.gov as NCT01127022.
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Affiliation(s)
- Sajin Bae
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Allyson A West
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Jian Yan
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Xinyin Jiang
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Cydne A Perry
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Olga Malysheva
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
| | - Sally P Stabler
- Department of Medicine and Division of Hematology, University of Colorado Health Sciences Center, Denver, CO
| | - Robert H Allen
- Department of Medicine and Division of Hematology, University of Colorado Health Sciences Center, Denver, CO
| | - Marie A Caudill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
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