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Rosenthal J, Alverson CJ, Largaespada-Beer N, Kauwell GPA, Bailey LB, Sabido JJ, Diaz M, Williams JL, Bernard K. National and regional population attributable fractions for anemia risk factors (iron, folate, and vitamin B12) in Belize: potential impact of fortification. Rev Panam Salud Publica 2024; 48:e61. [PMID: 38974807 PMCID: PMC11225218 DOI: 10.26633/rpsp.2024.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/13/2024] [Indexed: 07/09/2024] Open
Abstract
Objective To estimate the national and regional population attributable fraction (PAF) and potential number of preventable anemia cases for three nutritional risk factors (iron, red blood cell folate [RBCF], and vitamin B12 deficiencies) among women of childbearing age in Belize. Methods A national probability-based household and micronutrient survey capturing sociodemographic and health information was conducted among 937 nonpregnant Belizean women aged 15-49 years. Blood samples were collected to determine hemoglobin, ferritin, alpha-1-glycoprotein (AGP), RBCF, and vitamin B12 status. All analyses used sample weights and design variables to reflect a complex sample survey. Logistic regression was used to determine adjusted prevalence risk (aPR) ratios, which were then used to estimate national and regional PAF for anemia. Results The overall prevalence of anemia (hemoglobin <12 g/dL) was 21.2% (95% CI [18.7, 25.3]). The prevalence of anemia was significantly greater among women with iron deficiency (59.5%, 95% CI [48.7, 69.5]) compared to women without iron deficiency (15.2%, 95% CI [12.2, 18.3]; aPR 3.9, 95% CI [2.9, 5.1]). The three nutritional deficiencies examined contributed to 34.6% (95% CI [22.1, 47.1]) of the anemia cases. If all these nutritional deficiencies could be eliminated, then an estimated 5 953 (95% CI [3 807, 8 114]) anemia cases could be prevented. Conclusions This study suggests that among women of child-bearing age in Belize, anemia cases might be reduced by a third if three modifiable nutritional risk factors (iron, RBCF, and vitamin B12 deficiencies) could be eliminated. Fortification is one potential strategy to improve nutritional status and reduce the burden of anemia in this population.
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Affiliation(s)
- Jorge Rosenthal
- U.S. Centers for Disease Control and PreventionAtlanta, GAUnited States of AmericaU.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Clinton J Alverson
- U.S. Centers for Disease Control and PreventionAtlanta, GAUnited States of AmericaU.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | | | - Gail PA Kauwell
- University of Central FloridaOrlando, FLUnited States of AmericaUniversity of Central Florida, Orlando, FL, United States of America
| | - Lynn B Bailey
- University of GeorgiaAthens, GAUnited States of AmericaUniversity of Georgia, Athens, GA, United States of America
| | - Julio J Sabido
- Ministry of Health and WellnessBelmopanBelizeMinistry of Health and Wellness, Belmopan, Belize
| | - Melissa Diaz
- Ministry of Health and WellnessBelmopanBelizeMinistry of Health and Wellness, Belmopan, Belize
| | - Jennifer L Williams
- U.S. Centers for Disease Control and PreventionAtlanta, GAUnited States of AmericaU.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kevin Bernard
- Ministry of Health and WellnessBelmopanBelizeMinistry of Health and Wellness, Belmopan, Belize
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Sulistyoningrum DC, Sullivan TR, Skubisz M, Palmer DJ, Wood S, Ueland PM, McCann A, Makrides M, Green TJ, Best KP. Maternal serum unmetabolized folic acid concentration following multivitamin and mineral supplementation with or without folic acid after 12 weeks gestation: A randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13668. [PMID: 38783413 DOI: 10.1111/mcn.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/03/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Abstract
Pregnant women are advised to take folic acid (FA) supplements before conception and during the first trimester of pregnancy. Many women continue FA supplementation throughout pregnancy, and concerns have been raised about associations between excessive FA intake and adverse maternal and child health outcomes. Unmetabolized folic acid (UMFA) is found in serum after high FA intakes and is proposed as a biomarker for excessive FA intake. We aimed to determine if removing FA from prenatal micronutrient supplements after 12 weeks of pregnancy reduces serum UMFA concentrations at 36 weeks gestation. In this double-blind, randomized controlled trial conducted in South Australia, 103 women with a singleton pregnancy were randomly assigned at 12-16 weeks gestation to take a micronutrient supplement containing no FA or 800 µg/day FA from enrollment until 36 weeks gestation. Ninety women (0 µg/day FA n = 46; 800 µg/day FA n = 44) completed the study. Mean, UMFA concentration was lower in the women randomized to the 0 µg/day group compared to the 800 µg/day FA group, 0.6 ± 0.7 and 1.4 ± 2.7 nmol/L, respectively. The adjusted mean difference (95% CI) in UMFA between the groups was [-0.85 (-1.62, -0.08) nmol/L, p = 0.03]. Maternal serum and red blood cell folate concentrations were lower in the 0 µg/day FA group than in the 800 µg/day group (median 23.2 vs. 49.3 and 1335 vs. 1914 nmol/L, respectively; p < 0.001). Removing FA at 12-16 weeks gestation from prenatal micronutrient supplements reduced the concentration of UMFA at 36 weeks gestation.
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Affiliation(s)
- Dian C Sulistyoningrum
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas R Sullivan
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia
| | - Monika Skubisz
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Debra J Palmer
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Simon Wood
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Food, Nutrition and Health Program, University of British Columbia, Vancouver, British Columbia, Canada
- InovoBiologic Inc., Calgary, Alberta, Canada
| | | | | | - Maria Makrides
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Timothy J Green
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Karen P Best
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Cochrane KM, Elango R, Devlin AM, Mayer C, Hutcheon JA, Karakochuk CD. Supplementation with (6 S)-5-methyltetrahydrofolic acid appears as effective as folic acid in maintaining maternal folate status while reducing unmetabolised folic acid in maternal plasma: a randomised trial of pregnant women in Canada. Br J Nutr 2024; 131:92-102. [PMID: 37649241 DOI: 10.1017/s0007114523001733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Folic acid supplementation is recommended during pregnancy to support healthy fetal development; (6S)-5-methyltetrahydrofolic acid ((6S)-5-MTHF) is available in some commercial prenatal vitamins as an alternative to folic acid, but its effect on blood folate status during pregnancy is unknown. To address this, we randomised sixty pregnant individuals at 8-21 weeks' gestation to 0·6 mg/d folic acid or (6S)-5-MTHF × 16 weeks. Fasting blood specimens were collected at baseline and after 16 weeks (endline). Erythrocyte and serum folate were quantified via microbiological assay (as globally recommended) and plasma unmetabolised folic acid (UMFA) via LC-MS/MS. Differences in biochemical folate markers between groups were explored using multivariable linear/quantile regression, adjusting for baseline concentrations, dietary folate intake and gestational weeks. At endline (n 54), the mean values and standard deviations (or median, inter-quartile range) of erythrocyte folate, serum folate and plasma UMFA (nmol/l) in those supplemented with (6S)-5-MTHF v. folic acid, respectively, were 1826 (sd 471) and 1998 (sd 421); 70 (sd 13) and 78 (sd 17); 0·5 (0·4, 0·8) and 1·3 (0·9, 2·1). In regression analyses, erythrocyte and serum folate did not differ by treatment group; however, concentrations of plasma UMFA in pregnancy were 0·6 nmol/l higher (95 % CI 0·2, 1·1) in those supplementing with folic acid as compared with (6S)-5-MTHF. In conclusion, supplementation with (6S)-5-MTHF may reduce plasma UMFA by ∼50 % as compared with supplementation with folic acid, the biological relevance of which is unclear. As folate is currently available for purchase in both forms, the impact of circulating maternal UMFA on perinatal outcomes needs to be determined.
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Affiliation(s)
- Kelsey M Cochrane
- Food, Nutrition, and Health, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, Healthy Starts, Vancouver, Canada
| | - Rajavel Elango
- BC Children's Hospital Research Institute, Healthy Starts, Vancouver, Canada
- Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Angela M Devlin
- BC Children's Hospital Research Institute, Healthy Starts, Vancouver, Canada
- Paediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Chantal Mayer
- Obstetrics and Gynaecology, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute, Healthy Starts, Vancouver, Canada
- Obstetrics and Gynaecology, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, Healthy Starts, Vancouver, Canada
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Jones KS, Collins D, Meadows SR, Koulman A, Page P. National Diet and Nutrition Survey data reveal a decline in folate status in the United Kingdom population between 2008 and 2019. Am J Clin Nutr 2023; 118:1182-1191. [PMID: 37839706 PMCID: PMC10739772 DOI: 10.1016/j.ajcnut.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/28/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Folate is essential for healthy growth and development. Fortification of foods with folic acid can improve folate status and reduce risk of neural tube defects (NTD). Following concern around folate status in the United Kingdom, the United Kingdom government announced in 2021 the intention to introduce mandatory folic acid fortification. OBJECTIVE This study aimed to describe folate status in the United Kingdom population prior to the implementation of mandatory folic acid fortification of non-whole wheat (non-wholemeal) flour and to assess trends in folate status, including in females of reproductive age (FRA). METHODS Data were from the United Kingdom National Diet and Nutrition Survey Rolling Program (2008-2019), a cross-sectional, nationally representative survey of children and adults aged 1.5+ (n = 5792 with folate result). Serum folate concentration was measured by liquid chromatography tandem mass spectrometry (LC-MS/MS) and red blood cell (RBC) folate concentration by microbiological assay. Concentration data were compared against method-specific cut-offs and thresholds, and relationships were explored against demographic and lifestyle characteristics. RESULTS RBC and serum folate concentration significantly decreased by ∼3 percentage points per year between 2008 and 2019 in all age/sex groups. Prevalence of deficiency (RBC folate < 305 nmol/L) was highest in children aged 11 to 18 y (17% in 2016-2019). The proportion of FRA below the cut-off for increased risk of NTD (RBC folate < 748 nmol/L) increased from 69% to 89% between 2008 and 2019. Ethnicity, smoking status, and income were significant determinants of RBC and serum folate concentrations. CONCLUSIONS These data reveal a decline in population folate status in the United Kingdom between 2008 and 2019 and a high prevalence of folate deficiency. A high proportion of FRA had RBC folate concentrations below the cut-off for increased risk of NTD. These data provide information on folate status in a population not currently exposed to mandatory folic acid fortification and are essential to model and assess its impact.
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Affiliation(s)
- Kerry S Jones
- Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.
| | - David Collins
- Nutrition Measurement Platform, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Sarah R Meadows
- Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Albert Koulman
- Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Polly Page
- Nutrition Measurement Platform, MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
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Zhou Y, Wang A, Yeung LF, Qi YP, Pfeiffer CM, Crider KS. Folate and vitamin B12 usual intake and biomarker status by intake source in United States adults aged ≥19 y: NHANES 2007-2018. Am J Clin Nutr 2023; 118:241-254. [PMID: 37172826 PMCID: PMC10926004 DOI: 10.1016/j.ajcnut.2023.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/24/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Folate and vitamin B12 are important biomarkers of nutritional status of populations. OBJECTIVES This study aims to estimate folate and vitamin B12 usual intakes among United States adults and examine folate and vitamin B12 biomarker status by intake source. METHODS We analyzed data for United States adults aged ≥19 y from National Health and Nutrition Examination Survey 2007-2018 (n = 31,128), during which time voluntary corn masa flour (CMF) fortification was started. Usual intake was estimated using the National Cancer Institute method. Folate intake included folate from natural foods and folic acid from 4 sources: enriched cereal grain products (ECGPs), CMF, ready-to-eat cereals (RTEs), and folic acid-containing supplements (SUP). Vitamin B12 intake was mainly from food and supplements. RESULTS The median natural food folate intake (222 μg dietary folate equivalents (DFE)/d) was below the estimated average requirement (EAR) of 320 μg DFE/d. The proportions of those who consumed folic acid from ECGP/CMF only, ECGP/CMF + RTE, ECGP/CMF + SUP, and ECGP/CMF + RTE + SUP were 50%, 18%, 22%, and 10%, respectively. Median usual folic acid intakes (μg/d) were 236 (IQR: 152, 439) overall and 134, 313, 496, and 695 in the ECGP/CMF only, ECGP/CMF + RTE, ECGP/CMF + SUP, and ECGP/CMF + RTE + SUP folic acid consumption groups, respectively. Overall, 2.0% (95% CI: 1.7%, 2.3%) of adults, all of whom used folic acid supplements, consumed greater than the tolerable upper intake level (UL) of 1000 μg/d folic acid. The median usual vitamin B12 intake (μg/d) was 5.2 for vitamin B12 supplement nonusers and 21.8 for users. Consumption of RTE and/or supplements with folic acid was associated with higher serum and red blood cell folate concentrations. Vitamin B12 supplement users had significantly higher serum vitamin B12 concentrations. CONCLUSIONS Folic acid fortification plays a critical role in helping United States adults meet the folate EAR. At current fortification levels, United States adults who do not consume supplements do not have the usual folic acid intake exceeding the UL.
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Affiliation(s)
- Ying Zhou
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Arick Wang
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lorraine F Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Esmaeili Y, Mohammadi Z, Khavani M, Sanati A, Shariati L, Seyedhosseini Ghaheh H, Bidram E, Zarrabi A. Fluorescence anisotropy cytosensing of folate receptor positive tumor cells using 3D polyurethane-GO-foams modified with folic acid: molecular dynamics and in vitro studies. Mikrochim Acta 2023; 190:44. [PMID: 36602637 DOI: 10.1007/s00604-022-05558-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/29/2022] [Indexed: 01/06/2023]
Abstract
Integrated polyurethane (PU)-based foams modified with PEGylated graphene oxide and folic acid (PU@GO-PEG-FA) were developed with the goal of capturing and detecting tumor cells with precision. The detection of the modified PU@GO-PEG surface through FA against folate receptor-overexpressed tumor cells is the basis for tumor cell capture. Molecular dynamics (MD) simulations were applied to study the strength of FA interactions with the folate receptor. Based on the obtained results, the folate receptor has intense interactions with FA, which leads to the reduction in the FA interactions with PEG, and so decreases the fluorescence intensity of the biosensor. The synergistic interactions offer the FA-modified foams a high efficiency for capturing the tumor cell. Using a turn-off fluorescence technique based on the complicated interaction of FA-folate receptor generated by target recognition, the enhanced capture tumor cells could be directly read out at excitation-emission wavelengths of 380-450 nm. The working range is between 1×10 2 to 2×10 4 cells mL -1 with a detection limit of 25 cells mL -1 and good reproducibility with relative standard deviation of 2.35%. Overall, findings demonstrate that the fluorescence-based biosensor has a significant advantage for early tumor cell diagnosis.
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Affiliation(s)
- Yasaman Esmaeili
- Biosensor Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Mohammadi
- Biosensor Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Khavani
- Molecular Cell Biomechanics Laboratory, Departments of Bioengineering and Mechanical Engineering, University of California Berkeley, Berkeley, CA, 94720, USA
| | - Alireza Sanati
- Biosensor Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Laleh Shariati
- Department of Biomaterials, Nanotechnology and Tissue Engineering, School of Advanced Technologies in Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Applied Physiology Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Hezarjerib Ave, 8174673461, Isfahan, Iran
| | - Hooria Seyedhosseini Ghaheh
- Department of Pharmaceutical Biotechnology, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Bidram
- Biosensor Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
- Department of Biomaterials, Nanotechnology and Tissue Engineering, School of Advanced Technologies in Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Ali Zarrabi
- Department of Biomedical Engineering, Faculty of Engineering and Natural Sciences, Istinye University, Istanbul, 34396, Turkey.
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7
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Fazili Z, Paladugula N, Zhang M, Pfeiffer CM. Folate Forms in RBC and Whole-Blood Lysates Appear Stable When Stored Frozen for 2 Years. J Nutr 2021; 151:2852-2860. [PMID: 34091683 PMCID: PMC9210571 DOI: 10.1093/jn/nxab184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/09/2021] [Accepted: 05/14/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The use of RBC lysate (RBC-Lys) eliminates the need for serum folate and hematocrit (Hct) measurement to calculate RBC folate. Information on the long-term frozen storage stability of RBC-Lys is missing. OBJECTIVES We aimed to assess the comparability of RBC folate forms in whole-blood lysate (WB-Lys) and RBC-Lys and the folate stability in both matrices. METHODS We prepared conventional WB-Lys (1:11 dilution with 1% ascorbic acid) and RBC-Lys (1:11 dilution of washed and saline-diluted RBCs with 1% ascorbic acid) from EDTA blood (n = 60 adult donors) and stored lysates at -70°C until analysis at baseline (1 wk), 3, 6, 12, and 24 mo. Before analysis by HPLC-tandem MS, we incubated the WB-Lys (4 h at 37°C) and treated the RBC-Lys with human recombinant γ-glutamyl hydrolase for folate polyglutamate deconjugation. We analyzed RBC-Lys samples for hemoglobin (Hb) (same aliquot) to normalize for the preanalytical dilution; Hb-folate was converted to RBC folate for each folate form using the mean corpuscular Hb concentration. We analyzed Hct as well as folate forms in matching serum samples for traditional RBC folate calculation. We conducted descriptive data analyses (correlation, Bland-Altman plot, Deming regression). RESULTS At baseline, results for RBC folate forms derived from WB-Lys compared with RBC-Lys samples showed excellent correlation (Pearson r ≥ 0.97). Mean ± SD concentrations compared well for total folate (WB-Lys: 886 ± 255 compared with RBC-Lys: 899 ± 271 nmol/L), 5-methyltetrahydrofolate (WB-Lys: 831 ± 258 compared with RBC-Lys: 843 ± 276 nmol/L), and nonmethyl folate (WB-Lys: 53.3 ± 74.4 compared with RBC-Lys: 52.9 ± 70.7 nmol/L), but were 17% higher in RBC-Lys for pyrazino-s-triazine derivative of 4α-hydroxy-5-CH3-H4folate (MeFox) (WB-Lys: 147 ± 44.1 compared with RBC-Lys: 172 ± 53.5 nmol/L). Frozen storage of WB-Lys and RBC-Lys samples for ≤24 mo showed ≤5%, ≤5%, ≤13%, and ≤11% change in total folate, 5-methyltetrahydrofolate, nonmethyl folate, and MeFox, respectively. CONCLUSIONS Erythrocyte folate forms appear to be stable in RBC-Lys samples stored frozen at -70°C for ≤2 y. The relatively small changes in folate concentrations over time were comparable between RBC-Lys and conventionally prepared WB-Lys samples.
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Affiliation(s)
- Zia Fazili
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Neelima Paladugula
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ming Zhang
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Samson KLI, Loh SP, Lee SS, Sulistyoningrum DC, Khor GL, Shariff ZBM, Ismai IZ, Yelland LN, Leemaqz S, Makrides M, Hutcheon JA, Roche ML, Karakochuk CD, Green TJ. Weekly iron-folic acid supplements containing 2.8 mg folic acid are associated with a lower risk of neural tube defects than the current practice of 0.4 mg: a randomised controlled trial in Malaysia. BMJ Glob Health 2020; 5:e003897. [PMID: 33272946 PMCID: PMC7716666 DOI: 10.1136/bmjgh-2020-003897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/05/2020] [Accepted: 11/11/2020] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is >20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk. METHODS We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n=331) were randomised to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks. RESULTS At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7; p<0.0001) more likely to achieve an RBC folate >748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group. CONCLUSION Weekly IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed. TRAIL REGISTRATION NUMBER This trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12619000818134).
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Affiliation(s)
- Kaitlyn L I Samson
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Su Peng Loh
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Siew Siew Lee
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Dian C Sulistyoningrum
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Geok Lin Khor
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | | | - Irmi Zarina Ismai
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Lisa N Yelland
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shalem Leemaqz
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jennifer A Hutcheon
- Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Crystal D Karakochuk
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Timothy J Green
- SAHMRI Women and Kids, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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9
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Sulistyoningrum D, Green T, Palmer D, Sullivan T, Wood S, Makrides M, Skubisz M, Best KP. Study protocol for a randomised controlled trial evaluating the effect of folic acid supplementation beyond the first trimester on maternal plasma unmetabolised folic acid in late gestation. BMJ Open 2020; 10:e040416. [PMID: 33199423 PMCID: PMC7670954 DOI: 10.1136/bmjopen-2020-040416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Taking folic acid containing supplements prior to and during early pregnancy reduces the risk of neural tube defects. Neural tube defects occur prior to 28 days postconception, after which, there is no proven benefit of continuing to take folic acid. However, many women continue to take folic acid containing supplements throughout the pregnancy. At higher intakes, folic acid is not converted to its active form and accumulates in circulation as unmetabolised folic acid (UMFA). Recently, concerns have been raised about possible links between late gestation folic acid supplementation and childhood allergy, metabolic disease and autism spectrum disorders. We aim to determine if removing folic acid from prenatal micronutrient supplements after 12 weeks gestation reduces circulating levels of maternal UMFA at 36 weeks gestation. METHODS AND ANALYSIS This is a parallel-design, double-blinded randomised controlled trial. Women ≥12 and <16 weeks' gestation with a singleton pregnancy and able to give informed consent are eligible to participate. Women (n=100; 50 per group) will be randomised to receive either a micronutrient supplement containing 0.8 mg of folic acid or a micronutrient supplement without folic acid daily from enrolment until delivery. The primary outcome is plasma UMFA concentration at 36 weeks gestation. Secondary outcomes include red blood cell folate and total plasma folate concentration. We will assess whether there is a difference in mean UMFA levels at 36 weeks gestation between groups using linear regression with adjustment for baseline UMFA levels and gestational age at trial entry. The treatment effect will be described as a mean difference with 95% CI. ETHICS AND DISSEMINATION Ethical approval has been granted from the Women's and Children's Health Network Research Ethics Committee (HREC/19/WCHN/018). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12619001511123.
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Affiliation(s)
- Dian Sulistyoningrum
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Tim Green
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Debbie Palmer
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Thomas Sullivan
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Simon Wood
- Faculty of Science and Engineering, Curtin University, Perth, West Australia, Australia
- Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maria Makrides
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Monika Skubisz
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Karen P Best
- SAHMRI Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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10
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Hunt SE, Netting MJ, Sullivan TR, Best KP, Houghton LA, Makrides M, Muhlhausler BS, Green TJ. Red Blood Cell Folate Likely Overestimated in Australian National Survey: Implications for Neural Tube Defect Risk. Nutrients 2020; 12:E1283. [PMID: 32369938 PMCID: PMC7281964 DOI: 10.3390/nu12051283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
In 2009, the Australian government mandated the addition of folic acid to bread flour to reduce the incidence of neural tube defects (NTD)-affected pregnancies. In 2011-2012, the Australian Health Measures Survey (AHMS) reported a mean red blood cell (RBC) folate in women of reproductive age (16-44 y) of 1647 nmol/L. Over 99% of women had an RBC folate ≥ 906 nmol/L, a concentration consistent with a very low risk of NTDs if a woman became pregnant. However, RBC folate was measured using an immunoassay, which is not a recommended method due to questionable accuracy. The microbiological assay is the preferred method for RBC folate measurement. To determine whether the immunoassay method may have led to spurious conclusions about the folate status of Australian women, we collected fasting blood samples from 74 healthy non-pregnant, non-lactating women (18-44 y) and measured RBC folate using both the immunoassay and microbiological methods. Mean RBC folate (95% confidence interval) concentration measured with the immunoassay method was 1735 (1666, 1804) nmol/L compared with 942 (887, 1012) nmol/L using the microbiological method. No woman had an RBC folate < 906 nmol/L using the immunoassay method, whereas 46% of women had an RBC folate < 906 nmol/L using the microbiological method. The NTD risk was estimated to be 0.06% using the immunoassay method and 0.14% using the microbiological method. RBC folate using AHMS survey may have underestimated NTD risk in Australian women.
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Affiliation(s)
- Shannon E. Hunt
- School of Agriculture, Food and Wine, Faculty of Sciences, University of Adelaide, Adelaide 5005, South Australia, Australia;
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
| | - Merryn J. Netting
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- Adelaide Medical School, University of Adelaide, Adelaide 5005, South Australia, Australia
| | - Thomas R. Sullivan
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- School of Public Health, University of Adelaide, Adelaide 5005, South Australia, Australia
| | - Karen P. Best
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- Adelaide Medical School, University of Adelaide, Adelaide 5005, South Australia, Australia
| | - Lisa A. Houghton
- Department of Human Nutrition, University of Otago, Dunedin 9016, New Zealand;
| | - Maria Makrides
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- Adelaide Medical School, University of Adelaide, Adelaide 5005, South Australia, Australia
| | - Beverly S. Muhlhausler
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- Nutrition and Health, Health and Biosecurity Business Unit, Commonwealth Scientific and Industrial Research Organisation, Adelaide 5000, South Australia, Australia
| | - Tim J. Green
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide 5000, South Australia, Australia; (M.J.N.); (T.R.S.); (K.P.B.); (M.M.); (B.S.M.)
- Adelaide Medical School, University of Adelaide, Adelaide 5005, South Australia, Australia
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11
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Zhang M, Sternberg MR, Yeung LF, Pfeiffer CM. Population RBC folate concentrations can be accurately estimated from measured whole blood folate, measured hemoglobin, and predicted serum folate-cross-sectional data from the NHANES 1988-2010. Am J Clin Nutr 2020; 111:601-612. [PMID: 31858145 PMCID: PMC10059072 DOI: 10.1093/ajcn/nqz307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/18/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND RBC folate (RBF) is an indicator of folate status and risk of neural-tube defects. It is calculated from whole blood folate (WBF), serum folate (SFOL), and hematocrit (Hct). SFOL and/or Hct are sometimes unavailable; hemoglobin (Hb) is generally available in surveys. OBJECTIVES We assessed the ability of different RBF approximations to generate population data in women aged 12-49 y. METHODS Using SFOL, RBF, Hct, Hb, and mean corpuscular Hb content (MCHC) from prefortification (1988-1994) and postfortification (1999-2006, 2007-2010) NHANES we applied 6 approaches: #1) assume SFOL = 0; #2) impute SFOL (population median); #3) impute Hct (population median); #4) estimate Hct (Hb/MCHC); #5) assume SFOL = 0 and estimate Hct; and #6) predict SFOL (from WBF) and estimate Hct. For each approach, we calculated the paired percentage difference to the "true" RBF and estimated various statistics. RESULTS For 2007-2010 (unweighted data), the median relative difference from "true" RBF was lowest for approaches #2 (-0.74%), #4 (-0.96%), and #6 (-1.15%), intermediate for #3 (-3.36%), and highest for #5 (4.96%) and #1 (5.78%). The 95% agreement limits were smallest for approach #1 (2.33%, 13.0%) and largest for #3 (-20.8%, 11.3%). Approach #2 showed concentration-dependence (negative compared with positive differences at low compared with high RBF). Using weighted data, we found similar patterns across approaches for mean relative differences by demographic subgroup for all 3 time periods. CONCLUSIONS We obtained the best agreement between estimated and "true" RBF when we predicted SFOL using a regression equation obtained from a subset of samples (approach #6). Alternatively, the consistent overestimation of RBF when assuming SFOL = 0 (∼6%) could be addressed by adjusting the data (approach #5). Similar observations for pre- and postfortification periods suggest applicability to low and high folate status situations, but should be confirmed elsewhere. To estimate RBF, at least WBF and Hb are needed.
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Affiliation(s)
- Ming Zhang
- National Center for Environmental Health, CDC, Atlanta, GA, USA
| | | | - Lorraine F Yeung
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
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12
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Samson KLI, Loh SP, Khor GL, Mohd Shariff Z, Yelland LN, Leemaqz S, Makrides M, Hutcheon JA, Sulistyoningrum DC, Yu JJ, Roche ML, De-Regil LM, Green TJ, Karakochuk CD. Effect of once weekly folic acid supplementation on erythrocyte folate concentrations in women to determine potential to prevent neural tube defects: a randomised controlled dose-finding trial in Malaysia. BMJ Open 2020; 10:e034598. [PMID: 32029499 PMCID: PMC7044827 DOI: 10.1136/bmjopen-2019-034598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Folic acid (0.4 mg) taken prior to and during early pregnancy reduces the risk of neural tube defects (NTDs). Because these birth defects occur early in pregnancy, before women may know they are pregnant, many countries have mandated the addition of folic acid to food staples. In countries where fortification is not possible, and weekly iron folic acid programmes exist to reduce anaemia, the WHO recommends that 2.8 mg (7×0.4 mg) folic acid be given instead of the current weekly practice of 0.4 mg. Currently, there is a lack of evidence to support if the 2.8 mg folic acid per week dose is sufficient to raise erythrocyte folate concentrations to a level associated with a reduced risk of a NTD-affected pregnancy. We aim to conduct a three-arm randomised controlled trial to determine the effect of weekly folic acid with iron on erythrocyte folate, a biomarker of NTD risk. METHODS AND ANALYSIS We will recruit non-pregnant women (n=300; 18-45 years) from Selangor, Malaysia. Women will be randomised to receive either 2.8, 0.4 or 0.0 (placebo) mg folic acid with 60 mg iron weekly for 16 weeks, followed by a 4-week washout period. The primary outcome will be erythrocyte folate concentration at 16 weeks and the mean concentration will be compared between randomised treatment groups (intention-to-treat) using a linear regression model adjusting for the baseline measure. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of British Columbia (H18-00768) and Universiti Putra Malaysia (JKEUPM-2018-255). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS ACTRN12619000818134 and NMRR-19-119-45736.
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Affiliation(s)
- Kaitlyn L I Samson
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Su Peng Loh
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Geok Lin Khor
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Zalilah Mohd Shariff
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Lisa N Yelland
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Shalem Leemaqz
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Jennifer A Hutcheon
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dian C Sulistyoningrum
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica J Yu
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marion L Roche
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Luz Maria De-Regil
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Tim J Green
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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13
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Pfeiffer CM, Sternberg MR, Zhang M, Fazili Z, Storandt RJ, Crider KS, Yamini S, Gahche JJ, Juan W, Wang CY, Potischman N, Williams J, LaVoie DJ. Folate status in the US population 20 y after the introduction of folic acid fortification. Am J Clin Nutr 2019; 110:1088-1097. [PMID: 31504109 PMCID: PMC6821545 DOI: 10.1093/ajcn/nqz184] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/12/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Enriched cereal-grain products have been fortified in the United States for >20 y to improve folate status in women of reproductive age and reduce the risk of folic acid-responsive neural tube birth defects (NTDs). OBJECTIVES Our objectives were to assess postfortification changes in folate status in the overall US population and in women aged 12-49 y and to characterize recent folate status by demographic group and use of folic acid-containing supplements. METHODS We examined cross-sectional serum and RBC folate data from the NHANES 1999-2016. RESULTS Serum folate geometric means increased from 2007-2010 to 2011-2016 in persons aged ≥1 y (38.7 compared with 40.6 nmol/L) and in women (35.3 compared with 37.0 nmol/L), whereas RBC folate showed no significant change. Younger age groups, men, and Hispanic persons showed increased serum and RBC folate concentrations, whereas non-Hispanic black persons and supplement nonusers showed increased serum folate concentrations. The folate insufficiency prevalence (RBC folate <748 nmol/L; NTD risk) in women decreased from 2007-2010 (23.2%) to 2011-2016 (18.6%) overall and in some subgroups (e.g., women aged 20-39 y, Hispanic and non-Hispanic black women, and supplement nonusers). After covariate adjustment, RBC folate was significantly lower in all age groups (by ∼10-20%) compared with persons aged ≥60 y and in Hispanic (by 8.2%), non-Hispanic Asian (by 12.1%), and non-Hispanic black (by 20.5%) compared with non-Hispanic white women (2011-2016). The 90th percentile for serum (∼70 nmol/L) and RBC (∼1800 nmol/L) folate in supplement nonusers aged ≥60 y was similar to the geometric mean in users (2011-2014). CONCLUSIONS Blood folate concentrations in the US population overall and in women have not decreased recently, and folate insufficiency rates are ∼20%. Continued monitoring of all age groups is advisable given the high folate status particularly in older supplement users.
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Affiliation(s)
| | | | - Mindy Zhang
- National Center for Environmental Health, CDC, Atlanta, GA, USA
| | - Zia Fazili
- National Center for Environmental Health, CDC, Atlanta, GA, USA
| | - Renee J Storandt
- National Center for Health Statistics, CDC, Hyattsville, MD, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | - Sedigheh Yamini
- Center for Food Safety and Applied Nutrition, FDA, College Park, MD, USA
| | | | - WenYen Juan
- Center for Food Safety and Applied Nutrition, FDA, College Park, MD, USA
| | - Chia-Yih Wang
- National Center for Health Statistics, CDC, Hyattsville, MD, USA
| | | | - Jennifer Williams
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA, USA
| | - Donna J LaVoie
- National Center for Environmental Health, CDC, Atlanta, GA, USA
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Affiliation(s)
- Krista S Crider
- Centers for Disease Control and Prevention, National Center on
Birth Defects and Developmental Disabilities, Atlanta GA
| | - Christine M Pfeiffer
- Centers for Disease Control and Prevention, National Center for
Environmental Health, Atlanta, GA
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15
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Abstract
Optimising micronutrient status globally is a major health priority. Nutritional biomarkers are critical for the identification of nutrient inadequacies in light of the limitations of dietary assessment methods. Early diagnosis and prevention of nutrient inadequacies require sensitive, validated and harmonised methods to determine and monitor micronutrient status in individual healthcare and population-based surveys. Important criteria in the identification, validation and implementation of nutritional biomarkers include the testing of biomarker specificity and sensitivity, and their response to dietary as well as physiologic changes, e.g. age or pregnancy. Nutritional status can be categorised into deficient, suboptimal, adequate and excess status, where appropriate, and provided cut-offs are available. Cut-offs are quantitative measures to reflect health outcomes and are important in validating nutritional surveys, interventions and monitoring of populations. For many biomarkers, available cut-offs have limited interpretability and are most commonly derived in adult populations only. For the comparison of studies from across the globe, the harmonisation of analytical methods is essential and can be realised with the use of internationally available reference material and interlaboratory comparison studies. This narrative review describes current efforts on identifying and validating existing and new biomarkers, the derivation of biomarker cut-offs, and international efforts on harmonisation of laboratory methods for biomarker quantitation and their interpretation, in the example of B-vitamins. Establishing sensitive, reliable and cost-efficient biomarkers and related cut-offs for use in populations across the globe are critical to facilitating the early diagnosis of micronutrient inadequacies on the clinical and community-based level for timely intervention and disease prevention.
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16
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Crider KS, Devine O, Qi YP, Yeung LF, Sekkarie A, Zaganjor I, Wong E, Rose CE, Berry RJ. Systematic Review and Bayesian Meta-analysis of the Dose-response Relationship between Folic Acid Intake and Changes in Blood Folate Concentrations. Nutrients 2019; 11:nu11010071. [PMID: 30609688 PMCID: PMC6356991 DOI: 10.3390/nu11010071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/22/2018] [Accepted: 12/28/2018] [Indexed: 11/25/2022] Open
Abstract
The threshold for population-level optimal red blood cell (RBC) folate concentration among women of reproductive age for the prevention of neural tube defects has been estimated at 906 nmol/L; however, the dose-response relationship between folic acid intake and blood folate concentrations is uncharacterized. To estimate the magnitude of blood folate concentration increase in response to specific dosages of folic acid under steady-state conditions (as could be achieved with food fortification), a systematic review of the literature and meta-analysis was conducted. Of the 14,002 records we identified, 533 were selected for full-text review, and data were extracted from 108 articles. The steady-state concentrations (homeostasis) of both serum/plasma and RBC folate concentrations were estimated using a Bayesian meta-analytic approach and one-compartment physiologically-based pharmacokinetic models. RBC folate concentrations increased 1.78 fold (95% credible interval (CI): 1.66, 1.93) from baseline to steady-state at 375–570 µg folic acid/day, and it took a median of 36 weeks of folic acid intake (95% CI: 27, 52) to achieve steady-state RBC folate concentrations. Based on regression analysis, we estimate that serum/plasma folate concentrations increased 11.6% (95% CI: 8.4, 14.9) for every 100 µg/day folic acid intake. These results will help programs plan and monitor folic acid fortification programs.
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Affiliation(s)
- Krista S Crider
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Owen Devine
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
- Karna, LLC, Atlanta, GA 30329, USA.
- G²S Corporation, San Antonio, TX 78216, USA.
| | - Yan Ping Qi
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Lorraine F Yeung
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Ahlia Sekkarie
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Doctoral Program in Nutrition Health Sciences, Laney Graduate School, Emory University, Atlanta, GA 30322, USA.
| | - Ibrahim Zaganjor
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Department of Epidemiology, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Eugene Wong
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA.
- Department of Epidemiology, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Charles E Rose
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
| | - Robert J Berry
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA 30341, USA.
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