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Das R, Duggal M, Rosenthal J, Kankaria A, Senee HK, Jabbar S, Kaur M, Kumar V, Bhardwaj S, Singh N, Dhanjal GS, Kumar A, Rose CE, Bhatia R, Gupta R, Dalpath S, Crider KS, Zhang M, Pfeiffer CM, Gupta R, Mehta R, Raina N, Yeung LF. Folate and Vitamin B12 Status in Women of Reproductive Age in Rural Haryana, India: Estimating Population-Based Prevalence for Neural Tube Defects. Birth Defects Res 2024; 116:e2390. [PMID: 39162364 PMCID: PMC11373839 DOI: 10.1002/bdr2.2390] [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: 04/10/2024] [Revised: 07/13/2024] [Accepted: 07/20/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Folate and vitamin B12 deficiencies in pregnant women are associated with increased risk for adverse maternal and infant health outcomes, including neural tube defects (NTDs). METHODS A population-based cross-sectional survey was conducted in two rural areas in Ambala District, Haryana, India in 2017 to assess baseline folate and vitamin B12 status among women of reproductive age (WRA) and predict the prevalence of NTDs. We calculated the prevalence of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 775 non-pregnant, non-lactating WRA (18-49 years). Using red blood cell (RBC) folate distributions and an established Bayesian model, we predicted NTD prevalence. All analyses were conducted using SAS-callable SUDAAN Version 11.0.4 to account for complex survey design. RESULTS Among WRA, 10.1% (95% CI: 7.9, 12.7) and 9.3% (95% CI: 7.4, 11.6) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The prevalence of RBC folate insufficiency (<748 nmol/L) was 78.3% (95% CI: 75.0, 81.3) and the predicted NTD prevalence was 21.0 (95% uncertainly interval: 16.9, 25.9) per 10,000 live births. Prevalences of vitamin B12 deficiency (<200 pg/mL) and marginal deficiency (≥200 pg/mL and ≤300 pg/mL) were 57.7% (95% CI: 53.9, 61.4) and 23.5% (95% CI: 20.4, 26.9), respectively. CONCLUSIONS The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline against which results from future post-fortification surveys can be compared.
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Affiliation(s)
- Reena Das
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mona Duggal
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jorge Rosenthal
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ankita Kankaria
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hari K Senee
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shameem Jabbar
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manmeet Kaur
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Neha Singh
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gursharan S Dhanjal
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Kumar
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rita Bhatia
- McKing Consulting Corporation, Atlanta, Georgia, USA
| | - Rachita Gupta
- World Health Organization India Office, New Delhi, India
| | | | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mindy Zhang
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Rajesh Mehta
- World Health Organization, South-East Asia Regional Office, New Delhi, India
| | - Neena Raina
- World Health Organization, South-East Asia Regional Office, New Delhi, India
| | - Lorraine F Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Wang A, Fothergill A, Yeung LF, Crider KS, Williams JL. Update on the impact of voluntary folic acid fortification of corn masa flour on red blood cell folate concentrations-National Health and Nutrition Examination Survey, 2011-March 2020. Birth Defects Res 2024; 116:e2321. [PMID: 38457279 PMCID: PMC11187752 DOI: 10.1002/bdr2.2321] [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: 11/24/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Folic acid is a micronutrient that is effective at preventing neural tube defects (NTDs). In 2016, the FDA authorized the voluntary fortification of corn masa flour (CMF) with folic acid to reduce disparities in NTDs among infants of women who do not regularly consume other fortified cereal grains, in particular Hispanic women of reproductive age (WRA). METHODS We analyzed data from the National Health and Nutrition Examination Survey (NHANES) from 2011 to March 2020 assessing the impact of voluntary fortification of CMF on the folate status of Hispanic WRA. We analyzed folic acid usual intake and red blood cell (RBC) folate concentrations among non-pregnant, non-lactating Hispanic WRA, comparing pre-fortification (2011-2016) to post-fortification (2017-March 2020) data. RBC folate concentrations were used to create model-based estimation of NTD rates. RESULTS The proportion of Hispanic WRA with folic acid usual intakes <400 μg/d did not change (2011-2016: 86.1% [95% Confidence Interval, CI: 83.7-88.5]; 2017-March 2020: 87.8% [95% CI: 84.8-90.7]; p = .38) nor did the proportion of Hispanic WRA with RBC folate below optimal concentrations (<748 nmol/L, 2011-2016: 16.0% [95% CI: 13.7-18.2]; 2017-March 2020: 18.1% [95% CI: 12.1-24.0]; p = 0.49). Model-based estimates of NTD rates suggest further improvements in the folate status of Hispanic WRA might prevent an additional 157 (95% Uncertainty Interval: 0, 288) NTDs/year. CONCLUSIONS Voluntary fortification of CMF with folic acid has yet to have a significant impact on the folate status of WRA. Continued monitoring and further research into factors such as fortified product availability, community knowledge, and awareness of folic acid benefits would inform and improve future public health interventions.
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Affiliation(s)
- Arick Wang
- Prevention and Health Disparities Team, Infant Outcomes Monitoring, Research and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Amy Fothergill
- Prevention and Health Disparities Team, Infant Outcomes Monitoring, Research and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Lorraine F Yeung
- Prevention and Health Disparities Team, Infant Outcomes Monitoring, Research and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Krista S Crider
- Prevention and Health Disparities Team, Infant Outcomes Monitoring, Research and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Jennifer L Williams
- Prevention and Health Disparities Team, Infant Outcomes Monitoring, Research and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
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Qi YP, Crider KS, Williams AM, Tripp K, Mapango C, Rhodes EC, Nyirenda E, Phiri F, Zhang M, Jabbar S, Pfeiffer CM, Pachón H, Zimmerman S, Williams JL. Folate and vitamin B 12 status and predicted neural tube defects risk among nonpregnant women of reproductive age from the Malawi National Micronutrient Survey, 2015-2016. Birth Defects Res 2024; 116:e2329. [PMID: 38526193 PMCID: PMC11253844 DOI: 10.1002/bdr2.2329] [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: 10/03/2023] [Revised: 02/05/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Maternal folate and vitamin B12 deficiency can lead to serious adverse pregnancy outcomes. There are no nationally representative estimates on folate and vitamin B12 status among women of reproductive age (WRA) in Malawi. OBJECTIVE We assessed folate and vitamin B12 status among nonpregnant WRA in Malawi and predicted the risk of folate-sensitive neural tube defects (NTDs) were they to become pregnant. METHODS Using data from the cross-sectional, nationally representative 2015-2016 Malawi Micronutrient Survey, we calculated the proportion of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 778 nonpregnant WRA (15-49 years). We predicted NTD prevalence using red blood cell (RBC) folate distributions and a published Bayesian model of the association between RBC folate and NTD risk. Analyses accounted for complex survey design. RESULTS Among WRA, 8.5% (95% CI: 6.2, 11.6) and 13.3% (10.0, 17.4) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The proportion of vitamin B12 deficiency (<148 pmol/L) and insufficiency (≤221 pmol/L) was 11.8% (8.6, 16.0) and 40.6% (34.1, 47.4), respectively. RBC folate insufficiency (<748 nmol/L, defined as the concentration associated with the threshold for elevated NTD risk: >8 cases per 10,000 births) was widespread: 81.4% (75.0, 86.4). The predicted NTD risk nationally was 24.7 cases per 10,000 live births. RBC folate insufficiency and higher predicted NTD risk were more common among WRA living in urban areas or with higher education. CONCLUSIONS These findings highlight the importance of nutritional and NTD surveillance in Malawi and the opportunity for improving folate and vitamin B12 nutrition among Malawian WRA.
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Affiliation(s)
- Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Krista S. Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | | | - Katie Tripp
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia, USA
| | - Carine Mapango
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | - Elizabeth C. Rhodes
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Eunice Nyirenda
- Department of Nutrition, HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Felix Phiri
- Department of Nutrition, HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Mindy Zhang
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | - Shameem Jabbar
- National Center for Environmental Health, CDC, Atlanta, Georgia, USA
| | | | - Helena Pachón
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Food Fortification Initiative, Atlanta, Georgia, USA
| | - Sarah Zimmerman
- McKing Consulting Corporation, Atlanta, Georgia, USA
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia, USA
| | - Jennifer L. Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
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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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Larson LM, Thomas T, Kurpad AV, Martorell R, Hoddinott J, Adebiyi VO, Swaminathan S, Neufeld LM. Predictors of anaemia in mothers and children in Uttar Pradesh, India. Public Health Nutr 2024; 27:e30. [PMID: 38185818 PMCID: PMC10830375 DOI: 10.1017/s1368980024000028] [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: 09/21/2022] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Anaemia affects more than half of Indian women and children, but the contribution of its causes remains unquantified. We examined interrelationships between Hb and nutritional, environmental, infectious and genetic determinants of anaemia in non-pregnant mothers and children in Uttar Pradesh (UP). DESIGN We conducted a cross-sectional survey of households in twenty-five districts of UP between October and December 2016. We collected socio-demographic data, anthropometry and venous blood in 1238 non-pregnant mothers and their children. We analysed venous blood samples for malaria, Hb, ferritin, retinol, folate, Zn, vitamin B12, C-reactive protein, α1-acid glycoprotein (AGP) and β-thalassaemia. We used path analysis to examine pathways through which predictors of anaemia were associated with Hb concentration. SETTING Rural and urban households in twenty-five districts of UP. PARTICIPANTS Mothers 18-49 years and children 6-59 months in UP. RESULTS A total of 36·4 % of mothers and 56·0 % of children were anaemic, and 26·7 % of women and 44·6 % of children had Fe deficiency anaemia. Ferritin was the strongest predictor of Hb (β (95 % CI) = 1·03 (0·80, 1·27) g/dL in women and 0·90 (0·68, 1·12) g/dL in children). In children only, red blood cell folate and AGP were negatively associated with Hb and retinol was positively associated with Hb. CONCLUSIONS Over 70 % of mothers and children with anaemia had Fe deficiency, needing urgent attention. However, several simultaneous predictors of Hb exist, including nutrient deficiencies and inflammation. The potential of Fe interventions to address anaemia may be constrained unless coexisting determinants are jointly addressed.
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Affiliation(s)
- Leila M Larson
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC29208, USA
| | - Tinku Thomas
- Department of Biostatistics, St John’s Medical College, Bangalore, India
| | - Anura V Kurpad
- Department of Physiology, St John’s Medical College, Bangalore, India
| | - Reynaldo Martorell
- The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - John Hoddinott
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Victoria Oluwapamilerin Adebiyi
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC29208, USA
| | | | - Lynnette M Neufeld
- Food and Agriculture Organization of the United Nations (FAO), Rome, Italy
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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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Martinez H, Benavides-Lara A, Arynchyna-Smith A, Ghotme KA, Arabi M, Arynchyn A. Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age. Childs Nerv Syst 2023; 39:1719-1736. [PMID: 37103517 DOI: 10.1007/s00381-023-05913-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/28/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age. METHODS This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification. RESULTS Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition. DISCUSSION We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.
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Affiliation(s)
- Homero Martinez
- Global Technical Services, Nutrition International, 180 Elgin St. suite 1000, ON, Ottawa, Canada.
- Hospital Infantil de México Federico Gómez, Mexico City, Mexico.
| | - Adriana Benavides-Lara
- Costa Rican Birth Defects Register Center (CREC), Costa Rican Institute of Research and Education in Nutrition and Health (INCIENSA), Cartago, Costa Rica
| | - Anastasia Arynchyna-Smith
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kemel A Ghotme
- Translational Neuroscience Research Lab, Faculty of Medicine, Universidad de La Sabana, Chia, Colombia
- Department of Neurosurgery, Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Mandana Arabi
- Global Technical Services, Nutrition International, 180 Elgin St. suite 1000, ON, Ottawa, Canada
| | - Alexander Arynchyn
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Demuyakor ME, Jalal C, Williams AM, Bouckaert KP, Whitehead RD, Bhuiyan MM, Siraj S, Ara R, Pike V, Jefferds MED. Design, Methods, and Select Baseline Results from a School Nutrition Project for Adolescents in Bangladesh. Curr Dev Nutr 2023. [DOI: 10.1016/j.cdnut.2023.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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9
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Crider KS, Qi YP, Yeung LF, Mai CT, Head Zauche L, Wang A, Daniels K, Williams JL. Folic Acid and the Prevention of Birth Defects: 30 Years of Opportunity and Controversies. Annu Rev Nutr 2022; 42:423-452. [PMID: 35995050 PMCID: PMC9875360 DOI: 10.1146/annurev-nutr-043020-091647] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
For three decades, the US Public Health Service has recommended that all persons capable of becoming pregnant consume 400 μg/day of folic acid (FA) to prevent neural tube defects (NTDs). The neural tube forms by 28 days after conception. Fortification can be an effective NTD prevention strategy in populations with limited access to folic acid foods and/or supplements. This review describes the status of mandatory FA fortification among countries that fortify (n = 71) and the research describing the impact of those programs on NTD rates (up to 78% reduction), blood folate concentrations [red blood cell folate concentrations increased ∼1.47-fold (95% CI, 1.27, 1.70) following fortification], and other health outcomes. Across settings, high-quality studies such as those with randomized exposures (e.g., randomized controlled trials, Mendelian randomization studies) are needed to elucidate interactions of FA with vitamin B12 as well as expanded biomarker testing.
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Affiliation(s)
- Krista S Crider
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Yan Ping Qi
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Lorraine F Yeung
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Cara T Mai
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | - Lauren Head Zauche
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Arick Wang
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
| | | | - Jennifer L Williams
- Neural Tube Defects Surveillance and Prevention Team, Infant Outcomes Monitoring, Research, and Prevention Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
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Jory J. Red cell folate status among a subset of Canadian children with Down Syndrome post-fortification. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2022; 66:471-482. [PMID: 35266234 DOI: 10.1111/jir.12925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/31/2021] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Trisomy 21 or Down Syndrome (DS) is associated with altered methylation pathways. Children with DS may therefore represent a population subgroup with vulnerability to increased exposures to folic acid, which is involved in one-carbon metabolism. Folic acid (FA) fortification of flour and maternal FA supplementation are intended to reduce neural tube defects related to folate deficiency. The interventions have been widely successful in Canada. Emerging evidence suggests that higher FA exposures may also have potential negative consequences, including implications for DNA methylation. This retrospective chart review provides insight on the red blood cell (RBC) folate status of a subset of Canadian children and infants with DS, post-fortification. METHODS Children with DS in two Canadian provinces were assessed in the community. Access to RBC folate testing was variable, limiting sample size to 39 (n = 27 for children ≤6 years; n = 12 for children 6-18 years). All children with DS and an RBC folate result were included. The use of FA-containing supplements and formula was documented. RESULTS Among children 6-18 years, 100% had RBC folates >1000 nmol/L, 50% were >2000 nmol/L and 25% had levels above the upper laboratory reporting limit. Among the younger children (<6 years), 52% had RBC folates >2000 nmol and 2 children exceeded 3000 nmol/L. Among exclusively breast-fed infants (<12 months), 100% had RBC folates >1000 nmol/L and 50% had levels >2000 nmol/L, suggestive of in-utero or maternal exposures. RBC folate status among this subset of Canadian children with DS is higher than documented for the larger Canadian population, and higher than among US children with DS. CONCLUSIONS Young Canadian children with DS demonstrated high post-fortification RBC folate status. RBC folate status was higher than reported for the larger Canadian population, and higher than for US children with Down Syndrome. Consumption of folic acid-containing formula and/or supplements was relatively low among these Canadian children with DS, suggesting maternal FA supplements and/or FA-fortified foods may be important etiological factors. A larger, prospective study is needed to validate these results, and to explore potential health implications among this vulnerable population.
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Affiliation(s)
- J Jory
- Department of Family Relations and Applied Nutrition, University of Guelph, MacDonald Institute, Guelph, Ontario, Canada
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11
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Palchetti CZ, Steluti J, Sales CH, Fisberg RM, Marchioni DML. Folate and vitamin B12 status: temporal evaluation after mandatory fortification in Brazil. Eur J Clin Nutr 2022; 76:1266-1272. [PMID: 35318452 DOI: 10.1038/s41430-022-01096-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To perform temporal evaluation of folate and vitamin B12 status and their associated factors in a Brazilian population exposed to mandatory fortification. METHODS Data from the cross-sectional population-based studies 2008 and 2015 Health Surveys of São Paulo, including individuals ≥ 20 years, both sexes, N = 549 in 2008 and N = 610 in 2015. Folate and vitamin B12 biomarkers status, B-complex supplements and medications use, and dietary intake were assessed. RESULTS Serum folate concentrations increased in the entire population, adults and older adults in 2015 compared to 2008, while serum vitamin B12 concentration increased only in older adults. B-complex supplement use raised in 2015, reflecting in serum vitamins status. Overall serum vitamin B12 deficiencies (<200 pg/mL) were 23.2% and 21.2%, while serum folate deficiencies (<4 ng/mL) were 4.1% and 1.5% in 2008 and 2015, respectively. The lowest quintile of serum folate (≤8.7 ng/mL) was positively associated with smoking and oral contraceptive use, while the highest quintile (≥17.8 ng/mL) was inversely associated with smoking and positively with B-complex supplement use. The odds of having vitamin B12 deficiency was inversely associated with B-complex supplement use, higher serum folate median, higher dietary vitamin B12 intake and positively associated with using oral contraceptive. CONCLUSION Overall deficiency of folate has decreased in 2015, being almost non-existent. Low vitamin B12 status presented similar proportions in the overall population comparing both periods, except for older adults. Different predictive variables were identified to better understand vitamins status outcomes in the most recent period of the study.
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Affiliation(s)
- Cecília Zanin Palchetti
- Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, 01246-904, Brazil.
| | - Josiane Steluti
- Public Policies and Collective Health Department, Health and Society Institute, Federal University of Sao Paulo, Santos, 11015-020, Brazil
| | - Cristiane Hermes Sales
- Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, 01246-904, Brazil
| | - Regina Mara Fisberg
- Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, 01246-904, Brazil
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12
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Tong WW, Tong GH, Yang MH, Qin XS. Age and seasonal variation and establishment of reference intervals for water-soluble vitamins determined by liquid chromatography tandem mass spectrometry. Nutrition 2021; 95:111490. [PMID: 35026483 DOI: 10.1016/j.nut.2021.111490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We aimed to establish reference intervals for water-soluble vitamins determined by liquid chromatography tandem mass spectrometry to improve the diagnosis of vitamin deficiency and outcomes of associated conditions. METHODS In this retrospective analysis of 24 810 specimens, we aimed to examine sex-, age-, and season-related variations in vitamin levels in different groups, set reference-value intervals for vitamin levels, and evaluate these reference values against those recommended by manufacturers. RESULTS Levels of vitamins B3, B5, B6, B7, and B12 were higher, and those of vitamins B2, B9, and C were lower, in men than in women. There were seasonal variations in levels of vitamins B1, B3, B5, B6, B9, B12, and C. Levels of vitamins B1, B2, B3, B5, B6, B7, B9, and C differed across age groups; vitamin B1 displayed significant differences between ages 0 to 14 years and adults compared with reference change values. The lower limits of vitamins B1 (ages 15-100 y), B2, B3, B7, and C were lower, and that of vitamin B5 was higher, than the recommended reference values. Finally, the upper limits of vitamins B1, B3, B5, B6, and B7 were lower than the recommended values. CONCLUSIONS For values obtained using liquid chromatography tandem mass spectrometry, the lower limits of reference intervals for vitamins B1 (ages 15-100 y), B2, B3, B7, and C should be lowered, that of vitamin B5 should be raised, and the upper limits of reference intervals for vitamins B1, B3, B5, B6, and B7 should be lowered.
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Affiliation(s)
- Wei-Wei Tong
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guang-Hui Tong
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meng-Han Yang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiao-Song Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.
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13
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Samson KLI, Loh SP, Lee SS, Sulistyoningrum DC, Khor GL, Mohd Shariff ZB, Ismai IZ, Makrides M, Hutcheon JA, Roche ML, Green TJ, Karakochuk CD. The Inclusion of Folic Acid in Weekly Iron-Folic Acid Supplements Confers no Additional Benefit on Anemia Reduction in Nonpregnant Women: A Randomized Controlled Trial in Malaysia. J Nutr 2021; 151:2264-2270. [PMID: 33978167 DOI: 10.1093/jn/nxab115] [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: 01/29/2021] [Revised: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anemia prevalence is ≥20%; however, it is unknown whether the inclusion of folic acid in weekly IFA supplements reduces anemia. OBJECTIVES We examined whether the inclusion of folic acid in weekly IFA supplements conferred any benefit on hemoglobin (Hb) concentration, anemia reduction, or iron status [ferritin and soluble transferrin receptor (sTfR)], over iron alone. METHODS In this secondary analysis of a randomized controlled trial in Malaysia, n = 311 nonpregnant women (18-45 y old) received 60 mg Fe with either 0, 0.4, or 2.8 mg folic acid once-weekly for 16 wk. Fasting blood was collected at baseline and 16 wk. A generalized linear model (normal distribution with identity link) was used to assess Hb concentration at 16 wk (primary outcome). RESULTS At baseline, 84% of women had low folate status (plasma folate < 14 nmol/L). At 16 wk, marginal mean (95% CI) Hb was 131 (130, 133), 131 (129, 132), and 132 (130, 133) g/L; ferritin was 58.2 (53.9, 62.5), 56.5 (52.2, 60.9), and 58.0 (53.7, 62.3) μg/L; and sTfR was 5.8 (5.5, 6.1), 5.8 (5.5, 6.1), and 5.9 (5.6, 6.2) mg/L in the 0, 0.4, and 2.8 mg/wk groups, respectively, with no differences between groups (P > 0.05). Baseline plasma folate concentration did not modify the effect of treatment on Hb concentration at 16 wk. Among all women, the risks of anemia [risk ratio (RR): 0.65; 95% CI: 0.45, 0.96; P = 0.03] and iron deficiency based on ferritin (RR: 0.30; 95% CI: 0.20, 0.44; P < 0.001) were lower at 16 wk than at baseline. CONCLUSIONS Despite the low folate status among these nonpregnant Malaysian women, the inclusion of folic acid in weekly IFA supplements did not reduce anemia or improve iron status, over iron alone. However, the benefits of folic acid for neural tube defect prevention still warrant its retention in weekly IFA supplements.This trial was registered at www.anzctr.org.au as ACTRN12619000818134.
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Affiliation(s)
- Kaitlyn L I Samson
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Su Peng Loh
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Siew Siew Lee
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Dian C Sulistyoningrum
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Geok Lin Khor
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | | | - Irmi Zarina Ismai
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Maria Makrides
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Timothy J Green
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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14
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Wang A, Rose CE, Qi YP, Williams JL, Pfeiffer CM, Crider KS. Impact of Voluntary Folic Acid Fortification of Corn Masa Flour on RBC Folate Concentrations in the U.S. (NHANES 2011-2018). Nutrients 2021; 13:1325. [PMID: 33923768 PMCID: PMC8073626 DOI: 10.3390/nu13041325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Surveillance data have highlighted continued disparities in neural tube defects (NTDs) by race-ethnicity in the United States. Starting in 2016, the Food and Drug Administration (FDA) authorized voluntary folic acid fortification of corn masa flour to reduce the risk of neural tube defects (NTDs) among infants of Hispanic women of reproductive age. To assess the impact of voluntary corn masa fortification, cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011-2018 for Hispanic women of reproductive age with available red blood cell (RBC) folate concentrations were analyzed, with additional analyses conducted among Hispanic women whose sole source of folic acid intake was fortified foods (enriched cereal grain products (ECGP) only), excluding ready-to-eat cereals and supplements. RBC folate concentration (adjusted geometric mean) among Hispanic women of reproductive age did not differ between 2011-2016 and 2017-2018, though RBC folate concentration increased significantly among lesser acculturated Hispanic women consuming ECGP only. Concentrations of RBC folate for those born outside the U.S and residing in the U.S <15 years increased from 894 nmol/L (95% CI: 844-946) in 2011-2016 to 1018 nmol/L (95% CI: 982-1162; p < 0.001) in 2017-2018. Primarily Spanish-speaking Hispanic women of reproductive age who only consumed ECGP saw an increase from 941 nmol/L (95% CI: 895-990) in 2011-2016 to 1034 nmol/L (95% CI: 966-1107; p = 0.03) in 2017-2018. By subpopulation, we observed no significant changes in the proportion at risk of NTDs (<748 nmol/L) and no changes in the model-based estimated NTD rates following voluntary corn masa fortification. This analysis suggests that there is a remaining risk among Hispanics for folate sensitive NTDs, though continued monitoring of folate status in future NHANES data cycles will help inform the long-term efficacy of voluntary fortification of corn masa flour.
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Affiliation(s)
- Arick Wang
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37831, USA
| | - Charles E. Rose
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Yan Ping Qi
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Jennifer L. Williams
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
| | - Christine M. Pfeiffer
- Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, GA 30341, USA;
| | - Krista S. Crider
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA 30341, USA; (C.E.R.); (Y.P.Q.); (J.L.W.); (K.S.C.)
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15
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Chandiwana NC, Chersich M, Venter WF, Akpomiemie G, Hill A, Simmons B, Lockman S, Serenata CM, Fairlie L, Moorhouse MA. Unexpected interactions between dolutegravir and folate: randomized trial evidence from South Africa. AIDS 2021; 35:205-211. [PMID: 33086234 PMCID: PMC7810415 DOI: 10.1097/qad.0000000000002741] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Dolutegravir exposure at conception was associated with a preliminary signal of increased infant neural tube defect risk. As low maternal folate levels are linked with neural tube defects, we aimed to assess serum folate concentrations in women starting dolutegravir. DESIGN We analysed serum folate concentrations from stored plasma among women enrolled in the South African ADVANCE trial. METHODS We compared changes in mean serum folate and occurrence of low serum folate (<14.0 nmol/l) at weeks 0, 12 and 24 across study arms. In ADVANCE, 1053 treatment-naïve participants were randomized to initiate tenofovir-alafenamide/emtricitabine + dolutegravir (TAF/FTC + DTG), tenofovir-disoproxil-fumarate (TDF)/FTC + DTG or TDF/FTC/efavirenz (EFV). RESULTS Analysis includes 406 females, mean age 31.5 years and baseline CD4+ cell count 356 cells/μl. At baseline, folate concentrations were similar across treatment arms. However, serum folate increased over 12 weeks in the TAF/FTC + DTG arm (+4.0 ± 8.1 nmol/l), while folate concentrations decreased slightly in the TDF/FTC + DTG arm (-1.8 ± 8.9 nmol/l) and decreased in the TDF/FTC/EFV arm (-5.9 ± 8.1 nmol/l). Women taking TDF/FTC/EFV had low folate concentrations at both 12 and 24 weeks compared with the other arms (P < 0.001). Of 26 women who became pregnant on study before week 24, folate concentrations increased between baseline and 12 weeks by a mean 2.4 ± 7.1 nmol/l in the TAF/FTC + DTG arm and 2.3 ± 8.4 nmol/l in the TDF/FTC + DTG arm, but decreased by -3.3 ± 8.1 with TDF/FTC/EFV arm. CONCLUSION Unexpectedly, no declines were noted in the dolutegravir-containing arms, and concentrations were considerably higher than in the EFV arm. The possibility that dolutegravir may block cellular uptake of folate warrants investigation.
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Affiliation(s)
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College London, London, UK
| | - Shahin Lockman
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Bailey RL, Jun S, Murphy L, Green R, Gahche JJ, Dwyer JT, Potischman N, McCabe GP, Miller JW. High folic acid or folate combined with low vitamin B-12 status: potential but inconsistent association with cognitive function in a nationally representative cross-sectional sample of US older adults participating in the NHANES. Am J Clin Nutr 2020; 112:1547-1557. [PMID: 32860400 PMCID: PMC8184300 DOI: 10.1093/ajcn/nqaa239] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Potential safety concerns relative to impaired cognitive function may exist when high folic acid exposures are combined with low vitamin B-12 status. OBJECTIVES We aimed to examine the relation of the coexistence of high folate and low vitamin B-12 status with cognitive function, utilizing various definitions of "high" folate status. METHODS Cross-sectional data from older adults (≥60 y; n = 2420) from the 2011-2014 NHANES were analyzed. High folate status was defined as unmetabolized serum folic acid (UMFA) > 1 nmol/L or serum total folate > 74.1 nmol/L, and low vitamin B-12 status as methylmalonic acid > 271 nmol/L or serum vitamin B-12 < 150 pmol/L. Logistic regression models estimated ORs of scoring low on 1 of 4 cognitive tests: the Digit Symbol Substitution Test (DSST), the Consortium to Establish a Registry for Alzheimer's Disease Delayed Recall (CERAD-DR) and Word Learning tests, and the Animal Fluency test (AF). RESULTS A significant interaction was observed relative to scoring low on the DSST (<34; UMFA; P-interaction = 0.0071) and AF (serum folate; P-interaction = 0.0078) for low vitamin B-12 and high folate status. Among those with low vitamin B-12, high UMFA or high serum total folate was associated with higher risk of scoring low on the DSST (OR: 2.16; 95% CI: 1.05, 4.47) and the AF (OR: 1.93; 95% CI: 1.08, 3.45). Among those with "normal" vitamin B-12, higher UMFA or serum total folate was protective on the CERAD-DR. In noninteraction models, when high folate and normal vitamin B-12 status was the reference group, low vitamin B-12 combined with high UMFA was associated with greater risk based on the DSST (<34, OR: 2.87; 95% CI: 1.85, 4.45; <40, OR: 2.22; 95% CI: 1.31, 3.75) and AF (OR: 1.97; 95% CI: 1.30, 2.97); but low vitamin B-12 and lower UMFA (OR: 1.69; 95% CI: 1.16, 2.47) was also significantly associated for DSST < 40 risk. CONCLUSIONS Low vitamin B-12 was associated with cognitive impairment both independently and in an interactive manner with high folate for certain cognitive performance tests among older adults.
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Affiliation(s)
- Regan L Bailey
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Shinyoung Jun
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Lisa Murphy
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of
California, Davis, Davis, CA, USA
| | | | - Johanna T Dwyer
- Office of Dietary Supplements, NIH, Bethesda,
MD, USA
- Frances Stern Nutrition Center, Tufts Medical
Center, Boston, MA, USA
- Jean Mayer USDA Human Nutrition Research Center on Aging at
Tufts University School of Medicine, Boston, MA, USA
| | | | - George P McCabe
- Department of Statistics, Purdue University,
West Lafayette, IN, USA
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers
University, New Brunswick, NJ, USA
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17
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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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18
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Maruvada P, Stover PJ, Mason JB, Bailey RL, Davis CD, Field MS, Finnell RH, Garza C, Green R, Gueant JL, Jacques PF, Klurfeld DM, Lamers Y, MacFarlane AJ, Miller JW, Molloy AM, O'Connor DL, Pfeiffer CM, Potischman NA, Rodricks JV, Rosenberg IH, Ross SA, Shane B, Selhub J, Stabler SP, Trasler J, Yamini S, Zappalà G. Knowledge gaps in understanding the metabolic and clinical effects of excess folates/folic acid: a summary, and perspectives, from an NIH workshop. Am J Clin Nutr 2020; 112:1390-1403. [PMID: 33022704 PMCID: PMC7657327 DOI: 10.1093/ajcn/nqaa259] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/20/2020] [Indexed: 12/21/2022] Open
Abstract
Folate, an essential nutrient found naturally in foods in a reduced form, is present in dietary supplements and fortified foods in an oxidized synthetic form (folic acid). There is widespread agreement that maintaining adequate folate status is critical to prevent diseases due to folate inadequacy (e.g., anemia, birth defects, and cancer). However, there are concerns of potential adverse effects of excess folic acid intake and/or elevated folate status, with the original concern focused on exacerbation of clinical effects of vitamin B-12 deficiency and its role in neurocognitive health. More recently, animal and observational studies have suggested potential adverse effects on cancer risk, birth outcomes, and other diseases. Observations indicating adverse effects from excess folic acid intake, elevated folate status, and unmetabolized folic acid (UMFA) remain inconclusive; the data do not provide the evidence needed to affect public health recommendations. Moreover, strong biological and mechanistic premises connecting elevated folic acid intake, UMFA, and/or high folate status to adverse health outcomes are lacking. However, the body of evidence on potential adverse health outcomes indicates the need for comprehensive research to clarify these issues and bridge knowledge gaps. Three key research questions encompass the additional research needed to establish whether high folic acid or total folate intake contributes to disease risk. 1) Does UMFA affect biological pathways leading to adverse health effects? 2) Does elevated folate status resulting from any form of folate intake affect vitamin B-12 function and its roles in sustaining health? 3) Does elevated folate intake, regardless of form, affect biological pathways leading to adverse health effects other than those linked to vitamin B-12 function? This article summarizes the proceedings of an August 2019 NIH expert workshop focused on addressing these research areas.
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Affiliation(s)
- Padma Maruvada
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Patrick J Stover
- Texas A&M University College of Agriculture and Life Sciences, Texas A&M University AgriLife, College Station, TX, USA
| | - Joel B Mason
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Cindy D Davis
- Office of Dietary Supplements, NIH, Bethesda, MD, USA
| | - Martha S Field
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Richard H Finnell
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Cutberto Garza
- Professor Emeritus, Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jean-Louis Gueant
- University of Lorraine and University Regional Hospital Centre of Nancy, Nancy, France
| | - Paul F Jacques
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | - David M Klurfeld
- Department of Nutrition, Food Safety, and Quality, USDA Agricultural Research Service, Beltsville, MD, USA
| | - Yvonne Lamers
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Anne M Molloy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Irwin H Rosenberg
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | | | - Barry Shane
- Department of Nutritional Sciences & Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Jacob Selhub
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | | | | | - Sedigheh Yamini
- Office of Nutrition and Food Labeling, Center for Food Safety and Applied Nutrition, US FDA, College Park, MD, USA
| | - Giovanna Zappalà
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
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19
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Young MF, Guo J, Williams A, Whitfield KC, Nasrin S, Kancherla V, Suchdev PS, Crider KS, Pfeiffer CM, Serdula M. Interpretation of vitamin B-12 and folate concentrations in population-based surveys does not require adjustment for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2020; 111:919-926. [PMID: 32266401 PMCID: PMC7138687 DOI: 10.1093/ajcn/nqz303] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/14/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin B-12 and folate deficiencies in women and children have important public health implications. However, the evidence is conflicting and limited on whether the influence of inflammation on biomarker concentrations may be sufficiently and consistently influenced by inflammation to require adjustment for interpreting concentrations or estimating population prevalence of deficiencies. OBJECTIVE We examined correlations between concentrations of the inflammation biomarkers C-reactive protein (CRP) and α1-acid glycoprotein (AGP) and serum vitamin B-12 and serum and RBC folate among nonpregnant women of reproductive age (WRA; 15-49 yr) and preschool children (PSC; 6-59 mo). METHODS We analyzed cross-sectional data from 16 nationally representative nutrition surveys conducted in WRA (n = 32,588) and PSC (n = 8,256) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project. Spearman correlations between CRP or AGP and vitamin B-12 or folate concentrations were examined, taking into account complex survey design effects. RESULTS Correlations between inflammation and vitamin B-12 or folate were weak, with no clear pattern of association in either WRA or PSC. Correlation coefficients between CRP and vitamin B-12 for WRA and PSC ranged from -0.25 to 0.16, and correlations between AGP and vitamin B-12 ranged between -0.07 and 0.14. Similarly, correlations between CRP and serum folate ranged from -0.13 to 0.08, and correlations between AGP and serum folate between -0.21 and 0.02. Only 3 surveys measured RBC folate, and among them, correlations for WRA ranged from -0.07 to 0.08 for CRP and -0.04 for AGP (1 country). CONCLUSIONS Based on the weak and inconsistent correlations between CRP or AGP and vitamin B-12 or folate biomarkers, there is no rationale to adjust for inflammation when estimating population prevalence of vitamin B-12 or folate deficiencies in WRA or PSC.
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Affiliation(s)
- Melissa F Young
- Rollins School of Public Health, Emory University, Atlanta, GA, USA,Address correspondence to MFY (e-mail: )
| | - Junjie Guo
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anne Williams
- Rollins School of Public Health, Emory University, Atlanta, GA, USA,Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kyly C Whitfield
- Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Canada
| | | | - Vijaya Kancherla
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Parminder S Suchdev
- Rollins School of Public Health, Emory University, Atlanta, GA, USA,Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Krista S Crider
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Mary Serdula
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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20
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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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21
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Manandhar M, Beydoun H, Kancherla V. Association between body mass index and folate insufficiency indicative of neural tube defects risk among nonpregnant women of childbearing age in the United States, NHANES, 2007-2010. Birth Defects Res 2020; 112:490-502. [PMID: 32052935 DOI: 10.1002/bdr2.1658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Maternal folate status and obesity are known risk factors for neural tube defects (NTD) in the offspring. We examined the association between body mass index (BMI) categories and blood folate concentrations, specifically, red blood cell (RBC) folate concentrations indicative of NTD risk among nonpregnant women of child-bearing age (20-44 years) in the United States. METHODS We used data from 2007 to 2010 US National Health and Nutrition Examination Survey (NHANES). Overweight, obesity, and strata within obesity were examined. Serum and RBC folate concentrations were examined as continuous and categorical variables. RBC folate concentrations were grouped indicating high (≤585 nmol/L) and elevated risk (586-747 nmol/L) for NTDs. Unadjusted and adjusted prevalence odds ratios (aPOR) and their 95% confidence intervals (CI) were estimated using logistic regression. RESULTS Of the 30,878 participants, 25.6% were overweight, 32.7% obese, and 32.3% had RBC folate concentration indicating NTD risk (<748 nmol/L). Overweight was not associated with RBC folate level for NTD risk; however, a marginally significant negative association was noted for overall obesity and RBC folate concentrations indicative of elevated NTD risk (aPOR = 0.76; 95% CI = 0.45, 1.00). A significant protective association was noted between Class 3 obesity (BMI ≥40 kg/m2 ) and folate concentration indicative of high NTD risk (≤585 nmol/L; aPOR = 0.46; 95% CI = 0.24, 0.89). CONCLUSIONS The prevalence of RBC folate concentrations indicating elevated or high NTD risk varied by level of obesity among nonpregnant women of child-bearing age. Further studies are needed to understand the folate pathway in overweight and obese women and subsequent NTD risk in their offspring.
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Affiliation(s)
- Meryna Manandhar
- Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Hind Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Vijaya Kancherla
- Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia
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22
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Molloy J, Collier F, Saffery R, Allen KJ, Koplin JJ, Louise Ponsonby A, Tang MLK, Ward AC, Martino D, Burgner D, Carlin JB, Ranganathan S, Symeonedies C, Dwyer T, Vuillermin P. Folate levels in pregnancy and offspring food allergy and eczema. Pediatr Allergy Immunol 2020; 31:38-46. [PMID: 31566807 DOI: 10.1111/pai.13128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND High folate status in pregnancy has been implicated in the increased prevalence of allergic disease, but there are no published data relating directly measured folate status in pregnancy to challenge-proven food allergy among offspring. The study aim was to examine the association between red blood cell (RBC) folate status in trimester three of pregnancy and allergic disease among offspring. METHODS Red blood cell folate levels were measured at 28-32 weeks' gestation in a prospective birth cohort (n = 1074). Food allergy outcomes were assessed in 1-year-old infants by skin prick testing and subsequent food challenge. Eczema was assessed by questionnaire and clinical review. High trimester three RBC folate was defined as greater than (>) 1360 nmol/L. Binomial regression was used to examine associations between trimester three RBC folate and allergic outcomes, adjusting for potential confounders. RESULTS Red blood cell folate levels were measured in 88% (894/1064) of pregnant women. The mean concentration was 1695.6 nmol/L (standard deviation 415.4) with 82% (731/894) >1360 nmol/L. There was no evidence of either linear or non-linear relationships between trimester three RBC folate and allergic outcomes, nor evidence of associations between high RBC folate and food allergy (adjusted risk ratio (aRR) 2.89, 95% CI 0.90-9.35), food sensitization (aRR 1.72, 95% CI 0.85-3.49), or eczema (aRR 0.97, 95% CI 0.67-1.38). CONCLUSION The majority of pregnant women in this study had high RBC folate levels. There was no evidence of associations between trimester three RBC folate and food allergy, food sensitization, or eczema among the offspring, although larger studies are required.
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Affiliation(s)
- John Molloy
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia.,Child Health Research Unit, Barwon Health, Geelong, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia
| | - Fiona Collier
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia.,Child Health Research Unit, Barwon Health, Geelong, Victoria, Australia
| | - Richard Saffery
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Katrina J Allen
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia.,Centre for Epidemiology and Biostatistics, The University of Melbourne, Carlton, Victoria, Australia
| | - Anne Louise Ponsonby
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia
| | - Mimi L K Tang
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Alister C Ward
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - David Martino
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - David Burgner
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - John B Carlin
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Centre for Epidemiology and Biostatistics, The University of Melbourne, Carlton, Victoria, Australia
| | - Sarath Ranganathan
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Respiratory Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Christos Symeonedies
- Child Health Research Unit, Barwon Health, Geelong, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Terence Dwyer
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | | | - Peter Vuillermin
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia.,Child Health Research Unit, Barwon Health, Geelong, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Centre for Food and Allergy Research, Parkville, Victoria, Australia
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23
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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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24
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Zhang X, Liu J, Jin Y, Yang S, Song Z, Jin L, Wang L, Ren A. Folate of pregnant women after a nationwide folic acid supplementation in China. MATERNAL & CHILD NUTRITION 2019; 15:e12828. [PMID: 30970178 PMCID: PMC6859985 DOI: 10.1111/mcn.12828] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 11/30/2022]
Abstract
Folate insufficiency during the periconceptional period increases the risk of neural tube defects (NTDs) in offspring, and folic acid supplementation substantially reduces the risk. Widespread large-scale folic acid supplementation (0.4-mg folic acid tablet) has been adopted as a main strategy to prevent NTDs in China since 2009. We examined folate concentrations in plasma and red blood cells (RBCs) of pregnant women and the factors associated with blood folate concentrations in a population with a high prevalence of NTDs in northern China. A cross-sectional survey was conducted in 2014, and 1,107 pregnant women were recruited from 11 county or city maternal and child health centres across Shanxi province. Microbiological assays were used to determine folate concentrations. Factors associated with blood folate insufficiency were identified. The median (25th and 75th percentiles) folate concentrations were 28.4 (17.6, 45.2) nmol L-1 and 1,001.2 (658.7, 1,402.5) nmol L-1 in plasma and RBCs, respectively. According to the proposed RBC (906 nmol L-1 ) concentrations for optimal NTD prevention, 42.4% participants had RBC folate insufficiency. Rural women had a higher proportion of folate insufficiency than urban women. Folic acid supplementation was the only factor associated with RBC folate insufficiency. A large proportion of women had RBC folate concentrations that are not optimal for the prevention of NTDs despite free access to folic acid supplements. Actions that aim to improve folic acid supplementation compliance are needed to reach the full potential of the nationwide folic acid supplementation programme in terms of NTD prevention.
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Affiliation(s)
- Xuejuan Zhang
- Health Education DivisionShanxi Children's Hospital/Shanxi Maternal and Child Health Care HospitalTaiyuanP. R. China
| | - Jufen Liu
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive HealthBeijingChina
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
| | - Yongsheng Jin
- Department of Maternal and Child HealthHealth Commission of Shanxi ProvinceTaiyuanP. R. China
| | - Shuang Yang
- Department of Child and Adolescences, School of Public HealthShanxi Medical UniversityTaiyuanP. R. China
| | - Zhijiao Song
- Health Education DivisionShanxi Children's Hospital/Shanxi Maternal and Child Health Care HospitalTaiyuanP. R. China
| | - Lei Jin
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive HealthBeijingChina
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
| | - Linlin Wang
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive HealthBeijingChina
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
| | - Aiguo Ren
- Institute of Reproductive and Child Health/National Health Commission Key Laboratory of Reproductive HealthBeijingChina
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
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25
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Voluntary fortification is ineffective to maintain the vitamin B12 and folate status of older Irish adults: evidence from the Irish Longitudinal Study on Ageing (TILDA). Br J Nutr 2019; 120:111-120. [PMID: 29936926 DOI: 10.1017/s0007114518001356] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mandatory fortification of staple grains with folic acid and/or vitamin B12 (B12) is under debate in many countries including Ireland, which has a liberal, but voluntary, fortification policy. Older adults can be at risk of both deficiency and high folate status, although little is known on the actual prevalence and the major predictors. Population prevalence estimates from older adults (n 5290 ≥50 years) from the Irish Longitudinal Study on Ageing (TILDA) (Wave 1) are presented here. Measures included plasma total vitamin B12 and folate, whereas predictors included detailed demographic, socio-economic, geographic, seasonal and health/lifestyle data. The prevalence of deficient or low B12 status (45 nmol/l) was observed in 8·9 %, whereas high B12 status was observed in 3·1 % (>601 pmol/l). The largest positive predictor of B12 concentration was self-reported B12 injection and/or supplement use (coefficient 51·5 pmol/; 95 % CI 9·4, 93·6; P=0·016) followed by sex and geographic location. The largest negative predictor was metformin use (-33·6; 95 % CI -51·9, -15·4; P<0·0001). The largest positive predictor of folate concentration was folic acid supplement use (6·0; 95 % CI 3·0, 9·0 nmol/l; P<0·001) followed by being female and statin medications. The largest negative predictor was geographic location (-5·7; 95 % CI -6·7, -4·6; P<0·0001) followed by seasonality and smoking. B-vitamin status in older adults is affected by health and lifestyle, medication, sampling period and geographic location. We observed a high prevalence of low B12 and folate status, indicating that the current policy of voluntary fortification is ineffective for older adults.
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26
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Ferraro S, Panteghini M. Defining the plasma folate concentration for optimal neural tube defects prevention cannot ignore the impact of the employed methodology. Am J Clin Nutr 2019; 110:780-781. [PMID: 31505552 DOI: 10.1093/ajcn/nqz128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Simona Ferraro
- From the Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mauro Panteghini
- Research Centre for Metrological Traceability in Laboratory Medicine (CIRME), University of Milan, Milan, Italy (MP)
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27
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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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Vos MJ, Joost van Pelt L, Kok MB, Dijck-Brouwer DAJ, Heiner-Fokkema MR, Dikkeschei LD, Kootstra-Ros JE. Folate reference interval estimation in the Dutch general population. Pract Lab Med 2019; 16:e00127. [PMID: 31289733 PMCID: PMC6593182 DOI: 10.1016/j.plabm.2019.e00127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/27/2019] [Accepted: 06/04/2019] [Indexed: 11/28/2022] Open
Abstract
Background Folate functions as an enzyme co-factor within the one-carbon metabolic pathway, providing key metabolites required for DNA synthesis and methylation. Hence, insufficient intake of folate can negatively affect health. As correct interpretation of folate status is dependent on a well-established reference interval, we set out to perform a new estimation following the restandardization of the Roche folate assay against the international folate standard. Materials and methods The folate reference interval was estimated using samples obtained from the Dutch population-based Lifelines cohort. The reference interval was estimated using two methods: a nonparametric estimation combined with bootstrap resampling and by fitting the data to a gamma distribution. The lower reference limit was verified in a patient cohort by combined measurement of folate and homocysteine. Results Dependent on the method used for estimation and in- or exclusion of individuals younger than 21 years of age, the lower reference limit ranged from 6.8 to 7.3 nmol/L and the upper reference limit ranged from 26 to 38.5 nmol/L. Applying a lower reference limit of 7.3 nmol/L resulted in the following percentage of folate deficiencies over a period of 12 months: general practitioner 15.5% (IQR 4.0%), general hospital 12.8% (IQR 5.3%), academic hospital 9.6% (IQR 4.3%). Conclusions We estimated the folate reference interval in the Dutch general population which is not affected by a folic acid fortification program and verified the obtained lower reference limit by homocysteine measurements. Based on our results, we propose a folate reference interval independent of age of 7.3–38.5 nmol/L
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Affiliation(s)
- Michel J Vos
- Isala Hospital, Department of Clinical Chemistry and Laboratory Medicine, Zwolle, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - L Joost van Pelt
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Maarten B Kok
- Saltro, Diagnostic Center for Primary Care, Utrecht, the Netherlands
| | - D A Janneke Dijck-Brouwer
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - M Rebecca Heiner-Fokkema
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Lambert D Dikkeschei
- Isala Hospital, Department of Clinical Chemistry and Laboratory Medicine, Zwolle, the Netherlands
| | - Jenny E Kootstra-Ros
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
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Centeno Tablante E, Pachón H, Guetterman HM, Finkelstein JL. Fortification of wheat and maize flour with folic acid for population health outcomes. Cochrane Database Syst Rev 2019; 7:CD012150. [PMID: 31257574 PMCID: PMC6599881 DOI: 10.1002/14651858.cd012150.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Folate is a B-vitamin required for DNA synthesis, methylation, and cellular division. Wheat and maize (corn) flour are staple crops consumed widely throughout the world and have been fortified with folic acid in over 80 countries to prevent neural tube defects. Folic acid fortification may be an effective strategy to improve folate status and other health outcomes in the overall population. OBJECTIVES To evaluate the health benefits and safety of folic acid fortification of wheat and maize flour (i.e. alone or in combination with other micronutrients) on folate status and health outcomes in the overall population, compared to wheat or maize flour without folic acid (or no intervention). SEARCH METHODS We searched the following databases in March and May 2018: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In Process, Embase, CINAHL, Web of Science (SSCI, SCI), BIOSIS, Popline, Bibliomap, TRoPHI, ASSIA, IBECS, SCIELO, Global Index Medicus-AFRO and EMRO, LILACS, PAHO, WHOLIS, WPRO, IMSEAR, IndMED, and Native Health Research Database. We searched the International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing or planned studies in June 2018, and contacted authors for further information. SELECTION CRITERIA We included randomised controlled trials (RCTs), with randomisation at the individual or cluster level. We also included non-RCTs and prospective observational studies with a control group; these studies were not included in meta-analyses, although their characteristics and findings were described. Interventions included wheat or maize flour fortified with folic acid (i.e. alone or in combination with other micronutrients), compared to unfortified flour (or no intervention). Participants were individuals over two years of age (including pregnant and lactating women), from any country. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias. MAIN RESULTS We included 10 studies: four provided data for quantitative analyses (437 participants); five studies were randomised trials (1182 participants); three studies were non-RCTs (1181 participants, 8037 live births); two studies were interrupted time series (ITS) studies (1 study population of 2,242,438, 1 study unreported). Six studies were conducted in upper-middle-income countries (China, Mexico, South Africa), one study was conducted in a lower-middle-income country (Bangladesh), and three studies were conducted in a high-income country (Canada). Seven studies examined wheat flour fortified with folic acid alone or with other micronutrients. Three studies included maize flour fortified with folic acid alone or with other micronutrients. The duration of interventions ranged from two weeks to 36 months, and the ITS studies included postfortification periods of up to seven years. Most studies had unclear risk of bias for randomisation, blinding, and reporting, and low/unclear risk of bias for attrition and contamination.Neural tube defects: none of the included RCTs reported neural tube defects as an outcome. In one non-RCT, wheat flour fortified with folic acid and other micronutrients was associated with significantly lower occurrence of total neural tube defects, spina bifida, and encephalocoele, but not anencephaly, compared to unfortified flour (total neural tube defects risk ratio (RR) 0.32, 95% confidence interval (CI) 0.21 to 0.48; 1 study, 8037 births; low-certainty evidence).Folate status: pregnant women who received folic acid-fortified maize porridge had significantly higher erythrocyte folate concentrations (mean difference (MD) 238.90 nmol/L, 95% CI 149.40 to 328.40); 1 study, 38 participants; very low-certainty evidence) and higher plasma folate (MD 14.98 nmol/L, 95% CI 9.63 to 20.33; 1 study, 38 participants; very low-certainty evidence), compared to no intervention. Women of reproductive age consuming maize flour fortified with folic acid and other micronutrients did not have higher erythrocyte folate (MD -61.80 nmol/L, 95% CI -152.98 to 29.38; 1 study, 35 participants; very low-certainty evidence) or plasma folate (MD 0.00 nmol/L, 95% CI -0.00 to 0.00; 1 study, 35 participants; very low-certainty evidence) concentrations, compared to women consuming unfortified maize flour. Adults consuming folic acid-fortified wheat flour bread rolls had higher erythrocyte folate (MD 0.66 nmol/L, 95% CI 0.13 to 1.19; 1 study, 30 participants; very low-certainty evidence) and plasma folate (MD 27.00 nmol/L, 95% CI 15.63 to 38.37; 1 study, 30 participants; very low-certainty evidence), versus unfortified flour. In two non-RCTs, serum folate concentrations were significantly higher among women who consumed flour fortified with folic acid and other micronutrients compared to women who consumed unfortified flour (MD 2.92 nmol/L, 95% CI 1.99 to 3.85; 2 studies, 657 participants; very low-certainty evidence).Haemoglobin or anaemia: in a cluster-randomised trial among children, there were no significant effects of fortified wheat flour flatbread on haemoglobin concentrations (MD 0.00 nmol/L, 95% CI -2.08 to 2.08; 1 study, 334 participants; low-certainty evidence) or anaemia (RR 1.07, 95% CI 0.74 to 1.55; 1 study, 334 participants; low-certainty evidence), compared to unfortified wheat flour flatbread. AUTHORS' CONCLUSIONS Fortification of wheat flour with folic acid may reduce the risk of neural tube defects; however, this outcome was only reported in one non-RCT. Fortification of wheat or maize flour with folic acid (i.e. alone or with other micronutrients) may increase erythrocyte and serum/plasma folate concentrations. Evidence is limited for the effects of folic acid-fortified wheat or maize flour on haemoglobin levels or anaemia. The effects of folic acid fortification of wheat or maize flour on other primary outcomes assessed in this review is not known. No studies reported on the occurrence of adverse effects. Limitations of this review were the small number of studies and participants, limitations in study design, and low-certainty of evidence due to how included studies were designed and reported.
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Affiliation(s)
| | - Helena Pachón
- Food Fortification Initiative & Emory University1518 Clifton Rd NE, Room 2049AtlantaGeorgiaUSA
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Chen MY, Rose CE, Qi YP, Williams JL, Yeung LF, Berry RJ, Hao L, Cannon MJ, Crider KS. Defining the plasma folate concentration associated with the red blood cell folate concentration threshold for optimal neural tube defects prevention: a population-based, randomized trial of folic acid supplementation. Am J Clin Nutr 2019; 109:1452-1461. [PMID: 31005964 PMCID: PMC7099800 DOI: 10.1093/ajcn/nqz027] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/29/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For women of reproductive age, a population-level red blood cell (RBC) folate concentration below the threshold 906 nmol/L or 400 ng/mL indicates folate insufficiency and suboptimal neural tube defect (NTD) prevention. A corresponding population plasma/serum folate concentration threshold for optimal NTD prevention has not been established. OBJECTIVE The aim of this study was to examine the association between plasma and RBC folate concentrations and estimated a population plasma folate insufficiency threshold (pf-IT) corresponding to the RBC folate insufficiency threshold (RBCf-IT) of 906 nmol/L. METHODS We analyzed data on women of reproductive age (n = 1673) who participated in a population-based, randomized folic acid supplementation trial in northern China. Of these women, 565 women with anemia and/or vitamin B-12 deficiency were ineligible for folic acid intervention (nonintervention group); the other 1108 received folic acid supplementation for 6 mo (intervention group). We developed a Bayesian linear model to estimate the pf-IT corresponding to RBCf-IT by time from supplementation initiation, folic acid dosage, methyltetrahydrofolate reductase (MTHFR) genotype, body mass index (BMI), vitamin B-12 status, or anemia status. RESULTS Using plasma and RBC folate concentrations of the intervention group, the estimated median pf-IT was 25.5 nmol/L (95% credible interval: 24.6, 26.4). The median pf-ITs were similar between the baseline and postsupplementation samples (25.7 compared with 25.2 nmol/L) but differed moderately (±3-4 nmol/L) by MTHFR genotype and BMI. Using the full population-based baseline sample (intervention and nonintervention), the median pf-IT was higher for women with vitamin B-12 deficiency (34.6 nmol/L) and marginal deficiency (29.8 nmol/L) compared with the sufficient group (25.6 nmol/L). CONCLUSIONS The relation between RBC and plasma folate concentrations was modified by BMI and genotype and substantially by low plasma vitamin B-12. This suggests that the threshold of 25.5 nmol/L for optimal NTD prevention may be appropriate in populations with similar characteristics, but it should not be used in vitamin B-12 insufficient populations. This trial was registered at clinicaltrials.gov as NCT00207558.
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Affiliation(s)
- Meng-Yu Chen
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA,National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Charles E Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lorraine F Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ling Hao
- China Office, Centers for Disease Control and Prevention, US Embassy, Beijing, China
| | - Michael J Cannon
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
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Verstraete J, Kiekens F, Strobbe S, De Steur H, Gellynck X, Van Der Straeten D, Stove CP. Clinical determination of folates: recent analytical strategies and challenges. Anal Bioanal Chem 2019; 411:4383-4399. [DOI: 10.1007/s00216-019-01574-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/04/2018] [Accepted: 01/03/2019] [Indexed: 01/10/2023]
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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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Rogers LM, Cordero AM, Pfeiffer CM, Hausman DB, Tsang BL, De‐Regil LM, Rosenthal J, Razzaghi H, Wong EC, Weakland AP, Bailey LB. Global folate status in women of reproductive age: a systematic review with emphasis on methodological issues. Ann N Y Acad Sci 2018; 1431:35-57. [PMID: 30239016 PMCID: PMC6282622 DOI: 10.1111/nyas.13963] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/06/2018] [Accepted: 08/15/2018] [Indexed: 01/21/2023]
Abstract
Inadequate folate status in women of reproductive age (WRA) can lead to adverse health consequences of public health significance, such as megaloblastic anemia (folate deficiency) and an increased risk of neural tube defect (NTD)-affected pregnancies (folate insufficiency). Our review aims to evaluate current data on folate status of WRA. We queried eight databases and the World Health Organization Micronutrients Database, identifying 45 relevant surveys conducted between 2000 and 2014 in 39 countries. Several types of folate assays were used in the analysis of blood folate, and many surveys used folate cutoffs not matched to the assay. To allow better comparisons across surveys, we attempted to account for these differences. The prevalence of folate deficiency was >20% in many countries with lower income economies but was typically <5% in countries with higher income economies. Only 11 surveys reported the prevalence of folate insufficiency, which was >40% in most countries. Overall, folate status data for WRA globally are limited and must be carefully interpreted due to methodological issues. Future surveys would benefit from using the microbiologic assay to assess folate status, along with assay-matched cutoffs to improve monitoring and evaluation of folic acid interventions, thus informing global efforts to prevent NTDs.
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Affiliation(s)
- Lisa M. Rogers
- Evidence and Programme Guidance, Department of Nutrition for Health and DevelopmentWorld Health OrganizationGenevaSwitzerland
| | - Amy M. Cordero
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGeorgia
| | - Christine M. Pfeiffer
- National Center for Environmental HealthCenters for Disease Control and PreventionAtlantaGeorgia
| | | | | | | | - Jorge Rosenthal
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGeorgia
| | - Hilda Razzaghi
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGeorgia
| | - Eugene C. Wong
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGeorgia
- Oak Ridge Institute for Science and EducationOak RidgeTennessee
| | | | - Lynn B. Bailey
- Foods and Nutrition DepartmentUniversity of GeorgiaAthensGeorgia
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Obeid R, Schön C, Wilhelm M, Pietrzik K, Pilz S. Dietary and lifestyle predictors of folate insufficiency in non-supplemented German women. Int J Food Sci Nutr 2018; 70:367-376. [PMID: 30189767 DOI: 10.1080/09637486.2018.1511686] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Low folate status is a risk factor for birth defects. We studied concentrations of red blood cell (RBC)- and serum folate in 198 German women in relation to information on dietary folate intake, demographic and lifestyle factors. Median serum- and RBC-folate levels were; (14.7 and 589 nmol/L, respectively. Serum < 7.0 nmol/L or RBC-folate < 405 nmol/L were observed in 3.5% and 18.7% of the women, respectively. Three per cent of the women had both lowered serum and RBC-folate. Whereas RBC-folate > 952 nmol/L (optimal levels around conception) were observed in 9.6%. Serum- and RBC-folate were positively associated; they showed the expected correlations with homocysteine, but only weak correlations with folate intake. Younger age, lower fibre and higher carbohydrate intakes were associated with lower blood folate. Thus, folate intake of approximately 278 µg/d was not sufficient to achieve optimal folate status in young women. In conclusion, in the absence of fortification with folic acid, the majority of the women did not achieve folate status that is optimal for prevention of birth defects.
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Affiliation(s)
- Rima Obeid
- a Department of Clinical Chemistry and Laboratory Medicine , Saarland University Hospital , Homburg/Saar , Germany.,b Aarhus Institute of Advanced Studies, University of Aarhus , Aarhus C , Denmark
| | | | - Manfred Wilhelm
- d Department of Mathematics, Natural and Economic Sciences , University of Applied Sciences Ulm , Ulm , Germany
| | - Klaus Pietrzik
- e Department of Nutrition and Food Science , Rheinische Friedrich-Wilhelms University , Bonn , Germany
| | - Stefan Pilz
- f Division of Endocrinology and Diabetology, Department of Internal Medicine , Medical University of Graz , Graz , Austria
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Crider KS, Qi YP, Devine O, Tinker SC, Berry RJ. Modeling the impact of folic acid fortification and supplementation on red blood cell folate concentrations and predicted neural tube defect risk in the United States: have we reached optimal prevention? Am J Clin Nutr 2018; 107:1027-1034. [PMID: 29767673 PMCID: PMC6980262 DOI: 10.1093/ajcn/nqy065] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/16/2018] [Indexed: 01/10/2023] Open
Abstract
Background The US CDC and the Institute of Medicine recommend that women capable of becoming pregnant consume ≥400 µg synthetic folic acid/d to prevent neural tube defects (NTDs). The United States has 3 sources of folic acid: fortified enriched cereal grain products (ECGPs), fortified ready-to-eat (RTE) cereals, and dietary supplements. Objective Our objectives were as follows: 1) to estimate the usual daily folic acid intake and distributions of red blood cell (RBC) folate concentrations among women consuming folic acid from different sources; 2) to assess the usual daily total folic acid intake associated with optimal RBC folate concentrations for NTD prevention; 3) to predict NTD prevalence; and 4) to estimate the number of preventable folate-sensitive NTDs. Design NHANES data (2007-2012) for nonpregnant women of reproductive age (12-49 y) were used to estimate usual daily intakes of synthetic folic acid and natural food folate. We applied existing models of the relation between RBC folate concentrations and NTD risk to predict NTD prevalence. Results Based on the distribution of overall RBC folate concentrations (4783 women), the predicted NTD prevalence was 7.3/10,000 live births [95% uncertainty interval (UI): 5.5-9.4/10,000 live births]. Women consuming folic acid from ECGPs as their only source had lower usual daily total folic acid intakes (median: 115 µg/d; IQR: 79-156 µg/d), lower RBC folate concentrations (median: 881 nmol/L; IQR: 704-1108 nmol/L), and higher predicted NTD prevalence (8.5/10,000 live births; 95% UI: 6.4-10.8/10,000 live births) compared with women consuming additional folic acid from diet or supplements. If women who currently consume folic acid from ECGPs only (48% of women) consumed additional folic acid sources, 345 (95% UI: 0-821) to 701 (95% UI: 242-1189) additional NTDs/y could be prevented. Conclusions This analysis supports current recommendations and does not indicate any need for higher intakes of folic acid to achieve optimal NTD prevention. Ensuring 400 µg/d intake of folic acid prior to pregnancy has the potential to increase the number of babies born without an NTD.
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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
| | - 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
| | - Owen Devine
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA,Chestatee Solutions, Dahlonega, GA
| | - Sarah C Tinker
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Congenital and Developmental Disorders, Atlanta, GA
| | - 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,GS Corporation, San Antonio, TX
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Zhang M, Sternberg MR, Pfeiffer CM. Harmonizing the Calibrator and Microorganism Used in the Folate Microbiological Assay Increases the Comparability of Serum and Whole-Blood Folate Results in a CDC Round-Robin Study. J Nutr 2018; 148:807-817. [PMID: 30053280 PMCID: PMC8479687 DOI: 10.1093/jn/nxy030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/30/2018] [Indexed: 01/21/2023] Open
Abstract
Background Harmonizing critical reagents for the folate microbiological assay (MBA) may improve among-laboratory comparability. Objective We assessed the comparability of the MBA for serum folate (S-FOL) and whole-blood folate (WB-FOL) in an international comparison study. Methods Eight laboratories obtained a kit containing CDC microorganism inoculum (chloramphenicol-resistant Lactobacillus rhamnosus), CDC calibrator (5-methyltetrahydrofolate), and 23 serum and WB hemolysate samples each. Laboratories analyzed the samples in single measurement over 2 d using 4 conditions: in-house microorganism and in-house calibrator (IH-MO & IH-CAL), in-house microorganism and CDC calibrator (IH-MO & CDC-CAL), CDC microorganism and in-house calibrator (CDC-MO & IH-CAL), and CDC microorganism and CDC calibrator (CDC-MO & CDC-CAL). We calculated geometric mean concentrations for each laboratory and condition and compared data to the CDC MBA (target). Results The among-laboratory arithmetic mean S-FOL concentrations for the 4 conditions were 30.2, 28.1, 30.0, and 29.9 (group 1, 5-methyltetrahydrofolate IH-CAL) compared with 35.3, 33.3, 33.6, and 30.7 nmol/L (group 2, folic acid IH-CAL), respectively; and 428, 405, 398, and 393 (group 1) compared with 469, 423, 477, and 418 nmol/L (group 2), respectively, for WB-FOL. Differences to the CDC MBA target values were smaller for group 1 (range across conditions; S-FOL: 9.9-21%; WB-FOL: 9.0-18%) compared with group 2 laboratories (S-FOL: 13-30%; WB-FOL: 16-32%) and smaller when CDC reagents were used compared with in-house reagents (S-FOL: 12% compared with 22%; WB-FOL: 13% compared with 25%). A linear mixed model estimated a small microorganism effect (S-FOL: 2.3%; WB-FOL: 2.3%) and a larger mean calibrator effect; folic acid compared with 5-methyltetrahydrofolate calibrator produced 12% higher S-FOL and 15% higher WB-FOL results. When laboratories used CDC reagents, the estimated among-laboratory variability was ∼10% for S-FOL and WB-FOL. Conclusion Harmonizing the calibrator and microorganism for the folate MBA has the potential to improve the among-laboratory comparability in future surveys.
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Affiliation(s)
- Ming Zhang
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maya R Sternberg
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
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The pharmacokinetic advantage of 5-methyltetrahydrofolate for minimization of the risk for birth defects. Sci Rep 2018; 8:4096. [PMID: 29511242 PMCID: PMC5840174 DOI: 10.1038/s41598-018-22191-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 02/19/2018] [Indexed: 11/08/2022] Open
Abstract
Despite efforts to increase folic acid (FA) intake, even within countries mandating FA fortification, there remain pregnant women with folate levels inadequate to minimize congenital disorders (e.g., of the neural tube, heart, and lip/palate). The pharmacokinetics of FA and [6S]-5-methyltetrahydrofolate (5-MTHF) were examined to find a reliable and minimal dose for rapidly rescuing folate status prior to critical periods of embryonic development. Serum total folate increased much more rapidly over the first four days in insufficient women given 7.5 mg doses of 5-MTHF than the same regimen of FA (P for trend <0.0001). Nearly all women given 7.5 mg 5-MTHF (every 12 hours, five doses total) almost immediately reached 50 nM serum total folate. Moreover, this level could be maintained by subsequent administration of 0.4 mg/d of folic acid. Thus, 5-MTHF enables repletion of folate stores more quickly and uniformly than FA and without exposure to unmetabolized FA.
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38
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Bailey LB, Hausman DB. Folate status in women of reproductive age as basis of neural tube defect risk assessment. Ann N Y Acad Sci 2018; 1414:82-95. [PMID: 29139138 DOI: 10.1111/nyas.13511] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/31/2017] [Accepted: 09/09/2017] [Indexed: 12/31/2022]
Abstract
Reliable folate status data for women of reproductive age (WRA) to assess global risk for neural tube defects (NTDs) are needed. We focus on a recent recommendation by the World Health Organization that a specific "optimal" red blood cell (RBC) folate concentration be used as the sole indicator of NTD risk within a population and discuss how to best apply this guidance to reach the goal of assessing NTD risk globally. We also emphasize the importance of using the microbiologic assay (MBA) as the most reliable assay for obtaining comparable results for RBC folate concentration across time and countries, the need for harmonization of the MBA through use of consistent key reagents and procedures within laboratories, and the requirement to apply assay-matched cutoffs for folate deficiency and insufficiency. To estimate NTD risk globally, the ideal scenario would be to have country-specific population-based surveys of RBC folate in WRA determined utilizing a harmonized MBA, as was done in recent studies in Guatemala and Belize. We conclude with guidance on next steps to best navigate the road map toward the goal of generating reliable folate status data on which to assess NTD risk in WRA in low- and middle-income countries.
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Affiliation(s)
- Lynn B Bailey
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, Georgia
| | - Dorothy B Hausman
- Department of Foods and Nutrition, College of Family and Consumer Sciences, University of Georgia, Athens, Georgia
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Pfeiffer CM, Zhang M, Jabbar S. Framework for laboratory harmonization of folate measurements in low- and middle-income countries and regions. Ann N Y Acad Sci 2018; 1414:96-108. [PMID: 29377148 PMCID: PMC5849494 DOI: 10.1111/nyas.13532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/26/2017] [Indexed: 02/03/2023]
Abstract
The measurement of serum and red blood cell folate, two commonly used biomarkers of folate status in populations, is complicated by analytical and data interpretation challenges. Folate results show poor comparability across laboratories, even using the same analytical technique. The folate microbiologic assay produces accurate results and requires simple instrumentation. Thus, it could be set up and maintained in low- and middle-income country laboratories. However, the assay has to be harmonized through the use of common critical reagents (e.g., microorganism and folate calibrator) in order to produce comparable results across laboratories and over time, so that the same cutoff values can be applied across surveys. There is a limited need for blood folate measurements in a country owing to the periodic nature of surveys. Having a network of regional resource laboratories proficient in conducting the folate microbiologic assay and willing and able to perform service work for other countries will be the most efficient way to create an infrastructure wherein qualified laboratories produce reliable blood folate data. Continuous participation of these laboratories in a certification program can verify and document their proficiency. If the resource laboratories conduct the work on a fee-for-service basis, they could become self-sustaining in the long run.
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Affiliation(s)
- Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mindy Zhang
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shameem Jabbar
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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40
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Dwyer JT, Coates PM, Smith MJ. Dietary Supplements: Regulatory Challenges and Research Resources. Nutrients 2018; 10:nu10010041. [PMID: 29300341 PMCID: PMC5793269 DOI: 10.3390/nu10010041] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 01/14/2023] Open
Abstract
Many of the scientific and regulatory challenges that exist in research on the safety, quality and efficacy of dietary supplements are common to all countries as the marketplace for them becomes increasingly global. This article summarizes some of the challenges in supplement science and provides a case study of research at the Office of Dietary Supplements at the National Institutes of Health, USA, along with some resources it has developed that are available to all scientists. It includes examples of some of the regulatory challenges faced and some resources for those who wish to learn more about them.
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Affiliation(s)
- Johanna T Dwyer
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20892-7517, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20892-7517, USA.
| | - Michael J Smith
- National Center for Natural Products Research, University of Mississippi, MS 38677, USA.
- National Institute of Complementary Medicine, Western Sydney University, Penrith, NSW 2751, Australia.
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41
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Prevalence and Predictors of Subclinical Micronutrient Deficiency in German Older Adults: Results from the Population-Based KORA-Age Study. Nutrients 2017; 9:nu9121276. [PMID: 29168737 PMCID: PMC5748727 DOI: 10.3390/nu9121276] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 01/08/2023] Open
Abstract
Subclinical micronutrient deficiency in older adults is associated with chronic age-related diseases and adverse functional outcomes. In Germany, the older population is at risk of insufficient micronutrient intake, but representative studies on micronutrient status in old and very old adults are scarce. This study’s objectives were to estimate the prevalence of subclinical vitamin D, folate, vitamin B12 and iron deficiencies among older adults, aged 65 to 93, from the KORA-Age study in Augsburg, Germany (n = 1079), and to examine associated predictors, using multiple logistic regression. Serum concentrations of 25-hydroxyvitamin D (25OHD), folate, vitamin B12, and iron were analyzed. The prevalence of subclinical vitamin D and vitamin B12 deficiencies were high, with 52.0% and 27.3% of individuals having low 25OHD (<50 nmol/L) and low vitamin B12 concentrations (<221 pmol/L), respectively. Furthermore, 11.0% had low iron (men <11.6 µmol/L, women <9.0 µmol/L) and 8.7% had low folate levels (<13.6 nmol/L). Common predictors associated with subclinical micronutrient deficiency included very old age, physical inactivity, frailty and no/irregular use of supplements. Subclinical micronutrient deficiency is a public health concern among KORA-Age participants, especially for vitamins D and B12. The predictors identified provide further rationale for screening high-risk subgroups and developing targeted public health interventions to tackle prevailing micronutrient inadequacies among older adults.
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Cummings D, Dowling KF, Silverstein NJ, Tanner AS, Eryilmaz H, Smoller JW, Roffman JL. A Cross-Sectional Study of Dietary and Genetic Predictors of Blood Folate Levels in Healthy Young Adults. Nutrients 2017; 9:nu9090994. [PMID: 28885600 PMCID: PMC5622754 DOI: 10.3390/nu9090994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/15/2017] [Accepted: 08/31/2017] [Indexed: 01/21/2023] Open
Abstract
Since 1998, the U.S. has mandated folic acid (FA) fortification of certain grain products to reduce the risk of neural tube defects. Folate intake and red blood cell (RBC) folate concentrations increased substantially post-intervention, although recent studies raise concerns about the level of ongoing benefit. This study investigated blood folate level determinants in healthy young adults, including intake of naturally occurring food folate, synthetic FA, and the interaction of naturally occurring food folate with a common missense variant in the FOLH1 gene thought to affect absorption. Participants (n = 265) completed the Diet History Questionnaire II, RBC folate testing, and were genotyped for the 484T>C FOLH1 variant. Men reported significantly greater intake of all folate sources except for supplemental FA, but RBC folate levels did not significantly differ by sex. Synthetic FA was a stronger predictor of RBC folate than naturally occurring food folate. In the largest racial group, synthetic FA and the interaction of FOLH1 genotype with naturally occurring food folate significantly predicted RBC folate, with the overall model accounting for 13.8% of the variance in RBC folate levels. Blood folate levels rely on a complex interaction of natural and synthetic folate intake as well as FOLH1 genotype.
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Affiliation(s)
- Daniel Cummings
- Department of Biopsychology, Tufts University, 419 Boston Ave, Medford, MA 02155, USA.
| | - Kevin F Dowling
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
| | - Noah J Silverstein
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
| | - Alexandra S Tanner
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
| | - Hamdi Eryilmaz
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
| | - Jordan W Smoller
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
| | - Joshua L Roffman
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Charlestown, MA 02129, USA.
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Engle-Stone R, Nankap M, Ndjebayi AO, Allen LH, Shahab-Ferdows S, Hampel D, Killilea DW, Gimou MM, Houghton LA, Friedman A, Tarini A, Stamm RA, Brown KH. Iron, Zinc, Folate, and Vitamin B-12 Status Increased among Women and Children in Yaoundé and Douala, Cameroon, 1 Year after Introducing Fortified Wheat Flour. J Nutr 2017; 147:1426-1436. [PMID: 28592513 PMCID: PMC5483962 DOI: 10.3945/jn.116.245076] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/31/2017] [Accepted: 05/03/2017] [Indexed: 01/21/2023] Open
Abstract
Background: Few data are available on the effectiveness of large-scale food fortification programs.Objective: We assessed the impact of mandatory wheat flour fortification on micronutrient status in Yaoundé and Douala, Cameroon.Methods: We conducted representative surveys 2 y before and 1 y after the introduction of fortified wheat flour. In each survey, 10 households were selected within each of the same 30 clusters (n = ∼300 households). Indicators of inflammation, malaria, anemia, and micronutrient status [plasma ferritin, soluble transferrin receptor (sTfR), zinc, folate, and vitamin B-12] were assessed among women aged 15-49 y and children 12-59 mo of age.Results: Wheat flour was consumed in the past 7 d by ≥90% of participants. Postfortification, mean total iron and zinc concentrations of flour samples were 46.2 and 73.6 mg/kg (target added amounts were 60 and 95 mg/kg, respectively). Maternal anemia prevalence was significantly lower postfortification (46.7% compared with 39.1%; adjusted P = 0.01), but mean hemoglobin concentrations and child anemia prevalence did not differ. For both women and children postfortification, mean plasma concentrations were greater for ferritin and lower for sTfR after adjustments for potential confounders. Mean plasma zinc concentrations were greater postfortification and the prevalence of low plasma zinc concentration in women after fortification (21%) was lower than before fortification (39%, P < 0.001); likewise in children, the prevalence postfortification (28%) was lower than prefortification (47%, P < 0.001). Mean plasma total folate concentrations were ∼250% greater postfortification among women (47 compared with 15 nmol/L) and children (56 compared with 20 nmol/L), and the prevalence of low plasma folate values was <1% after fortification in both population subgroups. In a nonrepresentative subset of plasma samples, folic acid was detected in 77% of women (73% of those fasting) and 93% of children. Mean plasma and breast-milk vitamin B-12 concentrations were >50% greater postfortification.Conclusion: Although the pre-post survey design limits causal inference, iron, zinc, folate, and vitamin B-12 status increased among women and children in urban Cameroon after mandatory wheat flour fortification.
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Affiliation(s)
- Reina Engle-Stone
- Department of Nutrition, University of California, Davis, Davis, CA;
| | | | | | - Lindsay H Allen
- Department of Nutrition, University of California, Davis, Davis, CA
- USDA, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA
| | - Setareh Shahab-Ferdows
- Department of Nutrition, University of California, Davis, Davis, CA
- USDA, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA
| | - Daniela Hampel
- Department of Nutrition, University of California, Davis, Davis, CA
- USDA, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA
| | - David W Killilea
- Nutrition and Metabolism Center, Children's Hospital Oakland Research Institute, Oakland, CA
| | | | | | | | - Ann Tarini
- Helen Keller International, New York, NY
| | | | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA
- Bill & Melinda Gates Foundation, Seattle, WA
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Rosenthal J, Largaespada N, Bailey LB, Cannon M, Alverson CJ, Ortiz D, Kauwell GP, Sniezek J, Figueroa R, Daly R, Allen P. Folate Deficiency Is Prevalent in Women of Childbearing Age in Belize and Is Negatively Affected by Coexisting Vitamin B-12 Deficiency: Belize National Micronutrient Survey 2011. J Nutr 2017; 147:1183-1193. [PMID: 28404832 PMCID: PMC5548006 DOI: 10.3945/jn.116.242628] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/28/2016] [Accepted: 03/15/2017] [Indexed: 01/21/2023] Open
Abstract
Background: Folate deficiency, vitamin B-12 deficiency, and anemia can have adverse effects on birth outcomes. Also, low vitamin B-12 reduces the formation of metabolically active folate.Objectives: We sought to establish the baseline prevalence of and factors associated with folate deficiency and insufficiency, vitamin B-12 deficiency, and anemia among women of childbearing age (WCBA) in Belize.Methods: In 2011, a national probability-based survey was completed among Belizean nonpregnant WCBA aged 15-49 y. Blood samples for determination of hemoglobin, folate (RBC and serum), and vitamin B-12 (plasma) and sociodemographic and health information were collected from 937 women. RBC and serum folate concentrations were measured by microbiologic assay (MBA). Folate status was defined based on both the WHO-recommended radioproteinbinding assay and the assay adjusted for the MBA.Results: The national prevalence estimates for folate deficiency in WCBA, based on serum and RBC folate concentrations by using the assay-matched cutoffs, were 11.0% (95% CI: 8.6%, 14.0%) and 35.1% (95% CI: 31.3%, 39.2%), respectively. By using the assay-matched compared with the WHO-recommended cutoffs, a substantially higher prevalence of folate deficiency was observed based on serum (6.9% absolute difference) and RBC folate (28.9% absolute difference) concentrations. The prevalence for RBC folate insufficiency was 48.9% (95% CI: 44.8%, 53.1%). Prevalence estimates for vitamin B-12 deficiency and marginal deficiency and anemia were 17.2% (95% CI: 14.2%, 20.6%), 33.2% (95% CI: 29.6%, 37.1%), and 22.7% (95% CI: 19.5%, 26.2%), respectively. The adjusted geometric means of the RBC folate concentration increased significantly (P-trend < 0.001) in WCBA who had normal vitamin B-12 status relative to WCBA who were vitamin B-12 deficient.Conclusions: In Belize, the prevalence of folate and vitamin B-12 deficiencies continues to be a public health concern among WCBA. Furthermore, low folate status co-occurred with low vitamin B-12 status, underlining the importance of providing adequate vitamin B-12 and folic acid intake through approaches such as mandatory food fortification.
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Affiliation(s)
- Jorge Rosenthal
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA;
| | | | | | - Michael Cannon
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - C J Alverson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Dayrin Ortiz
- University of San Carlos, Guatemala City, Guatemala
| | | | - Joe Sniezek
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Robyn Daly
- Belize Ministry of Health, Belmopan, Belize
| | - Peter Allen
- Belize Ministry of Health, Belmopan, Belize
- Belize Ministry of Public Service, Belmopan, Belize
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Bailey RL, Fulgoni VL, Taylor CL, Pfeiffer CM, Thuppal SV, McCabe GP, Yetley EA. Correspondence of folate dietary intake and biomarker data. Am J Clin Nutr 2017; 105:1336-1343. [PMID: 28446502 PMCID: PMC5445676 DOI: 10.3945/ajcn.116.148775] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/27/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Public health concerns with regard to both low and high folate status exist in the United States. Recent publications have questioned the utility of self-reported dietary intake data in research and monitoring.Objectives: The purpose of this analysis was to examine the relation between self-reported folate intakes and folate status biomarkers and to evaluate their usefulness for several types of applications.Design: We examined usual dietary intakes of folate by using the National Cancer Institute method to adjust two 24-h dietary recalls (including dietary supplements) for within-person variation and then compared these intakes with serum and red blood cell (RBC) folate among 4878 men and nonpregnant, nonlactating women aged ≥19 y in NHANES 2011-2012, a nationally representative, cross-sectional survey, with respect to consistency across prevalence estimates and rank order comparisons.Results: There was a very low prevalence (<1%) of folate deficiency when serum (<7 nmol/L) and RBC (<305 nmol/L) folate were considered, whereas a higher proportion of the population reported inadequate total dietary folate intakes (6%). Similar patterns of change occurred between intakes and biomarkers of folate status when distributions were examined (i.e., dose response), particularly when diet was expressed in μg. Intakes greater than the Tolerable Upper Intake Level greatly increased the odds of having high serum folate (OR: 17.6; 95% CI: 5.5, 56.0).Conclusions: When assessing folate status in the United States, where fortification and supplement use are common, similar patterns in the distributions of diet and biomarkers suggest that these 2 types of status indicators reflect the same underlying folate status; however, the higher prevalence estimates for inadequate intakes compared with biomarkers suggest, among other factors, a systematic underestimation bias in intake data. Caution is needed in the use of dietary folate data to estimate the prevalence of inadequacy among population groups. The use of dietary data for rank order comparisons or to estimate the potential for dietary excess is likely more reliable.
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Affiliation(s)
- Regan L Bailey
- Departments of Nutrition Science and .,Office of Dietary Supplements, NIH, Bethesda, MD
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46
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Pfeiffer CM, Lacher DA, Schleicher RL, Johnson CL, Yetley EA. Challenges and Lessons Learned in Generating and Interpreting NHANES Nutritional Biomarker Data. Adv Nutr 2017; 8:290-307. [PMID: 28298273 PMCID: PMC5347107 DOI: 10.3945/an.116.014076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
For the past 45 y, the National Center for Health Statistics at the CDC has carried out nutrition surveillance of the US population by collecting anthropometric, dietary intake, and nutritional biomarker data, the latter being the focus of this publication. The earliest biomarker testing assessed iron and vitamin A status. With time, a broad spectrum of water- and fat-soluble vitamins was added and biomarkers for other types of nutrients (e.g., fatty acids) and bioactive dietary compounds (e.g., phytoestrogens) were included in NHANES. The cross-sectional survey is flexible in design, and biomarkers may be measured for a short period of time or rotated in and out of surveys depending on scientific needs. Maintaining high-quality laboratory measurements over extended periods of time such that trends in status can be reliably assessed is a major goal of the testing laboratories. Physicians, health scientists, and policy makers rely on the NHANES reference data to compare the nutritional status of population groups, to assess the impact of various interventions, and to explore associations between nutritional status and health promotion or disease prevention. Focusing on the continuous NHANES, which started in 1999, this review uses a "lessons learned" approach to present a series of challenges that are relevant to researchers measuring biomarkers in NHANES and beyond. Some of those challenges are the use of multiple related biomarkers instead of a single biomarker for a specific nutrient (e.g., folate, vitamin B-12, iron), adhering to special needs for specimen collection and handling to ensure optimum specimen quality (e.g., vitamin C, folate, homocysteine, iodine, polyunsaturated fatty acids), the retrospective use of long-term quality-control data to correct for assay shifts (e.g., vitamin D, vitamin B-12), and the proper planning for and interpretation of crossover studies to adjust for systematic method changes (e.g., folate, vitamin D, ferritin).
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Affiliation(s)
| | - David A Lacher
- National Center for Health Statistics, CDC, Hyattsville, MD; and
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47
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MacFarlane AJ. The elephant in the room: using nutritional biomarker cutoffs to assess status. Am J Clin Nutr 2016; 104:1493-1494. [PMID: 27852612 DOI: 10.3945/ajcn.116.146357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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