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Perin J, Mai CT, De Costa A, Strong K, Diaz T, Blencowe H, Berry RJ, Williams JL, Liu L. Systematic estimates of the global, regional and national under-5 mortality burden attributable to birth defects in 2000-2019: a summary of findings from the 2020 WHO estimates. BMJ Open 2023; 13:e067033. [PMID: 36717144 PMCID: PMC9887698 DOI: 10.1136/bmjopen-2022-067033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To examine the potential for bias in the estimate of under-5 mortality due to birth defects recently produced by the WHO and the Maternal and Child Epidemiology Estimation research group. DESIGN Systematic analysis. METHODS We examined the estimated number of under-5 deaths due to birth defects, the birth defect specific under-5 mortality rate, and the per cent of under-5 mortality due to birth defects, by geographic region, national income and under-5 mortality rate for three age groups from 2000 to 2019. RESULTS The under-5 deaths per 1000 live births from birth defects fell from 3.4 (95% uncertainty interval (UI) 3.1-3.8) in 2000 to 2.9 (UI 2.6-3.3) in 2019. The per cent of all under-5 mortality attributable to birth defects increased from 4.6% (UI 4.1%-5.1%) in 2000 to 7.6% (UI 6.9%-8.6%) in 2019. There is significant variability in mortality due to birth defects by national income level. In 2019, the under-5 mortality rate due to birth defects was less in high-income countries than in low-income and middle-income countries, 1.3 (UI 1.2-1.3) and 3.0 (UI 2.8-3.4) per 1000 live births, respectively. These mortality rates correspond to 27.7% (UI 26.6%-28.8%) of all under-5 mortality in high-income countries being due to birth defects, and 7.4% (UI 6.7%-8.2%) in low-income and middle-income countries. CONCLUSIONS While the under-5 mortality due to birth defects is declining, the per cent of under-5 mortality attributable to birth defects has increased, with significant variability across regions globally. The estimates in low-income and middle-income countries are likely underestimated due to the nature of the WHO estimates, which are based in part on verbal autopsy studies and should be taken as a minimum estimate. Given these limitations, comprehensive and systematic estimates of the mortality burden due to birth defects are needed to estimate the actual burden.
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Affiliation(s)
- Jamie Perin
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cara T Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ayesha De Costa
- Department of Maternal, Newborn, Child and Adolescent Health, and Ageing, World Health Organization, Geneve, Switzerland
| | - Kathleen Strong
- Department of Maternal, Newborn, Child and Adolescent Health, and Ageing, World Health Organization, Geneve, Switzerland
| | - Theresa Diaz
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Genève, Switzerland
| | - Hannah Blencowe
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Li Liu
- Population, Family, and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Crider KS, Wang A, Ling H, Potischman N, Bailey RL, Lichen Y, Pfeiffer CM, Killian JK, Rose C, Sampson J, Zhu L, Berry RJ, Linet M, Yu W, Su LJ. Maternal Periconceptional Folic Acid Supplementation and DNA Methylation Patterns in Adolescent Offspring. J Nutr 2023; 152:2669-2676. [PMID: 36196007 PMCID: PMC9839994 DOI: 10.1093/jn/nxac184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Folate, including the folic acid form, is a key component of the one-carbon metabolic pathway used for DNA methylation. Changes in DNA methylation patterns during critical development periods are associated with disease outcomes and are associated with changes in nutritional status in pregnancy. The long-term impact of periconceptional folic acid supplementation on DNA methylation patterns is unknown. OBJECTIVES To determine the long-term impact of periconceptional folic acid supplementation on DNA methylation patterns, we examined the association of the recommended dosage (400 μg/d) and time period (periconceptional before pregnancy through first trimester) of folic acid supplementation with the DNA methylation patterns in the offspring at age 14-17 y compared with offspring with no supplementation. METHODS Two geographic sites in China from the 1993-1995 Community Intervention Program of folic acid supplementation were selected for the follow-up study. DNA methylation at 402,730 CpG sites was assessed using saliva samples from 89 mothers and 179 adolescents (89 male). The mean age at saliva collection was 40 y among mothers (range: 35-54 y) and 15 y among adolescents (range: 14-17 y). Epigenome-wide analyses were conducted to assess the interactions of periconceptional folic acid exposure, the 5,10-methylenetetrahydrofolate reductase (MTHFR)-C677T genotype, and epigenome-wide DNA methylation controlling for offspring sex, geographic region, and background cell composition in the saliva. RESULTS In the primary outcome, no significant differences were observed in epigenome-wide methylation patterns between adolescents exposed and those non-exposed to maternal periconceptional folic acid supplementation after adjustment for potential confounders [false discovery rate (FDR) P values < 0.05]. The MTHFR-C677T genotype did not modify this lack of association (FDR P values < 0.05). CONCLUSIONS Overall, there were no differences in DNA methylation between adolescents who were exposed during the critical developmental window and those not exposed to the recommended periconceptional/first-trimester dosage of folic acid.
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Affiliation(s)
- Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Arick Wang
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Hao Ling
- US CDC China Office, Beijing, China
| | | | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Yang Lichen
- National Center for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Christine M Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, US CDC, Atlanta, GA, USA
| | - J Keith Killian
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Charles Rose
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Joshua Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Li Zhu
- School of Public Health, Peking University Health Science Center, Beijing, China (retired)
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, US CDC, Atlanta, GA, USA
| | - Martha Linet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Wang Yu
- Director General (former), Chinese Center for Disease Control and Prevention, Beijing, China
| | - L Joseph Su
- Cancer Prevention and Population Sciences Program, Division of Epidemiology, University of Arkansas, Little Rock, AR, USA
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Kancherla V, Botto LD, Rowe LA, Shlobin NA, Caceres A, Arynchyna-Smith A, Zimmerman K, Blount J, Kibruyisfaw Z, Ghotme KA, Karmarkar S, Fieggen G, Roozen S, Oakley GP, Rosseau G, Berry RJ. Mandatory food fortification with folic acid – Authors' reply. The Lancet Global Health 2022; 10:e1391-e1392. [DOI: 10.1016/s2214-109x(22)00375-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 01/10/2023] Open
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Zhou Y, Crider KS, Yeung LF, Rose CE, Li Z, Berry RJ, Li S, Moore CA. Periconceptional folic acid use prevents both rare and common neural tube defects in China. Birth Defects Res 2022; 114:184-196. [PMID: 35098705 PMCID: PMC11091954 DOI: 10.1002/bdr2.1983] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neural tube defects (NTDs) encompass a variety of distinct types. We assessed if the preventive effect of folic acid (FA) varied by NTD type and infant sex. METHODS We examined all pregnancies with NTD status confirmation from a pregnancy-monitoring system in selected locations in northern and southern regions of China between 1993 and 1996. Women who took 400 μg of FA daily during 42 days after last menstrual period were considered FA users. We analyzed NTD prevalence by FA use status, NTD type, geographic region, and infant sex. RESULTS Among 626,042 pregnancies, 700 were affected by an NTD. Among FA nonusers, 65 pregnancies (8.8 per 10,000) in the north and 51 pregnancies (1.2 per 10,000) in the south were affected by one of the two rare NTDs, that is, craniorachischisis, iniencephaly. FA use prevented occurrence of these two rare NTDs and reduced the prevalence of spina bifida (SB) by 78% (from 17.9 to 3.9 per 10,000) in the north and 51% (from 2.4 to 1.2 per 10,000) in the south. Among FA users, SB prevalence, including SB with high lesion level, was significantly reduced in both geographic regions. FA use reduced prevalence of anencephaly and encephalocele by 85% and 50%, respectively in the north, while it did not reduce the prevalence of these two NTDs in the south. There was a greater reduction in NTD prevalence in female than in male infants and fetuses. CONCLUSIONS This is the first study to show that FA prevents the entire spectrum of NTD types.
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Affiliation(s)
- Ying Zhou
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Krista S. Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lorraine F. Yeung
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Charles E. Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zhu Li
- Institute of Reproductive and Child Health, School of Public Health, Peking University, Beijing, China
| | - Robert J. Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Song Li
- Peking University Third Hospital, Beijing, China
| | - Cynthia A. Moore
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Bae S, Kamynina E, Guetterman HM, Farinola AF, Caudill MA, Berry RJ, Cassano PA, Stover PJ. Provision of folic acid for reducing arsenic toxicity in arsenic-exposed children and adults. Cochrane Database Syst Rev 2021; 10:CD012649. [PMID: 34661903 PMCID: PMC8522704 DOI: 10.1002/14651858.cd012649.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Arsenic is a common environmental toxin. Exposure to arsenic (particularly its inorganic form) through contaminated food and drinking water is an important public health burden worldwide, and is associated with increased risk of neurotoxicity, congenital anomalies, cancer, and adverse neurodevelopment in children. Arsenic is excreted following methylation reactions, which are mediated by folate. Provision of folate through folic acid supplements could facilitate arsenic methylation and excretion, thereby reducing arsenic toxicity. OBJECTIVES To assess the effects of provision of folic acid (through fortified foods or supplements), alone or in combination with other nutrients, in lessening the burden of arsenic-related health outcomes and reducing arsenic toxicity in arsenic-exposed populations. SEARCH METHODS In September 2020, we searched CENTRAL, MEDLINE, Embase, 10 other international databases, nine regional databases, and two trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the provision of folic acid (at any dose or duration), alone or in combination with other nutrients or nutrient supplements, with no intervention, placebo, unfortified food, or the same nutrient or supplements without folic acid, in arsenic-exposed populations of all ages and genders. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included two RCTs with 822 adults exposed to arsenic-contaminated drinking water in Bangladesh. The RCTs compared 400 µg/d (FA400) or 800 µg/d (FA800) folic acid supplements, given for 12 or 24 weeks, with placebo. One RCT, a multi-armed trial, compared FA400 plus creatine (3 g/d) to creatine alone. We judged both RCTs at low risk of bias in all domains. Due to differences in co-intervention, arsenic exposure, and participants' nutritional status, we could not conduct meta-analyses, and therefore, provide a narrative description of the data. Neither RCT reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Folic acid supplements alone versus placebo Blood arsenic. In arsenic-exposed individuals, FA likely reduces blood arsenic concentrations compared to placebo (2 studies, 536 participants; moderate-certainty evidence). For folate-deficient and folate-replete participants who received arsenic-removal water filters as a co-intervention, FA800 reduced blood arsenic levels more than placebo (percentage change (%change) in geometric mean (GM) FA800 -17.8%, 95% confidence intervals (CI) -25.0 to -9.8; placebo GM -9.5%, 95% CI -16.5 to -1.8; 1 study, 406 participants). In one study with 130 participants with low baseline plasma folate, FA400 reduced total blood arsenic (%change FA400 mean (M) -13.62%, standard error (SE) ± 2.87; placebo M -2.49%, SE ± 3.25), and monomethylarsonic acid (MMA) concentrations (%change FA400 M -22.24%, SE ± 2.86; placebo M -1.24%, SE ± 3.59) more than placebo. Inorganic arsenic (InAs) concentrations reduced in both groups (%change FA400 M -18.54%, SE ± 3.60; placebo M -10.61%, SE ± 3.38). There was little to no change in dimethylarsinic acid (DMA) in either group. Urinary arsenic. In arsenic-exposed individuals, FA likely reduces the proportion of total urinary arsenic excreted as InAs (%InAs) and MMA (%MMA) and increases the proportion excreted as DMA (%DMA) to a greater extent than placebo (2 studies, 546 participants; moderate-certainty evidence), suggesting that FA enhances arsenic methylation. In a mixed folate-deficient and folate-replete population (1 study, 352 participants) receiving arsenic-removal water filters as a co-intervention, groups receiving FA had a greater decrease in %InAs (within-person change FA400 M -0.09%, 95% CI -0.17 to -0.01; FA800 M -0.14%, 95% CI -0.21 to -0.06; placebo M 0.05%, 95% CI 0.00 to 0.10), a greater decrease in %MMA (within-person change FA400 M -1.80%, 95% CI -2.53 to -1.07; FA800 M -2.60%, 95% CI -3.35 to -1.85; placebo M 0.15%, 95% CI -0.37 to 0.68), and a greater increase in %DMA (within-person change FA400 M 3.25%, 95% CI 1.81 to 4.68; FA800 M 4.57%, 95% CI 3.20 to 5.95; placebo M -1.17%, 95% CI -2.18 to -0.17), compared to placebo. In 194 participants with low baseline plasma folate, FA reduced %InAs (%change FA400 M -0.31%, SE ± 0.04; placebo M -0.13%, SE ± 0.04) and %MMA (%change FA400 M -2.6%, SE ± 0.37; placebo M -0.71%, SE ± 0.43), and increased %DMA (%change FA400 M 5.9%, SE ± 0.82; placebo M 2.14%, SE ± 0.71), more than placebo. Plasma homocysteine: In arsenic-exposed individuals, FA400 likely reduces homocysteine concentrations to a greater extent than placebo (2 studies, 448 participants; moderate-certainty evidence), in the mixed folate-deficient and folate-replete population receiving arsenic-removal water filters as a co-intervention (%change in GM FA400 -23.4%, 95% CI -27.1 to -19.5; placebo -1.3%, 95% CI -5.3 to 3.1; 1 study, 254 participants), and participants with low baseline plasma folate (within-person change FA400 M -3.06 µmol/L, SE ± 3.51; placebo M -0.05 µmol/L, SE ± 4.31; 1 study, 194 participants). FA supplements plus other nutrient supplements versus nutrient supplements alone In arsenic-exposed individuals who received arsenic-removal water filters as a co-intervention, FA400 plus creatine may reduce blood arsenic concentrations more than creatine alone (%change in GM FA400 + creatine -14%, 95% CI -22.2 to -5.0; creatine -7.0%, 95% CI -14.8 to 1.5; 1 study, 204 participants; low-certainty evidence); may not change urinary arsenic methylation indices (FA400 + creatine: %InAs M 13.2%, SE ± 7.0; %MMA M 10.8, SE ± 4.1; %DMA M 76, SE ± 7.8; creatine: %InAs M 14.8, SE ± 5.5; %MMA M 12.8, SE ± 4.0; %DMA M 72.4, SE ±7.6; 1 study, 190 participants; low-certainty evidence); and may reduce homocysteine concentrations to a greater extent (%change in GM FA400 + creatinine -21%, 95% CI -25.2 to -16.4; creatine -4.3%, 95% CI -9.0 to 0.7; 1 study, 204 participants; low-certainty evidence) than creatine alone. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that FA supplements may benefit blood arsenic concentration, urinary arsenic methylation profiles, and plasma homocysteine concentration versus placebo. There is low-certainty evidence that FA supplements plus other nutrients may benefit blood arsenic and plasma homocysteine concentrations versus nutrients alone. No studies reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Given the limited number of RCTs, more studies conducted in diverse settings are needed to assess the effects of FA on arsenic-related health outcomes and arsenic toxicity in arsenic-exposed adults and children.
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Affiliation(s)
- Sajin Bae
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Elena Kamynina
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | | | - Adetutu F Farinola
- Faculty of Public Health, Department of Human Nutrition and Dietetics, University of Ibadan, Ibadan, Nigeria
| | - Marie A Caudill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Kancherla V, Pachón H, Blencowe H, Martinez H, Oakley GP, Berry RJ. The Fallacy of Using Administrative Data in Assessing the Effectiveness of Food Fortification. Comment on: "Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset. Nutrients 2020, 12, 247". Nutrients 2020; 12:nu12051352. [PMID: 32397301 PMCID: PMC7284892 DOI: 10.3390/nu12051352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/16/2020] [Indexed: 01/29/2023] Open
Abstract
Our objective in this comment is to highlight several limitations in an ecological research study that was published in Nutrients by Murphy and Westmark (2020) in January 2020. The study used data from the Food Fortification Initiative (FFI) website, and applying an ecological study design, made an error of “ecologic fallacy” in concluding that “national fortification with folic acid is not associated with a significant decrease in the prevalence of neural tube defects (NTDs) at the population level”. We list study limitations that led to their erroneous conclusions, stemming from incorrect considerations regarding NTD prevalence, the average grain availability for a country, the fortification coverage in a country, the population reach of fortified foods within a country, and the absence of the consideration of fortification type (voluntary vs. mandatory), country-specific policies on elective terminations for NTD-affected pregnancies, stillbirth proportions among those with NTDs, and fortification implementation. FFI data are derived from many sources and intended for fortification advocacy, not for hypothesis testing. The flawed study by Murphy & Westmark (2020) in Nutrients promotes a confusing and incorrect message to stakeholders, misguides policy makers, and hinders progress in global NTD prevention through a cost-effective, safe, and effective intervention: the mandatory large-scale folic acid fortification of staple foods.
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Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA; (G.P.O.J.); (R.J.B.)
- Correspondence: ; Tel.: +1-404-727-8884; Fax: 404-727-8737
| | - Helena Pachón
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA;
- Food Fortification Initiative, Atlanta, GA 30322, USA
| | - Hannah Blencowe
- Maternal Adolescent Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | | | - Godfrey P. Oakley
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA; (G.P.O.J.); (R.J.B.)
| | - Robert J. Berry
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA; (G.P.O.J.); (R.J.B.)
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Berry RJ. Lack of historical evidence to support folic acid exacerbation of the neuropathy caused by vitamin B12 deficiency. Am J Clin Nutr 2019; 110:554-561. [PMID: 31187858 PMCID: PMC6785032 DOI: 10.1093/ajcn/nqz089] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/17/2019] [Indexed: 12/22/2022] Open
Abstract
In 1998 a Tolerable Upper Intake Level (UL) for folic acid was established based on case reports from the 1940s suggesting that high-dosage folic acid intake, used to treat patients with pernicious anemia, had the potential to precipitate or speed-up the development of neurological problems. This UL has been employed in the decision-making process used by more than 80 countries to establish programs to fortify staple foods with folic acid to prevent neural tube birth defects. Some have claimed that this UL is flawed and has become an obstacle to the wider adoption of neural tube defect prevention programs and have called for re-evaluation of the scientific validity of this UL. Case reports cannot establish causality, but they can reveal patterns in the timing of the onset and treatment of patients with pernicious anemia. These patterns can be compared with secular trends of usual medical practice for the treatment of pernicious anemia and with the changes in usage of folic acid preparations, including recommended therapeutic dosage and precautions for its usage surrounding the synthesis of folic acid in 1945 and vitamin B12 in 1948. Folic acid package inserts, early editions of hematology textbooks, and international expert reports provide valuable historical information. The recommended therapeutic daily dosage for folic acid of 5-20 mg was unchanged from 1946 through to 1971. The likely cause of the neurological problems encountered is the development of vitamin B12 neuropathy when pernicious anemia was treated with high-dosage folic acid before vitamin B12 was widely available in the early 1950s. Thus, the historical record does not provide compelling evidence that folic acid can potentially cause neurologic complications among those with low vitamin B12 status and lends support for reconsidering the basis for the UL of folic acid.
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Affiliation(s)
- 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
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kancherla V, Carmichael SL, Feldkamp ML, Berry RJ. Teratology society position statement on surveillance and prevalence estimation of neural tube defects. Birth Defects Res 2019; 111:5-8. [PMID: 30569547 DOI: 10.1002/bdr2.1434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Vijaya Kancherla
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Suzan L Carmichael
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
| | - Marcia L Feldkamp
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert J Berry
- Department of Epidemiology, Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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11
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Linet MS, Wang L, Wang N, Berry RJ, Chao A, Hao L, Li Z, Fang L, Yin P, Potischman N, Sun X, Meng F, Yang R, Cong S, Fan J, Kitahara CM, Liang X, Liu F, Lu X, Lv F, Mu C, Sampson J, Tang Y, Wan W, Wang B, Wang H, Zhang L, Wang Y. Prospective investigation of folic acid supplements before and during early pregnancy and paediatric and adult cancers in the Chinese children and families cohort: a pilot study in a sample of rural and urban families. BMJ Open 2018; 8:e022394. [PMID: 30061446 PMCID: PMC6067353 DOI: 10.1136/bmjopen-2018-022394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/08/2018] [Accepted: 06/21/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the feasibility of long-term prospective follow-up and ascertainment of cancer in offspring and mothers from the 1993-1995 Chinese Community Intervention Program that provided folic acid supplements before and during early pregnancy to reduce neural tube defects. DESIGN Feasibility pilot study for a prospective cohort study. SETTING Families residing during 2012-2013 in one rural and one urban county from 21 counties in 3 provinces in China included in the Community Intervention Program campaign. PARTICIPANTS The feasibility study targeted 560 families, including 280 from the rural and 280 from the urban county included in the large original study; about half of mothers in each group had taken and half had not taken folic acid supplements. INTERVENTION The planned new study is observational. PRIMARY AND SECONDARY OUTCOME MEASURES Primary: incidence of paediatric cancers in offspring; secondary: other chronic diseases in offspring and chronic diseases in mothers RESULTS: Only 3.4% of pilot study families could not be found, 3.9% had moved out of the study area and 8.8% refused to participate. Interviews were completed by 82% of mothers, 79% of fathers and 83% of offspring in the 560 families. Almost all mothers and offspring who were interviewed also participated in anthropometric measurements. We found notable urban-rural differences in sociodemographic and lifestyle characteristics of the parents, but fewer differences among the offspring. In eight catchment area hospitals, we identified a broad range of paediatric cancers diagnosed during 1994-2013, although paediatric brain tumours, lymphomas and rarer cancers were likely under-represented. CONCLUSIONS Overall, 20 years after the original Community Intervention Program, the pilot study achieved high levels of follow-up and family member interview participation, and identified substantial numbers of paediatric malignancies during 1994-2013 in catchment area hospitals. Next steps and strategies for overcoming limitations are described.
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Affiliation(s)
- Martha S Linet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Linhong Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ning Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ann Chao
- Center for Global Health, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ling Hao
- CDC Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zhu Li
- Independent Consultant, Beijing, China
| | - Liwen Fang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Peng Yin
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Nancy Potischman
- Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland, USA
| | - Xin Sun
- National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Fanweng Meng
- Department of Surgery, Laoting County Maternal and Child Health Hospital, Laoting, China
| | - Ruilan Yang
- Taicang County Maternal and Child Hospital, Taicang, China
| | - Shu Cong
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jing Fan
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Cari M Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Xiaofeng Liang
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Fang Liu
- Center of Pediatric Blood Diseases, Tianjin Hematology Institute and Hospital, Tianjin, China
| | - Xiaojun Lu
- Department of Surgery, Taicang First People's Hospital, Taicang, China
| | - Fan Lv
- Department of Pediatric Oncology, Shanghai Xinhua Hospital, Shanghai, China
| | | | - Joshua Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Yongmin Tang
- Department of Hematology, Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Weiqing Wan
- Department of Neurosurgery, Tiantan Hospital, Beijing, China
| | - Baohua Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hongsheng Wang
- Department of Hematology/Oncology, Fudan University Children's Hospital, Shanghai, China
| | - Leping Zhang
- Department of Pediatric Hematology/Oncology, Peking University Renmin Hospital, Beijing, China
| | - Yu Wang
- Chinese Center for Disease Control and Prevention, Beijing, China
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Kotzur BA, Berry RJ, Zigan S, García-Triñanes P, Bradley MS. Particle attrition mechanisms, their characterisation, and application to horizontal lean phase pneumatic conveying systems: A review. POWDER TECHNOL 2018. [DOI: 10.1016/j.powtec.2018.04.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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Ailes EC, Gilboa SM, Gill SK, Broussard CS, Crider KS, Berry RJ, Carter TC, Hobbs CA, Interrante JD, Reefhuis J. Association between antibiotic use among pregnant women with urinary tract infections in the first trimester and birth defects, National Birth Defects Prevention Study 1997 to 2011. ACTA ACUST UNITED AC 2017; 106:940-949. [PMID: 27891788 DOI: 10.1002/bdra.23570] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/26/2016] [Accepted: 08/29/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies noted associations between birth defects and some antibiotics (e.g., nitrofurantoin, sulfonamides) but not others (e.g., penicillins). It is unclear if previous findings were due to antibiotic use, infections, or chance. To control for potential confounding by indication, we examined associations between antibiotic use and birth defects, among women reporting urinary tract infections (UTIs). METHODS The National Birth Defects Prevention Study is a multi-site, population-based case-control study. Case infants/fetuses have any of over 30 major birth defects and controls are live-born infants without major birth defects. We analyzed pregnancies from 1997 to 2011 to estimate the association between maternally reported periconceptional (month before conception through the third month of pregnancy) use of nitrofurantoin, trimethoprim-sulfamethoxazole, or cephalosporins and specific birth defects, among women with periconceptional UTIs. Women with periconceptional UTIs who reported penicillin use served as the comparator. RESULTS Periconceptional UTIs were reported by 7.8% (2029/26,068) of case and 6.7% (686/10,198) of control mothers. Most (68.2% of case, 66.6% of control mothers) also reported antibiotic use. Among 608 case and 231 control mothers reporting at least one periconceptional UTI and certain antibiotic use, compared with penicillin, nitrofurantoin use was associated with oral clefts in the offspring (adjusted odds ratio, 1.97 [95% confidence interval, 1.10-3.53]), trimethoprim-sulfamethoxazole use with esophageal atresia (5.31 [1.39-20.24]) and diaphragmatic hernia (5.09 [1.20-21.69]), and cephalosporin use with anorectal atresia/stenosis (5.01 [1.34-18.76]). CONCLUSION Periconceptional exposure to some antibiotics might increase the risk for certain birth defects. However, because individual birth defects are rare, absolute risks should drive treatment decisions.Birth Defects Research (Part A) 106:940-949, 2016.© 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elizabeth C Ailes
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Cheryl S Broussard
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Charlotte A Hobbs
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Julia D Interrante
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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15
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Kotzur BA, Bradley MSA, Berry RJ, Farnish RJ. Breakage Characteristics of Granulated Food Products for Prediction of Attrition during Lean-Phase Pneumatic Conveying. International Journal of Food Engineering 2016. [DOI: 10.1515/ijfe-2016-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Pneumatic conveying is utilised in a variety of industries to convey food products exhibiting diverse handling characteristics. Attrition of particles caused by this conveying process can result in a number of undesirable outcomes such as loss in product quality or issues in subsequent handling processes. The ability to predict the breakage behaviour of particulate materials is desirable in both new system design and resolving issues in existing plants. This work considers two different particulate materials (Salt and Golden Breadcrumbs) across a range of particle sizes, and quantifies their breakage behaviour under varying impact conditions. Narrow size fractions of each material were degraded; material retained on 250 µm and 355 µm sieves for Salt, and 500 µm, 710 µm and 1,000 µm sieves for Golden Breadcrumbs. Velocity was found to be the most influential factor with respect to particle attrition. The results from the narrow size fraction tests were superimposed to form a simulated full size distribution breakage behaviour, which was then compared to the experimentally determined behaviour. A good agreement was found, however the proportion of material predicted for size fractions smaller than 355 µm for Golden Breadcrumbs and 180 µm for Salt was under-predicted. Recommendations for increasing accuracy of the prediction method are given.
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16
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Affiliation(s)
- Patrick J Stover
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Robert J Berry
- Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, Georgia
| | - Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
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17
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Affiliation(s)
- A H Laing
- Department of Radiotherapy, Churchill Hospital, Headington, Oxford, OX3 7LJ
| | - R J Berry
- Department of Radiotherapy, Churchill Hospital, Headington, Oxford, OX3 7LJ
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18
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Affiliation(s)
- R J Berry
- Royal Free Hospital School of Medicine, London WC1
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19
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Dawson AL, Tinker SC, Jamieson DJ, Hobbs CA, Berry RJ, Rasmussen SA, Anderka M, Keppler-Noreuil KM, Lin AE, Reefhuis J. Twinning and major birth defects, National Birth Defects Prevention Study, 1997-2007. J Epidemiol Community Health 2016; 70:1114-1121. [PMID: 27325867 DOI: 10.1136/jech-2015-206302] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 04/26/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Twinning has been associated with many types of birth defects, although previous studies have had inconsistent findings. Many studies lack information about potential confounders, particularly use of fertility treatment. Our objective was to assess the association between twinning and birth defects in the National Birth Defects Prevention Study (NBDPS). METHODS We used data from the NBDPS, a population-based, case-control study of major birth defects in the USA, to evaluate associations between twinning and birth defects. The study population included mothers of twin and singleton controls (live-born infants without major birth defects), and cases (fetuses or infants with a major birth defect) born October 1997-December 2007. Adjusted ORs and 95% CIs were estimated using multivariable logistic regression stratified by use of fertility treatment. Twin sex-pairing data and a simulation approach were used to estimate the zygosity of twins. RESULTS In the unassisted conception stratum, we observed significant positive associations between twinning and 29 of 45 defect groups. The largest effect estimates were observed for multiple ventricular septal defects and cloacal exstrophy. Among mothers reporting any use of fertility treatments, we observed a significant association with twinning for 5 of 25 defect groups, with the largest effect estimates for hypoplastic left heart syndrome and omphalocele. OR estimates in the estimated monozygotic stratum were generally further from the null than in the dizygotic stratum. CONCLUSIONS Compared with singletons, a wide range of birth defects are significantly more common among twins. Birth defect risk in twins may be differential by use of fertility treatment.
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Affiliation(s)
- April L Dawson
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Sarah C Tinker
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | - Denise J Jamieson
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia, USA
| | - Charlotte A Hobbs
- College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - R J Berry
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
| | | | - Marlene Anderka
- Massachusetts Center for Birth Defects Research and Prevention, Boston, Massachusetts, USA
| | | | - Angela E Lin
- Massachusetts Center for Birth Defects Research and Prevention, Boston, Massachusetts, USA Genetics Unit, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia, USA
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20
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Affiliation(s)
- Lorraine F Yeung
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia.
| | - Robert J Berry
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia
| | - Cynthia A Moore
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia
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21
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Grosse SD, Berry RJ, Mick Tilford J, Kucik JE, Waitzman NJ. Retrospective Assessment of Cost Savings From Prevention: Folic Acid Fortification and Spina Bifida in the U.S. Am J Prev Med 2016; 50:S74-S80. [PMID: 26790341 PMCID: PMC4841731 DOI: 10.1016/j.amepre.2015.10.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 10/12/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Although fortification of food with folic acid has been calculated to be cost saving in the U.S., updated estimates are needed. This analysis calculates new estimates from the societal perspective of net cost savings per year associated with mandatory folic acid fortification of enriched cereal grain products in the U.S. that was implemented during 1997-1998. METHODS Estimates of annual numbers of live-born spina bifida cases in 1995-1996 relative to 1999-2011 based on birth defects surveillance data were combined during 2015 with published estimates of the present value of lifetime direct costs updated in 2014 U.S. dollars for a live-born infant with spina bifida to estimate avoided direct costs and net cost savings. RESULTS The fortification mandate is estimated to have reduced the annual number of U.S. live-born spina bifida cases by 767, with a lower-bound estimate of 614. The present value of mean direct lifetime cost per infant with spina bifida is estimated to be $791,900, or $577,000 excluding caregiving costs. Using a best estimate of numbers of avoided live-born spina bifida cases, fortification is estimated to reduce the present value of total direct costs for each year's birth cohort by $603 million more than the cost of fortification. A lower-bound estimate of cost savings using conservative assumptions, including the upper-bound estimate of fortification cost, is $299 million. CONCLUSIONS The estimates of cost savings are larger than previously reported, even using conservative assumptions. The analysis can also inform assessments of folic acid fortification in other countries.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia.
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia
| | - J Mick Tilford
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James E Kucik
- Office of the Associate Director for Policy, CDC, Atlanta, Georgia
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Orozco AM, Yeung LF, Guo J, Carriquiry A, Berry RJ. Characteristics of U.S. Adults with Usual Daily Folic Acid Intake above the Tolerable Upper Intake Level: National Health and Nutrition Examination Survey, 2003-2010. Nutrients 2016; 8:195. [PMID: 27043623 PMCID: PMC4848664 DOI: 10.3390/nu8040195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/11/2016] [Accepted: 03/22/2016] [Indexed: 11/16/2022] Open
Abstract
The Food and Drug Administration mandated that by 1998, all enriched cereal grain products (ECGP) be fortified with folic acid in order to prevent the occurrence of neural tube defects. The Institute of Medicine established the tolerable upper intake level (UL) for folic acid (1000 µg/day for adults) in 1998. We characterized U.S. adults with usual daily folic acid intake exceeding the UL. Using NHANES 2003–2010 data, we estimated the percentage of 18,321 non-pregnant adults with usual daily folic acid intake exceeding the UL, and among them, we calculated the weighted percentage by sex, age, race/ethnicity, sources of folic acid intake, supplement use and median usual daily folic acid intakes. Overall, 2.7% (standard error 0.6%) of participants had usual daily intake exceeding the UL for folic acid; 62.2% were women; 86.3% were non-Hispanic whites; and 98.5% took supplements containing folic acid. When stratified by sex and age groups among those with usual daily folic acid intake exceeding the UL, 20.8% were women aged 19–39 years. Those with usual daily intake exceeding the folic acid UL were more likely to be female, non-Hispanic white, supplement users or to have at least one chronic medical condition compared to those not exceeding the folic acid UL. Among those with usual daily folic acid intake exceeding the UL who also took supplements, 86.6% took on average >400 µg of folic acid/day from supplements. Everyone with usual daily folic acid intake exceeding the UL consumed folic acid from multiple sources. No one in our study population had usual daily folic acid intake exceeding the UL through consumption of mandatorily-fortified enriched cereal grain products alone. Voluntary consumption of supplements containing folic acid is the main factor associated with usual daily intake exceeding the folic acid UL.
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Affiliation(s)
- Angela M Orozco
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
- David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA 90095, USA.
| | - Lorraine F Yeung
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| | - Jing Guo
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| | - Alicia Carriquiry
- Department of Statistics, Iowa State University, Ames, IA 50011, USA.
| | - Robert J Berry
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
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Bailey LB, Stover PJ, McNulty H, Fenech MF, Gregory JF, Mills JL, Pfeiffer CM, Fazili Z, Zhang M, Ueland PM, Molloy AM, Caudill MA, Shane B, Berry RJ, Bailey RL, Hausman DB, Raghavan R, Raiten DJ. Biomarkers of Nutrition for Development-Folate Review. J Nutr 2015; 145:1636S-1680S. [PMID: 26451605 PMCID: PMC4478945 DOI: 10.3945/jn.114.206599] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/11/2014] [Accepted: 04/14/2015] [Indexed: 12/13/2022] Open
Abstract
The Biomarkers of Nutrition for Development (BOND) project is designed to provide evidence-based advice to anyone with an interest in the role of nutrition in health. Specifically, the BOND program provides state-of-the-art information and service with regard to selection, use, and interpretation of biomarkers of nutrient exposure, status, function, and effect. To accomplish this objective, expert panels are recruited to evaluate the literature and to draft comprehensive reports on the current state of the art with regard to specific nutrient biology and available biomarkers for assessing nutrients in body tissues at the individual and population level. Phase I of the BOND project includes the evaluation of biomarkers for 6 nutrients: iodine, iron, zinc, folate, vitamin A, and vitamin B-12. This review represents the second in the series of reviews and covers all relevant aspects of folate biology and biomarkers. The article is organized to provide the reader with a full appreciation of folate's history as a public health issue, its biology, and an overview of available biomarkers (serum folate, RBC folate, and plasma homocysteine concentrations) and their interpretation across a range of clinical and population-based uses. The article also includes a list of priority research needs for advancing the area of folate biomarkers related to nutritional health status and development.
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Affiliation(s)
- Lynn B Bailey
- Department of Foods and Nutrition, University of Georgia, Athens, GA;
| | - Patrick J Stover
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Helene McNulty
- Northern Ireland Centre for Food and Health, Biomedical Sciences Research Institute, University of Ulster, Londonderry, United Kingdom
| | - Michael F Fenech
- Genome Health Nutrigenomics Laboratory, Food, Nutrition, and Bioproducts Flagship, Commonwealth Scientific and Industrial Research Organization, Adelaide, Australia
| | - Jesse F Gregory
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL
| | - James L Mills
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | | | - Zia Fazili
- National Center for Environmental Health, CDC, Atlanta, GA
| | - Mindy Zhang
- National Center for Environmental Health, CDC, Atlanta, GA
| | - Per M Ueland
- Department of Clinical Science, Univeristy of Bergen, Bergen, Norway
| | - Anne M Molloy
- Institute of Molecular Medicine, Trinity College, Dublin, Ireland
| | - Marie A Caudill
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Barry Shane
- Department of Nutritional Sciences and Toxicology, University of California-Berkeley, Berkeley, CA
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA; and
| | | | - Dorothy B Hausman
- Department of Foods and Nutrition, University of Georgia, Athens, GA
| | - Ramkripa Raghavan
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD;
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24
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Tsang BL, Devine OJ, Cordero AM, Marchetta CM, Mulinare J, Mersereau P, Guo J, Qi YP, Berry RJ, Rosenthal J, Crider KS, Hamner HC. Assessing the association between the methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphism and blood folate concentrations: a systematic review and meta-analysis of trials and observational studies. Am J Clin Nutr 2015; 101:1286-94. [PMID: 25788000 DOI: 10.3945/ajcn.114.099994] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/09/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphism is a risk factor for neural tube defects. The T allele produces an enzyme with reduced folate-processing capacity, which has been associated with lower blood folate concentrations. OBJECTIVE We assessed the association between MTHFR C677T genotypes and blood folate concentrations among healthy women aged 12-49 y. DESIGN We conducted a systematic review of the literature published from January 1992 to March 2014 to identify trials and observational studies that reported serum, plasma, or red blood cell (RBC) folate concentrations and MTHFR C677T genotype. We conducted a meta-analysis for estimates of percentage differences in blood folate concentrations between genotypes. RESULTS Forty studies met the inclusion criteria. Of the 6 studies that used the microbiologic assay (MA) to measure serum or plasma (S/P) and RBC folate concentrations, the percentage difference between genotypes showed a clear pattern of CC > CT > TT. The percentage difference was greatest for CC > TT [S/P: 13%; 95% credible interval (CrI): 7%, 18%; RBC: 16%; 95% CrI: 12%, 20%] followed by CC > CT (S/P: 7%; 95% CrI: 1%, 12%; RBC: 8%; 95% CrI: 4%, 12%) and CT > TT (S/P: 6%; 95% CrI: 1%, 11%; RBC: 9%; 95% CrI: 5%, 13%). S/P folate concentrations measured by using protein-binding assays (PBAs) also showed this pattern but to a greater extent (e.g., CC > TT: 20%; 95% CrI: 17%, 22%). In contrast, RBC folate concentrations measured by using PBAs did not show the same pattern and are presented in the Supplemental Material only. CONCLUSIONS Meta-analysis results (limited to the MA, the recommended population assessment method) indicated a consistent percentage difference in S/P and RBC folate concentrations across MTHFR C677T genotypes. Lower blood folate concentrations associated with this polymorphism could have implications for a population-level risk of neural tube defects.
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Affiliation(s)
- Becky L Tsang
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Owen J Devine
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Amy M Cordero
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Claire M Marchetta
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Joseph Mulinare
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Patricia Mersereau
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Jing Guo
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Yan Ping Qi
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Robert J Berry
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Jorge Rosenthal
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Krista S Crider
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM)
| | - Heather C Hamner
- From the Division of Birth Defects and Developmental Disabilities, National Center for Birth Defects and Developmental Disabilities (NCBDDD), CDC, Atlanta, GA (AMC, RJB, JR, and KSC); the Division of Nutrition, Physical Activity, and Obesity, National Center on Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA (HCH); Acentia (contractor for CDC, NCBDDD), Falls Church, VA (JG); Carter Consulting Inc. (contractor for CDC, NCBDDD), Atlanta, GA (OJD, JM, and YPQ); the Oak Ridge Institute for Science and Education, Oak Ridge, TN (BLT, CMM, and YPQ); SciMetrika LLC (contractor for CDC, NCBDDD), Atlanta, GA (PM).
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Marchetta CM, Devine OJ, Crider KS, Tsang BL, Cordero AM, Qi YP, Guo J, Berry RJ, Rosenthal J, Mulinare J, Mersereau P, Hamner HC. Assessing the association between natural food folate intake and blood folate concentrations: a systematic review and Bayesian meta-analysis of trials and observational studies. Nutrients 2015; 7:2663-86. [PMID: 25867949 PMCID: PMC4425166 DOI: 10.3390/nu7042663] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/06/2015] [Accepted: 03/09/2015] [Indexed: 12/25/2022] Open
Abstract
Folate is found naturally in foods or as synthetic folic acid in dietary supplements and fortified foods. Adequate periconceptional folic acid intake can prevent neural tube defects. Folate intake impacts blood folate concentration; however, the dose-response between natural food folate and blood folate concentrations has not been well described. We estimated this association among healthy females. A systematic literature review identified studies (1 1992-3 2014) with both natural food folate intake alone and blood folate concentration among females aged 12-49 years. Bayesian methods were used to estimate regression model parameters describing the association between natural food folate intake and subsequent blood folate concentration. Seven controlled trials and 29 observational studies met the inclusion criteria. For the six studies using microbiologic assay (MA) included in the meta-analysis, we estimate that a 6% (95% Credible Interval (CrI): 4%, 9%) increase in red blood cell (RBC) folate concentration and a 7% (95% CrI: 1%, 12%) increase in serum/plasma folate concentration can occur for every 10% increase in natural food folate intake. Using modeled results, we estimate that a natural food folate intake of ≥ 450 μg dietary folate equivalents (DFE)/day could achieve the lower bound of an RBC folate concentration (~ 1050 nmol/L) associated with the lowest risk of a neural tube defect. Natural food folate intake affects blood folate concentration and adequate intakes could help women achieve a RBC folate concentration associated with a risk of 6 neural tube defects/10,000 live births.
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Affiliation(s)
- Claire M Marchetta
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN 37831, USA.
| | | | - Krista S Crider
- Division of Birth Defects and Developmental Disabilities (DBDDD), National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Becky L Tsang
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN 37831, USA.
| | - Amy M Cordero
- Division of Birth Defects and Developmental Disabilities (DBDDD), National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Yan Ping Qi
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN 37831, USA.
| | - Jing Guo
- Acentia, Falls Church, VA 22042, USA.
| | - Robert J Berry
- Division of Birth Defects and Developmental Disabilities (DBDDD), National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Jorge Rosenthal
- Division of Birth Defects and Developmental Disabilities (DBDDD), National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | | | | | - Heather C Hamner
- Division of Nutrition, Physical Activity, and Obesity (DNPAO), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
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26
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Crider KS, Devine O, Hao L, Dowling NF, Li S, Molloy AM, Li Z, Zhu J, Berry RJ. Population red blood cell folate concentrations for prevention of neural tube defects: Bayesian model. BMJ 2014; 349:g4554. [PMID: 25073783 PMCID: PMC4115151 DOI: 10.1136/bmj.g4554] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine an optimal population red blood cell (RBC) folate concentration for the prevention of neural tube birth defects. DESIGN Bayesian model. SETTING Data from two population based studies in China. PARTICIPANTS 247,831 participants in a prospective community intervention project in China (1993-95) to prevent neural tube defects with 400 μg/day folic acid supplementation and 1194 participants in a population based randomized trial (2003-05) to evaluate the effect of folic acid supplementation on blood folate concentration among Chinese women of reproductive age. INTERVENTION Folic acid supplementation (400 μg/day). MAIN OUTCOME MEASURES Estimated RBC folate concentration at time of neural tube closure (day 28 of gestation) and risk of neural tube defects. RESULTS Risk of neural tube defects was high at the lowest estimated RBC folate concentrations (for example, 25.4 (95% uncertainty interval 20.8 to 31.2) neural tube defects per 10,000 births at 500 nmol/L) and decreased as estimated RBC folate concentration increased. Risk of neural tube defects was substantially attenuated at estimated RBC folate concentrations above about 1000 nmol/L (for example, 6 neural tube defects per 10,000 births at 1180 (1050 to 1340) nmol/L). The modeled dose-response relation was consistent with the existing literature. In addition, neural tube defect risk estimates developed using the proposed model and population level RBC information were consistent with the prevalence of neural tube defects in the US population before and after food fortification with folic acid. CONCLUSIONS A threshold for "optimal" population RBC folate concentration for the prevention of neural tube defects could be defined (for example, approximately 1000 nmol/L). Population based RBC folate concentrations, as a biomarker for risk of neural tube defects, can be used to facilitate evaluation of prevention programs as well as to identify subpopulations at elevated risk for a neural tube defect affected pregnancy due to folate insufficiency.
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Affiliation(s)
- Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Owen Devine
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Ling Hao
- Peking University Health Science Center, Peking University, Beijing, China US Centers for Disease Control and Prevention, US Embassy, Beijing, China
| | - Nicole F Dowling
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Song Li
- Peking University Third Hospital, Beijing, China
| | - Anne M Molloy
- School of Medicine, Trinity College, Dublin, Ireland
| | - Zhu Li
- Peking University Health Science Center, Peking University, Beijing, China
| | - Jianghui Zhu
- Peking University Health Science Center, Peking University, Beijing, China Division of Risk Assessment, China National Center for Food Safety Risk Assessment, Beijing, China
| | - Robert J Berry
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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27
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Qi YP, Do AN, Hamner HC, Pfeiffer CM, Berry RJ. The prevalence of low serum vitamin B-12 status in the absence of anemia or macrocytosis did not increase among older U.S. adults after mandatory folic acid fortification. J Nutr 2014; 144:170-6. [PMID: 24306216 PMCID: PMC5291239 DOI: 10.3945/jn.113.183095] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Whether folic acid fortification and supplementation at the population level have led to a higher prevalence of vitamin B-12 deficiency in the absence of anemia remains to be examined among a nationally representative sample of older U.S. adults. We assessed the prevalence of low vitamin B-12 status in the absence of anemia or macrocytosis before and after fortification among adults aged >50 y using cross-sectional data from the NHANES 1991-1994 (prefortification) and 2001-2006 (postfortification). We compared the prefortification and postfortification prevalence of multiple outcomes, including serum vitamin B-12 deficiency (<148 pmol/L) and marginal deficiency (148-258 pmol/L) with and without anemia (hemoglobin <130 g/L for men, <120 g/L for women) and with and without macrocytosis (mean cell volume >100 fL) using multinomial logistic regression, adjusting for age, sex, ethnicity, body mass index, C-reactive protein, and vitamin B-12 supplement use. Prefortification and postfortification serum vitamin B-12 deficiency without anemia [4.0 vs. 3.9%; adjusted prevalence ratio (aPR) (95% CI): 0.98 (0.67, 1.44)] or without macrocytosis [4.2 vs. 4.1%; aPR (95% CI): 0.96 (0.65, 1.43)] remained unchanged. Marginal deficiency without anemia [25.1 vs. 20.7%; aPR (95% CI): 0.82 (0.72, 0.95)] or without macrocytosis [25.9 vs. 21.3%; aPR (95% CI): 0.82 (0.72, 0.94)] were both significantly lower after fortification. After fortification, higher folic acid intake was associated with a lower prevalence of low serum B-12 status in the absence of anemia or macrocytosis. Results suggest that the prevalence of low serum B-12 status in the absence of anemia or macrocytosis among older U.S. adults did not increase after fortification. Thus, at the population level, we found no evidence to support concerns that folic acid adversely affected the clinical presentation of vitamin B-12 deficiency among older adults.
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Affiliation(s)
- Yan Ping Qi
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA,To whom correspondence should be addressed.
| | - Ann N. Do
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA
| | - Heather C. Hamner
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA
| | - Christine M. Pfeiffer
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Robert J. Berry
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA
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28
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Fisk Green R, Byrne J, Crider KS, Gallagher M, Koontz D, Berry RJ. Folate-related gene variants in Irish families affected by neural tube defects. Front Genet 2013; 4:223. [PMID: 24223580 PMCID: PMC3818582 DOI: 10.3389/fgene.2013.00223] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/15/2013] [Indexed: 01/01/2023] Open
Abstract
Periconceptional folic acid use can often prevent neural tube defects (NTDs). Variants of genes involved in folate metabolism in mothers and children have been associated with occurrence of NTDs. We identified Irish families with individuals affected by neural tube defects. In these families, we observed that neural tube defects and birth defects overall occurred at a higher rate in the maternal lineage compared with the paternal lineage. The goal of this study was to look for evidence for genetic effects that could explain the discrepancy in the occurrence of these birth defects in the maternal vs. paternal lineage. We genotyped blood samples from 322 individuals from NTD-affected Irish families, identified through their membership in spina bifida associations. We looked for differences in distribution in maternal vs. paternal lineages of five genetic polymorphisms: the DHFR 19 bp deletion, MTHFD1 1958G>A, MTHFR 1298A>C, MTHFR 677C>T, and SLC19A1 80A>G. In addition to looking at genotypes individually, we determined the number of genotypes associated with decreased folate metabolism in each relative (“risk genotypes”) and compared the distribution of these genotypes in maternal vs. paternal relatives. Overall, maternal relatives had a higher number of genotypes associated with lower folate metabolism than paternal relatives (p = 0.017). We expected that relatives would share the same risk genotype as the individuals with NTDs and/or their mothers. However, we observed that maternal relatives had an over-abundance of any risk genotype, rather than one specific genotype. The observed genetic effects suggest an epigenetic mechanism in which decreased folate metabolism results in epigenetic alterations related to the increased rate of NTDs and other birth defects seen in the maternal lineage. Future studies on the etiology of NTDs and other birth defects could benefit from including multigenerational extended families, in order to explore potential epigenetic mechanisms.
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Affiliation(s)
- Ridgely Fisk Green
- Carter Consulting, Inc. and Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention Atlanta, GA, USA
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29
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Crider KS, Cordero AM, Qi YP, Mulinare J, Dowling NF, Berry RJ. Prenatal folic acid and risk of asthma in children: a systematic review and meta-analysis. Am J Clin Nutr 2013; 98:1272-81. [PMID: 24004895 PMCID: PMC5369603 DOI: 10.3945/ajcn.113.065623] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Childhood asthma has become a critical public health problem because of its high morbidity and increasing prevalence. The impact of nutrition and other exposures during pregnancy on long-term health and development of children has been of increasing interest. OBJECTIVE We performed a systematic review and meta-analysis of the association of folate and folic acid intake during pregnancy and risk of asthma and other allergic outcomes in children. DESIGN We performed a systematic search of 8 electronic databases for articles that examined the association between prenatal folate or folic acid exposure and risk of asthma and other allergic outcomes (eg, allergy, eczema, and atopic dermatitis) in childhood. We performed a meta-analysis by using a random-effects model to derive a summary risk estimate of studies with similar exposure timing, exposure assessment, and outcomes. RESULTS Our meta-analysis provided no evidence of an association between maternal folic acid supplement use (compared with no use) in the prepregnancy period through the first trimester and asthma in childhood (summary risk estimate: 1.01; 95% CI: 0.78, 1.30). Because of substantial heterogeneity in exposures and outcomes, it was not possible to generate summary measures for other folate indicators (eg, blood folate concentrations) and asthma or allergy-related outcomes; however, the preponderance of primary risk estimates was not elevated. CONCLUSIONS Our findings do not support an association between periconceptional folic acid supplementation and increased risk of asthma in children. However, because of the limited number and types of studies in the literature, additional research is needed.
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Affiliation(s)
- Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, GA (KSC, AMC, YPQ, NFD, and RJB), and Carter Consulting Inc, Atlanta, GA (JM)
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Odewole OA, Williamson RS, Zakai NA, Berry RJ, Judd SE, Qi YP, Adedinsewo DA, Oakley GP. Near-elimination of folate-deficiency anemia by mandatory folic acid fortification in older US adults: Reasons for Geographic and Racial Differences in Stroke study 2003-2007. Am J Clin Nutr 2013; 98:1042-7. [PMID: 23945721 PMCID: PMC5291238 DOI: 10.3945/ajcn.113.059683] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The United States implemented mandatory folic acid fortification of enriched cereal grains in 1998. Although several studies have documented the resulting decrease in anemia and folate deficiency, to our knowledge, no one has determined the prevalence of folate-deficiency anemia after fortification. OBJECTIVE We determined the prevalence of folate deficiency and folate-deficiency anemia within a sample of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. DESIGN The REGARDS cohort is a prospective cohort of 30,239 black and white participants living in the contiguous United States. We measured serum folate concentrations in a random sample of 1546 REGARDS participants aged ≥50 y with baseline hemoglobin and red blood cell mean corpuscular volume measurements. Folate deficiency was defined as a serum folate concentration <6.6 nmol/L (<3.0 ng/mL), and anemia was defined as a hemoglobin concentration <13 g/dL in men and <12 g/dL in nonpregnant women (WHO criteria). Folate-deficiency anemia was defined as the presence of both folate deficiency and anemia. RESULTS The mean hemoglobin concentration was 13.6 g/dL, and 15.9% of subjects had anemia. The median serum folate concentration was 34.2 nmol/L (15.1 ng/mL), and only 2 of 1546 participants 0.1%) were folate deficient. Both subjects were African American women with markedly elevated C-reactive protein concentrations, macrocytosis, and normal serum cobalamin concentrations; only one subject was anemic. Overall, the prevalence of folate-deficiency anemia was <0.1% (1 of 1546 subjects). CONCLUSION Our data suggest that, after mandatory folic acid fortification, the prevalence of folate-deficiency anemia is nearly nonexistent in a community-dwelling population in the United States.
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Affiliation(s)
- Oluwaseun A Odewole
- Department of Epidemiology and Center for Spina Bifida Research, Prevention and Policy, Rollins School of Public Health, Emory University, Atlanta, GA
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Quinlivan EP, Crider KS, Zhu JH, Maneval DR, Hao L, Li Z, Rasmussen SA, Berry RJ, Bailey LB. Hypomethylation of serum blood clot DNA, but not plasma EDTA-blood cell pellet DNA, from vitamin B12-deficient subjects. PLoS One 2013; 8:e65241. [PMID: 23785415 PMCID: PMC3681792 DOI: 10.1371/journal.pone.0065241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/22/2013] [Indexed: 12/20/2022] Open
Abstract
Vitamin B12, a co-factor in methyl-group transfer, is important in maintaining DNA (deoxycytidine) methylation. Using two independent assays we examined the effect of vitamin B12-deficiency (plasma vitamin B12<148 pmol/L) on DNA methylation in women of childbearing age. Coagulated blood clot DNA from vitamin B12-deficient women had significantly (p<0.001) lower percentage deoxycytidine methylation (3.23±0.66%; n = 248) and greater [3 H]methyl-acceptance (42,859±9,699 cpm; n = 17) than DNA from B12-replete women (4.44±0.18%; n = 128 and 26,049±2,814 cpm; n = 11) [correlation between assays: r = -0.8538; p<0.001; n = 28]. In contrast, uncoagulated EDTA-blood cell pellet DNA from vitamin B12-deficient and B12-replete women exhibited similar percentage methylation (4.45±0.15%; n = 77 vs. 4.47±0.15%; n = 47) and [3 H]methyl-acceptance (27,378±4,094 cpm; n = 17 vs. 26,610±2,292 cpm; n = 11). Therefore, in simultaneously collected paired blood samples, vitamin B12-deficiency was associated with decreased DNA methylation only in coagulated samples. These findings highlight the importance of sample collection methods in epigenetic studies, and the potential impact biological processes can have on DNA methylation during collection.
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Affiliation(s)
- Eoin P Quinlivan
- Biomedical Mass Spectrometry Laboratory, Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, United States of America.
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Hamner HC, Tinker SC, Berry RJ, Mulinare J. Modeling fortification of corn masa flour with folic acid: the potential impact on exceeding the tolerable upper intake level for folic acid, NHANES 2001-2008. Food Nutr Res 2013; 57:19146. [PMID: 23316130 PMCID: PMC3542400 DOI: 10.3402/fnr.v57i0.19146] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 10/31/2012] [Accepted: 12/04/2012] [Indexed: 11/23/2022] Open
Abstract
Background The Institute of Medicine set a tolerable upper intake level (UL) for usual daily total folic acid intake (1,000 µg). Less than 3% of US adults currently exceed the UL. Objective The objective of this study was to determine if folic acid fortification of corn masa flour would increase the percentage of the US population who exceed the UL. Design We used dietary intake data from NHANES 2001–2008 to estimate the percentage of adults and children who would exceed the UL if corn masa flour were fortified at 140 µg of folic acid/100 g. Results In 2001–2008, 2.5% of the US adult population (aged≥19 years) exceeded the UL, which could increase to 2.6% if fortification of corn masa flour occurred. With corn masa flour fortification, percentage point increases were small and not statistically significant for US adults exceeding the UL regardless of supplement use, sex, race/ethnicity, or age. Children aged 1–8 years, specifically supplement users, were the most likely to exceed their age-specific UL. With fortification of corn masa flour, there were no statistically significant increases in the percentage of US children who were exceeding their age-specific UL, and the percentage point increases were small. Conclusions Our results suggest that fortification of corn masa flour would not significantly increase the percentage of individuals who would exceed the UL. Supplement use was the main factor related to exceeding the UL with or without fortification of corn masa flour and within all strata of sex, race/ethnicity, and age group.
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Affiliation(s)
- Heather C Hamner
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Modell B, Berry RJ, Boyle CA, Christianson A, Darlison M, Dolk H, Howson CP, Mastroiacovo P, Mossey P, Rankin J. Global regional and national causes of child mortality. Lancet 2012; 380:1556; author reply 1556-7. [PMID: 23122246 DOI: 10.1016/s0140-6736(12)61878-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Chandler AL, Hobbs CA, Mosley BS, Berry RJ, Canfield MA, Qi YP, Siega-Riz AM, Shaw GM. Neural tube defects and maternal intake of micronutrients related to one-carbon metabolism or antioxidant activity. Birth Defects Res A Clin Mol Teratol 2012; 94:864-74. [PMID: 22933447 PMCID: PMC3518275 DOI: 10.1002/bdra.23068] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/26/2012] [Accepted: 07/12/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND Maternal nutritional status has been evaluated to clarify its role in development of neural tube defects (NTDs). Maternal folate intake during pregnancy has been closely evaluated for its association with NTDs. The study objective was to examine associations between NTDs and other dietary periconceptional micronutrient intake, particularly nutrients involved in one-carbon metabolism or antioxidant activity. METHODS Using data from the National Birth Defects Prevention Study, 1997-2005, logistic regression models were used to estimate the relative risk of NTDs based on maternal micronutrient intake. RESULTS Results were stratified according to folic acid supplement use, race/ethnicity, and maternal body mass index. Analyses included 954 cases (300 with anencephaly, 654 with spina bifida) and 6268 controls. Higher intakes of folate, thiamin, betaine, iron, and vitamin A were associated with decreased risk of anencephaly among some ethnic and clinical groups. In some groups, higher intakes of thiamin, riboflavin, vitamin B(6) , vitamin C, vitamin E, niacin, and retinol were associated with decreased risk of spina bifida. CONCLUSION In addition to folic acid, other micronutrients, including thiamin, betaine, riboflavin, vitamin B(6) , vitamin C, vitamin E, niacin, iron, retinol, and vitamin A, may decrease the risk of NTD occurrence. Birth Defects Research (Part A) 2012. © 2012 Wiley Periodicals, Inc.
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Affiliation(s)
- Angela L Chandler
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas 72202, USA
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Tinker SC, Hamner HC, Berry RJ, Bailey LB, Pfeiffer CM. Does obesity modify the association of supplemental folic acid with folate status among nonpregnant women of childbearing age in the United States? ACTA ACUST UNITED AC 2012; 94:749-55. [PMID: 22641603 DOI: 10.1002/bdra.23024] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/27/2012] [Accepted: 04/05/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND Obesity is associated with an increased risk of having a pregnancy affected by a neural tube defect (NTD). It is not clear whether the amount of folic acid required by obese women to protect against NTDs is the same as that for nonobese women. METHODS We analyzed data from the National Health and Nutrition Examination Survey, representative of the noninstitutionalized civilian U.S. population, to assess whether body mass index (BMI; normal weight, overweight, and obese categories) modified the association between supplemental folic acid intake and folate status. We estimated the geometric mean concentration among nonpregnant women of childbearing age (15-44 years) during the postfortification period of: serum folate (2003-2008); red blood cell (RBC) folate (2007-2008); and plasma total homocysteine (tHcy; 2003-2006), adjusted for age, race and ethnicity, and total dietary folate expressed as dietary folate equivalents for strata of supplement use and BMI. RESULTS BMI was inversely associated with serum folate among women who did not use supplements containing folic acid; no differences between women in different BMI categories were observed among supplement users. Regardless of supplement use, obese women had the highest RBC folate concentrations. There were no differences in tHcy by BMI, regardless of supplement use. CONCLUSIONS These results do not support a straightforward modification of the relationship between supplemental folic acid intake and folate status by BMI. In this population, BMI may affect the body distribution of folate, as reflected by lower serum and higher RBC folate levels in obese women who do not use supplements.
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Affiliation(s)
- Sarah C Tinker
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Abstract
DNA methylation is an epigenetic modification critical to normal genome regulation and development. The vitamin folate is a key source of the one carbon group used to methylate DNA. Because normal mammalian development is dependent on DNA methylation, there is enormous interest in assessing the potential for changes in folate intake to modulate DNA methylation both as a biomarker for folate status and as a mechanistic link to developmental disorders and chronic diseases including cancer. This review highlights the role of DNA methylation in normal genome function, how it can be altered, and the evidence of the role of folate/folic acid in these processes.
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Affiliation(s)
- Krista S Crider
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA.
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Crider KS, Quinlivan EP, Berry RJ, Hao L, Li Z, Maneval D, Yang TP, Rasmussen SA, Yang Q, Zhu JH, Hu DJ, Bailey LB. Genomic DNA methylation changes in response to folic acid supplementation in a population-based intervention study among women of reproductive age. PLoS One 2011; 6:e28144. [PMID: 22163281 PMCID: PMC3233549 DOI: 10.1371/journal.pone.0028144] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 11/02/2011] [Indexed: 12/02/2022] Open
Abstract
Folate is a source of one-carbons necessary for DNA methylation, a critical epigenetic modification necessary for genomic structure and function. The use of supplemental folic acid is widespread however; the potential influence on DNA methylation is unclear. We measured global DNA methylation using DNA extracted from samples from a population-based, double-blind randomized trial of folic acid supplementation (100, 400, 4000 µg per day) taken for 6 months; including a 3 month post-supplementation sample. We observed no changes in global DNA methylation in response to up to 4,000 µg/day for 6 months supplementation in DNA extracted from uncoagulated blood (approximates circulating blood). However, when DNA methylation was determined in coagulated samples from the same individuals at the same time, significant time, dose, and MTHFR genotype-dependent changes were observed. The baseline level of DNA methylation was the same for uncoagulated and coagulated samples; marked differences between sample types were observed only after intervention. In DNA from coagulated blood, DNA methylation decreased (−14%; P<0.001) after 1 month of supplementation and 3 months after supplement withdrawal, methylation decreased an additional 23% (P<0.001) with significant variation among individuals (max+17%; min-94%). Decreases in methylation of ≥25% (vs. <25%) after discontinuation of supplementation were strongly associated with genotype: MTHFR CC vs. TT (adjusted odds ratio [aOR] 12.9, 95%CI 6.4, 26.0). The unexpected difference in DNA methylation between DNA extracted from coagulated and uncoagulated samples in response to folic acid supplementation is an important finding for evaluating use of folic acid and investigating the potential effects of folic acid supplementation on coagulation.
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Affiliation(s)
- Krista S Crider
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
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Zhang Y, Riehle-Colarusso T, Correa A, Li S, Feng X, Gindler J, Lin H, Webb C, Li W, Trines J, Berry RJ, Yeung L, Luo Y, Jiang M, Chen H, Sun X, Li Z. Observed prevalence of congenital heart defects from a surveillance study in China. J Ultrasound Med 2011; 30:989-95. [PMID: 21705732 PMCID: PMC4469985 DOI: 10.7863/jum.2011.30.7.989] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES The purpose of this study was to estimate the prevalence of major and minor congenital heart defects among fetuses and neonates using sonography in a general population of 4 areas surrounding Shanghai, China. METHODS Pregnant women were recruited between April 2004 and December 2005 in Jiaxing City, Suzhou City, Changshu County, and Haining County. All participants could have 3 sonographic examinations performed by specially trained physicians regardless of medical indication: a fetal sonographic screen and fetal echocardiography between 20 and 28 weeks' gestation and neonatal echocardiography. Diagnoses of congenital heart defects were made on the basis of review of all available scans by an international group of experts in pediatric cardiology. Prevalence rates were calculated per 1000 births. RESULTS Among 4006 scanned fetuses and neonates, there were 75 congenital heart defects, including 12 major defects. The observed prevalence for all congenital heart defects was 18.7 (95% confidence interval, 14.8-23.5) per 1000 births, and the prevalence for major defects was 3.0 (95% confidence interval, 1.6-5.2) per 1000 births. The most common defects were ventricular septal defects (n = 47 [62.7%]), atrial septal defects (n = 14 [18.7%]), tetralogy of Fallot (n = 4 [5.3%]), and hypoplastic left heart syndrome (n = 3 [4.0%]). CONCLUSIONS The prevalence of all congenital heart defects in the 4 areas of China studied was higher than that reported in other countries, with ventricular septal defects being the most frequent defects. Our data likely reflect a better estimate of the total prevalence of congenital heart defects in China than reported previously.
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Affiliation(s)
- Yali Zhang
- School of Public Health, Peking University Health Science Center, 38 Xueyuan Rd, Haidian District, 100191 Beijing, China.
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Crider KS, Zhu JH, Hao L, Yang QH, Yang TP, Gindler J, Maneval DR, Quinlivan EP, Li Z, Bailey LB, Berry RJ. MTHFR 677C->T genotype is associated with folate and homocysteine concentrations in a large, population-based, double-blind trial of folic acid supplementation. Am J Clin Nutr 2011; 93:1365-72. [PMID: 21508090 DOI: 10.3945/ajcn.110.004671] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The methylenetetrahydrofolate reductase (MTHFR) genotype is associated with modification of disease and risk of neural tube defects. Plasma and red blood cell (RBC) folate and plasma homocysteine concentrations change in response to daily intakes of folic acid supplements, but no large-scale or population-based randomized trials have examined whether the MTHFR genotype modifies the observed response. OBJECTIVE We sought to determine whether the MTHFR 677C→T genotype modifies the response to folic acid supplementation during and 3 mo after discontinuation of supplementation. DESIGN Northern Chinese women of childbearing age were enrolled in a 6-mo supplementation trial of different folic acid doses: 100, 400, and 4000 μg/d and 4000 μg/wk. Plasma and RBC folate and plasma homocysteine concentrations were measured at baseline; after 1, 3, and 6 mo of supplementation; and 3 mo after discontinuation of supplementation. MTHFR genotyping was performed to identify a C→T mutation at position 677 (n = 932). RESULTS Plasma and RBC folate and homocysteine concentrations were associated with MTHFR genotype throughout the supplementation trial, regardless of folic acid dose. MTHFR TT was associated with lower folate concentrations, and the trend of TT < CC was maintained at even the highest doses. Folic acid doses of 100 μg/d or 4000 μg/wk did not reduce high homocysteine concentrations in those with the MTHFR TT genotype. CONCLUSION MTHFR genotype was an independent predictor of plasma and RBC folate and plasma homocysteine concentrations and did not have a significant interaction with folic acid dose during supplementation. This trial was registered at clinicaltrials.gov as NCT00207558.
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Affiliation(s)
- Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Crider KS, Bailey LB, Berry RJ. Folic acid food fortification-its history, effect, concerns, and future directions. Nutrients 2011; 3:370-84. [PMID: 22254102 PMCID: PMC3257747 DOI: 10.3390/nu3030370] [Citation(s) in RCA: 340] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 02/21/2011] [Accepted: 03/11/2011] [Indexed: 01/16/2023] Open
Abstract
Periconceptional intake of folic acid is known to reduce a woman’s risk of having an infant affected by a neural tube birth defect (NTD). National programs to mandate fortification of food with folic acid have reduced the prevalence of NTDs worldwide. Uncertainty surrounding possible unintended consequences has led to concerns about higher folic acid intake and food fortification programs. This uncertainty emphasizes the need to continually monitor fortification programs for accurate measures of their effect and the ability to address concerns as they arise. This review highlights the history, effect, concerns, and future directions of folic acid food fortification programs.
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Affiliation(s)
- Krista S. Crider
- The Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30033, USA;
- Author to whom correspondence should be addressed; ; Tel.: +1-404-498-3893
| | - Lynn B. Bailey
- The Food Science and Human Nutrition Department, University of Florida, Gainesville, FL 32611, USA;
| | - Robert J. Berry
- The Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30033, USA;
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Yeung LF, Cogswell ME, Carriquiry AL, Bailey LB, Pfeiffer CM, Berry RJ. Contributions of enriched cereal-grain products, ready-to-eat cereals, and supplements to folic acid and vitamin B-12 usual intake and folate and vitamin B-12 status in US children: National Health and Nutrition Examination Survey (NHANES), 2003-2006. Am J Clin Nutr 2011; 93:172-85. [PMID: 21084645 DOI: 10.3945/ajcn.2010.30127] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND US children consume folic acid from multiple sources. These sources may contribute differently to usual intakes above the age-specific tolerable upper intake level (UL) for folic acid and to folate and vitamin B-12 status. OBJECTIVE We estimated usual daily folic acid intakes above the UL and adjusted serum and red blood cell folate, serum vitamin B-12, homocysteine, and methylmalonic acid (MMA) concentrations in US children by age group and by the following 3 major folic acid intake sources: enriched cereal-grain products (ECGP), ready-to-eat cereals (RTE), and supplements containing folic acid (SUP). DESIGN We analyzed data in 4 groups of children aged 1-3, 4-8, 9-13, and 14-18 y from the National Health and Nutrition Examination Survey (NHANES), 2003-2006 (n = 7161). RESULTS A total of 19-48% of children consumed folic acid from ECGP only. Intakes above the UL varied from 0-0.1% of children who consumed ECGP only to 15-78% of children who consumed ECGP+RTE+SUP. In children aged 1-8 y, 99-100% of those who consumed ≥ 200 μg folic acid/d from supplements exceeded their UL. Although < 0.5% of children had folate deficiency or low vitamin B-12 status, the consumption of RTE or SUP with folic acid was associated with higher mean folate and vitamin B-12 concentrations and, in some older children, with lower homocysteine and MMA concentrations. CONCLUSIONS Our data suggest that the majority of US children consume more than one source of folic acid. Postfortification, the consumption of RTE or SUP increases usual daily intakes and blood concentrations of folate and vitamin B-12.
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Affiliation(s)
- Lorraine F Yeung
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Berry RJ, Cogswell ME, Yeung LF, Tinker SC, Bailey LB. Reply to AD Smith. Am J Clin Nutr 2010. [DOI: 10.3945/ajcn.2010.29346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tinker SC, Cogswell ME, Devine O, Berry RJ. Folic acid intake among U.S. women aged 15-44 years, National Health and Nutrition Examination Survey, 2003-2006. Am J Prev Med 2010; 38:534-42. [PMID: 20347553 DOI: 10.1016/j.amepre.2010.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 11/06/2009] [Accepted: 01/11/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND In 1998, the IOM recommended all women capable of becoming pregnant consume 400 microg of folic acid daily to prevent neural tube defects (NTDs). PURPOSE This paper aims to describe how different sources of folic acid contribute to achieving the recommended usual daily intake. METHODS Data on 2617 nonpregnant U.S. women aged 15-44 years from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys were analyzed in 2009. The usual daily folic acid intake from diet and supplements accounting for measurement error; the proportion of women consuming the recommended usual intake; and the adjusted associations of recommended intake with multiple characteristics were estimated. RESULTS Overall, 24% of nonpregnant U.S. women of childbearing age consumed the recommended usual intake (95% CI=20%, 27%). Intake was highest among non-Hispanic white women (30%), followed by Mexican-American (17%) and non-Hispanic black women (9%). Among women who used supplements with folic acid, 72% (95% CI=65%, 79%) consumed the recommended usual intake. Use of supplements was the strongest determinant (unadjusted prevalence ratio [PR]: 10.2, 95% CI=7.1, 14.7) of recommended intake, mediating associations of other characteristics. Among the 68% of women who did not use supplements, consumption of cereals with folic acid and having diabetes were the strongest determinants of recommended usual intake (PRs=20.2 and 0.10, respectively). CONCLUSIONS Given that consumption of folic acid is an important public health goal to prevent NTDs, an evaluation of strategies, beyond recommendations that women consume supplements, is needed.
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Affiliation(s)
- Sarah C Tinker
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia 30333, USA.
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Crider KS, Bean C, Berry RJ, Rasmussen S, Yang T, Hao L, Zhu L, Zhu J, Maneval D, Quinlivan E, Bailey L, Brant J. Are there changes in DNA methylation at tumor suppressor, imprinting or oncogenes in response to chronic consumption and withdrawal of folic acid? FASEB J 2010. [DOI: 10.1096/fasebj.24.1_supplement.107.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Krista Stimson Crider
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Christopher Bean
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Robert J Berry
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Sonja Rasmussen
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | | | - Ling Hao
- National Center for Maternal and Infant HealthPeking University Health Sciences CenterBeijingPeople's Republic of China
| | - Li Zhu
- National Center for Maternal and Infant HealthPeking University Health Sciences CenterBeijingPeople's Republic of China
| | - Jainghui Zhu
- National Center for Maternal and Infant HealthPeking University Health Sciences CenterBeijingPeople's Republic of China
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Tinker SC, Cogswell ME, Devine OJ, Berry RJ. Usual Folic Acid Intake among US Women Aged 15–44 Years, NHANES, 2003–2006. FASEB J 2010. [DOI: 10.1096/fasebj.24.1_supplement.560.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah C Tinker
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Mary E Cogswell
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Owen J Devine
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
| | - Robert J Berry
- National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaGA
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Cogswell M, Pfeiffer C, Tinker S, Berry RJ. Usual folic acid intake and folate status in US women aged 12–49 years, National Health and Nutrition Examination Survey (NHANES), 2001–2006. FASEB J 2010. [DOI: 10.1096/fasebj.24.1_supplement.560.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mary Cogswell
- National Center for Birth Defects and Developmental Disabilities
| | - Christine Pfeiffer
- National Center for Environmental HealthCenters for Disease Control and PreventionAtlantaGA
| | - Sarah Tinker
- National Center for Birth Defects and Developmental Disabilities
| | - Robert J Berry
- National Center for Birth Defects and Developmental Disabilities
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Abstract
Background After randomized, controlled trials established that consumption of folic acid before pregnancy and during the early weeks of gestation reduces the risk of a neural tube defect (NTD)-affected pregnancy, the United States Public Health Service recommended in 1992 that all women capable of becoming pregnant consume 400 μg folic acid daily. In 1998, folic acid fortification of all enriched cereal grain product flour was fully implemented in the United States and Canada. Objective To provide guidance on national fortification of wheat and maize flours to prevent 50 to 70% of the estimated 300,000 NTD-affected pregnancies worldwide. Methods An expert workgroup reviewed the latest evidence of effectiveness of folic acid flour fortification and the safety of folic acid. Results Recent estimates show that in the United States and Canada, the additional intake of about 100 to 150 μg/day of folic acid through food fortification has been effective in reducing the prevalence of NTDs at birth and increasing blood folate concentrations in both countries. Most potential adverse effects associated with folic acid are associated with extra supplement use not mandatory fortification. Fortification of wheat flour has a proven record of prevention in other developed countries. In 2009, 51 countries had regulations written for mandatory wheat flour fortification programs that included folic acid. Conclusions NTDs remain an important cause of perinatal mortality and infantile paralysis worldwide. Mandatory fortification of flour with folic acid has proved to be one of the most successful public health interventions in reducing the prevalence of NTD-affected pregnancies. Most developing countries have few, if any, common sources of folic acid, unlike many developed countries, which have folic acid available from ready-to-eat cereals and supplements. Expanding the number of developed and developing countries with folic acid flour fortification has tremendous potential to safely eliminate most folic acid-preventable NTDs.
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Yang Q, Cogswell ME, Hamner HC, Carriquiry A, Bailey LB, Pfeiffer CM, Berry RJ. Folic acid source, usual intake, and folate and vitamin B-12 status in US adults: National Health and Nutrition Examination Survey (NHANES) 2003-2006. Am J Clin Nutr 2010; 91:64-72. [PMID: 19828716 DOI: 10.3945/ajcn.2009.28401] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND US adults have access to multiple sources of folic acid. The contribution of these sources to usual intakes above the tolerable upper intake level (UL) (1000 microg/d) and to folate and vitamin B-12 status is unknown. OBJECTIVE The objective was to estimate usual folic acid intake above the UL and adjusted serum and red blood cell folate, vitamin B-12, methylmalonic acid, and homocysteine concentrations among US adults by 3 major folic acid intake sources-enriched cereal-grain products (ECGP), ready-to-eat cereals (RTE), and supplements (SUP)-categorized into 4 mutually exclusive consumption groups. DESIGN We used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 (n = 8258). RESULTS Overall, 2.7% (95% CI: 1.9%, 3.5%) of adults consumed more than the UL of folic acid. The proportions of those who consumed folic acid from ECGP only, ECGP+RTE, ECGP+SUP, and ECGP+RTE+SUP were 42%, 18%, 25%, and 15%, respectively. Of 60% of adults who did not consume supplements containing folic acid (ECGP only and ECGP+RTE), 0% had intakes that exceeded the UL. Of 34% and 6% of adults who consumed supplements with an average of < or = 400 and >400 microg folic acid/d, <1% and 47.8% (95% CI: 39.6%, 56.0%), respectively, had intakes that exceeded the UL. Consumption of RTE and/or supplements with folic acid was associated with higher folate and vitamin B-12 and lower homocysteine concentrations, and consumption of supplements with vitamin B-12 was associated with lower methylmalonic acid concentrations (P < 0.001). CONCLUSION At current fortification levels, US adults who do not consume supplements or who consume an average of < or =400 microg folic acid/d from supplements are unlikely to exceed the UL in intake for folic acid.
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Affiliation(s)
- Quanhe Yang
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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