Folic Acid Supplementation: Reducing the Risk of Neural Tube Defects - PowerPoint PPT Presentation

Loading...

PPT – Folic Acid Supplementation: Reducing the Risk of Neural Tube Defects PowerPoint presentation | free to view - id: f51a-NTRmN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Folic Acid Supplementation: Reducing the Risk of Neural Tube Defects

Description:

Most babies with NTD's are born to women with no risk factors ... Hispanic infants, particularly US-born Mexicans are at greatest risk for NTDs ... – PowerPoint PPT presentation

Number of Views:938
Avg rating:3.0/5.0
Slides: 69
Provided by: swedish
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Folic Acid Supplementation: Reducing the Risk of Neural Tube Defects


1
Folic Acid Supplementation Reducing the Risk of
Neural Tube Defects
  • Pregnancy Foresight Project, Swedish Medical
    Center, Seattle, WA
  • Based on a presentation developed by, and with
    permission from, Karla Damus, RN, MSPH, PhD
  • Dept Ob/Gyn and Womens Health
  • Albert Einstein College of Medicine
  • Senior Research Associate - March of Dimes
  • kdamus_at_marchofdimes.com

2
The Continuum of Reproductive Health
  • Improving health of infants requires focusing on
    the entire spectrum of reproductive health which
    extends from prior to conception through the
    first year of an infants life and throughout the
    womans childbearing years
  • Folic acid supplementation is a key preconception
    factor in preventing neural tube defects

3
Most Pregnancies Are Unplanned!
  • About half of all pregnancies are unplanned
  • Unplanned pregnancies are most common among teens
  • Depending on the age of the woman, the percentage
    of unplanned pregnancies varies from 33 78

4
Unintended Pregnancies United States, 1994
Percent
Source National Survey of Family Growth,
1995 Prepared by March of Dimes Perinatal Data
Center, 1998
5
Part I
  • Definition and Epidemiology of
  • Neural Tube Defects

6
Neural Tube Defects
Anencephaly absence of the majority of the brain
and surrounding area at birth. Spina Bifida
(open spine) defect of the spine that can
cause paralysis of varying degrees.
7
(No Transcript)
8
(No Transcript)
9
Open Neural Tube Defect Neural tube
defects are fairly common. Here is a large
meningomyelocele. Such defects can be suggested
by a elevated maternal serum alpha-fetoprotein.
10
Anencephaly The eyes appear proptotic
with anencephaly because of the lack of the
skull. Note the low set external ear.
11
Epidemiology of NTDs
  • Occur in about 1-2/1000 births in the US
  • Most babies with NTDs are born to women with no
    risk factors
  • Racial/ethnic variation in incidence of NTDs

12
Secular trends of spina bifida at birth per
10,000 births, North America, 1890-1990.
30
25
Boston Providence
20
Rate per 10,000 births
15
Atlanta
10
Rochester
5
NY
U.S.
1930
1940
1890
1900
1910
1920
1950
1960
1970
1980
1990
Year
13
Prevalence of Anencephaly and Spina
Bifida Metropolitan Atlanta Congenital Defects
Program 1968 - 2001
25
Multivitamin Change - 1973
Prenatally Diagnosed Cases
Hospital-based LB SB Babies
20
Prenatal Diagnosis - 1984
15
Before Fortification
After Fortification
Rate per 10,000
10

5
0
68
71
74
77
80
83
86
89
92
95
98
01
Year of Birth
14
Relative Risk for Spina Bifida By
Race/Ethnicity, U.S., 1983-1990
Based on 16 state-based birth defects
surveillance systems Source CDC, Teratology,
July/August 1997 Prepared by March of Dimes
Perinatal Data Center, 1999
15
Infant Deaths due to NTDs by Race/Ethnicity,
United States, 1996
Rate per 100,000 live births
Source National Center for Health Statistics,
1996 period linked birth/infant death
file Prepared by March of Dimes Perinatal Data
Center, 1999
16
NTDs Among Hispanic Infants
  • Hispanic infants, particularly US-born Mexicans
    are at greatest risk for NTDs
  • In 6 selected states, Hispanic infants had a
    significantly higher rate of NTDs than
    non-Hispanic white infants

17
Part II
  • Folic Acid Supplementation to Prevent NTDs

18
What is Folic Acid?
  • Folate is a water-soluble B vitamin derived from
    folate polyglutamates
  • Found in green leafy vegetables, organ meats,
    some fresh fruits
  • Susceptible to destructive oxidation with 50-95
    destroyed in canning and cooking

19
Definitions
  • FOLIC ACID (FA) pteroylglutamic acid synthetic,
    used in fortified foods supplements
  • FOLATES pteroyl - poly - glutamic acid appear
    naturally in foods or are formed in vivo

20
Structure of Tetrahydropteroylpoly-g-glutamate
Folates
Folic Acid
Source Shane. Folate Chemistry and Metabolism.
21
Folic Acid (FA) and Its Relationship to NTDs
  • FA deficiency described as tropical macrocytic
    anemia in the 1930s
  • Pure FA isolated from spinach in 1945 (folium-
    Latin for leaf)
  • NTDs linked to antifolates, 1950s
  • RBC folate decrease in NTD mothers, 1976
  • Essentially all clinical studies of FA, 1981-99
    reported a 50-85 decrease in NTDs

22
Multivitamin Folic Acid Neural Tube Defect
Studies, 1980-1999
'80-Smithells
'81-S. Wales
'88-Atlanta
'89-W. Australia
'89-CA/Illinois
'89-Boston
'90-Cuba
'91-UK-MRC
Randomized trials
'92-Hungary
Non-randomized trials
'93-New England
Observational studies
'95-California
'99-P.R. China
1.0
0.0
0.2
0.4
0.6
0.8
1.2
1.4
1.6
1.8
2.0
2.2
2.4
Risk Ratio With 95 Confidence Intervals
23
FA Role in Metabolism
  • Coenzyme in 1-carbon transfer reactions
  • biosynthesis of purines pyrimidines
    (DNA/RNA)
  • biosynthesis of serine methionine
  • degradation of histidine
  • degradation of homocysteine

24
Folic Acid Recommendations
  • USPHS September, 1992
  • All women of childbearing potential should
  • consume 0.4 mg (400 micrograms) of folic acid
    daily
  • Food Nutrition Board of IOM, 1998
  • Men (14 yr older) 400 µg any source
  • Women (14 yr older) 400 µg synthetic food
  • Pregnancy 600 µg synthetic food
  • Lactation 500 µg any source

25
NTD rate per 1,000 births by red cell folate
12
10
8
NTD Rate per 1,000 Births
6
4
2
0
400
600
800
200
Red Cell Folate, ng/mL

Daly et al., JAMA, 19952741698 1702.

26
Bioavailability of Food Folates
  • Folates are lost from foods by - preparation
    (heat, oxidation, leaching into
  • water) - inhibition of essential gut
    enzymes by
  • inhibitors in food, extremes in pH and
    rapid
  • transit time
  • Under controlled conditions, 30-80 of folate is
    absorbed
  • One careful 92-day metabolic study found no more
    than 50 bioavailability of various food folates

27
FA to Prevent NTDs
  • Diet
  • Fortification of grain products with folic acid
  • Multivitamin with 0.4 mg FA from before
  • conception through first 28 days

Remember 50 pregnancies unplanned
28
Dietary Folates/FA
Food Avg. µg in serving
Bioavailability ()
orange juice 109 43 spinach 102 63 turnip
greens 85 ? Asparagus 101 ? pinto beans 147
? beef liver 184 50 fortified bread (slice)
35 100 fortified
noodles 192 100 fortified brkf. Cereal 100 or
400 100
29
Consumption of Folic Acid Dietary
Folate Effect on Red Cell Folate, Ireland 1996.
Mean percentage change
Red cell folate mcg/L Pre- / post- intervention
Intervention method
Supplement 400 mcg FA
351 - 492
40 p
Fortified food 400 mcg FA
326 - 498
52 p
Dietary folate 400 mcg folate
366 - 394
11, NS
345 - 399
Dietary advice
16, NS
326 - 335
Controls
5
Cuskelly et al., Lancet 1996.
30
Drugs that Interfere with Folic Acid
  • Valproic acid (Depakene)- anitconvulsant
  • Phenobarbital, phenytoin (Dilantin),
    carbamazapine (Tegretol), primidone (Mysoline)-
    anit-seizure
  • Cimetidine (Tagamet)- for heartburn and reflux
  • Beta blockers and calcium-channel blockers used
    for HBP and certain disorders
  • Cholestyramine (Locholest, Questran)-
    cholesterol
  • Antibiotic combination of trimethoprim and a
    sulfonamide (Bactrim, Septra) commonly used for
    UTI
  • Triamterene (Dyrenium)- diuretic for HBP
  • Sulfasalazine (Azulfidine)- for ulcerative
    colitis other inflammatory conditions

31
Conditions that Require More Folic Acid
  • History of NTD affected pregnancy (4.0mg daily)
  • History of NTD
  • Diabetes
  • Alcoholism, alcohol abuse
  • Smoking
  • Illicit drug use
  • Obesity
  • Absorption disorders
  • Infection with HPV
  • Some prescribed medications
  • Some OTC (NSAIDs)

32
Folic Acid Deficiency May Reduce Risk of Health
Problems
  • Spontaneous pregnancy loss (recurrent)
  • Low birth weight and prematurity
  • Atherosclerotic vascular disease (stroke, CAD)
  • Colorectal and cervical cancer
  • Acute Leukocytic Leukemia
  • Alzheimers Disease

33
Summary Folic Acid - Neural Tube Defect Science
  • Increasing blood/RBC folate concentration
    decreases the risk of NTDs
  • Consumption of 400 micrograms of folic acid daily
    prior to conception - as part of a healthy diet -
    decreases the risk of NTDs in all populations up
    to 70
  • Ethnic and genetic variations in NTD risk remain
    poorly characterized

34
China-U.S. Collaborative Folic Acid Project
for NTD Prevention, 1993-1996.
Beijing
Hebei Province
Shanxi Province
Jiangsu Province
Shanghai
Zhejiang Province
35
China Folic Acid Community Intervention Program
to Prevent the Occurrence of Neural Tube
Defects, 1993 - 1996
Intervention 400 mcg folic acid supplement
daily
No Pills
Pills
5.0
4.0
85
3.0
41
NTD Rate/1000
2.0
1.0
0.0
North
South
Berry RJ, et al., NEJM 1999 3411485-90
36
Multivitamin Use/Folic Acid Congenital Heart
Defects, 1995-2000
Birth Defect Type
Randomized trial
Observational studies
All heart defects
Outflow tract
Septal defects
Coarctation
Risk Ratio and 95 CI
37
Multivitamin Use/Folic Acid Selected Non-NTD,
Non-CHD Birth Defects
All defects except NTD
Randomized trial
Czeizel
Non-randomized trial
Observational studies
Hayes
Oro-facial clefts
Shaw
Tolarova
Czeizel
Werler
CL /- CP
CP alone
Shaw
Limb
Yang
Werler
Li
Urinary tract
Werler
1.0
0.0
0.2
0.4
0.6
0.8
1.2
1.4
1.6
1.8
2.0
5.0
Risk Ratio and 95 CI
38
Part III
  • Educating Physicians and Patients about Folic
    Acid Supplementation

39
Three Approaches for Changing Behavior
Women
Professional Education
Community Action
Mass Media
40
Folic Acid to Prevent NTDs
  • Behavior Strategy Multivitamin containing 400
    micrograms folic acid - as part of a healthy
    diet - beginning before conception
  • Remember neural tube closes by day 28 pregnancy
  • Legislative Strategy Increase consumption of
    folic acid by fortification of grain products
    with folic acid - required of enriched grain
    products since January 1998
  • Remember 50 pregnancies unplanned

41
March of Dimes Folic Acid Campaign Evaluation
  • National telephone surveys conducted by Gallup in
    1995, 1997, 1998, 2000 and 2002
  • Surveys designed to evaluate womens changing
    awareness and reported behaviors related to folic
    acid and other pre-pregnancy health issues
  • Targeted English speaking women of reproductive
    age (18 to 45 years)

42
MOD FA Campaign Evaluation, cont.
  • 1995 Survey N2010
  • 1997 Survey N2001
  • 1998 Survey N2115
  • 2000 Survey N2000
  • 2002 Survey N2004
  • oversampled women who were pregnant in past 2
    years
  • Based on these sample sizes 95 confident that
    the margin of error attributable to sampling and
    other random effects could be /- 3 percentage
    points
  • The margin of error is greater for any subset
    analyses
  • Error bias can also be introduced into opinion
    polls due to question wording and practical
    difficulties in obtaining responses from
    telephone interviews

43
Folic Acid Awareness Have You Heard of Folic Acid?
Percentage of women ages 18-45
44
Folic Acid-Specific Knowledge March of Dimes
Folic Acid Survey
Percentage of women ages 18-45
45
Daily Use of Vitamin Containing Folic Acid
March of Dimes Folic Acid Survey
Percentage of women ages 18-45
Goal for non-pregnant women
46
Characteristics of Women Taking Daily Supplement
with Folic Acid March of Dimes Folic Acid Survey,
2002
47
Source of Information on Folic Acid March of
Dimes Folic Acid Survey, Selected Years
Percentage of women aware of folic acid
48
Reasons Why Women Do Not Take a Multivitamin
Daily March of Dimes Folic Acid Survey, 2002
49
Things Women Reported Might Encourage them to
Take a Multivitamin Daily March of Dimes Folic
Acid Survey, 2002
50
Folic Acid Knowledge and Behavior 1995 and 2002
Percentage of women ages 18-45
51
Summary
  • Between 1995 and 2002, folic acid awareness among
    women of childbearing age increased from 52 to
    80, meeting the March of Dimes goal for this
    objective
  • Despite an increase in awareness, in 2002
  • 1 in 5 women knew that folic acid can prevent
    birth defects
  • 9 out of 10 women did not know that folic acid
    should be taken prior to to pregnancy
  • In 2002, 1 in 3 women (33) reported consuming a
    multivitamin containing folic daily

52
Summary (contd)
  • When asked where they learned about folic acid
  • More than half of women reported the media as
    their source of information
  • Only 25 of women identified their health care
    provider
  • More than one-third (34) said they would be more
    likely to take a vitamin supplement daily if
    their health care provider advised them to do so

53
Summary (contd)
  • In 2002, nearly one in four women (24) did not
    take a multivitamin daily because they forget to
    take them
  • Most women (90) who did not take a multivitamin
    daily said they would be very likely or somewhat
    likely to do so if their health care provider
    recommended it

54
Folic Acid Education in Washington State
  • Surveyed physicians and patients at 6 Family
    Practice and Obstetric clinics
  • Rural and urban settings
  • Included 34 physicians, 120 pregnant women, 104
    non-pregnant women

55
Folic Acid Education in Washington State
  • 74 of physicians do not discuss folic acid
    supplementation with their non-pregnant patients
  • 53 of non-pregnant patients did not recall a
    discussion of folic acid supplementation

56
Folic Acid Education in Washington State
  • More than 80 of physicians discuss folic acid
    supplementation with their pregnant patients
  • More than 80 of pregnant patients recall a
    discussion of folic acid supplementation with
    their physician

57
Folic Acid Education in Washington State
  • Folic acid education is reaching the wrong
    group of women, i.e. supplementation during
    pregnancy is too late to prevent NTDs
  • Goal must be to reach pregnancy
    non-contemplators, and those seeking to become
    pregnant

58
Part IV Folic Acid Supplementation in the
Hispanic Community
  • Sociocultural Issues

59
NTDs The Hispanic Community
  • NTDs more common in Hispanic community than
    other US ethnic groups
  • Primary Care Providers should focus extra
    attention on educating Hispanic community about
    preconception folic acid supplementation

60
Focus Groups Findings in the Hispanic Community
  • A summary of the salient points and
    recommendations for Primary Care Providers

61
Focus Group Findings Hispanic Women
  • Sense of fatalism
  • Highlighting Latinas greater risk creates an
    overwhelming emotional response
  • Vitamins are perceived negatively
  • Most women accept that one day they will get
    pregnant
  • 18-24 year olds are attracted to health and
    beauty message

62
Hispanic Women Challenges
  • Hispanic women less likely to have heard the
    folic acid message, in Spanish or English
  • Less likely to know about importance of folic
    acid before pregnancy
  • Hispanic women less likely to take vitamin
    supplement, though there is considerable
    variation in this behavior
  • Fear of weight gain from vitamins

63
Hispanic Women Opportunities
  • Hispanic women receptive to message of before
    pregnancy,
  • Very willing to make behavior change for health
    of future babies
  • Women acknowledge diet is worse in US and need to
    make changes
  • Younger Hispanic women link general health to
    beauty
  • Open to hear weight gain has no basis in fact

64
Hispanic Women Opportunities for the Primary
Care Provider
  • Emphasize importance of good diet, healthy
    mothers and healthy babies
  • Advise women that vitamins do not cause weight
    gain
  • Vitamins (i.e. folic acid) before pregnancies are
    particularly important for mothers-to-be

65
Hispanic Women Opportunities for the Primary
Care Provider
  • Vitamins can improve the health of the mother
    even when she is not pregnant
  • Literate and low literate Hispanic women like
    messages in posters and fotonovelas
  • Waiting room, exam rooms, and bathrooms good
    place for posters and fotonovelas

66
Women Folic Acid From Freshmen Through the
Forties
  • The take-home message for all women during their
    reproductive years

67
The March of Dimes, the Centers for Disease
Control all members of the National Council on
Folic Acid recommends that -- All women of
childbearing potential consume 400 micrograms of
folic acid every day as part of a healthy diet.
68
(No Transcript)
About PowerShow.com