What is the Minimum

Effective Dose of Folic Acid

for Preventing NTDs?
James L. Mills, M.D., M.S.
Caroline Signore, M.D.
NICHD
Minimum Effective Dose:
Outline

Why is this a difficult question to

answer?
How can we estimate how much folic
acid is needed?
Actual experience with fortification
Conclusions
Minimum Effective Dose:

Why is This a Difficult

Question to Answer?
 The Definitive Study
Test reduced doses until NTD rates rise
400 g Protective
300 g Protective
200 g Protective
100 g Not Protective

UNETHICAL
 What do we Know About
Effective Dose?
Clinical trial dosesdefinitely work, but
too high
MRC, 1991: 4 mg
Czeizel, 1992: 800 g

Case control study dosespresumed to

work, but are lower doses effective?
Most U.S. studies reported on 400 g
 Complication: Genetic
Differences in Folate
Metabolism
MTHFR Genotype Mean RCF (g/L)

CC 347

CT 314

TT 284*

Molloy AM, et al., Lancet, 1997; *p<0.01

How Can We Estimate How
Much Folic Acid is Needed?
 Maternal Red Cell Folate vs.
NTD Risk in Dublin

Study Design
Reviewed early pregnancy maternal RCF
from nested case-control study of 84 cases
NTD and 266 normal controls
Logistic regression analysis to examine
relationship between RCF and NTD risk

Daly L, et al., JAMA, 1995

 Maternal RCF vs. NTD Risk
in Dublin
Continuous dose-
response
relationship

RCF < 150 ng/mL

Risk 6.6/1000

RCF > 400 ng/mL

Risk 0.8/1000

Daly L, et al., JAMA, 1995

 Maternal RCF vs. NTD Risk
in Dublin

Curve continues
down

Risk 0.2/1000?

Daly L, et al., JAMA, 1995

 Maternal RCF vs. NTD Risk
in Dublin
Curve flattens out
(genetic Mendelian
defects)

Risk 0.5/1000?

Unable to confirm
optimal RCF level,
but 400 ng/mL is
highly protective
Daly L, et al., JAMA, 1995
How Much Folic Acid is
Needed to Raise RCF to
Protective Levels?
 NICHD/Trinity
College/Health Research
Board Trial
Study design
Randomized, placebo-controlled trial
121 patients randomized to receive
placebo, 100 g, 200 g, or 400 g folic
acid/d
Compliance assessed by sign-in sheets
over 6 mo. study period

Daly S, et al., Lancet, 1997

 Results
Initial Final Median
Group N Median Median Change
RCF g/L RCF g/L g/L
Placebo 19 335 311 -12

100 g/d 22 309 375* 67

200 g/d 28 311 475* 130

400 g/d 26 350 571* 200

Daly S, et al. Lancet, 1997 * p < 0.001

 RCF and NTD Risk
Calculation

Initial and post-treatment RCF values

substituted into regression equation
from L. Daly, et al. to derive estimated
change in NTD risk

Daly S, et al. Lancet, 1997

 Results
Treatment Estimated
N Reduction in
Group NTD Risk
Placebo 19 0

100 g/d 22 22%

200 g/d 28 41%

400 g/d 26 47%

Daly S, et al. Lancet, 1997

 Minimum estimate
(considering non-compliance):

~200 g/d will

decrease NTD rate by 41%
 Literature Review and
Calculation of Folic Acid
Effect on Serum Folate

Mathematical model based on trials of

folic acid supplementation on plasma
folate
Calculated a dose-response equation

Wald N, et al. Lancet, 2001.

 Quantifying the Effect of
Folic Acid
Effect of Dose of Folic Acid on Change in
Serum Level by Age
30
Change in Serum

25
Folate (ng/mL)

20
15 Age 40-65
Age 20-35
10
5
0
0 0.2 0.4 0.6 0.8 1
Dose (mg/day)

Wald N, et al. Lancet, 2001.

Predicted plasma folate levels were
far lower than actual levels in
NHANES 1999-2000

The effects were inconsistent

by age
 Explanations

Non-compliance would lead to an

underestimation of effect
Studies selected for the model had
insufficient duration of exposure to
reach stable serum folate levels,
resulting in an underestimation of effect
 Exposure Time Required to
Reach Stable Folate Levels
14
12
Larger doses of folic
10
acid require a longer
Weeks

8
6 period to achieve
4 steady serum or
2 plasma
0
<=200 ug >=400 ug concentration
Daily Dose of Folic
Acid

Quinlivan EP and Gregory JF, Am J Clin Nutr, 2003

 Was Duration of Exposure
Sufficient to Produce Stable
Levels?
Adequate Inadequate
Duration Duration
Mean Age
20-35
2 (33%) 4 (67%)
Mean Age
40-65
4 (50%) 4 (50%)

TOTAL 6 (43%) 8 (57%)

 Differences May be Due to
Inadequate Time for Stabilization
Effect of Dose of Folic Acid on Change in
Serum Level by Age
30
Change in Serum

25
Folate (ng/mL)

20
15 Age 40-65
Age 20-35
10
5
0
0 0.2 0.4 0.6 0.8 1
Dose (mg/day)
Wald N, et al. Lancet, 2001.
Studies used in Walds model led
to an underestimation of folic
acid effect on serum folate
What Are Current Exposure
Levels?
 Estimated Folic Acid (ug/day)

0
100
200
300
FD
A
,1
99
3

C
au
d ill
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C 00
ho 1
u m
en
ko
vi
tc
h,
20
02

Q
ui
nl
iv
an
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00
3
Fortification
Estimating Daily
Folic Acid Intake After

Clinical
Theoretical
 How Has Fortification
Affected Folate Levels?
 Serum Folate Levels
Pre- and Post-Fortification
13.0
CDC 4.8 8.2 171%

18.7
Lawrence 12.6 6.1 48%
10.0
Jacques 4.6 5.4 117%

0 5 10 15 20
Serum Folate (ug/L)
 RCF Levels
Pre- and Post-Fortification

264
CDC 160 104 65%

327
Ray 233 94 40%

0 100 200 300 400

Red Cell Folate (ng/mL)
 Summary

Fortification probably increases folic

acid exposure by 200 g/day or more

Serum and red cell folate levels have

risen dramatically (by 171% and 65%,
respectively)
Actual Experience with
Fortification
 The Gold Standard

How much has the additional

200 g/day decreased NTD rates?
 Estimates Vary Because of
Ascertainment Problems

Method of Detection Percent

Ultrasonography 55%

MSAFP 25%

AF AFP 3%

Delivery 17%

Stevenson RE, et al., Pediatrics, 2000

 Experience: Nova Scotia
Population based study of all NTDs
from live births, stillbirths, and
terminations
Compared pre- and post-fortification at
150 g/100 g
Total NTD incidence fell by 54%
2.58/1000 1.17/1000

Persad VL, et al., CMAJ, 2002

 Estimated Effect

Canada: fortification at 150 g /100 g

grain 50% reduction

U.S. data with comparably ascertained

cases are still not widely available
Conclusions
 Conclusions

It is difficult to pinpoint the lowest

effective dose of folic acid
Data from Ireland indicate 200 g/day
will prevent at least 40% of NTDs
 Conclusions

Actual experience in Canada indicates

estimated doses of 200+ g/day will
prevent 50% or more
In the U.S., ~50% prevention may be
the maximum, or ~70% prevention may
be possiblehave we maxed out?
 Conclusions

Given food fortification and supplement use in

the U.S., many women will not need fortified
OCs
For women using supplements, fortified OCs
might put them over the IOMs recommended
limit
For other women, who do not take
supplements and who eat less fortified food,
fortified OCs could be beneficial