Shona Cawley

A review of European guidelines on periconceptional folic acid supplementation.

Strong evidence that folic acid (FA) prevents the majority of cases of neural tube defects (NTDs) has led to national organisations developing guidelines for women concerning periconceptional supplementation. In Europe, there is evidence of national variations in the incidence of NTDs, with a recent Irish study reporting an increase in the rate. This review compares the periconceptional FA supplementation guidelines between the different countries in Europe. An online search of country-specific guidelines produced before 2015 concerning periconceptional FA supplementation was conducted. If an English version was not available directly, the EUROCAT register was searched for the English version of the recommendations. We identified national guidelines from 20 European countries. Over half recommended that FA supplements be taken by women planning a pregnancy, but three recommended that they should be taken by all women of child-bearing age. Four guidelines recommended starting FA at least 4 weeks preconceptionally, but no country recommended starting FA at least 12 weeks preconceptionally as suggested by recently published studies. There is a need for further consideration of the duration of preconceptional FA supplementation specifically. The latest scientific evidence in this area should inform the development of European guidelines on FA, as there is wide variation in current recommendations. Overall, the wide variation in national guidelines concerning periconceptional FA supplementation may in part explain the differences in national rates of NTDs reported by EUROCAT. National guidelines on FA supplementation should be standardised across European countries.

Maternal folic acid supplementation trends 2009–2013

We analyzed trends in folic acid supplementation among women booking for antenatal care between 2009 and 2013.

An analysis of folic acid supplementation in women presenting for antenatal care.

BACKGROUND Neural tube defects (NTDs) are major congenital malformations that are potentially preventable if the woman takes periconceptional folic acid (FA) supplements. A recent report found that NTD incidence had increased in Ireland. This study examined the usage of FA supplementation in women presenting for antenatal care in a maternity hospital. METHODS Women were recruited at their convenience in the first trimester. Their clinical and sociodemographic details were computerized. Maternal weight and height were measured before calculating body mass index. Detailed FA questionnaires were completed under supervision of a trained researcher. RESULTS While 96.1% (n = 564) out of 587 reported that they took FA after they became pregnant, only 24.7% (n = 145) took it for >12 weeks preconceptionally as recommended. Only 5.7% (n = 6) of obese women took high-dose FA as recommended. On univariate analysis, the strongest predictors of preconceptional FA usage were higher maternal age, higher education and income, being married, being nulliparous, not smoking, infertility treatment and planned pregnancy. On multivariate analysis, both planned pregnancy and nulliparity were the most important predictors of preconceptional FA use. CONCLUSIONS Our study shows that current recommendations to prevent NTDs by FA supplementation pre-pregnancy are not being fully implemented in Ireland. We recommend a review of current public health policies on FA supplementation.

An estimation of periconceptional under-reporting of dietary energy intake

BACKGROUND The purpose of this cross-sectional study was to examine periconceptional misreporting of energy intake (EI) using the Willet food frequency questionnaire (WFFQ). METHODS Women were recruited in the first trimester. Women completed a semi-quantitative WFFQ. Maternal body composition was measured using eight-electrode bioelectrical impedance analysis. Under-reporters were those whose ratio of EI to their calculated basal metabolic rate fell below the calculated plausible threshold for their physical activity category. RESULTS The mean age was 30.1 ± 5.3 years (n = 524). The mean body mass index (BMI) was 25.4 ± 5.6 kg/m(2), and 16.6% were obese (BMI ≥ 30.0 kg/m(2)). Under-reported EI was observed in 122 women (23.3%) with no over-reporters in the sample. Under-reporters were younger (P < 0.001), less likely to have a normal BMI (P = 0.002) and more likely to be obese (P < 0.001) than plausible reporters. Under-reporters had higher percentage of body-fat and lower percentage of body fat-free mass (P < 0.001), were more likely to be at risk of relative deprivation (P = 0.001) and reported a higher percentage of EI from carbohydrate (P = 0.02) than plausible reporters. CONCLUSIONS Observed differences between under-reporters and plausible reporters suggest that the exclusion of these under-reporters represents an important potential source of bias in obesity research among women in the periconceptional period.

Knowledge about folic acid supplementation in women presenting for antenatal care

Background/Objectives:The incidence of neural tube defects (NTDs) in Ireland has increased in recent years. This study examines knowledge about folic acid (FA) supplementation for the prevention of NTDs among women presenting for antenatal care.Subjects/Methods:Women were recruited at their convenience in the first trimester after sonographic confirmation of an ongoing singleton pregnancy. A detailed questionnaire was completed under the supervision of a research dietitian. Clinical and socio-demographic details were collected.Results:Of the 587 women studied, 96% took FA during early pregnancy. Of these, 56.4% cited brain/spinal development or the prevention of brain/spinal defects, spina bifida or NTDs as the reason for taking FA. Multivariate analysis showed that women who were experiencing material deprivation or who were living in Ireland <5 years were least likely to be knowledgeable about the benefits of FA supplementation (P<0.05 for both). Over half (57.1%) of the women did not take FA preconceptionally. The main reason reported for not supplementing preconceptionally was that the woman did not expect to get pregnant (76.4%). Over one-third of women (35%), however, reported that they did not know they needed to take FA before becoming pregnant.Conclusions:These results highlight the need for a renewed public health campaign in Ireland about the importance of FA. As well as focusing on women who have recently come to live in Ireland, this campaign needs focus on women living in deprivation, as these are the women most at risk of having inadequate knowledge about the importance of FA in improving pregnancy outcomes.

Duration of periconceptional folic acid supplementation in women booking for antenatal care

OBJECTIVE To provide accurate estimates of the commencement time, duration and dosage of folic acid (FA) supplementation taken by Irish women in the periconceptional period. The study also aimed to establish the factors associated with optimal FA supplementation practices. DESIGN Cross-sectional observational study. Womens clinical and sociodemographic details were computerised. Maternal weight and height were measured before calculating BMI. Detailed FA supplementation questionnaires were completed under the supervision of a trained researcher. SETTING A large university maternity hospital, Republic of Ireland, January 2014-April 2016. SUBJECTS Women (n 856) recruited at their convenience in the first trimester. RESULTS While almost all of the women (97 %) were taking FA at enrolment, only one in four women took FA for at least 12 weeks preconceptionally (n 208). Among the 44 % of women who were supplementing with FA preconceptionally, 44 % (162/370) reported taking FA for less than the 12 weeks required to achieve optimal red-blood-cell folate levels for prevention of neural tube defects. On multivariate analysis, only planned pregnancy and nulliparity were associated with taking FA for at least 12 weeks preconceptionally. Among women who only took FA postconceptionally, almost two-thirds commenced it after day 28 of their pregnancy when the neural tube had already closed. CONCLUSIONS As the timing of FA was suboptimal both before and after conception, we recommend that current national FA guidelines need to be reviewed.

Relationship between fasting plasma glucose levels and maternal food group and macronutrient intakes in pregnancy

Aim Increased maternal body mass index (BMI) has been consistently associated with elevated blood glucose levels during pregnancy. Studies to date investigating the relationship between maternal blood glucose levels and dietary intake have shown mixed results. We investigated the association between maternal fasting plasma glucose (FPG) levels and food group and macronutrient intakes in the first trimester of pregnancy, after adjustment for maternal bodyweight. Methods Women were recruited after sonographic confirmation of an ongoing singleton pregnancy in the first trimester. Dietary information was collected using the validated Willett Food Frequency Questionnaire. Maternal height and weight were measured and BMI calculated. Body composition was measured using advanced bioelectrical impedance analysis. FPG levels were obtained for women who were selectively screened with a 75 g oral glucose tolerance test. Results No associations were observed between maternal FPG levels and food group or macronutrient intakes but higher energy and starch intakes were found in obese subjects (P = 0.009 and P = 0.03 respectively). On univariate analysis, higher FPG levels were associated positively with higher maternal bodyweight, BMI, body fat, fat free mass and visceral fat (all P 29.9 kg/m2 (OR 7.4, P = 0.01). Conclusions Our findings indicate that maternal BMI is the key determinant of maternal glycaemia. Interventions which focus on overall energy restriction and especially the limitation of dietary starch to optimise prepregnancy maternal bodyweight are likely to be useful in improving glycaemic control in higher risk pregnancies.

A web-based dietary intervention in early pregnancy and neonatal outcomes: a randomized controlled trial

Background Maternal nutrition is a determinant of pregnancy outcomes. Few studies have evaluated the potential of online nutrition resources to modify behaviour. This randomized controlled trial aimed to determine whether access to a customized evidence-based nutrition website in pregnancy improved neonatal outcomes. Methods Women <18 weeks gestation were recruited at their convenience. The control group received standard care. In addition to standard care, the intervention group received access to an evidence-based nutrition website, customized to the preferences of pregnant women. Results Of the 250 women, there were no differences in characteristics between the two groups. Of the women, 91.0% reported they make a conscious effort currently to eat a healthy diet. However, only 19.6% met dietary requirements for calcium, 13.2% for iron, 2.7% for folate and 2.3% for iodine. The most popular website section was pregnancy nutrition advice but engagement was not sustained. Access to the website was not associated with any improvement in clinical outcomes (P > 0.05). Conclusions We found that provision of a customized website providing nutrition information, did not improve neonatal outcomes. Future studies should explore whether redesign with website interactivity or embedding information on popular digital platforms sustains womens engagement and modifies dietary behaviour.

Folate and vitamin B12 levels in early pregnancy and maternal obesity

OBJECTIVE There is good evidence that periconceptual Folic Acid (FA) supplementation can prevent two thirds of Neural Tube Defects (NTDs). A two-fold increase in NTD rates have been associated with maternal obesity and, based on limited evidence, national guidelines have recommended prescribing high dose FA for women with a Body Mass Index (BMI) >29.9 kg/m2. This observational study examined the relationship between maternal BMI and serum folate, red blood cell (RBC) folate and plasma vitamin B12 measurements in early pregnancy. STUDY DESIGN Women were recruited at their convenience during their first antenatal visit to the hospital following sonographic confirmation of an ongoing pregnancy. Clinical, sociodemographic, dietary and supplementation details were collected and computerised. At the time of routine phlebotomy, samples were collected for serum folate, red blood cell (RBC) folate and plasma B12. RESULTS Of the 496 women, 19.6%. (n = 97) were obese based on a BMI > 29.9 kg/m2. After excluding energy under-reporters, there was no difference between obese women and women with a normal BMI in their dietary or supplementation intakes of folate. Compared with women with a normal BMI (n = 263), obese women had a lower median serum folate (32.0 nmol/L IQR 20.2 vs 36.2 nmol/L IQR 16.3, P = 0.02) and a lower median serum B12 (203.0 pmol/L IQR 102.5 vs 208.0 pmol/L IQR 125.3, P = 0.03), but there was no difference in the mean red blood cell (RBC) folate measurement. There was a negative correlation between increasing BMI and both serum folate (P = 0.03) and plasma B12 (P = 0.03), but no correlation between BMI and RBC folate (P = 0.13). CONCLUSION Our findings support existing recommendations that obese women should be prescribed higher doses of FA periconceptually. However, to prevent NTDs successfully they may also require B12 supplementation.

Comparison at the first prenatal visit of the maternal dietary intakes of smokers with non-smokers in a large maternity hospital: a cross-sectional study

Objectives Using detailed dietary and supplement questionnaires in early pregnancy, we compared the dietary intakes of micronutrients and macronutrients at the first prenatal visit of women who reported continuing to smoke during pregnancy with the intakes of women who were non-smokers. Design Cross-sectional study conducted between June 2014 and March 2016. Setting Stand-alone tertiary maternity hospital in an urban setting with approximately 8000 deliveries per year. Participants Women were recruited at their convenience after sonographic confirmation of an ongoing singleton pregnancy (n=502). Detailed dietary and supplement information was available for 398 women. Women <18 years and those who did not speak English fluently were excluded. Primary and secondary outcome measures The differences in dietary micronutrients and macronutrients and maternal folate levels between women who continued to smoke in pregnancy compared with non-smokers. Results Of the 502 women, the mean age was 30.5 (SD 5.6) years, 42.5% were nulliparas, 19.2% were obese and 398 (79.3%) completed the questionnaire satisfactorily. In the 50 (12.6%) current smokers, the micronutrients magnesium, iron, carotene and copper were lower (all p<0.005) whereas sodium and chloride were higher compared with the 348 (87.4%) non-smokers. Smokers reported lower intakes of dietary total folate (p=0.006) compared with non-smokers (i.e., dietary folate equivalents; intake from natural and fortified dietary sources) (p=0.005). Smokers also reported lower intakes of fibre than non-smokers (13.1 g (IQR 7.7) vs 16.3 g (IQR 8.5), p<0.001). The dietary intakes of former smokers compared favourably with non-smokers. Conclusions We found that women who continue to smoke during pregnancy have serious dietary inadequacies which could potentially aggravate fetal growth restriction associated with direct toxicity from cigarettes. This provides a further reason to promote smoking cessation interventions in pregnancy, and highlights the need for dietary and supplementation interventions in women who continue to smoke.