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1.  Intakes of Iron and Folate and Hematologic Indices According to the Type of Supplements in Pregnant Women 
Clinical Nutrition Research  2012;1(1):78-84.
Adequate amounts of nutrients during pregnancy are essential for maternal, fetal and child health. This study was conducted to investigate the intakes of iron and folate and the effect of supplements on anemia status during pregnancy. One hundred sixty five pregnant women completed questionnaires which included food frequencies and supplement use, and blood tests for hematologic indices. Pregnant women were divided into four groups based on the type of supplements; single nutrient group (S), multivitamins & minerals group (M), Single nutrient + multivitamins & minerals group (S+M), and no supplement group (N). Mean iron intake was 11.1 mg from food (46.3% of Recommended Nutrient Intakes, RNIs) and 66.8 mg from supplements. Mean folate intake was 231.2 µg from food (38.5% of RNI) and 822.7 µg from supplements. In the N group, the subjects who consumed iron and folate less than EAR were 85.7% and 95.2%, respectively. The subjects consumed iron more than UL were 81.0% in the S group, 88.9% in the M group, and 97.4% in the S+M group, and the subjects consumed folate more than UL were 4.8% in the S group, 1.6% in the M group, and 25.6% in the S+M group. The mean values of hemoglobin and hemotocrit in the M group were significantly higher than those in the N group. Despite the relatively high socio-economic status of the participants, overall intakes of iron and folate from food were far below the RNIs, suggesting that a supplement is needed for adequate nutritional status during pregnancy. A multivitamin supplement seems to be more effective than a single nutrient supplement such as iron or folic acid in the prevention of anemia. Further research is required to define the appropriate amount of supplemental iron and folic acid for Korean pregnant women.
doi:10.7762/cnr.2012.1.1.78
PMCID: PMC3572799  PMID: 23430062
Iron; Folate; Dietary supplements; Anemia; Pregnant women
2.  Preconceptional Folate Supplementation and the Risk of Spontaneous Preterm Birth: A Cohort Study 
PLoS Medicine  2009;6(5):e1000061.
In an analysis of a cohort of pregnant women, Radek Bukowski and colleagues describe an association between taking folic acid supplements and a reduction in the risk of preterm birth.
Background
Low plasma folate concentrations in pregnancy are associated with preterm birth. Here we show an association between preconceptional folate supplementation and the risk of spontaneous preterm birth.
Methods and Findings
In a cohort of 34,480 low-risk singleton pregnancies enrolled in a study of aneuploidy risk, preconceptional folate supplementation was prospectively recorded in the first trimester of pregnancy. Duration of pregnancy was estimated based on first trimester ultrasound examination. Natural length of pregnancy was defined as gestational age at delivery in pregnancies with no medical or obstetrical complications that may have constituted an indication for delivery. Spontaneous preterm birth was defined as duration of pregnancy between 20 and 37 wk without those complications. The association between preconceptional folate supplementation and the risk of spontaneous preterm birth was evaluated using survival analysis. Comparing to no supplementation, preconceptional folate supplementation for 1 y or longer was associated with a 70% decrease in the risk of spontaneous preterm delivery between 20 and 28 wk (41 [0.27%] versus 4 [0.04%] spontaneous preterm births, respectively; HR 0.22, 95% confidence interval [CI] 0.08–0.61, p = 0.004) and a 50% decrease in the risk of spontaneous preterm delivery between 28 and 32 wk (58 [0.38%] versus 12 [0.18%] preterm birth, respectively; HR 0.45, 95% CI 0.24–0.83, p = 0.010). Adjustment for maternal characteristics age, race, body mass index, education, marital status, smoking, parity, and history of prior preterm birth did not have a material effect on the association between folate supplementation for 1 y or longer and spontaneous preterm birth between 20 and 28, and 28 to 32 wk (adjusted HR 0.31, 95% CI 0.11–0.90, p = 0.031 and 0.53, 0.28–0.99, p = 0.046, respectively). Preconceptional folate supplementation was not significantly associated with the risk of spontaneous preterm birth beyond 32 wk. The association between shorter duration (<1 y) of preconceptional folate supplementation and the risk of spontaneous preterm birth was not significant after adjustment for maternal characteristics. However, the risk of spontaneous preterm birth decreased with the duration of preconceptional folate supplementation (test for trend of survivor functions, p = 0.01) and was the lowest in women who used folate supplementation for 1 y or longer. There was also no significant association with other complications of pregnancy studied after adjustment for maternal characteristics.
Conclusions
Preconceptional folate supplementation is associated with a 50%–70% reduction in the incidence of early spontaneous preterm birth. The risk of early spontaneous preterm birth is inversely proportional to the duration of preconceptional folate supplementation. Preconceptional folate supplementation was specifically related to early spontaneous preterm birth and not associated with other complications of pregnancy.
Editors' Summary
Background
Most pregnancies last about 40 weeks, but sometimes the new family member arrives early. Every year, half a million babies in the United States (12.5% of all babies) are born prematurely (before 37 completed weeks of pregnancy). Sadly, premature babies are more likely to die than full-term babies and many have short- and/or long-term health problems. Premature babies often have breathing problems, they are susceptible to life-threatening infections, and they are more likely to have learning and developmental disabilities than those born on time. The severity of these health problems depends on the degree of prematurity—preterm babies born between 34 and 36 weeks of pregnancy rarely develop severe disabilities, but a quarter of babies born before 28 weeks of pregnancy develop serious lasting disabilities and half have learning and behavioral problems. Although doctors have identified some risk factors for early delivery (for example, smoking), it is impossible to predict who will have an early birth and there is no effective way to prevent preterm births.
Why Was This Study Done?
Some researchers think that folate supplements may prevent preterm births. Folate (folic acid), a vitamin found in leafy green vegetables, fruits, and dried beans, helps to prevent neural tube birth defects. Consequently, women are encouraged to take folic acid supplements throughout (and preferably before) pregnancy and many governments now mandate that bread, pasta, and other grain products be fortified with folic acid to help women get sufficient folate. There is some evidence that women who deliver early have less folate in their blood than women who deliver at term. Furthermore, folate supplementation during pregnancy has increased the length of pregnancy in some but not all clinical trials. A possible explanation for these mixed results is that the duration of pregnancy reflects conditions in the earliest stages of pregnancy or before conception and that folate supplementation needs to start before conception to reduce the risk of preterm birth. In this study, the researchers test this idea by analyzing data collected from nearly 35,000 pregnant women enrolled in a study that was originally designed to investigate screening for Down's syndrome.
What Did the Researchers Do and Find?
During the first three months of their pregnancy, the women were asked whether they had taken folate supplements before conception. The duration of each pregnancy was estimated from ultrasound measurements taken early in the pregnancy and from the time of delivery. During the study, 1,658 women had spontaneous preterm deliveries before 37 weeks and 160 delivered before 32 weeks. After allowing for other maternal characteristics that might have affected the likelihood of preterm delivery, the risk of spontaneous preterm delivery between 20 and 28 weeks was 70% lower in women who took folate supplements for more than a year before becoming pregnant than in women who didn't take a supplement. Long-term folate supplementation also reduced the risk of preterm delivery between 28 and 32 weeks by 50% but did not affect the risk of preterm birth beyond 32 weeks. Folate supplementation for less than a year before conception did not reduce the risk of preterm birth, and folate supplementation was not associated with any other complications of pregnancy.
What Do These Findings Mean?
These findings show that folate supplementation for a year or more before conception is associated with a 50%–70% decrease in early (but not late) spontaneous preterm births and that the longer a woman takes folate supplements before becoming pregnant, the lower her risk of a preterm birth. Although the researchers allowed for maternal characteristics that might have affected the duration of pregnancy, it is possible that folate supplementation may not be responsible for the reduction in preterm birth risk seen in this study. For example, taking folate supplements may be a marker of healthy behavior and the women taking the supplements might have been doing something else that was reducing their risk of preterm birth. However, despite this and other limitations of this study, these findings suggest that long-term folate supplementation before conception is worth investigating further as a potential way to prevent preterm births.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000061.
This study is further discussed in a PLoS Medicine Perspective by Nicholas Fisk
The MedlinePlus encyclopedia contains a page on premature babies (in English and Spanish); MedlinePlus provides links to other information on premature babies (in English and Spanish)
The US National Institute of Child Health and Human Development provides information on preterm labor and birth
The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on preterm birth and on folic acid (in English and Spanish)
The Nemours Foundation, another nonprofit organization for child health, also provides information on premature babies (in English and Spanish)
The US Office of Dietary Supplements has a fact sheet on folate
doi:10.1371/journal.pmed.1000061
PMCID: PMC2671168  PMID: 19434228
3.  Folic acid supplementation, dietary folate intake during pregnancy and risk for spontaneous preterm delivery: a prospective observational cohort study 
Background
Health authorities in numerous countries recommend periconceptional folic acid to pregnant women to prevent neural tube defects. The objective of this study was to examine the association of folic acid supplementation during different periods of pregnancy and of dietary folate intake with the risk of spontaneous preterm delivery (PTD).
Methods
The Norwegian Mother and Child Cohort Study is a population-based prospective cohort study. A total of 65,668 women with singleton pregnancies resulting in live births in 1999–2009 were included. Folic acid supplementation was self-reported from 26 weeks before pregnancy until week 24 during pregnancy. At gestational week 22, the women completed a food frequency questionnaire, which allowed the calculation of their average total folate intake from foods and supplements for the first 4–5 months of pregnancy. Spontaneous PTD was defined as the spontaneous onset of delivery between weeks 22+0 and 36+6 (n = 1,628).
Results
The median total folate intake was 266 μg/d (interquartile range IQR 154–543) in the overall population and 540 μg/d (IQR 369–651) in the supplement users. Eighty-three percent reported any folic acid supplementation from <8 weeks before to 24 weeks after conception while 42% initiated folic acid supplementation before their pregnancy. Cox regression analysis showed that the amount of folate intake from the diet (hazard ratio HR 1.16; confidence interval CI 0.65-2.08) and from the folic acid supplements (HR 1.04; CI 0.95-1.13) was not significantly associated with the risk of PTD. The initiation of folic acid supplementation more than 8 weeks before conception was associated with an increased risk for PTD (HR 1.19; CI 1.05-1.34) compared to no folic acid supplementation pre-conception. There was no significant association with PTD when supplementation was initiated within 8 weeks pre-conception (HR 1.01; CI 0.88-1.16). All analyses were adjusted for maternal characteristics and socioeconomic, health and dietary variables.
Conclusions
Our findings do not support a protective effect of dietary folate intake or folic acid supplementation on spontaneous PTD. Pre-conceptional folic acid supplementation starting more than 8 weeks before conception was associated with an increased risk of PTD. These results require further investigation before discussing an expansion of folic acid supplementation guidelines.
doi:10.1186/1471-2393-13-160
PMCID: PMC3751653  PMID: 23937678
Pregnancy; Preterm delivery; Preterm birth; Gestational length; Folate; Folic acid supplementation
4.  Do dietary supplements improve micronutrient sufficiency in children and adolescents? 
The Journal of pediatrics  2012;161(5):837-842.e3.
Objective
To examine if children use supplements to fill gaps in nutritionally inadequate diets or whether supplements contribute to already adequate or excessive micronutrient intakes from foods.
Study design
Data were analyzed for children (2–18 y) from the NHANES 2003–2006, a nationally representative, cross-sectional survey (n=7,250). Diet was assessed using two 24-hour recalls, and dietary supplement use was assessed with a 30-day questionnaire.
Results
Prevalence of supplements use was 21% (< 2 y) and 42% (2–8 y). Supplement users had higher micronutrient intakes than nonusers. Calcium and vitamin D intakes were low for all children. Inadequate intakes of phosphorus, copper, selenium, folate, and vitamins B-6 and B-12 were minimal from foods alone among 2–8 y olds. However, among 9–18 y olds, a higher prevalence of inadequate intakes of magnesium, phosphorus, and vitamins A, C, and E were observed. Supplement use increased the likelihood of intakes above the Upper Tolerable Intake Level for iron, zinc, copper, selenium, folic acid, and vitamins A and C.
Conclusions
Even with the use of supplements, more than a one-third of children failed to meet calcium and vitamin D recommendations. Children 2–8 y had nutritionally adequate diets regardless of supplement use. However, in children older than 8 y dietary supplements added micronutrients to diets that would have otherwise been inadequate for magnesium, phosphorus, vitamins A,C, and E. Supplement use contributed to the potential for excess intakes of some nutrients. These findings may have implications for reformulating dietary supplements for children.
doi:10.1016/j.jpeds.2012.05.009
PMCID: PMC3477257  PMID: 22717218
children; NHANES; dietary supplement; users and non-users of supplements
5.  Assessment of dietary intake among pregnant women in a rural area of western China 
BMC Public Health  2009;9:222.
Background
Adequate maternal nutrient intake during pregnancy is important to ensure satisfactory birth outcomes. There are no data available on the usual dietary intake among pregnant women in rural China. The present study describes and evaluates the dietary intake in a cohort of pregnant women living in two counties of rural Shaanxi, western China.
Methods
1420 pregnant women were recruited from a trial that examined the effects of micronutrient supplementation on birth outcomes. Dietary information was collected at the end of their trimester or after delivery with an interviewed-administrated semi-quantitative food frequency questionnaire (FFQ). Nutrients intake was calculated from the FFQ and compared to the Estimated Average Requirements (EAR). The EAR cut-offs based on the Chinese Nutrition Society Dietary Reference Intakes (DRIs) were used to assess the prevalence of inadequate dietary intakes of energy, protein, calcium, zinc, riboflavin, vitamin C and folate. Mann-Whitney U and Kruskal Wallis tests were used to compare nutrient intakes across subgroups.
Results
The mean nutrient intakes assessed by the FFQ was similar to those reported in the 2002 Chinese National Nutrition and Health Survey from women living in rural areas except for low intakes of protein, fat, iron and zinc. Of the participants, 54% were at risk of inadequate intake of energy. There were high proportions of pregnant women who did not have adequate intakes of folate (97%) and zinc (91%). Using the "probability approach", 64% of subjects had an inadequate consumption of iron.
Conclusion
These results reveal that the majority of pregnant women in these two counties had low intakes of nutrients that are essential for pregnancy such as iron and folate.
Trial registration
ISRCTN08850194.
doi:10.1186/1471-2458-9-222
PMCID: PMC2716336  PMID: 19589154
6.  A Randomized Controlled Trial of Folate Supplementation When Treating Malaria in Pregnancy with Sulfadoxine-Pyrimethamine 
PLoS Clinical Trials  2006;1(6):e28.
Objectives:
Sulfadoxine-pyrimethamine (SP) is an antimalarial drug that acts on the folate metabolism of the malaria parasite. We investigated whether folate (FA) supplementation in a high or a low dose affects the efficacy of SP for the treatment of uncomplicated malaria in pregnant women.
Design:
This was a randomized, placebo-controlled, double-blind trial.
Setting:
The trial was carried out at three hospitals in western Kenya.
Participants:
The participants were 488 pregnant women presenting at their first antenatal visit with uncomplicated malaria parasitaemia (density of ≥ 500 parasites/μl), a haemoglobin level higher than 7 g/dl, a gestational age between 17 and 34 weeks, and no history of antimalarial or FA use, or sulfa allergy. A total of 415 women completed the study.
Interventions:
All participants received SP and iron supplementation. They were randomized to the following arms: FA 5 mg, FA 0.4 mg, or FA placebo. After 14 days, all participants continued with FA 5 mg daily as per national guidelines. Participants were followed at days 2, 3, 7, 14, 21, and 28 or until treatment failure.
Outcome Measures:
The outcomes were SP failure rate and change in haemoglobin at day 14.
Results:
The proportion of treatment failure at day 14 was 13.9% (19/137) in the placebo group, 14.5% (20/138) in the FA 0.4 mg arm (adjusted hazard ratio [AHR], 1.07; 98.7% confidence interval [CI], 0.48 to 2.37; p = 0.8), and 27.1% (38/140) in the FA 5 mg arm (AHR, 2.19; 98.7% CI, 1.09 to 4.40; p = 0.005). The haemoglobin levels at day 14 were not different relative to placebo (mean difference for FA 5 mg, 0.17 g/dl; 98.7% CI, −0.19 to 0.52; and for FA 0.4 mg, 0.14 g/dl; 98.7% CI, −0.21 to 0.49).
Conclusions:
Concomitant use of 5 mg FA supplementation compromises the efficacy of SP for the treatment of uncomplicated malaria in pregnant women. Countries that use SP for treatment or prevention of malaria in pregnancy need to evaluate their antenatal policy on timing or dose of FA supplementation.
Editorial Commentary
Background: Health authorities worldwide recommend that pregnant women supplement their diet with folate (one of the B-vitamins), normally 0.4 mg per day. There is good evidence from systematic reviews of controlled trials that folate supplementation around conception and early in pregnancy is effective in protecting against neural tube (spine and brain) defects; continued supplementation throughout pregnancy reduces the chance of anemia in the mother. In many African countries, including Kenya, the dose of folate used is 5 mg per day, because this dose is more easily available there. In Kenya, as well as elsewhere in Africa, sulfadoxine-pyrimethamine is also given twice or more after the first trimester to treat and/or prevent malaria infection (which is more likely, and can have serious consequences, when a woman is pregnant). However, there is some evidence from laboratory experiments and clinical studies, none of which were done in pregnant women, suggesting that folate supplementation might reduce the effectiveness of sulfadoxine-pyrimethamine. Therefore, these researchers conducted a trial to test this hypothesis in 415 pregnant Kenyan women with malaria parasites in the blood but no severe symptoms. All were given standard sulfadoxine-pyrimethamine treatment. The women were randomized to receive either folate 5 mg daily, folate 0.4 mg daily, or placebo tablets for 14 days, after which all women reverted to the standard folate 5 mg tablets. The women were followed up for 28 days after the initial sulfadoxine-pyrimethamine dose and the principal outcome the researchers were interested in was the failure of sulfadoxine-pyrimethamine treatment, defined as fever and the presence of parasites in the blood (clinical failure) or the failure of parasites to clear from the blood or to reappear too soon (parasitological failure).
What this trial shows: In this trial, women receiving folate 5 mg daily were approximately twice as likely to fail treatment with sulfadoxine-pyrimethamine than women receiving folate 0.4 mg or placebo. (Overall, around 27% of the women receiving folate 5 mg had treatment failure during the follow-up period.) All the treatment groups had similar levels of blood hemoglobin at the end of the study. There did not seem to be any major differences in adverse events (such as premature deliveries, stillbirths, or neonatal deaths) among women taking part in the different study groups.
Strengths and limitations: The randomization procedures were appropriate and procedures were used to blind participants and researchers to the different interventions, therefore reducing the risk of bias. Since the trial had a placebo arm, it was possible to conclude that the lower dose of folate (0.4 mg) did not significantly affect efficacy of sulfadoxine-pyrimethamine as compared with placebo. A limitation of the study is that the length of the intervention was short, since all women reverted to standard 5 mg folate after 14 days. It is therefore not clear whether a longer trial would have shown additional risks or benefits of the different doses of folate. Finally, PCR genotyping was not done on the parasites infecting women in the trial; this procedure could have distinguished between true treatment failures and new infections (but which would have been unlikely within 14 days).
Contribution to the evidence: Other trials and observational studies have suggested that high doses of folate can reduce the efficacy of sulfadoxine-pyrimethamine in children and adults. However these studies have not examined the effect in pregnant women, for whom most national bodies recommend regular folate supplementation. The results from this trial supports the findings from previous studies and enables the evidence to be generalized to pregnant women. The study also found no evidence that 0.4 mg folate compromises the efficacy of sulfadoxine-pyrimethamine. The findings suggest that the lower level of folate dosing should be used in pregnancy, or that antimalarial treatments other than sulfadoxine-pyrimethamine be used.
doi:10.1371/journal.pctr.0010028
PMCID: PMC1617124  PMID: 17053829
7.  Energy and nutrients in self-reported diet before and at week 18–22 of pregnancy 
Background
A satisfactory nutritional status, as a result of optimal food intake, before conception and during pregnancy, is important for a successful pregnancy.
Objective
To evaluate the energy and nutrient intake before conception and at mid-gestation in a group of pregnant women (n=50) in relation to the Nordic Nutrition Recommendations (NNR).
Design
Pre-pregnant diet was studied by an 84-item food-frequency questionnaire and mid-gestational diet by repeated 24 h dietary recalls.
Results
Average requirements (AR) were met for all nutrients except for selenium intake before pregnancy. Absolute intakes were below recommended intake (RI) according to NNR for folate, vitamin D, selenium, vitamin E and iron both before and at mid-gestation. However, intakes were still above the lower intake levels (LI) defined by NNR for almost all women. Twenty-three women were below LI for selenium before pregnancy and five for each of vitamin D and selenium at mid-gestation. When expressed as nutrient densities (amount of nutrient per energy unit), intakes were below NNR for folate, vitamin D and selenium before pregnancy, and for folate, vitamin D and iron at mid-gestation. Intakes were adjusted for underreporting, estimated to 20% as revealed after comparing energy intake/basal metabolic rate with grouped physical activity level values.
Conclusions
The reported food intake satisfied the recommended level of intake according to AR, but when using RI for planning a diet as a reference, folate, vitamin D, selenium and iron intake were insufficient. Most striking were the low levels of folate and vitamin D intake both before pregnancy and at mid-gestation.
doi:10.1080/17482970701420916
PMCID: PMC2606998
conception; dietary intake; 24 h dietary recall; folate; food-frequency questionnaire; vitamin D
8.  Risk of Suboptimal Iodine Intake in Pregnant Norwegian Women 
Nutrients  2013;5(2):424-440.
Pregnant women and infants are exceptionally vulnerable to iodine deficiency. The aims of the present study were to estimate iodine intake, to investigate sources of iodine, to identify predictors of low or suboptimal iodine intake (defined as intakes below 100 μg/day and 150 μg/day) in a large population of pregnant Norwegian women and to evaluate iodine status in a sub-population. Iodine intake was calculated based on a validated Food Frequency Questionnaire in the Norwegian Mother and Child Cohort. The median iodine intake was 141 μg/day from food and 166 μg/day from food and supplements. Use of iodine-containing supplements was reported by 31.6%. The main source of iodine from food was dairy products, contributing 67% and 43% in non-supplement and iodine-supplement users, respectively. Of 61,904 women, 16.1% had iodine intake below 100 μg/day, 42.0% had iodine intake below 150 μg/day and only 21.7% reached the WHO/UNICEF/ICCIDD recommendation of 250 μg/day. Dietary behaviors associated with increased risk of low and suboptimal iodine intake were: no use of iodine-containing supplements and low intake of milk/yogurt, seafood and eggs. The median urinary iodine concentration measured in 119 participants (69 μg/L) confirmed insufficient iodine intake. Public health strategies are needed to improve and secure the iodine status of pregnant women in Norway.
doi:10.3390/nu5020424
PMCID: PMC3635203  PMID: 23389302
iodine; pregnancy; prospective cohort; food frequency questionnaire; the Norwegian Mother and Child Cohort Study (MoBa)
9.  Folic acid supplementation, dietary folate intake during pregnancy and risk for spontaneous preterm delivery: a prospective observational cohort study 
Background
Health authorities in numerous countries recommend periconceptional folic acid supplementation to prevent neural tube defects. The objective of this study was to examine the association of dietary folate intake and folic acid supplementation during different periods of pregnancy with the risk of spontaneous preterm delivery (PTD).
Methods
The Norwegian Mother and Child Cohort Study is a population-based prospective cohort study. A total of 66,014 women with singleton pregnancies resulting in live births in 2002–2009 were included. Folic acid supplementation was self-reported from 26 weeks before pregnancy until pregnancy week 24. At gestational week 22, the women completed a food frequency questionnaire, which allowed the calculation of their average total folate intake from foods and supplements for the first 4–5 months of pregnancy. Spontaneous PTD was defined as the spontaneous onset of delivery between weeks 22+0 and 36+6 (n = 1,755).
Results
The median total folate intake was 313 μg/d (interquartile range IQR 167–558) in the overall population and 530 μg/d (IQR 355–636) in the supplement users. Eighty-five percent reported any folic acid supplementation from <8 weeks before to 24 weeks after conception while only 44% initiated folic acid supplementation before pregnancy. Cox regression analysis showed that the amount of dietary folate intake (hazard ratio HR 1.00; confidence interval 95% CI 0.61-1.65) and supplemental folate intake (HR 1.00; CI 1.00-1.00) was not significantly associated with the risk of PTD. The initiation of folic acid supplementation more than 8 weeks before conception was associated with an increased risk for spontaneous PTD (HR 1.18; CI 1.05-1.32) compared to no folic acid supplementation preconception. There was no significant association with PTD when supplementation was initiated within 8 weeks preconception (HR 0.99; CI 0.87-1.13). All analyses were adjusted for maternal characteristics and socioeconomic, health and dietary variables.
Conclusions
Our findings do not support a protective effect of dietary folate intake or folic acid supplementation on spontaneous PTD. Preconceptional folic acid supplementation starting more than 8 weeks before conception was associated with an increased risk of spontaneous PTD. These results require further investigation before discussing an expansion of folic acid supplementation guidelines.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-014-0375-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-014-0375-1
PMCID: PMC4240839  PMID: 25361626
Pregnancy; Preterm delivery; Preterm birth; Gestational length; Folate; Folic acid supplementation
10.  Food patterns and dietary quality associated with organic food consumption during pregnancy; data from a large cohort of pregnant women in Norway 
BMC Public Health  2012;12:612.
Background
Little is known about the consumption of organic food during pregnancy. The aim of this study was to describe dietary characteristics associated with frequent consumption of organic food among pregnant women participating in the Norwegian Mother and Child Cohort Study (MoBa).
Methods
The present study includes 63 808 women who during the years 2002–2007 answered two questionnaires, a general health questionnaire at gestational weeks 15 and a food frequency questionnaire at weeks 17-22. The exploration of food patterns by Principal component analyses (PCA) was followed by ANOVA analyses investigating how these food patterns as well as intake of selected food groups were associated with consumption of organic food.
Results
The first principal component (PC1) identified by PCA, accounting for 12% of the variation, was interpreted as a ‘health and sustainability component’, with high positive loadings for vegetables, fruit and berries, cooking oil, whole grain bread and cereal products and negative loadings for meat, including processed meat, white bread, and cakes and sweets. Frequent consumption of organic food, which was reported among 9.1% of participants (n = 5786), was associated with increased scores on the ‘health and sustainability component’ (p < 0.001). The increase in score represented approximately 1/10 of the total variation and was independent of sociodemographic and lifestyle characteristics. Participants with frequent consumption of organic food had a diet with higher density of fiber and most nutrients such as folate, beta-carotene and vitamin C, and lower density of sodium compared to participants with no or low organic consumption.
Conclusion
The present study showed that pregnant Norwegian women reporting frequent consumption of organically produced food had dietary pattern and quality more in line with public advice for healthy and sustainable diets. A methodological implication is that the overall diet needs to be included in future studies of potential health outcomes related to consumption of organic food during pregnancy.
doi:10.1186/1471-2458-12-612
PMCID: PMC3490940  PMID: 22862737
11.  Foods, Fortificants, and Supplements: Where Do Americans Get Their Nutrients?123 
The Journal of Nutrition  2011;141(10):1847-1854.
Limited data are available on the source of usual nutrient intakes in the United States. This analysis aimed to assess contributions of micronutrients to usual intakes derived from all sources (naturally occurring, fortified and enriched, and dietary supplements) and to compare usual intakes to the Dietary Reference Intake for U.S. residents aged ≥2 y according to NHANES 2003–2006 (n = 16,110). We used the National Cancer Institute method to assess usual intakes of 19 micronutrients by source. Only a small percentage of the population had total usual intakes (from dietary intakes and supplements) below the estimated average requirement (EAR) for the following: vitamin B-6 (8%), folate (8%), zinc (8%), thiamin, riboflavin, niacin, vitamin B-12, phosphorus, iron, copper, and selenium (<6% for all). However, more of the population had total usual intakes below the EAR for vitamins A, C, D, and E (34, 25, 70, and 60%, respectively), calcium (38%), and magnesium (45%). Only 3 and 35% had total usual intakes of potassium and vitamin K, respectively, greater than the adequate intake. Enrichment and/or fortification largely contributed to intakes of vitamins A, C, and D, thiamin, iron, and folate. Dietary supplements further reduced the percentage of the population consuming less than the EAR for all nutrients. The percentage of the population with total intakes greater than the tolerable upper intake level (UL) was very low for most nutrients, whereas 10.3 and 8.4% of the population had intakes greater than the UL for niacin and zinc, respectively. Without enrichment and/or fortification and supplementation, many Americans did not achieve the recommended micronutrient intake levels set forth in the Dietary Reference Intake.
doi:10.3945/jn.111.142257
PMCID: PMC3174857  PMID: 21865568
12.  Supplement use contributes to meeting recommended dietary intakes for calcium, magnesium and vitamin C in four ethnicities of middle-aged and older Americans: The Multi-Ethnic Study of Atherosclerosis 
Background
Low intake of nutrients is associated with poor health outcomes. Therefore, we examined the contribution of dietary supplementation to meeting recommended dietary intakes of calcium, magnesium, potassium and vitamin C in participants of the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort of Caucasian, African-American, Hispanic and Chinese participants ages 45-84 years. We also assessed the prevalence of intakes above Tolerable Upper Intake Levels (ULs).
Methods
At the baseline exam in 2000-01, 2,938 men and 3,299 women completed food-frequency questionnaires and provided information about dietary supplementation. We used relative risk regression to estimate the probability of meeting RDAs or AIs in supplement-users vs. non-users and Fisher's exact tests to compare the proportion of those exceeding ULs between the two groups. RDAs, AIs, and ULs were defined by the National Academy of Sciences Food and Nutrition Board's Dietary Reference Intakes (DRIs).
Results
After adjustment for age and education, the relative risk (RR) of meeting RDAs or AIs in supplement-users vs. nonusers ranged from 1.9 (1.6, 2.3) in Caucasian men to 5.7 (4.1, 8.0) in African American women for calcium, from 2.5 (1.9, 3.3) in Hispanic men to 5.2 (2.4, 11.2) in Chinese men for magnesium, and from 1.4 (1.3, 1.5) in African American women to 2.0 (1.7, 2.2) in Chinese men for vitamin C. The RRs for meeting RDAs for calcium differed significantly by ethnicity (p<0.021) and gender (p<0.001), by ethnicity for magnesium (p=0.001). The RR for each gender/ethnicity strata was close to 1 and did not reach statistical significance at alpha=0.05 for potassium. For calcium, 15% of high-dose supplement-users exceeded the UL compared with only 2.1% of nonusers. For vitamin C, the percentages were 6.6% and 0%, and for magnesium, 35.3% and 0% (p<0.001 for all).
Conclusion
Although supplement use is associated with meeting DRI guidelines for calcium, vitamin C and magnesium, many adults are not meeting the DRI guidelines even with the help of dietary supplements, and the effect of supplementation can vary according to ethnicity and gender. However, supplementation was not significantly associated with meeting DRIs for potassium. Also, high-dose supplement use is associated with intakes above ULs for calcium, magnesium and vitamin C.
doi:10.1016/j.jada.2008.11.023
PMCID: PMC2684701  PMID: 19248857
Dietary supplements; micronutrient intake; race; ethnicity; gender
13.  Nutrient Intake From Habitual Oral Diet in Patients With Severe Short Bowel Syndrome Living in the Southeastern United States 
Background and Aims
Little data are published on habitual home oral diet of short bowel syndrome (SBS) patients living in the United States.
Methods
We assessed habitual macro-and micronutrient intake from oral food and beverages in 19 stable patients with severe SBS who live in the Southeastern United States. Intestinal absorption of energy, fat, nitrogen (N) and carbohydrate (CHO) was determined in a metabolic ward setting.
Results
We studied 12 women and 7 men, age 48±3 years (mean±SE) receiving chronic PN for 31±8 months following massive small bowel resection (118±25 cm residual small bowel). Patients had intact (N=5), partial (N=9), or no residual colon (N=5). The subjects demonstrated severe malabsorption of energy (59±3% of oral intake), fat (41±5%), N (42±5%) and CHO (76±3%). Average oral energy intake was 2656±242 kcal/day (39±3 kcal/kg/day) and oral protein intake was 1.4 ±0.1 g/kg/d. Oral food/beverage intake constituted 49±4% of total (enteral + parenteral) daily fluid intake, 66±4% of total daily kcal and 58±5% of total daily N intake. Oral fat intake averaged 92±11g/day (≈ 35% of total oral energy). Oral fluid intake averaged 2712±240 ml/d, primarily from water, soft drinks, sweet tea and coffee. Simple sugars comprised 42±3% of oral CHO intake. Usual dietary intake of multiple micronutrients were below the Recommended Dietary Allowances (RDA) in a large percentage of patients: vitamin A (47%), vitamin D (79%), vitamin E (79%), vitamin K (63%), thiamine (42%), vitamin B6 (68%), vitamin B12 (11%), vitamin C (58%), folate (37%), iron (37%), calcium (63%), magnesium (79%) and zinc (68%). Only 7 patients (37%) were taking oral multivitamin-mineral supplements and only 6 subjects (37%) were taking oral iron and calcium supplements, respectively.
Conclusions
In these SBS patients living in the Southeastern United States, oral diet provides a significant proportion of daily nutrient intake. However, the types of foods and fluids consumed are likely to worsen malabsorption and increase PN requirements. Oral intake of essential micronutrients was very low in a significant proportion of this cohort of SBS patients.
doi:10.1016/j.nut.2007.12.016
PMCID: PMC2441845  PMID: 18328409
Short bowel syndrome; diet; vitamins; minerals; intestinal rehabilitation
14.  Dietary iron intake during early pregnancy and birth outcomes in a cohort of British women 
BACKGROUND
Iron deficiency during pregnancy is associated with adverse birth outcomes, particularly, if present during early gestation. Iron supplements are widely recommended during pregnancy, but evidence of their benefit in relation to infant outcomes is not established. This study was performed in the UK, where iron supplements are not routinely recommended during pregnancy, to investigate the association between iron intake in pregnancy and size at birth.
METHODS
From a prospective cohort of 1274 pregnant women aged 18–45 years, dietary intake was reported in a 24-h recall administered by a research midwife at 12-week gestation. Dietary supplement intake was ascertained using dietary recall and three questionnaires in the first, second and third trimesters.
RESULTS
Of the cohort of pregnant women, 80% reported dietary iron intake below the UK Reference Nutrient Intake of 14.8 mg/day. Those reported taking iron-containing supplements in the first, second and third trimesters were 24, 15 and 8%, respectively. Women with dietary iron intake >14.8 mg/day were more likely to be older, have a higher socioeconomic profile and take supplements during the first trimester. Vegetarians were less likely to have low dietary iron intake [odds ratio = 0.5, 95% confidence interval (CI): 0.4, 0.8] and more likely to take supplements during the first and second trimesters. Total iron intake, but not iron intake from food only, was associated with birthweight centile (adjusted change = 2.5 centiles/10 mg increase in iron, 95% CI: 0.4, 4.6). This association was stronger in the high vitamin C intake group, but effect modification was not significant.
CONCLUSION
There was a positive relationship between total iron intake, from food and supplements, in early pregnancy and birthweight. Iron intake, both from diet and supplements, during the first trimester of pregnancy was higher in vegetarians and women with a better socioeconomic profile.
doi:10.1093/humrep/der005
PMCID: PMC3057752  PMID: 21303776
birthweight; pregnancy; preterm birth; iron; diet
15.  Dietary iron intake during early pregnancy and birth outcomes in a cohort of British women 
BACKGROUND
Iron deficiency during pregnancy is associated with adverse birth outcomes, particularly, if present during early gestation. Iron supplements are widely recommended during pregnancy, but evidence of their benefit in relation to infant outcomes is not established. This study was performed in the UK, where iron supplements are not routinely recommended during pregnancy, to investigate the association between iron intake in pregnancy and size at birth.
METHODS
From a prospective cohort of 1274 pregnant women aged 18–45 years, dietary intake was reported in a 24-h recall administered by a research midwife at 12-week gestation. Dietary supplement intake was ascertained using dietary recall and three questionnaires in the first, second and third trimesters.
RESULTS
Of the cohort of pregnant women, 80% reported dietary iron intake below the UK Reference Nutrient Intake of 14.8 mg/day. Those reported taking iron-containing supplements in the first, second and third trimesters were 24, 15 and 8%, respectively. Women with dietary iron intake >14.8 mg/day were more likely to be older, have a higher socioeconomic profile and take supplements during the first trimester. Vegetarians were less likely to have low dietary iron intake [odds ratio = 0.5, 95% confidence interval (CI): 0.4, 0.8] and more likely to take supplements during the first and second trimesters. Total iron intake, but not iron intake from food only, was associated with birthweight centile (adjusted change = 2.5 centiles/10 mg increase in iron, 95% CI: 0.4, 4.6). This association was stronger in the high vitamin C intake group, but effect modification was not significant.
CONCLUSION
There was a positive relationship between total iron intake, from food and supplements, in early pregnancy and birth-weight. Iron intake, both from diet and supplements, during the first trimester of pregnancy was higher in vegetarians and women with a better socioeconomic profile.
doi:10.1093/humrep/der005
PMCID: PMC3057752  PMID: 21303776
birthweight; pregnancy; preterm birth; iron; diet
16.  Examination of Vitamin Intakes among US Adults by Dietary Supplement Use 
Background
More than half of US adults use dietary supplements. Some reports suggest that supplement users have higher vitamin intakes from foods than nonusers, but this observation has not been examined using nationally representative survey data.
Objective
The purpose of this analysis was to examine vitamin intakes from foods by supplement use and how dietary supplements contribute to meeting or exceeding the Dietary Reference Intakes for selected vitamins using data from the National Health and Nutrition Examination Survey among adults (aged ≥19 years) in 2003–2006 (n=8,860).
Results
Among male users, mean intakes of folate and vitamins A, E, and K from food sources were significantly higher than among nonusers. Among women, mean intakes of folate and vitamins A, C, D, and E from foods were higher among users than nonusers. Total intakes (food and supplements) were higher for every vitamin we examined among users than the dietary vitamin intakes of nonusers. Supplement use helped lower the prevalence of intakes below the Estimated Average Requirement for every vitamin we examined, but for folic acid and vitamins A, B-6, and C, supplement use increased the likelihood of intakes above the Tolerable Upper Intake Level.
Conclusions
Supplement use was associated with higher mean intakes of some vitamins from foods among users than nonusers, but it was not associated with the prevalence of intakes less than the Estimated Average Requirement from foods. Those who do not use vitamin supplements had significantly higher prevalence of inadequate vitamin intakes; however, the use of supplements can contribute to excess intake for some vitamins.
doi:10.1016/j.jand.2012.01.026
PMCID: PMC3593649  PMID: 22709770
Dietary supplements; NHANES; Vitamins; Users and non-users of supplements
17.  Dietary supplement use among elderly, long-term cancer survivors 
Introduction
The purpose of the present study was to assess dietary supplement use and its association with micronutrient intakes and diet quality among older (≥65y), long-term survivors (≥5 years post-diagnosis) of female breast, prostate, and colorectal cancer.
Methods
The sample included 753 survivors who participated in telephone screening interviews to determine eligibility for a randomized diet and physical activity intervention trial entitled RENEW: Reach-out to ENhancE Wellness in Older Cancer Survivors. Telephone surveys included two 24-hour dietary recalls and items regarding supplement use (type, dose, and duration). Nutrient intakes were compared to Dietary Reference Intakes (DRIs). Diet quality was assessed using the revised Healthy Eating Index (HEI). Descriptive statistics and multivariate logistic regression were used in this cross-sectional study.
Results
A majority of survivors (74%) reported taking supplements, with multivitamins (60%), calcium/vitamin D (37%), and antioxidants (30%) as the most prevalent. Overall proportions of the total sample with dietary intakes below Estimated Average Requirements (EARs) were substantial, although supplement users had more favorable mean HEI scores (P<0.01) and nutrient intakes for 12 of the 13 vitamins and minerals investigated (P-values <0.05). Supplement use was positively associated with older age (≥70 years) (odds ratio (OR) 1.70; 95% confidence interval (95% CI) 1.17, 2.46) and female gender (OR 1.49; 95% CI 1.04, 2.13), and negatively associated with current smoking (CI 0.40, 95% CI 0.21, 0.76). Individuals scoring higher on the Total Fruit (OR 1.12, CI 1.01, 1.23), Whole Grain (OR 1.14, CI 1.04, 1.25), and Oil (OR 1.10, CI 1.01, 1.11) components of the HEI were significantly more likely to take supplements, while those scoring higher on the Meat and Beans category (OR 0.81, CI 0.71, 0.93) were significantly less likely to take supplements. Compared to those with less than a high school education, survivors with a professional or graduate degree were significantly more likely to use supplements (OR 2.18, CI 1.13, 4.23).
Discussions/Conclusions
Demographic, disease, and health-related correlates of supplement use follow similar trends observed in the general population as well as previous reports from other cancer survivor populations. Supplement use may reduce the prevalence of nutrient inadequacies in this population, though survivors who use supplements are the least likely to need them.
Implications for Cancer Survivors
Supplement use may be an effective means for many survivors to achieve adequate nutrient intakes; however, open communication between healthcare providers and survivors is needed to ensure potential concerns are addressed as supplement use may not always be beneficial.
doi:10.1007/s11764-008-0060-3
PMCID: PMC2766274  PMID: 18792788
Dietary Supplements; Vitamins; Minerals; Long-Term Survivors; Elderly
18.  Reported dietary intake in early pregnant compared to non-pregnant women – a cross-sectional study 
Background
A woman’s nutritional status before conception and during pregnancy is important for maternal health and the health of the foetus. The aim of the study was to compare diet intake in early pregnant women with non-pregnant women.
Methods
Between September 2006 and March 2009, 226 women in early pregnancy were consecutively recruited at five antenatal clinics in Northern Sweden. Referent women (n = 211) were randomly selected from a current health screening project running in the same region (the Västerbotten Intervention Program; VIP). We collected diet data with a self-reported validated food frequency questionnaire with 66 food items/food aggregates, and information on portion size, alcohol consumption, and supplement intake. Data were analysed using descriptive, comparative statistics and multivariate partial least square modelling.
Results
Intake of folate and vitamin D from foods was generally low for both groups. Intake of folate and vitamin D supplements was generally high in the pregnant group and led to significantly higher total estimated intake of vitamin D and folate in the pregnant group. Iron intake from foods tended to be lower in pregnant women although iron supplement intake evened out the difference with respect to iron intake from foods only. Energy intake was slightly lower in pregnant women but not significant, a reflection of that they reported consuming significantly less of potatoes/rice/pasta, meat/fish, and vegetables (grams/day) than the women in the referent group.
Conclusions
In the present study, women in early pregnancy reported less intake of vegetables, potatoes, meat, and alcohol than non-pregnant women. As they also had a low intake (below the Nordic Nutritional Recommendations) of folate, vitamin D, and iron from foods, some of these women and their unborn children are possibly at risk for adverse effects on the pregnancy and birth outcome.
doi:10.1186/s12884-014-0373-3
PMCID: PMC4221707  PMID: 25361589
Pregnancy; Diet; Nutrition; Cross-sectional
19.  Dietary Supplement Use Within a Multiethnic Population as Measured by a Unique Inventory Method 
Use of dietary supplements is widespread, yet intakes from supplements are difficult to quantify. The Supplement Reporting (SURE) study utilized a unique inventory method to quantify dietary supplement use across one year in a sample of 397 supplement users. Interviewers visited participants’ homes in 2005–2006 to record supplement purchases and the number of pills in each supplement bottle every three months. Total use for the year was calculated from these inventories. Participants in this observational study were older adults (average age = 68 years) from the Multiethnic Cohort in Hawaii and Los Angeles, with approximately equal representation of males and females and six ethnic groups (Caucasian, Japanese-American, Hawaiian, African-American, Latinos born in the United States and Latinos born elsewhere). The most commonly used supplement type was one-a-day multivitamins/minerals, which were taken at least once during the year by 83% of men and 73% of women. Other common supplements were multivitamins, vitamin C, fish oil, vitamin E and bone or joint supplements. Participants used a median of 7 (women) and 5.5 (men) different supplements over the year. There were few differences in supplement use across ethnic groups for men, but usage tended to be highest for Caucasian and Japanese-American women. Use of non-vitamin/non-mineral supplements was common among these older adults, sometimes at high doses. When assessing intakes, supplement use should be correctly quantified because users tend to take many different supplements and nutrient intakes from supplements can be substantial. The inventory method may help improve the measurement of supplement use.
doi:10.1016/j.jada.2011.04.004
PMCID: PMC3182266  PMID: 21703385
Dietary supplement use; nutrient intakes; non-vitamin non-mineral supplements
20.  Effect of folate intake on health outcomes in pregnancy: a systematic review and meta-analysis on birth weight, placental weight and length of gestation 
Nutrition Journal  2012;11:75.
The beneficial effect of folic acid supplementation before and shortly after conception is well recognized, whereas the effect of supplementation during the second and third trimesters is controversial and poorly documented. Our aims were to systematically review randomized controlled trials (RCTs) investigating the effect of folate supplementation on birth weight, placental weight and length of gestation and to assess the dose–response relationship between folate intake (folic acid plus dietary folate) and health outcomes. The MEDLINE, EMBASE and Cochrane Library CENTRAL databases were searched from inception to February 2010 for RCTs in which folate intake and health outcomes in pregnancy were investigated. We calculated the overall intake-health regression coefficient ( β^) by using random-effects meta-analysis on a loge-loge scale. Data of 10 studies from 8 RCTs were analyzed. We found significant dose–response relationship between folate intake and birth weight (P=0.001), the overall β^ was 0.03 (95% confidence interval (CI): 0.01, 0.05). This relationship indicated 2% increase in birth weight for every two-fold increase in folate intake. In contrast, we did not find any beneficial effect of folate supplementation on placental weight or on length of gestation. There is a paucity of well-conducted RCTs investigating the effect of folate supplementation on health outcomes in pregnancy. The dose–response methodology outlined in the present systematic review may be useful for designing clinical studies on folate supplementation and for developing recommendations for pregnant women.
doi:10.1186/1475-2891-11-75
PMCID: PMC3499376  PMID: 22992251
Folate/folic acid; Pregnancy; Birth weight; Placental weight; Length of gestation; EURRECA
21.  Improvement of the Vietnamese Diet for Women of Reproductive Age by Micronutrient Fortification of Staples Foods and Condiments 
PLoS ONE  2012;7(11):e50538.
Background
A micronutrient survey carried out in 2010 among randomly selected Vietnamese women in reproductive age indicated that anemia and micronutrient deficiencies are still prevalent. The objective of this study was thus to analyze the dietary micronutrient intakes of these women, to select the food vehicles to be fortified and to calculate their contributions to meet the recommended nutrient intake (RNI) for iron, zinc, vitamin A and folic acid.
Main Findings
Consumption data showed that the median intake was 38.4% of the RNI for iron, 61.1% for vitamin A and 91.8% for zinc. However, more than 50% of the women had daily zinc consumption below the RNI. Rice and vegetable oil were consumed daily in significant amounts (median: 320.4 g/capita/day and 8.6 g/capita/day respectively) by over 90% of the women, making them suitable vehicles for fortification. Based on consumption data, fortified vegetable oil could contribute to an additional vitamin A intake of 27.1% of the RNI and fortified rice could increase the intake of iron by 41.4% of the RNI, zinc by 15.5% and folate by 34.1%. Other food vehicles, such as fish and soy sauces and flavoring powders, consumed respectively by 63% and 90% of the population could contribute to increase micronutrient intakes if they are properly fortified and promoted. Wheat flower was consumed by 39% of the women and by less than 20% women from the lowest socioeconomic strata.
Conclusion
The fortification of edible vegetable oils with vitamin A and of rice with iron, zinc and folic acid are the most promising fortification strategies to increase micronutrient intakes of women in reproductive age in Vietnam. While rice fortification will be implemented, fortification of fish and soy sauces with iron, that has been proven to be effective, has to be supported and fortification of flavouring powders with micronutrients investigated.
doi:10.1371/journal.pone.0050538
PMCID: PMC3511532  PMID: 23226308
22.  The association of time in the United States and diet during pregnancy in low-income women of Mexican descent 
Paediatric and perinatal epidemiology  2005;19(2):10.1111/j.1365-3016.2005.00640.x.
Summary
This study compared nutritional intake during pregnancy among women of Mexican descent according to country of birth (US vs. Mexico) and, for Mexico-born women, according to number of years lived in the United States (≤ 5 years, 6–10 years ≥11 years). A 72-item food frequency questionnaire (FFQ) was used to assess dietary intake in 474 pregnant Mexico-born immigrants and US-born Mexican-Americans. Mexico-born women had significantly higher intakes of calories (P = 0.02), fiber (P < 0.001), vitamin A (P < 0.001), vitamin C (P = 0.03), vitamin E (P < 0.01), folate (P < 0.01), calcium (P < 0.001) and zinc (P = 0.02) from their diets than US-born women. Intakes of all nutrients except vitamin C and zinc remained significantly higher in Mexico-born women when nutrients from both diet and vitamin supplements were considered. Among Mexico-born women, increasing years’ residence in the United States was associated with lower intake of calories (Ptrend < 0.01), fiber (Ptrend < 0.01), folate (Ptrend = 0.03), iron (Ptrend = 0.05) and zinc (Ptrend = 0.03), although only the trend for iron remained significant when vitamin supplement sources were included. A large percentage of women had inadequate intake of vitamin E (58%), folate (61%), iron (77%) and zinc (47%) from their diets during pregnancy and these rates were higher in US-born women than Mexico-born women.
doi:10.1111/j.1365-3016.2005.00640.x
PMCID: PMC3882002  PMID: 15787887
23.  Maternal B vitamin status in pregnancy week 18 according to reported use of folic acid supplements 
Scope
Epidemiological studies on the association between pregnancy outcomes and use of periconceptional folic acid are often based on maternal reported intake. Use of folic acid during pregnancy is associated with a higher socioeconomic status known to have an impact on diet quality. We have studied plasma B vitamin status according to reported use of folic acid supplements during the periconceptional period in Norwegian women.
Methods and results
Plasma levels of folate, cobalamin, pyridoxal 5′-phosphate (vitamin B6), riboflavin and the metabolic markers total homocysteine, methylmalonic acid and 3-hydroxykynurenine were measured in pregnancy week 18 and related to reported intake of folic acid from 4 weeks prior to conception throughout week 18 in 2911 women from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health.
Being a folic acid user during the periconceptional period was associated with a better socioeconomic status, and a higher intake of several micronutrients, including vitamins, trace-metals and omega 3 fatty acids. Folic acid users had a significantly better plasma B vitamin status.
Conclusions
Epidemiological data based on maternal reported intake of folic acid supplements during pregnancy, should take into account the numerous nutritional implications, in addition to higher blood folate levels, of being a folic acid user.
doi:10.1002/mnfr.201200114
PMCID: PMC3774931  PMID: 23001761
Folic acid; periconceptional; B vitamin status; pregnancy; micronutrients
24.  Inadequate Dietary Intake in Patients with Thalassemia 
Background
Patients with thalassemia have low circulating levels of many nutrients, but the contribution of dietary intake has not been assessed.
Objective
Assess dietary intake in a large contemporary sample of patients with thalassemia.
Design
Prospective, longitudinal cohort study using a validated food frequency questionnaire
Participants
221 patients (19.7±11.3 yrs, 106 female) categorized into three age groups: young children (3–7.9 y), older children/adolescents (8–18.9 yr), and adult (≥ 19 yr). 78.8% β-thalassemia; 90% chronically transfused.
Setting
10 hematology outpatient clinics in the United States and Canada.
Main outcome measures
Comparison of intake with U.S. Dietary Reference Intakes, and correlation with serum 25-OH vitamin D and total body iron stores.
Statistical Analyses Performed
Intake was defined as inadequate if less than the estimated average requirement (EAR). Chi-square, Fisher’s exact and Student’s t-test were utilized to compare intake between age categories and logistic regression analysis to test the relationship between intake and outcomes, controlling for age, gender and race.
Results
Over 30% of patients consumed inadequate levels of vitamin A, D, E, K, folate, calcium, and magnesium. The only nutrients for which >90% of patients consumed adequate amounts were riboflavin, vitamin B12 and selenium. Dietary inadequacy increased with increasing age group (p<0.01) for vitamins A, C, E, B6, folate, thiamin, calcium, magnesium and zinc. Over half the sample took additional supplements of calcium and vitamin D, although circulating levels of 25-OH vitamin D remained insufficient in 61% of patients. Dietary iron intake was not related to total body iron stores.
Conclusion
Patients with thalassemia have reduced intake of many key nutrients. These preliminary findings of dietary inadequacy is concerning and supports the need for nutritional monitoring to determine which patients are at greatest risk for nutritional deficiency. Future research should focus on the effect of dietary quality and nutritional status on health outcomes in thalassemia.
doi:10.1016/j.jand.2012.01.017
PMCID: PMC3419338  PMID: 22551675
Thalassemia; dietary intake; iron; vitamin D
25.  Comparison of dietary food and nutrient intakes by supplement use in pregnant and lactating women in Seoul 
Nutrition Research and Practice  2013;7(3):199-206.
This study was performed to compare the dietary food and nutrient intakes according to supplement use in pregnant and lactating women in Seoul. The subjects were composed of 201 pregnant and 104 lactating women, and their dietary food intake was assessed using the 24-h recall method. General information on demographic and socioeconomic factors, as well as health-related behaviors, including the use of dietary supplements, were collected. About 88% and 60% of the pregnant and lactating women took dietary supplements, respectively. The proportion of dietary supplements used was higher in pregnant women with a higher level of education. After adjusting for potential confounders, among the pregnant women, supplement users were found to consume 45% more vegetables, and those among the lactating women were found to consume 96% more beans and 58% more vegetables. The intakes of dietary fiber and β-carotene among supplement users were higher than those of non-users, by 23% and 39%, respectively. Among pregnant women, the proportion of women with an intake of vitamin C (from diet alone) below the estimated average requirements (EAR) was lower among supplement users [users (44%) vs. non-users (68%)], and the proportion of lactating women with intakes of iron (from diet alone) below the EAR was lower among supplement users [usesr (17%) vs. non-users (38%)]. These results suggest that among pregnant and lactating women, those who do not use dietary supplements tend to have a lower intake of healthy foods, such as beans and vegetables, as well as a lower intake of dietary fiber and β-carotene, which are abundant in these foods, and non-users are more likely than users to have inadequate intake of micro-nutrient such as vitamin C and iron.
doi:10.4162/nrp.2013.7.3.199
PMCID: PMC3679329  PMID: 23766881
Dietary intake; supplement; pregnant women; lactating women

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