1. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Chapter 2 Folic Acid

2. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri An Ounce of Prevention Addressing Health Issues of Adolescents and Young Adults

3. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Chapter 2 Folic Acid The miracle vitamin? Practical problem: What do I need to know about folic acid and how it affects health and fetal development?

4. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Key concepts 1.Folic acid Vitamin B9 Sources Functions 2.Importance prior to conception Reduction vs. prevention of birth defects Impact on general health Folic acid timing Neural tube closure Daily dietary recommendations

5. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Objectives 1.Define folic acid. 2.Analyze sources of folic acid and the daily dietary recommendation. 3.Simulate neural tube closure. 4.Summarize the characteristics of the two major neural tube defects, spina bifida and anencephaly. 5.Explain other health benefits of folic acid.

6. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Rationale Evidence suggests that taking folic acid before conception and during critical periods of fetal development decreases the risk for certain physical birth defects. This chapter provides general information about folic acid, its role in our bodies and how it reduces the chance for neural tube defects. Information about neural tube defects is also presented.

7. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri What is folic acid? The synthetic form of folate, vitamin B9.

8. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Sources of folate Food sources Green vegetables Orange juice Beans, nuts Liver Yeast breads Fruits Eggs

9. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Sources of folic acid 1.Foods enriched with folic acid — mainly grain products 2.Vitamins — the synthetic form of folate Enriched

10. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri U.S. dietary sources of folate and folic acid Highest Contributors Orange juice White bread Super-fortified cereals Dried beans Eggs Liver Richest Sources Liver Super-fortified cereals Cold cereals Asparagus Spinach Instant breakfast Bran/granola cereals Broccoli Avocados Adapted from American Journal of Clinical Nutrition vol. 50(3), Subar et al, 1989.

11. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Causes of low folic acid levels Alcohol Diet low in folate or folic acid Peak times of cell proliferation

12. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Folate or folic acid? Folic acid, the synthetic form, has almost 100 percent bioavailability Dietary folate  can be destroyed by cooking processing and storage  is not absorbed as well as synthetic folic acid  has 50 percent bioavailability

13. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Benefits of folic acid during pregnancy Prevention of neural tube defects Protective factor to reduce the risk of other birth defects Positive effects for pregnancy term and prenatal growth Decreases homocysteine effect on the placenta placental abruption clogging of placental blood vessels

14. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Folic acid also benefits heart health Taking folic acid can help to reduce the risks for cardiovascular disease — for everyone.

15. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Two major roles of folic acid 1.Nucleic acid synthesis and cell division DNA is made up of nucleic acids DNA replicates and divides during cell division Cell division develops and maintains our bodies Pregnancy is a time of rapid cell division

16. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri 2. Methylation Methylation is a biochemical process that turns genes “off.” Methylation is essential for normal development. Methionine is a naturally occurring amino acid. Homocysteine, also an amino acid, is produced in the body during the metabolism of methionine. As homocysteine increases, the risk of heart disease increases. When folic acid levels are low, homocysteine levels increase. Folic acid helps break down and reduce homocysteine in the body. Two major roles of folic acid

17. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Who should take folic acid? Everyone! Folic acid reduces the chance for birth defects and pregnancy problems, and helps prevent cardiovascular disease.

18. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri How much folic acid? Females of childbearing capability: 400 micrograms Females who have had one child with a neural tube defect: 4 milligrams (10 x 400 micrograms) 400 micrograms 400 micrograms

19. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri When to take folic acid? Before and after conception Throughout pregnancy While breastfeeding

20. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Development of the spinal cord Source: Answering Your Questions About Spina Bifida, a guide from The Spina Bifida Program, Department of General Pediatrics. Children’s National Medical Center, 1995. Washington, D.C.

21. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Neural tube defects (NTD) The neural tube  is an embryonic structure that will become the brain and spinal cord  develops first as a flat layer of cells that roll into a cylinder and “zip” shut Neural tube defects  affect the brain or spine, and occur when the tube fails to close  are the second most common birth defect

22. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Features of neural tube development and neural tube defects Reprinted by permission from The New England Journal of Medicine, 341[1999]:1509-1519.

23. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri What You Should Know About Folic Acid, for parents who have lost a pregancy or had a child with spina bifida, anencephaly, or encephalocele. Children’s Hospital Medical Center of Akron, fourth printing, 1999. Spina Bifida occurs when a baby’s spine does not form properly. Part of the spinal cord may be outside the bones of the spine (vertebrae) and is often not properly formed. This can lead to varying degrees of muscle weakness, paralysis, loss of sensation in the leg and/or poor bladder and bowel control. Some babies with spina bifida also develop fluid on the brain (hydrocephalus), which occasionally causes brain damage. Anencephaly is a neural tube defect in which the top part of the skull and brain fail to form properly. Babies with anencephaly may be miscarried, stillborn or die shortly after birth. Encephalocele is another less common neural tube defect. This occurs when part of a baby’s skull does not form properly and part of the brain is outside of the skull. Babies with this type of neural tube defect usually die. Babies who survive may have physical and mental handicaps. Neural tube defects (NTD)

24. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Spina bifida Can lead to paralysis and kidney malfunction The location, type and severity of the defect affects the level of impairment Requires surgery 24 to 48 hours after birth

25. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Complication of spina bifida: Hydrocephalus Excess fluid around the brain Surgical procedure inserts shunt to drain fluid into the abdomen Early treatment improves chances for normal cognitive development

26. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Anencephaly Partial or complete absence of the brain There are no options for surgical correction Infants are usually stillborn or die shortly after birth

27. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Encephalocele Brain tissue herniates into a sac protruding from the skull opening Rarer than other neural tube defects Methods of surgical correction and level of function vary

28. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Causes of neural tube defects Chromosomal abnormality Genetic syndrome Multifactorial inheritance combination of genetic and environmental factors 90 percent are multifactorial genetic and environmental factors not exactly known research continues, including the connection with folic acid

29. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Who is at risk for neural tube defects? All couples have some risk Factors that contribute to a higher risk English or Irish ancestry Family history of neural tube defects Low levels of folic acid Poor diet Maternal hyperthermia: exposure to high temperatures through tanning beds, saunas, hot tubs and high fever

30. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Reduce risks for neural tube defects Avoid high temperatures Maintain a healthy diet and weight Take folic acid daily before becoming pregnant

31. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Remember: The neural tube closes by day 28. Most pregnancies are unplanned. The neural tube closes before many women know they are pregnant. Get into the folic acid habit now.

32. An Ounce of Prevention  2000, 2005, 2011 The Curators of the University of Missouri Key learning activities Analyze labels Simulate neural tube closure Develop a marketing tool Add it Up folate in food calculation Folic Acid Bingo E-learning activity: Folic Acid Jeopardy