Folic acid deficiency (DNB Solved questions)

1. Dr.Padmesh. V
NEURAL TUBE DEFECT
ROLE OF FOLIC ACID
DR. PADMESH . V

2. Dr.Padmesh. V
• INTRODUCTION:
• Folate prevents NTDs.
• Folate functions in single-carbon transfer reactions .
• Exists in many chemical forms.
• Folic acid (pteroylmonoglutamic acid), which is the most oxidized and
stable form of folate, occurs rarely in food but is the form used in
vitamin supplements and in fortified food products.
• Most naturally occurring folates (food folate) are
pteroylpolyglutamates.

3. • ACTION OF FOLATE: Dr.Padmesh. V
• Folate coenzymes are involved in:
• (1) deoxyribonucleic acid (DNA) synthesis,
• (2) Purine synthesis,
• (3) generation of Formate into the formate pool, and
• (4) amino acid interconversion with the conversion of homocysteine
to Methionine providing methionine for the synthesis of S-
adenosyl-methionine (an agent important for in vivo methylation).
• Mutations in the genes encoding the enzymes involved in homocysteine
metabolism include 5,10 methylenetetrahydrofolate reductase
(MTHFR), cystathionine β-synthase, and methionine synthase.
• An association between a thermolabile variant of MTHFR and mothers of
children with NTDs may account for up to 15% of preventable NTDs.

4. • ACTION OF FOLATE: Dr.Padmesh. V
• Folic Acid in Prevention of NTDs
• Folic acid plays an important role in closure of neural tube
(neurulation).
• There are two general and important biological effects of folate.
• First, folate acts as a cofactor for enzymes involved in DNA and RNA
biosynthesis.
• Folate provides one-carbon units for the de-novo synthesis of DNA
bases (guanidine, adenine, and thymine).
• Folate requirements increase dramatically during the periods of rapid
growth of fetus.
• Thus with folate deficiency, DNA synthesis is inhibited and cells are
unable to manufacture enough DNA for mitosis, leading to limited
and/or imbalanced cell growth, followed by cell death.

5. • ACTION OF FOLATE: Dr.Padmesh. V
• Folic Acid in Prevention of NTDs
• Folic acid plays an important role in closure of neural tube
(neurulation).
• There are two general and important biological effects of folate.
• Second, folate is involved in the supply of methyl groups to the
methylation cycle.
• The methyl group is used by methionine synthetase, to recycle
homocysteine back to methionine. A disturbance in this process
causes hyperhomocysteinemia and shortage of methionine;
therefore cells are not able to methylate important compounds like
proteins, lipids and myelin.
• Thus, folate deficiency or genetically rooted error in folate
metabolism can cause developmental defects through disturbances
of DNA biosynthesis and/or the methylation cycle

6. Dr.Padmesh. V
• Maternal periconceptional use of folic acid supplementation reduces
the incidence of neural tube defects in pregnancies at risk by at least
50%.
• To be effective, folic acid supplementation should be initiated 1 mo
before the time of the planned conception and continued until at
least the 12th wk of gestation when neurulation is complete.

7. • PREVENTION. Dr.Padmesh. V
• Fortification of food: To increase folic acid intake, fortification of
flour, pasta, rice, and cornmeal .
• Health education: Informative educational programs.
• Folic acid vitamin supplementation;
• Consume food folate from a varied diet. Dietary sources of folate are
leafy green vegetables, legumes (beans, peas), citrus fruits
(juices), liver and whole bread .

8. • PREVENTION. Dr.Padmesh. V
• All women of childbearing age and who are capable of becoming
pregnant take 0.4 mg of folic acid daily.
• To avoid occurrence of NTD: 0.4 mg/day.
• If, however, a pregnancy is planned in high-risk women (previously
affected child), supplementation should be started with 4 mg of folic
acid daily, beginning 1 mo before the time of the planned
conception, and continued until at least the 12th wk of gestation
when neurulation is complete.
• To avoid recurrence of NTD: 4 mg/ day.

9. • PREVENTION. Dr.Padmesh. V
• Drugs that antagonize folic acid such as trimethoprim and the
anticonvulsants carbamazepine, phenytoin, phenobarbital, and
primidone, increase the risk of myelomeningocele.
• Women on anticonvulsants,antimetabolites, and oral contraceptives
have suboptimal folate status.
• Anticonvulsant valproic acid causes neural tube defects in ≈1–2% of
pregnancies, if the drug is administered during pregnancy.
• Some epilepsy clinicians recommend that all female patients of
childbearing potential who take anticonvulsant medications should
also receive folic acid supplements.

10. • PREVENTION. Dr.Padmesh. V
• GENETIC COUNSELING
• ANTE NATAL USG
• MSAFP

11. Dr.Padmesh. V
• Neural tube closure occurs during days 22-28.
• Therefore, advice regarding dietary
modification, supplementation, and food fortification should be in
the periconceptional period i.e. beginning at least 1 month before
conception and continuing through the first trimester.
• Studies have demonstrated that periconceptional folic acid
supplementation can prevent 50% or more of NTDs such as spina
bifida and anencephaly.

12. Dr.Padmesh. V
REFERENCE