Background: There has been a concern regarding the masking of vitamin B-12 deficiency in the post-fortification period (after January 1, 1998). Objective: The objective of this study was to investigate the potential masking of vitamin B-12 deficiency by comparing the proportion of individuals with low serum B-12 without macrocytosis between pre- and post-fortification periods using data from the National Health and Nutrition Examination Survey (NHANES). Methods: The study included 7242 individuals from NHANES III (pre-fortification group) and combined NHANES 1999-2000, 2001-2002, 2003-2004, 2005-2006 (post-fortification group). Vitamin B-12 deficiency and macrocytosis were defined as having <148 pmol/L of serum vitamin B-12 and mean corpuscular volume (MCV) of>98 fL, respectively. A multivariate logistic regression was performed to estimate the likelihood of being low serum B-12 without macrocytosis in the post-fortification period in relation to the pre-fortification period. Results: Between pre- and post-fortification periods, there was no significant difference in the proportion of individuals with low serum vitamin B-12 without macrocytosis. However, odds of having low serum vitamin B-12 without macrocytosis in the post fortification era increased in men (OR=2.65, 1.24-5.65), non-Hispanic blacks (OR=3.12, 1.04-9.35), Non-smokers (OR=4.63, 1.90-11.27), and those aged 55 and older (OR=2.183, 1.01-4.74) compared their respective counterparts in the pre-fortification period. Conclusions: No significant difference in the proportion of individuals with vitamin B-12 deficiency without macrocytosiss was seen between the pre and post-fortification periods suggesting no making of vitamin B-12 deficiency. In the post-fortification period, serum folate was found to be a predictor of the masking effect. The impact of increased folic acid intake in the post-fortification period needs to be evaluated on a periodic basis especially, in non-target population.

Statement of problem: We have shown that the C677T 5,10 methylenetetrahydrofolate reductase (MTHFR) variant is associated with elevated maternal serum α-fetoprotein (MSAFP), the most common screening test for neural tube defects (NTD). Therefore, past contradictory studies of NTDs and C677T MTHFR may have been biased because of changes in case populations after prenatal diagnosis and termination of pregnancy. Further, an unexplained elevation of MSAFP is known to increase the risk for later pregnancy complications. Is the C677T MTHFR variant a predisposing genetic variant for both NTDs and later complications of pregnancy? Methods: A retrospective study of women with pregnancies resulting in NTD outcome and women with unexplained elevations of MSAFP was undertaken. Women and their partners were genotyped for the C677T MTHFR allele. Couples with a pregnancy resulting in a NTD outcome were compared to couples whose pregnancy outcome did not involve. Couples with unexplained elevations of MSAFP who did and did not have later complications of pregnancy were also compared. Allele frequencies for all groups were then compared against the previously established Manitoba population allele frequency (based on 977 consecutive newborn metabolic screening bloodspots). A review of all studies of NTDs and association with the C677T MTHFR variant was undertaken to determine if the association between the variant and MSAFP is a source of bias. NTD incidence was examined before and after folic acid food fortification introduced in Canada in 1999. Results: There is an increase in the allele frequency of the C677T MTHFR variant in parents with an unexplained elevated MSAFP followed by later complications of pregnancy. The C677T MTHFR variant is also a contributing genetic factor to NTDs worldwide. The incidence of NTDs in Manitoba has decreased by 37% since food fortification with folic acid was introduced. Conclusions: The C677T MTHFR variant is a contributing genetic factor to both later complications of pregnancy after an unexplained elevation of MSAFP and to NTDs. This variant is folate sensitive and folic acid fortification has reduced the incidence of NTDs.