Iodine supplementation in pregnancy and its effect on child cognition

Maternal hypothyroidism and hypothyroxenemia due to iodine deficiency have been shown to affect development of the newborn negatively. Maternal iodine supplementation may therefore improve cognitive performance of the offspring, even in areas of mild-to-moderate iodine deficiency (ID). Several iodine supplementation studies have been performed in mildly ID pregnant women in Europe. These studies have shown that iodine supplementation increases maternal urinary iodine (UI) excretion and reduces thyroid volume, as well as prevents increases in infant thyroid volume and thyroglobuline. However, randomized controlled studies with long-term outcomes are lacking. Therefore, two trials were started in 2008 in areas of low iodine status; one in Bangalore, India (n=325), and another in Bangkok, Thailand (n=514). Pregnant women were recruited <14 weeks gestational age and randomized to either receive a daily dose of 200 μg I (as KI) or an identical placebo throughout pregnancy. Both trials are ongoing, and women are followed up during pregnancy and at delivery. UI, thyroid hormones, and thyroid size are measured. Birth outcomes are recorded, such as gestational age at delivery, height, weight, and APGAR scores, and cord blood and heel stick blood (<72 h) is collected from the child. Child development is assessed at 6 weeks of age using the Neonatal Behavioral Assessment Scale (NBAS), and at 12 and 24 months of age using the Bayley Scales of Infant Development. The outcomes of these trials will contribute importantly to the evidence base for iodine supplementation of pregnant women living in areas of mild iodine deficiency.     

The fruit bat as an experimental model of the neuropathy of cobalamin deficiency

The fruit bat provides a unique small mammal model of the neurological changes associated with cobalamin deficiency. Work with this model has shown that methionine moderates the development of the neurological impairment. This action does not appear to be via the methyl donor S-adenosylmethionine, but its role in the provision of formate is not excluded. Furthermore, methylation reactions in the nervous system are not impaired in severe cobalamin deficiency, despite low levels of methionine synthetase activity. The accumulation of physiologically inactive analogues of cobalamin also do not appear to be aetiologically important in the neuropathy. Brain folates are minimally affected by severe cobalamin deficiency, although liver folates decrease significantly. Deranged GABA function in the brain may play a role in the symptomatology of cobalamin deficiency. There is some evidence for the hypothesis that deranged fatty acid metabolism in neural tissue contributes to altered membrane structure and hence function. Changes in the properties of membrane proteins may play a contributory role. The biochemical basis of the neuropathy has still to be fully elucidated.     

Vitamin B12 absorption: Mammalian physiology and acquired and inherited disorders

Background

Vitamin B12 (cobalamin) is a cobalt-containing compound synthesized by bacteria and an essential nutrient in mammals, which take it up from diet. The absorption and distribution of dietary vitamin B12 to the organism is a complex process involving several gene products including carrier proteins, plasma membrane receptors and transporters. Disturbed cellular entry, transit or egress of vitamin B12 may lead to low vitamin B12 status or deficiency and eventually hematological and neurological disorders.

Objective

The aim of this review is to summarize the causes leading to vitamin B12 deficiency including decreased intake, impaired absorption and increased requirements. Under physiological conditions, vitamin B12 bound to the gastric intrinsic factor is internalized in the ileum by a highly specific receptor complex composed by Cubilin (Cubn) and Amnionless (Amn). Following exit of vitamin B12 from the ileum, general cellular uptake from the circulation requires the transcobalamin receptor CD320 whereas kidney reabsorption of cobalamin depends on Megalin (Lrp2).Whereas malabsorption of vitamin B12 is most commonly seen in the elderly, selective pediatric, nondietary-induced B12 deficiency is generally due to inherited disorders including the Imerslund-Gräsbeck syndrome and the much rarer intrinsic factor deficiency. Biochemical, clinical and genetic research on these disorders considerably improved our knowledge of vitamin B12 absorption.This review describes basic and recent findings on the intestinal handling of vitamin B12 and its importance in health and disease.     

Ocular,neurologic and hematologic manifestations of an inherited abnormality in vitamin B12 metabolism: case study and review of the literature

A deficiency of vitamin B₁₂ or cobalamin is well documented to cause both neurologic deficits and anemia. These clinical manifestations are particularly extensive when the lack of cobalamin occurs at birth. The profound deficits in Cobalamin C deficiency originate from the inability of the body's cells to transform inactive cobalamin obtained from the diet into an active form necessary for the proper growth and development of the child. The relevant biochemistry and physiology of cobalamin which functions in vital bodily processes is discussed. This serves to explain the laboratory abnormalities and some of the neurologic and ocular manifestations of cobalamin deficiency.     

Decreased Brain Levels of Vitamin B12 in Aging,Autism and Schizophrenia

Many studies indicate a crucial role for the vitamin B₁₂ and folate-dependent enzyme methionine synthase (MS) in brain development and function, but vitamin B₁₂ status in the brain across the lifespan has not been previously investigated. Vitamin B₁₂ (cobalamin, Cbl) exists in multiple forms, including methylcobalamin (MeCbl) and adenosylcobalamin (AdoCbl), serving as cofactors for MS and methylmalonylCoA mutase, respectively. We measured levels of five Cbl species in postmortem human frontal cortex of 43 control subjects, from 19 weeks of fetal development through 80 years of age, and 12 autistic and 9 schizophrenic subjects. Total Cbl was significantly lower in older control subjects (> 60 yrs of age), primarily reflecting a >10-fold age-dependent decline in the level of MeCbl. Levels of inactive cyanocobalamin (CNCbl) were remarkably higher in fetal brain samples. In both autistic and schizophrenic subjects MeCbl and AdoCbl levels were more than 3-fold lower than age-matched controls. In autistic subjects lower MeCbl was associated with decreased MS activity and elevated levels of its substrate homocysteine (HCY). Low levels of the antioxidant glutathione (GSH) have been linked to both autism and schizophrenia, and both total Cbl and MeCbl levels were decreased in glutamate-cysteine ligase modulatory subunit knockout (GCLM-KO) mice, which exhibit low GSH levels. Thus our findings reveal a previously unrecognized decrease in brain vitamin B₁₂ status across the lifespan that may reflect an adaptation to increasing antioxidant demand, while accelerated deficits due to GSH deficiency may contribute to neurodevelopmental and neuropsychiatric disorders.     

Low Birthweight (LBW) and Neonatal Hyperbilirubinemia (NNH) in an Indian Cohort: Association of Homocysteine,Its Metabolic Pathway Genes and Micronutrients as Risk Factors

Background & Aims

Indian subcontinent has the highest child mortality rates along with a very high frequency of low birthweight (LBW). Folate and vitamin B12 (Vit-B12) are necessary during foetal development and their deficiency prevalence in Indians is very high. The objective of the present paper is to assess whether foetal homocysteine (Hcy)/folate metabolic pathway genes, their cofactors and homocysteine level independently (or collectively) predispose children to Low birth weight.

Methods

Cord blood was collected for the study. Frequency of 5 SNPs in 4-Hcy-pathway genes, and levels of Hcy, Vit-B12 and folate were evaluated.

Results

Of the 421 newborns recruited for the study, 38% showed low birth weight (<2.5kg) and 16% were preterm babies. 101 neonates developed neonatal hyperbilirubinemia (NNH). High prevalence of Vit-B12 (65%) and folate (27%) deficiency was observed in newborns along with hyperhomocystinemia (hypHcy-25%). Preterm delivery, micronutrient deficiency, hypHcy and MTHFR 677T SNP are associated as risk factor while G allele of TCN2 C776G is protective against LBW. MTHFR 677T allele and folate deficiency are also independent risk factors for NNH.

Conclusion

We record the highest incidence of Vit-B12, folate deficiency and elevated Hcy levels, of all the studies so far reported on neonates. These together with MTHFR 677T are potential risk factors for LBW. Association of impaired folate/Hcy metabolism with NNH is reported for the first time and the possible way of interaction is discussed. It appears that proper nutritional management during pregnancy would reduce the risk of complex clinical outcomes.     

Homocysteine in the context of cobalamin metabolism and deficiency states

It is becoming increasingly clear that serum vitamin B12 (cobalamin) concentration is a dubious indicator of functional B12 status and, in contrast to long-standing convention, correlates poorly with haematological indices. This, in turn, has led to poorly defined reference intervals for serum B12. Patients presenting with neurological disturbance due to B12 deficiency are at risk of not being diagnosed if total reliance is placed on serum B12 levels and haematological parameters. Plasma homocysteine remethylation is uniquely placed at the metabolic end-point of B12 metabolism such that plasma total homocysteine is proving to be a sensitive marker of functional B12 status. Studies also show that plasma homocysteine correlates better with holotranscobalamin than serum B12. It is suggested that clinicians should cease to be guided by surrogate haematological markers when more specific tests of B12 deficiency, such as holotranscobalamin and total homocysteine, exist. These tests demand greater prevalence in routine diagnostic use.     

Effects of maternal vitamin B12 deficiency from end of gestation to weaning on the growth and haematological and immunological parameters in mouse dams and offspring

Vitamin B12-deficiency may induce specific symptoms as neurological alterations and unspecific symptoms such as anaemia and growth retardation. In this study, maternal vitamin B12 deficiency from end of gestation to weaning was evaluated in mouse dams, which was provoked by feeding a vitamin B12-deficient diet. The animals were divided into two groups (control and deficient). The control group received the vitamin B12-deficient diet supplemented with commercial vitamin B12. Compared to the control, the vitamin B12-deficient dams and their offspring showed a significant decrease of body weight (by 20 and 39%, respectively), serum vitamin B12 concentration (by 61 and 67%, respectively), haematological values as haematocrit (25 and 26%, respectively), and IgA producer cells (by 36 and 54%, respectively). In both, vitamin B12-deficient mouse dams and their offspring, histological alterations of small intestine were observed, whereas growth retardation occurred in the offspring only. This experimental murine model allows assessing the incidence of maternal cobalamin deficiency in offspring and would be useful for evaluating novel adjuncts such as functional foods to prevent vitamin B12 deficiency.     

Localization of DNA in ultrascopic nuclear appendages of polymorphonuclear white blood cells from patients with low serum B(12).

Polymorphonuclear white blood cells from patients with low serum vitamin B(12) (cobalamin) have ultrascopic appendages that project from their nuclear membranes. These appendages are most often found in the shape of blebs and stalks. Cytoplasmic rings that may be separated from the nucleus have also been seen. There is no known function for these appendages. Blood from 11 patients with low serum B(12) was processed for electron microscopic examination. In situ end-labeling of DNA and subsequent electron microscopic examination were performed. DNA was localized in all of the visualized appendages and rings. Treatment with DNases I and II decreased the labeling of these appendages by 63%. These DNA-laden appendages are a unique ultrastructural finding and may function to transfer fragmented DNA, which occurs in vitamin B(12) deficiency, from the nucleus into the cytoplasm.     

Comparative genomics of the vitamin B12 metabolism and regulation in prokaryotes

Using comparative analysis of genes, operons, and regulatory elements, we describe the cobalamin (vitamin B12) biosynthetic pathway in available prokaryotic genomes. Here we found a highly conserved RNA secondary structure, the regulatory B12 element, which is widely distributed in the upstream regions of cobalamin biosynthetic/transport genes in eubacteria. In addition, the binding signal (CBL-box) for a hypothetical B12 regulator was identified in some archaea. A search for B12 elements and CBL-boxes and positional analysis identified a large number of new candidate B12-regulated genes in various prokaryotes. Among newly assigned functions associated with the cobalamin biosynthesis, there are several new types of cobalt transporters, ChlI and ChlD subunits of the CobN-dependent cobaltochelatase complex, cobalt reductase BluB, adenosyltransferase PduO, several new proteins linked to the lower ligand assembly pathway, l-threonine kinase PduX, and a large number of other hypothetical proteins. Most missing genes detected within the cobalamin biosynthetic pathways of various bacteria were identified as nonorthologous substitutes. The variable parts of the cobalamin metabolism appear to be the cobalt transport and insertion, the CobG/CbiG- and CobF/CbiD-catalyzed reactions, and the lower ligand synthesis pathway. The most interesting result of analysis of B12 elements is that B12-independent isozymes of the methionine synthase and ribonucleotide reductase are regulated by B12 elements in bacteria that have both B12-dependent and B12-independent isozymes. Moreover, B12 regulons of various bacteria are thought to include enzymes from known B12-dependent or alternative pathways.     

Expression of fetal thymidine kinase in human cobalamin or folate deficient lymphocytes.

In extracts of peripheral blood lymphocytes of cobalamin or folate deficient patients thymidine kinase activity is increased three fold and exhibits properties of the fetal isoenzyme. Appropriate vitamin therapy results in reduction of this activity to normal levels and change from fetal to adult isoenzyme. The occurrence in cobalamin or folate deficiency of fetal thymidine kinase activity in non proliferating human lymphocytes is unique and may reflect events in the deficient marrow lymphoid progenitor cells.     

Inherited disorders of vitamin B12 utilization

Inborn errors of vitamin B12 (cobalamin) metabolism are associated with homocystinuria and methylmalonic aciduria, either alone or in combination. A number of these disorders have provided the first evidence for the existence of important steps in the transport or metabolism of cobalamin in eukaryotic cells. Eight complementation classes have been defined on the basis of somatic cell hybridization studies. Although the majority of patients present in infancy or early childhood, some are not diagnosed until adolescence or later. For some of these disorders, prenatal diagnosis and therapy with cobalamin during pregnancy has been attempted. Although only males have been described with cblE disease, all of these disorders are presumed to be autosomal recessive in inheritance. The clinical and laboratory aspects of the different complementation classes (cblA-cblG) are reviewed here.     

A Salmonella typhimurium cobalamin-deficient mutant blocked in 1-amino-2-propanol synthesis.

Salmonella typhimurium synthesizes cobalamin (vitamin B12) when grown under anaerobic conditions. All but one of the biosynthetic genes (cob) are located in a single operon which includes genes required for the production of cobinamide and dimethylbenzimidazole, as well as the genes needed to form cobalamin from these precursors. We isolated strains carrying mutations (cobD) which are unlinked to any of the previously described B12 biosynthetic genes. Mutations in cobD are recessive and map at minute 14 of the linkage map, far from the major cluster of B12 genes at minute 41. The cobD mutants appear to be defective in the synthesis of 1-amino-2-propanol, because they can synthesize B12 when this compound is provided exogenously. Labeling studies in other organisms have shown that aminopropanol, derived from threonine, is the precursor of the chain linking dimethylbenzimidazole to the corrinoid ring of B12. Previously, a three-step pathway has been proposed for the synthesis of aminopropanol from threonine, including two enzymatic steps and a spontaneous nonenzymatic decarboxylation. We assayed the two enzymatic steps of the hypothetical pathway; cobD mutants are not defective in either. Furthermore, mutants blocked in one step of the proposed pathway continue to make B12. We conclude that the aminopropanol for B12 synthesis is not made by this pathway. Expression of a lac operon fused to the cobD promoter is unaffected by vitamin B12 or oxygen, both of which are known to repress the main cob operon, suggesting that the cobD gene is not regulated.     

Genetic patterns of transcobalamin II and the relationships with congenital defects

The vitamin B12-binding protein, transcobalamin II, is a trace component of plasma with a rapid turnover. This protein is essential for absorption, transport, cellular uptake and for recycling of vitamin B12 (cobalamin). Congenital transcobalamin II deficiency, an inborn error of metabolism is inherited as a recessive trait. The homozygous form of the deficiency is accompanied by severe clinical, hematological and immunological disturbances in the first months of life. Analytical, genetic, biochemical and clinical aspects of transcobalamin II in man and in vertebrates have been reviewed here. A genetic polymorphism for the protein has been found in man, rabbits and mice. Family studies revealed that the genetic patterns in man are determined by four polymorphic and several rare alleles. This genetic variability has been applied in paternity testing and in population studies. Transcobalamin II typing in families of patients with the inherited functional deficiency has led to identification of various deficient alleles in heterozygous carriers of the defects. Applying transcobalamin II typing after bone marrow transplantation demonstrated that this protein originates partly in the bone marrow. Subsequent investigations in cell culture have shown that human skin fibroblasts and cultured bone marrow synthesize and secret isotypes of a transport protein corresponding to the genetic isotypes observed in plasma. Comparison of transcobalamin II types in umbilical cord serum with the maternal types, has proven that the transcobalamin II activity in the cord serum is derived from the fetus. This finding will be of crucial importance in the early diagnosis of the deficiency syndrome.     

MTHFR Polymorphisms Involved in Vitamin B12 Deficiency Associated with Atrophic Gastritis

Genetic polymorphisms affecting methylentetrahydrofolate reductase (MTHFR) activity may influence hematological and neurological dysfunction in cobalamin-deficient patients. We studied the prevalence of C677T and A1298C polymorphisms by analyzing genomic DNA in 30 cobalamin-deficient patients. No significant difference was found in 677 and 1298 genotype distribution with respect to hematological parameters, B₁₂ and folate levels, and neurological symptoms. The two MTHFR polymorphisms were not protective against anemia or neurological dysfunction in patients with cobalamin deficiency; however, we found evidence of a significant increase in atrophic gastritis in the 677TT group (P = 0.009) but not for the 1298CC genotype. Based on observations that inadequate cobalamin intake and reduced MTHFR activity might be significant risk factors for gastric cancer, and the increased risk of gastric cancer shown in patients affected by atrophic gastritis, we speculate that concomitant atrophic gastritis and impaired MTHFR function could have a role in the development of gastric cancer.     

The impact of assay quality and reference ranges on clinical decision making in the diagnosis of androgen disorders

The Endocrine Society guideline on Androgen Deficiency in Men emphasized that accurate measurement of testosterone (T) levels is central to the diagnosis of androgen deficiency. Similarly, accurate measurements of testosterone levels are important in the diagnosis of androgen disorders in women and children. However, the accuracy of direct radioimmunoassays for the measurement of total T levels has been questioned, especially in the low range prevalent in women, children, and androgen deficient men. Furthermore, reference limits for total and free T levels generated in a population-based sample of community-dwelling men, women, and children are not available. In the absence of standardized reference limits, the partitioning of total and free T levels into normal, low, or high values is fraught with substantial risk of misclassification. The recommendations for partitioning of individuals into those with low, normal, or high levels should be based on considerations of statistical distribution of total and free T values and the association of outcomes with varying degree of deviations from the reference limits. Ongoing efforts to generate population-based reference ranges for total and free testosterone levels in men and women will provide a framework for the interpretation of serum T levels and enhance the comprehensibility of circulating T values to practicing clinicians. These steps will facilitate the development of rational criteria for the diagnosis of androgen disorders in men, women, and children.     

Vitamin B12 (cobalamin) deficiency in elderly patients

VITAMIN B₁₂ OR COBALAMIN DEFICIENCY occurs frequently (> 20%) among elderly people, but it is often unrecognized because the clinical manifestations are subtle; they are also potentially serious, particularly from a neuropsychiatric and hematological perspective. Causes of the deficiency include, most frequently, food-cobalamin malabsorption syndrome (> 60% of all cases), pernicious anemia (15%–20% of all cases), insufficent dietary intake and malabsorption. Food-cobalamin malabsorption, which has only recently been identified as a significant cause of cobalamin deficiency among elderly people, is characterized by the inability to release cobalamin from food or a deficiency of intestinal cobalamin transport proteins or both. We review the epidemiology and causes of cobalamin deficiency in elderly people, with an emphasis on food-cobalamin malabsorption syndrome. We also review diagnostic and management strategies for cobalamin deficiency. Vitamin B₁₂ or cobalamin deficiency occurs frequently among elderly patients,¹ but it is often unrecognized or not investigated because the clinical manifestations are subtle. However, the potential seriousness of the complications (particularly neuropsychiatric and hematological)^1,2,3,4 requires investigation of all patients who present with vitamin or nutritional deficiency. We summarize the current state of knowledge on cobalamin deficiency, with a particular focus on deficiency in elderly people.In gathering information for this article, we systematically searched PubMed for articles published from 1990 to July 2003 (the search strategy is outlined in online Appendix 1 [www.cmaj.ca/cgi/content/full/171/3/251/DC1]). We have also included unpublished data from our working group, the Groupe d''étude des carences en vitamine B12 des Hôpitaux Universitaires de Strasbourg.     

Recombinant human lactoferrin treatment for global health issues: iron deficiency and acute diarrhea

Iron deficiency and diarrhea are two of the most significant issues for global health. Iron deficiency anemia is the most common nutritional deficiency in the world, affecting nearly 25% of the world population (UNICEF/WHO 1999). The prevalence of iron deficiency in developing countries is illustrated by comparison with other deficiencies: iron deficiency affects 3.5 billion people, while vitamin A and iodine deficiency affect 0.3 billion people and 0.8 billion people, respectively. The prevalence is highest among young children and women of childbearing age (particularly pregnant women). It is estimated that national productivity levels could be raised as much as 20% by correcting iron deficiency in developing countries. Recombinant human lactoferrin (rhLF), expressed and extracted from rice seed, is being evaluated by Ventria Bioscience for use as a dietary supplement to treat iron deficiency and/or iron deficiency anemia. Diarrhea is also a major world health issue. Sixty percent of children who die under age five die of pneumonia, diarrhea or measles. World Health Organization oral rehydration solution (WHO-ORS) is one of the major medical advances in the past 50 years, saving the lives of 1 to 2 million children annually. Many studies have demonstrated similar efficacy of rice-based ORS. There are studies documenting the reduced frequency of diarrhea in breast-fed children and this health improvement is attributed to the antimicrobial action of the human milk proteins lactoferrin and lysozyme. In vitro data document the growth inhibition of the diarrheal associated organisms: rotavirus, ETEC, cholera, salmonella, and shigella by human lactoferrin (hLF) and human lysozyme. Using Ventria's ExpressTec system, we have expressed human lactoferrin and human lysozyme in rice. In a rice-based ORS formulation, these proteins have the potential to provide not only the benefits of reduced stool volume and improved weight gain, but also shorten the course of diarrheal episodes via antimicrobial activity against the causative agent.     

cobA function is required for both de novo cobalamin biosynthesis and assimilation of exogenous corrinoids in Salmonella typhimurium

Salmonella typhimurium is able to synthesize cobalamin (B12) under anaerobic growth conditions. The previously described cobalamin biosynthetic mutations (phenotypic classes CobI, CobII, and CobIII) map in three operons located near the his locus (minute 41). A new class of mutant (CobIV) defective in B12 biosynthesis was isolated and characterized. These mutations map between the cysB and trp loci (minute 34) and define a new genetic locus, cobA. The anaerobic phenotype of cobA mutants suggests an early block in corrin ring formation; mutants failed to synthesize cobalamin de novo but did so when the corrin ring is provided as cobyric acid dicyanide or as cobinamide dicyanide. Under aerobic conditions, cobA mutants were unable to convert either cobyric acid dicyanide or cobinamide dicyanide to cobalamin but could use adenosylcobyric acid or adenosylcobinamide as a precursor; this suggests that the mutants are unable to adenosylate exogenous corrinoids. To explain the anaerobic CobI phenotype of a cobA mutant, we propose that the cobA gene product catalyzes adenosylation of an early intermediate in the de novo B12 pathway and also adenosylates exogenous corrinoids. Under anaerobic conditions, a substitute function, known to be encoded in the main Cob operons, is induced; this substitute function can adenosylate exogenous cobyric acid and cobinamide but not the early biosynthetic intermediate. The cobA gene of S. typhimurium appears to be functionally equivalent to the btuR gene of Escherichia coli.