The Bottom Line on Folic Acid

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Based on the studies covered in the Tuesday and Thursday posts, you may be confused about what you should do when it comes to folic acid, especially if you’re pregnant or thinking about getting pregnant. I read a lot of research to come up with this analysis and here’s what I found.

There are three areas of concern:

  • Too much folic acid could mask a B12 deficiency during pregnancy; there’s no research to support that. It can happen in the elderly who have problems absorbing B12, but doesn’t seem to happen in women of child-bearing age.
  • Excess blood folic acid may be related to tumor acceleration; there’s some rodent research to suggest some relationship but nothing in humans. They have also cited research on folic acid supplementation and prostate cancer. I examined numerous studies and there’s no clear relationship; some show some type of relationship, others show a reduction in risk.
  • There may be some effect on the children of mothers who get too much folic acid; there’s one study that suggest an increase in asthma in offspring but most studies seem to demonstrate a protective effect.

Where does that leave us? Most of the studies are not done very well when it comes to folate and folic acid intake. The folic acid intake is dependent on Food Frequency Questionnaires, which have severe limitations. The methodology for determining blood folic acid levels vary from study to study. The associations between intake and problems are weak at best.

But when it comes to pregnancy, there may be a solution. In a recent study, researchers examined the relationship between neural tube defects and the red blood cell folate level. As the estimated levels increased, the risk of neural tube defects decreased. The level which seemed to provide the lowest risk of neural tube defects was greater than 1,000 nmol/L. This was a single study and used interesting statistical techniques, but it seemed to provide for more precise folic acid supplementation.

 

The Bottom Line

The benefits of folic acid on neural tube defects have been impressive, and the concern over excess supplementation may be legitimate or not. It could be that women process folic acid too well or not well enough and that could impact dietary and supplementation intake. Research on the MTHFR polymorphisms continue with no recommendation for its diagnostic use at this time.

If you’re concerned, talk with your physician about getting a blood folate test. Levels of RBC folate levels can be estimated from that result. One key point: the test would be most beneficial before conception because neural tube defects happen in the first month of pregnancy. Still it’s one way to be more cautious in spite of the limited risk.

Let me close by saying that in all the research I did, what I could not find is any association between reasonable folic acid intake and miscarriages or other issues during pregnancy. Folic acid appears to be safe and protective and should be a part of prenatal nutrition.

If you want to know more about having the healthiest baby you can, check out Healthy Babies: From Conception to Breastfeeding. It’s available as a CD or MP3 download.

What are you prepared to do today?

Dr. Chet

 

Reference: BMJ 2014;349:g4554 doi: 10.1136/bmj.g4554

 

Prenatal Nutrition: More on Folic Acid

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The second study on folic acid supplementation before pregnancy examined similar blood and red blood cell folic acid levels at different times during pregnancy and in cord blood (1). The difference was that half of the subjects were randomly provided with 400 mcg folic acid to take during their second and third trimesters. As you would expect, the women who supplemented their diets had higher levels of all variables than controls.

The difference between the two studies I’ve examined was that even with supplementation, the unmetabolized folic acid levels were virtually undetectable in cord blood in this study. Moreover, the red blood cell levels of folic acid were considered to be in the normal range in spite of the supplementation.

Two studies. One suggests that prenatal supplements should consider reducing the amounts, while the other suggests that there’s no effect in the most common amount found in supplements. I’ll make sense of this in Saturday’s post.

What are you prepared to do today?

Dr. Chet

 

Reference: J Nutr 2016;146:494–500.

 

Prenatal Nutrition: Should You Worry About Folic Acid?

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I’ve been working on updating the research for the second edition of the Healthy Babies CD, and that includes nutrients such as probiotics, vitamin D, and one of the most important nutrients, folic acid. Since folic acid was added to cereal grains in 1998, there have been significant reductions in neural tube defects, but folic acid is not without controversy: the concern is getting too much folic acid from foods and supplements. There have been some studies suggesting a relationship between excess folic acid and an increased risk of some diseases. This week, I’m going to cover three studies that examine folic acid before and during pregnancy to help clarify things.

In a study published in 2015, researchers examined the levels of folic acid and unmetabolized folic acid (UFA) in the mother’s blood early in the pregnancy, at delivery, and in the umbilical cord blood. They found that folic acid and red blood cell (RBC) folic acid did not significantly change. There were differences between those who did and did not supplement with folic acid. They did find UFA in the blood and cord blood. The researchers felt that the RBC folic acid blood levels and the UFA were too high and that folic acid supplements should be changed to reflect the high readings.

Are their conclusions warranted? Let’s take a look at another study that examined the same variables the following year. I’ll let you know what a difference a year makes on Thursday.

What are you prepared to do today?

Dr. Chet

 

Reference: Am J Clin Nutr 2015;102:848–57.

 

BMI, WHR, and Lifestyle

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The study we’ve been examining is interesting on so many levels: large numbers of subjects; new statistical techniques due in large part to progress in computing capabilities; genetic analysis that allows for rapid analysis and identification of polymorphisms. It’s all very exciting. You’re probably anticipating a “but” coming and you’d be correct.

This study demonstrated that when using genetic information, WHR is a risk for CVD and type 2 diabetes even with a normal BMI. But there’s still at least two factors to consider that are dependent on each other.

First, just because someone has a mutated gene or genes, it doesn’t mean it will ever express itself, i.e., turn on. More than likely, the second factor has a role to play and that’s the lifestyle of the individual. Some studies refer to it as environment, but they’re intertwined. Where you live may limit or provide you with easy access to healthier foods. It may be easier to exercise in the suburbs than in a large city, or just the opposite given the park systems in different areas of the countries.

Then there’s the home environment: what foods you ate growing up and what your diet is now. All these can impact whether some genes may be expressed. Others may express themselves only when you get to a specific weight or fat intake. The variables are too numerous to consider.

I’m not attempting to confuse the issue. I just want you to know that while this study provides insight that we didn’t have before, you don’t have to be overly concerned. If you keep to a normal BMI and WHR, less than 0.9 for men and less than 0.8 for women, your risk for CVD and type 2 diabetes will not be high.

When all is said and done, it still comes down to three things. Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Waist-Hip Ratio vs. BMI

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In Tuesday’s message, I said researchers used a unique approach to answering the question of whether waist-hip ratio (WHR) is associated with cardiovascular disease and type 2 diabetes regardless of BMI. They found 48 genes which were associated WHR, a unique approach using the genetic information with Mendelian randomization of epidemiological data. If that isn’t a brain-full, I don’t know what is. Let me see if I can break it down for you.

As I’ve said many times before, epidemiological data cannot show cause and effect; they’re just observations. By using the genetic information related to WHR, researchers can analyze the data by statistically removing the effect of BMI. Because the genetic traits follow some randomization based on Mendel’s genetic work, if the WHR is still associated with the increased risks of disease, that means that where you carry your body fat is important, whether your BMI says you’re overweight or not.

They found that WHR is an independent risk factor for CVD and type 2 diabetes, confirming that the location of your body fat is important regardless of your BMI. That may be why people with a high BMI but low WHR have normal blood pressure and cholesterol levels while others with a normal BMI but a high WHR may have high numbers.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Redefining the Risks of Extra Weight

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Studies show that 70% of the population is overweight; by definition, that means that their body mass index (BMI) is greater than 25 or more. But are all overweight people at the same risk? Just because you’re overweight, are you automatically at greater risk for cardiovascular disease and type 2 diabetes?

That’s what a group of researchers in the U.S. attempted to find out. They had the benefit of access to the U.K. Biobank, an independently funded databank that has collected biometric data on over 500,000 subjects in the U.K. and contains accurate measures of BMI as well as the waist-hip ratio (WHR) on all subjects. They also had one more thing: the genetic information on a large sub-group of subjects. They identified 48 genes that seemed to be associated with WHR and used a unique approach to tease out the effects of WHR from BMI. I’ll cover that the rest of the week.

In the meantime, check out your BMI and measure your waist and hip to calculate your WHR. Measure your waist about an inch below your belly-button and your hips at the widest point; divide waist by hips and you have your ratio.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Should You Exercise During Pregnancy?

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While everyone wants a healthy baby, many women would like to control their weight gain and avoid gestational diabetes during pregnancy. That’s why I noticed one more article in the Medicine and Science in Sports and Exercise issue I read; in addition, I’ve recording the updated Healthy Babies: From Conception to Breastfeeding audio and want to include the latest research.

Researchers examined data from three studies on the effects of exercise on pregnant women. The first study included land-based exercises, the second was water-based exercises, and the third was a combination. They were compared with a control group of pregnant women who didn’t exercise. Here’s what researchers discovered:

  • Women who exercise in any way gained less weight; while it’s necessary to gain some weight while you grow a little person inside you, exercise helped women keep their weight from exceeding desirable levels.
  • Women who performed water exercises or a combination of water and land exercise had fewer cases of gestational diabetes. The authors theorized that because of the buoyancy factor of the water, women perceived water exercise as being less strenuous on the back and other joints and were able to exercise more.

The message is clear, ladies: it’s important to keep moving while you’re pregnant, under the guidance of your physician, of course. And it seems you can get even more benefits if you can work out in a pool. It’s a great investment in yourself and your life with your little one. And men, it wouldn’t hurt you to get in the pool, too—now that I have a two-year-old grandson, I have a new respect for the physical demands of fatherhood and you need to be ready.

What are you prepared to do today?

Dr. Chet

 

Reference: MSSE. DOI: 10.1249/MSS.0000000000001234

 

Can Vegetarian Protein Help You Build Muscle?

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People often ask me which is the best type of protein to build muscle when weight training. The reason for the question is bodybuilder and weight-training websites that condemn vegetarian protein as not good enough to build muscle. In the same issue of Medicine and Science in Sport and Exercise as the paper from Tuesday, a research study examined that question.

Researchers divided 54 men into three groups. One group got a vegetarian protein blend of soy and dairy, a second group got dairy-only protein, while the third received a maltodextrin placebo. They all performed the same weight training program for 12 weeks. The researchers then tested their strength as well as evidence of muscle growth after taking muscle biopsies.

All participants gained strength and muscle. Those who took the protein supplements gained slightly more muscle than the placebo group, but there were no differences in muscle gains between the soy-dairy blend and the whey-protein group.

This contributes to the body of research showing that it’s the protein that makes the difference, not whether it’s a vegetable or animal source of the protein. Use whichever fits your lifestyle better, but it’s doing the lifting that makes the real difference.

What are you prepared to do today?

Dr. Chet

 

Reference: MSSE. 2017 Feb 13. DOI: 10.1249/MSS.0000000000001224

 

Does Exercise Reduce Libido?

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A recent health headline said that strenuous exercise reduces a man’s libido. I would propose that nothing gets men’s attention—and probably quite a few women—more than sex. Should you be worried?

Researchers conducted an online survey targeting men that included questions about demographics, exercise habits, and sexual libido. What they found was that as exercise training increased, male libido decreased. The amount of exercise per week, the intensity of the exercise, and the number of years in serious training all seemed to play a factor in libido levels. The more serious their training for longer periods of time, the more affect on their libido.

Here’s the thing: this really applies only to serious marathoners or triathletes that spend over an hour training every day. What should have made headlines is that if men exercise at low or moderate levels, their libido is normal. What they didn’t even hint at was this: moderate exercise can increase energy and the all-important blood flow as well as making men and women feel better about themselves, all positives when we’re talking about libido. There’s nothing sexy about a couch potato.

This headline was based on just a survey with no hormonal measures, but it seems that a brisk walk or jog an hour a day is about right. It all comes down to this:

What are you prepared to do today?

Dr. Chet
Reference: MSSE. 2017 Feb 13. doi: 10.1249/MSS.0000000000001235

Echinacea and the Immune System

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As I write this, there are 1,098 citations in the PubMed database for echinacea. I looked at every title to see if it was relevant to answering one question: should people who have an autoimmune disease use echinacea for allergies and colds? I examined at least 100 abstracts and downloaded five papers that seemed to be significant. Here’s what I found.

The research on echinacea is a mess. There’s no consistency in the preparations used in research, the subjects included in the studies, the outcome variables that were examined, or the combination of herbs, vitamins, or minerals used in the preparations with echinacea. That’s just to find out if echinacea has any effect on catching or treating a cold. Beyond that outcome, the research is even less clear.

I found two studies that give some perspective on whether echinacea is safe for anyone to use including those who have an autoimmune disease. The first paper is a case study on a patient who suffered a breakdown in the myelin sheath after taking an herbal preparation (1). The paper reviewed all similar cases of echinacea causing similar symptoms. Based on their conclusions, boosting the immune system with echinacea could have negative effects.

There are several problems with this case study and the conclusions the authors made. While they assigned blame to echinacea, none of the subjects used echinacea alone nor were they administered the same way. Some were given orally while two others were injections. They did not examine any measures of immune function in the patients. They did not test for metabolites of echinacea nor any other herb in the blood of the subjects. They deduced that echinacea had to be to blame because of its reputation as an immune booster. One more thing: with the millions of uses of echinacea every day around the world, there were just four cases in 16 years. You read that correctly: four in 16 years. Those are pretty good odds.

In another paper, researchers examined the safety of oral preparations of echinacea (2). This was an old-school approach: instead of selecting research papers to include in a meta-analysis, they examined all the pertinent research one article at a time. They used their knowledge of how drugs are metabolized by the body, how they interact with other medications, and many other indications related to the safety of medications including herbals. They concluded that echinacea does not interact with medications to any degree. While it may change how the medication is metabolized, echinacea doesn’t change how effective the medication is.

More important, they concluded that there’s no indication in the science that echinacea is harmful to those with autoimmune diseases. They explain the reasons why physicians have believed echinacea could have consequences, but there was no evidence it was harmful. There was also no time restriction for the use of echinacea. If you have an autoimmune disease, I urge you to download and read the second reference for yourself. It’s open access and while it’s tough reading, it’s the best resource I’ve found on the issue.

 

The Bottom Line

If you have an autoimmune disease, you must check with your physician before using echinacea; he or she knows the specifics of your condition. Based on my review of the research, there’s no reason you cannot use echinacea to help your immune system when it’s under attack from a virus or allergens for a few days. But that’s not my call to make; there’s always the possibility of an abnormal response or of an allergic reaction to the plant material itself. It’s something you need to talk with your healthcare professional about, but it should be a discussion, not a lecture.

I know you want clear answers, but that’s just not completely possible in this case. What you have now is information with which to make an informed decision.

What are you prepared to do today?

Dr. Chet
References:
1. Balkan Med J 2016;33:366-9.
2. Planta Med 2016; 82: 17–31.