Possible explanations for the underperformance of folic acid fortification include genetic variation (Centers for Disease Control and Prevention, 2010). The severity of the neural tube defect is largely a function of position (Molloy et al., 2017). Estimates of neural tube defect prevalence vary widely and range from 0.3 to 199.4 per 10,000 births (Zaganjor et al., 2016). Neural tube defects are common and often severe congenital malformations that occur when the neural tube, the embryonic precursor to the brain and spinal cord, fails to close during the first month of gestation.
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However, in stratified models, we found evidence that arsenic exposure modified the effect of folic acid on spina bifida risk (Fig. 1). We conducted a hospital-based case-control study at the National Institute of Neurosciences & Hospital (NINS&H), the primary center for spina bifida surgery in Bangladesh. Building on these results, we conducted a larger, hospital-based case-control study at the national center for spina bifida treatment in Bangladesh.
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Our previous study discovered that higher water arsenic concentrations reduced the effectiveness of folic acid in spina bifida prevention . A recent systematic review showed there was inadequate evidence to determine the relationship between prenatal arsenic exposure and prevalence of NTDs , but the review did not address potential interactions between arsenic and folic acid that may affect spina bifida risk. Mother’s arsenic exposure modified the protective association of folic acid with spina bifida.
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Participation rates were 73% among potential families with spina bifida and 57% among potential controls. We enrolled 333 infants with initial diagnoses of spina bifida (meningocele or myelomeningocele) and 165 controls. We employed logistic regression models to assess the associations between arsenic concentrations and folic acid use (predictors) and case status. We did not include children with cancer (e.g. brain tumor) as controls because the link between arsenic and cancer is established in the literature , and thus we believed presentation of children with cancer to NINS&H and DSH is not independent of arsenic exposure . When a case was enrolled, we reviewed that week’s clinic lists and assembled a list of potential controls based on age within 6 months of the case and approached potential controls in order of the list. Previous reports from this population identified an association between father’s arsenic concentrations in fathers’ toenails and spina bifida .
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- Although we were not able to confirm previously identified associations between spina bifida risk and genetic variants restricted to certain biological pathways, such as folate metabolism, we were able to identify novel variants that may impact biological processes involved in early development.
- Flowchart of saliva DNA sample selection and case/control family https://wakelet.com/@spinracasinoen member inclusion in the study.
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Data from all samples available after filtering for duplicates and failed samples were then merged into a single multi-sample PED file for GWAS analysis. Of the remaining 749 saliva samples with GSA data, 36 duplicates were removed from further analysis. Of the 760 samples sent for analysis, four did not have sufficient quantities of DNA and were excluded from the genetic analysis. Seven hundred sixty saliva DNA samples were shipped to the Broad Institute (Cambridge, MA, USA) for DNA quantification and genetic analysis (Figure 1). Trained study staff collected saliva samples from children and their parents using the Oragene® OGR-575 kit (DNA Genotek Inc., Ottawa, ON, Canada), following the manufacturer’s instructions.
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Trained staff visited these sites and collected water samples in polyethylene containers. At enrollment, mothers were asked to identify the primary drinking water source they used when they learned they were pregnant. Folate status was additionally assessed in serum samples using Chemiluminescent Microparticle Immunoassay at NINS&H (ARCHITECT plus ci4100, Abbott Company, Abbott Park, IL, USA). We measured infant’s weight and head circumference using standardized protocols, and mother’s medication and vitamin intake using a structured questionnaire that included the seven major types of folic acid-containing tablets in Bangladesh.
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Additional preventive measures, such as folic acid fortification of the food supply and reduction of arsenic exposure, may be needed to optimize spina bifida prevention in areas with high arsenic exposures. Another possible explanation for why we did not find a primary effect of arsenic is that arsenic exposure by itself may be insufficient, and that the addition of other risk factors, such as inadequate folate, is a necessary contribution to disrupt neural tube closure. These studies suggest that prenatal folic acid supplementation may be less effective in spina bifida prevention in populations with high arsenic exposure because of interactions between arsenic and folic acid. Our results are consistent with recent studies conducted in high arsenic areas that suggest that environmental arsenic exposure may attenuate the protective benefit of folic acid supplements in preventing spina bifida. There was no significant main effect found between water and mother’s toenail arsenic concentrations and spina bifida risk (Supplemental Table 3). Thirteen mothers reported a diagnosis of diabetes, including mothers of 9 cases and 4 controls.
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We included families with children with lipomeningocele as controls because our study was primarily designed to investigate associations between arsenic and spina bifida (myelomeningocele and meningocele), and lipomeningocele would be present in the population that would give rise to cases. In our analysis including genetic variants spanning the genome, we did not observe significant differences in measured serum folate among mothers of cases and controls and did not identify any significant associations between genetic variants in genes relevant in folate pathways and case status in the child, maternal, or trio models. The genetic association analysis includes data from child-parent trios, allowing us to explore family-based, genome-wide association analyses in a unique study population with myelomeningocele and meningocele, subtypes of spina bifida, from Bangladesh, a country with relatively high prevalence of neural tube defects with a population that is underrepresented in genome-wide association studies (Gurdasani et al., 2019). In the current study, we build upon this previous analysis, performing a genome-wide scan of variants to assess genetic contributors to neural tube defect risk in a larger case-control population. In this study, we investigated the association of genetic variants spanning the genome with risk of spina bifida (i.e., myelomeningocele and meningocele) in a subset of families enrolled from December 2016 through December 2022 in a case-control study in Bangladesh, a population often underrepresented in genetic studies. A recent study from an area of Turkey with high arsenic exposures reported higher levels of arsenic in plasma samples of 100 mothers of NTD cases as compared to mothers from 70 controls .
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