Background and rationale of the SU.FOL.OM3 study: double-blind randomized placebo-controlled secondary prevention trial to test the impact of supplementation with folate, vitamin B6 and B12 and/or omega-3 fatty acids on the prevention of recurrent ischemic events in subjects with atherosclerosis in the coronary or cerebral arteries.

Cardiovascular diseases are the primary cause of mortality in France. Many epidemiological studies have shown that the total homocysteine concentration is a risk indicator for cardiovascular disease. Furthermore, it has been shown that the homocysteine concentration can be effectively lowered by supplementation with folic acid, vitamin B6 and B12. However, it is not yet known whether a reduction of the homocysteine concentration by such a supplementation indeed leads to a decreased risk of cardiovascular disease. Another possible dietary factor that may lower the risk of cardiovascular disease is fish-oil, which is rich in omega-3 fatty acids. These fatty acids lower platelet aggregation and triglyceride rich lipoproteins and may have antiarrhythmic effects. Some trials have investigated the effect of fish or fish-oil on cardiovascular mortality, and the results, although not conclusive, suggest a protective effect of a higher intake. In the SU.FOL.OM3 study we will evaluate the effect of supplementation at nutritional doses of folate (in the natural 5-methyl-tetrahydrofolate form) in combination with vitamin B6 and B12 and/or omega-3 fatty acids and/or placebo on recurrent ischemic diseases in a factorial design. The supplements will be randomly allocated to the participants in a double-blind fashion. In total 3,000 patients aged between 45 and 80 years who had a past history of myocardial infarction or unstable angina pectoris or an ischemic stroke will be included. The participants will be supplemented and followed up for a period of five years.

Vitamin status of a healthy French population: dietary intakes and biochemical markers.

The vitamin status of a representative population sample in a French district in the Paris area was assessed using a biochemical and dietary approach. Complete data were obtained for 1039 subjects 6 to 97 years old. Dietary intakes of most vitamins increased up to adolescence and then remained stable or decreased slightly in adult life. Total vitamin intakes were higher in men than in women (except for ascorbic acid), but the vitamin density of the diet was higher in females. Most subjects presented dietary intakes below the French recommended allowances for vitamin B1, B6, C, A and E. A variation in biochemical parameters according to age and sex was observed only for serum concentration of retinol, beta-carotene, vitamin E and C. Multiple regression analysis showed that dietary vitamin intakes were related to the biological status for vitamin B2, B6, C, folates, beta-carotene and vitamin E. Tobacco smoking, alcohol consumption and oral contraceptive were significantly correlated with biological status for several vitamins. While biochemical evidence of severe vitamin deficiency was not observed, a sizeable minority of the French population is not lavishly supplied with some vitamins, and this situation deserves investigation to see if any deleterious effects are associated with it.

Effects of diets with or without folic acid, with or without methionine, on fetus development, folate stores and folic acid-dependent enzyme activities in the rat.

Wistar female rats fed, since mating, with diets lacking either methionine, replaced in this case by homocystine (HF), or folic acid (MO), or both (HO). With diets lacking either one of the two factors, fetal weights remained in the range of the controls. When both factors were absent from the diet (HO), underweight fetuses were observed on day 20. In the offspring of folic acid-deficient mothers (MO), only folyloligoglutamates were lowered; total ones remained near control level. Switching HO females to a folic acid-supplemented diet from day 16 to 20 of pregnancy restored fetal weight and folates to the control level. The activity of folico-dependent enzymes of the whole fetal body or liver varied in parallel to fetal weight. We conclude from these data that: (1) methionine has a protective effect on folates in MO groups; (2) when folic acid is present in a diet containing homocystine but no methionine (MF), endogenous methionine synthesis is sufficient to cover maternal and fetal needs; (3) when the vitamin is also withdrawn (HO), methionine synthesis is no more adequate and fetal underdevelopment appears.

[Hyperhomocysteinemia: an independent risk factor or a simple marker of vascular disease?. 1. Basic data]. / L'hyperhomocystéinémie: facteur de risque cardiovasculaire ou simple marqueur ? 1. Données fondamentales.

Recent epidemiological studies have suggested that hyperhomocysteinemia is associated with increased risk of vascular disease. Homocysteine is a sulphur-containing amino acid whose metabolism stands at the intersection of two pathways: remethylation to methionine, which requires folate and vitamin B12 (or betaine in an alternative reaction); and transsulfuration to cystathionine which requires vitamin B6. The two pathways are coordinated by S-adenosylmethionine which acts as an allosteric inhibitor of the methylenetetrahydrofolate reductase (MTHFR) and as an activator of cystathionine beta-synthase (CBS). Hyperhomocysteinemia arises from disrupted homocysteine metabolism. Severe hyperhomocysteinemia is due to rare genetic defects resulting in deficiencies in CBS, MTHFR, or in enzymes involved in methyl cobalamine synthesis and homocysteine methylation. Mild hyperhomocysteinemia seen in fasting condition is due to mild impairment in the methylation pathway (i.e. folate or B12 deficiencies or MTHFR thermolability). Post-methionine-load hyperhomocysteinaemia may be due to heterozygous cystathionine-beta-synthase defect or B6 deficiency. Patients with homocystinuria and severe hyperhomocysteinemia develop arterial thrombotic events, venous thromboembolism, and more seldom premature arteriosclerosis. Experimental evidence suggests that an increased concentration of homocysteine may result in vascular changes through several mechanisms. High levels of homocysteine induce sustained injury of arterial endothelial cells, proliferation of arterial smooth muscle cells and enhance expression/activity of key participants in vascular inflammation, atherogenesis, and vulnerability of the established atherosclerotic plaque. These effects are supposed to be mediated through its oxidation and the concomitant production of reactive oxygen species. Other effects of homocysteine include: impaired generation and decreased bioavailability of endothelium-derived relaxing factor/nitric oxide; interference with many transcription factors and signal transduction; oxidation of low-density lipoproteins; lowering of endothelium-dependent vasodilatation. In fact, the effect of elevated homocysteine appears multifactorial affecting both the vascular wall structure and the blood coagulation system.

[Hyperhomocysteinemia: an independent risk factor or a simple marker of vascular disease? 2. Epidemiological data]. / L'hyperhomocystéinémie: facteur de risque cardiovasculaire ou simple marqueur ? 2. Données épidémiologiques.

Elevated plasma total homocysteine (tHcy) is considered as a risk factor for occlusive cardiovascular disease (CVD). This concept is based on the observations of premature vascular disease in patients with homocystinuria and on the association between tHcy and increased risk of CVD in prospective studies. However, some observations have raised questions about tHcy as a risk factor. First, low risk population based prospective studies tend to indicate a weak association or no association between tHcy and CVD. Second, several traditional risk factors for CVD are associated with tHcy and may confound the relation between tHcy and CVD. Third, the C667T transition of the methylenetetrahydrofolate reductase causes a moderate increase in tHcy but no or only minor increased CVD risk. Thus, only placebo-controlled intervention studies with tHcy-lowering B-vitamins and clinical endpoints can provide additional valid arguments for the debate over whether tHcy is a causal CVD risk factor.

[Assessment of the nutritional status of Algerian women in the reproductive age living in an urban, rural and semi-rural area]. / Evaluation de l'état nutritionnel de femmes algériennes en âge de procréer vivant en zones urbaine, rurale et semi-rurale.

We assessed the nutritional status of 302 menstruating women living in three urban, semi-rural and rural areas of eastern Algeria. The anthropometric data and the biochemical measurements (serum levels of total proteins, albumin, transferrin and prealbumin) have shown the absence of protein malnutrition and the evidence of problems of overweight, whatever the criterion used (body mass index or relative weight). There were no differences according to the residence. Anemia (defined by WHO references) was observed in 28% of urban women, 19% of semi-rural women and in 32% of rural women. Iron deficiency (defined by the association of serum ferritin level of 12 micrograms/l or less and transferrin saturation less than 15%) was observed in 29, 27 and 22% of the cases, respectively. Folate deficiency (defined by concentration of red blood cell folates of less than 100 micrograms/l) was observed in 48, 45 and 22% of cases, respectively. Finally, 81% of anemia were associated with biochemical evidence of iron and/or folate deficiency.

Iron and folate status in Zairian mothers and their newborns.

An evaluation of iron and folate status was carried out on 166 Zairian pregnant women from Kinshasa at delivery and in cord blood from their newborns. Anemia, defined as a low hematocrit value (less than 33%), was observed in 38% of pregnant women. Iron deficiency, recognized by a combination of abnormal values for serum ferritin level (less than or equal to 12 micrograms/l) and transferrin saturation (less than 16%) was present in 54% of pregnant women. Folate deficiency, defined by a red blood cell folate of less than 100 micrograms/l, was observed in 6% of cases. In anemic mothers, anemia was associated with iron deficiency in 57% of cases and with folate deficiency in 5%. Correlations between maternal and newborn iron and folate indicators were found. This study points out the necessity for developing strategies in African countries to combat nutritional anemias during pregnancy by specific measures combined with general strategies.

Folate status worsens in recently institutionalized elderly people without evidence of functional deterioration.

OBJECTIVE: To follow folate status, hematological and cognitive changes during the first year of institutionalization among elderly subjects. DESIGN: Prospective study. SETTING: Long-stay unit of the Dijon University Geriatric Hospital. SUBJECTS: Twenty women and four men older than 65 years admitted consecutively. MAIN OUTCOME MEASURES: Folate and vitamin B-6 dietary intake was evaluated by a five-day record on admission (day 1 or d 1), at day 45 (d 45), day 90 (d 90), day 135 (d 135), day 180 (d 180), day 360 (d 360). Circulating levels of folate, vitamin B-6, total homocysteine (tHcy), blood counts and cognitive performance were determined in parallel. RESULTS: From d 1 to d 360, mean folate and vitamin B-6 intakes remained below the French RDA and mean folate intakes decreased significantly (delta = 10.2%, p < 0.05). Mean plasma or erythrocyte folate decreased significantly (delta = 33.7%, p <0.05 and delta = -30.2%, p < 0.001, respectively) from d 1 to d 360; no significant change was observed for the other blood parameters. The incidence of folate deficiency increased (8% vs. 37% for plasma folate <6.8 nmol/L and 8% vs. 17% for erythrocyte folate <340 nmol/L) from d I to d 360. Mean plasma pyridoxal 5'-phosphate (PLP) remained <20 nmol/L during the one-year follow-up. There was no difference between genders for plasma tHcy. Although mean plasma tHcy was <14 micromol/L. plasma tHcy was >14 micromol/L in about one-third of the subjects. At each period, 50% or more subjects were anemic (Hct <35% in women and Hct <40% in men), but the anemia was normocytic (MCV <100 fL). Subjects had a moderate dementia at admission, and no change was observed during the study. CONCLUSIONS: Subjects were already vitamin B-6 deficient at admission. Folate status was impaired during the study. Low vitamin intakes were the main cause of vitamin B-6 deficiency and folate status deterioration. Hematology and mental status capacity were not aggravated by folate status deterioration. Plasma tHcy didn't appear to be an earlier predictor of folate deficiency.

"ESVITAF". Survey on the vitamin status of the French: relationships between nutrient intake and biochemical indicators.

The relationships between dietary data and biochemical nutritional status for vitamins B1, B2, A, E, beta-carotene, folic acid and iron have been studied using data from a survey conducted on 710 adults. Significant correlations were found between riboflavin intake and biochemical values for males only (r = -0.105, p less than or equal to 0.05), between beta-carotene intake and plasma beta-carotene (r = 0.232, for males and r = 0.292 for females, p less than or equal to 0.001), and between iron intake and plasma iron for males only (r = 0.115, p less than or equal to 0.05). Concerning nutrient densities, correlations were significant between dietary riboflavin and biochemical measure (r = 0.163, p less than or equal to 0.01 for males, r = -0.135, p less than or equal to 0.05 for females), between vitamin A intake (expressed in retinol equivalent) and beta-carotene (r = 0.212, p less than or equal to 0.001 for males, r = 0.157, p less than or equal to 0.01 for females) and for males only, between dietary iron and hemoglobin (r = 0.144, p less than or equal to 0.01). The dietary data for each nutrient were examined for their sensitivity, specificity and predictive values in identifying subjects with substandard or overstandard biochemical values. For all nutrients the positive predictive value percentage was always below 25%, the negative predictive value percentage always under 75%.

Factors determining the use of hormone replacement therapy in recent naturally postmenopausal women participating in the French SU.VI.MAX cohort.

The determinants of hormone replacement therapy (HRT) were studied in a cohort of recently postmenopausal women participating, in France, in a nutritional study (SU.VI.MAX Study). Analysis was performed-analysis on 592 women aged 45 years or more, who had undergone natural menopause which appeared in the 2 previous years. No differences were observed in education level, socio-professional categories, marital status, geographic residence, smoking habits, physical activity, or past contraceptive practice. Past regular gynecologic follow-up appeared to be the strongest determinant of HRT use (odds ratio [OR]: 3.18). Women who reported having had at least one of the studied pathologies (past history of breast cancer, phlebitis, anger, uterine fibroma, hypertension, diabetes or hypercholesterolemia), past abundant menstrual blood losses, and with body mass index (BMI) > or = 25 were less likely to be taking HRT than women free of pathology, with no history of past abundant menstrual blood losses and with low BMI (OR respectively of 0.40, 0.64, 0.62). Women over 51.3 years of age were less likely to use HRT than younger women (OR: 0.92). Finally, in our population, while socio-economic level was not a major determinant of HRT use, the regularity of gynecological follow-up before menopause, overweight, and the existence of a definite or possible contra-indication were strong determinants of HRT use.

Relationship between anaemia, iron and folacin deficiency, haemoglobinopathies and parasitic infection.

Iron status, folacin status, haemoglobinopathies, malarial infection and intestinal parasitosis frequencies were assessed in a representative sample of 586 subjects living in a rural district of South Benin. Anaemia according to WHO reference values for haemoglobin was observed in 42 per cent of subjects. The prevalence was higher in children and menstruating women. Iron deficiency, defined by two or more abnormal values in the four independent indicators of iron status used (transferrin saturation, erythrocyte protoporphyrin, serum ferritin, and mean corpuscular volume) was present in 30 per cent of subjects. Half of the anaemias were associated with iron deficiency. Folate deficiency was associated with anaemia in 20 per cent of subjects. Anaemia, iron and folacin status were not significantly related to the degree of malarial infection nor to the type of haemoglobin. Although hookworm infection was very common, there was no significant relationship between egg count and haemoglobin level or haematological parameters of iron and folacin status. The lack of correlation can be explained by the low wormload observed.

Nutritional anaemia in pregnant Beninese women: consequences on the haematological profile of the newborn.

An assessment of iron and folic acid status, blood thick film and haemoglobin (Hb) electrophoresis was performed on 126 pregnant women (and their newborn infants) and in ninety-five menstruating women in Cotonou (Benin). Anaemia (according to the World Health Organization (1972] was observed in 55% of pregnant women and in 39% of menstruating women. Fe-deficiency was defined as a low serum ferritin concentration (12 micrograms/l or less), combined with a low transferrin saturation (less than 16%) or a high erythrocyte protoporphyrin level (more than 3 micrograms/g Hb), or both. A moderate elevation in the serum ferritin concentration (between 13 and 50 micrograms/l), associated with a low transferrin saturation or a high erythrocyte protoporphyrin level, or both, indicated Fe-deficiency in an inflammatory context. Fe-deficiency was present in 73% of pregnant women and in 41% of menstruating women. Folate deficiency (defined as erythrocyte folate below 160 micrograms/l) was observed in 45% of pregnant women. In pregnant women, anaemia was associated with Fe-deficiency in 83% of cases and with folate deficiency in 48% of cases. Haemoglobinopathies were mainly heterozygous and did not seem to contribute significantly to anaemia. Intensity of malaria was not related to Hb level, but Plasmodium falciparum was found in 99% of subjects. Hb concentration and mean corpuscular volume were significantly lower in babies born of Fe-deficient mothers than in babies born of Fe-sufficient mothers. Hb concentration in newborn infants was positively correlated with maternal serum ferritin.

5,10-methylenetetrahydrofolate reductase common mutations, folate status and plasma homocysteine in healthy French adults of the Supplementation en Vitamines et Mineraux Antioxydants (SU.VI.MAX) cohort.

The 677cytosine mutation identified in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene has been frequently associated with an elevated plasma homocysteine concentration. The aim of the present study was to determine the impact of this MTHFR common mutation on plasma and erythrocyte folate (RCF) and plasma total homocysteine (tHcy) concentrations in healthy French adults. A cohort of 291 subjects living in the Paris area and participating in the Supplementation en Vitamines et Mineraux Antioxydants (SU.VI.MAX) study were analysed to assess the impact of MTHFR polymorphism 677C-->T on folate status and plasma tHcy concentration. The frequency of the mutant homozygote for 677C-->T polymorphism (677TT genotype) in the present cohort was 16.8%. There were significant differences in plasma tHcy between 677CC, 677CT and 677TT genotype groups. The RCF concentrations were significantly different between each genotype, the lowest levels being associated with the 677TT genotype. When segregated by gender, no differences in tHcy between homozygous 677TT, heterozygous 677CT and wild-type 677CC genotype groups in women were observed. The fasting tHcy in women was unrelated to the 677C-->T mutation. However, tHcy was significantly increased in men with the homozygous 677TT genotype. We also analysed the possible implication of a second new MTHFR polymorphism (1298A-->C) in subjects with mild hyperhomocysteinaemia (4th quartile of homocysteinaemia; tHcy >11.1 micromol/l). The polymorphism 1298A-->C did not have a notable effect on tHcy or on the RCF levels. Our observations confirm a relatively high frequency of the 677TT genotype in the French population. Women with this genotype did not show the same increase in tHcy observed in men. In the present study dietary folate intake was not measured. Thus, the interaction of dietary folate with the MTHFR genotype in the French population needs further study.