Natural Folate vs. Synthetic Folic Acid in Pregnancy

Sponsor

University of British Columbia (Other)

Overall Status

Active, not recruiting

CT.gov ID

NCT04022135

Collaborator

BC Children's Hospital Research Institute (Other)

Enrollment

Location

Arms

32.5

Anticipated Duration (Months)

1.8

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

In this two-arm, double-blind randomized pilot study, the investigators will recruit 60 generally healthy, low-risk pregnant women aged 19-42 years living in Vancouver, Canada. Participants will be randomized to supplement with either 0.6 mg/day folic acid or an equimolar dose (0.625 mg/day) of (6S)-5-methyltetrahydrofolic acid for 16-weeks of their pregnancy. Randomization will occur at 8-21 weeks gestation (after neural tube closure) to reduce the risk of harm should the natural folate prove less effective. All participants will also receive a prenatal multivitamin not containing any form of folate, to ensure adequacy of other nutrients (e.g. iron) required during pregnancy. Three-hour fasting venous blood samples will be collected at baseline and endline to measure serum and red blood cell folate, unmetabolized folic acid and other related biomarkers. Women will be given the option to continue supplementing until 1-week postpartum, and provide a small (3mL) breastmilk sample in order to measure differences in folates in breastmilk. These pilot data will be used to inform a definitive trial regarding the most effective form of folate supplementation for mothers and their babies.

Condition or Disease	Intervention/Treatment	Phase
Pregnancy	Dietary Supplement: Folic acid Dietary Supplement: (6S)-5-methyltetrahydrofolic acid	N/A

Detailed Description

A sample size of 50 women (25 in each group) are required to reliably estimate the distributions of serum and red blood cell folate. Thus, to account for drop outs or loss to follow up, a total of 60 women (30 in each group) will be recruited.

Aim 1: To establish the mean ± standard deviation change in serum folate, red blood cell folate, and unmetabolized folic acid levels in each group following supplementation with (6S)-5-methyltetrahydrofolic acid or folic acid for 16-weeks of pregnancy. Exploratory analyses will be to measure differences in folate forms and folate binding protein in breastmilk.

Aim 2: To determine participation recruitment and retention rate, the most effective recruitment strategies for this population, and adherence to study protocol (to inform a definitive trial).

Women may undergo informed consent process anytime <21 weeks gestation. Once participants indicate that they are interested in participating in the trial, the participant will be given a study ID, and a baseline visit will be scheduled.

The baseline visit will occur between 8-21 weeks gestation, and will involve discontinuation of current folate/prenatal vitamin supplementation, review and signing the informed consent form (a scanned copy will be shared with the participant), randomization to a folate group, provision of study supplements, completion of a baseline questionnaire, completion of a food frequency questionnaire, measurement of weight and height, and a small blood draw (12ml).

Intervention: total time: 16 weeks. Participants will supplement daily with the folate and prenatal vitamin supplements. The research coordinator will call the participants half way through the intervention period to serve as a reminder and answer any questions, which will enhance protocol adherence.

The endline visit will occur between 24-37 weeks gestation, and will involve collecting any remaining supplements (for capsule counts), a weight measurement, and a small blood draw (12ml), and completion of a short endline questionnaire.

Optional continuation of study: After the endline visit, women who are planning to breastfeed will have the option to continue supplementing with the study supplements until approximately 1 week postpartum, at which time they will provide a small (3 mL) breastmilk sample. The aims of this collection will be to measure difference in folate forms (including total proportion of unmetabolized folic acid) and breastmilk folate-binding protein.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

60 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

Double (Participant, Investigator)

Primary Purpose:

Other

Official Title:

Is Natural Folate as Effective as Synthetic Folic Acid in Increasing Serum and Red Blood Cell Folate Concentrations During Pregnancy? A Proof-of-concept Pilot Study

Actual Study Start Date :

Sep 16, 2019

Actual Primary Completion Date :

Sep 8, 2021

Anticipated Study Completion Date :

Jun 1, 2022

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Folic acid 0.6 mg/day	Dietary Supplement: Folic acid Participants will supplement with 0.6mg/day for 16 weeks.
Experimental: (6S)-5-methyltetrahydrofolic acid (Metafolin) 0.625 mg/d (an equimolar dose to folic acid)	Dietary Supplement: (6S)-5-methyltetrahydrofolic acid Participants will supplement with 0.625mg/day for 16 weeks. Other Names: Metafolin

Arm

Intervention/Treatment

Active Comparator: Folic acid

0.6 mg/day

Dietary Supplement: Folic acid

Participants will supplement with 0.6mg/day for 16 weeks.

Experimental: (6S)-5-methyltetrahydrofolic acid (Metafolin)

0.625 mg/d (an equimolar dose to folic acid)

Dietary Supplement: (6S)-5-methyltetrahydrofolic acid

Participants will supplement with 0.625mg/day for 16 weeks.

Other Names:

Metafolin

Outcome Measures

Primary Outcome Measures

Concentration of red blood cell folate levels [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
nmol/L; Reflects longer term status (e.g. previous 3-4 months)
Concentration of serum folate levels [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
nmol/L; Reflects recent status or dietary intake
Concentration of unmetabolized folic acid (and other folate forms: THF, 5-Methyl-THF, 5-formyl-THF, and 5,10-methenyl-THF) [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
nmol/L; unmetabolized folic acid is not incorporated into RBCs, rather it circulates in plasma

Secondary Outcome Measures

Concentration of total vitamin B-12 [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
pmol/mL; closely involved in folate metabolism and facilitating methionine cycles
Concentration of pyridoxal-5'-phosphate [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
nmol/L; closely involved in folate metabolism and facilitating methionine cycles
Concentration of vitamin B2 [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
nmol/L; closely involved in folate metabolism and facilitating methionine cycles
Concentration of betaine [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
µmol/L; closely involved in facilitating methionine cycles
Concentration of choline [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
µmol/L; closely involved in facilitating methionine cycles
Concentration of dimethylglycine [concentrations at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum, and calculation of change between time periods]
µmol/L; closely involved in facilitating methionine cycles
Concentration of S-adenosyl-methionine [concentrations at both baseline (8-21 weeks gestation) and endline (24-37 weeks gestation), and calculation of change between time periods]
µM; Metabolite produced in methionine cycles
Concentration of S-adenosyl-homocysteine [concentrations at both baseline (8-21 weeks gestation) and endline (24-37 weeks gestation), and calculation of change between time periods]
µM; Metabolite produced in methionine cycles
Concentration of total homocysteine [concentrations at both baseline (8-21 weeks gestation) and endline (24-37 weeks gestation), and calculation of change between time periods]
µmol/L; Metabolite produced in methionine cycles
Concentration of methionine [concentrations at both baseline (8-21 weeks gestation) and endline (24-37 weeks gestation), and calculation of change between time periods]
µmol/L; Metabolite produced in methionine cycles
Concentration of cysteine [concentrations at both baseline (8-21 weeks gestation) and endline (24-37 weeks gestation), and calculation of change between time periods]
µmol/L; Metabolite produced in methionine cycles
Collection of peripheral blood mononuclear layer cells [Collection at both baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum]
Gene variant assessment of MTHFR (677 C>T, rs1801133, and 1298 A>C, rs1801131) and DHFR (rs1643649 and rs70991108) and differences in DNA methylation, and frequency and cytotoxicity of immune cells in PBMCs.
Concentration of unmetabolized folic acid in breastmilk (and other folate forms: THF, 5-Methyl-THF, 5-formyl-THF, and 5,10-methenyl-THF) [Collection at 1 week postpartum]
nmol/L; folic acid that is unmetabolized and enters breastmilk as such
Folate binding protein in breastmilk [Collection at 1 week postpartum]
nmol folate binding per liter of milk
Breastmilk fatty acids & choline forms (free choline, betaine, phosphocholine, glycerophosophocholine) [Collection at 1 week postpartum]
Quantified via LC-MS/MS
Breastmilk human milk oligosaccharides and breastmilk microbiome [Collection at 1 week postpartum]
Quantified via HPLC-FL and PCR
Complete blood count [Baseline (8-21 weeks gestation), endline (24-37 weeks gestation), and postpartum]
Analysis will be performed using an automated hematology analyzer (Sysmex XNL550, Kobe, Japan)
Markers of Iron and Inflammation [Baseline (8-21 weeks gestation),and endline (24-37 weeks gestation)]
This will include measurement of serum ferritin (µg/L), soluble transferrin receptor (mg/L), body iron stores (mg/kg), retinol binding protein (µmol/L), CRP (mg/L), and AGP (g/L) in serum using a sandwich ELISA, and hormones that influence iron regulation in pregnancy, including serum hecipdin (ng/mL; measured with an ELISA) and serum erythropoietin (mIU/mL; measured with an immunoassay)

Eligibility Criteria

Criteria

Ages Eligible for Study:

19 Years to 42 Years

Sexes Eligible for Study:

Female

Accepts Healthy Volunteers:

Yes

Inclusion Criteria:

Pregnant woman (singleton pregnancy)
Living in the Greater Vancouver area and willing to travel to the University of British Columbia for study visits
<21 weeks gestation
19-42 years of age
willing to participate

Exclusion Criteria:

Have a pre-existing medical condition known to impact maternal folate status (malabsorptive of irritable bowel disease, active celiac disease, gastric bypass surgery, atrophic gastritis, epilepsy, advanced liver disease, kidney dialysis, type 1 or 2 diabetes mellitus, sickle cell trait/anemia)
Lifestyle factors known to impact maternal folate status (smoking, alcohol overuse, non-prescription drug use/abuse)
Are medium to high risk for development of an NTD-affected pregnancy (applies to women or their male partner: personal or family history [parents or siblings] of other folate sensitive congenital anomalies, personal NTD history or a previous NTD-affected pregnancy)
Are taking medications known to interfere with B-vitamin metabolism (Chloramphenicol, Methotrexate, Metformin, Sulfasalazine, Phenobarbital, Phenytoin, Primidone, Triamterene, Barbiturates)
pre-pregnancy body mass index ≥30 kg/m2
allergic to any of the supplement ingredients