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Am J Clin Nutr 2016;104:160715. Printed in USA. 2016 American Society for Nutrition 1607
serum and RBC folate, respectively) and even larger across- 2015, the WHO recommended a population cutoff for folate in-
platform variability (w1.5- to 6-fold and w8- to 40-fold differ- sufficiency in women of reproductive age on the basis of elevated
ences for serum and RBC folate, respectively) (GL Horowitz, DN risk of neural tube defects (NTDs) [RBC folate concentration
Alter, Chemistry Resource Committee, personal communication, ,906 nmol/L (9)] that was derived from epidemiologic data
2015). We know how folate assays used in the NHANES compare produced by a microbiologic assay [microbiologic assay with
(7) and can calculate assay-adjusted cutoffs; however, this type chloramphenicol-resistant strain and folic acid calibrator
of information is lacking for commonly used clinical assays, (MBA-2) (17)].
resulting in an inability to appropriately compare study data This study assessed commonly used folate cutoffs that were
produced with different clinical assays or interpret patient data. derived experimentally or from epidemiologic data and cutoff
The 1998 Institute of Medicine (IOM) Dietary Reference adjustments to obtain assay matching. We applied assay-matched
Intakes report (1) and WHO guidelines (3, 8, 9) are primary cutoffs (e.g., RPBA cutoffs with RPBA data) and assay-mismatched
sources for folate cutoffs (Table 1). Folate-depletion experiments cutoffs (e.g., MBA-1 cutoffs with RPBA data) for different levels of
conducted with the use of a microbiologic assay [microbiologic folate status (risk of deficiency on the basis of megaloblastic
assay with wild-type microorganism and folic acid calibrator anemia, possible deficiency on the basis of rising Hcy, and in-
(MBA-1) (14)] have defined stages of deficiency with megalo- sufficiency on the basis of elevated NTD risk) to serum and RBC
blastic anemia being the final stage of deficiency on the basis of folate data from persons $4 y old who were participating in the
a hematologic indicator. Serum folate concentrations ,7 nmol/L NHANES 19882010 and compared the resulting prevalence es-
indicated a negative balance (14). RBC folate concentrations ,363, timates and the extent of misinterpretation of folate status.
TABLE 1
Commonly used cutoffs to assess folate status and their assay-adjusted equivalents1
Published cutoff, Assay Adjusted cutoff, Target
Type of deficiency matrix nmol/L (reference)2 for cutoff3 Type of data Interpretation nmol/L (reference)4 assay5
TABLE 2
Assay-matched and assay-mismatched cutoffs for risks of folate deficiency, possible deficiency, or insufficiency applied to original or adjusted data from
participants aged $4 y in the prefortification (19881994) and postfortification (19992010) NHANES1
Serum folate, nmol/L RBC folate, nmol/L
Type of deficiency and cutoff, data 19881994 19992006 20072010 19881994 19992006 20072010
TABLE 4
Prevalence for risks of folate deficiency, possible deficiency, or insufficiency for the total population with the use of assay-matched or assay-mismatched
cutoffs and original or assay-adjusted data from participants aged $4 y in the prefortification (19881994) and postfortification (19992010) NHANES1
Serum folate RBC folate
Type of deficiency and cutoff, data 19881994 19992006 20072010 19881994 19992006 20072010
Population group ,53 (19881994) ,53 (19992006) ,74 (20072010) ,2153 (19881994) ,2153 (19992006) ,3054 (20072010)
Age group, y
411 ,1y ,1y ,1y 1.5 (1.1, 2.2) ,1y ,1y
1219 4.9 (3.8, 6.5) ,1y ,1y 12 (9.5, 14) 0.2 (0.1, 0.3) ,1y
2039 8.7 (7.2, 10) ,1y ,1y 8.9 (7.6, 10) 0.2 (0.1, 0.4) ,1y
4059 5.8 (4.9, 6.9) ,1y ,1y 8.0 (6.7, 9.4) 0.4 (0.2, 0.7) ,1y
$60 2.8 (2.2, 3.8) ,1y ,1y 4.5 (3.8, 5.4) 0.2 (0.1, 0.3) ,1y
Sex
Male 5.8 (4.8, 7.1) ,1y 0.1 (0.0, 0.2)* 6.6 (5.5, 7.8) 0.2 (0.2, 0.4) ,1y
Female 5.3 (4.5, 6.3) ,1y 0.1 (0.0, 0.2)* 8.2 (7.2, 9.4) 0.2 (0.1, 0.4) 0.2 (0.1, 0.4)*
Race-ethnicity
Mexican American 5.8 (4.9, 6.7) ,1y ,1y 7.0 (5.5, 8.7) 0.3 (0.1, 0.5)* ,1y
Non-Hispanic black 7.7 (6.7, 8.9) ,1y 0.3 (0.1, 0.6)* 18 (16, 20) 0.9 (0.6, 1.2) ,1y
Non-Hispanic white 5.5 (4.5, 6.6) ,1y 0.1 (0.0, 0.2)* 6.0 (5.0, 7.2) ,1y ,1y
Supplement use
Risk of folate insufficiency on the basis of elevated NTD population subgroup varied to the greatest extent by age group
risk with the use of original data in the prefortification period as follows: 1.1% for 411-y-olds
During 20072010, elevated NTD risks in women of repro- compared with 22% for 2039-y-olds for serum folate risk of
ductive age (1249 y) were 23% compared with 39% when we used deficiency on the basis of megaloblastic anemia (Supple-
an assay-matched cutoff compared with an assay-mismatched mental Table 6) and 8.7% for 411-y-olds compared with
cutoff, respectively (Table 4). In both cases, estimates varied by 48% for 2039-y-olds for serum folate risk of possible de-
race-ethnicity and supplement use status, but prefortification to ficiency on the basis of rising Hcy (Supplemental Table 7).
postfortification patterns were consistent with our observation in the Risk of folate insufficiency on the basis of elevated NTD risk
total population (Supplemental Table 5 and Table 7). varied by race-ethnicity both pre- and postfortification, but by
supplement use only postfortification (Supplemental Table 8).
Population group ,103 (19881994) ,103 (19992006) ,144 (20072010) ,3403 (19881994) ,3403 (19992006) ,6244 (20072010)
Age group, y
411 7.8 (6.3, 9.5) ,1y ,1y 20 (16, 23) 0.9 (0.7, 1.3) 2.1 (1.5, 3.0)
1219 38 (35, 42) 1.2 (0.9, 1.7) 2.1 (1.4, 3.1) 49 (45, 54) 6.3 (5.4, 7.3) 11 (8.8, 14)
2039 47 (44, 50) 2.6 (2.2, 3.1) 6.7 (5.7, 8.0) 46 (43, 48) 7.0 (6.0, 8.0) 12 (11, 14)
4059 40 (37, 43) 2.4 (2.0, 3.0) 4.9 (4.0, 5.8) 35 (32, 39) 4.5 (3.9, 5.2) 8.7 (7.1, 11)
$60 23 (21, 26) 1.2 (0.9, 1.5) 2.5 (1.9, 3.3) 24 (22, 26) 2.8 (2.4, 3.4) 4.6 (3.7, 5.5)
Sex
Male 38 (35, 41) 2.0 (1.7, 2.4) 4.7 (3.9, 5.5) 37 (35, 39) 4.9 (4.2, 5.6) 8.9 (7.8, 10)
Female 33 (31, 36) 1.7 (1.4, 2.0) 3.7 (3.2, 4.3) 37 (34, 40) 4.7 (4.3, 5.2) 8.2 (7.3, 9.3)
Race-ethnicity
Mexican American 41 (37, 44) 1.6 (1.2, 2.2) 5.4 (4.5, 6.5) 41 (36, 47) 5.0 (4.0, 6.2) 10 (8.2, 13)
Non-Hispanic black 46 (44, 48) 2.9 (2.3, 3.5) 7.7 (6.6, 9.1) 60 (58, 62) 13 (12, 15) 18 (16, 20)
Non-Hispanic white 34 (31, 37) 1.6 (1.4, 1.9) 3.4 (2.8, 4.3) 33 (31, 36) 3.1 (2.6, 3.7) 6.1 (5.1, 7.3)
Supplement use
Some previous reports used assay-mismatched cutoffs (20 similar for both biomarkers prefortification (serum folate: 5.6%;
25); sometimes, this practice was intentional because the use of RBC folate: 7.4%) and postfortification (serum and RBC folate
assay-matched cutoffs with postfortification NHANES data ,1%) when we used assay-matched cutoffs. Risks of possible
produced very-low prevalence estimates for risk of deficiency on deficiency on the basis of rising Hcy were also similar for both
the basis of megaloblastic anemia (small cell size) (23). None- biomarkers prefortification (serum folate: 35%; RBC folate:
theless, the use of assay-mismatched cutoffs may have been why 37%) and of similar magnitudes postfortification (serum folate:
prevalence estimates for serum folate were different than those 4.2%; RBC folate: 8.6%). Risk of insufficiency on the basis of
for RBC folate (24). In our report, risks of deficiency were elevated NTD risk in women of reproductive age could only be
interpreted with the use of RBC folate and it was 23% during the
20072010 postfortification period.
TABLE 7 Several expert panels have previously discussed the appro-
Prevalence for risk of folate insufficiency by population subgroup with the priateness of commonly used cutoffs to estimate the prevalence of
use of assay-matched cutoffs and original data for women aged 1249 y in
low folate status (1, 5, 8, 9, 10, 16). Some of those issues have
the postfortification (20072010) NHANES1
been summarized (2), and a recent review article discussed
RBC2 folate cutoff (,748 nmol/L3) general issues related to cutoffs for nutritional biomarkers (26).
and time period (20072010) Because a cutoff of adequacy should discriminate accurately
Race-ethnicity (with few misclassification errors) between healthy and at-risk
Mexican American 21 (17, 25) groups, it is preferred that cutoffs are identified or validated
Non-Hispanic black 38 (35, 41) through clinical trials with the use of accurate assays (2, 26). The
Non-Hispanic white 18 (16, 21) folate cutoffs for risk of deficiency on the basis of megaloblastic
Supplement use anemia were derived from experimental data (limited sample
Yes 12 (10, 14) size) and, therefore, were most closely aligned with this re-
No 30 (27, 33)
quirement. However, this was not the case for the cutoffs for risk
1
All values are percentages (95% CIs). Data were determined on the of possible deficiency on the basis of rising Hcy, which were
basis of elevated risk of neural tube defects. Data for 20072010 were gen- derived from cross-sectional prefortification NHANES data. A
erated with the CDC microbiologic assay with chloramphenicol-resistant validation of these cutoffs through experimental data are lacking
strain and 5-methyltetrahydrofolate calibrator.
2 and, thus, any resulting prevalence estimates should be inter-
RBC, red blood cell.
3
Microbiologic assay with chloramphenicol-resistant strain and folic preted with caution.
acid calibrator cutoff of 906 nmol/L was adjusted to microbiologic assay Another reason that cutoffs for risk of possible deficiency on
with chloramphenicol-resistant strain and 5-methyltetrahydrofolate calibra- the basis of rising Hcy should be used with caution is due to the
tor units (12, 13). underlying assay (BioRad RPBA). For whole-blood samples, the
1614 PFEIFFER ET AL.
relation between the BioRad RPBA and the MBA-3 depends on the traditional MBA-1 performed similarly to the current MBA-3.
the 5,10-methylenetetrahydrofolate reductase (MTHFR) C677T Thus, the use of IOM cutoffs for risk of deficiency with MBA-3
genotype, whereby RBC folate concentrations in persons with measured data should be acceptable.
a T/T genotype are overestimated and concentrations in persons A minor challenge related to folate cutoffs is the use of dif-
with a C/C genotype are underestimated (27). However, MTHFR ferent units (i.e., ng/mL compared with nmol/L) (26). The lit-
C677T genotype information is often not available, which ne- erature has been inconsistent about the use of conversion factors
cessitates the use of all-genotype rather than genotype- (e.g., 2.266 is typically used on the basis of the molecular weight
specific regression equations to adjust the data (7). Issues of of folic acid; and 2.178 is sometimes used on the basis of the
inaccurate RBC folate concentrations also appear to be present molecular weight of 5-methyltetrahydrofolate) and whether to
in other protein binding assays (28). Last, the BioRad RPBA round the cutoff (e.g., serum folate concentration of 6.8 compared
was discontinued w10 y ago and, to our knowledge, has not with 7 nmol/L; RBC folate concentration of 226.5 compared with
been used in other national nutrition surveys. Information on 227 nmol/L). Cutoffs that fall on the tail of a distribution can
how the BioRad RPBA compares with assays used in other produce very different prevalence estimates even with minor
nutrition surveys is missing, thereby making it impossible to changes in a cutoff. To avoid giving inappropriate implied
suggest appropriate adjustment factors. All of these issues limit precision, we rounded adjusted cutoffs to integers (Table 1).
the implementation of the WHO cutoffs for possible deficiency In conclusion, our work serves to re-evaluate the folate status of
on the basis of rising Hcy internationally and raise questions the US population prefortification and postfortification by applying
about the US data (19882006) specifically for RBC folate. our best understanding about folate cutoffs and describing their