1. Prevalence and Risk Factors for Spina Bifida in Latino Populations Mark Canfield, Ph.D. Manager, Birth Defects Epidemiology and Surveillance Branch Texas DSHS

2. Association of Spina Bifida with Maternal Race/Ethnicity 1 Canfield et al. 2009. Pediatr Perinatal Epidemiol. 2 Carmichael et al. 2003. BDRA. 3 Canfield et al. 2006. BDRA. Study LocationYearsNo. of Cases Relative Risk* (95% CI) Texas 1 1999–20035611.2 (0.9–1.6) California 2 1989–19977421.2 (1.9-1.6) National 3 1999–20013091.2 (1.0–1.4) *Compared to the referent category of non-Hispanic whites

3. Variable Whites cPR 1 Hispanics cPR 1 (95% CI) Blacks cPR 1 (95% CI) Subtype (N=923)(N=513)(N=316)(N=94) SB M 2 (N=790)Referent1.20 (1.03–1.40)0.89 (0.71–1.12) SB L 3 (N=133)Referent1.74 (1.23–2.46)0.25 (0.09–0.69) TotalReferent1.27 (1.11–1.46)0.80 (0.65–1.00) Case type SB M 2 (N= 790)(N=443)(N=257)(N=90) Isolated (N=683)Referent1.19 (1.01–1.40)0.79 (0.61–1.02) Multiple major defects (N=107)Referent1.26 (0.82–1.95)1.63 (0.97–2.72) Lesion level, isolated SB M 2 (N=657) (N=377)(N=215)(N=65) Cervical (N=5)Referent2.06 (0.29-14.66)2.20 (0.20-24.22) Thoracic (N=55)Referent1.33 (0.73-2.40)1.41 (0.67-2.99) Lumbar (N=525)Referent1.21 (1.01-1.46)0.67 (0.49-0.91) Sacral (N=72)Referent0.83 (0.48-1.43)0.88 (0.43-1.80) 1 PR = Prevalence ratio 2 SB M = Myelomeningocele, meningocele, and myelocele 3 SB L = Lipomyelomeningocele and lipomeningocele Agopian et al. 2011. Am J Med Genet A. Association of Race/Ethnicity with Spina Bifida Stratified by Clinical Subtype, 1997-2005

4. Variable Whites (N=385) PR 1 Hispanics (N=221) PR 1 (95% CI) Blacks (N=70) PR 1 (95% CI) Sex, isolated SB M 2 (N=676) Male (N=340)Referent1.55 (1.23–1.95)1.12 (0.80–1.56) Female (N=336)Referent0.90 (0.70–1.14)0.55 (0.37–0.82) Agopian et al. 2011. Am J Med Genet A. 1 PR=Prevalence ratio 2 SB M =Myelomeningocele, meningocele, and myelocele Association of Race/Ethnicity with Spina Bifida Stratified by Infant Sex, 1997-2005

5. CharacteristicCrude OR (95% CI) FatherWhiteReferent Hisp., US born1.30 (0.92–1.82) Hisp., MX/CA* born, 5+yrs in US1.95 (1.34–2.85) Hisp., MX/CA* born, <5yrs in US2.28 (1.13–4.58) MotherWhiteReferent Hisp., US born1.23 (0.92–1.63) Hisp., MX/CA* born, 5+yrs in US2.16 (1.56–3.00) Hisp., MX/CA* born, <5yrs in US1.92 (1.23–2.99) BothWhiteReferent Hisp., US born1.33 (0.88–2.02) Hisp., MX/CA* born, 5+yrs in US2.45 (1.49–4.03) Hisp., MX/CA* born, <5yrs in US3.28 (1.46–7.37) *MX/CA = Mexico/Central America Canfield et al. 2009. BDRA. Association of Maternal and Paternal Hispanic Birthplace/Immigration Factors with Spina Bifida, 1997–2003

6. Decline in the Prevalence of Spina Bifida by Race/Ethnicity US, 1995 – 2002 Williams et al. 2005. Pediatrics. Fortification

7. Prevalence of Spina Bifida in 10 US Regions, 2002 *Adjusted for maternal age Shin et al. 2010. Pediatrics.

8. Association of Race/Ethnicity with Selected Self-reported Preconception Health Indicators– Texas Pregnancy Risk Assessment Monitoring System, 2002–2010 Maternal Factors White (n=5413) Hispanic (n=5758) PR (95% CI) Black (n=4215) PR (95% CI) SmokingReferent0.35* (0.31-0.39).54* (0.49–0.60) No daily multivitaminReferent1.18* (1.14–1.21)1.18* (1.15–1.21) ObeseReferent1.29* (1.16-1.42)1.49* (1.36–1.64) CDC. 2012. Publication pending. * Association is statistically significant in multivariate models that included age, race/ethnicity, education, insurance, Medicaid, and pregnancy intent.

9. Variable # Foreign-Born# U.S.-BornAdjusted OR*95% CI Smoking 311050.240.16–0.37 Exposure to Passive Smoke 1361760.680.51–0.98 Periconceptional Folic Acid Supplements (daily v. none) 5475280.760.59–0.98 Obese (v. normal BMI) 761490.490.35–0.66 *Odds ratio adjusted for maternal age, education, and pregnancy intention, referent group is U.S. born Ramadhani et al. 2011. BDRA. The Association of Nativity with Selected Maternal Factors, Hispanic NBDPS Controls, 1997–2005

10. Folic Acid Awareness and Use Among Women with a History of an NTD-Affected Pregnancy Texas, 2000–2001 Canfield et al. 2002. MMWR.

11. Texas Neural Tube Defect Project–Mexican Americans on TX-US Border, 1994-2000 Cluster: Brownsville, Texas 1991 24 peer reviewed articles on risk factors NTD risk factors for folic acid deficient population: –Low serum B 12 –Periconceptional hyperthermia –Exposure to nitrosatable drugs with high nitrate/nitrite intake –Periconceptional diarrhea –Exposure to fumonisins –Hyperinsulinemia –Passive smoke exposure

12. Summary Relative to whites, Latinos are: –Only at modestly elevated risk of spina bifida, regardless of clinical phenotype or pattern –At greater risk if one/both parents foreign born –Less likely to be exposed to smoke (Foreign-born>US-born) –Less likely to supplement (Foreign-born>US-born) –More likely to be obese (US-born>Foreign-born)

13. Mark A Canfield, PhD, Manager Birth Defects Epidemiology and Surveillance Branch Texas Department of State Health Services Phone: (512) 776-6158 Email: mark.canfield@dshs.state.tx.us Web site: http://www.dshs.state.tx.us/birthdefects/ THANK YOU