1. Reduced Risks of Neural Tube Defects and Orofacial Clefts With Higher Diet Quality Carmichael SL, Yang W, Feldkamp ML, et al; National Birth Defects Prevention Study. Reduced risks of neural tube defects and orofacial clefts with higher diet quality. Arch Pediatr Adolesc Med. Published online October 3, 2011. doi:10.1001/archpediatrics.2011.185. Copyright restrictions may apply

2. Introduction Background –Nutrition research related to neural tube defects has tended to focus on 1 nutrient (eg, folate) at a time. –However, nutrition is more complex than 1 nutrient, and nutrition may affect development other than neural tube defects, such as orofacial clefts. –Examining overall diet quality offers a more holistic approach. Objective –To examine whether better maternal diet quality was associated with reduced risk for selected birth defects. Copyright restrictions may apply

3. Methods Study Design –Case-control analysis of data from the National Birth Defects Prevention Study, initiated with pregnancies (1997-2005) in 10 states. Sample –Cases included infants or fetuses with anencephaly, spina bifida, and cleft lip with or without cleft palate or cleft palate alone, as confirmed by clinical, surgery, or autopsy reports (n = 3824). –For each case, live-born controls without birth defects were randomly selected from the same state, per study year (n = 6807). Measures –Nutrition measures were derived from maternal interviews conducted 7 to 9 months after delivery. Mediterranean Diet Score and Diet Quality Index. Copyright restrictions may apply

4. Methods Limitations –Recall bias regarding nutrition factors during pregnancy. Could not validate women’s intake during pregnancy. However, other studies suggest minimal recall bias in analyses of birth defects. –Selection bias in participating in the study. Could not compare participants with nonparticipants. However, controls appeared representative of the general population of pregnant women. –Possibility of residual confounding factors. Adjustment for measured covariates did not affect results substantially, but variance due to unmeasured covariates is still possible. Copyright restrictions may apply

5. Results

6. Copyright restrictions may apply Results

7. Comment Higher maternal diet quality in the year before pregnancy was positively associated with lower risks for neural tube defects and orofacial clefts, even after adjusting for multiple confounders. These findings contrast with prior analyses of the same data set, which found no association between single nutrients and neural tube defects or orofacial clefts. Hispanic mothers tended to score higher on diet quality indices. –Mechanism is unclear; some studies have suggested better nutrient intakes among Hispanic individuals, especially those who are less acculturated. Copyright restrictions may apply

8. Comment Implications for Future Research in This Area –Given the continuing burden of neural tube defects and orofacial clefts in the United States and in other countries, the benefit of broad dietary value must be explored in greater depth to understand how components of diet interact and affect women. Implications for Health Policy –Messages about healthy nutrition for women trying to conceive and for women early in pregnancy may need to be broadened beyond single nutrients (eg, folate) to achieve maximal benefit. Copyright restrictions may apply

9. Contact Information If you have questions, please contact the corresponding author: –Suzan L. Carmichael, PhD, Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University, 1265 Welch Rd, Room X109B, Stanford, CA 94305-5415 (scarmichael@stanford.edu). Funding/Support This project was partially supported by grants R01 NS050249 and R03DE020112 from the National Institutes of Health and grants 6U01-DD- 000489 and 1U01-DD-0006982 from the Centers for Disease Control and Prevention. Copyright restrictions may apply