Print version ISSN 0101-6083
Rev. psiquiatr. clín. vol.39 no.3 São Paulo 2012
Cesar C. AlmeidaI; Helena P. BrentaniII; Orestes V. ForlenzaI; Breno S. DinizI, III
ILaboratory of Neuroscience (LIM-27),
Institute and Department of Psychiatry, Faculty of Medicine, University of São
IILaboratory of Genetics (LIM-27), Institute and Department of Psychiatry, Faculty of Medicine, USP
IIIWestern Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh School of Medicine
BACKGROUND: Complex B vitamin deficiency
has been associated to cognitive impairment and dementing disorders in the elderly.
OBJECTIVE: This work aims to assess whether patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI) have lower levels of folic acid and cobalamin (vitamin B12) compared to age and gender-matched controls.
METHODS: One hundred and forty six elderly subjects (40 AD, 56 MCI and 49 healthy older adults) were recruited for this study. Serum folic acid and vitamin B12 levels were measured by electrochemoluminescence.
RESULTS: Compared to MCI and healthy controls a statistically significant reduction in serum concentrations of folic acid in AD patients was found (p = 0.02). This result remained statistically significant after controlling for socio-demographic and cognitive performance variables (p = 0.01). No significant differences were found in serum concentrations of vitamin B12 in patients with AD, MCI and healthy controls. No significant changes in hematologic parameters were observed across these diagnostic groups.
DISCUSSION: The present study provides additional evidence that folic acid is reduced in patients with AD and reinforces the importance of nutritional changes, in particular the one-carbon metabolism, in the physiopathology of AD.
Keywords: Folic acid, vitamin B12, Alzheimer's disease, nutritional factors, one-carbon metabolism.
In the recent years, there is a growing awareness of the relevance of homocysteine and related metabolic pathways in the pathophysiology, and, possibly, the prevention of Alzheimer's disease (AD)1-3. Homocysteine is a sulfur aminoacid derived from the metabolism of methionine by two major metabolic pathways: remethylation and transsulfuration4. These pathways are regulated by dietary ingestion of methionine, but also by other nutritional factors, in particular, folate and vitamin B12 levels. The latter mechanism stimulates the re-methylation pathway leading to the conversion of homocysteine to methionine5. High homocysteine levels are associated with increased oxidative stress, DNA methylation and apoptosis, being a risk factor to several diseases, including cardiovascular and neurodegenerative disorders6-8.
Folic acid and vitamin B12 levels may serve as a surrogate marker of homocysteine levels in humans. Lower serum levels of both factors are significantly correlated with higher homocysteine levels in several studies9-12. Thus, dietary supplementation of folic acid and vitamin B12 would reduce homocysteine levels13 and improve cognitive performance and prevent the development of AD in at risk elderly subjects14. Studies with animal models of AD suggested that folic acid and vitamin B12 supplementation reduced AD-related neuropathology and improved cognitive function in these models15,16. A positive association between high folate intake and reduced risk of AD has also been reported17. Despite these evidences, many observational studies and randomized clinical trials did not find a significant benefit of folic acid and vitamin B12 supplementation to reduced the progression of disease or improve cognitive performance18-20.
Therefore, the aims of the present study are to assess differences of serum levels of folic acid and cobalamin (vitamin B12) between patients with AD and mild cognitive impairment (MCI) as compared to age-matched healthy controls and to assess the relationship between these vitamins and cognitive performance in this test group.
One hundred and forty six older adults were recruited to this study. They are part of a clinical cohort dedicated to the study of cognitive aging. Detailed description of the clinical and cognitive assessments and diagnostic procedures can be found elsewhere21,22. In brief, the patients underwent a comprehensive cognitive assessment which included the administration of the Rivermead Behavioral Memory Test (RBMT), the Fuld Object Memory Evaluation (FOME), the Trail Making Test A and B, semantic verbal fluency (category: fruit), the short cognitive test (SKT); the scores on the Mini-mental State Examination were used as a proxy measure of global cognitive performance.
The diagnosis of Alzheimer's disease (AD) was ascertained according to the NINCDS-ADRDA diagnostic criteria23. The diagnosis of mild cognitive impairment (MCI) was ascertained according to the Mayo Clinic criteria24. Elderly subjects with no evidence of cognitive impairment were regarded as healthy controls.
After clinical and cognitive assessments blood samples were taken from all subjects in the morning after 10 hours fasting. Serum folic acid and vitamin B12 levels were measured by electrochemoluminescence, as part of the routine laboratorial assessment.
Kolmogorov-Smirnoff tests were carried out to ascertained distribution normality of continuous variables. As the variables of interest in this study (i.e. folic acid and vitamin B12) did not show a normal distribution (p < 0.001), we carried out non-parametric statistical tests (Kruskal-Wallis or Mann-Whitney tests, when applicable) to assess for differences between diagnostic groups. Qui-square tests were carried out to assess for differences in frequency distribution of dichotomous variables. Spearman correlation tests were done address the correlation between folic acid and vitamin B12 levels and clinical and cognitive variables.
Tables 1 and 2 show the socio-demographic and cognitive performance variables for patients and controls. As expected, patients with AD and MCI were older, with less years of formal education and had worse cognitive performance. No significant differences in general nutritional status, as verified by total protein and hemoglobin levels, were observed among diagnostic groups (Table 3).
Patients with AD showed a significant reduction in serum concentrations of folic acid as compared to MCI subjects and healthy controls. No significant differences were observed between MCI and healthy controls. Also, no significant differences were observed in serum concentrations of vitamin B12 across the diagnostic groups (Table 3).
As age and education were significantly different between diagnostic groups, we carried out an analysis of covariance to control for the potential confounding effects of these variables on folic acid levels. After controlling for these factors, folic acid levels remained significantly reduced in patients with AD (F = 4.5, d.f. = 2, p = 0.01).
Spearman analysis showed a significant correlation between folic acid levels and memory scores (RBMT screening scores, rho = 0.190; p = 0.03), verbal fluency (rho = 0.247, p = 0.006) and Trail A (rho = -0.196; p = 0.03). There were no significant correlations with age, educational levels, hemoglobin or total protein serum levels, or scores on other cognitive tests.
In our study, we found a significantly lower folic acid levels in patients with AD as compared to subjects with MCI and healthy older adults, which was independent of age and educational level. No differences were observed between elderly controls and MCI subjects. In addition, lower folic acid level was correlated with worse cognitive performance, in particular in memory, language and psychomotor speed. It is important to note that, despite lower folic acid levels in AD patients, the median values was above the lower range of laboratorial reference values (i.e. 4.2 to 19.9 ng/ml). Thus, these patients did not show a clinically significant vitamin deficiency that could explain the present results. These results could not be better explained by differences in nutritional status. Thus, our results suggest that reduction in folic acid levels may be a metabolic feature in the pathophysiology of AD, with a possible negative effect on cognitive performance. Because patients with MCI did not display a similar reduction in the concentrations of folic acid, we speculate that this abnormality may be only observed in later stages of the neurodegenerative process (i.e. when subjects already present with clinically manifest dementia). Nevertheless, we must take into account that the lack of difference between patients with MCI and normal controls may be a consequence of the biological heterogeneity of the MCI group, which was recruited according to clinically-oriented diagnostic criteria.
Our results are in accordance with previous reports in the literature25,26. These studies found that the lower folic acid levels, higher the risk of AD in community-based studies. In contrast to our results, these studies also found a significant association between lower vitamin B12 levels and AD. Methodological differences, such as sample size and study setting, may in part explain these differences.
The actual mechanism that leads to a reduction of folic acid in AD remains to be established. One possible explanation is the evidence that there is an inverse relationship between folic acid and homocysteine levels (Morris, 2003). Folate is a co-factor in one-carbon metabolism during which it promotes the regeneration of methionine from homocysteine, a highly reactive sulfur-containing amino acid. Thus, patients with low folic acid levels may present with increased homocysteine levels what in turn is neurotoxic and lead to neurodegenerative changes27. This is reinforced by the evidence that high homocysteine levels are independently associated to AD28,29. So low folate status and elevated homocysteine besides the well-established roles on induction of DNA damage, increase the generation of reactive oxygen species and contribute to excitotoxicity, mitochondrial dysfunction and apoptosis. Also, low folate levels determine an imbalance between glycogen synthase kinase 3-beta (GSK-3b) and protein phosphatase 2A (PP2A) activity, leading to abnormal hyperphosphorylation of tau in AD30. Finally, methionine may be converted to S-adenosylmethionine (SAM), the principal methyl donor in most biosynthetic methylation reactions. Low folate leads to lower levels of SAM what in turn may increase DNA methylation and leading to changes in the epigenetic control of learning and memory acquisition31. Therefore, low folate level, as observed in our study, have several negative effects to neuronal functioning that are related to some extend to the pathophysiology of AD32.
In conclusion, our study showed a significant reduction in folate levels in patients with AD as compared to healthy controls. Our results highlight the importance of the assessment of nutritional aspects in AD and also for a possible role of folate deficiency in its physiopathological features. Despite previous clinical trial did not find a significant effect of folate supplementation to improve cognition on patients with AD, we can rule out potential beneficial effects of long-term folate supplementation for reducing the risk of AD.
None to declare.
Conflict of interest
None to declare.
This work was partially funded by grants of Fundação de Amparo à Pesquisa de São Paulo (Fapesp Grant nº 09/52825-8, Brazil), and Associação Beneficente Alzira Denise Hertzog da Silva (ABADHS).
Role of funding source
The funding sources did not have any role in the study conception, design, data analysis and in the elaboration of the manuscript.
Cesar C. Almeida designed the study, collected data, carried out the statistical analysis and wrote the manuscript. Helena P. Brentani and Orestes V. Forlenza analysed the data and wrote the manuscript.
1. Donini LM, De Felice MR, Cannella C. Nutritional status determinants and cognition in the elderly. Arch Gerontol Geriatr. 2007;44(Suppl 1):143-53. [ Links ]
2. Daviglus ML, Plassman BL, Pirzada A, Bell CC, Bowen PE, Burke JR, et al. Risk Factors and Preventive Interventions for Alzheimer Disease: State of the Science. Arch Neurol. 2011;68:1185-90. [ Links ]
3. Zhuo JM, Praticò D. Acceleration of brain amyloidosis in an Alzheimer's disease mouse model by a folate, vitamin B6 and B12-deficient diet. Exp Gerontol. 2010;45:195-201. [ Links ]
4. Selhub J. Homocysteine metabolism. Annu Rev Nutr. 1999;19:217-46. [ Links ]
5. Fuso A, Seminara L, Cavallaro RA, D'Anselmi F, Scarpa S. S-adenosylmethionine/homocysteine cycle alterations modify DNA methylation status with consequent deregulation of PS1 and BACE and beta-amyloid production. Mol Cell Neurosci. 2005;28:195-204. [ Links ]
6. Jacobsen DW. Hyperhomocysteinemia and oxidative stress: time for a reality check? Arterioscler Thromb Vasc Biol. 2000;20:1182-4. [ Links ]
7. Kruman II, Kumaravel TS, Lohani A, Pedersen WA, Cutler RG, Kruman Y, et al. Folic acid deficiency and homocysteine impair DNA repair in hippocampal neurons and sensitize them to amyloid toxicity in experimental models of Alzheimer's disease. J Neurosci. 2002;22:1752-62. [ Links ]
8. Obeid R, Herrmann W. Mechanisms of homocysteine neurotoxicity in neurodegenerative diseases with special reference to dementia. FEBS Lett. 2006;580:2994-3005. [ Links ]
9. Clarke R, Smith AD, Jobst KA, Refsum H, Sutton L, Ueland PM. Folate, vitamin B12, and serum total homocysteine levels in confirmed Alzheimer disease. Arch Neurol. 1998;55:1449-55. [ Links ]
10. Mattson MP, Shea TB. Folate and homocysteine metabolism in neural plasticity and neurodegenerative disorders. Trends Neurosci. 2003;26:137-46. [ Links ]
11. Quadri P, Fragiacomo C, Pezzati R, Zanda E, Forloni G, Tettamanti M, et al. Homocysteine, folate, and vitamin B-12 in mild cognitive impairment, Alzheimer disease, and vascular dementia. Am J Clin Nutr. 2004;80:114-22. [ Links ]
12. Remacha AF, Souto JC, Piñana JL, Sardà MP, Queraltó JM, Martí-Fabregas J, et al. Vitamin B12 deficiency, hyperhomocysteinemia and thrombosis: a case and control study. Int J Hematol. 2011;93:458-64. [ Links ]
13. Albert CM, Cook NR, Gaziano JM, Zaharris E, MacFadyen J, Danielson E, et al. Effect of folic acid and B vitamins on risk of cardiovascular events and total mortality among women at high risk for cardiovascular disease: a randomized trial. JAMA. 2008;299:2027-36. [ Links ]
14. Das UN. Folic acid and polyunsaturated fatty acids improve cognitive function and prevent depression, dementia, and Alzheimer's disease - but how and why? Prostaglandins Leukot Essent Fatty Acids. 2008;78:11-9. [ Links ]
15. Chan A, Shea TB. Folate deprivation increases presenilin expression, gamma-secretase activity, and Abeta levels in murine brain: potentiation by ApoE deficiency and alleviation by dietary S-adenosyl methionine. J Neurochem. 2007;102:753-60. [ Links ]
16. Parachikova A, Green KN, Hendrix C, LaFerla FM. Formulation of a medical food cocktail for Alzheimer's disease: beneficial effects on cognition and neuropathology in a mouse model of the disease. PLoS One. 2010;5:e14015. [ Links ]
17. Luchsinger JA, Tang MX, Miller J, Green R, Mayeux R. Relation of higher folate intake to lower risk of Alzheimer disease in the elderly. Arch Neurol. 2007;64:86-92. [ Links ]
18. Aisen PS, Schneider LS, Sano M, Diaz-Arrastia R, Van Dyck CH, Weiner MF, et al. Alzheimer Disease Cooperative Study. High-dose B vitamin supplementation and cognitive decline in Alzheimer disease: a randomized controlled trial. JAMA. 2008;300:1774-83. [ Links ]
19. Morris MC, Evans DA, Schneider JA, Tangney CC, Bienias JL, Aggarwal NT. Dietary folate and vitamins B-12 and B-6 not associated with incident Alzheimer's disease. J Alzheimers Dis. 2006;9:435-43. [ Links ]
20. Nelson C, Wengreen HJ, Munger RG, Corcoran CD. Dietary folate, vitamin B-12, vitamin B-6 and incident Alzheimer's disease: the cache county memory, health and aging study. J Nutr Health Aging. 2009;13:899-905. [ Links ]
21. Diniz BS, Nunes PV, Yassuda MS, Pereira FS, Flaks MK, Viola LF, et al. Mild cognitive impairment: cognitive screening or neuropsychological assessment? Rev Bras Psiquiatr. 2008;30:316-21. [ Links ]
22. Forlenza OV, Diniz BS, Talib LL, Radanovic M, Yassuda MS, Ojopi EB, et al. Clinical and biological predictors of Alzheimer's disease in patients with amnestic mild cognitive impairment. Rev Bras Psiquiatr. 2010;32:216-22. [ Links ]
23. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology. 1984;34:939-44. [ Links ]
24. Petersen RC, Doody R, Kurz A, Mohs RC, Morris JC, Rabins PV, et al. Current concepts in mild cognitive impairment. Arch Neurol. 2001;58:1985-92. [ Links ]
25. Wang HX, Wahlin A, Basun H, Fastbom J, Winblad B, Fratiglioni L. Vitamin B(12) and folate in relation to the development of Alzheimer's disease. Neurology. 2001;56:1188-94. [ Links ]
26. Ravaglia G, Forti P, Maioli F, Martelli M, Servadei L, Brunetti N, et al. Homocysteine and folate as risk factors for dementia and Alzheimer disease. Am J Clin Nutr. 2005;82:636-43. [ Links ]
27. Herrmann W, Obeid R. Homocysteine: a biomarker in neurodegenerative diseases. Clin Chem Lab Med. 2011;49:435-41. [ Links ]
28. Seshadri S, Beiser A, Selhub J, Jacques PF, Rosenberg IH, D'Agostino RB, et al. Plasma homocysteine as a risk factor for dementia and Alzheimer's disease. N Engl J Med. 2002;346:476-83. [ Links ]
29. Ho RC, Cheung MW, Fu E, Win HH, Zaw MH, Ng A, et al. Is high homocysteine level a risk factor for cognitive decline in elderly? A systematic review, meta-analysis, and meta-regression. Am J Geriatr Psychiatry. 2011;19:607-17. [ Links ]
30. Nicolia V, Fuso A, Cavallaro RA, Di Luzio A, Scarpa S. B vitamin deficiency promotes tau phosphorylation through regulation of GSK3beta and PP2A. J Alzheimers Dis. 2010;19:895-907. [ Links ]
31. Yu NK, Baek SH, Kaang BK. DNA methylation-mediated control of learning and memory. Mol Brain. 2011;4:5. [ Links ]
32. Coppedè F. One-carbon metabolism and Alzheimer's disease: focus on epigenetics. Curr Genomics. 2010;11:246-60. [ Links ]
Address correspondence to: Received: 23/1/2012
Breno S. Diniz
Av. Guilherme Mankel, 81, Vila Clarice
05176-000 - Sao Paulo, SP
Address correspondence to: