(Haworth et al., 1993; Kang et al., 1991b). Moreover, deletion of cystathionine β-synthase in the mouse yields a phenocopy of human homocystinuria but not an NTD (Watanabe et al., 1995). Subsequent work on other genetic markers of risk has not provided conclusive results (van der Put et al., 1997a, b).

Two studies have shown a statistically significant association between mothers of children with NTDs and a common variation within the gene for MTHFR (van der Put et al., 1995; Whitehead et al., 1995). This gene codes for a thermolabile variant of the enzyme that shows about 50 percent enzymatic activity and is associated with elevated serum homocysteine concentrations (Kang et al., 1991a). This association would account for approximately 15 percent of NTD cases (van der Put et al., 1995). The polymorphism was recently associated with low erythrocyte folate values (Molloy et al., 1997), which suggests that these values by themselves could account for the increased NTD risk. However, similar studies using linkage assessments are needed in suitable (genetically homogeneous) NTD populations with adequate numbers and types of controls.

No correlation has been found between two common mutations in cystathionine β-synthase and NTD prevalence in an Irish population (Ramsbottom et al., 1997). The gene for methionine synthase has only recently been cloned in mammals (Chen et al., 1997; Li et al., 1996). There are no reports of an association between mutations of this gene and NTDs.

The genetic mouse models of NTD suggest a variety of other candidate genes for human NTDs (Baldwin et al., 1992; Tassabehji et al., 1993). However, no reports assess whether any of the causative genes for mouse models show linkage with the common forms of human NTD. Because the likely heterogeneity of human NTDs may make it impossible to demonstrate linkage for any one candidate gene, candidate genes will need to be assessed in individuals with NTDs by sequence analysis.

A summary of evidence from animal studies on the etiology of NTD appears in Appendix M. Animal models of NTD have been examined and manipulated to elucidate the mechanisms of abnormal neurulation and to test etiologic hypotheses suggested by human epidemiological data.

Nutrition Evidence. Studies of migrant populations suggest a nutritional etiology for NTD (Borman et al., 1986; Carter, 1974). Lower socioeconomic class also correlates with NTD incidence (Elwood and Elwood, 1980; Laurence, 1990). Differences in diet and in supplement use could contribute to the inverse relationship of socio-