by Jasmine Jafferali, MPH
Parents who engaged in home baking in the early 1900’s routinely gave their kids a daily dose of cod liver oil. This daily spoonful was important for health and well-being because it contained vast amounts of vitamin D and DHA. Today, we suffer from information overload when it comes to fats. Whether it is good fats, bad fats, trans fats, polyunsaturated fats, unsaturated fats, the information about the different kinds of fats is confusing. Researchers continue to publish studies highlighting the importance of omega 3 fatty acids, throughout our lifespan. However, the greatest time of need for DHA is during fetal development and the first 2 years of a child's life.
What are fatty acids?
There are two types of fatty acids – omega 6 fatty acids and omega 3 fatty acids. They are both ‘essential’ fatty acids, which means your body cannot make them. These fatty acids need to be ingested. Both types are important for good health. However, most Americans consume much more omega 6 fatty acids than omega 3’s, placing our bodies in an omega 3 deficit. This becomes vitally important for the childbearing woman, since omega 3’s have proven benefits for mom and baby.
The three main forms of omega 3 fatty acids are:
• eicosapentaenoic acid (EPA)
• docosahexaenoic acid (DHA)
• alpha-linolenic acid (ALA)
DHA and EPA are considered to be richer nutrients than ALA because they are utilized better by the body. Once ingested, the body will convert ALA to DHA, but this process is not very effective or consistent. So, when considering the benefits of omega 3’s specifically for pregnancy and lactation, is it important to understand that not all omega 3’s are created equal. When thinking about food choices, or supplements, it is better to think about maximizing your DHA and EPA intake, and not just your overall omega 3 consumption.
The only way the developing fetus can obtain omega 3’s is from the mother’s diet. However, it is nearly impossible to get enough through diet alone, since a main dietary source of DHA is fish or algae (it should be noted that fish are rich in DHA because they eat algae, which is the primary DHA source). Since 2004, the FDA has recommended that women restrict their fish consumption during pregnancy (no more than 2, 6 -ounce servings a week) to limit the exposure to neurotoxins within the fish. Most experts agree that mercury consumption via fish is also concerning for infants and young children.
What is the right amount of omega 3’s for pregnancy & lactation?
200 mg vs. 300 mg vs 900 mg
Several research studies validate that most women are consuming less than adequate amounts of DHA and EPA to support this rapid fetal/newborn growth. One study cites that 90% of women are deficient, while another study indicates that the average amount daily consumed is only 68-75mg (Stark, K. Dl, et al, 2005). So, what is the right amount of DHA and EPA? There is no US RDA for omega 3’s. Although highly excessive amounts of over 2000 mg daily can potentially be dangerous (March of Dimes, 2011), there is a wide range of ‘normal’ daily recommendations. One group of experts feels that expecting mothers need a minimum of 200 mg of DHA and EPA per day to maximize fetal development (Koletzko, B., et al, 2008) http://www.ncbi.nlm.nih.gov/pubmed/18184094. Other experts around the world recommend that pregnant women consume at least 300 mg DHA per day (Simopoulos AP, Leaf A, Salem N, 2000). Alternatively, more recent studies recommend a daily dose of 900 mgs of DHA, which is the equivalent of one serving or three ounces of fresh water salmon per day. (Hibbeln JR, Davis JM 2009).
Pregnancy consumption & Infant outcomes
By the time a pregnant woman reaches 30-weeks gestation, the baby’s brain development is at its peak. Therefore, the third trimester is the most crucial time for a baby’s brain growth. In fact, DHA has been has been shown to improve brain function and eye development. DHA is most concentrated in the brain and eyes, making up about 70 percent of a newborn baby’s brain, retina and nervous system. Recent clinical research from 2008 confirmed that expectant moms who consumed omega-3 fats late in pregnancy gave their infants a higher concentration of DHA (validated by cord blood measurements). These infants did better in tests of infant brain and eye development at the ages of 6 and 11 months (Jacobson, J. L., et al,2008) http://www.jpeds.com/article/S0022-3476(07)00660-9/abstract. This association of higher cord DHA concentrations correlating with increased visual, cognitive, and motor development supports the need to substantially increase this important fatty acid during the third trimester spurt of synaptogenesis in brain and photoreceptor development. Other clinical studies show similar results, such as:
• Enhanced coordination and visual acuity during toddlerhood:
• Maternal consumption of DHA during pregnancy has been proven to enhance coordination and visual acuity in the offspring when tested at ages 2 ½ and 3 ½ (Dunstan, J.A., et al, 2008) (Williams, C., et al, 2001)
• Higher Verbal IQ scores:
• Children born of women who underconsume DHA during pregnancy have a higher risk for low verbal IQ scores, reduced fine motor skills and less developed social and communication skills (Hibbeln, J.R., et al, 2007)
• Improved digestive and skin health during infancy:
• A 2009 study found fish oil can improve digestive health, possibly by promoting immune cell membrane fluidity and healthy cytokine balance. This study investigated supplementing pregnant women from 25 weeks gestation through 3-4 months of breastfeeding with fish oil containing 1.6 grams of EPA and 1.1 grams of DHA. The results indicate that mothers given fish oil maintained healthy IgE production (allergies) and provided support for infant skin sensitivity (eczema) and immune health.
Pregnancy consumption & benefits for Labor & Delivery & Postpartum
Women who consume adequate omega 3’s during their pregnancy also gain specific benefits related to the labor and delivery and postpartum period.
• Reduced internal inflammation which decreases the chances of developing of preeclampsia.
• One study suggests that altered placental omega 3’s may result in altered membrane lipid fatty acid composition leading to increased release of sFlt-1 in circulation (Kulkarni, A. V., et al,k 2011) http://www.ncbi.nlm.nih.gov/pubmed/20956072
• May help in the prevention of early delivery.
• One study demonstrated an increase in the average gestational period of about six days (Smuts, C., et al, 2003)16 More recent studies are have conflicting results.
• A large scale study from 2009 (n=852) investigated the use of supplementation (1,200 mg EPA and 800 mg DHA) or matching placebo from 16-22 through 36 weeks of gestation. All participants had a history of a previous preterm delivery and were now carrying a singleton pregnancy. All received weekly intramuscular 17alpha-hydroxyprogesterone caproate (250 mg) as well. This study concluded there was no difference in incidence of preterm delivery between the two groups (Harper, M., et al, 2010) 14 http://www.ncbi.nlm.nih.gov/pubmed/20093894
• However, another large scale study, DOMInO (DHA to Optimize Mother Infant Outcome) trial, showed fewer preterm births (<34 weeks gestation) and fewer babies with low birth weight; with significantly fewer neonatal care admissions, compared with controls (Makrides M, Gibson RA, McPhee AJ, et al, 2010)
May help with weight loss during the postpartum period and later in life.
• A 2009 study found that mice who were given DHA & EPA had reduced glucose intolerance, less adipose tissue inflammation, and increased weight loss (Rossmeisl, M., et al, 2009)
May reduce postpartum depression, although studies are not conclusive on this issue.
• Research has found low levels of DHA in mother's milk and in the red blood cells of women suffering from postpartum depression. (Journal of Affective Disorders, 2002). Some scientists believe increasing levels of maternal DHA may reduce the risk of postpartum depression (Medscape, 2002). However a 2010 study published in the Journal of the American Medical Association, October 2010 found that prenatal supplementation of 800 mg of DHA (moms were supplemented from 21 weeks gestation through birth) did not result in lower levels of PP depression. Conversely, another small randomized study from 2011, presented at the recently held Experimental Biology Annual Meeting in Washington, DC, demonstrated that pregnant women taking fish oil capsules containing DHA showed consistent 6-point lower mean depression scores after pregnancy across numerous time points than did those receiving placebo. This study had a small n=52 and was conducted at the University of Connecticut school of nursing (?Experimental Biology 2011 Annual Meeting: Abstract 349.7.)
Newborn DHA consumption and benefits
As stated earlier, international consensus recommends 200 mg daily DHA intake for lactation women. When breastfeeding is not possible, an infant formula providing DHA at levels between 0.2 and 0.5 weight percent of total fat, and with the minimum amount of amino acids equivalent to the contents of DHA is also recommended. Dietary omega 3’s should continue after the first six months of life. However, again the recommendations vary and one group of experts feels that there is currently not sufficient information for quantitative recommendations (J. Perinat. Med. 2008; 36: 5-14.) http://www.ncbi.nlm.nih.gov/pubmed/18184094. However, a latter study published in 2009, found 900mg may be necessary to cover the needs of both mom and baby. This is crucial as the newborn baby’s brain triples its size during the first year of life. (Hibbeln JR, Davis JM. Considerations regarding neuropsychiatric nutritional requirements for intakes of omega-3 highly unsaturated fatty acids. Prostaglandins Leukot Essent Fatty Acids 2009;81:179-186.) Even though DHA is found naturally in breastmilk, the content of the breastmilk DHA varies based on the mom’s DHA consumption. So, it is important for lactating moms to supplement their diet with DHA. Boosting the omega 3 fatty acid content of your breast milk may offer the following advantages:
• Better psychomotor skills as toddlers:
• A 2005 study published in the July issue of American Journal of Clinical Nutrition showed that infants of mothers who supplemented with DHA during the first four months of breastfeeding had better psychomotor skills at 2 1⁄2 years of age.
• Better attention span at age 2 and enhanced cognitive skills at 6 months of age:
• A study published in Child Development, 2004 found that babies whose mothers had high blood levels of DHA at delivery had advanced attention spans into their second year of life. During the first six months of life, these infants were two months ahead in cognitive skills than babies whose mothers had lower DHA levels (http://www.ncbi.nlm.nih.gov/pubmed/20959577).
• Fostering of mental development: **ANN NEED CORRECT LINK HERE **
• Maternal intake of very-long-chain n-3 PUFAs during pregnancy and lactation may be favorable for later mental development of children. 2003 Jan;111(1):e39-44; http://www.ncbi.nlm.nih.gov/pubmed/1250959
• Improved sequential processing during early school years:**ANN NEED CORRECT LINK HERE **
• Another study in Pediatrics. 2008 Aug;122(2):e472-9; Assessed 7 year olds whose moms received polyunsaturated fatty acids during pregnancy and first 3 months of BF, finding this might be of importance for later cognitive function, such as sequential processing http://www.ncbi.nlm.nih.gov/pubmed/18676533
Since 2002, infant formula supplemented with DHA/ARA has been commercially available in the USA and is widely used at many maternity centers. The AAP has not taken an official stand on whether or not to recommend DHA fortified formula. However, many international experts throughout the world recommend DHA supplemented formulas for moms who are not breastfeeding. (*)Parents who are feeding formula to their baby should consider a formula with DHA added and talk with their doctor about this. The Society for Research in Child Development in 2009 found a boost in cognitive development when babies were fed formula fortified with DHA. By the time these babies reached 9 months of age, the babies given DHA scored higher on a problem solving test (Supplementing Babies’ Formula With DHA Boosts Cognitive Development, Study Finds, ScienceDaily retrieved from December 21, 2009).
Where are the omega 3’s hiding?
One of the best sources of DHA/EPA is cold water fish, yet regular fish consumption is not recommended for expectant/lactating moms or infants/children due to heavy metal contamination. Furthermore, it is best for this group to avoid the known ‘high-mercury’ level fish such as shark, tilefish, swordfish, and mackerel. This EPA brochure on fish and mercury can be printed and provided to patients.
Other natural sources of Omega 3’s are listed below:
The ‘Best’ Natural Sources:
• Organic or Grass-fed calf liver (eat sparingly during pregnancy to prevent excess vitamin A levels)
• oily, cold-water fish such as salmon, herring, sardines, and anchovies (one 3.5 ounce serving of salmon has 600 mg of DHA)
• Algae or algae oil (the EPA content of algae can vary greatly, so it is important to read the labels to see if the EPA content has been validated)
• egg yolks (Egg yolks have 25-50 mg of DHA; omega 3 fortified eggs may have more DHA, but they are generally higher in ALA than DHA – check the package. If the amount of ‘fortified’ DHA is not listed on the label, it falls below federal standards for reporting and is insignificant)
Other ‘Good’ natural sources:
The below sources are high in omega 3’s but contain ALA, instead of DHA. The body will convert ALA to DHA, but this process is ineffective and variable. Yet, these can be good choices when used in conjunction with other DHA sources.
• Ground flax seeds or unfiltered flax oil (40% omega 3)
• Chia Seeds (64% omega 3)
• Hemp oil or seeds (22% omega 3)
Omega 3 supplements
Some prenatal vitamins now have DHA, so expectant moms should check their prenatal vitamin bottle to see if your vitamin has DHA added. Below are things to look for when purchasing supplements:
• Look for the USP quality seal. This means the product has gone through a voluntary independent testing to validate the purity and quality of the product.
• Purchase only pharmaceutical grade fish oils. Typically oils processed in the Scandinavia use the highest quality fish. Pharmaceutical grade oil goes through additional processing to remove toxins and generally provide less gastric side effects.
• Fish oil should come from cod-liver NOT tuna. Fish that eat other fish, such as tuna tend to be higher in mercury. Beware that many baby foods and juices are fortified with tuna and soy oils.
• There are also vegan, algae-based DHA supplements available. This is an ideal source for those who do not consume any meat products. Many people report that the algae based DHA supplements also have less of the ‘fishy aftertaste” than fish oil. Algae supplements are available as tablet or as oils (oils should be purchased in dark, glass bottles and stored in the refrigerator to prevent them from going rancid). Some algae-based DHA supplements only state that they contain DHA and not EPA.
Additionally, keep in mind that it is the amount of DHA/EPA in the supplement that is important, not the overall amount of omega 3. So read the labels carefully to determine how much of the supplement is required to receive your daily DHA dose. Different supplement brands vary in their amount of DHA content. You may have to take 2 tablets of one brand to get enough DHA and 8 tables of another brand to receive the same DHA amount. Additionally be mindful of the DHA dosing in omega 3 bars and chews. They are designed to taste good, so you will often need 10-12 chews a days to receive adequate DHA. Cleveland Clinic has a nice chart that compares various supplements at http://my.clevelandclinic.org/heart/women/nutritioncorner_omega.aspx.
Another source of omega 3 is unfiltered flax oil or hemp oil. Although flax and hemp oils are primarily ALA instead of DHA, they are sometimes to be more palatable than fish oils. Some experts feel that pregnant women should not consume flaxseed because it can have an effect on hormone regulation. Additionally, a recent study also noted a 12% increase in preterm birth form flaxseed oil ingested during the last 2 trimesters of pregnancy http://www.nouvelles.umontreal.ca/archives/2007-2008/content/view/1939/249/index.htm. Pregnant women should always check with their doctor before supplementing with flaxseed, omega 3, or other supplements. Depending on each person’s personal situation, there can be possible concerns with vitamin overdosing, bleeding from excessive omega 3 supplementation, and other issues from co-morbidities, such as diabetes or high triglycerides. http://www.marchofdimes.com/pregnancy/nutrition_omega3.html & http://www.mayoclinic.com/health/flaxseed/NS_patient-flaxseed/DSECTION=safety.
A note on safety & recent environmental events
Many published studies have stated the benefits of fish oils. Unfortunately, the fishing industry is experiencing a decrease in large predatory fish populations. The BP Oil Spill and nuclear radiation leak following Japan’s tsunami has caused concern about the safety of the consumption of fish. The FDA claims fish oils are safe for consumption, but we don’t know the long term risks. Algae-based DHA is a more sustainable option, and it is free of the environmental pollutants that accumulate in the fatty tissue of fish, like mercury, PCBs, and dioxin. Most experts agree that the benefits of DHA outweighs the risk of not consuming it.
What can we tell our patients?
• DHA is a critical nutritient which cannot be produced by the human body
• Breastfeed your baby and consume adequate levels of DHA/EPA while lactating
• Consume at least 2 servings a week of fish and adjunct with ALA natural sources. Avoid/limit fish with high mercury levels.
• Consider Omega 3 supplementation especially during pregnancy, lactation, and when fish consumption may not be warranted or agreeable. Fish oils are the most complete source of both DHA and EPA. If using vegan supplements, look carefully to be sure it contains EPA too.
• Research supplements , read labels, and use pharmaceutical grade products
• Talk with your doctor, dietician, or healthcare provider about what Omega 3 dose is good for you. Current research demonstrates that safe, beneficial levels are between 200 – 900 mg daily. There is a wide range of ‘recommended doses’, so overdosing from consumption of natural food sources is unlikely. However, don’t go extreme on the omega 3 supplements since really high doses (2 grams or more daily) can cause bleeding issues and this can be worrisome for patients on certain medications, such as warfarin.
• There is overwhelming research that Omega 3’s are important nutrients for the childbearing family. However, much of the research on specific benefits of supplemental DHA and EPA are still inconclusive. More research needs to be done. Natural, food sources are always best, when possible. There could be additional nutritional benefits to eating real fish that we are unaware of. In general, eating things closest to they way nature makes them, is best. So, eat fish, when you can and when it is safe to do so.
Written by : Jasmine Jafferali, MPH
by Kim Wilschek, RN, CCE
For a few years now, the American Academy of Pediatrics has recommended vitamin D3 supplementation for breastfed infants (vitamin D3 is already added to infant formula) because of the increasing prevalence of rickets. However, the benefits of supplementation during pregnancy have recently been established in various papers. Vitamin D deficiency during pregnancy can lead to complications for both mom and baby, in many crucial areas outside of just ‘bone health’. Experts feel that some of the potential damage from vitamin D deficiency during the gestational period, especially in areas of brain and immune health, cannot be reversed by taking vitamin D after birth. Because most women are vitamin D deficient (one study demonstrated that 37 out of 40 pregnant women had suboptimal vitamin D blood levels), it is critical that expectant moms understand how to gauge and optimize their vitamin D levels.
What is Vitamin D?
Vitamin D is traditionally considered to be a fat soluble vitamin that helps the body absorb calcium. However, vitamin D is really a pro-hormone, or hormone precursor. Its metabolic product, 1,25-dihydroxyvitamin D (calcitriol), is actually a secosteroid hormone that is the key which unlocks binding sites on the human genome. The human genome contains more than 2,700 binding sites for calcitriol which are near genes related to many major human diseases. Vitamin D plays a role in bone and skeletal health, cancer, cardiovascular and hypertension, diabetes, metabolic syndrome, immune functioning, neuropsychological functioning (autism, cognition, and depression, and complication of pregnancy. Recent findings include the following implications of vitamin D deficiency during pregnancy:
• For Mom:
• 3X higher likelihood of gestational diabetes
• 5X higher risk of preeclampsia
• 4X higher likelihood of having a C/S
• 2X greater risk of a developing a bacterial vaginal infection
• For the child:
•Increased likelihood of cavities
•Increased likelihood of softening of the skull bones during infancy
•Higher prevalence of serious respiratory infections and asthma
•Decreased bone health by the age of 9
For more detail on the above, the Vitamin D Council (http://www.vitamindcouncil.org/news-archive/2009/pregnancy-and-gestational-vitamin-d-deficiency/) has an extensive review of gestational vitamin D deficiency research.
The good news and the bad news.
In November 2010, the Institute of Medicine (IOM) revised the guidelines for vitamin D (http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Brief.aspx). The RDA (or recommended daily allowance) for infants and children has doubled, and the RDA during pregnancy has tripled. More importantly, the safe ULI (upper limit) during pregnancy also increased. Safe levels of vitamin D during pregnancy are 600 – 4000 iu/day Many experts feel that the RDA is still too low, citing that toxicity will not result until daily intakes exceeds 10,000 iu/day. A landmark study by Hollis published this year, demonstrated that vitamin D supplementation of 4,000 IU/day for pregnant women was safe and most effective in achieving sufficient blood circulating levels. Additionally, the current estimated average requirement was comparatively ineffective at achieving adequate circulating 25(OH)D, especially in African Americans during pregnancy. Additional research by Holick in 2011 suggests that most teenagers and adults need at least 2000 IU of vitamin D a day to satisfy their body’s vitamin D requirement. Experts including those at the Linus Pauling Institute (LPI) continue to recommend a daily intake of 2,000 iu of vitamin D for most adults, including pregnant women, which is well below the UL of 4000 set by the IOM. Additionally, LPI recommends aiming for a serum 25-hydroxyvitamin D level of at least 80 nmol/l (32 ng/ml), instead of the new IOM recommendation of 30 nmol/L (12 ng/mL) for most people. You can find this information and more about the micronutrient needs during pregnancy and lactation at http://lpi.oregonstate.edu/infocenter/lifestages/pregnancyandlactation/index.html. It is important to note that the IOM based their recommendation on the review of bone health research only and did not consider the other benefits of higher vitamin D intake surrounding the childbearing period. Vitamin D utilization by the body is also affected by many other factors, including other micronutrient concentration and the amount of fat cells within the body. Therefore, the proper supplementation amount to achieve adequate blood levels can vary from person to person.
How can a pregnant women gauge the proper amount of vitamin D intake?
The AAP recommends (Pediatrics Volume 122, Number 5, November 2008) that pregnant women have their vitamin D status assessed via a blood test, or measurement of the 250OH-D level. The AAP recommends a sufficient range greater than 32 ng/mL. Expectant moms should be supplemented with adequate amounts of vitamin D3 to meet this threshold. The AAP further states that “ The knowledge that prenatal vitamins containing 400 IU of vitamin D3 have little effect on circulating maternal 25-OH-D concentrations, especially during the winter months, should be imparted to all health care professionals."
What can health practitioners tell pregnant patients?
• Ask for a vitamin D blood test early on during your pregnancy.
• Check the vitamin D amount in their prenatal vitamin and supplement with additional Vitamin D3 to obtain a blood level of at least 32 ng/ml
•Talk to their healthcare provider about this important issue
Need a handout?
Click here for an educational hand-out on Vitamin D dosing and good food sources.
Author: Kim Wilschek, RN, CCE; information current as of 9/1/11
Holick MF. The vitamin D solution: a 3-step strategy to cure our most common health problem. New York: Hudson Street Press; 2010, p. 336. Holick MF. Vitamin D: evolutionary, physiological and health perspectives. Curr Drug Targets 2011;12:4-18.
J Bone Miner Res. 2011 Jun 27. doi: 10.1002/jbmr.463. [Epub ahead of print] Vitamin D supplementation during pregnancy: Double blind, randomized clinical trial of safety and effectiveness Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL.. http://www.ncbi.nlm.nih.gov/pubmed/21706518 4.Institute of Medicine. Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011, p. 1015. Full Report: http://books.nap.edu/openbook.php?record_id=13050. Brief Report: http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Brief.aspx.