Carlo Agostoni Fondazione IRCCS Department of Maternal and Pediatric Sciences University of Milan, Italy

Energy Protein Fat quality docosahexaenoic acid Micronutrients Vitamin D Dieting during lactation?

The energy expended for lactation can be computed from the amount of milk produced, the energy content of the milk, and the energetic efficiency of milk synthesis. The efficiency of converting dietary energy into human milk has been estimated from theoretical biochemical efficiencies of synthesising the constituents in milk and from metabolic balance studies When the expenditure for digestion, absorption, interconversion and transport is taken into account, the estimate of efficiency of milk synthesis yields a figure of 80 85 %

Energy expenditure of lactation ( factorial approach) 670 kcal/d for a milk production of 800 g, a milk energy density of 0.67 kcal/g and an energetic efficiency of 80 %. TEE of lactating women measured by DLW more variable but includes the energetic efficiency of milk synthesis or changes in the energetic efficiency of physical activity. In four studies with well-nourished women fully breastfeeding between one and six months postpartum it was reported that TEE averaged 2160 kcal/d for an average milk energy output of 480 kcal/d. Butte et al 2001; Forsum et al 1992; Goldberg et al 1991; Lovelady et al 1993

For the additional energy requirement during lactation milk energy output and energy mobilisation from tissue stores accumulated during pregnancy have been considered. Based on a WHO-sponsored review (Butte and King, 2002) mean milk intakes of infants through six months postpartum measured by the test-weighing technique were 769 g/d for women exclusively breastfeeding. Correction of the mean milk intakes for the infant s insensible water loss during a feed (assumed to be equal to 5 %) gives a mean milk secretion over the first six months postpartum of 807 g/d (FAO/WHO/ UNU, 2004) for exclusively breastfeeding women. In well-nourished women it has been estimated that on average 172 kcal/d of tissue stores may be utilised to support lactation during the first six months postpartum (Butte and King, 2002), based on a rate of weight loss of -0.8 kg per month (Butte and Hopkinson, 1998). This will vary depending on the amount of fat deposited during pregnancy, lactation pattern and duration. Kcal/d: 670-170 = 500

Average +400-500 kcal/d +200-400 kcal/d

EFSA 2012, (confidencial, in progress) 2.1 MJ/d = 504 kcal

Energy Protein Fat quality docosahexaenoic acid Micronutrients Vitamin Dieting during lactation?

For lactation, the Panel accepted the factorial method which requires assessing milk volumes produced and the content of both protein nitrogen and non-protein nitrogen, as well as calculating the amount of dietary protein needed for milk protein production. As the efficiency of protein utilisation for milk protein production is unknown, the same efficiency as in the non-lactating adult (47 %) was assumed. The PRI was estimated by adding 1.96 SD to give an additional 19 g protein/d during the first six months of lactation (exclusive breastfeeding), and 13 g protein/d after six months (partial breastfeeding).

EFFICIENCY OF PROTEIN UTILIZATION The Panel considers that for healthy adults a protein efficiency value of 47 % is reasonable since it is the value derived from the nitrogen balance studies used to define nitrogen requirement in adults. There is no convincing scientific evidence that protein efficiency for maintenance of body protein and for protein deposition is lower during pregnancy or lactation. For infants and children, a value of 58 % for growth is justified because of an increased efficiency of dietary protein utilisation for growth.

Energy Protein Fat quality docosahexaenoic acid Micronutrients Vitamin D Dieting during lactation?

There are no data which would suggest that the fat intake as percentage of the total energy should differ from that of the diet in non-lactating women. Lactating women have an increase in energy expenditure consistent with the energy cost of milk synthesis. Part of this energy can be mobilised from subcutaneous fat particularly but the major part has to be provided by diet.

DRV= Dietary Reference Value

The Panel considers that during pregnancy and lactation an adequate n-3 long-chain polyunsaturated fatty acids supply consists of the Adequate Intake for adults (250 mg DHA plus EPA) and 100 to 200 mg additional preformed DHA. 100 to 200 mg of preformed DHA should be added during pregnancy and lactation to compensate for oxidative losses of maternal dietary DHA and accumulation of DHA acid in body fat of the foetus/ infant.

DHA in forebrain in 34 infants up to 2 years EPA

ARACHIDONIC ACID ADRENIC ACID LINOLEIC ACID

OLEIC ACID

Structural differences between BF (+ DHA) e FF (- DHA) in infants dead from cot death The mean weight percentage of docosahexaenoic acid was significantly greater (p < 0.02) in 5 breast-milk-fed infants (9.7%) than in 5 age-comparable formula-milk-fed infants (7.6%). Farquharson et al, Lancet 1992; 340:810 Breast-fed infants had a greater proportion of DHA in their erythrocytes and brain cortex relative to those fed formula (P < 0.005) but differences were not observed in retina. Cortex DHA increased in breast-fed (but not formula-fed) infants with age (r2 = 0.72, P < 0.01, n = 15), largely an effect of length of feeding (r2 = 0.62, P < 0.01, n = 35). There was an association between age at death and erythrocyte DHA with cortex DHA (r2 = 0.50, P < 0.01). Makrides et al, Am J Clin Nutr 1994;60:189

n-3 PUFA, enhance hepatic fatty acid oxidation and inhibit fatty acid synthesis and VLDL secretion by regulating gene expression PUFA (DHA) contro of hepatic metabolic processes Chem Phys Lipids 2008;153:3

ARA = 1 % colostrum, 0.5% mature milk = 14-15 mg/dl DHA = 0.5% colostrum, 0.25% mature milk = 7-8 mg/dl 700 ml human milk = 50/60 mg DHA = 10 mg/kg DHA/d in infants weighing 5-6 kg at three months of life

Total Lipids LA ALA ARA DHA

Ability to discriminate non-native phonetics at 9 months of age Observational studies: DHA: causal agent or marker?

LCPUFA-enriched human milk (maternal supplementation) Mental development at 1 yr 1 : + effects (LCPUFA: 20 wks PCA birth) Mental development at 4 yr 2 : + effects (LCPUFA: 18 wks PCA 3m) Mental development at 7 yr 3 No (mild) effects (same group as 4 yr) 1 Dunstan et al, Pediatr Res 2007; 62:689-94 2 Helland et al, Pediatrics 2003; 111: e39-44 3 Helland et al, Pediatrics 2008; 122:e472-9 Also found modifications of neonatal allergen-specific immune responses and clinical outcomes in infants at high risk of atopy

Effect of Supplementation of Lactating Women With Longchain Polyunsaturated Fatty Acids on Growth, Visual Function and Neurodevelopment of Breast-Fed Term Infants: A Systematic Review of Randomized Controlled Trials H Szajewska et al (unpubl.) INTERVENTION: Supplementation of maternal diet during breastfeeding with DHA from fish or algal oils or enriched eggs RESULTS: GROWTH: 3 trials no significant difference VISUAL FUNCTION: 4 trials 3, no effects, 1, effect on VEPs MENTAL DEVELOPMENT: 2 trials: 1, effect on Bayley MDI at 12 months, not at 24 months; 1, effect on Bayley PDI at 30 months CONCLUSIONS: Limited evidence, mild effects on mental development

Maternal diet Gestational age Parity Smoking (less fats, lower DHA levels, dose-dependent fashion) Alcohol intake

0.1 to 1 g/dl less fat and 2 to 3 mg/dl less DHA at 1, 3 and 6 months in milk of smoking vs non-smoking mothers Eur J Clin Nutr 2003; 57:1466

DIFFERENT RESULTS Different potentiality of endogenous synthesis on a genetic basis?

The genetic background may have a relevant role..

Energy Protein Fat quality docosahexaenoic acid Micronutrients Vitamin D Dieting during lactation?

VITAMIN D AND ADIPOGENESIS: NEW MOLECULAR INSIGHTS Nutr Rev 2008;66:40

Blood vitamin D levels > 50 nmol/l (> 20 ng/ml)

Research has shown that during lactation, supplements administered directly to the infant can easily achieve vitamind sufficiency; the mother needs much higher doses (100 g or 4000 IU per day) to achieve adult normal 25(OH)D concentrations in her exclusively breastfed infant. In addition, the relation (if any) of vitamin D insufficiency in the fetus or neonate to long-term nonskeletal outcomes such as type 1 diabetes and other chronic diseases needs to be investigated.

1. ENERGY RESTRCTION Weight gain in the postpartum period is a risk factor for long-term obesity BF women consume more energy than MF or FF women Overweight lactating women can restrict their energy intake by 500 kcal per day by decreasing foods high in fat and simple sugars Increased intake of fruits and vegetables should be recommended

2. ENERGY COMPOSITION Under moderate calorie restriction, milk production is not affected by maternal diet composition Milk fat, energy output, and energy expenditure are higher during a high-fat diet, which results in a greater negative energy balance, compared to an high-cho diet. The lactating mothers adapt to a low carbohydrate intake by decreasing carbohydrate oxidation Additional studies are warranted to determine whether a modest hypocaloric high-fat diet might promote greater weight loss during lactation than would an high-cho diet while maintaining sufficient milk production.

3. ENERGY EXPENDITURE women in the diet and exercise group lose more weight than control groups there are no differences in infant growth based on the current evidence, it is recommended that once lactation is established, overweight women may restrict their energy intake by 2092 kj/d (500 kcal/d) and exercise aerobically 4 d/ week to promote a weight loss of 0.5 kg/week.

A moderate weigh loss and fat reduction during breastfeeding are normal, but should not be forced An excess weight loss takes place when the body weight decreases below the pre-pregnancy limit It is suggested to drink around 1700 ml per day or a glass of water at any feeding

MACRONUTRIENTS QUANTITY eat more, no dietary restrictions, until you stop lactation, do not consider weight losing as primary UNLESS you are overweight 500 kcal less per day with adequate exercise MACRONUTRIENTS QUALITY Provide good protein sources and n-3 LC-PUFA, following your dietary habits in the second trimester of pregnancy, firstly fish intakes. PLEASE DO NOT SMOKE! MICRONUTRIENTS DHA and Vitamin D supplements may be good for lactating mothers, particularly when started in pregnancy, otherwise may be more effective as direct supplements to the infant.