Role of DHA in Early Life Nutrition in the First 1000 days

Role of DHA in Early Life Nutrition in the First 1000 days Role of DHA in Early Life Nutrition in the First 1000 days Professor Barbara School of Medicine, University of Wollongong, NSW, Australia Docosahexaenoic acid (DHA) Mammalian Polyunsaturated Fatty Acid Synthesis Pathway Brain Lipids - 10-20% is DHA - Omega-3, 90% is DHA 18:3n-3 (alpha-linolenic acid; ALA) delta-6 desaturase (FADS2) 18:4n-3 (stearidonic acid) Long chain fatty acid Elongase (ELOV5) 20:4n-3 (eicosatetraenoic acid) delta-5 desaturase (FADS1) 20:5n-3 (eicosapentaenoic acid) Very long chain fatty acid elongase (ELOV2) 22:5n-3 (docosapentaenoic acid) Very long chain fatty acid elongase (ELOV2) Semi-essential 22:6n-3 (docosahexaenoic acid; DHA) Beta oxidation 24:5n-3 (tetracosapentaenoic acid) delta-6 desaturase (FADS2) 18:2n-6 (linoleic acid; LA) delta-6 desaturase (FADS2) 24:6n-3 (tetracosahexaenoic acid) 18:3n-6 (gamma-linolenic acid) DHA promotes neurite outgrowth Long chain fatty acid Elongase (ELOV5) 20:3n-6 (dihomo-gamma-linolenic acid) delta-5 desaturase (FADS1) 20:4n-6 (arachidonic acid; ARA) Very long chain fatty acid elongase (ELOV2) 22:4n-6 (adrenic acid) Very long chain fatty acid elongase (ELOV2) 24:4n-6 (tetracosatetraenoic acid) delta-6 desaturase (FADS2) Parletta N, Milte CM, BJ. Nutritional modulation of cognitive function and mental health. Journal of Nutritional Biochemistry 2013;24:725-743 22:5n-6 (docosapentaenoic acid; n-6 DPA) Beta oxidation 24:5n-6 (tetracosapentaenoic acid)

DHA and cerebral cortex Apparent fractional conversion of labelled ALNA in men:epa 2.8%, DPA 1.2%, DHA 0.04 % Burdge GC et al. Br J Nutr 2002;88:355 Carver JD, et al. The relationship between age and the fatty acid composition of cerebral cortex and erythrocytes in human su bjects. Brain Research Bulletin 2001;56(2):79-85 DHA and the first 1000 days Very early pregnancy Later pregnancy 0-24 months Recommendations The critical requirement for DHA for fetal brain development, and the poor efficiency of its synthesis in humans, is therefore a metabolic problem to be overcome in pregnancy.

Day 15 of gestation - the first primitive brain cells are formed Day 28 of gestation - neural tube closure occurs Early gestational weeks the head of the embryo grows fastest Aim: To characterise the earliest fatty acid changes in pregnancy Our hypothesis - changes in maternal plasma PUFA concentration in very early gestation are vitally important. - Study Design - Study Design Population of women undergoing assisted conception to achieve accurately timed peri-conceptual sampling October 2007 April 2010 Undergoing frozen embryo transfer Women with a regular natural menstrual cycle to avoid the effects of exogenous hormones

- Study Design 196 women with a natural menstrual cycle received frozen embryo transfer (FET) 161 IVF cycles 35 withdrew 3 withdrew consent 25 cycles cancelled 7 lost to follow up 123 failed pregnancies 38 successful pregnancies 36 successful pregnancies 27 pregnancies with full fatty acid data Maternal plasma DHA (nmol/ml) 200 a 9 excluded due to lack of fatty acid data Maternal plasma DHA from pre-pregnancy to 45 days post-lh surge 220 2 excluded due to the FET not being their first attempt in this study a a,b b 180 160 Rate of change - The rate of change of FAs were calculated as the difference between the FA on day 18 post-lh surge and pre-lh surge and then divided by the difference in time (days) between day 18 & pre-lh surge - It was repeated for all other time points 140 120 100 1.9% 2.1% 2.5% Percent of Incremental Area Under the Curve - the amount of fatty acid released total fatty acids 2.3% 80 into the plasma over 45 days 60 40 20 0 Pre-pregnancy 18 29 45

Maternal plasma linoleic acid concentrations (nmol/ml plasma) in Not pregnant vs Pregnant Women Rate of change of DHA concentration (day 18-29) correlates with delta-6 desaturase activity (R2 adjusted = 41%, p=0.0002) 12 10 8 6 4 2 0 0.03-2 -4 0.04 0.05 0.06 0.07 0.08 0.09 0.1 Delta-6 desaturase activity index (at day 29 post-lh surge) (The ratio of dihomo-gamma-linoleic acid 20:3n-6 to LA 18:2n-6 ratio) Maternal plasma n-6 DPA and DHA in Singleton (n=20) vs Twin Pregnancies (n=7) Importance of n-6 DPA when DHA is low In DHA deficiency, n-6 DPA is used in place of DHA in the brain which seems to be a survival mechanism [Kim HY 2007]. Human studies support this in that supplementation with DHA in infants results in increased visual acuity, especially in girl infants [Innis et al 2008]. Our observation of elevated n-6 DPA, especially in twin pregnancy, may suggest a secondary mechanism to provide an alternative PUFA if there is insufficient DHA for neurological development at the critical time of neural tube closure. Innis SA, Friesen RW. Essential n-3 fatty acids in pregnant women and early visual acuity maturation in term infants. Am J Clin Nutr 2008;87:548 57. Kim HY. Novel mechanism of DHA in neural cells. J Biol chem. 2007;282:18661-18665.

Models of Day 18 Post-LH Surge Variables and Pregnancy Outcome at Day 45 Post-LH Surge Covariate Univariate odds ratio (95% confidence interval) P 2.05 (1.07, 3.92) 0.03 Plasma 18:2n-6 (500 nmol/ml) 0.44 (0.24, 0.82) 0.010 Erythrocyte saturated fatty acid (%) 3.37 (1.60, 7.11) Day 18 post-lh surge Log insulin (mu/l) C-statistic (Area Under Curve) Multivariable odds ratio (95% confidence interval) P 0.62 2.23 (1.01, 4.93) 0.048 0.69 0.48 (0.24, 0.99) 0.046 0.0014 0.70 3.12 (1.41, 6.92) 0.0050 - Summary of the pregnancy timeline C-statistic (Area under curve) 0.78 implantation LH surge Day 0 Day 7 Day Day1010 hcg in plasma from placenta Day 18 Day 29 Positive fetal heartbeat Day 45 Baseline Gestation (Days) - Summary of the pregnancy timeline Ref: Nilsson L, Hamberger L. A Child is Born 4 th Ed. 2003 - Summary of the pregnancy timeline Sources of DHA mobilisation XIncreased dietary DHA Increased synthesis from alpha-linolenic acid DHA mobilisation implantation LH surge Day 0 Day 7 Day Day1010 hcg in plasma from placenta Day 18 Day 29 Positive fetal heartbeat Day 45 Baseline implantation LH surge Day 0 Day 7 Day Day1010 Increased release from maternal adipose tissue and other maternal stores DHA mobilisation hcg in plasma from placenta Day 18 Day 29 Positive fetal heartbeat Day 45 Baseline Gestation (Days) Gestation (Days) Ref: Nilsson L, Hamberger L. A Child is Born 4 th Ed. 2003 Ref: Nilsson L, Hamberger L. A Child is Born 4 th Ed. 2003

DHA and the first 1000 days Very early pregnancy - mobilise DHA neural tube closure Later pregnancy 0-24 months Recommendations There is rapid accumulation of DHA (and arachidonic acid, AA) in the brain during the last trimester of pregnancy M. Makrides, R.A. Gibson. Long-chain polyunsaturated fatty acid requirements during pregnancy and lactation, American journal of clinical nutrition, 71 (2000) 307S-311S DHA is important for neurological development M. Makrides, R.A. Gibson. Long-chain polyunsaturated fatty acid requirements during pregnancy and lactation, American journal of clinical nutrition, 71 (2000) 307S-311S DHA is important for neurological development M. Makrides, R.A. Gibson. Long-chain polyunsaturated fatty acid requirements during pregnancy and lactation, American journal of clinical nutrition, 71 (2000) 307S-311S

Longitudinal study in pregnancy DHA is important for neurological development Maternal plasma fatty acids across trimesters(t1, T2 T3) and post-partum (PP) p<0.005 compared to T1 p<0.005 compared to T1 et al. Lipids 2007;42(4):335-344 M. Makrides, R.A. Gibson. Long-chain polyunsaturated fatty acid requirements during pregnancy and lactation, American journal of clinical nutrition, 71 (2000) 307S-311S Brain PUFA fingerprint DHA very important during last trimester of pregnancy and during first 2 years of life 20 15 10 5 0 Martinez M. J Pediatr 1992;120:S129-S138 LA ALNA AA 22:4n-6 22:5n-3 DHA DHA is essential for infant development & growth

From 14 weeks until delivery 25g/d margarine Control: 10.9g LA Exp: 9.0g LA & 2.8g ALA No increase in maternal plasma EPA, DPA & DHA P < 0.001 18:3n-3 supplementation during pregnancy does not result in increased maternal &neonatal DHA P < 0.01 De Groot RH, et al. Effect of Alpha-linolenic acid supplementation during pregnancy on maternal and neonatal polyunsaturated fatty acid status and pregnancy outcome. AJCN 2004;79:251-260 De Groot RH, et al. Effect of Alpha-linolenic acid supplementation during pregnancy on maternal and neonatal polyunsaturated fatty acid status and pregnancy outcome. AJCN 2004;79:251-260 P=0.041 From 20 weeks until delivery P<0.001 Control: Soy/Corn oil Exp: 600mg DHA From 20 weeks until delivery Control: Soy/Corn oil Exp: 600mg DHA P=0.004 Carlson S et al. DHA supplementation and pregnancy outcomes AJCN 2013;97:808-815 Carlson S et al. DHA supplementation and pregnancy outcomes AJCN 2013;97:808-815 P=0.022

From 20 weeks until delivery DHA and the first 1000 days Control: Soy/Corn oil Exp: 600mg DHA P=0.001 P=0.001 Very early pregnancy - mobilise DHA neural tube closure Later pregnancy - DHA supplementation better than ALA 0-24 months Recommendations Carlson S et al. DHA supplementation and pregnancy outcomes AJCN 2013;97:808-815 DHA and 0-24 months DIAMOND trial: Infants (n=191) 1-9 days old Control: 0% DHA, 0% ARA Exp 1: 0.32% DHA, 0.64% ARA Exp 2: 0.64% DHA, 0.64% ARA Exp 3: 0.96% DHA, 0.64% ARA For 12 months DHA and 0-24 months P=0.02 DIAMOND trial: Infants (n=191) 1-9 days old Control: 0% DHA, 0% ARA Exp 1: 0.32% DHA, 0.64% ARA Exp 2: 0.64% DHA, 0.64% ARA Exp 3: 0.96% DHA, 0.64% ARA For 12 months Assessments at 18mths Assessments at 18mths Drover JR et al. Cognitive function in 18-month-old term infants of the DIAMOND study: A randomized, controlled clinical trial with multiple dietary levels of docosahexaenoic acid Early Human Development 2011; 87:223 230 Drover JR et al. Cognitive function in 18-month-old term infants of the DIAMOND study: A randomized, controlled clinical trial with multiple dietary levels of docosahexaenoic acid Early Human Development 2011; 87:223 230 P=0.08

DHA and 0-24 months DIAMOND trial: Infants (n=191) 1-9 days old Control: 0% DHA, 0% ARA Exp 1: 0.32% DHA, 0.64% ARA Exp 2: 0.64% DHA, 0.64% ARA Exp 3: 0.96% DHA, 0.64% ARA For 12 months DHA and 0-24 months P=0.01 DIAMOND trial: Infants (n=191) 1-9 days old Control: 0% DHA, 0% ARA Exp 1: 0.32% DHA, 0.64% ARA Exp 2: 0.64% DHA, 0.64% ARA Exp 3: 0.96% DHA, 0.64% ARA For 12 months Assessments at 18mths Negative correlation between infant RBC-LA at 4mths: rs=-0.19 p=0.039 cognition rs=-0.21 p=0.022 language Conclusions: DHA supplementation is better than no DHA supplementation and 0.32% DHA is enough Higher infant RBC-LA levels is not optimal Negative correlation between infant RBC-LA at 12mths: rs=-0.19 p=0.041 language There are other studies with similar findings Drover JR et al. Cognitive function in 18-month-old term infants of the DIAMOND study: A randomized, controlled clinical trial with multiple dietary levels of docosahexaenoic acid Early Human Development 2011; 87:223 230 Drover JR et al. Cognitive function in 18-month-old term infants of the DIAMOND study: A randomized, controlled clinical trial with multiple dietary levels of docosahexaenoic acid Early Human Development 2011; 87:223 230 DHA and 0-24 months DHA and the first 1000 days LA has doubled in breastmilk & DHA has halved Very early pregnancy - mobilise DHA neural tube closure Later pregnancy - DHA supplementation better than ALA 0-24 months - DHA supplementation better than no DHA supplementation; high infant RBC-LA levels is not optimal Recommendations Innis SM. Dietary omega-3 fatty acids and the developing brain. Brain Research 2008;1237:35-43

Recommendations at least 200 mg DHA/d Recommendations Pregnant Women Actual Intakes Koletzko et al. Dietary fat intakes for pregnant and lactating women. British Journal of Nutrition (2007), 98, 873 877 Mean intakes Median intakes n Country Reference 118 65 92 Australia et al. (unpublished) 99 75 94 Australia Cosatto et al. Nutrients 2010;2:198-213 47 nr 29 New Mexico Albuquerque Glew et al. J Am Diet Assoc 2008;108:1693-1699 nr 55 1364 Mexico Caberera et al. Matern Child Nutr 2011;2:140147 nr 11 829 South India Dwarkanath et al. Asia Pac J Clin Nutr 2009;18:389-394 160 105 204 Canada Friesen & Innis J. Nutr 2009;139:2344-2350 Spanish, German, Hungary 90% pregnant women met the recommended 200mg DHA Franke et al. Ann Nutr Metab 2008;53:167-174 Conclusion DHA and the first 1000 days Very early pregnancy - mobilise DHA neural tube closure Later pregnancy - DHA supplementation better than ALA 0-24 months - DHA supplementation better than no DHA supplementation; high infant RBC-LA levels is not good Recommendations - 200mg DHA per day pregnancy & lactation