This document summarizes the impact of different sources of docosahexaenoic acid (DHA) and other micronutrients on cognitive development in babies. It finds that intake of DHA and omega-3 fatty acids is very low in Indian diets, especially for vegetarians, increasing risk of low birth weight. While fish is a good source of DHA, concerns about mercury contamination make algal sources of DHA a safer option. The document also reviews evidence that supplementation with DHA, calcium, vitamin D, and vitamin B12 during pregnancy can positively impact outcomes like risk of preeclampsia, gestational diabetes, and birth weight.

1. Impact of DHA Source on Cognitive
development of the baby and other
micronutrients
Dr Meenakshi Sharma
MD(AIIMS), FICMCH, FICOG
Consultant Obs&Gynae
Yashoda Superspeciality Hospital

2. Dr Meenakshi Sharma
MBBS(AIIMS), MD (AIIMS), FICMCH
● Consultant Obstetrics & Gynaecology, Yashoda Superspeciality Hospitals & Shanti
Mukund Hospital , Delhi
● Ex Registrar and Senior Research Associate AIIMS
● Former Specialist Dr Hedgewar Arogya Sansthan, Govt NCT Delhi
● Recipient of Dr RD Pandit research prize for Best thesis by FOGSI in 2003
Faculty for workshop & Conferences - (16)
Lectures delivered as faculty - (22)
Publications in International and National Journals– (11)
Abstracts Published – (10)
Scientific Papers Presented in National/International Conferences : 14
Member Affiliated Societies
● Life Member AOGD, FOGSI, Delhi Gynaecologist Forum- East, SFM, Trans Hindon
Gynae Forum
● Founder Member GESI,

4. 4
Do Indian pregnant women gets
enough omega fatty acid?

5. ◼ The intake of marine fish in Indian diets is very low except in
specific coastal regions, and, therefore, the average intakes of
LC n-3 PUFA are negligible
◼ The dietary recommendations by the ICMR have always stressed on
increasing n-3 PUFA intake in Indian diets; however, it is not quite
clear how that can be achieved.

6. INTAKE OF DHA
◼ Intake in third trimester of pregnancy
o India only 11 mg
o Bangladesh 30 mg/day
o Vegetarian diets provide very little, and vegan diets provide
basically no, preformed LC-PUFA
o DHA supplementation is advisable, and vegetarian sources of
DHA are available.
Ann Nutr Metab. 2014;65(1):49-80

7. 7
◼ In Indian diets, the intake of n-3 LC PUFA is
extremely low
◼ Large population in India is vegetarian
◼ High intake of omega 6/omega 3 fatty acids
◼ One of the probable reason for LBW
10year Long Observational study
Mani indu. International Journal of Epidemiology.2016; 45(2): 523-531

8. 8
• Diets lacking LC n-3 PUFA, low intakes of ALNA were associated with the
lowest birth weights and highest risk for SGA
• Best outcomes were associated with moderately high intakes of
ALNA along with at least a minimal amount of LC n-3 PUFA
Mani indu. International Journal of Epidemiology.2016; 45(2): 523-531

9. RECOMMENDATION OF DHA SUPPLEMENTATION
Authority DHA (mg/d)
National Institute of Health (NIH) 300mg per day of DHA in pregnant
and nursing women
American Academy of Pediatrics
(AAP)
The mother’s diet should include
an average daily intake of
300 mg of the ω-3 long-chain
PUFAs (DHA)
Nutrients. 2018 Apr; 10(4): 416.
Matern Health Neonatol Perinatol. 2017;3:22. Published 2017 Dec 12

10. OMEGA FATTY ACIDS & PREGNANCY
OUTCOME
10
• N= 200 Indian pregnant women included from 1st trimester
• Intervention:
• Omega Fatty acid (300mg/day) + Iron +Calcium
• Control Group : Iron + calcium
• 78.8%supplemented with omega 3
fatty acids had normal birth
weight
• 50% of women not supplemented with
omega 3 fatty acids had
normal birth weight
Anne S et al. Int J Reprod Contracept Obstet Gynecol. 2017 Dec;6(12):5396-5400

11. 11
Birth weight
(gm)
Omega
Supplemented
Group
Control
Group
<2000gm 4.00% 16.00%
2000-2499 17.20% 34.00%
2500-2999 63.60% 15.20%
3000 + 15.20% 3.00%
The results of the study suggest that increased intake of
omega 3 fatty acids can prevent low birth weight
Anne S et al. Int J Reprod Contracept Obstet Gynecol. 2017 Dec;6(12):5396-5400

12. DHA INCREASES GESTATION DAYS
12
• Randomized controlled trial
• N= 347 women
• Intervention:
• Group A: Ordinary egg (33mg DHA)
• Group B: Omega Fatty acid enriched egg (133mg)
• Birth weight of infants in the high-DHA egg group
was 103±64 gm higher than for infants whose
mothers consumed ordinary eggs
6-day longer period of gestation when DHA intake was increased during
the last trimester of pregnancy
Obstet Gynecol 2003;101:469–79

13. EFFECT OF DHA
SUPPLEMENTATION ON MATERNAL
OUTCOME
DHA to Optimize Mother Infant Outcome [DOMInO] trial -
Multicentric RCT
N= 2399 women who were < 21 weeks' gestation with singleton
pregnancies
Intervention: DHA (800mg/day) or Matching vegetable oil capsule from study
entry to birth
◼ In the DHA group, significantly fewer infants were born less than 34 weeks'
gestation but significantly more women were induced or had cesarean
sections because they were postterm.
◼ The clinical significance of these findings is difficult to balance, although the
reduction in preterm birth at less than 34 weeks' gestation was also
associated with fewer low birth weight infants and fewer admissions to
neonatal intensive care in the DHA group.
13
JAMA. 2010;304(15):1675-1683

14. EFFECT OF DHA
SUPPLEMENTATION ON BIRTH
WEIGHT
DHA to Optimize Mother Infant Outcome [DOMInO] trial -
Multicentric RCT
N= 2399 women who were < 21 weeks' gestation with singleton pregnancies
Intervention: DHA (800mg/day) or Matching vegetable oil capsule from study
entry to birth
14
• Mean birth weight was 68gm heavier
in DHA Group
JAMA. 2010;304(15):1675-1683

15. EFFECT OF DHA
SUPPLEMENTATION ON Cognitive
Development
DHA to Optimize Mother Infant Outcome [DOMInO] trial -
Multicenteric RCT
◼ Mean cognitive scores of children from women allocated to the
DHA group did not differ from mean scores of children of women
from the control group, although fewer children from the DHA
group had cognitive scores indicating delayed cognitive
development compared with controls.
15
JAMA. 2010;304(15):1675-1683

16. EFFECT OF DHA
SUPPLEMENTATION ON COGNITIVE
DEVELOPMENT
DHA to Optimize Mother Infant Outcome [DOMInO] trial -
Multicenteric RCT
◼ Mean language scores also did not differ between groups;
◼ However, a significant treatment × sex interaction indicated a
differential response of boys and girls.
◼ Girls from the DHA group had a lower mean language score than girls
from the control group, as well as an increased risk of delayed language
development, and the response of boys did not differ between groups.
For the secondary developmental outcomes, motor development,
social-emotional behavior, and adaptive behavior did not differ between
groups overall, although girls exposed to DHA in utero had poorer
mean adaptive behavior scores than girls from the control group. 16
JAMA. 2010;304(15):1675-1683

17. FISH OIL SUPPLEMENTATION IN
PREGNANCY
Vinding RK et al. BMJ. 2018 Sep 4;362:k3312.
n-3 LCPUFA
supplementation in
the third trimester
of pregnancy
stimulates healthy
somatic growth to
age 6 years

18. Is it
SAFE
in
pregnancy
?
DHA from Marine (Fish)
Source???

19. The dietary sources of omega-3 fatty acids are from marine sources, fish oil
supplements
Although seafood is a good source of DHA, concerns is about mercury
contamination.
Evidence of fetal neuron-developmental abnormalities was seen in infants
whose mothers consumed known, high amounts of mercury-rich seafood
Methylmercury (MeHg) is an organic form of mercury that can damage the
developing brains of human fetuses.
Mercury enters water sources & is consumed by fishes
DHA from Marine (Fish) Source
Rev Obstet Gynecol. 2008 Fall; 1(4): 162–
169.
Nutritional Health 2.4 (2018): 43-50.

20. Methyl
mercury
toxicity
DHA from Marine (Fish)
Source???

21. OMEGA FATTY ACIDS
◼ Mercury occurs naturally in the environment and
accumulates in the aquatic food chain, including fish,
as methylmercury
◼ Because of this, fish is the main source of
methylmercury in the diet for most people. High
levels of methylmercury can damage the
nervous system
◼ Unborn babies are particularly vulnerable
because their brains are developing very rapidly
◼ Some studies of populations that eat large amounts
of fish have reported a link between consumption of
fish by mothers and subtle developmental delays in
their children
Food Standards Australia and New Zealand.
https://www.foodstandards.gov.au/consumer/chemicals/mercury/documents/mif%20brochure.pdf

22. MeHg
Methylmercury (MeHg) is an
organic form of mercury
It can damage the developing
brains of human foetuses.
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

23. H2O
When Water & Bacteria come in contact with MeHg
MeHg
MeHg
Toxicity
increase
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

24. It enters food chain & when pregnant women
consume marine sourced DHA, even small
toxicity can magnify!
Foetus can develop
Congenital Minimata disease
Fishes consume
MeHg
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

25. Consuming MeHg during pregnancy
Children have neurological issues
MeHg has toxic effects on the nervous
system during embryonic development..
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

26. Human Nervous System begins to form..
Exposure to neurotoxins like MeHg can
lead to abnormalities
3rd week of gestation
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

27. • Lack of eye coordination
• Convulsions
• Neck instability
• Mental retardation,
• Reflex, growth, and cerebellar deficits
• Hyperkinesis
• Hypersalivation
• Hyperkinesia,
• Dysarthria,
• Strabismus,
Congenital Minimata disease
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

28. ✔ MeHg alters the cell cycle, preventing cerebellar and cortical neurons from
dividing and proliferating.
✔ Causes Degenerative damage on Purkinje cells, granule cells, and astrocytes,
affecting CNS's function and development, along with impairment of the blood-
brain-barrier.
✔ Impairs Glutathione (GSH) antioxidant systems in newborns. This effect can
damage a newborn's aerobic metabolism. As Neural tubes are not formed
MeHg
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

29. MeHg neurotoxin can transfer to an embryo
through the placenta and because the embryo is
highly susceptible to neurotoxicity, the damage to
the developing nervous system in utero can be
severe…
You have a
choice!
The Embryo project encyclopedia
https://embryo.asu.edu/pages/methylmercury-and-human-embryonic-development

30. VEG DHA
◼ For a long time, marine or fish sources were considered the only source of
DHA and thus unsuitable for vegetarians.
◼ The solution can be found in algal DHA.
◼ Derived from algae instead of fish, algal DHA is well perceived to be a pure,
premium source of DHA that can effectively ensure vegetarians get the vast
health benefits with a higher DHA status.
◼ Algal DHA is SAFE as it is free from Methyl Mercury.
◼ Vegetarian derived DHA is SAFE as it is free from Methyl Mercury which is a
neuro-toxin & can harm the growing foetus!
◼ According to USFDA, Algal DHA is generally recognized as safe (GRAS)
based on scientific procedures.
VEG
https://www.fda.gov/media/134100/download

31. CALCIUM
◼ Most common mineral in the human body
In pregnancy:
◼ supports the growth and development of the foetus
◼ Reduced bone resorption and skeletal loss associated with childbearing
In lactation:
◼ During lactation the oestrogen levels in women decreases making bones
weaker, therefore the intake of calcium during breastfeeding is important
◼ According to NIH & ACOG, 1000 mg of elemental calcium per day is
recommended in pregnancy
http://www.pathophys.org/osteoporosis
Cochrane Database Syst Rev.2014 Jun
24;6:CD001059
National Academies Press (US); 2011
ACOG. Nutrition During Pregnancy. Accessed
7/30/2018.

32. CALCIUM IN PREGNANCY AND LACTATION
Fetus in utero and the neonate
through breast-feeding are dependent
on maternal sources for the total
calcium load
Adequate maternal calcium intake can affect fetal bone
health positively.
Paediatr Perinat Epidemiol.2012 ;26 S1:138-52
Environ Health Perspect. 2009; 117(1): 26–31
Am J Obstet Gynecol. 2006 ;194(4):937-45

33. MEETING FETAL CALCIUM DEMAND
• At adequate levels of vitamin D, the calcium demands of
the mother and fetus are met through increased
intestinal calcium absorption
• Severe vitamin D deficiency with secondary
hyperparathyroidism during pregnancy leads to
abnormal calcium homeostasis in the neonate

34. Who are at risk of vitamin D
deficiency?
All of us

35. Infants born to mothers with hypovitaminosis D had 3.8
times higher risk of developing hypovitaminosis D as
compared to those born to mothers with normal vitamin D
levels
J Pediatr Endocrinol Metab. 2009 Mar;22(3):241-6
96.3 % of the lactating Indian women had vitamin D
deficiency. Serum 25(OH)D levels were significantly lower in
winter in the second and third trimesters
Br J Nutr. 2011 Nov;106(9):1383-9.
Mothers of babies who suffer hypocalcaemic seizures are more
likely to be vitamin D deficient (85%) than mothers of
babies who do not (50%)
Indian Pediatr 2010;47:581–6
Maternal vitamin D deficiency is potentially preventable with vitamin D
supplementation

36. ◼ 22 trials involving 3725 pregnant women were included
◼ Supplementation with vitamin D alone during pregnancy probably reduces the risk of
o pre-eclampsia (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.30 to 0.79; 4
trials, 499 women, moderate-certainty evidence) and
o gestational diabetes (RR 0.51, 95% CI 0.27 to 0.97; 4 trials, 446 women,
moderate-certainty probably reduces the risk of
o low birthweight (less than 2500 g) (RR 0.55, 95% CI 0.35 to 0.87; 5 trials,697
women, moderate-certainty evidence) compared to women who received placebo or
no intervention
◼ Supplementing pregnant women with vitamin D alone probably reduces the risk of pre-
eclampsia, gestational diabetes, low birthweight and may reduce the risk of severe
postpartum haemorrhage
Cochrane Database of Systematic Reviews 2019, Issue 7. Art. No.: CD008873. DOI: 10.1002/14651858.CD008873.pub4.

37. VITAMIN B12
◼ Demand increases during pregnancy due to rapid
cell multiplication resulting from the uterine
enlargement, placental development and fetal
growth
◼ Its secretion into breast milk is highly dependent
on current maternal intake and absorption
◼ Its deficiency can lead to poor fetal growth, brain
development, pregnancy outcome
Siddiqua et al., J Nutr Disorders Ther 2014, 4:2
H. Van Sande et al. Journal of Obstetrics and Gynecology 3 (2013) 599-
602

38. B VITAMINS
◼ Indian mothers have high homocysteine concentrations due to dietary
deficiencies (vitamin B12 and protein)
◼ Folic acid supplementation in pregnancy reduces the neural tube defects
◼ Vitamin B6 is crucial for the healthy function of the brain and nervous system
and thus plays a critical role in the development of baby
J Prenat Med. 2008 Oct-Dec; 2(4): 40–41
Asia Pac J Clin Nutr 2005;14 (2):179-181
H. Van Sande et al. Open Journal of Obstetrics and Gynecology 3 (2013)
599-602
Nutrients 2016, 8, 68

39. TAKE HOME MESSAGE
◼ The first 1000 days of life represents the time from pregnancy
through the child’s second birthday
◼ Optimal nutrition status during pregnancy is critical, as it
impacts early embryonic development, organogenesis and
neural development.
◼ Calcium, vitamin D, DHA and Folic acid plays important role in
both maternal and fetal health
◼ Long chain fatty acids are essential for the growth and
functional development of the brain in infants

40. TAKE HOME MESSAGE
◼ DHA is important for normal brain functions, the development of visual and
neural tissues and subsequently motor and cognitive development.
◼ DHA - Increases gestation length, enhance fetal and placental growth further
reduces the risk of complications
◼ Evidence of fetal neuron-developmental abnormalities was seen in infants
whose mothers consumed known, high amounts of mercury-rich seafood.
◼ MeHg neurotoxin can transfer to an embryo through the placenta and
because the embryo is highly susceptible to neurotoxicity, the damage to the
developing nervous system in utero can be severe
◼ Vegetarian derived DHA is SAFE as it is free from Methyl Mercury which is a
neuro-toxin & can harm the growing foetus!

41. 100% VEGETARIAN DHA