FOGSI Focus Nutrition in Women: Across Ages PDF

 FOGSI FOCUS NUTRITION IN WOMEN: ACROSS AGES Prelims.indd 1 26-06-2021 14:18:55 Prelims.indd 2 26-06-2021 14:18:55  FOGSI FOCUS NUTRITION IN WOMEN: ACROSS AGES...

 FOGSI FOCUS NUTRITION IN WOMEN: ACROSS AGES Prelims.indd 1 26-06-2021 14:18:55 Prelims.indd 2 26-06-2021 14:18:55  FOGSI FOCUS NUTRITION IN WOMEN: ACROSS AGES President FOGSI Alpesh Gandhi Editor in Chief Vice President FOGSI Secretary General FOGSI T Ramani Devi Jaydeep Tank Editors Vidya Thobbi Monika Gupta MD FICOG MS DNB MAMS FICOG FICMCH Chairperson North Zone Coordinator, Food and Food and Drug Medico-Surgical Drug Medico-Surgical Equipment Committee FOGSI 2018-2020 Equipment Committee FOGSI 2018-2020 ICOG Governing Council Member Secretary AOGD 2021-22 Professor and Unit Head, Obstetrics Professor, Obstetrics and Gynaecology, and Gynaecology VMMC and Safdarjung Hospital Al Ameen Medical College New Delhi, India Vijayapur, Karnataka, India New Delhi | Mumbai | Bengaluru INDIA Prelims.indd 3 26-06-2021 14:18:56  DISCLAIMER This book contains the views and opinions of the author and does not represent the decisions or stated policies of the Publisher. 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ISBN: Printed in India Published and exclusively distributed by EVANGEL PUBLISHING Prelims.indd 4 26-06-2021 14:18:56  Foreword It gives me immense pleasure to write a foreword for this endeavor of the FOGSI Food, Drugs and Medicosurgical Equipment Committee “FOGSI Focus—Nutrition in Women: Across Ages”. Academics and evidence based practice has been one of the priorities for FOGSI. This Focus is a step forward in working towards the mission. As an endeavor of FOGSI, this Focus summarizes for the readers, the essential and latest evidence based developments in the field of nutrition in lifecycle of a woman. The topics have been aptly chosen to cater to all phases of a woman’s life. It is comprehensive in its coverage as an amalgamation of latest topics related to nutrition in adolescence, reproductive life, pregnancy and menopause which are often neglected and overshadowed by other disease processes in a women’s life. Creating best awareness about this all important topic of nutrition is a step forward in the way of “Women Empowerment” as healthy women can contribute better towards personal and professional developments. I congratulate Dr Alpesh Gandhi and Dr T Ramani Devi to bring forward this concept of women’s health. The editors Dr Vidya Thobbi and Dr Monika Gupta and all contributors have worked hard to do justice to the latest evidence- based recommendations on pertinent topics on nutrition. This will definitely benefit the practicing clinicians, residents as well as faculty in Obstetrics and Gynaecology. I am sure the contents will help the readers in augmenting their clinical knowledge. CN Purandare MD MA Obst (IRL) DGO DFP DOBST RCPI (Dublin) FFIGO FRCOG (UK) FRCPI (Ireland) FACOG (USA) FSLCOG (SL) FTAOG (Tw) FEBCOG (EU) FDGGG (GER) FEMAO & G (UAE) FAMS FICOG FICMCH PGD MLS(Law) President FIGO (2015-2018) Emeritus Dean Indian College of Obstetricians and Gynaecologists President FOGSI (2009) President Indian College of OB GYN (2009) President MOGS (2004) Professor Emeritus O&G Research institute Ministry of Health Russian Federation Editor Emeritus Journal-FOGSI, Emeritus Prof OBGYN, Grant Medical College & J J Hospital, Mumbai, India Ex Hon Prof OBGYN,Grant Medical College & J J Hospital, Mumbai Prelims.indd 5 26-06-2021 14:18:56 Prelims.indd 6 26-06-2021 14:18:56  Special Message Dear All! Journey to healthy life is your lifestyle & diet is the main component of this. In 4 walls of Medical College the modern medicine Doctors are not taught about Nutrition & Diet. Newspapers, magazines these days are full of articles on diet and dieting which tells what is healthy, what is not, whether you should take fat or not. The information presented can often be confusing at best and plainly unscientific at worst While working as teacher with Indian doctors, I feel single most important factor which is lacking in their training is about ideal nutrition. India is poor, overpopulated and deeply religious country with diverse food practices to keep local people healthy & happy. If you want to become good to great doctor-you have to show the mirror of ideal nutrition and diet to your patients. That is why a Doctor should study in depth about nutrition and guide the patients about diet in diseases & age wise, otherwise time is not far away when the dieticians will take over as doctors. I congratulate the editors, Dr Vidya Thobbi & Dr Monika Gupta and all the authors for bringing out an excellent FOGSI focus which encourages gynaecologists to council patients on diet in their journey to healthy life. They also emphasize that nutritional intervention can make great difference in becoming healthy Sharda Jain MD (PGIMER) MNAMS FICOG FIMSA DHM QM & AHO PGDMLS (SYMBIOSIS) Secretary General, DGF Ethical committee Expert (OBGY), NMC Director, Lifecare Centre & Lifecare IVF, New Delhi Prelims.indd 7 26-06-2021 14:18:57 Prelims.indd 8 26-06-2021 14:18:57  President Message Dear FOGSIANs FOGSI believes that Nutrition is a basic human need, a basic human right and a prerequisite for a healthy life. An adequate, well balanced diet with a wide range of nutrients combined with regular physical activity is a cornerstone of good health. Better nutrition is directly related to improved health across lifespan, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Maternal malnutrition, before and in the pregnant state, is a worldwide problem with significant consequences, not only for survival and increased risk for acute and chronic diseases both in mother and child, but also for economic productivity of individuals in the societies and additional costs on the health system. Pre-pregnancy underweight and insufficient gestational weight gain are considered as individual risk factors for the occurrence of spontaneous interruption, preterm birth, fetal growth restriction, and hypertensive disorders, strongly associated with poorer perinatal outcome. Pre-conceptional care is essential and 1000 days needs to be extended to cover this period Maternal pre-pregnancy obesity is a contributing factor in the etiology of poor maternal outcomes such as gestational diabetes, pregnancy-induced hypertension, risk of preterm birth, pre-eclampsia and eclampsia, venous thromboembolism, fetal macrosomia. Maternal obesity contributes to development of a number of negative maternal health outcomes. Higher rate of instrumental delivery and caesarean section, longer postpartum hospital stays than non-obese women. It is FOGSI’s vision is to work for Anaemia Mukt Bharat, promotion of breastfeeding, prevention of Non Communicable Diseases and safeguarding and prevention of maternal and neonatal mortality to achieve SDG for our country. We have worked for nationwide mass awareness and sensitization of community as well. FOGSI believes that a proper, adequate, balanced diet with varied nutrition from conception, during intrauterine life to neonate, infant, adult age, Prelims.indd 9 26-06-2021 14:18:57  x FOGSI Focus—Nutrition in Women: Across Ages menopausal age and throughout life is essential for good health and wellbeing of everyone. I congratulate Dr Vidhya Thobbi, chairperson & Dr Monika Gupta, North- Zone coordinator FOGSI Foods, Drugs and Instruments committee, for editing this valuable FOGSI FOCUS and all the authors for their valuable contributions. I hope it will help our members in their routine practice. Please take care of yourself. Stay healthy, positive and safe. Alpesh Gandhi President, FOGSI Prelims.indd 10 26-06-2021 14:18:58  Vice President Message Dear All, It is my Privileged to present FOGSI Focus— Nutrition in Women: Across Ages as Vice President Incharge of Food, Drug and Medico Surgical Equipment Committee of FOGSI FOGSI has been always inspiring and promoting, knowledge sharing in the field of Obstetrics and Gynaecology. This FOGSI FOCUS is dedicated to nutrition in varying aspects of Obstetrics and Gynaecology. First 1000 days of conception to post-partum is considered to be the most important period in the growth of the fetus and the new born. Most of the diseases which are seen in early child hood will have an impact upon later onset adult disease. So, by manipulating the diseases from the mother and the new born we can successfully create a healthy and a disease free future generation. The incidence of infertility is on the rise, mostly because of the increase in the oxidative stress. This could very well be handled by manipulating the nutrition of the couple. Which can reduce the oxidative stress. This FOGSI FOCUS covers varying topics on the important of nutrition. I congratulate Prof. Dr. Vidya Thobbi, Chairperson Food, Drug and Medico Surgical Equipment Committee for being the main person behind such a beautiful FOGSI FOCUS. I also congratulate the Dr. Monika Gupta for having work hard along with Prof. Dr. Vidya Thobbi, to bring out this beautiful FOGSI FOCUS on nutrition. With best regards, T Ramani Devi MD DGO FICS FICOG National Vice president FOGSI 2020 Chairperson Endometriosis Committee of FOGSI 2014-16 Director Ramakrishna Medical Centre LLP Director Janani Fertility Centre Trichy, Tamil Nadu Prelims.indd 11 26-06-2021 14:18:58 Prelims.indd 12 26-06-2021 14:18:58  From Editors’ Desk Greetings to All !, It gives us immense pleasure to present to you the “FOGSI Focus— Nutrition in Women: Across Ages”. We are grateful to Dr Alpesh Gandhi, President FOGSI and Dr T. Ramani Devi, Vice-President In-charge for entrusting us with this opportunity. Of course, this opportunity has come with a huge responsibility of keeping up with the standards of evidence based education and learning. The theme of FOGSI for this year has been “Safety first, for Indian women and for FOGSIANS”. Keeping in line with this theme we are dedicating our focus to an important aspect of health of Indian women which is often neglected. Providing quality healthcare to our Indian women across all ages has always been the motive of all FOGSIANs. This is a small effort from us in the direction of women’s health i.e. nutrition for her in all stages of her life. On behalf of the editorial team I thank all the authors for their valuable contributions in covering important aspects of nutrition in women in their articles. We have tried to present to you, an exhaustive compendium of important topics in different categories like ‘nutrition in Adolescence, PCOS, reproductive age group, pregnancy and lactation and also menopause’. The importance of essential components of diet like ‘Proteins, Vitamins, Minerals and Probiotics’ has been well highlighted through various chapters. Another topic covered here is ‘Epigenetics of nutrition’ which is comparatively a newer and lesser discussed concept. We have also included the ‘FIGO Nutrition Guidelines and Checklists’ as a ready reckoner in the appendix section of the focus. We hope that this FOGSI Focus is beneficial for both practitioners and academicians. We look forward for your suggestions and feedback to bring forth the best in future as well. Happy Reading! Vidya Thobbi Monika Gupta Editors Prelims.indd 13 26-06-2021 14:18:58 Prelims.indd 14 26-06-2021 14:18:58  FOGSI 2020 Office Bearers President Dr. Alpesh Gandhi Secretary General Dr. Jaydeep Tank Vice President (West Zone) Dr. Atul Ganatra Vice President (West Zone) Dr. Archana Baser Vice President (North Zone) Dr. RaginiAgrawal Vice President (East Zone) Dr. Anita Singh Vice President (South Zone) Dr. T Ramani Devi Deputy Secretary General Dr. Madhuri Patel Treasurer Dr. Suvarna Khadilkar Joint Treasurer Dr. Parikshit Tank Joint Secretary Dr. Sunil Shah Immediate Past President Dr. Nandita Palshetkar President Elect Dr. S. Shantha Kumari Chairpersons of the Committees Adolescent Health Dr. Girish Mane Clinical Research Dr. Meena Samant Endocrinology Dr. RakhiSingh Endometriosis Dr. Asha Rao Endoscopic Surgery Dr. B Ramesh Ethics and Medicolegal Dr Manish Machave Family Welfare Dr. Shobha Gudi Food Drugs Medico Surgical Equipment Dr. Vidya Thobbi Genetics and FetalMedicine Dr. Mandakini Pradhan HIV/AIDS Dr.Anju Soni Imaging Science Dr. Meenu Agarwal Infertility Dr. Kundan lngale International Academic Exchange Dr.Varsha Baste MTP Dr. Bharti Maheshwari Medical Education Dr.Abha Singh Medical Disorders in Pregnancy Dr. Komal Chavan Midlife Management Dr. Rajendra Nagarkatti Oncology Dr. Bhagyalaxmi Nayak Perinatology Dr. VaishaliChavan Practical Obstetrics Dr. Sanjay Das Public Awareness Dr. Kalyan Barmade Quiz Dr. Sebanti Goswami Safe Motherhood Dr. Priti Kumar Breast Dr. Sneha Bhuyar Sexual Medicine Dr. Niraj Jadav Urogynaecology Dr.JB Sharma Young Talent Promotion Dr. Neharika Malhotra Bora Prelims.indd 15 26-06-2021 14:18:58 Prelims.indd 16 26-06-2021 14:18:58  Contributors Alpana Agrawal DGO DNB FICOG M G Hiremath MS Medical Superintendent Chief patron Founder secretary and Professor, Obstetrics & Gynaecology Past president KSOGA Santosh Medical College Ex-Vice President FOGSI Ghaziabad, Uttar-Pradesh, India Past chairperson FOGSI Breast Committee Principal Arati Shah MD MICOG KLES JGMM Medical College Department of Obstetrics & Gynaecology Hubli, West Bengal, India Pulse Clinic Ahmedabad, Gujarat, India Manpreet Kaur Tehalia MD CIMP Professor & Head, Obstetrics & Gynaecology Gurpreet Kaur Sandhu DGO Al-Ameen Medical College & Hospital Consultant, Obstetrics & Gynaecology Bijapur, Karnataka, India CSMSS Institute Kanchanwadi, Aurangabad, India Monika Gupta MS DNB MAMS FICOG FICMCH North Zone Coordinator, Food & Drug Hema Divakar DGO MD FICMCH          Medico-Surgical Equipment Committee FICOG PGDMLE FRCOG FOGSI 2018-2020 President FOGSI 2013 Secretary AOGD 2021-22 Ambassador to FIGO Professor, Obstetrics and Gynaecology, Consultant & Medical Director, Obstetrics & VMMC and Safdarjung Hospital Gynaecology New Delhi, India Divakars Speciality Hospital Bengaluru, Karnataka, India Nalini Anand MD Professor & Head, Obstetrics & Gynaecology Indranil Dutta MS PGDHHM PGDMLS DIPALS MP Shah Government Medical College FIAOG FIAMS Jamnagar, Gujarat, India Professor, Obstetrics & Gynaecology IQCMC Niranjana Asokan MS DNB MRCOG Durgapur, West Bengal, India Consultant, Obstetrics & Gynaecology Institute of Obstetrics and Gynaecology JB Sharma MD FRCOG PhD Chennai, Tamil Nadu,India Professor, Obstetrics and Gynaecology AIIMS Parul Jaiswal MD New Delhi, India Senior Resident , Obstetrics and Gynaecology AIIMS Jayanthy T MD FICOG New Delhi, India Professor & Head, Obstetrics & Gynaecology KIMS Prameela Menon MS DGO Bengaluru, Karnataka, India Secretary TOGS Professor, Obstetrics & Gynaecology Jyoti GS MD PGDMLE FICOG FICMCH Amala Institute of Medical Sciences Professor, Obstetrics & Gynaecology Thrissur, Kerala, India Ramaiah Medical College & Hospital Bengaluru, Karnataka, India Pratibha Singh MD FICOG CIMP FOGSI IMS IMA Consultant, Obstetrics & Gynaecology Jyoti Mary Jose DGO DNB Healing Touch Multispeciality Hospital Consultant, Obstetrics & Gynaecology Bhagalpur, Bihar, India Metropolitan Hospital Thrissur, Kerala, India Prelims.indd 17 26-06-2021 14:18:58  xviii FOGSI Focus—Nutrition in Women: Across Ages Rajendra Singh Pardeshi DGO FICOG Shehla Jamal DGO DNB Vice-President Association of Maharashtra Associate Professor OBG Society Obstetrics and Gynaecology Consultant, Obstetrics & Gynaecology RMRI Maharashtra, India Bareilly, Uttar Pradesh, India Rashmi Jalvee MS DNB Shyamala Guruvare MD Assistant Professor, Obstetrics & Gynaecology Professor, Obstetrics & Gynaecology HBT Medical College & Dr RN Cooper Hospital Kasturba Medical College, MAHE Mumbai, Maharashtra, India Manipal, Karnataka, India Reena Wani MD FRCOG DGO DNBE FCPS DFP FICOG Sindhu KS MS Additional Professor & Unit Head, Obstetrics Junior Resident, Obstetrics & Gynaecology & Gynaecology KIMS HBT Medical College & Dr RN Cooper Hospital Bengaluru, Karnataka, India Mumbai, Maharashtra, India Sneha Bhuyar MD FICMCH FICOG Rekha Rajendra Kumar MBBS MD DNB FICOG Chairperson Breast Committee FOGSI FICMCH PGDMLE Governing Council Member ICOG Chairperson, Infertility & ART Committee Managing Director , Obstetrics & KSOGA Gynaecology Hon. Secretary BSOG Sukhkarta Hospital, Medical Director & IVF Specialist, Yavatmal, Maharashtra, India Chandana Hospital & Miracle IVF Hospital Karnataka, India T Ramani Devi MD DGO FICS FICOG Vice President South Zone FOGSI 2020 Ritu Khanna MS Director, Obstetrics & Gynaecology Department of Obstetrics & Gynaecology Ramakrishna Medical Centre LLP Director & Senior Consultant Director, Janani Fertility Centre Khanna Medical Centre Trichy, Tamilnadu, India Varanasi, Uttar Pradesh, India T Mathangi DNB Sampath Kumari MD DGO FICOG FIME FC Dia. Consultant, Obstetrics & Gynaecology Professor & Head, Obstetrics & Gynaecology Seethapathy Clinic and Hospital Sri Muthukumaran Medical College Hospital Chennai, Tamilnadu, India & Research Institute Chennai, Tamilnadu, India Vidya Thobbi MD FICOG Chairperson Food & Drug Medico-Surgical Sanghamitra Paladugu MS Equipment Committee FOGSI 2018-2020 Senior Resident, Obstetrics & Gynaecology ICOG Governing Council Member Kasturba Medical College, MAHE Professor & Unit Head , Obstetrics & Manipal, Karnataka, India Gynaecology Al Ameen Medical College Sanjay Gupte MD DGO FICOG FRCOG Vijayapur, Karnataka, India Director, Obstetrics & Gynaecology Gupte Hospital and Centre for Research in Vijayalakshmi G Pillai DGO MRCOG Reproduction Senior Consultant & Head, Obstetrics & Pune, Maharashtra, India Gynaecology Vijayalakshmi Medical Centre Sheetal Joshi MSc MBA CDE ARTIST IAPEN IDA Kochi, Kerala, India Clinical Dietician, Department of Dietetics & Management Divakars Speciality Hospital Bengaluru, Karnataka, India Prelims.indd 18 26-06-2021 14:18:59  Contents Chapter 1. Adolescent Nutrition Sampathkumari, Niranjana Chapter 2. Nutrition in PCOS Sneha Bhuyar, Ritu Khanna Chapter 3. Preconceptional Nutrition Reena Wani, Rashmi Jalvee Chapter 4. Maternal Nutrition: A Way Forward T Ramani Devi, T Mathangi Chapter 5. BMI—What We Need to Know? Alpana Agrawal, Indranil Dutta Chapter 6. Essentials of Micronutrients Pratibha Singh, Shehla Jamal Chapter 7. DHA—A Key Nutrient Monika Gupta, Vidya Thobbi Chapter 8. Nutrition in FGR Jayanthy T, Sindu KS Chapter 9. Nutritional Deficiency and Anemia Vidya A Thobbi Chapter 10. Medical Nutritional Therapy in Management of Gestational Diabetes Mellitus—A More Practical Approach Hema Divakar, Sheetal Joshi Chapter 11. Nutritional Management in Pre Eclampsia-Gestosis Girija Wagh Chapter 12. Nutrition during Lactation—Eat Right, Baby Bright! Manpreet Kaur Tehalia, Jyothi GS Prelims.indd 19 26-06-2021 14:18:59  xx FOGSI Focus—Nutrition in Women: Across Ages Chapter 13. Fasting and Feasting Nalini Anand Chapter 14. Probiotics in Obstetrics and Gynecology JB Sharma, Parul Jaiswal Chapter 15. Malnutrition and Immunity in Women Jyoti Mary Jose, Prameela Menon Chapter 16. Proteins: Multifaceted Building Blocks Vidya Thobbi, Monika Gupta Chapter 17. Vitamin D: The All Important Vitamin Vijayalakshmi G Pillai Chapter 18. Role of Calcium in Women’s Health Shyamala Guruvare, Sanghamitra Paladugu Chapter 19. Nutrition in Midlife and Menopause Gurpreet Kaur Sandhu, Rajendra Singh Pardeshi Chapter 20. Micronutrients in Infertility MG Hiremath, Rekha Rajendrakumar Chapter 21. Epigenetics of Nutrition Arati Shah, Sanjay Gupte Appendix Prelims.indd 20 26-06-2021 14:18:59  Chapter 1 Adolescent Nutrition Sampathkumari, Niranjana Introduction All individuals have two growth phases during their lifetime—at infancy and at adolescence. Hence, they require lot of nutrients like vitamins and minerals. A study in 2000 analyzed adolescent nutrition and found malnutrition is common among adolescents. It reported that while developing countries suffer from undernutrition, adolescents in developed countries are under social pressure for achieving a distorted body image. On the other end of spectrum obese adolescents grow up to have chronic diseases and burden the health care.1 Global nutrition report 2020 states India will miss global nutritional targets by 2025, which includes adolescent underweight, overweight, and obesity among other indicators.2 The report says investing in nutrition gives a 16:1 benefit to cost ratio for low income and developing countries. Why Is It Important Adolescence is the period of growth and to support their growth, adequate nutrients are required. They are nutritionally vulnerable and deficiencies in adolescence cause problems in long-term health. India has about 253 million adolescents aged between 10–19 years, about 25% of total population, of which 40% girls and 18% boys are anemic.3 Proper nutrition ensures optimal growth. During growth spurt, between 9–11 years girls gain 24–26 cm and 11–14 years boys gain 27–29 cm in height. Undernutrition delays development of secondary sexual characters and pubertal changes by about 1 year in boys and 0.82 year in girls.4 Adolescents are not a homogenous group and require varied solution depending on their cultural, ethnic, and personal preferences. This period of transition to adulthood involves physical and psychological changes. Malnutrition can result in long–term health complications. Chapter-1.indd 1 25-06-2021 17:17:39  2 FOGSI–Focus on Nutrition in Women What Is Healthy Eating Growth and development in puberty requires additional energy. This energy is to be provided from healthy foods. Healthy eating involves diet rich in fiber, with restricted salt intake, adequate fruits, and vegetables. Chicken and fish are healthy options for non-vegetarian diet over red meat. A survey has reported that adolescents tend to eat added sugars, saturated fatty acids, salt, carbonated drinks more than the required.5 Along with healthy eating, an active lifestyle should be maintained to ensure proper growth and development. At least 60 minutes of moderate intensity workout is recommended for an adolescent. This should include daily aerobic exercises and exercise to strengthen bones for 3 days a week, and exercises to build muscles for remaining 3 days.6 This healthy lifestyle ensures they enter adulthood with good health and do not become burden of health care. Composition of Food Carbohydrates are the most important source of energy contributing to about 50–60% of total energy. NCEP recommendation states that only 30% of energy should be obtained from fat of which saturated fat should be 51 1,600 1,800 2,000–2,200 Chapter-2.indd 2 25-06-2021 17:17:46  Nutrition in PCOS 3 longer to digest and cause a less immediate impact on blood sugar levels and a small and sustained insulin response. Meals containing food groups having a low-glycemic index tend to improve insulin resistance whereas foods with a high-glycemic index worsen it. The affect of glycemic index of various food groups have a more important role in maintaining metabolic health rather than the total amount of carbohydrates in the diet. Eat Fewer Carbohydrates Blood glucose and insulin are proportionate to each other; the more the glucose in the blood the more insulin is secreted. The main dietary treatment is to eat small amounts of carbohydrates so that less insulin is secreted. In any meal the proportion of carbohydrate should be reduced to about 25% of the plate, and should be less processed, such as whole fruits (includes fiber) instead of fruit juices as this can blunt the surge in insulin secretion. Eat More Plant Foods Eating more of whole grain breads and whole wheat pasta and cereals like brown rice and fruits and vegetables, increases dietary fiber intake and helps one feel full on fewer calories. Fiber in these foods being indigestible, slows down the digestion process, and subsequently the release of glucose into the blood, blunting the insulin response. High-fiber diets also help in weight reduction. Pair Carbs with Protein Unprocessed carbohydrates (low glycemic index) with lean protein and a little fat (whole-grain crackers with reduced fat cheese) take long time to digest and help increase satiety. They also hold blood sugar steady and help avoid glucose dips that can trigger cravings for carbohydrate rich foods (high glycemic index). Fats and PCOS Fats should form 25% of a diet taken by these women. Unsaturated fats are more healthy than the saturated fats. Women with PCOS eating diets rich in omega-3 unsaturated fatty acids with a double bond tend to be at a lower risk of developing metabolic disorders later in life.1 Vitamin D Deficiency Studies have revealed that vitamin D plays a role in various metabolic pathways, including insulin metabolism, and affects the pathogenesis Chapter-2.indd 3 25-06-2021 17:17:46  4 FOGSI–Focus on Nutrition in Women of insulin resistance and PCOS. 2-4 The mechanism behind this effect is still unknown, but a possible role for ovarian dysfunction in the mechanisms that regulate apoptosis has been reported.5 Moreover, due to its immunomodulatory role, lack of vitamin D may cause inflammatory responses leading to insulin resistance.6 Conclusion Obesity, as such appears to be a disorder of caloric imbalance that results from intake of calories more than that can be consumed by the body. It cannot occur without intake of excess food. Lifestyle change in the form of small diets taken at regular frequent intervals and moderate exercise, half an hour every day, has proven to be a good initial strategy, in breaking the vicious cycle of increased body weight and metabolic milieu of insulin resistance in obese women having PCOS. It has been observed that a meagre 5% reduction of their body weight improves insulin sensitivity and restores ovulatory function in majority of such women. These women are recommended to take a balanced diet with just enough carbohydrates especially rich in fiber from whole grains, legumes, vegetables, and fruits having low glycemic index. This strategy not only helps in improving short-term reproductive goals, but also in addition, if practised lifelong, it reduces in them the risk of developing type II diabetes mellitus and cardiovascular disease, which otherwise they would have been more prone to, later in life. References 1. Zivkovic AM, German JB, Sanyal AJ, et al. Comparative review of diets for the metabolic syndrome: implications for non-alcoholic fatty liver disease. Am J Clin Nutr. 2007;86(2):285-300. 2. Verstuyf A, Carmeliet G, Bouillon R, et al. Vitamin D: a pleiotropic hormone. Kidney Int. 2010;78(2):140-5. 3. Alvarez JA, Ashraf A. Role of vitamin D in insulin secretion and insulin sensitivity for glucose homeostasis. Int J Endocrinol. 2010;2010:351385. 4. Ngo MD, Chan WP, Rajendran S, et al. Determinants of insulin responsiveness in young women: impact of polycystic ovarian syndrome, nitric oxide, and vitamin D. Nitric Oxide. 2011;25(3):326-30. 5. Homburg R, Amsterdam A. Polysystic ovary syndrome --loss of the apoptotic mechanism in the ovarian follicles? J Endocrinol Invest. 1998;21(9):552-7. 6. Bikle D. Nonclassic actions of vitamin D. J Clin Endocrinol Metab. 2009;94(1):26-34. Chapter-2.indd 4 25-06-2021 17:17:46  Chapter 3 Preconceptional Nutrition Reena Wani, Rashmi Jalvee Introduction Pregnancy is an exceptional phase in a women’s life; in that her health, well- being, and diet influence the health of not just one but two individuals. There is now a growing recognition of the importance of adolescent and women’s preconception nutritional status to improve maternal and infant outcomes. A World Health Organization (WHO) report shows that preconception care has a positive impact on maternal and child health outcomes.1 The three-months preceding pregnancy constitutes the preconception period. This period is now being redefined according to:2 „„ Biological perspective: Period before embryogenesis (weeks before pregnancy) „„ Individual perspective: A conscious intent to conceive (weeks to months prior to pregnancy) „„ Public health perspective: Period to address risk factors, viz., obesity, diet, etc. (months to years) Preconception care aims to provide biomedical, behavioral, and social health interventions to women and couples before pregnancy occurs. It involves providing care to improve the health of women and addresses behaviors and risk factors that may lead to adverse maternal and fetal outcomes. An important aspect of preconception care is the women’s nutrition. Maternal nutritional deficiencies can be rectified by micronutrient supplements during pregnancy, but they are sometimes not enough to improve long-term pregnancy and fetal outcomes. Several factors involved in determining the woman’s nutritional health include genetic make-up, lifestyle, medical disorders, or drug exposure. Preconception care addressing nutrition should include dietary adequacy, healthy weight, and any medical nutrition therapy. Chapter-3.indd 1 25-06-2021 17:17:51  2 FOGSI–Focus on Nutrition in Women Dietary Adequacy Women in the preconception period should be advised to eat nutrient-rich food. Factors that affect food intake include availability of food, income, woman’s beliefs and choices, traditions, cultures, and social, educational, and geographical aspects. Dietary Supplements Although many of the requisite vitamins, minerals, essential fatty acids, and other constituents are found in food, the physiologic demands of the woman during preconception and pregnancy may require additional dietary supplementation. Requirements for folic acid, calcium, iron, zinc, vitamin D, vitamin C, and vitamin B increase substantially during pregnancy. Folic Acid Folic acid is a B-complex, water soluble vitamin required for DNA synthesis and cell division. Dietary sources include green leafy vegetables, legumes, citrus fruits, cereals, and breads containing folic enriched flour. The synthetic form of folate is folic acid. Folic acid is used in fortified cereals and supplements to prevent development of neural tube defects (NTDs). As per the WHO recommendations, women trying to conceive should take folic acid supplement from the time they plan a pregnancy till 12 weeks of gestation.3 A Cochrane review concluded that folic acid supplementation taken in the periconceptional period reduced the risk of developing NTDs by 72% and the risk of recurrence of NTDs by 68%, compared with no intervention, placebo, or micronutrient intake without folic acid.4 The American College of Obstetrics and Gynecologists (ACOG) 5 recommends supplementation with 400 mcg of folic acid per day for average risk women. Women at increased risk of NTDs, viz., women with a previous pregnancy with NTD, obese women, diabetic with poor glycemic control or with seizure disorders, should be counseled to take 4 mg of folic acid daily. Iron Worldwide, the commonest cause of anemia in pregnancy is iron deficiency anemia.6 Women of reproductive age are at risk of iron deficiency due to poor diet, menstrual blood loss, and multiple frequent childbirths. Fetal complications include prematurity and intrauterine growth restriction. Women planning a pregnancy should consume iron-rich foods (meat, poultry, green leafy vegetables, jaggery, and iron-fortified cereals). To reduce Chapter-3.indd 2 25-06-2021 17:17:51  Preconceptional Nutrition 3 the incidence of anemia in women of reproductive age, WHO recommends intermittent iron and folic acid (IFA) supplementation for menstruating women in areas where anemia prevalence is over 20%.7 ACOG recommends that at a preconception visit, screening should be conducted for women with risk factors for iron deficiency for the purposes of identifying and treating anemia.8 Vitamin D Vitamin D is a lipid-soluble vitamin that regulates calcium and phosphate equilibrium, and thus bone metabolism. Vitamin D is produced by the body during exposure to sunlight, but is also found in oily fish, eggs, and fortified- food products. Dietary sources include fortified foods, viz., milk, orange juice, and breakfast cereals. Vitamin D deficiency during pregnancy is known to be associated with pre-eclampsia, low birth weight, impaired glucose tolerance in pregnancy, and impaired growth and bone development in the fetus.9 The ideal dose of vitamin D during periconceptional period is unknown. Vitamin D deficient women should be given information on vitamin D sources in the diet and supplementation. The RCOG recommends daily dose of 10 mcg (400 IU) of vitamin D for all during preconception period and pregnancy. Women at high risk of vitamin D deficiency, viz., women with increased skin pigmentation, reduced exposure to sunlight, or obese women are advised to take at least 1,000 units a day.9 Calcium Calcium plays an essential role in the development and maintenance of bone health. During pregnancy, fetus receives its nutrition from maternal sources. When completing a diet history during preconception counseling, it is important to ask about calcium consumption in the food (milk, cheese, sea-food, fortified orange juice, etc.), calcium supplementation, and use of antacids to assess the woman’s overall calcium intake. If dietary sources are inadequate, oral supplementation with calcium (1,000 mg) and vitamin D is recommended.10 Vitamin A Vitamin A is a fat-soluble vitamin, not synthesized in the body; available as: „„ Preformed Vitamin A: Present in foods of animal origin (liver, whole milk). It is absorbed as retinol and converted into retinal and retinoic acid in the body. „„ Provitamin A carotenoid: Vitamin A present in vegetables and fruits and converted into retinol in the body. Chapter-3.indd 3 25-06-2021 17:17:52  4 FOGSI–Focus on Nutrition in Women Isotretinoin: A synthetic form (13-cis retinoic acid) of vitamin A used to treat severe, cystic acne. Vitamin A is required for ocular function, integrity of epithelial tissue, immunity, development of bone, and normal embryonic development.11 As Vitamin A is lipid soluble, it crosses the placenta. Although normal fetal development requires vitamin A, high dose of preformed vitamin A supplementation is associated with miscarriage and birth defects that affect the CNS, craniofacial, cardiovascular, and thymus development.12 Women planning to conceive and pregnant women should be counseled that vitamin A supplementation above 700 mcg might be teratogenic and should be avoided.13 In areas of vitamin A deficiency, WHO recommends a maximum safe dose of up to 10,000 IU daily or 25,000 IU weekly after the first 60 days of gestation.14 Dietary sources of vitamin A and beta-carotene should be included in a healthy diet as they do not pose a risk of excessive intake. Vitamin A from beta-carotene is not known to increase the risk of birth defects. Isotretinoin is known to cause serious birth defects and should not be taken during pregnancy and preconception period. The current recommendation is to discontinue Isotretinoin at least 1 month prior to attempting pregnancy.15 Iodine Iodine is an essential nutrient acquired through the diet. It is essential for thyroid hormones synthesis, which are responsible for regulating growth, development, and metabolism. Iodine deficiency during pregnancy impairs the normal development of fetal CNS, particularly myelination. Salt iodization is the recommended, preferred strategy to control and eliminate iodine deficiency. WHO recommends a daily iodine intake of 150 g for adults (over 12 years of age) and 200 g for pregnant and lactating women.16 Essential Fatty Acids All women planning a pregnancy should be advised to consume foods rich in essential fatty acids (omega 3 and omega 6 fatty acids). Recent research has addressed the role of omega 3 fatty acids [docosahexanoic acid (DHA) and ecosapentanoic acid (EPA)] in the fetal cognitive and neurological development. These are essential fatty acids derived from sea food primarily from fatty fish. Fatty fish is a known source of contaminants, viz., mercury and persistent organic pollutants, particularly in larger fish species. ACOG recommends that women planning a pregnancy can eat up to 2–3 servings a week (8–12 ounces in total) of a variety of fish in order to avoid the harmful effects of mercury.17 Chapter-3.indd 4 25-06-2021 17:17:52  Preconceptional Nutrition 5 Caffeine Intake In the periconceptional period, women should be counseled that increased caffeine intake (>300 mg/day) may be associated with spontaneous abortions, low birth weight, and other adverse pregnancy outcomes. They should be advised that lowering daily caffeine intake to less than 200 mg/day appears to be safe and does not to be a major contributing factor in adverse pregnancy outcome.18,19 Alcohol Intake Women planning a pregnancy should be informed that consumption of alcohol in the periconceptional period is associated with spontaneous abortion, neural tube defects, and GI malformations, and also correlates with maternal depression. As per the ACOG recommendations 20 „„ Screen women in the reproductive age group for alcohol use. „„ Inform them about the potential risks of alcohol consumption. „„ Advise women that the effects of consuming alcohol on pregnancy begin early from the first trimester, and that no safe level of consumption has been established. „„ Women who are pregnant, planning to become pregnant, or at risk of becoming pregnant must abstain from alcohol use. The recommendation for nutrient intake is summarised in Table 1. Preconception Weight and Body Mass Index (BMI) Before embarking on a pregnancy, all women should be counseled to try to attain a body mass index (BMI) in the normal range, because abnormal high or low BMI is associated with infertility and adverse maternal and fetal outcoms. Obesity, defined as a BMI of 30 kg/m2 or greater, is associated with: „„ Maternal risks: Type 2 diabetes, hypertension, infertility, thromboembolic disease, cesarean delivery. „„ Perinatal risks: Preterm delivery, stillbirth, macrosomia, low Apgar scores. The risks associated with high BMI are best addressed before conception because during pregnancy, weight loss is not recommended. All women with a low BMI should be assessed for eating disorders and distortions of body image. Interventions to improve weight should support a healthy lifestyle: „„ addressing individual knowledge and skills, „„ reducing exposure to foods low in nutritional value and high in calories, and „„ increasing opportunities for physical activity. Chapter-3.indd 5 25-06-2021 17:17:52  6 Chapter-3.indd 6 TABLE 1 Peri-conception nutrition supplementation21 Nutrient Target population Recommended dose Evidence Folic acid All women planning a pregnancy 400 mcg daily from 4 weeks preconception to Prevention of NTD such as spina bifida and 12 weeks of gestation anencephaly Women at high risk of NTDs 4 mg daily from 4 weeks preconception to 12 (GDM, previous NTD, obesity, weeks of gestation anticonvulsant medication) Iodine All women 150 mcg daily while pregnant and breastfeeding Production of maternal thyroid hormone, fetal brain, and CNS development FOGSI–Focus on Nutrition in Women Iron Women with iron deficiency on Daily oral iron tablets containing at least 60 mg Prevention of anemia blood tests of elemental iron Vitamin D Women with vitamin D deficiency on 1,000 IU/day (vitamin D 30–49 nmol/L) Essential for bone development in the blood tests 2,000 IU/day (vitamin D 19 years) Vitamin A Retinol (liver, dairy, fish), carotenoids 700–900 mcg (sweet potatoes, carrots, spinach) Vitamin D Sunlight, fish oil, milk 600–800 IU Vitamin E Sunflower seeds, wheat germ, almonds 15 mg Vitamin K Leafy greens, soybeans, pumpkin 90–120 mcg Vitamin A Deficiency „„ Ocular change „„ Night blindness „„ Xerophthalmia „„ Extraocular changes „„ Growth retardation „„ Acquired immune deficiency „„ Increased risk of infections „„ Rough, dry skin, Acne „„ Poor functioning of lungs and digestive tract Chapter-6.indd 4 25-06-2021 17:18:11  Essentials of Micronutrients 5 Toxic Effects Very high amounts 50,000 IU/day for long can cause: „„ Poisoning „„ Hepatosplenomegaly „„ Birth defects „„ Fatigue, malaise „„ Anorexia, vomiting Vitamin D Deficiency „„ Rickets „„ Osteomalacia „„ Osteoporosis Toxic Effects „„ Hypervitaminosis „„ Hypercalcemia „„ Hyperphosphatemia „„ Hypertension which manifests as nausea and vomiting „„ Excessive thirst and polyuria, severe itching „„ Joint and muscle pains „„ Azotemia „„ Nephrolithiasis, ectopic calcification „„ Disorientation & coma Macrominerals These are required in high amounts than trace minerals to carry out their distinct roles in the body (Table 3). The macrominerals and their functions are: „„ Calcium: Essential for proper formation and function of bones and teeth. Aid in blood vessel contraction and muscle function. „„ Phosphorus: Part of the cell membrane and bone structure. „„ Magnesium: Helps with over 300 enzyme reactions, together with control of blood pressure. „„ Sodium: Electrolyte that helps in fluid balance and regulation of the blood pressure. „„ Chloride: Frequently found in combination with sodium. Assists in maintaining the fluid balance and is used to produce digestive juices. Chapter-6.indd 5 25-06-2021 17:18:12  6 FOGSI–Focus on Nutrition in Women „„ Potassium: Electrolyte that regulates fluid status in cells and aids in muscle function and nerve transmission. „„ Sulfur: Present, in every part of living tissue and present in the amino acids methionine and cysteine. TABLE 3 Recommended dietary allowances and sources of macrominerals Nutrient Sources RDA or AI (adults > 19 years) Calcium Broccoli, milk products, leafy greens 2,000–2,500 mg Phosphorus Turkey, salmon, yogurt 700 mg Magnesium Black beans, almonds, cashews 310–420 mg Sodium Canned soup, salt, processed foods 2,300 mg Chloride Celery, seaweed, salt 1,800–2,300 mg Potassium Bananas, lentils, acorn squash 4,700 mg Sulfur Garlic, onions, Brussels sprouts, eggs, None established mineral water Trace Minerals Trace minerals are required in lesser amounts than macrominerals, however, it still enables essential functions in your body (Table 4). Trace minerals and their functions: Iron: Helps in providing oxygen to muscles and aid in the production of certain hormones. Manganese: Helps in amino acid, carbohydrate, and cholesterol metabolism. TABLE 4 Recommended intakes of trace minerals and sources Nutrient Sources RDA or AI (adults > 19 years) Iron Oysters, white beans, spinach 8–18 mg Manganese Pineapple, pecans, peanuts 1.8–2.3 mg Copper Liver, crabs, cashews 900 mcg Zinc Oysters, crab, chickpeas 8–11 mg Iodine Seaweed, cod, yogurt 150 mcg Fluoride Fruit juice, water, crab 3–4 mg Selenium Brazil nuts, sardines, ham 55 mcg Chapter-6.indd 6 25-06-2021 17:18:12  Essentials of Micronutrients 7 Copper: Important for connective tissue genesis, along with normal brain and the nervous system function. Zinc: Essential for immune function, normal growth, and wound healing. Iodine: Helps in thyroid regulation. Fluoride: Requires for the growth of bones and teeth. Selenium: Essential for thyroid health, reproduction, and protection against oxidative damage. Macro- and Microminerals Deficiencies „„ Calcium and magnesium—Tetany-muscle cramps, numbness, and tingling in limbs. Rickets and osteoporosis–chronic deficiency. „„ Zinc—Develops as a part of malnutrition or malabsorption syndrome due to low intake or intestinal disease, can also affect CNS. „„ Iodine—During pregnancy, it can result in stillbirth, spontaneous abortion, congenital abnormalities such as cretinism, increased PNM, and goiter. „„ Iron—Anemia leads to reduced disease resistance and poor growth and development. Water Water is essential to human life. Role of water is to: „„ Stimulate the kidneys to remove toxins. „„ Transport nutrients and other body substances. „„ Help to regulating body temperature. „„ Help in digestion, absorption. „„ Help to keep skin and muscle toned. Healthy Balanced Diet It is essential to eat food from each group daily. Nutrient requirements vary depending on: „„ Age „„ Gender „„ Physical activity „„ Pregnancy „„ Breastfeeding „„ A healthy balanced diet provides adequate food for energy and nutrients (Fig. 2). Chapter-6.indd 7 25-06-2021 17:18:12  8 FOGSI–Focus on Nutrition in Women Fig. 2: Healthy balanced diet Micronutrients Health Benefits Although we only need micronutrients in micro amounts, but they are vital and deficiency of these can cause serious health problems. So they are mandatory for: „„ the adequate functioning of the body, „„ may even provide immunity to fight against disease, „„ also act as antioxidants, and „„ may provide immunity to fight against diseases like cancer, Alzheimer’s, and heart disease. Chapter-6.indd 8 25-06-2021 17:18:12  Essentials of Micronutrients 9 Micronutrient Deficiencies An inadequate amounts of these micronutrients can lead to negative side effects. Most of the healthy adults can get an appropriate amount of micronutrients from a balanced diet but there are also certain populations who are affected due to a lack of proper vitamins. These include: „„ Vitamin D: Approximately 77% of Americans are deficient in vitamin D, mostly due to lack of sun exposure. „„ Vitamin B12: Vegans and vegetarians may affect by vitamin B12 deficiency with abstain from animal products. Elderly individuals are also affected by less absorption of vitamins with age. „„ There is also a lack of vitamin A in most of the women and children in the developing countries. „„ Lack of Iron is commonly shown among preschool children and menstruating women. „„ There is also a lack of Calcium in almost 22% of men and 10% of women who are above 50 years old. Tackling Micronutrient Malnutrition See Figure 3. Fig. 3: Tackling micronutrient malnutrition Supplementation Taking a capsule or injection containing a sufficient amount of the deficient micronutrient (Fig. 4). Food Fortification Adding an essential micronutrient to commonly consumed processed foods such as cooking oil, sugar, salt, and flour. Chapter-6.indd 9 25-06-2021 17:18:12  10 FOGSI–Focus on Nutrition in Women Fig. 4: Micronutrient supplementation Dietary Diversification Increasing the variety and amount of micronutrient-rich foods, with social and behavior change activities, so that there is increased production or access to nutrient-rich foods. Biofortification Breeding varieties of a popular staple food crop with high amounts of at least one important micronutrient. Micronutrient Toxicities Micronutrient toxicities are infrequent than deficiencies. They are potentially to occur with large doses of the fat-soluble vitamins A, D, E, and K, since these can be stored in the liver and fatty tissues & cannot be eliminated from the body like water-soluble vitamins. Micronutrient toxicity generally develops from supplementing with excess amounts—rarely from food sources. It is also essential to know that excessive consumption of certain nutrients can still be dangerous even if it does not lead to overt toxicity symptoms. Conclusion Deficiencies of micronutrients are a major global health problem, and 2 billion people in the world today are estimated to be deficient in key vitamins and minerals like vitamin A, iodine, iron, and zinc. Micronutrients play a central part in metabolism and in the maintenance of tissue function. Since our body needs micronutrients in Chapter-6.indd 10 25-06-2021 17:18:13  Essentials of Micronutrients 11 specified amounts, deficit and surpluses of any one nutrient cause negative issues. Single micronutrient deficiency can easily be recognized and treated. Subclinical & multiple micronutrients deficiency is more difficult to recognize. Diet-related deficiencies do occur in vegans, the elderly, and the alcoholics. An adequate intake is necessary, but excess supplements to people who do not need them may be harmful. Bibilography 1. FAO/WHO. Vitamin and Mineral Requirements in Human Nutrition, 2nd edition. Geneva. World Health Organization. 2004;2:341. 2. Institute of Medicine. Food and Nutrition Board Dietary reference intakes. Application in dietary assessment. A report of the Subcommittee on Interpretation and uses of dietary reference intakes and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Washington D.C.: National Academic Press. 2000. 3. Shenkin A. Micronutrients in health and disease. Postgrad Med J. 2006;82(971): 559-67. 4. Shenkin A. The key role of micronutrients. Clin Nutr. 2006;25(1):1-13. 5. The World Health Report. 2001: Reducing risks, promoting healthy life. Geneva. World Health Organization. 2001. 6. UNICEF/UNU/WHO. Composition of a multi-micronutrient supplement to be used in pilot programmes among pregnant women in developing countries. Report of a Workshop. New York, UNICEF. 1999. 7. WFP. Nutrition in emergencies WFP experiences and challenges and micronutrient fortification: WFP experiences and ways forward. WFP Policy papers. 2004. 8. WHO/MI. Safe vitamin A dosage during pregnancy and lactation. Recommendations and report of 12. Chapter-6.indd 11 25-06-2021 17:18:13  Chapter 7 DHA—A Key Nutrient Monika Gupta, Vidya Thobbi Introduction Fats are essential for all organisms. Fatty acid (FA) has a variable length carbon chain with a methyl end and a carboxylic acid head. FAs can be classified based on the degree of saturation of their carbon chains. Saturated FAs have the maximum number of hydrogen atoms, while monounsaturated FAs have one, polyunsaturated FAs (PUFAs) have two or more, double bonds.1 Polyunsaturated FAs received from diet are necessary for various physiological processes; however, they cannot be produced in body and they need to be incorporated in diet. These are also called essential FAs. PUFA have a role in the following conditions:2 „„ Cardiovascular diseases „„ Rheumatoid arthritis „„ Neuropsychiatric diseases „„ Inflammation „„ Obesity There are two types of polyunsaturated FAs (Table 1): „„ Omega-3—Alpha-linolenic acid (ALA) is a parent omega-3 FA. „„ Omega-6—Linolenic acid (LA) is a parent omega-6 FA. Essential FAs are metabolized to long chain FA and form its metabolites. These metabolites are active and have physiological actions.3 TABLE 1 Various types of Polyunsaturated Fatty Acids Omega-3 FAs Omega-6 FAs zz Alpha-linolenic acid zz Linoleic acid zz Ecosapatothenic acid zz Gamma-linolenic acid zz Docosapentaenoic acid zz Diho-gamma- linolenic acid zz Docosahexaenoic acid zz Arachidonic acid zz Adrenic acid Chapter-7.indd 1 25-06-2021 17:18:52  2 FOGSI–Focus on Nutrition in Women Docosahexaenoic Acid (DHA) DHA is synthesized primarily in endoplasmic reticulum of liver from ALA. DHA is one of the most important omega-3 FA as it constitutes 10–20% of total lipids in brain. DHA is stored in phospholipid membranes and structures like synaptic terminus, mitochondria, and endoplasmic reticulum. Thus it is believed that DHA affects various cellular characteristics and physiological activities comprising membrane fluidity, transmembrane receptor function, gene expression, release of neurotransmitter, signal transduction, lipid raft function, myelination, neuroinflammation, and neuronal differentiation and growth. Due to variety of functions, DHA has key role in throughout human life-stages.4 Sources of DHA The primary source of omega FAs are vegetable oils including sunflower oil, safflower oil, sesame oil, palmolein oil, and corn oil. About 10–15% of omega-6 FAs are obtained as a fundamental component of cereals, pulses, tubers, legumes, and vegetables as “invisible fat”. Omega-3 FAs are available in abundance in dietary sources like vegetable oils like flaxseed or linseed oil, rapeseed or canola oil, peanut oil, olive oil, soya oil, walnut oil, green leafy vegetables, fenugreek seeds, kidney beans, dry fruits, oily cold-water, fish and fish oil.3 Different Functions of DHA in Body DHA is essential in initial growth and development of brain in infants and also maintenance of normal brain in adults. Along with DHA’s role in nervous system it also has role in multiple other organ systems and diseases (Table 2) as mentioned below:5 „„ Cardiovascular disease „„ Cancer „„ Inflammation „„ Asthma „„ Immunity Importance of DHA throughout Life Stages Humans require essential FAs for all physiological processes like growth, development, and the maintenance of cellular functions necessary to life. In the below section role of DHA during entire course the human life cycle is summarized. Fetal and Neonatal Development Fetal development is characterized by period of and rapid growth represents growth and metabolic turnover in the life stages of human. During this period Chapter-7.indd 2 25-06-2021 17:18:52  DHA—A Key Nutrient 3 TABLE 2 Organ system and role of DHA Diseases Role of DHA Nervous system—Infant zz Maintenance of normal neural functions zz Dominant structural FA in the brain gray matter and retina Nervous system—Adult zz Maintenance of the brain and of learning during aging zz Ameliorates the learning performance failure caused by cholinergic dysfunction zz Maintenance of the cognitive functions of the brain zz Neuronal protection in the CNS Cardiovascular diseases zz DHA supplements increase the HDLrLDL cholesterol ratio and decrease the total cholesterol HDL ratio, suggesting a decreased risk for coronary artery disease. zz DHA may have a role in preventing severe arrhythmias in myocardial ischemia Cancer zz DHA supplementation may be advantageous in adjuvant chemotherapy Inflammation zz EPA and DHA have anti-inflammatory properties and may change lymphocyte, monocyte, and macrophage functions Immunity zz Omega-3 to omega-6 long-chain FAs in the diet may modulate the host response to respiratory infection with less infection correlated with a higher level of omega-3 FAs weight of human brain increases 60 fold from 2nd trimester to 2 years of age. Among omega-3 FAs, DHA is present in abundance in the brain and retina, and constitutes approximately 50% weight of neuronal plasma membranes. DHA improves cell membranes fluidity and regulates physiology of neurotransmission, including signal transduction by acetylcholine, dopamine, and serotonin, and has major effect on cognition, vision, and behavior.6 Childhood Limited evidence is available on the association between consumption of FA and health outcomes in children above 2 years. Nonetheless, it is well recognized fact that an optimal intake of DHA is necessary for Child’s normal growth and development as well as cognitive development.6 A study was conducted on children aged 5 years whose mothers were supplemented with 200 mg/d of DHA while lactation and from delivery until 4 months post delivery, which showed that these children performed better on attention tasks than children whose mothers were supplemented with vegetable oil.7 DHA has also been effective in management of childhood diseases like attention-deficit hyperactivity disorder,8 upper respiratory illness, and allergy.9 Chapter-7.indd 3 25-06-2021 17:18:53  4 FOGSI–Focus on Nutrition in Women Adulthood In adults, Suboptimal intake of omega-3 FAs has been linked with many diseases including cardiovascular, inflammatory/autoimmune, neurodevelopmental, and psychiatric disorders.10,11 A study was conducted in 280 adult volunteers without neuropsychiatry diseases and they assessed cognitive functions, and it was found that higher levels of serum DHA to be related with significant improvement in nonverbal reasoning and mental flexibility, working memory, and vocabulary.11 It is also suggested that, in adults dietary intake of omega-3 FAs is associated with protective action on endothelial function.12 Advanced Age The aging is physiological process that leads to decline in functional and physiological processes that lead to change in nutritional needs in the ageing population. In the ageing population, omega-3 FAs have effects like inhibit hepatic triglyceride synthesis, decrease inflammation, and inhibit platelet aggregation. 13 DHA supplementation is also being associated with neuroprotective effects. 14 Moreover, oxidation of DHA activates neuroprostanes and neurofurans, which are effective anti-inflammatory metabolites similar to prostaglandins which have a role in maintaining brain health in elderly population.15,16 DHA in Pregnancy and Lactation Diet and lifestyle are important determinants of health of both mother and offspring, starting from the preconception period. During pregnancy, the quality of fats is more important than their total amount, especially for fetal development and infant growth. For this reason, it is necessary to improve the relative proportion of polyunsaturated fats rather than to increase the intake of total fats: an optimal intake of DHA is necessary for the growth and development of brain and retina.17 Among polyunsaturated FAs in brain and retina DHA is the predominant component. And hence is necessary during pregnancy for brain and retinal development of the fetus. It is also well known that DHA plays major roles in the psychomotor neurodevelopment in the first months of life, when it is supplied at high amounts by breastmilk.18 Benefits of DHA to Mother Multiple maternal benefits have been suggested with DHA supplementation in pregnant women. DHA supplementation in initial stage of pregnancy could decrease the occurrence of placental disorders. In the failure of a normal placentation may lead to complication of uteroplacental ischemia which further leads to several complications such as preeclampsia, fetal Chapter-7.indd 4 25-06-2021 17:18:53  DHA—A Key Nutrient 5 growth restriction, preterm labor, and PROM.19 In one of the review which evaluated the effects of DHA supplementation in prevention of placental disorders, this study concluded that supplementation of DHA in first trimester was associated with better outcome.20 Preeclampsia is another obstetrical complication caused due to placental dysfunction. This can be attributed to combination of extreme oxidative stress and endothelial dysfunction.20 In one of the study conducted they evaluated levels of serum FA concentrations in women with preeclampsia and it showed that low levels of DHA in maternal plasma, cord plasma, and placenta of preeclampsia women.21 Results of this study is disputable, as in one of the Systematic review by Cochrane showed that there is not enough evidence to support the use of marine oil supplementation in order to reduce the rate of preeclampsia.22 In obese pregnant women obstetrician have concern because of the increased risk of maternal and fetal morbidity. A review conducted recently studied the effect of poly unsaturated FAs in obese pregnant women associate with metabolic syndrome. This study concluded that PUFAs supplementation provide benefits, which include prevention of preterm labor and preterm birth and also improvement in fetal and neonatal outcome in obese pregnant women.23 Gestational diabetes mellitus (GDM) is another common complication encountered in pregnancy with rising prevalence of 3% and 10%. GDM is responsible for short- as well as long-term maternal and fetal morbidity. The corelation between DHA supplementation and incidence and severity of GDM has been studied. The DOMInO trial showed that a daily supplementation of 800 mg during the second trimester was unable to reduce the risk of GDM. Non the less in the DHA treated group there was a significant effect on perinatal mortality and neonatal convulsions.24 Lower serum PUFA levels were associated with major depression.25 In last trimester of pregnancy there is physiological depletion of PUFA can be correlated with an increased incidence of postpartum depression. A retrospective observational study conducted compared women having postpartum depression and controls this study showed that lower serum PUFA levels in the postpartum depression group and implied that there is possible benefit of a DHA supplementation.26 Another study reported that decreased ratio of DHA to omega-6 FAs is associated with the increased risk of postpartum depression.27 Benefits of DHA to Fetus Fetal growth depends on the normal functioning placenta and an optimal nutritional status of mother. Low birth (LB) weight infant are at high risk of short-term as well as long-term morbidity and mortality. Several studies have shown the effectiveness of DHA supplementation on weight of newborn. A small randomized controlled study conducted on 43 women who were Chapter-7.indd 5 25-06-2021 17:18:53  6 FOGSI–Focus on Nutrition in Women at high risk for preterm delivery. In this study they evaluated the effect of vaginally administered DHA versus placebo. In women supplemented with DHA had a significant increase in gestational age at delivery and in newborn birth weight.28 In another prospective study conducted concluded that a positive association amongst maternal DHA concentrations and birth weight.29 In another double blind controlled study including 350 women who received either 600 mg/d DHA or placebo, this study concluded that DHA supplementation in the last half of pregnancy was associated with overall increased gestation duration and infant size.30 Intrauterine growth restriction (IUGR) is a complex disorder. When IUGR is linked to placental insufficiency, fetal lipid metabolism may be adversely affected. Several animal studies have reported an damaged DHA transplacental transfer in IUGR. This could be one of the reasons for the neurological symptoms linked to IUGR.31 In a prospective study including pregnant women, DHA concentration of maternal erythrocyte in first trimester was linked with weight of neonates. Also in women who delivered low birth it was found that DHA levels were found to be low compared to controls.32 DHA is important to fetal, neural, and retinal development. Evidences available till now concludes that optimal DHA levels in mother may provide certain benefits for child’s neurodevelopment. Moreover, DHA is considered to be safe, with no adverse birth outcomes which can be correlated to DHA supplementation.33 Multiple governing bodies are recommending supplementation of DHA during pregnancy and lactation (Table 3). TABLE 3 Recommendations for DHA supplementation in pregnancy Authority Adults (DHA mg/day) Pregnancy (DHA mg/day) Year European food safety 250 250 2012 authority Nordic Nutrition 200–250 200 2012 Recommendations (NNR) WHO 200–1000/Week — 2003 National H