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Prof. Cristina CampoyDepartment of Paediatrics, University of Granada
Excellence Centre for Paediatric Research
NUTRIMENTHE Coordinator
NUTRIMENTHE OPEN FORUM
“Feeding the Future Generation”
Long term effects of prenatal nutrition on brain development
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INTRAUTERO ENVIRONMENT
BRAIN DEVELOPMENT
NUTRITIONEARLY PROGRAMMING
“Stimulus or insult operating at a critical or sensitive period of development could result in a long-standing or life-long effect on the structure or function of the organism”
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NUTRITION
ENVIRONMENT
ESTIMULATION
GENETICS
HEALTH STATUS
SLEEP
BEHAVIOR
BRAIN
DEVELOPMENT
Prof. Cristina Campoy. University of Granada. Spain. E-mail: [email protected]
IQ
MOTHER!
LIFE STYLE
LIFESTYLE
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AA>DHA DHA>AA
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Critical Stages of Mental Development
Social Ability
Emotional Control
Habituation
Binocular vision
Knows symbols
Knows quantity
Language
Age in yearsCritical Stage
Critical Stage receding
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STEPS OF BRAIN MATURATION
1st brain regions:Visual motorBalanceMotor performance
2nd brain regions:LearningMemoryLanguage mature
3rd Region (the frontal lobes)Executive functions (slow maturation process from 6 months to 15-16 year old with a critical period between 1 to 3 years and between 7 to 10 years old)
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Independently
In combination
KEY KEY KEY KEY
NUTRIENTSNUTRIENTSNUTRIENTSNUTRIENTS
n-3 PUFAs
Folate
Vitamin B12
Iron
Vitamins C & A
Zinc
Selenium
Iodine
Choline
Protein intake
COGNITIVE PERFORMANCE
BEHAVIOUR OF CHILDREN (ADHD,
Dyslexia, Dyspraxia and Autism)
THE BRAIN AND ITS DEVELOPMENTTHE BRAIN AND ITS DEVELOPMENTTHE BRAIN AND ITS DEVELOPMENTTHE BRAIN AND ITS DEVELOPMENT
Prof. Cristina Campoy. University of Granada. Spain. E-mail: [email protected]
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DHA and brain
� Lipids bound DHA in the membrane bilayer
– Membrane physicochemical properties
– Interaction with membrane proteins
– Membrane biogenesis
� Unesterified DHA
– Gene expression
– Ion channel activity
– Neuroprotective metabolites
35% PUFA
Delivery
3,000 nmol/g
2 y25 w
10,000 nmol/g
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Changes in the embryonic and fetal brain, brain synaptic membranes and retina:
“structure function role” Altered metabolism of come neurotransmitters:
DOPAMINE
SEROTONIN
MEMBRANE-ASSOCIATED ENZYMES
RECEPTOR ACTIVITIES
Deficits in behavioural tasks of learning
Increased stereotyped behaviour
FUNCTIONAL CONSEQUENCES
DHA Deficiency
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Neurogenesis
Dendritic arborization
Synaptogenesis
Selective Pruning
Myelination
(Georgieff, 2005)
Stage of development
Duration
Severity
DHA DEFICIENCY
�Decrease of the mean cell body size of neurons (hippocampus, hypothalamus and parietal cortex)
�Decrease the complexity of cortical dendritic arborization
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EPIDEMIOLOGICAL AND INTERVENTION STUDIES
Increased risk of poor visual and neural development
Low plasma and blood cell lipid DHA
Increased risk of dementia and cognitive decline in older individuals
(Bouwstra, 2003; Dunstan, 2006; Uauy,
2006; Hibbeln, 2007; Innis 2008)(Dullemeijer, 2007; Nurk, 2007; Van Gelder,
2007; Schaefer, 2006; Kalmijn, 2004)
Low dietary fatty acids + Genetic variation in fatty acid metabolism
Poor central nervous system functioning in infants & children
Long-lasting sequelae
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DHA accretion by the developmental brain
Martínez M: Tissue levels of polyunsaturated fatty acids during
early human development. J Pediatr. 1992; 120: S129-138.
?
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Fatty acids transplacental transport
AAAA
DHADHA Linoleic acidLinoleic acidαααααααα--Linolenico acidLinolenico acid
Crawford et al. 1998Crawford et al. 1998pp--FATPFATPFatty Acids Chain Lenght
Placental transfer(Godfrey KM 2002)
Placental Fatty acids transportprotein (p-FATP)
Placental membrane
Preferential transport for LCPreferential transport for LC--PUFAsPUFAs(Dutta Roy, et al. 2000)(Larqué E, et al. 2003)(Larqué E, Krauss-Estchmann S, Campoy C, et al., Am J Clin Nutr 2006)
Mother-fetal plasma fatty acids gradient
Fatty acids net flux through the plancenta(Elphick 1997)
Krauss-Etschmann S, Shadid R, Campoy C, et al., Am J Clin Nutr, 2007
Koletzko, et al. J Perinat Med, 2007Hanebutt FL, et al. Clin Nutr, 2008
FATP-1
FATP-4
Order of preference DHA>AA>ALA>LA
PP--FABPpmFABPpm
FAT/CD36FAT/CD36
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N-3 LCPUFAs Interventional studies
� Helland 2001/2008– EEG at 2 d and 3 m
– FTII at 6 m and 9 m
– K-ABC at 7 y
� Malcolm 2003– Electroretinogram at 15 w
� Tofail 2006– BSID at 10 m
� Judge 2007– FTII at 9 m
� Dunstan 2008– PPTV at 2 ½ y
– CBCL at 2 ½ y
� Helland 2003– K-ABC at 4 y
� Judge 2007– Problem solving at 9m
� Dunstan 2008– Eye hand coordination at 2 ½ y
No differencesDifferences
� Dziechciarz, 2010. Systematic review
RCTs – n-3 LCPUFA supplementation (pregnant and/or lactating women) - No differences in Neurodevelopment, nor in Visual function
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LCPUFA supplementation of formula during the first
2 postnatal months in healthy term infants does not
promote neurologicalcondition at school age.
Breast-fed infants have a slightly better
neurodevelopmental outcome than formula-fed infants – reflected by a reduced prevalence of fine
manipulative dysfunction.
The Groningen LCPUFA study no effect of postnatal long-chain polyunsaturated fatty acids in healthy term infants on neurological condition at 9 years (Corina de Jong, et al.,
BJN, 2010; 104, 566-572)
n: 314
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Linoleic acid (18:2Linoleic acid (18:2ωωωωωωωω--6)6)
γγγγγγγγ--linolenic acid (18:3linolenic acid (18:3ωωωωωωωω--6)6)
DGLA (20:3 DGLA (20:3 ωωωωωωωω--6)6)
∆∆--66--DesaturaseDesaturase
FADS2FADS2
ElongaseElongase
ELOVL5ELOVL5
AA (20:4 AA (20:4 ωωωωωωωω--6)6)
∆∆--55--DesaturaseDesaturase
FASD1FASD1
αααααααα--linolenic acid (18:3linolenic acid (18:3ωωωωωωωω--3)3)
18:418:4ωωωωωωωω--33
20:420:4ωωωωωωωω--33
EPA (20:5EPA (20:5ωωωωωωωω--3)3)
22:522:5ωωωωωωωω--33
ElongaseElongase
ELOVL5, ELOVL2ELOVL5, ELOVL2
DHA (22:6DHA (22:6ωωωωωωωω--3)3)
22:422:4ωωωωωωωω--66
22:522:5ωωωωωωωω--66
24:424:4ωωωωωωωω--66
ELOVL2ELOVL2
24:524:5ωωωωωωωω--66
FADS2FADS2
CSCS
ELOVL2ELOVL224:524:5ωωωωωωωω--33
FADS2FADS2
24:624:6ωωωωωωωω--33CSCS
Koletzko, Larqué, Demmelmair. J Perinat Med 2007
Innis S, Brain Research 2008
FETUS-NEONATE !!
∆∆66 ∆∆66
β-oxidation β-oxidation
Eicosanoids
Membranes
24:424:4ωωωωωωωω--33
22:422:4ωωωωωωωω--33
∆∆99
∆∆77Hackey-Shunt
Sprecher- Shunt
Plants Plants
Meat, eggs, fish
Fish, eggs,
poultry
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DIFFERENT RESULTS �
�Different potentiality of endogenous synthesis
on a genetic basis!
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NUHEAL STUDY
LC-PUFAS and/or 5-MTHF SUPPLEMENTATION DURING PREGNANCY and NEURODEVELOPMENT IN
THE OFFSPRING
Campoy C1, Escolano V1, Ramos R2, Haile G3,Csábi Gy4, Pérez-García M5, Décsi T4 and Koletzko B3
1Dept. of Paediatrics. University of Granada. Spain.2CIBER de Epidemiología y Salud Pública (CIBERESP), Spain.
3Dept. of Paediatrics. Ludwig-Maximiliams University of Münich. Germany. 4Department of Paediatrics. University of Pécs. Hungary.
5Department of Neuropsychology. University of Granada. Spain
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Recruitment
20 30
Wks gestation
Delivery 2 mon
cVEP
35352525
Randomized and double blinded
6 mon 20 mon
Bayley’s Test
4 yrs
Hempel Test
DHA
(n:69)
(500 mg/day)
5-MTHF
(n:65)
(400 µµµµ/day)
Placebo
(n:72)
DHA+5-
MTHF
(n:64)
270 healthy pregnant women
311 healthy pregnant women recruited
5.5 yrs
cVEP
6.5 yrs
Touwen Test Kaufmann Test
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9
10
11
12
13
14
15
20 weeks 30 weeks Delivery
DHA 5-MTHF Placebo DHA+5-MTHF
b
p<0.0001
b b
ab
a
a a
a
Plasma Phospholipid DHA (mg/dl)
Significant increase of DHA plasma phospholipids during the last weeks of pregnancy in the mothers & their offspringCampoy C, et al. JPGN, 2004 Decsi T, et al. Adv Exp Med Biol., 2005
Krauss-Estchmann S, et al. Am J Clin Nutr, 2007
EFFECTS OF PREGNANT WOMEN SUPPLEMENTATION WITH DHA and/or 5-MTHF DURING THE THIRD TRIMESTER OF PREGNANCY
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FOFO+5-MTHF5-MTHFPlacebo
P<0.001 P<0.001
P<0.001 General lineal model of repeated measures
Significant increase of DHA plasma phospholipids during the last weeks of pregnancy in the mothers & their offspringCampoy C, et al. JPGN, 2004
Decsi T, et al. Adv Exp Med Biol., 2005
Krauss-Estchmann S, et al. Am J Clin Nutr, 2007
Escolano M, et al. Clin Nutr, 2010
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DHA Plasma PLs (mg/dl)
PE
DH
A %
20 wks 30 wks Delivery
Correlation between DHA in plasma Phospholipids and the % of DHA in Phosphatidil Etanolamina during pregnancy
Escolano M, Campoy C, et al. Clin Nutr, 2010
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R=0.690
P<0.001
R=0.686
P<0.001
Escolano M, Campoy C, et al. Clin Nutr, 2010
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Evolution of folic acid concentrations through gestation and in the neonate, depending on the mother’s supplement received
p<0.005
p<0.05
nmol/L
<9 µµµµg
36.2% 53.5%
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• 4 years
HEMPEL Test
• 5.5 years
TOUWEN Test
• 6.5 years
KAUFMAN Test
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Hempel Neurologic Examination
5 clusters:5 clusters:
1. Fine motor function
2. Gross motor function
3. Posture and muscle tone
4. Reflexes
5. Visuomotor
Clinical conclusion:Clinical conclusion: Neurologically normal (no clusters of dysfunction) Simple MND (1 cluster of dysfunction)
Complex MND (≥ 2 clusters of dysfunction)
Definitely neurological abnormality
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Touwen neurological examination
Touwen, 1979
o Evaluation of spontaneous motor behavior into the neurological assessment
o Neurological examination of children with MND
o Evaluation of school age children from 4 years onwards
Hadders-Algra, 2002
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Suboptimal:
� 4 y
� 5 ½ y
NOS=56
NOS=64
NOS<56
NOS<64
Optimal:
� 4 y
� 5½ y
Optimal Suboptimal
P=0.015 P<0.001 P=0.002
5 ½ yT-Student
NUHEAL FOLLOW-UP
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Exp (B)(95% CI)
P% correct
classificationNaegelkerker R
Square
Cord DHA in plasma PLsMaternal age
1.094-2.262 0.014 89.8% 14.5%
Cord DHA in RBC PE 1.091-2.417 0.017 94.2% 19%
Cord DHA in RBC PC 1.003-2.643 0.049 91.7% 10.8%
Maternal DHA in RBC PE at delivery
Maternal age
1.235-2.603 0.002 92.4% 38.1%
Maternal DHA in RBC PC at delivery
Maternal age
1.445-4.664 0.001 92.8% 37.1%
Adjusted for: residence area, maternal age, pregnancy risk factors, delivery risk factors, perinatal morbidity, length of gestation, maternal status at work, parental education, study center
Logistic regression
NUHEAL FOLLOW-UP
Escolano MV, et al. J Nutr, 2010 – [accepted]
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P=0.03
P=0.01
P<0.001
NUHEAL
FOLLOW-UP
6.5 years
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Exp (B)(95% CI)*
P% correct
classificationNaegelkerker R
Square
Erythrocyte PE DHA at delivery
1.094-2.449 0.017 90 0.429
Erythrocyte PE AA/DHA at delivery
0.130-0.821 0.017 92.2 0.390
Confounders: parental cultural level, maternal status at work, length of gestation, perinatal morbidity, sex
22:6n-3
MPC > 50th Percentile
NUHEAL FOLLOW-UP
Campoy C, et al. Am J Clin Nutr, 2010 (accepted)
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NUHEAL FOLLOW-UP CONCLUSIONS
� Supplementation effectively increases DHA levels in maternal andumbilical plasma and erythrocyte PL.
� Plasma and erythrocyte fatty acids appear adequate to asses the fatty acid status. Type of study is a major consideration.
� Higher maternal and foetal DHA status during related to better performance on neuropsychomotor tests at 5 ½ and cognitive examination at 6 ½ years of age.
� LC-PUFA status prior to the 20th week of gestation might be relevant for children neurological development.
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SPECIAL THANKS TO:
University of MunichProf. Berthold Koletzko
Dr. Hans Demmelmair
Dr. Susanne Krauss-Eschtmann
Haile Gudrun
University of PécsProf. Támas Decsi
Dr. György Csábi
Dr. Eva Szábo
University of GranadaProf. Cristina Campoy
Dr. Francisco Cruz
Dr. Miguel Pérez
Dr. Rosa Ramos
Francisco J. Torres Espínola
Laboratorios Ordesa, S.L.
ALL OBSTETRICIAN TEAMS IN THE THREE COUNTRIES
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THANK YOU VERY MUCH FOR YOUR ATTENTION!