Effects of a lipid-based nutrient supplement during pregnancy and lactation on maternal plasma fatty acid status and lipid profile: Results of two randomized controlled trials☆

Con en s lis s a ailable a ScienceDi ec P os aglandins, Leuko ienes and Essen ial Fa y Acids jou nal homepage: www.else ie .com/loca e/ple a Effec s o a lipid-based nu ien supplemen du ing p egnancy and lac a ion on ma e nal plasma a y acid s a us and lipid p ofile: Resul s o wo andomized con olled ials ☆ B ie a M. Oaks a,⁎ , Rebecca R. Young a , Se h Adu-A a wuah b , Ulla Asho n c , K is ina H. Jackson d , Anna La ey b , Kenne h Male a e , Ha ie Ok onipa a , John Sadalaki e , Lacey M. Baldi iez , Se i Shahab-Fe dows , Pe Asho n c,g , Ka h yn G. Dewey a a P og am in In e na ional and Communi y Nu i ion, Depa men o Nu i ion, Uni e si y o Cali o nia, 3135 Meye Hall, One Shields A enue, Da is, CA 95616, USA b Depa men o Nu i ion and Food Science, Uni e si y o Ghana, Legon, Ghana c Cen e o Child Heal h Resea ch, Uni e si y o Tampe e School o Medicine and Tampe e Uni e si y Hospi al, Tampe e, Finland d OmegaQuan Analy ics, LLC, Sioux Falls, SD, USA e Uni e si y o Malawi College o Medicine, Depa men o Communi y Heal h, Blan y e, Malawi USDA, ARS Wes e n Human Nu i ion Resea ch Cen e , Da is, CA, USA g Depa men o Paedia ics, Tampe e Uni e si y Hospi al, Tampe e, Finland ARTICLE INFO Keywo ds: P egnancy Lac a ion Omega-3 a y acids Supplemen a ion Lipids Choles e ol ABSTRACT I is unknown whe he a no el small-quan i y lipid-based nu ien supplemen (SQ-LNS) con aining alpha- linolenic (ALA) and linoleic acids impac s ma e nal plasma lipids and a y acid s a us. We measu ed plasma a y acids (w %) and lipid concen a ions a 36 wk ges a ion and b eas milk a y acids (w %) a 6 mon hs pos pa um in a subsample o women en olled in a andomized con olled ial s udying he effec s o SQ-LNS on bi h ou comes and child g ow h. Women≤20 wk ges a ion in Ghana (n=1,320) and Malawi (n=1,391) we e assigned o ecei e daily ei he : 1) i on- olic acid (p egnancy); 2) mul iple mic onu ien s (p egnancy and lac a ion); o 3) SQ-LNS (p egnancy and lac a ion). A 36 wk, plasma ALA le els we e highe in hose ecei ing SQ-LNS. SQ-LNS inc eased b eas milk ALA in Ghana bu no Malawi. The e was no effec on plasma lipids o o he selec ed a y acids. SQ-LNS may impac plasma and b eas milk ALA le els depending on he popula ion. 1. In oduc ion Adequa e amoun s o he essen ial polyunsa u a ed a y acids (PUFAs) alpha-linolenic acid (ALA, omega-3) and linoleic acid (LA, omega-6) a e equi ed du ing p egnancy and lac a ion o op imal e al and in an g ow h [1]. Fa y acids a e ans e ed o he e us du ing p egnancy h ough he placen a and con inue o be p o ided du ing in ancy h ough he mo he 's milk. Thus, a y acid consump ion and body s o es o he mo he ha e a di ec effec on e al and in an a y acid s a us [1]. Fa y acid supplemen a ion ials in p egnan popula- ions ha e p ima ily ocused on he long-chain a y acid de i a i es o ALA –docosahexaenoic acid (DHA) and eicosapen aenoic acid (EPA) [2] –due o he accumula ion o DHA in he b ain and e ina and he low con e sion a e o ALA o DHA (app oxima ely 9% o ALA con e s o DHA in women) [3]. Howe e , se e al s udies in non-p egnan popula ions sugges ha bioma ke s o ALA s a us a e associa ed wi h heal h benefi s independen o DHA [4,5]. Only one ial o da e, conduc ed in he Ne he lands, has examined he effec o ma e nal ALA supplemen a ion on a y acid s a us du ing p egnancy [6]. ALA supplemen a ion led o highe concen a ions o ALA, eicosapen aenoic acid (EPA), and docosapen aenoic acid (DPA) (w %) in ma e nal plasma a deli e y bu had no effec on DHA o AA. h p://dx.doi.o g/10.1016/j.ple a.2017.01.007 Recei ed 23 Sep embe 2016; Recei ed in e ised o m 10 Janua y 2017; Accep ed 24 Janua y 2017 ☆ This publica ion is based on esea ch unded by a g an o he Uni e si y o Cali o nia, Da is om he Bill & Melinda Ga es Founda ion No. OPP49817 and ano he g an o he Uni e si y o Cali o nia, Da is om he Office o Heal h, In ec ious Diseases, and Nu i ion, Bu eau o Global Heal h, U.S. Agency o In e na ional De elopmen (USAID) unde e ms o Coope a i e Ag eemen No. AID-OAA-A-12-00005 h ough he Food and Nu i ion Technical Assis ance III P ojec (FANTA), managed by FHI 360. The findings and conclusions con ained wi hin he a icle a e hose o he au ho s and do no necessa ily eflec posi ions o policies o USAID o he Bill & Melinda Ga es Founda ion. ⁎ Co esponding au ho . E-mail add ess: [email p o ec ed] (B.M. Oaks). Abb e ia ions: ALA, α-linolenic acid; DHA, docosahexaenoic acid; DPA, docosapen aenoic acid; EPA, eicosapen aenoic acid; GC, gas ch oma og aphy; GLA, γ-linolenic acid; LA, linoleic acid; n-6, omega-6; n-3, omega-3; PUFA, polyunsa u a ed a y acids P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 0952-3278/ © 2017 The Au ho s. Published by Else ie L d. This is an open access a icle unde he CC BY license (h p://c ea i ecommons.o g/licenses/BY/4.0/). MARK A summa y o ALA supplemen a ion s udies (all non-p egnan pa i- cipan s, al hough some s udies included b eas eeding women) also indica ed ha ALA supplemen a ion gene ally esul ed in inc eases in plasma and b eas milk ALA bu had li le effec on DHA [7]. Howe e , he majo i y o hese s udies ha e been conduc ed in Eu ope and No h Ame ica, and i is possible ha popula ions wi h poo e nu i ional s a us migh espond diffe en ly o ALA supplemen a ion, as a ious ac o s can affec he con e sion o ALA o DHA (e.g., die s in Eu ope and No h Ame ica a e high in LA, which inhibi s con e sion o ALA o DHA) [8]. In many popula ions, o al ene gy in ake among p egnan and lac a ing women may be adequa e, bu he ALA and AA con en o he usual die may be low [9]. While es ima es specific o ALA and AA a e no a ailable, i is es ima ed ha he a ailabili y o omega-3 a y acids in he ood supply o Ghana ( < 0.4% o ene gy supply) and Malawi ( < 0.3% o ene gy supply) is below he minimum ecom- mended le el (0.5% o ene gy supply) o mee he needs o p egnan and lac a ing women in he popula ions [9]. Addi ionally, low ma e nal plasma choles e ol du ing p egnancy has been associa ed wi h ad e se bi h ou comes, such as p e e m bi h [10,11]. Choles e ol is equi ed o he s uc u al in eg i y o cell memb anes and as a p ecu so o s e oid ho mones [12,13], and is he e o e essen ial du ing p egnancy o e al cell o ma ion and placen al s e oid ho mone p oduc ion [14]. A he same ime, high choles e ol and iglyce ides a e also associa ed wi h ad e se bi h ou comes [15,16]. In Ghana, bo h low and high choles e ol may be a conce n. A ial conduc ed in Ghana in non-p egnan heal hy adul s showed ha peanu consump ion o e he cou se o 30 wk educed o al plasma choles e ol and iglyce ide concen a ions [17]. Small-quan i y lipid-based nu ien supplemen s (SQ-LNS) a e a no el o m o nu i ional supplemen a ion ha deli e mic onu ien s in a ood-base along wi h p o ein, a , and essen ial a y acids (EFA). SQ-LNS a e cu en ly being s udied as a home o ifican in lowe - and middle-income coun ies o p e en malnu i ion, pa icula ly in women and child en. We epo ed p e iously ha compa ed wi h i on- olic acid (IFA) and mul iple mic onu ien (MMN) capsules, p o iding a peanu -based SQ-LNS o p egnan and lac a ing women in Ghana p omo ed e al g ow h in ulne able women, such as p imipa as, and had a posi i e effec on child g ow h [18,19], bu had no significan effec on newbo n bi h size o child g ow h in Malawi [20,21]. While se e al o he s udies ha e also examined he impac o SQ-LNS on bi h size o child g ow h [22–24], no s udy has ye examined whe he SQ-LNS ha e an effec on bioma ke s o ma e nal a y acid s a us, e en hough a key aspec ha dis inguishes SQ-LNS om o he nu i ional supplemen s p oposed o lowe - and middle-income coun ies is ha i con ains EFA. The objec i e o he p esen s udy was o de e mine he effec s o SQ-LNS p o ided o women du ing p egnancy and lac a ion on ma e nal plasma a y acids and lipids and b eas milk a y acids. To add ess his objec i e, we compa ed plasma a y acids and lipid concen a ions a 36 wk ges a ion and b eas milk a y acids a 6 mo pos pa um o women ecei ing SQ-LNS du ing p egnancy and lac a- ion wi h hose o women ecei ing ei he IFA (du ing p egnancy only) o MMN (du ing p egnancy and lac a ion). Ou p ima y hypo heses we e ha compa ed o women who ecei ed IFA o MMN, women who ecei ed SQ-LNS du ing p egnancy and lac a ion would ha e: 1) lowe mean plasma o al choles e ol and iglyce ide concen a ions and a lowe p e alence o low o al choles e ol ( < 10 h pe cen ile o IFA g oup) a 36 wk ges a ion; and 2) highe le els o ALA and LA in plasma a 36 wk ges a ion and in b eas milk a 6 mo pos pa um. 2. Pa icipan s and me hods 2.1. Pa icipan s and s udy design This was a sub-s udy o pa icipan s om wo andomized con- olled ials conduc ed in Malawi and Ghana as pa o he In e na ional Lipid-Based Nu ien Supplemen s (iLiNS) P ojec (www.ilins.o g). The p ima y objec i e o hese ials was o de e mine he effec o SQ-LNS, p o ided du ing p egnancy, lac a ion, and ea ly childhood, on child g ow h a 18 mon hs o age, as compa ed wi h IFA p o ided du ing p egnancy o MMN p o ided o he mo he du ing p egnancy and he fi s six mon hs pos pa um. De ails o he s udy me hods ha e been epo ed elsewhe e [18,20,21]. B iefly, he s udy eams in Ghana and Malawi ec ui ed women a ending p ena al ca e isi s a ou heal h acili ies in semi-u ban a eas o he Yilo K obo and Lowe Manya K obo dis ic s abou 70 km no h o Acc a, Ghana be ween Decembe 2009 and Decembe 2011, and ou heal h acili ies in he u al Mangochi dis ic in sou he n Malawi be ween Feb ua y 2011 and Augus 2012. While he ials we e simila in design, each ial ope a ed independen ly and he e we e some diffe ences in inclusion/exclusion c i e ia. In Ghana, women we e eligible i hey we e: ≤20 wk ges a ion (confi med by ul asound), ≥18 y o age, had a comple ed an ena al heal h ca d, and signed o humb-p in ed in o med consen . We excluded women i hey we e: HIV posi i e, had as hma, epilepsy, ube culosis, a ch onic disease ha equi ed medical a en ion, did no eside in he defined ca chmen a ea, had a milk o peanu alle gy, o we e pa icipa ing in ano he clinical ial. The Malawi ial had simila exclusion and inclusion c i e ia, howe e women in Malawi we e eligible i hey we e ≥15 y o age and we e no excluded i hey we e HIV posi i e. A daily i on and olic acid capsule is he s anda d o ca e du ing p egnancy in bo h coun ies. In Malawi, nu i ional supplemen a ion be o e o a e p egnancy is no common. In Ghana, women con inue o ecei e he i on and olic acid capsule 6 wk a e deli e y and ecei e high dose i amin A wi hin 8 wk a e deli e y, and he use o die a y and he bal supplemen s in he s udy se ing is common. Women we e en olled in he ials a a mean o 16–17 wk ges a ion and ecei ed supplemen a ion h ough p egnancy and un il 6 mon hs pos pa um, which ep esen s an a e age o 56 wk o supplemen a ion. In bo h ials, p egnan women we e andomized o ecei e one o he ollowing h ee daily ea men s: 1) i on and olic acid (IFA, a capsule consis ing o 60 mg i on and 400 µg olic acid, ecei ed du ing p egnancy only); 2) mul iple mic onu ien s (MMN, a capsule consis - ing o 18 i amins and mine als [including 20 mg i on], ecei ed du ing p egnancy and he fi s 6 mon hs pos pa um); o 3) SQ-LNS (a 20 g sache which included he same 18 mic onu ien s as he MMN capsule plus ou addi ional mine als: calcium, phospho us, po assium, magnesium) (see Table 1 o nu ien con en o each supplemen ). Bo h he IFA and MMN g oups we e conside ed con ol g oups. G oup alloca ions we e de e mined by a s a is ician who used a compu e - gene a ed andomiza ion scheme in blocks o 9 (3 codes o each o he 3 in e en ions) and codes we e placed in sealed opaque en elopes. A woman chose an en elope om a s ack o en elopes (6 and 9 en elopes pe s ack in Malawi and Ghana, espec i ely) o de e mine he g oup alloca ion and ecei ed he fi s 2-wk supplemen a ion a his ime. Field wo ke s made home isi s biweekly, du ing which hey deli e ed he supplemen s and collec ed in o ma ion on he pa icipan 's ad- he ence o he s udy in e en ion. Adhe ence was assessed by ma e nal epo as well as by coun ing he numbe s o unconsumed capsules o sache s. This was a pa ially-blinded ial, as i was no possible o blind he fieldwo ke s and s udy pa icipan s o hose consuming capsules s. SQ-LNS (because o he s a kly diffe en cha ac e is ics). In Ghana, om he 1,320 women en olled in he ial, 510 we e excluded om he p esen analysis due o an e o in he labeling o he IFA and MMN supplemen s, esul ing in mixed exposu e [18]. F om he emaining 810 women, en olled om Oc obe 2010 o Decembe 2011, 369 women we e andomly selec ed o analysis o blood lipids and a y acids (Supplemen a y Fig. 1). In Malawi, om he 1,391 women en olled in he ial, 315 women we e andomly selec ed o analysis o a y acids and all 1,391 o blood lipids (Supplemen a y Fig. 2). The ins i u ional e iew boa ds a he College o Medicine Resea ch, B.M. Oaks e al. P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 29 Uni e si y o Malawi and he E hics Commi ee o Pi kanmaa Hospi al Dis ic , Finland app o ed he s udy p o ocol o he ial in Malawi. The ins i u ional e iew boa ds a he Uni e si y o Cali o nia, Da is; he Noguchi Memo ial Ins i u e o Medical Resea ch, Uni e si y o Ghana; and he Ghana Heal h Se ice app o ed he s udy p o ocol o he ial in Ghana. Bo h ials we e egis e ed a www.clinical ials.go (IDs: NCT01239693,NCT00970866). 2.2. B eas milk and blood sample collec ion A bo h si es, s udy nu ses collec ed enous blood samples om women a en ollmen and 36 wk ges a ion in o a hepa in- ea ed, ace elemen - ee, Sa s ed Mono e e ube. Because o he difficul y o ob aining as ing blood samples om p egnan women, non- as ing blood samples we e collec ed. Howe e , we collec ed in o ma ion ega ding ime be ween las meal and sample collec ion. Lab echni- cians cen i uged he blood samples a 4000 pm o 15 min o ob ain plasma. B eas milk was collec ed a 6 mon hs pos pa um. In Ghana, s udy nu ses assis ed women in collec ing a 10–20 mL mid-s eam b eas milk sample du ing a ollow-up clinic isi . In Malawi, women exp essed a ull milk sample om a single b eas du ing a home isi . A ained field wo ke hen mixed he b eas milk and collec ed a 10 mL sample, wi h he emaining milk p o ided o he in an by spoon. All samples we e s o ed a −20 °C wi hin 24 h o collec ion and mo ed o −80 °C o longe e m s o age. 2.3. Choles e ol and iglyce ide analysis Plasma samples om he Ghana ial we e analyzed in Acc a, Ghana o o al choles e ol, HDL-C, and iglyce ide concen a ions using a Flexo Junio Chemis y Analyze (Vi al Scien ific, Die en, Ne he lands). LDL-C was calcula ed using he F iedewald equa ion: LDL-C= o al choles e ol–(HDL-C)–( iglyce ides/5), mg/dL [25]. This is accep ed as an accu a e me hod o de e mining LDL-C concen a- ion, as long as iglyce ide concen a ion is no ≥400 mg/dL [25,26]; all o ou samples we e below his le el. Plasma samples om he Malawi ial we e shipped on d y ice o Da is, CA, whe e lab echnicians quan ified o al choles e ol and iglyce ide concen a ions by enzyma ic colo ime ic assay using a Cobas In eg a 400 plus au oma ic analyze (Roche Diagnos ic Co p., Indianapolis, IN). All lab echnicians we e blinded o he in e en ion g oups. 2.4. Fa y acids analysis Plasma and b eas milk samples om bo h ials we e shipped o OmegaQuan Analy ics (Sioux Falls, SD) o analysis o a y acids. Fa y acid composi ion was analyzed by gas ch oma og aphy wi h flame ioniza ion de ec ion. Plasma o b eas milk was added o a mix u e o sol en s (me hanol con aining 14% bo on ifluo ide: oluene: me ha- nol; 35:30:35 / / , all om Sigma-Ald ich, S . Louis, MO). The ube was o exed and hea ed in a ho ba h a 100 °C o 45 min. A e cooling, hexane (EMD Chemicals, USA) and dis illed wa e we e added. The sample was o exed and cen i uged, and hen an aliquo o he hexane phase was analyzed by gas ch oma og aphy using a GC-2010 (Shimadzu Co po a ion, Columbia, MD) equipped wi h a SP-2560, 100-m used silica capilla y column (0.25 mm in e nal diame e , 0.2 µm film hickness; Supelco, Belle on e, PA). Fa y acid composi ion was exp essed as a pe cen by weigh (w %) o o al iden ified a y acids. All lab echnicians we e blinded o he in e en ion g oups. 2.5. Ma e nal cha ac e is ics A en ollmen , an h opome is s measu ed weigh and heigh using high-quali y scales and s adiome e s. We calcula ed body mass index (BMI = kg/m 2 ). Lab echnicians assessed mala ia and HIV in ec ion s a us wi h apid es s. Concen a ions o inflamma o y bioma ke s C- eac i e p o ein (CRP, mg/L) and alpha-1 glycop o ein (AGP, g/L) we e measu ed in plasma by immuno u bidime ic assay using he au oanalyze s specified ea lie . T ained in e iewe s collec ed socio- economic and demog aphic in o ma ion a a ollow-up home isi . 2.6. Sample size and s a is ical analysis Fo analysis o a y acids and lipid concen a ions, we used a minimum effec size (Cohen's d) o 0.5 o calcula e sample size, assuming a wo-sided α=0.05% and 80% powe , equi ing a subsample o 79 pe g oup ( o al n=237). Allowing o a i ion and women missing a sample a ei he baseline o 36 wk ges a ion, 369 women we e andomly selec ed om he 810 women in Ghana en olled a e Oc obe 1, 2010. In Malawi, 315 women we e andomly selec ed om women wi h blood samples a bo h baseline and 36 wk ges a ion and a b eas milk sample a 6 mon hs pos pa um. The effec o he in e en ion on choles e ol and iglyce ide concen a ions was exam- ined in he ull sample in Malawi and in he subsample in Ghana. S a is ical analysis was pe o med acco ding o in en ion- o- ea and ocused on examining diffe ences be ween he h ee in e en ion g oups in plasma a y acid le els and lipid concen a ions a 36 wk ges a ion and b eas milk a y acid le els a 6 mon hs pos pa um. The p ima y a y acids o in e es we e ALA and LA. Seconda ily, o de e mine i he e was any impac on LCPUFAs, we also examined he effec o supplemen a ion on DHA, EPA, AA, he sum o DHA and EPA, he sum o all long chain omega-3 a y acids (DHA, EPA, and DPA), and he ollowing a ios: LA:AA, ALA:DHA, AA:EPA, and omega-6 a y acids:omega-3 a y acids. We limi ed ou analyses o hese a y acids and a ios as indica o s o LCPUFA me abolism and due o hei po en ial effec s on in an g ow h and neu ode elopmen [1,3]. Choles e ol and iglyce ides we e analyzed as concen a ions, and a y acids we e analyzed as pe cen age o o al a y acids (by weigh ). Loga i hmic ans o ma ion o all a y acid a iables and iglyce ide concen a ion was applied o app oxima e a no mal dis ibu ion o he da a which was e alua ed using he Shapi o-Wilk es . Fa y acids we e Table 1 Nu ien composi ion o supplemen s used in he s udy: i on and olic acid (IFA) capsule, mul iple mic onu ien (MMN) capsule, and small-quan i y lipid-based nu ien supplemen (SQ-LNS). Nu ien IFA MMN SQ-LNS (20 g) Ene gy (kcal) 0 0 118 P o ein (g) 0 0 2.6 Fa (g) 0 0 10 Linoleic acid (g) 0 0 4.59 α-linolenic acid (g) 0 0 0.59 I on (mg, e ous sulpha e) 60 20 20 Folic acid (µg, p e oyl monoglu amic acid) 400 400 400 Vi amin A (µg RE, e inyl ace a e) 0 800 800 Vi amin B12 (µg, cyanocobalamin 0.1%) 0 5.2 5.2 Vi amin B6 (mg, py idoxine hyd ochlo ide) 0 3.8 3.8 Vi amin C (mg, L-asco bic acid) 0 100 100 Vi amin D (IU, cholecalci e ol [D3]) 0 400 400 Zinc (mg, zinc sulpha e) 0 30 30 Thiamin (mg, hiamin hyd ochlo ide) 0 2.8 2.8 Ribofla in (mg, ibofla in) 0 2.8 2.8 Niacin (mg, niacinamide) 0 36 36 Vi amin E (mg, DL-α- ocophe ol ace a e) 0 20 20 Vi amin K (µg, phylloquinone 5%) 0 45 45 Pan o henic acid (mg, calcium pan o hena e) 0 7 7 Coppe (mg, encapsula ed coppe sulpha e) 0 4 4 Iodine (µg, po assium ioda e) 0 250 250 Manganese (mg, manganese sulpha e) 0 2.6 2.6 Selenium (µg, sodium seleni e 1.5%) 0 130 130 Calcium (mg, icalcium phospha e) 0 0 280 Phospho us (mg, icalcium phospha e) 0 0 190 Po assium (mg, po assium chlo ide) 0 0 200 Magnesium (mg, magnesium ci a e) 0 0 65 Phy a e (mg) 0 0 24.7 B.M. Oaks e al. P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 30 dicho omized in o high o low alues using a median cu -poin and low choles e ol was defined as < 10 h pe cen ile o he IFA g oup a 36 wk ges a ion. We also used he ollowing clinical defini ions: high o al choles e ol (≥240 mg/dL), high LDL-C (≥160 mg/dL), and low HDL-C ( < 50 mg/dL) [27,28]. We used he Household Food Insecu i y Access Scale [29] o es ima e ood insecu i y and c ea ed sco es using s anda d c i e ia adjus ed o he mon h o collec ion. An asse index was c ea ed using p incipal componen s analysis [30] based on household owne ship o a se o asse s ( adio, ele ision, cell phone, bed, ma ess, bed ne , and bicycle), ligh ing sou ce, d inking wa e supply, sani a ion acili ies, and floo ing ma e ials. We e alua ed he effec o he nu i ional in e en ion on lipids and a y acids in plasma using ANCOVA (con inuous ou comes) and logis ic eg ession (bina y ou comes) models, using he Tukey- K ame adjus men o mul iple compa isons and p < 0.05 indica ing s a is ical significance. We pe o med analyses bo h wi h and wi hou co a ia es, as guidelines o bes s a is ical p ac ices suppo he use o co a ia es in analyses o andomized con olled ials [31]. All models included he baseline alue o he ou come a iable. This is ma he- ma ically he same as es ing o a diffe ence in he change in he ou come (be ween baseline and 36 wk) be ween he h ee g oups. We used simila s a is ical analyses o a y acids in b eas milk, al hough hose models could no include a baseline alue, and we only had one ime poin o b eas milk sample collec ion. Pooled analyses included ial si e in all models. We conside ed co a ia es o inclusion in he model i hey we e associa ed wi h he ou come a iable a p < 0.1. Po en ial co a ia es we e selec ed om p e ious li e a u e and s a ed in a p edefined analysis plan; hey included baseline measu emen o he ou come a iable, ges a ional age, ma e nal age, educa ion le el, BMI and heigh , season o en ollmen , mala ia in ec ion, HIV s a us (Malawi only), inflamma o y ma ke s, household ood insecu i y, asse index, pa i y, si e o en ollmen , and ime since las meal. To de e mine whe he a pooled da a analysis could be conduc ed, we es ed o in e ac ion be ween s udy si e and in e en ion g oup. We also es ed o in e ac ion be ween he in e en ion g oup and ma e nal age, pa i y, and baseline BMI. All in e ac ions we e e alua ed in linea eg ession models and in e ac ion e m p- alues < 0.1 we e conside ed o be s a is ically significan . We compa ed baseline cha ac e is ics be ween women in each o he h ee in e en ion g oups, as well as be ween hose wi h comple e da a and hose wi h missing da a a 36 wk ges a ion, as his ime poin has he la ges p opo ion o missing da a. In sensi i i y analyses, we pe o med unadjus ed analyses using he same sample ha was used in adjus ed analyses, and conside ed a > 10% change in esul s o be indica i e o bias. We also pe o med ano he sensi i i y analysis o compa e hose ecei ing LNS wi h hose no ecei ing LNS (IFA g oup and MMN g oup combined) o all ou comes. Model assump ions we e checked using s anda d eg ession diagnos ics o linea i y, no mali y, le e age, and influence. All ana- lyses we e pe o med using SAS 9.4 (SAS Ins i u e, Ca y, NC). 3. Resul s A en ollmen , plasma a y acid da a we e a ailable o 628 women (313 in Ghana, 315 in Malawi) and plasma lipid da a o 1,718 women (347 in Ghana, 1,371 in Malawi). A 36 wk ges a ion, plasma a y acid and lipid da a om ollow-up isi s we e a ailable o 536 (221 in Ghana, 315 in Malawi) and 1,365 (298 in Ghana, 1,067 in Malawi) women, espec i ely. A 6 mon hs pos pa um, b eas milk a y acid da a we e a ailable o 618 women (303 in Ghana, 315 in Malawi). Loss- o- ollow-up did no diffe by in e en ion g oup in ei he ial. We compa ed women wi h missing da a a 36 wk ges a ion wi h hose who had comple e da a (Supplemen a y Table 1). Women wi h comple e blood lipid da a in Malawi diffe ed in some baseline cha ac e is ics and had lowe mean baseline choles e ol (121 s. 125 mg/dL, p=0.04) and iglyce ide (95 s. 101 mg/dL, p=0.02) concen a ions han hose wi h comple e da a. Women in Ghana wi h comple e plasma a y acid da a had highe mean concen a ion o DHA a baseline (5.1 s. 4.9%, p=0.04), bu we e o he wise simila . Baseline ma e nal cha ac e is ics did no diffe by in e en ion g oup in ei he si e (Table 2). Baseline alues o blood lipids and a y acids we e gene ally simila among in e en ion g oups wi hin each ial, al hough AA and iglyce ide le els we e highe in he IFA g oup in Malawi (Table 3). The e was no significan in e ac ion be ween s udy si e and in e en ion g oup, which allowed o pooled analyses. Howe e , gi en he diffe ences in baseline a y acid and blood lipid le els be ween he wo ials, analyses we e also conduc ed o each ial sepa a ely. A compa ison o he a y acid p ofiles o women in he wo coun ies is p esen ed in Fig. 1 and Fig. 2. A 36 wk ges a ion in he Malawi ial, a g oup diffe ence in mean plasma ALA was e iden in he adjus ed model (p=0.04), wi h women ecei ing SQ-LNS demons a ing highe alues compa ed wi h women ecei ing MMN (SQ-LNS: 0.49, MMN: 0.44 w %, Tukey-adjus ed p=0.04). In he Ghana ial, a significan g oup diffe ence was seen in he ALA:DHA a io in plasma a 36 wk ges a ion (p=0.03) and b eas milk a 6 mon hs pos pa um (p=0.03) ( a y acid a io esul s in Supplemen a y Table 2), wi h significan diffe ences o he ALA:DHA a io be ween SQ-LNS and IFA in plasma ( a io: 0.07 s. 0.06, p=0.03) and be ween SQ-LNS and MMN in b eas milk ( a io: 0.48 s. 0.39, p=0.02). The e was a significan diffe ence in mean plasma ALA in pooled analyses (p=0.04) (Table 3), which emained significan in analyses adjus ed o selec ed co a ia es (p=0.02). The SQ-LNS g oup had highe ALA le els compa ed wi h ei he he g oup ecei ing MMN (SQ-LNS: 0.38, MMN: 0.35% w , Tukey-adjus ed p=0.06) o IFA (SQ- Table 2 Baseline cha ac e is ics o he pa icipa ing women a en ollmen by s udy g oup. a Ghana Malawi Cha ac e is ic IFA (n=124) MMN (n=121) SQ-LNS (n=124) P c IFA (n=457) MMN (n=463) SQ-LNS (n=453) P c Ma e nal age, yea s 26.3 (5.0) 26.3 (5.5) 27.0 (5.4) 0.53 25.0 (6.1) 24.8 (6.1) 25.1 (6.2) 0.79 Educa ion, comple ed yea s 7.4 (3.3) 7.2 (3.3) 7.9 (3.7) 0.19 3.9 (3.4) 4.1 (3.4) 4.1 (3.6) 0.57 P imipa ous women 38.9% 34.9% 31.6% 0.46 20.4% 23.2% 22.4% 0.58 Ges a ional age a en ollmen , weeks 16.3 (3.3) 16.2 (3.0) 16.2 (3.1) 0.97 16.8 (2.1) 16.8 (2.1) 16.9 (2.2) 0.91 Body mass index (BMI), kg/m 2 24.7 (4.2) 24.7 (4.1) 24.8 (3.8) 0.98 22.1 (2.6) 22.2 (2.9) 22.2 (3.0) 0.58 Women wi h anemia (Hb < 100 g/l) 11.5% 16.7% 13.5% 0.47 21.2% 20.0% 21.4% 0.84 Women o e weigh o obese BMI (≥25 kg/m 2 ) 42.3% 40.3% 39.2% 0.88 13.2% 12.4% 13.3% 0.91 Women wi h a low BMI ( < 18.5 kg/m 2 ) 2.9% 1.6% 0.8% 0.46 6.0% 4.6% 5.8% 0.60 Women wi h a posi i e HIV es b –– – –15.5% 11.2% 14.2% 0.15 Women wi h a posi i e mala ia es (RDT) 6.5% 4.8% 9.0% 0.42 22.3% 24.2% 23.3% 0.79 a Mean (SD) excep whe e no ed. b HIV posi i e women we e excluded om he ial in Ghana. c p- alue ob ained om ANOVA (compa ison o means) o Fishe 's exac es (compa ison o p opo ions). B.M. Oaks e al. P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 31 Table 3 Median plasma ALA, LA, DHA, AA, and n6:n3 a io and mean ma e nal plasma lipids by in e en ion g oup. Ghana Malawi Pooled IFA MMN SQ-LNS p g IFA MMN SQ-LNS p g p g Fa y Acids (n=110) c (n=98) c (n=105) c (n=103) (n=106) (n=106) ALA, w % En ollmen 0.28 0.26 0.25 0.07 0.46 0.50 0.42 0.22 0.21 (0.23, 0.34) d (0.23, 0.31) (0.22, 0.32) (0.35, 0.61) (0.38, 0.64) (0.37, 0.54) 36 wk a 0.26 0.26 0.27 0.10 0.47 0.45 0.48 0.18 0.04 h (0.22, 0.30) (0.21, 0.32) (0.23, 0.32) (0.35, 0.59) (0.35, 0.55) (0.37, 0.59) LA, w % En ollmen 23.9 23.5 23.1 0.27 25.4 25.6 25.6 0.42 0.18 (21.6, 25.0) (21.6, 25.0) (21.3, 24.6) (22.9, 27.1) (23.3, 28.1) (22.6, 27.7) 36 wk a 22.0 22.1 22.6 0.13 25.2 25.8 25.6 0.28 0.14 (20.1, 23.7) (20.2, 24.1) (20.5, 24.6) (23.3, 27.5) (23.7, 28.5) (23.1, 28.5) DHA, w % En ollmen 5.08 4.99 5.06 0.29 4.62 4.28 4.38 0.62 0.34 (4.39, 5.65) (4.41, 5.63) (4.61, 5.81) (3.65, 5.17) (3.53, 5.01) (3.75, 5.00) 36 wk a 4.01 3.72 3.87 0.56 3.59 3.61 3.57 0.95 0.80 (3.33, 4.64) (3.27, 4.39) (3.41, 4.54) (3.01, 4.13) (2.89, 4.24) (3.07, 4.14) AA, w % En ollmen 6.09 6.24 5.90 0.24 8.30 7.74 7.89 0.04 0.52 (5.38, 6.87) (5.69, 7.23) (5.34, 6.60) (7.17, 9.36) (7.03, 8.53) (7.11, 8.88) 36 wk a 4.94 5.09 5.12 0.37 6.68 6.60 6.41 0.12 0.68 (4.45, 5.48) (4.29, 5.69) (4.51, 5.56) (5.91, 7.54) (5.87, 7.21) (5.66, 7.04) n6:n3 En ollmen 4.5 4.5 4.3 0.19 5.9 6.3 6.2 0.56 0.20 (3.9, 5.3) (3.8, 5.4) (3.8, 4.9) (5.0, 7.5) (5.0, 7.5) (5.1, 7.2) 36 wk a 5.4 5.6 5.5 0.35 7.3 7.2 7.3 0.79 0.59 (4.4, 6.4) (4.7, 7.2) (4.6, 6.5) (6.1, 8.8) (6.0, 9.1) (6.0, 8.6) Plasma Lipids (n=115) e (n=117) e (n=115) e (n=457) e (n=463) e (n=453) e Choles e ol, mg/dL En ollmen 144.0 ± 33.3 142.6 ± 32.2 145.2 ± 37.7 0.85 122.1 ± 32.4 121.3 ± 30.3 120.9 ± 30.7 0.84 0.89 36 wk 165.5 ± 41.0 163.5 ± 40.2 166.6 ± 43.5 0.86 149.6 ± 36.1 151.0 ± 39.0 150.9 ± 37.2 0.86 0.87 HDL-C, mg/dL b En ollmen 56.3 ± 21.5 54.5 ± 21.3 59.0 ± 24.2 0.31 ––– –– 36 wk 66.6 ± 29.7 66.0 ± 29.3 67.7 ± 31.6 0.92 ––– –– LDL-C, mg/dL b En ollmen 63.5 ± 28.7 64.3 ± 25.5 63.7 ± 29.0 0.98 ––– –– 36 wk 68.8 ± 32.9 68.8 ± 31.8 68.8 ± 34.9 1.00 ––– –– T iglyce ides, mg/dL En ollmen 125.9 ± 57.3 114.2 ± 55.7 115.4 ± 59.1 0.23 99.8 ± 43.1 94.1 ± 34.6 94.5 ± 35.8 0.04 0.01 36 wk 146.8 ± 76.1 144.2 ± 70.4 149.9 ± 74.9 0.86 150.8 ± 62.6 147.4 ± 61.4 150.0 ± 63.6 0.75 0.68 a Model includes baseline alue o ou come a iable o epo ed p- alue. b HDL-C and LDL-C we e no measu ed in Malawi. c Fo plasma a y acids a 36 wk ges a ion in Ghana, IFA: n=69, MMN: n=77, SQ-LNS: n=75 d Median (25 h pe cen ile, 75 h pe cen ile), all such alues. e Fo plasma lipids a 36 wk ges a ion in Ghana, IFA: n=95, MMN: n=104, SQ-LNS: n=99, and in Malawi, IFA: n=352, MMN: n=362, SQ-LNS: n=352. Mean ± SD, all such alues. g P- alues ob ained by ANOVA (baseline analyses) and ANCOVA (36 wk ges a ion analyses). h Two pai wise compa isons had a p- alue < 0.10: 1) SQ-LNS s. MMN, Tukey-adjus ed p=0.06; and 2) SQ-LNS s. IFA, Tukey-adjus ed p=0.08. Fig. 1. Fa y acid p ofile o ma e nal plasma a en ollmen and 36 wk ges a ion and b eas milk a 6 mo pos pa um. B.M. Oaks e al. P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 32 LNS: 0.38, IFA: 0.36% w , Tukey-adjus ed p=0.08). No o he diffe - ences in a y acid le els o a ios o blood lipid concen a ions be ween g oups we e significan . The e was no diffe ence in he p opo ion o women wi h low plasma choles e ol ( < 10 h pe cen ile o IFA g oup) ac oss he in e en ion g oups in ei he unadjus ed o adjus ed analyses. A 6 mon hs pos pa um, women ecei ing SQ-LNS in he Ghana ial had highe ALA le els in b eas milk (p=0.02) and a highe a io o ALA:AA (SQ-LNS: 1.07, MMN: 0.95: Tukey-adjus ed p=0.02) in b eas milk compa ed wi h women ecei ing MMN. See Table 4 o selec ed esul s. These diffe ences became non-significan in adjus ed analyses (da a no shown). In he Malawi ial and pooled analyses, b eas milk a y acid le els and a y acid a ios we e no significan ly diffe en ac oss in e en ion g oups in ei he unadjus ed o adjus ed analyses. 4. Discussion and conclusion 4.1. Discussion As SQ-LNS a e no el nu i ional supplemen s, his esea ch aimed o de e mine he effec o SQ-LNS du ing p egnancy and lac a ion on ma e nal plasma a y acid s a us and lipid concen a ions. We ound no significan diffe ence in plasma a y acid le els o lipid concen a- ions in Ghana o Malawi a 36 wk ges a ion, al hough pooled esul s sugges ha SQ-LNS supplemen a ion inc eases mean ma e nal plas- ma ALA le els du ing p egnancy. SQ-LNS inc eased ALA le els in b eas milk in Ghana bu did no impac b eas milk a y acid le els in Malawi. In e ms o DHA, ou esul s a e consis en wi h p e ious ALA supplemen a ion ials. A e iew by B enna e al. epo ed ha ou o 21 such ials, only 7 ials epo ed an effec on DHA [7], al hough o he omega-3 LCPUFAs (EPA, DPA) we e ypically highe in plasma om pa icipan s ecei ing ALA. I is possible ha he lack o an effec on LCPUFAs is due o he amoun o ALA (0.59 g) in SQ-LNS, as all o he ials in he e iew used highe ALA doses ( ange: 1.5–40 g). I is also possible ha SQ-LNS had a limi ed impac on plasma and b eas milk a y acids because i also included 4.59 g LA. A ecen e iew o he effec o die a y modifica ion o ALA and LA showed ha educing LA in ake was a key ac o o inc easing omega-3 LCPUFA le els [32]. I is likely ha women in he s udy a ea in Malawi egula ly consume fish high in DHA and AA and plan oils ha a e high in LA and low in ALA [33]. Food and Ag icul u e O ganiza ion (FAO) balance shee s also suppo he possibili y o high fish consump ion in Ghana and use o high LA/low ALA oils [9]. B eas milk DHA le els we e 2 and 3 imes highe in Malawi and Ghana, espec i ely, han he wo ldwide a e age (0.32 ± 0.22% [ ull ange: 0.06–1.40%]) es ablished by B enna e al. [34] As a poin o e e ence, Ghanaian milk DHA le els we e compa able o Japanese le els, whe e fish in ake is e y high. Bo h A ican coho s had subs an ially highe milk DHA le els han in he US (~0.2% [35]) and o he indus ialized coun ies. The milk AA alues we e wi hin he no mal ange desc ibed by B enna e al. [34] (0.47 ± 0.13% [ ull ange: 0.24–1.0%]), wi h he Malawi alues on he Fig. 2. ‘O he ’ a y acids ca ego y om Fig. 1 expanded. Table 4 Median b eas milk ALA, LA, DHA, AA, and n6:n3 a io by in e en ion g oup a 6 mon hs pos pa um. Ghana Malawi Pooled IFA (n=102) MMN (n=100) SQ-LNS (n=101) p a IFA (n=103) MMN (n=106) SQ-LNS (n=106) p a p a ALA, w % 0.41 b 0.38 0.44 0.02 0.59 0.63 0.64 0.33 0.11 (0.39, 0.44) (0.36, 0.40) (0.40, 0.47) (0.54, 0.63) (0.57, 0.68) (0.59, 0.69) LA, w % 10.4 10.3 10.9 0.14 15.7 16.5 15.8 0.32 0.41 (10.0, 10.7) (10.0, 10.6) (10.4, 11.4) (14.9, 16.5) (15.7, 17.2) (15.1, 16.5) DHA, w % 0.97 0.95 0.89 0.54 0.60 0.68 0.65 0.49 0.33 (0.86, 1.07) (0.87, 1.03) (0.81, 0.98) (0.55, 0.65) (0.61, 0.75) (0.57, 0.72) AA, w % 0.40 0.39 0.39 0.73 0.63 0.62 0.61 0.65 0.48 (0.38, 0.42) (0.37, 0.40) (0.37, 0.41) (0.60, 0.65) (0.59, 0.64) (0.59, 0.64) n6:n3 7.2 7.0 7.4 0.57 12.4 12.4 11.8 0.50 0.80 (6.6, 7.8) (6.5, 7.5) (6.8, 7.9) (11.6, 13.2) (11.3, 13.5) (11.0, 12.6) a P- alues ob ained by ANOVA. b Median (25 h pe cen ile, 75 h pe cen ile), all such alues. B.M. Oaks e al. P os aglandins, Leuko ienes and Essen ial Fa y Acids 117 (2017) 28–35 33 highe end and he Ghana alues on he lowe end o no mal. I is possible ha SQ-LNS had an impac on b eas milk ALA in Ghana bu no o he a y acids due o low die a y in ake o ALA bu high die a y in ake o DHA. I is unclea why he e was no a simila effec in Malawi. Women in he Malawi ial had highe b eas milk ALA han hose in Ghana, pe haps indica ing less abili y o espond o addi ional ALA. The women in he Malawi ial also had poo e indica o s o heal h s a us (highe p e alence o anemia and mala ia), which may ha e esul ed in educed co ela ion be ween a y acid in ake and a y acid bioma ke s in plasma. A ecen s udy showed ha in a Swedish popula ion in which sea ood in ake was co ela ed wi h se um DHA, he e was no such co ela ion among indi iduals wi h a opic eczema [36], aising he possibili y ha o he heal h condi ions migh be associa ed wi h disco dance be ween a y acid in ake and bioma ke s. The diffe en le els o mic onu ien s p o ided in he h ee diffe en supplemen s may ha e also impac ed women's a y acid s a us (i.e., excess i on can lead o lipid oxida ion o a y acids [37]; an ioxidan s, such as i amin E [α- ocophe ol], can p e en oxida ion o a y acids [38]). MMN and SQ-LNS had he same mic onu ien con en , excep ha SQ-LNS also con ained magnesium, phospho us, calcium, and po assium. While i is unlikely he addi ion o phospho us, calcium, o po assium affec ed a y acid le els, some esea ch in animal models has demons a ed ha deficiency in magnesium can esul in lowe PUFA concen a ions [39]. Peanu consump ion has been associa ed wi h imp o ed plasma lipid p ofiles in se e al s udies, including a ial in Ghana [17,40,41]. Gi en ha SQ-LNS is peanu -based, we had hypo hesized ha SQ-LNS may impac plasma lipid p ofiles o he women ecei ing his supple- men . The e a e se e al possible explana ions o he lack o an effec o SQ-LNS on plasma lipids in his s udy. Fi s , i is possible ha he dose o SQ-LNS was oo small o p oduce an effec . Second, he majo i y o he plasma lipid concen a ions a en ollmen we e wi hin he no mal ange o heal hy adul s, so i is possible ha he e was limi ed oppo uni y o imp o emen . Las ly, choles e ol and iglyce ide concen a ions inc ease o e he cou se o p egnancy [14] and he e- o e he choles e ol and iglyce ide lowe ing-effec associa ed wi h peanu consump ion migh be masked by he inc ease in bo h o hese plasma lipids du ing p egnancy. S eng hs o his s udy include igo ous ollow-up and moni o ing o compliance, he la ge sample size wi hin a andomized con olled ial s udy design, and he long du a ion o supplemen a ion. Women we e en olled in he ials a a mean o 16–17 wk ges a ion and ecei ed supplemen a ion h ough p egnancy and up o 6 mon hs pos pa um, which app oxima es 56 wk o supplemen a ion. P e iously, he longes du a ion o ALA supplemen a ion in a ial ha measu ed a y acid s a us was 42 wk [7,42]. Du a ion o ALA supplemen a ion has been shown o be a ac o wi h ega d o effec s on LCPUFAs, as a ial in Japanese men epo ed no effec in DHA a 3 mo, bu inc eased le els o DHA a e 10 mo o supplemen a ion [42]. The e a e limi a ions o his s udy. Ou ials expe ienced loss o ollow-up, howe e we conduc ed sensi i i y analyses and did no find e idence o his leading o a bias in esul s, excep o a bias owa ds he null o b eas milk a y acids om he Ghana ial. I was no possible o blind women o whe he hey we e assigned SQ-LNS s. a capsule, howe e we hink i is unlikely ha his pa ial blinding influenced hese esul s as lab echnicians we e blinded. Diffe en labo a o ies we e used o analyze he plasma lipids and diffe en me hods o b eas milk collec ion we e used be ween he wo ials, so we canno exclude he possibili y ha diffe ences in plasma lipids o b eas milk a y acid le els be ween he wo popula ions may be due o me hod o labo a o y analysis and collec ion, espec i ely. Howe e , exp essing a y acid le els as he pe cen age o o al a y acids by weigh should elimina e bias due o diffe ences in o al milk a concen a ions. Fa y acids we e analyzed in plasma as opposed o e y h ocy es, which may ha e led o g ea e wi hin-pe son a iabili y [43]. Plasma a y acids a e mo e s ongly influenced by ecen in ake compa ed o e y h ocy es [44]. Because o he difficul y o ob aining as ing blood samples om p egnan women, non- as ing blood samples we e collec ed. Howe e , we collec ed in o ma ion ega ding ime be ween las meal and sample collec ion and included his in adjus ed models when significan (p < 0.1). Typically, he e is minimal effec o as ing on o al choles e ol, HDL-C, and LDL-C, al hough iglyce ides end o be app oxima ely 15% highe in non- as ing s. as ing samples [45,46]. Las ly, we examined mul iple ou comes and hus ou esul s demons a ing an impac o SQ-LNS on plasma and b eas milk ALA le els may be due o chance. Howe e , we no e ha he supplemen con ained ALA and p e ious s udies suppo he biological plausibili y o an effec on ALA le els wi hou an effec on o he a y acid le els. 4.2. Conclusion The cu en o mula ion o SQ-LNS may inc ease plasma ALA in la e p egnancy in se ings simila o he s udy si es in Malawi and Ghana, and may impac b eas milk ALA le els in popula ions simila o he s udy popula ion in Ghana. Resea ch o e alua e diffe en o mula ions o SQ-LNS, pa icula ly wi h highe amoun s o ALA and lowe amoun s o LA, would be beneficial o u he examining he po en ial o SQ-LNS o affec ma e nal a y acid s a us. Conflic s o in e es KHJ is employed by OmegaQuan Analy ics, LLC, a comme cial labo a o y ha pe o med he a y acid analysis o his s udy. The o he au ho s decla e no conflic s o in e es ela ed o his s udy. Names o PubMed indexing Oaks, Dewey, Young, Adu-A a wuah, Asho n, Jackson, La ey, Male a, Ok onipa, Sadalaki, Baldi iez, Shahab-Fe dows, Vos i, Asho n T ial egis a ion ClinicalT ials.go , Iden ifie s NCT00970866 (Ghana ial) and NCT01239693 (Malawi ial). Acknowledgemen s We hank S ephen Vos i o his suppo in s udy design and logis ics ega ding he socioeconomic a iables; Ma y A imond o iLiNS P ojec managemen ; he iLiNS S ee ing Commi ee (h p://ilins.o g), o p o iding leade ship o he iLiNS-DYAD ials in Ghana and Malawi; and he women who pa icipa ed in he s udy. Appendix A. Suppo ing in o ma ion Supplemen a y da a associa ed wi h his a icle can be ound in he online e sion a doi:10.1016/j.ple a.2017.01.007. Re e ences [1] L. Lau i zen, S.E. Ca lson, Ma e nal a y acid s a us du ing p egnancy and lac a ion and ela ion o newbo n and in an s a us, Ma e n. Child Nu . 7 (2011) 41–58. [2] J.A. G eenbe g, S.J. Bell, W.V. Ausdal, Omega-3 a y acid supplemen a ion du ing p egnancy, Re . Obs e . 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