practice applications
Achieving Adequate DHA in
Maternal and Infant Diets
To the Editor:
Thank you for the Commentary by
Makrides in the October 2008 issue of
the Journal (1). This commentary
highlights the important role of the
long-chain n-3 fatty acid, docosa-
hexaenoic acid (DHA; 22:6 n-3), in
maternal and infant diets. This im-
portant commentary also calls atten-
tion to the limited ability to produce
DHA de novo from the short-chain n-3
precursor ␣-linolenic acid (ALA; 18:3
n-3) (2,3) and the challenge associ-
ated with achieving adequate DHA in
the diet particularly during preg-
nancy, nursing, and early postnatal
life (4) but overestimates the DHA
content of a few key foods. In the
United States, DHA intake during
pregnancy and nursing is estimated
to be only 50 mg/day falling from an
average of 70 mg/day among women
of child-bearing age (5) due, at least
in part, to Food and Drug Administra-
tion/Environmental Protection Agency
advisories regarding fish (6). In con-
trast, numerous expert and govern-
ment authorities worldwide recom-
mend that “pregnant and lactating
women should aim to achieve a di-
etary intake of n-3 long-chain polyun-
saturated fatty acid that supplies a
DHA intake of at least 200 mg/day”
(7-9).
However, the DHA content of lean
red meat and standard eggs cited by
Makrides is an overestimation of the
DHA content of these foods as pro-
duced in the United States and may,
instead, reflect the DHA content of
these foods in Makrides’s native Aus-
tralia where livestock feeding prac-
tices are different (10). A 100-g serv-
ing of lean red beef contains 30 mg
DHA, as noted in the current article,
only if it is from grass-fed cattle
(10,11). The US Department of Agri-
culture’s nutrient database, in con-
trast, lists 0 mg of DHA for most, if
not all, cuts of beef which are presum-
ably from grain-fed cattle. While this
may reflect the need to update the
current database, it appears that
© 2009 by the American Dietetic Association
grain-fed beef in the United States
may contain as little as 0 to 15 mg
DHA per 100 g (11,12). The typical
US egg (large, 50 g) is also a limited
source of DHA, containing only 20
mg DHA per egg not 45 mg (13) as
Makrides suggests. As noted, how-
ever, eggs can be enriched with DHA
by manipulating the laying hen’s diet
to include marine oils and microalgae
resulting in about 150 mg of DHA per
egg. Higher n-3 fatty acid totals, such
as the 195 mg noted by Makrides,
often reflect the contribution of ALA,
in addition to DHA, that occurs when
hens are fed flaxseed or marine oil
combined with flaxseed (14). Since
the conversion of ALA to DHA is min-
imal, an egg with higher levels of ALA
is not an adequate source of DHA.
Therefore, while Makrides calls at-
tention to important alternatives to
fish for DHA in the maternal diet, she
has overestimated the amount of DHA
these foods can provide in the US diet.
Alternatives to fish include prenatal
vitamins with DHA, which typically
contain at least 200 mg of DHA, and
DHA-fortified foods, such as milk and
yogurt, which typically contain 32 mg
DHA per serving. Many of these prod-
ucts are produced with a DHA-rich oil
from microalgae, which represents a
sustainable, vegetarian, and contam-
inant-free source of DHA for pregnant
and nursing women.
Mary E. Van Elswyk, PhD, RD
Owner and Principal Scientist
Van Elswyk Consulting Inc
Longmont, CO
Connye Kuratko, PhD, RD
Principal Scientist, Medical Affairs
Martek Biosciences Corporation
Columbia, MD
References
1. Makrides M. Outcomes for mothers and
their babies: Do n-3 long-chain polyunsat-
urated fatty acids and seafoods make a
difference? J Am Diet Assoc. 2008;108:
1622-1626.
2. Barcelo-Coblijn G, Murphy EJ, Othman R,
Moghadasian MH, Kashour T, Friel JK.
Flaxseed oil and fish-oil capsule consump-
tion alters human red blood cell n-3 fatty
acid composition: A multiple-dosing trial
comparing 2 sources of n-3 fatty acids. Am J
Clin Nutr. 2008;88:801-809.
Journal of the AMERICAN DIETETIC ASSOCIATION
LETTERS TO THE EDITOR
3. Harper CR, Edwards MJ, DeFilippis AP, Ja-
cobson TA. Flaxseed oil increases the plasma
concentrations of cardioprotective (n-3) fatty
acids in humans. J Nutr. 2006;136:83-87.
4. Francois CA, Connor SL, Bolewicz LC, Con-
nor WE. Supplementing lactating women
with flaxseed oil does not increase docosa-
hexaenoic acid in their milk. Am J Clin
Nutr. 2003;77:226-233.
5. Institute of Medicine. Dietary Reference In-
takes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein, and
Amino Acids (Macronutrient Report). Ta-
ble E-14. The National Academies Press
Web site. http://books.nap.edu/openbook.php?
record_id⫽10490&page⫽1056. Accessed De-
cember 30, 2008.
6. Oken E, Kleinman KP, Berland WE, Simon
SR, Rich-Edwards JW, Gillman MW. De-
cline in fish consumption among pregnant
women after a national mercury advisory.
Obstet Gynecol. 2003;102:346-351.
7. Koletzko B, Cetin I, and Brenna TJ. Perina-
tal Lipid Intake Working Group Consensus
Statement. Dietary fat intakes for pregnant
and lactating women. Br J Nutr. 2007;98:
873-877.
8. International Society for the Study of Fatty
Acids and Lipids. PUFA Recommendations.
International Society for the Study of Fatty
Acids and Lipids Web site. http://www.issfal.
org.uk/pufa-recommendations.html. Acces-
sed November 14, 2008.
9. Koletzko B, Lien E, Agostoni C, Bohles H,
Campoy C, Cetin I, Decsi T, Dudenhausen
JW, Dupont C, Forsyth S, Hoesli I, Hol-
zgreve W, Lapillonne A, Putet G, Secher NJ,
Symonds M, Szajewska H, Willatts P, Uauy
R; World Association of Perinatal Medicine
Dietary Guidelines Working Group. The
roles of long-chain polyunsaturated fatty ac-
ids in pregnancy, lactation, and infancy: Re-
view of current knowledge and consensus
recommendations. J Perinat Med. 2008;36:
5-14.
10. Howe P, Buckley J, Meyer B. Long-chain
omega-3 fatty acids in red meat. Nutr Diet.
2007;64(suppl 4):S135-S139.
11. Duckett SK, Wagner DG, Yates LD, Dolezal
HG, May SG. Effects of time on feed on beef
nutrient composition. J Anim Sci. 1993;71:
2079-2088.
12. US Department of Agriculture, Agricul-
tural Research Service. Research project:
Improving the accuracy of beef nutrient
data in the USDA National Nutrient Da-
tabase for standard reference Phase I and
Phase II. Project Number 1235-52000-051-
08. Agricultural Research Service Web site.
http://www.ars.usda.gov/research/projects/
projects.htm?ACCN_NO⫽412096. Accessed
October 21, 2008.
13. US Department of Agriculture. National
Nutrient Database. National Agriculture Li-
brary Web site. http://www.nal.usda.gov/
fnic/foodcomp/search/. Accessed November
14, 2008.
14. Van Elswyk ME. Comparison of n-3 fatty
acid sources in laying hen rations for im-
provement of whole egg nutritional quality:
403
LETTERS TO THE EDITOR
A review. Br J Nutr. 1997;78(suppl 1):S61-
S69.
doi: 10.1016/j.jada.2009.01.004
Author’s Response:
Van Elswyk and Kuratko correctly
identified that the docosahexaenoic
acid (DHA) composition of foods noted
in my commentary (1) were from Aus-
tralian sources. There are two main
reasons that would explain differ-
ences in the fatty acid composition of
foods between Australia and North
America. First, as Van Elswyk and
Kuratko acknowledge, current food
composition databases for individual
fatty acids in the United States have
limitations. Second, different farming
practices can conspire to reduce the
accumulation of DHA in the tissues
and products of farm animals. As
with humans, feeding farm animals
high levels of the n-6 fatty acid, lino-
leic acid, results in lower concentra-
tions of DHA accumulation in tissues.
However, this does not fully explain
the potential difference between Aus-
tralian and US food composition da-
tabases, as beef in Australia is “fin-
ished” with a period of grain feeding.
North American data indicate that
grain-fed beef contains some n-3 long-
chain polyunsaturated fatty acids and
a very small quantity of DHA (2).
Van Elswyk and Kuratko suggest
that food products supplemented with
404 March 2009 Volume 109 Number 3
DHA-rich oil are important food sources
for pregnant and nursing women. While
this may be true in many Westernized
countries, it is important for nutritionists
to consider the overall context of the diet.
DHA-rich or DHA-supplemented foods
will be less effective at improving DHA
status in a background diet rich in lino-
leic acid (the primary n-6 fatty acid),
compared with a diet that is low in lino-
leic acid (3).
Maria Makrides, PhD
Director
Child Nutrition Research Centre
Women’s and Children’s Health
Research Institute
North Adelaide, SA, Australia
References
1. Makrides M. Outcomes for mothers and their
babies: Do n-3 long chain polyunsaturated
fatty acids and seafoods make a difference?
J Am Diet Assoc. 2008;108:1622-1626.
2. Mandell IB, Buchanan-Smith JG, Holub BJ,
Campbell CP. Effects of fish meal in beef cattle
on growth performance, carcass characteristics,
and fatty acid composition of longissimus muscle.
J Anim Sci. 1997;75:910-919.
3. Mantzioris E, James MJ, Gibson RA, Cleland
LG. Differences exist in the relationships be-
tween dietary linoleic and alpha-linolenic ac-
ids and their respective long-chain metabo-
lites. Am J Clin Nutr. 1995;61:320-324.
doi: 10.1016/j.jada.2009.01.006
Concerns about the
Discretion of Sweetened
Beverages
To the Editor:
We read with great interest the ed-
itorial by Crawford and colleagues (1)
in the September 2008 issue of the
Journal. We congratulate the Jour-
nal and the authors for choosing such
an interesting topic as that of sweet-
ened beverages and child obesity. The
scientific environment is increasingly
paying attention to the potential pub-
lic health problems related to the con-
sumption of these types of beverages.
However, we would like to highlight
some points we think deserve further
attention.
First, we missed a more specific
explanation about the search strat-
egy used by the authors to examine
the available “evidence relating 28
different dietary factors to adiposity
to identify the dietary composition
and eating behaviors that would be
most conducive to the prevention
of overweight.” A mandatory step
needed to be able to replicate the
results is to provide the specific cri-
teria used for this literature search.
Second, we consider that some sub-
headings for the different sections of
this editorial perhaps have been used