Dr. Kristina Harris Jackson: Omega-3 DHA’s Role in Preterm Birth
OmegaMatters: Episode 15
Host: Dr. Bill Harris
Guest: Dr. Kristina Harris Jackson
Background and Key Takeaways: Kristina Harris Jackson, PhD, RD, is the Director of Research and part-owner of OmegaQuant Analytics, LLC, and an Assistant Professor (non-tenure) in the Department of Internal Medicine at the University of South Dakota Sanford School of Medicine. Kristina received her PhD in Nutritional Sciences from Pennsylvania State University in 2013 and completed her training to become a Registered Dietitian in 2014. Kristina continues her research in the area of omega-3s in maternal health, helping create the Prenatal DHA test and the Mother’s Milk DHA test, and continues her clinical work by consulting with clients on their lab values from OmegaQuant. Kristina lives in Sioux Falls, South Dakota with her partner and two kids and very old dog. In this episode, Dr. Bill Harris interviews his OmegaMatters co-host and daughter, Kristina Harris Jackson, PhD, RD, about the important role DHA plays before, during and after pregnancy.
Visit www.omegaquant.com/omegamatters-broadcasts/ to learn more.
Dr. Bill Harris: Hello everybody. And welcome to this next episode of Omega Matters. We’ve decided this week to actually interview one of the co-hosts of Omega Matters — my daughter, who I’m so proud of, Kristina Harris Jackson. Kristina’s been working with OmegaQuant for five or so years now. She obtained her PhD in nutrition at Penn State University and her RD also there. She did some postdoc work in in Denver for a year or so, and then moved back to Sioux Falls and joined us full time onsite at OmegaQuant. And she’s our central person who handles our clinical questions and interpretation of findings. And she’s also Director of Research at OmegaQuant. So, Kristina, great to have you on this topic today.
Kristina Jackson: Thank you very much.
Dr. Bill Harris: Today we’re going to talk about some work you’ve done in the area of omega-3 in pregnancy and early childhood nutrition. So, tell us how you got interested in that particular side of the omega-3 story.
Kristina Jackson: When I moved back and started to work at OmegaQuant again, you guys had just validated measuring DHA in breast milk spots, dried milk spots on filtered paper cards. And so, it was basically assigned to me to say, “Figure out what our target should be.” So, that was my first real dive into maternal health and omega-3. So, I really was into the breast milk literature for a long time. And then as I was looking into that to look for targets the pregnancy literature kept popping up and that seemed even more interesting potentially for health outcomes than the breast milk stuff. So, that’s how I ended up getting into it.
Dr. Bill Harris: You were actually involved physically with that sort of stage of life as well at that time. Weren’t you?
Kristina Jackson: True. That was during my pregnancy and having kids and all that stuff. So, it became more interesting for me.
Dr. Bill Harris: Okay.
Kristina Jackson: When you’re living it then that makes a difference. So, that’s where that came from.
Dr. Bill Harris: So, can you tell us just some of the studies you’ve been involved with in this area?
Kristina Jackson: Yes, so, we have done mostly studies with research partners. Although we have a couple, at least one that we did on our own — we did one breast milk study where we had people just measure their levels and, kind of use that information themselves to see if it made a difference. And it looked like it did make a little difference knowing their levels. We got samples from a controlled feeding study from Cornell that was focused on, choline actually, but they also were interested in how choline and fatty acids and DHA kind of interact in pregnancy. But we were interested in the fact that they had a controlled feeding study in pregnant women where they were all given 200 milligrams of DHA a day. So, we just wanted to know what the response was in red blood cells. So we just published in this paper and we’re going to talk about this today.
Dr. Bill Harris: Can you go back to that first study on breast milk? You said women who knew their breast milk, DHA levels, it helped. What do you mean and it helped?
Kristina Jackson: It increased their DHA levels by the end of the study.
Dr. Bill Harris: Right. Giving them the information about their milk DHA levels actually changed their behavior. So they started taking more, probably taking omega-3 more faithfully perhaps.
Kristina Jackson: Probably.
Dr. Bill Harris: So, again, if you inform people, if people are told about their status, they’ll do something about it.
Kristina Jackson: Mm-hmm (affirmative). Yep.
Dr. Bill Harris: Let’s back up a little bit about what, about why is DHA important in pregnancy.
Kristina Jackson: Yeah, so, DHA is important in pregnancy, like a lot of nutrients are at high need during pregnancy and DHA is one of those. So, DHA is important for, the main outcome that we see most consistently is that it reduces risk for preterm birth, especially early preterm birth, which is before 34 weeks. It’s also been extensively studied in the area infant cognition and development and their vision development. Often in premature babies, they’re looking at how DHA helps them continue to develop somewhat normally if they’re born quite early. DHA is also very rich in the brain and the eye. So, that’s why people started to look at DHA as an intervention, for babies and for pregnant women to take it. But really, the strongest evidence is around preterm birth.
Dr. Bill Harris: Do we have any idea why having a low omega-3 level would predispose to preterm birth in anyone?
Kristina Jackson: There are not a lot of clear diagnostic predictive tools to say someone is at higher risk for pre-term birth, unless you’ve already had preterm birth. Or there’s just a bunch of really vague risk factors like being very overweight or underweight, being very old or very young. But I think stress is one of the biggest things. Stress and illness are two kind of inflammatory processes that seem to be able to kick off early rupture of membranes. And so DHA and EPA both are really integral in the inflammatory process. Also, replacing arachidonic in the membrane, might also be part of this process because the oxylipins and the metabolites of arachidonic and DHA and EPA all are part of the part of the labor process, part of the uterus, some of the signals to the uterus to start squeezing. They’re involved there. It’s not entirely clear exactly what is going on, but I think it has to do with replacing arachidonic, changing the inflammatory state.
Dr. Bill Harris: Yeah, well now that we know that DHA supplementation can reduce risk for preterm birth, I would think that would foster some basic science research into saying, why would that be?
Kristina Jackson: Right.
Dr. Bill Harris: I think your most recent paper was talking about harmonizing DHA status. Can you tell us what that means and why it’s important?
Kristina Jackson: Yeah, so omega-3 testing in the blood is not standardized at all. So, you can get your omega-3s measured in plasma and red blood cells and whole blood — and every different method gives you different answers. So, when there’s research studies that come out and they do actually measure blood levels, which is not a given either, but if they measure blood levels before the study, at the beginning of the study and the end of the study, then it gives you an idea whether the people took their supplements — i.e., did they see an increase in the intervention group? It just gives you an idea of compliance. But the other thing that baseline levels do is it gives you an idea of the background intake of that population that happened to be in the study.
Kristina Jackson: So the problem is most of these studies are reporting different metrics. They’re either reporting whole blood DHA or a red blood cell DHA, and they aren’t on the same scale. So you can’t compare across and say, did this group come in and it had higher levels to begin with or lower levels — both of which would affect the outcomes. Research groups in this area, are people that we have done inter lab comparisons with. So, we know how our method compares to their method in measuring omega-3s. So, we were able to take the data they published about what the blood levels in their populations in their studies were and convert them to our numbers so that we can see across the board, for example, that this group started at 5% versus this group which started at 3%. This group went up by two percentage points, and this group didn’t go up at all. It just gives you context to be able to understand the populations in general and also how much their levels changed over the course of the study.
Dr. Bill Harris: That’s interesting. Why would a test in whole blood or a dry blood spot or a test in plasma or a test in red blood cells give you different numbers for DHA levels?
Kristina Jackson: Different parts of the blood use fatty acids differently. So, like in plasma, levels can go up and down kind of with what you eat. We compare the plasma and red blood cell, measures of omega-3s, to HbA1c and plasma glucose. It’s the same kind of idea where plasma glucose goes up and down with what you eat, as it should. So omega-3s in the plasma go up and down with what you eat pretty related to like the day before or the day of. But the red blood cell doesn’t get affected by that because it is about a three or four month marker of EPA and DHA intake, like HbA1c is for average plasma glucose.
Dr. Bill Harris: Okay.
Kristina Jackson: But we’re looking at a red cell membrane. So, we’re looking at something the body’s putting together in a certain way. We’re looking at red blood cells versus just what’s being absorbed in the plasma. So, that’s the big difference. And so they’re going to give really different numbers just because of that.
Dr. Bill Harris: So, you mentioned that you did inner laboratory analysis. So you shared blood samples between two labs and each did its own methods?
Kristina Jackson: Mm-hmm (affirmative).
Dr. Bill Harris: That’s how you converted one type of data to another. Yeah. Well, what studies did you include? You mentioned two big groups. Who did that?
Kristina Jackson: Susan Carlson’s group at Katy Medical Center has done a lot of work. And then Kathleen Gustafson is one of her collaborators. So, together they have a lot of studies in pregnant women where they’ve measured red blood cell phospholipids. And we know that when they get an omega-3 status, it’s a little higher than what we get. So, we are able to convert their numbers back to ours. The other big group is Maria Markrides and Bob Gibson in Adelaide, Australia, at the University of Adelaide. And they’ve done the biggest study ever on DHA and pregnancy. They did the DOMInO study and several others in this area. But the ORIP study is the only one with blood work for everybody. The other study worth mentioning is that Cornell study I talked about, where they had a controlled feeding study and, and gave everybody 200 milligrams of DHA throughout a certain part of their pregnancy. For us, this was kind of the 100% compliance measure because they were coming in to get their food every day and they had to take their pills then.
Dr. Bill Harris: Okay. So, can you kind of summarize what you found in this study?
Kristina Jackson: Yeah. So, when we put everybody on the same scale and we had their baseline and end of study omega red blood cell DHA values, we found that many of the two big studies that just happened — ORIP in Australia and ADORE at Kansas University — in both of them, the women started about 4% DHA and we think 5% DHA is a good target to be at. So, they were normal to high. In these studies, their final values averaged about 7% DHA, if I’m remembering correctly.
Dr. Bill Harris: This is on what dose?
Kristina Jackson: That was on 1000 milligrams of DHA a day.
Dr. Bill Harris: Okay.
Kristina Jackson: And the ORIP study had 800 milligrams a day of DHA and 100 milligrams of EPA. And theirs went up about a percent, maybe less than a percent. Theirs went from about 4.5-5.5% if I’m remembering correctly. So, there’s a really big difference in the changes there.
Dr. Bill Harris: So the levels went up appropriately to the dose in both of these studies or not.
Kristina Jackson: No. So, what we found was that the rise in DHA in the study was equivalent to the 200 milligrams from Cornell. So, it didn’t seem like they were taking 800 milligrams based on how much the level increased compared to the other studies. So, we included a bunch of other studies just to have those comparisons. It just showed that the change in blood levels that they got on their study was equivalent to about 200 milligrams of DHA, versus when it should have been 800 mg.
Dr. Bill Harris: Wow.
Kristina Jackson: It should have had an increase of probably 2% or more. So that was really striking to us and to me. We spent a lot of time trying to figure out why that happened.
Dr. Bill Harris: What were the clinical outcomes of these two studies?
Kristina Jackson: The ORIP study did not show a significant difference between the placebo and intervention group on pre-term birth. For ADORE, they did different kinds of statistics, but it was like 93% sure that the intervention group worked. So, I don’t know if I could say it’s significant or not, but they did have a decrease in early preterm birth in their intervention arm. And the interesting thing that the ADORE study did was they were looking at, they took baseline blood levels and they looked at women who came in above 4.8% by our scale, and below that, to compare if people were coming in with high DHA levels to begin with, did the intervention work, do they still need a really high dose of DHA to reduce preterm birth risk? And they found that the women who came in below 4.8%, there was a big difference between the intervention and the placebo.
Kristina Jackson: So, the intervention group got 1000 milligrams of DHA and their risk for preterm birth was about half of what the group was with the lower 200 milligrams a day dose. So, that was true in the women who with low levels to begin with coming in.
Dr. Bill Harris: Mm-hmm (affirmative).
Kristina Jackson: Which makes sense, like if they’re low, they need more, they’re kind of in a deficiency state. But the women who came in above 4.8%, it didn’t matter if they got 1000 or 200 milligrams of DHA, they have the same preterm birth rate. And they also, across the board had lower preterm birth rates than the women who came in at a lower level. So…
Dr. Bill Harris: Okay. So, that’s where you get your 5% red blood cells kind of separate low from adequate?
Kristina Jackson: We set the 5% on other studies. and then this one came out and it just happened to be the cut point that they chose to split the sample over. So, it’s just really fortunate that it’s really close to that. And it does kind of make the case that below 5% is deficient, above is sufficient — it may or may not be optimal. It’s lower than what we recommend for like the general population of an 8% Omega-3 Index. But for this population, that seems to be where you actually get a difference in outcomes, for preterm birth, but there might be other benefits for having higher than 5% DHA.
Dr. Bill Harris: Right. Right. Exactly. Interesting. So you know that having a low red blood cell DHA level does appear to increase risk for preterm birth. So, if you could wave a magic wand and you were in charge of the world and you could restructure obstetric healthcare in America, how would you incorporate what you’ve learned into routine care of pregnant women?
Kristina Jackson: I would just like this to be one of the standard of care tests. So, you come in at your first visit where you do blood work around the end of the first trimester, beginning of second, and you get your DHA level, your omega-3, your prenatal DHA level, and your doctor gets it and she looks at it. And if you come in and you’re low, below 5%, they prescribed to you a 1000 milligrams of DHA for the rest of your pregnancy. If you come in above 5%, they talk to you about what you’re doing. If you’re already taking an omega-3 supplement or you’re already eating fish, then they might just say, “Continue to do that. Continue to do at least 200 milligrams of DHA extra from what you did when you weren’t pregnant. So, you might just be able to be fine and continue on.”
Kristina Jackson: And then it would be great to recheck, especially the low women, the women who needed the 1000 milligrams, recheck them at any point in the late second, early third trimester, maybe even during, when you do your glucose testing, to make sure that they’re taking it or they’re getting enough, or, if they need a different kind of supplement or different kind of plan, there’s all kinds of different things you can do to make it easier.
Dr. Bill Harris: Yeah.
Kristina Jackson: Because, sometimes women can’t, you just can’t eat or take supplements normally when you’re pregnant, so you might just need to try something different. And doctors should make sure they’re actually doing it because if they’re not absorbing it or not taking it, it’s not going to do what it’s supposed to do.
Dr. Bill Harris: Yeah. So, even though these studies have been published and they’re out there in the medical literature, the obstetricians are not paying much attention to them yet?
Kristina Jackson: No, not that I’ve seen. Really the only things I see that is recommended for reducing preterm birth is like taking a baby aspirin or if someone has at really high risk, they’ll get shots of steroids.
Dr. Bill Harris: Oh!
Kristina Jackson: And there aren’t a lot of good treatments for people who are already at higher risk because anyone can have preterm birth. There’s very little, risk associated with taking omega-3s in pregnancy. And there’s been a ton of studies at much higher doses than 1000 milligrams. We also know pretty well that omega-3 status generally in the US at least is pretty low. So, it’s a good bet that a lot of pregnant women are also low coming into pregnancy.
Dr. Bill Harris: Should women eat more fish during pregnancy?
Kristina Jackson: Yeah.
Dr. Bill Harris: Any fish?
Kristina Jackson: Well, the fish conversation is very tricky, because of the mercury and toxins issues. But there’s a really strong push to promote fish intake during pregnancy instead of limiting it. The guidelines have even started to change. We’ve worked with the Seafood Nutrition Partnership, to help get the show that just eating fish in and of itself for pregnant women and their babies is really beneficial for cognitive outcomes, and actually, for all kinds different outcomes. So, most of the fish we eat are pretty low in mercury and the toxins that we’re worried about, like the salmon and the sardines.
Dr. Bill Harris: Yeah. oily fish.
Kristina Jackson: The oily fish and just white fish also, which is low in omega-3, but it’s still commonly eaten and those are typically pretty low in toxins. It’s the big game shark and swordfish and big tuna and mackerel that have higher levels of mercury. They’re just some that you shouldn’t have.
Dr. Bill Harris: Yeah. Sounds like a, a topic that might be worth another talk sometime.
Well, this has been great. Appreciate you summarizing this research you’ve done most recently.
I wish you luck as you continue to develop the research program there at OmegaQuant. Thank you.
Kristina Jackson: Thank you very much. Good chat.
Dr. Bill Harris: Good chat. Bye-bye.