Omega-3 DHA & and the Infant Brain

OmegaMatters: Episode 25

Hosts: Drs. Bill Harris & Kristina Harris Jackson

Background and Key Takeaways:

In this episode, Drs. Harris and Jackson speak with Drs. Kathleen Gustafson and Danielle Christifano, from the University of Kansas Medical Center. Drs. Harris and Jackson came to know them through the work with Susan Carlson’s lab, whom they’ve interviewed before about studying DHA in pregnancy. Kathleen was the director of the Neurophysiology core at the Hoglund Brain Imaging Center at the University of Kansas Medical Center until she recently retired. And she has expertise in neurophysiologic measurements, vision, retina, signal processing, and has collaborated on several nutrition studies. She also holds two patents related to human retinal dystrophin, and two patents related to the nutritional needs of premature infants. Dr. Christifano, or Danielle is an assistant professor in the Department of Nutrition and Dietetics, where she studies the influence of nutrition on neurophysiological outcomes in mothers and children using techniques available at the Hoglund Imaging Center. And she also has a keen interest in improving the accessibility of prenatal nutrition recommendations, including Omega-3 in clinical settings. In this episode, they talk about the importance of DHA, especially for pregnant women who don’t get enough in their diets and how that can impact infant neurodevelopment and preterm birth risk. For more information on OmegaMatters, visit:



Dr. Kristina Harris Jackson: All right. Welcome to Omega Matters, where we talk all things Omegas. I’m Kristina Jackson and this is Bill Harris. And today we are speaking with two research scientists from the University of Kansas Medical Center, Kathleen Gustafson and Danielle Christifano. We came to know them through the work with Susan Carlson’s lab, whom we’ve interviewed before studying DHA in pregnancy. Kathleen was the director of the Neurophysiology core at the Hoglund Brain Imaging Center at the University of Kansas Medical Center until she recently retired. And she has expertise in neurophysiologic measurements, vision, retina, signal processing, and has collaborated on several nutrition studies. She also holds two patents related to human retinal dystrophin, and two patents related to the nutritional needs of premature infants. Dr. Christifano, or Danielle is an assistant professor in the Department of Nutrition and Dietetics, where she studies the influence of nutrition on neurophysiological outcomes in mothers and children using techniques available at the Hoglund Imaging Center. And she also has a keen interest in improving the accessibility of prenatal nutrition recommendations, including Omega-3 in clinical settings. So we are very excited to talk to you now that I’ve gotten through the intro. So thank you guys for talking with us today.

Dr. Kathleen Gustafson: Thank you.

Dr. Kristina Harris Jackson: Yes. So first, can you each talk a little bit about your background and what brought you to where you are today in terms of your work?

Dr. Kathleen Gustafson: Sure. You want me to start?

Dr. Danielle Christifano: Yeah.

Dr. Kristina Harris Jackson: Yes.

Dr. Kathleen Gustafson: Okay. All right. Well, it’s a little bit lengthy, but I’ll try to keep it short. So my original interest was in infant vision development and retinal function. And my mentor, Gerhard Cibis is a pediatric ophthalmologist, and he was invited to collaborate in one of the conferences that was held in Adelaide, Australia. And at the last minute he couldn’t go, so he just kind of tossed me on a plane and said, “Take it away.” And that was my first introduction to the entire fatty acid world. And that’s where I met Susan Carlson and Bob Gibson and Martha Neuringer and many others, who have had great influence on this field and my career.

So afterwards, because of our expertise in measuring infant vision, we ended up participating in several large scale clinical trials. And I was all along very skeptical about the influence of DHA in infant vision development, but it wasn’t until we did a multi-site study where we used both electrophysiological and behavioral methods of visual assessment in infants that I was convinced that DHA definitely had a role in infant vision development. But nonetheless, I wanted to pursue dystrophin in the retina and find out what that was all about. And we were working with transgenic mice and very basic science, but I kept getting pulled in this direction to study the influence of fatty acids. So we kept getting involved in more and more trials, and the group of people in this field are so interesting and fun to work with that they eventually charmed me into their field and away from retina. And here I am today. So we’re not only colleagues, but good friends.

Dr. Bill Harris: How long you been at KU?

Dr. Kathleen Gustafson: Almost 20 years.

Dr. Bill Harris: Okay. Okay.

Dr. Kathleen Gustafson: Yeah. 20 years at the University of Missouri Children’s Mercy Hospital and 20 years at KU.

Dr. Bill Harris: Wow. You’re lucky you did the reverse. I did 11 years at KU Med and 11 years at St. Luke’s.

Dr. Kathleen Gustafson: Oh, well there you go. Flip flop. Yeah people ask me if I had to move when I went to KU and it’s like, no, just turned left instead of right.

Dr. Kristina Harris Jackson: There’s so much good stuff in Kansas City.

Dr. Kathleen Gustafson: That’s right.

Dr. Kristina Harris Jackson: Yeah. Danielle, how about you?

Dr. Danielle Christifano: My educational background is in biomedical and nutrition sciences, but I would say my interest in maternal and infant nutrition started about 14 years ago when I had the opportunity to live and work in Southeast Asia. During my time there, I had the chance to work with children, refugee populations who were just in dire need of micronutrient repletion. And this was the first time I saw firsthand the power of nutrition, and I was like, I need more. I need to know more now. And so I started applying for grad programs and from there went on to pursue a master’s in PhD in medical nutrition sciences at KU Medical Center. I had the honor and privilege of working with Dr. Susan Carlson, a true pioneer in omega-3 research for my master’s thesis, and then went on to pursue a PhD in something a bit different.

I was doing weight management in breast cancer survivors, but I missed maternal and fetal medicine so much, and that’s when I found Kathleen. So shortly after finishing my PhD, I was introduced to Kathleen who was doing this incredible work linking fetal electrophysiology to nutrition and studying omega-3 fatty acids and DHA. And I was like, I need more of this. This is exactly what I want to pursue in my career. And so something about Kathleen’s passion and incredible knack for teaching, she’s an incredible teacher. It really allowed me to pick up something totally new, which is electrophysiology. And so I started learning about all these electrophysiological measures and how it can be really a biomarker of health, not just in the fetus, but in adults too. And so here I am today still pursuing this research. I mean, very early in my career, I became faculty in the department about two years ago. And so yeah, just new here, but trying to do the important work that Kathleen and Susan have started. So that’s me.

Dr. Bill Harris: Good story. Great.

Dr. Kristina Harris Jackson: That’s great. Yeah, there’s a lot of ways you can study nutrition. You really have to find your niche. That’s fantastic. So that’s a perfect lead in. We’re going to start off with a paper from 2022 Journal of Nutrition, where it is bringing together all of the things, DHA, pregnancy and lots of measurements that you guys get to hopefully bring to the layperson ourselves. We are the laypeople. So this study, this paper is called DHA Supplementation During Pregnancy Enhances Maternal Vaguely Mediated Cardiac Autonomic Control In Humans. That’s the one we wanted to start with. It’s a mouthful. Can you guys set the stage? What was the study and what was the rationale behind it?

Dr. Kathleen Gustafson: Yeah, so this is basically a secondary analysis of the parent trial. And in the parent trial, our primary outcome measures were fetal neurodevelopment where we used heart rate variability metrics to analyze their neurodevelopment. And then we also looked at the relationship between maternal DHA and fetal DHA. So that’s a separate paper. But what led us up to this was in our previous trial, the preliminary work that led to this, it was a small R21. We only had 40 some women in it, and we just didn’t have enough power to look at the effect of DHA in pregnancy, in pregnant women. There have been lots of studies using DHA in adults. It shows that it lowers heart rate and improves heart rate variability, but there just has been no work in pregnant women. So the PANDA study is the one that gave us the power to look at the effect in pregnant women. So when we talk about heart rate variability, we’re really talking about a, it’s sort of a general proxy for good health and wellbeing in adults, in people. So we’re looking at autonomic balance.

Dr. Bill Harris: How do you describe heart rate variability?

Dr. Kathleen Gustafson: How do I describe? Well, there’s so many different metrics, and there’s the standardized clinical metrics that measure short term and overall heart rate variability. But there’s lots of different metrics. There’s time domain metrics, frequency domain metrics, non-linear metrics. Some of the non-linear metrics are especially interesting because they look at the complexity of a signal. So in the fetus, we use a combination of these measures to come up with what we call the fetal autonomic brain age score. And that was developed by colleagues in Germany that we partnered with to an analyze the fetal data.

Dr. Kristina Harris Jackson: In the question about heart, just like to set the heart rate variability, is it correct to say the same as in adults where generally you want a higher amount of variability is better? So if an adult’s running and their heart rate is up and then you want it to drop very quickly, back to kind of baseline, that’s a sign of a well-functioning heart? But if it doesn’t change very much, then things aren’t… Is that kind of right or is that too simplified?

Dr. Kathleen Gustafson: No, I don’t think it’s too simplified. What you want is a flexible system. You want a system that adapts a system that’s flexible, that can respond to whatever external or internal mechanisms there are. So high variability is good up to a point.

Dr. Kristina Harris Jackson: Right.

Dr. Kathleen Gustafson: Everything’s good, up to a point.

Dr. Kristina Harris Jackson: Exactly.

Dr. Kathleen Gustafson: And I tend to think in systems, like systems analysis. So when I think of a fetus, I think of a developing system, and you’ve got all these mechanisms that come together that regulate breathing and digestion and brain function and motor movement and all these types of things. And they all have to work together. So you have all these subsystems that have to come online and function normally. And so when we measure heart rate variability, we are measuring the variability between the beats of the heart. But that’s influenced by many things, including all the things I just mentioned, infection, brain function, even the microbiome, there’s some talk about the gut influencing vagal response.

Dr. Kristina Harris Jackson: Of course it does.

Dr. Kathleen Gustafson: And communication with the brain. So I think of this as a system that’s coming online and we’re measuring the function of the system, and then the system matures and peaks, and then as we get old and start to unravel, our systems unravel until we’re completely unraveled and dead. Heart rate variability decreases with time and age, and towards the end of life, what can I say?

Dr. Kristina Harris Jackson: Yeah.

Dr. Kathleen Gustafson: We’re all going downhill.

Dr. Kristina Harris Jackson: Yes. So you guys are looking at this dynamic system, which is really interesting. So can you describe, you talked about heart rate variability. Can you describe vagal tone now and what that means?

Dr. Kathleen Gustafson: Very simply put, vagal tone is linked to respiration. Most of the measures are dependent on the respiratory rate, but vagal tone is basically, gosh, sometimes it’s so simple, it’s hard to describe, but it’s just basically the superhighway of the nervous system that runs pretty controls, multiple systems, pupillary constriction, swallowing, breathing, gut function, all those types of things. So, it runs the entire length of the body and it gets input from all these different organs and works together. So a person with high vagal tone would have, well, let’s look at it this way on the one hand. So if you’re looking at the autonomic nervous system, you’re thinking about two branches, the sympathetic branch and the parasympathetic branch, and the Vagas is the parasympathetic branch, and they work together. There’s no good or bad here. They just work together and they should be fairly well balanced. So if you’re in a situation where you’re in the woods and you run across a bear and you starts running towards you, you need to be able to run.

And so your sympathetic system will kick in and you’ll start running and your heart will beat faster and pump more blood around, and you’ll breathe faster and everything works great. But then when that stress is over, you want to be able to slow all that down. And that’s where the vagus comes in. It also comes in, let’s say you’re concentrating on something like a sharp shooter who’s doing cross-country skiing, for example. And then they come across their target and they have to calm down and shoot and focus and hit the target. So that’s where a flexible system is useful. Think about the infant in SIDS. So for example, there’s some implication that there’s an autonomic dysfunction in SIDS’ deaths. And so the system has to be able to arouse and recover. So in the case where there’s low oxygen, maybe the baby would roll over and then resuscitate, where in some cases they don’t. So there’s serious, it has a function and it has a recovery function, and it plays roles in everything from fighting infection to everyday life to cognitive functions.

Dr. Kristina Harris Jackson: Yeah.

Dr. Kathleen Gustafson: Kind of covers it, I hope.

Dr. Bill Harris: So nutrition can influence vagal tone?

Dr. Kathleen Gustafson: I think so.

Dr. Danielle Christifano: Yes.

Dr. Bill Harris: Okay. We got a yes and an I think so, that’s pretty good.

Dr. Danielle Christifano: Newbie here.

Dr. Kathleen Gustafson: I would think so, especially with omega-3s. And one thing I wanted to point out about pregnancy, so this is really the important part of the study, is that when you’re talking about an adaptable system, so we have dramatic changes in the pregnant body, dramatic cardiovascular changes, metabolic changes, and these change across the course of gestation. So as gestation is prolonged, these changes are more dramatic. And what happens normally in pregnancy is there’s a shift towards more sympathetic balance. So a pregnant woman’s heart rate will be faster, her variability will be slightly lower. And then if you add on to these things, and if you’d like to read Bruce McEwens work on allostatic load, that’s a great primer for all of this. But all the concept of allostatic load and weathering are two important concepts here. So we have a functioning healthy person, and they become pregnant, and their heart rate variability will decrease, and their heart rate goes up, and this is a normal adaptation.

They become slightly insulin resistant. Again, a normal adaptation. So if you have a flexible system that’s healthy, then you should be able to get through that pregnancy with no big deal. But if you have an unhealthy system and you’re entering pregnancy with some of these stressors like maternal obesity, economic insecurity, these can be external or internal stressors, just general poor health, poor nutrition, then you’re just adding onto this load and then you add pregnancy to that. And this is where having a healthy heart rate variability becomes more important. And so that’s why we’re excited about the role of DHA, showing this influence, and specifically on vaguely mediated metrics, which shouldn’t have been a surprise to me, but I was surprised that it actually turned out that way. I mean, that’s what you would expect, but since when do you get what you expect, right?

Dr. Bill Harris: Yeah, right. So how exactly did you do the study? What was the design and conduct?

Dr. Kathleen Gustafson: Danielle, I’m talking too much. You want to take that?

Dr. Danielle Christifano: No, you’re doing a great job. Sure, I can take that easy question. So the PANDA study was two arms. We had an 800 milligram group and a 200 milligram group of DHA per day. And so women were randomized to receive either 800 milligrams or 200 milligrams at 12 to 20 weeks gestation throughout their pregnancy. And we followed the moms throughout their pregnancy and then the babies throughout the first year of life. In pregnancy, the two electrophysiology physiological measures that we collected were at 32 weeks and 36 weeks gestation. And so we brought women into the lab at Hoglund Biomedical Imaging Center, and we had them do biomagnetometry. So they sat in a fetal bio magnetometer, which is a giant device that fits over the maternal abdomen that measures all of the electrical signals that are naturally emitted from mom and baby simultaneously. And Kathleen can probably geek out on the physics and the physiology there, but essentially it allowed us to collect maternal heart rate and fetal heart rate simultaneously during these 30 minute data collection procedures.

And so we did that, like I said, at two points during pregnancy. And that’s the data that we used for the study that Kathleen was just referencing, where we found that there was a difference in maternal heart rate and maternal heart rate variability between the 800 milligram group and the 200 milligram group where the women who got the 800 milligram group had lower heart rate and higher variability compared to the women who got the 200 milligram dose. And that’s controlling for dietary intake, maternal weight, and things that we know that also affect heart rate variability. So we were really excited about this.

Dr. Kristina Harris Jackson: And that’s indicative of that more flexible system able to switch between sympathetic, parasympathetic a little bit easier. And so that’s how that all comes together. That’s fascinating. I also thought it was really interesting how you guys did talk about and couch the study and the fact that the system’s supposed to change, it’s naturally changing. It has to because it’s adapting to pregnancy. And so what you’re looking for is basically the control group is going to go on this trajectory, and you’re looking at the difference with the higher DHA group instead of, it’s just like, it’s a really interesting way, I feel like to look at data and it’s harder to explain and get out, but I feel like you guys did a really good job in the paper.

Dr. Bill Harris: How did it affect the babies?

Dr. Kathleen Gustafson: Yeah, so that was interesting. So this study that led up to this, we had two groups in that study and we gave pregnant women 600 milligrams of DHA or a placebo. So no supplement. Now the interesting difference between that study, what was called HOPE and this study, was that the women who entered the PANDA study had higher DHA status when they entered. And then we didn’t use a placebo, so we didn’t see any difference in the fetuses in our primary outcome measure. But that’s explained better when Danielle gets into her egg nutrition paper. So that was a little bit disappointing, but not terribly surprising.

We did see a difference in neurodevelopment after we collected the HOPE data, we went back once we developed this FA (fatty acid) tool with the German group, and we sent them our HOPE data. So they did see a difference in the fatty acid status in the babies that were in the HOPE trial or in the fetuses that were in the HOPE trial. So it’s a fetal measure. So that’s what sparked us to do it in this study. But we just didn’t feel right about knowing what we knew. We didn’t feel right about using a placebo in the follow up in PANDA. So we gave the over-the-counter dose — 200 mg — and compared that to 800 mg.

Dr. Kristina Harris Jackson: Yeah.

Dr. Bill Harris: And you saw differences in infant outcomes in PANDA too?

Dr. Kathleen Gustafson: No, we did not. I take that back, yes and no. So in the parent trial, we only looked at fetal autonomic neurodevelopment and equilibrium between mom and baby. And so in other words, was mom supplying enough DHA to her fetus? If we use EQ (equilibrium) between mom and baby as a sort of index of mom has enough DHA for the baby. And so we did see a difference there. The babies that were born, there was a higher incidence of equilibrium in the babies in the 800 milligram group. But it didn’t affect the neurodevelopmental score. There was no difference in that.

Dr. Kathleen Gustafson: Yeah, so I think it was a Dutch group that published some work on what they call equilibrium. So the concept is that if mom has adequate DHA stores that cross the placenta, the fetus should have DHA equal to mom or maybe even less, for example, maybe it didn’t need as much, so it didn’t take as much from mom. And that’s a big stretch. It’s not that simple. And I’m not a fatty acid person, and even I know that it can’t possibly be that simple. But I was reading a paper by Sheila in US, and something in it made me think that this was a reasonable concept that maybe women didn’t have enough to supply their infants. And that was certainly true in our first study where equilibrium, it never occurred in the placebo group, and it only occurred in 35% of the women in the supplemented group.

Dr. Bill Harris: And how do you measure it?

Dr. Kathleen Gustafson: You just measure red blood cell DHA cord blood and then compare that to maternal red blood cell at delivery.

Dr. Bill Harris: Oh, and if it’s the same value…

Dr. Kathleen Gustafson: If it’s the same or if the newborn is a little bit less, leaving mom with some reserve, this kind of makes sense. If mom’s going to breastfeed, she’s got some reserve. So in other words, the fetus isn’t drawing down mom’s stores and it leaves her with an adequate supply for breastfeeding, during which the infant brain will take up more DHA during breastfeeding.

Dr. Bill Harris: And women sort of at baseline, where people, women that are not supplementing with DHA would be a negative balance in a sense.

Dr. Kathleen Gustafson: Yeah, in a sense.

Dr. Bill Harris: Negative equilibrium or whatever.

Dr. Kathleen Gustafson: And so the Dutch group, they said 6% DHA, red blood cell DHA, or whichever measure they use, 6% was sort of the threshold where you just don’t achieve equilibrium, it’s just not going to happen. In our previous study, I think women were entering the trial at something like 4%. In this current study, it’s more like 7%. But one thing we did find is that the women who at delivery had less than 6% DHA, just like the Dutch group found, nobody below 6% achieved equilibrium with the fetus. And then the 800 milligram group, there were more cases where the mother infant pair achieved equilibrium, and that was significantly higher in the 800 milligram group.

So we accomplished that. But in the end, when we looked at the results, we looked at it by group, and then we looked at those had achieved equilibrium, and those that did not, and it didn’t make any difference in the neurodevelopment mental outcome for the fetus. So it was an interesting measure, and it does show that 6% is too low. And I think a lot of Susan’s work has also shown that 6% is sort of the threshold where you’re increasing your risk of preterm birth and those types of things.

Dr. Kristina Harris Jackson: And just to clarify, the values that you guys get at your lab are a little different than ours. So 6% I think is around 5% for us, and this is part of the whole thing, we’re trying to standardize how exactly the percentage is. But same idea of, it’s with so many things of once you hit a threshold, it might be harder to show an effect with a higher and higher dose. If women are below that threshold, you see more dramatic effects. And that to me is kind of HOPE versus PANDA in some respects, is that the women were in a greater need for DHA.

Dr. Kathleen Gustafson: Exactly.

Dr. Kristina Harris Jackson: It’s easier to see results in research.

Dr. Kathleen Gustafson: Right. And that’s the important concept here. We’re not out there to supplement DHA to women who don’t need it. There’s no point in this. We know that. Let’s focus on getting it into people who need it and health disparities and economic insecurity and those types of things.

Dr. Kristina Harris Jackson: Yeah, and there is a relationship between DHA and socioeconomic economic status as well.

Dr. Kathleen Gustafson: Exactly.

Dr. Kristina Harris Jackson: It all gets all mixed up. So Danielle, let’s keep moving on to the egg paper because this starts to bring together DHA and some other nutrients. The egg I also thought was interesting because the early, it wasn’t the HOPE, but it was KUDOS. They used DHA-enriched eggs, right, at KU?

Dr. Danielle Christifano: Not KUDOS.

Dr. Kristina Harris Jackson: Ok. But I just, when I think about pregnancy and women and eating fish, there’s a lot of issues around that. I mean around the worries about mercury, worries about food safety, and then also just tastes, some people, it’s just not going to happen. So I like the supplementation option, but I also really love an egg because it does have, I mean, it’s typically pretty well tolerated by a lot of people. It can get fairly enriched in DHA before tasting fishy, and then you get choline and lutein, so many important nutrients that, Danielle, I want you to talk about the next paper, which is called Intake Of Eggs, Choline, Lutein, Zeaxanthin and DHA During Pregnancy and the Relationship To Fetal Development. So let’s go there. What was the study?

Dr. Danielle Christifano: So this is another secondary analysis of PANDA. So it is the same women, the same babies. I think it’s important to point that out. We have a lot of papers now coming out on PANDA and ADAURA data, which is Susan Carlson’s large multi-site DHA supplementation trial. But because I’m a nutrition scientist and I always have my nutrition hat on, I knew because I was the one who administered food frequency questionnaires during pregnancy. So we had all of this data about what women were eating while they were pregnant, and I wanted to look at that. And so we have two different measures, two different food frequency questionnaires. So the first one was our DHAFF, that’s what we call it, the DHA food frequency questionnaire. It’s seven questions. I think we’re maybe going to talk about that a little bit later today.

But one of the questions is about egg intake. And for the reasons that you just mentioned, I was like, let’s look at how eggs, how just egg, a simple food could be related to some of the measures of fetal neurodevelopment. And then also we did what’s called the DHQFFQ. So that is a diet history questionnaire that has been used in many, many clinical trials now, and it’s a more overall assessment of diet. And so we collected that food frequency questionnaire in the beginning of the study. So we tried to capture pre-pregnancy diet, and then we also administered a very similar questionnaire during pregnancy at 32 weeks capturing sort of a pregnancy diet. So because we had collected both a measure of pre-pregnancy diet and diet during pregnancy, I just couldn’t resist looking at some of the nutrients and how they could affect neurodevelopment. And then I was specifically interested in those nutrients that we know to be neuroprotective in other research. So DHA, of course, that’s sort of our bread and butter here in the lab. I was also interested in choline and the carotenoids, you mentioned lutein and zeaxanthin.

And then because nutrients outside of supplements, like you mentioned, don’t exist in isolation. I mean, we’re eating foods. I was like, let’s take a look at eggs. And so when we did all these analyses, again, it was a secondary analysis, we found that maternal egg intake was associated with vaguely mediated fetal heart rate variability. And so that’s RMSSD, that’s one of the metrics that we measured in PANDA. We also found that egg intake was associated with the fetal autonomic brain age score, which Kathleen referred to earlier, the FA boss score at 36 weeks gestation. So we got really excited, egg intake alone is associated, even though we didn’t find a relationship with just DHA, we’re finding a relationship with this food, how cool is that? And then we wanted to look at not just eggs, but we wanted to look at the nutrients that I just mentioned, DHA, choline, lutein, zeaxanthin, and how they could potentially act synergistically. And when we did that, we found that there was also association between these nutrients and these measures of fetal neurodevelopment throughout gestation.

Dr. Kristina Harris Jackson: And so when you’re saying there’s these associations, can you say which direction they’re going? Is it more eggs?

Dr. Danielle Christifano: Yeah, yeah, more eggs was better fetal neurodevelopment scores. It gets a little messier when you’re looking at multiple interactions. So when we looked at interactions between choline, DHA, lutein and zeaxanthin, that’s a four-way interaction, and that is too much for anyone to wrap their head around in terms of the direction of the data doesn’t tell us anything about the direction of the relationship. It just tells us there is a relationship. So I think we really need to do some more work here to figure out how these things are interacting and what the relationships look like.

Dr. Bill Harris: So these were not DHA-enriched eggs?

Dr. Danielle Christifano: No.

Dr. Bill Harris: Regular eggs. Okay. Number two, when you talk about zeaxanthin, the carotenoids, and choline, you’re talking about total dietary or egg-derived zeaxanthin choline?

Dr. Danielle Christifano: Yeah. So we did one analysis that was just eggs alone, and then we did one analysis looking at whole diet, DHA, choline, zeaxanthin, and lutein.

Dr. Bill Harris: Okay. And was there a difference in…

Dr. Danielle Christifano: Both models showed an effect.

Dr. Bill Harris: Okay. Most of the, I don’t know what percent of the carotenoids in the diet come from eggs.

Dr. Kristina Harris Jackson: Yeah.

Dr. Bill Harris: Or total.

Dr. Danielle Christifano: I don’t know the answer to that question. Probably quite a bit.

Dr. Bill Harris: 50/50?

Dr. Danielle Christifano: Probably. I think that’s fair.

Dr. Bill Harris: Okay. Okay. All right. Interesting. And when you say neurodevelopmental outcomes, could you be a little more specific?

Dr. Kristina Harris Jackson: Yeah, can you break that one down a little bit?

Dr. Danielle Christifano: So I’m talking about the fetal heart rate variability and the fetal autonomic brain age score.

Dr. Kristina Harris Jackson: That fABAS one.

Dr. Bill Harris: Yeah, yeah, yeah.

Dr. Danielle Christifano: The brain age score?

Dr. Kristina Harris Jackson: Yeah.

Dr. Danielle Christifano: Kathleen, I’m going to let you take that. Our German colleagues created this.

Dr. Kathleen Gustafson: So the score itself is, the output of the score is gestational age. So using these metrics, and there’s a lot of complexity in the metrics — it’s not just standardized heart rate variability. They use a combination of these metrics and the output, and then they correlate that to gestational age. Maybe correlation isn’t the right word. So when they developed the tool, maybe it is correlation. Anyway, there’s a whole series of papers on how this tool was developed, but ultimately the end result was what they called a score. So it’s a comprehensive tool, but the inputs are heart rate variability, and then you get a score of the gestational age. So yeah, that’s basically it. It just predicts gestational age. And so if the fetus is 32 weeks and the score is 32 weeks, then the fetus is on track for neurodevelopment. If the score is 28 weeks and the fetus is 38 weeks, then that’s a low score. See what I mean?

Dr. Kristina Harris Jackson: I see what you mean.

Dr. Bill Harris: And presumably gestational age rate relates to brain age.

Dr. Kathleen Gustafson: Exactly.

Dr. Bill Harris: That’s implicit.

Dr. Kathleen Gustafson: Because fetal heart rate variability changes across the course of gestation. Before 32 weeks, there’s basically no variability. Things aren’t wired up properly yet. But when the sleep states start to emerge and the brain starts to develop, then you’ll start seeing changes in variability. So you use those changes to calculate your score.

Dr. Bill Harris: Do babies sleep in utero?

Dr. Kathleen Gustafson: They call it sleep. Yeah, they do have REM sleep, so yes, they do.

Dr. Bill Harris: Okay. What is heart rate variability measured at one and two days of age tell you?

Dr. Kathleen Gustafson: It’s just as useful.

Dr. Bill Harris: Okay.

Dr. Kathleen Gustafson: Let me put it that way. Now you can’t track this variability across gestation, but it is useful. So this biomagnetometer is a pretty rare thing. There’s only two in the United States, and we have one.

Dr. Kristina Harris Jackson: Oh my gosh.

Dr. Bill Harris: Oh, wow.

Dr. Kathleen Gustafson: Yeah. And the beauty of this is that we don’t have to put anything on the body. The woman just sits in front of it. We record the magnetic fields that come from her heart and the baby’s heart. But in order to use this tool, we had to spend at least five years characterizing the signals we got from it. So we characterize fetal diaphragmatic movements that produces a very distinct sinusoidal wave when the fetus is practicing breathing, and they modulate their heart rate around this breathing just like an adult would with respiratory sinus arrhythmia.

But in the fetus, it’s periodic breathing. So it comes and goes, and you can see their heart rate variability change when they’re practicing breathing. They also do this around non-nutritive suck, so the fetus will suck and swallow amniotic fluid and practice that sucking motion. Again, another developmental requirement so that the baby can come out and eat normally, have a strong suck swallow reflex. And the same with REM eye movements. That will change heart rate variability too. So we had to characterize all of these signals. Hiccups was another one we characterized because heart rate variability changes around that too. So once we had all these things and waveforms identified and characterized, then that helped track neurodevelopment as well.

Dr. Kristina Harris Jackson: That is awesome.

Dr. Bill Harris: Wow.

Dr. Kristina Harris Jackson: And we also, did you want to say something? I was just going to talk about choline. We did some work with the group at Cornell that studied Marie Coddles group, and they found that same dose of DHA, but higher choline, it caused a higher red blood cell DHA incorporation throughout pregnancy, which is the first time I think we’ve seen a totally different nutrient change the response to DHA, and it is during pregnancy. This is not necessarily tested just in anybody. So that egg, choline, eggs are a huge source for choline in pregnancy. And it’s also, I think I mentioned in here, not usually in prenatal supplements.

Dr. Danielle Christifano: Yeah. And we know DHA is reliant on phosphatidylcholine in order to get into the fetal brain. So the two are clearly acting together. And so I love the idea of two nutrients kind of working together to produce optimal outcomes.

Dr. Kristina Harris Jackson: And unfortunately these two are not in a standard prenatal.

Dr. Bill Harris: So taking that to the masses, what do you recommend to women that they eat more eggs and take DHA? I mean when they’re pregnant?

Dr. Danielle Christifano: Yeah. Well, Kathleen, do you want me to…

Dr. Kathleen Gustafson: I was driving to work one day and I thought, gosh, all this work 20 years later, what are we going to tell people? Eat right and exercise. Right? I mean, we’re right back to that.

Dr. Kristina Harris Jackson: It’s so true.

Dr. Kathleen Gustafson: I know. It’s much deeper than that. It’s deeper than that. And there’s a lot of things that have to happen.

Dr. Danielle Christifano: I’m actually writing a paper right now for a family practice journal on prenatal nutrition and neurodevelopment, trying to write it for a clinician. And I’ve created a handout that I hope that they will give to their patients that highlights different foods to eat, because so often we’re telling pregnant women what not to eat. And there’s some good research, qualitative research showing that women are just confused. They don’t know. They don’t know what to eat during pregnancy, they just know they shouldn’t eat fish. And so, yeah, I am not a dietician or a public health expert by any means, but I think this research certainly points to the fact that recommending simple foods like eggs or seafood if they can tolerate it, and if not, take a DHA supplement is a really simple message that we could share in the clinic.

Dr. Kristina Harris Jackson: Yeah, absolutely. I mean, fish are such an amazing package of nutrients for pregnancy. It’s kind of wild. And the fact that they’ve been, I mean, it’s ironic and sad how…

Dr. Bill Harris: Vilified.

Dr. Kristina Harris Jackson: Vilified they got and I mean, it was really based on research around pilot whale blubber being 20X, and it bled into anything from the ocean and caused, it’s like telephone. It’s like, well, don’t eat these fish. But then it just kind of came into like, well, just, I’m not going to bother eating fish. It could be bad, when actually not eating any fish completely eliminates omega-3s from your diet unless you supplement because EPA and DHA are only found of fish. So it’s kind of a natural experiment going on. But it does also show this is a nutrient of need that is missing in the diet of a lot of women. And in pregnancy, what’s great is you can also see these kind of immediate effects, even starting supplementation in the beginning/middle of pregnancy. It’s not like folic acid where if you don’t have it on board at the very beginning then you kind of miss your boat.

You can kind of do a saving dose a higher dose of DHA throughout the second half. But we also see that coming into pregnancy, all of the research is showing that baseline level of DHA, that alone predicts outcomes where if you’re higher, outcomes are typically better, especially with preterm birth. And if you’re lower, that’s where that higher dose thousand milligrams of DHA 800 are really needed to catch up. So let’s go to our last paper, which is very implementation-focused. So KU Med has so much of this great research and you guys want to get it going. How do we get this happening in the clinic and testing, questionnaires. There’s all different ways that we can try and assess DHA status. So please talk to us about your last paper, the Utility of a Seven Question Online Screener For DHA Intake and How it’s Being Used Clinically.

Dr. Danielle Christifano: So again, credit to Susan Carlson because I think in the final stages of her career, she has really been a champion of, okay, we know DHA is beneficial. Let’s get the information out the masses. And so we’ve been working together as a team to try and share the good news about DHA supplementation in a clinical setting. And one way that we’re trying to do that is by using the seven-question food frequency questionnaire. So both PANDA and the ADAURA study used the seven-question questionnaire about DHA intake. So we had a huge data set of people who had already completed this questionnaire, and we found that it was highly correlated with blood levels of DHA. So what they were reporting on this very simple questionnaire was almost as good as measuring their blood levels, not as good, and definitely not as good for research purposes.

I will say that I think it’s really important to still measure blood levels of DHA in research, but, we thought, okay, so let’s look at how this questionnaire predicts or is related to early preterm birth. And we found women who report consuming less than 150 milligrams of DHA early in pregnancy have a higher risk of early preterm birth. And then to go beyond that, the women that are reporting low levels of intake in early pregnancy are unfortunately also less likely to be adherent to our supplementation intervention. And so it’s this multifaceted problem. But we have taken that questionnaire now and we have started using it in the OB clinic at KU Medical Center. And so we have sort of an OB champion there, Dr. Jean Lee, who has allowed us to use this questionnaire with all new OB patients. So it’s a part of their intake forms.

They get a link to a REDCap survey. And so now we are building this huge dataset of DHA food frequency questionnaire,  so that we can try to understand the landscape of DHA intake in early pregnancy. And then also we’ve just started sending out a follow-up questionnaire asking, after you completed the seven question questionnaire, did your provider talk to you about DHA? How much did they recommend you take? And unfortunately, our data right now, and this is a project that is in process, but it’s showing that the women who report low intake, only about 35% are hearing anything from their provider about DHA. And we’ve had four or five early preterm births in the dataset now, and none of them reported hearing from their provider, and they all had low DHA intake. So it’s like, oh.

Dr. Bill Harris: Well, but this is a great study to do.

Dr. Kristina Harris Jackson: This is great data.

Dr. Bill Harris: And you’ve got approval from all these women to follow-up, et cetera as a research cohort.

Dr. Danielle Christifano: Yeah, it’s actually quality improvement. So it’s not technically research. So because it’s happening up in the clinic, it’s considered quality improvement. So that’s been fun to learn how that works.

Dr. Bill Harris: You can publish quality improvement.

Dr. Danielle Christifano: Totally.

Dr. Bill Harris: Stories, studies. That’s very interesting. That’s fantastic.

Dr. Kristina Harris Jackson: Yeah, I mean it’s fantastic and it sounds very real. This of course is happening. Implementation’s a whole different ballgame than the controlled setting of a research study. And in our perfect world, we would have an RBC DHA test or a whole blood DHA test at the first visit where you do blood work and then the doctor would actually have a number to treat. And you guys have the data.

Dr. Bill Harris: I wonder if they trust that number more than they trust the questionnaire. Would they be more compelled to say something to the woman if they had a lab slip with a number on it? This is below normal, asterisk, red dots and things like that versus the question? I don’t know.

Dr. Danielle Christifano: Yeah, I mean, the piece that we haven’t done yet that we’re wanting to do is to do some provider education around this. We hope to get some funding to actually do some serious focus groups and figure out how to enroll only people who have low DHA intake according to this questionnaire and give them a high dose from the beginning and support them throughout their pregnancy. But we’re working on getting that funded.

Dr. Bill Harris: Cool.

Dr. Kristina Harris Jackson: And the other piece would be could they give them a prescription for a high quality high dose because you say, go take a high dose supplement, and then you go to the grocery store and it’s like a nightmare. There’s so many options and confusion. So, it’ll almost be a drug model of you test, you have a treatment, it is just DHA or just EPA/DHA and an appropriate dose. I mean, you guys have the dose tested. And if it could be treated that way, to me that feels like a lot less pressure on the mom to go do one more thing.

Like you said, women are confused about what they have to eat, and they feel a lot of pressure. And it’s like stress is not good. Extra stress around eating is not good. And I feel like testing could take the stress off mom and just be like, we’re going to treat you for this low level of something. We’d love it if everybody, I mean public health-wise, we think fish need to be promoted a lot more. And most of the fish available are not super high in mercury. But for those low women who also you said are less likely to follow-up, less likely to adhere to just a general, you should go get a supplement. But if they’re given something, it just takes one barrier out of the way. And that’s what we’re…

Dr. Danielle Christifano: Unfortunately, even if they’re given it. Well, we found in our study, we gave the supplement and it was still a struggle. So I think we have more work to do there too.

Dr. Bill Harris: That’s true.

Dr. Kristina Harris Jackson: It’s tricky. But I also, this is one of the only things now that is a treatment for, or preventative for preterm birth.

Dr. Danielle Christifano: And providers don’t know that, unfortunately.

Dr. Kristina Harris Jackson: Yeah, no.

Dr. Bill Harris: Education is what’s missing here.

Dr. Kristina Harris Jackson: And I think we’ve gotten to a pretty good place where the story is, like you said, Kathleen, it comes back. Nutrition is so complicated, and then it always comes back to the simple stuff.

Dr. Bill Harris: Eat less, move more.

Dr. Kristina Harris Jackson: It’s kind of maddening. Yeah. Fantastic. We are so happy that you guys are still doing the work. I know, Kathleen, you are retired, and well deserved. It sounds like you’re still very busy.

Dr. Kathleen Gustafson: I try to stay involved. I’m still on as emeritus professor, so I can keep my finger in the DHA work.

Dr. Danielle Christifano: We’re not letting her go.

Dr. Kristina Harris Jackson: No.

Dr. Danielle Christifano: Never letting them go.

Dr. Kristina Harris Jackson: No. But it’s great to just meet the next generation and the kind of work that’s being done at KU is pretty extraordinary in this field, I think. Thank you.

Dr. Kathleen Gustafson: And I do want to kind of emphasize that any future trials with pregnant women, heart rate variability is very easy to record. I mean, it’s just an EKG. That’s all it is. You don’t need a biomagnetometer to do what we did. It’s very nice. It’s very nice if you’re doing fetal work. But like Dr. Harris suggested, you can measure these things in the newborn too, and you can measure other things in the newborn. So what I’d like to see in women who are enrolled in these studies is longer, longer duration recordings, wearables. That would be excellent. Especially if we could record heart rate variability during sleep. That would be even better. So there’s a lot of opportunities here to get some in-depth studies at a very low price.

Dr. Danielle Christifano: I’m working on getting those problems studied.

Dr. Kathleen Gustafson: Yeah.

Dr. Danielle Christifano: I want to do those studies. But yeah, others too. I mean, gosh, everyone, do the research.

Dr. Kathleen Gustafson: Yeah. There’s a lot of groups, not a lot, but there’s a few groups now that are really focusing on heart rate variability in pregnant women. What does this look like? What are the individual differences? So they’re kind of cleaning up the field for the rest of us that want to look at what things look like when they’re not normal.

Dr. Kristina Harris Jackson: And it’s such a functional measure that it takes so many things like, but it’s simple enough to grasp.

Dr. Kathleen Gustafson: Exactly.

Dr. Kristina Harris Jackson: We’re glad you guys are doing all the really detailed work and then you can bring it back and we can mostly understand these really complicated, interesting systems.

Dr. Kathleen Gustafson: Yeah, I think one of the most important things is that when we write these grants, at the end, we always say we want to affect policy. And I think we did. That makes me really happy that we actually accomplished this. So I think this work and future work and Susan’s work, all of this is working towards healthcare policy.

Dr. Kristina Harris Jackson: Yeah, absolutely.

Dr. Bill Harris: Great.

Dr. Kristina Harris Jackson: Well, we’ve reached the end of our time, and we’ve covered a lot. Thank you so much for joining us, and we will keep an eye on you guys and keep watching what you do.

Dr. Kathleen Gustafson: Excellent. Fund those studies.

Dr. Kristina Harris Jackson: Yes. Thanks.

Dr. Bill Harris: Thank you. Bye-bye.

Dr. Kathleen Gustafson: Okay, bye.

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