Influence of maternal and socioeconomic factors on breast milk fatty acid composition in urban, low-income families

Maternal and Socioeconomic Factors Affecting Polyunsaturated Fatty Acid Intake

This clinical summary emphasizes the role of long-chain polyunsaturated fatty acids (LCPUFA) intake on phospholipid fatty acid concentration in the erythrocyte membrane in pregnant women. It also highlights the various maternal and socioeconomic factors influencing the saturated fatty acid (SFA) and LCPUFA concentrations in the breast milk of low-income maternal cohorts.


Long-chain w-3 polyunsaturated fatty acids (omega-3 LCPUFA) play a crucial role in the growth and development of the offspring. Docosahexaenoic acid (DHA), an w-3 LCPUFA, is involved in brain growth and functioning and visual and neural processes. DHA is synthesized in the liver from a- linolenic acid (ALA); however, only a small amount of ALA is converted into DHA. The partial conversion frequently results in insufficient LCPUFA, especially during pregnancy and breastfeeding, when their needs are more significant.

The LCPUFA Intake Gap in Indian Mothers

The recommended daily intake of DHA is 300 mg/day (d) during pregnancy. DHA intake by Indian women is a meager 3% of the recommended amounts, about 0.011 g/d throughout pregnancy. This is lower than 10 times the consumption of pregnant women in United Kingdom (0.147 g/d) and the Denmark (0.182 g/d). 1 Thus, a diet rich in w-3 fatty acids is critical in ensuring adequate concentrations of LCPUFA in pregnant and lactating women. 1

Read this article, providing a summary of two independent clinical trials emphasizing the importance of PUFA on pregnancy and the growth and development of the offspring, and the factors influencing the composition of breast milk.

Study 1:


To analyze the effect of consuming LCPUFA on their concentrations in the erythrocyte membrane during pregnancy.

Study design and results

The details of the study design, which assessed the role of PUFA during pregnancy, are provided in table 1.1.

Table 1.1. Summary of the study design. 1 (Adapted from Dwarkanath et al., 2019)

Study type

Prospective cohort study

No. of participants, n


Study group

Pregnant women from urban South Indian middle-class population

Inclusion criteria

Women in the

  • First trimester at up to 12 weeks of gestation during 

  • Age group of 16-40 years

Exclusion criteria

Women with:

  • Multiple pregnancies

  • Chronic illnesses – diabetes mellitus, hypertension, heart disease and thyroid disease, hepatitis B surface antigen (HBsAg) positive, HIV or syphilis infection

Duration of study

Four years

Indain diet has a w-3:w-6 intake ratio of 1:30-70, much higher than 1:5-10 which is the recommended ratio for optimal health.The dietary graph of pregnant women over the 3 trimesters revealed increased intake of all w-3 fatty acids, while the w-6 fatty acids remained unchanged. Saturated and monounsaturated fatty acid intakes also increased, while PUFA intake remained unchanged. Thus LA or AA intake profile didn't show a significant variation. When trimester- based changes were analyzed, a significant increase in macronutrients and ALA (15-20%) intakes was seen in the 2nd and 3rd trimesters. DHA intakes were similar in the 2nd and 3rd trimester, EPA intakes showed an increased trend across the trimesters. 1

The effect of various fatty acid intakes on red cell membrane concentrations of w-3 and w-6 fatty acids is shown in Table 1.2. The quantity of EPA and DHA consumed during pregnancy was positively linked (p<0.01). 1

Table 1.2: Correlation (r values) between intake of fatty acids and red cell membrane concentrations across all three trimesters. (Adapted from Dwarkanath et al., 2009)


I trimester (n=133)

II trimester (n=130)

III trimester (n=123)

Linoleic acid



0.191 (p<0.05)

α-linolenic acid




Arachidonic acid




Eicosapentaenoic acid



0.370 (p<0.01)

Docosahexaenoic acid



0.413 (p<0.01)

The w-3: w-6 parent fatty acid ratio in red cell membranes showed a trend similar to that of the intake ratio. Comparison of individual fatty acid consumptions and the erythrocyte membrane concentration of w-3 and w-6 fatty acids (Table 1.2) implied that EPA and DHA intake and concentration were positively correlated throughout the pregnancy (p 0.01). 1


South Indian diets during normal pregnancies are low in w-3 fatty acids, and the red cell membrane concentration of DHA did not change throughout the pregnancy duration. Therefore, dietary methods for improving the consumption of w-3 fatty acids need to be considered in the diets of young women and especially during pregnancy.

Study 2:


To assess the effect of maternal and socioeconomic factors on the SFA and PUFA concentrations in the breast milk of low-income nursing women.

Study design and results:

The entire design of this study, evaluating the performance of rotavirus and oral poliovirus vaccines in developing countries (PROVIDE study), is summarized in table 2.1. 2

Table 2.1. A summary of the PROVIDE study design. (Adapted from Nayak et al., 2016)

Study type

Prospective cohort study

Duration of the study

One year

Study group

Group 1: 700 mothers and new-borns from slums in Bangladesh

Group 2: 372 mother-infant pairs from urban slums in Kolkata India

Clinical characteristics:

Postpartum weight, Kg

Stay home mother, %

Higher Education, %

49.4 ± 9.4

589 (86.2)

109 (16.0)

49.4 ± 9.7

355 (95.4)

126 (33.9)

Income, 1,000 currency units

12.8 ± 9.5


Key findings of this study 2

Figure1: Key findings of the the performance of rotavirus and oral poliovirus vaccines in developing countries (PROVIDE) study. Adapted from: Nayak et al., 2016. SFA: Saturated fatty acid; PUFA: Polyunsaturated fatty acid


The ratio of w-3: w-6 fatty acid in a pregnant woman's erythrocyte membranes directly correlates to the dietary intake of these components. Also, socioeconomic factors such as maternal education and household prosperity influence the composition of breast milk with regards to the amount of LCPUFA. In addition, maternal biological factors such as height and infant birth order also influence breast milk composition.


  1. Dwarkanath P, Muthayya S, Thomas T, Vaz M, Parikh P, Mehra R, Kurpad AV. Polyunsaturated fatty acid consumption and concentration among South Indian women during pregnancy. Asia Pacific journal of clinical nutrition. 2009 Jan;18(3):389-94.
  2. Nayak U, Kanungo S, Zhang D, Ross Colgate E, Carmolli MP, Dey A, Alam M, Manna B, Nandy RK, Kim DR, Paul DK. Influence of maternal and socioeconomic factors on breast milk fatty acid composition in urban, low-income families. Maternal & child nutrition. 2017 Oct;13(4):e12423.


The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well- balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Importance of Breastfeeding:

Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defense against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A', (ii) breast miIk- A) is, a complete and balanced food and provides all the nutrients needed by the infant [for the first six months of life] (B) has anti-infective properties that protect the infants from infection in the early months (C) is always available; (D) needs no utensils or water (which might, carry germs) or fuel for its preparation, (iii) breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes, (iv) mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators; (b) details of management of breast feeding, as under:- (i) breast-feeding- (A) immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly; (B) is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so (ii) in order to promote and support breast-feeding the mother's natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives. (iii) adequate care for the breast and nipples should be taken during pregnancy. (iv) it is also necessary to put the infant to the breast as soon as possible after delivery, (v) let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in"); (vi) give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth; (vii) the practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged; (viii) let the infants suckle on demand; (ix) every effort should be made to breast-feed the infants whenever they cry; (x) mother should keep her body and clothes and that of the infant always neat and clean.

Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle-feeding in the first weeks of life may reduce the supply of your own breastmilk and reversing the decision not to breast-feed is difficult.

Always consult your Healthcare Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.

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