The efficacy and safety of omega-3 fatty acids on depressive symptoms in perinatal women: a meta-analysis of randomized placebo-controlled trials

Omega-3 Fatty Acids and Neuroinflammation in Depression: Targeting Damage-Associated Molecular Patterns and Neural Biomarkers

Major Depressive Disorder (MDD) is a prevalent mental health condition with a complex pathophysiology involving neuroinflammation, neurodegeneration, and disruptions in neuronal and glial cell function. Microglia, the innate immune cells of the central nervous system, release inflammatory cytokines in response to pathological changes associated with MDD. Damage-associated molecular patterns (DAMPs) act as alarms, triggering microglial activation and subsequent inflammatory cytokine release. This review examines the cellular mechanisms underlying MDD pathophysiology, focusing on the lipid-mediated modulation of neuroinflammation. We explore the intricate roles of microglia and astrocytes in propagating inflammatory cascades and discuss how these processes affect neuronal integrity at the cellular level. Central to our analysis are three key molecules: High Mobility Group Box 1 (HMGB1) and S100 Calcium Binding Protein β (S100β) as alarmins, and Neuron-Specific Enolase (NSE) as an indicator of neuronal stress. We present evidence from in vitro and ex vivo studies demonstrating how these molecules reflect and contribute to the neuroinflammatory milieu characteristic of MDD. The review then explores the potential of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) as neuroinflammation modulators, examining their effects on microglial activation, cytokine production, and neuronal resilience in cellular models of depression. We critically analyze experimental data on how ω-3 PUFA supplementation influences the expression and release of HMGB1, S100β, and NSE in neuronal and glial cultures. By integrating findings from lipidomic and cellular neurobiology, this review aims to elucidate the mechanisms by which ω-3 PUFAs may exert their antidepressant effects through modulation of neuroinflammatory markers. These insights contribute to our understanding of lipid-mediated neuroprotection in MDD and may inform the development of targeted, lipid-based therapies for both depression and neurodegenerative disorders.

Omega-3 Polyunsaturated Fatty Acids in Depression

Omega-3 polyunsaturated fatty acids have received considerable attention in the field of mental health, in particular regarding the treatment of depression. This review presents an overview of current research on the role of omega-3 fatty acids in the prevention and treatment of depressive disorders. The existing body of evidence demonstrates that omega-3 fatty acids, in particular eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have antidepressant effects that can be attributed to their modulation of neuroinflammation, neurotransmitter function, and neuroplasticity. Nevertheless, clinical trials of omega-3 supplementation have yielded inconsistent results. Some studies have demonstrated significant reductions in depressive symptoms following omega-3 treatment, whereas others have shown minimal to no beneficial impact. A range of factors, encompassing dosage, the ratio of EPA to DHA, and baseline nutritional status, have been identified as having a potential impact on the noted results. Furthermore, it has been suggested that omega-3 fatty acids may act as an adjunctive treatment for those undergoing antidepressant treatment. Notwithstanding these encouraging findings, discrepancies in study designs and variability in individual responses underscore the necessity of further research in order to establish uniform, standardized guidelines for the use of omega-3 fatty acids in the management of depressive disorders.

Targeting maternal gut microbiome to improve mental health outcomes-a pilot feasibility trial

Background

Perinatal depression and anxiety (PDA) is prevalent in new and expectant mothers, affecting millions of women worldwide. Those with a history of mood and anxiety disorders are at the greatest risk of experiencing PDA in a subsequent pregnancy. Current safety concerns with pharmacological treatments have led to a greater need for adjunctive treatment options for PDA. Changes in the composition of the microbiome have been associated with various diseases during pregnancy, and these changes are thought to play some role in perinatal mood disorders. While the relationship between PDA and the microbiome has not been explored, evidence suggests that nutritional interventions with fiber, fish oils, and probiotics may play a favorable role in neuropsychiatric outcomes during and after pregnancy. The primary objective of the present study is to assess the feasibility and acceptability of a combination of nonpharmacological interventions to maintain stability in pregnant women who have a history of depression and/or anxiety. This study will also aim to understand ease of recruitment and protocol adherence in this cohort.

Methods

This is a single-centered, partially randomized, placebo-controlled, double-blind feasibility trial. One hundred pregnant women with a history of depression and/or anxiety/PDA will be recruited and randomized into one of four arms, which could include the following: receiving a daily dose of both investigational products and dietary counseling on increasing dietary fiber, receiving a daily dose of both investigational drugs only, receiving fish oil investigational product and placebo, and a control arm with no intervention. The study involves six study visits, all of which can be conducted virtually every 3 months from the time of enrollment. At all study visits, information on diet, mental health, physical activity, and sleep quality will be collected. Additionally, all participants will provide a stool sample at each visit.

Discussion

It is anticipated that pregnant women with a history of depression and anxiety will be particularly interested in partaking in this trial, resulting in favorable recruitment rates. Given the positive findings of omega-3 fatty acids (O3FAs) and probiotic supplements on mental health symptoms in nonpregnant adults, we expect a similar trend in PDA symptoms, with a low likelihood of adverse events. This study will build the foundation for larger powered studies to further contribute evidence for the efficacy of this potential preventative treatment option.

Trial registration

This trial was registered at ClinicalTrials/gov on October 6, 2023; NCT06074250. Trial Sponsor: The Canadian College of Naturopathic Medicine, 1255 Sheppard Ave E, Toronto, ON M2K 1E2, 416-498-1255.

Dietary Intake of Nutrients Involved in Serotonin and Melatonin Synthesis and Prenatal Maternal Sleep Quality and Affective Symptoms

Poor sleep quality and psychological distress in pregnancy are important health concerns. Serotonin and melatonin levels may underlie variation in these adverse outcomes. In this study, we examined dietary nutrients involved in serotonin and melatonin synthesis in relation to maternal sleep quality and affective symptoms during pregnancy. Pregnant women at no greater than normal medical risk at enrollment completed 24-hour dietary recalls in mid-late pregnancy. Usual intakes of vitamin B6, vitamin D, eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA), and tryptophan were estimated from dietary intake of foods and supplements using the National Cancer Institute (NCI) method. Sleep quality, depression, and anxiety were measured using validated questionnaires. Associations between nutrient intakes, sleep quality, and affective symptoms were estimated using generalized estimating equation models adjusting for potential confounding factors. In minimally adjusted models, EPA + DHA and tryptophan intakes were associated with a lower score indicating better sleep quality (b: -1.07, 95% CI: -2.09, -0.05) and (b: -12.40, 95% CI: -24.60, -0.21), respectively. EPA + DHA and tryptophan intakes were also associated with a lower odds of shorter sleep duration and sleep disturbances. In addition, tryptophan was associated with a lower odds of higher sleep latency. However, associations were attenuated and nonsignificant after adjustment for demographic and lifestyle factors. In conclusion, intakes of EPA + DHA and tryptophan were associated with improved sleep quality, but these associations were confounded by maternal demographic and lifestyle characteristics. This study highlights the need to consider dietary intake and pregnancy health in the context of demographic characteristics and lifestyle behaviors.

Docosahexaenoic Acid (DHA) and Eicosapentaenoic Acid (EPA)-Should They Be Mandatory Supplements in Pregnancy?

Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are essential fatty acids for the human body. Seafood and microalgae are the most important sources of omega-3 fatty acids. Supplementation with 200 mg/day of DHA during pregnancy and breastfeeding has been suggested for women and infants in countries with low seafood consumption. Maternal concentration of DHA and EPA was associated with concentration in cord blood and breast milk. High concentrations of DHA and EPA were identified at the level of retinal photoreceptors and neuronal cell membranes. It was observed that supplementation with DHA and EPA during pregnancy had beneficial effects on the neurological development of the fetus and infant by improving language, memory, attention, and hand coordination, affecting sleep patterns, and improving visual acuity. Beneficial effects on the development of the infant were also associated with the maternal intake of omega-3 fatty acids during breastfeeding. Supplementation with DHA and EPA may reduce the risk of preterm birth but also of preeclampsia in low-risk pregnancies. Women of childbearing age should have an intake of 250 mg/day of DHA + EPA from their diet or supplements. To reduce the risk of premature birth, pregnant women must additionally receive at least 100-200 mg of DHA every day. It is recommended that supplementation with omega-3 fatty acids starts before 20 weeks of pregnancy. Beneficial effects on the mother have been identified, such as the reduction of postpartum depression symptoms, the decrease of cardiovascular risk, and the anti-inflammatory role.

Clinical impacts of n-3 fatty acids supplementation on depression symptoms: an umbrella review of meta-analyses

Several meta-analyses investigating the efficacy of n-3 PUFA in alleviating depression symptoms have reported conflicting findings. In the present study, we aimed to perform an umbrella meta-analysis to provide a definite conclusion. A comprehensive systematic search of PubMed, Scopus, Embase, Web of Science and Cochrane Central Library was performed up to June 2021. Meta-analysis studies evaluating the effects of n-3 PUFA on depression symptoms were included. The quality of the included meta-analyses was assessed using AMSTAR questionnaire. Out of 101 studies, twenty-two studies with twenty-six effect sizes (ES) were eligible for inclusion. Sixteen ES showed significant improving effect of n-3 supplementation on depression symptoms among which eleven ES had small ES. The other studies observed no significant effect. Available evidence suggests that n-3 PUFA (EPA, DHA) supplementation could be considered as an effective add-on therapeutic approach in relieving depression symptoms.

The role of polyunsaturated fatty acids in the neurobiology of major depressive disorder and suicide risk

Long-chain polyunsaturated fatty acids (LC-PUFAs) are obtained from diet or derived from essential shorter-chain fatty acids, and are crucial for brain development and functioning. Fundamentally, LC-PUFAs' neurobiological effects derive from their physicochemical characteristics, including length and double bond configuration, which differentiate LC-PUFA species and give rise to functional differences between n(omega)-3 and n-6 LC-PUFAs. LC-PUFA imbalances are implicated in psychiatric disorders, including major depression and suicide risk. Dietary intake and genetic variants in enzymes involved in biosynthesis of LC-PUFAs from shorter chain fatty acids influence LC-PUFA status. Domains impacted by LC-PUFAs include 1) cell signaling, 2) inflammation, and 3) bioenergetics. 1) As major constituents of lipid bilayers, LC-PUFAs are determinants of cell membrane properties of viscosity and order, affecting lipid rafts, which play a role in regulation of membrane-bound proteins involved in cell-cell signaling, including monoaminergic receptors and transporters. 2) The n-3:n-6 LC-PUFA balance profoundly influences inflammation. Generally, metabolic products of n-6 LC-PUFAs (eicosanoids) are pro-inflammatory, while those of n-3 LC-PUFAs (docosanoids) participate in the resolution of inflammation. Additionally, n-3 LC-PUFAs suppress microglial activation and the ensuing proinflammatory cascade. 3) N-3 LC-PUFAs in the inner mitochondrial membrane affect oxidative stress, suppressing production of and scavenging reactive oxygen species (ROS), with neuroprotective benefits. Until now, this wealth of knowledge about LC-PUFA biomechanisms has not been adequately tapped to develop translational studies of LC-PUFA clinical effects in humans. Future studies integrating neurobiological mechanisms with clinical outcomes may suggest ways to identify depressed individuals most likely to respond to n-3 LC-PUFA supplementation, and mechanistic research may generate new treatment strategies.

A Randomized, Open-Label, Single-Dose, Crossover Study of the Comparative Bioavailability of EPA and DHA in a Novel Liquid Crystalline Nanoparticle-Based Formulation of ω-3 Acid Ethyl Ester Versus Omacor® Soft Capsule among Healthy Adults

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are well known for their capacity to lower triglyceride levels, but the clinical effectiveness is hindered by limited bioavailability and patient adherence. To address this challenge, we introduce a novel liquid crystalline nanoparticle-based formulation, the innovative medicine and drug delivery (IMD)-Omega soft capsule (cap), designed to optimize the pharmacokinetics (PK) and safety of EPA and DHA. This randomized, open-label, crossover study engages a cohort of 24 healthy adult subjects, utilizing key PK parameters like Cmax, AUC, Tmax, t½, and Ke to conduct a comprehensive evaluation. The trial compares the performance of the IMD-Omega soft cap with the well-established Omacor® soft cap. The IMD-Omega soft cap exhibited an impressive 110% increase in bioavailability for EPA and a remarkable 134% surge for DHA in comparison to the Omacor® soft cap over a span of 72 h. The key success can be attributed to the innovative liquid crystalline nanoparticle design, bolstering the dissolution and permeability of these essential fatty acids. Intriguingly, intra-participant variability for AUC0-72 h and Cmax were calculated at 45.04% and 34.26%, respectively. It is noteworthy that the parameters of Tmax for EPA (≈6.00 h) and DHA (≈5.00 h), t½ for both EPA and DHA ≈ 30-40 h, and Kel around 0.18-0.22 h-1 for EPA and ≈0.008-0.02 h-1 for DHA, displayed comparability between the IMD-Omega and Omacor® formulations. Encouragingly, the IMD-Omega soft cap showed excellent tolerability. The promise of optimized patient compliance and reduced dosages adds further weight to its potential significance.

Maternal n-3 PUFA Intake During Pregnancy and Perinatal Mental Health Problems: A Systematic Review of Recent Evidence

PURPOSE OF REVIEW

Pregnant women are vulnerable to mental health problems. Increasing evidence shows that omega-3 polyunsaturated fatty acid (n-3 PUFA) intake during pregnancy is beneficial to maternal perinatal mental health. A systematic review is needed to examine the associations reported in recent studies. The objective of this review was to provide an updated review on the association of antenatal n-3 PUFA intake via different sources (seafood, fish, overall diet, and supplementation) with perinatal mental health problems including depression, anxiety, and psychological distress.

RECENT FINDINGS

Searches were performed in Web of Science, Embase, PubMed, and APA PsycInfo databases on 21 June 2021. A total of 2133 records were screened. Data including the name of the first author, publication year, study design, sample characteristics, dietary assessment time and tools, mental health outcome measures, and other relevant information were extracted. In total, 13 articles were included in this review and assessed qualitatively. The results demonstrated that dietary intake of n-3 PUFA during pregnancy was associated with perinatal mental health, but the effect of n-3 PUFA supplementation was influenced by pre-existing medical conditions, socio-demographic characteristics, and dietary and lifestyle patterns during pregnancy. Our review found that sources of n-3 PUFA may have differential effects on woman's mental health during and after pregnancy. Further research using large-size cohort or well-controlled trial protocol is needed to determine the effect of n-3 PUFA supplementation during pregnancy on perinatal mental health.

DHA supplementation and pregnancy complications

Docosahexaenoic acid (DHA) supplementation is recommended for women during pregnancy because of its neurological, visual, and cognitive effects. Previous studies have suggested that DHA supplementation during pregnancy may prevent and treat certain pregnancy complications. However, there are contradictions in the current related studies, and the specific mechanism by which DHA acts remains unclear. This review summarizes the research on the relationship between DHA intake during pregnancy and preeclampsia, gestational diabetes mellitus, preterm birth, intrauterine growth restriction, and postpartum depression. Furthermore, we explore the impact of DHA intake during pregnancy on the prediction, prevention, and treatment of pregnancy complications as well as its impact on offspring neurodevelopment. Our results suggest that there is limited and controversial evidence for the protective effect of DHA intake on pregnancy complications, with the exception of preterm birth and gestational diabetes mellitus. However, additional DHA supplementation may improve long-term neurodevelopmental outcomes in the offspring of women with pregnancy complications.

Personalized Medicine of Omega-3 Fatty Acids in Depression Treatment in Obese and Metabolically Dysregulated Patients

The co-occurrence of depression and obesity has become a significant public health concern worldwide. Recent studies have shown that metabolic dysfunction, which is commonly observed in obese individuals and is characterized by inflammation, insulin resistance, leptin resistance, and hypertension, is a critical risk factor for depression. This dysfunction may induce structural and functional changes in the brain, ultimately contributing to depression's development. Given that obesity and depression mutually increase each other's risk of development by 50-60%, there is a need for effective interventions that address both conditions. The comorbidity of depression with obesity and metabolic dysregulation is thought to be related to chronic low-grade inflammation, characterized by increased circulating levels of pro-inflammatory cytokines and C-reactive protein (CRP). As pharmacotherapy fails in at least 30-40% of cases to adequately treat major depressive disorder, a nutritional approach is emerging as a promising alternative. Omega-3 polyunsaturated fatty acids (n-3 PUFAs) are a promising dietary intervention that can reduce inflammatory biomarkers, particularly in patients with high levels of inflammation, including pregnant women with gestational diabetes, patients with type 2 diabetes mellitus, and overweight individuals with major depressive disorder. Further efforts directed at implementing these strategies in clinical practice could contribute to improved outcomes in patients with depression, comorbid obesity, and/or metabolic dysregulation.

AKT and MAPK signaling pathways in hippocampus reveals the pathogenesis of depression in four stress-induced models

Major depressive disorder (MDD) is a highly heterogeneous psychiatric disorder. The pathogenesis of MDD remained unclear, and it may be associated with exposure to different stressors. Most previous studies have focused on molecular changes in a single stress-induced depression model, which limited the identification of the pathogenesis of MDD. The depressive-like behaviors were induced by four well-validated stress models in rats, including chronic unpredictable mild stress, learned helplessness stress, chronic restraint stress and social defeat stress. We applied proteomic and metabolomic to investigate molecular changes in the hippocampus of those four models and revealed 529 proteins and 98 metabolites. Ingenuity Pathways Analysis (IPA) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis identified differentially regulated canonical pathways, and then we presented a schematic model that simulates AKT and MAPK signaling pathways network and their interactions and revealed the cascade reactions. Further, the western blot confirmed that p-AKT, p-ERK12, GluA1, p-MEK1, p-MEK2, p-P38, Syn1, and TrkB, which were changed in at least one depression model. Importantly, p-AKT, p-ERK12, p-MEK1 and p-P38 were identified as common alterations in four depression models. The molecular level changes caused by different stressors may be dramatically different, and even opposite, between four depression models. However, the different molecular alterations converge on a common AKT and MAPK molecular pathway. Further studies of these pathways could contribute to a better understanding of the pathogenesis of depression, with the ultimate goal of helping to develop or select more effective treatment strategies for MDD.

Omega-3 fatty acid intake during pregnancy and risk of infant maltreatment: a nationwide birth cohort - the Japan Environment and Children's Study

BACKGROUND

Intake of omega-3 polyunsaturated fatty acids (PUFAs) has favorable effects, including reducing violent and aggressive behaviors, but its association with infant maltreatment is unknown. We therefore tested the hypothesis that maternal intake of omega-3 PUFAs is associated with a lower risk of infant maltreatment.

METHODS

Participants were 92 191 mothers involved in the ongoing Japan Environment and Children's Study. Omega-3 PUFA intake during pregnancy was measured using a food frequency questionnaire. Infant maltreatment was assessed using a self-reported questionnaire administered at 1 and 6 months postpartum.

RESULTS

Analysis using the lowest quintile of intake as a reference revealed that the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for cases of 'hitting' decreased as quintiles increased, with values for the second to fifth quintiles of 0.93 (95% CI 0.77-1.13), 0.79 (95% CI 0.64-0.97), 0.78 (95% CI 0.64-0.96), and 0.72 (95% CI 0.59-0.89), respectively. Adjusted ORs (95% CIs) for 'shaking very hard' at 6 months were 0.87 (0.73-1.04), 0.81 (0.67-0.97), 0.73 (0.61-0.89), and 0.78 (0.65-0.94), respectively. Adjusted ORs for 'leaving alone at home' for the second to fifth quintiles were 0.92 (0.87-0.98), 0.91 (0.86-0.97), 0.94 (0.88-0.99), and 0.85 (0.80-0.90), respectively.

CONCLUSIONS

Higher maternal intake of omega-3 PUFAs during pregnancy was associated with fewer cases of hitting and violent shaking and leaving the child alone at home, implying a lower risk of infant maltreatment. Our results indicate the potential applicability of omega-3 PUFAs in reducing infant maltreatment.

Anti-Inflammatory Treatment Efficacy in Major Depressive Disorder: A Systematic Review of Meta-Analyses

Purpose

Immune imbalances in major depressive disorder (MDD) have been targeted by anti-inflammatory treatment approaches in clinical trials to increase responsiveness to therapy. However, even after several meta-analyses, no translation of evidence into clinical practice has taken place. We performed a systematic review to evaluate meta-analytic evidence of randomized controlled trials on the use of anti-inflammatory agents for MDD to summarize efficacy estimates and elucidate shortcomings.

Methods

Pooled effect estimates and heterogeneity indices were primary outcomes. Characteristics of the included meta-analyses were extracted. Scientific quality of meta-analyses was assessed using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR).

Results

N=20 meta-analyses met the eligibility criteria. Study characteristics like outcome scales, composition of patient populations, and add-on or monotherapy regimen varied very little for celecoxib studies, varied little for minocycline studies, and were rather variable for omega 3 fatty acids studies. R-AMSTAR scores ranged from 26 to 39 out of 44 points indicating variable quality, where a comprehensive literature search was the strongest and the consideration of scientific quality in the conclusions was the weakest domain across all meta-analyses. For minocycline and celecoxib, superiority was demonstrated with medium to large effect size with substantial heterogeneity and with large to very large effect size with negligible heterogeneity, respectively. For omega 3 fatty acids, superiority was also demonstrated with mainly small and medium effect sizes with substantial heterogeneity. However, for minocycline and omega 3 fatty acids, non-significant meta-analyses were found also.

Conclusion

Even in our synthesized approach, no clear recommendations could be derived on the use of anti-inflammatory treatment for MDD due to several critical aspects like heterogeneity, diversity of patient populations, treatment regimen, and outcomes, and limited scientific quality. However, we observed clear inter-substance differences with meta-analytic evidence being strongest for celecoxib and weakest for omega 3 fatty acids.

Dietary intervention in depression - a review

Depression is a mental illness that affects the normal lives of over 300 million people. Unfortunately, about 30% to 40% of patients do not adequately respond to pharmacotherapy and other therapies. This review focuses on exploring the relationship between dietary nutrition and depression, aiming to find safer and efficient ingredients to alleviate depression. Diet can affect depression in numerous ways. These pathways include the regulation of tryptophan metabolism, inflammation, hypothalamic-pituitary-adrenal (HPA) axis, microbe-gut-brain axis, brain-derived neurotrophic factor (BDNF) and epigenetics. Furthermore, probiotics, micronutrients, and other active substances exhibit significant antidepressant effects by regulating the above pathways. These provide insights for developing antidepressant foods.

The Fibrinolytic System in Peripartum Depression

The relationship between depression and reduced fibrinolytic activity reflects the role of tissue plasminogen activator and plasmin in brain remodeling underlying resilience, depression remission, and reward processing, rather than the dissolution of fibrin clots. Individuals who experience depression demonstrate hippocampal and prefrontal cortex atrophy, as well as impaired neuronal connectivity. Brain-derived neurotrophic factor (BDNF), synthesized as a precursor that is activated through cleavage by tissue plasminogen activator and plasmin, influences adult neurogenesis and neuronal plasticity in the hippocampus and prefrontal cortex. Depression is associated with decreased brain levels of BDNF, due to reduced activity of tissue plasminogen activator and plasmin. Tissue plasminogen activator and plasmin also mediate the release of dopamine, a neurotransmitter implicated in motivation and reward. Peripartum depression defines a depressive episode that occurs during pregnancy or in the first month after delivery, reinforcing the concept that postpartum depression may be a continuum of antenatal depression. This article describes the fibrinolytic status in the healthy brain, in stress and depression, emphasizing the links between biological markers of depression and defective fibrinolysis. It also discusses the association between hypofibrinolysis and risk factors for perinatal depression, including polycystic ovary syndrome, early miscarriage, preeclampsia, stressful life events, sedentariness, eating habits, gestational and type 2 diabetes, and antithyroid peroxidase antibodies. In addition, it reviews the evidence that antidepressant medications and interventions as diverse as placebo, psychotherapy, massage, video game playing, regular exercise, dietary modifications, omega 3 fatty acid supplementation, neurohormones, and cigarette smoking may reduce depression by restoring the fibrinolytic activity. Last, it suggests new directions for research.

Evidence based recommendations for an optimal prenatal supplement for women in the US: vitamins and related nutrients

The blood levels of most vitamins decrease during pregnancy if un-supplemented, including vitamins A, C, D, K, B1, B3, B5, B6, folate, biotin, and B12. Sub-optimal intake of vitamins from preconception through pregnancy increases the risk of many pregnancy complications and infant health problems. In the U.S., dietary intake of vitamins is often below recommended intakes, especially for vitamin D, choline and DHA. Many studies suggest that insufficient vitamin intake is associated with a wide range of pregnancy complications (anemia, Cesarean section, depression, gestational diabetes, hypertension, infertility, preeclampsia, and premature rupture of membranes) and infant health problems (asthma/wheeze, autism, low birth weight, congenital heart defects, intellectual development, intrauterine growth restriction, miscarriage, neural tube defects, orofacial defects, and preterm birth). The primary goal of this paper is to review the research literature and propose evidence-based recommendations for the optimal level of prenatal supplementation for each vitamin for most women in the United States. A secondary goal was to compare these new recommendations with the levels of vitamins in over 180 commercial prenatal supplements. The analysis found that prenatal supplements vary widely in content, often contained only a subset of essential vitamins, and the levels were often below our recommendations. This suggests that increasing prenatal vitamin supplementation to the levels recommended here may reduce the incidence of many pregnancy complications and infant health problems which currently occur.

Continuous supplementation of folic acid in pregnancy and the risk of perinatal depression-A meta-analysis

BACKGROUND

The blood folic acid¹(FA) level of depressed patients seems to be lower than that of normal, and pregnant women are at greater risk of FA deficiency. The relationship between FA and perinatal depression has not been well described.

METHODS

We conducted a meta-analysis of the evidence for the association between the two, using current FA supplementation behavior during pregnancy and blood FA levels as exposures, and the incidence of perinatal depressive symptoms and mean Edinburgh Postnatal Depression Scale² (EPDS) scores as outcomes. The present study was recorded in PROSPERO (2019 CRD: 42,020,211,509).

RESULTS

Fifteen studies were identified, covering a total of 26,275 women from eleven observational studies and four randomized controlled trials. For the primary outcome of folic acid supplementation behavior and risk of perinatal depression, the overall odds ratio was 0.742 (95% CI: (0.647-0.852)), with a combined effect value of 0.84 (95% CI: (0.76, 0.93)) for studies in which an OR could be extracted. A negative association was observed between blood folate levels and depressive symptoms (Standardized mean difference (SMD) =-0.127, 95% CI:(-0.183,-0.071)). No association was observed between folic acid intervention and EPDS score. Continuous supplementation of folic acid during pregnancy may reduce the incidence of perinatal depressive symptoms (R = 0.017, (95 CI%:(0.014, 0.021)).

LIMITATIONS

Lack of rigorous randomized controlled trials due to ethical issues, and the research is heterogeneous and does not consider the influence of genetic factors.

CONCLUSIONS

Continuous use of FA during pregnancy may reduce the incidence of perinatal depressive symptoms.

The Problem of Malnutrition Associated with Major Depressive Disorder from a Sex-Gender Perspective

Major depressive disorder (MDD) is an incapacitating condition characterized by loss of interest, anhedonia and low mood, which affects almost 4% of people worldwide. With rising prevalence, it is considered a public health issue that affects economic productivity and heavily increases health costs alone or as a comorbidity for other pandemic non-communicable diseases (such as obesity, cardiovascular disease, diabetes, inflammatory bowel diseases, etc.). What is even more noteworthy is the double number of women suffering from MDD compared to men. In fact, this sex-related ratio has been contemplated since men and women have different sexual hormone oscillations, where women meet significant changes depending on the age range and moment of life (menstruation, premenstruation, pregnancy, postpartum, menopause…), which seem to be associated with susceptibility to depressive symptoms. For instance, a decreased estrogen level promotes decreased activation of serotonin transporters. Nevertheless, sexual hormones are not the only triggers that alter neurotransmission of monoamines and other neuropeptides. Actually, different dietary habits and/or nutritional requirements for specific moments of life severely affect MDD pathophysiology in women. In this context, the present review aims to descriptively collect information regarding the role of malnutrition in MDD onset and course, focusing on female patient and especially macro- and micronutrient deficiencies (amino acids, ω3 polyunsaturated fatty acids (ω3 PUFAs), folate, vitamin B12, vitamin D, minerals…), besides providing evidence for future nutritional intervention programs with a sex-gender perspective that hopefully improves mental health and quality of life in women.

The effects of omega-3 polyunsaturated fatty acids supplementation in pregnancy, lactation, and infancy: An umbrella review of meta-analyses of randomized trials

We aimed to perform an umbrella review of systematic reviews and meta-analyses (SRMAs) of randomized clinical trials (RCT) of the effects of long-chain omega-3 fatty acid supplementation in pregnancy, lactation, and infancy. We searched PubMed, Scopus, and Web of Science to November 2020. Two independent investigators extracted the information, evaluated the methodological quality of SRMAs using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR2), and rated the certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Either a fixed-effects or a random-effects model was used to recalculate the effect sizes and 95%CIs, depending on the number of trials. Overall, 28 SRMAs of RCTs, reporting 124 outcomes from 672 RCTs with 273,523 participants were considered eligible for the present umbrella review. Our results demonstrated evidence of moderate to high certainty that omega-3 supplementation reduced the risk of pre-eclampsia and low-birth weight and improved head circumference when used in pregnant women, and reduced severe retinopathy of prematurity and cholestasis when used in infancy. There were also favorable effects on preterm delivery, pre-natal and post-partum depression, glycemic control and inflammation markers in pregnant women, and sensitization to peanuts, positive skin prick tests, anthropometric measures, language development, visual acuity, and duration of ventilation in infants (GRADE = low). Our findings suggested that omega-3 supplementation during pregnancy can exert favorable effects against pre-eclampsia, low-birth weight, pre-term delivery, and post-partum depression, and can improve anthropometric measures, immune system, and visual activity in infants and cardiometabolic risk factors in pregnant mothers.

Active Women Across the Lifespan: Nutritional Ingredients to Support Health and Wellness

Women are the largest consumers of dietary supplements. Dietary supplements can play a role in health and performance, particularly for women. Growing evidence and innovations support the unique physiological and nutrient timing needs for women. Despite the need for more nutrition and exercise-specific research in women, initial data and known physiological differences between sexes related to the brain, respiration, bone, and muscle support new product development and evidence-based education for active women regarding the use of dietary supplements. In this narrative review, we discuss hormonal and metabolic considerations with the potential to impact nutritional recommendations for active women. We propose four potential areas of opportunity for ingredients to help support the health and well-being of active women, including: (1) body composition, (2) energy/fatigue, (3) mental health, and (4) physical health.

Maternal diet before and during pregnancy modulates microglial activation and neurogenesis in the postpartum rat brain

The implications of poor maternal diet on offspring metabolic and neuroimmune development are well established. Increasing evidence now suggests that maternal obesity and poor diet can also increase the risk of postpartum mood disorders, but the mechanisms are unknown. Here we investigated the effects of a poor, high-fat-high-sugar diet (HFSD) on peripheral and central inflammation, neurogenesis and postpartum anxiety-like behaviours. We hypothesised that long-term consumption of a HFSD pre- and post-conception would increase the levels of circulating cytokines and induce microglial activation, particularly in the arcuate nucleus of the hypothalamus (ARC), as the primary brain region involved in the integration of satiety signalling; and this would lead to increased anxiety, stress responsivity and disrupted neurogenesis. We further hypothesised that these effects would be ameliorated by consumption of a healthier diet during pregnancy - specifically a diet high in omega-3 polyunsaturated fatty acids (PUFAs). As expected, the HFSD significantly increased pre-conception body weight, elevated circulating cytokines and activated microglia in the ARC, as well as in the basolateral amygdala. The HFSD also significantly increased the numbers of immature (doublecortin (DCX)-positive) neurons in the subgranular/granular region of the hippocampus, a neurogenic response that was, surprisingly, mimicked by consumption of a diet high in omega-3 PUFAs. Despite these effects of peri-pregnancy dietary imbalance, we detected no differences in anxiety-like behaviours or hypothalamic-pituitary-adrenal (HPA) axis reactivity between the groups. A shift to a healthier diet post-conception reversed the peripheral inflammation and alleviated the microglial activation. These novel data indicate the importance of a balanced peri-pregnancy diet and highlight the need for future research into key triggers that alter the neuroimmune balance in the maternal brain.

Complementary medicines and therapies in clinical guidelines on pregnancy care: A systematic review

BACKGROUND

There is a need for evidence-based guidance on complementary medicines and therapies (CMT) use during pregnancy due to high prevalence of use and lack of guidance on the balance of benefit and harms.

AIM

Evaluate the extent to which current clinical practice guidelines relevant to Australian healthcare professionals make clear and unambiguous recommendations about CMT use in pregnancy, and synthesise these recommendations.

METHODS

The search included EMBASE, PubMed, the National Health and Medical Research Council's Clinical Practice Guidelines Portal, and websites of Australian maternity hospitals and professional/not-for-profit organisations for published guidelines on pregnancy care. Data were synthesised narratively. Guidelines were appraised by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

FINDINGS

A total of 48 guidelines were found, of which 41% provided recommendations that were not limited to routine vitamin and mineral supplementation. There were wide variations in recommendations, particularly for vitamin D and calcium. There was some consensus on recommending ginger and vitamin B6 for nausea and vomiting, and additional supplementation for women with obesity. Guidelines generally scored poorly in the domains of editorial independence and rigour of development.

DISCUSSION

There is a lack of guidance with regard to appropriate CMT use during pregnancy, which may result in less-than-optimal care. Inconsistency between guidelines may lead to variations in care.

CONCLUSION

Guidelines should include clear and unambiguous guidance on appropriate CMT use during pregnancy, be based on a structured search of the evidence and informed by stakeholder engagement.

Resolvins as potential candidates for the treatment of major depressive disorder

In contrast with the delayed onset of therapeutic responses and relatively low efficacy of currently available monoamine-based antidepressants, a single subanesthetic dose of ketamine, an N-methyl-D-aspartate receptor antagonist, produces rapid and sustained antidepressant actions even in patients with treatment-resistant depression. However, since the clinical use of ketamine as an antidepressant is limited owing to its adverse effects, such as psychotomimetic/dissociative effects and abuse potential, there is an unmet need for novel rapid-acting antidepressants with fewer side effects. Preclinical studies have revealed that the antidepressant actions of ketamine are mediated via the release of brain-derived neurotrophic factor and vascular endothelial growth factor, with the subsequent activation of mechanistic target of rapamycin complex 1 (mTORC1) in the medial prefrontal cortex. Recently, we demonstrated that resolvins (RvD1, RvD2, RvE1, RvE2 and RvE3), endogenous lipid mediators generated from n-3 polyunsaturated fatty acids (docosahexaenoic and eicosapentaenoic acids), exert antidepressant effects in a rodent model of depression, and that the antidepressant effects of RvD1, RvD2, and RvE1 necessitate mTORC1 activation. In this review, we first provide an overview of the mechanisms underlying the antidepressant effects of ketamine and other rapid-acting agents. We then discuss the possibility of using resolvins as novel therapeutic candidates for depression.

Importance of EPA and DHA Blood Levels in Brain Structure and Function

Brain structure and function depend on a constant and sufficient supply with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) by blood. Blood levels of EPA and DHA reflect dietary intake and other variables and are preferably assessed as percentage in erythrocytes with a well-documented and standardized analytical method (HS-Omega-3 Index^®). Every human being has an Omega-3 Index between 2 and 20%, with an optimum of 8–11%. Compared to an optimal Omega-3 Index, a lower Omega-3 Index was associated with increased risk for total mortality and ischemic stroke, reduced brain volume, impaired cognition, accelerated progression to dementia, psychiatric diseases, compromises of complex brain functions, and other brain issues in epidemiologic studies. Most intervention trials, and their meta-analyses considered EPA and DHA as drugs with good bioavailability, a design tending to produce meaningful results in populations characterized by low baseline blood levels (e.g., in major depression), but otherwise responsible for many neutral results and substantial confusion. When trial results were evaluated using blood levels of EPA and DHA measured, effects were larger than comparing EPA and DHA to placebo groups, and paralleled epidemiologic findings. This indicates future trial design, and suggests a targeted use EPA and DHA, based on the Omega-3 Index.

Omega-3 supplementation and diabetes: A systematic review and meta-analysis

This study aimed to review the literature on studies that evaluated the effects of omega-3 supplementation on parameters of diabetes in humans. An online search was conducted in the following databases: Pubmed, LILACS, Scielo, Scopus, and Web of Science. It included experimental studies that investigated the effects of omega-3 supplementation for diabetes treatment or prevention and its relationship with fasting blood glucose, insulin resistance, and glycated hemoglobin. Observational, non-human studies and non-randomized clinical trials were excluded. The Cochrane scale assessed the quality of the studies. A meta-analysis was carried out to evaluate the effect of omega-3 on fasting blood glucose, insulin resistance, and glycated hemoglobin. Thirty studies were included in the review. Almost 70% (n = 20) demonstrated at least one significant effect of the omega-3 supplementation related to diabetes. In the meta-analysis, there was a significant effect on the reduction of fasting blood glucose [SMD: -0.48; CI95%: -0.76, -0.19; p = 0.01; I2 = 88%] and insulin resistance [SMD: -0.61; CI95%: -0.98, -0.24; p = 0.01; I2 = 90%]. For glycated hemoglobin, there was no significant effect in the meta-analysis. This systematic review with meta-analysis demonstrated that supplementation with omega-3 has protective effects on diabetes parameters.

Acute Injection of Omega-3 Triglyceride Emulsion Provides Very Similar Protection as Hypothermia in a Neonatal Mouse Model of Hypoxic-Ischemic Brain Injury

Therapeutic hypothermia (HT) is a currently accepted treatment for neonatal asphyxia and is a promising strategy in adult stroke therapy. We previously reported that acute administration of docosahexaenoic acid (DHA) triglyceride emulsion (tri-DHA) protects against hypoxic-ischemic (HI) injury in neonatal mice. We questioned if co-treatment with HT and tri-DHA would achieve synergic effects in protecting the brain from HI injury. Neonatal mice (10-day old) subjected to HI injury were placed in temperature-controlled chambers for 4 h of either HT (rectal temperature 31–32°C) or normothermia (NT, rectal temperature 37°C). Mice were treated with tri-DHA (0.375 g tri-DHA/kg bw, two injections) before and 1 h after initiation of HT. We observed that HT, beginning immediately after HI injury, reduced brain infarct volume similarly to tri-DHA treatment (~50%). Further, HT delayed 2 h post-HI injury provided neuroprotection (% infarct volume: 31.4 ± 4.1 vs. 18.8 ± 4.6 HT), while 4 h delayed HT did not protect against HI insult (% infarct volume: 30.7 ± 5.0 vs. 31.3 ± 5.6 HT). HT plus tri-DHA combination treatment beginning at 0 or 2 h after HI injury did not further reduce infarct volumes compared to HT alone. Our results indicate that HT offers similar degrees of neuroprotection against HI injury compared to tri-DHA treatment. HT can only be provided in tertiary care centers, requires intense monitoring and can have adverse effects. In contrast, tri-DHA treatment may be advantageous in providing a feasible and effective strategy in patients after HI injury.

Exploring Herbal Medicine Use during Palliative Cancer Care: The Integrative Physician as a Facilitator of Pharmacist-Patient-Oncologist Communication

Oncology patients frequently use herbal and other forms of complementary medicine, often without the knowledge of oncologists, pharmacists, and other healthcare professionals responsible for their care. Oncology healthcare professionals may lack the knowledge needed to guide their patients on the safe and effective use of herbal medicinal products, a number of which have potentially harmful effects, which include direct toxicity and negative herb–drug interactions. The current review addresses the prevalence and expectations of oncology patients from herbal medicine, as well as evidence for the beneficial or harmful effects of this practice (potential and actual), especially when the herbal products are used in conjunction with anticancer agents. Models of integrative oncology care are described, in which open and effective communication among oncologists, pharmacists, and integrative physicians on the use of herbal medicine by their patients occurs. This collaboration provides patients with a nonjudgmental and multidisciplinary approach to integrative medicine, echoing their own health-belief models of care during conventional cancer treatments. The role of the integrative physician is to facilitate this process, working with oncologists and pharmacists in the fostering of patient-centered palliative care, while ensuring a safe and effective treatment environment. Case scenario: W. is a 56 year old female artist who was recently diagnosed with localized hormone receptor-positive breast cancer. Following lumpectomy and sentinel node dissection, she is scheduled to begin adjuvant chemotherapy with a regimen which will include adriamycin, cyclophosphamide, and paclitaxel (AC-T protocol). She is worried about developing peripheral neuropathy and its impact on her ability to paint, and she asks about a number of dietary supplements which she heard could prevent this from happening: omega-3, vitamin E, alpha-lipoic acid, and acetyl-l-carnithine. She is concerned, however, that the supplements may negatively interact with her chemotherapy regimen.

Omega 3 Fatty Acids and COVID-19: A Comprehensive Review

The rapid international spread of severe acute respiratory syndrome coronavirus 2 responsible for coronavirus disease 2019 (COVID-19) has posed a global health emergency in 2020. It has affected over 52 million people and led to over 1.29 million deaths worldwide, as of November 13th, 2020. Patients diagnosed with COVID-19 present with symptoms ranging from none to severe and include fever, shortness of breath, dry cough, anosmia, and gastrointestinal abnormalities. Severe complications are largely due to overdrive of the host immune system leading to "cytokine storm". This results in disseminated intravascular coagulation, acute respiratory distress syndrome, multiple organ dysfunction syndrome, and death. Due to its highly infectious nature and concerning mortality rate, every effort has been focused on prevention and creating new medications or repurposing old treatment options to ameliorate the suffering of COVID-19 patients including the immune dysregulation. Omega-3 fatty acids are known to be incorporated throughout the body into the bi-phospholipid layer of the cell membrane leading to the production of less pro-inflammatory mediators compared to other fatty acids that are more prevalent in the Western diet. In this article, the benefits of omega-3 fatty acids, especially eicosapentaenoic acid and docosahexaenoic acid, including their anti-inflammatory, immunomodulating, and possible antiviral effects have been discussed.