Omega-3 Supplementation Decreases Inflammation and Fetal Obesity in Pregnancy

In addition to the increase in obesity in adult and children, there has been a significant
increase in birth weights over the last 2 decades. Based on our preliminary data, maternal
pre-gravid obesity is the strongest risk factor for neonatal as well as adolescent obesity.
The long-term goals of our research are to examine therapeutic strategies to decrease fetal
adiposity. Obesity and pregnancy are both insulin resistant conditions associated with
chronic low-grade inflammation. Therefore, we hypothesize that n-3 PUFA dietary supplements
during pregnancy will act as insulin sensitizers decreasing peripheral insulin resistance and
inflammation. If correct this mechanism should decrease availability of maternal nutrients to
the fetus and subsequently reduce adiposity at birth. We plan a prospective randomized double
blind control trial of n-3 PUFA supplementation and placebo in overweight/obese women, with a
previous cesarean delivery, initiated in early pregnancy and maintained throughout pregnancy.
This proposal has two specific aims. Specific aim 1 is to evaluate the effect of n-3 PUFA
supplementation on maternal insulin sensitivity. Measures of maternal insulin sensitivity and
lipid metabolism will be made using the ISogtt, indirect calorimetry body composition
(BODPOD) and plasma lipid profile at baseline and after dietary intervention.

Specific aim 2 will assess the effect of n-3 PUFA on the inflammatory status in
overweight/obese pregnant women. We hypothesize that n-3 PUFA supplementation decreases
chronic inflammation during pregnancy by preventing monocyte activation and accumulation of
macrophages in WAT thus lowering systemic concentration of pro-inflammatory cytokines. We
plan to characterize the longitudinal changes in circulating monocytes and plasma adipokines
in order to define the inflammatory patterns in both groups over time. We will also determine
the abundance and phenotype of macrophages infiltrating WAT using flow cytometry,
immunohistochemistry and gene expression profiling. Furthermore, the role of PPARγ as a
central target of n-3 PUFA action to regulate insulin sensitivity will be examined by
characterizing the expression of PPARγ in WAT of both supplemented and control groups.
Additionally, we will investigate the direct affect of n-3 PUFA on the expression of
adiponectin and PPARγ regulated genes in primary cultured adipocytes.

In summary, this proposal combines both clinical and molecular methodologies in an
overweight/obese subject population in order to assess the effect of n-3 PUFA on inflammation
and insulin resistance. Preliminary data will also be obtained on fetal body composition in
order to later address the prevention of the long term adverse effects (developmental
programming) of maternal obesity in the developing fetus.

Inclusion Criteria:

- BMI (wt/ht2) > or = 25 at first antenatal visit

- Gestational age at randomization between 8-16 weeks

- No medical problems such as hyperlipidemia, hypertension, or pregestational diabetes

- Between the ages of 18 and 40 years old

- Non-smokers

- No obstetrical problems such as a history of preeclampsia or gestational diabetes

- Confirmed singleton pregnancy

Exclusion Criteria:

- Major fetal anomaly

- Regular intake of fish oil supplements (defined as greater than 500 mg per week within
the last four weeks). This is due to the placebo group receiving fish oil outside of
the study.

- Daily use of nonsteroidal anti-inflammatory agents

- Allergy to fish or fish products, gluten intolerant (because the placebo contains
wheat germ oil, which is not gluten free).

- Women who are vegetarians and do not eat any fish.

- Infants born preterm (less than 36 weeks gestation) or less than 2kg.

- Heparin use or known thrombophilia (thrombophilias include homozygous for Factor V
Leiden).

- Moderate or high titer IgG anticardiolipin antibodies or prolonged activated PTT or
other indication of presence of lupus anticoagulant, homozygous for prothrombin gene
(G20210A) mutation, antithrombin III deficiency.

- Protein S (low levels outside of pregnancy) or Protein C deficiency.

- Hyperhomocysteinemia (due to safety concerns because n-3 may affect bleeding time).

- Hemophiliacs including von Willebrand's disease (because of safety concerns associated
with the hemophilia treatment combined with the n-3 supplements).

- Planned termination of pregnancy.

- Current hypertension or current use of antihypertensive medication (including
diuretics), due to increased risk of adverse pregnancy outcome.

- Pregestational diabetes due to increased risks of affecting fetal growth. We will not
exclude women who develop GDM during pregnancy but consider a sub-analyses of these
women depending on the number of subjects. Known maternal medical complications:
cancer (including melanoma but excluding other skin cancers).

- Current hyperthyroidism if not adequately controlled.

- Renal disease with altered renal function (serum creatinine > 1.5).

- Epilepsy or other seizure disorder.

- Systemic lupus (not discoid lupus), scleroderma, polymyalgia rheumatic.

- Active liver disease (acute hepatitis, chronic active hepatitis, persistently abnormal
liver enzymes).

- Platelet or red blood cell disorder (including idiopathic thrombocytopenia purpura, a
history of alloimmune thrombocytopenia in a previous offspring, significant anemia due
to hemoglobinopathy but not sickle cell trait. Iron deficiency anemia will NOT be an
exclusion as long as the hemoglobin is > 8 gm/dl).

- Chronic pulmonary disease (asthma of any degree of severity is NOT an exclusion).

- Structural, functional or ischemic heart disease. Neither mitral valve prolapse nor
paroxysmal supraventricular tachycardia are considered exclusions.

- Known HIV positive with viral load greater than 1,000 copies/ml or CD4 count less than
350/mm3.

- Current or planned cerclage due to interference with the natural cause of delivery.

- Illicit drug or alcohol abuse during current pregnancy.

- At the time of birth, all infants will be evaluated by a pediatrician to make sure
that they are healthy. Infants will be excluded from further study if they have any
medical problems such as respiratory distress syndrome.

- Infants will also be excluded if they have any problems that exclude them from having
estimation of body composition, for e.g. birth weight less than 2 kg.