Fetal growth, omega-3 (n-3) fatty acids, and progression of subclinical

atheroscierosis: preventing fetal origins of disease? The Cardiovascular

Risk in Young Finns
^^
Michael R Skilton, Vera Mikkil, Peter Wirtz, Mika Ala-Korpela, Kyra A Sim, Pasi Soininen, Antti J Kangas,
Jornia SA Viikari, Markus Juonala, Toini Lxiitinen, Terho Lehtimki, Leena Taittonen, Mika Khnen, David S Celermajer,
and Olli T Raitakari
ABSTRACT
Background: Impaired fetal growth is independently associated
with an increased risk of cardiovascular events in adulthood. Prevention strategies that can be implemented during adulthood have
not been identified.
Objective: The objective was to determine whether habitual omega-3
(n-3) fatty acid intake is associated with the rate of increase of
carotid intima-media thickness during adulthood in individuals with
impaired fetal growth.
Design: This was a population-based, prospective cohort study of
1573 adults in Finland. Carotid intima-rnedia thickness was assessed in 2001 (at ages 24-39 y) and in 2007. Participants were
categorized as having had impaired fetal growth (tertn birth with
birth weight <10th percentile for sex or preterm birth with birth
weight <25th percentile for gestational age and sex; n = 193) or
normal fetal growth (all other participants; n = 1380). Omega-3
fatty acid intake was assessed by using a food-frequency questionnaire and on the basis of serum fatty acid concentrations.
Results: In multivariable models, the 6-y progression of carotid
intima-media thickness was inversely associated with dietary
omega-3 fatty acids in those with impaired fetal growth (P =
0.04). Sirnilatiy, serum omega-3 fatty acid concentrations were inversely associated with the 6-y progression of carotid intima-media
thickness in those with impaired fetal growth (P = 0.04) but were
not noted in those with normal fetal growth (P = 0.94 and P = 0.26,
respectively).
Conclusion: Dietary intake of omega-3 fatty acids is associated
with a slower rate of increase in carotid intima-media thickness in
those with impaired fetal growth.
Am J Clin Nutr 2013;97:5865.
INTRODUCTION
Impaired fetal growth is independently associated with an
increased risk of cardiovascular events in adulthood (1, 2).
Consistent with this, impaired fetal growth is also associated with
endothelial dysfunction and structural alterations to the vasculature, consistent with early atherosclerosis in children and young
adults (3-8).
Prevention strategies for cardiovascular disease in those who
had impaired fetal growth, which can be implemented during
adulthood, have not been identified. However, we recently
showed in a randomized trial in children that dietary supple-

58

mentation with omega-3 (n3) PUFAs appears to prevent or

ameliorate the inverse association between fetal growth and

From the Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders (MRS and KAS) and Sydney Medical School (DSC), University of
Sydney, Sydney, Australia; the Department of Food and Environmental Sciences, Division of Nutrition (VM), and the Institute for Molecular Medicine
Finland (PW), University of Helsinki, Helsinki, Finland; Computational
Medicine, Institute of Clinical Medicine (PW, MA-K, PS, and AJK), the
Department of Internal Medicine, Clinical Research Center (MA-K), and
the Department of Pediatrics (LT), University of Oulu, Oulu, Finland; Epidemiology and Biostatistics, Imperial College London. London, United
Kingdom (MA-K); the NMR Metabolomics Laboratory, School of Pharmacy, University of Eastern Finland, Kuopio, Finland (MA-K and PS); the
Department of Medicine. University of Turku and Turku University Hospital,
Turku, Finland (JSAV and MJ); the Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland (MJ
and OTR); the Department of Clinical Physiology and Nuclear Medicine,
University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland (T Laitinen); the Department of Clinical Chemistry, Fimlab Laboratories, Tampere University Hospital and University of Tampere School of
Medicine, Tampere, Finland (T Lehtimki); the Department of Pediatrics,
Vaasa Central Hospital, Vaasa, Finland (LT); the Department of Clinical
Physiology. Tampere University Hospital and University of Tampere, Tampere, Finland (MK): and the Department of Clinical Physiology. University
of Turku and Turku University Hospital, Turku. Finland (OTR).
"The Young Finns Study has been financially supported by the Academy
of Finland (grants 126925, 121584, 124282, 129378, 117797, and 41071);
the Social Insurance Institution of Finland, Kuopio (Tampere grants 9M048
and 9N035 to T Lehtimki): Turku University Hospital Medical Funds: Juho
Vainio Foundation; Paavo Nurmi Foundation; Finnish Foundation of Cardiovascular Research and Finnish Cultural Foundation; Sigrid Juselius Foundation; Tampere Tuberculosis Foundation; and Emil Aaltonen Foundation. This
work was also supported by the Academy of Finland (grant 250422 to PW
and grant 137870 to PS), the Responding to Public Health Challenges Research Programme of the Academy of Finland (grant 129429 to MA-K), the
Finnish Foundation for Cardiovascular Research (to PW and MA-K), the
Strategic Research Funding from the University of Oulu (MA-K), and
the Jenny and Antti Wihuri Foundation (AJK). MRS was supported by
a National Health and Medical Research Council of Australia fellowship
(grant 1004474).
Address correspondence and reprint requests to MR Skilton, Department
of Cardiology, Royal Prince Alfred Hospital, Missenden Road, Camperdown
NSW 2050. E-mail: michael.skilton@sydney.edu.au.
ReceivedJune 4, 2012. Aecepted for publication September 17. 2012.
First published online November 14, 2012; doi: 10.3945/ajcn.l 12.044198.

Am J Clin Nutr 2013;97:58-65. Printed in USA. 2013 American Society for Nutrition

FETAL GROWTH, OMEGA-3, AND ATHEROSCLEROSIS

increased carotid intima-media thickness (IMT) in childhood
(9).
Accordingly, by using an independent population cohort of
young adults, we assessed whether dietary omega-3 PUFA intake
during adulthood is inversely associated with the age-related
increase in carotid IMT in those who had experienced impaired
fetal growth. We also sought to determine whether any such
putative vascular benefits of omega-3 PUFAs are specific to those
with impaired fetal growth or are generalizable to those with
normal fetal growth.
SUBJECTS AND METHODS
Population
The Cardiovascular Risk in Young Finns Study is an ongoing
population-based study of atherosclerosis risk factors from
childhood to adulthood (10). In 1980, children and adolescents
aged 3-18 y were invited to participate ( = 3596). The study
was carried out in all Finnish university cities with medical
schools and their rural surroundings, with subjects chosen randomly from the national population register from these areas.
The 21-y and 27-y follow-up visits were undertaken in 2001 (n =
2265) and 2007 (n = 2197) with study participants being representative of the baseline cohort (11). Complete data for birth
weight, preterm birth, increase in carotid IMT, and omega-3
PUFAs (either dietary or serum data) were available for 1573
participants.
The procedures followed were in accordance with the ethical
standards of the institutions or regional committees on human
experimentation. The study complies with the Declaration of
Helsinki and was approved by local ethics committees, and
subjects gave written informed consent.
Fetal growth
Preterm birth status was defined as birth before 37 wk of
gestation, and the number of weeks preterm was ascertained in
those who reported preterm birth. Birth weight was averaged
between values recorded in 1983 and 1986. Impaired fetal growth
was defined as those 7) born at term with birth weight below the
10th percentile for sex or 2) born preterm with birth weight
below the 25th percentile for gestational age and sex (3). We
previously showed that participants in the Cardiovascular Risk
in Young Finns Study who meet this definition of impaired fetal
growth have worse vascular health, including increased carotid
IMT (3). In addition to those with impaired fetal growth, we also
studied these associations in a group with normal fetal growth.
The normal fetal growth group consisted of all participants
without impaired fetal growth. Results for this group were
similar when participants bom large-for-gestational age (term
birth with birth weight above the 90th percentile for sex) were
excluded (data not shown).
Dietary intake
Habitual dietary intake over the past year was assessed at the
2007 visit with a modified 131-itetTi food-frequency questionnaire developed by the Finnish National Institute for Health and
Welfare (12). Nutrient intake calculations, including omega-3
PUFAs and total energy intake, were based on the Finnish Food

59

Composition database (Fineli) (13). Dietary omega-3 PUFA was

defined as the total intake of 18:3n-3, 18:4n-3, 20:3n-3,
20:4n-3, 20:5n-3 (EPA), 21:5n-3, 22:4n-3, 22:5n-3, and
22:6n-3 (DHA).
Serum fatty acid analysis
Serum omega-3 PUFAs and DHA were measured by proton
nuclear magnetic resonance spectroscopy, as previously described (14, 15). The quantification of serum omega-3 PUFAs is
based on a shift in the signal induced by the omega-3 double-bond
position; accordingly, all omega-3 PUFAs are included in this
measure. For statistical analysis, the concentrations of serum
omega-3 PUFAs and DHA were expressed as mole percentages of
total serum fatty acids.
Carotid I]VIT
Ultrasound studies to measure carotid IMT were performed as
previously reported (11, 16). This technique was previously
shown to have a high degree of reproducibility in our laboratory
(16).
Assessment of socioeconomic, lifestyle, and cardiovascular
disease risk factors
Blood pressure was measured by using a random-zero sphygmomanometer (Hawksley & Sons); the average of 3 tneasurements
was used in the analysis. Fasting venous blood samples were
drawn, and serum was stored at 70 C until analyzed. Scrum
lipids were measured in duplicate as described previously (17),
LDL-cholesterol concentrations were calculated (18), highsensitivity C-reactive protein (hsCRP) concentrations were analyzed by latex turbidometric immunoassay (Wako Chemicals),
and plasma glucose concentrations were measured enzymatically (Olympus) (17).
A self-administered questionnaire was used to detennine current
medication use (including antihypertensive, lipid-lowering, and
oral contraceptive agents), prior diagnosis of diabetes, physical
activity, employment, marital status, and smoking status.
Statistical analysis
The prespecified primary analysis consisted of determining the
associations of omega-3 PUFAs with the progression of carotid
IMT in those with impaired fetal growth. For dietary omega-3
PUFAs, 3 multivariable linear regression models were constructed: model 1 (standard multivariable model) (19), adjusted
for dietary energy intake and alcohol intake; model 2 (energy
determinant model) (19), as per rnodel 1 with additional adjustment for major determinants of caloric intake (physical activity and BMI from the 2007 visit, concurrent to dietary
assessment); and model 3 (risk factor model), as per model 2 with
additional adjustment for cardiovascular disease risk factors
(LDL cholesterol, HDL cholesterol, triglycrides, hsCRP, glucose, and systolic blood pressure). For serum omega-3 PUFAs,
2 models were constructed: model 1 (standard multivariable
model) and model 2 (risk factor model), as per model 1 with
additional adjustment for cardiovascular disease risk factors
(LDL cholesterol, HDL cholesterol, triglycrides, hsCRP, glucose, systolic blood pressure, BMI, and physical activity). Both

60

SKILTON ET AL

dietary and serum omega-3 PUFA models were also adjusted for
age, sex, socioeconomic factors (marital and employment status),
smoking status, and carotid IMT from the 2001 visit. Heterogeneity of these associations by fetal growth status was assessed
(20). No sex-based differences were present (data not shown).
Statistical analyses were performed by using SPSS software
(version 17.0; SPSS). Nonnormally distributed variables were log
transformed before analysis, including dietary omega-3 PUFAs,
hsCRP, glucose, and triglycrides.

P = 0.004; standardized = 0.503, P = 0.0002, adjusted for total

dietary energy and energy from fat; standardized = 0.532, P <
0.0001, adjusted for total dietary energy, energy from fat,
physical activity, and BMI) and between serum omega-3
PUFAs in 2001 and 2007 (unadjusted r = 0.501, P < 0.0001),
indicative of good tracking of dietary and serum omega-3 PUFAs
during the 6-y follow-up period. Similar results were observed
in participants with normal fetal growth (see the Online Supplemental Material under "Supplemental data" in the online
issue).

RESULTS
Participant characteristics for those with impaired fetal growth
( = 193) and those with normal fetal growth (w = 1380) are
shown in Table 1. Briefly, LDL cholesterol, triglycrides,
hsCRP, and carotid IMT were all higher in the impaired fetal
growth group. Dietary energy intake, dietary omega-3 PUFAs,
serum omega-3 PUFAs, and the 6-y progression of carotid IMT
did not differ significantly between groups.

Dietary omega-3 PUFAs and serum omega-3 PUFAs

in participants with impaired fetal growth
Dietary omega-3 PUFAs were associated with serum omega-3
PUFAs assessed concurrently in 2007 (unadjusted r = 0.164, P =
0.04; standardized = 0.733, P < 0.0001, adjusted for total
dietary energy and energy from fat; standardized = 0.728, P <
0.0001, adjusted for total dietary energy, energy from fat,
physical activity, and BMl). Strong associations were also observed between dietary omega-3 PUFAs assessed in 2007 and
serum omega-3 PUFAs assessed in 2001 (unadjusted r = 0.223,

Omega-3 PUFAs and 6-y increase in carotid IMT

in participants with impaired fetal growth
Dietary omega-3 PUFAs were inversely associated with the 6y increase in carotid IMT among those with impaired fetal growth
(Table 2, Figure 1). This association was similar in standard
multivariable tiiodels adjusted for energy intake, energy determinant models further adjusted for sources of energy utilization, and also after adjustment for baseline levels of
established cardiovascular disease risk factors (Table 2). The
results were sitnilar after further adjustment for use of antihypertensive, lipid-lowering, and oral contraceptive agents (data
not shown) and in unadjusted and non-energy-adjusted models
(see the Online Supplemental Material under "Supplemental
data" in the online issue).
Serum omega-3 PUFAs were inversely associated with the 6-y
increase in carotid IMT among those with impaired fetal growth
(mean carotid IMT: - 1 2 yitm; 95% CI: - 2 2 , - 1 ; maxirnum
carotid IMT: see Figure 1), as was serum DHA (mean carotid
IMT: - 2 2 /xm; 95% CI: - 4 2 , - 3 ; maximum carotid IMT: - 2 1

TABLE 1
Participant characteristics and cardiovascular disease risk factors'

Age (y)
Sex (% male)
Birth weight (g)
Preterm (%)
BMI (kg/m^)
LDL cholesterol (mmol/L)
HDL cholesterol (mmol/L)
Triglycrides (mmol/L)"*
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Glucose (mmol/L)"*
hsCRP (mg/L)'*
Mean IMT (mm)
Maximum IMT (mm)
6-y inerease in mean IMT (^im)
6-y increase in maximum IMT (/J.m)
Dietary energy intake (kj/d)
Dietary omega-3 PUFA (g/d)"*
Serum omega-3 PUFA (% of total fatty acids)
Serum DHA (% of total fatty acids)

Impaired fetal
growth (H = 193)

Normal fetal growth

(n = 1380)

P value^

31.7 4.8^
46
2677 361
24
25.4 4.2
3.40 0.89
1.26 0.31
1.30(0.90)
117.5 13.1
70.9 11.2
5.02 (0.60)
1.05(1.65)
0.60 0.10
0.64 0.10
45 90
38 96
10,179 3156
2.82 (1.46)
3.52 l.ll
1.56 0.61

31.4 4.9
43
3613 472
9
24.8 4.3
3.22 0.82
1.30 0.32
1.13 (0.70)
115.7 13.0
70.0 10.5
4.98 (0.50)
0.80(1.50)
0.57 0.09
0.62 0.09
46 82
42 88
10,114 3479
2.84(1.40)
3.55 0.95
1.58 0.55

0.35
0.52
<0.0001
<0.0001
0.10
0.004
0.10
0.0002
0.06
0.32
0.42
0.003
0.002
0.003
0.81
0.65
0.81
0.84
0.69
0.62

'All data are from the 2001 study visit, except lor the dietary intake (2007) and 6-y change (2001-2007) variables.
hsCRP, high-sensitivity C-reactive protein: IMT, intima-media thickness.
^ Derived from independent-samples t test.
"' Mean SD (all such values).
'' Log transformed for analysis; values are presented as geometric means (interquartile ranges).

FETAL GROWTH, OMEGA-3, AND ATHEROSCLEROSIS

61

TABLE 2
Dietary omega-3 PUFAs and 6-y change in carotid I M T '

Impaired fetal growth

6-y change:
mean IMT
Model 1 : standard multivariate model
Dietary omega-3 PUFAs (^.im)
Model 2: energy determinant model'
Dietary omega-3 PUFAs (/m)
Model 3; risk factor model"*
Dietai^y omega-3 PUFAs (/xm)

P-heterogcneity
(intergroup
comparison)

Normaj fetal growth

6-y change:
maximum IMT

6-y change:
mean IMT

6-y change:
maximum
IMT

Mean
IMT

Maximum
IMT

1 ( - 1 8 , 19) 0.94

O.II

0.05

- 4 5 (-97, 7)

0.09

- 5 7 (-112. - 1 )

0.04 0 ( - 1 7 , 17)

1.00

- 5 2 ( - 1 0 4 . 1)

0.05

-65(-120,-10)

0.02 3 ( - 1 4 , 2 0 )

0.73 4 ( - 1 5 , 2 3 )

0.67

0.05

0.02

- 6 8 (-124, -13)

0.02

-75 (-134,-16)

0.01 4 ( - 1 4 , 2 2 )

0.65 5 ( - 1 4 , 2 4 )

0.58

0.01

0.01

'Dietary omega-3 PUFAs were log transformed for analysis; thus, the results reflect changes in IMT (95% CIs) associated with a 100% increase in
dietary omega-3 PUFAs under isocaloric conditions from multivariable linear regression. IMT, intima-media thickness.
"Standard multivariate model; adjusted for age, sex, soeioeconomic factors (marital status and employment status), smoking, alcohol intake, dietary
energy intake, and carotid IMT from the 2001 visit; impaired fetal growth ( = 171), normal fetal growth (n = 1234).
"'Energy determinant model: adjusted as per model I with additional adjustment for physical activity and BMI; impaired fetal growth (/? = 171), normal
fetal growth ( = 1210).
"'Risk factor model: adjusted as per model 2 with additional adjustment for cardiovascular disease risk factors [LDL cholesterol, HDL cholesterol,
triglycrides (log transformed), high-sensitivity C-reactive protein (log transformed), glucose (log transformed), and systolic blood pressure]; impaired fetal
growth (n = 167), normal fetal growth {n = 1189).

/xm; 95% CI: 42, 0). The association of serum omega-3

PUFAs with carotid IMT progression was weakened by adjustment for cardiovascular disease risk factors (mean carotid IMT:
- 7 xm; 95% CI; - 1 8 , 4; maximum carotid IMT*; - 6 m; 95%
CI; 18, 5), which suggests that established risk factors may, at
least in part, mediate the association of serum omega-3 PUFAs
with reduced carotid IMT progression in those with impaired
fetal growth. To inform further on these putative intermediaries,
we determined the cross-sectional associations of serum omega3 PUFAs with cardiovascular disease risk factors in participants
with impaired fetal growth. Indeed, there was a direct association of serum omega-3 PUFAs with HDL cholesterol (standardized = 0.203, P = 0.004), inverse associations with BMI
(standardized ^ = -0.180,/* = 0.02), and systolic blood pressure
(standardized = -0.205, P = 0.003), and there was some
evidence of an association with triglycrides (standardized =
0.141, P = 0.06). No such associations of serum omega-3
PUFAs with LDL cholesterol (standardized = 0.033, P =
0.65), glucose (standardized = -0.056, P = 0.45), or hsCRP
(standardized = -0.078, P = 0.30) were observed.

Omega-3 PUFAs and 6-y increase in carotid IMT

in participants vfith normal fetal growth
To ascertain whether or not these observed benefits of omega-3
PUFAs are restricted to those with impaired fetal growth, we then
examined these same associations in those with normal fetal
growth.
Participant characteristics for those with normal fetal growth
are shown in Table 1. In this group of participants, no evidence of
an association of dietary omega-3 PUFAs with the 6-y increa.se in
carotid IMT was observed (Table 2; Figure 1; see the Online
Supplemental Material under "Supplemental data" in the online
issue). Formal tests of heterogeneity indicated that these associations differed significantly by fetal growth status (Table 2).

Serum omega-3 PUFAs were not associated with the 6-y increase in carotid IMT in those with normal fetal growth (mean
carotid IMT: - 3 /xm; 95% CI: - 7 , 1; maxit"num carotid IMT:
see Figure 1), although this did not differ significantly from the
association in the impaired fetal growth group (both mean and
maximum carotid IMT; P-heterogeneity = 0.14). In contrast, serum DHA was inversely associated with the 6-y increase in carotid
IMT in those with normal fetal growth (mean carotid IMT: 9
fjim; 95% CI: - 1 6 , - 1 ; maximum carotid IMT: - 1 0 /xm; 95%
CI: - 1 9 , - 2 ; P-heterogeneity = 0.20 and P-heterogeneity = 0.35
by fetal growth status).

DISCUSSION
Impaired fetal growth is an important risk factor for adult
cardiovascular disease, with each 1-kg decrease in birth weight
being associated with a 10-20% increase in risk of adult
ischmie heart disease (2). Our current findings indicate that, for
individuals with impaired fetal growth, both dietary and serum
omega-3 PUFAs during adulthood are inversely associated with
an age-related increase in carotid IMT. These findings are consistent with the hypothesis that dietary omega-3 PUFAs may
counter the heightened cardiovascular and cerebrovascular risk
associated with impaired fetal growth (9) and are of particular
relevance to the ~ 1 2 % of the US population born each year
who meet our definition of impaired fetal growth.
We recently showed, in a separate population, that an early
childhood intervention of dietary omega-3 PUFA supplementation, from age 6 mo to 5 y, attenuates the inverse association of
impaired fetal growth with early arterial wall thickening at 8 y of
age (9), which suggests that an early childhood dietary omega-3
PUFA intervention may have cardiovascular benefits for children
born with impaired fetal growth. The current study assessed the
association of dietary (rather than supplementary) omega-3
PUFAs with an increase in carotid IMT in young adults who had

62
A

SKILTON ET AL

Impaired fetal growth

10

Normal fetal growth

Dietary omega-3 PUFA (g/d)

Dietary omega-3 PUFA (g/d)

Serum omega-3 PUFA (%)

Serum omega-3 PUFA (%)

10

11
FIGURE L Associations of 6-y increase in carotid IMT with dietary oinega-3 (n3) PUFAs in infants with impaired fetal growth (A) and normal fetal
growth (B) and with serum otnega-3 PUFAs in infants with impaired fetal growth (C) and normal fetal growth (D). Dietary and serum omega-3 PUFAs were
inversely associated with the 6-y inerease in carotid IMT in participants with impaired fetal growth but not in participants with normal fetal growth. Partial
residual plots are shown, with they axis recalibrated to the average increase in carotid IMT, adjusted as per standard multivariable models. Data are presented
as regression eoefficients and 95% CIs from multivariable linear regression. Dietary omega-3 PUFAs were log transformed for analysis, and serum omega-3
PUFAs are shown as a percentage of total serum fatty acids. In participants with impaired fetal growth, the 6-y progression of maximum carotid IMT was 57
/m (95% CI: 1, 112) lower per 100% inerease in dietary omega-3 PUFA intake under isocaloric conditions (A; n = 171) and 12 /xm (95% CI: 0, 23) lower per
unit increase in serum omega-3 PUFAs (C; n = 186), In participants with normal fetal growth, the 6-y progression of maximum carotid IMT was 1 /xm (95%
CI: 18, 19) higher per 100% inerease in dietary omega-3 PUFA intake under isocaloric conditions (B; = 1234) and 3/xm (95% CI: 2, 7) lower per unit
increase in serum omega-3 PUFAs (D; n = 1328), IMT, intima-media thickness.

impaired fetal growth, which is more direct evidence that dietary

omega-3 PUFAs may improve vascular health in those who had
experienced impaired fetal growth and is consistent with a reduction in risk of cardiovascular and cerebrovascular disease
events.
Clinical trials investigating the effects of dietary omega-3
PUFA supplementation on cardiovascular disease events and
mortality have had mixed findings (21-24), Similarly, some (25,
26) but not all observational studies (27) have reported a relation
of dietary omega-3 PUFAs with carotid IMT, When dietary
energy intake was accounted for, these associations of dietary

omega-3 PUFAs with carotid IMT remained significant in only

one study (25), These prior findings are similar for dietary intake
of marine-derived omega-3 PUFAs (25-27), whereas a-linolenic
acid was found to have a significant inverse relation with carotid
IMT in models adjusting for energy intake and other cofounders
(27, 28), With regard to serum or membrane fatty acids, several
cross-sectional studies have found evidence of associations between various individual omega-3 PUFAs and carotid IMT (29,
30), whereas other studies have failed to find such associations
(27, 31), Of interest, and consistent with our current findings,
Sekikawa et al (32) found an inverse association between serum

FETAL GROWTH, OMEGA-3, AND ATHEROSCLEROSIS

omega-3 PUFAs and carotid IMT in Japanese men bom in
postwar Japana 2-decade period that saw marked improvements in fetal growth (33). In contrast, they found no such association in third- and fourth-generation Japanese Americans or
white Americans (32).
To our knowledge, there have been no prior reports from observational studies of dietary omega-3 PUFAs or serum omega-3
PUFAs with the progression of earotid IMT. In clinical trials that
have detailed the effects on carotid atherosclerosis of dietary
intervention or omega-3 PUFA supplementation for > 2 y duration, most have shown no benefit with regard to carotid IMT,
including among participants with established cardiovascular
disease (34), hypertriglyceridemia (35), hypercholesterolemia
(36), and children (37). In contrast, beneficial effects of omega-3
PUFA interventions have been shown in one open-label study of
purified EPA in subjects with type 2 diabetes (38).
After identifying that dietary omega-3 PUFAs may reduce the
time-related increase in carotid IMT in those who had experienced impaired fetal growth, we determined whether the same
association was present in those who had experienced normal
fetal growth. We found that a similar association was not present
in this group and indeed we found some evidence of heterogeneity by fetal growth. This suggests that the mechanisms linking
dietary omega-3 PUFAs with reduced carotid IMT progression
are modified by fetal growth status. Nonetheless, the primary
hypothesis and aim of this analysis are informed only by the
associations observed in those with impaired fetal growth.
To further inform on potential mechanisms underlying the
observed benefits of omega-3 PUFAs on reduced progression
of carotid IMT, we constructed models that adjusted for traditional cardiovascular disease risk factors. For dietary omega-3
PUFAs, such adjustment did not materially alter the inverse
association with the 6-y increase in carotid IMT. In contrast,
cai"diovascular disease risk factors accounted for ~ 50% of the
association of serum omega-3 PUFAs with a reduced 6-y
increase in carotid IMT, which suggests that established risk
factors may mediate the association of serum omega-3 PUFAs
with a lower rate of progression of carotid IMT. We found in
a cross-sectional analysis that serum omega-3 PUFA concentrations were directly associated with HDL cholesterol
and inversely associated with systolic blood pressure and
BMI. Consistent with these findings, previously published
research suggests that dietary omega-3 PUFAs cause a modest
reduction in blood pressure (39) and a small increase in HDL
cholesterol (40). Furthermore, a small study in humans and an
experimental animal study have described reductions in body
fat accumulation and fat mass in response to dietary otTtega-3
PUFAs (41, 42). Although beyond the scope of the current
investigation, other potential meehanisms for this association
may involve the dysregulation of omega-3 PUFA metabolism
secondary to impaired fetal growth (43, 44) or omega-3
PUFA-derived improvements in insulin sensitivity after
"catch-up" growth (45). Regarding fatty acid subtypes, we
recently showed that serum DHA concentratiortSare inversely
associated with incident subclinical atherosclerosis in participants in the Young Finns Study (46); however, our current
study suggests that the inverse assoeiation of serum DHA
with IMT progression may be 2-fold stronger for those born
with impaired fetal growth when compared with those with
normal fetal growth.

63

The strengths of the current study included the prospective

nature of the population-based cohort and the relatively long
duration between carotid IMT measures. However, the current
study had sotne limitations. Given the age range of the cohort, we
were unable to use clinical cardiovascular events as an endpoint.
Instead, we used carotid IMTa noninvasive measure of subclinical atherosclerosis that is associated with the extent of
atherosclerosis and risk of future cardiovascular events ( 4 7 ^ 9 ) .
Fetal growth was not directly measured in participants but
rather was ascertained by using a questionnaire during childhood. The current study detailed regular dietary intake and did
not directly assess whether a dietary intervention of omega-3
PUFAs may reduce cardiovascular disease in those with impaired fetal growth. Accordingly, we cannot rule out a role for
other dietary components, the consumption of which is strongly
cotTelated with that of omega-3 PUFAs. In Finland, the predominant dietary sources of omega-3 PUFAs are rapeseed oil
and rapeseed oil-based margarines, with only 15% of dietary
omega-3 PUFAs coming from fish (50). Whether or not siinilar
findings would be present in populations with a higher proportion of dietary omega-3 PUFAs from marine sources is unknown; however, such diets would be rich in DHA, which was
strongly and inversely associated with the 6-y increase in carotid
IMT in our study. Finally, the food-frequency questionnaire was
administered in 2007 but not in 2001; however, the associations
with carotid IMT progression were similar for serum omega-3
PUFA, which were assessed in 2001.
In conclusion, we found that dietary omega-3 PUFAs and
serum omega-3 PUFAs are inversely associated with the 6-y
increase in carotid IMT in those with impaired fetal growth. This
finding suggests that dietary intake of omega-3 PUFAs may, at
least in part, prevent the well-established association of impaired
fetal growth with adult cardiovascular disease.
We acknowledge the expert technical assistance with data management and
the statistical analyses by Irina Lisinen and Ville Aalto.
The authors' responsibilities were as followsMRS, MA-K, JSAV,
MJ, T Laitinen, T Lehtimki, LT, MK, and OTR: designed the research;
PS and AJK: conducted the research; MRS and KAS: analyzed the data
and performed the statistical analysis; MRS, VM, PW, KAS. DSC, and
OTR: wrote the manuscript; and OTR: had primary responsibility for the
final content. All authors read and approved the final manuscript. The
former employer of MRS (2007-2010; Baker IDI Heart and Diabetes
Institute, Melbourne, Australia) receives financial support from Swisse
Vitamins (Melbourne, Australia), linked to the use of their trademark in
the marketing of certain fish-oil products; this financial support did not
directly support the salary or research of MRS, nor was it paid to the
institution on his behalf. MRS previously (2007-2010) received minor
support from Huon Aquaculture (Australia) for research related to
omega-3 PUFAs. None of the other authors disclosed any relevant financial or personal relations.

REFERENCES
1. Barker DJ. Winter PD. Osmond C, Margetts B, Simmonds SJ. Weight in
infancy and death from ischaemic heart disease. Lancet 1989;2:577-80.
2. Huxley R, Owen CG. Whincup PH, Cook DG. Rich-Edwards J, Smith
GD, Collins R. Is birth weight a risk factor for isehemic heart disease in
later life? Am J Clin Nutr 2007:85:1244-50.
3. Skilton MR, Viikari JS. Juonala M, Laitinen T, Lehtimki T, Taittonen L,
Khnen M, Celermajer DS. Raitakari OT Fetal growth and preterm birth
influence cardiovascular risk factors and arterial health in young adults: the
cardiovascular risk in young Finns study. Arterioscler Thromb Vase Biol
2011:31:2975-81.

64

SKILTON ET AL

4. Skilton MR. Evans N, Griffiths KA, Harmer JA, Celermajer DS. Aortic
wall thickness in newborns with intrauterine growth restriction. Lancet
2005 ;365:1484-6.
5. Leeson CP. Kattenhorn M. Morley R. Lucas A. Deanfield JE. Impact of
low birth weight and cardiovascular risk factors on endothelial function
in early adult life. Circulation 2001;103:1264-8.
6. Leeson CPM. Whincup PH, Cook DG, Donald AE, Papacosta O, Lucas
A, Deanfield JE. Flow-mediated dilation in 9- to 11-year-old children:
the influence of intrauterine and childhood factors. Circulation 1997:96:
2233-8.
7. Martin H. Hu J. Gennser G. Nonnan M. Impaired endothelial function
and increased carotid stiffness in 9-year-old children with low birthweight. Circulation 2000; 102:2739-44.
8. Maitin H. Lindblad B. Noi^man M. Endothelial function in newborn infants
is related to folate levels and birth weight. Pediatrics 2(K)7:119:1152-8.
9. Skilton MR. Ayer JG. Harmer JA, Webb K, Leeder SR. Marks GB,
Celemiajer DS. Impaired fetal growth and arterial wall thickening:
a randomized trial of omega-3 supplementation. Pediatrics 2012:129:
e698-703.
10. Raitakari OT. Juonala M, Rnnemaa T, Keltikangas-Jarvinen L, Rasanen
L, Pietikainen M, Hutri-Kahonen N. Taittonen L, Jokinen E, Mamiemi J,
et al. Cohort profile: the Cardiovascular Ri.sk in Young Finns Study. Int J
Epidemiol 2008;37:1220-6.
11. Koskinen J, Khnen M, Viikai^i JS, Taittonen L, Laitinen T, Rnnemaa T,
Lehtimki T, Hutii-Kahonen N, Pietikainen M, Jokinen E, et al. Conventional cardiovascular risk factors and metabolic syndrome in predicting
carotid intima-media thickness progression in young adults. The Cardiovascular Risk in Young Finns Study. Circulation 2009; 120:229-36.
12. Paalanen L. Mnnist S, Virtanen MJ, Knekt P, Rasanen L, Montonen
J. Pietinen P. Validity of a food frequency questionnaire varied by age
and body mass index. J Clin Epidemiol 2()()6;59:994-I001.
13. National Institute for Health and Welfare. Fineli. Finnish food composition database. Helsinki, Finland: National Institute for Health and
Welfare, Nutrition Unit. 2009.
14. Tukiainen T, Tynkkynen T, Mkinen V-P, Jylnki P, Kangas A, Hokkanen
J, Vehtai^i A, Grhn O, Hallikainen M, Soininen H, et al. A multimetabolite analysis of senim by IH NMR spectroscopy: early systemic
signs of Alzheimer's disease. Biochem Biophys Res Commun 2(X)8;375:
356-61.
15. Inouye M, Kettunen J, Soininen P, Silander K. Ripatti S, Kumpula LS,
Hamalainen F, Jousilahti P, Kangas AJ. Mannisto S, et al. Metabonomic. transcriptomic. and genomic variation of a population cohort.
Mol Syst Biol 2010;6:441.
16. Raitakari OT, Juonala M, Khnen M, Taittonen L, Laitinen T, MakiTorkko N, Jarvisalo MJ, Uhari M, Jokinen E, Rnnemaa T, et al.
Cardiovascular risk factors in childhood and carotid artery intimamedia thickness in adulthood: the Cardiovascular Risk in Young Finns
Study. JAMA 2003:290:2277-83.
17. Raiko JR. Viikari JS. Ilmanen A, Hutri-Kahonen N, Taittonen L, Jokinen
E, Pietikainen M, Jula A. Loo BM, Mamiemi J, et al. Follow-ups of the
Cardiovascular Risk in Young Finns Study in 2001 and 2007: levels and
6-year changes in risk factors. J Intern Med 2010:267:370-84.
18. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of
the preparative ultracentrifuge. Clin Chem 1972; 18:499-502.
19. Willett W. Stampfer M. Implications of total energy intake for epidemiologic analyses. In: Willett W. ed. Nutritional epidemiology. New
York, NY: Oxford University Press, 1998:273-301.
20. Altman DG. Bland JM. Interaction revisited: the difference between
two estimates. BMJ 2003;326:219.
21. GISSI-Prevenzione Investigators. Dietary supplementation with n - 3
polyunsaturated fatty acids and vitamin E after myocardial infarction:
results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio
della Sopravvivenza nell'Infarto miocardico. Lancet 1999;354:447-55.
22. Tavazzi L, Maggioni AP. Marchioli R. Bariera S, Franzosi MG, Latini
R, Lucci D, Nicolosi GL, Porcu M, Tognoni G. Effect of n - 3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSIHF trial): a randomised, double-blind, placebo-controlled trial. Lancet
2008;372:1223-30.
23. Yokoyama M, Origasa H. Matsuzaki M, Matsuzawa Y, Saito Y, Ishikawa
Y, Oikawa S, Sasaki J. Hishida H. Itakura H, et al. Effects of eicosapentaenoic acid on major coronaiy events in hypercholesterolaemic patients (JELIS): a randomised open-label, bUtided endpoint analysis.
Lancet 2007;369:1090-8.

24. Kromhout D, Giltay EJ, Geleijnse JM. n3 Fatty acids and cardiovascular events alter tnyocardial infarction. N Engl J Med 2010;363:
2015-26.
25. Hino A, Adachi H, Toyomasu K. Yoshida N, Enomoto M, Hiratsuka A,
Hirai Y, Satoh A, Imaizumi T. Very long chain N-3 fatty acids intake
and carotid atherosclerosis: an epidemiological study evaluated by
ultrasonography. Atherosclerosis 2004:176:145-9.
26. Ebbesson SO, Roman MJ. Devereux RB, Kaufman D, Fabsitz RR,
Maccluer JW, Dyke B. Laston S, Wenger CR, Comuzzie AG, et al.
Consumption of omega-3 fatty acids is not associated with a reduction
in carotid atherosclerosis: the Genetics of Coronary Artery Disease in
Alaska Natives study. Atherosclerosis 2008; 199:346-53.
27. Park Y. Lim J. Kwon Y, Lee J. Correlation of erythrocyte fatty acid
composition and dietary intakes with markers of atherosclerosis in
patients with myocardial infarction. Nutr Res 2009;29:39l-6.
28. Djousse L, Folsom AR, Province MA, Hunt SC, Ellison RC. Dietary
linolenic acid and carotid atherosclerosis: the National Heart, Lung, and
Blood Instute Family Heart Study. Am J Clin Nutr 2003;77:819-25.
29. Sala-Vila A, Cofn M, Prez-Heras A, Nez I, Gilabert R, Junyent M,
Mateo-Gallego R, Cenarro A, Civeira F, Ros E. Fatty acids in serum
phospholipids and carotid intinia-media thickness in Spanish subjects
with primary dyslipidemia. Am J Clin Nutr 2010:92:186-93.
30. Sekikawa A, Kadowaki T, El-Saed A. Okamura T, Sutton-Tyrrell K,
Nakamura Y, Evans RW. Mitsunami K-i, Edmundowicz D, Nishio Y,
et al. Differential association of docosahexaenoic and eicosapentaenoic
acids with carotid intima-media thickness. Stroke 2011:42:2538^3.
31. Yano Y, Hoshide S. Tamaki N, Inokuchi T, Nagata M, Yokota N, Hidaka
T, Kanemani Y, Matsuda S, Kuwabara M, et al. Regional differences in
hypertensive cardiovascular remodeling between fishing and farming
communities in Japan. Am J Hypertens 2011;24:437^3.
32. Sekikawa A. Curb JD, Ucshima H. El-Saed A, Kadowaki T, Abbott RD,
Evans RW, Rodriguez BL, Okamura T, Sutton-Tyrrell K, et al. Marinederived n - 3 fatty acids and athero.sclerosis in Japanese, JapaneseAmerican, and white men: a cross-sectional study. J Am Coll Cardiol
2008:52:417-24.
33. Gruenwald P, Funakawa H, Mitani S, Nishimura T, Takeuchi S. Infiuence of environmental factors on ftal growth in man. Lancet 1967;
1:1026-8.
34. Angerer P, Kothny W, Stork S, von Schacky C. Effect of dietary supplementation with omega-3 fatty acids on progression of atherosclerosis in carotid arteries. Cardiovasc Res 2002;54:183-90.
35. Baldassarre D, Amato M, Eligini S, Barbieri SS, Mussoni L, Frigerio
B. Kozakova M, Tremoli E, Sirtori CR, Colli S. Effect of n - 3 fatty
acids on carotid atherosclerosis and haemostasis in patients with
combined hyperlipoproteinemia: a double-blind pilot study in primary
prevention. Ann Med 2006:38:367-75.
36. Hjerkinn EM, Abdelnoor M, Breivik L, Bergengen L, EUingsen I,
Seljeot I, Aase O, Ole Klemsdal T, Hjermann 1, Arnesen H. Effect of
diet or very long chain omega-3 fatty acids on progression of atherosclerosis, evaluated by carotid plaques, intima-media thickness and by
pulse wave propagation in elderly men with hypercholcsterolaemia.
Fur J Cardiovasc Prev Rehabil 2006:13:325-33.
37. Ayer JG. Harmer JA. Xuan W, Toelle B, Webb K. Almqvist C, Marks
GB, Celermajer DS. Dietary supplementation with n - 3 polyunsaturated fatty acids in early childhood: effects on blood pressure
and arterial structure and function at age 8 y. Am J Clin Nutr 2009;90:
438^6.
38. Mita T. Watada H, Ogihara T, Nomiyama T, Ogawa O, Kinoshita J,
Shimizu T, Hirose T, Tanaka Y, Kawamori R. Eicosapentaenoic acid
reduces the progression of carotid intima-media thickness in patients
with type 2 diabetes. Athero.sclerosis 2007;191:162-7.
39. Morris MC, Sacks F, Rosner B. Does fish oil lower blood pressure? A
meta-analysis of controlled trials. Circulation 1993;88:523-33.
40. Harris WS. n 3 Fatty acids and serum lipoproteins: human studies.
Am J Clin Nutr 1997;65:1645S-54S.
41. Couet C. Delarue J, Ritz P, Antoine JM, Lamisse F. Effect of dietary
fish oil on body fat mass and basal fat oxidation in healthy adults. Int J
Obes Relat Metab Disord I997;21:637^3.
42. Ruzickova J, Rossmeisl M, Prazak T, Flachs P, Sponarova J, Veck M,
Tvrzicka E, Bryhn M, Kopecky J. Omega-3 PUFA of marine origin
limit diet-induced obesity in mice by reducing cellularity of adipose
tissue. Lipids 2004;39:l 177-85.
43. Labayen I, Moreno LA, Ruiz JR, Ortega FB, Sjostrom M, Huybrechts
I, Gonzalez-Gross M, Spinneker A, De Henauw S, Manios Y, et al.

FETAL GROWTH, OMEGA-3, AND ATHEROSCLEROSIS

Associations of birth weight with serum long chain polyunsaturated
fatty acids in adolescents; the HELENA study. Atherosclerosis 2011;
217:286-91.
44. Ozanne SE, Martensz ND, Petry CJ, Loizou CL, Hales CN. Maternal
low protein diet in rats programmes fatty acid desaturase activities in
the offspring. Diabetologia 1998:41:1337-^2.
45. Yepuri G, Marcelino H, Shahkhalili Y. Aprikian O, Mac K. Seydoux J,
L Miles J, Montani J-P, DuUoo AG. Dietary modulation of body
composition and insulin sensitivity during catch-up growth in rats:
effects of oil s rich in n - 6 or n - 3 PUFA. Br J Nutr 201 l;Jan 31:1-14.
46. Wiirtz P, Raiko JR. Magnussen CG, Soininen P. Kangas AJ, Tynkkynen
T, Thomson R, Laatikainen R, Savolainen MJ, Laurikka J. et al. Highthroughput quantification of circulating metabolites improves prediction
of subclinical atherosclerosis. Eur Heart J 2012;33(18):2307-16.

65

47. Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu C-r, Liu C-h, Azen SP.
The role of carotid arterial intima-i'nedia thickness in predicting clinical coronary events. Ann Intern Med 1998; 128:262-9.
48. Polak JF, Pencina MJ, O'Leary DH, D'Agostino RB. Common carotid
artery intima-media thickness progression as a predictor of stroke in
multi-ethnic study of atherosclerosis. Stroke 2011;42:3017-21.
49. Lorenz MW. Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of
clinical cardiovascular events with carotid intima-media thickness:
a systematic review and meta-analysis. Circulation 2007:115:459-67.
50. Paturi M, Tapanainen H. Reinivuo H, Piednen P. Finravinto 2007tutkimus-the National FINDIET 2007 Sui'vey. In: Paturi M. Tapanainen
H. Reinivuo H. Pietinen P, eds. Publications of the National Public Health
Institute. Helsinki, Finland: National Public Health Institute, 2008.

Copyright of American Journal of Clinical Nutrition is the property of American Society for
Nutrition and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.