healthcare

Article
Nutrition of Pregnant and Lactating Women in the First
1000 Days of Infant
Claude Billeaud 1, * , Juan Brines 2 , Wafae Belcadi 3 , Bérénice Castel 3 and Virginie Rigourd 4

1 Neonatology & Nutrition, CIC Paediatrics INSERM 1401 CHU, 33076 Bordeaux, France
2 Department of Pediatric, Obstetrics and Gynecology, Faculty of Medicine, Valencia University,
46010 Valencia, Spain; [email protected]
3 CIC Paediatrics INSERM 1401 CHU, 33076 Bordeaux, France; [email protected] (W.B.);
[email protected] (B.C.)
4 Neonatology and Director of “Lactarium de l’ile de France” Necker-Enfants Malades Hospital,
75015 Paris, France; [email protected]
* Correspondence: [email protected]

Abstract: Nutrition for pregnant and breastfeeding women is fundamental to the development of the
child in its first 1000 days and beyond. To evaluate the adequacy of this nutrition, we have relied
on historical dietary surveys and on personal French studies (4 studies from 1997 to 2014) involving
dietary surveys over 3 days (3D-Diet). Furthermore, our team specialized in lipids has measured the
fatty acids of breast milk, which reflect the dietary intake of lipids, from breast milk (1997–2014) and
from the lipids of cord blood and maternal fat tissue, in 1997. According to our results, pregnancy
needs require an additional 300 Kcal, but surveys show a bad equilibrium of macronutrients: an excess
of proteins of fetus [17% of total energy intake (TEI) vs. 15%], excess of fats (45% vs. 35%), excess of
saturated fatty acids (SFA), not enough polyunsaturated fatty acids (PUFA), particularly omega 3,





 and a deficit in carbohydrates (45% vs. 55%). There is also a deficiency in calcium, iron, magnesium,
Citation: Billeaud, C.; Brines, J.;
zinc, and vitamins D, B6, B5, and folates. Breast milk adequately provides all the macronutrients
Belcadi, W.; Castel, B.; Rigourd, V. necessary for the growth of the child. Proteins and carbohydrates vary little according to the mother’s
Nutrition of Pregnant and Lactating diet; on the other hand, its composition in lipids, trace elements, and vitamins is highly variable with
Women in the First 1000 Days of the mother’s diet of breast milk. In our study in 2014, in 80 participants, the diet was low in calories
Infant. Healthcare 2022, 10, 65. (1996 Kcal vs. 2200 Kcal RDA), normoprotidic, normolipidic, but low in carbohydrate, especially
https://doi.org/10.3390/ polysaccharides. We note a very insufficient intake of fish and dairy products, and therefore calcium,
healthcare10010065 but also magnesium, zinc, iron, and vitamins D, E, B6, and folate. Consequently, if the mother does
Academic Editor: not achieve a diet adequate to her needs during pregnancy and breastfeeding, it will be necessary to
Alessandro Sartorio resort to medicinal supplements in minerals, trace elements, vitamins, and omega 3.

Received: 2 December 2021

Keywords: breastmilk; human milk; pregnancy nutrition; lactation nutrition; lipids
Accepted: 27 December 2021
Published: 30 December 2021

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in 1. Introduction
published maps and institutional affil-
The supply of nutrients to the fetus and the infant during the first 1000 days of the
iations.
child’s [1] life, from conception to the end of the second year, depends on the supply of
nutrients from the diet of the pregnant and breastfeeding woman.
Therefore, the mother’s diet and lifestyle before and during pregnancy and lactation
Copyright: © 2021 by the authors.
constitute a determining factor in the infant’s health that can be projected on that of the
Licensee MDPI, Basel, Switzerland. child and future adult [2].
This article is an open access article Without diminishing the importance of the macronutrients (proteins, lipids, and carbo-
distributed under the terms and hydrates), in recent decades, research on human milk and infant nutrition has been mainly
conditions of the Creative Commons focused on the role of some essential fatty acids, vitamins, and trace elements. This interest
Attribution (CC BY) license (https:// has been greatly motivated by the demonstration of the causal relationship between folic
creativecommons.org/licenses/by/ acid deficiency in early pregnancy and neural tube defects in the fetus [3], or the function
4.0/). that long-chain essential fatty acids (omega 6 and omega 3 families) play for neuro-sensory

Healthcare 2022, 10, 65. https://doi.org/10.3390/healthcare10010065 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, x 2 of 11

interest has been greatly motivated by the demonstration of the causal relationship be-
Healthcare 2022, 10, 65 2 of 11
tween folic acid deficiency in early pregnancy and neural tube defects in the fetus [3], or
the function that long-chain essential fatty acids (omega 6 and omega 3 families) play for
neuro-sensory development during pregnancy and lactation (Figure 1).These relation-
development
ships betweenduring pregnancy
some nutrient and lactation
deficiencies and (Figure 1).These
pathologies relationships
of the between
fetus and infant some
have di-
nutrient
rectly deficiencies
raised questionsand pathologies
regarding of the fetus
the possibility ofand infant have
prevention directly
through raised
proper questions
supplemen-
regarding
tation [4]. the possibility of prevention through proper supplementation [4].

Figure
Figure1.1.Accretion
Accretionofofdocosahexaenoic
docosahexaenoicacid
acid(DHA-22:6n-3)
(DHA-22:6n-3)and andarachidonic acid.
arachidonic (AA-20:4n-6)
acid. (AA-20:4n-6)in
in
the
the brain ofdeceased
brain of deceasedchildren
children during
during the the
first first
yearsyears
of life.of life.

Inthis
In thisline,
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ourresearch
researchteam
teamhas hasbeen
beenparticularly
particularlyinterested
interestedininthe
thelipids
lipidsin
inbreast
breast
milk that reflect the nature of the lipids in the mother’s diet. The supplementation
milk that reflect the nature of the lipids in the mother’s diet. The supplementation with with
the very long-chain fatty acid omega-3 docosahexaenoic acid (DHA)
the very long-chain fatty acid omega-3 docosahexaenoic acid (DHA) not only promotes not only promotes
brainand
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developmentbut butalso
alsoplays
playsaa role
role in
in improving
improving preterm
preterm birth
birth [4].
[4]. The
The
aim of this paper is to evaluate the adequacy of the nutrition intake during
aim of this paper is to evaluate the adequacy of the nutrition intake during pregnancy and pregnancy and
lactation with recommended Diet Intake (RDI). We have relied on historical
lactation with recommended Diet Intake (RDI). We have relied on historical dietary sur- dietary surveys
and on
veys andpersonal French
on personal studies
French (4 studies
studies from from
(4 studies 1997 to
19972014) and one
to 2014) andEuropean Multicenter
one European Mul-
Study (2016–2020).
ticenter Study (2016–2020).
2. Material and Methods
2. Material and Methods
We have compared food consumption by 3D-Diets on the one hand, and the RDI from
We have compared food consumption by 3D-Diets on the one hand, and the RDI
the nutrition committees on the other to try to answer the question of supplements during
from the nutrition committees on the other to try to answer the question of supplements
pregnancy [5,6].
during pregnancy [5,6].
We have relied on historical dietary surveys, on personal French studies (4 studies
fromWe have
1997 reliedand
to 2014) on one
historical
Europeandietary surveys, Study
Multicenter on personal FrenchWe
(2016–2020). studies (4 studies
have used a few
from 1997 to 2014) and one European Multicenter Study (2016–2020). We have
demonstrative dietary surveys: an American survey: W.I.C. (Women, Infants and Children; used a few
demonstrative dietary
n = 500,000 women) surveys:
and an American
two French surveys: survey: W.I.C.
one reported by(Women,
Papoz [7]Infants
(n = 534and Chil-
women);
dren; n = 500,000
the other by Lecerfwomen) and two We
(n = 50 women). French surveys:
compare one reported
the results of theseby Papoz surveys
different [7] (n = with
534
women); the other by Lecerf (n = 50 women).
the RDI of the French Nutrition Committee (CNERMA). We compare the results of these different
surveys with the RDI
In addition, of theused
we have French
the Nutrition
experienceCommittee (CNERMA).
of our research group conducting 4 clinical
studies on 3-day dietary surveys from 1997 to 2014 (1997: 18 samples of milk; 2007: 142 sam-
ples of milk; 2012: 22 samples of milk and 2014: 80 samples of milk). We studied diets
of lactating women between 2- and 4-months post-partum (Mature breast, milk samples
Healthcare 2022, 10, 65 3 of 11

collected in the morning). The FAs composition of breast milk was determined by direct
transesterification and analyzed by FID-GPC. The data were compared by ANOVA and/or
Kruskall and Wallis test.
In addition, our laboratory team has studied lipids measuring fatty acids in the blood
of the mother and the newborn at birth cord, as well as in the adipose tissue on the
cesarean scar.
Given that energy intake varies a lot according to BMI, a first visit at the beginning of
pregnancy was considered to evaluate the woman’s nutrition status and performed.

3. Results and Comments

We will treat separately the data referring to the period of pregnancy and lactation.

3.1. Pregnant Women Nutrition

3.1.1. Energy Needs
The energy needs of pregnant women are estimated to 80,000 Kcal per 250 days, so
2300 Kcal per day [8].
Our estimate regarding additional nutrient needs per day according to the gestation
period are as follows: during the first trimester, no caloric supplement; during the second
trimester, 200 Kcal; and during the third trimester, 450 Kcal. Regarding the supplement
needs according to the gestation period, Koletzko considers that they should not exceed
10% of the total energy [9].

3.1.2. Macronutrients
The comparison between pregnant and non-pregnant macronutrient needs are the
same and there is an excess of total fats and proteins, but not enough carbohydrates (Table 1)
and energy. Indeed, the protein intake in surveys represents 15% of the total energy intake
(TEI) versus 13% of the TEI recommended, 85 g/d versus 60 g/d (RDI). Fats consumed
42–43% of the TEI versus 35% (RDI) and carbohydrates are insufficient, 42% of TEI versus
55% (RDI.) (Table 1).

Table 1. Survey and macronutrients/RDI.

W.I.C LECLERC PAPOZ

Nutrients RDI Needs
USA France France
Energy
1512–2400 2233 2136 2300 +100–450
Kcal/day
Protein 85 g 78 g 60 g Excess
68–110
g/day 15% 15% 13% Quality
Fats 104 g 103 g 90 g Excess
g/day 42% 43% 35% Quality
Carbohydrates 235 g 211 g 340 g +100
g/day 42% 40% 55% Quality

The comparison between the diet’s surveys and RDI shows a deficit in energy and
carbohydrates.

3.1.3. Proteins
Protein should represent 13% of the total energy intake, 1.1 g/kg/d [4]. In fact, on
average, mothers consume 18% of TEI in our survey in 1997 and 17% in 2014. Moreover,
we should provide 2/3 of animal proteins of good biological quality and 1/3 of vegetable
proteins. The problem arises with vegetarians who need to sort out vegetables’ rich in
essential amino acids and compensate for deficits in micronutrients and vitamins [4].
Healthcare 2022, 10, 65 4 of 11

3.1.4. Fats
We distinguish three types of fatty acids (FA): 1—saturated fatty acids (SFA) (no double
bonds), 2—monounsaturated fatty acids (MUFA, 1 double bond), the most important of
which is oleic acid, and 3—polyunsaturated fatty acids (more than two double bonds) which
are the essential fatty acids, precursors of the omega 3 and 6 families: linoleic acid (LA) and
omega 3 family: linolenic acid (ALA) which are converted in long chain polyunsaturated
fatty acids (LC-PUFA: Arachidonic acid “AA” omega 6, and docosahexaenoic acid “DHA”,
omega 3).
The intake of all types of fats varies with the mother’s fat diet: oils or meats and fish
intake AA and DHA are presented in Tables 2 and 3.

Table 2. Fatty acid oils composition.

Oils Peanuts Rapeseed Hazelnut Olive Grapeseed Soja Sunflower Sunflower Oleic
Saturated FA SFA 48–66 55–62 24–32 61–80 14–22 17–26 15–25 75–83
Monounsaturated MUFA 49–68 56–65 25–33 32–81 15–23 18–27 16–26 75–84
Linoleic Ac C18:2 n-6 14–28 18–22 55–62 3–14 65–73 50–62 62–70 10–21
Linolenic Ac C18:3 n-3 <0.3 8–10 <2 <1 <0.5 4–10 ≤0.2 ≤0.3
Polyunsaturated PUFA 14–28 26–32 57–64 4–15 65–73 54–72 62–70 10–22
The composition of omega 6 and 3 oils is different: rapeseed, soybean, walnut, and hazelnut oils contain both
ALA (ω3) and LA (ω6), whereas olive oil contains no omega 3 (no ALA).

Table 3. Fish fatty acid composition.

Arachidonic Acid (AA) Eicosapentaenoic Acid

Oily Fish DHA (mg/100 g)
(mg/100 g) EPA (mg/100 g)
Mackerel 70 1020 1940
Sardine - 1250 1790
Salmon 41 527 842
Albacore Tuna 42 562 313
Arachidonic Acid (AA)
Lean Fish EPA (mg/100 g) DHA (mg/100 g)
(mg/100 g)
Wild Sea Bar - 220 293
Cod <10 77 194
Dab <14 102 189
Sole <11 19 81
The table shows different contents in omega 3 (ALA, EPA, DHA) between oily and lean fishes.

Meat, eggs, and fish bring Arachidonic acid. Oily fishes (Table 3), such as mackerel,
170 g twice a week brings DHA (350 mg/day). Fish, and mainly oily fish, intake much
DHA. The Mackerel Fish is the richest in DHA [10]. Oily fish may contain traces of mercury
but the impact on child health might be outweighed by the importance of DHA intake on
neuro-sensory development. Among the oily fish low in mercury, sardines, herring, and
salmon should be best [4].
There are many Long Chain Polyunsaturated fatty acids (LCPUFA) needs for the brain
(Figure 1), as seen for the fetus from the 22nd week of the gestational age to 2- or 3-years
postnatal age. The total need in preterm is about 45 mg/kg/d, at least, and up to 60 mg of
DHA at birth [11]. The precursors (ALA and LA) of long-chain polyunsaturated fatty acids
(LCPUFA) are poorly metabolized to LCPUFA (DHA and AA). The placenta compensates
for this by a biomagnification phenomenon transferring more LCPUFA (DHA and AA) to
the cord blood and therefore to the fetus than the precursors (ALA and LA) [11].
In the Adipose tissue of pregnant women in a 1997 study [12]: there is a major
content of Saturated FA (32%) and Monounsaturated FA (51%). There is a bad ratio of
Healthcare 2022, 10, 65 5 of 11

Linoleic/linolenic acid 32, an excess of omega 6 (16%), and a lack of omega 3. Therefore,
we advise to intake more precursor of omega 3 (ALA). Polyunsaturated fatty acids are
essential, although there is a sufficient intake in fat too rich in linoleic acid provided by
olive oil and deficient in linolenic acid. The optimal Linoleic/linolenic ratio is 6–7 so that
the precursors are more easily transformed into long-chain fatty acids [13].
DHA and AA are essential for brain and retinal development and a supplementation
in DHA (200–350 mg) is necessary during pregnancy and lactation [14].
Pregnant women find these long-chain fatty acids in their food:
She finds ALA, EPA, and DHA in oily fish (salmon, mackerel, sardines, tuna), lean fish
and AA in eggs, meat, and offal (Table 2). Varying the oils (rapeseed mainly instead olive)
and eating oily fish, eggs, and meat are sufficient for a good lipid nutritional balance [10].
Trans fatty acids (TFAs) are harmful polyunsaturated fatty acids. Recent studies have
suggested that TFAs compete cis-PUFA metabolism: our study [12] is according to the study
performed by Koletzko [15], who reported that in premature infants, the level of plasma
elaidic acid is inversely correlated to long-chain PUFA levels (LA). An inverse correlation is
also observed between TFA levels and birth weight. This suggests that an exposure to high
levels of TFAs during pregnancy may impair fetus growth. The TFAs are found in bad fats
(shortenings) and white bread and pastries made with bad fats. The most elevated is 17%
of Total Fatty Acids in Canada and the USA. In France, 2% in 1997, and only 1% in 2014,
after improving the margarine quality in France [16].

3.1.5. Mineral Salts and Trace Elements

It is possible to balance the need for minerals, trace elements, and vitamins with a diet
as previously defined. As the recommended calcium requirement is 1000–1200 mg/d, a
small supplement of 200 mg of calcium is needed [17] (Table 4).

Table 4. Surveys minerals and/RDI.

W.I.C LECLERC PAPOZ

Nutrients RDI Needs
USA France France
Calcium
668–1670 975 869 1000 200
mg/d
Magnesium
187–269 339 260 480 300
mg/d
Iron
11.4–17 13.7 12.4 30 30
mg/d
Zinc
6–12 19 15
mg/d
The table shows a deficiency in pregnancy in Calcium, Magnesium, Iron, and Zinc.

This can easily be met if we drink more milk; however, this will provide more protein
and more saturated fat. There is a slight deficit (compared to the RDI) in magnesium
(150 mg/d) and iron (15 mg/d) if we consider that iron requirements are 30 mg/d or more
if there is anemia in pregnant women [18]. For zinc, there is a shortfall of 10 mg, the usual
recommended requirement is 19 mg, and the diet provides only 4–5 mg. In addition, the
Iodine deficiency must be corrected [19]. The WHO recommends a daily intake of 250 µg
iodine for pregnant women.

3.1.6. Vitamins
A usual diet provides only 3 micrograms of vitamin D, and the requirement is 10 mg–
12 mg to ensure the security needs during pregnancy, depending on the amount of sunshine.
Northern countries need a daily intake of 5 mg/day, which is surprising [20], and for
Southern countries the supplementation is not systematic, or a minimum of 5 mg.
Healthcare 2022, 10, 65 6 of 11

Group B vitamins: while vitamins B1 and B6 are moderately deficient, if we consider

that folate (vitamin B9 ) requirements are 500 µg, there is a risk since the average intake is
255 µg. Iron, cobalamin, and folate deficiencies must be associated in pregnancy anemia [3].
In total, with a balanced diet, the needs in proteins, lipids, carbohydrates, and energy
are covered. On the other hand, the intake of calcium, iron, vitamin D, iodine, and folate
remains insufficient (Table 5).

Table 5. Survey vitamins and RDI.

W.I.C LECLERC PAPOZ

Nutrients RDI Needs
USA France France
Vit D
3–5 3.4 10 +10
mg
Vit B1
1.2–1.7 1.3 1.3 1.5 +2.5
mg/day
Vit B6
0.6–2.1 1.6 1.7 2.5 +2
mg/day
Folates (B9 )
144–243 255 53 500 +300
mg/day
The table shows a deficiency in pregnancy in vitamins D, B1 , B6, and folates.

The micronutrients and vitamins intake are not always perfectly guaranteed. It seems
necessary to take care of this and add a supplement. Most often, we use multivitamins
and oligoelement supplements with no toxicity, except for vitamin A when we exceed
8000 ui/d, which could lead to heart and circulatory malformations, but retinol alone is
teratogenic but not the carotenes [21].
If the mother does not eat sufficiently oily fish, she must take a supplement of 200 to
350 mg of DHA.

3.2. Lactating Mothers Nutrition

Breast milk adequately provides all the macronutrients necessary for the harmonious
growth of the child. The composition of breast milk in proteins and carbohydrates varies
little according to the mother’s diet. On the other hand, its composition in lipids, trace
elements, and vitamins is very variable with the mother’s diet. These results come from
French and European multicenter studies [10,22–24] and American RDI [25–27], and also
from our French studies 1997–2014 and from the Multicentric European Study during
2016–2020: the ATLAS [28,29] and the Doctoral Thesis on Nutritional Sciences of one of the
authors [30].

3.2.1. Energy
The diet of breastfeeding women in 1997 was hyperproteic (105 g/d vs. 80 RDI),
hyperlipidic (130 g/d vs. 90 RDI), and often with an excess of saturated fatty acids (15% of
energy vs. 12% RDI), a deficit in polyunsaturated fatty acids (5% vs. 7% RDI), insufficient
in carbohydrates (285 g/d vs. 340 RDI), and hypercaloric at 2700 kcal.
In 2014, the 3-D-diets showed that it was normoprotein and normolipid, but hypocaloric
(1992 kcal/d) compared to 2300 kcal (RDI) and to ATLAS (2044 Kcal/d, 87 g/d of proteins,
78 g/d of fats, 285 g/d of carbohydrates).
The newborn consumes about 750 g of breast milk, which would mean that the mother
would need to produce this amount of milk with a supplement of 450 Kcal/d. However,
considering the stocks built up during pregnancy, the real supplement is between 70 and
200 Kcal/d [26].
Healthcare 2022, 10, 65 7 of 11

3.2.2. Proteins
The requirements are covered by the normal diet; there is even a tendency to over-
consume. The recommended protein intake during pregnancy is 1.1 g/kg/d, and 0.8
g/kg/d [4] during lactation. These values have been revised downwards due to the risk of
obesity in the child if too much protein is consumed during the first 1000 days of life. In
terms of quality, the intake of animal proteins with a high biological value must represent
at least 2/3 of the intake, which is the case in the French surveys; the remainder can be
made up of vegetable proteins. Animal proteins are represented by dairy proteins on the
one hand, but also by meat, fish, and eggs.
Vegans have proteins with a bad biological value and a deficit of vitamin B12 , D, and
microelements requiring a supplement [3].
This dietary behavior leads to an insufficient intake of calcium and an excess of animal
fats. Milk and dairy products are particularly useful in breastfeeding women to provide
calcium (1/2 L = 600 mg), such as firm cheese (700 mg/100 gr). On the other hand, such
as all foods of animal origin, they contain saturated fats. It is therefore recommended to
use semi-skimmed milk or special milk for pregnant women (enriched with vitamins and
trace elements).

3.2.3. Carbohydrates
Overall, the breastfeeding woman consumes relatively few carbohydrates (285 g/d in
French studies and 235 g/d in ATLAS vs. 340 RDI), (40% TEI vs. 53% RDI), and in terms of
quality, there is an excess of “simple” sugars (mono-disaccharides) (110 g/d vs. 10% RDI,
i.e., 60 g/d), and not enough polysaccharides (110 g/d) and fiber (11 g/d in French studies
and 20.2 g/d in ATLAS vs. 25 g/d RDI).
In terms of foods, sweets and pastries are consumed in excess by more than half of
the mothers. Bread (90 g/day vs. 250 g/day) and starchy foods (160 g/day) are avoided
and lead to a deficit of fibers which participate to intake an important functional human
milk oligosaccharides (HMO) and a deficit of slow sugars. The drink must be abundant
(2 L + water from food), 2.6 L/d in our study in 2014 avoiding sweetened fruit juices
(155 mL/d in our study vs. 100 mL desired).

3.2.4. Fat’s Composition

Fat’s composition of breast milk varies greatly with the mother’s diet. A mother who
is exclusively vegetarian will have a milk richer in fatty acids of the ω6 series (LA), whereas
Eskimo women, consuming exclusively fish, will produce a milk very rich in fatty acids of
the ω3 series (ALA, EPA and DHA).

3.2.5. Essential Fatty Acids

Our team has undertaken the regular monitoring of dietary surveys (Table 6). In
France, the monitoring was held regularly from 1997 until the ATLAS study in 2020 to
see the effect of a national program advising a higher intake of omega 3. Since 1997, the
French nutrition committees have recommended consuming more omega 3. We can see
that between 1997 and 2014, ALA has increased significantly from 0.52% to 0.96%, DHA
has increased but very slightly from 0.24% to 0.29% [24]. In the ATLAS study, we measured
fatty acids in mature milks from seven European countries, including France (n = 85), the
results of a publication accepted in the European Journal of nutrition (December 2021). The
results are not different from the French results of 2014 [29].
Healthcare 2022, 10, 65 8 of 11

Table 6. Fatty acids evolution in mature human milk from 1997 to 2020 in FRANCE [10,24,29].

1997 2007 2012 2014 [10] (1) 2014 [10] (2) 2020 [29]
Fatty Acids % PhD JFRN Barcelona PHRC ω3 PHRC ω3 ATLAS
n = 18 n = 142 n = 22 n = 80 n = 80 n = 85
ALA 0.52 (0.2) b 0.83 (0.14) b 0.86 (001) 0.96 (0.50) a 2.15 (0.74) a 0.93 (0.26)
LA 13.33 (19.62) b 11.14 (10.24) 9.27 (0.34) b 10.03 (3.0) 10.77 (2.11) 10.51 (1.46)
LA/ALA b b 10.77 10.73 a 5.54 (2.11) a 11.30
27.63 13.42
EPA 0.08 (0.003) 0.07 (0.002) 0.06 (0.0001) 0.09 (0.05) a 0.17 (0.01) a 0.09 (0.03)
DHA 0.26 (0.01) 0.24 (0.01) 0.24 (0.003) 0.29 (0.16) a 0.56 (0.40) a 0.33 (0.11)
AA 0.38 (0.05) 0.40 (0.01) 0.39 (0.001) 0.36 (0.07) a 0.33 (0.22) a 0.43 (0.07) a
AA/DHA 1.46 1.67 1.63 1.24 a 0.82 (0.15) a 1.52
SFA 48.05 (27.67) 47.50 (27.98) 48.84 (4.28) 46.71 (4.38) 43.76 (3.88) 43.96 (0.59)
MUFA 32.80 (13.39) 37.76 (15.84) 38.60 (2.62) 39.72 (3.12) 40.60 (7,63) 43.1 (3.79)
PUFA 15.35 (21.72) 13.45 (11.83) 11.64 (0.45) 12.54 (3.3) a 14.70 (2.7) a 12.95 (2.6)
TFAs 2.10 (0.62) b 1.30 (0.36) b 0.92 (0.09) b 1.03 (0.29) 0.94 (0.27) -
a, b a:
is statistical difference p < 0.05. is significant difference in interventional nutrition between column PHRC
w3 (1) and (2). b : is significant differences in spontaneous nutritional evolution with time.

In 2014 [10], we performed a nutritional intervention on a group of 80 breastfeeding

women by giving mackerel 170 g twice a week, providing 350 mg/d of DHA and ALA,
which respectively increased from 0.29% to 0.54%, and ALA from 0.96% to 2.15% while
the LA/ALA ratio decreased from 10.73 to 5.5. We found that the AA line decreased from
0.36% to 0.33%. We recommend that breastfeeding women should consume 10% LA and
2–4% of total fatty acids (TFA) as ALA from 30 g/day of rapeseed oil and 25 g of margarine
enriched with omega 3, and oily fish such as mackerel 170 g twice a week to increase DHA
and 0.33–0.7% of AA from eating eggs and meat. In the ATLAS study, the FA intakes results
were: SFA, 32 g/d or 41% of total fatty Acids (TFA); LA, 6.4 g/d i.e., 8.2% of TFA; ALA, 1
g/d i.e., 1.2% vs. 4% of TFA; EPA, 170 mg/d i.e., 0.2% of TFA; and DHA, 250 mg/d i.e., 0.3%
of TFA. These results show an excess of SFA and an insufficiency PUFA (LA and ALA), but
on the other hand, an intake of DHA at 250 mg, which is sufficient (with great variations
according to the diet of each woman).
In 2018, another French Study [31] concluded, “Main results showed that mean daily
intakes of n-3 PUFA were very low in this French woman population because no pregnant
and lactating women met recommended dietary intakes (RDIs).”

3.2.6. Minerals, Vegetables, Oligo-Elements, Vitamins

Vegetables
The category of vegetables and fruit is important for dietary balance as it provides
minerals, vitamins, and fibers. We observed a low consumption of raw vegetables (20 g/d
vs. 100 desired), vegetables (140 g/d vs. 250 desired), and fruit (160 g/d vs. 300 desired).

Minerals–Trace-Elements
The dietary behavior leads to an insufficient intake of calcium. Milk and dairy products
are particularly useful in breastfeeding women to provide calcium (1/2 L = 600 mg), firm
cheese (700 mg/100 g). On the other hand, such as all foods of animal origin, they contain
saturated fats. It is therefore recommended to use semi-skimmed milk or special milk
for pregnant women (enriched with vitamins and trace elements). Calcium intake is very
important. In fact, the production of 800 mL of breast milk leads to an additional need
of 200 mg, i.e., 1000–1200 mg/d. In 1997, our survey showed 6 times out of 18 there was
an insufficiency of milk consumption and therefore of calcium, but also of Mg (250 mg/d
vs. 480 mg/d RDI) and of Zinc (7 mg/d vs. 19 RDI). The Atlas study shows: (Calcium
Healthcare 2022, 10, 65 9 of 11

957 mg/d vs. 1000–1200 mg RDI), Magnesium (322.2 mg/d vs. 480 mg RDI), Zinc (10.2 mg
vs. 19 mg RDI), and Iron (16.4 mg vs. 9.5 mg RDI).

Vitamins
There is a real interest in suggesting vitamin supplements in view of the insufficiency
of vitamin D (2 g/d vs. 10 RDI), vitamin E (7 mg/d vs. 12 RDI), B6 (1.5 mg/d vs. 2.5
RDI), and folates (138 g vs. 500 RDI). A nutritional supplementation improves the coverage
of oligo-elements and vitamins. The Atlas study shows a deficiency in pantothenic acid,
folate, vitamin C, vitamin A, and vitamin D (Vit D, 5.3 mg/d vs. 10 RDI) (Vit A, 819 mg/d)
(Vit B1 , 1.6 mg/d; vit B6 , 2 mg/d; folates, 337.3 mg/d: vit C, 120.5 mg/d) (Table 7).

Table 7. Pregnancy and lactation recommended nutriments. ANSES. 2019 [23].

Pregnancy Lactancy
Nutrients
Intake RDI Intake RDI
Proteins % TEI 18 13 17 20
Fats % TEI 44 35 43 40
SFA % TEI 13 ≤ 15 12
MUFA% TEI 13 15 8 20
ω6 PUFA % TEI 4.1 = 3.9 4
ω3 PUFA % TEI 0.4 = 0.3 1
ω6/ω3 10 ≤ 13 5
Carbohydrates % TEI 38 40 40 55
Simple carbohydrates % TEI 14 ≤ 18 10
Fibers (g) 12 25 20 30
Alcohol (g) 3 = 5 0
Calcium (mg) 900 1000 800 1000
Magnesium (mg) 200 400 250 390
Iron (mg) 14 30 9.5 10
Zinc (mg) 5 14 9 19
Vitamin D (µg) 2.4 1.9 10
Vitamin B6 (mg) 1.5 = 1 2
Vitamin B9 (µg) 154 = 242 400

Proposal for a Typical Menu for Breastfeeding Woman

It is a balanced menu providing proteins in the form of dairy products (300 mL of
semi-skimmed milk, 2 yoghurts, 1 portion of cheese), no more than 150 g of “lean” meat or
2 eggs or oily fish (twice a week), which represents 15% of the energy intake in the form of
protein per day, and slow sugars will be provided by potatoes, bread, and cereals, to the
detriment of rapidly adsorbed sugars.
What kind of oils? This is the originality of the diet that we recommended: little butter
(10 g per day) and fats (30 g of rapeseed oil, i.e., 2 spoons, 25 g of margarine enriched in
ALA, mackerel 170 g twice a week for DHA, eggs, and meat twice a week for AA), starchy,
and bread (250 g each) per day. With these recommendations, the proper intake of vitamins
and oligo-elements is not assured, so it is advisable to guarantee it through supplements.

4. Conclusions
It is true that the pregnant woman has spontaneously balanced her nutritional intake
for the child she is carrying, since man has been able to perpetuate himself up to that point,
Healthcare 2022, 10, 65 10 of 11

but the micronutrients and vitamins intake were not always perfectly guaranteed; it is
necessary to ensure this for the well-being of the fetus and the mother.
A new concept has appeared, still “in gestation”, that of “milk” or “nutritional sup-
plement” for pregnant women. Milk is in fact an extremely practical food “vector” for
adding micronutrient supplements in a harmonious way. It is also necessary to insist on
the “variety” and “quality” of the diet, which guarantee a good nutritional balance [32].
In addition, it would seem desirable that every pregnant woman, especially if she
belongs to a risk group (multiple or repeated pregnancies, vegetarians, teenagers, socio-
economic problems, etc.), should be able to benefit from a consultation with a dietician from
the “maternity ward” at the beginning of her pregnancy in order to determine for each of
them a dietary pattern, and, if necessary, to prescribe appropriate nutritional supplements.
Obviously, the intake of alcohol and drugs, as well of medications contraindicated
during pregnancy and lactation should be totally prohibited.

Author Contributions: Conceptualization, C.B.; methodology, C.B.; validation, C.B., J.B.; formal
analysis, C.B.; investigation, C.B., W.B. and B.C.; resources, C.B.; data curation, C.B.; writing—original
draft preparation, C.B.; writing—review and editing, C.B. and J.B.; visualization, V.R.; supervision,
J.B.; project administration, C.B. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Informed Consent Statement: Not necessary for historical studies. For each study there were local
ethics committees.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to privacy and ethical restrictions.
Conflicts of Interest: No conflict of interest to disclose.

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