NUTRITION DURING

PREGNANCY

zzt’07

Nutrition before conceptionNutrition before conception

Risk assessment, health Risk assessment, health promotion, interventionpromotion, interventionWeightWeightWeightWeight

Maintain a healthy weightMaintain a healthy weightVitaminsVitamins

Folic acid/dayFolic acid/dayAvoid high doses of retinolAvoid high doses of retinol

Substance useSubstance useSubstance useSubstance useEliminate prior to Eliminate prior to pregnancypregnancy

Photo © PhotoDisc

Effect of nutritional status on Effect of nutritional status on pregnancy outcome

1. Maternal size- maternal size ~ placental size indicator of placental health determines the amount of nutrient available to the fetus birth weight- prepregnancy weight << lighter weight placenta risk for LBWg p

2. Weight Gain 2. Weight Gain During Pregnancy

Recommended weight gain during b d BMIpregnancy based on BMI

Total 1Total 1stst 22ndnd & 3& 3rdrdTotal 1Total 1stst 22ndnd & 3& 3rdrd

weight gain trim weekly gainweight gain trim weekly gain

U d i ht 12 5 U d i ht 12 5 18 2 3 0 4918 2 3 0 49Underweight 12.5 Underweight 12.5 –– 18 2.3 0.4918 2.3 0.49(BMI < 19.8)(BMI < 19.8)Normal weight 11.5 Normal weight 11.5 –– 16.0 1.6 0.4416.0 1.6 0.44(BMI 19.8 (BMI 19.8 –– 26) 26) Overweight 7.0 Overweight 7.0 –– 11.5 0.9 0.311.5 0.9 0.3(BMI 26 (BMI 26 –– 29)29)Obese 6.0 Obese 6.0 (BMI > 29)(BMI > 29)

Twins 15.9 Twins 15.9 –– 20.420.4Triplets/multiples >22.7Triplets/multiples >22.7

Normal components of maternal Normal components of maternal weight gain during pregnancy

Organ, tissue or fluid (g)UterusUterus 970970B tB t 450450BreastsBreasts 450450BloodBlood 12501250WaterWater 16801680FatFat 33503350Maternal components = 7700FetusFetus 34003400FetusFetus 34003400PlacentaPlacenta 650650Amniotic fluidAmniotic fluid 800800Non maternal components 4850Non-maternal components = 4850Total = 12550

3 Obesity3. Obesity

risk risk - Gestational DM- Pregnancy induced hypertensionPregnancy induced hypertension- cesarean section

IUFD- IUFDHesitant to gain weight during pregnancyShould be told that pregnancy is not a time for Should be told that pregnancy is not a time for weight loss

4. AdolescenceRisk factor for poor pregnancy outcome in teenagers

Maternal age ≤ 15 yrs Substance abuse : - Maternal age ≤ 15 yrs- Pregnancy < 2 yrs after

onset of menarche

- Substance abuse : smoking, drinking, drugs

- Poverty- Poor nutrition & low

prepregnancy weight- Poor weight gain

- Lack of social support- Lack of education

Rapid repeat pregnanciesPoor weight gain- Infection- STD infection

- Rapid repeat pregnancies- Lack of access to age-

appropriate prenatal care- preexisting anemia care

- Late entry into the health care system

Deficiencies of :Deficiencies of :- folic acid- other vitaminsother vitamins- calcium

vitamin D- vitamin D- energy

micronutrients- micronutrients

Clinical findings :Clinical findings :Clinical findings :Clinical findings :-- poor weight gain during pregnancypoor weight gain during pregnancy

LBWLBW-- LBWLBW-- premature birthpremature birth

Physiologic changes in the GI tractPhysiologic changes in the GI tract

Primarily as a result of the relaxation of smooth muscleEsophageal regurgitation, ↓ emptying time of the stomach, reverse peristalsis heart bburn

water absorption from the colon constipationconstipationHormonal changes nausea & vomiting

Nutritional requirementsNutritional requirements

Energy-- additional energy is requiredadditional energy is requiredgy qgy q-- metabolism metabolism by 15%by 15%-- 2002 DRI : 2002 DRI : 2002 DRI : 2002 DRI :

-- 11stst trim trim : = not pregnant: = not pregnant-- 22ndnd trimtrim : + 340 : + 340 –– 360 kcal/day 360 kcal/day 22 trimtrim : + 340 : + 340 360 kcal/day 360 kcal/day -- 33rdrd trimtrim : + 112kcal/day: + 112kcal/day

P t iProtein

Additional protein is required support the synthesis of maternal & fetal tissuessynthesis of maternal & fetal tissuesRDA : 71 g (> 25 g than not pregnant)Deficiency adverse consequencesDeficiency adverse consequences

Specific nutrients to consider

Folic acidFolic acidFolic acidFolic acidCalciumCalciumIIIronIronZincZinc

Folic acidFolic acid

↑↑ req for req for maternal erythropoiesismaternal erythropoiesis↑↑ req, for req, for -- maternal erythropoiesismaternal erythropoiesis-- fetal & placental growthfetal & placental growth-- prevention of NTDprevention of NTDprevention of NTDprevention of NTD

RDA : 600 RDA : 600 μμg g 400 400 μμg from fortified foods org from fortified foods orsupplement & 200 supplement & 200 μμg fromg fromfoodsfoods

Deficiency : Deficiency : -- megaloblastic anemiamegaloblastic anemiamegaloblastic anemiamegaloblastic anemia-- congenital malformationscongenital malformations

The Centers for Disease Control & The Centers for Disease Control & Prevention :

all all female of childbearing age female of childbearing age ↑↑ their intake of their intake of folic acid, because :folic acid, because :-- 50% of all pregnancies in US are unplanned50% of all pregnancies in US are unplanned-- neural tube closed by 28 days of gestationneural tube closed by 28 days of gestation

Supplementation should begin before Supplementation should begin before conceptionconception

US P bli H l h S i US Public Health Service :-- all women of childbearing age capable of all women of childbearing age capable of b h ldb h ld becoming pregnant should consume 400 becoming pregnant should consume 400 μμg g folic acid /day

The American College of OG :- women who are planning a pregnancy & have previously had a child with NTD take 4 mg of folic acid/day beginning 1 mo prior to conception – 3 mo of pregnancy

Three major type of Neural Tube Defects

Anencephaly Spina bifida Encephalocele

PHYSICAL IMPACTPHYSICAL IMPACT

Spina bifida often lif l causes lifelong

disabilities:

• paralysis

NTDs can require complex medical NTDs can require complex medical management, often including multiple surgeries.

Folate-rich Foods

Orange juice oranges

Folate rich Foods

• Orange juice, oranges• Liver• AvocadoAvocado• Dried beans and peas; lentils• Dark green leafy vegetables

(spinach, mustard, turnip, collard greens)B li• Broccoli

• Asparagus

Fortified FoodsFortified Foods

• Good way to get synthetic • Good way to get synthetic folic acid with minimal behavior changeg

• Blood levels are increasing

Pasta fortified with 140 micrograms per 100 grams flour(FDA, January 1998)( , Ja ua y 998)

Folic acid 30%Folic acid 30%

Iron Iron

RDA 27 mg/day (18 mg for non pregnant)RDA 27 mg/day (18 mg for non pregnant)RDA 27 mg/day (18 mg for non pregnant)RDA 27 mg/day (18 mg for non pregnant)Many women start pregnancy with poor iron Many women start pregnancy with poor iron stores & target iron intake is often not achieved stores & target iron intake is often not achieved ggfrom diet alone from diet alone ssupplementation is often upplementation is often necessarynecessary30 mg in divided doses of ferrous iron 30 mg in divided doses of ferrous iron supplements daily during the 2supplements daily during the 2ndnd & 3& 3rdrd trimtrim

CalciumCalcium

AI 1000 AI 1000 1300 mg1300 mgAI 1000 AI 1000 –– 1300 mg1300 mgSupplementation is necessary for those Supplementation is necessary for those

h d d k lk d h d d k lk d who do not drink milk or eat dairy who do not drink milk or eat dairy productsproductsDaily intake < AI Daily intake < AI ↑↑ calcium loss from calcium loss from maternal skeletonmaternal skeleton

Increased Requirements

Nonnutritive substances in food

CaffeineCaffeine- risk of 1st trim spontaneous abortion pas consumption from 100 mg to > 500 mg /day

Food beliefs

Most Most change their diets change their diets medical advice, medical advice, beliefs, food preferences, appetitebeliefs, food preferences, appetite, p , pp, p , ppMay be idiosyncratic or culturally patternedMay be idiosyncratic or culturally patternedHarmful :Harmful :Harmful :Harmful :-- elimination of animal proteinelimination of animal protein-- attempt to limit weight gain to produceattempt to limit weight gain to produceattempt to limit weight gain to produceattempt to limit weight gain to produce

smaller fetus smaller fetus easier deliveryeasier delivery

PicaPica

Consumption of substance with little or no Consumption of substance with little or no nutritional value (dirt, clay, ice, chalk, baking nutritional value (dirt, clay, ice, chalk, baking

d h i i h )d h i i h )soda, hair, stone, cigarette ashes)soda, hair, stone, cigarette ashes)Some reasons : Some reasons : -- relief of nausea or nervous tension relief of nausea or nervous tension -- a deficiency of an essential nutrienta deficiency of an essential nutrient-- pleasant sensation when chewingpleasant sensation when chewingPossible risks : gastrointestinal disordersPossible risks : gastrointestinal disorders

N & V itiNausea & Vomiting

Common during 1Common during 1stst trim, resolves 13trim, resolves 13thth –– 1414thth

kkwkwkVomit excessively Vomit excessively deficit in protein, deficit in protein, energy vitamins & mineralsenergy vitamins & mineralsenergy, vitamins & mineralsenergy, vitamins & mineralsFluid & electrolyte imbalance (+) Fluid & electrolyte imbalance (+) hospitalized for rehydration & prevent hospitalized for rehydration & prevent hospitalized for rehydration & prevent hospitalized for rehydration & prevent ketosisketosis

Recommendation for nausea & Recommendation for nausea & vomiting

Eat crackers or dry cereal before getting out of Eat crackers or dry cereal before getting out of Eat crackers or dry cereal before getting out of Eat crackers or dry cereal before getting out of bed in the morningbed in the morningEat small, frequent mealsEat small, frequent meals, q, qLiquids are best consumed between meals Liquids are best consumed between meals Avoid drinking coffee and teaAvoid drinking coffee and teaAvoid drinking coffee and teaAvoid drinking coffee and teaAvoid or limit intake of fatty and spicy foodsAvoid or limit intake of fatty and spicy foods

HeartburnHeartburn

Common during the latter part of Common during the latter part of pregnancy pregnancy pregnancy pregnancy Often occurs at night Often occurs at night Eff f f h l d Eff f f h l d Effect of pressure from the enlarged Effect of pressure from the enlarged uterus on the intestine & stomach, uterus on the intestine & stomach,

l i f h h l hi l i f h h l hi relaxation of the esophageal sphincter relaxation of the esophageal sphincter regurgitationregurgitation

Recommendation for heartburn

Eat small lowEat small low--fat meals, slowlyfat meals, slowlyEat small lowEat small low fat meals, slowlyfat meals, slowlyDrink fluids between mealsDrink fluids between mealsAvoid spicesAvoid spicesAvoid spicesAvoid spicesAvoid lying down for 1 to 2 hours after eating Avoid lying down for 1 to 2 hours after eating or drinkingor drinkingor drinkingor drinkingWear looseWear loose--fitting clothingfitting clothing

C ti ti & h h idConstipation & hemorrhoids

Usually occurs in the 3Usually occurs in the 3rdrd trimtrimCauses : Causes : Causes : Causes :

-- gut motilitygut motility-- physical inactivityphysical inactivity-- physical inactivityphysical inactivity-- pressure exerted on the bowel by the pressure exerted on the bowel by the

enlarged uterusenlarged uterusenlarged uterusenlarged uterus

Recommendation for constipation

Drink 2 to 3 quarts of fluids dailyDrink 2 to 3 quarts of fluids dailyDrink 2 to 3 quarts of fluids dailyDrink 2 to 3 quarts of fluids dailyEat highEat high--fiber foods, including cereals, fiber foods, including cereals, whole grains, legumes and fresh fruits and whole grains, legumes and fresh fruits and g , gg , gvegetablesvegetablesBe physically activeBe physically activep y yp y yAvoid taking laxativesAvoid taking laxatives

Gestational DMGestational DM

Goal :Goal :Goal :Goal :-- provide all required nutrientsprovide all required nutrients-- prevent hyperglycemia & ketosisprevent hyperglycemia & ketosisprevent hyperglycemia & ketosisprevent hyperglycemia & ketosis-- insure appropriate weight gaininsure appropriate weight gainMeal plan is individualized & expert care is Meal plan is individualized & expert care is Meal plan is individualized & expert care is Meal plan is individualized & expert care is neededneeded

Summary Summary

Energy intake to meet nutritional needs and Energy intake to meet nutritional needs and allow for about 0.4kg weight gain /wk during allow for about 0.4kg weight gain /wk during the last 30 wk of pregnancythe last 30 wk of pregnancythe last 30 wk of pregnancythe last 30 wk of pregnancyProtein intake to meet nutritional needsProtein intake to meet nutritional needsMineral & vitamin intakes to meet RDA Mineral & vitamin intakes to meet RDA Mineral & vitamin intakes to meet RDA Mineral & vitamin intakes to meet RDA ( For folic acid requires supplementation and ( For folic acid requires supplementation and for iron it is also likely that is required)for iron it is also likely that is required)y q )y q )Alcohol omittedAlcohol omittedCaffeine in moderationCaffeine in moderation

HEALTHY BABIES START WITH

HEALTHY MOMSHEALTHY MOMS