Nutrition In Pregnancy

BY- PROF. DR. MC BANSAL

DR. RIDHI KATHURIA

LET THY KITCHEN BE THY APOTHECARY, LET THY KITCHEN BE THY APOTHECARY, AND LET FOODS BE THY MEDICINEAND LET FOODS BE THY MEDICINE

Good nutrition is an important component of a healthy lifestyle and a healthy baby.

The best time to review the nutritional status to make appropriate changes is prior to conception.

A very important time of fetal development is during the first several weeks of pregnancy as all of the major fetal body systems are undergoing formation and rapid development.

Many women may not even realize they are pregnant at this time.

Therefore it is prudent to make your lifestyle and nutritional changes several months before conception occurs.

Pregnancy is the only time in life of women when weight gain is not only desirable, but also encouraged.

Weight gain should not be confused with being obese.

There are multiple growth spurts of multiple organ systems that contribute to the normal weight gain.

Placenta (avg) at term = 650gms *

Amniotic fluid = 800gms*

Breast enlargement = 405gms*

Uterine mass = 900gms*

Fat & fluid = 1200gms*

Maternal blood = 1800gms*

Average weighing baby = 2500 – 3000gms*

It is easy to see that the recommended weight gain of about 11,000gms (11-14 kg) is very appropriate.

* Weights are shown as approx values

Extra 11-14kgs recommended translate into an additional 200-300 calories/day.

This increases the average daily caloric intake from 2200 calories per day to approximately 2400-2700 calories per day.

Total extra energy cost of a pregnancy is 77,000kcal.

1st Trimester 85kcal/day

2nd Trimester 285kcal/day

3rd Trimester 475kcal/day

Pre pregnancy BMI Weight for Height Category

Recommended gain in body weight (kg)

<18.5 Underweight 12.5 – 18

18.5 – 24.9 Normal Weight 11.5 – 16

25 – 29.9 Overweight 7.0 – 11.5

About 75% of pregnant females in India are underweight & anaemic.

Anaemia thus remains a major cause of maternal & fetal morbidity, mortality and low birth weight.

Too early, Too close, Too many, Too late conception also adversely affect the health status (nutritional status) of the females.

Another indirect important factor is Gastro-intestinal Infections, Infestations, which are heralded further with under-nutrition, setting up a vicious cycle.

IMPORTANT NUTRIENTS FOR PREGNANCY

Folate

Iron

Calcium

Vitamin D

Vitamin A

Omega Fatty Acids

Essential Amino Acids from protein sources

Calorie providing Food (Carbohydrate and Fats in proper ratios)

• Why is it important in pregnancy– Needed to reduce risk of :- Neural tube defects Congenital heart defects, Cleft lips,  Limb defects Urinary tract anomalies Preterm delivery Infant low birth weight Fetal growth retardation

400 micrograms of synthetic folic acid daily from fortified foods and/or supplements has been suggested for all non-pregnant women, in order to have adequate folic acid intake even in case of unplanned pregnancies.

Ideal to start before conception occurs.

It is hypothesized that the insulin-like growth factor 2 gene is differentially methylated and these changes in IGF2 result in improved intrauterine growth and development.

RICH SOURCES OF FOLATERICH SOURCES OF FOLATE

Certain foods are very high in folate:

Leafy vegetables -  spinach, asparagus, turnip greens, lettuce.

Legumes - dried or fresh beans, peas and lentils

Egg yolks

Baker's yeast

Fortified grain products (pasta, cereal, bread)

Breakfast cereals (ready-to-eat and others)

Sunflower seeds

Liver and liver products

Kidney

Moderate amounts:

Fruit Juices (Orange Juice, Canned Pineapple Juice, Cantaloupe, Melon, Grapefruit Juice, Banana, Raspberry, Grapefruit And Strawberry)

Vegetables (Beets, Corn, Tomato Juice, Vegetable Juice, Broccoli, Brussels Sprouts)

• Why is it important in pregnancy

– Pregnancy causes a surge in the volume of blood in the body; the expanded volume may go up by 50%.

– To meet the demands of the increased blood volume, iron requirements go up significantly.

– Iron is also required for the normal development of the growing baby and the Placenta. 

On an average, the iron requirement during pregnancy is as follows:-

Basal iron = 280 mgExpansion of red cell mass = 570 mgFetal transfer = 200-350 mgPlacental development = 50-150 mgBlood loss at delivery (normal) = 100-250 mg

After deducting iron conserved by amenorrhoea (240-480mg), additional 500-600 mg iron is required in pregnancy.

If the patient is chronically anaemic, then her iron stores also stand to be depleted. This necessitates an extra supplementation of 500 mg is needed.

Thus Total Iron Supplementation Stands At 1000 Mg.

• Iron requirements in pregnancy go up from 18 to 27-30 mg per day.

• Because iron is not easily absorbed from the diet, it is recommended to take an iron supplement

• Risk profile of an anaemic mother includes- a)Preterm birth.b)Low birth weight.c)Increased blood loss during and after labour.d)Depleted stores.

oCooking In An Iron Skillet

o Red Meat 

o Poultry

o Lentils

o Beans

o Leafy Vegetables

o Pistachios

o Tofu

o Fortified Bread & Breakfast Cereals

o Soybean

o Spinach

o Beetroot

o Jaggery

RICH SOURCES OF IRONRICH SOURCES OF IRON

IRON PREPARATION

ELEMENAL IRON CONTENT

(mg%)DOSE (mg)

Ferrous Fumerate

30 200

Ferrous Gluconate

11 550

Ferrous Sulphate

20 300

Ferrous Penta-CarbonylFerrous Penta-Carbonyl Has Not Yet Been Approved By The FDA For Use During Pregnancy And Lactation.

However, If No Other Preparations Cant Be Used And Benefits Out Weigh The Risks, Then It Can Be Used With

High Degree Of Vigilance.

• Why is it important during pregnancy? 1. Total calcium concentration falls because of physiologic

hypoalbuminemia

2. Free ionized calcium concentration does not change (9-11gm%)

3. The placental produces 1,25-dihydroxyvitamin D, which results in increased intestinal absorption of calcium

4. Calcium is actively transported across the placenta to the fetus, facilitated by parathyroid hormone-related peptide

This increased demand if not met in the diet – Will lead to excessive calcium resorbtion from the maternal bones –

Osteoporosis.

Involved in mineralization of bones and teeth, energy and cell production and electrolyte acid-base buffering.

Fetal bone and teeth calcification primarily occurs in last 2-3 months.(total fetal requirement=)

2 cup full of milk daily or equivalent to supply 1200 mg calcium/1200mg phosphorous daily

Excess phosphorous can be a problem. Avoid snack foods, processed meats and cola drinks.

Therapeutic calcium supplementation (1200mg/day) should Be in the form of calcium citrate/ calcium gluconateSupplemented with vit -d

RICH SOURCES OF CALCIUMRICH SOURCES OF CALCIUM

Dairy foods - Milk, yogurt, Cheese, Cottage Cheese, Rasgullas.

Leafy & Green vegetables - Broccoli, Spinach, Okra, Horseradish, Watercress

Fruits - Oranges, Bananas.

Beans and Peas – Red kidney beans, Soyabean, Cabbage, Celery.

Tofu, Peanuts, Peas, Black Beans, Baked Beans

Fish - Salmon, Sardines

Miscellaneous - Sesame Seeds, Blackstrap Molasses, Corn, Almonds, Brown Sugar.

Fortified foods

Why is it important in pregnancy?

• It helps the body to use calcium that is consumed.• Maintain blood calcium & phosphorous levels.• Anti proliferative action.

RECENT STUDIES RECENT STUDIES INDICATE INDICATE

INCREASED RISK INCREASED RISK OF AUTISM IN OF AUTISM IN INFANTS WITH INFANTS WITH

VIT. D VIT. D DEFICIENCYDEFICIENCY

ᴥ Sunlight exposure

ᴥ Fish - Salmon, Tuna, Flounder, Sole.

ᴥ Milk

ᴥ Cereal

ᴥ Pork

ᴥ Mushrooms

ᴥ Riccota Cheese

ᴥ cod liver oil

Why is it important in pregnancy?

Need enough for healthy growth

Too much can cause birth defects

Formation of Rhodopsin, essential for normal vision

Glycoprotein synthesis (epithelial cell function)

Maintain normal skin health by switching on genes and differentiating keratinocytes (immature skin cells) into mature epidermal cells.

Regulates gene transcription.

Anti Oxidant action.

One of the rare entities which cause adverse effects if taken in excessive amounts.

Since vitamin A is fat-soluble, disposing of any excesses taken in through diet takes much longer than with water-soluble B vitamins and vitamin C.

This allows for toxic levels of vitamin A to accumulate.

ToxicityToxicity

Nausea

Irritability

Anorexia

Vomiting

Blurry vision

Headaches

Hair loss

Muscle & Abdominal pain

Drowsiness

Altered mental status.

Hair loss

Dry skin

Drying of the mucous membranes

Fever

Insomnia

Fatigue

Weight loss

Bone fractures

Anemia

Diarrhea

Liver (Beef, Pork, Chicken, Turkey, Fish)  

Cod Liver Oil

Dandelion Greens

Carrot

Broccoli Leaf

Sweet Potato 

Butter

Spinach 

Pumpkin 

Cheddar Cheese 

Melon

Egg

Apricot 

Papaya

Mango

Pea

Broccoli 

Milk

Tomatoes

Why are they important in pregnancy?

• They serve as building blocks of proteins.• Used in production of DNA, Cell membrane, Haemoglobin, Receptors, Enzymes, Neurotransmitters, Hormones, Antibodies & other Bioactive molecules .• Serve as body store of energy after fat stored in adipose tissue.

INDISPENSABLE INDISPENSABLE AMINO ACIDSAMINO ACIDS

DISPENSABLE AMINO ACIDS

CONDITIONALLY INDISPENSABLE

PRECURSORS OF CONDITIONALLY INDISPENSABLE

HISTIDINE ALANINE ARGININE GLUTAMINE/GLUTAMATE

ISOLEUCINE ASPARTIC ACID

CYSTEINE ASPARTATE

LEUCINE ASPARAGINE GLUTAMINE METHIONINE

LYSINE GLUTAMIC ACID GLYCINE SERINE

METHIONINE SERINE PROLINE GLUTAMIC ACID/AMMONIA

PHENYLALANIME TYROSINE SERINE

THREONINE CHOLINE

TRYPTOPHAN GLUTAMATE

VALINE PHENYLALANINE

 According to the American College of Nurse-Midwives, pregnant women require 71 grams of complete protein each day.

Some types of amino acid protein supplements contain only certain essential amino acids required by the body.

If consuming amino acid protein supplements during pregnancy, choose those that contain all nine essential amino acids.

Many types of amino acid protein supplements contain added ingredients such as Creatine, Herbs, Caffeine, Artificial Sweeteners and Preservatives.

A pregnancy diet has more restrictions than a non-pregnant person. Not all herbs and artificial sweeteners are safe for pregnant women.

In fact, according to the American Pregnancy Association, the FDA encourages pregnant women to consult with their healthcare provider before taking any types of herbal products. This includes amino acid protein supplements that contain herbs.

COMPLETE

COMPLETE

PROTEINS

PROTEINS

Proteins from- Meat, Poultry,

Fish, Eggs, Milk, Cheese,

Yoghurt.

Provide all nine essential

amino acids

INCOMPLETE

INCOMPLETE PROTEINS

PROTEINSProteins from- Legumes,

Grains, Nuts, Seeds,

Vegetables.Lack one or more

essential amino acids.

SITE OF PROTEIN

DEPOSITION

DEPOSITION (g) BY WEEKS OF GESTATION

Fetus 0.3 27 160 440

Placenta 2 16 60 100

Amniotic Fluid

0 0.5 2 3

Uterus 24 55 102 166

Breasts 9 36 72 81

Blood 0 30 102 135

TOTAL 35 165 498 925

10 20 30 40

Deposition Of Protein In The Deposition Of Protein In The Fetus & Maternal Tissues Fetus & Maternal Tissues

During PregnancyDuring Pregnancy

Omega-3 fatty acids are fats commonly found in marine and plant oils.

They are considered essential fatty acids, meaning that they cannot be synthesized by the human body but are vital for normal metabolism.

Though mammals cannot synthesize omega−3 fatty acids, they have a limited ability to form the long-chain omega−3 fatty acids including  Eicosapentaenoic AcidEicosapentaenoic Acid  Docosahexaenoic AcidDocosahexaenoic Acid   α-Linolenic Acidα-Linolenic Acid

DHA is important for development of the central nervous system in all mammals.

There is an enormous growth spurt in the human brain during the last trimester of pregnancy and the first postnatal months, with a large increase in the cerebral content of Arachidonic Acid (AA) and DHA.

The fetus and the newborn infant depend on a continual maternal The fetus and the newborn infant depend on a continual maternal supply of DHA and AA.supply of DHA and AA.

CARBOHYDRATESCARBOHYDRATES

Principle energy yielding food.

‘Digestible CarbsDigestible Carbs’ – Sugars & Starches.

‘Indigestible CarbsIndigestible Carbs’ – Cellulose, Hemicellulose, Gum, Pectin, Lignin.

Foods with carbohydrates in them have a wide range of effect on the blood glucose levels, during

digestion.

This is known as the This is known as the ‘Glycaemic Response’‘Glycaemic Response’

‘‘Glycaemic Index’Glycaemic Index’ is the effect of carbs on the blood glucose levels.

Rapidly breaking down carbs have high GI, and vice versa.

BASED ON NUMBER OF SUGAR UNITS

NAMENUMBER OF SUGAR

UNITSEXAMPLES

Monosaccharides 1 Glucose, Fructose

Disaccharides 2Sucrose, Lactose,

Maltose

Oligosaccharides 3-10 Raffinose, Stachyose

Polysaccharides >10Starch (plant food), Glycogen (animal

food)

Should Pregnant Women Go on Should Pregnant Women Go on Low-Carb Diets?Low-Carb Diets?

Pregnant women should not go on low-carb diets, let alone carb-free diets.

In fact, it is recommended that at least half of the calories that pregnant women consume should be carbohydrates.

The main reason is because carbs are known to turn to glucose, which is necessary for the unborn baby.

Carbs are known to provide the baby with nutrients, protein and healthy fats. All of these are quite essential to the proper

development of the baby.

Can a Carb-Free Diet Harm an Can a Carb-Free Diet Harm an Unborn Baby?Unborn Baby?

What many people do not realize is that a carb-free diet can actually harm an unborn baby.

It is highly likely that the baby will not get the nutrients that he or she needs for healthy development when one puts oneself on a

carb-free, high-protein diet.

When women choose to go on a diet that is high in protein when they are pregnant, their cortisol levels are known to increase.

When an unborn baby is exposed to higher cortisol levels, the chances that he or she will have high blood pressure later on in

childhood or adulthood increases.

Although a low-carb diet may not be as bad, it is important to keep in mind that these same side effects may also affect your

unborn baby when you restrict your carbs too much.

Are There Any Types of Carbs Are There Any Types of Carbs Pregnant Women Should Eat?Pregnant Women Should Eat?

There are various types of carbs that pregnant women should eat while they are pregnant in order to ensure the ultimate health

and development of their baby.

Some of these carbs include fruits, vegetables and whole grains.

These are what most people refer to as "GOOD CARBSGOOD CARBS" and ultimately, are what will provide the baby with the nutrients

needed for healthy development.

What Types of Carbs Should What Types of Carbs Should Pregnant Women Avoid?Pregnant Women Avoid?

There are many carbs that pregnant women should avoid, or only eat in moderation.

These are what most people call "BAD CARBSBAD CARBS." Some of these types of carbs include donuts, candy, fast food etc.

These carbs and known to cause weight gain and gestational diabetes among pregnant women.

Although eating bad carbs will not necessarily cause any harm to the baby, they will not provide any health benefits.

Eating bad carbs in moderation may not be harmful, but when it comes down to it, one should not eat them too frequently during

pregnancy.

WHY THE DEVELOPING BABY NEEDS FATSWHY THE DEVELOPING BABY NEEDS FATS

Babies need a diet high in beneficial fats, as these are their main source of energy.

A baby’s brain, which is around 60% fat, uses nearly three quarters of total dietary energy for growth, whereas an adult's uses only a fifth.

Once born, they’ll get a lot of essential fats from breastmilk, which contains over 50% of its calories as fat.

But while still in the womb, they rely on maternal fat supply.

FAT IS ESSENTIAL FOR VITAMIN FAT IS ESSENTIAL FOR VITAMIN ABSORPTIONABSORPTION

Fats act as carriers for fat-soluble Fats act as carriers for fat-soluble Vitamins such as A, D, E and K.Vitamins such as A, D, E and K.

Vitamin D Helps Keep Bones And Teeth Vitamin D Helps Keep Bones And Teeth Healthy.Healthy.

Vitamin E Protects Cell Membranes By Vitamin E Protects Cell Membranes By Acting As An AntioxidantActing As An Antioxidant

Vitamin K Helps Wounds Heal Properly As Vitamin K Helps Wounds Heal Properly As It Helps With Blood Clotting And Also It Helps With Blood Clotting And Also

Helps Build Strong BonesHelps Build Strong Bones

BUTTER & OTHER COOKING MEDIA FAT (g/unit)

Butter 100 g 81

Ghee 100 g 100

Vegetable Oil 100 g 100

Vegetable Hydrogenated Oil 100 g 100

BREADS AND CEREALS FAT (g/unit)

Chapati (one) 0.4

Puri (one) 2.8

Paratha (one) 4.1

Aloo ka Paratha (one) 3.5

Cooked Rice (3/4th katori) 0.1

Khicheri (1 katori) 7.3

Dosa 3.5

Bread large sized (1 slice) 0.7

Dry Cereal (3/4th katori) 0.3

LEGUMES (1 katori cooked dal including veg oil used) FAT (g/unit)

Bengal Gram (Channe ki dal) 4.1

Black Gram (Urad ki dal) 4.5

Green Gram (Moong ki dal) 5.6

Lentil (Masoor ki dal) 4.1

Red Gram (Arhar ki dal) 2.0

Sambar 2.1

Chickpea (Kabuli Channa) 6.6

Green Gram (Saboot Moong ki dal) 3.3

Lentil whole (Saboot Masoor ki dal) 2.5

Rajma 5.7

VEGETABLE PREPARATIONS (1 katori incld oil used) FAT (g/unit)

Matar Paneer (Cottage Cheese with Peas) 10.4

Aloo Matar (Potatoes with Peas) 6.4

Potato curry 6.2

Veg Kofta 13.7

Veg Korma 7.9

Aloo Baingan (Potatoes with Brinjal) 6.7

Carrots 6.0

Pumpkin 6.3

Cabbage 10.3

Ridge Gourd 7.3

Okra 15.0

Bhurtha 8.2

Stuffed Tomatoe 3.4

RAW VEGETABLES & FRUITS FAT (g/unit)

Green Peas 100 g 0.1

Brinjal 100 g 0.3

Sweet Potatoes 100 g 0.3

Beams 100 g 1.0

All other Vegetables 100 g < 0.3

Apple 100 g 0.5

Pear 100 g 0.2

Most other 100 g 0.3

SNACKS FAT (g/unit)

1 Samosa 12.6

1 -1/4th Upma 11.3

French Fries 90 g 11.3

Palora (4 pieces) 11.0

Besan ka Pura 11.7

Dahi Vada (1) 9.6

Masala Vada (2) 4.6

Poha 1-1/2 katori 13.1

Potato cutlet (1) 5.4

Chaat 10.0

MILK PRODUCTS FAT (g/unit)

Milk (1 cup) 8.6

2% Milk (1 cup) 4.9

Skimmed Milk (1 cup) 0.2

Buttermilk (1 cup) 2.4

Ice Cream regular (1 cup) 14.1

Yoghurt (1 cup) 9.8

Cottage Cheese (30 g) 1.2

Swiss Cheese (30 g) 7.9

Cheddar Cheese (30 g) 9.1

MEAT, FISH & POULTRY FAT (g/unit)

Lamb Leg (90 g) 9.4

Lamb Chop (90 g) 15.8

Chicken, white, no skin (90 g) 2.9

Fried Chicken (90 g) 7.9

Fried Liver (90 g) 9.8

Fried Fish (90 g) 12.5

Fish Jhol (1 katori) 2.5

Mutton ball curry (1 katori) 17.6

Prawn curry (1 katori) 6.5

Boiled Egg (1) 5-6

Fried Egg (1) 7-9

DESSERTS FAT (g/unit)

Halwa (100 g) 15.9

Jelly & Custards (100 g) 1.2

Kheer (150 g) 13.4

Sevian (100 g) 10.0

Suji Kheer (150 g) 14.2

Sriikhand (100 g) 19.7

Sandesh (2 pieces) 9.0

Besan ki Barfi (60 g) 25.4

Chikki (60 g) 12.0

Fruit Cake (50 g – 1 piece) 15.1

Jam Tart (35 g – 1 piece) 9.1

Lemon Tart (55 g – 1 piece) 9.2

Nutty Biscuits (40 g – 2 pieces) 13.8

MINERAL DIEARY SOURCES

RDA’S CLINICAL MANIFESTATION

SODIUMSODIUM Table salt, Dairy products

Adults = 1.5 g/dl Only excess loss can produce deficiency – Muscular cramps, Weakness, Hypovolemia

POTASSIUMPOTASSIUM Bananas, Muskmelon, Bael fruit, Citrus fruit, Leafy veg, Milk, Meat

Adults = 4.7 g/dlPreg = 4.7 g/dlLactation = 5.1 g/dl

Weakness, Paraesthesia, Arrhythmias.

MAGNESIUMMAGNESIUM Whole grains, Leafy veg

Men = 400 mg/dlWomen = 310 mg/dlPreg = 350 mg/dlLactation = 310 mg/dl

Muscle weakness, Twitching, Tremors, Numbness, Apathy.

PHOSPHORUSPHOSPHORUS Milk, Cheese, Yoghurt, Fish, Poultry, Meat, Grains.

Adults = 700 mg/dlPreg & Lactation = 700 mg/dl

Weakness, Fatigue, Leukocyte & Platelet dysfunction, Heart failure, Haemolysis

IODINE Seaweeds, Salt water fish, Shell fish, Iodised salt

Preg = 220 micro g/dlLactation = 290 micro g/dlWomen = 150 micro g/dl

Thyroid enlargement

Manganese Nuts, Dry fruits, Cereals, Unrefined grains, Tea

Women = 1.8 mg/dlPreg = 2.0 mg/dlLactation = 2.6 mg/dl

Impaired growth & skeletal development, Decline in reproductive function

Selenium Seafood, Muscle meat, Cereals

Women = 55 micro g/dlPreg = 60 micro g/dlLactation = 65 micro g/dl

Cardiomyopathy, CHF, Striated muscle degeneration

Zinc Nuts, Legumes, Meats, Shellfish

Women = 8 mg/dlPreg = 11 mg/dlLactation = 12 mg/dl

Growth retardation, Poor wound healing,Hypogonadism

TRIMESTERTRIMESTER EXTRA ENERGY EXTRA ENERGY NEEDSNEEDS

EXAMPLES OF FOODSEXAMPLES OF FOODS

1st trimester 100 extra calories each day

•A large apple OR•A slice of cheese OR•A glass of milk OR•A piece of bannock

2nd and 3rd trimester

300 extra calories each day

•A piece of toast with peanut butter and a glass of milk OR•A small piece of meat or fish with bannock OR•A bowl of vegetable soup with crackers and cheese

NOT ENOUGH WEIGHT GAINNOT ENOUGH WEIGHT GAIN

• Low birth weight baby

• Early birth

• Baby may not develop properly

• Baby may have life-long health problems

• Higher perinatal mortality

•Baby may have mental and behavioural problems

TOO MUCH WEIGHT GAINTOO MUCH WEIGHT GAIN

• High birth weight baby

• Difficult birth (Feto pelvic disproportion)

• Higher perinatal mortality

• Mother may develop gestational diabetes

• Baby may develop diabetes & cardiac problems in later life

• Too much caffeine is not good during pregnancy

• Coffee, tea and some pop has caffeine

• 3 small cups of coffee per day (400-450 mg of caffeine) is safe.

• Switch to decaf or try half decaf, half regular

• Smoking is harmful to the baby

• Passive smoking is dangerous

• Nicotine causes vasospasm leading toPlacental insufficiency.

• IUGR

• Preterm Birth.