Department of NutritionFaculty of Medicine

Universitas Indonesia2014

References

Brown JE. Nutrition through the Life Cycle 3rd ed., 2005 & 4th ed., 2008

Bowman BA, Russell RM. Present Knowledge in Nutrition 9th ed., 2006

De Maeyer AH, et al. Preventing and Controlling Iron Deficiency Anemia through Primary Health Care, 1989

Mahan LK, Escott-Stumps S. Krause’s Food & Nutrition Therapy 12nd ed., 2008

Lammi-Keefe CJ, et al. Handbook of Nutrition and Pregnancy, 2008

2

33

IntroductionIntroduction

Energy & nutrient requirements typicallyEnergy & nutrient requirements typically more more during pregnancy than during any other stage in during pregnancy than during any other stage in a woman’s adult lifea woman’s adult life

Additional requirement are required during Additional requirement are required during pregnancy for development of the fetus & for pregnancy for development of the fetus & for growth of maternal tissuesgrowth of maternal tissues

The materials required for this rapid growth & The materials required for this rapid growth & development depend on supply from the development depend on supply from the maternal diet maternal diet

44

The importance of nutrition during The importance of nutrition during pregnancy pregnancy

A. To set the nutritional foundations for A. To set the nutritional foundations for a a healthy adult lifehealthy adult life

Epidemiologic evidenceEpidemiologic evidence

strongly suggests certain adult strongly suggests certain adult chronic diseases correlate with chronic diseases correlate with nutritional conditions in uteronutritional conditions in utero

55

B. Nutrition during pregnancy:B. Nutrition during pregnancy:

Maintain maternal energy requirementsMaintain maternal energy requirements

PProvide substrate for development of new fetal rovide substrate for development of new fetal

tissues tissues

RReserve substrate for lactationeserve substrate for lactation

66

Prenatal nutrition:Prenatal nutrition:

• Weight gain in pregnancyWeight gain in pregnancy

• Dietary intake in pregnancyDietary intake in pregnancy

77

relate to baby’s birth weight

8

Baby low birth weight

• Untimely/inadequate feeding• Frequent infections• Inadequate food, health, & care

Child stunted

Adolescent stunted

Woman malnourished Pregnancy low weight gain

Higher maternal mortalityInadequate food, health, & care

Reduced physical capacity & fat free mass

Inadequate food, health, & care

Inadequate catch-up growth

Reduced mental capacity

Inadequate fetal nutrition

Higher mortality rate Impaired mental development risk of adult chronic diseases

Nutrition during pregnancy affects the health of both the mother & baby

From nutritional point of view, birth weight From nutritional point of view, birth weight depends on:depends on:

• Prepregnancy weight for height (W/H) Prepregnancy weight for height (W/H)

expressed in expressed in body mass index (BMI)body mass index (BMI)

• Weight gain during pregnancyWeight gain during pregnancy

Weight (kg)Weight (kg)

BMIBMI = =

HeightHeight22 (m (m22))

99

1010

Distribution Of Weight IncreaseDistribution Of Weight Increase

Fat storage in subcutaneous

tissues

Protein storage

4–4.5 kg

Fetus & placenta 5 kg

Uterus 0.5–1 kg

Breasts 1–1.5 kg

Water & electrolytes 1–1.5 kg

1111

Pregnancy weight gain recommendationsPregnancy weight gain recommendations

Prepregnancy weight status Prepregnancy weight status BMI*BMI*

Recommended weight Recommended weight gaingain

Underweight, <18.5 kg/mUnderweight, <18.5 kg/m22

Normal weight, 18.5–24.9 kg/mNormal weight, 18.5–24.9 kg/m22

Overweight, 25–29.9 kg/mOverweight, 25–29.9 kg/m22

Obese, 30 kg/mObese, 30 kg/m22 or higher or higher

Twin pregnancyTwin pregnancy

12.7–18.2 kg12.7–18.2 kg

11.4–15.9 kg11.4–15.9 kg

6.8–11.4 kg6.8–11.4 kg

6.9 kg at least6.9 kg at least

15.9–20.5 kg15.9–20.5 kg

*BMI categories modified based on 1997 changes from the Nutritional Institutes of Health. Young adolescences should achieve gains at the upper end of ranges, & short women at the lower end

Source: Brown JE, 2008

Physiological changes of pregnancyPhysiological changes of pregnancy

A.A. Blood volume & compositionBlood volume & composition Blood volume expands by 50%Blood volume expands by 50%

Hb value, blood glucose, serum albumin, Hb value, blood glucose, serum albumin, other serum protein, & water soluble vitaminsother serum protein, & water soluble vitamins

Plasma Plasma 43%, RBC 43%, RBC 17–25% 17–25% plasma plasma volumevolume more than RBC more than RBC hemodilutionhemodilution blood viscosity blood viscosity flow resistance flow resistance

facilitating blood flow to uterus & placentafacilitating blood flow to uterus & placenta

1212

B. Cardiovascular & pulmonary functionB. Cardiovascular & pulmonary function

C. Gastrointestinal functionC. Gastrointestinal function

an an of progesterone level of progesterone level

GI motility GI motility absorption of nutrients absorption of nutrients

D. Renal functionD. Renal function

1313

1414

Blood volumeBlood volume

High glomerular filtration rateHigh glomerular filtration rate

butbut

Renal tubules unable to adjust completelyRenal tubules unable to adjust completely

Amino acids, glucose, & water soluble vitamins Amino acids, glucose, & water soluble vitamins may appear in the urinemay appear in the urine

Ability to excrete water is loweredAbility to excrete water is lowered

EdemaEdema in the legs is common & normal in the legs is common & normal

Renal Function ………………………….. (cont’d)

1515

Changes in maternal homeostasis Changes in maternal homeostasis during pregnancy: during pregnancy:

Changes in efficiency of absorption from Changes in efficiency of absorption from the GI tract & excretion by the renal the GI tract & excretion by the renal systemsystem

Changes in maternal storageChanges in maternal storage

Care must be taken in Care must be taken in selecting optimal dietselecting optimal diet

1616

PlacentaPlacenta

Principal site of production for Principal site of production for

several hormones responsible for:several hormones responsible for:

• Regulating fetal growthRegulating fetal growth

• Development of maternal support Development of maternal support

tissuestissues

• The conduit for exchange of nutrients OThe conduit for exchange of nutrients O22

& waste products& waste products

1717

Ig: imunoglobulin

Transfer of substances across the placental membrane

1818

Unit feto-placental hormones:Unit feto-placental hormones:

Placental peptide hormonesPlacental peptide hormones- Human chorionic gonadotrophin - Human chorionic gonadotrophin - Human placental lactogen- Human placental lactogen- Pregnancy specific hormones- Pregnancy specific hormones

Steroid hormonesSteroid hormones- Estrogens- Estrogens- Progesterones- Progesterones

1919

Metabolic & hormonal changesMetabolic & hormonal changes

Metabolism & endocrine functions undergo Metabolism & endocrine functions undergo a large number of changes a large number of changes

during pregnancyduring pregnancy

Optimal growth of the fetusOptimal growth of the fetus

2020

Metabolic changes during pregnancy:Metabolic changes during pregnancy:

Homeostasis Homeostasis fluidfluid & & electrolyteelectrolyte

CHOCHO metabolism: metabolism:

glucoseglucose is the sole energy source for is the sole energy source for the fetusthe fetus

LipidLipid metabolism: metabolism:

lipogenesis & maternal fat storagelipogenesis & maternal fat storage

2121

Metabolic changesMetabolic changes … ……………………… (cont’d)…………………… (cont’d)

ProteinProtein metabolism: metabolism:

positive nitrogen (N) balance positive nitrogen (N) balance tissues synthesistissues synthesis

MineralMineral metabolism: metabolism:

Ca metabolism (Ca metabolism ( rate of bone turnover rate of bone turnover & & reformation)reformation)

2222

Summary of maternal anabolic & Summary of maternal anabolic & catabolic phases catabolic phases of pregnancy of pregnancy

Maternal anabolic phase Maternal anabolic phase 0–20 weeks0–20 weeks

Maternal catabolic phase Maternal catabolic phase 20+ weeks20+ weeks

Blood volume expansion, Blood volume expansion, cardiac cardiac outputoutput

Mobilization of fat & nutrient storesMobilization of fat & nutrient stores

Build up of fat, nutrient, & liver Build up of fat, nutrient, & liver glycogen storesglycogen stores

production & blood levels of glucose, production & blood levels of glucose, triglycerides, and fatty acids; triglycerides, and fatty acids; liver liver glycogen storesglycogen stores

Growth of some maternal organsGrowth of some maternal organs Accelerated fasting metabolismAccelerated fasting metabolism

appetite, food intake (positive energy appetite, food intake (positive energy balance)balance)

appetite & food intake; decline appetite & food intake; decline somewhat near termsomewhat near term

exercise toleranceexercise tolerance exercise toleranceexercise tolerance

levels of anabolic hormoneslevels of anabolic hormones levels of catabolic hormoneslevels of catabolic hormones

2323

Weight gainWeight gain

Weight should be gained throughout Weight should be gained throughout pregnancy, the most critical is in the pregnancy, the most critical is in the 22ndnd trimester trimester

Weight gain Weight gain

1. E1. Expansion of maternal blood volumexpansion of maternal blood volume

2. C2. Construction of fetal & placental tissuesonstruction of fetal & placental tissues

2424

The importance of body weight The importance of body weight among pregnant womenamong pregnant women

Women who are Women who are underweightunderweight are at are at risk for low risk for low birth weight babies (birth weight <2500 g), and birth weight babies (birth weight <2500 g), and can also can also the risk of gastroschisis the risk of gastroschisis

Women who are Women who are overweightoverweight or obese are at or obese are at risk for macrosomic infants (weight >4000 g). risk for macrosomic infants (weight >4000 g).

Macrosomic infants are at Macrosomic infants are at risk of shoulder risk of shoulder dystocia, etc.dystocia, etc.

2525

Nutrient requirement during pregnancyNutrient requirement during pregnancy

Additional amount of nutrients Additional amount of nutrients are neededare needed

Why?Why?

Required by the fetus to growRequired by the fetus to grow

To prepare mother’s body changes during To prepare mother’s body changes during pregnancypregnancy

Preparation for delivery & lactation periodPreparation for delivery & lactation period

2626

Energy needs during pregnancy Energy needs during pregnancy vary according to:vary according to:

Woman’s basal metabolic rate (BMR)Woman’s basal metabolic rate (BMR)

Prepregnancy weightPrepregnancy weight

Amount & composition of weight gainAmount & composition of weight gain

Stage of pregnancyStage of pregnancy

Physical activity levelPhysical activity level

2727

EnergyEnergy

Additional energy needs:Additional energy needs:

Added maternal tissuesAdded maternal tissues

Growth of the fetus & placentaGrowth of the fetus & placenta

Hytten & Leitch:Hytten & Leitch:

Energy cost ≈ 80,000 kcal in general:Energy cost ≈ 80,000 kcal in general: 11stst trimester: additional ≈ 180 kcal/day trimester: additional ≈ 180 kcal/day 22ndnd & 3 & 3rdrd trimester: additional ≈ 300 kcal/day trimester: additional ≈ 300 kcal/day

2828

Energy & MacronutrientEnergy & Macronutrient

WHO recommended an addition of WHO recommended an addition of 300 kcal/day (2300 kcal/day (2ndnd trimester & 3 trimester & 3rdrd trimester) trimester)

22ndnd trimester: mostly used for maternal trimester: mostly used for maternal factorsfactors

33rdrd trimester: for both maternal & fetal trimester: for both maternal & fetal factorsfactors

2929

CarbohydrateCarbohydrate (CHO)(CHO)

IOM IOM CHO adult & children: 130 g/day CHO adult & children: 130 g/day

(minimum 100 g/day); intake 135–175 g/day (minimum 100 g/day); intake 135–175 g/day

to prevent to prevent ketosisketosis & maintaining normal & maintaining normal

blood glucose levels. Adequate intake 175 gblood glucose levels. Adequate intake 175 g

In general In general 50–65%50–65% of total energy of total energy

If CHO is too low If CHO is too low gluconeogenesis gluconeogenesis

Gluconeogenesis is energically expensive: Gluconeogenesis is energically expensive:

80 g protein 80 g protein 50 g glucose 50 g glucose

3030

Dietary fiberDietary fiber//non starch polysaccharidesnon starch polysaccharides

Dietary fiber 10–14 g/1000 kcalDietary fiber 10–14 g/1000 kcal

Insoluble to soluble ratio = 3 : 1Insoluble to soluble ratio = 3 : 1

Soluble fiber: fruits, nuts, beans, cerealsSoluble fiber: fruits, nuts, beans, cereals

Insoluble fiber: fruits, vegetablesInsoluble fiber: fruits, vegetables

Criterion for Criterion for intake: intake: extrapolation based onextrapolation based on energy intake energy intake

3131

ProteinProtein

A number of amino acids are recognized as A number of amino acids are recognized as precursors of neurotransmittersprecursors of neurotransmitters

RDA for protein for the average adult is 0.8 g/kg/dRDA for protein for the average adult is 0.8 g/kg/d

During pregnancy; During pregnancy; additional protein additional protein approximately 1 kgapproximately 1 kg

AdditionalAdditional

11stst trimester trimester 1.3 g/d1.3 g/d

22ndnd trimester trimester 6.1 g/d6.1 g/d

33rdrd trimester trimester 10.7 g/d10.7 g/d

3232

F a tF a t

Metabolic functions of dietary fatMetabolic functions of dietary fat

Oxidized for energyOxidized for energy

Stored in adipose tissueStored in adipose tissue

Incorporated into cell membrane phospho-Incorporated into cell membrane phospho-lipidslipids Precursors for eicosanoid synthesisPrecursors for eicosanoid synthesis Influence on receptor functionInfluence on receptor function Influence on enzyme functionInfluence on enzyme function

3333

Essential fatty acids (EFAs)Essential fatty acids (EFAs)

Omega-3 (n-3) & omega-6 (n-6) fatty acidsOmega-3 (n-3) & omega-6 (n-6) fatty acids

All essential fatty acids (EFAs) are All essential fatty acids (EFAs) are polyunsaturated fatty acids (PUFAs)polyunsaturated fatty acids (PUFAs)

Synthesized in chloroplasts in plants & Synthesized in chloroplasts in plants & phytoplanktonphytoplankton

3434

IOM-FNB (2002) recommended intakes of IOM-FNB (2002) recommended intakes of EFAs EFAs during pregnancyduring pregnancy

Fatty acidsFatty acids % total energy% total energy

Linoleic acid (n-6)Linoleic acid (n-6)

-Linolenic acid (n-3)-Linolenic acid (n-3)

5.0–10.05.0–10.0

0.6–1.20.6–1.2

IOM-FNB: International of Medicine-Food and National Board

3535

Eicosapentaenoic acid (EPA)Eicosapentaenoic acid (EPA) & & docosahexaenoic acid (DHA):docosahexaenoic acid (DHA):

2 derivatives of 2 derivatives of -linolenic acid (n-3 fatty acid)-linolenic acid (n-3 fatty acid)

EPAEPA & & DHADHA perform specific functions in perform specific functions in the body particularly during pregnancy & the body particularly during pregnancy & lactationlactation

3636

EPAEPA: : inflammationinflammation dilate blood vesselsdilate blood vessels blood clottingblood clotting

DHADHA: :

the major structural component of phospholipids the major structural component of phospholipids in cell membranes in the central nervous system in cell membranes in the central nervous system (CNS), including retinal photoreceptors (CNS), including retinal photoreceptors

3737

Adequate intake Adequate intake of of EPAEPA & & DHADHA

during pregnancy & lactation is estimated during pregnancy & lactation is estimated

to be to be 300 mg/day300 mg/day

3838

Pedoman Umum Gizi Seimbang Pedoman Umum Gizi Seimbang (Depkes (Depkes RI)RI)

• CHO CHO 50–60% of total energy50–60% of total energy

SugarSugar not more than 5%not more than 5%

• LipidLipid 25% (at least 10%)25% (at least 10%)

• ProteinProtein 10–15%10–15%

Unit of energy:Unit of energy: kiloJoules (kJ) & Calorie (Cal) or kilocalorie (kcal) kiloJoules (kJ) & Calorie (Cal) or kilocalorie (kcal)

1 Cal or kcal = 4.184 kJ1 Cal or kcal = 4.184 kJ

3939

Required for production of several Required for production of several

coenzymescoenzymes & as & as cofactorscofactors of many of many

enzymes that catalyze numerous enzymes that catalyze numerous

metabolic pathwaysmetabolic pathways

4040

Requirements of vitamin B group per Requirements of vitamin B group per day day for adult female for adult female

NutrientNutrient RequirementRequirement PregnancyPregnancy

Vitamin BVitamin B11 0.5 mg/1000 kcal, 0.5 mg/1000 kcal, minimal 1 mg for minimal 1 mg for energy intake (2000 energy intake (2000 kcal)kcal)

+ 0.3 mg+ 0.3 mg

Vitamin BVitamin B22 1.3 mg1.3 mg + 0.3 mg+ 0.3 mg

NiacinNiacin 14 mg14 mg + 4.0 mg+ 4.0 mg

Vitamin BVitamin B66 1.3 mg1.3 mg + 0.4 mg+ 0.4 mg

Vitamin BVitamin B1212 2.4 2.4 gg + 0.2 + 0.2 gg

Folic acidFolic acid 400 400 gg + 200 + 200 ggSource: Widyakarya Nasional Pangan dan Gizi (WNPG) VIII, 2004

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Folic acidFolic acid

Deficiency in pregnancy has been linked Deficiency in pregnancy has been linked with maternal megaloblastic anemia & fetal with maternal megaloblastic anemia & fetal neural tube defect neural tube defect (NTD)(NTD)

Folic acid supplements should be Folic acid supplements should be administered 3 months prior to conception administered 3 months prior to conception & during& during

11stst trimester (400 trimester (400 g/day)g/day)

Female with history of delivering baby Female with history of delivering baby

with NTDwith NTD

supplementation of 4 mg/daysupplementation of 4 mg/day

4242

Vitamin CVitamin C

AntioxidantAntioxidant

Pregnancy Pregnancy intake: (+) 10 mg intake: (+) 10 mg

Criterion for increasing: Criterion for increasing:

amount needed to prevent amount needed to prevent scurvyscurvy in infant in infant

& estimated fetal transfer& estimated fetal transfer

4343

AntioxidantsAntioxidants

Brain is metabolically the most active organ & Brain is metabolically the most active organ & consumes maximum amount of consumes maximum amount of glucoseglucose & &

OO22 by product by product

OO22 free radicalsfree radicals

Reactive oxygen speciesReactive oxygen species

Antioxidants (vitamins A, C & E, Zn, Se, etc.)Antioxidants (vitamins A, C & E, Zn, Se, etc.)

4444

Fat Soluble VitaminsFat Soluble Vitamins

Fat soluble vitamins can be stored in adipose Fat soluble vitamins can be stored in adipose tissues & livertissues & liver

additional intake should be additional intake should be

carefully supervisedcarefully supervised Excessive intake Excessive intake malformation & abortion malformation & abortion

Brain development: vitamins A & E Brain development: vitamins A & E (antioxidants) are required(antioxidants) are required

4545

Brain development:Brain development:

IodineIodine (I): for synthesis tiriodothyronine (T (I): for synthesis tiriodothyronine (T33) & ) &

thyroxine (Tthyroxine (T44))

IronIron (Fe): required for myelin production (Fe): required for myelin production

ZincZinc (Zn): component of over 200 metalloenzymes (Zn): component of over 200 metalloenzymes

CopperCopper (Cu): important component of cytochrome (Cu): important component of cytochrome oxidase & superoxide dismutase oxidase & superoxide dismutase

(SOD) in the brain (SOD) in the brain

4646

Sodium Sodium

Hormonal milieu of pregnancy affects Hormonal milieu of pregnancy affects sodium metabolismsodium metabolism

Intake should not be excessive but do not Intake should not be excessive but do not less than 2 g/dayless than 2 g/day

Requirement of some minerals per day Requirement of some minerals per day for adult female for adult female

NutrientNutrient RequirementRequirement PregnancyPregnancy

II

FeFe

ZnZn

SeSe

150 150 gg

26 mg/day26 mg/day

≈ ≈ 9 mg/day9 mg/day

30 30 gg

+ 50 + 50 gg

11stst trimester trimester

22ndnd trimester + 9.0 mg trimester + 9.0 mg

33rdrd trimester + 13.0 mg trimester + 13.0 mg

11stst trimester + 1.7 mg trimester + 1.7 mg

22ndnd trimester + 4.2 mg trimester + 4.2 mg

33rdrd trimester + 9.8 mg trimester + 9.8 mg

+ 5 + 5 gg

Source: WNPG VIII, 20044747

4848

During pregnancy the requirement of During pregnancy the requirement of fluidfluid

Why?Why?

blood volume & blood volume & utero-placental perfusion utero-placental perfusion

Water & sodium intake are very important Water & sodium intake are very important

4949

WaterWater

Female adult ≈ 2 L/day Female adult ≈ 2 L/day

Pregnancy 2.3 L/dayPregnancy 2.3 L/day

SodiumSodium::

Pregnancy: Pregnancy: • Adequate intake (AI) 1.5 g/dayAdequate intake (AI) 1.5 g/day• Upper limit (UL) 2.3 g/dayUpper limit (UL) 2.3 g/day

Healthy adult at least 500 mg/dayHealthy adult at least 500 mg/day

5050

AlcoholAlcohol

Evidence from animal studies & human Evidence from animal studies & human experience:experience:

Associates heavy drink (>1 drink/day) Associates heavy drink (>1 drink/day) by a pregnant female with by a pregnant female with teratogenicity teratogenicity & & fetal alcohol syndromefetal alcohol syndrome

Fetal alcohol syndromeFetal alcohol syndrome

Features:Features:Prenatal & postnatal growth failurePrenatal & postnatal growth failure

Developmental delayDevelopmental delay

MicrocephalyMicrocephaly

Eye changesEye changes

Facial abnormalitiesFacial abnormalities

Skeletal joint abnormalitiesSkeletal joint abnormalities

5151

5252

Nonnutritive Substances in Nonnutritive Substances in FoodsFoods

Caffeine <100 mg/day Caffeine <100 mg/day ~ ~ 2 cups of coffee2 cups of coffee

Artificial sweeteners:Artificial sweeteners: sucralosesucralose approved by FDA in 1998; approved by FDA in 1998; sucrose derivative, 600 times sweetersucrose derivative, 600 times sweeter

Sucralose Sucrose

5353

Some obstetric complications with Some obstetric complications with nutritional interrelationshipsnutritional interrelationships

AnemiaAnemia in pregnancy in pregnancy

Hb concentration <11 g/dLHb concentration <11 g/dL

5454

Iron Deficiency AnemiaIron Deficiency Anemia

Iron deficiency anemia (IDA)Iron deficiency anemia (IDA) is a is a problem of serious public health problem of serious public health significancesignificance

Iron deficiency (ID) occurs when iron is Iron deficiency (ID) occurs when iron is absorbed in an absorbed in an insufficient amount insufficient amount to to meet the body’s requirementmeet the body’s requirement

5555

Iron DeficiencyIron Deficiency

Insufficiency may be due to:Insufficiency may be due to:

Inadequate iron intakeInadequate iron intake

Reduced bioavailability of dietary ironReduced bioavailability of dietary iron

Increased needs for ironIncreased needs for iron

Chronic blood lossChronic blood loss

5656

IronIron ………………………………………. ………………………………………. (cont’d)(cont’d)

When prolonged, ID leads to IDA When prolonged, ID leads to IDA

NormaNormall

Iron Iron depletiodepletionn

IDID IDAIDA

Plasma Ferritin Plasma Ferritin ((µg/L)µg/L)

Transferrin Transferrin Saturation (%)Saturation (%)

RBC Protoporphyrin RBC Protoporphyrin (µg/dL)(µg/dL)

Hemoglobin (g/dL)Hemoglobin (g/dL)

6060

3535

3030

≥≥1212

3535

3030

≥≥1212

<12 <12

<16<16

>100>100

>>1212

<12 <12

<16<16

>100>100

<12<12

<12

Iron deficiency in women [International Nutritional Anemia Consultative Group (INACG), 2002]

Iron Status

5757

The consequences of ID or IDA in The consequences of ID or IDA in pregnant women:pregnant women:

maternal morbidity & mortalitymaternal morbidity & mortality

fetal morbidity & mortalityfetal morbidity & mortality

risk of low birth weightrisk of low birth weight

5858

Megaloblastic AnemiaMegaloblastic Anemia

In pregnancy, In pregnancy,

megalobalstic anemia usually caused by megalobalstic anemia usually caused by

folic acid deficiencyfolic acid deficiency

5959

Other Other Obstetric Complications Obstetric Complications with with Nutritional Interrelationship Nutritional Interrelationship

Hyperemesis gravidarumHyperemesis gravidarum

Diabetes mellitusDiabetes mellitus

Underweight & poor weight gainUnderweight & poor weight gain

ObesityObesity

6060

ObesityObesity

Obesity in pregnancy Obesity in pregnancy the risk of: the risk of:

Gestational diabetesGestational diabetes

Pregnancy-induced hypertensionPregnancy-induced hypertension

Cesarean sectionCesarean section

Neural tube defect (NTD)Neural tube defect (NTD)

Delivery infant with macrosomiaDelivery infant with macrosomia

Intrauterine fetal demise (IUFD)Intrauterine fetal demise (IUFD)

Infant with cardiac defectsInfant with cardiac defects

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SummarySummary

Energy intake to meet nutritional needs & allow Energy intake to meet nutritional needs & allow for about a 0.4 kg weight gain per week during for about a 0.4 kg weight gain per week during the last 30 weeks of pregnancythe last 30 weeks of pregnancy

Protein intake to meet nutritional needs, about an Protein intake to meet nutritional needs, about an additional 20 g/dayadditional 20 g/day

Sodium intake that is not excessive but is no less Sodium intake that is not excessive but is no less than 2–3 g/day (5–6 g of table salt)than 2–3 g/day (5–6 g of table salt)

6262

Summary Summary …………………………. (cont’d)…………………………. (cont’d)

Mineral & vitamin intakes to meet the RDA (folic Mineral & vitamin intakes to meet the RDA (folic acid & possibly iron supplementation is required)acid & possibly iron supplementation is required)

Alcohol omittedAlcohol omitted

Caffeine in moderation:Caffeine in moderation:

less than 200 mg/day less than 200 mg/day equivalent to equivalent to

2 cups of coffee2 cups of coffee

6363

ConclusionConclusion

Nutrition during pregnancyNutrition during pregnancy

Maintains energy, macronutrients, & micronutrients Maintains energy, macronutrients, & micronutrients requirementsrequirements

Provide substrate for development of new fetal tissuesProvide substrate for development of new fetal tissues

Builds energy reserves for postpartum lactationBuilds energy reserves for postpartum lactation

Optimal nutrition during pregnancy is the most critical Optimal nutrition during pregnancy is the most critical importance; 70% of the human brain develops during fetal importance; 70% of the human brain develops during fetal lifelife

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Breastfeeding Breastfeeding is the gold standard & strongly is the gold standard & strongly

recommended method of feeding infantsrecommended method of feeding infants

World Health Organization (WHO) recommends World Health Organization (WHO) recommends

human milk human milk as the exclusive nutrient source for as the exclusive nutrient source for

the the first 6 months of lifefirst 6 months of life, with introduction of , with introduction of

solids at this time, and continued breastfeeding solids at this time, and continued breastfeeding

until at least 12 months postpartumuntil at least 12 months postpartum

6666

Breast feeding benefits to:

• Infant nutrition

• Gastrointestinal function

• Host defense

• Neurological development

• Psychological, economic, & environmental

well being

• etc.

6767

Healthy MotherHealthy Mother

Human milkHuman milk

Volume: Volume: 850 mL/day 850 mL/day

Energy content: 60–65 kcal/100 mLEnergy content: 60–65 kcal/100 mL

Lactating woman requires a moderately Lactating woman requires a moderately

large amount of extra energylarge amount of extra energy

6868

Adequate amount of human milk Adequate amount of human milk production depends upon: production depends upon:

Capacity of the mammary gland in milk Capacity of the mammary gland in milk synthesissynthesis

Activity, metabolism, hormonal, & Activity, metabolism, hormonal, & maternal dietmaternal diet

Amount of energy & nutrient stores that Amount of energy & nutrient stores that can be utilized can be utilized

6969

Daily intake

Available nutrients (intake & storage)

Body stores

Milk (energy & nutrients content)

Maternal activity & metabolism

Milk synthesis process

Source: Lawrence, 2000

Maintain maternal healthMaintain maternal health

Milk production that sufficient for Milk production that sufficient for the infantthe infant

Various mechanisms including Various mechanisms including adjustments to energy intake & its adjustments to energy intake & its expenditure to meet the energy expenditure to meet the energy requirement during lactation requirement during lactation

7070

Nutritional Needs of Lactating WomanNutritional Needs of Lactating Woman

7171

Estimated Energy Requirement (EER)Estimated Energy Requirement (EER)

The incremental The incremental energy cost energy cost of lactation is of lactation is determined by:determined by:

The amount of milk producedThe amount of milk produced

The energy density of the milk secretedThe energy density of the milk secreted

The energy cost of milk synthesisThe energy cost of milk synthesis

7272

EEREER of a of a healthy lactating woman healthy lactating woman can be estimated can be estimated

by a factorial approach from the by a factorial approach from the sum ofsum of::

(1) EER of a non-pregnant, non-lactating woman (1) EER of a non-pregnant, non-lactating woman

(of a given age, weight, & activity level)(of a given age, weight, & activity level)

(2) Estimated milk energy (2) Estimated milk energy

(3) Energy mobilization from tissue stores (3) Energy mobilization from tissue stores

(i.e. weight loss)(i.e. weight loss)

7373

Human milk composition per 100 mL:Human milk composition per 100 mL:

EnergyEnergy 60–65 kcal60–65 kcal

ProteinProtein 1.0–1.2 g1.0–1.2 g

Fat Fat 2.5–3.5 g2.5–3.5 g

Human milk contains Human milk contains

calciumcalcium 300 mg/day 300 mg/day

7474

MeasuringMeasuring nutritional requirements nutritional requirements of lactating woman of lactating woman (WNPG VIII, 2004)(WNPG VIII, 2004)

850 mL of human milk 850 mL of human milk ≈ ≈ 600 kcal600 kcal

Energy efficiency 80% Energy efficiency 80% requires an extra requires an extra (100 : 80) x 600 kcal =(100 : 80) x 600 kcal = 750 kcal/day750 kcal/day

200 kcal obtained from 200 kcal obtained from fat stores fat stores

extraextra energy intake: 750 kcal – 200 kcal energy intake: 750 kcal – 200 kcal

≈ ≈ 500–550 kcal/day500–550 kcal/day is sufficient is sufficient

7575

MeasuringMeasuring nutritional nutritional …………………. (cont’d)…………………. (cont’d)

ProteinProtein (850 : 100) x 1.5 g = 13 g (850 : 100) x 1.5 g = 13 g

Protein efficiency 80% Protein efficiency 80%

(100 : 80) x 13 g = 16.25 g (100 : 80) x 13 g = 16.25 g

((additionaladditional average average 17 g of protein/day17 g of protein/day))

7676

The The extra energyextra energy (calories) need of lactating (calories) need of lactating

woman should in the form of a woman should in the form of a well-balanced well-balanced

dietdiet, not come from high-calorie foods with , not come from high-calorie foods with

poor nutrient density such as sugar and oilspoor nutrient density such as sugar and oils

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CarbohydratesCarbohydrates

Source of energySource of energy

Protein Protein sparing effectsparing effect

50–60% of total calories50–60% of total calories

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FatsFats (1) (1)

Sources of EFAs & energySources of EFAs & energy

Polyunsaturated fatty acids (PUFAs): Polyunsaturated fatty acids (PUFAs): arachidonicarachidonic acid (AA) & acid (AA) & DHADHA essential in neural & visual acuity developmentessential in neural & visual acuity development

Several studies:

infants fed with human milk have better cognitive development & visual evoked potential (VEP) than those fed with commercial infant formulas

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DHADHA intake should be 300 mg/day in lactating intake should be 300 mg/day in lactating woman woman (Simopoulos et al, 1999) (Simopoulos et al, 1999)

Fatty acids of infant tissues depend on daily fats Fatty acids of infant tissues depend on daily fats intake intake DHA content of breast milk is >>> DHA content of breast milk is >>>

if the maternal DHA intake is >>>if the maternal DHA intake is >>>

The mother’s dietary fat intake should be The mother’s dietary fat intake should be optimal in order to have optimal in order to have optimal fatty acids optimal fatty acids compositioncomposition in her milk in her milk

FatsFats (2) (2)

ProteinProtein

The AKG (Indonesian RDA) suggests The AKG (Indonesian RDA) suggests an an

additionaladditional 17 g of protein a day 17 g of protein a day for lactation for lactation

(WNPG VIII, 2004)(WNPG VIII, 2004)

oror

70 g of protein a day70 g of protein a day

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Minerals

Calcium intake need to be regarded

During lactation secretion of calcium into breast milk averages ≈ 200 mg/day

Iron intake need for replacing the iron depletion

during pregnancy

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VitaminsVitamins

Fat soluble vitamins should be adequateFat soluble vitamins should be adequate

Water soluble vitamins intake depends on the Water soluble vitamins intake depends on the mother’s energy intakemother’s energy intake

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TaurineTaurine: :

• AntioxidantAntioxidant

• Conjugation of bile acids & saltsConjugation of bile acids & salts

NucleotideNucleotide: :

essential substances for protein synthesis, essential substances for protein synthesis, energy metabolism, etc.energy metabolism, etc.

Non-nutrients

Human milk Human milk contains high concentration of contains high concentration of taurine & nucleotidetaurine & nucleotide

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Undernourished WomanUndernourished Woman

Although the Although the quantityquantity of of

human milk is influenced human milk is influenced

by the mother’s nutritional by the mother’s nutritional

status, status, the quality is not the quality is not

significantly affectedsignificantly affected, ,

except for the fat, vitamin, except for the fat, vitamin,

& mineral contents& mineral contents

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Nutritional Status & Milk Nutritional Status & Milk VolumeVolume

Milk production of woman with Milk production of woman with

good nutritional statusgood nutritional status::

First months First months ≈ ≈ 600 mL600 mL

Third monthsThird months 700–750 mL 700–750 mL

Sixth monthsSixth months 750–800 mL 750–800 mL

The amount will The amount will depend on depend on

suckling frequency suckling frequency of the infantof the infant

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Physiology of milk productionPRH: pituitary releasing hormone

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Milk production of undernourished Milk production of undernourished woman:woman:

First 6 months First 6 months 500–700 mL500–700 mL

Second 6 months Second 6 months 400–600 mL400–600 mL

Second years Second years 300–500 mL300–500 mL

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Milk production of Milk production of ……………………… (cont’d)……………………… (cont’d)

Severe malnutrition mother Severe malnutrition mother fat content fat content in breast milk in breast milk <<<<<<

The water-soluble vitamins content The water-soluble vitamins content depends on the mother’s intake depends on the mother’s intake of these vitaminsof these vitamins

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ConclusionConclusion

Maternal diet play a role in both the Maternal diet play a role in both the nutrients & non-nutrients compositionnutrients & non-nutrients composition

Nutrients composition of lactating woman Nutrients composition of lactating woman is necessary to be regardedis necessary to be regarded

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Nutritional status of lactating woman play Nutritional status of lactating woman play an important role in one of the efforts to an important role in one of the efforts to achieve breastfeeding at the early life of an achieve breastfeeding at the early life of an individualindividual

Moreover, nutrition play a role in Moreover, nutrition play a role in determining the success of a child’s growth determining the success of a child’s growth & development since his or her early life& development since his or her early life

Conclusion ……………………………… (cont’d)

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To prevent malnutrition during lactation, To prevent malnutrition during lactation, early detection in early detection in antenatal careantenatal care is necessary is necessary by both anthropometric & laboratory by both anthropometric & laboratory assessment, and physical examination assessment, and physical examination

Conclusion ……………………………… (cont’d)

92

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