NUTRITION

 and  
REPRODUCTIVE  HEALTH  
Detty  S  Nurdiati  
Div  of  Maternal  Fetal  Medicine,  Dept  of  Obstetric  &  Gynecology  
Fac  of  Medicine,  Universitas  Gadjah  Mada,  Yogyakarta  
Nutrition  through   Higher
Impaired
immunity Impaired mental

the  Life  Cycle  

mortality development
rate Increased risk
of adult
chronic
disease
Baby
Reduced capacity to Untimely / inadequate
Low Birth Weight
care for baby weaning
Elderly Frequent
Malnourished
infections
Inadequate Inadequate
fetal nutrition catch up Inadequate
growth food, health
Inadequate & care
food, Infection
health e.g. malaria Anemia
& care
Anemia
Child Stunted
Reduced
Woman Pregnancy mental
Malnourished Low Weight Gain capacity
Micronutrient deficiencies
Adolescent Inadequate
Stunted
food, health &
care

Higher
maternal Inadequate Reduced
mortality food, health & mental
care capacity
Preconception  Nutrition  
Key  Nutrition  Concepts  
•  Fertility  is  achieved  and  maintained  by  carefully  orchestrated,  
complex  processes  that  can  be  disrupted  by  a  number  of  
factory  related  to  body  composition  and  dietray  intake  
•  Hormonal  contraceptives  can  adversely  affect  some  aspects  of  
nutritional  status  
Preconception  Nutrition  
Key  Nutrition  Concepts  

•  Optimal  nutritional  status  prior  to  pregnancy  enhances  the  

likelihood  of  conception  and  helps  ensure  a  healthy  
pregnancy  and  roburst  newborn  
•  Dietary  intake,  supplement  use,  weight  status  and  exercise  
levels  before  conception  affect  fertility  of  women  and  men  
and  the  course  and  outcome  of  pregnancy    
 Obesity  Overview  
•  Worldwide  obesity  has  nearly  tripled  since  1975.  
•  Most  of  the  world's  population  live  in  countries  where  
overweight  and  obesity  kills  more  people  than  
underweight.  
•  WHO  2016  
–  Adults  >  18  years:  
•  >1.9  billion  were  overweight  (39%)    
•  Of  these  over  650  million  were  obese  (13%)  
–  Under-­‐5  chindren:  
•  41  million  were  overweight  or  obese  in  2016.  
–  Children  and  adolescents  aged  5-­‐19  years:  
•  >340  million  were  overweight  or  obese      
Obesity  in  Indonesia  
Classification   BMI   %  
(WHO,  1995)  
Underweight   <18.5   17%  
           CED  I   <16.0  
           CED  II   16.0-­‐16.9  
           CED  III   17.0-­‐18.4  
Normal  weight   18.5-­‐24.9   71,7%  
Overweight   25.0-­‐29.9   11,4%  
Obese   >29.9  
           Class  I   30.0-­‐34.9  
           Class  II   35.0-­‐39.9  
           Class  III   >40   Nurdiati  et  al,  Concurrent  prevalence  of  chronic  energy  deficiency  
and  obesity  among  women  in  Purworejo,  Central  Java,  Indonesia,  
Food    &  Nutr  Bull,  1998,  Vol  19(4):321-­‐33.  
 Obesity  and    Type  2  Diabetes  Mellitus    
and  Cardiovascular  Disease  

Being  obese  increase  the  risk  of  CVD    

-­‐ Coronary  artery  disease  by  2.7  times   Metabolic  syndrome  ↑  
-­‐ Hypertension  by  5.4  times   •  Risk  factor  for  diabetes  
•  Risk  factor  for  CVD  

Degree  of  insulin  resistance  ↑  

Overweight/Obese  ↑  
•  Central  or  visceral  distribution  of  body  fat  

Being  obese  increase  the  risk  of  DM  

Guh  et  al,  2009;  Kulie  et  al,  2011,  Patterson,  2004  
by  12.41  times  
 Obesity  and  Musculoskeletal  Pain  
Osteoarthritis  are  more  common  among  obese  adults  
compared  with  nonobese  adults  (31%  vs  16%),  which  
Obese   cause  the  development/progression  of  LBP    
Women  

Direct  mechanical  stress  

on  the  intervertebral  disc  
Indirect  effects  of  
atherosclerosis  on  blood  
flow  to  the  lumbar  spine  

Low  back  
pain  
CDC,  2006;  Kulie  et  al,  2011  
 Obesity  and  Infertility  in  Women    
Hyper-­‐  
Abdominal  Obesity   androgenism  
↑insulin  à  ↓SHBG  synthesis    &  ↑ovarian  androgen  
produc:on  à  ↑func:onal  androgen  levels   Menstrual    
disorders  
Peripheral  adipose  Tissue  
Anovulatory  
↑aroma:za:on  à  ↑circula:ng  estrogen   cycles  

Circulating  Leptin  ↑  
Infertility/  
↓ovarian  follicular  development  and  ↓steroidogenesis   Subfertility  

Kulie  et  al,  2011;  Shah,  2009,  ASRM  2008  

 Obesity  and  Infertility  in  Women  
Mentrual  Disorders   Fecundity  
•  Puberty  at  younger  age   •  Having  first  child  at  older  
age  (late  getting  marriage  )  
•  Menarche  decreased  3-­‐5.5  
months   •  Alteration  of  the  quality  of  
oocytes  and  embryos  
•  Irregular  menses  
•  Female  sexual  dysfunction  
•  Polycyctics  ovarian  
syndrome  

Kulie  et  al,  2011,  ASRM  2008  

Obesity  and  Infertility  in  Men  
Biological  bases  infertility  in  obese  men  
•  Low  testosteron  and  sex  hormone  binding  globulin  levels  
•  Elevated  leptin,  FSH  and  estrogen  levels  
•  Oxidative  stress  and  inflammation  
•  Influence  the  sperm  
–  Decreased  sperm  count  and  sperm  motility    
–  Increased  malformed  sperm    
Obesity  and  Fertility  
Obesity  related  to  hormonal  and  metabolic  changes  
that  compromise  fertility  and  health  status  in  men  
and  women  
Weight  loss  and  fertility  
•  The  first  therapy  option  
•  ↓  3.5-­‐11  kg  in  women  with  BMI  >25  kg/m2  
•  Diet  and  exercise  are  the  first  choice  of  weight  reduc:on  
–  Less  cost  
–  Fewer  complica:on  
 Weight  Loss    

Diets  for  weight  loss   Bariatric  Surgery  

Healthful,  balanced  and  provided  all   BMI  >40  or  >  35  kg/m2  and  if  a  serious  
required  nutrients   obesity  related  medical  condition  exists  
Addressed  the  nutrient  deficit  (inadequate   Return  to  normal  hormone  levels,      
vit  D  and  Calcium)   ↓  inflammation  and  ↑  fertility  
Should  be  planned  to  the  individual  food   Related  to  number  of  complications  
preferences  and  resources   •  Develop  def  iron,  folate,  calcium  and  
Slow  weight  loss  will  be  maintained,   vit  A,  B12  and  K  
accompanied  with  acceptable  changes  in   •  ↑  chronic  vomiting  or  malabsorption  
diet,  physical  activity  and  lifestyle   or  fail  to  take  vit  and  mineral  suppl  
Cutting  back  on  intake  by  100  calories/day   Pregnancy  is  not  recommended  during  
can  lead  to  a  10  pound  loss/year   the  firt  year  after  bariatric  surgery  
 Premenstrual  Syndrome  
Abnormal  serotonin   Serotonin  reuptake  inhibitors  
Physical  signs   Psychological   Interventions   Results    
symptoms   Antidepressant  drugs   ↓  signs  &  symptoms  
Fatigue   Craving  for  sweet  or   Oral  contraceptives   ↓  signs  &  symptoms  
salty  food   Exercise  and  stress   Energy  level,  well  being  
Abdominal  bloating   Depression   reduction   feeling  ,  stress  relieve  
Swollen  hands/feet   Irritability   Caffeine  intake  ↓   ↓  signs  &  symptoms  
Headache   Mood  swings   Magnesium,  200  mg,  2-­‐c   ↓  swelling,  breast  
Tender  breasts   Anxiety   tenderness,  bloating  
Nausea     Social  withdrawl   Calcium,  1200  mg,  3-­‐c   ↓  irritability,  depression,  
Vitamin  D,  700  IU   anxiety,  headache,  cramps  
Vitamin  B6,  50-­‐100  mg   ↓  severity  of  PMS  
 Hypothalamic  Amenorrhea  
Energy  and  possible  nutrients  deficit  disrupt  hypothalamic  
signals  that  lead  to  normal  secretion  of  GnRH  and  LH  

Hypothalamic  Amenorrhea   Interventions  

Related  to  underweight,  fast  weight   Fertility  can  be  restored  by  hormonal  therapy  
loss  or  weight  loss  accompanied  by   The  risk  of  pregnancy  and  newborn  
intense  exercise   complications  are  higher  
Related  to  engagement  in  intelectual   The  first  therapy  option  is  weight  gain  
professions  or  those  exposed  to  social   Accomplished  by  the  consumption  of  a  
stress,  especially  accompanied  by   healthful  diet  
subtle  deficit  of  calorie  intake   Weight  gain  of  3-­‐5  kg  are  usually  sufficient  to  
Preceded  by  menstrual  irregularities   restore  fertility  and  improve  the  pregnancy  
lasting  months  to  years   outcome  
 The  Female  Athlete  Triad  and  Fertility  
Women  involved  in  sports  that  emphasize  a  lean  body  type  are  
compromising  their  health  à  high  physical  activity  and  negative  
caloric  balance  
Female  Athlete  Triad   Interventions  
Amenorrhea   Correction  of  the  negative  energy  
•  <30%  energy  requirement   balance  and  associated  eating  disorders  
•  ↓  LH  and  estrogen   and  on  restoration  of  bone  mass  
Disordered  eating   accretion  
Osteoporosis     Peak  bone  mass  <30  yo  à  interruption  
•  Hormonal  changes  à  metabolic  changes     in  bone  development  be  short  in  
•  ↓  bone  density   duration  
•  ↑  susceptibility  to  stress  fractures   Vitamin  D,  Calcium  and  other  suppl  
 Eating  Disorders  and  Fertility  
Anorexia  Nervosa  and  Bulimia  Nervosa  
Signs  and  symptoms   Interventions  
Anorexia  Nervosa   Anorexia  Nervosa  
•  Amenorrhea  à  cardinal  sign   •  Normalization  of  body  weight  
•  Irregular  release  of  GnRH  and  low  estrogen   •  Long-­‐term  and  multidisciplinary  
•  Low  body  fat  &  fat  intake,  excessive  exercise   services  
•  Long  effect  à  osteoporosis  and  short  stature   •  Hospitalization  may  be  required  
Bulimia  Nervosa   Bulimia  Nervosa  
•  Menstrual  disturbances  à  oligomenorrhea   •  Normalization  of  eating  behaviour  
or  amenorrhea   •  Cognitive  behavioural  therapy  is  
•  Infertility   better  than  psychotherapeutic  
•  Food  binges  and  crash  diets  are  related  to   medications  
low  FSH  and  LH  levels  
 Polycystic  Ovary  Syndrome  
Insulin  resistance  plays  role  in  most  cases,  have  genetic  
component  and  increase  with  overweight  and  obesity  
Clinical  signs   Interventions  
Menstrual  irregulation   Increase  insulin  sensitivity  
Polycystic  ovaries   •  Insulin  sensitizing  drugs:  metformin  
Excess  abdominal  fat   •  Weight  loss  and  exercise    
Insulin  resistance   •  ↓blood  lipids,  insulin,  fasting  glucose,  testosterone    
•  Weight  loss  of  5-­‐10%  of  initial  body  weight  
Overweight,  obesity  
Abn  facial  &  body  hair   Dietary  recommendation  
•  Marine  sources  of  the  omega-­‐3  fatty  acid  EPA  and  DHA  or  
High  testosterone  
fish  oils  à↑insulin  sensitivity  
Infertility   •  Whole  grains,  fruits,  vegetables  high  antioxidants  and  
Low  HDL-­‐cholesterol     fiber,  non  fat  dairy  products  and  low-­‐GI  carbohydrates  à  
High  triglyceride   limit  blood  glucose  and  insulin  production  
 Diabetes  Mellitus  Prior  to  Pregnancy  
Increased  risk  of  maternal  and  fetal  complications  

•  ↑  blood  glucose  at  the  first  2  months  of  pregnancy  are  teratogenic  
–  2-­‐3  fold  increase  in  congenital  abnormalities  in  newborn  
–  Related  to  malformations  of  the  pelvis,  CNS  and  heart  in  newborn  
–  Related  to  higher  rates  of  miscarriage  
 
 Diabetes  Mellitus  
Nutritional  Management  Type  I  DM   Nutritional  Management  Type  II  DM  
Main  goals:  blood  glucose  control,   Main  goals:  blood  glucose  control,  resolution  
resolution  of  coexisting  health  problems   of  coexisting  health  problems  and  health  
and  health  maintainance   maintainance  
Carbohydrate  controlled  diets   Diet  &exercise,  some  need  medications  
Replace  simple  sugars  with  artificial   American  Diabetes  Association’s  Gudelines  
sweeteners   •  Weight  loss:  7%  
Encouraged  food  low  in  glycemic  index   •  Cal:  protein  15-­‐20%,  fat  <30%,  50%  carbo  
and  high  fiber,  low  fat  meals  and  dairy   •  Cal:  saturated  fat  <7%,  trans  fat  lowest  
products,  fish,  dried  beans,  nuts,  seeds   •  Cholesterol  intake  <200  mg/day  
↓  calorie  diet,  if  weight  loss  is  needed   •  Fiber:  14  g  per  1000  calories  of  food  intake  
•  Whole  grain:  half  of  all  grain  intake    
↑  physical  activity   •  Low  glycemic  index  food:  rich  fiber  
Preconception  Nutrition  
Key  Nutrition  Concepts  

•  Nutrition  and  other  lifstyle  changes  are  a  core  component  of  

the  treatment  of  a  variety  of  common  health  problems  of  
women  and  men  prior  to  conception  
•  Nutritional  and  health  status  before  and  during  the  first  2  
months  after  conception  influences  embryonic  development  
and  the  risk  of  complication  during  pregnancy  
Thank  You  
 References  
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