CH Philippine Obstetrical and Gynecological Society [POGS] (Foundation), Inc. CLINICAL PRACTICE GUIDELINES on MATERNAL NUTRITION AND SUPPLEMENTATION First Edition November 2013 Task Force on the Clinical Practice Guidelines On Maternal Nutrition and SupplementationCopyright© 2013, Published by Philippine Obstetrical and Gynecolog’ POGS Building, No.56 Malakas Street, Diliman, 1100 Quezon City ‘Telephone Nos. (632) 921-7557, 921-9089, 135-2384, 435-2585, Fax: (692) 921.9089 E-mail address: pogs@platdsl.net Website: www pogsine.org, I Society (Foundation), Ine. ISBN 978-971-94651.9.5 Allrrights reserved. No part of this book may be reproduced in any for for by anty means without prior permission from the publisher. Printed by. OVT-Graphie Li (Printing & Publishing House) #23, 21 Street, Upper Plaza, West Rembo, Makati City ‘Tel. Nos: 882-4119 / 882.4120 + Telefax: 882-4120 RE RAUL M. QUILLAMOI President Philippine Obstexrcal and Gynecological Society [POC Mp 1 (Foundation), Ine, 2003 Maternal nutrition ‘most newlected aspect of prenatal cate, Iv is ikewise a major factor that affects the maternity mov maternal mortality rate though deel the primary determinant of pregnancy outcome yet, itis the ity rate which, in our country, i sill high. ‘The Philippine in the past few years, is still one of the highest among Asian counties. It has been suggested that addressing the problem of maternal malnutrition could significantly decrease maternal and infant mortality raes and i is for this reason that we would like to revive, rekindle, or reinforce that awareness among us obstetricians. No high-technology facilities ga healthy mother lelines (CPG) on can ever replace the role of proper maternal nutrition in ensus anda healthy fetus. Thus, the bitth of this Clinical Practice G Maternal Nutrition and Supplementation. This is the second handbook oa such concern, the first one published in 2000, which | had the privilege 10 Chairs tasked by then POGS President Dr Bernardita Javier. It is my fervent hope that this new CPG will fulfill our objective of giving ‘our utmost attention tothe role 9 maternal nutrition and supplementation in the care of our pregnant cients. Quality prenatal care need not be expensive. It must bbe easily accessible. practical and affordabic. yet evidence-based. Adduessing the pregnant woman's nutritional needs will enable us to help them achieve a healthy Pregnancy outcome. reserve my most humble appicciation to Dr, Ramoa T, Reyles, Chair of the ‘Task Foree on Maternal Nutrition and Supplementation, and to all the members of the Task Foree ~ I know how much time, enerny, and “lost income” you have sacrificed in coming up with this manual. Your commitment and love for POGS: is beyond reproach and for this the whole POGS family will aways be grateful RAUJA1. OUILLAMOR, MD.Eiawenes Ms ENRICO GIL C. OBLEPIAS, MD (Chair, Committee on the Clinical Practice Guidelines, 2013 Greetings! On behalf of the 2013 Philippine Obsteirical and Gynecological Sosiety (POGS) Board of Trastes, i is with great pleasure that I present to the members 2 new and | ‘updated Clinical Practice Guidelines (CPGs) for this year. ‘These include the: (1) Fits Edition POGS CPG on Reprostaciive and Reconstrictive Surgery, (2) Fist Kaliton POGS CPG on Maternal Nutsition and Supplementation, and (3) Third Edition POGS CPG on Abaormal Uterine Bleeding, ‘These are the results of our Sociry’s commitment to Keeping everyone updated with the latest in evidence based! medicine and abreast with the evtront management of obstetric and gynecological conditions. ‘What you have in your hands isthe First Edition of the CPG on Maternal Nutrition and Supplementation, From as carly as the proconceptional, to the prenatal and postnatal period, the nutcition ofthe mother isindeed a great factor in obstettic health, ‘With this in mind, this CPG was conceived with the goal of aiding al obstetricians in Jniding our patients in having the proper nutrition necessary for optimizing the best possible outcome of their pregnancy ~ for both the chikl and the mother herself My profound gratitade goes t0 Dr. Ramon T. Reyles whose leadership as Task Force (Chair made this undertaking possible. ‘The eame goo: to the Task Farce members For ‘heir dedication and their invaluable contribution of time and expertise Tothe Chairs and Training (fice of POGS.accredited OB.GYN residency training, institutions, members of the PROG and CREED, Regional Ditectors, and concerned Stakeholders, thank you for your much appreciated participation during the plenary and review of this CPG, is the fervent wish of the 2013 POGS Board of Trustees that this be assistance o us in our delivery of appropriate and adequ: bstetscian-gynecologiss reat e services 19 Our patients as = snip ght c.ofi.reras, MD erate RAMON T. REYLES, MD. (Chair, Task Foree on the CPG on Maternal Nutrtior 1d Supplementation, 2013, Maternal nut ndergraduate Obstetric jon is a topic lightly highlighted in the subjects and with even less discourse during Obstetric residency training ‘conferences. This Clinical Practice Guideline (CPG) therefore serves as an initial step towards filing the gap on the information deficit on maternal nutrition during pregnaney and even through lactation. Valuable local data fom the latest National Nutrition Survey of the Food and Nutrition Research Institute (FNRI) has been gathered and presented by the participating authors to depict the current state of maternal nutrition, Moreover, chapters of this handbook have specifically been apportioned to diseuss the clinical effects of the extremes of maternal nutritional status on neonatal outcome. Likewise, a chapter on maternal nutritional evaluation has been included in this (CPG which will serve as a fundamental guide to clinicians in the crucial initial assessment of a pregnant wonnan, Furthermore, incorporated in this handbook js a chapter on recommended weight gain for specific body mass indices and for specific number of intrauterine gestations, be it for singletons or multiples. ‘More importantly, the tabulation of the Recommended Energy and Nutritional Intake (REND for pregnant anc lactating women has been made available forthe clinicians’ quick reference Much gratitude is hereby expressed by the undersigned to all the contributing, authors and reviewers for their valuable time and expertise in-making the publication of this handbook possible. Much appreciation is likewise extended to the Philippine Obstetrical and Gynecological Socicty’s (POGS) Board of ‘Trustees in charge of creating CPGs, Dr. Enrico Gil C. Oblepias as well as to the POGS President, Dr, Raul M. Quillamor for entrusting this vital undertaking to the undersigned, KC% warhol. nfs aBOARD OF TRUSTEES 2013 OFFICERS Raul M. Quillamor, MD President Ma. Carmen H, Quevedo, MD Vice Presiden Anne Marie C. Trinidad, MD ‘Seeretary Benjamin D. Cuenca, MD Treasurer Ditas Cristina D. Decena, MD. Public Relations Officer BOARD OF TRUSTEES Mario A. Bernardino, MD ‘Mayumi 8. Bismark, MD Ramon M. Gonzales, MD Eileen M. Manalo, MD Enrico Gil C. Oblepias, MD Ronaldo R. Santos, MD COMMITTEE ON CLINICAL PRACTICE GUIDELINES, 2013 Barice Gil C. Obleyias, MD Chair MEMBERS Lourdes B. Capito, MD Ramon T. Reyles, MD Deifia A. Tan, MD) MANAGING EDITOR ‘Ana Vie ia V. Dy Feho, MD ‘TECHNICAL STAFF ASSISTANT Ms. Mary Joy’. Aquine VASK FORCE ONT 1G (ON MATERNAL NUTRITION AND SUPPLEMENTATION, 2013, Ramon T: Reytes, MD MEMBERS: Mario Benito F Batiste, MD Ma. Cristina B Crisotoga, MID Mila Z thay, MD Richard C Jordias, MD. Joseph U. Oliva, MD Rost Nines V. Niwa, MD Leslie Rigo’, MD Mary Josey Yue Lago, MD Silag, MD. ‘TASK FORCE REVIEWERS AND PLENARY REVIEWERS: Ms. Lats §, Aca, MD Daisy I Dalevan, MD Covcepcion P-Argonza, MD Amy P- Estella, MD CCymuhiaS Baconga, MD Elzabeh F Felipe, MD No Sican Rates AN Cainte7 Fanciers Regina A. Bardorg, MD Rosey C. Garcs, MD Jocelyn M, Beloy, MD (Chine 6, Goazeles, MD Natio A.Bernaring, MD Catheine T Sson, MD Mayumi. Bisemek, MD Ma. Arora M. Lara Ma. "Tinidad Cabaron, MD Mary Jey ¥. Laygo, MD ChaudetcR.Cabingue MD ArnoldP.Livag, MD Sharon A. Capol, MD HenretaS.Lucisan, MD Margarete. Chie, ME Carmel G. Madrigal-Dy, MD Conrado P-Crivstomo, MD Ma, Delia R. Mauenda, MD SovatadC,Cesostomo, MD Carolin Paula C, Mastin, MD Dites Cristina D. Decens, MD Ampaso M. Medina, MD ‘Arlene R.Dominguer, VD Cleofe. Medina, MD Rommel Z.Duesss, MD Eugenc B. Mendoza, MD ‘AiphaS. Montnos, MD Calle Ory, MD (Chrisia 5 Paina, 4D Raul M.Quilamos, MD Camelia P Reto, MD Helen Grace C. Roasa, MD Belen P Rajagokk, MD Flori C. Salvadog, MD Helen Grace Santos, MD LydelaPSeibo, MD Eka E Singh, MD Sueaane K. Tan, MD Janette P. Tequere, MD muna A. Vaez, MD Marilou Vay, MD ‘marys Digra 0. Y2200, MDDISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY This is the Clinical Practice Guidelines (CPG) on Maternal Nutrition and Supplementation, First Edition, November 2013. ‘+ This isthe publication of the Philippine Obsteuical and Gynecological Soci- ety [POGS| (Foundation), Ine. + This isthe owne:ship of the POGS, its officers, and its entire membership, +The obstetrician-gynecologisi, the general practitioner, the patient, the stu dent, the allied medical practitioner, or for that matter, any capacity of the person or individual who may read, quote, cite, reer to, or acknowledge, any, ‘9 part, oF the entirety of any topic, subject matter, diagnostic condition or ‘dea/s willfully telease and waive all che liabilities and responsibilities of the POGS, its olficers and general membership, as well asthe AdHoe Cor ‘on the Clinical Practice Guidelines and its Editorial Staff in any or all clin ical or other dispu conference audts/controversies, ease discussions/critiquing, es, disagreemer refer + The reader is encouraged to deal with each clinical case as a dist ‘unique clinical condition which will never fit into an exact location fence is made into any or all part/s oF this CPG + The intention and objective of this CPG is to serve as a guide, t clarify, 10 make dear the distinction. It is not the intention or objective of this CPG to serve as the ind precise answer, solution and treatment for clinical conilitions and situations. It is always encouraged to refer to the individual clinical ease as the one and only answer to the case in question, nor this CPG. + It is hoped that with the CPG at hand, the clinician will find a handy guide that leads to a clue, to a valuable pathway that leads to the discovery of cli. ical texts leading to clinical eeatments and eventually recovery. + Inbehalf of the POGS, its Board of Trustees, the Committee on The Clinical Practice Guidelines 2013, this CPG is meant to make each one of us a perfect image of Chris, the Healer. CPG ON MATERNAL NUTRITION AND SUPPLEMENTATION olde yeu Demographics on Maternal Nutrition in the Philippines ..... Ma, Cristina P, Crisologo, MD Assessment of Nutritional Status of Pregnant Women Mario Benito F Bautista, MD Recommended Weight Gain in Pregnancy Mary Jocelyn Yu-Laygo, MD Recommended Energy and Nutrient Intake .. Joseph U. Otivar, MD amd Mary Jocelyn YoeLaygo, MD Micronutrient Supplementation: Iron Folie Acid and lodine Joseph U. Olivay, MD Micronutrient Supplementation: Vitamins, Minerals and Electrolytes Joseph U. Ofnar, MD amd Raanon T: Reyles, MD Appendix 1 Burden of Undernutrition: Health Risks for the Mother, Fetus and Child. Rosa Ninee Velante-Nierwa, MD Appendix 2 Consequences of Obesity and Overnutrition in Pregnancy. Joyceline Noemi I. Silao, MD Appendix 3 Government Programs on Maternal Nutrition and Supplementation Mila Zaragoza-Ibay, MD ‘Appendix 4 Levels of Evidence and Grades of Recommendation 19 28 36 42DEMOGRAPHICS ON MATERNAL NUTRITION IN THE PHILIPPINES Ma. Cristina P. Crisologo, MO, FPOGS, FPSMEM. ‘The Pood and Nutrition Research Hnstitute (FNRI) of the Philippines is mandated by law to undertake research that defines the citizenry’s nutritional satus, with particular reference to the malnutrition problems, its causes and effects, and to identify alternative solutions «0 them. ‘To this end, a national nutrition survey is conducted every 5 years. The "National Nutrition Survey ‘conducted in 2008 carrie as its theme, “Vital Inputs to Nutrition Governance for Sustainable Development,” end this will be the main basis for the contents oF this chapter Pertinent results from this 7” FNRI Survey! ate elucidated in the succeeding sections ANTHROPOMETRIC SURVEY Among 1 to 19 year old adolescents: * Forevery 100 adolescents aged 11-19 years, 17 were underweight and about 5 were overweight. + There were more underweight 11 year old adoles [5 to 19 year old adolescents (13.8%). + Prevalence of underweight 21.7% vs 11.7%) and overweight (4.8% vs, 4.5%) were higher among male adolescents than the female, + The prevalence of unde-weight among the pre-adolescents/adolescents, 11 f0 19 years old hae! significantly ineacased by 1.0 percentage point between 2005 and 2008, + Overweight, on the oth percentage point from 4 is (25.5%) than the hand, had decreased significantly by 0.2 in 2005 to 4.6% in 2008. Among adults 20 years and over: * About 12 in every 100 adults 20 years and over were chronic energy Aeficient (CED), corresponding to a body mass index (BMI) of less than 18.5 ke/n + Overweight and obesity affect 27 adults in every 100, with the most number of obese indivituals coming from the national eapital region ¢NcR),‘= From 2003 to 2008, there was a significant decrease in the prevalence of CED among adults fram) 12.3% 10 11.6% + Incontrast, a 2.6 percentage point significant increase in the prevalen of ovenveight and obese among adults Was noted, Among pregnant women: The proportion of nuvitional at-risk pregnant women decreased significantly by 1.9 percentage point from 2005 40 2008, Regions {IT and VI posted the highest 1umbers of underweight lactating women, + There are about 26 nntritionally at-risk pregnant women for every 100 vest in Region [V-B and ARMM. women, with the numbers being bi Among lactating women + There was a significant reduction in the prevalence of underweight Jactating women fron 13.9% an 2005 40 13.1% in 2008, + There was. 3.8 peveentage point significant decrease in the prevalence of oversveight lactating women from 19.8% in 2005 to 16,0% in 2008. BIOCHEMICAL SURVE) ANEMIA’ + The overall prevalence of anemia, thom 6 months of age to the elderly (© 60 yours) is 19.5% The highest prevalence was observed among, infinis 6 months t0 <1 year at 5.7%, followed by pregnant women at 42.5%, + Based on the > 40% epidemiological eriteria for assessing severity and magnitude of anemia, the prevalence among infants and pregnant ‘women remains a significant public health problem, + Males had a significantly lower anernia prevalence compared to their female counterparts zanong the 13 to 19 year olds, 20 to 39 year olds, ‘and 40 to 59 year olds, © Based on the Z0US Prejected Population (using the 2000 Census), the dren. per age yroup are 2s Fallows: 6 months to year # 0,74 million, Ite S years is 2.1 milion, and 6 to 12 ‘years is 2.77 miltion + There was no signifieant decrease in anemia prevalence rate from 43.9% to 42.5% in 2008 among pregnant women. * Prevalence rate for lactaling women was significantly lower in 2008 at 31.4% compared to the 2003 anemia prevalence rate of 4 estimated number of anemic CLINICAL SURVEY: * The prevalence of hypertension (140/290 mmlg) among adults 25.3%, Itinereases with age starting from age 40 to 49 years 2 + The prevalence of high fasting blood sugar (> 125 mg/dl.) among adults is 4.8%, peaking at age 50 to 59 yeas, + Prevalence of impaired fasting glucose is 2. + Prevalence of high cho'esterol (160 mg/dL) among adults was 11.8%, and high triglyceride levels (>200 mg/dL) was 14.6%. In general, total cholesterol, LDL-c and triglyceride levels inereased with age, peaking fiom ages 40 t© 59 years. * Dyslipidemia based on total cholesterol, HDL-© and triglyceride levels tereaced from 2003 10 2008, + Based on the Radimer-Comell tool, about 3 out of 10 mothers experienced food insecurity because there was no food oF money to ‘buy food in the past 5 rnonths. + Skipped cating oF missing meal(s) was t among food insecure mothers. + Hunger was experienced by about ? out af 10 mothers. + One out of 10 children experienced hunger but did not cat becatis ‘was no food or money o buy food in the past 3 months, + OF the Louscholds, about 7 out of 10 mother respondents expressed anxiety regarding the safficiency of food in the household and money to bay Food. + Five out of 10 mothers felt their children were not eating enough in terms of quantity and nutritional adequacy because the households do jot have enough food and money to buy more foo. most frequent experience there ‘Table J. Percent of mothers who experienced food insecurity and frequency of rast J months: Philippines, 2008 Percent ‘or missing meal) | 369 putdid noteat 16 or the winie day | 95 ince of least one oF | 286 In other aspecis, protein-energy malnutrition (PEM) and micronutrient eficiencies remain the leading nutritional problems in the Philippines. The eeneral declining trend in the prevalence of underweight, wasting and stunting 3‘among Filipino children noted in the past 10 years was countered with the increase in the prevalence rate in 1998. About 4 million (31.8%) of the preschool population were found to be underweight for-age, 3 million (19.8%) adolescents and 5 million (13.2%) adults, including older persons were found to be underweight and chronically energy deficient, respectively.? ‘The status of micronutient malnutrition is likewise an important concern in the country. The vitamin A status of the country is considered severe subclinical deficiency affecting children 6 months to 5 years (8.2%) and pregnant women (7.19%). Icon deficiency anemia (IDA) is the most alarming, of the micronutrient deficiencies affecting a considerable proportion of infants (56.6%), pregnant women (50.7%), lactating women (45.7%) and male older persons (49.1%). Prevalence of IDA was mild (7Img/L). However, 35.8% children 6-12 years old stil sufler from moderate and severe IDA. In the 2011 survey updating the nutritional status of Filipino children and other population groups conducted! by the FNRI, initial results released in April 2012 showed that 35.7% or about a third of pregnant women below mally at risk, based on weight-for-height requirements “About twenty three percent (23.3%) or 1 out of 5 pregnant women above 20 years old is also at risk.’ “Thestudy also looked at the prevalence of nutritionally atcrisk pregnant women by months of pregnancy. Resulis showed that 27.9% Of pregnant women are nutritionally at-risk on the 1* trimester, 25.3% on the 2” trimester, and 23.2% on the 3 trimester. Pregnant women from MIMAROPA (43.6%), Western Visayas (33.2%), Cagayan Valley (32.6%) and SOCCSKSARGEN (29.4%) regions recorded the highest percentage of nutritionally at-risk cases, LACTATING MOTHERS' The survey also siudied the prevalence of malnourishment among, lactating mothers. Results reveated that 11.9% of lactating mothers are underweight, while 17.7% are overweight. + Based on age group, 11.8% of lactating mothers less than 20 yeuts old are underweight, 1.9% of lactating mothers more than 20 years old are also underweight. Being overweight is also a problem lactating mothers, About six percent (6.7%) of mothers less than 20 years old an 18.8% of mothers ‘over 20 years old are overweight. ‘The study shows that the poor health condition of pregnant women puts them at risk —they deliver low birth weight babies or have negative pregnancy outcomes like stillbirths and miscarriages. 4 REFERENCES: 1, 7° BNRENational Nutrition Survey 2. Iupiowve fo orglagiogn/murition(phl_en.stm accessed August 2013 3. hitp:JAcwwe.rapplencom/move-ph/33688-curvey-pregnant-mothers- ruatition-risk accessed August 2013ASSESSMENT OF THE NUTRITIONAL STATUS OF PREGNANT WOMEN Mario Benito F Bautista, MD, FPOGS, FPSUOG Recommendations Recommend assessing and documenting body mass index (BMI) ‘of all pregnant women at the initial visit. (Few! 1-2, Grade 8) Pregnant women found to have a BMI < 20 kg/m! should be referred for nuttition counseling and considered at increased risk for fotal growth restriction. (Leve! 112, Grae 83) 3. Recommend screening for inay women at every visit during preg wopriate weight gain for all 1. (Love Il, Grade C) 4. Pregnant women with inadequate weight gain at 28 weeks uutritional treatment need additional surveillance. Cor /referral to advanced prenatal cave provider, (Leve! IF2, Grade C) 5. Individualized weight gain should be based on pre-pregnancy ht. (Level IH, Grate C) tional assessment should include dietary, medical and socioeconomic -y, clinical evaluation and laboratory methods, (Level 1H, Grade C) 7. For women who are on either side of the normal BMI, signs of nutritional deficiencies should be sought out. (GPP) 6 Supporting Statements Pregnant women who experience inappropriate weight gain may be at risk for a number of complications. Excessive weight gain may increase the risk for macrosomic infants, shoulder dystocia, operative delivery and postpartum obesity. Inadequate weight gain isassociated with preterm delivery, intrauterine growth restriction (UGR), and low birth weight, Scicening for inappropriate ‘weight gain allows for early intervention to prevent these complications, Obesity is defined as a BMI of 30 kg/m? or greater and affects approximately one-third of adult women. Obese women are at increased risk for several pregnancy complications (see ‘Obesity’. 6 No systematic reviews or controlled trials of screening for inappropriate ‘weight gain during pregnancy were identified, Recommendations endorsed by the Institute of Medicine (IOM), American Academy of Pediatricians (AAP) and American College of Obstctsician and Gynecologists (ACOG) (1995) have been based on the pre-pregrancy BMI, Women with a BMI below 19.8 kg/m? ave recommended to gain 12.7 to 18.2 kg (28 to 40 Ib), women with a BML of 19.8 t0 26.0 kg/m are acvised t0 gain between 11.4 and 16.0 kg (25 to 35110), and women witha high BMI (26.0 to 29.0 kg/am?) are recommended to gain between 6,8 and 9.1 kg (15 1 20 th). Women who have a very high BMI Ge. above 29 kg/m’) are advised to gain at least 6.8 kg (15 Ib) (JOM, 1990).' Maternal BMLof less than 20 kg/m#at the start of pregnancy is associated with increased prevalence of preterm delivery and low-birth-weight infants? ‘This retrospective analysis did not look at ‘weight gain over the course of pregnancy on these outcomes.” Forinadequate weight gain, only balanced protein-energy supplementation ‘may be safe and effective. "High-protein and isocaloric protein-energy supplementation may be associated with untoward fetal effects. For excessive weight gain, protein-energy restriction is not significantly effective anc) may adversely impact birth weight. Excessive weight gain may >e associated with adverse changes in fetal or neonatal weight and minor maternal morbidity, but these data are difficult to separate fiom data concer 1e obesity (Kelly, etal, 1997). Maternal ‘overweight condition increases the tsk of antepartum sillbirth, especially term antepartum sillbith, whereas weight gain during pregnancy was not associated with risk Stephansson, etal, 2001). EVIDENCE TABLE. ‘Recomnien dations [ Sources of evidence | 1 | QE | SR | T] Route sesnentofDMTar [Sebi eto 2000 [UT Far |B svi | Nuttivion counseling for ‘Kramer, 2000 12 | Fav | 8 inadequate woightgainor | Sebi, eval, 2001 inital BAAL < 20 kg/m? —_ _|_ [3 | Routine screening for Kelly, et al, 1997 im | Fair inappropmate weight gain at cachvist _ 4 ) The pracizal evaluation of | Kelly, tal, 197 Fair | © voce gain at 281028 wocks | | Individualized weight gain | TOM, 1990 ia | Fair | © based on pre cy weight B= Level of Bids, OF = Quy of Evin, SR= Soom Recreation] 7Pregnant women with inadequate weight gain at 28 weeks who are ‘unresponsive to nutritional treatment need additional surveillance. Consider consultation/referral to advanced prenatal care provider The anthropomett BML, Looking for signs and symptoms of nutritional deficiencies routine. Lastly the hemoglobin and hematocrit should always be ight of the nutritional status of the worman clinical evaluation should include pre-pregnancy weight, measurements like the height, weight and calculation of her REFERENCES: 1 6 Institute of Medicine (U8), Subcommitee on Nuwitdonal Status and Weight Gain during. Pregnancy. Tnstiwte of Medicine (US) Subcommitice on Dietary Intake and Nutrient Supplements duning Pregnancy. Nutrition during, Pregrancy: part, weight gain: par II, nutrient supplements, Washington, DC fational Academy Press; 1990, 1-222 p. ie NJ, Jolly M. Maternal obesity and pregnancy outcome: a siudy of 287-213 pregnancies in London. Int J Obes Reiat Metals Disord. August 2001:25(8 1175-82 Kelly A, Kevany J, de Onis M, Shah PM, A WHO collaborative study of materoal anthropometry and pregnancy outcomes. Int J ‘ol Obsict 1997:5( 11-5, Kramer MS. Isocalori balanced protein supplementation in pregnancy. Eur J (Cin Narr 2000:54(2) 180, ‘Kramer MS, Enemsy/peotcia retrction for high weightfor-height or weight gin during pregnancy. Cochrane Database Syst Rey 2000,2);CDO00080 Kramec MS. High protein supplementation in pregnaney. Cochrane Databsse Syst Rev 2000;03:CD000105 Maternal Nutitional Assessment. AJPH Supplement 1973463, RECOMMENDED WEIGHT GAIN IN PREGNANCY Mary Jocelyn Yu-Laygo, MD Recommendations Preconception: ‘The pre-pregnancy weight should be within the desirable weight range based on the body mass index (BMI). (Level UI, Grace B) For obese women who are planning a pregnancy, pre-conception ng) is strongly encouraged. (Level 11), Grade B) Antepartum ‘The recommended weight gain should be based on pre-pregnancy BML. (Level 112, Grade) 4. ‘The total weight gain and the gain rate for multiple gestation is higher compared with singleton pregnancies. (Level ill, Gnade B) IL. Posteonception 5. No sccommendation is made for specific weights during the pectpartim period. Having a normal weight gain during pregnancy can avoid excess maternal weight retention during the postpartum period and having higher weight in their subsequent pregnancies. (Level Il, Grade B) Supporting Statements: 1 Preconception ‘The Committee to Reexamine the Institute of Medicine's (IOM) Pregnancy Weight Guidelines concludes that the factors that affect pregnancy begin before conception, The mother’s weight at the start 9Of the pregnancy is one of the most important modifiers of pregnaney weight gain.” ‘The 2009 IOM and National Research Council Guidelines for obese women supported weight loss before pregnancy to improve menstrual functioning, ovulation and metabolic profile and reduce infertility? ‘Tablet. Weight Classification according, to BNE OM) Category | Underweight 249 «| 5.0.29. 530.0 The World Health Organization (WHO) recommends a new cut-of value for Asian pop, : Table 2. Weight Class ng to BMI for Asian Populations Categor BMT (ke/m2) Low BMI (anderweighi) 185 Normal BMI(normal weight) 18.5229 Hligh BNI (overweigh) >23.0 TL. Antepartum Table 3. Recommended total and rate of weight gain by pre-pregnancy BMI Classificationof Prepregnancy BMI. Clasiction : BMI] Towa Weight | ~ Rates of Welght gain kg/m?) Gain (ibs) 2™ and 3" trimester el Adeiweekjt __| aga | e180] a Tay ‘Normal —__ | 18.50-24.99. 25-35, = [Overweigit 3500799 | 1325 Te W307) Obese al ees) [~ = 3000 —| 1120 54035) *Caladatons asame © 05:2 (1-4 is weight sn ta Te FTomeser” 10 Pregnant women who started pregnancy as underweight or who have not gained enough during pregnancy tend to have increased risk for preterm infant and low birth weight baby.’ Mothers who gain too much weight during, pregnancy have higher incidence of cacsarcan deliveries, preterm birth. They retain too much weight even ater pregnancy and have higher weight in their subsequent pregnancies. Gestational weight gain below the TOM recommendations among, overweight pregnant women does not appear to have a negative effect on fetal growth or neonatal outcomes. In several studies, overweight women who gained 2.7 ~ 6.4 ky (6~ 14 tb) kad similar fetal growth, perinatal and neonatal outcomes, and less postpartura weight retention as overweight women who gained weight within the currently recommended TOM range‘* For the foverveight and even the obee pregnant women who arc gaining less than the recommended amount but have appropriately growing fetus, no evidence ‘exists that encouraging increased weight gain to conform with the current IOM guidelines will improve maternal or fetal outcome."” Obese women are at increased risk for several pregnancy complications therefore preconception assessment and counseling are advised. Obstetricians should encourage obese patiens o undertake weight reduction program (diet, ‘exercise and behavioral modilcation) before attempting pregnancy. Initial prenatal visit should involve the cafcutation of the BMI and recommendations forappropriate weight gain reviewed at the first vsitand periodically throughout pregnancy. Bariatic surgery is an option before pregnancy however they are at increased risk of deficiencies of iron, vitamin B12, folate, vitamin D and calcium? ‘The 2009 10M recommendation provide the following guidelines regarding twin pregnancy: ‘Tle 4 Recommenited weight gain for Twin pregnancy _ Propregnaney BM ‘Total Weight DML (e/a?) Gain (ins) Gain(in ke) 18.5249 3254 168-245 250219.9 3150 14.1227 230 | 2a | ADL ‘There was insufficient information for the IOM committee to develop provisional guidelines for underweight women with multiple fetuses. A consistent rate of weight gain is advisable. A gain of 1.5 Ib/week during the an2° and 3” trimesters has been associated with a reduced risk of preterm and love-birth weight delivery in tin pregnancy. In triplets, the overal gin should be around 50 pounds witha steady rate of gain of approximately 5 Ib/week throughout the pregnancy."" ‘The American College of Obstetricians and Gynecologists (ACOG) recommends that women with multiple pregnancies consume about 500 more calories a day than usual," Table 5. Recommended weight gain in multiple pregnancy in ths" Multiples Ttvimester_[ 2” trimester | 3” trimester Twin 5.0) 15.20 10.20 asa, ‘Tipket 5.10 20:30 2025 | 45.60 “Quadeuplet 10.15 25:35 2025 5075 Ouinvuplee 1020 vas | _asa0 5.100 All. Posteonception Assistance through the postpartum period should be provided to help ‘women return to their prepregnancy weight within the first year following delivery.! REFERENCES: 1. Rasoussen KM, Yaktine AL. Weight Gain During Pregnancy: Reoxamining the Guidetines, Insite oF Medicine May 2008, 2 Rasmussen KM, Abrame B, Bodnar LM, Butte NF, Catalano PM, et al Recommendations for woight gsin ducing prepmancy in the conte of obesity epidemic. Amer Coll Obstet Gynecol 2010;116(3) 1191-95. 3. Rasmussen KM. Chaic of IOM Committee Report May 2009. Pregnancy ‘Weight Gain: Wat To Expect. Updated Feoruary 2013, 4. Schieve LA, Cogswell ME, Scanlon KS. An empirical evaluation of the Insttwte of Medicine's pregnancy weight gain guidelines by race, Obstet Gynecol 1998,91:878.84, 5. Langford A, Josiu C, Chang 11, Myles", Leet: Doct geetational weight gain alfect the risk of adverse matcena) and infant outcomes in oversight women? ‘Mater Chile Health J 2011;15:860.5. 6 Nohr EA, Vaeth M, Baker JL, Sorensen TI, Olsen J, et al. Combined ‘associations of prepregnancy Dody mass index apd gestational weight gain 2 with the outcome of pregnancy. Am J Clin Nutr 2008,87:1750-. Cedergren M. Effects ef gestions! weight gain and body mass index on ‘obstetic ouicome in Sweden. Int J Gynaecol Odstet 2096,95:269-74, Beyerlein A, Schiess! B, Lack N, von Kriee 8. Optimal gertational weigh! gain ranges for the avoidance of adverse birth weight outcomes a novel approc, Am J Clin Nate 200990 15528. (Okea B, Kleinman KP, Belfort MB, Hammitt JK, Gillman MW, Associations of eestasional weight gaia and showt.and tongesteron maternal and child health foateomes. Am J Epidemiol 2009; 170:173 80. ‘Committee Opinion No. $48 ~ Committee on Obstetric Practice. Weight gain ducing prognancy. Amer Coll Obstet Gynicco! 2013 ‘Muliptes: twins, wiplesand beyond March of Dimes. wwwmarchofeimes ‘com? /multiple-wins-trpletsand beyond. Asp ‘Weight Gain with Multiple Pregnancy. Excerped fiom ‘The Everything Twins, ‘Triplets, and More Book eopyright @2005, F HW Publications Ine Low Maternal Weight Osi ‘maternal weight gain 7-09 par wwcedph ca, gov/.../ WiePEPB-SL How | |RECOMMENDED ENERGY AND NUTRIENT INTAKE Joseph U. Olivar, MD, FPOGS Mary Jocelyn Yurlaygo, MO, FPOGS Recommen tions L. Preconception 1, The recommended total energy intake of a woman should be based on physical stature and physical activity level. (Level 13, Grade C) . 2. For an underweight woman, the total energy int fe based on activity level are stated in the table below, (Level IE, Grude C) Activity | Calories (Keal/kg/day) | seemieay 35 0 6 3. For women within the normal weight range, the total ene intake based om activity level are tated inthe abe sto. (Lee 113, Grade C) Activity | ators Occal/ha das) Sedentacy 30 Light activity 35 Moderate activity 40 4. For overweight women, the total vit women, the total energy intake based on activity evel are stated in the table below. (Lew! I1-3, Grade C) ‘Activity Calories (Keal/kg/day) Sedlentary 25 Light activity 30 Moderate activity 35 ‘| 4 5, ‘The computation of the total energy intake is done using the desirable body weight (DBW) multiplied by the calories. (Level 113, Grade C) I. Prenatal 6. For pregnant women in the 2! and 3% trimesters, 300 kcal/ day is added to the total computed daily energy intake, (Level Il, Grade oO 7. For women with multifetal pregnancy, 450 keal/day is added to tie total computed daily energy intake. (Level If), Grade C) 111. Postpartum 8. Lactating women require an additional 500 keal/day over the basal energy requirements during the first 6 months and like in the last second 6 months if lactation is continued. (Low! [, Grade Q) Supporting Statements ‘The revised edition of the dietary standards is changed from “Recomended Dictary Allovances (RDA)" to “Recommended Energy and Nutrient Intakes (RENI)” to emphasize that the standards are in terms of nutrients, and not foods or diets” RENIS are defined as levels of intakes of ‘energy and nutrients which, on the basis of current scientific knowledge, are considered adequate for the maintenance of health and welH-bcing of neadly all healthy persons in the population. For most nutrients they are equal to the fverane physiologic requirement (AR), corrected for incomplete utilization oF etary muttient bioavailability, plus two standard deviations (SD), or twice fan assumed coefficient of variation (CV), to cover the needs of almost all individuals in the population. In the case of nutrient for which data on AR arc insufficient, the RENT is aa “adequate intake” (AI) which is based on the ‘experimentally observed average intake of healthy individuals. For energy, the recommended intake level is set atthe estimated average requirement of individuals ina group (no SD), since intakes consistently above the individual's, requitements lead to overweight ar obesity Additional requirements during pregnancy are based on estimates of amounts laid down in fetal and maternal tissues, while those for lactating 15women, are based on amounts secreted in breast milk. ‘These amounts are then added to the requirements of nonpregnant, nonlactating women? ‘The recommended energy requirement of an individual is the level of energy intake from food that will balance energy expenditure when the fividual has a body size and composition, and level of physical activity, consistent with long-term good health as well as allow for the maintenance of economically necessary and socially desirable physical activity (FAO/WHO/ UNU, 1985), The Food and Nutrition Research Lastitute (FN) of the Department of Science and Technology (DOST) recommend the following reasonable energy allowance based the following activity levels.> Aetivity Keal/kg DBW/day Bed rest but mobile (hospital patients) 225 Sedentary (mostly sitting) 30.0 ‘Light ress maker, nurs, physician, driver) 350 “Moderate (heavy housework, mana labor) 40.0 ‘Very active (regular swinwning, farming) 450 Modified fom FNKE-DOST 2009" ‘To measure the DBW, one can use the Tannhauser’s Method. Step I. Measure the height in centimeters! Example: If the woman is 5 feel 4 inches tall, her height in centimeters 58 162.56em Height = 5 fect 4 inches = 64 inches = 66 inches x 2.54 centimeters 162.56em Step 2: Estimate the DBW Deduct 100 from the computed height in centimeters pBw 162.56 - 100 62.56 ky 16 ‘To apply this DBW to Filipino stature, deduct 10% pew 62.56 ky - 10% of 62.56 62.56 ky - 6.25 56.31 kg or 56 ke ‘Thus, a woman who siands 5 feet 4 inches tall will have an estimated DBW of 56 kg on which her caloric needs will be computed, ‘The ni determined through the body a ritional status (Nutriture) of the pregnant woman is then ass index (BMI, Classitie BMI (kg/?) Piinipal cata points | Adaitional cut-off points for Asians jenveigha =e 1850 Normal 1850.24.99) 18,3022.99 23,0024,99 Orenveishi S00 325.00 hese =300 0.00 ‘Aopicd fiom WHO, 1995, WHO, 2000, WHO 2008 ‘The additional cut-off points are used for interventions such as weight classification to determine the kcal/kg/day assignment to be used for Asians.” ‘The desirable BMI is 18.5-22.9 according to the Department of Health ‘Manual on Prevention of Noncommunicable Diseases." The FNRI, on the ‘other hand, specified the mean desirable BMI for women at 20.8 (22 for men) for purposes of computing the caloric needs. The DBW can also be computed from this using the formula below DBW = Desirable BML x Height (m?) For Pregnant Patients ‘The total energy requirement (TER) per day does not change for the 1* trimester. There is however an additional (from the normal requirement) 300 keal/day for the 2 and 3+ winesters of pregnaney (TER/day for 2" and 3° trimester of pregnancy = normal requirement + 300 keal/day), An additional awrequirement of 450 keal/day is added for those with multifetal pregnancy. Additional (from the normal requirement) 2 gor 9 of protein per day is needed for 2 trimester and 3! trimester of pregnancy, respectively. ‘The normal adult protein requirement for Filipinos is 1.1 g/kg DBW. The protein requirement in g/day is multiplied by 4 keal/g to obtain the calorie value of protein per day. This amount is deducted from the ‘TER of the day to obtain the nonprotein calories (NPC) ‘The NPCis then divided to 70% carbohydrates and 30% fats. ‘Phe keal of carbohycirates and of fats is divided by 4 keal/g and 9 keal/g, respectively for carbohycirates and fats to obtain grams of carbohydrates and fats. Another method of dividing the distribution as follows: Carbohydrates ~ 60% of the TER = keal of carbohydrates Proteins ~ 15% of the TER = kcal of prote Fats 25% of the TER = keal of fats for the day is via percentage To Obtain the Dietary Prescription for the Pregnant Patient This comes by having a prescription as below: Rx TER/day Carbohydrates roteins Pats Ckeal/day) — Cingrams/day) (in grams/day) (in grams/day) ‘The above prescription will requite the use of the FOOD EXCHANGE LAST for proper translation of the dictary prescription into the different meals, for the day. ‘The responsibility of converting the caloric prescription and translating these into meals falls imo the hands of dieticians and nutritionists, ‘The recommended food pyramid for pregnant and lactating mothers can be refered to in the appendix ‘REFERENCES 1 PNRI/DOST. Training Mama! for Heally Workers on Healthy Lifestyle: ‘An approaci for the prevention and contol of nor-communicable diseasss Natrtion edveation and counseling for population gious Module 3. FNRI- Dost, 2009 2. WHO expert consultation. Appropriate body-snast-index tor Asian populations ‘nd its implications for policy and intervention strategies, Lancet 2004157 163, 3. FNREDOST, Food exchange lists fr meal planning. FNREDOST. 1994 18 MICRONUTRIENT SUPPLEMENTATION: IRON, FOLIC ACID AND IODINE Joseph U, Olirar, MD, FPOGS FPSMFM |. Iron Supplementation oral iron and folic acid supplementation is recommended as part of the antenatal care to reduce the risk of low bicih weight, maternal anemia and jon deficiency." (Level I, Grade A) Tale 1. Suggested scheme for daily ron supplementation in pregnant ‘Supplement composition | Tron: 30-60 mq of elemenal iro? “| otic aca: 400 Frequency ‘one supplement daily | Duration throuhour prepay iron supplementation should begia as carly as posible Target e00p all pregnanc adolescent andadul ‘Tuble2. Dorcentage and amount of icon in come commonly used iron [Preparation Tron compound (ng pertabet Femousfamarste Fen luonate roa salve “Tous sulfate, anny {Hers suf, exit HD 2. In settings where the prevalence of anemia is < 40%, 30-60 mg of elemental iron with 400 pg (0.4 mg) may be used for a minimum of months. Avoiding iron supplementation during the 1" trimester ‘of pregnancy avoids the risk of aggravating nausca and vomiting, (Level IL, Grade B) 19In settings where anemia in pregnant women is a severe public health problem (40% or highe:), a daily dose of 60 mg of clemental iron with 400 jg (0.4 mg) of folic acid is preferred over a lower dose (30 mg). ‘Supplementation is started as early 2s possible. If there is nausea and vonniting during the I* trimester, iron supplementation is started after 14 weeks and consumed for a minimum duration of 6 months. Tron supplementation is, continued up to 3 months postpartum. (Lave! IF-1, Grade B) If a woman is diagnosed with anemia in a clinical setting, she should be treated with daily iron (120 mg of elemental iron) and folic acid (400 yg or 0.4 mg) supplementation until her hemoglobin concentration rises to normal.? She can then switch to the standard antenatal dose to prevent recurrence of anemia. (evel IL-1, Grade B) Where iron supplements containing 400 pg of folic acid are not available, an iron supplement with less folic acid may be used. Supplementation with less folic acid should be used only if supplements containing 400 wy are not available. (Level 1-1 Grade B) Iron supplementation is doubled (120 mg of elemental iron) she is large, has twin fetuses, begins supplementation late in pregnancy (minimum of 6 months supplementation cannot be achieved) and has been taking iron irregularly. (Level I, Grade 8) Inaddition to iron and folic acid, supplements may be formulated to include other vitamins and minerals according to the United Nations Multiple Micronutrient Preparation' to overcome other possible maternal micronutrient deficiencies, (Lew! IF, Grade B) In malaria-endemic areas, provision of iron and folic acid supplements should be implemented in conjunction with measures to prevent, diagnose and treat malaria.'* (Lew! Il-1, Grade B) I, Neural Tube Defect and Folic Acid Supplementation 9. For women at high risk of having a child with a neural tube defect (NTD) (buch as those with a personal history of NTD, a prior child with a NTD, or those on anticonvalsant medications), give a supplementation of 5 mg folic acid daily prior to conception, 20 10. throughout pregnancy and during the postpartum period. (Level I Grade A) For all other reproductive-aged women, give 0.4 to I mg folie acid daily prior to conception, throughout pregnancy, and during the postpartum period. (Level 1, Grade A) ble 3 Recommendations for fol acid supp! Om Po R | Pas risks, family history OE NTD, high-risk | extaie soup | | Patienis with no personal health fisks, planned pregnancy oO Pationis wit ton | with medications, additional lifestyle dict, no consistent birds contol, and possible teratogenic Folic Acid Dose i) Fotatewieh | foods, with daily supplementation | SUSE RIES | @Daity supplententation vith O41 mg fle Shere a Jaie.rich foods, with daly supplementation with 9 mg folie acit | | | | of poor compliance | | Substance use TI. Iodine Supplementation | acid supplementation to in pregnancy Daration of Supplementati Ci) Hepinning at Teast 3 months before conception and continuing und 10-12, weeks posteonception (2) From 12 weeks preconception and ‘continuing throughout pregnancy and the pospartam period (46 ‘weeks ora longas breastfeeding continues) ‘Acleast 23 months before conception and ‘Hheoughout pregnancy the pastpartum period (46 weeks or as Toag as breastfeeding ‘Counsel about folie 11, ‘The recommended 250g daily intake is met by the diet of Filipino prepregnant, pregnant and lactating mothers. No additional supplementation is sequired. (Level I-1, Grade B) anSupporting Statem Iron Supplementation ‘The updated Cochrane systematic review" assessing the ben and harms of iron supplementation in healthy pregnant women were reviewed for this guideline. ‘The review compared the daity provision ‘of iron supplements alone or in combination with folic acid or other micronutrients with no intervention, placebo or versus the use of the ‘same supplements but without iron (e.g, only folie acid) among pregnant ‘women living in a variety of settings, including malaria-endemic areas, Overall,” women taking daily iron supplements were less likely to have low birth weight babies compared with controls (average relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.97, II studies) and the mean birth weight was 30.81 g greater for those infants whose ‘mothers received iron during pregnancy (95% C1 5.94-55 68, |4 stuclies) ‘There was no significant effect on preterm birth or neonatal death Daily iron supplementation reduced the risk of maternal anemia at term by 70% (RR 0,30, 95% CI0.19-0.46, 14 trials) and iron deficiency at term by 57% (RR 0.43, 95% Ci 0.27-0.66, 7 studies), but it had no significant effect on the risk of infections during pregnancy (RK. 1.16, 95% CI 0.83-1.63, 2 studies). Women receiving iron had 8.88 ¢ more hemoglobin per liter at or near term (95% C1.6.96-10.80, 19 studies) than those who did not receive iron, At the same time, women who received iron supplements tended to report more frequently side effects (RR 2.36, 95% CI 0.96.5.82, 11 studies) and were at increased risk of high hemoglobin concentrations (ie. greater than 130 mg/L) during the 2" and 3% trimesters of pregnancy (RR 2.26, 95% CI 1.40-3.66, 10 studies) The intervention seems (0 be eflective among populations with different prevalences of anemia, and in settings deceribod ae malaria endemic, when compared with scitings where malaria is sporadic of absent, and regardless of whether the supplementation was initiated earlier or later than 20 weeks of gestation or whether the daily dose of elemental iran was 30 mg or less, 31-59 mg, or 60 mg or higher However, women receiving 60 mg of iron or more were more likely to have hemoglobin concentrations above 130 g/L and report side effects (RR 6.52, 95% Cl 1.13, 37.69) than dose women receiving 30:mg per day or less (RR LO1, 95% CL0.84-1.21), _ The overall quality of the evidence for icon supplementation versus no iron was moderate for low birth weight, preterm birth, maternal 2 IL anemia at term and maternal iron deficiency at term. The evidence was of Jow quality for birth weight, neonatal death, congenital anomalies, ‘maternal death, maternal severe anemia, and infections during pregnancy; whereas it was of very low quality for side effects. Neural Tube Defects and Folic Acid Supplementation” Folate (vitamin B,) is an essential nutrient that is required for deoxyribose nucleic acid (DNA) replication and.as a substrate fora range of enzymatic reactions involved in amino acid synthesis and vitamin ‘metabolism. Demands fos ‘alate increase during pregnancy becausc itis also required for growth and development of the fetus. Folate deficiency has been associated with abnormalities in both mothers (anemic, peripheral neuropathy) aad fetuses (congenital abnormalities). Dietary Supplementation with folie acd around the time of conception has tong, teen known fo reduce the risk of NTDs in the offspring ”"* ‘The term foie is typically used as a genetic name for the group of chemically related compounds based on the folic acid structure, Folate, ‘or vitamin B, is thought of as one of the 13 essential vitamins. It cannot be synthesized de noo by the body, and must be obtained either from diet or supplementation. Folic acid is a synthetic dictary supplement that is present in artificially entiched foods and pharmaceutical vitamins. Neither folate nor folicacidis metabolically active. Both must be reduced to participate in cellular metabolism. —L- (L-methylfolate) is the predominant micron circulates in plasma and that is involved in biologic processes. Benefits of Folic Acid Supplementation During Pregnancy | 1. Periconcoptional folic acid supplementation protects against | feial siructural anomalies, including NTD and congenital heart cdefects."228 2. Folate is one of the key nutrients for active erythropoiesis because Of its role in DNA gynthesis, In settings of low folate, anemia will likely ensue. During pregnancy, the expecied blood volume expansion requires an additional 450 ml of erythrocyte.” Without iron and folic acid supplementation, the pregnant woman suffers from anemia 3. Indirect evidence suggests that folate may indeed be important in the timing of labor. In one observational study; a shorter duration of pregnancy has been associated with low serum folate level. 23ml, 4. Because folic acid has been shown (o regulate trophoblast invasion, itis biologically plausible that folate deficiency may interfere with the eaily stages of placental development leading to complications like preeclampsia, abruption placenta, fetal growth resitiction, and even fetal death later in gestation, Iodine Supplementation Universal saltiodization (USI) remains the key strategy to eliminate iodine deficiency disorders. According to World Health Organizaiton (WHO), although programs to control iodine deficiency, such as salt iodization, have been effective for decades, iodine deficiency remains a major threat t0 the health and development of populations around the world, particularly among pregnant and laciating women and preschool chikiven in low-income countries. Tedine deficiency occurs when iodine intake falls below recommended levels and the thyroid gland iso longer able to syathes: sulficient amounts of thyroid hormone. ‘The resulting hypothyroidism (goiter) can occur at any stage of life, but the most devastating consequences of iodine deficiency take place during fetal development and childhood, with stillbirth, miscarriages, poor growth, and cognitive impairment, Although cretinism is the most extreme manifestation, of considerably greater significance are the more subtle degrées of metal impairment that lead to poor school pesformance, reduced intellectual ability, and impaired work capacity. Iodine deficiency is the world’s greatest single cause of preventable brain damage, and this fact is the primary motivation behind the current worldwide drive to eliminate iodine deficiency. The WHO Technical Consultation’ proposed tke daily recommended nutrient intake (NI) for iodine for pregnant and lactating ‘women, alle ‘The daily RNI for iodine proposed for pregnant and lactating women. should not to be exceeded, Population Recommended iodine | Level of iodine beyond intake which no added heath (uz day) benefit can be expected Lo og day) Pregnant women 30 Soe Lacating women 250 5500 u Most of the iodine absorbed by the body is eventually excreted in. the urine, although there may be small losses in feces. Although the concentration of iodine in the urine of an individual ean vary diurnally ‘and from day-to-day, the concentration of iodine in spot or casual samples Of urine taken fiom an adequate sample of schoolchildren has been shown to be a reliable biochemical marker of recent dietary intake by the ‘general population of the same area when measured using recommended methods.” For this reason, itis proposed that the median urinary iodine (UL) concentration was the best indicator to use in population surveys to assess the iodine nutviion of pregnant and lactating women, and of young children less than 2 years old Table 5. "The median or range in UL concenteations used to categorize the iodine intake of pregnant women, Lactating women and chikdren less than 2 years old. “opuiation G intake [ Pregnant women Tadaiing wom? “tin lactating women, the figures for median ULare fower than the fodine requirements reas? ofthe eine excreted inthe breast mk Where iodine deficiency is a public health problem, countries can be divided broadly into three categories based on national salt iodization coverage. + Category 1. Counties oF regions within countries in which iodine deficiency is under control ina sustained way because sal iodization has heen effective for more than 2 years. This is indicated by the fact that iodized salt is consumed by more than 90% of households ‘and that iodine nutrition is optimal according 10 WHO caiteria, including in pregnant women and children less than 2 years old. = Category 2. Countries or regions within countries in which not all salt is iodized, salt iodization is not regulated, or the distribution of iodized salt is uneven or has lapsed so that less than 90% of the households consume iodized salt and iodine nutrition is inadequate. © Category 3. Countries or regions within countries in which 25iodized salt is either not available or available only to a negligible extent, cither because the distribution system is weak or because an emergency has severely disrupted iodized salt supplies. In this category, it is assumed that less than 20% of the households coasume iodized oil and iodine nutrition is inadequate. Nowe: 1, In Category 1, the population is considered to be iodine sufficient, so pregnant and lactating women have no need for iodine supplements, not do children aged 0-24 months old reuire them, Indeed, the amount of iodine stored in the thyroid of a child at birth, when added to the iodine intake from the mother's breast milk, is likely to be sufficient to meet a child's need for iodine for the first 6 months of life and even up to 24 months af age 2. The Philippines, according to WHO report in 2007, has a median UL concentration of 200-299 1g. Itbelongs to Category | with risk of ioc induced hyperthyroidism, REFERENCES: WHO/CDC. Worldwide prevalence of anemia 1995-2005. WHO Global Database on Anemia. Geacva, World Health Organization, 2608 2. WEIO/UNICEE/UNU. Iron deficiency anemia assessment, prevention, and oat: a guide for program managers. Geneva, World Health Organization, 2001 4 Hemoglobin copcenation fr the diagnesis of anemia and assesment of severity. Vitamin and Mineral Nuttin fnermation Sse: Genew Went Health Orgunesion, 211 4. Iotecnstional Anemia Consultative Group, Report ofthe 2001 Internationa ‘Anemia Consalatie Group Sympcsan Why’ ion imertan and What © Wgatoue i new perp. Washinton DC INACG Seer 1 LozoWB,SinenexE Sint I. Dbl den of iron define in il snd low scioeconoi ta ongtudal ants of coi tet saree Tage 19 yeas Arch Pest Adolescent Med 2006, 10211081113 6 Murpty ta tation of hemoglobin evel intend Second tress Ahonome Lance, 1, 3992.98 7. Steer PI, Maternal hemoglobin concentration and birth weight. Am Chin Nur 20007 (Supp. §):81285 $1287. International Anemia Consultative Croup. Guidelines forthe eradication of iton deficiency anemia, A report of the Inernationst Nutritional Anemia 9, Gonsliatine Grosp, Washington, DC, The Mutrkion Foundation, (977129. hiro Bia dy cae pra forma nd eho ath ded to. lmao ula, Washingon, UC, Pan Annas Ha (Organization, 2007:1-4. me 26 a 2 23 m4 2s 26, 2, othell TH. ron requirements in pregnancy and strategies to meet them. Aw IClin Nutr 2000, 72(Suppl. 1)8257-S264. Stoltzs RJ, Dryfiss M. Guideline for the use of iron supplements to prevent and teat ivon deficiency anemia. International Nutsiional Anemia Consultative Group. Iron deficiency anemias; Report of a WHO study group. Geneva, World Health Organization, 1959 WHO Technical Report Series, No. 182 WHO. Guideline: Daily iron aad folic acid. supplementation in pregnant women. Geneva, Works Health Organization, 2012 UNICEF, WHO, UNU. Composition of a mult-micronutrien supplement to be used in plot programmes among pregnant women in developing counties report of a United Nations. Childrens Fund (UNICEF), World Health 1m (WHO), United Nations University (UNU) workshop held at UNICEF Headquarcers New York, July 9, 1999, New York, United Nations Global malaria report 2011, Global Malaria Programme. Genera, World Health Organization. Pefa-Rosas, ct al Daily oral iron supplementation during. pregnancy Cochrane Database Syit Revs, 2012, Issue 12. Art No: CDC04736, DOL zou F, Vaa Allen Mi, etal. Reduction in newraltube defectsater ‘acid fortification ie Canada, N Eng) J Med. 2007387: 135-142, Greenberg JA, Bell $1, Guan Y, Yu YH. Folic acid supplementation and a just neural ube defect prevention, Revs Obst: Gynecot pregnancy. Ai J Obstet Gynecol 1960;79: 750-757 Bodnar LM, Himes KP, Venkataramarsn R, etal. Maternal serum folatespecies nearly pregancy and isk of preterm birth. Am J Clin Nutr 2010,92;864-871 ‘Williams PI, Bulmer JN, Innes BA, Broughton Pipkin F. Possible oles for fic acid in the egulation of trophoblast invasion and placental development in ‘normal early human pregnancy. Biol Reprod. 2011;84:1 148-1133, ‘Wilson RD, Jodinsoa 34, Wyatt P etal; Genetics Commitee of the Society of Obstetticians and Gyncecologiss of Canada and the Mother Risk Program. Preconception vtamin/folic acid supplementation 2007; the use of folic cid in combination wih 1 multivitamin supplement for the prevention of neural tie eecte and other congenital anamalieg Oheter Gynaecol Can 2007;29:1008-1026, de BenoistB, McLean E, Anderssen M, Rogers L. Iodine deficiency in 2007 ‘Global progress since 2003. Food and Nutrition Bulletin, 2008;290) “Andersten Mi, de Beno’ B, Delange , Zapan J. Prevention arxl contol of fosine deficiency in pregnant and lactating woren andl in children fess than years old: conchusons and recommendations ofthe Technical Consolation, ‘WHO 2007. WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency Disorders ant Monitoring Their limination, A. Guide for Programme Menagers (WHO/NHD/01.1), 234 ef. Geneva’ Wor'd Health Organization, bup:// ‘worwsrho.int/at/ Docaments/assersment idd_monitoring. elimination. ‘The Recommended Erergy and Nutrient Intakes for Filipinos: FNRI and RENI for vitamins and inerals 27MICRONUTRIENT SUPPLEMENTATION: VITAMINS, MINERALS AND ELECTROLYTES Joseph U. Olivar, MD, FPOGS FPSMFM, FPSUOG Ramon I. Reyles, MO, FPOGS, FPSMFM, FPSUOG Recommendations I, Vitamins and Minerals Preconception 1, The recommended daily nutrient intake (RNI) of vitamins, minerals and trace elements during the preconception period are shown in the following table: (Level I-1, Grade B) Thiamine F (me) (ug) to | 400. Ld 400 i 00. =u 400. K wp | a 30 31 Et Twoa | Todiae | Magne: [Phos | Zine | Site ameae wu) | og | sium | pores | (mm | aim | side | nese 7 ca_| "aed D [imp |e a ee 27 |— 3020-0 Ss] [“16 liso | a0 0 ass z7_|1s0—| 05 [mo [ass] 2st ta from Recommended Energy ad Nutrient Intakes or Filipinos 2003 28 Prenatal 2. The recommended daily intake of vitamins, minerals and trace elements during prenatal period are shown in the following table: (Level II, Grade B) ‘Table 4. RNI of Water Soluble Vitamins by Trimester Trimester | Vit.C | Thiamine | Riboflavin | Niacin | Folate of (ma) (mg) amg) (mg) Ge Pregnancy — tes | moar |e Second [wo | 14 i | 600 (kit [sofa 600 Dia fi ReconamendEengyaadMeriot Tatas for Fiipvos 200 ‘Trimester of Pregoancy Third Daa fom Revo dod reg and int Takes fr Flips 200° RNLof id Trace Elements by Trimester Trimester | Cokin | toa | todioe | Magn Zine | Sele etree | tae) | rs) | Gx) | stom | phew | (og) | ive ancy dl fp _| "oe |_| Fist won| | mm | 205 | oo [at | 3s Seoad [eon | 34 | 200 | 205 | 100 [oo | 3s Te ‘aon _| 36 | ao0_| 205 | ~m00_ [96 [a5 [2s ‘eta on Reade Feo Nis or Pps 20 Postpartam 3. The recommended daily intake of vitamins, minerals and trace elements during the posttpartum period are shown in the following table: (Lev! II, Grade B) ‘Table 7 RNL of Water Soluble Vitamins lactation period Tadiation | ViteC | Thiamine | Riboflavia | Niace | Folaie | Vit Be “| doy | tong) | tong) | om) | og) | tome E omans | | 15 a 17 | so | 20 = Génie | 10 | 15 7 17 | so | 20 | 28 ata Fr: Recnmmnded Energy ad Tria Tbe or Filipinas 2002” 29‘Table, RNI of Fat Soluble Vitarnins by lactation period ‘Lactation | ‘Vit. vVit.D Vite Vit. K (ng) (os) (mg) (ue) Fémonis mi) 5 2] 26 moms ws 2 | a Dita Fon Recowonodl gy ant Nae Tes Flips 2 Table 9. RNL of Minerals and Teace Elements by Lactation Period Tacit | Cal Tedlae Mage | Phow | Zine | Sete | Pore | Manga | on” | ood | rhonss | (oi) | aim | fwd | ace oa)_| ed os) ro) wo | w |us| w | 2s | 26 20 | 0 w | 2s | 2 TI, Water and Electrolytes 4, To meet the minimum physiologic requirements of the fork female condition the table below gi ‘minimum daily water ing s the recommended wd electrolyte intake. (Level 1-1, Grade B) Table 10. Recommended Minimum Daily Water and Blectrolyte Intake. Water | Sodium | Chloride | Potassium im | @o | me (ms) ‘Adult > 18) 2500 500 750 2000 Pregnant +300 | 500 750 2000 Lactating 1" 6 months +750. 500 750 2000 1 ‘Data frorn Recommended Energy and Nuarient Tuiakes for Flipaas 200 Supporting Statements 1. Vitamins and Minerals Vitamin C ‘The 1989 Recommended Dietary Allowance (RDA) which was based on the amount that would maintain acceptable serum vitamin C 30 levels in Filipino men and women, is retained. These values are higher thanthe Food and Agricu'ture Organization / World Health Organization (FAO/WHO) RNI which is based on intake associated with adequate liver stores and associated with antioxidant protection. '* hia (Vtanin BL) “The Institute of Medicine, Food and Nutrition Board ((OM-FNB) (1998) and FAO/WHO recommendations (2002), which are both based ‘on the average requirement for normal erythrocyte transkctolase (ETK) activity and urinary thiamine excretion and twice an assumed coefficient of variation (CV) of 10% to cover the needs of 97.5% of individuals in the group, are adopted. The IOM-FNB and FAO/WHO-detived estimates, adjusted for Philippine reference body weights, are similar to the 1989 RDAs which were then based on 2 local study done in the 60s ‘on 10 adult Filipinos? Riboflavin (Vitamin 812) “The RNI is derived from the vequizement estimate of the JOM-FNB (1998) which is based on the amount of riboflavin intake to maintain riboflavin status of satisfactory erythrocyte glutathione reductase activity (EG-AC) level, as criterion of adequacy, These intake levels, which conform with the FAO/WHO tecommendations (2002), are close to the 1989 recommendations which were based on requirement estimates ‘obtained from Filipino adults consuming rice-based diets." Niacin ‘The FAO/WHO (2002) and IOM-FNB (1998) estimates, which are based on the ariount of niacin intake corresponding to an excretion (of N’methyl-nicotinamide that is above the minimal excretion at which deficiency symptoms occur, are also adopted for Filipinos. ‘These values are lower than the 1989 RDA because no correction is made for ‘inavailahility. The bioavailability of niacin is not considered in setting the RDA because of “lack of data on which to base the correction value” (IOM-ENB), 1998." Pyridoxine (Vitamin B6) “The RNI foradulisof 1.3 mg/day adopted by the FAO/ WHO (1998) is based on the amount required for normalization of the tryptophan load test? Cobalamin (Vitamin B12) ‘The IOM-FNB recommendation of 2.4 ug/day is based on the amount needed to mainain adequate hematological status? 31Folate ‘The FAO/WHO (2002) and [OM-FNB (1998) recommendations aze also adopted for Filipinos. ‘The requirement estimates of these two bodies are derived from the amount of Folate that will maintain adequate folate stores based on erythrocyte folate and plasma homocysteine levels. ‘To meet the new higher recommendations, higher intakes of vegetables and fruits, which are among the best sources of folate, arc recommended. Vitamin A ‘The recommended intake levels for vitamin A correspond (0 the sale levels of intake based on the average amounts of vitamin A required to mainiain a given body-pool size in well-nourished individuals. For adults, the RNI is equivalent to the estimated average requirement plus 28Ds. The Committee therefore adopts the higher recommendation sven by the FAO/WHO (2002)."? Viuarsin D The FAO/WHO and IOM-ENB recommendation of 5 jg/day for adults is based on the amount of vitamin D intake necessary to maintain vitamin D status as indicated by a satisfactory level of serum 25-hydroxy- vitamin D (25-OH-D). ‘The recommended intake levels, according 1o the [OM-FNB, will cover the needs of adults “regardless of exposure 10 sunlight." Vitamin E The safe level of intake for vitamin E for adults is 12 mg/day, ‘The term “safe” rather than “recommended” is used since the valve is derived from data for the United States (US) population whose mean PUFA intake can be presumed to be higher than that of Filipinos since the major source in the Filipino diet is the mecium-chain saturated fat ich coconut oil, High intakes of PUFA are typically accompanied by increased vitamin F intakes.'26 Vitamin K ‘The FAO/WHO (2002) Expert Pane''s recommendation set a daily intake of 51 e/kg as basis for setting RNI. The pane! also advised that all breastfed infants should receive vitamin K supplementation at birth according to nationally established guidelines. Cokeium The RNIs for Filipinos are allowances based on theoretical calcium requirement estimates which considered low animal protein intake levels, 2 ‘The FAO/WEEO (2002) provided these estimates for possible application to countries where the animal protein intake per capita is around 20-40 ‘only compared with 60-8) g in developed countries"? Ton ‘The recommended intake for iron is based on the amount of dietary iron needed to meet absorbed iron requirements, ‘This would correspond fo the amount acceded to cover menstrual losses for women of reproductive age, acjusied for bioavailability of iron in typical complete meals consumed by Filipinos. The Philippine RNI for iron is based on FAO/WHO (2002) estimates for basal losses, local data ‘on menstrual fosses and on bioavailability, iron absorption rates in the average Filipino diets, food consumption surveys, and in-vitro studies fon non-heme iron availability from rice-based diets. ‘The consumption of iron-rich foods and iron-fortified foods is recommended for women from adolescence onwards, Iron supplementation is recommenced to meet the needs of pregnant and lactating women. ‘The estimated iron requirement during the I" trimester of pregnancy and the 1* six months of lactation are actually lower than the requirement for menstruating nonpregnant, nonlactating women. However, the recommended intake for nonpregnant and nonlactating women are adopted (0 allow for bui up of iron stores during these periods." oie The FAO/WHO 2002) recommendations which concur with those of the IOM-ENB are adopted for all population groups, except pregnant and lactating women, The recommended intake level for adults corresponds to the intake necessary {0 maintain plasma iodide level above the critical limit likely to be associated with the onset of goiter. It corresponds to the daily iodine urinary excretion of 100 g/L." Phosphons ‘The RNIs are based on the intake required to maintain serum inorganic phosphate within the normal range? Seleniunt ‘The FAO/WHO recommendation (2002) of 31 g/day corresponds tothe level of intake that provides adequate reserves based on satislactory levels of plasma selenium, and of glutathione peroxidase activity.'* Magresiunt ‘The FAO/WHO rerommendation (200) is based on a requirement of 4 mg/kg body weight/day for adults to achieve a positive magnesium balance." 3Mangonese ‘The IOM-ENB recommendations (2002) is based on the median intake of Americans derived from the US Food and Drug Administration (FDA) Total Diet Study from 1991-19974 Line ‘The requitement for adults is based on the intake that will meet the daily absorbed zinc requirements of 0.072 and 0.059 mg/kg for adult males and females, respectively, and adjusted for bioavailability of 30% following the recommendation of FAO/WHO (2002).'* Fluoride IOM-ENB recommendations are based on “adequate intakes” that hhave been found to prevent dental caries.” TL, Water and Blectrotytes ‘The recommended water intake for adults under average conditions of energy expenditure and environmental exposure is 2500 mL, based on a recommended intake of 1 mL. per keal of energy expenditure (NRC, 1989). Temay be increased 10 3735 ml (1.5 mL-/kcal) to cover variations in activity level, sweating, and solute load. ‘Thisst is normally good indicator of the amount of extra water needed to meet the daily requirement, except for older persons whose thirst mechanism may be impaized, For infants, @ recommended intake of 15 mL/keal of energy expenditure, which corresponds to the water-to-energy ratio in human milk, has been established asa satisfactory level for the growing infant. The minimum requirements for electrolytes do not include allowance for large, prolonged losses from the skin through sweat, Therc is no evidence that higher intakes confer any health henefit, For adults (> 18 yoare old), desirable intakes of potassium may considerably exceed the minimum recommendations (~3500 mg). For children (< 18 years old) a growth rate of 50 percentile reported by the National Center for Health Statistics and averaged for males and females is assumed ([OM-FNB, 1989)."? REFERENCES: 1. Food and Agricultural Onganization/ World Health Organization (FAO/ WHO). Human vitamin and mineral soguirements, Report of a joint FAO/ WHO expert consultation, FAO/WHO. 2002, 34 6 Barba C, Cabvera MI Recommended enesgy and nutrient intakes for Filipinos 202. ASia Pac Clin Nutr 200831 7(823.599-408, Institute of Medicine, Food and Nutrition Board (|OM-FNE) 1999, Dietary refecenees intakes for calcium, phosphorus, magnesium, vitamin D, and Auoride: National Acad:my of Sciences, Weshington, DC. Institute of Medicine, Foed and Nutition Board, COM-FNB). 2001 Dietary reference intakes for vitsmin A, vitamin K,stseni, boron, chrarnive, copper, iodine, ito, manganes, molybdenum, nick), silicon, vanadium, and eine National Academy of S:iencrs, Washington DC. Instinte of Medicine, Food and Nutrition Boat, COM-FND). 1998. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin BS, folate, vitamin BID, panthotenic acid biotin, and choline. National Academy of Sciences, Washinggon DC. Insitute of Medicine, Food reference intakes for vita ‘Academy af Sciences, Ws ‘selenium, and carotenoxds. National 235APPENDIX 1 BURDEN OF UNDERNUTRITION: HEALTH RISKS FOR THE MOTHER, FETUS AND CHILD Rosa Niner Velante-Nierva, MD, FPOGS, FPSMFM, FPSUOG Undernut n can be classified as either Malnutrition Micronutrient deficiency Uncernutrition of the motlier and child is the single leading eause of health loss worldwide and the underlying cause of more tha: fone-thitd (3-5 million) of all Nutritional insults during critical periods of gestation may have @ permanent effect on progeny throughout postnatal life and beyond ®%? Health Risks for the Mother Women who are undernourished (with body mass index [BMI] of < 18.5 kg/m’) at the time of conception are ualikely to improve their nutvtional status daring, pregnancy, when their bodies have additional demands due to the growing fetus. ‘They may fail to gain sufficient weight during pregnancy and have higher tishs of Maternal morbidity and mortality Anemia ~ with subsequent increased risk of preterm birth Infection Poor pregnancy outcome Health Risks for the Fetus and Newborn Baby Intrauterine growth restriction (IUGR) fetuses resulting in low birth weigh (< 2.5 kg) infants. Undernourished women may lack the ‘uttitional stores required to support embryonic and fetal growth ‘nd in turn adversely affect the development of the fetus in the later 36 stages of pregnancy, Maternal undernutrition also reduces fetal growth in part by impairing placental development and function, Fetal hormones following maternal undernutrition emerges as a major contributor also to suboptimal feral growth and development Programmed changes induced by altered fetal hormone activity in- "utero can affect newborns and eventually yield disordered responses in adults." Evidence has shown that there is a greater incidence of IUGR births among women who are underweight or stunted prior to ‘conception, or who fail to gain sufficient weight during pregnancy, compared to women with normal weight and weight gain. ‘The meta-analysis repo:ted that a pre-pregnancy BMI below 20 kg/m? was associated with a significantly greater risk for TUGR, relative to a BML above 24 kg/m:, with an overall odds ratio (OR) of 1.8 (25% confidence interval [Ci] 1.72.0). In developing countries, it has been estimated that poor nuttitional status i pregnancy accounts for 14% of feruses with IUGR, and maternal stunting (chronic restriction of growth ia height indicated by a low height-for-age) may account for a further 18% IUGR in turn could increase the tisk for fetal and neonatal mortalities.*9* Birth defects Underdevelopment of some organs Cretinism Brain damage Health Risks for the Child in the Long Term Substantial epidemiological evidence links low birth weight, a rough indicator of TUGR, with increased risk of infectious morbidity and Malnourished girs are at risk in becoming yet another malnourished mother, thus contributing 10 the intergenerational cycle of ‘malnutrition. Women who had been severely undernourished during the 1* trimester gave birth to (on average) normal birth weight infants, but those infants gave birth to sinaller offspring in the following generation, Children who ate stunted or born with IUGR are also shown to complete fewer years of schooling and carn less income as 37 | |adults, hindering their cognitive growth and economic potential Maternal malnutrition results in. precocious maturation of the fetal hypothalamic pituitary axis, and these effects are associated with a delay, if not a permanent deficit in cognitive processes, motor skills, atention deficit disorders and school performance of affected ‘children. Failure of the fetus to develop optimally because of nutritional deprivation does not lead to immediate brain dysfunction, Rather, manifest only as predispositions until a time when the system is stressed by unusual circumstances Lower income, poor health, and reduced access to proper nutttion then continue to impact the health of children born into the next gencration, establishing a repetitive cycle. 424? There is a solid research evidence that low birth weight infants with stunting, severe wasting in the fist two years of life cause inreparable/irreversible harm by impeding physical growth and if followed by rapid weight gain in the 3-3 year age range could increase the risk of chronic/ metabolic diseases later in lif When a fetus is malnourished in the early (and later) stages of pregnancy it may also have a lifelong metabolic programming effect ‘which predisposes the baby to chronic health conditions Later in life. Metabolic disorders including: © Type 2diabetes melts ~ men who were born at a very low weight were seven times more likely to develop diaberes ‘mellitus compared to men born ata high weight © Dyslipitenia © Impaired enengy homeostasis © Obesity © Cardiovascular dsonders ~substudies have shown that birth weight parallel tends with biological risk factors for cardiovascular disorders . Exposure to maternal malnutition in the 1* uimester of Pregnancy was associated with an increased risk of obesity and coronary heart disease, while malnutrition in the or 3" trimester was associated with type 2 diabetes mellitus © Invmune mediated and inflammatory diseases — maternal ‘malnutrition may also have a direct influence, as evidenced by nutrient-driven epigenetic changes to developing T regulatory cells and subsequent risk of allergy or asthma. Early alterations to the immune system, resulting from either nutritional deficiencies or excesses, have broad relevance for immune-mediated diseases and chronic inflammatory conditions. a8 Health Risks Associ (Other long term health risks: Chronic kidney failure Chronic obstructive pulmonary disease Polycystic ovarian syndrome Organ dysfurction or abnormal development of organs including the testes ovaries, brain, heart, liver, small intestine and mammary gland Breast cane Osteoporosis Psychiatrie disorders including schizophrenia ted with Micronutrient Deficiency It was subsequently recognized that poor growth results not only from a deficiency of protein and energy but also from inadequate intake of ‘micronutrients that are vital during ra id growth phast Maternal health risks Tron-deficiency anemia in turn increases the risk of (© Maternal morbidity and mortality such as death from peripartum hemorshage (© Preterm birth (© Neurological dysfunction Vitamin A deficiency ~ is associated with night Vitamin B12 deficiency is associated with the following risks for pregnant women: Anemia © Neurological complications Vitamin K deficiency is associated with increased clotting time which presents particular risks during delivery Todine deficiency is associated with © Abortion © Stillbirth Zine deficiency is zssociated with: © Pre-eclampsia 39Fetal 6 Premature rupture of membranes © Preterm delivery ‘+ Magnesiua deficiency increases the risk of: © Preeclampsia © Preterm delivery * Vitamin C deficieney may play a role in preterm delivery ctiology!27"" ‘and neonatal health risks + Folatestatus in early pregnancy depends on preconception nutrition, Marginal maternal folate intake status can impair cellular growth in the fetus or placenta. Folate deficiency in carly pregnancy is associated with neural tube defects and has been linked to low bisth weight, IUGR, and preterm birth, lion deficiency which causes maternal anemia is associated with IUGR and low birth weight. Iron deficiency can also affect the absorption of folate. As folate absorption is most critical in the carly stages of pregnancy, ensuring adequate preconception iron status is also important, Calcium deficiency ~ restricts fetal skeletal development ‘+ Maternal vitamin D deficiency is associated with fetal rickets Maternal iodine deficiency is associated with the followi complications inthe infant: #270 © Congenital abnormalities Increased perinatal mortality Neurological cretinism Mental deticiency Myxodymarous cretinism (a type of cretinism in which Physical development is impaired) and dwariism (very short stature) © Psychomotor effect (afected! movement) cece Maternal zinc deficiency is associated with: © IUGR © Congenital abnormalities 40 REFERENCES 1. Maternal and Child Usdermutition, WHO, 2013, 2. United Nations System, Standing Commitee an Nutition, 2009 3, Abu Sua K, Fase D. Muernel Nesrtion and Birth Onteomes ‘Accepted fnsery 8, 2016 4 Reacemi 1, Neloon MM Moterat Undereurion Tajlunces Placer Peta Deswlopmnas. Society forthe Smaly of Repeat, In. 2010 5. Maternal Natriton During Pregnancy ane Lactation join pucaton: Brosfvding, LAU, Related Cornplewentery Feoing, and Moteral Nutrition Program and the (Chill Survivel Colabontions aned Rescues (CORE) Nurtin Working Grow ‘Aug 2006 6 Impact of Maternal Metron 00 Real HEALTH ODYSSEY ~ PRENATAL NUTRITION Report, Deore 2010 7 Black RE, Maternal anal Child Underwavtion Study Group. Maternal and child marion: bling mero for inp. Lane 2013 Black RE, Maternal and Child Undermertion Seady Grog Maternal nokia tasderearhion: glbal and gional exporures and heath conssywences Lance 2008 379603) 243-260 9 Mice-Looy O, Rolling Steno J, Yeung A Lang tem heat consequences ef poor ‘muriion daring prynac. Ttolgy. Universe of Mebourre, 2008, 0 Executive Sunnmary Sens String Commit: Blact RE, Adair , Aboud B, Celt BT Lancs Series Maternal end Old Undrmutriton 2008. 11, Blosser M, de Onis M, PruseUstun A, Compbdl Londeane D, Corvalan Cota ‘Malnasrion, Quamifeg the heals impect at rational and Toa! levels. Wecvard nd Healt On rt for Heath Dee Proton of the Munuen Enviroment Geneve 2005, 12, National Institute for Heath and Clinica! Kxeslnce, Ingrving the heat and imation of pregnant an boustingmotersandchilden i lor-acoe housed 200, fied 2008, wus 22), Ava fm worn. Nice on uk/ PHO, 41APPENDIX 2 CONSEQUENCES OF OBESITY AND. OVERNUTRITION IN PREGNANCY Joyceline Noemi Silao, MD, MHA, FPOGS, FPSMEM Erffects of Overweight and Obesity on Fertility and Conception The presence of excess adipose tissue in obesity affects sex hormone availability due to its ability to store lipid steroids such as anda Estrogen production and the concentration of sex hormone binding, slobulin in the blood are correlated with various meastites of body fat? There also seems to be a strong association hetwey insulin resistance, which is thought to reduce fertility.” Excessive weight gain at younger ages is associated with earlier ‘menarche and both high absolute weight and change in weight are associated with menstrual problems, Obesity in adolescence and young adulthood, as opposed to during infancy, is more strongly associated with amenorrhea, oligomenorrhea, and long menstrual cycles.’ obesity and Therese rds an inosine concn aes compared wih normal-weight women, paola among igre smokers.” * " ae Obesity is a stong risk factor for poetic evarian syndrome (@008), which relly io meistrual hregoartes and chronic anowtion? Higher rates of infertility are associated with central distribution of fat with higher waist: to-bip ratios.” Estimated 25% of ovulatory infertility in the United States? “Three fold increase in miscarriage? Lower implantation and pregnancy rates, as well as higher miscarriage rates and increased pregnzncy complications in women who undergo assisted reproduction’ a2 The Effect of Overweight and Obesity on Pregnancy Outcomes Maternal Complications During Pregnancy Diabetes Mellitus The risk of gestational diahetes mellitus (GDM) is increased twofold in overweight women; eightfold in the severely obese (body mass index [BMI] > 40)? An Australian Collabor ‘Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS), found that obese women were at higher risk of developing, GDM than women with « normal BMI (selative risk [RR] 2.10, 95% confidence interval CI} 1.17-3.79, p= 0.01 In a population study of 16,102 women (Weiss, etal) the incidence of GDM was 6.3% in the obese group (odds ratio [OR] 2.6) and 9.5% in the morbidly obese group (OR 4.0) compared to 2.3% in the control group. Ina UK study (Sebire, etal), women with a BMI ‘greater than 30 kg/a? are 3.6 times more likely to develop GDM compared with women with a normal BMI. Ina large Danish study consisting of 8092 women (Rhode, et al), the.odds of developing GDM also increases with BMI (OR | for BMI < 25 kg/m; OR 34 for BMI 25-29 kg/m? OR 15.3 for BMI > 30 kg/m)? In retrospective cohor! study by Bhattacharya, etal 24,241 nulliparous women delivering singleton babies in Aberdeen between 1976 and 2005), the prevalence of type I diabetes mellitus was higher in the morbidly obese sroup (1.9% vs. 0.2% normal group). © Inoverveight and obese women hyperinsulinemia is seen in hi levels” ‘Hypertension Gestational hyperteasion is more common in overweight and obese pregnant women.” In a population based screening study, Weiss, et al found an increased incidence of gestational hypertension in the obese and morbidly obese group, 10.2% and 12.3%, respectively compared to that of the normal weight group of 4.8%. Prevalence of pre-eslampsia is approximately twice in overweight ‘women (BML25-30} and approximately three times in obese women (BMLe" 30). Pre-cdanipsia is moze common in obese women with GDM thaa in women without GDM.” ‘The retrospective cohort study by Bhattacharya, et al (24,241 nulliparous women delivering singleton babies in Aberdeen between 431976 and 24 4 aled that both pre-eclampsia and gestational lyperte « Tinearly with increasing BML, resulting in 2.(95% C1 4.7-11.2) for preeclampsia and 3.1 estational hypertension in the mo:bidly obese jred to those of normal BMIL® porative Trial (ACTS), found that compared »ratal BMI, the risk of developing pregnancy- (PIE) was higher in overweight (RR 1.94, = 0.0001) and obese women (RR 3.19, 95% NOI). The RR for severe PLH was 2.76 (95% 1) in overweight women and 4.00 (95% C1 Jn obese women. Obese women had a RR for 1 of 2.99 (95% CL 1.88-4.73, p < 0.0001) ampsia (3.9 vs 13.5% in the obese group)?” was associated with higher rates of pre- it women (p = 0.016; excessive weight gain |, 24.2% in the overweight group and 35.4% ceateory Wh > An Austral with women cchampsia |i in normal in the obev) A sysien by O'Brien, doubled willl Bhattacharyy, obese (BMI ‘obese (BME 4 maternal BMI and risk of preeclampsia red that the risk of pre-eclampsia typically ) 7 kg/m? increase in pre-pregnaney BMI,” ind a3 times higher risk of pre-eclampsia in om’) and a 7 times higher risk in morbidly » primigravid women.” Maternal rish spoembolism is increased (0,05 vs 0.12% in the obese 10 srospective analysis of data obtained from a validated 1 Mabase system in the Nosth West ‘Thames Region (Lov | a higher prevalence of thromboembolism, in overweighf (0.07%) and in obese women compared 10 omen (0.08%) sence in the normal weight women." Mat Complications ip yytum Period Section sssociated morbidities are more common Jarge multicenter trial of overweight and arean delivery rate of 30% for nulliparous ‘han 30, 34% for those with a BME of 30- with a BMI of 35.39.9." = ‘were more likely to undergo a .“ : among obese ‘obese women sli ‘women with 4 I) 34.9, and 48% [oy Overweight anc! cesarean section overall (RR. 1.42, 95% CI 1.18-1.70, p = 0.0002 and RR 1,63, 95% CI 1.34-1,99, p< 0.0001, respectively), likewi have an emergency cesarean section (RK 1.48, 95% CI 1.19. 1.83, p = 0,0004 and 1.77, 95% CI 1.40-2.23, p < 0.0001, respectively) * Compared to workn with normal BMI, overweight and obese ‘women are more likely to require a cesarean section for the following, indications: 1) fetal distress (RK 1.40, 95% CL1,03-1.91, p=0.03 for 0.0004 for obese women), and ; 3) preeclampsia (RR 3.47, 85% Cl 1.39-8.65, p = 0.01) for obese women * ‘The ficquency of both lective (8.5% vs4%)and emergency cesarean section (13.4% vs 7.8%) were almost twice as high for the very obese women compared with the normal BMI group. Maternal obesity ‘was found to influence the route of delivery, independent of co ‘morbid conditions such as macrosomia, nulliparity, induction or diabetes mellitus. Inthe cohort of Bhattacharya, etal, electiveand emergency cesarean, sections were both more common in the morbidly obese group. However, only emergency cesarean section rates were significantly different in the other BMI categories. In contrast to women with normal BML, women who were morbidly obese had a 3 times (95% C1 1.7.6.1) higher risk of having an elective cesarean section, and 2.8 times (95% C1 2.0.3.9) higher risk of an emergency cesarean section. The adjusted OR for emergency cesarean section increased ‘with increasing BMI, with a protective effect seen in underweight women OR 0.7 05% CL0.6-0.8)." Stotland, et al conducted a retrospective cohort study of singleton, term, nulliparous, nondiabetic women with cephalic presentations delivered at a single university hospital. Excessive weight gain. during preynaney was found w be en independent risk factor for cesarean birth, even when birth weight ‘was not excessive. Women gaining above the Institute of Medicine (1OM) guidelines were more likely to have a cesarean birth, even hh weight was less than 4,000 g. In the multivariate analysis, women with excessive weight gain had an OR of 1.40 (95% CI 1.22. 1.59) for cesarean birth. (Level 112) Overweight or obese women have more postoperative complicat after cesarean delivery, such as wound infection/breakdown, ‘excessive blood loss, deep venous thrombophlebitis, and postpartum ‘endometrtis than do normal-weight women? ‘The lengsh of laboralso is longer in overweight and obese women.” 45Induction of Labor and Labor Complications: Overweight and obese women were more likely to undergo induction of labour, than women with a normal BMI (RR 1.33, 95% Cl 1.13-1.37, p = 0.001 and RR 1.78, 95% CL 1.51-2.09, p < 0.0001, respectively). In these subset of women, che indication ‘was more commonly hypertension (RR 1.93, 95% CI 1.21-3.08, p = 0.01 and RR 3.9, 95% CI 2.57-6.11, p < 0.0001, respectively), Induction for diabetes-related complications were likewise more frequent (RR 4.93 for overweight, 95% Cl 1.28-18.99, p = 0.02 and RR IL.6 for obese, 95% C1 3.20-41 69, p = 0.0002). The frequency Of induced labor was found by Bhaitacharya, et al to increase with rising BMI. It was highest in the morbidly obese with OR of LS (95% C11.3-2.5)." Higher rate of failed induction were found in obese women (7.9 vs 10,3 ¥s 14.6% with inc BM)’ Obesity increases risk of operative delivery (20.7% vs 33.8% in the obese and 47.4% in the morbidly obese group)? In comparison to worncn with normal BMI, there was also_a higher rate of obstetric complications in women who were overveight at their frst antenatal visit such as shoulder dystocia (I ys L.8and 1.9% with increasing BMI; p < 0.021) and third/fourth degree lacerations (26.3 ws 27.5 and 30.8% with increasing BML; p <0.001) (Kabiru, et al) In another study of 126,080 deliveries, after excluding women with hypertensive discase and diabetes mellitus, there was a three-fold increased tisk in failure to progress in the first stage of labor and a higher cesarean section rate of 27.8 vs 10.8% (OR 3.2) in the obese group compared with tlre normal weight group. The increase in ‘emergency cesarean sections in these obese women may be related to an increased number of large for gestational age infants, suboptimal uterine contractions and increased fat disposition in the soft tissues Of the pelvis leadling ta dystocia during labor? A hospital-based perinatal database showed that among women with a BMI > 35 undergoinga primary cesarean delivery, the overall ‘wound complication rate was 12.1%; with a greater risk in vertical skin incision (34.6 vs 9.4%) Postoperative respiratory complications such as pneumonitis are more common. Eaily mobilization, aggressive chest physiotherapy and adequate pain control are essential components of effective Postoperative care ‘The risk of postpartury ancmia was increased due to the higher prevalence of postpartum hemorrhage and abdominal deliveries among obese women, Macrosomia may also cause significant 46 postpartum blood loss by causing perineal rupture and hemorthage and lengthening of the period of bloody vaginal discharge after Gelivery. ‘The retrospective cohort study by Bhattacharya, et al, (24,241 nulliparous women delivering singleton babies) found a linear increase in mean postpartum blood loss with increasing BMI. The risk of postpartum hemorrhage, (more than 500 ml. for vaginal delivery and 1000 ml, for cesarcan delivery), was significantly higher only in the obese category (BMI 3034.9 ka/m'), OR 1.5 (25% CI 1.31.7), Other studies have reported conflicting results. Sebire, et al observed a 70% increase in postpartum hemorrhage while Bianco, etal found no such difference in the incidence.” In the puerperium, endometritis, postpartum hemorrhage, prolonged hospitalization and wound infections appear more frequent in obese women. Compared with the normal BM the risk of postpartum hemorshage rises with increasing BMI. Its about 30% and 70% more frequent for women with moderately and, highly raised) BMI, respectively ‘The high pre-pregnancy BML and weight gain between pregnancies reduce vaginal bir’ after a single low transverse caesarean delivery (YBAC) (54.6 v3 10.5%; p = 0.04). Adjustment for confounding factors such as ethricity, labor induction, gestational age at delivery and infant bi Ina study of 1,213 women, obese women were 50% Less successful when attempting a trial VBAC compared with underweight women (p= 0.043)" Birth Outcomes ‘Structural Anomalies i ‘There is conflicting evidence regarding the association between maternal obesity and cangenital malformations in the offspring. A systematic review and meta-analysis by Stothard, et al, however, shovred that maternal obesity is associated with an increased risk of a range of structural anomalies, although the absolute increase is likely to be small, Obese mothers were at increased odds of pregnancies affected by neural tube defects (NTD)(OR 1,87, 95% Cl 1.62-2.15), spina bfida (OR 2.24, 95% CI 1.86-2.69), cardiovascular anomalies (OR 1.30, 95% CI 1.12-1.51), septal anomalies (OR 1.20, 95% CI 1.09-1.31), left palate (OR 1.23, 95% CI 1.03-1.47), elelt and palate (OF 1.20, 95% Cl 1.03-1.40), anorectal atresia (OR 1.48, 95% CI 1.12-1.97), hydrocephaly (OR 1.68, 95% CI 1.19. 2.36), and limb reduction anomalies (OR 1.34, 95% CI 1.03-1.73) 4aA significant reduction in the risk of gastroschisis was seen among ‘obese mothers (OR 0.17, 95% CL 0.10.0.30). This is most likely ue to correlation with maternal age, since low maternal age is an established risk factor for gastroschisis and BML isin itself associated with age. Evidence were not robust to potential bias when it came to the risks of anencephaly among obese mothers, and for NTD and cardiovascular anomalies among overweight mothers.” ‘The meta-analysis of Stothard, et al included the large population based study of Waller, etal. Inthe latter, data from the Nationa Birth Deleets Prevention Study of index pregnancies between October | 1997 and December 31, 2002 were analyzed. Results showed that ‘mothers of offsprings with spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction detects, diaphragmatic hernia and omphalocele were significantly more likely 10 be obese than mothers of controls, with OR ranging between 1,33 and 2.10 Mothers of offspring with gastroschisis were significantly less likely to be obese than mothers of controls. Maternal obesity was associated! with significantly increased risk for offspring with spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction, defects, diaphragmatic hernia, and omphalocele, with ORs ranging from 1.33 t0 2.10. Maternal obesity was also associated with a borderline inereasc in risk for cleft palate and a strony and significantly decreased risk for gastroschisis (adjusted OR 0.19, 95% CL 0.100.34), Maternal overweight status was associated with a significantly increased risk for heart defects, hypospadias and omphalocele (ORs ranging from I.13-1.50) and a borderline increase in risk for craniosynostosis (adjusted OR 1.28, 95% CI 1.00-1.64), Mothers who were underveight had no significant increase or decrease in the risk for these birth defers, except for 2 modest increase in risk for cleft lip with or without cleft palate (adjusted OR 1.35, 95% CI. 1.04-1.76), Exclusion of maternal diabetee mellitus reoulted in a decrease in OR slightly wail the null for 7 birth defects ~ spina bifida: OR 2.09; (95% Cl 1.63-2.10); heart defects: OR 1.26 (95% CI 1.11-1.43); anorectal atresia: OR 1.21 (95% Cl 0.89-1.63); hypospadias: OR 1.21(95% Cl 0.93-1.58); limb reduction defects: OR 1.16 (95% C1 0.88-1.52); diaphragmatic hernia: OR 141 (95% CI 1.01-1.97); and omphalocele: OR 1.27 (05% CI 0.83-1,96). However, the adjusted OR for gastroschisis remained about the same (OR 0.20; 95% C1 0.11-0.37). One case-control study (Waller, tal) found that women with a BM > 31 kg/m? bad a significantly increased risk of delivering infants with N'TD and defects of the central nervous system, great vessels in the heart, ventral wall and other intestinal defects. ‘The association 48 between spina bifida and obesity was also confirmed in a study which concluded that for every incremental unit increase (kg/m) in BMI, the risk of NTD increased by 7%, ‘There is also an increase in other malformations such as omphalocele (three-fold), cardiac anomalies (especially septal defects, two-fold) and multiple defects among infants of the overweight and obese group. Other studies, however, have not found an association between maternal obesity and an increased risk of congenital malformation in offsprings” + The higher prevalence of congenital anomalies in offsprings of obese women suggests that maternal adiposity alters development in the sensitive embryonic period. In a study of 10,240 US women enrolled in the National Birth Defects Prevention Study, 1997-2002, the OR of structura birth defects ranged from 1.3t0 2.1 among obese compared with nor-obese mothers. NTDs are approximately twice as high with spina bifida being more common than anencephaly. Other birth defects more frequent in offspring of obese women include oral clefts, heart anomalies, hydrocephaly, and abxiominal wall abnormalities. The relationship between maternal obesity and NTDs persists after controling for self-reported folie acid intakes. ‘This suggests that other factors such as poor glycemic control contribute to congenital anomalies in obese women.” Intrauterine Fetal Demise: + Maternal obesity recently emerged as a risk factor for intrauterine feial death QUFD)ané stillbirth. In the United Kingdotn perinatal ‘mortality was inereased to 5.7 per 1000 in the obese group versus 1.4 per 1000? + In a. prospective population-based cohort study (n=3,480), antepartum stillbirth inereased three-fold in morbidly obese women compared with women with a normal BMI. In a large Swedish 167,750), the risk of late fetal iy ceasing, prepregrancy BMI ‘The risk of late fetal death among nulliparas with normal BMI was Goubled, among overweight tripled and among obese quadrupled thatamong lean women, Among the parous women, the risk of late fetal death was significantly increased only among obese women. For early neonatal death, the risk was doubled in nulliparous but not in parous women with a higher BME. The Swedish Medical Birth Register, on onalysis with adjustments for multiple variables showed that overweight (BMI 25.29.9 kg/m?) and obese (DMI © 30 kg/m?) wornen had a two-fold increase in the risk of term antepartum stillbirth. Weight gain during pregnancy however, was not associated with an increased risk of antepartum stillbirth. In 49Prete 4 Danish study involving 24,505 singleton pregnancies, maternal obesity was associated with more than double the risk of stilbitth (OR 28) and neonatal death (OR 2.6) compared with women of normal weight. No single cause of death explained the higher risk of stillbirth in children of obese women. However, higher Proportions of stillbirths caused by unexplained intrauterine death and fetopiacental dysfunction were found in children of obese women compared with children of non-obese women (BMI < 30 kg/m’), There was no apparent cause of neonatal death.” In a Canadian study of more than 84,000 women, a maternal pregravid body weight more than 68 ky increased the tisk of fetal death by 2.9-f0ld after adjusting for age, diabetes mellitus, and hypertensive disonders. A systematic review of articles on tisk factors for antepartum stillbirth Likewise reported a thrcefold increased risk for silbinh among obese women after adjusting for ‘ge, parity, maternal diabetes mellitus, and hypertension as well as ‘a mumber of social Factors.” m delivery: ‘The incidence of preterm bisth tends 10 decrease, rather than increase, with increasing pregravid BMI once medical inductions are accounted for in the analysis.” ‘The retrospective cohort study by Bhattacharya, et al (24,241 nulliparous women delivering singleton babies in Aberdeen between 1976 and 2005), adjusted data failed to show any differences in the risk of delivery before 37 completed weeks in the different BMI categories. The risk of preterm delivery before 33 weeks however, vas higher in the obese group but notin the morbidly obese.” Macrosomia, Large for Gestational Age Infants: Several countries have reported an increase in mean birth weight lover the past decade and an inereace in the proportion of large babies. One explanation for this increase could be the inerease in ‘maternal BMI over the same time period ? ‘The impact of maternal abnormal body habitus on birth weight increases with increasing BMI and is associated with significant obstetric morbidity Obesity and pregestational diabetes mellitus (pre-GPM) are independently associated with an increased risk of large for estational age infants® Although pre 4000 g (OR 1.53, 95% C1 1.44-1,63; and OR 2.00, 95% CI 1 842.18), macrosomia (OR 1.67, 95% CL | 42-1.97, and OR 3.23, 95% C12.39-4.37), and subsequent offprirg everweight/obesity (OR 1,95, 95% C1 1.77. 2.13, and OR 3.06, 95% CI 2,68-3.49), respectively. + Obesity, even in the absence of maternal diabetes mellitus, is associated with increased maternal insulin resistance and. fetal hyperinsulinemia, Insulin-resistant mothers have higher fasting plasma triglyceride levels and greaterleucine turnover. Amino acids are insulin secretagogues and its increased influx could stimulate fetal hyperinsulinemia, Placental lipases can cleave triglyceride and fice fatty aciuis anc (ransferved Ww the fetus «ess a lenua torial placenta, ‘The combination of an increased energy flux to the fetus and fetal hyperinsulinemia may explain the increased frequency of large for gestational age infants seen in obese women without diabetes mellitus.’ Brsaatfosting ‘There is some evidence of an association between maternal overweight or obesity and decreased rates of breastfeeding. A high BMI before conception has been shown to be inversely related to the successful initiation of breastfeeding, the duration of lactation, and the amount of milk produced, Poor lactation performance is 51attributed to mechanical difficulties associated with latching on and proper positioning of the infant; the high cesarean section rates among overweight or obese women, which delays the onset of first suckling; and a lower prolactin response t0 suckling, at 48 hours and more after delivery, which may compromise milk production and, overtime, lead to early cessation of lactation, It is unfortunate since breastfeeding has many protective effects against childhood morbidities, including the development of obesity liter in li. Furthermore, children whose mothers were obese prior to pregnancy and who were never breastfed had.a six times preset risk Of being overwcight compared with children whose mothers wer ‘ormal weight and who breastfed for at least 4 months (The 1996 National Longitudinal Survey of Youth) The Effects of Maternal Overweight/Obesity on Short-term and Long. term Child Health Status Maternal pregravid weight has an early and persistent effect on childhood overweight status as well as a dynamic effect on the process of overweight development, There isa positive association between maternal pregravid BMI and childhood weight status with ‘an adjusted OR ranging from two to four? ‘Maternal overweight and obesity, independent of GDM, is linked to the development of the metabolic syndrome (obesity, hypertension, salipidemia, and glucose intolerance) in the offspring, Boney, tal found that exposure of children to maternal obesity was as sisong a predictor of risk for metabolic syndrome (MS) as lange for gestational age status. Maternal obesity (prepregnancy BMI of > 21.3 kg/m’) vs nonobese had a hazards ratio (HR) of developing metabolicsyndrome of 1.81 (95% CI 1.03.3.19, p =0.039). Children Who were large for gestational age at birth had a twofold increased hazard of MS by 11 years of age (HR 2.19, 95% CI 1.25-3 82; p = 9.01).# Boney, tal followed a cohort of 84 ehildrea who were large for gestational age and 95 who were appropriate for gestational age at birth, showed thatthe risk of having two or more components of the MS at age 11 was 1.81 (95% CI 1.03.3.19), ifthe mother was ‘obese prior to pregnancy.’ Infants who are at the highest end of the distribution for weight or BMI or who grow rapidly during infancy are at increased risk of subsequent obesity. Obese babies were nine times more likely than normal weight babies to grow into obese adults, and infants who ‘ew rapidly were five times more likly to become obese? 52 Long-term Consequences for the Mother A weight gain in pregnancy of over 9 kg is more likely to be retained when not prepan’ (Green, et al 1988). Gestational weight gain and postpartum behaviors’ associated with weight change from early pregnancy to I-year postpartum have been investigated in 540 New York women, One-year postpartum, the women were a mean 1.5 + 5.9 kg heavier, while 25% experienced a weight gain of 4.6 kg or more. Weigit gain in excess of guidelines was three times ‘more likely in low-income groups. Gestational weight gain, a lack ‘of postpartum exercise and food intake were all associated with ‘weight gain to L-year postpartum. In a randomised comtrotted trial (RCT of 120 normal weight women, healthy eating and exercise were used to prevent excessive weight gain in pregtancy. In the intervention group, weight gain exceeded 15.9 kg in 33% women Compared with 5% in the untreated group. The postpartum retention of weight was proportional to weight gain in pregnancy Obesity in pregnancy is a major predictor of obesity ater in lie, which is commonly associated with the development of chronic hypertension, dyslipidemia and type 2 diabetes mellitas? ‘Abrasis | Asia ‘nd | Pacific Pater | Standart World teat Organization* Undernche eI8s =x_| 19826 | iss2a9 | >isseoa50 | 20249 | 185229 ecommended Pregnancy weight gain i MA1594g) ‘Overweiuht 26.1-29 25.0299 228.00<300 | 25-299 | 23249 (Recommended Pregnancy weight gain | cbs) E Cow BMT [ ‘Noval BN igh BM __| (Overweihi e Obese - 53In the 2 and 3° trimesters of pregnancy, gestational weight gain ‘was considered adequate if it was within the range recommended by the 2009 JOM/NRC based on pre-pregnancy BMI, For women ‘with pre-pregnancy BMI below 18.5 kg/m’, a gain between 0.44 and 0.58 kg/week is recommended; BMI from 18,5 to 24.9 kg/m?, a gain from 0.35 to 0.50 kg/week, BMI from 25 10 29.9 kg/m, a gain from 0.23 to 0.33 kg/week; and BMI c” 30 kg/m’, a gain from 0.17 to 0.27 ka/week A total weight gain from 12.5 t0 18 kg. was considered adequate for women with pre-pregnaney BMI below 18.5 kg/m a total gain from 11.5 to 16 kg for those with pre-pregnancy BMI from 18,5 {0 24.9 kg/m’; a total gain from 7 to 11.5 kg for those with pre-pregnancy BMI from 25 to 29.9 ke/ mt; and a total gain from 5 to 9 kg for those with pre pregnaney BMI c” 30 kg/m, In the 2 trimester, insufficient weight gain was associated with small for gestational age (RR 1.72, 95% CI 1.26- 2.33), and excessive weight gain with large for gestational age (RR 1.64, 95% Cl 1.16-2.31). In the 3* trimester, excessive weight sai ‘was associated with preterm birth (RR 1.70, 95% Cl L.08-2.70) and cesarean detivery (RR 1-21, 95% C1 1.03-1 44). Women with less than recommended gestational weight gain in the 2" trimester had allesser risk of cesarean deliveries (RR 0.82, 95% C1 0.71-0,96) than women with adequate gestational weight gain in this trimester. NCES Siega-Riz, Anna Mar 1. Theimplications of maternal overweight and obesity on the course of pregnancy and birth outcomes. Matern Child Health 3 2006;10:S153-$156. Sicga-Rie, Anna-Maria, Prepreprancy obesity: Determinants, consequences, fv cotione. Am Soe Nit Ady Nut 2012;3L 05-107. Doda, eal. Limiting weight gain in overweight and obese women daring pregnancy (0 improve health outcomes: the LIMIT randomised contralled ial DMC Pregaaney Childbirds 201 1:11:79 ‘Tanentsapf, etal. Systematic review of clinical tials on diciary interventions {0 prevent excessive woight gain during pregnancy among. normal wight, ‘overweight and obese women. BMC Pregnancy Childbieth 201 11:81 Oveng Nim, al ifestyle incervention for overweight and obese pregpsant ‘women to improve pregnancy outcome: systematic review and metaanaiysis BMC Med 2012; 10:47, 54 Vinter CA, The LiP (Liftstyle in Pregnancy) Study: A randomized controlled in 360 obese pregnant women. Diabetes Care tial f lifestyle imervent 2011;34:2802.2507, Position of the American Dietetic Assocation and American Society for [Nutrtion, Obesiy, Reproduction, and Pregnancy Outcomes, J Amer Diabetic Assoe 2009; 109918927. Athukorl, eta. The 1sk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy Childbieh 2010;10.56 Yo C Teoh Robison 8, Obesity in pregraney, BJOG 2006,115:1117-1125, Stothard KJ, eal. Maternal oversight and obesity and the risk of congenital anoavalies: A systematic review and meta-analysis, JAMA 2009;301(6):36 650. ‘Stuebe, et al, Mixernal BMI, glucose tolerance, and adverse pregnancy ‘outcomes. Arm J Obstet Gynecol. 2012;207(1):62 oney CM, Metabolic syndrome in childhood: Association with bith weight maternal obesity, aed gestational diabetes mellitus. Pediatr 2005;115@):290. 296. Bhattacharya, & al Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies, BMC Public Health 200757168 Stoiland NE, Hopkins LM, Caugliey AB. Gestational weight gain, macrosomia, and ask of cesarean birth in nondiabetic nullipares: Obstet Gynecol. 2004;104(9):61-7, Waller KD, ct al. Prepregnancy obesity as a risk ficior for structural birth defects, Arch Pedias Adolesc Med 2007;161(8):745-750. rehmer M, Duncan BB, Kac G, Schmidt M. 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