Protein is a macronutrient of major importance in human nutrition.

Plant and animal proteins are composed of more than 20 individual amino
acids. Within the body, amino acids are used for a wide variety of
structural proteins and enzymes; and they serve as a source of energy,
carbon, and nitrogen.

Protein has an energy value of approximately 5.5 kcal/g. Of this,

approximately 4 kcal/g is used during metabolism; the unmetabolized portion is
excreted as urea and other compounds. For meeting metabolic needs and promoting
satisfactory rates of protein synthesis, the diet must provide amino acids of
adequate quality and quantity.

Amino acids and nitrogen are available to mammals through degradation of

proteins and other nitrogenous compounds. Mammals can synthesize nonessential
amino acids de novo, if enery and suitable forms of carbon and nitrogen are
available. Thus, net requirements for nonessential amino acids can be met both by
dietary protein and by endogenous synthesis of amino acids. Ordinarily, the
following amino acids are considered to be essential amino acids, because they
cannot be synthesized by mammals: histidine, isoleucine, leucine, lysine,
methionine + cystine, phenylalanine + tyrosine, threonine, tryptophan, and valine
(NRC, 1989). Thus, these must be provided in adequate amounts by the diet. Other
amino acids, such as arginine and taurine, may functionally appear to be essential
during fetal and infant development in some species (Gaull, 1983; Sturman, 1986;
Visek, 1986), because the metabolic pathways have not yet fully developed to adult
levels and because the amount needed to cover growth and net new

Protein accretion is high. Developmental immaturity of biochemical pathways

may also limit conversion of pairs of metabolically related essential amino acids,
such as conversion of phenylalanine to tyrosine.

In postnatal life, ingested protein is hydrolyzed to amino acids, which are

absorbed and carried via the portal system to the liver. The amino acids then enter
the systemic circulation and are distributed throughout the body. The liver is an
especially active site for synthesis of protein from amino acids. Since considerable
reutilization of amino acids occurs, there is synthesis and degradation of more
protein daily than has been ingested.

IMPORTANCE

Pregnancy Complicates the already complex metabolism of amino acids.

Expansion of blood volume and growth of the maternal tissues require substantial
amounts of protein Oble 19-1). Growth of the fetus and placenta also places protein
demands on the pregnant woman. Thus, additional protein is essential for the
maintenance of a successful pregnancy. However, a review of the processes
controlling these changes in maternal protein metabolism is beyond the scope of
this chapter.

Maternal protein restriction, alone and in combination with energy restriction,

results in consistently decreased fetal growth in many species (Fattet et al., 1984;
Hill, 1984; Lederman and Rosso, 1980, Pond et al, 1988; Rosso, 1977a,b, 1980;
Rosso and Streeter, 1979). These modeLs demonstrate not only decreased body
weight and growth but also decreased numbers of cells and a variety of
biochemical changes. A particular concern is that the developing fetus may or may
not adequately compensate for some Of the effects of maternal protein deprivation,
and effects may even span generations
the fetus receives a continuous stream of amino acids from the mother via the
placenta (Battaglia, 1986); the amino acids cross the placenta by a complex series
of transport systems, probably including both active and facilitated transport
systems. Tansport systems may differ on the maternal and fetal sides of the
placenta, and different classes of amino acids are transported by different placental
systems (Battaglia, 1986; Eaton and Yudilevitch, 1981; Lemons and Schreiner,
1983; Schneider et al., 1979; Smith, 1986; Yudilevitch and Sweiry, 1985). Amino
acid concentrations are typically somewhat higher in the fetus than in the mother
(Cetin et al., 1988; Soltesz et al., 1985; Yudilevitch and Sweiry, 1985). Moreover,
the placenta is very active metabolically, and in laboratory animals, it plays an
important role in nitrogen metabolism (Meschia et al., 1980). Because of the
complexity of the transport processes and placental metabolism, it is dificult to
predict the effect of altered maternal protein intake on fetal amino acid metabolism,
both in terms of the total quantitative amino acid flux and in terms of relative
changes in the fluxes of individual amino acids.

The fetus must handle rapid entry of both exogenous and endogenous Amino
acids, and it must provide for the rapid accretion of new protein (Battaglia, 1986).
Studies in the unstressed fetal lamb have shown rapid turnovers of leucine and
lysine in amounts severalfold higher than umbilical uptakes of the amino acids
from the placenta (Battaglia, 1986). More recently, turnover measurements of the
nonessential amino acid glycine have suggested the interconversion of glycine and
serine in the fetal liver (Marconi et al., 1989). The sheep fetus also appears to
catabolize amino acids to urea at a rapid rate (Lemons et al., 1976).

Several investigators have studied the effect of direct amino acid infusion in
experimentally induced growth retardation in fetal animals (Charlton and
Johengen, 1985; et al., 1984; Mulvihill et al., 1985). These studies have
demonstrated at least partial restitution of birth weight with direct nutritional
supplementation. However, there is no evidence that amino acid supplementation
of normally grown fetuses significantly increases birth weights above those
achieved by controls.

ESTIMATED REQUIREMENTS
 Information regarding total protein requirements during pregnancy has been
provided through the factorial approach, balance studies, turnover studies, and
epidemiologic surveys (seet Chapter 12). As noted above’ there are theoretical and
experimental differences of opinion regarding requirements for protein and amino
acids.

The results of body composition studies in human and nonhuman

Species have formed the basis for estimation of protein accretion in the fetus.
Hytten and Leitch (1971) reviewed classic studies of human body composition
(Kelly et al., 1951; Widdowson and Dickerson, 1964) and estimated fetal protein
requirements to be approximately 440 g over the course of pregnancy and the
placental protein requirement to be an additional 100 g Cläble 19-1). Other
reviewers, using much of the same published data on humans, estimated a nitrogen
accumulation of 50 to 60 g for a full-term 3,300-g fetus (SparB, 1984; Ziegler et
al., 1976). The data on which such factorial estimates are based are limited,
however, and lacking in important details such as accurate gestational age. The
results differ because of differences in mathematical modeling and data bases
(Hytten and Leitch, 1971; SparB, 1984; Ziegler et al., 1976). At the standard
estimate of 6.25 g of protein per gram of nitrogen, this would amount to 310 to 375
g Öfprotein per human fetus at full term somewhat lower than previous estimates.
Both approaches estimating fetal amino acid and nitrogen requirements
demonstrate that the fetus and placenta present a substantial demand for amino
acids from the mother.

Nitrogen is found in many compounds other than protein. Nucleic acids and
polyamines are two such compounds that may be of particular relevance to the
growing fetus. In detailed studies of the chemical composition of the guinea pig
fetus, approximately 20% of the nitrogen content was found in compounds other
than protein (Sparks et al., 1985). If this is also true of the human fetus, its protein
content and requirements may be lower than current estimates.

Using the factorial approach and assuming a 40-week gestation and a 3,300-g
newborn, Hytten and Leitch (1971) estimated that 925 g is the total increment in
body protein during pregnancy Cläble 19-1). More recent nitrogen balance studies
(Appel and King, 1979; Johnstone et al., 1981) suggest that nitrogen retention
approaches the factorial estimate, if adjustment is made for unmeasured losses.

TUrnover studies have that protein turnover increases early and remains
elevated throughout pregnancy (de Benoist et al., 1985; Fitch and King, 1987;
Jackson, 1987). Some investigators have expressed technical concerns about using
turnover measurements to estimate protein requirements during pregnancy (Fitch
and King, 1987). All human studies to date have used nonessential amino acids to
measure the turnover Of protein in pregnant women, further complicating the
interpretation of these data.

The deposition of protein is not necessarily linear throughout pregnancy.-

Early during pregnancy, the fetal component is minimal, whereas the requirement
for maternal volume expansion and tissue growth may be SUbstantial. Late in
pregnancy, the fetus may account for the major increase in protein needs. The
additional requirement averaged over gestation appears to be roughly 3 to 4 g of
protein per day. If it is assumed that there is a 15% variation in birth weight and
that dietary protein is converted at 70% efliciency, the requirement for protein
would be an additional 6.0 g/day averaged over pregnancy, but the demand is
highest (10.7 g/day) in the last trimester (NRC, 1989). On the basis of these and
other considerations, a maternal protein intake of 10 g/day over the Recommended
Dietary Allowance (RDA) for protein (i.e., a total of 60 g/day) is recommended
throughout pregnancy. This subcommittee notes that most foods that are good
sources of protein (e.g., grains, flesh foods, milk, cheese, and dried peas and beans)
are also good sources of many other nutrients and thus their use should be
encouraged as part of a balanced diet during pregnancy.

USUAL INTAKES
 As discussed in Chapter 13, usual protein intakes by pregnant women in the
United States range from 75 to 110 B/day. The estimated average intakes of protein
by low-income women enrolled in the Supplemental Food Program for Women,
Infants, and Children (WIC) were higher than the 1980 RDA of 74 g/day, even
before participation in the program (Rush et al., 1988). However, inadequate
energy intake may contribute to protein deficiency if there is compensatory
catabolism of protein and amino acids to meet energ needs. Thus, the adequacy of
dietary protein must be considered in the context of total nutrient intake.

CRITERIA FOR DEFICIENCY

Deficiency of protein is diffcult to assess, both because of protein’s dynamic

and complex metabolism and because protein deficiency is generally associated
with deficiencies of other nutrients and energy. Classic signs of protein deficiency
include poor growth, muscular weakness, poor hair growth, and low serum
albumin, which may result in edema. Classic protein deficiency is rare in the
general U.S. population, occurring primarily in people with serious illness or injury
rather than as a result of poo r dietary intake. However, protein-energy malnutrition
is relatively common in other areas of the world, especially among children, and it
is associated with decreased birth weight. It is difficult, however, to isolate the
effect Of protein malnutrition from that of energy intake.
 The results of most common laboratory tests used to assess protein deficiency
show changes during pregnancy. With the increase in plasma volume, there is a
decreased concentration of albumin and certain other blood constituents. However,
some blood proteins, especially those whose levels are influenced by estrogen,
increase during pregnancy. Urea nitrogen and alpha amino nitrogen levels decrease.

SUPPLEMENTATION STUDIES

A large body of literature documents the results of protein supplementation

programs during pregnancy in regions where malnutrition is found. Many of these
studies are examined in Chapter 7, In Guatemala, studies were conducted to
determine the effects of a protein-energy supplement and a low energr supplement
on maternal and newborn outcomes among chronically malnourished rural women
(Delgado et al., 1982; Lechtig et ale, 1975, 1978) (see Chapter 7, mle 7-2B). In
these widely cited studis, investigators found minimal change in birth weight and
no effect on gestational duration among women receiving either supplement. Post
hoc analysis demonstrated a significant positive effect of spontaneous energy
intake on birth weight and maternal weight gain regardless of the protein content of
the supplement.

In Colombia, investigators examined the effect of a supplement containing 20

g of protein and 150 kcal of energy given to poor urban women in Bogota. They
found an approximately 50-g increase in birth weight in the supplemented group
and no effect on gestational duration (Mora et al., 1979). In Taiwan,
supplementation with both protein and calories failed to statistically increase the
birth weights of infants born to poor rural women (Adair and Pollitt, 1985; Adair et
al., 1983; McDonald et al., 1981; Wohlleb et al., 1983).

Studies in the developed world have also demonstrated minimal changes in

birth weight as a result of protein supplementation. In the United Kingdom,
protein-energ supplementation of pregnant Asian women in Birmingham led to
significantly higher maternal weight gains than did energ supplements alone;
however, only the supplement that contained vitamins in addition to protein and
enery was associated with a significant increase in birth weight (Viegas et al,
1982a,b). Rush et al. (1980) found significant decreases in both gestational length
and birth weight and marginally significant increases in mortality and preterm birth
rate with high-density protein supplementation of poor women in Harlem, New
York. Adams and colleagues (1978) reported that a high-protein supplement given
to women in San Francisco resulted in a 45-g decrease in birth weight, comPared
with controls, and a 140-g decrease in birth weight, compared with infants of
mothers who were provided with energy supplements. Reviews of WIC have
demonstrated minimal effects of program participation on birth weight, gestational
duration, or the incidence of low birth weight (Kennedy and Kotelchuck, 1984;
Metcoff et al., 1985; Rush et al.,
 In a comprehensive review of the literature on supplementation, Rush and
colleagues (1984) reported an inverse relationship between birth weight

And protein density in supplements. An increase in prematurity has not been

generally associated with supplements that provide protein-to-enerw ratios
comparable to those found in usual diets.

To summarize, in many studies, protein-energy 'supplements have been given

to pregnant women in an effort to determine the effect on maternal and fetal
outcomes. In many of them, no significant changes were found in either birth
weight or gestational duration; in others, small changes—from a 30- to 100-g
increase in birth weight—were observed. The biologic importance of changes of
this magnitude (1 to 3% of the full-term birth weight) is not certain. It is diffcult to
interpret these studies because of variations in baseline nutritional status,
composition of the supplements, and other characteristics; it is particularly
problematic to separate the effect of the protein from that of the enery in the
supplements.

RECOMMENDATIONS REGARDING SUPPLEMENTATION

 On the basis of the estimated additional needs for protein and energ during
pregnancy and the usual intake of these nutrients from the U.S. diet, the
subcommittee concludes that the additional requirement for protein during
pregnancy can be met from dietary sources. Because evidence suggests possible
harm from specially formulated high-protein supplements, the use of special
protein powders or specially formulated high-protein beverages should be
discouraged.

CLINICAL IMPLICATIONS

A moderate increase in the use of food sources of protein, such as whole

grains, milk, and legumes, as part of a balanced diet, is encouraged during
pregnancy since these foods are valuable sources of other nutrients. e Assessment
of adequacy of protein status is most important in women whose energy intake is
low.

e Use of specially formulated protein supplements (e.g., protein powders) is

not recommended during pregnancy.
 Protein has an energy value of approximately 5.5 kcal/g. Of this,
approximately 4 kcal/g is used during metabolism; the unmetabolized
portion is excreted as urea and other compounds. For meeting metabolic
needs and promoting satisfactory rates of protein synthesis, the diet must
provide amino acids of adequate quality and quantity.
Amino acids and nitrogen are available to mammals through
degradation of proteins and other nitrogenous compounds. Mammals can
synthesize nonessential amino acids de novo, if enery and suitable forms of
carbon and nitrogen are available. Thus, net requirements for nonessential
amino acids can be met both by dietary protein and by endogenous
synthesis of amino acids. Ordinarily, the following amino acids are
considered to be essential amino acids, because they cannot be synthesized
by mammals: histidine, isoleucine, leucine, lysine, methionine + cystine,
phenylalanine + tyrosine, threonine, tryptophan, and valine (NRC, 1989).
Thus, these must be provided in adequate amounts by the diet. Other amino
acids, such as arginine and taurine, may functionally appear to be essential
during fetal and infant development in some species (Gaull, 1983;
Sturman, 1986; Visek, 1986), because the metabolic pathways have not yet
fully developed to adult levels and because the amount needed to cover
growth and net new
protein accretion is high. Developmental immaturity of biochemical
pathways may also limit conversion of pairs of metabolically related
essential amino acids, such as conversion of phenylalanine to tyrosine.
In postnatal life, ingested protein is hydrolyzed to amino acids, which
are absorbed and carried via the portal system to the liver. The amino acids
then enter the systemic circulation and are distributed throughout the body.
The liver is an especially active site for synthesis of protein from amino
acids. Since considerable reutilization of amino acids occurs, there is
synthesis and degradation of more protein daily than has been ingested.

IMPORTANCE
Pregnancy Complicates the already complex metabolism of amino
acids. Expansion of blood volume and growth of the maternal tissues
require substantial amounts of protein Oble 19-1). Growth of the fetus and
placenta also places protein demands on the pregnant woman. Thus,
additional protein is essential for the maintenance of a successful pregnancy.
However, a review of the processes controlling these changes in maternal
protein metabolism is beyond the scope of this chapter.
Maternal protein restriction, alone and in combination with energy
restriction, results in consistently decreased fetal growth in many species
(Fattet et al., 1984; Hill, 1984; Lederman and Rosso, 1980, Pond et al, 1988;
Rosso, 1977a,b, 1980; Rosso and Streeter, 1979). These modeLs
demonstrate not only decreased body weight and growth but also decreased
numbers of cells and a variety of biochemical changes. A particular concern
is that the developing fetus may or may not adequately compensate for
some Of the effects of maternal protein deprivation, and effects may even
span generations-
 the fetus receives a continuous stream of amino acids from the mother
via the placenta (Battaglia, 1986); the amino acids cross the placenta by a
complex series of transport systems, probably including both active and
facilitated transport systems. Tansport systems may differ on the maternal
and fetal sides of the placenta, and different classes of amino acids are
transported by different placental systems (Battaglia, 1986; Eaton and
Yudilevitch, 1981; Lemons and Schreiner, 1983; Schneider et al., 1979;
Smith, 1986; Yudilevitch and Sweiry, 1985). Amino acid concentrations are
typically somewhat higher in the fetus than in the mother (Cetin et al., 1988;
Soltesz et al., 1985; Yudilevitch and Sweiry, 1985). Moreover, the placenta is
very active metabolically, and in laboratory animals, it plays an important
role in nitrogen metabolism (Meschia et al., 1980). Because of the
complexity of the transport processes and placental metabolism, it is dificult
to predict the effect of altered maternal protein intake on fetal amino acid
metabolism, both in terms of the total quantitative amino acid flux and in
terms of relative changes in the fluxes of individual amino acids.
The fetus must handle rapid entry of both exogenous and endogenous
amino acids, and it must provide for the rapid accretion of new protein
(Battaglia, 1986). Studies in the unstressed fetal lamb have shown rapid
turnovers of leucine and lysine in amounts severalfold higher than umbilical
uptakes of the amino acids from the placenta (Battaglia, 1986). More
recently, turnover measurements of the nonessential amino acid glycine
have suggested the interconversion of glycine and serine in the fetal liver
(Marconi et al., 1989). The sheep fetus also appears to catabolize amino
acids to urea at a rapid rate (Lemons et al., 1976).
Several investigators have studied the effect of direct amino acid
infusion in experimentally induced growth retardation in fetal animals
(Charlton and Johengen, 1985; et al., 1984; Mulvihill et al., 1985). These
studies have demonstrated at least partial restitution of birth weight with
direct nutritional supplementation. However, there is no evidence that
amino acid supplementation of normally grown fetuses significantly
increases birth weights above those achieved by controls.

ESTIMATED REQUIREMENTS

Information regarding total protein requirements during pregnancy h as

been provided through the factorial approach, balance studies, turnov er
studies, and epidemiologic surveys (seet Chapter 12). As noted above' there
are theoretical and experimental differences of opinion regard ing
requirements for protein and amino acids.

The results of body composition studies in human and nonhuman

 species have formed the basis for estimation of protein accretion in the
fetus. Hytten and Leitch (1971) reviewed classic studies of human body
composition (Kelly et al., 1951; Widdowson and Dickerson, 1964) and
estimated fetal protein requirements to be approximately 440 g over the
course of pregnancy and the placental protein requirement to be an
additional 100 g Cläble 19-1). Other reviewers, using much of the same
published data on humans, estimated a nitrogen accumulation of 50 to 60 g
for a full-term 3,300-g fetus (SparB, 1984; Ziegler et al., 1976). The data on
which such factorial estimates are based are limited, however, and lacking in
important details such as accurate gestational age. The results differ because
of differences in mathematical modeling and data bases (Hytten and Leitch,
1971; SparB, 1984; Ziegler et al., 1976). At the standard estimate of 6.25 g
of protein per gram of nitrogen, this would amount to 310 to 375 g Öfprotein
per human fetus at full term—somewhat lower than previous estimates. Both
approaches estimating fetal amino acid and nitrogen requirements
demonstrate that the fetus and placenta present a substantial demand for
amino acids from the mother.
Nitrogen is found in many compounds other than protein. Nucleic acids
and polyamines are two such compounds that may be of particular relevance
to the growing fetus. In detailed studies of the chemical composition of the
guinea pig fetus, approximately 20% of the nitrogen content was found in
compounds other than protein (Sparks et al., 1985). If this is also true of the
human fetus, its protein content and requirements may be lower than current
estimates.
Using the factorial approach and assuming a 40-week gestation and a
3,300-g newborn, Hytten and Leitch (1971) estimated that 925 g is the total
increment in body protein during pregnancy Cläble 19-1). More recent
nitrogen balance studies (Appel and King, 1979; Johnstone et al., 1981)
suggest that nitrogen retention approaches the factorial estimate, if
adjustment is made for unmeasured losses.
TUrnover studies have that protein turnover increases early and
remains elevated throughout pregnancy (de Benoist et al., 1985; Fitch and
King, 1987; Jackson, 1987). Some investigators have expressed technical
concerns about using turnover measurements to estimate protein
requirements during pregnancy (Fitch and King, 1987). All human studies
to date have used nonessential amino acids to measure the turnover Of
protein in pregnant women, further complicating the interpretation of these
data.
The deposition of protein is not necessarily linear throughout
pregnancy.- Early during pregnancy, the fetal component is minimal,
whereas the requirement for maternal volume expansion and tissue growth
 may be SUbstantial. Late in pregnancy, the fetus may account for the major
increase in protein needs. The additional requirement averaged over
gestation appears to be roughly 3 to 4 g of protein per day. If it is assumed
that there is a 15% variation in birth weight and that dietary protein is
converted at 70% efliciency, the requirement for protein would be an
additional 6.0 g/day averaged over pregnancy, but the demand is highest
(10.7 g/day) in the last trimester (NRC, 1989). On the basis of these and
other considerations, a maternal protein intake of 10 g/day over the
Recommended Dietary Allowance (RDA) for protein (i.e., a total of 60
g/day) is recommended throughout pregnancy. This subcommittee notes
that most foods that are good sources of protein (e.g., grains, flesh foods,
milk, cheese, and dried peas and beans) are also good sources of many other
nutrients and thus their use should be encouraged as part of a balanced diet
during pregnancy.

USUAL INTAKES
As discussed in Chapter 13, usual protein intakes by pregnant women in
the United States range from 75 to 110 B/day. The estimated average intakes
of protein by low-income women enrolled in the Supplemental Food
Program for Women, Infants, and Children (WIC) were higher than the 1980
RDA of 74 g/day, even before participation in the program (Rush et al.,
1988). However, inadequate energy intake may contribute to protein
deficiency if there is compensatory catabolism of protein and amino acids to
meet energ needs. Thus, the adequacy of dietary protein must be considered
in the context of total nutrient intake.

CRITERIA FOR DEFICIENCY

Deficiency of protein is diffcult to assess, both because of protein's
dynamic and complex metabolism and because protein deficiency is
generally associated with deficiencies of other nutrients and energy. Classic
signs of protein deficiency include poor growth, muscular weakness, poor
hair growth, and low serum albumin, which may result in edema. Classic
protein deficiency is rare in the general U.S. population, occurring primarily
in people with serious illness or injury rather than as a result of poo r dietary
intake. However, protein-energy malnutrition is relatively common in other
areas of the world, especially among children, and it is associat ed with
decreased birth weight. It is difficult, however, to isolate the effect Of protein
malnutrition from that of energy intake.
 The results of most common laboratory tests used to assess protein
deficiency show changes during pregnancy. With the increase in plasma
volume, there is a decreased concentration of albumin and certain other
blood constituents. However, some blood proteins, especially those whose
levels are influenced by estrogen, increase during pregnancy. Urea nitrogen
and alpha amino nitrogen levels decrease.
SUPPLEMENTATION STUDIES
A large body of literature documents the results of protein
supplementation programs during pregnancy in regions where
malnutrition is found. Many of these studies are examined in Chapter 7, In
Guatemala, studies were conducted to determine the effects of a protein-
energy supplement and a low energr supplement on maternal and newborn
outcomes among chronically malnourished rural women (Delgado et al.,
1982; Lechtig et ale, 1975, 1978) (see Chapter 7, mle 7-2B). In these
widely cited studis, investigators found minimal change in birth weight
and no effect on gestational duration among women receiving either
supplement. Post hoc analysis demonstrated a significant positive effect of
spontaneous energy intake on birth weight and maternal weight gain
regardless of the protein content of the supplement.
In Colombia, investigators examined the effect of a supplement
containing 20 g of protein and 150 kcal of energy given to poor urban
women in Bogota. They found an approximately 50-g increase in birth
weight in the supplemented group and no effect on gestational duration
(Mora et al., 1979). In Taiwan, supplementation with both protein and
calories failed to statistically increase the birth weights of infants born to
poor rural women (Adair and Pollitt, 1985; Adair et al., 1983; McDonald
et al., 1981; Wohlleb et al., 1983).
Studies in the developed world have also demonstrated minimal
changes in birth weight as a result of protein supplementation. In the
United Kingdom, protein-energ supplementation of pregnant Asian
women in Birmingham led to significantly higher maternal weight gains
than did energ supplements alone; however, only the supplement that
contained vitamins in addition to protein and enery was associated with a
significant increase in birth weight (Viegas et al, 1982a,b). Rush et al.
(1980) found significant decreases in both gestational length and birth
weight and marginally significant increases in mortality and preterm birth
rate with high-density protein supplementation of poor women in Harlem,
New York. Adams and colleagues (1978) reported that a high-protein
supplement given to women in San Francisco resulted in a 45-g decrease
in birth weight, comPared with controls, and a 140-g decrease in birth
weight, compared with infants of mothers who were provided with energy
supplements. Reviews of WIC have demonstrated minimal effects of
program participation on birth weight, gestational duration, or the
incidence of low birth weight (Kennedy and Kotelchuck, 1984; Metcoff et
al., 1985; Rush et al.,
In a comprehensive review of the literature on supplementation, Rush
and colleagues (1984) reported an inverse relationship between birth
weight
and protein density in supplements. An increase in prematurity has not been
generally associated with supplements that provide protein-to-enerw ratios
comparable to those found in usual diets.
To summarize, in many studies, protein-energy 'supplements have
been given to pregnant women in an effort to determine the effect on
maternal and fetal outcomes. In many of them, no significant changes were
found in either birth weight or gestational duration; in others, small
changes—from a 30- to 100-g increase in birth weight—were observed.
The biologic importance of changes of this magnitude (1 to 3% of the full-
term birth weight) is not certain. It is diffcult to interpret these studies
because of variations in baseline nutritional status, composition of the
supplements, and other characteristics; it is particularly problematic to
separate the effect of the protein from that of the enery in the supplements.

RECOMMENDATIONS REGARDING SUPPLEMENTATION

On the basis of the estimated additional needs for protein and energ during
pregnancy and the usual intake of these nutrients from the U.S. diet, the
subcommittee concludes that the additional requirement for protein during
pregnancy can be met from dietary sources. Because evidence suggests possible
harm from specially formulated high-protein supplements, the use of special
protein powders or specially formulated high-protein beverages should be
discouraged.
 CLINICAL IMPLICATIONS
A moderate increase in the use of food sources of protein, such as whole
grains, milk, and legumes, as part of a balanced diet, is encourage d during
pregnancy since these foods are valuable sources of other nutrients. e
Assessment of adequacy of protein status is most important in women whose
energy intake is low.
e Use of specially formulated protein supplements (e.g., protein
powders) is not recommended during pregnancy.