NUTRITION: A LIFE SPAN APPROACH

Dr. Hajra Ahmad

AIOU
Unit-3: NUTRITION AND PREGNANCY

Contents :
• 3.1 Physiological demands of pregnancy
• 3.2 Nutrient requirements in pregnancy.
• 3.3 Diet in relation to pregnancy outcomes.
• 3.4 Nausea and vomiting of pregnancy (NVP).
• 3.5 High-risk pregnancies.
 Learning objectives
By the end of this chapter, the reader should be able to:
• Describe the physiological adaptations during pregnancy and their
role in maintaining the fetus health.
• Learn about increased maternal demand for energy, protein, and
micronutrients during pregnancy.
• Describe the nutrition-related factors that determine the risk of
miscarriage and stillbirth.
 Learning objectives

• Understanding of the risk of the preterm delivery, and describe the

role of nutrition in determining this risk.
• Describe the hypertensive disorders of pregnancy and pre-eclampsia
and their prevention.
• Discuss the incidence and prevention of nausea and vomiting.
• Highlight the hazards associated with obesity in pregnant women.
 Physiological demands of pregnancy

• Pregnancy is a period of intense physiological adaptations and involves

constant responses to the need for:
a) Oxygen,
b) Nutrients,
c) Changing hormonal environment.
• Pregnancy is an anabolic state and hormones produced by the placenta
ensure that nutrients are metabolized in a manner that allows:
a) Maintenance of maternal homeostasis,
b) Provides support for the growth of the placenta and fetus,
c) Prepares the maternal system for later lactation.
 Maternal Anabolic/catabolic phases of pregnancy
Anabolic Phase (0-20weeks) Catabolic Phase (20 + weeks)

Blood volume expansion, increased Mobilization of fat and nutrient stores

cardiac output

Buildup of fat, nutrients, and liver Increased production of blood glucose

glycogen stores. levels, triglycerides and fatty acids;
decreased liver glycogen stores.

Growth of some maternal Accelerated fasting metabolism .

organs,Increesaed appetite ,food intake Increased appetite and food intake ,
( positive energy balance) decline somewhat near term.

Decreased exercise tolerance . Increased exercise tolerance .

Increased levels of anabolic hormones Increased levels of catabolic hormones
 Normal changes in maternal physiology during pregnancy

• Blood volume expansion

• Blood volume increases 20%
• Plasma Volume increases 50%
• Edema occurs in 60-75 % of women
• Hemodilution: Concentration of most vitamins and minerals
decreases.
• Increased concentration of blood lipid levels.
• Blood glucose levels increase due to increased insulin resistance .
Normal changes in maternal physiology during pregnancy

• Maternal organ and tissue enlargement:

(heart,thyroid,liver,kidneys,uterus , breasts,adpose tissues )
• Hormones: (Placental secretions of large amounts of hormones needed
to support physiological changes of pregnancy.)
• Circulatory system:
• Increased cardiac output ( 30-50%)
• Increased heart rate (16%)
• Decreased blood pressure in the first half of pregnancy( -9%),followed by a
return to non pregnancy levels in 2nd half.
Normal changes in maternal physiology during pregnancy

• Respiratory system:
• Increased amount of air inhaled and exhaled (30-40%).
• Increased Oxygen consumption (10%).
• Food Intake:
• Increased appetite and food intake; weight gain.
• Taste and odor changes
• Increased thirst
 Normal changes in maternal physiology during pregnancy

• Gastrointestinal changes:
• Relaxed gastrointestinal muscle tone
• Increased gastric and intestinal transit time
• Nausea (70%), Vomiting (40%)
• Heartburns
• Constipation
 Normal changes in maternal physiology during pregnancy

• Kidney Changes:
• Increase Glomerular filtration rate
• Increased sodium conservation
• Increased nutrient spoilage into urine; protein is conserved
• Increased risk of urinary and reproductive tract infection.
Normal changes in maternal physiology during pregnancy

• Immune system:
• Suppressed Immunity
• Increased risk of urinary and reproductive tract
infections
• Basal Metabolism:
• Increased BMR in 2nd half of the pregnancy
• Increased body temperature .
Physiological demands of pregnancy

• Maternal weight gain and body composition changes

• Weight gain in pregnancy can be highly variable ( Average 12.5 kg).
• Blood volume expansion and cardiovascular changes
• Renal changes
• Respiratory changes
• Gastrointestinal changes
• Metabolic adaptations
Components of weight gain during pregnancy

Component Weight gain in games

Fetus 3550
Placenta 670
Uterus 1120
Amniotic Fluid 896
Breasts 448
Blood supply 1344
Extracellular fluid 3200
Maternal fat stores 3500
Total weight gain at term 14.7 kg or 32-Ib
Recommended Weight Gain

BMI Weight
Weight Gain Weight Gain
(kg)
(kg) (lbs)
Height (m2)
Underweight
12.7-18.2 28-40
BMI < 18.5
Normal Weight
11.4-15.9 25-35
BMI 19-24.9
Overweight
6.8-11.4 15-25
BMI 25-29.9
Obese
6.8 <15
BMI > 30.0
Rate of Weight Gain
• Pattern of weight gain in pregnancy as important as
total weight gain.

• Deviations from expected patterns of weight gain

are signals for intervention.

• Pre-term birth rate doubles when 3rd trimester

weight gain is low or inadequate.

• Pregnancy is an anabolic state, resulting in increased

energy (300 kcal/day) and nutrient needs.
Nutritional Requirements during pregnancy

Nutritional requirements depend on :

• Perinatal Nutrition
• Maternal Developmental Stage
• Fetal Growth and Development
• Growth of Maternal Supporting Tissues
• Expansion of Maternal Blood Volume

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Nutrient requirements in pregnancy
• Energy, protein, and lipids
• Pregnancy considerably increases the maternal demand for energy
for:
a) Growth of the fetus and placenta,
b) The deposition of fat reserves for lactation,
c) and the expansion of maternal tissues.
Nutrient requirements in pregnancy
• Micronutrients:
• Iron : High iron requirements , with the fetus taking up as much as 400 mg
over full gestation, with up to 175 mg accumulating in the placenta
• Calcium and other minerals
a) The fetus accumulates large quantities of most minerals during late
gestation.
b) The fetal skeleton deposits Ca, mg, and phosphorus in the last trimester,
c) High uptakes of zinc, copper, and other trace metals are also noted.
• Vitamin D : Pregnant women have increased requirements for vitamin D. It is
associated with changes in the metabolism of vitamin D.
Basics of a good diet during pregnancy

1 Provide sufficient calories to support appropriate rates of Wt gain

2 Follow the My plate/Food Guide Pyramid food group recommendations
3 Provide all essential nutrients at the recommended levels of intake from
the diet
4 Include 400 mcg of folic acid daily
5 Provide sufficient dietary fiber ( 28 g/day)
6 Include 9 cups of fluid daily
7 Include salt “to taste”
8 Exclude unnecessary drugs and make the meals enjoyable
Change in Requirements of Selected Nutrients During
Pregnancy

• Most of increased need occurs in

2nd and 3rd trimesters
• Nutrient requirements are
increased disproportionately to
energy requirements
• Reserves are particularly
important during 1st trimester or
when intakes may not be
consistent
• Larger increases in requirements
may be needed for adolescents or
undernourished women
0 1 2 3
x Prepregnancy DRI

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 Protein and Energy Requirements

• Energy
• Sustains metabolic activity
• Supports protein synthesis
• Reflects fat and
carbohydrate intakes after
increased protein
requirement is included
• Protein
• Expansion of maternal
blood volume
• Growth of breast and
uterine tissues
• Growth of fetal tissues

+10 g/day
+300 kcal/day

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Energy and Nutrient Needs during Pregnancy

1. Energy
• +300 calories in 2nd and 3rd trimester
• how much extra food is 300 kcals?
2. Protein
• +10 grams; how much extra food?
3. Essential Fatty Acids
• omega 6 f.a.: vegetable oils, poultry, meats
• omega 3 f.a.: oils, nuts, seeds, soybeans, shellfish and fish
4. Nutrients for Blood Production/Cell Growth
• key roles in synthesis of DNA and new cells
• folate
• vitamin B-12
• iron: to support enlarged blood volume and provide for placental and fetal needs;
supplement needed;
• zinc
5. Nutrients for Bone Development
• vitamin D
• calcium
 Folic Acid

• Reduces risk of having a baby with neural tube

defects
• Reduces the risk of premature birth
• Recommended amount of folic acid is 0.4 milligrams
(400 micrograms) per day
Neural Tube Defects
Good Sources of Folic Acid
• Green leafy vegetables
• Fortified cereals
 Iron

• Reduces the risk of premature birth and low birth

weight .

• Not getting enough iron could cause anemia

• Could contribute to developmental delays and behavioral

disturbances in the infant and poor health in the mother
• Contributes to mortality and other health problems
 Good Sources of Iron
• Lean red meat
• Green leafy vegetables
• Fortified breakfast cereals
 Omega-3 Fatty Acids

• Important for brain development and preventing

preterm birth
• Essential for visual development
• Reduces the incidence of heart disease and heart
related death of the infant
• Recommended 300 milligrams per day
 Good Sources of Omega-3 Fatty Acids
• Fish oil capsules
• Certain fish such as salmon, trout, mackerel, sardines, and fresh tuna
• Vegetable oils such as sunflower , flaxseed, and walnut oils
 Calcium and Vitamin D

• Calcium and vitamin D are needed for strong bones

and teeth

• Vitamin D is needed for the formation of the fetal

bones

• Recommended 10 micrograms of Vitamin D per day

Good Sources of Calcium and Vitamin D

• Milk and other dairy products

• Eggs
• Meat
• Certain fish such as salmon, trout, mackerel,
sardines, and fresh tuna
 Vitamin A and Iodine

• Vitamin A is needed in small amounts to protect the

fetus from immune system problems, blindness,
infections, and death
• Can cause birth defects in high doses
• Lack of iodine could contribute to stillbirth, birth
defects, and decreased brain development
• Iodine is important for brain development
Nutrition-Related Concerns during Pregnancy

• Nausea
• Keep crackers by bedside; arise slowly; eat bland foods;
eat whatever sounds good; include protein; eat regularly
• Constipation and Hemorrhoids
• Eat high fiber; exercise; drink fluids; go when need to;
• Heartburn
• Eat slowly; relax; small frequent meals; avoid food
offenders; don’t lie down after eating;
Nutrition-Related Concerns during Pregnancy

• Food Cravings
• Strong desires to eat particular foods
• Don’t reflect real physiological needs
• Due to hormone-induced changes in sensitivity to taste
and smell
• Food Aversions
• Strong desires to avoid particular foods
• Nonfood Cravings
• Pica: cravings for nonfood items such as laundry starch,
clay, dirt, ice
• Cultural phenomenon not a response to nutrient need
Critical periods During Pregnancy

• Times during which tissues and organs

differentiate and mature.
• If proper “building” blocks (proteins,
carbohydrates, lipids) are not present the
tissue/organ does not develop properly and
cannot catch up.

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Diet in relation to pregnancy outcomes
• Human gestation is long and has evolved to maximize the growth of the
brain and produce an infant.
• In this period the developing infant is vulnerable to adverse factors that
impact upon the mother.
• Miscarriage and stillbirth
• Miscarriage, also is defined as the natural end of pregnancy at a stage
of fetal development prior to the fetus being capable of survival.
• With modern medical technology, fetuses of 23–24 weeks gestation
may be considered viable, so miscarriage refers to loss of pregnancy
prior to this stage.
Diet in relation to pregnancy outcomes
• Pre-pregnancy BMI and pregnancy weight gain
• The relationship between pre-pregnancy BMI and weight gain in
pregnancy is important.
• Obesity and overweight are widely regarded as risk factors for
preterm delivery.
• Results in increased prevalence of complications of pregnancy due to
high BP and relative insulin resistance that accompany obesity.
• Results in increased medical interventions and premature induction
of labor.
Nausea and vomiting of pregnancy (NVP)
• NVP as a normal physiological process
• NVP is a commonly reported symptom associated with early pregnancy.
• Most studies show the prevalence of NVP is between 60% and 80%.
• Hyperemesis gravidarum:
• The severity of NVP symptoms varies enormously between women
• Rarely the extent of those symptoms become so great that there is a threat
to the health of the pregnant woman or her child.
• The severity of HG symptoms will generally result in hospitalization for
treatment using vitamin supplements, and intravenous infusion of fluids and
electrolytes.
Cravings and aversions

• Surveys of the prevalence of food aversions and cravings suggest that

between 50% and 60% of women will experience these changes to
their eating and drinking behaviors.
• Aversions reported by pregnant women are most commonly to
caffeine-based drinks, red and white meats, fish, and eggs.
• Cravings in early pregnancy are often for foods with a high sugar
content, with sweets, chocolate, and cakes being widely favored,
along with fruit and fruit juices.
• The reasons why women develop cravings and aversions in pregnancy
are not well understood.
Cravings and aversions

• Pica :
• Pica represents an extreme form of craving behavior.
• Pica is the ingestion of substances that have no nutritive value and pica
behaviors include:
a) The consumption of clay or soil (geophagia),
b) Ice (pagophagia),
c) laundry starch (amylophagia), or other substances such as soap or chalk.
• Pica in pregnancy appears to be a behavior that is most commonly
associated with women of low socioeconomic status
Dietary Quality and Timing: The First Trimester

• Both the amount of a nutrient and its timing of intake are

extremely important to fetal development.
• The first trimester is a time of rapid cell division, organ
development, and preparation for the demands of rapid fetal
growth that occur later in pregnancy.
• Critical nutrients during this phase include:
• Protein
• Folic acid
• Vitamin B12
• Zinc

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Energy Needs During Pregnancy

• Extra Energy Needs for Normal Weight Women:

• First trimester - 0 kilocalories/day
• Second trimester - 350 kilocalories/day
• Third trimester - 500 kilocalories/day
• There is great variability among pregnant women with
regard to energy costs during pregnancy related to
differences in body size and lifestyles.
• Appropriate weight gain and appetite are better
indicators of energy sufficiency than the amount of
kilocalories consumed.
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High-risk pregnancies
• A number of pregnancies may be considered to be at higher than
normal risk:
• These require close monitoring and possible medical intervention in
order to ensure a successful outcome.
• Gestational diabetes : Gestational diabetes is a syndrome of insulin
resistance that develops during pregnancy.
High-risk pregnancies
• Multiple pregnancies
• Multiple pregnancies (twins, triplets, quadruplets, or greater) are
associated with significantly greater risks for a number of adverse
maternal and fetal outcomes of pregnancy.
• Fetal alcohol spectrum disorders
• Extremes of alcohol consumption, for example, where pregnant woman
is an alcoholic, are associated with a range of fetal abnormalities that
are collectively known as the fetal alcohol spectrum disorders (FASD).
• The prevalence of these disorders is difficult to estimate as affected
children can be undiagnosed until they reach school age.
 High-Risk Pregnancies

• Maternal weight
• Maternal nutrition
• Socioeconomic status
• Lifestyle habits
• Age
• Previous pregnancies
• number; interval; outcomes; birthweight; multiples
• Maternal health
• high blood pressure; diabetes; chronic disease
Conditions occurring in extremes of weight

• Excessive weight gain

• Increased risk of gestational diabetes, pregnancy induced
hypertension & pre-eclampsia
• Increased risk of congenital defects
• Increased risk of fetal macrosomia
• Increased risk of abnormal labour, emergency C-Section
• Risk of overweight or obesity post-partum
• Risk of T2DM post partum

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Conditions occurring in extremes of weight

• Inadequate weight gain

• Increased risk of low birth
• Increased risk of infant morbidity and mortality
• Effect of energy-sparing adaptations
• Degenerative disease in adulthood

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Conditions That May Result in Inadequate Nutrient Intake and
Weight Gain During Pregnancy

• Nausea and vomiting

• Heartburn
• Constipation
• Food aversions – caffeinated beverages, and meats.
• Food avoidances – milk, lean meats and liver.
• Poor pre-pregnancy diet:
• Inappropriate dietary patterns
• History of frequent dieting or eating disorders
• Excessive physical activity

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 What to Avoid

• Cigarette smoking (incl. second-hand):

• Decreases vitamin C absorption
• Produces toxins - nicotine and cyanide
• Causes vasoconstriction
• Is associated with low birth weights
• Medicinal drugs and herbal supplements: NO, incl.
aspirin and ibuprofen; consult your physician.

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What to Avoid

• Illegal drugs
• Environmental contaminants: mercury and lead (some
large ocean fish).
• Mega vitamins/minerals: especially vitamin A. Prenatal
vitamins – YES.
• Dieting: NO
• Sugar substitutes and caffeine – avoid or limit.

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Summary
• Pregnancy is accompanied by major maternal adaptations that support
the development of the placenta and allow fetal growth and development.
• These adaptations, and the growth of the fetus, greatly increase the
demand for energy and nutrients.
• Changes to maternal physiology, behavior, and the mobilization of pre-
pregnancy stores are often sufficient to meet requirements for nutrients
without changes to intake.
• Optimal maternal weight gain in pregnancy is a key determinant of
pregnancy outcome.
• Advised weight gains vary depending upon pre-pregnancy BMI.
Summary
• Nutrition-related factors are predictive of a number of adverse pregnancy
outcomes, including miscarriage and stillbirth, GDM, preterm delivery, and the
hypertensive disorders of pregnancy.
• Maternal obesity is a major risk factor for most of the adverse pregnancy
outcomes.
• NVP is a normal feature of the early stages of most pregnancies.
• These symptoms may be protective and are associated with a lower risk of early
miscarriage.
• HG is the most extreme form of nausea and vomiting in pregnancy.
• This condition requires robust intervention as it is associated with greater risk of
both maternal fetal deaths.