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Nutrition in pregnancy copy.pptx

  1. Dr.Ankita gaur Dr. Nidhi k shah
  2. • In terms of nutrition, pregnancy and lactation is a state of increased demand for energy, proteins, vitamins, and minerals to due to increased growth of the maternal tissues, foetus, placenta and increased basal metabolic rate. • Inappropriate energy or protein intakes in pregnancy has been linked with an increased risk of non-communicable diseases such as type 2 diabetes and obesity in the offspring. • Calorie requirement : 300 kcal over the nonpregnant state. • Average weight gain during pregnancy : 10-12.5 kg • The weight gain should not exceed 2.5 kg in a month or 0.9 kg in a week. • Excessive weight gain is associated with Gestational hypertension and (birth weight > 4 kg) • Low weight gain (<6 kg) is associated with Intrauterine growth restriction
  3. Recommended weight gain for singleton pregnancies: (WHO ) (IOM )
  4. Special conditions -  MULTIPLE GESTATION - For twin pregnancy, the IOM recommends a gestational weight gain of 17-25 kg (37–54 lb) for women of normal weight, 14-23 kg (31–50 lb) for overweight women, and 11-19 kg (25–42 lb) for obese women.  BARIATRIC SURGERY AND PREGNANCY - All patients are advised to delay pregnancy for 12- 18 months after surgery to avoid pregnancy during the rapid weight loss phase. Patients should be evaluated for nutritional deficiencies, including iron, B12, folate, vitamin D and calcium, and supplemented with vitamins as necessary.  ADOLESCENT PREGNANCY - Mean GWG ranges from 10.0 to 16.7 kg in normal weight adults whereas 14.6 to 18.0 kg in adolescents giving birth to term infants.
  5. Recommended dietary allowances in Indian women (macronutrients, vitamins, and minerals) Nutrient Non-pregnant Pregnant Lactation Energy (Kcal/d) 2850 3200 3450 Protein (g/d) 55 78 74 Iron (mg/d) 21 35 21 Calcium (mg/d) 600 1200 1200 Vitamin B12 (μg/d) 1 1.2 1.5 Folate (mg/d) 200 500 300
  6. Nutrient Non-pregnant Pregnant Lactation Vitamin A (μg/d) 600 800 950 Ascorbic acid (mg/d) 40 60 80 Niacin (mg/d) 16 18 20 Riboflavin (mg/d) 1.7 2 2.1 Thiamine (mg/d) 1.4 1.6 1.9 Vitamin B6 (mg/d) 2.0 2.5 2.5 Zinc (mg/d) 10 12 12 Iodine (mcg/d) 150 220 290 Magnesium (mg/d) 310 310 310
  7. Pregnancy diet should ideally be light, nutritious and easily digestible. The diet should consist of milk, green vegetables and fruits and should be salt restricted. Dietic advice should be given with due consideration to the food habits, socioeconomic status and should be reasonable and realistic.
  8. The diet during pregnancy should be adequate to provide : 1.Good maternal health 2.Optimal foetal growth 3.The strength and vitality required during labour 4.Successful lactation
  9. Deficiency of macronutrients, micronutrients and its complications in pregnancy and lactation Micronutrient deficiency Complications in pregnancy Iron • Anaemia • Preterm birth • Low birth weight (LBW) Vitamin B 12 • Macrocytic anemia • Neurologic dysfunction • Intrauterine growth retardation (IUGR) • Lbw • Preterm delivery • Pregnancy-induced hypertension • Neural tube defects Vitamin D • Autoimmune diseases • Asthma • Type 1 diabetes in the newborn (later in life) Calcium • Preclampsia Iodine • Cretinism Selenium • Miscarriage • Pre-eclampsia • Fetal growth restriction
  10. Consequences of maternal malnutrition Consequences for maternal health • Anemia • Increased infection • Lethargy and weakness, lower productivity • Increased risk of maternal complications and mortality Consequences for fetal health • Birth defects • Cretinism • IUGR, LBW, and prematurity • Increased risk of infection • Increased morbidity and mortality of fetus, neonates, and infants
  11. Pregnancy and protein metabolism  Active amino acid transfer takes place from the maternal circulation to the foetus.  There is improved dietary protein utilization and nitrogen retention to fulfil the enhanced demands of late pregnancy and to ensure an adequate supply of nutrients to the fetus..  An increased turnover of proteins is seen in early pregnancy as compared to nonpregnant women.  Increase in protein synthesis was reported by 15% in the second and 25% during the third trimester.  In late pregnancy - decreased urea synthesis - reduction in urinary nitrogen excretion - increased nitrogen retention.  A balanced protein energy supplementation during pregnancy improves fetal growth and reduces the risk of lbw in the baby.  Recommended protein intake in pregnancy – 60 g/day (1.1 g/kg/day)  Sources of protein – poultry, meat, fish, dairy products , soya chunks .
  12.  The diet of the pregnant woman should be reviewed at the booking visit and advice given.  The patient should be advised an adequate fluid intake.  Intake of caffeine and alcohol should be restricted.  Smoking should be restricted.  WELL BALANCED DIET  Daily caloric intake should be increased by 300 kcal  Daily caloric requirement in pregnancy – 2500 kcal  Daily protein intake should be increased by 15 g per day  Daily protein requirement in pregnancy – 60 g/day A normal diet reinforced with leafy vegetables, fruits, nuts and with atleast 500 ml of milk will meet the nutritional demands of a pregnancy. Bananas, groundnuts and jaggery are excellent supplements for low groups.
  15. FOLIC ACID  Folic acid supplementation is very important during the pre and periconception period as it reduces the risk of congenital malformations.  Folic acid supplementation of 400 mcg/per day should be given from 1 month prior to conception and to be continued till 3 month post conception.  Sources of folic acid : leafy vegetables, meat, liver, kidney, chicken, egg yolk, lentils, beetroot, almonds, banana, whole wheat grain,  Risk of deficiency : 1. Neural tube defects 2. Cleft lip, congenital heart disease 3. Megaloblastic anaemia 4. Preeclampsia (accumulation of homocysteine is associated with folate deficiency)  400 mcg (0.4 mg) folic acid supplementation is RECOMMENDED preconceptionally and throughout pregnancy for women with a history of congenital anomalies (neural tube defects, cleft palate)
  16. IRON  WHO lists iron deficiency as the major cause of anemia. Anemia is the direct cause of 3-7% of maternal deaths.  Supplementary iron therapy is needed for all pregnant women from 16 weeks onwards. Incidence – According to WHO  40% of world’s population suffers from anemia.  Pregnant and elderly constitute 50%.  Non pregnant women constitute 35%.  Incidence in India is about 40-60%.  ICMR reports Indian incidence as 62%.
  17. Intensified National Iron Plus Initiative (I- NIPI, 2018)
  18. Dietary sources rich in iron o Vegetables – spinach and fenugreek o Cereals – whole wheat, jowar and bajra. o Pulses – green peas and ground nuts o Fruits – apple and banana o Dates and jaggery o Liver, meat, fishes and egg
  19. Role of specific vitamins and minerals during pregnancy and lactation CALCIUM  Calcium is required for the growth and development of bones as well as teeth of the fetus.  Lactating woman produces about 750 ml of milk daily, which represents about 280 mg of calcium.  ICMR recommends a total of 1.2 g of calcium intake in pregnancy and to continue with 1.2 g during lactation.  Sources of calcium – milk, yogurt, cheese, green leafy vegetables like spinach & fenugreek, soybeans.  All women should be encouraged to consume a litre of milk a day. It provides 1 g calcium, proteins, vitamin A and Vitamin D.  80 % of the total foetal calcium is deposited in the third trimester.  Restrict salt intake as salt increases urinary excretion of calcium.
  20. Calcium supplementation helps in: 1.Reducing the risk of pregnancy-induced hypertension (PIH). 2.Proper formation, growth, and development of bones and teeth in the fetus. 3.Maintenance of fetal bone mineralization. 4.Secretion of breast milk rich in calcium. 5.Prevention of osteoporosis in the mother.
  21. VITAMIN D  Vitamin D helps to absorb calcium and phosphorous from dietary intakes.  Vitamin D deficiency is common during pregnancy, especially in high-risk groups like vegetarians, women living in cold climates, and women with darker skin.  Vitamin D can be synthesized in the skin through exposure to ultraviolet light or can be obtained through dietary intake. Sunlight exposure is infuenced by skin color, latitude, season, life style and cultural practice.  10-15 minutes sunshine, 3 times a week is enough to produce the body’s requirement of vitamin D.  Sources of Vitamin D – Fish, red meat, liver, egg yolk, butter, cheese, dairy products, mushroom  Vitamin D supplementation - 1000–2000 IU per day
  22. IODINE  In pregnancy, the iodine requirement is enhanced.  Iodine deficiency results in cretinism - retarded physical and mental development.  Sources of iodine : Iodized salt and sea food  Risk of deficiency : 1. Miscarriage 2. Still births 3. Congenital anomalies 4. Goiter 5. Neurological cretinism 6. Myxoedematous cretinism. 7. Hypothyroidism 8. Mental retardation with deafness, spastic diplegia, squint.
  23. ESSENTIAL FATTY ACIDS (FATS)  Omega-3 fatty acids particularly docosahexaenoic fatty acid (DHA) – impacts fetal and infant neurodevelopment.  Eicosapentaenoic acid (EPA) and DHA intake is recommended in pregnancy and lactation. MYO-INOSITOL is reported to play an important role in the mother and fetus, in preventing gestational diabetes. VITAMIN B GROUP (B1, B2, B3, B6, B9, AND B12) –  Enhances the immune system and reduces the plasma concentration of homocysteine.  Risk of vitamin b deficiency : (associated with elevated maternal plasma homocysteine) 1. Pre-eclampsia 2. Premature birth 3. LBW
  24.  Sources of Thiamine – grains, cereals  Sources of Riboflavin – meat, liver, grains  Sources of Nicotinic acid – meat, nuts, cereals  Sources of Vitamin B12 – animal proteins
  25. VITAMIN A  Adequate maternal dietary vitamin A is recommended in the maintenance of adequate levels in the breast milk.(RDA in pregnancy - 800 μg)  Sources of Vitamin A – vegetables, fruits, liver. VITAMIN E  Protects polyunsaturated fatty acid from free radical damage. VITAMIN C  Stimulates better absorption of iron  Acts as an antioxidant  Sources of Vitamin C – citrus fruits(lemon, sweet lime, orange)
  26. Lactation  First 4 days postpartum - colostrum  10 to 15 days - transitional milk  After 15 days – mature milk  Milk composition is dramatically altered:  Sodium and chloride concentrations fall  Lactose, immunoglobulin A (IgA), lactoferrin (LTF), and other components of mature milk increase.  The nutrient composition of human milk is strongly influenced by the stage of lactation.  During mammary involution,  The concentration of lactose decreases fivefold  The concentration of proteins increases six-fold with a high content of antibacterial proteins
  27. Nutritional Requirements of Lactating Mother  According to the WHO expert committee, the optimal daily milk output of the mother’s milk is estimated to be 850 ml.  The ICMR Nutrition Expert Committee has estimated that the average amount of milk secreted by lactating mothers in India to be 600 ml.  The effect of maternal nutrition during lactation (about 80% of energy, 50% of proteins and 30% of the calcium) is converted into the milk to the newborn.  During lactation, the mother requires an additional intake of energy (at least 550 kilocalories more). During the first 6 months of lactation and for the next 6 months, additional energy 400 kilocalories per day must be supplemented.  According to the ICMR and NIN, the recommended daily increment in protein intake in lactating women is about 20–30 g/day during lactation.
  28. Exclusive breastfeeding is recommended for the first 6 months of life and is associated with decreased incidence of infections and chronic diseases.
  29.  Human milk is the best nutrition source for infants, as it contains the right balance of essential nutrients and other bioactive factors such as hormones, antibodies, bioactive molecules, and stem cells.  Milk stimulates immunological competence and thus improves the survival of the offspring.  Current dietary intake, nutrient stores, and alterations in nutrient utilization are the three aspects of maternal nutrition that have an impact on human milk composition.  Lactating mothers should be supplemented with required nutrient supplementation to fulfill their own needs and needs of the feeding baby through healthy breast milk.  The fourth trimester : the transition period after childbirth  The fourth trimester is marked by significant biological, psychological, and social changes.  Mothers are faced with multiple challenges such as physical recovery, hormonal imbalance, disturbance of sleep, and care (feeding) of the newborn.  The mother must be provided with sufficient nutritional intake to their nutritional demand during the early postpartum period