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
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
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.
16. 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)
17. 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%.
20. 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
21.
22.
23.
24. 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.
25. 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.
26. 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
27. 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.
28. 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
29. Sources of Thiamine – grains, cereals
Sources of Riboflavin – meat, liver, grains
Sources of Nicotinic acid – meat, nuts, cereals
Sources of Vitamin B12 – animal proteins
30. 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)
31. 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
32. 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.
33. Exclusive breastfeeding is recommended for the first 6 months of
life and is associated with decreased incidence of infections and
chronic diseases.
34. 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
