Nutrition during Pregnancy & Lactation A New Perspective

1. Nutrition during Pregnancy & Lactation
A New Perspective
Narendra Malhotra
Jaideep Malhotra
drnarendra@malhotrahospitals.com
jaideepmalhotraagra@gmail.com
FOGSI’S ADBHUT MATRUTVA INITIATIVE

2. Maternal Nutrition Overview
 At no other time in woman’s life is nutrition so important as
before, during and after pregnancy
• Preconception nutrient needs
• Pregnancy increased nutrient demands
• Lactation nutrient needs

3. Maternal Nutrition Issues
Effect of nutritional inadequacies at different
points in the life cycle

5. Maternal Malnutrition: A Life-Cycle Issue (1)
 Infancy and early childhood (0-24 months)
• Suboptimal breastfeeding practices
• Inadequate complementary foods
• Infrequent feeding
• Frequent infections
 Childhood (2-9 years)
• Poor diets
• Poor health care
• Poor education

6. Maternal Malnutrition: A Life-Cycle Issue (2)
 Adolescence (10-19 years)
• Increased nutritional demands
• Greater iron needs
• Early pregnancies
 Pregnancy and lactation
• Higher nutritional requirements
• Increased micronutrient needs
• Closely-spaced reproductive cycles

7. Maternal Malnutrition: A Life-Cycle Issue (3)
 Throughout life
• Food insecurity
• Inadequate diets
• Recurrent infections
• Frequent parasites
• Poor health care
• Heavy workloads
• Gender inequities

8. Fetal origin of adult diseases
It is now widely accepted that the
risks of a number of chronic diseases
in adulthood such as diabetes
mellitus, hypertension and coronary
heart disease may have their origins
before birth
JK Science, Dep of obs & gyn,
Indraprastha hospital, 2007, 9(4)

9. Confidential © 2011 Abbott Nutrition
Programming Effects of
Maternal Undernutrition

10. Effects of undernutrition
Ref: Maternal nutrition: Effects on health in the next generation Caroline Fall; Indian J Med Res 130, November 2009, pp 593-599
Cortisol
Maternal
diet
Uteroplacentral
blood flow
Placentral
transfer
Fetal
genome
Nutrient demand exceeds supply
FETAL UNDERNUTRITION
Brain sparing Down regulation
of growth
Early
Maturation
Altered
body
composition
Impaired development:
bloodvessels,liver,
kidneys,pancreas.
↓ Insulin/IGF-1
Secretion and
sensitivity
Central
obesity
Insulin
resistance
Hyperlipidaemia
Hypertension
Type 2 diabetes and CHD
Muscle ↓

11. Conceptual frameworks for how maternal diet and
micronutrients status may affect the development of chronic
disease in the offspring
Ref: Stewart CP, J Nutr 2010 140(10): 437-445 PMID 20071652
Hormonal adaptations
Fe,Zn,Ca
•Increased stress hormones
•Decreased somatotrophic
hormones(GF,Insulin)
Epigenetic gene
regulation
Folate ,Vitamin B-12
Restricted foetal growth and
development
Maternal micronutrient deficiency
Renal function
Fe, Zn,Vitami n A foalte
•Impaired
nephrogenesis/
Reduced
nephronendowment
•Reduced GFR
•Increased sodium
sensitivity
Cardiovascular function
Fe,Zn,Viatmin A folate
•Impaired
vascularization
•Malformations
•Cardiac hpertrophy
Pancreas / β –cell
function
Fe,Zn,folate,Vitamin
B-12
•Reduction in
number and area of
β - cell
Body composition
Mg,Zn,folate,Vitamin
B-12
•Reduced lean body
mass
•Altered fat deposition
or metabolism
•Sedentary behaviour
•Altered appetite
•regulation
Primary Function
Vitamin A,Vitamin D
•Reduced bronchial
branching & alveoli
•Reduced elastin
•Reduced VEGF
•Chronic respiratory
infections
•Reduced lung
capacity
Hypertension
Insulin resistance
and β – cell
dysfunction
Cardio metabolic
risk

12. Maternal nutrition
 A healthy, balanced diet that
contains adequate amounts
of nutrients is essential for
the development of a baby
 During pregnancy and after
delivery, a mother’s body
goes through many
physiological changes,
including a need for
increased nutrients and
energy

13. The Nutritional Status Of
Pregnant Women In India

14. Current scenario in India
 18% of pregnant women consumed
< 50% of calories
 34% of pregnant women consumed <50%
of protein
 85% of pregnant women consumed <50%
iron
 57% of pregnant women consumed <50%
b-caroten - relative to their
RDA(recommended dietary allowance)
Ref: Indian Pediatrics 1999; 36: 991-998

15. Current scenario in India
 Pregnant women with the calorie
consumption of less than 50% of the
recommended had a lower serum zinc level
compared to the women who had a higher
calorie intake
Asia Pac J Clin Nutr 2008;17 (2):276-279
 Results on dietary intake showed that 18%,
34%, 85% and 57% of the pregnant women
were consuming less than 50% of calories,
proteins, iron and b-carotene, respectively as
compared to their RDA

16. Average intake of nutrients
J Hum Ecol, 29(3): 165-170 (2010)

17. Study from Andhra Pradesh
European Journal of Clinical Nutrition 2003; 57, 52–60

18. Study from northern India
Maternal and Child Nutrition (2008), 4, pp. 86–94

19. Calcium Status in India
 Indian RDA for non-pregnant women has
been increased from 400 mg/day to 600
mg/day.
 Over 50% of women, are not meeting
this number
 There is evidence of calcium depletion,
measured by bone mineral density,
particularly in women after repeated
pregnancy and lactation

20. Vitamin D status in India
 Rickets has become rare, but
recent studies from North and
South India show that vitamin D
deficiency exists in adults
based on serum levels of 25-
hydroxy vitamin D2

21. Vitamin D status in India (Review article)–
Summary of Indian studies
 All studies uniformly point to low 25(OH)D levels in the
populations studies despite abundant sunshine in our country
 All studies have uniformly documented low dietary calcium
intake compared to Recommended Daily/Dietary Allowances
(RDA) by Indian Council of Medical Research (ICMR)
 Vit D status of children - very low in both urban and rural
populations
 Pregnant women and their new born had low vitamin D status
 Dietary calcium supplementation had positive effect on
25(OH)D levels
JAPI, 2009; (57):40-48

22. Presentation Title
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Nutrient Intake of Lactating Mothers from Hisar
- Ind Jr Social Research 1998;39(2):91-99

23. Pregnancy – importance of nutrients
 There are periods before and during
pregnancy in which specific
nutrients are required for optimal
development.
 There is growing evidence that
optimal dietary intake of important
nutrients, like iodine,
docosahexaenoic acid (DHA),
choline, and folate, is necessary
during pregnancy and lactation
Am J Clin Nutr 2009;89(suppl):685S–7S

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25. Presentation Title
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BRAIN NUTRIENTS

26. DHA
 Docosahexaenoic acid (DHA, 22:6n23)- limited
capacity for synthesis inside body, hence
conditionally required in diet
 Major omega-3 fatty acid needed to build fetal brain
 Critical period during which dietary DHA may be
needed to optimize brain development extends from
mid-pregnancy into the first year of life
 DHA accumulation in fetal brain is most rapid during
the last intrauterine trimester & first year of life
Am J Clin Nutr 2009;89(suppl):685S–7S
Brain Nutrients

27. Folate, Choline
 Folate is an essential vitamin, whereas choline is class
of nutrients for which there is limited capacity for
synthesis inside body, & therefore conditionally
required in the diet
 Choline is required for membrane synthesis,
methylation reactions, and for neurotransmitter
synthesis
 Maternal dietary deficiency of either choline or folic
acid diminishes new nerve formation (neurogenesis)
and increases neural cell death in the fetal brain
Am J Clin Nutr 2009;89(suppl):685S–7S
Brain Nutrients

28. Iodine
 Providing adequate iodine in mid-to-
late pregnancy improves infant
cognitive development, there are
greater benefits when iodine is given
before or early in pregnancy
Am J Clin Nutr 2009;89(suppl):685S–7S
Brain Nutrients

29. Iodine
 WHO increased their recommended iodine intake during
pregnancy from 200 to 250 mcg/d & suggested a median
urinary iodine (UI) concentration of 150– 249 lg/L indicates
adequate iodine intake in pregnant women
 Cross-sectional studies - reported impaired intellectual
function & motor skills in children from iodine-deficient areas
 An adequate iodine supply should continue after child birth
 Iodine requirement of women who is fully breastfeeding her
infant is even higher than that during pregnancy
Brain Nutrients

30. Choline
 Choline status during pregnancy influences brain
development in fetus
 Transport of choline from mother to fetus depletes maternal
plasma choline
 Demand for choline is so high that stores are depleted
 Hence supply of choline is critical during pregnancy
 Because milk contains a great deal of choline, lactation
further increases maternal demand for choline, resulting in
further depletion of tissue stores
Brain Nutrients

31. Choline
 During pregnancy and lactation - maternal reserves depleted
 At the same time, the availability of choline for normal
development of brain is critical
 Lack of choline in a mother’s diet during pregnancy and
lactation may have life-long adverse effects on their child
 The Institute of Medicine (IOM) of the National Academy of
Sciences set an adequate intake (AI) level for choline of 550
mg/day for men and 425 mg/day for women
Journal of the American College of Nutrition, 2004; 23 (6), 621S–626S
Brain Nutrients

32. Folic acid
 Neural Tube Defects (NTDs) are common (the most common
malformations of the central nervous system and probably
second only to cardiac defects) among major congenital
anomalies
 Maternal folic acid supplementation prevents a substantial
proportion of NTDs
 American College of Obstetricians and Gynecologists &
American Academy of Pediatrics, Food and Nutrition Board of
the Institute of Medicine also recommended that all women
capable of becoming pregnant should consume 0.4 mg of
folate daily from supplements or fortified foods or a
combination of the 2 in addition to consuming folate from a
varied diet
Am J Clin Nutr 2007;85(suppl):285S– 8S
Brain Nutrients

33. Folic acid
 Plays important role in nucleic acid synthesis
 Marginal folate intake during gestation can impair
cellular growth & replication in the fetus or placenta
 Sustained intake after complete closure of the neural
tube to decrease the risk of other poor pregnancy
outcomes
 During pregnancy, low concentrations of dietary and
circulating folate are associated with increased risks
of preterm delivery, infant low birth weight, and
fetal growth retardation
Am J Clin Nutr 2000;71(suppl):1295S–303S
Brain Nutrients

34. GROWTH NUTRIENTS
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35. Calcium
 Developing fetal skeleton accumulates about 30 g of calcium
by term, about 80% of it during the third trimester
 Women lose 300 to 400mg of calcium daily through breast
milk, this calcium demand is met by a 5–10% loss of skeletal
mineral content during 6 months of exclusive lactation
 Women nursing twins, Ca losses may be as great as 1000 mg
or more
 Limited maternal intake of Ca & other minerals may adversely
affect fetal skeletal development, or perhaps lead to severe
losses of maternal bone mineral content during pregnancy
 Low calcium intake might adversely affect fetal development,
and is important to recommend calcium supplementation
during pregnancy
Journal of Mammary Gland Biology and Neoplasia,2005,10(2)
Growth Nutrients

36. Vitamin D
 Maternal vit D deficiency during pregnancy was reported about 18% in UK,
25% in the UAE, 80% in Iran, 42% in northern India, 61% in New Zealand
and 60–84% of pregnant non-Western women in the Netherlands, have
been shown serum concentrations of 25(OH)D [25 Hydroxy vitamin D3]
<25 nmol/l
 Studies show that infants are entering the world with a vitamin D deficit
that begins in utero (within womb of mother)
 Concern is based on the strong relationship between maternal and fetal
(cord blood) circulating 25(OH)D levels, studies from many countries, have
demonstrated a high prevalence of vitamin D deficiency in mother-infant
pairs at birth
 Significance of maternal deficiency during pregnancy - fetus developing in
a state of hypovitaminosis D, which likely has significant effects on fetal
and childhood bone development
Am J Clin Nutr 2009;89(suppl):685S–7S
Growth Nutrients

37. Vitamin D
 Risk of osteoporotic fracture in adulthood could be determined partly
by environmental factors during fetal life and early infancy
 In a longitudinal study, 198 children born were followed up for 9 years
of age.
 Body builds, nutrition, and vit D status of mothers recorded during
pregnancy
 Children were followed up at age 9 yrs to relate these maternal
characteristics to their body size and bone mass
 Reduced concentration of 25(OH)-vitamin D in mothers during late
pregnancy was associated with reduced whole-body and lumbar-spine
bone-mineral content in children at age 9 years
 Reduced concentration of umbilical-venous calcium also predicted
reduced childhood bone mass
 Vitamin D supplementation of pregnant women, could lead to
reductions in the risk of osteoporotic fracture in their offspring
Lancet 2006; 367: 36–43
Growth Nutrients

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IMMUNE NUTRIENTS

39. Vitamin C, Zinc
 Vitamin C concentrations in the plasma and white blood cells
(leukocytes) rapidly decline during infections and stress
 Supplementation of vitamin C was found to improve
components of the human immune system such as
antimicrobial and natural killer cell activities, lymphocyte
proliferation and other immune reactions
 Vitamin C contributes to maintain integrity of cells and
thereby protects them against reactive oxygen species
generated during the metabolic reactions and the
inflammatory response
 Zinc under-nutrition or deficiency was shown to impair
cellular intermediates of innate immunity such as
phagocytosis ,natural killer cell activity, and other immune
mechanisms
Ann Nutr Metab 2006;50:85–94
Immune Nutrients

40. Vitamin E
 Vitamin E is nature’s most effective lipid-
soluble, chain-breaking antioxidant,
protecting cell membranes from peroxidative
damage
 Research evidence suggests that an adequate
intake of vitamin E and the other antioxidants
can provide protection from the increasingly
high free-radical concentrations caused by air
pollutants and current lifestyle patterns
Am J Clin Nutr l99l;53: 10505- 55
Immune Nutrients

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DIGESTIVE NUTRIENTS

42. FOS (Fructo-oligo saccharides)
 Stimulate the growth of beneficial bacteria present
in colon
 Growth of beneficial bacteria helps in keeping
healthy and strong large intestine.
 Prebiotics keep
• Beneficial bacteria healthy
• Have lipid reducing activity,
• Boost the immune system
• Help in improving mineral absorption and balance,
• Clear the gut of harmful microorganisms,
• Help in prevention of constipation and diarrhea
Pharma Times - Vol 40 - No. 9 - September 2008
Digestive Health

43. FOS
 Human gut micro-flora can play a major role in host
health.
 Prebiotics are nondigestible food ingredients that
beneficially affect the host by selectively stimulating
the growth and/or activity of one or a limited
number of beneficial bacterial species already
resident in the colon, and thus help to improve host
health.
 Intake of prebiotics can significantly modulate the
colonic micro-flora by increasing the number of
beneficial bacteria and thus changing the
composition of the micro-flora.
J. Nutr. 125: 1401-1412, 1995
Digestive Health

44. Nutraceuticals
 "Nutraceutical" is a made-up word combining the
words nutrition and pharmaceuticals, creating the
concept that extracts from food can be used as
drugs, i.e. food supplements
 Nutraceuticals (often referred to as phytochemicals
or functional foods) are natural, bioactive chemical
compounds that have health promoting, disease
preventing or medicinal properties

45. nutraceuticals
 There is a lot of confusion regarding the terminologies like
“nutraceuticals”
 “functional foods”
 “dietary supplements”
 “designer foods”
 “medical foods”
 “pharmafoods”
 “phytochemicals” etc.

46.  Nutraceuticals have been claimed to have a physiological
benefit or provide protection against the following
diseases (and/or found to act as)
 Cardiovascular agents
 Antiobese agents
 Antidiabetics
 Anticancer agents
 Immune boosters
 Chronic inflammatory disorders
 Degenerative diseases

47. Phytochemicals
 A phytochemical is a chemical that
acts as nutraceutical or dietary
supplement that comes from
plants
• Isoflavones from soy
• Antioxidants from
vegetables
• Lycopene from tomatoes

48. Actions of nutraceuticals in PIH
 Antioxidant pathway
 Inflamatory pathway
 Immunomodulation

49. Actions of nutraceuticals
 Inhibits the production of proinflammatory cytokines in
vascular intima tissue.
 Reverses impaired NO production .
 Positive impact on platelet aggregation, triglycerides and LDL

50. Herbs , flowers , ayurvedic medicinal plants

51. Some examples of nutrients and
nutraceuticals
•Vit c
•Vit e
•Zn
•Beta carotenes
•Carotenoids
•Glutathione
Flavonides Selenium
Copper
Mangnese
Vit a
Lycopene
L arginine

52. Fruits , legumes , vegetables
Tomatoes, oranges, apricots, garlic, brocolli,
Fruit- juices, legumes, sprouts

53. nutraceuticals
(mechanism of action)
 Nutrients and nutraceuticals
with calcium channel blocking activity
(thus antihypertensive activity) include α-Lipoic
acid, magnesium, Vitamin B6 (pyridoxine), Vitamin C,
N acetyl cysteine, Hawthorne, Celery, ω-3 fatty acids
etc12.

54. Flavonoids
 Flavonoids are widely distributed in onion,
endives,cruciferous vegetables, black grapes, red
wine,grapefruits, apples, cherries and berries13
 Flavonoids block the angiotensin-converting enzyme
(ACE) that raises blood pressure; by blocking the
"suicide" enzyme cyclooxygenase that breaks down
prostaglandins, they prevent platelet stickiness and
hence platelet aggregation.

55. Dietary fiber
 Dietary fiber preparation from
defatted rice bran has laxative and
cholesterol-lowering ability with
attendant benefits towards
prevention or alleviation of
cardiovascular
disease, diabetes, diverticulosis and
colon cancer.

56. Omega 3 – fatty acids
 Fatty acids of the omega-3 series
(n-3 fatty acids) present in fish
are well established dietary
components affecting plasma
lipids and the major
cardiovascular disorders, such as
arrhythmias.

58. The evidences
A Peer-Reviewed Journal on Nutraceuticals and Nutrition
ISSN-1521-4524
The Role of Vascular Biology,
Nutrition and Nutraceuticals in the Prevention
and Treatment of Hypertension
Mark C. Houston,MD, SCH, FACP, FAHA
The Journal of the American Nutraceutical Association
Supplement No. 1 April 2002

59. Controversy
 The relationship between calcium and risk of
hypertension is inconsistent and inconclusive, and
the relationship between calcium and risk of
pregnancy-induced hypertension and preeclampsia is
highly unlikely.
 Treatment with beta carotene,vitamin A, and
vitamin E may increase mortality. The potential roles
of vitamin C and selenium on mortality need further
study.

60. The results, however, with supplemental magnesium,
calcium, potassium, omega fatty acids, garlic, tea,
mushrooms, and seaweed have been inconsistent,
and should not be recommended for blood pressure
reduction.
On the other hand, observational studies with
vitamins E and C, as well as Coenzyme Q-10 and L-
arginine, have been associated with more consistent
blood-pressure-lowering effects in those with
hypertension.

61.  Accordingly, Houston suggests that
"there is a role for the selected use of
single and component nutraceuticals,
vitamins, antioxidants, and minerals in
the treatment of hypertension based on
scientifically controlled studies as a
complement to optimal nutritional,
dietary, and
other lifestyle modifications."

62. conclusion
 Nutraceuticals have a direct role in PIH
 May have a role in prevention, arrest of progression of the
disease.
 Further research is needed in this field

63. Overall care during pregnancy and lactation

64. Intervention - Preconception
 Visit to doctor
 Change in lifestyle
 Diet and nutrition
• Weight control
• Use of vitamins or other supplements
• Eating habits, such as a vegetarian diet or fasting
 Keeping fit
 Medical conditions
http://www.acog.org/publications/patient_education/bp056.cfm

65. Principles – Antenatal advice
 Regular health check up
 Maintain or improve health status
to optimum status till delivery by
judicious advice regarding diet,
drugs and hygiene
 Improve and tone up psychology by
explaining principal changes &
events likely to occur during
pregnancy and labour
Dutta D.C. Text book of obs, 2004

66. Diet
 Starting a healthy diet before pregnancy
 Diet - Quantity and quality
 Basic and extra nutrients for
• Maintenance of maternal health
• Needs of growing fetus
• Strength and vitality required during labour
• Successful lactation
 Special concerns
http://www.acog.org/publications/patient_education/
bp001.cfm
Dutta D.C. Text book of obs, 2004

67. Planning healthy meals
 Include all food groups in
diet
• Vegetables & fruits
• Milk and dairy foods
• Cereals & Grains
• Meat, beans, and eggs
• Fats and oils

68. Confidential © 2011 Abbott Nutrition
MEAL PLANNING FOR PREGNANT WOMEN

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76. Special concerns
 Caffeine
• Limited intake during pregnancy
• Excess caffeine can interfere with sleep and contribute to nausea and light-
headedness
• Can increase urination and lead to dehydration
 Vegetarian diets – low intake of iron, vitamin B12, vitamin D
 Pica
• Strong urge to eat nonfood items such as clay, ice, laundry starch, or
cornstarch
• May affect intake of nutrients and can lead to constipation and anemia

77. Supplementary nutrition
 Personal food preferences, lifestyle habits and
special needs may affect the intake of
nutrients
 Essential vitamins lacking in diet or destroyed
during cooking
 Nutritional supplements are one of the ways
to fill the nutritional gap that may be arising
due to improper diet
 It fills the gap by providing the vitamins,
minerals, and other substances that may be
missing out

78. Vital nutrients in breast milk
 Breast milk provides all the nutrients a baby
needs to grow well for the first six months of
life. The key nutrients in breast milk support
the optimal growth and development of the
baby and all organs and systems.
 Breast milk contains:
• DHA and AA - building blocks of brain & eye
development
• Taurine & choline - support overall mental development
& functioning.
• Calcium and vitamin D for bone development
• Many protective factors that protect the infant from
infections
• Fat, protein and carbohydrate, which are easily digested
and absorbed

79. Company Conf
Mother’s nutrition influences the
composition and quality of breast milk
 The nutritional needs of a
breastfeeding mother is high -
increased demand for Energy, Vitamins
C, B12
• Nutrients consumed by mother is
transferred to the growing baby to support
its growth and development.
• Nutritional deficiencies may develop during
this period and affect both mothers and
infants
 Maintaining a diet of fruits, vegetables,
whole grains, lean meats, and dairy
products regularly will help to meet
nutritional needs

80. Nutrition during lactation
 Human milk feeding is adequate as the sole source of
nutrition for up to age 6 month providing that the maternal
diet and reserves are adequate and a sufficient quantity is
transferred to the infant
 Milk secreted in 4 months represents an amount of energy
roughly equivalent to the total energy cost of pregnancy
 As with energy, recommended intakes for several vitamins
and minerals are higher in lactation than in pregnancy
 Maternal nutritional adequacy does influence performance
indexes both in pregnancy and lactation

81. Method to enhance active
components in food
 Manipulating the diet to get maximum
level of active components
 Combination of food ingredients rich in
nutraceuticals
 Fortifying food with active ingredients
 By fermentation of food products
 Changing food habits to natural type of
diet

82. CONCLUSION
 Nutraceuticals are present in most of the food ingredients with
varying concentration
 Concentration, time and duration of supply of nutraceuticals
influence human health
 Manipulating the foods, the concentration of active ingredients can
be increased
 Diet rich in nutraceuticals along with regular exercise, stress
reduction and maintenance of healthy body weight will maximise
health and reduce disease risk

83. “The doctor of the future will give no medicine, but will
interest his patient in the care of the human frame, in diet and
in the cause and prevention of disease” –
Thomas Edison.

84. thank you

99. AIMS OF OBSTETRICAL CARE IS
so both are safe and Happy

100. A fetal programmed baby of the future……………………..