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Chapter 4 Nutrition During Pregnancy


Chapter 4 Nutrition During Pregnancy Nutrition Through the Life Cycle Judith E. Brown Differences by Race Differences ... – PowerPoint PPT presentation

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Title: Chapter 4 Nutrition During Pregnancy

Chapter 4Nutrition During Pregnancy
Nutrition Through the Life Cycle Judith E. Brown
  • Topics covered include
  • Status of pregnancy outcome
  • Reducing infant mortality and morbidity
  • Physiology of pregnancy
  • Embryonic fetal growth and developmen
  • Pregnancy weight gain
  • Nutrition and course/outcome of pregnancy
  • Nutrient needs during pregnancy

  • Topics covered include
  • Exercise and Pregnancy
  • Food Safety issues during pregnancy
  • Common Health Problems during pregnancy

Time-related Terms Before, During, and After
The Status of Pregnancy Outcomes
  • Infant mortality
  • Reflects general health status of a population
  • Decreases in mortality related to improvements in
    social circumstances, safe nutritious food
    supply, infectious disease control

Natality Statistics Rates, Definitions, and
Trends in the Rates in the United States
Differences by Race
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Chronology of Events Related to Declines in
Infant Mortality in the United States
Low Birthweight, Preterm Delivery, and Infant
  • Low birth weight or preterm infants at high risk
    of dying in 1st year of life
  • 8.2 of births are LBW yet comprise 66 of infant
  • 12.7 are born preterm yet account for high
    incidence of infant deaths

Reducing Infant Mortality and Morbidity
  • Improve birth weight of newborns
  • Desirable birth weight 3500-4500 g (7 lb. 12
    oz.-10 lb.)
  • Infants born with desirable wt are less likely to
  • Heart and Lung diseases
  • Diabetes
  • Hypertension

Health Objectives for 2010 for the Nation
Related to Pregnant Women and Infants
  • The Health Objectives for 2010 in relation to
    pregnant women and infants focus on
  • The reduction of low birth weight,
  • Preterm delivery
  • Infant mortality
  • A number of the objectives are related to

Health Objectives for 2010 for the Nation
Related to Pregnant Women and Infants
  • Nutrition related objectives
  • Reduce anemia in pregnant females
  • Reduce incidence of spina bifida
  • Increase abstinence form alcohol use and reduce
    the incidence of fetal alcohol syndrome
  • Increase appropriate weight gain during pregnancy

Physiology of Pregnancy
  • Key terms
  • Gestational age
  • Assessed from date of conception
  • Average pregnancy is 38 weeks
  • Menstrual age
  • Assessed from onset of last menstrual period
  • Average pregnancy is 40 weeks

Maternal Physiology
  • Changes in maternal body composition functions
    occur in specific sequence

Normal Physiological Changes during Pregnancy
  • Two phases of changes
  • Maternal anabolic changes
  • Takes place in the 1st half of pregnancy
  • Maternal catabolic changes
  • Takes place in the 2nd half of pregnancy

Maternal Anabolic and Catabolic Phases of
Body Water Changes
  • Body water
  • Increases from 7 L to 10 L
  • Results from increased blood and body tissues
    extracellular volume amniotic fluid
  • Edema
  • Swelling due to accumulation of extracelluar fluid

Key Placental Hormones and Examples of their Roles
Maternal Nutrient Metabolism
  • Changes can be seen in the first few weeks after
  • Ensures that nutrients will be available to the
    fetus when needed.

Carbohydrate Metabolism
  • Glucose is preferred fuel for fetus
  • Diabetogenic effect of pregnancy results from
    maternal insulin resistance

Carbohydrate Metabolism
  • Early pregnancy
  • High estrogen progesterone stimulate insulin
    which increases glucose? glycogen fat
  • Late pregnancy
  • Human chorionic somatotropin (hCS) prolactin
    inhibit conversion of glucose to glycogen fat

Protein Metabolism
  • About 925 g of protein accumulate during
  • Protein amino acids conserved during pregnancy
  • No evidence the body stores protein early in
  • Needs must be met by mothers intake of protein

Fat Metabolism
  • Fat stores
  • Accumulate in first half of pregnancy
  • Enhanced fat mobilization in last half
  • Blood lipid levels increase
  • Increased cholesterol is substrate for steroid
    hormone synthesis

Mineral Metabolism
  • Calcium
  • Increased bone turnover reformation
  • Sodium
  • Accumulation in mother, placenta, fetus
  • Restriction of sodium potentially harmful

The Placenta
  • Functions
  • Hormone enzyme production
  • Nutrient gas exchange
  • Remove waste from fetus
  • Structure
  • Double lining of cells separating maternal
    fetal blood

Structure of the Placenta
The Placenta
  • Nutrient Transfer
  • Factors that affect the transfer
  • Size and charge of molecules
  • Small molecules pass through most easily
  • Lipid solubility of particles
  • Concentration of nutrients in maternal and fetal

The Placenta
  • Nutrient Transfer
  • The fetus is not a parasite
  • Nutrients first used for maternal needs, then for
    placenta last for fetal needed
  • The fetus is harmed more than the mother by poor
    maternal nutrition

Embryonic and Fetal Growth and Development
  • Growth and Development
  • Is at the highest level during the 9 months of
  • If rate gain continued at this level, at 1 year
    of age the infant would be 160 lbs.
  • Table 4.12 provides an overview of embryonic and
    fetal development during pregnancy

Critical Periods of Growth and Development
  • Differentiation
  • Cellular acquisition of one or more
    characteristics or functions different from that
    of the original cell
  • Critical Periods
  • Preprogrammed time periods during embryonic
    fetal development when specific cells, organs
    tissues are formed integrated or functional
    levels established

Critical Periods of Growth and Development
  • Four periods of growth development
  • 1) Hyperplasia(? cell multiplication)
  • 2) Hyperplasia hypertrophy
  • 3) Hypertrophy(? cell growth)
  • 4) Maturation (stabilization of cell number

Fetal Body Composition
Variation in Fetal Growth
  • Variations linked to
  • Energy, nutrient, oxygen availability
  • Genetically programmed growth development
  • Insulin-like growth factor (IGF-1) is main fetal
    growth stimulator

Newborn Weight Classifications
  • Terms to describe newborn size
  • SGA (small for gestational age)
  • dSGA (disproportionately small for gestational
  • pSGA (proportionately small for gestational age)
  • LGA (large for gestational age)
  • Ponderal Index (similar to BMI)
  • Calulated by wt in g divided by cube of lt times
  • PI for normal wt 23-25

Nutrition, Miscarriages and Preterm Delivery
  • Miscarriages
  • Thought to be caused by genetic, uterine, or
    hormonal abnormalities
  • Preterm Delivery
  • Infants born preterm are at risk for death,
    neurological problems, congenital malformations,
    chronic health problems

Fetal-Origins Hypothesis of Later Disease Risk
  • Theory that exposures to adverse nutritional
    other conditions during critical or sensitive
    periods of growth development can permanently
    affect body structures functions
  • Changes may predispose individuals to CVD, type 2
    diabetes, hypertension, other disorders in
    later life

The Fetal-Origins Hypothesis
  • Mechanisms underlying the fetal origins
  • Influenced by genes
  • Also influenced by environmental exposure (in
  • AKA developmental plasticity
  • Concept that the development can be modified by
    particular environmental conditions experienced
    by a fetus or infant

The Fetal-Origins Hypothesis
  • Environmental Exposures
  • Modify development
  • Epigenetic mechanisms
  • Epigenetics (epiover, above)
  • Biological mechanisms that change gene function
    without changing the structure of DNA.
    Epigenetic mechanisms are affected by
    environmental factors.

The Fetal-Origins Hypothesis
  • Nutrition programming
  • Fetal exposure to certain levels of energy
    nutrients modify function of genes in ways that
    affect metabolism development of diseases in
    later life
  • Limitations of the fetal-origins hypothesis
  • Unanswered questions
  • What levels are related to changes?
  • What exposures?

Pregnancy Weight Gain
  • Weight gain during pregnancy is related to the
    weight and health status of the newborn infant
  • Recommendations for weight gain during pregnancy
    is found in Table 4.17
  • Recommendations for weight gain are influenced by
    the pre-pregnancy status of the mother

Pregnancy Weight Gain Recommendations
Rate of Pregnancy Weight Gain
  • 2-5 pounds in first trimester
  • Gradual consistent gains thereafter

The Institute of Medicines Prenatal Weight-gain
Composition of Weight Gain
  • The fetus is only about 1/3 of the total weight
  • The balance of the weight gain is related to body
    fat changes, placenta, amniotic fluid, increase
    of extracellular fluids, and blood supply of the

Postpartum Weight Retention
  • Much concern over pregnancy weight gain and
    long-term obesity
  • 15 pounds lost at delivery
  • Wt loss difficult in women who gained gt45 pounds
    or with low activity levels
  • Women with recommended wt gain in pregnancy are
    2 pounds heavier at 1 yr postpartum
  • Lactating women lose slightly more

Nutrition and the Course and Outcome of Pregnancy
  • Famine and pregnancy outcome
  • The Dutch Hungerwinter, 1943-1944
  • Decline in pregnancy rates
  • Lower birth weights
  • The siege of Leningrad, 1942
  • Increase in infertility low birth weights
  • Infant death rates increased
  • Food shortages in Japan
  • Similar to the outcomes found in Holland and
    Leningrad above

Nutrition and the Course and Outcome of Pregnancy
  • Contemporary prenatal nutrition research results
  • Good nutritional status maintained before and
    throughout pregnancy decreases the risk of birth
    defects, suboptimal fetal growth and development,
    and chronic health problems later in life.

Nutrient Needs During Pregnancy
  • Nutrient needs vary during the course of the
  • Overall, nutrient needs can be met with well
    balanced, adequate and healthful diets consisting
    of basic foods

Nutrient Needs During Pregnancy
  • Energy requirements in pregnancy
  • 300 additional cal/d
  • 340/d in 2nd trimester 452/d in 3rd trimester
  • Assessment of caloric intake
  • Most easily assessed by pregnancy weight gain
  • As long as there is no noticeable edema

Carbohydrates, Artificial Sweeteners and Alcohol
  • Carbohydrate intake (50-65)
  • Basic foods such as
  • vegetables, fruits, and whole grains with fibers
    best choice
  • Artificial sweeteners
  • No scientific evidence of harm
  • Alcohol ingestion
  • Strongly advised to avoid during pregnancy

  • Protein requirements
  • 25 g/day or 71 g
  • Average intake of typical female 78 g

The Need for Fat
  • Pregnant women consume 33 of total calories
    from fat
  • Fat consumed in food is used as an energy source
    for fetal growth and development
  • Fat serves as a source of fat-soluble vitamins
  • Fat provides essential fatty acids

Maternal Intake of Omega-3 Fatty Acids and
Pregnancy Outcome
  • Adequate EPA DHA during pregnancy lactation
    linked to higher intelligence, better vision
    more mature CNS
  • Dietary intake recommendations for EPA DHA
  • Do not exceed 3 grams per day

Other Nutrient Needs
  • The need for water during pregnancy
  • Met by increased levels of thirst
  • Average consumption 9 cups fluid per day
  • Recommend water, diluted fruit juice, iced tea,
    and other unsweetened beverages

Other Nutrient Needs
  • Folate and pregnancy outcome
  • Folate background
  • Known to be associated with anemia and reduced
    fetal growth
  • Folate requirements ? - extensive organ and
    tissue growth
  • Functions of folate
  • Metabolic reactions
  • Deficiencies lead to abnormal cell division and
    tissue formation

Other Nutrient Needs
  • Folate and pregnancy outcome
  • Folate and congenital abnormalities
  • NTDs Neural Tube Defects
  • Malformations of the spinal cord and brain
  • Three major types
  • Spina bifida
  • Anencephaly
  • Encephalocele

Other Nutrient Needs
  • Folate and pregnancy outcome
  • Folate status of women in the United States
  • Have improved with fortified cereals and
  • Recommended intake of folate
  • 600 mcg DFE (dietary folate equivalents)

Other Nutrient Needs
  • Dietary sources of folate
  • Fruits, vegetables, whole grains

A Newborn Child with Spina Bifida
Other Nutrient Concerns
  • Vitamin A
  • Needed for cell differentiation
  • In U.S. more concern re toxicity
  • Vitamin D
  • Supports fetal growth
  • Supports immune system
  • Fluoride
  • Teeth begin to develop
  • Not recommended to supplement

Other Nutrient Concerns
  • Calcium requirements in pregnancy
  • Needed for fetal skeletal mineralization and
    maintain maternal bones
  • Calcium and release of lead from bones
  • Low intakes of calcium are related to increased
    release of leadharmful to fetus
  • Needs can be met with 3 cups of milk or
    calcium-fortified soymilk or other adequate
    sources of calcium.
  • (See Table 1.14 in Chapter 1)

Iron Status and the Course and Outcome of
  • Additional iron needs for pregnancy
  • 300 mg for fetus placenta
  • 250 mg lost at delivery
  • 450 mg for increased RBC
  • Iron-deficiency anemia in pregnancy
  • Early pregnancy-risk of preterm delivery
  • Late pregnancy-lower scores on intelligence,
    language, gross motor and attention tests

Iron Status and the Course and Outcome of
  • Assessment of iron status
  • Iron deficiency A condition marked by depleted
    iron stores with weakness, fatigue, short
    attention span, poor appetite, increased
    susceptibility to infection and irritability
  • Iron deficiency anemia a condition marked by low
    hemoglobin with signs of iron deficiency plus
    paleness, exhaustion and rapid heart rate

Iron Status and the Course and Outcome of
Iron Status and the Course and Outcome of
  • Pros Cons of Iron Supplementation
  • Iron is absorbed better from supplements
    containing iron only than when mixed with other
  • Amount absorbed depends on the need and the
    amount of iron in the supplement
  • Side effects-nausea, cramps, gas constipation

Iron Status and the Course and Outcome of
  • Pros Cons of Iron Supplementation
  • New concern free radicals in GI tract-gtcause
    inflammation mitochondrial damage to cells
  • May interfere with zinc absorption

Iron Status and the Course and Outcome of
  • Recommendations related to iron supplementation
    in pregnancy
  • Supplement with 30-mg iron daily after the 12th
    week of pregnancy
  • Recommended intake of iron during pregnancy
  • Upper limit is set at 45 mg per day

Other Mineral Concerns
  • Iodine
  • Required for thyroid function energy production
    and for fetal brain development
  • Sodium
  • Restriction not indicated in normal pregnancy or
    for control of edema or high blood pressure
  • Plays a critical role in maintaining bodys water

Bioactive Components of Food
  • Bioactive food components are foods or dietary
    supplements other than those needed to meet basic
    human nutritional needs that are responsible for
    changes in health status
  • Are not considered essential nutrients but
    influence health

Caffeine Use in Pregnancy
  • No apparent long-term consequences for children
    of coffee intake during pregnancy
  • Generally concluded-intake of up to 4 cups of
    coffee per day is safe

Healthy Diets for Pregnancy
Healthy Diets for Pregnancy
  • Effect of taste and smell changes during
    pregnancy on intake
  • May lead to changes in taste and smell
  • Pica may result
  • Pica
  • Eating disorder Eat non-food substances

Healthy Diets for Pregnancy
  • Assessment of dietary intake
  • Cultural considerations
  • Evaluation of
  • Dietary intakes
  • Weight status
  • Biomarkers of nutrient status
  • Vitamin mineral supplementation
  • Herbal remedies

Dietary Supplements During Pregnancy
  • Multivitamin and Mineral Prenatal Supplements
  • Nutrient needs should be met by a well-balanced
  • Iron is considered to be the exception
  • Recommended for inadequate diets, multifetal
    pregnancy, smokers, drinkers, vegans, or
    diagnosed nutrient deficiencies

Herbs to Avoid in Pregnancy
Exercise and Pregnancy Outcome
  • No evidence that moderate or vigorous exercise
    undertaken by healthy women is harmful
  • Exercise recommendation for pregnant women
  • 3-5 times each week for 30 minutes at 60-70 VO2

Food Safety Issues during Pregnancy
  • Foodborne illness
  • Listeria monocytogenes
  • Toxoplasma gondii
  • Mercury contamination
  • High levels in large, long-lived predatory fish
  • Lower content in bottom feeders
  • Avoid shark, swordfish, king mackerel and tile

Common Health Problems during Pregnancy
  • Nausea and vomiting
  • Hyperemesis gravidarum
  • Severe N/V during most of pregnancy
  • Management of nausea and vomiting
  • Separate liquid food intake
  • Avoid odors and foods that trigger N/V
  • Dietary supplements for the treatment of nausea
    and vomiting
  • Vitamin B6, multivitamins, ginger

Common Health Problems during Pregnancy
  • Heartburn
  • Management of heartburn
  • Ingest small meals frequently
  • Do not go to bed with a full stomach
  • Avoid foods that make heartburn worse
  • Constipation
  • Prevention
  • Consume dietary fiber
  • Drink water along with the fiber
  • Laxative pills are not recommended
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