Chapter 4 - Nutrition during pregnancy

Folate

-1949 R.D. Mussey had an idea about the effects of low folate in the diet of a pregnant woman. However, fortification occurred in 1998. -Recommendations: 400 mcg from fortified foods/supplements, 200 mcg from vegetables and fruit. *DFE (Dietary folate equivalents) equals: 1mcg food folate, 0.6 mcg fortified foods/supplements, 0.5 mcg supplement on empty stomach. -Bioavailability of folic acid and dietary folate differ. folic acid is 100% bioavailable if taken in a supplement on an empty stomach. 85% if consumed w food/fortified food, and 50% in naturally occurring in foods. -effects: neural tube defects, malformation of the spinal cord and brain. Three main types: 1. Spina bifida- most common. Tiny bones of the vertebrate do not close completely. 2.Anencephaly- most severe. Babies are missing major parts of the brain, skull, and scalp. Do not survive long after birth, just a few hours 3. Enchephalocele - rare and it affects the brain and skull. A sac that contains the membranes that cover the brain pikes through and opening in the skull allowing part of the brain to poke through, too. Need surgery to place parts of the brain back inside the skull and close the opening.

Placenta characteristics

-22 cm in diameter and 2-2.5 cm thick. -Weighs about 410 g (about 1 lb) but it can vary. -the surface should be maroon. -Umbilical cord: 55-60 cm in length, 2.0-2.5 diameter.

Periconceptional

-4 - 4wks

Carbohydrate metabolism

-45-65% calories *Artificial sweeteners have shown no scientific evidence of harm. It promotes availability of glucose to fetus because it is the preferred fuel (fat can be used for E as well). It results in "diabetogenic effect of pregnancy" -Early in pregnancy high estrogen and progesterone stimulate insulin production which increases conversion of glucose to glycogen and fat. -Second half, hCS and prolactin from pituitary gland inhibit conversion of glucose to glycogen and fat. At the same time insulin resistance in Mon increases her reliance on fat stores for energy. There is a decrease in material utilization of glucose. It also increases liver production of glucose. All provide constant supply of glucose for fetal growth and development.

Protein Metabolism

-71 g/day (RDA of 46 g/day + 25 g extra). Not a problem since average intake of typ. female is 78g/day. Protein and nitrogen are needed for synthesis of new maternal and fetal tissue (fetal, placental, uterine, and breast tissue). Protein and amino acids are conserved during pregnancy (decreased levels of nitrogen excretion and conversion of amino acids for protein tissue synthesis). There is no evience that the body stores protein early in pregnancy but needs must be met by mother's intake of protein.

Iron

-Additional 1000 mg are needed: 300 for fetus + placenta, 250 lost at delivery, and 450 mg for increased red blood cells. -Recommendations: 30 mg supplement daily after the 12th week. 60-180 mg/day for iron deficiency anemia. UL during pregnancy is 45 mg/day. -Deficiency (anemia): early pregnancy risk of preterm delivery, late pregnancy - lower scores of intelligence, language,gross motor and attention tests. -Supplementation pros: Iron can be absorbed better from supplements containing iron only than when mixed w other minerals. The amount absorbed depends on the need of the woman and the amount in the supplement. Supplementation cons: free radicals in GI tract cause inflammation and mitochondrial damage to cells. It may also interfere w zinc absorption but it needs more research. -Side effects: nausea, cramps, gas, and constipation. Makes it had to take it.

Mineral metabolism

-Calcium: It is needed for bone formation. Bone turnover and reformation, maternal absorption, and mobilization from bone are all increased. -Sodium: it accumulates in mother, placenta, and fetus. It is crucial for elevated levels of body water and tissue synthesis. The kidney increases aldosterone and that leads to sodium retention. Accumulated will go the mother, placenta, and fetus. *No low sodium diets during pregnancy, they are potentially harmful.

Importance of gaining weight

-Decreases the risk of delivering a small infant -Lower risk of infant mortality in first year -Lower probability of diseases (diabetes, CVDs, hypertension, and other chronic diseases...) later in life.

Common health problems

-Heartburn: relaxation of gastrointestinal tract muscles (progesterone). It can be managed by ingesting sm meals frequently, avoid going to bed w a full stomach, elevate upper body during sleep. -Constipation and hemorrhoids: relaxed gastrointestinal muscle tone. To avoid, increase fiber intake (30g day), drink water, increase soluble fiber (metamucil, citrucel ok). Laxative pills are not recommended. -Nausea and vomiting: it is common from 5-12 wks and not just mornings. Improve symptoms by continuing to gain weight, separate liquids from food intake, avoid odors and foods that trigger it, select well tolerated foods. It can be treated with vietamin B6 (10-25 mg dose every 8 hrs, do not exceed 100mg), diclectin prescription B6 w doxylamine, and ginger (1g/day for 4 days) -Hyperemesis gravidarum: it is severe nausea and vomiting during most pregnancy. Results are weight loss, electrolyte imbalances and dehydration.

Key placental hormones

-Human chorionic gonadotropin (hHG): (highest, first) is the first one to increase, big spike at around 10 wks. Stimulates the corpus luteum to produce estrogen and progesterone. Stimulates growth of the endometrium. The placenta produces estrogen and progesterone after the first 2 months of pregnancy. -Progesterone: maintains the implant; stimulates growth of the endometrium and its secretion of nutrients; relaxes smooth muscles f the uterine blood vessels and gastrointestinal tracts, breast development, and lipid deposition. -Estrogen: increases lipid formation and storage, protein synthesis, and uterine blood flow; prompts uterine and breast duct development; promotes ligament flexibility. -Human chorionic somatotropin (hCS): Increases maternal insulin resistance to maintain glucose availability for fetus; promotes protein synthesis and the bkdwn of fat for E for maternal use. -Leptin: may participate in the regulation of appetite and lipid metabolism, weight gain, and utilization of fat stores.

Body water changes

-It increases from 7L to 10L. -2/3 intracellular: blood and body tissues -1/3 extracellular: fluid in spaces b/w cells

Fat metabolism

-It is required to build up maternal stores, it is used as energy source for fetal growth and development. It also serves as a source of fat-soluble vitamins and provides essential fatty acids. Changes in lipid metabolism promote accumulation of maternal fat stores in 1st half and fat mobilization during 2nd half. Blood lipids increase during pregnancy, including cholesterol. It is considered a substrate for steroid hormone synthesis for fetus for nerve and cell membrane function. There is no correlation w atherosclerosis but looks like it by 3rd trimester. Levels return to normal postpartum. Cholesterol: goes from 175 to 200 in the 2nd trimester, to 240 during the 3rd trimester. 165 is normal for nonpregnant women.

Essential fatty acids

-LInoleic: safflower, corn, sunflower and soy oil -Alpha-linolenic: flaxseed, walnuts, soybeans, canola, and leafy green vegetables. It includes 2 very important members, their adequate consumption during pregnancy and lactation is linked to higher intelligence, better vision, and more mature CNS. It is recommended to take 300 mg/day. 1.EPA: eicopentanoic acid 2.DHA: docosahexaenoic acid -300mg/day, 2 4oz servings ea week -Good sources fish and seafood low in mercury (shirmp, canned light tuna, salmon, pollock and catfish) -No more than 6oz/wk of albacore tuna or tuna steak. -Avoid: high fat fish and big fish (sword fish, king mackerel, and shark)

DRIs changes

-Protein: from 46g to 71 g/day -Energy: 2nd trimester +350 kcal to 3rd trimester +452 kcal -Iron: from 18 mg to 27 mg -Folic acid: from 400 mcg to 600 mcg -Calcium: 1000 mg/day, no change

Good diet basics

-Provide enough calories and follow the MyPlate food recommendations, which will provide all essential nutrients -600mcg of folate, of which 400 mcg is folic acid, daily. -300 mg EPA and DHA daily -Enough fiber (28g/day) and 9c fluids -include salt to taste -Exclude alcohol and limit coffee to <4 per day

2020 health objectives

-Reduce: -fetal and infant deaths -maternal mortality -low/very low birthweight -fetal and infant deaths Increase: -adequate prenatal care -alcohol abstinence during pregnancy -appropriate weight gain.

critical periods

-When errors in growth are irreversible -When specific cells, tissues, and organs are formed -pre-programed, same for every pregnancy

Miscarriage

0-20 weeks

Baby stages

0-8wks embryo 8-40wks fetus 0-1wk neonatal 1- 12wks postneonatal

Periods of growth and development

1. Hyperplasia (increased cell multiplication 2. Hyperplasia and pypertrophy 3. Hypertrophy (increased cell number and size.)

Weight gain

1st trimester: 3-5 lbs 2nd and 3rd trimester: approx. 1 lb per week

Fetal death/stillbirth

20-40 wks

Perinatal

20-41 wks

Term

38-42 wks

very preterm

<34 wks

preterm

<37wks

postterm

>42 weeks

Iron absorption

Aids: vitamin C Blocks: Tannins (teas), calcium

Gestational age

Assesed from date of conception, an average of 38 wks (266 days)

Menstrual age

Assessed from onset of last menstrual period. an average of 40 wks (in the US)

Food safety

Because of increased progesterone levels, immunity decreases and makes the mom more susceptible to foodborne illnesses. -Lysteria monocytegnes is an important one to watch out for. The placenta does not protect against it and it is associated w stillbirth and spontaneous abortion. Products such as raw/smoked fish, oysters, unpasteurized cheese, raw/undercooked meat, unpasteurized milk, and not stored or heated correctly luncheon meats, hot dogs, and other processed meats. -Toxoplasma gondii: it is contained in cat litter, raw/undercooked meats, surface of unwashed fruits and veggies. Can cause mental retardation, blindness, seizures and death. It is transferred from mom to baby. -Mercury contamination: it travels from mother's blood to fetus. It causes a fetal neurotoxin that can cause mind-severe effects on fetal brain development. Avoid long-lived predatory fish (shark, swordfish, tilefish albacore tuna, walleye, pickerel and bass.

Low birth weight

Can be due to smoking, small amount of time between pregnancies.

Physiology of pregnancy

Changes in maternal body composition and functions occur in specific sequence. -20wks: maternal plasma volume -20wks: maternal nutrient stores -31 wks: placenta weight -37 wks: uterine blood flow -37 wks: fetal weight

Iron deficiency anemia

Effects are pale skin, fatigue, and shortness of breath

Overweight recommendation

Even if some is overweight it is never recommended to diet to lose weight

Weight gain distribution

Fetus - 7.7 lb Fat stores - 6-8 lb Blood volume - 3-4 lb Fluid volume - 2-3 lb Uterus - 2 lb Amniotic fluid- 2 lb Placenta - 1.5 lb Breasts - 1-3 lb

Exercise

If you are healthy and your pregnancy is normal, it is safe to continue or start most types of exercises with minor tweaks. IT does not increase your risk for miscarriage, low birth weight, or early delivery. You can keep doing the same workouts w your health care provider approval. If you start to lose weight, increase calorie intake. -CDC recommends at least 150 min of moderate-intensity aerobic activity per week. It can be divided into 30 min w/o 5 days a week. They can be further divided into 10 w/os throughout the day. -Examples: brisk walking and gardening (raking, weeding, digging). If new to w/o, start out slowly and gradually increase your activity. Begin w 5 min. a day and so on until you go up to 30. Benefits: -Reduces back pain and constipation -Decreases the risk for gestational diabetes, preeclampsia, and cesarean delivery. -Healthy weight gain, strengthens heart and blood vessels. -helps you lose baby weight afterwards.

Fetal body composition

It changes throughout pregnancy. There is a progressive increase in fat, protein, and mineral content. There are drastic changes in the last 5 weeks w substantially increase in body fat, glycogen stores and mineral content. Variations linked to: -Not generally due to genetic causes -Most cases Env. factors, energy, nutrient, and Oxigen availablility.. -Factors with genetically programmed growth and development. -Insulin-like growth factor (IGF-1) is the primary growth stimulator of fetus and also promotes uptake of nutrients by fetus and inhibits fetal tissue bkdown (levels sensitive to maternal nutrition.

Pica

It is an eating disorder in which people eat non-food substances. It results in less nutritious food intake, excessive calorie intake in case of starch, interfere wi mineral absorption, intake of toxic substances, gastric bowel obstruction, and infection/parasites. Women w this condition tend to be iron deficient. Most often involves: -Geophagia: eating dirt or clay, baking soda or powder -Pagophagia: eating ice or freezer frost. Related to iron deficiency anemia. -Amylophagia: eating starch: laundry or corn -Plumbism: eating lead from wall plaster (poisoning, decreased growth, intellingnece, hearing problems, poor classroom attention

Calcium

It is needed for fetal skeletal mineralization and maintain maternal bones. During the last 2 trimesters, your body absorbs more calcium from food. During the last trimesters, mobilization of calcium from mom's skeleton to fetus occurs. Also, calcium excretion in urine decreases. Bone mineral turnover takes place at a higher rate. -The demand peaks in 3rd trimester when fetal bones are mineralizing at a high rate.. -Last quarter of pregnancy needs for calcium increases by 300 mg/day *Calcium taken from bones during pregnancy can be replaced if woman has an adequate intake. -RDA: pregnant (19-50) 1000mg, girl (<18) 1300 mg, non pregnant (19-50) 1000 mg(the same).

Edema

It is not a concern if not associated w hypertension. It does have a dilution effect of some vitamins and minerals. Some swelling can be see due to accumulation of extracellular fluid.

Placenta

It means "cake" in latin and develops from embryonic tissue. It is larger than the fetus for most of the pregnancy so development precedes fetal development. -Functions: hormone and enzyme production, nutrient and gas exchange, and remove waste from fetus. It is a double lining of cells separating the maternal and fetal blood. -Priorities: it will take nutrients for itself before givng to the fetus bc its health can be compromised if nutrient supplies fall short to sustain nutrient supply and health of mother. -Nutrient transfer: nutrients are first used for maternal needs,, then the placenta, and last for fetal needs. The fetus is harmed more than mother's poor nutrition.

US infant mortality

It ranks 56th even though it spends more money in health care than any other nation.

Infant mortality

It reflects general health and socioeconomic status of a population. It decreases when there are improvements in social circumstances, infectious disease control, and availability of safe and nutritious food. Decline starting in 1870 w the industrial revolution, 1880 germ theory, 1890 pasteurization of milk, 1910 improved sanitation/nutrition, 1935 social security, 1945 penicillin, 1955 widespread vaccinations, 1970 neonatial intensive care,

PCOS treatment goal

Its primary goal is to increase insulin sensitivity.

Lab iron status

Most common measures are hemoglobin and ferritin.

Critical periods

Preprogrammed time periods during embryonic and fetal development when specific cells, organs, and tissues are formed and integrated or functional levels established. Most intense are the 1st 2 months of pregnancy.

Nutrient needs

Req. increase due to protein and fat tissue synthesis - expanding metabolically active tissue. It will also depend on pre-pregnancy weight and activity level. The weight gain is acceptable as long there is no edema. -2nd trimester: +340 kcal/day -3rd trimester: + 452 kcal/day

Maternal anabolic changes

They occur during the 1st half of the pregnancy (20wks). The mother's capacity to deliver nutrients, oxygen and blood to fetus is built. About 10% of the fetal growth occurs. -Blood volume expands, cardiac output increases -Buildup fat, nutrient, and liver glycogen stores -Growth of some maternal organs -Increased appetite, food intake (positive caloric balance) -Decreased exercise tolerance -Increased levels of anabolic hormones.

Maternal catabolic changes

They occur during the 2nd half of the pregnancy (20-40wks). Here, nutrients are delivered to the fetus from stored nutrient and energy stores. About 90% of the fetal growth occurs -Mobilization of fat and nutrient stores -increased production of blood levels of glucose, triglycerides and fatty acids; decreased liver glycogen stores -Accelerated fasting metabolism -increased appetite and food intake decline somewhat near term -increased levels of catabolic hormones

Weight gain guidelines

Underweight (<18.5) 28-40lbs Normal (18.5-24.9) 25-35 lbs Overweight (25-29.9) 15-25 lbs Obese (30>) 11-20 lb Twin 25-54 lbs

WIC

Women, infants, and children

The fetus is not a parasite

maternal needs will first be covered before the fetus. The fetus is harmed more than the mother by poor nutrition.

Gravida

number of previous pregnancies

Parity

number or previous deliveries Nulliparous: 0,Primiparous: 1, multiparous: 2 or more.

Diabetogenic effect of pregnancy

results from maternal insulin resistance to provide glucose to fetus.