Chapter 9 Nutrition for Childbearing

Obese pregnancy associated with

*higher risk for: - spontaneous abortion - gestational diabetes - gestational HTN - preeclampsia - prolonged labor - c sec birth - congenital anomalies - macrosomia - postpartum hemorrhage - wound complications - thromboembolic disorders -other postpartum complications -children have increase risk for obesity *advise to lose wt before conception.

wt gain recommendations

-based on BMI before pregnancy.

-inadequate nutrient diet causes:

-anemia -neural tube defect -inadequate fetal nutrient stores -low protein, iron, folic acid.

Low pregnancy weight associated with

-preterm labor -SGA -Increased perinatal mortality

Weight Gain during Pregnancy

-Insufficient weight gain during pregnancy has been associated with low birth weight (less than 2500 g or 5.5 lb), small-for-gestational age (SGA) infants, preterm birth, and failure to initiate breastfeeding. -Low weight gain in the second trimester is especially associated with poor infant birth weight, even if overall gain is within the recommended range. -average wt gain is 40 lbs -wt gain can cause fat stores, producing ketones, which can cause preterm labor. -adolescent pregnancy wt gain should be base on peds BMI. *The recommended gain for women of normal prepregnancy weight who are carrying twins is 17 to 25 kg (37 to 54 lb).

Normal weight (BMI 18.5-24.9)

-Total gain: 11.5-16 kg (25-35 lb) -weekly gain (2nd & 3rd trimester: Range: 0.35-0.5 kg (0.8-1 lb) Mean: 0.42 kg (1 lb)

Underweight (BMI <18.5)

-Total gain: 12.5-18 kg (28-40 lb) -weekly gain (2nd & 3rd trimester: Range: 0.44-0.58 kg (1-1.3 lb) Mean: 0.51 kg (1 lb)

Excess wt gain

-associated with: 1. increased birth weight of infants. 2. gestational diabetes 3. prolonged labor 4. birth trauma 5. asphyxia 6. cesarean birth 7. low Apgar scores 8. hypoglycemia 9. overweight in children 10. postpartum weight retention.

Vitamins

Although most people do not eat as much of every vitamin and mineral each day as recommended, true deficiency states for most nutrients are uncommon in North America. Fat-Soluble Vitamins Fat-soluble vitamins (A, D, E, and K) are stored in the liver. Deficiency states are not as likely to occur but excessive intake of these vitamins can be toxic. For example, too much vitamin A can cause fetal defects. The nurse should ask about vitamins and medications taken by pregnant women and counsel them about the dangers of excess vitamins

Calories

Approximately 80,000 additional calories are needed during pregnancy (Hark & Catalano, 2012). These extra calories furnish energy for production and maintenance of the fetus, placenta, added maternal tissues, and increased basal metabolic rate. Most pregnant women need a daily caloric intake of 2200 to 2900 calories, depending on their age, activity level, and prepregnancy BMI (ADA, 2008). During the first trimester of pregnancy, no added calories are needed. However, the daily caloric intake for adolescent and adult pregnant women should increase by 340 calories during the second trimester and 452 calories during the third trimester (Institute of Medicine, Food and Nutrition Board, [IOM], 2002). This increase can be achieved relatively easily with a variety of foods and only a small increase in food (Table 9-3).

Fats

Fats provide energy and fat-soluble vitamins. When decreasing calories is necessary, a reduction, but not elimination, of carbohydrates and fats is important. If carbohydrate and fat intake provides insufficient calories, the body uses protein to meet energy needs. This use decreases the amount of protein available for building and repairing tissue. Women often restrict fat to prevent weight gain. However, essential fatty acids such as alpha-linolenic acid and linoleic acid, help in the fetal neurologic and visual development. Docosahexaenoic acid (DHA) is also important for fetal visual and cognitive development. These fatty acids are found in canola, soybean, and walnut oils, as well as some seafood such as bass or salmon (Nichols-Richardson, 2011a).

Protein

Protein is necessary for metabolism, tissue synthesis, and tissue repair. The daily protein RDA is 46 g for females, depending on their age and size. A protein intake of approximately 71 g each day is recommended during the second half of pregnancy because of expansion of blood volume and growth of maternal and fetal tissues (Erick, 2012). This is an increase of 25 g of protein daily. Protein is generally abundant in diets in most industrialized nations. Diets low in caloric intake may also be low in protein, however. If calories are low and protein is used to provide energy, fetal growth may be impaired. The nurse should teach women at risk for poor protein diets how to determine intake and increase food sources of protein. When a woman needs to increase intake, she should eat more protein-rich foods rather than use high-protein powders or drinks. Protein substitutes increase protein intake but do not have the other nutrients provided by foods.

Southeast Asian Dietary Practices

Southeast Asians include those from Cambodia, Laos, and Vietnam. Traditional cooking methods in these countries include searing fresh vegetables quickly with small portions of meat, poultry, or fish in a little oil over high heat. Meals cooked in this manner are low in fat and retain vitamins. Most meals are accompanied by rice, which increases the intake of complex carbohydrates, and soup. White rice is usually preferred over brown rice. A salty fish sauce called nuoc mam is also part of most meals (Appel, 2013). Tofu and fresh fruits are frequent additions. Many Southeast Asians eat American foods along with their traditional diet. Such foods as eggs, beef, pork, and bread add nutrients but also fat to the diet. Candy, soft drinks, coffee, butter or margarine, and fast foods have been less favorable influences because they are low in nutrients but high in sugar or fat.

Estimated average requirement (EAR)

The amount of a nutrient estimated to meet the needs of half the healthy people in an age group.

BMI calculation

To work out your BMI: divide your weight in kilograms (kg) by your height in metres (m) then divide the answer by your height again to get your BMI For example: if you weigh 70kg and you're 1.75m tall, divide 70 by 1.75 - the answer is 40 then divide 40 by 1.75 - the answer is 22.9 your BMI is 22.9kg/m2

Water-Soluble Vitamins

Water-soluble vitamins (B6, B12, and C; folic acid; thiamin; riboflavin; and niacin) are not stored in the body as easily as fat-soluble vitamins. Therefore, they should be included in the daily diet. Because excess amounts are excreted in urine, the chances of toxicity from excessive intake are lower, but toxicity can occur with megadoses. Water-soluble vitamins are easily transferred from food to water during cooking. Foods should be steamed, microwaved, or prepared in only small amounts of water. The remaining water can be used in other dishes such as soups.

Obese (BMI ≥30)

-Total gain: 5-9 kg (11-20 lb) -weekly gain (2nd & 3rd trimester: Range: 0.17-0.27 kg (0.4-0.6 lb) Mean: 0.22 kg (0.5 lb)

Adequate intake (AI)

The nutrient intake assumed to be adequate when an RDA cannot be determined.

Energy

The energy provided by foods for body processes is calculated in kilocalories. Kilocalories (commonly called calories [the term used in this book]) refers to a unit of heat and is used to show the energy value in foods. Calories are obtained from carbohydrates and proteins, which provide 4 calories in each gram, and fats, which provide nine calories in each gram.

Pattern of wt gain

The general recommendation is an increment of about 0.5 to 2 kg (1.1 to 4.4 lb) during the first trimester.

TABLE 9-2 RECOMMENDATIONS FOR DAILY ENERGY, CARBOHYDRATE, AND PROTEIN INTAKES FOR WOMEN AGES 15 TO 50 YEARS

*ENEGERY: -non-preg adult female: Varies greatly according to body size, age, and physical activity level. Example: Woman, 30 years, active, height 1.65 m (65 inches), weight 50.4 kg (111 lb), body mass index (BMI) 18.5 needs 2267 kcal Same woman, weight 68 kg (150 lb), BMI 24.99 needs 2477 kcal -pregnancy: *First trimester: No change from nonpregnant needs *Second trimester: 340 kcal above nonpregnant needs *Third trimester: 452 kcal above nonpregnant needs -Lactation: *First 6 months: 330 kcal above nonpregnant needs (with an additional 170 kcal drawn from maternal stores). *Second 6 months: 400 kcal above nonpregnant needs *CARBS: -non-preg: 130g -preg: 175g -lactation: 210g *PROTEIN: -non-preg: 46g -preg: 71g -lactation: 71g

TABLE 9-3 EXTRA FOODS NEEDED TO MEET PREGNANCY REQUIREMENTS*

*Energy (kcal) 1 carrot, 1 slice whole wheat bread, 1 T peanut butter, ½ banana, and 1 cup low-fat milk in 2nd trimester; add 1 oz cheddar cheese in third trimester *Protein 3 oz meat or poultry or 3 c milk or 3.5 oz cheddar cheese or 1 c cottage cheese or 3.75 oz peanuts or 1⅔ c pinto or kidney beans. *Iron ½ c raisin bran, or 1 c beef chuck, 1 c pinto beans, and 3 eggs *Thiamin 1.5 oz pork or 2.5 oz peanuts or 1⅔ c brown rice or 1.5 c orange juice *Riboflavin ¾ c low-fat milk or ¾ c low-fat cottage cheese or 1.5 c broccoli or ¾ c cooked spinach or 1¼ egg or 2 chicken drumsticks or 4 oz lean beef *Niacin 2 T peanut butter or 3 oz ground beef or 1.5 oz pork chop or 1.5 oz salmon; also made by body from tryptophan *Vitamin C 2 T orange juice or 1.5 peaches or 1 banana or 1.5 pear or 1 c watermelon or ¼ c tomato juice

Overweight (BMI 25-29.9)

-Total gain: 7-11.5 kg (15-25 lb) -weekly gain (2nd & 3rd trimester: Range: 0.23-0.33 kg (0.5-0.7 lb) Mean: 0.28 kg (0.6 lb)

Anemia

Anemia Anemia is a common concern during pregnancy. Hemoglobin values decrease during the second trimester of pregnancy as a result of plasma increases diluting the blood. This physiologic anemia is normal (see Chapter 7). During the third trimester, hemoglobin levels generally rise to prepregnant levels because of increased absorption of iron from the gastrointestinal tract, even though iron is transferred to the fetus primarily during this time. A woman may begin pregnancy with anemia or develop it during pregnancy. She is considered anemic if her hemoglobin is less than 11 grams per deciliter (g/dL) or her hematocrit is less than 33% during the first and third trimesters or the hemoglobin is less than 10.5 g/dL or hematocrit is less than 32% in the second trimester (Cunningham et al., 2010). Iron stores may be measured by determining the serum ferritin level. A ferritin level less than 10 nanograms per 100 mL indicates that the anemia is caused by iron deficiency (Pagana & Pagana, 2011). If fetal iron stores during the third trimester are sufficient, anemia will not develop in the newborn for the first 4 to 6 months after birth. However, if the woman's intake of iron is insufficient, her hemoglobin levels may not rise during the third trimester, iron deficiency anemia may develop, and transfer of iron to the fetus may be decreased. Iron deficiency anemia occurs in as many as 47% of pregnant women (Kilpatrick, 2009). Anemic women need iron supplements and help choosing foods high in iron (see Table 9-5).

Carbs

Carbohydrates may be simple or complex. The most common simple carbohydrate is sucrose (table sugar), which is a source of energy but provides no other nutrients. Fruits and vegetables contain simple sugars along with other nutrients. Complex carbohydrates are present in starches such as cereal, pasta, and potatoes. They supply vitamins, minerals, and fiber. They should be the major source of carbohydrates in the diet because of their value in providing other nutrients. Another type of carbohydrate is fiber, the nondigestible product of plant foods and an important source of bulk in the diet. Fiber absorbs water and stimulates peristalsis, causing food to pass more quickly through the intestines. Fiber helps prevent constipation and also slows gastric emptying, causing a sensation of fullness.

Folic Acid

Folic acid (also called folate) can decrease the occurrence of neural tube defects such as spina bifida and anencephaly in newborns. It may also help prevent cleft lip, cleft palate, and some heart defects (CDC, 2011b; Nichols-Richardson, 2011a). Adequate intake of folic acid is especially important before conception and during the first trimester because the neural tube closes before many women realize they are pregnant. Because about half of pregnancies are unplanned, all women of childbearing age should consume at least 400 micrograms (mcg) (0.4 mg) of folic acid every day. Once pregnancy occurs, daily intake of 600 mcg (0.6 mg) of folic acid is recommended. Although the CDC recommends a daily folic acid intake of 400 mcg (0.4 mg) for women capable of childbearing, the U.S. Preventive Services Task Force (USPSTF) recommends 400 to 800 mcg (0.4 to 0.8 mg) each day. The dose should be taken for at least 1 month before conception and for 2 to 3 months after conception (USPSTF, 2009). No change has been made in USPSTF's recommendation of 600 mcg (0.6 mg) of folic acid daily for the rest of pregnancy. For women who have previously had a child with a neural tube defect, the recommended dose is 4 mg (4000 mcg) daily during the months before conception (CDC, 2011b). Women often do not realize the importance of folic acid in their diet before pregnancy begins, and many do not meet the recommended level in spite of a national campaign to make the public more aware of this problem. Inadequate intake of folic acid is the most prevalent vitamin deficiency during pregnancy (Hark & Catalano, 2012). One third of births occur to women ages 18 to 24 years, but women in this group have lower intake of supplements containing folic acid and less knowledge of the need for folic acid than older women (CDC, 2008b). More education is necessary to increase folic acid use in women of childbearing age. Fortunately, since food fortification with folic acid was begun, folic acid deficiency has decreased (CDC, 2012). A Healthy People 2020 goal is for women of childbearing potential to take in at least 400 mcg of folic acid each day (U.S. Department of Health & Human Services [HHS], 2010). To help achieve adequate intake in the United States and Canada, folic acid is added to breads, cereals, and other products containing enriched flour.

Recommended dietary allowance (RDA)

The amount of a nutrient that is sufficient to meet the needs of almost all (97% to 98%) healthy people in an age group. The actual needs of individuals (particularly for calories and protein) may vary according to body size, previous nutritional status, and usual activity level.

Tolerable upper intake level (UL)

The highest amount of a nutrient that can be taken without probable adverse health effects by most people.

Nutrient Density

The quantity and quality of the various nutrients in each 100 calories of food is the nutrient density. Foods of high nutrient density have large amounts of quality nutrients per serving. During pregnancy, the increased need for most nutrients may not be met unless calories are selected carefully. The term empty calories refers to foods that are high in calories but low in other nutrients. Many snack foods contain excessive calories and low nutrient density and are high in fat and sodium. Increased calories should be "spent" on foods that provide the nutrients needed in increased amounts during pregnancy. Women often use sugar substitutes to reduce their caloric intake. Saccharin (Sweet'N Low), sucralose (Splenda), and aspartame (Equal or NutraSweet) are considered safe for normal women during pregnancy. Use of aspartame by women with phenylketonuria can result in fetal brain damage because these women lack the enzyme to metabolize aspartame (Pronsky & Crowe, 2012).