Nutrition in Pregnancy Presented by Dee Anne Domnick, CPM, LM, MH Throughout Pregnancy & While Breastfeeding: Make most of your food choices healthy ones. Eating too many foods that are high in fat during pregnancy leads to too much weight gain for you without meeting your increased need for nutrients. Some nutrient requirements more than double during pregnancy, while caloric needs increase only about 15 percent Why is a healthy diet important during pregnancy? For the health of both the pregnant woman and the developing baby Healthy foods are the building blocks of the growing baby since pregnancy is a complex time of developing new tissues and organs. Approximately half of all pregnancies in the United States result in prenatal or postnatal death or an otherwise less than healthy baby. Major developmental defects, such as neural tube and heart deformities, occur in approximately 120,000 of the 4 million infants born here each year. Exposure to toxic chemicals, both manufactured and natural, cause about 3 percent of all developmental defects At least 25 percent might be the result of a combination of genetic and environmental factors. Monitoring of Weight Gain is Important —Especially of Underweight Women In addition to the growth of the fetus associated with maternal weight gain, pregnant woman store fat to prepare the mother for lactation. Weight Gain During Pregnancy An additional 25-35 pounds is considered desirable for the benefit of both the mother and developing infant – Recommended by the National Academy of Sciences /Institute of Medicine Women who are underweight when they conceive should gain about 28-40 pounds Those who are overweight should gain no more than 15-25 pounds Short women (under 62 inches) should set lower goals for weight gain, 18-30 pounds Extremely Obese Women should gain no more than 15 pounds Young Adolescents should gain between 28 and 40 pounds, regardless of their prepregnancy weight and height Women Carrying Twins should gain 35-45 pounds, regardless of pre-pregnancy weight and height Is it necessary to take a vitamin/mineral supplement during pregnancy? Though it’s possible to meet the requirements for most nutrients through a balanced diet, most experts recommend pregnant women take daily vitamin supplements, including iron & folic acid, as a safe guard. According to the National Academy of Sciences/ Institute of Medicine, supplementation should begin at the start of the second trimester at the following levels: Iron.....................30 milligrams (mg) Folic Acid......400 micrograms (mcg) Calcium...........………………250 mg Vitamin C………………...……50 mg Vitamin B12…….....…………...2 mcg Vitamin D………..…………….5 mcg Copper………………………….2 mg Zinc………………………..…..15 mg Vitamin B6………………..……..2 mg Vegans Add an additional: 10 mcg of Vitamin D 2 mcg of Vitamin B12 About Folic Acid Folic acid in a vitamin supplement, when taken one month before conception and throughout the first trimester, has been proven to reduce the risk for an NTD-affected pregnancy by 50% to 70%. Folic acid, a B-vitamin, is necessary for proper cell growth and development of the embryo. Newborn with Spina Bifida Anencephaly Cleft Lip & Palette Folic Acid--important in cell development (a water soluble vitamin) Recent research suggests that taking folic acid before and during early pregnancy can reduce the risk of spina bifida and other neural tube defects (NTD’s) in infants. The U.S. Public Health Service recommends that all women of childbearing age that are capable of becoming pregnant should consume 400 micrograms (mcg) of folic acid daily to reduce their risk of having an NTD-affected pregnancy. How Can Women Get Enough Folic Acid? There are three ways women can get enough folic acid to help prevent spina bifida and anencephaly. They can choose to: 1. Take a vitamin supplement containing 400 micrograms of folic acid daily. 2. Eat a fortified breakfast cereal daily which contains 100% of the recommended daily amount of folic acid (400 micrograms). 3. Increase consumption of foods fortified with folic acid (e.g., “enriched” cereal, bread, rice, pasta, and other grain products) in addition to consuming food folate from a varied diet (e.g., orange juice and green vegetables). Foods rich in folate include: orange juice from concentrate, dark-green leafy vegetables: (spinach, broccoli, asparagus, romaine lettuce) other vegetables: (carrots, tomatoes, potatoes) beans and pulses like black-eyed beans & lentils whole grains (i.e. brown rice & some cereals) citrus, bananas, kiwis and strawberries, liver fish eggs milk Vitamin A supplementation is not recommended during pregnancy Excessive levels of Vitamin A can be toxic to the fetus Adequate levels of Vitamin A are available through a balanced diet Calories--To support the rapid growth of the fetus, pregnancy demands an additional 300 calories a day over pre-pregnancy needs This is approximately the same number of calories as supplied by 2 ½ cups of low-fat milk OR 1 cup of ice cream OR A bagel with cream cheese OR A tuna fish sandwich Protein Both the expectant mother and developing fetus need increased amounts of protein. It is recommended that pregnant women consume 60 grams of protein a day. This is only 10 grams more than nonpregnant women. Since most Americans regularly consume more than they require, most women will not need to consciously increase their protein consumption during pregnancy. Protein Sources Seeds Nuts Beans, legumes Grains Sprouts Eggs Dairy Products Fish Lean Meats Fowl Suggestions for Complementing Proteins (they do not need to be consumed at the same meal as believed) These are menu ideas for vegetarian dishes: Stir fried tofu and rice Tomato, rice and beans Rice-bean casserole Wheat-soy bread Lentil curry on rice Corn-soy bread Bean or pea curry on rice Corn tortillas and beans Pea soup and toast Legume soup with bread Bread made with milk or cheese Pasta with milk or cheese Rice and milk pudding Cereal and milk Rice-cheese dishes or casseroles Cheese sandwiches Yogurt and barley soup Sesame and milk Sesame seeds in bean soup Lentils and rice Wheat bread with baked beans Iron The iron requirement doubles during pregnancy: 30 mg/day during the second and third trimesters. •Additional iron is needed as a result of increased maternal blood volume. Also, the fetus stores enough iron to last through the first few months of life. What is anemia? Anemia is a blood disorder that is defined as: a level of red blood cells (RBCs) that is below normal, or a level of hemoglobin that is below normal (hemoglobin is the oxygencarrying protein in red blood cells). There are several forms of anemia, such as: iron deficiency anemia hemolytic anemia (destruction of RBCs) vitamin B-12 deficiency anemia folic acid deficiency anemia Vit. E deficiency anemia Vit. C deficiency anemia anemias caused by inherited abnormalities of RBCs (for example, sickle cell anemia and thalassemia) anemia caused by chronic (ongoing) disease, such as rheumatoid arthritis. and more To Get the Most of Iron from One's Diet: Eat high-iron meals with vitamin C or foods high in vitamin C. (Taking 200-500 mg. of Vit. C nearly doubles iron absorption). Tannic acid, caffeine, and phosphates inhibit iron absorption; avoid them. Avoid antacids; they neutralize stomach acids, which enhance iron absorption. Minimize use of laxatives, which decrease the amount of time the body has to absorb iron. Minimize consumption of refined carbohydrates; they cause the secretion of more-alkaline digestive juices, which decrease the acidity of the stomach. Do not take iron supplements or high-iron meals with dairy products, which neutralizes stomach acidity. Niacin, B1, B2, pantothenic acid, choline, B12, folic acid, cobalt, and copper are involved in the absorption, assimilation, and utilization of iron. Use leavened whole grains; yeast in the fermentation process makes iron available. Do not rely on iron-fortified foods; iron used by manufacturers is often a phosphate compound not soluble in the human digestive tract. Large doses of supplemental zinc or calcium interfere with iron absorption. Cast-iron cookware adds iron to food, especially if the food cooked in it is acidic. Minimize exposure to cigarette smoke and other air pollutants. Regular aerobic exercise improves iron absorption because of the body's greater need for oxygen-carrying capacity. Choose iron supplements carefully. You can help reduce your risk of iron deficiency anemia by eating foods that contain iron all throughout pregnancy. These include: Red meats Shellfish Poultry (dark meat) Eggs Fortified breakfast cereals & whole grain breads (check the container to see if the cereal or bread contains iron) Oatmeal Blackstrap molasses Green leafy vegetables Baked potato, with skin Cooked beans Raisins, dates, prunes, figs, apricots Selected Food Sources of Heme Iron Food Milligrams per serving Chicken liver, pan-fried, 3 ounces 11.0 Oysters, canned, 3 ounces 5.7 Beef liver, pan-fried, 3 ounces 5.2 Beef, chuck, blade roast, lean only, braised, 3 ounces 3.1 Turkey, dark meat, roasted, 3 ounces 2.0 Beef, ground, 85% lean, patty, broiled, 3 ounces 2.2 Beef, top sirloin, steak, lean only, broiled, 3 ounces 1.6 Tuna, light, canned in water, 3 ounces 1.3 Turkey, light meat, roasted, 3 ounces 1.1 Chicken, dark meat, meat only, roasted, 3 ounces 1.1 Chicken, light meat, meat only, roasted, 3 ounces 0.9 Tuna, fresh, yellowfin, cooked, dry heat, 3 ounces 0.8 Crab, Alaskan king, cooked, moist heat, 3 ounces 0.7 Pork, loin chop, broiled, 3 ounces 0.7 Shrimp, mixed species, cooked, moist heat, 4 large 0.3 Halibut, cooked, dry heat, 3 ounces 0.2 % DV* 61 32 29 17 11 12 9 7 6 6 5 4 4 4 2 1 *DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The FDA requires all food labels to include the percent DV (%DV) for iron. The percent DV tells you what percent of the DV is provided in one serving. The DV for iron is 18 milligrams (mg). A food providing 5% of the DV or less is a low source while a food that provides 10–19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site. Selected Food Sources of Non-Heme Iron Food Milligrams per serving Ready-to-eat cereal, 100% iron fortified, ¾ cup 18.0 Oatmeal, instant, fortified, prepared with water, 1 packet 11.0 Soybeans, mature, boiled, 1 cup 8.8 Lentils, boiled, 1 cup 6.6 Beans, kidney, mature, boiled, 1 cup 5.2 Beans, lima, large, mature, boiled, 1 cup 4.5 Ready-to-eat cereal, 25% iron fortified, ¾ cup 4.5 Blackeye peas, (cowpeas), mature, boiled, 1 cup 4.3 Beans, navy, mature, boiled, 1 cup 4.3 Beans, black, mature, boiled, 1 cup 3.6 Beans, pinto, mature, boiled, 1 cup 3.6 Tofu, raw, firm, ½ cup 3.4 Spinach, fresh, boiled, drained, ½ cup 3.2 18 Spinach, canned, drained solids ½ cup 2.5 14 Spinach, frozen, chopped or leaf, boiled ½ cup 1.9 Raisins, seedless, packed, ½ cup 1.6 Grits, white, enriched, quick, prepared with water, 1 cup 1.5 Molasses, 1 tablespoon 0.9 5 Bread, white, commercially prepared, 1 slice 0.9 Bread, whole-wheat, commercially prepared, 1 slice 0.7 4 % DV* 100 61 48 37 29 25 25 24 24 20 21 19 11 9 8 5 Iron tea Drink daily for iron maintenance. Take with Vit. C & folic acid supplements for persistent anemia. Mix equal parts: Yellow Dock root Nettles Red Raspberry leaf tea Dulse Drink 1 cup daily Parsley Nutritionally: the culinary multi-vitamin; a nutrient powerhouse. Contains high levels of: beta carotene vitamin B12 Chlorophyll Calcium more vitamin C than citrus fruits and just about all other known nutrients. is just like an immuneenhancing multi-vitamin and mineral complex in green plant form. It is one of the most important herbs for providing vitamins to the body. Parsley is made up of proteins (20 per cent), flavonoids (maintain blood cell membranes, antioxidant helper), essential oils, iron, calcium, phosphorus, manganese, inositol, sulphur, vitamin K, beta carotene, and especially vitamin C. Iron Tincture (This is an alternative to iron supplements) Dandelion root Yellow Dock root Nettle leaf Take 1-2 droppers/day (depending on degree of anemia). Calcium Rich Foods Leafy Greens Tofu Almonds Beans Sesame seeds Black strap molasses Figs Cheese and milk Sardines and salmon Hard water What Is Preeclampsia? Preeclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Metabolic Toxemia of Late Pregnancy is evidenced by symptoms of: High blood pressure Edema Sudden weight gain Proteinuria Spots before the eyes Headaches Elevated liver enzymes in the most severe cases eclamptic seizures. Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. Eclampsia When preeclampsia causes seizures, the condition is known as eclampsia--the second leading cause of maternal death in the U.S. The Brewer Diet for Pregnancy adapted from: What Every Pregnant Woman Should Know by Tom and Gail Brewer •4 exchanges of milk (1 cup each): whole milk, low fat, skim, buttermilk. If using soy milk, 1.5 cups per serving. One serving of cheese is approximately 1.25 ounces. •2 calcium replacements for each serving of unfortified soy: almonds, walnuts, sunflower seeds, brazil nuts, broccoli, molasses, wheat germ* •2 eggs •6 exchanges of fish, liver, chicken, lean beef, lamb or pork, any kind of cheese. Beans, grains, nuts and seeds and vegetables may also be included in this area, but do not count an item twice. (Average exchange is 1 ounce meat or hard cheese, 1/4 cup of tuna or soft cheese, 1 cup of milk, 1 egg, 1/2 cup beans or grains, 2 to 3 ounces of nuts, and about 5 ounces of most vegetables.) •2 exchanges of fresh, dark green, leafy vegetables: broccoli, brussels sprouts, spinach, romaine lettuce... (Average exchange is 1/2 to 1 cup) •5 exchanges of whole grain bread, starchy vegetables and fruits. (An average exchange is 1 slice bread, 1/2 cup cereal, pasta or rice, and 1/2 piece of fruit.) •2 exchanges Vitamin C foods. (Average exchange is 1 fruit or 1/2 cup.) •5 exchanges fats and oils. (1 tablespoon butter, oil or mayonnaise) •1 exchange Vitamin A food •Drink to thirst •Salt foods to taste •Liver (4 ounces) once a week (Though some people object to eating any organ meat during pregnancy because of the risk of toxic chemicals supposed in organ meats.) Who Is More Likely to Develop Preeclampsia? Women with chronic hypertension (high blood pressure before becoming pregnant) Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy Women who are obese prior to pregnancy Pregnant women under the age of 20 or over the age of 40 Women who are pregnant with more than one baby Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma. Pregnant women should use caution with vitamins A, C, and D in higher doses than the recommended daily allowances. Synthetic vitamin A in some drugs used for acne and psoriasis can cause birth defects in the developing fetus. The concern with toxicity of vitamin D in pregnancy is calcification of the placenta and other soft tissues. The mother is also more prone to developing kidney stones. Vitamin C taken in extra large doses is thought to cause miscarriage in the early weeks of pregnancy and can cause harm to the baby after birth. Pica— a rare craving to eat substances other than food, such as dirt, clay, ice, laundry starch or coal. Speculated to be psychological, cultural, or even physiological. The craving may indicate a nutritional deficiency such as anemia, or may result in anemia. In some cases interferes with adequate nutrient intake or absorption Should be discouraged. Caffeine in Pregnancy Some studies suggest that drinking more than 2 to 3 cups of coffee daily increases the chances of low birth weight. Watch for hidden caffeine in teas, soft drinks, & chocolate products. As with other diuretics, caffeine consumption should be discussed with one’s healthcare practitioner Should sodium intake be restricted during pregnancy? Answer: No. In fact, sodium requirements increase during pregnancy. The sodium provided by the average diet is likely to be adequate for expectant mothers. Use of additional salt is rarely warranted. Excessive sodium intake does contribute to high pressure in some people. Is it safe to have an occasional cocktail, beer or glass of wine? Because the effects of occasional alcohol consumption during pregnancy are unknown, most health authorities recommend not drinking alcohol during pregnancy. Habitual alcohol consumption does affect the developing infant. Studies show that pregnant women who drink 1-2 drinks per day tend to have smaller babies. Alcohol Use in Pregnancy Women who use alcohol during pregnancy have a greater risk of giving birth to babies with fetal alcohol effects (FAE) or the more serious fetal alcohol syndrome (FAS). Fetal Alcohol Syndrome (FAS) Characterized by: Growth retardation Facial malformations Heart malformations Small head size Mental deficiency FAS affects about 40 percent of babies born to women who drink heavily throughout pregnancy. Tips for Reading Food Labels Check out those little stickers on the fresh fruits and vegetables in your market. A five digit code beginning with a 9 means that produce was grown organically. A five digit code beginning with an 8 identifies genetically engineered produce. A label with four digits indicates conventionally grown food. For further details, read "Talking Fruit" at http://www.plantea.com/genetically-modified-foods.htm Packaged food with the USDA ORGANIC symbol must follow these labeling guidelines: * 100 Percent Organic = 100% * Organic = at least 95% * Made with Organic = at least 70% To learn more, read "How to Read the New Organic Labels" at http://www.theorganicreport.com/pages/12_how_to_read_th e_new_organic_labels.cfm Pregnancy presents a good opportunity for nutrition education. The basic principles of good nutrition—balance, variety and moderation—should be encouraged during pregnancy and as lifetime habits. Clients should be counseled to enjoy a variety of nutrient-rich foods for their own good health and the health of their unborn children.