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Transcript of Nutr.-Pregnancy & Lactation_UNIB-P Raya.ppt
Department of NutritionFaculty of Medicine
Universitas Indonesia2014
References
Brown JE. Nutrition through the Life Cycle 3rd ed., 2005 & 4th ed., 2008
Bowman BA, Russell RM. Present Knowledge in Nutrition 9th ed., 2006
De Maeyer AH, et al. Preventing and Controlling Iron Deficiency Anemia through Primary Health Care, 1989
Mahan LK, Escott-Stumps S. Krause’s Food & Nutrition Therapy 12nd ed., 2008
Lammi-Keefe CJ, et al. Handbook of Nutrition and Pregnancy, 2008
2
33
IntroductionIntroduction
Energy & nutrient requirements typicallyEnergy & nutrient requirements typically more more during pregnancy than during any other stage in during pregnancy than during any other stage in a woman’s adult lifea woman’s adult life
Additional requirement are required during Additional requirement are required during pregnancy for development of the fetus & for pregnancy for development of the fetus & for growth of maternal tissuesgrowth of maternal tissues
The materials required for this rapid growth & The materials required for this rapid growth & development depend on supply from the development depend on supply from the maternal diet maternal diet
44
The importance of nutrition during The importance of nutrition during pregnancy pregnancy
A. To set the nutritional foundations for A. To set the nutritional foundations for a a healthy adult lifehealthy adult life
Epidemiologic evidenceEpidemiologic evidence
strongly suggests certain adult strongly suggests certain adult chronic diseases correlate with chronic diseases correlate with nutritional conditions in uteronutritional conditions in utero
55
B. Nutrition during pregnancy:B. Nutrition during pregnancy:
Maintain maternal energy requirementsMaintain maternal energy requirements
PProvide substrate for development of new fetal rovide substrate for development of new fetal
tissues tissues
RReserve substrate for lactationeserve substrate for lactation
66
Prenatal nutrition:Prenatal nutrition:
• Weight gain in pregnancyWeight gain in pregnancy
• Dietary intake in pregnancyDietary intake in pregnancy
77
relate to baby’s birth weight
8
Baby low birth weight
• Untimely/inadequate feeding• Frequent infections• Inadequate food, health, & care
Child stunted
Adolescent stunted
Woman malnourished Pregnancy low weight gain
Higher maternal mortalityInadequate food, health, & care
Reduced physical capacity & fat free mass
Inadequate food, health, & care
Inadequate catch-up growth
Reduced mental capacity
Inadequate fetal nutrition
Higher mortality rate Impaired mental development risk of adult chronic diseases
Nutrition during pregnancy affects the health of both the mother & baby
From nutritional point of view, birth weight From nutritional point of view, birth weight depends on:depends on:
• Prepregnancy weight for height (W/H) Prepregnancy weight for height (W/H)
expressed in expressed in body mass index (BMI)body mass index (BMI)
• Weight gain during pregnancyWeight gain during pregnancy
Weight (kg)Weight (kg)
BMIBMI = =
HeightHeight22 (m (m22))
99
1010
Distribution Of Weight IncreaseDistribution Of Weight Increase
Fat storage in subcutaneous
tissues
Protein storage
4–4.5 kg
Fetus & placenta 5 kg
Uterus 0.5–1 kg
Breasts 1–1.5 kg
Water & electrolytes 1–1.5 kg
1111
Pregnancy weight gain recommendationsPregnancy weight gain recommendations
Prepregnancy weight status Prepregnancy weight status BMI*BMI*
Recommended weight Recommended weight gaingain
Underweight, <18.5 kg/mUnderweight, <18.5 kg/m22
Normal weight, 18.5–24.9 kg/mNormal weight, 18.5–24.9 kg/m22
Overweight, 25–29.9 kg/mOverweight, 25–29.9 kg/m22
Obese, 30 kg/mObese, 30 kg/m22 or higher or higher
Twin pregnancyTwin pregnancy
12.7–18.2 kg12.7–18.2 kg
11.4–15.9 kg11.4–15.9 kg
6.8–11.4 kg6.8–11.4 kg
6.9 kg at least6.9 kg at least
15.9–20.5 kg15.9–20.5 kg
*BMI categories modified based on 1997 changes from the Nutritional Institutes of Health. Young adolescences should achieve gains at the upper end of ranges, & short women at the lower end
Source: Brown JE, 2008
Physiological changes of pregnancyPhysiological changes of pregnancy
A.A. Blood volume & compositionBlood volume & composition Blood volume expands by 50%Blood volume expands by 50%
Hb value, blood glucose, serum albumin, Hb value, blood glucose, serum albumin, other serum protein, & water soluble vitaminsother serum protein, & water soluble vitamins
Plasma Plasma 43%, RBC 43%, RBC 17–25% 17–25% plasma plasma volumevolume more than RBC more than RBC hemodilutionhemodilution blood viscosity blood viscosity flow resistance flow resistance
facilitating blood flow to uterus & placentafacilitating blood flow to uterus & placenta
1212
B. Cardiovascular & pulmonary functionB. Cardiovascular & pulmonary function
C. Gastrointestinal functionC. Gastrointestinal function
an an of progesterone level of progesterone level
GI motility GI motility absorption of nutrients absorption of nutrients
D. Renal functionD. Renal function
1313
1414
Blood volumeBlood volume
High glomerular filtration rateHigh glomerular filtration rate
butbut
Renal tubules unable to adjust completelyRenal tubules unable to adjust completely
Amino acids, glucose, & water soluble vitamins Amino acids, glucose, & water soluble vitamins may appear in the urinemay appear in the urine
Ability to excrete water is loweredAbility to excrete water is lowered
EdemaEdema in the legs is common & normal in the legs is common & normal
Renal Function ………………………….. (cont’d)
1515
Changes in maternal homeostasis Changes in maternal homeostasis during pregnancy: during pregnancy:
Changes in efficiency of absorption from Changes in efficiency of absorption from the GI tract & excretion by the renal the GI tract & excretion by the renal systemsystem
Changes in maternal storageChanges in maternal storage
Care must be taken in Care must be taken in selecting optimal dietselecting optimal diet
1616
PlacentaPlacenta
Principal site of production for Principal site of production for
several hormones responsible for:several hormones responsible for:
• Regulating fetal growthRegulating fetal growth
• Development of maternal support Development of maternal support
tissuestissues
• The conduit for exchange of nutrients OThe conduit for exchange of nutrients O22
& waste products& waste products
1717
Ig: imunoglobulin
Transfer of substances across the placental membrane
1818
Unit feto-placental hormones:Unit feto-placental hormones:
Placental peptide hormonesPlacental peptide hormones- Human chorionic gonadotrophin - Human chorionic gonadotrophin - Human placental lactogen- Human placental lactogen- Pregnancy specific hormones- Pregnancy specific hormones
Steroid hormonesSteroid hormones- Estrogens- Estrogens- Progesterones- Progesterones
1919
Metabolic & hormonal changesMetabolic & hormonal changes
Metabolism & endocrine functions undergo Metabolism & endocrine functions undergo a large number of changes a large number of changes
during pregnancyduring pregnancy
Optimal growth of the fetusOptimal growth of the fetus
2020
Metabolic changes during pregnancy:Metabolic changes during pregnancy:
Homeostasis Homeostasis fluidfluid & & electrolyteelectrolyte
CHOCHO metabolism: metabolism:
glucoseglucose is the sole energy source for is the sole energy source for the fetusthe fetus
LipidLipid metabolism: metabolism:
lipogenesis & maternal fat storagelipogenesis & maternal fat storage
2121
Metabolic changesMetabolic changes … ……………………… (cont’d)…………………… (cont’d)
ProteinProtein metabolism: metabolism:
positive nitrogen (N) balance positive nitrogen (N) balance tissues synthesistissues synthesis
MineralMineral metabolism: metabolism:
Ca metabolism (Ca metabolism ( rate of bone turnover rate of bone turnover & & reformation)reformation)
2222
Summary of maternal anabolic & Summary of maternal anabolic & catabolic phases catabolic phases of pregnancy of pregnancy
Maternal anabolic phase Maternal anabolic phase 0–20 weeks0–20 weeks
Maternal catabolic phase Maternal catabolic phase 20+ weeks20+ weeks
Blood volume expansion, Blood volume expansion, cardiac cardiac outputoutput
Mobilization of fat & nutrient storesMobilization of fat & nutrient stores
Build up of fat, nutrient, & liver Build up of fat, nutrient, & liver glycogen storesglycogen stores
production & blood levels of glucose, production & blood levels of glucose, triglycerides, and fatty acids; triglycerides, and fatty acids; liver liver glycogen storesglycogen stores
Growth of some maternal organsGrowth of some maternal organs Accelerated fasting metabolismAccelerated fasting metabolism
appetite, food intake (positive energy appetite, food intake (positive energy balance)balance)
appetite & food intake; decline appetite & food intake; decline somewhat near termsomewhat near term
exercise toleranceexercise tolerance exercise toleranceexercise tolerance
levels of anabolic hormoneslevels of anabolic hormones levels of catabolic hormoneslevels of catabolic hormones
2323
Weight gainWeight gain
Weight should be gained throughout Weight should be gained throughout pregnancy, the most critical is in the pregnancy, the most critical is in the 22ndnd trimester trimester
Weight gain Weight gain
1. E1. Expansion of maternal blood volumexpansion of maternal blood volume
2. C2. Construction of fetal & placental tissuesonstruction of fetal & placental tissues
2424
The importance of body weight The importance of body weight among pregnant womenamong pregnant women
Women who are Women who are underweightunderweight are at are at risk for low risk for low birth weight babies (birth weight <2500 g), and birth weight babies (birth weight <2500 g), and can also can also the risk of gastroschisis the risk of gastroschisis
Women who are Women who are overweightoverweight or obese are at or obese are at risk for macrosomic infants (weight >4000 g). risk for macrosomic infants (weight >4000 g).
Macrosomic infants are at Macrosomic infants are at risk of shoulder risk of shoulder dystocia, etc.dystocia, etc.
2525
Nutrient requirement during pregnancyNutrient requirement during pregnancy
Additional amount of nutrients Additional amount of nutrients are neededare needed
Why?Why?
Required by the fetus to growRequired by the fetus to grow
To prepare mother’s body changes during To prepare mother’s body changes during pregnancypregnancy
Preparation for delivery & lactation periodPreparation for delivery & lactation period
2626
Energy needs during pregnancy Energy needs during pregnancy vary according to:vary according to:
Woman’s basal metabolic rate (BMR)Woman’s basal metabolic rate (BMR)
Prepregnancy weightPrepregnancy weight
Amount & composition of weight gainAmount & composition of weight gain
Stage of pregnancyStage of pregnancy
Physical activity levelPhysical activity level
2727
EnergyEnergy
Additional energy needs:Additional energy needs:
Added maternal tissuesAdded maternal tissues
Growth of the fetus & placentaGrowth of the fetus & placenta
Hytten & Leitch:Hytten & Leitch:
Energy cost ≈ 80,000 kcal in general:Energy cost ≈ 80,000 kcal in general: 11stst trimester: additional ≈ 180 kcal/day trimester: additional ≈ 180 kcal/day 22ndnd & 3 & 3rdrd trimester: additional ≈ 300 kcal/day trimester: additional ≈ 300 kcal/day
2828
Energy & MacronutrientEnergy & Macronutrient
WHO recommended an addition of WHO recommended an addition of 300 kcal/day (2300 kcal/day (2ndnd trimester & 3 trimester & 3rdrd trimester) trimester)
22ndnd trimester: mostly used for maternal trimester: mostly used for maternal factorsfactors
33rdrd trimester: for both maternal & fetal trimester: for both maternal & fetal factorsfactors
2929
CarbohydrateCarbohydrate (CHO)(CHO)
IOM IOM CHO adult & children: 130 g/day CHO adult & children: 130 g/day
(minimum 100 g/day); intake 135–175 g/day (minimum 100 g/day); intake 135–175 g/day
to prevent to prevent ketosisketosis & maintaining normal & maintaining normal
blood glucose levels. Adequate intake 175 gblood glucose levels. Adequate intake 175 g
In general In general 50–65%50–65% of total energy of total energy
If CHO is too low If CHO is too low gluconeogenesis gluconeogenesis
Gluconeogenesis is energically expensive: Gluconeogenesis is energically expensive:
80 g protein 80 g protein 50 g glucose 50 g glucose
3030
Dietary fiberDietary fiber//non starch polysaccharidesnon starch polysaccharides
Dietary fiber 10–14 g/1000 kcalDietary fiber 10–14 g/1000 kcal
Insoluble to soluble ratio = 3 : 1Insoluble to soluble ratio = 3 : 1
Soluble fiber: fruits, nuts, beans, cerealsSoluble fiber: fruits, nuts, beans, cereals
Insoluble fiber: fruits, vegetablesInsoluble fiber: fruits, vegetables
Criterion for Criterion for intake: intake: extrapolation based onextrapolation based on energy intake energy intake
3131
ProteinProtein
A number of amino acids are recognized as A number of amino acids are recognized as precursors of neurotransmittersprecursors of neurotransmitters
RDA for protein for the average adult is 0.8 g/kg/dRDA for protein for the average adult is 0.8 g/kg/d
During pregnancy; During pregnancy; additional protein additional protein approximately 1 kgapproximately 1 kg
AdditionalAdditional
11stst trimester trimester 1.3 g/d1.3 g/d
22ndnd trimester trimester 6.1 g/d6.1 g/d
33rdrd trimester trimester 10.7 g/d10.7 g/d
3232
F a tF a t
Metabolic functions of dietary fatMetabolic functions of dietary fat
Oxidized for energyOxidized for energy
Stored in adipose tissueStored in adipose tissue
Incorporated into cell membrane phospho-Incorporated into cell membrane phospho-lipidslipids Precursors for eicosanoid synthesisPrecursors for eicosanoid synthesis Influence on receptor functionInfluence on receptor function Influence on enzyme functionInfluence on enzyme function
3333
Essential fatty acids (EFAs)Essential fatty acids (EFAs)
Omega-3 (n-3) & omega-6 (n-6) fatty acidsOmega-3 (n-3) & omega-6 (n-6) fatty acids
All essential fatty acids (EFAs) are All essential fatty acids (EFAs) are polyunsaturated fatty acids (PUFAs)polyunsaturated fatty acids (PUFAs)
Synthesized in chloroplasts in plants & Synthesized in chloroplasts in plants & phytoplanktonphytoplankton
3434
IOM-FNB (2002) recommended intakes of IOM-FNB (2002) recommended intakes of EFAs EFAs during pregnancyduring pregnancy
Fatty acidsFatty acids % total energy% total energy
Linoleic acid (n-6)Linoleic acid (n-6)
-Linolenic acid (n-3)-Linolenic acid (n-3)
5.0–10.05.0–10.0
0.6–1.20.6–1.2
IOM-FNB: International of Medicine-Food and National Board
3535
Eicosapentaenoic acid (EPA)Eicosapentaenoic acid (EPA) & & docosahexaenoic acid (DHA):docosahexaenoic acid (DHA):
2 derivatives of 2 derivatives of -linolenic acid (n-3 fatty acid)-linolenic acid (n-3 fatty acid)
EPAEPA & & DHADHA perform specific functions in perform specific functions in the body particularly during pregnancy & the body particularly during pregnancy & lactationlactation
3636
EPAEPA: : inflammationinflammation dilate blood vesselsdilate blood vessels blood clottingblood clotting
DHADHA: :
the major structural component of phospholipids the major structural component of phospholipids in cell membranes in the central nervous system in cell membranes in the central nervous system (CNS), including retinal photoreceptors (CNS), including retinal photoreceptors
3737
Adequate intake Adequate intake of of EPAEPA & & DHADHA
during pregnancy & lactation is estimated during pregnancy & lactation is estimated
to be to be 300 mg/day300 mg/day
3838
Pedoman Umum Gizi Seimbang Pedoman Umum Gizi Seimbang (Depkes (Depkes RI)RI)
• CHO CHO 50–60% of total energy50–60% of total energy
SugarSugar not more than 5%not more than 5%
• LipidLipid 25% (at least 10%)25% (at least 10%)
• ProteinProtein 10–15%10–15%
Unit of energy:Unit of energy: kiloJoules (kJ) & Calorie (Cal) or kilocalorie (kcal) kiloJoules (kJ) & Calorie (Cal) or kilocalorie (kcal)
1 Cal or kcal = 4.184 kJ1 Cal or kcal = 4.184 kJ
3939
Required for production of several Required for production of several
coenzymescoenzymes & as & as cofactorscofactors of many of many
enzymes that catalyze numerous enzymes that catalyze numerous
metabolic pathwaysmetabolic pathways
4040
Requirements of vitamin B group per Requirements of vitamin B group per day day for adult female for adult female
NutrientNutrient RequirementRequirement PregnancyPregnancy
Vitamin BVitamin B11 0.5 mg/1000 kcal, 0.5 mg/1000 kcal, minimal 1 mg for minimal 1 mg for energy intake (2000 energy intake (2000 kcal)kcal)
+ 0.3 mg+ 0.3 mg
Vitamin BVitamin B22 1.3 mg1.3 mg + 0.3 mg+ 0.3 mg
NiacinNiacin 14 mg14 mg + 4.0 mg+ 4.0 mg
Vitamin BVitamin B66 1.3 mg1.3 mg + 0.4 mg+ 0.4 mg
Vitamin BVitamin B1212 2.4 2.4 gg + 0.2 + 0.2 gg
Folic acidFolic acid 400 400 gg + 200 + 200 ggSource: Widyakarya Nasional Pangan dan Gizi (WNPG) VIII, 2004
4141
Folic acidFolic acid
Deficiency in pregnancy has been linked Deficiency in pregnancy has been linked with maternal megaloblastic anemia & fetal with maternal megaloblastic anemia & fetal neural tube defect neural tube defect (NTD)(NTD)
Folic acid supplements should be Folic acid supplements should be administered 3 months prior to conception administered 3 months prior to conception & during& during
11stst trimester (400 trimester (400 g/day)g/day)
Female with history of delivering baby Female with history of delivering baby
with NTDwith NTD
supplementation of 4 mg/daysupplementation of 4 mg/day
4242
Vitamin CVitamin C
AntioxidantAntioxidant
Pregnancy Pregnancy intake: (+) 10 mg intake: (+) 10 mg
Criterion for increasing: Criterion for increasing:
amount needed to prevent amount needed to prevent scurvyscurvy in infant in infant
& estimated fetal transfer& estimated fetal transfer
4343
AntioxidantsAntioxidants
Brain is metabolically the most active organ & Brain is metabolically the most active organ & consumes maximum amount of consumes maximum amount of glucoseglucose & &
OO22 by product by product
OO22 free radicalsfree radicals
Reactive oxygen speciesReactive oxygen species
Antioxidants (vitamins A, C & E, Zn, Se, etc.)Antioxidants (vitamins A, C & E, Zn, Se, etc.)
4444
Fat Soluble VitaminsFat Soluble Vitamins
Fat soluble vitamins can be stored in adipose Fat soluble vitamins can be stored in adipose tissues & livertissues & liver
additional intake should be additional intake should be
carefully supervisedcarefully supervised Excessive intake Excessive intake malformation & abortion malformation & abortion
Brain development: vitamins A & E Brain development: vitamins A & E (antioxidants) are required(antioxidants) are required
4545
Brain development:Brain development:
IodineIodine (I): for synthesis tiriodothyronine (T (I): for synthesis tiriodothyronine (T33) & ) &
thyroxine (Tthyroxine (T44))
IronIron (Fe): required for myelin production (Fe): required for myelin production
ZincZinc (Zn): component of over 200 metalloenzymes (Zn): component of over 200 metalloenzymes
CopperCopper (Cu): important component of cytochrome (Cu): important component of cytochrome oxidase & superoxide dismutase oxidase & superoxide dismutase
(SOD) in the brain (SOD) in the brain
4646
Sodium Sodium
Hormonal milieu of pregnancy affects Hormonal milieu of pregnancy affects sodium metabolismsodium metabolism
Intake should not be excessive but do not Intake should not be excessive but do not less than 2 g/dayless than 2 g/day
Requirement of some minerals per day Requirement of some minerals per day for adult female for adult female
NutrientNutrient RequirementRequirement PregnancyPregnancy
II
FeFe
ZnZn
SeSe
150 150 gg
26 mg/day26 mg/day
≈ ≈ 9 mg/day9 mg/day
30 30 gg
+ 50 + 50 gg
11stst trimester trimester
22ndnd trimester + 9.0 mg trimester + 9.0 mg
33rdrd trimester + 13.0 mg trimester + 13.0 mg
11stst trimester + 1.7 mg trimester + 1.7 mg
22ndnd trimester + 4.2 mg trimester + 4.2 mg
33rdrd trimester + 9.8 mg trimester + 9.8 mg
+ 5 + 5 gg
Source: WNPG VIII, 20044747
4848
During pregnancy the requirement of During pregnancy the requirement of fluidfluid
Why?Why?
blood volume & blood volume & utero-placental perfusion utero-placental perfusion
Water & sodium intake are very important Water & sodium intake are very important
4949
WaterWater
Female adult ≈ 2 L/day Female adult ≈ 2 L/day
Pregnancy 2.3 L/dayPregnancy 2.3 L/day
SodiumSodium::
Pregnancy: Pregnancy: • Adequate intake (AI) 1.5 g/dayAdequate intake (AI) 1.5 g/day• Upper limit (UL) 2.3 g/dayUpper limit (UL) 2.3 g/day
Healthy adult at least 500 mg/dayHealthy adult at least 500 mg/day
5050
AlcoholAlcohol
Evidence from animal studies & human Evidence from animal studies & human experience:experience:
Associates heavy drink (>1 drink/day) Associates heavy drink (>1 drink/day) by a pregnant female with by a pregnant female with teratogenicity teratogenicity & & fetal alcohol syndromefetal alcohol syndrome
Fetal alcohol syndromeFetal alcohol syndrome
Features:Features:Prenatal & postnatal growth failurePrenatal & postnatal growth failure
Developmental delayDevelopmental delay
MicrocephalyMicrocephaly
Eye changesEye changes
Facial abnormalitiesFacial abnormalities
Skeletal joint abnormalitiesSkeletal joint abnormalities
5151
5252
Nonnutritive Substances in Nonnutritive Substances in FoodsFoods
Caffeine <100 mg/day Caffeine <100 mg/day ~ ~ 2 cups of coffee2 cups of coffee
Artificial sweeteners:Artificial sweeteners: sucralosesucralose approved by FDA in 1998; approved by FDA in 1998; sucrose derivative, 600 times sweetersucrose derivative, 600 times sweeter
Sucralose Sucrose
5353
Some obstetric complications with Some obstetric complications with nutritional interrelationshipsnutritional interrelationships
AnemiaAnemia in pregnancy in pregnancy
Hb concentration <11 g/dLHb concentration <11 g/dL
5454
Iron Deficiency AnemiaIron Deficiency Anemia
Iron deficiency anemia (IDA)Iron deficiency anemia (IDA) is a is a problem of serious public health problem of serious public health significancesignificance
Iron deficiency (ID) occurs when iron is Iron deficiency (ID) occurs when iron is absorbed in an absorbed in an insufficient amount insufficient amount to to meet the body’s requirementmeet the body’s requirement
5555
Iron DeficiencyIron Deficiency
Insufficiency may be due to:Insufficiency may be due to:
Inadequate iron intakeInadequate iron intake
Reduced bioavailability of dietary ironReduced bioavailability of dietary iron
Increased needs for ironIncreased needs for iron
Chronic blood lossChronic blood loss
5656
IronIron ………………………………………. ………………………………………. (cont’d)(cont’d)
When prolonged, ID leads to IDA When prolonged, ID leads to IDA
NormaNormall
Iron Iron depletiodepletionn
IDID IDAIDA
Plasma Ferritin Plasma Ferritin ((µg/L)µg/L)
Transferrin Transferrin Saturation (%)Saturation (%)
RBC Protoporphyrin RBC Protoporphyrin (µg/dL)(µg/dL)
Hemoglobin (g/dL)Hemoglobin (g/dL)
6060
3535
3030
≥≥1212
3535
3030
≥≥1212
<12 <12
<16<16
>100>100
>>1212
<12 <12
<16<16
>100>100
<12<12
<12
Iron deficiency in women [International Nutritional Anemia Consultative Group (INACG), 2002]
Iron Status
5757
The consequences of ID or IDA in The consequences of ID or IDA in pregnant women:pregnant women:
maternal morbidity & mortalitymaternal morbidity & mortality
fetal morbidity & mortalityfetal morbidity & mortality
risk of low birth weightrisk of low birth weight
5858
Megaloblastic AnemiaMegaloblastic Anemia
In pregnancy, In pregnancy,
megalobalstic anemia usually caused by megalobalstic anemia usually caused by
folic acid deficiencyfolic acid deficiency
5959
Other Other Obstetric Complications Obstetric Complications with with Nutritional Interrelationship Nutritional Interrelationship
Hyperemesis gravidarumHyperemesis gravidarum
Diabetes mellitusDiabetes mellitus
Underweight & poor weight gainUnderweight & poor weight gain
ObesityObesity
6060
ObesityObesity
Obesity in pregnancy Obesity in pregnancy the risk of: the risk of:
Gestational diabetesGestational diabetes
Pregnancy-induced hypertensionPregnancy-induced hypertension
Cesarean sectionCesarean section
Neural tube defect (NTD)Neural tube defect (NTD)
Delivery infant with macrosomiaDelivery infant with macrosomia
Intrauterine fetal demise (IUFD)Intrauterine fetal demise (IUFD)
Infant with cardiac defectsInfant with cardiac defects
6161
SummarySummary
Energy intake to meet nutritional needs & allow Energy intake to meet nutritional needs & allow for about a 0.4 kg weight gain per week during for about a 0.4 kg weight gain per week during the last 30 weeks of pregnancythe last 30 weeks of pregnancy
Protein intake to meet nutritional needs, about an Protein intake to meet nutritional needs, about an additional 20 g/dayadditional 20 g/day
Sodium intake that is not excessive but is no less Sodium intake that is not excessive but is no less than 2–3 g/day (5–6 g of table salt)than 2–3 g/day (5–6 g of table salt)
6262
Summary Summary …………………………. (cont’d)…………………………. (cont’d)
Mineral & vitamin intakes to meet the RDA (folic Mineral & vitamin intakes to meet the RDA (folic acid & possibly iron supplementation is required)acid & possibly iron supplementation is required)
Alcohol omittedAlcohol omitted
Caffeine in moderation:Caffeine in moderation:
less than 200 mg/day less than 200 mg/day equivalent to equivalent to
2 cups of coffee2 cups of coffee
6363
ConclusionConclusion
Nutrition during pregnancyNutrition during pregnancy
Maintains energy, macronutrients, & micronutrients Maintains energy, macronutrients, & micronutrients requirementsrequirements
Provide substrate for development of new fetal tissuesProvide substrate for development of new fetal tissues
Builds energy reserves for postpartum lactationBuilds energy reserves for postpartum lactation
Optimal nutrition during pregnancy is the most critical Optimal nutrition during pregnancy is the most critical importance; 70% of the human brain develops during fetal importance; 70% of the human brain develops during fetal lifelife
6565
Breastfeeding Breastfeeding is the gold standard & strongly is the gold standard & strongly
recommended method of feeding infantsrecommended method of feeding infants
World Health Organization (WHO) recommends World Health Organization (WHO) recommends
human milk human milk as the exclusive nutrient source for as the exclusive nutrient source for
the the first 6 months of lifefirst 6 months of life, with introduction of , with introduction of
solids at this time, and continued breastfeeding solids at this time, and continued breastfeeding
until at least 12 months postpartumuntil at least 12 months postpartum
6666
Breast feeding benefits to:
• Infant nutrition
• Gastrointestinal function
• Host defense
• Neurological development
• Psychological, economic, & environmental
well being
• etc.
6767
Healthy MotherHealthy Mother
Human milkHuman milk
Volume: Volume: 850 mL/day 850 mL/day
Energy content: 60–65 kcal/100 mLEnergy content: 60–65 kcal/100 mL
Lactating woman requires a moderately Lactating woman requires a moderately
large amount of extra energylarge amount of extra energy
6868
Adequate amount of human milk Adequate amount of human milk production depends upon: production depends upon:
Capacity of the mammary gland in milk Capacity of the mammary gland in milk synthesissynthesis
Activity, metabolism, hormonal, & Activity, metabolism, hormonal, & maternal dietmaternal diet
Amount of energy & nutrient stores that Amount of energy & nutrient stores that can be utilized can be utilized
6969
Daily intake
Available nutrients (intake & storage)
Body stores
Milk (energy & nutrients content)
Maternal activity & metabolism
Milk synthesis process
Source: Lawrence, 2000
Maintain maternal healthMaintain maternal health
Milk production that sufficient for Milk production that sufficient for the infantthe infant
Various mechanisms including Various mechanisms including adjustments to energy intake & its adjustments to energy intake & its expenditure to meet the energy expenditure to meet the energy requirement during lactation requirement during lactation
7070
Nutritional Needs of Lactating WomanNutritional Needs of Lactating Woman
7171
Estimated Energy Requirement (EER)Estimated Energy Requirement (EER)
The incremental The incremental energy cost energy cost of lactation is of lactation is determined by:determined by:
The amount of milk producedThe amount of milk produced
The energy density of the milk secretedThe energy density of the milk secreted
The energy cost of milk synthesisThe energy cost of milk synthesis
7272
EEREER of a of a healthy lactating woman healthy lactating woman can be estimated can be estimated
by a factorial approach from the by a factorial approach from the sum ofsum of::
(1) EER of a non-pregnant, non-lactating woman (1) EER of a non-pregnant, non-lactating woman
(of a given age, weight, & activity level)(of a given age, weight, & activity level)
(2) Estimated milk energy (2) Estimated milk energy
(3) Energy mobilization from tissue stores (3) Energy mobilization from tissue stores
(i.e. weight loss)(i.e. weight loss)
7373
Human milk composition per 100 mL:Human milk composition per 100 mL:
EnergyEnergy 60–65 kcal60–65 kcal
ProteinProtein 1.0–1.2 g1.0–1.2 g
Fat Fat 2.5–3.5 g2.5–3.5 g
Human milk contains Human milk contains
calciumcalcium 300 mg/day 300 mg/day
7474
MeasuringMeasuring nutritional requirements nutritional requirements of lactating woman of lactating woman (WNPG VIII, 2004)(WNPG VIII, 2004)
850 mL of human milk 850 mL of human milk ≈ ≈ 600 kcal600 kcal
Energy efficiency 80% Energy efficiency 80% requires an extra requires an extra (100 : 80) x 600 kcal =(100 : 80) x 600 kcal = 750 kcal/day750 kcal/day
200 kcal obtained from 200 kcal obtained from fat stores fat stores
extraextra energy intake: 750 kcal – 200 kcal energy intake: 750 kcal – 200 kcal
≈ ≈ 500–550 kcal/day500–550 kcal/day is sufficient is sufficient
7575
MeasuringMeasuring nutritional nutritional …………………. (cont’d)…………………. (cont’d)
ProteinProtein (850 : 100) x 1.5 g = 13 g (850 : 100) x 1.5 g = 13 g
Protein efficiency 80% Protein efficiency 80%
(100 : 80) x 13 g = 16.25 g (100 : 80) x 13 g = 16.25 g
((additionaladditional average average 17 g of protein/day17 g of protein/day))
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The The extra energyextra energy (calories) need of lactating (calories) need of lactating
woman should in the form of a woman should in the form of a well-balanced well-balanced
dietdiet, not come from high-calorie foods with , not come from high-calorie foods with
poor nutrient density such as sugar and oilspoor nutrient density such as sugar and oils
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CarbohydratesCarbohydrates
Source of energySource of energy
Protein Protein sparing effectsparing effect
50–60% of total calories50–60% of total calories
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FatsFats (1) (1)
Sources of EFAs & energySources of EFAs & energy
Polyunsaturated fatty acids (PUFAs): Polyunsaturated fatty acids (PUFAs): arachidonicarachidonic acid (AA) & acid (AA) & DHADHA essential in neural & visual acuity developmentessential in neural & visual acuity development
Several studies:
infants fed with human milk have better cognitive development & visual evoked potential (VEP) than those fed with commercial infant formulas
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DHADHA intake should be 300 mg/day in lactating intake should be 300 mg/day in lactating woman woman (Simopoulos et al, 1999) (Simopoulos et al, 1999)
Fatty acids of infant tissues depend on daily fats Fatty acids of infant tissues depend on daily fats intake intake DHA content of breast milk is >>> DHA content of breast milk is >>>
if the maternal DHA intake is >>>if the maternal DHA intake is >>>
The mother’s dietary fat intake should be The mother’s dietary fat intake should be optimal in order to have optimal in order to have optimal fatty acids optimal fatty acids compositioncomposition in her milk in her milk
FatsFats (2) (2)
ProteinProtein
The AKG (Indonesian RDA) suggests The AKG (Indonesian RDA) suggests an an
additionaladditional 17 g of protein a day 17 g of protein a day for lactation for lactation
(WNPG VIII, 2004)(WNPG VIII, 2004)
oror
70 g of protein a day70 g of protein a day
8080
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Minerals
Calcium intake need to be regarded
During lactation secretion of calcium into breast milk averages ≈ 200 mg/day
Iron intake need for replacing the iron depletion
during pregnancy
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VitaminsVitamins
Fat soluble vitamins should be adequateFat soluble vitamins should be adequate
Water soluble vitamins intake depends on the Water soluble vitamins intake depends on the mother’s energy intakemother’s energy intake
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TaurineTaurine: :
• AntioxidantAntioxidant
• Conjugation of bile acids & saltsConjugation of bile acids & salts
NucleotideNucleotide: :
essential substances for protein synthesis, essential substances for protein synthesis, energy metabolism, etc.energy metabolism, etc.
Non-nutrients
Human milk Human milk contains high concentration of contains high concentration of taurine & nucleotidetaurine & nucleotide
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Undernourished WomanUndernourished Woman
Although the Although the quantityquantity of of
human milk is influenced human milk is influenced
by the mother’s nutritional by the mother’s nutritional
status, status, the quality is not the quality is not
significantly affectedsignificantly affected, ,
except for the fat, vitamin, except for the fat, vitamin,
& mineral contents& mineral contents
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Nutritional Status & Milk Nutritional Status & Milk VolumeVolume
Milk production of woman with Milk production of woman with
good nutritional statusgood nutritional status::
First months First months ≈ ≈ 600 mL600 mL
Third monthsThird months 700–750 mL 700–750 mL
Sixth monthsSixth months 750–800 mL 750–800 mL
The amount will The amount will depend on depend on
suckling frequency suckling frequency of the infantof the infant
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Physiology of milk productionPRH: pituitary releasing hormone
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Milk production of undernourished Milk production of undernourished woman:woman:
First 6 months First 6 months 500–700 mL500–700 mL
Second 6 months Second 6 months 400–600 mL400–600 mL
Second years Second years 300–500 mL300–500 mL
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Milk production of Milk production of ……………………… (cont’d)……………………… (cont’d)
Severe malnutrition mother Severe malnutrition mother fat content fat content in breast milk in breast milk <<<<<<
The water-soluble vitamins content The water-soluble vitamins content depends on the mother’s intake depends on the mother’s intake of these vitaminsof these vitamins
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ConclusionConclusion
Maternal diet play a role in both the Maternal diet play a role in both the nutrients & non-nutrients compositionnutrients & non-nutrients composition
Nutrients composition of lactating woman Nutrients composition of lactating woman is necessary to be regardedis necessary to be regarded
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Nutritional status of lactating woman play Nutritional status of lactating woman play an important role in one of the efforts to an important role in one of the efforts to achieve breastfeeding at the early life of an achieve breastfeeding at the early life of an individualindividual
Moreover, nutrition play a role in Moreover, nutrition play a role in determining the success of a child’s growth determining the success of a child’s growth & development since his or her early life& development since his or her early life
Conclusion ……………………………… (cont’d)
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To prevent malnutrition during lactation, To prevent malnutrition during lactation, early detection in early detection in antenatal careantenatal care is necessary is necessary by both anthropometric & laboratory by both anthropometric & laboratory assessment, and physical examination assessment, and physical examination
Conclusion ……………………………… (cont’d)
92
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