Adequate nutrition before and during pregnancy has greater potential for a long term health impact than it does at any other time. Maternal health is a complex, influenced by various genetic, social & economical factors, infections & environmental condition, many of which may affect the social growth. Physiological adaptations result in improved utilization of nutrients either through increased absorption decreased excretion or alterations in metabolism.
A woman who has been well nourished before conception begins her Pregnancy with reserves of several nutrients so that the needs of the growing fetus can be met without affecting her health. Infant who are well nourished in the womb, have an enhanced chance of entering life in good physical & mental health. The effects of under nutrition during reproduction will vary depending upon the nutrients involved, the length of time it is lacking & the stage of gestation at which it occurs.
A woman whose diet is adequate before pregnancy is usually able to bear a full term viable infant, without extensive modifications of her diet. Mother’s diet should produce adequate nutrients so that maternal stores do not get depleted & produce sufficient milk to nourish her child after birth. The nutritional demands are highly increased in an adolescent mother.
PHYSIOLOGICAL & PSYCHOLOGICAL CHANGES
Pregnancy is an emotional time for the women who becomes pregnant, especially, if she is pregnant for the first time. The physiological changes together with the hormonal changes make pregnancy a psychological event for the women.
Each trimester whether it proceeds smoothly or with associated problems like the ability to excrete water is lowered & edema in legs & ankles is common & normal, there is decreased ability to taste saltiness etc. can create a mental state that the mother may experience as unique, irrespective of the fact that she may or may not be pregnant for the first time. Physical stress, hormonal changes, coping with a changing body shape & yet going about in life & performing daily living, attending to the needs of the family & children all together may affect the emotional equilibrium of the would-be-mother.
Increase in nutritional requirements depends on the nature of metabolic changes of pregnancy & the nutrition reserves of the mother. The RDA of the expectant mother is given in the following table:-
RECOMMENDED DIETARY ALLOWANCES OF AN EXPECTANT MOTHER:-
|NUTRIENT||NORMAL ADULT WOMAN||PREGNANT WOMAN|
|Vit. C mg||40||60|
PRINCIPLE OF DIET
High calorie, High protein, High fat, High CHO, High vitamin & minerals, High fluid
ENERGY : Energy needs during pregnancy increase because of the additional energy required for the following:
Ø The growth & activity of the foetus.
Ø The growth of the placenta.
Ø The normal increase in maternal body size.
Ø The additional work involved in carrying the weight of the foetus & extra maternal tissues.
Ø The slow but steady rise in basal metabolic rate during pregnancy.
For an Indian woman of 55kg, the total energy cost of pregnancy is about 80,000 kcals of this 36,000 kcals is deposited as fat, which is utilized subsequently during lactation. Hence ICMR recommended energy requirement of pregnant women as follows:-
Sedentary worker: 1900+350= 2250 kcals
Moderate worker: 2230+350= 2580 kcals
Heavy worker: 2850+350= 3200 kcals
The caloric requirement of a pregnant woman is mostly increased in the latter half of pregnancy. The increase in calories for trimester-wise is as follows:-
1st trimester: 10 cals/day
2nd trimester: 90 cals/day
3rd trimester: 200 cals/day
350 extra calories can look like any of the combination of food such as 1 cup milk, 1 serving dry cereal, 1 banana.
PROTEIN : The normal protein requirement of an adult woman is 55g/day. ICMR prescribed for a pregnant woman 78g/day. Additional protein is essential for:-
Ø Rapid growth of fetus .
Ø The enlargement of the uterus, mammary gland & placenta.
Ø Increase in maternal circulating blood volume & subsequent demand of increased plasma protein to maintain colloidal osmotic pressure & circulation of tissue fluids.
Ø Formation of amniotic fluid & storage reserves for labor & delivery.
Ø Transfer of amino acids from the mother to fetus.
If protein requirements are not met during pregnancy:-
Ø There is increased risk of pregnancy.
Ø The foetus may grow at the expense of mother.
Ø Maximum growth of baby cannot be obtained.
Ø Number of cells in tissue particularly in brain may be less.
Sources:- Milk, Meat, Egg, Cheese, Pulses & Legumes, Whole grains, Nuts & Oilseeds.
CARBOHYDRATES & FATS : Carbohydrates (65-70% of total calorie) & fats (30-35% of total calorie) should be supplied in diet.
CALCIUM : ICMR calcium requirement of an adult woman is 400 mg/day. Requirement increases during pregnancy to 1000 mg/day. A full term fetal body is made up of 30 gm of calcium. Increased intake of calcium by the mother is highly essential, not only for the calcification of fetal bones & teeth but also for protection of calcium resources of the mother. Use of vitamin D & calcium reduces muscular cramps of pregnancy.
To prevent ‘osteomalacia’ mother’s diet should contain adequate amount of vitamin D & sufficient amount of calcium. Dairy products are primary source of calcium. Green leafy vegetables & Fish also contribute to calcium.
IRON : Normal iron requirement of an adult woman is 35 mg/day. ICMR requirement of iron increases to 38 mg/day during pregnancy.
The increase in iron by 8 mg/day can be attributed to the following:-
Ø Iron is also required for the growth of fetus & placenta.
Ø It is also required for the formation of Hb as there is 40-50% increased maternal blood volume.
Ø Loss of maternal iron through skin & sweat is about 170 mg of iron.
To increase the amount of iron in diet, include iron-rich snacks: raw coconut (nariyal) slices, raisins, dates, nuts (such as walnuts, pistachios, cashew-nuts) , roasted pumpkin seeds, groundnuts & jaggery, iron fortified cereals & grains, egg yolk salad, sesame seeds.
Ways to increase iron in daily food:- These ‘Power Food’ can help increase daily iron intake:-
Ø Green leafy vegetables such as fenugreek, spinach, coriander, mint, lotus stem can be used for all sorts of food. Use them to make raitas, salads, fillers for sandwiches, stuffed parathas or rotis.
Ø Spices such as cumin seed, bay leaf, turmeric can be used to flavor curry or vegetable.
Ø Soya nuggets can be added to pulaos & salads or cook them with potatoes or other vegetables such as capsicum & peas. Soya granules make tasty pakoda & can be used to stuff parathas.
Ø Rice flakes
Ø Semolina can be used to cook kheer or upma.
Ø Pulses & legumes such as Bengal gram, chickpea, kidney beans, lentils, red gram etc. use any of them to make dal, sprouts, salads, sweet treats like moong dal halwa. Increase the amount of iron in dal by adding leafy greens such as spinach, radish leaves.
Ø Fruits rich in iron pomegranates, watermelon, seethaphal, phalsa.
Ø Tamarind can be used to make chutney or enhance the flavor of dish such as sambhar.
Ø Use iron fortified salt.
Ø Meat is one of the best sources of iron.
Ø Cooking in iron utensils is another way of increasing iron content of the food.
What helps the body to absorb iron?
Vitamin C helps the body to absorb the iron. So, try to take vitamin C with meals when taking iron supplement. This is especially important if someone is vegetarian because the iron from vegetarian sources is not absorbed by the body as easily as iron from non-vegetarian sources.
Sources:- amla, guava, orange, tomato, lemon.
SODIUM : Normal adult woman requirement of sodium should be maintained to prevent any defective disorders & deficiency.
During pregnancy there is an increase in the extracellular fluid which calls for 80% increase in the body sodium. Restriction in the diet can cause a severe hormonal & biochemical changes.
When blood sodium level drops; kidney produces the hormone renin; as a result of which the sodium that is needed for use by the body is retained.
When the system is overtaxed it can result in sodium deficiency causing an increased risk of eclampsia, prematurity & low birth weight of infants.
Sodium is restricted when there is edema or hypertension.
IODINE : ICMR recommends additional requirement of 25µg during pregnancy to the adult requirement of 100-200 µg. Iodine deficiency in mother can lead to abortion, stillbirths, congenital anomalies, increased prenatal mortality, cretinism & psychomotor defects. Mothers who are residing in goiter endemic area should ensure that they got enough iodine through iodized salt & other means.
ZINC :Low zinc during pregnancy doubles the risk of low birth weight & trebles the risk of preterm delivery.
Sources :-Herrings & oysters are rich sources while flesh is good sources. Cereals, pulses, nuts & oilseeds, vegetable & fruits are fair sources.
VITAMIN A :Normal requirement of β-carotene for an adult woman is 4800 mcg. 6400 mcg is suggested during pregnancy. Vitamin A requirements during pregnancy have been calculated on the basis of the vitamin content of liver of the newborn.
Sources:- liver, egg yolk, butter, dark green & yellow vegetables & fruits are good sources of vitamin A.
VITAMIN D :Vitamin D is highly essential as it enhances the maternal calcium absorption. Its active form calcidiol & calcitriol cross the placenta with ease & play an important role in calcium metabolism of the fetus. Maternal deficiency of vitamin D results in neonatal hypocalcaemia & hypoplasia. Excessive vitamin D result in complications such as hypercalcaemia, calcium deposits in various vital organs & mental retardation in the infants.
VITAMIN E : Vitamin E has an important role to play in the reproductive process & reduces the number of spontaneous abortions & stillbirths. Requirement of vitamin E increases with increased intake of PUFA.
VITAMIN K :Vitamin K is essential for synthesis of prothrombin i.e. necessary for normal coagulation of blood. It is highly essential for preventing neonatal hemorrhage.
Rich sources:– green leafy vegetables
Good sources:- cereals, legumes, milk, egg, meat, fish & other vegetable are good sources.
Fair sources:– fruits are fair sources.
WATER SOLUBLE VITAMINS
THIAMINE : For a pregnant woman the requirement is increased by 0.2 mg/day. In some cases thiamine helps to relieve the nausea of pregnancy.
Dietary sources: – whole cereals, pulses & legumes, oilseeds & nuts are good sources of thiamine. Rice polishing, wheat germ & dried yeast are rich sources. Meat, fish, egg, milk, vegetable & fruits are fair sources.
RIBOFLAVIN : In a pregnant woman the RDA is increased by 0.3 mg/day. Requirements are increased due to increase in maternal body size & growth of fetus & accessory tissues. Riboflavin is present in higher amounts in the fetal blood than in maternal blood.
Dietary sources: – liver, dried yeast, egg powder, whole & skim milk powder are the richest sources of riboflavin. Fresh milk, egg, meat & fish, whole cereals & millet, legumes & green leafy vegetables are good sources.
NIACIN :ICMR recommendations of niacin RDA for an adult woman are 12 mg for sedentary worker, 14 mg for moderate worker & 16 mg for heavy worker. In a pregnant woman the RDA is increased by 2 mg, corresponding to the increase in calories.
Dietary sources: –richest natural sources of niacin are dried yeast, rice polishing, liver & peanut. Whole cereals, legumes, meat & fish are good sources.
VITAMIN B6 : Normal requirement of pyridoxine in adult woman is 2.5 mg. ICMR suggested for pregnancy 2.5 mg/day. During “toxaemia of pregnancy” (high B.P., edema, proteinuria) the B6 levels are lower. Women who used oral contraceptives prior to conception often enter pregnancy with low tissue levels of vitamin B6. There is no satisfactory theory to explain that these low levels affect the outcome of pregnancy but they do reduce the amount of pyridoxine in breast milk during lactation. B6 is said to be used to control nausea of pregnancy.
Dietary sources: – dried yeast, rice polishing, wheat germ & liver are rich sources. Whole cereals, Pulses & legumes, oilseeds & nuts, egg, milk, meat & fish & green leafy vegetables are good sources.
FOLIC ACID : An adequate amount of folic acid is essential before & during pregnancy. Folic acid is essential for cell division & organ formation that takes place in the 3rd trimester of pregnancy. Therefore, it is an extremely important nutrient for women of reproductive age.
Dietary sources:- dried yeast, liver, wheat germ, rice polishing, dark green leafy vegetables, legumes, orange juice, soya, almonds & peanuts.
VITAMIN B12 : Normal adult woman’s requirement of vitamin B12 is 1.2 mcg & this requirement remains the same even during pregnancy. Vegetarian mothers have more chances of getting B12 deficiency.
Dietary sources:- vitamin B12 is present only in foods of animal origin. It is not present in foods of vegetable origin. Liver is the richest natural source of vitamin B12. Meat, fish, kidney, brain & eggs are good sources. Fresh milk, milk powder & cheese are fair sources.
VITAMIN C : ICMR recommendations of vitamin C during pregnancy is 60 mg same as normal woman requirement. Low maternal intake of vitamin C is associated with premature rupture of fetal membranes & increased neonatal death rates.
Dietary sources:- amla, guava, lime juice, orange, pineapple, mango(ripe), papaya(ripe), tomato(ripe), cabbage, amaranth leaves, Brussels sprouts, spinach, radish leaves.
WATER needs increase during pregnancy for carrying essential nutrients into the placenta. Extra water is also needed for prevention of urinary tract infection & to prevent dehydration. Dehydration in pregnancy may cause contractions & premature labor, especially in the 3rd trimester.
OTHER ISSUES IN PREGNANCY
Morning sickness Nausea & vomiting (usually resolves after the first 12 weeks of pregnancy)
Ø Eat frequent small meals
Ø Eat easy to digest starchy foods like rice, fruits, potatoes, pasta, vegetables
Ø Avoid spicy foods
Ø Limit fried foods & foods with lots of butter
Ø Drink beverages between meals rather than with meals
Ø Get plenty of rest
Ø Drink enough fluids as vomiting leads to dehydration
Ø Skim milk is better tolerated than whole milk
Ø Strongly flavored foods may be restricted if the nausea persists or patient complains of heartburn & gastric distress.
Food cravings & aversions to certain foods are common during pregnancy. There is no evidence that food cravings are the result of nutrient deficiencies & their cause remains a mystery. The most commonly craved foods are sweets & dairy products. The most common aversions reported are to alcohol, coffee, other caffeinated drinks, meats & strongly spiced foods. Consumption of non-food items like laundry starch, ice cubes or clay is called PICA. It occurs more often during pregnancy. The etiology of pica is poorly understood. One theory suggests that the ingestion of non-food substance relieves nausea & vomiting.
Some may experience occasional bouts of constipation during pregnancy. Constipation is caused by the relaxation & slowing down of the large intestine due to the continuously expanding uterus.
Ø Eat high fiber foods.
Ø Drink at least 12 glasses of fluid per day.
During the final months of pregnancy, heartburn may become an issue. Heartburn become common as the growing baby puts pressure on the digestive organs.
Ø Eat small frequent meals.
Ø Walk after eating or sit upright to promote the downward flow of gastric juice.
Ø Sleep with your head elevated.
Ø Wear comfortable clothes.
EDEMA & LEG CRAMPS
Mild, physiologic oedema is usually present in the extremities in the 3rd trimester. The swelling of the lower extremities may be caused by the pressure of the enlarging uterus on the veins returning fluid from the legs. This normal oedema requires no sodium restriction or other dietary changes.
The common occurrence of cramps during pregnancy, manifested nocturnally by sudden contractions of the muscle, is thought to be related to a decline in serum calcium levels related to a calcium- phosphorous imbalance.
Anemia Physiological changes in the blood occur progressively during normal pregnancy. Haemoglobin mass increases, red blood cell volume increases, plasma volume rises, & haemoglobin concentration drops from 13.4 to 11.6 g per 100 ml. Severe anemia in pregnant women increases maternal morbidity & mortality & involves a higher risk of the fetus. A pregnant woman is labeled anemic if from the 28th week onwards the haemoglobin is less than 10 g per 100 ml of blood.
Pregnancy Induced Hypertension (toxaemia)
Studies conducted at National Institute of Nutrition (1992-93) indicate that severe pregnancy induced hypertension (eclampsia) is associated with higher incidence of vitamin A & protein deficiencies resulting in poor pregnancy outcome.
Gestational diabetes During pregnancy glycosuria is not uncommon, because of the increased circulating blood volume & its load of metabolites. Most of these women revert to normal glucose tolerance after delivery.
o Small and frequent feedings should be taken. Avoid fasting or missing any meal.
o More fibre should be included in the diet to prevent constipation which is a common problem during pregnancy. 5-6 servings of fruits & vegetables should be included in the daily diet.
o Diet should be rich in calcium to prevent osteomalacia.
o Iron rich foods should be taken to prevent anaemia & to build up iron stores in the foetal body.
o Diet should contain optimum amount of sodium. In case of oedema or hypertension, sodium is restricted.
o Inclusion of green leafy vegetables ensures minerals like calcium & iron.
o Plenty of water should be taken to keep the bowels regular.
o Fatty rich foods, fried foods, excessive seasoning, strongly flavored vegetables may be restricted in case of nausea and gastric distress.
o Fluids should be taken between meals rather than along with the meals.
o Adequate amount of calories should be taken so that enough fat is deposited during pregnancy which is required for lactation.
o Take health drinks like proteinex mum, pro P & L.