Nutrition in pregnancy & lactation.pptx

Nutrition plays an important role during pregnancy & postpartum. Let us understand the nutrient requirements as per ICMR guidelines

1. Nutrition in Pregnancy & Lactation Dr Nupur Gupta

2. During pregnancy nutritional requirement increases significantly Table 1. Recommended dietary allowances in Indian women (macronutrients, Vitamins, and minerals) Nutrient Non-pregnant Pregnant Energy (Kcal/d) 2850 3200 Protein (g/d) 55 78 Calcium (mg/d) 600 1200 Iron (mg/d) 21 35 Vitamin A (µg/d) 600 800 Ascorbic acid (mg/d) 40 60 Folate (mg/d) 200 500 Niacin (mg/d) 16 18 Riboflavin (mg/d) 1.7 2.0 Thiamine (mg/d) 1.4 1.6 Vitamin B6 (mg/d) 2.0 2.5 Vitamin B12 (µg/d) 1 1.2 Zinc (mg/d) 10 12 Iodine (mcg/d) 150 220 Magnesium (mg/d) 310 310 Table 1. Recommended dietary allowances in Indian women (macronutrients, Vitamins, and minerals) Nutrient Non-pregnant Lactation Energy (Kcal/d) 2850 3450 Protein (g/d) 55 74 Calcium (mg/d) 600 1200 Iron (mg/d) 21 21 Vitamin A (µg/d) 600 950 Ascorbic acid (mg/d) 40 80 Folate (mg/d) 200 300 Niacin (mg/d) 16 20 Riboflavin (mg/d) 1.7 2.1 Thiamine (mg/d) 1.4 1.9 Vitamin B6 (mg/d) 2.0 2.5 Vitamin B12 (µg/d) 1 1.5 Zinc (mg/d) 10 12 Iodine (mcg/d) 150 290 Magnesium (mg/d) 310 310

3. Weight Gain in Pregnancy

4. Pregnancy- Recommended protein intake Maximum during 3 rd Trimester For 10 kg gestational wt gain - 1, 7 and 23 g/day in 1st, 2nd, and 3rd trimesters respectively.

5. Recommended Daily Allowances Particulars Body weight (kg) Net energy (kcal/d) Protein (g/d) Visible fat (g/d) Calcium (mg/d) Iron (mg/d) Women Sedentary work 55 1900 55 20 600 21 Moderate work 2230 25 Heavy work 2850 30 Pregnant women +350 [phone] Lactation (months) – 6 +600 +19 21 6 – 12 +520 +13 Source: NIN guideline.

6. Status of pregnancy nutrition in India

7. *aerated cold drinks, white flour preparations, sweet and sugar coated food items ^ Nutrient Adequacy Ratio (NAR) = Participant’s nutrient intake of a day/ RDA of the respective nutrient (adequate (≥1.00), fairly adequate (0.66 − <1.00) or inadequate (<0.66) NAR for various nutrients). The current consumption pattern of pregnant women 32% women are ignorant about consuming a balanced diet 2 58% perceived that sugar contains a lot of vitamins and minerals 2 ~69% consume an inadequately diversified diet 3.4   93% consume sugar-containing foodstuff 5 Reasons for poor nutrition Lack of information regarding balanced diet 1 Eating junk food 1* 54% women do not consume fruits even once a week 6 Stereotype menu – same quality of food everyday 1

8. NFHS 5 study shows pregnant women take iron-folic acid supplements for at least 100 days pregnant women are anemic Only 44% 52%

9. Pregnant women in India fail to consume recommended amount of nutrition-rich foods 1 * Nutrient Adequacy Ratio (NAR) = Participant’s nutrient intake of a day/ RDA of the respective nutrient (adequate (≥1.00), fairly adequate (0.66 − <1.00) or inadequate (<0.66) NAR for various nutrients). -National Nutrition Monitoring Bureau (NNMB) 2012 ~6/10 consume <54% RDA of Protein 2,* 6/10 consume 3, * <50% vitamins & minerals 3 Fruits Pulses Milk and Milk Product Green Leafy Vegetable Vegetable -84% -38% -84% -82% -53%

10. A low nutritional quantity and quality of the diet can significantly compromise pregnancy outcomes 1,2 IUGR-Intrauterine growth restriction Protein and micronutrient High calorie diet Small for gestational age 3-5 Low birth weight 2,6 IUGR 5,7,8 Pre-term delivery 2,9 Protein and micronutrient &

11. 22% increase in birth weight on adherence to IFA supplementation 2 Only 6 out of 10 pregnant women comply with the recommended regimen of Folic-Calcium-Iron supplementation Cluster randomized double blind controlled trial including 5828 pregnant women and 4697 live births found a

12. What are the key nutrients that are missing? Macronutrients or Micronutrients

13. Nutrients

14. Maternal blood volume expansion during pregnancy can result in anaemia 1 Iron requirement increases by almost 70% 2 RBC production Folic acid, Vitamin B 6 , B 12 , Riboflavin Almost 95% of the Indian mothers have been reported to suffer from anaemia during pregnancy 4 35-40% increase in maternal blood volume 1 Almost 45% of the required iron is spent to support blood volume expansion 3 A group of nutrients work together to maintain blood health 3,5-7 Iron absorption and mobilization Folic acid, Riboflavin, Vitamin C

15. Significant transplacental calcium transfer occurs to meet the demands of the fetus 1 Constant transfer of 250-350 mg/ day calcium for rapid mineralization of fetal skeleton 2,3 Significant increase in intestinal absorption of calcium and calcitonin levels 4,5 Almost 2-4% of maternal Bone Mineral Density may be lost during the 3rd trimester 3 Bone requires assistance from a group of nutrients to maintain calcium availability 6-9 Vitamin D Absorption of calcium and phosphorus and assists bone growth and remodeling Vitamin C Synthesis of collagen Vitamin K Synthesis bone protein Vitamin A Multiplication of osteoblasts Magnesium Normal functioning of the osteoclasts

16. Impact of micronutrient deficiencies on maternal health and fetal growth outcomes Maternal anaemia Iron, Folic acid, Vitamin C, Riboflavin Pre-eclampsia Calcium, Vitamin E, C, B2, B6, B12, D, Thiamine, Riboflavin, Niacin Spontaneous abortions Zinc Low bone mineral density Calcium, Vitamin D, Vitamin A, C LBW Zinc, Vitamin D, B2, B6, B12, Thiamine, Riboflavin, Niacin, Iron, Iodine IUGR Zinc, Iodine, Magnesium Birth defects* Zinc, Vitamin D, B2, B6, B12, Thiamine, Riboflavin, Niacin, Folic acid, Iron Preterm delivery Zinc, Iron, Vitamin B2, B6, B12, Calcium * Anacephaly , orofacial clefts, heart defects, neutral tube defects LBW- Low birth weight IUGR- Intra Uterine Growth Retardation Mother's Health 1-4 Fetal Growth 1-4

17. Long-term complications of FGR - A medical concern? Joung KE et al. Current Pediatrics Reports. 2020;8:45–55 FGR infants because of in-utero epigenetic modifications are more likely to develop “Fetal origin of Adult Diseases (FOAD)” in their adolescence and adulthood Intrauterine Growth Restriction (IUGR) Postnatal catch-up growth Early life nutrition and environment Dysregulation of appetite Alteration of HPA axis Epigenetic modification Potential role of microbiome Pancreatic beta cell mass Muscle mass Oxidative stress Epigenetic modification Vascular remodeling Oxidative stress Epigenetic modification Obesity Type 2 Diabetes Cardiovascular Disease IUGR Neonate Postnatal abnormal nutrition Adult male and female Metabolic programming/Epigenetic modification in antenatal period

18. Insufficient calories, macro and micronutrients can lead to deficiencies in building materials for the development and growth of the fetus 1 Hypocalci meia Selenium deficiency Maternal iodine deficiency P re-eclampsia Miscarriage, pre-eclampsia fetal growth restriction Irreversible damage to a child’s normal physical growth and mental development

19. Complex carbohydrate intake during pregnancy

20. Limiting added sugar with adequate intake of nutrients reduces risk of excessive Gest Wt Gain & associated consequences 1 GWG-Gestational weight gain

21. Added sugar has zero nutritional value 1 GWG-Gestational weight gain Added Sugar Displaces nutritionally superior foods Evokes cravings for sweet food Insulin resistance Induces a state of ‘internal starvation’ Risk of Obesity 1 Low micronutrient intake 3 Affects maternal and fetal h ealth 1,4-12   Promotes a host of disease states that impair nutrient absorption and energy homeostasis 1 Preeclampsia, GWG, low birth weight, SGA

22. 93% pregnant women consume excess sugar-containing food (85 g) during pregnancy. 1 1.3X greater risk for having an infant in the rising-high BMI trajectory group 2 for having an overweight/obese children at 4 years of age 2 Sugar-containing foods 1.1X risk for macrosomia 2 3.8X higher risk for preeclampsia 2 22% higher risk for GDM 2 38% greater risk of preterm delivery 2 5.4 kg greater weight gain 2 1.1X risk for macrosomia 2 2X greater risk for atopic asthma in mid-childhood 2 41.7% risk of obese offspring 2

23. The foundation for germ cells/grandchildren gets impacted with maternal nutrition Did you know? Your health depends on what your grandmother ate while she was pregnant with your mother ! New study states that grandmothers who ate well during pregnancy & kept their daughters well-nourished in their first few years have healthier grandchildren. You are what your grandmother ate, scientists say , available at: https://www.smh.com.au/lifestyle/health-and-wellness/you-are-what-your-grandmother-ate-scientists-say-20140218-32wtg.html So the first 500 days of mothers diet is not only important for her baby but also affects the future generations to come .

24. The first 500 days (9 months pregnancy and 6 months lactation) are physiologically and nutritionally demanding period 1 During this period the infant is entirely dependent for its nutrition on the mother via the placenta and then via exclusive breastfeeding. 4

25. Optimum protein, adequate vitamins and minerals intake during pregnancy and lactation is associated with the overall growth and development of the newborn till the age of 5 years

26. Protein supplementation Folic acid supplementation Vitamin D supplementation Clinical evidence suggesting the benefits of supplementation in pregnant/lactating women 15% and 25% absolute increase in protein synthesis occurs during the second and third trimesters Reduces the risk of congenital malformations Improves neonatal outcomes Absorb calcium and phosphorus Improve skeleton formation 95-324 g increase in birth weight 4.6-6.1 mm increase in height 79% reduction in the incidence of megaloblastic anemia 28% reduction in the risk of SGA 75.38 g increase in birth weight 65% reduction in fetal or neonatal mortality

27. Clinical evidence suggesting the benefits of supplementation in pregnant/lactating women Oral vitamin B-12 supplementation during pregnancy and early lactation increases maternal, breast milk, and infant measures of vitamin B-12 status

28. Meta-analysis (13 randomized trials, n=15,730) pregnant women on calcium supplementation Meta-analysis : Pre-natal supplementation With multi-micronutrients on pregnancy outcomes Clinical evidence suggesting the benefits of supplementation in pregnant/lactating women 35% reduction in high BP 64% reduction in the risk of pre-eclampsia , 34% reduction in the risk of preterm birth 20% reduction in maternal death or serious morbidity 19% reduction in the risk of low birth weight Difference of 54 g in the birth weight of mothers receiving multi-micronutrients

29. Role of DHA during pregnancy

30. In pregnant women, the lowest DHA intakes were reported in India in the third trimester of pregnancy at only 11 mg. 1 Maternal DHA concentration is physiologically reduced by 50%, possibly due to 2 Decreased intake Increased maternal blood volume Enhanced placental and fetal requirements. 2 Indian pregnant women consume only 6% of the daily recommended intake of DHA 3

31. Maternal deficiency of DHA has been associated with perinatal depression 2 DHA can be a possible preventive or therapeutic modalities for depression, 2 as it plays a major role in anti-inflammatory effects. 3 There is a gradual decline of maternal DHA status during pregnancy 1

32. Fetal DHA deficiency constrains CNS development in infants 1   Also, Behavioral changes Associated with learning difficulties and dementia 1 Infants with DHA deficiency are at 2 2X increased risk of visual acuity at 2 months 3X increased risk of lower language development assessed as words understood at 14 months 2X increased risk of lack in understanding words 2X increased risk in producing sentences at 18 months

33. * DHA supplementation results in 1 A supplement of 600 mg DHA/d in the last half of gestation resulted in overall greater gestation duration and infant size. A reduction in early preterm and very-low birth weight could be important clinical and public health outcomes of DHA supplementation. 1 2.6% Higher maternal and cord RBC-phospholipid-DHA   40.8 d shorter hospital stays for infants born preterm Improvement in cognitive abilities 42% decrease in the risk of having an early premature baby DHA supplementation may be the best predictor for nervous system development 3

34. 70% brain development completes in-utero 1 Multiple micronutrients assist the process of brain development during pregnancy 1-4 Iron, Choline, DHA, Zinc, Vitamin A, D, B 1 , B 2 , B 6 , B 12 , Selenium Iron, DHA, Zinc, Vitamin B 2 , Folic Acid, Iodine

35. Need for additional nutrients during lactation

36. Every 1 out of 2 lactating women (56%) have a minimum diversified diet (MDD) 1 Therefore, mothers may need to take supplements or natural foods fortified with these nutrients. 2 Some nutrient requirements are difficult to obtain through dietary sources, especially: 2 I ron Iodine Folic acid V itamin A

37. Maternal requirements may also vary through different stages of lactation 1

38. The mother must be provided with sufficient nutritional intake to meet their nutritional demand during the early postpartum period. 1 In the early postpartum period, multiple challenges are faced by a mother 1 Physical recovery Hormonal imbalance Disturbance of sleep Care (feeding) of the newborn

39. The energy demands of lactation exceed pre-pregnancy demands increase by ~640 kcal/day during the first 6 months post partum compared with 300 kcal/day during the last two trimesters of pregnancy 1 According to the WHO expert committee, the optimal daily milk output of the mother’s milk is estimated to be 850 ml. 2 The effect of maternal nutrition during lactation ( about 80% of energy, 50% of proteins and 30% of the calcium ) is converted into the milk to the newborn. 2 Poor nutritional status during development can result in structural and functional alterations that can persist throughout life in the key organs .

40. Pregnancy requires changes in the quantity as well the quality of the diet 1-7 *Vitamin A, Vitamin B2 Vitamin B6, Vitamin C, Iron, Folic acid, Calcium ^ It is necessary to improve the relative proportion of polyunsaturated fats rather than to increase the intake of total fats: an adequate intake of docosahexaenoic acid (DHA, of the n-3 series), essential for the growth and development of brain and retina, is of utmost importance High quality diet Higher quantity ~42% more protein 2 25%-150% more micronutrients* ,2 Protein quality 3,4 (protein source) 5 Fat ( polyunsaturated) 4,5,^ Carbohydrates (low glycemic index) 6 No added sugar 6,7

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