Preconception and prenatal nutrition
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Preconception and Prenatal Nutrition. Introduction: Infant mortality- the odds that a newborn will live past its first month is one of the most important measures of a country’s quality of life. An article in USA Today, states that USA has 4.3 deaths per 1000 live births each year.

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Preconception and Prenatal Nutrition

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Preconception and prenatal nutrition

Preconception and Prenatal Nutrition

Introduction:

Infant mortality- the odds that a newborn will live past its first month is one of the most important measures of a country’s quality of life.

An article in USA Today, states that USA has 4.3 deaths per 1000 live births each year.

According to a recent study, published in journal PLoS Medicine, USA ranks 41st among 193 nations. Two decades ago, it ranked 28th.

But actually, the mortality rate is improving and the situation is not really worse in USA than before.


Preconception and prenatal nutrition1

Preconception and Prenatal Nutrition

  • It is just that the other countries are advancing faster in reducing the neonatal mortality rate. This indicates that USA has to progress even faster.

  • Premature births, low birth weight, lack of prenatal care, high rates of obesity and inadequate preventive health care contribute for a higher neonatal mortality rate.


Preconception and prenatal nutrition2

Preconception and prenatal nutrition

PRECONCEPTION HEALTH CARE AND NUTRITION

  • Preconception care is a set of interventions to identify and modify biomedical, behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management.

  • Unhealthy diet and habits like consumption of junk foods, smoking, alcohol during the child bearing age can cause adverse fetal health problems.


Preconception and prenatal nutrition3

Preconception and Prenatal Nutrition

  • Consumption of nutrient dense food is vital

    cream

    Eggs,

    Raw milk,

    Butter

    Fish and shellfish

  • The nutritional status during the preconception and prenatal period determines the perinatal phase of pregnancy outcome. (It’s like a setting up a strong foundation for a building)


Preconception nutrition goals

Preconception Nutrition Goals

  • The Centre for Diseases and Control(CDC) aims for achieving 4 preconception goals :

  • To improve knowledge, attitudes, and behaviors of men and women related to preconception health.

    2.To ensure that all US women of childbearing age receive preconception care services(screening, counseling and interventions) that will enable them to enter pregnancy in optimal health.


Goals

goals

3. To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception period that can prevent or minimize health problems for a mother and her future children.

4. To reduce the disparities in adverse pregnancy outcomes


Preconception and prenatal nutrition4

Preconception and Prenatal Nutrition

  • Preconception risk factors:

    DiabetesFoliate deficiency

    Obesity HIV/AIDS

    Hypertension Hypothyroidism

    PCOS (Polycystic Ovary Syndrome) Epilepsy

    Smoking (preterm birth, lowbirth wt)

    STD(associated with ectopic pregnancy, infertility, chronic pelvic pain)

    PKU(Phenylketonuria- Mothers should adhere to low phenylalanine diet before conception and throughout the pregnancy)

  • Some disorders are genetic, neurological and metabolic disorder


Preconception nutrition

Preconception nutrition

  • Preconception nutrition determines the hair color, brain development, skin color and development of diabetes of the fetus(phenotype and genotype)

  • Determines the prepregnancy weight of the mother.

  • Healthy nutritional status will result in healthy pregnancy and healthy babies, who, in turn will deliver healthy babies in her/his adulthood and the cycle goes on. (It’s like ‘What comes first –chicken or eggs’. Still it is a puzzle)


Prenatal nutrition

Prenatal Nutrition

  • Maternal nutrition during pregnancy is very crucial and vital as it affects both the health of the mother and the growing fetus.

  • The calorie intake and specific nutrients requirements also increases.

  • The nutritional status of the mother determines the length of the gestation


Prenatal nutrition1

Prenatal Nutrition

  • Nutrient Recommendations

    The quality of the diet during pregnancy has a profound impact on fetal and maternal outcomes.

    Macronutrients

    DRI for macronutrients during pregnancy

  • CHO --175 g/d

  • protiens -- 71g/d (25 g more than the nonpreg women)

  • fat -- 20-35% of the total energy expenditure.

    αlinolenic acid (Omega 3)—1.4 g/d

    linoleic acid (Omega 6) --- 13 g/d

  • water – 3 l/d

  • fiber – 28g/d

    EPA and DHA (long-chain omega 3 FA)canbe synthezied from linoleic and α-linolenic acid.


Prenatal nutrition2

Prenatal Nutrition

  • Sources of Omega -3 fatty acids include

    - vegetable oils (canola oil, flaxseed oil, soyabean oil)

    - fish oil and

    - fatty fish

  • Sources of Omega – 6 fatty acids include

    - nuts

    - seeds and

    - vegetable oils (corn oil, soyabean and safflower)

  • Non-nutritive sweetner:

  • Aspartame (Equal or Nutrasweet) is safe during pregnancy if used within the FDA guidelines. Women with PKU should however restrict this.

  • Saccharin (Sweet’n Low) should be avoided during pregnancy


Prenatal nutrition3

Prenatal Nutrition

  • Protein – building maternal tissue and fetal growth.

    - moderate protein intake is optimal during pregnancy

    Micronutrients

    Certain Minerals and Vitamins are of significant importance in pregnancy. Some of the key micronutrients are Mg, Fe, Folate, VitD, B vitamins.

    Deficiency: abnormal prenatal development and pregnancy outcome.

    Inhibitors : phytates and polyphenols


Prenatal nutrition4

Prenatal Nutrition

  • DRI for Micronutrients for pregnant women

    Mg- 400-360mg/d (14-50yrs)

    Folate – 600µg/d ( “ ) (to avoid NTD)

    Vit D - 15µg/d ( “ )

    Thiamin – 1.4 mg/d ( “ )

    Riboflavin – 1.4mg/d ( “ )

    Niacin – 18mg/d ( “ )

    Biotin – 30µg/d ( “ )

    Pantothenic acid – 6mg/d( “ )

    Vit B 6 – 1.9mg/d ( “ )

    Vit B 12 – 2.6µg/d ( “ )

    Fe – 27mg/d ( “ )more Fe is needed for developing fetus and placenta and ↑ in bld volume.


Prenatal nutrition5

Prenatal Nutrition

  • Magnesium:

    Functions- energy production, synthesis of nucleic acid, proteins, ion transport across membranes, cell signaling, bone structural integrity.

    - effective in controlling eclampsia, preeclampsia, arrhythmia, severe asthma, migraine

    Deficiency- chronic diseases

    Food sources – green leafy vegetables, nuts, legumes,whole grains

  • Iron:(essential component of multiple proteins and enzymes)

    Functions- O2 transport and storage, e-transport, energy metabolism and DNA sysnthesis.

    Food Sources: Heme Fe (readily absorbed) Meat, poultry, fish.

    Non-hemeFe – legumes (requires additional Vit C, organic acids to enhance absorption)


Prenatal nutrition6

Prenatal Nutrition

Good sources of Fe – Beef, lentils, beans, bran cereal, raisins

Deficiency -- anemia

Inhibitors of Non-hemeFe – phytates, polyphenols and soyproteins

  • Folate and Folic acid:

    Functions- nucleic acid and amino acid metabolism

    - interacts with B 6 and B12

    Deficiency – low birth wt, premature birth, neural tube defects(NTD),

    ↑ homocysteine levels (predictor of poor preg outcomes)

    Food Sources-

    Folic acid – supplements and fortified foods. Folic acid is 100% absorbed

    Folate – (only partially absorbed) asparagus, spinach, lentils, broccoli, orange juice.


Prenatal nutrition7

Prenatal Nutrition

  • Vitamin D:

    Functions- essential for skeletal health, efficient utilization of Ca, BP regulation, insulin secretion, immunity, cell differentiation

    Deficiency- osteomalacia

    Food sources – fortified with Vit D – dairy products, cereals, orange juice

  • B vitamins:

    Function – participate in many metabolic pathways including energy metabolism

    Deficiency- leads to hypomethylation of DNA and altered gene expression

    - homocysteinemia and poor pregnancy outcome

    - Homocysteine may cause oxidative stress and susequent placental ischemia

    - ↑ free radical O2,↓nitrous oxide leading to endothelial dysfunction

    - homocysteine is thrombogenic

    .


Issues in pregnancy

Issues in Pregnancy

  • Maternal overweight and obesity are associated with:

    Higher risk of GDM (gestational diabetes Mellitus)

    Hypertension

    Pre-term delivery

    Labor induction

    Postpartum hemorrhage

    Preeclampsia (high blood pressure and protein in the urine develop in the late 2nd and 3rd trimester) (may result in inadequate placental bld supply)

    Macrosomia (aka large for gestational age-LGA) may result in

    C- section and

    Neonatal hypoglycemia (low glucose level)


Issues in pregnancy1

Issues in Pregnancy

  • Multiple Gestation

    - due to assisted reproductive technologies (ART)

    New borns conceived through ART are at higher risk for

    - prematurity

    - low birth weight (2500g and less)

    - perinatal mortality

    Women who conceive through ART are more likely to develop

    - preeclampsia (↑ in BP)

    - GDM

    - preterm birth (<37 weeks)


Issues in pregnancy2

Issues in Pregnancy

  • Gastrointestinal Discomforts

    - Nausea and vomitting(current dietary recommendation to reduce the symptom is to take multivitamin in preconception period, supplementation with Vit B6, eating ginger as nonpharmacolgic option)

    - Heart burn

    - Ptyalism (excessive secretion of saliva. Dietary alterations include chewing gum and restriciting fluids)

    - Constipation (DRI for fiber intake during pregnancy is 28g/day and increase in fluid intake)

    - Diarrhea (may be due to food borne infections and irritable bowel syndrome. Acute diarrhea may lead to severe dehydration and result in loss of important electrolytes)


Issues in pregnancy3

Issues in Pregnancy

  • Eating disorders

    - anorexia nervosa

    - Bulimia nervosa

    Clinical manifestation

    - menstrual dysfunction

    - low bone density

    - sexual dysfunction

    - miscarriage

    - preterm delivery or low birth weight

    - delayed fetal growth


Issues in pregnancy food safety

Issues in Pregnancy-Food safety

  • Seafood - Excellent source of lean protein and omega-3 FAs

    - contain traces of mercury.(avoid large fish)

    FDA and EPA recommends that

    - pregnant women

    - Women of childbearing age,

    - young children

    consume 12 oz of fish /week that are lower in mercury

    - Shrimp, canned tuna, salmon, pollock, catfish

    avoid eating

    - shark

    - swordfish

    - mackerel

    - tilefish


Food safety

Food Safety

  • Listeriosis:

    - caused by Listeriamonocytogenes ( a gram+ve bacterium)

    People at risk

    - pregnant women (septicemia, meningitis, encephalitis, cervical infections)

    - elderly

    - adults with weak immune system

    Symptoms

    - persistent fever

    - nausea

    - vomiting

    - diarrhea

    The onset time to gastrointestinal symptoms is probably greater than 12 hrs


Food safety1

Food Safety

  • Foods to avoid

    - Hot dogs/ luncheon meats (deli)

    - soft cheese (feta, brie, camembert, blue cheese, roquefort, queso fresco unless the label says made with pasturized milk

    - unpasteurized milk, eggs, juice

    - refrigerated pates or meat spreads

    - refrigerated smoked seafood


Polycystic ovary syndrome pcos

Polycystic ovary syndrome (PCOS)

What is it?

A problem in women when the ovaries grow many small cysts. The cysts are not harmful but cause hormonal imbalance which is associated with

  • anovulatoryinfertilty

  • Type II diabetes

  • Abnormal lipid profiles

  • Cardiovascular disease

  • Hyperinsulinaemia (due to insulin resistance)

    Causes:

    The hormone levels get out of balance. (there are several causes for the changes in the hormone levels). Normally, the ovaries make tiny amount of androgens(male sex hormone), but, in PCOS, they make more amounts


Polycystic ovary syndrome

Polycystic ovary syndrome

In 2010, Barry et al demonstrated hyperandrogenism in utero environment in PCOS pregnancies. But, Anderson et al (2010) demonstrated decreased intrauterine androgen levels and large for gestational age in the offspring of women with PCOS.

Design: Prospective case-control study

Participants: Thirty- nine women with PCOS and 31 control women and their infants .

Objectives: To determine whether the infants of women with PCOS have increased intrauterine androgen levels or reduced birth weight.

Outcome Measures: Birth weight and mixed cord blood testosterone (T), androstenedione (A), dehydroepiandrosterone, 17-hydroxyprogesterone, estradiol (E2) and dihydrotestosterone levels were measured

Result: There was a significant ↑in the prevelance of LGA infants in PCOS group. Cord blood E2 and A levels were lower (P<0.05). Testosterone to E2 ratios did not differ in female PCOS vs control offspring. There was no difference in E2 and A levels in the male PCOS vs control offspring. There was no difference in 17-hydroxygrogesterone or other androgen levels in either male or female PCOS offspring vs respective control group

Conclusions: Offspring of women with PCOS were more likely to be LGA. Female offspring of PCOS have lower cord blood A levels and lower E2 levels. The study demonstrated decreased fetal or placental production of steriods.


References

References

1. Improving infant mortality in the US and Worldwide.American Academy of Pediatrics. Updated onSept 1st2011

http://www.healthnewsdigest.com/news/Children_s_Health_200/Improving_Infant_Mortality_in_the_U_S_and_Worldwide.shtml. Retrived on Sep1st.

2. http://theweek.com/article/index/218803/infant-mortality-why-does-america-lag-behind . Accessed onSept 1st.

3. http://www.getting-pregnant.com/preconception-nutrition.html. Accessed on Sept 1st.

4. Johnson K, Postner SF, Biermann J, Cordero JF, AtrashHK, Parker CS, Boulet S, Curtis MG. Recommendations to improve preconception health and health care---United States. A report of the CDC. MMWR.2006;55(RR06):1-23.

5. Lamy C. Neurological disorders in pregnancy.J Neurol Neurosurg Psychiatry .2005;76:299

6. http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm. accessed on Sept 2nd 2011.

7. Chu SY, Callaghan WM, Kim C, et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care. 2007;30:2070-2076.

8. http://www.nlm.nih.gov/medlineplus/ency/article/002251.htm. Accessed on Sept 2nd 2011.

9. http://www.nlm.nih.gov/medlineplus/ency/article/007306.htm. Accessed on Sept 2nd 2011.

10. Chan RL,OlshanAF,Savitz DA, et al. Maternal influences on nausea and vomiting in early pregnancy. Matern.Child Health J. 2009.


References1

References

11.http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/New%20Material/5DRI%20Values%20SummaryTables%2014.pdf. Accessed on Sept 2nd 2011.

12. Environmental Protection Agency. Fish Advisories. What you need to know about Mercury in fish and shellfish. http://www.epa.gov/fishadvisories/advice. Accessed on Sept 2nd 2011.

13. Barry JA, Kay AR, Navartnarajah R, Iqbal S, et al. Umbilical vein testosterone in female infants born to mothers with polycystic ovary syndrome is elevated to male levels. J ObstetGynaecol. 2010;Vol. 30:5:444

14. Samour PQ, King K. Pediatric Nutrition, Fourth Edition. Jones and Bartlett Learning, LLC. Sudbury, MA 2012.

15. Langley-Evans SC, Lilley C, McMullen S. Maternal Protein restriction and fetal growth: Lack of evidence of a role for homocysteine in fetal programming. Br j Nutr. 2006;96:578-86.

16.Gardiner PM, Nelson L, Shellhass CS, et al. The clinical content of preconception care: Nutrition and dietary supplements. Am j Obstet Gynecol. 2008; 199(6 Suppl2):S345-356.

17. Jeanes YM, Barr S, Smith K, Hart KH. Dietary management of women with polycystic ovary syndrome in the United Kingdoms: the role of dietitians. J Hum Nutr Diet. 2009;22:551-558.

18. Hawthorne G. Metformin use and diabetic pregnancy-has its time come? Diabet Med. 2006;23:223-7

19. Cuco G et al. Dietary patterns and associated lifestyles in preconception, pregnancy and postpartum. Eur j ClinNutr. 2006;60:364-371.


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