Maternal Nutrition

1. Maternal Nutrition • Preconception • Lifestyle issues • Preexisting conditions • Physiological changes during pregnancy • Nutritional implications • Nutrient requirements during pregnancy • Recommended weight gain • Lifestyle choices

2. Preconception • ______ • _________ • _________ • medical conditions • psychological readiness/stress • ________, e.g. • restrictions, eating disorders • folic acid intake • _______________________________________ • previous __________

3. Preexisting Medical Conditions/Pregnancy related Conditions • Inborn Errors of Metabolism • Other conditions

4. Phenylketonuria (PKU) • ______________________ • Lack of _________ to convert phenylalanine (phe) to tyrosine (tyr) leads to __________________ • mental retardation, death • Risk for:

5. PKU treatment • maintain __________ as low as possible • maintain serum ________ • control ____________ • special low-phe foods are necessary • maintain ______________ ________ during pregnancy • People with PKU should not use aspartame

6. Celiac Disease • Sensitivity to ______ (in wheat, rye, barley…) • Causes malabsorption of ___ and ______________ • general _____________ • general nutrient _________ • ___________ • Often undiagnosed! • Must follow _________ diet

7. Type I Diabetes • pregnancy will make ____________ even harder • increased need for ________ • uncontrolled blood glucose can cause damage to fetus as well as stress on mother • ____________ fairly common during pregnancy • blood _________, • glomerular filtration rate (GFR)

8. Gestational Diabetes • Risk factors: • Risk for: • _______________ • spontaneous __________ • perinatal ___________ • later development of Type II diabetes (_________)

9. Pregnancy-induced hypertension (PIH) • [preeclampsia eclampsia] • Characterized by: • Risk for: • ______________________ • HBP, _______________, type II diabetes

10. PIH risk factors • preexisting ____________ • ____________ • PIH history • dietary deficiencies: • age extremes • Do not restrict ________!

11. Physiological Changes during Pregnancy

12. Glossary • ___________ = protein to which oxygen bind in RBC • ___________ = volume of packed red blood cells (RBC) • __________ = physiological (normal) anemia of pregnancy • _______________ = waves of involuntary muscle contractions in the GI system • _____ = Urinary tract infections • Glomerular filtration rate (GFR) = rate at which fluid passes through the kidneys

13. GI system • changed ___________ • increased __________ • decreased __________ • hypoperistalsis • enhanced ____________ • heartburn • nausea, vomiting, constipation • avoid strong smells or fried, greasy foods; eat dry crackers before getting out of bed; try small, frequent meals; megadoses of vitamin B6? • _____________

14. Fluids • Blood • blood __________: 150% • blood ____________ • 12-50 ml/min to 500-600 ml/min • RBC increase less than BV = ________________ aka “physiological anemia of pregnancy” • Body ________content increases as much as 20%

15. Blood pressure • drops early, then prone to rise in later pregnancy • _________________ increases due to increased efficiency of gas exchange in the lungs • shift of diaphragm position leads to ____________

16. Clinical Blood Values Normal Pregnancy Hema tocrit 35% 29-31% Hemo globin 13-14 g/dl 10-11 g/dl Cholesterol <200 200-325 mg/dl mg/dl Folacin 5-21 3 mcg/dl mcg/dl Iron >50 >40 mcg/dl mcg/dl TIBC 250-400 300-450 mcg/dl mcg/dl

17. Table 4-10, p. 95

18. Renal function • growth of uterus causes ______________ • greater need to ____________ • susceptibility to __________ • renal ________ and ____ increase • greater capacity to __________ • greater amounts of nutrients are ___________, perhaps more than healthy kidneys can ________ • _____uria and ______uria are fairly common • increased need for _____________

19. Basal metabolic rate (BMR) ___________ • ____________ nitrogen balance

20. Fuel Usage • Fetus: needs mostly ________ • 50-70%CHO, 20%aa, rest from fat • hoards __________ for tissue building • Mother:_____ becomes more important • _______________ decreases because of relative lack of ____________ • more ____ is stored for future needs, including _________ • (with less GNG and more lipolysis, __________ may occur)

21. Hormones (proteins, steroids) 1) _____________ • relaxes smooth muscle cells • GI motility • maternal ________ stores • capillary tension • renal _____ excretion 2) ____________ • promotes _____ growth/function • alters _______________ structure • flexibility • water ______ = normal if without HBP and proteinuria

22. The Placenta • Organ that supports __________ • ___________ to the uterus • site of ________ synthesis • establish pregnancy • provide for fetal metabolism and glandular systems • suppress ______________ • ______ of oxygen, nutrients, and ______________ • Mother and fetal blood supplies are always ____________ • Affected by ____________, insufficient blood supply, inappropriate _____________

23. Placental Nutrient Exchange • Simple (passive) diffusion • oxygen, CO2, fatty acids, fat-soluble vitamins, electrolytes • Facilitative diffusion • CHO • Active ________ • amino acids, water-soluble vitamins, minerals • Pinocytosis • immunoglobulin G (IgG)

25. Stages of Fetal Growth 1) _________________(~ 2 weeks) • rapid ______________ • early placenta • implantation of ____________ 2) __________ stage (to 2 months) • ____derm CNS, hair, ____ • ____derm voluntary muscles, _____, cardiovascular system, ______ systems • ____derm digestive and ________ systems, glandular organs 3) ____ stage (to 38-40 weeks) • ______ from 6 g to 3000-3500 g

26. Stages of Fetal Growth • Blastogenesis and embryonic • Hyperplasia occurs • ____________ status important • only serious general malnutrition would cause harm • certain deficiencies/exposures could cause __________ • _______ is closed by day ____ • _____ stage • hyper_____ and hyper____, then just _____________ • malnutrition now probably not teratogenic, but could easily affect __________

27. Illustration 4-11, p. 105

29. Terminology forpteroylglutamic acid • ________ = term for synthetic form used in supplements and in food fortification • ________ = term for naturally occurring form found in foods; generic term • ________ = generic term • Tetrahydrofolate (THF) = __________

30. Functions of Folate Co-enzyme in transfer of one-carbon units • _________ and _________ • synthesis of • formation of

32. DRIs for Folate • Dietary Folate Equivalents (DFEs) 1 DFE = 1 mcg food folate = 0.6 mcg synthetic folic acid in combination with food = 0.5 mcg synthetic folic acid taken on empty stomach

33. DRIs for Folate Life stage group RDA (mcg/day) Adults Pregnant women 400# 600# #All women capable of becoming pregnant are recommended to consume 400 mcg of folic acid

34. Growth Retardation • Severity, timing, and duration of deficiencies matter • If only hyper______ affected, later rehabilitation might reverse effects • Other effects might persist • Fetus does not always act as an efficient “___________” • Growth failure low __________ (____) baby = <_____ g • postnatal risk of • tissue changes: placental cells, brain cell #, _________, organ size, altered ___________

35. Table 4-15, p. 103

37. Correlates of fetal birth weight • _____________ (prepregnancy height, weight) • ______weight (____ healthy wt) • risk for ____, premature birth, ____, pregnancy complications (caesarian birth), low Apgar score • _______ (~____ healthy wt) • risk for ________________________, prolonged labor, pregnancy complications (caesarian) • baby: ______, difficulty regulating blood glucose • Maternal weight gain • _______ pound gain recommended

38. Maternal Weight Gain Depends on prepregnancy weight and health Recommended gain: BMI 28-40 12.5-18 kg lb Low 25-35 11.5-16 (<18.5) Normal 15-25 7-11.5 (18.5-24.9) 5-9.1 11-20 High (25 to 29.9) 35-45 15.9-20.5 Obese (30+) Twins

39. Nutrient Needs during Pregnancy Dietary Guidelines for Americans, 2005 Executive Summary http://www.health.gov/dietaryguidelines/dga2005/document/html/executivesummary.htm

41. BMR, physical activity tissue growth DNA synthesis DNA synthesis, neurological function Bone Bone Bone Teeth Calcium metabolism Nutrient Needs during Pregnancy Nutrient Why change?

42. kcal needs kcal needs kcal needs protein needs Cell differentiation oxygen transport DNA synthesis, enzyme co-factor... Thyroid function Connective tissue No change! Nutrient Needs during Pregnancy Nutrient Why change?

43. Total Ca (mg) Available Ca (mg) Servings to = milk Food Milk Juice w/ Ca Tofu, Ca-set Spinach Beans, white Turnip greens Kale Broccoli Cabbage Soy milk 300 300 258 122 113 99 47 35 25 5 96 150 80 6 20 51 28 18 16 2 1.0 0.6 1.2 15.5 5.0 2.0 3.5 5.0 5.0 60.5 Bioavailability of Calcium in Foods

44. Table 4-29, p. 122

45. Food Beliefs, Cravings, Aversions, Avoidances • Cultural beliefs and attitudes • perhaps restrict food intake in order to have a smaller baby • ____________ = compulsions for or against certain foods • very _________ • ____ = compulsion to consume non-food items • displace nutrients • lead, heavy metal poisoning • __________ • __________

46. __________ = conscious decisions about food • __________: No known safe level of intake • Fetal Alcohol Spectrum, including Fetal Alcohol________ • primary cause of preventable mental retardation in the U.S. • _______:possible _______ • < moderate use recommended • food ____________ • saccharin? • aspartame: not for PKU • _______: O2 to fetus ____

47. Update: Trends in Fetal Alcohol Syndrome -- United States, 1979-1993 MMWR Weekly April 07, 1995 / 44(13);249-251

48. http://www.cdc.gov/ncbddd/fasd/data.html; accessed February 2, 2012

49. Food Safety Concerns • Listeriosis • L. monocytogenes thrives at refrigerator temperatures • Toxoplasmosis • T. gondii transmitted from cat litter (not house cats) • Mercury contamination • predator fish • SO…don’t eat undercooked fish or meat, poorly stored processed meat, unpasteurized milk or cheese, predator fish