Overview of Nutritional requirements in Pregnancy

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PP-NXM-IND-0251 9th Apr 2019

Table of Content

Nutrition in Life of Women01

Folic Acid02

Vitamin B1203

Calcium & Vitamin D04

Iron02

Vitamin B601

NUTRITION IN LIFE OF WOMEN

Nutrition Status: Worldwide

Global Nutrition Report [Internet]. Ebrary.ifpri.org. 2016 [cited 6 April 2019]. Available from:

http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/filename/130565.pdf

Malnutrition affects 1 in 3 people worldwide

7 billion people worldwide

About 2 billion suffer from

micronutrient malnutrition

Approx. 800 million people have

calorie deficiency

Out of 5 billion adults

Nearly 2 billion are overweight or

obese

1 in 12 have type 2 diabetes

Out of 667 million children under age 5 worldwide

159 million under age 5 are stunted 50 million do not weigh enough for their height 41 million are overweight

57 countries out of 129 with data show serious levels of both undernutrition and adult

overweight/obesity

http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/130354/filename/130565.pdf

Nutrition Status: India

38.4% children are

stunted

35.7% children are

underweight

National Family Health Survey - 4 [Internet]. National Family Health Survey, India. 2016 [cited 6 April

2019]. Available from: http://rchiips.org/NFHS/pdf/NFHS4/India.pdf

58.5% children (6 – 59

months are anemic (< 11

g/dl)

53 % women (15 – 49

years) in total are

anemic

50.3 % pregnant women

(15 – 49 years) are

anemic (< 11 g/dl)

53.1 % non-pregnant

women (15 – 49 years)

are anemic (< 12 g/dl)

For growth and appropriate milestones

For growth, development and to fight infections

For growth spurt, maturation and

bone development

For maintaining health, productivity and prevention of

diet-related disease and to support

pregnancy/lactation

For being physically active

and healthy

Nutrition is Important in all Stages of Life

Infants

Childhood

Adolescence Adulthood

Elderly

National Institute of Nutrition. Dietary guidelines for Indians: a 2nd ed. Hyderabad [Internet].

Ninindia.org. 2010 [cited 6 April 2019]. Available from:

http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf


Nutrition for Pregnancy & Lactation

1. National Institute of Nutrition. Dietary guidelines for Indians: a 2nd ed. Hyderabad [Internet]. Ninindia.org. 2010

[cited 6 April 2019]. Available from: http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf

2. Marangoni F, Cetin I, Verduci E, Canzone G, Giovannini M, Scollo P et al. Maternal Diet and Nutrient

Requirements in Pregnancy and Breastfeeding. An Italian Consensus Document. Nutrients. 2016;8(10):629.

Physiologically and nutritionally demand is high1

Woman’s body increases fat deposits during this period to meet additionalnutritional requirement1

During lactation, nutritious food is needed for milk production and to maintainmother’s health2

Nutrition is an important element of health in this situation2

Nutrients required in Pregnancy & Lactation

National Institute of Nutrition. Dietary guidelines for Indians: a 2nd ed. Hyderabad [Internet]. Ninindia.org. 2010 [cited 6

April 2019]. Available from: http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf

Additional calories and protein

Folic acid

↓ risk of congenital malformations

↑ birth weight

Iron

Meet high needs for erythropoiesis

Calcium

Formation of bones and teeth of offspring

Production of calcium rich milk

Prevent osteoporosis in woman

Important nutrients


Nutrients required in Pregnancy & Lactation

National Institute of Nutrition. Dietary guidelines for Indians: a 2nd ed. Hyderabad [Internet]. Ninindia.org. 2010 [cited 6

April 2019]. Available from: http://ninindia.org/DietaryGuidelinesforNINwebsite.pdf

Marangoni F, Cetin I, Verduci E, Canzone G, Giovannini M, Scollo P et al. Maternal Diet and Nutrient Requirements in

Pregnancy and Breastfeeding. An Italian Consensus Document. Nutrients. 2016;8(10):629.

Important nutrients

Iodine

Proper mental health and growth of fetus and infant

Vitamin D

For embryo implantation and regulating the

secretion of several hormones

Vitamin A

Required to improve child survival

Vitamin C

Important for absorption of Iron


FOLIC ACID IN PREGNANCY

Importance of Folic Acid in Pregnancy

• Folic acid and folate (its naturally occurring state) are water-soluble vitamin B9

• Folic acid supplementation plays an integral role in pre-pregnancy counselling

and pregnancy care

• There is a link between folic acid deficiency during pregnancy and fetal neural

tube defects (NTDs)

• Folic acid also prevents pre-conceptionally recurrent and first occurrence of

NTDs

Talaulikar V, Arulkumaran S. Folic acid in pregnancy. Obstetrics, Gynaecology & Reproductive Medicine. 2011 May 31;21(5):147-8.

Czeizel AE, Dudás I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. New England

Journal of Medicine. 1992 Dec 24;327(26):1832-5.

Toriello HV. Folic acid and neural tube defects. Genetics in medicine. 2005 Apr 1;7(4):283-4.

Need of Folic Acid during Pregnancy

• Folic acid helps to synthesize cells, repair DNA and serves as a

cofactor in other biological reaction in the body

• During pregnancy, there is high demand of RBC production due to

fetal growth which results in reduction of blood folate level

• The neural tube normally starts forming in first trimester, hence folic

acid is more essential during initial pregnancy

• Around 5-15 % of population compromises the tissue folate levels

due to variation of 5, 10-methylenetetrahydrofolate reductase enzyme


Implications of Folic Acid Deficiency

Abnormal Hemopoiesis

Megaloblastic Anemia

Hyperhomocysteinemia

Neural Tube Defects An additional requirement of 300 and 100 μg respectively during pregnancy and lactation may be added for meeting the factorial extra needs

Nutrient Requirements And Recommended Dietary Allowances For Indians [Internet]. studylib.net. 2009 [cited 6 April

2019]. Available from: https://studylib.net/doc/8290839/nutrient-requirements-and-recommended-dietary-allowances-

for

https://studylib.net/doc/8290839/nutrient-requirements-and-recommended-dietary-allowances-for

Folic Acid Requirements

Category Folic Acid required

Women of child bearing age planning for

pregnancy- without prior history of NTD

0.4 mg (400 μg) daily

Women with a previous pregnancy

affected by NTD

5 mg daily- starting 1 month before

conception

BMI more than 30 5 mg daily- starting 1 month before

conception and continue during the

first trimester

Women with diabetes and epilepsy 5 mg daily

After first trimester, women receiving

higher dose of folic acid can transit to

daily multivitamin supplements

Multivitamin supplements containing

0.4 mg folic acid- for the duration of

pregnancy and lactation


Folic acid: SOGC Recommendation

A folate-supplemented diet with additional daily supplementation of

multivitamins with 5 mg folic acid should begin at least –

• Three months before conception and continue until 10 to 12 weeks post

conception

• From 12 weeks post-conception and continuing throughout pregnancy and

the postpartum period (4–6 weeks or as long as breastfeeding continues)

• Supplementation should consist of a multivitamin with folic acid (0.4–1.0

mg)

Wilson RD, Désilets V, Wyatt P, Langlois S, Gagnon A, Allen V, Blight C, Johnson JA, Audibert F, Brock JA, Koren G. Pre-conceptional

vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural

tube defects and other congenital anomalies. Journal of obstetrics and gynaecology Canada. 2007 Dec 1;29(12):1003-13.

Recommended Daily Allowance for Folic Acid

Category Body Weight (kg) RDA (mg/d)

Adult Female 55 200

Pregnancy 55 500

Lactation 55 300

Infants 5.4 (0-6 m)

8.4 (6-12m)

25

25

Nutrient Requirements And Recommended Dietary Allowances For Indians [Internet]. studylib.net. 2009 [cited 6 April 2019].

Available from: https://studylib.net/doc/8290839/nutrient-requirements-and-recommended-dietary-allowances-for


VITAMIN B12 IN PREGNANCY

Importance of Vitamin B12 in Women

• Pregnant women with low or marginal levels of vitamin B12 : at ↑ risk of

having children with neural tube defects

• Exclusively breastfed children of mothers with vitamin B12 deficiency : ↑

risk of failure to thrive, hypotonia, ataxia, developmental delays, anemia,

and general weakness

• Women at high risk of or with known vitamin B12 deficiency should

supplement with vitamin B12 while pregnant or breastfeeding

Langan RC, Zawistoski KJ. Update on Vitamin B 12 Deficiency. American family physician. 2011 Jun 15;83(12).

Risk Factors for Vitamin B12 Deficiency

Decreased IlealAbsorption

• Crohn disease

• Ileal resection

• Tapeworm infestation

Decreased Intrinsic Factor

• Atrophic gastritis

• Pernicious anemia

• Postgastrectomy syndrome (includes Roux-en-Y gastric bypass)

Genetic • Transcobalamin II deficiency

Inadequate Intake

• Alcohol abuse

• Older persons

• Vegetarians (includes exclusively breastfed children of vegetarian mothers)

Prolonged Medication Use

• Histamine H2 blockers

• Metformin

• Proton pump inhibitors


Implications of Vitamin B12 deficiency

Affects Fetal Development

Failure To Thrive

Movement Disorders

Megaloblastic Anemia

Hyperhomocysteinemia

Office of Dietary Supplements - Vitamin B12 [Internet]. Ods.od.nih.gov. 2018 [cited 6 April 2019]. Available from:

https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

The American Dietetic Association recommends supplemental vitamin B12 for

vegans and lacto-ovo vegetarians during both pregnancy and lactation to ensure

that enough vitamin B12 is transferred to the fetus and infant

https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Recommendations for Vitamin B12 Supplementation

• Vitamin B12 is as effective as intramuscular vitamin B12 injections, high dose oral vitamin B12 might be a reasonable choice for replacement in many patients with vitamin B12 deficiency, regardless of the etiology

• Vitamin B12 supplementation to reduce elevated serum homocysteine levels in patients with mild to moderate Alzheimer disease should not be given because it does not alter the rate of cognitive decline

• Vitamin B12 supplementation to reduce levels of serum homocysteine in high-risk patients is not recommended because it does not reduce cardiovascular mortality


Recommended Daily Allowance for Vitamin B12

Category Recommended intake

Adult female (NPNL) 1.0 μg/d

Pregnancy 1.2 μg/d

Lactation 1.5 μg/d

Infant 0.2 μg/d

Nutrient Requirements And Recommended Dietary Allowances For Indians [Internet]. studylib.net. 2009 [cited 6 April

2019]. Available from: https://studylib.net/doc/8290839/nutrient-requirements-and-recommended-dietary-allowances-for

NPNL: non-pregnant non- lactating


VITAMIN B6 IN PREGNANCY

Importance of Vitamin B6 in Pregnancy

• Vitamin B6 is a water-soluble vitamin naturally occurs in three forms -

pyridoxine, pyridoxal and pyridoxamine

• It plays an important role in metabolic processes in the body and also

helps with the development of the nervous system

• During pregnancy, vitamin B6 helps to prevent pre-eclampsia,

preterm birth and may also reduce pregnancy related nausea

• Vitamin B6 decreases throughout during pregnancy in plasma and

blood, especially in the third trimester

Salam RA, Zuberi NF, Bhutta ZA. Pyridoxine (vitamin B6) supplementation during pregnancy or labour for maternal and neonatal

outcomes. Cochrane Database of Systematic Reviews. 2015(6).

Importance of Vitamin B6 in Pregnancy

• Vitamin B6 plays an important role in the healthy functioning of brain

and nervous system

• It is important for healthy function of the brain and nervous system

• Vitamin B6 is necessary for the production of 2 main neurotransmitters- serotonin and norepinephrine

• Resolves nausea and vomiting (morning sickness) also maintains

blood glucose levels

• Prevents several issues in newborns (eczema and low birth weight)

Natural Sources of Vitamin B6 During Pregnancy - American Pregnancy Association [Internet]. American Pregnancy Association.

2018 [cited 6 April 2019]. Available from: http://americanpregnancy.org/pregnancy-health/natural-sources-of-vitamin-b6-during-

pregnancy/

http://americanpregnancy.org/pregnancy-health/natural-sources-of-vitamin-b6-during-pregnancy/

Source of Vitamin B6

Fish




Implications of Vitamin B6 Deficiency

Dermatitis/ Cheilosis

Microcytic Anemia

Depression And Confusion

Glossitis

Week Immune System

In Infants: Irritability, Abnormally Acute Hearing and Convulsive Seizures

Office of Dietary Supplements - Dietary Supplement Fact Sheet: Vitamin B6 [Internet]. Ods.od.nih.gov. 2017 [cited 6 April 2019].

Available from: https://ods.od.nih.gov/factsheets/VitaminB6-HealthProfessional/

Recommended Daily Allowance for Vitamin B6

Category Body Weight (kg) RDA (mg/d)

Adult Female 55 2.0

Pregnancy 55 2.5

Lactation 55 2.5

Infants 5.4 (0-6 m)

8.4 (6-12m)

0.1

0.4




IRON IN PREGNANCY

Iron Deficiency in India

• 50-70% of population in India are anemic

• According to WHO, hemoglobin below 7gm/dl is severe anemia

• As of 2010, in India, prevalence of mild anemia was 13%, moderated

was 57% and severe anemia was 12%

• According to NNMB and NFHS-3 surveys, in mean prevalence of

anemia was 24.3% aged more than 20 years

Sharma JB, Shankar M. Anemia in pregnancy. JIMSA. 2010 Oct;23(4):253-60.

Nutrient Requirements And Recommended Dietary Allowances For Indians [Internet]. studylib.net. 2009 [cited 6 April 2019]. Available from:



Importance of Iron in Pregnancy

• Iron is needed for fetus growth, maternal tissue expansion including

the red cell mass, iron in the placental tissue and the blood loss

during parturition

• Additional 760 mg of iron is required during pregnancy

• In Indian women, a gestational weight gain should be around 10-12

kgs

• During lactation, iron requirement is the total of mother requirement

plus making up the iron lost in the breast milk




Implications of Iron Deficiency

Low birth weight and small for

gestational age

Preterm labor

Perinatal mortality

Rasmussen KM. Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth, length of

gestation and perinatal mortality?. The Journal of nutrition. 2001 Feb 1;131(2):590S-603S

Auerbach M. Commentary: Iron deficiency of pregnancy-a new approach involving intravenous iron. Reproductive Health. 2018

Jun;15(1):96.

Upadhyay C, Upadhyay N. Effect of anemia on pregnancy outcome: a prospective study at tertiary care hospital. International

Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2017 Nov 23;6(12):5379-83.

Iron Supplementation in Pregnancy

• An additional 760 mg of iron is required during the entire pregnancy

period in Indian women

GWG: gestational weight gain

Recommended Dietary Allowance: 35 mg/day

Trimester Requirement mg

10 kg GWG 12 kg GWG

1st Trimester 130 138

2nd Trimester 320 372

3rd Trimester 310 351

Total 760 861




Benefits of Iron Supplementation

• Daily oral iron supplementation resulted in a significantly higher

maternal mean hemoglobin (Hb) concentration and a reduced risk of

anemia in mothers at term

• ↓ risk of iron-deficiency anemia and also a ↑ mean Hb concentration

within 1 month postpartum

• The benefits to the infant :

1. significant increase in birth length

2. higher mean ferritin concentrations at 3 and 6 months of age

Yakoob MY, Khan YP, Bhutta ZA, Bhutta, Seshadri, Barker, Wu, Ramakrishnan, de Benoist,

Kovacs, Kupka. Maternal mineral and vitamin supplementation in pregnancy. Expert Review of

Obstetrics & Gynecology. 2010 Mar 1;5(2):241-56.

Recommended Daily Allowance for Iron

Category Body weight

Kg

Requirement

µg/kg/d

Absorption

assumed %

RDA mg/d

Adult Woman 55 30 8 21

Pregnant

woman

55 51 8 35

Lactating

woman (0-

6m)

55 23 8 25

Infants 5.4 (0-6 m)

8.4 (6-12 m)

46 (0-6 m)

87 (6-12 m)

---

15 (6-12 m)

---

5 (6-12 m)




Absorption of Iron Supplements

Fishbane S. A Physician’s Guide to Oral Iron Supplements [Internet]. Sabm.org. 2018 [cited 6 April 2019]. Available from:

https://www.sabm.org/wp-content/uploads/2018/08/Physician-Guide-to-Oral-Iron-Nov-2013.compressed.pdf.

Recommendation: prescribed daily iron supplement in 2 or 3 equally spaced

doses

Oral iron supplements must dissolve rapidly in the stomach so that the iron can be absorbed in the duodenum or upper jejunum

Enteric-coated preparations and long-acting supplements may be ineffective, since they do not

dissolve in the stomach

CALCIUM AND VITAMIN D

Importance of Calcium in Pregnancy

• Required for the skeletal development of the fetus

• Role in neuromuscular function and blood coagulation

• Deficiency alters membrane permeability and smooth muscle

contractility could affect blood pressure, as well as lead to premature

uterine contractions and subsequent delivery

Yakoob MY, Khan YP, Bhutta ZA, Bhutta, Seshadri, Barker, Wu, Ramakrishnan, de Benoist, Kovacs, Kupka.

Maternal mineral and vitamin supplementation in pregnancy. Expert Review of Obstetrics & Gynecology. 2010

Mar 1;5(2):241-56.

Need of Calcium Supplementation in Pregnancy

• R D A in pregnancy: 1200 mg/day

• Supplementation during pregnancy

– ↓ the risk of high blood pressure (with or without proteinuria) by 30%

(RR:0.70; 95%CI: 0.57-0.86)

– It also significantly reduced the risk of preeclampsia by 52% (RR:0.48;

95%CI: 0.33-0.69)

Yakoob MY, Khan YP, Bhutta ZA, Bhutta, Seshadri, Barker, Wu, Ramakrishnan, de Benoist, Kovacs, Kupka. Maternal

mineral and vitamin supplementation in pregnancy. Expert Review of Obstetrics & Gynecology. 2010 Mar 1;5(2):241-56.




Importance of Vitamin D in Pregnancy• During pregnancy, vitamin D deficiency has been linked with a

number of serious short- and long-term health problems in offspring,

(impaired growth, skeletal problems, Type 1 diabetes, asthma and

schizophrenia)

• It also has consequence on fetal hypovitaminosis D, neonatal rickets

and tetany, and infantile rickets

• Vitamin D deficiency early in pregnancy has been associated with a 5

fold increased risk of preeclampsia

• Also, vitamin D deficiency early in pregnancy may increase the risk of

low birth weight babies

• Recommended dietary allowance: 400 IU

Yakoob MY, Khan YP, Bhutta ZA, Bhutta, Seshadri, Barker, Wu, Ramakrishnan, de Benoist, Kovacs, Kupka. Maternal mineral and

vitamin supplementation in pregnancy. Expert Review of Obstetrics & Gynecology. 2010 Mar 1;5(2):241-56.

Nutrient Requirements And Recommended Dietary Allowances For Indians [Internet]. studylib.net. 2009 [cited 6 April 2019]. Available

from: https://studylib.net/doc/8290839/nutrient-requirements-and-recommended-dietary-allowances-for


Recommendations for Calcium and Vitamin D for Pregnancy and Lactation

RDA : 1000 mg/day

Pre-eclampsia

Preterm Premature Rupture Of The Membranes

Early Contraction

CalciumRDA : 400 - 600 IU/day

Impaired Growth

Skeletal Problems

Pre-eclampsia

Type 1 Diabetes

Asthma

Schizophrenia

Vitamin D

Bodnar LM, Catov JM, Simhan HN, Holick MF, Powers RW, Roberts JM. Maternal vitamin D deficiency increases the risk of preeclampsia. The

Journal of Clinical Endocrinology & Metabolism. 2007 Sep;92(9):3517-22.



“Low calcium intake may be associated with vitamin D deficiency and may be a risk

factor for preeclampsia”


Recommended Daily Allowance for Calcium

Category Calcium Required mg/d

Adult Women 600

Pregnancy 1200

Lactation 1200

Infants 500

Post-menopausal women 800




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