Department of Nutrition

Faculty of Medicine
Universitas Indonesia
2014

References
Brown JE. Nutrition through the Life Cycle 3 rd ed.,
2005 & 4th ed., 2008
Bowman BA, Russell RM. Present Knowledge in
Nutrition 9th ed., 2006
De Maeyer AH, et al. Preventing and Controlling Iron
Deficiency Anemia through Primary Health Care,
1989
Mahan LK, Escott-Stumps S. Krauses Food &
Nutrition Therapy 12nd ed., 2008
Lammi-Keefe CJ, et al. Handbook of Nutrition and
Pregnancy, 2008
2

Introduction
Energy & nutrient requirements typically more
during pregnancy than during any other stage in
a womans adult life
Additional requirement are required during
pregnancy for development of the fetus & for
growth of maternal tissues
The materials required for this rapid growth &
development depend on supply from the
maternal diet
4

The importance of nutrition during

pregnancy
A. To set the nutritional foundations for
a healthy adult life
Epidemiologic evidence
strongly suggests certain adult
chronic diseases correlate with
nutritional conditions in utero
5

B. Nutrition during pregnancy:

Maintain maternal energy requirements
Provide substrate for development of new fetal
tissues
Reserve substrate for lactation

Prenatal nutrition:
Weight gain in pregnancy
Dietary intake in pregnancy

relate to babys
birth weight

Nutrition during pregnancy affects the health

of both the mother & baby
Higher mortality rate

Impaired
mental development

Baby
low birth weight
Inadequate
fetal nutrition

Woman malnourished
Pregnancy low
weight gain

Higher maternal mortality

Inadequate
catch-up growth

risk of adult chronic diseases

Untimely/inadequate feeding
Frequent infections
Inadequate food, health,
& care
Child stunted

Adolescent stunted
Inadequate food,
health, & care

Reduced
mental capacity
Inadequate food,
health, & care

Reduced physical capacity

& fat free mass
8

From nutritional point of view, birth weight

depends on:
Prepregnancy weight for height (W/H)
expressed in body mass index (BMI)
Weight gain during pregnancy

Weight (kg)
BMI =
Height2 (m2)
9

Distribution Of Weight Increase

Breasts 11.5 kg
Uterus 0.51 kg

Fat storage in
subcutaneous
tissues

44.5 kg

Protein storage

Fetus & placenta 5 kg

Water & electrolytes

11.5 kg

10

Pregnancy weight gain recommendations

Prepregnancy weight status
BMI*
Underweight, <18.5 kg/m2
Normal weight, 18.524.9 kg/m2
Overweight, 2529.9 kg/m2
Obese, 30 kg/m2 or higher
Twin pregnancy

Recommended weight
gain
12.718.2 kg
11.415.9 kg
6.811.4 kg
6.9 kg at least
15.920.5 kg

*BMI categories modified based on 1997 changes from the Nutritional Institutes
of Health. Young adolescences should achieve gains at the upper end of ranges,
& short women at the lower end

Source: Brown JE, 2008

11

Physiological changes of pregnancy

A. Blood volume & composition
Blood volume expands by 50%

Hb value, blood glucose, serum albumin,

other serum protein, & water soluble vitamins
Plasma 43%, RBC 1725% plasma
volume more than RBC hemodilution
blood viscosity flow resistance
facilitating blood flow to uterus & placenta
12

B. Cardiovascular & pulmonary function

C. Gastrointestinal function
an of progesterone level
GI motility absorption of nutrients

D. Renal function
13

Renal Function .. (contd)

Blood volume
High glomerular filtration rate
but
Renal tubules unable to adjust completely
Amino acids, glucose, & water soluble vitamins
may appear in the urine
Ability to excrete water is lowered
Edema in the legs is common & normal
14

Changes in maternal homeostasis

during pregnancy:
Changes in efficiency of absorption from
the GI tract & excretion by the renal
system
Changes in maternal storage

Care must be taken in selecting optimal diet

15

Placenta
Principal site of production for
several hormones responsible for:
Regulating fetal growth
Development of maternal support
tissues
The conduit for exchange of nutrients O 2
& waste products
16

Transfer of substances across the placental membrane

Ig: imunoglobulin
17

Unit feto-placental hormones:

Placental peptide hormones
- Human chorionic gonadotrophin
- Human placental lactogen
- Pregnancy specific hormones
Steroid hormones
- Estrogens
- Progesterones
18

Metabolic & hormonal changes

Metabolism & endocrine functions undergo
a large number of changes
during pregnancy

Optimal growth of the fetus

19

Metabolic changes during pregnancy:

Homeostasis fluid & electrolyte
CHO metabolism:
glucose is the sole energy source for the
fetus
Lipid metabolism:
lipogenesis & maternal fat storage
20

Metabolic changes (contd)

Protein metabolism:
positive nitrogen (N) balance
tissues synthesis

Mineral metabolism:
Ca metabolism ( rate of bone turnover
& reformation)
21

Summary of maternal anabolic &

catabolic phases
of pregnancy
Maternal anabolic phase
020 weeks
Blood volume expansion, cardiac
output
Build up of fat, nutrient, & liver
glycogen stores
Growth of some maternal organs

Maternal catabolic phase

20+ weeks
Mobilization of fat & nutrient stores

production & blood levels of glucose,

triglycerides, and fatty acids; liver
glycogen stores
Accelerated fasting metabolism

appetite, food intake (positive energy appetite & food intake; decline
balance)
somewhat near term
exercise tolerance

exercise tolerance

levels of anabolic hormones

levels of catabolic hormones

22

Weight gain
Weight should be gained throughout
pregnancy, the most critical is in the
2nd trimester
Weight gain
1. Expansion of maternal blood volume
2. Construction of fetal & placental tissues
23

The importance of body weight

among pregnant women
Women who are underweight are at risk for
low birth weight babies (birth weight <2500 g),
and can also the risk of gastroschisis
Women who are overweight or obese are at
risk for macrosomic infants (weight >4000 g).
Macrosomic infants are at risk of shoulder
dystocia, etc.
24

Nutrient requirement during pregnancy

Additional amount of nutrients are needed
Why?
Required by the fetus to grow
To prepare mothers body changes during
pregnancy
Preparation for delivery & lactation period
25

Energy needs during pregnancy

vary according to:
Womans basal metabolic rate (BMR)
Prepregnancy weight
Amount & composition of weight gain
Stage of pregnancy
Physical activity level
26

Energy
Additional energy needs:
Added maternal tissues
Growth of the fetus & placenta
Hytten & Leitch:
Energy cost 80,000 kcal in general:

1st trimester: additional 180 kcal/day

2nd & 3rd trimester: additional 300 kcal/day
27

Energy & Macronutrient

WHO recommended an addition of
300 kcal/day (2nd trimester & 3rd trimester)
2nd trimester: mostly used for maternal
factors
3rd trimester: for both maternal & fetal
factors
28

Carbohydrate (CHO)
IOM CHO adult & children: 130 g/day
(minimum 100 g/day); intake 135175 g/day
to prevent ketosis & maintaining normal
blood glucose levels. Adequate intake 175 g
In general 5065% of total energy
If CHO is too low

gluconeogenesis

Gluconeogenesis is energically expensive:

80 g protein

50 g glucose
29

Dietary fiber/non starch polysaccharides

Dietary fiber 1014 g/1000 kcal

Insoluble to soluble ratio = 3 : 1
Soluble fiber: fruits, nuts, beans, cereals
Insoluble fiber: fruits, vegetables
Criterion for intake:
extrapolation based on energy intake
30

Protein
A number of amino acids are recognized as
precursors of neurotransmitters
RDA for protein for the average adult is 0.8 g/kg/d
During pregnancy; additional protein
approximately 1 kg
Additional
1st trimester
1.3 g/d
2nd trimester
6.1 g/d
3rd trimester
10.7 g/d
31

Fat
Metabolic functions of dietary fat
Oxidized for energy
Stored in adipose tissue
Incorporated into cell membrane phospholipids
Precursors for eicosanoid synthesis
Influence on receptor function
Influence on enzyme function
32

Essential fatty acids (EFAs)

Omega-3 (n-3) & omega-6 (n-6) fatty acids
All essential fatty acids (EFAs) are
polyunsaturated fatty acids (PUFAs)
Synthesized in chloroplasts in plants &
phytoplankton

33

IOM-FNB (2002) recommended intakes of EFAs

during pregnancy
Fatty acids
Linoleic acid (n-6)
-Linolenic acid (n-3)

% total energy
5.010.0
0.61.2

IOM-FNB: International of Medicine-Food and National Board

34

Eicosapentaenoic acid (EPA) &

docosahexaenoic acid (DHA):
2 derivatives of -linolenic acid (n-3 fatty acid)

EPA & DHA perform specific functions in

the body particularly during pregnancy &
lactation

35

EPA:

inflammation
dilate blood vessels
blood clotting

DHA:
the major structural component of phospholipids
in cell membranes in the central nervous system
(CNS), including retinal photoreceptors

36

Adequate intake of EPA & DHA

during pregnancy & lactation is
estimated
to be 300 mg/day

37

Pedoman Umum Gizi Seimbang (Depkes

RI)

CHO
Sugar

5060% of total energy

not more than 5%

Lipid

25% (at least 10%)

Protein

1015%

Unit of energy:
kiloJoules (kJ) & Calorie (Cal) or kilocalorie (kcal)
1 Cal or kcal = 4.184 kJ
38


Required for production of several
coenzymes & as cofactors of many
enzymes that catalyze numerous
metabolic pathways
39

Requirements of vitamin B group per

day
for adult female
Nutrient
Requirement
Pregnancy
Vitamin B1

0.5 mg/1000 kcal,

minimal 1 mg for
energy intake (2000
kcal)

+ 0.3 mg

Vitamin B2

1.3 mg

+ 0.3 mg

Niacin
Vitamin B6

14 mg
1.3 mg

+ 4.0 mg
+ 0.4 mg

Vitamin B12

2.4 g

+ 0.2 g

Folic acid

400 g

+ 200 g

Source: Widyakarya Nasional Pangan dan Gizi (WNPG) VIII, 2004

40

Folic acid
Deficiency in pregnancy has been linked with
maternal megaloblastic anemia & fetal
neural tube defect (NTD)
Folic acid supplements should be
administered 3 months prior to conception
& during
1st trimester (400 g/day)
Female with history of delivering baby
with NTD
supplementation of 4 mg/day
41

Vitamin C
Antioxidant
Pregnancy intake: (+) 10 mg
Criterion for increasing:

amount needed to prevent scurvy in infant

& estimated fetal transfer

42

Antioxidants
Brain is metabolically the most active organ &
consumes maximum amount of glucose &
O2 by product

O2 free radicals

Reactive oxygen species

Antioxidants (vitamins A, C & E, Zn, Se, etc.)
43

Fat Soluble Vitamins

Fat soluble vitamins can be stored in adipose

tissues & liver

additional intake should be

carefully supervised
Excessive intake malformation & abortion
Brain development: vitamins A & E

(antioxidants) are required

44

Brain development:
Iodine (I): for synthesis tiriodothyronine (T3) &
thyroxine (T4)
Iron (Fe): required for myelin production
Zinc (Zn): component of over 200 metalloenzymes
Copper (Cu): important component of cytochrome
oxidase & superoxide dismutase
(SOD) in the brain
45

Sodium

Hormonal milieu of pregnancy affects

sodium metabolism

Intake should not be excessive but do not

less than 2 g/day

46

Requirement of some minerals per day

for adult female
Nutrient

Requirement

Pregnancy

I
Fe

150 g
26 mg/day

Zn

9 mg/day

Se

30 g

+ 50 g
1st trimester
2nd trimester + 9.0 mg
3rd trimester + 13.0 mg
1st trimester + 1.7 mg
2nd trimester + 4.2 mg
3rd trimester + 9.8 mg
+ 5 g

Source: WNPG VIII, 2004

47

During pregnancy the requirement of fluid

Why?
blood volume & utero-placental perfusion

Water & sodium intake are very important

48

Water
Female adult 2 L/day
Pregnancy 2.3 L/day

Sodium:
Pregnancy:
Adequate intake (AI) 1.5 g/day
Upper limit (UL) 2.3 g/day

Healthy adult at least 500 mg/day

49

Alcohol
Evidence from animal studies & human
experience:
Associates heavy drink (>1 drink/day)
by a pregnant female with
teratogenicity & fetal alcohol
syndrome
50

Fetal alcohol syndrome

Features:
Prenatal & postnatal growth failure
Developmental delay
Microcephaly
Eye changes
Facial abnormalities
Skeletal joint abnormalities

51

Nonnutritive Substances in Foods

Caffeine <100 mg/day ~ 2 cups of coffee
Artificial sweeteners:
sucralose approved by FDA in 1998;
sucrose derivative, 600 times sweeter

Sucralose

Sucrose

52

Some obstetric complications with

nutritional interrelationships
Anemia in pregnancy

Hb concentration <11 g/dL

53

Iron Deficiency Anemia

Iron deficiency anemia (IDA) is a problem
of serious public health significance
Iron deficiency (ID) occurs when iron is
absorbed in an insufficient amount to
meet the bodys requirement

54

Iron Deficiency
Insufficiency may be due to:
Inadequate iron intake
Reduced bioavailability of dietary iron
Increased needs for iron
Chronic blood loss

55

Iron .
(contd)

When prolonged, ID leads to IDA

Iron Status
Norma
l
Plasma Ferritin
(g/L)
Transferrin
Saturation (%)

60

Iron
depletio
n
<12

35

35

30

30

ID
<12
<16

IDA
<12
<16
>100

>100
RBC Protoporphyrin
(g/dL)
12
12
<12
Hemoglobin (g/dL)
>12
Iron deficiency in women [International Nutritional Anemia Consultative
Group (INACG), 2002]

56

The consequences of ID or IDA in

pregnant women:
maternal morbidity & mortality
fetal morbidity & mortality
risk of low birth weight

57

Megaloblastic Anemia
In pregnancy,
megalobalstic anemia usually caused by
folic acid deficiency

58

Other Obstetric Complications with

Nutritional Interrelationship
Hyperemesis gravidarum
Diabetes mellitus
Underweight & poor weight gain
Obesity

59

Obesity
Obesity in pregnancy the risk of:
Gestational diabetes
Pregnancy-induced hypertension
Cesarean section
Neural tube defect (NTD)
Delivery infant with macrosomia
Intrauterine fetal demise (IUFD)
Infant with cardiac defects
60

Summary
Energy intake to meet nutritional needs & allow
for about a 0.4 kg weight gain per week during
the last 30 weeks of pregnancy
Protein intake to meet nutritional needs, about an
additional 20 g/day
Sodium intake that is not excessive but is no less
than 23 g/day (56 g of table salt)

61

Summary . (contd)
Mineral & vitamin intakes to meet the RDA (folic
acid & possibly iron supplementation is required)
Alcohol omitted
Caffeine in moderation:
less than 200 mg/day equivalent to
2 cups of coffee

62

Conclusion
Nutrition during pregnancy

Maintains energy, macronutrients, & micronutrients

requirements
Provide substrate for development of new fetal tissues
Builds energy reserves for postpartum lactation
Optimal nutrition during pregnancy is the most critical
importance; 70% of the human brain develops during fetal
life
63

Breastfeeding is the gold standard & strongly

recommended method of feeding infants
World Health Organization (WHO) recommends
human milk as the exclusive nutrient source for
the first 6 months of life, with introduction of
solids at this time, and continued breastfeeding
until at least 12 months postpartum
65

Breast feeding benefits to:

Infant nutrition

Gastrointestinal function
Host defense
Neurological development
Psychological, economic, & environmental
well being
etc.
66

Healthy Mother
Human milk
Volume:

850 mL/day

Energy content: 6065 kcal/100 mL

Lactating woman requires a moderately

large amount of extra energy
67

Adequate amount of human milk

production depends upon:
Capacity of the mammary gland in milk
synthesis
Activity, metabolism, hormonal, &
maternal diet
Amount of energy & nutrient stores that
can be utilized
68

Daily intake
Maternal activity
& metabolism
Available nutrients
(intake & storage)

Milk (energy &

nutrients
content)
Milk synthesis
process

Body stores

Source: Lawrence, 2000

69

Nutritional Needs of Lactating Woman

Maintain maternal health
Milk production that sufficient for
the infant
Various mechanisms including
adjustments to energy intake & its
expenditure to meet the energy
requirement during lactation
70

Estimated Energy Requirement (EER)

The incremental energy cost of lactation is
determined by:
The amount of milk produced
The energy density of the milk secreted
The energy cost of milk synthesis

71

EER of a healthy lactating woman can be estimated

by a factorial approach from the sum of:
(1) EER of a non-pregnant, non-lactating woman
(of a given age, weight, & activity level)
(2) Estimated milk energy
(3) Energy mobilization from tissue stores
(i.e. weight loss)

72

Human milk composition per 100 mL:

Energy
Protein
Fat

6065 kcal
1.01.2 g
2.53.5 g

Human milk contains

calcium 300 mg/day

73

Measuring nutritional requirements

of lactating woman (WNPG VIII, 2004)
850 mL of human milk 600 kcal
Energy efficiency 80% requires an extra
(100 : 80) x 600 kcal = 750 kcal/day
200 kcal obtained from fat stores
extra energy intake: 750 kcal 200 kcal
500550 kcal/day is sufficient
74

Measuring nutritional . (contd)

Protein (850 : 100) x 1.5 g = 13 g
Protein efficiency 80%
(100 : 80) x 13 g = 16.25 g
(additional average 17 g of protein/day)

75

The extra energy (calories) need of lactating

woman should in the form of a well-balanced
diet, not come from high-calorie foods with
poor nutrient density such as sugar and oils

76

Carbohydrates
Source of energy
Protein sparing effect
5060% of total calories

77

Fats (1)
Sources of EFAs & energy
Polyunsaturated fatty acids (PUFAs):
arachidonic acid (AA) & DHA
essential in neural & visual acuity development

Several studies:
infants fed with human milk have better cognitive
development & visual evoked potential (VEP)
than those fed with commercial infant formulas
78

Fats (2)
DHA intake should be 300 mg/day in lactating
woman (Simopoulos et al, 1999)
Fatty acids of infant tissues depend on daily fats
intake DHA content of breast milk is >>>
if the maternal DHA intake is >>>

The mothers dietary fat intake should be

optimal in order to have optimal fatty acids
composition in her milk
79

Protein
The AKG (Indonesian RDA) suggests an
additional 17 g of protein a day for lactation
(WNPG VIII, 2004)

or
70 g of protein a day

80

Minerals
Calcium intake need to be regarded
During lactation secretion of calcium into breast
milk averages 200 mg/day
Iron intake need for replacing the iron depletion
during pregnancy

81

Vitamins
Fat soluble vitamins should be adequate
Water soluble vitamins intake depends on the
mothers energy intake

82

Non-nutrients
Taurine:
Antioxidant
Conjugation of bile acids & salts

Nucleotide:
essential substances for protein synthesis,
energy metabolism, etc.
Human milk contains high concentration of
taurine & nucleotide
83

Undernourished Woman
Although the quantity of
human milk is influenced
by the mothers nutritional
status, the quality is not
significantly affected,
except for the fat, vitamin,
& mineral contents
84

Nutritional Status & Milk

Volume
Milk production of woman with
good nutritional status:
First months
Third months
Sixth months

600 mL
700750 mL
750800 mL

The amount will depend on

suckling frequency of the infant
85

Physiology of milk production

PRH: pituitary releasing hormone
86

Milk production of undernourished

woman:
First 6 months

500700 mL

Second 6 months 400600 mL

Second years

300500 mL

87

Milk production of (contd)

Severe malnutrition mother
fat content in breast milk <<<
The water-soluble vitamins content
depends on the mothers intake
of these vitamins

88

Conclusion
Maternal diet play a role in both the
nutrients & non-nutrients composition
Nutrients composition of lactating woman
is necessary to be regarded

89

Conclusion (contd)
Nutritional status of lactating woman play
an important role in one of the efforts to
achieve breastfeeding at the early life of an
individual
Moreover, nutrition play a role in
determining the success of a childs growth
& development since his or her early life

90

Conclusion (contd)
To prevent malnutrition during lactation,
early detection in antenatal care is necessary
by both anthropometric & laboratory
assessment, and physical examination

91

92

93