Healthy Eating During Pregnancy Pregnancy is one of the most nutritionally demanding periods of a woman's life. The gestational period involves rapid cell division and organ development. An adequate supply of nutrients is essential to support this period of tremendous fetal growth. The chart on the next page, illustrates how the requirement for some nutrients more than doubles during pregnancy, while caloric needs increase only about 15 percent. Pregnant women need to choose nutrient- dense foods to assure an adequate nutrient intake. For many women this requires some improvement of present eating habits. This brochure reviews nutritional requirements of pregnant women, including information on recommended weight gain, protein needs, vitamin and mineral supplementation and the overall safety of foods in the diet. A Message from the March of Dimes Good nutrition during pregnancy is very important for the health of the expectant mother and her baby. Healthy Eating During Pregnancy is a concise and up-to-the-minute storehouse of information about maternal nutrition. The March of Dimes is pleased to work with the International Food Information Council in bringing this booklet to nutritionists, health professionals and writers for the benefit of mothers and babies. Jennifer Howse, Ph.D. President March of Dimes Birth Defects Foundation Recommended Dietary Allowances for Pregnant Women Percent Increase over Nonpregnant Women Source: Recommended Dietary Allowances, 10th Edition. National Research Council, National Academy of Sciences, 1989. Calories 14% Protein 20% Vitamin D 100% Vitamin E 25% Vitamin K 8% Vitamin C 17% Thiamin 36% Riboflavin 23% Niacin 13% Vitamin B6 27% Folate 122% Vitamin Bl2 10% Calcium 50% Phosphorus 50% Magnesium 14% Iron 100% Zinc 25% Iodine 17% Selenium 18% Source: Recommended Dietary Allowances, 10th Edition. National Research Council, National Academy of Sciences, 1989. Weight Gain A low gestational weight gain often results in a low birth-weight infant who may experience delayed development. Low birth-weight infants (less than 5.5 pounds at birth) and particularly very low birth-weight infants (less than 3.5 pounds at birth) have a statistically greater risk of disease development and mortality during the first month of life than infants born weighing at least seven pounds. In addition to the growth of the fetus associated with maternal weight gain, pregnant women store fat to prepare the mother for lactation. Development of these fat stores is so critical that maternal body weight may be protected even at the expense of fetal growth. Therefore, it is particularly important to monitor the weight gain of underweight women who plan to breast feed. In 1990 the National Academy of Sciences/Institute of Medicine (NAS/IOM) issued new recommendations for weight gain during pregnancy. Now, an additional 25-35 pounds is considered desirable for both the mother and infant. This is slightly higher than the previous recommendation of 20-25 pounds. However, there are exceptions to the general recommendations, since goals for weight gain should be based on prepregnancy weight and height. Women who are underweight when they conceive should gain about 28 to 40 pounds. Those who are overweight should gain no more than 15 to 25 pounds. Short women, under 62 inches, should set lower goals for weight gain, 18 to 30 pounds. Since extremely obese women with lower weight gains have been found to have successful pregnancies and healthy babies, it is recommended that their gestational gain be limited to 15 pounds. Obese women require individual nutrition counseling to assure adequate nutrient intake and to discourage them from any attempts to lose weight during pregnancy. Caloric restriction during pregnancy has been associated with reduced birth weights. Young adolescents should gain between 28 and 40 pounds and women carrying twins should gain 35 to 45 pounds, regardless of their prepregnancy weight and height. Patterns of weight gain are as important as total weight gain. Therefore it is important to set goals for weight gain with the mother and monitor her progress carefully, using a standardized weight-gain grid in the prenatal record. This should begin with accurate measurement and recording of height and weight on the initial prenatal visit and regular weigh-ins recorded at each visit. Persistent deviations from expected patterns of weight gain are signals for intervention and reassessment of weight-gain goals. Weight maintenance or slight losses are normal during the first trimester. Women with healthy prepregnancy weights should gain an average of one pound a week during the second and third trimesters. Women who were underweight before conception should gain slightly more than one pound per week. Those who were initially over weight should gain at a slower rate of about 2/3 pound per week. Recommended Total Weight Gain for Pregnant Women By Prepregnancy Body Mass Index (BMI)* Weight-for-Height Category Recommended Total Weight Gain Kilograms Pounds Low (BMI 19.8) 12.5 - 18.0 28 - 40 Normal (BMI 19.8 to 26.0) 11.5 - 16.0 25 - 35 High (BMI 26.0 to 29.0) 7.0 - 11.5 15 - 25 Obese (BMI 29.0) 6.0 15 * Body mass index, or BMI, is an indicator of nutritional status based on two common measurements, height and weight. Because it reflects body composition such as body fat and lean body mass, BMI is considered a more accurate indicator than height/weight tables. BMI is calculated using the following formula: ht/wt2 = kg/m2 x 100. BMI can be calculated using metric or English measurements (lb/in2 x 100). It is advisable to use the same units commonly used in the clinic. BMIs listed in this table are based on metric calculations, but can be converted to English by using the following formula: BMI (metric) x 0.142 = BMI (English); BMI (English) x 7 = BMI (metric). Source: National Academy of Sciences. Nutrition During Pregnancy: Weiqht Gain and Nutrient Supplements. Washington, DC: National Academy Press, 1990. Food Choices Food requirements during pregnancy are not drastically different from a normal well-balanced diet. Nutrient needs are higher, but the general principles of sound nutrition diet variety, balance and moderation still apply. There are no "perfect" foods that supply all the necessary nutrients. A variety of foods with a balance of choices over the course of the day will provide the recommended amount of calories, protein, vitamins and minerals required during pregnancy. During pregnancy, eating should be as much a pleasure as it is throughout life. Expectant mothers should continue to enjoy favorite foods in moderation. Attention to portion size and frequency of consumption is the key to choosing occasional treats while keeping total caloric intake under control. The guidelines for daily food choices, adapted from U.S. Department of Agriculture recommendations, outline the kinds of foods and recommended amounts to eat daily. Individual requirements vary, depending on caloric needs. Use the guidelines to determine the basics of the diet. Additional servings and larger portion sizes can be recommended in cases of slow weight gain while smaller portions of higher calorie foods may be advised in cases of rapid weight gain. Guidelines for Daily Food Choices for Pregnant Women Suggested Daily Servings of Various Foods and Serving Sizes Breads, Cereals and other Whole grain and Enriched Products 6-11 servings -- 1 slice bread; 1/2 hamburger bun or english muffin; 3-4 small or 2 large crackers; 1/2 cup cooked cereal, pasta or rice; 1 ounce ready-to-eat cereal. Fruits 2-4 servings (Include at least one citrus fruit or juice.) --3/4 cup juice; 1 medium apple, banana or other fruit; 1/2 cup fresh, cooked or canned fruit. Vegetables 3-5 servings (Include at least two servings of dark green leafy, yellow or orange vegetables.) -- 1/2 cup cooked or chopped raw vegetables; 1 cup leafy raw vegetables. Meat, Poultry, Fish and Alternates 2-3 servings -- Total of 6-7 ounces cooked lean meat/poultry/fish/other protein sources daily; 1 oz. = 1 egg; 1/2 cup cooked beans; 2 tablespoons peanut butter. Milk, Cheese and Yogurt 4 servings -- 1 cup milk; 1 cup buttermilk; 8 ounces yogurt; 1-1/2 ounces natural cheese; 2 ounces processed cheese. Fats, Sweets and Alcohol-- Limit fats and sweets and avoid alcoholic beverages. Adapted from United States Department of Agriculture Home & Garden Bulletin No. 232-8. Calories and Nutrients of Concern Calories To support the rapid growth of the fetus, pregnancy demands an additional 300 calories a day over prepregnancy needs. This is approximately the same number of calories as supplied by 2-1/2 cups of low- fat milk, one cup of ice cream, a bagel with cream cheese or a tuna fish sandwich. This additional caloric requirement may seem small, but it will supply the extra energy essential to support the growth of the fetus. Some expectant mothers may be tempted to literally "eat for two," or double the amount of food they normally eat. This practice is likely to result in excessive weight gain. Protein Both expectant mother and developing fetus need increased amounts of protein. In 1989 the Recommended Dietary Allowance for protein during pregnancy was significantly reduced, based on revised estimates of the efficiency of protein utilization in pregnant women. It is recommended that pregnant women consume 60 grams of protein a day, or only 10 grams more than nonpregnant women. Ten grams of protein is roughly equivalent to the amount in 1-1/2 ounces of meat or 1-1/4 cups of milk. Since most Americans regularly consume more protein than they require, most women will not need to consciously increase protein consumption during pregnancy. Lean meats, poultry and fish are good sources of protein that also supply other hard-to-get nutrients, such as iron, B vitamins and trace minerals. Dried beans, lentils, nuts, eggs and cheese are other high- protein foods. Since an adequate supply of protein is generally provided through a balanced diet, there usually is no need to use high-protein beverages, supplements or powders. Although there is no question of the benefits of adequate protein intake, some studies suggest that excessive protein supplementation could be detrimental to the developing fetus, resulting in delayed growth or preterm delivery. Although protein needs can be met by a well-selected lacto-ovo (milk and egg) vegetarian diet, pregnant vegans, who eat only plant foods, should be referred to a registered dietitian for diet counseling to assure an adequate intake of protein and essential vitamins and minerals. Calcium The calcium requirement during pregnancy is 1200 mg/day, a 50 percent increase over the requirement for nonpregnant women. Women who are not pregnant generally consume only about 75 percent of the recommended amount of calcium, so most pregnant women need to intentionally add calcium-rich foods to the diet. Adequate calcium intake is especially critical for pregnant women under 25 years of age whose bones are continuing to increase in density. Milk, yogurt, frozen yogurt, ice cream, ice milk and cheeses are calcium-rich foods. Non-fat and low- fat dairy products supply equal amounts of calcium with fewer calories than higher fat counterparts. Green leafy vegetables, tofu, and canned salmon (bones included) are other good sources of calcium. Calcium- fortified foods, such as some orange juice and breakfast cereals, can also provide significant amounts of calcium and can be selected by women who do not eat dairy products. Pregnant women should consume at least four servings of calcium-rich foods a day, or the equivalent of one quart of milk. Although pregnant women may consume more dairy products, they often do not meet their calcium needs through food sources alone. The NAS/IOM recommends calcium supplementation for pregnant women who consume only one serving of calcium-rich food a day. Calcium supplements are utilized best when taken at mealtime. Iron The iron requirement doubles during pregnancy, from 15 to 30 mg/day. Additional iron is needed as a result of increased maternal blood volume. The fetus also stores enough iron to last through the first few months of life. Pregnant women need to know which foods are iron-rich and to be encouraged to consume them regularly. Liver and red meat are particularly rich in iron. Other meats, fish and poultry are also good sources of iron. Enriched and whole grain breads and cereals, green leafy vegetables, legumes, eggs and dried fruit also provide iron. The iron in fruit, vegetables, cereals and eggs is not absorbed as efficiently as iron from meat, fish and poultry. Iron absorption from these nonflesh foods is enhanced when consumed with foods high in vitamin C, such as orange juice, or served with meat, fish or poultry. A well-balanced diet provides women with a maximum of 12-14 mg. of iron. As a result, maternal iron stores are often tapped to meet the demands of pregnancy. Since many women enter pregnancy with low iron reserves, they risk developing anemia. The NAS/IOM recommends routine supplementation of ferrous iron for pregnant women at a level of 30 mg/day during the second and third trimesters. Most prenatal supplements supply this dosage. Iron supplements are absorbed best when taken between meals, with liquids other than milk, coffee or tea. Taking them at bedtime often reduces problems of gastric irritation. Folic acid Because of its important role in cell development, pregnant women need more than twice the amount of folic acid (a water-soluble vitamin) than nonpregnant women. Research suggests that folic acid supplementation during the weeks leading up to and following conception may help prevent neural tube defects, like spina bifida, in newborns. A study conducted in the United Kingdom associated folic acid supplementation with reduced incidence of neural tube defects in newborns of mothers who had previously given birth to infants with this defect. Studies conducted in the United States have been less conclusive but the observation warrants additional investigation. A report from the U.S. Public Health Service recommends that women with histories of pregnancies involving neural tube defects be informed that folic acid supplementation may be protective in subsequent pregnancies. However, the NAS/IOM does not recommend routine folic acid supplementation by women considering pregnancy. The NAS/IOM does recommend modest supplementation, 300 mcg/day, for pregnant women who are abusers of alcohol, cigarettes or drugs, or who have malabsorption syndromes. The NAS/IOM also recommends supplementation for women who are unable to consume enough folic acid through dietary sources. Women planning to conceive and pregnant women should try to consume more foods rich in folic acid. Liver, deep-green leafy vegetables, legumes (lima beans, black beans, black-eyed peas, etc.), lean beef, veal, oranges, and whole-grain breads and cereals are good sources of folic acid. Adequate amounts of folic acid for pregnancy will be consumed when liberal quantities of fruits and vegetables are included in a well- balanced diet. By eating a variety of foods from all the major food groups, most pregnant women can meet their nutrient requirements and those of their growing fetus. Common Questions and Answers Is it necessary to take a vitamin/mineral supplement during pregnancy? Pregnant women who eat a balanced diet, including a variety of foods in the recommended amounts, should be able to meet their requirements for most nutrients, except iron, through foods. A 1990 NAS/IOM report stated, "Evidence is not sufficient to conclude that routine supplementation with other nutrients is warranted, although clearly there are situations requiring special consideration." Yet, this recommendation has been challenged by some who believe that routine supplementation should be prescribed as a preventive measure. The NAS/IOM recommends supplements for women who are vegetarians, smoke cigarettes, drink alcoholic beverages, use illicit drugs or are carrying twins. Supplementation should begin at the start of the second trimester at the following levels: Iron 30 milligrams (mg) Vitamin C 0 mg Zinc 15 mg Folic Acid 300 micrograms (mcg) Copper 2 mg Vitamin B6 2 mg Calcium 250 mg Vitamin D 5 mcg Source: Nutrition During Pregnancy. National Academy Press, 1990. Strict vegetarians should receive additional daily amounts of 10 mcg vitamin D, and 2 mcg vitamin Bl2, according to the NAS/IOM report. Because excessive levels of vitamin A can be toxic to the fetus and adequate levels are available through a balanced diet, vitamin A supplementation is not recommended during pregnancy. There is no evidence that vitamin B6 supplementation is an effective treatment for morning sickness. Is it safe to consume low-calorie sweeteners during pregnancy? Currently, there are three low-calorie sweeteners approved for use in foods and as table top sweeteners: aspartame, saccharin and acesulfame K. Aspartame consists of two amino acids, aspartic acid and phenylalanine as the methyl ester, the basic building blocks of protein. Aspartame has been extensively studied and all reports indicate that aspartame use during pregnancy is safe for the mother and fetus, except for women who have phenylketonuria (PKU) and must restrict their intake of phenylalanine from all sources. Studies show that PKU heterozygote pregnant women (those who carry the PKU gene but do not have the disease themselves) metabolize aspartame sufficiently to protect the fetus from abnormal phenylalanine levels. The Food and Drug Administration has approved aspartame as a safe food ingredient for the general population, including pregnant women. A task force of the American Academy of Pediatrics Committee on Nutrition also concluded that aspartame is safe for both the mother and developing baby. Saccharin is not metabolized and passes through the digestive tract unchanged. Although saccharin can cross the placenta, there is no evidence that it is harmful to the fetus. Both The American Dietetic Association and the American Diabetes Association recommend saccharin be used in moderation during pregnancy. Acesulfame K is not metabolized and is excreted unchanged by the kidneys. Reproduction and teratology studies in animals have shown no toxic effect due to acesulfame K. Low-calorie sweeteners can be useful to pregnant women who have diabetes, who need to control caloric intake or who enjoy the taste of products containing sweeteners. Yet pregnancy is a period of increased caloric need when most women need to consume more rather than fewer calories, so caloric restriction usually is discouraged. Do food cravings indicate nutritional deficiency? No. Food cravings and aversions to certain foods are common during pregnancy. There is no evidence that food cravings are the result of nutrient deficiencies, and their cause remains a mystery. There is no harm in satisfying food cravings within reason, especially when they make a nutritional contribution to the diet. Some pregnant women have the urge to eat nonfood substances, like laundry starch or clay. Known as pica, the consumption of nonfood items is not safe. The etiology of pica has been speculated to be psychological, cultural or even physiological. In some cases pica may be practiced in an effort to relieve nausea. It has been suggested that pica is a sign of anemia, but it appears that anemia may be a result rather than a cause of pica. Women at high-risk of practicing pica are likely to live in rural areas and have a childhood or family history of pica. The practice should be discouraged. In some cases it involves consumption of large amounts of nonfood items that displaces foods and interferes with adequate nutrient intake. Is moderate caffeine consumption safe? Major studies over the last decade have found no association between birth defects and caffeine consumption. Even offspring of the heaviest coffee drinkers were not found to be at higher risk of birth defects. Evidence from other human studies also supports the conclusion that moderate consumption of caffeine by pregnant women does not predispose the mother to spontaneous abortion or preterm delivery. While many studies show no relationship between birth weight and caffeine consumption, some studies suggest that drinking more than two or three cups of coffee daily (approximately eight cups of tea or nine cans of caffeinated soft drinks) increases the chances of low birth weight. The Food and Drug Administration has stated that, "there is insufficient evidence to conclude that caffeine adversely affects the reproduction in humans." As with all foods, pregnant women should apply the principle of moderation to caffeine consumption and discuss it with their personal physician. A reasonable guideline for daily intake is around 300 mg. The opposite chart provides the approximate caffeine content of various foods and beverages. Caffeine Content of Food and Beverages Milligrams of Caffeine Item Average Range Coffee (5-oz. cup) Brewed, drip method 115 60-180 Brewed, percolator 80 40-170 Instant 65 30-120 Decaffeinated, brewed 3 2-5 Decaffeinated, instant 2 1-5 Tea (5-oz. cup) Brewed, major U.S. brands 40 20-90 Brewed, imported brands 60 5-110 Instant 30 25-50 Iced (12-oz. glass) 70 67-76 Some soft drinks (6 oz.) 18 15-30 Cocoa beverages 4 2-20 Chocolate milk beverages (8 oz.) 5 2-7 Milk chocolate (1 oz.) 6 1-15 Dark chocolate semi-sweet (1 oz.) 20 5-35 Baker's chocolate (1 oz.) 26 26 Chocolate-flavored syrup (1 oz.) 4 4 Source: U.S. Food and Drug Administration and National Soft Drink Association Should sodium intake be restricted during pregnancy? No. In fact, sodium requirements increase during pregnancy. But, the sodium provided by the average diet is likely to be adequate for expectant mothers. Use of additional salt is rarely warranted. At one time, salt was routinely restricted during pregnancy in an effort to reduce the incidence of toxemia (a condition characterized by a combination of symptoms including hypertension, fluid retention and protein in the urine). But there is no evidence that sodium restriction prevents or alleviates toxemia. Excessive sodium intake does contribute to high blood pressure in some people. Women who have been advised to limit sodium before becoming pregnant should continue this practice until they discuss it with their doctors. Can morning sickness and other forms of GI distress be relieved? Although some expectant mothers may never experience it, morning sickness is common, and it does not necessarily occur only in the morning. Feelings of nausea may be relieved by eating low-fat, high- carbohydrate foods like dry toast, plain crackers or cereal. Some women have such severe cases of nausea and vomiting that they cannot stand even the thought of food. Soft drinks, popsicles or hard candy may be agreeable and will supply fluid and a few calories. Small, frequent meals tend to be tolerated better than large ones during periods of nausea. Fluids often are better tolerated between meals rather than with them. Constipation also can be a problem and may partially result from decreased intestinal motility, characteristic of the second and third trimesters. Foods high in fiber, such as fresh fruits and vegetables and whole grain breads and cereals can help alleviate constipation. Liberal consumption of fluids and a regular pattern of moderate exercise also can be helpful. Is it safe to have an occasional cocktail, beer or glass of wine? Because the effects of occasional alcohol consumption during pregnancy are unknown, most health authorities recommend not drinking alcohol during pregnancy. There are no data that support a safe level of alcohol consumption during pregnancy. As a result, the consensus is to recommend abstinence. Some women are concerned about having consumed moderate amounts of alcohol soon after conception, before having become aware of the pregnancy. Small amounts of alcohol consumed during a limited period of time should not be a cause of concern. Habitual alcohol consumption does affect the developing infant. Studies show that pregnant women who drink one to two drinks a day tend to give birth to smaller babies. Women who use excessive alcohol during pregnancy are at greater risk of giving birth to babies with fetal alcohol effects (FAE) or the more serious fetal alcohol syndrome (FAS). Characterized by growth retardation, facial and heart malformations, small head size and mental deficiency, FAS affects about 40 percent of babies born to women who drink heavily throughout pregnancy. FAE are more common and variable, including growth retardation, mild behavioral and intellectual impairments or learning disabilities and minor malformations. Conclusion Because many pregnant women are particularly receptive, pregnancy presents a good opportunity for nutrition education. The basic principles of good nutrition D balance, variety and moderation D should be encouraged during pregnancy and as lifetime habits. Clients should be counseled to enjoy a variety of nutrient-rich foods for their own good health and the health of their unborn children. References American Academy of Pediatrics, Committee on Nutrition. Final Report, Task Force on the Dietary Management of Metabolic Disorders, 1985 Council on Scientific Affairs. Saccharin, review of safety issues. JAMA 254: 2622, 1985. Halmesmaki, E. Raivio, K.O., and Ylikorkala 0. Patterns of alcohol consumption during pregnancy. J Ob Gyn 69:594-497, 1987. Institute of Medicine. Nutrition During Pregnancy: Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990. Kaufman, M. et al. Maternal Nutrition: Contemporary Approaches to Interdisciplinary Care. White Plains, NY: The March of Dimes Birth Defects Foundation, 1988. Lecos, C. Caffeine jitters: some safety questions remain. FDA Consumer. 21:22-27, Dec. 1987/Jan. 1988 Leviton, A. Caffeine consumption and the risk of reproductive hazards. J Repro Med., 33:175-178, 1988. London, R. Saccharin and aspartame, are they safe to consume during pregnancy? J Repro Med. 33:17-21, 1988. National Research Council. Recommended Dietary Allowances. Washington, D.C.: National Academy Press, 1989. Position of the American Dietetic Association: Appropriate use of nutritive and non-nutritive sweeteners. JADA 87: 1689-1994, 1987. A Report of the Public Health Service Expert Panel on the Content of Prenatal Care. Caring for Our Future: The Content of Prenatal Care. Washington, D.C.: U.S. Department of Health and Human Services, 1989. Winick, M. Nutrition and Pregnancy. White Plains, NY: March of Dimes Birth Defects Foundation, 1986. Worthington-Roberts, BS and Williams, SR. Nutrition During Pregnancy and Lactation, 4th Ed. St. Louis, MO: Times, Mirror, Mosby College Publishing, 1989. March Of Dimes Birth Defects Foundation International Food Information Council Foundation Reprinted from the International Food Information Council Foundation and the March of Dimes Birth Defects Foundation, 1993

Home	The Library Catalogue
Books	Health Links

LinkExchange Member

Free Home Pages at GeoCities