Pregnant Women

Candidate name: Amna Adil
Candidate number: PK 203/0005
Report writing
Topic: Are pregnant women taking enough

Calcium and Vitamin D in their diet?

Are pregnant women taking enough Calcium and Vitamin D in their diet?
i
REPORT WRITING
Topic: Are pregnant women taking enough
Calcium and vitamin D in their diet?
INTRODUCTION:
Pregnancy is critical period for both expecting mother and fetus.
Every pregnant woman desires to produce a healthy baby. There is a popular
saying that a pregnant women should "eat for two”, it means that her diet
should provide sufficient nutrients to cope with the demands for the
growing baby as well as the needs of her own body. Her physical health,
socio-economic conditions and eating habits can have a far reacting affect
on the life of the baby.
Calcium and vitamin D play a very important role during
pregnancy. They are responsible for the formation of bone structure and
cartilages of the fetus. It promotes adequate mineralization of the fetal
skeleton and teeth and the health of the mother. Most calcium is required
during the 3rd trimester when the skeletal bones are growing most rapidly
and teeth are forming.
The study will mainly focus on the intake of calcium and vitamin D of
the low income pregnant women between the ages of 25 to 40 years. As
Pakistan is a developing country so there is a high ratio of low income group.
The reason for choosing this specific income group is that deficiency of
calcium and vitamin D is quite prevalent among these women. There is a high
social economic disparity prevailing here. The low food budget and less
awareness regarding balanced healthy diet for pregnant women ultimately
affect their eating habits. This may results in low birth weight and
osteoporosis in these young women. In developing country like Pakistan most
of the low income pregnant women it is difficult to spend large amount on
food for themselves, hence, an unbalanced nutrionally inferior diet is eaten,
containing insufficient amounts of nutrients especially calcium and vitamin d
to meet the needs of pregnant women. This leads to a high deficiency of
calcium rich foods thus resulting incidence of low birth weight and softening
of bones and it includes osteomalacia in women. This deficiency may have
long-term consequences for the growth and development of themselves and
for their children.
ii
Reason for taking up this topic was to have an interaction with
pregnant women of limited income group and to identify their problems
regarding balance diet. As calcium and vitamin d are very important minerals
during pregnancy this will give me an opportunity to observe the affects of
limited intake of calcium rich foods on this group of women. I am looking
forward to the field work which will include interview, observation and study
of the effect of calcium and vitamin D on this very special time in the life of
a woman.
AIMS AND OBJECTIVES

• Asses the amount of calcium rich foods in pregnant women.
• Asses the amount of vitamin d rich foods in pregnant women.
• Identification of calcium and vitamin d rich foods locally available.
• To observe signs and symptoms of calcium and vitamin d deficiency in
pregnant women.
• Study the reasons for social problems faced by these women and
sufficient or insufficient calcium and vitamin D intake affect on diet.
• Problems and risk for the developing baby.
• Suggested dishes providing calcium and vitamin d in a meal to low
income women.
• identification locally available sources of calcium and vitamin d
• Suggest preventive measures to reduce the chances of calcium and
vitamin d deficiency.
• What do they eat daily?
LIMITATIONS
• Survey carried out on low income families only.
• only a selected number of pregnant women will be considered i.e. 10-15
• women having their 1st or 2nd child will be selected
• women should be in last trimester of pregnancy
• only a specific age group i.e. 25-40 are taken into consideration
PLANNING
• Information will be gathered from internet and available books.
• questionnaires will be made to record the calcium and vitamin d intake
of low income women
iii
• the calcium and vitamin d content in the diet of low income women will
be analyzed using questionnaires and food tables
• Comparing of results will be done with the RDA's to check whether
the calcium and vitamin d intake of low income women is sufficient or
not.
iv
THEORETICAL RESEARCH
CALCIUM
Calcium is the most abundant mineral present in the body almost 40%
of the total mineral mass i.e. 3lb of body’s weight. Majority of calcium
present in bone where, together with phosphorus it plays an essential part in
hardening the skeleton and teeth. In addition, this calcium is a reserve of
the mineral for its role in the body fluids as ionic calcium, which is essential
for many functions.
• BLOOD CLOTTING
One of the most important and vital function of calcium is blood
clotting. In this process, Calcium ions participate in several reactions in the
cascade that leads to formation of fibrin, the main protein component of a
blood clot. The conversion of prothrombin to thrombin requires calcium,
without sufficient calcium in the blood clots will not form. Clotting is very
important in labor and delivery.
• TRANSMISSION OF NERVE IMPULSES

When an impulse reaches its target site, such as a muscle,
other nerve cells or a gland, the impulse is transmitted across the junction
between the nerve and its target cells. In many nerves, arrival of action
potentials at the target site stimulates an influx of calcium ions into the
nerve from the extra cellular medium. The rise in intra cellular calcium ions
then triggers release of neurotransmitter, which are responsible for
carrying impulses to the target cells. Calcium also may influence the flow of
other ions in and out of nerve cells.
• MUSCLE CONTRACTION
The critical role of calcium in muscle contraction is most easily
understood in the case of skeletal muscles. When a skeletal muscle is
stimulated by a nerve impulse from the brain, calcium ions are released from
v
Intracellular store with in the muscle cells. The resulting increase in the
concentration of calcium ions in a muscle cell is one factor, along with ATP,
that permits the contractile proteins, actin and myosin, to interact. This
leads to muscle contraction.
• CELL METABOLISM
Finally, calcium ions help regulate metabolism in the cell by
participating in calmodulin, i.e., a cell protein that binds calcium ion, system.
When calcium enters a cell (because of hormone action) and bonds to the
protein calmodulin, the resulting protein-calcium complex regulate the
activity for enzymes that synthesis glycogen.
Calcium also support and feed the perineal muscles to make
them supple for dilation at delivery. Calcium will help to prevent and minimize
stretch marks, although stretch marks tend to be more of a hereditary
situation.
Calcium helps in the process of secretion of fluids e.g. Bile, pancreatic
fluid, gastric, intestinal, hormonal, mucous all rely on calcium to move the
small droplets through the cells boundaries, and cell walls. It maintains the
balance of proteins in the body by AMP (adenosine monophosphate) and helps
to control cholesterol.
VITAMIN D
For years vitamin D was thought to have one primary function in
the body, namely to help regulate blood calcium. Calcitriol, the active
hormone form of vitamin D, increases calcium and phosphorus absorption in
the small intestine by the means of two separate mechanisms. In one
process, calcitriol travels into the nucleus of intestinal cells and binds to
specific nuclear receptor on DNA, there by stimulating synthesis of a
variety of calcium transport proteins. These proteins increase calcium and
phosphorus absorption from the small intestine since they form a specific
calcium carrier. In the other process, calcitriol likely alters the membranes
of intestinal cells, allowing more passive calcium absorption into the
intestinal cells. Since calcitriol treatment increases calcium absorption even
before the calcium transport protein appear in the cell, this second
mechanism is probably partially responsible for enhanced calcium absorption.
When blood calcium is low, the parathyroid gland releases parathyroid
hormone, which acts to stimulate synthesis of calcitriol in the kidneys. The
vi
calcitriol then interacts with cells in the small intestine, and with specific
bone and kidney cells. In the intestinal cells, calcitriol promotes calcium
absorption. In the bone-reabsorbing cells, called osteoclasts, calcitriol and
parathyroid hormone stimulate the release of bone calcium to the blood. In
the kidneys, calcitriol and parathyroid hormone prevent calcium loss via the
urine. Together, these three functions, i.e., increase absorption of calcium
and phosphorus from small intestine; reduces calcium excretion by the
kidneys; and it indirectly helps regulate calcium deposition in the bones.
DEFICIENCY DISEASES
RICKETS
Without adequate calcium and phosphorus deposition, the skeleton
fails to mineralize properly and bones weaken and bow under pressure. When
these effects occur in a child, the disease is called rickets. Signs of rickets
include enlarged head, joints, and rib cage, a deformed pelvis and bowed legs.
, the problem is likely to worsen during pregnancy because of the active
transplacental transport of calcium to the developing fetus. Hypovitaminosis
D during pregnancy has important consequences for the newborn, including
fetal Hypovitaminosis D, neonatal rickets and tetany, and infantile rickets.
vii
OSTEOMALACIA
Rickets in adults is called osteomalacia, which means “soft bones”. It
occurs most often in women who have low calcium intake and little exposure
to sunlight and who go through repeated pregnancies and periods of
lactation. The leg bones may soften to such an extent that a young women
who is tall and straight at 20 may become bend, bowed legged and stooped
before she is 30. It can cause fractures in the hip, spine, and other bones.
OSTEOPOROSIS
Osteoporosis, which means “porous bones”, is at epidemic
proportions particularly in women after the menopause. It is a painful and
potentially crippling disease, which is due to the loss of calcium in the bones.
By the age of fifty up to 25 per cent of the skeleton could be missing due to
Osteoporosis. This can increase the risk of bone fractures, loss of height
and formation of a “dowager’s hump” all due to the soft and thinning bones.
Osteoporosis can be further classified as type 1 (postmenopausal), which
appears in the years right after menopause, and type 2 (senile), which is
found in people of advances ages.
In osteomalacia, the bone is abnormal because it contains too little
calcium. In contrast, bone composition in osteoporosis is essentially normal.
viii
The bone may contain some extra sodium ions, but there is just less bone
throughout the body. Because these bones have less substance, osteoporosis
can lead to fractures in old age, distorted body shape, and loss of teeth.
Factors contributing to the development of osteoporosis could include the

following:
• Vitamin D Deficiency-lack of Vitamin D decreases the bones’

absorption of calcium.
• Estrogen Deficiency-without estrogen, bones demineralization
accelerates in women.
• Inactivity-weight bearing exercise is necessary to stimulate bone
strengthening. A lack of exercise may contribute to a loss of bone
calcium.
• Gender-women are at a greater risk than men are.
• Heredity-if the disease runs in your family—mother or grandmother.
• Race-Caucasian and Asian women are most at risk for the disease, but
African American and Hispanic women can get it too.
• Figure type-women with small bones and those who are thin are more
liable to have osteoporosis.
• Early menopause-women that stop menstruating early because of
heredity, surgery or lots of physical exercise may lose large amounts
of bone tissue early in life. Conditions such as anorexia and bulimia
may also lead to early menopause and osteoporosis.
• Diet-people who do not get enough calcium or protein may be more
likely to have osteoporosis. People who constantly diet are more prone
to the disease
ix
FOOD SOURCES
CALCIUM
Dairy products, such as milk and yoghurt are major source of
calcium in Pakistani diets, people over here does not consume much cheese.
x
To get a good daily intake of calcium diet choices are important. At least
three servings a day of dairy products is essential to maintaining good
calcium levels. Okra is another great calcium source. Today many products,
like orange juice, have calcium added. Making simple choices when buying
foods with added calcium can help you to get enough calcium daily. Wheat
cereals and some vegetables like spinach also provide calcium but these are
not good sources because calcium and many other nutrients are not fully
absorbed due to NSP (fiber) and acids present in cereals and vegetables.
Omega 3 and 6 fatty acids that are found in fish oil and evening
primrose oil if taken in large doses increase the absorption of calcium from
the gut like vitamin D does. Not only do they increase calcium absorption but
they also reduce calcium loss in the urine. PUFAs prevent the abnormal
deposition of calcium in soft tissue and increase calcium levels in bones.
PUFAs can help with the bone loss at menopause.
VITAMIN D
The most nutrient dense sources of vitamin D are fatty fish e.g.
sardines and salmon, fortified milk, and some fortified breakfast cereals.
Although eggs, butter, liver and a few brands of margarine contain some
vitamin D but large servings should be eaten to obtain appreciable amount of
the vitamin. But the main source of vitamin D is sunlight which is a non food
source which converts a natural substance i.e. ergosterol in the skin to
active form of vitamin D. body should be exposed to sunlight daily for the
formation of vitamin D.
xi
CALCIUM AND VITAMIN D REQUIREMENT DURING

PREGNANCY
In females, skeleton growth continues until approximately age
20, but the bone mineral content may accure until age of 35. Calcium is a
nutrient central to this process. During pregnancy, calcium nutrition may be
especially important for women’s own bone health and that of their babies.
During a full term pregnancy, the fetus takes approximately 30g calcium
from the mother, which may occur at the expense of mother’s bone, if
calcium intake is insufficient. In addition, women who consume more calcium
and vitamin D during pregnancy may have higher levels of calcium in their
breast milk, and babies born to women with higher calcium intake may have
better bone mineralization and lower blood pressure in later life, though this
may or may not be a causal association.
Calcium supplements have shown to protect against pre-eclampsia
i.e. high blood pressure in pregnancy. It is a good idea to increase calcium
consumption during the last 3 months of pregnancy and the first few months
of lactation to ensure that the body get sufficient amount of calcium to help
bone development and growth. In pregnant women, calcium intake is also
important. Baby needs calcium to grow and takes this calcium from the
mother. So increased calcium intake is important during pregnancy. Pregnant
and breast feeding mother should get 1,400mg a day and older adults should
have 1,500mg a day. It is very difficult to take too much calcium and intakes
xii
of up to 2,500mg have proven safe. Excess calcium is easily removed form
the body through waste.
SUPPLEMENTS
Calcium supplements have shown to protect against pre-eclampsia
which is high blood pressure in pregnancy. Supplements can also be part of a
woman's health and nutrition program; however, certain precautions need to
be identified. Associated with the taking of calcium supplements may be the
development of kidney stones or distress experienced in the digestive
system. Therefore, in considering taking these calcium supplements, it is
important to consult with your physician. It is important to remember that
when taking calcium supplements the daily-recommended dose should be
adhered
No woman should take extra vitamin D in pregnancy unless recommended
by their doctor
Professor James Walker
Royal College of Obstetricians
xiii
CONCLUSION
A survey was conducted on pregnant women, who were in their last

trimester. Their ages ranged between 24-40 years. And they belonged to
lower middle class families, their total house hold income ranged from 8000
to 30000 rupees. The international standard for weight gain in pregnancy is
15 to 17 kg. But as Pakistan is a developing country they are not much aware
of their nutritional needs, thus resulting in less food intake so weight gain
standard in Pakistan is 10-12 kg. The survey showed that 67% of the
pregnant women were underweight compared to their height, age and weight.
During pregnancy requirements for calcium and vitamin D
increases many folds. Calcium is required by both mother and the fetus.
44%of the pregnant women were not consuming milk on daily basis and in one
case it was one or two glasses of milk per week. The average intake of milk
was 1 glass per day. 40% of expecting mothers were taking carton milk but
33% had fresh milk intake. Only 27%were dependent on dried powdered milk
as it was an expensive source. They were taking many milk dishes e.g. kheer,
firni, custard, vermicelli, gajraila (local dish) etc and milk shakes e.g. milk
soda, fruit shakes and lassi. Most of them were taking these once a week but
in one case it was once in a month.
The most popular dairy product among pregnant women was
yoghurt and mostly it was taken as a part of meal as raita or lassi. Cheese
was not a major source of calcium in their diet as it is not easy to keep in hot
summer climate. Only 1 out of 12 women had lactose intolerance so she was
not consuming milk on daily basis.
Those who took 1 glass of milk daily and were not careful
about their dairy intake they mentioned problems like pains in different
parts of body e.g. back ache, head ache, pain in joints etc. It was observed
that these pregnant women were not dependent on food sources for calcium
and vitamin D intake but preferred supplements as their source. The
supplements which they were taking were Cal-1000 tablets, VC-Cal tablets,
Oslate tablets and Qalsan tablets.
Therefore the survey conducted revealed that very
few pregnant women had nutritional knowledge about their dietary needs.
They had many social and economic problems which main reason for their
less intake of nutritious diet. As they live in a male dominant society,
husbands and male members of the family are given priority in every aspect,
xiv
especially food. Thus the women have to eat left over food whether they are
pregnant, lactating or ill. Survey also showed that they were consuming more
of fatty food instead of high protein, calcium or carbohydrate diet. They
had a misconception that fatty food is best for the developing baby. Fatty
foods e.g. butter and highly saturated ghee was a part of their every meal.
Exposure to sunlight
7
6
5
4
3
2
1
0
Women who Women who do
Expose Not expose
Themselves to Themselves to
Sunlight Sunlight
xv
types of milk consumed by

pregnant women
fresh milk
carton milk
dry milk
weight of pregnant women
0%
42%
58%
Pink color = under weight

Purple color = normal weight
xvi
back ache and arthritis pains in

pregnant women
do not suffer from any

number of
women
pains
do suffer from back

ache and arthritis
0 2 4 6 8
likness and dislikness of milk

among pregnant women
70%
60%
percentages
50%
40%
30%
20%
10%
0%
women who like women who dislike
milk milk
xvii
Pictures taken of pregnant women during the visit to Atchison hospital
xviii
xix
xx
xxi
xxii
EVALUATION
The main aim of this report was to assess the deficiency of calcium and
vitamin d in pregnant women. The survey showed that the women of this
selected group were severely deficient in these nutrients. Recommended
Daily Intake is 3-4 servings of milk and milk products but due to their lack
of awareness and economic problems they were not consuming it. Mostly the
women of this age group were unaware of their dietary needs.
The survey was conducted in a Government Lady Aitchison
hospital, Lahore and the gynecologist was Dr.Naghmana Bashir. I came
across many pregnant women and was able to directly interact with them and
understand what they were going through. It was heart warming experience
to see a life being generated from a life. I was surprised to find that
pregnant women were deficient not even in Calcium and Vitamin D but in
many other essential nutrients as well. They were facing so many problems.
As we are living in male dominating society, so male members of the members
are given priority over females in every aspect of life. Food is first served
to the male members and the left over is given to the females even if they r
pregnant or lactating.
Not only in food, in education as well lower class do not
educate their daughters because they think it’s a waste of money as they
just have to give birth and care for in laws. There are several taboos that
pregnant women should not eat fish, which is a rich source of vitamin d,
because it may harm the baby. Pregnant women are advised to consume more
of fatty foods in every meal because they think it will make the baby
healthy and ease in delivery.
My diary of activities started from February, I planned it but my
diary of activities did not go well in time. As Pakistan is a developing country,
So our government does not have health counseling or health benefits for
the low income class who can not afford private hospitals. Governments
should make education compulsory on every one whether a boy or a girl.
Government should increase the health standards and medical facilities in
government hospitals. Awareness should be given through media; different
programs should be launched or presented on women’s health and needs.
Seminars should be held in hospitals for doctors to discuss new ways to give
awareness to pregnant women.
xxiii
I gained many personal benefits. I gained confidence, my
conversation skills improved from this survey. I learned to operate blood
pressure apparatus. I became proficient at using Microsoft Word, Microsoft
Excel and picture manager. Over all it was a highly learning experience.
xxiv
BIBLIOGRAPHY
References from web sites

• www.aboutcalcium.net/The_Importance_Of_Calcium_In_The_Diet.ht
ml - 18k
• www.zimbio.com/Pregnancy+And+Birth/articles/33/IMPORTANCE+CA
LCIUM+MAGNESIUM
• www.aboutcalcium.ne
• www.osteoporosis.org.au/files/internal/oa_calcvitd_pharma.pdf
• www.sonoma-
county.org/health/ph/mchfieldnursing/pregnancy_pyramid.htm
• www.news.bbc.co.uk/1/hi/health/4584518.stm - 33k
• www.womenshealthprognosis.com/womens-health-and-nutrition.html -
14k -
References from books

• Barasi, Mary E, Human Nutrition 2nd Edition, Hodder Arnold
Publishers, London.
• Robinson, Corinne H and Lawler, Marilyn R, Normal and Therapeutic
Nutrition 7th edition, Macmillan Publishers, New York.
• Wardlaw, Gordon M Insel, Paul M, Perspectives in Nutrition 3rd
Edition, Mosby Publishers, London.
• Whitney, Eleanor Noss and Rolfes, Sharon Rady, Understanding
Nutrition 9th Edition, Wadsworth publishers, New York.
xxv
SAMPLE QUESTIONNAIRE
1. Age
2. height
3. weight
4. pregnancy stage(month)
5. income
A) Less than 10000 b) 10000 c) 20000 d) 30000
6. Do you consume milk daily?

a) Yes b) no
7. How many glasses of milk you consume everyday?

a) 1 b) 2 c) 3 d) per week
8. What type of milk you are consuming?

a) Fresh milk b) dry milk c) carton milk
9. Identify other milk products in your diet?

a) Cheese b) yoghurt
10. Do you have any problem in digesting milk or milk products?

a) Yes b) no
11. Identify milk dishes you consume?
12. How much of these do you take per week?

xxvi
13. Do you take calcium and vitamin D supplements?

a) Yes b) no
14. Name it?
15. Do you suffer from any backache?

a) Yes b) no
16. Do you suffer from any pain in joints?

a) Yes b) no
17. Do you expose your body to sunlight?

a) Yes b) no
xxvii

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Candidate name: Amna Adil

Candidate number: PK 203/0005

Topic: Are pregnant women taking enough

Candidate name: Amna Adil

AIMS AND OBJECTIVES

• TRANSMISSION OF NERVE IMPULSES

Factors contributing to the development of osteoporosis could include the

• Vitamin D Deficiency-lack of Vitamin D decreases the bones’

CALCIUM AND VITAMIN D REQUIREMENT DURING

A survey was conducted on pregnant women, who were in their last

types of milk consumed by

weight of pregnant women

Pink color = under weight

back ache and arthritis pains in

do not suffer from any

do suffer from back

likness and dislikness of milk

Pictures taken of pregnant women during the visit to Atchison hospital

References from web sites

References from books

6. Do you consume milk daily?

7. How many glasses of milk you consume everyday?

8. What type of milk you are consuming?

9. Identify other milk products in your diet?

10. Do you have any problem in digesting milk or milk products?

11. Identify milk dishes you consume?

12. How much of these do you take per week?

13. Do you take calcium and vitamin D supplements?

14. Name it?

15. Do you suffer from any backache?

16. Do you suffer from any pain in joints?

17. Do you expose your body to sunlight?

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