C.

NUTRITIONAL NEEDS AND RECOMMENDATIONS FOR PREGNANCY

I. Energy (Calorie) Needs

        The DRI of calories for women of childbearing age is 2200. An
additional 300 calories, or total caloric intake of 2500 calories, is
recommended to meet the increased needs of pregnancy. In addition to
supplying energy for a fetus, this increase provides calories to sustain an
elevated metabolic rate in the woman from increased thyroid function and
an increased workload from the extra weight she must carry. 
An inadequate intake of carbohydrates can lead to protein
breakdown for energy, depriving a fetus of essential protein, and possibly
resulting in ketoacidosis, a possible cause of fetal and neurologic
disorders. Advise women to obtain calories from complex carbohydrates
(cereals and grains) rather than simple carbohydrates (sugar and fruits)
because these are more slowly digested so help regulate glucose and
insulin levels. Do not recommend sugar substitutes for women during
pregnancy, because a pregnant woman needs sugar to maintain glucose
levels. Even obese women should never consume fewer than 1500
calories per day. When helping a woman plan an increased caloric intake,
consider her lifestyle. 
For example, many women commonly skip meals, have erratic
eating patterns, or rely on fast and convenience foods. For pregnancy, a
woman needs to add calories by eating foods rich in protein, iron, and
other essential nutrients rather than eating more fast-food, empty-calorie
foods such as pretzels and doughnuts. 
Suggest preparing snacks such as carrot sticks or cheese and
crackers early in the day when fatigue is usually less, keeping them
readily available in the refrigerator. Otherwise, later in the day when she is
tired, a woman may snack on empty-calorie foods simply because they
require no preparation. 
The easiest method for determining if a woman’s caloric intake is
adequate is assessing the weight she is gaining. Keep in mind that the
weight gain pattern is as important as the total weight gain. Even if a
woman has surpassed her target weight before the end of the third
trimester, encourage her not to restrict her caloric intake. She should
continue to gain weight because a fetus grows rapidly during these final
weeks.

II. Protein Needs

              The DRI for protein in women is 46 g/d. During pregnancy, the
need for protein increases to 71 g daily. If protein needs are met, overall
nutritional needs are likely to be met as well with the possible exceptions
of vitamins C, A, and D) because of the high incorporation of other
nutrients with protein foods. If protein intake is inadequate, iron, B
vitamins, calcium, and phosphorus also will probably be inadequate.
Vitamin B12 is found almost exclusively in animal protein, so if animal
 protein is excluded from the diet, vitamin B12 deficiency can occur unless
this is supplemented. 
Extra protein is best supplied by meat, poultry, fish, yogurt, eggs,
and milk, because the protein in these forms contains all nine essential
amino acids, or is a complete protein. The protein in nonanimal sources
does not contain all essential amino acids (and so is incomplete protein). It
is possible to provide all amino acids by combining nonanimal proteins.
Proteins that when cooked together provide all essential amino acids are
termed complementary proteins. Examples are beans and rice, legumes
and rice, or beans and wheat. A woman with a family history of high
cholesterol levels (hypercholesterolemia) probably should not eat more
than two or three eggs per week because of the high cholesterol content
of eggs. 
Encourage such women to eat lean meat, to cook with olive oil
instead of lard or butter, and to remove the skin from poultry to reduce its
fat content. She also should not eat lunch meats such as bologna or
salami as food staples, because their protein content may not be high and
their fat content is invariably exceptionally high. 
Milk is a rich source of protein. Unfortunately, some women resist
drinking it because it can be high in calories as well as fat. Others cannot
drink it because of lactose intolerance. Some women find it difficult to
drink a quart of milk a day because they simply do not like its taste. 
Nonfat milk supplies the same protein and half the calories as
regular milk and is very low in fat. Buttermilk can be substituted, although
it contains a large amount of sodium, or chocolate or another flavoring can
be added to make milk palatable. Yogurt or cheese may also be
substituted for milk, or milk may be incorporated into custards, eggnogs,
or cream soups. Women who are lactose intolerant can add a lactase
supplement, buy lactose-free milk, or take a calcium supplement
(Bauchner, 2007).

PROTEIN SOURCES
-meat
- poultry
- fish
- yogurt
- eggs
- milk
III. Fat Needs
         Only linoleic acid, an essential fatty acid necessary for new cell
growth, cannot be manufactured in the body from other sources. Because
 linoleic acid must be obtained from food, women must be sure to consume
a source of this nutrient during pregnancy. 
Vegetable oils are a good source. In addition, using vegetable oils
(e.g., safflower, corn, olive, peanut, and cottonseed) that have a low
cholesterol content rather than animal oils (butter) is recommended for all
adults as a means of preventing hypercholesterolemia and coronary heart
disease. 
Women should also try and ingest omega-3 oils, found primarily in
fish, omega-3–fortified eggs, and the newer omega-3–fortified spreads
(Bourre, 2007).

FAT SOURCES
-safflower
- corn
- olive
- peanut
-cottonseed

IV. Vitamin Needs

          The intake of vitamins as a daily dietary supplement has become so
common that their importance may be underestimated by some women.
Requirements for both fat-soluble and water-soluble vitamins increase
during pregnancy to support the growth of new fetal cells Vitamin
deficiency can result in several common problems. 
For example, vitamin D, essential for calcium absorption, when
lacking, can begin to diminish both fetal and maternal mineral bone
density. Lack of vitamin A results in tender gums and poor night vision.
For as-yet-unknown reasons, there is an association between multivitamin
supplementation during pregnancy and reduced cancers such as
neuroblastoma, leukemia, and brain tumors in children (Goh et al., 2007).
Although vitamin needs do increase during pregnancy, most of the vitamin
intake requirements (with the exception of folic acid) can be met by eating
a healthy, varied diet with plenty of fruits and vegetables plus daily
prenatal vitamins. 
Women who were taking oral contraceptives before they became
pregnant should be certain to include good sources of vitamins A and B
and folic acid in early pregnancy because oral contraceptives may deplete
stores of these vitamins. Counsel women not to use mineral oil as a
laxative because it can prevent the absorption of fat-soluble vitamins from
the gastrointestinal tract, limiting their availability to the body. If a woman
is housebound, be certain that she is taking a prenatal vitamin containing
vitamin D because she is probably not receiving as much sun exposure as
normally (More, 2007). Commonly, a prenatal vitamin is prescribed during
pregnancy to be certain that pregnant women ingest sufficient vitamins.
Caution women to avoid taking of vitamins. 
 The mechanism of placental transfer of water-soluble vitamins
makes fetal blood levels regularly higher than maternal blood levels, so a
maternal overdosage can cause fetal toxicity. Megadoses of vitamin C
may cause withdrawal scurvy in the infant at birth. The fat-soluble vitamins
are stored in the body rather than excreted and so can reach toxic levels
even more easily. There may be an association between excessive
vitamin A intake and fetal malformation. 
It is well documented that the intake of excessive vitamin A in the
form of isotretinoin (Accutane), a medication prescribed for acne, causes
congenital anomalies(Karch, 2009). Although folic acid (folacin) belongs to
the B-vitamin group, its importance during pregnancy warrants a separate
discussion. Found predominantly in fresh fruits and vegetables, folic acid
is necessary for red blood cell formation. As a woman’s blood volume
doubles during pregnancy, this makes her folic acid needs increase
substantially. Without adequate folic acid, megaloblastic anemia (large but
ineffective red blood cells) may develop. 
If a woman has this blood pattern at the time of birth, the infant may
be affected as well. For this reason, as well as its importance in preventing
neural tube defects, women should eat foods high in folic acids such as
vegetables and fruit and should take a prenatal vitamin that contains a
folic acid supplement of 0.4 to 1.0 mg (Subramanian et al., 2008). When
cautioning women about vitamin use, advise them not to leave prenatal
vitamins within the reach of small children. The excessive folic acid and
iron in them can cause poisoning in small children.

Essential Vitamins Why You Need It: Food Sources:

Vitamin A & Beta Helps bones and teeth grow Liver, milk, eggs,
Carotene carrots, spinach, green
(770 mcg, daily max = and yellow
1000 mcg) vegetables, broccoli,
potatoes, pumpkin,
yellow fruits,
cantaloupe

Vitamin D (5 mcg/600 IU, Helps body use calcium and Milk, fatty fish, sunshine
daily max = 4000 IU) phosphorus; promotes strong
teeth and bones

Vitamin E (15 mg, daily Helps body form and use red Vegetable oil, wheat
max = 1000 mg) blood cells and muscles germ, nuts, spinach,

Vitamin C (80 – 85 mg*, An antioxidant that protects
daily max = 2000 mg) tissues from damage and
helps
body absorb iron; builds a
healthy immune system
Thiamin/B1 (1.4 mg) Raises energy level and
regulates the nervous system
Riboflavin/B2 (1.4 mg) Maintains energy, good
eyesight, healthy skin
Niacin/B3 (18 mg, daily Promotes healthy skin,
max = 35 mg) nerves, and digestion
Pyridoxine/B6 (1.9 mg, Helps form red blood cells;
daily max = 100 mg) helps to reduce morning
sickness
Vitamin B12 (2.6 mcg) An important factor in DNA
fortified cereals
Citrus fruits, bell
peppers, green beans,
strawberries,
papaya, potatoes,
broccoli, tomatoes
Whole grain, fortified
cereals, wheat germ,
organ meats,
eggs, rice, pasta,
berries, nuts, legumes,
pork
Meats, poultry, fish,
dairy products, fortified
cereals,
eggs
High-protein foods,
fortified cereals, and
bread, meats,
fish, milk, eggs,
peanuts
Chicken, fish, liver,
pork, eggs, soybeans,
carrots, cabbage,
cantaloupe, peas,
spinach, wheat germ,
sunflower seeds,
bananas,
beans, broccoli, brown
rice, oats, bran,
peanuts, walnuts
Shellfish, fish, beef,
 synthesis, and may help liver, pork, eggs, dairy,
prevent neural tube defects poultry
(NTDs)

Folic Acid/Folate(400 – Helps support the placenta Oranges, orange juice,

800 mcg†, daily max = and prevents spina bifida and strawberries, green
1000 mcg) other NTDs leafy vegetables,
spinach, beets,
broccoli, cauliflower,
fortified cereals,
peas, pasta, beans,
nuts

Vitamin C (80 – 85 mg*, An antioxidant that protects Citrus fruits, bell

daily max = 2000 mg) tissues from damage and peppers, green beans,
helps strawberries,
body absorb iron; builds a papaya, potatoes,
healthy immune system broccoli, tomatoes

V. Mineral Needs
         Minerals are necessary for new cell building in a fetus. Because they
are found in so many foods and because mineral absorption improves
during pregnancy, mineral deficiency, with the exception of calcium,
iodine, and iron, is rare.

Calcium and Phosphorus. 

The skeleton and teeth constitute a major portion of a fetus. Tooth
formation begins as early as 8 weeks in utero. Bones begin to calcify at 12
weeks. To supply adequate calcium and phosphorus for bone formation,
pregnant women need to eat foods high in calcium and vitamin D
(necessary for calcium to be absorbed from the gastrointestinal tract and
to enter bones). The recommended amount of calcium during pregnancy
is 1300 mg. If a woman cannot drink milk or eat milk products such as
cheese, she can be prescribed a daily calcium supplement. 
Most foods high in protein are also high in phosphorus, so by eating
high-protein foods, women receive enough phosphorus, also important for
bone growth. Before nutrition counseling in pregnancy became common,
women expected to lose “a tooth a child”—that is, they believed a fetus, as
he or she grew, could drain calcium from their teeth. 
Although it is unlikely that a woman will lose a tooth with pregnancy
today, the concern reflected in this myth about a fetus taking calcium from
the mother is well founded. However, the calcium in teeth is not as readily
absorbed as that of bone. It is more likely that inadequate calcium intake
will result in diminished maternal bone density rather than weakened
teeth. With an adequate calcium intake during pregnancy, a fetus will
receive the needed calcium for growth and mineralization of the fetal
skeleton without taking any away from the maternal bones or teeth.

Iodine.
Iodine is essential for the formation of thyroxine and, therefore, for
the proper functioning of the thyroid gland. As thyroid function increases
during pregnancy, a woman needs to ingest enough iodine during
pregnancy to supply this increased need. If iodine deficiency occurs, it can
cause hypothyroidism and thyroid enlargement (goiter) in a woman. In
extreme instances, it can cause the same symptoms in a fetus. 
Thyroid enlargement in a fetus at birth is serious because the
increased pressure of the enlarged gland on the airway could lead to early
respiratory distress. If not discovered at birth, hypothyroidism may lead to
the infant’s being cognitively challenged. 
The DRI for iodine is 220 -g daily during pregnancy. Seafood is the
best source of iodine. In areas where the water and soil are known to be
deficient in iodine such as the Great Lakes area in the United States, it is
suggested that women use iodized salt rather than plain salt to ensure a
healthy iodine intake (Marchioni et al., 2008). Iron. A fetus at term has a
hemoglobin level of 17 to 21 g per 100 mL of blood, a level that is
necessary to oxygenate the blood during intrauterine life. 

Iron
Iron is needed to build this high level of hemoglobin. In addition,
after week 20 of pregnancy, a fetus begins to store iron in the liver to last
through the first 3 months of life, when intake will consist mainly of milk,
typically low in iron. In addition to supplying these high fetal needs, a
woman needs iron to build an increased red cell volume for herself and to
protect against iron lost in blood at birth. 
The DRI for iron for pregnant women is 27 mg. An average diet
supplies about 6 mg of iron per 1000 calories. If a woman eats a 2500-
calorie diet daily, her daily intake, therefore, is about 15 mg iron. Because
only 10% to 20% of dietary iron is absorbed, she is actually taking in less
than this amount (closer to 1.5 to 3 mg). 
Therefore, dietary supplementation with 15 mg iron per day helps
ensure that adequate iron is ingested and absorbed. Stress to women that
iron supplementation is intended as a supplement to, not a replacement
for, iron-rich foods. Women with low incomes may find it difficult to eat
adequate iron-rich foods because the foods richest in iron (e.g., organ
meats; eggs; green, leafy vegetables; whole grains; enriched bread; dried
fruits) are also expensive. Iron absorption increases in an acid
environment, so eating iron-rich foods or swallowing iron pills with
 ascorbic acid (found in orange juice) may increase absorption. Oral iron
compounds turn stools black or blackish green. 
The compounds can be irritating to the stomach or cause
constipation in some women. If this happens, urge women not to stop
taking the iron compound but to always take the iron pills with food and
increase fluid intake or fiber to relieve constipation. Some women may
need a prescribed stool softener such as docusate sodium (Colace); this
stool softener is not associated with teratogenic action, so it can be taken
safely during pregnancy.

      Fluoride. 
Because fluoride aids in the formation of sound teeth, a pregnant
woman should drink fluoridated water. In an area where the water is not
fluoridated either naturally or artificially, supplemental fluoride may be
recommended. Fluoride in large amounts causes brown-stained teeth, so
a woman should not take the supplement more often than prescribed or if
the tap water in her area is already fluoridated. Many women, worried
about added chemicals in their city water supply, switch to bottled water
during pregnancy. If they do this, advise them to buy a fluoridated type or
alert their health care providers that they may need a supplement.

       Sodium
            Sodium is the major electrolyte that acts to maintain fluid in the
body: when sodium is retained rather than excreted by the kidneys, an
equal or balancing amount of fluid is also
retained. Retaining enough fluid during pregnancy in the maternal
circulation is important to ensure a pressure gradient to allow the optimal
exchange of nutrients across the placenta. Unless a woman is
hypertensive or has heart disease with required sodium restriction when
she enters pregnancy, she should continue to add salt to foods as usual
during pregnancy.
However, she should use moderation with foods that are extremely
salty, such as lunch meats or potato chips, or with additive monosodium
glutamate. Too much salt could result in the retention of excessive
amounts of fluid, putting a strain on her heart as blood volume doubles.

      Zinc
Zinc is necessary for the synthesis of DNA and RNA. Although not
proved, zinc deficiency may be associated with preterm birth. The DRI for
zinc during pregnancy is 12 mg or an increase of 3 mg over prepregnancy
needs. Most people who take in adequate protein also take in adequate
zinc because zinc is contained in foods such as meat, liver, eggs, and
seafood. It is also a component of prenatal vitamins to help ensure an
adequate intake (Rolfes, Pinna, & Whitney, 2009).

ZINC SOURCES
 - meat
- liver
                      -eggs
                     -seafood.
    VI. Fluid Needs
Extra amounts of water are needed during pregnancy to promote
kidney function because a woman must excrete waste products for two.
Two or three glasses of fluid daily over and above the three servings of
milk recommended by the food pyramid is a common recommendation
during pregnancy (a total of six to eight glasses daily).

   VII. Fiber Needs

Constipation can occur during pregnancy from slowed peristalsis
because of the pressure of the uterus on the intestine. Eating fiber-rich
foods, foods consisting of parts of the plant cell wall resistant to normal
digestive enzymes such as broccoli and asparagus, are a natural way of
preventing constipation because the bulk of the fiber left in the intestine
aids evacuation. 
Fiber also has the advantage of lowering cholesterol levels and
may remove carcinogenic contaminants from the intestine. Therefore,
encourage women to eat plenty of fresh fruits and vegetables, especially
green, leafy vegetables, to provide fiber. Eating fiber-rich foods this way is
a better choice for preventing constipation than taking a fiber laxative.
Doing so allows a woman to receive nutrients from the food as well as
preventing constipation (Derbyshire, 2007)

FIBER SOURCES
- broccoli and asparagus
 -vegetables and fruits

   VIII. DIET RECCOMENDATION

                     Based on a 2500 calorie diet. Your needs may vary depending on age, sex, and activity
level.
Dairy Group—3 cups per day; be sure to choose lower fat selections
                   Count as 1 cup: 1 cup (8 ounces) 1% or skim milk; 1 cup low-fat yogurt; 2 cups low-fat or
fat-free cottage cheese; 1Ѕ cups low-fat or fat-free ice cream; 1Ѕ ounces of low fat hard
cheese (cheddar, mozzarella, Swiss, or parmesan); 1/3 cup shredded cheese; 2
ounces processed cheese (American); 1 cup pudding (made with milk).
                 Meat and Meat Alternatives—5.5 ounce equivalents (or the amount of a food that has a
similar nutrition value as 5.5 ounces of meat)
                 Count as 1 ounce equivalent: 1 ounce lean meat, fish, or poultry; 1 egg; 1 slice lunch meat;
1 tablespoon peanut butter; 1/4 cup cooked kidney, pinto, or garbanzo beans.
Fruit Group—2 cups
                    Count as 1 cup: 1 cup (8 ounces) 100% juice; 1 large banana or orange; 1 small apple; 1
cup canned fruit. Include one Vitamin C source such as an orange or orange juice every
day.
Vegetable Group—2.5 cups
                    Count as 1 cup: 1 cup cooked vegetables; 2 cups raw leafy vegetables; 1 cup (8 ounces)
100% juice. Include one serving of a dark green leafy vegetable every day.
                Grain Group—6 ounce equivalents (or the amount of a food that has a similar nutrition
value to 6 ounces of a grain)
                     Count as 1 ounce equivalent: 1 slice 100% whole grain bread; 1 cup whole grain, ready-
to-eat cereal; Ѕcup cooked cereal, rice, or pasta, Ѕ “mini” bagel, 1 small tortilla, 6
inches in diameter; 1 pancake, 4Ѕ inches in diameter.
Oils and Solid Fats—use sparingly
               Common portions: 1 tablespoon corn, safflower, or cottonseed oil; 1 tablespoon margarine;
1 tablespoon mayonnaise; 1 ounce nuts; and 4 large olives.
               Most cakes, pies, cookies, soft drinks, sugar, honey, candy, jams, jellies, gravies, butter,
and sour cream have either an oil or solid fat and may be loaded with simple sugars.
Eat them in moderation; save them to eat only if you need extra calories after eating the
basic needed foods.
PREGNANCY FOOD PYRAMID

A Guide to Daily Food Choices when Pregnant

Oils and Solid Fats Use sparingly

Milk, Yogurt, and Cheese Group 3 cups

Vegetable Group 2.5 cups

Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts

5.5 ounce equivalents
Group

Fruit Group 2 cups

Bread, Cereal, Rice, and Pasta Group 6 ounce equivalents

D. REFERENCE

Nutrients & Vitamins for Pregnancy. (2019, September 20). Retrieved from
https://americanpregnancy.org/pregnancy-health/nutrients-vitamins-pregnancy/?
fbclid=IwAR0sD1blQs0KZ8KGlcH4BH022gTXM3z-8V-BGUfMHkER04VsMILZ2PfAhtw
Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & child health nursing: Care of the
childbearing & childrearing family. Wolters Kluwer. Page 288-291