Lect-2. Maternal Nutrition Unit 1

Maternal Nutrition
Imran Waheed
Demonstrator
(INS-KMU)
Applied Nutrition Unit-I

Objectives
By the end of this unit, the students will be able to:

• Identify nutritional need in pregnancy and Lactation
• Identify pre-pregnancy diet
• Discuss the nutritional need in pregnancy and
adolescents
• Identify nutritional risk factors of pregnancy
• Discuss concerns during pregnancy / weight
gain/feeding twins/DM in pregnancy.
• Identify prevalence of Iron deficiency anemia in
Pakistani women.
Monday, March 30, 2020 Imran Waheed 2
Introduction to Applied Nutrition
• Nutrition at optimal levels is fundamental in

the maintenance of positive health.
• Maternal nutrition is very important for the
course and outcome of pregnancy.
• Lactation represents a stage where health and
nutritional status of the infant are dependent
on the mother.

Cont…
• Successful pregnancy and lactation require
adjustments in maternal body composition,
metabolism and function of various physiological
systems.
• Thus improving the nutrition and health of girls and

younger women and of mothers during pregnancy
and lactation will derive benefits in terms of improved
health of their children throughout their lives.
Pregnancy
• Pregnancy is a period of great physiological stress
for women as they nurture a growing fetus in their
body.
• Some changes occur in mother’s body which
influence the need for nutrients and their use as:
• A. Increased Basal metabolic rate (BMR): Fetal
growth and development increases the BMR by 5 %
during 1st trimester and 12 % during 2nd & 3rd
trimester. This increases the total energy
requirement of mother.
Cont…
• B. Changes in Body fluid: Mother’s blood volume
increases so as to carry the appropriate amount of
nutrients to the fetus and metabolic wastes away
from the fetus. Increased blood volume decreases
the concentration ratio of plasma protein,
hemoglobin and other blood constituents.
• C. Gastrointestinal Changes: Alteration in GI
functions includes nausea, vomiting and
constipation. In the later trimester the absorption
of vit B12, iron and calcium increases in order to
meet the increased needs of mother and fetus.
Importance of Good Nutrition During Pregnancy
• Good health of fetus and newborn depends upon the

nutritional status of the mother during and prior to
conception.
• A well nourished woman prior to conception enters
pregnancy with nutrients reserve to meet the nutritional
needs of the fetus without affecting her own tissues and
health.
• A well nourished mother minimizes complications during
pregnancy and premature delivery.
• Poor mother nutrition put the fetus on the risk of developing
complications , congenital defects and even death.
• Low nourished mother results in the delay of baby’s
milestones.
Nutritional Needs During Pregnancy
Nutrients need increases:

• To develop maternal organs like uterus, placenta,
and breast tissues.
• To build up body nutrients reserve.
• During 1st trimester qualitative improvement of
nutrients is needed.
• During 2nd and 3rd trimester both qualitative and
quantitative improvement of nutrients is needed.
Energy Requirement During Pregnancy
• Additional energy is required during pregnancy.

• Additional 300 Kcal is required
Group Energy Requirement (Kcal)
Sedentary 1875 + 300 = 2175

worker
Moderate 2225 + 300 = 2525
worker
Heavy worker 2925 + 300 = 3225

Nutritional Demands
• Energy Needs
• Mothers need more Kcal for two reasons:
• To supply the increased fuel demanded by the
increased BMR
• To spare protein for the newly added tissues

Protein Requirement during Pregnancy
Protein is a primary need during pregnancy

Additional 15 g protein is required for:
• Enlargement of maternal tissues
• Growth of placenta
• Growth of fetus
• Increased maternal blood volume
• Formation of amniotic fluid
• Preparation for labor and lactation
Calcium Requirement During Pregnancy
• Fetal bone, teeth development and growth.

• Decreases the risk of low birth weight and
maternal hypertension and pre-eclampsia.
• Helps in muscle contraction.
• Helps in blood clotting.
RDA during pregnancy is 1g.

Iron during Pregnancy
• Fetal growth
• Increases RBC production in mothers
• Building iron stores in fetal liver
• RDA: 3 g/day

Folic Acid
• Folic acid 400 mcg/d (RDA)

• Needed for maternal blood formation
• Prevents fetal neural tube defects and improves
birth weight.
• Pregnant women: 600 mcg (RDA)

• Breastfeeding women: 500 mcg (RDA)

Other Considerations During Pregnancy
• Avoid caffeine as it crosses placenta and enters

fetal blood circulation and increases the risk of
premature delivery.
• Avoid smoking as it results in placental
abnormalities and low birth weight (LBW).
• Avoid Alcohol as it causes LBW, growth
retardation, and mental retardation

Importance of Nutrition during Lactation
• Mother needs extra nutrition to baby’s

nutritional needs.
• Inadequate maternal nutrition affects the
normal growth of the baby and ultimately
mother herself.

During Lactation
• Protein Requirement:
• Protein need increases in lactation as mother’s
milk contains 1.15g of protein/100 ml.
• During first 6 months of lactation 75. g/d is
required.
• During 6—12 months of lactation 65 g/d is
required.

During Lactation
• Calcium:
• Additional calcium is required for breast milk
secretion as 30—40 mg/100 ml is secreted per
day.
• Iron:
• Iron intake should be increased to 30 mg/d to
make up the iron secreted milk.
• Note: 1 mg of iron/d is lost during menstrual
period.
During Lactation
• Vit A (950mcg/d):
• Breast milk is rich in vit A.
• About 350 mcg /d of vit A is secreted in mother’s
milk.

Nutrients Requirement
Nutrient Non-Pregnant Pregnant Increase
Energy (kcal) 2100 2400 300

Protein (g) 44 74 30
Retinol (μg) 800 1000 200
Vitamin D (μg) 7.5 12.5 5
Vitamin E (mg) 8 10 2
Vitamin C (mg) 60 80 20
Riboflavin (mg) 1.3 1.6 0.3
Nicotinic acid (mg) 14 16 2
Vitamin B6 (mg) 2 2.6 0.6
Folic acid (μg) 400 800 400
Thiamin (mg) 1.1 1.5 0.4
Calcium (mg) 800 1200 400
Iron (mg) 18 30 12
Zinc (mg) 15 20 5
Nutritional Risk Factors in
Pregnancy
Risk Factors presented at the onset of pregnancy
 Age:
 15 years or younger
 35 years or older
 Frequent pregnancies:
 Three or more during a 2 year period
 Poor obstetric history or poor fetal performance
 Poverty
 Bizarre or faddist food habits
 Abuse of nicotine, alcohol, or drugs
 Therapeutic diet required for a chronic disorder
• Weight: less than 85% of standard weight or
• more than 120% of standard weight

Conti…
Risk factors occurring during pregnancy

 Low hemoglobin
 Hemoglobin less than 12.0 gm/dl
 Hematocrit less than 35.0 %
 Inadequate weight gain
 Any weight loss
 Weight gain of less than 1 kg per month after the
first trimester
 Excessive weight gain: grater than 1 kg per week
after the first trimester

Risk Factors for Pregnant Teens
• Maternal age, especially <16 years old

• Pregnancy less than 2 years after onset of menarche
• Poor nutrition, low prepregnancy weight, poor weight
gain
• Infection or sexually transmitted disease
• Preexisting anemia
• Substance abuse: smoking, drinking, and drugs
• Poverty; lack of social support or education
• Rapid repeat pregnancies
• Lack of access to age-appropriate prenatal care

Concerns During Pregnancy
Nausea and Vomiting

 Strategies for managing morning sickness:
– Eat small, low-fat meals and snacks
– Drink fluids between meals, avoid caffeine
– Limit spicy and high-fat foods
– Avoid lying down after eating or drinking
– Take a walk after meals
– Wear loose-fitting clothes

Conti…
Constipation:
• Increase fluid and fiber intake to reduce
constipation.
Pica:
• Pica is a disorder that causes cravings for
items that contain no nutritional value.
• Pregnant women with pica may want to eat
clay, cigarette ashes, or starch, among other
strange substances.
Conti…
• When a woman has pica during pregnancy, it

may indicate a lack of a specific vitamin or
mineral.
Food Aversions:
• During pregnancy, many women experience
aversions to particular foods, means they
never want to eat them.

Conti…
Food Cravings:
• The sudden, irresistible, and intense urge to eat
something specific is referred to as a food
craving.
 Common cravings during pregnancy include:
• Chocolate
• Spicy foods
• Fruits
• Mashed potatoes and pizza

Obstetrical History
• Past medical history (wt gained in pregnancy)

• Current dietary intake patterns
• Vitamin, mineral and herbal intake
• Caffeine and other fluids
• Nausea, vomiting, and heartburn
• Constipation

Obstetrical Physical Exam
• Low pre-pregnancy weight and low maternal weight

gain are risk factors for:
– Intrauterine growth retardation
– Low birth weight baby
– Increased incidence of perinatal death
• The average birth weight is 3.5 kg though the

range of normal is between 2.5 and 4.5 kg (all
but 5 % of newborns will fall into this range).
• Need to asses:
– Pre-pregnancy weight (BMI)
– Current weight (BMI)
– Weight gain from previous visit

Weight Gain During Pregnancy
• It is natural and necessary to gain weight during

pregnancy as uterus, placenta, breast, blood
volume, body fluids and fat increases.
• Average weight gain is 25—35 lbs
• Teen pregnant gains more weight than a
mature woman.

Recommended Weight Gain
S.No BMI Weight (kg) BMI Value Weight Gain (kg) Weight Gain (lbs)
Height (m2)
1 Underweight BMI < 18.5 12.7-18 28-40
2 Normal Weight BMI 19-24.9 11.3-15.8 25-35
3 Overweight BMI 25-29.9 6.8-11.3 15-25
4 Obese BMI > 30.0 5-9 11-20

Conti…
• The IOM guidelines for pregnancy weight gain

when a woman is having twins are as follows:
S.No BMI Weight (kg) Weight Gain (kg) Weight Gain (lbs)
Height (m2)
1 Underweight 22.6 kg to 28.1 kg 50 to 62 lbs
2 Normal weight 16.7 to 24.5 kg 37 to 54 lbs
3 Overweight 14 to 22.6 kg 31 to 50 lbs
4 Obese 11.3 to 19 kg 25 to 42 lbs

Feeding Twins
• Breastfeeding helps babies’ health and

development.
• Giving birth to more than one baby poses
additional challenges for a mother planning to
breastfeed.
• They have extra demands of frequent suckling,
coordinating the potentially differing needs of
more than one baby, or the need to express milk
and to feed different babies by different feeding
methods.

Conti…
• The mothers have a greater likelihood of

giving birth preterm and their babies being
admitted to the neonatal intensive care unit,
which can lead to delayed starting or early
stopping of breastfeeding.

Conti…
Issues With Breastfeeding Twins:

• Prematurity and smallness is more common with
twin and multiple births.
• This means that twins are often a lighter birth
weight than singleton babies and are more likely
to be sleepy and not as able to suck effectively.
• Often, mothers need to express their breast milk
which is offered to their twins via a feeding tube
or bottle.
Conti…
• If a mother has had a caesarian section
delivery then it can be more awkward for her
to position herself comfortably when
breastfeeding.
• It can take a while for a mother to learn how
to attach one baby to each breast at a feed
times.
• Twin breastfeeding can take up many hours of
time.

Conti…
• Deciding what works – as every mother and her

twins are unique. For some, synchronizing the
twins breastfeeds works best and for others,
feeding them separately is a more realistic
option.
• Twins may not have the same sucking and
feeding behaviors. They can display marked
differences in their breastfeeding behaviors and
this can make the practical aspects of
breastfeeding a challenge.

Diabetes Mellitus
• A metabolic condition characterized by

chronic hyperglycemia as a result of defective
insulin secretion, insulin action or both.
• Type 1(IDDM)
• Type 2(NIDDM)
• Gestational diabetes
• Others/Secondary

Gestational Diabetes
• Carbohydrate intolerance of variable severity

with onset or first recognition during
pregnancy.
• Every year 2% to 10% pregnancies are effected
by gestational diabetes .
• It usually goes away after birth. But up to 10%
of women who have gestational diabetes get
type 2, weeks or even years later.

Conti…
• Gestational diabetes is more of a risk for the

baby than the mother.
• A baby might have unusual weight gain before
birth, trouble breathing at birth, or a higher
risk of obesity and diabetes later in life.
• The mother might need a cesarean section
because of an overly large baby, or she might
have damage to her heart, kidney, nerves, and
eyes.

Gestational Diabetes Treatment
• Careful meal planning to make sure you get

enough nutrients without too much fat and
calories
• Daily exercise
• Keeping weight gain under control
• Taking insulin to control your blood sugar
levels, if needed

Iron Deficiency Anemia
• A pathological condition in which oxygen

carrying capacity of RBCs is insufficient to meet
the needs of the body.
• WHO recommends the HB %age should not fall
below 11 g/dl throughout pregnancy.
• Centers for Disease Control and Prevention
(CDC) refers the value of 10.5 g/dl .

• Susceptible Population:
– Pregnant woman who has not been taking iron
supplements
– Pregnant Woman with multiples (more than one child)
– Have had two pregnancies close together
– Infants and children
– Menstruating females
– Low income women

Conti…
• A pregnant woman who vomit a lot because

of morning sickness
• A woman who had anemia before becoming
pregnant
• A pregnant teenager

• Weakness, fatigue, poor work performance, and

changes in behavior.
• Physical signs include pallor, fatigue, coldness and

paresthesia (a sensation of tingling, burning, or
numbness) of the extremities, greater susceptibility
to infections.
• Infants and young children with iron deficiency may

have low IQ levels, poor cognitive and motor
development, learning, and behavioral problems.
Iron Treatment Recommendations
• Iron-rich foods:
– Meat, fish, poultry, eggs
– Organ meats
– Peas and beans
– Dried fruit
– Whole grain and cereal

Prevalence of Anemia in Pregnancy in
Pakistan
The value for Prevalence of anemia among
pregnant women (%) in Pakistan was 51.30 as of
2016. In the past 30 years this reached a
maximum value of 51.30 in 2016 and a minimum
value of 47.40 in 2002.
Factors:
• Dietary and socioeconomic factors.
• Likes and dislikes in food
• Pica, tea consumption, and low intake of eggs and
red meat are associated with anemia.
Conti…
Recommendations:
• Women of childbearing age should be provided
nutritional education regarding food sources of
iron, especially prior to becoming pregnant, and
taught how food choices can either enhance or
interfere with iron absorption.
• If a woman is diagnosed with anemia during
pregnancy, her daily elemental iron should be
increased to 120 mg until her Hb concentration
rises to normal (Hb 110 g/L or higher)

References
• 1. Guideline: Daily iron and folic acid supplementation in pregnant
women. Geneva: World Health Organization; 2012
[archived](http://www.who.int/nutrition/publications/micronutrients/gui
delines/daily_ifa_supp_pregnant_women/en/)
• 2. The clinical use of blood in general medicine, obstetrics, paediatrics,
surgery & anaesthesia, trauma & burns. Geneva, World Health
Organization; 1998
(http://www.who.int/bloodsafety/clinical_use/en/Manual_EN.pdf).
• 3. WHO recommendations on antenatal care for a positive pregnancy
experience. Geneva: World Health Organization; 2016
(http://www.who.int/reproductivehealth/publications/maternal_perinatal
_health/anc-positive-pregnancy-experience/en/).
• 4. WebMD Medical Reference Reviewed by Michael Dansinger, MD on
December 13, 2019.
https://www.webmd.com/diabetes/guide/types-of-diabetes-mellitus


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Maternal Nutrition

Applied Nutrition Unit-I

By the end of this unit, the students will be able to:

• Nutrition at optimal levels is fundamental in

Monday, March 30, 2020 Imran Waheed 3

• Thus improving the nutrition and health of girls and

• Good health of fetus and newborn depends upon the

Nutrients need increases:

• Additional energy is required during pregnancy.

Group Energy Requirement (Kcal)

Sedentary 1875 + 300 = 2175

Monday, March 30, 2020 Imran Waheed 9

Monday, March 30, 2020 Imran Waheed 10

Protein is a primary need during pregnancy

• Fetal bone, teeth development and growth.

Monday, March 30, 2020 Imran Waheed 12

Monday, March 30, 2020 Imran Waheed 13

• Folic acid 400 mcg/d (RDA)

• Pregnant women: 600 mcg (RDA)

Monday, March 30, 2020 Imran Waheed 14

• Avoid caffeine as it crosses placenta and enters

Monday, March 30, 2020 Imran Waheed 15

• Mother needs extra nutrition to baby’s

Monday, March 30, 2020 Imran Waheed 16

Monday, March 30, 2020 Imran Waheed 17

Monday, March 30, 2020 Imran Waheed 19

Energy (kcal) 2100 2400 300

Monday, March 30, 2020 Imran Waheed 22

Risk factors occurring during pregnancy

Monday, March 30, 2020 Imran Waheed 23

• Maternal age, especially <16 years old

Monday, March 30, 2020 Imran Waheed 24

Nausea and Vomiting

Monday, March 30, 2020 Imran Waheed 25

• When a woman has pica during pregnancy, it

Monday, March 30, 2020 Imran Waheed 27

Monday, March 30, 2020 Imran Waheed 28

• Past medical history (wt gained in pregnancy)

Monday, March 30, 2020 Imran Waheed 29

• Low pre-pregnancy weight and low maternal weight

• The average birth weight is 3.5 kg though the

Monday, March 30, 2020 Imran Waheed 30

• It is natural and necessary to gain weight during

Monday, March 30, 2020 Imran Waheed 31

2 Normal Weight BMI 19-24.9 11.3-15.8 25-35

3 Overweight BMI 25-29.9 6.8-11.3 15-25

4 Obese BMI > 30.0 5-9 11-20

Monday, March 30, 2020 Imran Waheed 32

• The IOM guidelines for pregnancy weight gain

2 Normal weight 16.7 to 24.5 kg 37 to 54 lbs

3 Overweight 14 to 22.6 kg 31 to 50 lbs

4 Obese 11.3 to 19 kg 25 to 42 lbs

Monday, March 30, 2020 Imran Waheed 33

• Breastfeeding helps babies’ health and

Monday, March 30, 2020 Imran Waheed 34

• The mothers have a greater likelihood of

Monday, March 30, 2020 Imran Waheed 35

Issues With Breastfeeding Twins:

Monday, March 30, 2020 Imran Waheed 37

• Deciding what works – as every mother and her

Monday, March 30, 2020 Imran Waheed 38

• A metabolic condition characterized by

Monday, March 30, 2020 Imran Waheed 39

• Carbohydrate intolerance of variable severity