• Low body-mass index: declined but continues to be prevalent in Asia and Africa

• Prevalence of stunting decreased but higher in SSA and south asia

• Undernutrtion caused 45% of all child deaths in 2011.
• World Health Assembly nutrition targets by 2025(base is 2012)
o 40% reduction in the number of children under age five who are stunted
o 30% reduction in low birth weight
o No increase in childhood overweight
o Increase the rate of exclusive breastfeeding in the first six months up to at least 50%
o Reduce and maintain childhood wasting to less than 5%
• The resolution adopted by the General Assembly on 25 September 2015, sets 17 Sustainable
Development Goals (SDG) and 169 targets
• The two targets within the second goal which are closely linked to undernutrition include:
o “By 2030, end hunger and ensure access by all people
o “By 2030, end all forms of malnutrition and address the nutritional needs of adolescent
girls, pregnant and lactating women and older persons”
• HTN disorders of pg has been associated with deficiency in calcium, vitamin e and c
• Obstructed labor has been eliminated as a cause of maternal death in industrialized countries
• Obstructed labor is strongly related to a woman’s age and parity. Very young women and
women giving birth for the first time at risk
• Hypertensive disorders of pregnancy affect about 10% of all pregnant women around the world.
Low Calcium, Zinc and magnesium - more importantly linked (Vitamin D??). Others such as
thiamine and Sodium chloride postulated Supplementation with calcium from at the latest 34
weeks of pregnancy;
• Although pre-eclampsia was reduced by calcium supplementation, this was not clearly reflected
in any reduction in severe pre-eclampsia, eclampsia, or admission to ICU. So WHO recommends,
In areas where dietary calcium intake is low, calcium supplementation during pregnancy at
doses of 1.5–2.0 g elemental calcium/day is recommended for the prevention of preeclampsia
in all women, but especially in those at high risk of developing pre-eclampsia.
• Individual or combined vitamin C and vitamin E supplementation during pregnancy is not
recommended to prevent the development of pre-eclampsia and its complications
• Increased maternal levels of preformed vitamin A (retinoic acid) have been shown to be
associated with spontaneous abortion and malformations involving the central nervous system
and cardiac development. daily doses of up to 10.000 IU (equivalent to 3000 mcg retinol) or
weekly 25.000 IU after day 60 are probably safe especially in areas where vitamin A deficiency is
thought to be common.
• Note that Routine Vitamin A supplementation is not recommended during pregnancy. Only In
areas where there is a severe public health problem that is If Night blindness prevalence is >5 %
• Zinc intake of women is on average 9.6 mg/d (SD 1.2) in contrast to the 1990 Recommended
Dietary Allowances (RDA) of 15 and 19 mg, respectively, during pregnancy
• Outcomes that appear to be zinc dependent are PROM, PTL, Abruption and Prolonged labor
• Maternal undernutrition can be just low BMI or including micronutrient deficiencies
• 12.5 kg as the physiological norm for average weight gain for a full-term pregnancy of 40
weeks. Approximately 5% of the total weight gain occurs in the first 10–13 weeks of pregnancy.
 The remainder is gained relatively evenly throughout the rest of pregnancy, at an average rate
of approximately 0.45 kg per week
• Fat is stored most rapidly during mid-pregnancy
• The fetus(highest) and the fat stored (2nd highest) almost contribute to the 50% of the weight
gained during PG
• Recommended weight gain
o Low (BMI<18.5) 12.5 - 18 kg
o Normal (BMI 18.5-25) 11.5 – 16 kg
o High (BMI>25.0-29.0) 7 – 11.5 kg
o Very high (BMI>29.0) > 5-9 kg
• Weekly 0.9-1.8kg (1 trimester ) and 0.4-0.5kg weekly in the 2nd and 3rd trimester .(For 2nd and
st

3rd TM, overweight-Normal BMI-underweight........0.3kg/wk, 0.4 and 0.5 respectively)

• Expected weight gain for twin pregnancies? 37-54 pound for women of normal BMI and
overweight women (31-50 pound) and obese women (25-42 pound)
• What about if a woman gain 16kg at 7 months? Will she be encouraged to stop gaining weight?
NO she must still gain more during the last 2 month but slow the increase in weight to parellel
the rise on the prenatal weight gain chart.
• What if she did not gain the needed weight, would she be encouraged to gain rapidly? No she
should gain slowly again a little more weight than the typical pattern to meet the gian by the
end of pregnancy
• Pre-pregnant weight and BMI determine maternal response to reproductive outcomes
o BMI < 16.9 Preference to the mother
o BMI 17.0-18.4 Mother and Foetus
o BMI > 18.5 Preference to Fetous
• Plasma volume begins to rise as early as the first 6–8 weeks of pregnancy and increases by
approximately 1500 ml by the 34th week.
• Plasma concentrations of lipids, fat-soluble vitamins and certain carrier proteins usually increase
during pregnancy and there is a Fall in circulating concentrations of albumin, most amino
acids, many minerals and water soluble vitamins due partly due to increased glomerular
filtration
• Red cell mass normally rises by about 200–250 ml during pregnancy
• human chorionic somatomammotropin
• protein may be stored in early pregnancy and used at a later stage to meet the demands of the
growing fetus.
• Many women in low-income countries do not seek prenatal advice until the 2nd trimester. In
this situation it is recommended that women increase their energy intake by 1.5 MJ/d (360
kcal/day) in the second trimester in order to reach the total energy costs of pregnancy.
o Only Eleven percent of women made their first ANC visit before the fourth month of
pregnancy (EDHS 2011)
• RDA for protein increase by additional 25gm/day during pregnancy
• The joint FAO/WHO/UNU consultation determined that an average increase in protein intake of
6 g per day was required during pregnancy. (3 cups of milk)
• The safe level of protein intake for a non-pregnant woman is 0.83 g/kg per day (46gm/day
• The essential fatty acids (EFAs) are linoleic, alpha-linolenic acid and their long-chain derivatives,
arachidonic acid (AA) and docosahexaenoicacid (DHA) are found in sea food
• The long-chain polyunsaturated fatty acids (PUFAs) are particularly important for neural
development and growth. The brain grows most rapidly during the third trimester of
pregnancy and in early infancy and consequently
• Taking cod liver oil supplements is not advised during pregnancy as they can contain high
levels of vitamin A, same goes for protein supplement (for different reasons)
• Pregnant women, and those who may become pregnant, are also advised to avoid marlin, shark
and swordfish due to the risk of exposure to methylmercury, which at high levels can be
harmful to the developing nervous system of the fetus
• Requirements for starch, sugar and non-starch polysaccharides (dietary fiber) during pregnancy
are not increased.
• Women with low intakes of non-starch polysaccharides(dietary fiber) may benefit from
increased intakes, to within a range of 12–24 g per day
• Vitamin A intakes should be increased throughout pregnancy by 100 μg per day (to 700 μg per
day). This is to allow for adequate maternal storage so that vitamin A is available to the fetus
during late pg. supplemental dose associated with teratogenic effects is 3000 μg per day
• Thiamin (B1) and riboflavin (B2) are needed for the release of energy in the body’s cells.
Requirements for thiamin parallel the requirements for energy and are subsequently higher for
the last trimester of pregnancy (an increase of 0.1 mg to a total of 0.9 mg per day during the
last trimester). The increment for average riboflavin intake is 0.3 mg per day (to a total of 1.4
mg per day) throughout pregnancy
• The increment in vitamin C intake of 10 mg per day (to a total of 50 mg per day) during the last
trimester of pregnancy is to ensure that maternal stores are maintained, particularly towards
the final stages of pregnancy.
• The vitamin D status of adult women is maintained more by exposure to sunlight than through
diet, and there is currently no RNI for vitamin D for adults under 65 years
• 3 units per week (1 unit is 125-250ml glass=8g alcohol) during the first trimester of pregnancy
leads to an increased risk of spontaneous abortion, and intakes over 15 units per week may
have a negative effect on birthweight. So no more than 1–2 units at any stage of pregnancy
• Caffeine easily crosses the feto-placental unit because the principal enzyme involved in caffeine
metabolism in the liver, is absent in the placenta and the fetus. should limit their caffeine
intake to 300 mg per day (around four cups of coffee).
• caffeine consumption was found to be associated with a statistically significant 50% increased
risk of IUGR at intakes of 200–299 mg/day and above
• Listeriosis from raw or partially cooked eggs, poultry and Toxoplasmosis found in raw meat,
unpasteurised milk and cat faeces
• Listeria bacteria are destroyed by heat. So heat your food
• Infancy and early childhood (0-24 months)
o Suboptimal breastfeeding practices
o Inadequate complementary foods
o Infrequent feeding
o Frequent infections
• Childhood (2-9 years)
o Poor diets
o Poor health care
o Poor education
• Adolescence (10-19 years)
o Increased nutritional demands
o Greater iron needs
o Early pregnancies
• Pregnancy and lactation
o Higher nutritional requirements
o Increased micronutrient needs
o Closely-spaced reproductive cycles
• Stunting often begins very early in life, typically in utero, and generally continues during the
first two post-natal years
• Most of the decline in length-for-age occurs during the complementary feeding period,
between 6 and 24 months of age
• Infant mortality (particularly neonatal mortality) increases exponentially at birth weights below
2500 g(LBW)
• There are two main causes of LBW: being born small for gestational age, or being born
prematurely. In developing countries, the majority of LBW infants are small but are not born
prematurely
• IUGR
o birth weight less than 10th (or 5th) percentile for GA;
o Birth weight less than 2500 g and GA greater than or equal to 37 weeks; and
o Birth weight less than 2 standard deviations below the mean value for gestational age
• Rates of IUGR-LBW can be categorized as percentages of all births, as low (<5%), moderate (5-
10%), high (10-15%) and very high (>15%).
• Barker’s hypothesis; IUGR may cause individuals to be programmed differently, as a result of
their adaptations to adverse in utero environments: the concept of ‘fetal programming”. ‘fetal
programming’, whereby a stimulus or insult at a critical period in early life development has a
permanent effect on the structure, physiology or function of different organs and tissues
• A birthweight of 3.1–3.6 kg has been shown to be associated with optimal maternal and fetal
outcomes for a full-term infant
• THE 4 TOO’S TOO YOUNG...TOO OLD...TOO SOON...TOO MANY
• The fetus undergoes its maximum increase in length at 20-30 weeks of gestation, and in weight
during the third trimester. Therefore, the timing of undernutrition in utero has different effects
on weight and length. Stunted (also called symmetrically or proportionately growth-retarded)
infants have a normal ponderal index (PI) (defined as weight/length) but their weight, length,
head and abdominal circumferences are below the 10th percentile of reference values. Wasted
(asymmetrically or disproportionately growth retarded) infants have a relatively normal length
and head circumference, but their body weights and PIs are low due to a lack of fat, and
sometimes of lean tissue
• Third trimester maternal supplementation would most likely to improve birth weight (fetal fat
deposition) In earlier trimesters, when maternal fat is increasing fastest, supplementation would
be more likely to benefit maternal weight gain