WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC)

There have always been differing approaches, even controversies with regard to the role of food intake during pregnancy. Traditional beliefs from a wide variety of cultures present divergent approaches. At present, nutritional care during pregnancy is based on the following general premises: women are encouraged to eat a variety of foods "to appetite", to achieve adequate weight gain as determined by their pre-pregnancy body mass index, and to breast-feed their infants after birth. Underweight women or women with low pregnancy weight gains are at higher risk of delivering an infant weighing less than 2500gm. Overweight women or those who gain a large amount of weight during pregnancy are more likely to deliver big babies.

The purpose of this document is to understand pregnancy and nutrition issues faced by women and their families during childbearing years. Nutritional problems can be found in women of every socioeconomic status and range from an inability to acquire and prepare food to eating disorders. If the women cannot afford a sufficient supply of food, she should be referred to food pantries and soup kitchens in her area. All low-income women should receive information about the Special Supplemental Food Program for Women, Infants and Children (WIC) and food stamp program. All WIC programs have nutritionists who are required to counsel patients on these matters. Poor weight gain also may reflect substance abuse, domestic violence, or depression.

Weight Gain Recommendation for Pregnancy:
BMI (weight for height)	Recommended Weight Gain
Low (BMI<19.8 or <90%IBW	12.5-18 kg (28-40lb)
Normal (BMI 19.8-26or 90-120%IBW)	11.5-16kg (25-35lb)
High (BMI 26-29 or 120-135% IBW)	7-11.5kg (15-25lb)
Obese (BMI>29 or >135% IBW)	6+kg (15+lb)

Body Mass Index (BMI) = weight in kg/height in m². Ideal Body Weight (IBW), the tables for computing these are available.

The weight gain recommendations just discussed concern total weight gain, which in reality is not known until delivery. Your healthcare providers depend instead upon measurements of the rate and pattern of weight gain during the course of a pregnancy. In cases in which weight gain deviates from expected, an assessment of dietary intake and activity patterns should be done. An assessment by a nutritionist or registered dietitian skilled in counseling perinatal patients might be beneficial.

Diet:
Evidence is increasing that diet before pregnancy may have an important influence on pregnancy outcome, like the reduced risk of recurrence of neural tube defects with preconception folate supplementation. The Centers for Disease Control (CDC, 1992) recommends that all women of childbearing age who are capable of becoming pregnant be advised to consume at least 4 mg of folate daily.
Intensive preconception management of blood sugar in diabetics has shown reduced risks of congenital malformations. Quitting smoking, stopping the use of illicit drugs and alcohol also helps to have healthy babies.

Calories:
Total caloric intake appears to be the most important nutritional factor relating to birth weight. It has been estimated that a typical pregnancy costs 80,000 additional calories over pre-pregnancy requirements or about 300 extra calories per day. This energy substrate intake will theoretically provide a weight gain of 10-12 kg at term. The quantity of protein, vitamins, and minerals per 100 calories of food is an important concept.

Protein:
Eating patterns in the United States tend toward diets that are adequate or even excessive in protein-rich foods. The estimated requirement for protein in pregnancy is 60 gm, about 15gm over nonpregnant requirements. Protein containing foods can be excellent sources of vitamins and minerals such as iron, vitamin B6, and zinc.

Sodium:
Although sodium is not restricted during pregnancy, excessive use is not recommended. A diet of primarily natural foods can be safely salted "to taste". Processed foods are already high in sodium and should be consumed in moderation. Higher intake of sodium has possible relationship to the development of hypertension in susceptible individuals.

Iron:
Hemodilution during pregnancy decreases hemoglobin concentration. Increasing iron intake through diet or supplements can limit the decrease. It is estimated that 500 mg of iron are needed for the increase in maternal red blood cell volume and 300 mg of iron for fetal erythropoiesis. Therefore, daily supplementation of 30 mg of elemental iron during the pregnancy is recommended. Therapeutic iron in doses of 60 to 120 mg per day is prescribed for women who are diagnosed with iron deficiency anemia, that is, hemoglobin of less than 11gm/100 ml (hematocrit of less than 33%).

Calcium:
The RDA for calcium is 1200 mg, which is sufficient to meet fetal needs and maintain maternal calcium balance. Women who are unable to increase their intake of calcium foods to achieve the RDA should take a calcium supplement of 600 mg per day.

Folate:
The recommended intake for folate is increased during pregnancy from 2 mg to 4 mg per day. Although it is possible to meet this requirement through a well-selected diet, some women, especially those in high-risk groups may require daily supplementation of up to 3 mg folate. The Centers for Disease Control recommends that women who have previously delivered infants with neural tube defects be given supplements containing 4 mg/day of folate, starting at least four weeks before conception and for the first 3 months of pregnancy. Multivitamins containing folate should not be used to achieve the desired level of supplementation, as potentially harmful quantities of other nutrients (such as vitamin A) could be ingested. Dietary sources include eggs, leafy vegetables, oranges, legumes, and wheat germs.

Recommended levels of Vitamin and Mineral Supplementation:

The National Academy of Sciences recommends;
Iron	30 mg		Vitamin B6	2 mg
Zinc	15 mg		Folate	3 mg
Copper	2 mg		Vitamin C	50 mg
Calcium	250 mg		Vitamin D	5 micro gm (200IU)

Supplementation for women in special circumstances:

1. Complete Vegetarians (consume no animal products whatsoever)
   10 micro gm (400 IU) Vitamin D, 2 micro gm Vitamin B12
2. Women under age 25 whose daily intake of calcium is less than 600 mg;
   600 mg calcium
3. Women with low intake of vitamin D-fortified milk, especially those who have minimal exposure to sunlight;
   10 micro gm (400 IU) Vitamin D.