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13 dietary guidelines

The Dietary Guidelines for Americans translates scientific information on nutrient requirements and dietary characteristics that promote good health into recommendations and advice for the food intake by the general public. Thus, the Dietary Guidelines is the backbone of nutrition education efforts throughout the country. They also reflect nutrition policy in the United States because it provides the basis for the all federal food and nutrition programs, i.e., food stamps Women, Infants, and Children (WIC) school meal programs and emergency feeding efforts. The first edition of the Dietary Guidelines was released in 1980, and then it has been revised every 5 years. The sixth, and latest, edition was released in 2005 33 . The first five editions of the Guidelines consisted of 7 or 10 statements providing guidance on how to adopt a pattern of eating that supports good health. The statements were remarkably consistent from one edition to the next 34 . Common themes in all five editions...

42 dietary changes throughout pregnancy

That are sweet and or sour, with fruits and fruit juices being most commonly consumed 18, 22, 27 . Whether these dietary changes are related to taste 28 and olfactory changes 29 during pregnancy has been the focus of a few experimental studies. In the 1990s, Duffy and colleagues published one of the only prospective studies (i.e., the Yale Pregnancy Study) on taste changes during pregnancy 28 . Women were tested before they became pregnant and then during each trimester throughout their pregnancy. During each test session, women were asked to rate the intensity and hedonic value of sodium chloride (salt), citric acid (sour), quinine (bitter), and sucrose. The results indicated that bitter sensitivity increased during the first trimester, a finding that coincides with previous work 30 . These data suggest that avoidance of bitter-tasting foods such as green vegetables during early pregnancy 31 may be due, in part, to this initial hypersensitivity to bitter stimuli. As pregnancy...

Will Breast Feeding Help You Lose Weight

Breast-feeding burns calories, so you may lose weight without cutting back on calories. It also shrinks the uterus, which can make you look more svelte (if that word can be used without irony for the mother of a newborn). On the other hand, bottle-feeding mothers can try some exercises and weight-loss diets that are not advisable when you're starting to breast-feed. Either way, it's wise to assume that it will take you nine months to a year to get back to your prepregnancy weight. While breastfeeding, a woman of normal weight should lose no more than one to two pounds a month. But compared to all the life-altering changes that come along with any baby, the extra limitations on nursing mothers are relatively minor and last only a few months. For most women, no dietary changes are needed, for instance. Leaving a newborn home requires planning, no matter how you feed her, and breast milk can be saved in bottles to allow Mom time away from the baby for work or play. Besides,...

2526 Appetite suppressants obesity and weight loss

Amjepramone (synonym diethylpropion), clobenzorex, dexfen-fluramine, fenfluramine, fenproporex, mazindol, mefenorex, norpseu-doephedrine, phentermine. and sibutramine are used as appetite suppressants. Amfepramone, clobenzorex, fenproporex, mefenorex, and phentermine share the pharmacological properties of amphetamines dexfenfluraminc, fenfluramine, and sibutramine stimulate the release Orlistat inhibits intestinal lipase and reduces fat absorption, which results in weight reduction. A French collaborative study by Teratology Information Services, which evaluated 168 pregnancies primarily exposed to dexfenflu-ramine, did not provide any indication of teratogenic properties in this appetite suppressant (Vial 1992). Obesity and weight loss Several publications discuss the association of maternal obesity and pregnancy complications, including birth defects (Scialli 2006). A preconceptionally existing maternal obesity is, according to a retrospective case-control study on 277 neural tube...

Infants of overweight and obese women

If infants of women with GDM have increased body fat rather than fat-free mass, what then is the difference if any in body composition between pregravid overweight obese women as compared with lean or average weight women Sewell et al. evaluated 76 singleton neonates of overweight obese women and 144 neonates of lean average women again using anthropometric and TOBEC measures of body composition.37 None of these women had GDM. There were no significant differences in gestational age between the groups. Additionally, there were no significant differences in maternal age, parity, use of tobacco or obstetrical or maternal medical problems between the groups. However, 14 of the infants of the overweight obese mothers had macrosomic infants (birthweight 4 kg) as compared with only 5 in the neonates of the lean average weight women (P 0.04), while weight gain in the overweight obese group was actually less (13.8 7.5vs. 15.2 5.3 kg, P 0.001) than in the lean average weight women. The...

Supplementing your diet

If your diet is healthy and balanced, you get most of the vitamins and minerals you need naturally with the exception of iron, folic acid, and calcium. To make sure you get enough of these nutrients and to ensure against inadequate eating habits, your practitioner is likely to recommend prenatal vitamins. In the case of vitamins, more isn't necessarily better take only the Getting enough calcium from your diet alone is possible if you really pay attention. You can get it from three to four servings of calcium-rich foods, such as milk, yogurt, cheese, green leafy vegetables, and canned fish with bones (if your stomach can take it). Supermarkets also stock special lactose-free foods that are high in calcium. The following list indicates portions of foods that qualify as one serving (300 mg of calcium) If your diet is low in calcium, take a supplement. Tums and some other antacids contain quite a bit of calcium and, at the same time, help relieve any pregnancy heartburn you may have. (A...

Dieting Fasting And Food Restriction

The degree to which the mother is parasitized by the fetus has been the subject of debate for many decades. Although the fetus can draw on maternal stores when maternal dietary input is limited, the extent and duration of this process is unknown. The known effects of food restriction on body composition of pregnant and nonpregnant rats have provided new insights into the nature of maternal-fetal interactions. At term, pregnant rats fed 50 of the food consumed by control animals had a body composition similar to that of pair-fed nonpregnant rats, whereas the mean body weight of the fetus was significantly reduced. These results support the idea that the pregnant, food-restricted rat is not extensively parasitized by the fetus. In addition, data suggest that important metabolic adjustments must occur to allow the

610calorie recommendations and weight gain during pregnancy

Calorie recommendations for the pregnant bariatric patient include approximately 300 kcal day above maintenance guidelines for bariatric surgery. As with protein, calorie recommendations may vary between institutions. Typically, 1 year after surgery, individuals consume approximately 1,200 kcal day, so this would result in a caloric recommendation of 1,500 kcal day for pregnant bariatric patients. These are general guidelines, and each patient should be monitored for appropriate weight gain during pregnancy to ensure she is getting adequate caloric intake. Weight gain during pregnancy after bariatric surgery is variable, as with any pregnancy. There are no published guidelines for pregnancy weight gain in bariatric patients. Therefore, the guidelines set forth by the Institute of Medicine should be used (Table 6.2) 28 . The postoperative BMI should be used to determine the appropriate weight category. Even when weight gain is normal and expected during pregnancy, some patients may...

22 gestational weight gain recommendations

Although the need for appropriate weight gain during pregnancy has long been recognized, recommendations for weight gain have changed over the years as new data have become available. The changes in recommended ranges for gestational weight gain are summarized in Table 2.1. Prior to 1970, it was standard obstetric practice to restrict gestational weight gain to between 18 and 20 lb (8-9 kg) 2 . Overeating was believed to cause large babies and, as a consequence, more difficult deliveries. In 1970, the Food and Nutrition Board's Committee on Maternal Nutrition 6 recommended a higher gestational weight gain, 20-25 lb (9-11.5 kg). The increase was based on new evidence that low weight gain was related to increased risk of delivering low-birth-weight infants, with those infants at increased risk of mortality and developmental problems. This recommendation was followed by heightened interest in helping pregnant women achieve appropriate weight gain and nutrient intake. For example, the US...

85adolescent barriers to healthy eating

Practically speaking, knowledge of nutrients and their value is often not sufficient to encourage teenagers to consume the appropriate foods. Motivational approaches are often necessary to enable diet-related behavior change and to assist the teen in overcoming environmental obstacles and other barriers to healthy eating. Teens are frequently not involved in either food purchase or preparation in the household. Their financial situation may preclude the purchase of fruits and vegetables. For those who obtain supplemental food from the Women, Infants, and Children (WIC) program, often purchases are expended before the month is over. Also, school lunch choices for those still attending school are widely varied from system to system, and the optional food line may be overwhelmed with high-fat content items, providing relatively few healthy choices. For example, in northeast Ohio, one local school system provides a basic healthy lunch (based on the US Food and Drug Administration FDA...

Understanding your babys Weight gain

Although your weight gain may follow a path all its own, your baby's own bulking-up pattern is likely to progress slowly at first, and then pick up at about 32 weeks, only to slow again in the last weeks before birth. At 14 to 15 weeks, for example, the baby puts on weight at about 0.18 ounce (5 grams) per day, and at 32 to 34 weeks, 1.06 to 1.23 ounces (30 to 35 grams) per day (that's about half a pound or 0.23 kilograms each week). After 36 weeks, the fetal growth rate slows to about a quarter of a pound per week, and by 41 to 42 weeks (you're overdue at this point), minimal or no further fetal growth may occur. Check out Chapter 7 for more about how your baby grows. In addition to your diet and weight gain, the following factors affect fetal growth Your practitioner keeps an eye on your baby's growth rate, most often by measuring fundal height and paying attention to your weight gain. If you put on too little or too much weight, if your fundal height measurements are abnormal, or...

861 Community Based Nutrition Programs

In addition, each community should have some way to access the WIC program. Many adolescent patients will be eligible for WIC services. To be eligible, the pregnant adolescent must meet specific residency, income, and nutritional risk criteria as specified by WIC. To qualify based on nutritional risk, the adolescent must have a medically-based risk such as anemia, be underweight (less than 100 pounds) or overweight (over 200 pounds), have a history of pregnancy complications or poor pregnancy outcomes, or have other dietary risks such as failure to meet the dietary guidelines for any food groups or have inappropriate nutrition practices, e.g., pica. The WIC fact sheet states in part 31 In most WIC state agencies, WIC participants receive checks or vouchers to purchase specific food each month that are designed to supplement their diets. A few WIC state agencies distribute the WIC foods through warehouses or deliver the foods to participants' homes. The foods provided are high in one...

132 recommendations for weight gain during pregnancy

Guidelines for weight gain during pregnancy aim to promote adequate, but not excessive, weight gain for optimal fetal development. Weight gain is highly correlated with infant birth weight making optimal weight gain during pregnancy important to fetal outcomes 1 . For a thorough discussion of optimal weight gain for pregnancy, the reader is referred to Chap. 2, Optimal Weight Gain, in Part 1 of this book. In brief, the Institute of Medicine (IOM) developed guidelines for maternal weight gain based on aggregate data examining fetal outcomes and associated maternal conditions 1 . These guidelines, adapted by both the American College of Obstetrics and Gynecology (ACOG) and the American Dietetic Association (ADA), use maternal body mass index (BMI, kg m2) prior to conception (Tables 13.1, 13.2) as a starting point for recommended weight gain during pregnancy 1-4 . Although these guidelines are available to women during pregnancy, educational programs regarding how to follow these...

What if Your Child Is Overweight

Many healthy infants and toddlers alternate between looking pudgy and looking thin as they grow. But even if your child seems to be consistently overweight, don't restrict his food intake without first consulting his doctor. You may be advised to control his food consumption enough to slow or stop weight gain as he grows and let his height catch up with his weight. Like the child who seems to never eat meals, an overweight child may be overdoing consumption of juice, milk, and nutritionally empty high-calorie foods. Another common factor Your child may not be getting enough physically active play. Recent research indicates that genetic factors play an important role in a child's tendency to gain weight excessively. For more information on obesity in children, see Chapter 32, Health Problems in Early Childhood.

1421 Definition and Regulation of Dietary Supplements

The Dietary Supplement Health and Education Act (DSHEA) of 1994 issued by the US Food and Drug Administration (FDA) defines the term dietary supplement as a product that collectively meets the following requirements 5 A product (other than tobacco) intended to supplement the diet or contain one or more The FDA requires that all dietary supplements be labeled as such. However, unlike drugs, dietary supplements do not need approval before they are marketed. The manufacturers and distributors of supplements are responsible for ensuring their safety and making sure that label claims are accurate and truthful. For more information concerning the regulation of dietary supplements marketed within the United States, the reader is referred to the FDA's Center for Food Safety and Applied Nutrition help-line (1-888723-3366) or their website (http list.html).

1422 Recommended Nutrient Intakes and Dietary Supplement

Although during pregnancy a number of metabolic adaptations are orchestrated to support both increased maternal and fetal needs for many nutrients, the body's requirements for some nutrients cannot be met without increased dietary intake. Indeed, available evidence indicates that dietary requirements for 14 of the 21 essential micronutrients increase during pregnancy. These nutrients comprise seven vitamins, five minerals, and choline 6 . As such, it is important to increase one's intake of these nutrients to prevent deficiencies. It is also important during this period of the lifespan to not consume too much of each nutrient to reduce risk for levels of intake that may be harmful. The Institute of Medicine's (IOM) Dietary Reference Intakes (DRIs) are considered to be the gold standard in recommendations for nutrient intake, and having a basic knowledge of this set of dietary reference standards is important for understanding nutrient requirements and potential impacts of dietary...

The obesity component

The worldwide obesity epidemic has been a major driving force in the recognition of metabolic syndrome.45 Several of the definitions proposed for metabolic syndrome include increased waist circumference.48-50 This factor is known to be associated with a relative predominance of visceral over subcutaneous adipose tissue,51,52 which results in a higher rate of Aging, obesity, physiological stress, corticosteroid use flux of adipose-tissue-derived free fatty acids to the liver through the splanchnic circulation, thereby effecting glucose production, lipid synthesis, and prothrombotic protein secretion - all features of metabolic syndrome.53 Obesity, aging, and diabetes can amplify genetic tendencies toward the clinical expression of the disorder (Figure 41.2). Familial clustering of DM and hypertension has been reported by several investigators, who also observed a close association of insulin resistance with obesity-related hypertension.54,55

156weight gain and birth weight in vegetarian pregnancy

Vegetarians as a group tend to be leaner than do nonvegetarians, with vegans tending to have a lower BMI than other vegetarians 16, 17 . This suggests that vegetarian women tend to begin pregnancy with a lower BMI than do nonvegetarians. Standard weight gain recommendations should be used for vegetarians 18 . Weight gain of pregnant lacto-ovo vegetarians and vegans is generally adequate 14, 19, 20 . Birth weights of infants of vegetarian women have been frequently shown to be similar to those of infants born to nonvegetarian women and to birth weight norms 19-22 . Low birth weights have been reported in some macrobiotic populations 23, 24 . These low birth weights appear to be due to low maternal weight gain secondary to inadequate energy intake 23, 24 . Use some refined foods (i.e., enriched grains, fruit juices) if dietary fiber intake is high

Healthy Weight Gain during Pregnancy

As a general guide, you can use your rate of weight gain as an indicator of whether you are eating enough for both yourself and your baby. Gaining the appropriate amount of weight in pregnancy ensures that your baby is of good birth-weight and also means that you do not have too many extra kilos to shed after delivery. How much weight you need to gain depends on various factors including your pre-pregnan-cy weight, your health status and whether you are carrying a single baby or twins triplets. You can discuss with your doctor to determine how much weight you should gain. Most pregnant women should expect a weight gain of 10-12 kg throughout the entire pregnancy. The weight gain of the mother is mainly due to the increased water retention, thus, maternal weight gain does not necessarily correlate well with the baby's weight at delivery. If you have gained more weight than recommended, do not try to lose weight. It is never safe to lose weight during pregnancy as both you and your baby...

5If you are overweight during pregnancy

Moreover, you may find it more difficult to lose the extra weight after delivery. Thus, it increases the risk of obesity-related conditions like high blood pressure, diabetes or heart disease. Remember, you should not go on a diet to lose weight when you are pregnant. Instead, focus on eating healthily to control your rate of weight gain so that both you and baby will have optimal nutrition.

Maintaining your diet

During breast-feeding, as during pregnancy, your nutrition is largely a matter of educated common sense. Your breast milk's quality isn't significantly affected by your diet unless your eating habits are truly inadequate. However, if you don't take in enough calories or water, your body has a difficult time producing adequate milk. You may also find that your baby reacts a different way to certain foods. For example, he may be extra gassy if you've eaten particular foods. If you pay attention to how your baby responds to different foods, you can figure out what foods to avoid. Breast-feeding women should take in 400 to 600 calories a day more than they would normally eat. The exact amount varies according to how much you weigh and how much fat you gained during pregnancy. Because lactating does burn fat, breast-feeding helps get rid of some of the extra fat stores you may have. But avoid losing weight too fast, or your milk production will suffer. Also, avoid gaining weight while...

1864Sources of Calcium in the Diet

Approximately two thirds of dietary calcium intake in the United States is from fluid milk and other dairy products 35 . Nondairy sources include calcium-fortified orange juice, and rice or soy beverages. Salmon with bones and some green leafy vegetables such as broccoli may also contribute to the intake of calcium however, in general these sources contain less calcium per serving than do milk and dairy products (Table 18.4). The calcium bioavailability of nondairy foods is variable 36, 37 . For most solid foods, the bioavailability of calcium is inversely associated with its oxalate content. For example, the calcium bioavailability from foods high in oxalates such as spinach and rhubarb is low, whereas it is high in foods with low concentrations of oxalates such as kale, broccoli, and bok choy 38 . Supplemental sources of calcium come in a variety of preparations, both liquid and solid. Calcium from carbonate and citrate are the most common forms of calcium supplements 39 . Ingestion...

1872 Recommended Dietary Intake for Vitamin D

Due to the very small and insignificant amounts of vitamin D secreted in human milk, it has historically been concluded that there is no evidence that lactation increases maternal requirements for vitamin D. Therefore, the current recommended adequate intake remains similar to nonlactating adults and is set at 200 IU day 21 . Since the establishment of this recommended dietary intake of vitamin D in 1997, concerns about the wide spread prevalence of vitamin D deficiency have surfaced in the medical and scientific literature. Furthermore, the basis of these recommendations was made prior to the use of circulating 25-hydroxyvitamin D as an indicator of vitamin D status. To date, there is no scientific literature available pertaining to the minimum vitamin D intake needed to maintain normal concentrations of maternal circulating 25-hydroxyvitamin D. The appropriate dose of vitamin D during lactation appears to be greater than the current dietary reference intake of 200 IU day....

1873Dietary Intake of Vitamin D

Since the primary source of vitamin D is synthesis in the skin, very little survey data are available regarding dietary vitamin D intake. As the widespread use of sunscreens and public health recommendations to avoid sun exposure limits this endogenous source of vitamin D, most people necessarily rely on vitamin D from either dietary or supplemental sources. Although dietary sources may provide an amount to meet the currently published 1997 recommendations for vitamin D, they fall short of meeting the suggested requirement proposed in recent studies 49, 53 . A supplemental source of vitamin D is likely required to meet these latter proposed recommendations, at least in the winter months when sun exposure is limited.

4312 Appetite suppressants

Pharmacological effects on the infant of appetite suppressants such as amfepramone ( diethylpropiorin), dexfenfluramine, fenproporex, mefenorex, norpseudoephedrine, sibutramine, and orlistat have not been studied. Weight reduction in the mother releases contaminants from her fatty tissue, which results in an additional burden on the mother's milk (see Chapter 4.18). Recommendation. Appetite suppressants are contraindicated during breastfeeding. The accidental Intake of a single dose does not require limitation of breastfeeding.

1874Sources of Vitamin D in the Diet

Only a few foods are natural sources of vitamin D. These include liver, fatty fish such as salmon, and eggs yolks. Cod liver oil is an excellent source of vitamin D, containing approximately 1,360 IU tablespoon. The major dietary sources of vitamin D, however, are vitamin D fortified foods including milk (100 IU per 8-oz. serving), some orange juices (100 IU per 8-oz. serving), and some margarines (60 IU tablespoon). Breakfast cereals, breads, crackers, cereal grain bars and other foods may be fortified with 10-15 of the recommended daily value for vitamin D. Supplemental vitamin D is available in two distinct forms, vitamin D2 and vitamin D3. Vitamin D3, however, has proven to be a more potent form, with a 70 greater increase in 25-hydroxyvitamin D concentrations 59 .

1882 Recommended Dietary Intake for Folate

The bioavailability of naturally occurring folates in food and synthetic forms of the vitamin is thought to differ considerably. A folic acid supplement taken on an empty stomach is thought to be 100 bioavailable compared to about 50 for naturally occurring food folate (Table 18.5) 62 . In an effort to take into account the different bioavailability of folate from natural versus synthetic sources, folate requirements are now expressed as dietary folate equivalents (micrograms of DFE) micrograms of food folate + (1.7 x mcg of folic acid). The recommended dietary allowance (RDA) for folate published by the US Institute of Medicine for breastfeeding women aged 14-50 years is 500 mcg DFEs per day. The scientific evidence necessary to establish an RDA is more robust than that for an adequate intake level. An RDA is the average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97-98 ) healthy individuals. The RDA of 500 mcg DFEs per day is the...

1883Dietary Intake of Folate

Prior to folic acid fortification of the food supply in North America in 1998, a reduction in maternal folate stores during lactation was observed and was likely due to poor dietary folate intakes 64-67 . Since implementation of the fortification program, significant improvements in blood folate status of reproductive age women, including pregnant and lactating women, have been described 68, 69 . Dietary folate intakes from unfortified foods during lactation, however, remain suboptimal for approximately one third of women as demonstrated in a sample of well-nourished lactating Canadian women 70 . On average in this study, natural food folate provided 283 71 mcg day folate, while folic acid from fortified foods supplied approximately 125 35 mcg day folic acid. The investigators concluded that without mandatory folic acid fortification, 98 of lactating women would not have met their requirements for folate from diet alone 70 .

1884Sources of Folate in the Diet

Natural rich sources of folate are green leafy vegetables as well as citrus fruit juices, liver, and legumes. After folic acid fortification of the food supply, the category bread, rolls, and crackers became the single largest contributor of total folate in the American diet, contributing 16 of total intake, surpassing natural vegetable folate sources 71 . Table 18.6 presents data on the major dietary contributors of folate in the diets of a sample of pregnant and lactating Canadian women 70 . Orange juice was the largest source of total dietary folate (11.1 ), while enriched pasta products were the second largest contributor (8.8 ). Based on the US Department of Agriculture's (USDA's) Dietary Guidelines and MyPyramid, or Canada's Food Guide for Healthy Eating, the grains food group provided 41 of total dietary folate 19, 20 . Thus, women avoiding white bread and enriched pasta to lose weight may be at particular risk of low folate intake.

1893Dietary Intake of Vitamin B12

Low dietary vitamin B12 intakes during lactation typically occur when either the mother is a strict vegetarian or in a developing country where the usual consumption of animal products is low. Since the frequent consumption of animal foods is common in North America, median vitamin B12 intake from food in the general adult population in the United States of 3-4 mcg day and Canada of 4-7 mcg day are well above recommended levels 62 . Nonetheless, there are data to suggest the prevalence of suboptimal vitamin B12 deficiency may be higher than previously appreciated in reproductive age females. For example, House et al. 78 reported that 44 of a large sample of pregnant women in the province of Newfoundland in Canada (n 1,424) had serum vitamin B12 concentrations during the first trimester of pregnancy below a commonly used cut-off value indicative of below-normal or deficient vitamin B12 status (

18102Recommended Dietary Intake for Iron

Iron-deficiency anemia during pregnancy, particularly in the third trimester, is common in both developed and developing countries, and is well described in the literature 5, 81-88 . While less well characterized, due to the net maternal iron deficit accrued during pregnancy (RDA 27 mg day), available evidence suggests a high prevalence of maternal iron deficiency early postpartum, despite women meeting dietary recommendations for lactation. The recovery of iron stores and alleviation of iron deficiency during this period is important, as low maternal iron status is related to fatigue, depression, decreased work capacity, and decreased ability of the mother to care for her newborn infant 89-91 .

18104 Sources of Iron in the Diet

Two types of iron are present in the diet heme and nonheme iron. Heme iron is obtained from animal sources such as meat, poultry, and fish, and is about 20-30 absorbed. Non-heme iron, present in plant foods, iron fortificants, and iron supplements, is less bioavailable with absorption of 5-10 81 . Dietary factors such as vitamin C and the presence of meat, fish or poultry can enhance the absorption of non-heme iron, while phytates found in legumes, grains and rice, polyphenols (in tea, coffee, and red wine) and vegetable proteins, such as those in soybeans, can inhibit non-heme iron absorption. Iron sources obtained from a typical Western diet consisting of abundant animal foods and sufficient sources of vitamin C were estimated to be approximately 18 bioavailable the bioavailability of iron from a vegetarian diet is approximately 10 81 . As a result, the requirement for iron is 1.8 times greater for vegetarians. The average iron content of fruit, vegetables, breads, and pasta ranges...

18112Recommended Dietary Intake for LCPUFAs

Currently, there are no specific recommendations for DHA, EPA, or ARA intake in North America 7 . There are, however, very specific recommendations for ALA and linoleic acid. For nonpregnant nonlactating women, the US Institute of Medicine recommends an adequate intake level of 1.1 g day ALA or an acceptable macronutrient distribution range of 0.6-1.2 energy. For pregnant and lactating women, they recommend 1.4 g day. They do make the recommendation that up to 10 of this range can be consumed as DHA and or EPA. At a workshop on the Essentiality of and Recommended Dietary Intakes (RDIs) for Omega-6 and Omega-3 Fatty Acids held by the National Institutes of Health (NIH) in 1999, attendees recommended that pregnant and lactating women consume 300 mg day of DHA 125 . For nonpregnant nonlactating women, the US Institute of Medicine recommends an adequate intake level of 12 g day linoleic acid or an acceptable macronutrient distribution range of 5-10 energy. For pregnant and lactating...

2032 Obesity and Pregnancy

Chile is a good example in terms of the nutrition transition as seen in developing countries 13 . As indicated above, successful private and public programs have practically eliminated undernutrition, but the situation has gone to the other extreme, obesity being the principal problem today. The 2003 National Health Survey showed that 27.3 of all women aged 17-44 were obese, higher than the prevalence observed in men (19.2 ). Figure 20.4 compares the prevalence of obesity related to age in Chilean women obtained by Berrios et al. 14-16 from observations in 1987 and 1992 in Santiago, and from the CARMEN Study in 1998 carried out in Valparaiso 10 , using a body mass index (BMI) of 27.3 kg m2 as a cutoff point. A marked increase in obesity prevalence was seen in the 25- to 34-year-old group, and prevalence consistently increased with age. A recent national survey showed that of women 17 years of age and older, 33 were overweight, and 25 were obese. In other words, less than 50 of the...

Losing Weight Following The Birth

H er th rou g h th e ea rly b rea stfe ed i n g p eri od . I t i s i mportant not to try to lose weight quickly after the birth while you a re b rea stfeed i n g o r th e q ua I i ty a nd q ua nti ty of you r milk will be reduced. S o , i f yo u must lose weight, leave it u nti I b rea stfe ed i n g i s well established, at I ea st th ree months after the birth, a n d prefera b ly after you r ba by i s weaned. And take it off slowly it took you n i n e months to put the weight on, so t ry to ta ke i t o ff j u s t a s g ra d u a I I y.

2253 Dietary Diversification and Modification

Dietary diversification and modification, which can include home gardening, food processing techniques, reducing consumption of foods that inhibit non-heme iron absorption, and increasing consumption of foods that enhance non-heme iron absorption, serve as methods to increase dietary intake and bioavailability of iron (Table 22.5) 62, 63 . Nutrition education about home gardening of micronutrient-rich foods, and drying of meats and fish, for example, can potentially improve micronutrient content of the diet. Increasing iron-rich flesh food consumption serves as an ideal dietary solution to improving iron intake however, flesh foods are expensive and certain cultural or religious beliefs might preclude the intake of these foods 63 . Iron in food exists in two forms non-heme iron and heme iron. Plant foods and dairy products contain non-heme iron and flesh foods, such as meat and fish, contain heme iron, which is much more bioavailable than non-heme iron. Efficiency of heme iron...

Growth Charts and Body Mass Index Charts

Growth is one of the most important indicators of a child's health. The pattern of a child's weight gain and growth in height can be affected by a number of specific growth disorders as well as by many nutritional problems and chronic medical conditions (see Chapter 17, Growth and Development, and the entry for Growth Disorders in Chapter 32, Health Problems in Early Childhood ). For this reason, at periodic health visits your child's doctor will weigh and measure your child and plot the measurements on standard growth charts. BMI (body mass index) for age, pages 784 and 785

Using the USDA Food Guide Pyramid

No single food can satisfy all your nutritional needs. The USDA Food Guide Pyramid, shown in Figure 4-2, is a general guideline that illustrates the relative proportions of servings you should eat in each group. To get some specific recommendations tailored for your pre-pregnancy weight and activity level, go to and click on the Pregnancy and Breastfeeding link. Use the USDA Food Guide Pyramid to help you eat healthily during pregnancy. Use the USDA Food Guide Pyramid to help you eat healthily during pregnancy. The USDA Food Guide Pyramid includes the following food groups. They appear from left to right on the pyramid Fruits A variety of fruits is an important part of your diet while you are pregnant. Fruits are not only a good source of vitamins and minerals, but they also provide fiber, which is very important during pregnancy to help reduce constipation. Fruits contain healthy amounts of vitamins A and C, as well as potassium. Oils and Fats Oils are fats that...

Blood Pressure Devices for Use in Pregnancy and Obesity

National Academy of Sciences (USA) 2004 Dietary Reference Intakes 3. Altunkan S, 0ztas K and Altunkan E 2006 Validation of the 0mron 637IT wrist blood pressure measuring device with a position sensor according to the International Protocol in adults and obese adults. Blood Pressure Monitoring, 11(2) 79 - 85

54 weight gain recommendations and consequences of noncompliance

In 1990, the IOM issued recommendations for weight gain during pregnancy based on prepregnancy weight status 3 . The goal of these recommendations was to optimize neonatal birth weight to between 3 and 4 kg and prevent the morbidity and mortality associated with low birth weight (LBW). According to these recommendations, an underweight woman (based on WHO BMI criteria above) should gain 28-40 lb (12.5-18 kg), a normal weight woman should gain 25-35 lb (11.5-16 kg), an overweight woman should gain 15-25 lb (7-11.5 kg), and an obese woman should gain less than or equal to 15 lb (7 kg). Recently, these recommendations have been criticized for being too liberal and not making allowances for women who gain excessive amounts of weight during pregnancy. Evidence is mounting that significant numbers of women, particularly overweight and obese women, are not adhering to IOM guidelines. In an investigation of over 120,000 women enrolled in Women, Infants, and Children (WIC) clinics over a...

Getting to your ideal body weight

The last thing most women need is another reason to be concerned about weight control. But this point is important Pregnancy goes most smoothly for women who aren't too heavy or too thin. Overweight women stand a higher-than-normal risk of developing diabetes or high blood pressure during pregnancy, and they're more likely to end up delivering their babies via cesarean section. Underweight women risk having too-small (low birth-weight) babies. Try to reach a healthy, normal weight before you get pregnant. Trying to lose weight after you conceive isn't advisable, even if you're overweight. And if you're underweight to begin with, catching up on pounds when the baby is growing may be difficult. (Read more about your ideal weight and weight gain in Chapter 4.)

52obesity definition

BMI is considered the gold standard when determining weight status, and provides the basis for current weight gain recommendations from the IOM. It is calculated by dividing weight in kilograms by height in meters squared. BMI is not valid while pregnant, and so should be measured pre- and postgestation. In the case where pregesta-tional weight is unknown, the first weight measured at prenatal clinic is generally used to calculate prepregnancy BMI 3 . Pregestation and postpartum obesity is most commonly defined according to the World Health Organization's (WHO) definition underweight, BMI 18.5 kg m2 normal weight, BMI 18.5-24.9 kg m2 overweight, BMI 25-29.9 kg m2 and obese, BMI 30 kg m2 4 . Less often, obesity is defined using the exact weight in kilograms or pounds. Since the definition of obesity is often not consistent in studies using absolute weight rather than BMI, this review focuses on those studies using weight classification based on BMI.

Optimal Weight Gain

Summary Optimal birth weight and outcome are influenced by maternal weight gain. Low gestational weight gain is associated with poor fetal growth and risk of preterm delivery. Excessive weight gain affects infant growth, body fatness in childhood, and the potential for postpartum weight retention and future obesity. Guidelines from the Institute of Medicine recommend that a woman with a normal body mass index (BMI) of 19.8 to 26 should gain 11.5-16 kg (25 to 35 lb). Women with a lower-than-normal BMI should gain slightly more, and those with a BMI greater than 26 should gain 5.911.5 kg (13 to 25 lb). Ideally, weight gain recommendations should be individualized to promote the best outcomes while reducing risk for excessive postpartum weight retention and reducing the risk of later chronic disease for the child and adult. Keywords Gestational weight gain, Energy cost of pregnancy, Body mass index (BMI), Postpartum weight retention, Fetal growth

Caloric restriction

Caloric restriction in pregnant women with GDM is another aspect of medical nutritional therapy that needs to be addressed. When women who are classified as obese or overweight prior to pregnancy, the amount of weight gain in pregnancy differs from those who are at a normal or underweight prior to pregnancy. The National Academy of Science has recommended that for women greater than 150 of ideal body weight, no more than 15 pounds should be gained with pregnancy. Optimal infant birthweight was achieved when less than 3 kg or no weight was gained in these women.31 Hypo-caloric diets have been explored in women with GDM based upon a 2400 kcal day diet. Investigators32 compared a 2400 kcal day diet to a 1200 kcal day diet and achieved significant differences in average glucose and fasting insulin levels, but not in fasting or postglucose challenge tests. Those in the 1200 kcal day group developed ketonemia and ketouria, therefore the study was discontinued due to the controversial...

1051Weight Gain

Weight gain recommendations are based on the 1990 Institute of Medicine's publication, Nutrition during Pregnancy, according to the women's prepregnancy BMI (Table 10.2) 37 . The prepregnancy BMI and the amount of weight gained during pregnancy are two factors affecting perinatal outcome. Weight gain below the Institute of Medicine's recommendations is associated with low birth weight and small-for-gestational-age infants. Excessive weight gain may lead to macrosomia, cesarean section, and unnecessary postpartum weight retention. Overweight women with diabetes need to gain minimum weight to decrease the risk of macrosomia.

Dietary Management

Keeping a dietary history may also reveal problem areas that can be addressed by altering habits. A fibre-rich diet may be advised when the stool requires 'bulking out' or constipation is present, although for some patients this can make their symptoms worse. Caffeine, alcohol, fat and sorbitol-rich foods (e.g. ice cream, chewing gum, honey and jam) are known to aggravate IBS and should be taken in moderation2. IBS can be exacerbated by dietary habits rather than specific foods, e.g. large, rushed or irregular meals2 are also predictors of symptom intensity, with the absence of stress manifesting improved symptoms5.

Dietary control

In gestational diabetes, there is no unambiguous scientific literature to demonstrate that good dietary control, or a special diet, will result in the birth of a smaller infant. Nevertheless, legal cases are often argued on the basis that better diabetic control would have resulted in a smaller baby and in fewer problems at the time of delivery. The court held that the diagnosis of gestational diabetes had never been established during her pregnancy and that it could not be determined retrospectively. Moreover, even if she did have gestational diabetes, there was no convincing evidence that dietary management or insulin would have affected the size of the baby. The expert medical evidence in this case was contradictory, but the judge said that Although this case was heard in 1982, many would argue that scientific evidence on the benefits of dietary control in gestational diabetes has changed little since then.

123weight gain

HIV-infected pregnant women tend to gain less weight during pregnancy compared with women who are not infected 4 , putting them at higher risk for complications. Additionally, HIV infection is oftentimes associated with wasting and a progressive loss of body mass 18 . This can lead to adverse pregnancy outcomes. Weight loss or suboptimal weight gain during pregnancy is related to increased risk of intrauterine growth retardation (IUGR) 10 , fetal death, preterm delivery, and low-birth-weight (LBW) infants 19, 20 . While overall weight gain is indicative of pregnancy outcomes, Villamor et al. showed that weight loss during the third trimester was more strongly associated with preterm delivery than weight loss during the second trimester, but weight loss during the second trimester was related to an increased risk of fetal death 19 . Weight gain goals during pregnancy for HIV-infected women are the same as those for uninfected women. This weight gain is representative of two entities,...

Whats New in This Edition

As in the first two editions, we rely on scientific data rather than opinion or hearsay. Recent medical research has answered some earlier questions, helping us to give better care to pregnant women. For example, we've added new information about revised dietary recommendations from the U.S. Department of Agriculture. Societal and cultural trends that affect us all also affect pregnant women. Topics like Botox and thimerisol weren't important issues when we wrote the first edition, but we discuss them in this edition because they come up more frequently today. Most importantly, we have listened to our patients' comments and suggestions for a third edition, and incorporated many of those ideas into this book.

12 nutrient recommendations for pregnancy

During the first trimester of pregnancy, nutrient needs generally do not increase above the nonpregnant state. Although the fetus is undergoing rapid developmental change early in gestation, most of the nutrients for growth in maternal and fetal tissues are required later in pregnancy. For this reason, the DRIs were generally based on needs during the last half of pregnancy. To allow for optimal storage and accumulation of functional reserve in early pregnancy, however, recommendations were not varied by trimester, with the exception of dietary energy (see discussion below). Dietary Reference Intakes for Women 19-30 Years of Age. (Adapted from 4, 14, 19, 29, 30, 31, 36, 39 ) Dietary Reference Intakes for Women 19-30 Years of Age. (Adapted from 4, 14, 19, 29, 30, 31, 36, 39 ) Extrapolation based on average maternal weight gain Extrapolation based on average maternal weight gain Extrapolation based on average maternal weight gain Dietary Reference Intakes for Women 19-30 Years of Age....

122 Water Soluble Vitamins

Folate is involved in single-carbon transfer reactions, notably important for the synthesis of nucleic acids and certain amino acids for new cell and tissue production. Erythrocyte folate is considered the best marker of long-term folate status in pregnancy serum folate can also be used but reflects more recent changes in dietary intake. With inadequate folate intake, serum and erythrocyte folate concentrations decline, and megaloblastic anemia can develop. Impaired folate status during pregnancy may be involved with adverse outcomes such as pregnancy complications, spontaneous abortion, preterm delivery, and low birth weight 14 . Results from supplementation trials suggest that an additional 200 mcg of dietary folate equivalent* is required to maintain optimal folate status during pregnancy 15 . *Dietary folate equivalents are used to account for the differences in bioavailability between food folate ( 50 bioavailable) and folic acid used in supplements and food fortification ( 85...

124 Nutrients without Increased Requirements during Pregnancy

The fact that requirements for some nutrients do not increase during pregnancy does not imply that these nutrients are not critical to maternal and fetal health. Calcium is a case in point. The needs of the fetus for calcium are substantial, averaging 300 mg day. However, due to homeostatic adjustments, the dietary requirements for calcium do not change during pregnancy. An integrated system of hormones, namely parathyroid hormone and 1,25-dihydroxyvitamin D, regulate intestinal absorption, urinary excretion, and bone flux of calcium. During pregnancy, the efficiency of calcium absorption increases by nearly 50 , such that fetal needs appear to be met without increasing calcium intake or net losses of maternal bone mineral 11, 29 .

From Here to Maternity

In this chapter, we go over what you need to know before you conceive. (We also provide some information on medications and vaccines that those who are already pregnant may be interested in, too.) The first step is to visit your practitioner and go over your family and personal health history. That way, you can discover whether you're in optimal shape to get pregnant, or whether you need to take some time to gain or lose weight, improve your diet, quit smoking, or discontinue medications that could be harmful to your pregnancy. We also give you some basic advice about the easiest way to conceive, and we touch on the topic of infertility.

Longterm consequences of intrauterine exposures

Testing the hypotheses that the consequences of alterations in intrauterine metabolic insult are conditioned by the time in gestation that the exposure occurred and that important outcomes may have latency before appearing much later in development required a long-term perspective. At the Northwestern University DPC, that was implemented through an NIH-funded 'Prospective, long term follow-up study of offspring of diabetic mothers' that has continued for more than two decades. It was initiated between 1978 and 1983 and focused on neurobehavioral development, adipose tissue development and obesity and P-cell function and glucose homeostasis. However, the majority of the studies that confirmed the initial hypotheses that lifelong functions of these tissues are vulnerable to intrauterine insult were not concluded until after Norbie's sudden, untimely death. For the purpose of this report, the commentary has been limited to several reports of Silverman and co-workers.23-26 These indicate...

Facilitated anabolism

Norbie Freinkel

The metabolic changes that can be observed during the disposition of food intake are numerous. Many aspects of a characteristic diurnal metabolic profile of pregnancy were described in reports from the Northwestern group. The mediation of the these changes and the implications for normal pregnancy as well as the states of altered nutrition or metabolism (obesity, diabetes, malnutrition) are not fully defined and continue to be of great interest to investigators. Norbie interpreted the perturbations that were observed in normal

Protein and amino acid metabolism

The accretion of protein is essential for fetal growth and must be sustained by the active transfer of amino acids from maternal circulation. There is no evidence that pregnant women store protein during early pregnancy, when fetal needs are scarce. Therefore, the increased requirements of late pregnancy must be met by metabolic adjustments that enhance both dietary protein utilization and nitrogen retention in order to satisfy fetal demands. Protein metabolism changes gradually throughout gestation, so that nitrogen conservation for fetal growth achieves full potential during the last quarter of pregnancy.7 Nitrogen balance studies showed that the rate of maternal nitrogen retention between 20 and 40 weeks of gestation was greater than the predicted need,8 leading to the proposal that the mother gains additional protein in her own tissues. The increased nitrogen retention in late pregnancy is due to a reduction in urinary nitrogen excretion as a consequence of decreased urea...

Accelerated starvation

Fasted state or starvation' is exaggerated during pregnancy.7 Since the exaggerated changes differed in both temporal and absolute dimensions, Norbie characterized this pattern as 'accelerated starvation.'9 A number of clinical and epidemio-logical studies suggest that greater than normal levels of ketonemia ketonuria during pregnancy may have adverse effects on fetal development and subsequently, adverse neurological consequences.10-12 Thus, it is common clinical practice to avoid dietary manipulations during pregnancy that might enhance ketogenesis such as marked restriction of calorie or carbohydrate intake. However, since the demonstration of 'accelerated starvation' was initially documented in animal models and in women that were subjected to prolonged starvation prior to having termination of pregnancy in early or mid gestation, the relevance of 'accelerated starvation' to the clinical management of normal, healthy pregnancies was uncertain until the report entitled '...

Vitamin metabolism in pregnancy

Adequate maternal micronutrient and vitamin status is especially critical during pregnancy and lactation. Several micronutrient deficiencies (like iron, iodine, zinc) are well established as contributors to abnormal prenatal development and or pregnancy outcome. But less well-recognized for their importance are deficiencies of vitamins. Evidence is accumulating that maternal antioxidant status is important to prevent abnormal pregnancy outcomes. In lactation, the maternal status of several of these vitamins affects their concentration in breast milk. The main cause of multiple vitamin deficiencies is a poor quality diet, even though gene polymorphism can also impair vitamin absorption or alter their metabolism, and cause vitamin deficiency. In some diets high in unrefined grains and legumes, the amount of nutrients consumed may be adequate, but dietary constituents, such as phytanes and polyphenols, can also limit their absorption.

233Total Energy Expenditure

Free-living TEE has been measured by DLW in well-nourished women 15, 30-33 . In these studies, TEE increased on average by 1, 6, and 19 over baseline values in the first, second, and third trimesters. Furthermore, BMR increased by 2, 9, and 24 , and AEE (TEE - BMR) changed by -2, 3, and 6 relative to baseline. On the basis of the larger increment in BMR, physical activity decreased as pregnancy advanced. These findings support the idea that women may conserve energy by reducing the pace or the intensity with which an activity is performed. Pregnant women may also change their activity patterns and thereby reduce the amount of time spent in activities. However, reduction in physical activity does not compensate for increases in BMR and energy deposited in maternal and fetal tissues. Thus, extra dietary energy is ordinarily required as pregnancy progresses 15 .

24 body weight changes after pregnancy

Both mean gestational weight gain and prevalence of overweight women in the US population have increased over the past two decades 44, 45 . Gunderson and Abrams 43 reviewed the literature to examine whether increased gestational weight gain is responsible in part for the increasing prevalence of overweight women. The majority of the epidemiological studies provided data on average body weight gain among pregnant women, without comparison groups. The estimate for weight gain from these studies ranged from 1.4 kg to 1.5 kg by 6-12 months postpartum 46-48 . Gunderson and Abrams also reviewed data from the 1988 National Maternal and Infant Health Survey (NMIHS) 44 , a US representative sample, which revealed a median weight change of 1 kg at 10-18 months postpartum. These relatively small average maternal In a recent study of over 1,000 mother-child pairs investigators found that mothers with greater gestational weight gain had children with more adiposity at 3 years of age, measured by...

Mechanisms leading to the development of gestational diabetes

Because the insulin resistance that takes place in the second half of pregnancy plays a key role in the development of ges-tational diabetes, any condition susceptible to exacerbating this resistance may play a role in the development of GDM. Higher plasma levels of triglycerides and NEFA and lower plasma levels of adiponectin have been associated with higher insulin resistance and therefore to a higher risk of developing GDM. Obesity also increases insulin resistance.38,39 Added to the pregnancy-induced insulin resistance, it makes obese pregnant women more prone to the development of GDM.

Prenatal Care To Reduce Psychosocial And Environmental Risk

Although meaningful clinical studies of nutrition during pregnancy have been difficult to design, it has been demonstrated that maternal prepregnancy weight and weight gain during pregnancy are associated with neonatal weight. Underweight women or women with poor weight gain during pregnancy have a greater risk of delivering an infant weighing less than 2,500 g (64). Conversely, obesity places a woman at higher risk of complications such as gestational diabetes. Women also may benefit from iron and vitamin supplementation, especially those with iron deficiency anemia or poor nutritional status.

251Anthropometric Measures

At the first prenatal visit, the woman's height without shoes should be determined, preferably with a wall stadiometer, the accuracy of which has been verified. Gestational age should be determined from the onset of the woman's last menstruation, supplemented by estimates based on the obstetric clinical examination and by early ultrasound if available. A weight-for-height category derived from the patient's height and prepregnancy weight needs to be established. The resulting BMI should be compared to reference values for BMI. This comparison will provide the bases for the creation of a plan for overall and incremental weight gain and dietary counseling. Other measures that provide information on body composition would add substantially to understanding of the meaning of a given weight gain. Fetal growth may be influenced more by specific maternal tissue changes (accretion of lean tissue, fat or body water), than by total gestational weight gain. For example, skin-fold thickness has...

Physical Activity and Exercise in Pregnancy

Because habits adopted during pregnancy can result in persistent lifestyle improvements, exercise during pregnancy could significantly reduce the lifetime risks of obesity, chronic hypertension and diabetes not only for pregnant women, but also for their families as well. Overall, a woman whose exercise habits have become firmly entrenched during pregnancy stands a much better chance of maintaining them after her child is born.

Summary on early growth delay

Another important work on GDM was done by the present leader of the Diabetes Centre, Peter Damm.25 His DMSc was entitled 'Gestational diabetes mellitus and subsequent development of overt diabetes mellitus - a clinical, metabolic and epidemiological study.' He investigated the prognosis of women with previous GDM with respect to subsequent development of diabetes and also the identification of predictive factors for the development of overt diabetes in these women. He also evaluated insulin sensitivity in glucose-tolerant non-obese women with previous GDM and controls. A decreased insulin sensitivity due to a decreased non-oxidative glucose metabolism in skeletal muscle was found in women with previous GDM. The same group of previous GDM women had

32 physiological changes in pregnancy

Activity in the second and third trimesters 12 . There is a link between strenuous physical activity and the development of intrauterine growth restriction in the presence of dietary restrictions. Mothers with physically demanding and repetitive jobs were reported in several studies to deliver early and give birth to small-for-gestational-age infants 13-15 meanwhile, other studies on vigorous exercise found no difference 16 or an increase 17 in infant birth weight. It appears that infant birth weight is not affected by exercise if energy intake is adequate 18 , and that fetal weight can be maintained with adequate nutritional intake.

242 Diet manipulations and treatment

Dietary measures are often suggested for the mildly symptomatic women, although little evidence supports these measures. Women may benefit from frequent and small meals, with high carbohydrate and low fat conLent. Salty foods may be tolerated better in the morning, and sour or tart beverages may be tolerated better than water (Quinlan 2003). An algorithm of treatment would depend on the women's preferences and the availability of the different modes of therapy. It would seem sensible to start treatment with dietary measures, lifestyle modifications and vitamin Bj,. It' symptoms persist, treatment with meto-clopramide or diclectine (if available) should be started. The first-and some of the second-generation antihistamines are a good option, and if they fail then ondansetron would be the next choice. Intractable cases arc best treated with intravenous antiemetics and steroids, and rehydration therapy in severe cases, parenteral nutrition should be considered. Vitamin B1 should be...

38 nutritional requirements for the active pregnant woman

Although the nutritional needs of active pregnant women are not clearly defined, nutritional needs in pregnancy have been well researched. Energy requirements during the second and third trimesters of pregnancy are an average of 300 kcal a day above prepregnancy requirements 40 . A wide variability in metabolic energy expenditure in pregnancy makes it difficult to set standards for energy requirements 41 . Exercise during pregnancy requires an additional caloric allowance for increased metabolism and greater energy expenditure both during and after the activity. Other factors affecting caloric requirements in pregnancy include prepregnancy body mass index, maternal age, and appetite. Estimation of caloric needs is further complicated by pregnancy changes in maternal extracellular fluid, maternal fat stores, the weight of the fetus and supporting tissue (uterus, placenta, amniotic fluid, and mammary glands), as well as changes in fat-free muscle mass due to variations in activity...

310clinical applications for exercise in pregnancy

Results from the National Health and Nutrition Examination Survey (NHANES) reveal that from 2003-2004 an estimated 66 of adults (over age 20) were either overweight or obese 55 . The obesity rate in women of childbearing age is increasing. In 2003, 19.6 of US women of reproductive age (18-44 years) were classified as obese (BMI 30) 56 . Whether this trend in weight status is associated with the liberalization of the weight gain guidelines in pregnancy is unclear. However, data show that with each subsequent pregnancy, there is a greater risk of postpartum weight retention 57 . A greater focus is needed to prevent excessive weight gain in pregnancy this may be accomplished in part through exercise. One study revealed that women who gained excessive weight and failed to lose weight by 6 months postpartum were 8.3 kg heavier 10 years later 58 . A 15-year follow up study to determine the effects of weight gain in pregnancy revealed that the 1-year postpartum timeframe was the greatest...

2512Constipation during pregnancy

Therapeutically, an improvement should first be attempted with dietary changes, including increased fluid and fiber intake, training of the defecation reflex, and increased physical activity. When these measures are not successful, it may be necessary to use a laxative to enhance the effectiveness of defecation. Laxatives should only be used in pregnancy when dietary and physical measures have been unsuccessful. In this case, stool-bulking agents are the drugs of choice (Bonapace 1998).

Nutrition in pregnancy

What a woman eats during pregnancy affects not only her own state of health but that of her baby as well. Optimum nutrition greatly increases the chances of having a healthy, trouble-free pregnancy. More importantly still, it can have a profound effect on the health of children for the rest of their lives, helping to prevent problems such as coronary artery disease and stroke, bronchitis, obesity and diabetes. What's more, the size, and possibly even the function, of a child's brain depends on its mother's nutrition during pregnancy (Delisle 2002, Godfrey & Barker 2001, Harding 2003, Kind et al 2006).

Early Beliefs And Practices

During the 19th century, much of what was recommended about diet during pregnancy was based on casual observation rather than controlled studies. Because little information was available on the nutrient composition of foods or their biological value, dietary advice was influenced by beliefs that obvious physical properties of different foods could produce specific effects on the mother or the child. These beliefs were often colored by the emotional and mystical aura surrounding the pregnant state. For example, pregnant women were sometimes forbidden to eat salty, acidic, or sour foods for fear the infant would be born with a sour disposition. Eggs were sometimes restricted because of their association with reproductive function. Certain foods were encouraged for their presumed beneficial effects. Pregnant women were often advised to eat broths, warm milk, and ripe fruits to soothe the fetus and ease the birth process. At this time dietary recommendations for pregnancy also were...

Feeding and Nutrition Challenges

During tube feedings, your baby may be offered a pacifier or the breast that is empty of milk to encourage and satisfy the infant's desire to suck. You may be concerned about your baby using a pacifier because you've heard that in full-term infants the use of pacifiers in the first few weeks of life may lead to breast-feeding difficulties. In the premature baby, however, nonnutritive sucking (sucking without taking milk) is calming to the infant, helps digestion, and improves weight gain.

42 Substandard Maternal Nutrition and Increased Maternal Weight Loss

As loss of appetite is often associated with depression, untreated depression during pregnancy may result in substandard maternal nutrition and lower-than-normal maternal weight gain. Studies have shown that intrauterine growth retardation (IUGR) and low neonatal birthweights have been linked to inadequate maternal nutrition and or low maternal weight gain (54). The Centers for Disease Control have classified LBW as the second leading cause of neonatal morbidity and mortality (55).

46longterm consequences of early flavor learning

Significant traces of the effects of early feeding experiences may remain as children age. In an 8-year longitudinal study of 70 white mother-child dyads living in Tennessee 59 , interviews were conducted to determine whether food-related experiences at 2-24 months predicted dietary variety when children were between the ages of 6-8 years. Although vegetable variety in school-aged children was weakly correlated with mothers' vegetable preferences, 25 of the variance in school-aged children's fruit variety was predicted by breastfeeding duration and early fruit variety experience. Similar findings were reported in another longitudinal study from France 60 and a retrospective survey study conducted in England 61 . It is important to note that much of the research showing relationships between food habits in childhood and later in life are correlational in nature and consequently inconclusive regarding cause and effect relationships. The generality of such findings may be limited since...

Taking Your Infant Home

Most babies can go home when they are able to keep their body temperature normal in an open crib, take all their feedings by breast or bottle, and gain weight steadily. The average baby meets these criteria about two to four weeks before the original due date, but this varies greatly, especially for the smallest and sickest premature infants.

Food for conception and pregnancy

Food cravings (the most common being for salty or sweet food) are usually a sign of nutritional deficiencies. In others words, the diet is not properly balanced and may have been out of balance for many years. This should be remedied before conception and pregnancy. Chinese dietary therapy suggests that pregnant women should eat according to their intuition and be guided by what their body is telling them. Vegetarians will often find themselves drawn to dairy foods, eggs, fish and even chicken. They should try to eat a variety of foods, but bitter herbs should be avoided.

Fetal Risk Summary

A woman with primary gout and gouty nephropathy was treated with 300 mg day of allopurinol throughout gestation (8). She was delivered of an appropriate-for-gestational-age 2510-g healthy female infant at 35 weeks' gestation. The infant's weight gain was normal at 10 weeks of age, but other developmental milestones were not provided.

Diet and Exercise for the Expectant Mother

Understanding healthy weight gain yours and your baby's Optimizing your diet Taking food safety into account Staying fit during pregnancy Through the ages, women have received all kinds of advice about what, and how much, to eat while they're expecting. Cultural traditions, religious beliefs, and scientific thinking have all had their influence. As recently as a generation ago, women were told to limit how much they ate and drank and thus keep their weight gain to a minimum. At other times, they were encouraged to eat lots of fatty foods the notion being that the greater the weight gain, the healthier the child. These days, your practitioner's advice is likely to depend on your particular health habits and your size when your pregnancy begins. Also, if you're carrying more than one baby, you're expected to gain more than the average number of pounds. Of course, health involves more than just eating well. Exercise is as important while you're pregnant as it was before, although what...

Determining how much is enough

The best way to figure out your ideal weight and weight gain is to look at a measurement that's known as body mass index (BMI), a number that takes into account both height and weight. Find your body mass index by looking up your measurements on the chart in Figure 4-1. Locate your weight on the vertical line on the left-hand side of the chart and your height on the horizontal (bottom) line. (Alternatively, use the metric measurements on the right-hand and top sides.) Find the place where those two points intersect on the chart, and then follow the diagonal line closest to that point to find your BMI. The body mass index chart. The body mass index chart. After you know your body mass index, you can figure out your ideal weight gain during pregnancy by consulting Table 4-1. (But don't forget, this number refers to women carrying only one baby ) Table 4-1 Figuring Out Your Ideal Weight Gain Body Mass Index Recommended Weight Gain These numbers refer to total weight gain during the...

Insulin signaling system in normal pregnancy and in gestational diabetes mellitus

IRS-1, a cytosolic protein, binds to the phosphorylated intracellular substrates, thereby transmitting the insulin signal downstream. The distribution of the IRS proteins tends to be tissue specific IRS-2 is more copious in the liver and pancreas, whereas both IRS-1 and IRS-2 are widely expressed in skeletal muscle. Insulin stimulates the activation and binding of the lipid kinase enzyme, phos-phatidylinositol (PI)-3-kinase, and its binding to IRS-1. The formation of PI is essential for insulin action on glucose transport. Knockout of the IRS-1 gene causes only a moderate increase in insulin resistance due to increased insulin secretion, but not overt diabetes. In women with GDM, the skeletal muscle contains lower levels of IRS-1 protein and significantly less insulin-stimulated IRS-1 tyrosine phosphorylation, while levels of the IRS-2 protein are increased. These findings suggest that the insulin resistance of GDM may be exerted through a decrease in the...

Avoiding Weight obsession

For the most part, use the charts of optimal weight gain as a guide, but don't become fanatical about how much you weigh. Even if the amount you gain is somewhat off course, if your doctor says that the baby is growing normally, you have nothing to worry about. Women who gain more than average can still have healthy babies, and so can women who gain very little. If your weight gain is way too high or way too low, your doctor can check the baby's growth by measuring the fundal height (see Chapter 3) or scheduling you for a sonogram. If you deviate significantly from the recommended weight gain, your doctor will probably want to evaluate your diet. He may refer you to a nutritionist or dietitian who can give you specific advice about what and how much to eat.

531 Infertility and Risk of Miscarriage

Adverse effects of obesity on natural conception and assisted reproductive therapy in women are well documented in the literature 5-8 (see Table 5.1). For example, Rich-Edwards et al. 7 found that, among 2,500 married, infertile nurses, those with pregestational obesity experienced more frequent anovulation and had longer mean time to pregnancy than did normal-weight women. Also, higher rates of early miscarriage have been found among obese women as compared with women of normal weight. In a case-control study of 1,644 obese women compared with 3,288 normal weight, age-matched controls, Lashen et al. 9 found an increase risk of first trimester and recurrent miscarriage associated with pregestational obesity. Similarly, a Swedish population-based cohort study of over 800,000 women showed that obesity was associated with a twofold greater risk of spontaneous abortion compared with normal weight mothers 10 . Potential Reasons for Infertility in Obese Women In overweight women conceiving...

532 Neural Tube Defects and Congenital Malformations

Several reports suggest an increased risk of congenital malformations, particularly neural tube defects (NTD), for infants born to obese mothers 25-28 . In a case-control study by Waller et al. 25 of 499 mothers of infants with NTDs, 337 mothers of infants with other major birth defects and 534 mothers of infants without birth defects (n 534), women who were obese before pregnancy (BMI 31 kg m2) were significantly more likely to have an infant with an NTD, e.g., spina bifida, compared with normal weight mothers. Results were adjusted for age, race, education, and family income. In a comparison of 604 fetuses and infants with NTDs and 1,658 fetuses and infants with other major malformations, Werler et al. 26 found a significant association between NTD and maternal pregestational weight, independent of folic acid intake. Ray et al. 27 examined antenatal maternal screening data from over 400,000 women in Canada to determine whether the risk of NTDs was lower after flour fortification...

533 Preeclampsia and Gestational Diabetes

While the normal pregnancy is characterized by maternal hemodynamic changes and an insulin resistant state, obesity in pregnancy appears to complicate these expected physiological adaptations to pregnancy. Accordingly, the risk for hypertensive disorders and gestational diabetes (GDM) is reportedly higher in obese and morbidly obese women compared to women who are not obese. In a prospective, multicenter study of more than 16,000 women, Weiss et al. 31 observed a 2.5-fold greater risk of gestational hypertension, and a 2.6-fold greater risk of GDM among obese versus nonobese women. Risk for these conditions was even greater in a morbidly obese subset, e.g., 3.2- and 4-fold respectively. Similarly, these researchers found the risk for developing preeclampsia was 1.6 and 3.3 times more likely to develop in obese and morbidly obese women, respectively. Results from this study have been confirmed by others 32, 33 and found to be independent of other related factors including age, parity,...

Taking Stock of What Youre Taking In

Sticking to a well-balanced, low-fat, high-fiber diet is important not only for your baby but also for your own health. Consuming adequate protein is also important because protein carries out many of the body's functions. The fiber in your diet helps to prevent or reduce constipation and hemorrhoids. By not consuming too much fat, you help keep your heart healthy and avoid putting on extra pounds that may be difficult to shed. Avoiding excessive weight gain also decreases your chances of developing stretch marks. To read more about stretch marks, see Chapter 7. If your diet is balanced and not too heavy in sugar or fat, you don't need to modify the way you eat dramatically. During pregnancy, you should take in roughly 300 extra calories a day, on average. That means that if you're at a healthy weight and you're taking in 2,100 calories per day, while pregnant you should take in an average of 2,400 calories per day (perhaps a little less during your first trimester and a little more...

534Thromboembolic Complications

In the United States, thromboembolic disease is the leading cause of death in pregnant women 36 . Obesity is a documented risk factor for thromboembolism in pregnancy. As evidence, in a retrospective study 37 comparing 683 obese women with 660 normal weight women (all had singleton live births), the risk of thromboembolic disease was twofold greater among obese versus normal weight women. The risk of developing thromboembolic disease is increased for about 6-8 weeks after delivery and is much greater after a cesarean section than after vaginal delivery 36 . Postpartum heparin therapy is often recommended for patients thought to be at high risk for venous throm-boembolism 38 . Also, obese pregnant women may warrant prophylaxis measures against venous thromboembolism, such as compression stockings or heparin therapy, especially if exposed to other risk factors (e.g., bed rest).

535Preterm Delivery Cesarean Section and Operative Complications

Obesity has been independently associated with an increased risk of a number of obstetric complications including preterm delivery, cesarean section, and post-cesarean section infectious morbidity. With respect to preterm delivery, BMI on both ends of the weight spectrum, e.g., BMI 40 kg m2 and BMI

Lipid metabolism and transport in STZinduced diabetic rats

Hypoinsulinemic diabetes is known to result in fat release from adipose tissues, due to the weakened restraint of triglyceride (TG) lipolysis. In non-pregnant animals, this leads to increased hepatic fat oxidation and ketogenesis. However, in pregnant animals, additional tissues take up free fatty acids (FFA) released by lipolysis, namely the placenta and fetus. In STZ diabetic rats, a significant correlation was found between maternal levels of TG, placental TG and fetal TG, all of which were markedly elevated (Figure 12.2).18 There was also a marked increase in TG and FFA in the fetal circulation. Fetal weight does not increase, probably due to the short duration of diabetic pregnancy insufficient for appreciable intrafetal fat accretion and also due to rather severe diabetes in these experiments.18 In another report on diabetes in pigs, fetal obesity was observed.28 Based on the pattern of distribution of the injected 14C-fatty acid and 3H2O radioactivity, it was shown that the...

Risks of Untreated Illness in the Mother

Although clinicians have appropriate concern regarding the risks associated with fetal exposure to psychiatric medications, the potential impact of untreated psychiatric illness on the child's well-being has often been overlooked. Depression may be associated with significant morbidity in the mother. It increases the risk of self-injurious or suicidal behaviors in the mother but also may contribute to inadequate self-care and poor compliance with prenatal care. Women with depression often present with decreased appetite and consequently lower-than-expected weight gain in pregnancy, factors that may be associated with negative pregnancy outcomes (Zuckerman et al. 1989). In addition, pregnant women with depression are more likely to smoke and to use either alcohol or illicit drugs, behaviors that further increase risk to the fetus (Zuckerman et al. 1989).

552Considerations for Bariatric Surgery

Given the growing number of women with severe obesity, it is not surprising that the number of women who are seeking extreme measures to lose weight, e.g., bariatric surgery, is increasing. As discussed in detail in Chap. 6 ( Pregnancy and Weight Loss Surgery ), surgical interventions to lose weight, unless expertly planned, are not without potential consequences for mother and infant. In addition to promoting weight loss, malabsorptive type surgeries such as gastric bypass have resulted in suboptimal maternal

Eating right vegetarianstyle

If you're a vegetarian, rest assured that you can produce a healthy baby without eating steak. But you do have to plan your diet more carefully. Vegetables, whole grains, and legumes (peas and beans) are rich in protein, but most don't have complete proteins. (They don't contain all the essential amino acids that your body can't produce by itself.) To get all the necessary protein, you can combine various proteins, for example, whole grains with legumes or nuts, rice with kidney beans, or even peanut butter with whole-grain bread. The combination doesn't have to occur at the same meal, only on the same day, but a good rule of thumb is to try to get some protein with each meal. If you don't eat any animal products, including milk and cheese, your diet may not provide enough of six other important nutrients vitamin B12, calcium, riboflavin, iron, zinc, and vitamin D. Bring up the topic with your doctor. You may also want to discuss your diet with a nutritionist.

553Improving Compliance to IOM Recommendations

In 2000, Abrams et al. 72 conducted a systematic review of available observational data published between 1990 and 1997 on weight gain and maternal and fetal outcomes. Not surprising, this review showed that pregnancy weight gain within the IOM recommended range was associated with the best outcome for both mothers and infants. However, this review also found that most women were noncompliant with these guidelines many women were gaining excessive amounts of weight. Researchers speculated many reasons for these findings, including environmental temptations, inactivity, and prepregnancy restrictive dieting. They also reported that many women were not given appropriate targets for weight gain. The Women and Infants Starting Healthy study also found that from pregnant women studied in the San Francisco Bay area (excluding women with preterm birth, multiple gestation, or maternal diabetes), 50 of obese women were given advice by their physician to overgain, 35 of underweight women were...

554Successful Interventions

So what works to control excessive weight gain in pregnancy Unfortunately, few studies have been done to answer this question. A Medline search using the keywords pregnancy, intervention, weight gain, revealed three intervention trials for healthy pregnant women in this area. The most recent study 74 investigated whether individual counseling on diet and physical activity during pregnancy could increase diet quality and leisure time physical activity and prevent excessive weight gain among healthy pregnant primiparas. The study was conducted in six maternity clinics in Finland. Women in the treatment group received one 30-min counseling session on diet and physical activity and three 10-min booster sessions on the same until the 37th gestation week. Weight gain, diet, and physical activity guidelines appropriate for pregnancy were recommended as part of counseling. The control group received standard maternity care. Results showed that, while participants in the treatment group...

Further Observations On Energy Costs

Gambian women have provided an outstanding example of energy sparing during pregnancy. This was illustrated using whole body calorimetry. Components of daily energy expenditure were measured before and serially during pregnancy. Weight gain was 15 lb (6.8 kg), fat deposition was 4.4 lb (2 kg), and lean tissue deposition was 11 lb (5 kg). Basal metabolic rate was depressed during the first 18 weeks of gestation. Individual responses to pregnancy correlated with changes in body mass. There was no significant increase in the cost of treadmill exercise, 24-hour energy expenditure, activity, or diet-induced thermogenesis during pregnancy despite body weight gain. Total energy costs over 36 weeks were markedly lower than reported for well-nourished Western populations. To test whether energy-sensitive adjustments in gestational metabolism occur in women other than those studied in the Gambia and England, researchers from the United Kingdom conducted a retrospective analysis of data on basal...

Nutritioninduced diabetes

When animals are fed a high carbohydrate diet, consisting mainly of fructose, they display features of Type 2 diabetes within a short time. Fasting hyperglycemia, hyperinsulinemia and hyper-lipidemia as well as insulin resistance develop.101-103 Some of these features can be ameliorated by supplementing the diet with fish oil104 or by troglitazone as a food admixture.105 Although this has been known for a long time surprisingly little use has been made of this model in pregnancy. One additional effect of the diet is the development of hypertension. This was also found in pregnancy106 suggesting that the fructose-induced diabetes may result in the development of sustained hypertension during pregnancy via the

Comparing forms of exercise

Weight-bearing exercises like running, walking, aerobics, and using a stair-climbing machine or an elliptical trainer are great, as long as you don't do too much. These exercises require you to support all your weight, which is ever-increasing. Because your joints are loosening and your center of gravity is shifting at the same time, you run a slightly higher risk of injuring yourself. Remember to do only what you know you can rather than setting off on a new exercise routine that is too demanding for your current state of fitness, not to mention your pregnancy. You may find it easier, particularly later in pregnancy, to perform nonweight-bearing exercises. Because your weight is supported, you have less chance of injuring yourself, and your joints aren't stressed. If you're new to exercise, a low-intensity workout in the pool or on a stationary bike is ideal.

Taking Care of a Nursing Mother

The Food Guide Pyramid eating plan described in Chapter 22, Healthy Eating, is healthy for children and will be just as healthy for you. Just eat more servings six to eleven servings from the grain group of foods, three to five servings of vegetables, two to four servings of fruit, and three servings of meat, eggs, nuts, or dry beans. Load up on foods from the dairy group to keep up your supply of calcium. If you do not eat dairy products, make sure you get enough calcium. Try calcium-fortified orange juice or cereal, or take a supplement.

Sarah C Couch and Richard J Deckelbaum

Summary Obesity in pregnancy is associated with numerous maternal and neonatal complications including difficulty conceiving, increased risk of miscarriage, fetal anomalies and mortality, higher rates of gestational hypertension, gestational diabetes and preeclampsia, and an increased risk of cesarean section and delivery related complications. Nevertheless, more women are entering pregnancy with excessive weight and are gaining weight above the Institute of Medicine (IOM) recommendations during pregnancy. Weight loss is not recommended during pregnancy however, overweight and obese women should be advised to aim for a moderate weight loss prior to conception and during the postpartum period. Strategies for achieving moderate progestational and postpartum weight loss include a low-calorie, low-fat diet and at least 45 min of daily physical activity. Benefits to mother and child are achieved with even a moderate weight loss. Importantly, health care professionals should counsel women...

Change from physiology to pathophysiology

Human pregnancy is an insulin-resistant condition. Although there is a 4- to 5-fold range of insulin resistance in the general population, there is a relatively uniform 40-50 increase (from the pregravid condition) in insulin resistance and increase in insulin secretion in obese patients of 60 in the first phase of secretion and 130 in the second phase.7 These alterations in insulin have been previously ascribed to a variety of reproductive hormones such as human placental lactogen, cortisol, progesterone and estrogen.8 More recent data have implicated adypocyte placental secreted factors such as cytokines, in particular tumor necrosis factor alfa (TNF-a) and leptin as active candidates in the alteration of insulin sensitivity in pregnancy. Adiponectin belongs to the family of adipocytokines which also includes leptin, TNF-a, resistin, interleukin-6 (IL-6), and others.8,9 Adiponectin is associated with obesity, diabetes, cardiovascular disease and dyslipidemia.10-12 From a metabolic...

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101 Everyday Tips for Losing 10 Pounds

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