Preconception and Prenatal Nutrition

1. Preconception and Prenatal Nutrition Introduction: Infant mortality- the odds that a newborn will live past its first month is one of the most important measures of a country’s quality of life. An article in USA Today, states that USA has 4.3 deaths per 1000 live births each year. According to a recent study, published in journal PLoS Medicine, USA ranks 41st among 193 nations. Two decades ago, it ranked 28th. But actually, the mortality rate is improving and the situation is not really worse in USA than before.

2. Preconception and Prenatal Nutrition • It is just that the other countries are advancing faster in reducing the neonatal mortality rate. This indicates that USA has to progress even faster. • Premature births, low birth weight, lack of prenatal care, high rates of obesity and inadequate preventive health care contribute for a higher neonatal mortality rate.

3. Preconception and prenatal nutrition PRECONCEPTION HEALTH CARE AND NUTRITION • Preconception care is a set of interventions to identify and modify biomedical, behavioral and social risks to a woman’s health or pregnancy outcome through prevention and management. • Unhealthy diet and habits like consumption of junk foods, smoking, alcohol during the child bearing age can cause adverse fetal health problems.

4. Preconception and Prenatal Nutrition • Consumption of nutrient dense food is vital cream Eggs, Raw milk, Butter Fish and shellfish • The nutritional status during the preconception and prenatal period determines the perinatal phase of pregnancy outcome. (It’s like a setting up a strong foundation for a building)

5. Preconception Nutrition Goals • The Centre for Diseases and Control(CDC) aims for achieving 4 preconception goals : • To improve knowledge, attitudes, and behaviors of men and women related to preconception health. 2.To ensure that all US women of childbearing age receive preconception care services(screening, counseling and interventions) that will enable them to enter pregnancy in optimal health.

6. goals 3. To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception period that can prevent or minimize health problems for a mother and her future children. 4. To reduce the disparities in adverse pregnancy outcomes

7. Preconception and Prenatal Nutrition • Preconception risk factors: DiabetesFoliate deficiency Obesity HIV/AIDS Hypertension Hypothyroidism PCOS (Polycystic Ovary Syndrome) Epilepsy Smoking (preterm birth, lowbirth wt) STD(associated with ectopic pregnancy, infertility, chronic pelvic pain) PKU(Phenylketonuria- Mothers should adhere to low phenylalanine diet before conception and throughout the pregnancy) • Some disorders are genetic, neurological and metabolic disorder

8. Preconception nutrition • Preconception nutrition determines the hair color, brain development, skin color and development of diabetes of the fetus(phenotype and genotype) • Determines the prepregnancy weight of the mother. • Healthy nutritional status will result in healthy pregnancy and healthy babies, who, in turn will deliver healthy babies in her/his adulthood and the cycle goes on. (It’s like ‘What comes first –chicken or eggs’. Still it is a puzzle)

9. Prenatal Nutrition • Maternal nutrition during pregnancy is very crucial and vital as it affects both the health of the mother and the growing fetus. • The calorie intake and specific nutrients requirements also increases. • The nutritional status of the mother determines the length of the gestation

10. Prenatal Nutrition • Nutrient Recommendations The quality of the diet during pregnancy has a profound impact on fetal and maternal outcomes. Macronutrients DRI for macronutrients during pregnancy • CHO --175 g/d • protiens -- 71g/d (25 g more than the nonpreg women) • fat -- 20-35% of the total energy expenditure. αlinolenic acid (Omega 3)—1.4 g/d linoleic acid (Omega 6) --- 13 g/d • water – 3 l/d • fiber – 28g/d EPA and DHA (long-chain omega 3 FA)canbe synthezied from linoleic and α-linolenic acid.

11. Prenatal Nutrition • Sources of Omega -3 fatty acids include - vegetable oils (canola oil, flaxseed oil, soyabean oil) - fish oil and - fatty fish • Sources of Omega – 6 fatty acids include - nuts - seeds and - vegetable oils (corn oil, soyabean and safflower) • Non-nutritive sweetner: • Aspartame (Equal or Nutrasweet) is safe during pregnancy if used within the FDA guidelines. Women with PKU should however restrict this. • Saccharin (Sweet’n Low) should be avoided during pregnancy

12. Prenatal Nutrition • Protein – building maternal tissue and fetal growth. - moderate protein intake is optimal during pregnancy Micronutrients Certain Minerals and Vitamins are of significant importance in pregnancy. Some of the key micronutrients are Mg, Fe, Folate, VitD, B vitamins. Deficiency: abnormal prenatal development and pregnancy outcome. Inhibitors : phytates and polyphenols

13. Prenatal Nutrition • DRI for Micronutrients for pregnant women Mg- 400-360mg/d (14-50yrs) Folate – 600µg/d ( “ ) (to avoid NTD) Vit D - 15µg/d ( “ ) Thiamin – 1.4 mg/d ( “ ) Riboflavin – 1.4mg/d ( “ ) Niacin – 18mg/d ( “ ) Biotin – 30µg/d ( “ ) Pantothenic acid – 6mg/d( “ ) Vit B 6 – 1.9mg/d ( “ ) Vit B 12 – 2.6µg/d ( “ ) Fe – 27mg/d ( “ )more Fe is needed for developing fetus and placenta and ↑ in bld volume.

14. Prenatal Nutrition • Magnesium: Functions- energy production, synthesis of nucleic acid, proteins, ion transport across membranes, cell signaling, bone structural integrity. - effective in controlling eclampsia, preeclampsia, arrhythmia, severe asthma, migraine Deficiency- chronic diseases Food sources – green leafy vegetables, nuts, legumes,whole grains • Iron:(essential component of multiple proteins and enzymes) Functions- O2 transport and storage, e-transport, energy metabolism and DNA sysnthesis. Food Sources: Heme Fe (readily absorbed) Meat, poultry, fish. Non-hemeFe – legumes (requires additional Vit C, organic acids to enhance absorption)

15. Prenatal Nutrition Good sources of Fe – Beef, lentils, beans, bran cereal, raisins Deficiency -- anemia Inhibitors of Non-hemeFe – phytates, polyphenols and soyproteins • Folate and Folic acid: Functions- nucleic acid and amino acid metabolism - interacts with B 6 and B12 Deficiency – low birth wt, premature birth, neural tube defects(NTD), ↑ homocysteine levels (predictor of poor preg outcomes) Food Sources- Folic acid – supplements and fortified foods. Folic acid is 100% absorbed Folate – (only partially absorbed) asparagus, spinach, lentils, broccoli, orange juice.

16. Prenatal Nutrition • Vitamin D: Functions- essential for skeletal health, efficient utilization of Ca, BP regulation, insulin secretion, immunity, cell differentiation Deficiency- osteomalacia Food sources – fortified with Vit D – dairy products, cereals, orange juice • B vitamins: Function – participate in many metabolic pathways including energy metabolism Deficiency- leads to hypomethylation of DNA and altered gene expression - homocysteinemia and poor pregnancy outcome - Homocysteine may cause oxidative stress and susequent placental ischemia - ↑ free radical O2,↓nitrous oxide leading to endothelial dysfunction - homocysteine is thrombogenic .

17. Issues in Pregnancy • Maternal overweight and obesity are associated with: Higher risk of GDM (gestational diabetes Mellitus) Hypertension Pre-term delivery Labor induction Postpartum hemorrhage Preeclampsia (high blood pressure and protein in the urine develop in the late 2nd and 3rd trimester) (may result in inadequate placental bld supply) Macrosomia (aka large for gestational age-LGA) may result in C- section and Neonatal hypoglycemia (low glucose level)

18. Issues in Pregnancy • Multiple Gestation - due to assisted reproductive technologies (ART) New borns conceived through ART are at higher risk for - prematurity - low birth weight (2500g and less) - perinatal mortality Women who conceive through ART are more likely to develop - preeclampsia (↑ in BP) - GDM - preterm birth (<37 weeks)

19. Issues in Pregnancy • Gastrointestinal Discomforts - Nausea and vomitting(current dietary recommendation to reduce the symptom is to take multivitamin in preconception period, supplementation with Vit B6, eating ginger as nonpharmacolgic option) - Heart burn - Ptyalism (excessive secretion of saliva. Dietary alterations include chewing gum and restriciting fluids) - Constipation (DRI for fiber intake during pregnancy is 28g/day and increase in fluid intake) - Diarrhea (may be due to food borne infections and irritable bowel syndrome. Acute diarrhea may lead to severe dehydration and result in loss of important electrolytes)

20. Issues in Pregnancy • Eating disorders - anorexia nervosa - Bulimia nervosa Clinical manifestation - menstrual dysfunction - low bone density - sexual dysfunction - miscarriage - preterm delivery or low birth weight - delayed fetal growth

21. Issues in Pregnancy-Food safety • Seafood - Excellent source of lean protein and omega-3 FAs - contain traces of mercury.(avoid large fish) FDA and EPA recommends that - pregnant women - Women of childbearing age, - young children consume 12 oz of fish /week that are lower in mercury - Shrimp, canned tuna, salmon, pollock, catfish avoid eating - shark - swordfish - mackerel - tilefish

22. Food Safety • Listeriosis: - caused by Listeriamonocytogenes ( a gram+ve bacterium) People at risk - pregnant women (septicemia, meningitis, encephalitis, cervical infections) - elderly - adults with weak immune system Symptoms - persistent fever - nausea - vomiting - diarrhea The onset time to gastrointestinal symptoms is probably greater than 12 hrs

23. Food Safety • Foods to avoid - Hot dogs/ luncheon meats (deli) - soft cheese (feta, brie, camembert, blue cheese, roquefort, queso fresco unless the label says made with pasturized milk - unpasteurized milk, eggs, juice - refrigerated pates or meat spreads - refrigerated smoked seafood

24. Polycystic ovary syndrome (PCOS) What is it? A problem in women when the ovaries grow many small cysts. The cysts are not harmful but cause hormonal imbalance which is associated with • anovulatoryinfertilty • Type II diabetes • Abnormal lipid profiles • Cardiovascular disease • Hyperinsulinaemia (due to insulin resistance) Causes: The hormone levels get out of balance. (there are several causes for the changes in the hormone levels). Normally, the ovaries make tiny amount of androgens(male sex hormone), but, in PCOS, they make more amounts

25. Polycystic ovary syndrome In 2010, Barry et al demonstrated hyperandrogenism in utero environment in PCOS pregnancies. But, Anderson et al (2010) demonstrated decreased intrauterine androgen levels and large for gestational age in the offspring of women with PCOS. Design: Prospective case-control study Participants: Thirty- nine women with PCOS and 31 control women and their infants . Objectives: To determine whether the infants of women with PCOS have increased intrauterine androgen levels or reduced birth weight. Outcome Measures: Birth weight and mixed cord blood testosterone (T), androstenedione (A), dehydroepiandrosterone, 17-hydroxyprogesterone, estradiol (E2) and dihydrotestosterone levels were measured Result: There was a significant ↑in the prevelance of LGA infants in PCOS group. Cord blood E2 and A levels were lower (P<0.05). Testosterone to E2 ratios did not differ in female PCOS vs control offspring. There was no difference in E2 and A levels in the male PCOS vs control offspring. There was no difference in 17-hydroxygrogesterone or other androgen levels in either male or female PCOS offspring vs respective control group Conclusions: Offspring of women with PCOS were more likely to be LGA. Female offspring of PCOS have lower cord blood A levels and lower E2 levels. The study demonstrated decreased fetal or placental production of steriods.

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