nutrition

MaternalNutritionDietaryGuide.pdf

References 1. Institute of Medicine (IOM). Nutrition During Pregnancy: Re- port of the Committee on Nutritional Status During Pregnancy and Lactation. Washington: National Academy Press, 1990.

2. WHO. Safe Vitamin A Dosage during Pregnancy and Lactation. WHO/NUT/98.4. Geneva: World Health Organization, 1998.

3. UNICEF/UNU/WHO. Iron Deficiency Anaemia: Assessment, Prevention, and Control. WHO/NHD/01.3. Geneva: World Health Organization, 2001.

4. Stoltzfus RJ, Dreyfuss ML. Guidelines for the Use of Iron Sup- plements to Prevent and Treat Iron Deficiency Anemia, Wash- ington, DC: The International Nutritional Anemia Consultative Group, 1998.

Maternal Nutrition Resources Food composition tables available in many countries can help field workers identify good, local sources of nutrient- rich foods. The Food and Agriculture Organization’s website (www.fao.org/infoods) lists countries or regions with food composition tables. The nutrient content of specific quantities of most foods can be calculated using the nutrient database on the United States Department of Agriculture website (www.nal.usda.gov/fnic/foodcomp). Additional re- sources on maternal nutrition are available from the LINKAGES Project and members of the CORE Group.

Maternal Nutrition During Pregnancy and Lactation is a joint publication of LINKAGES: Breastfeeding, LAM, Related Complementary Feeding, and Maternal Nutrition Program and the Child Survival Collaborations and Resources (CORE) Nutrition Working Group. The CORE Group is a membership association of more than 35 U.S. nongovernmental organizations working together to promote and improve pri- mary health care programs for women and children and the communities in which they live. Support for LINK- AGES was provided to the Academy for Educational Development (AED) by the Bureau for Global Health of the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No. HRN-A-00-97-00007-00. The opinions expressed herein are those of the authors and do not necessarily re- flect the views of USAID or AED. August 2004

Visit the LINKAGES website at www.linkagesproject.org and the CORE website at www.coregroup.org

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Maternal Nutrition During Pregnancy and Lactation Health workers often lack adequate information to counsel pregnant and lactat- ing women on how to meet increased nutrient requirements through dietary and behavioral changes and other health practices. They are uncertain how to translate general requirements into individual recommendations. This docu- ment attempts to fill this information gap and to help programs develop appro- priate protocols and counseling materials on maternal nutrition.

Women’s nutrient needs increase during pregnancy and lactation, as shown in tables 1-3 inside this folder. Some of the increased nutrient requirements protect maternal health while others affect birth out- come and infant health. If the requirements are not met, the conse- quences can be serious for women and their infants.

During pregnancy all women need more food, a varied diet, and micronutrient supplements. When energy and other nutrient intake does not increase, the body’s own reserves are used, leaving a pregnant woman weakened. Energy needs increase in the second and particularly the third trimester of pregnancy. Inadequate weight gain during pregnancy often results in low birth weight, which in- creases an infant’s risk of dying. Pregnant women also require more protein, iron, iodine, vitamin A, folate, and other nutrients. Deficien- cies of certain nutrients are associated with maternal complications and death, fetal and newborn death, birth defects, and decreased physical and mental potential of the child.

Lactation places high demands on maternal stores of energy, protein, and other nutrients. These stores need to be established, conserved, and replenished. Virtually all mothers, unless extremely malnourished, can produce adequate amounts of breastmilk. The en- ergy, protein, and other nutrients in breastmilk come from a moth- er’s diet or her own body stores. Women who do not get enough en- ergy and nutrients in their diets risk maternal depletion. To prevent this, extra food must be made available to the mother. Breastfeeding also increases the mother’s need for water, so it is important that she drink enough to satisfy her thirst.

Maternal deficiencies of some micronutrients can affect the quality of breastmilk. These deficiencies can be avoided if the mother improves her diet before, during, and between cycles of pregnancy and lacta- tion, or takes supplements. For example, studies have shown that appropriate supplementation improves vitamin A levels in the moth- er, in her breastmilk, and in the infant.

Meeting Nutrient Requirements Adequate energy intake and a diversified diet that includes fruit, vegetables, and animal products throughout the life cycle help en- sure that women enter pregnancy and lactation without deficiencies and obtain adequate nutrients during periods of heightened demand. Some nutrient requirements, particularly iron, folic acid, and vita- min A, are more difficult to achieve than others through food sources. For this reason, supplements with these nutrients are recommended in addition to improved diets. Fortified foods should be promoted through counseling and social marketing in countries where foods fortified with iron, iodine, folic acid, or vitamin A are available and affordable.

Table 1 Weight Gain Recommenda- tions for Pregnancy is based on pre- pregnancy weight. Individual energy requirements vary according to pre- pregnancy height and weight, meta- bolic rate, and activity level. Energy requirements will increase in special circumstances such as adolescence, multiple pregnancies, and HIV infec- tion. Health workers should assess the nutritional situation of women of reproductive age and tailor antenatal care messages about dietary intake, healthy levels of weight gain during pregnancy, and gradual weight loss during lactation according to pre-preg- nancy body mass index (BMI).

Table 2 Micronutrient Supplemen- tation during Pregnancy and Lac- tation shows the dosage and timing for vitamin A, iron/folate, and iodine supplementation. Appropriate regi- mens for micronutrient supplemen- tation vary with the prevalence and epidemiology of deficiencies and with existing policies and programs. Health workers should consult local protocols.

Table 3 Summary of Increased Nutritional Needs during Preg- nancy and Lactation gives examples of common foods in various parts of the world and lists actions health workers can take to promote improved nutrient intake. The examples show nutrient variations in comparable quantities of food, underlining the necessity of tailoring messages to local foods. For example, because an extra serving of potatoes or tortilla does not provide nearly as many additional calories as a serving of cassava, a generic mes- sage to eat an additional serving of the staple food may not be appropriate.

LINKAGES ! Academy for Educational Development ! 1825 Connecticut Avenue, NW, Washington, DC 20009 Phone (202) 884-8221 ! Fax (202) 884-8977 ! E-mail [email protected] ! Website www.linkagesproject.org

Improving Nutrition throughout the Life Cycle Pregnancy and lactation are times of heightened nutritional vulnerability. How- ever, the threat of malnutrition begins in the womb and continues throughout the life cycle. A mother who was malnour- ished as a fetus, young child, or adolescent is more likely to enter pregnancy stunted and malnourished. Her compromised nu- tritional status affects the health and nu- trition of her own children.

Growth faltering earlier in life leaves women permanently at risk of obstetric complications and delivering low birth weight babies. Deficiencies of some micro- nutrients, such as folic acid and iodine, affect the fetus shortly after conception.

Supporting Interventions The following interventions can improve maternal nutrition and com- plement food-based approaches and micronutrient supplementation:

Reduction of malaria infection in pregnant women in endemic areas. Malaria causes anemia in several ways, primarily by destroy- ing red blood cells and suppressing production of new red blood cells. Over the past decade, new approaches to controlling malaria in preg- nancy that emerged in Africa proved highly effective. These approach- es include insecticide-treated materials (ITMs) and intermittent preventive treatment after the first trimester (i.e., after quickening), a strategy that is gaining recognition as more effective than prophy- laxis. Pregnant women in malaria endemic areas should be given in- termittent preventive treatment according to national protocols and protected from further infection by using bednets and other ITMs.

Reduction of hookworm infection in pregnant women in en- demic areas. Hookworm is an important cause of anemia in many situations. In areas where hookworm is considered a public health problem, WHO recommends deworming pregnant women after the first trimester (i.e., after quickening). Wearing footwear and carefully disposing of feces can prevent hookworm infection.

Birth spacing of three years or longer. Adequate spacing between pregnancies gives a woman’s body time to recover and replenish nu- trients. Pregnant and lactating women and their partners can be counseled on child spacing.

Decreased work load or rest during pregnancy. Minimizing heavy work and reducing work hours enable energy-deficient women to conserve energy needed for pregnancy and lactation.

Health workers should mobilize sup- port for maternal nutrition at all levels through the following actions:

Initiate or strengthen health service systems for timely provision of micronu- trient supplements, deworming, and ma- laria treatment. Involve community leaders and other in- fluential people in discussing increased nutritional demands during pregnancy and lactation and the need for more rest and a decreased workload. Disseminate messages to women and their families through varied channels and contact points. Counsel not only women, but also their husbands and elders. Promote dietary diversification, coupled with food production or income-genera- tion activities, to make more diverse foods available at the family level. Pro- mote fortified foods where available and affordable. Negotiate with women and their families to take small steps to improve maternal diet and to increase opportunities for resting.

•

5. WHO. Postpartum Care of the Mother and Newborn: A Practi- cal Guide. WHO/RHT/MSM.98.3 Geneva: World Health Organiza- tion, 1998.

6. Food and Nutrition Board, Institute of Medicine. Dietary Refer- ence Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Wash- ington: National Academies Press, pre-publication date 2002, fi- nal version forthcoming.

7. Food and Nutrition Board, Institute of Medicine. Dietary Refer- ence Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chro- mium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington: National Academies Press, 2002.

LINKAGES Publications Frequently Asked Questions on Breastfeeding and Ma- ternal Nutrition. Updated 2004.

Essential Health Sector Actions to Improve Maternal Nutrition in Africa. 2001.

Maternal Nutrition: Issues and Interventions. (comput- er based slide presentation) Updated 2004.

Recommended Feeding and Dietary Practices to Im- prove Infant and Maternal Nutrition. 1999.

The Case for Promoting Multiple Vitamin/Mineral Sup- plements for Women of Reproductive Age in Developing Countries. 1998.

Using the Essential Nutrition Actions to Improve the Nutrition of Women and Children: A Four-Day Training Course for Program Managers and Pre-service Instruc- tors. 2004.

CORE Members’ Publications CARE. Promoting Quality Maternal and Newborn Care: A Reference Guide for Program Managers. 1998.

CARE. The Healthy Newborn: A Reference Manual for Program Managers. 2002.

Freedom from Hunger. Women’s Health: Healthy Wom- en, Healthy Families. (10 learning sessions for group- based education programs) 2003.

By the time the pregnancy is detected, permanent damage is done. For these reasons, maternal malnutrition cannot be addressed during preg- nancy alone. The periods before and between pregnancies provide an opportunity for women of reproductive age to prepare for pregnancy by consuming an adequate balanced diet, including supplements and forti- fied foods where available, and by achieving a desirable weight.

Overweight and obesity at all ages, even in poor communities, present a difficult challenge for maternal and child health programs. Under- weight and overweight often occur in the same communities and even the same households. Maternal overweight and obesity increase the risk of perinatal mortality, premature delivery, major birth defects, and maternal obstetric complications, including hypertension and gesta- tional diabetes. Maternal and child health programs should alert wom- en at all stages of the life cycle to the need to adjust diet and physical activity levels to achieve and maintain a desirable weight for their own health as well as for better birth outcomes.

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tra -f

a m

ily fo

o d

d ist

ri- b

ut io

n b

y e

d uc

a tin

g m

e n

a nd

o ld

e r w

o m

e n.

p ro

ve fo

o d

a nd

e c

o no

m ic

s e

c ur

ity a

nd ,

in ru

ra l a

re a

s, p

ro m

o te

s m

a ll

liv e

st o

c k

p ro

d -

uc tio

o un

se l p

re g

na nt

w o

m e

n a

nd th

e ir

fa m

- ilie

s o

n th

e n

e e

d fo

r p ro

te in

a nd

id e

nt ify

c a

l f o

o d

s ric

h in

p ro

te in

1 w

ho le

e g

g 1

c hi

c ke

n liv

e r (

20 g

)

1 w

ho le

c a

rro t

1 c

up c

o o

ke d

g re

e ns

1 c

up c

o o

ke d

p um

p ki

n 1

m e

d iu

m m

a ng

=9 83

R A

=1 32

5 RA

E =

15 0

RA E

=1 01

0 RA

E =2

29 R

A E =3

21 R

A E

Li ve

r, e

g g

s, d

a rk

o ra

ng e

a nd

y e

llo w

fr ui

ts a

ve g

e ta

b le

s, d

a rk

g re

e n

ve g

e ta

b le

s, re

d p

a lm

o il,

rti fie

d o

ils o

r o th

e r f

o rti

fie d

p ro

d uc

70 0

RA Ed

+7 0

RA E

+6 00 RA

8 m g

m g

+3 +4

o m

o te

in c

re a

se d

c o

ns um

p tio

n a

p ro

d uc

tio n

o f f

re sh

o r d

rie d

fr ui

ts a

ve g

e ta

b le

iti a

te o

r s tre

ng th

e n

sy st

e m

s fo

r p re

na ta

l a

nd p

o st

p a

rtu m

s up

p le

m e

nt a

tio n.

A ni

m a

l s o

ur c

e fo

o d

s su

c h

a s

re d

m e

a ts

, r e

d o

rg a

n m

e a

ts , p

o ul

try , f

ish ; f

o rti

fie d

fo o

d s;

b e

a ns

a nd

s o

m e

re e

n le

a fy

v e

g e

ta b

le s

3. 5

o z/

10 0g

li ve

r 3.

5 o

z/ 10

0g re

d m

e a

1 c

up b

la c

k b

e a

ns 1

c up

le nt

ils 1

c up

s p

in a

c h

=2 .5

m g

=2 .7

m g

* =

6. 6

m g

* =3

.6 m

g *=

4. 3

m g

o m

o te

s up

p le

m e

nt s

d ur

in g

p re

g na

nc y

a nd

c o

ns um

p tio

n o

f i ro

n- fo

rti fie

d fo

o d

s w

he re

va ila

b le

o un

se l o

n c

o p

in g

w ith

s id

e e

ffe c

ts o

f su

p p

le m

e nt

ro m

o te

c o

ns um

p tio

n o

f i ro

n- ric

h fo

o d

s a

fo o

d s

th a

t e nh

a nc

e a

b so

rp tio

n (m

e a

t, fis

p o

ul try

, a nd

v ita

m in

C -ri

c h

fo o

d s)

ug g

e st

a lte

rn a

tiv e

s to

te a

o r c

o ffe

e w

ith

m e

a ls.

re ve

nt a

nd tr

e a

t m a

la ria

in e

nd e

m ic

a re

a s

p e

r W H

O p

ro to

c o

ls fo

r p re

g na

nt w

o m

e n.

p le

m e

nt d

e w

o rm

in g

p ro

g ra

m s.

D a

rk g

re e

n le

a fy

v e

g e

ta b

le s,

le g

um e

s, n

ut s,

li ve

1/ 2

c up

p e

a nu

ts 3.

5 o

z/ 10

0g li

ve r

=2 17

μ g

=1 06

μ g

o un

se l w

o m

e n

to in

c re

a se

c o

ns um

p tio

n o

f fo

la te

-ri c

h fo

o d

ro vi

d e

s up

p le

m e

nt s

(c o

m b

in a

tio n

o f i

ro n-

fo lic

a c

id ),

p a

rti c

ul a

rly d

ur in

g fi

rs t w

e e

ks o

f p

re g

na nc

Se a

fo o

d , i

o d

ize d

s a

Pr o

m o

te c

o ns

um p

tio n

o f i

o d

ize d

s a

lt. W

he re

io d

in e

d e

fic ie

nc y

is e

nd e

m ic

a nd

d ize

d s

a lt

is no

t a va

ila b

le , s

up p

le m

e nt

a tio

n m

a y

b e

n e

e d

M ilk

a nd

m ilk

p ro

d uc

ts , w

ho le

fi sh

( in

c lu

d in

g b

o ne

s) ,

d a

rk g

re e

n le

a fy

v e

g e

ta b

le s,

le g

um e

Pr o

m o

te c

o ns

um p

tio n

o f c

a lc

iu m

-ri c

h fo

o d

s th

ro ug

ho ut

th e

li fe

c yc

le .

=3 06

m g

=9 5

m g

=1 50

-3 00

m g

1 c

up w

ho le

m ilk

o r y

o g

hu rt

1 c

up w

hi te

b e

a ns

o r c

hi c

kp e

a s

1 c

up d

a rk

le a

fy g

re e

n ve

g e

ta b

le s

O rg

a n

m e

a ts

, r e

d m

e a

t, p

o ul

try , w

ho le

fi sh

o m

o te

s m

a ll

liv e

st o

c k

p ro

d uc

tio n

a nd

a q

ua c

ul tu

re fo

r t a

rg e

te d

fe e

d in

g o

f c hi

ld re

n a

nd p

re g

na nt

a nd

la c

ta tin

g w

o m

e n.

ro m

o te

g e

rm in

a tio

n a

nd fe

rm e

nt a

tio n

re d

uc e

p hy

ta te

in c

e re

a l-b

a se

d d

ie ts

1 e

g g

70 g

c hi

c ke

n, s

te w

e d

1 c

up c

o w

’s m

ilk 1

c up

d rie

d b

e a

ns , p

e a

s, le

nt ils

10 0

g te

m p

e h

o r t

o fu

=1 9

=1 8

g =1

6- 18

=9 .6

g (r

a w

o r c

o o

ke d

) =6

=4 .2

-6 .1

m g

=0 .5

-5 .2

m g

=2 .9

-4 .7

m g

3. 5

o z/

10 0g

li ve

r, ki

d ne

y 3.

5 o

z/ 10

0g b

e e

f, p

o rk

3. 5o

z/ 10

0g s

e a

fo o

d (

fis h,

e tc

)

3. 5

o z/

10 0g

m a

rin e

fi sh

o r s

he llf

ish =8

0 μg

*( w

he n

e a

te n

w ith

fo o

d s

hi g

h in

v ita

m in

C )