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1A HEALTHY START IN LIFE ANTENATALNUTRITION
2.0 Antenatal nutrition2.1 Nutrition during pregnancy (1,2,3,4,5)Nutritiousfoodsandanactivelifestylecanhelpachieveoptimalhealththroughoutlife.Goodnutritionisimportantatallstagesthroughoutlifeandparticularlyduringpregnancy.Thehealthandnutritionalstatusofmothersandchildrenareintimatelylinked(1).
Beginningpregnancywithahealthydietisgivingthebabythebestpossiblenutritionaladvantage.Awidevarieddietisvitalinsupportingthegrowthanddevelopmentofthefoetusandthemaintenanceofthewoman’sownhealth.Nutritionalrequirementsformostnutrientsincreaseduringpregnancy,particularlyfolate,iron,zincandvitaminC(2).Thereisonlyasmallriseinenergyrequirements,whichcanbeachievedbyeatingforexampleanextra2–3slicesofbreadperday(3).
Table 5 Foodrecommendationsduringpregnancy
Food group Number of serves 1 serveBread, cereal , rice, pasta, noodles
4 – 6
2slicesbread1mediumbreadroll1cupcookedrice,pastaornoodles1cupbreakfastcerealflakesorporridge½cupmuesli
Fruit
4
1piecemediumsizedfruit2piecessmallerfruit8strawberries20grapesorcherries½cupjuice1cupdiced/cannedfruit1½Tbspsultanas
Vegetables, legumes
5 – 6
1mediumpotato/yam½mediumsweetpotato1cuplettuceorsaladvegetables½cookedvegetables
Meat, fish, poultry, eggs, nuts and legumes
1½
65–100gcookedmeat/chicken80–120gcookedfish2smalleggs1/2 cupcookeddriedbeans,lentils,chickpeas,splitpeasorcannedbeans1/3cuppeanuts/almonds
Dairy
2
1cupmilk40g(2slices)cheese200gyoghurt1cupcustard
Extra foods0 – 2½
1Tbspmargarineoroil1cansoftdrink½smallchocolatebar4plainsweetbiscuits
Adaptedfromthe Australian Guide to Healthy Eating
2 A HEALTHY START IN LIFE ANTENATALNUTRITION
2.2 Sample meal planThe following examples illustrate how the Australian Guide to Healthy Eating can be incorporated into a daily meal plan to meet minimum nutritional requirements.
Breakfast
1cupbreakfastcerealflakes/1cupporridge
Milk(250ml)
1cupstrawberries/1freshorange/½grapefruit
Morning tea
2ricecakes/1slicetoastwith1slicecheeseandtomato
Lunch
Salmon/eggortuna/andsaladbreadroll
1piecefreshfruit
Afternoon tea
1scone
½cupfruitjuice
Dinner
1smallsteak(100g)withmixedvegetables(total1½cups)
1smallpotato
1cupfruitsaladwith2Tbspyoghurt
Supper
2slicesraisintoast,scrapemargarine
Parenthandoutsavailableat
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
3A HEALTHY START IN LIFE ANTENATALNUTRITION
Folate during pregnancyFolateisaBgroupvitaminneededforhealthygrowthanddevelopment.Itsrequirementsareincreasedduringpregnancyfornormalgrowthoftheunbornbaby.Adequatefolateintakehelpstopreventneuraltubedefectsinthebaby,suchasspinabifida(2).
Thevitaminisknownasfolatewhenitisfoundnaturallyinfoodandasfolicacidwhenitisaddedtofoodorusedindietarysupplements(4).
Therecommendedintakeofdietaryfolateforpregnantwomenis600µg/daythroughoutpregnancy.However,toreducethelikelihoodofneuraltubedefectsinthebaby,itisrecommendedthatwomenconsumeanadditional400µg/dayfolicacidthroughasupplementorintheformoffortifiedfoodsforatleast1monthbeforeand3monthsafterconceptioninadditiontoconsumingfoodfolatefromavarieddiet(2).
Itisdifficulttogetenoughfolatefromnaturalsourcesalonetoreducetheriskofneuraltubedefectsinpregnancy.Folicacidsupplementsareavailableoverthecounter.Womenwhohaveafamilyhistoryofneuraltubedefectslikespinabifidarequiremedicaladvicebeforebecomingpregnant(4)astheymayneedevenhigheramountsoffolicacid.
Goodsourcesoffolateincludeleafyvegetables,wholegrains,fortifiedcereals,peas,nuts,avocadosandyeastextracts(egMarmite, Promite, Vegemite etc).
Forfurtherinformationandparenthandouts:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
Checkdiet contains rich sources of folate before and during pregnancy✔✔
advise women to take folate supplements for 1 month before conception ✔✔and during the first trimester of pregnancy
if dietary intake is poor, consider continuing folate supplement after ✔✔the first trimester
folic acid intakes should not exceed 800 – 1000 µg/day.✔✔
4 A HEALTHY START IN LIFE ANTENATALNUTRITION
Iron during pregnancyIronisacomponentofhaemoglobin,thecomponentofbloodwhichcarriesoxygenaroundthebody.Thepeakironrequirementinpregnancyoccursthroughoutthesecondandthirdtrimesters.Thisistosupporttheexpansionofthematernalredbloodcellmass,thegrowingfoetusandtheplacenta.Alackofironmayresultinanaemia.Womenwhosedietpriortopregnancywaslowiniron,mayhavelowironstores.Thisincreasestheirriskofdevelopingirondeficiencyanaemiaduringpregnancy.Dietaryironisusedbythegrowingbabyfirst,leavingthemother’sstoresdepletedifherintakeisinadequate.Lowironlevelsinearlypregnancyhavebeenlinkedtoprematurebirthandlowbirthweight.
TheRDIforironinpregnancyis27mg/day(5).Amixeddietofanimalandplantfoodscanhelpyouachieveyourironintake.AbsorptionofironisbetterfromanimalfoodscomparedtoplantsourcesandtherecommendeddietaryintakesarebasedonamixedWesterndiet.
Therearetwotypesofironinfood:ironfromanimalfoods(calledhaemiron)andironfromplantfoods(callednon-haemiron).
Haemironistakenupbythebodyabout10timesbetterthannon-haemiron.Meatsarethebestsourceofiron.Theredderthemeat,thehigheritisiniron.Thismeansbeefandlambarehigherinironthanpork,chickenorfish.Colouredfleshfish,suchastunaandmulletarehigherinironthanreeffish,suchasbarramundi.
Non-haemironisfoundinsomeplantfoodssuchas:
wholegrainandironfortifiedbreadsandcerealsfoods,eg.breakfastcereal✔■
withaddediron
legumes,eg.kidneybeans,bakedbeans✔■
greenleafyvegetables,eg.spinachandbroccoli✔■
nutsanddriedfruit.✔■
Rememberthatironfromthesefoodsisnottakenupbythebodyaswellasironfromanimalfoods.Youwillneedtoeatmoreofthesefoodsiftheyareyouronlyironsource.
AddingaglassoffruitjuiceorotherfoodsrichinvitaminC(suchastomato,broccoliorcapsicum)toamealwillincreasetheamountofironthebodyabsorbs.Incontrast,tea,coffeeandunprocessedbrancaninhibitironabsorption.
Indicators of iron deficiency
Ironstatusisdeterminedbymeasuringbloodlevelsofhaemoglobin,serumferritinandserumtransferrin.Serumferritinisthebestindicatorofironstores.Lowserumferritinlevelsindicatedepletedironstores.Haemoglobinisnotasensitiveindicatorofironstatus,withlevelsdecreasingoftenonlywhenferritinstoresareseverelydepleted.Inaddition,haemoglobinlevelsdecreaseduringthethirdtrimesterofpregnancyduetohaemodilutioneffects.Ferritinlevelsremainunchangedduringthistime.Serumtransferrintransportsironintheblood.Transferrinvaluesincreasewithirondeficiencyanddecreasewithironoverload.Ironintakeshouldbeincreasedwhenserumferritinlevelsarelow.Ideallythedietshouldbeexaminedforadequateironintake.Ifthedietappearstoprovideadequateirondespitelowferritinlevels,supplementsmaybeconsidered.
5A HEALTHY START IN LIFE ANTENATALNUTRITION
Checkif serum ferritin levels are low, iron intake needs to be increased✔✔
iron supplements may cause constipation. Constipation may be minimised ✔✔by consuming adequate intakes of dietary fibre and fluid. Foods from the meat/meat alternatives group provide the best sources of iron. Vegetarians need to consume vitamin C rich foods with meals to increase iron vabsorption and eat a good variety of non-haem iron sources.
IodineTheRDIforiodineinpregnancyis220ug/day(5).Iodinedeficiencyinpregnancycanaffectgrowthanddevelopmentintheunbornchild,increasethechanceofmiscarriageandhaveseriousimplicationsforintellectualdevelopment.Iodinecanbefoundindairyproductsiemilkandyoghurt,breadbakedwithiodisedsaltandsaltwaterfish.Itisveryimportantformotherstoconsumesufficientiodinefromthetimeofconception,justasitisforthemorewell-knownnutrientsofironandfolate(5).
Multivitamin supplementsApartfromtherecommendedfolatesupplement,itisbesttoobtainnutrientsfromahealthydiet.MultivitaminsnotdesignedforpregnancyarenotrecommendedastherearedangersassociatedwithexcessivedosesofnutrientssuchasVitaminsA,DandB6(2).
Alternative and herbal remediesMostherbalandhomeopathicremedieshavenotbeentestedtodeterminetheirsafetyduringpregnancy.Manyherbalpreparationshaveadrug-likeeffectandshouldbeusedwiththesamecautionaswithotherdrugsduringpregnancy.Herbalpreparationsshouldbeavoidedduringthefirsttrimester.TheNationalPrescribingService(NPS)Medicineslinecanprovideinformationregardingalternativetreatmentsinpregnancy,phone1300888763.
Patienthandoutsavailableat
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
6 A HEALTHY START IN LIFE ANTENATALNUTRITION
2.3 Special considerations during pregnancyListeriaListeriaarebacteriacarriedinsomefoodsthatcancauseaninfectioncalledlisteriosis.Thebacteriacommonlyinhabitsoil,water,plantsandsewerage.Theinfectionmaycausefewornosymptomsinhealthypeople,includingpregnantwomen.However,theriskoftransmissionfromtheinfectedpregnantwomantoherunbornchildishigher.Infectionofthefoetuscanleadtomiscarriage,stillbirth,prematurebirthorsevereillnessinnewbornbabies(2).
Thebestwaystoavoidlisteriainfectionsincludehygienicpreparation,storingandhandlingoffood.Foodsshouldbeeatenfresh,orthoroughlycooked,orwellwashedifeatenraw(fruitandvegetables).Leftoverscanbeeateniftheyhavebeenrefrigeratedimmediatelyandstoredforlessthan24hours.
Thefoodsmostlikelytocarrythebacteria,increasetheriskofinfectionandthereforeshouldbeavoided,include:
softandsemisoftcheeses,eg.brie,camembert,ricotta,blue,fetta✔■
softserveicecream✔■
unpasteuriseddairyproducts✔■
pate✔■
chilledseafood✔■
salads-fruit/vegetable,eg.prepared,prepackaged,smorgasbord/saladbars✔■
coldmeats,includingchicken,eg.deli,sandwichbars,andpackagedready-to-eat.✔■
Healthy tips
always wash hands before preparing or serving food and after handling ✔✔animals or visiting the toilet
animals can carry the toxoplasmosis parasite which can cause disease in ✔✔humans so keep them out of the kitchen; avoid touching faeces and wear rubber gloves under garden gloves
wash cookware and utensils well after use ✔✔
store raw foods down low in the fridge and check fridge temperature ✔✔regularly
foods and leftovers that belong in the fridge should always be refrigerated ✔✔as soon as possible
thaw frozen meats in the fridge ✔✔
once cooked, pasta and rice should be stored in the fridge ✔✔
look for ‘best before’ and ‘use by’ dates on packaged foods.✔✔
Forfurtherinformation:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
7A HEALTHY START IN LIFE ANTENATALNUTRITION
MercuryFishisasafeandimportantpartoftheAustraliandiet.Itcontainsanexcellentsourceofprotein,islowinsaturatedfat,highinomega3fishoilsandisanexcellentsourceofiodine.Therehasbeensomeconcernregardingthelevelofmercuryinfish,specificallyaccumulationofmercuryinfishthatarehigherupthefoodchain.
Food Standards Australia and New Zealand(FSANZ)advisespregnantwomen,andwomenplanningpregnancy,toeatavarietyoffishaspartofahealthydiet.However,pregnantwomenshouldlimittheirintakeofcertaintypesoffish.
Table 6. Recommendationsoffishconsumptionduringpregnancy
Pregnantwomenandwomenplanningpregnancy(1serve=150g)
1serveper fortnight ofshark(flake)orbillfish(swordfish/broadbillandmarlin)andNOotherfishthatfortnight
OR
1serveperweek oforangeroughy(deepseaperch)orcatfishandNOotherfishthatweek
OR
2–3servesperweekofanyotherfishandseafoodnotlistedabove
AdaptedfromFood Standards Australia and New Zealand
Forfurtherinformation:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
CaffeineCaffeineisachemicalfoundinmanyfoodsanddrinks,includingcoffee,teaandcola.Itaffectsthenervoussystemandcancauseirritability,nervousnessandsleeplessness.Duringpregnancyittakeslongertobreakdowncaffeine.
Whilehavinglargeamountsofcaffeinedoesnotappeartocausebirthdefects,drinkinghighamountsofcaffeinemaymakeitmoredifficulttobecomepregnantandmayincreasetheriskofmiscarriage.
Itisbesttolimitthedailyamountofcaffeineto:
2cupsofcoffee,or✔■
4cupsoftea,or✔■
4cupsofcoladrink,or✔■
lessthan1cupofcolaorenergydrinksthatcontainextracaffeine,or✔■
decaffeinatedvarietiesareanoptionwhichcontainslittlecaffeinehoweversafelevelsof✔■
decaffeinatedproductsforpregnantwomenareunknown.
(ReproducedwiththepermissionofCommonwealthDepartmentofHealthandAgeing)
Artificial sweetenersTheuseofonlysomeartificialsweetenersisconsideredtobesafeduringpregnancy.FSANZhaslistedaspartame(marketedinfoodproductsasEqual, Hermesetas and Nutrasweet)andsucralose(Splenda)assafetouseduringpregnancy(2).
8 A HEALTHY START IN LIFE ANTENATALNUTRITION
AlcoholDuringpregnancyalcoholcrossestheplacentaandcanleadtophysical,growthandmentalproblemsinsomebabies.Babiesaffectedbyalcoholtendtohavelowbirthweights.Theymayalsohavephysicalandbehaviourproblemsatbirthandthroughoutchildhood.(2)
Therearenoknownsafelevelsofalcoholconsumptioninpregnancy.Therefore,itisbesttoavoiddrinkingalcoholduringpregnancyasmuchaspossible.
The Australian National Health and Medical Research Council (NHMRC) has made the following recommendations for women who are pregnant or planning a pregnancy:
Women may consider not drinking alcohol at all
It is most important not to become intoxicated
Women who choose to drink should have less than 7 standard drinks per week
Women should have at least 2 alcohol free days a week
On any 1 day no more than 2 standard drinks should be consumed. These drinks should be spread over at least 2 hours.
Drinkinglargerquantitiesatanyonetimemayaffectthedevelopingfoetalbrain.
1standarddrinkisequalto:✔■
100mlwine✔■
1‘pot’ofbeer(285ml)✔■
1can/stubbie(375ml)lowalcoholbeer✔■
1nipofspirits(30ml)✔■
60mlfortifiedwine(portorsherry).✔■
Checkalcohol consumption is reduced to nil where possible. If alcohol is consumed, ✔✔the intake should not exceed more than 2 standard drinks per day.
Morning sicknessMorningsicknessisacommonsymptomofearlypregnancyand,inmanycases,goesawaybytheendofthefirsttrimester.Itiscausedbychangesinhormonesduringpregnancyandmaymakeeatingdifficult.Althoughitiscalled‘morningsickness’,nausea(withorwithoutvomiting)canhappenatanytimeoftheday.Asmallnumberofwomenexperienceseverevomitingwhichcanleadtodehydrationandelectrolyteimbalances.Suchwomenrequiremedicalassistanceandpossiblyhospitaladmissionforcorrection.Inothercases,frequentandprolongednausea/vomitingcanleadtoaninadequateenergyintakewhichresultsinweightloss.Thisweightlossusuallyceasesoncenauseareducesandappetiteimproves.
Checkadequate energy intake to prevent weight loss✔✔
if morning sickness persists with vomiting more than twice daily for more ✔✔than 2 days, medical intervention should be sought as hospitalisation may be required. Ensure adequate fluid replacement to avoid dehydration.
Patienthandoutsavailableat
qheps.health.qld.gov.au/ahwac/content/nemo_review.htm
Thefollowingpagecanbeusedasaparenthandout.
9A HEALTHY START IN LIFE ANTENATALNUTRITION
Morning sickness
Morningsicknessdoesnotusuallycauseanyproblemsfortheunbornbaby.Somefoodandeatingsuggestionsthatmayhelpmanagesymptomsofmorningsicknessornauseainclude:
eatsmallermealsmoreoften.missingmealscanmakenauseaworse✔■
avoidlargedrinks.havefrequentsmalldrinksbetweenmeals✔■
limitfatty,spicyandfriedfoods✔■
foodhasastrongerodourorsmellwhenitisheated,whichmaymake✔■
nauseaworse.ifpossible,haveotherpeoplehelpwithcooking,orprepareyourfoodattimesofthedaywhenyoufeelbetter
tryeatingadrybiscuitbeforeyougetoutofbedinthemorning✔■
eatahealthysnackbeforeyougotobedatnight.thismightincludefruit✔■
(fresh,tinned,dried),crackerswithhardcheeseoryoghurt
avoidfoodsiftheirtaste,smellorappearancemakeyoufeelsick✔■
ifvomiting,itisimportanttodrinkenoughfluids.Itmaybeeasiertohave✔■
lotsofsmalldrinksthantotryanddrinkalargeamountinonego.Tryavarietyoffluidssuchaswater,fruitjuice,lemonadeandclearsoups.Sometimesitcanbehelpfultotrycrushedice,slushies,iceblocksorevensuckonfrozenfruitsuchasgrapesororangesegments.
Note: Thestomachacidsinvomitingcansoftenteethenamel.Itisbestnottouseatoothbrushtocleantheteethstraightaftervomitingasthismaydamagethem.Haveadrinkofwatertocleanyourmouth.
10 A HEALTHY START IN LIFE ANTENATALNUTRITION
ConstipationConstipationiscommoninpregnancyforthefollowingreasons:
Intestinalmuscleappearstolosetone,makingitdifficultforfoodtopassthrough:✔■
thebabyinlatterpregnancy,placespressureontheintestine,exacerbatingtheproblem✔■
ironsupplementationmaycauseconstipationinsomewomen.✔■
Constipationcanbeminimisedbyensuring:adequateexercise✔■
highfibreintake✔■
adequatefluidintake(1.5–2Lperday).✔■
Checkensure adequate fibre intake by eating fruit, vegetables and wholemeal/✔✔wholegrain breads and cereals
ensure adequate fluid intake (ie. 1.5 l/day)✔✔
regular activity ✔✔
regular use of laxatives is not recommended.✔✔
Parenthandoutsavailableathttp://qheps.health.qld.gov.au/ahwac/content/nemo_review.htm
HeartburnHeartburnoccursforanumberofreasonsincluding:
Relaxationoftheoesophagealmusclesduringpregnancy(underhormonalinfluences)✔■
allowsacidtorunintotheoesophagus,andpressurefromthegrowingbabyonthestomachcausesabackflowofacid.Somesuggestionsforreliefofheartburninclude:
Eatsmallermealsfrequently✔■
Chewfoodwell✔■
Avoidfattyandspicyfoodswhichmayirritatethecondition✔■
Drinkfluidsseparatelytomeals✔■
Snackondrybiscuitsortoast✔■
Sippingmilkmayeaseheartburntemporarily✔■
Relaxwhileeating✔■
Avoidlyingdownorbendingoverdirectlyaftermeals✔■
Don’tsmoke✔■
Avoidalcohol✔■
Careneedstobetakentoensurenoneofthefoodgroupsareomittedfromthediet,✔■
sincethiscanreducethenutritionaladequacyofthediet
Someantacidsaresafetotakeduringpregnancy,butmayinhibitironabsorption.✔■
Recommenduseundermedicalsupervision.
Parenthandoutsavailable
qheps.health.qld.gov.au/ahwac/content/nemo_review.htmwww.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
11A HEALTHY START IN LIFE ANTENATALNUTRITION
2.4 Weight gain during pregnancyAhealthyweightgainduringpregnancycanvarybetweenindividualsanddependsonpre-pregnantweight.Itisrecommendedwomenwhoareplanningapregnancyshouldattempttoreachahealthybodyweightbeforetheybecomepregnantasbeingoverweightorobese,orunderweight,priortoconceptionisassociatedwithanincreasedriskofanumberofcomplications.
Anaverageweightgainduringpregnancyforapersonofahealthyweightis10-15kg.ThebreakdownofthisweightgainisillustratedinTables7and8.Thematernalfatstoresareusedlaterintheproductionofbreastmilk.Healthyweightgainismostlyseeninthesecondandthirdtrimesters(afterthefirst3months)ofpregnancy.Thisisthetimeofpregnancywhenmother’senergy(kilojoule)requirementsincrease.However,itisbesttofocusonfoodqualityratherthanquantitytomeetthenutritionalneedsinpregnancy.Thereisnoreasontoincreasefoodquantitytothepointof‘eatingfortwo’asthisislikelytoleadtoextraweightgain.
Howeveritmustbestressedthatpregnancyisnotthetimeforweightlossdiets.Restrictingfoodandnutrientintakecompromisesboththedevelopmentofthebabyandthemother’snutritionalstatus.Womenwhoareunderweightorhavesomeformofeatingdisorderplacetheirbabyandthemselvesatnutritionalrisk.Ifthemothers’dietisinadequate,maternalstoreswillbedepleted.Thiscancompromisethemothers’health,sincethebabytakesthenutrientsitrequiresfirst.
TheInstituteofMedicine(IOM)recommendsweightgainrangesbasedonpre-pregnancybodymassindex(BMI)(8).Researchhasshownpregnancyweightgainwithintheserangesisassociatedwiththebestoutcomeforbothmothersandinfants.TocalculateBMIusethefollowingequationorrefertoFigure3.
BMI=w(kg)/ht(m)2
Figure 3 BodyMassIndexchart
12 A HEALTHY START IN LIFE ANTENATALNUTRITION
Table 7 Recommendedtotalweightgainduringpregnancy,proportionaltoweightforheight
Weight-for-height category Recommended total gain (kg)
Low(BMI<19.8) 12.5-18
Normal(BMI19.8-26.0) 11.5-16
High(BMI>26-29.0) 7-11.5
Obese(BMI>29.0) >6.0
Table 8 Thegeneralguidetothepatternofweightgainduringpregnancy
Trimester Healthy weight Underweight Overweight Obese
1st 0-2 1-3 0-1 0-1
2nd 4-6 5-8 3-4 2-3
3rd 4-6 5-8 3-4 2-3
Total 11-16kg 12-18kg 7-11kg <7kg
Thepatternofweightgainvariesforeachwomanandeachpregnancy.Specificadviceforindividualneedsshouldbesoughtfromaqualifieddietitianorhealthprofessional.
Healthy eating to increase weight gain Sometimesifwomensufferfrommorningsicknessearlyinpregnancyitmaybedifficulttogainweightandsometimesmayloseasmallamount.Thisisnotcauseforconcernaslongasweightgainstartsinthesecondtrimesterofthepregnancy.
Inadequateweightgaininpregnancycanadverselyaffectthehealthofmotherandbaby.Ifnotgainingenoughweightsuggesttheseideas:
Eat3mealsaday✔■
Includesnacksbetweenmeals✔■
Enjoyhealthysnackfoodssuchas:✔■
Freshordriedfruit✔■
Yoghurt✔■
Nutsandseeds✔■
Mueslibars✔■
Biscuitsandcheese✔■
Milkdrinks✔■
13A HEALTHY START IN LIFE ANTENATALNUTRITION
Healthy eating to control weight gain Pregnancyisnotatimeforstrictdieting.However,excessiveweightgainduringpregnancycancauseproblemswithhighbloodpressure,gestationaldiabetesforthemother,alargeforgestationalagebabyanddeliverycomplications.Ifmotherisoverweightitisimportantcontrolweightgaininpregnancy.
Limit the amount of fat eaten
Limitintakeofbiscuitsandcakes✔■
Limitintakeofchipsandcrisps✔■
Reducetheamountoffatusedincooking✔■
Chooselowfatdairyproductsincludingmilk,yoghurt,andcheese✔■
Avoidcreamandsourcream✔■
Trimallthefatoffmeatbeforecooking✔■
Removetheskinfromchicken✔■
Limithighfattake-awayfoods✔■
Limit high sugar foods
Drinkwaternotsoftdrinkorcordial✔■
Use“diet”orlowjouleproducts✔■
Limitfruitjuicestoonceaday,thesearehighinsugar✔■
Limitchocolates,lolliesandsweets✔■
Limitintakeofdesserts✔■
Minimisesnacking✔■
Increasephysicalactivity✔■
Checkweight loss is not recommended during pregnancy✔✔
weight gain education provided based on pre-pregnant BMI.✔✔
Returning to pre-pregnant weight Manywomenareconcernedaboutweightgainedduringpregnancyandarekeentoreturntotheirpre-pregnancyweightassoonaspossibleaftertheirbabyisborn.Itisimportanttorememberthatawoman’snutritionalrequirementsremainincreasedwhilebreastfeeding.Itisessentialthatintakeisnotrestrictedtoapointwherenutritionalrequirementsarenotmet.
Womenwhogainexcessiveweightduringpregnancyareatriskofpostpartumweightretention(9).Thegreatestamountofweightlossoccursinthefirst3monthsafterbirthandthencontinuesataslowandsteadyrateuntil6monthsafterbirth(9).
14 A HEALTHY START IN LIFE ANTENATALNUTRITION
Healthy eating tips for those trying to lose weightExercisingisagoodwayofstimulatingweightloss.Notonlydoesithavephysicalbenefitseg.weightlossandimprovedgeneralhealth,butalsopsychologicalbenefitsforthemother.Theexerciseneednotbevigorous.Infact,regularwalkingisaverygoodformofactivity.Encouragemotherstoexerciseregularly-atleast5timesaweekfor30minutesatatime.
Frequentbreastfeedingcanbebeneficialforweightlossandincreaseswiththelengthofthelactationcourse.
Theextraenergyrequiredtobreastfeedcanoftenbesignificant.Thesurplusfatstoreslaiddownduringpregnancy(ie.aroundhips)canbeusedtomeettheseadditionalenergyneeds.
Encouragemotherstoeatregularmeals.Skippingmealscanresultinsnackingbetweenmeals.Itcanalsoslowdownthebody’smetabolism,makingitmoredifficulttoloseweight.
Avoidchoosingfoodswithahighfatcontentiechooseleancutsofmeat,skinlesschickenandfish;choosecookingmethodsthatuseminimalfat;chooselowfatproductswherepossible;uselessmargarine,butter,oil;avoidcakes,biscuits,chocolates,lollies,cordialsandsoftdrinks.
Healthy eating tips for those trying to gain weightSomewomenalsolosealotofweightwhiletheyarebreastfeedingandfinditdifficulttomaintainanacceptableweight.ThisisNOTanindicationthatbreastfeedingshouldstop.Thefollowinglistsgivesomeideasforgainingandmaintainingweight.
Don’tskipmeals.✔■
Havethreemainmealsandthreebetweenmealsnacks.✔■
Keepeasytopreparenutritioussnacksonhandegcrackersandcheese,freshfruit,✔■
yoghurt,nuts,seeds,driedfruit,cannedbeans,flavouredmilk,fruitsmoothies,breakfastcerealsandmilk.
Prepareapackedlunchorvarietyofsnackstohaveinacontainerbesideyouwhen✔■
babyfeeds.
Prepareandfreezemealsinadvancewhenpossible(oraskyourfriends/familytohelp).✔■
Checkif client is experiencing problems returning to healthy weight range ✔✔recommend consultation with a dietitian/ nutritionist.
15A HEALTHY START IN LIFE ANTENATALNUTRITION
2.5 Groups requiring special attention during pregnancy
Vegetarian and vegansVegetarianismmeansdifferentthingstodifferentpeople.Table9outlinesthevariouseatingpracticesofdifferentgroupsofvegetariansandtheirmajorfoodsources(refertosamplevegetarianmealplanbelow).Itispossibletomeetnutrientrequirementswhilefollowingavegetarianmealplan.However,timemustbespentensuringthenutritionaladequacyofthediet,particularlywiththeincreasedrequirementsofpregnancyandlactation.Thefollowingnutrientsrequireparticularattentionwhenplanningabalancedvegetarianmealplan.
Table 9 Typesofvegetariansandmajorfoodsources
Foods eaten No red meat Lacto-ovo vegetarian
Ovo- vegetarian
Lacto vegetarian
Vegan
Plants ✔ ✔ ✔ ✔ ✔
Animalmeats (Chickenandfish)
Eggs ✔ ✔ ✔
Milkandmilkproducts
✔ ✔ ✔
Energy
Becausevegetariandietstendtobehighinfibretheyincreasesatietyandcausepeopleto‘fillup’quicker.Itis,therefore,importanttoensureadequatefoodisprovidedandweightgainisappropriate.Highenergyvegetarianfoodsincludenuts,nutorotherseedpasteseg.tahini,peanutbutteranddriedfruits.
Protein
Essentialor‘indispensable’aminoacidsmustbeobtainedfromthedietasthebodyisunabletomakethem.Animalfoodsincluding;milk,milkproducts,fishandmeatarecompleteproteinsastheycontainalltheessentialaminoacidsintheproportionsrequired.Incontrast,plantfoodsareincompleteproteinsourcesastheydonotcontainthecorrectbalanceoftheessentialaminoacids.Itis,therefore,importantthatvegetarianswhoareavoidinganimalproducts,consumeavarietyofplantfoodstoensurealltheessentialaminoacidsareobtained.Iron,zinc,calciumandvitaminB12arenutrientsthatmaybelacking.
Zinc (2)
Zincisacomponentofvariousenzymesthathelpmaintainstructuralintegrityofproteinsandhelpregulategeneexpression:Therefore,gettingenoughisparticularlyimportantfortherapidcellgrowththatoccursduringpregnancy.TheRDIforzincduringpregnancyis11mg/day.Zinccanbefoundinleanmeat,wholegraincereals,milk,seafood,legumesandnuts.
Vitamin B12
SignificantamountsofB12areusuallyfoundinanimalproducts,sointakecouldbelimited.AgoodamountcanbeconsumedbyhavingatleasttwoservesofsoymilkfortifiedwithB12daily.Foodfermentedbymicro-organisms(soysauce,miso,tempeh),manure-grownmushrooms,spirulinaandyeastmaycontainsmallamountsofvitaminB12,butthisisnotsufficienttomeetrequirementsforvitaminB12.
16 A HEALTHY START IN LIFE ANTENATALNUTRITION
A sample vegetarian meal plan:
Breakfast
½cupmueslior2wheatbiscuits
Milk
1slicewholemealtoastwithpeanutbutter
1orange
Morning tea
2wholemealcrackerswithtomatoandcheese
Freshfruit
Lunch
Wholemealroll,1-2cupsofsaladwithanavocado
Milkand2tspMilo
Afternoon tea
½cupalmondsand4Tbspraisins
Dinner
1cupkidneybeans
2-3cupsservesvegetablesincludingbroccoli
Fruityoghurt
Supper
2slicesofraisintoastwithmargarine
Soybeverage,fortifiedwithcalciumandvitaminB12couldreplacemilkinveganmealplans
Check
foods from the meat, fish, poultry, eggs, nuts, legumes groups and iron ✔✔fortified cereals should be consumed each day for adequate iron and zinc intake. Soy beverages should be fortified with calcium (containing at least 115mg per 100mL) and B12
ensure sufficient energy is consumed and appropriate weight gained ✔✔
consider supplementation with a multivitamin (which includes iron, zinc, ✔✔calcium and B12) if needs are not being met
refer to dietitian for individual assessment and advice. ✔✔
17A HEALTHY START IN LIFE ANTENATALNUTRITION
TeenagersThenutrientrequirementsofpregnantteenagersareincreased.Notonlymusttheyeattoprovidethenutrientsrequiredforthepregnancy,butalsotoprovidefortheirowngrowthanddevelopmentduringpuberty.Pregnantteenagersshouldbetreatedasaseparategroup.TherearespecificRDIsforpregnantteenagersbetween14-18years.Girlswithalowgynaecologicalage(differencebetweenageofmenarcheandageatconception)requireadditionalnourishmentastheyareoftenstillgrowing.Eveniftheyhavestoppedgrowing,teenagegirlswithalowgynaecologicalagearelikelytohaveinadequatenutrientstores,becauseittakesabout2yearstobuildupstoresaftermenarch(10).
Itisimportanttoensureteenagemothershaveanappropriateweightgainduringpregnancy.Pregnantadolescentsareatriskofbothinadequateandexcessiveweightgain(11).Theyareatriskforadverseoutcomesincludinglowbirthweight,pretermdelivery,anaemia,andexcessivepostpartumweightretentionduetoacombinationofphysiological,socioeconomic,andbehaviouralfactors(11).Itisworthbearinginmindthatatthistimeinateenager’slife,thereareanumberofotherfactorswhichimpactontheireatingpatterns,forexample:peerpressure,socialsupports,lackofshoppingandcookingskillsandafearofgainingweightandbecoming“fat”.
Aboriginal and Torres Strait Islander womenSeeAboriginalandTorresStraitIslandersection
Obese pregnant womenMaternaloverweightandobesityisnowanimportantissueinaboutonethirdofallpregnanciesintheAustraliancontext(13).Increasedmaternalbodymassindex(BMI)atconceptionisassociatedwitharangeofadversematernal,obstetricandneonataloutcomes.Hypertensivedisordersofpregnancy,impairedglucosemetabolism,gestationaldiabetes,hyperlipidemia,caesareansectiondelivery,prolongedmaternalhospitalization,foetalandneonataldeath,birthdefectsandneonatalintensivecareadmissionareallconsequencesofmaternalobesity(13,14,15).
Overweightandobesityhasbeenassociatedwithreducedinitiationanddurationofbreastfeeding(16,17).Thecausesforthismaybemultifactorial.Factorstoconsiderinpoorlactationperformanceinclude:
Socio-culturalfactors,suchasconcernaboutbodyshape,lowselfesteemandpoor✔■
mentalhealth(16)
Physicalfactorsforexample,womenwithlargebreastsmayhavemechanicaldifficulties✔■
withbreastfeeding(16)
Physiologicalfactorssuchasreducedprolactinresponsetosuckling(18)✔■
Check
overweight and obese women identified as high risk during pregnancy✔✔
advice about appropriate weight gain✔✔
oral glucose tolerance test (OGTT) taken 24 – 28 weeks gestation✔✔
targeted for post partum lactation consultant assistance with ✔✔breastfeeding.
18 A HEALTHY START IN LIFE ANTENATALNUTRITION
Women with diabetes in pregnancy
Pre-existing Type 1 and Type 2 diabetesWomenwithpreexistingdiabetescanhaveahealthyandsuccessfulpregnancy.Howevertheyneedclosemonitoringbyateamincludinganobstetrician,endocrinologist(orphysicianexperiencedindiabetescareduringpregnancy),diabeteseducatoranddietitiantoensurethediabetesiswellmanagedduringthepregnancy.
Womenwithpre-existingdiabeteshaveahigherriskofinfants:
havingabirthdefect;✔■
beingbornprematurely;✔■
havingalowbirthweightorbeingmacrosomic;✔■
havingdangerouslylowbloodsugarlevelsafterbirth.✔■
Itisimportantthatwomencontroltheirbloodsugarlevelsbeforebecomingpregnantandthroughoutthepregnancytominimisetheserisks.
Gestational diabetesInsomewomenduringpregnancytheirabilitytoutiliseglucosebecomesimpaired.Thehormonesproducedbytheplacentacauseinsulinresistance.Ifthebodyisunabletomeettheincreasedneedforinsulingestationaldiabetesdevelopusuallyaroundthe24th–28thweekofgestation.
Gestational diabetes is more likely to occur in (19):
Women over 30 years of age✔■
Women with a family history of Type 2 diabetes✔■
Women who are overweight✔■
Aboriginal and Torres Strait Islander women✔■
Certain ethnic groups are also at increased risk: Indian, Chinese, Polynesian/Melanesian, ✔■
Vietnamese, Middle Eastern
Women who have had gestational diabetes during previous pregnancies✔■
Women who have had difficulty carrying a pregnancy to term.✔■
GestationaldiabetesisdiagnosedafteraGlucoseChallengeTest(GCT)whichisascreeningtest.IfthisisabnormalanOralGlucoseToleranceTest(OGTT)isnecessary.
Ifgestationaldiabetesisuntreatedthereisincreasedriskofalargeforgestationalagebaby,deliverycomplicationsandlowbloodsugarlevelsofthebabyatbirth.
There are four basic components to treatment of gestational diabetes: dietary modifications, physical activity, medications and monitoring blood glucose levels.
These women should be referred to a dietitian for individualised nutritional advice. The most important points are for regular carbohydrate distribution and low glycemic index (GI) diet.
After the birth of the baby, the mother’s blood sugar levels should return to normal and an OGTT at around 6 weeks post partum should be done to confirm this.
Women who develop gestational diabetes are at increased risk of developing Type 2 diabetes later in life with a 30% – 50% chance of developing it within 15 years after pregnancy (19).
19A HEALTHY START IN LIFE ANTENATALNUTRITION
2.6 Exercise during pregnancy (20,21,22)Regularexerciseduringpregnancyisinmostcases,safeforbothmotherandbaby.Womenshouldbeencouragedtoinitiateorcontinueexerciseduringthistimetoobtainthehealthbenefitsassociatedwithsuchactivities.
Adoctor,physiotherapistorexercisephysiologistcanprovideindividualadviceforwomenaboutexerciseduringpregnancy.
Benefits of exercising regularly throughout pregnancy include:
resistancetofatigue✔■
reducedbackpain,constipation,bloatingandswelling✔■
improvedposture✔■
improvedweightcontrol✔■
stressrelief✔■
improvedsleep✔■
preparationforphysicaldemandsoflabour✔■
fasterrecuperationafterlabour✔■
fasterreturntopre-pregnancyfitnessandhealthyweight.✔■
Body changes during pregnancy
Hormonesproducedduringpregnancy,suchasrelaxin,softentheligamentsthatsupportjoints,resultinginjointsbeingmoremobileandincreasingtheriskofjointinjury.
Extraabdominalweightshiftsthebody’scentreofgravity,placingstressonthepelvisandlowerbackjoints,andcanaffectbalance.
Pregnancyincreasesrestingheartrate.
General exercise suggestions
Aimfor4to5exercisesessionsperweek.✔■
Don’ttrytoexercisetoofarbeyondcurrentfitnesslevel.✔■
Warmupandcooldownforaround10minutes.✔■
Trytoexerciseonsoftsurfaces,suchasgrassorcarpet.✔■
Avoidexercisinginthemiddleofthedayorhothumidconditions—takecarenotto✔■
overheat.
Maintainamoderateintensity—keepheartratebelow140beatsperminute.✔■
Restfrequently,particularlyiffeelingbreathless.✔■
Wearasupportivebraandfootwear.✔■
Wherecool,loosefittingclothing.✔■
Changepositionsslowlyandgradually.✔■
20 A HEALTHY START IN LIFE ANTENATALNUTRITION
Suggested activitiesWater activities✔■
Walking ✔■
Swimming✔■
Yoga✔■
Dancing✔■
Pilates✔■
Pregnancy exercise classes✔■
Cycling on a stationary bike✔■
Exercises to avoidContactsportsorthoseactivitieswherethereispotentialforlossofbalancethatcould✔■
resultintraumatobaby.
Exercisinginwaterwherethetemperatureisgreaterthan32ºC.✔■
Activitiesthatinvolvejolting,jarringorrapidchangesofdirection,particularlyinthelatter✔■
stagesofpregnancy.
After16weeksavoidactivitiesinvolvinglyingflatonback—theweightoftheuterusand✔■
babycompressthemainarterybacktotheheart.Thiscanlowerbloodpressureandresultinfeelingsofdizzinessandlightheadedness.
Scubadiving-babiesarenotprotectedfromdecompressionsickness.✔■
Don’texercisewhenill.✔■
Conditions requiring medical supervision while exercising in pregnancy
Cardiacdisease✔■
Restrictivelungdisease✔■
Persistentbleedinginthesecondandthirdtrimesters✔■
Pre-eclampsiaorpregnancy-inducedhypertension✔■
Pretermlabour(previous/present)✔■
Intrauterinegrowthrestriction✔■
Cervicalweakness/cerclage✔■
Placentapraeviaafter26weeks✔■
Pretermprelabourruptureofmembranes✔■
Heavysmoker(morethan20cigarettesaday)✔■
Orthopaediclimitations✔■
Poorlycontrolledhypertension✔■
Extremelysedentarylifestyle✔■
Unevaluatedmaternalcardiacarrhythmia✔■
Chronicbronchitis✔■
Multiplegestation(individualisedandmedicallysupervised)✔■
Poorlycontrolledthyroiddisease✔■
Malnutritionoreatingdisorder✔■
Poorlycontrolleddiabetesmellitus✔■
Poorlycontrolledseizures✔■
Anaemia.✔■
21A HEALTHY START IN LIFE ANTENATALNUTRITION
Warning signs to cease exercise
Excessiveshortnessofbreath✔■
Chestpainorpalpitations✔■
Pre-syncopeordizziness✔■
Painfuluterinecontractionsorpretermlabour✔■
Leakageofamnioticfluid✔■
Vaginalbleeding✔■
Excessivefatigue✔■
Abdominalpain,particularlyinbackorpubicarea✔■
Pelvicgirdlepain✔■
Reducedfetalmovement✔■
Dyspnoeabeforeexertion✔■
Headache✔■
Muscleweakness✔■
Calfpainorswelling✔■
Medicaladviceshouldbesoughtifanyoftheabovesymptomsoccur.
Pelvicfloorexerciseshouldbedonebefore,duringandafterpregnancy.
Careshouldbetakenwithbacksupport.
Wheneverchangingposition,bendingandlifting:
tightenabdominalmuscles-particularlythetransverseabdominalmusclewhichformsa✔■
naturalcorsetinthelowerpartoftheabdomen
tightenpelvicfloormuscles✔■
uselegmuscles.✔■
Informationsheetcanbefoundat:
www.betterhealth.vic.gov.au
Check
women have no contraindications to exercise✔✔
advise of benefits of exercising in pregnancy✔✔
inform of criteria to cease exercise.✔✔
22 A HEALTHY START IN LIFE ANTENATALNUTRITION
2.7 Antenatal breastfeeding education Healthprofessionalsoftenleavediscussionofbreastfeedinguntillaterinthepregnancy.Researchdemonstratesthattheearlierinthepregnancyadecisiontobreastfeedismadethemorelikelythebreastfeedingwillbesuccessful(23).Thedecisionisusuallymadebeforepregnancyandisbasedonlifeexperiences,beliefsandattitudesoffamilyandotherstobreastfeeding(24).
Antenatal education should include:
importance of exclusive breastfeeding for the first 6 months ✔■
(including the nutritional and protective benefits)
basic breastfeeding management✔■
coping with minor problems (23). ✔■
Mothersshouldbeencouragedtobecomefamiliarandcomfortablewithhandlingtheirbreasts(23).
Virtuallyeverymothercanbreastfeed,butforsomeitisnotsoeasyandlearningandpatiencearenecessary(23).
Benefits of breastfeeding for mother
Helpsuterusreturntopre-pregnantstatefaster✔■
Canhelpwithweightlossafterbaby✔■
Reduceslikelihoodofovarianandpremenopausalbreastcancer✔■
LessenslikelihoodofmotherswithgestationaldiabetesdevelopingType2diabetes(24).✔■
Formula feeding increases the risk of baby developing:
Infectionsanddiseasessuchasurinarytractinfections,gastrointestinalinfections(eg.✔■
diarrhoea)andrespiratoryillnesses(eg.asthma)andsomechildhoodcancers
Allergiesandfoodintolerancessuchascoeliacdisease✔■
Obesity,diabetesandheartdiseaselaterinlife.✔■
Benefits of breastfeeding to the community
Reducedhealthcarecostsfromillnessandchronicdiseaseprevention✔■
Reducedecologicaldamagefromproduction,packaging,anddisposalofbreastmilk✔■
substitutesandcontainers.Italsosavesfoodresources,fuelandenergy.
23A HEALTHY START IN LIFE ANTENATALNUTRITION
Guide to educationEarly pregnancy
Ask questions ‘how do you plan to feed your baby?’•✔
Importance of decision about feeding choice•✔
Assess knowledge and perceptions regarding breastfeeding•✔
Reasons mothers choose•✔
Explore and identify concerns and feelings •✔
Acknowledge and validate feelings•✔
Educate using targeted messages to address individual concerns•✔
Benefits of breastfeeding (infant, mother, community)•✔
Risks of formula-feeding•✔
Ease of breastfeeding, difficulties that may be encountered•✔
Breastfeeding with modesty•✔
Family involvement•✔
Lack of dietary restrictions and lifestyle changes•✔
Feasibility with employment•✔
Availability of people to assist•✔
Identify breastfeeding resource network (family and friends, health care providers and •✔
mother-to-mother support groups).
Later in pregnancy
Practical skills on how to breastfeed•✔
Possible difficulties and how to overcome these•✔
Importance of skin-to-skin contact and rooming in•✔
More information can be found on the following sites
HowdoIstartbreastfeeding?www.health.qld.gov.au/phs/documents/cyhu/28099.pdf
BreastfeedingGettingStartedwww.health.qld.gov.au/phs/documents/cyhu/28098.pdf
Antenatal checklist
education on healthy eating and special considerations in pregnancy ✔✔provided
calculate pre-pregnant BMI - provide education on appropriate ✔✔weight gain
breastfeeding education provided✔✔
glucose screen for gestational diabetes at 24-28 weeks gestation.✔✔
24 A HEALTHY START IN LIFE ANTENATALNUTRITION
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