Unit two
- 1. Unit two NUTRITIONALASSESSMENT DURING PREGNANCY INTRODUCTION • Maternal nutrition has a critical role in the reduction of both maternal morbidity and mortality. The term Maternal Nutrition refers to nutritional status during any stage of a woman´s reproductive age that eventually could affect her health and that of the fetus and infant. • There are heightened nutrient needs during pregnancy; without an increase in caloric and nutritional intake to meet the increased demands during this period, the fetus uses its own reserves making it more susceptible to pregnancy-related complications . • Women´s nutritional status is most vulnerable during pregnancy;
- 2. Cont….. • maternal malnutrition becomes a cycle when malnourished mothers give birth to low birth weight infants who in turn become malnourished mothers themselves • Basic nutritional evaluation tools during pregnancy will be detailed in this chapter, these must be used especially in high risk populations that include: Pregnant adolescents . Women with low prepregnancy weight. Women with unfavorable prognostic factors e.g., Obesity and anemia. Women with a history of low birth-weight infants. Women who don‟t gain sufficient weight during their pregnancy.
- 3. Intro…… • Women with a frequent history of conception. Women of low socioeconomic status. Women with diseases that can influence the nutritional status e.g., Allergy, diabetes, tuberculosis, drug addiction, and mental depression.
- 4. Daily caloric needs • Calories increases during pregnancy to support the mother and to support the proper growth and development of the fetus , • the Recommended Daily Intake (RDI) for energy intake is increased by 300 calories per day for the 2nd and 3rd trimester. However, all the calories should be healthy calories containing: • plenty of proteins. • complex carbohydrates ( fruit, whole-grain starch and potates) which considered as main energy source. • Fibers • Vitamins • minerals
- 5. Weight gain during pregnancy • A weight gain of 11.2 to 15.9 kg (25 to 35 lbs.) is recommended during pregnancy but for more precise calculation, the normal healthy weight gain in pregnancy should be calculated according the Body Mass Index. Where: • Overweight women ( BMI>25 kg/m2) are advised to get 7 kgs. • Normal women (BMI 18.5-25 kg/m2) are advised to get 10 kgs. • Underweight women (BMI<18.5 kg/m2) are advised to get 14 kgs.
- 6. Specific requirements There are specific set of nutrients which is highly required during pregnancy more than any other nutrients such as: • Proteins • Folic acid • Calcium • Iron • Vitamin c • Omega- 3
- 7. Essential nutrients a) Folic Acid • Which is very important to prevent neural tube defect like spina bifida and improve the birth weight. • 400 mg tablet of supplement is required daily for the first trimester. • Green leaf vegetables are rich in folic acid.
- 8. Essential nutrients…………. b) Calcium • RDA for calcium is 1 gram. • Required for development of bones and teeth of the fetus. • Decrease risk of HTN, low birth weight and chronic HTN in newborns. • To keep the bones strong and healthy. • To provide proper muscle contraction. • Important for blood clotting.
- 9. Essential nutrients………… c) Proteins • Growth of fetus • Development of placenta • Increased blood volume • Enlargement of maternal tissues. • RDA 70 grams per day • Source: lean meat and eggs.
- 10. Essential nutrients…….. d) omega- 3 • Development of CNS, brain growth and eye development. • Found in fish oil. • Reduce the risk of heart disease in infants. • RDA 300 mg
- 11. Essential nutrients….. e) Iron • Fetal growth and enlargement of maternal tissue. • To supply the increased RBC mass. • To build up iron stores in the fetus liver • RDA 30 mg
- 12. Essential nutrients……… f) Vitamin C • It increases iron absorption. • Prevent preterm delivery • RDA 60 mg
- 13. Cont…. • ABSOLUTELY avoid smoking and drinking alcohols • drink large amount of water to prevent constipation and to be well hydrated. • avoid raw fish and meat. • avoid caffeine • Maintain a balanced healthy diet to meet up the requirements of nutrition.
- 14. Recommendations Recommendation 1: Preconception folic acid; folic acid is provided as supplements in addition to the adequate intake of high folic acid food sources. Recommendation 2: Proper antenatal care which ensures a proper weight gain during pregnancy. Recommendation 3: Iron and vitamin A supplementation during pregnancy. Recommendation 4: Nutritional counseling and education to ensure a healthy diet during both pregnancy and lactation. Recommendation 5: Breast feeding and nutritional education during emergencies.
- 15. The main forms of maternal malnutrition include Macronutrient deficiencies: (Protein Energy Malnutrition - PEM) which is managed by ensuring adequate variety of foods to include the 6 major groups, adequate frequency of food intake, adequate amounts of food, and proper personal and environmental hygiene. • Micronutrient deficiencies: such as vitamin A deficiency (VAD), iron deficiency anemia (IDA), and iodine deficiency disorders (IDD); these conditions result in increased risk of low birth weight, maternal mortality, and neonatal and infant mortality. • Anemia accounts for approximately 20% of maternal deaths as it increases the risk of both hemorrhage and prolonged labor, which can lead to sepsis. Management of micronutrient deficiency consists of supplementation with fortified foods and mineral/vitamin formulations, and adequate intake of foods rich in micronutrients such as fruits, dark-green and brightly colored vegetables.
- 16. Causes and consequences of maternal Malnutrition Underlying Causes: • Inadequate maternal care. • Household food insecurity. • Unhealthy environment, insufficient health services, and poor hygiene and sanitation Immediate causes: • Infections and diseases. • Poor access to basic health services (e.g. inadequate iron and folic acid supplementation) • Frequent parasites and infections. • Inadequate food intake due to diet characterized by low, highly variable over seasons, and often low nutrient density. Consequences: • Maternal Health • Increased risk of maternal death • Increased risk of infections. o Anemia • Compromised immune functions. o Lethargy and weakness. • Lower productivity. • infant/child Health • Increased risk of fetal and neonatal death. • Intrauterine growth retardation, low birth weight, preterm birth. • Compromised immune functions. o Birth defects.Basic Causes • Political structure • Resources and their control • Heavy workloads o Frequent births • Harmful local practices and food taboos. • Intra-household food distribution does not favor women
- 17. GOALS AND OBJECTIVES • The main purpose of the maternal nutritional assessment is to support health care providers in the provision of maternal nutrition care and support services, it can also be used by health training institutions and other organizations, as well as other governing bodies implementing maternal nutrition interventions. • These guidelines were established to break the intergeneration cycle of maternal malnutrition through outlining special nutritional aspects that enable optimal nutritional status of the mother as well as providing much safer and ideal birth outcomes.
- 18. To contribute to the reduction of maternal malnutrition the implementation of the following goals must be achieved: • To improve the knowledge and skills of service providers at all levels to respond to maternal and child nutritional needs. • To improve provision of quality maternal and child nutritional services at community and health facility level. • To advocate for support of appropriate interventions that address maternal nutrition at all levels. • To facilitate health care providers and other stakeholders in interpersonal nutrition education and counseling, community dialogue, developing the health education for improved maternal nutrition. • To strengthen integration of nutrition interventions for adolescent, pregnant, and lactating women within existing health services.
- 19. NUTRITIONALASSESSMENT FOR PREGNANCY Pregnant females who are in general at risk for nutritional problems at even greater risk, and because of the importance of nutrition in the course and outcome of pregnancy, all pregnant women should have a formal assessment of their nutritional status at the beginning of their prenatal care with ongoing surveillance throughout the pregnancy The purpose of the nutrition assessment is to: • Evaluate the nutritional status of the pregnant. • Identify those pregnant who are at nutritional risk. • Formulate an individualized nutrition care plan with follow-up. The Nutritional assessment takes into account different aspects: including relevant obstetric, medical, psychology and diet history, BMI along with weight gain, and lab tests and values.
- 20. Cont……… 1. Relevant History In order to have much more precise information; the following steps will help Obstetric History • Women with previous pregnancies may be at increased nutritional risk as a result of depleted nutrient reserves, the length and time between pregnancies can play a vital role as well especially if the time between pregnancies is less than one year. • History of pre-term delivery (<37 weeks of gestational) or low/high birth weight of infants the first could indicate nutritional problems while the latter may suggest latent diabetes. • History of weight gain during previous pregnancies and any pregnancy-related complications e.g., gestational diabetes, hypertension, anemia, vomiting and nausea. • Previous use of supplements or drugs e.g., contraceptives. • The experience of breast feeding.
- 21. Psychological History • Economic status since limited and low income may mean limited food availability. • Living situation. • Access to medical care. • Emotional health or any psychological/mental- related problems. • Education level • Employment situation.
- 22. Medical History • The presence of any chronic or metabolic diseases e.g., cardiovascular, renal diseases or cystic fibrosis. • Physical disabilities • Previous history of eating disorders e.g., anorexia and bulimia nervosa. • Past or current intake of cigarettes smoking or alcohol. • Previous nutritional deficiencies. • History of medication usage. • Status of physical activity (type, duration, and intensity
- 23. 2. Anthropometric Measurements • Pre-pregnancy BMI Classifications: According to recommendations set by the Institute of Medicine (IOM). Pre-pregnancy BMI categories Values (kg/m2) Underweight < 19.8 Normal 19.8-26 Overweight 26.1-29 Obese >29
- 24. Pregnancy weight gain recommendations Pre-pregnancy BMI categories (kg/m2) Recommended total weight gain 1st trimester 2nd and 3rd trimester underweight 12.5-18 2.3 0.49 Normal 11.5-16 1.6 0.44 Overweight 7-11.5 0.9 0.30 Obese 6-7 Twins (any BMI) 16-20 Triplet (any BMI) 23
- 25. MUAC (Mid-Upper Arm Circumference) • MUAC is a good indicator of the protein reserves of a body, and a thinner arm reflects wasted lean mass, i.e., malnutrition. The WHO Collaborative Study 1995 showed MUAC cut-off values of < 21 to 23 cm as having significant risk for low birth weight (LBW).
- 26. References of Laboratory Values during Pregnancy Tests Non-pregnant 1”st trimester 2nd trimester 3rd trimester Erythropoietin (U/L) 4–27 12–25 8–67 14–222 Ferritin (ng/ml) 10-150 6-130 2-230 1-116 Hemoglobin (g/dl) 12-15.8 11.6-13.9 9.7-14.8 9.5-15.0 Hematocrit (%) 35.4-44.4 31.0-41.0 30.0-39.0 28.0-40.0 TIBC (µg/dl) 251-406 3.42-4.55 2.81-4.49 2.71-4.43 WBC (x 106/mm3) 3.5-9.1 5.7-13.6 5.6-14.8 5.9-16.9 Platelet (x106/L) 165-415 174-391 155-409 146-429 Transferrin (mg/dl) 200-400 254-344 220-441 288-530 MCH (pg/cell) 27-32 30-32 30-33 29-32 MCV (µm3) 79-93 81-96 82-9 81-99 (According to University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Dallas, TX, USA)
- 27. Dietary Intake/Needs • Estimated Needs: According to National academy of science institute of medicine guidelines for pregnancy: BMI (kg/m2) Estimated calories intake/kg/day Underweight (<19.8) 36-40 Normal Weight (19.8-26) 30 Overweight (26.1-29) 24 Obese (>29) 12-18 Twin Gestational Addition of 500 Kcal/day to the above recommendations • According to the caloric distribution during pregnancy, carbohydrate is 45-55%, protein 15-20% and fat is 35%. • Estimated needs from fluid: The recommended fluid needs for pregnancy (8-10 cups/day) around 2000 -2500 ml.
- 28. According to Institute of Medicine (IOM) The needed components Estimated needs for pregnant women Energy (Kcal) + 0 (1st trimester) + 340 (2nd trimester) + 452 (3rd trimester) Protein (g) 71 Vitamin A (mcg) 750-770 Vitamin D (meg) 5 Vitamin E (mg) 15 Vitamin C (mcg) 80-85 Thiamin (mcg) 1.4 Riboflavin (mg) 1.4 Niacin (mg) 18
- 29. Continued) The needed components Estimated needs for pregnant women Vitamin B6 (mcg) 1.9 Folate (mcg) 600 Vitamin B12 (mcg) 2.6 Calcium (mg) 1300 Phosphorus (mg) 700-1250 Magnesium (mg) 350-400 Iron (mg) 27 Zinc (mg) 11-12 Iodine (mcg) 220
- 30. PROPER WAYS OF CARRYING OUT THE HISTORY OF DIETARY INTAKE • The purpose of assessing the dietary intake is to evaluate the nutritional quality of the diet. Food intake information may be obtained by different methods including: 24-hour food recall, food frequency questionnaire, food record; and diet history. • The method chosen depends on the specificity desired, the time available, the cooperation of the patients, and the training of the personnel
- 31. Dietary Assessment methods Methods Strength Limitation Application 24-hours recall(15) Does not require literacy, Relatively low respondent burden, Data may be directly entered into a dietary analysis program, May be conducted in-person or over the telephone Dependent on respondent‟s memory, Relies on self- reported information, Requires skilled staff, Time consuming, Single recall does not represent usual intake. Appropriate for most people as it does not require literacy, Useful for the assessment of intake of a variety of nutrients and assessment of meal patterning and food group intake, Useful counseling tool Food frequency (16-18) Quick, easy and affordable, May assess current as well as past diet, In a clinical setting, may be useful as a screening tool. Does not provide valid estimates of absolute intake of individuals, Can‟t assess meal patterning, May not be appropriate for some population groups. Does not provide valid estimates of absolute intake for individuals, thus of limited usefulness in clinical settings, May be useful as a screening tool, however, further development research is needed.
- 32. Dietary Assessment methods … Methods Strength Limitation Application Food record (19-27 Does not rely on memory, Food portions may be measured at the time of consumption, Multiple days of records provide valid measure of intake for most nutrients. Recording foods eaten may influence what is eaten, Requires literacy, Relies on self-reported information, Requires skilled staff, Time consuming Appropriate for literate and motivated population groups, Useful for the assessment of intake of a variety of nutrients and assessment of meal patterning and food group intake, Useful counseling tool Diet history (28) Able to assess usual intake in a single interview, Appropriate for most people. Relies on memory, Time consuming (1 to 1-1/2 hours), Requires skilled interviewer. appropriate for most people as it does not require literacy, Useful for assessing intake of nutrients, meal patterning and food group intake, Useful counseling tool.
- 33. Thank you for your attention