CHAPTER 14: Nutrition during Pregnancy and Lactation: Physiology of Pregnancy Pregnancy, from conception to birth, usually 40-week

k gestation in humans 40-week divided into three 3-month periods, each called a trimester Many physiological changes take place in mother to support her developing offspring and to prepare her for lactation Early Events of Prenatal Growth and Development Fertilization to form zygote Implantation in the uterus (~7 days) Formation of amniotic sac and placenta The First Creation of Life (1-3 days) sperm penetrates egg, nuclei interchange (come together), divide into 2 cells, then 4 cells (4-6 days) Called morula after division, starts to invaginate, outer layer = ectoderm, forms amniotic sac and implants in uterus Endoderm = inner part is what we grow from (gastrointestinal tract) Implantation (Day 7) Uterine lining forms thick mass rich in blood vessels (in fertilized egg) 2 umbilical veins and 2 umbilical arteries o Arteries bring blood from heart body (oxygenated) o Veins bring blood from body heart (deoxygenated) o For baby, veins bring blood from body placenta (oxygenated) o For baby, arteries bring deoxygenated blood toward placentamom (who exhales out Growth of Embryo and Fetus Weeks = zygote formation and implantation 3-8 weeks = embryonic development (CND, heart, extremities, eyes, ears, teeth) o Also teeth, external genitalia (later like 8 weeks) Fetal development (9-38 weeks) damage from teratogens may be less severe About 2 weeks after fertilization, the developing offspring is an embryo The heart is already beating at 4 weeks of gestation (about 3 cm embryo) Beginning at 9th week of development and continuing until birth, developing offspring is a fetus (16 cm) Birth of an Infant Spontaneous abortion or miscarriage occur id pregnancy is interrupted spontaneously prior to 7th month Infants born before 36 weeks of gestation are preterm or premature Infants born on time but have failed to grow normally are small-for-gestational-age Those weighing less than 2.5 kg (~6 lbs) have low birth weight, and less thank 1.5 kg have very low birth weight Recommendations for Weight Gain during Pregnancy Gaining right amount of weight is essential to health of both mother and fetus Prepregnancy Weight Status Recommended Total Gain o Underweight (BMI<18.5 kg/m^2 28-40lbs o Normal weight (BMI 18.5-24.9) 25-35lbs o Overweight (BMI 25-29.9) 15-25lbs o Obese (BMI>30) 11-20lbs Distribution of Weight during Pregnancy Recommended weight gain for healthy, normal-weight women is 25-35 lbs o Fetus 7-8lbs, amniotic fluid 2 lbs, placenta 1-2 lbs, uterus 2 lbs, maternal blood 3-4, breast tissue 2 lbs, ECF 4lbs, maternal fat 4-11lbs Pattern Weight Gain during Pregnancy

 The rate of weight gain is as important as the total weight gain Complications of Pregnancy Pregnancy-induced hypertension (PIH)>140/90mmHg (occurs 6-7% cause of 15% deaths) Gestational hypertension- usually develops after 12th week of pregnancy Preeclampsia- hypertension and protein in urine Eclampsia o Hypertension, protein in urine and seizures o Can be life-threatening to mother and fetus Gestational diabetes mellitus (~7% related obesity)- increased risk for both mother and infant The Nutritional Needs of Pregnancy Maternal intake must supply nutrients to the fetus while continuing to meet mothers needs Increased energy needs is proportionally smaller than those for protein, vitamins, and minerals (need more protein, so need consume more nutrient-dense food) Dont need increase intake of Vit D, K, calcium, and phosphorus Changes in body lead to need for increase in iron, folate Energy Needs Energy needs increase during pregnancy to deposit and maintain new fetal and maternal tissues During 1st trimester, total energy expenditure changes little, EER remains same as before pregnancy During 2nd trimester, additional 340 kcal/d recommended During 3rd trimester, additional 452 kcal/d recommended Protein, Carbohydrate, and Fat Recommendations Additional protein is needed for formation and growth of new cells o RDA: +25 g/day or 1.1 g/kg of body weight/day Additional carbs needed to provide sufficient glucose to fuel fetal and maternal brains (glucose is primary source of energy for fetus) o +45 g/d (~175 g/d well below average intake of 300 g/d); so no additional intake is really needed Total fat intake does not need to increase, but additional linolenic acid (omega-6) and alphalinolenic (omega-3) fatty acids (essential) are recommended Fluid and Electrolyte Needs Need for water is increased because of increase in blood volume, production of amniotic fluid, and needs of fetus o Recommendation is increased from 2.7 L/d to 3 L/d No evidence that requires for K, Na, or Cl are different from that of non-pregnant women Micronutrient Needs- Vitamins Vitamin D- regular sun exposure enough? Prenatal supplements can help Vitamin C deficiencies increases risk for premature birth and eclampsia (+10 mg/d) Vitamin B12- RDA 2.6 g/d; vegan mothers must consume fortified foods or supplements Other B vitamins- requirements for thiamin, niacin, riboflavin, and B6 increase o Folate or folic acid needed- spinal, neural tube defects Critical Periods of Fetal Development Normal development: within critical period Before: adverse influence felt late but temporarily impairs development, but a full recovery is possible After: adverse influence felt early permanently impairs development, and a full recovery never occurs Micronutrient NeedsFolate Adequate intake is crucial even before conception Low maternal intake increases risk of fetal abnormalities that involve the formation of neural tube

Inadequate status can cause megaloblastic anemia, increase risk of preterm delivery, low birth weight, and fetal retardation Folate and the Risk of Neural Tube Defects Neural tube defects (NTD) such as spina bifida and anencephaly are caused by a combination of factors including low folate levels and a genetic predisposition Micronutrient NeedsMinerals Calcium (30 gm for fetus) o Absorption increase o AI remains the same as for nonpregnant women (1000 mg/d) Zinc o Deficiency is associated with an increased risk of fetal malformation, prematurity, and low birth weight o Iron supplement may compromise zinc status Iron o Needs are high o Absorption is increased and loss is decreased o Iron deficiency is common, associated with low birth weight and preterm delivery o Iron supplements - recommended during the 2nd and 3rd trimesters Meeting Nutrient Needs with Food and Supplements The energy and nutrient needs can be met following the dietary recommendations and adding nutrient-dense choices Supplements often required for certain nutrients (folate 600ug and iron 27 mg/d); for people with limited food choices (vegetarians) or high demands (teenagers) Hormonal and physiological changes can cause food cravings (pica) and aversions Factors That Increase the Risks of Pregnancy Maternal nutritional status Maternal health status Socioeconomic factors Exposure to toxic substances Maternal Malnutrition Before pregnancy o Inability to conceive o Inadequate nutrient storage for completion of pregnancy During pregnancy o Fetal growth retardation, low birth weight, birth defects, premature birth, spontaneous abortion, and stillbirth Immediate effects o Most damaging in the 1st trimester o Embryonic/fetal malformation, death Long-term effects o Adaptations that change fetal structure, physiology, and metabolism that affect the child's risk of developing chronic diseases later in life Maternal Health Status Chronic diseases o Women with chronic diseases such as hypertension, diabetes, and phenylketonuria (PKU) must manage their health carefully to assure a healthy pregnancy Reproductive history o Frequent pregnancies, with little time in between, increase the risk of poor pregnancy outcomes o Pregnancies with long intervals may increase risk of eclampsia Maternal Age The pregnant teenager

o Greater risk of PIH, premature and low-birth-weight deliveries o Nutrition needs may be higher than those of a pregnant adult The older mother o Higher risk of gestational diabetes, PIH, low-birth-weight deliveries and chromosomal abnormalities (especially Down syndrome) o Careful medical monitoring important Socioeconomic Factors Low-income level is one of the greatest risk factors for poor pregnancy outcome Many low-income women do not receive any medical care until late in pregnancy Higher incidence of growth retardation, low-birth-weight and preterm infants Exposure to Toxic Substances A teratogen is any chemical, biological, or physical agent that causes birth defects Potential Toxic Exposures Environmental toxins o Cleaning solvents, lead and mercury, some insecticides, or paint Caffeine and herbs o Available research on caffeine during pregnancy has been inconsistent o More than 300 mg/day of caffeine is not recommended (3 cups coffee, 7 c. tea or cola) o No more than 2 cups of herb tea daily due to lack of information about herb safety Drinking, Smoking, and Drug Use Prenatal exposure to alcohol can cause a spectrum of disorders: 1ary cause of preventable birth defects o Fetal alcohol syndrome (FAS) o Alcohol-related neurodevelopmental disorders (ARND) o Alcohol-related birth defects (ARBD) o Complete abstinence from alcohol is recommended Cigarette smoke o Reduces birth weight, increases the risk of preterm delivery and early death (Sudden infant death syndrome, SIDS, or crib death) o Problems later in life Drug use o Legal or illicit, many can affect both fertility and pregnancy outcome The Physiology of Lactation Lactation involves o Synthesis of the milk component (proteins, lactose, lipids) o Movement of milk components through milk ducts to the nipple Colostrum o The first milk rich in proteins and immune factors Hormonal Control of Lactation Suckling of the infant sends signals to the hypothalamus in mothers brain The hypothalamus signals the release of the pituitary hormones prolactin and oxytocin o Prolactin stimulates milk production o Oxytocin promotes let-down of milk Maternal Nutrient Needs During LactationEnergy and Macronutrients The need for nutrients is even greater during lactation than during pregnancy High energy demands for production of milk (600900 ml daily) o The energy comes from the diet and stored fat o + 330 kcal/day during the first 6 month and + 400 kcal/day -second 6 month o Human milk contains about 160 kcalories per cup (240 ml). Ensure adequate protein intake o + 25 g/day Higher requirements for carbohydrates and essential fatty acids

Maternal Nutrient Needs During LactationFluid To avoid dehydration and ensure adequate milk production, lactating women need to consume about 1 liters of additional fluid daily Maternal Nutrient Needs During LactationMicronutrients The recommended intakes of vitamin B6, B12, other B vitamins, folate, and vitamins A, C, E are increased o Infants from vegan mothers should be supplemented with vitamin B12 Nutritional Needs of Infants Must support the continuing growth and development, and increasing level of activity Energy Needs and Fat Intake Newborns need more kcalories per pound of body weight than anyone at any other time Fat intake: about 50% of total energy during the 1st 6 months and 40% during the 2nd 6 months Need sufficient supply of docosahexaenoic acid and arachidonic acid (Essential fatty acids) Carbohydrate, Protein and Fluid Needs Carbohydrate o About 40% of the energy from milk (lactose) o Needs increase as the % of total energy increases with growth Protein o Very high need compared with adults o Ideal source for newborns is human milk Fluid o Higher proportion of body water than adults o Water losses are higher o Breast milk usually meets the needs in healthy infants o Additional fluid if diarrhea or vomiting Micronutrient Needs Iron- The most commonly deficient nutrient; should be added after 4 to 6 months Fluoride- Depends on access to fluoridated water-may or may not need supplementation Vitamin D- All breast-fed infants should receive supplementation Vitamin K- All breast-fed infants should receive a single intramuscular injection Vitamin B12- Breast-fed infants of vegan mothers should be supplemented CHAPTER 15: Nutrition from Infancy to Adolescence Nourishing Infants, Toddlers, and Young Children The best indicator of adequate nourishment: a normal growth pattern Inconsistent growth patterns suggest nutritional problems Growth Charts of Children Age 4-6 = critical drop in weight; essential loss of baby fat 1st year 50% length (10 in) 2nd year 5 in 3rd yr 4 in >2-3 in/yr Nutrient Needs of Infants and ChildrenEnergy and Protein Total energy and protein needs increase as body size increases Higher needs for boys than for girls Nutrient Needs of Infants and ChildrenFat and Carbohydrate Fat o Infants need high-fat diet (50% <6 m; 40% >6m) o Proportion of kcalories from fat reduced as infants grow o Recommendation >3yr same as adults o Essential fatty acids

Carbohydrate o Recommendations -same as adults o Most from whole grains, fruits, and vegetables o Fiber supplements - not recommended o Food high in added sugars should be limited Nutrient Needs of Infants and ChildrenFluids and Electrolytes Fluid losses decline by 1 yr of age Drinking enough water to satisfy thirst Fluid needs increase - increased temperature or sweat losses Nutrient Needs of Infants and ChildrenMicronutrients Calcium, vitamin D and bone health o Adequate calcium essential for maximum peak bone mass o Vitamin D Iron and anemia o Younger children need more iron than adult men o Many children do not get enough iron o Caution - Iron supplements Feeding Infants Introduce solid foods slowly > 46 mo. - infant's feeding abilities and GI tract are ready Increase variety with developmentally appropriate choices Caution about Food Allergies Food allergies: improper immune responses against food allergens Food intolerances - no antibodies: eg. Lactose intolerance, gluten intolerance Food allergies diagnosed by elimination diet and food challenge Prevention and management of food allergies o Breast-feeding reduces the risk o Introduce new food items one at a time, rec. 1st food: rice cereal, 3-4 day interval between new food o Avoid offending food Establish Good Eating Behavior Introduce new foods regularly Continue to offer variety of foods Offer nutritious meals and snacks throughout the day Establish habit of eating breakfast Eating Environment Influences childrens eating patterns TV-advertisement, poor eating habits-more snacks & fatty/sweet food, less veg./fruits- if watch >4h/d 40% likely to be overweight Children need companionship, conversation, and a pleasant location at mealtimes Mealtime should not be a battle zone food should not be used as a reward or punishment Nutrition and Health Concerns in ChildrenChildhood Obesity Television watching contributes to obesity Influences activity level, snacking behavior, and kinds of foods children choose Fast food o high in energy, fat, sugar, and sodium; o low in calcium, fiber, and vitamins A and C Nutrition and Health Concerns in Children Dental caries o High sugary foods -promote tooth decay (cavities) o Poor dental hygiene increases risk o Long term use of baby bottle: Baby-bottle tooth decay

Hyperactivity o Part of attention deficit hyperactivity disorder (ADHD) o Research does not show that high sugar intake is the cause????? o Some children sensitive to food additives o Caffeine is a stimulant Nutrition and Health Concerns in ChildrenLead Toxicity Lead toxic in children <6 yrs Certain groups at higher risk Children - blood lead levels tested Adolescentsthe Changing Body Adolescent growth spurt 11 in, 40% bone mass Puberty; 2 yr lag in boys growth spurt Menarche - girls (13 17% body fat for menses) Hormonal changes affect body composition (boys: taller/heavier/leaner; girls: slower growth, 2x more fat, 1/3 less muscle) Nutrient intake can affect sexual development and growth Adolescent Nutrient NeedsMinerals Iron o Iron-deficiency anemia common (boys: rapid growth; girls: menarche) o RDAs are greater than for adults o Girls need more iron Zinc o Even mild deficiency can cause growth retardation and altered sexual development Calcium o AIs are higher than those for adults o Intakes are typically low lower milk intake vs. soda Special Concerns for Teenagers Eating for appearance and performance Eating disorders o ~ 1% of teenage females have anorexia and 4% of college-age women have bulimia Athletes o Taking dietary supplements, using anabolic steroids, or consuming inappropriate diets and experimenting with fad diets are common among teen athletes o Most dangerous practices - to control weight. Girls : gymnastics, dance, ballet > amenorrhea, osteoporosis; boys: wrestling What Are American Children Eating? 60-80% age 2 to 9 consumed diets that need improvement Older children -diets get worse CHAPTER 13: Nutrition and Physical Activity Types of muscle fiber: Slow twitching fibers: prolonged, low to medium level of activity endurance - use aerobic source of energy from mitochondria, take longer to produce energy more energy ~ 34-36 ATP per glucose molecule Fast twitching fibers: gets energy 10x faster anaerobic glycolysis no need for oxygen limited energy, only 2 ATP per glucose molecule Exercise, Health and Fitness Fitness: ability to perform routine physical activity without undue fatigue Overload principle: the body adapts to stresses Aerobic exercise: endurance exercises: jogging, swimming or cycling, or any exercise that increases heart rate and requires oxygen

Cardiorespiratory system: circulatory and respiratory systems, delivering oxygen and nutrients to the cells. Exercise, the Heart and the Muscles Aerobic exercise: o strengthens heart muscle, o increases stroke volume o decreases resting heart rate Aerobic capacity (VO2 max): maximum ability to generate ATP by aerobic metabolism during exercise. Stress or overload: muscles adapt - increase in size and strength: hypertrophy Atrophy-become smaller and weaker (lack of use) Exercise builds and maintains muscles (LBM). Fit people > LBM not fit. The Process of Anaerobic Metabolism Anaerobic metabolism (anaerobic glycolysis): metabolism in the absence of oxygen o 1 glucose = 2 ATP Aerobic metabolism: metabolism in the presence of oxygen. o Glucose, fatty acids and amino acids - completely broken down to form CO2 and H20 and to produce ATP. Health Benefits of Exercise Benefits of regular exercise: o Weight management o Cardiovascular health o Diabetes prevention or management o Bone and joint health o Possible reduction of cancer risk o Psychological health o Increased flexibility Components of a Good Exercise RegimenAerobic Activity Maximum heart rate = 220 age Target heart rate = 60-85% of the maximum heart rate Maintain target heart rate for 30 to 60 minutes Fueling Exercise by the Minute Instant energy: ATP-creatine phosphate Short term energy (anaerobic metabolism) Long-term energy (aerobic metabolism) Effects of Exercise Intensity (% of ATP from different nutrients) Rest: mostly fatty acids, little glucose and amino acids used Moderate-intensity activity: even fatty acids and glucose use, little amino acid use High-intensity activity: almost only glucose used, very little or no fatty acid/amino acid used Relationship of Exercise to Intake Source of energy - as important as the amount of energy in an athletes diet Vitamins and minerals o B vitamins o Antioxidant vitamins: vitamins C and E o Iron o Calcium Proportion of energy for athletes and healthy individuals o 45-65% total energy from carbohydrates o 20-35% from fat o 10-35% from protein

Fluid Needs for Physical Activity Water: eliminate heat, transport oxygen and nutrients to the muscles and remove waste products (lactic acid, CO2) The ability to dissipate heat depends on hydration levels. At rest - lose about 4 cups of water per day through evaporation from the skin and lungs. Even with regular consumption, it may not be possible to consume sufficient fluid to remain properly hydrated. Failure to compensate for fluid losses can result in dehydration. If heat cannot be lost from the body, body temperature rises and exercise performance as well as health can be jeopardized. Dehydration occurs when water loss is great enough for blood volume to decrease. Dehydration reduces the bodys ability to deliver oxygen and nutrients to muscles. Hyponatremia Normal blood sodium concentration Water and sodium lost in sweat Replacing just water dilutes sodium (hyponatremia)