Balanced diet in pregnancy Pregnancy is a critical phase of human development. The nutritional status of a mother at conception is a key factor for overall fetal development. It is important that pregnant women eat balanced nutritious food, exercise moderately and limit the exposure to damaging substances and bacteria to ensure uncomplicated pregnancy and a healthy baby. This article discusses the importance of adequate inclusion of all the macro- and micronutrients should constitute the balanced diet during pregnancy.
The maternal-fetal association is a complex phenomenon which is influenced by associated socioeconomic, biological, and demographical factors. Of these, fetal development is mainly based on the maternal nutrition. A balanced maternal nutrition is necessary to prevent short- and long-term health and development consequences that may occur due to inadequate nutrition.
National Family Health Survey (NFHS)-4 published in 2015-16 revealed that around 22.9% of women of reproductive age (18-49 years) have BMI <18 kg/m2, suggestive of severe nutritional deficiency and under-nutrition. It is well known that undernourished women will give birth to an undernourished baby, resulting in a never-ending cycle of undernutrition through generations. Several studies have indicated that maternal malnutrition increases the risk of gestational anemia, hypertension, miscarriages, stillbirths and increases the risk of preterm delivery and maternal mortality. Additionally, it can have serious consequences on the growth of the infant resulting in intra-uterine growth restriction (IUGR), low birth weight that may have life-long consequences on the physical and emotional well-being of the infant. Furthermore, malnutrition can also result in impaired immunity of infants, thus making them susceptible to various infections. Hence, consumption of balanced nutritious diet is critical for the well-being of both, mother and the baby.
Recommended Nutrient Uptake during Pregnancy
Energy And Protein
Energy derived from carbohydrates is necessary for intrauterine growth. It is important that pregnant women chose high-quality carbohydrates like whole grains, non-starchy vegetables, fruits, beans, lentils etc. A study by Loy et.al. in Malaysia indicated that increased consumption of fruits was associated with increased birth weight, birth length, and head circumference. Protein provides the building blocks for overall growth, development, or repair. It is recommended to add 0.5 gm of protein during the first trimester, 6.9 gm during second and 22.7 gm during the third trimester of pregnancy. WHO report on Antenatal care indicates that high-protein supplementation does not provide sufficient benefits to the undernourished women and hence, not recommended for improving maternal and fetal outcomes.
Iron & Folic Acid
As per NFHS-4 data, there are about 53.1% women from the reproductive age that are anemic. Adequate iron stores are necessary for maternal well-being. In addition to anemia, iron deficiency affects energy utilization which affects physical performance and immunity. Hence timely iron supplementation is necessary in pregnant women. WHO recommends oral consumption of 30-60 mg of iron per day (refer Table 1). Furthermore, it emphasizes that in developed countries where anemia in pregnant women is prevalent, a daily dose of 60 mg should be preferred over lower dose. Folate protects fetal against certain congenital anomalies. Folate (Vitamin B9) deficiency in presence of anemia is also linked to neural tube defects. Additionally, folic acid deficiency increases homocysteine levels in blood and the risk for heart diseases.
Calcium and/or Vitamin D deficiency leads to porous, weak bones and to rickets. Sufficient scientific evidence indicates that calcium supplementation decreases the risk of pre-eclampsia, hypertension during pregnancy. It is recommended that calcium supplementation should be divided into three doses, and preferably consumed at mealtime. However, iron and calcium supplementation should be consumed several hours apart to avoid negative interaction between the two nutrients.
Vitamin A is necessary for clear vision in dim light, hence, vitamin A deficiency can lead to night blindness. WHO recommends vitamin A supplementation of no more than 10000 IU/day or 25000 IU/week (Refer Table 1).
Lack of iodine in the water and diet is the main cause of iodine deficiency in India, especially in rural population. Iodine is required for thyroid hormones which are necessary for growth and development. Iodine deficiency causes goiter, neonatal hypothyroidism, cretinism among newborns, and stunting. The worst consequence of iodine deficiency is stillbirth. In India, around 90000 stillbirths and neonatal deaths occur due to maternal iodine deficiency. In short, poor neuronal development due to iodine deficiency during the critical developmental phase can cause reversible brain damage or mental retardation.
Multiple Micronutrient (MNM) supplements
WHO indicates that MNM supplementation is not essential to improve maternal and fetal outcomes. Such micronutrients include Vitamin B1, B2, B6, B12, C, D, E, zinc, copper, niacin, and selenium apart from folate, vitamin A, iron and iodine.
During pregnancy, vitamin B12 is concentrated in the fetus and stored in the liver. So postpartum infants can sustain for the first several months even if they are born to vitamin B12-replete mothers. Vitamin B12 deficiency can cause some neurological symptom, while in severe cases, it causes brain atrophy. Additionally, infants may experience physical symptoms such as abnormal pigmentation, hypotonia, enlarged liver and spleen, anorexia, failure to thrive and diarrhea. Animal products like fish, meat, poultry, eggs, milk and milk products contain naturally occurring Vitamin B12.
Docosahexaenoic Acid (DHA)
Omega -3 fatty acids, DHA and eicosapentaenoic acid (EPA), are essential and should be obtained from diet. During the last trimester fetal accrues around 50-70 mg/day of DHA that is necessary for neurodevelopment and retinal development. Extensive research on the benefits of DHA for the maternal health indicates reduced chances of preterm birth and post-partum depression. Due to the limited ability of human body to synthesize, either supplementation or ensuring consumption of DHA rich food is highly recommended. European Food Safety Authority (EFSA), US Department of Health & Human Services, and a Joint FAO/WHO Expert Consultation recommends adults to consume at least 250 mg/day EPA plus DHA and pregnant/lactating women should consume minimum of 300mg/day of DHA plus EPA (with at least 200mg/day of DHA). Food options that are DHA-rich include vegetable oils, fish, seafood, or DHA supplements (fish oil or algae extracted DHA). Most Indian pregnant women are likely to fall short of their daily DHA intake, due to dietary preferences and hence daily ensuring daily consumption of DHA rich food is highly recommended.
Table 1: Essential Nutrients During Pregnancy (Adapted and modified from a) Dietary guidelines for Indians by National Institution of Nutrition, India (2011); b) Reaching Optimal Iodine Nutrition in Pregnant and Lactating Women and Young Children by WHO (2007); c) Clinical Dietetics and Nutrition by F. P. Antia (p. 455), 1998, Oxford University Press)
Following check-list you may recommend to all pregnant women to ensure nutritious meals, uncomplicated pregnancy and a healthy baby:
Eating at the right time of the day: Skipping breakfast, late meals, eating unhealthy food should be avoided. Indian women should avoid fasting during pregnancy.
Ensure a healthy diet which provides adequate energy, proteins, vitamins, and minerals by consuming a variety of foods. Indian women should consider consuming whole grains like whole wheat chapatti, rice, oats etc., protein-rich servings including milk and milk-based products, dals, pulses, chicken, fish, eggs etc. Additionally, eating 3-5 servings of vegetables, leafy vegetables, and fruits.
Ensure appropriate fatty acid (specifically DHA) content through fish, nuts (walnuts, peanuts). Adequate consumption of iron, folic acid, fatty acid, Vitamin D, and Calcium.
Reduce caffeine intake and restrict or prohibit alcoholic beverages.
Avoid food that may contain harmful bacteria. Such as unpasteurized milk, raw cheese, uncooked meat etc.
Limit the "trans-fat" consumption by restricting pastries, chips, cookies, chips, or fried food.
Attend at least 8 ANC contacts, as recommended by 2016 WHO ANC model.
Leading healthy lifestyle including physical exercise for achieving strength throughout pregnancy. However, Indian women should choose activities that have minimal risk of loss of balance and fetal injury.
Sufficient evidence indicates the importance of consuming necessary amount of iron, folate, calcium, and iodine during pregnancy for better maternal and fetal outcomes. All women should be encouraged to eat balance nutritious food before, during, and after pregnancy to ensure healthy living.