Nutrition in Pregnancy

Aka: Nutrition in Pregnancy, Pregnancy Related Nutrition, Dietary Guidelines in Pregnant Women, Weight Gain in Pregnancy, Vitamin Supplementation in Pregnancy

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II. Physiology

  1. Weight gain distribution over multiple components
    1. Fetus
    2. Placenta, amnion, and Uterus
    3. Edema and Increased Blood Volume
    4. Breast engorgement
  2. Adequate Weight Gain in Pregnancy
    1. Prevents Intrauterine Growth Retardation (IUGR)
      1. Especially in third trimester
  3. Obesity in pregnancy associated risks
    1. BMI >25 kg/m2
      1. Preterm delivery
      2. Gestational Diabetes
      3. Gestational Hypertension
    2. BMI >30 kg/m2 (compared with BMI 20)
      1. Fetal death (RR 1.3)
      2. Stillbirth (RR 1.5)
      3. Perinatal death (RR 1.3)
      4. Johansson (2014) BMJ 349:g6572 [PubMed]

III. Approach: Weight Gain in Pregnancy

  1. Normal conception weight (BMI = 18.6 to 25)
    1. Total weight gain: 11 to 16 kg (25 to 35 lb)
    2. Gain 1st trimester: 1 to 2 kg (3 to 5 lb) per month
    3. Gain 2nd/3rd: 0.5 to 1 kg (1 to 2 lb) per week
  2. Low weight at conception (BMI < 18.5)
    1. Total gain: 13 to 18 kg (28 to 40 lb)
  3. Overweight at conception (BMI 25 to 29)
    1. Total weight gain: 7 to 11 kg (15 to 25 lb)
    2. Gain 1st trimester: 1 to 2 kg (2 to 4 lb) per month
    3. Gain 2nd/3rd: 0.5 kg (1 lb) per week
  4. Morbidly Overweight at conception (BMI >=30)
    1. Total weight gain: 5 to 9 kg (11 to 20 lb)

IV. Indications: Intensive Nutrition Counseling

  1. Weight gain <0.90 kg (2 lb) per month
  2. Weight gain >2.92 kg (6 lb 8 oz) per month
  3. Weight gain < 4.5 kg (10 lb) by mid-pregnancy

V. Approach: Postpartum Weight Loss

  1. Plan for gradual weight loss
  2. Weight loss 0.36 - 0.45 kg (13 oz - 1 lb) per week

VI. Guidelines: National Research Council RDA Recommendations

  1. Dispelling the myth of very high calorie intake
    1. Women should NOT double their Caloric Intake in pregnancy
  2. Daily Caloric Intakes are estimates for a moderately active woman
    1. Individualize Caloric Intake for body habitus and activity level
  3. Non-Pregnant Woman Example
    1. See Nutrition Guidelines
    2. Daily Caloric Intake: 2200 KCals for moderately active woman (range 1800-2400 calories/day)
    3. Daily Protein intake: 55 grams
  4. Pregnant Women: First Trimester Example
    1. Daily Caloric Intake 2300 KCals (100 additional calories per day)
    2. Equivalent of 100 additional calories/day
      1. One and one half slices of bread per day
      2. One Cup of milk or fruit juice
      3. One Banana
  5. Pregnant Women (Second and third trimester) Example
    1. Daily Caloric Intake: 2500 KCals (300-400 additional calories/day)
    2. Daily Protein intake: 60 grams (5 to 7 oz/day)
    3. Vegetables: 2.5 to 3.5 cups/day
    4. Fruits: 1.5 to 2.5 cups/day
    5. Grains: 6 to 10 oz/day
    6. Oils: 24 to 36 g/day
    7. Equivalent of 300-400 additional calories/day
      1. Two slices of bread and one half avocado per day
      2. 1 cup blueberries and 2 hard boiled eggs
  6. Lactating Women Example
    1. Daily Caloric Intake: 2600 KCals (400 additional calories/day)
    2. Daily Protein intake: 65 grams

VII. Guidelines: Vitamin Supplementation in Pregnancy

  1. See Prenatal Vitamins (PNV)
  2. See Folic Acid Supplementation in Pregnancy
  3. Vegetarian or Vegan diet
    1. Consider Vitamin B12 Supplementation
    2. Consider Vitamin D Supplementation
  4. Calcium Supplementation
    1. See Dietary Calcium
    2. Calcium 1000 mg per day (PNV contains 200-300 mg Calcium)
  5. Elemental Iron
    1. See Dietary Iron
    2. Elemental Iron 30 mg per day (PNV contains 27 mg Elemental Iron)
  6. Folic Acid
    1. See Folic Acid Supplementation in Pregnancy
    2. Folic Acid 400 to 1000 mcg per day (PNV contains 600 mcg)
    3. Up to 4000 mcg Folic Acid recommended daily if increased risk for Neural Tube Defect
  7. Omega-3 Fatty Acids
    1. See Omega-3 Fatty Acid Supplement (use safe preparations without Mercury Poisoning risk)
    2. Omega-3 Fatty Acid 650 mg per day (PNV contains variable amounts up to 450 mg)
      1. Roughly Half of Omega-3 Fatty Acid should be Docosahexaenoic Acid
  8. Vitamin D
    1. See Vitamin D
    2. Vitamin D 600 IU per day (PNV contains 200 to 600 IU)

VIII. Guidelines: Specific Components and Additives

  1. Artificial Sweeteners
    1. Artificial Sweeteners are associated with Large for Gestational Age infants and Childhood Obesity
      1. Zhu (2017) Int J Epidemiol 46(5): 1499-508 [PubMed]
    2. Specific sweeteners
      1. Avoid Saccharin (crosses placenta and may deposit in fetal tissue)
      2. Sucralose and Acesulfame-K are likely safe in pregnancy
      3. Aspartame is likely safe in pregnancy
        1. Theoretical risk of exposing an undiagnosed fetus with PKU to Phenylalanine
  2. Caffeine
    1. Association with Spontaneous Abortion, preterm delivery and low birth weight with Caffeine >350 mg/day
    2. Limit Caffeine to <200 to 300 mg/day (2 cups of coffee)
  3. Herbal teas
    1. Avoid chamomile, licorice, peppermint, raspberry leaf (risk or Preterm Labor, Spontaneous Abortion)
    2. Safe teas in moderation include Ginger, citrus peal, lemon balm, rose hips
  4. Vitamin A Toxicity
    1. Avoid liver products
  5. Mercury
    1. See Mercury Content in Fish
    2. Avoid shark, swordfish, mackerel, tilefish and tuna
    3. Limit other fish to 12 ounces per week
  6. Toxins
    1. Various pollutants in farmed salmon (polychlorinated biphenyls, dioxins)

IX. Guidelines: Foodborne Illness Prevention

  1. General
    1. Avoid cross contamination (wash cutting boards, utensils and hand with soap and water)
  2. Toxoplasmosis risk
    1. Unpasteurized dairy and soft cheeses (e.g. Feta, Brie, Caembert, Blue cheese, queso fresco)
    2. Unwashed fruits and vegetables (see below)
  3. Listeria risk (Listeriosis risk in 18 fold higher in pregnancy; fetal mortality approaches 35%)
    1. Unpasteurized dairy and soft cheeses (e.g. Feta, Brie, Caembert, Blue cheese, queso fresco)
    2. Unwashed fruits and vegetables
      1. Wash fruits and vegetables before eating
    3. Unpasteurized raw juice or milk
    4. Deli meats, hot dogs or meat spreads (unless steaming hot, >165 F or >74 C)
    5. Under cooked meats
    6. Bean Sprouts
    7. Left-overs
      1. Reheat completely before eating
    8. Raw or smoked, refrigerated seafood
  4. Salmonella risk
    1. Raw eggs (e.g. caesar salad, eggnog, raw cookie dough)
  5. Parasites and Norovirus
    1. Raw fish or shellfish

X. References

  1. Cogswell (1999) Obstet Gynecol 94:616-22 [PubMed]
  2. Ramirez (2023) Am Fam Physician 108(2): 139-50 [PubMed]
  3. Zolotor (2014) Am Fam Physician 89(3): 199-208 [PubMed]

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