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NUTRITION DURING PREGNANCY
 
  Nutrition During Pregnancy Healthy eating is important during pregnancy. Good nutrition is needed to meet the added demands on your body as well as those of your growing baby. Eating healthy while you’re pregnant may take a little extra effort, but it will have major benefits for you and your baby. If you already eat a balanced diet, all you have to do is add a few extra well-chosen calories. If you have not been eating a healthy diet, pregnancy is a great time to change old habits and develop healthy new ones. Breastfeeding mothers need to pay careful attention to their diets as well (see Chapter 18, “Breastfeeding and FormulaFeeding Your Baby”). Healthy eating also includes knowing how much you should eat. Pregnant women used to be told to “eat for two.” This is still true—to a point. We now know that you can’t just eat twice as much as you normally do. Finding a balance between getting enough nutrients to fuel the baby’s growth and maintaining a healthy weight is important for your and your baby’s future health. A pregnant woman who has a body mass index (BMI) in the normal range before pregnancy needs, on average, only about 300 extra calories a day—the amount in a glass of skim milk and half a sandwich. If you are pregnant with twins, you’ll need 600 extra calories per day. You can calculate your BMI using an online calculator (you can find one at www.nhlbi.nih.gov/health/educational/lose_wt/BMI/) or use the chart in Appendix A.     313  314  •  NUTRITION Balancing Your Diet Nutrients are the building blocks of the body. Important nutrients include proteins, carbohydrates, and fats. When you’re pregnant, you not only need to maintain your own body with nutrients, you also need to support the growth of your baby. Getting enough nutrients during pregnancy safeguards your own health and contributes to your baby’s normal development. Protein Protein provides the nutrients your body needs to grow and repair muscles and other tissues. Protein is found in the following foods: • Beef, pork, and fish • Poultry • Eggs • Milk, cheese, and other dairy foods • Beans and peas • Nuts and seeds For vegetarians, protein can be found in nuts, seeds, nut butters, and soy products such as tempeh and tofu. Vegetarians who include dairy products in their diets also can get needed protein from milk and eggs. Carbohydrates All carbohydrates are broken down into glucose, the body’s main fuel that powers all of its activities. There are two types of carbohydrates: simple carbohydrates and complex carbohydrates. Simple carbohydrates provide a quick energy boost because they are digested and absorbed rapidly. They are found in naturally sweet foods like fruits and also can be added to foods in the form of table sugar, honey, and maple syrup. Simple carbohydrates often are high in calories. It is best to limit your intake of simple carbohydrates to those found naturally in food. Stay away from sugary drinks and foods with added sugar. Complex carbohydrates include dietary fiber and starches. It takes your body longer to process them, so complex carbohydrates provide longerlasting energy than simple carbohydrates. Complex carbohydrates are found in bread, rice, pasta, some fruits, and starchy vegetables such as potatoes and corn. NUTRITION DURING PREGNANCY  •  315 Fiber is found in plant foods. It is the part of the plant that your body cannot digest. Fiber passes relatively unchanged through your digestive system. It can help prevent constipation by adding bulk to the stool, making it easier to pass. You should eat about 25 grams of fiber daily. The following foods are good sources of fiber: • Fruits (especially dried fruits, berries, oranges, apples, and peaches with the skin) • Vegetables (such as dried beans, peas, and leafy vegetables like spinach and kale) • Whole-grain products (such as whole-wheat bread or brown rice) Fiber also helps maintain a stable blood glucose level because it passes slowly through the digestive tract. Foods that do this are described as “low glycemic” because they do not cause the blood glucose level to spike. Eating lowglycemic foods can help you feel full and reduce the feeling of hunger. Lowglycemic foods also may help reduce cholesterol levels and prevent diabetes. Fats The body needs a certain amount of fat to function normally. Some types of fats, called omega-3 fatty acids, play an important role in brain development. Fats also are essential to the function of the immune system, aid in blood clotting, and help your body use vitamins A, D, E, and K. The fat in the foods you eat is digested and sent to the liver. The liver then assembles the fat into lipoproteins. Lipoproteins are made of cholesterol, fats, and protein. Lipoproteins carry fat through your bloodstream for use by or storage in other parts of the body. There are different types of fat found in foods. You should be aware of these different types of fat in your diet: • Saturated fats come mainly from meat and dairy products. They tend to be solid when chilled. Examples include butter and lard. There also are two plant-based saturated fats: 1) palm oil and 2) coconut oil. • Unsaturated fats tend to be liquid and come mostly from plants and vegetables. Olive, canola, peanut, sunflower, and fish oils are all unsaturated fats. • Trans fats are unsaturated fats that have been chemically processed to be solid at room temperature. This is done to make foods last longer and give them better flavor. Vegetable shortenings, margarines, crackers, cookies, and snack foods like potato chips often contain trans fats. 316  •  NUTRITION Oils and fats give you important nutrients. During pregnancy, the fats you eat provide energy and help build many fetal organs and the placenta. However, too much saturated fat and trans fat can lead to health problems, including heart disease. Fats should make up about 20–35% of your total food intake—that’s about 6 tablespoons per day. Most of the fats and oils in your diet should be unsaturated fats, such as olive oil and peanut oil. Limit saturated fats, such as butter and fatty red meats, and avoid trans fats, which have no nutritional value. Planning Healthy Meals It’s not hard to plan healthy meals while you are pregnant, and the U.S. Department of Agriculture has made it even easier by creating www. choosemyplate.gov. The “MyPlate” web site helps everyone from dieters and children to pregnant women learn how to make healthy food choices at every meal. With MyPlate, you can get a personalized nutrition and physical activity plan by using the “SuperTracker” program. This program shows you the foods and amounts that you need to eat each day during each trimester of pregnancy. The amounts are calculated according to your height, prepregnancy BMI, due date, and how much you exercise during the week. The amounts of food are given in standard sizes that most people are familiar with, such as cups and ounces. The Five Food Groups To get an idea of how MyPlate works, Table 17-1 shows the foods and amounts that a pregnant woman with a normal BMI before pregnancy should eat for each trimester of pregnancy. You’ll notice that food is broken down into the following five food groups: 1. Grains—Bread, pasta, oatmeal, cereal, and tortillas are all grains. Make one half of the grains you eat whole grains. Whole grains are those that have not been processed and include the whole grain kernel. They include oats, barley, quinoa, and brown rice. Look for the words “whole grain” on the product label. 2. Fruits—Fruits can be fresh, frozen, canned, or dried. Juice that is 100% fruit juice also counts. NUTRITION DURING PREGNANCY  •  317 Table 17-1 Daily Food Choices Recommended daily food intake for a pregnant woman who is a normal weight and who gets less than 30 minutes of exercise each day. First Second Third Trimester Trimester Trimester Comments Total calories per day 1,800 2,200 2,400 Grains 6 ounces 7 ounces 8 ounces   1 ounce is one slice of bread, ½ cup of cooked rice, ½ cup of cooked pasta, 3 cups of popped popcorn, or five whole wheat crackers Vegetables 2 ½ cups 3 cups 3 cups   2 cups of raw leafy vegetables count as 1 cup Fruits 1 ½ cup 2 cups 2 cups   One large orange, one small apple, eight large strawberries, or ½ cup of dried fruit count as 1 cup Dairy 3 cups 3 cups 3 cups   Two small slices of swiss cheese or 1 /3 cup of shredded cheese count as 1 cup Protein foods 5 ounces 6 ounces 6 ½ ounces   1 ounce lean meat or poultry, one egg, 1 tablespoon peanut butter, or ½ ounce of nuts or seeds count as 1 ounce Fats and oils 5 teaspoons 7 teaspoons 8 teaspoons   Olives, some fish, avocados, and nuts 3. Vegetables—Vegetables can be raw or cooked, frozen, canned, dried, or 100% vegetable juice. Make sure that you get a mixture of dark green, orange, starchy, and other vegetables, including dry beans and peas. 4. Dairy—Milk and products made from milk, such as cheese, yogurt, and ice cream, make up the dairy group. Make sure any dairy foods you eat are pasteurized (see the section “Food Safety” in this chapter for information about foodborne illnesses) and choose fat-free or low-fat (1%) varieties. 5. Protein Foods—Protein foods include meat, poultry, seafood, beans and peas, eggs, nuts, and seeds. Include a variety of proteins in your diet and choose lean or low-fat meat and poultry. 318  •  NUTRITION Key Vitamins and Minerals Vitamins and minerals play important roles in all parts of your body. During pregnancy, you need more folic acid and iron than a woman who is not pregnant (see Table 17-2). Taking a prenatal vitamin supplement can ensure that you are getting these extra amounts. A well-rounded diet should supply all of the other vitamins and minerals you need during pregnancy. Table 17-2 Key Vitamins and Minerals During Pregnancy Nutrient (Daily Recommended Why You and Amount) Your Baby Need It Best Sources Calcium Builds strong bones Milk, cheese, yogurt, sardines, green (1,300 mg for ages and teeth leafy vegetables 14–18 years; 1,000 mg for ages 19–50 years)    Iron Helps red blood cells Lean red meat, poultry, fish, dried beans (27 mg) deliver oxygen to your and peas, iron-fortified cereals, baby prune juice Vitamin A Forms healthy skin and Carrots, green leafy vegetables, (750 micrograms for eyesight; helps with sweet potatoes ages 14–18 years; bone growth 770 micrograms for ages 19–50 years)    Vitamin C Promotes healthy Citrus fruit, broccoli, tomatoes, (80 mg for ages gums, teeth, and bones strawberries 14–18 years; 85 mg for ages 19–50 years)    Vitamin D Builds your baby’s Sunlight, fortified milk, fatty fish such as (600 international bones and teeth; salmon and sardines units) helps promote healthy eyesight and skin Vitamin B6 Helps form red blood Beef, liver, pork, ham, whole-grain (1.9 mg) cells; helps body use cereals, bananas protein, fat, and carbohydrates Vitamin B12 Maintains nervous Meat, fish, poultry, milk (vegetarians (2.6 micrograms) system; needed to should take a supplement) form red blood cells Folic acid Helps prevent birth Green leafy vegetables, orange juice, (600 micrograms) defects of the brain beans, fortified cereals, enriched and spine and supports bread and pasta, nuts the general growth and development of the fetus and placenta NUTRITION DURING PREGNANCY  •  319 Folic Acid Folic acid, also known as folate, is a B vitamin that is important for pregnant women. Taking 400 micrograms (0.4 mg) of folic acid daily for at least 1 month before pregnancy and during pregnancy may help prevent major birth defects of the baby’s brain and spine called neural tube defects. Current dietary guidelines recommend that pregnant women get at least 600 micrograms of folic acid each day from all sources, including food and vitamin supplements. Many foods contain folic acid, such as fortified cereal, enriched bread and pasta, peanuts, dark green leafy vegetables, orange juice, and beans. However, it may be hard to get all of the folic acid you need from food alone. To ensure they are getting enough, pregnant women should take a daily vitamin supplement that contains folic acid. Most prenatal multivitamin supplements contain 600–800 micrograms of folic acid. Some women may need a higher amount of folic acid each day. If you have already had a pregnancy affected by a neural tube defect or if you are taking an antiseizure medication, talk with your health care provider to make sure you get the right amount. Iron Iron is used by your body to make a substance in red blood cells that carries oxygen to your organs and tissues. During pregnancy, you need more iron than you did before pregnancy. This extra iron helps your body make more blood to supply oxygen to your baby. Not having enough iron is called irondeficiency anemia. Anemia increases the risk of certain problems, including preterm delivery and having a low-birth-weight baby. The recommended daily intake for iron during pregnancy is 27 mg, which is found in most prenatal vitamin supplements. You also can eat foods rich in a certain type of iron called heme iron. Heme iron is absorbed more easily by the body and is found in animal foods, such as red meat, poultry, and fish. Your blood will be tested during pregnancy to check for anemia. If you are found to be anemic, your health care provider may recommend additional iron supplements. Calcium Calcium is used to build your baby’s bones and teeth. All women aged 19 years and older should get 1,000 mg of calcium each day. For those aged 14–18 years, the recommended amount is 1,300 mg a day. Milk and other 320  •  NUTRITION dairy products, such as cheese and yogurt, are the best sources of calcium. If you have trouble digesting milk products, you can get calcium from other sources, such as broccoli, fortified orange juice, sardines or anchovies with the bones, or a calcium supplement. Vitamin D Vitamin D works with calcium to help build your baby’s bones and teeth. It also is key for healthy skin and eyesight. While you’re pregnant or breastfeeding, you need 600 international units of vitamin D each day. Most prenatal vitamins have about 400 international units of vitamin D per tablet. You can get the extra amounts of vitamin D from your diet. Good sources are vitamin D-fortified milk and breakfast cereal, salmon, and egg yolks. Also, exposure to sunlight converts a chemical in the skin to vitamin D. Many women, however, still do not get enough vitamin D every day. If your health care provider thinks you may have low levels of vitamin D, a test can be done to check the level in your blood. If it is below normal, you may need to take a vitamin D supplement. Putting It All Together All of this advice can seem overwhelming. The following tips can help guide you when you are making food choices and ensure that you’re eating in a healthy way: • Make one half of your plate fruits and vegetables. • Switch to skim milk or 1% milk. • Make one half of your grains whole grains. • Vary your protein sources. Eat fish 2–3 times a week (see the section “Fish and Shellfish” later in this chapter for information about the types of fish to choose), and choose lean meats and poultry. Vegetarians can get protein from a wide variety of plant-based foods such as nuts, seeds, and soy products. • Limit foods with “empty” calories. These are foods that have a lot of calories but little nutritional value, such as candy, chips, and sugary drinks. • Take a vitamin supplement that contains 600 micrograms of folic acid and 27 mg of iron. NUTRITION DURING PREGNANCY  •  321 When planning your meals, remember to add snacks, which are a good way to get needed nutrition and extra calories. Pick snacks that have the right nutrients and that are low in fat and sugar. Fruit, cereal, and yogurt are healthy snack choices. You may find it easier to eat six smaller meals spread out over the day than to try to consume your necessary nutrients and calories in three larger meals, especially later on in pregnancy when you may be experiencing indigestion after eating larger meals. To make these mini meals, just divide the daily recommended amount of foods from each of the food groups into small portions. Milk and half a sandwich made with meat, fish, peanut butter, or cheese with lettuce and tomato make an excellent mini meal. Other ideas are low-fat milk and fresh fruits, cheese and crackers, and soups. Weight Gain During Pregnancy The amount of weight you should gain depends on your health and your BMI before pregnancy. Recommendations for weight gain for women who are pregnant with twins are somewhat higher (see Table 17-3). Weight gain during pregnancy should be gradual. During your first 12 weeks of pregnancy—the first trimester—you may gain only 1–5 pounds or no weight at all. In your second and third trimesters, if you were a healthy weight before pregnancy, you should gain between ½ pound and 1 pound per week. The key to gradual weight gain is to slowly increase the number of calories you consume throughout your pregnancy. In the first trimester, when weight gain is minimal, no extra calories usually are needed. In the second trimester, you need an extra 340 calories a day, and in the third trimester, about 450 extra calories a day. Keep in mind that these amounts are for women who were a normal weight before pregnancy. If you were overweight or obese, you may need fewer extra calories. My Plate. What should your plate look like? Half of your plate should be fruits and vegetables. The other half should be lean protein and whole grains. You also should take a prenatal vitamin supplement containing folic acid and iron each day. Courtesy of United States Department of Agriculture Center for Nutrition Policy and Promotion. 322  •  NUTRITION You will have your weight checked at each prenatal care visit, and your health care provider will keep track of how much weight you have gained. A woman who gains too few pounds is more likely to have a small baby (less than 5½ pounds). These babies often have health problems after birth. Women who gain too much weight also are at risk of health problems. These problems include gestational diabetes mellitus, high blood pressure, and a baby that’s too large (macrosomia). If you are overweight or gaining weight too quickly, it may be necessary to adjust your nutrition and exercise plan. Talk to your health care provider first before making any major changes. Usually, you can start by cutting down on the “extra” calories that you consume from extra fats and sugars. Watch your portion size, and avoid second helpings. Focus on eating foods that have lots of nutrients, such as beans, leafy greens, and nuts. Special Concerns Certain foods, diets, or health conditions often cause some pregnant women to be concerned about their diets. Being aware of these concerns is important. Fish and Shellfish Fish and shellfish are excellent sources of omega-3 fatty acids. Three of these fatty acids—DHA, EPA, and ALA—are considered “essential,” meaning that Table 17-3 Weight Gain During Pregnancy Recommended Recommended Total Weight Gain Rate of Weight Gain Weight Gain Prepregnancy During Pregnancy in the Second and During Pregnancy Body Mass With a Single Baby Third Trimesters* With Twins Index (in Pounds) (Pounds per Week) (in Pounds) Underweight 28–40 1.0–1.3 — (BMI less than 18.5) Normal weight 25–35 0.8–1.0 37–54 (BMI 18.5 –24.9)    Overweight 15–25 0.5–0.7 31–50 (BMI 25 –29.9)    Obese 11–20 0.4–0.6 25–42 (BMI more than 30) Abbreviation: BMI, body mass index. *Assumes a first-trimester weight gain between 1.1 pounds and 4.4 pounds. Data from Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009. NUTRITION DURING PREGNANCY  •  323 they are not manufactured by the body and are supplied by diet alone. There is strong scientific evidence to suggest that these fats are important in the development of the fetal nervous system. Fish are also a good source of protein and other nutrients. To gain these benefits, women who are or who may become pregnant or who are breastfeeding should eat at least 8 ounces and up to 12 ounces (about two to three servings) of fish or shellfish per week. Some types of fish have higher levels of a metal called mercury than others. Mercury has been linked to birth defects. To limit your exposure to mercury, follow a few simple rules. Choose fish that are lower in mercury, such as shrimp, salmon, catfish, canned light tuna (not albacore, which has a higher level of mercury), and sardines. Do not eat shark, swordfish, king mackerel, or tilefish, which have the highest levels of mercury. If you want to eat albacore tuna, limit the amount to 6 ounces a week. If you eat fish caught in local waters, check any advisories about mercury or other pollutants (see the “Resources” section in this chapter). If no information is available, limit your intake of such fish to 6 ounces a week, and do not eat any other fish that week. Caffeine Although there have been many studies on whether caffeine increases the risk of miscarriage, the results are unclear. Most experts believe that consuming less than 200 mg of caffeine a day during pregnancy is safe. That is equal to one 12-ounce cup of coffee. Remember that caffeine also is found in teas, colas, and chocolate. Make sure you count these sources in your total caffeine for the day. Vegetarian Diets There are different types of vegetarians—some include dairy products in their diets and others strictly avoid all products that come from animals. If you are a vegetarian, it still is possible to get all of the nutrients you and your baby need during pregnancy. It just takes extra planning. It’s a good idea to tell your health care provider at your first prenatal care visit that you are a vegetarian and ask for a recommended diet plan you can follow. The following tips can help you maximize the key nutrients you need while still eating a vegetarian diet: • Make sure you get enough protein from foods such as soy milk, tofu, and beans. Eggs, milk, and cheese also are good protein sources if you eat some animal foods. 324  •  NUTRITION • Eat lots of iron-rich vegetables and legumes, such as spinach, white beans, kidney beans, and chickpeas. You can increase the amount of iron that your body absorbs if you also eat foods high in vitamin C, like oranges or tomatoes, at the same time that you eat an iron-rich food. • To get the recommended amount of calcium if you don’t eat dairy foods, eat dark leafy greens, calcium-enriched tofu, and other calcium-enriched products (soy milk, rice milk, and orange juice). • Vitamin B12 can be obtained by eating cereals that are fortified with this vitamin or by drinking milk. Lactose Intolerance Women who have trouble digesting dairy products can get calcium from other foods, including seeds, nuts, and soy. Lactose-free milk, cheese, and other dairy products also are available in grocery stores. Talk with your health care provider if you are having trouble consuming the recommended 1,000 mg each day. You may be advised to take a calcium supplement. Celiac Disease Women who have celiac disease are unable to eat foods containing gluten, which is found in wheat, barley, and rye. There are many foods that are gluten free, so pregnant women with celiac disease can choose fruits, vegetables, meats, potatoes, poultry, and beans. There also are many gluten-free products sold in grocery and natural food stores or online. Food Safety Pregnant women can get food poisoning just like anyone else. However, food poisoning in a pregnant woman can cause serious problems for both her and her baby. Vomiting and diarrhea can cause your body to lose too much water and can disrupt your body’s chemical balance. Several types of bacteria can cause food poisoning. It’s important to contact your health care provider as soon as you have these signs and symptoms. Listeriosis is a type of food-borne illness caused by bacteria. Pregnant women are 13 times more likely to get listeriosis than the general population. Listeriosis can cause mild, flu-like symptoms such as fever, muscle aches, and diarrhea, but it also may not cause any symptoms at all. However, it can lead to serious complications for your baby, including miscarriage, stillbirth, NUTRITION DURING PREGNANCY  •  325 and premature delivery. If you think you have eaten food contaminated with this bacteria or if you have any of the symptoms of listeriosis, call your health care provider. Antibiotics can be given to treat the infection and protect your baby. To help prevent getting the bacteria, avoid eating the following foods while you’re pregnant: • Unpasteurized milk and foods made with unpasteurized milk, including soft cheeses such as feta, queso blanco, queso fresco, Camembert, Brie, or blue-veined cheeses unless the label says “made with pasteurized milk.” • Hot dogs, luncheon meats, and cold cuts unless they are heated until steaming hot just before serving. • Refrigerated pâté and meat spreads • Refrigerated smoked seafood While you are pregnant, avoid all raw and undercooked seafood, eggs, and meat. Do not eat sushi made with raw fish (cooked sushi is safe). In addition, follow these four steps for food safety: 1. Clean. – Wash your hands with soap and water before and after handing raw food. – Wash fruits and vegetables under running tap water before eating, cutting, or cooking. – Keep your kitchen clean. Wash your utensils, countertops, and cutting boards with soap and hot water after handling and preparing uncooked foods. You can sanitize them by applying a solution of 1 teaspoon of liquid chlorine bleach per gallon of water. Allow the surface to air dry. 2. Separate. – Keep raw meat, poultry, eggs, and seafood and their juices away from ready-to-eat food. – Separate raw meat, poultry, and seafood from produce in your shopping cart by placing them into plastic bags. – Keep raw meat, poultry, and seafood on a plate, in a container, or in a sealed plastic bag in the refrigerator. – Use a separate cutting board for raw meat, poultry, and seafood. – Never put cooked food back on the same plate that previously held raw food unless the plate has been washed in hot, soapy water. Do not use sauce used to marinate raw food on cooked food unless it is boiled first. 326  •  NUTRITION 3. Cook. – Use a food thermometer to check doneness of meat, poultry, seafood, and egg products. These items should be cooked to a safe minimum temperature (see www.foodsafety.gov/keep/charts/mintemp.html). – Place the food thermometer in the thickest part of the food, away from bone, fat, and gristle. 4. Chill. – Keep your refrigerator at 40°F or below and the freezer at 0°F or below. – Thaw food in the refrigerator, microwave, or in cold (not hot) water. – Do not leave food at room temperature for more than 2 hours (1 hour when the temperature is above 90°F). – Meat and poultry defrosted in the refrigerator may be refrozen before or after cooking. If thawed in the microwave or cold water, cook before refreezing. – Only buy eggs from a refrigerator or refrigerated case. Store eggs in the refrigerator in their original carton and use within 3–5 weeks. – When selecting precut produce, choose only those items that are refrigerated or surrounded by ice and keep them refrigerated at home to maintain both quality and safety. Eating well during your pregnancy is one of the best things you can do for yourself and your baby. Start now on balancing healthy eating with maintaining a healthy weight to give your baby the best start in life.