maternal and fetal nutrition - · pdf filematernal and fetal nutrition c hapter shannon e....

288

Maternal and

Fetal Nutrition

C h a p t e r

SHANNON E. PERRY

10

• Explain recommended maternal weight gain dur-ing pregnancy.

• Compare the recommended level of intake ofenergy sources, protein, and key vitamins andminerals during pregnancy and lactation.

• Give examples of the food sources that providethe nutrients required for optimal maternal nutri-tion during pregnancy and lactation.

• Examine the role of nutrition supplements dur-ing pregnancy.

• List five nutritional risk factors during preg-nancy.

• Compare the dietary needs of adolescent andmature pregnant women.

• Give examples of cultural food patterns andpossible dietary problems for two ethnic groupsor for two alternative eating patterns.

• Assess nutritional status during pregnancy.

LEARNING OBJECTIVES

adequate intakes (AIs) Recommended nutrient in-takes estimated to meet the needs of almost allhealthy people in the population; provided for nu-trients or age-group categories where the availableinformation is not sufficient to warrant establish-ing recommended dietary allowances

anthropometric measurements Body measure-ments, such as height and weight

body mass index (BMI) Method of calculating ap-propriateness of weight for height (BMI � weight/height2)

Dietary Reference Intakes (DRIs) Nutritional rec-ommendations for the United States, consisting ofthe recommended dietary allowances, adequate in-takes, and tolerable upper intake levels; the upperlimit of intake associated with low risk in almostall members of a population

intrauterine growth restriction (IUGR) Fetal under-growth from any cause

kcal Kilocalorie; unit of heat content or energy equalto 1000 small calories

lactose intolerance Inherited absence of the en-zyme lactase

physiologic anemia Relative excess of plasma lead-ing to a decrease in hemoglobin concentration andhematocrit; normal adaptation during pregnancy

pica Unusual craving during pregnancy (e.g., forlaundry starch, dirt, red clay)

pyrosis A burning sensation in the epigastric andsternal region from stomach acid (heartburn)

Recommended Dietary Allowances (RDAs) Rec-ommended nutrient intakes estimated to meet theneeds of almost all (97% to 98%) of the healthypeople in the population

KEY TERMS AND DEFINITIONS

ELECTRONIC RESOURCESAdditional information related to the content in Chapter 10 can be found on

the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/• NCLEX Review Questions• WebLinks

or on the interactive companion CD • NCLEX Review Questions• Critical Thinking Exercise-Nutrition Education• Plan of Care—Nutrition during Pregnancy

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Nutrition is one of the many factorsthat influence the outcome of preg-nancy (Fig. 10-1). However, maternalnutritional status is an especially sig-

nificant factor, both because it is potentially alterable andbecause good nutrition before and during pregnancy is animportant preventive measure for a variety of problems.These problems include birth of low-birth-weight (LBW) andpreterm infants. It is essential that the importance of goodnutrition be emphasized to all women of childbearing po-tential. Nutrition assessment, intervention, and evaluationmust be an integral part of the nursing care provided to allpregnant women.

The Pregnancy Nutrition Surveillance System (PNSS)was developed to help health professionals identify and re-duce pregnancy-related health risks (Centers for DiseaseControl and Prevention [CDC], 2004). The data collectedfrom programs such as the Special Supplemental NutritionProgram for Women, Infants, and Children (WIC) andprenatal clinics funded by Maternal and Child HealthProgram Block Grants are submitted to the CDC. Annualdata summaries allow states to monitor trends in preva-lence of prenatal risk factors that predict low birth weightand infant mortality, as well as monitor infant feedingpractices.

The first trimester of pregnancy is a crucial one for embry-onic and fetal organ development. A healthful diet beforeconception is the best way to ensure that adequate nutrientsare available for the developing fetus. Folate or folic acid in-take is of particular concern in the periconceptual period.Folate is the form in which this vitamin is found naturallyin foods, and folic acid is the form used in fortification ofgrain products and other foods and in vitamin supplements.Neural tube defects, or failure in closure of the neural tube,are more common in infants of women with poor folic acidintake. It is estimated that the incidence of neural tube de-fects could be halved if all women had an adequate folic acidintake during the periconceptual period (Kilpatrick & Laros,2004). All women capable of becoming pregnant are advisedto consume 400 mcg of folic acid daily in fortified foods(e.g., ready-to-eat cereals and enriched grain products) or sup-plements in addition to a diet rich in folate-containing foodssuch as green leafy vegetables, whole grains, and fruits.

Both maternal and fetal risks in pregnancy are increasedwhen the mother is significantly underweight or overweightwhen pregnancy begins. Ideally, all women would achievea desirable body weight before conception.

NUTRIENT NEEDS BEFORE CONCEPTION

C H A P T E R 10 Maternal and Fetal Nutrition 289

Fig. 10-1 Factors that affect the outcome of pregnancy.

Education Knowledge Skills Comprehension Language Perinatal education

Socioeconomic status Income meets needs for food, shelter, clothing Health insurance/Medicaid

Health status Physical Psychologic EmotionalHealth services Available Accessible Acceptable Affordable

Nutrition Dietary intake adequate Food supply Good quality Available Affordable

Self-care Wanted pregnancy Program Adherence Compliance Active involvement Collaboration

Family Size Composition Stability Support available

Personal Genetics Culture Race/ethnicity Language

Environment Home Community Exposure to teratogens

288-315_CH10_Lowdermilk.qxd 11/15/05 11:06 AM 89

Nutrient needs are determined, at least in part, by the stageof gestation. The amount of fetal growth varies during thedifferent stages of pregnancy. During the first trimester, thesynthesis of fetal tissues places relatively few demands on ma-ternal nutrition. Therefore during the first trimester, whenthe embryo or fetus is very small, the needs are only slightlyincreased over those before pregnancy. In contrast, the lasttrimester is a period of noticeable fetal growth when mostof the fetal stores of energy sources and minerals are de-posited. Basal metabolic rates (BMRs), when expressed askilocalories (kcal) per minute, are approximately 20% higherin pregnant women than in nonpregnant women. This in-crease includes the energy cost for tissue synthesis.

The Food and Nutrition Board of the National Academyof Sciences publishes recommendations for the people ofthe United States, the Dietary Reference Intakes (DRIs).The DRIs consist of Recommended Dietary Allowances(RDAs) and Adequate Intakes (AIs), as well as UpperLimits (ULs), guidelines for avoiding excessive intakes ofnutrients that may be toxic if consumed in excess. RDAsfor some nutrients have been available for many years, andthey have been revised periodically. RDAs are recom-mendations for daily nutritional intakes that meet theneeds of almost all (97% to 98%) of the healthy membersof the population. AIs are similar to the RDAs and are be-lieved to cover the needs of virtually all healthy individu-als in a group, except that they deal with nutrients forwhich there are not enough data to be certain of their re-quirements. The RDAs and AIs include a wide variety ofnutrients and food components, and they are divided intoage, sex, and life-stage categories (e.g., infancy, pregnancy,and lactation). They can be used as goals in planning thediets of individuals (Table 10-1).

Energy NeedsEnergy (kilocalories or kcal) needs are met by carbohydrate,fat, and protein in the diet. No specific recommendationsexist for the amount of carbohydrate and fat in the diet ofthe pregnant woman. However, intake of these nutrientsshould be adequate to support the recommended weightgain. Although protein can be used to supply energy, its pri-mary role is to provide amino acids for the synthesis of newtissues (see the discussion on protein later in this chapter).The RDA during the second and third trimesters of preg-nancy is 300 kcal greater than prepregnancy needs. Very un-derweight or active women or those with multifetal gesta-tions will require more than 300 additional kcal to sustainthe desired rate of weight gain.

Weight gainThe optimal weight gain during pregnancy is not known

precisely. It is known, however, that the amount of weightgained by the mother during pregnancy has an important

NUTRIENT NEEDS DURING PREGNANCY

bearing on the course and outcome of pregnancy. Adequateweight gain does not necessarily indicate that the diet is nu-tritionally adequate, but it is associated with a reduced riskof giving birth to a small-for-gestational-age (SGA) or preterminfant.

The desirable weight gain during pregnancy varies amongwomen. The primary factor to consider in making a weightgain recommendation is the appropriateness of the prepreg-nancy weight for the woman’s height. Maternal and fetalrisks in pregnancy are increased when the mother is eithersignificantly underweight or overweight before pregnancy,and when weight gain during pregnancy is either too low or too high. Severely underweight women are more likely to have preterm labor and to give birth to LBW infants.Women with inadequate weight gain have an increased riskof giving birth to an infant with intrauterine growth re-striction (IUGR). Greater-than-expected weight gain duringpregnancy may occur for many reasons, including multiplegestation, edema, preeclampsia, and overeating. When obe-sity is present (either preexisting or developed during preg-nancy), there is an increased likelihood of macrosomia andfetopelvic disproportion; operative birth; emergency ce-sarean birth; postpartum hemorrhage; wound, genital tract,or urinary tract infection; birth trauma; and late fetal death.Obese women are more likely than normal-weight womento have gestational hypertension and gestational diabetes;their risk of giving birth to a child with a major congenitaldefect is double that of normal-weight women.

A commonly used method of evaluating the appropri-ateness of weight for height is the body mass index (BMI),which is calculated by the following formula:

BMI � weight/height2

where the weight is in kilograms and height is in meters.Therefore for a woman who weighed 51 kg before pregnancyand is 1.57 m tall:

BMI � 51/(1.57)2, or 20.7

Prepregnant BMI can be classified into the following cat-egories: less than 19.8, underweight or low; 19.8 to 26, nor-mal; 26 to 29, overweight or high; and greater than 29, obese(Institute of Medicine, 1992).

For women with single fetuses, current recommendationsare that women with a normal BMI should gain 11.5 to 16kg during pregnancy, underweight women should gain 12.5to 18 kg, overweight women should gain 7 to 11.5 kg, andobese women should gain at least 7 kg (Institute of Medi-cine, 1992). Adolescents are encouraged to strive for weightgains at the upper end of the recommended range for theirBMI because it appears that the fetus and the still-growingmother compete for nutrients. The risk of mechanical com-plications at birth is reduced if the weight gain of short adultwomen (shorter than 157 cm) is near the lower end of theirrecommended range. In twin gestations, gains of approxi-mately 16 to 20 kg appear to be associated with the best out-comes (Malone & D’Alton, 2004).

290 U N I T T H R E E PREGNANCY

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Pattern of weight gainWeight gain should take place throughout pregnancy. The

risk of giving birth to an SGA infant is greater when the weightgain early in pregnancy has been poor. The likelihood ofpreterm birth is greater when the gains during the last half ofpregnancy have been inadequate. These risks exist even whenthe total gain for the pregnancy is in the recommended range.

The optimal rate of weight gain depends on the stage ofpregnancy. During the first and second trimesters, growthtakes place primarily in maternal tissue; during the thirdtrimester, growth occurs primarily in fetal tissues. Duringthe first trimester there is an average total weight gain of only 1 to 2.5 kg. Thereafter the recommended weightgain increases to approximately 0.4 kg/week for a womanof normal weight (Fig. 10-2). The recommended weekly

weight gain for overweight women during the second andthird trimesters is 0.3 kg, and for underweight women it is0.5 kg. The recommended caloric intake corresponds to thispattern of gain. For the first trimester there is no increment;during the second and third trimesters an additional 300kcal/day over the prepregnant intake is recommended. Theamount of food providing 300 kcal is not great. It can beprovided by one additional serving from any one of the fol-lowing groups: milk, yogurt, or cheese (all skim milk prod-ucts); fruits; vegetables; and bread, cereal, rice, or pasta.

The reasons for an inadequate weight gain (less than 1 kg/month for normal-weight women or less than 0.5 kg/monthfor obese women during the last two trimesters) or excessiveweight gain (more than 3 kg/month) should be evaluatedthoroughly. Possible reasons for deviations from the expected


Fig. 10-2 Prenatal weight gain chart for plotting weight gain of normal-weight women. NOTE:Young adolescents, African-American women, and smokers should aim for the upper end of therecommended range; short women (�157 cm) should strive for gains at the lower end of the range.

Age (at conception)

Prepregnant weight

Height (w/o shoes)

Desirable weight

% Desirable weight

Body mass index

Term weight goal

14 16 18 20 22 24 26 28 30 32 34 36 38 40 42

1412108642 16 18 20 22 24 26 28 30 32 34 36 38 40 42

18192021222324

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rate of weight gain, besides inadequate or excessive dietaryintake, include measurement or recording errors, differencesin weight of clothing, time of day, and accumulation of flu-ids. An exceptionally high gain is likely to be caused by anaccumulation of fluids, and a gain of more than 3 kg in amonth, especially after the twentieth week of gestation, of-ten heralds the development of preeclampsia.

Hazards of restricting adequateweight gainFigure-conscious women may find it difficult to make the

transition from guarding against weight gain before preg-nancy to valuing weight gain during pregnancy. In coun-seling these women the nurse can emphasize the positive effects of good nutrition as well as the adverse effects of maternal malnutrition (manifested by poor weight gain) oninfant growth and development. This counseling includesinformation on the components of weight gain during preg-nancy (Table 10-2) and the amount of this weight that willbe lost at birth. Early in a woman’s pregnancy, explainingways to lose weight in the postpartum period helps relieveher concerns. Because lactation can help to reduce mater-nal energy stores gradually, this provides an opportunity topromote breastfeeding.

Pregnancy is not a time for a weight-reduction diet. Evenoverweight or obese pregnant women need to gain at leastenough weight to equal the weight of the products of con-ception (fetus, placenta, and amniotic fluid). If they limittheir caloric intake to prevent weight gain, they may also ex-cessively limit their intake of important nutrients. Moreover,dietary restriction results in catabolism of fat stores, whichin turn augments the production of ketones. The long-termeffects of mild ketonemia during pregnancy are not known,but ketonuria has been found to be correlated with the oc-currence of preterm labor. It should be stressed to obesewomen (and to all pregnant women) that the quality of theweight gain is important, with emphasis placed on the con-sumption of nutrient-dense foods and the avoidance ofempty-calorie foods.

Weight gain is important, but pregnancy is not an excusefor uncontrolled dietary indulgence. Excessive weight gained

during pregnancy may be difficult to lose after pregnancy,thus contributing to chronic overweight or obesity, an eti-ologic factor in a host of chronic diseases including hyper-tension, diabetes mellitus, and arteriosclerotic heart disease.The woman who gains 18 kg or more during pregnancy isespecially at risk.

ProteinProtein, with its essential constituent nitrogen, is the nutri-tional element basic to growth. Adequate protein intake is essential to meet increasing demands in pregnancy. These de-mands arise from the rapid growth of the fetus; the enlarge-ment of the uterus and its supporting structures, mammaryglands, and placenta; an increase in maternal circulating bloodvolume and subsequent demand for increased amounts ofplasma protein to maintain colloidal osmotic pressure; andthe formation of amniotic fluid.

Milk, meat, eggs, and cheese are complete-protein foodswith a high biologic value. Legumes (dried beans and peas),whole grains, and nuts are also valuable sources of protein.In addition, these protein-rich foods are a source of other nu-trients such as calcium, iron, and B vitamins; plant sourcesof protein often provide needed dietary fiber. The recom-mended daily food plan (Table 10-3) is a guide to the


TABLE 10-2

Tissues Contributing to Maternal WeightGain at 40 Weeks of Gestation

TISSUE KILOGRAMS POUNDS

Fetus 3-3.9 7-8.5Placenta .9-1.1 2-2.5Amniotic fluid .9 2Increase in uterine tissue .9 2Breast tissue .5-1.8 1-4Increased blood volume 1.8-2.3 4-5Increased tissue fluid 1.4-2.3 3-5Increased stores (fat) 1.8-2.7 4-6

Critical Thinking ExerciseNutrition and the UnderweightPregnant Adolescent

Carmen, of Hispanic heritage, is 15 years old and is 3 months pregnant. She comes to her initial appointmentfor diagnosis and care. She appears to be underweightfor her height. To provide optimum care for her, you planto calculate her prepregnancy BMI. When her pregnancyis confirmed, you are asked to compose a food plan withCarmen that meets the minimum daily requirements andallows for growth of the pregnancy. You know that it is im-portant to include consideration of personal preferencesand cultural factors in your plan. With Carmen, identifybarriers to implementing the plan.1 Evidence—Is there sufficient evidence to draw con-

clusions about an appropriate nutrition plan, takinginto consideration personal preferences and culturalfactors?

2 Assumptions—Describe underlying assumptionsabout each of the following issues:a. Dietary Reference Intakes for pregnancy and lac-

tationb. Indicators of nutritional risk in pregnancyc. Daily food guide for pregnancy and lactationd. Sources of calcium for women who do not

drink milk3 What implications and priorities for nursing care can

be drawn at this time?4 Does the evidence objectively support your con-

clusion?5 Are there alternative perspectives to your conclusion?

��


amounts of these foods that would supply the quantities ofprotein needed. The recommendations provide for only amodest increase in protein intake over the prepregnant lev-els in adult women. Protein intake in many people in theUnited States is relatively high, so many women may notneed to increase their protein intake at all during pregnancy.Three servings of milk, yogurt, or cheese (four for adoles-cents) and 5 to 6 oz (140 to 168 g) (two servings) of meat,poultry, or fish supply the recommended protein for thepregnant woman. Additional protein is provided by veg-etables and breads, cereals, rice, and pasta. Pregnant ado-lescents, women from impoverished backgrounds, andwomen adhering to unusual diets, such as a macrobiotic(highly restricted vegetarian) diet, are those most likely tohave inadequate protein intake. The use of high-protein sup-plements is not recommended, because these have been as-sociated with an increased incidence of preterm births.

FluidsEssential during the exchange of nutrients and waste productsacross cell membranes, water is the main substance of cells,blood, lymph, amniotic fluid, and other vital body fluids. Italso aids in maintaining body temperature. A good fluid in-take promotes good bowel function, which is sometimes aproblem during pregnancy. The recommended daily intakeis about six to eight glasses (1500 to 2000 ml) of fluid. Water,milk, and juices are good fluid sources. Dehydration may in-crease the risk of cramping, contractions, and preterm labor.

Women who consume more than 300 mg of caffeinedaily (equivalent to about 500 to 750 ml of coffee) may beat increased risk of miscarriage and of giving birth to infantswith IUGR. The ill effects of caffeine have been proposedto result from vasoconstriction of the blood vessels sup-plying the uterus or from interference with cell division inthe developing fetus. Consequently, caffeine-containing


TABLE 10-3

Daily Food Guide for Pregnancy and Lactation

SUGGESTED NUMBER OF SERVINGS

NONPREGNANT,NONLACTATING PREGNANT LACTATING

FOOD GROUP SERVING SIZE WOMAN WOMAN WOMAN

GRAIN PRODUCTS

6-11 6-11 6-11

VEGETABLES

3-5 3-5 3-5

FRUITS

2-4 2-4 2-4

2-3 3 or more 4 or more

MEAT, POULTRY, FISH, DRY BEANS, NUTS, AND EGGS

Up to 6 oz total Up to 6 oz total Up to 6 oz total

c, cup; T, tablespoon.

1⁄2 c cooked dried beans, 1 egg, or 11⁄2T peanutbutter is equivalent to 1 oz of meat

Eat peanut butter or nutsrarely to avoid exces-sive fat intake. Limit eggintake to reduce choles-terol intake; trim fatfrom meat, and removeskin from poultry.

1 c milk or yogurt; 11⁄2 ozcheese

MILK AND MILKPRODUCTS

1 medium apple, orange,banana, peach, etc; 1⁄2 csmall or diced fruit; 3⁄4 cjuice

Include citrus fruits, straw-berries, or melons fre-quently.

Eat dried beans and peasoften; count 1⁄2 c cookeddried beans or peas as aserving of vegetables or1 oz from meat group.

1 c raw leafy greens; 1⁄2 cof others

Eat dark green leafy anddeep yellow often.

1 slice bread; 1⁄2 bun,bagel, or English muffin;1 oz ready-to-eat cereal;1⁄2 c cooked grains

Include whole-grain andenriched breads, cere-als, pasta, and rice.


products such as caffeinated coffee, tea, soft drinks, and co-coa beverages should be avoided or consumed only in lim-ited quantities.

Aspartame (NutraSweet, Equal), acesulfame potassium(Sunett), and sucralose (Splenda), artificial sweeteners

commonly used in low- or no-calorie beverages and low-calorie food products, have not been found to have adverseeffects on the normal mother or fetus. Aspartame, whichcontains phenylalanine, should be avoided by the womanwith phenylketonuria (PKU) (Box 10-1).


Use of Artificial Sweeteners during Pregnancy

All of the following sweeteners are approved for use in allage groups, including pregnant women, in the UnitedStates:

NEOTAME

• Brand names: none (not currently available)• Primary uses: approved in the United States but not cur-

rently marketed; proposed for use in beverages, frozendesserts, yogurt, chewing gum, toppings, fillings, fruitspreads, table-top sweetener

• Sweetness: 8000 times sweeter than sugar• Shelf life: similar to aspartame (about 5 months in a soft

drink)• Suitability for cooking: good, but loses sweetness if

cooked at high temperatures or for prolonged periods• Health concerns: none known; contains phenylalanine but

not in a form that can be metabolized

SACCHARIN

• Brand name: Sweet ‘n Low• Primary uses: fountain drinks, chewable vitamins and

medications, table-top sweetener• Sweetness: 300 times sweeter than sugar• Shelf life: long• Suitability for cooking: good, does not lose sweetness

during cooking• Health concerns: linked to bladder cancer in rats

SUCRALOSE

• Brand name: Splenda• Primary uses: baked goods, beverages, frozen desserts,

gelatins, table-top sweetener• Sweetness: 600 times sweeter than sugar• Shelf life: long• Suitability for cooking: very good, does not break down

during cooking (maltodextrin is added to give productsbetter bulk and texture)

• Health concerns: none known

SUGAR ALCOHOLS (not technically artificial sweet-eners; contain almost as many calories as sugar)

• Types: sorbitol, xylitol, lactitol, mannitol, and maltitol• Primary uses: sugar-free candy, cookies, and chewing

gum• Sweetness: most are about 70% as sweet as sugar;

xylitol equals sugar in sweetness• Shelf life: long• Suitability for cooking: good• Advantages over sugar: do not promote tooth decay,

more slowly metabolized so that they do not create arapid peak in blood glucose

• Health concerns: diarrhea can occur with large intakes

BOX 10-1

Sugar is important for the volume and moisture of baked goods. Artificial sweeteners may produce a good-tasting product, but some sugar is necessaryin many recipes to yield normal volume and texture.

ACESULFAME K

• Brand names: Sunett, Sweet One• Primary uses: baked goods, frozen desserts, candies, bev-

erages• Sweetness: 200 times sweeter than sugar• Shelf life: long• Suitability for cooking: good, does not break down when

heated• Health concerns: none known

ASPARTAME

• Brand names: Equal, NutraSweet, NatraTaste• Primary uses: beverages, frozen desserts, dairy products,

chewing gum, breakfast cereals, table-top sweetener• Sweetness: 180 times sweeter than sugar• Shelf life: relatively short (about 5 months in a soft drink)• Suitability for cooking: breaks down and loses sweetness

if cooked at high temperatures or for long periods• Health concerns: contains phenylalanine, a consideration

in the diets of people with phenylketonuria


Minerals and VitaminsIn general the nutrient needs of pregnant women, except per-haps for folate and iron, can be met through dietary sources.Counseling about the need for a varied diet rich in vitaminsand minerals should be a part of every pregnant woman’searly prenatal care and should be reinforced throughoutpregnancy. Supplements of certain nutrients (listed in the fol-lowing discussion) are recommended whenever the woman’sdiet is very poor or whenever significant nutritional risk fac-tors are present. Nutritional risk factors in pregnancy arelisted in Box 10-2.

IronIron is needed both to allow transfer of adequate iron to

the fetus and to permit expansion of the maternal red bloodcell (RBC) mass. Beginning in the latter part of the firsttrimester, the blood volume of the mother increases steadily,peaking at about 1500 ml more than that in the nonpreg-nant state. In twin gestations, the increase is at least 500 mlgreater than that in pregnancies with single fetuses. Plasmavolume increases more than RBC mass, with the differencebetween plasma and RBCs being greatest during the secondtrimester. The relative excess of plasma causes a modest de-crease in the hemoglobin concentration and hematocrit,termed physiologic anemia of pregnancy. This is a normaladaptation during pregnancy.

However, poor iron intake and absorption, which can re-sult in iron deficiency anemia, is relatively common amongwomen in the childbearing years. It affects nearly one fifthof the pregnant women in industrialized countries. The ma-ternal mortality rate is increased among anemic women, whoare poorly prepared to tolerate hemorrhage at the time ofbirth. In addition, anemic women may have a greater like-lihood of cardiac failure during labor, postpartum infections,and poor wound healing. The fetus is also affected by ma-ternal anemia. The risk of preterm birth is about threefold

greater in anemic women, and fetal iron stores may also bereduced by maternal anemia. Anemia is more commonamong adolescents and African-American women thanamong adult Caucasian women.

The Institute of Medicine (1992) recommended that allpregnant women receive a supplement of 30 mg of ferrousiron daily, starting by 12 weeks of gestation. (Iron supplementsmay be poorly tolerated during the nausea that is prevalentin the first trimester.) If maternal iron deficiency anemia ispresent (preferably diagnosed by measurement of serum fer-ritin, a storage form of iron), increased dosages (60 to 100 mgdaily) are recommended. Certain foods taken with an ironsupplement can promote or inhibit absorption of iron fromthe supplement. Even when a woman is taking an iron sup-plement, she should include good food sources of iron in herdaily diet (see Table 10-1).

CalciumThere is no increase in the DRI of calcium during preg-

nancy and lactation, in comparison with the recommenda-tion for the nonpregnant woman (see Table 10-1). The DRI(1000 mg daily for women age 19 and older and 1300 mgfor those younger than age 19) appears to provide sufficientcalcium for fetal bone and tooth development to proceedwhile maternal bone mass is maintained.

Milk and yogurt are especially rich sources of calcium,providing approximately 300 mg/cup (240 ml). Neverthe-less, many women do not consume these foods or do notconsume adequate amounts to provide the recommendedintakes of calcium. One problem that can interfere withmilk consumption is lactose intolerance, which is an in-ability to digest milk sugar (lactose) and is caused by the ab-sence of the lactase enzyme in the small intestine. Lactoseintolerance is relatively common in adults, particularlyAfrican-Americans, Asians, Native Americans, and Inuits.Milk consumption may cause abdominal cramping, bloat-ing, and diarrhea in such people. Yogurt, sweet acidophilusmilk, buttermilk, cheese, chocolate milk, and cocoa may betolerated even when fresh fluid milk is not. Commercialproducts that contain lactase (e.g., Lactaid) are widely avail-able. Many supermarkets stock lactase-treated milk. The lac-tase in these products hydrolyzes, or digests, the lactose inmilk, making it possible for lactose-intolerant people todrink milk.

In some cultures, adults rarely drink milk. For example,Puerto Ricans and other Hispanic people may use milk onlyas an additive in coffee. Pregnant women from these culturesmay need to consume nondairy sources of calcium. Vege-tarian diets may also be deficient in calcium (Box 10-3). Ifcalcium intake appears low and the woman does not changeher dietary habits despite counseling, a daily supplementcontaining 600 mg of elemental calcium may be needed.Calcium supplements may also be recommended when apregnant woman experiences leg cramps caused by an im-balance in the calcium/phosphorus ratio.


Indicators of Nutritional Risk in Pregnancy

• Adolescence• Frequent pregnancies: three within 2 years• Poor fetal outcome in a previous pregnancy• Poverty• Poor diet habits with resistance to change• Use of tobacco, alcohol, or drugs• Weight at conception under or over normal weight• Problems with weight gain• Any weight loss• Weight gain of less than 1 kg/mo after the first

trimester• Weight gain of more than 1 kg/wk after the first

trimester• Multifetal pregnancy• Low hemoglobin or hematocrit values (or both)

BOX 10-2



EVIDENCE-BASED PRACTICE

Calcium Supplementation for Preventing Preeclampsia

Statistical Analyses

• Similar data were pooled, and effect size (the differencebetween intervention and control groups in each trial) wascalculated. The calculations comparing high risk and lowrisk women, and baseline low and adequate dietary cal-cium, were analyzed post hoc (after the main calculations).

FINDINGS

• Calcium supplementation was associated with signifi-cantly less high blood pressure than placebo. The differ-ence was more marked in the group of women at highrisk for gestational hypertension and in the group ofwomen with low baseline dietary calcium. Preeclampsiawas likewise significantly reduced with calcium in low riskwomen and markedly reduced in high risk women andwomen with low baseline dietary calcium, but the effectwas not significant with women who had adequate base-line dietary calcium. The risk of preterm birth and low birthweight was significantly decreased among high riskwomen taking calcium. There was no difference in cae-sarean births, admission to NICU, or perinatal death. Datawere inadequate to make determinations about maternaldeath or serious morbidity, placental abruptions,mother’s length of stay, small-for-gestational-age babies,or childhood disabilities. One follow-up study of childrenat 7 years of age found fewer elevated blood pressuresin the calcium group than placebo, suggesting a linger-ing benefit for the offspring. No side effects of calciumwere recorded in these trials.

LIMITATIONS

• The doses and types of calcium differed, as did the def-initions of high risk and the baseline dietary calcium in-take, causing heterogeneity in the trials and limiting gen-eralizability. Some randomization was not well described.In general, however, these were strong trials in that theywere large, double-blinded, and placebo-controlled trials.

CONCLUSIONS

• Supplemental calcium is associated with less hyperten-sion and less preeclampsia, as well as less preterm birthand low birth weight, especially in those women at highrisk.

IMPLICATIONS FOR PRACTICE

• Health care providers should support calcium supple-mentation for women at high risk for gestational hyper-tension, as well as in communities with low baseline cal-cium intake.

IMPLICATIONS FOR FURTHER RESEARCH

• Research should focus on women at high risk for gesta-tional hypertension and communities with low baselinedietary calcium, and on ideal dosages of calcium. The onestudy of long-term benefits for offspring was promising.Researchers should distinguish between small-for-gestational-age babies and preterm babies, because theyare different conditions and have different prognoses.

BACKGROUND

• Hypertensive disorders of pregnancy are associated withmaternal and fetal death and morbidity. Hypertension leadsto poor uterine perfusion, preterm birth, fetal distress, lowbirth weight, and perinatal fetal mortality. In the mother,preeclampsia can lead to edema; seizures; renal failure; thesyndrome of hemolysis, elevated liver enzymes, and lowplatelets (HELLP); admission to intensive care; cesareanbirth; and maternal death. Gestational hypertension is usu-ally defined as new-onset diastolic blood pressure over 90mm Hg, or a rise over baseline for systolic blood pressureof 30 mm Hg or for diastolic pressure of 15 mm Hg. Pre-eclampsia is diagnosed when gestational hypertension isaccompanied by proteinuria of 2�, or 300 mg in 24 hours.Blood pressure climbs when the endothelial walls becomeinflamed from unknown causes. Low calcium intake maystimulate either parathyroid hormone or renin release,which increases cellular uptake of calcium, leading to va-sospasm. Calcium supplementation reduces parathyroidhormone, thus reducing intravascular inflammation, andmay be a treatment for gestational hypertension. Calciummay also relax the smooth muscles in the uterus, reduc-ing the risk of preterm labor. Calcium is cost-effective, fa-miliar, and available. No risk of renal stones has been noted.

OBJECTIVES

• The goal of the review was to determine whether calciumsupplementation during pregnancy affected preeclamp-sia, and related adverse maternal and fetal outcomes. Ofinterest were comparisons of women at low risk for pre-eclampsia with high risk mothers (teens, women with his-tory of preeclampsia or prepregnancy hypertension, in-creased sensitivity to angiotensin II) and comparisons ofwomen with low dietary calcium baselines (under 900mg/day) with women with adequate dietary calcium. Theintervention was oral calcium, at least 1 g/day. The con-trols took a placebo. Maternal outcome measures in-cluded hypertension, proteinuria, placental abruption, ce-sarean birth, mother’s length of stay, eclampsia, renalfailure, HELLP, intensive care unit admission, and ma-ternal death. Fetal or neonatal outcomes includedpreterm labor (before 37 weeks), low birth weight, smallsize for gestational age, admission to neonatal intensivecare unit (NICU), length of stay longer than 7 days, peri-natal death, long-term disability, and childhood hyper-tension (greater than 95th percentile).

METHODS

Search Strategy

• The reviewers searched the Cochrane database, MEDLINE,30 journals and conferences, and a weekly current aware-ness service of 37 journals. Search keywords were cal-cium, hypertension, pregnancy, blood pressure, and com-binations of these terms.

• Eleven randomized, placebo-controlled trials were selected, representing 6894 women from Argentina, theUnited States, Australia, Ecuador, and India. The trialswere published from 1989 to 2001.

Reference: Atallah, A., Hofmeyr, G., & Duley, L. (2003). Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane Review). InThe Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.


SodiumDuring pregnancy the need for sodium increases slightly,

primarily because the body water is expanding (e.g., the ex-panding blood volume). Sodium is essential for maintainingbody water balance. In the past, dietary sodium was routinelyrestricted in an effort to control the peripheral edema thatcommonly occurs during pregnancy. It is now recognized thatmoderate peripheral edema is normal in pregnancy, occur-ring as a response to the fluid-retaining effects of elevated lev-els of estrogen. An excessive emphasis on sodium restrictionmay make it difficult for pregnant women to achieve an ad-equate diet. Grain, milk, and meat products, which are goodsources of other nutrients needed during pregnancy, are sig-nificant sources of sodium. In addition, sodium restrictionmay stress the adrenal glands and the kidney as they attemptto retain adequate sodium. In general, sodium restriction isnecessary only if the woman has a medical condition suchas renal or liver failure or hypertension.

Excessive intake of sodium is discouraged during preg-nancy just as it is in nonpregnant women, because it maycontribute to abnormal fluid retention and edema. Table salt(sodium chloride) is the richest source of sodium. Most

canned foods contain added salt unless the label specificallystates otherwise. Large amounts of sodium are also found inmany processed foods, including meats (e.g., smoked orcured meats, cold cuts, and corned beef), baked goods, mixesfor casseroles or grain products, soups, and condiments.Products low in nutritive value and excessively high insodium include pretzels, potato and other chips, pickles, cat-sup, prepared mustard, steak and Worcestershire sauces,some soft drinks, and bouillon. A moderate sodium intakecan usually be achieved by salting food lightly in cooking;adding no additional salt at the table; and avoiding low-nutrient, high-sodium foods.

ZincZinc is a constituent of numerous enzymes involved in

major metabolic pathways. Zinc deficiency is associatedwith malformations of the central nervous system in in-fants. When large amounts of iron and folic acid are con-sumed, the absorption of zinc is inhibited and serum zinclevels are reduced as a result. Because iron and folic acidsupplements are commonly prescribed during pregnancy,pregnant women should be encouraged to consume goodsources of zinc daily (see Table 10-1). Women with anemiawho receive high-dose iron supplements also need sup-plements of zinc and copper (King, 2000).

FluorideThere is no evidence that prenatal fluoride supplemen-

tation reduces the child’s likelihood of tooth decay duringthe preschool years (Fluoride Recommendations WorkGroup, 2001). No increase in fluoride intake over the non-pregnant DRI is currently recommended during pregnancy.

Fat-soluble vitaminsFat-soluble vitamins—A, D, E, and K—are stored in the

body tissues. With chronic overdoses these vitamins canreach toxic levels. Because of the high potential for toxicity,pregnant women are advised to take fat-soluble vitamin sup-plements only as prescribed. Vitamins A and D deserve spe-cial mention.

Adequate intake of vitamin A is needed so that sufficientamounts can be stored in the fetus. Dietary sources can read-ily supply sufficient amounts. Congenital malformationshave occurred in infants of mothers who took excessiveamounts of vitamin A during pregnancy, and therefore sup-plements are not recommended for pregnant women. Vi-tamin A analogs such as isotretinoin (Accutane), which areprescribed for the treatment of cystic acne, are a special con-cern. Isotretinoin use during early pregnancy has been as-sociated with an increased incidence of heart malformations,facial abnormalities, cleft palate, hydrocephalus, and deaf-ness and blindness in the infant, as well as an increased riskof miscarriage. Topical agents such as tretinoin (Retin-A) do not appear to enter the circulation in any substantialamounts, but their safety in pregnancy has not been con-firmed.


Calcium Sources for Women Who Do NotDrink Milk

Each of the following provides approximately the sameamount of calcium as 1 cup of milk.

FISH

3-oz can of sardines41⁄2-oz can of salmon (if bones are eaten)

BEANS AND LEGUMES

3 cups cooked dried beans21⁄2 cups refried beans2 cups baked beans with molasses1 cup tofu (calcium is added in processing)

GREENS

1 cup collards11⁄2 cups kale or turnip greens

BAKED PRODUCTS

3 pieces cornbread3 English muffins4 slices French toast2 waffles (7 inches in diameter)

FRUITS

11 dried figs11⁄8 cups orange juice with calcium added

SAUCES

3 oz pesto sauce5 oz cheese sauce

BOX 10-3


Vitamin D plays an important role in absorption and me-tabolism of calcium. The main food sources of this vitaminare enriched or fortified foods such as milk and ready-to-eatcereals. Vitamin D is also produced in the skin by the actionof ultraviolet light (in sunlight). Severe deficiency may leadto neonatal hypocalcemia and tetany, as well as hypoplasiaof the tooth enamel. Women with lactose intolerance andthose who do not include milk in their diet for any reasonare at risk for vitamin D deficiency. Other risk factors are hav-ing dark skin; habitually using clothing that covers most ofthe skin (e.g., Arab women with extensive body covering);and living in northern latitudes where sunlight exposure islimited, especially during the winter. Use of recommendedamounts of sunscreen with a sun protection factor (SPF) rat-ing of 15 reduces skin vitamin D production by as much as99% (Scanlon, 2001), reinforcing the need for regular intakeof fortified foods or a supplement.

Water-soluble vitaminsBody stores of water-soluble vitamins are much smaller

than those of fat-soluble vitamins. Water-soluble vitamins,in contrast to fat-soluble vitamins, are readily excreted in theurine. Therefore good sources of these vitamins must be con-sumed frequently. Toxicity with overdose is less likely thanwith fat-soluble vitamins.

Because of the increase in RBC production during preg-nancy, as well as the nutritional requirements of the rapidlygrowing cells in the fetus and placenta, pregnant womenshould consume about 50% more folic acid than nonpreg-nant women, or about 0.6 mg (600 mcg) daily. In the UnitedStates all enriched grain products (this includes most whitebreads, flour, and pasta) must contain folic acid at a level of1.4 mg/kg of flour. This level of fortification is designed tosupply approximately 0.1 mg of folic acid daily in the averageAmerican diet and has significantly increased folic acid con-sumption in the population as a whole. All women of child-bearing potential need careful counseling about includinggood sources of folic acid in their diet (Box 10-4; see Table10-1). Supplemental folic acid is usually prescribed to ensurethat intake is adequate. Women who have borne a child witha neural tube defect are advised to consume 4 mg of folicacid daily, and a supplement is required for them to achievethis level of intake.

Pyridoxine, or vitamin B6, is involved in protein metab-olism. Although levels of a pyridoxine-containing enzymehave been reported to be low in women with preeclampsia,there is no evidence that supplementation prevents or correctsthe condition. No supplement is recommended routinely, butwomen with poor diets and those at nutritional risk (see Box10-2) may need a supplement providing 2 mg/day.

Vitamin C, or ascorbic acid, plays an important role intissue formation and enhances the absorption of iron. Thevitamin C needs of most women are readily met by a dietthat includes at least one daily serving of citrus fruit or juiceor another good source of the vitamin (see Table 10-1), butwomen who smoke need more. For women at nutritional

risk, a supplement of 50 mg/day is recommended. However,if the mother takes excessive doses of this vitamin duringpregnancy, a vitamin C deficiency may develop in the in-fant after birth.

Multivitamin and multimineralsupplements during pregnancyThe consensus of the 1992 Institute of Medicine com-

mittee is that food can and should be the normal vehicle tomeet the additional needs imposed by pregnancy, except foriron. Recall that a supplemental dose of 30 mg/day is rec-ommended. In addition, the recommended folate intakemay be difficult for some women to achieve. Some womenhabitually consume diets that are deficient in necessary nu-trients and, for whatever reason, may be unable to changethis intake. For these women, a multivitamin-multimineral


Food Sources of Folate

FOODS PROVIDING 500 mcg OR MORE PER SERVING

• Liver: Chicken, turkey, goose (31⁄2 oz)


• Liver: Lamb, beef, veal (31⁄2 oz)


• Legumes, cooked (1⁄2 cup)• Peas: Black-eyed peas, chickpeas (garbanzos)• Beans: Black, kidney, pinto, red, navy• Lentils

• Vegetables (1⁄2 cup)• Asparagus• Spinach, cooked

• Papaya (1 medium)• Breakfast cereal, ready-to-eat (1⁄2-1 cup)• Wheat germ (1⁄2 cup)


• Vegetables (cup)• Broccoli• Beans: lima, baked, or pork and beans• Greens: collards or mustard, cooked• Spinach, raw

• Fruits (1⁄2 cup)• Avocado• Orange or orange juice

• Pasta, cooked (1 cup)• Rice, cooked (1 cup)


• Bread (1 slice)• Egg (1 large)• Corn (1⁄2 cup)

BOX 10-4


supplement should be considered to ensure that they con-sume the RDA for most known vitamins and minerals. It isimportant that the pregnant woman understand that the useof a vitamin-mineral supplement does not lessen the needto consume a nutritious, well-balanced diet.

Other Nutritional Issues duringPregnancy

Pica and food cravingsPica, the practice of consuming nonfood substances (e.g.,

clay, dirt, and laundry starch) or excessive amounts of food-stuffs low in nutritional value (e.g., cornstarch, ice, bakingpowder, and baking soda), is often influenced by the woman’scultural background (Fig. 10-3). In the United States it appearsto be most common among African-American women,women from rural areas, and women with a family historyof pica. Regular and heavy consumption of low-nutrientproducts may cause more nutritious foods to be displacedfrom the diet, and the items consumed may interfere with theabsorption of nutrients, especially minerals. Women with picahave lower hemoglobin levels than those without pica. Thepossibility of pica must be considered when pregnant womenare found to be anemic. The nurse should provide counsel-ing about the health risks associated with pica.

The existence of pica, as well as details of the type andamounts of products ingested, is likely to be discovered onlyby the sensitive interviewer who has developed a relation-ship of trust with the woman. It has been proposed that picaand food cravings (e.g., the urge to consume ice cream, pick-les, or pizza) during pregnancy are caused by an innate driveto consume nutrients missing from the diet. However, re-search has not supported this hypothesis.

Adolescent pregnancy needsMany adolescent females have diets that provide less than

the recommended intakes of key nutrients, including energy,calcium, and iron. Pregnant adolescents and their infants areat increased risk of complications during pregnancy and par-turition. Growth of the pelvis is delayed in comparison withgrowth in stature, and this helps to explain why cephalo-pelvic disproportion and other mechanical problems asso-ciated with labor are common among young adolescents.Competition for nutrients between the growing adolescentand the fetus may also contribute to some of the poor out-comes apparent in teen pregnancies. Pregnant adolescentsare encouraged to choose a weight gain goal at the upper endof the range for their BMI.

Efforts to improve the nutritional health of pregnant ado-lescents focus on improving the nutrition knowledge, mealplanning, and food preparation and selection skills of youngwomen; promoting access to prenatal care; developing nutrition interventions and educational programs that areeffective with adolescents; and striving to understand the fac-tors that create barriers to change in the adolescent popu-lation.

PreeclampsiaThe cause of preeclampsia is not known. There has been

speculation that the poor intake of several nutrients, in-cluding calcium, magnesium, vitamin B6, and protein, mightfoster its development. There is no definite evidence that nu-tritional deficiencies are causes or that nutritional supple-ments can help prevent it. At present, a diet adequate in therecommended nutrients (see Table 10-1) appears to be thebest means of reducing the risk of preeclampsia.


Fig. 10-3 Nonfood substances consumed in pica: (center) red clay from Georgia (left to right);Nzu from Eastern Nigeria, baking powder, corn starch, baking soda, laundry starch, and ice. Someindividuals practice poly-pica (consuming more than one of these substances.) (Courtesy ShannonPerry, Phoenix, AZ.)


Exercise during pregnancyModerate exercise during pregnancy yields numerous

benefits, including improving muscle tone, potentially short-ening the course of labor, and promoting a sense of well-being. If no medical or obstetric problems contraindicatephysical activity, pregnant women should perform 30 min-utes of moderate physical exercise on most, if not all, daysof the week (American College of Obstetricians and Gyne-cologists [ACOG], 2002). Two nutritional concepts are es-pecially important for women who choose to exercise dur-ing pregnancy. First, a liberal amount of fluid should beconsumed before, during, and after exercise because dehy-dration can trigger premature labor. Second, the calorie in-take should be sufficient to meet the increased needs of preg-nancy and the demands of exercise.

Nutritional needs during lactation are similar in many waysto those during pregnancy (see Table 10-1). Needs for energy(calories), protein, calcium, iodine, zinc, the B vitamins (thi-amine, riboflavin, niacin, pyridoxine, and vitamin B12), andvitamin C remain greater than nonpregnant needs. The rec-ommendations for some of these (e.g., vitamin C, zinc, andprotein) are slightly to moderately higher than during preg-nancy (see Table 10-1). This allowance covers the amount ofthe nutrients released in the milk, as well as the needs of themother for tissue maintenance. In the case of iron and folicacid, the recommendation during lactation is lower than dur-ing pregnancy. Both of these nutrients are essential for RBCformation and therefore for maintaining the increase in theblood volume that occurs during pregnancy. With the de-crease in maternal blood volume to nonpregnant levels af-ter birth, maternal iron and folic acid needs also decrease.Many lactating women have a delay in the return of menses;this conserves blood cells and reduces iron and folic acidneeds. It is especially important that the calcium intake beadequate; if it is not and the women does not respond to dietcounseling, a supplement of 600 mg of calcium per day maybe needed.

The recommended energy intake is an increase of 500 kcalmore than the woman’s nonpregnant intake. The Instituteof Medicine (1992) recommends that lactating women con-sume at least 1800 kcal/day; it is difficult to obtain adequatenutrients for maintenance of lactation at levels below that.Because of the deposition of energy stores, the woman whohas gained the optimal amount of weight during pregnancyis heavier after birth than at the beginning of pregnancy. Asa result of the caloric demands of lactation, however, the lac-tating mother usually experiences a gradual but steady weightloss. Most women rapidly lose several pounds during the firstmonth after birth whether or not they breastfeed. After thefirst month the average loss during lactation is 0.5 to 1 kga month.

NUTRIENT NEEDS DURING LACTATION

Fluid intake must be adequate to maintain milk pro-duction, but the mother’s level of thirst is the best guide tothe right amount. There is no need to consume more flu-ids than those needed to satisfy thirst.

Smoking, alcohol intake, and excessive caffeine intakeshould be avoided during lactation. Smoking may not onlyimpair milk production but also may expose the infant tothe risk of passive smoking. It is speculated that the infant’spsychomotor development may be affected by maternal al-cohol use, and alcoholic beverages (two drinks per day) mayimpair the milk ejection reflex. Caffeine intake may lead toa reduced iron concentration in milk and consequently con-tribute to the development of anemia in the infant. The caf-feine concentration in milk is only approximately 1% of themother’s plasma level, but caffeine seems to accumulate inthe infant. Breastfed infants of mothers who drink largeamounts of coffee or caffeine-containing soft drinks may beunusually active and wakeful.

During pregnancy, nutrition plays a key role in achieving anoptimum outcome for the mother and her unborn baby.Motivation to learn about nutrition is usually higher duringpregnancy as parents strive to “do what’s right for the baby.”Optimum nutrition cannot eliminate all problems that mayarise during pregnancy, but it does establish a good foun-dation for supporting the needs of the mother and her un-born baby.

Assessment and Nursing DiagnosesAssessment is based on a diet history (a description of thewoman’s usual food and beverage intake and factors affect-ing her nutritional status, such as medications being taken andadequacy of income to allow her to purchase the necessaryfoods) obtained from an interview and review of the woman’shealth records, physical examination, and laboratory results.Ideally, a nutritional assessment is performed before con-ception so that any recommended changes in diet, lifestyle,and weight can be undertaken before the woman becomespregnant.

Diet historyObstetric and gynecologic effects on nu-

trition. Nutritional reserves may be depleted in the mul-tiparous woman or one who has had frequent pregnancies(especially three pregnancies within 2 years). A history ofpreterm birth or the birth of an LBW or SGA infant mayindicate inadequate dietary intake. Preeclampsia may alsobe a factor in poor maternal nutrition. Birth of a large-for-gestational-age (LGA) infant may indicate the existence ofmaternal diabetes mellitus. Previous contraceptive meth-ods also may affect reproductive health. Increased men-strual blood loss often occurs during the first 3 to 6 months

CARE MANAGEMENT



after placement of an intrauterine contraceptive device.Consequently the user may have low iron stores or eveniron deficiency anemia. Oral contraceptive agents, on theother hand, are associated with decreased menstrual lossesand increased iron stores. Oral contraceptives, however,may interfere with folic acid metabolism.

Medical history. Chronic maternal illnesses such asdiabetes mellitus, renal disease, liver disease, cystic fibrosisor other malabsorptive disorders, seizure disorders and theuse of anticonvulsant agents, hypertension, and PKU mayaffect a woman’s nutritional status and dietary needs. Inwomen with illnesses that have resulted in nutritional deficitsor that require dietary treatment (e.g., diabetes mellitus,PKU), it is extremely important for nutritional care to bestarted and for the condition to be optimally controlled be-fore conception. A registered dietitian can provide in-depthcounseling for the woman who requires a therapeutic dietduring pregnancy and lactation.

Usual maternal diet. The woman’s usual food andbeverage intake, adequacy of income and other resources tomeet her nutritional needs, any dietary modifications, foodallergies and intolerances, and all medications and nutritionsupplements being taken, as well as pica and cultural dietaryrequirements, should be ascertained. In addition, the presenceand severity of nutrition-related discomforts of pregnancy,such as morning sickness, constipation, and pyrosis (heart-burn), should be determined. The nurse should be alert to anyevidence of eating disorders such as anorexia nervosa, bulimia,or frequent and rigorous dieting before or during pregnancy.

The impact of food allergies and intolerances on nutri-tional status ranges from very important to almost none. Lac-tose intolerance is of special concern in pregnant and lac-tating women because no other food group equals milk andmilk products in terms of calcium content. If a woman haslactose intolerance, the interviewer should explore her intakeof other calcium sources (see Box 10-3).

The assessment must include an evaluation of thewoman’s financial status and her knowledge of sound dietarypractices. The quality of the diet improves with increasingsocioeconomic status and educational level. Poor womenmay not have access to adequate refrigeration and cookingfacilities and may find it difficult to obtain adequate nutri-tious food. The pregnancy rates are high among homelesswomen, and many such women cannot or do not take ad-vantage of services such as food stamps.

Box 10-5 provides a simple tool for obtaining diet historyinformation. When potential problems are identified, theyshould be followed up with a careful interview.

Physical examination. Anthropometric (body)measurements provide short- and long-term informationabout a woman’s nutritional status and are therefore essen-tial to the assessment. At a minimum, the woman’s heightand weight must be determined at the time of her first pre-natal visit, and her weight should be measured at each sub-sequent visit (see earlier discussion of BMI).

A careful physical examination can reveal objective signsof malnutrition (Table 10-4). It is important to note, however,that some of these signs are nonspecific and that the physi-ologic changes of pregnancy may complicate the interpreta-tion of physical findings. For example, lower extremity edemaoften occurs in calorie and protein deficiency, but it may alsobe a normal finding in the third trimester of pregnancy. In-terpretation of physical findings is made easier by a thoroughhealth history and by laboratory testing, if indicated.

Laboratory testing. The only nutrition-related lab-oratory testing needed by most pregnant women is a hema-tocrit or hemoglobin measurement to screen for the presenceof anemia. Because of the physiologic anemia of pregnancy,the reference values for hemoglobin and hematocrit must beadjusted during pregnancy. The lower limit of the normalrange for hemoglobin during pregnancy is 11 g/dl in the firstand third trimesters and 10.5 g/dl in the second trimester (com-pared with 12 g/dl in the nonpregnant state). The lower limitof the normal range for hematocrit is 33% during the first andthird trimesters and 32% in the second trimester (comparedwith 36% in the nonpregnant state). Cutoff values for anemiaare higher in women who smoke or who live at high altitudes,because the decreased oxygen-carrying capacity of their RBCscauses them to produce more RBCs than other women.

A woman’s history or physical findings may indicate theneed for additional testing, such as a complete blood cellcount with a differential to identify megaloblastic or macro-cytic anemia and measurement of levels of specific vitaminsor minerals believed to be lacking in the diet.

The assessment gives a basis for making appropriate nurs-ing diagnoses.

• Imbalanced nutrition: less than body requirements related to—inadequate information about nutritional needsand weight gain during pregnancy—misperceptions regarding normal body changesduring pregnancy and inappropriate fear of be-coming fat—inadequate income or skills in meal planning andpreparation

• Imbalanced nutrition: more than body requirements re-lated to—excessive intake of energy (calories) or decrease inactivity during pregnancy—use of unnecessary dietary supplements

• Constipation related to—decrease in gastrointestinal motility because of elevated progesterone levels—compression of intestines by the enlarging uterus—oral iron supplementation

Expected Outcomes of CareAn individualized plan of care based on the nursing di-agnoses should be developed in collaboration with thewoman. For many women with uncomplicated pregnancies,



the nurse can serve as the primary source of nutrition ed-ucation during pregnancy. The registered dietitian, who hasspecialized training in diet evaluation and planning, nu-tritional needs during illness, and ethnic and cultural foodpatterns, as well as translating nutrient needs into food pat-terns, often serves as a consultant. Pregnant women with

serious nutritional problems, those with intervening ill-nesses such as diabetes (either preexisting or gestational),and any others requiring in-depth dietary counseling shouldbe referred to the dietitian. The nurse, dietitian, physician,and nurse-midwife collaborate in helping the womanachieve nutrition-related expected outcomes. Some


Food Intake Questionnaire

Which of the following did you eat or drink yesterday? If the way you ate yesterday wasn’t the way you usually eat,choose a recent day that was typical for you.

NUMBER OF NUMBER OF

FOOD OR DRINK SERVINGS FOOD OR DRINK SERVINGS

Beer, wine, other alcoholic drinks Orange or grapefruit juiceTea Fruit juice other than orange or Coffee grapefruitFruit drink Soft drinksWater MilkCheese Cereal with milkMacaroni and cheese YogurtOther foods with cheese (such as Pizza

lasagna, enchiladas, cheeseburgers) Melon (such as watermelon, cantaloupe, Orange or grapefruit honeydew)Bananas Berries (kind )Peaches or apricots ApplesGreen salad Other fruitSpinach or greens BroccoliGreen peas Green beansSweet potatoes Potatoes (other than fried)Carrots CornMeat Other vegetablesFish Chicken or turkeyPeanut butter EggDried beans or peas NutsBacon or sausage Hot dogBread Cold cuts (e.g., bologna)Rice Roll/bagelSpaghetti or other pasta NoodlesTortillas ChipsFrench fries CakeCookie Donut or pastryPie

Are you often bothered by any of the following? (Circle all that apply)Nausea Vomiting Heartburn Constipation

Are you on a special diet? No Yes If yes, what kind? Do you try to limit the amount or kind of food you eat to control your weight? No Yes Do you avoid any foods for health or religious reasons? No Yes If yes, what foods? Do you take any prescribed drugs or medications? No Yes

If yes, what are they? Do you take any over-the-counter medications (such as aspirin, cold medicines, Tylenol)?

No Yes If yes, what are they? Do you take any herbal supplements?

No Yes If yes, what are they? Do you ever have trouble affording the food you need? No Yes Do you have any help getting the food you need? No Yes (Circle all that apply)

Food stamps WIC School lunch or breakfastFood from a food pantry, soup kitchen, or food bank

BOX 10-5



TABLE 10-4

Physical Assessment of Nutritional Status

SIGNS OF GOOD NUTRITION SIGNS OF POOR NUTRITION

GENERAL APPEARANCE

Alert, responsive, energetic, good endurance Listless, apathetic, cachectic, easily fatigued, looks tired

MUSCLES

Well developed, firm, good tone, some fat under skin

NERVOUS CONTROL

GASTROINTESTINAL FUNCTION

CARDIOVASCULAR FUNCTION

HAIR

Shiny, lustrous, firm, not easily plucked, healthy scalp

SKIN (GENERAL)

Smooth, slightly moist, good color

FACE AND NECK

ORAL CAVITY

EYES

EXTREMITIES

No tenderness, weakness, or swelling; nails firm and pink

SKELETON

No malformations Bowlegs, knock-knees, chest deformity at diaphragm,beaded ribs, prominent scapulas

Edema, tender calves, tingling, weakness; nails spoon-shaped, brittle

Eye membranes pale, redness of membrane, dryness,signs of infection, Bitot’s spots, redness and fissuring ofeyelid corners, dryness of eye membrane, dull appear-ance of cornea, soft cornea, blue sclerae

Bright, clear, shiny, no sores at corners of eyelids, mem-branes moist and healthy pink color, no prominentblood vessels or mound of tissue (Bitot’s spots) onsclera, no fatigue circles beneath

Gums spongy, bleed easily, inflamed or receding; tongueswollen, scarlet and raw, magenta color, beefy, hyper-emic and hypertrophic papillae, atrophic papillae; teethwith unfilled caries, absent teeth, worn surfaces, mottled

Reddish pink mucous membranes and gums; no swellingor bleeding of gums; tongue healthy pink or deep red-dish in appearance, not swollen or smooth, surfacepapillae present; teeth bright and clean, no cavities, nopain, no discoloration

Scaly, swollen, skin dark over cheeks and under eyes,lumpiness or flakiness of skin around nose and mouth;thyroid enlarged; lips swollen, angular lesions or fis-sures at corners of mouth

Skin color uniform, smooth, pink, healthy appearance; noenlargement of thyroid gland; lips not chapped orswollen

Rough, dry, scaly, pale, pigmented, irritated, easilybruised, petechiae

Stringy, dull, brittle, dry, thin and sparse, depigmented,can be easily plucked

Rapid heart rate, enlarged heart, abnormal rhythm, ele-vated blood pressure

Normal heart rate and rhythm, no murmurs, normal bloodpressure for age

Anorexia, indigestion, constipation or diarrhea, liver orspleen enlargement

Good appetite and digestion, normal regular elimination,no palpable organs or masses

Inattentive, irritable, confused, burning and tingling ofhands and feet, loss of position and vibratory sense,weakness and tenderness of muscles, decrease or lossof ankle and knee reflexes

Good attention span, not irritable or restless, normal re-flexes, psychologic stability

Flaccid, poor tone, undeveloped, tender, “wasted” appear-ance


common nutrition-related outcomes are that the womanwill take the following actions:

• Achieve an appropriate weight gain during pregnancy.An appropriate goal for weight gain takes into accountsuch factors as prepregnancy weight, whether she isoverweight or obese or underweight, and whether thepregnancy is single or multifetal.

• Consume adequate nutrients from the diet and sup-plements to meet estimated needs.

• Cope successfully with nutrition-related discomfortsassociated with pregnancy, such as morning sickness,pyrosis (heartburn), and constipation.

• Avoid or reduce potentially harmful practices such assmoking, alcohol consumption, and caffeine intake.

• Return to prepregnancy weight (or an appropriateweight for height) within 6 months of giving birth.

Plan of Care and InterventionsNutritional care and teaching generally involve the fol-lowing: (1) acquainting the woman with nutritional needsduring pregnancy and, if necessary, the characteristics of an adequate diet; (2) helping her individualize her diet sothat she achieves an adequate intake while conforming to her personal, cultural, financial, and health circum-stances; (3) acquainting her with strategies for coping withthe nutrition-related discomforts of pregnancy; (4) helpingher use nutrition supplements appropriately; and (5) con-sulting with and making referrals to other professionals orservices as indicated. Two programs that provide nutritionservices are the food stamp program and WIC. These pro-grams provide vouchers for selected foods to pregnant andlactating women, as well as infants and children at nutri-tional risk. WIC foods include items such as eggs, cheese,milk, juice, and fortified cereals—foods chosen because theyprovide iron, protein, vitamin C, and other vitamins.

Adequate dietary intakeDiet teaching can take place in a one-on-one interview or

in a group setting. In either case, teaching should emphasizethe importance of choosing a varied diet composed of read-ily available foods, rather than specialized diet supplements.Good nutrition practices (and avoidance of poor practicessuch as smoking and alcohol or drug use) are essential con-tent for prenatal classes designed for women in early preg-nancy (see Guidelines/Guías box).

MyPyramid (Fig. 10-4), an update of the Food GuidePyramid, can be used as a guide for making daily food choicesduring pregnancy and lactation, just as it is during other stagesof the life cycle. Five categories are specified: grains, vegeta-bles, fruits, milk, and meats and beans. At least 3 oz of wholegrain breads, cereals, rice, and pasta per day is recommended.Other daily recommendations are 21⁄2 cups of vegetables, 2 cups of fruits, 3 cups of low-fat or fat-free milk or milk prod-ucts, and 51⁄2 oz of protein (meat and beans). Most of the fatin the diet should come from fish, nuts, and vegetable oils.The importance of consuming adequate amounts from the

milk, yogurt, and cheese group needs to be emphasized, es-pecially for adolescents and women under age 25, who arestill actively adding calcium to their skeletons. Staying withindaily calorie needs and exercising a minimum of 30 minutesper day is important.

Pregnancy. The pregnant woman must understandwhat adequate weight gain during pregnancy means, rec-ognize the reasons for its importance, and be able to eval-uate her own gain in terms of the desirable pattern. Manywomen, particularly those who have worked hard to controltheir weight before pregnancy, may find it difficult to un-derstand why the weight gain goal is so high when a new-born infant is so small. The nurse can explain that maternalweight gain consists of increments in the weight of many tis-sues, not just the growing fetus (see Table 10-2).

Dietary overindulgence, which may result in excessive fatstores that persist after giving birth, should be discouraged.Nevertheless, it is best not to focus unduly on weight gainbecause this could result in feelings of stress and guilt in thewoman who does not follow the preferred pattern of gain.Teaching regarding weight gain during pregnancy is sum-marized in Box 10-6.

Postpartum. The need for a varied diet with portionsof food from all food groups continues throughout lactation.As mentioned previously, the lactating woman should be


GUIDELINES/GUÍAS

Diet and Nutrition

• You need to gain weight.• Usted necesita aumentar de peso.

• You need to control your weight gain.• Usted necesita controlar su aumento de peso.

• Eat nutritious foods.• Coma alimentos nutritivos.

• Eat foods high in protein, calcium, vitamins, and iron.• Coma alimentos altos en proteínas, calcio, vitaminas,

y hierro.

• Eat a lot of fruits and vegetables.• Coma muchas frutas y vegetales.

• Drink four glasses of milk a day.• Tome cuatro vasos de leche diariamente.

• Drink low-fat instead of whole milk.• Tome la leche baja en grasa en lugar de la leche entera.

• Avoid salty foods like sausage, hot dogs, and frenchfries.

• Evite alimentos muy salados como calchichas, perroscalientes, y papitas fritas.

• Avoid fried foods.• Evite las frituras.

• Avoid caffeine.• Evite la cafeína.

• There is caffeine in Coca-Cola, tea, and chocolate.• Hay cafeína en la Coca-Cola, el té, y el chocolate.

• Take prenatal vitamins.• Tome vitaminas prenatales.


Fig. 10-4 MyPyramid: a guide to daily food choices. (Modified from U.S. Department of Healthand Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans,2005, 6th ed. Washington, DC: U.S. Government Printing Office and U.S. Department of AgricultureCenter for Nutrition Policy and Promotion, April 2005, CNPP-16).

307


advised to consume at least 1800 kcal daily, and she shouldreceive counseling if her diet appears to be inadequate in anynutrients. Special attention should be given to her zinc, vi-tamin B6, and folic acid intake because the recommendationsfor these remain higher than for nonpregnant women (seeTable 10-1). Sufficient calcium is needed to allow for bothmilk formation and for maintenance of maternal bone mass.It may be difficult for lactating women to consume enoughof these nutrients without careful diet planning.

The woman who does not breastfeed loses weight gradu-ally if she consumes a balanced diet that provides slightly lessthan her daily energy expenditure. Lactating and nonlactat-ing women should know that fat is the most concentratedsource of calories in the diet (9 kcal/g versus 4 kcal/g in car-bohydrates and proteins). Therefore the first step in weightreduction (or preventing excessive weight gain) is to evalu-ate sources of fat in the diet and explore with the woman waysof reducing them. Even foods such as vegetables that are nat-urally low in fat can become high in fat when fried or sautéed,served with excessive amounts of salad dressing, consumedwith high-fat dips or sauces, or seasoned with butter or ba-con drippings. A reasonable weight loss goal for nonlactat-ing women is 0.5 to 1 kg/week; a loss of 1 kg/month is rec-ommended for most lactating women who need to loseweight. A woman who is lactating may be able to lose up to2 kg/month without decreasing her milk supply.

Daily food guide and menu planning. Thedaily food plan (see Table 10-2 and Fig. 10-4) can be usedas a guide for educating women about nutritional needs dur-ing pregnancy and lactation. This food plan is generalenough to be used by women from a variety of cultures, in-cluding those following a vegetarian diet. One of the morehelpful teaching strategies is to assist the woman to plan dailymenus that follow the food plan and are affordable, have re-alistic preparation times, and are compatible with personalpreferences and cultural practices. Information regarding cul-tural food patterns is provided later in this chapter.

Medical nutrition therapy. During pregnancyand lactation, the food plan for women with special med-ical nutrition therapy (therapeutic diets) may have to bemodified. The registered dietitian can instruct these womenabout their diets and assist them in meal planning. However,the nurse should understand the basic principles of the dietand be able to reinforce the diet teaching.

The nurse should be especially aware of the dietary mod-ifications necessary for women with diabetes mellitus (eithergestational or preexisting). This is necessary because this dis-ease is relatively common and because fetal deformity anddeath occur more often in pregnancies complicated by hy-perglycemia or hypoglycemia (see discussion of diabetes inChapter 22).

Counseling about ironsupplementationAs mentioned earlier, the nutritional supplement most

commonly needed during pregnancy is iron. However, a va-riety of dietary factors can affect the completeness of ab-sorption of an iron supplement. The following points shouldbe addressed in patient education:

• Bran, milk, egg yolks, coffee, tea, or oxalate-containingvegetables such as spinach and Swiss chard will inhibitiron absorption if consumed at the same time as iron.

• Iron absorption is promoted by a diet rich in vitaminC (e.g., citrus fruits and melons) or “heme iron” (foundin red meats, fish, and poultry).

• Iron supplements are best absorbed on an empty stom-ach; to this end they can be taken between meals withbeverages other than milk, tea, or coffee.

• Some women have gastrointestinal discomfort whenthey take the supplement on an empty stomach; there-fore a good time for them to take the supplement isjust before bedtime.

• Constipation is common with iron supplementation.

• Iron supplements should be kept away from any chil-dren in the household because their ingestion couldresult in acute iron poisoning and even death.

Coping with nutrition-relateddiscomforts of pregnancyThe most common nutrition-related discomforts of preg-

nancy are nausea and vomiting (or “morning sickness”), con-stipation, and pyrosis.

Nausea and vomiting. Nausea and vomiting aremost common during the first trimester. Usually, nausea andvomiting cause only mild to moderate problems nutrition-ally, although they may cause substantial discomfort. Anti-emetic medications, vitamin B6, and p6 acupressure may beeffective in reducing the severity of nausea ( Jewell & Young,2004). The pregnant woman may find the following sug-gestions helpful in alleviating the problems:

• Eat dry, starchy foods such as dry toast, Melba toast,or crackers on awakening in the morning and at othertimes when nausea occurs.


Weight Gain during Pregnancy

• Progressive weight gain during pregnancy is essentialto ensure normal fetal growth and development andthe deposition of maternal stores that promote suc-cessful lactation.

• Recommended weight gain during pregnancy is de-termined largely by prepregnancy weight for height:normal-weight women, 11.5-16 kg; underweightwomen, 12.5-18 kg; overweight women, 7-11.5 kg.

• Weight gain should be achieved through a balanceddiet of regular foods chosen from all the different foodgroups (see Table 10-3).

• The pattern of weight gain is important: approximately0.4 kg/week during the second and third trimesters fornormal-weight women; 0.5 kg/week for underweightwomen; and 0.3 kg/week for overweight women.

BOX 10-6


• Avoid consuming excessive amounts of fluids early inthe day or when nauseated (but compensate by drink-ing fluids at other times).

• Eat small amounts frequently (every 2 to 3 hours), andavoid large meals that distend the stomach.

• Avoid skipping meals and thereby becoming extremelyhungry, which may worsen nausea. Have a snack suchas cereal with milk, a small sandwich, or yogurt beforebedtime.

• Avoid sudden movements. Get out of bed slowly.

• Decrease intake of fried and other fatty foods. Starchessuch as pastas, rice, and breads and low-fat, high-protein foods such as skinless broiled or baked poul-try, cooked dry beans or peas, lean meats, and broiledor canned fish are good choices.

• Some women find that tart foods or drinks (e.g.,lemonade) or salty foods (e.g., potato chips) are tol-erated during periods of nausea.

• Fresh air may help relieve nausea. Keep the environ-ment well ventilated (e.g., open a window), go for awalk outside, or decrease cooking odors by using anexhaust fan.

• During periods of nausea, eat foods served at cool tem-peratures and foods that give off little aroma.

• Try herbal teas such as those made with raspberry leafor peppermint to decrease nausea.

• Ginger root may be effective in reducing nausea.

• Avoid brushing teeth immediately after eating.Hyperemesis gravidarum (severe and persistent vomiting

causing weight loss, dehydration, and electrolyte abnor-malities) occurs in up to 1% of pregnant women. Intravenousfluid and electrolyte replacement is usually necessary forwomen who lose 5% of their body weight. Often this is fol-lowed by improved tolerance of oral intake; therapy thenconsists of frequent consumption of small amounts of low-fat foods. Enteral tube feeding using small-bore nasogastrictubes has been successful for some women. Because pul-monary aspiration of the feeding is a potential complicationif vomiting occurs, antiemetic medications are sometimesused in conjunction with tube feedings. Tube feedings maybe used to supplement oral intake, with the volume of thetube feeding gradually being decreased as oral intake im-proves. In some instances, total parenteral nutrition (bal-anced intravenous feedings of amino acids, carbohydrate,lipid, vitamins, and minerals) is used to nourish women withhyperemesis gravidarum when their nutritional status hasbeen severely impaired.

Constipation. Improved bowel function generally re-sults from increasing the intake of fiber (e.g., wheat bran andwhole-wheat products, popcorn, and raw or lightly steamedvegetables) in the diet. Fiber helps retain water within thestool, creating a bulky stool that stimulates intestinal peri-stalsis. The recommendation for adults for fiber is 25 to 35g/day. An increase of approximately 15% would be optimal.An adequate fluid intake (at least 50 ml/kg/day) helps hydratethe fiber and increase the bulk of the stool. Making a habit

of regular exercise that uses large muscle groups (walking,swimming, cycling) also helps stimulate bowel motility.

Pyrosis. Pyrosis, or heartburn, is usually caused byreflux of gastric contents into the esophagus. This conditioncan be minimized by eating small, frequent meals rather thantwo or three larger meals daily. Because fluids increase thedistention of the stomach, they should not be consumedwith foods. The woman needs to be sure to drink adequateamounts between meals. Avoiding spicy foods may help al-leviate the problem. Lying down immediately after eatingand wearing clothing that is tight across the abdomen cancontribute to the problem of reflux.

Cultural influencesConsideration of a woman’s cultural food preferences en-

hances communication and provides a greater opportunityfor following the agreed-on pattern of intake. Women inmost cultures are encouraged to eat a diet typical for them.The nurse needs to be aware of what constitutes a typical dietfor each cultural or ethnic group. However, several variationsmay occur within one cultural group. Therefore a careful ex-ploration of individual preferences is needed. Although someethnic and cultural food beliefs may seem, at first glance, toconflict with the dietary instruction provided by physicians,nurses, and dietitians, it is often possible for the empathichealth care provider to identify cultural beliefs that are con-gruent with the modern understanding of pregnancy and fe-tal development. Many cultural food practices have somemerit or the culture would not have survived. Food cravingsduring pregnancy are considered normal by many cultures,but the kinds of cravings often are culturally specific. In mostcultures women crave acceptable foods, such as chicken, fish,and greens among African-Americans. Cultural influenceson food intake usually lessen if the woman and her familybecome more integrated into the dominant culture. Nutri-tion beliefs and the practices of selected cultural groups aresummarized in Table 10-5.

Vegetarian diets. Vegetarian diets represent anothercultural effect on nutritional status. Foods basic to almost allvegetarian diets are vegetables, fruits, legumes, nuts, seeds, andgrains. However, there are many variations in vegetarian di-ets. Semivegetarians, who are not truly vegetarians, includefish, poultry, eggs, and dairy products in their diets but do noteat beef or pork. Such a diet can be completely adequate forpregnant women. Besides plant products, lacto-ovovegetariansalso eat dairy products and eggs. Iron and zinc intake may notbe adequate in these women, but such diets can be otherwisenutritionally sound. Strict vegetarians, or vegans, consumeonly plant products. Because vitamin B12 is found only infoods of animal origin, this diet is therefore deficient in vi-tamin B12. As a result, strict vegetarians should take a sup-plement or regularly consume vitamin B12–fortified foods (e.g.,soy milk). Vitamin B12 deficiency can result in megaloblasticanemia, glossitis (inflamed red tongue), and neurologic deficitsin the mother. Infants born to affected mothers are likely tohave megaloblastic anemia and exhibit neurodevelopmental




TABLE 10-5

Characteristic Food Patterns of Selected Cultures

FRUITS BREADS POSSIBLEMILK GROUP PROTEIN GROUP AND VEGETABLES AND CEREALS DIETARY PROBLEMS

NATIVE AMERICAN (MANY TRIBAL VARIATIONS; MANY “AMERICANIZED”)

MIDDLE EASTERN* (ARMENIAN, GREEK, SYRIAN, TURKISH)

AFRICAN-AMERICAN (PARTICULARLY SOUTHERN AND RURAL)

CHINESE (CANTONESE MOST PREVALENT)

Tendency of some im-migrants to use largeamounts of grease incooking

Limited use of milk andmilk products

Often low in protein,calories, or both

Soy sauce (high sodium)

Rice/rice flourproducts

Cereals, noodlesWheat, corn, mil-

let seed

Many vegetablesRadish leavesBean, bamboo sprouts

Pork sausage‡Eggs and pigeon eggsFishLamb, beef, goatFowl: chicken, duckNutsLegumesSoybean curd (tofu)

Milk: water buffalo

Extensive use of frying,smothering in gravy,or simmering

Fats: salt pork, bacondrippings, lard, andgravies

High consumption ofsweets

Insufficient citrusVegetables often boiled

for long periods withpork fat and muchsalt

Limited amounts frommilk group†

Cornmeal andhominy grits

RiceBiscuits, pancakes,

white breadsPuddings: bread,

rice

Leafy vegetablesGreen and yellow veg-

etablesPotato: white, sweetStewed fruitBananas and other

fresh fruit

Pork: all cuts, plus or-gans, chitterlings

Beef, lambChicken, gibletsEggsNutsLegumesFish, game

Milk†Ice creamCheese: longhorn,

American

Fry many meats andvegetables

Lack of fresh fruitsInsufficient foods from

milk groupHigh consumption of

sweetenings, lambfat, and olive oil

Cracked wheatand dark bread

Peppers, tomatoes,cabbage, grapeleaves, cucumbers,squash

Dried apricots, raisins,dates

LambNutsDried peas, beans,

lentilsSesame seeds

YogurtLittle butter

Obesity, diabetes, alco-holism, nutritionaldeficiencies ex-pressed in dentalproblems and irondeficiency anemia

Inadequate amounts ofall nutrients

Excessive use of sugar

Refined breadWhole wheatCornmealRiceDry cereals“Fry” breadTortillas

Green peas, beansBeets, turnipsLeafy green and other

vegetablesGrapes, bananas,

peaches, other freshfruits

Roots

Pork, beef, lamb, rabbitFowl, fish, eggsLegumesSunflower seedsNuts: walnuts, acorn,

pine, peanut butterGame meat

Fresh milkEvaporated milk for

cookingIce creamCream pie

MSG, monosodium L-glutamate.*Religious holidays may involve fasting, which is believed to increase the likelihood of preterm labor. Fasting requirement may be waived during preg-nancy.†Lactose intolerance relatively common in adults.‡Lower in fat content than Western sausage.



TABLE 10-5

Characteristic Food Patterns of Selected Cultures—cont’d


FILIPINO (SPANISH-CHINESE INFLUENCE)

ITALIAN

JAPANESE (ISEI, MORE JAPANESE INFLUENCE; NISEI, MORE WESTERNIZED)

HISPANIC, MEXICAN-AMERICAN

Limited meats primarilydue to cost


Large amounts of lardAbundant use of sugarTendency to boil veg-

etables for long periods

Rice, cornmealSweet bread, pas-

triesTortilla: corn, flourVermicelli (fideo)

Spinach, wild greens,tomatoes, chilies,corn, cactus leaves,cabbage, avocado,potatoes

Pumpkin, zapote,peaches, guava, pa-paya, citrus

Beef, pork, lamb,chicken, tripe, hotsausage, beef intes-tines

FishEggsNutsDry beans: pinto, chick-

peas (often eatenmore than once daily)

MilkCheeseFlan, ice cream

Excessive sodium: pickles, salty crispseaweed, MSG, andsoy sauce

Insufficient servingsfrom milk group

May use prewashedrice

Rice, rice cakesWheat noodlesRefined bread,

noodles

Many vegetables andfruits

Seaweed

Pork, beef, chickenFishEggsLegumes: soys, red,

lima beansTofuNuts

Increasing amountsbeing used byyounger genera-tions

Prefer expensive im-ported cheeses; re-luctant to substituteless expensive do-mestic varieties

Tendency to overcookvegetables

Limited use of wholegrains

High consumption ofsweets

Extensive use of oliveoil

Insufficient servingsfrom milk group

PastaWhite breads,

some wholewheat

FarinaCereals

Leafy vegetablesPotatoesEggplant, tomatoes,

peppersFruits

MeatEggsDried beans

CheeseSome ice cream


Tendency to prewashrice

Tendency to have onlysmall portions of pro-tein foods

Rice, cooked cereals

Noodles: rice,wheat

Many vegetables andfruits

Pork, beef, goat, rabbitChickenFishEggs, nuts, legumes

Flavored milkMilk in coffeeCheese: gouda,

cheddar

Continued



TABLE 10-5

Characteristic Food Patterns of Selected Cultures—cont’d


PUERTO RICAN

SCANDINAVIAN (DANISH, FINNISH, NORWEGIAN, SWEDISH)

SOUTHEAST ASIAN (VIETNAMESE, CAMBODIAN)

JEWISH: ORTHODOX*

High intake of sodiumin meat products

Wide varietyWide varietyMeat (bloodless;Kosher prepared):beef, lamb, goat,deer, poultry (alltypes), no pork

Fish with fins andscales only

No crustaceans

Milk†Cheese†

Fresh milk productsgenerally not con-sumed

Poultry/eggs may belimited

Meat considered “un-clean” is avoided

Preference for a diethigh in salt and pep-per, as well as riceand pork

High intake of MSGand soy sauce

Rice: grains, flour,noodles

French bread“Cellophane”

(bean starch)noodles

Seasonal variety: freshor preserved

Green, leafy vegetablesYamsCorn

Fish (daily): fresh,dried, salted

Poultry/eggs: duck,chicken

PorkBeef (seldom)Dry beansTofu

Generally not takenCoffee with con-

densed cow’s milkPlain yogurtIce cream (rare)Soybean milk

Insufficient fresh fruitsand vegetables

High consumption ofsweets, pickled orsalted meats, and fish

Whole wheat, rye,barley, sweets(cookies andsweet breads)

BerriesDried fruitVegetables: cole slaw,

roots

Wild gameReindeerFish (fresh or dried)Eggs

CreamButterCheeses

Small amounts of porkand poultry

Extensive use of fat,lard, salt pork, andolive oil

Lack of milk products

RiceCornmeal

Avocado, okraEggplantSweet yamsStarchy vegetables and

fruits (viandas)

PorkPoultryEggs (Fridays)Dried codfishBeans (habichuelas)

Limited use of milkproducts

Coffee with milk(café con leche)

delays. Iron, calcium, zinc, and vitamin B6 intake may alsobe low in women on this diet, and some strict vegetarians haveexcessively low caloric intakes. The protein intake should beassessed especially carefully because plant proteins tend to beincomplete in that they lack one or more amino acids requiredfor growth and maintenance of body tissues. The daily con-sumption of a variety of different plant proteins (grains, driedbeans and peas, nuts, and seeds) helps provide all of the es-sential amino acids.

EvaluationIn evaluating the adequacy of nutritional intake during preg-nancy, the woman’s weight gain can be compared with stan-dardized grids showing recommended patterns (see Fig.

10-2). These grids are based on mean data and do not alwaysaccount for factors such as ethnic or racial variations. To eval-uate the adequacy of the woman’s diet, it can be comparedwith the plan in Table 10-2. It is essential that individual fac-tors affecting nutritional needs and dietary intake be con-sidered.

Physical examination and laboratory testing can be usedto confirm that nutritional status is adequate (see the sec-tion on assessment). When weight gain is inadequate orwhen nutritional deficits are present, the nurse must re-assess the woman and her understanding of her nutritionalneeds, reinforce teaching as needed, and continue toreevaluate her nutritional status regularly (see Plan ofCare).



Nutrition during PregnancyPLAN OF CARE

NURSING DIAGNOSIS Deficient knowledge re-lated to nutritional requirements during preg-nancy

Expected Outcome The patient will delineate nutri-tional requirements and exhibit evidence of incor-porating requirements into diet.

Nursing Interventions/Rationales

• Review basic nutritional requirements for a healthy diet us-ing recommended dietary guidelines and MyPyramid to pro-vide knowledge baseline for discussion.

• Discuss increased nutrient needs (calories, protein, minerals,vitamins) that occur as a result of being pregnant to increaseknowledge needed for altered dietary requirements.

• Discuss the relationship between weight gain and fetalgrowth to reinforce interdependence of fetus and mother.

• Calculate the appropriate total weight gain range during preg-nancy using the woman’s body mass index (BMI) as a guideand discuss recommended rates of weight gain during thevarious trimesters of pregnancy to provide concrete meas-ures of dietary success.

• Review food preferences, cultural eating patterns or beliefs,and prepregnancy eating patterns to enhance integration ofnew dietary needs.

• Discuss how to fit nutritional needs into usual dietary patternsand how to alter any identified nutritional deficits or excessesto increase chances of success with dietary alterations.

• Discuss food aversions or cravings that may occur duringpregnancy and strategies to deal with these if they are detri-mental to fetus (e.g., pica) to ensure well-being of fetus.

• Have woman keep a food diary delineating eating habits, di-etary alterations, aversions, and cravings to track eatinghabits and potential problem areas.

NURSING DIAGNOSIS Imbalanced nutrition: morethan body requirements related to excessive in-take or inadequate activity levels (or both)

Expected Outcome The patient’s weekly weightgain will be reduced to the appropriate rate usingher BMI and recommended weight gain ranges asguidelines.


• Review recent diet history (including food cravings) using afood diary, 24-hour recall, or food frequency approach to as-certain food excesses contributing to excess weight gain.

• Review normal activity and exercise routines to determinelevel of energy expenditure; discuss eating patterns and rea-sons that lead to increased food intake (e.g., cultural beliefsor myths, increased stress, boredom) to identify habits thatcontribute to excess weight gain.

• Review optimal weight gain guidelines and their rationale toensure that woman is knowledgeable about healthfulweight gain rates.

• Set target weight gains for the remaining weeks of the preg-nancy to establish goals.

• Discuss with the woman what changes can be made in diet,activity, and lifestyle to enhance chances of meeting weightgain goals and dietary needs.Weight-reduction diets shouldbe avoided, because they may deprive the mother and fetusof needed nutrients and lead to ketonemia.

NURSING DIAGNOSIS Imbalanced nutrition: lessthan body requirements related to inadequateintake of needed nutrients

Expected Outcome The woman’s weekly weightgain will be increased to the appropriate rate usingher BMI and recommended weight gain ranges asguidelines.


• Review recent diet history (including food aversions) usinga food diary, 24-hour recall, or food frequency approach toascertain dietary inadequacies contributing to lack of suffi-cient weight gain.

• Review normal activity and exercise routines to determinelevel of energy expenditure; discuss eating patterns and rea-sons that lead to decreased food intake (e.g., morning sick-ness, pica, fear of becoming fat, stress, boredom) to identifyhabits that contribute to inadequate weight gain.

• Review optimal weight gain guidelines and their rationale to ensure that woman is knowledgeable about healthfulweight gain rates.

• Set target weight gains for the remaining weeks of the preg-nancy to establish goals.

• Review increased nutrient needs (calories, protein, minerals,vitamins) that occur as a result of being pregnant to ensurethat woman is knowledgeable about altered dietary re-quirements.

• Review relationship between weight gain and fetal growthto reinforce that adequate weight gain is needed to promotefetal well-being.

• Discuss with woman what changes can be made in diet, ac-tivity, and lifestyle to enhance chances of meeting set weightgain goals and nutrient needs of mother and fetus.

• If woman has fear of being fat, if symptoms of an eating dis-order are evident, or if problems in adjusting to a changingbody image surface, refer woman to the appropriate men-tal health professional for evaluation, because intensivetreatment and follow-up may be required to ensure fetalhealth.

COMMUNITY ACTIVITY

on nutrition that could be placed in the clinic? Arethe nutrition education materials culturally relevant?Identify strengths and weaknesses of nutrition ed-ucation in that setting. Develop a feasible plan for im-proving nutrition education in the clinic.

Visit a prenatal clinic. Identify sources of nutrition ed-ucation that are evident in the waiting room. Doesthe clinic employ a nutritionist or dietitian? Who pro-vides nutrition counseling in the clinic? Are print ma-terials available in multiple languages? Are inter-preters available? Are there sources of free materials

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• A woman’s nutritional status before, during, andafter pregnancy contributes significantly to herwell-being and that of her infant.

• Many physiologic changes occurring during preg-nancy influence the need for additional nutrientsand the efficiency with which the body uses them.

• Both the total maternal weight gain and the pat-tern of weight gain are important determinants ofthe outcome of pregnancy.

• The appropriateness of the mother’s prepregnancyweight for height (BMI) is a major determinant ofher recommended weight gain during pregnancy.

• Nutritional risk factors include adolescent preg-nancy, nicotine use, alcohol or drug use, bizarre orfaddish food habits, a low weight for height, andfrequent pregnancies.

• Iron supplementation is usually routinely recom-mended during pregnancy. Other supplementsmay be warranted when nutritional risk factors arepresent.

• The nurse and the woman are influenced by cul-tural and personal values and beliefs during nu-trition counseling.

• Pregnancy complications that may be nutrition re-lated include anemia, preeclampsia, gestational di-abetes, and IUGR.

• Dietary adaptation can be an effective interventionfor some of the common discomforts of preg-nancy, including nausea and vomiting, constipa-tion, and heartburn.

Key Points

Nutrition and the Underweight PregnantAdolescent1 Yes. A dietary assessment using a food intake questionnaire

should be conducted and a physical assessment of nutritionalstatus performed. Based on these data, the desired pattern ofweight gain during pregnancy, and a knowledge of characteris-tic food patterns of Hispanic people, planning can begin.

2 a. A list of Dietary Reference Intakes for pregnancy and lac-tation can be shared with Carmen. Through discussion, youcan determine whether Carmen is ingesting adequateamounts of these important elements and whether supple-mentation of vitamins and minerals is necessary.

b. While reviewing indicators of nutritional risk in pregnancywith Carmen, problem areas can be identified, and recom-mendations for change provided as needed.

c. The daily food guide for pregnancy and lactation can be shared with Carmen. It can provide a basis for plan-ning appropriate menus to provide the necessary nutrientsand provide more energy (calories) to increase her weightgain, taking into consideration the growth needs of an ado-lescent

d. As someone of Hispanic heritage, Carmen may be lactoseintolerant and may need sources of calcium other than milk.Through careful questioning, her lactose status can be de-termined and counseling can be provided about nonmilksources of calcium.

3 As part of her prenatal care, Carmen (and all pregnant women)should receive nutrition counseling. Carmen is currently un-derweight. Carmen can be assisted to plan menus that allow aweight gain to support growth of the pregnancy and the fetusand provide nutrients to support her own growth.

4 Yes, there is ample evidence about DRIs in pregnancy and lac-tation. Nutrition counseling should be part of the plan of carefor Carmen.

5 Often adolescents have inadequate intakes of appropriate nu-tritional elements. They may try to maintain a slender appear-ance. Women who are underweight are at risk for preterm birthas well as for having a fetus with IUGR. Carmen could be try-ing to hide her pregnancy by limiting her weight gain. Fast foodchoices as well as ethnic and cultural patterns of eating couldbe factors. Enlisting the support of her family would likely behelpful in planning appropriate meals.

Answer Guidelines to Critical Thinking Exercise

American Botanical CouncilP.O. Box 144345Austin, TX 78714-4345512-926-4900www.herbalgram.org

American Diabetes AssociationDiabetes Information Service Center1660 Duke St.Alexandria, VA 22314800-342-2383www.diabetes.org

American Dietetic Association216 West Jackson Blvd., Suite 800Chicago, IL 60606-6995www.eatright.org

American Medical AssociationDepartment of Foods and Nutrition515 N. State St.Chicago, IL 60610www.ama-assn.org

Anorexia Nervosa and Related Eating Disorders, Inc.www.anred.com

Resources


Body Mass Index CalculatorNational Heart, Lung, and Blood Institute Information CenterP.O. Box 30105Bethesda, MD 20824-0105301-592-8573www.nhlbisupport.com/bmi

Center for Food Safety and Applied NutritionFood and Drug Administration200 C St., SWWashington, DC 20250202-720-2791www.usda.gov/usda.htm

Food and Nutrition BoardInstitute of Medicine2101 Constitution Ave., NWWashington, DC 20418202-334-1732www.iom.eduemail: [email protected]

MyPyramid:www.mypyramid.gov

National Dairy Council6300 N. River Rd.Rosemont, IL 60018www.nutritionexplorations.org

Nutritional content of foods:www.nal.usda.gov/fnic/foodcomp

Office of Dietary SupplementsNational Institutes of Health31 Center Dr., Room 1829Bethesda, MD 20892-2086301-435-2920www.ods.od.nih.gov

RDAs according to age and sex:www.nal.usda.gov

Society for Nutrition Education1001 Connecticut Ave., NW, Suite 529Washington, DC 20036-5528202-452-8534www.sne.orgemail: [email protected]

Special Supplemental Nutrition Program for Women, Infants, andChildren (WIC)

Food and Consumer Service3101 Park Center Dr., Room 819Alexandria, VA 22302703-305-2286www.usda.gov

U.S. Department of AgricultureFood and Nutrition Information Center14th and Independence Ave., SWWashington, DC 20250202-720-2791www.usda.gov


American College of Obstetricians and Gynecologists (ACOG). (2002).Exercise during pregnancy and the postpartum period. ACOGCommittee Opinion No. 267. Obstetrics & Gynecology, 99(1), 171-173.

Atallah, A., Hofmeyr, G., & Duley, L. (2003). Calcium supplementa-tion during pregnancy for preventing hypertensive disorders and re-lated problems (Cochrane Review). In The Cochrane Library, 2004, Issue 2. Chichester, UK: John Wiley & Sons.

Boushey, C., Edmonds, J., & Welshimer, K. (2001). Estimates of theeffects of folic-acid fortification and folic-acid bioavailability forwomen. Nutrition, 17(10), 873-879.

Centers for Disease Control and Prevention (CDC). (2004). PNSS preg-nancy nutrition surveillance system. Internet document available atwww.ced.gov/nccdphp/dnpa/PNSS.htm (accessed August 22,2004).

Fluoride Recommendations Work Group. (2001). Recommendationsfor using fluoride to prevent and control dental caries in the UnitedStates. Morbidity and Mortality Weekly Report, 50(RR-14), 1-42.

Food and Nutrition Board, Institute of Medicine. (1997). Dietary ref-erence intakes for calcium, phosphorus, magnesium, vitamin D, and fluo-ride. Washington, DC: National Academy Press.

Food and Nutrition Board, Institute of Medicine. (1998). Dietary ref-erence intakes for thiamine, riboflavin, niacin, vitamin B6, folate, vitaminB12, pantothenic acid, biotin, and choline. Washington, DC: NationalAcademy Press.

Food and Nutrition Board, Institute of Medicine. (2000). Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids.Washington, DC: National Academy Press.

Food and Nutrition Board, Institute of Medicine. (2001). Dietary ref-erence intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper,iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.Washington, DC: National Academy Press.

Food and Nutrition Board, National Academy of Science, NationalResearch Council. (1989). Recommended dietary allowances (10th ed.).Washington, DC: National Academy Press.

Institute of Medicine. (1992). Nutrition during pregnancy and lactation:An implementation guide. Washington, DC: National Academy Press.

Jewell, D., & Young, G. (2004). Interventions for nausea and vomitingin early pregnancy (Cochrane Review). In The Cochrane Library, 2004,Issue 4. Chichester, UK: John Wiley & Sons.

Kilpatrick, S., & Laros, R. (2004). Maternal hematologic disorders. InR. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Prin-ciples and practice (5th ed.). Philadelphia: Saunders.

King, J. (2000). Determinants of maternal zinc status during pregnancy.American Journal of Clinical Nutrition, 71(5 suppl), 1334S-1343S.

Malone, F., & D’Alton, M. (2004). Multiple gestation: Clinical char-acteristics and management. In R. Creasy, R. Resnik, & J. Iams (Eds.),Maternal-fetal medicine: Principles and practice (5th ed.). Philadelphia:Saunders.

Scanlon, K. (Ed.). (2001). Final report of the vitamin D expert panel. Atlanta,GA: Centers for Disease Control and Prevention.

References


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