Medical

Introduction

• The importance of nutrition throughout the life cycle cannot be refuted

• However, the significance of nutrition during specific times of growth, development, and aging is becoming increasingly appreciated

• Proper nutrition during pregnancy is essential for good health of baby

'Healthy Mothers for Healthy and Smart Babies!'

• Studies have shown that women with poor nutritional status had adverse pregnancy outcome1

• Nutritional intake is extremely important during all phases of life and pregnancy is no exception. In fact, a diet rich in the right nutrients, vitamins and minerals before and during pregnancy will help lady and her baby be as healthy as possible

• So it is very essential to take nutritional substance for healthy & smart babies

1 Food, Nutrition & Diet 2000 edition

Nutritional deficiencies in Pregnancy

• There are several factors which lead to nutritional deficiencies during pregnancy– Infection– Pre-existing anemia– Poverty– Low pre-pregnancy body weight

Infection

• Infection plays big role in causing depletion in nutrition

• As in India the incidence of infectious diseases is very high it is one of the prime cause of lack of nutrition1

• Infection lessens the immune power of human being which leads to less assimilation of nutrients from food

• So there is need of external nutritional support other than food

1 W.H.O.

Pre-existing anemia

• Anemia is defined as reduction in circulating hemoglobin (Hb) mass below critical level

• WHO has accepted 11 gm% as the normal Hb level in pregnancy

• Nutritional anemia is one of India's major public health problems. The prevalence of anemia ranges from 33% to 89% among pregnant women1

• So there is need of external nutritional support other than food

1 Food Nutr Bull. 2006 Dec;27(4):311-5. Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India.Toteja GS, Singh P, Dhillon BS, Saxena BN etal

Poverty• The Planning Commission has estimated

that 27.5% of the population was living below the poverty line in 2004–20051

• Poverty causes less intake of nutrient food which itself leads loss of health

• As for healthy babies healthy mothers are needed poverty is one of the cause for poor nutritional status of ladies

1Poverty estimates for 2004-05, Planning commission, Government of India, March 2007. Accessed: August 25, 2007

Low pre-pregnancy body weight

• To gain something you have to lose something

• To gain slim & trim body physique ladies are losing their health

• It leads to poor nutritious health of mothers

• So the nutritional supplement is needed for healthy mothers

POORNUTRITION

STATUSPreexisting

anemia

Infection Low prepregnancy body wt.

Poverty

Deficiencies ofFolic Acid

Other VitaminsCalcium

MicronutrientsEnergy

Clinical FindingsPoor weight gain during pregnancy

Low birth wt.

Premature Birth

Maternal nutrition before and during pregnancy

• Emerging evidence now suggests that use of micronutrient- containing prenatal vitamins before and during pregnancy is associated with reductions in the risk of congenital defects, preterm delivery, low infant birth weight, and pre-eclampsia1

1 Maternal nutrition before and during pregnancy. Scholl TO. Nestle Nutr Workshop Ser Pediatr Program. 2008; 61:79-89.

Nutritional requirements during pregnancy

• Folic Acid: This vitamin is needed before pregnancy as well as during pregnancy. Folic acid helps to reduce the baby’s risk for neural tube defects that affect the brain and spinal cord. Neural tube defects likely occur in the first month of pregnancy, making it important to get the proper amount of folic acid before pregnancy.

• Folic acid also plays a role in DNA synthesis and cell formation.

• Folic acid has become recognized as an important nutrient during pregnancy1

1 J Obstet Gynaecol. 2008 Jan;28(1):3-13 Folic acid in pregnancy and fetal outcomes.Goh YI, Koren G.

Vitamin B(12)

• A diet low in vitamin B(12) is associated with an increased risk of a child with a CHD1

• Iron, folate and B(12) status should be monitored during pregnancy/lactation in developing countries, where nutritional deprivation is more prevalent 2

• Infant health may also be at risk through a compromised endowment of these micronutrients at birth2

1 Dietary intake of B-vitamins in mothers born a child with a congenital heart defect. Verkleij-Hagoort AC, etal Eur J Nutr. 2006 Dec;45(8):478-86. Epub 2006 Nov 21.

2 Iron status, serum folate and B (12) values in pregnancy and postpartum: report from a study in Jordan.Ann Saudi Med. 2000 Sep-Nov;20(5-6):371-6.

Nutritional requirements during pregnancy

Iron: There is a high iron demand during pregnancy, as extra iron is needed to make red blood cells that carry oxygen through body and to baby. If lady do not have enough iron in her diet, her body will draw on its own iron stores to supply it to baby. The result is feelings of tiredness and low iron stores called iron deficiency anemia.

• According to the DRIs1 pregnant women should have at least 27mg of iron daily

1 Dietary Reference Intakes

Iron

• Iron deficiency is the most common cause of nutritional anemia. During pregnancy there is a high risk of developing it, due to the increase of iron requirements for fetal and maternal tissues growth1

1 Iron stores status at early pregnancy Invest Clin. 2005 Jun;46(2):121-30. Barón MA, Solano L, Peña E, Del Real S.

Carbonyl Iron Carbonyl iron exhibits 2-5 times higher bioavailability than other elemental iron forms Carbonyl iron is as well absorbed as ferrous sulfate and ferrous fumarate without the attendant risk of iron toxicity The natural, self-regulated delayed release of carbonyl iron makes it significantly safer than other ferrous iron salts used in ordinary prenatal vitamins. Carbonyl iron leads to an enhanced increase in mean haemoglobin levels, reticulocyte counts, haematocrit and mean corpuscular volume with MR carbonyl iron as compared to ferrous fumarate Gastric tolerability and patient compliance are superior to fumarate. Sacks and Houchin, Am. J. Clin. Nutr. 31:566-571, 1978 J Indian Med Assoc. 2005 Jun;103(6):338-42

Presentation

• Chemical structure

• Amino acids: essential & non-essential

• Function

• Sources & quality

• Digestion & absorption

• Milk constituents: casein & whey-protein

• Requirements

• Cow’s milk & protein

• Check your knowledge

: Proteins

The key lines

• Protein is essential for life

• Protein is the main building component of

the body

• Protein forms the basic structure of each

cell in the body

Protein consists of amino acids

• Can be compared with a chain of beads- - - - - - - -| | | | | | | |- etc

poly-peptide = protein

• Building unit -|- = amino acid

• A few amino acids linked together- -| |- -| | |- - - di- , tri-, or oligo-peptides

Am ino acids folded in a 3-dim ensional structure

Protein contains

• C = carbon

• H = hydrogen

• O = oxygen

• N = nitrogen

N= key elem ent for building tissues

Amino acids: 2 groups

• Essential amino acids

— Must be supplied with food

— Cannot be synthesised (made) by our body

• Non essential amino acids

— Can be synthesised by our body

Essential (indispensable) amino acids

• Isoleucine

• Leucine

• Lysine

• Methionine

• Phenylalanine

• Threonine

• Tryptophan

• Valine

• Histidine

Function of protein (1)

• Major functional & structural component

of all cells in body Î required for growth,

maintenance, renewal (repair) of all body

cells

• Functions as enzyme, transport carrier,

hormone

— All enzymes, many hormones, blood

transport molecules, hair, fingernails, etc.

are proteins

Function of protein (2)

• Amino acids play a role as precursors

(forerunner) for e.g. many enzymes,

hormones, vitamins

• Constituent of antibodies which protect

against infection & disease

• Supplies energy in particular

circumstances (e.g. in malnourishment),

— When fat & carbohydrate intake is

inadequate

Sources & quality

• Protein in food: different quantity & quality

• Nutritional value of protein: determined by amino acid composition

— Biological value (BV)

High biological value

Protein that contains all essential amino acids

in sufficient proportions

Low biological value

Protein which is deficient (poor) in 1/more

essential amino acids

Animal & vegetable protein

Animal protein• Sources: e.g. meat, poultry, fish, eggs, milk,

dairy products• Almost same proportion of each essential amino

acid as human protein — Complete protein: high BV

Vegetable protein• Sources: e.g. vegetables, legumes, plants,

grains, nuts, seeds• Deficient in 1/more essential amino acids

— Incomplete protein: low BV

• Deficient (poor) amino acid = limiting amino acid

Digestion, absorption and synthesis

Digestion

• Protein is hydrolysed (digested / cleaved)

by particular protein-cleaving enzymes

• Place of action: stomach & small intestine

• Enzymes cleave protein in small units:

— amino acids & short chain peptides

Absorption

• Small units: absorbed by small finger-like

projections (villi), lining the intestinal wall

• Small peptides Î free amino acids

• Free amino acids Î blood Î liver

Synthesis

• Amino acids Î new (cell specific) protein =

synthesis = continuing process

• Body protein is continuously broken down

(into amino acids) and re-synthesised (amino

acids are re-built to protein)

Milk = high quality protein

• Cow’s milk (and dairy products) = excellent source of high quality protein

— All essential amino acids in proportions needed by the body

cow's milk 80/20

casein

w hey

protein

Casein

• In milk: salt of calcium

• Fraction that forms curds

• Not coagulated by heat

— Precipitated (separated) by acids (action of acid

in e.g. stomach) or by enzyme obtained from

stomach of calves (production of cheese)

• Does not denature easily: proteins denature

when they lose their 3-dimensional structure

W hey-protein

• Occurs in whey fraction: watery part of m ilk

• W hey = liquid rem aining after m ilk has been

curdled and strained

• By- product of cheese production: used for

nutritional ( and com m ercial) uses

Protein requirements

• Requirement depends on age, gender (and situation)

• Infants, children, pregnant & lactating need additional protein (essential amino acids)

— Synthesis of new body tissues Î healthy growth & development

• Healthy adults require continuous supply of protein Î tissue maintenance & repair

• Every country: own, local nutrient recommendations

— Internationally: US/Canadian Dietary Reference Intakes (DRIs)

High quality protein

• Cow ’s m ilk ( and dairy products) = excellent source of

h igh quality protein

— All essential am ino acids in proportions needed by

the body for good grow th & developm ent

— BV = com plete protein

— Casein / w hey protein = 80/ 20

3.4 g protein/ 100 ml: 500 ml/ day = 17 g of protein = RDA 30% (men) and 37% (women)

020406080

100

Protein RDA

500 ml cow's milk versus RDA average men 19-50 years

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20

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60

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100

Protein RDA

500 ml cow's milk versus RDA average women 19-50 years

Whey protein

• It is the name for a collection of globular proteins that can be isolated from whey, a by-product of cheese manufactured from cow's milk.

• It is typically a mixture of beta-lactoglobulin (~65%), alpha-lactalbumin (~25%), and serum albumin (~8%), which are soluble in their native forms, independent of pH.

Whey Protein Nutritional values

Essential Amino Acid

Protein-Source

Wheat Rice Soya Egg Casein Whey Proteins

Iso-leucine 14 15 21 28 46 55

Leucine 27 32 31 34 91 111

Lysine 11 15 26 29 77 88

Methionine 6 10 5 14 29 25

Phenylanine 18 18 19 23 51 34

Threonine 12 15 16 21 43 72

Tryptophan 5 5 5 5 12 30

Valine 18 25 24 29 57 52

Histidine 21 21 24 21 30 22

mg/gram of protein Source: Nutritive values of Indian food by G.Gopalan & Others, Published by National Institute of Nutrition, Hyderabad

Protein Efficiency Ratio

Protein Source PER value Wheat 1Rice 1.25Soya 2.12Casein 2.5Lactabumin 2.86Whey proteins 3

The Protein Efficiency Ratio ( PER) is used as measure of growth expressedIn terms of weight gain of an adult by consuming 1 gm of food protein

Source : Newzealand Dairy Board

Biological value (BV)

• It is a measure of the proportion of absorbed protein from a food which becomes incorporated into the proteins of the organism's body

• It summarizes how readily the broken down protein can be used in protein synthesis in the cells of the organism

• Whey has the highest Biological Value (BV) of any known protein

Comparison for BV for different sources of protein

Whey Protein 104

Whole Egg 100

Egg White (Albumin) 88

Casein 77

Rice 74

Soya 59

Wheat 54Source: European Dairy Association

Whey Protein

• Protein requirements are increased during pregnancy due to cell growth, blood production and maternal storage reserves for labor, delivery and lactation

• Whey is a dietary supplement used for babies and malnourished people to help them gain weight1

• Whey protein enhances the hemoglobin levels in blood2

1. Kennedy RS, Konok GP, Bounous G et al:

The use of a whey protein concentrate in the treatment of patients with metastatic carcinoma: A phase I/II clinical study. Anticancer Res 1995; 15:2643-2650.

2. Report from the Dept. of Nutrition, College of Home Science U.A.S., Dharwad (2000-2001)

Vitamin C

• Vitamin C or L-ascorbate is an essential nutrient

• In humans, vitamin C is a highly effective antioxidant, acting to lessen oxidative stress

• Vitamin C is categorized as Pregnancy category ‘A’

• It aid in the body’s ability to absorb iron

The pregnancy category of a pharmaceutical agent is an assessment of the risk of fetal injury due to the pharmaceutical, if it is used as directed by the mother during pregnancy

Pregnancy Category A Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Vitamin C

• Routine antioxidant supplementation during pregnancy to reduce the risk of pre-eclampsia and other serious complications in pregnancy1

1 Antioxidants for preventing pre-eclampsia. Rumbold A, Duley L, Crowther CA, Haslam RR. Cochrane Database Syst Rev. 2008 Jan 23 ;( 1):CD004227

Docosahexaenoic Acid (DHA)

• DHA is a type of fat that is mainly found in fatty fish. It seems to be important in the development of the brain and the retina

• DHA plays a crucial role in the growth and development of the central nervous system as well as visual functioning in infants1

• Pregnant and lactating women should aim to achieve an average daily intake of at least 200 mg DHA2

1 Dunstan JA, Simmer K, Dixon G, Prescott SL. Cognitive assessment at 21/2 years following fish oil supplementation in pregnancy: a randomized controlled trial. Arch Dis Child Fetal Neonatal Ed . 2006 Dec 21. 2 J Perinat Med. 2008; 36(1):5-14. Koletzko B, Lien E, Agostoni C, et.al,The roles of long-chain polyunsaturated fatty acids in pregnancy, lactation and infancy: review of current knowledge and consensus recommendations.

Docosahexaenoic Acid (DHA)

• Docosahexaenoic acid (DHA) is essential for the growth and functional development of the brain in infants. DHA is also required for maintenance of normal brain function in adults1

• The inclusion of plentiful DHA in the diet improves learning ability, whereas deficiencies of DHA are associated with deficits in learning1

• The visual acuity of healthy, full-term, formula-fed infants is increased when their formula includes DHA1

1. Horrocks LA, Pharmacol Res 1999 Sep; 40(3):211-225

Docosahexaenoic Acid (DHA)

• Poor maternal DHA status increases risk of inadequate DHA to support brain and retinal development, delaying or limiting neural and visual system development1

1 Early Hum Dev. 2007 Dec;83(12):761-6. Epub 2007 Oct 24 Fatty acids and early human development. Innis SM.

Child Dev. 2004 Jul-Aug;75(4):1254-67. Links

Maternal DHA and the development of attention in infancy and toddlerhood.

– Colombo J, Kannass KN, Shaddy DJ, Kundurthi S, Maikranz JM, Anderson CJ, Blaga OM, Carlson SE.

– Department of Psychology and The Schiefelbusch Institute for Lifespan Studies, University of Kansas, Lawrence 66045, USA. colombo@ku.edu

– Infants were followed longitudinally to document the relationship between docosahexaenoic acid (DHA) levels and the development of attention. Erythrocyte (red-blood cell; RBC) phospholipid DHA (percentage of total fatty acids) was measured from infants and mothers at delivery. Infants were assessed in infant-control habituation at 4, 6, and 8 months augmented with psychophysiological measures, and on free-play attention and distractibility paradigms at 12 and 18 months. Infants whose mothers had high DHA at birth showed an accelerated decline in looking over the 1st year and increases in examining during single-object exploration and less distractibility in the 2nd year. These findings are consistent with evidence suggesting a link between DHA and cognitive development in infancy. Copyright 2004 Society for Research in Child

Calcium & Vitamin D

• Calcium is required for normal growth and development as well as maintenance of the skeleton1

• Vitamin D is also essential for intestinal calcium absorption and plays a central role in maintaining calcium homeostasis and skeletal integrity2

• Increasing maternal vitamin D intakes during pregnancy may decrease the risk of wheeze symptoms in early childhood#

1 Novartis Found Symp. 2007;282:123-38; discussion 138-42, 212-8. Calcium and vitamin D. Cashman KD

2 Maternal vitamin D intake during pregnancy and early childhood wheezing. Devereux G, etal Am J Clin Nutr. 2007 Mar; 85(3):853-9

Fats & Carbohydrates

• Fats– Vitamins A, D, E, and K are fat-soluble,

meaning they can only be digested, absorbed, and transported in conjunction with fats

– Maintaining body temperature– Promoting healthy cell function – Serve as energy stores for the body

• Carbohydrates– It is a source of fuel for the mother

Composition

   MOMPLAN

Sr No Composition Each 30 gm

MOMPLAN contains :

1 Whey Protein 6 gm

2 Carbohydrates 18gm

3 Fat 0.3 gm

4 Calcium Carbonate equivalent to elemental Calcium 500 mg

5 Vitamin C 40 mg

6 Carbonyl Iron equivalent to elemental iron 45 mg

7 Folic Acid 400 mcg

8 Vitamin B 12 1.5 mcg

9 Vitamin D 200 i.u

10 DHA 100 mg