Pregnancy - Nutritional considerations

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Pregnancy - Nutritional considerations
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Nutritional considerations
The complex processes that occur during pregnancy require a rich supply of protein, vitamins and minerals for both mother and child. If you've built up good stores of nutrients before conception through a healthy diet, the added demands of pregnancy can be met with modest adjustments. If, however, your nutrient stores are low, you run a greater risk of diet-related problems during pregnancy, such as anaemia.

But while your need for certain nutrients does increase during pregnancy, the old adage 'eating for two' doesn't necessarily mean you should eat twice as much food, for a number of reasons:

Your growing baby isn't as big as an adult.
During pregnancy, your body becomes more efficient at absorbing nutrients in the digestive system.
Your body also doesn't excrete nutrients - instead, it builds up stores of vitamins and minerals.

It's the quality of your diet that's important, not the quantity.

Energy
In theory, the energy cost of pregnancy has been estimated to be 80,000 calories. But there's no need to increase your overall energy intake until the last trimester, when all that's needed is an extra 200 calories a day. This is the equivalent of a couple of slices of toast with low-fat spread and a glass of milk.

Protein
There is no need to increase your protein intake, as long as you follow healthy eating principles and include some lean meat, fish or poultry, dairy products, grains, nuts and pulses.

Fibre
It's particularly important to eat more fibre to avoid the common pregnancy niggles of constipation and piles (haemorrhoids). Increase your fibre intake by eating lots of fruit and vegetables, wholemeal bread and cereals, brown rice, wholemeal pasta and pulses. You should also drink more. Increasing fibre without enough fluids can exacerbate constipation.

Folic acid
This is particularly important before conception and during the first trimester of pregnancy. Mothers who are deficient in folic acid are at increased risk of having a baby with a neural tube defect (NTD), such as spina bifida.

From the moment you start trying to conceive until the end of week 12 of pregnancy, you should take a daily 400mcg supplement of folic acid. Women with a history of NTDs should be prescribed a 5mg supplement.

These supplements should be in addition to dietary intakes, which should be about 200mcg per day. You can boost your folic acid intake by choosing foods such as:

fortified breakfast cereals
wholemeal and wholegrain breads and rolls
green leafy vegetables - cabbage, broccoli, spinach, Brussels sprouts, spring greens, kale, okra and fresh peas
pulses - chickpeas, black-eyed beans and lentils

Folic acid is easily lost during cooking, so steam vegetables or cook in only a little water for a short time to retain as much goodness as possible.

Iron
Many women of child-bearing age have low iron stores. Your iron levels will be measured throughout pregnancy, and if found to be low you'll be prescribed an iron supplement. Nevertheless, it's important to maintain a good iron intake during pregnancy.

Good sources of iron can be split into two categories: meat-based (haem) and plant-based (non-haem):

Meat-based Plant-based
Lean red meat - beef, pork, and lamb. Fortified breakfast cereals, eggs, baked beans and other pulses, green leafy vegetables such as spinach and broccoli, dried apricots and prunes, wholegrain breads and cereals.

The body doesn't absorb iron from non-meat foods as easily as it does from meat sources. However, you can enhance iron absorption by including a source of vitamin C with your meal. In contrast, tannins found in black tea reduce the absorption. So, it's better to have a glass of orange juice with your bowl of cereal in the morning than a cup of tea.

Vitamin A
Although liver and liver products, such as pat» and liver sausage, are good sources of iron, they can also contain very high concentrations of vitamin A. If taken in excess, this vitamin can build up in the liver and cause serious harm to a growing baby.

As a result, the Department of Health advises all pregnant women to avoid liver and liver products. You should also be aware that some vitamin supplements are high in this vitamin, so always choose a specially prepared pregnancy supplement.

However, the form of vitamin A derived from green, orange, and yellow fruit and vegetables - known as carotene - has very positive health benefits, and is plentiful in red, yellow and orange peppers, mango, carrots, sweet potatoes, apricots, tomatoes and watercress.

Vitamin C
To help your body absorb and effectively use iron and other nutrients from your food, you should eat plenty of vitamin C-rich foods. Good sources include citrus fruits (oranges, tangerines, grapefruit and lemons), blackcurrants, strawberries, kiwi fruit, peppers, tomatoes and green leafy vegetables. Aim to eat at least five portions of fruit and vegetables every day.

Vitamin D
This is sometimes referred to as the 'sunshine vitamin' because it's made when the skin is exposed to sunlight. Vitamin D is essential for forming and maintaining healthy bones and teeth. It's found in only a few foods, including fortified margarines and reduced-fat spreads, fortified breakfast cereals, oily fish and meat. A small amount can also be found in milk and eggs.

Pregnant and breastfeeding women with dark skin or those who always cover their skin, are at particular risk of a vitamin D deficiency and may require a supplement. These should be available at your local health centre. Ask your dietician, practice nurse or doctor for more information.

Calcium
Your requirements of this essential mineral double during pregnancy, and are particularly high during the last ten weeks when calcium is being laid down in your baby's bones. Despite this, though, no dietary increase is thought necessary because your body adapts to absorb more calcium from the foods eaten.

This means, though, that it's important to eat sufficient calcium-containing foods. Good sources include milk and dairy foods such as cheese, yoghurt and fromage frais. Pregnant women should aim to have three servings of foods from this group every day (typical servings include a glass of milk, milk with cereal, a small chunk of cheese and a small pot of yoghurt). Other sources include bread, green vegetables, canned fish with soft, edible bones (salmon, sardines and pilchards), dried apricots, sesame seeds, tofu, fortified orange juice and fortified soya milk.

If you're pregnant or breastfeeding and you receive Income Support or Jobseeker's Allowance, you're entitled to free milk (up to seven pints a week). Ask your midwife or health visitor for further details.

A balanced diet
Most of the additional nutrient needs of pregnancy can be met by eating a well-balanced and varied diet. With a few exceptions, you can continue to eat a normal, healthy diet. This includes regular meals and snacks, and a sensible healthy eating regime containing:

Plenty of starchy carbohydrates - bread, rice, pasta, breakfast cereals, chapattis, couscous and potatoes.
Plenty of fruit and vegetables - at least five portions a day.
Lots of milk, yoghurt, fromage frais and pasteurised cheeses.
Enough protein, such as meat, fish, eggs (well-cooked), beans and pulses.
Not too many fat-rich and sugary foods.
Aim to have at least eight glasses of fluids per day.

What to avoid
Food poisoning
Pregnant women should be careful not to expose themselves to any risk of food poisoning, which is potentially very dangerous to the unborn baby, especially in the case of listeriosis and toxoplasmosis.

If you follow the guidelines below, your risk of food poisoning will be low:

Always wash your hands before preparing food.
Keep kitchen surfaces, cooking utensils, tea towels and so on scrupulously clean.
Store cooked and ready-to-eat food in separate containers and shelves in the fridge; don't let juices from raw or thawing meat or fish drip onto other foods.
Use separate chopping boards for preparing meat or poultry, and fruit and vegetables.
Wash fruit and vegetables thoroughly to remove dirt and soil.
Never eat food that has passed its use-by or expiration date.
Cook food thoroughly and according to manufacturers' instructions.
Cool leftover food quickly and use within 24 hours.
Wash your hands carefully after touching any animals.

Listeriosis is a rare flu-like illness caused by the bacteria listeria monocytogenes. In pregnancy it may cause miscarriage, stillbirth or severe illness in the newborn baby. Pregnant women are advised to avoid those foods where high levels of the bacteria are occasionally found: pat», prepared salads such as potato or coleslaw, and soft and blue-veined cheeses such as brie, camembert and stilton. There is no risk associated with hard cheeses such as cheddar or with cottage cheese, processed cheese or cheese spread.

Toxoplasmosis is an illness caused by a parasite found in cat faeces, raw meat, soil on vegetables and, occasionally, goats' milk. In rare cases it can be passed on to the unborn baby, resulting in a range of problems, some of them serious. As a safeguard, pregnant women shouldn't eat raw or undercooked meat, unpasteurised goats' milk or cheese, or unwashed raw fruit and vegetables. Good food hygiene practices should be followed with pets too: contact with cat litter trays or soil that may have been fouled by cats should be avoided. If this isn't possible, make sure you wear gloves.

Salmonella poisoning isn't likely to have a direct adverse effect on the baby, but it is best avoided. As a precaution, steer clear of foods containing raw or lightly cooked eggs (eg, homemade mayonnaise, some sauces and mousses). Eggs dishes should be cooked until both the white and yolk are solid. Raw meat and chicken can also be a source of salmonella, so make sure all meat - and especially poultry - is thoroughly cooked. It's also important to avoid contamination of other foods by washing your hands after touching raw meat and by preventing raw meat and poultry from touching or dripping onto other food, especially that which is already cooked or will be eaten raw. Take care at parties, where food is left in warm rooms and the bacteria grow quickly.

Alcohol
Heavy drinking during pregnancy will harm the unborn child, and there is evidence that it's associated with birth defects and lower birth weight. Excess alcohol may also affect the mother's nutritional status by affecting or substituting for other foods.

Pregnant women should avoid alcohol completely, the government advises, although the Royal College of Obstetricians and Gynaecologists says there's no evidence a couple of units once or twice a week will harm the baby. Binges (for example, getting drunk) are definitely to be avoided.

Caffeine
Caffeine, found in tea, coffee and many soft drinks, interferes with your body's absorption of iron and other nutrients. Current recommendations suggest that pregnant women should have no more than 300mg of caffeine per day, which is equivalent to four cups of coffee, six cups of tea, or eight cans of cola.

Troubleshooting
Morning sickness
Nausea and vomiting (especially in early pregnancy and not necessarily limited to the morning) affects about 70 per cent of pregnant women, and can range in severity from just feeling queasy to being unable to keep anything down. Only in around two per cent of women is the condition severe enough for medical intervention. However, check with your doctor or midwife if you are unable to keep anything down for sustained periods, as this can lead to dehydration.

There are things you can do to minimise the effects of pregnancy nausea:

Have small meals more often - every one to two hours during the day. Base these on carbohydrate-rich foods such as bread or rolls, plain biscuits, crispbreads, oatcakes, pasta, rice or potatoes.
Avoid fatty foods - these may be hard to digest and 'sit' heavily in your stomach.
Take small sips of fizzy drinks - the bubbles in the drink can help alleviate the sickness.
Stick to foods that don't take a lot of preparation.
Keep a couple of biscuits beside your bed - it can help to nibble on a plain biscuit before you get up in the morning.
Catch up on good days, making sure you have a variety of foods. Perhaps plan ahead and cook meals in advance to freeze.
Try not to have too much black tea and coffee. Caffeine and tannins found in these drinks can aggravate nausea and vomiting. As an alternative, try ginger and lemon, peppermint or chamomile tea.

The good news is, morning sickness generally only lasts for the first three months.

Cravings
Food cravings and food aversions are common during pregnancy. The causes aren't fully understood; changes in the gut, hormones and heightened sense of taste and smell have all been suggested. They're unlikely to have an adverse affect, provided the overall diet is nutritionally balanced. The most common aversions are to alcohol, caffeinated drinks, fatty foods and meats.

Heartburn and constipation
Indigestion, heartburn and intestinal discomfort are common especially later in pregnancy when the baby displaces or squashes internal organs. Fortunately, they are usually temporary problems. Women tend to learn which foods to avoid to prevent or alleviate such problems. However, it may help to have smaller, more frequent meals, and to avoid lying down within one to two hours of eating. Some indigestion remedies available from pharmacies are suitable for pregnant women - but check before you buy.

Constipation may be alleviated by consuming foods rich in fibre and starchy carbohydrates, as well as plenty of fluids. Fibre-rich foods include breakfast cereals, wholegrain bread and rolls, wholewheat pasta, brown rice, fruit and vegetables, nuts, seeds and pulses. It's important to keep your stools soft so they can pass easily and avoid the possibility of piles. Gentle exercise also helps to keep your gut moving.

Weight gain
The optimum weight gain in pregnancy is 12.5kg (27lb). However, in practice different women gain different amounts and many women who don't fall within this range still go on to give birth to healthy babies. Weight gains substantially more than 12.5kg in women of normal weight before pregnancy are unlikely to reflect an increase in foetal weight, maternal lean tissue or water. Rather, the excess weight is a gain in maternal fat. Because of this, concerns have been expressed that excessive weight gain can lead to overweight and obesity. Your doctor or midwife will advise you about weight gain, but it's important that you don't 'diet' during pregnancy.

Vegetarians and vegans
A well-planned vegetarian or vegan diet should be adequate to maintain the health of both mother and child during pregnancy. General guidelines for vegetarian diets can be found in the restricted diets section. Mothers-to-be on vegan diets that are restricted in any way should seek the help of a registered dietician for further advice.

Coeliac and diabetes
If you have diabetes or coeliac disease and are pregnant, ask to be referred to a state-registered dietician. They will make sure your diet is well balanced to provide all the nutrients required for a healthy pregnancy.

Key points:
Take a folic acid supplement providing 400µg per day for the first 12 weeks of pregnancy.
A healthy balanced diet provides all the nutrients that most pregnant women need, but some may require supplements.
If supplements are used, the best choice is a specially-prepared formula for pregnancy. Supplements containing vitamin A should be avoided.
Pregnant women should not eat liver, dishes containing raw or partially cooked eggs, or soft or blue-veined cheese, and should limit alcohol to 1 to 2 units once or twice a week.

Be scrupulous about food hygiene.
The average weight gain during pregnancy is 12.5kg, but there's a huge variation among individuals. Watch your weight gain, and speak to your midwife if you're concerned. Don't diet while pregnant.