Maternal Health and Breast Milk Nutrients

Chapter 1

• Risk of dietary deficiency increases with low nutrient intakes, and risk of overdose reactions increases with high nutrient intakes
• There are several reference points on the nutrient intake spectrum, including the Estimated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL)
• Carbohydrates include simple sugars (monosaccharides like glucose, fructose, galactose and disaccharides like sucrose, maltose, lactose) and complex carbohydrates (starches like plant form and glycogen like animal form), and fiber
• Alcohol sugars include alcohol (ethanol)
• The recommended carbohydrate intake level is 45-65%
• Recommended fiber intake is 21-25 grams for females and 30-38 grams for males
• Protein sources include high-quality proteins from milk, cheese, meat, eggs, etc.
• Recommended protein intake is 10-35%
• Fats (lipids) include fats that are solid at room temperature and oils that are liquid at room temperature
• Triglycerides are composed of 3 fatty acids to glycerol
• Essential fatty acids include linoleic acid, a parent omega-6 found in seed oils, and alpha-linolenic, a parent omega-3 found in sea fish and flax seeds
• Hydrogenation and trans fat occurs when hydrogen is added to unsaturated fatty acids, changing the structure of fatty acid from cis to trans structure
• Dietary Cholesterol is a fat-like, clear liquid in animal products and is a precursor to vitamin d, estrogen, and testosterone, found in egg yolks, meat, milk, milk products, and fats (butter)
• The recommended fat intake is 20-35% and should contain no trans fats
• Vitamins include fat-soluble vitamins (A, D, E, K) and water-soluble vitamins (Thiamin, Riboflavin, Niacin, B6, Folate, B12, biotin, pantothenic acid, choline, vitamin c)
• Minerals: 15 essential minerals, include calcium, phosphorus, magnesium, iron, zinc, fluoride, iodine, selenium, copper, manganese, chromium, molybdenum, sodium, potassium, chloride
• Water: Adults are 60-70% water, 15-16 cups (male), 11 cups (female)
• Nutrition Assessment: ABCDs of nutrition assessment involves anthropometric measures, biochemical tests, clinical observations, and dietary intake

Chapter 2: Preconception Nutrition

• Begin preparing 3 months before conception
• Infertility: 15% couples infertile, 44% couples eventually conceive, 20-25% healthy couples conceive
• Miscarriage: loss of conceptus during the first 20 weeks of pregnancy can be caused by defects in the fetus, maternal infection, structural abnormalities of the uterus, or endocrine or immunological disturbances
• Subfertility: reduced level of fertility characterized by an unusually long time for conception; 18% couples experience subfertility, sperm abnormalities, multiple miscarriages, or infrequent ovulation
• Female Reproductive system and Hormone: 4 hormones are involved, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, and progesterone
• Hormonal effects during menstrual cycle involve gonadotropin-releasing hormone (GnRH) which stimulates the pituitary to release LH and FSH; follicle-stimulating hormone (FSH) stimulates growth of ova; luteinizing hormone stimulates secretion of progesterone
• Menstrual Cycle- 28 days, has 2 phases Follicular phase (1st), and Luteal phase (2nd)
• Follicular Stage: anterior pituitary released FSH and LH travel to ovaries, 15-20 eggs then grow in own follicle, estrogen levels rise because of increase in FSH, enough estrogen is released, FSH is turned off, limiting number of follicles that mature, one follicle becomes dominant and mature
• Luteal Stage: 14 days after Follicular stage, estrogen stimulates the release of LH, which causes the follicle to release its egg from the ovary (ovulation occurs), empty follicle becomes corpus luteum, which secretes progesterone, progesterone readies the uterus for a fertilized egg, egg not fertilized, menstruation occurs
• Contraceptives contain forms of estrogen (birth control): estradiol and progestin suppress the action of LH and FSH thereby ovulation; progestin blocks LH and ovulation and induces a barrier to sperm by causing cervical mucus to become thick and sticky

Chapter 3: Preconception Nutrition: Conditions and Intervention

• Obesity/Overweight:
  • Lose 5-10% of body weight to restore ovulation
  • Can cause PCOS, insulin resistance, issues with menstruation and ovulation
  • Increased fat tissue enhances endogenous and exogenous steroidal hormones and increase storage of lipid soluble steroids
  • Change in metabolism and excretion of hormones or altered production or steroid binding proteins (SHBG)
  • Product too much estrogen from adrenal androgens
  • Excessive estrogen feedback to HPO axis and inhibits ovary function
• Diabetes and Infertility:
  • Type 1, 2 Gestational
  • Chronic high blood glucose levels affect hormone levels
  • Carbohydrate counting to manage
• Polycystic Ovary Syndrome (PCOS:
  • Affects 5-10% women
  • Characterized by high levels of intra-abdominal fat
  • Insulin resistance is the leading cause
• Hyperinsulinemia linked to hyperandrogenemia:
  • Insulin acts with LH to enhance androgen production in the ovary
  • Insulin decreases hepatic synthesis and secretion of sex hormone-binding globulin, hormone that binds testosterone in circulation, increasing the amount of free testosterone
  • Increase insulin sensitivity and can be treated with insulin-sensitizing drugs
• Diet recommendations: lean proteins, whole grains, fruits and vegetables, regular meals, non-fat dairy, and low-glycemic index carbohydrates
• Underweight
  • Low BMIS may develop anovulation and amenorrhea
  • Reduced hypothalamic production of gonadotropic releasing hormone
  • To increase BMI, eat more food
  • Hypothalamic amenorrhea, loss of menstrual cycles due to absence of ovulation, deficits of energy and nutrients
  • Anorexia nervosa and bulimia nervosa are linked to hypothalamic amenorrhea
  • More likely to miscarry, have preterm delivery, and deliver low birthweight infants
  • Theory of nutritional infertility
  • Low fuel detected by neuron cells, releases neuropeptide Y and catecholamines
  • Works on hypothalamus to block GnRH so that no ovum or sperm will grow
• Negative Energy Balance:
  • Female athletic triad
  • Energy intake is 30% less than required
  • Decrease in LH, FSH, and estrogen
  • Treatment includes correction of negative energy balance, restoration of ovulation, and bone mass accretion
• Vitamin and Mineral Deficiencies untreated Celiac Disease:
  • Folate- lactose maldigestion, intolerance
  • Vitamin B12- weight loss, Vitamin A- anemia, Vitamin D- osteoporosis, Vitamin E- Subfertility, Vitamin K- growth failure, irritable bowel disease,Calcium and Iron
  • Treat celiac disease by eliminating foods that have gluten and replacing them with rice, soy, corn
• Nutritional recommendations During Conception: women need folate, iodine, DHA, multivitamins
• Men need zinc and antioxidants
• Iron creates hemoglobin which attaches to red blood cells and delivers oxygen throughout the body, the daily dose is 27 mg, Iron supplements
• Iodine for thyroid function, drink water, iodized salt, seafood, reduce stress, increase exercise
• Multivitamin: Prenatal vitamin
• Coffee: No more than 200 mg, caffeine contributes to miscarriage and low birth weight

Chapter 4-1: Nutrition During Pregnancy

• Low birthweight (2500 g), preterm delivery, infant mortality
  • 8% (66% of infant deaths) LBW, 11.4% born preterm
• Reducing infant mortality and morbidity
  • Desirable birth weight: 3500-4500 grams (7lbs 12oz- 10lbs), less likely to develop heart and lung diseases, diabetes, and hypertension
• Gestational age (doctors): assessed date of conception, 38 wks
• Menstrual age: assessed day of last period, 40 wks
• Maternal anabolic phase: first 20 weeks of pregnancy, mother's body builds capacity to deliver all blood, oxygen, and nutrients to fetus required during the second half of pregnancy, mothers symptoms: increased appetite, increase in anabolic hormones, decreased exercise tolerance
• Maternal catabolic phase: last 20 weeks of pregnancy, mobilization of stored nutrients, mothers symptoms: increase in catabolic hormones, increase in exercise tolerance
• Expecting mother relies on specific hormones such as progesterone, estrogen, human chorionic gonadotropic (hCG), leptin, and human chorionic somatomammotropin
• First weeks: the increase is 50 ml during in the 10th week to 800 mL in the 20th week of gestation
• Increase cholesterol is used for steroid hormone synthesis and by the fetus for nerve and cell membrane function Does not increase risk of atherosclerosis
• Changes in body water: increase 7-10 L, building blood and tissues first trimester
• Calcium metabolism occurs with bone turnover and reformation, Increased levels of body water and tissue synthesis require sodium and other minerals
• Embryonic and Fetal Growth and Development: Hyperplasia, Hyperplasia and Hypertrophy, Hypertrophy, and Maturation
• Insulin-like growth factor (IGF-1) is the main fetal growth stimulator
• Normal weight gain is 25-35 lb; 1/3 weight gain goes to fetus, increased body fat helps meet nutritional needs of the mother and fetus while 30,000 calories are needed.
• Glucose preferred fuel for fetus (50-80%), Early pregnancy: high estrogen and progesterone stimulate insulin, need more glucose to conversion to glycogen and fat , Late pregnancy: human chorionic somatotropin (hCS) and prolactin inhibit conversion of glucose to glycogen and fat
• Maternal protein accumulates in blood, uterus, breasts, fetus, placenta, and amniotic fluid, Need high amounts for rapid growth of maternal and fetal tissues (2nd and 3rd trimesters),Natural decline in total nitrogen Glucose preferred fuel for fetus (50-80%), Early pregnancy: high estrogen and progesterone stimulate insulin, need more glucose to conversion to glycogen and fat, Late pregnancy: human chorionic somatotropin (hCS) and prolactin inhibit conversion of glucose to glycogen and fat. Fat metabolism -Fat stores accumulate in first half and enhance fat mobilization in last half, Blood lipid levels increase
• Glucose preferred fuel for fetus (50-80%), Early pregnancy: high estrogen and progesterone stimulate insulin need more glucose to conversion to glycogen and fat, Late pregnancy: human chorionic somatotropin (hCS) and prolactin inhibit conversion of glucose to glycogen and fat

Chapter 4-2: Nutrition During Pregnancy

• Deficiencies lead to congenital abnormalities
• Folate: Metabolic reactions,, Check folate status by assessed by serum and red cell folate levels, Vegetables and fruit,600 mcg
• Failure of the neural tube to close early in gestation
• Causes of NTD, Lack of folic acid or vitamin B12, magnesium, and zinc; Obesity; Glucose intolerance/diabetes, MTHFR genotype (methylenetetrahydrofolate reductase), Women who take anti-seizure drug valproate without appropriate folic acid supplementation
• The need for vitamins and minerals during pregnancy involves Choline: B-complex vitamin RDA: 450 mg, and include vitamin A Need to eat a balanced diet of meals and snacks, listen to hunger and fullness cues, and engage in physical activity- Insulin-like growth factor (IGF-1) is the main fetal growth stimulator

Chapter 5: Nutrition During Pregnancy: Conditions and Interventions

• Several unfavorable metabolic changes involve increased blood glucose levels, blood concentration of insulin, insulin resistance, blood pressure, high C-reactive protein levels
• Type 1 diabetes in Pregnancy involves more hazards, mother at risk for kidney disease, hypertension, preclampsia
• Women without diabetes: 75-mg oral glucose tolerance test 24-28 wks: Fasting plasma glucose > 92 mg/dL, 1-hr plasma glucose> 180 mg/dL, 2-hr plasma glucose > 153 mg/dL

Chapter 5a; Obesity, effects, actions, and management

• Obese: 11-20 lb
• Pregnancy after bariatric surgery
• Deficiencies of many nutrients (Thiamin, vitamins D, B12, folate, iron and calcium) will also affect weight gain Need to eat a balanced diet of meals and snacks, listen to hunger and fullness cues, and engage in physical activity Gestational Diabetes: a diabetic state in pregnancy that results in increase of spontaneous abortion, stillbirth and congenital abnormalities
• Linked to excess body fat, unhealthy diets, low physical activity levels The diagnosis of Gestational Diabetes can include: 75-mg oral glucose tolerance test 24-28 wks: Fasting plasma glucose > 92 mg/dL 1-hr plasma glucose> 180 mg/dL or 2-hr plasma glucose > 153 mg/dL

Hypertensive Disorders of Pregnancy

There are many risks one of which is5-10% pregnancy, stillbirths, fetal and newborn deaths •Related to chronic inflammation, oxidative stress, nd damage to endothelium of blood vessels •Preeclampsia-eclampsia only manifests during Pregnancy- can be identified by •Signs: high blood pressure, liver complications, protein in urine, water retention and swelling, seeing double, vomiting, vaginal bleeding, headache above eyes, belly ache

Chapter 6: Nutrition during Lactation

• Lactation Physiology: Alveoli are the rounded or oblong shaped cavity present in breast's; Secretory cells: are responsible for secreting milk; Myoepithelial cells are the ones that surround secretory cells and contract to cause milk ejection into ducts
• Hormonal control of lactation occurs with:
• Prolactin which is a hormone that promotes milk production (sucking)
• Oxytocin release which is then responsible for ejection of milk from the milk gland (suckling or nipple stimulation)

Three general stages of Lactogenesis

• Lactogenesis I: milk formation is initiated
• Lactogenesis II: increased blood flow to breast: milk "comes in"
• Lactogenesis III: milk composition becomes stable

Chapter 7: Nutrition During Lactation: Conditions and Interventions, mastitis, and more.

• Prevented by proper positioning of baby on best
• Engorgement of Brests can be overfilled with milk when the supply and demand process aren't established and can be solved by Nursing frequently to prevent, newborns may nurse every hour and a half, cabbage leaves may be used to reduce discomforts
• Localized blockage of milk resulting from milk stasis can be solved by massaging and by a warm compress
• Mastitis-Inflammation of breast can have -Infective or non-infective, and is only an issue if there are missing a feedings
• Galactagogue will be prescribed when there is low milk production/supply because of most medications that are excreted in breast milk