Nutrition and Breastfeeding

Chapter 1: Nutrition Basics

• Nutrient intake is associated with risk of dietary deficiency and risk of overdose reactions with both increasing as nutrient intake increases
• EAR: Estimated Average Requirement
• RDA: Recommended Dietary Allowance
• AI: Adequate Intake
• UL: Tolerable Upper Intake Level

Carbohydrates

• Simple sugars include monosaccharides, such as glucose, fructose, and galactose and disaccharides, such as sucrose, maltose, and lactose
• Complex carbohydrates include starches found in plant form and glycogen found in animal form
• Fiber is also a complex carbohydrate
• Alcohol sugars, also known as alcohol (ethanol), are sources of carbohydrates
• Recommended carbohydrate intake is 45-65% of daily calories
• Recommended fiber intake is 21-25 grams for females and 30-38 grams for males

Protein

• High-quality proteins are found in milk, cheese, meat, eggs, etc.
• The recommended protein intake is 10-35% of daily calories

Fats

• Lipids include fats, which are solid at room temperature, and oils, which are liquid at room temperature
• Triglycerides consist of 3 fatty acids to glycerol
• Essential fatty acids include linoleic acid (parent omega-6 found in seed oils) and alpha-linolenic acid (parent omega-3 found in sea fish and flax seeds)
• Hydrogenation and trans fat involve adding hydrogen 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 a precursor to vitamin D, estrogen, and testosterone, found in egg yolks, meat, milk, milk products, fats (butter)
• Recommended fat intake is 20-35%, with no trans fats

Vitamins and Minerals

• Fat-soluble vitamins include A, D, E, K
• Water-soluble vitamins include Thiamin, Riboflavin, Niacin, B6, Folate, B12, biotin, pantothenic acid, choline, vitamin C
• 15 essential minerals: Calcium, phosphorus, magnesium, iron, zinc, fluoride, iodine, selenium, copper, manganese, chromium, molybdenum, sodium, potassium, chloride

Water

• Adults are 60-70% water
• Recommended intake is 15-16 cups for males and 11 cups for females

Nutrition Assessment

• ABCDs of nutrition assessment include:
  • Anthropometric measures
  • Biochemical tests
  • Clinical observations
  • Dietary intake

Chapter 2: Preconception Nutrition

• Begin preparing for conception 3 months prior to trying
• Infertility affects 15% of couples, with 44% eventually conceiving on their own:
  • 20-25% of healthy couples conceive
• Miscarriage is defined as the loss of conceptus in the first 20 weeks of pregnancy:
  • Can be caused by defects in the fetus
  • Can be caused by maternal infection
  • Can be caused by structural abnormalities of the uterus
  • Can be caused by endocrine or immunological disturbances
• Subfertility is characterized by reduced level fertility and an unusually long time for conception:
  • Affects 18% of couples
  • Can be caused by sperm abnormalities
  • Can be caused by multiple miscarriages
  • Can be caused by infrequent ovulation
• Female reproductive hormones are important for the menstrual cycle:
  • The menstrual cycle lasts 28 days
  • The first phase is the Follicular phase
  • The second phase is the Luteal phase
• Four key hormones involved in the process are:
  • Follicle-stimulating hormone (FSH)
  • Luteinizing hormone (LH)
  • Estrogen
  • Progesterone
• Hormonal effects during the menstrual cycle include:
  • Gonadotropin-releasing hormone (GnRH) stimulates the pituitary gland to release LH and FSH
  • Follicle-stimulating hormone (FSH) stimulates growth of ava
  • Luteinizing hormone stimulates secretion of progesterone
• Follicular Stage:
  • The anterior pituitary releases FSH and LH travel to the ovaries
  • 15-20 eggs then grow, each in their own follicle
  • Rising estrogen levels increase production of FSH
  • Once enough estrogen is released, FSH is turned off, which limits the number of follicles that mature
  • Only one follicle becomes dominant and mature
• Luteal Stage:
  • Occurs 14 days after the Follicular stage
  • Estrogen then stimulates the release of LH, which causes the follicle to release its egg from the ovary (ovulation occurs) -The empty follicle becomes the corpus luteum, which secretes progesterone -Progesterone readies the uterus for a fertilized egg -If the egg is not fertilized, menstruation occurs
• Contraceptives contain forms of estrogen and prevent pregnancy through:
  • Estradiol and progestin suppress the action of LH and FSH, thereby blocking ovulation
  • Progestin also blocks LH and ovulation, creating a barrier to sperm in the form of thick, sticky cervical mucus

Chapter 3: Preconception Nutrition, Conditions and Intervention

• Losing 5-10% of body weight can restore ovulation in obese or overweight individuals:
  • PCOS
  • insulin resistance
  • issues with menstruation and ovulation
• Increased fat tissue enhances endogenous and exogenous steroidal hormones & increases the storage of lipid-soluble steroids
• A change in the metabolism and excretion of hormones or altered production of steroid binding proteins (SHBG)
• Producing excessive estrogen from adrenal androgens
• Excessive estrogen feedback to the HPO axis inhibits ovary function
• Diabetes and Infertility includes:
  • Type 1, 2 Gestational
  • Chronic high blood glucose levels affect hormone levels
  • Manage with carbohydrate counting
• Polycystic Ovary Syndrome (PCOS) characteristics:
  • Affects 5-10% of women
  • High levels of intra-abdominal fat
  • Insulin resistance is the leading cause
• Hyperinsulinemia is linked to hyperandrogenemia:
  • As a result, insulin acts with LH to enhance androgen production in the ovary
  • Insulin decreases hepatic synthesis and secretion of sex hormone-binding globulin, the hormone that binds testosterone in circulation, increasing the amount of free testosterone
• Increased insulin sensitivity can be achieved with insulin-sensitizing drugs
• Diet recommendations: Lean proteins, whole grains, fruits and vegetables, regular meals, non-fat dairy, and low-glycemic index carbohydrates
• Underweight individuals:
  • Low BMIs may develop anovulation and amenorrhea
  • Reduced hypothalamic production of gonadotropic releasing hormone
  • To increase BMI, eat more/ increase calorie intake
  • Hypothalamic amenorrhea
• Anorexia nervosa and bulimia nervosa are linked to hypothalamic amenorrhea, with the following risks:
  • More likely to miscarry
  • Increased risk of preterm delivery
  • Increased risk of delivering low birth weight infants
• Theory of nutritional infertility:
  • Low fuel detected by neuron cells
  • Release neuropeptide Y and catecholamines:
    • Work on hypothalamus to block GnRH so that no ovum or sperm will grow
• Negative Energy Balance results in:
  • Female athletic triad
  • Energy intake is 30% less than required
  • Decrease in LH, FSH, and estrogen
• Treatment should focus on:
  • Correction of negative energy balance
  • Restoration of ovulation
  • Bone mass accretion
• Vitamin and Mineral Deficiencies untreated from 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
  • Supplement with 27 mg iron per day (creates hemoglobin which attaches to red blood cells and delivers oxygen throughout the body)
  • Iodine for thyroid function, achieved via drinking water, iodized salt, reducing stress, or increasing exercise
  • Prenatal multivitamin supplements
  • Limit coffee consumption to 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, and infant mortality can result in:
  • 8% (66% of infant deaths) LBW
  • 11.4% born preterm
• Reduced mortality results in:
  • Desirable birth rate: 3500-4500 grams (7lbs 12oz- 10lbs)
  • Reduced risk of developing heart and lung diseases, diabetes, and hypertension later in life
• Gestational age (doctors) involves the: Assessing the date of conception
  • which relates to when the doctor believes the baby will be delivered (around 38 weeks)
• Menstrual age involves the: Assessing the day of the mother's last period
  • which relates to when the mother believes the baby will be delivered (around 40 weeks)
• Maternal anabolic phase: first 20 weeks of pregnancy leads to:
  • Mother's body builds capacity to deliver all blood, oxygen, and nutrients that the fetus requires during the second half of pregnancy
• Characteristics include:
  • Increasing appetite
  • Increasing of anabolic hormones
  • Decreased tolerance to exercise
• Maternal catabolic phase: lasts 20 weeks of pregnancy leads to:
  • Mobilization of stored nutrients
• Characteristics include:
  • Increasing catabolic hormones
  • Decreased tolerance to exercise
• Insulin levels rise during weeks 24-36, until delivery:
  • Body can't maintain glucose or insulin

Development of placenta;

• Large endocrine organ that develops in the uterus within first several weeks of conception

• Secretes vital hormones Fights internal infections Exchanges nutrients and oxygen from the mother to the fetus Removes waste product from the fetus to the mother's blood supply changes in hormones

• Specific hormones a mother relies on include progesterone, estrogen, human chorionic gonadotropic (hCG), leptin, and human chorionic somatomammotropin

• Changes in body water: -Increase 7-10 L -Building blood and tissues first trimester -First weeks: 50 ml during week 10th to 800 mL week 20th of gestation

• Maternal nutrient metabolism during pregnancy:

  • 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
  • Maturation

• Pregnancy Weight Gain & nutrient needs:

  • Normal weight gain: 25-35 lb
  • ⅓ weight gain goes to the fetus
  • Increase body to provide nutritional needs of the mother & fetus
  • 30,000 calories
  • Carb intake: 45-65%
  • Alcohol: none
  • Protein intake: increase
  • Fat: 33%

Vitamins and Minerals during pregnancy:

• Need omega-3 fatty acids, EPA, DHA

• Early pregnancy: high estrogen and progesterone stimulate insulin and a need for more glucose conversion to glycogen and fat

• Glucose preferred fuel for fetus (50-80%)

• 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

• Fat Metabolism:

  • Fat stores accumulate in the first half and enhance fat mobilization in the last half

Vitamins and Minerals during pregnancy

• Folate

• Iron

• Vitamin A & D

• Calcium

• Need to drink 300 mL/day of water –Need Sodium – Limit Sweeteners

• Avoid Lead exposure because it impacts children's cognitive function

• Experience Gastrointestinal disturbances such as Nausea and vomiting:

  • starts around 6th week
  • Usually disappear around 12th week
  • Fluid intake is important
  • Diarrhea is concerning in pregnant women because It causes can result in -infectious agents, medications, food poisoning, food intolerances, lactose, fructose, sorbitol and mannitol intolerances

• Rehydrate and maintain electrolytes

• Eat High fiber diet with adequate amounts of fluids and stool bulking agents

• Heartburn:

• Relaxation of GI muscles secondary to an increase in estrogen and progesterone

• Stomach contents move into esophagus causing heartburn or more severely Gastroesophageal reflux disease

• Pressure from uterus and fetus can cause heartburn

• Can lead to a Gastroesophageal reflux disease which is impacted by fluctuating hormones on the function of the lower esophageal sphincter

• Triggers are eating before bed, intake of fatty or spicy foods, caffeine, mints, chocolate, and side effects of medication

• Constipation: can result in the 3rd trimester

• Need to Increase fiber and fluid and Do not take laxatives

• Pregnant women still need 30 minutes of exercise five times a week

• Anxiety and depression most common mental health issues

Chapter 4-2: Nutrition During Pregnancy

• Folate: Needed for Metabolic reactions as deficiencies lead to congenital abnormalities where it Check folate status by assessed by serum and red cell folate levels

• Source and recommendation: Vegetables and fruit and Consume 600 mcg everyday

• Neural Tube Defect: results in Failure of the neural tube to close early in gestation so you must assess with Diagnosis: alpha-feta protein and fetal ultrasound and Consume 4 mg folic acid

• Lack of folic acid or vitamin B12, magnesium, zinc as well as those with obesity, glucose intolerance/diabetes, MTHFR genotype (methylenetetrahydrofolate reductase) and, Women who take anti-seizure drug valproate without appropriate folic acid supplementation are reasons this Deficiency occurs

- Dietary Folate equivalents (DFE):

- 1 mcg food folate

• 0.6 mcg folic acid consumed in fortified, or a supplement taken with food

• 0.5 mcg of folic acid takes as a supplement on an empty stomach

• Choline: B-complex vitamin, RDA: 450 mg for baby's embryonic growth, including the development of the heart, lungs, kidneys eyes and bones as well as the circulatory, respiratory, and central nervous systems and Helps postpartum tissue repair and maintain normal vision helps maintain normal vision, fights infection, supports your immune system and helps with fat metabolism and (4000 IUS – no more than 8000 IUS

• Vitamin D: Supports fetal growth RDA: 15 mcg (600IU) to an Upper limit: 4000IU to prevent Deficiency lead to smaller bones, poorly calcified bones and abnormal enamel, dental cavities higher risk for Higher risk for preeclampsia, preterm birth, maternal infection Obese and vegan at risk

• Calcium: Needed for fetal skeletal mineralization and maternal ones so we need to drink Three cups of milk or calcium-fortified soymilk and a good Source of iron

• Iron:

  • 300mg for the fetus and placenta
  • 250 mg lost at delivery
  • 450 mg for increased red blood cell mass
  • iron deficiency: depleted iron stores- Leads to Weakness, fatigue, short attention span, poor appetite, increased susceptibility to infection and irritability and, Iron deficiency anemia: low hemoglobin Can lead to low Paleness, exhaustion, rapid heart rate and lead to preterm delivery and low birth rate Increase intake Calcium and Vitamin C
    • 18-27 mg of elemental iron everyday
    • Mild anemia: no effect
    • Moderate anemia: increased weakness, lack of energy, fatigue and poor work performance
    • Severe anemia: palpitations, tachycardia, breathlessness, increased cardiac output leading o to cardiac stress which can cause de-compensation and cardiac failure

• Baby could be born preterm and have low birth weight, stillbirth, newborn death, anemia in future and we need to take 30-mg iron supplement daily lodine

• Required for thyroid function and energy production and for fetal brain development Sodium

Chapter 5: Nutrition During Pregnancy Conditions and Interventions

• Obesity in Pregnancy Can Lead to: Several unfavorable metabolic changes such as Increased blood glucose levels, Blood concentration of insulin, Insulin resistance and- Blood that pressure and High C-reactive protein levels and Low HDL-cholesterol

• Several Effects on the Mother includes such disease states like Hypertension and Gestational diabetes and Thromboembolism and Obstructed sleep apnea and Hemorrhage and Labor problems and Pregnancy loss

• Effect on Babies include Malformation such as Macrosomia and Birth injury and Perinatal death and can develop Later diabetes & obesity

• The best interventions include eating a variety of basic foods and physical activity

• Weight loss not recommended during pregnancy The Ideal Pregnancy weight:

Underweight : 28-40lb

Normal weight: 25-35lb

Overweight: 15-25lb

Obese: 11-20 lb

Twin Pregnancy: 25-54

• Pregnancies after bariatric surgery result in: deficiences with your intake of Thiamin, vitamins D, B12, and not intaking enough folate/iron and calcium Inadequate weight gain during pregnancy

• Gestational Disbetese:

  • Is caused by being Predisposed to insulin resistance and have impaired insulin production and this occurs in 2-12% (88% of pregnancy diabetes patients are newly diagnosed) There is an Increased risk of spontaneous abortion, stillbirth, congenital abnomalies, or lead to neonatal death Linked to excess body fat, and unhealthy diets

• There is an increase of blood glucose as a part of the Pregnancy

Diagnosis of Gestational Diabetes:

• Pregnant women without diabetes should recieve a 75-mg oral glucose tolerance test while at 24-28 wks -Fasting plasma glucose > 92 mg/dL -1-hour plasma glucose> 180 mg/dL -2-hour plasma glucose > 153 mg/dL

• Pregnant women with preexisting diabetes, should watch out for:.

  • Hemoglobin A1c > 6.5% -Fasting plasma glucose> 126 mg/dL -Two-hour glucose > 200mg/dL after 75-gram oral glucose

• Normal < 140 mg/dL

• Impaired>140 <200 mg/dL

• Diabetes >200 mg/dL

Eat whole-grain breads and cereals, vegetables, fruits and high-fiber foods and Limit sugar and consume Low-glycemic index foods

• Manage Hyperglycemia/ hypoglycemia by taking control of your levels of Intake

Hypertensive Disorders of Pregnancy Affect 5-10% of pregnancies which leads to stillbirths and fetal/newborn deaths Relate to chronic inflammation, oxidative stress, nd is damaging, Impaired blood flow to endotheluim Treat Preeclampsia with calcium and Vitamin D Chronic Hypertension:

• Prior to pregnancy or diagnosed before 20 weeks
• Older women, high blood pressure
• Focus On consuming vitamin D, C, calcium, fiber, and antioxidant Preeclampsia-eclampsia.

Chapter 6: Nutritions during Lactation

• Lactation Physiology Alveoli -Rounded or oblong shaped cavity that is present in breast
• Serve as the location Secretory cells: responsible for secreting milk Myoepithelial cells: cells surround secretory cells and contract to cause milk ejection into the ducts
• Mammary gland develops in 12 to 18 months: to promote Hormonal control of lactation
• Prolactin: hormone that promotes milk production (sucking) and Oxytocin: responsible for ejection of milk from the milk gland and can start the cycle Suckling: where Milk ejection occurs from the Ducts
• Stage and development of Lactogenesis where different type of colostrums release
• Stage Lactogenesis I: Milk formation begins and high in Proteins, and Water
• Stage Lactogenesis II: two to five days after birth, transitional milk": increased blood flow to breast: milk "comes in"
• Stage Lactogenesis III: 10 days after birth, mature milk": milk composition is stable and has Energy
• Lipids helpProvide half the calories in human milk
• In hindmilk less in foremilk- DHA
• Vitamin A: Colostrum does has twice the concentration as mature milk
• Colostrum has approximately twice the concentration of vitamin A as mature milk does.

Chapter 7: Nutrition During Lactation Interventions

• Sore Nipples; can be Prevented by proper positioning of baby on breast if the nipples are: Flat or Inverted

• Should not impact breastfeeding

• Difficult to maintain latch and roll nipple between fingers and or use a breast pump prior to feeding will help latch If Letdown Failure- Milk does not eject from the breast Oxytocin nasal spray can be recommended and Relaxation is important If you have a fast stream can result in a Hyperactive Letdown -If too active may cause infant to cough or choke

• Can manage by: Waiting, -Express milk until the flow slows then allow infant to nurse.

• Milk volume exceeds intake -Hyperlactation resulting

• Moms experience painful breasts - Babies have difficulty latching

• Prevention strategies include Nurse baby one side and -Engorgement and a Plugged duct for preventing/decreasing the flow.

• Prevent with Empting your breasts Avoid Mastitis

• Treat/prevent with Antibiotics

• Avoid low milk Supply- Caused by Lactation medication Avoid Alchol abuse during breastfeeding

• If a baby hasNeonatal Jaundice and Kernicterus you need to: -Use Light therapy

• Low risk if used -Low allergen maternal diet associated with reduction in distressed behavior

• Avoid food intolerance: cows, milk, eggs, peanuts, tree nuts, wheat, soy and fish

• Vitamin K: receive injections and Vitamin D: exclusively breastfed infants need supplements at two months but, avoid Fluoride or iron

• Ensure your maternal Diet has sufficient Energy and to provide for milk production energy in first six months: 500

• If Infant experience: colics Defined as crying for more than 3 hours with no medical cause

• Cows like cabbage, broccoli, and chocolate is not needed during maternal diet during breast feeding