CLINICAL PRACTICE GUIDELINES on MATERNAL NUTRITION AND SUPPLEMENTATION First Edition November 2013 PROPERTY OF DEPARTMENT OF OBSTETRICS AND GYNECOLOGY OUT PATIENT DEPARTMENT Task Force on the Clinical Practice Guidelines On Maternal Nutrition and Supplementation(id Philippine Obstetrical and Gynecological N ji) Society [POGS] (Foundation), Inc. ay ca CLINICAL PRACTICE GUIDELINES on MATERNAL NUTRITION AND SUPPLEMENTATION First Edition November 2013 Task Force on the Clinical Practice Guidelines On Maternal Nutrition and SupplementationDISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY © This is the Clinical Practice Guidelines (CPG) on Maternal Nutrition and Supplementation, First Edition, November 2013. * — This is the publication of the Philippine Obstetrical and Gynecological Soci- ety [POGS] (Foundation), Inc. * This is the ownership of the POGS, its officers, and its entire membership. * — The obstetrician-gynecologist, the general practitioner, the patient, the stu- dent, the allied medical practitioner, or for that matter, any capacity of the person or individual who may read, quote, cite, refer to, or acknowledge, any, or part, or the entirety of any topic, subject matter, diagnostic condition or idea/s willfully release and waive all the liabilities and responsibilities of the POGS, its officers and general membership, as well as the AdHoc Committee on the Clinical Practice Guidelines and its Editorial Staff in any or all clin- ical or other disputes, disagreements, conference audits/controversies, case discussions/critiquing. * The reader is encouraged to deal with each clinical case as a distinct and unique clinical condition which wil{ never fit into an exact location if refer- ence is made into any or ail part/s of this CPG. * — The intention and objective of this CPG is to serve as a guide, to clarify, to make clear the distinction. It is not the intention or objective of this CPG to serve as the exact and precise answer, solution and treatment for clinical conditions and situations. It is always encouraged to refer to the individual clinical case as the one and only answer to the case in question, not this CPG, * — It is hoped that with the CPG at hand, the clinician will find a handy guide that leads to a clue, to a valuable pathway that leads to the discovery of clin- ical tests leading to clinical treatments and eventually recovery. + Inbehalf of the POGS, its Board of Trustees, the Committee on The Clinical Practice Guidelines 2013, this CPG is meant to make each one of us a perfect image of Christ, the Healer. vi camiiitlimmeeee eRe ae eile aN Rela 2a Pr Uile) TOPICS / CONTENTS Demographics on Maternal Nutrition in the Philippines ... Ma. Cristina P. Crisologo, MD Assessment of Nutritional Status of Pregnant Women ... Mario Benito F: Bautista, MD Recommended Weight Gain in Pregnancy . Mary Jocelyn Yu-Laygo, MD Recommended Energy and Nutrient Intake ... Joseph U. Olivar, MD amd Mary Jocelyn Yu-Laygo, MD Micronutrient Supplementation: Iron Folic Acid and Jodin Joseph U. Olivar, MD Micronutrient Supplementation: Vitamins, Minerals and Electrolytes .... Joseph U. Olivar, MD amd Ramon T. Reyles, MD Appendix 1 Burden of Undernutrition: Health Risks for the Mother, Fetus and Child... Rosa Ninez Velante-Nierva, MD Appendix 2 Consequences of Obesity and Overnutrition in Pregnancy... doyceline Noemi I, Silao, MD Appendix 3 Government Programs on Maternal Nutrition and Supplementation Mila Zaragoza-Tbay, MD Appendix 4 levels of Evidence and Grades of Recommendation.DEMOGRAPHICS ON MATERNAL NUTRITION IN THE PHILIPPINES Ma. Cristina P. Crisologo, MD, FPOGS, FPSMFM The Food and Nutrition Research Institute (FNRI) of the Philippines is mandated by law to undertake research that defines the citizenry’s nutritional satus, with particular reference to the malnutrition problems, its causes and effects, and to identify alternative solutions to them. To this end, a national nutrition survey is conducted every 5 years. The 7* National Nutrition Survey vonducted in 2008 carried as its theme, “Vital Inputs to Nutrition Governance tor Sustainable Development,” and this will be the main basis for the contents of this chapter. Pertinent results from this 7 FNRI Survey! are elucidated in the succeeding sections: ANTHROPOMETRIC SURVEY Among II to 19 year old adolescents: * For every 100 adolescents aged 11-19 years, 17 were underweight and about 5 were overweight. * — There were more underweight 11 year old adolescents (25.5%) than the 13 to 19 year old adolescents (13.8%). * Prevalence of underweight (21.7% vs 11.7%) and overweight (4.8% vs 4.5%) were higher among male adolescents than the female. + The prevalence of underweight among the pre-adolescents/adolescents, 1 to 19 years old had significantly increased by 1.0 percentage point between 2005 and 2008. * Overweight, on the other hand, had decreased significantly by 0.2 percentage point from 4.8% in 2005 to 4.6% in 2008. Among adults 20 years and over: * About 12 in every 100 adults 20 years and over were chronic energy deligient (CED), corresponding to a body mass index {BMI) of less Than 18.5 kg/m’, ¢ Overweight and obesity affect 27 adults in every 100, with the most humber of obese individuals coming from the national capital region (NCR).Am . Am . From 2003 to 2008, there was a significant decrease in the prevalence of CED among adults from 12.3% to 11.6%. In contrast, a 2.6 percentage point significant increase in the prevalence of overweight and obese among adults was noted. ong pregnant women: The proportion of nutritional at-risk pregnant women decreased significantly by 1.9 percentage point from 2005 to 2008. Regions III and VI posted the highest numbers of underweight lactating women. There are about 26 nutritionally at-risk pregnant women for every 100 women, with the numbers being highest in Region [V-B and ARMM. ong lactating women: ‘There was a significant reduction in the prevalence of underweight lactating women from 13.9% in 2005 to 13.1% in 2008. There was a 3.8 percentage point significant decrease in the prevalence of overweight lactating women from 19.8% in 2005 to 16.0% in 2008. BIOCHEMICAL SURVEY ANEMIA: . The overall prevalence of anemia, from 6 months of age to the elderly (> 60 years) is 19.5%. The highest prevalence was observed among infants 6 months to <1 year at 55.7%, followed by pregnant women at 42.5%. Based on the = 40% epidemiological criteria for assessing severity and magnitude of anemia, the prevalence among infants and pregnant women remains a significant public health problem. Males had a significantly lower anemia prevalence compared to their female counterparts among the 13 to 19 year olds, 20 to 39 year olds, and 40 to 59 year olds. Based on the 2008 Projected Population (using the 2000 Census), the estimated number of anemic children per age group are as follows: 6 months to | year is 0.74 million, | to 5 years is 2.1 million, and 6 to !2 years is 2.77 million. There was no significant decrease in anemia prevalence rate from 43.9% to 42.5% in 2008 among pregnant women. Prevalence rate for lactating women was significantly lower in 2008 at 31.4% compared to the 2003 anemia prevalence rate of 42.2% CLINICAL SURVEY: The prevalence of hypertension (2140/290 mmlly) among adults is 25.3%. ILincreases with age starting from age 40 to 49 yeurs 2 ° The prevalence of high fasting blood sugar (> 125 mg/dL) among adults is 4.8%, peaking at age 50 to 59 years. * Prevalence of impaired fasting glucose is 2.7% + Prevalence of high cholesterol (>160 mg/dL) among adults was 11.8%, and high triglyceride levels (>200 mg/dL) was 14.6%. In general, total cholesterol, LDL-c and triglyceride levels increased with age, peaking from ages 40 to 59 years. * Dyslipidemia based on total cholesterol, HDL-c and triglyceride levels has significantly increased from 2003 to 2008. VOOD INSECURITY * Based on the Radimer-Cornell tool, about 3 out of 10 mothers experienced food insecurity because there was no food or money to buy food in the past 3 months. Skipped eating or missing meal(s) was the most frequent experience among food insecure mothers. * — Hunger was experienced by about 2 out of 10 mothers. One out of 10 children experienced hunger but did not eat because there was no food or money to buy food in the past 3 months, * Of the households, about 7 out of 10 mother respondents expressed anxiety regarding the sufficiency of food in the household and money to buy food. Five out of 10 mothers felt their children were not eating enough in terms of quantity and nutritional adequacy because the households do not have enough food and money to buy more food. lille 1. Percent of mothers who experienced food insecurity and frequency of « perience in the past 3 months: Philippines, 2008 ices Percent Frequency () ' _ ‘once _ | More than once Skipped eating or missing meal(s) | 269 34.5 65.5 | Hungry but did not eat 16.1 41.0 59.0 Did not cat for the whole day 35 44.7 553 “a with experience of a least one of 28.6 the indices In other aspects, protein-energy malnutrition (PEM) and micronutrient deticienci remain the leading nutritional problems in the Philippines. The general declining trend in the prevalence of underweight, wasting and stuntingamong Filipino children noted in the past 10 years was countered with the increase in the prevalence rate in 1998. About 4 million (31.8%) of the preschool population were found to be underweight-for-age, 3 million (19.8%) adolescents and 5 million (13.2%) adults, including older persons were found to be underweight and chronically energy deficient, respectively.” The status of micronutrient malnutrition is likewise an important concern in the country. The vitamin A status of the country is considered severe subclinical deficiency affecting children 6 months to 5 years (8.2%) and pregnant women (7.1%). Iron deficiency anemia (IDA) is the most alarming of the micronutrient deficiencies affecting a considerable proportion of infants (56.6%), pregnant women (50.7%), lactating women (45.7%) and male older persons (49.1%). Prevalence of IDA was mild (71mg/L). However, 35.8% children 6-12 years old still suffer from moderate and severe IDA. In the 2011 survey updating the nutritional status of Filipino children and other population groups conducted by the FNRI, initial results released in April 2012 showed that 35.7% or about a third of pregnant women below 20 years old are nutritionally at risk, based on weight-for-height requirements. About twenty three percent (23.3%) or 1 out of 5 pregnant women above 20 years old is also at risk.’ The study also looked at the prevalence of nutritionally at-risk pregnant women by months of pregnancy. Results showed that 27.9% of pregnant women are nutritionally at-risk on the 1* trimester, 25.3% on the 2™ trimester, and 23.2% on the 3” trimester, Pregnant women from MIMAROPA (43.6%), Western Visayas (33.2%), Cagayan Valley (32.6%) and SOCCSKSARGEN (29.4%) regions recorded the highest percentage of nutritionally at-risk cases. LACTATING MOTHERS’ * The survey also studied the prevalence of malnourishment among lactating mothers. Results revealed that 11.9% of lactating mothers are underweight, while 17.7% are overweight. * Based on age group, 11.8% of lactating mothers less than 20 years old are underweight, 11.9% of lactating mothers more than 20 years old are also underweight. «Being overweight is also a problem among lactating mothers. About six percent (6.7%) of mothers less than 20 years old and 18.8% of mothers over 20 years old are overweight. « The study shows that the poor health condition of pregnant women puts them at risk —they deliver low birth weight babies or have negative pregnancy outcomes like stillbirths and miscarriages, a montis REFERENCES: A; x 7" FNRI National Nutrition Survey hulp:H/www fa0.orglag/agn/nutrition/phl_en.stm accessed August 2013 Mttp://www.rappler.comimove-ph/33688-survey-pregnant-mothers- nutrition-risk accessed August 2013Pa ASSESSMENT OF THE NUTRITIONAL STATUS OF PREGNANT WOMEN Mario Benito F. Bautista, MD, FPOGS, FPSUOG — Recommendations 1. Recommend assessing and documenting body mass index (BMI) of all pregnant women at the initial visit. (Level II-2, Grade B) 2. Pregnant women found to have a BMI < 20 kg/m? should be referred for nutrition counseling and considered at increased risk for fetal growth restriction. (Level II-2, Grade B) 3. Recommend screening for inappropriate weight gain for all women at every visit during pregnancy. (Level III, Grade C) 4, Pregnant women with inadequate weight gain at 28 weeks who are unresponsive to nutritional treatment need additional surveillance. Consider consultation/ referral to advanced prenatal care provider. (Level II-2, Grade C) 5. Individualized weight gain should be based on pre-pregnancy weight. (Level III, Grade C) 6. Nutritional assessment should include dietary, medical and socioeconomic history, clinical evaluation and laboratory methods. (Level III, Grade C) 7. For women who are on either side of the normal BMI, signs of nutritional deficiencies should be sought out. (GPP) Supporting Statements Pregnant women who experience inappropriate weight gain may be at risk for a number of complications. Excessive weight gain may increase the risk for macrosomic infants, shoulder dystocia, operative delivery and postpartum obesity. Inadequate weight gain is associated with preterm delivery, intrauterine growth restriction (IUGR), and low birth weight. Screening for inappropriate weight gain allows for early intervention to prevent these complications. Obesity is defined as a BMI of 30 kg/m? or greater and affects approximately one-third of adult women. Obese women are at increased risk for several pregnancy complications (sce ‘Obesity’). a a No systematic reviews or controlled trials of screening for inappropriate weight gain during pregnancy were identified. Recommendations endorsed by the Institute of Medicine (TOM), American Academy of Pediatricians (AAP) and American College of Obstetrician and Gynecologists (ACOG) (1995) have been based on the pre-pregnancy BMI. Women with a BMI below 19.8 kg/m? are recommended to gain 12.7 to 18.2 kg (28 to 40 Ib), women with a BMI of 19.8 to 26.0 kg/m? are advised to gain between 11.4 and 16.0 kg (25 to 35 Ib), and women with a high BMI (26.0 to 29.0 kg/m?) are recommended to gain between 6.8 and 9.1 kg (15 to 20 Ib). Women who have a very high BMI (i.¢,, above 29 kg/m) are advised to gain at least 6.8 kg (15 Ib) (IOM, 1990).! Maternal BMI of less than 20 kg/m’ at the start of pregnancy is associated with increased prevalence of preterm delivery and low-birth-weight infants.” This retrospective analysis did not look at weight gain over the course of pregnancy on these outcomes.? For inadequate weight gain, only balanced protein-energy supplementation may be safe and effective. High-protein and isocaloric protein-energy supplementation may be associated with untoward fetal effects. For excessive weight gain, protein-energy restriction is not significantly effective and-may adversely impact birth weight." Excessive weight gain may be associated with adverse changes in fetal or neonatal weight and minor maternal morbidity, but these data are difficult to separate from data concerning baseline obesity (Kelly, et al, 1997).? Maternal overweight condition increases the risk of antepartum stillbirth, especially (erm antepartum stillbirth, whereas weight gain during pregnancy was not «associated with risk (Stephansson, et al, 2001).>° UVIDENCE TABLE Recommendations Sources of evidence | LE | QE | SR 1 | Routine assessment of BMI at Sebire, et al, 2001 1-2 | Fair B first visit 2 | Nutrition counseling for Kramer, 2000 112 | Fair | B inadequate weight gain or Sebire, et al, 2001 initial BMI < 20 kg/m? 4 | Routine screening for | inappropriate weight gain at each visit | The practical evaluation of weight gain at 24 to 28 weeks 5 | Individualized weight gain 10M, 1990 Il | Fair | C based on pre-pregaancy weight _ evel of Evidences QE Quality uf lividence; SR = Strength of Recon Kelly, et al, 1997 Il | Fair | C Kelly, et al, 1997 1-2 | Fair | C 7Pregnant women with inadequate weight gain at 28 weeks who are ‘unresponsive to nutritional treatment need additional surveillance. Consider consultation/referral to advanced prenatal care provider. The clinical evaluation should include pre-pregnancy weight, anthropometric measurements like the height, weight and calculation of her BMI. Looking for signs and symptoms of nutritional deficiencies should be routine. Lastly the hemoglobin and hematocrit should always be interpreted in the light of the nutritional status of the woman.’ REFERENCES: 1. Institute of Medicine (U.S.). Subcommittee on Nutritional Status and Weight Gain during Pregnancy. Institute of Medicine (U‘S.). Subcommittee on Dietary Intake and Nutrient Supplements during Pregnancy. Nutrition during pregnancy: part I, weight gain: part I[, nutrient supplements. Washington, DC: National Academy Press; 1990. 1-222 p. 2. Sebire NJ, Jolly M. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord August 2001;25(8):1175-82 3. Kelly A, Kevany J, de Onis M, Shah PM. A WHO collaborative study of maternal anthropometry and pregnancy outcomes. Int J Gynaecol Obstet 1997;5():1-15. 4, Kramer MS. Isocaloric balanced protein supplementation in pregnancy. Eur J Clin Nutr 2000;54(2):180. 5. Kramer MS. Energy/protein restriction for high weight-for-height or weight gain during pregnancy. Cochrane Database Syst Rev 2000;(2):CD000080. 6. Kramer MS. High protein supplementation in pregnancy. Cochrane Database Syst Rev 2000;(2):CD000105. 7. Maternal Nutritional Assessment. AJPH Supplement 1973;63. RECOMMENDED WEIGHT GAIN IN PREGNANCY Mary Jocelyn Yu-Laygo, MD. Recommendations I, Preconception: 1. The pre-pregnancy weight should be within the desirable weight range based on the body mass index (BMI). (Level Ill, Grade B) 2, For obese women who are planning a pregnancy, pre-conception assessment and counseling is strongly encouraged. (Level III, Grade B) 11. Antepartum 3. The recommended weight gain should be based on pre-pregnancy BMI. (Level II-2, Grade B) 4, The total weight gain and the gain rate for multiple gestation is higher compared with singleton pregnancies. (Level III, Grade B) III. Postconception 5. No recommendation is made for specific weights during the postpartum period. Having a normal weight gain during pregnancy can avoid excess maternal weight retention during the postpartum period and having higher weight in their subsequent pregnancies. (Level III, Grade B) Supporting Statements: \, Preconception The Committee to Reexamine the Institute of Medicine’s (IOM) Pregnancy Weight Guidelines concludes that the factors that affect pregnancy begin before conception. The mother's weight at the startof the pregnancy is one of the most important modifiers of pregnancy weight gain.! The 2009 IOM and National Research Council Guidelines for obese women supported weight loss before pregnancy to improve menstrual functioning, ovulation and metabolic profile and reduce infertility? Table 1. Weight Classification according to BMI (IOM) Category BMI (kg/m?) Underweight <18.5 Normal weight 18.5-24.9 Overweight 25.0-29.9 Obese (all classes) > 30.0 The World Health Organization (WHO) recommends a new cut-off value for Asian populations as follows:> Table 2. Weight Classification according to BMI for Asian Populations 18.5 ~ 22.9 > 23.0 Normal BMI(normal weight) High BMI (overweight) Il. Antepartum Table 3. Recommended total and rate of weight gain by pre-pregnancy BMI Classificationof Prepregnancy BMI. Classification of Prepregaancy BMI Total Weight | Rates of Weight gain BMI {kg/m’) Gain (ibs) 2" and 3" trimester (ibs/week)* ‘Underweight < 18,50 28-40 1 1.3) Normal 18.50-24,99 25-35 T (08-1) Overweight 25.00-29.9 15-25 06 (0.50.7) Obese (all classes) 30.00 11:20 *Calculations assume a 0.5-2 kg (1.1-4.dlbs) weight gain in the I" trir 10 Tie Pregnant women who started pregnancy as underweight or who have not gained enough during pregnancy tend to have increased risk for preterm. infant and low birth weight baby.? Mothers who gain too much weight during pregnancy have higher incidence of caesarean deliveries, preterm birth. They ‘retain too much weight even after pregnancy and have higher weight in their subsequent pregnancies? Gestational weight gain below the IOM recommendations among overweight pregnant women does not appear to have a negative effect on fetal growth or neonatal outcomes. In several studies, overweight women who gained 2.7 — 6.4 kg (6 — 14 Ib) had similar fetal growth, perinatal and neonatal outcomes, and less postpartum weight retention as overweight women who pained weight within the currently recommended IOM range.** For the overweight and even the obese pregnant women who are gaining less than the recommended amount but have appropriately growing fetus, no evidence exists that encouraging increased weight gain to conform with the current 1OM guidelines will improve maternal or fetal outcome." Obese women are at increased risk for several pregnancy complications therefore preconception assessment and counseling are advised. Obstetricians should encourage obese patients to undertake weight reduction program (diet, exercise and behavioral modification) before attempting pregnancy. Initial prenatal visit should involve the calculation of the BMI and recommendations ‘orappropriate weight gain reviewed at the first visitand periodically throughout pregnancy. Bariatric surgery is an option before pregnancy however they are al increased risk of deficiencies of iron, vitamin B12, folate, vitamin D and calcium? The 2009 IOM recommendation provide the following guidelines ieparding twin pregnancy:"” tube 4, Recommended weight gain for Twin pregnancy Prepregnancy BMI Total Weight Total Weight WMI g/m?) Gain (in Ibs) Gain(in kg) Normal 185.249 37-54 16.8-24.5 “verweight | 25.0-29.9 31-50 14.1-22.7 hese 230 25-42 113-191 There was insufficient information for the OM committee to develop provisional guidelines for underweight women with multiple fetuses. A consistent rate of weight gain is advisable, A gain of 1.5 Ib/week during the a2”! and 3“ trimesters has been associated with a reduced risk of preterm and low-birth weight delivery in twin pregnancy. In triplets, the overall gain should be around 50 pounds with a steady rate of gain of approximately 1.5 Ib/week throughout the pregnancy."’ The American College of Obstetricians and Gynecologists (ACOG) recommends that women with multiple pregnancies consume about 500 more calories a day than usual.'? Table 5. Recommended weight gain in multiple pregnancy in Ibs!” [LMtuttiptes Ytrimester | 2*trimester | 3%trimester | Total Twin 5-10 15-20 10-20 35-45, Triplet 5-10 20-30 20-25 45-60 Quadrupiet 10-15 25-35 20-25 50-75 7 Quintuplet 20 | 2535 | 25-30 65-100 Ul. Postconception Assistance through the postpartum period should be provided to help women return to their prepregnancy weight within the first year following delivery.! REFERENCES: 1. Rasmussen KM, Yaktine AL. Weight Gain During Pregnancy: Reexamining the Guidelines. Institute of Medicine May 2009 2. Rasmussen KM, Abrams B, Bodnar LM, Butte NF, Catalano PM, et al. Recommendations for weight gain during pregnancy in the context of the obesity epidemic. Amer Coll Obstet Gynecol 2010;116(5):1191-95. 3. Rasmussen KM. Chair of IOM Committee Report May 2009. Pregnancy Weight Gain: What To Expect. Updated February 2013. 4, Schieve LA, Cogswell ME, Scanlon KS. An empirical evaluation of the Institute of Medicine's pregnancy weight gain guidelines by race. Obstet Gynecol 1998;91:878-84. 5, Langford A, Joshu C, Chang JJ, Myles T, Leet T. Does gestational weight gain affect the risk of adverse maternal and infant outcomes in overweight women? Matera Child Health J 2011;15:860-5. 6. Nobr EA, Vaeth M, Baker JL, Sorensen TI, Olsen J, et al. Combined associations of prepregnancy body mass index and gestational weight gain 12 x cea with the outcome of pregnancy. Am J Clin Nutr 2008;87:1750-9. Cedergren M. Effects of gestational weight gain and body mass index on obstetric outcome in Sweden. Int J Gynaecol Obstet 2006;93:269-74. Beyerlein A, Schiessl B, Lack N, von Kries R. Optimal gestational weight gain ranges for the avoidance of adverse birth weight outcomes: a novel fh Am J Clin Nutr 2009;90:1552-8. approach. Oken E, Kleinman KP, Belfort MB, Hammitt JK, Gillman MW. Associations of gestational weight gain and short-and longer-term maternal and child health outcomes. Am J Epidemiol 2009; 170:173-80. Committee Opinion No. 548 — Committee on Obstetric Practice. Weight gain during pregnancy. Amer Coll Obstet Gynecol 2013. Multiples: twins, triplets and beyond/ March of Dimes. wwwmarchoféimes. com//multiples-twins-triplets-and-beyond. Aspx ‘Weight Gain with Multiple Pregnancy. Excerpted from The Everything Twins, Triplets, and More Book copyright @2005, F+W Publications Inc. Low Maternal Weight Gain. www.cdph.ca.gov/.../wic-PEPB-131-low maternal weight gain 7- 09.pdfRECOMMENDED ENERGY AND NUTRIENT INTAKE Joseph U. Olivar, MD, FPOGS Mary Jocelyn Yu-Laygo, MD, FPOGS Recommendations I. Preconception 1. The recommended total energy intake of a woman should be based on physical stature and physical activity level. (Level 113, Grade ©) i intake based on 2. For an underweight woman, the total energy int activity level are stated in the table below. (Level [1-3, Grade C) Activity Calories (Keal/kg/day) Sedentary 35 Light activity 40 Moderate activity 45 3. For women within the normal weight range, the total energy intake based on activity level are stated in the table below. (Level ‘IE-3, Grade C) ee ‘Activity Calories (Keal/kg/day) Sedentary 30 Light activity 35 Moderate activity 40 4. For overweight women, the total energy intake based on activity level are stated in the table below. (Level J-3, Grade C) Activity Calories (Keal/kg/ day) Si 25 sedentary Light activity 30 Moderate activity as |_Moderate ony et _nememiienseesna-1n 5. The computation of the total energy intake is done using the desirable body weight (DBW) multiplied by the calories. (Level IL-3, Grade C) IL Prenatal 6, For pregnant women in the 2™ and 3" trimesters, 300 kcal/day is added to the total computed daily energy intake. (Level Il, Grade QO 7. For women with multifetal pregnancy, 450 kcal/day is added to the total computed daily energy intake. (Level II, Grade C) UI. Postpartum 8. Lactating women require an additional 500 kcal/day over the basal energy requirements during the first 6 months and likewise in the last second 6 months if lactation is continued. (Level III, Grade C) Supporting Statements The revised edition of the dietary standards is changed from |tccommended Dietary Allowances (RDA)" to “Recommended Energy and Nutrient Intakes (RENI)” to emphasize that the standards are in terms of auitrients, and not foods or diets.'!- RENIs are defined as levels of intakes of vnergy and nutrients which, on the basis of current scientific knowledge, are sidered adequate for the maintenance of health and well-being of nearly ill healthy persons in the population. For most nutrients, they are equal to the sverage physiologic requirement (AR), corrected for incomplete utilization or ‘ictary nutrient bioavailability, plus two standard deviations (SD), or twice si assumed coefficient of variation (CV), to cover the needs of almost all ‘dividuals in the population. In the case of nutrient for which data on AR ue insufficient, the RENI is an “adequate intake” (AJ) which is based on the « -perimentally observed average intake of healthy individuals. For energy, iw recommended intake level is set at the estimated average requirement of tclividuals in a group (no SD), since intakes consistently above the individual’s tcjuirements lead to overweight or obesity. Additional requirements during pregnancy are based on estimates of amounts laid down in fetal and maternal tissues, while those for lactating awomen, are based on amounts secreted in breast milk. These amounts are then added to the requirements of nonpregnant, nonlactating women. The recommended energy requirement of an individual is the level of energy intake from food that will balance energy expenditure when the individual has a body size and composition, and level of physical activity, consistent with long-term good health as well as allow for the maintenance of economically necessary and socially desirable physical activity (FAO/WHO/ UNU, 1985). The Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST) recommend the following reasonable energy allowance based the following activity levels.’ ‘Activity Keal/kg DBW /day Bed rest but mobile (hospital patients) 275 [ Sedentary (mostly sitting) 30.0 Light (dress maker, nurse, physician, driver) 35.0 Moderate (heavy housework, manwal labor) 40.0 Very active (regular swimming, farming) L 45.0 Modified from FNRI-DOST 200% To measure the DBW, one can use the Tannhauser’s Method. Step 1. Measure the height in centimeters:' Example: If the woman is 5 feet 4 inches tall, her height in centimeters is 162.56cm 5 feet 4 inches = 64 inches 66 inches x 2.54 centimeters = 162.56cm Height Step 2: Estimate the DBW Deduct 100 from the computed height in centimeters DBW 162.56 - 100 62.56 kg a: a To apply this DBW to Filipino stature, deduct 10% DBW 62.56 kg - 10% of 62.56 62.56 kg - 6.25 = 56.31 kg or 56 kg Thus, a woman who stands 5 feet 4 inches tall will have an estimated BW of 56 kg on which her caloric needs will be computed. The nutritional status (Nutriture) of the pregnant woman is then dctermined through the body mass index (BMI). Classification BMI (kg/m!) ‘Principal cut-off points ‘Additional cut-off points for Asians Underweight | <18.50 <18.50 Normal 18.50-24,99 18.50-22.99 23.00-24.99 ‘Overweight >25.00 >25.00 Obese 230.00 230.00 Adopted from WHO, 1995, WHO, 2000, WHO 2008 The additional cut-off points are used for interventions such as weight «lussification to determine the kcal/kg/day assignment to be used for Asians.? The desirable BMI is 18.5-22.9 according to the Department of Health Manual on Prevention of Noncommunicable Diseases.' The FNRI, on the «ther hand, specified the mean desirable BMI for women at 20.8 (22 for men) tor purposes of computing the caloric needs. The DBW can also be computed liom this using the formula below.’ DBW = Desirable BMI x Height (m2) Far Pregnant Patients The total energy requirement (TER) per day does not change for the I" \vimester. There is however an additional (from the normal requirement) 300 heal/day for the 2™ and 3“ trimesters of pregnancy (TER/day for 2™ and 3 irimester of pregnancy ® normal requirement + 300 kcal/day). An additional _requirement of 450 keal/day is added for those with multifetal pregnancy. Additional (from the normal requirement) 2 g or 9 g of protein per day is needed for 2™ trimester and 3” trimester of pregnancy, respectively. The normal adult protein requirement for Filipinos is 1.1 g/kg DBW. The protein requirement in g/day is multiplied by 4 keal/g to obtain the caloric value of protein per day. This amount is deducted from the TER of the day to obtain the nonprotein calories (NPC). ‘The NPC is then divided to 70% carbohydrates and 30% fats. The keal of carbohydrates and of fats is divided by 4 kcal/g and 9 kcal/g, respectively for carbohydrates and fats to obtain grams of carbohydrates and fats. Another method of dividing the TER for the day is via percentage distribution as follows: Carbohydrates — 60% of the TER = kcal of carbohydrates Proteins ~ 15% of the TER = kcal of proteins Fats — 25% of the TER = kcal of fats To Obtain the Dietary Prescription for the Pregnant Patient ‘This comes by having a prescription as below: Rx TER/day Carbohydrates Proteins Fats (kcal/day) (ingrams/day) —_(in_grams/day) {in grams/day) The above prescription will require the use of the FOOD EXCHANGE LIST for proper translation of the dietary prescription into the different meals for the day, The responsibility of converting the caloric prescription and translating these into meals falls into the hands of dieticians and nutritionists. The recommended food pyramid for pregnant and lactating mothers can be referred to in the appendix. REFERENCES 1. FNRI/DOST, Training Manval for Health Workers on Healthy Lifestyle: ‘An approach for the prevention and control of non-communicable diseases. ‘Nutrition education and counseling for population groups Module 3. FNRI- DOST. 2009 2. WHO expert consultation. Appropriate body-mass-index for Asian populations and its implications for policy and intervention strategies, Lancet 2004;157- 163. 3. FNRI-DOST, Food exchange lists for meal planning, FNRI-DOST. 1994 aia el MICRONUTRIENT SUPPLEMENTATION: IRON, FOLIC ACID AND IODINE Joseph U. Otivar, MD, FROGS FPSMFM Recommendations 1, Iron Supplementation 1. Daily oral iron and folic acid supplementation is recommended as part of the antenatal care to reduce the risk of low birth weight, maternal anemia and iron deficiency.” (Level I, Grade A) , Table 1. Suggested scheme for daily iron supplementation in pregnant women" Supplement composition | Iron: 30-60 mg of elemental iron” Folic acid: 400 yg (0.4 mg) Frequency ‘one supplement daily Duration throughout pregnancy; iron supplementation should begin as early as possible’ ‘Target group all pregnant adolescent and adult women "Table 2. Percentage and amount of iron in some commonly used iron compounds'’ Preparation Iron compound | Elemental iron (mg) per tablet ig) pes Ferrous fumarate ‘ 200 fe oo Ferrous gluconate 300 36 Ferrous sulfate (7H,0) 300 60 Ferrous sulfate, anhydrous 200 zn Ferrous sulfate, exsiccated (1H,0) 200 a 2. In settings where the prevalence of anemia is < 40% : %, 30-60 mg of clemental iron with 400 11g (0.4 mg) may be used for ¢ minimum of ¢ ponte. Aralding Aton supplementation during the 1* trimester pregnancy avolds the risk of a; ti iti tee as iggravating nausea and vomiting.3. In settings where anemia in pregnant women is a severe public health problem (40% or higher), a daily dose of 60 mg of elemental iron with 400 ug (0.4 mg) of folic acid is preferred over a lower dose (30 mg). "Supplementation is started as early as possible. If there is nausea and yomiting during the 1* trimester, iron supplementation is started after 14 weeks and consumed for a minimum duration of 6 months. Iron supplementation is continued up to 3 months postpartum. (Level II-1, Grade B) 4. If a woman is diagnosed with anemia in a clinical setting, she should be treated with daily iron (120 mg of elemental iron) and folic acid (400 pg or 0.4 mg) supplementation until her hemoglobin concentration rises to normal.? She can then switch to the standard antenatal dose to prevent recurrence of anemia. (Level H-1, Grade B) 5. Where iron supplements containing 400 pg of folic acid are not available, an iron supplement with less folic acid may be used. Supplementation with less folic acid should be used only if supplements containing 400 pg are not available. (Level IE-1, Grade B) 6. Iron supplementation is doubled (120 mg of elemental iron) if she is large, has twin fetuses, begins supplementation late in pregnancy (minimum of 6 months supplementation cannot be achieved) and has been taking iron irregularly. (Level IT-1, Grade B) 7. Imaddition to iron and folic acid, supplements may be formulated to include other vitamins and minerals according to the United Nations Multiple Micronutrient Preparation" to overcome other possible maternal micronutrient deficiencies. (Level II-1, Grade B) 8. In malaria-endemic areas, provision of iron and folic acid supplements should be implemented in conjunction with measures to prevent, diagnose and treat malaria.’ (Level IT-1, Grade B) Neural Tube Defect and Folic Acid Supplementation 9. For women at high risk of having a child with a neural tube defect (NTD) (such as those with a personal history of NTD, a prior child with a NTD, or those on anticonvulsant medications), give a supplementation of 5 mg folic acid daily prior to conception, throt ut it i coy Pregnancy and during the postpartum period. (Level I, 10. For all other reproductive-a; i " Do ged women, give 0.4 to 1 mg folic acid daily prior to conception, throughout pregnancy, and ‘turing the Postpartum period. (Level I, Grade A) Jubie 3. Recommendations for folic acid supplementation in Pregnancy Option Population Folic Acid Dose Santen A” | Patients with health | (1) Folate-rich a Sanna = risks, family history | foods, with daily least 3 months ofNTD, high-risk | supplementation before conception and ic group with 5 mg folic acid_| continuing until 10-12 wecks postconception (2) Daily (2) From 12 weeks supplementation preconception and with 0.4-1 mg folic | continuing throughout acid pregnancy and the postpartum period (4-6 reeks or as [ong as - : : astfeeding continues) B alien wit m0 Good diet of folate- [Atleast 23 ont » persona lth rich foods with daily | before conception and risks, planned supplementation throughout pregnancy pregnancy with 0.4-1 mg folic | and the postpartum acid period (4-6 weeks or as Jong as breastfeeding — continues) c Panenis with istry Folatesich foods, | Counsel Sam folic poor compliance | with daily acid supplementati wit sapedications. supplementation prevent cirh detec ° nal lifestyle with ic ac iti seco ite 5 mg folic acid eas sinonal health diet, no consistent _ birth control, and | possible teratogenic substance use \stapted from Wilson RD et a (1. Iodine Supplementation 11, The recommended 250 ng daily intake is met by the diet of Filipino Prepregnant, pregnant and lactating mothers. No additional supplementation ts required. (Level I!-1, Grade B) 2Supporting Statements L Iron Supplementation The updated Cochrane systematic review'* assessing the benefits and harms of iron supplementation in healthy pregnant women were reviewed for this guideline. The review compared the daily provision of iron supplements alone or in combination with folic acid or other micronutrients with no intervention, placebo or versus the use of the same supplements but without iron (e.g. only folic acid) among pregnant women living ina variety of settings, including malaria-endemic areas. Overall, women taking daily iron supplements were less likely to have low birth weight babies compared with controls (average relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.97, 11 studies) and the mean birth weight was 30.81 g greater for those infants whose mothers received iron during pregnancy (95% CI 5.94-55.68, 14 studies). ‘There was no significant effect on preterm birth or neonatal death. Daily iron supplementation reduced the risk of maternal anemia at term by 70% (RR 0.30, 95% CI 0.19-0.46, 14 trials) and iron deficiency at term by 57% (RR 0.43, 95% CI 0.27-0.66, 7 studies), but it had no significant effect on the risk of infections during pregnancy QR 1.16, 95% CI 0.83-1.63, 2 studies). Women receiving iron had 8.88 g more hemoglobin per liter at or near term (95% CI 6.96-10.80, £9 studies) than those who did not receive iron. At the same time, women who received iron supplements tended to report more frequently side effects (RR 2.36, 95% CI 0.96-5.82, 11 studies) and were at increased risk of high hemoglobin concentrations (i.e. greater than 130 mg/L) during the 2" and 3" trimesters of pregnancy (RR 2.26, 95% CI 1.40-3.66, 10 studies). The intervention seems to be effective among populations with different prevalences of anemia, and in settings described as malaria- endemic, when compared with settings where malaria is sporadic or absent, and regardless of whether the supplementation was initiated earlier or later than 20 weeks of gestation or whether the daily dose of elemental iron was 30 mg or less, 31-59 mg, or 60 mg or higher. However, women receiving 60 mg of iron or more were more likely to have hemoglobin concentrations above 130 g/L and report side effects (RR 6.52, 95% CI 1.13, 37.69) than dose women receiving 30 mg per day or less (RR 1.01, 95% CI 0.84-1.21). ‘The overall quality of the evidence for iron supplementation versus no iron was moderate for low birth weight, preterm birth, maternal a anemia at term and maternal iron deficiency at term. The evidenc ; D a L e was of low quality for birth weight, neonatal death, congenital anomalies, maternal death, maternal severe anemia, and infections during pregnancy; whereas it was of very low quality for side effects. Neural Tube Defects and Folic Acid Supplementation” Folate (vitamin B,) is an essential nutrient that is requi deoxyribose nucleic acid (DNA) replication and as a substrate oe of enzymatic reactions involved in amino acid synthesis and vitamin metabolism. Demands for folate increase during pregnancy because it is also required for growth and development of the fetus. Folate deficiency has been associated with abnormalities in both mothers (anemia, peripheral neuropathy) and fetuses (congenital abnormalities). Dietary supplementation with folic acid around the time of conception has long been known to reduce the risk of NTDs in the offspring.!7'8 The term folate” is typically used as a generic name for the group of chemically related compounds based on the folic acid structure. Folate, or vitamin B, is thought of as one of the 13 essential vitamins, It cannot be synthesized de novo by the body, and must be obtained either from diet or supplementation. Folic acid is a synthetic dietary supplement that is present in artificially enriched foods and pharmaceutical vitamins, Neither folate nor folic acid is metabolically active. Both must be teduced to participate in cellular metabolism. L-5-methy]-tetrahydrofolate (L-methylfolate) is the predominant micronutrient form of folate that circulates in plasma and that is involved in biologic processes, Benefits of Folic Acid Supplementation During Pregnancy 1. Periconceptional folic acid supplementation protects against ual ‘seal anomalies, including NTD and congenital heart 2 Folate is one of the key nutrients for active erythropoiesis because of its role in DNA synthesis. In settings of low folate, anemia will likely ensue. During pregnancy, the expected blood volume expansion requires an additional 450 mL of erythrocyte.” Without iron and folic acid supplementation, the pregnant woman suffers from anemia. 3. Indirect evidence suggests that folate may indeed be important in the timing of labor. In one observational study,2! a shorter duration of pregnancy has been associated with low serum folate level. aIl. 4. Because folic acid has been shown to regulate trophoblast invasion, 22 it is biologically plausible that folate deficiency may interfere with the early stages of placental development leading to complications like preeclampsia, abruption placenta, fetal growth restriction, and even fetal death later in gestation. Yodine Supplementation Universal salt iodization (USI) remains the key strategy to eliminate jodine deficiency disorders. According to World Health Organizaiton (WHO),* although programs to control iodine deficiency, such as salt iodization, have been effective for decades, iodine deficiency remains a major threat to the health and development of populations around the world, particularly among pregnant and lactating women and preschool children in low-income countries. Iodine deficiency occurs when iodine intake falls below recommended levels and the thyroid gland is no longer able to synthesize sufficient amounts of thyroid hormone. The resulting hypothyroidism (goiter) can occur at any stage of life, but the most devastating consequences of iodine deficiency take place during fetal development and childhood, with stillbirth, miscarriages, poor growth, and cognitive impairment. Although cretinism is the most extreme manifestation, of considerably greater significance are the more subtle degrees of mental impairment that lead to poor school performance, reduced intellectual ability, and impaired work capacity. Iodine deficiency is the world’s greatest single cause of preventable brain damage, and this fact is the primary motivation behind the current worldwide drive to eliminate iodine deficiency. The WHO Technical Consultation’® proposed the daily recommended nutrient intake (RNID) for iodine for pregnant and lactating women. . Table 4. The daily RNI for iodine proposed for pregnant and lactating women should not to be exceeded. Population Recommended iodine Level of iodine beyond intake which no added health (ug day) benefit can be expected (ug day) Pregnant women. 250 > 500 Lactating women 250 =a 24 —_— Most of the iodine absorbed by the body is eventually excreted in the urine, although there may be small losses in feces. Although the concentration of iodine in the urine of an individual can vary diurnally and from day-to-day, the concentration of iodine in spot or casual samples of urine taken from an adequate sample of schoolchildren has been shown to be a reliable biochemical marker of recent dietary intake by the general population of the same area when measured using recommended methods.” For this reason, it is proposed that the median urinary iodine (UI) concentration was the best indicator to use in population surveys to assess the iodine nutrition of pregnant and lactating women, and of young children less than 2 years old. Table 5, The median or range in UI concentrations used to categorize the iodine intake of pregnant women, lactating women and children less than 2 years old, Population Group Median UI Category of iodine Concentration intake (ug) Pregnant women = 150 Insufficient 150 - 249 ‘Adequate 250 — 499 More than adequate 2500 No added health benefit _ expected Lactating women* <100 Insufficient = 100 ‘Adequate “In lactating women, the figures for median UF are lower than the iodine requirements because of the iodine excreted in the breast milk. Where iodine deficiency is a public health problem, countries can be divided broadly into three categories based on national salt iodization coverage. * Category 1. Countries or regions within countries in which iodine deficiency is under control in a sustained way because salt iodization has been effective for more than 2 years. This is indicated by the fact that iodized salt is consumed by more than 90% of households and that iodine nutrition is optimal according to WHO criteria, including in pregnant women and children less than 2 years old. Category 2. Countries or regions within countries in which not all salt is iodized, salt iodization is not regulated, or the distribution of iodized salt is uneven or has lapsed so that less than 90% of the households consume iodized salt and iodine nutrition is inadequate. * Category 3, Countries or regions within countries in whichiodized salt is either not available or available only to a negligible extent, either because the distribution system is weak or because an emergency has severely disrupted iodized salt supplies. In this category, it is assumed that less than 20% of the households consume iodized oil and iodine nutrition is inadequate. Note: 1. In Category 1, the population is considered to be iodine sufficient, so pregnant and lactating women have no need for iodine supplements, nor do children aged 0-24 months old require them. Indeed, the amount of iodine stored in the thyroid of a child at birth, when added to the iodine intake from the mother’s breast milk, is likely to be sufficient to meet a child’s need for iodine for the first 6 months of life and even up to 24 months of age. ' 2. The Philippines, according to WHO report in 2007," has a median Ul concentration of 200-299 ug. It belongs to Category 1 with risk of iodine- induced hyperthyroidism. REFERENCES: 1. WHO/CDC. Worldwide prevalence of anemia 1993-2005. WHO Giobal Database on Anemia. Geneva, World Health Organization, 2008 2. WHO/UNICEF/UNU. Iron deficiency anemia assessment, prevention, and control: a guide for program managers. Geneva, World Health Organization, 2001 , 3. Hemoglobin concentrations for the diagnosis of anemia and assessment of severity, Vitamin and Mineral Nutrition Information System, Geneva, World Health Organization, 2011 ; 4, International Anemia Consultative Group. Report of the 2001 International ‘Anemia Consultative Group Symposium. Why is iron important and what to. do about it: a new perspective. Washington, DC, INACG Secretariat, 2002:1- 5. Tovoft B, Jimenez E, Smith JB. Double burden of iron deficiency in infancy and low socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years. Arch Pediatr Adolescent Med 2006, 160:1108-1113. 6, Murphy JF et al, Relation of hemoglobin levels in first and second trimesters me. Lance, 1986, 3:992-995. ; 1. Stork Maternal hemoglobin concentiation and birth weight. Am J Clin Nutr );71 Suppl. 5):$1285-S1287. | 8. ent Arena Consultative Group. Guidelines for the eradication of iron deficiency anemia. A report of the International Nutritional Anemia Consultative Group. Washington, DC, The Nutrition Foundation, 1977:1-29. 9. Chaparro C. Essential delivery care practices for maternal and newborn health and nutrition, Informational Bulletin. Washington, DC, Pan American Health Organization, 2007:1-4. 10. ii 20. 21. 23. 24. 25. 26, 27. Bothwell TH. Iron requirements in pregnancy and strategies to meet them. Am J Clin Nutr 2000; 72(Supp!. 1):8257-S264. Stoltzfus RJ, Dryfuss M. Guideline for the use of iron supplements to prevent and treat iron deficiency anemia. International Nutritional Anemia Consultative Group. Iron deficiency anemias: Report of a WHO study group. Geneva, World Health Organization, 1959 WHO Technical Report Series, No. 182 WHO. Guideline: Daily iron and folic acid supplementation in pregnant women, Geneva, World Health Organization, 2012. UNICEF, WHO, UNU. Composition of a multi-micronutrient supplement to be used in pilot programmes among pregnant women in developing countries: report of a United Nations Children’s Fund (UNICEF), World Health Organization (WHO), United Nations University (UNU) workshop held at UNICEF Headquarters, New York, July 9, 1999, New York, United Nations Children's Fund, 2000 Global malaria report 2011. Global Malaria Programme. Geneva, World Health Organization. Pefta-Rosas, ct al. Daily oral iron supplementation during pregnancy, Cochrane Database Syst Revs, 2012, Issue 12, Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub4 Pitkin RM. Folate and neural tube defects. Am J Clin Nutr 2007:85:285S-288S. De Wals P, Tairou F, Van Allen MI, et al. Reduction in neural-tube defects after fotic acid fortification in Canada. N Engl J Med. 2007; 135-142. Greenberg JA, Bell SJ, Guan Y, Yu YH. Folic acid supplementation and pregnancy: More than just neural tube defect prevention. Revs Obstet Gynecol 2011;4(2). Pritchard JA, Adams RH. Erythrocyte production and destruction during pregnancy. Am J Obstet Gynecol 1960;79:750-757. Bodnar LM, Himes KP, Venkataramanan R, et al, Maternal serum folate species in early pregnancy and risk of preterm birth. Am J Clin Nutr 2010;92:864-871 Williams PJ, Bulmer JN, Innes BA, Broughton Pipkin F. Possible roles for folic acid in the regulation of trophoblast invasion and placental development in normal early human pregnancy. Biol Reprod. 2011;84:1148-1153. Wilson RD, Johnson JA, Wyatt P, et al; Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada and the Mother Risk Program. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can 2007;29: 1003-1026. de Benoist B, McLean E, Anderssen M, Rogers L. Iodine deficiency in 2007: Global progress since 2003. Food and Nutrition Bulletin, 2008;29(3). Anderssen M, de Benoist B, Delange F, Zupan J. Prevention and control of iodine deficiency in pregnant and lactating women and in children less than 2-years-old: conclusions and recommendations of the Technical Consultation, WHO 2007. WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency Disorders and Monitoring Their Elimination. A Guide for Programme Managers. (WHO/NHD/01.1), 2nd ed. Geneva: World Health Organization. http:// www.who.int/nut/Documents/assessment_idd_monitoring_elimination. ‘The Recommended Energy and Nutrient Intakes for Filipinos: FNRI and RENI for vitamins and minerals. 27MICRONUTRIENT SUPPLEMENTATION: VITAMINS, MINERALS AND ELECTROLYTES Joseph U. Olivar, MD, FROGS FPSMFM, FPSUOG Ramon T. Reyles, MD, FPOGS, FPSMFM, FPSUOG Recommendations I. Vitamins and Minerals Preconception | 1, The recommended daily nutrient intake (RNI) of vitamins, minerals and trace elements during the preconception period are shown in the following table: (Level II-1, Grade B) Table 1. Preconception RNI by Age Range of Water Soluble Vitamins. in | VitC | Thiamine | Riboflavin | Niacin | Folate B6 B12 orass (mg) (mg), (mg) (mg) | (ug) | (mg) | (ue) | 13.15 65, 10 10 14 400. 1.2 2.4 16-18 70 id di 14 400, 12 24 19-29 0 Ld Ll 14 400 1.3 24 30-49 70 Ll Li 14 400, 12 24 Data rom Recommended Energy and Nutrient Intakes for Filipinos 2002 Table 2. Preconception RNI by Age Range of Fat Soluble ‘Age in Vit. A Vit.D VitE Vit. K years ss) tug) (aug) vs) 13-15, 450 5 12 49 16-18 450 # 12 50. 19-29 500 5 12 SL 30-49 500, 3 12 51 Data from Recommended Energy and Nutrient Intakes for Filipinos 2002 Table 3, Preconception RNI by Age Range of Minerals and Trace Elements i st Tron Jodine | Magne- Phos- | Zinc | Sile- Fluo- ‘Manga- ae = (rg) (us) sium phorus | (mg) nium ride nese (ng), (mg) ue)_| (mg) | (mg) _| 13-15 1000 2 4350 220 1250 79 3 25 16 16-18 1000 27 150 240 1250 7 36. 25 16 19.29 750 27 150. 205 700 45. 18 30-49 750 27 150, 205 700_ 4s | Data from Recommended Energy and Nutrient Intakes for Filipinas 2002 Prenatal 2 The recommended daily intake of vitamins, minerals and trace elements during prenatal period are shown in the following table: (Level IT-1, Grade B) ‘ible 4, RNI of Water Soluble Vitamins by Trimester | Trimester | Vit. C | Thiamine | Riboflavin | Niacin | Folate | Vit. | Vite of (mg) (mg) (mg) (mg) (ns) Be | BI2 Pregnancy (mg) | (ug) First 80. 14 17 18 soo | 19 | 26 Second 80 14 17 18 600 | 19 | 26 | third 80 14 LT 18 600 [| 19 | 26 ! uta from Recommended Energy and Nutrient Intakes for Filipinos 2002" _ Huble 5 RNI of Fat Soluble Vitamins by Trimester Trimester Vit. A Vit. D Vit. E Vit. K of Pregnancy (ug) (ug) (mg) (ug) First 800 5 12 51 Second 800 5 2 SL | Third 300 5 12 51 11a from Recommended Energy and Nutrient Intakes Jor Filipinos 200 ht 6, RNI of Minerals and Trace Elements by Trimester Trimester | Calcium | Iron | Iodine [ Magne- | Phos- | Zinc | Sele- | Fluo- Manga- col Prege (mg) | (mg) | (ugy sium | phorus | (mg) | nium | ride | nese nancy (amg) | (mg) op | my | (mg) dust 800 27 200 20S 700 Sa 35 25 20 Second: 800 M 200 205 700 6.6 35 25 20 Thad 800 38 200 205 700 96 35 aS 2.0 | from Recommended Energy ard Nutrient Intakes for Filipinos 2002" Postpartum 3. The recommended daily intake of vitamins, minerals and trace elements during the posttpartum period are shown in the following table: (Level II-1, Grade B) joie 7. RNI of Water Soluble Vitamins lactation period \actation | Vit.C] Thiamine | Riboflavin | Niacin | Folate | Vit.B6 | Vir. BI2 i ee (mg) | (mg) | ua) | re) | ug) | emonths | 15 us 7 7 500 20 28 a r | months | '00 is w 17 500 2.0 28 ‘ata from Recomended Energy and Netrient Intakes for Filipins 2007"Tuble 8. RINI of Fat Soluble Vitamins by lactation period Lacta Vit. K Vit. A Vit. D Vit. E “ (ug) (us) (mg) us) 1* 6 months 900 5 12 51 2™ 6 months 900 5 12 51 Data from Recommended Energy and Nutrient Intakes for Filipinos 200: Table 9. RNI of Minerals and Trace Elements by Lactation Period. Fluoride | Mange- i i - | Phos- | Zinc | Sele- Lactatic Caldum | Yon | Iodine | Mag- e fang sean (zag) | (mug) | (ug) | nesium | phorus | (mg) | nium (mg) re (me) | (mg) (yg) te 750 a7 | 200 | 250 | 700 | "5 | 40 25 26 6 months a hs 750 30 | 200 | 250 | oo | WS | 40 25 26 ‘mont Data from Recommended Energy and Nutrient Intakes for Filipinos 200: Tl. Water and Electrolytes ini i i i f the following is eet the minimum physiologic requirements o! ‘ female condition the table below gives the recommended minimum daily water and electrolyte intake. (Level II-1, Grade B) Table 10. Recommended Minimum Daily Water and Electrolyte Latake. Water Sodium | Chloride Potassium (mL) (ng) (mg) (mg) Adult > 18) 2500 500 750 2000 Pregnant + 300 500 750 2000 ving 750 2000 st + 750- 500 1*6 months 1000 ‘Data From Recommended Energy and Nutrient Intakes for Filipinos 2002 Supporting Statements J. Vitamins and Minerals amin C vente 1989 Recommended Dietary Allowance (RDA) which was based on the amount that would maintain. acceptable serum vitamin levels in Filipino men and women, is retained. These values are higher than the Food and Agriculture Organization/ World Health Organization (FAO/WHO) RNI which is based on intake associated with adequate liver stores and associated with antioxidant protection, Thiamin (Vitamin B1) The Institute of Medicine, Food and Nutrition Board (IOM-FNB) (1998) and FAO/WHO recommendations (2002), which are both based on the average requirement for normal erythrocyte transketolase (ETK) activity and urinary thiamine excretion and twice an assumed coefficient of variation (CV) of 10% to cover the needs of 97.5% of individuals in the group, are adopted. The IOM-FNB and FAO/WHO-derived estimates, adjusted for Philippine reference body weights, are similar to the 1989 RDAs which were then based on a local study done in the ’60s on 10 adult Filipinos,?# Riboflavin (Vitamin B12) The RNI is derived from the requirement estimate of the IOM-FNB (1998) which is based on the amount of riboflavin intake to maintain riboflavin status of satisfactory erythrocyte glutathione reductase activity ({EG-AC) level, as criterion of adequacy. These intake levels, which conform with the FAO/WHO recommendations (2002), are close to the 1989 recommendations which were based on requirement estimates obtained from Filipino adults consuming rice-based diets. Niacin The FAO/WHO (2002) and IOM-FNB (1998) estimates, which are based on the amount of niacin intake corresponding to an excretion of N’methyl-nicotinamide that is above the minimal excretion at which deficiency symptoms occur, are also adopted for Filipinos. These values are lower than the 1989 RDA because no correction is made for bioavailability. The bioavailability of niacin is not considered in setting the RDA because of “lack of data on which to base the correction value” (IOM-FNB), 1998.!° Pyridoxine (Vitamin BO) The RNI for adults of 1.3 mg/day adopted by the FAO/WHO (1998) is based on the amount required for normalization of the tryptophan load test. Cobalamin (Vitamin B12) The IOM-FNB recommendation of 2.4 g/day is based on the amount needed to maintain adequate hematological status.’ BMNae . * ‘The FAO/WHO (2002) and IOM-FNB (1998) recommendations for Filipinos. The requirement estimates of these two poles are deve from the amount of folate that will maintain adequate folate stores based on erythrocyte folate and plasma omonene levels. To meet the new higher recommendations, higher intakes o! vegetables and fruits, which are among the best sources of folate, are recommended.'*5 are recommended intake levels for vitamin A correspond to the safe levels of intake based on the average amounts of vitamin A required to maintain a given body-pool size in well-nourished individuals. aa adults, the RNI is equivalent to the estimated average requirement plus 2SDs. The Committee therefore adopts the higher recommendation given by the FAO/WHO (2002).'? nD at FAO/WHO and IOM-FNB recommendation of 5 g/day for i itamin D intake necessary to maintain adults is based on the amount of vitamin D intal vitamin D status as indicated by a satisfactory level of serum 25-hydroxy- vitamin D (25-OH-D). The recommended intake levels, according to the IOM-FNB, will cover the needs of adults “regardless of exposure to sunlight”. tamin E ete safe level of intake for vitamin E for adults is 12 mg/day. “4 ” i d since the value is The term “safe” rather than “recommended” is use: derived from data for the United States (US) population whose mean PUFA intake can be presumed to be higher than that of Filipinos since the major source in the Filipino diet is the medium-chain saturated fat- rich coconut oil. High intakes of PUFA are typically accompanied by increased vitamin E intakes.'’* itamin K . ; ” The FAO/WHO (2002) Expert Panel's recommendation set a daily intake of 51 pg/kg as basis for setting RNI. The panel also advised that all breastfed infants should receive vitamin K supplementation at birt according to nationally established guidelines, cae RNIs for Filipinos are allowances based on theoretical calcium requirement estimates which considered low animal protein intake levels. 32 — The FAO/WHO (2002) provided these estimates for possible application to countries where the animal protein intake per capita is around 20-40 g only compared with 60-80 g in developed countries,'2 Iron The recommended intake for iron is based on the amount of dietary iron needed to meet absorbed iron requirements, This would correspond to the amount needed to cover menstrual losses for women of reproductive age, adjusted for bioavailability of iron in typical complete meals consumed by Filipinos, The Philippine RNI for iron is based on FAO/WHO (2002) estimates for basal losses, local data on menstrual losses and on bioavailability, iron absorption rates in the average Filipino diets, food consumption surveys, and in-vitro studies on non-heme iron availability from rice-based diets. ‘The consumption of iron-rich foods and iron-fortified foods is recommended for women. from adolescence onwards, Iron supplementation is recommended to meet the needs of pregnant and lactating women, The estimated iron requirement during the 1" trimester of Pregnancy and the 1* six months of lactation are actually lower than the requirement for menstruating nonpregnant, nonlactating women. However, the recommended intake for nonpregnant and nonlactating women are adopted to allow for build- up of iron stores during these periods.'? Jodine The FAO/WHO (2002) recommendations which concur with those of the IOM-FNB are adopted for all population groups, except pregnant and lactating women. The recommended intake level for adults corresponds to the intake necessary to maintain plasma iodide level above the critical limit likely to be associated with the onset of goiter. It corresponds to the daily iodine urinary excretion of 100 yg/L.!4 Phosphorus The RNIs are based on the intake required to maintain serum inorganic phosphate within the normal range. Selenium The FAO/WHO recommendation (2002) of 31 ug/day corresponds to the level of intake that provides adequate reserves based on satisfactory Jevels of plasma selenium, and of glutathione peroxidase activity.'* Magnesium The FAO/WHO recommendation (200) is based on a requirement of 4 mg/kg body weight/day for adults to achieve a Positive magnesium balance.'*Manganese The IOM-FNB recommendations (2002) is based on the median intake of Americans derived from the US Food and Drug Administration (FDA) Total Diet Study from 1991-1997. Zine ‘The requirement for adults is based on the intake that will meet the daily absorbed zinc requirements of 0-072 and 0.059 mg/kg for adult males and females, respectively, and adjusted for bioavailability of 30% following the recommendation of FAO/WHO (2002).'* Fluoride {OM-FNB recommendations are based on “adequate intakes” that have been found to prevent dental caries.° Il, Water and Electrolytes The recommended water intake for adults under average conditions of energy expenditure and environmental exposure is 2500 mL based on a recommended intake of 1 mL per kcal of energy expenditure (NRC, 1989). Tt may be increased to 3735 mL (1.5 mL/keal) to cover variations in activity level, sweating, and solute load. Thirst is normally a good indicator of the amount of extra water needed to meet the daily requirement, except for older persons whose thirst mechanism may be impaired. For infants, a recommended intake of 1.5 mL/kcal of energy expenditure, which corresponds to the water-to-energy ratio in human milk, has been established as a satisfactory level for the growing infant. The minimum requirements for electrolytes do not include allowance for large, prolonged losses from the skin through sweat. There is no evidence that higher intakes confer any health benefit. For adults (> 18 years old), desirable intakes of potassium may considerably exceed the minimum recommendations (~3500 mg). For children (< 18 years old) a growth rate of 50" percentile reported by the National Center for Health Statistics and averaged for males and females is assumed (IOM-FNB, 1989).'* REFERENCES: 1. Food and Agricultural O:ganization/World Health Organization (FAO/ WHO). Human vitamin and mineral requirements, Report of a joint FAO/ WHO expert consultation, FAO/WHO. 2002. a4 cociimmiomsmennass Barba C, Cabrera MI. Re i : {1 Recommended energy and nutrient intakes for Filipinos tek saa institute of Medicine, Food and Nutrition Board (IOM-FNB) 1997, Dietary references intakes for calci ences. int m, phosphorus, magnesium, vi fluoride. National Academy of Sciences, Washington DC “amin Dy and Jastute of Medicine, Food and Numition Board, ((OM-FNB) 2001 Dictar reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, ane, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc, ional Academy of Sciences, Washington DC. ranean. Institute of Medicine, Food and Nutriti i : >» Ee 1 Nutrition Board, (IOM-FNB). 1998. Di ference intakes for thiamin, riboflavin, niacin, vitamin Be folate deat B12, panthotenic acid, bioti i Wainpanotenic acid, bitin, and choline, National Academy of Sciences, Institute of Medicine, Food and Nutrition Board, ((OM-FNB). 2000. Dietary reference intakes for vitamin C, vitamin E, selenium, and 101 ation Vita , Selenium, and carotenoids. NationalAPPENDIX 1 : LTH BURDEN OF UNDERNUTRITION: HEA RISKS FOR THE MOTHER, FETUS AND CHILD Rosa Ninez Velante-Nierva, MD, FPOGS, FPSMFM, FPSUOG Undernutrition can be classified as either: Malnutrition | Micronutrient deficiency iti ild is the single leading cause ¢ — Undernutrition of the mother and child is t! of health loss worldwide and the underlying cause of more than one-third (3-5 million) of ail , ; « Nutritional insults during critical periods of gestation may have a permanent effect on progeny throughout postnatal life and beyond.£*” Health Risks for the Mother * Women who are undernourished (with body mass index [BMI] of < 18.5 kg/m?) at the time of conception are unlikely to improve their nutritional status during pregnancy, when their bodies have additional demands due to the growing fetus. * They may fail to gain sufficient weight during pregnancy and have higher risks of 67 4‘ ity Maternal morbidity and mortalit ; Anemia — with subsequent increased risk of preterm birth Infection Poor pregnancy outcome Health Risks for the Fetus and Newborn Baby i itis Iting in tow birth trauterine growth restriction (IUGR) fetuses resu! > . a (< 28 kg) infants. Undernourished women may lack the nutritional stores required to support embryonic and fetal fro and in turn adversely affect the development of the fetuw in the later stages of pregnancy. Maternal undernutrition also reduces fetal growth in part by impairing placental development and function. Fetal hormones following maternal undernutrition emerges as a major contributor also to. suboptimal fetal growth and development. Programmed changes induced by altered fetal hormone activity in- utero can affect newborns and eventually yield disordered responses in adults.'34 Evidence has shown that there is a greater incidence of IUGR births among women who are underweight or stunted prior to conception, or who fail to gain sufficient weight during pregnancy, compared to women with normal weight and weight gain. The meta-analysis reported that a pre-pregnancy BMI below 20 kg/m? Was associated with a significantly greater risk for TUGR, teiative to a BMI above 24 kg/m®, with an overall odds ratio (OR) of 1.8 (95% confidence interval [CT] 1.7-2.0). In developing countries, it has been estimated that poor nutritional status in Pregnancy accounts for 14% of fetuses with TUGR, and maternal stunting (chronic restriction of growth in height indicated by a low height-for-age) may account for a further 18% TUGR in turn could increase the risk for fetal and neonatal mortalities.67?? Birth defects Underdevelopment of some organs Cretinism Brain damage Nealth Risks for the Child in the Long Term * — Substantial epidemiological evidence links low birth weight, a rough indicator of IUGR, with increased risk of infectious morbidity and mortality later in life, * Malnourished girls are at risk in becoming yet another malnourished mother, thus contributing to the intergenerational cycle of malnutrition. Women who had been severely undernourished during the I* trimester gave birth to (on average) normal birth weight infants, but those infants gave birth to smaller offspring in the following generation. * Children who are stunted or born with TUGR are also shown to complete fewer years of schooling and carn less income as a?adults, hindering their cognitive growth and economic potential. Maternal malnutrition results in precocious maturation of the fetal hypothalamic pituitary axis, and these effects are associated with a delay, if not a permanent deficit in cognitive processes, motor skills, attention deficit disorders and school performance of affected children. Failure of the fetus to develop optimally because of nutritional deprivation does not lead to immediate brain dysfunction. Rather, manifest only as predispositions until a time when the system is stressed by unusual circumstances. Lower income, poor health, and reduced access to proper nutrition then continue to impact the health of children born into the next generation, establishing a repetitive cycle.'6°""? There is a solid research evidence that low birth weight infants with stunting, severe wasting in the first two years of life cause irreparable/irreversible harm by impeding physical growth and if followed by rapid weight gain in the 3-5 year age range could increase the risk of chronic/ metabolic diseases later in life. When a fetus is malnourished in the early (and later) stages of pregnancy it may also have a lifelong metabolic programming effect which predisposes the baby to chronic health conditions later in life. Metabolic disorders including: 0 Type 2 diabetes mellitus - men who were born at a very low weight were seven times more likely to develop diabetes mellitus compared to men born at a high weight Dyslipidemia Impaired energy homeostasis Obesity Cardiovascular disorders ~ substudies have shown that birth weight parallel trends with biological risk factors for cardiovascular disorders coco Exposure to maternal malnutrition in the 1* trimester of pregnancy was associated with an increased risk of obesity and coronary heart disease, while malnutrition in the 2™4 or 3 trimester was associated with type 2 diabetes mellitus 0 Immune-mediated and inflammatory diseases — maternal malnutrition may also have a direct influence, as evidenced by nutrient-driven epigenetic changes to developing T regulatory cells and subsequent risk of allergy or asthma. Early alterations to the immune system, resulting from either nutritional deficiencies or excesses, have broad relevance for immune-mediated diseases and chronic inflammatory conditions, * Other long term health risks: Chronic kidney failure Chronic obstructive pulmonary disease Polycystic ovarian syndrome Organ dysfunction or abnormal! development of organs including the testes ovaries, brain, heart, liver, small intestine and mammary gland Breast cancer Osteoporosis Psychiatric disorders including schizophrenia Heaith Risks Associated with Micronutrient Deficiency It was subsequently recognized that poor growth results not only from a deficiency of protein and energy but also from inadequate intake of micronutrients that are vital during rapid growth phases." Maternal health risks « — Tron-deficiency anemia in turn increases the risk of: o Maternal morbidity and mortality such as death from peripartum hemorrhage o Preterm birth o Neurological dysfunction * Vitamin A deficiency — is associated with night-blindness. * Vitamin B12 deficiency is associated with the following risks for pregnant women: o Anemia © Neurological complications * Vitamin K deficiency is associated with increased clotting time which presents particular risks during delivery * — Jodine deficiency is associated with 0 Abortion o — Stillbirth © = Zine deficiency is associated with: a Preeclampsia aoo Premature rupture of membranes o Preterm delivery Magnesium deficiency increases the risk of: 0 Pre-eclampsia o Preterm delivery Vitamin C deficiency may play a role in preterm delivery etiology?" Fetal and neonatal health risks Folate status in early pregnancy depends on preconception nutrition. Marginal maternal folate intake status can impair cellular growth in the fetus or placenta. Folate deficiency in early pregnancy is associated with neural tube defects and has been linked to low birth weight, IUGR, and preterm birth. Iron deficiency which causes maternal anemia is associated with IUGR and low birth weight. Iron deficiency can also affect the absorption of folate. As folate absorption is most critical in the early stages of pregnancy, ensuring adequate preconception iron status is also important. Calcium deficiency — restricts fetal skeletal development Maternal vitamin D deficiency is associated with fetal rickets Maternal iodine deficiency is associated with the following complications in the infant: ia 0 Congenital abnormalities Increased perinatal mortality Neurological cretinism Mental deficiency Myxodymatous cretinism (a type of cretinism in which physical development is impaired) and dwarfism (very short stature) o Psychomotor effect (affected movement) eoceo Maternal zinc deficiency is associated with: o IUGR © Congenital abnormalities REFERENCES: 10. i. 12. Maternai and Child Undernutrition, WHO, 2013 United Nations System, Standing Committee on Nutrition, 2009 Abu-Saad K, Frase D, Maternal Nutrition and Birth Outcomes Accepted January 8, 2010, mae Belkacemi L, Nelson M. Maternal Undernutritic » Ne E ion Influences Placental-. Development, Society for the Study of Reproduction, Inc, cat “ tobe Matra Nurton Daring Preganey and Latton ont plication: Beating La, Reled Conplanentary Feting, and Maternal Marion Program nd the id it Ch Surival Calan ond Rescurs (CORE) Marton Working romp Impact of Maternal Nutrition on Fetal HEALTH NUTRITION Report, December 2010 ODYSSEY = PRENATAL Black RE, Maternal and Child Undernutrition ingen hi Study Gi Me nutrition: building momentum for impact. Lancet Bae Me Metered ae child Black RE, Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lav 2008;371(9608):243-260, ° fame Miese-Looy G, Rollings-Scattergood J, Yeuns pucrces : 3 i Yeung A. Long-term health tutrton during pregnance. Teratology. University of Melbourne, 2008. tee Executive Summary Series Steering Cc ittee: ir mary ig Committee: Black RE, Adair L, Ah i 1B The Lane's Series on Maternal on Child Undernaton 20080 nn 8 Blossner M, de M, -Ustun A, il M, de Onis M, Pruss , Campbell-Lendrum D, Corvalan C, ais Quantifying the health impact at national and local ioels Woodend rn : : ‘eat Org Nutrition for Health & Dev. Protection of the Human Environment National Institute for Health and Clinical Excelh : in 1 lence. Improving the health and ‘ution of proqant and breasfeting other and cen osicme hoaschois [eited 2009, August 22], Available from: www. Nice. org.uk/PHOL1. . arAPPENDIX 2 CONSEQUENCES OF OBESITY AND OVERNUTRITION IN PREGNANCY Joyceline Noemi I. Silao, MD, MHA, FROGS, FPSMFM Effects of Overweight and Obesity on Fertility and Conception . The presence of excess adipose tissue in obesity affects sex hormone availability due to its ability to store lipid steroids such as androgens. Estrogen production and the concentration of sex hormone-binding globulin in the blood are correlated with various measures of body fat.” There also seems to be a strong association between obesity and insulin resistance, which is thought to reduce fertility.” Excessive weight gain at younger ages is associated with earlier menarche and both high absolute weight and change in weight are associated with menstrual problems. Obesity in adolescence and young adulthood, as opposed to during infancy, is more strongly associated with amenorrhea, oligomenorthea, and long menstrual cycles.” There is some evidence of an increased time to conception for obese compared with normal-weight women, particularly among cigarette smokers,” Obesity is a strong risk factor for polycystic ovarian syndrome (PCOS), which results in menstrual irregularities and chronic anovulation.” Higher rates of infertility are associated with central distribution of fat with higher waist- to-hip ratios.” Estimated 25% of ovulatory infertility in the United States” Three fold increase in miscarriage” Lower implantation and pregnancy rates, as well as higher miscarriage rates and increased pregnancy complications in women who undergo assisted reproduction’ a2 The Effect of Overweight and Obesity on Pregnancy Outcomes Maternal Complications During Pregnancy Diabetes Mellitus The risk of gestational diabetes mellitus (GDM) is increased twofold in overweight women; eightfold in the severely obese (body mass index [BMI] > 40).’ An Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS), found that obese women were at higher risk of developing GDM than women with a normal BMI (relative risk [RR] 2.10, 95% confidence interval [CI] 1.17-3.79, p = 0.01)® In a population study of 16,102 women (Weiss, et al), the incidence of GDM was 6.3% in the obese group (odds ratio [OR] 2.6) and 9.5% in the morbidly obese group (OR 4.0) compared to 2.3% in the control group. Ina UK study (Sebire, et al), women with a BMI greater than 30 kg/m? are 3.6 times more likely to develop GDM compared with women with a normal BMI. Ina large Danish study consisting of 8092 women (Rhode, et al), the odds of developing GDM also increases with BMI (OR | for BMI < 25 kg/m?; OR 3.4 for BMI 25-29 kg/m’; OR 15.3 for BMI > 30 kg/m?) In retrospective cohort study by Bhattacharya, et al (24,241 nulliparous women delivering singleton babies in Aberdeen between 1976 and 2005), the prevalence of type I diabetes mellitus was higher in the morbidly obese group (1.9% vs. 0.2% normal group)." In overweight and obese women hyperinsulinemia is seen in higher levels.” Hypertension Gestational hypertension is more common in overweight and obese pregnant women.’ In a population based screening study, Weiss, et al found an increased incidence of gestational hypertension in the obese and morbidly obese group, 10.2% and 12.3%, respectively compared to that of the normal weight group of 4.8%." Prevalence of pre-eclampsia is approximately twice in overweight women (BMI 25-30) and approximately three times in obese women (BMI e” 30). Pre-eclampsia is more common in obese women with GDM than in women without GDM,’ The retrospective cohort study by Bhattacharya, et al (24,241 nulliparous women delivering singleton babies in Aberdeen between aa1976 and 2005) revealed that both pre-eclampsia and gestational hypertension increased linearly with increasing BMI, resulting in an adjusted OR of 7.2 (95% CI 4.7-11.2) for pre-eclampsia and 3.1 (95% CI 2.0-4.3) for gestational hypertension in the morbidly obese category when compared to those of normal BMI." ‘An Australian Collaborative Trial (ACTS), found that compared. with women with a normal BMI, the risk of developing pregnancy- induced hypertension (PIH) was higher in overweight (RR 1.94, 95% CI 1.43-2.65, p < 0.0001) and obese women (RR 3.19, 2% CI 2.36, 4.30, p < 0.0001). The RR for severe PIH was 2.76 5 Yo CI 1,35-5.64, p = 0.01) in overweight women and 4.00 (95% CI 1.93-8.30, p = 0.0002) in obese women. Obese women hada RR for developing preeclampsia of 2.99 (95% CI 1.88-4.73, p < 0.0001). 9 Increased risk of pre-eclampsia (3.9 vs 13.5% in the obese group). Excessive weight gain was associated with higher rates of pre- eclampsia in overweight women (p = 0.016; excessive weight gain in normal group [9.7%], 24.2% in the overweight group and 35.4% i up). . a ee iow of maternal BMI and risk of preeclampsia by O’Brien, et al, showed that the risk of pre-eclampsia typically doubled with each 5 to 7 kg/m? increase in pre-pregnancy BML Bhattacharya, et al found a 3 times higher tisk of pre-eclampsia in obese (BMI 30-39.9 kg/m*) and a 7 times higher risk in morbidly obese (BMI > 40 kg/m”) primigravid women."* Maternal risk for thromboembolism is increased (0.05 vs 0.12% in the obese group). A retrospective analysis of data obtained from a validated maternity database system in the North West Thames Region (London) showed a higher prevalence of thromboembolism in overweight women (0.07%) and in obese women coe %) compared to 0.04% prevalence in the normal weight women.’ Maternal Complications in the Peripartum Period Cesarean Section . Cesarean deliveries and associated morbidities are more common among obese women. A large multicenter trial of overweight and obese women showed. a cesarean delivery rate of 30% for nulliparous women with a BMI less than 30, 34% for those with a BMI of 30- 34.9, and 48% for women with a BMI of 35-39.9.7 Overweight and obese women were more likely to undergo a aa cesarean section overall (RR 1.42, 95% CI 1.18-1.70, p = 0.0002 and RR 1.63, 95% CI 1.34-1.99, p < 0.0001, respectively), likewise, have an emergency cesarean section (RR 1.48, 95% CT 1.19- 1.83, p = 0.0004 and 1.77, 95% CI 1.40-2.23, p < 0.0001, respectively).* Compared to women with normal BMI, overweight and obese women are more likely to require a cesarean section for the following indications: 1) fetal distress (RR 1.40, 95% CI 1.03-1.91, p = 0.03 for overweight women and RR 1.71, 95% CI 1.23-2.40, p = 0.002 for obese women); 2) failure to progress (RR 1.50, 95% CI 1.10-2.06, p = 0.01 for overweight women and RR 1,84, 95% CI 1.31-2.58, p = 0.0004 for obese women), and ; 3) preeclampsia (RR 3.47, 95% CI 1.39-8.65, p = 0.01) for obese women.* The frequency of both elective (8.5% vs 4%) and emergency cesarean section (13.4% vs 7.8%) were almost twice as high for the very obese women compared with the normal BMI group. Maternal obesity was found to influence the route of delivery, independent of co- morbid conditions such as macrosomia, nulliparity, induction or diabetes mellitus.? In the cohort of Bhattacharya, et al, elective and emergency cesarean sections were both more common in the morbidly obese group. However, only emergency cesarean section rates were significantly different in the other BMI categories. In contrast to women with normal BMI, women who were morbidly obese had a 3 times (95% CI 1.7-6.1) higher risk of having an elective cesarean section, and 2.8 times (95% CI 2.0-3.9) higher risk of an emergency cesarean section. The adjusted OR for emergency cesarean section increased with increasing BMI, with a protective effect seen in underweight women OR 0.7 (95% CI 0.6-0.8).'* Stotland, et al conducted a retrospective cohort study of singleton, term, nulliparous, nondiabetic women with cephalic presentations delivered at a single university hospital. Excessive weight gain during pregnancy was found to be an independent risk factor for cesarean birth, even when birth weight ‘was not excessive. Women gaining above the Institute of Medicine (IOM) guidelines were more likely to have a cesarean birth, even if birth weight was less than 4,000 g. In the multivariate analysis, women with excessive weight gain had an OR of 1.40 (95% CI 1.22- 1,59) for cesarean birth.'"* (Level IJ-2) Overweight or obese women have more postoperative complications after cesarean delivery, such as wound infection/breakdown, excessive blood loss, deep venous thrombophlebitis, and postpartum endometritis than do normal-weight women.” The length of labor also is longer in overweight and obese women.’ 45Overweight and obese women were more likely to undergo induction of labour, than women with a normal BMI (RR 1.33, 95% CI 1.13-1.57, p = 0.001 and RR 1.78, 95% CI 1.51-2.09, p < 0.0001, respectively). In these subset of women, the indication was more commonly hypertension (RR 1.93, 95% CI 1.21-3.08, p = 0.01 and RR 3.96, 95% CI 2.57-6.11, p < 0.0001, respectively). Induction for diabetes-related complications were likewise more frequent (RR 4.93 for overweight, 95% CI 1.28-18.99, p = 0.02 and RR 11.6 for obese, 95% CI 3.20-41.69, p = 0.0002).* The frequency of induced labor was found by Bhattacharya, et al to increase with rising BMI. It was highest in the morbidly obese with OR of 1.8 (95% CI 1.3-2.5)."" Higher rate of failed induction were found in obese women (7.9 vs 10.3 vs 14.6% with increasing BMI). Obesity increases risk of operative delivery (20.7% vs 33.8% in the obese and 47.4% in the morbidly obese group).’ In comparison to women with normal BMI, there was also a higher rate of obstetric complications in women who were overweight at their first antenatal visit such as shoulder dystocia (1 vs 1.8 and 1.9% with increasing BMI; p < 0.021) and third/fourth degree lacerations (26.3 vs 27.5 and 30,8% with increasing BMI; p < 0.001) (Kabiru, et al)? In another study of 126,080 deliveries, after excluding women with hypertensive disease and diabetes mellitus, there was a three-fold increased risk in failure to progress in the first stage of labor and a higher cesarean section rate of 27.8 vs 10.8% (OR 3.2) in the obese group compared with the normal weight group. The increase in emergency cesarean sections in these obese women may be related to an increased number of large for gestational age infants, suboptimal uterine contractions and increased fat disposition in the soft tissues of the pelvis leading to dystocia during labor.’ A hospital-based perinatal database showed that among women with a BMI > 35 undergoing a primary cesarean delivery, the overall wound complication rate was 12.1%; with a greater risk in vertical skin incision (34.6 vs 9.4%).? Postoperative respiratory complications such as pneumonitis are more common. Early mobilization, aggressive chest physiotherapy and adequate pain control are essential components of effective postoperative care.” The risk of postpartum anemia was increased due to the higher prevalence of postpartum hemorrhage and abdominal deliveries among obese women. Macrosomia may also cause significant 46 postpartum blood loss by causing perineal rupture and hemorrhage and lengthening of the period of bloody vaginal discharge after delivery.” The retrospective cohort study by Bhattacharya, et al, (24,241 nulliparous women delivering singleton babies) found a linear increase in mean postpartum blood loss with increasing BMI. The risk of postpartum hemorrhage, (more than 500 mL for vaginal delivery and 1000 mL for cesarean delivery), was significantly higher only in the obese category (BMI 30-34.9 kg/m’), OR 1.5 (95% CI 1.3-1.7). Other studies have reported conflicting results. Sebire, et al observed a 70% increase in postpartum hemorrhage while Bianco, et al found no such difference in the incidence,"? In the puerperium, endometritis, Postpartum hemorrhage, prolonged hospitalization and wound infections appear more frequent in obese women. Compared with the normal BMI group, the risk of postpartum hemorrhage rises with increasing BMI. It is about 30% and 70% more frequent for women with moderately and highly raised BMI, respectively.’ The high pre-pregnancy BMI and weight gain between pregnancies reduce vaginal birth after a single low transverse caesarean delivery (VBAC) (54.6 vs 70.5%; p = 0.04). Adjustment for confounding factors such as ethnicity, labor induction, gestational age at delivery and infant birth weight were done. In a study of 1,213 women, obese women were 50% less successful when attempting a trial VBAC compared with underweight women (p = 0.043)? Birth Outcomes There is conflicting evidence regarding the association between maternal obesity and congenital malformations in the offspring. A systematic review and meta-analysis by Stothard, et al, however, showed that maternal obesity is associated with an increased risk of a range of structural anomalies, although the absolute increase is likely to be small. Obese mothers were at increased odds of pregnancies affected by neural tube defects (NTD) (OR 1.87, 95% CI 1.62-2.15), spina bifida (OR 2.24, 95% Cl 1.86-2.69), cardiovascular anomalies (OR 1.30, 95% CI 1.12-1.51), septal anomalies (OR 1.20 95% CI 1.09-1.31), cleft palate (OR 1.23, 95% CI 1.03-1.47), cleft lip and palate (OR 1,20, 95% CI 1.03-1.40), anorectal atresia (OR 1.48, 95% CI 1.12-1.97), hydrocephaly (OR 1.68, 95% CI 1.19. 2.36), and limb reduction anomalies (OR 1.34, 95% Cl 1.03+1.73), ayA significant reduction in the risk of gastroschisis was seen among obese mothers (OR 0.17, 95% CI 0.10-0.30). This is most likely due to correlation with maternal age, since low maternal age is an established risk factor for gastroschisis and BMI isin itself associated with age. Evidence were not robust to potential bias when it came to the risks of anencephaly among obese mothers, and for NTD and cardiovascular anomalies among overweight mothers." ‘The meta-analysis of Stothard, et al included the large population- based study of Waller, et al. In the latter, data from the Nationa! Birth Defects Prevention Study of index pregnancies between October I, 1997 and December 31, 2002 were analyzed. Results showed that mothers of offsprings with spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia and omphalocele were significantly more likely to be obese than mothers of controls, with OR ranging between 1.33 and 2.10. Mothers of offspring with gastroschisis were significantly less likely to be obese than mothers of controls. Maternal obesity was associated with significantly increased risk for offspring with spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele, with ORs ranging from 1.33 to 2.10. Maternal obesity was also associated with a borderline increase in risk for cleft palate and a strong and significantly decreased risk for gastroschisis (adjusted OR 0.19, 95% CI 0.10-0.34). Maternal overweight status was associated with a significantly increased risk for heart defects, hypospadias and omphalocele (ORs ranging from 1.13-1.50) and a borderline increase in risk for craniosynostosis (adjusted OR 1.28, 95% CI 1.00-1.64). Mothers who were underweight had no significant increase or decrease in the risk for these birth defects, except for ‘a modest increase in risk for cleft lip with or without cleft palate (adjusted OR 1.35, 95% CI 1.04-1.76). Exclusion of maternal diabetes mellitus resulted in a decrease in OR slightly toward the null for 7 birth defects — spina bifida: OR 2.09; (95% CI 1.63-2.70); heart defects: OR 1.26 (95% CI 1.11-1.43); anorectal atresia: OR 1.21 (95% CI 0.89-1.63); hypospadias: OR 1.21(95% CI 0.93-1.58); limb reduction defects: OR 1.16 (95% CI 0.89-1.52); diaphragmatic hernia: OR 1.41 (95% CI 1.01-1.97); and omphalocele: OR 1.27 (95% CI 0.83-1.96). However, the adjusted OR for gastroschisis remained about the same (OR 0.20; 95% CI 0.11-0.37).! One case-control study (Waller, et al) found that women with a BMI > 31 kg/m? had a significantly increased risk of delivering infants with NTD and defects of the central nervous system, great vessels in the heart, ventral wall and other intestinal defects. The association between spina bifida and obesity was also confirmed in a study which concluded that for every incremental unit increase (kg/m?) in BMI, the risk of NTD increased by 7%. There is also an increase in other malformations such as omphalocele (three-fold), cardiac anomalies (especially septal defects, two-fold) and multiple defects among infants of the overweight and obese group. Other studies, however, have not found an association between maternal obesity and an increased risk of congenital malformation in offsprings” The higher prevalence of congenital anomalies in offsprings of obese women suggests that maternal adiposity alters development in the sensitive embryonic period. In a study of 10,240 US women enrolled in the National Birth Defects Prevention Study, 1997-2002, the OR of structural birth defects ranged from 1.3t0.2.1 among obese compared with non-obese mothers. NTDs are approximately twice as high with spina bifida being more common than anencephaly. Other birth defects more frequent in offspring of obese women include oral clefts, heart anomalies, hydrocephaly, and abdominal wall abnormalities. The relationship between maternal obesity and NTDs persists after controlling for self-reported folic acid intakes. This ‘Suggests that other factors such as poor glycemic control contribute to congenital anomalies in obese women,’ Intrauterine Fetal Demise: . Maternal obesity recently emerged as a risk factor for intrauterine fetal death (1UFD) and stillbirth. In the United Kingdom perinatal lard as increased to 5.7 per 1000 in the obese group versus In a prospective population-based cohort study (n=3,480), antepartum stillbirth increased three-fold in morbidly obese women compared with women with a normal BMI. In a large Swedish population-based cohort study (n=167,750), the risk of late fetal death increased consistently with increasing prepregnancy BMI. The risk of late fetal death among nulliparas with normal BMI was doubled, among overweight tripled and among obese quadrupled that among lean women. Among the parous women, the risk of late fetal death was significantly increased only among obese women. For early neonatal death, the risk was doubled in nulliparous but not in parous women with a higher BMI. The Swedish Medical Birth Register, on analysis with adjustments for multiple variables showed that overweight (BMI 25-29.9 kg/m’) and obese (BMI e” 30 kg/m’) women had a two-fold increase in the risk of term antepartum stillbirth. Weight gain during pregnancy however, was not associated with an increased risk of antepartum stillbirth, In 49a Danish study involving 24,505 singleton pregnancies, maternal obesity was associated with more than double the risk of stillbirth (OR 2.8) and neonatal death (OR 2.6) compared with women of normal weight. No single cause of death explained the higher risk of stillbirth in children of obese women. However, higher proportions of stillbirths caused by unexplained intrauterine death and fetoplacental dysfunction were found in children of obese women compared with children of non-obese women (BMI < 30 kg/m), There was no apparent cause of neonatal death.” In a Canadian study of more than 84,000 women, a maternal pregravid body weight more than 68 kg increased the risk of fetal death by 2.9-fold after adjusting for age, diabetes mellitus, and hypertensive disorders. A systematic review of articles on tisk factors for antepartum stillbirth likewise reported a threefold increased risk for stillbirth among obese women after adjusting for age, parity, maternal diabetes mellitus, and hypertension as well as a number of social factors.” Preterm delivery; The incidence of preterm birth tends to decrease, rather than increase, with increasing pregravid BMI once medical inductions are accounted for in the analysis.’ The retrospective cohort study by Bhattacharya, et al (24,241 nulliparous women delivering singleton babies in Aberdeen between 1976 and 2005), adjusted data failed to show any differences in the risk of delivery before 37 completed weeks in the different BMI categories. The risk of preterm delivery before 33 weeks however, was higher in the obese group but not in the morbidly obese.’ Macrosomia, Large for Gestational Age Infants: Several countries have reported an increase in mean birth weight over the past decade and an increase in the proportion of large babies. One explanation for this increase could be the increase in maternal BMI over the same time period.” The impact of maternal abnormal body habitus on birth weight increases with increasing BMI and is associated with significant obstetric morbidity.’ Obesity and pregestational diabetes mellitus (pre-GDM) are independently associated with an increased risk of large for gestational age infants.’ Although pre-GDM has a greater effect than maternal obesity on the frequency of large for gestational age, more of the large for gestational age babies are born to obese women than women with diabetes mellitus because maternal 50 Obesity is more prevalent than diabetes mellitus. Risk of having a large for gestational age baby increases by approximately 60% in obese compared with normal-weight women.’ The Australian collaborative trial states that compared to women with ‘4 vorpal BMI, overweight and obese mothers had babies with significantly greater mean birth weights (mean diamete: 64.4, 95% CI -0.9 to 129.8, p = 0.05 im MD 99.7, 95% cai 178.2, p= 0.01, for overweight and obese respectively), and; greater head circumferences (MD 0.30, 95% CI 0.1-0.5, p = 0.01 and MD 0.34, 95% CI 0.1-0.6, p = 0.01, overweight and obese respectively). Furthermore, babies of obese mothers were more likely to be large for gestational age (RR 2.08, 95% CI 1.47-2. macrosomic (RR 4.54, 95% CI 2.01-10.24, p = 0.0003).8 Several studies have shown that maternal obesity and excessive weight gain during pregnancy are associated with macrosomic babies.° A systematic review and meta-analysis showed a relationship of pre- pregnancy BMI and offspring birth weight and offspring overweight or obesity. Pre-pregnancy overweight/ obesity increased the risk of being large for gestational age (OR 1.53, 95% CI 1,44-1.63, and OR 2.08, 95% CI 1.95-2.23), high birth weight > 4000 g (OR 1.53 95% CI 1.44-1.63; and OR 2.00, 95% CI 1.84-2 18), macrosomia (OR 1.67, 95% CI 1.42-1.97, and OR 3.23, 95% CI 2.39-4.37), and subsequent offspring overweight/obesity (OR 1.95, 95% CI 1.77- 2. 13, and OR 3.06, 95% CI 2.68-3.49), respectively.” : Obesity, even in the absence of maternal diabetes mellitus, is associated with increased maternal insulin resistance and fetal hyperinsulinemia. Insulin-resistant mothers have higher fasting plasma triglyceride levels and greater leucine turnover. Amino acids are insulin secretagogues and its increased influx could stimulate fetal hyperinsulinemia. Placental lipases can cleave triglyceride and free fatty acids are transferred to the fetus across a hemochorial placenta. The combination of an increased energy flux to the fetus and fetal hyperinsulinemia may explain the increased frequency of large for gestational age infants seen in obese women without diabetes mellitus? Breastfeeding: There is some evidence of an association between maternal overweight or obesity and decreased rates of breastfeeding. A high BMI before conception has been shown to be inversely related to the successful initiation of breastfeeding, the duration of lactation and the amount of milk produced. Poor lactation performance isattributed to mechanical difficulties associated with latching on and proper positioning of the infant; the high cesarean section rates among overweight or obese women, which delays the onset of first suckling; and a lower prolactin response to suckling at 48 hours and more after delivery, which may compromise milk production and, over time, lead to early cessation of lactation. It is unfortunate since breastfeeding has many protective effects against childhood morbidities, including the development of obesity later in life. Furthermore, children whose mothers were obese prior to pregnancy and who were never breastfed had a six times greater risk of being overweight compared with children whose mothers were normal weight and who breastfed for at least 4 months (The 1996 National Longitudinal Survey of Youth).’ The Effects of Maternal Overweight/Obesity on Short-term and Long- term Child Health Status Maternal pregravid weight has an early and persistent effect on childhood overweight status as well as a dynamic effect on the process of overweight development. There is a positive association between maternal pregravid BMI and childhood weight status with an adjusted OR ranging from two to four,’ Maternal overweight and obesity, independent of GDM, is linked to the development of the metabolic syndrome (obesity, hypertension, dyslipidemia, and glucose intolerance) in the offspring. Boney, et al found that exposure of children to maternal obesity was as strong a predictor of risk for metabolic syndrome (MS) as large for gestational age status. Maternal obesity (prepregnancy BMI of > 27.3 kg/m?) vs nonobese bad a hazards ratio (HR) of developing metabolic syndrome of 1.8! (95% Ci 1.03-3.19, p = 0.039). Children who were large for gestational age at birth had a twofold increased hazard of MS by II years of age (HR 2.19, 95% CI 1.25-3.82; p = 0.01).” Boney, et al followed a cohort of 84 children who were large for gestational age and 95 who were appropriate for gestational age at birth, showed that the risk of having two or more components of the MS at age 11 was 1.81 (95% CI !.03-3.19), if the mother was obese prior to pregnancy.’ Infants who are at the highest end of the distribution for weight or BMI or who grow rapidly during infancy are at increased risk of subsequent obesity. Obese babies were nine times more likely than norma! weight babies to grow into obese adults, and infants who grew rapidly were five times morc likely to become obese.” ee Long-term Consequences for the Mother A weight gain in pregnancy of over 9 kg is more likely to i when not pregnant (Green, et al 1988). Gestational fat ips and postpartum behaviors associated with weight change from early pregnancy to 1-year Postpartum have been investigated in 540 New York women. One-year postpartum, the women were a mean 15 + 5.9 kg heavier, while 25% experienced a weight gain of 4.6 kg or more. Weight gain in excess of guidelines was three times more likely in low-income groups. Gestational weight gain, a lack of postpartum exercise and food intake were all associated with weight gain to 1-year postpartum. In a randomised controlled trial {RCT) of 120 normal weight women, healthy eating and exercise were used to prevent excessive weight gain in pregnancy. In the intervention Sroup, weight gain excceded 15.9 kg in 33% women compared with 58% in the untreated group. The postpartum retention of weight was proportional to weight gain in pregnancy. Obesity in pregnancy is a major predictor of obesity later in life, which is commonly associated with the development of chronic hypertension, dyslipidemia and type 2 diabetes mellitus.” Gestational Weight Gain and its Consequences Weight Classification According to BMI Weight 1996 Institute of [Ni r i ational Heart, | Abr i Classification | Institute of | Preventive | Lung and Blood and pee Medicine’ | Medicine (10M) | Institute; | Parker' | Standard BMI Pre-pregnancy | World Health 5 a ae BMI Organization" jerweight < 19.8 <198 < 185 <2 | <185 Normai weight | > 19.8-26 18.5-24.9 =18.5t0< 25.0 | 20-249 | 185-229 (Recommended pregnancy weight gain 11.4-15.9 kp) Overweight 26.1-29 25.0-29.9 225.010 < 30.0 | 2529.9 | 23.249 (Recommended . Pregnancy weight gain 6.8-11.4 Low BMI < 19.8 ® ‘Normal BMI 198.25 High BMI > 26.1 Overweight 25-30 ‘Obewe “30In the 2" and 3" trimesters of pregnancy, gestational weight gain was considered adequate if it was within the range recommended by the 2009 IOM/NRC based on pre-pregnancy BMI. For women with pre-pregnancy BMI below 18.5 kg/m’, a gain between 0.44 and 0.58 kg/week is recommended; BMI from 18.5 to 24.9 kg/m’, a gain from 0.35 to 0.50 kg/week; BMI from 25 to 29.9 kg/m’, a gain from 0.23 to 0.33 kg/week; and BMI e” 30 kg/m’, a gain from 0.17 to 0.27 kg/week.’ A total weight gain from 12.5 to 18 kg was considered adequate for women with pre-pregnancy BMI below 18.5 kg/m’; a total gain from 11,5 to 16 kg for those with pre-pregnancy BMI from 18.5 to 24.9 kg/m’; a total gain from 7 to 11.5 kg for those with pre-pregnancy BMI from 25 to 29.9 kg/ m®; and a total gain from 5 to 9 kg for those with pre-pregnancy BMI e” 30 kg/m?. In the 2” trimester, insufficient weight gain was associated with smail for gestational age (RR 1.72, 95% CI 1.26- 2.33), and excessive weight gain with large for gestational age (RR 1.64, 95% CI 1.16-2.31). In the 3” trimester, excessive weight gain was associated with preterm birth (RR 1.70, 95% CI 1.08-2.70) and cesarean delivery (RR 1.21, 95% CI 1.03-1.44). Women with less than recommended gestational weight gain in the 2" trimester had a lesser risk of cesarean deliveries (RR 0.82, 95% Ci 0.71-0.96) than women with adequate gestational weight gain in this trimester.'* REFERENCES: Siega-Riz , Anna-Maria, Barbara L, The implications of maternal overweight and obesity on the course of pregnancy and birth outcomes, Matern Child Health J 2006;10:S153-S156. Siega-Riz, Anna-Maria. Prepregnancy obesity: Determinants, consequences, and solutions. Am Soc Nutr Adv Nutr 2012;3:105-107, Dodd, et al. Limiting weight gain in overweight and obese women during pregnancy to improve health outcomes: the LIMIT randomised controlled trial. BMC Pregnancy Childbirth 2011;11:79 Tanentsapf, et al. Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. BMC Pregnancy Childbirth 2011 11:81. Oteng-Ntim, et al. Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis. BMC Med 20012;10:47. i“ Vinter CA. ‘The LiP (Lifestyle in Pregnancy) Study: A randomized controlled trial of lifestyle intervention in 360 obese pregnant women. Diabetes Care 2011;34:2502-2507. Position of the American Dietetic Association and American Society for Nutrition, Obesity, Reproduction, and Pregnancy Outcomes, J Amer Diabetic Assoc 2009; 109:918-927. Athukorala, et al. The risk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy Childbirth 2010;10:56. Yu C, Teoh T, Robinson S. Obesity in pregnancy. BJOG 2006;113:1117-1125 Stothard KJ, et al. Maternal overweight and obesity and the risk of’ congenital anomalies: A systematic review and meta-analysis. JAMA 2009;301(6):636- 650. Stuebe, et al, Maternal BMI, glucose tolerance, and adverse pregnancy outcomes. Am J Obstet Gynecol. 2012;207(1):62. Boney CM. Metabolic syndrome in childhood: Association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatr 2005;115(3):290- 296. Bhattacharya, et al. Effect of body mass index on pregnancy outcomes in aulliparous women delivering singleton babies. BMC Public Health 2007:7:168, Stotland NE, Hopkins LM, Caughey AB. Gestati i NE, Hop , : jonal_ weight gain, macrosomia, and risk of cesarean birth in nondiabetic null t macronomia, and i of nndiabetic nulliparas. Obstet Waller KD, et al. Prepregnancy obesity as a risk factor for structural bi defects. Arch Pediatr Adolesc Med 2007:161@):745-750, val Dinh Distiner M, Duncan BB, Kae G, Schmidt M, Association of second and third imester weight gain in pregnancy with maternal and fetal outco: ONE 8(1}: €54704, doi:10.1371 /journal.pone.0054704 mes: Pos Yu Z, Han S, Zhu J, Sun X, Ji C, et al. Prey index i Z, Han S, Zhu J, Sun X, Ji C, et al. Pre-pregnancy bod relation o {infant birth weight and offspring overucight/obesiy. A sytersars review and meta-Analysis 2013. PLoS ONE 8(4): £61627. doi: review and me (4): £61627. doi: 10.1371 /journal.APPENDIX 3 GOVERNMENT PROGRAMS ON MATERNAL NUTRITION AND SUPPLEMENTATION Mila Zaragoza-lbay, MD, MBAH, FPOGS, FPSUOG, FPSMFM Background The Legal Basis: Executive Order 128 Section 22. The Food and Nutrition Research Institute (FNRI). The FNRI is mandated to: _ a) undertake research that defines the citizenry’s nutritional status, with reference particularly to the malnutrition problem, its causes and effects, and identify alternative solutions to them b) develop and recommend policy options, strategies, programs and projects which address the malnutrition problem for implementation by the aj riate agencies c) ceserainate uence findings and recommendations to the relevant end-users, Food Assistance Programs or Projects Various food assistance programs or projects implemented by national government agencies and nongovernment offices (NGOs): 1 Supplementary Feeding Program and Food Security for Distressed Families ae of Social Welfare and Development (DSWD). The Supplementary Feeding Program involved the provision of food supplements to severely and moderately underweight preschoolers without medical complications and uncovered by any other feeding programs. DSWD continued with the Food Security for Distressed Families Programs that provided supplementary feeding using local commodities. 2, Targeted Food Assistance Program (TFAP) of the Department of Health (DOH). The TFAP is the food assistance program of the DOH which targets severely and moderately underweight children aged 1 to 7. It is also covers pregnant and lactating mothers in their an and 3" trimesters of pregnancy, as well as underweight and anemic mothers. 3. Targeted Maternal and Child Health Program (TMCHP) and Food Transition Strategy of CRS. The dioceses of the Catholic church implement the TMCHP in coordination and technical guidance from the CRS. It covers 6-11 month old infants except those overweight; underweight 12-60 month old preschoolers; pregnant mothers in their 3° trimester and lactating women. The Food Transition Strategy, another scheme in anticipation of the phase- out, used local food commodities especially rice and mungbeans in supplementary feeding programs. Public-Private Partnerships ‘With the participation of the government and private sectors in the Philippines, weekly iron-folic acid supplementation introduced within a social marketing framework and a social mobilization campaign successfully improved knowledge and practice of buying and regularly taking supplements by women of reproductive age, both pregnant and non-pregnant. Adolescent girls in school were also active participants. The Philippines’ DOH implemented an iron supplementation program for pregnant and lactating women almost three decades ago. A circular issued in 1977 stated that, beginning at the 4" month of pregnancy and during lactation a supplement containing 60 mg elemental iron and 2 mg folic acid should be taken twice a day. A revised iron supplementation policy was issued in 2003 (Administrative Order No. 3-As. 2000: Guidelines on Micronutrient Supplementation), which stated that a dose containing 60 mg elemental iron and 400 mg folic acid should be taken daily as soon as pregnancy is diagnosed, or for at least 6 months during the entire duration of pregnancy, and continued for 3 months after delivery,‘ REFERENCES: 1. Paulino LS, etal. Weekly iron folic acid supplementation to improve iron status and prevent pregnancy anemia in Filipino women of reproductive age: The Philippine experience through government and private partnership nutrition reviews (Article first published online: 28 JUN 2008 | DOI: 10.1114/).1753- 4887.2005.1b00156.x) 2. Salonga AM, Basilio JA. State of maternal nutrition in the Philippines and its impact on aconatal morbidity and mortality. Transforming advocacy topolicy: maternal nutrition and its impact on neonatal morbidity and mortality (Convenors: Department of Health; and Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines Manila) ‘Tutali CO. Philippine Government Policies on Maternal, Newborn and Child Health and Nutrition: Towards Achieving MDGs 4 and 5. APPENDIX 4 LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION LEVEL DEFINITION rT Evidence obtained from at least one properly randomized controlled triai Il Evidence obtained from well-designed controlled trials without randomization IL-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group IL-3 Evidence obtained from multiple time series with or without the intervention. sine Opinions of respected authorities, based on clinical experience; descriptive studies and case reports or reports of expert committees. GRADE DEFINITION A There is good evidence to support the recommendation of the practice in maternal nutrition and supplementation. B There is fair evidence to support the recommendation of the practice in maternal nutrition and supplementation. Cc There is insufficient evidence to recommend for or against the inclusion of the practice in maternal nutrition and supplementation. D There is fair evidence to support the recommendation that the practice be excluded in maternal nutrition and supplementation, E There is good evidence to support the recommendation that the practice be excluded in maternal nutrition and supplementation. 'P | A good practice point (GPP) is a recommendation for best GPI practice based on the experience of the Task Force.