Reducing the proportion of infants born small, early, or both would clearly decrease infant mortality (African Americans

are the highest)

Health2020- focus on the reduction of LBW, preterm delivery, and infant mortality. Related to nutritional status
-improving prenatal weight gain, access to care, and behaviors that adversely affect the curse and outcome of pregnancy in all populations
-Pregnancy begins at conception (14 days after a womans next menstrual cycle and ovulation occurs)
-Maternal physiological changes begin within one week after conception
1. to provide the fetus with sufficient energy, nutrients, and oxygen for growth, the mother must first expand the volume of plasma that can be circulated (gestational week 20)
2. maternal nutrient stores are accumulated next (established in advance of the time they will be needed to support large gains in fetal weight) (gestational week 20)
3. maximal weight of placental growth is timed to precede that of fetal weight gain (gestational week 31)
4. increase in uterine blood flow (gestastional week 37)
5. This sequence of events ensures that the placenta is fully prepared for the high level of fx that will be needed as fetal weight increases most rapidly (gestastional week 37)
Normal physiological changes during pregnancy
Two groups: those occurring in the 1st half (maternal anabolic) (only 10% growth in fetus) and those occurring in the 2 nd half (maternal catabolic)(90% growth in fetus)
-blood volume expansion, increased cardiac output (about 2/3 of expansion is extracellular (blood and body tissues and 1/3 is intracellular (fluid in spaced btwn cells)
-assoc. with edema, fatigue, tired, exhausted, weight gain. Birth weight is strongly related to plasma volume
-concentrations of many vitamins and minerals in blood decrease (fat soluble levels increase and water soluble levels decrease
-Hormonal changes: placental secretions of large amnts of hormones, such as steroid hormones (testosterone, progesterone and estrogen)
-Progesterone- maintains the implant; stimulates growth of the endometrium and its secretion of nutrients; relaxes smooth muscle of the uterine blood vessels and GI tract;
stimulates breast development; promotes lipid deposition
-estrogen- increases lipid formation and storage, protein synthesis, and uterine blood flow; prompts uterine and breast duct development; promotes ligament flexibility
-human chorionic gonadotropin (maintains early pregnancy by stim. The corpus luteum to produce estrogen and progesterone. Stimulates growth of the endometrium. The
placenta produces estrogen and progesterone after the 1st 2 months of pregnancy)
-human chorionic somatotropin (increases maternal insulin resistance to maintain glucose availability for fetal use, promotes protein synthesis and the breakdown of fat for
energy for maternal use)
-leptin- may participate in the regulation of appetite and lipid metabolism, weight gain, and utilization of fat stores
-Carbohydrate Metabolism- promote the availability of glucose to the fetus (accomplished by promotion of maternal insulin resistance)- diabetogenic effect of pregnancy
-carb metabolism in the first half of preg. Is characterized by estrogen and progesterone stimulated increases in insulin production and conversion of glucose to glycogen
and fat
-in the 2nd half, rising levels of hCS and prolactin from mothers pituitary gland inhibit the conversion of glucose to glycogen and fat
-at the same time, insulin resistance builds in mother, increasing her reliance on fats for energy
-decreased conversion of glucose to glycogen and fat, lowered maternal utilization of glucose, and increased liver production of glucose help to ensure that a
constant supply of glucose for fetal growth and development
-accelerated fasting metabolism- maternal metabolism is rapidly converted toward glucogenic amino acid utilization, fat oxidation, and increased production of ketones with fasts that last longer
than 12 hours. Decreased levels of plasma glucose and insulin and increased levels of triglycerides, FFA, and ketones are seen hours before they occur in nonpregnant fasting women. The rapid
conversion to fasting metabolism allows pregnant women to use primarily stored fat for energy while sparing glucose and amino acids for fetus. Although these metabolic adapt. Help ensure
constant fetal supply of glucose, fasting eventually increased the dependence of the fetus on ketone bodies for energy. Prolonged fetal utilization of ketones, such as occurs in women with poorly
controlled diabetes or who lose weight during part of all of pregnancy, is ass. with reduced growth and impaired intellect of offspring
-protein metabolism- nitrogen and protein are needed in increased amounts for synthesis of new maternal and fetal tissue (reduced levels of NH excretion and conserve of AA)
-fat metabolism- promote fat stores in 1st half and fat mobilization in 2nd half. Blood levels of many lipoproteins increase dramatically.
-Plasma TG levels increase 1st and most dramatically, reaching 3x nonpregnant levels by term. Cholesterol containing lipoproteins, phospholipids, and fatty acids also increase but to a
lesser extent than the TG
-increased cholesterol supply is used by the placenta for steroid hormone synthesis and by the fetus for nerve and cell membrane formation
-abnormally high levels of TG may indicate the existence of insulin resistance prior to pregnancy. This increases the risk of diabetes and hypertension during pregnancy
-a reduced cholesterol diet during pregnancy has been found to lower maternal cholesterol levels somewhat, it does not appear to alter cord and neonatal cholesterol levels
-small increased in HDL cholesterol as well as other changes in serum lipids appear to revert the prepregnancy levels postpardum
-Mineral metabolism- calcium metabolism is characterized by an increased rate of bone turnover and reformation
-elevated levels of body water and tissue synthesis are accompanied by increased requirements for sodium and other minerals
-this is accompanied by changes in the kidneys that increase aldosterone secretion and the retention of sodium (low salt diet is not recommended during pregnancy)
-The placenta- fx includes: hormone and enzyme production, nutrient and gas exchange btwn the mother and fetus, and removal of waste products from the fetus
-acts as a barrier to some harmful compounds, and it governs the rate of passage of nutrients and other substances into and out of fetal circulation
-barrier to the passage of maternal RBC, bacteria, and many large proteins
-prevents the mixing of fetal and maternal blood until delivery, when ruptures in blood vessels may occur
-placenta uses 30-40% of the glucose delivered by the maternal circulation
-nutrient transfer depends on: the size and the charge of molecules available for transport, lipid solubility of particles being transported, concen. Of nutrients in maternal and fetal blod
-passive diffusion- water, some AA and glucose, FFA, ketones, vitamins E and K, some minerals (Na, Cl), gases
-facilitated diffusion- some glucose, iron, vitamins A and D
- active transport- water-soluble vitamins, some minerals (Ca, Zinc, iron, K), and amino acids
-Endocytosis- immunoglobulins, albumin
-The fetus is not a parasite- the fetus cannot take whatever nutrient it needs from the mothers body at the mothers expense. Nutrients support mother then placenta then fetus.
-Embryonic and fetal growth and development-
-hyperplasia- increase in cell multiplication of the forebrain is btwn 10 and 20 weeks of gestation (brain is 1 st organ that develops in humans along with CNS)
-heart and adrenal glands come next when talking about nutrient demand (after brain and CNS)
-neural tube develops into the brain and spinal cord during weeks 3 and 4 after conception
-pancreas does not undergo hyperplasia until the third trimester of pregnancy
-hyperplasia/hypertrophy- cell multiplication continues at a lower rate but cells get bigger (this can be due to accumulation of protein and lipids inside the cell)
-specialized fx of cells, such as production of digestive enzymes by cells w/in the small intestine or neurotransmitters by nerve cells, occurs along w/ increases in cell
number and size
-hypertrophy- cells continue to accumulate protein and lipids, and functional levels continue to grow in sophistication, but cells no longer multiply
-reduction in cell size can be due to unfavorable nutrient environments (some functional changes can often be reduces or reversed later if deficits are corrected)
-can see deficits in organ and tissue fx, such as reduced mental capabilities or declines in muscular coordination
-maturation- stabilization of cell number and size occurs after tissues and organs are fully developed later in life
Fetal body composition- increases in fat, protein, and mineral content (biggest changes take place in the last 5 weeks of pregnancy when fat and mineral content increase substantially)
-insulin like growth factor 1 is the primary growth stimulator of the fetus (promotes uptake of nutrients by the fetus and inhibits fetal tissue breakdown)
-small for gestational age (SGA)- newborn weight is <10th percentile for gestational age (Small for date)
-disproportionally SGA (dSGA)- newborn weight is <10th percentile for weight for gestational age; length and head circumference are normal (asymmetrical SGA)
-look skinny, wasted, and wrinkly, tend to have small abdominal circumferences, reflecting a lack of glycogen stores in the liver, and little body fat
-generally have smaller organ sizes but the normal # of cells in organs and tissues (experiences in utero mal nutrition in the third trimester)
-short term episodes of malnutrition, such as maternal weight loss or low weight gain late in preg. That compr. Energy, nutrient, or o2 avail are assoc with dSGA
-risk of developing the hypos after birth (hypoglycemia, hypocalcemia, hypomagnesiumenia, hypothermia)
-greater risk than others for heart disease, hypertension, and type 2 diabetes (if maternal undernutrition was short, they tend to experience good catching up with rehab)
-proportionally SGA (pSGA)- newborn weight, length, and head circumference are <10 th percentile for gestational age (symmetrical SGA)
-look small but well proportioned (experienced long term malnutrition in utero, due to factors such as prepregnancy underweight, consist. Low rates of maternal weight
gain in pregnancy and other corresponding inadequate dietary intake, or chronic exposure to alcohol)
-generally have a reduced # of cells in organs and tissues (exhibit fewer health problems at birth than dSGA but catch up growth is poorer)
-excessive weight gain appears to increase risk of obesity and insulin resistance related disorders such as hypertension and type 2 diabetes later in life
-Large for gestational age (LGA)- weight for gestational age exceeds the 90th percentile for gestational age. BW greater than 4500 g (10lbs) (macrosomic)
-related to prepregnancy obesity, poorly controlled diabetes in pregnancy, excessive weight gain in pregnancy, and other factors
-expect for infants born to uncontrolled diabetes, they experience far lower illness and death rates than SGA and tend to be taller later in life
-delivery and postpartum complications in mothers tend to be higher (increased rates of operative delivery, should dystocia, and postpartum hemorrhage)
Nutrition, miscarriage, and preterm-
 -miscarriages- primarily caused by noninherited chromosome abnormalities, thyroid disorders, hormonal imbalances, reproductive tract infections, drug or alcohol abuse, or disorders
such as a polycystic ovary syndrome
-underweight women are at a higher risk of miscarriage than are normal or overweight women
-elevated blood cholesterol (>230mg/dL) or TG concentration (>140mg/dL) and high levels of markers of inflammation in the 1 st half of pregnancy
-use of multivitamin supplement very early in pregnancy has been shown to reduce the risk
-preterm delivery- greater risk than other infants of death, neurological problems reflected later in IQ scores, ADHD, enrollment in special ed, and congenital malformations and
chronic health problems such as cerebral palsy.
-risk of these outcomes increases as gestational age decreases (infants born very preterm (<34 weeks) commonly have problems related to growth, digestion, respiration,
and other conditions due to immaturity
-low stores of fat, essential fatty acids, glycogen, calcium, iron, zinc, and other nutrients in very preterm infants may also interfere after delivery
-breast milk content of riboflavin and vitamins A, C, and b12 may be low in women who have inadequate intake of these during 3 rd trimester
-use of multivitamin or folic acid supps before and early pregnancy have shown decreased risk of preterm
-caffeine intake up to 300mg has no effect, intake of 1-3 fish meals a week has protective effect
-underweight women who gain less than the rec. amnt during pregnancy are at high risk of preterm
-women who enter pregnancy obese are also at an increased risk but to a lesser extent as being underweight
-women who exercise are at a lower risk than women who dont
-increased levels of cholesterol, TG, FFA, and levels of markers of inflammation show increased preterm delivery (not know if antioxidants or measures reduc lipids helps)
Energy and nutrient needs during pregnancy-high quality diet (regular intake of veggies, fruits, legumes, nuts, fish, poultry, vegetable oils, and adequate fiber and nutrient intakes
Energy- requirements increase mainly due to protein and fat tissue synthesis, and the energy cost of maintaining an expanding amount of metabolically active tissues
- Protein synthesis primarily occurs in fetal, placental, uterine, and breast tissue.
- Most of the fat synthesized during pregnancy is used to buildup maternal fat stores
- Expanded metabolic activity related to the increased work of the mothers cardio, resp, and renal systems is responsible for increase in energy needed for basal metabolism
- Fetus accounts for about 1/3 of the increased energy needs for pregnancy
- Increased need for energy avg 300kcal/day, or a total pregnancy of 80,000kcal. DRI for energy intake for pregnancy are +340kcal.day for the 2 nd trimester and +452kcal/day for
the 3rd trimester (estimated calorie balance is higher than calorie intake throughout pregnancy and becomes negative postpartum)
Carbohydrates- approx. 45-65% of total caloric intake (minimum of 175 grams to meet the fetal brains needs for glucose)
-veggies, fruits, and whole grain products contain fiber are good high carb foods(provide beneficial phytochemicals,such as plant antioxidants, protection against constipation)
-sources of carbs that do not contain added sugars and fat tend to be less energy dense to help women manage pregnancy weight gain (no evidence art. Sweeteners are harmful
Alcohol- readily passes through the placenta to the fetus where it can act as a toxin and interrupt normal growth and development (increased risk of abnormal mental development and
growth in offspring)
-in utero alcohol exposure during the second half of the first trimester is the most critical period (fetal alcohol spectrum disorders)
Proteins- 71g/day. Less is used for energy and more is used for protein synthesis (fetusmaternal blood and ECF volumeuterusplacenta)
-protein requirements increase during pregnancy primarily due to protein tissue accretion. (protein supps do not benefit the course or outcome in well nourished women)
Fats- 33% of total calories on average from fat (energy source for fetal growth and serves as a source of fat-soluble vitamins)
-recommended consume 13 grams of linoleic acid (essential fatty acid- sallflower, corn, sunflower, and soy oil) daily, and 1.4 grams of the of alpha linolenic acid (flaxseed,
walnut, soybean, canola oils, and leafy green veggies).
-linoleic acid is the primary fatty acid of the n-6 and alpha linoleic acid is of n-3 (these are long chain polyunsaturated fatty acids)- brain, retina, and neural tissue of fetus
-EPA and DHA- derived from alpha linolenic acid. In pregnant women, 9% of alpha-linolenic acid is converted to these
-depends on the consumption of food sources of DHA and EPA then or use of supps. (fish and seafood)
-given adequate intake, fetal EPA and DHA blood concentrations become higher than maternal blood in third trimester
-Eicosanoid derivativers of EPA reduce inflammation, dilate blood vessels, and reduce blood clotting
-DHA is a major structural component of phospholipids in cell membranes in the CNS, including retinal photoreceptors (optimal fx of the CNS depends on availability
of sufficient amounts of DHA during critical phases)
-300mg/day but dont exceed 3 grams per day (found in fish, fish oils, and seafood)(fish liver oils also contain high amounts of Vit A and D
-DHA is available from egg yolk and DHA fortified eggs, orange juice, snack bars and cookies,
-human milk from woman w/ adequate amnts is an excellent source of DHA. Also prenatal vitamins are becoming a source
-recommended that pregnant women consume at least two, four-ounce servings of cooked fish or seafood each week
(select foods low in mercury, such as shrimp, canned light tuna, salmon, Pollock, and catfish)
(high leveled foods are swordfish, king mackerel, tilefish, and shark)
-no more than 6 ounces a week of albacore tuna or tuna steak should be consumed each week