nutrition assessment during penance

1. Unit two
NUTRITIONALASSESSMENT DURING PREGNANCY
INTRODUCTION
• Maternal nutrition has a critical role in the reduction of both maternal
morbidity and mortality. The term Maternal Nutrition refers to nutritional
status during any stage of a woman´s reproductive age that eventually
could affect her health and that of the fetus and infant.
• There are heightened nutrient needs during pregnancy; without an
increase in caloric and nutritional intake to meet the increased demands
during this period, the fetus uses its own reserves making it more
susceptible to pregnancy-related complications .
• Women´s nutritional status is most vulnerable during pregnancy;

2. Cont…..
• maternal malnutrition becomes a cycle when malnourished mothers give
birth to low birth weight infants who in turn become malnourished mothers
themselves
• Basic nutritional evaluation tools during pregnancy will be detailed in this
chapter, these must be used especially in high risk populations that include:
Pregnant adolescents .
 Women with low prepregnancy weight.
 Women with unfavorable prognostic factors e.g., Obesity and anemia.
 Women with a history of low birth-weight infants.
 Women who don‟t gain sufficient weight during their pregnancy.

3. Intro……
• Women with a frequent history of conception.
 Women of low socioeconomic status.
 Women with diseases that can influence the nutritional status e.g.,
Allergy, diabetes, tuberculosis, drug addiction, and mental
depression.

4. Daily caloric needs
• Calories increases during pregnancy to support the mother and to
support the proper growth and development of the fetus ,
• the Recommended Daily Intake (RDI) for energy intake is
increased by 300 calories per day for the 2nd and 3rd trimester.
However, all the calories should be healthy calories containing:
• plenty of proteins.
• complex carbohydrates ( fruit, whole-grain starch and potates)
which considered as main energy source.
• Fibers
• Vitamins
• minerals

5. Weight gain during pregnancy
• A weight gain of 11.2 to 15.9 kg (25 to 35 lbs.) is recommended
during pregnancy but for more precise calculation, the normal
healthy weight gain in pregnancy should be calculated according
the Body Mass Index.
Where:
• Overweight women ( BMI>25 kg/m2) are advised to get 7 kgs.
• Normal women (BMI 18.5-25 kg/m2) are advised to get 10 kgs.
• Underweight women (BMI<18.5 kg/m2) are advised to get 14 kgs.

6. Specific requirements
There are specific set of nutrients which is highly required during
pregnancy more than any other nutrients such as:
• Proteins
• Folic acid
• Calcium
• Iron
• Vitamin c
• Omega- 3

7. Essential nutrients
a) Folic Acid
• Which is very important to prevent
neural tube defect like spina bifida
and improve the birth weight.
• 400 mg tablet of supplement is
required daily for the first trimester.
• Green leaf vegetables are rich in
folic acid.

8. Essential nutrients………….
b) Calcium
• RDA for calcium is 1 gram.
• Required for development of bones and teeth of the fetus.
• Decrease risk of HTN, low birth weight and chronic HTN in
newborns.
• To keep the bones strong and healthy.
• To provide proper muscle contraction.
• Important for blood clotting.

9. Essential nutrients…………
c) Proteins
• Growth of fetus
• Development of placenta
• Increased blood volume
• Enlargement of maternal tissues.
• RDA 70 grams per day
• Source: lean meat and eggs.

10. Essential nutrients……..
d) omega- 3
• Development of CNS, brain growth and eye
development.
• Found in fish oil.
• Reduce the risk of heart disease in infants.
• RDA 300 mg

11. Essential nutrients…..
e) Iron
• Fetal growth and enlargement of maternal tissue.
• To supply the increased RBC mass.
• To build up iron stores in the fetus liver
• RDA 30 mg

12. Essential nutrients………
f) Vitamin C
• It increases iron absorption.
• Prevent preterm delivery
• RDA 60 mg

13. Cont….
• ABSOLUTELY avoid smoking and drinking alcohols
• drink large amount of water to prevent constipation and to be
well hydrated.
• avoid raw fish and meat.
• avoid caffeine
• Maintain a balanced healthy diet to meet up the requirements of
nutrition.

14. Recommendations
 Recommendation 1: Preconception folic acid; folic acid is provided
as supplements in addition to the adequate intake of high folic acid
food sources.
 Recommendation 2: Proper antenatal care which ensures a proper
weight gain during pregnancy.
 Recommendation 3: Iron and vitamin A supplementation during
pregnancy.
 Recommendation 4: Nutritional counseling and education to ensure
a healthy diet during both pregnancy and lactation.
 Recommendation 5: Breast feeding and nutritional education during
emergencies.

15. The main forms of maternal malnutrition include
Macronutrient deficiencies: (Protein Energy Malnutrition - PEM) which is managed by
ensuring adequate variety of foods to include the 6 major groups, adequate frequency of food
intake, adequate amounts of food, and proper personal and environmental hygiene.
• Micronutrient deficiencies: such as vitamin A deficiency (VAD), iron deficiency anemia
(IDA), and iodine deficiency disorders (IDD); these conditions result in increased risk of
low birth weight, maternal mortality, and neonatal and infant mortality.
• Anemia accounts for approximately 20% of maternal deaths as it increases the risk of both
hemorrhage and prolonged labor, which can lead to sepsis.
Management of micronutrient deficiency consists of supplementation with fortified foods
and mineral/vitamin formulations, and adequate intake of foods rich in micronutrients such as
fruits, dark-green and brightly colored vegetables.

16. Causes and consequences of maternal
Malnutrition
Underlying Causes:
• Inadequate
maternal care.
• Household food
insecurity.
• Unhealthy
environment,
insufficient
health services,
and poor
hygiene and
sanitation
Immediate causes:
• Infections and diseases.
• Poor access to basic health
services (e.g. inadequate
iron and folic acid
supplementation)
• Frequent parasites and
infections.
• Inadequate food intake due
to diet characterized by
low, highly variable over
seasons, and often low
nutrient density.
Consequences:
• Maternal Health
• Increased risk of
maternal death
• Increased risk of
infections. o Anemia
• Compromised immune
functions. o Lethargy
and weakness.
• Lower productivity.
• infant/child Health
• Increased risk of fetal
and neonatal death.
• Intrauterine growth
retardation, low birth
weight, preterm birth.
• Compromised immune
functions. o Birth
defects.Basic Causes
• Political structure
• Resources and their control
• Heavy workloads o Frequent births
• Harmful local practices and food taboos.
• Intra-household food distribution does not favor women

17. GOALS AND OBJECTIVES
• The main purpose of the maternal nutritional assessment is to support
health care providers in the provision of maternal nutrition care and
support services, it can also be used by health training institutions and
other organizations, as well as other governing bodies implementing
maternal nutrition interventions.
• These guidelines were established to break the intergeneration cycle of
maternal malnutrition through outlining special nutritional aspects that
enable optimal nutritional status of the mother as well as providing
much safer and ideal birth outcomes.

18. To contribute to the reduction of maternal malnutrition the implementation of
the following goals must be achieved:
• To improve the knowledge and skills of service providers at all levels to
respond to maternal and child nutritional needs.
• To improve provision of quality maternal and child nutritional services at
community and health facility level.
• To advocate for support of appropriate interventions that address maternal
nutrition at all levels.
• To facilitate health care providers and other stakeholders in interpersonal
nutrition education and counseling, community dialogue, developing the
health education for improved maternal nutrition.
• To strengthen integration of nutrition interventions for adolescent,
pregnant, and lactating women within existing health services.

19. NUTRITIONALASSESSMENT FOR
PREGNANCY
 Pregnant females who are in general at risk for nutritional problems at even
greater risk, and because of the importance of nutrition in the course and outcome
of pregnancy, all pregnant women should have a formal assessment
of their nutritional status at the beginning of their prenatal care with ongoing
surveillance throughout the pregnancy
The purpose of the nutrition assessment is to:
• Evaluate the nutritional status of the pregnant.
• Identify those pregnant who are at nutritional risk.
• Formulate an individualized nutrition care plan with follow-up.
The Nutritional assessment takes into account different aspects: including relevant
obstetric, medical, psychology and diet history, BMI along with weight gain, and lab
tests and values.

20. Cont………
1. Relevant History
In order to have much more precise information; the following steps will help
Obstetric History
• Women with previous pregnancies may be at increased nutritional risk as a result of depleted
nutrient reserves, the length and time between pregnancies can play a vital role as well
especially if the time between pregnancies is less than one year.
• History of pre-term delivery (<37 weeks of gestational) or low/high birth weight of infants
the first could indicate nutritional problems while the latter may suggest latent diabetes.
• History of weight gain during previous pregnancies and any pregnancy-related
complications e.g., gestational diabetes, hypertension, anemia, vomiting and nausea.
• Previous use of supplements or drugs e.g., contraceptives.
• The experience of breast feeding.

21. Psychological History
• Economic status since limited and low income may mean limited
food availability.
• Living situation.
• Access to medical care.
• Emotional health or any psychological/mental- related problems.
• Education level
• Employment situation.

22. Medical History
• The presence of any chronic or metabolic diseases e.g.,
cardiovascular, renal diseases or cystic fibrosis.
• Physical disabilities
• Previous history of eating disorders e.g., anorexia and bulimia
nervosa.
• Past or current intake of cigarettes smoking or alcohol.
• Previous nutritional deficiencies.
• History of medication usage.
• Status of physical activity (type, duration, and intensity

23. 2. Anthropometric Measurements
• Pre-pregnancy BMI Classifications: According to recommendations set by
the Institute of Medicine (IOM).
Pre-pregnancy BMI categories Values (kg/m2)
Underweight < 19.8
Normal 19.8-26
Overweight 26.1-29
Obese >29

24. Pregnancy weight gain recommendations
Pre-pregnancy
BMI categories
(kg/m2)
Recommended
total weight gain
1st trimester 2nd and 3rd
trimester
underweight 12.5-18 2.3 0.49
Normal 11.5-16 1.6 0.44
Overweight 7-11.5 0.9 0.30
Obese 6-7
Twins (any BMI) 16-20
Triplet (any BMI) 23

25. MUAC (Mid-Upper Arm Circumference)
• MUAC is a good indicator of the protein reserves of a body, and a
thinner arm reflects wasted lean mass, i.e., malnutrition. The WHO
Collaborative Study 1995 showed MUAC cut-off values of < 21 to
23 cm as having significant risk for low birth weight (LBW).

26. References of Laboratory Values during
Pregnancy
Tests Non-pregnant 1”st trimester 2nd trimester 3rd trimester
Erythropoietin (U/L) 4–27 12–25 8–67 14–222
Ferritin (ng/ml) 10-150 6-130 2-230 1-116
Hemoglobin (g/dl) 12-15.8 11.6-13.9 9.7-14.8 9.5-15.0
Hematocrit (%) 35.4-44.4 31.0-41.0 30.0-39.0 28.0-40.0
TIBC (µg/dl) 251-406 3.42-4.55 2.81-4.49 2.71-4.43
WBC (x 106/mm3) 3.5-9.1 5.7-13.6 5.6-14.8 5.9-16.9
Platelet (x106/L) 165-415 174-391 155-409 146-429
Transferrin (mg/dl) 200-400 254-344 220-441 288-530
MCH (pg/cell) 27-32 30-32 30-33 29-32
MCV (µm3) 79-93 81-96 82-9 81-99
(According to University of Texas Southwestern Medical Center, Department
of Obstetrics and Gynecology, Dallas, TX, USA)

27. Dietary Intake/Needs
• Estimated Needs: According to National academy of science institute
of medicine guidelines for pregnancy:
BMI (kg/m2) Estimated calories intake/kg/day
Underweight (<19.8) 36-40
Normal Weight (19.8-26) 30
Overweight (26.1-29) 24
Obese (>29) 12-18
Twin Gestational Addition of 500 Kcal/day to the above
recommendations
• According to the caloric distribution during pregnancy, carbohydrate is 45-55%, protein 15-20% and fat is 35%.
• Estimated needs from fluid: The recommended fluid needs for pregnancy (8-10 cups/day) around 2000 -2500
ml.

28. According to Institute of Medicine (IOM)
The needed components Estimated needs for pregnant women
Energy (Kcal) + 0 (1st trimester)
+ 340 (2nd trimester)
+ 452 (3rd trimester)
Protein (g) 71
Vitamin A (mcg) 750-770
Vitamin D (meg) 5
Vitamin E (mg) 15
Vitamin C (mcg) 80-85
Thiamin (mcg) 1.4
Riboflavin (mg) 1.4
Niacin (mg) 18

29. Continued)
The needed components Estimated needs for pregnant women
Vitamin B6 (mcg) 1.9
Folate (mcg) 600
Vitamin B12 (mcg) 2.6
Calcium (mg) 1300
Phosphorus (mg) 700-1250
Magnesium (mg) 350-400
Iron (mg) 27
Zinc (mg) 11-12
Iodine (mcg) 220

30. PROPER WAYS OF CARRYING OUT THE HISTORY OF
DIETARY INTAKE
• The purpose of assessing the dietary intake is to evaluate the
nutritional quality of the diet. Food intake information may be
obtained by different methods including: 24-hour food recall, food
frequency questionnaire, food record; and diet history.
• The method chosen depends on the specificity desired, the time
available, the cooperation of the patients, and the training of the
personnel

31. Dietary Assessment methods
Methods Strength Limitation Application
24-hours recall(15) Does not require literacy,
Relatively low respondent
burden, Data may be directly
entered into a dietary
analysis program, May be
conducted in-person or over
the telephone
Dependent on respondent‟s
memory, Relies on self-
reported information,
Requires skilled staff, Time
consuming, Single recall
does not represent usual
intake.
Appropriate for most people
as it does not require literacy,
Useful for the assessment of
intake of a variety of
nutrients and assessment of
meal patterning and food
group intake, Useful
counseling tool
Food frequency (16-18) Quick, easy and affordable,
May assess current as well as
past diet, In a clinical setting,
may be useful as a screening
tool.
Does not provide valid
estimates of absolute intake
of individuals, Can‟t assess
meal patterning, May not be
appropriate for some
population groups.
Does not provide valid
estimates of absolute intake
for individuals, thus of
limited usefulness in clinical
settings, May be useful as a
screening tool, however,
further development research
is needed.

32. Dietary Assessment methods …
Methods Strength Limitation Application
Food record (19-27 Does not rely on memory,
Food portions may be
measured at the time of
consumption, Multiple days
of records provide valid
measure of intake for most
nutrients.
Recording foods eaten may
influence what is eaten,
Requires literacy, Relies on
self-reported information,
Requires skilled staff, Time
consuming
Appropriate for literate and
motivated population groups,
Useful for the assessment of
intake of a variety of
nutrients and assessment of
meal patterning and food
group intake, Useful
counseling tool
Diet history (28) Able to assess usual intake in
a single interview,
Appropriate for most people.
Relies on memory, Time
consuming (1 to 1-1/2
hours), Requires skilled
interviewer.
appropriate for most people
as it does not require literacy,
Useful for assessing intake of
nutrients, meal patterning
and food group intake,
Useful counseling tool.

33. Thank you for your attention