Carol Williams

IFCcic & World Vision

Maternal Nutrition.

Infant Feeding Consortium cic.

Maternal Nutrition

1. ENERGY
2. MICRONUTRIENTS

IFC cic

Carol Williams, 2011

Aims of this session

Essentials of nutrition recommendations
understanding RDAs
Energy needs of pregnant and lactating women
Influence of pre-pregnancy Body Mass Index
and pregnancy weight gain on maternal and
foetal outcomes
Nutrient requirements during lactation
Influence of maternal diet on breastmilk
composition
IFC cic

Nutrition Essentials: Whats on a Food Label

Macronutrients
Protein
Fat

Of which
Saturates
Monounsaturates
Polyunsaturates
(includes Essential Fatty
Acids , LCPUFAs)

Carbohydrates
Of which Sugars

Fibre
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Micronutrients
Vitamins
Minerals
Iron (Fe)
Sodium (salt)
Energy
K calories
K joules
(4.18 kj = 1kcal)

Carol Williams, 2011

Recommended Nutrient Intakes

Also known as:
Recommended Daily Intakes/ Amounts
Reference Nutrient Intakes
Dietary Reference Values
Guideline Daily Amounts
Amount required to
Prevent clinical signs of deficiency
Maintain nutrient balance, and appropriate
circulating levels and tissue concentrations
(stores)
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Recommended Daily Amounts (RDAs)

Overall Principle
Average
Requirement
enough for 50%
people

RDA is more
than enough for
97% of people

Adequate Intake
RNI

LRNI

+ 2SD

- 2SD

28 August 2011

CWilliams

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

Carol Williams, 2011

Carol Williams, 2011

Definitions
Reference Nutrient Intake (RNI or RDA)
+ 2 Standard Deviations
amount that is enough to meet the needs of
nearly everyone (97.5%)
Estimated Average Requirement (EAR)
Amount to meet the needs of 50% of population
Lower Reference Nutrient Intake (LRNI).
-2 Standard Deviations
amount that is enough for only the small number
of people who have low requirements (2.5%).
IFC cic

Carol Williams, 2011

Carol Williams

IFCcic & World Vision

Interpreting data: Example Vitamin C

Which do we use?

(UK figures)

Mg/day
adult

LRNI

EAR

RNI

10

25

40

1. So if average intake in a country is 30mg/day is

this enough?

1. For Vitamins and Minerals we use RDA/

RNI because we want to make sure
everyone has enough
2. For Macronutrients we use Average
Requirements as we dont want people
having more calories, fat etc than they need.
Vitamin C mg/day

2. If an individual has an intake of 30mg is this

enough?
IFC cic

Carol Williams, 2011

adult
IFC cic

LRNI

EAR

RNI

10

25

40

Carol Williams, 2011

Whose RDA?

Weak points in RDA estimates.

Dietary Reference Intakes, Institute of Medicine,

National Academy of Sciences USA 2011
revision.
FAO/WHO Human Energy Requirements 2004
FAO/WHO vitamin & mineral requirements 2001
UK Dietary Reference Values 1991

Data often lacking on infants, children, pregnant

and lactating women and elderly
Estimated by extrapolation
Figures for adolescents also problematic,
because depends on timing of adolescent
growth spurt.

South East Asia Harmonization of RDAs

The SEA-RDA is equivalent to the RNI as used by
the FAO/WHO Report on Human Vitamin & Mineral
Requirements. Barba & Cabrera. Asia Pac J Clin Nutr

Figures estimated per Kg, then applied to

average weight man (74kg) or women (62kg)
Differences in body weight make a big difference

2008
IFC cic

Carol Williams, 2011

Definitions continued
Upper Tolerable Nutrient Level (UL)
Maximum intake from food that is unlikely to pose
risk of adverse health effects.
For most nutrients absorption or excretion are
regulated so no need for UL. May not function with
intakes from nutritional supplements
beta-carotene vitamin B6, vitamin E, boron,
copper, selenium, zinc and silicon
Protective nutrient intake
Amount greater than the RNI, which may be
protective against a specified health or nutritional
risk of public health relevance (eg vitamin C)
IFC cic

Carol Williams, 2011

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

IFC cic

Carol Williams, 2011

Calculating Energy Requirements

Use doubly-labelled water to measure energy
expenditure.

Basal Metabolic Rate BMR

Cell function and replacement, metabolism,
cardiac, respiratory and brain function,
maintentence of body temperature,

Physical Activity
Thermogenesis metabolic response to
food
Cost of synthesising new tissue growth
for children.
IFC cic

Carol Williams, 2011

Carol Williams

IFCcic & World Vision

Calories per gram of different

macronutrients

Physical Activity Levels - PALs

Energy needs = BMR x PAL
PAL of 1.4 reflects the lifestyle of most adults in
the UK. Sedentary Lifestyle.
Physical Activity Ratios used to calculate daily PAL
1.0 = in bed
1.2 = Reading, driving
3 = walking
5 = moderate swimming, gentle cycling
7 = football, cycling, climbing stairs
IFC cic

Carol Williams, 2011

Additional Energy Requirements for

Pregnancy FAO 2004, UK SACN 2009.
Needed for increase in tissue mass

Kcal/gram
Fat

Alcohol

Protein

Carbohydrates
(including sugars)

IFC cic

Carol
Carol
Williams,
Williams
2011

BMR in pregnancy
BMR increases during pregnancy in healthy well
nourished groups due to
Rapid tissue synthesis
Increase active tissue mass
Increased cardiovascular and respiratory work
Increases 5%, 10%, 25% in 1st, 2nd 3rd trimester.

Plus any increase in energy expenditure due to

Desirable pregnancy weight gain 10 -14kg.

Mean 12Kg.( to produce baby ~3.3kg)
IFC cic

Carol Williams, 2011

But get a decrease in BMR in pregnancy in some

(malnourished) populations.
BMR closely correlated with gestational wt gain
and pre-pregnancy fat mass.
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Pregnancy Weight Gain

Is non-linear:
11% - first trimester
47% - second trimester
42% - third trimester
Building up of adipose stores is main
determinant of energy needs in first 30 weeks.
Last 10 weeks of pregnancy fat deposition in
mother virtually stops, energy used for foetal
tissue synthesis.

Measuring overweight & obesity

Pre-pregnancy or 1st trimester
Weight (kg)/ divided by height (m)2
BMI categories
30+
Very overweight
25 30
Overweight
18.5 25 Healthy
(<23 for south Asian origin)
less < 18.5 Underweight
17-18.5
Mild malnutrition
16-17 Moderate malnutrtn
<16 Severe Malnutrition

Protein deposition occurs primarily in the second

(20%) and third trimesters (80%).

IFC cic

Carol Williams, 2010

2011

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

Carol Williams, 2011

IFC cic

Carol Williams, 2011

Carol Williams

IFCcic & World Vision

Pregnancy & maternal overweight/ obesity

NHS Annual Evidence Update: Antenatal and Pregnancy
Care - Maternal Obesity 2009

BMI >30 Higher risk of

Maternal and foetal complications
Neural tube defects, congenital malformations
Pre term delivery
Hypertension - (pre-eclampsia)
Gestational diabetes
Caesarean section
Obese women - energy restriction can lead to
adverse foetal outcomes. Different adipose sites
used in pregnancy.
IFC cic

Carol Williams, 2011

Women with BMI over 30

Loose weight before pregnancy
loosing 5-10% of weight before becoming
pregnant could increase their chance of
becoming pregnant
Pre-pregnancy weight greater health impact that
actual weight gained during pregnancy.
No rapid weight loss or crash diets during
pregnancy as this can harm the health of the
child.
can lead to a condition known as ketoacidosis
where there is very high levels of certain fatty
acids in the blood, and that can be associated
with death of the baby and cognitive impairment
of the child in later life.
IFC cic

Recommendations for health

professionals working with women and
young children.
Women who are pregnant (or who may
become pregnant) 2008

Carol Williams, 2011

Under-nutrition
Sub-optimal pre-pregnancy weight or
height
<50kg or 150cm increased risk
maternal complications
<45kg or 148cm increased risk
poor foetal outcomes.
Women with BMI<18.5 must gain more weight than
with normal BMI (more than12kg) depending on their
height, to have babies with adequate birth wt.

IFC cic

Carol Williams, 2011

Consequences of chronic maternal

energy deficiency

Attained maternal wt (pre-pregnancy plus wt

gain) most significant predictor of Low birth weight
and
Inter Uterine Growth
Retardation
IFC cic
Univ
Westminster
Carol Williams, 2009
2011

Effects of IUGR

More Infections
Obstructed labour
Increased maternal
mortality (MDG)
Increased neonatal
and infant mortality
Low Birth Weight
intrauterine growth
retardation

IUGR infants are

at higher risk of dying.
more likely to remain small than those of normal
birth weight.
likely to be susceptible to infections because of
impaired immunity
IUGR newborns in industrialized countries show
some catch-up in growth in 1-2 yrs of life,
thereafter growth tracks at this centile. In
developing countries, catch-up tends not to
occur.
17-19 years, IUGR are around 5 cm in height
and 5 kg in weight less relative to non-IUGR
subjects.

IFC cic
Univ
Westminster

IFC cic
Univ
Westminster

Carol Williams, 2009

2011

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

Carol Williams, 2009

2010
2011

Carol Williams

IFCcic & World Vision

Barker Hypothesis
Foetal origins of adult
disease hypothesis
Foetal programming
hypothesis
Thrifty phenotype
Adverse environments in
foetal life and early
childhood establish
increased risk of disease in
adult life

IFC cic
Univ
Westminster

Linkages, Nepal

Carol Williams, 2009

2010
2011

From Adam Cunliffe

STRONG association
low pre-pregnancy
weight and IUGR.
Most LBW in developing
countries is due to IUGR,
primarily due to maternal
undernutrition before
conception or during
pregnancy

If under-nutrition interventions are directed at

pregnant women it is too late.
Pre-pregnant weight is important
IFC cic
Univ
Westminster

Carol Williams, 2009

2010
2011

Teenage Mums
Need energy for their own growth as
well as pregnancy
May not have any fat stores to draw
Usually need to eat more than older
pregnant women to avoid constraining
own growth and development.
Nutrients of concern: Energy, Iron,
Vitamin A, Zinc
Vulnerable group in need of extra provision for
IFC cic + postnatal generally
Aug-11
Carol
CarolWilliams,
Williams,IFC
cic
preg
2011not
just for nutrition

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

Foetal origins of disease hypothesis

(thrifty phenotype/ Barker Hypothesis)
susceptibility to adulthood cardiovascular
disease (CVD), non-insulin-dependent diabetes
mellitus (NIDDM), and the insulin resistance
syndrome (IRS) is programmed in utero and is a
response to foetal under-nutrition..
adaptation to undernutrition in foetal life
permanent metabolic and endocrine changes
occur which would be beneficial if nutrition
remained scarce after birth. If nutrition becomes
plentiful, however, these changes predispose to
obesity and impaired glucose tolerance.
IFC cic
Univ
Westminster

Carol Williams, 2009

2010
2011

Eating more? Boosting pregnancy energy intakes

Supplement studies in pregnancy fail to find
convincing results, because fail to correct
for gestational age
pre-pregnancy weight
adjustment in physical activity
displacement, eat the supplements but less of
normal diet.
intake maternal weight fetal growth.
Hypothesis no longer acceptable
Aug-11
IFC
Univ
cic
Westminster

Carol
Carol
Williams,
Williams
2010
2009

28

Teenage mothers
About 16 million women 1519
years old give birth each year,
about 11% of all births worldwide.
Ninety-five per cent of these births
occur in low- and middle-income
countries.
Half of all adolescent births occur
in just seven countries:
Bangladesh, Brazil, the Democratic
Republic of the Congo, Ethiopia,
India, Nigeria and the United
States
IFC cic
Aug-11

London Evening
Standard

Carol
CarolWilliams,
Williams,IFC
2011
cic

Carol Williams

IFCcic & World Vision

Reproduction against the odds

Gambia Study 1980s Prentice. New Scientist
Research pre 1980s suggested that women
from developing countries produce less milk
(500ml/day) compared with developed countries
(1000ml/day).
Hypothesis: Milk production limited by lack of
food.
In Gambia - Infants grew well until 3 months
then severe growth faltering.
This coincided with hungry season and
maternal weight loss
IFC cic

Carol Williams, 2011

2. Energy content

750ml /day
67-70kcals/100ml

Total calories produced/day 500kcals

3. Efficiency of production

80-90%

4. Extra dietary energy mother requires/day to

make the milk
500 x 100 = 625 kcals/day
80
IFC cic

Carol Williams, 2011

Human uniquely adapted to

preserve feeding of infant
Milk production only constrained in
severely malnourished, especially
where poor dietary intake in pregnancy
is followed by poor intake during
lactation
Stress of pregnancy and lactation in
humans is low baby grows slowly
(allows for differentiation and
development of brain) one fifteenth
stress of mouse or cow
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Results:

No effect on milk production

Mums felt better fewer clinic visits,
more agricultural production
Earlier return of fertility.
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Energy costs of lactation?

1. Average milk production

Intervention: Calorie rich biscuit

- added approx 430kcals/day

Carol Williams, 2011

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia

Carol Williams, 2011

Adaptive strategies/consequences
Decrease in activity levels
compared to pregnancy??
BMR BMR declines in
pregnancy and this persists if
diet regularly insufficient
during lactation
Increased efficiency of milk
production
IFC cic

Carol Williams, 2011

Report on Human
Energy Requirements.
FAO/WHO 2004

Energy requirement for lactation

energy intake that will maintain body weight and
composition, level of physical activity and
breastmilk production ALL of which are
consistent with good health for woman and her
child
.. and allow her to perform economically
necessary and socially desirable activities.
assuming she resumes her usual level of
physical activity soon after giving birth
IFC cic

Carol Williams, 2011

Carol Williams

IFCcic & World Vision

Energy requirements for lactation 0-6M

Exclusive Breastfeeding
FAO/WHO 2003

500kcal/day for
well nourished
mothers,
assumes 0.8kg wt
loss/month.
675kcal/day for
undernourished
mothers
IFC cic

Carol Williams, 2011

Energy Requirements for lactation after 6M

Example of extra food needed each day by a

breastfeeding woman
60 g rice

(1 fistful) 240 calories

30 g beans (1/2 fistful) 120 calories

vegetables (1 fistful)
half a banana

90 calories

5 ml oil (1 teaspoonful) 50 calories

IFC cic

Carol Williams, 2011

Maternal post partum weight loss

FAO/WHO 2003

Mean amount Breastmilk

produced similar in
different population groups
Main factor influencing
energy needs are
Duration
Exclusivity
Hence need population
specific energy
requirements for
lactating women.
IFC cic

Carol Williams, 2011

Studies on weight loss and

breastfeeding somewhat
inconclusive because many
other variables - and not
exclusive BF.
Overall, breastfeeding women
tend to loose more weight
during second 6 months of
continued breastfeeding,
than in first 6 months.
Breastfeeding frequency
relates to rate of weight loss
IFC cic

Carol Williams, 2011

Summary Nutritionally Equipped for

Pregnancy & Lactation
For pregnancy - interventions greatest effect if
delivered before conception and during the first
12 weeks.
For breastfeeding IF mother low prepregnancy weight and did not gain ideal
pregnancy weight, her energy stores for lactation
will be low, so she needs extra calories when
breastfeeding.
BUT if mother normal pre-pregnancy weight and
pregnancy weight gain, she does not need to eat
for two when breastfeeding.
IFC cic

Carol Williams, 2011

Maternal & Child Nutrition: Infant and

Young Child Feeding Advocacy Course.
Phnom Penh, Cambodia