Nutrition in pregnancy

By Gillian (CARiNG Pharmacist) | Malaysia | Wed Mar 18, 2015 12:42pm

Nutrition in pregnancy

Good nutrition before and during pregnancy is important.  Poor nutrition can increase the risks of birth defects and of having an infant with low birth weight. Evidence shows that low birth weight and preterm birth may increase the risk in adult life of certain medical conditions.  These include high blood pressure, insulin resistance, cardiovascular disease and reduced bone mass.   However, the idea of 'eat for two', even if you are having twins, is not encouraged.

During pregnancy your body is more efficient at using the nutrients found in food.  Although adequate weight gain is crucial to reduce the risks of having an infant of low birth weight, excessive weight gain should be avoided.  Before pregnancy, women who are thin (BMI < 18.5) need to gain more weight than women with ideal weight (BMI 18.5 – 24.9).  For overweight women (BMI > 25) need to gain less weight. 

For women with a normal pre-pregnancy weight, 11.3 – 15.9kg is a healthy weight gain. Too much weight gain increases your risk of developing problems later in the pregnancy such as high blood pressure. Also, extra weight is difficult to shed after the birth. If you are under weight or overweight your target may be slightly different. For obese pregnant women, restrictions in food intake during pregnancy are never recommended without the supervision of a registered dietitian. If possible, ideal body weight should be achieved before conception.

What should I eat?
Aim to eat a healthy balance diet that contains a variety of:

A third of most meals should be starch-based foods such as rice, bread, potatoes, noodles and cereals – choose high fibre varieties when possible. These provide energy, vitamin B complex and some minerals.

Eat less refined carbohydrates including sugary food, cakes, biscuits, chocolate and confectionery.

Protein foods
Have 2-3 portions of protein foods each day. These are needed for the growth and development of your baby. Good sources are lean meat, fish, eggs, beans, milk, cheese, and vegetable proteins. Opt for low fat varieties when possible.

Small amounts of fats are required as they are high in calories. Use good fats such as poly- or mono-unsaturated oils such as olive, grape seed or sunflower.  Limit the intake of bad fats such as saturated fats (e.g. butter, lard, suet) and trans-fats.

Fruit and vegetables
Aim to have 5 or more servings of fruits and vegetables each day - (which everyone should be eating, not just pregnant women).  They are high in fibre and rich in many vitamins and minerals that are essential for good health.  Try as wide variety of colours as possible.

Dairy products
Other than their proteins, they are an important source of calcium, which is required for growth and development of healthy bones and teeth. Drink 1 pint of milk each day. You may replace 1/3 of this pint for 25g (1oz) of hard cheese or a small pot of yogurt for variety.

Probiotic drinks or live and bio yogurts are safe to drink.

What about supplements?

Folic acid
Folic acid helps to reduce the incidence of neural tube defects, such as spina bifida. If you are planning a pregnancy (the time you stop using contraception) you should take a daily supplement of 0.4mg of folic acid before you become pregnant and for the first 12 weeks of your pregnancy.

Spina bifida, a malformation of the baby’s spine, occurs at some point during the first 28 days of pregnancy. If folic acid is not started until your pregnancy is confirmed, the damage may already have been done.

Most women need 400 micrograms (0.4 mg) a day.  Women with increased risk of having a child with a spinal cord problem need 5 mg a day. You have an increased risk if:
  • You or your partner have (or have a family with) a spinal cord defect.
  • You are taking medication for epilepsy.
  • You are obese - BMI is 30 or more.
  • You have had a previously affected pregnancy.
  • You have coeliac disease, diabetes, sickle cell anaemia, or thalassaemia.

In addition to taking a supplement, food rich in folic acid should be eaten. These are raw or lightly cooked green vegetables, oranges, fresh orange juice, baked beans, brown rice, potatoes and fortified breakfast cereals and breads.

Vitamin D
Vitamin D is recommended for all pregnant women to prevent a bone condition called rickets in you and your baby. The best source of vitamin D is sunlight. And it is quite difficult to obtain 10 micrograms daily of vitamin D from diet alone.  Taking a supplement providing 10 micrograms daily of vitamin D may therefore be an option, particularly for Asian women who have low sunlight exposure.    

The increased requirement of iron during pregnancy is met through cessation of menstruation, mobilization of maternal iron stores and increased absorption from the diet.  Therefore not all pregnant women are prescribed iron tablets.  However, you should still make sure that your diet contains plenty of iron.  Foods rich in iron should be considered throughout pregnancy and these include red meat, whole meal bread, fortified breakfast cereals, green vegetables and beans.  Eat a good source of vitamin C (e.g. fresh orange juice, fruits, and tomatoes) with every meal as this improves iron absorption.  Iron is also included in most pregnancy vitamins.    

Growing baby needs calcium to develop.  Calcium is important to build strong bones and teeth, and to grow healthy.  If you don't get sufficient calcium in your diet during pregnancy, your baby will take it from your bones, putting you at risk for osteoporosis.   

Most Malaysian women don't get enough calcium. Aim for four servings of dairy products (cheese, milk, yogurt) or other calcium-rich foods a day (firm tofu made with calcium sulfate, spinach, sesame seeds, dry roasted almonds, calcium-fortified orange juice, soy drinks).

In populations where calcium intake is low, calcium supplementation is recommended for pregnant women who have one or more of the following risk factors for pre-eclampsia: previous pre-eclampsia, chronic hypertension, diabetes, renal disease, obesity, autoimmune disease, nulliparity, women age 35 or more, teenage pregnancy, and pregnancy conditions leading to large placentas (e.g. twin pregnancy). This is not an exhaustive list.  Speak to your doctor if you have any concern.

WHO provides guideline on Calcium supplementation in pregnant women. All pregnant women, particularly those at higher risk of gestational hypertension, need 1.5 to 2.0g of elemental calcium per day, from 20 weeks gestation until the end of pregnancy. Make sure your total intake from food and supplements does not exceed 2.5g.  The total daily dosage should be taken at 3 divided doses, preferably taken at mealtimes. Your body can only absorb about 500 mg of calcium at a time.  Most prenatal vitamins provide between 150 to 200mg of calcium, and a separate calcium supplement could be considered.  It is important not to overdo it.  Excessive amount of calcium can cause constipation, hinder the absorption of iron and zinc from foods, and may also increase your risk of kidney stones.

Omega 3
Omega 3 fatty acids (specifically DHA and EPA) are important for your baby's brain and eye development. Cold-water fish – also referred to as oily fish – contain the highest amounts of omega-3s.  Taking omega-3 supplement might be a good idea if you're not eating fatty fish once or twice a week or you're avoiding fish that are high in mercury. With the advance of pharmaceutical technology, most omega 3 supplements are virtually mercury-free. 
Avoid fish oil supplements derived from cod liver oil as it may contains the amount of vitamin A that are potentially harmful during pregnancy.
Most experts suggest 300 milligrams (mg) of DHA a day during pregnancy. Taking a daily supplement with 200 mg of DHA may be sufficient since the rest can be obtained from other foods.  Select a brand that also contains some EPA- so far there's no consensus on how much EPA needed.  Many foods are now fortified with omega-3s.  These include eggs, milk, yogurt, margarine, soy drinks and cereal.  Some contain very little DHA or EPA, but small amounts add up.  Look for products that contain at least 50 mg of DHA per serving.  
If you are allergy to fish, omega-3 supplements derived from algae is an excellent alternative.  These supplements have no mercury, no fishy aftertaste, and they are also suitable for vegetarians.

What should I avoid?

Vitamin A
Excessive vitamin A could harm your baby, particularly during the first three months of pregnancy.  It is unlikely you will get too much vitamin A from a normal varied diet. But women planning to conceive or pregnant women should avoid taking any supplements containing vitamin A or fish liver oils unless instructed by their GP.  High sources of vitamin A such as liver should also be avoided. Vitamin A found in dairy products (milk, yogurt) or in plant sources (carrots, green vegetables) is safe to consume. 

Food & drink to avoid
Fish provides a good source of high quality protein, vitamins and minerals.  Eat at least two portions of fish per week, with at least one portion being oily fish (see below). Oily fish are rich in omega-3 fatty acids which are important to aid brain development. 

However, there are concerns about the mercury content in some fish – mercury can harm the developing nervous system of a feotus.  As a result, the Food Standards Agency advises:
  • Avoid shark, marlin and swordfish
  • Limit fresh tuna to 2 steaks per week and tinned tuna to 4 medium cans per week.
  • Eat other oily fish (salmon, sardines, pilchards and mackerel) to no more than 2 portions per week.

 White fish such as cod and haddock do not need to be restricted.

Both you and your partner should avoid alcohol when you are planning to get pregnant.  Alcohol can adversely affect a baby’s development particularly during the first three months of pregnancy. 
If you do choose to drink alcohol, you should only drink a maximum of one or two units once or twice a week. The less you drink the better for your baby. 

You should limit your intake of caffeine to 200mg each day.  Too much caffeine increases your risk of having a miscarriage and a baby with low birth weight. The increased risk is small, but it is best to play safe.  As a rough guide, the following contain about 200mg of caffeine:
  • 2 mugs of tea or instant coffee
  • 1 mug of brewed or filtered coffee
  • 200g of plain chocolate
  • 400g of milk chocolate
  • 5 cans of cola
  • 2 cans of energy drinks

Food which may have high levels of listeria
Listeria is a germ that can cause a flu-like illness if it occurs in pregnancy.  It can cause miscarriage, birth defects, stillbirth, or infections in the baby after birth. Listeria has been associated with some foods. Foods which are most at risk of carrying listeria are:
  • Under-cooked meats.  This also applies to pre-cooked meats.  Reheat all ready-cooked meals until they are piping hot.
  • Raw or under-cooked eggs.  Avoid  all recipes that use raw eggs.
  • Mould-ripened and soft cheeses such as brie, Camembert and blue-veined cheeses. (Hard cheeses such as Cheddar are safe to eat).
  • Raw shellfish and raw fish.
  • Unpasteurized milk

  1. WHO Calcium supplementation in pregnant women
  2. www.patient.co.uk/health/diet-and-lifestyle-during-pregnancy
  3. Departments of Nutrition and Dietetics and Norfolk and Norwich University Hospitals NHS Foundation Trust
  4. www.babycenter.com




Safe Disposal of Medicine

By Lee Yean Ling (CARiNG Pharmacist) | Malaysia | Tue Apr 21, 2015 5:51pm

Medicines play an important role in our life... they‘re stored in every household..
Read More >

FAT, ditch it or not?

By Charlene Ooi (CARiNG Pharmacist) | Malaysia | Sat Mar 07, 2015 12:07pm

Fat is a scary word. We often relate fat to obesity and cholesterol. The fact is we need to consume fat to stay healthy. Of course not just any types...
Read More >

Antibiotic resistance? Why should I be concerned?

By Goh Kay Lai (CARiNG Pharmacist) | Malaysia | Thu Mar 05, 2015 4:58pm

It is estimated 700,000 die from infection of antibiotic-resistant bacteria worldwide and these number can further increase to 10 million by 2050 if its treatment could not be found.  Antibiotic resistance is a serious...Read More >