Importance of micro-nutrients supplementation during pregnancy
With the increasing consciousness flourishing among people for the best antenatal care, the Internet is bombarded with information on how to remain healthy during pregnancy. Following a balanced diet during the significant milestone is very important to both the mother as well as the growing fetus. While we know most of the food items to avoid during pregnancy like alcohol, cigarettes and cold drinks, many of us are still unknown and unaware of which nutrients to consume more to nourish the mother as well as the growing baby. Pregnancy increases the demand for nutrients and supplementation becomes a necessity. During pregnancy, a woman’s macro-nutrients (carbohydrate, protein, and fat) intake grows dramatically. However, the intake needs of micro-nutrients (vitamins, minerals, and trace elements) increases even more parallel to the micro-nutrients.
Parul Christian, Dr. P.H., of Johns Hopkins University summarizes: “Micro-nutrients inadequacy is a critical concern among pregnant women and young children throughout the world. Gestation and the early postnatal period are considered sensitive periods for brain development, and nutritional deprivation during this period may lead to functional impairments”. Deficiencies in maternal micro-nutrients status are a result of poor quality diets, high fertility rates, repeated pregnancies, short inter-pregnancy intervals, and increased physiological needs. These factors are aggravated by often inadequate health systems with poor capacity, by poverty and inequities, by socio-cultural factors such as early marriage and adolescent pregnancies, and some traditional dietary practices. Deficiency of micro-nutrients during pregnancy may give rise to complications such as anemia and hypertension, as well as impairing fetal function, development and growth.
- Iron:
Iron is a mineral that is found in many proteins and enzymes that the body needs in order to stay healthy. Most of the iron in our bodies is found inside hemoglobin, the pigment in red blood cells. Low levels of hemoglobin are also known as anemia. A report from the World Health Organization estimates that 48% of the world’s pregnant women and a report from Nepal Demographic and Health Survey (NDHS), 2016 indicates that 41% of pregnant women in Nepal are anemic which has resulted as; anemia, a leading cause for increasing the risk of maternal complications and impelling it to become a major root for maternal morbidity and mortality. A majority of these cases of anemia are due to iron deficiency as iron is the major constituent required in the synthesis of haemoglobin. Complications like low birth weight, preterm birth, and in severe cases, perinatal mortality may result from an anemic mother. Iron supplements are particularly important for pregnant women who have anemia. In women who have normal iron levels, taking iron supplements as a precautionary measure probably doesn’t have any health benefits. They can get enough iron from their diet. The vulnerability of an individual to iron deficiency depends on the amount of iron stored within their bodies. The body iron requirement for a pregnancy is approximately 1,000 mg. During pregnancy, loss of blood occurs most frequently,
- During delivery (both C-section as well as in vaginal delivery)
- Basal loss of blood during pregnancy
Hence, an adequate amount of iron in a balanced diet is very much essential.
Sources of Iron:
- Liver (The best source of iron among animal products)
- Eggs
- Red meat
- Oily fish
Some plants are also a very good source of iron. These include
- Cereals
- Legumes such as lentils and beans
- Green leafy vegetables like lettuce and spinach
- Herbs like parsley and cress.
Supplementation iron:
WHO suggests the intake of 30–60 mg of elemental iron to prevent maternal anemia, low birth weight, and preterm birth. Some formulations of iron available in the market are: Ferrous gluconate, Ferric ammonium citrate, Ferrous sulfate, Ferrous sulfate anhydrous, Ferrous fumarate, Carbonyl iron and Polysaccharide-iron complex. Each of the above mentioned formulations have different percentage of Iron contents.
Iron appears to be best tolerated when administered at bedtime. Potential side effects of iron administration include heartburn, nausea, upper abdominal discomfort, and constipation.
2. Folic acid:
This vitamin is known as ‘folate’ when it is found naturally in food, such as green leafy vegetables, and as ‘folic acid’ when it is added to food, such as bread and breakfast cereals, or used in dietary supplements. Folate deficiency, leading to megaloblastic anemia is the second leading cause of anemia during pregnancy. Folate, a vitamin-B derivative is very important in synthesis and maintenance of DNA and also in fetal development. In the first few weeks of pregnancy, folic acid helps in the formation of the embryonic neural tube, the precursor to the baby’s brain and spinal cord, to close properly. It also assists in the formation of the fetus’ heart and circulatory system and helps lower the chances of birth defects. Because folic acid is water-soluble, the body does not store excess of it. Instead, it gets passed through the urine. Folic acid also decreases the risk of miscarriage, gestational diabetes (diabetes occurring only during pregnancy), preterm birth, neural tube defects in the fetus, and congenital heart defects.
Sources of Folic acid:
Dietary folate is a naturally occurring nutrient found in foods such as:
- Vegetables (broccoli, cabbage, cauliflower, spinach, green beans, lettuce, mushrooms)
- Fruit (avocado, grapefruit, orange)
- Legumes (chickpeas, soya beans, lima beans, red kidney beans, lentils, haricot beans)
- Eggs
- Nuts
- Juices (many apple and orange juices)
- Liver
Supplementation of folic acid:
Folic acid is a synthetic dietary supplement that is present in artificially enriched foods and pharmaceutical vitamins. Experts at the American College of Obstetricians and Gynecologists (ACOG), the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force (USPSTF) all recommend pregnant women to consume at least 400 mcg (micrograms) of folic acid every day. The folic acid supplements are easily available in Pharmacies.
3. Calcium:
Calcium is a very important mineral required in human development since the very beginning. Consumption of an appropriate amount of calcium during pregnancy is very important to both the fetus as well as the mother. Calcium helps strengthen the baby’s rapidly-developing bones and teeth, and boosts muscle, heart and nerve development as well. Intake of calcium during pregnancy helps to overcome the risk associated with gestational hypertension (rise in blood pressure during pregnancy) and pre-eclampsia (a complication of gestational hypertension associated with the presence of protein in urine). Gestational hypertensive disorders are the second main causes of maternal morbidity and mortality, as well as being associated with an increased risk of preterm birth and fetal growth restriction, the leading cause of early neonatal and infant mortality. Calcium supplementation during pregnancy reduces the incidence of gestational hypertension by 35%, pre-eclampsia by 52%–55%, and preterm births by 24%.
Sources of Calcium:
- Milk is the best source of calcium.
- Cheese
- Yogurt
- Tofu
- Canned salmon
- Turnip greens
- Black-eyed peas
- Broccoli
- Orange juice
- Cereals
- Almonds
Supplementation of Calcium:
The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant and breastfeeding moms aged 19 and over, consume 1,000 mg of calcium each day. The World Health Organization (WHO) now recommends 1.5 g to 2.0 g of elemental calcium per day for pregnant women with low dietary calcium intakes. Calcium supplements can be found in nearby pharmacies in combination with vitamin-D. But supplements should be added to the existing balance diet, not replace it from natural sources of calcium.
However, ingesting too much calcium can cause constipation, kidney stones, irregular heartbeat, and low calcium in the baby’s body.
4. Vitamin-D:
Vitamin D is a vital nutrient required for calcium absorption and bone metabolism. Vitamin D deficiency is estimated to affect one billion people globally and is increasingly recognized as being common amongst pregnant women. The biologically active form of vitamin D is 25-hydroxyvitamin D. A systematic review suggested that women with a lower level of circulating 25-hydroxyvitamin D (25(OH)D) in pregnancy have an increased risk of preeclampsia, gestational diabetes mellitus, preterm birth which are the most prevalent complications of maternal hypocalcemia (low levels of calcium) and is clearly associated with substantial morbidity. Besides, an association between lower levels of Vitamin D and a higher risk of Cesarean section and bacterial vaginosis has also been demonstrated along with less efficient glucose metabolism in the fetus.
Sources of Vitamin D:
- Sunlight
- Egg yolk
- Fatty fish such as Catfish, Tuna, Salmon and Mackerel
Although liver and cod liver oil are a good source of vitamin D, they are not recommended during pregnancy because they contain too much vitamin A which is to be avoided during pregnancy.
Supplementation of Vitamin D:
According to WHO, pregnant women should be encouraged to receive adequate nutrition, which is best achieved through the consumption of a healthy balanced diet. Vitamin D supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.
Pregnancy is one of the most important periods in life when increased micro-nutrients and macro nutrients are importantly needed by the body; both for the health and well-being of the mother and for the growing fetus and newborn child. The necessity for improved diets, health, and sanitation are consistently recommended, throughout the world. Micro-nutrients likely to be important for maternal, infant and child outcomes include iron, folate, vitamin D and calcium as mentioned above and besides these, other important nutrients include magnesium for preventing gestational hypertension and pre-eclampsia, probiotics to reduce the incidence of allergy among children, Vitamin C for tissue repair, healing, and bone development, Iodine for normal functioning of the thyroid gland, Vitamin B-12 for improving nervous system development in fetus and zinc for proper tissue growth which is mostly encouraged through appropriate dietary intake. Consequently, supplementation programs, fortification and nutrition, and health support needs to be scaled-up, supported by social and cultural measures all around the globe.
Because of the life-long influences on reproductive outcomes, both clinical and public health measures need to ensure adequate micro-nutrients intakes during pregnancy. Many antenatal cares aren’t being able to afford this for vulnerable populations. However, the success could help break the inter-generational reality of low birth weight infants growing up disadvantaged and stunted. In addition to programs to reduce micro-nutrient deficiencies such as micro-nutrients supplementation and food fortification, needed complementary interventions should optimally improve overall maternal nutrition and also reduce the burden of maternal infections such as HIV and malaria, improve sanitation, and actively address gender and social disadvantage. Further, with the objective to contribute towards improving the health, nutrition and well-being of infants and young children (0–5 years), and the health and well-being of mothers and mothers-to-be by protecting, promoting, supporting and monitoring Maternal, Infant and Young Child Nutrition (MIYCN) has been established by World health organisation (WHO) worldwide.
References:
- Lim CE, Yii MF, Cheng NC, Kwan YK. The role of micronutrients in pregnancy. Australian Journal of General Practice. 2009 Dec 1;38(12):980.
- Darnton-Hill I, Mkparu UC. Micronutrients in pregnancy in low-and middle-income countries. Nutrients. 2015 Mar;7(3):1744–68.
- Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition During Pregnancy: Part I Weight Gain: Part II Nutrient Supplements. Washington (DC): National Academies Press (US); 1990. 14, Iron Nutrition During Pregnancy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235217/
- https://www.whattoexpect.com/pregnancy/pregnancy-health/folic-acid-during-pregnancy/
- Greenberg JA, Bell SJ, Guan Y, Yu YH. Folic acid supplementation and pregnancy: more than just neural tube defect prevention. Reviews in Obstetrics and Gynecology. 2011;4(2):52.
- https://www.rcog.org.uk/globalassets/documents/guidelines/scientific-impact-papers/vitamin_d_sip43_june14.pdf
