Chapter 1
The Islamic university of Gaza
Faculty of nursing
Midwifery department
Human Nutrition
Lecturer : wafa Abeid
Feb. 2015
Chapter 1: nutrition
basic concepts
Health: The merging and balancing of five physical and psychological dimensions of health: physical, mental, emotional, social, and spiritual.
Nutrition: The study of essential nutrients and the process by which nutrients are used and quality of nutrients
Nutrients: Substances in food required by the body for energy, growth, maintenance and repair.
Role of nutrition:
• Physical health of the body .depends on the quantity and quality of nutrients,
• Intellectual health relies on a well functioning brain and central nervous system, (iron deficiency
• . anemia affects intellectual health),
• Emotional health may be influenced by poor eating habits (hypoglycemia),
• Social health often centers around food-related occasions, and
• Spiritual health often has ties to food.
Health promotion: increases the level of health of individuals, families, groups, and communities.
Role of nutrition:
Healthy people 2010, defines some objective nutrition as decreasing daily fat intake, and less total caloric intake.
Wellness: is a lifestyle that enhance each of the five dimensions of health. Wellness nutrition approaches food consumption as a positive way to nourish the body. Consuming a diet based on lower fat/higher fiber and moderate caloric consumption is essential to convey competency to care for ourselves.
Disease prevention:
Is the recognition of a danger to health that could be reduced or alleviated through specific actions or changes in life style behaviors.
There are three levels of prevention,
1. Primary: activities to avert the initial development of a disease or poor health, low fat and high fiber diet is important;
2. Secondary: early detection to halt or reduce the effects of a disease or illness, sodium intake restriction may control HTN, and consequently avoid HD;
Tertiary: to minimize further complications or to assist in the restoration of health. Direct treatments of many disorders have a dietary components (ulcer, coronary heart disease
-Nutrition is consider as vital component in personal health care.
-Promotion of health, and prevention of disease for all people, rests on whole food supply.
-Human nutrition depends on attitudes toward food, and eating pattern through our life span, under influence of community, nation, and over all world.
-We need nutrition for maintenance of growth, activity ,and reproduction.
-The body need energy to carry out vital function as breathing, and the people need energy to perform physical activity, that could be met by food .
-Dietetics is the health profession ,having primary responsibility of application of nutritional care, in various state of health , and disease, with assistance of nurse and physician.
Definition of nutrition:
-Nourishment that sustain life, it begins from the moment of conception until death .
-The food people eat, and how it nourishes their bodies.
Kinds of nutrients:
1- Macro nutrients :
-Fats, carbohydrates ( CHO), proteins .
-Supply energy, build tissue.
2- Micro nutrients :
-Vitamins( vits ),minerals.
-Need in small amount.
-Regulate, and control body process.
-Source of energy:
1-Carbohydrates CHO :
-Primary source of energy.
-Sugar is simple CHO food, while starch is complex CHO food .
-The quick source of energy is glycogen.
-Each one gram of CHO, yield 4kilocalories .
-50to60% of energy taken from CHO diet .
2-Fats:
-Comes from plants and animals.
-Saturated fat from animals .
-Unsaturated fat from vegetables, and oil products .
-Each one gram of fat yield 9 kilocalories.
-25to30% of energy taken from fat .
3-Proteins:
-The body take energy from protein, when there is insufficient amount of CHO, and fat .
-Each one gram of protein yield 4kilo calories.
-15to29%of total energy taken from protein.
-The primary function of protein ,are building and energy.
NOTE: caloric is unit of heat used in the nutritional science, each 1000 calories equal 1 kilocalorie.
*Tissue building:
1-Protein the primary source:
-Responsible for tissue building .
-The necessary unit of building is called amino acid.
2-Minerals :
-Calcium and phosphorus help in building, and maintain bone tissue.
-Iron help in build of hemoglobin of red blood cell.
3-Vitamins:
-Vit C build tissue, and prevent bleeding in tissue .
4-Fatty acid .
-Metabolic regulation ,and control:
1-Vitamines:
-Many vits act as co-enzyme or cell enzyme, to govern chemical reactions in cell metabolism , example B-complex vits .
2-Minerals :
-Act as co-enzyme factors of cell metabolism.
Example: the trace element cobalt act with B12, to prevent occurrence of pernicious anemia,
3-Water and fiber :
-Regulate the passage of food through gastro intestinal tract (GIT), that help in absorption of different nutrient .
-Remember : water is the fundamental agent for life, provide the basis of metabolic process .
Nutritional assessment:
Nutritional assessment is the process of determining nutritional status. It may reveal nutrient deficiencies or excesses. The deficiency may be primary due to inadequate intake or secondary as a result of body inefficient use of nutrients. We can use two levels: evaluating the dietary intake, and evaluating the intake besides considering how the body uses the nutrients.
Diet Evaluation: 24-hour recall, usual food intake, a food record, a food frequency checklist, or a diet history. One the data collected, they can be analyzed.
Assessment of nutritional status:
1. Clinical examination, observing eyes, mucous membranes, skin, hair, mouth, teeth, and tongue.
2. Biochemical analysis of body tissue, blood and urine tests, iron.
3. Anthropometric measurements, Ht, wt, limp circumference.
Levels of nutritional status
Ideal nutrition:
Positive nutrition .-
-Well developed body .-
Ideal weight .-
Good muscle development, and tone .-
-The skin is smooth, and clear, hair is glassy .
-The eye clear, and bright .
Posture is good .-
-Facial expression is alert .
Appetite, digestion ,and elimination are normal .-
mentally and physically alert. -
Having essential nutrition, to resist infectious disease. -
-Sleep well at nigh.
-Border line nutrition -
-Poor eating habits, Whose living in stress environment, with low income .
-Has no reservoir of nutrition .
-At risk of physical illness
3-Malnutrition :
Nutrients energy are not enough to meet day to day needs .-
Associated with poverty .--
Affect infants, children, pregnant women, and elderly. -
Increase infant mortality rate, because of poverty, low income and, un-educated mother.-
- Children and pregnancy ,develop anemia result in ,
Low resistance to infectious disease.
Impaired learning ability. -
Reduce activity level .-
-Apathy .
Elderly suffering of chronic disease.
Over nutrition .-
-Over weight and obesity .
-Excess energy intake .
Lead to chronic disease, as hyper tension, and DM .
Note: *
-Specific dietary factors lead to:
-Coronary heart disease( CHD). -
High blood pressure( HTN ).- -
Stroke( CVA).- -
Some type of cancer . -
--DM.
Obesity .
Recommendation for good nutrition :
Eat variety of food , Well balanced diet. -
Maintain ideal weight. -
-Avoid too much fat ,saturated fat, and cholesterol.
Eat food with adequate starch, and fiber .-
-Avoid too much sugar.
-Avoid too much sodium.
Avoid alcohol intake. -
.chapter 2
Digestion ,Absorption ,& metabolism
- body food component travel together ,through GIT into the cell.
*basic principles of digestion:
-digestion:
prepares the food for the body use ,under effect of muscular &chemical reaction.
-muscular layer of the elementary system (serosa,submucosa,&mucosa),&fiber layer longitudinal or circular layer, help in the movement of food &push it forward ,this movement called peristalsis.
-chyme:fluid secreted by GIT to help in digestion .
-the action of food is under control of nervous system at GIT wall called intra-mural nervous plexus extend from esophagus to anus responsible for regulation of the rate &intensity of muscle contraction with coordination in various movement.
*definition of digestion:
-the process of break down food to release its nutrients for absorption & transport to the cell for use in the body .
*peristalsis:
Wave like progression of contraction & relaxation .
**types of GIT secretion:
-1-Enzymes: chemical action e.g. lipase ,amylase .
-2-hydro-choloric acid & buffer ions : necessary ph .
-3-mucous:protect the inside wall tissue of GIT,lubricate &facilitate food mass passage .
-4-water & electrolyte.
Mouth& esophagus: preparation &delivery:
-1*mastication:
-chewing break-down food into smaller particles by teeth & jaw muscle with tongue.
-2*swallowing:
-occur at mouth & pharynx.
-rapid less than one second .
-coordination &swallowing comes from(swallowing centre area) in the brain stem.
-gravity &muscle at the base of the tongue ,help in the movement of the food down to esophagus ,in the up-right position .
-in the stomach food enter by opening of the sphincter to prevent reflux ,&occurrence of heart burn .
** chemical or secretary digestion : 3 pairs of salivary glands ,parotid ,sub-maxillary , sub-lingual ,secrete salivary amylase this enzyme is specific for starch digestion .
*factors affect salivary secretion :-
1-sight . 2-smell. 3-taste. 4-touch. 5-thought of like & dis-like of food.
-normal range of daily saliva secretion between 800-1500ML,pH neutral 6.0 7.4
-stomach : storage & initial digestive process
.
-as the food enter the stomach ,the muscle of the stomach mix the food ,storage ,&control emptying .
-when the food mixed with chyme ,the pyloric sphincter constrict & relax for control of emptying at duodenum.
**types of stomach secretion :
a-acid : HCL hydro chloric acid .
b-mucous : protect the wall of lining stomach & lubricant .
c- enzymes: pepsin ,break down of protein (pepsinogen converted to pepsin under HCL secretion ),gastric lipase for fat , rennin in child-hood aid in co-agulation of milk ,but absent in adult .
-control process of gastric secretion under effect of :
1-nervous stimulus in response to sense ,ingested food & emotions ,e.g. anger & hostility increase secretion , while fear & depression ,decrease secretion .
2-hormonal stimulus in response to entrance of food into stomach ,e.g. gastric enterogastrone .
-small intestine: major digestion & absorption
-under control of nervous plexuses or hormonal stimulation ,the wall stretch from pressure of food .
-small intestine is chemical digestion by secrete large number of enzymes & assistance of pancreatic enzyme .
** types of secretion :
a- enzymes .
b-mucous from glands near the duodenum to protect the mucosa of intestine .
c-hormones that stimulate pancreas to secrete alkaline juice .
d-bile secreted from liver &store by gall bladder to dissolve fat .
Absorption
-end product of digestion .
-CHO (glucose, fructose, galactose ).
-fat (fatty acid ,glycerides).
-protein (amino-acid ).
-villi: finger like projection seen under microscope help in absorption .
*Routes of absorption :
-proteins &CHO become water soluble ,enter to blood stream ,go to liver ,&other tissue ,while fat is not water soluble ,bile secreted in intestine ,help in digestion of fat .
Large intestine : final absorption & waste elimination .
Water absorption take side at colon .
As much as 25% of meal may remain in rectum up to 7 hrs.
Mineral absorption :
Essential minerals as Na & K go to blood stream .
Bacteria in the colon syntheses vit K .
-intestinal bacteria affect color & odor of the stool .
Brown stool comes from bile pigment .
Intestinal gas or flatus produced by bacteria .
Fiber does not digested so it contribute to form bulk of the stool .
Normal feces contain 75% water, 25% solids .
Solids ( fiber ,bacteria ,minerals ,small amount of fat , mucous).
Metabolism
1-CHO metabolism :
Source of blood glucose *CHO &non CHO substances *
*CHO sources:
-dietary starch & sugars .
-glycogen from liver & muscle tissue , by hydrolysis glycogen to glucose .
*non CHO sources:
-from protein & fat .
-indirect source of glucose .
*in case of protein glycogenic amino-acid could be used in energy , if insufficient CHO .
*in case of fat broken to fatty acid &glycerol ,glycerol converted to glycogen in the liver .
-the process of production of glucose from protein or fat is called gluconeogenesis.
- *uses of blood glucose :
-normal blood glucose level 70-120mg \dl.
1- energy production .
2-energy storage :
Glucose converted to glycogen , stored in liver 7 muscle tissue .
Excess glucose converted to fat & stored in adipose tissue (fat tissue ).
3- glucose product :
Glucose enter in DNA &RNA building .
**hormonal controls :
-blood sugar lowering hormones
a- insulin decrease blood sugar ,produced by beta cells in the pancreas.
-convert glucose in the liver to glycogen by process called glycogen sis .
-convert glucose to fat & storage in adipose tissue .
b-blood sugar raising hormones :
*1-glycogen -produced from alpha cells of pancreas, opposite action of insulin .
*2-somatostatin:
-delta cells of pancreas .
-anti insulin effect
.
*3-steroid hormones :
-secreted from adrenal gland .
-anti insulin effect .
*4-Epinephrine :
-secreted from adrenal medulla .
-break down glycogen in the liver to glucose .
*5-grouth hormone :
-secreted from anterior pituitary gland .
-anti insulin effect .
*6-thyroxine :
-increase glucose absorption from intestine .
-2-lipid metabolism :
*liver &muscle responsible for fat production& fat breakdown .
*lipo-protein comes from absorption of protein &fat from intestine .
*GH, ACTH, TSH increase release of fatty acid /
*cortisone & hydro-cortisone increase fatty acid production .
*Epinephrine ,non epinephrine ,thyroxin ,insulin * decrease cholesterol secretion .
-3-protein metabolism
: -responsible about tissue building ,&tissue break down .
-GH,gonadotrophine hormone ,thyroxin participate in tissue anabolism tissue catabolism .
-break down of protein give amino acid .
-amino acid divided to :
*1 nitrogen ,end product is ammonia passed in urine & stool .
*2non nitrogen residue (ketoacid).
*3control agent (co-enzymes),enter in metabolic process .
Carbohydrates
*CHO is called quick energy .
*CHO major source of energy.
@Importance of CHO diet :
1-easily grown in plants ( grains ,vegetables ,fruits ).
2-low coast .
3-stored easily .
** classification of CHO :
CARBON ,HYDREGEN ,OXYGEN
@ monosaccharide:
- simple ( single sugar )
- glucose ,fructose ,galactose .
a- glucose : -sweet sugar
-found in corn syrup
- comes from starch digestion .
- old name dextrose .
- running in the blood stream .
- normal glucose level 70-110 mg %.
b-fructose :
-the sweetest of simple sugar .
- founds in honey , fruits .
- during metabolism ,fructose converted to glucose ,to form energy .
c-galactose :
- produced by human digestion .
-lactose change to glucose to form energy .
@ Disaccharides:
-two sugar molecules linked together .
- sucrose ,lactose ,maltose .
* sucrose ( glucose + fructose ).
* lactose (glucose + galactose ).
* maltose (glucose+ glucose ).
a-sucrose :
- table sugar .
-made from sugar cane ,& sugar beets .
-30-40 % contribute in the total Kcal .
-found in pineapple & carrots .
b-lactose :
-sugar in milk is called lactose .
-the least sweet disaccharides .
c-maltose:
-malt product of starch breakdown ,& germinating cereal grains .
@ polysaccharides:
- made-up of many sugar unit .
- - most important one is starch .
- Other type glycogen & dextrin & non digest able form of dietary fiber ( cellulose & noncellulose ),that provide important bulk in the diet .
*starch:
- most significant poly-saccharides .
-made up of many chains of simple glucose .
- starch mixture is thickened by cooling , because the starch granules has gel like quality that thick the mixture .
- important source of dietary CHO .
- significant factor in human nutrition .
-major food that contain starch include ( cereal grains ,legumes ,potatoes ,& other vegetables ).
* glycogen:
- it forms during cell metabolism .
- stored in small amount in the liver & muscle tissue , help to sustain normal blood glucose level during fasting period such as sleeping hours .
-dietary CHO is essential to maintain these needed .
- glycogen storage prevent the symptoms of low CHO intake ( fatigue ,dehydration ,& energy loss ).
-* dextrin:
-formed from break down of starch .
- starch+ water = soluble starch + maltose .
- soluble starch + maltose =dextrin + maltose .
-dextrin + water =maltose .
-maltose + water = glucose + glucose .
*oligosaccharides :-
- small portion of partially digested starch .
- it is irregular form .
- used in special formula for infant , or person with gastro-intestinal problem ,because it is easier to digest .
-* dietary fiber :
- cellulose found in the framework of plants , the human cant digest it , because lack of digestive enzyme , so it form bulk of diet thus stimulate peristalsis .
** Function of CHO:
- 1-energy production .
- 2-glycogen storage in the liver & muscle .
- 3-regulation protein metabolism .
- 4-anti-ketogenic effect { prevent formation of keton bodies from fat .
• keton bodies accumulated in case of {starvation ,un controlled DM, very low CHO diet }.
-5- heat action [ contractile process of the heart ].
-6-CNS stimulation { hypoglycemic shock lead to irreversible brain damage }.
* Digestion of CHO:
@ mechanical or muscular function that break the food into small particles .
@ chemical process in which specific enzyme break down food in to smaller usable metabolic product .
- mouth : mastication breaks food into fine particles & mix it with salivary secretion .
- -salivary amylase is secreted by parotid gland act on starch to break it in to starch & maltose .
- Stomach ,mix food with gastric secretion, no specific enzyme break down of CHO .
- - more food by peristalsis go to the 1st portion of the small intestine through pyloric sphincter .
- Small intestine :
- Mechanical & chemical digestion of CHO is completed in small intestine by intestinal & pancreatic enzyme .
- Pancreatic enzyme:
- Secretion of pancreas enter the duodenum .
- Pancreatic amylase break down of starch & maltose .
- Intestinal secretion :
- Sucrase , lactase , maltase act on disaccharides to change it in to glucose ,galactose ,& fructose to be ready for absorption .
** absorption of CHO:
-glucose carried in to the cell to produce energy or storage .
-the major glucose absorption mechanism is an active transport [ pumping system ] requiring Na as carrier substance .
- villi & micro-villi absorb about 90% of digested food .
-simple sugar enter portal circulation to liver .
** metabolism of CHO :
- chemical process in living
Organics by which energy is made available for function of entire organism
- cells are the functional unit of life in human body .
- the most important end product of CHO digestion is glucose .
- the liver is the major site of handling glucose .
-in the cell glucose is burned to produce energy through chemical reaction .
-extra glucose not immediately needed for energy may changed to fat & stored .
Proteins
- essential life substance of all living matter .
- act as structural unit to build our bodies .
- specific structural chemical units amino acids
- amino [alkaline substance carbon, hydrogen ,o2& NH2.
- Essential amino acid are 9 in number :
- Significant in our diet .
- The body unable to syntheses these 9 amino acid so get it from our food .
- *types of protein :
- 1-myosin : found in muscle ,has role in contraction & relaxation of muscle .
- 2-collagen: has role in strength of bone .
- 3-hemoglobin attach with iron in the RBCs ,help in carrying o2.
- 4- albumin : major plasma protein .
- 5- globulin : alpha beta gamma globulin ,act as antibodies of immuno system
- N.B: complete protein foods comes from animal source as egg ,milk, cheese , meat .
- Incomplete proteins food : plant food ,deficient of one or more essential amino acid , mostly of plant origin grains ,legumes ,nuts seeds .
- Mixture of protein animals & plant animals give balance in the ratio of amino acid .
- Functions of protein :
- A- growth & tissue building maintenance .
- B- specific physiological roles :
- Some types of amino acid used as neurotransmitter substance in the brain .
- Aid in metabolic hormones as thyroxin
- C- available energy .
- **digestion ,absorption & metabolism of proteins:
- @ mouth : mechanical break down of food by chewing food mix it with saliva ,push it to stomach .
- @ stomach : break down of protein to small particles by secreting enzymes pepsin ,HCL ** provide acidic media to convert pepsinogen to pepsin .
- Rennin : found in infancy & childhood to digest milk , rennin prevent too rapid passage of food from the child stomach .
- @ small intestine :alkaline media in the intestine ,also pancreatic secretion like trypsin & chemotropism.
- ** absorption of amino acid :
- the end product of protein digestion is the amino acid ,which is water soluble so absorption occur through blood stream .
- absorption of amino acid at duodenum carried by pyridoxine [ vit B 6 ].
- Metabolism of protein :
- Important protein balance is anabolism & catabolism .
- Protein more found in liver ,pancreas ,kidney & plasma lower protein in the brain ,muscle ,& skin .
- Tissue catabolism occur in case of starvation & aging process { tissue break down are exceed than tissue building } .
- Destruction of protein resulted in ; urea , uric acid ,ammonia .
- Protein requirement :
- Protein is essential nutrient .
- Under develop countries protein energy malnutrition .
- Primary role of amino acid important for growth ,& maintenance of tissue .
- Age ,body size ,general physical state has role in protein requirement .
- Disease increase need of protein diet especially in case of fever .
- Traumatic injury ,post surgical state require protein for wound healing .
- In case of burn , the need of protein increased .
- Protein should be adequate in quantity & quality.
- The need of protein increase in case of pregnancy .
Fats
- one important of macronutrient .
- each one gm of fat yield 9 kcal of energy .
• importance of fat :
• 1-source of energy & storage .
• 2-essential nutrient supply .
• 3-food satiety [ feeling of taste ,& add flavor to food , slow gastric emptying .
• Function of Fat :
• 1-energy production .
• 2-thermal insulation .
• 3-vital organ protection .
• 4-nerve impulse transmission .
• 5-enter in cell membrane structure & help in transportation of nutrient cross the cell membrane .
• 6-enter in cell metabolism { lipo protein carry fat in the blood to all cells }.
• 7-essential precursor substance{ fatty acid & cholesterol }.
• N B : too much of fat store in adipose tissue lead to increase body WT hypertension ,heart disease ,diabetes mellitus .
*physical characteristic of fat : greasy in touch ,insoluble in water .
*types of fat :
1- saturated fat : comes from animal origin ,fatty acid saturated with hydrogen .
2- monosaturated fat : comes from plant origin as olive oil ,fatty acid saturated with one hydrogen ion .
3- poly saturated fat : fatty acid is saturated with two or more of hydrogen ion ,comes from plant source as coconut oil, palm oil .
*essential fatty acid : the body cant manufacture it & therefore must obtain it from the diet .
-function :
@ membrane structure { strength the cell membrane }.
@cholesterol transport to blood .
@has role in blood clotting prolonged of clotting time
@ local hormone like effect { prostaglandin ,prostacycline thromboxane ,& leukotriens .
Prostaglandins :
- 1stly discovered in the semen which comes from prostatic gland .
- Has role in smooth mulched tone & platelet aggregation .
- Derived from fatty acid
- Hormone like action ,regulation of gastric acid secretion.
- Has role in inflammatory process & body temp. control .
- Lower of Bp .
*Triglycerides:
Three fatty acid chains attached with glycerol ,[ monoglycerids ,diglycerids ,triglycerides ].
- saturated fatty acid comes from animal source as milk , meat ,eggs .
- unsaturated fat comes from plant source as vegetable oils .
• visible & hidden food fat :
visible butter, margarine ,oil salad dressing ,bacon & cream .
- hidden fat : egg yolk is fat , white is pure protein , also nuts seeds , olives ,avocadoes .
*cholesterol :
Run in blood stream , consider vital structure in human metabolism , origin from steroid .
- essential in formation of bile .
- enter in enzymatic digestion of fat .
- found in large amount in the brain &nerve tissue .
- essential component of cell membrane .
- cholesterol has role in cardio vascular disease { atherosclerosis }.
• NB:
Lipoprotein is a mixture of lipid & protein .
-HDL: high density lipoprotein .
-LDL: low density lipo protein .
* digestion of fat:
-in the mouth fat break down into small particles by chewing & mastication .
-in the stomach mechanical mixing of fat with gastric secretion .
- in the small intestine , bile secretion & pancreatic enzyme , with small intestine secretion digest fat .
- because fat is not water soluble unite with protein to form lipo protein go to lymphatic system for absorption .
- metabolism : burn out of fat to produce energy .
Vitamins
Doesn't metabolize to yield energy .
-vital to life .
-group of substance turned out to have the particular metabolic activity .
- nitrogen –containing chemical substance called an amine { vital amine }.
*definition of vitamins :
-vital organic dietary substance that is not an energy producing CHO,fat ,protein ,needed in very small quantities to perform a particular metabolic function .
It cant be manufactured by the body & therefore must be supplied in food .
** classification of vitamins :
1- Fat soluble vitamins :
A,D,E,K
- they can be stored .
-associated with lipid .
2- water soluble vitamins :
-B complex family ,C
-they cannot be stored .
-vitamins B act as co-enzyme in cell metabolism .
-vita mine C is vital structural agent .
Fat soluble vitamins
** vitamin A :
- has specific function in the retina of the eye .
- found only in animal food sources .
- deposited in the liver ,kidneys ,lungs , & fat tissue .
- found in egg yolk ,liver ,pigment of carrots .
- absorption of vit A under assistance of :
1- bile salts so obstruction of bile duct , infectious hepatitis & liver cirrhosis = decrease the absorption of vit A .
2- pancreatic lipase .
3- Dietary fat stimulate bile release for effective absorption of vitamin A .
• absorption of vitamin A through small intestine to blood stream then to the lymphatic system then to liver 90% stored at liver .
• functions of vitamin A :
1- has role in visual adaptation to light & dark .
2- has role in covering epithelial tissue .
3- reproductive function .
• vitamin A deficiency lead to night blindness ,this condition usually cured in about 30 minutes by an injection of vitamin A .
• vitamin A is necessary to build & maintain healthy epithelial tissue & act as barrier to infections .
• the epithelium include not only the outer skin , but also the inner mucous membrane .
• without vitamin A the epithelial cells become dry & flat , then gradually harden to form keratin .
• keratin is a protein that forms dry scale like tissue , normal in the nail & hair , but abnormal in the skin & mucous membrane .
• ** deficiency of vitamin A lead to :
1- eye : cornea dries , blindness .
2- respiratory tract : dryness of epithelium & cracked of salivary glands .
3- gastro intestinal system : decrease of mucous membrane secretion affect on digestion & absorption .
4- genitourinary tract : vaginal infection & dryness of vaginal mucosa ,urinary tract infection ,stone formation .
5- integmentary function : skin become dry & scaly
6- tooth formation : decrease development of teeth
** N. B : vitamin A is essential for bone growth .
Vitamin A is necessary to support normal sexual maturation during adolescence period .
-sever deficiency of vitamin A lead to sterility
** vitamin A deficiency due to :
1- in-adequate dietary intake .
2- poor absorption due to lack of bile .
3- disease of the liver or intestine that obstruct its metabolism & absorption .
** hyper vitaminosis:
- joint pain
- thickening of long bone
- loss of hair
- jaundice
- liver affection ,portal hyper tension & ascites
** source of vitamin A : animal source [ liver ,kidney ,butter egg yolk ]
- plant source : green vegetables ,fruit
** vitamin D :
- fat soluble vitamin
- vit D 2, vit D 3
- Absorption of vit D 3in small intestine with aid of bile secretion
- Synthesis of vit D by help of skin [sun light ] ,liver ,kidney
- Vit D carries on globulin protein molecule to the liver & to kidney
- Chemical name of vit D is calcitriol
- Parathyroid hormone regulate calcium & phosphorus , also calcitonin secreted from thyroid gland enter in the process of bone mineralization
- Rickets is sever deficiency of vit D in children ,while osteo-malachia is deficiency of vit D in adult
- Osteo-malachia occur mostly in women child-Bering age who get little exposure to sunlight or having poor diet ,or who have frequent pregnancies
- Rickets most frequent in infant 6-18 months .
- Vit D used treatment of osteoporosis .
- Vit D stored in adipose tissue
** vit D toxicity lead to bone pain ,hyper-calcemia & failure to thrive .
- source of vit D from fruits ,liver oils ,milk
Vitamin E
- ant sterility vitamin , aid in increase sexual powers
- significant in human nutrition
- pale yellow oil
- insoluble in water
- absorbed in bile with lipid
- absorbed from small intestine
- stored in liver & fat tissue
** functions of vit E :
1- help in formation of cell membrane
2- protect the cell membrane from damage , deficiency of vit E lead to damage of cell membrane in RBC so it broken ,loss of its content then hemolytic anemia will be developed .
*vit E deficiency in adult lead to
{ neurological syndrome of vit E deficiency
1- spinal cord which affect walking & activity .
2- retina of the eye that damage vision
** vit E is important diet for pregnant & lactating mother
** vit E is the only one of fat soluble vits has no toxic effect on human
** vit E used in case of chronic pancreatic insufficiency & mal absorption
** food that contain vit E : vegetables ,oils ,nuts ,fruits ,cereals , meat
Vitamin K
- responsible for blood clotting
- synthesize by intestinal bacteria [ flora]
- vit K1 found in plant
- vit K2 found in intestinal bacteria
- vit K 3 water soluble doesn't require bile for absorption .
- vit K absorbed from intestine to lymphatic system .then to portal circulation to liver
- vit K stored in liver in small amount
- major function of vit K synthesis of blood clotting factors in the liver
- neonatology : the sterile intestinal tract of the newborn not well developed of bacterial flora ,so hemorrhagic disease of the newborn occur ,so prophylactic vit K immediately after birth should be given .
- antimetaboiltes inhibit the action of vit K
- vit K used as antidote of anticoagulant therapy
- in case of mal absorption there is prolonged blood clotting
- source of vit K comes from most vegetables especially green & in the liver .
Water soluble vitamins
** vitamin C :
- found in lemon juice to prevent scurvy .
- chemical name of vit c is ascorbic acid .
- like glucose structure .
- easily destroyed by alkaline , high temperature & o2
- don’t cut vegetables into small pieces until time of use ,keep juice tightly closed .
- easily absorbed from small intestine .
- cows milk contains very little vit C .
- **functions :
- Has role in cell metabolism .
- Build & maintain body tissue { bone matrix ,cartilage ,connective tissue }
- ** high concentration of vit C found in :
- Adrenal gland ,brain liver ,kidney ,pancreas ,thymus & spleen
- Vit C has role in formation of RBCs
- Vit C is necessary for syntheses of hormone as nor adrenaline
- vit C play role in wound healing
- vit c enter in formation of neurotransmitter of brain
- vit C help in resistance of fever & infection
- additional vitC required for growth during childhood ,pregnancy & lactation
- source of vit C : citrus fruit ,tomatoes sweet potatoes green vegetables .
- * signs & symptoms of vit C deficiency :
- *-weak capillaries ,& easily ruptured by trauma, bleeding gums [ gingivitis ]
B- vitamins
- vit B 1 ,B 2, B 6 ,B 12
- act as co-enzyme
** Vit B 1 :
- called thiamine
- water soluble vit
- destroyed by alkaline substance
- well absorbed in acidic media especially in the duodenum
- has role of metabolism
- deficiency of vit B 1 called : Beriberi
- ** signs & symptoms of Beriberi :
- 1-aneroxia
- 2-indigestion
- 3-constipation
- 4-parlysis
- 5-edema of lower limb
- 6-muscle pain
- ** the need of vit B 1 is increased during pregnancy ,lactation ,infancy ,childhood ,adolescence
- ** Riboflavin [ vit B 2 ]:
- Yellow –green pigment
- Water soluble
- Destroyed by light
- Absorbed in the upper part pf small intestine [ intestinal mucosa ]
- Milk decrease absorption of B vit B 2
- Act as co-enzyme
- Has role in production of energy
- Aid in tissue building
- Deficiency of bit B 2 lead to : tissue inflammation & break down , poor wound healing ,cracked lip ,swollen tongue
- *pyridoxine : { vit B 6 }
- Water soluble vit
- Sensitive to light
- Absorbed in the upper portion of the intestine
- Has role in protein metabolisms
- Bit B 6 regulate brain activity
- Neuritis is deficiency of this vit .
**cobalamine : { vit B 12 }
Deficiency of this vit lead to pernicious anemia
-source of this vit is mainly from animal origin
- absorption of cobalamin in the ileum
-this is common in vegetarian .
-
Minerals
- one of micronutrient substances .
- these elements deposited in the rock ,go to soil, then to plants , animal eat it ,then go to human .
- inorganic elements
- has vital role in human metabolism { building ,activity ,regulating ,transmitting ,& controlling }
- Na ,K [ shift of body water ]
- Ca ,ph provide structure of the body framework
- Iodine need for thyroid hormone
- 2% of Ca need to build the skeletal tissue .
** types of minerals :
1- major mineral
- found in large amount
-seven major minerals ( ca ,Mg ,Na ,K,ph ,sulfur & chloride )
2- Trace elements :
- found in small amount
- as iron ,iodine ,zinc ,copper ,Manganese ,fluoride
** Major minerals:
@ calcium :
10- 30 % of ca in diet is absorbed
-absorption of ca take place in small intestine especially in acidic media of duodenum
-** factors increasing ca absorption :
1- vit D hormone :
- consider as control agent of ca absorption
- vit D carry ca in the duodenum to mucosa of cell then to blood circulation
2- body need :
-growth
-state of hypocalcaemia
-pregnancy
-lactation
More ca is absorbed
3-diatery protein & CHO :
- greater percentage of ca is absorbed when the diet is high in protein
-lactose enhances ca absorption through the action of lactobacilli which produce lactic acid & lower intestinal pH
4- acidity :
- acidic media of intestine enhance ca absorption
** factors decreasing ca absorption :
1- vit D deficiency
2- dietary fat : excess fat decrease ca absorption
3- fiber & other binding agent
4- alkalinity : decrease ca absorption in alkaline media
N.B : in elderly person & post menopausal women the ability to absorb ca is reduced
** ca output :
70-90 % of ca remains to be eliminated in the feces,small amount of ca may be excreted in the urine
- daily requirement of ca 200mg \ day
** ca in the bone :
99% of ca storage in bone & teeth
** ca in the blood :
1% of ca circulate in the blood & other body fluid
**control agent of ca balance :
1- parathyroid hormone :
-release PTH to maintain normal level of ca
-stimulate intestinal mucosa for ca absorption
-stimulate kidney to excrete phosphorous
2- vit D hormone .
3-calcitonin : special C cell in the thyroid gland ,it prevent abnormal rise in serum ca
** functions of ca :
1- bone formation
2- tooth formation
3- general metabolic function
4- blood clotting
5- nerve stimulation
6- muscle contraction & relaxation
7- cell membrane permeability
8- enzyme activation
** clinical problems :
1- tetany : decrease ca
2- rickets
3- osteomalachia
4- osteoporosis
5- hypercalcemia ,renal stone
- food source of ca : milk ,cheese egg ,green vegetables , nut ,grains
** phosphorous :
1% of total body weight
- closely associated with ca ,called metabolic twin
- absorbed in the jejunum
- ph found in bone ,blood ,& cells
- ph under control of PTH& vit D
** physiological function of ph :
1- bone & tooth formation
2- general metabolic activity
3- absorption of glucose & glycerol
4- transport of fatty acid ,phospholipids
5- energy metabolism ( ATP)
6- buffer system [ control acid –base balance in the blood
** hypophosphatemia :
- celiac disease
- rickets
- osteomalachia
- hyperparathyroidism
symptom include muscle weakness
** hyperphosphatemia :
Renal disease
Hypoparathyrodism
- food source : milk & milk product ,lean meat
*sodium :
-absorbed through small intestine
-excreted through kidney under effect of aldestrone hormone
** physiological function of Na :
1- water balance .
2- acid base balance
3- cell permeability
4- muscle action
food source : salt used in cooking ,milk ,meat ,egg, carrot
** potassium :
-mainly found inside the cell
-has significant effect on muscle activity especially heart muscle
-absorbed in small intestine
-excreted through kidney
** physiological function of K :
1- water ,acid base balance
2- muscle activity
3- CHO metabolism
4- Protein synthesis
Food source : grains ,fruit banana orange ,green vegetables
**manganese :
Mg present in all body cell
-has role in energy production & build tissue
-it also aid in normal muscle action
- found in fruit ,nut ,grain
** chloride :
- out side of the cell
- help in control water acid –base balance
- highest concentration in the spinal fluid
- found in HCL hydro choleric acid
Trace element
** Iron :
- 45 mg \ Kg body weight .
- Enter information of hemoglobin .
- Storage mainly in the liver ,spleen ,& bone marrow .
- Excess iron storage called hemosidrosis .
- Absorbed in acidic media of the stomach .
• factors increased absorption of iron :
• 1- body need : during growth period [ pregnancy ,lactation ,childhood ]
• 2-acidic media : vit c aid in absorption of iron
• 3- calcium
• *factors decrease iron absorption :
• 1- substance as phosphate ,tea ,coffee
• 2- reduce gastric acid secretion
• 3- infection
• 4 –GIT disease as malabsorption
• physiological function of iron :
1- oxygen transport
2- cellular oxidation to produce energy .
3- growth need
** iron deficiency anemia may be :
1- nutritional anemia ,inadequate supply of iron
2- hemorrhagic anemia ,excessive iron blood loss.
3- Post gastrectomy anemia
4- Malabsorption anemia
5- Chronic disease anemia [ arthritis ]
*source of iron in food : liver ,egg ,vegetables ,cereals ,flour ,bread .
** Iodine
-participate in synthesis of thyroxin hormone
- 20% on iodine in thyroid gland
-absorbed in small intestine in form of iodide ,go to blood stream ,join with protein to thyroid gland & other tissue .
* physiological function of iodine :
1- thyroid hormone synthesis
2- plasma thyroxin : carry iodine in plasma protein to body cell [ muscle ,skin ,skeletal tissue ]
- hypothyroidism : decrease thyroxin hormone , creationism in children ,myexdema in adult .
- goiter is an enlargement of thyroid gland with decrease function .
\\ food source of iodine is sea food .
** Zink :
-stored in pancreas , liver ,kidney ,lung ,muscle ,bone , prostate .
* deficiency of Zink lead to :
1- hypogonadism : decrease function of gonads
2-taste & smell defect
3-decrease wound healing
4-chronic illness in aging [ reduce immune function ]
5- malabsorption disease .
- food source : sea food ,meat ,egg .
** Copper :
- iron twin
- act on energy production
- deficiency occur with total parentral nutrition
- found in liver ,seafood ,nuts ,seeds
** Manganese :
- stored in liver ,bone ,pancreas ,pituitary
- important in metabolic reaction .
- deficiency of manganese in D.M
- source : plant food ,cereal ,grains ,nuts ,tea ,coffee , vegetables .
** Fluoride :
- found in bone & teeth .
- deficiency of this substance lead to dental caries .
- fish & fish product & tea contain the highest concentration of fluoride .
- fluoridation of public water is very important .
Energy balance & weight management
- in the human body ,the various metabolic process converted ,stored chemical energy in our foods to other forms of energy for the body work .
- energy is available in four basic forms of life { chemical ,mechanical ,electrical ,thermal }.
- `over ultimate source of power is the sun .
- Chemical energy is changed to electrical energy in brain & nerve activity , it changed to mechanical energy in muscle contraction ,it changed to thermal energy in the regulation body temp.
- Types of energy :
- 1- free energy : at any given moment in the performance of task ,it is unbound & motion .
- 2- potential energy : in the energy that is stored or bound in the various chemical compounds available for conversion to free energy as needed for work .
- The basic input of energy comes from our food .
- Physical energy output is evident in our activities
** controls agent regulate cell activities :
@enzymes:
- all enzymes protein compounds .
- they are produced in the cell ,under control of specific genes .
- each specific gene controls the making of specific enzyme .
- there are thousands of enzymes in each cell .
- each enzyme works on its own particular substance .
- @ co-enzyme :
- Many reactions require partner to assist the enzyme in completing the reaction .
- These co-enzyme involve several of vits especially B- complex vits & mineral .
- @hormones:
- Hormones act as messenger to triggering or control enzyme action as : TSH; control on metabolic action .
- Insulin ;act on glucose utilization .
- Steroid ;regulate the cell activity to syntheses enzymes .
**source of stored energy :
- when food is not available in case of fasting or starvation the body take energy from his storage
- 1* glycogen : found in the liver & muscle .
- 2*muscle mass: protein exists in limited amount in muscle mass .
- 3* dispose fat tissue.
- N.B: one Kcal equal 4.184 KiloJol
- Mega joule = 239Kcal
- 1gm of beverage alcohol yield 7Kcal
Obesity
- excess body weight .
- over weight .
- fatness an excessive accumulation of fat in the body .
- body 50%water ,25% fat ,20% lean body mass ,5% minerals
- but it differ :
- * gender : woman have more fat tissue ,men has more muscle mass .
- *age : younger adult have more lean body mass & less fat than do older adult .
*physical exercise : physical activities less fat
*race : black women have more mineral mass than do white women .
* climate : those in cold climate have more s.c fat than in those in hot tropical area .
*weight extreme : obese person have excess fat in relation to lean body mass .
Male : 47.7Kg ,150cm
Female : 45Kg ,150cm
1Kg = 2.2 lb [ pound ]
** adverse effect of obesity :
- hyper tension
- D.M { NIDDM}
- Hyper cholestrolemia
- Coronary heart disease
- Cancer colon , rectum, in male prostate , in female uterus ovaries cervix & gall bladder .
** causes of obesity :
@ genetic metabolic factors
Familial ,hereditary , foods habit & attitude
@psychological factors
@ social { sedentary life }
@ physiological factors early puberty , pregnancy ,after menopause
• management of obesity :
put personal program of diet requiem.
- programme of activities & exercise
- manage stress without eat
- change attitude toward food
- eat nutritional balance rich in CHO ,fiber , starch
- diet moderate in sugar
- protein & fat in accepted amount
- focus on plant fat
** eating disorder
@ aneroxia nervosa :
- self induced starvation
- among adolescent girls
- fear of weight gain
- refuse to eat ,even they may be hungry
- They often perceive them selves to be fat
- Severely under weight , emaciated
- Malnutrition & require hospitalization
@ bulimia nervosa :
- among young women
- ingestion of large amount of food & induced vomiting .
*** extreme of under weight :
Associated with poverty
- poor living condition
- associated with long term disease .
- lead to growth retardation & failure to thrive .
• causes ;
• wasting disease , fever , cancer
• poor food intake , decrease appetite
• mal absorption due to prolonged diarrhea , GIT disease , abuse of laxative
• hormonal imbalance hyper thyrodism
• energy imbalance ,increase physical activity , decrease energy intake
• poor living situation irregular ,inadequate meat
** treatment :
-high calories
- high protein
-high CHO
- moderate fat
Feeding methods
Enteral & parenteral nutrition
-enteral nutrition is needed for persons with underlying chronic disease or traumatic injury .
-also elderly person ,these patients expose to burn ,or malignant cancer need enteral nutrition to restore some of their health .
** mode of enteral nutrition support :
1- oral supplements .
-add energy –nutrient food as Ensure with or between
Meals .
2-tube feeding :
-insufficient food intake either as supplement or as the complete meal .
** nutrient component :
1- carbohydrate
2- protein
3- amino acid
4- fat
5- vitamins & minerals .
** ways of formula feeding :
1- nasogastric tube :
- indicated in short term theorpy .
- 2- esophagostomy { cancer neck } or traumatic injury
- 3-gastrostomy : tube placed in the stomach .
- 4- jejunostomy :
- Tube placed in the duodenum or jejunum of small intestine .
- Indicated in case of cancer stomach .
** nursing care :
1- check for gastric residuals .
2- note any signs of abdominal distension .
3- monitor vital signs as temperature ,pulse ,respiration .
4- monitor the flow rate & record intake & output .
5- report patient response to the formula .
6- monitor state of hydration .
7- follow up of lab investigation as needed .
**N.B: - vomiting ,abdominal distension , frequency of bowel movement after formula feeding ,if developed better to give intermittent bolus feeding until tolerance to formula occur .
** parenteral feeding :
- total parentral nutrition .
- any feeding methods other than by the normal gastro-intestinal route .
- given through central or peripheral veins .
- when the GIT cant be used .
** indication for TPN:
1- problems in the gastro-intestinal tract .
2- sever mal nutrition .
3- patient expose to sepsis ,chemotherapy .
4- malabsorption & inadequate oral intake .
5- massive burn .
6- comatose patient .
7- hepatic insufficiency .
Nutrition during pregnancy & lactation
** factors determining nutritional needs :
@ age & parity :
- teenage mother
- number of pregnancy & interval between pregnancies ,reflect on outcome of pregnancy .
- @preconception nutrition :
- Diet ,food habits
- General health & fitness.
- State of nutrition at time of conception .
@fetus ,mother ,placenta interaction .
** energy need during pregnancy ,calories increased to nourish baby ,with appropriate weight gain .
** protein need60gm \ day help in rapid growth of the fetus ,enlargement of uterus .
** calcium 1200 gm\day ,essential for skeletal tissue growth .
- drink cup of milk daily is essential .
** iron 30gm \day .
- supplementary iron given because of insufficient maternal stores .
- vitamins A,B,C,D,with adequate exposure to sunlight .
** general dietary problems :
1- nausea & vomiting .
2- hyper emesis gravid rum .
3- constipation .
4- hemorrhoids .
5- heart burn or gastric pressure .
** weight gain during pregnancy : 10-12 Kg
-fetus : 3.400 gm
-placenta : 450 gm
-amniotic fluid : 900 gm
-uterus : 1100 gm
Breast 1400gm
-blood volume : 1800 gm
- maternal body : 1800 gm
** nutritional risk factors in pregnancy :
1- age : less than 15 yrs ,more than 35 yrs .
2- frequent pregnancy 3 or more during two years period .
3- poor obstetrical history .
4- poverty .
5- abuse of nicotine ,alcohol ,or drugs
6- inadequate weight ,less than 85 % of standard weight ,more than 120% of standard weight .
** complications of pregnancy :
1- anemia : common problem during pregnancy { iron deficiency ,folate deficiency ,hemorrhagic anemia }
2- pregnancy induced hypertension { PIH }:
-low to free salt diet .
-low cholesterol .
-high protein ,vitamins ,& minerals .
-normal CHO .
- monitor of body weight .
- restriction of fluid .
3- gestational diabetes mellitus :
- low CHO diet especially glucose .
-low cholesterol diet .
-normal protein diet .
Exercise
- stress reduction .
- insulin therapy .
4- maternal phenylekentonuria .
** nutrition during lactation :
-because mother breast feeding , she need good nutrition in form of protein ,milk ,milk product ,minerals ,& vitamins .
-finally mother need period of rest & relaxation to take care of her self ,her baby & her family .
Nutrition Issues During Lactation
WHO recommends human milk as the exclusive nutrient source for the first 6 months of life, with introduction of solids at this time, and continued breastfeeding until at least 12 months postpartum.
Recommending breastfeeding as the preferred feeding choice for infants stems from acknowledging benefits to infant nutrition; gastrointestinal function; host defense;
neurodevelopment; and psychological, economic, and environmental well-being.
breastfeeding decreases the rate of postneonatal infant mortality
(∼21%), and reduces the incidence of a wide range of infectious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis,
otitis media, urinary tract infection, and late-onset sepsis rates in preterm infants.
Breastfeeding is also associated with slight improvements in cognitive development in both term-born and prematurely born infants
During the first 4–6 months of life,
an infant will double its birth weight accumulated during the entire 9 months of pregnancy
The energy content of breast milk secreted in the first 4 months
postpartum alone well exceeds the energy demands of an entire pregnancy
ENERGY
1. Estimated Energy Requirements
The incremental energy cost of lactation is determined by the amount of milk produced (exclusivity and duration), the energy density of the milk secreted, and the energy cost of milk synthesis. Age, weight, height, and level of physical activity affect the required energy.
Milk energy output is tabulated by multiplying the volume of milk produced by its energy density. The daily volume of milk produced from birth to six months is 0.78 l/day. From
7 to 12 months, mean milk production is estimated to be 0.6 l/day, reduced with the introduction of solid foods
Generally, well-nourished women will lose on average 0.8 kg/month (1.8 pounds/month) for the first 6 months postpartum; undernourished
women can expect to lose 0.1 kg/month.
Anemia and Iron Deficiency
← Pregnant women, women of childbearing age, and young children are especially vulnerable to iron deficiency and iron-deficiency anemia (IDA).
Stages of iron deficiency
1.Iron depletion
• Reduction of iron stores
• ↓ Serum ferritin
• ↑ Total iron binding capacity (TIBC)
2. Iron-deficient erythropoiesis
• Exhaustion of iron stores
• ↓ Serum iron
• ↓ Transferrin saturation
• ↑ Free erythrocyte protoporphyrin (FEP)
• ↑ Serum transferrin receptor concentration
3. Iron-deficiency anemia
• Exhaustion of iron stores and microcytic, hypochromic erythrocytes
• ↓ Hemoglobin
• ↓ Hematocrit
← Anemia is the most widely used indicator of ID in most settings.WHO reference values for anemia are hemoglobin < 11 g/dl for pregnant women and children under 5, < 12 g/dl for non-pregnant women, and < 13 g/dl for men.
← Not all anemia is caused by iron deficiency, and not all iron deficiency results in anemia. Megaloblastic anemia is associated with inadequate intakes of folate and vitamin B12 while infections and genetic can cause Thalassemia.
Assessment Of Iron Deficiency And Anemia.
← 70-80% of iron in the body is contained in Hb, an erythrocyte protein that transports oxygen from the lungs to tissues in the body. Hb concentration is used to diagnose anemia. Hct is also used in anemia Dx
Both Hb & Hct concentrations can be influenced by factors influencing erythrocyte production and cause anemia. These include parasitic
infections and other nutritional
deficiencies (i.e. B12, folate, vitamin A).
← WHO recommends including hemoglobin and serum ferritin.
IRON REQUIREMENTS DURING PREGNANCY
← Iron (Fe) requirements increase dramatically during pregnancy due to the rapid expansion of BV, tissue accretion, and potential for blood loss during delivery.
← For a normal pregnancy, it has been estimated that women need at least 6 mg of Fe/day compared with only 1.3 mg of Fe/day when they are not pregnant.
Consequences Of Iron Deficiency And Anemia During Pregnancy
1. Anemia and Maternal Mortality
• Tiredness and, therefore, quality of life is affected
• Severe anemia (HB < 7 g/dl) is associated with an increased risk of mortality. Severely anemic women tend to be at increased risk of blood loss and cardiac failure, which can result in death.
2. Birth Outcomes
• Severe anemia has been associated with an increased risk of stillbirth and infant mortality, in addition to increased risk of delivering a preterm and/or low-birth-weight baby.
• Women who received iron–folate supplements along with vitamin A during pregnancy show reduction in LBW incidence 43-34%. Iron supplementation of iron-replete women during pregnancy significantly reduced the prevalence of LBW and prematurity by almost half.
Early Childhood Growth and Development
← Iron stores in infants at birth depend on maternal iron status and that clinical practices, such as delayed clamping of the umbilical cord, could help boost iron stores safely.
← Full term babies typically have adequate iron stores during the first 6 months of life, but this is not for babies of anemic women.
← Women continue to be at risk of developing anemia and/or ID during the postpartum; affect both mother and baby.
← Women who are iron deficient may be at increased risk of depression and impaired cognitive function and this, in turn, would affect their ability to take care of their child and may indirectly influence child growth and development
Strategies To Combat Iron Deficiency
And Iron-Deficiency Anemia
Role of Multivitamin–Mineral Supplements
Coexistence of several micronutrient deficiencies in many developing countries as a result of poor diets, both in terms of quantity and quality are combined with the increased requirements during pregnancy
Timing of Supplementation
Weekly supplementation of women of reproductive age both before and during pregnancy improved iron reserves effectively and safely
Diabetes and Pregnancy
▪ Diabetes mellitus is the most common complication of pregnancy; 90% during pregnancy; 10% predated the pregnancy.
▪ Although morbidity & mortality , the prevalence of fetal complications in diabetic mothers > in non-diabetic.
▪ Optimal glycemic control, before and during pregnancy can reduce risk of perinatal complications.
▪ Previously, diabetic women were advised not to conceive or to abort; infants were often stillborn or born with major malformations.
▪ Medical nutrition therapy was the primary method of management for pregnant
▪ Even after insulin injections revolution, nutrition therapy remained. Weight gain and sodium were restricted
▪ After 1970, the same regimen for the general pregnant population was
recommended for diabetic pregnant
women.
Classification of Diabetes
DM is defined as a group of metabolic
diseases characterized by hyperglycemia resulting from defects in insulin secretion,
insulin action or both.
DM is classified into:
1. Type 1 diabetes,
- insulin-dependent or juvenile-onset diabetes,
- autoimmune destruction of the pancreatic beta-cells,
- 5–10% of all diabetes cases,
- requires exogenous insulin
- diagnosed primarily < 30 years of age.
2. Type 2 diabetes, non-insulin dependent diabetes/ adult-onset
- 90% of diabetes cases,
- Insulin resistance, rather than insulin deficiency, and obesity are associated with type 2 diabetes.
3. GDM; degree of glucose intolerance with onset or first recognition during pregnancy.
- Risk factors of GDM;
age of onset, presence of preexisting
complications and degree of metabolic
control
Preexisting diabetes
Pathophysiology of Normal Pregnancy
- Nutrients; glucose, AA, and FA pass across the placenta to the fetus.
- In 1st trimester, maternal glycogen storage and endogenous glucose production increase.
- Pregnancy hormones, estrogen, progesterone, and the constant fetal demand of glucose lower fasting maternal blood glucose levels,
- The maternal appetite ; consumption of
additional calories, Fasting and
postprandial glucose levels.
- Elevated hormonal levels increase insulin resistance.
- Insulin resistance peaks by the latter part of the third trimester,
- After delivery, insulin production returns to prepregnancy levels.
1. Type 1 Diabetes
• Blood glucose levels remain elevated as insulin deficiency, thhe risk of diabetic ketoacidosis in the absence or lack of insulin.
• Women in optimal glycemic control
may experience insulin sensitivity
and decreased insulin requirements
in the first trimester.
▪ With pregnancy advancement, insulin resistance and additional insulin is necessary.
Type 2 Diabetes
• Associated with impaired insulin secretion, insulin insensitivity, and
pancreatic beta-cell dysfunction.
• Clients usually older and heavier.
• The fetal pancreas secretes additional insulin due to hyperglycemia; macrosomia.
Complications Associated with Preexisting, Diabetes
1. Fetal; During 1st trimester; spontaneous abortions and congenital malformations including CNV, heart, lungs, GIT, kidneys, urinary tract, skeleton, and placenta. During 2nd and 3rd; macrosomia, neonatal hypoglycemia and hypocalcemia, hyperbilirubinemia, polycythemia, RDS, preterm delivery, and stillbirth are expected.
2.Maternal
o Preconceptional maternal complications include nephropathy, neuropathy, retinopathy, hypertension, and diabetic ketoacidosis.
o Diabetic nephropathy is associated with
other complications including
preeclampsia, anemia, IUGR, fetal
termination, and preterm delivery.
o Complications that develop during pregnancy include hypertensive disorders, polyhydramnios, preterm delivery, and cesarean section.
Nutrition therapy:
The goals are
1) to provide adequate nutrients for
maternal-fetal nutrition,
2) to provide sufficient calories for
appropriate weight gain, and
3) to achieve and maintain optimal
glycemic control.
I. Weight gain; Excessive wt gain may lead
to macrosomia, CS, and postpartum
wt retention. Overweight women
with diabetes need to gain minimum
wt to minimize risk of macrosomia.table
10-2, p.140
II. Energy Requirements;
• First trimester: no calorie increase
• Second trimester: usually need +160 kcal (8 kcal/week × 20 weeks) + 180 kcal
• Third trimester: usuall +272 kcal (8
• kcal/week × 34 weeks) + 180 kcal
• The energy requirements depend on; age, height, weight, and physical activity level
• Adequate calories are required to avoid starvation ketosis and ketoacidosis.
• A comprehensive nutrition history/ questionnaire, food record/diary
and blood glucose records, and regular monitoring of weight are used to develop individualized meal plans.
• Fluctuating blood glucose levels may necessitate frequent adjustments in the meal plan.
III. Macronutrients
Requirement of protein is 71 g/day (1.1 g/kg/day >18 years), high-fat diets are not recommended with adequate carbohydrate intake in pregnancy (175 g/day) to ensure sufficient glucose for fetal brain growth and development.
IV. Micronutrients
Calcium, vitamin D, magnesium, iron, and folic acid are frequently consumed in
inadequate amounts in pregnancy. Supplements are required. Folate deficiency is associated with maternal megaloblastic
anemia, neural tube defects, spontaneous abortions, and low birth weight
V. Nonnutritive Sweeteners; five are recommended including saccharine.
Postpartum, insulin requirements usually decrease, also, there are no contraindications to lactation for the woman with diabetes, and women
should be encouraged to breastfeed. The meal plan is adjusted to include additional
snacks to avoid hypoglycemia.
3. GESTATIONAL DIABETES MELLITUS
← It is estimated that 90% of cases of diabetes in pregnancy is GDM.
← similar to type 2 diabetes, as it is associated with insulin resistance and insensitivity.
← With increased hormonal levels,
beta-cells are unable to produce
or secrete sufficient insulin for
glucose regulation.
← Lactogen and cortisol block insulin receptors causes inadequate circulating insulin.
Complications:
▪ Maternal risks include hypertension, higher rates of CS and preterm deliveries
Fetal; Congenital anomalies are rare, macrosomia is the most common. Other complications include neonatal hypoglycemia and hypocalcemia, hyperbilirubinemia, and polycythemia. The risk for RDS decreases with full term.
Risk Factors for GDM:
• Obese
• Previous history of GDM
• Glycosuria
• Strong family history of diabetes
Nutrition Therapy
Goals; 1. keep normoglycemia,
2. provide sufficient calories to
promote appropriate wt gain
and avoid maternal ketosis, and
3. provide adequate nutrients for
maternal and fetal health
Dietary recommendations:
- The amount, source, and distribution of carbohydrates are determined in conjunction with blood glucose monitoring.
- It’s recommended to restrict
CHO content to 40–45% of total calories,
but not < 175 g/day to achieve blood
glucose goals.
- Carbohydrate sources include whole grains, dried beans and peas, and lentils, which are more nutrient dense and have a lower glycemic response than processed foods (e.g., cereals, rice, and potatoes).
- The distribution of CHO into three meals and two to four snacks will help control
postmeal blood glucose levels.
- Carbohydrate intake is more restricted at breakfast than at other meals, as hormonal levels are higher in the morning.
- The total amount of CHO at
Breakfast 15 to 45 g.
- Breakfast cereals, milk, and fruit may need to be consumed at other meals or snacks.
- Carbohydrate distribution at lunch and dinner is usually 30–45 g or higher,.
- The distribution of snacks is 15–45 g, with a smaller snack in the morning. An evening snack will help avoid overnight starvation ketosis.
- Protein intake increases to 25–25% of total calories as the CHO level is reduced, > 71 g/day or 1.1 g/kg/day.
- Fat makes up 35–40% of the
total calories, with the majority as monosaturated and polyunsaturated fats.
Postpartum;
- Breastfeeding, unless contraindicated, is recommended for women with GDM
- Lactation may improve glucose control, mobilize fat stores, promote weight loss, and protect against future risk of developing diabetes
Postpartum Weight Retention
← >1/3 of pregnant women gain more wt during pregnancy than is recommended, particularly overweight or obese women.
← Wt loss among women postpartum is highly variable; most women will retain 0.5 -3 kg from their previous pregnancy
← At 18 months postpartum, 20% of women will be more than 5 kg heavier than they were before pregnancy.
← A lactating has the same physiologic requirements for regulating body wt as one that is not, except the continuous production of milk creating a much higher energy output.
← The total energy cost to a woman who is exclusively breastfeeding an infant 0 to 6 months is estimated to be 500 kcal/day; could result in 0.5 kg/week of wt loss.
← Higher energy intakes in lactating women versus nonlactating women may be attributed to enhanced appetite due to increased prolactin levels and higher energy demands.
← The most consistent and strongest determinant of weight loss during lactation is pregnancy wt gain.
← Other factors include pre-pregnancy wt, age, parity, race, smoking, exercise, return to work outside the home, and lactation.
← Breastfeeding results in a faster rate of postpartum weight loss than formula feeding; 0.6–2.0 kg /12 months.
← Breastfeeding facilitates changes in body composition; fat is mobilized from the trunk and thigh areas.
Exercise And Lactation
← Physical activity at any age is essential to minimize the risk of several morbidity and mortality; specifically in lactation, it improves cardiovascular fitness, plasma lipid levels, and insulin response. Besides, it promotes body wt regulation and optimizes bone health
← Also it has the potential to benefit psychosocial well-being in lactation, such as improving self-esteem and reducing depression and anxiety.
← Resuming physical activity gradually, and only when a woman’s body has healed substantially from pregnancy and delivery (usually 4–6 weeks postpartum). They must avoid fatigue, remain well hydrated, and watch for abnormal bleeding or pain.
Achieving a balance of diet and exercise for Mom And Baby
Table 18.3. Maintaining a healthy diet during lactation is essential to ensures that macro- and micronutrient intake is adequate to support optimal maternal health and breastfeeding success.
A. Calcium
← 99% of total body ca is found in bones and teeth. Remainder plays a role in BP regulation, muscle contraction, nerve transmission, and
hormone secretion.
← Calcium homeostasis is maintained by parathyroid hormone, hypercalcemia, and calcitonin, hypocalcium.
← Secretion of ca into breast milk averages about 200 mg/day.
← During pregnancy; increased maternal bone resorption and decreased renal ca excretion rates occur to meet the elevated calcium demands of lactation.
← The concentration of ca in breast milk decreases after 3–6 months; greatest loss of bone mineral content occurs within the first few months postpartum.
← Ca adequate Intake during lactation is 1,000 mg/day for women (19–50 y), if < age of19;1,300 mg.
← Loss of ca from maternal skeleton is not prevented by increased dietary intake, even among women with low baseline ca intakes.
← The bone mineral changes occurring during and following lactation are a normal physiological response, and an increased requirement for calcium is not needed.
← Sources of ca; milk and other dairy products, salmon with bones, some green leafy vegetables such as broccoli.
← The absorption of supplemental calcium is greatest when ca is taken in doses of 500 mg or less
Vitamin D
• The main function of vit D is to maintain normal blood ca & Ph; promoting bone health.
• Provitamin is obtained from food, vit is synthesized in the skin by exposure to ultraviolet light.
• Human milk contains low amounts of vitamin D; 4 to 40 IU/l. Infant formula is routinely fortified with 400 IU vitamin D per liter, while the breastfed infant is primarily dependent upon endogenous synthesis or supplemental sources of vitamin D.
• Breastfed infants are recommended to be given a 400 IU vitamin D supplement each day.
• There is no evidence that lactation increases maternal requirements for vitamin D; similar to nonlactating adults 200 IU/day. Currently, an intake of 2,000 IU/day for lactating women to be the tolerable upper intake level. The tolerable upper limit for vitamin D consumption by adults should be set at10,000 IU/day.
• Obesity is linked with poorer vitamin D status; obese subjects may have a greater requirement for vitamin D than their non-obese.
• Sources of vit D in the diet include liver, fatty fish such as salmon, and eggs yolks. Milk may be fortified with vit D.
• Supplemental vitamin D is available in
two distinct forms, vitamin D2 and
vitamin D3.
C. Folate
← Folate; a number of related compounds
that are involved in the metabolism of
nucleic and amino acids, and therefore
the synthesis of DNA, RNA, an
proteins.
← Folic acid is a synthetic form of the vitamin, used in vitamin supplements
and food fortification.
← The average amount of folate secreted into human milk is estimated to be 85 mcg/ liter/day. With the exception of severe maternal folate deficiency (i.e., megaloblastic anemia), the content of folate in human milk remains stable and appears to be conserved at the expense of the mother’s folate stores.
← A folic acid supplement taken on an empty stomach is thought to be 100% bioavailable compared to about 50% for naturally occurring food folate.
← The recommended dietary allowance for folate for breastfeeding women aged 14–50 years is 500 mcg per day.
← Lactating women who are planning a subsequent pregnancy, or who are not taking effective precautions to prevent one, should be encouraged to consume 400 mcg folic acid supplement daily for at least 4 weeks before and 12 weeks after conception to reduce the risk of having a subsequent child with NTD
← Overzealous use of folic acid supplements is not risk free; may mask a vitamin B12 deficiency by correcting its characteristic symptom, megaloblastic anemia.
← Dietary Intake of Folate; without mandatory folic acid fortification, 98% of lactating women would not have met their requirements for folate from diet alone.
← Sources of Folate; green leafy vegetables as well as citrus fruit juices, liver, and legumes.
D. Vitamin B12
• Known as cobalamin, and required for RBCs formation & normal neurological function. Similar to folate, it is involved in DNA synthesis.
• Vit B12 deficiency is associated with DNA production disruption; megalo-blastic anemia and neurological complications.
• Vit B12 deficiency may result from
inadequate absorption rather than a dietary deficiency; chronic antacid use, atrophic gastritis, or pernicious anemia.
• High doses of synthetic folic acid (greater than 1,000 mcg) can mask vitamin B12 deficiency.
• Megaloblastic anemia is the clinical
indicator of vitamin B12 deficiency.
• Vitamin B12 is excreted in the bile and effectively reabsorbed it can take
up to 20 years for a vitamin B12
deficiency to develop due to low vitamin B12 intake. However, deficiency due to poor absorption can take only a few years to develop.
• During lactation, the concentration of vit B12 in human milk varies widely, and reflects maternal vitamin B12 intake and status. Low maternal intake or poor absorption rapidly leads to a low level of vitamin B12 in human milk.
• Severe deficiency can occur after approximately 4 months of age in exclusively breast-fed infants
of mothers with inadequate intake.
• Symptoms of infantile vitamin
B12 deficiency include irritability,
abnormal reflexes, feeding
difficulties, reduced level of alertness
or consciousness leading to coma,
and permanent development
disabilities.
• The concentration of vit B12 in human milk changes very little after the first month postpartum; 0.33 mcg/day during the first 6 months of lactation, and 0.25 mcg/day during the second 6 months.
• The RDA for lactating women age 14–50 years is 2.8 mcg/day; higher
than nonpregnant, nonlactating
women (2.4 mcg/day).
• Low dietary vit B12 intakes during lactation typically occur when either the mother is a strict vegetarian or when usual consumption of animal products is low.
• Sources of Vit B12; in the diet
vit B12 is synthesized by bacteria and found primarily in meat, eggs, fish (including shellfish), and to a lesser extent dairy products. Plant sources, such as spirulina (algae طحالب) and nori (seaweed), contain vitamin B12 analogues. Milk and milk products are a good source of vitamin B12 (0.9 mcg/250 ml), while vegans are recommended to consume a supplement (2.8 mcg/ day) and/or ensure their diet includes foods fortified with vitamin B12.
E. IRON
← Iron is an essential component of numerous proteins and enzymes in the human body.
← Iron is stored in the form of ferritin,
primarily in the liver but also in bone marrow and the spleen.
← With the exception of pregnancy
and menstruation, the iron content of the
body is highly conserved. The secretion of iron into breast milk is low, with the average milk iron being in the order of 0.35 mg/l.
← Maternal dietary intake has little effect on milk iron levels.
← Iron requirements during lactation (9 mg/day) are lower than those for nonpregnant, nonlactating (18 mg/day) assuming that exclusively breastfeeding women will not resume menses for a period of 6 months postpartum. If the mother is adolescent; iron is10 mg/day.
← The UL for all breastfeeding women is 45 mg of iron per day.
← Iron-deficiency anemia during pregnancy, particularly in the third trimester, is common, and also maternal iron deficiency early postpartum, despite women meeting dietary recommendations for lactation.
← Maternal iron status is related to fatigue, depression, decreased work capacity, and decreased ability of the mother to care for her newborn infant
← Median iron intake of nonpregnant nonlactating women is ~12 mg/day, and that of pregnant women is 15 mg/day.
← Sources of iron; heme and nonheme iron. Heme iron is obtained from animal sources such as meat, chicken, and fish, and is about 20–30% absorbed. Non-heme iron, present in plant foods, iron fortificants, and iron supplements, is less bioavailable with absorption of 5–10% s. Dietary factors such as vitamin C and the presence of meat, fish or poultry can enhance the absorption of non-heme iron, while
phytates found in legumes, grains and rice, polyphenols (in tea, coffee, and red wine) and vegetable proteins, such as those in soybeans, can inhibit non-heme iron absorption.
← The requirement for iron is 1.8 times greater for vegetarians.
F. Long-Chain Polyunsaturated Fatty
← LC-PUFAs are fatty acids with a backbone of greater than 20 carbons, and are of either of the omega-3 or omega-6 series; humans are able to synthesis these LC-PUFAs from
fatty acid precursors via a series of elongation and desaturation steps at all stages of the life cycle.
← LC-PUCFAs are essential for the development and maturation of
the fetal and neonatal brain, fluidity in membranes, and gene expression.
← Infants fed formulas without DHA and ARA, have lower levels of DHA and ARA in their blood compared with either breastfed infants or infants fed formulas supplemented with these fatty acids.
← The US Institute of Medicine assumes that the fatty acid composition of breast milk meets the requirements of most infants.
← New evidence does suggest that supplementation of women prenatally with DHA may affect maturation of the visual system of infants and their ability to problem solving.
← There is some evidence to suggest a potential for omega-3 fatty acids in the prevention of depression during the postpartum period,
← Currently, there are no specific recommendations for DHA, EPA, or ARA intake; 12 g/day may be enough
← Sources of LC-PUFAs; meat and eggs are rich sources of ARA, while EPA and DHA are derived mainly from fatty fish such as mackerel, salmon, herring, trout, and sardines. Several foods are available that have added omega-3 fats including eggs, milk, yogurt, cheese, pasta, and bread.
Iron Requirements and Adverse Outcomes
← Iron deficiency continues to be one of the most prevalent nutritional deficiency diseases in the world and has a particularly high prevalence in pregnancy (around 60% in developing countries)
← The assessment of iron in pregnancy can be challenging due to the rapid expansion of the maternal blood volume and then rapid fetal and placental growth.
← Iron deficiency in pregnancy has several negative effects including maternal and infant mortality in severe cases, but also shortened gestation, prematurity, and poorer infant development in less severe cases.
Poor iron, even in the first trimester, is associated with IUG restriction, and development and persistent consequences for infant neurodevelopment and functioning.
Iron Balance In Pregnancy:
Iron Needs for Mother and Fetus
Iron requirements increase quite dramatically during pregnancy.
← Iron requirements increased from 45 mg for the umbilicus and placenta for a total requirement of >220 mg.
Iron for the Maternal Red Cell Mass and Anemia
RBCs mass in pregnancy is not a static number and can be affected by the amount of iron supplementation that has occurred during the pregnancy
Table 16.1
Estimated Median Iron Requirements (mg) During Pregnancy
|Total |3rd trimester |2nd trimester |1st trimester | |
|245 mg |145 mg |75 mg |25mg |Fetu |
|75 mg |45 mg |25 mg |5 mg |Placenta & |
| | | | |umbilicus |
|450 mg |225 mg |225 mg |5–10 mg |RBC mass |
| |415 mg |325 mg |35–40 mg |Total |
← The amount of additional iron needed for RBCs expansion depends on the numbers of fetuses.
WHO recommends iron supplements 30–60 mg/day if the woman has iron stores; if not 120–240 mg/day advocated
← Current target Hb concentrations in each
trimester are based on supplementation trials, which suggest that Hb > 11g in first
and third trimesters and 10.5 g in the second trimester represent reasonable clinical
expectations of lower normal levels ( U shape)
Iron Absorption
← The capacity to increase the efficiency
of iron absorption appears to maximize at around 40–60% in the second trimester
← The efficiency of iron absorption is strongly associated with the iron status of the woman; more ferritin are much less efficient than women with a low ferritin level
← When there is insufficient dietary and reserve iron to meet the demands, essential body iron from maternal pools are sacrificed with a resulting maternal iron deficiency.
← The placental transfer of iron with severe iron deficiency associated with upregulation of placental ferritin receptors and presumably
an increase in placental-fetal transfer of iron
Assessment Of Iron Status
Assessing iron status cannot rely solely on Hb, hematocrit (Hct) value. The various categories of
iron status, adequate, low or depleted iron stores, iron deficient erythropoiesis, and iron
deficiency anemia, are all characterized by a range of values of a number of biomarkers
that are sensitive to iron storage, iron transport, or tissue iron deficiency
Consequences Of This Negative Iron Balance
• The effect of depletion of the essential body pools of iron include anemia, altered hormone metabolism, altered energy metabolism, depressed immune functioning, and changes in behavior and cognition.
• The possible causal routes include direct and indirect effects of anemic hypoxia, placental delivery of iron, and alterations in hormonal control of pregnancy due to alterations in the stress: hypothalamic–pituitary–adrenal axis system.
• Maternal anemia has been related to maternal mortality, fetal mortality, fetal growth retardation, pregnancy complications, and a small amount on infant growth.
Anemia And Birth Weight, Gestational Age,
And Infant Mortality
• There is a U-shaped curve relationship between the maternal hemoglobin concentration and the proportion of LBW infants.
• The cause of the elevation in prevalence of LBW infants with high Hgb is improper expansion of the maternal plasma volume, while insufficient erythropoiesis and poor volume expansion in low Hgb.
• The optimal maternal Hb for minimal incidence of LBW in the published literature varies.
• The hemoglobin concentration and the definition of anemia are trimester dependent, with a clear nadir of concentration in mid-gestation.
• Severity of anemia is an additional factor associated with an increased risk of LBW
and prematurity with severe anemia (Hb < 8g)
Maternal Anemia And Mortality
← Maternal mortality is correlated with the severity of anemia in pregnancy.
← Severe anemia (Hb < 6–7 g/l or Hct < 0.14) is associated with an increased rate of maternal death.
← In very severe anemia, the death rate may be as high as 20%, greater than the comparison group of minimum mortality.
← Transfusion is needed.
← When the Hb is this low, compensatory mechanisms begin to fail, lactic acid levels rise, and cardiac failure may occur.
Iron Deficiency Anemia And Pregnancy Outcomes
← Iron deficiency anemia has an impact on fetal G&D similar to anemia in general. Particularly in the first trimester, it is more strongly related to prematurity and LBW than anemia of any cause later in pregnancy; anemia at other times had little effect.
← Lower maternal iron status is associated with
lower cord blood iron, prematurity, and lower
Apgar scores.
← Based on several studies, there is a relationship of elevated ferritin with preterm birth, LBW, and preeclampsia .
← Higher ferritin concentrations may be more an indication of upper genital tract infection and a subsequent development of spontaneous preterm delivery than an indication that higher iron status is bad for fetal G&D.
← Elevations of ferritin in mid-gestation increase the risk for pregnancy complications.
← Prophylactic iron supplementation during the first trimester of pregnancy in poor women improves birth weight, lower the incidence of prematurity, but did not alter the incidence of SGA deliveries
← Timing and dose of supplementation, as well as the frequency of supplementation, are important considerations in interventions during pregnancy.
← The most common side effects of iron include black stools, constipation, GI upset, and vomiting.
← Alternative strategies to minimize the need for oral iron supplements include a diet that is high in iron-containing foods; most notably this is red meat. Fish, lamb, and other meats also contain significant amounts of iron.
← A reduction in inhibitors of iron absorption (tea, coffee, high-phytate-containing grains and
breads) may provide some addition benefit in
terms of bioavailable iron.
Maternal Iron Status And Other Fetal Outcomes
Infant Development
There is a relationship between newborn cord ferritin levels and cognition and behavior at 5 years of age.
Infants of iron-deficient anemic mothers had lower developmental scores than had infants of mothers who were not anemic.
Maternal postpartum depression related to Hb concentration in the months after delivery of the infant may contribute to changes in infant
development.
Infant Iron Status
← There is a general correlation between maternal Hb in the third trimester with the infant Hb at 9 months of age.
← M anemia may be related to infant anemia in early life on some occasions, but commonly the relationship is more strongly expressed at 9–12 months of age when infant iron stores have been exhausted.
Conclusion
← Iron deficiency and anemia during pregnancy have functional outcomes for both the mother and the developing infant.
← The strong epidemiological data show a strong impact of anemia during the first trimester on the short-term outcomes of pregnancy such as gestational age and birth weight.
← The severity of iron deficiency and anemia over the course of pregnancy appears to be a determinant of postnatal development of infants and their neurodevelopment in the first and second years of life.
← As it is very difficult to begin oral iron treatment before the 8–10th week of pregnancy, it might be prudent to adopt the approach of the folic acid supplementation recommendations and suggest that women who plan to become pregnant be certain their iron status is good.
← This means the serum ferritin should be higher than 40–50 mcg/l prior to pregnancy and the woman should be quite faithful in her consumption of modest doses of iron supplements.
[pic][pic]
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NB:- water is the over all vital nutrients, enter in all of life process,
-Metabolism: sum of chemical process in the body, to sustain life, and health .
Metabolites any substance that produced by metabolism or by metabolic process
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