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~ 1 ~ Mattson During GPre,gna~CY Part I WEIGHT GAIN Part II NUTRIENT SUPPLEMENTS Subcommittee on Nutritional Status and Weight Gain During Pregnancy Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy Committee on Nutritional Status During Pregnancy and Lactation Food and Nutrition Board Institute of Medicine National Academy of Sciences NATIONAL ACADEMY PRESS Washington, D.C. 1990

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National Academy Press - 2101 Constitution Avenue, N.W. . Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Samuel O. Thier is president of the Institute of Medicine. This study was supported by project no. MCJ 116011 from the Maternal and Child Health Program (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services. Library of Congress Catabging-in-Publication Data Institute of Medicine (U.S.). Subcommittee on Nutritional Status and Weight Gain During Pregnancy. Nutrition during pregnancy: part I, weight gain: part II, nutrient supplements / Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. p. cm. Includes bibliographical references. ISBN 0-309-041384 1. Pregnancy-Nutritional aspects. ~ Pregnant women-Weight gain. I. Institute of Medicine (U.S.). Subcommittee on Dietary Intake and Nutrient Supplements during Pregnancy. II. Title. [DNLM: 1. Nutrition-in pregnancy. 2. Weight Gain-in pregnancy. WQ 175 I617n] RG559.I57 1990 618.2'~dc20 DNLM/DLC for Library of Congress Copyright ~ 1990 by the National Academy of Sciences 90-5661 CIP No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the U.S. Government. Printed in the United States of America First Printing, May 1990 Second Printing, March 1995

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SUBCOMMITTEE ON NUTRITIONAL STATUS AND WEIGHT GAIN DURING PREGNANCY JANET C. KING (Chair), Department of Nutritional Sciences, University of California, Berkeley, California NANCY F. BUTTE, Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas RONALD A. CHEZ, Department of Obstetrics and Gynecology, University of South Florida School of Medicine, Tampa, Florida JERK D. HAAS, Division of Nutritional Sciences, Cornell University, Ithaca, New York JOEL C. KLEINMAN, Division of Analysis, National Center for Health Statistics, Hyattsville, Maryland MICHAEL S. KRAMER, McGill University, Montreal, Quebec, Canada SALLY A. LEDERMAN, Center for Population and Family Health, School of Public Health, and Institute of Human Nutrition, Columbia University, New York, New York SUBCOMMITTEE ON DIETARY INTAKE ANI) NUTRIENT SUPPLEMENTS DURING PREGNANCY LINDSAY ALLEN (Chair), Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut GERTRUD S. BERKOWITZ Departments of Obstetrics, Gynecology, and Reproductive Science, and Community Medicine, Mount Sinai Medical Center, New York, New York PETER DALLMAN, Department of Pediatrics, University of California, San Francisco, California K. MICHAEL HAMBIDGE, Department of Pediatrics, School of Medicine, University of Colorado, Denver, Colorado AVANELLE KIRKSEY, Department of Foods and Nutrition, School of Consumer and Family Science, Purdue University, West Lafayette, Indiana JENNIFER R. NIEBYL, Department of Obstetrics and Gynecology, University of Iowa College of Medicine, Iowa City, Iowa JOHN W. SPARKS, Department of Pediatrics, School of Medicine, University of Colorado, Denver, Colorado Staff CAROL WEST SUITOR, Program Officer MARIAN M. F. MILLSTONE, Research Assistant WILHELMENA TAMALE, Senior Secretary . . . 111

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COMMITTEE ON NUTRITIONAL STATUS DURING PREGNANCY AND LACTATION ROY M. PITKIN (Chair), Department of Obstetrics and Gynecology, School of Medicine, University of California, Los Angeles, California BARBARA ABRAMS, Program in Public Health Nutrition, School of Public Health, University of California, Berkeley, California LINDSAY ALLEN, Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut JERK D. HAAS, Division of Nutritional Sciences, Cornell University, Ithaca, New York MARGIT HAMOSH, Division of Developmental Biology and Nutrition, Georgetown University Medical Center, Washington, D.C. FRANCIS E. JOHNSTON, Department of Anthropology, University of Pennsylvania, Philadelphia, Pennsylvania JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California CHARLES S. MAHAN, Department of Health and Rehabilitative Services, State Health Office, Tallahassee, Florida KATHLEEN M. RASMUSSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. SPARKS, Department of Pediatrics, School of Medicine, University of Colorado, Denver, Colorado MERVYN W. SUSSER, Sergievsly Center, Columbia University, New York, New York Staff CAROL WEST SUITOR, Program Officer VIRGINIA H. LAUKARAN, Senior Staff Officer (until August 1988) CHESSA K LUTTER, Program Officer (until August 1988) MARIAN M. F. MILLSTONE, Research Assistant WILHELMENA TAMALE, Senior Secretary SANDRA JOHNSON, Senior Secretary (until November 1989) 1V

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FOOD AND NUTRITION BOARD RICHARD J. HAVEL (Chair), Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California DONALD B. McCORMICK (VIce Chair), Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia EDWIN L. BIERMAN, Division of Metabolism, Endocrinology, and Nutrition, University of Washington School of Medicine, Seattle Washington EDWARD J. CALABRESE, Environmental Health Program, Division of Public Health, University of Massachusetts, Amherst, Massachusetts DORIS H. GALLOWAY, University of California, Berkeley, California DeWIll GOODMAN, Institute of Human Nutrition, Columbia University, New York, New York M.R.C. GREENWOOD, University of California, Davis, California JOAN D. GUSSOW, Department of Nutrition Education, Teachers College, Columbia University, New York, New York JOHN E. KINSELLA, Institute of Food Science, Cornell University, Ithaca, New York LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii REYNALDO MARTORELL, Food Research Institute, Stanford University, Stanford, California WALTER MERTZ, Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland MALDEN C. NESHEIM, Office of the Provost, Cornell University, Ithaca, New York JOHN LISTON (Ex Officio), Division of Food Science, School of Fisheries, College of Ocean and Fishery Sciences, University of Washington, Seattle, Washington ARNO G. MOI-ULSKY (Ex Offirio), Center for Inherited Diseases, University of Washington, Seattle, Washington ROY M. PITKIN (Ex Option, Department of Obstetrics and Gynecology, School of Medicine, University of California, Los Angeles, California Staff SUSHMA PALMER, Director (until September 1, 1989) ALVIN G. LAZEN, Interim Director (beginning September 5, 1989) FRANCES M. PETER, Deputy Director SHIRLEY ASH, Financial Specialist USE HAYMAN, Administrative Assistant

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Preface In the quest for a favorable outcome of pregnancy, namely, delivery of a full-term, healthy infant of appropriate size, pregnant women have long directed their attention to weight gain and dietary intake. However, despite many reports on the subject published since the early 1970s, consensus has not been reached regarding recommendations for gestational weight gain. Furthermore, many women and health care providers in the United States have become concerned about the adequacy of the usual dietary intake of nutrients during pregnancy. Consequently, vitamin-mineral supplemen- tation during pregnancy has become widespread. Recognizing a need to examine these issues carefully, the Bureau of Maternal and Child Health and Resources Development of the U.S. Department of Health and Human Services (DHHS) asked the National Academy of Sciences to conduct a study of maternal nutrition. In response, the Committee on Nutritional Status During Pregnancy and Lactation was formed in the Food and Nu- trition Board, Institute of Medicine, and subcommittees were appointed to focus on specific aspects of the overall charge. The first two of the commit- tee's reports are presented in this volume as Part I, Nutritional Status and Weight Gain, and Part II, Dietary Intake and Nutrient Supplements. These reports are preceded by an overall summary (Chapter 1~. The third report of the committee, to be published within the year, will focus on nutrition during lactation. The major objective of the Subcommittee on Nutritional Status and Weight Gain During Pregnancy was to evaluate the scientific evidence and formulate recommendations for desirable weight gains during pregnancy. . . V11

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. . . V111 PREFACE The Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy evaluated the scientific evidence and formulated recommenda- tions on vitamin, mineral, and protein supplementation during gestation. Both subcommittees were asked specifically to consider the justification for special recommendations for pregnant adolescents, women over age 35, and women of black, Hispanic, and Southeast Asian origin. The approaches to the study are described in detail in the separate introductions to the two parts of the report. This volume should be widely used both by researchers and students seeking a fuller knowledge of pregnancy and by health care providers seek- ing guidance for practice. Therefore, we have included some discussions of value to both these groups as well as some that will be less relevant to one or the other. Both subcommittees benefited from advice and suggestions provided by the Committee on Nutritional Status During Pregnancy and Lactation, from the sharing of information between the subcommittees, and from the assistance provided by the Food and Nutrition Board and its Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. The committee and subcommittees appreciate the support provided by the Food and Nutrition Board staff headed by Dr. Sushma Palmer (until September 1989) and including Drs. Virginia Laukaran and Chessa Lutter (prior to August 1988), Dr. Carol West Suitor (beginning August 1988), Mrs. Frances Peter, Ms. Marian Millstone, Ms. Wilhelmena Tamale, Ms. Sandra Johnson (until November 1989), and Ms. Janie Marshall. Many people made important contributions to this combined report by giving presentations, providing the subcommittees with data or special writ- ten reports or analyses, sharing their views during workshops, commenting on drafts, or otherwise serving as resource persons. In particular, the com- mittee and subcommittees wish to thank Dr. Judith Brown, University of Minnesota; Dr. Neville Coleman, Bronx Veterans' Administration Medical Center; Dr. Catherine Cowell, Bureau of Nutrition, City of New York; Dr. Jan Dodds, Bureau of Nutrition, New York State; Dr. J. V. G. ~ Durnin, University of Glasgow; Dr. Jan Ekstrand, University of Iowa; Dr. Virginia Ernster, University of California, San Francisco; Dr. J. David Erickson, Centers for Disease Control; Dr. J. M. Gertner, New York Hospital; Dr. J.-P. Habicht, Cornell University; Dr. Suzanne Harris, Food and Consumer Services, U.S. Department of Agriculture (USDA); Mr. Jay Hirshman, Food and Nutrition Service, USDA; Dr. Frank Hytten, retired; Ms. Patricia Jensen, Santa Clara County Department of Health, California; Ms. Heidi Kalkwarf, Cornell University; Dr. Susan Krebs-Smith, Human Nutrition Information Service, USDA; Ms. Lynn Kuba, Childbirth Educator, Fairfax County, Va.; Ms. Alice Lenihan, National Association of WIC (Supple- mental Food Program for Women, Infants, and Children) Directors; Ms.

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PREFACE 1X Brenda List, Food and Nutrition Service, USDA; Ms. Ruth Lubic, Maternity Center Association, New York City; Ms. Shelly Marks, Harbor University of California at Los Angeles Medical Center; Dr. Richard Naeye, Pennsyl- vania State University College of Medicine; Dr. Godfrey Oakley, Centers for Disease Control; Dr. James Olson, Iowa State University; Dr. Theresa Scholl, School of Osteopathic Medicine, University of Medicine and Den- tistry of New Jersey; Dr. Rita Thomas, Bristol-Myers; Dr. Bea van den Berg, University of California, Berkeley; Dr. Honor Wolfe, Wayne State University School of Medicine; Dr. Jose Villar, National Institute of Child Health and Human Development; Dr. Catherine Woteki, National Center for Health Statistics; Dr. Ray Yip, Centers for Disease Control; and Ms. Colette Zyrkowski, Centers for Disease Control. The committees extend special thanks to Ms. Elizabeth Brannon of the Office of Maternal and Child Health, DHHS, for encouragement, facilitating searches for data, and identifying resource people and materials. '2~ I. ~ ROY M. PITKIN, Chair Committee on Nutritional Status During Pregnancy and Lactation

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Contents 1 Summary 2 Introduction PART I NUTRITIONAL STATUS AND WEIGHT GAIN Historical Trends in Clinical Practice, Maternal Nutritional Status, and the Course and Outcome of Pregnancy 4 Assessment of Gestational Weight Gain Total Amount and Pattern of Weight Gain: Physiologic and Maternal Determinants 6 Body Composition Changes During Pregnancy 7 Energy Requirements, Energy Intake, and Associated Weight Gain During Pregnancy Effects of Gestational Weight Gain on Outcome in Singleton Pregnancies 9 Weight Gain in Twin Pregnancies 10 Causality and Opportunities for Intervention 1 27 37 63 96 121 137 176 212 222

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xii 11 Introduction PART II DIETARY INTAKE AND NUTRIENT SUPPLEMENTS 12 Assessment of Nutrient Needs 13 Dietary Intake During Pregnancy 14 Iron Nutrition During Pregnancy 15 Trace Elements 16 Calcium, Vitamin D, and Magnesium 17 Vitamins A, E, and K 18 Water-Soluble Vitamins 19 Protein and Amino Acids 20 Substance Use and Abuse During Pregnancy 21 Periconceptional Vitamin Supplementation and Neural Tube Defects APPENDIXES A Considerations in Constructing Gestational Weight Gain Charts B Provisional Weight Gain Charts by Prepregnancy Weight for Height C Table for Estimating Body Mass Index D Biographical Sketches of Committee Members Acronyms Glossary Index CONTENTS 237 245 258 272 299 318 336 351 380 390 412 423 429 433 437 441 443 449