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8 formation of definitive embryonic structure is most susceptible to the teratogenic effects of intrinsic and extrinsic environ- mental factors and to potentiation of genetic tendencies that may produce irreversible abnormalities. This is also the period of nausea and vomiting and bizarre appetites which, if not corrected, may lead to irreversible complications in the last two trimesters of pregnancy. Since the first trimester is the formative period for the embryo and the time when definitive maternal patterns are established, every effort should be made to correct the problems of early pregnancy and establish a satisfactory nutritional intake. This will provide for the molecular integrity of developing embryonic structures, including the placenta, and their subsequent growth, for the nutrient stores in the newly-born infant, and for adequate lactation. To achieve effective nutritional management during pregnancy, it is necessary to individualize food plans to meet the needs of each patient. Physicians planning a diet for a pregnant woman must make dietary adjustments after considering the patient's nutritional status, age, body size, genetic pattern, physical activity, economic status, cultural and environmental background, food preferences, and existing medical complications. It is also necessary to determine the

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10 jC a lories Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Prepregnancy 2100 Calories Pregnancy 2300 Calories Lactation 3100 Calories An increased intake of calories are needed to meet the energy costs of the pregnant woman. These include calories for the building of new tissue in the fetus and placenta, the increased physical work load associated with normal activities of the mother, and the increased basal energy requirements dur- ing pregnancy. The increase in weight associated with pregnancy accelerates, beginning with small increments during the early weeks and increasing in the latter months before term, with an average gain between 0.5-0.8 pounds per week over the entire period.(Figure I, Appendix page 55) The intake should allow a gain in weight totaling approximately 24 pounds. Weight gain is one measure of the adequacy of caloric intake. Rapid gain in weight which is not related to caloric intake may indicate water retention. (27) The usual caloric intakes of some pregnant women may require little change. Other women may need either more or less than the 200 additional calories per day recommended on the average during pregnancy. Adjustments in caloric allow- ances need to be made after considering weight, height, age,

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11 and activity level. Some women may so reduce physical activity during the third trimester that the extra demands for calories may be largely met without additional caloric intake. Allowances for women of body-size and age different from that of the reference woman may be estimated from data recorded in Table I, page 12. The diets of some women with poor eating habits commonly include large quantities of sweets, sodas, and starchy foods which are proportionately high in calories, but which may lack essential nutrients. An important function of nutritional management in these cases is to help such women adjust their eating habits to include the essential nutrients within the calories allowed. The additional energy requirements of lactation are proportional to the quantity of milk produced. The basic diet must be supplemented by approximately 120 calories for every 100 ml of milk produced. An appropriate caloric intake for the lactating woman is one on which the woman's weight remains constant. A diet which provides generous amounts of all of the essential nutrients, to be described, along with the additional items commonly used in preparing meals will usually provide adequate calories necessary for successful pregnancy.

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13 Protein Recommended allowances for a v/oman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 78 grams daily Lactation 98 grams daily During pregnancy the growth of the fetus and accessory tissues increases protein needs. Adequate protein -, is required throughout pregnancy, but large additional demands are made during the last two trimesters. These requirements are greatest if the woman entered pregnancy in poor nutritive s'tatu s and for the pregnant adolescent. Protein allowances for women who are lactating may be derived by addition of 20 grams protein daily to pregnancy allowances, on the assumption that 850 ml breast milk is produced daily. However, protein allowances during lactation must be adapted to the quantities of milk produced. Meats, milk products, eggs, and fish supply the essential amino acids in proportions similar to body needs and I have high nutritive value. Proteins from fruits, vegetables, grains, and nuts supply important amounts of many amino acids, but do not supply as complete an assortment as animal proteins, so the nutritive value is lower. Therefore, to insure a diet with a high nutritive value of protein, some portion of the protein intake should come from animal sources. Some animal

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14 protein should be included in each meal since it is necessary to have both essential and non-essential amino acids available simultaneously for efficient protein bio-synthesis. Nitrogen balance studies (24) have shown that when the diet of the pregnant woman does not contain sufficient calories from carbohydrates and fats, protein is used for energy, and the body becomes depleted in the protein reserve necessary for the building of new tissue. Milk and milk products are protein-rich foods and are also good sources of calcium, phosphate, B vitamins and minerals. Meats and eggs are also protein-rich and good sources of iron and B vitamins. If the protein content of the diet is low, these other nutrients are also apt to be inadequate. Table II shows representative examples of food selections which supply the recommended amounts of protein. Many other food combinations will yield a similar amount of protein.

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16 GOOD AND FAIR SOURCES OF PROTEIN (3, 33) Food GOOD SOURCES Amount Pork, cooked lean Chicken, drumsticks Beef, stewed Liver Hamburger, cooked Cheese, Cheddar type Fish, canned Chile con carne (with beans) Cottage cheese Milk, nonfat dry Chicken, stewed Milk, nonfat or whole Eggs Pork and beans, canned Frankfurters Protein (grams) Calories 3 oz. 25 220 2 medium 24 180 3 oz . 23 245 3 oz. 22 195 % lb. 21 245 3 oz . 21 315 h cup 19 160 1 cup 19 335 h cup 19 100 3/4 cup 19 190 3 oz . 18 170 2 cups 18 180-320 3 18 240 1 cup 16 320 2h 15 390 Food FAIR SOURCES Amount Beans, dried, cooked Peas, blackeyed, cooked Peanut butter Tortillas, corn Bread, enriched whole grain Rice, cooked 1 cup Protein (grams) Calories 1 cup 15 , 230 1 cup 13 190 3 tbsp. 12 285 6 9 380 4 slices 8 240 185

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17 Calcium Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 1.3 grams (1300 mg) daily Lactation 1.3 grams (1300 mg) daily For the adolescent girl who is pregnant or lactating, the calcium allowance is 1.8 grams daily. During pregnancy and lactation, the demand for calcium is increased to provide for the skeletal structures of the fetus and for the production of milk during the lactation period. Calcium is also important to maintain systems of blood coagula- tion, neuromuscular conduction, and muscle contractility. When dietary calcium is insufficient, the most readily mobilized calcium is found in the trabecular portion of bones of the mother. Milk and milk products are the richest food sources of calcium. To provide enough calcium for the infant's bone and tooth development without depleting the expectant mother's supply, three cups of milk daily or its equivalent are recom- mended. One quart or more daily is advised during lactation. Part of the milk may be offered as cheese or in prepared dishes. Skim milk is as acceptable a source of calcium, pro- tein, and riboflavin as is whole milk, and provides about half of the calories.

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18 Calcium tablets are not acceptable substitutes for food sources of calcium because they do not supply the protein and vitamins found in food, may not be as readily utilized, and are a more expensive source of calcium than that found in foods. The use of non-food calcium is not recommended. Approximate Contribution to Recommended Daily Dietary Allowances for a Pregnant Woman 18-35 Years of WHOLE MILK, 3 cups (1% pints) Calories 20% | Protein ZZZZZZHIIZ 35% I Calcium 65% Riboflavin 80%

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20 Iron • Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 20 rr.g daily Lactation 20 mg daily Similar allowances are recommended for adolescent girls who are pregnant or lactating. During pregnancy there is an increased need for iron in the diet in order to: maintain the mother's stores of iron and her hemoglobin level, furnish iron for feto-placental development, and furnish the infant with iron stores needed for blood formation during the neonatal period before iron-rich foods are added to the diet. Iron balance in women of child bearing age is apt to be precarious because of the regular loss of menstrual blood and because of poor food practices. Women entering pregnancy with iron deficiency anemia need prescribed medicinal iron in addition to food sources of iron. In fact, it is not unreasonable to provide supplemental iron to all pregnant women. (See page 47 for recommended dosage.) To insure intake of the recommended amounts of iron careful food planning is necessary. The iron in meat, eggs, and poultry is absorbed more readily than that from vegetable sources. (9)

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21 GOOD AND FAIR SOURCES OF IRON (3, 33) GOOD SOURCES Food Liver, pork Kidney Liver, beef Liverwurst Heart Beans (cooked, dried) Pork, lean Beef, lean Amount Iron (mg ) 3 oz. 19.0 3 oz. 9.5 3 oz . 7.5 3 oz . 5.1 3 oz . 5.0 1 cup 4.6 3 oz . 3.2 3 oz. 3.2 Calories 210 170 195 240 160 230 220 170 FAIR SOURCES Food Raisins Prunes Greens, cooked Sardines Bread, enriched whole grain Amount Iron (mg ) 1/2 cup 2.8 1/2 cup 2.2 3/4 cup 2.0 2 oz. 1.8 3 slices 1.8 Calories 230 190 30 120 180

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22 Ascorbic Acid, _(Vitamin C) Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib) . Pregnancy 100 mg daily Lactation -100 mg daily Ascorbic acid is essential for the maintenance of normal connective tissue; it is important for the health of gums and teeth; and it facilitates the absorption of iron. Food sources of ascorbic acid include fruits, especially citrus fruits, vegetables, and liver. Vitamin A Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 6000 IU daily Lactation 8000 IU daily Vitamin A is essential in cell development, in tooth formation, in normal bone growth, and for healthy skin. It also has an important role in the chemistry of vision, enabling the eye to adapt to dark and light. The most abundant food sources of vitamin A are milk, butter, egg yolk, liver and the carotenoid pigments of green leafy vegetables, tubers, and fruits. Vitamin A in large amounts may produce toxic effects, however, this is not a hazard at usual levels of intake. Vitamin D Recommended allo-.vances for a woman with a prepregnant

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23 weight of 58 kg (128 Ib). Pregnancy 400 IU daily Lactation 400 IU daily Vitamin D provides for the absorption and retention of calcium and phosphorus and is required for skeletal growth. Food sources of vitamin D include whole milk fortified with 400 IU per quart, butter, fish oil, egg yolk, and liver. Other foods may have vitamin D added. Excessive quantities of vitamin D are toxic. In the adult, doses in the order of 2000 to 3000 IU pe r day may lead to minimal toxicity. A newly recognized infantile hypercalcemia syndrome with developmental cardiac abnormalities suggests that smaller excesses in pregnancy may be toxic to the fetus.

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24 GOOD AND FAIR SOURCES OF ASCORBIC ACID (3, 33) GOOD SOURCES Food Orange Strawberries, raw Green pepper, cooked Cantaloupe Brussel sprouts Orange juice (frozen, diluted) Grapefruit, raw Grapefruit juice (canned) Greens, cooked turnip, mustard, collard* Amount Ascorbic Acid (mg) 1 medium 75 3/4 cup 66 1 whole 64 1/2 (5 in- 63 ches dia.) 1/2 cup 57 1/2 cup 56 1/2 52 3/4 cup 50 3/4 cup 50 Calories 60 40 20 60 20 55 55 60 30 FAIR SOURCES Food Spinach, cooked Pepper, green and red, raw Tomato, fresh Cauliflower, cooked Sweet potato, baked Cabbage, raw Tomato (canned, cooked or juice) Asparagus, cooked White potato (boiled in jacket or baked) Liver Amount Ascorbic (mg) 3/4 cup 40 1/2 40 1 wedge 34 2" x 7" 1/2 cup 33 1 medium 24 1/2 cup 24 1/2 cup 23 1/2 cup 23 1 medium 22 3 oz. 22 Calories 30 10 50 12 80 24 23 20 90 195 *Servings of greens are given as 3/4 cup since this is an amount apt to be eaten by persons who like cooked greens.

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25 FOOD SOURCES OF VITAMIN A (3, 33) Food Amount Vitamin A Calories (International Units) Liver 3 oz. 45,420 195 Greens, cooked 3/4 cup 6,000 - 11,000 20 - 40 Potato, sweet 1 8,910 155 Carrots 1/2 cup 7,610 20 Pumpkin 1/2 cup 7,295 40 Cantaloupe 1/2 6,540 60 Winter squash 1/2 cup 4,305 65 Apricots 3 2,890 55 Egg yolk 1 580 60 Butter or forti- 1 tbsp. 460 100 fied margarine Milk, whole 1 cup 350 160 Milk, half & half 1/4 cup 290 80

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26 Thiamine Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 1.0 mg daily Lactation 1.2 mg daily Thiamine helps to maintain appetite and normal cardiac and neurologic functions and is necessary in systems of carbohy- drate metabolism. Thiamine is sparingly stored in the body. Although widely distributed in plant and animal foods, thiamine occurs in small amounts. A varied diet helps to insure an adequate thiamine intake. Good sources include organ meats, milk, lean pork, dried beans, nuts, whole grain and enriched breads, and cereals. Riboflavin Recommended allowances for a woman with a prepregnant weight of 58kg (128 Ib) . Pregnancy 1.6 mg daily Lactation _ 1.9 mg daily Riboflavin functions in a number of important enzyme systems in tissues and respiration. It assists in the metabolism of carbohydrate and amino acids. Good sources of riboflavin are milk, milk products, and organ meats. Fair sources include meats, poultry, dark green leafy vegetables, and enriched or

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27 whole grain bread and cereal. Eighty percent of the recommended riboflavin allowance for pregnancy is supplied by 3 cups of milk per day. » Niacin Recommended allowances for a woman with a prepregnant weight of 58 kg (128 Ib). Pregnancy 17 mg equivalents daily Lactation 21 mg equivalents daily Niacin is needed for the vital processes of translating sources of energy into usable form. If the protein in the diet is of good quality and of sufficient amount, niacin intake will be adequate. Folacin Pregnancy approximately 400 jig Folacin (folic acid) requirements are increased during pregnancy, particularly during the 2nd and 3rd trimesters because of the demands of the growing fetus. The normal adult require- ment is approximately 50 micrograms daily. Although precise information is not available, the minimum requirement during pregnancy is probably 400 micrograms. Folacin deficiency results in megaloblastic maturation arrest of the bone marrow and anemia. Ascorbic acid is necessary for the maintenance of folacin in its active form. Folacin occurs in a wide variety of foods of animal and vegetable origin.