Purnell, L. D. (2014). Guide to culturally competent health care. (3rd ed.). Philadelphia, PA: F. A. Davis.

Shivakumar, G. (2015). Exercise improves depressive symptoms during pregnancy. BJOG: An International Journal of
Obstetrics and Gynaecology, 122 (1), 63.

Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice Hall Health.

Sut, H. K., & Kaplan, P.B. (2015). Effect of pelvic muscle floor exercise on pelvic floor muscle activity and voiding
functions during pregnancy and the postpartum period. Neurourology and Urodynamics. doi:10.1002 /nau.22728.

Tiran, D. (2012). Ginger to reduce nausea and vomiting during pregnancy: Evidence of effectiveness is not the same as
proof of safety. Contemporary Therapies in Clinical Practice, 18, 22–25.

Toohill, J., Fenwick, J., Gamble, J., Creedy, D., Bulst, A., Turkstra, E., & Ryding, E. (2014). A randomized controlled trial of
a psycho-education intervention by midwives in reducing childbirth fear in pregnancy women. Birth, 41 (4), 384–395.

United States Department of Health and Human Services (HHS). (2013). Healthy People 2020. Retrieved from
http://www.healthypeople.gov/2020

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/knowledge/ccknow.htm

Wisner, K. L., Sit, D. K. Y., Altemus, M., Bogen, D. L., Famy, C. S., Pearlstein, T. B., … Perel, J. M. (2012). Mental health
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Zavorsky, G. S., & Longo, L. D. (2011). Adding strength training, exercise intensity, and caloric expenditure to exercise
guidelines in pregnancy. Obstetrics & Gynecology, 117(6), 1399–1402.

Chapter 11 Maternal Nutrition

Monart Designs/Fotolia

When I was young I thought nutrition was boring. Now that I am pregnant I find it endlessly fascinating. I
realize how important good nutrition is for me, for my husband, and for the well-being of our child. My
mother just laughs and reminds me about the times I resisted her efforts to help me develop better eating
habits. Oh well, it is just another example of how smart our parents get as we get older!
—Maria, 26

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 Learning Outcomes
11.1 Describe the recommended levels of weight gain during pregnancy when providing nursing care for pregnant
women.
11.2 Explain the significance of specific nutrients in the diet of the pregnant woman.
11.3 Compare nutritional needs during pregnancy, the postpartum period, and lactation with nonpregnant
requirements.
11.4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.
11.5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake
and status in the nursing management of pregnant women.
11.6 Compare recommendations for weight gain and nutrient intakes in the pregnant adolescent with those for
the mature pregnant adult.
11.7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent.
11.8 Compare nutritional counseling issues for breastfeeding and formula-feeding mothers.

A woman’s nutritional status before and during pregnancy can significantly

influence her health and the health of her fetus. In most prenatal clinics and
offices, nurses offer nutritional counseling directly or work closely with the
nutritionist in providing nutritional assessment and teaching. This chapter focuses
on the nutritional needs of the pregnant woman. Special sections consider the
nutritional needs of the pregnant adolescent and the woman after giving birth.

Fetal growth occurs in three overlapping stages:

1. Growth by increase in cell number

2. Growth by increase in cell number and cell size
3. Growth by increase in cell size alone

Nutritional problems that interfere with cell division may have permanent
consequences. If the nutritional deficit occurs when cells are mainly enlarging, the
changes are usually reversible when normal nutrition resumes.

Growing fetal and maternal tissues require increased quantities of nutrients. These
are listed in the Dietary Reference Intakes (DRIs) , a broad array of dietary
reference values developed jointly by the United States and Canada, as either the
Recommended Dietary Allowance (RDA) or Adequate Intake (AI). An RDA is the
daily dietary intake that is considered sufficient to meet the nutritional
requirements of nearly all individuals in a specific life stage and gender group. An
AI is a value cited for a nutrient when there are insufficient data to calculate an
estimated average requirement.

Table 11–1 Daily Food Plan for Pregnancy and Lactation

Food Group Nutrients Food Source Recommended Recommended
Provided Daily Amount Daily Amount
During Pregnancy During
Lactation

Dairy Protein; Milk—whole, 2%, skim, dry, Four 8-oz cups (five Four 8-oz cups
products riboflavin; buttermilk for teenagers) used (five for
vitamins A, plain or with teenagers);
D, and Cheeses—hard, semisoft, flavoring, in shakes, equivalent
others; cottage amount of
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 calcium; Yogurt—plain, low-fat soups, puddings, cheese, yogurt,
phosphorus; custards, cocoa and other dairy
zinc; Soybean milk—canned, dry products
magnesium Calcium in 1 cup
milk equivalent to
1½ cups cottage
cheese, 1½ oz hard
or semisoft cheese,
1 cup yogurt, 1½
cups ice cream
(high in fat and
sugar)

Meat and Protein; Beef, pork, veal, lamb, Three servings (one Two servings
meat iron; poultry, animal organ serving = 2 oz),
alternatives thiamine, meats, fish, eggs; legumes; combination in
niacin, and nuts, seeds, peanut butter, amounts necessary
other grains in proper vegetarian for same nutrient
vitamins; combination (vitamin B12 equivalent (varies
and supplement needed) greatly)
minerals

Grain B vitamins; Breads and bread products Six to 11 servings Same as for
products, iron; whole such as cornbread, muffins, daily: one serving = pregnancy
whole grain grain also waffles, hotcakes, biscuits, one slice bread, ¾
or enriched has zinc, dumplings, cereals, pastas, cup or 1 oz dry
magnesium, rice cereal, ½ cup rice
and other or pasta
trace
elements;
provides
fiber

Fruits and Vitamins A Citrus fruits and juices, Two to four Same as for
fruit juices and C; melons, berries, all other servings (one pregnancy
minerals; fruits and juices serving for vitamin
raw fruits C): one serving =
for one medium fruit,
roughage ½ –1 cup fruit, 4 oz
orange or grapefruit
juice

Vegetables Vitamins A Leafy green vegetables; Three to five Same as for

and and C; deep yellow or orange servings (one pregnancy
vegetable minerals; vegetables such as carrots, serving of dark
juices provides sweet potatoes, squash, green or deep
roughage
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 such as peas, green beans, for vitamin A): one
broccoli; other vegetables serving = ½ –1 cup
such as beets, cabbage, vegetable, two
potatoes, corn, lima beans tomatoes, one
medium potato

Fats Vitamins A Butter, cream cheese, As desired in Same as for

and D; fortified table spreads; moderation (high in pregnancy
linoleic acid cream, whipped cream, calories): one
whipped toppings; avocado, serving = 1 tbsp
mayonnaise, oil, nuts butter or enriched
margarine

Sugar and Sugar, brown sugar, honey, Occasionally, if Same as for

sweets molasses desired pregnancy

Desserts Nutritious desserts such as Occasionally, if Same as for

puddings, custards, fruit desired pregnancy
whips, and crisps; other
rich, sweet desserts and
pastries

Beverages Fluid Coffee, decaffeinated As desired, in Same as for

beverages, tea, bouillon, moderation pregnancy
carbonated drinks

Miscellaneous Iodized salt, herbs, spices, As desired Same as for

condiments pregnancy

Note: The pregnant woman should eat regularly: three meals a day, with nutritious snacks of fruit,
cheese, milk, or other foods between meals if desired. (More frequent but smaller meals are also
recommended.) Four to six 8-oz glasses of water and a total of eight to ten 8-oz cups total fluid intake
should be consumed daily. Water is an essential nutrient.

Women can get most of the recommended nutrients by eating a well-balanced diet
each day. The basic food groups and recommended amounts during pregnancy and
lactation are presented in Table 11–1 .

Maternal Weight Gain

Maternal weight gain is an important factor in fetal growth and newborn birth weight. Optimal weight gain depends on
the woman’s body mass index (BMI) (a measure of body fat based on height and weight) and her prepregnant
nutritional state. An adequate weight gain indicates an adequate caloric intake. However, it does not ensure that the
woman has a good diet nutritionally. The pregnant woman must maintain the nutritional quality of her diet as her
weight gain progresses.

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 Healthy People 2020
(MICH-16.5) Increase the proportion of women delivering a live birth who had a healthy weight prior to
pregnancy

The Institute of Medicine (IOM) (2009) has established optimum ranges of weight gain based on a woman’s BMI,
and the American College of Obstetricians and Gynecologists (ACOG) (2013a) supports these recommendations. The
IOM’s optimum ranges of weight gain are as follows:

Underweight woman: BMI less than 18.5: 28 to 40 lb (12.5 to 18.0 kg)

Normal-weight woman: BMI between 18.5 and 24.9: 25 to 35 lb (11.5 to 16.0 kg)
Overweight woman: BMI between 25 and 29.9: 15 to 25 lb (7.0 to 11.5 kg)
Obese woman: BMI equal to or greater than 30: 11 to 20 lb (5.0 to 9.1 kg)

The average maternal weight gain is distributed as follows:

11 lb (5 kg) Fetus, placenta, amniotic fluid

2 lb (0.9 kg) Uterus

4 lb (1.8 kg) Increased blood volume

3 lb (1.4 kg) Breast tissue

5 to 10 lb (2.3 to 4.5 kg) Maternal stores

The pattern of weight gain is important. For women of normal weight, the IOM recommendations are based on a first-
trimester weight gain of 1.1 to 4.4 lb (0.5 to 2.0 kg) followed by a gain of about 1 lb (0.45 kg) per week during the
second and third trimesters. The rate of weight gain in the second and third trimesters needs to be slightly higher for
underweight women and slightly lower for women who are overweight (0.6 lb) or obese (0.5 lb) (IOM, 2009).

The prevalence of obesity in the United States has increased dramatically over the past 25 years. The recent National
Health and Nutrition Examination Survey found that in the United States more than one third of women are obese and
8% of reproductive-aged women are extremely obese (ACOG, 2013a). Pregnant women who are obese are at risk for
many pregnancy complications including gestational diabetes mellitus, preeclampsia, and cesarean birth. Their fetuses
are at increased risk for congenital anomalies, stillbirth, prematurity, macrosomia, and childhood obesity. Thus it is
recommended that these women receive counseling on strategies to move toward and to remain at a healthful weight
prior to conceiving (ACOG, 2013b).

The incidence of bariatric surgery among obese reproductive-aged women is increasing (ACOG, 2013a). Women who
lose weight after weight-loss surgery are less likely to have complications during pregnancy. The need for vitamin
supplementation should be evaluated as these women are at risk for deficiencies in iron, vitamin B12, folate, vitamin D,
and calcium. Women who have undergone gastric band surgery should be referred to their general surgeon to evaluate
the need for a band adjustment.

Clinical Tip

Weight varies with time of day, amount of clothing, inaccurate scale adjustment, or weighing error. Do not
overemphasize a single weight, but pay attention to the overall pattern of weight gain.

Because of the association between maternal weight gain and pregnancy outcome, most caregivers pay close attention
to weight gain during pregnancy (Figure 11–1 ). Weight gain charts can be useful in monitoring the rate and pattern
of weight gain over time.

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 All pregnant women should include a variety of nutrient rich foods each day to ensure they are meeting the nutritional
needs of both themselves and their babies. The U.S. Department of Agriculture (USDA) offers an online tool
(choosemyplate .gov) that can help expectant women customize an eating plan based on age, weight, height, physical
activity, and gestation stage (Figure 11–2 ).

Nutritional Requirements
The RDA for almost all nutrients increases during pregnancy, although the amount of increase varies with each nutrient.
These increases reflect the additional requirements of both the mother and the developing fetus.

Figure 11–1
It is important to monitor a pregnant woman’s weight over time.

Figure 11–2
MyPlate is part of an initiative to encourage healthy eating. It illustrates the five food groups and encourages people to
fill half their plates with fruits and vegetables.
Source: USDA (U.S. Department of Agriculture).

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 Calories
The term calorie (cal) designates the amount of heat required to raise the temperature of 1 g of water 33.8°F
(1.0°C). The kilocalorie (kcal) is equivalent to 1000 cal and is the unit used to express the energy value of food.

The dietary reference intakes for energy requirements during pregnancy do not change during the first trimester.
During the second and third trimesters, pregnant women should consume an extra 300 kcal/day. Prepregnant weight,
height, maternal age, health status, and activity level all influence caloric needs, and weight should be monitored
regularly during the pregnancy. See Teaching Highlights: Adding 300 kcal During Pregnancy.

Carbohydrates
Carbohydrates provide the body’s main source of energy as well as the fiber necessary for proper bowel functioning. If
the total caloric intake is not adequate, the body uses protein for energy. Protein then becomes unavailable for growth
needs. In addition, protein breakdown leads to ketosis.

The carbohydrate and caloric needs of the pregnant woman increase, especially during the last two trimesters.
Carbohydrate intake promotes weight gain and growth of the fetus, placenta, and other maternal tissues. Dairy
products, fruits, vegetables, and whole-grain cereals and breads all contain carbohydrates and other important
nutrients.

Protein
Protein supplies the amino acids required for the growth and development of maternal tissues, such as the uterus and
breasts, and to meet fetal needs. This is especially important during the last half of pregnancy, when fetal growth is
greatest.

The protein requirement for a pregnant woman is 60 g/day, an increase of 14 g over nonpregnant levels. Animal
products such as meat, fish, poultry, and eggs provide high-quality protein. Dairy products are also important protein
sources. A quart

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 Teaching Highlights Adding 300 kcal During Pregnancy
The notion of “eating for two” may result in overeating. Emphasize the relatively small increase in calories
necessary during pregnancy.
The additional 300 kcal/day recommended during pregnancy can be achieved by adding two milk servings and
one serving of meat or alternative.
MyPlate is designed to represent the food groups needed to make a balanced diet. Following MyPlate
recommendations, women should aim to have half their plate consist of fruits and vegetables, make at least
half their grains whole grains, and switch to fat-free or low-fat (1%) milk. Women are encouraged to drink
water rather than sugary drinks and compare the sodium content of foods and choose foods that are lower in
sodium (USDA, 2012). A balanced diet includes the following:
Grains: Six to eleven servings (one serving = 1 slice bread, ½ hamburger roll, 1 oz dry cereal, 1 tortilla, ½
cup pasta, rice, grits)
Fruits: Two to four servings; one should be a good source of vitamin C (one serving = 1 medium-sized
piece of fruit, ½ cup juice)
Vegetables: Three to five servings (one serving = 1 cup raw vegetable, 1 cup green leafy vegetable, ½
cup cooked vegetable)
Dairy: Two to three servings (one serving = 1 cup milk or yogurt, 1.5 oz hard cheese, 2 cups cottage
cheese, 1 cup pudding made with milk)
Meats and alternatives: Two to three servings (one serving = 2 oz cooked lean meat, poultry, or fish; 2
eggs; ½ cup cottage cheese; 1 cup cooked legumes [kidney, lima, garbanzo, or soybeans, split peas]; 6 oz
tofu; 2 oz nuts or seeds; 4 tbsp peanut butter)
Not all foods that are nutritionally equivalent have the same number of calories; it is important to consider that
when making food choices.
Consider using low-fat milk, lean cuts of meat, or fish broiled or baked instead of fried.
Foods can be combined. For example, 1 cup spaghetti with a 2-oz meatball would count as 1 serving meat, ¾
cup spaghetti = 1 grain, and ¼ cup tomato sauce = ½ serving vegetable.
Use a calorie-counting guide to compare the calories in a variety of foods that are equivalent, such as 2 oz
beef and 2 oz fish or 1 cup low-fat milk and 1 cup whole milk.

of milk supplies 32 g of protein, more than half the average daily protein requirement. A woman can incorporate milk
into her diet in a variety of dishes, including soups, puddings, custards, sauces, and yogurt. Beverages such as hot
chocolate and milk-and-fruit drinks can also be included, but they are high in calories. Various kinds of hard and soft
cheeses and cottage cheese are excellent protein sources, although cream cheese is considered a fat source only.
Women who have allergies to milk, are lactose intolerant, or practice vegetarianism may find soy milk acceptable. It can
be used in cooked dishes or as a beverage. Tofu, or soybean curd, can replace cottage cheese.

Fat
Fats are valuable sources of energy for the body and aid in the absorption of fat-soluble vitamins. Fats are more
completely absorbed during pregnancy, resulting in a marked increase in serum lipids, lipoproteins, and cholesterol,
and decreased elimination of fat through the bowel. Fat deposits in the fetus increase from about 2% at midpregnancy
to almost 12% at term. However, fat requirements are unchanged during pregnancy and should account for about 20%
to 35% of daily caloric intake, of which 10% or less should be saturated fat.

Essential fatty acids are important for the development of the central nervous system of the fetus. Of particular interest
are the omega-3 fatty acids and their derivative, docosahexaenoic acid (DHA). Maternal dietary intake of DHA during
pregnancy may reduce the risk of preterm birth and low birth weight, and may enhance fetal and infant brain
development (Carlson, Colombo, Gajewski, et al., 2013). Oily fish provide the best source of DHA (however, see the
Mercury in Fish section later in this chapter); other sources include fortified dairy products, and even some fortified
soymilk. Plant sources of omega-3 fatty acids include soybean oil, canola oil, flaxseeds and their oil, and walnuts.

Minerals

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 Calcium and Phosphorus
Calcium and phosphorus are involved in the mineralization of fetal bones and teeth and acid–base buffering. The body
absorbs and uses calcium more efficiently during pregnancy. Some calcium and phosphorus are required early in
pregnancy, but most fetal bone calcification occurs during the last 2 to 3 months. Teeth begin to form at about 8 weeks’
gestation and are formed by birth. The 6-year molars begin to calcify just before birth.

The identified AI for calcium for the pregnant or lactating woman, ages 19 or older, is 1000 mg/day. It is 1300 mg/day
for pregnant women younger than age 19. If calcium intake is low, fetal needs will be met at the mother’s expense by
demineralization of bone.

A diet that includes 4 cups of milk or an equivalent dairy alternative will provide sufficient calcium. Smaller amounts of
calcium are supplied by legumes, nuts, dried fruits, and dark green leafy vegetables (such as kale, cabbage, collards,
and turnip greens).

The RDA for phosphorus is 700 mg/day for the pregnant or lactating woman ages 19 and older. It is 1250 mg/day for
pregnant women younger than 19 years. Because phosphorus is so widely available in foods, the daily requirement is
readily supplied through calcium- and protein-rich foods.

Iodine
Iodine is an essential part of the thyroid hormone thyroxine. The thyroid gland may become enlarged if iodine is not
replaced by adequate dietary intake or an additional supplement. Moreover, cretinism may occur in the baby if the
mother has a severe iodine deficiency. Pregnant women can meet the iodine allowance of 220 mcg/day by using iodized
salt. When salt is restricted, the physician may prescribe an iodine supplement.

Sodium
Sodium is essential for proper metabolism and the regulation of fluid balance. Sodium intake in the form of salt is never
entirely restricted during pregnancy even when hypertension is present. The pregnant woman may season food to taste
during cooking but should avoid using extra salt at the table. She can avoid excessive intake by eliminating salty foods
such as potato chips, ham, sausages, and sodium-based seasonings.

Zinc
Zinc is needed for protein metabolism and the synthesis of DNA and RNA. It is essential for normal fetal growth and
development as well as milk production during lactation. The RDA during pregnancy is 11 mg/day for women ages 19
and older. This increases to 12 mg during lactation. Sources include meats, shellfish, poultry, whole grains, and
legumes.

Magnesium
Magnesium is essential for cellular metabolism and structural growth. The RDA for pregnancy is 350 mg/day for women
ages 19 to 30 and 360 mg for women 31 to 50 years of age. Good sources include milk, whole grains, dark green
vegetables, nuts, and legumes.

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 Iron
Iron requirements increase during pregnancy because of the growth of the fetus and placenta and the increased
maternal blood volume. Anemia in pregnancy is mainly caused by low iron stores, although it may also be caused by
inadequate intake of other nutrients, such as vitamins B6 and B12, folic acid, ascorbic acid, copper, and zinc. Iron
deficiency anemia is generally defined as a decrease in the oxygen-carrying capacity of the blood. Anemia leads to a
significant reduction in hemoglobin in the volume of packed red cells per deciliter of blood (hematocrit) or in the
number of erythrocytes. Iron deficiency anemia in pregnancy is associated with an increased incidence of preterm birth,
low-birth-weight newborns, and maternal and infant mortality (Hark & Catalano, 2012).

Fetal demands for iron further contribute to symptoms of anemia in the pregnant woman. The fetal liver stores iron,
especially during the third trimester. The baby needs this stored iron during the first 4 months of life to compensate for
the normally inadequate levels of iron in breast milk and non–iron-fortified formulas.

To prevent anemia, the woman must balance iron requirements and intake. Adequate iron intake is a problem for
nonpregnant women and a greater one for pregnant women. By carefully choosing foods high in iron, the woman can
increase her daily iron intake considerably. Lean meats, dark green leafy vegetables, eggs, and whole-grain and
enriched breads and cereals are the usual food sources of iron. Other iron sources include dried fruits, legumes,
shellfish, and molasses.

Iron absorption is usually higher for animal products than for vegetable products. However, the woman can increase
absorption of iron from nonmeat sources by combining them with meat or a food rich in vitamin C. The RDA for iron
during pregnancy is 27 mg/day, but this intake is almost impossible to achieve through diet alone. Thus, in the second
and third trimesters, the pregnant woman should take a daily supplement of 30 mg elemental iron (Hark & Catalano,
2012). Unfortunately, iron supplements often cause gastrointestinal discomfort, especially if taken on an empty
stomach. Taking the iron supplement after a meal may help reduce this discomfort. Iron supplements may also cause
constipation, so an adequate fluid intake is important in pregnancy.

Vitamins
Vitamins are organic substances needed for life and growth. They are found in small amounts in specific foods and
generally cannot be synthesized by the body in adequate amounts.

Vitamins are grouped according to solubility. Vitamins A, D, E, and K dissolve in fat; vitamin C and the B-complex
vitamins dissolve in water. An adequate intake of all vitamins is essential during pregnancy; however, several are
required in larger amounts to fulfill specific needs.

Fat-Soluble Vitamins
The fat-soluble vitamins, A, D, E, and K, are stored in the liver and thus are available if the dietary intake becomes
inadequate. The major complication related to these vitamins is not deficiency but toxicity due to overdose. Unlike
water-soluble vitamins, excess amounts of vitamins A, D, E, and K are not excreted in the urine. Symptoms of vitamin
toxicity include nausea, gastrointestinal upset, dryness and cracking of the skin, and loss of hair.

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 Vitamin A
Vitamin A is involved in the growth of epithelial cells, which line the entire gastrointestinal tract and make up the skin. It
also plays a role in the metabolism of carbohydrates and fats. Without vitamin A the body cannot synthesize glycogen,
and the body’s ability to handle cholesterol is also affected. In addition, the protective layer of tissue surrounding nerve
fibers does not form properly if vitamin A is lacking.

Probably the best known function of vitamin A is its effect on vision in dim light. A person’s ability to see in the dark
depends on the eye’s supply of retinol, a form of vitamin A. Adequate vitamin A prevents night blindness. Vitamin A is
associated with the formation and development of healthy eyes in the fetus. The RDA for vitamin A is 770 mcg/day for
pregnant women ages 19 and older.

Although routine supplementation with vitamin A is not recommended, supplementation with 5000 International Units is
indicated for women whose dietary intake may be inadequate, such as strict vegetarians and recent emigrants from
countries where deficiency of vitamin A is endemic. Rich sources of vitamin A include deep green, deep orange, and
yellow vegetables; animal sources include egg yolk, cream, butter, and fortified margarine and milk.

Vitamin D
Vitamin D is best known for its role in the absorption and use of calcium and phosphorus in skeletal development. To
supply the needs of the developing fetus, the pregnant woman should have a vitamin D intake of 5 mcg/day. Main food
sources of vitamin D include fortified milk, margarine, butter, and egg yolks. Drinking a quart of milk daily provides the
vitamin D needed during pregnancy. Vitamin D is also obtained through the synthesis of sunlight on the skin. However,
during the winter months women who live in northern latitudes are at risk for limited sun exposure, as are women who
routinely wear sun protection including high sun protection factor (SPF) products and protective clothing.

Vitamin D deficiency is more common than previously recognized. While universal screening for vitamin D deficiency is
not currently recommended, women at risk (vegetarians, women with limited sun exposure, ethnic and racial groups
with dark skin) may be screened. If a deficiency is identified, a daily dose of 1000 to 2000 International Units is safe
(ACOG, 2011).

Excessive intake of vitamin D usually comes from high-potency vitamin preparations, not from the diet. Overdoses
during pregnancy can cause hypercalcemia, or high blood calcium levels, due to withdrawal of calcium from the skeletal
tissue. Symptoms of toxicity include excessive thirst, loss of appetite, vomiting, weight loss, irritability, and high blood
calcium levels.

Vitamin E
The major function of vitamin E, or tocopherol, is antioxidation. Antioxidants such as vitamin E protect the body’s cells
from the destructive effects of free radicals. Vitamin E takes on oxygen, thus preventing another substance from
combining with the oxygen in a process called oxidation. For example, vitamin E helps spare vitamin A by preventing its
oxidation in the intestinal tract and in the tissues. It decreases the oxidation of polyunsaturated fats, thus helping to
retain the flexibility and health of the cell membrane. For this reason, vitamin E affects the health of all cells in the
body.

Vitamin E is also involved in certain enzymatic and metabolic reactions. It is essential for the synthesis of nucleic acids
required in the formation of red blood cells in the bone marrow. Vitamin E is useful in treating certain types of muscular
pain and intermittent claudication, in surface healing of wounds and burns, and in protecting lung tissue from the
damaging effects of smog. These functions may help explain the abundant claims and cures attributed to vitamin E,
many of which have not been scientifically proved.

The recommended intake of vitamin E for pregnant women is unchanged at 15 mg/day. Vitamin E is widely distributed
in foodstuffs, especially vegetable fats and oils, whole grains, greens, and eggs. Excessive intake of vitamin E has been
associated with abnormal coagulation in the newborn.

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 Vitamin K
Vitamin K, or menadione (as used synthetically in medicine), is essential for the synthesis of prothrombin, so its function
is related to normal blood clotting. It is synthesized in the intestinal tract by the Escherichia coli bacterium normally
found in the large intestine. However, the body’s need for vitamin K is not totally met by synthesis. Green leafy
vegetables are excellent sources. The RDA for vitamin K, 90 mcg per day, does not increase during pregnancy.

Intake of vitamin K is usually adequate in a well-balanced prenatal diet. Problems may arise if an illness is present that
results in malabsorption of fats or if antibiotics are used for an extended period, which would inhibit vitamin K synthesis
by destroying intestinal E. coli.

Water-Soluble Vitamins
Water-soluble vitamins are excreted in the urine. Since only small amounts are stored, adequate amounts must be
consumed daily. During pregnancy the concentration of water-soluble vitamins in the maternal serum falls, whereas
high concentrations are found in the fetus.

Vitamin C
The requirement for vitamin C (ascorbic acid) increases in pregnancy from 75 to 85 mg. Vitamin C’s major function is to
aid in the formation and development of connective tissue and the vascular system. Ascorbic acid is essential to the
formation of collagen, which binds cells together. If the collagen begins to disintegrate because of a lack of ascorbic
acid, cell functioning is disturbed and cell structure breaks down, resulting in muscular weakness, capillary hemorrhage,
and eventual death. These are symptoms of scurvy, the disease caused by vitamin C deficiency. Surprisingly, newborns
of women who have taken megadoses of vitamin C may have a rebound form of scurvy.

Maternal plasma levels of vitamin C progressively decrease during pregnancy, with values at term being about half
those found at midpregnancy. It appears that ascorbic acid concentrates in the placenta; levels in the fetus are 50% or
more above maternal levels.

A nutritious diet should meet the pregnant woman’s needs for vitamin C without additional supplementation. Common
food sources of vitamin C include citrus fruit, tomatoes, cantaloupe, strawberries, potatoes, broccoli, and other leafy
greens. Ascorbic acid is readily destroyed by water and oxidation. Therefore, foods containing vitamin C must be stored
and cooked properly.

The B vitamins include thiamine (B1), riboflavin (B2), niacin, folic acid, pantothenic acid, vitamin B6, and vitamin B12.
These vitamins serve as vital coenzyme factors in many reactions such as cell respiration, glucose oxidation, and
energy metabolism. The quantities needed increase as caloric intake increases to meet the metabolic and growth needs
of the pregnant woman.

Thiamine. Required amount increases from the prepregnant level of 1.1 mg/day to 1.4 mg/day. Sources: pork, liver,
milk, potatoes, and enriched breads and cereals.
Riboflavin. Deficiency is manifested by cheilosis (fissures and cracks of the lips and corners of the mouth) and other
skin lesions. During pregnancy women may excrete less riboflavin and still require more because of increased
energy and protein needs. An additional 0.3 to 1.4 mg/day is recommended for pregnant women ages 19 and older.
Sources: milk, liver, eggs, enriched breads, and cereals.
Niacin. Intake should increase 4 mg/day during pregnancy to 18 mg. Sources: meat, fish, poultry, liver, whole
grains, enriched breads, cereals, and peanuts.
Folic acid (folate). Required for normal growth, reproduction, and lactation, folic acid prevents the macrocytic,
megaloblastic anemia of pregnancy, which is rarely found in the United States, but does occur. Inadequate intake of
folic acid has been associated with neural tube defects (NTDs) (spina bifida, meningomyelocele) in the fetus or
newborn. Although these defects are considered multifactorial, research indicates that most of these birth defects
could be prevented if folic acid supplementation recommendations were followed before most women know they are
pregnant (Centers for Disease Control and Prevention [CDC], 2012). Consequently, experts recommend that
all women of childbearing age (15 to 45 years) consume 400 mcg of folic acid daily because half of all U.S.
pregnancies are unplanned and NTDs occur very early in pregnancy (3 to 4 weeks after conception), before most
women realize they are pregnant (CDC, 2012). Folic acid can be made inactive by oxidation, ultraviolet light, and
heating. To prevent unnecessary loss, foods should be stored covered to protect them from light, cooked with only a

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 small amount of water, and not overcooked. Sources: fresh green leafy vegetables, liver, peanuts, and whole-grain
breads and cereals.

Healthy People 2020

(MICH-14) Increase the proportion of women of childbearing potential with intake of at least 400 mcg of
folic acid from fortified foods or dietary supplements

Pantothenic acid. No allowance has been set during pregnancy, but 5 mg/day is considered a safe, adequate
intake. Sources: meats, egg yolk, legumes, and whole-grain cereals and breads.
Vitamin B6 (pyridoxine). Associated with amino acid metabolism, thus a higher-than-average protein intake
requires increased pyridoxine intake. The RDA during pregnancy is 1.9 mg/day, an increase of 0.6 mg over the
allowance for nonpregnant women. Generally, the slightly increased need can be supplied by diet. Sources: wheat
germ, yeast, fish, liver, pork, potatoes, and lentils.
Vitamin B12 (cobalamin). Plays a role in the synthesis of DNA and red blood cells, and is important in maintaining
the myelin sheath of nerve cells. Vitamin B12 is the cobalt-containing vitamin found only in animal sources. Women of
reproductive age rarely have a B12 deficiency. However, vegetarians/vegans (see later discussion on vegetarianism)
can develop a deficiency so it is essential that their dietary intake be supplemented with this vitamin. Occasionally,
vitamin B12 levels decrease during pregnancy but increase again after childbirth. The RDA during pregnancy is 2.6
mcg/day, an increase of 0.2 mcg. A deficiency may be because of a congenital inability to absorb vitamin B12,
resulting in pernicious anemia. Infertility is a complication of this type of anemia. Sources: foods that come from
animals.

Clinical Tip

More women are consuming over-the-counter (OTC) vitamin, mineral, and food supplements today than in the
past. Ask about the use of any OTC supplements to help avoid potentially harmful excess intakes.

Fluid
Water is essential for life, and it is found in all body tissues. It is necessary for many biochemical reactions. It also
serves as a lubricant, as a medium of transport for carrying substances in and out of the body, and as an aid in
temperature control. A pregnant woman should consume at least eight to ten 8-oz glasses of fluid each day, of which
four to six glasses should be water. Because of their sodium content, sodas and diet sodas should be consumed in
moderation. Caffeinated beverages have a diuretic effect, which is counterproductive to increasing fluid intake.

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 Clinical Reasoning Weight Gain in Pregnancy
Jaya Singh, a 28-year-old, G1P0, is 14 weeks pregnant. The rate and total amount of her weight gain during the
first trimester have been consistent with recommendations. She has gained an average of 0.5 kg (1 lb) per week
during both of the past 2 weeks. Her appetite is good, and she consumes three meals per day and snacks
between meals on occasion.

Jaya has altered her diet because she is concerned about excessive weight gain. She told you that she has
decreased her intake from the bread and dairy groups in order to limit her caloric intake. Because she has
omitted most dairy products, she has increased her consumption of salads and broccoli to provide calcium
sources.

A diet history revealed the following:

Grain 3–4 servings, mainly cereal and rice

Fruit 2–4 servings, fresh fruit

Vegetables 3–5 servings, salads, peas, corn, broccoli

Meat 4–5 servings, beef, pork, chicken

Dairy occasionally cheese, ice cream, pudding

Fats, oils, occasionally salad dressings, margarine, desserts sweets

Beverages 8–10 servings, soda, juices, water

After assessing her diet history, what is your evaluation of Jaya’s diet? How would you counsel her?

Table 11–2 Vegetarian Food Groups

Food Group Mixed Diet Lacto-ovovegetarian Lactovegetarian Vegan

Grain Bread, cereal, rice, pasta Bread, cereal, rice, pasta Bread, cereal, rice, Bread, cereal, rice,
pasta pasta

Fruit Fruit, fruit juices Fruit, fruit juices Fruit, fruit juices Fruit, fruit juices

Vegetable Vegetables, vegetable juices Vegetables, vegetable juices Vegetables, vegetable Vegetables, vegetable
juices juices

Dairy and dairy Milk, yogurt, cheese Milk, yogurt, cheese Milk, yogurt, cheese Fortified soy milk, rice
alternatives milk

Meat and meat Meat, fish, poultry, eggs, legumes, tofu, Eggs, legumes, tofu, nuts, Legumes, tofu, nuts, nut Legumes, tofu, nuts, nut
alternatives nuts, nut butters nut butters butters butters

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 Vegetarianism
Vegetarianism is the dietary choice of many people for religious, health, or ethical reasons. There are several types of
vegetarians. Lacto-ovovegetarians include milk, dairy products, and eggs in their diet. Lactovegetarians
include dairy products but no eggs in their diets. Vegans are “pure” vegetarians who will not eat any food from
animal sources.

The expectant mother who is vegetarian must eat the proper combination of foods to obtain adequate nutrients. If her
diet allows, a woman can obtain ample and complete proteins from dairy products and eggs. An adequate, pure vegan
diet contains protein from unrefined grains (brown rice, whole wheat), legumes (beans, split peas, lentils), nuts in large
quantities, and a variety of cooked and fresh vegetables and fruits. Complete proteins can be obtained by eating
different types of plant-based proteins such as beans and rice, peanut butter on whole-grain bread, and whole-grain
cereal with soy milk, either in the same meal or over the day. Seeds may provide adequate protein in the vegetarian
diet if the quantity is large enough. Obtaining sufficient calories to ensure adequate weight gain may be difficult
because vegan diets tend to be high in fiber and therefore filling.

Because vegans use no animal products, a daily supplement of 4 mg of vitamin B12 is necessary. If soy milk is used, only
partial supplementation may be needed. If no soy milk is taken, daily supplements of 1200 mg of calcium and 10 mg of
vitamin D are needed.

Because the best sources of iron and zinc are animal products, vegan diets may also be low in these minerals. In
addition, a high-fiber intake may reduce mineral (calcium, iron, and zinc) bioavailability. Nurses need to emphasize the
use of foods containing these nutrients. A vegetarian food group guide appears in Table 11–2 .

Factors Influencing Nutrition

It is important to consider the many factors that affect a client’s nutrition. What are the age, lifestyle, and culture of the
pregnant woman? What food beliefs and habits does she have? What a person eats is determined by availability,
economics, and symbolism. These factors and others influence the expectant mother’s acceptance of dietary
recommendations.

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 Evidence-Based Practice Lifestyle Interventions to Improve Dietary
Behaviors of Pregnant Women
Clinical Question
Can prenatal counseling improve the nutritional intake of pregnant women? Are these interventions effective
across cultures?

The Evidence
Lack of sound nutritional intake can lead to a host of problems during pregnancy. Excessive weight gain has been
linked to significant morbidity for both mother and baby. Even when weight is controlled, many pregnant women
do not get adequate dietary intake of fruits, vegetables, and fiber in particular. Current practice guidelines
recommend aggressive management of maternal weight before, during, and after pregnancy, and it is widely
supported that nutritional counseling can be effective in preventing excessive weight gain. Two studies focused
on nutritional counseling as a part of prenatal care, and its effectiveness in affecting eating behavior. In one
study, researchers measured whether a relationship existed between healthcare providers discussing diet with
their pregnant clients and subsequent changes in dietary intake. A second study reviewed a community-based,
healthcare provider–led lifestyle intervention exclusively aimed at Spanish-speaking mothers. Taken together,
more than 600 mothers were included in these studies; this yields a strong level of evidence.

The researchers found that healthcare providers can influence maternal nutritional intake when they counsel
mothers about its importance during routine prenatal care (May, Suminski, Berry, et al., 2014). Mothers who
were provided information in the context of healthy behaviors were more likely to engage in healthy dietary
practices during pregnancy than mothers who did not receive counseling from their healthcare providers. Similar
findings were yielded in the Spanish-speaking population. When mothers received culturally appropriate
interventions about lifestyle modifications in the prenatal period, they were more likely to reduce daily
consumption of sugar, saturated fat, and caloric intake, and to increase vegetable and fiber intake (Kieffer,
Welmerink, Sinco, et al., 2014).

Best Practice
The healthcare provider can have an impact on prenatal nutrition simply by addressing healthy lifestyle issues
during pregnancy. This type of prenatal counseling is effective across other cultures when provided in an
appropriate language and in a culturally sensitive way.

Clinical Reasoning
What are some cultural influences on nutrition that should be considered in prenatal counseling? What are other
lifestyle behaviors that should be addressed alongside nutritional counseling in prenatal support services?

Common Discomforts of Pregnancy

Gastrointestinal functioning can be altered at times during pregnancy, resulting in discomforts such as nausea,
vomiting, heartburn, and constipation. Although these changes can be uncomfortable for the woman, they are seldom a
major problem. These discomforts and dietary modifications that may provide relief are discussed in Chapter 10 .

Complementary and Alternative Therapies

While the use of some herbal, botanical, and alternative therapies may seem like a natural and safe alternative to some
individuals, the pregnant consumer should take caution. Few clinical trials exist that have examined the safety of
supplements and herbs during pregnancy. Many herbs, such as black haw, chamomile, dandelion, ginger, nettle leaf,
and red raspberry are considered safe for use in pregnancy. Other herbs could pose a risk (Shinde, Patil, & Bairagi,
2012). Pregnant women should be advised to consult reputable sources such as the National Center for
Complementary and Alternative Medicine website about these therapies and should also speak with their healthcare
providers to determine the safety of such products or therapies.
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 Use of Artificial Sweeteners
Foods and beverages that contain artificial sweeteners are increasingly available. Sweeteners classified as Generally
Recognized as Safe (GRAS) by the U.S. Food and Drug Administration (FDA) are acceptable for use during pregnancy
and include acesulfame potassium (Sweet One), aspartame (NutraSweet, Equal), saccharin (Sweet’N Low, Sugar Twin),
sucralose (Splenda), and stevia (Truvia, PureVia, SunCrystals). As with other foods, moderation should be exercised in
using artificial sweeteners.

Energy Drinks
Energy drinks, such as Monster Energy, Red Bull, and 5-Hour Energy, used to boost performance and delay fatigue have
become increasingly popular in recent years. These beverages are soft drinks with ingredients such as caffeine,
ginseng, guarana, taurine, and sugar added to provide stimulation and increase energy. Because they are classified as
dietary supplements and not food, they are not subject to the same regulations and monitoring as food (Guilbeau,
2012). The caffeine content of energy drinks can be as high as 300 mg (equivalent to about three average cups of
brewed coffee). Excessive intake of energy drinks can cause a variety of symptoms, including anxiety, headache,
agitation, tremors, seizures, psychosis, and altered mental state (Rath, 2012).

Energy drinks have come under scrutiny for the general public because of concerns about workplace safety when drinks
are used to counter the effects of inadequate sleep and reports of deaths following excessive use (Meier, 2012).
Research on the effects of caffeine on pregnancy are mixed, therefore pregnant women are advised to use energy
drinks cautiously and include the drink’s caffeine content in calculating daily caffeine intake in order to stay within
recommended levels.

Foodborne Illnesses
Because of the risk of Salmonella contamination in raw eggs, pregnant women are advised to avoid eating or tasting
foods that may contain raw or lightly cooked eggs. Examples include cake batter, homemade eggnog, sauces made
with raw eggs such as Caesar salad dressing, and homemade ice cream.

Listeria monocytogenes is another bacterium that poses a threat to an expectant mother and her fetus. Listeria
organisms are especially challenging because they can be found in refrigerated, ready-to-eat foods such as
unpasteurized milk and dairy products, meat, poultry, and seafood. To prevent listerial infection (listeriosis), pregnant
women should be advised to do the following (U.S. Food and Drug Administration [FDA], 2014):

Maintain refrigerator temperature at 40°F (4°C) or below and the freezer at 0°F (–18°C).
Refrigerate or freeze prepared foods, leftovers, and perishables within 2 hours after eating or preparation.
Do not eat hot dogs and luncheon meats unless they are reheated until they are steaming hot.
Avoid soft cheeses such as feta, brie, Camembert, blue-veined cheeses, queso fresco, or queso blanco (a soft cheese
often used by Hispanic women in their cooking) unless the label clearly states that they are made with pasteurized
milk.
Do not eat refrigerated patés or meat spreads, foods that contain raw (unpasteurized) milk, or drink unpasteurized
milk.
Avoid eating refrigerated smoked seafood such as salmon, trout, cod, tuna, or mackerel unless it is in a cooked dish
such as a casserole. Canned or shelf-stable patés, meat spreads, and smoked seafood are considered safe to eat.

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 Mercury in Fish
Fish and shellfish are important parts of a healthy diet, but nearly all contain traces of mercury. Although this is not a
concern for most people, some fish and shellfish contain higher levels of mercury than others, and mercury can pose a
serious threat to the developing nervous system of an unborn baby or a young child.

Safety Alert!

Women who are pregnant or who may become pregnant, breastfeeding mothers, and young children should not
eat swordfish, shark, tilefish, or king mackerel because these fish contain high levels of methyl mercury.

Many pregnant women are aware of the mercury warning, but are far less aware of the important nutritional value of
fish, especially fish high in DHA. Consequently, fish consumption has declined but a strong body of evidence supports
the nutritional value of fish during pregnancy (Carlson et al., 2013). Thus pregnant women need to be encouraged to
eat at least 8 oz and up to 12 oz/week (two average meals) of shellfish and fish that are lower in mercury (USDA,
2012). Commonly eaten fish that are lower in mercury include canned light tuna, shrimp, salmon, catfish, and pollack.
Albacore (white) tuna has more mercury than canned light tuna; therefore only 6 oz/week of albacore tuna is
recommended.

Lactase Deficiency (Lactose Intolerance)

Some individuals have difficulty digesting milk and milk products. This condition, known as lactase deficiency
(lactose intolerance) , results from an inadequate amount of the enzyme lactase, which breaks down the milk
sugar lactose into smaller digestible substances.

Lactase deficiency is found in most adults of African, Mexican, Native American, Ashkenazi Jewish, and Asian descent
and, indeed, in many other adults worldwide. People of northern European heritage are usually not affected. Symptoms
include abdominal distention, discomfort, nausea, vomiting, loose stools, and cramps.

Figure 11–3
Cultural factors affect food preferences and habits.
Source: © Arto/Fotolia.

In counseling pregnant women who might be intolerant of milk and milk products, be aware that even one glass of milk
can produce symptoms. Milk in cooked form, such as custards, is sometimes tolerated, as are cultured or fermented
dairy products such as buttermilk, some cheeses, kefir, and yogurt. Lactase deficiency need not be a problem for
pregnant women because the enzyme is available over-the-counter in tablets or drops. Lactase-treated milk is also
available commercially in some grocery stores.

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 Cultural, Ethnic, and Religious Influences
Cultural, ethnic, and religious backgrounds determine people’s experiences with food and influence food preferences
and habits (Figure 11–3 ). People of different nationalities are accustomed to eating different foods because of the
kinds of foodstuffs available in their countries of origin. The way food is prepared varies, depending on the customs and
traditions of the ethnic and cultural group. In addition, the laws of certain religions forbid the use of some foods and
direct the preparation and serving of meals. (See Developing Cultural Competence: The Kosher Diet.)

Developing Cultural Competence The Kosher Diet

The kosher diet followed by many Jewish people forbids the eating of pork products and shellfish. Certain cuts of
meat from sheep and cattle are allowed as are fish with fins and scales. In addition, according to kosher dietary
rules, meat and dairy products should not be mixed and eaten at the same meal.
In each culture, certain foods have symbolic meaning. Generally, these symbolic foods are related to major life
experiences such as birth, death, or developmental milestones. Although generalizations have been made about the
food practices of ethnic and religious groups, there are many variations. The extent to which people continue to eat
traditional ethnic foods and follow food-related ethnic customs is affected by their exposure to other cultures and the
availability, quality, and cost of traditional foods.

When working with pregnant women from any ethnic background, it is important to understand the impact of the
woman’s cultural beliefs on her eating habits and to identify any beliefs she may have about food and pregnancy.
Talking with the client can help determine the level of influence that traditional food customs exert. It is then possible to
give dietary advice in a way that is meaningful to the woman and her family.

Psychosocial Factors
Various psychosocial factors may influence a woman’s food choices. The sharing of food has long been a symbol of
friendliness, warmth, and social acceptance in many cultures. Some foods and food practices are associated with
status. Some foods are prepared “just for company”; others are served only on special occasions or holidays.

Socioeconomic level may be a determinant of nutritional status. Poverty-level families cannot afford the same foods
that higher income families can. Thus pregnant women with low incomes are frequently at risk for poor nutrition.

Knowledge about the basic components of a balanced diet is essential. Often educational level is related to economic
status, but even people on very limited incomes can prepare well-balanced meals if they know enough about nutrition.

The expectant mother’s attitudes and feelings about her pregnancy influence her nutritional status. For example, foods
may be used as a substitute for the expression of emotions, such as anger or frustration, or as a way of expressing
feelings of joy. The woman who is depressed or does not wish to be pregnant may manifest these feelings in loss of
appetite or overindulgence in certain foods.

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 Eating Disorders
Two serious eating disorders, anorexia nervosa and bulimia nervosa (or simply bulimia), affect millions of men and
women, although they develop most commonly in adolescent girls and young women. Both conditions are psychologic
disorders that can have a major impact on physiologic well-being.

Anorexia nervosa is an eating disorder characterized by an extreme fear of weight gain and fat. People with this
problem have distorted body images and perceive themselves as fat even when they are extremely underweight. Their
dietary intake is very restrictive in both variety and quantity. They may also engage in excessive exercise to prevent
weight gain.

Bulimia is characterized by binge eating (secretly consuming large amounts of food in a short time) and purging. Self-
induced vomiting is the most common method of purging; laxatives or diuretics may also be used. Individuals with
bulimia nervosa often maintain normal or near-normal weight for their height, so it is difficult to know whether bingeing
and purging occur.

Women with anorexia nervosa do not often become pregnant because of the physiologic changes that affect their
reproductive systems. Women with bulimia can become pregnant. Their self-induced vomiting may produce many of
the same complications as hyperemesis gravidarum (see Chapter 15 ). In both anorexia nervosa and bulimia, a
multidisciplinary approach to treatment, involving medical, nursing, psychiatric, and dietetic practitioners, is indicated.
Pregnant women with eating disorders need to be closely monitored and supported throughout their pregnancies.

Pica
Pica is the persistent eating of substances, such as soil or clay (geophagia), powdered laundry starch or corn starch
(amylophagia), soap, baking powder, ice (pagophagia), freezer frost, burned matches, paint, or ashes that are not
ordinarily considered edible or nutritionally valuable. Most women who eat such substances do so only during
pregnancy.

Women who practice pica may have nutrient deficiencies because they often consume a less varied diet than they
might otherwise eat. Iron deficiency anemia is the most common concern in pica. Eating laundry starch or certain types
of clay may contribute to iron deficiency because they interfere with iron absorption. The ingestion of large quantities of
clay could fill the intestine and cause fecal impaction; eating starch may be associated with excessive weight gain. Lead
levels should be checked in women who may have eaten peeling paint.

Assessment for pica is an important part of a nutritional history. However, a woman may be embarrassed about her
cravings or reluctant to discuss them for fear of criticism. Using a nonjudgmental approach, give the woman information
that can help her decrease or eliminate this practice. Some women are able to switch to eating nonfat powdered milk
instead of powdered laundry starch and frozen fruit juice instead of ice. Others find that sucking on hard lemon or mint
candies helps decrease the craving.

Nutritional Care of the Pregnant Adolescent

Nutritional care of the pregnant adolescent is of particular concern to healthcare professionals. Many adolescents are
nutritionally at risk because of a variety of complex emotional, social, and economic factors. Important nutrition-related
factors to assess in pregnant adolescents include low prepregnant weight, low weight gain during pregnancy, young
age at menarche, smoking, excessive prepregnant weight, anemia, unhealthy lifestyle (drugs or alcohol use), chronic
disease, and history of an eating disorder.

The nutritional needs of adolescents are generally estimated by using the Dietary Reference Intakes (DRIs) for
nonpregnant teenagers (ages 11 to 14 or 15 to 18) and adding nutrient amounts recommended for all women. If she is
mature (more than 4 years since menarche), the pregnant adolescent’s nutritional needs approach those reported for
pregnant adults. However, adolescents who become pregnant less than 4 years after menarche are at risk because of
their physiologic and anatomic immaturity. They are more likely than older adolescents to still be growing, which can

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 affect the fetus’s development. Thus young adolescents (ages 14 and younger) need to gain more weight than older
adolescents (18 years and older) to produce babies of equal size.

In determining the optimal weight gain for the pregnant adolescent, add the recommended weight gain for an adult
pregnancy to that expected during the postmenarchal year in which the pregnancy occurs. If the teenager is
underweight, additional weight gain is recommended to bring her to a normal weight for her height.

Specific Nutrient Concerns

Caloric needs of pregnant adolescents vary widely. Major factors in determining caloric needs include whether growth
has been completed and the physical activity level of the individual. Figures as high as 50 kcal/kg have been suggested
for young, growing teens who are very active physically. A satisfactory weight gain usually confirms an adequate caloric
intake.

An inadequate iron intake is a major concern with the adolescent diet. Iron needs are high for the pregnant teen due to
the requirement for iron by the enlarging maternal muscle mass and blood volume. Iron supplements are definitely
indicated.

Calcium is another important nutrient for pregnant adolescents. Inadequate intake of calcium is often a problem in this
age group. Adequate calcium intake is necessary to support normal growth and development of the fetus as well as
growth and maintenance of calcium stores in the adolescent. An extra serving of dairy products is usually suggested for
teenagers. Calcium supplementation is indicated for teens who dislike milk unless they consume enough other dairy
products or significant calcium sources.

Because folic acid plays a role in cell reproduction, it is also an important nutrient for pregnant teens. As previously
indicated, a supplement is usually recommended for pregnant females of all ages.

Other nutrients and vitamins must be considered when evaluating the overall nutritional quality of the teenager’s diet.
Nutrients that have frequently been found to be deficient in this age group include zinc and vitamins A, D, and B6.
Eating a variety of foods—especially fresh and lightly processed foods—helps the teen get adequate amounts of trace
minerals, fiber, and other vitamins.

Dietary Patterns
Healthy adolescents often have irregular eating patterns. Many skip breakfast, and most tend to be frequent snackers.
Teens rarely follow the traditional three-meals-a-day pattern. Their day-to-day intake often varies drastically, and they
eat food combinations that may seem bizarre to adults. Despite these practices, adolescents usually achieve a better
nutritional balance than most adults would expect.

In assessing the diet of the pregnant adolescent, it is important to consider the eating pattern over time, not simply a
single day’s intake. Once the pattern is identified, counseling can be directed toward correcting deficiencies.

Counseling Issues
Counseling about nutrition and healthy eating practices is an important element of care for pregnant teenagers. Nurses
can effectively provide this counseling in a community setting. It may be individualized, involve other teens, or provide
a combination of both approaches. If an adolescent’s family member does most of the meal preparation, it may be
useful to include that person in the discussion if the adolescent agrees. Involving the expectant father in counseling
may also be helpful. Clinics and schools often offer classes and focused activities designed to address this topic.

The pregnant teenager’s understanding of nutrition will influence not only her well-being but also that of her child.
However, teens tend to live in the present, and counseling that stresses long-term changes may be less effective than
more concrete approaches. In many cases, group classes are effective, especially those with other teens.

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 Nursing Management

For the Pregnant Woman Desiring Optimum Nutrition

Nursing Assessment and Diagnosis

To plan an optimal diet with each woman, it is essential to assess nutritional status. The woman’s medical record and a
client interview provide information about the following:

Woman’s height and weight, as well as her weight gain during pregnancy
Pertinent laboratory values, especially hemoglobin and hematocrit
Clinical signs that have possible nutritional implications, such as constipation, anorexia, or heartburn
Dietary history to evaluate the woman’s views on nutrition as well as her specific nutrient intake

While gathering data, seek information about psychologic, cultural, and socioeconomic factors that may influence food
intake. Also use the opportunity to discuss important aspects of nutrition within the context of the family’s needs and
lifestyle. A nutritional questionnaire is often useful in gathering and recording important facts. This information can be
used to develop an intervention plan to fit the woman’s individual needs. The sample questionnaire shown in
Figure 11–4 has been filled in to demonstrate this process.

Once information is obtained, begin to analyze the information, formulate appropriate nursing diagnoses, and, with the
woman, develop goals and desired outcomes. Nursing diagnoses might include the following (NANDA-I © 2014).

For a woman during the first trimester, the diagnosis may be Nutrition, Imbalanced: Less than Body
Requirements related to nausea and vomiting. If a woman has excessive weight gain, the diagnosis might be
Overweight, Risk for, related to excessive caloric intake. Be specific in addressing issues such as inadequate intake
of nutrients, including iron, calcium, or folic acid; problems with nutrition because of a limited food budget; problems
related to physiologic alterations, including anorexia, heartburn, or nausea; and behavioral problems related to
excessive dieting, binge eating, and so on. At other times, the diagnosis Knowledge, Readiness for Enhanced,
related to nutrition may seem most appropriate, especially if the woman asks for information about nutrition.

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 Planning and Implementation
After determining the nursing diagnosis, plan an approach to address any nutritional deficiencies or improve the overall
quality of the diet. To be truly effective, this plan must be made in cooperation with the woman. The following example
demonstrates ways to plan with the woman based on the nursing diagnosis (NANDA-I © 2014):

Nutrition, Imbalanced: Less than Body Requirements related to low intake of calcium
Goal: The woman will increase her daily intake of calcium to the minimum DRI level.
Implementation:
1. Plan with the woman how to add more milk or dairy products to the diet (specify amounts).
2. Encourage the use of other calcium sources such as leafy greens and legumes.
3. Plan for the addition of powdered milk in cooking and baking.
4. If none of the preceding options is realistic or acceptable, consider the use of calcium supplements.

Most families can benefit from guidance about food purchasing and preparation. Advise women to plan food purchases
thoughtfully by preparing general menus and a list before shopping. It is also helpful to monitor sales, compare brands,
and be cautious when purchasing convenience foods, which tend to be expensive. Other techniques for keeping food
costs down without jeopardizing quality include buying food in season, using bulk foods when appropriate, using whole-
grain or enriched products, buying lower grade eggs (grading has no relation to the egg’s nutritional value but indicates
color of the shell, delicacy of flavor, and so forth), and avoiding foods from specialty shops and foods in elaborate
packaging.

Health Promotion: Optimizing Maternal–Fetal Health summarizes key actions pregnant women can take to optimize
maternal health and reduce the risk of birth defects.

Health Promotion Optimizing Maternal–Fetal Health

Achieve appropriate weight gain based on prepregnancy weight and BMI.
Participate in regular physical activity (at least 30 minutes of moderate, safe activity on most, if not all, days).
Consume a variety of healthy foods that form the basic food groups, including fruits, vegetables, grains,
proteins, and dairy using MyPlate as a guideline.
Consume 8 to 12 oz of fish high in omega-3 fatty acids weekly.
Take appropriate vitamin and mineral supplements.
Consume caffeine in moderation.
Avoid alcohol, tobacco, and other harmful substances.
Follow safe food handling practices.

Source: Data from the American College of Obstetricians and Gynecologists (2013). Nutrition during pregnancy. Patient Education Pamphlet AP001. Washington, DC: Author.

Evaluation
Once a plan has been developed and implemented, the nurse and client may wish to identify ways of evaluating its
effectiveness. Evaluation may involve keeping a food journal, writing out weekly menus, returning for weekly weigh-ins,
and the like. If anemia is a special problem, periodic hematocrit assessments are indicated.

Postpartum Nutrition
Nutritional needs change following childbirth. Nutrient requirements vary depending on whether the mother decides to
breastfeed. An assessment of postpartum nutritional status is necessary before nutritional guidance is given.

Postpartum Nutritional Status

Postpartum nutritional status is determined by assessing the new mother’s weight, hemoglobin and hematocrit levels,
clinical signs, and dietary history. As mentioned previously, an ideal weight gain during pregnancy is 25 to 35 lb (11.5
to 16.0 kg). After birth there is a weight loss of approximately 10 to 12 lb (4.5 kg to 5.4 kg). Additional weight loss is
most rapid during the next few weeks as the body adjusts to the end of pregnancy. The mother’s weight then begins to
stabilize. This weight stabilization may take 6 months or longer.

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 The mother’s weight should be considered in terms of ideal weight, prepregnancy weight, and weight gain during
pregnancy. Refer women who want information about weight reduction to a dietitian or community-based nutritional
program.

Figure 11–4
The form shown here is a sample nutritional questionnaire used in the nursing management of a pregnant woman.

Hemoglobin and erythrocyte levels should return to normal within 2 to 6 weeks after childbirth. Iron supplements are
generally continued for 2 to 3 months following childbirth to build stores depleted by pregnancy.

Constipation is a common problem following birth. To prevent it the woman should maintain a high fluid intake, which
helps keep the stool soft. Dietary sources of fiber, such as whole grains, fruits, and vegetables, also help prevent
constipation.

It is important to get specific information on dietary intake and eating habits directly from the woman. Visiting the
mother during mealtimes provides an opportunity for unobtrusive nutritional assessment. Which foods has the woman
selected? Is her diet nutritionally sound? A comment focusing on a positive aspect of her meal selection may initiate a
discussion of nutrition.
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 Notify the dietitian about any woman whose cultural or religious beliefs require specific foods so that appropriate meals
can be prepared for her. Also consider referring women with unusual eating habits or numerous questions about good
nutrition to the dietitian. In addition, providing literature on nutrition ensures that the woman has a source of
information at home.

During the childbearing years the risk for obesity becomes especially problematic for women. Consequently, it is critical
to use the postpartum period to change behaviors and help promote effective weight management in women.

Nutritional Care of Formula-Feeding Mothers

After birth the formula-feeding mother’s dietary requirements return to prepregnancy levels. If the mother has a good
understanding of nutritional principles, it is sufficient to advise her to reduce her daily caloric intake by about 300 kcal
and to return to prepregnancy levels for other nutrients. If the mother has a limited understanding of nutrition, now is
the time to teach her the basic principles and the importance of a well-balanced diet. Her eating habits and dietary
practices will eventually be reflected in the diet of her child.

If the mother has gained excessive weight during pregnancy (or perhaps was overweight before pregnancy) and wishes
to lose weight, a referral to the dietitian is appropriate. The dietitian can design weight reduction diets to meet
nutritional needs and food preferences. Weight loss goals of 1 to 2 lb (0.45 to 0.9 kg)/week are usually suggested.

In addition to meeting her own nutritional needs, the new mother is usually interested in learning how to provide for her
infant’s nutritional needs. A discussion of infant feeding that includes topics such as selecting infant formulas, formula
preparation, and vitamin and mineral supplementation are appropriate and generally well received.

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 Nutritional Care of Breastfeeding Mothers
A breastfeeding woman needs increased nutrients. Table 11–1 provides a sample daily food guide for lactating
women. It is especially important for the breastfeeding mother to consume sufficient calories because inadequate
caloric intake can reduce milk volume. However, milk quality generally remains unaffected. The breastfeeding mother
should increase her calories by about 200 kcal over her pregnancy requirement, or 500 kcal over her prepregnancy
requirement. This results in a total of about 2500 to 2700 kcal/day for most women.

Because protein is an important ingredient in breast milk, an adequate intake while breastfeeding is essential. An intake
of 65 g/day during the first 6 months of breastfeeding and 62 g/day during the second 6 months is recommended. As in
pregnancy, it is important to consume adequate nonprotein calories to prevent the use of protein as an energy source.

Calcium is an important ingredient in milk production. Requirements during lactation remain the same as during
pregnancy—an increase of 1000 mg/day. If the intake of calcium from food sources is not adequate, calcium
supplements are recommended.

Iron is not a principal mineral component of milk; thus the needs of lactating women are not substantially different from
those of nonpregnant women. However, supplementation for 2 to 3 months after childbirth is advisable to replenish
maternal stores depleted by pregnancy.

Clinical Tip

Explain to breastfeeding mothers that liquids are especially important during lactation because inadequate fluid
intake may decrease milk volume. Encourage them to drink at least eight to ten 8-oz glasses of fluid daily,
including water, juice, milk, and soups.

In addition to counseling breastfeeding mothers on how to meet their increased nutrient needs, the nurse should
discuss a few issues related to infant feeding. For example, many mothers are concerned about how specific foods they
eat will affect their babies during breastfeeding. Generally, the breastfeeding mother need not avoid any foods except
those to which she might be allergic. Occasionally, however, some breastfeeding mothers find that their babies are
affected by certain foods. Onions, turnips, cabbage, chocolate, spices, and seasonings are commonly listed as
offenders. The best advice to give the breastfeeding mother is to avoid those foods she suspects cause distress in her
baby. For the most part, however, she should be able to eat any nourishing food she wants without fear that her baby
will be affected. For further discussion of successful infant feeding, see Chapter 25 .

Community Resources
Food is a significant portion of a family’s budget, and meeting nutritional needs may be a challenge for families on
limited incomes. Community-based services offered through clinics, local agencies, schools, and volunteer organizations
address these needs. Increasingly, nurses play an important role in managing such community-based services,
especially services focusing on client education. Most communities offer special assistance to qualifying families to
meet their nutritional needs. The Supplemental Nutrition Assistance Program (SNAP), formerly referred to as the Food
Stamp Program, provides an Electronic Benefit Transfer or EBT card, which is similar to a debit card, for participating
households whose net monthly income is below a specified level. This card can be used to purchase food for the
household each month.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is designed to assist pregnant or
breastfeeding women with low incomes and their children under 5 years of age. To be eligible, applicants must meet
income guidelines (income at or below 185% of the U.S. poverty level), state residency requirements, and be
individually determined to be nutritionally at risk by a healthcare professional (Food and Nutrition Service, 2013).
The program provides food assistance, nutrition education, and referrals to healthcare providers. The food distributed,
including dried beans and peas, peanut butter, eggs, cheese, milk, fortified adult and infant cereals, juice, and iron-
fortified formula, is designed to provide good sources of iron, protein, and certain vitamins and minerals for people with
an inadequate diet.
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 Focus Your Study
Maternal weight gains averaging 25 to 35 lb (11.5 to 16.0 kg) for a normal-weight woman are associated with the
best reproductive outcomes.
If the diet is adequate, folic acid and iron are the only supplements generally recommended during pregnancy.
Women should not restrict caloric intake to reduce weight during pregnancy.
Pregnant women should be encouraged to eat regularly and to eat a wide variety of foods, especially fresh and
lightly processed foods.
Taking megadoses of vitamins during pregnancy is unnecessary and potentially dangerous.
Pregnant women who eat vegetarian diets should place special emphasis on obtaining ample proteins, calories,
calcium, iron, vitamin D, vitamin B12, and zinc through food sources or supplementation if necessary.
Pregnant women should avoid eating fish such as swordfish, shark, tilefish, or king mackerel, which contain high
levels of mercury, and should limit their intake of fish that are lower in mercury.
Food safety and sanitation should be a priority when preparing and storing food; foods that are known to cause
foodborne illness should be avoided during pregnancy.
Evaluation of physical, psychosocial, and cultural factors that affect food intake is essential before the nurse can
determine nutritional status and plan nutritional counseling.
Adolescents who become pregnant less than 4 years after menarche have higher nutritional needs and are
considered to be at high biologic risk.
Weight gains during adolescent pregnancy must accommodate recommended gains for a normal pregnancy plus
necessary gains due to growth.
After childbirth, the formula-feeding mother’s dietary requirements return to prepregnancy levels.
Breastfeeding mothers require an additional 200 calories above pregnancy intake and increased fluid intake to
maintain ample milk volume.

Clinical Reasoning in Action

Sandra Hill is a 17-year-old at 19 weeks’ gestation with her first pregnancy. She

presents to you accompanied by her mother. Her mother tells you that Sandra is an active teenager who plays sports
and has been taking dance lessons for 5 years. She maintains a B+ average in school. Sandra voices concern about
potential weight gain during pregnancy. She tells you that this was not a planned pregnancy and she has ambivalent
feelings about it. You become concerned as she tells you that she has reduced her caloric intake over the past few
months to try to keep her weight down and camouflage her pregnancy. You do a nutritional assessment and find that
she is deficient in calcium, iron, and protein. Sandra seems to have irregular eating patterns and she admits to skipping
breakfast often. She asks why she has to gain so much weight when you explain the nutritional needs of her baby
during the pregnancy.

1. Discuss weight distribution in pregnancy.

2. Discuss foods that will increase calcium, protein, and iron in her diet.
3. Explain why folate supplementation is important.
4. What criteria will measure adequate caloric intake during pregnancy?

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 References
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pregnancy (Committee Opinion No. 495). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013a). Obesity in pregnancy (Committee Opinion No.
549). Washington, DC: Author.

American College of Obstetricians and Gynecologists (ACOG). (2013b). Weight gain during pregnancy (Committee
Opinion No. 548). Washington, DC: Author.

Carlson, S. E., Colombo, J., Gajewski, B. J., Gustafson, K. M., Mundy, D., Yeast, J., … Shaddy, D. J. (2013). DHA
supplementation and pregnancy outcomes. The American Journal of Clinical Nutrition, 97 (4), 808–815.

Centers for Disease Control and Prevention (CDC). (2012). Folic acid: Recommendations. Retrieved from http://
www.cdc.gov/ncbddd/folicacid/recommendations.html

Food and Nutrition Service. (2013). WIC: The Special Supplemental Nutrition Program for Women, Infants, and Children.
Retrieved from http://www.fns.usda .gov/wic/default.htm

Guilbeau, J. R. (2012). Health risks of energy drinks. Nursing for Women’s Health, 16 (5), 423–428.

Hark, L., & Catalano, P. M. (2012). Nutritional management during pregnancy. In S. G. Gabbe, J. R. Niebyl, J. L. Simpson,
M. B. Landon, H. L. Galan, E. R. M. Jauniaux, & D. A. Driscoll (Eds.), Obstetrics: Normal and problem pregnancies (6th
ed.). Philadelphia, PA: Elsevier Saunders.

Institute of Medicine (IOM). (2009). Weight gain during pregnancy: Reexamining the guidelines. Washington, DC:
National Academies Press.

Kieffer, E., Welmerink, D., Sinco, B., Welch, K., Clayton, E., Schumann, C., & Uhley, V. (2014). Dietary outcomes in a
Spanish-language randomized controlled diabetes prevention trial with pregnant Latinas. American Journal of Public
Health, 104 (3), 526–533.

May, L., Suminski, R., Berry, A., Linklater, E., & Jahnke, S. (2014). Diet and pregnancy: Healthcare providers and patient
behaviors. The Journal of Perinatal Education, 23 (1), 50–56.

Meier, B. (2012). F.D.A. may tap experts on energy drinks. New York Times. Retrieved from http://www.nytimes
.com/2012/11/28/business/fda-may-tap-experts-on -energy-drinks.html?_r=0

Rath, M. (2012). Energy drinks: What is all the hype? The dangers of energy drink consumption. Journal of the American
Academy of Nurse Practitioners, 24 (2), 70–76.

Shinde, P., Patil, P., & Bairagi, V. (2012). Herbs in pregnancy and lactation: A review appraisal. International Journal of
Pharmaceutical Sciences and Research, 3 (9), 3001–3006.

U.S. Department of Agriculture (USDA). (2012). Maternal intake of seafood omega-3 fatty acids and infant health: A
review of the evidence. Retrieved from http://www.cnpp.usda.gov/sites/default/files/
nutrition_insights_uploads/Insight46.pdf

U.S. Food and Drug Administration (FDA). (2014). Food safety for moms-to-be: While you’re pregnant—listeria.
Retrieved from http://www.fda.gov/Food/FoodborneIllness Contaminants/PeopleAtRisk/ucm083320.htm

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