Nutrition Counseling in Pregnancy

Encouraging healthy nutrition for pregnant patients is an important topic for physician-patient conversation. Family physician, Dr. Kathryn Boling, offers this advice when counseling a patient during prenatl visits.

This article was reprinted with permission from Maryland Academy of Family Physicians.


As part of an initial prenatal visit, all women should be counseled to eat a well-balanced and varied diet that includes meats, dairy products, fruits, vegetables, and grains. It is important that women and their physicians understand that baseline caloric requirements do not increase until the second and third trimesters of pregnancy – and then only by 340-450 calories a day. Whether or not pregnant, a person’s baseline caloric needs depend on body size and exercise activity. In general, sedentary persons will remain at a stable weight if they consume 13 calories per pound of body weight each day. Exercise (depending upon the intensity) raises that maintenance requirement to 16-18 calories per pound of body weight daily.1

This means a moderately active 125-lb woman will need approximately 2,000 calories a day to maintain her weight if she is not pregnant. During pregnancy, she will need the same 2,000 calories a day until her second trimester of pregnancy when she will require between 2300-2500 calories a day. Most guidelines recommend that women with a normal BMI gain between 25-35 lb during pregnancy. Higher or lower weight gain has been associated with increased risks to mothers and babies. Understanding these basic guidelines surrounding the daily caloric requirements of both pregnant and non-pregnant patients is the cornerstone to helping all patients maintain a healthy weight throughout the course and changing circumstances of their lifetimes.

Kathryn Boling, M.D.

Kathryn Boling, M.D.

Dr. Boling is a PGY-2 at the Medstar Franklin Square Medical Center Family Medicine Residency in Baltimore. Prior to entering medical school, she practiced for many years as a Nurse Practitioner specializing in Women’s Health Care. 

Besides routine counseling about alcohol, cigarette smoking, and drug use, pregnant women should also be counseled regarding the use of nutritional supplements in pregnancy. Many patients are already taking nutritional supplements, and certain ones may even be harmful during pregnancy. For instance, vitamin A intake should be limited to less than 5,000 units a day, as higher levels have been implicated in fetal defects. This is in contrast to other supplements that are recommended both before and during pregnancy like folic acid supplementation (0.4-0.8 mg) which should be started at least 1 month pre-conception and taken at least until the 12th week of gestation in order to prevent neural tube defects. Other supplements may be required depending upon the patient’s usual dietary habits. Patients who have been screened and found to be anemic may require iron supplementation. Patients whose diets are deficient in calcium may require supplementation to meet the calcium requirement during pregnancy of 1000 mg-1300 mg each day. Women who live in areas with decreased sunlight may require vitamin D supplementation – but no more than of 200 IU per day as higher levels may be toxic to the fetus.2

Part of the initial pregnancy visit should include a diet history from the patient. This can help the physician tailor his or her recommendations regarding diet. There are many common dietary practices that might require education and/or modification. For instance, women who consume artificially sweetened foods and drink should be counseled regarding the unknown effects of these sweeteners, especially saccharin which is known to cross the placenta and may remain in fetal tissue. Caffeine can probably be consumed in moderation, but should be limited to 150-300 mg/day (about 1½ cups of coffee).  

Women should avoid unpasteurized milk and milk products as pregnant women have increased susceptibility to Listeria and Toxoplasmosis, bacteria sometimes found in unpasteurized milk products. Soft cheeses, lunch meats and meat spreads may also carry Listeria, and pregnant women should be counseled regarding this risk. Everyone should avoid raw eggs, but pregnant women should be counseled specifically about the risk of Salmonella leading to intrauterine sepsis. Finally, pregnant women should wash all fruits and vegetables before eating them and should use caution regarding foods cut on a cutting board that may have not been properly washed between uses.

Herbal preparations should be used with caution, as many have never been tested for safety. Teas containing ginger, citrus peel, lemon balm, and rose hips are probably safe. However, pregnant women should avoid teas containing chamomile, licorice, peppermint or raspberry leaf as there is some controversy regarding their safety in pregnancy – particularly the first trimester.3

To avoid Listeria, leftover foods should be thoroughly heated and processed meats like hot dogs should be heated to steaming hot. Raw or undercooked meats should be avoided to prevent Toxoplasmosis. Utensils and cutting boards used to cut these foods should be washed with soap and water before further use. 

Pregnant women should limit their intake of fish and seafood products to 12 ounces per week (about two fish meals/week). Pregnant women may eat farm-raised salmon in moderation; however, they should avoid raw seafood of any type due to possible contamination with parasites and Norwalk-like viruses. Due to high levels of mercury, seafood like shark, swordfish, king mackerel, tilefish, tuna steaks and other long-lived fish high on the food chain should be avoided completely.3

In essence, the nutritional component of prenatal counseling is extremely important. It begins with a clear and concise explanation of the basics – calorie requirements before, during, and after pregnancy. It continues as the physician obtains a good dietary history and tailors counseling to address relevant dietary issues. And most importantly, it is not a one-time counseling session: nutritional counseling and guidance should continue throughout the pregnancy as caloric requirements change and issues arise. It is through this education that patients will obtain the most benefit – both to their own health and that of their newborn baby. 

References

1. Good nutrition: Should guidelines differ for men and women? The Harvard Medical School Family Health Guide(www.health.harvard.edu)(www.health.harvard.edu)Viewed 11/5/12.

2. Harnish, JM, Harnish, PH, Harnish Dr., Sr  Family Medicine Obstetrics: pregnancy and Nutrition. Prim Care.(www.ncbi.nlm.nih.gov) 2012 Mar;39(1):39-54.

3. Kirkham, Colleen, MD; Susan Harris, MD; Stefan Grzybowski, MD. Evidenced-Based Prenatal Care: Part 1. General Prenatal Counseling and issues. Am Family Physician. 2005 Apr 1;71(7):1307-1316.

CME questions for this article and other articles from the Winter 2013 issue(www.google.com) of Family Doctor appear on the Journal CME Quiz at http://mdafp.org/winter-2013-cme-quiz/(mdafp.org) 

Kathryn Boling, M.D.

Kathryn Boling, M.D.

Dr. Boling is a PGY-2 at the Medstar Franklin Square Medical Center Family Medicine Residency in Baltimore. Prior to entering medical school, she practiced for many years as a Nurse Practitioner specializing in Women’s Health Care.