Dietary supplements for women who plan to become pregnant, pregnant women and lactating women. What is important?

A balanced and varied diet, as well as a lifestyle before pregnancy, during pregnancy and breastfeeding are not only important for the pregnant woman, but just as much for the child.

A normal BMI before pregnancy affects fertility, the course of pregnancy and childbirth, as well as the health of the child. Before pregnancy itself, women should try to get closer to a normal body weight. Energy needs in the second and third trimester of pregnancy increase by only 10% compared to those before pregnancy. Weight gain during pregnancy should be 10-16 kg.

Obese women have an increased risk for gestational diabetes, high blood pressure, premature birth and complications during childbirth.

The habits that a child acquires begin already in the mother's womb. An increased frequency of obesity (2 times higher), metabolic syndrome (4-5 times higher) and diabetes in macrosomic children (those with increased body weight at birth) has been proven.

Also, undernourished women should aim to reach a normal body weight before becoming pregnant.

During pregnancy, the demand for certain nutrients increases much more than the energy consumption, so attention should be paid primarily to the quality of the diet.

In order to give the child a good starting position, a healthy lifestyle should be adopted before pregnancy, and we should also think about the supply of nutrients that are important for the proper development of the embryo.

Women should follow the general rules of proper nutrition and emphasize intake:

• vegetables, fruits, whole grains,
• milk and dairy products with low fat content and lean meat,
• marine fish, which contains omega-3 fatty acids (DHA and EPA) (e.g.salmon, mackerel, sardines), even twice a week
• enough water, at least 1.5 L per day
• balanced, smaller, more frequent meals (5 meals a day, 3 main meals and 2 snacks)
• avoid starvation and/or skipping meals

During pregnancy, you should pay special attention to some foods and limit their intake:

Drinks containing caffeine should be consumed in moderation. Up to 3 cups of coffee per day are acceptable. Caffeinated energy drinks are not recommended, and alcohol should be avoided almost entirely.

It is necessary to limit the intake of sweets and snacks.

Avoid raw animal products that may contain toxoplasmosis, listeriosis or salmonella, microorganisms that could harm the child.Examples include raw or partially cooked meat (salami, sausages, ham), raw fish (eg sushi, smoked salmon), unpasteurised milk and cheese made from unpasteurised milk and raw egg dishes (eg tiramisu).

Preporuka za trudnice jest konzumacija svježe pripravljene hrane i namirnica koja nije podgrijavana te stoga svakako valja pripaziti u restoranima. Osim odabira sigurne hrane, odnosno zdravstveno ispravnih namirnica, i pridržavanja higijenskih mjera, odgovarajuće skladištenje hrane također ima važnu ulogu u zaštiti od bolesti koje se prenose hranom. Priprema hrane uključuje i pranje ruku prije i poslije, jer se i prilikom pripreme dolazi u dodir sa sirovim namirnicama. Voće i povrće prije upotrebe obavezno oprati (uzročnici bolesti su također prisutni i u tlu). Listeria se može naći u grijanoj hrani, može rasti na niskoj temperaturi hladnjaka i u hrani koja je vakumirana.

Smoking during pregnancy is not acceptable, it is also not advisable to stay in rooms where others smoke (passive smoking).Smoking during pregnancy increases the risk of miscarriage, doubles the chance of premature birth, reduces the chances of a child being born with a normal body weight, and slows down the development of the fetus's lungs. Here is some information in numbers: if you smoke 2 cigarettes a day during pregnancy, in 280 days of pregnancy your child will smoke 560 cigarettes before being born.

What are the essential nutrients when planning a pregnancy, during pregnancy and breastfeeding, for which the need increases and whose deficit must not occur?

In order to be completely sure that you are taking in sufficient amounts of important minerals and vitamins during pregnancy, it is necessary to take nutritional supplements.Deficiency of certain minerals and vitamins such as: folic acid, iodine, omega-3 fatty acids (especially docosahexaenoic fatty acid-DHA), vitamin D and iron, can have a negative impact on the proper growth and development of the embryo/child.

Parents are often faced with confusing and conflicting advice from different sources. Therefore, professional associations have created harmonized guidelines. Members of European and American associations participated in the drafting process** and systematically collected and evaluated the following recommendations.

For many nutrients, a significant increase in requirements appears only after the 4th month of pregnancy, but even before the beginning of pregnancy, it is recommended to increase the intake of folic acid, iodine and iron.

Folic acid

Women who are planning pregnancy, or who cannot exclude the possibility of pregnancy, should take a supplement of at least 400 µg of folic acid, and then should continue supplementation during pregnancy, especially until the end of the first trimester. When supplemental folic acid intake begins immediately before or immediately after conception, the supplement should contain more than 400 µg of folic acid. In this way, there is a faster formation of the tissue concentration of folic acid, effective for the prevention of neural tube defects.

In addition to the additional intake of folic acid through dietary supplements, it is absolutely necessary to adhere to a balanced diet that includes the consumption of foods containing folate (a form of folic acid naturally present in food). Plant foods such as green leafy vegetables, cabbage, legumes, whole grains, brown rice, tomatoes and oranges are good sources of folate.

During pregnancy, with proper nutrition and supplementation, the reference value for folic acid intake should be reached, which increases by 50%, up to 600 µg per day.

Folic acid is an important substrate for cell division and growth processes. Sufficient intake reduces the incidence of serious birth defects, i.e. damage to the neural tube. Some studies have also shown a reduction in the risk of other birth defects, including congenital heart disease and cleft palate.

Closure of the neural tube occurs 3-4 weeks after fertilization. Therefore, folic acid intake should be started before conception in order to achieve an optimal preventive effect.

Women who have an increased risk of neural tube defects should take 5 mg of folic acid during pregnancy.There is an increased risk of developing neural tube defects if:

• she or her partner has a neural tube defect
• she or her partner has a family history of neural tube defects
• have had a previous pregnancy with a neural tube defect
• if they have diabetes
• if they are taking therapy for epilepsy

Omega-3 fatty acids (DHA and EPA)

Omega-3 fatty acids, especially DHA (docosahexaenoic fatty acid), play an important role in the development of a child's brain and eye. DHA makes up 50% of the building material of the brain and 65% of the background of the eye. EPA - eicosapentaenoic fatty acid is primarily cardioprotective and anti-inflammatory.

Omega-3 fatty acids should always be consumed through food, i.e. by consuming fish twice a week. Recommended types of fish are salmon (thermally processed), mackerel and sardines.

To help achieve the recommended doses of omega-3 fatty acids; 200 mg of DHA per day and an intake of DHA + EPA of at least 250 mg per day, it is recommended to take part in the form of quality food supplements.

Iodine

During fertilization, pregnancy and breastfeeding, a good supply of iodine is necessary.

Iodine is important because it affects the production of thyroid hormones and thus the development of the child's brain.

Good sources of iodine include marine fish and seafood, iodized table salt, and dairy products. A daily iodine supplement of 100-150 µg is recommended for women who are pregnant or breastfeeding. Even mild iodine deficiencies can have negative consequences for the child. If you have thyroid disease, you should consult your doctor about planning a pregnancy.

Iron

Pregnant women should ensure sufficient amounts of iron through a balanced diet and, if necessary, by combining it with a nutritional supplement containing this important mineral. Iron needs increase during pregnancy because more iron is needed for the development of the fetus, placenta and increased blood volume. However, during pregnancy, menstrual iron loss stops and intestinal iron absorption increases.

The reference value for iron intake is 30 mg per day.

Iron in a form that our body can easily absorb is mainly present in meat, meat products and fish.

Foods of plant origin, such as nuts and leafy vegetables, contain iron, which, however, is not easily absorbed in the intestines, i.e. their bioavailability is low.Simultaneous intake of vitamin C, for example in citrus fruits, improves iron absorption.

General prophylactic iron supplementation is not recommended during pregnancy, since increased iron intake, in women with adequate iron status, may have adverse effects.

Pregnant women should replace iron only if the doctor advises it based on a blood test.

Vitamin D

The mother's supply of vitamin D has a direct effect on the child's supply of vitamin D. Vitamin D regulates the amount of phosphate and calcium in the body, which are needed for bones, teeth, skin and vision to develop properly. Vitamin D is naturally found in blue fish, eggs and meat, but in very small quantities, so we cannot completely rely on dietary intake.On the other hand, the production of vitamin D improves when the skin is exposed to the sun, and this again depends on the summer months, that is, on the angle of incidence of the sun's rays on our planet. The average dietary intake of vitamin D is about 2-4 µg per day, and this intake is not sufficient for the desired serum concentration of 25-hydroxycholecalciferol of at least 50 nmol/L.

Osobe koje su u posebnom riziku od deficita vitamina D jesu: tamnopute osobe, osobe koje ne borave na suncu i/ili upotrebljavaju pokrivala te zaštitu od sunca u obliku krema visokog zaštitnog faktora.                                                                                                                                                           Iz razloga što većinu godine, veliki broj osoba, jako teško postiže željenu koncentraciju vitamina D u serumu, stručnjaci preporučuju suplementaciju vitaminom D od 20 µg (800 IU) per day.

Vegetarian diet during pregnancy

• A vegetarian diet that includes the consumption of milk, dairy products and eggs (lacto ovo vegetarianism) with appropriate food choices can cover most nutrients even during pregnancy.
• It is necessary to ensure a sufficient intake of iron, i.e. an iron supplement based on the blood count.
• If fish is not consumed, it is necessary to supplement omega-3 fatty acids (DHA and EPA).

A lacto-ovo vegetarian diet is adequate during pregnancy planning and pregnancy and breastfeeding, taking into account the above, except for vitamin D, folic acid and iodine, which should always be supplemented. Milk and milk products, eggs, legumes and whole grains usually provide sufficient protein intake. Eggs, legumes, whole grains and some types of vegetables can also contribute to iron intake. However, the risk of insufficient iron supply is increased in lacto vegetarian women. Pregnant women who already follow a vegetarian diet for a long time before pregnancy also show an increased risk of vitamin B deficiency₁₂ i cinka.

Vegan diet during pregnancy

A completely plant-based food selection (vegan diet) does not provide an adequate intake of the necessary nutrients during pregnancy. Pregnant women who practice a vegan diet need special medical advice and require supplementing their diet with micronutrients.

With a strictly plant-based (vegan) diet during pregnancy, intake of energy, protein, omega-3 fatty acids, iron, calcium, iodine, zinc, B vitamins₂, vitamin B₁₂ i vitamina D su često kritični, uz značajne zdravstvene rizike za dijete i trudnicu. Deficit vitamina B₁₂, uz  vegansku prehranu u trajanju od nekoliko godina, može dovesti do teških i dugotrajnih oštećenja djetetovog živčanog sustava za vrijeme trudnoće.

Therefore, women who choose to remain on a vegan diet, before and during pregnancy and breastfeeding, require qualified nutritional counseling and supplementation to cover the critical nutrient needs of mother and child.

Literature:

1. Association of German Gynecologists, German Federal Institute for Risk Assessment, German  Federal Center for Health Education, Cochrane Library, German Nutrition Society, German Society for Obstetrics and Gynecology, German Society for Pediatrics and Adolescent Health, German Midwife Organization
2. European Commission, European Bureau for Food Safety
3. Research Institute for Child Nutrition, Institute of Medicine (IOM; USA)
4. National Institute for Health and Clinical Excellence (UK)
5. National Commission for Breast-Feeding at the Federal Institute for Risk Assessment, World Health Organization

Author: Maja Gudelj, MD, specialist in gynecology and obstetrics