1. بسم بسم الله الله الرحمن الرحمن الرحيم Community Medicine Lec - 9 -

2. Learning objectives At the end of this lecture student would be able to : 1-Determine special problem in diet therapy. 2-Outline determining factors for maternal nutritional requirements. 3-Discuss nutritional requirements during pregnancy and lactation. 4-Enumerate reasons for increased protein requirements during pregnancy and lactation. To a level accepted to the accreditation standard of the College.

3. Special problems in diet therapy o Transitional feeding refers to the process of return to the usual feeding pattern after total parenteral nutrition, peripheral hyper alimentation or enteral feeding by gastrostomy, jejunostomy, esophagostomy or nasogastric tube. o After extended periods of disuse, the gut may not function normally and unless the transition process is carefully monitored, oral intake and or food absorption may be inadequate. 1.Transition 1.Transition from one route of feeding to another.

4. 2.Adherence to diet pCpC ompliance with therapeutic dietary recommendations is relatively easy to monitor in hospitalized patients. However, patient may refuse or be unable to eat or may miss meals because of diagnostic tests. Therefore, nutritional status and patient adherence should be monitored carefully even in the hospital. pTpT o implement therapeutic diets in outpatients, patient must be motivated and must understand the diet instructions and the changes in what to be eaten. New food buying, food preparation, and eating habits may be required.

5. p Psychological support ; assistance in learning new food preparation buying and management skills ;help with eating,help in obtaining financial support to buy special foods ;and general education about importance of diet are as important as nutritional advice. 3.Assuring the continuity of nutritional care (the team concept) : pNutrition is too important to be the sole responsibility of a single member of the health team. pNutritional counseling can and does change dietary habits and each health -care provider has a critical role in assuring that nutrition is adequate. However :

6. p Physicians rarely obtain through diet histories, address potential barriers to change in eating habits, or offer special guidance on food selection. Nutrition during pregnancy & lactation pThe major role of physicians is to expand the content of nutritional information they provide, to emphasize the health benefits of good nutrition to refer those requiring help to dietitians or other specialized providers. pMaternal nutrition is critically important for both mother and her child. pSeveral determining factors for maternal nutritional requirements :-

7. 1.Age 1.Age & parity ¦ Maternal age to start with pregnancy is very important e.g. A teenage pregnant need to add her own growth needs to those imposed by her pregnancy state. ¦ Multiparty also need more nutritional requirements. 2.Pre - conception nutrition Maternal nutrition and health status before becoming pregnant has an important impact upon pregnancy outcome.

8. 3.The complex metabolic interactions of gestation During pregnancy, woman body, placenta and fetus will form a unique biological unit with a constant biological interactions and nutritional requirements. 4.Placenta work in a selective manner ۞ Vitamin C concentration in fetal serum is usually 2- 4 times that of the mother. ۞ Vitamin A serum level in mother is greater than in fetus. ۞ Placenta conserve much hemoglobin for fetal construction at the expense of his mother.

9. 5.Maternal weight Underweight mother tend to add weight at the beginning of pregnancy on the expense of her child or fetus. Excessive weight gain can affect fetus and process of delivery. Nutritional requirements during pregnancy ۞ During pregnancy, the caloric requirements must be increased by 10-15% of the daily standard needs in the pre-pregnancy period. ۞ About 300-400 Kcal/day is the amount of additional caloric requirements specially during the second and third trimesters. ۞ An additional 20-30 gms of proteins is recommended throughout pregnancy.

10. ۞ Additional calcium need is about 0.4 gm daily. Note :- 1.In regard to lactation, additional 40 gms of proteins is needed daily. 2.Each 100 ml of breast milk require 130 Kacl as an additional requirement. ۞ Daily additional iron requirements is 30-60 mg. ۞ A proportional increase in vitamins intake should be done with the increased caloric requirements.

11. About 800 ml of milk is usually produced during 24 hours, thus about 1000 Kcal is the additional caloric requirements for lactation. ۞ It is essential to ask pregnant and lactating women to properly utilize available food stuffs in the region. ۞ During pregnancy, usually there is some discomfort feeling after taking three main meals, thus it is better to have 5-6 meals during pregnancy and even during lactation. ۞ In regard to protein source, it is better to advice pregnant to have plant origin protein with a twice weekly animal origin proteins for essential amino acids supplement. ۞ It is better to encourage breast feeding practices.

12. Reasons for increased protein requirements 1.Rapid growth of developing fetus. 2.Placenta development. 3.Maternal breast tissue increase. 4.Increased circulating blood volume by 20-50%. 5.Amniotic fluid formation. 6.Increased storage reserve by about 200-300gm of nitrogen to be used for labour and during immediate postpartum period.