498695

research-articleXXXX
AJLXXX10.1177/1559827613498695American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

American Journal of Lifestyle Medicine Mar • Apr 2014

Lara B. Harvey, MD, MPH, and

Hope A. Ricciotti, MD

Nutrition for a Healthy Pregnancy

Abstract: Nutrition is a known, an investment in the future health for long-term health implications of high
powerful determinant of perinatal health both later in life. Proper nutrition can gestational weight gain, as well as new
and one that is increasingly recognized prevent birth defects and allow research on the peripartum risks to
to have further reaching effects than neonates to start life at a healthy weight, mother and fetus attributed to obesity,
previously understood. It is well known reducing later risks of disease. Maternal led to reconsideration of the previous
that healthy nutrition during the benefits of a healthy diet and weight guidelines. The revised guidelines take
peripartum period can prevent birth gain include lowering the risks of into account the health and weight of
defects in the neonate. New research pregnancy related disorders, reducing both the mother and the fetus, so that
suggests that peripartum nutrition may the likelihood of cesarean delivery, and the needs of both can be balanced, and
also modulate the risk of chronic disease allowing women a greater chance of include a new category for obese
in later life. Proper nutrition and regaining a healthy weight. Topics such women.1
weight gain during pregnancy also have
maternal benefits including lowered
risks of pregnancy related disorders. Proper nutrition can prevent birth
Good peripartum nutrition is a potential
tool to impact the rising prevalence of defects and allow neonates to start
obesity and related health disorders. This
article will review nutrition guidance life at a healthy weight, reducing
in pregnancy including macro and
micronutrient recommendations, newer
later risks of disease.
recommendations for appropriate
weight gain based upon body mass as the fetal origins of adult disease,
Current
index categories, and avoidance of pregnancy after weight loss surgery, and
Recommendations
potentially harmful substances. Current glycemic index diets are also current in
topics will also be discussed including the dialogue surrounding nutrition in The 2009 Institute of Medicine report
fetal origins of adult disease, pregnancy pregnancy. differs in several ways from its
after weight loss surgery, environmental predecessor. The newer guidelines are
bisphosphonates, and glycemic index based on World Health Organization
Brief History of Dietary
diets. body mass index (BMI) categories and
Recommendations in
now include a category for obesity for
Keywords: pregnancy; weight gain; the United States
whom less gestational weight gain is now
fetal origins of adult disease; obesity; The 1990 Institute of Medicine report recommended. Based on prepregnancy
exercise; bisphenol A (BPA); bariatric and recommendations for weight gain BMI, underweight women (<18.5 kg/m2)
surgery during pregnancy were designed to should gain 28 to 40 lbs, about 1 lb a
minimize premature births and small- week in the second and third trimester,
for-gestational-age infants.1 In the years assuming a 1.1- to 4.4-lb weight gain in
Introduction
since the publication of the 1990 the first trimester. Normal weight women
Nutrition in pregnancy is important for guidelines, the surge in obesity (18.5-24.9 kg/m2) should gain 25 to 35
maternal and neonatal health, and it is prevalence and concerns for the lbs, again about 1 lb a week in the

DOI: 10.1177/1559827613498695. Manuscript received January 20, 2013; revised May 10, 2013; accepted May 10, 2013. From Department of Obstetrics, Gynecology
and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Address correspondence to Hope A. Ricciotti, MD,
Department of Obstetrics, Gynecology and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215;
e-mail: hricciot@bidmc.harvard.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2013 The Author(s)

80
 vol. 8 • no. 2
second and third trimester. Overweight
women (25.0-29.9 kg/m2) should gain 15
to 25 lbs with about 0.6 lb a week gain in
the second and third trimester. Obese
women (≥30.0 kg/m2) should gain 11 to
20 lbs, with about 0.5 lb a week gain in
the second and third trimester.1
Obesity
No discussion of nutrition in pregnancy
is complete without addressing the most
important public health problem facing
the United States today: obesity. The
surge in the prevalence of obesity in the
past 30 years is enormous and has
important consequences for the health
care system and society in general. Two
thirds of US adults are now categorized
as overweight or obese.2,3
One third of reproductive-age women
are obese.1 During pregnancy, these
women are at a higher risk for
spontaneous abortion, gestational
hypertension, preeclampsia, gestational
diabetes, macrosomia, and cesarean
delivery than their normal-weight
counterparts. Obesity can complicate
fetal surveillance antenatally and
intrapartum by making it difficult to
perform ultrasounds, monitor fetal heart
rate, and monitor contractions.
Furthermore, the risk of cesarean
delivery is higher for obese women, who
tend to have longer operating times,
higher blood loss, more wound
infections, more endometritits, and more
anesthesia-related complications.4
The initial intervention for the
overweight or obese pregnant patient is
provider counseling on exercise and
dietary modification. According to 433
respondents of a survey of practicing
members of the American College of
Obstetricians and Gynecologists (ACOG),
63.4% use prepregnancy BMI to tailor
their weight gain recommendations.5
Monitored exercise programs have had
some success in moderating gestational
weight gain for the overweight.6 A review
of antenatal dietary modifications
suggested they may reduce gestational
weight gain without impacting neonatal
birth weights.7 One review of the
literature notes that antenatal lifestyle
changes may reduce the weight gained
during gestation and identified a trend
toward reduced gestational diabetes, but
was not able to identify a difference in
other negative outcomes. The authors
identify a lack of high-quality evidence on
this subject.8 The Institute of Medicine
report “Weight Gain During Pregnancy:
Reexamining the Guidelines” recommends
preconceptual, antenatal, and postpartum
counseling on diet and physical activity to
help achieve the recommended weight
gain goals.1 One study noted that
excessive gestational weight gain among
women with normal prepregnancy BMIs
did not increase fetal growth or prolong
gestation, and mothers had a greater
postpartum BMI and higher levels of
subcutaneous fat when compared with
those with normal weight gain.9
Glycemic Index
A current interest in nutrition research
is the idea of the glycemic index, which
can be conceptualized as the rate at
which carbohydrate can be digested into
glucose and then released into the blood
stream. Research in this area has recently
been applied to pregnancy. One
systematic literature review described
studies suggesting a low glycemic index
diet during pregnancy may decrease
large-for-gestational-age birth weights
among healthy pregnancies.10 Low
glycemic index diets may be most
helpful for patients with gestational
diabetes by lowering insulin
requirements without causing fetal harm,
but more data are needed before
recommendations can be made.10 A
Cochrane review came to a similar
conclusion: Low glycemic index diets
may have potential in managing and
preventing poor outcomes associated
with gestational diabetes, but more trials
are needed to establish parameters.11
Postpartum Weight Loss
Retained weight can increase a
woman’s risk for chronic diseases such
as type 2 diabetes and also increase the
chance of entering a subsequent
pregnancy at a higher prepregnancy BMI
with its attendant risks.1 Several studies
have demonstrated the connection
between gestational weight gain above
American Journal of Lifestyle Medicine
the recommended levels and increased
postpartum weight retention.1,12 A
longitudinal study from Stockholm
observed that total weight gain during
pregnancy was related to amount of
weight gain during the first trimester.
Women reporting previous weight
cycling and those who reported
increased desire for sugary food had
slightly higher weight gains during
pregnancy. Regular breakfast and lunch
habits are associated with returning to
prepregnancy weight.13
Ethnic and socioeconomic variations
may exist in the patterns of postpartum
weight retention. A study of 461
low-income, nonobese women that
measured fasting insulin levels at entry to
prenatal care found that those in the
highest quartile had significantly higher
gestational weight gain and postpartum
weight retention.14 A longitudinal study
of 427 low-income minority women
found that 62% exceeded the weight gain
recommendations for their BMI. Fifty-two
percent retained greater than 10 pounds
1 year postpartum, suggesting the need
for better counseling and interventions in
these groups.15
Breastfeeding
There are conflicting data regarding the
association of breastfeeding with
postpartum weight loss. Although
frequently touted as a method to lose
weight postpartum, the association of
breastfeeding with postpartum weight
loss may be weak. Data from the World
Health Organization Multicentre Growth
Reference Study showed that duration
and intensity of breastfeeding explained
little of the variation in postpartum
weight changes observed in different
women.16 Additionally, a longitudinal
cohort from Stockholm did not find
breastfeeding to have a large impact on
return to pre-pregnancy weight.13
However, in a longitudinal US study of
low-income minority mothers,
breastfeeding was associated with
postpartum weight loss.15
Fetal Origins of Adult Disease
A growing body of evidence supports
the theory that the intrauterine
81
 American Journal of Lifestyle Medicine
environment, of which nutrition is an
important part, has a potentially larger
role in an individual’s future health
profile than previously understood.17,18
This theory has continued to evolve
since epidemiological observations
revealed that small-for-gestational-age
infants had increased risk of heart
disease as adults.19 Prenatal exposure to
the Dutch Famine of 1944-1945 was
associated with impaired glucose
tolerance in adults, suggesting that
epigenetic changes triggered by the
nutritional environment in utero continue
to affect metabolism later in life.19,20
Further research has demonstrated that a
nutritionally restricted intrauterine
environment may increase the risk of
coronary artery disease, type 2 diabetes,
and hyperlipidemia.18 Study in this area
continues, but the fetal origins of adult
disease theory suggests that intrauterine
nutrition has an even greater role in the
long-term health of the fetus that
previously suspected.
Food-Borne Illnesses
and Pathogens
Mercury.  Mercury has the potential to
cause fetal damage as a neurotoxin.
Although there are multiple ways for
humans to be exposed to mercury, the
most common way is through consump-
tion of seafood. Mercury enters local
ecosystems, most often as a result of
industrial pollution, is consumed by
smaller animals and fish, and is then
concentrated in larger predator fish higher
in the food chain.21 For this reason, the
US Department of Agriculture (USDA)
recommends against pregnant women
eating shark, swordfish, king mackerel, or
tilefish, all of which are large predator
fish. Additionally, the USDA recommends
eating 12 ounces (approximately 2 meals)
per week of fish and shellfish that contain
lower levels of mercury such as shrimp,
canned light tuna, salmon, pollock, and
catfish. White or albacore tuna has slightly
more mercury, and so should only be
eaten once a week. Regarding the safety
of fish caught in local lakes, rivers, and
coastal areas, the USDA recommends
checking local advisories. In the absence
of information, only 1 serving per week
82
of these should be eaten.22 Concern about
the level of mercury in seafood may lead
some women to avoid it altogether;
however, consumption of seafood has
clear and demonstrable benefits for the
fetus, so clear messaging is important so
that women do not avoid consuming
seafood. For example, analysis of the
Seychelles Child Development Study
found that children with higher levels of
methylmercury prenatally, suggesting
higher seafood intakes, had better scores
in some areas of neurocognitive and
behavioral testing at age 17 years.23
Warnings about the risk of mercury need
to be carefully balanced with counseling
regarding the benefits of a diet that
includes seafood.23
Toxoplasmosis.  Toxoplasmosis is an
illness caused by the parasite Toxo-
plasma gondii. Primary infections during
pregnancy can cause morbidity through
vertical transmission to the fetus resulting
in blindness, epilepsy, and mental
disability. Risk of contracting the
infection during pregnancy can be
reduced by cooking all meat to safe
temperatures per USDA guidelines,
washing fruits and vegetables thoroughly,
hand washing by pregnant women and
those around them, and cleaning all food
preparation surfaces carefully. The
organism can spend part of its life cycle
in cats, and pregnant women should
therefore avoid getting a new cat during
pregnancy and minimize exposure to
strays. Additional measures for women
who have cats are to keep them indoors,
have someone else change the litter box
daily, and avoid feeding them raw
meat.24 Toxoplasmosis can also be
contracted from environmental sources,
so women should avoid drinking
untreated water and contacting soil or
sand unless wearing gloves.
Food-Borne Illness.  Listeria monocyto-
genes is a bacterium found in water, soil,
animals, and humans that causes a food
borne illness characterized by flu-like
and gastrointestinal symptoms. Listeria
can contaminate undercooked meats
(beef, pork, lamb), processed/deli meats,
cold cooked chicken, raw seafood, soft
Mar • Apr 2014
cheeses, raw vegetables and fruits, and
unpasteurized dairy products. In the
United States, about 1600 people are
affected by listeriosis annually. It
primarily affects pregnant women, who
are approximately 13 times more likely
to be affected than the general popula-
tion, though it also affects immunosup-
pressed individuals and the elderly. In
pregnancy, it can result in miscarriage,
premature delivery, neonatal infection,
and even death. Listeria is killed by
cooking and by pasteurization. Safe food
handling practices are an important part
of preventing listeria infections. Food
preparation surfaces should be washed
with soap and warm water to avoid
cross-contamination. Avoid processed
meats such as deli cuts and hot dogs
unless heated to steaming. Be careful
that juices from these products do not
contaminate other foods nearby. Wash all
produce. Also avoid unpasteurized dairy
products and soft cheeses made from
unpasteurized milk.25
Salmonella is another type of bacteria
causing food borne illness, usually
associated with fever, diarrhea and
abdominal pain.26 Salmonella is
commonly thought of contaminating
eggs and poultry, but can be found in
fruits, vegetables, and in prepared and
frozen foods as well.27 Additionally,
salmonella can be contracted from
contact with reptiles, birds, or baby
chicks.28 In pregnancy, it can cause
potentially severe complications,
including intrauterine fetal death and
sepsis.29 Excellent hand hygiene and safe
food preparation techniques can help
prevent infection with salmonella.28
Environmental Estrogens/
Bisphenol A
Environmental endocrine disrupters are
defined as chemicals with agonist or
antagonist actions at in vivo endocrine
targets such as estrogen, thyroid, and
androgen receptors.30 An enormous
amount of attention has been placed on
these compounds recently in popular,
medical, and government sources,
especially for bisphenol A (BPA), which
is used in the production of plastic.
Nearly 100 tons of BPA are released into
 vol. 8 • no. 2
the atmosphere yearly. BPA can be found
in plastic food containers like water
bottles and plastic cling films as well as
in resins covering metal food cans. BPA
is a xenoestrogen, which is a substance
that imitates the action of estrogen and
may have weak thyroid hormone
antagonist properties as well.30 Data from
the National Health and Nutrition
Examination Survey suggest that more
than 90% of the general US population
has detectable BPA in urine samples.31
The end effects of this exposure are
unclear. Some studies note an association
between BPA and childhood obesity32
and adult cardiovascular disease and
type 2 diabetes mellitus.33 A 2011 study
in the journal Pediatrics associated
increasing amounts of BPA in maternal
and infant urine with more anxious and
depressed behavior and poorer
emotional control as measured by
validated scales among girls at 3 years of
age.34 A recent review also noted studies
that claimed behavioral abnormalities
among girls exposed to BPA and also
earlier breast development.35 These
studies are suggestive, but more research
needs to be done to determine the true
epidemiological impact of BPA. There is
a growing body of early data on BPA
exposure and adverse outcomes in
animals and in humans, so some
pregnant women may desire to limit
exposure. The compound is ubiquitous,
however, making it difficult to avoid.36,37
Supplements/Micronutrients
Folic Acid.  Adequate levels of folic acid
intake in pregnancy decrease the
occurrence of neural tube defects such
as spina bifida. The United States
Preventive Service Task Force recom-
mends that all women of childbearing
capability consume 0.4 to 0.8mg folate
daily to decrease the incidence of these
defects. ACOG recommends supplemen-
tation of 4 mg per day for women with a
prior history of pregnancies affected by
neural tube defects. Those taking
antiepileptic drugs may also need higher
levels of folic acid.38
Iron.  Iron deficiency is one of the most
common micronutrient deficiencies and
is especially common in pregnant
women. Insufficient iron levels are
associated with preterm delivery and low
birth weight infants. The Centers for
Disease Control and Prevention recom-
mends screening all pregnant women for
anemia at the first prenatal visit and
encouraging iron supplementation as
well as an iron-rich diet.39
Vitamin D.  Vitamin D is a fat-soluble
vitamin found naturally in fish, fish oils,
egg yolks, and is fortified in grains and
dairy products. The skin, in response to
sunlight, produces vitamin D. It is
recommended that pregnant women
supplement their diet with 600 IU of
vitamin D daily, and most prenatal
vitamins contain this amount. Vitamin D
deficiency is more common in those
with darker skin who cannot produce
vitamin D as well as in some vegetarians
who do not consume any animal
products. It is also seen in individuals
with diseases that can result in malab-
sorption such as with Crohn’s disease,
celiac disease, and cystic fibrosis. Finally,
those with limited exposure to sunlight
and obese individuals can be at risk for
deficiencies, since vitamin D is extracted
from the blood by fat cells.
Severe maternal vitamin D deficiency is
associated with skeletal disease in the
neonate. ACOG states that there is
currently no evidence to support routine
screening for vitamin D deficiency in
pregnancy.40 However, practitioners may
elect to test based on clinical indicators.40
Vitamin D deficiency and its impact on
areas beyond bone health, including
polycystic ovarian syndrome and type 1
diabetes, is a subject of current research
interest.41,42 Prospective randomized trials
are needed to clarify the role of vitamin
D in the prevention of preterm birth or
preeclampsia.40 There is a correlation
between vitamin D deficiency and
obesity.43 Furthermore, some studies
suggest that supplementing with vitamin
D may improve insulin resistance profiles
in gestational diabetes.44
Iodine.  Pregnant women are recom-
mended to receive 220 µg of iodine daily
and lactating women 290 µg daily for the
American Journal of Lifestyle Medicine
neurocognitive benefit of their children.
Iodine deficiency is the leading cause of
preventable intellectual disability. Severe
decreases can cause maternal thyroxine
deficiency and can lead to maternal and
fetal goiter, cretinism, and neonatal
hypothyroidism. However, even mild
deficiency may affect the cognitive
abilities of affected children. Obstetric and
perinatal consequences include increased
pregnancy loss and infant mortality.45
Vitamin A.  There is risk to ingestion of
supratherapeutic levels of certain
micronutrients in pregnancy. For
example, intake of greater than 10 000
IU daily of vitamin A in pregnancy is
associated with an increased risk of fetal
malformations.46 Patients should be
counseled that vitamins above the
recommended doses are not necessarily
beneficial and may be harmful.
Docosahexanoic Acid.  There had been a
surge in interest in docosahexanoic acid
(DHA) supplements after several
epidemiologic suggested benefits in
infant neurocognitive scores as well as
improved maternal depressive symptoms
and maternal lipid profile. However,
randomized controlled trials have been
disappointing and suggest that DHA
supplementation does not affect the
incidence of preeclampsia, gestational
diabetes, postpartum depression, or
cognitive development of offspring.39,40
Smoking
Tobacco use in pregnancy is associated
with numerous harmful effects and is one
of the most important modifiable risk
factors in pregnancy. ACOG47 reports that
smoking is associated with intrauterine
growth restriction, placenta previa,
abruptio placentae, decreased maternal
thyroid function, preterm premature
rupture of membranes, low birth weight,
perinatal mortality, and ectopic pregnancy.
An estimated 5–8% of preterm
deliveries, 13–19% of term deliveries
of infants with low birth weight, 23–
34% cases of sudden infant death
syndrome (SIDS), and 5–7% of
preterm-related infant deaths can be
83
 American Journal of Lifestyle Medicine
attributed to prenatal maternal
smoking.47(p1241)
Obstetricians and midwives are present
at an important time in a smoker’s life,
when motivation to quit may be high
and chances of success may be greater
for their patient. It is critical that
obstetricians screen all women
presenting for prenatal care for tobacco
use and take advantage of the
opportunity to counsel and offer support
in smoking cessation.47
Alcohol
It is clear that alcohol affects
pregnancies in a dose related manner. A
recent meta-analysis noted that large
amounts of alcohol in pregnancy are
correlated with low birth weight, preterm
birth, and small-for-gestational-age
infants; however, light to moderate
drinking did not show an effect.48 A
recent literature review on alcohol in
pregnancy noted no increase in
abnormal pregnancy outcomes with low-
level alcohol consumption.49 The authors
advocated counseling against daily
drinking but also noted that the dangers
“of minimal alcohol use should not be
overstated.” However, other studies have
demonstrated that even small exposures
to alcohol in early pregnancy have been
associated with miscarriage.50
Additionally, a study published in
Pediatrics noted that very low levels of
exposure to alcohol in utero (less than 1
drink per week) were associated with
later behavior problems in girls.51
Another study noted a dose–response
effect between in utero alcohol exposure
and behavior problems at age 6 to 7
years.52 Pregnant women are advised to
abstain from alcohol because the dose
required to cause ill effects is unknown
and may vary across individuals.
Additionally, potential ill effects may not
be apparent until years later.
Caffeine
Many expectant mothers worry about
the effect of caffeine on fetal health.
ACOG reports that moderate caffeine
intake (less than 200 mg per day or about
12 oz of home-brewed coffee) is not
84
associated with ill effects. There is
evidence to suggest that preterm labor,
fetal APGAR scores, miscarriage and even
infant sleep patterns are not affected by
moderate maternal caffeine use. ACOG
endorses the view that moderate caffeine
intake in pregnancy is safe, but also
cautions that the effects of consumption of
large amounts of caffeine on miscarriage
and the effect of caffeine on intrauterine
growth restriction are less clear.53-55
Herbal Medications
An analysis of data from the National
Birth Defects Prevention Study found
that the prevalence of use of herbal
products 3 months before or during
pregnancy was 10.9%. The authors
conclude that up to 395 000 births in the
United States had antenatal exposure to
herbal products.56 Because they are
unregulated, the safety profile of these
products is unknown.57,58 Practitioners
should initiate a frank discussion with all
prenatal patients about the use of such
products, emphasizing the lack of data to
support safe use in pregnancy.
Exercise
ACOG encourages moderate exercise
for 30 minutes a day for most, if not all,
days of the week for healthy pregnant
women without obstetric or medical
complications. Generally, a large number
of activities are safe, but avoidance of
activities that carry a risk of abdominal
trauma and falls, such a horseback
riding, downhill skiing, and contact
sports are discouraged. Scuba diving is
also prohibited given the risk of
decompression sickness.59 Exercising
during pregnancy has been shown to
reduce excess weight gain and decrease
weight retention postpartum.59,60 Studies
examining the impact of exercise before
and during pregnancy on the
development of gestational diabetes
suggest a benefit, though there are no
randomized controlled trials.61,62
Special Situations
There are several notable clinical
situations in nutrition and pregnancy that
deserve extra attention as they grow
increasingly common in the United States.
Mar • Apr 2014
Multiples.  The incidence of multiple
pregnancies is increasing and presents
additional nutritional challenges. Women
pregnant with twins who start pregnancy
with a normal BMI are advised by the
Institute of Medicine to gain between 37
and 54 lbs by the end of pregnancy to
optimize birth weight and minimize the
morbidity associated with preterm birth
and low birth weight. A recent review
suggested a caloric intake for normal-
BMI women with twins of 40 to 45 kcal/
kg each day.63 Iron, folate, calcium,
magnesium, and zinc supplementation,
and possible vitamin D and DHA dosed
above that of a standard prenatal vitamin
are recommended.63 Many health care
providers recommend additional input
from a nutritionist to provide appropriate
education and support for fetal growth
for women with twins or higher order
multiples.
Vegetarian Diets.  The American Dietetic
Association states that vegetarian diets are
appropriate for all stages of life, including
pregnancy and lactation, if carefully
planned to meet increased demand for
quality and quantity of macro- and
micronutrients. Special attention should
be given to the adequate intake of
protein, n-3 fatty acids, iron, zinc, iodine,
calcium, and vitamins D and B12.
Especially for vegan diets, eating foods
fortified with vitamin B12 such as yeast
extracts, vegetable stock, veggie burgers,
textured vegetable protein, soymilk,
vegetable and sunflower margarines, and
breakfast cereals is essential as vitamin
B12 is important for brain and neurocog-
nitive development in the fetus and
neonate.64 Advice from a nutritionist can
provide guidance.65
Pregorexia.  The media has reported on
a new cultural trend of “pregorexia,”
which refers to extreme dieting and
exercise during pregnancy in order to
control weight gain. Some women may
feel increased pressure to gain minimal
weight during pregnancy, and to lose it
as quickly as possible postpartum, and
the celebrity baby culture is a powerful
force in changed expectations around
what is normal in the peripartum
 vol. 8 • no. 2
period.66-69 More value is placed on
maintaining a “thin” and stylish appear-
ance during pregnancy than has been
the case in previous decades. Efforts to
achieve this may come at a detriment to
the nutritional needs of the mother and
fetus. Clinicians should be cognizant of
this trend in popular culture and
watchful regarding its effect on their
patients. Health care providers are in a
position to counteract this pressure and
give reasonable and healthful advice on
nutrition and weight gain in pregnancy.
Weight Loss Surgery.  With one third of
adult women in the United States now
obese,1,4 the numbers of women pursuing
pregnancy after weight loss surgery
continue to increase. ACOG reports that
in 2004, half of bariatric procedures were
performed in reproductive-age women.70
Women undergoing bariatric surgery
should be advised to avoid pregnancy for
12 to 18 months postoperatively, the time
during which rapid weight loss occurs.
They should be counseled that they are at
increased risk of unplanned pregnancy
during this time, as menstrual cycles may
regulate and fertility increases with an
improved metabolic profile.70 In many
studies, maternal and fetal outcomes
improve after bariatric surgery, including
an apparent decrease in the rate of
gestational diabetes and hypertensive
disorders, including preeclampsia.70,71
Nevertheless, because these procedures
result in malabsorption or restriction of
intake of important micro- and macronu-
trients, special consideration to nutrition
must be given to these patients in
pregnancy. These women should be
supplemented with a prenatal vitamin and
multivitamin, taking care not to ingest
vitamin A in excess of 5000 IU per day. If
oral supplementation is not effective,
parenteral must be considered. Protein,
iron, vitamin B12, folate, vitamin D,
calcium,70,71 vitamin A, and vitamin K
deficiencies have been reported in this
group.70 Some experts recommend
including a minimum of 60 g protein per
day, 400 µg per day folate, 50 to 100 mg
elemental iron, and at least 1000 mg
calcium.72 Consideration may be given to
evaluating for deficiencies at the
beginning of pregnancy and targeting
specific supplements. Alternatively, some
practitioners evaluate hematocrit, iron,
ferritin, calcium, and vitamin D trimesterly.
Adolescents.  Pregnant adolescents are
another group that requires special
nutritional consideration. A recent study
from the United Kingdom found that
pregnant teens take in less than
recommended vitamin B12 and folate,
which is associated with small-for-gesta-
tional-age births.73 Adolescents who
experience domestic violence, contract a
sexually transmitted infection, or have an
unplanned pregnancy are at higher risk
for not achieving weight gain goals.74
These risks factors may be especially
prevalent in the teen population.
Pregnancy is a time of dynamic
physiological change and development.
Research is only starting to elucidate the
way perinatal nutrition shapes the future
health profile of the fetus and mother.
Health practitioners have the
opportunity to have a resonating impact
on health outcomes by counseling this
population. AJLM
References
1. Rasmussen KM, Yaktine AL, eds. Weight
Gain During Pregnancy: Reexamining
the Guidelines. Washington, DC: National
Academies Press; 2009.
2. Institute of Medicine. Accelerating progress
in obesity prevention: solving the weight
of the nation. http://www.iom.edu/
Reports/2012/Accelerating-Progress-in-
Obesity-Prevention.aspx. Accessed June 9,
2012.
3. Glickman D, Parker L, Sim LJ, De Valle
Cook H, Miller EA, eds; Committee
on Accelerating Progress in Obesity
Prevention, Food and Nutrition Board.
Accelerating Progress in Obesity
Prevention: Solving the Weight of the
Nation. Washington, DC: National
Academies Press. http://books.nap.edu/
openbook.php?record_id=13275. Accessed
June 1, 2012.
4. American College of Obstetricians and
Gynecologists. ACOG Committee Opinion
number 315, September 2005. Obesity in
pregnancy. Obstet Gynecol. 2005;106:
671-675.
5. Power ML, Cogswell ME, Schulkin J. US
obstetrician-gynecologist’s prevention and
American Journal of Lifestyle Medicine
management of obesity in pregnancy. J
Obstet Gynaecol. 2009;29:373-377.
6. Nascimento SL, Surita FG, Parpinelli MÂ,
Siani S, Pinto e, Silva JL. The effect of an
antenatal physical exercise programme on
maternal/perinatal outcomes and quality
of life in overweight and obese pregnant
women: a randomised clinical trial. BJOG.
2011;118:1455-1463.
7. Quinlivan JA, Julania S, Lam L. Antenatal
dietary interventions in obese pregnant
women to restrict gestational weight gain
to institute of medicine recommendations:
a meta-analysis. Obstet Gynecol.
2011;118:1395-1401.
8. Oteng-Ntim E, Varma R, Croker H, Poston
L, Doyle P. Lifestyle interventions for
overweight and obese pregnant women to
improve pregnancy outcome: systematic
review and meta-analysis. BMC Med.
2012;10:47.
9. Scholl TO, Hediger ML, Schall JI, Ances
IG, Smith WK. Gestational weight gain,
pregnancy outcome, and postpartum
weight retention. Obstet Gynecol.
1995;86:423-427.
10. Louie JC, Brand-Miller JC, Markovic TP,
Ross GP, Moses RG. Glycemic index and
pregnancy: a systematic literature review. J
Nutr Metab. 2010;2010:282464.
11. Tieu J, Crowther CA, Middleton P. Dietary
advice in pregnancy for preventing
gestational diabetes mellitus. Cochrane
Database Syst Rev. 2008;(2):CD006674.
12. Nehring I, Schmoll S, Beyerlein A, Hauner
H, von Kries R. Gestational weight
gain and long-term postpartum weight
retention: a meta-analysis. Am J Clin Nutr.
2011;94:1225-1231.
13. Ohlin A, Rössner S. Factors related to
body weight changes during and after
pregnancy: the Stockholm Pregnancy and
Weight Development Study. Obes Res.
1996;4:271-276.
14. Scholl TO, Chen X. Insulin and the ‘thrifty’
woman: the influence of insulin during
pregnancy on gestational weight gain and
postpartum weight retention. Matern Child
Health J. 2002;6:255-261.
15. Gould Rothberg BE, Magriples U, Kershaw
TS, Rising SS, Ickovics JR. Gestational
weight gain and subsequent postpartum
weight loss among young, low-income,
ethnic minority women. Am J Obstet
Gynecol. 2011;204:52.e1-52.e11.
16. Onyango AW, Nommsen-Rivers L, Siyam
A, et al. Post-partum weight change
patterns in the WHO Multicentre Growth
Reference Study. Matern Child Nutr.
2011;7:228-240.
17. Seki Y, Williams L, Vuguin PM, Charron
MJ. Mini review: epigenetic programming
85
 American Journal of Lifestyle Medicine
of diabetes and obesity: animal models.
Endocrinology. 2012;153:1031-1038.
18. Gillman MW, Barker D, Bier D, et al.
Meeting report on the 3rd International
Congress on Developmental Origins of
Health and Disease (DOHaD). Pediatr Res.
2007:61(5 pt 1):625-629.
19. Wadhwa PD, Buss C, Entringer S,
Swanson JM. Developmental origins of
health and disease: brief history of the
approach and current focus on epigenetic
mechanisms. Semin Reprod Med.
2009;27:358-368.
20. Ravelli AC, van der Meulen JH, Michels
RP, et al. Glucose tolerance in adults
after prenatal exposure to famine. Lancet.
1998;351:173-177.
21. Agency for Toxic Substances & Disease
Registry. Toxicological profile for mercury.
http://www.atsdr.cdc.gov/toxprofiles/
TP.asp?id=115&tid=24. Accessed June 9,
2012.
22. US Environmental Protection Agency.
Fish consumption advisories—general
information. http://water.epa.gov/scitech/
swguidance/fishshellfish/fishadvisories/
general.cfm. Accessed June 9, 2012.
23. Davidson PW, Cory-Slechta DA, Thurston
SW, et al. Fish consumption and prenatal
methylmercury exposure: cognitive and
behavioral outcomes in the main cohort
at 17 years from the Seychelles Child
Development Study. Neurotoxicology.
2011;32:711-717.
24. Centers for Disease Control and
Prevention. Toxoplasmosis. http://www.
cdc.gov/parasites/toxoplasmosis/. Accessed
June 9, 2012.
25. Centers for Disease Control and Prevention.
Listeria (listeriosis). http://www.cdc.gov/
listeria/. Accessed June 9, 2012.
26. Centers for Disease Control and
Prevention. Salmonella. http://www.cdc.
gov/salmonella/. Accessed May 9, 2013.
27. Centers for Disease Control and
Prevention. Salmonella is a sneaky germ:
seven tips for safer eating. http://www.
cdc.gov/Features/VitalSigns/FoodSafety/.
Accessed May 9, 2013.
28. Centers for Disease Control and
Prevention. Salmonella—prevention.
http://www.cdc.gov/salmonella/general/
prevention.html. Accessed May 9, 2013.
29. Scialli AR, Rarick TL. Salmonella sepsis and
second-trimester pregnancy loss. Obstet
Gynecol. 1992;79(5 pt 2):820-821.
30. Vandenberg LN, Maffini MV, Sonnenschein
C, Rubin BS, Soto AM. Bisphenol-A and the
great divide: a review of controversies in
the field of endocrine disruption. Endocr
Rev. 2009;30:75-95.
86
31. Calafat AM, Ye X, Wong L-Y, Reidy
JA, Needham LL. Exposure of the U.S.
population to bisphenol A and 4-tertiary-
octylphenol: 2003-2004. Environ Health
Perspect. 2008;116:39-44.
32. Trasande L, Attina TM, Blustein J.
Association between urinary bisphenol
A concentration and obesity prevalence
in children and adolescents. JAMA.
2012;308:1113-1121.
33. Lang IA, Galloway TS, Scarlett A,
et al. Association of urinary bisphenol A
concentration with medical disorders and
laboratory abnormalities in adults. JAMA.
2008;300:1303-1310.
34. Braun JM, Kalkbrenner AQ, Calafat AM,
et al. Impact of early-life bisphenol A
exposure on behavior and executive
function in children. Pediatrics.
2011;128:873-882.
35. Braun JM, Hauser R. Bisphenol A and
children’s health. Curr Opin Pediatr.
2011;23:233-239.
36. Groff T. Bisphenol A: invisible pollution.
Curr Opin Pediatr. 2010;22:524-529.
37. Welshons WV, Nagel SC, vom Saal FS.
Large effects from small exposures. III.
Endocrine mechanisms mediating effects of
bisphenol A at levels of human exposure.
Endocrinology. 2006;147(6 suppl):S56-S69.
38. US Preventive Services Task Force. Folic
acid for the prevention of neural tube
defects: U.S. Preventive Services Task Force
recommendation statement. Ann Intern
Med. 2009;150:626-631.
39. Recommendations to prevent and
control iron deficiency in the United
States. Centers for Disease Control
and Prevention. MMWR Recomm Rep.
1998;47(RR-3):1-29.
40. ACOG Committee on Obstetric Practice.
ACOG Committee Opinion No. 495:
vitamin D: screening and supplementation
during pregnancy. Obstet Gynecol.
2011;118:197-198.
41. Chakhtoura M, Azar ST. The role of
vitamin d deficiency in the incidence,
progression, and complications of type
1 diabetes mellitus. Int J Endocrinol.
2013;2013:148673.
42. Thomson RL, Spedding S, Buckley
JD. Vitamin D in the aetiology and
management of polycystic ovary
syndrome. Clin Endocrinol (Oxf).
2012;77:343-350.
43. Vanlint S.Vitamin D and obesity. Nutrients.
2013;5:949-956.
44. Soheilykhah S, Mojibian M, Moghadam
MJ, Shojaoddiny-Ardekani A. The
effect of different doses of vitamin D
supplementation on insulin resistance
Mar • Apr 2014
during pregnancy. Gynecol Endocrinol.
2013;29:396-399.
45. Stagnaro-Green A, Sullivan S, Pearce
EN. Iodine supplementation during
pregnancy and lactation. JAMA.
2012;308:2463-2464.
46. Rothman KJ, Moore LL, Singer MR, Nguyen
US, Mannino S, Milunsky A. Teratogenicity
of high vitamin A intake. N Engl J Med.
1995;333:1369-1373.
47. Committee opinion no. 471: smoking
cessation during pregnancy. Obstet
Gynecol. 2010;116:1241-1244.
48. Patra J, Bakker R, Irving H, Jaddoe
VW, Malini S, Rehm J. Dose-response
relationship between alcohol
consumption before and during
pregnancy and the risks of low
birthweight, preterm birth and small
for gestational age (SGA)—a systematic
review and meta-analyses. BJOG.
2011;118:1411-1421.
49. Pregnancy and alcohol: occasional,
light drinking may be safe. Prescrire Int.
2012;21:44-50.
50. Andersen AM, Andersen PK, Olsen
J, Grønbæk M, Strandberg-Larsen K.
Moderate alcohol intake during pregnancy
and risk of fetal death. Int J Epidemiol.
2012;41:405-413.
51. Sayal K, Heron J, Golding J, Emond A.
Prenatal alcohol exposure and gender
differences in childhood mental health
problems: a longitudinal population-based
study. Pediatrics. 2007;119:e426-e434.
52. Sood B, Delaney-Black V, Covington C, et
al. Prenatal alcohol exposure and childhood
behavior at age 6 to 7 years: I. Dose-
response effect. Pediatrics. 2001;108:E34.
53. Jarosz M, Wierzejska R, Siuba M. Maternal
caffeine intake and its effect on pregnancy
outcomes. Eur J Obstet Gynecol Reprod
Biol. 2012;160:156-160.
54. Santos IS, Matijasevich A, Domingues MR.
Maternal caffeine consumption and infant
nighttime waking: prospective cohort
study. Pediatrics. 2012;129:860-868.
55. American College of Obstetricians and
Gynecologists. ACOG Committee Opinion
No. 462: moderate caffeine consumption
during pregnancy. Obstet Gynecol.
2010;116(2 pt 1)467-468.
56. Louik C, Gardiner P, Kelley K, Mitchell AA.
Use of herbal treatments in pregnancy. Am
J Obstet Gynecol. 2010;202:439.e1-439.e10.
57. Licata A, Macaluso FS, Craxì A. Herbal
hepatotoxicity: a hidden epidemic. Intern
Emerg Med. 2013;8:13-22.
58. Moussally K, Oraichi D, Bérard A. Herbal
products use during pregnancy: prevalence
 vol. 8 • no. 2
and predictors. Pharmacoepidemiol Drug
Saf. 2009;18:454-461.
59. Committee on Obstetric Practice. ACOG
Committee Opinion. Exercise during
pregnancy and the postpartum period.
Number 267, January 2002. American
College of Obstetricians and Gynecologists.
Int J Gynaecol Obstet. 2002;77:79-81.
60. Stuebe AM, Oken E, Gillman MW.
Associations of diet and physical activity
during pregnancy with risk for excessive
gestational weight gain. Am J Obstet
Gynecol. 2009;201:58.e1-58.e8.
61. Dempsey JC, Butler CL, Sorensen TK,
et al. A case-control study of maternal
recreational physical activity and risk of
gestational diabetes mellitus. Diabetes Res
Clin Pract. 2004;66:203-215.
62. Dempsey JC, Sorensen TK, Williams MA,
et al. Prospective study of gestational
diabetes mellitus risk in relation to
maternal recreational physical activity
before and during pregnancy. Am J
Epidemiol. 2004;159:663-670.
63. Goodnight W, Newman R. Optimal nutrition
for improved twin pregnancy outcome.
Obstet Gynecol. 2009;114:1121-1134.
64. Black MM. Effects of vitamin B12 and
folate deficiency on brain development
in children. Food Nutr Bull. 2008;29(2
suppl):S126-S131.
65. Craig WJ, Mangels AR. Position of the
American Dietetic Association: vegetarian
diets. J Am Diet Assoc. 2009;109:
1266-1282.
66. Min J. In celebrity climate, from bump to
paunch, pudgy moms can’t get a break.
The New York Times. August 17, 2012.
http://www.nytimes.com/2012/08/19/
fashion/in-celebrity-climate-from-bump-
to-paunch-pudgy-moms-cant-get-a-break.
html?pagewanted=all&_r=0. Accessed July
10, 2013.
67. Fiore BM. Pregorexic: are some pregnant
women putting their fetuses at risk? Fox
News. December 7, 2011.
68. Mayo Clinic. Pregorexia: a legitimate
problem during pregnancy? http://www.
mayoclinic.com/health/pregorexia/
AN02077. Accessed May 28, 2012.
69. During pregnancy, starving for two.
Well. http://well.blogs.nytimes.
com/2009/06/02/starving-for-twoa/.
Accessed July 15, 2012.
American Journal of Lifestyle Medicine
70. American College of Obstetricians and
Gynecologists. ACOG Practice Bulletin No.
105: bariatric surgery and pregnancy. Obstet
Gynecol. 2009;113:1405-1413. http://www.
acog.org/Resources_And_Publications/
Practice_Bulletins/Committee_on_Practice_
Bulletins_—_Obstetrics/Bariatric_Surgery_
and_Pregnancy. Accessed July 31, 2012.
71. Magdaleno R Jr, Pereira BG, Chaim EA,
Turato ER. Pregnancy after bariatric
surgery: a current view of maternal,
obstetrical and perinatal challenges. Arch
Gynecol Obstet. 2012;285:559-566.
72. Beard JH, Bell RL, Duffy AJ. Reproductive
considerations and pregnancy after
bariatric surgery: current evidence and
recommendations. Obes Surg. 2008;18:
1023-1027.
73. Baker PN, Wheeler SJ, Sanders TA, et al. A
prospective study of micronutrient status
in adolescent pregnancy. Am J Clin Nutr.
2009;89:1114-1124.
74. Berenson AB, Wiemann CM, Rowe TF,
Rickert VI. Inadequate weight gain among
pregnant adolescents: risk factors and
relationship to infant birth weight. Am J
Obstet Gynecol. 1997;176:1220-1224.
87