Eating during pregnancy and breastfeeding, simple, yet complicated.

/ Antenatal, Postnatal / By

Pregnancy is a time a great excitement for families, but at the same time a lot of us worry about growing our little bubs to be healthy and thriving. There are many factors that influence the growth and development of the growing bub, but science consistently highlights the significance of good nutrition in this process.

Around the world, including in Australia, pregnant women struggle to meet the recommended intake of important nutrients to support healthy pregnancy outcomes from food alone. Shockingly, studies show that nearly all pregnant Australian women do not consume the Australian Guide for Healthy Eating recommended quantities for all five food groups and therefor is missing out on essential nutrients.1234 This is because of many reasons, sometimes beyond the control of the individual such as pregnancy symptoms, access to good quality food, financial restraints and unreliable or inaccurate information from questionable sources.

Why nutrition matters in pregnancy and breastfeeding?

Ever emerging research show that what the mother eats 3 months before conception as well as during pregnancy and breastfeeding has a significant effect on the long-term health of the mother and baby. This impact can also cross generations, meaning that your nutrition during these critical windows can impact your future grandchildren. 567

During pregnancy your body will undergo substantial changes to ensure a healthy baby, safe delivery, and ability to breastfeed. Weight changes, hormone changes, blood and fluid shifts, increased oxygen demands and many complicated physical and chemical changes to support the production of breastmilk, to name a few. To support all these changes, the nutritional needs of women during pregnancy and breastfeeding is significantly more than a non-pregnant woman. While calorie and protein requirements do increase, the heightened demand for specific micronutrients, such as vitamins and minerals, takes center stage.8  There are often also changes to the gut function (due to either hormones or organs making space for the growing baby) that leads to nausea, reflux or constipation. Studies further show that adherence to a healthy diet with an emphasis on fruits, vegetables, fish, grains and legumes in the postpartum period is associated with fewer post-partum depression symptoms9 while a deficiency of calcium, iron, and folate could be associated with maternal depression.10

The Dilemma

Despite research showing that most women are not getting enough vitamins and minerals from their diets11, many are told to just “manage their weight”, which is not very useful information and, in some instances, just fuels anxiety and less than ideal eating habits. Others are told to unnecessarily restrict key food groups due to unfounded concerns about food intolerances. Common pregnancy-related issues like nausea, constipation, and reflux further complicate the situation. Others are concerned about food safety and unsure what foods they should avoid.

The Solution

To address these challenges, the focus during pregnancy and breastfeeding should shift towards the quality and diversity of one’s diet. The need for supplements should be individually assessed by a trained professional to bridge nutritional gaps.

Key Nutrients for Pregnancy and Breastfeeding

A balanced, varied diet using the Australian Guide for Healthy Eating is essential, with daily Folic Acid and Iodine supplements recommended. Many women potentially require additional supplementation of some key nutrients.

  1. Folate/folic acid:
    Folate, also known as folic acid (the synthetic form), is a B vitamin that is essential for a wide range of bodily functions including cell growth and the formation of blood cells. It is particularly important during pregnancy for the development of the foetus. It helps close the neural tube, which will be your baby’s future spinal cord and brain! This process starts very early on in gestation therefor pre-conception (1-3months before pregnancy) supplementation is ideal, otherwise as soon as you find out you are pregnant until 12 weeks gestation. During pregnancy you need 600mcg folate and during breastfeeding 500mcg folate. Those who have had weight loss surgery, individuals with malabsorption conditions such as coeliac or liver disease have additional needs. A small number of the population also has what is called a “MTHFR genetic mutation” which in short just means that they have a specific gene that reduces their ability to activate the synthetic form of folic acid to folate and therefor absorption is lower. In such cases they might need an activated form of synthetic folic acid called L-methylfolate or folinic acid. These are more expensive than normal folic acid and is not needed as standard care. Discuss any concerns with your GP and Dietitian.

    Good food sources of folate are leafy green vegetables, whole grains, wheat germ, peas, nuts, avocado and yeast extracts (e.g. marmite, promite, vegemite etc.). In Australia commercially (non-organic) produced breads and some breakfast cereals are also fortified with folic acid.

  2. Choline
    Choline is often seen as the new kid on the block. We have known about it for some time, but the true importance of this vitamin is still emerging. Our bodies do produce a small amount of Choline, but not enough to support pregnancy and breastfeeding so dietary intake of choline is essential. Women need 440mg choline per day during pregnancy and 550mg whilst breastfeeding. A 2019 study showed that less than 1% of Australian women in child-bearing age reach this level.12

    Choline helps folate metabolism (and therefor neural tube development) and is best known for its role in the development of a baby’s brain and lifelong memory function of the infant. Eggs are one of the richest food sources of choline, with two eggs providing more than half of the recommended intake for pregnant and breastfeeding women. Other food sources include red meat, chicken salmon, cow’s milk, wheat germ peanuts, tofu (soybeans), almonds and peanuts. High dose choline supplementation is not routinely recommended and not all prenatal supplements contain choline. Your dietitian can help you plan your diet to ensure you get enough choline if you are concerned.

  3. Iodine
    Iodine needs increase by at least 50% in pregnancy as it supports your thyroid function which is very important as it ensures your baby’s growth and brain development is on track. These requirements increase even further during breastfeeding. Iodine deficiency can result in significant growth and cognitive impairments. A recent Australian study showed that only roughly 1 in 4 women meet their Iodine requirements during preconception and pregnancy from food alone.13

    While eating seafood, seaweed, eggs, dairy, commercially (non-organic) produced bread and iodised table salt (note NOT ALL salt is iodised, check the label) could be sufficient if you are not pregnant, your requirements are much higher during pregnancy, and it is recommended that you also use a supplement that provides 150 microgram Iodine daily throughout pregnancy and breastfeeding. Women with pre-existing thyroid conditions should seek advice from their medical practitioner prior to taking a supplement.

  4. Iron
    Iron needs during pregnancy almost doubles compared to not being pregnant (27mg per day vs 18mg). Your body uses iron to make red blood cells which in turns carries oxygen through your blood. When you are growing a tiny human, your body is making a lot more red blood cells to support this process. Iron deficiency is the most common nutritional deficiency in the world and low levels can make you feel (extra) tired and reduce your immunity and therefor your risk for infections. Your baby is relying on you to have sufficient iron stores for their first 4-6 months of life as ‘boost’ of iron will be passed to the baby via the umbilical cord before it is clamped and cut after birth. Advocating for ‘delayed cord clamping’ where possible after delivery is also important.

    Many women struggle to meet their iron requirements during pregnancy, with some studies showing almost 99% of women in the study group not meeting their iron needs! Routine iron supplementation is not recommended at this stage and blood tests will be performed at different stages throughout the pregnancy to check for iron deficiency and supplements prescribed as needed. It is important to include at least two serves meat, chicken, fish, legumes or nuts every day and choose fortified wholegrain breads/cereals and green leafy vegetables regularly as these are good sources of iron. Adding a vitamin C rich food (eg. Tomato, citrus, red capsicum) to iron rich meals will also help absorption. Certain foods/nutrients such as tea, coffee, calcium and zinc could interfere with iron absorption.

    The following groups are higher risk for deficiency:
    • Pregnant women who follow predominantly plant-based diets (vegetarian/vegan)
    • Pregnancy close together (< 1 years)
    • Severe morning sickness
    • Aboriginal and Torres Straight Islanders
    • Past history of anaemia
    • Previous weight loss or gastric surgery
    • Use of certain medications that may interfere with iron absorption such as anti-reflux medication.

  5. Vitamin B12
    Vitamin B12 is found in any animal-based products such as eggs, dairy, fish and meat. B12 helps the formation of DNA, red blood cells and development of the nervous system, important stuff for a developing baby! While most women get enough B12 in their diets, it is important that pregnant women following predominantly plant-based diets (vegan/vegetarian) discuss this their GP and dietitian as they might be at increased risk of a deficiency. The use of certain medications may interfere with B12 absorption such as anti-reflux medication. Please discuss this with your pharmacist or GP if you have concerns.
  6. Calcium and Vitamin D
    Calcium and vitamin D work together to maintain good bone health for you and your growing baby’s bones. Deficiencies are also associated with increased risk of complications, such as pre-eclampsia (pregnancy induced high blood pressure), preterm birth and low birth weights. Some emerging evidence is also showing a correlation between low vitamin D and the development of allergies, but more research is needed.

    Calcium requirements during pregnancy is similar to that of a non-pregnant woman (1000mg per day) which is roughly 2 ½ serves of dairy foods. If you exclude dairy from your diet for whatever reason, you must ensure you obtain it from non-diary sources such sardines or pink salmon (with bone), green leafy veggies, calcium fortified plant milks (with at least 120mg/100ml calcium) and soy beans. Calcium is stored in the bones of your body. When you don’t consume enough calcium in your diet, the body takes calcium from your bones to use it where needed which can cause osteoporosis long-term. Prolonged breastfeeding (>12 months) has also shown to increase the risk for osteoporosis in the absence of adequate calcium intake. As moms we are so focussed on the growth and development of the baby, we forget that our own health is important too!

    The main source of vitamin D is safe sun exposure. Some food sources include sun-exposed mushrooms (putting it in the sun for 15 minutes increase the vitamin D level), eggs and salmon, but dietary sources alone would only provide about 10% of your vitamin D needs. It is important to note that although cod liver oil contain vitamin D, they are not recommended in pregnancy as they also contain too much vitamin A for pregnant women.
    Your GP will test your vitamin D levels early in pregnancy and advise on the appropriate dosage if you are deficient. If no deficiency, a daily intake of 400IU (10μg) vitamin D daily as part of a pregnancy multivitamin is recommended. This is also important if you are breastfeeding, because uncorrected low vitamin D levels in the mother would result in insufficient amounts of vitamin D being passed through breastmilk to the baby and they would require supplements also.

  7. Omega 3
    Without getting very technical, omega 3 is a type of fat that based on its chemical structure is often referred to as a ‘good fat’ or polyunsaturated fat. Our bodies do not make omega 3 fats, so we must obtain them from our diet. DHA and EPA are types of Omega 3 that offers many health benefits ranging from mental health to and prevention of chronic disease. A Danish study showed that omega 3 (specifically DHA) can be highly protective of pre-term labour.14 In pregnancy and breastfeeding a diet rich in omega 3 fatty acid also supports the baby’s brain, eye and nervous system development. Your baby’s brain grows rapidly during the last month of pregnancy and throughout the first years of life, so substantial amounts of omega 3 fatty acids (especially DHA) are required. Omega 3 fatty acid levels decrease significantly following birth unless the baby receives it from either through breast milk or infant formula supplemented with omega 3.

    Low-mercury oily fish such as salmon, trout, mackerel, and sardines are the highest omega 3 sources, but other seafood also contain omega 3 (eg. Mussels and calamari). It is recommended that oily fish is included 2-3 times per week (+-150g per serve) in the diet. Plant sources such as nuts, seeds, legumes and soy also contain omega 3 but it requires extra ‘steps’ in the body to be converted into EPA and DHA. Sometimes it is difficult to obtain enough omega-3 from dietary sources alone due to various factors (especially if on a plant-based diet) in which case an omega-3 supplement, either from fish or algae sources should be used. This should be discussed with your GP and dietitian to ensure the correct timing, dose and source is used. Remember Cod liver oil SHOULD NOT be used as it is too high in vitamin A.

    Read more about low mercury fish here: https://www.foodstandards.gov.au/consumer/chemicals/mercury/Pages/default.aspx

In summary

  • It is undisputed that what we eat prior to conception and during pregnancy and breastfeeding impacts the growth and development of future little Australians.
  • Almost all Australian pregnant women do not eat the correct amounts from all 5 the recommended food groups (Australian Guide for Health Eating) which is subjecting them to potential nutrient deficiencies.
  • Folate supplementation should be taken ideally 1-3 months prior to conception and continued until 12 weeks.
  • Iodine supplementation should be taken daily for the duration of pregnancy and breastfeeding.
  • Certain groups and situations are at higher risk of nutrient deficiencies and should take early action.
  • You should be able to enjoy eating during pregnancy and breastfeeding, having peace of mind that you are nourishing yourself and your growing bub. Your diet does not have to be perfect every day, but certain nutrients do not be prioritised.
  • YOU matter too. Antenatal and post-natal nutrient depletion will have a negative impact on your physical and mental health.
  • If you feel you are struggling or feel unsure about your own situation, come and talk to our dietitian to get some sensible, practical and evidence-based recommendations.

REFERENCES

1Hure, A., Young, A., Smith, R., & Collins, C. (2009). Diet and pregnancy status in Australian women. Public health nutrition, 12(6), 853-861.
2Maneschi, K., Geller, T., Collins, C. E., Gordon, A., & Grech, A. (2023). Maternal diet quality and nutrient intakes across Preconception and pregnancy are not consistent with Australian guidelines: results from the pilot Baby1000 study. Food Science & Nutrition.
3Malek, L., Umberger, W., Makrides, M., & Zhou, S. J. (2016). Adherence to the Australian dietary guidelines during pregnancy: evidence from a national study. Public health nutrition, 19(7), 1155-1163.
4Bookari, K., Yeatman, H., & Williamson, M. (2017). Falling short of dietary guidelines–What do Australian pregnant women really know? A cross sectional study. Women and Birth, 30(1), 9-17.
5Gluckman, P. D., Hanson, M. A., Buklijas, T., Low, F. M., & Beedle, A. S. (2009). Epigenetic mechanisms that underpin metabolic and cardiovascular diseases. Nature Reviews Endocrinology, 5(7), 401-408.
6Stephenson, J., Heslehurst, N., Hall, J., Schoenaker, D. A., Hutchinson, J., Cade, J. E., … & Mishra, G. D. (2018). Before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. The Lancet, 391(10132), 1830-1841.
7Thurow, R (2016), Author of the First 1,000 days: A Crucial Time for Mothers and Children – and the world. New York Public Affairs
8Jouanne, M., Oddoux, S., Noël, A., & Voisin-Chiret, A. S. (2021). Nutrient requirements during pregnancy and lactation. Nutrients, 13(2), 692.
9Opie, R. S., Uldrich, A. C., & Ball, K. (2020). Maternal postpartum diet and postpartum depression: a systematic review. Maternal and child health journal, 24, 966-978.
10Khan, R., Waqas, A., Bilal, A., Mustehsan, Z. H., Omar, J., & Rahman, A. (2020). Association of Maternal depression with diet: A systematic review. Asian Journal of Psychiatry, 52, 102098.
11Blumfield, M. L., Hure, A. J., Macdonald-Wicks, L., Smith, R., & Collins, C. E. (2013). Micronutrient intakes during pregnancy in developed countries: systematic review and meta-analysis. Nutrition reviews, 71(2), 118-132.
12Probst, Y., Guan, V., & Neale, E. (2019). Development of a choline database to estimate Australian population intakes. Nutrients, 11(4), 913.
13Maneschi, K., Geller, T., Collins, C. E., Gordon, A., & Grech, A. (2023). Maternal diet quality and nutrient intakes across Preconception and pregnancy are not consistent with Australian guidelines: results from the pilot Baby1000 study. Food Science & Nutrition.
14Olsen, S. F., Halldorsson, T. I., Thorne-Lyman, A. L., Strøm, M., Gørtz, S., Granstrøm, C., … & Zhou, W. (2018). Plasma concentrations of long chain n-3 fatty acids in early and mid-pregnancy and risk of early preterm birth. EBioMedicine, 35, 325-333.

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