Community Lecture Series “Healthy Diet and Weight Gain in Pregnancy” – Mai Hoang, MD

Community Lecture Series “Healthy Diet and Weight Gain in Pregnancy” – Mai Hoang, MD


– Good evening, everyone. My name is Mai Hoang. I am one of the obstetrician
and gynecologists. I work at Palo Alto Medical Foundation. I work at their Los Gatos office site, which is just down the street, right across the parking
lot from Good Samaritan, where we are right now. Before we start with the talk, I’m just gonna introduce
myself a little bit to you, everybody. I grew up in southern California. I did my college education at UCLA. Then I moved to the east coast. I did my medical school in Vermont at the University of
Vermont, in Burlington. I did my training in
obstetric and gynecology at Yale University at the
Yale New Haven Hospital. So tonight, we’re gonna
talk about healthy diet and weight gain in pregnancy. Feel free to interrupt me, ask any question, as we go along. So at the end of the lecture today, what I hope is for you to be able to know and select what are some of
the healthy food options, how much of it to have. We’ll be able to figure
out how many calorie you and your baby need during the pregnancy so that you can have
a healthy weight gain. We will also learn about
what are some of the problem that can happen when
you gain too much weight during the pregnancy course, before you went into labor, during labor, as well as the postpartum period. So in 2005, the USDA and
the Department of Health and Human Services introduce
a new food pyramid. This is very different from
the previous food pyramid that we had in the past because
it introduce the concept of physical activities. It’s very important that we
incorporate physical activities for kind of the healthy lifestyle. According to this recommendation, all men and women and children, regardless of whether they’re pregnant or not, should have at least three
ounces of whole grain a day, okay, that 50% of your grain intake should could from whole grain. They also recommend that we eat two and half cup of vegetable, two cup of fruits everyday. Less than 15% of elementary
school-aged children are able to meet this requirement and eat this five cup of
vegetable and fruit a day. So that’s definitely an
area for us to improve on whether we’re pregnant
or have kids or not. They also recommend that
we keep a total fat intake to 20 to 30% of total calorie. These fat should come
from polyunsaturated fat as well as monounsaturated. They recommend that all men and women, and children as well,
should have a minimum of 3 cup of milk product everyday. We should vary our protein source, not just to have it come from meat but also to come from fish,
nuts, as well as peas. In 2011, they came out, again, the USDA and Department of
Health and Human Services, came out with this new
model called My Plate. This is meant for you to remind yourself at every meal, we should
have fruit, vegetable, grain, protein and dairy. This is not meant to tell you proportion of how much you should have
but it’s more like a reminder that every meal, we should try to get as much of this as we can. So now we’re gonna talk about
the important macronutrients and micronutrients in pregnancy. The first thing that come
to mind is folic acid. Folic acid is very important. I’m sure many of you have heard of in different magazines
and talking to your doctor and just searching on the internet, that folic acid is very important. The reason why it’s important is that if you take it before you get pregnant, it can reduce the incident
of neural tube defect by 36%, simply by taking 400 microgram a day. Neural tube defect is a structural anomaly of the brain and the spinal cord, so most common example that people hear about is anencephaly, so the baby doesn’t have
a normal brain structure or spina bifida, where the
spine is abnormally formed and the brain or the spinal cord tissue is prolapsing through. This is the second most common
major congenital anomaly and it occur in 1.4 to two
pregnancy per every 1,000. So it’s quite very common and as I said, it’s one
of the few intervention that we can do to prevent having this congenital abnormality. So before you get pregnant,
you should take 400 microgram of folic acid a day, okay? For at least a month before
you try to get pregnant and during pregnancy, you
should take 600 microgram a day. Iron is also important because it increase the red blood cell. That is important for blood flow and oxygen delivery to the baby. We should get 27 milligram daily. The source for iron come
from meat, as we know, but it also come from
fish, spinach, dry beans, and of course you can get
it through iron tablet. If you’re gonna take iron tablet, it’s very important that
you take it with vitamin C. Vitamin C, whether in the pill form, as orange juice or oranges, help your body to absorb the iron better. Calcium is important because it helps strengthen
the bone and the teeth, not just for the mom
but also for the baby, especially for the baby as
the development is happening. For women between the age of 19 to 50, we recommend that they take
1000 milligram everyday. Source for calcium, of course, as we know, come from milk and dairy product, but also from dark and
leafy green vegetable, as well as sardine and calcium supplement. Vitamin D, like calcium,
is also very important. It helps bone and teeth strengthening, but it’s also important for
the skin and the eyesight. We should get 600 international unit daily and the source of that is sunlight, fortified food that we can see. They always say in the supermarket that you can buy milk or soy milk, that they always say
fortified with calcium D. You can take it that way, or it can also come
from fish, like salmon. It’s important that we eat
healthy sources of fat, okay? Healthy fatty acids. The most common thing that we think about is the omega 3 fatty acid. These are important because
it help develop the brain before and after birth. There are studies that shows that if women eat eight to 12 ounces of fish per week, while they’re pregnant or during breastfeeding, that it can improve the
baby motor function. Also, it help to improve
any behavior problem and we can see that the effect lasts up until 14 and 17 years old. So when we talk about fish, we think about the mercury level in fish. Mercury toxicity can lead to motor, intellectual and psychosocial impairment. So, we want to limit the amount of mercury containing
fish that we’re eating. Fishes that are lowest in mercury level are salmon, tilapia, cod, haddock as well as shrimp. Those that are high in mercury level that we should, whether you’re
pregnant or not pregnant are tilefish from the Gulf of Mexico, swordfish, the king mackerel and shark, although most of us don’t
eat shark on a regular basis, so I think we’re okay
from that standpoint. So next let’s take a break
and talk about listeriosis. Listeriosis is a food-born illness that is caused by a bacteria
called listeria monocytogene. This bacteria can infect both pregnant and non-pregnant women, but among the pregnant women, they are at 13 times
higher chance of developing this listeriosis than
the general population. If infected for the mom,
they have very little to no symptoms at all. They might get diarrhea
or some flu-like symptom and that’ll be it. But for the baby, it can
have major complication. The baby can be infected in what we call neonatal listeriosis. It can lead to miscarriages,
preterm delivery as well as stillbirth. To avoid listeriosis, we want
to avoid eating uncooked meat. We want to avoid eating cold meats, so such as hot dog, cold
cut lunch meat, okay? We also want to avoid smoked seafood, even if they’re refrigerated. We want to avoid unpasteurized
diary product, okay? And those are the most common way that we can avoid listeriosis. So here is a summary of a chart, listing all the different
vitamin and mineral that are important in pregnancy. It lists what they are,
the amount that they are, why your body need it and
where you can find it from. You can find a copy of this chart in the package in the
handout that you got. So let’s talk about
weight gain in pregnancy. In 2009, the Institute
of Medicine recommend that pregnant women should aim for a certain amount of weight gain. This is to make sure that the baby and the mom will be healthy. So they recommend that
for underweight women, and underweight is determined
by the body mass index that is less than 18.5. For those women, they should gain, for the pregnancy from
the start until the end, they should gain about 28 to 40 pound. They also said that at
the end of the pregnancy, okay, toward the end part
of the second trimester, as well as the third trimester, the pregnant women should gain
about one pound a week, okay. They recommend that
the normal weight woman should gain between 24 to 35 pound. That the overweight
women and the obese women should gain less. They should gain 15 to 25
pound, for being overweight and 11 to 20 pound for obese. The rate of weight gain toward
the end of the pregnancy should be about half a pound a day. Now, keep in mind that this
is only a guideline, okay? This recommended weight
gain is a guideline. It’s meant for you to
start the conversation, for you to talk to your doctor, for you to monitor your weight and see how you are doing as
the pregnancy goes on, okay? As long as your baby is
growing appropriately, and we do that when you
come to the prenatal visit, as long as your baby is
growing appropriately, even if you don’t meet this
recommended weight gain, it is okay. We do not recommend that you go out and try to gain more weight
just to meet this guideline because there’s no evidence, no data to shows that simply doing that will improve the outcome
for you and your baby. So here is kind of the same information but in a graph format, okay? It tell us that the obese women, represented by the pink line, should gain less weight than
the normal weight women, represented by the blue line. The dashes are just the
range of weight gain. Notice that most of the weight gain happen toward the second
part of the pregnancy. So, during the first trimester, if you are not gaining weight because you’re nauseous, you’re vomiting because of morning sickness,
it is completely okay. You don’t have to worry about
the well-being of your baby because the weight gain will happen toward the end of the pregnancy. So, all of that weight gain, what that mean is that in a day, all you need for you and
for your growing baby, is about 300 calorie a day. That’s on top of what your
body need already, okay? So depending on what you eat, okay, 300 calorie total a day
could be met very easily. You can get that by drinking
one glass of skim milk, by eating one chicken breast from KFC, or eating half of a sandwiches
from Panera or Subway. Here is a sample menu for a pregnant woman who is normal weight, who
get less than 30 minute of exercise everyday, okay, how much they should eat in
the different fruit category, as the pregnancy goes on. Notice how as the pregnancy go on in the first, second and third
trimester, the total calorie that’s require doesn’t
change significantly. So you don’t need that much for your baby. For twins, if you have twins, we recommend that you gain more than if you just have one baby, okay? Again, this is a
recommended guideline only. And again, obese women
should gain less weight than the normal weight women, okay? For the normal weight women
who’s pregnant with twin, we recommend them gaining
between 37 to 54 pound. If they are obese, then they should gain between 25 to 42 pounds. It is very important that you incorporate physical activities in your daily life throughout
the whole pregnancy because physical activities
improve the wellbeing for you during pregnancy. So it help with the back pain. It help with the swelling. It increase your energy level. In addition, it help you
to cope in labor better. There’s a recent study
published in Spain this year that shows that women who exercise between 50 to 60 minute each time, three times a week, that
those pregnant women, when compared to the
one who do not exercise that, in labor, the first stage of labor is significantly shortened
if they exercise. So, the first stage of labor is when you go from
your cervix being closed to 10 centimeters to where
you’re ready to push. That stage can be
shortened by over two hour if you’re able to exercise,
three times a week, about an hour each time. So it’s important. What you should do during pregnancy, what kind of activities level, kinda depends on what
is your starting weight, how comfortable you are, did you exercise before you were pregnant, where you are in the pregnancy or is there any problem, any complication with the pregnancy. But in general, we recommend 30 minutes of brisk walking daily,
about five days a week. We recommend that you avoid
contact sport, obviously. We don’t want you to get injured and fall and hurt baby as well. We want you to avoid scuba diving because that’s for oxygenation. We also recommend you avoid activities with a high risk of falling, such as riding horses, for example. The goal is that you should stay hydrated and well oxygenated with
whatever physical activities that you do. So, what happen if you
gain too much weight? Well, for the mom, before labor process during the pregnancy, when you gain too much weight, you are at a high risk of
developing gestational diabetes. Your chance of having
diabetes during pregnancy increase two to 10 time higher, compared to if you did
not gain a lot of weight or if you didn’t start at being obese at the start of your pregnancy. You’re also at a higher risk of developing high blood
pressure during the pregnancy. You’re at high risk of
delivering your baby early, of having a c-section, as
well as having stillbirths. During labor, obese mom or
mom who have gained a lot of weight in pregnancy,
face several difficulties. The first thing that they face is that it’s harder for
the healthcare provider to monitor the baby. So when you’re in labor, we
monitor the baby heart rate with a monitor that we
place on your belly. So if there’s a lot of excess tissue, it might be hard for
us to monitor the baby. We might have problem managing your pain so the anesthesiologists might have difficulty placing the epidural and that the epidural might not work well for you during your labor process. They are also at a higher surgical risk, meaning that if they
have to have a c-section, it would take longer for
us to operate on them. They will have a higher blood loss, a higher chance of infection,
as well as blood clots. During the postpartum period, mom who gain a lot of weight or if they start out being obese, they’re at a higher chance
of keeping those weight and not losing them. The problem with keeping the weight that you gained during pregnancy, put you at risk of developing
chronic diseases later in your life, such as high blood pressure, coronary artery disease,
as well as diabetes. You’re also less likely to initiate and sustain breastfeeding. For the baby, what would happen if the mom are overweight to start with
at the start of the pregnancy or if they gain a lot of weight? Well, the baby are more likely to have certain birth defect. So obese mom have one
to three percent chance of having baby with birth defect, compared to non-obese mom. Also, it is harder for us to monitor or to use ultrasound to
detect congenital anomaly for the baby if there’s a lot of tissue, making it harder for
us to do the ultrasound to recognize that there is an anomaly. So, if there’s an anomaly,
we’re more likely to miss it because of you being overweight. There’s also risk for the
baby become macrosomic, meaning the baby is larger than expected for where they are in the pregnancy. And with that, the baby can develop injury as the baby try to go
through the birth canal. Also, childhood obesity is a risk when the mom gain a lot of
weight during the pregnancy or the mom start out being obese. While some people may think that, you know, it’s only going to be temporary, the pregnancy for a few months. Once the baby is out,
we’ll take care of the baby and the baby will be okay. Well that’s not necessarily true because what happen in utero, does not necessarily stay intrauterine. So what that mean is that in rats, we have seen that if we
restrict their calorie, we don’t feed them, okay, in the early part of the pregnancy, at the beginning of the fetal development, that the offspring rat, you know, that developed obesity, as well as metabolic syndrome. Metabolic syndrome are
high blood pressure, abnormal glucose testing, so pre-diabetic, or abnormal cholesterol level. Now, for the rat, if we
restrict the caloric intake in the second part of the pregnancy, we find out that the offspring have higher chance of developing diabetes. Well, why is that? So there’s this hypothesis
called Barker hypothesis, and what he and his team proposed is that what happened to
the mom during pregnancy, can change the environment
inside the uterus. And this change in the environment can reprogram the baby metabolic ability, putting the baby at risk
for chronic diseases such as diabetes, high blood
pressure, or heart diseases. This is a very simplistic diagram that show you there are different proteins and different hormone that are
basically counterbalancing, telling the baby to eat and grow or not to eat and grow. It’s the body way of preparing the baby for what happen when the baby is born. So for example, if the mom is pregnant, let’s say, at a time when
there is very little food, like in a famine, which
happen throughout history in the past and even now in
certain part of the world, the body, the pregnancy
kinda sense from the mom that there’s not much food. So then the baby brain changes, the forming of the baby kinda changes, kinda prepare the baby so
that when the baby is born, the baby will be prepared
for an environment with very little food. If that environment changes, if there’s all of a sudden a lot of food, that kind of imbalance will, what the baby was pre-programmed
now during pregnancy and what the body of the baby sense now that the baby is born, that discrepancy put the baby at risk where they can’t metabolize very well and they are risk for
developing childhood obesity as well as obesity as an adult. And you can see, this effect passing on through the next generation as well. We see similar effect when the mom overeat during pregnancy as well. It’s through a separate mechanism but the theory behind it is the same. So what that tell you is
that there is genetic makeup for the mom and for the baby that kinda tell what the baby body will do and those genetic thing
we cannot do about. However, what happen during pregnancy, the input that you put to
your baby to the pregnancy, that can changes because
your baby can change and respond to that. So that is an area that
you can kind of work on to make sure that the
baby will not be at risk. Also, after the baby is
born, there is some control. You know you can control what happen in the early life of the baby, controlling the nutrient
deficiency or excess. You can monitor that so that
you can decrease the chance of the baby of having diabetes
as an adult in the future. So in summary, a healthy pregnancy involve a well balanced diet of fruit, vegetable, lean protein
with supplementation of folic acid, calcium and iron. Remember that you are not eating for two even though, with all the
raging hormone and everything, it feel like you are eating for two and you sometime want to eat for two, but remember that your baby just need about 300 calorie a day. Remember to incorporate
physical activities, daily, throughout the pregnancy because that will
improve the labor process and help you to have a healthy pregnancy. Lastly, remember that your weight gain, your nutrition during pregnancy, can effect the future
wellbeing of your baby, even as the baby become an adult. Thank you for your time. Any question you have for me? Yes? – [Audience Member] The
baby inside the body, when they develop, they
develop very slowly. Is it true at a point, the
baby starts to grow faster? – Yes. – [Audience Member] And at that point, will the mother’s weight also grow? – Yes, yes. So, that’s back here where
you see this trajectory where you see the mom
weight is very little and then the mom weight kinda shot up throughout the pregnancy. Kinda the same thing. In the early part of the pregnancy, the baby is not really growing side wise. The baby is kind of developing
all the important organs so the brain, the heart, you
know all the different organ. And then toward the end
part of the pregnancy, that’s when the baby
start to grow the weight, so that happen at the end. And it kinda reflect with the mom where at the beginning,
she’s growing very little and then at the end, she grow, I mean, she gain a lot of weight. Not growing, sorry. – [Audience Member] So it
happens about the 13th week? – Yeah, so starting in
the second trimester. Second trimester is about 13 to 14 week and that’s when you can really see growth, the weight gain, the rate of
the weight gain to increase. Yeah. Yes. – [Audience Member] What
about in other countries where they have different
types of foods they eat. Does that effect babies? I know, you know, Japan
they’ll eat raw fish and here we say don’t eat raw fish. So how does that work? – Yeah, so, you know, I think there’s also a little bit… The different as well as
when we talk about Japanese, who live in Japan and who eat raw fish, they have a different kind
of immunity than we are. So just as, for example, men and women who live in developing country, eating or drinking unfiltered
water, they don’t get sick. But we come there, we drink
the water, we get sick. Because our body has a
different kind of immunity than to them, okay? So I think that explain why as well. And, for us here, this is kinda recommend, this is based on the American diet. There are variation between
the different ethnic group, what they eat, but the key thing, what’s important in what you eat, the different vitamin. So whether, you know, we
eat sushi or we don’t sushi, we still should get calcium. We should still get vitamin D. There are certain nutrient,
vitamin and mineral, that we need to get
throughout the pregnancy, regardless of what our diet is because of our ethnic background. Yes. (audience member speaking faintly) – [Audience Member] If we take too much of certain vitamin or
minerals, it could be harmful. – Yes. – [Audience Member] So for pregnant women, they also have to watch out,
they don’t go overboard. – Yes, so some of the vitamin that we want to make sure they don’t go overboard, first of all, is iron. If you have too much iron,
that can be a problem. Now, most women, that’s not a problem because our body able to
kinda clear out the excess and just kinda get rid of it
so it’s not become a problem. There are people with a certain diseases where the body cannot clear
that and that can be a toxic. Most of us, however, we
don’t have this problem, especially for women. Women, because the
losing blood every month, they tend to be more anemic. They tend to have low iron to start out, so it’s very hard for them to
kind of overdose themselves and take too much iron. Okay, all right. Thank you everybody for coming.