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OCR for page 258
1 ~
Dietary Intake During Pregnancy
Since nutrient supplementation of healthy pregnant women is necessary
only when the usual intake of nutrients from the diet is insufficient to meet
physiologic requirements (see Chapter 12), in this chapter the subcommittee
reviews data on the usual dietary intake of nutrients by pregnant women and
identifies nutrients that are frequently consumed below the recommended
levels. The subcommittee noted that if a population group were to consume,
on average, less of a nutrient than the Recommended Dietary Allowance
(RDA) (NRC, 1989), this would not necessarily imply that they are deficient
in that nutrient. It may, however, mean that some individuals within the
group are at risk of deficiency.
AVAILABLE DIETARY DATA
The following review of data on nutrient intakes during pregnancy is
restricted to women residing in the United States. Lack of data prevented
the inclusion of some essential nutrients, and certain others were excluded
(e.g., phosphorus) because adequacy of intake has been well established.
Limited data on the nutrients omitted from Able 13-1 are provided in
Chapters 15, 17, and 18. All reports published since 1978 were selected if
they included data for energy and at least four nutrients. That year was
selected as a cutoff point because older data are unlikely to be representa-
tive of current nutrient intakes for several reasons. For example, advice to
restrict weight gain during pregnancy by reducing food intake is given less
frequently than it was in the past. Furthermore, estimates of the nutrient
258
OCR for page 259
DIETARY INTAKE
259
composition of foods have been revised. Thus, nutrient data bases have
changed accordingly over time and have become more complete. There
have also been changes in the types of foods available to and consumed by
the U.S. public, and in the 1980s, the food intake of increasing numbers
of pregnant women was affected by their participation in the Special Sup-
plemental Food Program for Women, Infants, and Children (WIC) (see
Chapter 3, Figure 3-5~.
Table 13-1 summarizes the references from which data were abstracted;
provides the year of each report; and notes the population groups studied,
the stage of pregnancy at which intake was measured, the dietary data
collection method, and the number of days that intake was measured.
LIMITATIONS OF THE DATA
Neither the National Health and Nutrition Examination Surveys
(NHANES), the Nationwide Food Consumption Surveys (NFCS), nor the
Continuing Survey of Food Intake by Individuals (CSFII) selves as a source
of representative dietary data for pregnant women in the United States.
Since the number of pregnant women included in the surveys is small, e.g.,
116 of 2,910 women in the first wave of CSFII in 1985 (USDA, 1985), valid
comparisons cannot be made across age, ethnic, or socioeconomic groups.
However, results from one analysis of CSFII data on pregnant women are
included in Able 13-2.
Low-income women were heavily represented in the recent dietary
intake studies (at least 8 of the 11 studies) of pregnant women included in
Table 13-2. That is, many studies were conducted with WIC participants,
whose family income is less than 185% of the national poverty level. This
factor, combined with the small sample size of most studies, introduces
some uncertainty regarding the extent to which the data can be generalized
to the ethnic and age groups specified in Tables 13-1 and 13-2.
Differences between studies make it difficult to compare their results.
Although most investigators used a 24-hour diet recall method to obtain the
dietary data, the accuracy of the food intake information must have varied
with the level of training of the interviewers, the use of food models, the
time available for the interview, characteristics of the subjects such as their
education level and economic status, and the sensitivity and knowledge
of interviewers concerning cultural food patterns. In the studies in which
women were asked to record or to record and weigh their intake, it is
likely that some women changed their food intake because of the need to
keep a record. Different investigators used different nutrient data bases,
which vary in completeness and accuracy (Dwyer and Suitor, 1984~. This
is especially likely to affect estimates of the intakes of such nutrients as
folacin, vitamin Be, and zinc.
OCR for page 260
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OCR for page 264
264
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
In 1988, approximately 523,000 pregnant women per month were par-
ticipants in WIC (J. Hirshman, Food and Nutrition Service, personal com-
munication, 1988~. Several investigators (see Table 13-1) did not identify
the proportion of their subjects who were enrolled in WIC or separate the
dietary intake data of participants from those of nonparticipants. Nutrient
intakes by women from lower socioeconomic groups may be increased by
participation in this program, as described later in this chapter.
Information on the effects of pregnancy on food choices and patterns,
diet quality, and nutrient intake in the United States is virtually nonexistent.
Since 1978, no investigator in the United States has made a systematic study
of intake before and throughout pregnancy in the same women. With two
exceptions (Endres et al., 1985; S. Murphy and B. Abrams, University of
California at Berkeley, personal communication, 1988), no comparisons
were made between nonpregnant and pregnant women.
It is unclear whether or how appetite changes during pregnancy. Data
on intakes during the first trimester are scarce because most women make
no more than one prenatal visit during this time. (In 1985, 18.1% of the
pregnant women in the United States received no prenatal care in the first
trimester. For teenagers and black women, first-trimester prenatal care was
even less common [IOM, 1988~.) In the few early studies in which appetite
was investigated, some women reported that their appetite was greater,
whereas others reported no difference (see review by Taggart, 1961~. Beat
(1971) reported that appetite decreased in the first trimester, improved in
the fifth month, and declined thereafter.
Nausea during early pregnancy was reported by about half of the
pregnant women studied by Brandes (1967~. It is not known how nausea
and vomiting affect the daily amount and nutritional quality of food con-
sumed, but these unpleasant conditions have been associated with favorable
pregnancy outcomes (Brandes, 1967; Klebanoff et al., 1985; Tierson et al.,
1986~. The few attempts to investigate whether maternal diet contributes to
nausea or vomiting have failed to find a relationship. The lack of evidence
that vitamin Be supplements help relieve nausea is discussed in Chapter 18.
Food-related behaviors that change more often during pregnancy than
at any other stage of life include cravings, aversions to specific foods, and
pica (the ingestion of nonfood substances such as laundry starch) (NRC,
1982~. In one study of married pregnant women of northern European
background from middle- and upper-income groups in the United States,
76% reported a craving for at least one food item, and 85% reported
aversion to at least one (Tierson et al., 1985~. These cravings and aversions
had predictable effects on the amounts of the specific foods consumed,
but it was not possible to generalize about the overall nutritional impact
because of the large number and variety of foods involved. In another study
of a random sample of 463 women who had recently delivered babies, more
OCR for page 265
DIETARY INTAKE
265
than 90% reported a craving for at least one food item during their last
trimester of pregnancy, and more than 50% reported aversion to at least
one (Worthington-Roberts et al., 1989~.
NUTRIENT INTAKES OF PREGNANT WOMEN
Nutrient intake data from studies of pregnant women during the 1980s
are summarized in Table 13-2. Average intakes reported to be lower than
the 1989 RDAs for pregnant women are set in boldface type. The RDAs for
protein, vitamins, and minerals provide a substantial margin of safety and
exceed the requirements of almost all individuals in a specific population
group. For example, approximately 50% of the population has an adequate
intake of a nutrient at >77% of the RDA, and 97.5% has an adequate
intake at 100% of the RDA, assuming that the RDAs are 30% (about 2
standard deviations) higher than the mean requirement of the population.
The following generalizations can be made about the data presented
in Table 13-2:
· The nutrient intake by pregnant women in the United States has
been measured in relatively few studies during the last decade. Information
is particularly sparse on adult women of northern European descent.
· Reported mean daily energy intakes varied markedly, ranging from
approximately 1,500 to 2,800 kcal. The extent to which this reflects dif-
ferences in data collection techniques (and consequently over- or underre-
porting of food intake) or differences in age, body size, or activity level is
not clear. Not surprisingly, with a few exceptions, mean nutrient intakes by
the groups tended to rise or fall with the reported energy intake.
· On average, intakes of protein, riboflavin, vitamin Bit, and niacin
exceeded the RDAs, and there was only one report of low vitamin C intake.
This exception (Brennan et al., 1983a,b) was for the chemically analyzed
vitamin C content of the foods consumed, which was substantially lower
than that calculated from food composition tables. Average thiamin intakes
were close to the RDA in all studies.
Some nutrients were consumed consistently in amounts substan-
tially less than the RDA. These include vitamins Be, D, E, and folacin;
. . .
iron; zinc; an' magnesium.
· Mean calcium intake was less than the RDA in all but one study, in
which high intakes of all nutrients were reported for a group of teenagers
(Lords et al., 1985), and very close to the RDA in another study (Suitor
et al., 1989~. Calcium values shown in Able 13-2 were especially low for
nonparticipants in WIC (Rush et al., 1988), black women (Brennan et al.,
1983a), and Navajo women (Butte et al., 1981~.
.
OCR for page 266
266
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
· In the few studies that included vitamin E, intake averaged about
half of the RDA for women of Hispanic and Navajo origin but was some-
what higher for others. The few studies including vitamin D indicated that
intake of that vitamin was approximately half the RDA
· There was a wide range in mean nutrient intake across different
samples of pregnant teenagers. One group of investigators (Endres et al.,
1985, 1987) found that the quantity and quality of the diet consumed by
pregnant adolescents was similar to that consumed by pregnant adults.
In contrast, Loris et al. (1985) observed higher intakes of energy and
most other nutrients among adolescents as well as a greater weight gain
than is typical for adults. Adolescents receiving more nutrition education
consumed greater amounts of energy-400 kcaVday on average more than
did those with little nutrition education.
.
Some of the food composition data bases lacked information on
nutrients that may be present in the diets of pregnant women at levels
that are substantially less than recommended. This may partially explain
why many of the investigators did not present values for zinc; magnesium;
copper; and vitamins Be, Bit, D, and E.
The mean daily consumption of iron from foods ranged from 10.3
to 16.6 ma. The highest iron intakes were reported for black and Navajo
women. However, comparisons of adequacy of iron intake were not made
based on the amount of available iron (see Chapter 144.
Vitamin A intakes were reported in international units (IUs) or in
milligrams, whereas the RDAs are given as micrograms of retinal equiv-
alents (REs). The subcommittee converted intake data to micrograms of
RE based on the assumption that 1 RE is equivalent to 5 IU of vitamin
A obtained from the typical U.S. diet in the form of retinal (from animal
products) and carotenoids (from plants) (Olson, 1987) and that 1 mg of
retinal equals 3,333 IU. Mean intakes of this vitamin appeared to be close
to the RDA, on average, but were low in pregnant Navajo women.
In summary, the data in Table 13-2 indicate that, on average, pregnant
women in the studies cited probably met their RDA for protein, thiamin,
riboflavin, niacin, and vitamins A' Bit, and C. They were less likely to
have met their RDAs for vitamins Be, D, E, and folacin; iron; calcium;
zinc; and magnesium. Because the RDA for iron during pregnancy is more
than twice as high as average intake, it cannot be met from dietary sources
without the use of highly fortified foods or very careful food selection (see
Chapter 14~.
The fact that the average intake of eight nutrients by almost all groups
studied was substantially below the RDAs for pregnant women should be
interpreted with caution. The RDAs for all vitamins and minerals include
a safety factor to cover the needs of even those healthy individuals whose
OCR for page 267
DIETARY INTAKE
267
metabolism is such that their requirements are especially high; thus, it is
possible that the RDAs for these eight nutrients are quite generous for
most women. The food intake methods used in these studies may have
underestimated true consumption. In the case of vitamin D, synthesis in
the skin during summer months can contribute substantially to vitamin D
adequacy. Finally, the number of women studied is relatively small, and
women with medium to high incomes were underrepresented.
These data should also be interpreted in light of the fact that even the
well-balanced diets of healthy, nonpregnant adults provide low amounts
of these same nutrients relative to the RDAs (King et al., 1978; Peterkin,
1986~. In the 1985 CSFII, a sample of all women aged 19 to 50 consumed
less than three-quarters of their 1980 RDAs for iron, magnesium, calcium,
zinc, vitamin Be, and folate (Peterkin, 1986~. (Vitamin D intakes were not
reported.) Nonetheless, of these nutrients, the Report on Nutni;~on Moni-
toring in the United States (LSRO, 1989) categorized only iron and calcium
as food components that are recommended for high-priority monitoring
status because they represent public health problems in the population.
ASSOCIATIONS OF MATERNAL CHARACTERISTICS WITH
NUTRIENT INTAKE DURING PREGNANCY
Ethnic Background
There have been no studies of both dietary and sociodemographic
factors in a large, random sample of pregnant women in the United States.
In a national sample of 1,503 women between the ages of 19 and 50,
93.4 % of whom were not pregnant or lactating (USDA, 1985), the most
notable ethnic difference was calcium intake, which was 464 mg/day for
blacks compared with 656 mg/day for whites (Peterkin, 1986~. The data in
liable 13-2 suggest that this difference persists during pregnancy.
In the National WIC Evaluation (Rush et al., 1988), in which all of
the subjects were from low-income households, a few notable differences
in intake were ascribed to ethnic background after a variety of maternal
characteristics had been controlled statistically. Before registration in WIC,
blacks had much lower intakes (703 mg/day) of calcium than did white non-
Hispanics (1,045 mg/day), whereas Hispanic women consumed intermediate
amounts (862 mg/day). Suitor et al. (1990) reported similar trends in
calcium intake by ethnic groups among low-income pregnant women in
Massachusetts. This situation may be explained in part by the much higher
prevalence of lactose intolerance among blacks and Hispanics, sometimes
resulting in their subsequent avoidance of milk. Data from one study (Villar
et al., 1988) indicated that lactose intolerance abates during pregnancy, but
this is unlikely to change dietary patterns substantially. Rush et al. (1988)
OCR for page 268
268
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
reported that enrollment in WIC was associated with 170- and 150-mg/day
increases in calcium intake by blacks and Hispanics, respectively; however,
average intakes remained low, especially for blacks. Lactose intolerance
may not prevent blacks and Hispanics from consuming at least some of the
dairy products supplied by WIC. It is also possible, however, that women
reported a higher than actual consumption of the foods from the WIC
package.
Socioeconomic and Demographic Factors
In the National WIC Evaluation (Rush et al., 1988), investigators ex-
amined associations between nutrient intake and factors such as income and
occupation at the time of registration in the program. In this analysis, the
relationships between specific socioeconomic or demographic factors and
intake were controlled for all other maternal characteristics at registration
that might confound interpretation of the results by differentially affecting
intake. These included maternal ethnic background, age, parity, history of
low birth weight or infant death, cigarette smoking, alcohol intake, par-
ticipation in assistance programs, income, family size, and parental work
status.
In these WIC-eligible, low-income women, employment was generally
not associated with higher nutrient intakes and, in fact, was negatively
related to calcium consumption. Wives of agricultural workers consumed
substantially more energy, pro rein, and iron than did other women. The
reasons for these associations were not established. On the other hand,
Suitor et al. (1990) reported higher intakes of protein and zinc by employed
rather than by unemployed low-income pregnant women. In the National
WIC Evaluation, the number of people in the household had a minimal
effect on nutrient intake by pregnant women. Income had a positive
relationship to the intake of energy and protein by pregnant women: an
additional 1.4 kcal of energy and 0.04 g of protein was consumed for every
$100 per year increase in income. These results differ somewhat from
those reported for the largely nonpregnant sample of women aged 19 to
50 who participated in CSFII. Their mean intakes of calcium; magnesium;
iron; zinc; and vitamins Be, E, and folate increased slightly with income
(Peterkin, 1986~. To some extent, the apparent effects of income in the
CSFII analysis may be due to other demographic differences, such as
household composition and lower proportions of blacks and Hispanics in
the higher-income groups.
WIC Participation
The third-trimester mean intake of several nutrients by women who
were WIC participants was significantly higher than that of nonparticipants
OCR for page 269
DIETARY INTAKE
269
(Rush et al., 1988~. For protein, the intake was 5 g/day higher; for iron, 3.2
mg/day; for calcium, 133 mg/day; and for vitamin C, 32 mg/day. Vitamin A
intake was unchanged. Among WIC participants there were also statistically
significant higher daily intakes of energy (111 kcal), magnesium (25 mg),
thiamin (0.34 lug), riboflavin (0.37 lug), niacin (3.2 mg), vitamin B6 (0.34
mg), and vitamin BE (1.3 Age. In a smaller study, Suitor et al. (1990) found
that WIC participants had significantly higher intakes of protein, calcium,
iron, and vitamin B6 per 1,000 kcal compared with nonparticipants. The
strongest explanation for the higher intakes is the greater nutrient density
of WIC foods compared with that of women's usual diets; the relative
increases for most nutrients were higher than that for energy.
In the National WIC Evaluation (Rush et al., 1988), the effects of
WIC on nutrient intake appeared to be generally uniform across sociode-
mographic groups, except for the greater improvements in calcium intake
by blacks. The heaviest cigarette smokers also benefited more; WIC par-
ticipation increased their intake of most nutrients.
Maternal Age
There are insufficient data from random national surveys to describe
the effects of maternal age on nutrient intake during pregnancy, but data
from CSFII and NHANES II indicate that intakes of most nutrients and
of energy by women decrease with age (Carroll et al., 1983; USDA, 1985~.
As shown in Table 13-2, there are wide differences among the reported
intakes by pregnant teenagers in several small studies (Endres et al., 1985,
1987; Loris et al., 1985~. In contrast to the data on nonpregnant women,
the National WIC Evaluation (Rush et al., 1988) indicated that younger
women consumed less energy (intake increased by 18 kcal/day for each year
of age), protein (0.5 g/year), and calcium (8 mg/year).
SUMMARY
Data on the reported dietary nutrient intakes by pregnant women stud-
ied in the past decade show that the intakes of eight nutrients consistently
average less than the 1989 RDAs, namely, vitamins Be, D, E, and folate;
iron; calcium; zinc; and magnesium. Because of these apparent shortfalls,
the subcommittee paid special attention to evidence regarding the need to
supplement pregnant women with those nutrients. Somewhat less attention
was directed toward protein; thiamin; riboflavin; niacin; and vitamins A,
Bit, and C, because average dietary intakes generally meet the 1989 RDAs.
The most notable relationship between ethnic background and dietary in-
take is a lower consumption of calcium by blacks, Hispanics, and American
Indians. WIC participation is associated with higher intakes of energy and
a number of vitamins and minerals.
OCR for page 270
270
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
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Representative terms from entire chapter:
dietary intake
