1 NUTRITIONAL ASPECT OF PREGNANCY Teaching Team of Nutrition Throughout Life Cycle GIZ Department, Human Ecology Faculty Bogor Agricultural University 2007

2 I. DEFINITION Pregnancy : It is the condition of having a developing embryo or fetus in the body after union of an ovum and spermatozoa. The period is from conception to child-birth lasting 40 weeks or 280 days.

3 II. Weight Changes 1. The total number of weight gained in pregnancy varies from one woman to another. 2. The normal weight gain for the average Filipino woman is approximately kg; for the entire pregnancy. a. Guide for Weight Gain 1 st trimester – 1 lb. per month or 3 lbs. (1.1 kg) 2 nd trimester – 2 lb per month or 6 lbs. (2.2 kg) 3 rd trimester – 1 lb per week or 12 lbs. (5.0 kg)

4 Table Average weight gain during pregnancy in industrialized countries _____________________________________________________ Time of pregnancy (week) Weight gain (kg) – – – – – – – Total10 –

5 Weight gain : week of pregnancy kg/week 0-10 week0,065 kg week0,335 kg week0,450 kg week0,335 kg

6 Recommended weight gain during pregnancy is based on nutritional status before pregnant Nutritional status IMTWeight gain (kg) Very low < 16,5 Low16,5-19,713,0-18,0 Normal19,8-26,011,5-16,0 Over weight26,0-29,0 7,0-11,5 Obes > 29,0 < 6,8 Twin16,0-20,5

7 Component of maternal weight gain during pregnancy Weight gain (g) at : 10 week 20 week 30 week 40 week Maternal comp.: Fat deposit Interstitial fluid Blood Uterus Breast Total Fetus component : Fetus Amniotic fluid Placenta Total Total weight gain

8 Weight gain of the fetus : week: 10 g/week week: 85 g/week week: 200 g/week week: 70 g/week

9 Substances transferred to the fetus and placental during pregnancy Newborn (g) Placental and amniotic fluid (g) Total weight Water Protein Fat Sodium Potassium Chloride Calcium Phosphorus Magnesium Iron

10 A.ENERGY. -additional energy is required during pregnancy for: - the growth of the fetus; placenta and maternal tissues and their maintenance; for the increases in BMR; for better utilization of dietary protein and good pregnancy outcome. - The addition of 300 kcal/day during the second and third trimesters of pregnancy is recommended, while for the first trimesters is 180 kcal/day. III. NUTRITIONAL REQUIREMENT DURING PREGNANCY

11 ENERGI (WKNPG, 2004): Tambahan energi untuk ibu hamil : - pertumbuhan bayi - placenta dan rahim - cadangan energi bagi ibu - cadangan energi bagi ASI - basal metabolisme

12 ESTIMASI AKE IBU HAMIL Umur (th) AKE (kkal/hari) Wanita Hamil Trimester Trimester Trimester

13 ESTIMASI AKE IBU HAMIL Tambahan AKE Wanita Hamil Trimester kkal Trimester kkal cadangan dan 160 kkal peningkatan pengeluaran energi Trimester kkal cadangan dan 270 kkal peningkatan pengeluaran energi

14 ESTIMASI AKE IBU HAMIL Tambahan AKE Wanita Hamil bukan angka mutlak tetapi merupakan angka yang mendekati Kecukupan untuk sebagian besar populasi

15 Components of protein & fat accumulated during pregnancy (g) ProteinFat Fetus Placenta Amniotic fluid 3 4 Uterus Breasts Blood Maternal fat store Total

16 Energy cost of pregnancy  g protein x gross E (5.6 kcal/g) = 925 x 5.6 =  g fat x gross E (9.5 kcal/g) = 3825 x 9.5 =  O2 consumption  Tissue synthesis & maintenance that tissue Efficiency 90% =>

17 Energi WHO Expert Group Total st trimester nd trimester rd trimester

18 B.Protein – increases by an average of 17 g/day throughout pregnancy - to meet the needs of the developing maternal tissues; - to support the growth of the fetus and the placenta; - for normal pregnancy and outcome; - to protect against risk associated with low protein intakes.

19 ESTIMASI ANGKA KECUKUPAN PROTEIN IBU HAMIL: Trimester 1, 2, 3 EAR = 0,9 g/ kg B/ hr AKP = 1,1 g/ kg B/ hr = + 17

20 Protein WHO Expert Group Total st quarter nd quarter rd quarter th quarter

% (2 SD birth weight) = g 1200 x 100/70 = 1700 g protein = 6 g protein /d

22 C. Vitamin A essential to the welfare of the epithelial tissues including the skin and the membranes that line glandless ducts and passages of the gastrointestinal, urinary and respiratory tracts. The RDA of 475 RE/day for the pregnant woman also accounts for the Vitamin A storage in the fetal tissues

23 -Vit. A dibutuhkan untuk integrasi sel ephitelial -Asam retinoat melalui aktivasi reseptor asam retinoat (RAR) dan reseptor retinoat X (RXR) dalam nukleus mengatur ekspresi berbagai gen yang mengkode untuk protein struktur, enzim, protein matrik -Asam retinoat juga berperan penting dalam perkembangan embrio -Asam retinoat juga penting dalam pembentukan tungkai dan lengan, jantung, mata dan telinga. - Retinoat penting untuk fungsi kekebalan -Vitamin A penting untuk fertilitas

24 D. Vitamin C – an extra 10 mg/day is recommended for the pregnant woman to maintain the integrity or fetal membranes and for tissues structure. E. Thiamin, Riboflavin, and Niacin – are important during pregnancy particularly with reference to energy intake and carbohydrate, protein, and lipid metabolism. Additional amounts of 0.3 mg, 0.6 mg and 3 NE/day for thiamin, riboflavin, and niacin, respectively, are recommended during the second and third trimesters.(1mg Niacin =60mg tryptophan)

25 F. FOLIC ACID : the only nutrient for which the RDA during pregnancy is more than twice the non- pregnancy levels. The recommended intake for the pregnant woman, which is a total of 600 µg daily or an additional 200 µg/day is based on the folate role in promoting normal fetal growth (DNA synthesis) and in erythrocyte maturation.

26 G. Calcium – an additional allowance of 150 mg or a total of 950 mg/day is recommended to promote adequate mineralization of the fetal skeleton and deciduous teeth. G. Kalsium (Ca): -Kalsium berperan sebagai komponen tulang dan gigi. -Kalsium berfungsi sebagai pengatur metabolisme darah, penghantar impuls saraf, produksi hormon produksi, aktivitas enzim, pengaturan permeable membran, pengaturan kontrkasi jantung, pemeliharaan keseimbangan elektrolit

27 an additional allowance of 150 mg Ca or a total of 950 mg/day is recommended to promote adequate mineralization of the fetal skeleton and deciduous teeth.

28 ESTIMASI Angka Kecukupan Kalsium IBU HAMIL UmurAK-Ca (mg/hari) Wanita Hamil Trimester Trimester Trimester

29 H. Iron – the daily requirement of 41 mg is higher than what can be provided by the usual diet alone, thus, supplementation is recommended. This amount is needed to replace maternal iron losses, allowance for the placenta. Infants are born with high hemoglobin levels and with a supply of iron stored in the liver. I. Iodine – an additional allowance of 25 µg/day is recommended so as not to compromise the development of the fetus.

30 H. Iron (Fe): the daily requirement of 41 mg is higher than what can be provided by the usual diet alone, thus, supplementation is recommended. This amount is needed to replace maternal iron losses, allowance for the placenta. Infants are born with high hemoglobin levels and with a supply of iron stored in the liver..

31 ESTIMASI AK-Fe IBU HAMIL -MASA KEHAMILAN (280 hari) - Kehilangan basal= 250 mg - Janin dan plasenta = 315 mg - hemoglobin dan cadangan = 500 mg - Total= 1100 mg

32 ESTIMASI AK-Fe IBU HAMIL MASA KEHAMILAN (trimester 2 & hari) - trimester 1 kecukupan besi = 26 mg/hari - melahirkan= 250 mg - cadangan = 250 mg - janin & plasenta = 315 mg - Total= 565 mg - tambahan besi rata trimester 2= 2,7 mg/hari - tambahan besi rata trimester 3= 3,1 mg/hari

33 ESTIMASI AK-Fe IBU HAMIL MASA KEHAMILAN (trimester 2&3 192 hari) - RDA trimester 2 = 42 mg/hari - RDA trimester 3= 47 mg/hari - tingkat penyerapan besi = 12 % - RDA disesuaikan trimester 2 = 35 mg/hari - RDA disesuaikan trimester 3 = 39 mg/hari

34 Fungsi Iodium: - Iodium penting untuk sistem reproduksi -Iodium penting untuk produksi hormon tiroid yaitu hormon yang dibutuhkan untuk perkembangan dan pertumbuhan saraf otot pusat, pertumbuhan tulang, dan perkembangan fungsi otak. -Juga dibutuhkan untuk sel darah merah, pernafasan sel dan menjaga keseimbangan metabolisme tubuh. I. Iodium (I):

35 an additional allowance of 25 µg/day Iodium is recommended so as not to compromise the development of the fetus.

36 IODIUM Selama hamil dan menyusui kebutuhan iodium dihitung sebesar 3,5 ug/kg/hari. Angka kecukupan iodium (AKI) (WKNPG, 2004) ditentukan berdasarkan AKI FAO/WHO 2001 yaitu 200 ug/hari Batas aman iodium untuk wanita dewasa adalah 1100 ug/hari Batas aman untuk BUMIL adalah 900 ug/hari

37 ESTIMASI AK-I IBU HAMIL Kelompok RDA Wanita dewasa (Ug/hari)150 Wanita hamil (Ug/hari) Trimester Trimester Trimester 3 +50

38 J. Other nutrients : 1. Zinc – an extra intake of 3 mg/day or a daily intake of 12 mg is recommended for normal fetal growth and development. Zinc is important in protein, RNA, and DNA synthesis and in cell division and differentiation.

39 ESTIMASI AK-Zn IBU HAMIL Kelompok RDA Wanita dewasa (mg/hari)9,8 Wanita hamil (mg/hari) Trimester 1 + 1,211,0 Trimester 2 + 4,114,0 Trimester ,220,0

40 J. Other nutrients : 2. Sodium – the increase in extra cellular fluids calls for an increase in body sodium, thus, restriction of sodium intake is not recommended as a routine procedure. Sodium restriction stresses the renin-angiotensin - aldosterone mechanism in order to maintain homeostasis. The additional needs in pregnancy is 69 mg/day.

41 Table Increase in Recommended Dietary Allowances to meet needs of pregnancy Nutrients1 st trimester2 nd trimester3 rd trimester Energy, kcal Protein, kcal17 Vitamin A, RE25 Vitamin C, mg10 Thiamin, mg00.3 Riboflavin00.6 Niacin, NE033 Folate, µg200 Calcium, mg400 Iron, mg41** Iodine, µg25 * FNRI ** Cannot be met by the usual diet, thus, supplementation is recommended.

42 Tabel. Angka Kecukupan Gizi Wanita Hamil *(or./hr) Zat GiziTidak Hamil Hamil (+an zat gizi) Hamil (total kecuk. Zat gizi) Tr 1Tr 2Tr 3 Tr 1 Tr 2 Tr 3 Energi (kkal) Protein (g) Karbohidrat (g) Serat Makanan (g) Vit. A (RE) Vit. D (ug) Vit. E (mg) Vit K (ug) Tiamin (mg) Riboflavin (mg) Niasin (mg) Asam Folat (ug) Piridoksin (mg) Vit. B12 (ug) Vit C (mg)) ,0 1, ,3 2, , ,4 +0, , ,4 +0, , ,4 +0, ,3 1, ,7 2, ,3 1, ,7 2, ,3 1, ,7 2,6 85

43 Tabel. Angka Kecukupan Gizi Wanita Hamil *(or./hr) Zat GiziTidak Hamil Hamil (+an zat gizi) Hamil (total kecuk. Zat gizi) Tr 1Tr 2Tr 3 Tr 1 Tr 2 Tr 3 Kalsium (mg) Fosfor (mg) Magnesium (mg) Fluor (mg) Besi (mg) Iodium (ug) Seng (mg) Mangan (mg) Selenium (ug) AIR (Ltr) Natrium (mg) Klor (mg) Kalium (mg) , ,3 1,8 30 2, , ,7 + 0, , ,2 + 0, , ,2 + 0, , , , , , , , ,

44 Umur ibu hamil : th; Berat Badan : 52 kg ( Sumber: Widya Karya Nasional Pangan dan Gizi - WKNPG, 2004) Untuk memenuhi kebutuhan dengan meningkatnya aktifitas fisiologis ibu hamil, serta pertumbuhan dan perkembangan janin, diperlukan penyesuaian2 terhadap kebutuhan energi dan zat2 gizinya! Terdapat peningkatan kebutuhan akan Energi dan zat2 gizi (Tabel Angka Kecukupan Zat Gizi Untuk Wanita Hamil) (WKNPG, 2004) ! Angka Kecukupan Gizi yang dianjurkan tersebut adalah untuk ibu yang sebelum hamil kondisinya sehat, bukan yang mengalami kurang gizi !

45 KECUKUPAN : Requirement = kebutuhan Estimated Average Requirement = EAR Reference Nutrient Intake = RNI Recommended Dietary Allowances = RDA Angka Kecukupan Gizi - AKG

46 A. First trimester – mild nausea and vomiting due to excessive hormone production. B. Loss of appetite – remedied by giving high CHO foods like cracker, jelly, and dry toast before arising. Fluids should be taken between meals. C. Pica – abnormal craving for food not fit for eating. D. Constipation – give plenty of fruits and vegetables and adequate fluid intake. E. Overweight/Obesity – excessive weight gain increases the incidence of toxemia and eclampsia. F. Anemia – increase food rich in iron and take iron supplement. G. Toxemia of Pregnancy – characterized by high blood pressure, albuminuria, and rapid weight gain due to edema. Low sodium, high protein diet is recommended. IV. COMPLICATION OF PREGNANCY/PROBABLE PROBLEM

47 A. Age Critical age for pregnancy is below 15 years old and over 35 years. Mother who are between 20 and 29 years of age have the best outcome or pregnancy. B. Parity First pregnancy often complicated by toxemia and by problem of labor and delivery. C.Past obstetrical performance D.Race E. Social class as determined by income, occupation and education V. FACTORS AFFECTING PREGNANCY

48 F. Smoking It limit fetal development due to decreased food intake of the mother and the effects of carbon monoxide and nicotine. G. Alcohol Excessive alcohol consumption result to fetal alcohol syndrome (with malformation : physical and mental). H. Heavy meals such as lead and mercury This will result to brain damage.

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50 VI. IMPACT OF NUTRIENT DEFICIENCY

51 Kurang Energi Kronis (KEK): Ibu hamil yang menderita KEK akan menghambat pertumbuhan janin sehingga akan menimbulkan resiko pada bayi dengan Berat Badan Lahir Rendah (BBLR) Defisiensi Energi

52 Kurang Energi Protein (KEP): Ibu hamil yang menderita KEP akan menghambat pertumbuhan janin sehingga akan menimbulkan resiko pada bayi dengan Berat Badan Lahir Rendah (BBLR) Defisiensi Protein

53 Kurang Vitamin A (KVA): Vitamin A berperanan penting dalam : Pembelahan dan pertumbuhan sel mukosa Metabolisme besi, terutama dalam P enggunaan kembali simpanan besi dalam Hati (turnover besi) Defisiensi : Menyebabkan keguguran dan BBLR Defisiensi Vitamin A

54 Asam folat bagian penting sel darah merah Sebagai ko-enzim dalam metabolisme beberapa asam amino Dampak defisiensi asam folat : - gangguan pembelahan dan pertumbuhan sel dan/atau plasenta - timbulnya anemia megaloblastik - defisiensi pada bulan-bulan pertama kehamilan menyebabkan gangguan sistem syaraf fetus DEFISIENSI ASAM FOLAT

55 KALSIUM: - Berperan pada pembentukan tulang dan gigi. - Defisiensi Kalsium pada BUMIL menyebabkan : demineralisasi (pengambilan kalsium pada tulang dan gigi) beresiko terjadinya osteoporosis. menurunnya kinerja fisik, menurunnya daya tahan tubuh Defisiensi Kalsium

56 ANEMIA GIZI BESI ( Kurang Gizi Besi, KGB): Anemia karena rendahnya konsumsi makanan sumber zat besi (termasuk pangan hewani, sumber heme-iron) Dapat dikoreksi melalui pemberian/supplementasi tablet besi-folat (min 90 tablet selama hamil) Prevalensinya cukup tinggi (51%) Dampak anemia : - Menurunnya kemampuan aktivitas fisik (letih, lesu) dan produktivitas - Pendarahan (hemorrhage), pre-eclampsia pada ibu - Kematian ibu pada saat post-partum - Hambatan pertumbuhan fetus dgn segala konsekuensinya - Kegagalan pertumbuhan dan perkembangan fisik anak - Anemia pada awal kehamilan  kerusakan otak fetus secara permanen - Meningkatnya kematian prenatal dan perinatal

57 BESI Kurang Darah (KD) Ibu hamil yang menderita KD akan menghambat pertumbuhan janin sehingga akan menimbulkan resiko pada bayi dengan Berat Badan Lahir Rendah (BBLR), juga beresiko mengalami pendarahan sebelum atau pada saat persalinan yang dapat menyebabkan kematian ibu dan bayi

58 Gangguan Akibat Kurang Iodium (GAKI): Dampak defisiensi : Retardasi mental pada bayi yang dilahirkan, Abnormalitas kognitif : bisu, tuli, dsb Keguguran, karena iodium berperan penting dalam fertilitas Defisiensi IODIUM

59 DEFISIENSI ZINK Zink berperan dalam pembelahan sel dan sintesa protein Dampak defisiensi : - Gangguan pertumbuhan jaringan - Pendarahan selama dan setelah kehamilan - Tekanan darah tinggi - Gangguan pertumbuhan fetus - Keguguran dan kematian perinatal

60 VII. PROGRAM PENANGGULANGAN MASALAH GIZI SELAMA KEHAMILAN Suplementasi tablet besi-folat, (kadar besi 60 mg, asam folat 250 ug), dikonsumsi minimal 90 tablet selama kehamilan PMT bagi ibu hamil (pemberian makanan tambahan kudapan atau makanan biasa dengan komposisi energi Kcal dan protein gram selama 90 hari makan) sasaran keluarga miskin program JPS-BK untuk mengatasi masalah KEK Pemantauan status gizi dan kesehatan melalui pemeriksaan di Posyandu atau Polindes dengan menggunakan KMS Ibu Hamil

61 Susunan menu ditentukan : - Kuantitas makanan - Kualitas makanan Saat BUMIL terjadi peningkatan kebutuhan zat gizi untuk itu diperlukan tambahan zat gizi seperti karbohidrat, lemak, protein, vitamin dan mineral. Mengkonsumsi makanan beragam berarti kekurangan zat gizi pada jenis makanan yang satu akan dilengkapi olek jenis makanan lainnya. VIII. PENYUSUNAN MENU IBU HAMIL

62 MENU SEIMBANG: Berdasarkan AKG perorang per hari yang disederhanakan dalam bentuk bahan makanan dengan memakai ukuran rumah tangga, dengan mengkonsumsi makanan tersebut diperhitungkan kebutuhan gizi BUMIL dapat tercukupi.

63 Susunan menu terdiri dari : - Makanan pokok Terdiri dari nasi, nasi jagung, tiwul, nasi tiwul, umbi-umbian. Makan pokok memberi rasa kenyang. - Lauk Terdiri dari daging, ikan, kacang-kacangan. Lauk memberikan rasa nikmat - Sayur dan buah

64 Langkah-langkah menyusun menu cara sederhana

65 Pedoman Menu Sehari-hari menurut Kelompok Umur dan Jenis Kelamin NoKel. Umur Mkn pokok LaukPaukSayurBuahKudapanSusu (pm)(pl)(Pp)(Ps)(Pb)(pk) 1.Anak-anak Pria Remaja Sumber : Depkes (1995)

66 Pedoman Menu Sehari-hari menurut Kelompok Umur dan Jenis Kelamin NoKel. Umur Mkn pokok LaukPaukSayurBuahKudapanSusu (pm)(pl)(Pp)(Ps)(Pb)(pk) 3.Wanita Remaja Pria Dewasa >= Wanita Dewasa >=

67 Pedoman Menu Sehari-hari menurut Kelompok Umur dan Jenis Kelamin NoKel. Umur Mkn pokok LaukPaukSayurBuahKudapanSusu (pm)(pl)(Pp)(Ps)(Pb)(pk) 6.Wanita Hamil Wanita Menyusui

68 Keterangan : 1 Pm = 1 Porsi makanan pokok = 100g beras = 200g nasi 1 Pl = 1 Porsi lauk (daging, ikan atau telur) = 50g 1 Pp = 1 Porsi pauk (tempe, tahu dan hasil olahan) = 50g 1 Pb = 1 Porsi buah =100g 1 Ps = 1 Porsi sayuran 1 Pk = 1 porsi kudapan 1 Pu = 1 gls susu = 200g Untuk dewasa dan remaja ditambah 3 sdm gula dan 4 sdm minyak goreng Untuk anak-anak: * 1-3 tahun: 2 sdm gula & 2 sdm minyak goreng * 4-6 tahun: 3 sdm gula & 2 sdm minyak goreng * 7-12 tahun: 3 sdm gula & 3 sdm minyak goreng 1 sdm gula = 10 gram & 1 sdm minyak = 10 gram)

69 SUSUNAN MENU IBU HAMIL: Nasi/pengganti 5-6piring 600 g Lauk hewani 4-5potong 200 g Lauk nabati 3-4potong 150 g Sayuran 2-3mangkok Buah-buahan 3potong 300 g Kudapan 1 porsi Susu 1gelas 200 g Air Minum lainnya 6-8 gelas

70 Pesan Dasar Menuju Hidup Sehat Bagi Ibu Hamil Makanlah Aneka Ragam Makanan Makanlah lebih banyak dan sering dari biasanya Gunakan Garam beryodium Makanlah makanan sumber zat besi Biasakan Makan Pagi Minumlah air bersih, aman dan cukup jumlahnya Lakukan kegiatan fisik dan olahraga secara teratur Hindari rokok dan minuman beralkohol