Special Nutrition for Vegetarian Pregnancy

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Lately, vegetarian diets are increasingly popular in the community. There are various considerations why vegetarians choose this type of diet, whether it be an ecological, philosophical, religious, or just want a healthier lifestyle. There are different types of vegetarian diets of most restrictive to the most flexible, but according to the American Dietetic Association (2009), 2 vegetarian definitions most commonly used in the research are:

Vegan : a diet that prohibit consumptions of any foods from animals origin

Vegetarian : does not consume foods of animal origin except eggs (ovo) and dairy (lacto)

 
Vegetarian diets are often associated with a number of health benefits, including reducing blood cholesterol levels, the risk of heart disease, hypertension, cancer and type 2 diabetes. Vegetarians also tend to have a lower body mass index (BMI). Vegetarian diets tend to be low in saturated fat and cholesterol, and higher levels of dietary fiber, magnesium, potassium, vitamins C and E, folate, carotenoids, flavonoids and other phytochemicals. Differences in these nutrients might explain some of the health benefits of the vegetarian who has a varied and balanced diet. However, vegans and some other vegetarians may have a low intake of vitamin B12, calcium, vitamin D, zinc, and omega 3 long chain fatty acids. Vegetarians should pay particular attention to ensure they get sufficient amounts of calcium, iron, zinc, vitamin B12 and vitamin D (Mahan and Stump, 2004).

Especially for vegetarian pregnant women, the American Dietetic Association (2009) has summarized the research literature on evidence-analysis was used to evaluate a variety of studies on the (www.adaevidencelibrary.com). Nutritional and energy needs of pregnant women vegetarians and non-vegetarians really no different, except the higher iron needed for vegetarians. Here’s the review:

1. Energy & macronutrients consumption
There are 4 primary research studies that examine the macronutrient intake of pregnant women or lacto-ovo vegetarian. In the limited research on non-US populations indicates that the macronutrient intake in pregnant women pregnant vegetarians alike with non-vegetarian with some of the following exceptions (as a percentage of energy consumption):
– Pregnant women receiving protein vegetarian statistically lower than non-vegetarian expectant mothers
– In contrast, vegetarian pregnant women obtain carbohydrates that are statistically higher than non-vegetarian pregnant women.
However, no research has reported a significant difference between macronutrient intake of pregnant women vegetarian and non-vegetarian, nor is there a protein deficiency in pregnant women vegetarian. As for pregnant women vegan, there has been no research that focuses on macronutrients consumption.

2. The condition of newborn babies
The study is limited to the population of non-US shows that there is no significant difference between the health of newborn babies from non-vegan vegetarians and non-vegetarians mothers. However, none of the studies focused on pregnant vegans.

3. Micronutrients consumption
Based on 10 studies (2 of them performed in the US) , only a few micronutrient consumptions are lower in vegetarians than non-vegetarians , namely vitamin B12, vitamin C, calcium and zinc . The vegetarian diet also does not meet the standards for the following micronutrients in most countries studied:
– Vitamin B12 (di UK)
– Iron (in US, for both vegetarians & omnivores)
– Folate (di Germany)
– Zinc (in UK)

4. Micronutrients bioavailability
Of the 6 studies that tested the bioavailability of various micronutrients in pregnant women vegetarian vs. non-vegetarian, only serum vitamin B12 were significantly lower in non-vegan-vegetarian than non-vegetarians. One study reported that low serum vitamin B12 possibly due to high serum total homocysteine in lacto-ovo vegetarian compared to omnivores. Whereas zinc levels did not differ significantly between non-vegan-vegetarian and non-vegetarian. Vegetarians who have a high intake of calcium may be at risk for zinc deficiency (due to the interaction between phytate, calcium, and zinc). Based on limited evidence, plasma folate levels may actually be higher among some vegetarian groups than non-vegetarian.

5. Micronutrients & birth results
Limited evidence from 7 studies (outside the US) indicates that the micronutrient content of a balanced vegetarian diet during pregnancy does not harm the health of the born babies. However, there is a possible risk of a false positive diagnosis of Down Syndrome in the fetus if serum free β-HCG and α-fetoprotein levels in pregnant women is used as an indicator for the vegetarians.

6. Nutrients consideration
Results of the analysis indicated that the evidence-based vegetarian diet produces adequate nutrition and a positive effect on fertility. These key nutrients for pregnancy , including vitamin B12 , vitamin D , iron , and folate , while breastfeeding , including vitamin B12 , vitamin D , calcium and zinc. The following is a discussion of some important nutrients on a vegetarian pregnant women:
– Protein
Protein is one of the main macronutrient energy contributor. Milk and eggs are good sources of protein for lacto-ovo vegetarians. As for vegans, can meet the daily needs of the vegetable protein if the source is varied (such as cereals and beans) and sufficient total energy. Most vegetarians can meet or exceed the daily requirement of protein, but the protein content in their diets tend to be lower than omnivores. Lower protein intake generally cause daily fat intake is also low due to the high protein animal food is also rich in fat. Although vegetarians tend to consume less protein than non-vegetarians, total consumption generally meet the needs of RDA per day ( Emery & Sanders , 2002).
– Vitamin B12
Vitamin B12 is only contained in food animal products so that might be a problem for vegans. Diet for pregnant and lactating vegetarians should contain sufficient sources of vitamin B12 daily needs, so we need vitamin B12 fortified foods such as breakfast cereals, soy milk or vitamin B12 supplementation.
– Vitamin D
Vitamin D is essential for bone health. Both types of vitamin D (D2 and D3) are used in supplements and food fortification. Vitamin D3 (cholecalciferol) is derived from animal food and may be obtained through ultraviolet irradiation of 7-dehydrocholesterol from lanolin, whereas vitamin D2 (ergocalciferol) is produced from the ultraviolet irradiation of ergosterol from yeast and can be consumed by vegans. Although some studies show that vitamin D2 is less effective than vitamin D3 in maintaining serum 25-hydroxyvitamin D, other studies found that both are equally effective. Based on recommendations for pregnancy and breastfeeding, if there is concern about the synthesis of vitamin D because exposure to sunlight is limited, color, season, or sunscreen use, pregnant and lactating women should use vitamin D supplements or foods fortified with vitamin D (eg: milk cow, soy milk, rice milk, orange juice, breakfast cereals and margarine). There are no specific studies that tested the vitamin D status of pregnant women vegetarian.
– Iron
Generally, vegetarian diets tend to be low in iron than omnivorous diet, although iron non-heme contained in fruits, vegetables and cereals can generally be assisted high content of ascorbic acid (Vitamin C) for the assimilation of iron contained therein. Because the bioavailability of non-heme iron in a vegetarian diet that is lower than heme iron that comes from animal foods, the recommended iron intake for vegetarians is 1.8 times more than non-vegetarians (Institute of Medicine, 2001). Iron supplementation may also be required to prevent and treat iron deficiency anemia, which is common during pregnancy.
– Folate
Folate or vitamin B9 is essential to prevent spina bifida (neural tube defects) in the baby and needed early in pregnancy for normal neural tube development. Research has shown that women who had babies with spina bifida have folate intake and lower blood folate levels than other women. Many vegan foods are good sources of folate include folate fortified bread, pasta, cereals, dried beans, green leafy vegetables and orange juice. Women who are planning a pregnancy or in the pre-conception period are advised to consume 400 mcg of folate daily from supplements (folic acid), folate fortified foods, or both.
– Zinc
Zinc bioavailability in vegetarian diets tend to be lower than a non-vegetarian diet, mainly due to high content of phytic acid on a vegetarian diet. Zinc source for vegetarians can be obtained through soy products, nuts, seeds and cheese or via supplementation.
– Calcium
Calcium along with vitamin D is important for bone health and is necessary for the development of the baby’s bones and teeth. Calcium intake in lacto-ovo vegetarian more or less the same or even higher than omnivores because they consume dairy products. However, vegan that does not consume any dairy products most probably have less calcium intake, thus requiring additional supplementation of calcium or calcium fortified foods to meet daily calcium needs. Green vegetables are low in oxalate (such as broccoli, bok choy, Chinese cabbage, mustard greens, kale) and fruit juices fortified with calcium citrate malate are also a good source of calcium with high bioavailability.
– Omega 3 Fatty Acids
Although a vegetarian diet rich in omega-6 fatty acids, but the content of omega-3 fatty acids (such as EPA and DHA) was limited. Vegetarians (especially vegans) tend to have high levels of EPA and DHA were lower in the blood. Though DHA plays an important role in pregnancy and lactation. Infants of vegetarian mothers tend to have a shorter umbilical cord and plasma DHA were lower than infants of non-vegetarians. DHA contained in breast milk in vegan and lacto-ovo-vegetarians also lower than non-vegetarians. Because of the beneficial effects of DHA on the length of pregnancy, visual function baby, and neural development, pregnant women and lactating vegetarians and vegans should choose food sources of DHA such as flaxseed, walnuts, canola oil, soybeans, fortified foods DHA (such as eggs of chickens feed by DHA-rich microalgae for lacto-ovo vegetarians) or using DHA supplements derived from microalgae. While supplementation with ALA (precursor DHA) in pregnancy and lactation has not been proven effective in increasing infant DHA levels or breast milk DHA concentration.

In Indonesia, already established an RDA-Recommended Daily Allowance (AKG 2013) in detail for every age and stage in life (including pregnancy) in the Ministry of Health Regulation (Permenkes RI No. 75/ 2013). Based on this, here is the details of macronutrients and micronutrients that are needed more during pregnancy:

 

Nutrient

Unit

AKG 2013

 

 

Trimester 1

Trimester 2

Trimester 3

Energy kcal

+180

+300

+300

Protein g

+20

+20

+20

Fat g

+6

+10

+10

Omega 6 g

+2

+2

+2

Omega 3 g

+0.3

+0.3

+0.3

Carbohydrate g

+25

+40

+40

Fiber g

+3

+4

+4

Water ml

+300

+300

+300

Vitamin A mcg

+300

+300

+350

Vitamin B1 mg

+0.3

+0.3

+0.3

Vitamin B2 mg

+0.3

+0.3

+0.3

Vitamin B3 mg

+4

+4

+4

Vitamin B5 mg

+1

+1

+1

Vitamin B6 mg

+0.4

+0.4

+0.4

Folate mcg

+200

+200

+200

Vitamin B12 mcg

+0.2

+0.2

+0.2

Choline mg

+25

+25

+25

Vitamin C mg

+10

+10

+10

Calcium mg

+200

+200

+200

Magnesium mg

+40

+40

+40

Manganese mg

+0.2

+0.2

+0.2

Copper mcg

+100

+100

+100

Chromium mcg

+5

+5

+5

Iron mg

+0

+9

+13

Iodine mcg

+70

+70

+70

Zinc mcg

+2

+4

+10

Selenium mcg

+5

+5

+5

Basically, a planned vegetarian diet is safe enough for every stage in life, including pregnancy. Besides guided by Indonesian’s RDA 2013 (Permenkes No. 75/2013) as detailed previously, the vegetarian pregnant women can also use a healthy diet guidelines for vegetarians reported by the American Dietetic Association (2009) as follows:

–  Select the type of food that is varied, including cereals, vegetables, fruits, nuts, grains, and dairy products and eggs ( for lacto-ovo vegetarians )

–  Minimize consumption of food high in sugar, sodium, fat, especially saturated fat and trans fat.

–  If you consume animal products such as dairy products and eggs, choose low-fat and moderate consumption.

–  Use of vitamin B12 supplements on a regular basis and if rarely exposed to sunlight exposure, also consume vitamin D supplements

 

References:

American Dietetic Association: Position of American Dietetic Association: vegetarian diets, J Am Diet Assoc. 2009;109: 1266-1282

Emery, P., Sanders, T. 2002. Molecular Basis of Human Nutrition. Taylor & Francis Ltd. p. 32. ISBN 978-0-7484-0753-8

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academies Press; 2001.

Mahan, K. & Stump, S.E. 2004. Krause’s Food, Nutrition & Diet Therapy. 11th Edition. USA: Elsevier.

Peraturan Menteri Kesehatan RI No. 75 tahun 2013 Tentang Angka Kecukupan Gizi yang Dianjurkan Bagi Bangsa Indonesia.

Vegetarian Nutrition in Pregnancy. American Dietetic Association Evidence Analysis Library Web site. http://www.adaevidencelibrary.com/ topic.cfm?cat3125.

Zulkarnain, M. R. Energi dan Gizi untuk Bumil Vegetarian. Food for Kids Indonesia, February 2016 edition (p.31-38).