ISHRANA I TRUDNOĆA. Dr Barbara Damnjanović Pažin
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1 ISHRANA I TRUDNOĆA Dr Barbara Damnjanović Pažin
2 TRUDNOĆA 280 dana, 40 nedelja, 10 lunarnih meseci Negelovo pravilo: VTP=PM+7dana 3 meseca Posteljica conditio sine qua non Embrionalni period Fetalni period Porodjaj: Preterminski < 37+0 ng Terminski, ng Posterminski, > 42+0 ng Anatomske i funkcionalne promene na genitalnim organima i dojkama PROMENE URINARNOG TRAKTA Vol bubrega za 30% Dilatacija sabirnog sist. duzina uretre i intrauretralni P zatvaranja za 20% protoka za % glomerularna filtracija za 50% retencija Na, K ekskrecije Ca, glukoze mokracne kis. i nekih ak. totalnog sadrzaja vode, 6-7l u ekstracelijskom i 2l u intracel. prostoru PROMENE RESPIRATORNOG SISTEMA umereno funkcionalnog rezidualnog kapaciteta disajnog Vol. za 40% hiperventilacija i hipokapnija minutnog resp. Vol. za 30-50% I potrosnja O2 za 20-40% ADAPTACIJA ORGANIZMA NA NA TRUDNOCU TRUDNOĆU PROMENE KARDIOVASKULARNOG SISTEMA Vol. plazme (45%), eritropoeza, Rbc (20-30%), fizioloska hemodilucija anatomske promene (hipertrofija glatkih m., razmeksanje kolagena) funkcionalne promene ( udarni Vol %, sistemski vaskularni otpor i krvni pritisak protoka kroz matericu sa 2% na 17%, tj ml/min., bubrege, dojke i kozu)
3 Position statement of the Academy of Nutrition and Dietetics: Nutrition and Lifestile for a Healthy Pregnancy Outcome Women of childbearing age should adopt a lifestile optimizing health and reducing risk of birth defects, suboptimal fetal development, and chronic health problems in both mother and child. Components leading to healthy pregnancy outcome include: healthy pregnancy weight appropriate weight gain physical activity during pregnancy consumption of a wide variety of foods appropriate vitamin and mineral supplementation avoidance of alcohol and harmful substances safe food handling
4 German National Consensus Recommendations on Nutrition and Lifestile in Pregnancy Misliti na dvoje, ali ne jesti za dvoje Energetske potrebe rastu samo za 10% I to u III trimestru Značajno se menjaju nutritivne potrebe Rastu potrebe za pojedinim vitaminima i mineralima PaŽnju obratiti na kvalitet, a ne na kvantitet ishrane!!!
5 TELESNA MASA I NUTRITIVNI STATUS PRE TRUDNOĆE Prekoncepcioni nutritivni i metabolički status BMI i stepen gojaznosti pre trudnoće, imaju veći uticaj na perinatalni ishod od prirasta težine u toku trudnoce (GWG*) 1) Pothranjene rizik za prevremeni porodjaj i radjanje dece male za gestacijsku dob (SGA*) radjanje dece prevelike za gestacijsku dob, carski rez, preeklamspija 2) Gojazne rizik za spontani pobacaj, prevremeni porodjaj (klasa III) kongenitalne anomalije, gestacijski dijabetes, intrauterinu smrt ploda, hipertenziju u trudnoci, carski rez, neuspešan vaginalni porodjaj posle carskog reza, TEB, postoperativne komplikacije i maternalni mortalitet rizik od IUGR* i SGA* Klasa gojaznosti BMI I 30-34,9 *GWG=Gestational weight gain; SGA=Small for gestational age; IUGR=Intrauterine growth restriction II 35-39,9 III 40
6 PRIRAST TELESNE MASE U TRUDNOĆI (GWG) Neadekvatan i ekscesivan prirast tezine u trudnoći, smatra se važnim faktorom za gojaznost u detinjstvu, a takodje i gojaznost u odraslom dobu i kardiometabolicke bolesti From Institute of Medicine: Weight gain during pregnancy: reexamining the guidelines, Washington, DC, National Academies Press, Posted online, May 28, Prepregnancy Weght Status SINGLETON PREGNANCY Underweight (BMI<18.5) Normal weight (BMI = ) Overweight (BMI = ) Obese (BMI 30) TWIN PREGNANCY Underweight Normal weight Overweight Obese Recommended Weight Gain (kg) Isuffiicient data
7 PRIRAST TELESNE MASE U TRUDNOĆI (GWG) EKSCESIVAN PRIRASTIRAST Carski rez Odrzanje povećane težine posle porodjaja Radjanje dece velike telesne mase za starost trudnoće Prevremeni porodjaj NIZAK PRIRAST Radjanje dece niske telesne mase za starost trudnoće Prevremeni porodjaj
8 Makronutritienti i trudnoća 1) Ugljeni hidrati: 45-65% 6-9 porcija žitarica celog zrna (Vit. B, vlakna, minerali) 7 porcija voća i povrća (vlakna, folna kis., Vit., antioksidansi ) 2) Proteini: 60 g/dan Meso niskog sadržaja masti, živina (bez kozice), riba, mahunarke, koštunjavo voće, jaja, tofu min. 4 porcije mlečnih proizvoda niskog % mm, (Ca, Vit. A, D i B) 3) Masti: 20-35% Polinezasićene mk. (DHA=dokozaheksaenska kis) Primeri kvalitetnih izvora makronutritienata 1) 1 porcija = parče hleba ili ½ cup kuvanog pirinča, testenine ili dr. žitarica = 1 srednja jabuka ili banana = 1 cup svežeg lisnatog povrća ili ½ cup druge vrste povrća (kuvanog ili svezeg) 2) 1 porcija = 55-85g ribe ili mesa niskog sadržaja masti, kuvanog, dinstanog, pečenog na grilu ili u rerni = ½ cup tofu ili kuvanih mahunarki = 1 jaje = 1/3 cup koštunjavog voća = 2 kk kikiriki putera = šolja surutke, mleka, kis. mleka, jogurta 3) Dobri izvori masti riba, koštunjavo voće i biljna ulja (maslinovo )
9 DHA DOKOZAHEKSAENSKA KISELINA Omega-3 masna kiselina Esencijalna za razvoj mozga i očiju kod ploda i odojčeta Epidemioloske studije su pokazale manju učestalost prevremenog porodjaja, male težine na rodjenju i preeklampsije, kod onih grupa koje u ishrani koriste veće količine ribe Preporuke = 200 mg/dan OPREZ!!! Ukoliko je izvor riblje ulje ili riba, treba voditi računa o izboru vrste ribe, jer pojedine imaju visok sadržaj žive (ajkula, sabljarka, skusa, velika tuna)
10 DIJETETSKE PREPORUKE U TRUDNOĆI German recommendations vs. The MYPLATE food plan Nemačke preporuke DODATNE ENERGETSKE POTREBE U III TRIMESTRU (~10%): Parče hleba od celog zrna+list sira (45%mm)+paradajz = ~ 260 Kcal 1 porcija jogurta (1,5%mm)+šaka bobičastog voća+žitarice celog zrna = ~ 210 Kcal tanjir supe od povrća sa rezancima = ~ 250 Kcal TANJIR: 50% VOĆE I/ILI POVRĆE 20% IZVOR PROTEINA NISKOG SADRŽAJA MASTI 25% ŽITARICE CELOG ZRNA OBROCI: 3 MANJA OBROKA 2-3 UŽINE * Svaki sa izvorom proteina niskog sadržaja masti Američke preporuke DODATNE E-POTREBE U II TRIMESTRU (~340Kcal): 1 srednja banana+ 1 1/2 kk kikiriki putera+230ml mleka niskog %mm U III TRIMESTRU (~450Kcal): 340 ml voćnog frapea (voće, sok, jogurt niskog %mm)+2 kk trail mix
11 Mikronutritienti i trudnoća : VITAMINI MINERALI Folati Vit. D Vit. B grupe Niacin Vit. E Vit. C Pantotenska kis. Gvoždje Jod Kalcijum
12 MIKRONUTRITIENTI OD POSEBNOG ZNAČAJA Folati i folna kiselina -siteza nukleinskih kiselina, crvenih krvnih zrnaca, rast ploda I posteljice - Deficit moze uzrokovati: 1. NTD 2. Prevremeni porodjaj Suplementacija prekoncepciono i min. u I trimestru 400 mikrograma/dan Kalcijum - metabolizam kostiju - za optimalno delovanje + Vit. D + Mg - suplementacija u trudnoći: 1. rizik od PE 2. rizik od prevremenog porodjaja 3. Protektivno za intoksikaciju ploda olovom Jod 220 mikrog/dan (supl. ~ mikrog) - Povećane potrebe - Deficit tezeg stepena moze dovesti kod ploda/deteta, do teških ostećenja: 1. Kognitivnih i 2. Motornih funkcija Gvozdje -Hgb, transport kiseonika - Deficit moze dovesti do: 1. Prevremenog porodjaja 2. Radjanja dece male telesne mase - Preporuke variraju, max mg/dan - Vit. C pospešuje apsorpciju - Kafa, čaj, mleko i Ca inhibiraju apsorpciju
13 Vulnerable Vitamins & Minerals The vitamins and minerals where the risk of deficiency is most likely are: What & how much you need per day Folic Acid 400mcg supplement plus 300mcg from food. 3 4 women fail to eat enough from diet and over half do not take a folic acid supplement prior to confirmation of pregnancy. Role in pregnancy Particular concerns/times Rich sources Contributes to maternal tissue growth during pregnancy. Taking the correct amount can reduce the risk of having a baby with Spina Bifida by 40%. Women should take a 400mcg folic acid supplement from the time contraception stops and until at least the twelfth week of pregnancy and also choose foods rich in folates. Women with multiple pregnancies history of neural tube defects should double the dose. or with a previous Black eye beans, brussels sprouts, beef or yeast extract, kidney, kale, spinach, spring greens, granary bread, broccoli and green beans. Also added to some soft grain breads and breakfast cereals. Vitamin D 10 mcg Up to 100% of women fail to consume sufficient amounts from their diets. Contributes to normal absorption/utilisation of calcium. All pregnant and breastfeeding women in the UK should take a 10mcg vitamin D supplement daily. Main source is sunlight. Also found in oily types of fish, eggs and full fat dairy products. Also added to margarines, some yoghurts and breakfast cereals. Iron 14.8mg 8 out of 10 women eat too little. 2 in 5 women enter pregnancy iron deficient. Contributes to normal formation of red blood cells and haemoglobin. Anaemia is common during pregnancy affecting both the mother s and baby s wellbeing. All meat, especially red meat, fortified breakfast cereals and white bread, beans, chick peas, baked beans, eggs, dried fruit, nuts and seeds. Calcium 700mg 1 in 2 women eat too little. Calcium is needed for the maintenance of normal bone and teeth. Most of the baby s calcium is laid down in bones during the 3rd trimester. Milk, cheeses, yoghurt, fortified soya milk and soya products, canned fish e.g. pilchards and sardines, added to white bread, beans and baked beans, almonds and hard tap water. For many women intakes of magnesium, zinc, iodine, copper & potassium are also below ideal levels. 8
14 VEGETARIJANCI OVOLAKTO-VEGETARIJANCI Zadovoljavaju unos većine nutritienata (jaja i mlečni proizvodi) Potrebno suplementirati: Vit. D Folna kis. Fe Jod +/- Vit B12 Zn DHA (ukoliko ne jedu ribu i morske plodove) VEGANI Nezadovoljavajć unos nutritienata Vit. B12 hronični deficit teško i trajno oštećenje nervnog sistema deteta Savetovanje sa nutricionistom Neophodna suplementacija!!!
15 TEČNOST Ukupan unos = 3l/dan (ili 35ml/kg TM) Samo tečnošću = 2,3l/dan Minimalno 1,5l/dan Kafa i čaj restriktivno, zbog poluživota kofeina sa straošću trudnoće (npr. u I trim oko 3h, u III trim h) ACOG kofein do max. 200mg/dan ~ 340ml skuvane kafe
16 FIZIČKA AKTIVNOST Aktivnost je preporučljiva i povoljno utiče na zdravlje trudnice i ploda Uobičajena dnevna aktivnost, lake vezbe (gimnastika) i šetnja Sportistkinje NE TREBA da upražnjavaju fizičku aktivnost visokog intenziteta, kao ni onu vrstu sporta koja može dovesti do povrede (grupni sportovi, skokovi, ronjenje, alpsko skijanje ) Trening treba da bude UMERENOG intenziteta ( Talk test ) Preporučuju se individualni sportovi koji angažuju velike mišićne grupe (plivanje, aerobik u vodi, biciklizam u drugom trimestru, nordijsko skijanje) i na nadmorskoj visini ne većoj od m PREPORUKE: 150 MINUTA UMERENE AEROBNE AKTIVNOSTI NEDELJNO (CDC) MINIMUM 30 MIN. VEŽBANJA UMERENOG INTENZITETA DNEVNO,,min. 5 dana nedeljno (ACOG)
17 HVALA NA PAŽNJI!
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