Eating for two: Diet in pregnancy

"You're pregnant, beta! You need to eat for two now!"

"Doctor, she isn't eating as much as she should. I've been force- feeding her ghee and almonds. After all, we want a brilliant child!"

"I know I've loose motions, doctor. But I couldn't help having the roadside pani puri! It was just too tasty!"

"I was so lean before my pregnancy. And now I just can't seem to get rid of my excess weight!"

"My mother isn't allowing me to walk because I'm pregnant. I'm getting really bored with the relentless bed rest!"

Familiar situations?

Pregnancy cravings, a stupendous weight gain, 'eating for two', myths and misconceptions about what one should and shouldn't eat while pregnant- are all common questions women get to me during consultations. It is important to understand basic nutrition in pregnancy, so as to be better equipped to deal with the do's and don'ts.

How much weight should one ideally gain in pregnancy?

There's no magic number to answer this question, because the ideal weight gain is different for each pregnant mother. It depends on a lot of factors such as your age, your pre- pregnancy body weight (or BMI), your activity level, any other comorbid conditions like diabetes, high blood pressure that you may be having, and your overall nutritional state. Remember always, that 'if I gain more weight, my baby will be healthier', is a myth!

When you are around 1 1/2 months pregnant, your baby is around the size of a pea. At 5 months, your baby weighs around 300 grams, At 7 months, it weighs around 1.2- 1.5 kilos, and at term, the average Indian baby weighs between 2.5- 3.5 kilos. The placenta weighs around 500 grams, the water around the baby another kilo or so. Some weight gain can be attributed to fluid retention, blood volume expansion and so on. That means, if you put on 15 kilos in pregnancy, you are just going to lose a third of it once you deliver! The rest of it is your fat gain, and that's why women struggle to 'get back in shape' after delivery.

As is commonly taught in medical schools, the fetus is an 'ideal parasite'. The baby growing within you always takes what it needs. What does that mean? If you have a deficiency of certain nutrients, there is still a chance that your baby would be healthy, but at the cost of your health.

It also means that even if a woman may not gain a lot of weight while pregnant, her baby may still have an average healthy birth weight as long as she's eating right.

Doctors often recommend the ideal weight gain to each woman based on all the factors mentioned above. On an average, a young woman with a normal BMI and no other risk factors can gain around 10- 12 kilos throughout the course of pregnancy. An underweight woman can gain around 15 kilos, an overweight woman around 7- 10 kilos, and an obese woman only around 3- 5 kilos! These figures may vary based on other risk factors. Also, it is important to understand that most of the weight gain needs to occur in the later months of pregnancy. In the first trimester, several times there's just a borderline weight gain, sometimes none, and sometimes even weight loss due to nausea and vomiting. But even in the later months, it is recommended that one should not gain more than 1.5- 2 kilos a month!

Another thing we need to understand is that 'weight gain' does not necessarily mean being 'nutritionally sufficient'. One needs to gain weight by eating right- the diet needs to have proteins, fats, carbohydrates, vitamins, minerals and micronutrients in the right proportion for an optimally healthy pregnancy. A 'balanced diet' is the key to this.

What does a balanced diet comprise of?

If one looks at the traditional meal pattern of any region, it is 'whole' and contains all the essential ingredients in the right proportion. For instance, a traditional Maharashtrian meal contains carbohydrates (chapatis, bhakris or rice), proteins (dals or sprouts), vitamins, minerals and fibre (vegetables, salads or fruits), fat (oil/ ghee), probiotics (yoghurt or buttermilk), and calcium, essential oils, Omega 3 fatty acids (chutneys of seeds like sesame or flaxseeds). Likewise the whole meals of all regions in India are balanced and healthy.

Often, for our 'convenience' or ease, we happen to skip a few of these ingredients, thus overdosing on one component and entirely missing out on another. This may lead to certain preventable issues in pregnancy such as anaemia, gestational diabetes or fetal growth restriction.

A balanced diet with an ideal proportion of each component is what is needed for an uneventful pregnancy.

To quote an easy to understand way of 'balance', for each roti you have, ensure you have a bowl each of salad, vegetables, dal and buttermilk.

What foods can I eat and what should I avoid?

A healthy home-cooked balanced meal is ideal for a pregnant woman.

Having said that, ensure that you include lots of fresh fruits, vegetables, sprouts, pulses, legumes, whole grains, yoghurt and buttermilk in your diet. Ensure that you wash fruits and vegetables well in warm water before you consume them raw- a lot of them may be layered with pesticides or a coat of wax to make them shiny.

You should have adequate fluids- depending on the season and your activity, atleast 3- 4 litres in a day- more in summers.

Consumption of alcohol, aerated beverages, canned foods, foods containing preservatives, artificial colours, chemicals, synthetic substances should preferably be avoided.

Restrict the intake of tea and coffee to not more than two cups a day.

Even if you eat out, ensure you eat foods that are freshly and hygienically prepared- go for something like idlis or dosas which you know cannot be stored for long, instead of salads or cold sandwiches. Avoid roadside foods, or eating at places, the hygiene standards of which are questionable. Oily or spicy food may cause acid reflux, hence is best avoided.

Homemade soups and salads are healthy and ensure you consume vegetables and fluids in the right proportion.

Cravings can be satiated by hygienically preparing pani puris or chat at home- when you can be certain of the water used, and the cleanliness of the hands that dip into it!!

The reason for avoiding roadside food is not because it will harm the baby, but because if you fall ill after eating it, there are restrictions on the medications that can be safe in pregnancy, and you would have to suffer.

It is important to eat regional and seasonal- for the optimal nutrient proportion, and to go easy on your digestive system.

I don't feel hungry. Is that worrisome? Will it cause my baby to stop growing?

A pregnant woman, especially in the first trimester, can have the tendency to lose her appetite. You may feel full even after eating just a third of what you were accustomed to before pregnancy. In such a scenario, family members can especially get paranoid and fussy, urging you to eat against your wishes and throw up! 

I always suggest that you take it easy. Eat in the quantity you feel comfortable consuming, but ensure you have small frequent meals- eat something every 2- 3 hours instead of three large main meals. The pregnancy hormones can affect your appetite in a huge way, and if you vomit all that you eat, it won't serve the purpose!

Eat foods you are comfortable with, especially those with simple carbohydrates. You may have an aversion to strong smells and tastes, masalas and oils. Bland foods like crackers, fruits like apples, pears, dry toast, small power bites like rajgira laddoo, groundnut chikkis may be ideal foods that will not cause you to throw up, yet give you the energy you need.

In the first trimester, the baby is very small, hence your dietary pattern will not adversely affect its growth. However, an insufficient intake and food perversions may cause nutritional deficiencies in your body, which is why you need to eat right, and also ensure you stay well hydrated.

Not all women may have aversions in pregnancy, that solely depends on how well your body adapts to the hormonal changes. If you are able to tolerate most foods, you can go for a healthy balanced diet as mentioned earlier.

I recommend that you have an early dinner in pregnancy. Progesterone causes the sphincter muscles at the bottom of your food pipe to relax, which can lead to reflux if you lie down soon after your meal. If you feel hungry again at bedtime, you may have a fruit or a powerbite such as a couple of rajgira laddoos with some milk. This may help to reduce your vomiting.

Most of your nausea, vomiting and aversions reduce and gradually disappear after you cross into the second trimester.

Is it necessary to eat ghee, laddoos, dry fruits in pregnancy?

The answer is a big NO!

In the first trimester, one requires the same calories per day as a non- pregnant woman. In the second trimester, an additional 340 calories a day and in the third trimester, an additional 450 calories a day are required.

Moreover, most pregnant women tend to restrict their activities compared to the pre- pregnancy stage.

Ghee, laddoos, sweets, fried foods and a lot of other such high calorie foodstuff, especially when you are already eating enough through your balanced meals, tends to accumulate as fat in your body- the same fat that is so difficult to get rid of post delivery! 

Dry fruits such as walnuts are an excellent source of Omega 3 fatty acids, as are flaxseeds. Almonds provide essential amino acids, black raisins and dates are rich sources of iron, so they can definitely be had in moderation. Restrict the intake to nor more than 4- 5 each of walnuts, almonds, and 15- 20 black raisins per day.

Small truffle- sized laddoos made of equal proportions of dates, walnuts and half the quantity of unpolished sesame seeds are excellent power bites and rich sources of iron and calcium in pregnancy.

Restrict the intake of saturated fats such as ghee, and also refined sugars, as are found in sweets. 

Being pregnant definitely does not give you the green light to eat gigantic proportions of things which are said to be 'bad for health'.

Remember, you need to avoid things you wouldn't like your baby to eat- maida, refined foods, chemicals, preservatives, excessive sugars, palm oil, saturated fats, dalda and so on are best avoided!

Occasional indulgences are fine, but should be in moderation, and also be clubbed with adequate physical activity.

What will happen if I put on too much weight in pregnancy?

It is a myth that the more weight you put on, the healthier your baby would be.

Obesity may put you at a higher risk of developing conditions like diabetes or high blood pressure in pregnancy.

These conditions may lead to intra- uterine growth restriction in the baby. Such babies have a deficient blood supply, are smaller than their counterparts, may need premature delivery, NICU care, respiratory support after birth. You may have a higher chance of needing a Caesarean delivery, and an uncontrolled blood pressure may also put you at risk of several dreadful complications such as convulsions, a deranged liver or kidney function or bleeding.

The importance of a healthy diet cannot be emphasized enough!

My mother says I've to drink two glasses of milk in a day. I cannot stand the smell of it. Will it cause a calcium deficiency and weak bones in my baby?

Many women develop an aversion to milk, which is unfortunately obsessively force- fed by elders in the family! Remember, humans are the only mammals who source milk from other animals! That obviously means it is replaceable. Milk is definitely a good source of calcium, but not the only one! Soy, tofu, green leafy vegetables, figs, whole cereals like ragi, sprouts, sesame, walnuts, almonds, broccoli are some of the non- dairy calcium- rich foods commonly available in the Indian household.

I recommend the intake of yoghurt or buttermilk since they are probiotics, rather than whole milk. They are better tolerated by pregnant women as well.

In the second trimester, in our country, most practitioners start the woman on oral iron and calcium supplements, to be continued till delivery. This usually takes care of the body's increased requirements owing to pregnancy.

Will taking iron supplements cause my baby's complexion to become dark?

The only thing iron supplementation can darken is your stool!

Many women want a fair- complexioned baby, hence skip the iron prescribed by their doctor, leading to anaemia and other complications.

Among the dietary sources of iron are spinach, moringa, dates, red meat etc.

Iron does NOT cause your baby to become darker. Skin tone depends on heredity, genetic factors and after birth- factors like sunlight exposure leading to melanin secretion.

Remember, what is more important than how your baby looks is how you raise him/ her, and the values you impart.

Why is it important that I maintain good nutrition in pregnancy?

What happens inside the uterus stays with your baby for life!

In 1990, the British epidemiologist David Barker, proposed a hypothesis based on a series of studies that babies with intrauterine growth restriction and low birth weight are more likely to develop obesity, hypertension, hyperlipidemia and complications including heart disease and stroke earlier in life than their healthy counterparts. 

Another recent field of interest is 'nutritional epigenetics', which covers food affecting patterns of gene regulation. A lot of lifestyle based diseases such as diabetes, hypertension, obesity as well as certain cancers can be linked to epigenetics, that is, the way in which your DNA and RNA replicates. A sedentary lifestyle, obesity, smoking, alcohol consumption, a diet rich in saturated fats have been proven through several studies to negatively impact gene expression through free radicals and certain toxic substances, whereas a nutritionally sufficient diet rich in fresh fruits and vegetables, ample physical activity has shown to have a protective effect.

In simple terms, this means, what you eat now is going to affect your health, as well as your baby's future health in a more direct way than you had imagined!

Every mother loves her babies a lot, and protects them with her life- and needless to say, it is hence important to keep yourself fit by eating right before and during pregnancy to give your baby the gift of good health!

The writer is a dynamic and highly approachable obstetrician, gynaecologist and infertility specialist practicing in Pune.

What to expect when you're expecting- how your body changes in pregnancy

Pregnancy, in real life, isn't defined by the picture portrayed by Bollywood in our minds. The changes happening in your body while pregnant go way beyond vomiting and tamarind- craving, which, unfortunately, are the only things women are prepared for! 

The human body is indeed a miracle of nature. Each and every organ system undergoes changes when a woman is pregnant, to accommodate comfortably, another human being growing within her.

You may not physically experience all of these changes even though they're happening within you. Moreover, not every woman may experience every symptom in the list! Remember that you're unique. Just because your sister or best friend went through something during her pregnancy does not necessarily mean that it has to happen to you too!

What are the commonest symptoms you may experience?

* A missed period: 

For a woman usually getting her menses like clockwork on the precise date of the month, a missed period may indicate pregnancy. 

An increasing number of women these days are faced with irregular periods, hence it may be difficult for them to predict if they've really missed their period. In such a scenario, a positive urine pregnancy test may help to clinch the diagnosis of pregnancy.

Is it possible that you don't miss a period and can still be pregnant?

Very very rarely, but yes, it is known to happen. Sometimes, when the embryo makes its way into the uterus and burrows into the endometrium, or the lining inside the uterus, the woman may experience some bleeding or spotting called 'implantation bleeding', which she may mistake for her period. This may lead to the perception of not missing your period but still being pregnant.

* A positive urine pregnancy test (UPT):

A urine pregnancy test is based on the premise of the pregnancy hormone, or beta human chorionic hormone (beta hCG) which is excreted in the urine of a pregnant woman.

Traditionally, the UPT is done on the morning sample of urine, because it was initially believed that since you don't empty your bladder overnight, the first sample of urine in the morning is more concentrated and has a greater chance of showing a positive value than the ones voided later. However, the present day test kits available are highly sensitive to even low values of beta hCG in the urine, and can show a positive test even when checked later in the day.

The UPT generally turns positive when checked around a week after your missed period. If you check it too early, it may show a negative result even if you are pregnant, because the values of beta hCG in your urine are not significantly high yet.

How do you do a urine pregnancy test?

Add two drops of urine to the well on the test strip and wait for five minutes.

There are two markers on the test strip. 'C' stands for control, and 'T' stands for test. The test strip is so designed that it reacts to the beta hCG, if present in the sample put on it and changes colour to pink. The control line shows you the intensity of the colour that indicates a positive. Thus, two dark pink lines denote a positive and one dark pink line denotes a negative.

There are instances when you get a dark pink line on the control point and a light pink line on the test point. This is what we usually term as a 'weak positive'. There could be a few reasons for this, the commonest being that it is a very early pregnancy, and the beta hCG in your urine hasn't yet reached a significantly high value to appear as positive on the UPT strip. Sometimes it could be an error, and sometimes if you keep the strip for very long, you can see the test line growing darker even if the test is negative. Hence, it is important to interpret the results of the UPT within 5 minutes. However, if you do get a weak positive result on the UPT strip, please consult your doctor. The next step they would advise is to do a beta hCG test on your blood sample, which would detect even the slightest positive, even if the values are very low.

* Morning sickness:

Here comes the classical Bollywood 'Main maa banane wali hoon' symptom!

hCG and progesterone are usually the hormones that cause a woman to feel nauseated in the first trimester of pregnancy. The severity of this symptom may vary with each individual. A few lucky women breeze through the entire duration of pregnancy without a single episode of vomiting, whereas quite a few develop food aversions, inability to tolerate any food orally, severely reduced appetite, which may even lead to weight loss in the first three months of pregnancy. Women with twins or triplets usually have a more severe degree of nausea and vomiting, because of the obvious reason of the pregnancy hormones being at a higher level in the body as compared to a singleton pregnancy.

Your doctor may prescribe certain oral medications which you can safely take, should you develop nausea or vomiting. Sometimes a few of these tablets may cause you to feel sleepy through the day, hence we recommend that you take them only when required.

In the event of very severe vomiting wherein the woman is unable to tolerate any food orally, she may need to be admitted and given intravenous fluids and medications to avoid dehydration.

Classically, this symptom reduces in intensity and severity after the woman crosses 12 weeks of pregnancy, even though there may be a few exceptions.

* Frequency of urination:

Anatomically, the uterus is sandwiched between the urinary bladder in the front and the rectum, i.e. the pouch that holds your stools, behind. Hence, when the uterus starts increasing in size due to pregnancy, it may exert pressure on these two organs, leading most commonly to frequency of urination. Some women may even experience a sense of incomplete voiding, and may need to go back to urinate very soon after the previous washroom visit.

Sometimes you may even experience a change in your bowel habits.

This symptom also gets better once you cross the twelfth week of pregnancy, and can recur during the last trimester once the baby's head starts exerting pressure on the urinary bladder once again.

* Vague aches and pains, tiredness:

It commonly occurs in pregnancy that you feel dull and easily tired even after performing a routine activity that you may be very well used to. You may also experience a stretching pain in your lower belly. That may be due to the increased blood flow to your uterus and other pelvic organs owing to pregnancy. However, any lower abdominal pains are to be taken seriously and informed to your doctor, unless they reassure you that the pain is indeed due to pelvic pressure and stretching of your ligaments due to the growing uterus.

With advancing pregnancy, your posture changes, and the point of weight- bearing in your spine changes too. Ultimately, you may have backache. It may be relieved by rest, correct posture and a few back exercises as advised by the doctor.

Another change you may experience in the later months of pregnancy is swelling in your feet. The pregnant uterus sits on the veins responsible for carrying blood from your legs back to your heart for oxygenation and pumping. This leads to congestion and something that we term as a 'dependent oedema'. This swelling classically worsens after sitting with your legs hanging down, or prolonged standing at the end of a working day, and is relieved on rest. However, swelling on your legs needs to be brought to the attention of your doctor, as it may be an early sign of raised BP.

In the later months of pregnancy, we recommend that you lie sideways when you go to bed, to relieve the pressure off the veins.

* Breast changes:

With pregnancy, your body starts preparing your breasts to feed the baby once it is born. Your breasts may start feeling heavier, and may swell up in size. The brassiere you're used to may start feeling uncomfortably tight. Your nipples may become larger and more prominent, and the areola, i.e. the dark brown circle of skin around your nipple may also enlarge in size and become darker. You may also see some small round painless pimple- like projections along the border of the areola. These are called Montgomery's tubercles and are a normal breast change in pregnancy.

Sometimes you may also experience a sticky, whitish or watery discharge from your nipples in pregnancy- it is nothing to be alarmed about, but do not try and squeeze it out. We usually suggest avoiding breast and nipple stimulation in pregnancy, since the same hormone 'oxytocin', which is responsible for milk expression, is also responsible for labour pains.

* Weight gain, the 'baby bump':

A pregnant woman may not start gaining weight immediately after the pregnancy is confirmed. In fact, a few women may also lose weight in the first trimester on account of reduced appetite, nausea and vomiting.

A baby bump too, is not evident until the second trimester. Upto 12 weeks of pregnancy, the uterus is within the pelvis, i.e. lies inside the bony cage around the area of your hips. Once the pregnancy crosses the 12 week milestone, the uterus gradually starts to grow above the pelvic bone and become more visible in the lower belly as a bump. Before that, whatever you may see is just belly fat! To assess the size of the pregnant uterus till that time, the doctor may have to perform an internal examination 'per vaginum' (PV) in which he/she may insert two fingers into your vagina and assess the size of your uterus with the other hand pressing your lower abdomen.

A few women may not have a very protuberant baby bump. It depends on the tone of your abdominal wall muscles, the size of the baby, and also the position of the baby within you. Shorter women, those carrying twins, women with lax abdominal muscles or larger sized babies may have a bigger baby bump. Hence, the growth of your baby is not dependent on how apparent your baby bump is, contrary to popular belief. Your doctor would check the size and advise serial ultrasound examinations to be able to comment on the growth.

* Skin changes:

Stretch marks are more evident in leaner women with a good skin tone over the belly. Your skin comprises of collagen fibres. As your belly expands due to the growing uterus, these collagen fibres get stretched and damaged, which leads to stretch marks. You may notice similar marks on the skin of people who put on or lost weight suddenly. 

You may also see a vertical dark line running along the centre of your abdomen past your belly button.

Pregnancy may even lead to pigmentation over your skin, which may lead to you appearing a few tones darker than usual. Some women may experience darkening over the cheek bones and root of the nose. Acne, or pimples over the face, back and upper arms is also a common complaint which may be attributed to the pregnancy.

A few women may also experience hair fall. Your hair may lose its lustre.

Do not fret over the lack of the so- called 'pregnancy glow' if you're afflicted with any of the above. Being a mother does not imply being conventionally good- looking, fitting into fashionable clothes and having a clear skin and photogenic body. It is more about accepting and coming to terms with the fact that your body would be undergoing irrevocable changes. But given that you have another human being growing inside you, I would say that you're still the most beautiful and gifted woman ever, and that you should be confident and love yourself even more than before!

* Changes happening inside you- the other organ systems:

The human body is a marvel of nature. In order to accomodate the baby, its growth and yet not cause too much strain on your body, there are a lot of changes which start happening within each and every organ system. Your blood volume expands in size, your heart pumps more effectively, your blood pressure drops by a few millimeters, the muscle sphincters in your digestive system relax- and a lot more goes on within you without even making the change obvious. Your metabolism changes- your baby now needs a constant supply of glucose for its growth. If you're a diabetic, you may notice that your blood sugars drop in the initial few months of pregnancy, which later reverses and you may then require a higher dose of medications. You do not need to worry about these changes, unless, of course, you have any pre-existing diseases, which you must share with your doctor so that he/ she would be able to analyse how pregnancy would affect your disease, and how the disease may affect the pregnancy- and take the necessary measures to ensure that you and the baby sail through all the three trimesters with minimal worries!

* Perception of the baby's movements:

You may not be able to feel the baby's movements even as late as the fifth month of pregnancy. Usually, a woman pregnant for the first time may be able to perceive fetal movements as early as the 18th week of pregnancy, and if it's your second or third baby, you may even feel then a couple of weeks earlier.

However, do not fret even if you're a bit late in beginning to feel the movements- each woman's perception may vary based on several factors.

We do not recommend counting the baby's movements till 28-30 weeks of pregnancy.

* Feeling of 'tightening' or the Braxton Hicks contractions:

You may occasionally feel your tummy hardening through the pregnancy. The difference between labour pains and Braxton Hicks contractions is that they are essentially painless, infrequent and do not progressively increase in severity and frequency.

Moreover, if your doctor performs an internal examination, they would find that your cervix hasn't yet started to open up with Braxton Hicks contractions. However, it is always prudent to get checked by a professional to ascertain that the hardening of your belly you feel is indeed due to Braxton Hicks contractions and not labour pains.

Pregnancy is an experience in itself. It is essential to be prepared for this journey by knowing what's right, and not just hearsay and rumours. Remember, never hesitate to get your doubts clarified by your doctor- no matter how silly they may seem. Sometimes, the silliest of mistakes can be the most troublesome! And most importantly, love yourself, and embrace the changes in your mind and body that pregnancy brings with it- that is the secret to a healthy, happy motherhood!

The writer is a dynamic, highly approachable obstetrician, gynaecologist and infertility specialist practicing in Pune.