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Review Article
Accepted after revision: December 3, 2013 Published online: February 7, 2014 German National Consensus Recommendations
on Nutrition and Lifestyle in Pregnancy by the
‘Healthy Start – Young Family Network’

B. Koletzko a C.P. Bauer b P. Bung c M. Cremer d M. Flothkötter e C. Hellmers f M. Kersting g M. Krawinkel h H. Przyrembel i R. Rasenack j T. Schäfer k K. Vetter l U. Wahn m A. Weissenborn i A. Wöckel n a Dr. von Hauner Children’s Hospital, University of Munich Medical Center, Munich , b Department of Pediatrics, Fachklinik Gaissach, Gaissach , c Gynecology Clinic, Bonn , d Nutrition Consultant, Idstein , e aid infodienst for Nutrition, Agriculture and Consumer Protection, Bonn , f Faculty of Economic and Social Sciences, Midwifery Studies, Fachhochschule Osnabrück, Osnabrück , g Research Institute of Child Nutrition (FKE), Dortmund , h Institute for Nutritional Sciences, Justus Liebig University of Giessen, Giessen , i Federal Institute for Risk Assessment (BfR), Berlin , j Department of Gynecology and Obstetrics, University of Freiburg, Freiburg , k Institute for Social Medicine, University Schleswig-Holstein, Lübeck , l Vivantes Klinikum Neukölln, and m Department of Pediatrics, Charité-University Medicine Berlin, Berlin , and n Department of Gynecology and Obstetrics, University of Ulm, Key Words
should include folic acid and iodine, iron (in case of subopti- Child health · Metabolic programming · Nutrition · Physical mal iron stores), the ω–3 fatty acid docosahexaenoic acid (in case of infrequent consumption of ocean fish) and vitamin D (in case of decreased sun exposure and decreased endoge-nous vitamin D synthesis). Pregnant women should not Abstract
smoke and not stay in rooms where others smoke or have Diet and physical activity before and during pregnancy af- smoked before (passive smoking). Alcohol consumption fect short- and long-term health of mother and child. The should be avoided, since alcohol can harm unborn children.
energy needs at the end of pregnancy increase only by about 10% compared to nonpregnant women. An excessive ener-gy intake is undesirable since maternal overweight and ex-cessive weight gain can increase the risks for a high birth This review article is translated and adapted from: Koletzko B, Bauer weight and later child overweight and diabetes. Maternal CP, Bung P, Cremer M, Flothkötter M, Hellmers C, Kersting M, Krawin-kel M, Przyrembel H, Rasenack R, Schäfer T, Vetter K, Wahn U, Weis- weight at the beginning of pregnancy is especially impor- senborn A, Wöckel A: Ernährung in der Schwangerschaft – Teil 1. tant for pregnancy outcome and child health. Women should Handlungsempfehlungen des Netzwerks ‘Gesund ins Leben – Netz- strive to achieve normal weight already before pregnancy. werk Junge Familie’. Dtsch Med Wochenschr 2012;137:1309–1314, Regular physical activity can contribute to a healthy weight and: Koletzko B, Bauer CP, Bung P, Cremer M, Flothkötter M, Hell- and to the health of pregnant women. The need for certain mers C, Kersting M, Krawinkel M, Przyrembel H, Rasenack R, Schäfer T, Vetter K, Wahn U, Weissenborn A, Wöckel A: Ernährung in der nutrients increases more than energy requirements. Before Schwangerschaft – Teil 2. Handlungsempfehlungen des Netzwerks and during pregnancy, foods with a high content of essential ‘Gesund ins Leben – Netzwerk Junge Familie’. Dtsch Med Wochen- nutrients should be preferentially selected. Supplements schr 2012;137:1366–1372. Prof. Berthold Koletzko, Dr. med. Dr. med. habil. (MD, PhD) Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital University of Munich Medical Center E-Mail office.koletzko   @   med.lmu.de Introduction
searches were not performed. Formulated under group consensus, the key statements represent the evidence lev- Prior to and during pregnancy, women and their part- el of expert recommendations. These should be updated ners need clear information on and support of a health- at regular intervals (at least every 5 years) to maintain promoting lifestyle. Here, we present practice guidelines their validity. The authors consider that a systematic lit-that were developed with and are supported by the German erature review would be desirable for future recommen- professional associations and scientific societies for obste- tricians and gynecologists, midwives and pediatricians. The ‘Healthy Start – Young Family Network’ (www.
These recommendations apply to pregnant women in Ger- gesund-ins-leben.de) is a project of the Federal Govern- many and should form a uniform and harmonized basis ment’s National Action Plan IN FORM – Germany’s na-for nutrition recommendations during pregnancy for all tional initiative to promote healthy diets and physical ac-health care professionals and organizations that provide tivity, and of the National Action Plan against Allergies advice to expecting parents. While many of these recom- of the Federal Ministry for Food, Agriculture and Con- mendations may also be appropriate for other populations, sumer Protection. The Network is financed by this minis- it is necessary to take the specific dietary, lifestyle and oth- try. Medical and scientific professional societies, profes- er conditions of the targeted population into account.
sional associations, as well as professionally focused insti- For expecting parents, pregnancy is an intense, excit- tutions collaborate in this network in order to provide ing and challenging time. Generally, they aim at doing the parents with information on pregnancy and childbirth. right things for a healthy development of their child and The project is coordinated by the ‘ aid infodienst e.V.’, its best possible start in life. The topics of nutrition during pregnancy and the prevention of child allergy receive par-ticular attention by expecting parents. However, expect-ing parents are often confronted with and confused by Key Statements and Practice Recommendations
conflicting advice provided by different sources. There-fore the ‘ Healthy Start – Young Family Network’ aimed at Energy and Nutrient Needs in Pregnancy developing harmonized practice recommendations as a common basis for communication by health care profes- sionals as well as for the distribution by network media. • Energy needs increase only slightly during the course From 2009 to 2011, relevant publications, meta-analyses of pregnancy. Energy needs during the final months of and guidelines, as well as recommendations and refer- pregnancy are about 10% higher than before pregnan- ence values for nutrient intakes from professional orga- nizations and institutions that make statements about the • Compared to the increase in energy needs, the need for nutrition and health of pregnant women and/or allergy certain vitamins and minerals/trace elements in preg- prevention (Association of German Gynecologists, Ger- nancy show a much greater increase. Therefore, preg- man Federal Institute for Risk Assessment, German Fed- nant women should pay special attention to the qual- eral Center for Health Education, Cochrane Library, Ger- man Nutrition Society, German Society for Obstetrics and Gynecology, German Society for Pediatrics and Ado- Resting energy expenditure increases only slightly lescent Health, German Midwife Organization, European during pregnancy, primarily in the second and third tri- Commission, European Bureau for Food Safety, Research mester. There is a high amount of variability in energy Institute for Child Nutrition, Institute of Medicine (IOM; needs, which are in part related to the level of physical USA), National Institute for Health and Clinical Excel- activity. This appears to be one reason for the consider- lence (UK) and National Commission for Breast-Feeding able differences in the published reference values on ad- at the Federal Institute for Risk Assessment, World Health ditional energy needs during the course of pregnancy [1– Organization) were systematically collected and evaluat- 6] . The recommendation of providing about 10% more ed by the Network Scientific Advisory Board, whose energy in the final months of pregnancy underlines that members are authors of this publication. The recommen- the energy needs increase only slightly, which is covered dations were developed based primarily on existing by relatively small food portions ( table 1 ). Pregnant wom-guidelines, meta-analyses and systematic summaries. In en often overestimate their energy needs. A diet provid-the framework of the Network , systematic literature ing too much energy can have unfavorable effects on the Table 1. Examples of foods with high nutrient densities meeting
The estimated 10% increased energy needs at the end of pregnancy can be covered, for example, by either: – A piece of whole-grain bread (without fat spread) with a slice of cheese (45% fat) and a tomato (∼260 kcal) – Or one serving of low-fat yogurt (1.5% fat) with a handful of berries and three tablespoons of whole-grain cereal (∼210 – Or a plate of vegetable soup with noodles (around 40 g dry Ener Protein Vit. AVit. B Vit. B Vit. B Folat Vit. C weight gain in and the course of the pregnancy and on the Fig. 1. Reference nutrient intakes for pregnant women expressed
health of the unborn child [7–10] .
as percentage of reference intake values for nonpregnant women. The recommended intake for several nutrients shows a much Relative to energy needs, the needs for many vitamins greater increase then the recommended energy intake [data de- and some minerals increase much more ( fig. 1 ). For many nutrients, a marked increase in needs occurs only after the 4th month of pregnancy, but an increased intake even before the beginning of pregnancy is recommended for folic acid, iodine and iron [2] .
livery and complications during delivery [7, 8] . Children Given the only small increase in energy needs, nutri- of overweight mothers carry an increased risk for later ent-dense foods (i.e. foods with a high content of essential overweight and for congenital disorders, such as spina nutrients relative to the energy content) are desirable in bifida, and heart and other birth defects [8, 13] . Over- and the diet of pregnant women to supply adequate amounts underweight women should aim to reach a normal weight of minerals, vitamins and other micronutrients. During before becoming pregnant.
counseling, the concept of ‘think for two, but do not eat From the second trimester onwards, a considerable for two’ (do not eat double portions) should be empha- weight gain commences, which comprises the weight of sized and illustrated by examples of foods with high nu- the fetus, placenta, amniotic fluid, the gain of maternal trient densities providing for the modestly increased en- tissue, such as breast and uterine tissue, an increase in blood volume and extracellular fluids, as well as fat depos-its. A normal weight gain during pregnancy lies between 10–14 kg [6] and 10–16 kg [14] .
The United States IOM recommended different levels of weight gain during pregnancy according to the body • The weight before pregnancy is important for fertility, mass index before pregnancy: underweight and normal the course of pregnancy and childbirth, as well as for weight women should gain more than overweight or child health. Women should strive to approach a nor- obese women [15] . For normal weight women, the IOM mal body weight before becoming pregnant.
recommends a weight gain of 11.5–16 kg. More recent • The adequate gestational weight gain for normal- study results question the basis for a general clinical prac- weight women is between 10 and 16 kg.
tice application of these recommendations that are based on observational studies in the United States, especially The body weight at the beginning of pregnancy ap- the application for overweight and obese women [4] . pears to have a greater impact on the health of the moth- Data from the nationwide German Child and Adolescent er and child than the weight gained during the pregnancy Health Study (KiGGs) show that the risk for later child- [4, 11] . In Germany, around 20% of women aged 20–39 hood overweight is indeed higher when normal-weight years are overweight and another 9–14% are obese [12] . women gain a lot of weight during pregnancy; however, Overweight and obese women have an increased risk for the magnitude of the effect is limited. With 1 kg of addi-gestational diabetes, high blood pressure, premature de- tional weight gain, the risk for childhood overweight in- creases only by about 1% [16] . For overweight and obese act number of meals depends on the needs and prefer-pregnant women in Bavaria, a weight gain according to ences of the particular pregnant woman.
the IOM recommendations was associated with a lower The weighting of different food groups recommended incidence of preeclampsia and nonelective cesarean sec- for abundant, moderate or sparing consumption should tions, but with a higher number of diabetes, premature indicate that these food groups contribute differently to births and low birth weight, as well as higher perinatal nutrient and energy needs during pregnancy. The high mortality [17] . A further retrospective observational needs of folic acid and iodine in pregnancy cannot be pro- study showed a reduced risk for complications in very se- vided for by a well-balanced diet alone, therefore the use of verely obese women (body mass index >40) who lost supplements providing these nutrients is recommended.
weight during pregnancy. These results underline that The fluid requirements during pregnancy increase in collectively, the available data do not suffice for the adop- proportion to energy requirements by about 300 ml per tion of the IOM recommendations into standard clinical day during the last few months of pregnancy [20] . The practice in Germany. Future recommendations for a de- reference intake value for the total amount of water con- sirable weight progression during pregnancy may arise sumed from foods and drinks for 19- to 50-year-olds is 35 from ongoing intervention studies [18] . However, over- ml/kg body weight and day, which also applies to preg- weight and obese pregnant women may be advised to nant women [2] . Hence, fluid intake should not be less adopt a balanced diet and regular physical activity.
than 1.5 liters of water per day [2] . Higher amounts of fluid intake may be necessary in hot environments or dur- Nutrient-dense foods such as vegetables, fruits, whole grains and low-fat milk products should be preferentially • A balanced and varied diet is important for the health consumed to help meeting the increased needs for vita- of pregnant women and their children.
mins and minerals. The consumption of five portions of • Regular meals are desirable during pregnancy and fruits and vegetables per day is desirable [21] . Grain prod- contribute to the well-being of the pregnant woman.
ucts, especially from whole grains, and potatoes have a • Pregnant women should pay special attention to in- high content of vitamins, minerals and fiber and should clude vegetables, fruit, whole grains, low-fat milk and be preferentially consumed during pregnancy. Low-fat low-fat meat products and oily fish in their regular preparations of potatoes and grains are preferred.
diet. The use of supplements is recommended to en- Low-fat milk and milk products provide protein, cal- sure an adequate intake of iodine and folic acid. In a cium, iodine and other nutrients, and are important com-well-balanced diet, certain food groups are weighted ponents of a well-balanced diet. Meat provides well bio-differently: available iron and should be included in the diet of preg- – Abundant amounts of water or other low-calorie bev- nant women. A preference for certain iron-rich meat erages and plant-based foods should be consumed.
types is not necessary in mixed diets. However, low-fat – Moderate amounts of animal-based foods should be meats and meat products are preferred. eaten, with a preference for low-fat milk and milk Sweets and snack products with a high energy content products, low-fat meats and oily fish.
and low nutrient density should only be consumed in – Foods with a high content of saturated fats as well as small quantities.
sweets and snack products should be eaten sparingly.
In order to reach the recommended levels of long- chain ω–3 fatty acids, an average intake of 200 mg of do- A well-balanced diet and regular exercise before and cosahexaenoic acid (DHA) per day should be reached during pregnancy not only benefits the mother and the during pregnancy. Two portions of fish should be con-child in the short term, but can also have long-term posi- sumed per week, with one portion of an oily fish like tive effects on health and well-being [19] . Choosing ap- mackerel, herring, sardines or salmon [12, 22] . A high propriate foods can meet the higher need for a number of consumption of carnivorous fish types like tuna and nutrients during pregnancy, with the exception of folic swordfish, which are at the end of the maritime food acid and iodine. The consumption of special dietetic chain and may exhibit a high amount of toxic or harmful foods is usually not necessary. Taking supplements can- substances, should be avoided [23] . It is recommended not replace a well-balanced diet. Regular meals spread that pregnant women who do not regularly eat seafood throughout the day promote well-being, although the ex- take a supplement providing the ω–3-fatty acid DHA [24] . Plant oils should be consumed regularly because of to markedly reduce the risk for serious birth defects, their high amount of monounsaturated and essential namely neural tube defects, in numerous studies and in a polyunsaturated fatty acids. In contrast, fats with a high Cochrane meta-analysis [28, 29] . In some studies, also a portion of saturated fatty acids (fats that are solid at room risk reduction for other congenital birth defects, includ- temperature) should be consumed sparingly.
ing congenital heart disease and cleft palate, were report- Vitamin D. Seafood (especially oily fish) contributes to ed [28, 30–34] , even though no significant effects for the the provision of iodine and vitamin D. The vitamin D sta- prevention of these birth defects were found in the cited tus of a pregnant woman directly affects the vitamin D Cochrane meta-analysis [28] . status and health of the child, especially bone mineraliza- Closure of the neural tube occurs 3–4 weeks after con- tion [25–27] . Vitamin D is obtained from the diet and is ception [28, 35] . Therefore, folic acid supplementation also synthesized in the skin during exposure to sunlight. should start prior to conception to reach an optimal pre-An adequate time spent outdoors can help to provide a ventive effect. Women planning a pregnancy or who can-sufficient supply of vitamin D. Regarding light skin types, not rule out becoming pregnant should take a supple- it is sufficient to expose the face and arms to sunlight for ment including 400 μg folic acid daily in addition to a 5–10 min without sun protection around midday. Sun- well-balanced diet, and they should continue supplemen- burn should be avoided. The German Nutrition Society tation at least until the end of the first trimester [36] . recommends a daily vitamin D supplement of 20 μg (800 When supplementation begins shortly before or just after IU) for pregnant women who do not synthesize sufficient conception, supplements should contain more than 400 vitamin D because of lack of or insufficient exposure to μg folic acid, since this leads faster to tissue concentra-sunlight [2] . The average intake of vitamin D through the tions that are considered effective for prevention [37] . A diet is around 2–4 μg daily [12] . This amount is not daily intake of up to 1,000 μg of folic acid is considered as enough to reach desirable serum concentrations of 25-hy- the maximum safe level of intake by the European Food droxycholecalciferol of at least 50 nmol/l through the en- dogenous synthesis of vitamin D in winter, and in sum- The German Nutrition Society reference values for fo- mer in case of limited sunlight exposure. Pregnant wom- late equivalent intake during pregnancy can hardly be en who rarely spend time in the sunlight, cover their skin reached through diet alone [2, 12] . In Germany, there is or use sunscreen lotions, as well as women with darker no systematic fortification of common foods with folic skin types should supplement their diet with vitamin D to acid [39] . Even if certain food manufacturers fortify foods reach a desirable serum concentration.
with folic acid, women are still advised to supplement their diet with folic acid before and during pregnancy. Currently, only a small portion of women achieves an ef-fective preventive folic acid supply before and during • Women planning a pregnancy should take a folic acid Supplementation with folic acid can be continued after supplement (400 μg folic acid daily) in addition to a the 12th week of pregnancy. Further research is required well-balanced diet in order to meet the higher need for to explore the reported possible benefits of multivitamins folic acid. They should continue supplementation at with folic acid supplementation concerning the reduction least until the end of the first trimester.
in the risk of preeclampsia, improvement in the often Folate status is important for cell division and growth poor vitamin D status and its consequences for mother processes. Plant-based foods like green leafy vegetables, and child, in addition to the reduction in the risk for con-cabbage, legumes, whole-grain products, tomatoes or or- genital birth defects and low birth weight. When preg- nant women take multivitamins, they should ensure that the multivitamins contain 400 μg of folic acid. The average folate intake in the German population lies clearly below the reference values, and 86% of Ger- man women do not meet intake recommendations [12] . During pregnancy, the reference intake value for folate (calculated as folate equivalents) increases by 50% to 600 • A sufficient iodine intake should be promoted before μg/day [2] . A supplement with at least 400 μg of folic acid and during pregnancy. The use of iodized table salt, the (alone or in combination with micronutrients) was shown consumption of seafood twice weekly, as well as the regular consumption of milk and milk products is ad- Pregnant women should ensure an adequate intake of foods with well-absorbable iron. These include meat, • In addition, pregnant women should take a supple- meat products and fish. Some plant-based foods such as ment containing 100–150 μg of iodine daily. Women whole grains and dark types of vegetables have a large with thyroid disease should consult their physician.
amount of iron, however, with a lower bioavailability. Si- multaneous consumption of vitamin C-rich foods (like A good iodine status is not only important during citrus fruits) along with iron-rich grains or vegetables can pregnancy, but is already important for fertilization. improve iron absorption. Women wishing to become pregnant should be coun- A general prophylactic iron supplementation is not seled on the significance of iodine supply. In order to sup- recommended during pregnancy, since an increased iron port a good iodine status, iodized salt should be used in intake in women with an adequate iron status may have households, restaurants and canteens, and for the prepa- adverse effects [45, 47] . Iron supplementation during ration of ready-made foods such as bread. pregnancy should always be considered individually In pregnancy, the iodine reference intake value in- based on a medical consultation that includes history and creases from 200 to 230 μg/day [2] . On average, about 120 μg of iodine is consumed through foods and iodized salt per day. Even a mild iodine deficiency can have negative Vegetarian Nutrition during Pregnancy should take a daily iodine supplement in addition to di- etary iodine supply. An iodine supplement of 100–150 μg • A vegetarian diet that includes consumption of milk, per day seems sufficient. This equates to the lower to mid- milk products and eggs (ovo-lacto vegetarianism) with dle area of the safe range (100–200 μg/day) of iodine sup- adequate food choices can cover most nutrient needs plementation during pregnancy, as defined in the Ger- man Motherhood Guidelines [42] . If multivitamin prepa- • To ensure an adequate iron intake, iron supplements rations containing sufficient iodine are taken, no should be considered based on a blood test and medi- additional iodine supplement should be used. The use of dried algae or seaweed supplements with possible exces- • If seafood consumption is avoided, the long-chain ω–3 sive iodine amounts that may affect thyroid function is fatty acid DHA should be supplemented.
An ovo-lacto vegetarian diet with adequate food choic- es can achieve an overall good nutrient status during pregnancy, with the exception of vitamin D, folic acid and iodine, which should always be supplemented, as well as • Pregnant women should ensure an adequate intake of iron, which should be supplemented when medically ad- vised. Pregnant vegetarian women who do not eat fish • Iron supplementation should be determined individu- should take a supplement with the ω–3 fatty acid DHA, since synthesis of α-linoleic acid from some plant-based oils is marginal and meeting the needs is not guaranteed Iron needs increase during pregnancy, because more [48, 49] . Low-fat milk and milk products, eggs, legumes iron is needed for the fetus, placenta and increased blood and grain products usually provide a sufficient protein volume of the expectant mother [44] . However, during intake. Eggs, legumes, whole-grain products and some pregnancy, iron loss during menstruation ceases, and in- types of vegetables can contribute to iron intake. How- testinal iron absorption increases [45] . Different recom- ever, the risk for an insufficient iron supply is increased mendations have been given for iron supply in pregnan- in ovo-lacto vegetarians [50, 51] . Pregnant women who cy. The reference values for iron intake during pregnancy already followed a vegetarian diet for a prolonged time for Germany of 30 mg/day are about twofold higher than before they became pregnant also show an increased risk for nonpregnant women [2] , which are usually not cov- for deficiencies in vitamin B 12 and zinc [50, 52–54] . Coun- ered by diet alone [12] . Other expert groups consider seling of pregnant, vegetarian women should therefore about equal iron needs for pregnant as for nonpregnant consider micronutrient intakes, and these women should women [45, 46] .
be counseled to supplement when necessary.
negative and can lead to severe illness, premature birth or stillbirth. In Germany, the Robert Koch Institute registers 10–40 cases of connate toxoplasmosis [57] and around • With a purely plant-based (vegan) diet, a sufficient nu- 20–40 cases of neonatal listeriosis [58] per year (www.rki.
trient intake during pregnancy, even with careful food de). Pregnant women should take precautionary mea- choices, is not possible without supplementation. A sures in order to avoid these infections.
vegan diet proposes serious health risks, especially for Concerning toxoplasmosis, the consumption of not the development of the child’s nervous system. fully cooked meats (e.g. raw sausages, salami and ham) • Pregnant women consuming vegan diets need specific from pork, lamb and game is particularly problematic medical counseling and require micronutrient supple- [59–61] . Beef also plays a role and should also not be con- sumed uncooked as a precautionary measure.
Raw meat products, smoked fish and soft cheeses, also With a strictly plant-based, so-called vegan diet during those made from pasteurized milk, present a high risk of pregnancy, intake of energy, protein, long-chain ω–3 fat- containing pathogenic listeria; unpasteurized milk and ty acids, iron, calcium, iodine, zinc, vitamin B 2 , vitamin products containing unpasteurized milk products, and B 12 and vitamin D are often critical, with considerable vegetables and salads also carry this risk [62–66] . Listeria health risks for the child and the pregnant woman. A vi- can also be found in heated foods. Listeria can grow at tamin B 12 -deficient vegan diet lasting several years can cool temperatures, such as those found in a refrigerator, lead to severe and long-lasting damage to the child’s ner- and also in and on foods that were packed under protect- vous system during pregnancy [52, 55, 56] . Women who ed or vacuum-sealed environments. For this reason, preg-choose to stick to a vegan diet before and during preg- nant women should not eat sausages and cheeses that nancy require qualified nutrition counseling. Vegans have not been freshly sliced. need supplementation in order to cover the nutrient Pregnant women should consume meals as soon after as possible preparation. In restaurants and cafeterias, they should consume meals that have been heated directly pri- Protecting against Food-Borne Illnesses during Raw, animal-based foods present a higher risk for oth- er disease-causing agents, for example salmonella, which can endanger the health of pregnant women and their • Pregnant women should not eat raw, animal-based unborn children.
foods. This includes raw meat or meat which is not In addition to choosing safe foods, hygiene and the thoroughly cooked, raw sausages like salami, raw ham, safe storage of foods play an important role in protecting raw fish, raw seafood, unpasteurized milk, raw eggs, as against food-borne illnesses. Sanitary food preparation well as foods made of products which are not thor- includes washing hands before and after coming into oughly cooked. Also, soft cheese and smoked fish contact with raw foods, and washing fruits and vegetables should be avoided.
before use (disease-causing agents are also present in the • Raw fruit and vegetables as well as lettuce should be soil). In order to prevent cross contamination, the same washed well before consumption, be prepared freshly kitchen utensils should not be used for both cooked and and be eaten soon after preparation. Foods grown in raw meals without being washed in between. or near the ground should be peeled. These foods, like all perishable foods, should be freshly prepared and consumed soon after preparation. Preprepared, pack-aged salads should not be eaten by pregnant women. • Foods that are grown in or near to the ground should • Exercise during pregnancy is desirable and supports be stored separately from other foods to avoid cross • Pregnant women should be active every day through daily routine activities or exercise.
Food-borne illnesses can be harmful to health. During • Athletic training should only be practiced with moder- pregnancy, listeriosis and toxoplasmosis can be transmit- ate intensity during pregnancy. This intensity is defined ted to the unborn child if the pregnant woman is antibody by the ability to converse while exercising (talk test). During pregnancy, exercise with moderate intensity ing education of health care professionals. The statements (not increasing the strength and endurance of the wom- of an Australian report seem appropriate [79] : The risk to en) appears to be beneficial. For example, physical exer- harm the fetus is highest when frequent and large amounts cise is considered to reduce the risk for gestational diabe- of alcohol are consumed. The risk to harm the fetus is low tes and preeclampsia, and to help prevent excessive weight when women only consumed a small amount of alcohol gain. Regular, moderately intense exercise is recom- before they became aware of their pregnancy.
mended as long as there are no medical contraindications [4, 67–69] .
Women should not begin new types of sports during pregnancy with movements that they are not accustomed to. For pregnant women, inappropriate types of sports • Pregnant women should not smoke and not stay in include those with a high risk for injury and falls, for ex- rooms where people are smoking or have smoked.
ample, team, contact or fighting sports, and diving. Sports that draw upon big muscle groups like biking, swimming Smoking can increase the risk for premature birth and and water aerobics, hiking and Nordic Walking are rec- miscarriage, birth defects, early placental abruption, low ommended. Healthy pregnant women can be active at el- birth weight, and the later risk for allergies and over- evations up to 2,000–2,500 m, especially when they are weight [80–84] . Pregnant women should not smoke and accustomed to these altitudes [70, 71] .
should avoid passive smoke exposure. Obstetricians, Regular exercise outdoors is desirable with respect to midwives and other health professionals should explicitly supporting an adequate vitamin D status [72] . Pregnant address pregnant women and their partners regarding to-women often show low blood vitamin D levels, which are bacco consumption, motivate them to quit and advise associated with poor child bone mineralization and mus- them that pregnancy is a good opportunity to stop smok- cle mass during school age [18, 27, 73–76] . Vitamin D ing. Women from lower socioeconomic groups, single status can be improved through vitamin D formation in mothers and mothers under age 20 smoke more often the skin, which is induced by sunlight exposure.
during pregnancy [84] , therefore these groups should be specifically targeted. Special materials for smoking cessa- tion during pregnancy and for health professionals coun-seling pregnant women in smoking cessation, as well as • Pregnant women should avoid drinking alcohol. The safest option is to avoid any alcohol consumption dur- Caffeinated Beverages during Pregnancy Alcohol during pregnancy can lead to birth defects, • Pregnant women should only drink caffeinated bever- growth restriction, damage of tissues and nerve cells as well ages in moderate amounts. Up to 3 cups of coffee per as to an irreversible decrease in the child intelligence devel- opment, and it can also have adverse effects on the child’s • The consumption of caffeinated energy drinks are dis-later behavior (hyperactivity, impulsivity, distraction, risky behavior, disorders of mental and social development and disorders of social maturity) [77, 78] . The individual risk is The data are inadequate for quantifying caffeine influenced by maternal and fetal characteristics and is dif- amounts that do not present a risk for mother and child ficult to predict. A safe and risk-free amount of maternal and for conclusive assessment of possible detrimental ef-alcohol consumption for the fetus, or a time window dur- fects. A Cochrane meta-analysis based only on two stud- ing pregnancy which does not present a risk from alcohol ies showed no detrimental effects to the length of gesta-consumption, cannot be defined based on the available ev- tion or to birth weight of the consumption of up to 3 cups idence. The recommendation to completely avoid alcohol of coffee per day during pregnancy [85] . As a precaution-during pregnancy can promote uncertainty and feelings of ary measure, high caffeine intake is discouraged. For this guilt in women who consumed alcohol early in pregnancy reason, pregnant women are discouraged from consum-before they were aware of the pregnancy. The risks and ing so-called energy drinks, which usually have high their assessment should be addressed during the continu- ing at allergy prevention in the child are not recommend-ed, and they can induce increased risks of insufficient nu- trient intake. Avoidance of foods to which pregnant wom- • In pregnancy, medications should only be started or en show an allergic reaction should be continued.
stopped after consulting a physician.
In order to prevent allergies in children, pregnant women should avoid smoking and areas where there is This recommendation includes not only prescription smoke or where there has been smoking previously. In drugs but also over-the-counter medications. Medica- families with a medical history of allergies, the acquisition tions that were taken before pregnancy should not be of cats or other animals with fur should be avoided. Preg-stopped by the women without previous consultation nant women should avoid high exposure to air pollutants with a doctor [87] . Information about the safety of medi- and mold accumulation in order to protect their health.
cations during pregnancy and breast-feeding can be found under: www.embryotox.de.
Practice Recommendations as a Base for Counseling Expectant parents are generally open for health-pro- moting changes in their lifestyle, particularly if they ex-pect benefits for the child. Doctors, midwives and other health care professionals should utilize this opportunity • Expectant parents should inform themselves about and actively approach couples who wish to have a child breast-feeding already during pregnancy and should and expectant parents to inform and motivate them on obtain counseling. Breast-feeding is the best choice for health-promoting dietary and lifestyle choices. These practice recommendations developed in consensus with the relevant professional societies can serve as a basis for The advantages of breast-feeding are outlined in the counseling on nutrition and physical activity during Guidelines for Infant Nutrition and the Nutrition of Breast- pregnancy, and for responding to questions and concerns Feeding Mothers [88] . Since an early latch and timely of the target group. Doctors, midwives and other distrib-breast-feeding are very important for successful breast- utors of health information should take the questions and feeding, and since insecurities often lead to premature concerns of the target group seriously. Positive messages weaning [89–91] , women and their partners should ob- should be emphasized, and the joy regarding the expected tain breast-feeding counseling already during pregnancy. Skilled personnel who counsel expectant parents should actively approach the subject and motivate pregnant women to breast-feed.
Clinical and Practical Implications
Nutrition during Pregnancy for the Prevention of • The energy needs during the course of pregnancy in- crease only about 10%, while the need for micronutri-ents increases much more. Adherence to a balanced diet and good food choices are of great importance. • The avoidance of certain foods during pregnancy is • Normal weight should be strived for, when possible not beneficial for the prevention of later allergy in the • Adherence to a balanced diet and wise food choices are • Regular consumption of oily fish during pregnancy is important. Folate/folic acid and iodine must always be recommended, also for the prevention of allergies.
supplemented. It should be checked if further nutri- • The consumption of pre- and probiotics during preg- ents need to be supplemented. Special attention should nancy does not offer proven benefits for allergy pre- be given to pregnant women who follow vegetarian or • Alcohol and smoking should be avoided during preg- These recommendations are based on the National nancy. Women who smoke should be supported to Guidelines for Allergy Prevention [92] . There is no evi- dence that a low-allergen diet during pregnancy leads to a • During pregnancy, regular, daily exercise (exercise of reduced allergy risk in the child. Dietetic restrictions aim- References
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