FROM THE ACADEMY

Position Paper

Position of the Academy of Nutrition and Dietetics:

Nutrition and Lifestyle for a Healthy Pregnancy Outcome
ABSTRACT
It is the position of the Academy of Nutrition and Dietetics that women of childbearing
age should adopt a lifestyle optimizing health and reducing risk of birth defects, suboptimal fetal development, and chronic health problems in both mother and child.
Components leading to a healthy pregnancy outcome include healthy prepregnancy
weight, appropriate weight gain and physical activity during pregnancy, consumption of
a wide variety of foods, appropriate vitamin and mineral supplementation, avoidance of
alcohol and other harmful substances, and safe food handling. Pregnancy is a critical
period during which maternal nutrition and lifestyle choices are major inuences on
mother and child health. Inadequate levels of key nutrients during crucial periods of
fetal development may lead to reprogramming within fetal tissues, predisposing the
infant to chronic conditions in later life. Improving the well-being of mothers, infants,
and children is key to the health of the next generation. This position paper and the
accompanying practice paper (www.eatright.org/members/practicepapers) on the same
topic provide registered dietitian nutritionists and dietetic technicians, registered; other
professional associations; government agencies; industry; and the public with the
Academys stance on factors determined to inuence healthy pregnancy, as well as an
overview of best practices in nutrition and healthy lifestyles during pregnancy.

POSITION STATEMENT
It is the position of the Academy of Nutrition
and Dietetics that women of childbearing
age should adopt a lifestyle 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 prepregnancy
weight, appropriate weight gain and physical
activity during pregnancy, consumption of a
wide variety of foods, appropriate vitamin
and mineral supplementation, avoidance of
alcohol and other harmful substances, and
safe food handling.

J Acad Nutr Diet. 2014;114:1099-1103.

HIS POSITION PAPER PROVIDES

Academy of Nutrition and Dietetics members, other professional associations, government
agencies, industry, and the public with
the Academys stance on factors determined to inuence healthy pregnancy, as
well as emerging factors. Women with
inappropriate weight gain, hyperemesis,
multiple gestations, poor dietary patterns
(eg, disordered eating), or chronic disease
should be referred to a registered dietitian nutritionist (RDN) for medical nutrition therapy. For specic practice
recommendations, refer to the Academys
practice paper on Nutrition and Lifestyle
for a Healthy Pregnancy Outcome.1

choices are major inuences on mother

and child health. Improving the wellbeing of mothers, infants, and children
is key to the health of the next generation. One in 33 babies (approximately
3%) is born with a birth defect2; in 2010,
low-birth-weight
(LBW)
infants
comprised 8.1% of US births.3 Birth defects and LBW are ranked rst and second, respectively, among the 10 leading
causes of death in US infants in 2006.3 A
womans chance of having a healthy
baby improves when she adopts healthy
behaviors, including good nutrition;
recommended supplementation; and
avoidance of smoking, alcohol, and illicit
drugs before becoming pregnant.2

TRENDS IMPACTING
PREGNANCY OUTCOMES
Birth Defects, Low Birth Weight,
and Viable Birth Trends

OBESITY AND GESTATIONAL

DIABETES

Pregnancy is a critical period during

which maternal nutrition and lifestyle
2212-2672/$36.00
http://dx.doi.org/10.1016/j.jand.2014.05.005

2014 by the Academy of Nutrition and Dietetics.

Prepregnancy body mass index (BMI) is

an independent predictor of many
adverse outcomes of pregnancy. The
prevalence of obesity in women 12 to
44 years of age has more than doubled
since 1976. In 1999 to 2004, nearly two
thirds of women of childbearing age
were classied as overweight (BMI

25) and almost one third were obese

(BMI
30).4 Overconsumption/overweight throughout the reproductive
cycle are related to short- and longterm maternal health risks, including
obesity, diabetes, dyslipidemia, and
cardiovascular disease. Caloric excess
does not guarantee adequate intake or
nutrient status critical to healthy
pregnancy outcomes.5
To improve maternal and child health
outcomes, women should weigh within
the normal BMI range when they
conceive and strive to gain within
ranges recommended by the Institute of
Medicine (IOM) 2009 pregnancy weight
guidelines.4 High rates of overweight
and obesity are common in population
subgroups already at risk for poor
maternal and child health outcomes,
compounding the need for intervention.4 In addition to health risks,
gestational weight gain beyond the
recommendation substantially increases risk of excess weight retention
in obese women at 1 year postpartum.6
More information on obesity and pregnancy outcomes can be found in the

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FROM THE ACADEMY

Position of the Academy of Nutrition
and Dietetics and American Society for
Nutrition: Obesity, Reproduction, and
Pregnancy Outcomes. 7
New diagnostic criteria for gestational diabetes mellitus (GDM) are expected to increase the proportion of
women diagnosed with GDM, with
potentially 18% of all pregnancies
affected.8 Immediately after pregnancy,
5% to 10% of women with GDM are found
to have diabetes, usually type 2. Women
who have had GDM have a 35% to 60%
chance of developing diabetes in the
next 10 to 20 years.8 RDNs can provide
valuable guidance to women seeking
assistance regarding optimal weight
and healthy food selection before, during, and post pregnancy. Additional information and guidance is available in
the Academys GDM Evidence-Based
Nutrition Practice Guideline.9

Hypertension and Preeclampsia

Prevalence of chronic hypertension in
pregnancy in the United States is estimated to be as high as 5%. This is primarily attributable to the increased
prevalence of obesity, as well as delay in
childbearing to ages when chronic hypertension is more common.10 Hypertension in pregnancy can harm both
mother and fetus, and women with
chronic hypertension are more likely to
experience preeclampsia (17% to 25% vs
3% to 5% in the general population).10
Age, preconception weight and health
status, access to timely and appropriate
health care, and poverty are some of the
numerous factors affecting maternal
health and the likelihood of a healthy
pregnancy. Referral to the RDN and/or
social worker may assure appropriate
care will be available, given the aforementioned factors that can inuence
maternal and fetal outcomes.

OPTIMIZING PREGNANCY
OUTCOMES WITH HEALTHY
LIFESTYLE CHOICES
Evidence is building that maternal diet
and lifestyle choices inuence the
long-term health of the mothers children. Prepregnancy adherence to
healthful dietary patterns, including
the alternate Mediterranean Diet, Dietary Approaches to Stop Hypertension
(DASH), and alternate Healthy Eating
Index, have been associated with a 24%
to 46% lower risk of GDM.11 Populationbased research provides evidence that
1100

maternal metabolic conditions may be

associated with neurodevelopmental
problems, including autism and developmental delays in children.12 Inadequate levels of key nutrients during
crucial periods of fetal development
may lead to reprogramming within
fetal tissues, predisposing the infant to
chronic conditions in later life. Those
conditions include obesity, cardiovascular disease, bone health, cognition,
immune function, and diabetes.13
Maternal weight gain during pregnancy outside the recommended range
is associated with increased risk to
maternal and child health.4 Although
physiological responses to prenatal
overnutrition result in poor health
outcomes that emerge in childhood
and adolescence, fetal undernutrition
responses range from fetal survival to
poor health outcomes emerging later
in the offsprings adult life.14 The IOM
recommends that more US women
achieve gestational weight gain within
the range identied for their prepregnant BMI.4 Pregnant women benet
from eating a variety of foods to meet
nutrient needs and consuming sufcient calories to support recommended
weight gain. Details regarding recommended energy requirements and recommended
weight
gain
during
pregnancy can be found in the related
practice paper.1

Energy Expenditure
Physical activity during pregnancy
benets a womans overall health. In a
low-risk pregnancy, moderately intense
activity does not increase risk of LBW,
preterm delivery, or miscarriage.15 Recreational moderate and vigorous physical activity during pregnancy is
associated with a 48% lower risk of hyperglycemia, specically among women
with prepregnancy BMI <25.16 A prenatal nutrition and exercise program,
regardless of exercise intensity, has
been shown to reduce excessive gestational weight gain and decrease weight
retention at 2 months postpartum in
women of normal prepregnant BMI.17

Appropriate and Timely Nutrient

Supplementation
Iron. Iron deciency with resultant
anemia is the most prevalent micronutrient deciency worldwide, affecting
primarily pregnant or lactating women
and young children.18 Iron-deciency

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

anemia in pregnant women in industrialized countries is 17.4%,19 with approximately 9% of adolescent girls and
women of childbearing age in the United
States having inadequate stores of body
iron.20 The high incidence of iron deciency underscores the need for iron
supplementation in pregnancy. During
the rst two trimesters of pregnancy,
iron-deciency anemia increases the risk
for preterm labor, LBW, and infant mortality.18 Maternal and fetal demand for
iron increases during pregnancy; this
increase cannot be met without iron
supplementation.18

Folic Acid. Folic acid is recognized as

important before and during pregnancy
because of its preventive properties
against neural tube defects. All women,
including adolescents, who are capable
of becoming pregnant should consume
400 mg/day folic acid from fortied
foods and/or dietary supplements, in
addition to eating food sources of
folate.21 Pregnant women are advised to
consume 600 mg dietary folate equivalents daily from all food sources. Dietary
folate equivalents adjust for the difference in bioavailability of food folate
compared with synthetic folic acid. One
dietary folate equivalent is equal to 1 mg
food folate, which is equal to 0.6 mg folic
acid derived from supplements and
fortied foods taken with meals.14
Women who have had an infant with a
neural tube defect should consult with
their health care provider regarding
the recommendation to take 4,000 mg
folic acid daily before and throughout
the rst trimester of pregnancy.22 An
association between the lack of periconceptual use of vitamins or supplements containing folic acid with an
excess risk for birth defects due to diabetes mellitus23 highlights ongoing
research.
Vitamin D. The function of vitamin D
during pregnancy for both mother and
fetus is not fully dened at present.24
Although vitamin D supplementation during pregnancy has been suggested as an intervention to protect
against adverse gestational outcomes,
including LBW,25 the need, safety, and
effectiveness of vitamin D supplementation during pregnancy remains
controversial.24 The IOM recommends
600 IU per day of vitamin D to meet the
needs of most North American adults,
including pregnant women.26 Ongoing
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FROM THE ACADEMY

research suggests higher levels of supplementation are safe and effective for
improving maternal and infant vitamin
D status.24

Choline. Choline is an essential

nutrient during pregnancy because of
its high rate of transport from mother
to fetus. Maternal deciency of choline
can interfere with normal fetal brain
development. Although choline is
found in many foods, the majority of
pregnant women are not achieving the
Adequate Intake for pregnancy of 450
mg choline per day.27
Calcium. The Dietary Reference Intake
for calcium in pregnancy is equal to that
of nonpregnant women of the same age
because of increased efciency in calcium absorption during pregnancy and
maternal bone calcium mobilization.26
Women with suboptimal intakes
(<500 mg/day) may need additional
amounts to meet both maternal and
fetal bone requirements.28

Iodine. Iodine is required for normal

brain development and growth; iodine
deciency worldwide is a growing
concern. During pregnancy, iodine requirements increase, making mother
and developing fetus vulnerable.
Congenital hypothyroidism is associated with cretinism, and clinical hypothyroidism has been associated with
increased risk of poor perinatal outcomes, including prematurity, LBW,
miscarriage, preeclampsia, fetal death,
and impaired fetal neurocognitive
development.29 Recent national surveys
indicate a subset of pregnant and
lactating US women may have mild to
moderately inadequate dietary iodine
intake.30 The IOM recommends an
iodine intake from dietary and supplement sources of 150 mg/day before
conception, and 220 mg per day for
pregnant women.31

Environmental and Dietary Issues

Foodborne Illness during Pregnancy. Pregnant women and their fetuses are at increased risk of developing
foodborne illness because of the hormonal changes of pregnancy that lead to
decreased cell-mediated immune function. Of greatest concern during pregnancy are Listeria monocytogenes,
Toxoplasma gondii, Brucella species, Salmonella species, and Campylobacter
July 2014 Volume 114 Number 7

jejuni.32 Pregnant women should closely

adhere to food-safety recommendations
outlined in the 2010 Dietary Guidelines
for Americans.21 Updated food-safety
guidelines can be reviewed on the Food
and Drug Administration at www.
fda.gov/Food/ResourcesForYou/Health
Educators/ucm083308.htm.

Benets and Concerns Regarding

Fish and Seafood Consumption. The nutritional value of seafood
is particularly important during fetal
growth and development, as well as in
early infancy and childhood.14 Intake of
n-3 fatty acids, particularly docosahexaenoic acid, from at least 8 oz of seafood
per week for pregnant women is associated with improved infant visual
and cognitive development.14 Although
prenatal mercury exposure (
1 mg/g)
was found to be associated with a
greater risk of attention-decit hyperactivity disorderrelated behaviors,
prenatal sh consumption of more than
two servings per week was protective of
those behaviors.33 RDNs and dietetic
technicians, registered, can help pregnant women balance the benets of
eating sh while avoiding high-mercury
content seafood.

Non-Nutritive Sweeteners. Although

calorie and blood glucose control are
acknowledged benets of non-nutritive
sweeteners, limited research addresses
the safety of non-nutritive sweeteners
on healthy pregnancy or in GDM.34

Alcohol. Alcohol should not be

consumed by pregnant women or
those who may become pregnant.14
Drinking alcohol during pregnancy,
especially in early pregnancy, may
result in behavioral or neurological
defects in the offspring and affect a
childs future intelligence. No safe level
of alcohol consumption during pregnancy has been established.14
Caffeine. Caffeine half-life increases in
pregnancy from 3 hours in the rst
trimester to 80 to 100 hours in late
pregnancy. Women who are pregnant or
trying to become pregnant are advised
by the American College of Obstetricians and Gynecologists35 to consume
no more than 200 mg of caffeine per
daythe approximate amount in one
12-oz cup of coffee. However, birth defects research indicates moderate or
high amounts of beverages and foods

containing caffeine do not increase

the risk of congenital malformations,
miscarriage, preterm birth, or growth
retardation.36

Hydration and Water Needs. Adequate hydration is essential to healthy

pregnancy, as a woman accumulates 6
to 9 L of water during gestation. The
total water Adequate Intake for pregnancy (including drinking water, beverages and food) is 3 L/day. This
includes approximately 2.3 L (approximately 10 cups) as total beverages.37
Energy Drinks. An energy drink is any
beverage that contains some form of
legal stimulant and/or vitamins added
to provide a short-term boost in energy. These drinks may contain substantial and varying amounts of sugar
and caffeine, as well as taurine, carnitine, inositol, ginkgo, and milk thistle.
Many of these have not been studied
for safety during pregnancy. Ginseng,
another common ingredient, is not
recommended for use during pregnancy. The avoidance of energy drinks
during pregnancy is advised.

Sugar-Sweetened Drinks. Sugarsweetened beverages, including regular sodas, sport drinks, energy drinks,
and fruit drinks, provide 35.7% of
added sugars in the US diet.14 Reduced
consumption of sources of added
sugars lowers the calorie content of the
diet without compromising nutrient
adequacy.

Health Conditions Between and

After Pregnancies
Maternal return to healthy weight status postpartum can prevent future
overweight and obesity.14 The 2010
Dietary Guidelines for Americans forms
the basis for nutrition counseling for
postpartum women, and RDNs and dietetic technicians, registered, can assist
women in achieving their prepregnancy weight.21 Outside of weight
status, recent research has shown that
diet quality, dietary intake, and overall
nutritional status can affect the risk of
postpartum depression. An association
among n-3 fatty acids, serotonin
transporter genotype, and postpartum
depression has been identied.38 Lowincome women with depressive
symptoms and life stressors are at risk
for low-prenatal diet quality, so

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FROM THE ACADEMY

intensive dietary intervention before
and during pregnancy may be needed
to promote optimal health.39 The risk
of maternal and infant mortality and
pregnancy-related complications can
be reduced with increased access to
quality interconception care.

9.

10.

Seely EW, Ecker J. Chronic hypertension

in pregnancy. N Engl J Med. 2011;365(5):
439-446.

11.

Tobias DK, Zhang C, Chavarro J, et al.

Prepregnancy adherence to dietary patterns and lower risk of gestational diabetes. Am J Clin Nutr. 2012;96(2):289-295.

12.

Krakowiak P, Walker CK, Bremer AA,

et al. Maternal metabolic conditions
and risk for autism and other neurodevelopmental disorders. Pediatrics.
2012;129(5):e1121-e1128.

CONCLUSIONS
Pregnancy has been regarded as a
maternal phase with requisite additional
nutritional requirements; mounting evidence suggests that the prenatal period
constitutes a critical convergence of
short- and long-term factors affecting
the lifelong health of mother and child.
The aim of prenatal nutrition is to support a healthy uterine environment for
optimal fetal development while supporting maternal health.5 The ideal prenatal diet should limit overconsumption
for the mother and prevent undernutrition for the fetus5; a healthy lifestyle includes regular physical activity and
avoidance of harmful practices.

13.

14.

15.

References
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2.

Academy of Nutrition and Dietetics. Practice Paper of the Academy of Nutrition and
Dietetics: Nutrition and lifestyle for a
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Centers for Disease Control and Prevention. FastStats: Births and natality. http://
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Rasmussen KM, Yaktine AL, eds. Weight

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Shapira N. Prenatal nutrition: A critical

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Vesco KK, Dietz PM, Rizzo J, et al. Excessive gestational weight gain and postpartum weight retention among obese
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Hanley B, Dijane J, Fewtrell M, et al.

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Correa A, Gilboa SM, Botto LD, et al. Lack

of periconceptional vitamins or supplements that contain folic acid and diabetes
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Hollis BW, Johnson D, Hulsey TC,

Ebeling M, Wagner CL. Vitamin D supplementation during pregnancy: Doubleblind, randomized clinical trial of safety
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25.

Thorne-Lyman A, Fawzi WW. Vitamin D

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Intakes for calcium and vitamin D. 2010.
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27.

Caudill MA. Pre- and postnatal health:

Evidence of increased choline needs. J Am
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28.

Hacker AN, Fung EB, King JC. Role of calcium during pregnancy: Maternal and
fetal needs. Nutr Rev. 2012;70(7):397-409.

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Amarasiriwardena C, Korrick SA. Prenatal
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37.

Institute of Medicine. Dietary reference

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Fowles ER, Stang J, Bryant M, Kim SH.

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This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on May 3, 2002 and reafrmed on
June 11, 2006 and September 9, 2010. This position is in effect until December 31, 2018. Requests to use portions of the position or republish in
its entirety must be directed to the Academy at [email protected].
Authors: Sandra B. Procter, PhD, RD/LD, Kansas State University, Manhattan, KS; Christina G. Campbell, PhD, RD, Iowa State University, Ames, IA
(Lead Author).
Reviewers: Jeanne Blankenship, MS, RD (Academy Policy Initiatives & Advocacy, Washington, DC); Quality Management Committee (Melissa N.
Church, MS, RD, LD, Chickasaw Nutrition-Get Fresh! Program, Oklahoma City, OK); Sharon Denny, MS, RD (Academy Knowledge Center, Chicago,
IL); Public Health dietetics practice group (DPG) (Kathryn Hillstrom, EdD, RD, CDE, California State University, Los Angeles, CA); Vegetarian
Nutrition DPG (Reed Mangels, PhD, RD, LDN, FADA. University of Massachusetts, Amherst); Kathleen Pellechia, RD (US Department of Agriculture,
WIC Works Resource System, Beltsville, MD); Julie A. Reeder, PhD, MPH, CHES (State of Oregon WIC Program, Portland, OR); Tamara Schryver, PhD,
MS, RD (TJS, Communications LLC, Minneapolis, MN); Alison Steiber, PhD, RD (Academy Research & Strategic Business Development, Chicago, IL);
Womens Health DPG (Laurie Tansman, MS, RD, CDN, Mount Sinai Medical Center, New York, NY).
Academy Positions Committee Workgroup: Cathy L. Fagen, MA, RD (Chair) (Long Beach Memorial Medical Center, Long Beach, CA); Ainsley M.
Malone, MS, RD, CNSC, LD (Mount Carmel West Hospital, Columbus, OH); Jamie Stang, PhD, MPH, RD, LN (Content Advisor) (University of
Minnesota, Minneapolis, MN).
We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the
supporting paper.

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