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Protein and Immunonutrients: Shaping the Health of Mother and Child
By - Danone Nutricia Academy

Mother's Day is just around the corner! It is a celebration honouring motherhood, maternal bonds, and the influence of women as mothers in the society. This unique day provides an opportunity to focus on the motherhood-related health aspects that need attention.

Conception marks the initiation of rapid and significant physiological changes in a woman, continuing until the baby’s birth.1 Thus, the nutritional requirements are also high during pregnancy to promote maternal metabolism, tissue growth, and support the development of a fetus.1 This article emphasizes on the significance of immuno nutrients such as protein and micronutrients for mother and child’s health in the first 1000 days of life.

Maternal malnutrition is the predominant cause of low birth weight and impaired foetal health outcomes.2 Studies show that perinatal protein and micronutrient deficiencies can negatively impact proper growth and development of organs in the foetus. Adverse pregnancy outcomes and long-term metabolic dysfunctions are the likely outcomes in such cases.1,2 Adequate intake of energy, protein, and other macronutrients is thus vital to ensure gestational weight gain and growth of the foetus.3 Among these, proteins play an essential role in structural (collagen, keratin) and functional (enzymes, transport proteins, and hormones) development of tissues and organs.1

Role of protein quality in the first 1000 days of life

Protein sources and quality

A high-quality protein is easily digestible and supplies all the essential amino acids required for growth, repair, and maintenance.1 Plant-based foods like nuts, grains, legumes, etc. are largely considered as primary protein sources, but may lack few of the essential amino acids.1 However, appropriate combinations of vegetarian sources can ensure that complete protein is achieved by complementation of amino acids. Animal sources of protein like milk and milk products, fish, eggs etc. are considered complete sources, with all the essential amino acids. Altogether, these protein sources should be optimized to meet body’s entire amino acid requirements during pregnancy.1,4

Protein turnover during pregnancy

Evidence suggests that the protein turnover in the first trimester is almost similar in pregnant and non-pregnant women. In contrast, protein synthesis increases by 15% and 25% in the second and third trimesters, respectively.1 These changes in protein metabolism occur to meet increased fetal demands, maintain maternal homeostasis, and prepare for lactation phase.1

Protein quality in Indian traditional diet

A post-hoc analysis of results of a survey by National Nutrition Monitoring Bureau (NNMB) of India revealed following facts for the quality of protein consumed by pregnant women in India.4

  • A pooled, diet protein inadequacy risk of 76.9% was reported for corrected digestible indispensable amino acid (DIAA) requirements for Indian pregnant women.
  • An inverse relationship between DIAA score for pregnancy diet and prevalence of LBW in India.

Thus, the review highlighted the need of improvement in protein adequacy of Indian diet for pregnant women. Table 1 represents the latest recommended daily allowance (RDA) for protein in pregnant and lactating mothers.

Table 1: Protein requirements during pregnancy, lactation, and infancy3(Adapted NIN Report, 2020)

Time

Protein requirements (g/Day)

Pregnant women

Third trimester

68

Lactating women

First six months

63

Next six months

59

Impact of mother’s diet on fetal development

The composition of the mother’s diet and birth outcomes are associated with each other. Thus, maternal nutritional status impacts fetal body weight and proportion. 3,5 A few observational studies showed that maternal protein intake was associated with increased birth weight independent of energy intake, body mass index (BMI), maternal age, or lifestyle-related factors. The protein intake of 10-25% of the total energy may be safe.1

Outcomes of clinical trials investigating the role of protein quality on maternal and foetal Health
  • Higher protein intake is linked with increased birth weight and ponderal index5
  • The consumption of a higher amount of energy from the protein in the initial stages of pregnancy was significantly and positively associated with 16 g increase in birth weight (95% confidence interval [CI]; borderline values: 2.8 to 29.2 g) and 4.2 g increase in placental weight (95% CI; borderline values: –0.4 to 8.5 g) for every 1% increase of protein in the diet. This correlation was independent of maternal age, parity, and smoking.
  • The intake of energy from dairy protein was favorably linked with birth weight and improved ponderal index. A 0.12 kg/m3 increase in the ponderal index and a 24 g increase in birth weight was observed for every 1% increase in dairy protein intake.
Role of micronutrients in maternal and child health

Multiple micronutrient deficiencies may present during pregnancy and lactation, which may contribute to poor pregnancy outcomes, infant growth and weak immune system of the mother.5 The most prominent cause of micronutrient deficiencies is a poor-quality diet.7 Table 2 presents the latest National Institute of Nutrition (NIN) experts recommended daily allowance (RDA) of essential immunonutrients and their role during pregnancy and lactation.

Table 2: Role and RDA of immunonutrients during pregnancy and lactation3, 8-11

Micronutrient

RDA3,11

Role

Pregnancy

Lactation

Vitamins

Biotin

[μg/day (AI)]

40

45

·        Synthesis of essential carboxylase enzyme required for rapidly dividing cells of developing fetus8

Folate

(μg/day)

570

330

·     Plays a role in cell-mediated and innate immunity10

·     Assists Th-mediated immune response10

·     Amino acid and nucleic acid metabolism

·     Embryonic and fetal growth8

·     Needed for neural tube closure Prevention of neural tube defects8

Riboflavin (mg/day)

2.7

2.9 – 3.0

·        Energy metabolism and antioxidant functions8

Vitamin A

(μg/day)

900

950

·      Essential for normal functioning of macrophages, neutrophils, and N cells10

·      Assists in maintaining the functional and structural integrity of mucosal cells in skin and respiratory tract innate barrier10

·      Required for the proper functioning of B and T lymphocytes10

 

Vitamin B6

(mg/day)

2.3

+0.17 -

+0.26

·     Regulation of inflammation10

·     Plays a role in NK cell activity and cytokine production9Nervous system function8

·     Red blood cell transformation8

·     Nucleic acid synthesis8

Vitamin B12

(μg/day)

2.45

3.2

·     Plays a role in NK cell activity10

·     Involve in cellular and humoral immunity10

·     A cofactor for essential enzymes for embryonic and fetal development (gene expression, cell differentiation, and organ formation)8

Vitamin C

(mg/day)

80

110

·     Support integrity of epithelial barrier by enhancing collagen synthesis10

·     Stimulate production, function, and movement of leukocytes10

·     May increase antibody serum level10

Minerals

Calcium

(mg/day)

1,000

1,200

·        Maternal and fetal bone health8

Chromium

(mg/day)

 50

50

·        Control of blood glucose in gestational diabetes8

Iodine (μg/day)

250

280

·     Maternal thyroid hormone production

·     Normal fetal brain development8

Iron

(mg/day)

27

23

·     Role in regulation of cytokine production and activity10

·     Differentiation and proliferation of T lymphocytes10

·     Need to meet the increased demand to transport oxygen8

·     Growth and development of the placenta and fetus8

Magnesium

(mg/day)

440

400

·        Normal embryonic and fetal development8

Zinc

(mg/day)

14.5

14

·      Protection against ROS and RNS due to its antioxidant effects10

·      Role in maintaining skin and mucosal membrane integrity10

·      Prevention of several adverse events associated with zinc deficiency such as premature delivery, low birth weight, laborand delivery complications, as well as congenital anomalies8

Other nutrients

Choline

[mg/day (AI)]

45011

55011

·      Liver function8

·      Placental function8

·      Embryonic and fetal bone development8

RDA: recommended daily allowance; AI: adequate intake; NK: natural killer; RNS: reactive nitrogen species;
ROS: reactive oxygen species; Th: helper T cell

Importance of nutritional supplementation through diet or nutritional therapy

Women are commonly vulnerable to micro- and macro-undernutrition during their pregnancy and lactation period due to increased food and nutrient requirements.12 Evidence suggests that nutritional deficiencies are present in all segment of the populations and continues throughout the lifetime of a women.12 WHO recommends adequate energy/protein intake in pregnant women to meet pre-pregnancy BMI and individualized gestational weight gain.1 Therefore, a review of NNMB survey from India recommended optimising the diet of Indian pregnant women for its protein quality.4 Another study recommended a balanced protein intake through supplements in women, who are at risk of protein deficits to improve pregnancy outcomes.13

A Cochrane Review of 12 randomized controlled trials (n=6705) reported that protein-energy supplementation in pregnant women increased birth weight and even decreased risk of small-for-gestational-age (SGA) infants and stillbirth. 1

Like macronutrients, micronutrients too play a critical role in cellular signalling and functioning, reproductive health, work capacity, learning, and cognitive function, as well as in the evolution of microbial virulence.14 Various micronutrients such as vitamin C, riboflavin zinc, iron, etc. have immune-modulating functions; thus, affect the susceptibility to infectious diseases. The antioxidant function of some micronutrients regulates immune homeostasis.14 Therefore, micronutrient supplementation is preferred to prevent and manage micronutrient deficiencies in such populations.14

A woman’s health affects socio-economic aspects of the family.14 The importance of a balanced and healthy diet before and during pregnancy and lactation should not be undermined.1 Evidence suggests that the risk of protein inadequate diet among Indian pregnant women is significantly high and associated with prevalence of LBW.4 Therefore, nutritional supplementation is critical in meeting the recommended dietary intake of protein and immune nutrients in women.14
On this ‘Mother’s Day 2021’, let us join hands to nourish motherhood!

References:
  1. Mousa A, Naqash A, Lim S. Macronutrient and micronutrient intake during pregnancy: an overview of recent evidence. Nutrients. 2019 Feb;11(2):443.
  2. Oke SL, Hardy DB. Effects of Protein Deficiency on Perinatal and Postnatal Health Outcomes.Handbook of Famine, Starvation, and Nutrient Deprivation.2017 Jun.
  3. Nutrient requirements, recommended dietary allowances, and estimated average requirements for Indians. National Institute of Nutrition (NIN) Expert Group Report [Internet] 2020 [Cited 2021 May 05]. Available from: https://www.nin.res.in/nutrition2020/RDA_short
    _report.pdf
  4. Bandyopadhyay S, Shivakumar N, Kurpad AV. Protein intakes of pregnant women and children in India—protein quality implications. Maternal & child nutrition. 2020 Dec;16:e12952.
  5. Moore VM, Davies MJ, Willson KJ, Worsley A, Robinson JS. Dietary composition of pregnant women is related to size of the baby at birth. The Journal of nutrition. 2004 Jul;134(7):1820-6.
  6. Smith WJ, Underwood LE, Clemmons DR. Effects of caloric or protein restriction on insulin-like growth factor-I (IGF-I), and IGF-binding proteins in children and adults. The Journal of Clinical Endocrinology & Metabolism. 1995 Feb;80(2):443-9.
  7. Allen LH. Multiple micronutrients in pregnancy and lactation: an overview. Am J Clin Nutr. 2005 May;81(5):1206S-12S.
  8. Micronutrient Needs During Pregnancy and Lactation. [Internet] 2016 [Cited 2020 June 14]. Available from: https://lpi.oregonstate.edu/mic/life-stages/pregnancy-lactation
  9. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. [Internet] 1998 [Cited 2020 Aug 26]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK114310/
  10. Maggini S, Pierre A, Calder PC. Immune function and micronutrient requirements change over the life course. Nutrients. 2018 Oct;10(10):1531.
  11. Korsmo HW, Jiang X, Caudill MA. Choline: Exploring the growing science on its benefits for moms and babies. Nutrients. 2019 Aug;11(8):1823.
  12. Rao KM, Balakrishna N, Arlappa N, Laxmaiah A, Brahmam GN. Diet and nutritional status of women in India. Journal of Human Ecology. 2010 Mar 1;29(3):165-70.
  13. WHO, Balanced energy and protein supplementation during pregnancy. [Internet] 2020 [Cited 2020 June 22]. Available from
    :https://www.who.int/elena/titles/energy_protein
    _pregnancy/en/#:~:text=Current%20evidence
    %20indicates%20that%20balanced
    ,especially%20among%20undernourished%
    20pregnant%20women.
  14. Salam RA, Das JK, Bhutta ZA. Multiple micronutrient supplementation during pregnancy and lactation in low-to-middle-income developing country settings: impact on pregnancy outcomes. Ann Nutr Metab 2014;65(1):4-12.

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