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Candidate name: Amna Adil Candidate number: PK 203/0005 Report writing Topic: Are pregnant women taking enough Calcium and Vitamin D in their diet? Candidate name: Amna Adil Are pregnant women taking enough Calcium and Vitamin D in their diet? i

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Page 1: pregnant women

Candidate name: Amna AdilCandidate number: PK 203/0005

Report writing

Topic: Are pregnant women taking enough Calcium and Vitamin D in their diet?

Candidate name: Amna Adil Candidate number: PK 203/0005

REPORT WRITINGAre pregnant women taking enough Calcium and Vitamin D in their diet? i

Page 2: pregnant women

Candidate name: Amna AdilCandidate number: PK 203/0005

Topic: Are pregnant women taking enough

Calcium and vitamin D in their diet?

INTRODUCTION: Pregnancy is critical period for both expecting mother and fetus. Every pregnant woman desires to produce a healthy baby. There is a popular saying that a pregnant women should "eat for two”, it means that her diet should provide sufficient nutrients to cope with the demands for the growing baby as well as the needs of her own body. Her physical health, socio-economic conditions and eating habits can have a far reacting affect on the life of the baby. Calcium and vitamin D play a very important role during pregnancy. They are responsible for the formation of bone structure and cartilages of the fetus. It promotes adequate mineralization of the fetal skeleton and teeth and the health of the mother. Most calcium is required during the 3rd trimester when the skeletal bones are growing most rapidly and teeth are forming. The study will mainly focus on the intake of calcium and vitamin D of the low income pregnant women between the ages of 25 to 40 years. As Pakistan is a developing country so there is a high ratio of low income group. The reason for choosing this specific income group is that deficiency of calcium and vitamin D is quite prevalent among these women. There is a high social economic disparity prevailing here. The low food budget and less awareness regarding balanced healthy diet for pregnant women ultimately affect their eating habits. This may results in low birth weight and osteoporosis in these young women. In developing country like Pakistan most of the low income pregnant women it is difficult to spend large amount on food for themselves, hence, an unbalanced nutrionally inferior diet is eaten, containing insufficient amounts of nutrients especially calcium and vitamin d to meet the needs of pregnant women. This leads to a high deficiency of calcium rich foods thus resulting incidence of low birth weight and softening of bones and it includes osteomalacia in women. This deficiency may have long-term consequences for the growth and development of themselves and for their children. Reason for taking up this topic was to have an interaction with pregnant women of limited income group and to identify their problems regarding balance diet. As calcium and vitamin d are very important minerals during pregnancy this will give me an opportunity to observe the affects of limited intake of calcium rich foods on this group of women. I am looking forward to the field work which will Are pregnant women taking enough Calcium and Vitamin D in their diet? ii

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Candidate name: Amna AdilCandidate number: PK 203/0005

include interview, observation and study of the effect of calcium and vitamin D on this very special time in the life of a woman.

AIMS AND OBJECTIVES Asses the amount of calcium rich foods in pregnant women. Asses the amount of vitamin d rich foods in pregnant women. Identification of calcium and vitamin d rich foods locally

available. To observe signs and symptoms of calcium and vitamin d

deficiency in pregnant women. Study the reasons for social problems faced by these women and

sufficient or insufficient calcium and vitamin D intake affect on diet.

Problems and risk for the developing baby. Suggested dishes providing calcium and vitamin d in a meal to

low income women. identification locally available sources of calcium and vitamin d Suggest preventive measures to reduce the chances of calcium

and vitamin d deficiency. What do they eat daily?

LIMITATIONS Survey carried out on low income families only. only a selected number of pregnant women will be considered

i.e. 10-15 women having their 1st or 2nd child will be selected women should be in last trimester of pregnancy only a specific age group i.e. 25-40 are taken into consideration

PLANNING Information will be gathered from internet and available books. questionnaires will be made to record the calcium and vitamin d

intake of low income women the calcium and vitamin d content in the diet of low income

women will be analyzed using questionnaires and food tables Comparing of results will be done with the RDA's to check

whether the calcium and vitamin d intake of low income women is sufficient or not.

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Candidate name: Amna AdilCandidate number: PK 203/0005

THEORETICAL RESEARCH

CALCIUM Calcium is the most abundant mineral present in the body almost 40% of the total mineral mass i.e. 3lb of body’s weight. Majority of calcium present in bone where, together with phosphorus it plays an essential part in hardening the skeleton and teeth. In addition, this calcium is a reserve of the mineral for its role in the body fluids as ionic calcium, which is essential for many functions.

BLOOD CLOTTING

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One of the most important and vital function of calcium is blood clotting. In this process, Calcium ions participate in several reactions in the cascade that leads to formation of fibrin, the main protein component of a blood clot. The conversion of prothrombin to thrombin requires calcium, without sufficient calcium in the blood clots will not form. Clotting is very important in labor and delivery.

TRANSMISSION OF NERVE IMPULSES When an impulse reaches its target site, such as a muscle, other nerve cells or a gland, the impulse is transmitted across the junction between the nerve and its target cells. In many nerves, arrival of action potentials at the target site stimulates an influx of calcium ions into the nerve from the extra cellular medium. The rise in intra cellular calcium ions then triggers release of neurotransmitter, which are responsible for carrying impulses to the target cells. Calcium also may influence the flow of other ions in and out of nerve cells.

MUSCLE CONTRACTION The critical role of calcium in muscle contraction is most easily understood in the case of skeletal muscles. When a skeletal muscle is stimulated by a nerve impulse from the brain, calcium ions are released from

Intracellular store with in the muscle cells. The resulting increase in the concentration of calcium ions in a muscle cell is one factor, along with ATP, that permits the contractile proteins, actin and myosin, to interact. This leads to muscle contraction.

CELL METABOLISM Finally, calcium ions help regulate metabolism in the cell by participating in calmodulin, i.e., a cell protein that binds calcium ion, system. When calcium enters a cell (because of hormone action) and bonds to the protein calmodulin, the resulting protein-calcium complex regulate the activity for enzymes that synthesis glycogen. Calcium also support and feed the perineal muscles to make them supple for dilation at delivery. Calcium will help to prevent and minimize stretch marks, although stretch marks tend to be more of a hereditary situation.

Calcium helps in the process of secretion of fluids e.g. Bile, pancreatic fluid, gastric, intestinal, hormonal, mucous all rely on calcium to move the small droplets through the cells boundaries, and cell walls. It maintains the balance of proteins in the body by AMP (adenosine monophosphate) and helps to control cholesterol.

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Candidate name: Amna AdilCandidate number: PK 203/0005

VITAMIN D For years vitamin D was thought to have one primary function in the body, namely to help regulate blood calcium. Calcitriol, the active hormone form of vitamin D, increases calcium and phosphorus absorption in the small intestine by the means of two separate mechanisms. In one process, calcitriol travels into the nucleus of intestinal cells and binds to specific nuclear receptor on DNA, there by stimulating synthesis of a variety of calcium transport proteins. These proteins increase calcium and phosphorus absorption from the small intestine since they form a specific calcium carrier. In the other process, calcitriol likely alters the membranes of intestinal cells, allowing more passive calcium absorption into the intestinal cells. Since calcitriol treatment increases calcium absorption even before the calcium transport protein appear in the cell, this second mechanism is probably partially responsible for enhanced calcium absorption. When blood calcium is low, the parathyroid gland releases parathyroid hormone, which acts to stimulate synthesis of calcitriol in the kidneys. The calcitriol then interacts with cells in the small intestine, and with specific bone and kidney cells. In the intestinal cells, calcitriol promotes calcium absorption. In the bone-reabsorbing cells, called osteoclasts, calcitriol and parathyroid hormone stimulate the release of bone calcium to the blood. In the kidneys, calcitriol and parathyroid hormone prevent calcium loss via the urine. Together, these three functions, i.e., increase absorption of calcium and phosphorus from small intestine; reduces calcium excretion by the kidneys; and it indirectly helps regulate calcium deposition in the bones.

DEFICIENCY DISEASES

RICKETS Without adequate calcium and phosphorus deposition, the skeleton fails to mineralize properly and bones weaken and bow under pressure. When these effects occur in a child, the disease is called rickets. Signs of rickets include enlarged head, joints, and rib cage, a deformed pelvis and bowed legs. , the problem is likely to worsen during pregnancy because of the active transplacental transport of calcium to the developing fetus. Hypovitaminosis D during pregnancy has important consequences for the newborn, including fetal Hypovitaminosis D, neonatal rickets and tetany, and infantile rickets.

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OSTEOMALACIA Rickets in adults is called osteomalacia, which means “soft bones”. It occurs most often in women who have low calcium intake and little exposure to sunlight and who go through repeated pregnancies and periods of lactation. The leg bones may soften to such an extent that a young women who is tall and straight at 20 may become bend, bowed legged and stooped before she is 30. It can cause fractures in the hip, spine, and other bones.

OSTEOPOROSIS Osteoporosis, which means “porous bones”, is at epidemic proportions particularly in women after the menopause. It is a painful and potentially crippling disease, which is due to the loss of calcium in the bones. By the age of fifty up to 25 per cent of the skeleton could be missing due to Osteoporosis. This can increase the risk of bone fractures, loss of height and formation of a “dowager’s hump” all due to the soft and thinning bones. Osteoporosis can be further classified as type 1 (postmenopausal), which appears in the years right after menopause, and type 2 (senile), which is found in people of advances ages.

In osteomalacia, the bone is abnormal because it contains too little calcium. In contrast, bone composition in osteoporosis is essentially normal. The bone may contain some extra sodium ions, but

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there is just less bone throughout the body. Because these bones have less substance, osteoporosis can lead to fractures in old age, distorted body shape, and loss of teeth.

Factors contributing to the development of osteoporosis could include the following:

Vitamin D Deficiency-lack of Vitamin D decreases the bones’ absorption of calcium.

Estrogen Deficiency-without estrogen, bones demineralization accelerates in women.

Inactivity-weight bearing exercise is necessary to stimulate bone strengthening. A lack of exercise may contribute to a loss of bone calcium.

Gender-women are at a greater risk than men are. Heredity-if the disease runs in your family—mother or

grandmother. Race-Caucasian and Asian women are most at risk for the

disease, but African American and Hispanic women can get it too.

Figure type-women with small bones and those who are thin are more liable to have osteoporosis.

Early menopause-women that stop menstruating early because of heredity, surgery or lots of physical exercise may lose large amounts of bone tissue early in life. Conditions such as anorexia and bulimia may also lead to early menopause and osteoporosis.

Diet-people who do not get enough calcium or protein may be more likely to have osteoporosis. People who constantly diet are more prone to the disease

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FOOD SOURCES

CALCIUM Dairy products, such as milk and yoghurt are major source of calcium in Pakistani diets, people over here does not consume much cheese. To get a good daily intake of calcium diet choices are important. At least three servings a day of dairy products is essential to maintaining good calcium levels. Okra is another great calcium source. Today many products, like orange juice, have calcium added. Making simple choices when buying foods with added calcium can help you to get enough calcium daily. Wheat cereals and some vegetables like spinach also provide calcium but these are not good sources because calcium and many other nutrients are not fully absorbed due to NSP (fiber) and acids present in cereals and vegetables.

Omega 3 and 6 fatty acids that are found in fish oil and evening primrose oil if taken in large doses increase the absorption of calcium from the gut like vitamin D does. Not only do they increase calcium absorption but they also reduce calcium loss in the urine. PUFAs prevent the abnormal deposition of calcium in soft tissue and increase calcium levels in bones. PUFAs can help with the bone loss at menopause.Are pregnant women taking enough Calcium and Vitamin D in their diet? ix

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Candidate name: Amna AdilCandidate number: PK 203/0005

VITAMIN D The most nutrient dense sources of vitamin D are fatty fish e.g. sardines and salmon, fortified milk, and some fortified breakfast cereals. Although eggs, butter, liver and a few brands of margarine contain some vitamin D but large servings should be eaten to obtain appreciable amount of the vitamin. But the main source of vitamin D is sunlight which is a non food source which converts a natural substance i.e. ergosterol in the skin to active form of vitamin D. body should be exposed to sunlight daily for the formation of vitamin D.

CALCIUM AND VITAMIN D REQUIREMENT DURING PREGNANCY In females, skeleton growth continues until approximately age 20, but the bone mineral content may accure until age of 35. Calcium is a nutrient central to this process. During pregnancy, calcium nutrition may be especially important for women’s own bone health and that of their babies. During a full term pregnancy, the fetus takes approximately 30g calcium from the mother, which may occur at the expense of mother’s bone, if calcium intake is insufficient. In addition, women who consume more calcium and vitamin D during pregnancy may have higher levels of calcium in their breast milk, and babies born to women with higher calcium intake may have better bone mineralization and lower blood pressure in later life, though this may

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Candidate name: Amna AdilCandidate number: PK 203/0005

or may not be a causal association.

Calcium supplements have shown to protect against pre-eclampsia i.e. high blood pressure in pregnancy. It is a good idea to increase calcium consumption during the last 3 months of pregnancy and the first few months of lactation to ensure that the body get sufficient amount of calcium to help bone development and growth. In pregnant women, calcium intake is also important. Baby needs calcium to grow and takes this calcium from the mother. So increased calcium intake is important during pregnancy. Pregnant and breast feeding mother should get 1,400mg a day and older adults should have 1,500mg a day. It is very difficult to take too much calcium and intakes of up to 2,500mg have proven safe. Excess calcium is easily removed form the body through waste.

SUPPLEMENTS Calcium supplements have shown to protect against pre-eclampsia which is high blood pressure in pregnancy. Supplements can also be part of a woman's health and nutrition program; however, certain precautions need to be identified. Associated with the taking of calcium supplements may be the development of kidney stones or distress experienced in the digestive system. Therefore, in considering taking these calcium supplements, it is important to consult with your physician. It is important to remember that when taking calcium supplements the daily-recommended dose should be adhered

No woman should take extra vitamin D in pregnancy unless recommended by their doctor Professor James Walker Royal College of Obstetricians

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Candidate name: Amna AdilCandidate number: PK 203/0005

CONCLUSION

A survey was conducted on pregnant women, who were in their last trimester. Their ages ranged between 24-40 years. And they belonged to lower middle class families, their total house hold income ranged from 8000 to 30000 rupees. The international standard for weight gain in pregnancy is 15 to 17 kg. But as Pakistan is a developing country they are not much aware of their nutritional needs, thus resulting in less food intake so weight gain standard in Pakistan is 10-12 kg. The survey showed that 67% of the pregnant women were underweight compared to their height, age and weight. During pregnancy requirements for calcium and vitamin D increases many folds. Calcium is required by both mother and the fetus. 44%of the pregnant women were not consuming milk on daily basis and in one case it was one or two glasses of milk per week. The average intake of milk was 1 glass per day. 40% of expecting mothers were taking carton milk but 33% had fresh milk intake. Only 27%were dependent on dried powdered milk as it was an expensive source. They were taking many milk dishes e.g. kheer, firni, custard, vermicelli, gajraila (local dish) etc and milk shakes e.g. milk soda, fruit shakes and lassi. Most of them were taking these once a week but in one case it was once in a month. The most popular dairy product among pregnant women was yoghurt and mostly it was taken as a part of meal as raita or lassi. Cheese was not a major source of calcium in their diet as it is not easy to keep in hot summer climate. Only 1 out of 12 women had lactose intolerance so she was not consuming milk on daily basis. Those who took 1 glass of milk daily and were not careful about their dairy intake they mentioned problems like pains in different parts of body e.g. back ache, head ache, pain in joints etc. It was observed that these pregnant women were not dependent on food sources for calcium and vitamin D intake but preferred supplements as their source. The supplements which they were taking were Cal-1000 tablets, VC-Cal tablets, Oslate tablets and Qalsan tablets. Therefore the survey conducted revealed that very few pregnant women had nutritional knowledge about their dietary needs. They had many social and economic problems which main reason for their less intake of nutritious diet. As they live in a

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male dominant society, husbands and male members of the family are given priority in every aspect, especially food. Thus the women have to eat left over food whether they are pregnant, lactating or ill. Survey also showed that they were consuming more of fatty food instead of high protein, calcium or carbohydrate diet. They had a misconception that fatty food is best for the developing baby. Fatty foods e.g. butter and highly saturated ghee was a part of their every meal.

Are pregnant women taking enough Calcium and Vitamin D in their diet? xiii

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types of milk consumed by pregnant women

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Pictures taken of pregnant women during the visit to Atchison hospital

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Candidate name: Amna AdilCandidate number: PK 203/0005

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Are pregnant women taking enough Calcium and Vitamin D in their diet? xx

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EVALUATION

The main aim of this report was to assess the deficiency of calcium and vitamin d in pregnant women. The survey showed that the women of this selected group were severely deficient in these nutrients. Recommended Daily Intake is 3-4 servings of milk and milk products but due to their lack of awareness and economic problems they were not consuming it. Mostly the women of this age group were unaware of their dietary needs. The survey was conducted in a Government Lady Aitchison hospital, Lahore and the gynecologist was Dr.Naghmana Bashir. I came across many pregnant women and was able to directly interact with them and understand what they were going through. It was heart warming experience to see a life being generated from a life. I was surprised to find that pregnant women were deficient not even in Calcium and Vitamin D but in many other essential nutrients as well. They were facing so many problems. As we are living in male dominating society, so male members of the members are given priority over females in every aspect of life. Food is first served to the male members and the left over is given to the females even if they r pregnant or lactating. Not only in food, in education as well lower class do not educate their daughters because they think it’s a waste of money as they just have to give birth and care for in laws. There are several taboos that pregnant women should not eat fish, which is a rich source of vitamin d, because it may harm the baby. Pregnant women are advised to consume more of fatty foods in every meal because they think it will make the baby healthy and ease in delivery. My diary of activities started from February, I planned it but my diary of activities did not go well in time. As Pakistan is a developing country, So our government does not have health counseling or health benefits for the low income class who can not afford private hospitals. Governments should make education compulsory on every one whether a boy or a girl. Government should increase the health standards and medical facilities in government hospitals. Awareness should be given through media; different programs should be launched or presented on women’s health and needs. Seminars should be held in hospitals for doctors to discuss new ways to give awareness to pregnant women. I gained many personal benefits. I gained confidence, my conversation skills improved from this survey. I learned to operate blood pressure apparatus. I became proficient at using

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Microsoft Word, Microsoft Excel and picture manager. Over all it was a highly learning experience.

BIBLIOGRAPHY

References from web sites www.aboutcalcium.net/

The_Importance_Of_Calcium_In_The_Diet.html - 18k www.zimbio.com/Pregnancy+And+Birth/articles/33/

IMPORTANCE+CALCIUM+MAGNESIUM Are pregnant women taking enough Calcium and Vitamin D in their diet? xxiii

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www.aboutcalcium.ne www.osteoporosis.org.au/files/internal/oa_calcvitd_pharma.pdf www.sonoma-county.org/health/ph/mchfieldnursing/

pregnancy_pyramid.htm www.news.bbc.co.uk/1/hi/health/4584518.stm - 33k www.womenshealthprognosis.com/womens-health-and-

nutrition.html - 14k -

References from books Barasi, Mary E, Human Nutrition 2nd Edition, Hodder Arnold

Publishers, London. Robinson, Corinne H and Lawler, Marilyn R, Normal and

Therapeutic Nutrition 7th edition, Macmillan Publishers, New York.

Wardlaw, Gordon M Insel, Paul M, Perspectives in Nutrition 3rd Edition, Mosby Publishers, London.

Whitney, Eleanor Noss and Rolfes, Sharon Rady, Understanding Nutrition 9th Edition, Wadsworth publishers, New York.

SAMPLE QUESTIONNAIRE

1. Age

2. height

3. weight

4. pregnancy stage(month)

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5. income A) Less than 10000 b) 10000 c) 20000 d) 30000

6. Do you consume milk daily? a) Yes b) no

7. How many glasses of milk you consume everyday? a) 1 b) 2 c) 3 d) per week

8. What type of milk you are consuming? a) Fresh milk b) dry milk c) carton milk

9. Identify other milk products in your diet? a) Cheese b) yoghurt

10. Do you have any problem in digesting milk or milk products? a) Yes b) no

11. Identify milk dishes you consume? 12. How much of these do you take per week?

13. Do you take calcium and vitamin D supplements? a) Yes b) no

14. Name it?

15. Do you suffer from any backache? a) Yes b) no

16. Do you suffer from any pain in joints? a) Yes b) no

17. Do you expose your body to sunlight? a) Yes b) no

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