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They Are What You Eat—
Nutrition in a Plural Pregnancy

  Reprinted with permission from Twin Services,
Parenting Education Handout #120

Before we found out I was having twins, my obstetrician kept scolding me for gaining so much weight. I was ravenously hungry all the time and was eating constantly just to keep going. Not junk food, just lots of nutritious snacks. By the fifth month, I was getting so huge that he did an ultrasound test to determine the due date, thinking I must have gotten the conception date wrong. When the twins shows up, he decided I wasn't over-eating, after all." Fortunately for herself and her babies, this mother heeded her body's signals to eat not only high quality foods, but large quantities, as well. Both of her infants, born at 39 weeks, weighted over six pounds at birth and had no significant health problems. Though she had gained nearly 60 pounds, she was back to her pre-pregnancy weight after six months of breast feeding the twins.

For many years, it has been standard obstetrical practice to advise pregnant women is to limit their weight gain to 24 pounds, or even less. Now, however, there is a growing volume of nutritional research and clinical observation which disputes the wisdom of this advice. Many researchers and physicians now recommend gains of up to 40 pounds for one baby and up to 60 pounds for twins. What does this mean for a woman carrying twins, triplets or more? It means that if her multiples go undetected and she follows traditional weight guidelines, her body is most likely not getting the nutrients and calories it needs to grow two or more healthy fetuses and also sustain the pregnancy to full-term.

There are many factors which contribute to a healthy pregnancy - heredity, appropriate exercise, avoidance of tobacco, alcohol and drugs - but, of those under the mother's control, the single most important element in a successful outcome is probably good nutrition. Your body is a sophisticated chemical factory and the food, air and water you take in are the raw materials fueling its continuous operation. The science of nutrition is vast and complex, involving study of biochemical interactions among thousands of different substances inside living human beings. Thus, well-designed studies of the effects of particular nutrients are difficult to conduct, especially on people. Animal studies have taught us a lot, but the results cannot always be applied directly to humans. Nevertheless, a great deal has been learned about basic nutrition and about its vital importance in pregnancy.

Family practice physicians and obstetricians should not necessarily be faulted for not being up to the minute on all the confusing and sometimes contradictory nutrition research. Only recently have any U.S. medical schools even offered courses on nutrition. The subject was usually addressed only in the context of diseases caused by severe vitamin deficiencies, most of which are rare in this country today. Many doctors are becoming more willing to refer patients to consultants for specialized advice. Just as the best person to ask about medication side-effects and drug interactions may be your pharmacist rather than your interest, the best person to ask about nutrition in pregnancy is often a registered dietitian (RD) rather than your obstetrician. Dietitians have studied biochemistry and nutrition on a post-graduate university level and know how to design diets and explain healthful food preparation in a practical, understandable way. If you are pregnant or breast feeding and feel you need more nutritional guidance than your doctor has time to give you, ask for a referral to an RD, or look in the yellow pages under dietitian. Some health maintenance organizations and clinics have dietitians on staff and include a nutrition consultation as part of routine prenatal care. Your insurance plan may cover this service if the referral is made by your physician. It would be impossible in this brief article to introduce and explain all aspects of good prenatal nutrition. But we would like to summarize for you some recent dietary recommendations for women expecting twins and refer you to three books which contain more extensive information as well as actual meal plans.

In several research studies in which pregnant women were given supportive and specific nutritional counseling and not required to limit weight gains arbitrarily, nearly all of the multiple pregnancies resulted in full-term deliveries of healthy babies weighing over five and one half pounds. Another significant finding in these mothers was the absence of toxemia (or pre-eclampsia), a life -threatening condition now believed by many to be related to nutrition and which is more common in multiple pregnancies. Since 60 percent of all twins are born prematurely or of low birth weight and multiples have a higher rate of birth defects, these results are significant and encouraging. Based on our review of U.S., Canadian and European research, we believe that the U.S. Recommended Daily Allowances for pregnant women for many nutrients are too low. Since they are minimum standards, they can safely be exceeded, and, especially in the case of multiple pregnancy, it is much better to err on the high side than on the low side.

Here is a list of essential nutrients and the amount required daily by expectant mothers of twins, compiled from tables in Having Twins (by Elizabeth Noble) and Make Room For Twins (by Terry Alexander), which also list food sources and sample menus. In keeping with our "better higher than lower" philosophy, we have chosen the higher figures where the two books did not agree. Even so, there are several cases, most notably Vitamin B and C, where many researchers would feel that these values are still too low.

 Calories 4,000

 Protein 145 grams

 Vitamin A 5-8,000 IU

 Vitamin C 100mg (milligrams)

 Vitamin D 600 IU

 Vitamin E 12 mg

 Thiamin (B-1) 2 mg

 Riboflavin (B-2) 2 mg

 Niacin (B-3) 20 mg

 Pyridoxine (B-6) 3.2 mg

 Folic Acid 1.25 mg

 Vitamin B-12 5 mcg (micrograms)

 Calcium 1600 mg

 Iron 100 mg

 Magnesium 600 mg

 Phosphorus 1600 mg

 Potassium 3250 mg

 Iodine 150 mcg

 Zinc 25 mg

Ms. Noble points out that "only a few of these nutrients tend to be lacking in the average diet of a pregnant woman and require special attention. These are protein, calories, iron, calcium, vitamin B-12 for vegetarians and pyridoxine (vitamin B-6)." There are also other B vitamins and trace minerals not included above for which minimum requirements have not yet been determined for pregnant women. However, if you eat a variety of fresh, minimally processed foods, you'll get these other nutrients, too. Sodium (salt) is also an essential nutrient in pregnancy and, unless you have a pre-existing kidney or heart condition, you do not need to eliminate salt from your diet, despite its relationship to high blood pressure when over-used.

Gail Sforza Brewer, M.A., author of What Every Pregnant Woman Should Know - The Truth about Diet and Drugs in Pregnancy and Tom Brewer, M.D., have developed "The No-Risk Diet for Expectant Mothers of Twins." This diet is also in Having Twins. The suggested quantities of food are tremendous and many women pregnant with multiples have trouble getting it all down due to nausea and pressure on stomach and intestines from an expanding uterus. Try five or six small meals a day, rather than three larger ones.

Eating for three is hard work and you have at most about six months from the diagnosis of multiples until they are born to give them the nutritional foundation they need for good physical and mental health.

This has only been an introduction to a complex subject. For more complete information, refer to the resource below.

Recommended Reading

Having Twins: A Parent's Guide to Pregnancy, Birth and Early Childhood by Elizabeth Noble. Houghton Mifflin Co., Boston 1991.

When You're Expecting Twins, Triplets, or Quads by Barbara Luke and Tamara Eberlein. Harper Collins, N.Y., 1999.

The information in this article is not a substitute for professional medical or psychological advice. Please consult with your health care advisor about specific questions or problems. This article may be printed out for personal use but may not be reproduced in any other manner, including electronic, without prior written consent from Twin Services. For more information, call 510-524-0863 or twinservices@juno.com



The information in this article is not a substitute for professional medical or psychological advice. Please consult with your health care advisor about specific questions or problems.

Pat Malmstrom
Twin Services Consulting
P.O. Box 10066, Berkeley, CA 94709

Copyright Patricia Malmstrom 1978-2006.