Effect of Omega-3 Fatty Acid Supplementation During Pregnancy on Pregnancy Outcome

Al-Azhar `University – Gaza

Deanship of Postgraduate Studies

Master of Clinical Nutrition

Effect of Omega-3 fatty acid supplementation during pregnancy on pregnancy outcome

By Mohammed Rasmi Mahmoud El-Mallahi

Supervisors Dr. Usama M. Abu Mohsen Dr. Samir M. Radi Prof. Dr. of Pharmaceutical Chemistry Ass. Prof. of Public Health & Nutrition Faculty of Pharmacy- Al Azhar University Ministry of Health

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master in Clinical Nutrition

2017

D E C L A R A T I O N

I, the undersigned hereby, declare that the thesis titled: Effect of Omega-3 fatty acid supplementation during pregnancy on pregnancy outcomes.

Is my own research and the work provided in this thesis, unless otherwise referenced, is the researcher own work, and has never been submitted elsewhere for any other degree qualifications nor for any academic titles, nor for any other academic or publishing institutions.

I, here to, affirm that I will be completely responsible in academic and legal terms if this work proves the opposite.

Mohammed R. M. El-Mallahi

Date: 4 / 6 / 2017

Signature: …………………….

III

D E D I C A T I O N

Every Challenging work needs self-efforts as well as guidance of those who were very close to our hearts.

My humble effort I dedicate to my sweet and lovely Father and Mother, whose affection, love, engorgement and prays of day and night make me able to get success and honor, To my lovely Wife (Asmaa), My sweet son (Yazan), My dear brother and sisters (Mahmud, Ilham, Reham), My uncles and all family, My dear teachers, colleagues and to the real friends, To all of them I dedicate this work.

Mohammed R. M. El-Mallahi

A C K N O W L E D G M E N T

First, I would like to record my gratitude to my great teachers Dr. Samir M. Radi and Dr. Usama M. Abu Mohsen for their supervision, advice, and guidance from the very early stage of this research as well as giving me extraordinary experiences. Much thanks and appreciation to my great teachers Dr. Mazen A. El Sakka and Dr. Baker M. Zabut for their valuable advices and suggested modifications.

I express my thanks to the Deanship of Postgraduate studies & Research affairs of Al-Azhar University, Deanship of College of Pharmacy, Ministry Of Health, Martyrs Rafah and Khanyounis health care centers and to the nursing team for their cooperation and assistance in data collection. Special thanks to Dr. Jihad Krunz for his supervision and Dr. Akram Baroud “Lab. technician” for his help.

Finally, thanks for all the participants who participated in this study. To all of these individuals, I would not have made it without him.

Mohammed R. M. El-Mallahi

ABSTRACT

Background: Obstetricians and multiple nutritional associations emphasis using of Omega-3 fatty acids (ω-3 FAs) supplementation during pregnancy.

Objective: To determine whether ω-3 FAs supplementation during pregnancy have a beneficial role on pregnancy outcomes.

Materials and methods: This study employed a clinical randomized controlled trial design, that conducted on 92 pregnant females that were stratified according to Number of pregnancies, Maternal age and Maternal Body Mass Index prior to pregnancy, and simple randomization for allocation into two groups (intervention and control group). The intervention group was received ω-3 FAs 300 mg/day from week 20 of gestation to delivery, Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery. While the control group was supplemented with Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery.

Results: Results of the study showed a significant improvement in maternal biochemical investigations and pregnancy outcomes among intervention group compared with control group. There is significant increment in the Hemoglobin (p =0.029), in addition to significant reduction of Triglycerides levels (TGs) (p =<0.001) after 4 months of intervention, and in the TGs level (p =<0.001) after 8 weeks of delivery. Also, There is control in the Gestational Weight Gain during pregnancy (P=0.016) and a significant reduction of Systolic Blood Pressure(p =0.017) after 4 months of intervention. These significant improvements showed in the intervention group when compared with the control group after intervention period. Moreover, ω-3 FAs supplementation associated with improvement in infant anthropometrics, There was a healthy significant increase in Weight (p =<0.001), Length (p =<0.001), and head circumference (p =<0.001) in the intervention group when compared with the control group at the three measurements. In contrast, there is no statistical differences between the groups in the gestational length (p =0.217) and in Diastolic Blood Pressure (p =0.089) at the three measurements after 4 months of intervention.

Conclusion: There was a significant differences with better changes among the ω-3 FAs group compared with control group after 4 months of intervention program on pregnancy outcomes for mothers and their infants as well.

Key words: Omega-3 fatty acids, Hemoglobin, Triglyceride, Infant anthropometrics.

يهخص انذساست

يقذيت: اؼٌذ٠ذ ِٓ أغببء اٌخ١ٌٛذ ٚ اٌج١ؼّبث اؼٌب١ٌّت اٌّخخصصت فٟ اٌخغز٠ت حٛصٟ بشذة بخٕبٚي ِىًّ األ١ِٚجب- 3 خالي ِشاحً اٌحًّ.

هذف انذساست: دساعت ِذٜ حأث١ش ِىًّ األ١ِٚجب-3 خالي ِشاحً اٌحًّ ٍٝػ ٔخبئج اٌحًّ عٛاء ٍٟػ األَ أٚ اٌطفً.

يُهجيت انبحث: حُ اعخخذاَ ١ػٕت غبم١ت ػشٛائ١ت أثٕبء اٌذساعت ٚرٌه ببعخخذاَ ِجػّٛت حذخً ٚ ِجػّٛت ظببطت , أجش٠ج اٌذساعت فٟ ِشوضٞ شٙذاء سفح ٚ خبٛ١ٔٔظ اٌصحٟ فٟ إٌّطمت اٌجٕٛب١ت ِٓ لطبع غضة , ٚ شٍّج 29 ِشبسوب ٚحُ حص١ٕفُٙ حغب ػذد ِشاث اٌحًّ, ػّش األَ ٚ ِؤشش وخٍت جغُ األَ لبً اٌحًّ ٚ ببعخخذاَ غش٠مٗ ػشٛائ١ت بغ١طت حُ حص١ٕفُٙ ي ِجػّٛخ١ٓ , ِجػّٛت اٌخذخً ح١ث حُ اػطبء٘ب ِىًّ األ١ِٚجب3- ٚاٌّجػّٛت اٌعببطت ح١ث حُ اعخثٕبء٘ب ِٓ ِىًّ األ١ِٚجبٚ , 3-لذ حُ اػطبء حّط اٌف١ٌٛه ٚ اٌحذ٠ذ ٌٍّجػّٛخ١ٓ ِٓ بذا٠ت اٌحًّ.

انُخائج: حش١ش ٔخبئج اٌذساعت اٌٟ ححغٓ ٍِحٛظ راث دالٌت احصبئ١ت فٟ فحٛصبث اٌذَ ٌّجػّٛت األ١ِٚجب-3 ح١ث ٚجذ ص٠بدة فٟ ِغخٜٛ اّٛ١ٌٙغٍٛب١ٓ (ٚ (p = 0.029 وزٌه أخفبض فٟ ِغخٜٛ اٌذْٛ٘ اٌثالث١ت فٟ دَ األَ (p=<0.001) بؼذ 4 أشٙش ِٓ اٌخذخً, ببإلظبفت ٌالٔخفبض فٟ ِغخٜٛ اٌذْٛ٘ اٌثالث١ت بؼذ 8 أعبب١غ ِٓ اٌٛالدة (p =<0.001) وزٌه ٚجذ ححىُ فٟ اٌٛصْ اٌّىخغب أثٕبء فخشة اٌحًّ (ٚ , (P = 0.016 ححغٓ ٍِحٛظ ِثبج احصبئ١ب فٟ ظغػ اٌذَ االٔمببظp = 0.017) ٟ) بؼذ 4 اشٙش ِٓ اٌخذخً. ٘زا اٌخحغٓ ظٙش فٟ اٌّجػّٛت اٌخٟ حٕبٌٚج ِىًّ األ١ِٚجبػ 3-ٕذ اٌّمبسٔت ِغ اٌّجػّٛت اٌعببطت اٌخٟ حُ اعخثٕبئٙب ِٓ ِىًّ األ١ِٚجب-3 بؼذ أمعبء فخشة اٌخذخً. ػالٚة ٍٝػ رٌه فبْ ِىًّ األ١ِٚجب-3 ِشحبػ بخحغٓ راث دالٌت احصبئ١ت ٍِحٛظت فٟ اٌم١بعبث األٔثشٚبٛ١ِخش٠ت ٌٍطفً بض٠بدة صح١ت فٟ اٌٛصْ )ٚ (p=<0.001 اٌطٛي (ٚ (p =<0.001وزٌه فٟ ِحػ١ اٌشأط (p =<0.001) ِمبسٔت ِغ اٌّجػّٛت اٌعببطت, وّب أظٙشث إٌخبئج ػذَ ٚج دٛ فشٚق راث دالٌت احصبئ١ت ب١ٓ اٌّجػّٛخ١ٓ ف١ّب ٠خؼٍك ببٌفخشة اٌض١ِٕت ٌٍحًّ )ٚ (p=0.217وزٌه فٟ ظغػ اٌذَ االٔبغبغp = ٟ) (0.089 بؼذ 4 أشٙش ِٓ اٌخذخً.

انخالصت: ِٓ إٌخبئج ٠ّىٓ أْ حخٍص اٌذساعت إٚ ٌٟجٛد ححغٓ صحٚ ٟحغزٞٚ ٍِحٛظ ِثبج إحصبئ١ب ٌذٜ ِجػّٛت األ١ِٚجب-3 ِمبسٔت ِغ اٌّجػّٛت اٌعببطت ف١ّب ٠خؼٍك بٕخبئج اٌحًّ عٛاء ٍٟػ األَ أٚ اٌٌّٛٛد.

انكهًاث انًفخاحيت: ِىًّ األ١ِٚجب-3, اٌذْٛ٘ اٌثالث١ت, اّٛ١ٌٙجٍٛب١ٓ, ل١بعبث اٌطفً.

VII

TABLE OF CONTENTS

DECLARATION III DEDICATION IV ACKNOWLEDGMENT V ABSTRACT VI VII يهخص انذساست TABLE OF CONTENTS VIII LIST OF TABLES XIII LIST OF FIGURES XV LIST OF ABBREVIATIONS XVI

CHAPTER 1: INTRODUCTION 1

1.1. Background 1

1.2. Neonatal Anthropometric Measurements 3

1.3. Statement Of Research Problem 3

1.4. Justification Of The Study 4

1.5. Goal And Objective Of The Study 5

1.6. Context Of The Study 5

1.6.1. Geography And Demography 5

1.6.2. Health Services Context 5

1.6.2.1. Martyrs Rafah Health Center 6

1.6.2.2. Martyrs Khan Younis Health Center 6

1.7. Hypothesis 6

1.8. Definition Of Terms 6

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CHAPTER 2: LITERATURE REVIEW 8

2.1 Pregnancy Outcomes 8

2.1.1. Stillbirth 8

2.1.2. Preterm Birth 8

2.1.3. Neonatal Anthropometrics 9

2.1.3.1. Birth Weight 9

2.1.3.2. Causes And Risk Factors Of Low Birth Weight 10

2.1.3.3. Newborn Head Circumference 13

2.1.3.4. Newborn Length 14

2.2. Gestational Weight Gain 15

2.3. Nutritional Requirements during pregnancy 17

2.4. Association Between Omega-3 Fatty Acids And Neonatal 24 Anthropometry

2.5. Association Between Omega-3 Fatty Acids And Pregnancy 25 Durational Period

2.6. Association Between Omega-3 Fatty Acids And Post Prandial 25 Triglyceride

2.7. Association Between Omega-3 Fatty Acids And Blood Pressure 26

CHAPTER 1: METHODOLOGY 28

3.1. Study Setting 28

3.2. Target Population 28

3.3. Study Design 28

3.4. Sampling Design 28

3.4.1. Sampling Technique 28

3.4.2. Sample Size Calculation 29

3.4.3 Sampling Frame 29

3.4.3.1. Inclusion Criteria 29

3.4.3.2. Exclusion Criteria 30

3.5. Intervention Strategy 30

3.6. Data Collection 30

3.7. Materials And Methods 31

3.7.1. Structured Questionnaire 31

3.7.2. Qualitative Food Frequency Questionnaire 31

3.7.3. Anthropometric Measurements 31

3.7.3.1. Maternal Anthropometrics 31

3.7.3.2. Newborn Anthropometrics 32

3.7.4. Pregnancy Duration 34

3.7.5. Maternal Blood Pressure Measurements 34

3.7.6. Maternal Biochemical Investigation 35

3.7.7. Supplementations 36

3.8. Data Management And presentation 36

3.9. Statistical Analysis 36

3.10. Ethical Consideration 36

3.11. Limitations of the study 37

3.12. Profile Of The Study 38

CHAPTER 4: RESULTS 39

4.1. Descriptive Statistics 39

4.1.1. Socio-demographic and Socio-economic Characteristics 39

4.1.2. Paternal Characteristics 40

4.1.3. Social Characteristics 41

4.1.4. Medical and Nutritional Characteristics 42

4.1.5. Lifestyle Characteristics 43

4.1.6. Maternal Anthropometrics and Gestational Weight Gain 44

4.1.7. Food consumption pattern for all subjects 45

4.2. Analysis of Variances 53

4.2.1.1. Maternal Biochemical 53

4.2.1.2. Gestational Weight Gain during pregnancy 55

4.2.1.3. Gestational Length 56

4.2.1.4. Maternal Blood Pressure 57

4.2.2. Infant anthropometrics 57

CHAPTER 5: DISCUSSION 61

5.1. Socio-demographic and Socio-economic Characteristics 61

5.2. Paternal Characteristics 62

5.3. Medical and Nutritional Characteristics 63

5.3.1. Diet Regimen 63

5.3.2. Distance Between Pregnancies 63

5.3.3. Disorders in the Pregnancy 63

5.3.4. Sporting 64

5.4. Dietary Data 65

5.5. Maternal Biochemical Changes 70

5.6. Maternal Gestational Weight Gain 72

5.7. Gestational Length 73

5.8. Maternal Blood Pressure 73

5.9. Infant Anthropometrics 74

CHAPTER 6: CONCLUSION AND RECOMMENDATIONS 75

6.1. Conclusion 75

6.2. Recommendations 76

REFERENCES 77

ANNEXES 98

ANNEXE A-1 Approval From Dean Of Faculty Of Pharmacy 98

ANNEXE A-2 Approval From Helsinki Committee 99

ANNEXE A-3 Signed Consent Form 100

ANNEXE B Two-Weeks Health Recall 102

ANNEXE C Questionnaire 103

XII

LIST OF TABLES

Table:2.1 Recommended GWG. 16 Table:2.2 Recommended Serving Size from Each Food Group in Pregnancy. 24 Table:3.1 Classification of BMI according to WHO. 3 2 Table:3.2 New guidelines for Gestational Weight Gain (GWG). 3 2 Table:3.3 Biochemical cutoff points for pregnancy. 35 Table:4.1 Socio-demographic and Socio-economic characteristics. 40 Table:4.2 Paternal characteristics. 41 Table:4.3 Social Characteristics. 41 Table:4.4 Medical and Nutritional Characteristics. 42 Table:4.5 Continue Medical and Nutritional Characteristics. 43 Table:4.5 Lifestyle Characteristics. 43

Table:4.6 Maternal anthropometric and GWG during pregnancy. 44 Table:4.7 Gestational Weight Gain (GWG) recommendations and 46 participants GWG. Table:4.8 Differences between the control group and the intervention group 46 with food consumption pattern of Grains, legumes. Table:4.9 Differences between the control group and the intervention group 47 with food consumption pattern of Proteins. Table:4.10 Differences between the control group and the intervention group 48 with food consumption pattern of Dairy products. Table:4.11 Differences between the control group and the intervention group 49 with food consumption pattern of Vegetables.

Table:4.12 Differences between the control group and the intervention group 50 with food consumption pattern of Fruits. Table:4.13 Differences between the control group and the intervention group 51 with food consumption pattern of Fats. Table:4.14 Differences between the control group and the intervention group 52 with food consumption pattern of Nuts. Table:4.15 Comparison of maternal biochemical within and between each 53 groups (Time treatment interaction). Table:4.16 Comparison of Triglyceride (TG) level 8 weeks post-delivery. 53 Table:4.17 Differences in GWG between the control and intervention groups. 55

XIII

Table:4.18 Differences in gestational length between the groups. 56 Table:4.19 Comparison of Blood Pressure (BP) measurements between the 57 groups. Table:4.20 infants anthropometrics baseline characteristics. 57 Table:4.21 Comparison of infants anthropometrics within and between each 58 groups (Time treatment interaction).

XIV

LIST OF FIGURES

Figures 3.1 Profile of the study 38 Figures 4.1 Changes in the Hemoglobin level mg/dl 54 Figures 4.2 Changes in the Triglyceride Level 54 Figures 4.3 Changes in the GWG (kg) 55 Figures 4.4 Changes in Infants Weight (grams) 59 Figures 4.5 Changes in Infants Length (cm and mm) 59 Figures 4.6 Changes in Infants Head Circumference (cm and mm) 60

LIST OF ABBREVIATIONS

ω-3 FAs Omega-3 fatty acids ω-3 PUFAs Omega - 3 Polyunsaturated fatty acids EPA Eicosapentaenoic acid DHA Docosahexaenoic acid ALA α - Linolenic acid BP Blood Pressure SBP Systolic Blood Pressure DBP Diastolic Blood Pressure PIH Pregnancy Induced Hypertension PCBs polychlorinated biphenyls DRI Dietary reference intakes RDA Recommended dietary Allowance TGs levels Triglycerides Levels PPTGs Postprandial triglycerides VLDLs Very low density lipoproteins Hb Hemoglobin NTD Neural - tube defects LBW Low birth weight ELBW Extremely low birth weight VLBW Very low birth weight SGA Small for gestational age SDP Smoking During Pregnancy GWG Gestational Weight Gain EDC Estimated Date of Confinement BMI Body Mass Index FFQ Food Frequency Questionnaire WHO World Health Organization AHA American Heart Association MOH Ministry Of Health

PCBS Palestinian Central Bureau of Statistics UNRWA United Nations Relief and Works Agency

XVI

CHAPTER 1

INTRODUCTION

1.1.Background

Omega-3 fatty acids (ω-3 FAs) are long-chain polyunsaturated essential fatty acids (PUFAs) that are necessary for good health and development (Coletta, et al., 2010).

Unlike ω-3 FAs from plant sources such as flaxseed and canola oils, Fish and other seafood contain long-chain ω-3 PUFAs, which are essential nutrients. The most biologically active forms of ω-3 FAs are α-linolenic acid (ALA), Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA). These are called essential fatty acids because the body particularly cannot produce them in sufficient amount, so they must be consumed from food and fishes (Coletta, et al., 2010).

The prenatal period is a time of increased risk for ω-3 FAs deficiency as maternal tissue stores tend to decline as they are used for the developing fetus (Swanson, Block, & Mousa, 2012). Marine oil supplements are often recommended to pregnant women to fulfill their ω-3 FAs requirements. The use of marine oil supplements during pregnancy has been studied as a possible strategy to prevent preterm birth (or increase gestational age) and prevent eclampsia, as well as to increase birth weight along with other potential benefits such as improving fetal brain development, reducing the risk of cerebral palsy and postpartum depression (Newnham, et al., 2014).

The role of maternal diet in the development of the fetal brain has not been adequately explored. Marine ω-3 FAs have been proposed to be important for brain development and reducing the risk of cerebral palsy (Khan, et al., 2017). Perinatal depression is a complex mental health disorder that can manifest during pregnancy or after childbirth. Evidence suggests that low levels of ω-3 FAs are correlated with depressive symptoms during pregnancy and after delivery because They may produce antidepressant effects due to their role in serotonin functioning (Borja, et al., 2010).

The fatty acids DHA and EPA that are contained in marine oils, seafood, eggs and other dairy products are the precursors of prostaglandins, which have been shown to

1 influence the constriction of blood vessels. Among pregnant women and non-pregnant adults, marine oils have been promoted as a treatment for hypertension, or high Blood Pressure (BP) and those with clinical atherosclerotic disease or hypercholesterolemia (Maehre, et al., 2015).

Pre-eclampsia in the mother and a baby being born too soon or too small are relatively common complication of pregnancy that can sometimes seriously affect the health of the baby and the mother. ω-3 FAs found in fish/marine oils may prevent these complications. The findings were that fish/marine oil supplements taken in pregnancy increase the length of pregnancy by two to three days, slightly increase a baby's birth weight and slightly reduce the number of babies born before 34 weeks gestation (Makrides, et al., 2006).

Nutritional advice for pregnant women regarding marine oil consumption may be complicated with warnings that suggest limiting overall fish consumption. Fish are an important source of ω-3 FAs, however many types of fish may be potentially contaminated with methyl mercury or polychlorinated biphenyls (PCBs), which can be harmful to fetal development (Starling, et al., 2015). These potentially harmful contaminants can accumulate more in fish meat than in fish oil. However, there may still be safety concerns if unrefined fish oil preparations are consumed, as they may contain pesticides and PCBs residues (Rawn, et al., 2009).

According to Makrides, et al., (2006), The doses of EPA and DHA derived from the marine oils ranged from 133 mg/day to 3 g/day, although most trials involving the majority of women assessed a dose of 2.7 g of EPA and DHA per day (Makrides, et al., 2006). Such a dose would be difficult to achieve from food sources. As an example, this would require a woman to eat 300 g of cooked salmon daily. Although the doses appear high compared with what may be achievable through the diet, the marine oil interventions appeared safe. There were no increases in bleeding or hemorrhage either before or after birth. The only side-effects associated with fish oil supplementation were belching and unpleasant taste, and these are relatively minor.

Maternal nutritional status emphasis the consideration of all pediatric and maternal nutritionists. Some of them, use some of selective nutritional supplementation like ω-3 FAs, and they test the associations between the ω-3 FAs supplementation and pregnancy outcomes. Despite that, the effect of the ω-3 FAs

2 supplementation on pregnancy outcomes are still controversial in literature. The purpose of this study is to determine whether ω-3 FAs supplementation during pregnancy have a beneficial role on pregnancy outcomes.

1.2.Neonatal anthropometric measurements

Neonatal anthropometry is an inexpensive, noninvasive and convenient tool for bedside evaluation, especially in sick and fragile neonates (Silva, 2012). Anthropometry can be used in neonates as a tool for several purposes: diagnosis of fetal malnutrition and prediction of early postnatal complications; postnatal assessment of growth, body composition and nutritional status; prediction of long- term complications including metabolic syndrome; assessment of dysmorphology and estimation of body surface (Otupiri, et al., 2014).

Direct measurements, such as body weight, length and head circumference are the most commonly used measurements for nutritional assessment in clinical practice in Gaza strip health centers. Body weight is the most reliable anthropometric measurement and therefore is often used alone in the assessment of the nutritional status, despite not reflecting body composition (Silva, 2012).

1.3.Statement of research problem

According to many surveys, Most pregnant women likely eat little fish and therefore do not consume enough ω-3 FAs primarily due to concern about the adverse effects of mercury and other contaminants on the developing fetus (Coletta, et al., 2010). Good nutrition and healthy life style are important for prevention of any deterioration on maternal and neonatal health (Kaiser & Allen, 2008).

Bad dietary habits and unhealthy life style has great impact on maternal and neonatal health (Murray & McKinney, 2014). As a result, nutritional assessment and follow up are essential to improve pregnancy outcomes and prevent it’s complications. Unfortunately, nutritional assessment of the risk factors of neonatal complications are not adequately investigated in Palestinian authority. Since, the prevalence of Low Birth Weight (LBW) among births in Gaza Strip constitute as 6% and the preterm birth which consider as the third leading cause of death in infancy (Van den Berg, et al., 2015).

Therefore, this study could answer important questions related to the ω-3 FAs intake in relation to pregnancy outcomes and the risks of neonatal complications.

1.4.Justification of the study

 A little information is available about adequacy of ω-3 FAs intake during pregnancy and its relation to pregnancy outcomes in the Gaza Strip.  The effect of ω-3 FAs supplementation intake on pregnancy outcomes are still controversial issue.  There was no published information available on the effect of ω-3 FAs intake on pregnancy outcomes.  This study will aimed to assess the adequacy of ω-3 FAs intake during pregnancy and its relation to pregnancy outcomes in Gaza Strip.

1.5.Goal and objectives of the study

Main goal:

To determine whether Omega-3 fatty acids (ω-3 FAs) supplementation during pregnancy have a beneficial role on pregnancy outcomes.

Specific objectives:

 To compare neonatal anthropometric measurements directly post to delivery, after one month and after 2 months of delivery between groups.  To compare maternal biochemical (Hemoglobin (Hb) and post-prandial triglyceride levels(PPTGs) ) between groups.  To compare Gestational Weight Gain (GWG) between the intervention and control group at the 2nd and 3rd trimester of pregnancy.  To compare pregnancy duration and maternal Blood pressure (BP) between groups.  To estimate the dietary intake adequacy and consumption pattern.

1.6.Context of the study

1.6.1.Geography and demography

The total area of Palestinian territories is 6,257 Km², which comprise West Bank and Gaza Strip (UNEP, 2003). The total Population of the State of Palestine at mid- 2016 was about 4.81 million, 2.93 million in the West Bank and 1.88 million in Gaza Strip. According to the Palestinian Central Bureau of Statistics (PCBS), Population density of the State of Palestine in general is high at 800 persons/ Km² , particularly in Gaza Strip 5,154 persons/Km² compared to a lower population density in the West Bank at 519 persons/Km² at mid-2016 (PCBS, 2016). Gaza Strip consist of 5 governorates ( North Gaza, Gaza, Middle Zone, Khan Yunis, and Rafah ), there are 351,934 living in Khan Yunis and 233,490 living in Rafah (PCBS, 2016).

1.6.2.Health services Context ‎

The five main health providers of health services in Palestine are Ministry of Health (MOH), United Nations Relief and Works Agency (UNRWA), Nongovernmental health organization (NGOs) and Palestinian Military Medical Services (PMMS). MOH bears the heaviest burden, as it has the responsibility. In the Gaza Strip, there are 54 primary health care centers. The health services are distributed throughout Palestine. In addition MOH provides a number of specific health programs as: health education\ community involvement, school health, immunization, human resources development, and referral of patients to non MOH facilities (when services are not available in governmental facilities). UNRWA operates 20 primary health care centers scattered in eight refugee camps in the Gaza Strip . The NGOs sector operates 206 primary health care centers and general clinics, 66 of them in Gaza Strip, where PMMS operate 23 primary health care centers and clinics, seven of them in Gaza Strip (MOH, 2012).

The hospital services are operated by the government and non-government sectors. The hospitals in both sectors have improved in terms of facilities, technical and support services over the years by adding new departments and diagnostic equipment, as well as providing continuous professional training. There are 81 hospitals in Palestine, 51 in WB and 30 in Gaza Strip. The total number of beds is 5,414 in government and non-government hospitals; 58.4% in West Bank and 51.6%

5 in Gaza Strip. In Palestine, there are 13 beds per 10,000 of populations; 12.3 beds/10,000 populations in West Bank and 14.2 beds/10,000 population in Gaza Strip (MOH, 2012).

1.6.2.1.Martyrs Rafah Health Center

The center was established at the beginning of the sixties, it has been developed and added new sections in it. In 2009 the number of employees amounted to 61 employees, serving the region with a population of 80 thousand people, the average number of patients 450 cases a day.

1.6.2.2.Martyrs Khan Younis Health Center

The center was established in 1967, it has been added to Medicare in 1976, serving the region with a population of 100 thousand people, the number of employees 66 staff members, the average number of patients 550 cases a day. the center works double shifts, 12 hours a day.

1.7.Hypothesis

H0: Null hypothesis

There is no significant differences in the changes between the Omega-3 fatty acids (ω-3 FAs) group and the control group after 4 months of intervention program on pregnancy outcomes.

H1: Hypothesis of difference

There is a significant differences in the changes between the ω-3 FAs group and the control group after 4 months of intervention program on pregnancy outcomes.

1.8.Definition of terms

Pregnancy: The period from conception to birth, pregnancy usually lasts 40 weeks, beginning from the first day of the woman's last menstrual period, and is divided into three trimesters, each lasting three months (Jukic, et al., 2013).

2. Neonatal anthropometry: is the measurement of the newborn body compartments (Cauble, Dewi, & Hull, 2017). We were measured the head circumference, body weight and length.

Omega-3 fatty acids (ω-3 FAs): are long-chain polyunsaturated essential fatty acids that are necessary for good health and development (Muldoon, et al., 2014). The respondents were supplemented with 300 mg/day of ω-3 FAs.

3. Folic acid: folic acid is one of a water-soluble B vitamin. Folic acid supplement is the synthetic form of this vitamin (MOH, 2009). The respondents were supplemented with 400 mcg/daily of folic acid.

4. Iron: Iron is an essential nutrient because it is a central part of Hb, which carries oxygen in the blood (Hurrell, et al., 2014). The respondents were supplemented with 27 mg /daily of iron.

5. Pregnancy outcomes: are the final results of conception and ensuing pregnancy, including maternal biochemical in the blood, maternal BP, pregnancy duration. In addition, newborn anthropometric measurements (Bhattacharya, et al., 2012).

CHAPTER 2

LITERATURE REVIEW

2. nd 2.1.Pregnancy Outcomes

Pregnancy outcomes are the final result of conception and ensuing pregnancy, including Maternal Mortality, Infant Mortality, Stillbirth and Low Birth Weight (LBW). Also, include Live Birth (Full Term or Preterm Birth), Spontaneous Abortion and Induced Abortion.

2.1.1. Stillbirth

A stillbirth is the death of a baby before or during delivery. Both miscarriage and stillbirth are terms describing pregnancy loss, but they differ according to when the loss occurs. A miscarriage usually refers to a fetal loss less than 20 weeks after a woman becomes pregnant, and a stillbirth refers to a loss 20 or more weeks after a woman becomes pregnant (CDC, 2016).

Known causes of stillbirth generally fall into one of three broad categories; Problems with the baby (birth defects or genetic problems), Problems with the placenta or umbilical cord (this is where the mother and baby exchange oxygen and nutrients), and certain conditions for examples; uncontrolled diabetes, high BP, or obesity (Vaishali & Pradeep, 2008).

Stillbirth with an unknown cause is called unexplained stillbirth. Having an unexplained stillbirth is more likely to occur the further along a woman is in her pregnancy. Some of the factors that increase the risk for a stillbirth include the mother as being of black race, being a teenager, being 35 years of age or older, being obese, smoking cigarettes during pregnancy, and having certain medical conditions (CDC, 2016).

2.1.2. Preterm birth

Pregnancy is considered full term if birth falls between 37 to 42 weeks of the estimated due date. A baby born prior to week 37 is considered premature, While a baby that still hasn’t been born by week 42 is considered overdue.

Preterm birth is the greatest contributor to infant death, with most preterm-related deaths occurring among babies who were born very preterm (before 32 weeks) (Goldenberg & McClure, 2010).

Preterm birth is also a leading cause of long-term neurological disabilities in children. In most cases, preterm labor begins unexpectedly and the cause is unknown. Like regular labor, signs of early labor are contractions (the abdomen tightens like a fist) every 10 minute, Pelvic pressure (the feeling that the baby is pushing down), Low dull backache and Cramps (feel like a menstrual period) with or without diarrhea (CDC, 2016).

Abortion is the ending of pregnancy by removing a fetus or embryo before it can survive outside the uterus (Grimes & Stuart, 2010). An abortion which occurs spontaneously is also known as a miscarriage. An abortion may be caused purposely and is then called an induced abortion, or less frequently, "induced miscarriage".

2.1.3. Neonatal anthropometrics

2.1.3.1.Birth weight

Birth weight is the body weight of a baby at its birth. The normal neonatal body weight is between 2.5 and 5 kg (WHO, 2009). LBW is defined as a birth weight of a live born infant of less than 2,500 g regardless of gestational age (WHO, 2009). Some LBW babies are healthy, even though they are small (Goldenberg, et al., 2008). But being LBW can cause serious health problems for majority of born babies. Interestingly, a lot of studies pointed that, there is strong and significant relationship between nutritional status of mothers and birth babies morbidity and mortality (Black, et al., 2008).

Low birth weight outcome considered as one of the common problems associated with pregnancy gives birth around the world, some statistics in the USA pointed that LBW rate still high 8.02% (Martin, et al., 2013). The major causes of LBW in general are; Malnutrition, Recurrent infections, and Neurodevelopmental delay (Roy, 2016). While, the causes of prematurity are; Low maternal weight, teenage, multiple pregnancy, Previous preterm baby, cervical incompetence, Antepartum hemorrhage, acute systemic disease, Poor nutritional status of mother, Hypertension, toxemia,

9 anemia, post maturity, Chronic malaria, chronic illness, and Tobacco use (Goldenberg, et al., 2008).

Many previous studies classified LBW on three categories can be distinguished by firstly, premature or preterm LBW babies (born before 37 complete weeks of gestation or with fewer than 259 days of gestation). Secondly, term LBW, that is, born between 37 and 42 complete weeks of gestation, or between 259 and 293 days of gestation. And finally, post term LBW, born after 42 weeks or 294 days of gestation (WHO, 2009).

Low birth weight can be presented as Extremely low birth weight (ELBW) infant is defined as one with a birth weight of less than 1000g (2lb, 3oz) (Glass, et al., 2015). Most ELBW infants are also the youngest of premature newborns, usually born at 27 weeks' gestational age or younger, and Very low birth weight (VLBW) infants is defined as born at less than 1500g (WHO, 2014). That's can be caused by Small for gestational age (SGA); Infants whose weight is less than the lower limit of the confidence interval of the normal curve for weight by weeks of gestation. And Intra- uterine growth restriction (IUGR): A process of whatever etiology that can limit the potential for intra-uterine growth of the fetus, resulting in LBW (WHO, 2009).

2.1.3.2.Causes and risk factors of Low Birth Weight (LBW)

2.1.3.2.1.Genetic factors (inherited component)

The genetic influence on birth size has been recognized for many years, Epidemiological studies have shown that genetic factors account for 38–80% birth weight variance (Johnston, et al., 2002). A genetic analysis of parent-offspring covariance in birth weight indicated that about 60% of the variance in birth weight could be explained by effects of fetal genes, While no effects of maternal genes were detectable (York, et al., 2014).

Birth weight influenced by parental, placental, and fetal factors. There are complex interactions between genetic and environmental factors of parental, placental, and fetal origin. LBW and fetal thinness have been associated with Non- Insulin Dependent Diabetes Mellitus (NIDDM) and insulin resistance in childhood and adulthood.

A defect in the sensing of glucose by the pancreas, caused by a heterozygous mutation in the glucokinase gene, could reduce fetal growth and birth weight in addition to causing hyperglycemia after birth (Haliloglu, et al., 2016). The observations suggest that if a mother had a glucokinase mutation, the birth weight was increased by a mean 601g as a result of maternal hyperglycemia in pregnancy. Mutations in the glucokinase gene of the fetus result in reduced birth weight by 533g (Haliloglu, et al., 2016). The placenta develops to its full size during the second trimester, to facilitate the fetal growth acceleration after 20 weeks of gestation. Up to 20% of idiopathic SGA term deliveries have confined placental mosaicism.

2.1.3.2.2.Environmental and physiological factors

The fact that low maternal weight gain causes LBWs has been known since the 1970s. Maternal low weights (<50 kg) before pregnancy are known to increase the risk of LBW significantly (Khan, Nasrullah, & Jaleel, 2016). Mothers’ active or passive exposure to cigarette smoke during pregnancy has negative effects on the newborn can significantly increase the risk of LBWs (Miyake, et al., 2013).

The fact that smoking slows down fetal growth has been known for a long time. The percentage of LBWs for mothers who married consanguineously was 2.33 times higher than that of mothers who did not, it is a known fact that consanguineous marriages increase the rate of occurrence of genetic diseases. The proportion of consanguineous marriages is higher here than it is in Western nations. An average of one-fifth of marriages is consanguineous (Bagheri, Farvardin, & Saadat, 2015).

Pregnancy at extreme of reproductive age both young teenagers (younger than 15) and older women (after 40 years) are at high risk for giving birth to LBW babies (Aras, 2013). Generally, teenaged mothers and older mothers are at higher risk of delivering LBW babies than mothers aged 20 to 34 years (Reichman & Teitler, 2006).

Increased paternal age is positively associated with the probability of LBW, the associations between paternal age and LBW were as strong as those between maternal age and LBW (Lawlor, et al., 2015). Paternal occupational exposure and low levels of education may be associated with LBW; however, further studies are needed (Shah & Births, 2010).

In addition, the exposure to air pollution (both indoor and outdoor) and drinking water contaminated with lead, which are considered environmental risk factors (Kjellstrom, et al., 2006).

2.1.3.2.3.Diet and life style factors

Lifestyle behaviors such as; Cigarette smoking, Weight gain during pregnancy, and Heavy use of alcohol and other drugs play an important role in determining fetal growth. The relationship between lifestyle risk factors and LBW is complex and is affected by psychosocial, economic, and biological factors. Cigarette smoking is the largest known risk factor for LBW (Johnson, Jones, & Paranjothy, 2017).

Nutrition plays a major role in maternal and child health. Poor maternal nutritional status has been related to adverse birth outcomes; however, the association between maternal nutrition and birth outcome is complex and is influenced by many biologic, socioeconomic, and demographic factors, which vary widely in different populations (Kader & Perera, 2014).

Understanding the relation between maternal nutrition and birth outcomes may provide a basis for developing nutritional interventions that will improve birth outcomes, long-term quality of life, reduce mortality, morbidity, and health-care costs. However, nutrient deficiencies are generally found in low socioeconomic status populations, where they are more likely to involve multiple rather than single deficiencies (Gernand, et al., 2016).

Maternal nutritional deficiencies are also likely to have different effects depending upon the stage of fetal development at which they occur. A number of experimental animal studies and observational human studies point to the importance of nutritional insults that occur at the very earliest embryonic stages to subsequent fetal growth and birth outcomes (Marques, et al., 2016).

Evidences from animal studies indicates that fetal growth is most affected by maternal dietary nutrient deficiencies (particularly deficiencies of protein and micronutrients) during the peri-implantation stage and the stage of rapid placental development (Nafee, et al., 2008). Thus, researchers need to move beyond treating diet during pregnancy in isolation and begin focusing on maternal nutritional status throughout the periconceptional, pregnancy, and lactation periods as a continuum that

12 affects maternal, fetal, and infant health (Dean, et al., 2014). This approach has critical implications for when and how maternal dietary intake is assessed, when interventions are begun, and how study results are then interpreted.

2.1.3.3.Newborn head circumference

2.1.3.3.1.Macrocephaly

Macrocephaly is a condition in which the head is abnormally large this includes the scalp, the cranial bone, and the contents of the cranium. Macrocephaly may be pathologic, but many people with an unusually large head and large skull are healthy. Pathologic macrocephaly may be due to megalencephaly (enlarged brain), hydrocephalus (water on the brain), cranial hyperostosis (bone overgrowth), and other conditions (Williams, et al., 2008).

Pathologic macrocephaly can be caused by congenital anatomic abnormalities, genetic conditions, or by environmental events. Many genetic conditions are associated with macrocephaly, including cardiofaciocutaneous syndrome; Fragile X syndrome; leukodystrophies (brain white matter degeneration) such as Alexander disease and Canavan disease. Environmental events associated with macrocephaly include infection, neonatal intraventricular hemorrhage (bleeding within the infant brain), subdural hematoma (bleeding beneath the outer lining of the brain), subdural effusion (collection of fluid beneath the outer lining of the brain), and arachnoid cysts (cysts on the brain surface) (Williams, et al., 2008).

2.1.3.3.2.Microcephaly

Microcephaly is a medical condition in which the brain does not develop properly resulting in a smaller than normal head (Phelps, 2011). Microcephaly may be present at birth or it may develop in the first few years of life.

Often people with the disorder have an intellectual disability, poor motor function, poor speech, abnormal facial features, seizures, and dwarfism (Phelps, 2011). The disorder may stem from a wide variety of conditions that cause abnormal growth of the brain, or from syndromes associated with chromosomal abnormalities.

Microcephaly usually is the result of abnormal brain development, which can occur in the womb (congenital) or during infancy. Microcephaly may be genetic (CDC, 2016). Other causes may include: Craniosynostosis, Chromosomal abnormalities as Down syndrome, Decreased oxygen to the fetal brain (cerebral anoxia), Infections of the fetus during pregnancy, Exposure to drugs, alcohol or certain toxic chemicals in the womb, Severe malnutrition and Uncontrolled phenylketonuria in the mother (CDC, 2016). Checking the circumference, or the distance, around newborns head can indicate normal growth or alert for possible issues (Villar, et al., 2014).

2.1.3.4. Newborn Length

Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. The normal reference range of the newborn length is from 46 to 56 cm (Onis, 2006).

Stunted growth is a reduced growth rate in human development. It is a primary manifestation of malnutrition (or more precisely undernutrition) and recurrent infections, such as diarrhea and helminthiasis, in early childhood and even before birth, due to malnutrition during fetal development brought on by a malnourished mother (Spears, 2013).

It is defined as the percentage of children, aged 0 to 59 months, whose height for age is below minus two standard deviations (moderate and severe stunting) and minus three standard deviations (severe stunting) from the median of the World Health Organization (WHO) Child Growth Standards (Cintron, 2014).

Stunting starts from pre-conception when an adolescent girl and who later becomes mother is undernourished and anemic; it worsens when infants’ diets are poor, and when sanitation and hygiene is inadequate. It is irreversible by the age of two. Child survival and health is inseparably connected to reproductive and, maternal health (Prendergast & Humphrey, 2014).

Stunted children may never regain the height lost as a result of stunting, and most children will never gain the corresponding body weight. Living in an environment where many people defecate in the open due to lack of sanitation, is an important cause of stunted growth in children (Spears, 2013).

Stunting must be carried over from in utero growth retardation in short-stature mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence (Solomons, et al., 2015).

2.2.Gestational Weight Gain (GWG)

The weight a woman gains during pregnancy, known as GWG, has important health implications for both mother and child. The Institute of Medicine (IOM) provides GWG recommendations that promote optimal health by balancing risks associated with too much or too little GWG and are specific to a woman's Pre pregnancy Body Mass Index (BMI); (weight [kg]/height [m]2) (Rasmussen & Yaktine, 2010). Not only is pre-existing maternal obesity associated with adverse pregnancy outcomes, but also gaining too much weight during pregnancy has been linked with poor pregnancy outcomes. Whereas, inadequate GWG increases the risk for LBW, Gaining excessive weight during pregnancy can result in the delivery of a large for gestational age (LGA) baby or macrosomia (Kiel, et al., 2007). Macrosomia has been associated with adverse maternal and neonatal outcomes, including caesarean birth, prolonged labor, birth trauma, cephalopelvic disproportion, birth asphyxia, and increased risk of perinatal mortality (Zhang, et al., 2008). Overweight and obese women are more likely to gain excessive gestational weight and retain it after delivery. Excessive GWG in this case is defined as weight gained in excess of the 1990 Institute of Medicine recommendations for GWG (Riz & Laraia, 2006). Excessive GWG has in turn been associated with preeclampsia, failed induction, caesarean delivery and LGA infants (DeVader, et al., 2007).

The two key periods in a woman’s life where she is more likely to gain weight are pregnancy and menopause. In an effort to encourage appropriate weight gain during pregnancy because of the increasing prevalence of obesity among women of reproductive age, increases in GWG and to reduce the risk of SGA, the Institute of

Medicine (IOM), developed prenatal weight gain recommendations (Rasmussen, et al., 2008). Pre pregnancy BMI was categorized as underweight (BMI <18.5), normal weight (BMI = 18.5–24.9), overweight (BMI = 25.0–29.9), and obese (BMI ≥30.0). GWG was calculated by subtracting pre pregnancy weight from delivery weight, and was categorized as inadequate, appropriate, or excessive if a woman gained below, within, or above the BMI-specific IOM recommendations, respectively.

Table (2.1): Recommended Gestational Weight Gain (GWG) Recommended Range of Mean Rate of Weight Gain in Pre-Pregnancy BMI Total Weight Gain the 2nd and 3rd Trimester Category Kg Lbs kg/week lb/week

Underweight: 12.5-18 28-40 0.5 1.0 BMI < 18.5

Normal Weight: 11.5-16 25-35 0.4 1.0 BMI 18.5 – 24.9

Overweight: 7-11.5 15-25 0.3 0.6 BMI 25.0 – 29.9

Obese: BMI ≥ 30 5-9 11-20 0.2 0.5 Recommended GWG (Rasmussen, et al., 2008).

The American College of Obstetricians and Gynecologists recommends that clinicians calculate a woman's pre pregnancy BMI at the first prenatal care visit, educate her on the importance of appropriate GWG goals, and counsel her on appropriate dietary and physical activity behaviors to achieve these goals. Education, counseling, and monitoring of GWG should continue throughout pregnancy (Obstetricians & Gynecologists, 2013). The IOM developed an evidence-based toolkit that includes educational materials for clinicians and women and a BMI-specific weight gain tracker that can be used to monitor and compare GWG with recommended ranges throughout pregnancy. Interventions that might promote appropriate GWG combine several strategies, including dietary goals, physical activity, routine self-monitoring of weight, and frequent provider contact. Most women need to consume an additional 340–450 calories per day only during the second and third trimesters to support the metabolic demands of pregnancy (Rasmussen & Yaktine, 2010), dietary goals might be helpful to meet these additional energy requirements (Phelan, et al., 2011).

Physical activity, when combined with dietary goals, has been found to be an effective strategy in preventing excessive GWG (Phelan, et al., 2011).

Pregnant women should engage in 150 minutes per week of moderate-intensity physical activity, such as brisk walking. Some women might believe that physical activity during pregnancy is risky (Kraschnewski & Chuang, 2014), however, physical activity is safe and recommended for most pregnant women and might reduce some pregnancy-related complications. Routine self-monitoring of weight gain should begin early in pregnancy and continue frequently between prenatal care visits so that signals of inadequate or excessive GWG can be identified when small, corrective steps can be taken (Phelan, et al., 2011). Notably, excessive GWG early in pregnancy strongly predicts total excessive GWG, suggesting that women with early excessive GWG might need to be prioritized for interventions (Knabl, et al., 2014). Frequent, ongoing contact with health care providers beyond routine prenatal care, such as nurses or nutrition specialists, might also help women achieve appropriate GWG.

2.3.Nutritional requirements during pregnancy

More important, nutritional status considered as one of the most important challenges that face pregnant women and its further influences of gives birth on their health. It is advisable to start nutritional care in the early period before pregnancy, when pregnancy occur prenatal care is very important for the health of mother’s and for the proper development of the fetus (Scholl, et al., 2008). Also for proper outcome, the most important issue that must be taken into account is a sufficient quantity of food ingredients such as protein, vitamins, carbohydrates and fat (Martin, Ling, & Blackburn, 2016).

The fetus in the first trimester of pregnancy consider small in size, Therefore the requirements of the mothers of food increased at a slow rate during this period (Lee, et al., 2006). In the last trimester of pregnancy is moving an increasing demand and greater amounts of essential nutrients, which the fetus need it for the purpose of growth, it must be noted here that the amounts of intake is slightly greater than recommended intakes in order to reserve and safety (Miller, 2011).

It is essential that the quantities of energy intake must be sufficient to meet the requirements and sparing the use of proteins for energy instead of use in the construction of the tissues, and is usually recommended to increase capacity by 285 kcal per day during the 280 days of pregnancy than they consume by non-pregnant women (Hytten & Chamberlain, 1980). The increase in the amount of 15 grams of protein intake per day is enough to meet the needs of pregnant women's, in cases of risky pregnant mother's 100 grams of protein a day may be required (Kramer & Kakuma, 2010).

The contents of protein and nitrogen is a basic food items in growth. Also pregnant mothers must take sufficient amount of vitamins A,D,C,B, Where they are important in the formation of teeth, normal growth of bones, vision and building of connective tissues (Derbyshire, 2011). There is a strong need for minerals' during pregnancy, which is very important in building of a skeleton system, those are calcium, phosphorus and magnesium (Derbyshire, 2011).

Maternal micronutrient requirements during pregnancy increase to meet the physiologic changes in gestation and fetal demands for growth and development. The only recommendation for pregnancy currently exists for iron and folic acid supplementation use (Christian, 2010). By contrast, Other study was conducted to investigates the rate of ω-3 FAs use in pregnant women and its effect on pregnancy outcomes, suggested that increased consumption of ω-3 FAs can prevent low birth weight, pre-term labor and preeclampsia (Fereidooni & Jenabi, 2014).

2.3.1.Total Energy

Extra dietary energy is required during pregnancy to make up for the energy deposited in maternal and fetal tissues (Gionbelli, et al., 2015). The rise in energy expenditure attributable to increased basal metabolism and to changes in the energy cost of physical activity (Lof, et al., 2005). Weight gain during pregnancy results from products of conception as fetus, placenta, and amniotic fluid, increases in various maternal tissues as uterus, breasts, blood, and extracellular extravascular fluid, and increases in maternal fat stores (Rasmussen & Yaktine, 2010).

The extra energy needs are easily met by adding a small snacks during the day (Wen, et al., 2010). Eating smaller amounts of food more frequently also has the

18 benefit of helping with some of the uncomfortable side effects of pregnancy including; nausea and heartburn (Lee & Saha, 2011).

The energy needs are no higher than the Estimated Energy Requirement for non- pregnant women until the second trimester; thereafter (Butte & King, 2005). The extra energy need per day is 340 kcal and 460 kcal in the second and third trimesters, respectively (WHO, 2004). While, the normal weight women should add 350 kcal/day in the second trimester and 500 kcal/day in the third trimester, the overweight and obese woman should add 450 kcal/day in the second trimester and addition of 35 Kcal/ day in the third trimester, and the underweight woman should add 150 kcal/day, 200 kcal/day and 300 kcal/day in the first, second, and third trimester, respectively (Butte, et al., 2004).

2.3.2.Lipids and Fats

Lipid includes sterols, phospholipids and triglyceride (TG) which are primarily made up of fatty acid which must be taken adequately to meet the demand of growing fetus. The main biological functions of lipids include storing energy, signaling, and acting as structural components of cell membranes. Fats are also a source of concentrated calories and may be beneficial to women who are at risk of energy malnutrition during pregnancy (Delaney & Fascetti, 2012).

Women who are not at risk should avoid excess fat because it can easily lead to undesired weight gain; moderation is essential (Jones, et al., 2009). During pregnancy the need of fats roughly estimated about 25 % to 35 % of the total daily calories need, and they need about 13g of Linoleic acid and 1.4g of ALA daily (Sizer, et al., 2012).

2.3.3.Carbohydrates

Carbohydrates are the main source of energy in the human body. They are broken down into simple sugars like glucose, which pass easily across the placenta and provide energy to support fetus growing during pregnancy (Forbes, 2012). The RDA for carbohydrate during pregnancy is 175g/day, increased from 130 g/day for non- pregnant women (Sizer, et al., 2012).

Some carbohydrates, especially sugars, are broken down quickly by the body and can cause a rapid increase in blood glucose and insulin levels. These are known as high Glycemic Index (GI) foods.

High Glycemic Index foods include many refined foods like white bread, white rice, sugary foods such as cakes, biscuits and potatoes (Louie, et al., 2017).

On the other hand, foods that are broken down more slowly are categorized as low GI foods, these keep blood sugar levels more stable (Eleazu, 2016). Low GI starchy foods are considered to be healthier among pregnant woman and should be selected over refined, which include Bananas, Sweet potatoes, chickpeas, whole grain breads, cereals and pasta (Gray, 2015). Pregnant woman should be advised that a low carbohydrate diet is dangerous during pregnancy and could place the baby at risk for poor growth (Moore & Davies, 2005). A mild restriction of dietary carbohydrate may be recommended if the mother is diabetic and obese (Castilla, et al., 2013).

2.3.4.Proteins

The amino acids that make up protein are the building blocks of the body's cells and of baby's body as well. It's important to get enough protein throughout pregnancy, but it's especially critical during the second and third trimesters (Borazjani, Angali, & Kulkarni, 2013). That's when the baby is growing the fastest, and breasts, organs are getting bigger to accommodate the needs of growing baby.

Pregnant woman should consume a proper amount of proteins, in order to meet the fetus needs throughout pregnancy period and the critical periods as well. Hence, the pregnant woman should take into account the quality and quantity of consumed proteins (Imdad & Bhutta, 2011). The Dietary Reference Intake (DRI) of protein for pregnant women is 71 g/d , While Recommended Dietary Allowance (RDA) is 1.1 g/d (Sizer, et al., 2012).

2.3.5.Omega-3 polyunsaturated fatty acids (ω-3 PUFAs)

Omega-3 fatty acids must be consumed in the diet. Adequate consumption of ω-3 FAs is vitally important during pregnancy as they are critical building blocks of fetal brain and retina. ω-3 FAs may also play a role in determining the length of gestation and in preventing perinatal depression (Coletta, et al., 2010).

The three types of ω-3 FAs involved in human physiology are ALA found in plant oils, EPA and DHA both commonly found in marine oils.

α-Linolenic acid (ALA) is found in many plant foods, including kale, spinach, purslane, soybeans, walnuts and many seeds such as chia, flax and hemp seeds. ALA is also found in some animal fats (Burdge, 2006).

Both EPA and DHA are mostly found in seafood, including fatty fish and algae. For this reason, they are often called marine ω-3 FAs. EPA concentrations are highest in herring, salmon, eel, shrimp and sturgeon, and grass-fed animal products such as dairy and meats (Martins, et al., 2013).

Evidences suggest that low levels of ω-3 FAs are correlated with depressive symptoms during pregnancy and after delivery, and may produce antidepressant effects due to their role in serotonin functioning (Hart & Marino, 2010).

Omega-3 FAs are critical for fetal neurodevelopment and may be important for the timing of gestation and birth weight as well (Greenberg, et al., 2008), The findings were that fish/marine oil supplements taken in pregnancy increase the length of pregnancy by two to three days, slightly increase a baby's birth weight and slightly reduce the number of babies born before 34 weeks gestation (Makrides, et al., 2006).

The typical Western diet is deficient in ω-3 PUFAs in general, and in DHA in particular. Although seafood is a good source of both DHA and EPA, concerns about mercury contamination have led to both fear and confusion about whether to recommend it during pregnancy. Both the Environmental Protection Agency and The American College of Obstetricians and Gynecologists recommend that women consume 12 ounces of seafood per week from low-mercury species (Nesheim, et al., 2015).

The mercury found in 2 servings of the approved seafood poses little risk to the fetus (Mozaffarian & Rimm, 2006). For those seeking to avoid seafood, there are few non-supplement options. Plant-based ω-3 FAs like flaxseed oil, are poorly converted to the biologically active ω-3 FAs EPA, and converts even less to DHA (Lane, et al., 2014).

Fish oil supplements are commercially available from multiple companies. The amount of EPA and DHA per capsule varies, but most contain one-third to one-half of these ω-3 FAs (e.g., in a 1000 mg capsule, 300 or 500 mg would come from EPA and DHA).

Most commercially available fish oil supplements contain less than 1 to 2 ppb of mercury compared with less than 0.05 ppb in seafood, but because the amount of fish oil used (1–2 g a day) is much smaller than what is consumed when eating seafood (200 g twice a week), the risk of mercury toxicity is inconsequential.

2.3.6.Folic acid

Folic acid is a type of B vitamin that is normally found in foods such as dried beans, peas, lentils, oranges, whole-wheat products, liver, asparagus, beets, broccoli, Brussels sprouts, and spinach. Women who have had a pregnancy affected by a Neural Tube Defects (NTDs) as spina bifida or anencephaly and are planning a pregnancy should receive 4.0 mg of folic acid supplementation per day for 1 month before conception through the first 3 months of pregnancy (Sizer, et al., 2012). There is growing concern worldwide that prenatal high folic acid in the presence of low vitamin B12 causes epigenetic changes in the unborn predisposing them to metabolic syndromes, central adiposity and adult diseases such as Type 2 diabetes (Yajnik, et al., 2008).

Fortification with folic acid of all types of white flour, enriched pasta, and corn meal became mandatory in some countries as Canada. The goal of fortification was to increase by approximately 30 to 70% the average intake of folic acid among women of childbearing age without posing a risk to the general public. Higher levels of fortification were not adopted because of concern about exceeding the recommended daily upper intake level of 1000 μg for adults (De Wals, et al., 2007).

In 2007, a study was conducted for reduction of NTDs, showed that food fortification with folic acid was associated with a significant reduction in NTDs in Canada. Furthermore, the risk reduction appeared greatest in regions in which the rates were highest before the fortification program was implemented (De Wals, et al., 2007).

2.3.7.Iron

Iron is a trace mineral that is essential for making Hemoglobin (Hb), that is protein in red blood cells which carries oxygen to other cells, it's an important component of myoglobin; a protein that helps supply oxygen to the muscles, collagen; a protein in bone, cartilage, and other connective tissues, because of that iron bioavailability is a critical point in pregnancy (Black, 2001).

The DRI for iron during pregnancy is 27 mg/day, and is particularly vital to meet this recommendation during the second and third trimesters, the natural product of iron include; liver, turkey, duck, cooked clams, chicken, soybeans, fortified cereals, lentils, spinach, lima beans, refried beans, chickpeas, tomatoes, and prune juice (Sizer, et al., 2012).

Supplementation with iron is generally recommended during pregnancy to meet the iron needs of both mother and fetus. When detected early in pregnancy, Iron Deficiency Anemia (IDA) is associated with an increase in the risk of preterm delivery (Scholl, 2005).

Maternal anemia when diagnosed before mid-pregnancy is also associated with an increased risk of preterm birth. During the 3rd trimester, maternal anemia usually is not associated with increased risk of adverse pregnancy outcomes and may be an indicator of an expanded maternal plasma volume. High levels of Hb, hematocrit (Hct), and ferritin are associated with an increased risk of fetal growth restriction, preterm delivery, and preeclampsia (Scholl, 2005).

Recommended Serving Size from Each Food Group in Pregnancy

Adequate nutrient intake is important for successful pregnancy and positive outcomes. According to American Heart Association (AHA, 2017), Pregnant woman should be encouraged to plan their diet intake according to the dietary guide which presented in the table below.

Table (2.2): Recommended Serving Size from Each Food Group in Pregnancy. Food group In pregnancy

Grains 9 serving

Vegetables 4 serving

Fruits 3 serving

Meat, poultry and fish 2 serving

Dairy product 2-3 serving

Nuts, seeds and legumes 2 serving

Recommended Serving Size from Each Food Group in Pregnancy (AHA, 2017).

2.4.Association between Omega-3 fatty acids (ω-3 FAs) and neonatal anthropometry

Intake of marine fat, rich in Omega-3polyunsaturated fatty acids (ω-3 PUFAs), may increase birth weight by prolonging gestation in human beings by interfering with uterine production of prostaglandins, possibly by inhibiting the endogenous production of arachidonic acid derived eicosanoids such as prostaglandins PGF2α and PGE2, which are mediators of uterine contractions and cervical ripening (Hadley, et al., 2016).

Fish consumption during pregnancy increase fetal growth seen in non-smokers could be due to marine ω-3 FAs improving placental blood flow by increasing the ratio of prostacyclin's to thromboxane. Smoking may possibly interfere with this mechanism via nicotine's inhibitory effect on platelet thromboxane production (Barua, et al., 2015). Infants of women in the lowest quartile of fish consumption had a smaller head circumference at birth than those of women consuming higher amounts of fish (Thorsdottir, et al., 2004).

Other Studies suggested that, the absence of an adverse relation between lack of fish consumption and reduced birth size as measured by weight, length and head circumference. However, The use of marine oil supplements during pregnancy has been studied as a possible strategy to increase birth weight along with other potential benefits such as improving fetal brain development, reducing the risk of cerebral

24 palsy and postpartum depression (Olafsdottir, et al., 2005). Biological determinants and maternal cigarette smoking during pregnancy remain important determinants of birth size (Berger, et al., 2014).

2.5.Association between Omega-3 fatty acids (ω-3 FAs) and pregnancy durational period

Low consumption of fish is a strong risk factor for preterm delivery and LBW. In women with zero or low intake of fish, small amounts of ω-3 FAs provided as fish or fish oil may confer protection against preterm delivery and LBW (Newnham, et al., 2014).

Marine oil supplements are often recommended to pregnant women to fulfill their ω-3 FAs requirements. The use of marine oil supplements during pregnancy has been studied to prevent preterm birth (or increase gestational age) and prevent eclampsia (Olafsdottir, et al., 2005). The findings were that fish/marine oil supplements taken in pregnancy increase the length of pregnancy by two to three days, slightly increase a baby's birth weight and slightly reduce the number of babies born before 34 weeks gestation (Makrides, et al., 2006).

Other studies demonstrated that Elongated ω-3 PUFAs intake and seafood intake were not associated with length of gestation or risk of preterm birth. According to Knudsen, et al., There is no differences in timing of spontaneous delivery was detected in the fish oil groups or the flax oil group, compared with the control group (Knudsen, et al., 2006).

2.6.Association between Omega-3 fatty acids (ω-3 FAs) and post prandial triglycerides (PPTGs)

A strong correlation was detected between the consumption of fish or other sources of dietary ω-3 FAs and cardiovascular events, The paradigm that ω-3 FAs act exclusively by lipid reduction has been challenged. ω-3 FAs have a potent antiarrhythmic action, inhibit thrombogenesis, improve endothelial reactivity, lower BP and reduce pro inflammation (Breslow, 2006).

Omega-3 FAs of marine origin lower Systolic Blood Pressure (SBP) and TGs but raise Low Density Lipoprotein (LDL) cholesterol compared with ω-3 and ω-6 FAs from plants (Chandra, et al., 2014).

Dietary fish and fish oils may be useful components of diets for the treatment of hypertriglyceridemia as the fish-oil diet led to decreases in both plasma cholesterol and TG, as compared with the control diet. Very low density lipoproteins (VLDLs) were also reduced markedly (Bradberry & Hilleman, 2013).

Epidemiologic studies suggest that, elevated PPTGs are associated with future cardiovascular events. Monocyte activation plays an important role in vascular diseases. ω-3 FAs lower fasting TG levels. The effects of ω-3 FAs on PPTG and the role of PPTG for monocyte activation are insufficiently understood. The PPTG increase does not stimulate monocytes beyond their circadian activation patterns. ω-3 FAs reduce fasting TG and the PPTG increase (Schirmer, et al., 2012).

Elevation of PPTGs impairs endothelial function and contributes to the development of atherosclerosis. ω-3 FAs significantly decreased PPTG elevation and postprandial endothelial dysfunction, suggesting that ω-3 FAs may have vascular protective effects in postprandial state (Miyoshi, et al., 2014). ω-3 FAs achieved a significant reduction of fasting and PPTGs without adverse reactions in the treatment group than control group (Kim, et al., 2015).

2.7.Association between Omega-3 fatty acids (ω-3 FAs) and Blood Pressure (BP)

Epidemiological and clinical studies suggest that, consumption of Omega-3 polyunsaturated fatty acids (ω-3 PUFAs) contributes to the reduction of cardiovascular mortality through different mechanisms including modulation of cellular metabolic functions, gene expression and beneficial effects on lipid profile or BP (Cabo, et al., 2012).

High doses of ω-3 PUFAs ( ≥ 3 g/day) produces a small but significant decrease in BP, especially SBP in older and hypertensive subjects; however, the evidence is not consistent among different studies. ω-3 PUFAs consumption might have a place in the control of patients with mild hypertension before starting drug treatment and of those who prefer changes of lifestyles like diet (Cabo, et al., 2012).

There is substantial evidence that ω-3 FAs reduce BP, with a greater effect in hypertensive patients and those with high-normal BP. The dose of ω-3 FAs required to achieve a BP reduction is likely to be at least 3-4 g/day (Mori, 2010).

The fatty acids DHA and EPA that are contained in marine oils are the precursors of prostaglandins, which have been shown to influence the constriction of blood vessels. Among pregnant women and non-pregnant adults, marine oils have been promoted as a treatment for hypertension, or high BP and those with clinical atherosclerotic disease or hypercholesterolemia (Lordan, Ross, & Stanton, 2011).

CHAPTER 3

RESEARCH METHODOLOGY

3. 3.1.Study Setting

This study was carried out at Rafah and Khanyounis governmental primary health care centers in Rafah and Khanyounis governorate, Gaza Strip, Palestine.

3.2.Target population

Pregnant, the first or the second pregnancy, who aged from 20 to 35 years old, and attended governmental primary health care centers in Rafah and Khanyounis governorate in the Gaza Strip.

3.3.Study design

This study employed a clinical randomized controlled trial design, that conducted on 92 pregnant.

3.4.Sampling design

This study was utilized a randomized controlled clinical trial, in which participants were stratified according to number of pregnancies (1st pregnancy, 2nd pregnancy), maternal age (20-24.11, 25-29.11, 30-35 years and months), maternal BMI 2 months prior to pregnancy (<18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, >40) into different strata. Then, subjects were randomly allocated into two groups using a simple random method (the stratification and randomization process had been illustrated in the study profile chart). ω-3 FAs was supplemented to the intervention group throughout the intervention period, and the control group did not received ω-3 FAs supplementations.

3.4.1. Sampling technique

Stratification sampling methodology was used in this study. Stratified randomized sampling approaches based on age, number of pregnancies, and maternal BMI prior to pregnancy. Then randomized allocation of the participants into control and intervention groups.

The intervention group consists of 46 participants were on ω-3 FAs 300mg/day from week 20 of gestation to delivery and Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the end of pregnancy. While the control group consists of 46 participants was supplemented with Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery.

3.4.2. Sample size calculation.

4. To calculate the sample size two mean formulas were used as follow

5. ( )

6. σ = 8 (Bulstra Ramakers, et al., 1995)

7. Δ = 5 mmHg (expected systolic blood pressure reduction after 4 months of the trial (Bulstra Ramakers, et al., 1995)

8. Z (α/2) = 1.96 for α = 0.05 (two-tailed)

9. z_(β )= 0.84 for 80% power

10.

11. n = 40.14 = 41

12. Total number of cases in each group = 41 + non response rate 10%.

13. n = 41+ 4.1 = 45.1 = 46 cases in each group.

The total sample size was 92 of with a signiﬁcance level of P ˂ 0.05.

3.4.3. Sampling frame.

The sampling frame for this study was based on the lists of pregnant women at the targeted primary health care centers, inclusion and exclusion criteria, as follows:

3.4.3.1.Inclusion Criteria:

 Pregnant women aged between 20-35 years.  Pregnant women 20 weeks gestation.

 First or second pregnancy.  Agree to participant in the trial.

3.4.3.2.Exclusion Criteria:

 Diagnosed with current major illness like (renal disease, cardiovascular disease,… etc.).  Associated with chronic diseases "Ex : HTN , DM,… etc. ".  History of GDM or PIH.  History of abortion.  Tobacco use.  Participating in other clinical trial.

Sampling collection was based on the sampling frame for this study which was based on the lists of pregnant women at the targeted clinics.

3.5. Intervention strategy

Omega-3 fatty acids was supplemented to the intervention group at 8 pm daily after meals. Also, the compliance into the intervention program was assessed by 2 weeks meeting with the subjects. In addition to that, subjects were filled up the compliance checklist. Also, respondents were contacted by phone once weekly to insure compliance. More important, two- weeks health recall (ANNEXE B) was applied to insure the safety of the supplements on pregnant health.

3.6. Data Collection

The data of this study were collected from August 2016 to March 2017, through pre tested questionnaire via individual interviews with subjects, also performing anthropometric measurements and sampling for chemical investigations. The data collection were applied by the researcher and the expert team for filling questioner to perform anthropometric measurements and filling Food Frequency Questionnaire (FFQ) as well. The data collection were applied every 2 days in the week by the researcher and the expert team.

3.7. Materials and methods

The following techniques and tools were used in the study to collect the required data.

3.7.1.Structured Questionnaire

Pre designed structured interview questionnaire was designed and checked for competence and accuracy to collect the following data :

 Personal information.

 Socio-demographic information.

 Socioeconomic information.

 Medical information.

 Nutritional information.

3.7.2.Qualitative Food Frequency Questionnaire (FFQ)

Qualitative FFQ was used to assess food consumption pattern of the pregnant women. The interviews were conducted by asking the pregnant about the usual frequency consumption of different food groups wither daily, weekly or monthly consumption to find out any food items that may interfere with the intervention. The different food items consumed by the pregnant were classified into different groups according to WHO dietary guidelines.

3.7.3. Anthropometric measurements

3.7.3.1.Maternal anthropometrics

The anthropometric measurements of mothers were taken at 2 months prior to pregnancy, at 28 weeks of gestation, and at the end of the pregnancy. The measured anthropometrics are height, weight, and BMI. We ask the mother about her weight 2 months before pregnancy, and this is very subjective, but this just to stratified the subjects according to their BMI. In addition, we measured the BMI at 28 weeks of gestation and at the end of pregnancy to compare the GWG between the intervention and the control group. The weight and height of maternal were taken on calibrated trusted devices. the BMI was calculated according to this formula kg/m2.

According to The WHO, the BMI classified to underweight, normal weight, overweight, and obese. Table (3.1) shows the BMI categories according to WHO classification of BMI (WHO, 2006):

Table 3.1: Classification of BMI according to WHO (2006) BMI Weight Status Below 18.5 Underweight 18.5 – 24.9 Normal 25.0 – 29.9 Overweight More than 30 Obese

Because of the increasing prevalence of obesity among women of reproductive age, increases in GWG and the associated health complications of both. Hence, the appropriate GWG during pregnancy (Rasmussen, et al., 2008) is listed in the table 3.2 below, this guidelines are based on WHO cut-off points for the BMI categories, and include a specific, relatively narrow range, of recommended gain for obese women.

Table 3.2: New guidelines for Gestational Weight Gain (GWG) Recommended range of Mean rate of weight gain in Pre-pregnancy total weight gain the 2nd and 3rd trimester BMI categories Kg Kg/week Underweight BMI < 18.5 12.5-18 0.5 Normal weight BMI 18.5-24.9 11.5-16 0.4 Overweight BMI 25-29.9 7-11.5 0.3 Obese BMI ≥ 30 5-9 0.2 Recommended GWG (Rasmussen, et al., 2008).

3.7.3.2.Newborn anthropometrics

The anthropometric measurements of newborns were taken post to delivery, after one month, and after 2 months of delivery.

Neonatal anthropometric measurements are routine procedures in most of obstetric and neonatal departments. Moreover, weight, length and head circumference at birth are indicators of the quality and quantity of growth, hence these variables were evaluated using standardized instruments. Furthermore, not all of these measurements currently are a routine procedure in every obstetric and neonatal units.

3.7.3.2.1.Newborn body weight

The weight of a newborn is a key measure of health status during pregnancy. The average gestation for a full-term infant is 40 weeks, with a range from 37 to 42 weeks. Full-term infants usually weigh 2500–3800 grams (Zohdi, et al., 2012). Infants with normal birth weights are less likely to require intensive care and usually healthy in the long run. Conversely, preterm births, regardless of birth weight, are those born at 37 weeks or less (Mathews & MacDorman, 2011). Over the first 5–7 days following birth, the body weight of a term neonate decreases by 3–7% (Haiek, et al., 2001). Birth weight is doubled by 4 months and tripled by 13 months in boys and 15 months in girls (Onis, 2006). The weight of newborns was taken using a calibrated trusted electronic weighting device (at birth, after one month, and after 2 months of delivery). More important, the three weight measurements were taken without cloths and in worm healthy room.

3.7.3.2.2.Newborn Length

It can be difficult to measure a newborn length accurately, especially if they move a lot. Despite the difficulty, we may still want to have an idea of how the newborn compares to the growth according to normal cutoff points. A recumbent- length measurement board with an attached right-angled headpiece was used to measure the length of the newborns. The measurements were done by two nurses. Although, this was the way by wish the length of the newborns was measured (Covering the board with scale paper, removing all hats and hair barrettes or anything on hair that could prevent obtaining an accurate measurement, gently placing the infant on his/her back on the recumbent board, holding the crown of the infants head firmly against the headboard until the measurement is complete, making sure that the is looking up and that the head, body, and toes are in a straight line, holding the infant’s legs together just above the knees and gently pushing both legs down against the measuring board, fully extending the child, sliding the footboard against the

33 infant’s feet until the heels of both feet touch the footboard with toes pointed upward, reading the measurement, and recording the measurements in the data set). The normal reference range of the newborn length is from 46 to 56 cm (Onis, 2006).

3.7.3.2.3.Newborn head circumferences

A newborn's head is very large in proportion to the body, and the cranium is enormous relative to his or her face. While the adult human skull is about one seventh of the total body length, the newborn's is about one-fourth. Normal head circumference for a full-term infant is 33–36 cm at birth (Cartwright & Wallace, 2007). The head growth can signal certain medical conditions or developmental problems. Checking the circumference, or the distance, around newborn head can indicate normal growth or alert for possible issues (Villar, et al., 2014). Soft and flexible measuring tape wrapped around the head just above eyebrows and ears and then around the back of the head where head slopes up prominently from the neck, and the newborns head measured at the place their circumference is largest, then we were lined up the starting line on the measuring tape with the final point of the measurement.

3.7.4. Pregnancy duration

The average pregnancy duration, or gestation, is calculated as 40 weeks. This is because pregnancy is counted from the first day of the woman’s last period, not the date of conception which generally occurs two weeks later, followed by five to seven days before it settles in the uterus. Since some women are unsure of the date of their last menstruation (perhaps due to period irregularities), a pregnancy is considered full term if birth falls between 37 to 42 weeks of the estimated due date. A baby born prior to week 37 is considered premature, while a baby that still hasn’t been born by week 42 is said to be overdue. Gynecologists and Obstetricians were calculate the Estimated Date of Confinement (EDC), and we were minus the date of delivery from EDC. Then we were compare the results between the groups.

3.7.5. Maternal Blood Pressure (BP) measurements.

Blood Pressure was measured at the 20 weeks of gestation, after 28weeks, and at the end of pregnancy. Respondents were is relaxed by allowing 10 minutes to relax before the first reading using sphygmomanometer, and they were sited upright with

34 their upper arm positioned. Excess clothing that might interfere with the BP cuff or constrict blood flow in the arm was removed. After 5 minutes of the first reading, the second reading was taken and the average of two reading was reported.

3.7.6. Maternal Biochemical Investigation

Hemoglobin level in the plasma was measured at the 20 weeks of gestation, after 8 weeks, and at the end of pregnancy. The PPTG was measured at the 28 weeks of gestation, at the end of pregnancy, and 8 weeks after labor. The PPTG was taken after 2 hours of meal. A lot of studies indicated that non-fasting TG levels were predictive of myocardial infarction, ischemic heart disease, and death in men and women (Nordestgaard, et al., 2007). In addition, the normal cutoff points according to Kits were clarified in table (3.3).

Table 3.3: Biochemical cutoff points for pregnancy Test Type Normal Second Third Recommended value trimester trimester value Hb level* 11.5-15.0 9.7 - 14.8 g/dl 9.5 -15 g/dl 10-15 g/dl g/dl PPTGs Less than Less than 150 75 -382 mg/dl 131 – 453 mg/dl 200 mg/dl mg/dl * Hb and TG cutoff during pregnancy (James, et al., 2010).

Kits and devices

 Postprandial triglycerides (Mindray BS-400 Chemistry Analyzer (Less than 150 mg/dl recommended, 200-239 mg/dl upper limit, more than 240 mg/dl high value), sensitivity: 3 mg/dl).

 Hemoglobin level (Mindray BC 3000 plus, 2015 (11.5-15.0 g/dl normal value, 11.6-13.9 g/dl first trimester, 9.7-14.8 g/dl second trimester, 9.5-15 g/dl third trimester) sensitivity: 0.2 g/dl).

3.7.7. Supplementations

The intervention group was received ω-3 FAs 300 mg/day from week 20 of gestation to delivery, Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery. ω-3 FAs 300 mg/day, which consists of EPA 180 mg and DHA 120 mg. While the control group consists of 46 participants was supplemented with Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery.

3.8.Data management and presentation

The researcher obtained data from respondents, maternal BP and biochemical measurements, infants anthropometric measurements, and maternal records. All of the obtained data were reviewed before being entered into the study database. Data were entered into an Statistical Package for Social Sciences (SPSS) version 18 for Windows. The level of significance was set at 0.05. The data treatment involved overviewing all data sets, coding of the data, designing data entry model, defining variables, coding variables, data cleaning, frequency table for the study variables. The data treatment involved cleaning and organizing the data for analysis, which included numbering the results, codifying the data, entering the data into the computer, checking the data for accuracy, and transforming the data if necessary.

3.9.Statistical analysis

Frequency distribution were generated for all variables and for quantitative variables, means and standard deviations were calculated. For analysis of variance, one-way repeated measure ANOVA, Independent t-test, and chi-square were used.

3.10.Ethical consideration

The researcher obtained acceptance and agreements from important institutes that related to this study: approval of Dean of postgraduate studies & research affairs and Dean of faculty of pharmacy (ANNEXE A-1), approval from general directorate for Human Resource Development at MOH, approval from Helsinki Committee (ANNEXE A-2), the interviewed mothers received a complete explanation of the study and signed consent form (ANNEXE A-3) to take the optional to share in the study.

3.11.Limitations of the study

 Lack of supporting agencies for funding research study.

 Inability to applied more specific biochemical tests, and all geographical distribution with small sample size because of the expensive price with difficult coordination with MOH.

 Limited educational resources like books, journals, and online access.

3.12.Profile of the study

Assessment of Eligibility

Enrolled n=92

Stratification and allocation of respondents in either control or intervention group, according to Number of pregnancies, Maternal age and Maternal BMI prior to pregnancy

No. of pregnancy No. of pregnancy

1st pregnancy 2nd pregnancy

Age in years (20-24.11, 25-29.11, Age in years (20-24.11, 25-29.11, 30-35 years and months) 30-35 years and months)

BMI prior to pregnancy(<18.5, 18.5- BMI prior to pregnancy(<18.5, 18.5- 24.9, 25-29.9, 30-34.9, 35-39.9, >40) 24.9, 25-29.9, 30-34.9, 35-39.9, >40)

Simple randomization for allocation into 2 groups

Intervention group n=46 Control group n=46

Intervention program

Data entry and data editing

Data analysis and results 38

CHAPTER 4

RESULTS

4. This chapter presents results of the analysis. The first section describes the basic information derived from analysis of each variable through descriptive statistics. The second section presents results derived from cross analysis using One-way repeated measures ANOVA and Independent Samples t-Test.

4.1.Descriptive statistics

4.1.1. Socio-demographic and Socio-economic characteristics.

Table (4.1) presents the socio-demographic and socio-economic characteristics of the respondents. The mean age of the responders was 24 years. Almost, 100.0% of the total respondents were lived in city, whereas 44.6% lived in Rafah and 55.4% in Khan Younis.

The relative poverty and the deep poverty lines according to family income (for reference household consisted of 2 adults and 3 children) in the Palestinian Territory in 2010 were 2,237 NIS, and 1,783 NIS respectively (PCBS, 2014), The average of total income of the subjects was 901.1 NIS, the majority of the respondents 90.2% were under absolute or deep poverty, 66.7% of the respondents feel that the total monthly income not enough for food, and also 5.4% depend on regular aids.

Table 4.1: Socio-demographic and Socio-economic characteristics Profile Variables Mean (SD) Frequency Percentage Age 24(3.75) Rafah 41 44.6% Address Khan Younis 51 55.4% Total 92 100.0% City 92 100.0% Camps 0 0.00% Residence Rural area 0 0.00% Total 92 100.0% Privet 87 94.6% Accommodation type Rental 5 5.4% Total 92 100.0% Dose family receives Yes 5 5.4% No 87 94.6% aids? Total 92 100.0% Total Income NIS 901.1(733.38) Less than 1783 NISa 83 90.2% Between 1783- 2236.9 NISb 1 1.1% Family Income NIS More than 2237 NISc 8 8.7% Total 92 100.0% Did you feel that the Yes 31 33.7% total income enough No 61 66.7% for food? Total 92 100.0% a Deep or absolute poverty b Under relative poverty c Not poor

4.1.2. Paternal characteristics

Table 4.2 shows that, more than half of the participants 38(41.3%) had attained a university level of education, (51.1%) secondary school level, and 7.6% had attained a low educational level. Also, (28.3%) of respondents husband had attained a university level of education, (46.7%) secondary school level, and (25.0%) had attained a low educational level. The majority of respondents 95.7% not work, and more than one third of their partners was not work. One third of the respondents husbands smoke, and 24.2% of them smoke in the whereabouts of their wives.

Table 4.2: Paternal characteristics Profile Variables Frequency Percentage Primary 7 7.6% Maternal Education Secondary 47 51.1% level University 38 41.3% Total 92 100.0% Primary 23 25.0% Father Education Secondary 43 46.7% Level University 26 28.3% Total 92 100.0% Yes 4 4.3% Do you work ? No 88 95.7% Total 92 100.0% Do your husband Yes 60 65.2% No 32 34.8% work? Total 92 100.0% Is your husband Yes 29 31.5% No 63 68.5% smoker? Total 92 100.0% Yes 7 24.2% Smoke in the same No 22 75.8% place Total 29 100.0%

4.1.3. Social characteristics

Table (4.3) shows the social characteristics of the participants. More than half of the respondents 54.3% was pregnant before this pregnancy, the average distance between this pregnancy and the previous one was 26 months.

Table 4.3: Social Characteristics Profile Variables Mean (SD) Frequency Percentage Yes 50 54.3% Do you have child No 42 45.7% Total 92 100.0% How many child did Zero 42 45.7% One 50 54.3% you have Total 92 100.0% Distance between pregnancies/ month 26.12(15.98)

4.1.4. Medical and Nutritional characteristics

Table (4.4) shows the medical and nutritional characteristics of the participants. The majority of the respondents 92.4% did not follow any type of diet regimen, and 7.6% who follow diet regime, don’t follow their diet regime by nutritionist. In addition, 97.8% of the respondents depending on home-cooked meals regularly. Moreover, none of the respondents was previously complained from dental problems, food sensitivity, and none of them had under general operation before 2 years from the pregnancy. Almost of all respondents complain of different pregnancy disorders in the pregnancy period. 40, 30, 70 out of 92 of respondents were complained from epigastric burn, constipation, nausea and vomiting, respectively. The first visit to the Gynecologist was beyond the second month of the pregnancy, and the majority of the respondents 84.8% were visit Gynecologist once monthly. The majority of the respondents 64.1% have three meals per day.

Table 4.4: Medical and Nutritional Characteristics

Profile Variables Mean (SD) Frequency Percentage Yes 7 7.6% Follow Diet Regimen No 85 92.4% Total 92 100% Nutritionist 0 0.00% Source of Diet hysicianGynecologist 4 57.1% Internet 3 42.9% Regimen Others 0 0.00% Total 7 100% Home made 90 97.8% Restaurants 1 1.1% Regular Diet Both 1 1.1% Total 92 100% Yes 0 0.00% Dental Problems No 92 100.0% Total 92 100.0% Yes 0 0.00% Operations No 92 100.0% Total 92 100.0% Yes 0 0.00% Food Sensitivity No 92 100.0% Total 92 100.0%

Table 4.4: Continue Medical and Nutritional Characteristics Profile Variables Mean (SD) Frequenc Percentage Disorders in the Yes y 92 100.0% No 0 00.0% Pregnancy Total 92 100.0% Hemorrhoids 0 00.0% Diarrhea 0 00.0% What type of Diseases? Epigastric burn 40 43.5% Constipation 30 32.6% Nausea and Vomiting 70 76.1% Gynecologist First visit (month) 2.5 (1.58) Once month mont 78 84.8% Gynecologist monthly Twice 7 7.6% Not Matched 7 7.6% visit (month) Total 92 100%

Once 1 1.1% Twice 14 15.2% Meals per a day Three 59 64.1% More than 3 18 19.6% Total 92 100%

4.1.5. Lifestyle Characteristics

Table (4.5) shows lifestyle characteristics of the participants. The majority of respondents (96.75%) were physically inactive, and the average time spent on physical activity for who are physically active was 21.67 minutes daily.

Table 4.5: Lifestyle Characteristics Profile Variables Mean (SD) Frequenc Percentage Yes y 3 3.3% Sporting No 89 96.75% Total 92 100% Walking 3 3.3% Type of Sporting Not Sporting 89 96.75% Total 92 100% Sporting Duration 21.67(2.88) (minutes)

4.1.6. Maternal Anthropometrics and Gestational Weight Gain (GWG)

Table (4.6) shows the maternal anthropometrics and GWG characteristics for both groups. The mean of the pre conception BMI for all respondents was 23.26, the majority of the respondents 67.4% have normal weight, 26.1% overweight, and 6.5% was underweight. The total GWG was 13.75 kg, were distributed through the second semester 6.50 kg, and in the third semester was 7.25 kg.

Table 4.6: Maternal anthropometric and GWG during pregnancy Profile Variables Mean (SD) Frequency Percentage Preconception Height 162.66(5.65) Preconception Weight 61.47(8.078) Preconception BMI 23.26(2.96) Underweight 6 6.5% Normal weight 62 67.4% Overweight 24 26.1% Total 92 100% 2nd Trimester GWG 6.50(4.994) 3rd Trimester GWG 7.25(1.216) Total pregnancy GWG 13.75(1.614) BMI classification according to WHO (WHO, 2006)

Table 4.7 shows the total GWG for both groups according to BMI classification and in relation with the recommended total GWG (Rasmussen, et al., 2008) at the end of pregnancy. The intervention group met the recommended total GWG, while the underweight participants in the control group were not met the recommended total GWG.

Table 4.7: Gestational Weight Gain (GWG) recommendations and participants GWG Recommended Participants total GWG range of total

GWG Pre-pregnancy Kg Intervention Met Control Met BMI categories group (Yes/No) group (Kg) (Yes/No) n (Kg) N (Kg) Underweight BMI < 18.5 12.5-18 3 12.60 Yes 3 11.75 No Normal weight BMI 18.5-24.9 11.5-16 31 12.47 Yes 31 13.33 Yes Overweight BMI 25-29.9 7-11.5 12 9.97 Yes 12 10.90 Yes

4.1.7.Food consumption pattern for all Subjects

4.1.7.1.Grains and Legumes Group

Table (4.8) shows the differences between food items (Grains and Legumes) that consumed between intervention and control groups and for both groups. Results of this study indicated that there is no statistical significant differences between intervention and control group in ingestion of Grains and Legumes food group. The majority of respondents 95.7% consume bread daily, 59.8% rice 2-3 times per weeks, 27.2% once weekly consume fava beans, 28.3% consume falafel once weekly.

Table 4.8: Differences between the control group and the intervention group with food consumption pattern of Grains, legumes Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 88(95.7%) 44(50.0%) 44(50.0%) 2-3 week 2(2.2%) 1(50.0%) 1(50.0%) Bread Once Weekly 0(0.00%) 0(0.00%) 0(0.00%) χ2=0000 0.999 Once Monthly 0(0.00%) 0(0.00%) 0(0.00%) Rarely 2(2.2%) 1(50.0%) 1(50.0%) Daily 6(6.5%) 4(66.7%) 2(33.3%) 2-3 week 55(59.8%) 24(43.6%) 31(56.4%) Rice Once Weekly 23(25.0%) 15(65.2%) 8(34.8%) χ2=5.974 0.201 Once Monthly 1(1.1%) 1(100.0%) 0(0.00%) Rarely 7(7.6%) 2(28.6%) 5(71.4%) Daily 13(14.1%) 11(84.6%) 2(15.4%) 2-3 week 23(25.0%) 10(43.5%) 13(56.5%) Fava beans Once Weekly 25(27.2%) 12(48.0%) 13(52.0%) χ2=7.689 0.104 Once Monthly 6(6.5%) 2(33.3%) 4(66.7%) Rarely 25(27.2%) 11(44.0%) 14(56.0%) Daily 11(12.0%) 10(90.9%) 1(9.1%) 2-3 week 23(25.0%) 10(43.5%) 13(56.5%) Falafel Once Weekly 26(28.3%) 13(50.0%) 13(50.0%) χ2=9.391 0.052 Once Monthly 10(10.9%) 5(50.0%) 5(50.0%) Rarely 22(22.9%) 8(36.4%) 14(63.6%)

4.1.7.2. Proteins Group

Table (4.9) indicated that there is no statistical significant differences between all food items (proteins) that consumed between intervention and control groups and for except in poultry food item χ2=9.721, p = 0.045, which was considered marginal significance. 30 out of 46 in the control group consume poultry once weekly, while 17 out of 46 of the intervention group consume poultry once weekly.

42.4% consume red meat 2-3 times per week, 57.6% consume egg on daily basis, 32.6% and 26.1 consume fish once/week and rarely, respectively.

Table 4.9: Differences between the control group and the intervention group with food consumption pattern of Proteins. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 11(12.0%) 5(45.5%) 6(54.5%) 2-3 week 39(42.4%) 17(43.6%) 22(56.4%) Red Meat Once Weekly 27(29.3%) 18(66.7%) 9(33.3%) χ2=4.510 0.341 Once Monthly 9(9.8%) 4(44.4%) 5(55.6%) Rarely 6(6.5%) 2(33.3%) 4(66.7%) Daily 6(6.5%) 3(50.0%) 3(50.0%) 2-3 week 32(34.8%) 11(34.4%) 21(65.6%) Poultry Once Weekly 47(51.1%) 30(63.8%) 17(36.2%) χ2=9.721 0.045

Once Monthly 3(3.3%) 0(0.00%) 3(100%) Rarely 4(4.3%) 2(50.0%) 2(50.0%) Daily 0(0.00%) 0(0.00%) 0(0.00%) 2-3 week 21(22.8%) 8(38.1%) 13(61.9%) Fish Once Weekly 30(32.6%) 17(56.7%) 13(43.3%) χ2=1.783 0.619 Once Monthly 17(18.5%) 9(52.9%) 8(47.1%) Rarely 24(26.1%) 12(50.0%) 12(50.0%) Daily 53(57.6%) 26(49.1%) 27(50.9%) 2-3 week 23(25.0%) 13(56.5%) 10(43.5%) Egg Once Weekly 6(6.5%) 2(33.3%) 4(66.7%) χ2=3.577 0.466 Once Monthly 2(2.2%) 2(100%) 0(0.00%) Rarely 8(8.7%) 3(37.5%) 5(62.5%)

4.1.7.3.Dairy Products Group

Table (4.10) indicated that there is no statistical significant differences between all dairy products that consumed between intervention and control groups. More than one third of respondents consume milk on daily basis. 37% of the control and intervention group consume yogurt on daily basis.

Also, 58.8% of the respondents in the control group consume cheese on daily basis comparison with 41.2% of the intervention group.

Table 4.10: Differences between the control group and the intervention group with food consumption pattern of Dairy products. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 32(34.8%) 17(53.1%) 15(46.9%) 2-3 week 15(16.3%) 9(60.0%) 6(40.0%) Milk Once Weekly 5(5.4%) 2(40.0%) 3(60.0%) χ2=1.502 0.826 Once Monthly 3(3.3%) 1(33.3%) 2(66.7%) Rarely 37(40.2%) 17(45.9%) 20(54.1%) Daily 34(37.0%) 22(64.7%) 12(35.3%) 2-3 week 24(26.1%) 10(41.7%) 14(58.3%) Yogurt Once Weekly 5(5.4%) 1(20.0%) 4(80.0%) χ2=7.408 0.116 Once Monthly 4(4.3%) 3(75.0%) 1(25.0%) Rarely 25(27.2%) 10(40.0%) 15(60.0%) Daily 51(55.4%) 30(58.8%) 21(41.2%) 2-3 week 16(17.4%) 9(56.2%) 7(43.8%) Cheese Once Weekly 6(6.5%) 1(16.7%) 5(83.3%) χ2=7.095 0.131 Once Monthly 6(6.5%) 2(33.3%) 4(66.7%) Rarely 13(14.1%) 4(30.8%) 9(69.2%)

4.1.7.4.Vegetables Group

Table (4.11) shows the differences between vegetables item that consumed between intervention and control groups and for both groups. Results of this study indicated that there is no statistical significant differences between intervention and control group in vegetables food group. 44.6% consume salad daily, 43.5% consumed cooked vegetables daily and 59.8% of respondents consume avocado 2-3 week.

Table 4.11: Differences between the control group and the intervention group with food consumption pattern of Vegetables. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 41(44.6%) 24(58.5%) 17(41.5%) 2-3 week 31(33.7%) 15(48.4%) 16(51.6%) Salad Once Weekly 7(7.6%) 3(42.9%) 4(57.1%) χ2=5.481 0.241 Once Monthly 4(4.3%) 0(0.00%) 4(100%) Rarely 9(9.8%) 4(44.4%) 5(55.6%) Daily 40(43.5%) 26(65.0%) 14(35.0%) 2-3 week 37(40.2%) 15(40.5%) 22(59.5%) Cooked Once Weekly 4(4.3%) 2(50.0%) 2(50.0%) χ2=7.543 0.183 Vegetable Once Monthly 3(3.3%) 1(33.3%) 2(66.7%) Rarely 8(8.7%) 3(37.5%) 5(62.5%) Daily 6(6.5%) 4(66.7%) 2(33.3%) 2-3 week 55(59.8%) 24(43.6%) 31(56.4%) Avocado Once Weekly 23(25.0%) 15(65.2%) 8(34.8%) χ2=5.974 0.201 Once Monthly 1(1.1%) 1(100.0%) 0(0.00%) Rarely 7(7.6%) 2(28.6%) 5(71.4%)

4.1.7.5.Fruits Group

Table (4.12) indicated that there is no statistical differences between control and intervention groups in the fruits food group. More than half of respondents 51(55.4%) consume fresh fruits and natural fruits juice on daily basis.

Table 4.12: Differences between the control group and the intervention group with food consumption pattern of Fruits. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 51(55.4%) 25(49.0%) 26(51.0%) 2-3 week 21(22.8%) 11(52.4%) 10(47.6%) Fresh Fruit Once Weekly 12(13.0%) 5(41.7%) 7(58.3%) χ2=5.401 0.249 Once Monthly 4(4.3%) 1(25.0%) 3(75.0%) Rarely 4(4.3%) 4(100%) 0(0.00%) Daily 51(55.4%) 24(47.1%) 27(52.9%) 2-3 week 20(21.7%) 13(65.0%) 7(35.0%) Fruit Juice Once Weekly 10(10.9%) 3(30.0%) 7(30.0%) χ2=5.862 0.210 Once Monthly 4(4.3%) 1(25.0%) 3(75.0%) Rarely 7(7.6%) 5(71.4%) 2(28.6%)

4.1.7.6.Fats Group

Table (4.13) shows the differences between Fats item that consumed between intervention and control groups and for both groups. Results of this study indicated that there is no statistical significant differences between intervention and control group in fats food group. 52.2% consumed olive oil daily, 43.5% consumed other natural plant oil 2-3 week, 63.0% consumed margarine rarely, and 37.0% consume Tahini rarely.

Table 4.13: Differences between the control group and the intervention group with food consumption pattern of Fats. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 48(52.2%) 20(41.7%) 28(58.3%) 2-3 week 18(19.6%) 10(55.6%) 8(44.4%) Olive Oil Once Weekly 6(6.5%) 3(50.0%) 3(50.0%) χ2=4.771 0.312 Once Monthly 3(3.3%) 1(33.3%) 2(66.7%) Rarely 17(18.5%) 12(70.6%) 5(29.4%) Daily 35(38.0%) 17(48.6%) 18(51.4%) 2-3 week 40(43.5%) 21(52.5%) 19(47.5%) Other Plant Oil Once Weekly 5(5.4%) 2(40.0%) 3(60.0%) χ2=0.773 0.942 Once Monthly 3(3.3%) 2(66.7%) 1(33.3%) Rarely 9(9.8%) 4(44.4%) 5(55.6%) Daily 2(2.2%) 150.0%) 1(50.0%) 2-3 week 10(10.9%) 6(60.0%) 4(40.0%) Margarine Once Weekly 9(9.8%) 2(22.2%) 7(77.8%) χ2=3.324 0.505 Once Monthly 13(14.1%) 7(53.8%) 6(46.2%) Rarely 58(63.0%) 30(51.7%) 28(48.3%) Daily 16(17.4%) 11(68.8%) 5(31.2%) 2-3 week 21(22.8%) 12(57.1%) 9(42.9%) Tahini Once Weekly 11(12.0%) 5(44.5%) 6(54.5%) χ2=4.840 0.304 Once Monthly 10(10.9%) 3(30.0%) 7(70.0%) Rarely 34(37.0%) 15(44.1%) 19(55.9%)

4.1.7.7.Nuts Group

Table (4.14) indicated that, there is no statistical differences between groups in the nuts food group. 14.1% consume Almond daily, 17.4% consume Almond rarely, 26.1% consumed mixed nuts once weekly, 20.7% consume mixed nuts rarely.

Table 4.14: Differences between the control group and the intervention group with food consumption pattern of Nuts. Both Control Intervention Test P Food Item Groups Group Group Value Value Daily 13(14.1%) 7(53.8%) 6(46.2%) 2-3 week 23(25.0%) 9(39.1%) 14(60.9%) Almond Once Weekly 24(26.1%) 11(45.8%) 13(54.2%) χ2=2.581 0.630 Once Monthly 16(17.4%) 10(62.5%) 6(37.5%) Rarely 16(17.4%) 9(56.2%) 7(43.8%) Daily 12(13.0%) 5(41.7%) 7(58.3%) 2-3 week 21(22.8%) 10(47.6%) 11(52.4%) Mixed Nuts Once Weekly 24(26.1%) 12(50.0%) 12(50.0%) χ2=0.855 0.931 Once Monthly 16(17.4%) 8(50.0%) 8(50.0%) Rarely 19(20.7%) 11(57.9%) 8(42.1%)

4.2.Analysis of variances

4.2.1. Maternal

4.2.1.1.Maternal biochemical changes

Table 4.15: shows that there is a statistical significant differences between groups in Hb and TG level in the blood (F = 3.866, p = 0.029 and F = 193.508, p = <0.001, respectively) after 4 months of intervention. When we applied within group analysis and multiple comparisons within each group, the Hb level in the intervention group increased significantly (0.4 g/dl, p = 0.045 and 0.47 g/dl, p = 0.002) form the first measurements to third measurements and from the second measurements to the third measurement. The mean TG level increased from the second semester to the third semester in the intervention group about 41.85 mg/dl, and in the control group about 45.02 mg/dl. Figures 4.1, 4.2 shows the significant increment in the Hb of intervention group comparison with the control group, in addition to significant reduction of TG level among intervention comparison to control group.

Table 4.15: Comparison of maternal biochemical within and between each groups (Time treatment interaction) Control Group (n=46) Intervention Group (n=46) F P Measurements statistics value Mean Diff P Mean Diff P (95% C.I.) Value* (95% C.I.) Value* Hb g/dl 3.866 0.029 Pre – Post1 -0.004(-.520, 0.511) >0.999 0.07(-0.364, 0.499) >0.999 Pre – Post2 -0.13(-0.601, 0.340) >0.999 -0.41(-0.806, -0.007) 0.045* Post1–Post2 -0.13(-0.455, 0.203) >0.999 -0.47(-0.793, -0.155) 0.002* TG mg/dl 193.508 <0.001 Pre – Post1 -45.02(-55.625,-34.419) <0.001* -41.85(-47.823,-35.872) <0.001* One- way repeated measures ANOVA between and within the groups analyses were applied, followed by Pairwise Comparison with confidence interval adjustment. * Pairwise comparison with Bonferroni to correct the level of significance. Hb: (PRE = Baseline measurement of mean variable , POST1 = 28th week of gestation, POST2 = at the end of pregnancy). TG: (PRE = Baseline measurement of mean variable , POST1 = at the end of pregnancy.

Table 4.16: shows that there is a statistical significant differences between the control and intervention group (t = 4.152, p = <0.001) in the TG level after 8 weeks of delivery. The intervention group reach the recommended TG value which is less than 150mg/dl comparison with 173 in the control group.

Table 4.16: Comparison of Triglyceride (TG) level 8 weeks post-delivery. Variables Control Group Intervention Group Mean t P Value* (n = 46) (n =46) Diff Test Mean(SD) Mean(SD)

TG post delivery 172.93(31.668) 148.04(25.505) 24.89 4.152 <0.001 Independent Samples Test between the groups were applied. The level of significance is < 0.05

Figure 4.1: changes in the Hemoglobin (Hb) level mg/dl

Figure 4.2: Changes in the Triglyceride (TG) Level

4.2.1.2.Gestational Weight Gain (GWG) during pregnancy.

Table 4.17: after 4 months of intervention, results of this study shows that there is a statistical significant differences between the intervention group and the control group in the GWG (P = 0.016). The total GWG in the intervention group was 11.79kg and 12.597 kg in the control group. Figures 4.3 shows the direction of increment in the body weight during pregnancy in both groups.

Table 4.17 : Differences in GWG between the control and intervention groups

Variables Control (n=46) Intervention (n=46) P value 2nd Trimester 5.095(0.645) a 4.793(0.556) 0.018

3rd Trimester 7.502(1.312) 7.002 (1.068) 0.048

Total GWG 12.597(1.687) 11.795(1.448) 0.016

Independent t-test was applied to analyses between control and intervention groups a Mean (Standard Deviation) The level of significance is < 0.05

Figure 4.3: Changes in the Gestational Weight Gain (GWG) (kg).

4.2.1.3.Gestational length

Results of this study shows that there is no statistical differences between the groups in the gestational length p = 0.217. We found a trend for a modestly increased length of gestation among the ω-3 FAs group (2.217 day) when compared with the control group ( Table 4.18).

Table 4.18: Differences in gestational length between the groups Variables Control (n=46) Intervention (n=46) Mean Diff P value

Gestational length -3.46(8.645) a -1.24(8.457) -2.217 0.217

Independent t-test was applied to analyses between control and intervention groups a Mean (Standard Deviation) The level of significance is < 0.05

4.2.1.4.Maternal Blood Pressure (BP)

Table 4.19: shows that there is a statistical significant differences between groups in Systolic Blood Pressure (SBP) in the first, second, and third measurements (t = 2.433 p = 0.017, t = 2.433 p = 0.017, t = 2.433 p = 0.017, respectively) after 4 months of intervention, the intervention group have a significant lower of SBP than the control group. In addition there is no statistical significant differences between the groups in Diastolic Blood Pressure (DBP) in the first, second, and third measurements. The mean SBP1 was 122.06 mmHg in the control group, while the mean SBP1 was 119.67 mmHg in the intervention group. The SBP in the control group decreased (from 122.06 to 119.06 to 113.06 mmHg) from the first to second to third measurements respectively. While, the SBP in the intervention group decreased (from 119.67 to 116.67 to 110.67mmHg) from the first to second to third measurements respectively. In addition, the DBP in the control group decreased (from 75.65 to 70.15 to 64.15mmHg) from the first to second to third measurements respectively. While, the DBP in the intervention group decreased (from 74.89 to 69.39 to 63.39mmHg) from the first to second to third measurements respectively with lower level than control group.

Table 4.19: Comparison of Blood Pressure (BP) measurements between the groups. Control Group Intervention Group Mean t P Value* (n = 46) (n =46) Diff Test Variables Mean(SD) Mean(SD) SBP1 122.06(4.419)a 119.67(4.989) 2.391 2.433 0.017 DBP1 75.65(1.702) 74.89(2.469) 0.760 1.720 0.089 SBP2 119.06(4.419) 116.67(4.989) 2.391 2.433 0.017 DBP2 70.15(1.702) 69.39(2.469) 0.760 1.720 0.089 SBP3 113.06(4.419) 110.67(4.989) 2.391 2.433 0.017 DBP3 64.15(1.702) 63.39(2.469) 0.760 1.720 0.089 Independent Samples t-test between the groups were applied. The level of significance is < 0.05

4.2.2. Infant anthropometrics

Table (4.20): shows some anthropometric characteristics post to delivery. The mean weight in the control group is 3304.78 g and the mean weight in the intervention group was 3441.30 g. The mean length for both groups was 48.95 cm. the mean head circumference for all respondents was 35.04 cm, there was differences between groups with higher anthropometrics of intervention group to control group in weight, length and Head circumference.

Table 4.20: infants anthropometrics baseline characteristics Profile Variables5. Mean (SD) Both groups 3373.04 (529.27) Weight Control 3304.78 (482.84) Intervention 3441.30 (569.04) Both groups 48.95 (3.08) Length Control 48.36 (3.71) Intervention 49.54 (2.18) Both groups 35.04 (1.64) Head circumference Control 34.88 (1.80) Intervention 35.20 (1.46)

Table (4.21): shows the there is a statistical significant differences between the groups in the weight (F= 458.910, p = <0.001), length (F= 313.138, p = <0.001), and head circumferences (F= 234.109, p = <0.001).

The infants weight increased 2338.0 g in the intervention group from the first measure to the third measure, while the control group increased 2233.3 g. Also, the infants length increased 9.45 cm in the intervention group from the first measure to the third measure, while the control group increased 7.97 cm. The infants head circumference increased 4.2 cm in the intervention group from the first measure to the third measure, while the control group increased 3.8 cm. Figures 4.4, 4.5, 4.6 shows the nutritional status among studied infants according to anthropometric indicators with statistically significant greater healthy measurements of the intervention group compared with control group.

Table 4.21: Comparison of infants anthropometrics within and between each groups (Time treatment interaction) Control Group (n=46) Intervention Group (n=46) F P value Measurements statistics Mean Diff P Mean Diff P (95% C.I.) Value* (95% C.I.) Value* Weight 458.910 <0.001 1st – 2nd -1035.44(-1289.4,-781.4) <0.001* -1048.9(-1328.7,-769.0) <0.001* 1st – 3rd -2233.3(-4466.2,-2000.2) <0.001* -2338.0(-2479.7,-2196.2) <0.001* 2nd –3rd -1197.8(-1533.1,-862.4) <0.001* -1289.1(-1595.4,-982.8) <0.001* Length 313.138 <0.001 1st – 2nd -4.66(-5.756,-3.569) <0.001* -4.76(-5.622,-3.899) <0.001* 1st – 3rd -7.97(-9.605,-6.350) <0.001* -9.45(-10.522,-8.390) <0.001* 2nd –3rd -3.31(-4.678,-1.951) <0.001* -4.69(-5.896,-3.494) <0.001* Head circumferences 234.109 <0.001 1st – 2nd -2.1(-2.744,-1.437) <0.001* -2.4(-3.257,1.664) <0.001* 1st – 3rd -3.8(-4.610,-3.072) <0.001* -4.2(-5.101,-3.477) <0.001* 2nd –3rd -1.7(-2.136, -1.363) <0.001* -1.8(-2.240,1.415) <0.001* One- way repeated measures ANOVA between and within the groups analyses were applied, followed by Pairwise Comparison with confidence interval adjustment. * Pairwise comparison with Bonferroni to correct the level of significance. 1st measure = 1st measure post to delivery, 2nd measure = one month post to delivery, 3rd measure = two months post to delivery.

Figure 4.4: Changes in Infants Weight (g).

Figure 4.5: Changes in Infants Length (cm and mm).

Figure 4.6: Changes in Infants Head Circumference (cm and mm).

CHAPTER 5

DISCUSSION

The present study designed to determine whether Omega-3 fatty acids (ω-3 FAs) supplementation during pregnancy have a beneficial role on pregnancy outcomes. Ninety two pregnant women were enrolled in this study, and 46 out of them were supplemented with ω-3 FAs. Recently, a lot of studies was design to enhance pregnancy outcomes, by using a number of supplementations like ω-3 FAs (Carlson, et al., 2013; Larqu, et al., 2012; Coletta, et al., 2010). Results of this study prove that, the supplementation of ω-3 FAs during pregnancy tend to improve pregnancy outcomes.

5.1.Socio-demographic and Socio-economic characteristics of the subjects

The subjects of this study was distributed from the southern Gaza Strip governorates, Who are attend governmental primary health care centers. The total income for the majority of respondents 90.2% was less than 1,783 NIS. According to PCBS the relative poverty and the deep poverty lines according to for reference household consisted of 2 adults and 3 children in the Palestinian Territory in 2010 were 2,237 NIS, and 1,783 NIS respectively (PCBS, 2014). The poverty rate among Palestinian individuals was 38.8% in the Gaza Strip, 21.1% from Gaza Strip people complain from deep poverty (PCBS, 2014). In addition to that, more than one fourth of females in the labor force were unemployed in the 1st quarter of 2016 at 26.6% out of them 18.0% in the West Bank and 41.2% in Gaza Strip. Unemployment rate reached 42.8% among females compared to 22.3% among males (PCBS, 2016).

Poverty is associated with an increase in many of the medical and behavioral risk factors associated with preterm birth, systemic inflammation, chronic hypertension, diabetes, obesity, preeclampsia, and other pregnancy outcomes (Nagahawatte & Goldenberg, 2008). In addition, the lower socioeconomic status have been consistently associated preterm birth and intrauterine growth restriction (Luo, et al., 2006).

5.2.Paternal characteristics

Maternal education reflected a certain constellation of influencing factors which were unique for particular educational levels and stood for better self-care, better use of the health care system and better knowledge of health-related behavior. A lot of researchers pointed that low educated mothers increase the risk for delivering a small- for gestational age infant (Raum, et al., 2001), maternal mortality (Karlsen, et al., 2011), maternal obesity (Gaillard, et al., 2013). Moreover, low educated mother have elevated crude risks of preterm birth, stillbirth, neonatal and post-neonatal death when compared with mothers who had completed community college or at least some university (Luo, et al., 2006). In contrast, one study revealed that, there is no relation between maternal education and LBW (Silvestrin, et al., 2013).

Results of this study indicated that, 24.2% of recruited participants exposed to negative smoking from those who their partners are smokers. Exposed to cigarettes or Smoking During Pregnancy (SDP) is considered the number one cause of harmful results for babies and mother. Because, mothers can pass unhealthy chemicals; For example, smoking of exposed to smoking pregnant women pass on the 7,000 toxic and cancer-causing chemicals contained in cigarettes to their unborn child (Lareau, 2014). Babies born to mothers who smoke or exposed to cigarettes smoking often prematurely, smaller, lower lung function, more learning disorders, sudden infant death syndrome and less healthy than other infants whose mothers do not smoke, while women who smoke are more likely to miscarry, or experience conditions such as abruptio placenta and placenta Previa (Lareau, 2014). A lot of studies confirmed the impact of smoking during pregnancy (SDP) on pregnancy outcomes. One of them pointed that, women exposed to tobacco smoke in utero during fetal life were at higher risk of developing gestational diabetes and obesity (Mattsson, et al., 2013). Another one reveled that, there is associations between SDP in mothers and cognition and externalizing behaviors in their offspring is primarily due to genetic effects that influence the behaviors in both generations (Halkola, et al., 2014). In addition to that, smoking at week 12 of gestation showed decreased fetal growth as reflected by all growth parameters at 20–34 weeks, leading to a reduced fetal size at week 34, while fetuses of smokers who quit smoking before week 12 showed reduced growth only in femur length (Iiguez, et al., 2013).

5.3.Medical and Nutritional Characteristics

5.3.1. Diet regimen

Findings of this study pointed that, Just 7 out of 92 of the participants in this study following diet Regimen, and no one consulting nutritionist nor dietetics. Dietary planning should undertake before, during and after pregnancy, because nutrition of the fetus began at conception. The demand of nutrients during pregnancy period are increased, to ensure healthy growth of the fetus (Reese, et al., 2008). In addition, Preconception nutritional planning is very important to avoid some risks, for example; adequate intake of folic acid can prevent spina bifida (Klusmann, et al., 2005). Nutritional consultation is very important for all pregnant women, because there are some important food and supplements must be increased pre, during, and post pregnancy. On the other hand, There are some foods must be avoided like seafood known to be high in mercury because of the risk of birth defects (Einarson, et al., 2010) and limit caffeine consumption in large amounts because it may associated with miscarriage (Cunningham, et al., 2016).

5.3.2. Distance between pregnancies

Findings of this study pointed that, the mean spacing time between pregnancies was 26.12 months. This results considered in line with the recommended spacing time between pregnancies (Makrides, et al., 2006). The length of time between giving birth to one baby and getting pregnant with the next should be 18 months or more (Davis, et al., 2014; Wendt, et al., 2012). Women who get pregnant sooner than that are more likely to have a premature baby and LBW (Wendt, et al., 2012). A gap of at least 18 months will give mothers time to recover their energy and replenish the nutrients that lost during their previous pregnancy (Chinebuah & Escamilla, 2001). On the other hand, long intervals between pregnancies (five years or more) are associated with an increased risk of; preeclampsia, preterm birth, LBW, small size for gestational age (Wendt, et al., 2012).

5.3.3. Disorders during Pregnancy

Pregnant women often complains from common symptoms, discomforts and some health problems during pregnancy like constipation, heartburn, and hemorrhoids (Vazquez, 2010).

Findings of this study indicated that, 43.5%, 32.6%, and 76.1% out of 92 respondents complain from epigastric burn, constipation, nausea and vomiting, respectively. These results were in line with other studies which indicated that, constipation occurs in 11% to 38% of pregnant women, epigastric burn occurs about 17% to 45% (Vazquez, 2010), and nausea and vomiting occurs about 70-80% of all pregnant women to some extent (Einarson, et al., 2012). These complications usually considered physiological changes because of hormonal and anatomic changes. For instance, the elevation of progesterone levels during pregnancy and reduction of motilin hormone levels lead to increases in bowel transit time, which can lead to greater absorption of water, which causes stool to dry out (Longo, et al., 2010). In addition to that, the enlargement of the uterus later in pregnancy may slows onward movement of feces (Cullen & O'Donoghue, 2007). Moreover, Iron supplementation can cause constipation (Andrews & Storr, 2011). A huge evidences pointed that, the nutritional management of constipation are consumption of recommended daily dietary fibers, drinking recommended daily water and fluid, and practicing recommended daily sports (Longo, et al., 2010). Symptoms of nausea and vomiting during pregnancy differ among women. It can begin as early as the second week of gestation (Lacroix, et al., 2000), peaking in intensity between 8 and 12 weeks (Chan, et al., 2012), and subsiding by the twentieth week of gestation (Lacroix, et al., 2000). The majority of pregnant women who complains from nausea and vomiting resolve within 16 to 20 weeks with no harm to the pregnancy (Lee & Saha, 2011). Heartburn in pregnancy is reported to be between 17% and 45% among pregnant women (Vazquez, 2010). Its resulted from hormonal changes (estrogen and progesterone), that’s cause a reduction in lower esophageal sphincter pressure, decreases in gastric motility, which leads to prolonged gastric emptying time and increased risk of epigastric burn (Ali & Egan, 2007). The key nutritional managements of heartburn are life style modification and dietary modification (Festi, et al., 2009; Kang & Kang, 2015; Law, et al., 2010; Vazquez, 2010).

5.3.4. Sporting

Findings of this study indicated that, 89 out of 92 respondents were physically inactive during pregnancy period, no one have medical condition or disorders that may make the physical activity is contraindication, and the time spend for women who doing exercise (21.6 minutes daily) was less than the recommended daily

64 physical activity for pregnant women, and this results may due to cultural background.

Exercise has become a vital part of many people lives. In fact, most health care providers encourage pregnant women to be physically active to maintain good health for maternal and for their babies (Szymanski & Satin, 2012). A lot of researchers reveled that, exercise during pregnancy can reduce backaches, constipation (Liddle & Pennick, 2015), boost energy levels and prevent excess weight gain (Mottola, et al., 2010), promote muscle tone, strength and endurance (Hammer, et al., 2000), reduce the risk of gestational diabetes (Padayachee & Coombes, 2015), perform better during labor and delivery (Tomic, et al., 2013), reduce or prevents preeclampsia (Kasawara, et al., 2015), reduce or prevents preterm delivery (Satterfield, et al., 2016). In the absence of any obstetric or medical complications, most women can maintain a regular and recommended exercise regimen during pregnancy.

The recommended exercise regimen during pregnancy are, brisk walking, swimming, cycling, and yoga (Hegaard, et al., 2010). While, walking is a great exercise for beginners, because it provides moderate aerobic conditioning with minimal stress on joints (Padayachee & Coombes, 2015). More important, for most pregnant women, at least 30 minutes of moderate exercise is recommended on most, if not all, days of the week (Evenson, et al., 2014). Also, pregnant women who have never exercised regularly before pregnancy, they can safely begin an exercise program during pregnancy (Evenson & Bradley, 2010).

5.4.Dietary Data

5.4.1.Proteins

Findings of this study revealed that, one fourth (26.1%) of the targeted population consumed fish rarely and half (50.1%) of them consumed poultry on weekly basis. Almost of recruited pregnant women eat alternative source of proteins regularly. While, the recommended protein requirements during pregnancy is 1.1 g/kg per day or approximately 71 g protein per day starting in the second trimester, which is approximately 25 g more than what is recommended for non-pregnant women (Lowensohn, et al., 2016).

Protein is crucial for baby's inside the mother growth, especially during the second and third trimesters (Borazjani, et al., 2013). Consuming the proper amounts of protein during pregnancy can help to transport nutrients and oxygen to and from those cells and also control blood clotting, particularly those in and around the uterus and placenta (Brett, et al., 2014). Proteins also play important role in hair and fingernail growth along with the regulation of hormone secretion and digestion (Koniuszy, 2016). In addition to that, Proteins high in ω-3 FAs like DHA provide the nutrients necessary for proper cognitive activity and growth particularly of the brain and eyes (Jeromson, et al., 2015).

5.4.2.Fats

Results of this study indicated that, out of all respondents half of them (52%) consumed olive oil on daily basis, and 20% consumed olive oil 2-3 times on weekly basis. The presence of Fats in diets is very important because they provide energy, important for digestion, absorption, and transportation of fat soluble vitamins (Brown, et al., 2012), and many other functions.

During pregnancy, some fats are especially important during pregnancy because they support fetal brain and eye development (Greenberg, et al., 2008). Fats also help the placenta and other tissues grow, and studies show that some fats may help prevent preterm birth and LBW (Coletta, et al., 2010). The American Heart Association (AHA) recommends that the majority of fat consuming come from unsaturated fats, the healthiest kind. These include both polyunsaturated fats and monounsaturated fats, both of which are especially important during pregnancy (Muskiet, 2010). The best source of ω-3 FAs are fish, But some types of fish contain contaminants such as mercury. So, it prefer to consume seafood high in DHA and low in mercury, such as salmon, anchovies and sardines (O'Reilly, et al., 2010).

5.4.3.Dairy products

Dairy products are a type of food produced from or containing the milk of mammals. Dairy products include food items such as yogurt, cheese, and butter. Milk and dairy foods are healthy foods and considered nutrient-rich because they serve as good sources of calcium and vitamin D (Ross, et al., 2011).

They provide phosphorus, potassium, magnesium, and vitamins A, B12, and riboflavin (Spence, et al., 2011).

Pregnant woman provides between 50 and 330 mg of calcium to the fetus to support skeletal development (Beinder, 2007). If mother did not consume enough calcium-rich foods like milk, she will lose calcium from her bones to meet fetal needs (Heringhausen & Montgomery, 2005). In addition to that, vitamin D is an essential micronutrient during pregnancy for preventing neonatal rickets, preterm birth, LBW and dental caries of infancy (Karras, et al., 2016).

Habitual consumption of milk during pregnancy has been associated with a lower risk for premature birth and neonatal death (Brantster, et al., 2012). It is also noteworthy that, yogurt and cheese consumption during pregnancy is considered as important as that of milk, and is especially recommended in case of lactose intolerance (Rozenberg, et al., 2016). This is because yogurt and cheese contain the enzyme lactase, which breaks down lactose and converts it into lactic acid, therefore preventing the unpleasant symptoms of lactose intolerance (Silanikove, et al., 2015). On the other hand, insufficient milk intake during pregnancy is associated with decreased birth weight and health problems in babies due to protein insufficiency (Borazjani, et al., 2013). It may also, provokes maternal calcium deficiency, since calcium can play a role in cardiovascular development in the fetus and increase the risk of neonatal high BP (Ross, et al., 2011). One clinical trial, done on pregnant female who complains of low calcium level, indicated that infants from the mothers who received the calcium supplement had a significantly higher bone mineral composition than those from mothers who received placebos (Goldberg, et al., 2006).

Findings of this study indicated that, majority of the respondents consumed an adequate amount of dairy products on a regular basis. While 40% of all studied population rarely consumed milk product. It is recommended that pregnant women to consume three to four servings of calcium-rich foods a day, enough to give 1,000 mg of calcium recommended dose for women age 19 and older, while women under 19 need 1,300 mg/day (Ross, et al., 2011). Furthermore, vitamin D is rare in food sources outside of fortified milk. One cup of fortified, low-fat milk provides 117 IU of the 600 IU of vitamin D need each day of pregnancy (Mulligan, et al., 2011); three cups per day provides 59 percent of pregnant needs.

5.4.4. Grains and Legumes

Findings of this study indicated that, majority of the respondents consumed bread on daily basis, 59.8% consumed rise 2-3 time per week, 27.2% consumed Fava beans rarely, 28.3% Falafel once weekly.

Carbohydrates provide energy required for daily activities, the source of glucose is from the starches and sugars that eaten (Aller, et al., 2011). The fibrous food provides ammunition for fighting certain diseases like type 2 diabetes and obesity (Abutair, et al., 2016). Fiber also helps indigestion and keeping the cholesterol and the heart diseases under control (Asif, 2014).

Results of this study indicated that, 32.6% of respondents complains from constipation, even they consume a proper amounts of carbohydrates in regular basis. This results may due to other factor like lack of physical activity. Many starchy foods also provide other important nutrients for fetal development, including calcium, iron and B vitamins (Stevenson, et al., 2012).

Extremely low-carb diets may not be safe during pregnancy (Mavropoulos, et al., 2005), Without a certain amount of good carbohydrates, the body cannot use its fat in the normal way, and there is an incomplete breakdown of fat, called ketones (Manninen, 2004).

Furthermore, sometimes constipation can result as a side effect of low-carb dieting (Bae, 2014). it is recommended that, 45 to 65 % of daily calories should come from carbohydrate sources (Skerrett & Willett, 2010).

5.4.5.Fruit and Vegetables

Findings of this study indicated that, majority of the respondents 44.6% consumed Salad on daily basis, 40.2% consumed Cooked vegetables 2-3 time per week, 25.0% consumed Avocado once weekly, 55.4% Fresh fruits or Fruit juices on daily basis.

Fruit and vegetables are packed with powerful nutrients that support pregnant and fetal development during pregnancy (Murphy, et al., 2014). Fruit and vegetables are an best source of many well-known vitamins, minerals, antioxidant and fiber. They provide key nutrients, such as ascorbate, carotenoids, folate and magnesium, which all

68 contribute to fetal growth and development (Migliozzi, et al., 2015). Consuming a proper amounts of fruit and vegetables during pregnancy can helps to reduce newborn’s risk of disease and other health issues (Murphy, et al., 2014). A good intake of fruit and vegetables as part of a well-balanced pregnancy diet may also help to protect against developing allergies and allergic symptoms later in life (Boeing, et al., 2012). Also, higher intake of leafy vegetables and apples in pregnancy has been linked to less wheeziness in infancy (Miyake, et al., 2010). Also, vitamin E which can be found in spinach and broccoli is thought to help prevent wheezing and asthma (Miyake, et al., 2010). The nutrients that provided by fruit and vegetables like; vitamin C is an essential for normal immune protection, and they found in Broccoli, Citrus fruits, and Tomatoes (Chambial, et al., 2013). Potassium is helps to maintain BP, and they found in Avocados, Bananas and Dark leafy greens (Ellison & Terker, 2015). Folic Acid is essential to reduce the risk of NTDs, Sources of it are Broccoli, Spinach and Asparagus (Imbard, et al., 2013). Calcium contributes to fetal bones and teeth developing, and they found in Dark leafy vegetables, such as broccoli, kale and Brussels sprouts (Ross, et al., 2011). Also, Fibers can prevents or treat constipation, including Peas, Sweet potatoes and Legumes (Slavin, 2013). On the other hand, low consumption of fruit and vegetables during pregnancy can associated with health conditions, like fetal cells damage (Everitt, et al., 2006), Also, increased risk to develop allergies and allergic symptoms later in life (Boeing, et al., 2012).

Moreover, low consumption of fruit and vegetables may resulted in un stability of BP (Maas & Franke, 2009). In addition, it may increase the risk of spina bifida and NTDs due to folic acid deficiency (Czeizel, et al., 2013). In order to prevent the up mention problems, researchers recommend to eat at least 400 g of fruit and vegetables daily, to lower the risk of serious health problems such as heart disease, stroke, diabetes and obesity (Dhandevi & Jeewon, 2015). Also, Eating at least 5 portions of fruit and vegetables per day as part of a healthy pregnancy diet will provide many of the nutrients needed to support your own health and your baby’s development (Boeing, et al., 2012).

5.4.6.Nuts

Findings of this study indicated that, 26.1% and 17.4% consumed Almond once weekly and rarely, respectively. Also, 20.7% of respondents consumed mixed nuts rarely. Nuts are a healthy snack, but high in calories. However, because nuts contain filling protein, it can keep appetite under control (Ros, 2010). It may help lower cholesterol when substituted for other foods, they contain monounsaturated and polyunsaturated fats which protect heart health, they may also protect against irregular heart rhythms, improve blood vessel function and lower cardiovascular risk (Ros, 2010). During pregnancy, Pregnant women need to eat a healthy and balanced diet with plenty of protein, carbohydrates and healthy fats, because all of the nutrients a developing fetus receives comes directly from maternal diet. Nuts are high in a range of healthy nutrients that a developing fetus needs. A typical can of mixed nuts contains a mixture of Peanuts, Walnuts, Brazil nuts, Almonds, Pecans, Cashews and Hazelnuts. Moreover, Nuts are a good source of folic acid, the micronutrient that helps prevent spina bifida and other NTDs (Ros, 2010). Moreover, The fiber in nuts can also be beneficial for relieving constipation caused by pregnancy (Trottier, Erebara, & Bozzo, 2012). In the past, Pregnant women have been advised not to eat nuts or peanuts during pregnancy if they had a family history of nut allergies or other allergic conditions, but now pregnant women need not to avoid nuts, even with a family history of allergies, unless they themselves are allergic (Maslova, et al., 2012). The recommended nuts needs during pregnancy is about 2 servings daily.

5.5.Maternal biochemical changes

5.5.1.Hemoglobin (Hb) Level

Anemia is a condition that develops when blood lacks enough healthy red blood cells or Hb, when red blood cells, or Hb is abnormal or low, the cells in body will not get enough oxygen that resulted in fatigue (Reza, et al., 2013). Furthermore, Anemia in pregnancy is associated with increased rates of maternal and perinatal mortality, premature delivery, LBW, and other adverse outcomes (Sukrat, et al., 2013). During pregnancy, Hb and Hct concentrations typically decrease during the first trimester and reach the lowest levels at the end of second trimester and increase again during the third trimester of pregnancy (Laflamme, 2011).

Physiologically, this drop is attributed to increase of plasma volume and hence decrease of blood viscosity, lead to better circulation in placenta (Tan, 2013). The combination of expansion maternal plasma volume and decreased iron supply causes Iron deficiency (Miller, 2013). This induces a modest decrease in Hb levels during pregnancy.

Results of this study indicated that, the Hb level was increase in both groups, but it increase more significant in the intervention group when compared with the control group. The proposed mechanism by which ω-3 FAs can improve iron metabolism in the pregnancy is that, ω-3 FAs can act as antioxidant by several mechanisms, which reduce oxidative stress (Glaser, et al., 2013). Any type of oxidative stress may impact the metabolism of iron (Galaris & Pantopoulos, 2008). By this way ω-3 FAs can improve iron metabolism in pregnant women. However, further studies needed to be conducted to understanding the mechanisms by wish how ω-3 FAs supplementation improve iron metabolism.

5.5.2.Triglycerides (TGs)

Results of this study indicated that, TG level in the second and third semester was in line with the recommended TG value during pregnancy (James, et al., 2010). On the other hand, most TG levels return to normal four weeks postpartum, and these changes may be due to the change in metabolism of the pregnant women as well as diet during and after pregnancy. In contrast to pregnancy period, TG level in the intervention group reach the recommended level of TG which is less than 150 mg/dl as a part of follow up level.

Complex changes occur in lipid profiles from the 12th week of gestation to the end of the pregnancy in response to estrogen stimulation and insulin resistance (Ghio, et al., 2011). In the first trimester there is an increase in ovarian estrogen and progesterone followed by pancreatic beta-cell hyperplasia leading to increase in insulin secretion which increases TGs (Kalkhoff, 1982). While, in the 2nd and 3rd trimester there is increased ovarian and placental estrogen which increases TGs (Pillay, et al., 2016). Increased maternal TG level contributing to fetal growth and development and serving as an energy depot for maternal dietary fatty acids (Herrera, 2000).

5.6.Maternal Gestational Weight Gain (GWG)

Weight gain is an inevitable part during pregnancy, the controlling of weight is of great importance, because it can affect the immediate and future health of a woman and their infants (Rasmussen & Yaktine, 2009). Insufficient gestational weight gain (GWG) has been linked with increased risks of LBW, SGA, and preterm birth, while excessive GWG has been associated with large for gestational age, gestational diabetes, preterm birth, caesarean section, infant mortality, postpartum weight retention, and childhood obesity (Drehmer, et al., 2013; Fraser, et al., 2011; Li, et al., 2013; Viswanathan, et al., 2008). Less or excessive GWG is connected bad infant health outcomes (Dunlop, et al., 2015), while the recommended GWG is connected with better health outcomes (Rasmussen, et al., 2009).

Results of this study shows that, the ω-3 FAs supplementation control the GWG in the intervention group when compared with the control group, especially the overweight participants. In addition to that, the underweight participants in the control are less than the recommended GWG. Till now, no studies was conducted to discussing the association between ω-3 FAs supplementation and controlling of GWG. On the other side, longitudinal studies were conducting on normal women who consume ω-3 FAs regularly were less likely to be overweight than those with low ω-3 FAs consumption (He, et al., 2002). Conversely, other study revealed that the consumption of ω-3 FAs among normal male adults was connected with increased body weight (Iso, et al., 2001). The difference between the up mentioned two studies may due to sex differences. A lot of clinical trials indicating that, the supplementation of ω-3 FAs can control and lose of body weight (Thorsdottir, et al., 2007).

Omega-3 FAs supplementation can control weight among normal human adults by several mechanisms includes; modulation of postprandial satiety (Parra, et al., 2008), decrease adipose tissue mass and the development of obesity by targeting a set of key regulatory transcription factors involved in adipogenesis and lipid homeostasis (Madsen, Petersen, & Kristiansen, 2005), decrease the growth of the adipose cell, probably through stimulated -oxidation (Nakatani, et al., 2003). Further investigations needs to understanding the exact mechanisms by which how ω-3 FAs can control weight among pregnant women.

5.7.Gestational length

The impact of ω-3 FAs supplementation on the length of gestation still controversial in literature. This may due to sample size, starting day of supplementation, different doses and different methodology. Results of this study indicated that, the supplementation of ω-3 FAs prolonged the gestational period 2.2 days when compared with the control group. Results of this study was in line with other studies (Carlson, et al., 2013; Larqu, et al., 2012; Makrides, et al., 2011; Smuts, et al., 2003). While other studies reveled that, there is no impact of ω-3 FAs supplementation on gestational length (Harper, et al., 2010; Ramakrishnan, et al., 2010). However, researchers who find impact of ω-3 FAs on gestational period, confirmed that the ω-3 FAs supplementation reduce the risk of prematurity in high- risk populations (Olsen, et al., 2000) and optimize fetal brain development (Innis, 2008). The reduction of ω-3 FAs will resulted in increased prostaglandin E2 and prostaglandin F2α, and these proinflammatory eicosanoid production have been associated with the initiation of labor and preterm labor (Roman, et al., 2006). On the other hand, the inclusion of more EPA in the daily diet will increase production of prostacyclin, which may promote myometrial relaxation and then reduce the risk of prematurity (Olsen, 2004; Roman, et al., 2006).

5.8.Maternal Blood Pressure (BP)

A lot of literature indicated the beneficial effects of ω-3 FAs supplementation and lowering effect on BP among normal adults (Cabo, et al., 2012; Cicero, et al., 2009). In fact, studies on pregnant women still more contradictory. Some studies reveled that, ω-3 FAs supplementation reduce the risk of pre-eclampsia or PIH (Williams, et al., 1995). Whereas, others studies were found no association (Olsen, et al., 2000) Results of this study indicated that there is no statistical differences between the group in the DBP, and significant statistical differences between the groups in the SBP. But these results may be medically not significant. However, the proportion of women with diastolic above 85 mmHg and systolic above 135 mmHg tended to be lower in the intervention group compared with the control group. The presents study results emphasizes that, the ω-3 FAs could reduce the incidence of pre-eclampsia or PIH, as some studies have demonstrated (Dyerberg, et al., 1985; England, et al., 1987).

5.9.Infant anthropometrics

The use of ω-3 FAs in the management of infant birth weight still controversial in literature. One of these studies revealed that, ω-3 FAs increase Birth weight, Length, and Head circumference (Carlson, et al., 2013). While, Another failed to show any effects on birth weight (Horvath, et al., 2007). Results of this study revealed that, ω-3 FAs supplementation increase of weight, length, and head circumference in the ω-3 FAs group when compared with the control group 136.52 g, 1.18 cm, and 0.32 cm, respectively at the birth. Higher intakes of ω-3 FAs during pregnancy may lead to infants with a higher birth weight, as well as reducing the risk of preterm births (Coletta, et al., 2010; Greenberg, et al., 2008). The major effects of higher levels of ω- 3 PUFAs during pregnancy are associated with the development of brain and nerve tissues during the period of maximum intrauterine accretion (Agostoni, 2010). In the third trimester of pregnancy, ω-3 FAs are selectively transferred to the fetus to meet the demands of rapid brain growth, and DHA accumulates in the fetal brain at a rate of 14.5 mg/week (McNamara & Carlson, 2006). Since the human brain composed of lipids, with phospholipids making up 22% of the cerebral cortex and 24% of the white matter (Bradbury, 2011).Since the head circumference was the important indicator of the brain development (Treit, et al., 2016). The importance of this study, is that the head circumference it was naturally grows in the intervention group than in the control group at the three level of measurements, which indicate more development in the brain.

CHAPTER 6

CONCLUSION AND RECOMMENDATION

6.1.Conclusion

 The effect of Omega-3 fatty acids (ω-3 FAs) supplementation during pregnancy on pregnancy outcomes was determined by using randomized controlled clinical trial.  Ninety two participants were selected from Rafah and Khanyounis governmental primary health care centers according to eligibility criteria and enrolled the study.  Stratification of the participants based on Number of pregnancies, Maternal age and Maternal BMI prior to pregnancy was applied then the subjects were randomly allocated into two groups (intervention and control group).  The intervention group was received ω-3 FAs 300 mg/day from week 20 of gestation to delivery, Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery.  The control group was supplemented with Folic acid 400 mcg/day and Iron 27 mg/day from the beginning of pregnancy to the delivery.  Omega-3 supplements shows a significant increase in Maternal Hb and significant reduction in TGs in the blood after 4 months of intervention, and in the TGs levels after 8 weeks of delivery.  Also, there is control in the GWG during pregnancy and significant reduction in the SBP at the three measurements after 4 months of intervention.  In addition, significant improvement in infant anthropometrics with a healthy increased in Weight, Length, and head circumference among the intervention group compared with control group.  Moreover, there is a modestly increased in the length of gestational period in intervention group when compared with the control group.

6.2.Recommendations

This study has investigated one of the controversial points in the strategies to improve pregnancy outcomes and supported by clinical evidence the beneficial effects of ω-3 FAs supplementation during pregnancy on pregnancy outcome. From the results of this study, the following recommendations are suggested:

6.2.1.For policy makers. Improvement of the existing programs in health system by further supplementation with ω-3 FAs in addition to iron and folic acid that should be strengthened and continue in the MOH and UNRWA health system.

6.2.2.For clinical nutritionist.

Improvement of the national nutrition strategy for Palestine by MOH and other related international agencies by recruitment of clinical nutritionists in governmental primary health care centers and hospitals for positive and optimal health outcomes among pregnant and their infants as well.

6.2.3.For pregnant women Pregnant women should increase their intake of Omega-3 rich food such as dark leafy greens, nuts, seeds, fish (2 servings per week), beans, whole grains, avocados, milk and fruits. They also should regularly practice appropriate exercises and monitor body weight.

6.2.4.National level To develop the national nutrition strategy for Palestine by MOH with cooperation of other ministries, NGOs and related international agencies, with greater focus on: Maternal nutritional and food support, Breastfeeding promotion and support, Micro-nutrient supplementation, Complementary feeding; and Nutrition education.

6.2.5.For future studies Further researches are recommended on periodic nutritional assessment of pregnant women, including dietary studies, conducted more proposed specific tests such as LDL, HDL and cholesterol, increase sample size and increase the intervention period.

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ANNEXE A

ANNEXE A-1

APPROVAL FROM DEAN OF FACULTY OF PHARMACY

ANNEXE A-2

APPROVAL FROM HELSINKI COMMITTEE

ANNEXE A-3

SIGNED CONSENT FORUM

اقرار موافقة للمشاركة فً دراسة بحثٌة سرٌرٌة

جامعة االزهر بغزة

تأثٌر تناول مكمل األومٌجا -3 أثناء فترة الحمل على نتائج الحمل

أختً المشاركة فً هذا البحث الرجاء مراجعة هذا النموذج وطرح ومناقشة أي أسئلة ترٌدها مع أخذ الوقت الكافً لذلك, حٌث ٌمكنك مناقشة ومراجعة طبٌبك المختص, عائلتك, وأصدقائك وذلك التخاذ القرار بالمشاركة أو عدم المشاركة فً هذا البحث. قد ٌحتوي هذا النموذج بعض الكلمات التً ٌمكن أن ال تستطٌعً فهمها, لذلك الرجاء طرح األسئلة حولها لغرض تفسٌرها بشكل واضح.

الهدف من الدراسة هً الختبار مدى تأثٌر مكمل األومٌجا -3 على نتائج الحمل بعد 4 شهور من التجربة, حٌث أنه سٌتم اختٌارك عشوائٌا فً أحدى مجموعات الدراسة التً سٌتم شرحها فً األسفل.

المجموعة األولى: هً المجموعة الضابطة, هذه المجموعة لن تعطى مكمل االومٌجا -3 طوال فترة الدراسة وستستمر على نفس النمط الغذائً.

المجموعة الثانٌة: هً مجموعة التجربة, هذه المجموعة سٌتم تزوٌدها بمكمل االومٌجا -3 طوال فترة الدراسة وستستمر على نفس النمط الغذائً.

تشمل المشاركة فً البحث اإلجراءات التالٌة:

 سحب عٌنات الدم.

 أخذ قٌاسات الجسم.

 أخذ قٌاسات ضغط الدم.

 أخذ قٌاسات جسم الطفل.

 تناول مكمل األومٌجا3-.

 وتعبئة االستبٌان الخاص بالدراسة.

المخاطر التً تصحب الدراسة.

ال توجد مخاطر على صحة المشتركٌن فً االنضمام لهذا البحث.

مصروفات الدراسة

جمٌع مصروفات الدراسة من قٌاسات وتحلٌل عٌنات الدم ومقارنتها وأخذ قٌاسات الجسم وقٌاسات ضغط الدم والمكمل الغذائً وكل إجراءات الدراسة ستكون بشكل مجانً للمشتركٌن فً الدراسة.

حماٌة سرٌة البٌانات.

سوف ٌتم نشر جمٌع النتائج والتحلٌالت اإلحصائٌة للنتائج التً تم جمعها خالل الدراسة فً المؤتمرات العلمٌة وجمٌع المحافل العلمٌة, مع األخذ بعٌن االعتبار أنه لن ٌتم نشر اسمك أو اي بٌنات تعرٌفٌة عنك.

100

سٌتم التعامل مع جمٌع البٌانات الشخصٌة والسجالت الطبٌة التً تحتوي على معلوماتك الشخصٌة على أنها معلومات سرٌة.

نوع المشاركة.

مشاركتك فً هذا البحث هً مشاركة طوعٌة, حٌث بإمكانك عدم المشاركة أو االنسحاب فً أي وقت ترٌدٌه أثناء المشاركة, وسوف لن تتحملً أي نتائج أو عقوبات أو غرامة مالٌة أو أي نوع من أنواع العقوبات بسبب االنسحاب من البحث.

تكالٌف العناٌة الطبٌة الناجمة عن المخاطر المرتبطة بالدراسة.

فً حال واجهتك أي أمراض أو مشاكل صحٌة بسبب الدراسة, سوف أقوم بمعالجتك مباشرة دون أن تدفعً أي مصارٌف خاصة بالعالج.

استفسارات اخرى

إن كان لدٌك أي استفسارات ال تترددي بالتواصل معً أنا الباحث/ محمد رسمً محمود المالحً على رقم الجوال 0595637264 أو برٌد الكترونً [email protected].

ال توقع على الموافقة فً هذا البحث فً حال عدم أخذ الفرصة الكافٌة فً الرد على استفساراتك أو أنك غٌر مقتنعة باألجوبة المقدمة من الباحث.

بٌان واقرار الموافقة

لقد قرأت نموذج الموافقة للمشاركة فً هذا البحث. وقد أتٌحت لً الفرصة الكاملة لمناقشة هذه الدراسة البحثٌة مع الباحث محمد رسمً محمود المالحً. و لقد أجاب عن جمٌع أسئلتً باللغة التً أفهم, دون اجباري على المشاركة فً البحث.

وقد تفهمت جمٌع االجراءات المطلوبة منً والحقوق التً أتمتع بها حٌن مشاركتً فً هذا البحث.

موافقة على االشتراك فً هذا البحث : نعم  ال 

االسم رباعً:......

التوقٌع:...... تارٌخ التوقٌع:......

101

ANNEXE B

TWO-WEEKS HEALTH RECALL

1 هم شعش ِث بأحذ االعشاض انخانيت أثُاء حُاونك يكًم االوييجا-3 ؟

 اٌغؼبي َعى ال

 حشلت اؼٌّذة )حضاص( َعى ال

 صٛؼبت فٟ اٌبٍغ َعى ال

 حىت جٍذ٠ت َعى ال

 حٛسَ فٟ جفٓ ا١ؼٌٓ أٚ اٌشفبٖ َعى ال

 ِشاسة فٟ اٌٍغبْ ٚ اٌفُ َعى ال

 اعٙبي َعى ال

 أخفبخبث فٟ اؼٌّذة َعى ال

 أخفبض ظغػ اٌذَ َعى ال

 اخخالي فٟ ٔبعبث اٌمٍب َعى ال

 صغٍٍت فٟ ا١ؼٌٓ َعى ال

 أخشٜ َعى ال

إرا كاَج اإلجابت َعى انشجاء انخىضيح: ......

......

انخاسيخ: ......

انخىقيع: ......

102

ANNEXE C

QUESTIONNAIRE

بسى هللا انشحًٍ انشحيى

أخخٟ اؼٌض٠ضة, اٌغالَ ١ٍػىُ ٚ سحّت هللا ٚبشوبحٗ .... ٚبؼذ.

٘زا االعخب١بْ اٌزٞ ب١ٓ أ٠ذ٠ىُ ٛ٘ جضء ِٓ دساعت ٠مَٛ بٙب اٌببحث ِحّذ سعّٟ ِحّٛد اٌّالحٟ, بٙذف دساعت ِذٜ حأث١ش ِبدة األ١ِٚجب-3 خالي ِشاحً اٌحًّ ٍٝػ ٔخبئج اٌحًّ فٟ ِحبفظخٟ سفح ٚ خبٛ١ٔٔظ, ٚرٌه ١ًٌٕ دسجت اٌّبجغخ١ش فٟ بشٔبِج اٌخغز٠ت االو١ٕ١ٍى١ت – و١ٍت اٌص١ذٌت بجبؼِت األص٘ش – غضة, ع١أخز االعخب١بْ بعغ اٌذلبئك ِٓ ٚلخىُ اٌث١ّٓ, ٌزا ٠شجٝ احببع اٌخ١ٍؼّبث اٌخب١ٌت :-

1. لشاءة وً عؤاي ٚ ِب ٠خبؼٗ ِٓ اجبببث بذلت.

ٚ .9ظغ ػالِت ) / ( فٟ اٌخبٔت اٌخٟ حؼبش ٚ ٓػجٙت ٔظشن .

ج١ّغ اٍٛؼٌِّبث اؼٌّطبة ع١خُ ؼِبٌجخٙب بشىً عشٞ ٌٍغب٠ت, ٟ٘ ٚ حغخخذَ ألغشاض اٌبحث اٍّٟؼٌ فمٚ ,ػ األْ اْ وٕج ِٛافمت ٍٝػ اٌّشبسوت فٟ اٌبحث, اٌشجبء ابذئٟ بمشاءة األعئٍت ثُ حذدٞ االجببت اٌخٟ حؼبش ٚ ٓػجٙت ٔظشن .

1. انًعهىياث االجخًاعيت انذيًىغشافيت

االسم: ...... المجموعة: ...... الرقم التسلسلً: ...... العمر بالسنة: ......

العنوان : رفح خانٌونس

مكان السكن : مدٌنة مخٌم الجئٌن رٌف

نوع السكن : ملك اٌجار

المستوى التعلٌمً لألم : المرحلة األساسٌة المرحلة الثانوٌة المرحلة الجامعٌة

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المستوى التعلٌمً للزوج : المرحلة األساسٌة المرحلة الثانوٌة المرحلة الجامعٌة

عدد أفراد األسرة : ......

العمل لألم : تعمل ال تعمل

العمل للزوج : ٌعمل ال ٌعمل

هل تتلقى األسرة نعم ال مساعدات ؟

الدخل الشهري لألسرة بالشٌكل : ......

هل دخل األسرة ٌكفً نعم ال االحتٌاجات الغذائٌة ؟

هل زوجك مدخن ؟ نعم ال

ان كان نعم فهل ٌدخن نعم ال فً نفس أماكن تواجدكم ؟

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2. السجل الطبً الغذائً

هل تتبع نظام غذائً نعم ال معٌن ؟

إذا كانت اإلجابة نعم أخصائً تغذٌه طبٌب الوالدة االنترنت أخرون فما مصدر هذا النظام الغذائً ؟

بشكل اعتٌادي هل المنزل المطعم المنزل وفً المطاعم تتناولٌن الطعام فً؟

هل لدٌك مشكلة نعم ال باألسنان قبل الحمل ب 6 أشهر ؟

هل تعرضت إلجراء نعم ال عملٌات كبرى أي كان نوعها قبل سنتٌن من الحمل ؟

هم حعاَيٍ يٍ حساسيت َعى ال نُىع يعيٍ يٍ انطعاو ؟

إذا كانت اإلجابة نعم حدد ما هو هذا الطعام : ......

عذد يشاث انحًم قبم هزِ انًشة )عذد يشاث انحًم انسابقت( ؟ : ......

هل لدٌك أطفال ؟ نعم ال

كم عدد األطفال ؟ ال يىجذ طفل واحد

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الفترة بٌن هذه الوالدة وسابقتها : أقل من سنتٌن أقل من 3 سنوات 3 سنوات فأكثر ال ٌنطبق

......

هل عانٌت من نعم ال أمراض أثناء فترة الحمل ؟

هل عانٌت من ؟ بواسٌر اسهال حرقان فً المعدة امساك قًء

أمراض أخرى: ......

التارٌخ المتوقع للوالدة الحالٌة : ......

التارٌخ الفعلً للوالدة الحالٌة : ......

الزٌادة أو النقصان بٌن التارٌخ الفعلً للوالدة والتارٌخ المتوقع: ......

متى كانت أول زٌارة لك لطبٌب الوالدة ؟ : ......

كم مرة شهرٌا تزورٌن طبٌب مرة واحدة مرتٌن ال ٌنطبق الوالدة أو العٌادة ؟

كم عدد الوجبات التً تتناولٌنها وجبة واحدة وجبتٌن 3 وجبات أكثر من 3 وجبات ٌومٌا ؟

هل تمارسٌن الرٌاضة ) غٌر َعى ال األعمال المنزلٌة ( ؟

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ما هو نوع الرٌاضة التً تمارسٌنها ٌومٌا ؟ : ......

يذة يًاسست انشياضت بانذقيقت: ......

3. طول و أوزان و مؤشر كتلة الجسم لألم الحامل خالل فترة الدراسة

قبل الحمل بشهرٌن عند األسبوع 82 نهاٌة الحمل

انطىل ـــــــــــ ـــــــــــ

انىصٌ

يؤشش كخهت انجسى ـــــــــــ ـــــــــــ

4. ضغط دم األم الحامل

عند األسبوع 82 عند األسبوع 82 نهاٌة الحمل

ضغط انذو

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5. التحالٌل المخبرٌة لألم:-

عند األسبوع 82 عند األسبوع 82 نهاٌة الحمل

هيًىجهىبيٍ انذو

عند األسبوع 82 نهاٌة الحمل بعد الوالدة ب 2 أسابٌع

انذهىٌ انثالثيت

6. قٌاسات الطفل:-

وصٌ انطفم بعذ انىالدة يباششة بعذ شهش يٍ انىالدة بعذ شهشيٍ يٍ انىالدة

انىصٌ ) جشاو (

انطىل ) سى , يههيًخش (

يحيط انشأس ) سى , يههيًخش(

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) النظام والنمط الغذائً( Food Frequency Questionnaire االسم: ...... التارٌخ : ...... الرقم التسلسلً : ...... المجموعة : ......

ظغ ػالِت ) / ( فٟ اٌخبٔت اٌخٟ حؼبش ٚ ٓػجٙت ٔظشن عدد مرات االستهالك البدائل الغذائٌة 2-3 فً كل ٌومٌا كل شهر نادرا األسبوع أسبوع الحبوب- البقول- النشوٌات 1. الخبز )عٌش( 2. أرز 3. فول مدمس 4. فالفل مجموعة اللحوم 1. لحم 2. دجاج 3. أسماك¥ 4. بٌض مجموعة األلبان 1. حلٌب أي نوع 2. لبن أي نوع )زبادي( 3. جبن مجموعة الخضروات 1. خضار طازجة )سلطة( 2. خضار مطهٌة )طبٌخ( 3. أفوكادو مجموعة الفاكهة 1. فواكه طازجة 2. عصٌر فواكه طبٌعٌة مجموعة الدهون 1. زٌت زٌتون 2. زٌت نباتً طبٌعً اخر 3. سمن 4. طحٌنة

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عدد مرات االستهالك البدائل الغذائٌة 2-3 فً كل ٌومٌا كل شهر نادرا األسبوع أسبوع المكسرات 1. اللوز 2. مكسرات مشكلة

¥ تحدٌد نوع السمك......

أشكركم على مشاركتكم و تعاونكم معً و أسال هللا أن ٌجعل تعاونكم هذا فً مٌزان حسناتكم .

انباحث

يحًذ سسًي انًالحي

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