Obstetrical Health Promotion

Nutritional
Guidelines
for
a Multiple
Pregnancy
 This booklet contains general information that is not

specific to you. If you have any questions after reading

this, ask your own physician or health care worker. They

know you and can best answer your questions.

Prepared by:

Pauline Brazeau-Gravelle, R.D.

Any reproduction of any part of this booklet is

prohibited unless authorized in writing by the authors.

P334 (07/02)

Printed at The Ottawa Hospital

Table of Contents

General guidelines ...............................................................1

Special considerations .......................................................... 2

Your food guide ................................................................... 3
Protein ............................................................................... 5
Calcium ..............................................................................7
Iron ................................................................................... 9
Folic acid ..........................................................................11
Supplementation ............................................................... 13
Weight gain ......................................................................14
Resources .........................................................................15
Nutritional Care

T
he purpose of the following guidelines is to help you
achieve optimal nutrition during your multiple pregnancy
in order to promote maternal-fetal well-being.

General Guidelines
1. Follow Canada’s Food Guide to Healthy Eating and enjoy
a variety of foods from all four food groups.
2. Use the “other” foods (fats, oils and sweets) to obtain ade­
quate amounts of essential fatty acids (EFA).
3. Increase your energy intake: + 200 Kcal/day or more in
the first trimester, + 400 Kcal/day or more in the second
trimester, + 600 Kcal/day or more in the last trimester.
4. Include more protein sources in your diet from the first to
the second trimester, and more again in the last trimester.
5. Maximize your calcium intake, especially in the last trimes­
ter, where at least 1600 mg/day is suggested.
6. Maintain your iron intake at a minimum of 30 mg/day.
7. Meet your folic acid requirement set at 800 µg/day.
8. Use salt according to taste.
9. Drink adequate fluid. Six to eight glasses of fluids including
water each day is important.
10. Ensure optimal weight gain at all times as multiple gesta­
tions have a higher incidence of premature delivery.

1
Special Considerations

1. Hyperemesis Gravidarum:
If you are experiencing nausea and/or vomiting, ask for
more specific nutritional guidelines.
2. Bedrest:
With a restriction in your activity level, you may find
that eating can be a problem because of poor appetite,
constipation, heartburns, etc. If you require help with these
very real problems, ask for our booklet.
3. Specific Nutritional Concerns:
If you suffer from lactose intolerance, food allergies or
aversions, eating disorders, gastrointestinal disorders, ane­
mia, diabetes, etc., ask for a nutritional assessment.
4. Non-Nutritive Substances:
Caffeine, alcohol, artificial sweeteners and smoking may
have an impact on your nutritional status. Ask for more
information if you use one or more substance.
5. Supplementation:
Vitamins and minerals can help you meet your extra needs,
but be cautious. Ask for advice regarding supplementation.
6. Lactation:
If you are considering breastfeeding, your energy and
nutrient needs will continue to be higher than those for sin­
gle pregnancies.

Consult your dietitian for further information.

2
Your Food Guide for

a Multiple Pregnancy

Food group Number of servings

daily
Milk products (MP) 4–6
Grain products (GP) 8–12
Vegetables and fruit (VF) 6–10
Meat and alternatives (MA) 2–3
Fats, oils and sweets (FOS) adequate amounts of EFA

Refer to Canada’s Food Guide to Healthy Eating for information

on the size of servings.
This food guide will provide you with about 2200–2600 calo­
ries. It meets the nutrient needs for the second and third tri­
mesters of the average, healthy woman expecting twins or
triplets. The foods listed here are to guide you only, as the
needs of each individual varies. If this is not enough food for
you, more servings can be selected from the food groups.
Small frequent meals with snacks will help you eat larger vol­
umes of food.
Taste and enjoyment can also come from other foods and bev­
erages that are not part of the 4 food groups: fats, oils and
sweets. Use these foods in moderation and select those with
high quality nutritional value. In fact, this group can provide
you with adequate amounts of essential fatty acids.

Emphasis should be on balance and variety, not num­

bers and quantity.

3
Here is a sample day’s menu for a twin pregnancy
incorporating foods from the Food Guide for a Multiple
Pregnancy:

Breakfast Supper
1/2 grapefruit (VF) Pasta (GP)

Shreddies (GP) and milk (MP) Tomato (VF) meat sauce (MA)

Whole wheat toasts (2GP) Grated cheese (MP)

with margarine (FOS) Sauteed zucchini or broccoli (VF)
in canola oil (FOS)
Milk pudding (MP)

Lunch Snacks
Baked beans or chicken leg Yogurt (MP)

(MA) and bread (GP), Bran muffin (GP)

margarine (FOS) Cheese (MP) and crackers (GP)

Spinach and tomato salad (VF) Hard boiled egg (MA)

with salad dressing (FOS) Fresh fruit (VF)
Banana (VF) Carrot and turnip sticks (VF)
Milk (MP)

This menu, for example, includes a minimum of 6 servings of

milk products (MP), 7 vegetables and fruits (VF), 8 grain prod­
ucts (GP) and 3 meat and alternatives (MA).

4
Protein

Protein requirements during pregnancy are based on the needs

of the nonpregnant woman (44 g/d) plus the extra amounts
needed to support the synthesis of new tissue.
Your need for protein is estimated as follows:
1st trimester: + 10 g/day
2nd trimester: + 40 g/day
3rd trimester: + 48 g/day
If you are eating enough food from all four food groups as out­
lined in the Food Guide for a Multiple Pregnancy, you should
get enough protein.
Meat, fish, eggs and poultry are good sources of complete pro­
teins. Meat alternates such as legumes (beans, peas and len­
tils), nuts and seeds are also good sources of protein.*

*Vegetarians and vegans must ensure excellent

complementarity of proteins and take adequate vita­
min mineral supplementation.

5
Here is the protein content of one average serving in
each food group:
Milk products 8g
(250 ml)
Grain products 2g
(1 slice, 125 ml)
Vegetables and Fruit 1–2 g
(125 ml, 1 medium)
Meat (50–100 g) 15–30 g
Meat alternatives
– legumes, nuts, seeds 6–18 g
(125–250 ml)
– egg (1) 6g
– peanut butter (15 ml) 4g

6
Calcium

Calcium requirements during pregnancy are based on the

needs of the nonpregnant woman (1000 mg/d) plus the rate of
accretion by the fetus from the maternal blood supply. The
fetus acquires most of its calcium in the last trimester when
skeletal growth is maximum and teeth are being formed.
Your need for calcium is estimated as follows:
1st trimester: + 200 mg/day
2nd trimester: + 200 mg/day
3rd trimester: + 600 mg/day
Four cups of milk contain enough calcium to meet your mini­
mum daily requirements of 1200 mg. In the last trimester, it is
suggested to increase your intake to a minimum of 1600 mg/d.
The upper limit recommended is 2500 mg/day.
Milk products are well established as being the most concen­
trated source of calcium and being better absorbed (an aver­
age value of 30%).
Non-dairy food sources of calcium are acceptable choices, but
it may be difficult to meet your requirements without the inclu­
sion of milk products since the absorption* and utilization of
calcium is not equivalent.

*Dietary factors enhancing calcium absorption

include dairy foods eaten with meals and moderate
amounts of fiber and caffeine.

7
Equivalent bioavailable calcium

Food Serving Calcium % Servings

(mg) amount to
absorbed replace
milk

Dairy

Milk 250 ml 315 32 1

Cheese (hard) 50 g 350 30 1
Cheese (cottage) 250 ml 174 30 2
Yogurt (fruit) 175 g 259 30 1 1/3
Ice milk 125 ml 109 30 3
Ice cream 125 ml 100 30 3 1/2
Frozen yogurt 125 ml 147 30 2 1/3
Milk dessert 125 ml 140 30 2 1/2

Non-dairy

Red kidney beans 250 ml 52 17 11 1/2

Soy beverage 250 ml 10 31 31 1/2
Tofu, calcium set 100 g 150 31 2

Broccoli 125 ml 38 52 5
Spinach 125 ml 129 5 15

Almonds 125 ml 200 21 2 1/3

Sesame seeds 125 ml 104 21 4 2/3

Fruit juice
(fortified) 250 ml 300 30 1

Soy drink
(fortified) 250 ml 300 30 1

8
Iron

Iron requirements during pregnancy are based on the iron that

the nonpregnant, nonlactating woman needs (18 mg/d) plus
the iron contributed to the fetus, the iron in the placenta and
cord and the iron in the blood lost at delivery.
Your need for iron is estimated as follows:
1st trimester: an extra 9 mg/day
2nd trimester: an extra 10–15 mg/day
3rd trimester: an extra 12–27 mg/day
Your need for iron will be the highest in your third trimester,
when 30–45 mg is the recommended daily intake.
The best food sources, called heme iron, come from animal
products such as red meat, fish and poultry.
Other important sources of iron, called non-heme iron, can be
found in vegetable foods, fruits, grains and cereals and eggs.
To help your body absorb more iron, eat foods that contain
heme iron and/or vitamin C when you eat vegetable foods and
foods that act as iron inhibitors.*

*Beware of iron inhibitors, such as oxalates in spin­

ach, phytates in whole grains, legumes

and tannins in tea and coffee.

9
All iron is not created equal

Heme iron Non-heme iron

• approximately 23% • only 3–8% absorption

absorption
• absorption not affected • absorption may be
by other food staples increased or decreased
by other foods
• found only in animal • found mostly in vegetable
products foods
• good sources: • good sources:
– organ meats – dried fruits
– beef – whole grain cereals
– pork
– enriched cereals and
– oysters
pasta
– scallops – dark green leafy

– turkey (dark meat) vegetables

– legumes (lentils, beans

and peas)

10
Folic acid

Folic acid requirements during pregnancy are based on the

needs of the nonpregnant woman (400 µg/day) plus the
amount needed for the metabolism of proteins and the forma­
tion and reproduction of cells. In fact, because of its role in the
prevention of neural tube defects, it is now recommended that
folic acid intake be increased prior to conception.
During pregnancy, your need for folic acid is estimated as fol­
lows:
1st trimester: an extra 200 µg/day
2nd trimester: an extra 200–400 µg/day
3rd trimester: an extra 400–800 µg/day
Folic acid is generally found in fresh greens, some fresh fruits,
whole grains, organ meats, milk and oysters.
Prolonged or intense cooking can destroy much of the folic acid
in foods.*
Your requirements for folic acid during pregnancy may be diffi­
cult to meet through diet alone. It is therefore suggested that
you get additional folic acid through supplementation.

*Eating foods raw or fresh minimizes cooking losses

of the vitamin.

11
Food sources of folate

Excellent Good Fair

Peanuts (60 ml) Peanut butter (30 ml) Tofu (100 g)

Soy flour (60 ml) Tahini (30 ml) Sesame seeds
Sunflower seeds Filberts, hazelnuts, (60 ml)
(60 ml) walnuts (125 ml) Banana (1 med.)
Toasted wheat Orange juice (fresh Tomato (1 med.)
germ (30 g) or frozen) (125 ml) Pear (1 med.)
Beef kidneys (60 g) Orange (1 med.) Carrot, raw (1 med.)
Dry brewer’s Bran cereals (30 g) Celery, raw (1 stalk)
yeast (5 ml) Egg (1 large) Grapefruit (1/2)
Asparagus Beets, cooked Raspberries (125 ml)
(4 spears) (125 ml) Strawberries (125 ml)
Brussels sprouts Broccoli, cooked Mixed vegs. (125 ml)
(125 ml) (125 ml) Bread (1 sl.)
Spinach (125 ml) Cauliflower, cooked Bagel (1/2)
Leafy greens (125 ml) Whole wheat flour
(125 ml) Corn, cooked (125 ml) (125 ml)
Beans, cooked Peas, cooked (125 ml) Milk (250 ml)
(125 ml) Parsnips, cooked
Lentils, cooked (125 ml)
(125 ml) Chinese cabbage, cooked
(125 ml)
Beans sprouts, cooked
(125 ml)

12
Supplementation

Emphasis should always first be placed on improving diet qual­

ity. However, women expecting multiples may benefit from
supplementation.
Because of the plethora of products available, you should ask
for advice in choosing safe and adequate supplements.*
Usually, one prenatal vitamin and mineral tablet is sufficient.
Other supplements may be needed depending upon the labora­
tory data and the dietary intake. These may include folic acid,
iron or calcium.
Supplements should be taken at bedtime or between meals,
unless directed otherwise, with water or juice, not milk, tea or
coffee. Supplemental calcium and iron are best absorbed when
taken between meals and at different times of the day.

*When buying a maternal supplement, make

sure there is a drug information number
(DIN) on the label.

13
Weight gain

Nutrition has a great overall influence on fetal growth in multi­

ple gestations. Moreover, your rate of weekly weight gain is a
very significant variable in the outcome of your pregnancy.
During the first trimester, your weight gain should be approxi­
mately 2.0–3.0 kg.
In the second and third trimesters, a gain of approximately
.68–1.0 kg per week will help you reach a desirable total
weight gain of ~ 16–20 kg for twins and 23 kg for triplets.
Weight gain is usually dependant on the pre-pregnancy body
mass index (BMI). If your weight was below normal (BMI
< 20), it is recommended to gain according to the upper
range, while you may expect to gain less if your body weight
was above normal (BMI > 27).
Use the grid on the next page to plot your gain and optimize
your outcome.

14
Resources
Further advice:
➤ Call the dietitian: 737-8906
➤ Discuss with your nurse/health care provider.

Further reading:
➤ How to Eat Well While on Bedrest During Pregnancy
(The Ottawa Hospital, revised 1997)
➤ Nutritional Guidelines to Help Control Nausea and
Vomiting During Pregnancy (The Ottawa Hospital,
revised 1997)
➤ Nutritional Guidelines to Help Increase Your Intake
of Iron (The Ottawa Hospital, revised June 2002)
➤ Nutritional Guidelines to Help Increase Your Fibre
Intake (The Ottawa Hospital, 2000)
➤ Nutritional Guidelines to Help Control Caffeine
Intake (The Ottawa Hospital, 2000)
➤ Nutritional Guidleines for Eating Fish During Preg­
nancy (The Ottawa Hospital, 2002)
➤ Nutritional Guidelines to Help Increase Your Intake
of Essential Fatty Acids (The Ottawa Hospital, 2002)

15
Notes

16