2006darwin deen, md aecom comprehensive nutritional care for prenatal patients darwin deen, md, ms

2006 Darwin Deen, MD AECOM

Comprehensive Nutritional Care for Prenatal Patients

Darwin Deen, MD, MS

March 2006 Darwin Deen, MD, MS

NAA Objectives for Students

Identify at least three common high-risk eating patterns (e.g., low calcium intake) that may negatively impact the growth and development of pediatric and adolescent females.

Describe the potential metabolic, immunologic, social, economic, and health benefits of breast-feeding.

Cite the current nutritional recommendations for adolescents and adult women during preconception, pregnancy, and lactation. Identify at least four types of foods or supplements that should be included or avoided in the diet during this period.


NAA Objectives for Students

Describe how to assess the nutritional status of adolescent and adult women during

preconception, pregnancy (including multiple gestation), post-partum, and lactation.

Take an appropriate medical history and assess the nutritional status of an adolescent female or a pregnant and/or lactating woman, including family, social, nutritional/dietary, physical activity, and weight histories; use of prescription medicines, over-the-counter medicines and dietary supplements; and consumption of alcohol and other recreational drugs.


NAA Objectives for Residents

Identify at least five medical conditions common to women that may increase medical and/or nutritional risk during pregnancy, and describe at least one intervention to effectively address the nutritional effects of each condition.

Summarize the American Diabetes Association (ADA) criteria used to diagnose gestational diabetes, and outline the ADA principles for treating diabetes during pregnancy.

Given the pre-pregnancy height and weight, calculate a patient’s Body Mass Index (BMI) and identify appropriate weight gain goals for normal-weight, underweight, and overweight pregnant women.

2006 Darwin Deen, MD AECOM

Nutritional Assessment

Components of Prenatal Nutritional Assessment:Consider populations at riskConsider nutrients in needScreen for nutrition-related nutrientsAsk about dietary intake, follow weight


Potential Problem Populations

Nutrition-related problems are more prevalent in certain populations.

The concept of the "at-risk" patient can help inform our screening efforts.



Adolescent patients (particularly those within 3 years of menarche), those with multiple gestations or short inter-pregnancy intervals (less than 1 year), obese patients, patients with psychiatric or substance abuse problems and those with economic or social problems which limit their ability to obtain, prepare, and store adequate food supplies are at risk for nutrition-related problems during pregnancy.



Be alert for patients with eating disorders (who may be very wary of gaining weight) or those following fad diets (which may not provide adequate nutrients for the pregnancy).

Vegetarianism is not a fad diet. Patients who follow this particular dietary regimen can have perfectly healthy babies but must exercise increased vigilance to assure adequate supply of limiting nutrients (Vitamin D, Vitamin B12, and calcium).


Iron Intake in Non-Pregnant Women (16-39 y/o): United States, 1988-1994

11.8

12

12.2

12.4

12.6

12.8

13

Totalpopulation

White-nonHispanic

Black non-Hispanic

MexicanAmerican

mg

Adapted from The Department of Health and Human Services Centers of Disease Control and Prevention, July 2002.


Iron Intake in Non-Pregnant Women by Income (16-39 y/o): United States, 1988-1994

12

12.2

12.4

12.6

12.8

13

13.2

Total population Poverty incomeratio <1.300

Poverty incomeratio >1.300

mg



Potential Problem Nutrients

Calories, Protein, Folic Acid, Pyridoxine, Iron, Zinc, Calcium

Nutritional assessment during pregnancy is aimed at assuring adequate supplies of all nutrients required for optimal pregnancy outcome.

Some of these nutrients have been found to be inadequate in the diets of many American women (B6, folate, Zn,& Fe).


Screening for Iron Deficiency

Measure Hematocrit and Hemoglobin at entry into care and repeat at 24-28 weeks (more frequently if intervention is indicated).

A Hgb level of 11mg/dL (HCT=35) or less is diagnostic of anemia and should be followed by iron studies (serum ferritin, serum iron, and iron-binding capacity).

Risks for iron deficiency include previous anemia, poor dietary intake, or chronic blood loss (e.g. heavy menses).


Meal Pattern

Prenatal patients should be encouraged to eat at least three meals and one or two snacks daily.

This pattern will prevent wide swings in blood sugar and avoid discomfort related to large meals.


Dietary Recall

Ask all patients about the foods they routinely eat.

You are looking for obvious gaps such as too few servings of dairy or little or no fruits and/or vegetables.

Patients with these eating patterns have been shown to have a greater prevalence of nutrient intakes less than 50% of the RDA.

All patients should be encouraged to select from a variety of nutrient dense foods (not nutrient poor items such as candy and soda).


DAILY FOOD GUIDE FOR PREGNANCY

FOOD GROUP DAILY SERVINGS

Fats, Oils, & Sweets use sparingly

Milk, Yogurt, & Group 4 servings

Vegetable Group 3 - 5 servingsMeat, Poultry, Fish, Dry Beans, Eggs & Nuts 2 - 3 servings

Fruit Group 2 -3 servingsBread, Cereal, Rice & Pasta Group

6 - 11 servings


DAILY FOOD GUIDE FOR VEGETARIAN PREGNANCY

FOOD GROUP DAILY SERVINGSFats, Oils, & Sweets 2 servings

Calcium / B12 rich foods or supplements

8 servings /4 servings

Vegetable Group 3 - 5 servings

Beans, Nuts, Seeds, & Eggs

7 servings

Fruit Group 2 -3 servings

Bread, Cereal, Rice & Pasta Group

6 - 11 servings


Screening for Diabetes Mellitus

Because of the increased prevalence of DM in pregnancy it is recommended that all pregnant women be screened for gestational diabetes.

Patients with a history of GDM during a previous pregnancy should have a 3 hour glucose tolerance test.

Those with a strong family history of DM should be screened early in pregnancy (14 wks.) And all women should be screened at 24-28 weeks with a 1 hour glucose challenge.


Nutrition Education During

Pregnancy


Nutrient Needs to Support a Healthy Pregnancy

What should you tell your patients about Calories?


Calorie needs to support a healthy pregnancy:

Adequate calories can be obtained by encouraging patients to eat a reasonable quantity of food when they are hungry. The vast majority of pregnant women gain sufficient weight to have a healthy baby without any special dietary intervention. Women need to understand that the increased caloric requirements to support a pregnancy are minimal (75,000kcal/40wks or ~266 kcal/d, the equivalent of 1 cup of flavored yogurt): they do not need to "eat for two."


Calorie needs to support a healthy pregnancy:

Special populations where calories may be a problem:– Teens must meet the needs of their own

growth as well as the additional needs of the fetus.

– Overweight women should not diet but should be cautious about excessive caloric intake.



What should you tell your patients about protein intake?


Protein requirements to support a healthy pregnancy:

The diet of most Americans is high in protein, thus increased protein needs in pregnancy are usually met by merely increasing food intake. The recommended distribution of macronutients (15% of calories from protein, 30% or less from fat, and 55% from carboydrate) is appropriate even for pregnancy.


Protein requirements to support a healthy pregnancy:

Special populations at risk:– Pregnant teens (same issue as calories)– Vegetarian (or specifically vegans) patients may need

special dietary counseling to assure adequate protein intake: i.e. increased attention to protein containing foods and protein complementarity (rice and beans, grains, low fat dairy, fish, poultry and meat).



What should you tell your patients about dietary fiber intake?


Fiber intake to Support a Comfortable Pregnancy

Adequate amounts of insoluble dietary fiber (wheat bran) is importance for the maintenance of colonic peristalsis and the prevention of constipation (a common problem during pregnancy).



What should you tell your patients about vitamin intake during pregnancy?


Vitamin Needs to Support a Healthy Pregnancy

The requirements for many vitamins are increased but not above that available via regular dietary sources (except for folic acid). Of equal concern is the potential for vitamin toxicity (the fetus may be more susceptible than the mother) or conditional deficiency (i.e. the potential to create deficiency in the infant once they are removed from the placental source of vitamins provided at pharmacological levels in utero).



Megadosing should be discouraged and women should be asked about their use of vitamin and other dietary supplements (my advice to patient's is that pregnancy is not the time to use "experimental" supplements like chromium picolinate or CoQ10).

Food sources are preferred over supplements. Adequate Vit D should be assured from dairy sources or routine prenatal vitamins and adequate Vit A should be obtained from foods high in beta carotene (to avoid the toxicity of retinoids) such as green pepper, carrots, squash, etc.).



Folic acid: Evidence category A recommendation for periconceptual folic acid supplementation to reduce the incidence of neural tube defects (NTDs). Unfortunately by the time we see a patient for prenatal care it is often too late to prevent NTDs. Therefore this topic should be appropriately addressed during pre-conceptual counseling. Prenatal supplements contain 800 mcgs of folic acid which is enough to meet the needs for increased hematopoesis during pregnancy and to prevent NTDs.


Folic Acid Requirements to Support a Healthy Pregnancy

Patients with a history of previous NTDs and adolescents (who have been shown to have a higher prevalence of folate deficiency) may require higher doses. Folic acid is easily destroyed by heat thus the best dietary sources are limited to uncooked fruits and vegetables. Organ meats, beans, and nuts, while cooked are also good sources. Foods are a secondary source.


Folate Intake in Non-Pregnant Women by Income (16-39 y/o)United States, 1988-1994

210

215

220

225

230

235

240

245

Total population Poverty incomeratio <1.300

Poverty incomeratio >1.300

mg




Minerals Iron needs in pregnancy are estimated at 30-60

mg/d of elemental iron. This quantity is not easily derived from the diet as iron absorption is only 10-15% of dietary iron. Iron from heme sources (meat) is more bioavailable that iron from non-heme sources and vitamin C has been shown to increase the absorption of non-heme iron.

RDA: pre-pregnant:18 mg/d, pregnant: 30 mg/d, lactation: 15 mg/d



More on iron: patients should be encouraged to include red meat, eggs, and organ meats in their diet to promote iron absorption or to combine foods high in vitamin C (citrus fruits, green pepper) in the same meal as non-heme iron containing foods (dark green leafy vegetables, beans, raisins, prunes).



Even more on iron: the decision of whether to supplement routinely depends on the prevalence of iron deficiency in your population. Prenatal vitamins contain ~30 mg of iron which when combined with the 15 mg in the typical diet should be adequate. Iron supplements are indicated only for pre-existing anemias or patients who do not include adequate food sources of iron in their regular diet.


Food Sources High in Iron

Food Amount Iron (mg)

Beef (cooked regular hamburger)

4 oz 2.1

Steak 3 oz 2.6

Spinach (cooked) 1 6.4

Black beans (dry, cooked)

½ cup 2.5

Chili w/ meat and beans

1 cup 4.3

Instant oatmeal 1 packet 6.7

Peas (frozen, cooked)

1 cup 2.5



Calcium needs are 1000-1300 mg/d. This is the amount found in 4 servings of dairy products per day. If your patients are not able to achieve this level of dairy intake, supplements may be warranted. Other food sources include: fish with bones (e.g. sardines and canned salmon, bok choy, broccoli, or fortified foods like orange juice).



More on calcium: In addition to the importance of calcium to prevent maternal bone loss, studies have documented beneficial effects of calcium supplements (at 1500 mg/d) on pregnancy induced hypertension, pre-eclampsia, and premature labor.



Food Sources High in Calcium

Food Amount Calcium (% RDA)

Calories

1% Milk 8 oz 29% 102

Cheese 1 oz 16% 110

Spinach (cooked) 1 cup 24% 41

Soy Milk (Fortified)

1 cup 37% 98

Sardines 3.75 oz 35% 191

Fortified Cereal 3/4 cup 110% 97

Fortified OJ 1 cup /112



Zinc has been added to prenatal supplements in the past few years in recognition of the fact that the American diet does not contain adequate zinc (dietary sources: oysters and whole grains) and studies have demonstrated decreased levels of zinc in the cord blood of premature infants. Prenantal supplements usually contain ~25 mg of zinc.



Breastfeeding Promotion

Remember that breastfeeding promotion must start before delivery.

Patients who are breastfeeding must continue their good diet and supplements (iron may be discontinued).

Breastfeeding requires more calories than pregnancy (~850 Kcal/d).

These are usually supplied both from dietary sources (~500 Kcal/d) and maternal fat stores (~350 Kcal/d).


Breastfeeding Promotion

Patients who fail to gain adequate weight during pregnancy may be at risk if they decide to breastfeed and patients who are not planning on breastfeeding should probably gain slightly less weight during their pregnancies.


Infant Feeding Education

Physicians should initiate discussions about infant feeding guidelines during prenatal care.

Parents-to-be need to be informed about recommended schedules of introduction of feeds other than breast milk or formula.

Cultural patterns and expectations should be elicited.


Weight Gain

How much weight should your pregnant patient gain?


Monitoring Weight Gain

Weight gain guidelines: the greatest contributor to infant birth weight is maternal weight gain during pregnancy. The Institute of Medicine has published guidelines for prenatal weight gain which vary depending upon the patient's initial weight. Patients within 10% of ideal body weight (IBW) should gain 24-30 lbs.



Weight gain guidelines: Patients who are underweight when they become pregnant or adolescents who have not achieved full growth themselves should gain ~ 5 lbs more. Patients who are overweight when they start pregnancy should gain 20 lbs or less.



Pattern of weight gain: Most patients gain no weight or up to 5 lbs during the first trimester and then about 1 lb per week. More common is a pattern of some weight loss during the first trimester and then catch-up over the next 20 weeks. Remember that food intake commonly declines near the end of pregnancy when partial mechanical obstruction of the GI tract is common and weight gain at this time may reflect fluid balance not increased fetal tissue.


Weight Gain Guidelines:

Current weight as % of Ideal Body Weight

Suggested Prenatal Weight Gain

(in Lbs)

<90% 28-40

90-120% 25-35

>120% 15-25



Using a grid: if there is a suspicion of inadequate or excess weight gain, use a prenatal weight gain grid to plot the patient’s weights. Remember to weight the patient yourself and to use the same scale each time.

Intervention for deviations from expected weight gain:– Inadequate weight gain: diet history, r/o hyperemesis,

refer to RD for calorie count– Excessive weight gain: limit “empty” calories, increase

exercise as appropriate, refer to RD for education if needed.


Problem Identification and Intervention

AnemiaPICAHyperemesisPotential Exposures


Fish Warning

In 2001 the FDA issued a Food Advisory warning pregnant women to avoid fish that might be high in mercury:

Shark, Swordfish, King mackerel, Tilefish Recommended to limit other fish to 2-3

servings (12 oz) per week.Albacore “white” Tuna has more than

“light” (6 oz/wk OK)Fish low in Hg: shrimp, canned light tuna,

salmon, pollock, and catfish.


Is there a problem?

The researchers have concluded that there is no evidence of neurodevelopmental risk from prenatal methyl mercury exposure resulting solely from ocean fish consumption. Lancet before23/05/2003


And, fish may be beneficial

Fewer SGA babies with more fish intake (33 gm/d)

Dr Imogen Rogers, of the University of Bristol in southwestern England, said in a report published in the Journal of Epidemiology and Community Health.


Vitamin A

Retinol/retinoic acid are teratogenicSupplements should not exceed 5,000 IU/dNote that no amount of carotenoids are

teratogenic.


Problem Identification and Intervention

Anemia: iron & MVI supplements, CBC & ferritin levels

PICA: ice chips and laundry starch are commonly consumed. Discourage if excessive.

Hyperemesis: if standard interventions (dry crackers before rising, limit beverages with meals) fail, patients who are losing weight should be hospitalized for enteral or parenteral nutritional support.


Patient Questions

1. Is it OK to eat sushi?

2. Is it OK to use "natural" vitamins?

3. How much calcium does the patient need?

4. My question for you: how can you get the answers to these (and other questions) when you need them?


Answer to Patient Questions

1. Is it OK to eat sushi? No

2. Is it OK to use "natural" vitamins? Yes

3. How much calcium doI need? < 18 y.o. 1,300 mg/d 19-50 y.o. 1,000 mg/d

1 serv = 250 mg Best sources: yogurt, Instant Breakfast, lactaid, milk, figs,

sardines, canned salmon, cream soup, pudding, low fat cheese, etc.


Calcium in Pregnancy

Cochrane Systematic Review suggests calcium supplementation may be beneficial reduce risk of HT in high risk women (pre-eclampsia) or those with poor intake*.

6 of 9 studies positive for higher birth weights

* http://www.gfmer.ch/Endo/Course2003/PDF/Calcium_pregnancy.pdf

2006darwin deen, md aecom comprehensive nutritional care for prenatal patients darwin deen, md, ms

Documents

nutritional effects

obese patients

medical andor nutritional

weight histories

social problems

comprehensive nutritional

prepregnancy height

dietary intake