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Welcome
Current Recommendations and advice: Promoting a healthy diet during pregnancy and early years
time for another drink
Bradford Nutrition: The local hot potatoes and how we can manage them
Final Thoughts
Networking & Information
Current recommendations and advice:
Promoting a healthy diet during
pregnancy and the early years
Dr Helen Crawley
May 2016
Where should we get advice – and
what are the key things to
consider?
• Who should we take advice from?
• What are the key things we should
focus on to improve nutrition from pre-
conception to five years?
• What works – and what support is there
out there for you?
Maternal and child nutrition
Implementing NICE guidance
2nd edition March 2012
NICE public health guidance 11
NICE Quality Standards (98)
2015• NICE quality standards are a concise set of
prioritised statements designed to drive
measurable quality improvements in the 3
dimensions of quality – patient safety, patient
experience and clinical effectiveness – for a
particular area of health or care.
• https://www.nice.org.uk/guidance/qs98/
chapter/List-of-quality-statements
Who do we listen to?
• There are global codes and conventions
which have been set up to protect
women and children
What does this mean?
• This means that in public health we
work within the WHO Code of
marketing of breastmilk substitutes
and relevant WHA resolutions - and
do not use any materials, resources or
information produced by a company
which makes breastmilk substitutes, or
markets food for infants under 6
months.
Nutrition matters
• We are in a new era of understanding
about the importance of nutrition in
determining inter-generational health.
•
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Unfit for pregnancy?
• Young women in the UK are
the most malnourished
group of the population
• They typically have low
status of a wide range of
nutrients, some are too thin
and many too fat, most eat
too few fruits and vegetables
and dietary variety may be
limited.
Young women in low income
households
• Studies show young women in low
income households:
• Have high fat, salt and sugar intakes.
• 1/3 have very low intakes of iron, zinc,
potassium, riboflavin.
• Intakes of vitamin A, calcium,
magnesium and iodine are frequently
very low.
• If they smoke diet is often worse.
Does it matter?
• Children born to poorly nourished parents are
unlikely to reach their full potential.
• Iodine deficiency disorders are the
commonest cause of learning disabilities
worldwide
• If a woman has little or no dairy foods and
does not eat fish it is unlikely she will have
adequate iodine status in the UK – new data
suggests this is becoming a significant
problem among some young women in
particular.
• Low maternal iodine status was associated with an
increased risk of suboptimum scores for verbal IQ at age
8 years, and reading accuracy, comprehension and
reading score at age 9 years
• Results suggested a worsening trend in cognitive
outcome with decreasing maternal status
• Possible in-utero effect of sub-optimal iodine status
2013;382:331-37
Folic acid and vitamin D • An association between the development of
neural tube defects (NTD) and folic acid was
first suggested more than 35 years ago – and
has been recommended for women planning
a pregnancy – and in the first 12 weeks of
pregnancy since 1992.
• Recommendations that all women should
take vitamin D in pregnancy and when
breastfeeding have been in place since 2003
– new recommendations are due this July to
increase amount suggested, and timing in
infancy.
Healthy Start
• The UK revised welfare food scheme – revamped in 2006 to offer vouchers to buy milk, vitamins and fruit and vegetable to low income families and women under 18 years.
• Food vouchers worth £3.10 a week, £6.20 for infants in first year.
• Also free vitamins for pregnant and nursing women and children 1-4 years.
• Universally free in some areas. Bradford?
What is the ideal outcome of a
pregnancy?
• Delivery of a full-term healthy infant with a birth weight of 3.1-3.6kg
• Avoidance low birth weight
(< 2.5kg)
• Prevention of maternal mortality, complications of pregnancy, labour and delivery
• Preventing pre- and perinatal morbidity and mortality
Risk factors for LBW
• Nutritional status of mother: short stature, low pre-pregnancy BMI, low gestational weight gain
• Low dietary micronutrient intake
• Smoking, substance abuse, hard physical work
• Poorer prenatal care
• Multiple births
• Psychosocial factors (stressful life events, low social support, depression)
• Many of these are more common among low SE groups
What is the evidence for a
nutritional link to LBW?
• Low gestational weight gain in women who are underweight or normal weight before pregnancy is associated with risk of LBW
• The optimum weight gain for best fetal outcome has been found in studies of many women, to be 10-14kg with an average of 12kg
• NICE antenatal guidance (clinical guidance 62) updated 2016
• NICE Quality Standards (QS22) in 2012
Obesity in pregnancy
• Obesity causes major difficulties throughout pregnancy and in terms of outcome
• Increases gestational diabetes, hypertension, pre-eclampsia, congenital defects, increases chance of abnormal labour and complications – particularly maternal death
• Women obese pre-pregnancy are at greatest risk
• Obese mothers have larger babies and babies born at >4.5kg are also at increased risk of mortality, morbidity
• NICE guidance (PH27, 2011) on obesity before, during and after pregnancy
Alcohol ….
• The Chief Medical Officers’ 2016
guideline is
• If you are pregnant or planning a
pregnancy, the safest approach is not to
drink alcohol at all, to keep risks to your
baby to a minimum.
• Drinking in pregnancy can lead to long-
term harm to the baby, with the more
you drink the greater the risk.• https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48
9795/summary.pdf
• Women who find out they are pregnant
after already having drunk during early
pregnancy, should avoid further drinking,
but should be aware that it is unlikely in
most cases that their baby has been
affected.
• https://www.gov.uk/government/uploads/system/uploads/attachment
_data/file/489795/summary.pdf
Advice to
• Avoid certain foods and drinks
• Limit certain foods/ingredients
• Take some supplements
• Eat ‘a normal healthy diet’ – What does
this look like?
How much does it cost?
How to support dietary
change?
• Behaviour change is complex – but we
know people find it easier to make
changes if they are:
• Involved in the discussion
• Given practical skills
• Given confidence
Unequivocal evidence
• Essential for health of the
infant short and longterm
• Determines population
development
• Protects mother’s health
• And important in terms of
sustainability and health of
the planet.
“When Britain has one of the lowest rates of
breastfeeding you have to ask the question why? Are
British women educated enough about breastfeeding,
or are there other reasons or barriers getting in the
way?’
Risks of not breastfeeding?
Using breastmilk substitutes is associated with a
number of specific health hazards to which
breastfed babies are not exposed. These include:
• the possibility of over- or under-concentrating
formula milk during reconstitution
• the potential for infection introduced by using
substitute milk products, bottles, teats, and other
vessels
• potential risk from ingredients and contaminants
in formula/infant milks
UK recommendations
• In 2003 the UK adopted the WHO
recommendation that babies should be
exclusively breastfed for the first 6
months of life – 26 weeks
• Supported by UNICEF, WHO and all major
health agencies
Currently 90% maternity services and 82%
health visitor settings are registered/accredited
with Unicef Baby Friendly.
Who else offers support and
guidance?
Infant formula
• The Infant Formula and Follow on
Formula Regulations (2007) determine
the composition of infant milks.
• Most claims made to differentiate products
are made for unnecessary ingredients –
and to avoid being miseld, people should
only seek independent information on
infant milks.
Formula milk safety
• Powdered milks must
be made up safely as
they are not sterile.
• There are clear
guidelines for this
published by
DH/FSA/UNICEF
(2011)
Complementary feeding
• UK advice says:
• Introduce complementary food
alongside breast milk at ‘about’ 6
months of age in the first year of life
• Breastfeed throughout first year and as
long after that as mother wishes
• ‘about 6 months’
• Despite current rumours, this is unlikely
to change
Impact of poor nutrition in
early life• Growth stunting
• Poorer immune system
• Impaired cognitive development
• Childhood obesity and type 2
diabetes
• Tooth decay
• Poorer development oromotor
skills
• Fussiness around food type and
texture leading to more limited
diets
Introducing solids
Key factor is ‘readiness for solids’
www.nhs.uk/start4life/solid-foods
Key messages:• Between 6 months and 1 year babies need to get used to lots
of different flavours and textures and learn to feed
themselves.
• Simple ‘family’ foods low in salt and sugar are fine –
meat, fish, eggs, pulses, fruits, vegetables, starchy roots,
cereals should be main components of meals. Diet quality
matters.
• Milk or water to drink
• Appetites will vary day to day and week to week
• Keep offering foods even if not eaten
• Elements of baby led weaning – but needs to meet individual
needs
• Commercial baby foods are poor value for money and are
generally too soft and too sweet.
Fussy eating
• Parental attitudes to
feeding children in many
western countries
becoming anxiety driven
• Concern that children ‘not
liking’ food is a problem,
leading to medicalisation of
early feeding and search
for ‘solutions’
• This has been stimulated
by baby food industry.
Tiny Tastes programme
• Developed by
psychologists at
UCL
(www.weightconcern
.com)
• Uses principles of
repeated exposure
and familiarisation
Who to take nutrition advice
from?
• Code compliant, policy based
organisations/programmes.
• Dietitians or AfN registered nutritionists with a
specialism in public health.
• Schemes which support eating well in early
years settings should be free of commercial
involvement – e.g. HENRY, Food for Life EY
Award
Things to look out for:
• A ‘Healthy Weight,
Healthy Nutrition’
training pack will be
cascaded to HV
nationally during
2016/2017 by The
Institute of Health
Visiting.
Childhood obesity strategy
• No-one knows when this
will come out – will have to
include some statements
related to pre-conception
to five
• In the meantime we have
the WHO ECHO
recommendations which
provide a clear framework
for action
www.firststepsnutrition.org
helen@firststepsnutrition
@1stepsnutrition
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Bradford Nutrition –
the local hot potatoes and how
we can manage them.Clare Gelder
Principal Dietitian
Aim
• To provide an overview of local nutritional
issues affecting women of child bearing age
and young children in Bradford
• Consider the and the management strategies as
well as the difficulties faced when dealing with
these issues
Learning Outcomes
At the end of the session, delegates will have an
understanding of ;
– The common nutritional problems observed in
these population groups
– How these issues are managed
– Strategies and practical interventions
– Signposting to further resources and support
Drivers for Change• National Institute for Health & Care Excellence
– Antenatal care CG62
– Antenatal & Postnatal Mental Health CG45
– Diabetes CG63,
– Maternal and Child nutrition PH11
– Quitting smoking in pregnancy PH26
– Weight Management before, during and after pregnancy PH27
– Pregnancy & complex social factors CG110
• Every Baby Matters Strategy
Bradford
• The average number of babies per mother in
Bradford is 2.24 (2013: 8,039 babies born)
• National Total Fertility Rate is 1.82
(Office National Statistics, 2014)
• In the UK: 1 in 5 women diagnosed
‘clinically obese’ in pregnancy
• In Bradford its 1 in 4 women
Bradford Infant Mortality
• 8,322 live births district wide (B&A)
• Infant Mortality Rate (IMR) is the number of deaths
under 1 years old per 1000 live births.
• National = 4.0. Bradford = 5.8 (2016 health profile)
• Was 7.0 (2010-2012)
• Bradford was 8.3 (2005-7), 7.9 (2008-10) 5.1 (2014-15)
• 69 infant deaths in 2010, 59 recorded 2010-12
• 58% births in poorest 40% of Bradford
Importance of good nutrition in
pregnancy
• ↓ risk of foetal and maternal deficiencies
• ↑ chance of healthy pregnancy (mother and
baby)
• Preparation for breastfeeding
• Improved development and long term health
(mother and child)
Preparing for pregnancy
Women with BMI 30 or more• Encourage weight loss before pregnancy
• Discuss health risk
• Highlight benefits of weight loss
• Support from weight loss programmes
• Aim for 5-10% weight loss initially
• Encourage a BMI in healthy range
• Advise folic acid supplements
Pregnancy
Women with BMI 30 or more• Biggest risk is from being obese rather than weight
gained during pregnancy
• Dieting is NOT recommended
• Appropriate weight gain:
Pregnancy:
Women with BMI 30 or more• Discuss health risks
• Benefits of healthy diet and physical activity
for mum and baby
• Address concerns – diet and activity
• Advice from a reputable source
• Offer referral to a dietitian
• Dispel myths – eating for two
• Healthy Start Scheme
After childbirth:
Women with BMI 30 or more• 6-8 week postnatal check - opportunity to discuss weight
• If not ready, offer further appointment in 6 months
• Realistic expectations for weight loss
• Take account of demands of caring and health issues
• Family support
• Encourage breastfeeding
• Physical activity – check with GP/midwife first
• Support from structured weight management groups
Effective weight loss programmes –
before and after pregnancy
• Based on balanced, healthy diet
• Encourage regular physical activity
• Incorporate behaviour change advice
• Identify and address people’s barriers
• Practical and tailored to individuals
• Sensitive to the person’s concerns
• Realistic weight loss of 0.5 – 1 kg per week
Who is at risk of vitamin D deficiency?• Those with someone else in the family with vitamin D deficiency
• People from South Asian, African, African Caribbean and Middle Eastern backgrounds
• Those that have a low exposure to sunlight due to wearing concealing clothing or spending time indoors
• Teenagers (growth spurt)
• Strict sunscreen users
• People who are obese (BMI>30)
• Pregnant or breastfeeding women
• Breastfed and some formula fed babies
• Children during periods of rapid growth such as in infancy
• Children with chronic conditions (malabsorption, juvenile idiopathic arthritis, rheumatic conditions, chronic steroid use, diabetes, disability and reduced mobility)
• People on medications interfering with Vit D metabolism: phenytoin, carbamazepine, steroids, rifampicin
Discretionary Vitamin D
Supplementation Policy
• All pregnant women booked with a midwife in
B+A receive free vitamin D supplements
• All infants in B+A receive free vitamin D
supplements from birth to 6 months(some will continue to receive free up to 2 years)
Healthy Start vitamin tablets and
drops are the preparation of choice
Childhood obesity
• 20% under 5’s (OW/O)
• Associated with fussy eating, early weaning and
deprivation
• Genetics
• Lifestyle factors (activity, labour and time saving
devices and choice of leisure activities)
Solution
• Healthy, balanced diet and adequate activity
Rickets
• 67 cases of Rickets were diagnosed between 2007 and 2010
(NHS B&A, 2010).
• 20 cases were diagnosed between 2012 and 2015
(Source: SystmOne).
These figures are suggestive of a decrease in the
incidence of Rickets
Iron Deficiency Anaemia
• 40% of under 5’s in Bradford (diet)
• Immigrants and deprived areas (most effected)
• Infections, poor weight gain, development and cognitive delay and behavioural disorders
• Late weaning, inappropriate weaning, early weaning and excessive cows milk
Solution
• Improving maternal nutrition, appropriate weaning and a balanced diet
Faddy Eating
• High prevalence (70% of 2yr olds)
• Deprived areas most effected
• Decreases with age (by 5yrs 1%)
• Associated with Vit D and Iron deficiency and late or inappropriate weaning
• Frequent drinks, snacking behaviour, lack of routine, unclear boundaries, neophobia, parental expectations and anxieties, parental depression,
Faddy Eating
Solution
• Parental education – meal routine, portion sizes and
menu planning
• Realistic expectations – children are not little adults
• Reassurance – most children grow out of faddy eating
behaviours
• Consistency – parental confidence, establish new
norms
• Peer support for children – positive role models
• Healthy Start vitamin supplements
Faltering growth
• Commonly, infants may show some weight
faltering in the first 2 years of life but it can
also affect older children.
• Under-nutrition accounts for 95% of the
faltering growth causes e.g. impaired
absorption, increased requirements,
insufficient energy given.
• 5% of the faltering growth comes from major
organic disease.
Faltering Growth Pathway
• It is estimated that of the children who have
faltering growth, only 5% will have significant
safeguarding concerns, e.g. abuse, neglect
• Children who are severely undernourished
from whatever cause may suffer long term
growth, developmental, behavioural and
emotional problems.
Faltering Growth Pathway
• Developed in Bradford as part of the EBM
working group on nutrition
• To be rolled out to GP and HV asap
• Provides a clear schematic of what to do and
when
Complimentary Feeding
• Exclusive breastfeeding for six months confers
several benefits on the infant and the mother,
• Complementary foods should be introduced at
6 months of age (26 weeks) while continuing
to breastfeed.
• The DH Guidelines recommend the
introduction of solid food ‘at around six
months’
Weaning - Born in Bradford
• Older, better educated mums -> less chips and potatoes.
• Later weaning -> less processed meat.
• Breastfeeding, older mums, higher education -> more vegetables.
• Similar for fruit.
• Older mothers -> less sweet snacks.
• Later weaning, older mums, better education -> less savoury snacks.
• Earlier weaning, younger mums, less education -> more sugar-sweetened
drinks.
• Overweight & older mothers -> low-sugar drinks.
* Adjusted for maternal age, parents’ education, ethnic group, energy intake, &
infant age
Pink Sahota, BiB, 2013
Complimentary feeding
Solution:
•Consistent messages from practitioners
•Promotion of best practice weaning
•Access to complimentary feeding workshops for
all
Poor Oral Health
• Bradford rates higher than national average
• Higher incidence in deprived areas
• Poor oral hygiene + sugary food/drinks
Solution
• Brushing teeth x2 daily, fluoride toothpaste and
avoiding sugary food/drink between meals
Conclusion
• There are many problems faced in the BSB
relating to nutrition
• Many solutions require education of workers
and volunteers to ensure consistent messages
• Need to tap in to the experts to ensure best
practice is driven forward
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