Download Canadian Consensus on Female Nutrition: Adolescence

CLINICAL PRACTICE GUIDELINE
No. 333, June 2016
Canadian Consensus on Female Nutrition:
Adolescence, Reproduction, Menopause, and
Beyond
This Clinical Practice Guideline has been prepared by the
Nutrition Working Group; endorsed by Dietitians of Canada,
the Canadian Association of Perinatal and Women’s Health
Nurses and the Canadian Nutrition Society; reviewed by the
Society of Obstetricians and Gynaecologists of Canada
(SOGC) Family Physician Advisory, Clinical Practice e
Obstetrics and Clinical Practice e Gynaecology committees;
Bureau of Nutritional Sciences and the Office of Nutrition
Policy and Promotion of Health Canada; Drs. Debra Katzman
and Alison Rodrigues from the Division of Adolescent
Medicine at the Hospital for Sick Children; and approved by
the Board of the SOGC.
CO-AUTHORS
Kristi Adamo, PhD, Ottawa ON
Kendra Brett, PhD, Ottawa ON
Nasreen Khatri, MD, Toronto ON
Nicole Robinson, MA, Ottawa ON
Lindsay Tumback, MSc, RD, Saskatoon SK
SPECIAL CONTRIBUTOR
Anthony Cheung, MD, Vancouver BC
NUTRITION WORKING GROUP
PRINCIPAL AUTHORS
Deborah L. O’Connor, PhD, RD, Toronto ON
Jennifer Blake, MD, Ottawa ON
Rhonda Bell, PhD, Edmonton AB
Angela Bowen, PhD, RN, Saskatoon SK
Jeannie Callum, MD, Toronto ON
Shanna Fenton, MD, Saskatoon SK
Disclosure Statement: Disclosure statements have been received
from all members of the committee(s). The SOGC received an
unrestricted educational grant from Nestlé Nutrition. The content
of the guideline was developed entirely independently, and was
embargoed throughout the entire development process, up to the
time of publication. Contributing funders had no input into the
development of the guideline content.
The authors wish to acknowledge the expertise and support of Dr.
Julia Ewaschuk, medical editor, in completing this guideline. The
literature searches and bibliographic support for this guideline were
undertaken by Becky Skidmore, Medical Research Analyst, SOGC.
Katherine Gray-Donald, PhD, Montreal QC
Melissa Rossiter, PhD, RD, Charlottetown PEI
Key Words: Nutrition, lifecycle, female, women, food, eating,
nutrients, vitamins, minerals, macronutrients, energy, adolescence,
pre-conception, pregnancy, postpartum, lactation, menopause,
older women, eating disorders, weight loss, health, chronic disease,
deficiency, supplements
http://dx.doi.org/10.1016/j.jogc.2016.01.001
J Obstet Gynaecol Can 2016;38(6):508e554
Copyright ª 2016 The Society of Obstetricians and Gynaecologists of
Canada/La Société des obstétriciens et gynécologues du Canada.
Published by Elsevier Inc. All rights reserved.
Abstract
Objectives: To provide health care professionals in Canada with the
basic knowledge and tools to provide nutrition guidance to women
through their lifecycle.
Outcomes: Optimal nutrition through the female lifecycle was
evaluated, with specific focus on adolescence, pre-conception,
pregnancy, postpartum, menopause, and beyond. The guideline
begins with an overview of guidance for all women, followed by
chapters that examine the evidence and provide recommendations
for the promotion of healthy nutrition and body weight at each life
stage. Nutrients of special concern and other considerations unique
to each life stage are discussed in each chapter.
Evidence: Published literature, governmental and health agency reports,
clinical practice guidelines, grey literature, and textbook sources were
used in supporting the recommendations made in this document.
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions.
They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written
permission of the SOGC.
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventative Health Care
Quality of evidence assessment*
Classification of recommendations†
I: Evidence obtained from at least one properly randomized
controlled trial
II-1: Evidence from well-designed controlled trials without
randomization
II-2: Evidence from well-designed cohort (prospective or
retrospective) or case-control studies, preferably from more than
one centre or research group
II-3: Evidence obtained from comparisons between times or places
with or without the intervention. Dramatic results in uncontrolled
experiments (such as the results of treatment with penicillin in the
1940s) could also be included in the category
III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees
A. There is good evidence to recommend the clinical preventive
action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a
recommendation for or against use of the clinical preventive action;
however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical
preventive action
E. There is good evidence to recommend against the clinical
preventive action
L. There is insufficient evidence (in quantity or quality) to make a
recommendation; however, other factors may influence decisionmaking
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.
†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in The Canadian Task Force on
Preventive Health Care.
Values: The quality of evidence was rated using the criteria described
in the report of the Canadian Task Force on Preventive Health Care.
refined grains reduces the risk of chronic diseases including type 2
diabetes, cardiovascular disease, and cancer. (II-2)
1. A balanced and varied diet higher in vegetables, fruit, whole grains,
low- or non-fat dairy, seafood, legumes, and nuts; moderate in
alcohol (for non-pregnant and non-lactating women); lower in red
and processed meats; and low in sugar-sweetened beverages and
2. Women’s health, including their nutritional status, can be adversely
affected by psycho-social, economic, or geographic circumstances
which comprise their “food environment.” Barriers to healthy eating may
include individual factors (e.g., physical ability, income), social factors
(e.g., family situation, social support), community factors (e.g., proximity to grocery stores), and relevant policies (e.g., eligibility for social
support programs). Women at high risk for poor nutritional status may
benefit from additional dietary counselling or targeted interventions. (III)
ABBREVIATIONS
3. A carefully planned vegetarian diet is healthy throughout the lifecycle; careful attention to protein is required. Other nutrients of
concern for strict vegetarians (e.g., vegans) include zinc, iron,
vitamin B12, and omega-3 fatty acids. (II-2)
Chapter 2: General Female Nutrition
Summary Statements
AI
adequate intake
ALA
alpha-linolenic acid
BMI
body mass index
CFG
Canada’s Food Guide
CPNP
Canada Prenatal Nutrition Program
CVD
cardiovascular disease
DASH
Dietary Approaches to Stop Hypertension
DHA
docosahexaenoic acid
DRI
Dietary Reference Intakes
EAR
estimated average requirement
GDM
gestational diabetes mellitus
GWG
gestational weight gain
LGA
large for gestational age
NTD
neural tube defect
PCOS
polycystic ovary syndrome
PHAC
Public Health Agency of Canada
RDA
recommended dietary allowance
SGA
small for gestational age
SOGC
Society of Obstetricians and Gynaecologists of Canda
UL
tolerable upper intake level
WHI
Women’s Health Initiative
Recommendations
1. Emphasize the importance of sound nutrition throughout the female lifecycle, with an overall focus on women’s intake of nutritious
foods in appropriate amounts for maintaining a healthy weight. (I-A)
2. Discussions of dietary intake with women should identify practical,
easy to understand, easy to implement, and sustainable dietary
practices. (III-B)
3. Stress the importance of maintaining a healthy body weight throughout
the lifecycle. Body mass index (weight in kg/height in metres2) and
waist circumference (cm) provide a general idea of health risk and
should be measured as a routine part of physical assessments. (II-2A)
This recommendation does not apply to adolescents and women with
eating disorders or women who are pregnant.
4. Support women in understanding specific nutrients of concern
across the female lifecycle, which include calcium, iron, folate,
vitamin B12, and vitamin D. Ensure that women are aware of foods
rich in these nutrients, and encourage their regular consumption in
appropriate amounts. (III-A)
5. Women who are at high risk for iron deficiency (e.g., low or no meat
intake; low socioeconomic status; immigrants from developing
countries; First Nations, Inuit, and Métis women; significant blood
loss due to menstruation, child birth) should be screened by
measuring hemoglobin and serum ferritin. If iron deficiency is
identified, oral elemental iron therapy should be initiated and
continued for at least 6 months; higher doses are required for
women with severe anemia. Iron should be taken with a source of
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Chapter 4: Pre-conceptual Nutrition
vitamin C. (III-A) Patients with an underlying condition that causes
iron deficiency or who do not respond to treatment should be
referred for further investigation and management.
6. Routine testing of healthy women without symptoms or risk factors for
vitamin B12 deficiency is not recommended. Consider supplementary
vitamin B12 for women with risk factors for deficiency (e.g., vegetarian/
vegan diet, over age 50, gastric disorders such as atrophic gastritis or
gastric bypass, small bowel disease, and regular use of metformin,
chronic H2-blockers, or proton pump inhibitors). (III-A)
7. Women who are not able to consume the recommended dietary
allowance of calcium in their diet may benefit from a calcium
supplement. (II-2A) When counselling a woman in the selection of
a calcium supplement, ensure that the supplement provides an
adequate dose of “elemental calcium” and that the woman understands she needs to look specifically for this on the label. It is
best to take multiple small doses of calcium as absorption is
inversely related to intake; no more than 500 to 600 mg of
elemental calcium at any one time. (II-2A) Caution should be used
to avoid exceeding the upper limit for calcium from diet and supplements combined (2500 mg for adult women).
8. Recommend a vitamin D supplement to all Canadian women who
consume insufficient dietary vitamin D (I-A), particularly those with
decreased cutaneous synthesis due to being homebound, having
darker skin pigmentation, or who cover their skin.
9. Screening for vitamin D deficiency by measuring serum 25(OH)D is
not necessary for the general population but should be carried out
in high risk women such as those with a history of fractures,
malabsorption, renal disease, or using medications that impact
vitamin D or bone metabolism (e.g., chronic steroid use, anticonvulsant therapy). (III-A)
10. During routine visits, advise all women of reproductive age about
the benefits of adequate intake of folate from foods (e.g., dark
green, leafy vegetables and legumes) and folic acid in a multivitamin supplement. (I-A)
Chapter 3: Adolescence Nutrition
Summary Statements
1. Adolescence is a key time to continue or initiate obesity prevention.
(III)
2. The highest prevalence of eating disorders occurs among female
adolescents. (II-2)
Recommendations
1. Discuss good nutrition and explore and address potential body image concerns with all adolescent female patients. Teach adolescents and their parents about the benefits of a varied diet higher in
vegetables, fruit, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; lower in red or processed meat; and low in sugarsweetened beverages and refined grains. (III-A)
2. Since it is known to produce widespread positive outcomes,
encourage adolescents and their families to eat meals together. (I-A)
3. The weight and height of all adolescents should be measured
and their body mass index calculated using the World Health Organization Growth Charts which are for children and youth up to
19 years. (III-A)
4. To ensure optimal bone development, adolescent females should be
counselled to consume their RDAs for calcium (1300 mg/day) and
vitamin D (600 IU/day), ideally through food or, if necessary, through
supplementation. (I-A)
5. Be alert to eating patterns and body image of all preteen and
adolescent females. (III-A)
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Summary Statement
1. It is estimated that approximately one half of pregnancies in Canada
are unplanned and thus it is important that all women of reproductive
age maintain good nutrition. (III)
Recommendations
1. Follow the 2015 Society of Obstetricians and Gynaecologists of
Canada guideline for the supplementary use of folic acid by women
of reproductive age. Women of childbearing age should consume
0.4 mg folic acid in a daily multivitamin for at least 2 to 3 months prior
to pregnancy. Women of childbearing age at moderate or high risk
for bearing an offspring with a neural tube defect should consume a
1 and 4.0 mg folic acid supplement, respectively, at least 3 months
prior to conceiving and until 12 weeks gestational age. Thereafter,
daily supplementation should consist of a multivitamin with 0.4 to 1.0
mg folic acid throughout pregnancy and postpartum as long as
breastfeeding continues.(III-A)
2. Promote increased dietary intake for women who are ovulating
abnormally due to underweight by encouraging increased meal
frequency and size, and avoidance of fasting, meal-skipping, and
excessive exercise. (II-3A)
3. Provide a weight-management strategy for women who are ovulating abnormally due to overweight by recommending strategies such
as appropriate dietary adjustments, increased physical activity, and
reduced sedentary behaviour. (II-2A)
4. Recommend a low glycemic index diet to overweight women with polycystic ovary syndrome to improve insulin sensitivity and fertility. (I-A)
Chapter 5: Nutrition in Pregnancy
Summary Statements
1. High-quality dietary intake and appropriate food selections are
important for all pregnant women, and can be achieved by following
Canada’s Food Guide as applied to pregnancy. Food selections
should emphasize choosing a variety of nutrient-dense foods from
all 4 food groups, as opposed to energy-dense, nutrient-poor foods.
A nutrient-rich, energy-appropriate diet will help to ensure a woman’s own nutritional requirements are met and facilitate healthy
development of her fetus throughout the pregnancy. (III)
2. The amount of energy required to support pregnancy (for women
with a pre-pregnancy body mass index of 18.5 to 25) is modest, with
no recommended increase in calorie intake during the first trimester
and an increase of only 340 and 450 kcal/day in the second and
third trimesters, respectively. This generally equates to only 2 to 3
additional Canada’s Food Guide servings per day from any of the 4
food groups in the second and third trimesters. (III) Energy requirements for women with a pre-pregnancy body mass index above
25 kg/m2 are not well established.
Recommendations
1. Measure and discuss weight gain for pregnancy with all women as
early in pregnancy and as regularly as is feasible. Recommendations for the range of pregnancy-related weight gain should be
based on the woman’s pre-pregnancy body mass index (Table 6).
Gaining weight within recommended ranges will help to optimize
maternal, infant, and child health outcomes. (III-A)
2. Women who have not met the minimum or have exceeded the
maximum amount of weight gain recommended for a specific gestational age require additional follow-up and assessment. They should
be encouraged to increase or slow their rate of weight gain to fall within
the recommended ranges of weekly rate of gain until delivery. (III-A)
Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
3. Support women in understanding how to meet recommendations for
specific nutrients of concern during pregnancy, which include folate,
iron, choline, omega-3 fatty acids, and iodine. (III-A)
2. Discuss the benefits of exclusive breastfeeding for improving
short- and long-term health outcomes for the mother and infant.
(II-2A)
4. Follow the 2015 Society of Obstetricians and Gynaecologists of
Canada guideline for the supplementary use of folic acid by pregnant women. Pregnant women at low or moderate risk for bearing an
offspring with a neural tube defect should consume 0.4 and 1 mg
folic acid, respectively, in a daily multivitamin or if they are at high
risk for bearing offspring with neural tube defects, a 4.0 mg folic acid
supplement 12 weeks prior to and after conception followed by 0.4
to 1 mg until weaning. (II-2A) Caution women not to take more than 1
daily dose of their multivitamin. (III-B)
3. A reduction in caloric intake of 500 kcal/day and participation in
moderate aerobic exercise (walking, jogging, dancing; 65% to 80%
maximum heart rate) 4 days per week should promote a gradual
measured weight loss of 0.5 kg/week postpartum. (I-A)
5. Recommend a supplement containing 16 to 20 mg of elemental iron
to pregnant women who are in good health. Therapeutic doses of
iron may be required for women demonstrating biochemical evidence of iron deficiency. (e.g., a low hemoglobin and a serum ferritin
<30 ug/L at any point during pregnancy). (I-A)
6. Emerging evidence suggests that choline (II-2B), omega-3 fatty
acids (I-A), and iodine (I-B) are important nutrients that may be
limited in the diets that pregnant women consume. Discuss foods
rich in these nutrients (e.g., eggs for choline; fatty fish and nuts/
seeds for omega-3 fatty acids; saltwater fish low in methylmercury;
and iodized salt) with women as the pregnancy progresses.
7. Emphasize the importance of limiting or avoiding certain foods
during pregnancy (e.g., avoid foods potentially contaminated with
bacteria and fish with high levels of methylmercury). Many herbs
should be limited or avoided during pregnancy (Appendix B). (III-A)
4. Advise lactating mothers to provide their infants with 400 IU of
vitamin D per day. (I-A)
5. Women should consume at least 150 g of fish each week, as fatty
fish are an important source of docosahexaenoic acid. However,
lactating women need to limit consumption of tuna, shark, swordfish,
marlin, orange roughy, and escolar to < 150 g per month. Lactating
women should avoid canned albacore (white) tuna, but may
consume up to 300 g/week of light canned tuna. (III-A)
6. Maternal intake of allergy and infant colic-associated foods (dairy,
eggs, peanuts, tree nuts, wheat, soy, and fish) and cruciferous
vegetables, cow’s milk, onion, and chocolate have been associated
with colic symptoms in exclusively breastfed young infants, but not
allergy formation in the child. Eliminate foods one at a time to
determine association with infant symptoms. (I-B)
7. Bulk-forming laxatives (psyllium or methylcellulose) are not
absorbed by the gut and should not have negative consequences
for the breastfed infant. Stimulant laxatives should be avoided.
(III-A)
8. Women with hemorrhoids or perineal injury are advised to eat a
high-fibre diet along with adequate water intake (Table 7). (I-A)
8. Follow the 2010 Society of Obstetricians and Gynaecologists of
Canada guideline for alcohol use during pregnancy. There is evidence that alcohol consumption in pregnancy can cause fetal harm.
(II-2A) There is insufficient evidence regarding fetal safety or harm at
low levels of alcohol consumption in pregnancy. (III-C)
Chapter 7: Nutrition During Menopause and Beyond
Chapter 6: Postpartum Nutrition and Lactation
1. Changes in women’s health, social, or family circumstances at the
time of menopause may adversely impact nutrition (e.g., changes in
meal habits, distracted eating, ill health, mood, family stresses). (III)
Summary Statements
1. Optimal postpartum nutrition can be achieved by consuming a highquality and varied diet following Canada’s Food Guide. The elevated
nutritional requirements of breastfeeding women can be met by
consuming 2 to 3 extra servings each day from any of the 4 groups
from Canada’s Food Guide and a multivitamin supplement, as during pregnancy. These extra servings will supply the modest increase
in energy requirements to support lactation (w 350 to 400 kcal over
pre-pregnancy requirements). (III)
2. Gradual weight loss postpartum to achieve pre-pregnancy weight
and a healthy body weight is encouraged. There is little evidence
that either breastmilk volume or nutrient content is adversely
affected by gradual postpartum weight loss and exercise. (I)
3. Breastfeeding is the normal and unequalled method of feeding infants. Exclusive breastfeeding should be encouraged for the first 6
months, and sustained for up to 2 years or longer, with appropriate
complementary feeding of infants. (I)
Recommendations
1. Emphasize the need for appropriate nutrition to achieve a healthy
body weight postpartum (I-A) and promote lactation. (II-2B)
Summary Statement
Recommendations
1. Women are often concerned with perimenopausal weight gain;
advise that weight gain can be reduced by modest calorie restriction,
along with adequate protein intake (0.8 to 1.2 g/kg divided over 3
meals). (III-B)
2. Insulin resistance increases with age; recommend that menopausal
women consume complex carbohydrates with a low glycemic index.
(II-2B)
3. Recommend regular, weight-bearing exercise to preserve skeletal
muscle mass. (I-A)
4. To preserve bone health, advise a daily intake of 1200 mg calcium
and 800 IU vitamin D to menopausal women, along with regular
moderate- to vigorous-intensity physical activity of at least 2.5 hours
per week which includes weight-bearing activity (see Chapter 2 for
more detail on calcium supplementation). (I-A)
5. Menopausal women are less likely to absorb naturally occurring
vitamin B12 (II-2A) and should aim to consume 2.4 mg/day through
fortified foods (e.g., non-dairy milks, meat substitutes) or supplements, and may benefit from having their B12 status assessed. (I-A)
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CHAPTER 1
INTRODUCTION
R
egular consumption of a varied and balanced diet is a
key component of a healthy lifestyle. The foods
women eat each day provide a source of essential nutrients and energy which, when provided in the correct
amounts, facilitate healthy development during adolescence, pregnancy, and lactation; maintain body functions;
and reduce the risk of many chronic diseases later in life.1
It is important to understand that individual food choices
made by females of all ages and physiological stages are
influenced by a number of factors that collectively
constitute the “food environment,” including food habits
established during childhood, accessibility/availability of
foods, ethnicity and culture, geography, education, income, food trends, media, and public policy.2 Aspects of
the current Canadian food environment can present a
challenge to women aiming to consume a balanced,
nutritious, energy-appropriate diet because energy-dense
processed foods high in sodium and sugar-sweetened
beverages are now widely available and frequently consumed.3e9 Women living in remote areas and those with
social struggles face many challenges in accessing nutritious food.
A visit with a health care professional, whether routine
or for a specific medical concern, provides an opportunity to initiate a dialogue about nutrition, screen for
the basic elements of a healthy diet, and offer specific
advice to improve dietary choices or nutrition-related
health behaviours or make an appropriate referral for a
more comprehensive nutritional assessment. Completing
a comprehensive nutritional assessment and effecting
change can be daunting tasks in a busy clinical practice.
However, routine health care of a woman should include
a basic screen to assess the adequacy of her diet, whether
she is maintaining a healthy lifestyle and body weight,
and any factors that may be restricting her ability to
maintain a healthy lifestyle and body weight. Discussing
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behaviour change strategies as appropriate, such as
reducing screen time and the frequency of eating at fast
food restaurants or increasing the frequency of family
meals and importance of reading food labels, in a short
clinic visit can help facilitate change in unhealthy eating
patterns and provide a basis for ongoing discussion.
These discussions may facilitate referral to other health
care providers, such as a dietitian. Motivational interviewing is an effective clinical technique to faciliate
patient-centered behavioural change.10 In addition,
because popular media often highlight research promoting nutritional supplements and diets, medical professionals should have current knowledge of dietary
trends and identify nutritional choices (including supplements) that may be harmful.
The aim of this consensus document is to provide health
care professionals in Canada with the basic knowledge
and tools to provide nutrition guidance to females from
adolescence through their reproductive years to menopause and beyond. The information is intended to be
useful to those without formal training in nutrition but
who wish to begin to incorporate elements of evidencebased nutrition into their practice. This guideline begins
by providing general guidance for all women, regardless
of life stage (see Chapter 2), and then expands on unique
nutrition considerations during adolescence, preconception, pregnancy, postpartum, menopause, and
beyond. It is beyond the scope of this guideline to
provide nutritional therapies for women diagnosed with
an acute or chronic medical condition who may have
altered nutritional requirements (e.g., gestational diabetes, kidney failure). Published literature, governmental
and health agency reports, clinical practice guidelines,
grey literature, and textbook sources were used in the
preparation of this document. The graded recommendations are intended to be useful to health care professionals from novice to nutrition experts in caring for
their patients.
CHAPTER 1:
REFERENCES
5. Moubarac JC, Receveur O, Cargo M, Daniel M. Consumption patterns of
sweetened food and drink products in a Catholic Middle Eastern
Canadian community. Public Health Nutr 2014;17:471e8.
1. Health Canada. Eating Well with Canada’s Food Guide. 2011. Available at:
http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
Accessed on August 14, 2015.
6. Nikpartow N, Danyliw AD, Whiting SJ, Lim HJ, Vatanparast H. Beverage
consumption patterns of Canadian adults aged 19 to 65 years. Public Health
Nutr 2012;15:2175e84.
2. Chan C. Food Environment, Health, and Chronic Disease. Green Paper
Prepared for the Alberta Institute of Agrologists. 2015. Available at: http://
www.albertaagrologists.ca/document/1911/Mar30_Green%20PaperFinal.
pdf. Accessed on November 10, 2015.
7. Tanase CM, Koski KG, Laffey PJ, Cooper MJ, Cockell KA. Canadians
continue to consume too much sodium and not enough potassium. Can
J Public Health 2011;102:164e8.
3. Danyliw AD, Vatanparast H, Nikpartow N, Whiting SJ. Beverage intake
patterns of Canadian children and adolescents. Public Health Nutr
2011;14:1961e9.
4. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA.
Consumption of ultra-processed foods and likely impact on human health.
Evidence from Canada. Public Health Nutr 2013;16:2240e8.
8. Black JL, Billette JM. Fast food intake in Canada: differences among
Canadians with diverse demographic, socio-economic and lifestyle
characteristics. Can J Public Health 2015;106:e52e8.
9. Garriguet D. Canadians’ eating habits. Health Rep 2007;18:17e32.
10. American College of Obstetricians and Gynecologists. Motivational
interviewing: a tool for behavior change. ACOG Committee Opinion No.
423. Obstet Gynecol 2009;113:243e6.
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CHAPTER 2
General Female Nutrition
PROMOTION OF HEALTHY NUTRITION
In promoting good nutrition for women throughout the
lifecycle, the focus should be on healthy eating and not on
individual nutrients. Canada’s Food Guide1 describes the
amount and type of each of the 4 food groups to be
consumed per day, with recommendations specific to age
(children, adolescents, adults) and physiological stage
(pregnancy and breastfeeding).2 CFG provides recommendations that allow, under most circumstances, a healthy
woman to meet her requirements for protein, fat, dietary
fibre, and most essential vitamins and minerals from
diet alone. The accompanying My Food Guide Servings
Tracker3 allows a woman to assess whether her diet is
optimal and also can be used by health care professionals
as a tool for nutrition screening. CFG is available in English, French, and 10 other languages commonly used by
Canadians; it is intended to provide nutrition guidance for
the general population but may not be appropriate for
every Canadian woman or subgroups of women. CFG for
First Nations, Inuit, and Métis4 is an adaptation of the
2007 Food Guide that includes consideration of traditional/country foods and availability, accessibility, and
affordability of foods. This adapted version is available in
English, Inuktitut, Ojibwe, Plains Cree, and Woods Cree.
The most recent version of CFG was released in 2007 and
like prior food guides was developed with the primary goal
of guiding individuals in meeting minimum nutrient requirements.5 As the role of diet in preventing chronic
diseases is becoming clear, it has been suggested that CFG
now requires revision to more effectively improve Canadians’ health and well-being.6 A revised food guideline
would benefit from more comprehensive information on
multiethnic dietary patterns in its development and
improved guidance on the number of food servings based
on physical activity level, which will help women maintain a
healthy body weight.
If a health care professional is interested in detailed information about individual nutrients, how the recommendations were established, and how best to assess a
woman’s status for a nutrient, the Dietary Reference
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Intakes published by the U.S. Institute of Medicine provides an excellent resource.7 Health Canada provides a
document to assist in the understanding and appropriate
use of each DRI component (estimated average requirement; recommended dietary allowance; and tolerable upper
intake level).8 These documents may be downloaded in pdf
format for free. A summary of the DRIs for women is
provided in Appendix A.
Available evidence, mostly epidemiological, indicates that
some dietary patterns are associated with poorer health and
development of chronic disease, specifically type 2 diabetes,
cardiovascular disease, and hypertension.9,10 For example,
“Western”-style diets, high in red meats, saturated fats,
sodium, and added sugars, are associated with obesity, type
2 diabetes, hypertension, and atherosclerotic cardiovascular
disease.9 The present diet of many Canadians is dominated
by processed foods, which typically are high in salt and fat
and low in dietary fibre, and contribute to the development
of obesity and chronic diseases.11
In preparation for their new 2015 Dietary Guidelines, the
U.S. Departments of Health and Human Services and
Agriculture recently completed a comprehensive series of
systematic reviews of the literature examining the association between dietary patterns and health outcomes.10 The
Dietary Guidelines Advisory Committee concluded that a
healthy dietary pattern was one that was higher in vegetables, fruit, whole grains, low- or non-fat dairy, seafood,
legumes, and nuts; moderate in alcohol (for non-pregnant
or lactating adults); lower in red or processed meat; and
low in sugar-sweetened beverages and refined grains.
Several other approaches have been developed to guide
healthy eating and risk reduction for chronic diseases,12
including the Dietary Approaches to Stop Hypertension
diet,13 the Mediterranean diet,14 and CFG. All 3 of these
approaches emphasize the consumption of fruits, vegetables, nuts, legumes, low-fat dairy, and whole grains and low
intake of sodium, sweetened beverages, and red and processed meats. The DASH diet also is low in snacks, sweets,
meats, and saturated and total fat and is associated with
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lower blood pressure, particularly when combined with a
low-sodium diet ( 1.2 g/day).15 It is worth noting that
CFG recommendations are similar to the DASH diet. The
Mediterranean diet also includes olive oil as a significant
source of monounsaturated fat; has low to moderate
amounts of fish, poultry, and dairy products; and little red
meat. The Mediterranean diet appears to reduce the risk of
cardiovascular events,16,17 decrease morbidity and mortality,18 and improve cognitive function.19
It is estimated that about one-third of all cancers can be
prevented by eating well, being active, and maintaining a
healthy body weight.20 The Canadian Cancer Society recommends a diet high in fibre with limited saturated and
trans fat that contains a variety of foods from the CFG,
including lots of vegetables and fruits.21 There are no
event-driven randomized trials of any dietary intervention
for the prevention of cancer; however, there are observational studies that suggest associations between specific
dietary exposures22e24 and either increased (e.g., processed
meat,25 alcohol26) or reduced (e.g., dietary fibre,27 antioxidants and polyphenols in fruits and vegetables,28 high
omega-3 intake29) risk for cancer.
Dietary salt is a contributor to the risk of hypertension; salt
intake can contribute to hypertension and cardiac disease.30
A recent Cochrane meta-analysis concluded that modest
salt reduction can reduce blood pressure and recommends
that daily salt intake be reduced to 3 g/day.31 Women
should be counselled to reduce salt intake by reducing
consumption of processed foods and moderating the use
of salt in food preparation and at the table.30
The Heart and Stroke Foundation of Canada in its new
guidance on saturated fat recommends Canadians
consume a variety of natural/whole and minimally processed foods with every meal, eat more vegetables and fruit
(one-half a plate at every meal), choose whole grains,
include a variety of proteins in the diet from various
sources (e.g., beans, lentils, legumes, nuts, lower-fat dairy),
and drink water to satisfy thirst instead of sugar-sweetened
beverages.32 It needs to be acknowledged that a recent
meta-analysis found no association between saturated fat
and all-cause mortality, cardiovascular disease, stroke, and
type 2 diabetes and has created some controversy in this
area.33 In the same meta-analysis, an association was found
between trans unsaturated fats and these outcomes. Trans
fat is found naturally in dairy products and also is produced when liquid oil is chemically processed into solid fat.
In Canada, a product containing chemically produced trans
fats must provide this information on the food label. The
Canadian Heart and Stroke Foundation acknowledged that
dietary guidance that began in the early 1980s to reduce
overall fat intake by replacing saturated fats with carbohydrates may have played a role in increasing calorie consumption and obesity.32
Summary Statement
1. A balanced and varied diet higher in vegetables, fruit,
whole grains, low- or non-fat dairy, seafood, legumes,
and nuts; moderate in alcohol (for non-pregnant and
non-lactating women); lower in red and processed
meats; and low in sugar-sweetened beverages and
refined grains reduces the risk of chronic diseases
including type 2 diabetes, cardiovascular disease, and
cancer. (II-2A)
Recommendation
1. Emphasize the importance of sound nutrition
throughout the female lifecycle, with an overall focus
on women’s intake of nutritious foods in appropriate
amounts for maintaining a healthy weight. (I-A)
Physical Activity
It is important to recognize that a healthy diet is one
component of a healthy lifestyle, which includes being
physically active, building a circle of social contacts to
create a personally supportive environment, reducing
stress, and choosing not to smoke.34 Physical activity deserves special mention in the context of this nutrition
guideline given its role in energy expenditure and maintainence of a healthy body weight. Physical activity also is
associated with better health, including lower risk for many
diseases, including heart disease, cancer, osteoporosis, and
depression, and should be encouraged.35 The Public
Health Agency of Canada, the Canadian Society for Exercise Physiology, and ParticipACTION publish complementary guidelines for the amount of physical activity
healthy women should engage in each day.35,36 Online information, such as the PHAC’s Tips to get Active,37 provides useful tips on how to get more active and to limit
sedentary activity. PHAC recommends that adolescents
engage in at least 60 minutes of moderate to vigorous
activity per day; adults (18 to 64) and older adults (65 and
older) should accumulate 150 minutes of moderate to
vigorous activity weekly in sessions of 10 minutes or more.
Social Determinants of Health and the Food
Environment
It is important for all health care professionals to be
cognizant of the fact that a woman’s health, including her
nutritional status, can be adversely affected by a number of
psychosocial, economic, or geographic factors, commonly
referred to as the social determinants of health.38 In the
context of food, these factors are often referred to as the
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“food environment” in which a woman lives. A woman’s
ability to eat a healthy diet can be influenced by her physical
ability, mental health, cognitive ability, dental health,
poverty, cultural factors, and food preferences. These factors should be kept in mind when evaluating women’s diets
and when making recommendations. Even though many
women and their health care providers are aware of the
links between diet and risk for disease, often both the
woman and provider are unsure of which dietary advice is
most appropriate or how to incorporate dietary advice into
the patient’s “food environment.” In addition to thinking
broadly about the risks for specific diseases and barriers to
eating well, it is important to offer advice that is practical,
easy to understand, easy to implement, sensitive to economic and cultural factors, and sustainable over time.
Assessment by a registered dietitian is an important
component of assessing and modifying diets for complex
cases, but dietary advice delivered by primary care providers is a key component of quality primary care and
health maintenance for all. A few examples of the importance of understanding the “food environment” in which
women eat are described in the following sections.
Food Insecure Women
Approximately 12.5% of households in Canada are food
insecure, and among those whose major source of income is
social assistance, 68% are food insecure.39 Most recent reports suggest that food insecurity is most prevalent in Canada’s North (e.g., 45% in Nunavut) and the Maritimes. Low
socioeconomic status is frequency associated with poorer diet
quality40; healthy food choices such as fresh fruit and vegetables are often more expensive than energy-dense, processed
foods.41 The health care provider will need to work with
women and be sufficiently engaged in their community to
make the appropriate referrals necessary for their patients to
access social assistance, housing, and employment supports.
First Nations, Inuit, and Métis
In counselling a First Nations, Inuit, or Métis woman, it is
important to discuss consumption of traditional or
“country” foods. As with all populations, there is considerable variation with respect to the dietary patterns of the
First Nations, Inuit, and Métis in Canada; however, many
continue to include some traditional/country foods in their
diet. Importantly, traditional/country foods are associated
with significant cultural, economic, and nutritional benefits
that include higher intakes of protein; vitamins riboflavin,
B6, D, and E; iron; zinc; copper; magnesium; manganese;
and potassium.42 For First Nations, Inuit, or Métis women
experiencing intermittent or persistent food insecurity, the
hunting and community sharing of traditional/country
foods can be an important source of nutrition. The
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clinician also must be mindful that women consuming
traditional/country foods may have higher serum
contaminant levels (e.g., mercury, polychlorinated biphenyls), particularly in Arctic communities (Chapter 5,
Table 8, and Appendix B of this document).43
Newcomers
Depending on their country of origin, socioeconomic
status, and ability to communicate in their new community,
newcomers may face a number of challenges in consuming
a diet consistent with good health.44 Many immigrants to
Canada may, in fact, be healthier than Canadian-born
women, but over time experience a partially diet-related
deterioration in health.45 Traditional dietary practices
from a newcomer’s home country are most notable during
the perinatal period and often are enforced by female relatives living in the home.46 In counselling newcomers, an
understanding of these issues will enhance the effectiveness
of discussion on the role of diet in their health.
Older Women
When counselling the aging female regarding diet, it may be
appropriate to discuss physical abilities to eat, chew, swallow,
digest, and eliminate food; intolerances to various foods;
interactions between foods and medications; appetite
changes; unintended changes in weight; changes in smell and
taste; as well as any other factors previously listed that might
inhibit a woman’s ability to consume a nutritious diet.
Summary Statement
2. Women’s health, including their nutritional status, can
be adversely affected by psycho-social, economic, or
geographic circumstances which comprise their “food
environment.” Barriers to healthy eating may include
individual factors (e.g., physical ability, income), social
factors (e.g., family situation, social support), community factors (e.g., proximity to grocery stores), and
relevant policies (e.g., eligibility for social support
programs). Women at high risk for poor nutritional
status may benefit from additional dietary counselling
or targeted interventions. (III)
Recommendation
2. Discussions of dietary intake with women should
identify practical, easy to understand, easy to
implement, and sustainable dietary practices. (III-B)
HEALTHY BODY WEIGHT
Screening
Health care professionals should calculate their patient’s
body mass index as part of their nutrition screening and
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not rely on weight. BMI is the ratio of an individual’s
weight to height and is calculated as BMI ¼ weight in kilograms/height in metres (Table 1).47 Most women who
have a high BMI (i.e., > 25) have a higher percentage of
body fat.48 A higher percentage of body fat, particularly
abdominal fat, is associated with many chronic diseases,
including diabetes, heart disease, and some forms of cancer. In contrast, a low BMI (i.e., < 18.5) is associated with
health problems such as undernutrition, eating disorders,
and osteoporosis. Even though BMI provides a general
idea of health risk, measures of centralized obesity, such as
waist circumference and waist-to-hip and waist-to-height
ratios, may offer a more accurate prediction of cardiovascular risk factors.49
It is important to note that BMI is a screening tool only,
has limitations, and is best employed to assess population
risk. It may or may not reflect a woman’s nutritional status;
however, its use in conjunction with CFG’s My Food
Guide Servings Tracker serves as an important element of
nutrition screening in a busy health professional’s office.
Other measurements, such as waist circumference, particularly in those with BMI over 25 and under 35, and general
physical examination findings can add to the clinical
assessment.49 Unintentional weight loss should be noted as
a potential indicator of malnutrition.
Weight Loss
Canadian clinical practice guidelines have been developed
by the Canadian Medical Association to guide clinicians
on management and prevention of obesity in their patients.50,51 For women with a BMI > 25 or a waist
circumference above an ethnic-specific cut-off,52,53 the
clinician is advised to carry out both clinical and laboratory assessments to assess for comorbidities. Sensitivity
is required when measuring and weighing women in
terms of language used to communicate with patients
about their weight, as is an appreciation of how
Table 1. Health risk classification according to BMI47
Classification
BMI category (kg/m2)
Risk of developing
health problems
Underweight
< 18.5
Increased
Normal weight
18.5 to 24.9
Least
Overweight
25.0 to 29.9
Increased
Obese class I
30.0 to 34.9
High
Obese class II
35.0 to 39.9
Very high
Obese class III
40.0
Extremely high
NOTE: For persons over age 65, the “normal” range may begin slightly above
BMI 18.5 and extend into the “overweight” range.
unintended biases regarding body weight, shape, and size
could influence treatment decisions.54e56 Patients should
be assessed for depression, eating and mood disorders,
and readiness to change lifestyle practices; any medical or
mental comorbidities should be treated. Laboratory investigations should include determination of blood pressure, heart rate, fasting glucose, and lipid profile (total
cholesterol, triglycerides, low-density and high-density lipoprotein cholesterol, and the ratio of total cholesterol to
high-density lipoprotein cholesterol). A comprehensive
healthy lifestyle intervention is advised for both overweight and obese women willing to make a change. Clinicians are advised to reach out to other health care
professionals to develop a comprehensive weight management and healthy lifestyle program. Available evidence
suggests that more comprehensive and intensive interventions that include behavioural therapy along with
changes in nutrition and physical activity seem to be the
most successful approaches to improving long-term
weight and health status.50,51 It is recommened that
practitioners not routinely offer pharmacotherapy for
overweight or obese women; however, it may be warranted in certain situations in which obesity-related
morbidities are present and the woman has not been
successful in achieving or maintaining a clinically
important weight loss using lifestyle interventions.57
Bariatric surgery is recommended for adults with severe
obesity with a BMI 40 or a BMI 35 with severe
comorbid disease (e.g., diabetes, hyperlipidemia,
hypertension).58
Dietary interventions to achieve weight loss can prevent
the development of diabetes in overweight women at risk
for diabetes and can improve glycemic control, dyslipidemia, and hypertension in those with overt diabetes. Weight
loss also can reduce total mortality if sustained long
term.51 Even a modest weight loss of 5% to 10% can be
clinically very meaningful.59,60 Several dietary patterns have
been used to reduce caloric intake and affect weight loss,
including balanced low-calorie diets, low-fat diets, lowcarbohydrate diets, and Mediterranean diets. Despite
claims that various diets, which vary dramatically in the
relative proportion of protein, fats, or carbohydrates,
promote better weight loss, research has demonstrated that
short- and long-term weight loss outcomes are equivalent
regardless of which macronutrients are emphasized.61 The
key to healthy weight loss is adherence to a reduced-calorie
diet with negative energy balance; exercise is important in
maintaining long-term weight loss.62 Weight cycling has
been associated with increased risk of type 2 diabetes63
and other cardiometabolic risk factors64 and should be
avoided.
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Recommendation
3. Stress the importance of maintaining a healthy body
weight throughout the lifecycle. Body mass index
(weight in kg/height in metres2) and waist
circumference (cm) provide a general idea of health
risk and should be measured as a routine part of
physical assessments. (II-2A) This recommendation
does not apply to adolescents and women with eating
disorders or women who are pregnant.
NUTRIENTS OF SPECIAL CONCERN
In the context of this guideline, a nutrient of concern is
defined as one in which there is an elevated risk of suboptimal intake from a typical diet. In many instances if
intake from dietary sources is insufficient, a supplement
may be recommended. When counselling patients
regarding supplements, ensure that the patient verifies that
the container label has a drug identification number or
natural product number to ensure that the supplement has
been reviewed for safe use in Canada.
Recommendation
4. Support women in understanding specific nutrients of
concern across the female lifecycle, which include
calcium, iron, folate, vitamin B12, and vitamin D.
Ensure that women are aware of foods rich in these
nutrients, and encourage their regular consumption in
appropriate amounts. (III-A)
Iron
Iron is a trace mineral found in several important proteins in
the body, including enzymes, cytochromes, myoglobin, and
hemoglobindthe latter playing a critical role in the transport
of oxygen to tissues.65 Dietary iron is found as either heme
(contained within a porphyrin ring structure) or nonheme
iron.65 Heme iron, the most bioavailable form of dietary iron,
comes from animal products (e.g., meat, fish, and poultry) as
hemoglobin and myoglobin. Nonheme iron primarily comes
from plant foods such as nuts, fruits, vegetables, grains, and
tofu.65 Nonheme iron is less bioavailable than heme sources,
but absorption can be enhanced by consuming it with meat
and/or ascorbic acid (vitamin C).65 The absorption of both
heme and nonheme iron is inhibited by calcium.65 Appendix C
Table 1 summarizes the iron content of some common foods
consumed by Canadian women.
Iron deficiency usually is defined in the following 3 stages: (1)
iron storage depletion (low serum ferritin); (2) early functional iron deficiency or iron deficient erythropoiesis
(reduced transferrin saturation, increased free erythrocyte
protoporphyrin, increased transferrin receptor); and (3) iron
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deficiency anemia (reduced hemoglobin). In Canada, 1 in 10
otherwise healthy premenopausal women have depleted iron
stores (4% also are anemic).66 The RDA for iron for premenopausal women is 18 mg per day, of which only 1.4 mg/
day is absorbed.66 However, the average dietary intake of iron
is only 9 mg per day, placing most women at risk for iron
deficiency.66 Obesity doubles the likelihood of iron deficiency, possibly due to the low-grade inflammation caused by
excessive adiposity.67,68 Iron deficiency (without anemia) has
been shown to cause a reversible reduction in exercise capacity,69 cognitive function,70,71 and energy.72,73 Identification of the cause of the iron deficiency is important to
facilitate iron repletion and to prevent recurrence (i.e., blood
loss vs. poor dietary intake vs. poor absorption). Risk factors
for deficiency include low or no meat intake, low socioeconomic status, subgroups of immigrants from developing
countries,74 Inuit and First Nations women,75 and women
who experience substantial blood loss (e.g., heavy menses,
childbirth, regular blood donor).76 Women who are at high
risk for iron deficiency should be screened by measuring both
hemoglobin and serum ferritin. Clinicians should be aware
that ferritin is an acute-phase reactant and may be elevated in
patients with chronic inflammation or infection. Patients with
an underlying condition that causes iron deficiency should be
treated or referred to a subspecialist as appropriate.77 Iron
therapy should be initiated if ferritin is <30 mg/L and dosage
dependent on the presence of mild (hemoglobin 80 to 120 g/
L) or severe (hemoglobin < 80 g/L) anemia. Women with
iron deficiency (ferritin < 30 mg/L) and severe anemia should
be treated with higher doses of elemental iron.78,79 Oral doses
of elemental iron range from 60 to 300 mg/day, depending
on a number of factors, including the severity of iron deficiency, age of the patient, and patient tolerance.78,79
Recommendation
5. Women who are at high risk for iron deficiency (e.g., low
or no meat intake; low socioeconomic status;
immigrants from developing countries; First Nations,
Inuit, and Métis women; significant blood loss due to
menstruation, child birth) should be screened by
measuring hemoglobin and serum ferritin. If iron
deficiency is identified, oral elemental iron therapy
should be initiated and continued for at least 6 months;
higher doses are required for women with severe anemia.
Iron should be taken with a source of vitamin C. (III-A)
Patients with an underlying condition that causes iron
deficiency or who do not respond to treatment should be
referred for further investigation and management.
Vitamin B12
Vitamin B12 serves as a coenzyme that converts homocysteine to methionine in the body and is involved in the
CHAPTER 2: General Female Nutrition
metabolism of fatty acids and amino acids.80 Vitamin B12
is found in foods of animal origin, including meat, fish,
poultry, milk, and eggs.80 Unless fortified, plants are not
good sources of vitamin B12.80 In Canada some plantbased beverages (e.g., soy, rice, almond beverages) and
soy-based meat alternatives are fortified with vitamin B12;
however, it is important to check food labels because there
is variation in fortification among products and brands.
It is estimated that 5% of Canadians have vitamin B12
deficiency (< 148 pmol/L), which can cause anemia and
neurological abnormalities.81 However, there is some evidence to suggest a higher cut-off should be used for
maximal protection against neural tube defects (< 220
pmol/L).82 The following are risk factors for vitamin B12
deficiency: gastric disorders (atrophic gastritis, gastric
bypass); small bowel disease; and use of metformin, chronic
H2-blockers, or proton pump inhibitors; and vegetarian/
vegan diet. Older age has been associated with vitamin B12
malabsorption and lower vitamin B12 status. Symptoms of
overt deficiency include neurological symptoms and cytopenias with macrocytic or megaloblastic changes. The
metabolism of vitamin B12 and folic acid metabolism are
closely related; very high intakes of folic acid can mask
vitamin B12 deficiency.83 Routine annual testing for vitamin
B12 deficiency of healthy women without symptoms or risk
factors for deficiency is not recommended.84
fortified plant-based beverages (soy, almond, or rice),
calcium-fortified orange juice, dark green vegetables (e.g.,
broccoli, kale, bok choy; 2 to 3 servings required to equal a
serving of dairy), and fish with edible, soft bones (e.g.,
canned salmon or sardines). Appendix C Table 3 provides
a list of good sources of dairy and non-dairy sources of
calcium. It should be noted that the RDA for calcium
varies by age; women over age 50 have an increased calcium requirement (1200 mg/day; see Appendix A, Table 2). Several resources for tracking calcium consumption
exist, including the Calcium Calculator resource by the
International Osteoporosis Foundation86 or Dietitians of
Canada eaTracker.87
National data suggest that many adolescent girls and
women in Canada do not consume the recommended
amounts of calcium in their diet.88 Sufficient calcium
consumption in adolescence and young adulthood ensures
maximum accretion of bone mass, which is achieved between the ages of 16 and 30. After age 30, the amount of
bone broken down exceeds that which is formed. Other
factors influence bone health and the later risk of osteoporosis, including genetics and modifiable risk factors,
such as consuming adequate amounts of vitamin D (see
the following section); smoking cessation; and weight
bearing exercise, such as walking, jogging, and resistance
training.89
Recommendation
Recommendation
6. Routine testing of healthy women without symptoms
or risk factors for vitamin B12 deficiency is not
recommended. Consider supplementary vitamin B12
for women with risk factors for deficiency (e.g.,
vegetarian/vegan diet, over age 50, gastric disorders
such as atrophic gastritis or gastric bypass, small bowel
disease, and regular use of metformin, chronic H2blockers, or proton pump inhibitors). (III-A)
7. Women who are not able to consume the
recommended dietary allowance of calcium in their
diet may benefit from a calcium supplement. (II-2A)
When counselling a woman in the selection of a
calcium supplement, ensure that the supplement
provides an adequate dose of “elemental calcium” and
that the woman understands she needs to look
specifically for this on the label. It is best to take
multiple small doses of calcium as absorption is
inversely related to intake; no more than 500 to 600 mg
of elemental calcium at any one time. (II-2A) Caution
should be used to avoid exceeding the upper limit for
calcium from supplements and diet combined (2500
mg for adult women).
Calcium
Calcium is the most abundant mineral in the human body,
comprising 40% of the total mineral mass.85 Up to 99% of
calcium is found in bones and teeth, with the remaining 1%
located in intracellular and extracellular fluids. As the distribution of this mineral would suggest, it is critically
important for bone and dental health, as well as muscle
function, nerve transmission, and hormone secretion.85
The major sources of calcium in the diet are from milk and
alternatives, such as cheese and yogurt. For example, a
single cup (250 mL) of milk contributes 300 of the 1000
mg of calcium recommended for a woman between 19 and
50 years of age.85 Non-dairy sources of calcium include
Vitamin D
Vitamin D is a fat-soluble vitamin, best known for its role
in facilitating intestinal absorption of calcium and phosphorus, maintaining normal blood levels of these minerals,
and promoting skeletal growth and strong bones.85
Research regarding vitamin D is extremely active at present, including investigation regarding its role in modulation of cell growth, immune function, inflammation, and
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cell proliferation differentiation, and apoptosis as possible
strategies to reduce the risk of chronic diseases, including
multiple sclerosis and some types of cancer.85 Most dietary
sources of vitamin D in Canada come from fortified foods
because few foods contain abundant amounts of this
nutrient naturally. Federal regulation requires that cow’s
milk and margarine be fortified with vitamin D in Canada.
Legislation allows for plant-based beverages such as
almond and soy milk and orange juice to be fortified with
vitamin D, but it is not required; hence careful reading of
food labels is necessary. The only natural sources of
vitamin D in the Canadian diet are fatty fish (e.g., salmon,
mackerel, herring, and sardines), egg yolks, and mushrooms. A major source of vitamin D comes from conversion of 7-dehydrocholesterol in the skin to
cholecalciferol, also called D3. It is estimated that at latitudes above 40 , which would include all of Canada (e.g.,
Toronto at 43 and Edmonton at 53 ), there is reduced
synthesis of cutaneous vitamin D for up to 6 months of
the year.90 Other factors that may influence the synthesis of
vitamin D in the skin include older age, being homebound,
covering the skin when outdoors, skin pigmentation, use of
sunscreen, and pollution. First Nations women, particularly
those who are pregnant, are at high risk of vitamin D
insufficiency.91
Due to concern about the impact of sun exposure and
ultraviolet radiation on the risk of skin cancer, the DRIs for
vitamin D primarily are based on intake from the diet and
supplements, with minimal contribution from cutaneous
synthesis (see Appendix A).85 Research indicates that most
Canadians consume less than the EAR of vitamin D, and
many are at risk of deficiency, particularly in the winter.90
Approximately 37% of Canadians enrolled in the Canadian Health Measures Survey (2007-2011) had serum
25(OH)D concentrations < 50 nmol/L.92 Vitamin D
deficiency can result in increased risk of rickets (in the
young) or osteomalacia (later in life). It generally is agreed
that the best available indicator of vitamin D status is
serum 25(OH)D, which represents the contribution of diet,
supplements, and endogenous synthesis. There is controversy as to what the appropriate cut-off value for serum
25(OH)D should be, and the results are assay dependent.
The U.S. Institute of Medicine suggests that women are at
risk of deficiency at serum 25(OH)D concentrations of
< 30 nmol/L. Some women potentially are at risk for
inadequacy at concentrations between 30 and 50 nmol/L.
Nearly all women are sufficient at concentrations 50
nmol/L. Other expert bodies (e.g., Canadian Paediatric
Society, Osteoporosis Canada) suggest that an appropriate
cut-off for sufficiency should be 75 nmol/L.93,94 Women
with a BMI 30 are more likely to have lower serum
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25(OH)D concentrations, possibly due to changes in
vitamin binding protein affinity or vitamin D receptor
function in the adipocyte.95 Those with inflammatory
bowel disease, who have undergone gastric bypass surgery,
or who have another condition that affects fat absorption
may have lower serum 25(OH)D concentrations due to
impaired absorption of this fat-soluble vitamin. Laboratory
testing is only recommended in higher-risk patients when
results will be used to inform more aggressive therapy (e.g.,
osteoporosis, chronic kidney disease, malabsorption,
obesity with comorbid conditions such as liver disease).
Health Canada recommends that women over age 50
should take a daily vitamin D supplement of 400 IU (see
Chapter 7).96
Recommendations
8. Recommend a vitamin D supplement to all Canadian
women who consume insufficient dietary vitamin D
(I-A), particularly those with decreased cutaneous
synthesis, due to being homebound or having darker
skin pigmentation, or who cover their skin.
9. Screening for vitamin D deficiency by measuring
serum 25(OH)D is not necessary for the general
population but should be carried out in high risk
women such as those with a history of fractures,
malabsorption, renal disease, or using medications
that impact vitamin D or bone metabolism (e.g.,
chronic steroid use, anticonvulsant therapy). (III-A)
Folate
Folate is a water-soluble B vitamin that serves as a coenzyme in the body to transfer single carbons and is therefore
closely tied to deoxyribonucleic acid, ribonucleic acid, and
amino acid biosynthesis. As the universal methyl donor in
the body, it is believed to play an important role in
epigenetic programming and gene expression. Folate is
found naturally in dark, green leafy vegetables and legumes.
In Canada certain grains are fortified with folic acid,
including white wheat flour and enriched cornmeal at 0.15
mg/100 g and enriched pasta at 0.20 mg/100 g.97 Since the
1998 introduction of mandatory white flour, cornmeal, and
enriched pasta fortification with folic acid, folate deficiency
(red blood cell folate concentration < 305 nmol/L) among
otherwise healthy Canadians is uncommon.98 However, at
least 20% of otherwise healthy women of reproductive age
have red blood cell folate concentrations below levels
believed to be maximally protective against a NTD (906 to
1000 nmol/L).98e100 Folic acid supplement use is the most
significant predictor of folate concentrations in Canadian
women of childbearing age,101,102 and the prevalence of
RBC folate < 906 nmol/L in women who do not consume
a supplement is approximately 24%.103
CHAPTER 2: General Female Nutrition
A new SOGC guideline on pre-conception folic acid/
multivitamin supplementation for the primary and secondary prevention of NTDs and other folic acidesensitive
congenital anomalies recently was published, reflecting
evidence obtained post-folic acid fortification of the food
supply.104 The guideline recommends that health care
professionals advise all women of reproductive age about
the benefits of folic acid in a multivitamin supplement
during routine visits. More detail regarding this guideline
can be found in Chapter 4. Women who adhere to a strict
gluten-free diet may not consume substantial amounts of
folic acid through fortified foods because cornmeal is the
only gluten-free folic acidefortified food.105 This may be
of particular relevance to women who are at risk for unplanned pregnancy and not consuming a folic acide
containing supplement. In Canada, whole wheat flour is
not fortified with folic acid, though it does contain
endogenous folate. Extending the current folic acid fortification strategy in Canada to whole wheat flour may
benefit those adhering to a dietary guidance associated with
optimal health (e.g., more whole grains and less refined
flour).106
Recommendation
10. During routine visits, advise all women of
reproductive age about the benefits of adequate
intake of folate from foods (e.g., dark green, leafy
vegetables and legumes) and folic acid in a
multivitamin supplement. (I-A)
SPECIAL CONSIDERATIONS
Vegetarian Diets
Even though recent Canadian data are not available, it is
believed that a signicant number of Canadian adolescents
and women are following vegetarian diets. Based on dietary
recall data from the 1999-2004 National Health and
Nutrition Examination Survey, it was estimated that 7.5%
of American women consume a vegetarian diet.107 A
vegetarian may exclude all red meat, poultry, and fish and
consume dairy products and eggs (lacto-ovo vegetarian),
exclude red meat and poultry but consume fish (semivegetarian), or exclude all animal products including dairy
and eggs (vegan). The reasons for following a vegetarian
diet also vary, including religious reasons, concerns over
animal welfare or environmental sustainability, and others.
Most available evidence suggests that a carefully planned
vegetarian diet can be a healthy one throughout a female’s
lifecycle, including during pregnancy and lactation.108,109 In
fact, individuals who follow a vegetarian diet tend to have
higher intakes of fruits and vegetables, fibre, and
antioxidants and lower caloric and saturated fat intake.
Vegetarians also tend to have lower low-density lipoprotein
cholesterol; rates of hypertension, obesity, and type 2 diabetes; and risk of death from ischemic heart disease than
do non-vegetarians.108
In addition to the nutrients of concern for all women (iron,
calcium, and vitamins B12 and D as previously discussed)
protein, omega-3 fatty acids, and zinc are additional nutrients of concern for vegetarians. Protein is important for
building and maintaining lean body mass, red blood cells,
and important enzymes in the body. Vegetarians should be
aware that because plant proteins do not result in the same
anabolic response as do animal proteins, consumption of
more plant protein than the current RDA may be
required.110 A vegetarian’s protein requirements can be met
through consumption of a variety of plant foods
throughout the course of a day. It is important to consume
complementary proteins; however, these do not need to be
consumed during a single meal.111 Some examples of
plant-based sources of protein include tofu (soy), fortified
soy beverages, textured vegetable protein, soy-based veggie
burgers, beans (e.g., kidney, black, white), peas (e.g.,
chickpeas, black-eyed peas), and lentils. These foods also
contain zinc, a nutrient needed for growth and development and maintenance and strengthening of the immune
system. Vegetarian diets that exclude fatty fish, eggs, or
generous amount of algae are likely to be low in the longchain omega-3 polyunsaturated fatty acids eicosapentaenoic acid and docosahexaenoic acid. Because endogenous
production of eicosapentaenoic acid and DHA from the
precursor fatty acid alpha-linolenic acid is believed to be
inefficient in humans, there is concern that reliance on
alpha-linolenic acid can result in insufficient omega-3 longchain polyunsaturated fatty acids for optimal cardiovascular health and fetal neurodevelopment.112,113
Summary Statement
3. A carefully planned vegetarian diet is healthy
throughout the lifecycle; careful attention to protein is
required. Other nutrients of concern for strict
vegetarians (e.g., vegans) include zinc, iron, vitamin
B12, and omega-3 fatty acids. (II-2)
Eating Disorders
Eating disorders are psychiatric disorders with diagnostic
criteria based on psychological, behavioural, and physiological characteristics. The Diagnostic and Statistical
Manual of Mental Disorders 5th edition, provides diagnostic criteria and guidelines for the identification and
treatment of eating disorders.114 Although there is significant variation in the symptoms and severity of eating
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disorders, 4 categories are recognized: restrictive
(anorexia), bulimic (bulimia nervosa), binge eating disorder,
and others in which all the criteria for anorexia nervosa,
bulimia nervosa, and binge eating disorder are not met,
referred to as “other specified feeding or eating disorder.”114 Anorexia nervosa is characterized by distorted
body image and excessive dieting leading to severe weight
loss with pathological fear of gaining weight. Bulimia
nervosa is characterized by frequent episodes of binge
eating followed by compensatory behaviours such as selfinduced vomiting to avoid weight gain. New to the
DSM-5 is the recognition of binge eating disorder, which is
defined as recurring episodes of eating significantly more
food in a short period than most people would eat under
similar circumstances, with episodes marked by feelings of
lack of control. The DSM-5 is careful to distinguish between binge eating disorder and overeating, which is a
common challenge for many Canadians.114
Although much is unknown, certain risk factors have been
associated with eating disorders, including sex, ethnicity,
early childhood eating and gastrointestinal problems, sexual
abuse and other traumas, substance use, elevated weight
and shape concerns, thin-ideal internalization, body
dissatisfaction, negative self-evaluation, negative affect,
weight loss dieting, and general psychiatric morbidity.115
Prevalence rates for eating disorders generally are higher
in women than men, with anorexia nervosa and bulimia
nervosa affecting women at 10 times the rate of men.115,116
The greatest frequency of anorexia nervosa and bulimia
nervosa occurs during adolescence, and there is an overall
trend of an increasing prevalence of eating disorders at
younger ages.115,117 The highest reported incidence of
anorexia nervosa for females occurs between ages 15 and
19, with the highest reported incidence of bulimia nervosa
occurring in females aged 20 to 24.116 However, evidence
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111. Young VR, Pellett PL. Plant proteins in relation to human protein and
amino acid nutrition. Am J Clin Nutr 1994;59:1203Se12S.
95. Pereira-Santos M, Costa PR, Assis AM, Santos CA, Santos DB. Obesity and
vitamin D deficiency: a systematic review and meta-analysis. Obes Rev
2015;16:341e9.
96. Vitamin D and calcium: updated Dietary Reference Intakes. Ottawa: Health
Canada; 2012.
97. Canada Gazette Part II. Food and drug regulations - amendment SOR/96527, 130:3318e3320, 1996.
98. Colapinto CK, O’Connor DL, Tremblay MS. Folate status of the population
in the Canadian Health Measures Survey. Can Med Assoc J
2011;183:E100e6.
99. Crider K, Devine O, Hao L, Dowling N, Li S, Molloy A, et al. Population
red blood cell folate concentrations for prevention of neural tube defects:
bayesian model. BMJ 2014;349:g4554.
100. Daly L, Kirke P, Molloy A, Weir D, Scott J. Folate levels and neural tube
defects. Implications for prevention. JAMA 1995;274:1698e702.
101. Colapinto C, O’Connor D, Dubois L, Tremblay M. Folic acid supplement
use is the most significant predictor of folate concentrations in Canadian
women of childbearing age. Appl Physiol Nutr Metab 2012;2-12:284e92.
102. Colapinto CK, O’Connor DL, Dubois L, Tremblay MS. Prevalence and
correlates of folic acid supplement use in Canada. Health Rep
2012;23:39e44.
103. Shi Y, De Groh M, MacFarlane AJ. Socio-demographic and lifestyle factors
associated with folate status among non-supplement-consuming Canadian
women of childbearing age. Can J Public Health 2014;105:e166e71.
104. Wilson DR. Pre-conception folic acid and multivitamin supplementation for
the primary and secondary prevention of neural tube defects and other folic
acid-sensitive congenital anomalies. J Obstet Gynaeol Can 2015;37:534e49.
105. Theethira TG, Dennis M, Leffler DA. Nutritional consequences of celiac
disease and the gluten-free diet. Expert Rev Gastroenterol Hepatol
2014;8:123e9.
106. Chan YM, MacFarlane AJ, O’Connor DL. Modeling demonstrates that
folic acid fortification of whole-wheat flour could reduce the prevalence
of folate inadequacy in Canadian whole-wheat consumers. J Nutr 2015;145:
2622e9.
107. Farmer B, Larson BT, Fulgoni 3rd VL, Rainville AJ, Liepa GU. A vegetarian
dietary pattern as a nutrient-dense approach to weight management: an
112. Kris-Etherton PM, Harris WS, Appel LJ. Fish consumption, fish oil,
omega-3 fatty acids, and cardiovascular disease. Circulation
2002;106:2747e57.
113. Koletzko B, Lien E, Agostoni C, Böhles H, Campoy C, Cetin I, et al. The
roles of long-chain polyunsaturated fatty acids in pregnancy, lactation and
infancy: review of current knowledge and consensus recommendations.
J Perinat Med 2008;36:5e14.
114. Feeding and eating disorders (DSM-5). In: American Psychiatric Assocition,
editor. Diagnostic and statistical manual of mental disorders. 5th edition.
Arlington, VA: American Psychiatric Association; 2013.
115. Ozier A, Henry B, The American Dietetic Association. Position of the
American Dietetic Association: nutrition intervention in the treatment of
eating disorders. J Am Diet Assoc 2011;111:1236e41.
116. Micali N, House J. Assessment measures for child and adolescent eating
disorders: a review. Child Adolesc Mental Health 2010;16:122e7.
117. Rosen D. Identification and management of eating disorders in children and
adolescents. Pediatrics 2010;126:1240e53.
118. Seidenfeld M, Rickert V. Impact of anorexia, bulimia and obesity on the
gynecologic health of adolescents. Am Fam Physician 2001;64:445e50.
119. Dotti J. Eating disorders, fertility, and pregnancy: relationships and
complications. J Perinat Neonatal Nurs 2001;15:36e48.
120. Cho I, Blaser MJ. The human microbiome: at the interface of health and
disease. Nat Rev Genet 2012;13:260e70.
121. Ley RE, Bäckhed F, Turnbaugh P, Lozupone CA, Knight RD, Gordon JI.
Obesity alters gut microbial ecology. Proc Natl Acad Sci U S A
2005;102:11070e5.
122. Clemente JC, Ursell LK, Parfrey LW, Knight R. The impact of the gut
microbiota on human health: an integrative view. Cell 2012;148:1258e70.
123. De Filippo C, Cavalieri D, Di Paola M, Ramazzotti M, Poullet JB, Massart S,
et al. Impact of diet in shaping gut microbiota revealed by a comparative
study in children from Europe and rural Africa. Proc Natl Acad Sci U S A
2010;107:14691e6.
124. Simpson HL, Campbell BJ. Review article: dietary fibre-microbiota
interactions. Aliment Pharmacol Ther 2015;42:158e79.
125. Xu Z, Knight R. Dietary effects on human gut microbiome diversity. Br J
Nutr 2015;113:S1e5.
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CHAPTER 3
Adolescent Nutrition
PROMOTION OF HEALTHY NUTRITION
HEALTHY BODY WEIGHT
Adolescence is frequently characterized as a time when
females are nutritionally vulnerable. Energy and nutrient
requirements increase, reflecting a growth surge, the rate of
which peaks about 2 years after puberty begins. At this
time menstruation commences and girls continue to
experience linear growth for 1 to 2 years thereafter,
reaching their adult height around 14 or 15. This occurs at
a time characterized by a greater tendency to skip meals,
increased consumption of meals outside the home,
increased snacking, and an interest in dieting. Special
consideration needs to be given to adolescent females who
are pregnant or who are breastfeeding to ensure their diet
provides sufficient energy and nutrients to meet their own
elevated requirements and those of their fetus or newborn.
As with all females through the lifecycle, it is recommended
that a health care professional calculate the BMI of adolescents as part of routine nutrition screening rather than simply
measuring weight. Unlike for adults, however, the BMI cutoff used to screen for a healthy body weight differs by age.
The BMI should be evaluated against the World Health
Organization Growth Charts for Canada specifically
designed for children aged 2 to 19 years, which are available
at www.whogrowthcharts.ca.5 The Dietitians of Canada
website also provides a BMI calculator, which can be found
at http://www.dietitians.ca/Your-Health/Assess-Yourself/
Assess-Your-BMI/BMI-Children.aspx.6 Once BMI
percentile is calculated, the BMI should be compared against
the weight categories found in Table 2.
Available evidence underscores the importance of
encouraging female adolescents to frequently eat meals
with their family1e4. It has been demonstrated that adolescents who more frequently eat meals with their parents
demonstrate better school performance, are at lower risk
of substance abuse, and are more successful at maintaining
a healthy body weight.1 In addition, meal frequency with
parents is associated with a number of other behaviors
indicative of superior social adjustment, such as decreased
early sexual activity and positive personal view of the
future.2e4
The Canadian Task Force on Preventive Health Care
recently published a new guideline that provides physicians
with direction on growth monitoring and prevention and
management of overweight or obesity in children and
youth in primary care settings.7 Of note, the guideline
recommends that primary care physicians do not routinely
offer structured interventions aimed at preventing overweight and obesity in healthy-weight children and youth.
For children who are overweight or obese, the Canadian
Task Force on Preventive Health Care recommends that
the primary care practitioner offer or provide a referral to
structured behaviour intervention aimed at healthy weight
management but does not recommend either pharmacological or surgical intervention.7
Recommendations
1. Discuss good nutrition and explore and address
potential body image concerns with all adolescent
female patients. Teach adolescents and their parents
about the benefits of a varied diet higher in vegetables,
fruit, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; lower in red or processed meat; and
low in sugar-sweetened beverages and refined grains.
(III-A)
2. Since it is known to produce widespread positive
outcomes, encourage adolescents and their families to
eat meals together. (I-A)
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Table 2. Interpretation of BMI values for adolescent
females
BMI percentile
Weight category
< 3rd percentile
Risk for underweight
3rd to 85th percentile
Healthy weight
85th to 97th percentile
Overweight
97th to 99.9th percentile
Obese
> 99.9th percentile
Severely obese
CHAPTER 3: Adolescent Nutrition
The American Academy of Pediatrics provides additional
guidance, proposing a staged care approach for weight
management of overweight and obese adolescents.8 The
stages include (1) Prevention Plus (healthy lifestyle changes
including consumption of > 5 servings of fruit and vegetables/day, reduction of sugar-sweetened beverages, < 2
hours/day screen time (e.g., watching television, playing on
the internet etc.), > 1 hour/day physical activity); (2) Structured Weight Management (closer monitoring, structured
meals and snacks, 60 minutes/day supervised physical
activity, 1 hour screen time/day; (3) Comprehensive
Multidisciplinary Intervention (weekly visits, involvement of
a multidisciplinary team, and increased intensity of behaviour
change strategies); and (4) Tertiary Care (meal replacement,
very-low energy diet, medication, and surgery).8
Dietary factors and food behaviours associated with
overweight and obesity in adolescents include lower intake
of fruits and vegetables, consumption of excessive quantities of sugar-sweetened beverages, low dietary fibre
intake, skipping breakfast, and greater frequency in eating
out, particularly fried foods.9 Available evidence also suggests that an increase in sedentary activity, particularly
television and other screen time, and an overall decrease in
physical activity contribute to increased obesity in adolescents.10 Physical activities enjoyed during childhood are
often replaced by sedentary behaviours and electronic social networking, which are in turn associated with unhealthy eating behaviours.11 Health care professionals
should be aware that barriers to physical activity may exist
for some adolescent females due to their environment (e.g.,
personal safety walking to and from school).
Summary Statement
1. Adolescence is a key time to continue or initiate obesity
prevention. (III)
Recommendation
3. The weight and height of all adolescents should be
measured and their body mass index calculated using
the World Health Organization Growth Charts which
are for children and youth up to 19 years. (III-A)
NUTRIENTS OF SPECIAL CONCERN
As described in Chapter 2, folate, vitamin B12, iron, calcium, and vitamin D are nutrients of special concern to all
women, including adolescents. Health care professionals
caring for adolescent females are encouraged to review
these nutrients of special concern. Calcium and vitamin D
warrant additional comment in relation to their key role in
skeletal health during adolescence.12 Peak calcium accretion
into bone occurs during adolescence, with approximately
40% of the adult female skeleton accrued in a 4-year period
between 12 and 16 years of age.13 Current available evidence suggests that low calcium intake during childhood
and adolescence may be an important risk factor for fractures both during that period and later in life.13 National
data from the Canadian Community Health Survey indicate
that at least 70% of adolescent girls likely are not meeting
their dietary requirement for calcium.14 Even among girls
who use multivitamins and mineral supplements, 55% of
girls do not meet their calcium requirement.14 Over 90% of
adolescence girls do not meet their vitamin D requirement
from diet alone.14 However, this percentage decreased to
36% among supplement users.14 Blood values from the
Canadian Health Measures Survey suggest that 20% of
adolescent girls have plasma vitamin D levels below a cutoff consistent with optimal bone health (40 nmol/L).15,16
Consuming the recommended amount of calcium (1300
mg/day from 9 to 18 years of age) and vitamin D (600 IU/
day) in adolescence and young adulthood ensures
maximum accretion of bone mass, which is achieved between 16 and 30 years of age. After 30, the amount of bone
broken down exceeds that which is formed.
Recommendation
4. To ensure optimal bone development, adolescent
females should be counselled to consume their
Recommended Daily Allowances for calcium (1300
mg/day) and vitamin D (600 IU/day), ideally through
food or, if necessary, through supplementation. (I-A)
SPECIAL CONSIDERATIONS
Feeding and Eating Disorders
As discussed in Chapter 2, the greatest frequency of eating
disorders occurs during adolescence. It is important to
note that the increase in the prevalence of obesity and
diabetes seen in adolescents has resulted in an increased
focus on dieting and weight loss in this population.17
Table 3 outlines factors that have been linked to an
increased risk of weight control behaviours in teenagers.18
In addition to the psychological, social, and physical
complications of eating disorders that are relevant
throughout the lifespan, irreversible complications in adolescents can include growth retardation, loss of dental
enamel from chronic vomiting, structural brain changes,
puberty delay or arrest, and impaired acquisition of peak
bone mass.19 The severity, duration, and timing of an
eating disorder will impact the degree to which an eating
disorder affects the biochemical status of various nutrients
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Table 3. Correlates of dieting and unhealthy weight control behaviours in teenagers
Individual factors
Family factors
Environmental factors
Other factors
Female
Overweight and obesity
Body image dissatisfaction and
distortion
Low self-esteem
Low sense of control over life
Psychiatric symptoms:
depression and anxiety
Vegetarianism
Early puberty
Low family connectedness
Absence of positive role models
Parental dieting
Parental endorsement or
encouragement to diet
Parental criticism of the
adolescent’s weight
Weight-related teasing
Poor involvement in school
Peer group endorsement of
dieting
Involvement in weight-related
sports
Certain chronic illnesses,
especially diabetes
Presence of other risk
behaviours: smoking,
substance abuse, unprotected
sex
Adapted from Canadian Paediatric Society.18
and the clinical consequences of the nutrient deficiency.
Insufficient calories, protein, calcium, and vitamin D are
especially important to identify, given their role in growth
and development and attainment of peak bone mass.20
Patients with eating disorders often suffer from other comorbid psychiatric disorders such as depression, anxiety,
body dysmorphic disorder, and substance abuse.20,21
The American Academy of Pediatrics states that “screening
questions about eating patterns and body image should be
asked of all preteens and adolescents.”17 However, it is
common for patients with eating disorders to hide their
illness, so accurate diagnosis may require information from
parents about behaviours and attitudes. Diagnosis and
assessment of eating disorders in adolescents can require
different approaches than those used in adults due to
different psychological and behavioural presentations. For
example, although BMI may be used to assess proportion
of ideal weight in adults, it is not appropriate for eating
disorder screening in children and adolescents.19 The
feeling of loss of control in relation to binge eating is often
not expressed by children and adolescents, and they often
have difficulty in describing how much food they have
eaten, creating challenges with diagnosis based on previous
DSM criteria.19 However, revisions to the DSM-5 criteria
are more developmentally sensitive and to some extent
have addressed this challenge.22 There are several assessment measures available, most of which were developed
for use with adults with adaptations created for use with
children and adolescents. The Canadian Paediatric Society
recommends the tools detailed in Table 4.23
In addition, The children’s Eating Attitude Test is a 26-item
measure for 9- to 14-year-olds that examines eating and
dieting attitudes and behaviors and is reliability-tested for
children.24 Example questions include, “I am terrified of
being overweight,” “I eat diet foods,” and, “I stay away
from foods with sugar in them.” Children are asked to rate
the frequency of each attitude or behavior on a 6-item
Likert scale, with answers to each question ranging from
“Never” (1) through “Always” (6).
Treatment
Optimal treatment includes early identification of
abnormal eating attitudes and behaviours, or changes in
growth and development. Treatment requires collaboration
among an interdisciplinary team of health professionals,
including nutrition, medical, and mental health specialists
with expertise in child and adolescent eating.25,26 Most
adolescent patients with eating disorders are treated in
outpatient settings. Family-based therapy is a first-line
psychological treatment for adolescents with anorexia
Table 4. Tools to screen for eating disorders in children and adolescents
Time required to
complete
Availability
Additional comments
Parent, patient
5 to 10 minutes,
and 5 minutes
for scoring
Free
Available in
French
Easily accessible. A
standardized, self-report
measure of symptoms and
concerns characteristic of
eating disorders. Does not
detect binge eating disorder.
Physician with
patient
Less than
5 minutes
Free
5-item questionnaire to assess
for core features of anorexia
nervosa and bulimia nervosa.
Screening tool
Age group(s)
Completed by
Eating Attitudes
Test (EAT-26)
Middle to high
school-aged
children and
adolescents
SCOFF Eating
Disorders
Questionnaire
High schoolaged children
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CHAPTER 3: Adolescent Nutrition
nervosa.25,26 Weight restoration, nutritional rehabilitation,
calcium and vitamin D supplementation, and resumption
of spontaneous menses are important goals of treatment.
Treatment goal weight should take into account premorbid
trajectories for height, weight, and BMI; age at pubertal
onset; and current pubertal stage.25,26 Treatment messaging
should focus on health-centered behaviours rather than
weight-centered outcomes.25,26
REFERENCES
1. Berge JM, Wall M, Hsueh TF, Fulkerson JA, Larson N, NeumarkSztainer D. The protective role of family meals for youth obesity: 10-year
longitudinal associations. J Pediatr 2015;166:296e301.
2. Eisenberg M, Neumark-Sztainer D, Fulkerson J, Story M. Family meals and
substance use: is there a long-term protective association? J Adolesc Health
2008;43:151e6.
3. Eisenberg M, Olson RE, Newmark-Sztainer D, Story M, Bearinger L.
Correlations between family meals and psychosocial well-being among
adolescents. Arch Pediatr Adolesc Med 2004;158:792e6.
4. Fulkerson J, Story M, Mellin A, Leffert N, Newmark-Sztainer D, French S.
Family dinner meal frequency and adolescent development: relationships
with developmental assets and high-risk behaviors. J Adolesc Health
2006;39:337e45.
5. Dietitians of Canada. WHO Growth Charts. Available at: www.
whogrowthcharts.ca Accessed on April 28, 2016.
6. Dietitians of Canada. BMI Calculator for Children and Teens. 2014.
Available at: www.whogrowthcharts.ca Accessed on April 28, 2016.
7. Canadian Task Force on Preventive Health Care. Recommendations
for growth monitoring, and prevention and management of
overweight and obesity in children and youth in primary care. CMAJ
2015;187:411e21.
8. Spear B, Barlow S, Ervin C, Ludwig D, Saelens B, Schetzina K, et al.
Recommendations for the treatment of child and adolescent overweight
and obesity. Pediatrics 2007;120:S254e88.
9. Gurnani M, Birken C, Hamilton J. Childhood obesity: Causes,
consequences, and management. Pediatr Clin North Am 2015;62:821e40.
10. Janssen I, Katzmarzyk PT, Boyce WF, King MA, Pickett W. Overweight and
obesity in Canadian adolescents and their associations with dietary habits
and physical activity patterns. J Adolesc Health 2004;35:360e7.
11. Sampasa-Kanyinga H, Chaput JP, Hamilton HA. Associations between the
use of social networking sites and unhealthy eating behaviours and excess
body weight in adolescents. Br J Nutr 2015;114:1941e7.
12. Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D.
Washington, DC: The National Academies Press; 2011.
13. Greer F, Krebs N. Optimizing bone health and calcium intakes of infants,
children and adolescents. Pediatrics 2006;117:578e85.
14. Shakur YA, Tarasuk V, Corey P, O’Connor DL. A comparison of
micronutrient inadequacy and risk of high micronutrient intakes among
Summary Statement
2. The highest prevalence of eating disorders occurs
among female adolescents. (II-2)
Recommendation
5. Be alert to eating patterns and body image of all
preteen and adolescent females. (III-A)
vitamin and mineral supplement users and nonusers in Canada. J Nutr
2012;142:534e40.
15. Taylor CL, Carriquiry AL, Bailey RL, Sempos CT, Yetley EA.
Appropriateness of the probability approach with a nutrient status
biomarker to assess population inadequacy: a study using vitamin D. Am J
Clin Nutr 2013;97:72e8.
16. Whiting S, Langlois K, Vatanparast H, Greene-Finestone L. The vitamin
status of Canadians relative to the 2011 Dietary Reference Intakes: an
examination in children and adults with and without supplement use. Am J
Clin Nutr 2011;94:128e35.
17. Rosen D. Identification and management of eating disorders in children and
adolescents. Pediatrics 2010;126:1240e53.
18. Canadian Paediatric Society. Dieting in Adolescence. 2014. Available at:
http://www.cps.ca/documents/position/dieting-adolescence. Accessed on
August 20, 2015.
19. Micali N, House J. Assessment measures for child and adolescent eating
disorders: a review. Child Adolesc Mental Health 2010;16:122e7.
20. Golden NH, Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J,
et al. Eating disorders in adolescents: position paper of the Society for
Adolescent Medicine. J Adolesc Health 2003;33:496e503.
21. Ozier A, Henry B, The American Dietetic Association. Position of the
American Dietetic Association: Nutrition intervention in the treatment of
eating disorders. J Am Diet Assoc 2011;111:1236e41.
22. Feeding and eating disorders (DSM-5). In: American Psychiatric
Association, editor. Diagnostic and Statistical Manual of Mental
Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association;
2013.
23. Canadian Pediatric Society. Condition-Specific Screening Tools and Rating
Scales. 2014. Available at: http://www.cps.ca/en/tools-outils/conditionspecific-screening-tools-and-rating-scales#eating-disorders. Accessed on
August 20, 2015.
24. Maloney MJ, McGuire JB, Daniels SR. Reliability testing of a children’s
version of the Eating Attitude Test. J Am Acad Child Adolesc Psychiatry
1988;27:541e3.
25. Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES,
Garber AK, et al. Update on the medical management of eating
disorders in adolescents. J Adolesc Health 2015;56:370e5.
26. Society for Adolescent Health and Medicine, Golden NH, Katzman DK,
Sawyer SM, Ornstein RM, Rome ES, et al. Position paper of the Society
for Adolescent Health and Medicine: medical management of restrictive
eating disorders in adolescents and young adults. J Adolesc Health
2015;56:121e5.
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CHAPTER 4
Pre-conceptual Nutrition
PROMOTION OF HEALTHY NUTRITION
It is estimated that approximately one half of pregnancies
in North America are unplanned,1 and thus it is important
that all women of reproductive age maintain good nutrition. If a woman indicates that she is planning a pregnancy,
a basic nutrition screen consisting of a comparison of her
usual intake with CFG and an assessment of her body
weight, as described in Chapter 2, should be conducted. In
addition, the nutrition messages presented in Chapter 2
should be reviewed or reemphasized. Clinicians should
further emphasize the important role of consuming a folic
acidecontaining multivitamin supplement and working
toward achieving a healthy body weight before conception,
if applicable. These 2 issues, in addition to a discussion of
the role of nutrition in fertility, are described in this section.
Summary Statement
1. It is estimated that approximately one half of
pregnancies in North America are unplanned and thus
it is important that all women of reproductive age
maintain good nutrition. (III)
HEALTHY BODY WEIGHT
Canadian data indicate that women with a higher prepregnancy BMI are more likely to gain more weight during
pregnancy than recommended than are women with an
ideal BMI or those who are underweight.2 Furthermore,
younger, less educated, primiparous, and Aboriginal women
tend to gain more weight than recommended during
pregnancy.2 These and other factors in the food environment should not be overlooked in the pre-pregnancy
period because they can hinder or enhance a woman’s ability
to gain an appropriate amount of weight during her
pregnancy.
In Canada, one third of women enter pregnancy with a BMI
25, putting them at increased risk for poor health and
poor pregnancy outcomes, such as gestational diabetes,
Caesarean delivery, and large-for-gestational age more than
4000 to 4500 g) babies.3e8 Recent evidence also indicates a
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potential increased risk of preterm birth in women with a
high pre-pregnancy BMI.9 Difficulties in breastfeeding also
may be encountered by women entering pregnancy with a
BMI 25 due to decreased milk supply related to low
prolactin levels.10 Furthermore, infants born to women with
a high pre-pregnancy BMI are less likely to be breastfed, are
breastfed for a shorter duration, and are more likely to be
overweight as children, compared to infants born to women
with a normal pre-pregnancy BMI.5,11
Although it is estimated that less than 10% of Canadian
women enter pregnancy with a low BMI, this remains a significant concern due to the associated risks for poor health
and poor pregnancy outcomes.4 A pre-pregnancy BMI < 18.5
is linked to preterm birth, small-for-gestational-age babies
([SGA] weight below 10th percentile for gestational age), and
an increased risk of spontaneous miscarriage.5,8 Underweight
women are 1.2 times more likely to have a spontaneous
miscarriage than women with an ideal BMI and have a higher
risk of spontaneous miscarriage than overweight women.12
Women with a low pre-pregnancy BMI may reduce these
risks by gaining the recommended amount of gestational
weight described in Table 6 (see Chapter 5).
It is important to assess for a BMI change between pregnancies, particularly because dieting between pregnancies is
common in our image-conscious society. Previous preterm
birth is a significant risk factor for preterm birth in subsequent
pregnancies.13 If a woman who has had a previous preterm
birth decreases her BMI by 5 kg/m2 between pregnancies, her
risk of another preterm birth is further increased.14
NUTRIENTS OF CONCERN
Folate
The SOGC recently published a revised guideline on the use
of folic acidecontaining multivitamin supplements for the
primary and secondary prevention of NTDs and other folic
acidesensitive congenital anomalies.15 This revision reflects
new data on the folate status of Canadian women post-folic
acid fortification of the food supply. Health professionals
should review this revised folic acid guideline in its entirety.
CHAPTER 4: Pre-conceptual Nutrition
Briefly, the revised guideline recommends that women at low
to moderate personal, family, or health risk for folate-sensitive
NTDs consume a 0.4 to 1 mg folic acid-multivitamin daily, in
addition to a folate-rich diet at least 2 to 3 months before
conception, throughout pregnancy, and during the postpartum period as long as breastfeeding continues. Women at
high risk of bearing offspring with an NTD as a result of
personal NTD history, previous pregnancy affected by a
NTD, or a male partner at high risk for bearing an offspring
with a NTD are advised to consume a folate-rich diet and a
4.0 mg folic acid supplement at least 3 months prior to
conceiving and until 12 weeks gestational age. Thereafter,
daily supplementation should consist of a multivitamin with
0.4 to 1.0 mg folic acid throughout pregnancy and postpartum as long as breastfeeding continues. Routine folate
measurements are not recommended unless there is concern
regarding poor nutrient intake, symptoms of folate deficiency,
or macrocytic anemia.15
Recommendation
1. Follow the 2015 Society of Obstetricians and
Gynaecologists of Canada guideline for the
supplementary use of folic acid by women of
reproductive age. Women of childbearing age should
consume 0.4 mg folic acid in a daily multivitamin for at
least 2 to 3 months prior to pregnancy. Women of
childbearing age at moderate or high risk for bearing an
offspring with a neural tube defect should consume a
1 and 4.0 mg folic acid supplement respectively at least
3 months prior to conceiving and until 12 weeks
gestational age. Thereafter, daily supplementation should
consist of a multivitamin with 0.4 to 1.0 mg folic acid
throughout pregnancy and postpartum as long as
breastfeeding continues. (III-A)
SPECIAL CONSIDERATIONS
Fertility, Weight, and Diet
Good nutrition, healthy lifestyle, a healthy body weight, and
avoidance of substance abuse optimize fertility and improve
general and pre-pregnancy health. Although nutrition and
potential nonpharmacological intervention for patients
desiring pregnancy are key areas of interest, they are unlikely
to alter fertility if the underlying cause is related to permanent
anatomical or structural abnormalities. Pre-pregnancy
adherence to various dietary patterns associated with quality
of the diet (e.g., Mediterranean diet) or a low risk of infertility
has not been associated with a decreased risk of pregnancy
loss.16 However, ovulatory dysfunction related to weight and
energy balance can be mitigated through improvements in
the dietdhowever, it needs to be acknowledged that most
ovulatory dysfunction is due to non-weight related factors.17
Regardless, there should be no undue delay in seeking
medical consultation, particularly when female age is already
a concern, rather than hoping that a specific diet may correct
the problem. Women who are extremely underweight or
overweight frequently have few or no ovulations and as a
result have subfertility and other health issues related to
energy balance and altered hormonal functions.18
When energy demand is high, as in exercise, or energy supply
is insufficient, as in eating disorders, reproduction is suspended in favour of more essential metabolic functions.
Strenuous exercise on a consistent basis can result in low body
weight, low percent fat content, and hormone changes.19 The
energy deficiency associated with eating disorders and strenuous exercise can result in amenorrhea.20,21 Whereas otherwise normal weight women may present with a limited period
of amenorrhea after a crash diet or women with bulimia may
have regular cycles in between binge eating and purging behaviours, grossly underweight women with anorexia nervosa
have amenorrhea in addition to a distorted body image and
other more serious health issues (see Chapter 3).20 The
treatment goal for underweight women experiencing amenorrhea is to balance caloric intake and energy expenditure by
increased caloric intake and/or decreased exercise.
Obesity increases the risk of menstrual abnormalities, reduces the likelihood of conception within 1 year of
cessation of contraception, and increases ovulatory
dysfunction compared with normal weight women.22 A
progressive and statistically significant worsening of in vitro
fertilization outcomes (clinical pregnancy, live birth rate)
occur at higher BMIs.23 There also is a strong association
between obesity, increased androgen levels, impaired
glucose tolerance, irregular menstrual cycles, and infertility
in women with polycystic ovary syndrome.24 It is estimated
that 50% of women with PCOS are obese.25 It is important
to address lifestyle changes in overweight women, focusing
on nutrition and physical activity. Even a small reduction in
weight of 2% to 5% can result in improvements in metabolic and reproductive function and should be the first
treatment.26 Insulin sensitivity and regularity of menstrual
cycles have been shown to be improved by a low glycemic
index diet compared with a conventional diet in women
with PCOS.27 The glycemic index is a scale given to
carbohydrate-containing foods to denote their relative
impact on the rise in blood glucose after ingestion.28 Foods
with a low glycemic index result in less of a diversion of
blood glucose than do high glycemic index foods after
ingestion (see Appendix C, Table 6).
Even though no specific dietary regimen has been proven
to increase fertility (i.e., studied via randomized controlled
trial), a dietary pattern to reduce the risk of ovulatory
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infertility has been proposed from data collected as part of
the Nurses’ Health Study II.29,30 In this study a cohort of
approximately 18,000 registered nurses aged 25 to 42 were
followed-up for 8 years as they tried to become or became
pregnant.29,30 The dietary pattern that was associated with
lower risk of ovulatory disorder infertility was as follows
(numbers in parentheses represent the most favoured
quintile versus the least favored quintile for each diet
category):
Lower intake of trans fat (1.4% vs. 1.7% of calories) with
greater intake of monounsaturated fat (12% vs. 11.6% of
calories)
Lower intake of animal protein (12.8% vs. 15.5% of
calories) with greater vegetable protein intake (5.5% vs.
4.4% of calories)
Higher intake of high-fibre (20 vs. 15.9 g/day) and lowglycemic carbohydrates (53.7 vs. 54.4 g/day)
Greater preference of high-fat dairy products (1.2 vs. 0.6
servings/day)
Higher nonheme iron intake (53.3 vs. 14.5 g/day)
Higher frequency of multivitamin use (0.93 vs. 0.08
tablets/day) and iron supplementation
Overweight women (BMI 25 to 29.9) and women with a
BMI < 20 had a similarly higher risk of ovulatory disorder infertility, whereas obese women (BMI 30) had
more than two-fold greater risk compared with women
with a normal BMI (20 to 24.99).
At a glance, the diet associated with improved fertility reflects a healthful dietary pattern containing low-glycemic
foods and limited intake of nutrients that may increase
insulin resistance such as trans fatty acids. The diet is
consistent with the hypothesis that glucose homeostasis
and insulin sensitivity are important determinants of
ovulatory function and fertility in otherwise healthy
REFERENCES
1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the
United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90e6.
women. In a follow-up study, it was reported that several
vitamins from food sources (thiamin, folate, vitamins C
and E), but not supplements, were related to a reduction in
endometriosis risk.31 The authors concluded that positive
association between food sources and improved fertility
suggests that the protective mechanisms may not be related
to the micronutrients themselves but rather to other
components in the foods rich in these micronutrients. As
in other population-based studies, these data need to be
interpreted with caution because it is unclear whether all
potential known and unknown confounders were
accounted for in the statistical analysis.
Recently, it has become popular for some couples to take
antioxidants (e.g., coenzyme Q10) to improve their fertility
potential. Antioxidants scavenge free radicals and reduce
reactive oxygen species that are detrimental to mitochondrial health (including those of oocytes and sperm).32,33
Most of these studies have been based on animal or
in vitro experiments and still are preclinical, but they
warrant further research to better define the benefits of
taking antioxidants in enhancing fertility.
Recommendations
2. Promote increased dietary intake for women who are
ovulating abnormally due to underweight by
encouraging increased meal frequency and size, and
avoidance of fasting, meal-skipping, and excessive
exercise. (II-3A)
3. Provide a weight-management strategy for women
who are ovulating abnormally due to overweight by
recommending strategies such as appropriate dietary
adjustments, increased physical activity, and reduced
sedentary behaviour. (II-2A)
4. Recommend a low glycemic index diet to overweight
women with polycystic ovary syndrome to improve
insulin sensitivity and fertility. (I-A)
6. Tjepkema M. Measured obesity. Adult obesity in Canada: measured height
and weight. 2005. Available at: http://aboutmen.ca/application/www.
aboutmen.ca/asset/upload/tiny_mce/page/link/Adult-Obesity-in-Canada.
pdf. Accessed on April 16, 2016.
2. Lowell H, Miller D. Weight gain during pregnancy: adherence to Health
Canada’s Guidelines. Health Rep 2010;21:31e6.
7. Torloni MR, Betrán A, Horta BL, Nakamura MU, Atallah AN, Moron AF,
et al. Prepregnancy BMI and the risk of gestational diabetes: a systematic
review of the literature with meta-analysis. Obes Rev 2009;10:194e203.
3. Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al.
Maternal obesity and risk of caesarean delivery: A meta-analysis. Obes
Rev 2007;8:385e94.
8. Viswanathan M, Siega-Riz AM, Moos MK, Deierlein A, Mumford S, Knaack J,
et al. Outcomes of maternal weight gain [evidence report/technology assessment
No, 168]. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
4. Health Canada. Prenatal Nutrition Guidelines for Health Professionals.
Gestational Weight Gain. 2010. Available at: http://www.hc-sc.gc.ca/fnan/nutrition/prenatal/ewba-mbsa-eng.php. Accessed April 16, 2016.
9. McDonald SD, Han Z, Mulla S, Beyene J. Knowledge Synthesis Group.
Overweight and obesity in mothers and risk of preterm birth and low birth
weight infants: systematic review and meta-analyses. BMJ 2010;341:c3428.
5. Margerison Zilko CE, Rehkopf D, Abrams B. Association of maternal
gestational weight gain with short- and long-term maternal and child
health outcomes. Am J Obstet Gynecol 2010;202:574e8.
10. Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity
diminish the prolactin response to suckling in the first week postpartum.
Pediatrics 2004;113:e465e71.
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CHAPTER 4: Pre-conceptual Nutrition
11. Amir LH, Donath SA. Systematic review of maternal obesity and
breastfeeding intention, initiation and duration. BMC Pregnancy
Childbirth 2007;4:9.
12. Helgstrand S, Andersen AM. Maternal underweight and the risk of
spontaneous abortion. Acta Obstet Gynecol Scand 2005;84:1197e201.
13. Garn JV, Nagulesapillai T, Metcalfe A, Tough S, Kramer MR. International
comparison of common risk factors of preterm birth between the U.S. and
Canada, using PRAMS and MES (2005-2006). Matern Child Health J
2015;19:811e8.
14. Merlino A, Laffineuse L, Collin M, Mercer B. Impact of weight loss between
pregnancies on recurrent preterm birth. Am J Obstet Gynecol
2006;195:818e21.
15. Wilson DR. Pre-conception folic acid and multivitamin supplementation for
the primary and secondary prevention of neural tube defects and other folic
acid-sensitive congenital anomalies. J Obstet Gynaecol Can 2015;37:534e49.
16. Gaskins AJ, Rich-Edwards JW, Hauser R, Williams PL, Gillman MW,
Penzias A, et al. Prepregnancy dietary patterns and risk of pregnancy loss.
Am J Clin Nutr 2014;100:1166e72.
17. Hull M, Glazener C, Kelly N, Conway D, Foster P, Hinton R, et al.
Population study of causes, treatment, and outcome of infertility. BMJ
1985;291:1693e7.
18. Wang JX, Davies M, Norman RJ. Body mass and probability of pregnancy
during assisted reproduction treatment: retrospective study. BMJ
2000;321:1320e1.
19. Orio F, Muscogiuri G, Ascione A, Marciano F, Volpe A, La Sala G, et al.
Effects of physical exercise on the female reproductive system. Minerva
Endocrinol 2013;38:305e19.
20. Mitan LA. Menstrual dysfunction in anorexia nervosa. J Pediatr Adolesc
Gynecol 2004;17:81e5.
21. Williams NI, Leidy HJ, Hill BR, Lieberman JL, Legro RS, De Souza MJ.
Magnitude of daily energy deficit predicts frequency but not severity of
menstrual disturbances associated with exercise and caloric restriction. Am J
Physiol Endocrinol Metab 2015;308:E29e39.
22. Practice Committee of the American Society for Reproductive Medicine. Obesity
and reproduction: a committee opinion. Fertil Steril 2015;104:1116e26.
23. Provost MP, Acharya KS, Acharya CR, Yeh JS, Steward RG, Eaton JL, et al.
Pregnancy outcomes decline with increasing recipient body mass index: an
analysis of 22,317 fresh donor/recipient cycles from the 2008-2010 Society
for Assisted Reproductive Technology Clinic Outcome Reporting System
registry. Fertil Steril 2016;105:364e8.
24. Mortada R, Williams T. Metabolic syndrome: polycystic ovary syndrome.
FP Essent 2015;435:30e42.
25. Gambineri A, Pelusi C, Vicennati V, Pagotto U, Pasquali R. Obesity and the
polycystic ovary syndrome. Int J Obes Relat Metab Disord
2002;26:883e96.
26. Vause TDR, Cheung AP, Sierra S, Claman P, Graham J, Guillemin JA, et al.
Ovulation induction in polycystic ovary syndrome - clinical guideline.
J Obstet Gynaecol Can 2010;32:495e502.
27. Marsh KA, Steinbeck KS, Atkinson FS, Petocz P, Brand-Miller JC. Effect of
a low glycemic index compared with a conventional healthy diet on
polycystic ovary syndrome. Am J Clin Nutr 2010;92:83e92.
28. Canadian Diabetes Association. The Glycemic Index. 2015. Available at:
http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/dietnutrition/the-glycemic-index. Accessed on November 13, 2015.
29. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. A prospective
study of dietary carbohydrate quantity and quality in relation to risk of
ovulatory infertility. Eur J Clin Nutr 2009;63:78e86.
30. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Diet and lifestyle
in the prevention of ovulatory disorder infertility. Obstet Gynecol
2007;110:1050e8.
31. Darling AM, Chavarro JE, Malspeis S, Harris HR, Missmer SA.
A prospective cohort study of vitamins B, C, E, and multivitamin intake
and endometriosis. J Endometr 2013;5:17e26.
32. Bentov Y, Esfandiari N, Burstein E, Casper RF. The use of mitochondrial
nutrients to improve the outcome of infertility in older patients. Fertil Steril
2010;93:272e5.
33. Lenzi A, Sgrò P, Salacone P, Paoli D, Gilio B, Lombardo F, et al. A placebocontrolled double-blind randomized trial of the use of combined l-carnitine
and l-acetyl-carnitine treatment in men with asthenozoospermia. Fertil Steril
2004;81:1578e84.
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CHAPTER 5
Nutrition in Pregnancy
PROMOTION OF HEALTHY NUTRITION
Expectant women should be advised to follow CFG recommendations specifically as they apply to pregnancy.1 In
making food selections from CFG, emphasis should be on
selecting a variety of nutrient-dense foods, as opposed to
energy-dense foods, from all 4 food groups. In addition to
CFG, Health Canada has a web page focused on prenatal
nutrition that is targeted toward health professionals.2
A nutrient-rich, energy-appropriate diet helps to ensure a
woman’s own nutritional requirements are met and facilitates
healthy development of her fetus.3 A growing body of evidence, primarily from animal and human epidemiological
studies, suggests that maternal nutritional intake during
pregnancy may program future energy and nutrient
metabolism and the risk of chronic disease in the offspring
during childhood, early adulthood, and beyond.4e6 To
support the rapid rate of anabolic activity associated with
accretion of maternal tissues (uterus, breasts, blood, extravascular fluids, and maternal fat stores) and development of
the placenta and fetus, requirements for many nutrients are
elevated during pregnancy. As a result, the DRIs for many
nutrients are higher during pregnancy than at other stages of
the lifecycle (see Appendix A). In contrast, the incremental
increase in the amount of energy required to support pregnancy among women with a pre-pregnancy BMI of 18.5 to
25 is modest with no recommended increase in calorie intake
during the first trimester and an incremental increase of only
340 and 450 kcal/day in the second and third trimesters,
respectively (Table 5).7e9 This equates generally to only 2 or
Table 5. Energy and macronutrient dietary intake recommendations for pregnancy for women with a pre-pregnancy BMI
of 18.5 to 25
Nutrients
Recommendation
Energy
First trimester
Estimated energy requirement (EER) for non-pregnant female (i.e., no additional energy required)
Second trimester
EER þ 340 kcal/day
Third trimester
EER þ 450 kcal/day
Protein
10% to 35% energy* þ 1.1 g/kg/day†
Total fat
20% to 35% energy*
Saturated fat
Choose lean meat, milk, and alternatives to help reduce amount of saturated fat in diet
Polyunsaturated fat
n-6
5% to 10% energy (13 g/day [AI])
n-3
0.6% to 1.2% energy (1.4 g/day [AI])
Trans fat
Avoid sources of industrial trans fats8
Carbohydrate
45% to 65% energy*
Fibre
28 g/day (AI†)
Values presented are from the Dietary Reference Intakes.7
Definitions for AMDR and AI can be found in Appendix A.
*Acceptable macronutrient distribution range (AMDR).
†Emerging evidence suggests that protein requirements in pregnancy may fall between 1.22 g/kg/day (early gestation) and 1.52 g/kg/day (late gestation), although
these observations require confirmation.9
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3 additional CFG servings from any food group in the second and third trimesters. Currently there are no energy
requirement guidelines established specifically for women
who enter pregnancy with a BMI > 25 (i.e., in the overweight
or obese BMI categories).
Clinicians should reinforce general nutrition guidance for
all women as described in Chapter 2 and emphasize the
importance of enhancing the nutrient density of foods
consumed during pregnancy. A nutrition screen should be
completed if it was not performed in the pre-conceptual
period (see Chapter 4). Strategies to increase the nutrient
density of foods include choosing lower fat milk and alternatives, selecting lean meat and alternatives prepared
with little or no added fat, choosing meat alternatives more
often (e.g., beans, lentils, and tofu), and satisfying thirst
with water instead of juice or sugar-sweetened beverages.
Other specific examples of food choices and serving sizes
are found in the CFG.1 Women should focus on limiting
foods and beverages that are high in calories, fat, sugar, or
salt or that are not part of the 4 food groups.
Summary Statements
1. High-quality dietary intake and appropriate food
selections are important for all pregnant women, and
can be achieved by following Canada’s Food Guide as
applied to pregnancy. Food selections should
emphasize choosing a variety of nutrient-dense foods
from all 4 food groups, as opposed to energy-dense,
nutrient-poor foods. A nutrient-rich, energy-appropriate diet will help to ensure a woman’s own nutritional
requirements are met and facilitate healthy development of her fetus throughout the pregnancy. (III)
2. The amount of energy required to support pregnancy
(for women with a pre-pregnancy body mass index of
18.5 to 25) is modest, with no recommended increase
in calorie intake during the first trimester and an
increase of only 340 and 450 kcal/day in the second
and third trimesters, respectively. This generally
equates to only 2 to 3 additional Canada’s Food Guide
servings per day from any of the 4 food groups in the
second and third trimesters. (III) Energy requirements
for women with a pre-pregnancy body mass index
above 25 kg/m2 are not well established.
HEALTHY BODY WEIGHT
Maternal body weight is used throughout pregnancy as a
general indicator of the mother’s health and the health of
the developing infant. Historically and still today, Health
Canada’s guidelines for weight gain in pregnancy (gestational weight gain) have been based on those identified by
the Institute of Medicine.10 Previous iterations of GWG
guidelines were constructed with the primary intention of
avoiding low weight gain in pregnancy, reducing rates of low
birth weight, and reducing the number of babies born
SGA.10 The guidelines were updated by the IOM in 2009,
and adopted by Health Canada in 2010. They now align
with the current BMI cut-points, provide guidance about
the lower and upper range of appropriate gestational
weights, and reflect the increasing number of women
entering pregnancy with a high BMI (see Table 6).10e12
Considerable evidence exists supporting the independent
contribution of maternal pre-pregnancy BMI and GWG
to maternal and child health outcomes.13e16 Low prepregnancy BMI (< 18.5 kg/m2) and GWG below the lower
limit of the recommended range are associated with greater
risk of low birth weight, preterm birth, SGA infants, and a
failure to initiate breastfeeding.17,18 Mothers with excessive
GWG also are at increased risk of complications of pregnancy (gestational diabetes, preeclampsia, emergency
Caesarean delivery), preterm birth, having an LGA baby,
and experiencing postpartum weight retention and are more
often less likely to initiate and maintain breastfeeding than
those meeting GWG recommendations.10,11,18e21 Women
with excessive GWG are at a 10% to 40% increased risk of
having a child who is overweight or obese early in life.22e25
Mothers who have exceeded GWG recommendations may
then enter subsequent pregnancies at a higher body weight
and be at further risk for complications of pregnancy.22e24
Average GWG has increased dramatically over the last 4
decades around the world.26,27 As few as 20% of Canadian
women meet GWG guidelines in some pre-pregnancy BMI
categories, and women with a pre-pregnancy BMI of 25.5
to 29.9 are w3 times more likely to exceed GWG recommendations compared with those with a BMI between
18.5 and 24.9.13,17,21,28 When maternal obesity prior to
Table 6. How much weight should a woman gain during
pregnancy?
Pre-pregnancy BMI
Mean rate of
weight gain in
second and third
trimesters
Recommended total
weight gain
kg/week
kg
lbs
BMI < 18.5
0.5
lb/week
1
12.5 to 18
28 to 40
BMI 18.5 to 24.9
0.4
1
11.5 to 16
25 to 35
BMI 25.0 to 29.9
0.3
0.6
7 to 11.5
15 to 25
BMI 30.0*
0.2
0.5
5 to 9
11 to 20
Based on Rasmussen et al.10; Health Canada11; and Kapadia et al.12
*A lower weight gain for women with a BMI 35 is controversial and should be
undertaken based on clinical judgement and a thorough assessment of the
19,24,30,31
risks and benefits to mother and child.
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
pregnancy is combined with excessive GWG, the risk for
adverse pregnancy outcomes is further increased.
Among Canadian women, those who are younger, primigravida, with less education, who self-identify as Aboriginal, or are living in Atlantic Canada are less likely to gain
within the recommended ranges of GWG.17 Even though
no difference was found in rates of excessive GWG by
household income, a higher percentage of women with low
household income gained less weight than recommended.17 Many of the social determinants of health (e.g.,
inadequate housing, limited economic opportunities, high
food costs, limited food choices) may negatively impact
GWG and should be considered when discussing strategies
to optimize diet, physical activity, and other healthy lifestyle
behaviours during pregnancy.29
Detailed rationale for these updated pregnancy weight gain
guidelines can be downloaded from the U.S. National Academy
of Pediatrics at www.nap.edu/catalog/12584/weight-gainThe
during-pregnancy-reexamining-the-guidelines.10,11,32
GWG range for women with a healthy pre-pregnancy BMI
(between 18,5 and 24.99 kg/m2) established by these guidelines
is consistent with newly published GWG standards.33
After assessment of a woman’s pre-pregnancy BMI, clinicians should discuss weight gain recommendations for
pregnancy with all women as early in pregnancy and as
regularly as feasible. Appropriate ranges of weight gain
differ between categories of pre-pregnancy BMI, as outlined in Table 6. Encourage women to identify and implement practical, sustainable healthy behaviours to meet
weight gain recommendations10; health behaviours may
need to be modified as pregnancy progresses. If women
have exceeded their target GWG goal before delivery, they
should be encouraged and supported to adopt and maintain
healthy lifestyle behaviours and to follow the recommended
weekly rates of gain until delivery. Despite decreased odds
of LGA, the increased odds of SGA and a lack of information on preterm birth indicate that gestational weight
loss should not be advocated in general for obese women.
Available evidence suggests that when women are made
aware of pregnancy-related weight gain recommendations
early in pregnancy and information and support regarding
healthy eating and physical activity are provided, they are
more likely to achieve the target GWG goals.34e36
Recommendations
1. Measure and discuss weight gain for pregnancy with all
women as early in pregnancy and as regularly as is
feasible. Recommendations for the range of
pregnancy-related weight gain should be based on the
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woman’s pre-pregnancy body mass index (see
Table 6). Gaining weight within recommended ranges
will help to optimize maternal, infant, and child health
outcomes. (III-A)
2. Women who have not met the minimum or have
exceeded the maximum amount of weight gain
recommended for a specific gestational age require
additional follow-up and assessment. They should be
encouraged to increase or slow their rate of weight gain
to fall within the recommended ranges of weekly rate
of gain until delivery. (III-A)
NUTRIENTS OF SPECIAL CONCERN
Recent data suggest that even among relatively affluent
women in Canada, many will not meet their RDA for
several micronutrients during pregnancy, including folate,
vitamin B12, and iron, without a vitamin and mineral
supplement.37e39 As described in Chapter 2, folate,
vitamin B12, iron, calcium, and vitamin D are nutrients of
special concern to all women in Canada, including pregnant women. Folate and iron warrant additional comment
in relation to their key role in pregnancy and life-stage
specific recommendations.40,41 Clinicians also should be
aware of emerging evidence of the importance of omega-3
fatty acids, choline, and iodine in the promotion of a
healthy pregnancy and shortcomings of prenatal supplements commonly used in Canada.
Folate
As described in the Chapter 4, the SOGC has a revised
guideline on the use of folic acidecontaining multivitamin
supplements for the primary and secondary prevention of
NTDs and other folic acid-sensitive congenital anomalies.
Women at low and moderate personal, family, or health risk
for folate-sensitive NTDs are advised to consume a 0.4 and
1 mg folic acidecontaining multivitamin daily, respectively,
in addition to a folate-rich diet at least 2 to 3 months before
conception, throughout pregnancy, and during the postpartum period as long as breastfeeding continues.42 Women
at high risk for an NTD as a result of personal NTD history,
previous pregnancy affected by an NTD, or who have a
male partner at high risk for an NTD are advised to
consume a folate-rich diet and a 4.0 mg folic acid supplement at least 3 months prior to conceiving and until 12
weeks gestational age. Thereafter, daily supplementation
should consist of a multivitamin with 0.4 to 1.0 mg folic acid
throughout pregnancy and postpartum as long as breastfeeding continues.42 Red blood cell folate concentrations
among pregnant Canadian women are frequently much
higher than the level associated with maximal NTD
CHAPTER 5: Nutrition in Pregnancy
protection (906 nmol/L).43e45 Data in animal models
suggest high intakes of supplemental folic acid during
pregnancy may have negative consequences on fetal development.46e49 However, there is no consistent evidence that
high maternal supplemental folic acid intake during pregnancy causes harm in human offspring.50,51 If women are
concerned about high red blood cell folate concentrations, a
safe option is to recommend that they consume a regular
women’s daily multivitamin (i.e., not a prenatal vitamin),
which contains 0.4 mg folic acid. Caution women not to take
more than 1 daily dose of their multivitamin to prevent them
from exceeding the upper limit of other nutrients, such as
vitamin A, which is 3000 mg retinol activity equivalent
(RAE) or 10,000 IU.
Iron
During the second and third trimesters of pregnancy, women
require more iron to support expansion of their red blood cell
mass and accretion of maternal and fetal tissues. The RDA
for iron during pregnancy is 27 mg/day (compared with 15
and 18 mg/day for non-pregnant females 14 to 18 and 19 to
31 years of age, respectively). Most women will have trouble
ingesting this amount of iron from diet alone.37,38
There are a number of negative consequences of suboptimal iron status during pregnancy, which include maternal
anemia, fatigue, decreased work capacity, preterm birth, low
infant birth weight, and increased perinatal mortality.41,52
Meta-analysis of randomized control trials (n ¼ 48) and
cohort studies (n ¼ 44) examining the efficacy of prenatal
iron supplementation reveals positive associations with
maternal hemoglobin concentration and birth weight,
decreased risk of maternal iron deficiency at term, and likely
a reduction in the incidence of low birth weight.53,54 Health
Canada recommends a supplement containing 16 to 20 mg
of elemental iron as effective and safe for pregnant women
who are in good health.2,55 They used a modelling process
to determine the amount of elemental iron as a supplement
required to complement usual iron intakes from mixed diets
without exceeding the Tolerable Upper Level.55 Most
available prenatal supplements in Canada have more than
this amount of iron; however, there is no evidence that this
is unsafe or that higher levels of iron affect adherence to
daily use.56 In fact, the World Health Organization recommends 30 to 60 mg of elemental iron during pregnancy
to reduce the risk of low birth weight and maternal iron
deficiency.57 Temporary discontinuation of iron-containing
prenatal supplements has been shown to improve symptoms in women with severe nausea and vomiting during
pregnancy.58 Intermittent (weekly) iron plus folic acid
supplementation produces similar reductions in iron deficiency as does daily supplementation, with fewer side
effects.59 Health Canada’s guidance does not preclude the
need for therapeutic doses of iron for women demonstrating biochemical evidence of iron deficiency.
Choline
Like folate and vitamin B12, choline also is involved in 1carbon transfer reactions in the body. Metabolites of choline
are required for synthesis of cell membranes (phosphatidylcholine), neurotransmission, and methyl metabolism, functions essential to fetal brain development and tissue
expansion.60 Higher choline intake during the periconceptional period has been associated with a reduction in NTDs.61
The richest sources of dietary choline come from meat and
egg yolk, although choline can be found in a variety of plant
sources in lower concentrations. Insufficient data were available to establish an RDA for choline, and only an adequate
intake value is available (see Appendix A for definitions). Even
though comparing dietary intakes to the adequate intake levels
normally will overestimate the prevalence of true inadequacy,
intakes above this level for choline during pregnancy (450
mg/day) have been associated with improved placental
function and attenuated fetal response to stress.62,63 Available
data would suggest that the majority of pregnant women have
dietary intakes of choline below the adequate intake, and
choline is not a common ingredient of prenatal supplements
that are available in Canada.39,64,65 Therefore, it is recommended that pregnant women be encouraged to consume
choline-rich foods.
Omega-3 Fatty Acids
Omega-3 fatty acids are a group of long-chain polyunsaturated fatty acids with a chemical structure that is
distinctive from other fatty acids. Omega-3 fatty acids support fetal growth and retinal and neurological development.66
As essential nutrients, omega-3 fatty acids must be obtained
from food. N-3 fatty acids are derived from both plant and
animal sources. Alpha-linolenic acid (ALA) is essential in the
diet at 0.6% to 1.2% of energy.7 Dietary sources include
vegetable oils (e.g., canola, flax oil, walnut oil) and nuts and
seeds (e.g., walnut, flax seeds). ALA may be used as an energy
source or converted to other omega-3 fatty acids, including
the long-chain polyunsaturated fatty acid DHA. DHA is
important in neural and visual development in the fetus and
may be conditionally essential because it is unclear whether
sufficient DHA can be converted from ALA to meet the
DHA requirements for pregnancy.67e70 Excellent dietary
sources of DHA include fatty fish (e.g., salmon, rainbow
trout, mackerel) and omega-3 enriched eggs. Given the health
benefits of fish consumption (e.g., important source of protein, low in saturated fat) and evidence that fish consumption
and not using a DHA supplement is best associated with
positive pregnancy outcomes (e.g., gestational length and
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child neurodevelopment), Health Canada advises women to
consume at least 150 g (5 oz) of fish each week.68 As discussed in the section on Unsafe Foods During Pregnancy
later in this chapter, some types of fish contain environmental
contaminants such as methylmercury. Health Canada’s
guidance on which fish should be avoided during pregnancy
can be found at http://www.hc-sc.gc.ca/fn-an/securit/
chem-chim/environ/mercur/cons-adv-etud-eng.php.
Iodine
Iodine is a mineral found in very small quantities in the
body (15 to 20 mg), mostly in the thyroid gland; it’s only
known function is synthesis of thyroid hormone.71 Thyroid hormone plays key roles in enhancing lipolysis and
muscle contraction, promoting bone development,
increasing heart rate, and stimulating nutrient ingestion
and absorption. Iodine has been added to table salt in
Canada for almost 100 years because the iodine content
of foods reflects the iodine content of the soil, and some
areas around the Great Lakes and Rocky Mountains are
low in iodine. Salt used in processed foods, the primary
source of sodium in Canadians diets, does not need to
contain iodine. Sea salts and gourmet salts if marketed in
Canada as table salt or for general household purposes
are required to be iodinated72; however, adherence to
legislation is unknown.
Recent data from the 2009-2011 Canadian Health Measures Survey suggest that there may be an increased
prevalence of low iodine levels based on a single urinary
concentration per participant.73 Given the known variability in these measures, a true measure of the prevalence
of low iodine will require duplicate urinary measures.74
This analysis is being planned as part of Cycle 5 of the
Canadian Health Measures Survey. Low iodine levels could
be attributed, at least in part, to a reduction in the consumption of table salt in response to calls to decrease sodium intake.73 There also is increasing popularity of noniodized salts, including sea salt. Even though there is
insufficient evidence to suggest that there have been
adverse consequences during pregnancy as a result of
changes in table salt consumption, given that the requirement for iodine is elevated in pregnancy, a supplement may
be prudent.41,75 Accumulating evidence in recent times
supports the identification of iodine status of pregnant
women as a public health concern in other Western
countries, for example in the United States,75,76 Australia,77
and Western Europe.78e80 Currently available prenatal
supplements in Canada contain sufficient amounts of
iodine to meet the needs of a pregnant women.
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Recommendations
3. Support women in understanding how to meet
recommendations for specific nutrients of concern
during pregnancy, which include folate, iron, choline,
omega-3 fatty acids, and iodine. (III-A)
4. Follow the 2015 Society of Obstetricians and
Gynaecologists of Canada guideline for the
supplementary use of folic acid by pregnant women.
Pregnant women at low or moderate risk for bearing an
offspring with a neural tube defect should consume 0.4
and 1 mg folic acid, respectively, in a daily multivitamin
or if they are at high risk for bearing offspring with
neural tube defects, a 4.0 mg folic acid supplement 12
weeks prior to and after conception followed by 0.4 to 1
mg until weaning. (II-2A) Caution women not to take
more than 1 daily dose of their multivitamin. (III-B)
5. Recommend a supplement containing 16 to 20 mg of
elemental iron to pregnant women who are in good
health. Therapeutic doses of iron may be required for
women demonstrating biochemical evidence of iron
deficiency. (e.g., a low hemoglobin and a serum ferritin
<30 ug/L at any point during pregnancy). (I-A)
6. Emerging evidence suggests that choline (II-2B),
omega-3 fatty acids (I-A), and iodine (I-B) are
important nutrients that may be limited in the diets
that pregnant women consume. Discuss foods rich in
these nutrients (e.g., eggs for choline; fatty fish and
nuts/seeds for omega-3 fatty acids; saltwater fish low
in methylmercury; and iodized salt) with women as the
pregnancy progresses.
SPECIAL CONSIDERATIONS
Women at High Risk for Poor Nutritional Status
For women with social, economic, or geographic at-risk
circumstances (e.g., low income, low literacy), dietary
advice is associated with improved infant birth weight and
reduced risk of some poor pregnancy outcomes (e.g.,
preterm birth, still birth, SGA infants). The Canada Prenatal Nutrition Program funds community groups to
develop or enhance programs for vulnerable pregnant
women with the aims of reducing the incidence of unhealthy birth weights, improving the health of infants and
mothers, and encouraging breastfeeding. Among its services, CPNP offers dietary counselling to all program
participants. A summative evaluation of CPNP reveals that
the program is relevant for at-risk populations and demonstrates a number of positive effects on personal health
practices and birth outcomes for women with a higher
exposure to the program.81
CHAPTER 5: Nutrition in Pregnancy
Hyperemesis Gravidarum
Nausea and vomiting are common in pregnancy, affecting
70% to 80% of pregnant women.82 Hyperemesis gravidarum is the most severe form of nausea and vomiting of
pregnancy, occurring in about 1% of pregnancies. Hyperemesis gravidarum is defined as persistent vomiting that
leads to a weight loss of greater than 5% of pre-pregnancy
weight with associated electrolyte imbalance and ketonuria.83 The SOGC has a guideline on the management of
nausea and vomiting of pregnancy to which clinicians are
referred for guidance in counselling pregnant women with
nausea and vomiting of pregnancy.84
Unsafe Foods During Pregnancy
Consumption of certain foods and herbs should be limited
or avoided all together during pregnancy. These include
foods potentially contaminated with bacteria or pathogens
(e.g., some processed meats, raw fish, raw eggs, unpasteurized cheeses, sprouts), fish with high levels of methylmercury, and liver. Appendix B includes a comprehensive
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guideline on alcohol consumption during pregnancy.85
Recommendation
7. Emphasize the importance of limiting or avoiding
certain foods during pregnancy (e.g., avoid foods
potentially contaminated with bacteria and fish with
high levels of methylmercury). Many herbs should be
limited or avoided during pregnancy (Appendix B).
(III-A)
8. Follow the 2010 Society of Obstetricians and
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25. Schack-Nielsen L, Michaelsen KF, Gamborg M, Mortensen EL,
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28. Weisman CS, Hillemeier MM, Downs DS, Chuang CH, Dyer AM.
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33. Cheikh Ismail Leila, Bishop Deborah C, Pang Ruyan, Ohuma Eric O,
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36. Harrison CL, Lombard CB, Strauss BJ, Teede HJ. Optimizing healthy
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37. Cooper M, Greene-Finestone L, Lowell H, Levesque J, Robinson S. Iron
sufficiency of Canadians. Health Rep 2012;23:3e10.
38. Cooper MJ, Cockell KA, L’Abbe MR. The iron status of Canadian
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39. Masih SP, Plumptre L, Ly A, Berger H, Lausman AY, Croxford R, et al.
Pregnant Canadian women achieve recommended intakes of one-carbon
nutrients through prenatal supplementation but the supplement
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2015;145:1824e34.
40. Institute of Medicine. Dietary Reference Intakes for thiamin, riboflavin,
niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and
choline. Washington, DC: The National Academies Press; 1998.
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41. Institute of Medicine. Dietary Reference Intakes for vitamin A, vitamin K,
arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum,
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42. Wilson DR. Pre-conception folic acid and multivitamin supplementation for
the primary and secondary prevention of neural tube defects and other folic
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43. Fayyaz F, Wang F, Jacobs RL, O’Connor DL, Bell RC, Field CJ, et al. Folate,
vitamin B12, and vitamin B6 status of a group of high socioeconomic status
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cohort. Appl Physiol Nutr Metab 2014;39:1402e8.
44. Houghton LA, Sherwood KL, Pawlosky R, Ito S, O’Connor DL. [6S]-5Methyltetrahydrofolate is at least as effective as folic acid in preventing a
decline in blood folate concentrations during lactation. Am J Clin Nutr
2006;83:842e50.
45. Plumptre L, Masih SP, Ly A, Aufreiter S, Sohn KJ, Croxford R, et al. High
concentrations of folate and unmetabolized folic acid in a cohort of pregnant
Canadian women and umbilical cord blood. Am J Clin Nutr 2015;102:848e57.
46. Mikael LG, Deng L, Paul L, Selhub J, Rozen R. Moderately high intake of
folic acid has a negative impact on mouse embryonic development. Birth
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folic acid disrupts embryonic development in mice. Birth Defects Res A
Clin Mol Teratol 2011;91:8e19.
48. Keating E, Correia-Branco A, Araujo JR, Meireles M, Fernandes R,
Guardao L, et al. Excess perigestational folic acid exposure induces
metabolic dysfunction in post-natal life. J Endocrinol 2015;224:245e59.
49. Penailillo R, Guajardo A, Llanos M, Hirsch S, Ronco AM. Folic acid
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dehydrogenase 2 in rats. PLoS One 2015;10:e0121098.
50. Dominguez-Salas P, Cox SE, Prentice AM, Hennig BJ, Moore SE. Maternal
nutritional status, C(1) metabolism and offspring DNA methylation: a
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Res 2015;7:538e46.
52. Scholl TO. Iron status during pregnancy: setting the stage for mother and
infant. Am J Clin Nutr 2005;81:1218Se22S.
53. Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW, et al.
Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes:
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54. Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Daily oral iron
supplementation during pregnancy. Cochrane Database Syst Rev
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55. Cockell KA, Miller DC, Lowell H. Application of the Dietary Reference
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56. Nguyen P, Nava-Ocampo A, Levy A, O’Connor DL, Einarson TR,
Taddio A, et al. Effect of iron content on the tolerability of prenatal
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57. World Health Organization. Daily iron and folic acid supplementation during
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58. Gill SK, Maltepe C, Koren G. The effectiveness of discontinuing ironcontaining prenatal multivitamins on reducing the severity of nausea and
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59. Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Intermittent oral iron
supplementation during pregnancy. Cochrane Database Syst Rev
2012;7:CD009997.
CHAPTER 5: Nutrition in Pregnancy
60. Zeisel SH. Choline: critical role during fetal development and dietary
requirements in adults. Annu Rev Nutr 2006;26:229.
food-labelling-for-industry/salt/eng/1391790253201/1391795959629?
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dietary intake of choline and betaine and neural tube defects in offspring.
Am J Epidemiol 2004;160:102e9.
73. Statistics Canada. Iodine Status of Canadians, 2009-2011. 2013. Available at:
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62. Jiang X, Bar HY, Yan J, Jones S, Brannon PM, West AA, et al. A higher
maternal choline intake among third-trimester pregnant women lowers
placental and circulating concentrations of the antiangiogenic factor fms-like
tyrosine kinase-1 (sFLT1). FASEB J 2013;27:1245e53.
74. Zimmermann MB, Andersson M. Assessment of iodine nutrition in
populations: past, present, and future. Nutr Rev 2012;70:553e70.
63. Jiang X, Yan J, West AA, Perry CA, Malysheva OV, Devapatla S, et al.
Maternal choline intake alters the epigenetic state of fetal cortisolregulating genes in humans. FASEB J 2012;26:3563e74.
64. Lewis ED, Subhan FB, Bell RC, McCargar LJ, Curtis JM, Jacobs RL, et al.
Estimation of choline intake from 24 h dietary intake recalls and
contribution of egg and milk consumption to intake among pregnant and
lactating women in Alberta. Br J Nutr 2014;112:112e21.
65. Visentin CE, Masih S, Plumptre L, Malysheva O, Nielsen DE, Sohn KJ,
et al. Maternal choline status, but not fetal genotype, influences cord
plasma choline metabolite concentrations. J Nutr 2015;145:1491e7.
66. Coletta JM, Bell SJ, Roman AS. Omega-3 fatty acids and pregnancy. Rev
Obstet Gynecol 2010;3:163e71.
67. Gould JF, Smithers LG, Makrides M. The effect of maternal omega-3 (n-3)
LCPUFA supplementation during pregnancy on early childhood cognitive
and visual development: a systematic review and meta-analysis of
randomized controlled trials. Am J Clin Nutr 2013;97:531e44.
68. Health Canada. Prenatal Nutrition Guidelines for Health Professionals: Fish
and Omega-3 Fatty Acids. 2009. Available at: http://www.hc-sc.gc.ca/fnan/alt_formats/hpfb-dgpsa/pdf/pubs/omega3-eng.pdf. Accessed on
November 17, 2015.
69. Imhoff-Kunsch B, Briggs V, Goldenberg T, Ramakrishnan U. Effect of n-3
long-chain polyunsaturated fatty acid intake during pregnancy on maternal,
infant, and child health outcomes: a systematic review. Paediatr Perinat
Epidemiol 2012;26(Suppl 1):91e107.
70. Saccone G, Berghella V, Maruotti GM, Sarno L, Martinelli P. Omega-3
supplementation during pregnancy to prevent recurrent intrauterine
growth restriction: systematic review and meta-analysis of randomized
controlled trials. Ultrasound Obstet Gynecol 2015;46:659e64.
71. Swanson CA, Pearce EN. Iodine insufficiency: a global health problem?
Adv Nutr 2013;4:533e5.
72. Canadian Food Inspection Agency. Labelling Requirements for Salt: Iodide
Declaration. 2015. Available at: http://inspection.gc.ca/food/labelling/
75. Caldwell KL, Jones R, Hollowell JG. Urinary iodine concentration: United
States National Health and Nutrition Examination Survey 2001-2002.
Thyroid 2005;15:692e9.
76. Perrine CG, Herrick K, Serdula MK, Sullivan KM. Some subgroups of
reproductive age women in the United States may be at risk for iodine
deficiency. J Nutr 2010;140:1489e94.
77. Charlton KE, Yeatman H, Brock E, Lucas C, Gemming L, Goodfellow A,
et al. Improvement in iodine status of pregnant Australian women 3 years
after introduction of a mandatory iodine fortification programme. Prev
Med 2013;57:26e30.
78. Andersen SL, Sorensen LK, Krejbjerg A, Moller M, Klitbo DM, Nohr SB,
et al. Iodine status in Danish pregnant and breastfeeding women including
studies of some challenges in urinary iodine status evaluation. J Trace Elem
Med Biol 2015;31:285e9.
79. Bath SC, Furmidge-Owen VL, Redman CW, Rayman MP. Gestational changes
in iodine status in a cohort study of pregnant women from the United
Kingdom: season as an effect modifier. Am J Clin Nutr 2015;101:1180e7.
80. Mian C, Vitaliano P, Pozza D, Barollo S, Pitton M, Callegari G, et al. Iodine
status in pregnancy: role of dietary habits and geographical origin. Clin
Endocrinol (Oxf) 2009;70:776e80.
81. Public Health Agency of Canada. Summative Evaluation of the Canada
Prenatal Nutrition Program 2004-2009. 2010. Available at: http://www.
phac-aspc.gc.ca/about_apropos/evaluation/reports-rapports/2009-2010/
cpnp-pcnp/index-eng.php. Accessed on April 16, 2016.
82. Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin
North Am 2011;40:309e34. vii.
83. Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea
and vomiting during pregnancy. Br J Gen Pract 1993;43:245e8.
84. Arsenault MY, Lane CA, MacKinnon CJ, Bartellas E, Cargill YM,
Klein MC, et al. The management of nausea and vomiting of pregnancy.
J Obstet Gynaecol Can 2002;24:817e31. quiz 32e3.
85. Carson G, Cox LV, Crane J, Croteau P, Graves L, Kluka S, et al. Alcohol use
and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can
2010;32:S1e31.
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CHAPTER 6
Postpartum Nutrition and Lactation
PROMOTION OF HEALTHY NUTRITION
Current research indicates that adequate nutrition and
achieving a healthy body weight postpartum can significantly affect short- and long-term health outcomes of both
mother and child.1 Many of these relationships are mediated by the role of postpartum weight retention in the
development of obesity and chronic disease, including
diabetes and cardiovascular disease (discussed later in this
chapter). Postnatal obesity can cause serious obstetrical
problems and fetal complications in subsequent pregnancies.2 Losing weight between pregnancies increases the
likelihood of a successful vaginal birth after Caesarean in
subsequent pregnancies.3
Maternal obesity also is negatively associated with breastfeeding success4 and provision of breast milk. This is an issue
as breastfeeding is known to reduce the risk of acute otitis
media, non-specific gastroenteritis, severe lower respiratory
infection, atopic dermatitis, and obesity in infants.1,5 In
women, breastfeeding history is associated with a reduced
risk of breast and ovarian cancers.1,6 The association of early
cessation of breastfeeding or not breastfeeding with postpartum depression is controversial; an association was reported in one systematic review7 but not in another.6 Even
though a complete understanding of why obese women have
lower rates of breastfeeding is unknown, it has been shown
that obesity is associated with a lower prolactin response to
sucking.8 Prolactin is a hormone produced in the pituitary
gland that plays an important role in mammary gland
development and in breast milk production and nutrient
composition.9,10
As in pregnancy, the elevated nutrient requirement of
lactation can be met by only 2 or 3 additional servings from
any of the 4 food groups in the CFG per day and a
multivitamin supplement containing 0.4 to 1.0 mg folic
acid.11,12 These extra servings will support the modest
increase in energy requirements needed for lactation. If a
woman’s normal dietary intake was very different from
CFG recommendations pre-pregnancy, guidance regarding
the number of servings will need to be modified
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accordingly. The incremental energy requirements of
lactation are based on the amount of energy secreted in
breastmilk (assuming 780 mL/day in the first 6 months
and 610 mL/day thereafter) minus the energy laid down
during pregnancy as adipose (assuming ideal BMI and
appropriate GWG) (see Table 7).13 Women who are
underweight, are nursing multiple infants, or exercise
vigorously may need additional calories.
Table 7. Energy and select macronutrient dietary intake
recommendations for women postpartum
Nutrients
Recommendation
Energy
Non-lactating
Estimated energy requirement
(EER) for non-pregnant female
Lactating
0 to 6 months postpartum
EER þ 330 kcal/day
7 to 12 months postpartum
EER þ 400 kcal/day
Protein
Non-lactating
Lactating
Total fat
10%e35% energy*
þ 0 g/kg/day
þ 1.3 g/kg/day
20% to 35% energy*
n-3 Polyunsaturated fat
Non-lactating
þ0
Lactating
þ 1.3 g/day
Fiber
Non-lactating
þ0
Lactating
14 to 18 years of age
þ 4 g/day† (29 g total, 14 g/1000
kcal)
19 to 20 years of age
þ 4 g/day† (29 g total, 14 g/1000
kcal)
Water
Non-lactating
þ0
Lactating
14 to 18 years of age
þ1.5 L† (3.8 L total)
19 to 20 years of age
þ1.1 L† (3.8 L total)
Values presented are from the Dietary Reference Intakes.13
Definitions for AMDR and AI can be found in Appendix A.
*Acceptable macronutrient distribution range (AMDR).
†Adequate intake.
CHAPTER 6: Postpartum Nutrition and Lactation
Summary Statement
1. Optimal postpartum nutrition can be achieved by
consuming a high-quality and varied diet following
Canada’s Food Guide. The elevated nutritional requirements of breastfeeding women can be met by
consuming 2 to 3 extra servings each day from any of
the 4 groups from Canada’s Food Guide and a
multivitamin supplement, as during pregnancy. These
extra servings will supply the modest increase in energy requirements to support lactation (w 350 to 400
kcal over pre-pregnancy requirements). (III)
Recommendations
1. Emphasize the need for appropriate nutrition to
achieve a healthy body weight postpartum (I-A) and
promote lactation. (II-2B)
2. Discuss the benefits of exclusive breastfeeding for
improving short- and long-term health outcomes for
the mother and infant. (II-2A)
HEALTHY BODY WEIGHT
Counselling
Postpartum weight retention is a significant contributor to the
risk of obesity, with younger, poorer, and less educated
women at the greatest risk.14,15 Women with an elevated prepregnancy BMI and GWG above the recommended range
appear to be at the greatest risk of postpartum weight retention.15,16 In the Danish National Birth Cohort (n ¼ 23 701),
postpartum weight retention at 6 months and weight gain at 6
to 18 months were equally associated with an increase in body
weight and BMI-adjusted waist circumference after 7 years.17
The 6-week postpartum visit with a health care professional is
an important opportunity to engage in a discussion about
postpartum weight retention/reduction, a healthy diet, and
regular exercise.18 The Canadian clinical practice guidelines on
the management and prevention of obesity in adults and
children, reviewed in Chapter 2 in the Weight Loss section,
provide a framework for assessment and stepwise management.19e21 The Canadian Task Force on Preventive Health
Care guidelines specific for growth monitoring and prevention
and management of overweight and obesity in children and
youth as well as the staged approach recommended by the
American Academy of Pediatrics may be more appropriate for
weight management of adolescent mothers.21,22
Weight Loss
Historically, women and their health care providers have
been concerned about the effect of limiting dietary intake
and engaging in exercise postpartum on the volume and
nutrient content of breastmilk.23 There is little evidence
that either breastmilk volume or nutrient content is
adversely affected by gradual postpartum weight loss and
moderate exercise once lactation is established.24,25 Metaanalysis of randomized controlled trials indicates that
diet alone or in combination with exercise is more effective
than exercise alone or usual care (e.g., no diet or exercise)
in helping to lose weight postpartum.26 Lovelady et al.
reported that among overweight postpartum women,
reducing their intake by 500 kcal/day and engaging in
moderate aerobic exercise (walking, jogging, dancing; 65%
to 80% maximum heart rate) 4 days per week was sufficient to promote weight loss of 0.5 kg/week postpartum.27,28 Recent meta-analyses do not support the view
that lactating women are likely to lose more weight postpartum than women who formula feed their infants.29,30
Women with gestational diabetes mellitus (GDM) generally
follow a prescribed diet during pregnancy to avoid medical
complications for mother and infant, but most return to their
usual pre-pregnancy diet after giving birth, despite GDM
putting them at risk for developing type II diabetes.2 One
small study showed that among women with GDM who did
not continue with their pregnancy diet regimen at 9 months
postpartum, 26% experienced impaired glucose tolerance
and 97% experienced at least 1 abnormal lipid value.31
“Interestingly, higher lactation intensity and longer duration were independently associated with lower 2-year incidence of diabetes after GDM pregnancy suggesting lactation
may reduce the risk of diabetes after GDM delivery.32” It is
especially important for women to lose weight between
pregnancies to reduce risk of GDM in future pregnancies.2
Summary Statement
2. Gradual weight loss postpartum to achieve
pre-pregnancy weight and a healthy body weight is
encouraged. There is little evidence that either breastmilk
volume or nutrient content is adversely affected by
gradual postpartum weight loss and exercise. (I)
Recommendation
3. A reduction in caloric intake of 500 kcal/day and
participation in moderate aerobic exercise (walking,
jogging, dancing; 65% to 80% maximum heart rate) 4
days per week should promote a gradual measured
weight loss of 0.5 kg/week postpartum. (I-A)
NUTRIENTS OF SPECIAL CONCERN
Contrary to popular belief, maternal intake and maternal
deficiency of certain nutrients can adversely affect the concentration in breastmilk.33 These nutrients include thiamin,
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
riboflavin, vitamin B6, vitamin B12, choline, vitamin A,
vitamin D, selenium, and iodine.33 Evidence among lactating
women is lacking, but nationally representative data for
Canadian women of reproductive age suggest a low prevalence of inadequate thiamin, riboflavin, and vitamin B6 dietary intakes.34 Selenium deficiency is very rare in North
America.35 Women who are vegetarians or consume very
small amounts of meat may have suboptimal levels of
vitamin B12 and choline (see Chapter 2, Vitamin B12 section, and Chapter 5, Choline section). Even though dietary
data suggest a high prevalence of low intakes of vitamin A
among Canadian women, blood values from the U.S. National Health and Examination Survey suggest a very low
prevalence of suboptimal serum vitamin A concentrations.34,36 Although more research needs to be conducted to
establish the prevalence of low iodine, as discussed in
Chapter 5, Iodine section, there is concern that there may be
an increasing prevalence of iodine deficiency among women
of reproductive age (see Chapter 5, Iodine section).36e39
Vitamin D is found in low concentrations in breastmilk,
even among well-nourished women, and hence breastmilk
is not a reliable source of vitamin D for the infant. As a
result, Health Canada recommends that breastfed infants
be supplemented with 400 IU/day of vitamin D.40 Research
regarding the effect of high-dose maternal vitamin D supplementation during pregnancy and/or lactation on infant
vitamin D status is promising. Two randomized controlled
trials (one a small pilot study) showed that lactating women
who supplement with 6000 to 6400 IU of vitamin D per day
provided their infants with adequate vitamin D (25 OH
vitamin D levels > 50 nmol/L); a prospective, observational randomized follow-up trial (n ¼ 160) showed that
high-dose vitamin D supplementation (35 000 IU per week)
in the third trimester of pregnancy significantly improved
infant vitamin D status in the early neonatal period.41e44
However, given that these high doses of vitamin D are
above the tolerable upper intake level (UL) of 4000 IU/day
for pregnant and lactating women,45 a recommendation in
support of this practice could not be made in the absence of
a formal risk assessment. Interestingly, a new Canadian
randomized controlled trial showed that more than 90% of
infants born to mothers supplemented with 2000 IU/day of
vitamin D from 13 to 24 weeks of pregnancy to 8 weeks
postpartum maintained adequate vitamin D levels.46 This
suggests that a lower dose of supplemental vitamin D
initiated in early pregnancy and continued during lactation
may be an alternative strategy to infant supplementation.
Recommendation
4. Advise lactating mothers to provide their infants with
400 IU of vitamin D per day. (I-A)
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The fatty acid composition of breastmilk and specifically the
omega-3 fatty acid content (e.g., ALA and DHA) also reflect
maternal diet.47 These fatty acids have many important functions in the body, including neural and visual development of
infants. Important dietary sources of omega-3 fatty acids are
reviewed in Chapter 5, Omega-3 Fatty Acids section. A recent
Cochrane review concluded that supplementation of breastfeeding women with DHA did not appear to improve children’s neurodevelopment, visual acuity, or growth.48 Health
Canada advises women to consume at least 150 g (5 oz) of fish
each week; fatty fish are an important source of DHA. As
discussed in the Omega-3 Fatty Acids section of Chapter 5,
some types of fish contain environmental contaminants such
as methylmercury. Health Canada’s guidance on which fish
should be avoided during pregnancy and lactation can be
found at http://www.hc-sc.gc.ca/fn-an/securit/chem-chim/
environ/mercur/cons-adv-etud-eng.php.
Recommendation
5. Women should consume at least 150 g of fish each
week, as fatty fish are an important source of
docosahexaenoic acid. However, lactating women
need to limit consumption of tuna, shark, swordfish,
marlin, orange roughy, and escolar to < 150 g per
month. Lactating women should avoid canned
albacore (white) tuna, but may consume up to 300 g/
week of light canned tuna. (III-A)
SPECIAL CONSIDERATIONS
Lactation
Supporting Exclusive Breastfeeding
Breastfeeding is the normal and unequalled method of
feeding infants.40 Exclusive breastfeeding should be encouraged for the first 6 months and sustained for up to 2 years or
longer with appropriate complementary feeding of infants.
Breastfeeding Resources and Supports:
LaLeche League: www.lllc.ca
Public Health Agency of Canada: http://www.phacaspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhoodenfance_0-2/nutrition/
American Academy of Pediatrics: http://www2.aap.
org/breastfeeding/
Almost 90% of women initiate breastfeeding,49 but only
about 26% of Canadian women exclusively breastfeed to 6
months. Common reasons given for discontinuing breastfeeding before 6 months include “inconvenience,” “fatigue,” and “concerns about milk supply.”50 There is
considerable variation in breastfeeding rates for First Nations, Inuit, and Métis women in Canada, with rates
CHAPTER 6: Postpartum Nutrition and Lactation
generally lower than that of the non-Aboriginal population.51,52 Engaging women with local or online support
may make the difference between the stopping or continuation of breastfeeding. Nurses, midwives, and physicians
can help by offering counselling regarding the infant’s latch,
promoting breastmilk, pumping, and the storage of
expressed breastmilk. La Leche League is a longestablished source for breastfeeding support and information.53 The Public Health Agency of Canada provides
free materials to promote and support breastfeeding,
including “Ten Valuable Tips for Successful
Breastfeeding.”54
Non-nutrititive Components in the Maternal Diet
Affecting Milk Composition
Many women are concerned about the effect of consuming
non-nutritive compounds, including alcohol, and environmental contaminants. A summary of common concerns
can be found in Table 8.55e65
and chocolate have been associated with colic symptoms in exclusively breastfed young infants, but not
allergy formation in the child. Eliminate foods one at a
time to determine association with infant symptoms.
(I-B)
Cultural Considerations
Food is very important in different cultures; it often is
associated with comfort and nurturing, but also can hold
special importance within beliefs around childbirth and
lactation. Studies have shown that there can be marked
changes in food consumption during childbearing that
reflect both modern dietary recommendations and
continuation of traditional meals. This may be more pronounced if there are female relatives close by; therefore,
traditional beliefs should be considered in any dietary interventions offered.66,67
Mental Health
Summary Statement
3. Breastfeeding is the normal and unequalled method of
feeding infants. Exclusive breastfeeding should be
encouraged for the first 6 months and sustained for up
to 2 years or longer, with appropriate complementary
feeding of infants. (I)
Recommendation
6. Maternal intake of allergy and infant colic-associated
foods (dairy, eggs, peanuts, tree nuts, wheat, soy, and
fish) and cruciferous vegetables, cow’s milk, onion,
Women who are anxious or depressed postpartum are not
likely to eat well, which could further negatively influence
their mood.68 Adequate intake of macronutrients (e.g.,
carbohydrates, proteins, and fats) is necessary for mood
stability, specifically, neurotransmission. Decreased intake
of omega-3 fatty acids, iron, folate, and vitamins B2 and B6
is associated with postpartum depression.69 Carbohydrates
provide spikes in energy and can improve mood by producing serotonin, but this is followed by a decrease in serotonin and spikes in insulin levels, which negatively affect
mood.70
Table 8. Components of the maternal diet affecting the breastfed infant
Potential components
Recommendations for breastfeeding women
Allergy-associated foods (dairy, eggs,
peanuts, tree nuts, wheat, soy, and
fish)
Avoidance of high-allergyeassociated foods during lactation does not prevent atopic disease in
infants.55 Reducing the consumption of allergy-associated foods in the maternal diet may provide
some reduction of food allergy symptoms.56 Following a hypoallergenic diet may require support
from a registered dietitian. There is no evidence that the order of food introduction is related to food
allergy.57
Other foods associated with infant
colic
Maternal intake of cruciferous vegetables (cauliflower, cabbage, garden cress, bok choy, broccoli, and
Brussels sprouts), cow’s milk, onion, and chocolate has been associated with colic symptoms in
exclusively breastfed young infants58e60; may eliminate items one at a time to determine whether
one is causing colic symptoms.56,60e62
Mercury
Limit consumption of tuna, shark, swordfish, marlin, orange roughy, escolar to < 150 g per month.
Avoid canned albacore (white) tuna, but may consume up to 300 g/week of light canned tuna.63
Caffeine
Heavy maternal caffeine consumption ( 300 mg/day) does not increase the number of times that
3-month-old infants awaken in the night.64
Some commercially prepared coffees and beverages contain > 300 mg per portion; women should be
advised to pay attention to how much caffeine they are consuming.
Long-term effects of caffeine in breastmilk on the infant are unknown.
Alcohol
Pump and store breastmilk before drinking alcohol, and pump again and discard the milk after at least
2 hours have passed since drinking alcohol.57,65
Alcohol does not improve either the quality or the quantity of breastmilk; may hinder the let-down reflex;
no sleep benefits to the mother or baby; may have long-term effects on the developing child.57,65
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Eating problems, such as bulimia, food preoccupation, and
oral control appear to improve after giving birth.70 If
anorexia, bulimia, and binge eating do continue, they often
are associated with increased risk of postpartum
depression.71
diet, including prunes,75 along with adequate water intake
(see Table 7).72,76 A 2014 Cochrane review found no
studies on the use of laxatives postpartum,77 and a review
of the use of stool softeners found them to be ineffective in
the general population.78
Recommendations
Constipation and Hemorrhoids
Women should have a bowel movement within 3 days
postpartum; however, constipation is a common postpartum problem.72 Postpartum women who are constipated should be reassured and have their diet and fluid
intake assessed.72,73 Bulk-forming laxatives (psyllium or
methylcellulose) are not absorbed by the gut and should
not have negative consequences for the infant.74 Women
with hemorrhoids should be advised to eat a high-fibre
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2011. Available at: https://www.health.qld.gov.au/multicultural/health_
workers/profiles-complete.pdf. Accessed on November 17, 2015.
67. Chen LW, Low YL, Fok D, Han WM, Chong YS, Gluckman P, et al. Dietary
changes during pregnancy and the postpartum period in Singaporean
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Chinese, Malay and Indian women: the GUSTO birth cohort study. Pub
Health Nutr 2014;17:1930e8.
guidance/cg37/evidence/full-guideline-485782237. Accessed on April 17,
2016.
68. Ravindran AV, Lam RW, Filteau MJ, Lesperance F, Kennedy SH, Parikh SV,
et al. Canadian Network for Mood and Anxiety Treatments (CANMAT)
clinical guidelines for the management of major depressive disorder in
adults. V. Complementary and alternative medicine treatments. J Affect
Disord 2009;117(Suppl 1):S54e64.
73. Shin GH, Toto EL, Schey R. Pregnancy and postpartum bowel changes:
constipation and fecal incontinence. Am J Gastroenterol 2015;110:521e9. quiz 30.
69. Price Judge M, Tatano Beck C. Postpartum depression and the role of
nutritional factors. In: Lammi-Keefe CJ, Couch SC, Philipson EH, editors.
Handbook of nutrition and pregnancy. Totowa, NJ: Human Press; 2008.
75. Han YH, Yon MY, Hyun TS. Effect of prune supplementation on dietary
fiber intake and constipation relief. Korean J Community Nutr
2008;13:426e38.
74. Nice FJ, Snyder JL, Kotansky BC. Breastfeeding and over-the-counter
medications. J Hum Lact 2000;16:319e31.
70. von Soest T, Wichstrom L. The impact of becoming a mother on eating
problems. Int J Eat Disord 2008;41:215e23.
76. Derbyshire E, Davies J, Costarelli V, Dettmar P. Diet, physical inactivity and
the prevalence of constipation throughout and after pregnancy. Matern
Child Nutr 2006;2:127e34.
71. Mazzeo SE, Slof-Op’t Landt MC, Jones I, Mitchell K, Kendler KS,
Neale MC, et al. Associations among postpartum depression, eating
disorders, and perfectionism in a population-based sample of adult women.
Int J Eat Disord 2006;39:202e11.
77. Turawa EB, Musekiwa A, Rohwer AC. Interventions for treating
postpartum constipation. Cochrane Database Syst Rev 2014;9:CD010273.
72. National Institute for Health and Clinical Excellence. Routine postnatal care
of women and their babies. 2006. Available at: https://www.nice.org.uk/
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78. Canadian Agency for Drugs and Technologies in Health. Treatments for
Constipation: A Review of Systematic Reviews. 2014. Available at: http://
www.ncbi.nlm.nih.gov/pubmedhealth/PMH0071338/pdf/
PubMedHealth_PMH0071338.pdf. Accessed on November 18, 2015.
CHAPTER 7
Nutrition During Menopause and Beyond
PROMOTION OF HEALTHY NUTRITION
Menopause can create an opportunity for renewed attention to health and diet, or it can bring challenges to good
nutrition; it is an important time to review dietary habits
and make adjustments to lay the foundations for health
and prevent disability in the decades to come. This chapter
builds on the general information provided in Chapter 2,
focusing on the nutritional needs of women entering the
menopausal transition and into the post-menopausal years,
as defined by the STRAW system (Figure).1 This chapter
references evidence from studies of older adults but does
not comprehensively address the needs of elderly women.
The authors suggest it would be beneficial to develop a
guideline to comprehensively address nutritional issues in
this latter subgroup of women.
Figure. The Stages of Reproductive Aging Workshop D 10 staging system for reproductive aging in women. FMP:
final menstrual period; FSH, follicle-stimulating hormone; AMH, anti-mullerian hormone
Reproduced by permission of Harlow et al.1
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Menopause commonly arrives at the same time as changes
in the family. Being an “empty-nester” can lead to changes
in meal preparation and eating routines. Less regular meal
habits, a greater reliance on prepared meals, eating meals
out, and/or eating while watching television2 or otherwise
distracted eating are all factors that can lead to an excess
intake of calories with low nutritional value. Diet also can
be affected by ill health, mood changes, or family and social
stresses. The likelihood of being able to take positive
advantage of menopause is influenced by one’s health and
life experience leading up to menopause. In the Women’s
Health Initiative epidemiological study, the dietary habits of
93,676 women were studied prospectively.3 Women in the
fifth quintile for healthiest dietary choices also rated highest
for reported exercise and lowest for caloric intake and were
found to be psychologically more optimistic.3 They also
were better educated and reported higher incomes. Women
who do not have these advantages may require more
support to be able to adopt healthy nutritional choices.3
Summary Statement
1. Changes in women’s health, social, or family
circumstances at the time of menopause may adversely
impact nutrition (e.g., changes in meal habits,
distracted eating, ill health, mood, family stresses).
(III)
HEALTHY BODY WEIGHT
Weight control consistently emerges as a major concern
among women in/at menopause, and weight gain is typical
at this time. In observational studies of weight gain
throughout the menopausal transition, women gained on
average approximately 2 kg (4.5 lb).4,5
The Role of Hormone Therapy on Weight Gain
The findings of the effect of hormone therapy on weight
gain and body composition are of concern to women; the
results of several large trials and longitudinal studies have
been reviewed6,7 and vary from no effect to beneficial. In
the Danish Osteoporosis Prevention Study, weight gain
was greater in control women (no hormone therapy) than
in women randomly assigned to receive estrogen, as well as
those who self-selected estrogen.8 The difference weight
gained between women receiving estrogen therapy and
those that did not was almost entirely accounted for by
decreased fat accumulation. In a longitudinal Australian
study, women (premenopausal or perimenopausal at
baseline and combination of premenopausal, perimenopausal, postmenopausal at 5-year follow-up) demonstrated
weight gain between baseline and 5-year follow-up, except
for those undergoing estrogen replacement therapy.9 The
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WHI substudy of estrogen plus progestin on weight gain
and body composition found that women randomly
assigned to receive estrogen plus progestin maintained or
gained lean body mass, with less accumulation of body
fat.10 Post-menopausal weight gain is not without consequence. In addition to known risks of cardiovascular disease, diabetes, and hypertension,11 the WHI found that a
5% increase in body weight in women of normal BMI was
associated with an increased relative risk of breast cancer
(hazard ratio 1.36; 95% CI, 1.1 to 1.65).12
Adipose Tissue
Being overweight or obese is a major health issue in older
adults, and the health risks are exacerbated with abdominal
fat deposition, a pattern that is commonly seen after
menopause and strongly related to the risk of coronary heart
disease.13 Central adiposity also is associated with an
increased risk of dementia.14 In a recent multicenter, multiethnic, longitudinal study, 43% of U.S. women who were
obese when they entered menopause progressed from
benign obesity to an at-risk phenotype over 7 years of
observation.15 The increase of visceral adipose tissue began
in the perimenopausal phase, 3 to 4 years before menopause,
and correlated with a decrease in estrogen (estradiol) and an
increase in follicular-stimulating hormone.15 Estrogens influence adipose tissue lipoprotein lipase activity and increase
lipolysis.16 Abdominal fat deposition is increased in response
to chronic stress, through the action of cortisol, but can by
modified by increased fitness. Basal and 24-hour cortisol and
adrenocorticotropic hormone levels rise with age.16
Exercise is an important part of a healthy lifestyle for
women who are overweight and obese; PHAC and Canadian Society for Exercise Physiology recommend 2.5 hours
per week of moderate- to vigorous-intensity exercise for
older adult women.17 After observing a cohort of obese
women for 7 years, the SWAN study found that impaired
glucose tolerance was most predictive of the progression
from a metabolically benign to a high cardiometabolic risk
(e.g., 2 of the following: high blood pressure, elevated
triglycerides, fasting glucose), whereas physical fitness was
the only lifestyle factor that protected women from
progressing to the high cardiometabolic at-risk obese
phenotype.15
Muscle Mass
Accelerated loss of muscle mass and strength occurs in
women around the time of menopause, with a decline of
0.6% to 1% of muscle mass per year post-menopause and
a 21% decline in muscle strength between ages 25 and 55,
occurring at a rate of 1.5% per year. Loss of muscle mass is
aggravated by physical inactivity, low protein intake, and
CHAPTER 7: Nutrition During Menopause and Beyond
cortisol, whereas vitamin D and sex hormones are associated with better maintenance of muscle mass and
strength.18 Loss of muscle strength is a contributor to the
risk of falls and fractures; it can be quantified with standardized measures of strength, such as grip strength, and
with decreased performance on tests of overall strength,
such as the “timed up and go.”19,20 Both of these validated
measures are directly related to an individual’s risk of
disability, fracture, and mortality risk. Studies are conflicting as to whether loss of estrogen or estrogen together with
progesterone is implicated in the accelerated muscle mass
loss observed after menopause, or whether muscle loss is
diminished in women undergoing hormone replacement.18
Physical activity is associated with improved muscle
function.21
Weight Loss
Because energy requirements diminish as age progresses,22
menopausal women need to restrict caloric intake and increase physical activity to maintain body weight. Awareness
of what one is eating and portion control are fundamental
to maintaining a healthy diet and can be facilitated by the
use of mobile apps, which allow contemporaneous
recording and nutritional analysis. Regular exercise has
been found to assist in reducing the likelihood of weight
and waist-circumference gain.23
Weight gain and loss at midlife requires careful attention to
nutritional intake; loss of excess fat may be the goal, but it
is important for women to maintain lean body mass.
Skeletal mass is lost in the years after menopause, and
unless adequate protein is maintained (i.e., 0.8 to 1.2 g/kg/
day, discussed in the following section), weight loss in older
adults can be associated with further loss of muscle mass.
A preoccupation with scale weight may deflect attention
from the more important issue of body composition and
the need to maintain strength. The goal of weight loss
should be to both improve health immediately and to set
the basis for future good health and freedom from
disability.
Recommendations
1. Women are often concerned with perimenopausal
weight gain; advise that weight gain can be reduced by
modest calorie restriction, along with adequate protein
intake (0.8 to 1.2 g/kg divided over 3 meals). (III-B)
2. Insulin resistance increases with age; recommend that
menopausal women consume complex carbohydrates
with a low glycemic index. (II-2B)
3. Recommend regular, weight-bearing exercise to preserve skeletal muscle mass. (I-A)
NUTRIENTS OF SPECIAL CONCERN
Protein
Adequate protein intake is important for maintenance of
muscle mass and strength, as well as for maintenance of
healthy bone mass and prevention of sarcopenia.24,25
Multiple factors have been identified that affect protein
metabolism, including age, obesity, the presence of type 2
diabetes, intercurrent illness, and stress. The current DRI is
0.8 g protein/kg body weight.26 In Canada, CFG recommends 2 servings of meat or meat alternatives daily for an
average adult woman.27 Current recommendations are
based largely on studies that used nitrogen balance-based
methodologies, and whether they should be increased
continues to be debated.24 In considering protein requirements for older adults there is increasing research
supporting the need for a higher protein intake. In Finland,
the Nutritional Guideline for Older People28 is based on a
functional assessment and recommends that “the protein
intake of older people be higher than for younger population groups e at least 1-1.2 g/bodyweight (kg).”
Other recent reports also suggest that 1.2 g/kg/day may
be a more accurate recommendation for older women.29,30
Even though younger adults appear to be able to efficiently
extract protein from a diet with protein skewed toward a
large evening meal, older adults show greater absorption
when presented with protein distributed evenly across 3
meals.31 Distributing the protein evenly over 3 meals, as
opposed to a larger evening meal, has been shown to
improve muscle synthesis by 25% (P < 0.03).31 With
respect to protein sources, CFG recommends at least 2
servings of fish per week, frequent consumption of meat
alternatives such as legumes and tofu, and lean cuts of
meat with little added salt or fat.27
Carbohydrates
Carbohydrate-rich foods are an important source of energy, dietary fibre, vitamins, and minerals. The DRI for
carbohydrate is 130 g/daily, although little research appears
to have been carried out regarding adults over 50. Typical
Western diets can exceed this recommended minimum
intake several fold; the acceptable macronutrient distribution range for carbohydrates, to meet energy, fibre, and
micronutient needs, is 45% to 65% of daily energy intake.26
Insulin resistance tends to increase with age,32 and for any
individual there are many modifying factors, notably genetic predisposition, and other lifestyle factors such as
stress and physical activity. There is growing consensus that
low glycemic-index carbohydrates (see Appendix C,
Table 6) are preferred.33 The appropriate contribution of
carbohydrates to the diet may vary among individuals.
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Calcium
Requirements for calcium increase after menopause; the
current DRI is 1200 mg per day from diet and/or supplements for women over 50.34 Because calcium cannot be
absorbed in large quantities and can cause both hypercalcemia and hypercalciuria,35 it is best provided in multiple,
small doses, or for practicality, as a slow release formulation.
Vitamin D
There is consensus that all adults over 50 should take a
daily vitamin D supplement for bone strength and to
reduce fracture risk, but the recommended amount varies.
The WHI reported a decrease in hip fracture in women
who took 400 IU of vitamin D daily with 1000 mg of
calcium.36 CFG states that all adults over 50 should take a
daily vitamin D supplement of 10 micrograms (400 IU), in
addition to following CFG.27 Osteoporosis Canada also
recommends routine vitamin D supplementation year
round for post-menopausal women over 50, but the recommendations is 800 to 2000 IU daily.37 Considering these
recommendations and the fact that RDA for vitamin D
increases from 600 IU to 800 IU after 70 years of age, the
authors advise a daily intake of 800 IU vitamin D.
Vitamin B12
Low plasma vitamin B12 status in early adulthood likely
reflects low intakes of animal products and/or a vitamin
B12-containing supplement, but suboptimal vitamin B12
status later in life frequently reflects issues of absorption.38
The main cause of vitamin B12 malabsorption later in life
are atrophy of gastric mucosa (secondary to atrophic
gastritis) and a gradual loss of gastric acid, which is
necessary to release the vitamin from food.38,39 As a result,
10% to 30% of adults over 50 may be unable to absorb
naturally occurring vitamin B12.40 In light of this knowledge, the DRI advises that most of vitamin B12 (2.4 mg/
day [RDA]) for adults over 50 be consumed from fortified
foods (e.g., non-dairy milks, meat substitutes) or a vitamin
B12-containing supplement.40
Recommendations
4. To preserve bone health, advise a daily intake of 1200
mg calcium and 800 IU vitamin D to menopausal
women, along with regular moderate- to vigorousintensity physical activity of at least 2.5 hours per week
which includes weight-bearing activity (see Chapter 2
for more detail on calcium supplementation). (I-A)
5. Menopausal women are less likely to absorb naturally
occurring vitamin B12 (II-2A) and should aim to
consume 2.4 mg/day through fortified foods (e.g., nondairy milks, meat substitutes) or supplements, and may
benefit from having their B12 status assessed. (I-A)
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SPECIAL CONSIDERATIONS
Bone Mass
Bone mineral density declines with age, with rapid losses
associated with menopause. In a study of healthy postmenopausal women, multiple nutrients were associated
with increased bone density, notably protein and calcium,
as well as magnesium, zinc, and vitamin C.41 A diet rich in
these nutrients should be accompanied by weight-bearing
exercises, core strength, and resistance training, all of
which are helpful in reducing falls and fractures. Current
recommendations for adults and older women call for at
least 2.5 hours per week of moderate- to vigorous-intensity
exercise.17 There also are specific exercise guidelines provided by Osteoporosis Canada through the BoneFit program and other specialized programs available for at-risk
women.42
Cardiovascular
The rate of CVD increases after menopause; the risk of
myocardial infarction becomes equal to that of men, and
the risk of hypertension is greater than in men. Femalespecific risk factors include hypertensive disorders of
pregnancy, menopause, and the use of hormonal therapies
for contraception and menopausal symptoms.43 Diet can
play a substantial role in mitigating the risk of developing
CVD. The Interheart study identified daily intake of fruits
and vegetables as a preventative factor for CVD.44 In a
recent review relating to the impact of dietary patterns,45 a
consistent benefit of a high-quality diet in reducing allcause mortality, CVD, and cancer was reported. The
healthiest adults (i.e., those with lowest risk of CVD)
consumed a diet rich in fruits and vegetables, plant and
seafood protein, healthy fats, and low-fat dairy; consumed
alcohol in moderation; and had a lower intake of refined
grains, sugars, and salt.45
Cognition
Memory lapses are a common and distressing, but
benign, feature of menopause that does not lead to dementia.46 A recent systematic review of dietary patterns
and risk of dementia (43 trials included) determined that
the Mediterranean diet and higher consumption of unsaturated fatty acids, antioxidants, and B vitamins
decreased the risk of dementia, whereas smoking and
higher consumption of aluminum increased the risk of
dementia.47 Furthermore, low levels of vitamin D were
associated with cognitive decline.47 Because the postmenopausal decline in estrogen can contribute to cognitive and memory impairment, the impact of supplementary soy isoflavones on cognition has been investigated
and deemed to have no effect.48,49
CHAPTER 7: Nutrition During Menopause and Beyond
Food or Supplements as Therapy for Menopausal
Hot Flashes
There has been long-standing interest in the potential of plantbased compounds to moderate hot flashes. A lack of association between dietary phytoestrogens or fibre intake and the
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49. Henderson VW, St John JA, Hodis HN, Kono N, McCleary CA,
Franke AA, et al. Long-term soy isoflavone supplementation and
cognition in women: a randomized, controlled trial. Neurology
2012;78:1841e8.
50. Gold EB, Leung K, Crawford SL, Huang MH, Waetjen LE, Greendale GA.
Phytoestrogen and fiber intakes in relation to incident vasomotor
symptoms: results from the Study of Women’s Health Across the Nation.
Menopause 2013;20:305e14.
51. Lethaby A, Marjoribanks J, Kronenberg F, Roberts H, Eden J, Brown J.
Phytoestrogens for menopausal vasomotor symptoms. Cochrane
Database Syst Rev 2013;12:CD001395.
CHAPTER 7: Nutrition During Menopause and Beyond
APPENDIX A*: DIETARY REFERENCE INTAKES TABLES
*Adapted from: Institute of Medicine. Dietary Reference Intakes Tables and Application. 2015. Available at: http://iom.edu/Activities/Nutrition/
SummaryDRIs/DRI-Tables.aspx.
An estimated average requirement (EAR) is the average daily nutrient intake level estimated to meet the requirements of half of the healthy
individuals in a group.
A recommended dietary allowance (RDA) is the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97% to
98%) healthy individuals in a group. It is calculated from an EAR. If sufficient scientific evidence is not available to establish an EAR, and thus
calculate an RDA, an adequate intake (AI) is usually developed. For healthy infants, an AI is the mean intake of healthy breastfed infants. The AI
for other life stages and sex groups is believed to cover the needs of all healthy individuals in a group for which there is a lack of data to establish
with certainty an EAR or RDA.
A tolerable upper intake level (UL) is the highest level of nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements. In the absence
of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised
not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to
individuals with predisposing conditions that modify their requirements or sensitivity to the nutrient.
JUNE JOGC JUIN 2016
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Table 1. Summary by nutrientdprotein, carbohydrate and vitamins
CHO{
(g/day)
Life stage
EAR
RDA
Protein
(g/kg/day)
Vitamin A* (mg/day)
Vitamin C (mg/day)
Vitamin D
(mg/day#)
EAR
EAR
EAR
EAR
RDA
RDA
UL
RDA
UL
Vitamin E†
(mg/day)
RDA
UL
EAR
RDA
UL
Females
9 to 13 y
100
130
0.76
0.95
420
600
1700
39
45
1200
10
15
100
9
11
600
14 to 18 y
100
130
0.71
0.85
485
700
2800
56
65
1800
10
15
100
12
15
800
19 to 30 y
100
130
0.66
0.80
500
700
3000
60
75
2000
10
15
100
12
15
1000
31 to 50 y
100
130
0.66
0.80
500
700
3000
60
75
2000
10
15
100
12
15
1000
51 to 70 y
100
130
0.66
0.80
500
700
3000
60
75
2000
10
15
100
12
15
1000
> 70 y
100
130
0.66
0.80
500
700
3000
60
75
2000
10
20
100
12
15
1000
14 to 18 y
135
175
0.88
0.88
530
750
2800
66
80
1800
10
15
100
12
15
800
19 to 30 y
135
175
0.88
0.88
550
770
3000
70
85
2000
10
15
100
12
15
1000
31 to 50 y
135
175
0.88
0.88
550
770
3000
70
85
2000
10
15
100
12
15
1000
14 to 18 y
160
210
1.05
1.05
885
1200
2800
96
115
1800
10
15
100
16
19
800
19 to 30 y
160
210
1.05
1.05
900
1300
3000
100
120
2000
10
15
100
16
19
1000
31 to 50 y
160
210
1.05
1.05
900
1300
3000
100
120
2000
10
15
100
16
19
1000
Pregnancy
Lactation
Vitamin K (mg/day)
Life stage
AI
Thiamin (mg/
day)
Riboflavin (mg/
day)
Niacin‡ (mg/day)
EAR
EAR
EAR
RDA
RDA
RDA
Vitamin B6 (mg/day)
UL
EAR
RDA
UL
Females
9 to 13 y
60
0.7
0.9
0.8
0.9
9
12
20
0.8
1
60
14 to 18 y
75
0.9
1
0.9
1
11
14
30
1
1.2
80
19 to 30 y
90
0.9
1.1
0.9
1.1
11
14
35
1.1
1.3
100
31 to 50 y
90
0.9
1.1
0.9
1.1
11
14
35
1.1
1.3
100
51 to 70 y
90
0.9
1.1
0.9
1.1
11
14
35
1.3
1.5
100
> 70 y
90
0.9
1.1
0.9
1.1
11
14
35
1.3
1.5
100
14 to 18 y
75
1.2
1.4
1.2
1.4
14
18
30
1.6
1.9
80
19 to 30 y
90
1.2
1.4
1.2
1.4
14
18
35
1.6
1.9
100
31 to 50 y
90
1.2
1.4
1.2
1.4
14
18
35
1.6
1.9
100
14 to 18 y
75
1.2
1.4
1.3
1.6
13
17
30
1.7
2
80
19 to 30 y
90
1.2
1.4
1.3
1.6
13
17
35
1.7
2
100
31 to 50 y
90
1.2
1.4
1.3
1.6
13
17
35
1.7
2
100
Pregnancy
Lactation
Vitamin B12
(mg/day)
Folate§ (mg/d)
Life stage
EAR
RDA
9 to 13 y
250
300
14 to 18 y
330
400k
19 to 30 y
320
31 to 50 y
UL
Pantothenic acid (mg/day)
Biotin (mg/day)
EAR
RDA
AI
AI
600
1.5
1.8
4
800
2
2.4
5
400k
1000
2
2.4
320
400k
1000
2
51 to 70 y
320
400
1000
> 70 y
320
400
1000
14 to 18 y
520
600k
19 to 30 y
520
600k
31 to 50 y
520
600k
1000
Choline
(mg/day)
AI
UL
20
375
2000
25
400
3000
5
30
425
3500
2.4
5
30
425
3500
2
2.4
5
30
425
3500
2
2.4
5
30
425
3500
800
2.2
2.6
6
30
450
3000
1000
2.2
2.6
6
30
450
3500
2.2
2.6
6
30
450
Females
Pregnancy
3500
Continued
554.e2
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JUNE JOGC JUIN 2016
CHAPTER 7: Nutrition During Menopause and Beyond
Table 1. Continued
Vitamin B12
(mg/day)
Folate§ (mg/d)
Life stage
EAR
RDA
UL
14 to 18 y
450
500
19 to 30 y
450
500
31 to 50 y
450
500
1000
Pantothenic acid (mg/day)
Biotin (mg/day)
EAR
RDA
AI
AI
800
2.4
2.8
7
1000
2.4
2.8
7
2.4
2.8
7
Choline
(mg/day)
AI
UL
35
550
3000
35
550
3500
35
550
3500
Lactation
*As Retinol Activity Equivalents (RAEs): 1 RAE ¼ 1 mg retinol, 12 mg b-carotene, 24 mg a-carotene, or 24 mg b-cryptoxanthin.
†As a-tocopherol, which includes RRR-a-tocopherol, the only form of a-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of a-tocopherol
(RRR-, RSR-, RRS-, and RRS- a-tocopherol) that occur in fortified foods and supplements. Does not include the 2S-stereoisomeric forms of a-tocopherol (SRR-, SSR-,
SRS-, and SSS- a-tocopherol), also found in foods and supplements.
‡As niacin equivalents: 1 mg of niacin ¼ 60 mg of tryptophan. Note the UL for niacin applies to synthetic forms from supplements or fortified foods.
§As dietary folate equivalents: 1 dietary folate equivalent ¼ 1 mg food folate ¼ 0.6 mg of folic acid from fortified food or as a supplement consumed with food ¼ 0.5 mg of
folic acid taken on empty stomach. The UL for folate applies to synthetic folic acid only from supplements and fortified foods.
kIt is recommended the reader refer to the new SOGC guideline on pre-conception folic acid/multivitamin supplementation for the primary and secondary prevention of
NTDs and other folic acidesensitive congenital anomalies, reflecting evidence obtained post-folic acid fortification of the food supply.1
{Digestible.
#1 ug of Vitamin D ¼ 40 IU.
CHO: carbohydrate.
JUNE JOGC JUIN 2016
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Table 2. Summary by nutrientdelements
Boron (mg/day)
Life stage
Chloride
(g/day)
Calcium (mg/day)
Chromium (mg/day)
Fluoride
(mg/day)
Copper (mg/day)
UL
EAR
RDA
UL
AI
UL
AI
EAR
RDA
UL
AI
UL
9 to 13 y
11
1100
1300
3000
2.3
3.4
21
540
700
5000
2
10
14 to 18 y
17
1100
1300
3000
2.3
3.6
24
685
890
8000
3
10
19 to 30 y
20
800
1000
2500
2.3
3.6
25
700
900
10 000
3
10
31 to 50 y
20
800
1000
2500
2.3
3.6
25
700
900
10 000
3
10
51 to 70 y
20
1000
1200
2000
2
3.6
20
700
900
10 000
3
10
> 70 y
20
1000
1200
2000
1.8
3.6
20
700
900
10 000
3
10
14 to 18 y
17
1000
1300
3000
2.3
3.6
29
785
1000
8000
3
10
19 to 30 y
20
800
1000
2500
2.3
3.6
30
800
1000
10 000
3
10
31 to 50 y
20
800
1000
2500
2.3
3.6
30
800
1000
10 000
3
10
14 to 18 y
17
1000
1300
3000
2.3
3.6
44
985
1300
8000
3
10
19 to 30 y
20
800
1000
2500
2.3
3.6
45
1000
1300
10 000
3
10
31 to 50 y
20
800
1000
2500
2.3
3.6
45
1000
1300
10 000
3
10
Females
Pregnancy
Lactation
Iodine (mg/day)
Life stage
Iron† (mg/day)
EAR
RDA
UL
EAR
9 to 13 y
73
120
600
14 to 18 y
95
150
900
19 to 30 y
95
150
31 to 50 y
95
51 to 70 y
95
> 70 y
Manganese
(mg/day)
Magnesium (mg/day)
Molybdenum (mg/day)
RDA
UL
EAR
RDA
UL
AI
UL
EAR
RDA
UL
5.7
8
40
200
240
350
1.6
6
26
34
1100
7.9
15
45
300
360
350
1.6
9
33
43
1700
1100
8.1
18
45
255
310
350
1.8
11
34
45
2000
150
1100
8.1
18
45
265
320
350
1.8
11
34
45
2000
150
1100
5
8
45
265
320
350
1.8
11
34
45
2000
95
150
1100
5
8
45
265
320
350
1.8
11
34
45
2000
14 to 18 y
160
220
900
23
27
45
335
400
350
2
9
40
50
1700
19 to 30 y
160
220
1100
22
27
45
290
350
350
2
11
40
50
2000
31 to 50 y
160
220
1100
22
27
45
300
360
350
2
11
40
50
2000
14 to 18 y
209
290
900
7
10
45
300
360
350
2.6
9
35
50
1700
19 to 30 y
209
290
1100
6.5
9
45
255
310
350
2.6
11
36
50
2000
31 to 50 y
209
290
1100
6.5
9
45
265
320
350
2.6
11
36
50
2000
Females
Pregnancy
Lactation
Nickel (mg/day)
Life stage
Phosphorus (mg/day)
UL
EAR
RDA
UL*
9 to 13 y
0.6
1055
1250
14 to 18 y
1
1055
1250
19 to 30 y
1
580
31 to 50 y
1
51 to 70 y
> 70 y
Potassium (g/day)
Selenium (mg/day)
Sodium
(g/day)
Zinc (mg/day)
AI
EAR
RDA
UL
AI
UL
4
4.5
35
40
280
1.5
2.2
4
4.7
45
55
400
1.5
2.3
700
4
4.7
45
55
400
1.5
580
700
4
4.7
45
55
400
1
580
700
4
4.7
45
55
1
580
700
3
4.7
45
14 to 18 y
1
1055
1250
3.5
4.7
19 to 30 y
1
580
700
3.5
4.7
31 to 50 y
1
580
700
3.5
4.7
EAR
RDA
UL
7
8
23
7.3
9
34
2.3
6.8
8
40
1.5
2.3
6.8
8
40
400
1.3
2.3
6.8
8
40
55
400
1.2
2.3
6.8
8
40
49
60
400
1.5
2.3
10.5
12
34
49
60
400
1.5
2.3
9.5
11
40
49
60
400
1.5
2.3
9.5
11
40
Females
Pregnancy
Continued
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CHAPTER 7: Nutrition During Menopause and Beyond
Table 2. Continued
Nickel (mg/day)
Life stage
Phosphorus (mg/day)
UL
EAR
RDA
UL*
14 to 18 y
1
1055
1250
19 to 30 y
1
580
700
31 to 50 y
1
580
700
4
Potassium (g/day)
Selenium (mg/day)
Sodium
(g/day)
Zinc (mg/day)
AI
EAR
RDA
UL
AI
UL
EAR
RDA
UL
4
5.1
59
70
400
1.5
2.3
10.9
13
34
4
5.1
59
70
400
1.5
2.3
10.4
12
40
5.1
59
70
400
1.5
2.3
10.4
12
40
Lactation
*g/day.
†The requirement for iron is 1.8 times higher for vegetarians.
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Table 3. DRI: Recommended dietary allowances and adequate intakes, total water, and macronutrients
Total water* (L/day) Carbohydrate‡ (g/day) Total fibre (g/day) Linoleic acid (g/day) a-Linolenic acid (g/day) Protein† (g/day)
Life stage
AI
RDA
AI
AI
AI
RDA
9 to 13 y
2.1
130
26
10
1
34
14 to 18 y
2.3
130
26
11
1.1
46
19 to 30 y
2.7
130
25
12
1.1
46
31 to 50 y
2.7
130
25
12
1.1
46
51 to 70 y
2.7
130
21
11
1.1
46
> 70 y
2.7
130
21
11
1.1
46
14 to 18 y
3
175
28
13
1.4
71
19 to 30 y
3
175
28
13
1.4
71
31 to 50 y
3
175
28
13
1.4
71
14 to 18 y
3.8
210
29
13
1.3
71
19 to 30 y
3.8
210
29
13
1.3
71
31 to 50 y
3.8
210
29
13
1.3
71
Females
Pregnancy
Lactation
*Total water includes all water contained in food, beverages, and drinking water.
†Based on g protein per kg of body weight for the reference body weight (e.g., for adults 0.8 g/kg body weight for the reference body weight).
‡Digestible.
REFERENCE
1. Wilson DR. Pre-conception folic acid and multivitamin supplementation for
the primary and secondary prevention of neural tube defects and other folic
acid-sensitive congenital anomalies. J Obstet G Can 2015;37:534e49.
554.e6
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CHAPTER 7: Nutrition During Menopause and Beyond
APPENDIX B: FOODS TO AVOID/LIMIT DURING PREGNANCY
AVOID
Documented adverse effects
Alcohol1
Alcohol consumption during pregnancy may harm the fetus
No amount of alcohol is considered safe during pregnancy
Amino acid supplements2e4
Not recommended due to insufficient information on their safety during pregnancy
Soy protein or isoflavone supplements5,6
A high intake of isoflavones is mildly estrogenic, and these concentrated sources potentially could adversely affect fetal development, although
this has not been studied in pregnancy
Foods potentially contaminated with bacteria7
Raw or unpasteurized dairy products, including pasteurized soft and
semi-soft cheese (e.g., Brie or Camembert) and unpasteurized semi-soft
cheeses (e.g., blue-veined cheese)
Raw or undercooked meats, fish, eggs
Shellfish (oysters, clams)
Raw sprouts
Unpasteurized juices
Herbs4,8e12
Aloe13
Black cohosh14
Blue cohosh15
Buckthorn
Calendula (Marigold)
Chamomile (excessive use)16
Chaste tree (Chasteberry)17,18
Coltsfoot19
Comfrey19,20
Dong quai21
Ephedra22,23
Evening primrose oil24e26
Feverfew
Ginko
Ginseng
Juniper
Kava
Licorice (as an herb)
Labrador tea
Lobelia
Passionflower
Pennyroyal
Sage
Sassafras
Senna
St. John’s wort
Tea tree oil
Thuja
Uva-ursi
almond oil27
AVOID
Insufficient reliable information available to recommend use
Herbs4,28
Burdock29
Fennel30
Hops31
Japanese mint
Lemon balm32,33
Linden
Red bush tea (Rooibos tea)
Valerian
Wild yam
LIMIT
34,35
Fish
No more than 150 g/month:
Fish with higher levels of methylmercury
Fresh/frozen tuna,
Shark
Swordfish
Escolar
Marlin
Orange roughy
150 g/week:
Low mercury cooked fish
Salmon
Trout
Herring
Haddock
Canned, light tuna
Pollock (Boston bluefish)
Sole
Continued
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Appendix B. Continued
300g/week:
Canned (white) albacore tuna
(Does not apply to canned light tuna, which contains other species of tuna that are low in mercury.)
Flounder
Anchovy
Char
Hake
Mullet
Smelt
Atlantic mackerel
Lake white fish
Beef liver36,37
Limit consumption during the first trimester to 1 serving (75g)/week due to high vitamin A content*
Safe to consume in moderation after the first trimester
Caffeine38
Limit caffeine intake to 300 mg/day
w 18 oz (2.25 cups) brewed coffee (135 mg caffeine/8oz)
w 25 oz (3 cups) instant coffee (76 to 106 mg caffeine/8oz)
w 48 oz (6 cups) leaf or bag tea (50 mg caffeine/8oz)
Herbs
Limit consumption to the amount commonly found
in foods or consumed in moderation as herbal
beverages (2 to 3 cups per day)
Herbal supplements (tablets, capsules, or extracts)
are not recommended due to potential adverse
effects
Bitter orange/orange peel39,40
Echinacea41,42
Peppermint43
Red raspberry leaf44e47
Rose hip4
Rosemary4
*RDA of vitamin A is 770 mg (retinol activity equivalent [RAE])/day with a tolerable upper limit of 3000 mg/day. One serving (75 g) of beef liver contains 5800 RAE.
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CHAPTER 7: Nutrition During Menopause and Beyond
REFERENCES
1. Carson G, Vitale Cox L, Crane J, Croteau P, Graves L, Kluka S, et al.
Alcohol use and pregnancy consensus clinical guidelines. J Obstet
Gynaecol Can 2010;32(Suppl 3):S1e31.
2. Kramer MS, Kakuma R. Energy and protein intake in pregnancy. Cochrane
Database Syst Rev 2003;(4):CD000032.
3. Rush D, Stein Z, Susser M. A randomized controlled trial of prenatal
nutritional supplementation in New York City. Pediatrics
1980;65:683e97.
4. Natural Medicines Comprehensive Database. Available by subscription at:
http://naturaldatabase.therapeuticresearch.com/home.aspx?cs¼&s¼ND.
Accessed on April 16, 2016.
5. Early exposure to soy isoflavones and effects on reproductive health:
a review of human and animal studies. Dinsdale EC1, Ward WE.
Nutrients. 2010 Nov;2(11):1156-87. doi:10.3390/nu2111156. Epub 2010
Nov 23.
6. Kurzer MS. Hormonal effects of soy in premenopausal women and men.
J Nutr 2002;132:570Se3S.
7. Government of Canada. Food Safety for Pregnant Women. Available at:
http://healthycanadians.gc.ca/eating-nutrition/healthy-eating-sainealimentation/safety-salubrite/vulnerable-populations/pregnant-enceinteseng.php. Accessed on April 17, 2016.
8. Newall CA, Anderson LA, Philpson JD. Herbal medicine: a guide for
healthcare professionals. London: The Pharmaceutical Press; 1996.
9. McGuffin M, Hobbs C, Upton R, Goldberg A, editors. American Herbal
Products Association’s botanical safety handbook. Boca Raton, FL: CRC
Press, LLC; 1997.
10. Bradley PR, editor. British herbal compendium: a handbook of scientific
information on widely used plant drugs, vol. 2. Bournemouth, UK:
British Herbal Medicine Association; 2006.
11. Health Canada. Nutrition for a healthy pregnancy: national guidelines for
the childbearing years. Ottawa, ON: Minister of Public Works and
Government Services Canada; 1999.
12. Public Health Agency of Canada. The Sensible Guide to a Healthy
Pregnancy. 2011. Available at: http://www.phac-aspc.gc.ca/hp-gs/pdf/
hpguide-eng.pdf. Accessed on April 16, 2016.
13. Mueller SO, Stopper H. Characterization of the genotoxicity of
anthraquinones in mammalian cells. Biochim Biophys Acta
1999;1428:406e14.
14. Dugoua JJ, Seely D, Perri D, Koren G, Mills E. Safety and efficacy of black
cohosh (Cimicifuga racemosa) during pregnancy and lactation. Can J Clin
Pharmacol 2006;13:e257e61.
15. Dugoua JJ, Perri D, Seely D, Mills E, Koren G. Safety and efficacy of blue
cohosh (Caulophyllum thalictroides) during pregnancy and lactation. Can J
Clin Pharmacol 2008;15:e66e73.
16. Jensen-Jarolim E, Reider N, Fritsch R, Breiteneder H. Fatal outcome of
anaphylaxis tocamomile-containing enema during labor: a case study.
J Allergy Clin Immunol 1998;102(6 Pt 1):1041e2.
17. Dugoua JJ, Seely D, Perri D, Koren G, Mills E. Safety and efficacy of
chastetree (Vitex agnuscastus) during pregnancy and lactation. Can J Clin
Pharmacol 2008;15:e74e9.
18. Daniele C, Thompson Coon J, Pittler MH, Ernst E. Vitex agnus castus: a
systematic review of adverse events. Drug Saf 2005;28:319e32.
19. Chojkier M. Hepatic sinusoidal-obstruction syndrome: toxicity of
pyrrolizidine alkaloids. J Hepatol 2003;39:437e46.
20. Stickel F, Seitz HK. The efficacy and safety of comfrey. Public Health Nutr
2000;3:501e8.
21. Shi M, Chang L, He G. Stimulating action of Carthamus tinctorius L.,
Angelica sinensis (Oliv.) Diels and Leonurus sibiricus L. on the
uterus [Article in Chinese] Zhongguo Zhong Yao Za Zhi 1995;20:
173e5. 192.
22. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous
system events associated with dietary supplements containing ephedra
alkaloids. N Engl J Med 2000;343:1833e8.
23. Lee A, Ngan Kee WD, Gin T. A dose-response meta-analysis of
prophylactic intravenous ephedrine for the prevention of hypotension
during spinal anesthesia for elective cesarean delivery. Anesth Analg
2004;98:483e90.
24. Dove D, Johnson P. Oral evening primrose oil: its effect on length of
pregnancy and selected intrapartum outcomes in low-risk nulliparous
women. J Nurse Midwifery 1999;44:320e4.
25. Wedig KE, Whitsett JA. Down the primrose path: petechiae in
a neonate exposed to herbal remedy for parturition. J Pediatr
2008;152:140. 140.e1.
26. Cant A, Shay J, Horrobin DF. The effect of maternal supplementation with
linoleic and gammalinolenic acids on the fat composition and content of
human milk: a placebo-controlled trial. J Nutr Sci Vitaminol (Tokyo)
1991;37:573e9.
27. Facchinetti F, Pedrielli G, Bononi G, Joppi M, Verlato G, Dante G, et al.
Herbal supplements in pregnancy: unexpected results from a multicentre
study. Hum Reprod 2012;27:3161e7.
28. Rosti L, Nardini A, Bettinelli ME, Rosti D. Toxic effects of a herbal tea
mixture in two newborns. Acta Paediatr 1994;83:683.
29. Health Canada. Monograph: Burdock - Oral. 2008. Available at: http://
webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id¼51&lang¼eng.
Accessed on April 17, 2016.
30. Health Canada. Monograph: Fennel, Bitter. 2008. Available at: http://
webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id¼50&lang¼eng.
Accessed on April 17, 2016.
31. Health Canada. Monograph: Hops. 2008. Available at: http://webprod.hcsc.gc.ca/nhpid-bdipsn/monoReq.do?id¼117&lang¼eng. Accessed on
April 16, 2016.
32. European Medicines Agency, Committee on Herbal Medicinal Products.
Community Herbal Monograph on Melissa Officinalis L. Folium. 2013.
Available at: http://www.ema.europa.eu/ema/index.jsp?curl¼pages/
medicines/herbal/medicines/herbal_med_000146.jsp&mid¼WC0b01
ac058001fa1d. Accessed on April 17, 2016.
33. Health Canada. Monograph: Lemon Balm. 2008. Available at: http://
webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id¼125&lang¼eng.
Accessed on April 17, 2016.
34. Health Canada. Mercury in Fish. 2008. Available at: http://www.hc-sc.gc.
ca/fn-an/securit/chem-chim/environ/mercur/cons-adv-etud-eng.php.
Accessed on April 17, 2016.
35. Health Canada. Prenatal Nutrition Guidelines for Health Professionals: Fish
and Omega-3 Fatty Acids. 2009. Available at: http://www.hc-sc.gc.ca/fnan/alt_formats/hpfb-dgpsa/pdf/pubs/omega3-eng.pdf. Accessed on April
17, 2016.
36. Health Canada. Nutrient Value of Some Common Foods. 2008. Available
at: http://www.hc-sc.gc.ca/fn-an/alt_formats/pdf/nutrition/fiche-nutridata/nvscf-vnqau-eng.pdf. Accessed on April 16, 2016.
37. IOM DRI’s Institute of Medicine. Dietary Reference Intakes for vitamin A,
vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese,
molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: The
National Academies Press; 2001.
38. Health Canada. Caffeine in Foods. 2012. Available at: http://www.hc-sc.gc.
ca/fn-an/securit/addit/caf/index-eng.php. Accessed on April 17, 2016.
39. Nykamp DL, Fackih MN, Compton AL. Possible association of acute
lateral-wall myocardial infarction and bitter orange supplement. Ann
Pharmacother 2004;38:812e6.
40. Sultan S, Spector J, Mitchell RM. Ischemic colitis associated with use of a
bitter orange containing dietary weight-loss supplement. Mayo Clin Proc
2006;81:1630e1.
41. Perri D, Dugoua JJ, Mills E, Koren G. Safety and efficacy of echinacea
(Echinacea augustifolia, e. purpurea and e. pallida) during pregnancy and
lactation. Can J Clin Pharmacol 2006;13:e262e7.
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42. Gallo M, Sarkar M, Au W, Pietrzak K, Comas B, Smith M, et al. Pregnancy
outcome following gestational exposure to echinacea: a prospective
controlled study. Arch Intern Med 2000;160:3141e3.
43. Health Canada. Monograph: Peppermint. 2008. Available at: http://
webprod.hc-sc.gc.ca/nhpid-bdipsn/monoReq.do?id=144. Accessed on
April 17, 2016.
44. Mullen W, McGinn J, Lean ME, MacLean MR, Gardner P, Duthie GG,
et al. Ellagitannins, flavonoids, and other phenolics in red raspberries and
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their contribution to antioxidant capacity and vasorelaxation properties.
J Agric Food Chem 2002;50:5191e6.
45. Parsons M, Simpson M, Ponton T. Raspberry leaf and its effects on labour:
safety and efficacy. J Aust Coll Midwives 1999;12:20e5.
46. Simpson M, Parsons M, Greenwood J, Wade K. Raspberry leaf in pregnancy:
its safety and efficacy in labor. J Midwifery Womens Health 2001;46:51e9.
47. Holst L, Haavik S, Nordeng H. Raspberry leafdshould it be recommended
to pregnant women? Complement Ther Clin Pract 2009;15:204e8.
CHAPTER 7: Nutrition During Menopause and Beyond
APPENDIX C: FOOD SOURCES OF NUTRIENTS OF SPECIAL CONCERN AND THE GLYCEMIC INDEX OF
SELECTED FOODS
Table 1. Iron*
Food
Serving size
Iron (mg)
Spinach, cooked
125 mL (1/2 cup)
2.0 to 3.4
Tomato puree
125 mL (1/2 cup)
2.4
Edamame/baby soybeans, cooked
125 mL (1/2 cup)
1.9 to 2.4
Lima beans, cooked
125 mL (1/2 cup)
2.2
Asparagus, raw
6 spears
2.1
Hearts of palm, canned
125 mL (1/2 cup)
Potato, with skin, cooked
1 medium
Snow peas, cooked
125 mL (1/2 cup)
1.7
Turnip or beet greens, cooked
125 mL (1/2 cup)
1.5 to 1.7
Prune juice
125 mL (1/2 cup)
1.6
Apricots, dried
60 mL (1/4 cup)
1.6
Beets, canned
125 mL (1/2 cup)
1.6
Kale, cooked
125 mL (1/2 cup)
1.3
Vegetables and fruits
2.0
1.3 to 1.9
1
Green peas, cooked
125 mL ( /2 cup)
1.3
Tomato sauce
125 mL (1/2 cup)
1.3
Oatmeal, instant, cooked
175 mL (3/4 cup)
4.5 to 6.6
Cream of wheat, all types, cooked
175 mL (3/4 cup)
5.7 to 5.8
Cereal, dry, all types
30 g (check product label for serving size)
4.0 to 4.3
Granola bar, oat, fruits and nut
1 bar (32 g)
1.2 to 2.7
Cracker, soda
6 crackers
1.5 to 2.3
Oat bran cereal, cooked
175 mL (3/4 cup)
Grain products
Pasta, egg noodles, enriched, cooked
2.0
1
125 mL ( /2 cup)
1.3
175 mL (3/4 cup)
2.0
Milk and alternatives
Yogurt, soy
Meats and alternatives
Meat and poultry
Duck, cooked
75 g (21/2 oz)
1.8 to 7.4
Moose or venison, cooked
75 g (21/2 oz)
2.5 to 3.8
Beef, various cuts, cooked
75 g (21/2 oz)
1.4 to 3.3
Ground meat (beef, lamb), cooked
75 g (21/2 oz)
1.3 to 2.2
Lamb, various cuts, cooked
75 g (21/2 oz)
1.3 to 2.1
Chicken, various cuts, cooked
75 g (21/2 oz)
0.4 to 2.0
Pork, various cuts, cooked
75 g (21/2 oz)
0.5 to 1.5
Ground meat (turkey, chicken, pork), cooked
75 g (21/2 oz)
0.8 to 1.2
Organ meats
Liver, pork, cooked†
75 g (21/2 oz)
13.4
Liver (chicken, turkey, lamb), cooked†
75 g (21/2 oz)
6.2 to 9.7
Kidney, lamb, cooked
75 g (21/2 oz)
9.3
Liver, beef, cooked†
75 g (21/2 oz)
4.9
Kidney (beef, veal, pork), cooked
75 g (21/2 oz)
2.3 to 4.4
75 g (21/2 oz)
7.2
Fish and seafood
Octopus, cooked
1
Oysters, cooked
75 g (2 /2 oz)
Seafood (shrimp, scallops, crab), cooked
75 g (21/2 oz)
3.3 to 9.0
2.2 to 2.3
Continued
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Table 1. Continued
Food
Serving size
Iron (mg)
Sardines, canned
75 g (21/2 oz)
1.7 to 2.2
Clams, canned
75 g (21/2 oz)
2.0
Fish (mackerel, trout, bass), cooked
75 g (21/2 oz)
1.4 to 1.7
Tuna, light, canned in water
75 g (21/2 oz)
1.2
Tofu, cooked
150 g (3/4 cup)
2.4 to 8.0
Soybeans, mature, cooked
175 mL (3/4 cup)
6.5
Lentils, cooked
175 mL (3/4 cup)
4.1 to 4.9
Beans (white, kidney, navy, pinto, black, Roman/cranberry, adzuki), cooked
175 mL (3/4 cup)
2.6 to 4.9
Pumpkin or squash seeds, roasted
60 mL (1/4 cup)
1.4 to 4.7
Peas (chickpeas/garbanzo, black-eyed, split), cooked
175 mL (3/4 cup)
1.9 to 3.5
Tempeh/fermented soy product, cooked
150 g (3/4 cup)
Meatless (sausage, chicken, meatballs, fish sticks), cooked
75 g (2.5 oz)
Baked beans, canned
175 mL (3/4 cup)
Nuts (cashews, almonds, hazelnuts, macadamia, pistachio nuts), without shell
60 ml (1/4 cup)
1.3 to 2.2
Eggs, cooked
2 large
1.2 to 1.8
Sesame seeds, roasted
15 mL (1 Tbsp)
1.4
Meatless, luncheon slices
75 g (2.5 oz)
1.4
Hummus
60 mL (1/4 cup)
1.4
Almond butter
30 mL (2 Tbsp)
1.2
Meat alternatives
3.2
1.5 to 2.8
2.2
Miscellaneous
Blackstrap molasses
15 mL (1 Tbsp)
3.6
Yeast extract spread (marmite or vegemite)
30 mL (2 Tbsp)
1.4
*Adapted from Dietitians of Canada. Food Sources of Iron. Available at: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Minerals/Food-Sources-of-Iron.
aspx.
†Pregnant women should limit intake of liver to 1 serving every 2 weeks.
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CHAPTER 7: Nutrition During Menopause and Beyond
Table 2. Vitamin B12*
Serving size
Vitamin B12 mg
3.3% homo, 2%, 1%
250 mL (1 cup)
1.2 to 1.4
Skim
250 mL (1 cup)
1.3
Buttermilk
250 mL (1 cup)
1.0
Chocolate, milk
250 mL (1 cup)
1.0
Food
Vegetables and fruits
(this food group contains very little of this nutrient)
Grains products
(this food group contains very little of this nutrient)
Milk and alternatives
Milk
Cheese
Swiss/Emmental
50 g (11/2 oz)
1.7
Cottage cheese
250 mL (1 cup)
1.5
Feta, gouda, edam, gruyere, brie, cheddar, fontina, mozzarella, provolone
50 g (11/2 oz)
0.7 to 0.9
Processed cheese slices, cheddar
50 g (11/2 oz)
0.4
Yogurt
Plain (regular, low fat)
175 g (3/4 cup)
1.0
Fruit bottom (regular, low fat)
175 g (3/4 cup)
0.8 to 0.9
Yogurt beverage
200 mL
0.6
250 mL (1 cup)
1.0
Milk alternatives
Soy beverage, fortified
Meat and alternatives
Organ meat
Liver (lamb, veal, beef) cooked
75 g (21/2 oz)
Kidney, lamb cooked
75 g (21/2 oz)
59.2
Kidney, veal, cooked
75 g (21/2 oz)
27.7
Giblets, turkey, cooked
75 g (21/2 oz)
24.9
Kidney, beef, cooked
75 g (21/2 oz)
18.7
52.9 to 64.3
1
Liver (chicken, pork), cooked
75 g (2 /2 oz)
12.6 to 15.9
Pate (goose liver, chicken liver)
75 g (21/2 oz)
6.1 to 7.1
75 g (21/2 oz)
0.2 to 0.3
Ground, cooked
75 g (21/2 oz)
2.4 to 2.7
Various cuts, cooked
75 g (21/2 oz)
1.3 to 2.5
Various cuts, cooked
75 g (21/2 oz)
0.8 to 1.1
Ground, cooked
75 g (21/2 oz)
0.8 to 0.9
Ham, cooked
75 g (21/2 oz)
0.7
Bacon, strips, cooked
3 slices (24 g)
0.3 to 0.4
Poultry
Turkey, duck or chicken, cooked
Beef
Pork
Miscellaneous
Caribou/reindeer, cooked
75 g (21/2 oz)
Salami (beef, pork)
75 g (21/2 oz) or 3 slices
1.1 to 2.1
Sausage (pepperoni, chorizo, Polish, Italian, frankfurter)
75 g (21/2 oz)
0.9 to 1.5
1
5.0
Deli meat (pastrami, mortadella, bologna)
75 g (2 /2 oz) or 3 slices
Wiener/hot dog
1 wiener (45 g)
1.1 to 1.3
1.2
Fish and seafood
Clams, cooked
75 g (21/2 oz)
Oysters, cooked
75 g (21/2 oz)
Mussels, cooked
75 g (21/2 oz)
Mackerel (King, Atlantic), cooked
75 g (21/2 oz)
74.2
18.2 to 26.3
18.0
13.5 to 14.3
Continued
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Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond
Table 2. Continued
Serving size
Vitamin B12 mg
Herring, cooked or kippered
250 mL (1 cup)
7.2 to 914.0
Tuna, bluefin, raw or cooked
75 g (21/2 oz)
8.2 to 9.3
Roe, raw
75 g (21/2 oz)
9.0
Crab, Alaska King, cooked
75 g (21/2 oz)
8.6
Sardines, canned in oil or tomato sauce
75 g (21/2 oz)
6.8
Food
1
Caviar (black, red)
75 g (2 /2 oz)
6.0
Trout, cooked
75 g (21/2 oz)
3.7 to 5.6
Salmon, red/sockeye, cooked
75 g (21/2 oz)
4.4
Salmon, pink/humpback, with bones, canned
75 g (21/2 oz)
3.7
Salmon, Atlantic, wild, cooked
75 g (21/2 oz)
2.3
Tuna, light, canned in water
75 g (21/2 oz)
2.2
Meatless (chicken, fish sticks, wiener /frankfurter, meatballs), cooked
75 g (21/2 oz)
1.0 to 3.8
Meatless luncheon slices
75 g (21/2 oz)
3.0
Soy burger
75 g (21/2 oz)
1.8
Egg, cooked
2 large
Meat alternatives
1.5 to 1.6
Other
Almond, oat, or rice beverage, fortified
250 mL (1 cup)
1.0
Red Star Yeast Flakes (Vegetarian Support Formula)
2 g (1 tsp powder or 2 tsp flaked)
1.0
*Adapted from Dietitians of Canada. Food Sources of Vitamin B12. Available at: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Vitamins/Food-Sourcesof-Vitamin-B12.aspx.
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CHAPTER 7: Nutrition During Menopause and Beyond
Table 3. Calcium*
Food
Serving size
Calcium (mg)
Vegetables and fruits
Vegetables
Collards, frozen, cooked
125 mL (1/2 cup)
189
Spinach, frozen, cooked
125 mL (1/2 cup)
154
125 mL (1/2 cup)
155
Fruit
Orange juice, fortified with calcium
Milk and alternatives
Buttermilk
250 mL (1 cup)
Soy beverage, fortified with calcium
250 mL (1 cup)
321 to 324
370
3.3% homo, 2%, 1%, skim, chocolate milk
250 mL (1 cup)
291 to 322
Dry powdered milk
24 g (4 Tbsp) to make 250 mL of milk
302
Cheese
Gruyere, swiss, goat, low-fat cheddar, mozzarella
50 g (11/2 oz)
396 to 506
Processed cheese slices (swiss, cheddar, low-fat swiss or cheddar)
50 g (11/2 oz)
276 to 386
Cheddar, colby, edam, gouda, mozzarella, blue
50 g (11/2 oz)
252 to 366
Ricotta cheese
125 mL (1/2 cup)
269 to 356
Cottage cheese
250 mL (1 cup)
146 to 217
Yogurt, plain
175 g (3/4 cup)
292 to 332
Yogurt, fruit bottom
175 g (3/4 cup)
221 to 291
Yogurt, soy
175 g (3/4 cup)
206
Yogurt beverage
200 mL
190
Kefir
175 g (3/4 cup)
187
Miscellaneous
Meats and alternatives
Fish and seafood
Sardines, Atlantic, canned in oil, with bones
75 g (21/2 oz)
Salmon (pink/humpback, red/sockeye), canned, with bones
75 g (21/2 oz)
Mackerel, canned
75 g (21/2 oz)
286
179 to 208
181
1
Sardines, Pacific, canned in tomato sauce, with bones
75 g (2 /2 oz)
180
Anchovies, canned
75 g (21/2 oz)
174
Meat alternatives
150 g (3/4 cup)
234 to 347
Goat’s milk or rice beverage, fortified with calcium
250 mL (1 cup)
319 to 345
Blackstrap molasses
15 mL (1 Tbsp)
Tofu, prepared with calcium sulfate
Other
179
*Adapted from Dietitians of Canada. Food Sources of Calcium. Available at: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Osteoporosis/Food-Sourcesof-Calcium.aspx.
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Table 4. Vitamin D*
Food
Serving size
Vitamin D (IU)
Milk and alternatives
Soy beverage, fortified with vitamin D
250 mL (1 cup)
Milk (3.3% homo, 2%, 1%, skim, chocolate milk)
250 mL (1 cup)
Skim milk powdered
24 g (will make 250 mL of milk)
123
103 to 105
103
Meat and alternatives
Fish and seafood
Salmon, sockeye/red, canned, cooked, or raw
75 g (21/2 oz)
530 to 699
Salmon, humpback/pink, canned, cooked, or raw
75 g (21/2 oz)
351 to 497
Salmon, coho, raw or cooked
75 g (21/2 oz)
326 to 421
Snapper, cooked
75 g (21/2 oz)
Salmon, chinook, raw or cooked
75 g (21/2 oz)
Whitefish, lake, cooked
75 g (21/2 oz)
Mackerel, Pacific, cooked
75 g (21/2 oz)
Salmon, Atlantic, raw or cooked
75 g (21/2 oz)
181 to 246
Salmon, chum/keta, raw or cooked
75 g (21/2 oz)
203 to 221
Mackerel, canned
75 g (21/2 oz)
Herring, Atlantic, pickled
75 g (21/2 oz)
Trout, cooked
75 g (21/2 oz)
Herring, Atlantic, cooked
75 g (21/2 oz)
161
Roe, raw
30 g (1 oz)
145
Sardines, Pacific, canned
75 g (21/2 oz)
144
Halibut, cooked
75 g (21/2 oz)
144
Tuna, albacore, raw or cooked
75 g (21/2 oz)
82 to 105
392
319 to 387
369
342
219
210
150 to 210
Fats and oils
Cod liver oil
5 mL (1 tsp)
427
Other
Goat’s milk, fortified with vitamin D
250 mL (1 cup)
100
Rice, oat, almond beverage, fortified with vitamin D
250 mL (1 cup)
88 to 90
*Adapted from Dietitians of Canada. Food Sources of Vitamin D. Available at: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Vitamins/Food-Sources-ofVitamin-D.aspx.
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CHAPTER 7: Nutrition During Menopause and Beyond
Table 5. Folate*
Food
Serving size
Folate (mg)
Edamame/baby soybeans cooked
125 mL (1/2 cup)
106 to 255
Okra, frozen, cooked
125 mL (1/2 cup)
142
Spinach, cooked
125 mL (1/2 cup)
121 to 139
Artichoke, cooked
125 mL (1/2 cup)
79 to 106
Turnip greens, collards, cooked
125 mL (1/2 cup)
68-93
Broccoli, cooked
125 mL (1/2 cup)
Vegetables and fruit
Vegetables
89
Asparagus, cooked
4 spears
Brussels sprouts, frozen, cooked
6 sprouts
80 to 88
Lettuce (Romaine, mesclun)
250 mL (1 cup)
Escarole or endive, raw
250 mL (1 cup)
Beets, cooked
125 mL (1/2 cup)
Potato, with skin, cooked
1 medium
Spinach, raw
250 mL (1 cup)
61
1
81
83
65 to 80
75
72
48-66
Fruits
Avocado
/2 fruit
Grain products
Pasta, egg noodles, enriched, cooked
125 mL (1/2 cup)
138
Pasta, white, enriched, cooked
125 mL (1/2 cup)
83 to 113
Bagel, plain
1
Bread, white
1 slice (35 g)
/2 bagel (45 g)
101
60
Meat and alternatives
Meat alternatives
Beans, cranberry/roman, cooked
175 mL (3/4 cup)
Lentils, cooked
175 mL (3/4 cup)
265
Peas (chickpeas, black-eyed,y pigeon)cooked
175 mL (3/4 cup)
138 to 263
Beans (mung, adzuki), cooked
175 mL (3/4 cup)
234 to 238
3
271
Beans (pink, pinto, navy, black, white, kidney, great northern), cooked
175 mL ( /4 cup)
157 to 218
Sunflower seeds, without shell
60 mL (1/4 cup)
77 to 81
Meatless (fish sticks, meatball, chicken), cooked
75 g (21/2 oz)
59 to 77
Liver (turkey, chicken), cooked
75 g (21/2 oz)
420 to 518
Liver (lamb, veal), cooked
75 g (21/2 oz)
262 to 300
Liver (beef, pork), cooked
75 g (21/2 oz)
122 to 195
Organ meats
Miscellaneous
Yeast extract spread (vegemite or marmite)
30 mL (2 Tbsp)
371
*Adapted from Dietitians of Canada. Food Sources of Folate. Available at: http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Vitamins/Food-Sources-ofFolate.aspx.
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Table 6. Glycemic index of selected foods
Low GI (55 or less)
Medium GI (56 to 70)
High GI (> 70)
Sweet potatoes, yams
New potatoes
Baked potatoes, French fries
Converted (parboiled) rice
Brown rice, basmati rice
White rice, instant rice
Breads made from heavy mixed grains, pumpernickel,
or stone-ground flours
Rye bread, whole wheat bread, pita bread
White bread, bagels
All bran type cereal
Shredded wheat type cereal
Bran flake type cereal
Steel cut oats
Quick oats
Instant oats, cream of wheat
Pasta
Couscous
Popcorn, rye crisp crackers
Milk, yogurt
Ice cream
Chickpeas, lentils, split peas
Black bean soup, green pea soup
Apple
Cantaloupe, raisins
GI: glycemic index.
554.e18
l
JUNE JOGC JUIN 2016
Pretzels, soda crackers
Dried dates