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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. 508 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 509 CLINICAL PRACTICE GUIDELINE 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) 510 l JUNE JOGC JUIN 2016 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) JUNE JOGC JUIN 2016 l 511 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 512 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 513 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 514 l JUNE JOGC JUIN 2016 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 CHAPTER 2: General Female Nutrition 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 JUNE JOGC JUIN 2016 l 515 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond “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 516 l JUNE JOGC JUIN 2016 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 CHAPTER 2: General Female Nutrition 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. JUNE JOGC JUIN 2016 l 517 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 518 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 519 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 520 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 521 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 REFERENCES 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. 2. Health Canada. Canada’s Food Guide: Advice for Different Ages and Stages. 2011. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/ choose-choix/advice-conseil/index-eng.php. Accessed on November 9, 2015. 3. Health Canada. My Food Guide Servings Tracker. 2011. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/track-suivi/index-eng. php. Accessed on August 14, 2015. indicates that binge eating disorders occur across the lifespan, and there is an increasing prevalence of eating disorders for middle-aged women.116 Eating disorders can have significant implications on sexual and reproductive health, including hypothalamic suppression and amenorrhea.118 Eating disorder behaviour during pregnancy is linked to preterm delivery, low birth weight, intrauterine growth restriction, Caesarean section, and low Apgar scores.119 For further discussion of assessment and treatment of eating disorders, refer to Chapter 3. Relationship between Diet, a Healthy Microbiome, and Health A growing body of literature points to the critical interplay of our microbiome (i.e., totality of bacteria, protozoa, viruses, fungi, and their genetic elements) with our diet and our health.120 Microbes, or the bacterial components of the microbiome, in the colon produce energy and vitamins by fermentation of nondigestible dietary components; they metabolize xenobiotics and assist in the development and maintenance of a healthy gut and immune system. Bacterial diversity in our gastrointestinal tract appears to be inversely related to obesity and immune-related and inflammatory diseases, including inflammatory bowel disease and Crohn’s disease.121,122 Adults are believed to have a core microbiome that is shaped by early life events, including mode of birth (vaginal vs. Caesarean), infant feeding (breast milk vs. formula), and medication use (antibiotics). The core microbiome can change in adulthood but generally is more resilient than in early childhood. While much remains to be learned, a varied diet rich in whole gains, fiber-rich vegetables, yogurts, and naturally fermented foods appears to lead to a diverse and healthy gut microbiome with Prevotella over Bacteroides.123e125 Western-style diets high in fat and sugar and low in fibre decrease beneficial Firmicutes.124 6. Jessri M, L’Abbe MR. The time for an updated Canadian Food Guide has arrived. Appl Physiol Nutr Metab 2015;40:854e7. 7. Health Canada. Dietary Reference Intake Report Lists. 2010. Available at: http://www.hc-sc.gc.ca/fn-an/nutrition/reference/dri_rep-rap_anref-list/ index-eng.php. Accessed on August 15, 2015. 8. Health Canada. Using the Dietary Reference Intakes. 2003. Available at: http://www.hc-sc.gc.ca/fn-an/nutrition/reference/dri_using-util_anrefeng.php. Accessed on November 11, 2015. 9. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Geneva, Switzerland: World Health Organization; 2003. 4. Health Canada. Eating Well with Canada’s Food Guide - First Nations, Inuit and Métis. 2010. Available at: http://www.hc-sc.gc.ca/fn-an/food-guidealiment/fnim-pnim/index-eng.php. Accessed on August 15, 2015. 10. Dietary Guidelines Advisory Committee, U.S. Department of Agriculture, and U.S. Department of Health and Human Services. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington, DC: U.S. Department of Agriculture and U.S. Department of Health and Human Services; 2015. 5. Katamay SW, Esslinger KA, Vigneault M, Johnston JL, Junkins BA, Robbins LG, et al. Eating well with Canada’s Food Guide (2007): development of the food intake pattern. Nutr Rev 2007;65:155e66. 11. 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. 522 l JUNE JOGC JUIN 2016 CHAPTER 2: General Female Nutrition 12. Salehi-Abargouei A, Maghsoudi Z, Shirani F, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH)-style diet on fatal or nonfatal cardiovascular diseasesdincidence: a systematic review and metaanalysis on observational prospective studies. Nutrition 2013;29:611e8. 32. Heart and Stroke Foundation of Canada. Saturated Fat, Heart Disease and Stroke. 2015. Available at: http://www.heartandstroke.com/site/c. ikIQLcMWJtE/b.9314923/k.E0FA/Saturated_fat_heart_disease_and_ stroke.htm. Accessed on November 9, 2015. 13. Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC. Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis [e-pub ahead of print] Br J Nutr 2015:1e15. Accessed on April 28, 2016. 33. de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, et al. Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ 2015;351:h3978. 14. Gerber M, Hoffman R. The Mediterranean diet: health, science and society. Br J Nutr 2015;113(Suppl 20):S4e10. 34. Health Canada. Healthy Living. 2013. Available at: http://www.hc-sc.gc.ca/ hl-vs/index-eng.php. Accessed on November 11, 2015. 15. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001;344:3e10. 35. Public Health Agency of Canada. Benefits of Physical Activity. 2011. Available at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/pa-ap/02paapeng.php. Accessed on August 14, 2015. 16. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99:779e85. 17. Rees K, Hartley L, Flowers N, Clarke A, Hooper L, Thorogood M, et al. ‘Mediterranean’ dietary pattern for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013;8:CD009825. 18. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014;17:2769e82. 19. Valls-Pedret C, Sala-Vila A, Serra-Mir M, Corella D, de la Torre R, Martinez-Gonzalez MA, et al. Mediterranean diet and age-related cognitive decline: a randomized clinical Trial. JAMA Intern Med 2015;175:1094e103. 20. Wiseman M. The second World Cancer Research Fund/American Institute for Cancer Research expert report. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. Proc Nutr Soc 2008;67:253e6. 21. Canadian Cancer Society. Eating Well. 2015. Available at: http://www. cancer.ca/en/prevention-and-screening/live-well/nutrition-and-fitness/ eating-well/?region¼on. Accessed on August 14, 2015. 22. Gonzalez CA, Riboli E. Diet and cancer prevention: contributions from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Eur J Cancer 2010;46:2555e62. 23. Giacosa A, Barale R, Bavaresco L, Gatenby P, Gerbi V, Janssens J, et al. Cancer prevention in Europe: the Mediterranean diet as a protective choice. Eur J Cancer Prev 2013;22:90e5. 24. Brennan SF, Cantwell MM, Cardwell CR, Velentzis LS, Woodside JV. Dietary patterns and breast cancer risk: a systematic review and metaanalysis. Am J Clin Nutr 2010;91:1294e302. 25. Bouvard V, Loomis D, Guyton KZ, Grosse Y, Ghissassi FE, BenbrahimTallaa L, et al. Carcinogenicity of consumption of red and processed meat. Lancet Oncol 2015;16:1599e600. 26. Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, et al. Alcohol consumption and site-specific cancer risk: a comprehensive doseresponse meta-analysis. Br J Cancer 2015;112:580e93. 27. Liu L, Wang S, Liu J. Fiber consumption and all-cause, cardiovascular, and cancer mortalities: a systematic review and meta-analysis of cohort studies. Mol Nutr Food Res 2015;59:139e46. 28. Vieira AR, Abar L, Vingeliene S, Chan DS, Aune D, Navarro-Rosenblatt D, et al. Fruits, vegetables and lung cancer risk: a systematic review and metaanalysis. Ann Oncol 2016;27:81e96. 29. Yang B, Wang FL, Ren XL, Li D. Biospecimen long-chain N-3 PUFA and risk of colorectal cancer: a meta-analysis of data from 60,627 individuals. PLoS One 2014;9:e110574. 36. Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines. 2015. Available at: http://www.csep.ca/english/view.asp?x¼804. Accessed on August 14, 2015. 37. Public Health Agency of Canada. Physical Activity: Tips to Get Active. 2011. Available at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/pa-ap/04 paap-eng.php. Accessed on August 14, 2015. 38. Public Health Agency of Canada. What Makes Canadians Healthy or Unhealthy? 2013. Available at: http://www.phac-aspc.gc.ca/ph-sp/ determinants/determinants-eng.php#unhealthy. Accessed on November 9, 2015. 39. Tarasuk V, Mitchell A, Dachner N. Household Food Insecurity in Canada, 2012. Research to Identify Policy Options to Reduce Food Insecurity (PROOF) Toronto. 2014. Available at: http://nutritionalsciences.lamp. utoronto.ca/wp-content/uploads/2014/05/Household_Food_Insecurity_ in_Canada-2012_ENG.pdf. Accessed on November 10, 2015. 40. Kirkpatrick SI, Dodd KW, Parsons R, Ng C, Garriguet D, Tarasuk V. Household food insecurity is a stronger marker of adequacy of nutrient intakes among Canadian compared to American youth and adults. J Nutr 2015;145:1596e603. 41. Darmon N, Drewnowski A. Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis. Nutr Rev 2015;73:643e60. 42. Gagne D, Blanchet R, Lauziere J, Vaissière É, Vézina C, Ayotte P, et al. Traditional food consumption is associated with higher nutrient intakes in Inuit children attending childcare centres in Nunavik. Int J Circumpolar Health 2012;71:18401. 43. Wilson D, de la Ronde S, Brascoupe S, Apale AN, Barney L, Guthrie B, et al. Health professionals working with First Nations, Inuit, and Metis consensus guideline. J Obstet Gynaecol Can 2013;35: 550e8. 44. Anderson L, Hadzibegovic DS, Moseley JM, Sellen DW. Household food insecurity shows associations with food intake, social support utilization and dietary change among refugee adult caregivers resettled in the United States. Ecol Food Nutr 2014;53:312e32. 45. Sanou D, O’Reilly E, Ngnie-Teta I, Batal M, Mondain N, Andrew C, et al. Acculturation and nutritional health of immigrants in Canada: a scoping review. J Immigr Minor Health 2014;16:24e34. 46. Abbato S, Division of the Chief Health Officer of Queensland Health. Community Profiles for Health Care Providers. 2011. Available at: https://www.health.qld.gov.au/multicultural/health_workers/profilescomplete.pdf. Accessed on April 17, 2016. 47. Health Canada. Body Mass Index (BMI) Nomogram. 2012. Available at: http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/ bmi_chart_java-graph_imc_java-eng.php. Accessed on November 15, 2015. 30. Health Canada. Sodium in Canada. 2012. Available at: http://www.hc-sc.gc. ca/fn-an/nutrition/sodium/index-eng.php. Accessed on November 17, 2015. 48. Meeuwsen S, Horgan GW, Elia M. The relationship between BMI and percent body fat, measured by bioelectrical impedance, in a large adult sample is curvilinear and influenced by age and sex. Clin Nutr 2010;29:560e6. 31. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013;346:f1325. 49. Lee CMY, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. J Clin Epidemiol 2008;61:646e53. JUNE JOGC JUIN 2016 l 523 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 50. Brauer P, Gorber SC, Shaw E, Singh H, Bell N, Shane AR, et al. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. Can Med Assoc J 2015;187:184e95. 51. Lau D, Douketis J, Morrison K, Hramiak I, Sharma A, Ur E. Canadian Clinical Practice Guidelines on the management and prevention of obesity in adults and children [summary] Can Med Assoc J 2007;176:S1e13. supplementation in female soldiers during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr 2009;90:124e31. 70. Bruner AB, Joffe A, Duggan AK, Casella JF, Brandt J. Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls. Lancet 1996;348:992e6. 71. Murray-Kolb L, Beard J. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr 2007;85:778e87. 52. Fernández JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference percentiles in nationally representative samples of African-American, European-American, and Mexican-American children and adolescents. J Pediatr 2004;145:439e44. 72. Krayenbuehl P, Battegay E, Breymann C, Furrer J, Schulthess G. Intravenous iron for the treatment of fatigue in nonanemic, premenopausal women with low serum ferritin concentration. Blood 2011;118:3222e7. 53. He W, Li Q, Yang M, Jiao J, Ma X, Zhou Y, et al. Lower BMI cutoffs to define overweight and obesity in China. Obesity (Silver Spring) 2015;23:684e91. 73. Vaucher P, Druais P, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. Can Med Assoc J 2012;184:1247e54. 54. Ostbye T, Taylor Jr DH, Yancy Jr WS, Krause KM. Associations between obesity and receipt of screening mammography, Papanicolaou tests, and influenza vaccination: results from the Health and Retirement Study (HRS) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study. Am J Public Health 2005;95:1623e30. 74. Nybo M, Friis-Hansen L, Felding P, Milman N. Higher prevalence of anemia among pregnant immigrant women compared to pregnant ethnic Danish women. Ann Hematol 2007;86:647e51. 55. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015;16:319e26. 56. Volger S, Vetter ML, Dougherty M, Panigrahi E, Egner R, Webb V, et al. Patients’ preferred terms for describing their excess weight: discussing obesity in clinical practice. Obesity (Silver Spring) 2012;20:147e50. 57. Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA 2014;311:74e86. 58. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724e37. 75. Christofides A, Schauer C, Zlotkin SH. Iron deficiency and anemia prevalence and associated etiologic risk factors in First Nations and Inuit communities in Northern Ontario and Nunavut. Can J Public Health 2005;96:304e7. 76. Smith GA, Fisher SA, Doree C, Di Angelantonio E, Roberts DJ. Oral or parenteral iron supplementation to reduce deferral, iron deficiency and/or anaemia in blood donors. Cochrane Database Syst Rev 2014;7:CD009532. 77. Goddard AF, James MW, McIntyre AS, Scott BB. British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309e16. 78. Stoltzfus RJ, Dreyfuss ML, World Health Organization. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. Washington, DC: Ilsi Press; 1998. 59. Schellenberg ES, Dryden DM, Vandermeer B, Ha C, Korownyk C. Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis. Ann Intern Med 2013;159:543e51. 79. World Health Organization. Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. Vitamin and Mineral Nutrition Information System. 2011. Available at: http://www.who. int/vmnis/indicators/serum_ferritin.pdf. Accessed on November 18, 2015. 60. Yoon U, Kwok LL, Magkidis A. Efficacy of lifestyle interventions in reducing diabetes incidence in patients with impaired glucose tolerance: a systematic review of randomized controlled trials. Metabolism 2013;62:303e14. 80. 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. 61. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008;359:229e41. 81. MacFarlane A, Greene-Finestone L, Shi Y. Vitamin B-12 and homocysteine status in a folate-replete population: results from the Canadian Health Measures Survey. Am J Clin Nutr 2011;94:1079e87. 62. Sacks F, Bray G, Carey V, Smith S, Ryan D, Anton SD, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360:859e73. 82. Molloy A, Kirke P, Troendle J, Burke H, Sutton M, Brody L, et al. Maternal vitamin B12 status and risk of neural tube defects in a population with high neural tube defect prevalence and no folic acid fortification. Pediatrics 2009;123:917e23. 63. Neamat-Allah J, Barrdahl M, Husing A, Katzke VA, Bachlechner U, Steffen A, et al. Weight cycling and the risk of type 2 diabetes in the EPIC-Germany cohort. Diabetologia 2015;58:2718e25. 83. Reynolds E. Vitamin B12, folic acid, and the nervous system. Lancet Neurol 2006;5:949e60. 64. Montani JP, Schutz Y, Dulloo AG. Dieting and weight cycling as risk factors for cardiometabolic diseases: who is really at risk? Obes Rev 2015;16(Suppl 1):7e8. 65. 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. 66. Cooper M, Greene-Finestone L, Lowell H, Levesque J, Robinson S. Iron sufficiency of Canadians. Health Rep 2012;23:3e10. 67. Manios Y, Moschonis G, Chrousos G, Lionis C, Mougios V, Kantilafti M, et al. The double burden of obesity and iron deficiency on children and adolescents in Greece: the Healthy Growth Study. J Hum Nutr Diet 2012;26:470e8. 84. Langan R, Zawistoski K. Update on vitamin B12 deficiency. Am Fam Physician 2011;83:1425e30. 85. Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011. 86. International Osteoporosis Foundation. Calcium Calculator. 2015. Available at: http://www.iofbonehealth.org/calcium-calculator. Accessed on November 17, 2015. 87. Dietitians of Canada. EaTracker. 2015. Available at: https://www.eatracker. ca/. Accessed on August 14, 2015. 88. Shakur Y, Tarasuk V, Corey P, O’Connor D. A comparison of micronutrient inadequacy and risk of high micronutrient intakes among vitamin and mineral supplement users and nonusers in Canada. J Nutr 2012;142:534e40. 68. Moschonis G, Chrousos G, Lionis C, Mougios V, Manios Y. Association of total body and visceral fat mass with iron deficiency in preadolescents: the Healthy Growth Study. Br J Nutr 2012;108:710e9. 89. Cauley JA. Bone health after menopause. Curr Opin Endocrinol Diabetes Obes 2015;22:490e4. 69. McClung J, Karl J, Cable S, Williams K, Nindl B, Young A, et al. Randomized, double-blind, placebo-controlled trial of iron 90. Whiting S, Langlois K, Vatanparast H, Greene-Finestone L. The vitamin status of Canadians relative to the 2011 Dietary Reference Intakes: an 524 l JUNE JOGC JUIN 2016 CHAPTER 2: General Female Nutrition examination in children and adults with and without supplement use. Am J Clin Nutr 2011;94:128e35. analysis of the national health and nutrition examination survey 1999-2004. J Am Diet Assoc 2011;111:819e27. 91. Lehotay DC, Smith P, Krahn J, Etter M, Eichhorst J. Vitamin D levels and relative insufficiency in Saskatchewan. Clin Biochem 2013;46:1489e92. 108. Craig WJ, Mangels AR. Position of the American Dietetic Association and Dietitians of Canada: vegetarian diets. J Am Diet Assoc 2009;109:1266e82. 92. Sarafin K, Durazo-Arvizu R, Tian L, Phinney KW, Tai S, Camara JE, et al. Standardizing 25-hydroxyvitamin D values from the Canadian Health Measures Survey. Am J Clin Nutr 2015;102:1044e50. 109. Piccoli GB, Clari R, Vigotti FN, Leone F, Attini R, Cabiddu G, et al. Veganvegetarian diets in pregnancy: danger or panacea? A systematic narrative review. BJOG 2015;122:623e33. 93. Godel JC. Vitamin D supplementation: recommendations for Canadian mothers and infants. Position Statement of the Canadian Paediatric Society. Paediatr Child Health 2007;12:583e9. 110. van Vliet S, Burd NA, van Loon LJ. The skeletal muscle anabolic response to plant- versus animal-based protein consumption. J Nutr 2015;145:1981e91. 94. Hanley D, Cranney A, Jones G, Whiting S, Leslie W, Cole D, et al. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. Can Med Assoc J 2010;182:E610e8. 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. JUNE JOGC JUIN 2016 l 525 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) 526 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 527 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 528 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 529 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 530 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 531 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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. 532 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 533 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.9 534 l JUNE JOGC JUIN 2016 CHAPTER 5: Nutrition in Pregnancy 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. JUNE JOGC JUIN 2016 l 535 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 536 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 537 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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. 538 l JUNE JOGC JUIN 2016 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 REFERENCES 1. Health Canada. Canada’s Food Guide: Pregnancy and Breastfeeding. 2011. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/choosechoix/advice-conseil/women-femmes-eng.php. Accessed on November 17, 2015. 2. Health Canada. Prenatal Nutrition. 2011. Available at: http://www.hc-sc.gc.ca/ fn-an/nutrition/prenatal/index-eng.php. Accessed on November 17, 2015. list of foods and herbs to be avoided or limited and those with insufficient reliable information available to recommend use during pregnancy. No amount of alcohol is considered safe during pregnancy; follow the SOGC 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 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). 12. Kapadia MZ, Park CK, Beyene J, Giglia L, Maxwell C, McDonald SD. Weight loss instead of weight gain within the guidelines in obese women during pregnancy: a systematic review and meta-analyses of maternal and infant outcomes. PLoS One 2015;10:e0132650. 13. Ferraro ZM, Barrowman N, Prud’homme D, Walker M, Wen SW, Rodger M, et al. Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index. J Matern Fetal Neonatal Med 2011;25:538e42. 3. King J. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr 2000;71:1218Se25S. 14. Gaillard R, Durmuş B, Hofman A, Mackenbach JP, Steegers EA, Jaddoe VW. Risk factors and outcomes of maternal obesity and excessive weight gain during pregnancy. Obesity 2013;21:1046e55. 4. Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Effect of in utero and early-life conditions on adult health and disease. N Engl J Med 2008;359:61e73. 15. Guelinckx I, Devlieger R, Beckers K, Vansant G. Maternal obesity: pregnancy complications, gestational weight gain and nutrition. Obes Rev 2008;9:140e50. 5. Harding JE. The nutritional basis of the fetal origins of adult disease. Int J Epidemiol 2001;30:15e23. 16. Ludwig DS, Currie J. The association between pregnancy weight gain and birthweight: a within-family comparison. Lancet 2010;376: 984e90. 6. Langley-Evans S. Nutrition in early life and the programming of adult disease: a review. J Hum Nutr Diet 2015;28:1e14. 7. Institute of Medicine. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: The National Academies Press; 2005. 8. de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, et al. Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ 2015;351:h3978. 9. Stephens TV, Payne M, Ball RO, Pencharz PB, Elango R. Protein requirements of healthy pregnant women during early and late gestation are higher than current recommendations. J Nutr 2015;145:73e8. 10. Rasmussen KM, Yaktine AL. Weight Gain During Pregnancy: Reexamining the Guidelines. 2009. Available at: http://www.nap.edu/catalog.php? record_id¼12584. Accessed on November 17, 2015. 11. 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 on April 16, 2016. 17. Lowell H, Miller D. Weight gain during pregnancy: adherence to Health Canada’s Guidelines. Health Rep 2010;21:31e6. 18. Winkvist A, Brantsaeter AL, Brandhagen M, Haugen M, Meltzer HM, Lissner L. Maternal prepregnant body mass index and gestational weight gain are associated with initiation and duration of breastfeeding among Norwegian mothers. J Nutr 2015;145:1263e70. 19. Crane JM, White J, Murphy P, Burrage L, Hutchens D. The effect of gestational weight gain by body mass index on maternal and neonatal outcomes. J Obstet Gynaecol Can 2009;31:28e35. 20. Dzakpasu S, Fahey J, Kirby RS, Tough SC, Chalmers B, Heaman MI, et al. Contribution of prepregnancy body mass index and gestational weight gain to adverse neonatal outcomes: population attributable fractions for Canada. BMC Pregnancy Childbirth 2015;15:21. 21. Kronborg H, Vaeth M, Rasmussen KM. Obesity and early cessation of breastfeeding in Denmark. Eur J Public Health 2013;23:316e22. 22. Mamun AA, Mannan M, Doi SA. Gestational weight gain in relation to offspring obesity over the life course: a systematic review and biasadjusted meta-analysis. Obes Rev 2013;15:338e47. JUNE JOGC JUIN 2016 l 539 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 23. Nehring I, Lehmann S, von Kries R. Gestational weight gain in accordance to the IOM/NRC criteria and the risk for childhood overweight: a metaanalysis. Pediatr Obes 2013;8:218e24. 24. Oken E, Taveras EM, Kleinman KP, Rich-Edwards JW, Gillman MW. Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol 2007;196:322e8. 25. Schack-Nielsen L, Michaelsen KF, Gamborg M, Mortensen EL, Sorensen TI. Gestational weight gain in relation to offspring body mass index and obesity from infancy through adulthood. Int J Obes 2010;34:67e74. 26. Robinson HE, O’Connell CM, Joseph KS, McLeod NL. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol 2005;106:1357e64. 27. Kim SY, Dietz PM, England L, Morrow B, Callaghan WM. Trends in prepregnancy obesity in nine states, 1993-2003. Obesity (Silver Spring) 2007;15:986e93. 28. Weisman CS, Hillemeier MM, Downs DS, Chuang CH, Dyer AM. Preconception predictors of weight gain during pregnancy: prospective findings from the Central Pennsylvania Women’s Health Study. Womens Health Issues 2010;20:126e32. 29. Willows N. Determinants of healthy eating in Aboriginal peoples in Canada: the current state of knowledge and research gaps. Can J Public Health 2005;96:S32e41. 30. Hinkle SN, Sharma AJ, Dietz PM. Gestational weight gain in obese mothers and associations with fetal growth. Am J Clin Nutr 2010;92:644e51. 31. 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. 32. 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. 33. Cheikh Ismail Leila, Bishop Deborah C, Pang Ruyan, Ohuma Eric O, Kac Gilberto, Abrams Barbara, et al. Gestational weight gain standards based on women enrolled in the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project: a prospective longitudinal cohort study. BMJ 2016;352:i555. 34. Rodgers AB, Yaktine AL. Committee on Implementation of the Institute of Medicine Pregnancy Weight Gain Guidelines, Board on Children, Youth, and Families, Food and Nutrition Board, Institute of Medicine, National Research Council. Leveraging action to support dissemination of the pregnancy weight gain guidelines. Workshop summary. Washington, DC: The National Acadmies Press; 2013. 35. Bogaerts AF, Devlieger R, Nuyts E, Witters I, Gyselaers W, Van den Bergh BR. Effects of lifestyle intervention in obese pregnant women on gestational weight gain and mental health: a randomized controlled trial. Int J Obes 2013;37:814e21. 36. Harrison CL, Lombard CB, Strauss BJ, Teede HJ. Optimizing healthy gestational weight gain in women at high risk of gestational diabetes: a randomized controlled trial. Obesity 2013;21:904e9. 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 adolescents and adults: current knowledge and practical implications. Can J Diet Pract Res 2006;67:130e8. 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 composition, including choline, requires reconsideration. J Nutr 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. 540 l JUNE JOGC JUIN 2016 41. 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. 42. 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. 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 women in the Alberta Pregnancy Outcomes and Nutrition (APrON) 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 Defects Res A Clin Mol Teratol 2013;97:47e52. 47. Pickell L, Brown K, Li D, Wang XL, Deng L, Wu Q, et al. High intake of 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 supplementation during pregnancy induces sex-specific changes in methylation and expression of placental 11beta-hydroxysteroid 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 review of current evidence in human subjects. Proc Nutr Soc 2012;71:154e65. 51. Wang T, Zhang HP, Zhang X, Liang ZA, Ji YL, Wang G. Is folate status a risk factor for asthma or other allergic diseases? Allergy Asthma Immunol 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: systematic review and meta-analysis. BMJ 2013;346:f3443. 54. Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2012;12:CD004736. 55. Cockell KA, Miller DC, Lowell H. Application of the Dietary Reference Intakes in developing a recommendation for pregnancy iron supplements in Canada. Am J Clin Nutr 2009;90:1023e8. 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 multivitamins in pregnancy. BMC Pregnancy Childbirth 2008;8:17. 57. World Health Organization. Daily iron and folic acid supplementation during pregnancy. Available from: http://www.who.int/elena/titles/guidance_ summaries/daily_iron_pregnancy/en/. Accessed March 22nd 2016 58. Gill SK, Maltepe C, Koren G. The effectiveness of discontinuing ironcontaining prenatal multivitamins on reducing the severity of nausea and vomiting of pregnancy. J Obstet Gynaecol 2009;29:13e6. 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? chap¼5#s6c5. Accessed on August 23, 2015. 61. Shaw GM, Carmichael SL, Yang W, Selvin S, Schaffer DM. Periconceptional 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: http://www.statcan.gc.ca/pub/82-625-x/2012001/article/11733-eng.htm. Accessed on August 23, 2015. 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. JUNE JOGC JUIN 2016 l 541 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 542 l JUNE JOGC JUIN 2016 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, JUNE JOGC JUIN 2016 l 543 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) 544 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 545 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 REFERENCES 1. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries [evidence report/technology assessment No. 153]. Rockville, MD: Agency for Healthcare Research and Quality; 2007. 2. Turner M, Layte R. Obesity levels in a national cohort of women 9 months after delivery. Am J Obstet Gynecol 2013;209:124.e1e7. 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 (see Table 7). (I-A) 14. Endres LK, Straub H, McKinney C, Plunkett B, Minkovitz CS, Schetter CD, et al. Postpartum weight retention risk factors and relationship to obesity at 1 year. Obstet Gynecol 2015;125:144e52. 15. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: The National Academies Press; 2009. 16. Begum F, Colman I, McCargar LJ, Bell RC. Gestational weight gain and early postpartum weight retention in a prospective cohort of Alberta women. J Obstet Gynaecol Can 2012;34:637e47. 3. Callegari LS, Sterling LA, Zelek ST, Reed SD. Interpregnancy body mass index change and success of vaginal birth after cesarean. Am J Obstet Gynecol 2014;210:330.e1e7. 17. Kirkegaard H, Stovring H, Rasmussen KM, Abrams B, Sorensen TI, Nohr EA. How do pregnancy-related weight changes and breastfeeding relate to maternal weight and BMI-adjusted waist circumference 7 y after delivery? Results from a path analysis. Am J Clin Nutr 2014;99:312e9. 4. Turcksin R, Bel S, Galjaard S, Devlieger R. Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Matern Child Nutr 2014;10:166e83. 18. National Institute for Clinical Health and Excellence. Weight Management Before, During and After Pregnancy. 2010. Available at: https://www.nice. org.uk/guidance/ph27. Accessed on November 17, 2015. 5. Monasta L, Batty GD, Cattaneo A, Lutje V, Ronfani L, Van Lenthe FJ, et al. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes Rev 2010;11:695e708. 19. Brauer P, Connor Gorber S, Shaw E, Singh H, Bell N, Shane AR, et al. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. Can Med Assoc J 2015;187:184e95. 6. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and metaanalysis. Acta Paediatr 2015;104:96e113. 7. Slusser W. Breastfeeding and maternal and infant health outcomes in developed countries. AAP Grand Rounds 2007;18:15e6. 8. Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics 2004;113:e465e71. 9. Powe CE, Allen M, Puopolo KM, Merewood A, Worden S, Johnson LC, et al. Recombinant human prolactin for the treatment of lactation insufficiency. Clin Endocrinol (Oxf) 2010;73:645e53. 10. Powe CE, Puopolo KM, Newburg DS, Lonnerdal B, Chen C, Allen M, et al. Effects of recombinant human prolactin on breast milk composition. Pediatrics 2011;127:e359e66. 11. Health Canada. Canada’s Food Guide: Pregnancy and Breastfeeding. 2011. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/choosechoix/advice-conseil/women-femmes-eng.php. Accessed on November 17, 2015. 12. 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. 13. Institute of Medicine. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: The National Academies Press; 2005. 546 l JUNE JOGC JUIN 2016 20. Lau D, Douketis J, Morrison K, Hramiak I, Sharma A, Ur E. Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary] Can Med Assoc J 2007;176:S1e13. 21. 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. 22. 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. 23. O’Connor DL, Houghton LA, Sherwood KL. Nutrition issues during lactation. In: Lammi-Keefe CJ, Couch SC, Elliot H, editors. Handbook of nutrition and pregnancy. Totowa, NJ: Humana Press; 2008. p. 257e82. 24. 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 on April 16, 2016. 25. Davies GA, Wolfe LA, Mottola MF, MacKinnon C. Society of Obstetricians and Gynaecologists of Canada, SOGC Clinical Practice Obstetrics Committee. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiol 2003;28:330e41. 26. Amorim Adegboye AR, Linne YM, Lourenco PM. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database Syst Rev 2007;18:CD005627. 27. Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proc Nutr Soc 2011;70:181e4. CHAPTER 6: Postpartum Nutrition and Lactation 28. Lovelady CA, Garner KE, Moreno KL, Williams JP. The effect of weight loss in overweight, lactating women on the growth of their infants. N Engl J Med 2000;342:449e53. 29. He X, Zhu M, Hu C, Tao X, Li Y, Wang Q, et al. Breast-feeding and postpartum weight retention: a systematic review and meta-analysis. Public Health Nutr 2015;18:3308e16. 30. Neville CE, McKinley MC, Holmes VA, Spence D, Woodside JV. The relationship between breastfeeding and postpartum weight changeda systematic review and critical evaluation. Int J Obes (Lond) 2014;38:577e90. 31. Fehler KL, Kennedy LE, McCargar L, Bell R, Ryan E. Postpartum dietary changes in women with previous gestational diabetes mellitus. Can J Diabetes 2007;31:54e61. 32. Gunderson, et al. Lactation and Progression to Type 2 Diabetes Mellitus After Gestational Diabetes Mellitus: A Prospective Cohort Study. Ann Intern Med 2015;163(12):889e98. http://dx.doi.org/10.7326/M15-0807. 33. Allen LH. B vitamins in breast milk: relative importance of maternal status and intake, and effects on infant status and function. Adv Nutr 2012;3:362e9. 34. Shakur YA, Tarasuk V, Corey P, O’Connor DL. A comparison of micronutrient inadequacy and risk of high micronutrient intakes among vitamin and mineral supplement users and nonusers in Canada. J Nutr 2012;142:534e40. 35. Institute of Medicine. Dietary Reference Intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington, DC: The National Academies Press; 2000. 48. Delgado-Noguera MF, Calvache JA, Bonfill Cosp X, Kotanidou EP, GalliTsinopoulou A. Supplementation with long chain polyunsaturated fatty acids (LCPUFA) to breastfeeding mothers for improving child growth and development. Cochrane Database Syst Rev 2015;7:CD007901. 49. Gionet L. Health at a Glance: Breastfeeding Trends in Canada [Statistics Canada]. 2013. Available at: http://www.statcan.gc.ca/pub/82-624-x/2 013001/article/11879-eng.pdf. Accessed on April 17, 2016. 50. Brown CR, Dodds L, Legge A, Bryanton J, Semenic S. Factors influencing the reasons why mothers stop breastfeeding. Can J Public Health 2014;105:e179e85. 51. Dietitians of Canada. Registered Dietitians in Aboriginal Communities: Feeding Mind, Body and Spirit. 2012. Available at: http://www.dietitians. ca/Downloads/Public/ANN-Report-Final-2012.aspx. Accessed on November 18, 2015. 52. Health Canada. Breastfeeding Initiation in Canada: Key Statistics and Graphics (2009-2010). 2012. Available at: http://www.hc-sc.gc.ca/fn-an/ surveill/nutrition/commun/prenatal/initiation-eng.php. Accessed on November 19, 2015. 53. La Leche League. La Leche League Canada - Supporting breastfeeding families since 1961. Available at: www.lllc.ca. Accessed on November 19, 2015. 54. Public Health Agency of Canada. Ten Valuable Tips for Successful Breastfeeding. 2009. Available at: http://www.phac-aspc.gc.ca/hp-ps/dcadea/stages-etapes/childhood-enfance_0-2/nutrition/tips-cons-eng.php. Accessed on November 19, 2015. 36. Pfeiffer CM, Sternberg MR, Schleicher RL, Haynes BM, Rybak ME, Pirkle JL. The CDC’s second national report on biochemical indicators of diet and nutrition in the U.S. population is a valuable tool for researchers and policy makers. J Nutr 2013;143:938Se47S. 55. Greer FR, Sicherer SH, Burks AW, American Academy of Pediatrics Committee on Nutrition, American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics 2008;121:183e91. 37. Statistics Canada. Iodine status of Canadians, 2009-2011. 2013. Available at: http://www.statcan.gc.ca/pub/82-625-x/2012001/article/11733-eng.htm. Accessed on August 23, 2015. 56. Nocerino R, Pezzella V, Cosenza L, Amoroso A, Di Scala C, Amato F, et al. The controversial role of food allergy in infantile colic: evidence and clinical management. Nutrients 2015;7:2015e25. 38. Caldwell KL, Jones R, Hollowell JG. Urinary iodine concentration: United States National Health And Nutrition Examination Survey 2001-2002. Thyroid 2005;15:692e9. 57. Health Canada. Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months. 2015. Available at: http://www.hc-sc.gc.ca/fnan/nutrition/infant-nourisson/recom/recom-6-24-months-6-24-mois-eng. php. Accessed on November 18, 2015. 39. 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. 40. Health Canada. Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. 2015. Available at: http://www.hc-sc.gc.ca/fn-an/ nutrition/infant-nourisson/recom/index-eng.php. Accessed on August 29, 2015. 58. Hall B, Chesters J, Robinson A. Infantile colic: a systematic review of medical and conventional therapies. J Paediatr Child Health 2012;48:128e37. 59. Iacovou M, Ralston RA, Muir J, Walker KZ, Truby H. Dietary management of infantile colic: a systematic review. Matern Child Health J 2012;16:1319e31. 41. Hollis BW, Wagner CL, Howard CR, Ebeling M, Shary JR, Smith PG, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics 2015;136:625e34. 60. Lust KD, Brown JE, Thomas W. Maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast-fed infants. J Am Diet Assoc 1996;96:46e8. 42. Kulie T, Groff A, Redmer J, Hounshell J, Schrager S, Vitamin D. an evidence-based review. J Am Board Fam Med 2009;22:698e706. 61. Critch J. Infantile colic: is there a role for dietary interventions? Paediatr Child Health 2011;16:47e9. 43. Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med 2006;1:59e70. 62. Thalheimer JC. Recognizing cow’s milk protein allergy in infants - evidence shows eliminating milk and soy can help. Today’s Dietitian 2012;14:14. 44. Perumal N, Al Mahmud A, Baqui AH, Roth DE. Prenatal vitamin D supplementation and infant vitamin D status in Bangladesh [e-pub ahead of print] Public Health Nutr 2015;:1e9. 45. Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011. 46. March KM, Chen NN, Karakochuk CD, Shand AW, Innis SM, von Dadelszen P, et al. Maternal vitamin D(3) supplementation at 50 mg/d protects against low serum 25-hydroxyvitamin D in infants at 8 wk of age: a randomized controlled trial of 3 doses of vitamin D beginning in gestation and continued in lactation. Am J Clin Nutr 2015;102:402e10. 47. Innis SM. Impact of maternal diet on human milk composition and neurological development of infants. Am J Clin Nutr 2014;99:734Se41S. 63. Health Canada. Consumption Advice: Making Informed Choices about Fish. 2008. Available at: http://www.hc-sc.gc.ca/fn-an/securit/chemchim/environ/mercur/cons-adv-etud-eng.php. Accessed on November 18, 2011. 64. Ross C. Maternal caffeine consumption and infant nighttime waking: prospective cohort study. Breastfeed Rev 2012;20:56. 65. Bowen A, Tumback L. Alcohol and breastfeeding: dispelling the myths and promoting the evidence. Nurs Womens Health 2010;14:454e61. 66. Queensland Government. Community Profiles for Health Care Providers. 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 JUNE JOGC JUIN 2016 l 547 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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/ 548 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 549 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 550 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 551 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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) 552 l JUNE JOGC JUIN 2016 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 REFERENCES 1. Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, et al. Executive summary of the Stages of Reproductive Aging Workshop þ 10: addressing the unfinished agenda of staging reproductive aging. Menopause 2012;19:387e95. 2. Bowman SA. Television-viewing characteristics of adults: correlations to eating practices and overweight and health status. Prev Chronic Dis 2006;3:A38. 3. Hingle MD, Wertheim BC, Tindle HA, Tinker L, Seguin RA, Rosal MC, et al. Optimism and diet quality in the Women’s Health Initiative. J Acad Nutr Diet 2014;114:1036e45. 4. Sowers M, Zheng H, Tomey K, Karvonen-Gutierrez C, Jannausch M, Li X, et al. Changes in body composition in women over six years at midlife: ovarian and chronological aging. J Clin Endocrinol Metab 2007;92:895e901. 5. Sternfeld B, Wang H, Quesenberry Jr CP, Abrams B, Everson-Rose SA, Greendale GA, et al. Physical activity and changes in weight and waist circumference in midlife women: findings from the Study of Women’s Health Across the Nation. Am J Epidemiol 2004;160:912e22. 6. Davis SR, Castelo-Branco C, Chedraui P, Lumsden MA, Nappi RE, Shah D, et al. Understanding weight gain at menopause. Climacteric 2012;15:419e29. prevention of hot flashes has been well established.50,51 Regardless, public interest in the use of soy for the alleviation of the symptoms of menopause remains; women for whom estrogen is contraindicated should use caution before using these food-derived compounds in pharmacological doses. 16. Mastorakos G, Valsamakis G, Paltoglou G, Creatsas G. Management of obesity in menopause: diet, exercise, pharmacotherapy and bariatric surgery. Maturitas 2010;65:219e24. 17. Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines. 2015. Available at: http://www.csep.ca/english/view.asp?x¼804. Accessed on August 14, 2015. 18. Maltais ML, Desroches J, Dionne IJ. Changes in muscle mass and strength after menopause. J Musculoskelet Neuronal Interact 2009;9:186e97. 19. Cooper R, Kuh D, Hardy R. Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ 2010; 341:c4467. 20. Sirola J, Rikkonen T, Tuppurainen M, Jurvelin JS, Alhava E, Kroger H. Grip strength may facilitate fracture prediction in perimenopausal women with normal BMD: a 15-year population-based study. Calcif Tissue Int 2008;83:93e100. 21. Straight CR, Ward-Ritacco CL, Evans EM. Association between accelerometer-measured physical activity and muscle capacity in middleaged postmenopausal women. Menopause 2015;22:1204e11. 22. Health Canada. Estimated Energy Requirements. 2014. Available at: http:// www.hc-sc.gc.ca/fn-an/food-guide-aliment/basics-base/1_1_1-eng.php. Accessed on November 10, 2015. 23. Choi J, Guiterrez Y, Gilliss C, Lee KA. Physical activity, weight, and waist circumference in midlife women. Health Care Women Int 2012;33:1086e95. 7. Norman RJ, Flight IH, Rees MC. Oestrogen and progestogen hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution. Cochrane Database Syst Rev 2000;(2):Cd001018. 24. Arentson-Lantz E, Clairmont S, Paddon-Jones D, Tremblay A, Elango R. Protein: a nutrient in focus. Appl Physiol Nutr Metab 2015;40:755e61. 8. Jensen LB, Vestergaard P, Hermann AP, Gram J, Eiken P, Abrahamsen B, et al. Hormone replacement therapy dissociates fat mass and bone mass, and tends to reduce weight gain in early postmenopausal women: a randomized controlled 5-year clinical trial of the Danish Osteoporosis Prevention Study. J Bone Miner Res 2003;18:333e42. 26. Institute of Medicine. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: The National Academies Press; 2005. 9. Guthrie JR, Dennerstein L, Dudley EC. Weight gain and the menopause: a 5-year prospective study. Climacteric 1999;2:205e11. 10. Chen Z, Bassford T, Green SB, Cauley JA, Jackson RD, LaCroix AZ, et al. Postmenopausal hormone therapy and body compositionda substudy of the estrogen plus progestin trial of the Women’s Health Initiative. Am J Clin Nutr 2005;82:651e6. 11. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Geneva, Switzerland: World Health Organization; 2003. 12. Neuhouser ML, Aragaki AK, Prentice RL, Manson JE, Chlebowski R, Carty CL, et al. Overweight, obesity, and postmenopausal invasive breast cancer risk: a secondary analysis of the Women’s Health Initiative Randomized Clinical Trials. JAMA Oncol 2015;1:611e21. 13. Rexrode KM, Carey VJ, Hennekens CH, Walters EE, Colditz GA, Stampfer MJ, et al. Abdominal adiposity and coronary heart disease in women. JAMA 1998;280:1843e8. 14. Kerwin DR, Gaussoin SA, Chlebowski RT, Kuller LH, Vitolins M, Coker LH, et al. Interaction between body mass index and central adiposity and risk of incident cognitive impairment and dementia: results from the Women’s Health Initiative Memory Study. J Am Geriatr Soc 2011;59:107e12. 15. Khan UI, Wang D, Karvonen-Gutierrez CA, Khalil N, Ylitalo KR, Santoro N. Progression from metabolically benign to at-risk obesity in perimenopausal women: a longitudinal analysis of study of women across the nation (SWAN). J Clin Endocrinol Metab 2014;99:2516e25. 25. Morais JA, Chevalier S, Gougeon R. Protein turnover and requirements in the healthy and frail elderly. J Nutr Health Aging 2006;10:272e83. 27. Health Canada. Eating Well with Canada’s Food Guide. Available at: http:// www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php. 2011. Accessed on August 14, 2015. 28. Suominen MH, Jyvakorpi SK, Pitkala KH, Finne-Soveri H, Hakala P, Mannisto S, et al. Nutritional guidelines for older people in Finland. J Nutr Health Aging 2014;18:861e7. 29. Rafii M, Chapman K, Owens J, Elango R, Campbell WW, Ball RO, et al. Dietary protein requirement of female adults >65 years determined by the indicator amino acid oxidation technique is higher than current recommendations. J Nutr 2015;145:18e24. 30. Tang M, McCabe GP, Elango R, Pencharz PB, Ball RO, Campbell WW. Assessment of protein requirement in octogenarian women with use of the indicator amino acid oxidation technique. Am J Clin Nutr 2014;99:891e8. 31. Mamerow MM, Mettler JA, English KL, Casperson SL, Arentson-Lantz E, Sheffield-Moore M, et al. Dietary protein distribution positively influences 24-h muscle protein synthesis in healthy adults. J Nutr 2014;144:876e80. 32. Basu R, Dalla Man C, Campioni M, Basu A, Klee G, Toffolo G, et al. Effects of age and sex on postprandial glucose metabolism: differences in glucose turnover, insulin secretion, insulin action, and hepatic insulin extraction. Diabetes 2006;55:2001e14. 33. Chiu C-J, Liu S, Willett WC, Wolever TM, Brand-Miller JC, Barclay AW, et al. Informing food choices and health outcomes by use of the dietary glycemic index. Nutr Rev 2011;69:231e42. 34. Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011. JUNE JOGC JUIN 2016 l 553 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 35. Gallagher JC, Smith LM, Yalamanchili V. Incidence of hypercalciuria and hypercalcemia during vitamin D and calcium supplementation in older women. Menopause 2014;21:1173e80. 36. Prentice RL, Pettinger MB, Jackson RD, Wactawski-Wende J, Lacroix AZ, Anderson GL, et al. Health risks and benefits from calcium and vitamin D supplementation: Women’s Health Initiative clinical trial and cohort study. Osteoporos Int 2013;24:567e80. 37. Hanley DA, Cranney A, Jones G, Whiting SJ, Leslie WD, Cole DE, et al. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. Can Med Assoc J 2010;182:E610e8. 38. Allen LH. How common is vitamin B-12 deficiency? Am J Clin Nutr 2009;89:693Se6S. 39. van Asselt DZ, van den Broek WJ, Lamers CB, Corstens FH, Hoefnagels WH. Free and protein-bound cobalamin absorption in healthy middle-aged and older subjects. J Am Geriatr Soc 1996;44:949e53. 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. 41. Ilich JZ, Brownbill R, Tamborini L. Bone and nutrition in elderly women: protein, energy, and calcium as main determinants of bone mineral density. Eur J Clin Nutr 2003;57:554e65. 42. Osteoporosis Canada. BoneFit. 2015. Available at: http://www. osteoporosis.ca/programs-and-resources/bonefit/. Accessed on November 11, 2015. 43. Harvey RE, Coffman KE, Miller VM. Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease. Womens Health (Lond Engl) 2015;11:239e57. 554 l JUNE JOGC JUIN 2016 44. Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937e52. 45. Liese AD, Krebs-Smith SM, Subar AF, George SM, Harmon BE, Neuhouser ML, et al. The Dietary Patterns Methods Project: synthesis of findings across cohorts and relevance to dietary guidance. J Nutr 2015;145:393e402. 46. Maki PM. Verbal memory and menopause. Maturitas 2015;82:288e90. 47. Cao L, Tan L, Wang HF, Jiang T, Zhu XC, Lu H, et al. Dietary patterns and risk of dementia: a systematic review and meta-analysis of cohort studies [e-pub ahead of print] Mol Neurobiol 2015;. 48. Fournier LR, Ryan Borchers TA, Robison LM, Wiediger M, Park JS, Chew BP, et al. The effects of soy milk and isoflavone supplements on cognitive performance in healthy, postmenopausal women. J Nutr Health Aging 2007;11:155e64. 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 l 554.e1 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 l 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 l 554.e3 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 554.e4 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 554.e5 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 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 554.e7 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. 554.e8 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 554.e9 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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 554.e10 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 554.e11 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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. 554.e12 l JUNE JOGC JUIN 2016 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 JUNE JOGC JUIN 2016 l 554.e13 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. 554.e14 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 554.e15 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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. 554.e16 l JUNE JOGC JUIN 2016 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. JUNE JOGC JUIN 2016 l 554.e17 Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond 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