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Sexual & Reproductive Health Nutrition for Women Part I: Sexual & Reproductive Health 8th edition • Revised December 2009 by Dale Ames Kline, ms, rd, cnsc, ld 6400 Branch Arlington Blvd, Falls Church, VA22107 22042 7950 Jones Drive, 7th Floor, McLean, VA 1-888-781-5388 www.nutritiondimension.com 1-800-866-0919 • www.continuingeducation.com 7950 Jones Branch Drive, 7th Floor, McLean, VA 22104 1-800-866-0919 (US & Canada) • 1-703-854-2531 (overseas) FAX:1-703-854-2531 • e-mail: [email protected] Nutrition for Women Part I: Sexual & Reproductive Health 8th Edition – Revised December 2009 By Dale Ames Kline, ms, rd, cnsc, ld Dale Ames Kline, MS, RD, CNSC, LD president of Nutrition Dimension, Inc., has created continuing education programs since 1984. A former hospital chief clinical dietitian and nutrition educator in the WIC program, she has written, edited and presented numerous continuing education seminars and home study courses and has lectured before international, national, state and local groups of medical, fitness and nutrition professionals. Dale has been active in local, state and regional dietetics associations, was named “Recognized Young Dietitian of the Year” in 1984 and awarded "Outstanding Nutrition Entrepreneur of the Year" in 2001 by the Nutrition Entrepreneurs Practice Group. Dale was elected as a Professional Issues Delegate to the House of Delegaes of ADA in 2003. Dale resides in Southern Oregon. Education: BA, Tufts University; MS, University of Missouri. Important - Read Before Proceeding EXPIRATION DATE: Students must submit this course for continuing education credit no later than December 31, 2014. Credit will not be awarded for this course after that date. Course Code: RD106, CHES106, FIT106, AT106 This course approved for RD, DTR................. 10 CPEU CDM............10 Clock Hours CHES......................10 CECH ACE.......................... 1.0 CEC NATA (BOC)..............5 CEU NSCA-CC................0.7 CEU ACSM........................10 CEU CFCS..........................10 PDU Editing/proofreading: Rich Kline, Gwen Hulbert Design: Knotwork Graphic Design & Typesetting © 1988-2010 Nutrition Dimension/Gannett Education, Inc. No part of this course may be reproduced, duplicated or copied in any way without the written permission of the copyright holder. (See note on Page ii) Sexual & Reproductive Health ii How to Earn Continuing Education Credit 1.Read or watch the course material. Don’t forget to review the course objectives and take note of course tools available to you. The objectives provide specific learning goals and an overview of the course. Read the material in the order presented. If you need help with the material, please e-mail [email protected] with your specific question. We will forward your inquiry to the author, so allow adequate time for a reply. 2.CE credit will not be awarded for this course after December 31, 2014. 3.If you have an account on Nurse.com, TodayinPT.com, or TodayinOT.com, or NutritionDimension. com, please use that account username and password to sign in on ContinuingEduation.com. If you don’t already have one, please sign up for a user account. Click “sign up” or “login” in the upper right hand corner of any page on ContinuingEducation.com. If you have a CE Direct login ID and password (generally provided by your employer), please log in as you normally would at lms.nurse. com and search for this topic title. 4.Go to the “my courses” section of “my account.” Click on the title of the course you want to complete and then on “start course.” 5.Click “start test” to begin the exam. To earn contact hours, you must achieve a score of 75% on your multiple-choice exam for most courses. For webinar courses, you will need to achieve a score of 100%. You may retake the test as many times as necessary to pass. Clues are not provided on the exam. Certificates will be date/time stamped with the time and date of the day the user passes the test (Eastern Time, U.S.). 6.After successfully completing your exam click, “complete required survey.” In order to complete the test process and receive your certificate of completion, you must take a few moments to answer a brief survey about the course material. 7.After completing the survey, you will be taken to your transcript. Under Courses Completed, you can view, print, or e-mail your certificate. 8.Three months after you complete a course, you will receive an e-mail asking you to complete a followup survey. This is vital to our educational requirements so we can report our quality outcomes and effectiveness. We report course completions to National Commission for Health Education Credentialing (NCHEC) quarterly and The Association of Nutrition & Foodservice (ANFP, formerly DMA) monthly. Other professions should follow their certifying organization’s reporting instructions. We keep a record of course completions for 7 years. A Word About Copyrights: We encourage health professionals to use material from this course in their practice. Please follow these guidelines: (1) Credit the author, Nutrition Dimension/Gannett Education and any referenced source. (2) Course material may not be sold, published, or made part of any program for which a fee is charged, without written permission from Nutrition Dimension/Gannett Education. (3) Inform Nutrition Dimension/Gannett Education by letter if you wish to make significant use of material from this course (e.g. if you wish to duplicate Appendix pages for a training session or patient handout). Sexual & Reproductive Health iii Contents Page Chapter 1 Introduction 3 Chapter One: Premenstrual Syndrome What is PMS? • Diagnosing PMS • Causes and treatment • Nutritional factors • Carbohy- drates • Fats and fatty acids • Placebo effect • Dietary recommendations • Vitamin/Mineral Supplements • Herbs 15 Chapter Two: Oral Contraceptives How oral contraceptives work • Risks and benefits of OCA • Lipid metabolism • Protein metabolism • Venous thromboembolytic diseass and strokes • Carbohydrate metabo lism • Vitamin B6 • Other vitamins • Minerals • Bone mineral density • Dietary recommen dations 31 Chapter Three: Factors Affecting Pregnancy Outcome Risk factors • Nutrition and fertility • Diseases in later life • Epigenetics 39 Chapter Four: Physiological Changes which Alter Nutrient Needs Hormones • Blood • Cardiovascular system • Renal function • Liver • Gastrointestinal system Metabolism • Placenta • Fetal growth and gene regulation • Pregnancy and Ω-3 fatty acids 53 Chapter Five: Nutrient Needs in Pregnancy Calories • Protein • Fat intake • Fiber and Carbohydrates • Sodium • Iron • Zinc and Iron • Folic acid • Zinc • Calcium • Vitamin D • Fluoride • Vitamin B6 • Other vitamins and minerals 79 Chapter Six: Weight Gain in Pregnancy Optimal weight gain • Evaluating prepregnancy weight • Weight gain recommendations: Normal weight/underweight/overweight • Weight gain in adolescents • Twin pregnancies, multiple pregnancies and more • Monitoring weight gain • Counseling principles • Exercise Case studies 101 Chapter Seven: Diet Assessment for Pregnancy Dietary guidelines • MyPyramid for moms • Calories • Food groups: Meat/meat alternatives Dairy group • Fruits/vegetables • Breads/cereals • Feedback form • Assessing the diet 119 Chapter Eight: Special Diet Problems, Supplementation and Exercise Weight gain • Nausea & vomiting • Heartburn and constipation • Leg cramps • Non-nutritive sweeteners • Caffeine • Bariatric surgery • Food safety • Herbs • Adolescent pregnancy Supplementation • Pica • Vegetarian diets • Exercise 139 Chapter Nine: Medical Complications Calcium, magnesium and preeclampsia • Prostaglandins and preeclampsia • Diabetes • Pathophysiology of diabetes • Classification of diabetes • Diabetes onset prior to pregnancy • Gestational diabetes • Nutritional management of pregestational diabetes HIV and AIDS 155 Chapter Ten: Alcohol, Tobacco & Other Drugs Fetal alcohol syndrome • Smoking • Drugs • Use of medication in pregnancy • Street drugs 169 References 183 Appendices 201 Examination Sexual & Reproductive Health iv Learning Objectives Upon successful completion of this course, the student will be able to: 1. Explain how PMS is diagnosed. 2. List three dietary changes that may alleviate symptoms associated with PMS. 3. Describe the metabolic alterations that occur with use of oral contraceptives, and three nutrients whose requirements change. 4. Explain the relationship of oral contraceptive use and bone mineral density. 5. Discuss the impact of the nutritional status of pregnant women on pregnancy outcome. 6. List three factors which influence the nutritional status of a pregnant woman. 7. Discuss the relationship of fetal development to nutrient requirements, by trimester. 8. Identify the proper weight gain for the pregnant woman who at conception is normal weight, underweight or overweight. 9. Plot the weight gain of a pregnant woman on a prenatal weight gain grid. 10. List the current intake recommendations during pregnancy for the following nutrients: calories, protein, sodium, iron, folic acid, zinc and calcium. 11. Determine a plan of nutrient supplementation for pregnant women who prior to pregnancy are well nourished, poorly nourished or anemic. 12. Analyze the diet of a pregnant woman, using a food frequency form, to determine if it meets the dietary recommendations for pregnancy. 13. Recommend three solutions for the common complaints of pregnancy: nausea, vomiting, heartburn and constipation. 14. Design a diet for a gestational diabetic that has the appropriate number and distribution of calories. 15. Explain the current treatment for preeclampsia and its rationale. 16. Explain the effects of maternal cigarette smoking on the fetus and pregnancy outcome. 17. Identify a safe level of consumption of caffeine and alcohol for the pregnant woman. 18. Discuss the importance of Ω-3 fatty acids in fetal development and preeclampsia and list four sources in the diet. Sexual & Reproductive Health 1 Introduction The role of nutrition in sexual and reproductive health, particularly in healthy pregnancy and childbearing, is the focus of this course. In the 21 years since the original version of this course was published, research has continued to document the important role of nutrition in sexual and reproductive health. Major studies affirming the importance of folic acid in preventing neural tube defects in babies, for instance, have confirmed recommendations made in the first edition of this course and led to the fortification of wheat flour with folic acid beginning in 1998. This has reduced the number of babies born with neural tube defects. It is gratifying to see early research leading to positive action which improves quality of life and prevents problems for women and newborns. While progress has been made in understanding the cause or causes of premenstrual syndrome, many questions remain. We will review what is known about PMS, including the role of nutrition in preventing the symptoms of PMS. The nutritional effects of oral contraceptive use are now well understood. Numerous metabolic changes occur with the use of oral contraceptives, altering nutrient needs. Dietary recommendations to ensure proper intake of specific nutrients will be discussed for women in general and for those women who would like to get pregnant following discontinuation of the pill. The effect of the third-generation hormones and newer hormone delivery systems will be reviewed. The course explains how several factors affect the nutritional needs of the pregnant woman: physiological changes associated with pregnancy, prepregnancy nutritional status, and pre-existing diseases and conditions. Evidence has shown that a mother’s prepregnancy weight and her weight gain during pregnancy are linked to the birth weight of her child. Low birth weight correlates with increased morbidity and mortality for newborns. In 2009, because more childbearing women are overweight and obese, which can Sexual & Reproductive Health 2 effect pregnancy outcome, and more retain gained weight after delivery, the Institute of Medicine (IOM) and the National Research Council of the National Academies published new guidelines for weight gain during pregnancy, the first since 1990. These are discussed at length. The incidence of low birth weight babies has declined over the years — however, the birthweight of babies is increasing to the point of being unhealthy. Education of proper nutrition and exercise throughout the childbearing years is stressed in the new IOM weight gain guidelines, which have been incorporated into this course. Evidence has been accumulating that nutrition in utero may affect the long term health of the baby, especially its risk for heart disease, diabetes and hypertension. The role of epigenetics in pregnancy and the health of offspring is introduced. Dietary practices that can be modified to affect pregnancy outcome will be examined: intake levels of specific nutrients, weight gain, exercise, smoking, use of alcohol and drugs, pregnancy-induced hypertension, diabetes and bariatric surgery. How to manage some of the common problems of pregnancy, such as nausea and vomiting, heartburn, and leg cramps will be covered. It has been assumed that most women get adequate vitamin D due to exposure to the sun, but over the past 10 to 15 years researchers have found that many women living in northern climates do not make enough vitamin D, and in fact may be deficient. The section looks at the problems with inadequate vitamin D in pregnancy and how to ensure adequacy. MyPyramid, which replaces the Food Guide Pyramid, now has a section for pregnancy and breastfeeding. It is a great interactive tool that provides individualized meal plans, "MyPyramid Plan for Moms," has a menu planner and many educational resources to help pregnant women make the best food choices. These plans are now in household measures — cups and ounces — not "servings." To be consistent with MyPyramid, I have changed the forms and assessment tools to household measurements as well. Other information in this edition includes periodontal disease and pregnancy, a vegetarian food guide pyramid, an appendix on weight gain for twin pregnancies, a discussion of oxidative stress and preeclampsia, and the new FDA guidelines on fish consumption during pregnancy. Finally, the latest information on the importance of drug therapy for pregnant women with HIV/AIDS will be discussed. This is the eighth edition of this course. It is amazing to me how time flies and how much more is known about nutrition and pregnancy than when I wrote the first edition, in 1988. I would like to thank the customers of Nutrition Dimension for their overwhelming support of this course and their positive feedback. I would also like to acknowledge the efforts of Brenda Dobson, MS, RD, for research assistance and her dedication to maternal and child health issues. Sexual & Reproductive Health 3 Chapter One: Premenstrual Syndrome Premenstrual Syndrome (PMS) was first described in 1931 by Robert T. Frank, MD. The symptoms he documented were similar to those used today to diagnose PMS. The cause of PMS, according to Frank, was an increase in the plasma concentration, and decrease in the urine concentration, of sex hormones. He reasoned that the cure was to reduce the hormone levels, and his treatment was radiation of the ovaries, which may have successfully treated the disorder, but obviously created a host of new problems. We've come a long way since then, thankfully. Understanding of the causes and development of effective treatments for PMS has continued since 1931, but not as fast as many would like. There was very little research into PMS until the 1970s. Research greatly expanded in the 1980s and continues. Unfortunately, there are still as many questions as answers. PMS Facts • Incidence: 75% of menstruating women complain of symptoms • 3 to 8% diagnosed using strict diagnostic criteria • 10 to 15% of women have severe, debilitating symptoms • Onset of symptoms 7 to 14 days prior to menstruation • Symptoms disappear within 4 days of menstruation • Diagnosis should be done prospectively Barnhart, et al., 1995; Bianchi-Demicheli, 2002 Sexual & Reproductive Health 4 WHAT IS PMS? One reason for the lack of progress is definition and diagnosis. PMS is a set of symptoms, physiological and psychological, that occurs prior to menstruation. These symptoms cause physical and behavioral changes that interfere with the lives of the women affected, but are difficult to quantify. Onset of the symptoms occurs seven to 14 days prior to menstruation and disappears within four days of when menstruation begins (Rapkin, 2003). ("Premenstrual Dysphoric Disorder" (PMDD) is used by some practitioners and researchers interchangeably with PMS. It is generally considered to be similar to PMS, but as we will see, it is usually more severe. In this course I will consider PMS and PMDD one disorder but note when there is a clear distinction between the two.) The incidence of PMS reported in the literature is 5 to 97 percent of menstruating women — a range that further illustrates the subjective nature of the condition. It is generally accepted that between 30 and 60 percent of women have had PMS, but that number declines drastically to 3 to 8 percent when more strict diagnostic criteria are applied (Barnhart, et al., 1995; Bianchi-Demicheli, et al., 2002). Of those women with PMS, 10 to 15 percent have severe symptoms that make it difficult for them to carry on their normal lives and cause them to seek medical help. Using a figure of 50 million women of reproductive age in this country, that means 37.5 million have some symptoms and 1.5 to 4 million have diagnosable PMS which has caused them to seek treatment. The most common reported symptoms are breast swelling and tenderness, headaches, backaches, skin disorders, weight gain, bloating, mood swings, irritability, depression and anxiety. Other symptoms, although not as common, include food carvings (sweets, chocolate, salt, carbohydrates), nausea, joint pain, dizziness, lethargy, fatigue, sleep disturbances and aggression. Further complicating the problem is women’s reluctance to bring this disorder to the attention of their physicians. Many feel that their symptoms are solely psychological, not physiological. Unfortunately, that had also been the thinking of much of the medical community until recently, making it difficult for women to talk about this disorder. Now, although the cause has not been determined, there is acceptance of this disorder as a disease and not “all in the minds” of the women affected. Symptoms of PMS Breast tenderness Breast swelling Weight gain Headache Depression Anxiety Binge eating Dizziness Irritability Lethargy Fatigue Aggression Hyperalgesia Cramping Mood swings Acne Joint pain Nausea Sleep disturbances Thirst Bloating Sexual & Reproductive Health 5 DIAGNOSING PMS A PMS diagnosis requires not only symptoms, but a characteristic pattern of onset and disappearance of symptoms, and severity. The onset of symptoms must correspond to hormonal changes which occur with the phases of a woman’s menstrual cycle, as shown in the chart below. Phases of the Menstrual Cycle Phase Menstrual Mid-follicular Ovulatory Luteal Days of Cycle 0- 7 7 - 14 14 - 21 21 - 28 For a woman to be diagnosed as having PMS, her symptoms must correspond with the luteal phase of the menstrual cycle, disappear at the onset of or during menstruation and not reappear for at least a week (Barnhart, et al., 1995; Bianchi-Demicheli, et al., 2002; Dickerson, et al., 2003). There is a consensus in the medical community that it is the timing of the appearance and disappearance of the symptoms, rather than any specific symptoms, that leads to a diagnosis of PMS. To gather the information needed for a diagnosis, questionnaires asking patients to rate their symptoms are used. These questionnaire should be prospective, based on events as they occur. Retrospective questionnaires, based on past events and experiences, are not as valuable as respondents tend to overestimate the presence and severity of symptoms. Mortola (1990) and other researchers have found that a prospective inventory is easy to complete and is a valid and reliable diagnostic tool. Most importantly, a comparison between cycles must be done to determine the changes in the severity of symptoms within a cycle and between cycles. Therefore, the questionnaire must be kept for several consecutive menstrual cycles. The symptoms must be severe enough to interfere with normal functions, i.e. school, work, social activities, relationships. The American College of Obstetricians and Gynecologists established criteria to diagnose PMS and PMDD, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria (Rapkin, 2003): • PMS: one moderate-to-severe mood symptom and one physical symptom • PMDD: a total of five symptoms with one severe mood symptom CAUSES AND TREATMENT Numerous causes of PMS have been theorized but, to date, none have been proven. PMS is a probably a complex interaction between ovarian steroid production, endogenous opioid peptides, central nervous system neurotransmitters, prostaglandins, peripheral and autonomic nervous systems and endocrine systems, but no one is sure of the exact mechanisms of action. Sexual & Reproductive Health 6 Mood changes associated with PMS may be caused in part by the ability of estrogen and progesterone to act within the brain. Receptors in the brain for both hormones have been identified, as has their ability to stimulate or inhibit brain activities. However, progesterone levels are not abnormal in all women with PMS. Many have normal progesterone levels throughout the monthly cycle and still have weight gain and bloating. Treatment with progesterone will correct hormonal imbalances. However, in an evidence-based review of effective treatments, progesterone has not been shown to be effective in treating PMS (Douglas, 2002). In a review of trials of progesterone use to treat PMS, the authors stated they could not conclude that progesterone treatment was or was not effective (Ford, et al., 2009). The authors found many flaws in the individual studies, especially differences in criteria between studies, so that comparisons were difficult to draw. Another theory cites an endogenous opiate peptide imbalance. Opiate peptides are small protein molecules that have numerous functions as neurotransmitters and neuromodulators. They affect the levels of norepinephrine and dopamine, regulate endocrine secretion, influence mood and behavior, alter production and secretion of hormones, inhibit fluid secretion in the bowel and decrease peristalsis. Cyclic changes in endogenous opiate peptide activity during the menstrual cycle may alter the body’s physiology enough to cause some symptoms of PMS, such as mood changes, water retention and constipation. There is not sufficient evidence to support this theory at the present time, although research continues. Other research has focused on alterations in neurotransmitters as the cause of PMS — specifically, changes in serotonin activity and the serotonin receptor 5-HT. Serotonin is involved in our moods, especially irritability, anger and depression as well as specific food cravings (Bianchi-Demicheli, et al., 2002). Estrogen decreases the sensitivity of serotonin receptors and increases the sensitivity of serotonin antagonists. During the luteal phase of menstruation, serotonin levels are decreased in the blood of women with PMS (Ashby, 1988). Women with PMS do have a heightened sensitivity to the serotonin receptor 5-HT during the luteal phase that increases premenstrually (Freeman, 1992). Although the exact cause(s) of PMS are unknown, some treatments have been proven clinically effective. Begging the question "why?", we can review the literature to see if good scientific evidence exists for the various PMS treatments commonly used. The consensus is that two treatments are supported by enough quality research to recommend their use: calcium supplements and selective serotonin reuptake inhibitors (SSRI) (Douglas, 2002; Rapkin, 2003; Brown, et al, 2009). Other therapies that have some empirical evidence of benefits include vitamin B6, evening primrose oil, oral contraceptives, complex carbohydrate drinks, cognitive behavioral relaxation therapy and aerobic exercise (Douglas, 2002; Rapkin, 2003). The best approach is to try to alter lifestyle first, such as exercise, diet and stress. If symptoms still persist after two or three months, then drugs can be used (BianchiDemicheli, et al., 2002). Sexual & Reproductive Health 7 Serotonin reuptake inhibitors (SSRI) have shown good success in treating PMS and are the first drug of choice for more severe PMS (Barnhart, et al., 1995; Moline and Zendell, 2000; Bianchi-Demicheli, et al., 2002; Vleck and Safranek, 2002; Brown, et al., 2009 ). In a review of 15 randomized controlled trials involving 884 women, the evidence supported the use of SSRI to treat severe PMS (Wyatt, et al., 2006). This conclusion was supported by a newer meta-analysis of over 2,294 women, in which SSRI drugs were found to be highly effective in treating severe PMS (Brown, et al., 2009). SSRI drugs that have been investigated include: fluoxetine (Fluctine®), sertraline (Zoloft®), paroxetine (Deroxat®), citalopram (Seropram®), venlafaxine (Efexor®) and fluvoxamine (Luvox®) (Bianchi-Demicheli, et al., 2002; Brown, et al., 2009). Vitamin E has been used to treat breast tenderness in women with PMS. Women given 400 IU of vitamin E for two months had substantial relief from breast tenderness (London, et al., 1987). No more recent studies on vitamin E have been reported. Debate over the effects of caffeine on breast tenderness continues. Some studies show that caffeine (from soft drinks, coffee, tea, chocolate or over-the-counter drugs) increases breast tenderness, while other studies don't. This may be due to the effect of caffeine on magnesium levels, which will be discussed in the next section. NUTRITIONAL FACTORS Deficiencies and imbalances of various vitamins, minerals and nutrients in the diet have been theorized to cause PMS symptoms. Only one, calcium, has well-documented studies to back up its benefits. Other nutrients, such as magnesium, carbohydrates, vitamin D, vitamin E and vitamin B6 appear to be of benefit, but more studies are needed. Let's look at what we know. • Calcium does appear to reduce the symptoms of PMS, especially water retention, mood changes, food cravings and pain, in doses of 1200 to 1600 mg/day (Thys-Jacobs, et al., 1998, Ward and Holimon, 1999). Thys-Jacobs and colleagues (1998) conducted a double-blind, placebo-controlled, multi-center clinical trial comparing calcium supplementation to a placebo on PMS symptoms. The supplemented group showed a significant reduction in symptoms, 48 percent, by the third treatment cycle, compared to a 30 percent reduction in the control group. Calcium metabolism, including intestinal absorption and parathyroid gene expression, is regulated by estrogen. Alterations of calcium metabolism resulting in hypocalcemia, occur in PMS, leading to symptoms of depression, anxiety and other mood changes (Thys-Jacobs, 2000). Supplementing with calcium reverses the calcium deficiency, alleviating those symptoms associated with the low serum calcium levels. Note how similar the symptoms of hypocalcemia are to those of PMS. Other studies have found that women with a history of PMS have reduced bone mass and an increased risk for osteoporosis (Bendich, 2000). • Vitamin D may also be beneficial to women with PMS. In a study using data from the prospective Nurses' Health Study II cohort, researches found an inverse relationship between vitamin D intake and PMS , as well as calcium intake and PMS (Bertone- Sexual & Reproductive Health 8 Johnson, et al., 2005). As intake of each nutrient increased, the incidence of PMS decreased. The intake of vitamin D in the highest quintile was 706 IU/day, versus 112 IU/ day in the lowest quintile. For calcium, the highest quintile had an intake of 1283 mg/day, versus 529 mg/day in the lowest quintile. In more recent studies, calcium plus vitamin D, or calcium alone, were effective in decreasing PMS symptoms (Khajehei et al., 2009; Ghanbari et al., 2009). It is recommended that women with PMS supplement approximately 1200 mg/day of calcium, well within tolerable limits. This amount of calcium will help alleviate PMS symptoms as well as maximize bone health. Not all the calcium needs to be supplemented; as intake increases, supplementation can decrease. In addition, getting adequate vitamin D is also important, whether from the sun, food or supplementation. Women living in more northern climates are more likely to be vitamin D-deficient and should supplement with up to 1000 IU per day (Holick, 2004; Hollis, 2004). • Vitamin B6 is necessary for the production of the neurotransmitters dopamine, norepinephrine and serotonin, which control and affect our moods. In women taking oral contraceptives, vitamin B6 metabolism was altered, causing low serum B6 levels. When women with low serum B6 levels were supplemented with vitamin B6, metabolism and serum levels were normalized and behavioral changes, such as depression, mood swings and irritability were helped by the additional vitamin B6. Some of the mood changes experienced by women using oral contraceptives are experienced by women with PMS. Supplemental vitamin B6 seems to help some women not only with mood changes, but other symptoms as well. Not all women are helped by B6 supplementation. Berman and others (1990), in a study of the effects of 250 mg of supplemental vitamin B6 on PMS, found that subjects reported improvement of their symptoms, but noted that there was no significant change in the biochemical indices of vitamin B6 status. Bendich (2000) found conflicting results in a review of the literature, while Wyatt and colleagues (1999) believe that supplemental vitamin B6, up to 100 mg/day, is likely to be of benefit in treating premenstrual symptoms and premenstrual depression. Bendich noted that most of the studies were small, with flawed methodologies, but that the results of all the studies combined indicate a potential for vitamin B6 to relieve some PMS symptoms. Newer research is needed to determine the effectiveness of vitamin B6. Caution must be used when using vitamin B6. Peripheral nerve damage (reversible if supplementation stopped soon after symptoms appear) can develop in sensitive individuals at doses above 100 mg/day, a level below the 200 to 500 mg/day which is recommended by some PMS practitioners. The tolerable upper limit (UL) for vitamin B6 is 100 mg/day, a level designed to protect the most sensitive individuals (IOM, 1998). • Magnesium. Serum levels of magnesium and zinc have been shown to be significantly reduced, and serum copper significantly elevated, in the luteal phase of menstruation in women with PMS (Posaci, et al., 1994, Chuong and Dawson, 1994). It is magnesium that appears to play a role in the development of PMS. Excess intake of alcohol, salt and caffeine can decrease magnesium levels and worsen symptoms in PMS (Rapkin, 2005). Sexual & Reproductive Health 9 There are several potential mechanisms by which magnesium may cause or exacerbate PMS. Magnesium is involved in neurotransmitter activity, including serotonin, as well as neuromuscular function, cell membrane stability and vascular contraction, all of which are "abnormal" in PMS. Only a few small studies have investigated whether or not supplemental magnesium can alleviate or reduce symptoms of PMS in doses of 200 to 360 mg/day. One study found that supplementation of 200 mg magnesium a day significantly reduced mild fluid retention symptoms of PMS (Walker, 1998). According to Bendich (2000), these studies are promising but do not conclusively prove clinical benefit. More studies are needed. However, it will do no harm to supplement magnesium in doses of 250 mg to 400 mg/day. In a recent study comparing women receiving intravenous magnesium infusion and controls, there was no difference in the amount of magnesium retained by the two groups, indicating no magnesium deficiency (Khine et al., 2006). When the subjects knew they were getting a magnesium infusion, there was an improvement in mood. When the authors then changed the study to a double-blind, placebo-controlled study, there was no difference in the effect of the intravenous magnesium on mood. Changes in blood sugar levels, causing hypoglycemia, have been blamed for PMS. Evidence does not support this theory, though it is true that some women experience cravings for sweets and chocolate during PMS, and many increase their caloric intake. The cravings have not been definitely linked to low blood sugar levels. In fact, increased appetite may be due to increased progesterone, which has an appetite-enhancing effect. Many studies, including one by Lissner and coworkers (1988), have shown that caloric intake varies during the monthly menstrual cycle, most likely due to hormonal fluctuations. Martini and colleagues (1994) found significant increases in mean intakes of energy, protein, carbohydrate and fat during the midluteal phase of the menstrual cycle, compared with the mid-follicular cycle. Cross, et al. (2001) found that some women with PMS — but not all — increase their nutrient intake during the premenstrual phase of the menstrual cycle. CARBOHYDRATES The types and amounts of carbohydrate in the diet may affect PMS. Wurtman and colleagues (1989) studied food intake and mood changes during the follicular and luteal phases of the menstrual cycle. In one study, 19 patients who claimed to suffer from PMS (and who had mood scores determined by both a self-test and a psychiatric interview) were monitored for food intake. They took meals in a common dining room. Women with PMS increased their caloric intake and ate more carbohydrate-rich foods in the luteal phase of their menstrual cycles, while the control group did not change its consumption patterns. Wurtman’s second study investigated the effects of carbohydrate-rich meals on mood and plasma levels of glucose, insulin and amino acids. Eighteen women with PMS, and 14 age-matched non-PMS controls, differed significantly in their behavioral Sexual & Reproductive Health 10 response to a carbohydrate-rich meal during the late luteal phase of their menstrual cycles, but not during the follicular phase. Interestingly, the biochemical parameters did not differ in the two groups. Increasing carbohydrate consumption without increasing protein increases the production and release of serotonin, a brain neurotransmitter involved in mood and behavior. In a pilot study in 2008, there were no differences in insulin sensitivity between the follicular and luteal phases of the menstrual cycle, although cravings increased during the luteal phase while the distribution of calories remained the same (Trout, et al., 2008). The women in this pilot study ate 55 to 64 percent of their calories from carbohydrate. Along those same lines, tryptophan is the precursor of serotonin. In women with documented PMS, a tryptophan-depleting diet significantly aggravates PMS symptoms (Menkes, et al., 1994). Sayegh and colleagues (1995) had women diagnosed with PMS drink a specially formulated, carbohydrate-rich beverage that increased serum tryptophan levels. After consumption of the beverage, PMS symptoms — mood, cognitive function and appetite disturbances — improved. In a more recent study, a carbohydrate-rich beverage, given twice a day to women with PMS five days prior to menstruation, decreased mood symptoms in 33 percent of the women (Freeman, 2002). Only 5 percent of the women given a placebo had improvement in their mood symptoms. More research is needed to determine if carbohydraterich foods or drinks can alleviate PMS symptoms. Again, using this treatment will do no harm until the scientific evidence proves it is or is not clinically beneficial. FATS AND FATTY ACIDS Fatty acids are the precursors to prostaglandins (PG), substances which have regulatory functions in the body similar to hormones. They can influence dilation of the veins and arteries, capillary permeability, fluid balance, neurotransmitter activity, immune function and cerebral blood flow. Prostaglandin PGE1 stimulates progesterone production and is produced from omega-6 (Ω-6) fatty acids, primarily linoleic acid. Animal fats, high in arachidonic acid, decrease progesterone synthesis by producing the prostaglandin PGF2 which discourages progesterone synthesis as shown in the diagram on the next page. Evening primrose oil, sold as Efamol®, is 5 to 20 percent gamma-linolenic acid (GLA). In the body GLA is converted to PGE1, with the enzymes and cofactors vitamin C, B6, niacin, magnesium and zinc. PGE1 prevents fluid retention, is anti-clotting, reduces insulin response to glucose and reduces the neuroendocrine response to low blood sugar, among other functions. Evening primrose oil has been investigated as a treatment of PMS, with mixed results. Some studies reported relief from the use of evening primrose oil, others did not. In a review of the literature on evening primrose oil and PMS, there was insufficient evidence to show that evening primrose oil was of much benefit in women with PMS (Budeiri, et al, 1996; Rapkin, 2005). 11 Sexual & Reproductive Health Dietary Fatty Acids & PMS Polyunsaturated Vegetable Oils Saturated Fats Animal Fats Linoleic Acid Prostaglandin E1 Progesterone increases Arachidonic Acid Prostaglandin F2 Progesterone decreases THE PLACEBO EFFECT In analyzing all the data available on the relationship of various modes of treatment for PMS, one fact becomes clear: While treatment of any kind seems to help, not all symptoms are alleviated, and in some women there is no effect. The benefits of dietary change cannot always be explained by available research. The benefits of many dietary changes have not been proven, although — anecdotally — they appear to work. It may be that in combination with other therapies, diet is an effective treatment. Some of the response to diet and nutritional supplements can be explained by the placebo effect. Studies quote that from 50 to 90 percent of the benefits from various treatments are due to the placebo effect, as indicated in Hammarback’s 1989 review of PMS. If a treatment seems to help, is not harmful or expensive, why not try it? If positive results are due to the placebo effect, so what? When a woman is suffering from PMS and needs help, changing the diet may be an easy answer. Even if the changes do not relieve the PMS symptoms, a nutritionally sound diet will be beneficial in the long run. Until more research is completed, we will not have definitive answers on how diet and supplements affect PMS. Until then, we can use diet as a form of treatment, since it is not harmful and may be extremely beneficial. DIETARY RECOMMENDATIONS To be effective, dietary changes for PMS need to become a permanent part of a woman’s life. Nutrition counselors need to ensure that the diets are nutritionally sound, with safe levels of vitamin and mineral supplements. • Limit intake of refined sugar to prevent decreased magnesium absorption (Also, foods that are high in refined sugar tend to be low in most other nutrients.) • Limit salt intake to 2300 mg/day (Dietary Guidelines for Americans, 2005). Salt causes water retention and can increase the bloating and weight gain of PMS. Limit the amount of salt added to food and limit foods high in salt: processed Sexual & Reproductive Health 12 foods, salty snack foods, canned soups, ham, bacon, luncheon meats, hot dogs, soy sauce, pickled foods and marinated foods (if salt is used). Read the label to determine if salt is added to foods bought at the supermarket. Some women find they only need to limit salt intake for two weeks prior to menstruation. • Rely as much as possible on plant sources instead of animal sources to meet protein needs. Plant protein is low in fat, and most of the fat found in these foods is polyunsaturated. Use low-fat and non-fat dairy products, as they are excellent sources of calcium and protein, as well as vitamin D. • Increase intake of complex carbohydrates, including dried peas and beans, vegetables, grains and fruits. These foods provide magnesium, vitamin C, B6, folate, zinc and other important nutrients often inadequate in the diet. Dietary changes without supplementation can help women with PMS. Make changes slowly. If too many dietary changes are attempted at once, failure is likely. VITAMIN/MINERAL SUPPLEMENTS Nutrition supplements have become a part of the treatment for PMS. Studies investigating the role of specific nutrients and PMS have come up with contradictory results. Stewart (1987), in a study of 11 women with PMS, found nutritional deficiencies of vitamin B6 in eight women, and of magnesium and zinc in 10 women. Other deficiencies found were: • chromium in five women; • potassium in four; • vitamin E in three, and • vitamin B1 and vitamin B2 in one woman each. These deficiencies were corrected by vitamin and mineral supplements. Mira, et al., (1988) found no nutrient deficiencies in his study of women with PMS, nor did Berman, et al., (1990). Although Berman found no nutritional deficiencies, the study documented symptom relief in the women taking 250 mg of supplemental pyridoxine daily. It is difficult to determine the role of vitamin and mineral supplements in PMS, with the exception of calcium. Many studies are not conclusive, particularly those on vitamin B6, E and magnesium. The results are equivocal. There are few studies on other nutrients, such as vitamin D. With this in mind, the wisest course is to assist women to supplement vitamins and minerals, if that is their choice and the doses are not harmful. Supplements that may be of benefit and are not harmful are: • 1200 to 1600 mg of calcium; • 250 to 400 mg of magnesium; • a maximum of 100 mg vitamin B6; • 15 mg of zinc; • 400 to 1000 IU vitamin D, and • 200 IU of vitamin E. Sexual & Reproductive Health 13 These nutrients can be included in a broad-spectrum multivitamin and mineral supplement containing most nutrients at or slightly above RDA amounts, or supplemented as individual nutrients. Keep in mind that it may take two to three months to see benefit from the vitamins and minerals. The chart below summarizes the dietary changes for women with PMS and the recommended vitamin and mineral supplements. Dietary Recommendations for PMS Reduce: • refined sugar • salt • alcohol, coffee, tea, chocolate, tobacco Increase: • complex carbohydrates • green leafy vegetables • legumes and whole grains and cereals • fish, poultry, low-fat and non-fat dairy products Supplement: Broad-spectrum multivitamin/ mineral; • 250 - 400 mg magnesium • 50 to 100 mg vitamin B6 • 15 mg zinc • 200 to 400 IU vitamin E • 1200 to 1600 mg calcium (reduce if calcium intake is high) • 400 - 1000 IU vitamin D HERBS The use of herbs in the treatment of PMS has grown rapidly. The herbs most commonly used for PMS include: chasteberry (Vitex agnus-castus), crampbark (Viburnum opulus), black haw (Viburnum prunifolium) and dong quai (Angelica sinensis). These herbs can relieve some of the symptoms of PMS. An in-depth discussion of herbs is beyond the scope of this course, but can be found in the Nutrition Dimension course, Herbal Supplements, by Leslie Kay. However, one herb, chasteberry, deserves discussion. • Chasteberry contains flavonoids and iridoids as well as compounds similar to sex hormones (Atkinson, 2006). Researchers and herbalists believe that chasteberry works by decreasing the effects of estrogen and increasing the effects of progesterone. It is also speculated that chasteberry may bind to opioid receptors, beta-endorphins and neuroactive flavonoids (Schellenberg, 2001). In 2001, Schellenberg and colleagues published a double-blind, placebo-controlled trial of 168 women given either chasteberry or a placebo for three menstrual cycles. Fifty-two percent of women in the study group and 24 percent of women in the placebo group reported improvements in symptoms. In a review of the literature available, Tesch (2002) concludes that chasteberry may improve symptoms of PMS, but that more research is needed. According to Fugh- Sexual & Reproductive Health 14 Berman and Kronenberg (2003), there is preliminary data to suggest chasteberry may be beneficial in women with PMS. The active ingredients in chasteberry include flavonoids, which are found in many foods. Christie and colleagues (2004) studied the effect of a flavonoid extract (from plant foods) on fluid retention in PMS. While the study was small, 30 women, there was enough improvement in "leg health" scores (amount of fluid retention in the legs) to conduct a larger study. In Chinese women, chasteberry decreased symptoms of PMS and was safe and effective in a dose of 40 mg herbal drug (He et al, 2009). An in-depth discussion of herbs is beyond the scope of this course, but can be found in the Nutrition Dimension course, Herbal Supplements, by Leslie Kay. For health professionals and clients looking for information on PMS, there are many reliable sites the contain excellent information. Two sites that I have found useful are: • Association of Reproductive Health Professionals: <www.arhp.org> • US Dept. of Health and Human Services, women's health: <www.womenshealth.gov> Sexual & Reproductive Health 15 Chapter Two: Oral and Hormonal Contraceptives Eight to 10 million women in the United States, and up to 100 million women world-wide, use hormonal contraceptive agents for birth control. (For a complete list and explanation of various types of birth control methods and side effects go to: <www.womenshealth.gov>) Hormonal contraceptives contain synthetic hormones, estrogens and/or progestogens (also called progestins), that inhibit ovulation and alter the metabolism of the body. Hormonal contraceptives come in different forms. Most common are oral contraceptive agents (OCA), but newer delivery systems are available, including implants, injectables, patches, vaginal rings, implantable rods and intrauterine devices. One implant, Implanon®, is a single rod implanted under the skin which releases hormones for three to five years. It has been used in Europe and became available in the US in July 2006. Injectable contraceptives are monthly hormone shots. Patches are put on by the user once a week for three weeks; the fourth week no patch is worn. The vaginal ring, worn three weeks each month, releases hormones to prevent pregnancy. Intrauterine devices, inserted by a clinician, can remain in place up to five years. While less research is available on these newer types of contraceptives, more studies are becoming available (Depieres, 2002; Davidson, 2003; Inal, et al., 2008; Cagnacci, et al., 2009). Since OCA were the predominant form of contraception for over 30 years, there is much more research available on them. Thus, OCA will be the form of contraception discussed in detail in this chapter, unless noted otherwise. Fifty different metabolic reactions caused by the hormones in OCA may impact nutritional needs and requirements. It is important to understand the hormonal and metabolic changes that result from OCA use in order to adequately counsel women on their nutritional needs while taking OCA, or when discontinuing their use to prepare for pregnancy. 16 Sexual & Reproductive Health The Association of Reproductive Health Professionals (ARHP) has a web site — www.arhp.org — that contains many good resources for health professionals and clients on oral contraceptives. HOW ORAL CONTRACEPTIVES WORK At the beginning of the menstrual cycle, follicle stimulating hormone (FSH) increases and stimulates ovarian follicular growth and maturation, as shown in the graph below. As a result of the increase in FSH, the levels of estrogen and progesterone increase. Hormonal Changes During the Menstrual Cycle FSH LH Progesterone Estrogen 20 Progesterone Estrogen 10 LH FSH 0 0 Menstrual Phase 7 Midfollicular Phase 14 Ovulatory Phase 21 28 Luteal Phase (premenstrual) Days of the Menstrual Cycle When estrogen reaches a critical level, it stimulates the hypothalamic-pituitary axis to produce more luteinizing hormone (LH) with a smaller surge of FSH. The increased levels of FSH and LH cause the release of an ovum. Progesterone and estrogen secretion increase at this time to allow the uterus to prepare for the ovum. When no egg is present, the estrogen and progesterone levels decrease and the mucosal lining is sloughed off. The fall in estrogen and progesterone levels stimulates the hypothalamus and pituitary gland to secrete FSH and the cycle repeats itself. 17 Sexual & Reproductive Health OCA interfere with the production of hormones so that the early rise in FSH and the mid-cycle LH surge are absent, preventing ovulation. Pregnancy is also prevented by an alteration in the cervical mucus, which becomes thick and viscous and interferes with sperm penetration. Changes in the endometrium occur so that the glands do not produce sufficient glycogen to support the embryo in the endometrium prior to implantation. Finally, the ovary is less responsive to the same amount of gonadotropins (LH, FSH) so it does not release an egg. RISKS AND BENEFITS OF OCA The oral contraceptives in use today are very different from those used 30 years ago. Instead of the high-dose, single-hormone pill of the 1960s which contained 150 mcg of estrogen, low-dose, mixed-hormone preparations with both estrogen and progesterone predominate today. The most common dose of estrogen is 30 to 35 mcg. A third generation of progesterone derivatives will be discussed later in the chapter. As shown in the chart below, there are benefits and risks to oral contraceptives. Some health benefits include less anemia from less bleeding, correcting menstrual disorders, reducing the incidence of some diseases and protecting against other diseases and certain cancers. The negative side effects of OCA include nausea, vomiting, breakthrough bleeding, bloating, weight gain, edema, central nervous system side effects (headaches, dizziness, fatigue, nervousness, mood changes), decreased libido, scant periods, amenorrhea, breast tenderness, hypertension and facial pigmentation. The lower the dose of OCA, the fewer side effects. Risks vs. Benefits of OCA Risks Thromboembolic disease Cardiovascular disease Side effects: • nausea • vomiting • breakthrough bleeding • weight gain • bloating • edema • fatigue • psychological changes • scant periods • hypertension • headaches and/or dizziness Benefits Effective contraception Correction of menstrual disorders: • increased regularity • decreased flow • decreased PMS Decreased incidence of: • benign breast disease • ovarian cysts • pelvic inflammatory disease • endometriosis • ectopic pregnancy Protects against: • endometrial, ovarian cancer • osteoporosis (controversial) Sexual & Reproductive Health 18 Serious health problems such as venous thromboembolic disease (blood clot that blocks a vein) and cardiovascular disease, specifically stroke and myocardial infarction, may occur with use of oral contraceptives. As you will see later, the increases in risk for these more serious diseases is affected by the type and amount of estrogen and the type of progestogen in a specific pill. OCA use was thought to prevent bone loss, a risk factor for osteoporosis. The increased estrogen in OCA decreases the body’s ability to use the calcium stored in the bones, thereby protecting against bone loss. However, this is not as clear cut as once thought. Studies are mixed with some showing that OCA prevent loss of bone mineral density while others show an increased loss of bone mineral density. This will be discussed in more detail later in this chapter. The estrogen and progestogen in oral contraceptives change the body’s metabolism both directly (discussed later) and indirectly. Indirectly they cause the adrenal cortex to produce the stress hormone cortisol. The increase in cortisol has an effect on protein, carbohydrate and fat metabolism. The chart below summarizes some of the metabolic alterations caused by oral contraceptives. Metabolic Alterations with OCA Lipid Alterations in serum lipids: • total cholesterol • VLDL • LDL • HDL • triglycerides Increase in free fatty acids Carbohydrate Alteration in glucose tolerance Hyperinsulinemia Alterations in insulin sensitivity Protein Increased production of serum proteins: • transferrin • albumin • ceruloplasmin • C-reactive protein Changes in blood coagulation proteins Mobilization of amino acids to the liver LIPID METABOLISM Increased incidence of cardiovascular disease — ischemic heart disease, myocardial infarction, hemorrhagic stroke, thrombotic stroke, deep vein thrombosis and thromboembolism — in women using OCA has been reported in epidemiological studies in the literature. It is through direct alterations in metabolism that OCA exert their effect. Both the estrogen and progestogens found in OCA alter serum lipids. The high-dose OCA, containing 50 to 150 mcg estrogen and 1 to 10 mg of progestogen (or equivalent amount of other forms of progestogen), have a more profound effect on serum lipids than low- Sexual & Reproductive Health 19 dose OCA, containing 20 to 35 mcg estrogen and minimal progestogen ( less than 750 mcg norethisterone and up to 100 mcg levonorgestrel). Third generation progestogens — desogestrel, norgestimate, gestodene and drospirenone — are derivatives of levonorgestrel and have a different effect on serum lipids than earlier progestogens used in oral contraceptives. The chart below shows how the hormones in OCA affect serum lipids. Note that the newest progestogen, drospirenone (found in Yasmin®) may increase triglycerides, unlike the other third generation progestogens (Taneepanichskul and Phupong, 2007). Serum lipid profiles associated with increased risk for heart disease are increased total cholesterol and LDL-cholesterol, and decreased HDL-cholesterol. As noted below, the older progestogens most adversely affect serum lipids by decreasing cardioprotective HDL and increasing total cholesterol and LDL-cholesterol. The newer progestogens have the reverse effect, increasing the ratio of the cardioprotective HDL in relation to the LDL (London, 1992; Kafrissen and Corson, 1992, Porrka, et al., 1995; Machado, et al., 2004). Effect of Hormones on Serum Lipids Change in Serum Lipids Serum Lipid Estrogen Levonorgestrel* Desogestrel** Unchanged or Unchanged or Unchanged Triglyceride £ VLDL § § LDL cholesterol HDL cholesterol HDL2 cholesterol Total cholesterol *Norethisterone and older progesterones have this same effect on serum lipids. **Norgestimate and gestodene have the same effect on lipids. Also, they beneficially alter serum LDL:HDL ratio. London RS, Obstet Gyn Surv, 1992. §VLDL increase not affected by progestogens, only estrogen component of OCAs. £ Drospirenone may increase triglycerides. (In two separate studies conducted in Europe, Jick, et al., (1995) and Lewis, et al., (1996) concluded that third generation OCA are associated with reduced risk of myocardial infarction or with no difference, when compared with second generation OCA. Keep in mind the incidence level is low to begin with.) Sexual & Reproductive Health 20 Rabe and colleagues (1992) reported that after two years on Norplant®, total serum cholesterol and triglycerides decreased. All lipoproteins and apolipoproteins, with the exception of LDL and apolipoprotein AII, decreased as well, including HDL. They concluded that Norplant may be cardioprotective. The NuvaRing®, with 15 mcg ethinylestradiol and 120 mcg etonogestrel, was found to have minimal effect on lipids, compared to OCA (Tuppurainen, et al., 2004). The implant Implanon® increased cholesterol and triglycerides in one study. More needs to be done to determine if this is clinically significant (Inal, et al., 2008). The increase in serum triglycerides and VLDL is related to the estrogen in OCA. Walsh and Sacks (1993) investigated the mechanism responsible for the increase in these serum lipids. They found that there was an increase in the production of triglycerides and VLDL but no decrease in the catabolism of these lipids. The increase in production does not appear to promote atherosclerosis. Other researchers have also concluded that, while there may be an increase in triglycerides and VLDL, the levels are within the normal range (Gaspard, et al., 2004; Guazzelli, et al., 2005). Triglycerides are converted to large VLDL particles, then small VLDL particles. People with hypertriglyceridemia have a problem converting the large VLDL to small VLDL. The large VLDL stay in circulation longer and accumulate cholesterol esters, which promote arterial plaque. Women taking OCA may produce more VLDL, but they are converted to small-particle VLDL and catabolized before they accumulate cholesterol, and therefore are not atherogenic. The good news is that the use of OCA does not seem to affect mortality related to cardiovascular disease (CVD) (Graff-Iversen, et al., 2006). In this Norwegian study, there was no difference in the CVD death rate between women who used OCA and those who did not. As discussed earlier, low-dose OCA have effects that are much less pronounced than those of high-dose pills, and are much safer. However, metabolic changes occur even at very low levels of hormone intake, and must be considered when choosing a safe method of birth control. Increased cortisol appears to have an effect on lipid metabolism independent of the effect of estrogen and progestogen. Cortisol mobilizes fatty acids from adipose tissue and cells, increasing circulating free fatty acids. Cells in the body then shift away from utilizing glucose as the predominant energy source to relying on fatty acids for energy. Ketones, by-products of fat metabolism, increase in the blood as the body increases the use of fats for energy. Using fatty acids as an energy source has a ketogenic effect, seen when cortisol is available to mobilize fats from storage. Again, this effect is blunted in the low-dose OCA. Any woman with a family history of heart disease or elevated blood lipids is at increased risk for plaque buildup, a risk factor in coronary heart disease. These women should be monitored during OCA use and encouraged to make dietary changes to decrease the amount of fat and cholesterol in the diet. Sexual & Reproductive Health 21 PROTEIN METABOLISM The most striking changes seen in protein metabolism are the types and amount of proteins and enzymes synthesized by the liver. Women using OCA have increases in ceruloplasmin, retinol binding protein, transferrin, beta1A-globulin, alpha1-antitrypsin, fibrinogen, renin and alpha2-globulin, as well as decreased albumin. Some of the proteins that are increased are carrier proteins for minerals — that is, their role in the body is to transport minerals through the blood. Ceruloplasmin transports copper, and transferrin transports iron. By increasing carrier proteins, more minerals can be transported in the blood and the blood levels can increase. This is indeed the case with both copper and iron. Serum levels of both minerals are increased in women using OCA. The increase in fibrinogen and other coagulation proteins by the liver makes the blood more coagulable, increasing the possibility of thromboembolic disease — blood clots and phlebitis. It is the estrogen component of OCA which is primarily responsible for these changes. The dose of estrogen in the OCA is positively correlated with the risk for venous blood clots (Hedon, 1990). As the amount of estrogen in OCA decreases, so does the risk for thromboembolism. Brasdevant, et al., (1993) and Massafra, et al., (1993) found that when the dose of ethinyl estradiol (estrogen) was reduced from 35 mcg to 20 mcg, there was no substantial change in blood clotting factors. Petitti, et al., (1996) found that low-dose OCA did not appear to increase the risk of stroke and that stroke was a rare event in women of childbearing age. The incidence of stroke in women aged 15 to 44 was 5.4 per 100,000 women-years for hemorrhagic stroke and 5.6 per 100,000 women-years for ischemic stroke. Smoking was positively correlated with OCA use and hemorrhagic stroke. Brasdevant, et al., (1993) also found that the reduced estrogen in OCA decreased the amount of renin substrate. Alpha2-globulin, a protein, is converted to angiotensin I. Renin then acts on the angiotensin I to convert it into angiotensin II, a potent vasoconstrictor, which can increase blood pressure in susceptible women. This would aggravate hypertension. A decrease in renin production, however, would decrease the effect of OCA on blood pressure. C-reactive protein (CRP), a marker of inflammation, has recently come under scrutiny as an indicator for heart disease (Pearson, et al., 2003). In a very small study of women using OCA, Dreon, et al., (2003) found CRP levels two times higher in women who used OCA compared to those who did not. All CRP levels were within normal limits. Gaspard, et al., (2003) found no changes in CRP with OCA use for one year. The reason for the different findings on the relationship of CRP and OCA use may be that other factors also influence CRP. Raitakari and colleagues (2005) found that OCA use does increase CRP, but so does obesity and physical activity — and not all women using OCA have increased CRP levels. In another study, OCA use increased CRP and being overweight increased the median CRP level two-fold (Buchbinder, et al, 2008). Only some of the increase in CRP can be explained by OCA use. More studies are necessary to determine if there is any clinical significance to the use of OCA and changes in CRP. Sexual & Reproductive Health 22 VENOUS THROMBOEMBOLYTIC DISEASES AND STROKES A surprising discovery is that third generation OCA, with small doses of estrogen, are responsible for an increase in the incidence of venous thromboembolytic disease (VTE), including deep vein thrombosis (DVT) and pulmonary embolism. It appears that third generation progesterones (gestodene and desogestrel), and not estrogen, are the culprits. These progesterones, unlike first and second generation progesterones norethindrone and levonorgestrel, increase pro-coagulatory and fibrinolytic activity that leads to a considerable stimulation of fibrin turnover. This may increase the risk of VTE (Kuhl, et al., 1995; Hedenmalm and Samuelsson, 2005; Jick, et al., 2006). Jick, et al., (1995) found that the risk for nonfatal DVT expressed as the number per 100,000 women years was: 16.1 for levonorgestrel, 29.3 for desogestrel, and 28.1 for gestodene. The excessive risk above the older OCA was 16 per 100,000 women years. Bloemenkamp, et al., (1995) found a 2.5-fold higher risk for DVT in women taking third generation OCA. In two studies undertaken by the World Health Organization (WHO) (Lancet, 1995), the same results were found. The risk for VTE was increased, although the rate was less than previously reported. In one study , users of older OCA had a 3.5 times higher risk of VTE than non-users, while users of third generation OCA had a 9.1 times higher risk; the other study came to the same conclusion. It also found that body mass index (BMI) was correlated with increased risk for VTE. Two newer studies did find that the duration of use, dose of estrogen and the type of progestogen were associated with the risk for VTE (Ligegaard, et al., 2009; van Hylckama, et al., 2009). The longer a woman is on the OCA, the lower the risk for VTE. As the dose of estrogen decreases (from 50 mcg to 30 to 40 mcg, then to 20 mcg), the risk of VTE correspondingly decreases. There is a different risk ratio for VTE for each type of progestogen. If the estrogen in the OCA is 30 to 40 mcg, the risk for VTE would be 1.91 for levonorgestrel, 3.37 for norgestimate, 4.38 for gestodene, 5.58 for desogestrel and 7.90 for drospirenone (Ligegaard, et al., 2009). Put another way, the risk for VTE using gestodene is 4.38 times the risk of a woman not using OCA. The authors of this study also concluded that progestogen only OCA and intrauterine devices did not increase the risk of VTE. Overall, the risk for VTE in OCA users is low. In the general population, the risk of VTE is 1 in 10,000 and during pregnancy the risk is eight to 10 in 10,000. The use of lowdose OCA increases the risk to three to four in 10,000, while third generation OCA increases that risk to six in 10,000, less than the risk during pregnancy (Kovacs, 2002). The risk for strokes is also higher for women who use OCA. Gillum and colleagues (2000) looked at 16 studies published from January 1960 through November 1999, and found that non-smoking women using OCA containing 35 mcg estrogen had an additional 4.1 ischemic strokes per 100,000 women. If the dose of estrogen was over 50 mcg, the risk for stroke was three times higher in OCA users than in non-OCA users. However, no increased risk of ischemic stroke was found in young Australian women using OCA with less than 50 mcg of estrogen (Siritho, et al., 2003). Sexual & Reproductive Health 23 The pendulum continues to swing: in a review of the literature on the use of OCA and the risk of stroke, Chan and colleagues (2004) found that cohort studies did not find a relationship between the use of OCA and an increased risk of stroke. Neither did Yang (2009) find any significant association between ischemic or hemorrhagic stroke with OCA use. Case-controlled studies, however, did find a significant association between thrombotic stroke and the use of OCA. The authors felt that the risk of stroke from OCA use may be less than previously thought due to the small significance, the methodological problems with many studies and the fact that the dose of estrogen used now is so much lower than those in the studies. CARBOHYDRATE METABOLISM Glucose intolerance and hyperinsulinemia, due to alterations in insulin sensitivity, are changes in carbohydrate metabolism caused by OCA. Progestogens have more of an effect on carbohydrate metabolism than estrogens by increasing insulin secretion and insulin resistance of cells. Not all progestogens have the same effect on carbohydrate metabolism. Those that are more androgenic — 19-nortestosterone and norgestrel derivatives — have a more profound effect than the less androgenic progestogens — desogestrel, norgestimate and gestodene. Estrogen may impair the initial secretion of insulin by the pancreas but does not have a sustained effect on carbohydrate metabolism. During OCA use the cells of the body are somewhat resistant to insulin. The pancreas will increase production, causing hyperinsulinemia. Even with the high levels of insulin, the serum levels of glucose increase. Wynn and colleagues (1986) found that serum glucose levels deteriorated over a three-year period in women taking high-dose OCA; women taking low-dose OCA showed changed serum glucose at three months, but no further changes. Other researchers have found some slight changes in fasting insulin and glucose levels, but they never reached significance nor had any clinical relevance (Skouby, et al., 2005; Nessa, et al., 2005). Insulin sensitivity was found to decrease in women taking OCA with 30 mcg estrogen and 150 mcg desogestrel (Cagnacci, et al., 2009a). The clinical significance still needs to be determined. Studies by London (1992), Kafrissen and Corson (1992), Shoupe (1993), Wilde and Balfour (1995) and Gaspard, et al., (2003) found that the newer progestogens do not seem to alter carbohydrate metabolism. These studies looked at fasting serum and insulin, and rises in serum glucose and insulin after a challenge with glucose, and found no significant changes in these parameters. They concluded that desogestrel and norgestimate have a less pronounced effect on carbohydrate metabolism than nortestosterone and levonorgestrel. The vaginal ring also did not alter insulin sensitivity in its users (Cagnacci, et al, 2009b). Average increases in blood glucose are approximately 10 mg/dL. In the normal individual, this is not enough to cause any problems. The body can adjust. In individuals susceptible to diabetes, the change in glucose tolerance may pose a slight risk of causing the diabetes to surface. 24 Sexual & Reproductive Health In OCA users, there is an increase in both free and bound cortisol; this has the effect of mobilizing glucose for the cells. In addition, an increase is seen in growth hormone and xanthurenic acid, which bind to insulin. This could be another explanation for altered carbohydrate metabolism. With insulin bound to other compounds, it is unavailable to move glucose into the cells, so the serum glucose level increases. Changes with low-dose OCA are minor in comparison to those from high-dose OCA, but are still a consideration for women using OCA. VITAMIN B6 Vitamin B6 (pyridoxine) is required for functions in the body that involve amino acids and proteins. The conversion of tryptophan to niacin and serotonin requires vitamin B6. When vitamin B6 is deficient, the body is unable to complete this conversion. It then excretes compounds that are not fully metabolized, indicating that a deficiency exists. It has been suspected that women using OCA may have inadequate vitamin B6. Lussana (2003) did find significantly lower vitamin B6 levels in women using oral contraceptives compared to non-users. In OCA users, there is an increased excretion of intermediary tryptophan metabolites involved in the conversion of tryptophan to niacin, indicating insufficient vitamin B6 to complete the metabolic process, as shown below. Tryptophan Metabolism Tryptophan TO 5-hydroxytryptophan PLP SEROTONIN (5-hydroxytryptamine) PLP = pyridoxal phosphate (vitamin B6) TO = tryptophan oxygenase kynurenine PLP 3-hydroxykynurenine kynurenic acid xanthurenic acid PLP 3-hydroxyanthranilic acid NIACIN Researchers found it took 20 to 30 mg of pyridoxal phosphate (vitamin B6), which is 10 to 15 times the Recommended Daily Allowance (RDA) for vitamin B6, to normalize tryptophan metabolism. Sexual & Reproductive Health 25 The cause of this vitamin B6 inadequacy could be an increased need for vitamin B6 or interference with its metabolism. Estrogen sulfate esters may interfere with the activity of a pyridoxine enzyme, PLP, by competing with it for binding sites. Increased liver production of an enzyme, tryptophan oxygenase, allows more tryptophan to be converted to niacin, increasing the need for PLP and vitamin B6. Altered tryptophan metabolism due to a vitamin B6 deficiency may explain behavioral changes in women using OCA. It’s common to hear complaints of anxiety, lethargy, depression, irritability and emotional instability. Vitamin B6 is required to convert tryptophan to the neurotransmitter serotonin. With inadequate vitamin B6, less serotonin is produced, possibly causing changes in behavior. An increase in the conversion of tryptophan to niacin increases the need for vitamin B6 in that pathway, so not enough pyridoxine is available for the tryptophan-toserotonin pathway. The increased use of tryptophan would decrease the amount of unbound tryptophan available to cross the blood-brain barrier, where serotonin is produced. Furthermore, the intermediary tryptophan metabolites may block the transport of free tryptophan across the blood-brain barrier, decreasing the available tryptophan for conversion to serotonin. Masse, et al., (1996) investigated the effect of newer OCA on 23 young women. All had adequate vitamin B6 intake. The plasma and erythrocyte levels were adequate, but a disturbance in B6 metabolism was detected. OTHER VITAMINS • Riboflavin. Riboflavin is necessary to convert pyridoxine (vitamin B6) to pyridoxal phosphate (PLP). With the increased need for pyridoxine in the conversion of tryptophan, riboflavin may also be needed in increased amounts. In many OCA users, riboflavin levels are found to be low. • Folic Acid. Folic acid levels in the serum and red blood cells have been determined to be low in OCA users. Whether it is a problem of absorption, uptake or utilization by the tissues is not clear. Steegers, et al., (1993) found that use of OCA with less than 50 mcg of estrogen significantly lowered serum levels of folate and vitamin B12. Green, et al., (1998), however, found no difference in serum folate and red blood cell folate levels in adolescent girls. Folic acid is critical for normal fetal development, especially between the 18th and 27th day of pregnancy, when a woman may not know she is pregnant. During this time the neural tube develops and then closes. It is within this structure that the central nervous system develops. If a woman has been using OCA and has low serum folic acid levels, there could be a problem during the first trimester from inadequate folic acid. In 1992 the US Public Health Service (USPHS) recommended that all women of childbearing age who are capable of becoming pregnant should consume 0.4 mg (400 mcg) of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other neural tube defects (NTD). Sexual & Reproductive Health 26 In 1996, the US Food and Drug Administration (FDA) mandated that all enriched cereal grain products be fortified with folic acid. The Institute of Medicine (1998) recommends that to get adequate amounts of folic acid, women capable of becoming pregnant should consume 400 mcg a day of folate — from supplements, fortified foods or both — as well as continue to eat foods high in folate. They go on to say that the evidence shows that folate from supplements is more protective than from food. Other dietary sources of folic acid are encouraged, but not relied on to be adequate for most women. Appendix #12 lists dietary sources of folic acid. Many dietary studies, including the National Health and Nutrition Examination Survey II (NHANES II) and NHANES III show that folic acid is not always consumed in RDA amounts. To see if the fortification of cereal grain products with folic acid was working. The Centers for Disease Control (CDC) compared serum and red blood cell folate levels for childbearing-aged women who participated in the 1999 NHANES survey to those who participated in the third NHANES study (1988 to 1994). From NHANES III to NHANES 1999, mean serum folate concentrations for all women aged 15 to 44 years increased from 6.3 to 16.2 ng/mL while red blood cell folate increased from 181 to 315 ng/mL (MMWR, 2000). This met the national health objective of increasing red blood cell folate levels in non-pregnant women, aged 15 to 44, to 220 ng/mL. In addition, fortification of foods has resulted in a 26 percent decline in neural tube defects (MMWR, 2004). There is still room for improvement. The number of women taking folate supplements did not increase from 1998 to 2003. It did go up in 2004, with approximately 40 percent of women of childbearing years taking a folate supplement, and remained at 40 percent in 2007 (MMWR, 2004; MMWR, 2008). Those least likely to take a folate supplement are non-white, young and less educated, with Hispanics the least likely to take a folate supplement and with the highest incidence of neural tube defects (MMWR, 2008). There is still a lot more work to do to increase folate supplementation and intake in childbearing women, which will help to decrease neural tube defects even further. • Vitamin A. OCA use increases vitamin A in the serum by as much as 50 percent, although the levels are not high enough to be toxic. Therefore, the requirement for vitamin A does not increase and may be lower than the RDA. The most likely problem from increased serum levels would be in supplementing too much vitamin A, not from getting too little. Women should be cautioned about the possibility of toxicity from supplementing vitamin A, which is fat-soluble and stored in the body. Instead, supplementation with beta carotene is preferable, since it is nontoxic even in very high amounts. • Vitamin C. Vitamin C levels are reduced in the plasma, leukocytes and platelets from OCA use. Estrogen increases the breakdown of vitamin C by increasing ceruloplasmin levels. Ceruloplasmin increases the oxidation of ascorbic acid. The increased dietary need is not great and can be met easily by increasing vitamin C-rich foods in the diet. • Vitamin B12. Vitamin B12 levels are decreased in the plasma but not in erythrocytes. Green, et al., (1998) found that adolescent girls using OCA had a 33 percent reduction in serum B12 levels. The question remains if the changes seen in vitamin B12 are Sexual & Reproductive Health 27 caused by an increased need for vitamin B12 or from a redistribution of vitamin B12. Intake of vitamin B12 is important due to its essential role in fetal development, so any women who gets pregnant after discontinuing prolonged OCA use should pay attention to her vitamin B12 status and ensure that intake is adequate. MINERALS Mineral levels do change in women using OCA. The chart below summarizes both vitamin and mineral changes in women using OCA. Serum copper levels increase, due to the increased production of its carrier protein ceruloplasmin. Therefore, the requirement for copper does not change. Plasma and erythrocyte levels of zinc decrease in OCA users. As with folic acid and vitamin B12, zinc is critical for fetal development, particularly the first trimester. Zinc is often deficient in the diet; the average intake is less than 70 percent of the RDA. A woman contemplating pregnancy should take a careful look at her diet to determine its adequacy for zinc. If it is inadequate, she should consider a supplement. Iron status in women using OCA improves. An increase in transferrin, the protein carrier for iron, increases the amount of iron in the blood. Total iron binding capacity (TIBC) increases significantly as well (Steegers, et al., 1993). Decreased menstrual blood loss decreases the monthly iron loss. These three factors decrease the likelihood of iron deficiency anemia in women using OCA. Nutrient Changes with OCA MECHANISMS FOR CHANGE Increased utilization Decreased serum levels Changes in storage sites Increased GI absorption Decreased bone resorption SERUM CHANGES Nutrients Decreasing Riboflavin Folic Acid Vitamin B6 Vitamin B12 Zinc Magnesium Nutrients Increasing Iron Copper Vitamin A Sexual & Reproductive Health 28 BONE MINERAL DENSITY The effect of OCA on bone mineral density (BMD) in women appears to be related to the type of OCA used — depot medroxyprogesterone acetate (Depo-Provera® or DMPA) injections, levonorgestrel (Norplant) subdermal implants or hormonal pills. Researchers are looking to see how each type of OCA impacts bone density in the short term and what, if any, are the long-term clinical consequences, such as increased or decreased risk of fracture. Many of the studies done to date are contradictory due to differences in design, techniques for measuring bone density, age of the participant and type of OCA. With that in mind, it does appear that hormonal pills and Norplant implants have a positive effect on bone mineral density, while DMPA or Depo-Provera injections may have a slightly negative effect on BMD, although the effect is reversible once the injections are stopped (Cromer, et al., 1996, 1999; Diaz, et al., 1999; Di, et al., 1999; Berenson, et al., 2001; Nappi, et al., 2005; Kaunitz, 1999; Wanichsetakul, et al., 2002). Berenson and colleagues (2001) found that BMD decreased by 2.74 in women using DMPA for 10 to 14 months. The control group had a decrease of 0.37 percent in BMD as well. Women using OCA with norethendrone had a 2.33 percent increase in BMD, while those using OCA with desogestrel had an increase in BMD of 0.33 percent. Average intake of calcium in all groups was 565 mg, well below the recommended level of 1000 to 1300 mg/day. Other researchers have also found an increase in BMD in women using OCA pills (Elgan, et al., 2003; Lattakova, et al., 2009). Wanichsetakul, et al., (2002) found the only significant difference in BMD in women using DMPA was in the lumbar spine. In young women, it appears that the use of DMPA also causes a loss of BMD in the hip and spine that is greater than in older women and was reversible when the contraceptive was discontinued (Scholes, et al., 2005). Cromer and colleagues (2008) compared the BMD in DMPA and oral contraceptive users, to BMD in non contraceptive users. In the 24 months of the study, the bone mineral density in the spine and femoral neck decreased 1.5 percent and 5.2 percent in the DMPA users, went up 4.2 percent and 3.0 percent in the oral contraceptive users and increased 6.3 percent and 3.8 percent in the untreated group. The difference between DMPA and the other two groups was significant. The biggest BMD loss was in the first year, with an average loss of 1.4 percent BMD slowing to 0.1 percent the second year. BMD was within normal limits for all groups. Contrary to the studies cited above, Prior and colleagues (2001) found OCA users had significantly lower BMD than non-users in the spine and the trochanter. These results were not related to length of OCA use or age at first use. This study was a part of the Canadian Multicentre Osteoporosis Study and contradicts the Berenson study, but agrees with other studies that found decreased BMD in OCA users (Polatti, et al., 1995; Drake, et al., 1996; Almstedt, et al., 2005). In a review of the literature from 1966 through 2005, Martins and colleagues (2006) determined that the results of the studies investigating combined hormonal contraceptives with BMD and/or fractures are inconclusive. However, there did appear to be a Sexual & Reproductive Health 29 trend, based on age. Adolescents and young women had generally lower BMD compared to girls who were not using hormonal contraceptives. Premenopausal women were no different than non-users of OCA. Perimenopausal and postmenopausal OCA users preserved their BMD compared to non-users, but overall BMD was the same for OCA users and non-users. If you consider that a 1 percent increase in BMD is related to a 7 percent decrease in vertebral fractures, the clinical significance of OCA use is clear (Prior, et al., 2001). If the use of OCA increases BMD, that has a very positive effect on the number of fractures and even the incidence of osteoporosis. Should OCA use decrease BMD, the reverse would be true. Clinicians need a clearer picture of the relationship of OCA use to BMD. Studies are under way to answer this question. When deciding the best method of contraception, the age of the woman should be a consideration. DMPA interferes with accumulation of bone density. Considering that 37 percent of total skeletal mass is accumulated in adolescence, DMPA may not be the best choice for this group of females. However, for older women it may be a better choice as they have already accumulated much of their skeletal mass. Regardless of the choice of OCA, adequate calcium intake is essential. Increasing calcium intake to recommended levels — 1000 to 1300 mg/day — is able to protect young women from loss of BMD while using OCA (Teegaarden, et al., 2005). Adequate vitamin D is necessary as well to absorb the calcium. DIETARY RECOMMENDATIONS Caloric intake between OCA users and non-users is similar (Eck, et al., 1997, Pelkman, et al., 2001). In the study by Eck, OCA users ate 32 to 35 percent of their calories from fat, versus 28.5 to 28.8 percent in the non-users group. Resting energy expenditure varied depending upon the phase of the menstrual cycle. Total REE for the month was not different between the two groups, but the pattern of energy expenditure during the various phases was. Others studies have also found that overall OCA use and use of DMPA is not associated with altered energy intake, energy expenditure, weight gain or increased body fat (Lloyd, et al., 2002; Pelkman, et al., 2001). In a newer study DMPA was found to cause weight gain that was fat and not lean muscle (Berenson and Rahman, 2009). After 36 months in the study, DMPA users gained an average of 5.12 kg with 4.94 kg of fat, while OCA users gained 1.47 kg with 1.9 kg fat and nonhormonal birth control users gained 2.05 kg with 1.17 kg fat. The authors of the study speculate that the increase in weight and fat with DMPA is not due to an increase in appetite or decrease in energy expenditure but related to the glucocorticoid-like activities of the hormone. Women who choose to use DMPA should be more careful with their diet and be sure to exercise so they do not gain weight or gain an excessive amount of weight. Sexual & Reproductive Health 30 The following are dietary recommendations for women using OCA: • Monitor cholesterol levels and cholesterol intake. This is especially important for women with a familial history of heart disease, stroke or with elevated blood lipids. OCA with very low doses of hormones or the newer progestogens may not present a problem. • Reduce total fat intake to 30 percent or less of total calories. Decrease saturated fat intake to less than 10 percent of total fat intake by reducing consumption of animal proteins and by using non-fat or low-fat dairy products. • Increase consumption of foods high in vitamins C, B6, B12, folic acid and zinc. Foods that have a good supply of these nutrients are: green leafy vegetables, fruits, dried peas and beans, poultry, seafood, grains, vegetables and lean meats. Folic acid is extremely sensitive to water and heat. By boiling foods, 80 to 90 percent of the folic acid is destroyed. Try to eat dark green vegetables raw to obtain the most folic acid, or microwave vegetables to reduce loss of folic acid and other water-soluble vitamins. • If the diet is inadequate in any of the above nutrients, supplement to 100 percent of the RDA. • Consume 400 mcg of folic acid to prevent neural tube defects if you are of childbearing age from supplements, fortified foods or both, as well as eating foods high in folate. See Appendix #12 for folic acid content of foods. • For women trying to get pregnant or who get pregnant soon after stopping oral contraceptives, supplement with vitamins B6, and zinc at 100 percent of the RDA. • For women with depression associated with oral contraceptives, supplement B6 up to 100 mg/day. No side effects have been seen at that dose, but increasing the dose increases the possibility of side effects. In a study, Ubbink et al. (1987), found that supplementing with 200 mg of vitamin B6 did not raise serum levels any higher than 100 mg. The extra vitamin B6 was being excreted, not utilized by the body. Therefore, the body can only handle so much vitamin B6 at a given time. Any vitamin B6 above that level will be cleared from the body. • Consume adequate amounts of calcium. If unable to meet requirements through food, consider a supplement. The recommended adequate intake is 1300 mg/day for girls up to 18 years of age; 1000 mg for women 18 to 50 years of age and 1200 mg/day for women over 50 (Institute of Medicine, 1998). Make sure you are getting adequate vitamin D to absorb the calcium. Sexual & Reproductive Health 31 Chapter Three: Factors Affecting Pregnancy Outcome The health and eating habits of the mother directly affect the fetus and the outcome of pregnancy. In a country that is well-nourished, with a plentiful food supply, it is disheartening to realize that malnutrition and poor eating habits lead to maternal, fetal and neonatal complications. The chart below lists poor outcomes of pregnancy. Poor Pregnancy Outcomes • Low birth weight (LBW), <2500 gm birth weight • Very low birth weight (VLBW), <1500 gm birth weight • Small for gestational age • Fetal growth restriction (FGR) • Prematurity • Pregnancy complications • Congenital anomalies • Neonatal illness • Maternal or fetal mortality • Hypertension, cardiovascular disease and other chronic diseases later in life All of these poor outcomes can be caused by poor maternal nutrition. That is not to say that poor diet is the only cause of poor pregnancy outcomes. Many other factors influence the course and outcome of pregnancy. Neonatal mortality, defined as deaths during the first 28 days after birth, is related Sexual & Reproductive Health 32 to the course of pregnancy. Since 1970, when the National Academy of Sciences published Maternal Nutrition and the Course of Pregnancy, there has been a dramatic increase in the interest of the relationship of nutrition to the course of pregnancy. This interest has translated into better prenatal care, government programs to teach and feed pregnant women, and research and training for health professionals. The results are encouraging. To highlight the relationship of nutrition to pregnancy outcome, births during the four-year siege of Sarajevo, Bosnia, were studied to see what nutritional effect the war had on pregnancy outcomes. Infant mortality during the war climbed to 36 per 1,000 live births from a pre-war level of 15.8 per 1,000 live births (Simic, et al., 1995). Morbidity increased from 3.4 percent to 8.2 percent in the same period, while babies born with congenital malformations increased from 0.4 percent to 3.0 percent during the war. In the United States, The National Center For Health Statistics (NCHS) in 1990 reported that between the years 1950 and 1987 infant mortality rates declined from 29.2 to 10.1 deaths per 1,000 live births. From 1990 to 1997 the infant mortality rate has fallen from 9.2 to 7.2 deaths per 1,000 live births. Even better, between 1995 and 2001 the infant mortality rates dropped another 10 percent to 6.8 per 1,000 live births — the lowest rate ever recorded (NCHS, 2003). Between 1950 and 2001, the infant mortality rate declined by 77 percent. For the first time since 1958, the infant mortality rate increased in 2002 to 6.95 deaths per 1,000 live births (NCHS, 2008) mostly due to an increase in the number of infants born weighing less than 750 gm (1 lb, 10.5 oz). The majority of these infants die within the first year of life (NCHS, 2008). Since 2002, the infant mortality rate has declined slightly, with rates of 6.84 in 2003, 6.78 in 2004, 6.86 in 2005 and 6.71 (preliminary) in 2006 (NCHS, 2008). As you can see , the infant mortality rate has stayed fairly constant the past few years. This is the first time there was a plateau and no serious decline in infant mortality rates. Hispanic women have the highest infant mortality rate — 13.63 — of any ethnic group, with Cuban women having the lowest — 4.42 (NCHS, 2008). Preterm infants (born before 37 weeks gestation) account for the highest percentage of infant deaths, 68.6 percent. Very preterm infants are only 2 percent of births but account for over half of the infant deaths in 2005. The plateau in infant mortality is due to the increase in very preterm births but no decline in their mortality (NCHS, 2008). The incidence of low birth weight (LBW) babies steadily declined between 1960 and 1984, when it was 6.7 percent. In the 1990s the percent of LBW babies increased by 9 percent, to 7.6 percent, due to the increase in multiple births. The rate of LBW babies in 2003 was 7.93 percent, with a continued increase in multiple births (NCHS, 2005). In 2006, the incidence of LBW climbed to 8.3 percent without a rise in multiple births (NCHS, 2009). The incidence of very low birth weight (VLBW) babies accounted for 1.45 percent of all births in 2003, also influenced by the increase in multiple births. Unfortunately, the incidence of LBW and VLBW babies is higher in African-American and Hispanic populations. In 2006, the incidence of VLBW babies was 1.49 percent (NCHS, January, 2009). Sexual & Reproductive Health 33 Other data reported by NCHS is that maternal weight gain has increased. Between 1940 and 1960 the average gain was 22 lb. In 1970 the average gain was 27 lb, increasing to 33 lb by the 1980s and dropping to 30.5 lb in 1998, where it remained in 2000 (NCHS, 2002). That translates to a 40 percent increase in maternal weight gain from the 1940s to today. For every 2.2 lb (1 kg) increase in maternal weight gain, there was a 20 to 30 gm increase in birth weight. From 1990 to 2006 the percentage of pregnant women gaining more than 40 lb rose 30 percent, from 16.0 to 20.7 percent (NCHS, January, 2009). Often overlooked is the rate of fetal mortality, defined as spontaneous intrauterine death any time during pregnancy. Generally, only fetal deaths after 20 weeks are reported. In 2005, the rate was 6.22 per 1,000 live births, down considerably from 7.75 in 1990 (NCHS, April, 2009). The rates for fetal mortality differ by age, ethnic groups, multiple births and number of previous pregnancies. More research is needed to determine its causes and prevention strategies. Despite our best efforts, malnutrition and inadequate diets during pregnancy still exist. Government agencies studying the United States population have found dietary, biochemical, clinical and anthropometric evidence of poorly nourished Americans. Lower socioeconomic groups have a larger percentage of malnutrition, but socioeconomic status alone does not ensure an adequate diet. RISK FACTORS & OUTCOME When trying to reduce the risk of a poor pregnancy outcome, it is important to separate factors you can control from those you cannot. The most important controllable factors in perinatal mortality are prenatal medical care (started in the first trimester) and adequate nutrition (resulting in proper weight gain) during pregnancy. Late or no prenatal care is one of the biggest contributors to poor pregnancy outcome. The purpose of prenatal care is to assess medical and nutritional risks to determine the best treatment during pregnancy. Many risk factors relate to the nutritional status of the mother and can be obtained with the obstetrical history, number of previous pregnancies, intervals between pregnancies, birth control methods, birth weight of other children and weight gain with each pregnancy. Knowing any pre-existing conditions or illnesses helps determine nutritional recommendations. Most of all, good prenatal care can prevent complications before they threaten the health and welfare of either the mother or the fetus. Appropriate weight gain is critical to a good pregnancy outcome. In 2009, the Institute of Medicine (IOM) updated the 1990 guidelines for appropriate weight gain during pregnancy. The new report emphasizes nutrition and weight gain recommendations for overweight and obese women to prevent poor pregnancy outcomes in both the mother and baby, as this problem has been growing over the years. Research has linked not just prepregnancy weight to outcome, but specifically excessive weight gain in overweight or obese women. Sexual & Reproductive Health 34 Some of the complications of excessive weight gain include: • gestational diabetes; • gestational hypertension; • preeclampsia; • Cesarean delivery; • large-for-gestational-age babies; • congenital anomalies, and • short- and long-term health of the baby (Kiel, et al., 2007, ADA, 2009). Chapter 6 will cover this topic in detail. Health habits that affect the nutrient status of the mother must also be considered: smoking, alcohol consumption, drug use, pica, excessive supplementation, fad diet, weight-loss diet, eating habits and patterns. The chart below summarizes factors affecting pregnancy outcome, with a complete list in Appendix #1. Factors Affecting Pregnancy Outcome General Factors Nutritional status Prepregnancy weight Body mass index (BMI) Parity Socioeconomic status Adolescence Depression Illnesses Diabetes Hypertension Renal disease Heart disease Liver disease AIDS Cancer Infectious disease Present Pregnancy Weight gain Dietary adequacy Disordered eating Complications: hypertension, gestational diabetes Use of alcohol, drugs, tobacco Agrichemicals in water Prenatal care Hyperemesis gravidarum Bariatric surgery Previous Pregnancies Preeclampsia LBW, FGR Stillbirth Neonatal death Multiple pregnancies Pregnancy intervals The interval between pregnancies appears to influence outcome. As the interval between pregnancies decreases, the risk of LBW, preterm birth and small size for gestational age (SGA) increases (Zhu, et al., 1999; Khoshnood, et al., 1998). The interval between pregnancies when the risk is lowest is 18 months to 59 months (Conde-Agudelo, et al., 2006). Women giving births less than 18 months, or more than 59 months, from Sexual & Reproductive Health 35 their previous delivery, had increased risk of delivering babies that were preterm, LBW and SGA. The risk is greatest when the interval is less than six months. The optimal interpregnancy interval is 18 to 23 months. Disordered eating can increase the risk for LBW, preterm and SGA babies (Conti, et al., 1998). A history of disordered eating did not effect pregnancy outcome, but disordered eating prior to or during pregnancy does increase the risk. Another risk factor may be agrichemicals in surface water. Women who conceived during the months when agrichemicals in surface water were highest (April to July) had the highest incidence of birth defects (Winchester, et al, 2009). Over the years, researchers have compiled evidence that periodontal disease, such as periodontitis, adversely effects pregnancy outcome, leading to preterm and very preterm babies (Sanchez, et al., 2004; Jarjoura, et al., 2005). The rate of preterm delivery in women with moderate to severe periodontal disease was 28.6 percent, compared to 11.2 percent in healthy women (Offenbacher, et al., 2006). In another study, the rate for SGA babies was 3.2 percent in healthy women, 6.5 percent in women with mild periodontal disease and 13.8 percent in women with moderate to severe periodontal disease (Boggess, 2006). Since periodontal disease is an infectious and inflammatory condition, it may be that certain cytokines and prostaglandins produced to fight the infection, initiate the process that leads to preterm delivery and SGA babies (Tucker, 2006). A newer study (Gomes-Filho, et al., 2009) found no association between periodontal disease and either prematurity or LBW. At this point the relationship of periodontal disease to birth weight and prematurity is not clear. The American Dietetic Association (ADA) has updated a 2002 position paper entitled Nutrition and Lifestyle for a Healthy Pregnancy Outcome, which reviews the relationship of nutrition and pregnancy outcome (ADA, 2008) and published a new position paper titled Obesity, Reproduction and Pregnancy Outcomes (ADA, 2009). NUTRITION AND FERTILITY If nutrition during pregnancy improves pregnancy outcome, what about periconceptional nutrition? Will diet and/or supplementation increase fertility and rates of conception, or decrease poor outcomes? The relationship of nutrition and fertility is being investigated and includes the following: maternal height, body weight (too low or too high), body composition, eating disorders, athletic training, vegetarian diets, excessive carotene intake, phytoestrogens in foods, iron deficiency (serum ferritin below 40 ng/mL), caffeine, coffee intake, alcohol intake (moderate or excessive), cigarette smoking (Brown, 1993) and polycystic ovarian disease, one of the leading causes of infertility in the country (Scalzo, 2001). Women trying to conceive may want to avoid alcohol, as alcohol intake may make it more difficult to conceive (Jensen, et al., 1998). The effect of caffeine on fertility is still up in the air, with studies showing different effects. Caan, et al., (1998) found no differences in fertility in women consuming high, moderate or low amounts of caffeine. Sexual & Reproductive Health 36 Jensen et al. (1998), however, found that women consuming over 700 mg/day of caffeine had a more difficult time conceiving. Other nutrients consumed prior to pregnancy may effect the course of the pregnancy. Dietary Ω-3 fatty acids now appear to be linked to both maternal reproduction and the proper development of the brain and retina of the fetus in utero, and the baby after birth. Inadequate amounts of dietary Ω-3 fatty acids during pregnancy or after birth may have serious consequences. (This will be discussed in detail in the next chapter.) Folic acid is required early in pregnancy to prevent neural tube defects. Periconceptional supplementation with 800 mcg folic acid decreased the incidence of the occurrence of neural tube defects in pregnant women (Czeizel and Dudas, 1992). In newer studies, periconceptual supplementation with folate reduced the incidence of neural tube defects and reduced the incidence of early spontaneous preterm birth by 50 to 70 percent (Wolff, et al., 2009; Bukowski, et al., 2009). Periconceptional vitamin supplementation with folic acid does not appear to protect against cleft palate and cleft lip (Czeizel, et al., 1999). Abnormal maternal folate metabolism, in a preliminary study, increased the risk of offspring with Down Syndrome (James, et al., 1999). Zinc supplementation may prevent some abnormal fetal development (Keen and Zidenberg-Cher, 1994; King, 2000; Hess and King, 2009). While much remains to be learned about periconceptional nutrition, it does no harm to improve dietary intake and take a daily vitamin and mineral supplement, and may prove beneficial. We do know about obesity, however. In the US, approximately 25 percent of infertility appears to be caused by overweight and obesity (ADA, 2008). Issues that negatively impact fertility of overweight and obese women include (ADA, 2008): • increased time to conception • increased risk for polycystic ovarian syndrome • higher waist-to-hip ratio • lower implantation and pregnancy rates with reproductive technology Overweight or obese women should consider losing weight prior to getting pregnant — especially if they are having difficulty conceiving. Some studies suggest there is an increase in spontaneous abortions in obese women undergoing fertility treatment (ACOG, 2005). CDC recommends improving weight status prior to pregnancy. DISEASES IN LATER LIFE In a review of the relationship of pregnancy to disease in later life, James (1997) found that not only are periconceptional nutritional status and nutrition during pregnancy linked to pregnancy outcome, but that they also may be linked to diseases such as hypertension, heart disease, stroke and diabetes later in life. It appears that these chronic diseases are related to the size of a baby at birth. Babies that are either LBW or SGA, but not preterm, have an increased incidence of these chronic diseases (Godfrey and Baker, 2000). Sexual & Reproductive Health 37 It appears that the fetus adapts physiologically, structurally and metabolically when there is an insult at a critical developmental stage. This is called "programming," and the change is permanent. One such insult is not meeting the demand for a specific nutrient at the time it is required by the fetus. (Langley-Evans, et al., 1998). (Chapter Five will discuss the timing of fetal nutrient requirements in more detail.) Epidemiological studies gave the first clue to the relationship of birth weight to coronary heart disease (CHD). In England, 16,000 babies have been traced from birth to the present. Infants born with a LBW had significantly higher death rates from CHD. As birth weight increased, the rate of death from CHD decreased (Osmond, et al., 1993; Barker, et al., 1993). This relationship has been confirmed in other studies, including the US Nurses Study, which looked at 70,297 nurses in the United States (Rich-Edwards, et al., 1997). Now there is widespread acceptance that fetal growth restriction (LBW and SGA) is associated with CHD in later life. Painter (2006) studied the effects of the 1944-1945 Dutch famine on the age of onset of CHD. Compared with individuals not exposed to the famine, the researchers found an earlier age of onset in the individuals exposed to the famine. However the mortality rate from all causes in the individuals exposed to the famine does not appear to be related to famine exposure (Huxley, 2006). As with CHD, an association has been found between LBW and SGA babies and high blood pressure and hypertension in over 34 studies; it is unrelated to other lifestyle factors such as smoking, alcohol intake and obesity in adulthood (Godfrey and Barker, 2000). The incidence of altered glucose tolerance, insulin resistance and Type 2 diabetes is higher in people who were LBW babies. In one study, infants weighing less than 5.5 lb had a 40 percent incidence of Type 2 diabetes and impaired glucose tolerance. That rate fell to 14 percent among those weighing up to 9.5 lb at birth. The incidence increased if birth weight was over 9.5 lb at birth (Hales, et al., 1991). The relationship between LBW and glucose tolerance is independent of lifestyle. However, poor lifestyle choices can compound the problem. Those individuals who were born small and are obese in adulthood have the highest incidence of impaired glucose tolerance and Type 2 diabetes (Hales, et al., 1991). EPIGENETICS Epigenetics refers to how genes express themselves, not to the coding sequence of DNA. Siblings may have the same gene, but in one the gene is “turned on” and in the other it is “turned off,” which alters the functioning of the gene. There are “marks” or metabolic changes in DNA, RNA or histones (part of the chromatin in the nucleosome of the cell) that determine if the gene is “on” or “off,” and these marks can be inherited. For instance, a common epigenetic change is the methylation of DNA (the addition of a methyl group to the base cytosine). Hypermethylation causes the gene to turn “off.” When the cells divide, the change to the DNA is copied and passed on to the next generation of cells (Ross, 2007). In other cases, a portion of the gene may be hypomethylated, which expresses the gene (Zeisler, 2009). Sexual & Reproductive Health 38 Epigenetics may be the link between our genetic makeup and the environment. While it is difficult to alter our genes during our lifetime, epigenes can be modified by diet and environment, then passed down through generations (Stover, 2006). Many of the diseases associated with aging, such as cancer, heart disease and autoimmune diseases, may result from epigenetic changes that alter our physiology. The same may be true during pregnancy. The fetus inherits the genes from its parents but also inherits the epigenetic codes marks on the genes that control the expression of the gene. In addition, the fetus can also adapt to its environment by altering its own epigenetic code (Zeisel, 2009). The methylation of DNA, RNA and histones requires S-adenosylmethionine (SAM), a methyl donor. The availability of SAM is influenced by the amount of choline, methionine and folate in the body. Too much or too little can cause epigenetic changes (Zeisel, 2009). In mice, the agouti gene determines the color of fur. The folic acid intake of pregnant mice determines the offspring's fur color. If the agouti gene promoter region is turned on, the offspring's coat color is yellow; if it is turned off due to methylation of DNA, the coat color is darker, as the gene is not able to express itself (Stover, 2006). The coat color stays with offspring for their entire life. So changing folic acid intake, either increasing or decreasing it, alters the expression of the agouti gene and fur color in mice. Pregnant women during the Dutch famine of World War II delivered small babies due to the lack of food. Their children, even though they had plenty of food while they were growing up and during pregnancy, also delivered small children, smaller than would have been predicted (www.epigenome.eu/en/2,48,872, accessed 10/24/07). It is thought that the lack of food in the first generation altered epigenes related to the size of offspring and that information was passed on to the next generation. Epigenetics may explain some inherited susceptibilities to disease, such as asthma, diabetes, heart disease and obesity (Zeisel, 2009; Waterland, 2009). The bottom line is that a mother's diet affects not only the short-term health of her baby, but the long-term health as well. The goal of health care professionals is to determine the nutritional risks that may impact the outcome of the pregnancy, and to intervene before any damage is done to the fetus. Health professionals, including nutrition professionals, should actively discourage smoking, alcohol consumption and illicit drug use in order to improve pregnancy outcomes. If a woman follows sound dietary guidelines and minimizes other lifestyle risks, she will have done the best she can to create a normal, healthy infant. In fact, if women are given advice to eat well, gain weight, take prenatal vitamins, don't drink alcohol, don't do drugs and don't smoke cigarettes, they have a lower incidence of LBW babies than those women who do not recall getting this prenatal advice (Kogan, et al., 1994). The following chapters will cover nutrition-related risk factors, explaining what they are, how to identify and assess them in a pregnant woman, and how to use nutrition to improve the course and outcome of pregnancy. Sexual & Reproductive Health 39 Chapter Four: Physiological Changes Which Alter Nutrient Needs During pregnancy, the body undergoes many physiological changes necessary for a successful pregnancy outcome, as shown below. Every organ in the body will have additional demands put on it as the pregnancy progresses, increasing the need for nutrients. Many of these physiological changes have nutritional implications. Physiological Changes in Pregnancy Blood Plasma volume increases Red blood cells increase Leukocytes increase Renal Function Renal blood flow increases Glomerular filtration rate increases Nutrients “spill” into urine Heart Cardiac output increases Heart rate increases Peripheral vascular resistance increases Fluid leakage into tissues Liver Protein production increases Cholesterol production increases Increased workload GI Tract Smooth muscles affected Peristalsis decreases Placenta Nutrient & waste transfer Source of growth factors Hormones Pregnancy hormones produced Increases in estrogen & progesterone Metabolism Altered carbohydrate, fat & protein metabolism Decreased sensitivity to insulin Sexual & Reproductive Health 40 HORMONES Human chorionic gonadotropin (hCG), produced during pregnancy, prevents the corpus luteum from returning to its normal size at the end of the female menstrual cycle. Instead, it stimulates the corpus luteum to secrete more hormones — estrogen and progesterone — that cause the endometrium to store nutrients. The corpus luteum grows larger, about two times its original size one month after the pregnancy begins. The secretion of these sex hormones is vital to early fetal development. By about week 12, the placenta can secrete enough estrogen and progesterone to maintain the pregnancy, so the corpus luteum returns to its normal size and production of hCG decreases. The increased level of estrogen during pregnancy affects different organ systems of the body, one of which is stimulation of uterine growth. The heart has an increase in blood volume, heart rate, stroke volume and cardiac output. The additional blood volume necessary to carry nutrients and waste products requires the heart to work harder, and it is able to adapt by increasing output. An increase in renal retention of sodium is caused by estrogen. Increasing blood and plasma volume requires additional water; sodium retention increases the amount of water in the body. An increase in serum proteins produced in the liver is also caused by increased estrogen production. These proteins carry nutrients, enzymes, albumin, etc. Each performs a vital function for pregnancy. Increases in progesterone levels are responsible for an elevation in basal body temperature, which slightly increases caloric need and stimulation of maternal respiration. Unlike estrogen, progesterone stimulates the kidneys to lose sodium, due in part to increased aldosterone production, which is involved in water balance. The net result is a slight loss of sodium from the kidneys, affecting sodium requirements during pregnancy. The most noticeable effect of increased progesterone is a decrease in activity of smooth muscles, such as the colon. When peristalsis of the colon decreases, constipation results. The cardio-esophageal sphincter, located where the esophagus enters the stomach, is a smooth muscle that provides pressure to keep the contents of the stomach from regurgitating into the esophagus. During pregnancy, this sphincter is relaxed, so heartburn results. Constipation and heartburn are common in pregnancy. The placental hormone human chorionic somatomammotropin (hCS), also known as human placental lactogen (hPL) is secreted by the 5th week of pregnancy. It reaches a peak secretion of 1 to 2 gm/day, paralleling the growth of the placenta. Mammary tissue growth is stimulated by hCS. Metabolically, hCS plays a weak role in causing the deposition of protein into tissues. (Growth hormone is 100 times more effective than hCS in promoting tissue growth.) Sensitivity of tissues to insulin decreases in the presence of hCS, decreasing glucose utilization in the mother, thus allowing more glucose to be available for the fetus. In addition, hCS increases the release of free fatty acids from fat stores, providing an alternative fuel source for the mother. During pregnancy, there can be a 40 to 60 percent decline in insulin sensitivity due to hCS, as well as an increased production of adiponectin by maternal and fetal tissue (NAS, 2009). Sexual & Reproductive Health 41 BLOOD Many changes occur in blood volume and the red blood cells, as shown in the graph below. There is an increase in plasma volume of 40 to 50 percent over non-pregnant levels, while total blood volume expansion is 35 percent. The number of red blood cells increases by 20 percent. Increase in the plasma volume begins at 6 to 8 weeks gestation, at which point it steadily rises until it peaks somewhere between the 30th and 34th week. Plasma volume expands earlier than red blood cells, causing a temporary fall in hematocrit levels, known as hemodilution of pregnancy. The hematocrit begins to fall somewhere in mid-pregnancy, around the 20th to 24th week, as the plasma volume (but not the number of cells) expands rapidly. It is common to see women with normal hematocrits at the beginning of pregnancy drop below normal as the pregnancy progresses. By the end of the pregnancy, many return to normal levels. Expansion of Blood & Components 50 % Expansion 40 30 10 0 Plasma Blood Red Blood Cells Hemoglobin drops during pregnancy by as much as 2 gm/dL, due to the diluting effect of plasma expansion and the increased need for red blood cell production. The production of red blood cells does not begin until the second trimester, with the greatest rise late in the third trimester. A normal nonpregnant (and prepregnant) hemoglobin value of 13.5 gm/dL decreases to about 11.6 gm/dL in the second trimester of pregnancy, even in iron-supplemented women. In the last trimester of pregnancy, the hemoglobin rises by about 1 gm/ dL to 12.5 gm/dL by the 36th week of gestation. (These values are norms, and vary in individuals.) Sexual & Reproductive Health 42 Expansion of the plasma volume is critical for a successful pregnancy. The increased circulation is needed for the skin to dissipate heat, for kidneys to increase filtration and for perfusion of the placenta. Red blood cell volume is utilized by the fetus and by the mother for the additional metabolizing tissue. When the plasma does not expand sufficiently, problems with the pregnancy can result. Other changes seen in the blood of pregnant women include an increase in the number of leukocytes, mostly neutrophils. Some pregnant women, about 20 percent, may have an increase in the number of immature leukocytes. In addition, there is a twoto four-fold increase in levels of fibrinogen. Many serum, plasma and blood levels of various nutrients change during pregnancy, therefore it is difficult to use them to assess the nutritional status of pregnant women. Some nutrients increase, others decrease and still others stay the same. Changes from trimester to trimester also occur, as is the case with iron, zinc, calcium, vitamin B6 and others. A lower blood level does not necessarily indicate a problem and may only be a physiologic adaptation to pregnancy. For example, after the 10th week of pregnancy, triglyceride concentrations may be up to 20 percent higher in pregnant women than in nonpregnant women. Cholesterol and fatty acids also increase, but not as much as triglycerides. Serum albumin, on the other hand, decreases by 8 to 10 percent during the first 10 weeks of pregnancy and continues to decline another 10 percent for the duration of the pregnancy (King, 2000). Until each nutrient can be studied and normal pregnancy values determined for each trimester, it is difficult to interpret nutritional status using laboratory values — except for the most researched nutrients: iron, calcium and glucose. CARDIOVASCULAR SYSTEM The heart must work harder during pregnancy. Total cardiac output is 30 to 40 percent higher in pregnancy. The heart rate increases by approximately 10 to 15 beats per minute, rising to 85 to 90 beats per minute. The cardiac output per beat also increases, as does the stroke volume (by 30 percent) — the heart can pump more blood with each beat. To accomplish this additional work there is a decrease in peripheral vascular resistance and in arterial blood pressure. Because there is less resistance to the blood flowing through the arteries and veins, it is easier for the heart to circulate blood and plasma. Both the systolic and diastolic blood pressure decrease. One side effect of the decrease in blood pressure and vascular resistance is leakage of fluid from capillaries into intercellular spaces. This causes edema, noted in one-third of all pregnant women. Edema is normal in pregnancy and does not need to be treated the same as in a nonpregnant woman. Using diuretics to treat edema during pregnancy can cause more harm than good because it decreases the plasma volume expansion. Sexual & Reproductive Health 43 RENAL FUNCTION During pregnancy the kidneys must filter extra waste products, not only for the mother and her additional tissue, but also for the fetus. To be able to do this, the blood flow to the kidneys increases by 30 to 40 percent, reaching 600 to 1000 mL/min. The amount of plasma that is filtered increases by 50 percent. Due to this increased load, the kidneys are not as efficient in filtering water, electrolytes and solutes — glucose, amino acids, urea and creatinine. As a result, some of these substances are not cleared as quickly or efficiently and may “spill” into the urine. In a nonpregnant woman, glucose does not appear in the urine until the blood level reaches a concentration of 190 mg/dL. In pregnancy, glucose may appear in the urine with blood concentrations as low as 155 mg/dL. Amino acids, not normally found in the urine of healthy nonpregnant women, may appear in the urine of healthy pregnant women and can reach 2 gm/day. Folate excretion can double to 10 to 15 mcg/day, not a large amount. Some women, however may lose up to 50 mcg/day (Picciano, 1996). Sodium balance is also affected. With so much blood and plasma being filtered, the kidneys are not as effective in handling sodium and there tends to be a sodium loss from the kidneys. Considering the amount of extra work done by the kidneys, they are amazingly efficient — but not as efficient as in nonpregnant women. LIVER The liver has many roles during pregnancy, although its blood flow does not change. The liver is the site of protein production, which increases. However, due to the diluting effect of pregnancy, total serum proteins decrease by 20 percent. Proteins that increase in pregnancy include albumin, which helps maintain the increased fluid volume, and carrier proteins such as transferrin, ceruloplasmin and fibrinogen. Cholesterol and serum lipids increase 25 to 40 percent and 200 to 400 percent respectively over nonpregnant levels (Hachey, 1994). Some of this change may be due to alterations in metabolism (discussed later). Another cause may be that cholesterol is a precursor of steroid hormones, which increase during pregnancy. The work of the liver increases dramatically during pregnancy. The detoxification of harmful compounds and substances increases, as does the metabolic workload required for the mother and fetus. The liver works in concert with the placenta as a multiorgan system for the exchange of nutrients. This is designed to ensure adequate nutrient production to meet fetal needs, especially amino acids (Battaglia and Thureen, 1997). GASTROINTESTINAL SYSTEM Many of the problems associated with the gastrointestinal tract occur as a result of decreased smooth muscle activity mentioned earlier, such as increased gastric emptying time and decreased intestinal tract motility. Sexual & Reproductive Health 44 When the stomach gets too full, the contents of the stomach are easily regurgitated into the esophagus. Hydrochloric acid, used to digest food, irritates the esophagus, causing heartburn. The solution to this problem is to eat smaller meals low in fat more frequently. Never letting the stomach get too full decreases the possibility of reflux. Other tips include: keep the head above the rest of the body (don't lie down, sit up); eat early so food is digested by bedtime; only eat foods as tolerated; and wear loose clothing. If the problem persists, a non-aluminum antacid will relieve the symptoms. (An additional benefit of the antacid is that it has approximately 250 mg calcium/tablet, which the body will absorb.) Appendix #11 lists some other tips for heartburn during pregnancy. Constipation in pregnancy is caused by a decrease in peristalsis, due to smooth muscle relaxation. The pressure of the fetus in the abdomen can also slow down transit time of food in the intestinal tract. Increasing fiber and fluids in the diet can relieve constipation. Natural laxatives can also be used, as long as they are not digested and just pass through the intestinal tract. Exercise is another remedy for constipation. Walking, or any activity that does not stress the body, will help. If everything fails, remember, the constipation will only last as long as the pregnancy. Nausea and vomiting are common during the first trimester of pregnancy due to changes in hormones. Usually, the discomfort lasts for the first 12 to 15 weeks of pregnancy and then disappears. As long as there is adequate weight gain and the woman is not severely underweight, few problems result. Appendix #13 lists some tips for managing nausea and vomiting. This topic will also be covered in more detail in Chapter Eight. However, the most important point to remember is to listen to your patients and don't close your mind to any possibility. Erick (1994) found that potato chips and lemonade worked wonders for many of her patients who had morning sickness. The saltiness of the potato chips calmed the nausea and caused thirst. The sweet and sour favors of lemonade seemed to keep the nausea at bay. METABOLISM Maternal metabolism alters during pregnancy to what is known as “accelerated starvation,” since it mimics metabolic alterations seen during fasting or starvation. Decreased concentrations of glucose and amino acids, increased concentrations of free fatty acids, ketones, triglycerides and cholesterol, and decreased responsiveness to insulin characterize maternal metabolism, as shown in the chart on the following page. King (1994, 2000) found that energy metabolism differs greatly among women during pregnancy depending upon their prepregnancy energy status and their situation during pregnancy. Actual total requirements may be zero for the undernourished woman whose body adaptations spare energy for fetal growth. If energy is abundant and the woman is well-nourished, her needs may be nearly 120,000 kcal during the course of the pregnancy. Sexual & Reproductive Health 45 Maternal Metabolic Changes in Pregnancy Decreased blood level: • Glucose • Amino acids • Insulin Increased blood level: • Free fatty acids, ketones • Triglycerides • Cholesterol • Cytokines - leptin, adiponectin Overall Changes: • Shift from glucose to fat as major energy source • Decreased responsiveness of tissues to insulin • Slight change in blood pH from ketones The fetus utilizes mostly glucose for energy. It uses very small amounts of free fatty acids. The placenta itself is a major metabolic organ, consuming large quantities of glucose. The only source of these energy substrates is the mother. To get the energy the mother needs, the body switches from using glucose to using fat as the primary energy source, saving most glucose for use by the placenta and fetus. Early in the second trimester, you begin to see a general drop in the mother's serum glucose levels. Following a meal, however, the maternal metabolism reacts differently, with transient hyperglycemia, hyperinsulinemia and increased insulin resistance in the liver, muscle and adipose tissue. The chart below shows hormones whose production increases during pregnancy and which are responsible for many of the metabolic alterations noted during pregnancy. In addition to hormones, cytokines are involved in energy expenditure, although the exact mechanisms are only beginning to be elucidated (NAS, 2009). Hormones Affecting Metabolism hCG • increases estrogen and progesterone Estrogen • impairs glucose tolerance • antagonistic effect to insulin hPL/hCS • decreases glucose utilization Pituitary Prolactin • decreases insulin sensitivity • decreases insulin binding within • causes deposition of protein into tissues adipose tissue (weakly) • stimulates lipolysis Glucocorticoids (cortisol) • mobilizes amino acids Thyroxine • antagonist to insulin • increases basal metabolic rate Sexual & Reproductive Health 46 PLACENTA The placenta is an organ located high on the back wall of the uterus. Arteries and capillaries of the maternal circulation feed into it and veins drain blood from it. The umbilical cord has two arteries and one vein to supply the fetus. We can say that the circulations of the mother and fetus meet, but never touch. A membrane separates the two circulatory systems. One major function of the placenta is to exchange nutrients, oxygen and waste products between the mother and the fetus. Nutrients are transferred across the placenta by passive diffusion, facilitated diffusion, active transport, convection and vesicular transport. The chart below summarizes placental transfer of nutrients. To be transported by passive diffusion, the concentration of the nutrients must be higher in the maternal blood than in the fetal blood. If so, the nutrients will cross the membrane to the fetus. Nutrients that are passively diffused include oxygen, carbon dioxide, water, electrolytes and many vitamins and minerals. Placental Nutrient Transport Passive Diffusion • Water • Oxygen • Carbon dioxide • Electrolytes • Many vitamins & minerals Facilitated Diffusion • Glucose Vesicular Transport • Immunoglobulins Active Transport • Amino acids • Calcium • Iron • Potassium • Phosphorus • Vitamin B6 Convection • Volume of fluid flows through pores in placental membrane and takes solutes with it Since the fetus must have glucose for energy, a means to help glucose get to the fetus has been created. Glucose, transported by facilitated diffusion, attaches to a protein molecule that helps the glucose cross the placenta, even if the maternal glucose concentration is not much greater than or even lower than the fetal concentration. The transporter is known as membrane-localized glucose transporter (GLUT). Other nutrients — amino acids, calcium, iron, potassium, phosphorus and vitamin B6 — are actively transported from the mother to the fetus. Even if the concentration of nutrients in the maternal blood is less than the fetal blood, the nutrients will cross the placenta with the help of an energy-requiring transport system. The significance of the active transport of these nutrients is that the fetus will get nutrients at the expense of the mother. If the mother is not consuming enough calcium, iron or protein, her body stores will be used by the fetus. Sexual & Reproductive Health 47 This is the reason iron deficiency anemia can result from pregnancy. If calcium intake is inadequate, calcium from the bones will be used, causing a thinning of bones. Protein stores in muscle mass will be broken down if the fetus needs more protein. Protein levels in fetal circulation can be two times higher than in maternal circulation (some of the protein and amino acids are used for energy by the fetus). The reverse is also true. If vitamin B6 is supplemented in large doses and the maternal blood levels are high, excessive amounts can be actively transported across the placenta to the fetus. Other nutrients that passively diffuse, if supplemented in large doses, may cross to the fetus in excessive amounts. So is the fetus a complete parasite, as is historically believed? The answer is no. If the mother does not have sufficient vitamins and minerals in her blood, they cannot cross the placenta, with the exception of the actively transported nutrients noted above. That means deficiencies in the maternal diet can affect the fetus. The fetus cannot get nutrients if they are not in sufficient concentration in the maternal blood. Adequate uterine blood flow is essential for normal nutrient transfer. Any disruption decreases the nutrients available for placental transfer. A decrease in the expansion of the plasma fluid volume can disrupt nutrient transfer. When the plasma volume is smaller, there is less perfusion of the placenta and fewer nutrients are present to cross the placenta. FETAL GROWTH AND GENE REGULATION Another role of the placenta, besides nutrient transfer, is the production of growth factors necessary for the normal development of the placenta and fetus. These growth factors are peptides and cytokines, which modulate amino acid transport and increase glucose uptake and utilization, RNA, DNA and protein synthesis, cell replication and fat accretion (Garnica and Chan, 1997; NAS, 2009). Some growth factors include: • Insulin-like growth factor (IGF)-I Ty and IGF-II • Transforming growth factor (TGF) • Platelet-derived growth factor (PDGF) alpha and beta • Type I IGF-I receptor (IGF-IR) • Fibroblast growth factor (FGF) • Leptin During pregnancy, the concentration of IGF-1 increases and there is a positive correlation between fetal and cord plasma concentrations of IGF-I and birthweight (Garnica and Chan, 1997; Hay, 1999; Jansson and Powell, 2000). IGF-I decreases protein breakdown and increases protein accretion. What's interesting is that nutrient supply influences the production of growth factors. The intracellular glucose concentration regulates IGF-I and IGF-II production (Hay, 1999; Garnica and Chan, 1997). If inadequate amounts of glucose are available, less IGF-I and IGF-II are produced, decreasing the weight of the fetus at birth. Besides the overall weight of the fetus, IGF-I influences the growth of organs, particularly the brain and the myelinization of the brain (Hay, 1999). Sexual & Reproductive Health 48 It may be that lack of sufficient energy affects birth weight not just by denying the fetus adequate energy, but because the quantity of growth factors is insufficient to promote optimal growth in utero (Hay, 1999). Leptin production by the plancenta increases, with a large percent going to the mother to help her accumulate fat during pregnancy (NAS, 2009). OMEGA-3 FATTY ACIDS (Ω-3) Fatty acids are an integral part of every cell membrane, hence they are called essential fatty acids (EFA). Two, linoleic acid (LA, 18:2 Ω-6) and alpha-linolenic acid (ALA, 18:3 Ω-3), make up a large portion of the fatty acids found on the cell membranes. Humans can not synthesize EFA so they must be included in the diet. EFA are metabolized in the liver to long chain polyunsaturated fatty acids (LCP). Three of these, arachidonic acid (AA, 20:4 Ω-6), eicosapentaenoic acid (EPA, 20:3 Ω-3) and docosahexaenoic acid (DHA, 22:6 Ω-3), are incorporated into cell membranes in all tissues of the body. Linoleic acid is considered the “parent” of the Ω-6 fatty acids and alpha-linolenic acid is the “parent” of the Ω-3 fatty acids. The types of fats eaten determine the fatty acid makeup of cells. For instance, if the diet is high in LA-containing vegetable oils, the cell membrane will have a high concentration of AA. If the diet contains ALA, there will be EPA and DHA incorporated into the cell membrane. Cell membranes contain both types of LCP but the amounts differ based on what the mother eats. Placental and fetal development require that LCP be transported from maternal circulation, across the placenta, into the fetal venous blood, since the fetus and placenta can not metabolize EFA to LCP. The LCP are incorporated into the central nervous system, brain and tissues of the fetus. The first few weeks after conception — usually before the mother knows she is pregnant — are the most active period of brain cell division. The last trimester is the most rapid period of brain growth and requires a substantial amount of DHA, since 50 percent of the LCP in the brain is DHA. It is estimated that the fetus requires a total of 600 gm DHA, or 2.2 gm/day if averaged over the entire pregnancy (Connor, 1996). Another study estimated that a full-term infant has a total DHA content of 3800 mg (Das, 2003). Fatty acids are stored in the body and can be delivered to the fetus when needed, so a mother with a store of DHA can supply it to the fetus. Pregnancy causes a decline in the EFA and LCP status of the mother, especially EPA and DHA (Hornstra, 2000). Studies investigating Ω-3 fatty acid intake during pregnancy have found that maternal DHA concentration drops dramatically during pregnancy and may develop into a deficiency (Holman, et al., 1991; Innis and Elias, 2003). It is postulated that the mother's ability to supply DHA may be insufficient to meet the needs of the fetus if she has inadequate stores and/or intake (Connor, Backgrounder, 1996). Supplementing pregnant women with DHA, 200 mg/day, increased the amount of DHA in cells. The level of DHA did decline in the supplemented women during the third trimester, but the decline was less than the placebo group (Montgomery, et al., 2003). Sexual & Reproductive Health 49 Rebuilding maternal supplies of fatty acids take time, most likely over six months (Hornstra, 2000). If the interval between pregnancies is short, the supply of EFA and LCP may not be adequate for the second fetus. Connor et al. (Lipids, 1996) supplemented the diet of 15 women for nine weeks with 2.6 gm/day of Ω-3 fatty acids, of which 1.01 gm was DHA. The result was an increase in the DHA content of red blood cells (RBC) from 4.69 to 7.15 percent. Plasma DHA content increased from 2.12 to 3.15 percent at term. Infants had an increase in RBC DHA from 5.86 to 7.92 percent and an increase in plasma DHA from 3.47 to 5.05 percent. The concentration of DHA in infant RBC and plasma rose 35 and 45 percent respectively. Other studies have supplemented both Ω-3 and Ω-6 fatty acids and found increases in fetal and maternal tissue and plasma levels (Hornstra, 2000; Smuts, et al., 2003). If supplementing EFA or LCP, it is important to supplement both. Too much of one or the other can create imbalances. While Ω-6 fatty acids are plentiful in the diet, Ω-3 fatty acids are not. Pregnant women may not get adequate amounts of dietary Ω-3 fatty acids. If a mother's intake of EFA is low, body stores can be used. However, much more LA is stored than ALA in body fat, making it difficult to meet fetal DHA requirements. Since the mother is the fetus' sole source of EPA, DHA and AA, it is essential to consume adequate Ω-3 fatty acids during pregnancy. Inadequate LCP may influence the outcome of pregnancy. Researchers have been investigating whether or not there is a link between insufficient LCP during pregnancy and duration of pregnancy, fetal growth, infant birth weight, preeclampsia, depression, infant visual function and infant neurodevelopment. Foreman-van Drongelen, et al., (1995) found a significant relationship between birth weight, length and head circumference, and LCP levels in the umbilical artery wall. Higher umbilical levels of LCP correlated with a more advanced gestational age and anthropometric measurements. DHA, in particular, has been positively associated with birth weight (Hornstra, 2000). As fetal and cord levels of DHA increase, so does infant birth weight. In a study that looked at fish intake and preterm delivery, Olsen and colleagues (2002) found that as intake of seafood (fish) increased, the incidence of preterm deliveries decreased. Women with the highest intake of seafood had a preterm delivery rate of 1.9 percent, while the group with the lowest intake had a 7.1 percent rate of preterm deliveries. Low birth weight and intrauterine growth retardation also decreased with increasing seafood intake, while mean birth weight, duration of gestation and birth weight adjusted for gestational age tended to increase with increasing seafood intake. These associations were strongest for fish intakes below (or above) 15 gm of fish or 0.15 gm long chain fatty acids a day. Conner's studies show that increasing dietary Ω-3 fatty acids will increase levels in the mother and fetus and can affect the outcome of pregnancy and possibly even children's IQ. Helland et al. (2003) found that supplementation with long chain Ω-3 fatty acids during pregnancy improved the mental development of children at age 4. While this is a preliminary study, it raises intriguing possibilities. Petridou et al. (1998) studied 109 children with CP and 278 control children in Greece, and found an inverse relationship between fish Sexual & Reproductive Health 50 intake and CP — as fish intake went up, the incidence of CP went down. This warrants a larger, multicenter study. Not all studies have found a link between LCP and pregnancy outcome. In 2005, the Agency for Healthcare Research and Quality (AHRQ) reviewed the literature to determine the health effects of Ω-3 fatty acids on child and maternal health (Lewin, et al., 2005). They looked at how maternal intake of Ω-3 fatty acids influences: • duration of gestation; • SGA babies; • clinical outcomes in term and preterm babies; and • growth patterns, neurological, visual or cognitive development outcomes in term or preterm infants. The authors of the review concluded that there is a lack of safety data on LCP supplementation, which needs to be corrected. The relationship of maternal LCP intake to pregnancy outcomes was either inconclusive or there were no relationships. The influence of Ω-3 fatty acids on the duration of pregnancy was the one area where there is some data to support it, but it is by no means conclusive. The full report is available at:: <www.ahrq.gov/downloads/pub/evidence/pdf/o3maternalchild/o3mch.pdf> The evidence for Ω-3 fatty acids improving growth patterns, neurological, visual or cognitive development was also inconclusive. Jensen (2006) published a review of the studies on the effects of Ω-3 during pregnancy and lactation and found: Although the results of the studies summarized above are inconsistent, some evidence suggests that higher Ω-3 fatty acid intakes during pregnancy may increase gestational duration without obvious adverse effects. Keep in mind that one reason the studies are inconclusive is the difficulty in designing a study that takes all of the factors of dietary fat intake into account, e.g. ratio of Ω-3 to Ω-6 fatty acids, dietary intake of Ω-3 and Ω-6 fats, length of time necessary to change cellular composition of fats, and determining the optimal intake. At present, we know the importance of adequate LCP during pregnancy, but the effect of less than optimal amounts is still uncertain, as is how much LCP is optimal. The recommendations from "expert panels" range from 200 to 300 mg/day DHA (Simopoulos, et al., 1999; AOCS, 2003), which appear safe. The March of Dimes recommends 200 mg/day of DHA intake (www.marchofdimes.com/pnhec/159_55030.asp). SOURCES OF Ω-3 The chart on the next page shows the sources of LA, ALA, EPA and DHA. As you can see, the only sources of LCP are EPA and DHA, found in fish. The body can convert some of the ALA to EPA and DHA, but it is very inefficient. Only about 5 to 10 percent of ALA is converted to EPA and a lesser percentage is converted to DHA. While the necessity of LCP are now recognized for pregnant women, intake of fish and fish oil supplements to provide LCP can be problematic due to the contamination of fish with mercury, which the body converts to the toxic methylmercury. Sexual & Reproductive Health 51 Sources & Metabolism of Fatty Acids Ω-6 Fatty Acids Linoleic acid (LA) Arachidonic acid (AA) Dietary Sources Nuts, seeds, vegetable & seed oils (body converts linoleic acid to arachidonic acid) Ω-3 Fatty Acids Alpha-linolenic acid (ALNA) Dietary Sources Green plants, algae, rapeseed (canola oil), soybeans, flax, flaxseed, walnuts Marine oils, fish Marine oils, fish Eicosapentaenoic acid (EPA) Docosahexaenoic acid (DHA) Grams of EPA & DHA in 3 oz of: Sardines 3.3 Mackerel 2.5 Bass 0.8 Oysters 0.6 Trout Tuna 1.6 0.5 Bluefish 1.5 Crab 0.3 Salmon Shrimp 1.0 0.3 Notes: The conversion of ALNA to EPA and DHA is inefficient in adults. Preterm and full term infants have limited ability to convert the ALNA to EPA and DHA, but can convert LA to AA. EPA is easily converted to DHA in adults and infants. Presently, the amount of mercury necessary to produce developmental toxicity is not known and hotly debated (Charnley, 2006). The average mercury intake of pregnant women is 1.4 mcg/day according to the EPA and 0.8 mcg/day according to the FDA. To protect pregnant women and their babies, policy-makers have come up with an amount of mercury considered to have no adverse effects — this "no-adverse-effect level" (NOAEL) is then divided by a safety factor. The final number is called the "reference dose" (RfD) by the EPA (Charnley, 2006). To simplify this issue for the public, the EPA and FDA revised their consumer advisory on fish intake in 2004. The advisory emphasizes the benefits of eating fish, but for women of childbearing age or planning to get pregnant, there are ways to minimize mercury intake from fish. They can thus feel confident they are not exposing themselves and their babies to harmful effects of mercury (FDA, 2004). The three steps to limiting mercury intake are found in the chart on the next page. The bottom line is that women who are or may become pregnant can eat some fish, enough to meet their needs. One 6 oz serving of salmon has 900 to 1400 mg of DHA; other white fish has 200 to 700 mg DHA/6 oz serving. Tuna (light) has 500 to 1500 mg/6 oz serving. If you consider the requirement of approximately 200 to 300 mg DHA/day, one serving of white fish and one serving of salmon or tuna will meet that requirement. Eating plant sources of Ω-3 fatty acids will also contribute to overall DHA intake. Womenshealth.gov has a fact sheet for use with clients that lists the fish to eat and not eat during pregnancy and recommended amount. This is available at: <www.womenshealth.gov/pregnancy/mom-to-be-tools/fish-facts.pdf.> The March of Dimes has information on their website, that can be used with clients on omega-3 fatty acids in pregnancy and mercury and fish in pregnancy. Sexual & Reproductive Health 52 FDA/EPA Consumer Advisory on Methylmercury in Fish 1. Do not eat shark, swordfish, king mackerel or tilefish because they contain high levels of mercury. 2. Eat up to 12 oz (two average meals) a week of a variety of fish and shellfish that are lower in mercury. • Five of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollock and catfish. • Another commonly eaten fish, albacore ("white tuna") has more mercury than canned light tuna. So when choosing your two meals of fish and shellfish, you may eat up to 6 oz (one average meal) of albacore tuna per week. 3. Check local advisories about the safety of fish caught by family and friends in your local lakes, rivers and costal areas. If no advice is available, eat up to 6 oz (one average meal) per week of fish you catch from local waters, but don't consume any other fish during that week. Premature infants can be born with or can develop impaired vision or nervous system disorders due to insufficient DHA levels in the brain and retina (Salem and Ward, 1993). Even adequate DHA levels at birth can drop rapidly since there are no fat stores to supply DHA and infants have limited ability to elongate ALA to DHA. For this reason, all formulas now contain DHA, although the amounts vary in specific formulas. PLASMA VOLUME EXPANSION AND NUTRIENT TRANSFER It is essential that plasma volume expands adequately. Otherwise, cardiac output is impaired and less blood flows to the placenta, decreasing its size and surface area and ability to transport nutrients to the fetus. Any disease or treatment that results in decreased plasma expansion, cardiac output, placental blood flow, placental size or nutrient transfer can cause a poor pregnancy outcome. Decreased placental size and nutrient transfer can increase the risk for fetal growth retardation, resulting in low birth weight and/or a small-for-gestational age (SGA) baby. Inadequate glucose can decrease the production of placental growth factors leading to low birth weight and growth retardation. Treating edematous pregnant women with diuretics can cause a 50 percent reduction in plasma volume expansion, seriously affecting the fetus and the delivery of nutrients. Pregnancy is not a time for diuretic use. Improper transfer of nutrients can alter the outcome of pregnancy, as you will see in the next chapter. Sexual & Reproductive Health 53 Chapter Five: Nutrient Needs in Pregnancy Nutrition sets the foundation for the life of every child. The quality of the first six to 12 months of a baby’s life is determined by the mother’s nutritional status and diet while pregnant. Poor nutrient intake during pregnancy can affect a child for life, if severe damage results from poor nutritional status and intake. Pregnancy is a time of growth for both mother and the fetus. The mother’s body undergoes many changes necessary to carry the fetus to term. The uterus and breasts increase in size; blood volume and extracellular fluid volume expand. To meet the nutritional demands of maternal and fetal growth, additional nutrients are necessary. Meeting the nutritional demands of pregnancy will affect the outcome of the pregnancy. The fetus relies on the mother for all its nutritional needs. If the nutrients are unavailable, the fetus will suffer. Nutrition impacts weight gain, birth weight, gestational age, congenital anomalies, nutritional status and birth defects in the fetus as well as chronic diseases in later life. The importance of proper nutrient intake during pregnancy cannot be overemphasized. Both the amount of a nutrient and its time of ingestion, in relation to fetal development, are extremely important, as shown in the chart on the next page. The first trimester of pregnancy is a time of rapid cell division and organ development. Nutrients essential for this process — zinc, folic acid, vitamins B12 and D and protein — are critical during the first three months, as are folic acid and essential fatty acids in the months prior to pregnancy. The second trimester shows continued rapid cell growth and organ development, and the fetus grows in size. Thus, caloric intake becomes more important during the second trimester and is particularly important during the third trimester, when the fetus triples in size and completes development of organ systems. 54 Sexual & Reproductive Health Timing of Nutrient Intake 2nd Trimester 3rd Trimester • Hyperplasia • Hypertrophy • Organs still developing • Growth increases • Plasma volume expands rapidly • Slow red blood cell increase • Hypertrophy • Rapid growth of fetus • Rapid bone growth and mineralization • Red blood cell increase Nutrients Nutrients 1st Trimester • Hyperplasia • Rapid cell division • Organs develop Nutrients Zinc, folic acid, protein, Ω-3 & Ω-6 fatty acids, vitamins B6 and B12 and D Calories, protein, iron, folic acid, zinc, vitamins B6 and B12 and D Calories, protein, iron, calcium, magnesium, B vitamins, DHA (Ω-3 fatty acids) and vitamin D Understanding when nutrients are required is as important as understanding how much of a particular nutrient is necessary. A summary of nutrient requirements for pregnancy is provided in the chart below. Recommended Dietary Reference Intake for Pregnancy Vitamins ≤18 Years A* 750 mcg D£ 5 mcg 15 mg E** C§ 80 mg K¶ 75 mcg 600 mcg Folic Acid Thiamin (B1) 1.4 mg Riboflavin (B2) 1.4 mg 18 mg Niacin (B3) Pyridoxine (B6) 1.9 mg B12 2.6 mcg Pantothenic Acid¶ 6 mcg Biotin¶ 30 mcg Choline¶ 450 mg Minerals ≥18 Years 770 mcg 5 mcg 15 mg 85 mg 90 mcg 600 mcg 1.4 mg 1.4 mg 18 mg 1.9 mg 2.6 mcg 6 mcg 30 mcg 450 mg ≤18 Years Calcium Chromium¶ Copper Fluoride¶ Iron Iodine Magnesium Manganese¶ Molybdenum Phosphorus Selenium Zinc 1300 mg 29 mcg 1000 mcg 3 mg 27 mg 220 mcg 400 mg 2 mg 50 mcg 1250 mg 60 mcg 12 mg ≥18 Years 1000 mg 30 mcg 1000 mcg 3 mg 27 mg 220 mcg 350 mg 2 mg 50 mcg 700 mg 60 mcg 11 mg Note: values are Recommended Dietary Allowances (RDA); those marked ¶ are Adequate Intakes (AI) * As retinol activity equivalents (RAEs) 1 RAE = 1 μg retinol, 12 μg B-carotene £ As cholecalciferol. 1 ug cholecalciferol = 40 IU vitamin D. **alpha tocopherol (Equivalent to approximately 13.5 IU); § Smokers require an additional 35 mg/day Sexual & Reproductive Health 55 CALORIES To meet the energy demands of both maternal and fetal tissues, approximately 60,000 kcal are required during the course of pregnancy (IOM, 2002). This requirement includes the increased metabolic needs of the fetus and maternal tissues, the increased cardiac output, and the needs of the placenta and uterine muscle. This caloric level may be overestimated for sedentary women. Additional caloric needs during the first trimester are minimal. Cellular division is rapid, but the weight of the fetus during the first trimester is negligible. About 2,100 to 2300 kcal/day is sufficient to meet all additional calorie demands, with most of those calories needed for maternal tissues. Caloric needs increase as the pregnancy progresses. During the second and third trimesters, the caloric needs increase above pre-pregnancy intake. The increase in calories accounts for the more rapid growth of the fetus in the later stages of pregnancy. As the weight of the mother increases, it takes more energy to do the same amount of work. Therefore, the exact number of calories to recommend will vary, based on the individual. The DRI (Dietary Reference Intake) for calories for pregnant women has changed. When the new Institute of Medicine recommendations came out in 2002, DRI were based on age, trimester and total calories (IOM, 2002). Prior recommendations were for a specific number of calories above normal consumption. The new recommendations for caloric intake are: • For females aged 14 through 18: >> 2368 for the first trimester; >> 2708 for the second trimester; and >> 2820 for the third trimester. • For women aged 19 through 50: >> 2403 for the first trimester; >> 2743 for the second trimester; and >> 2855 for the third trimester. (See Appendix #3A.) In sum, no additional calories for the first trimester, an additional 340 kcal for the second trimester and an additional 452 kcal for the third trimester in each age group. Women who remain physically active during pregnancy — especially those who engage in weight-bearing activities such as walking, bicycling, tennis, jogging — may have caloric needs higher than sedentary women. Physically active women have been shown to have babies who weigh less than babies of sedentary women. This is most likely due to higher caloric needs which were not met during pregnancy. If weight gain is adequate and sufficient calories are being consumed, the birth weight of the baby is not affected, regardless of the amount of physical activity. (The Prenatal Weight Gain Grid, discussed in the next chapter, is the best tool for monitoring weight gain.) In a recent study to measure the energy costs of pregnancy, based on pre-pregnancy Body Mass Index (BMI), Butte and colleagues (2004) found that women with a normal pre-pregnancy BMI had a negligible increase in caloric needs the first trimester, Sexual & Reproductive Health 56 but that their needs increased by 350 kcal/day in the second trimester and 500 kcal/day in the third trimester. Basal metabolic rates (BMI) increased throughout the pregnancy, but were not offset by a decrease in activity as once thought. Women with either a low or normal pre-pregnancy weight had less of an increase in BMR than the high prepregnancy BMI group. One explanation for the higher increase in BMR in the high-BMI group was increased fat deposition, which was considered unhealthy. The results of the study by Butte are close to the IOM recommendations in the second trimester, but are approximately 50 kcal/day higher in the third trimester. The variability in energy needs and energy expenditure in pregnant women makes it difficult to advise women what to eat during pregnancy. For normal-weight and overweight women in developed countries, the need for food may be very small, especially if activity levels decline. These women may not need 2800 kcal in the third trimester. Underweight women may need more. Therefore, “eating to appetite” is probably the best advice that can be offered (King, et al., 1994; King, 2000). Many women watch their weight, which can present a problem when they become pregnant, if they have trouble increasing their intake. Adolescents are extremely weightconscious, trying to keep their intake down to avoid gaining. PROTEIN This is the backbone of all new tissues created during pregnancy. Both cells and the substances necessary for metabolism are made from protein. During pregnancy, the body conserves protein, especially during the last half of pregnancy when the demand is greatest. Hormones and growth favors anabolism (tissue growth), so the body retains nitrogen for amino acid and protein synthesis. Protein is stored in maternal tissues. The greatest storage occurs in the last 10 weeks of pregnancy. The total amount of protein needed for the fetus, placenta, amniotic fluid, uterus, blood and extracellular fluid is estimated at 925 gm for a normal 270day pregnancy, with 760 gm accumulated in the last 20 weeks (King, 2000; IOM, 2002). Maternal protein deficiency can have serious fetal consequences. Metabolism is altered if the quantity and/or quality of protein is inadequate. Even though amino acids are transported from mother to fetus across a concentration gradient, if the supply is inadequate in the mother, the fetus will be deficient. No longer is the requirement for protein during pregnancy based on maternal age. According to the IOM (2002) report: “For adolescents, the additional need for protein during the second and third trimesters is assumed to be the same as for adult women.” The DRI for protein for nonpregnant women is 0.8 gm/kg, or 48 to 52 gm/day. Adding an additional 25 gm for pregnancy, the daily requirement would be about 70 to 75 gm/day, as shown in the chart on the next page. For multiparous pregnancies, the recommendation is an additional 50 gm protein/day, with enough calories (1000/day) to spare the protein, starting the 20th week gestation (IOM, 2002). The average daily protein intake in the US is 75 to 100 gm, so it appears that protein intake is not usually a problem in pregnant women, at least in this country — with Sexual & Reproductive Health 57 two exceptions. Vegans need careful planning to meet protein needs. Low-income women, who lack adequate financial resources to purchase expensive red meat, poultry and fish, may consume diets low in protein. Work with these women to plan higherprotein meals with low-cost protein sources. Protein Requirement 1.1 gm/kg/day of protein or 0.8 gm/kg/day + 25 gm/day additional protein Example:Weight in pounds ÷ 2.2 = kg 135 pounds ÷ 2.2 = 61.4 kg (61.4 kg x 1.1) = 70.5 gm (61.4 kg x 0.8 ) + 25 = 74 gm Special consideration +50 gm/day beginning 20th week for multiparous pregnancy* Note: No longer is the protein requirement for pregnancy based on age. * Must have adequate calories (1,000/day) to spare protein Women with seemingly adequate protein intake may indeed have a protein deficiency if their caloric intake is inadequate. To meet the energy demands of pregnancy, some amino acids will be used for energy. The adequacy of protein in the diet of a pregnant women must be evaluated in the context of her total diet. FAT INTAKE Many pregnant women reduce their dietary fat intake because the general population is constantly advised to lower total fat consumption. Although the literature documenting the safety of restricted-fat but energy-adequate diets in pregnancy is incomplete, a diet limited to 30 percent of calories from fat is acceptable. However, this is true only if total energy is adequate, if the quality and amount of dietary protein is sufficient, if micronutrients are maintained at recommended levels, and if essential fatty acids supply at least 5 percent of total energy (Hachey, 1994; IOM, 2002). Very-low-fat diets are not warranted, because they do not supply adequate amounts of essential fatty acids and fat-soluble vitamins — and as we saw in the previous chapter, inadequate docosahexaenoic acid is linked to LBW babies. In addition, the bulk of this high-carbohydrate diet may discourage adequate energy intake. Evidence suggests that Ω-3 fatty acids may improve pregnancy outcome. Observational studies have shown that women who eat higher amounts of fish have longer pregnancies, higher birth weights, improved placental blood flow and a lower incidence of preelcampsia (Murtaugh and Weingart, 1995; Makrides, 2008; Carlson, 2009). Supplementation with Ω-3 fatty acid during the third trimester of pregnancy increased the Sexual & Reproductive Health 58 length of pregnancy (Smuts, et al., 2003). Since the initiation of labor needs prostaglandin F2α and E2, it is plausible that an increase in Ω-3 fatty acids will inhibit the production of these prostaglandins, increasing the duration of pregnancy. In a multicenter trial in Europe, women who had one preterm birth supplemented with 2.4 gm/day of Ω-3 fatty acids from fish oil had a lower incidence of a second preterm birth (Olsen et al., 2000). However, a similar study in the US did not show the same results (Harper, 2008). One other interesting study showed that women who ate more than 340 gm of fish per week had children with improved outcomes (scores) for prosocial behavior, fine motor skills, communication and social development (Hibbeln, et al., 2007). The authors conclude that the fish intake didn't prevent bad pregnancy outcomes but instead had beneficial effects on the children. Recommendations have been set in the US for the amount of fatty acids in the diet of pregnant women, although the data for determining them was slim (IOM, 2002). Because of the lack of good data, the Adequate Intake (AI) for individual fatty acids is based on median intake of pregnant women. The RDI published in 2002 recommend an AI of 13 gm/day of the Ω-6 linoleic acid and 1.4 gm/day of the Ω-3 alpha-linolenic acid (IOM, 2002). The ratio of the two fatty acids should be no more than 5 linoleic to 1 alpha-linolenic acid (IOM, 2002). In Europe, joint recommendations on dietary fat intake in pregnancy and lactation were released in 2007 and include (Koletzko, et al., 2007): • average of 200 mg DHA/day DHA; • intakes of up to 1 gm/day DHA or 2.7 gm/day Ω-3 fatty acids appear safe; • women of childbearing years should aim to consume one to two servings of oily fish a week; • α-linolenic acid, the DHA precursor, is far less effective in DHA deposition in fetal brain than DHA; and • dietary inadequacies should be screened for and counseling offered. Appendix #3A contains the DRI for Ω-3 fatty acids. Keep in mind that these recommendations may not be optimal as the data to make these recommendations was limited. In addition, intake of linoleic acid is usually adequate, but intake of α-linoleic acid is not. I suspect the recommended AI of these fatty acids will change as more research becomes available. Appendix #14 contains the Ω-3 fatty acids content of foods. FIBER AND CARBOHYDRATES New recommendations for fiber and carbohydrate intake during pregnancy were revealed in the IOM (2002) report: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. The AI for pregnant women, regardless of age, is 28 gm/day of total fiber. Total fiber consists of dietary fiber and functional fiber: these two types of fiber are very different. Dietary fiber consists of non-digestible carbohydrates and lignins that are part of plants, such as cellulose, pectin, gums, hemicellulose, beta-glucans, oligosaccharides, fructans and lignans (IOM, 2002). Functional fibers such as pectin, gums, chitin, Sexual & Reproductive Health 59 polydextrose, inulin and indigestible dextrins are isolated nondigestible carbohydrates that have beneficial physiological effects in humans (IOM, 2002). See Appendix #3A for more information on the sources of various fibers. Average fiber intake, based on the Continuing Survey of Food Intakes by Individuals 1994-1996 (CSFII), which was adjusted for fiber not in the database, is 17.1 to 18.8 gm/ day for women. The intake is well below the 28 gm/day recommended for pregnancy. The DRI for carbohydrate during pregnancy is 175 gm/day, which accounts for both maternal and fetal glucose needs (IOM, 2002). The median intake of carbohydrates is approximately 180 to 230 gm/day, which is within the recommendations. Following a low carbohydrate diet is not appropriate during pregnancy. Appendix #3A contains the DRI for carbohydrates during pregnancy. SODIUM Six to 8 liters of water are retained during pregnancy. It takes 19,500 mg of sodium to retain the additional water. Since there is a slight sodium loss through the kidneys, some additional dietary sodium is needed during pregnancy. The additional water is needed to increase the volume of plasma and intracellular fluid, to maintain blood flow to the kidneys and for perfusion of the placenta. If the plasma does not expand and the placenta is not perfused, there will be less nutrients available to the fetus; decreased blood flow to the kidneys increases circulation of toxins. No salt restriction is necessary during pregnancy. Women who do not salt their food, cook with salt, or eat salty foods, may on occasion need to increase salt consumption. Some women crave salt when pregnant and may go as far as licking table salt to alleviate craving. In most cases, those who crave salt are those who do not eat much. Salt limitation is not the way to relieve edema. Limiting salt may restrict plasma volume expansion. Treat edema by elevating the feet, sleeping on the left side and restricting activity. Remember, some edema is normal in pregnant women, and should be viewed as a sign that plasma volume is expanding. However, it is important to differentiate normal pregnancy edema from serious edema (2+ to 3+ pitting edema), which is not normal during pregnancy. Some women may need to limit salt intake to control blood pressure. IRON The total iron needed during pregnancy averages between 1000 and 1100 mg —for red blood cell production, development of the placenta and fetus, and maintaining maternal blood volume (anticipating blood losses during delivery), as shown in the chart on the next page (Hallberg, 1988; Bothwell, 2000; IOM, 2001). The need for iron is not consistent during pregnancy. During the first trimester, the iron demands of the fetus are low — maternal iron status is essentially unchanged from pre-pregnancy. During the second trimester, maternal plasma begins to expand faster than red blood cells and the demand for iron increases, causing a fall in hemoglobin, serum iron, and serum ferritin levels, and an increase in transferrin (MMWR, 1998). Sexual & Reproductive Health 60 Iron Needs During Pregnancy Tissue Fetus and placenta Maternal blood Iron losses Total Iron for Pregnancy Iron retained after delivery Total Iron Needs Iron Needs (mg) 320 500 250 1070 150-200 700-800 The greatest demand for iron occurs in the third trimester. Since iron is transported against a concentration gradient, iron will continually be pulled from maternal stores. At delivery, it is not uncommon to see levels of hemoglobin and iron higher in umbilical cord blood than in maternal blood. The indices of iron status most commonly used are hemoglobin (Hb) and hematocrit (Hct) levels. During pregnancy, these levels begin to drop during the end of the first trimester, and reach their lowest level at the end of the second trimester (due to the rapid plasma volume expansion). They may actually begin to rise somewhat during the third trimester, even though this is the period of highest demand, if the woman is supplementing with iron or has adequate stores (MMWR, 1998). Otherwise, hemoglobin and hematocrit levels continue to fall in the third trimester (Bothwell, 2000). Iron deficiency anemia, with resulting insufficient hemoglobin, can cause complications in pregnancy. Metabolism is altered, there is a smaller increase in plasma and red cell volume, and less oxygen is transported to the tissues, decreasing energy production. The immune system can be impaired, decreasing resistance to infection. Also, placental insufficiency or hypertrophy decreases nutrient transfer to the fetus. Increased incidence of urinary tract infections, pyelonephritis (inflammation of the kidney), preeclampsia and pica are seen in anemic women (MMWR, 1998). Complications of anemia affect the outcome of pregnancy — higher incidence of premature delivery (associated with low birth weight), stillbirth, and perinatal mortality are seen. There are three stages of iron depletion, with increasing severity. • Stage one is a depletion of iron stores without interference with Hb production. Low serum ferritin level, the storage form of iron, with a normal Hb level indicates a depletion of iron stores. Most pregnant women have low or depleted serum ferritin stores during the third trimester without hemoglobin production problems, indicating a physiological adaptation to pregnancy. However, low serum ferritin during the first or second trimester means a woman may progress to stage two or three. • Stage two of iron depletion is impaired Hb production, evidenced by a low ratio of serum iron to total iron-binding capacity (Fe/TIBC), low mean corpuscular Sexual & Reproductive Health 61 volume (MCV), and normal serum Hb. The serum Hb may be within normal range, but may have decreased from mid-normal range to low-normal range. • Stage three, iron deficiency anemia, is characterized by low serum ferritin levels, low serum iron, decreased Hb and decreased MCV. The published literature suggests that maternal anemia diagnosed at the beginning of prenatal care is associated with an increased risk of preterm delivery, while anemia diagnosed during the third trimester is not. Lack of association during the third trimester may occur, because hemodilution makes it difficult to distinguish between anemia and expanded plasma volume (Scholl and Hediger, 1994). In fact, Steer (2000) suggests that Hb levels between 9.5 to 11.5 gm/dL with normal MCV of 84 to 99 fL, minimizes low birth weight and preterm labor. Hemoglobin levels of 9.5 to 11.5 gm/dL normally indicate anemia. However, if the MCV is normal, as it is with a value above 84 fL, the lower Hb is not a concern. The type of birth control method used by women will affect the iron status at the beginning of pregnancy. Oral contraceptives decrease blood loss by 50 percent, conserving iron. Intrauterine devices (IUD), although used by few women, double blood loss during menstruation and thus decrease iron stores. All pregnant women should have their iron status assessed using Hb and Hct values. If these are low other tests can be done to determine if a woman has low iron stores, preventing iron deficiency anemia later in the pregnancy. Smoking and higher altitudes cause an increase in Hb and Hct levels. The chart below, adapted from CDC, shows lab values indicating anemia and adjustments for smoking and living at higher altitudes. Misdiagnosis of anemia occurs if Hb and Hct are not adjusted. Lab Indicators of Anemia Pregnancy: 1st trimester 2nd trimester 3rd trimester Smoking Adjustment¶ 0.5 - <1.0 pack/day 1.0 - <2.0 packs/day ≥ 2.0 packs/day Hb* (gm/dl) Hct** (%) <11.0 <10.5 <11.0 <33.0 <32.0 <33.0 +0.3 +0.5 +0.7 +1.0 +1.5 +2.0 *Hb=hemoglobin **Hct = hematrocrit ¶ Add to Hb/Hct value to determine if anemia is present Source:CDC, USDHHS, MMWR, 47 (RR-3), April 3, 1998. Altitude (feet)¶ 3,000-3,999 4,000-4,999 5,000-5,999 6,000-6,999 7,000-7,999 8,000-8,999 9,000-9,999 10,000-11,000 Hb* (gm/dl) Hct** (%) +0.2 +0.3 +0.5 +0.7 +1.0 +1.3 +1.6 +2.0 +0.5 +1.0 +1.5 +2.0 +3.0 +4.0 +5.0 +6.0 Sexual & Reproductive Health 62 Dietary sources of iron, no matter what the choices, are usually not sufficient to meet the iron demands of pregnancy. The iron requirement of pregnancy is 700 to 800 mg — most of it needed in the second half of pregnancy. Iron absorption increases during each trimester, from 0.4 mg/day the first trimester to 1.9 mg/day the second trimester to 5.0 mg/day the third trimester, regardless of the foods eaten (Bothwell, 2000). The DRI for iron during pregnancy is 27 mg/day from 14 to 50 years of age (IOM, 2001). If a women consumes of 10 to 15 mg of iron a day during pregnancy, and absorbs from 0.4 to 5.0 mg/day, based on trimester, the total amount of iron absorbed during pregnancy is 600 mg, below the 800 mg needed. The difference must be made up by iron stores or supplements. It is very common to see women iron-deficient at the end of pregnancy, as measured by levels of serum ferritin. Iron from animal sources, heme iron, is more easily absorbed than non-heme iron, from plant sources. Absorption of non-heme iron is decreased by phytates (in whole grains and legumes), calcium and phosphorus (in milk), tannins (in tea) and polyphenols (in vegetables). Ascorbic acid increases absorption of non-heme and heme iron. Absorption of non-heme iron ranges from 6 to 13 percent (Charlton and Bothwell, 1983). Absorption of non-heme iron is inversely related to iron stores. As absorption increases, stores decrease, and vice versa. Heme iron — found in meat, poultry and fish — is better absorbed than non-heme iron and few factors interfere with its absorption. Overall, iron absorption from food is difficult to assess due to the many variables. It may be possible to increase or decrease the amount of iron absorbed, but not by much. Reddy, et al., (2000) found that only 16.5 percent of the variance in iron absorption is due to food constituents: meat, phytates and ascorbic acid. No other nutrients studied — calcium, phosphorus, phenols — influenced iron absorption. Supplementation can reverse the fall in hemoglobin, serum iron and serum ferritin. How much to supplement and what method of supplementation to use are widely debated and researched. Absorption of supplemental iron is affected by the dose, iron stores and the delivery form — alone or in combination with other vitamins and minerals. Studies have shown that supplementing pregnant women with 30 mg of elemental iron significantly raises their serum iron levels. High doses of supplemental iron can cause many GI side effects. The chart on the next page refers. Most pregnant women are routinely supplemented with 27 mg of ferrous iron, enough to allow them to absorb 2.5 to 3 mg/day. When considering whether to supplement with iron, certain factors should be considered. Calcium, magnesium or zinc can decrease iron absorption. Any of these minerals, supplemented at the same time as iron, can interfere with iron absorption, as can food. Layrisse et al. (1973), found that 50 percent more iron is absorbed when it is given between — not with — meals. When iron is taken as a part of a multivitamin and mineral preparation, very little of the iron may be released from the pill. Seligman et al. (1983) found iron release from a prenatal vitamin and mineral supplement was, at best, 1 percent. This is of particular concern since the majority of women in the US take a vitamin and mineral supplement with iron and feel it will meet their iron needs during pregnancy, when in fact it may not. Sexual & Reproductive Health 63 Rationale for Iron Supplementation Dietary iron intake Dietary iron absorbed (6-25% absorption rate) 10-15 mg/day 0.9-3.75 mg/day Total dietary iron for pregnancy (270 days): Absorbable iron from 27mg supplement Total supplement for pregnancy (270 days): Total intake from diet and supplements 240-800 mg 2.7 mg 725 mg 965 - 1725 mg 30 mg ferrous iron equals: 150 mg ferrous sulfate 300 mg ferrous gluconate 100 mg ferrous fumarate Consideration of the effects of iron on other nutrients is important. Breskin, et al., (1983) found that women using a vitamin and mineral supplement with 30 to 60 mg of iron had significantly lower serum zinc levels than when less iron was present. The Institute of Medicine recommends supplementing with 15 mg of zinc and 2 mg of copper when iron is supplemented at or above 30 mg/day. Clinical trials have shown that iron supplementation is effective in raising serum hemoglobin and ferritin levels (Yip, 1996; Madhavan, et al., 2004). Unfortunately, when supplementation is done on a widespread basis, it is not as effective due to problems with compliance. Most women do not like taking iron. It causes many gastrointestinal disturbances — nausea, constipation, metallic taste in the mouth, loss of appetite, upset stomach, gas, etc. — so many women just stop taking it. A big part of the non-compliance issue may be that physicians are prescribing too much iron. The higher the dose, the lower the compliance. Ridman et al. (1996) compared pregnant women supplemented with a single weekly dose of 120 mg ferrous sulfate with those receiving a daily dose of 60 mg. The effects on serum hemoglobin and ferritin were comparable. This raises the possibility that one weekly dose may be enough for some women. Other studies have also concluded that weekly supplementation with iron is as effective as daily supplementation, as long as the woman is not anemic at the beginning of the pregnancy (Casanueva, et al., 2006; Mukhopadhyay, et al., 2004). To decrease the symptoms associated with iron supplementation, instruct your client to take iron before bed. Another option is to decrease the total amount taken. If a woman is not anemic, 30 mg/day or 60 mg/week is adequate and is associated with minimal side effects. If a woman is anemic, she needs to take a higher dose, which will be prescribed by her physician. There is no benefit to prescribing iron supplements that women do not take. It is better to find a smaller dose that is tolerated by the woman. I have found that liquid iron, such as Floridex,® sold in health food stores, is much better tolerated than pills. It contain ferrous gluconate, herbals and fruit extracts and vitamin C to increase absorption. Sexual & Reproductive Health 64 The CDC recommends the following to prevent anemia in pregnant women: • Start oral, low-dose (30 mg/day) iron supplements at first prenatal visit; • Encourage pregnant woman to eat iron-rich foods; • Encourage pregnant women to eat foods that enhance absorption; and • Screen women for anemia at the first prenatal care visit. ZINC AND IRON Zinc is essential during the first trimester; iron is not. It is important to ensure adequate zinc early in pregnancy. Numerous studies have shown that supplementing with iron increases hemoglobin levels, but reduces serum zinc levels (Breskin, et al., 1983; O'Brien, et al., 1999). Since it interferes with zinc, iron supplementation is not recommended during the first trimester. This is especially true for women with adequate iron stores and serum hemoglobin levels. They could wait until the second trimester to begin the higher level of iron supplementation without any problem. More recently, Harvey and colleagues (2007) found that supplementation with 100 mg iron/day had no detectable adverse effects on zinc metabolism. Note that this study was small, 13 women, and the study period was the second and third trimesters. Women who are severely iron-deficient pose a problem. Supplementation with iron should begin as early as possible, but zinc and copper should be supplemented as well. O'Brien and colleagues (1999) showed that supplementing with zinc and iron prevented a fall in zinc levels while increasing serum iron. Taking supplemental iron in the ferrous form, as a single pill rather than as part of a multi-vitamin and mineral preparation, between meals, and without tea, coffee or milk (which inhibit absorption), will maximize iron absorption. Pica, the eating of non-food substances, is often associated with iron deficiency. Moore and Sears (1994) estimated that pica may occur in as many as half of iron-deficient patients. No one knows if pica causes iron deficiency or if iron deficiency causes a craving for non-food substances. (Pica will be discussed in Chapter Eight.) FOLIC ACID Folic acid is a water-soluble B-complex vitamin, involved in the synthesis of amino acids as well as purines and pyrimidines (molecules necessary for the production of RNA, DNA, and red blood cells). Folate is the naturally-occurring form of the vitamin and folic acid is the synthetic form (which is better absorbed). A deficiency of folic acid (or folate) leads to impaired cell division and altered protein synthesis. During the first trimester of pregnancy, when cells are rapidly dividing, adequate folic acid is critical. Poor outcomes of pregnancy have been attributed to inadequate maternal folate, including spontaneous abortions, fetal malformation, toxemia, preterm and small-for-gestational-age babies and antepartum hemorrhage (Pietrzik and Thorand, 1997). Sexual & Reproductive Health 65 A folic acid deficiency results in megaloblastic anemia, characterized by large, nucleated red blood cells. Without sufficient folic acid, red blood cells cannot be synthesized. An MCV greater than 95 fL indicates a folic acid deficiency. Serum folate levels decrease during pregnancy, beginning at mid-pregnancy, most likely due to blood volume expansion, increased urinary excretion and hormonal influences on folate metabolism. Supplementing with folic acid will prevent a deficiency, but may not reverse the physiological changes due to pregnancy. Studies have also shown increased birth weights and prevention of preterm deliveries in women with low serum and erythrocyte levels who supplemented with 150 to 200 mcg/day folic acid (Mukherjee, et al., 1984). Scholl and colleagues (1996) found that (after controlling for maternal characteristics, energy intake and other correlated nutrients) women with a low mean daily folate intake (less than 240 mcg/day) had a nearly two-fold greater risk of preterm delivery and infant LBW. Lower concentrations of serum folate at gestational week 28 were also associated with a greater risk of preterm delivery and low birth weight. (The study was observational; so, it is possible that folate may be a marker for other aspects of maternal lifestyle or nutritional status that are causally related to preterm birth.) In another study, intakes of folate below 500 mcg/day and serum folate levels below 16.3 ng/mL in the second trimester were associated with an increased risk of preterm delivery (Siega-Riz, et al., 2004). The average intake of folate in the study was 463 mcg/day. Deficient levels of folate have been linked to neural tube defects (NTD), such as spina bifida, myelomeningocele, and anencephaly in infants. The central nervous system develops inside the neural tube, which forms early in fetal life (between the 18th and 20th day) and closes between the 24th and 27th day of pregnancy. At this time, many women do not even know they are pregnant. Studies done in northern Europe suggest that when women with one child with a neural tube defect are supplemented with folic acid, the incidence of a second child with a neural tube defect is decreased significantly (Smithells, et al., 1980, 1983). A study published by the MRC Vitamin Study Research Group (Lancet, 1991) resolved the debate over the effectiveness of folic acid supplementation and neural tube defects. The study, a randomized double-blind prevention trial of 1,817 women, found that 4 mg of folic acid reduced the incidence of neural tube defects by 72 percent over the control group. The researchers concluded that : Folic acid supplementation starting before pregnancy can now be firmly recommended for all women who have had an affected pregnancy, and public health measures should be taken to ensure that the diet of all women who may bear children contains an adequate amount of folic acid. Further proof of the link between folic acid and NTD came in a retrospective, casecontrol study published in 1993 (Werler, et al., 1993). This study looked at infants with congenital malformations. It concluded that 0.4 mg of supplemental folic acid, periconceptionally, can decrease the occurrence of NTD by 60 percent, and a high intake of dietary folate may do the same thing. Sexual & Reproductive Health 66 It has been suggested that abnormal folate metabolism causes some women to need more folate than others (Pietrzik and Thorand, 1997; Boddie, et al., 2000). In these women, folate absorption is decreased, necessitating a higher intake to prevent NTD. In fact, a genetic abnormality in folate metabolism may be a risk factor for Down syndrome. Mothers of Down syndrome children were found to have abnormal folate metabolism by James, et al., (1999). This, however, was just one study and further confirmation is needed. While other factors besides diet can cause NTD — genetics, geographic location, socioeconomic status, race, nutrition and maternal health — the US Public Health Service (USPHS) believes there is enough compelling information to make definite recommendations on folic acid intake: All women of childbearing age in the United States who are capable of becoming pregnant should consume 0.4 mg (400 mcg) of folic acid per day for the purpose of reducing their risk of having a pregnancy affected with spina bifida or other NTD. Since 1998, manufacturers can fortify cereal grains and flour (enriched bread, pasta, flour, breakfast cereal and rice) with 140 mcg folic acid per 100 gm of flour (Hine, 1996). Keep in mind that some, but not all, enriched bread, pasta and baked goods are made from folic acid-fortified flour — the label must so indicate. Prepared baked goods may or may not be made of folic acid-fortified flour. The folic acid content of foods in the database of a nutrition program may or may not differentiate between synthetic folic acid and naturally-occurring folate — check with the company. Determining the folate/folic acid intake of a pregnant women (or anyone), can thus be difficult. A serving of a folic acid-fortified grain product provides about 40 mcg of folic acid; fortified breakfast cereals can provide 25 to 100 percent of the RDI for folic acid. It is estimated that folic acid fortification of grain will increase folic acid intake by 100 mcg a day — and, in fact, women probably cannot meet their folic acid requirement without the fortified grain products (Firth, 1998; Cuskelly, et al., 1999; Kloeblen, 1999). Firth, et al., (1998) found that without fortified foods, folic acid intake would only average 288 mcg/day. In 1998 the IOM made a new recommendation for folate intake during pregnancy, and another recommendation to prevent NTD. The reason they have two recommendations is that neural tube development occurs during the first four weeks after conception, when the woman is least likely to know she is pregnant. Therefore, all women capable of getting pregnant should have sufficient levels of folic acid to prevent NTD. As the IOM report stated: It is recommended that women capable of becoming pregnant consume 400 mcg of folic acid daily from supplements, fortified foods or both in addition to consuming food folate from a varied diet. Sexual & Reproductive Health 67 The IOM decided that fortification or supplementation of synthetic folic acid, with its superior absorption, is the only way to ensure women are getting enough folic acid. Absorption of folate from food is approximately 50 percent, while absorption from fortified foods is 85 percent and absorption from a supplement is 100 percent (Federal Register, 1993; Bailey, 1998; Suitor and Baily, 2000). Fortified food eaten with other foods has an absorption rate 1.7 times more efficient than when eaten alone. (IOM, 1998). With this knowledge, the IOM Food and Nutrition Board decided to express the DRI for folate in terms of Dietary Folate Equivalents (DFE), which takes into account the differing absorption rates of synthetic folic acid and food folate (IOM, 1998). For pregnant women, the DRI for folate is 600 DFE (600 mcg). To calculate DFE, use the information in the chart below. Appendix #12 lists folate content of foods. (Keep in mind that it is difficult to determine the DFE of foods made from flour, as the synthetic folic acid versus natural folate is not differentiated.) Dietary Folate Equivalents (DFE) Source Food folic acid Food fortified with folic acid Folic acid supplements Absorption 50% absorption 85% absorption 100% absorption Absorption compared to food 1.7 2.0 1 DFE in food = 1 mcg folic acid from food 1 DFE in fortified foods = 1.7 mcg folic acid from food 1 DFE from supplement = 2 mcg folic acid from food Example 400 mcg folic acid supplement = 800 DFE (400 x 2) 1 cup fortified pasta, 85 mcg fortified folic acid = 144 mcg DFE (85 x 1.7) 1/2 cup spinach, 100 mcg folic acid = 100 mcg DFE Many foods do contain quite a bit of folic acid. Foods high in folic acid are dark green leafy vegetables, liver, kidneys, legumes, oranges, grains and wheat germ. Cooking vegetables in water and high heat destroys 80 to 90 percent of the folic acid. If the vegetables are eaten raw, little or no folic acid is lost. Since 50 percent of dietary folic acid is absorbed in the intestinal tract, it is possible to get adequate folic acid needed for pregnancy from diet alone, but it is better to rely on supplements and folic acid fortified foods. In December 1993, the FDA approved a health claim that linked folic acid to reduced incidence of NTD. A product must contain 10 percent of the RDI (Reference Daily Intake), which for folate is 0.4 mg (400 mcg), in order to make a health claim. If the label claims “high in folate,” it means a serving of food provides 20 percent or more of the RDI of folate. If the label claims it is a “good source” of folate it means the food provides 10 to 19 percent of the RDI (Kurtzweil, 1996). Sexual & Reproductive Health 68 Don't forget, pregnant women need 50 percent more folate than nonpregnant women, so the RDI is not the best guide for pregnant women, unless you adjust for the increased pregnancy needs. Has fortification of grains and flour with folic acid made a difference? The answer is yes. Quinlivan and Gregory (2003) found that the average intake of folic acid has risen in the US by 215 to 240 mcg/day, which is two to three times the expected increase of 70 to 130 mcg/day, while Choumenkowitch, et al., (2002) found the increase to be 190 mcg/day. The CDC compared serum and red blood cell folate levels for childbearing-aged women. From NHANES III (1988-1994) to NHANES 1999, mean serum folate concentrations for aged 15 to 44 increased from 6.3 to 16.2 ng/mL, while red blood cell folate increased from 181 to 315 ng/mL (MMWR, 2000). More importantly, the incidence of NDT has decreased by 26 percent since the onset of folic acid fortification of grains and flour (MMWR, 2004), a good outcome. However, only 40 percent of childbearing-age women take a folic acid supplement (MMWR, 2004). Increasing that number can reduce NTD even further. For more information on folic acid, visit: <www.folicacid.net> From statistics released in April 2009, it appears that the reduction in incidence of NTD, in particular spina bifida and anencephalus, has stopped. In 1991 the incidence of spina bifida per 100,000 live births was 24.88, decreasing to 17.96 in 2005 and 17.99 in 2006 (Matthews, 2009). For anencephalus it was 18.38 in 1991, 10.39 in 2004, 11.11 in 2005 and 11.21 in 2006. Getting more childbearing age-women to supplement folic acid may help to reduce the incidence of NTD even more. Folate metabolism is controlled by a number of genes which can have single nucleotide polymorphisms (SNP) — alterations in the gene that effect enzymes involved in folate metabolism. One SNP in the MTHFR gene, found in 8 to 15 percent of the population (Zeisel, 2009), can reduce folate enzymatic activity by 50 percent. Other genes can also have polymorphisms, altering folate metabolism. Individuals with them may need more folate than the rest of the population, including pregnant women. How much folate is required is related to the requirement for choline, which also takes part in one-carbon transfers and methylation reactions. Choline is found in the diet in eggs and meat and can be made in the body from phosphatidylcholine. Premenopausal women make more choline than postmenopausal women, since estrogen induces a gene that increases the production of choline. During pregnancy, estrogen levels are higher, so there is more choline produced and transferred from the mother to the fetus (Zeisel, 2009). Lack of sufficient choline may also increase the risk for NTD (Zeisel, 2009). Like folate, there are SNP in the genes that control choline metabolism and these are fairly common, increasing the dietary requirements for choline. If you look at the metabolic pathways for one-carbon transfers, both folate and choline are required. If one of the nutrients is insufficient, you need a higher intake of the other to prevent metabolic abnormalities, including the development of NTD in pregnancy (Zeisel, 2009). It could be that the lack of a further decline in the incidence of NTD in the US may not only be due to women not consuming the recommended amount of folate or folic acid, but also that some women may have a higher need for folate and/or choline which is not met. Sexual & Reproductive Health 69 ZINC Zinc is involved in over 70 metabolic reactions in the body and is essential for DNA and RNA production, protein synthesis, cell division and cell replication. Rats can be made zinc-deficient in as short a period of time as six days, as evidenced by decreased DNA in the brain. Studies done on rats have shown that a zinc deficiency severely impacts the outcome of pregnancy, causing congenital anomalies and malformations, including abnormal brain development and behavior. It may also cause a reduction in the zinc level in dental enamel and dentin, increasing susceptibility to dental caries (Beach, et al., 1983). In humans, the relationship of zinc to pregnancy outcome is much less clear. Numerous studies have shown a relationship between low serum zinc levels in cord and/or maternal blood and abnormal deliveries, congenital abnormalities (mostly involving the central nervous system), low birth weight and preterm delivery. However, other studies have not (King, 2000). In an excellent review of zinc and pregnancy, King (2000) discusses over 52 studies done on humans and concludes that while there is a relationship between zinc status and outcome, the cause is most likely altered utilization, not deficiency. A diet high in phytates (cereal-based), supplementing with high amounts of iron, smoking, alcohol abuse and an acute stress response to infection or trauma, all decrease zinc utilization. Due to a lack of data on normal values of serum zinc during pregnancy, it is difficult to determine how many pregnant women are zinc-deficient. In addition, serum zinc levels decline during pregnancy as plasma volume expands (King, 2000). In a newer review of maternal zinc supplementation, Hess and King (2009) found a 14 percent reduction in premature delivery and positive effect on birthweight in a subset of zinc-deficient women. Zinc supplementation did not effect iron status. Approximately 100 mg of additional zinc is needed during the course of pregnancy, much of it during the third trimester. The first and second trimester needs call for an additional 0.5 and 1.5 mg, respectively, of zinc daily, while 4 mg/day is required in the third trimester. Zinc deficiencies in the US have been well documented; it is considered one of the hardest nutrients to consume in DRI amounts. The average zinc intake is approximately 8 to 14 mg/day, which may or may not meet the 11 to 12 mg/day needed during pregnancy. Vegetarians may have a lower intake, since the best source of dietary zinc is red meat and they have a much higher intake of plant and cereal — foods high in phytates. Most people get 70 percent of their dietary zinc from meat (NRC, 1989). In pregnancy, the DRI increases to 15 mg. Absorption of zinc is approximately 20 percent. The timing of zinc intake is as important as the quantity. During the first trimester, when much blastogenesis occurs, zinc is essential for normal fetal development. Inadequacies cannot be made up later in the pregnancy. Once an organ is malformed, no amount of zinc can repair the damage. Since zinc is often inadequate in the diet, a supplement of 10 to 15 mg/day is recommended during the first trimester, especially if iron is also supplemented (ADA, 2002). 70 Sexual & Reproductive Health As discussed previously in this chapter, supplementation exceeding 60 mg of elemental iron can lower plasma zinc concentrations. Thus, iron supplementation should be delayed until the second trimester to avoid interference with zinc. If the woman is iron-deficient, smaller doses of iron (taken separately from zinc) will minimize interference with zinc absorption. Alcohol and cadmium (which is found in cigarettes) interfere with zinc metabolism. Alcohol increases urinary zinc losses and decreases plasma zinc concentration. Increased placental cadmium levels alter the cadmium-to-zinc ratio and are related to infant birth weight (Kuhnert, et al., 1988). Therefore, alcohol users and smokers need to be especially careful to make sure they are receiving adequate zinc in their diet or through supplements. Dietary sources of zinc include meat, poultry, oysters, seafood, whole grain cereals, milk, liver and eggs. With the exception of oysters, foods do not contain a lot of zinc. For example, one 3 oz serving of meat contains only 1 to 2 mg of zinc, while an 8 oz glass of milk contains just 0.88 mg of zinc. CALCIUM Calcium is necessary for bone and tooth formation in the fetus, as well as muscle contraction and relaxation, blood clotting and blood pressure regulation. Changes in calcium metabolism that occur during pregnancy — intestinal absorption, renal reabsorption and bone turnover — are caused by hormonal changes regulating calcium metabolism, as shown in the diagram below. Calcium Physiology Low plasma calcium Increase in parathyroid hormone (PTH) Kidney Increased production active Vitamin D Increased calcium conservation Absorption of Calcium increases plasma calcium Bone cells Decreased urinary calcium excretion Increased bone demineralization Increased bone loss plasma calcium Sexual & Reproductive Health 71 The need for calcium increases as the pregnancy progresses. Eighty percent of the calcium required during pregnancy is required during the third trimester, when the fetal bones are mineralized at a rapid rate. Forbes (1976) determined that approximately 50 mg/day of calcium is transferred from the mother to the fetus, increasing to 330 mg/ day at 35 weeks gestation. It is estimated that 200 mg/day of calcium is deposited in the fetal skeleton (Prentice, 1994). To meet this increased need for calcium, absorption increases during pregnancy, from 33 percent pregnancy to 50 percent during the second trimester and 53.8 percent during the third trimester (Ritchie, et al., 1998). If the mother's diet is inadequate in calcium, decreased storage of calcium is common, since calcium is transported against a concentration gradient. Serum levels of calcium are thus not a good indicator of calcium status, since calcium will be pulled out of the bones to normalize serum levels. Maternal parathyroid hyperplasia during pregnancy may be due to low calcium intake. When serum calcium levels fall, the body signals the parathyroid gland to secrete parathyroid hormone (PTH), which increases intestinal calcium absorption and decreases loss from the kidneys. The net result is an increase in serum calcium levels, shutting off the production of PTH. If the serum levels of calcium are still too low, the level of PTH increases, signaling the bone cells to release calcium into the serum, thus raising calcium levels high enough to turn off the parathyroid gland’s production of PTH. With increased estrogen production during pregnancy, the bone cells are more resistant to the parathyroid hormone, so it takes higher levels to cause the bones to begin releasing calcium. The resistance of the bone cells to parathyroid hormone makes the gland work harder, causing hyperplasia, as shown in the diagram below. Maternal Parathyroid Hyperplasia Decreased plasma calcium Parathyroid gland secretes PTH Dietary calcium inadequate to increase serum calcium Estrogen decreases effectiveness of PTH Parathyroid gland secretes more PTH Bones demineralized for calcium Increased plasma calcium Sexual & Reproductive Health 72 Early in the third trimester, blood pressure begins to elevate, corresponding to the increased need for calcium. In pregnant women, the great demand for calcium can lower serum levels. If calcium is being utilized rapidly, maternal serum calcium levels drop, causing a rise in blood pressure. O’Brien and Dufour (1994) found that by 34 to 36 weeks gestation, pregnant women with calcium intakes less than 1200 mg/day had higher systolic and diastolic readings (3 to 6 mm Hg) than pregnant women with higher calcium intakes. This is above the 5 mm Hg increase in blood pressure commonly seen in all pregnant women. Supplementing calcium in nonpregnant individuals with high blood pressure will lower their blood pressure — while calcium supplementation of pregnant women has not been studied, it may be beneficial and will do no harm. Calcium may also have a role in reducing the risk of preterm delivery in populations at risk for low calcium intake. Calcium supplementation, in theory, reduces smooth muscle tone, including uterine muscle. In one study, supplementation with 2 gm/day decreased preterm delivery and low birth weight in an adolescent population (Murtaugh and Weingart, 1995). If confirmed by further study, calcium supplementation would be a simple and inexpensive intervention to reduce preterm birth. However, high doses of calcium may cause constipation and decrease intestinal absorption of iron, zinc and other minerals. The DRI for calcium during pregnancy is 1300 mg/day for pregnant women under age 19 and 1000 mg for those 19 years and older, either from the diet or supplements (IOM, 1997). Adequate calcium in the third trimester is critical for the fetus, and protects the mother from depleted calcium stores. The DRI for calcium is the same for pregnant and non-pregnant women. The IOM, after reviewing the studies, felt that as long as calcium intake was adequate, there was no effect on maternal bone mineral density (IOM, 1997). Food sources of calcium include dairy products, kale, broccoli, greens, tofu (processed with calcium), amaranth, sardines and salmon (with bones), tortillas (made with lime or calcium carbonate), sesame seeds, almonds and other nuts, soy nuts, okra, white beans and tempeh. Foods fortified with calcium are now available, including orange juice, milk, cheese, yogurt, cereals and bread (Wonder Bread®). Women who are lactose intolerant can buy a milk called Lactaid®, or a Lactaid pill that breaks down milk sugar, enabling them to drink milk or eat foods with lactose. Otherwise, they must rely on other foods high in calcium, calcium-fortified foods or a supplement. Supplementation of calcium can be from an antacid, as long as it does not contain aluminum. This is an added benefit if the woman has heartburn, as it “kills two birds with one stone.” Absorption of calcium is improved if consumed with or at the end of a light meal (Heaney, et al., 1989). Another good calcium supplement is calcium carbonate or calcium citrate. Avoid oyster shell calcium, bone meal and dolomite, as they may be contaminated with heavy metals. Calcium carbonate interferes with iron absorption, so don’t take them together. Sexual & Reproductive Health 73 Adequate calcium is especially important for younger pregnant woman and adolescents. Being pregnant while bones are still forming can decrease bone density, if calcium intake is low, and increase the likelihood of osteoporosis later in life. While this holds true for older women as well, it is more detrimental to younger women. Adequate calcium intake prevents bone loss during pregnancy. The IOM (1990) states that women under 25 years old with low calcium intakes — defined as below 600 mg/day — should be supplemented with 600 mg daily. To enhance absorption and limit interaction with iron supplements, the calcium supplements should be taken at mealtime. VITAMIN D In the last few years researchers have begun to document a much higher incidence of vitamin D deficiency in pregnant women (Hollis and Wagner, 2004a). It was thought that the majority of the US population met their vitamin D requirement through exposure to sunlight, since diet contains minimal amounts of naturally occurring vitamin D. However, it is now well documented that individuals living above 35º latitude — roughly, Washington, DC, Little Rock, AR, and San Jose, CA — have difficulty making adequate vitamin D in winter, due to the angle of the sun. In addition, individuals with darker skin need much longer sun exposure, up to 10 times as long, to make the same amount of vitamin D as people with lighter skin (Hollis and Wagner, 2004b). The vitamin D requirement for the entire population, including pregnant women, is really unknown. The DRI was based on unsubstantiated data and determined before measurement of serum vitamin D — 25(OH)D — was possible. For children, the DRI of 10 mcg (400 IU) was based on the amount of vitamin D in 1 tsp of cod liver oil given to prevent rickets, while the adult dose of 5 mcg (200 IU) was based on the amount of vitamin D necessary to prevent osteomalacia in the absence of sunlight (Vieth, 1999). Vitamin D has functions beyond its role in calcium and bone metabolism. Many organs and cells of the body contain vitamin D receptors that are necessary for their normal function. Newly discovered functions of vitamin D include: anti-inflammatory agent; cell growth regulation, blood pressure, and immunity; stimulates insulin production; decreases autoimmune diseases; and may prevent chronic diseases such as diabetes, cancer, multiple sclerosis, heart disease and schizophrenia (Vieth, 1999). Vitamin D status of the infant at birth is related to the vitamin D status of the mother, as the cord blood will contain 50 to 60 percent of the maternal circulating concentrations of vitamin D (Hollis and Wagner, 2004a). A vitamin D deficiency in pregnant women can cause problems for the mother and fetus. Maternal effects of a vitamin D deficiency include decreased serum calcium concentrations and possible decreased weight gain the third trimester (Specker, 1994). Fetal vitamin D deficiency can delay growth and bone ossification, and cause enamel hypoplasia and problems with calcium regulation (i.e. hypocalcemia and tetany), decrease bone mineral content and skeletal mineralization as well as cause congenital rickets and craniotabes (Specker, 1994; van der Meer, et al., 2006). It is also possible that a vitamin D deficiency may increase the risk for chronic diseases later in life. Sexual & Reproductive Health 74 Adequate vitamin D appears to increase serum calcium concentrations of the fetus by the 4th day of life, improves neonatal handling of calcium and prevents osteomalacia (IOM, 1997; Specker, 2004). It may even influence postnatal mineral homeostasis, growth and bone mass (Pawley and Bishop, 2004). At issue is whether or not a vitamin D deficiency decreases maternal weight gain, fetal growth and birth weight. At this point in time we still do not know how much vitamin D is required during pregnancy and what constitutes a "normal" serum vitamin D level. The present AI for vitamin D in pregnancy is 200 IU, but according to Hollis (2007) : ...the current recommended AI of 200 IU/day for vitamin D is useless for maintaining nutritional status, yet alone improving it. This is especially true in populations of people of color living in northern latitudes. Clinical studies to date with respect to vitamin D supplementation during pregnancy and lactation are largely dated and grossly inadequate, and as a result, very little clinical information can be derived from them. Some researchers suggest that levels below 25 nmol/L are deficient and above 50 nmol/L are necessary for proper functioning of the body’s cells and organs, with a range of 78 to 100 nmol/L necessary for bone health and chronic disease prevention (Holick, 2004b). Heaney (2003) suggests that levels below 80 nmol/L are deficient. Higher levels can be tolerated without any adverse effects. Sunlight can provide between 10,000 and 20,000 IUs per day (Holick, 2004b) and lifeguards and sunbathers can have serum vitamin D levels of up to 250 nmol/L without any signs of toxicity. As vitamin D intake increases, so does serum vitamin D (Hollis and Wagner, 2004a). A study published by van der Meer, et al., (2006) uses a definition of vitamin D deficiency as below 25 nmol/L. In this study of pregnant women in the Netherlands, 8 percent of pregnant Western women and over 50 percent of darker-pigmented pregnant women were vitamin D deficient. Had the criteria for vitamin D deficiency been set higher, an even greater number of pregnant women would have been vitamin D deficient. A 2006 study found a correlation of milk intake to infant birth weight in pregnant women living in Calgary, Canada (51º North), independent of other risk factors. As milk intake increased, so did birth weight (Mannion, et al., 2006). For each 1 mcg (40 IU) increase in vitamin D intake, birth weight increased by 11 gm. No differences in infant head circumferences and lengths were found between women with higher and lower milk consumption. No serum vitamin D levels were taken. In studies of lactating women, 400 IU of vitamin D did not raise serum vitamin D in the lactating women. In fact, their serum levels declined (Hollis and Wagner, 2004b). The authors feel that 400 IU recommendation during lactation is way too low, especially for darker pigmented women and infants and that the recommendation should be as high as 4000 IU per day for lactating women. In a newer study to assess the vitamin D status of pregnant women and their offspring in Pittsburgh, PA (latitude 40º North) by race and season, a surprisingly high number of women and neonates were vitamin D deficient or vitamin D insufficient, Sexual & Reproductive Health 75 shown in the chart below (Bodnar, et al., 2007). Many of the women with a vitamin D deficiency or insufficiency took a prenatal supplement the last trimester of pregnancy and 45 percent took a supplement prior to pregnancy. More black women and infants had vitamin D deficiencies and insufficiencies than white women, due in part to the increased skin pigmentation and the fewer number of women who took supplements prior to or during pregnancy. White babies born in the spring had a 75 percent increase in the incidence of vitamin D insufficiency compared to white babies born in the summer. The variation in vitamin D insufficiency in black women and babies did not vary as much as the white women and babies. Vitamin D Deficiency in Mothers & Neonates 37-42 weeks gestation Serum 25(OH)D, nmol/L Vitamin D status, % Deficient: <37.5 nmol/L Insufficient: 37.5-80 nmol/L Sufficient: >80 nmol/L White Women n=200 Black Women n=200 80.4 49.4 5.0 41.2 53.8 29.2* 54.1 16.7 Neonates, White Cord Blood Serum 25(OH)D Vitamin D status, % Deficient: <37.5 nmol/L Insufficient: 37.5-80 nmol/L Sufficient: >80 nmol Neonates, Black 67.4 39.0* 9.7 56.4 33.9 45.6* 46.8 7.6 * Different from white women or white babies. Adapted from Bodnar et al, 2007. Without any exposure to sunlight, it is suggested that adults need a minimum of 1000 IU/day vitamin D (Holick, 2004a). Heaney (2004, 2005) found that calcium absorption was not maximized until a serum level of vitamin D reached 75 to 80 nmol/L. To achieve a serum vitamin D level of 80 nmol/L could require a daily intake of up to 2200 IU (Heaney, 2005). At present, the upper limit recommended for vitamin D is 2000 IU/ day. Toxicity is not seen even at serum vitamin D levels of 250 nmol/L, requiring a vitamin D intake of 10,000 IU/day (Heaney 2005). Individuals exposed to adequate sunlight have serum vitamin D concentrations averaging 150 nmol/L (Vieth, 1999). In 1997, the Dietary Reference Intake for vitamin D was published by the Institute of Medicine (IOM, 1997). The adequate intake recommended for pregnant women is 5 mcg or 200 IU (IOM, 1997). Sexual & Reproductive Health 76 At this time, it appears the 1997 recommended levels are too low, but the exact recommendation still needs to be determined. Drs Hollis and Wagner are conducting a multiyear, double-blind, placebo-controlled study of the effects of supplementing pregnant women with up to 4000 IU vitamin D per day. At the present time, if a pregnant woman is not getting adequate sunlight to meet her vitamin D requirement, supplementation is necessary and levels up to 2000 IU are safe. FLUORIDE Primary dentition begins developing by the 10th to 12th week of gestation. In the third trimester, the first four permanent molars and eight of the permanent incisors begin to develop. Tooth enamel formed when fluoride is taken is calcium fluorapatite, which is six to 10 times more resistant to acid dissolution than calcium hydroxyapatite, normal enamel. The effectiveness of a fluoride supplement to improve the quality and strength of the teeth is being debated. For a long time it was thought that fluoride did not cross the placenta, but evidence shows that fluoride does indeed cross the placenta (Glenn, et al., 1982). There is no consensus on the use of fluoride supplementation during pregnancy. The American Dental Association has not endorsed fluoride supplementation during pregnancy and the Institute of Medicine in 1997 concluded there is not enough research to warrant recommending fluoride supplementation during pregnancy. The DRI for fluoride for pregnant women is the same as nonpregnant women, 3 mg/day (IOM, 1997). In 2005 the American Dietetic Association came out with a position paper on Oral Health and Nutrition (ADA, 2005), which you may want to consult as a reference. In the position paper, it is recommended that pregnant women not supplement fluoride, but can use fluoridated toothpaste/rinse and drink fluoridated water. The 2000 report: Oral Health in America: A Report of the Surgeon General concludes that fluoride supplementation during pregnancy does not seem to benefit the fetus. Normal intake of fluoride from food and water is sufficient for pregnant women (US Dept Health and Human Services, 2000). VITAMIN B6 Vitamin B6 is required for over 100 enzymatic reactions involving amino acids. Besides this vitamin's important role in protein metabolism, synthesis of red blood cells and central nervous system development, it is also involved in carbohydrate and lipid metabolism, immunity and hormonal functions. During pregnancy there is a gradual decline in blood levels of vitamin B6 and vitamin B6 -dependent enzymes, up to 30 percent in non-supplemented women at 30 weeks gestation and 25 percent at delivery. The greatest decline is between the fourth and eighth month of pregnancy. Lumeng et al. (1976), found that it took 4 to 10 mg of supplemental pyridoxine to normalize serum vitamin B6 levels to those similar to the beginning of pregnancy. The question remains if that is even desirable. Studies investigating the relationship of vitamin B6 status to poor pregnancy outcome — preeclampsia and low birth weight — are inconclusive. Sexual & Reproductive Health 77 A woman who was taking oral contraceptives 2 to 3 months prior to becoming pregnant may have marginal serum vitamin B6 levels. In this case, a supplement slightly higher than the 1.9 mg DRI for pregnancy may be necessary, particularly if the diet was low in vitamin B6 (IOM, 1997). An additional 2 mg/day will be sufficient. Other women who would benefit from supplemental vitamin B6 are pregnant adolescents, women with multiple fetuses and women who are substance abusers. Supplementing too much vitamin B6 may not be wise, as mentioned earlier. Since vitamin B6 is actively transported across the placenta, too much vitamin B6 may cross to the fetus and cause abnormally high fetal levels of vitamin B6 if the maternal concentration is high. This observation has not been confirmed or denied by research, but seems logical. OTHER VITAMINS AND MINERALS Concern has again been raised about the safety of ingesting high doses of vitamin A (retinol) during pregnancy. Rothman and colleagues (1995) recently published a study of more than 22,000 women. One of 57 women who consumed more than 10,000 IU of vitamin A (as retinol, not beta-carotene) daily during pregnancy had a child with birth defects of the head, heart, brain, or spinal cord. In 1995, the FDA recommended that women in their childbearing years limit their intakes of preformed vitamin A to about 100 percent of the Daily Value (5000 IU). In addition, pregnant women were advised to limit their intake of liver and fortified cereals. A Tolerable Upper Intake Level (UL) for preformed Vitamin A was established by the IOM (2001), based on the teratogenicity of preformed Vitamin A as the critical adverse effect. For all other adults, liver abnormalities were used as the critical adverse effect. The UL for preformed vitamin A for women of childbearing years is 2800 mcg/day for girls 14 to 18 years of age and 3000 mcg/day for women 19 to 50 years of age (IOM, 2001). Women should choose fortified foods that contain vitamin A in the form of betacarotene rather than preformed vitamin A, whenever possible. High intakes of fruits and vegetables rich in beta-carotene and other carotenoids are not a concern. The NAS/ IOM report (2001) recommended that supplementation with preformed vitamin A should be avoided during the first trimester unless there is specific evidence of a deficiency. Vitamins and minerals that now have either an DRI or AI include copper, chromium, manganese and molybdenum. The values are shown in Appendix #2 and #3. Other nutrients, with no DRI or AI established, now have Tolerable Upper Intake Levels (UL), as noted in Appendix #3. These include: boron, nickel and vanadium. The DRI for the remaining vitamins and minerals are slightly higher during pregnancy. These nutrients are important for health during pregnancy, but do not affect pregnancy outcome as much as the nutrients discussed earlier. Appendices #2 and #3 list the DRI for vitamins and minerals. The 10th edition of the RDA, published in 1989, for the first time included a recommendation for selenium — 65 mcg, which was lowered to 60 mcg with the new recommendations (IOM, 2000). While selenium is important in protecting the body from free radical damage, no known adverse outcome of pregnancy has been identified in women Sexual & Reproductive Health 78 with inadequate selenium intake. Much research is needed to determine normal laboratory values, since plasma selenium declines during the course of pregnancy. The chart below shows the increase in the DRI/AI for pregnant women. Increased Nutrient Requirements for Pregnant Women Same Vitamin E Vitamin K Calcium Phosphorus Fluoride 31 to 49% Zinc Unclear Vitamin D (amount needed unclear) Up to 15% Energy Vitamin A Vitamin B12 Choline Copper Magnesium Selenium Total fiber Ω-6 fatty acids 16 to 30 % Vitamin C Niacin Thiamin Chromium Manganese Energy Carbohydrates Ω-3 fatty acids 50 to 70% Vitamin B6 Folate Iron (≥19 years) 71 to 80% Iron (≤18 years) As you can see from this chapter, there is a lot of information available on the effects of nutrient intake on the outcome of pregnancy. There are still many questions that remain unanswered, as well. For a pregnant woman the best course of action is to eat as healthful a diet as possible. The better the diet, the better the chance of a normal, healthy baby. Sexual & Reproductive Health 79 Chapter Six: Weight Gain in Pregnancy Maternal weight gain is correlated with birth weight, and birth weight is correlated with infant morbidity and mortality. As birth weight increases, infant morbidity and mortality decreases. A baby weighing less than 5.5 lb (2500 gm) is more likely to have health problems or die soon after birth. Several factors influence weight gain during pregnancy. One is the duration of the pregnancy. The shorter the duration of the pregnancy, the less the infant will weigh. Poor nutritional status and weight gain during pregnancy can cause premature labor and delivery, as can other medical complications of pregnancy. Smoking impacts birth weight. The more cigarettes smoked, the greater the decrease in birth weight. Alcohol and substance abuse can also retard growth and the weight of a newborn. Lack of food, or other decreased caloric intake, can have profound effects on weight gain. In these instances, the nutritional content is usually inadequate as well. Encouraging proper weight gain in a pregnant woman is essential. Improper weight gain is a key factor in a poor outcome of pregnancy. In May 2009, the Institute of Medicine (IOM), Food and Nutrition Board of the National Academy of Sciences (NAS) updated the 1990 publication Nutrition During Pregnancy, Weight Gain and Nutrient Supplements — the first update in 19 years. (The companion publication, Nutrition During Pregnancy and Lactation: An Implementation Guide (NAS, 1992) is still a valuable resource, especially for nurses and health educators, as it includes tips and pointers on evaluating weight gain (and nutrition) during pregnancy.) The new IOM publication, entitled Weight Gain During Pregnancy: Reexamining the Guidelines, examines many of the changes in the health of women of childbearing years since 1990 that have necessitated a review of the previous guidelines. Among those changes are an increase in pre-pregnancy body weight and gestational weight gain (GWG), and new the racial/ethnic subgroups in the population. Sexual & Reproductive Health 80 In addition, there has been an increase in overweight and obesity among a subgroup of women at higher risk for poor pregnancy outcomes, and in women getting pregnant at an older age, who are more likely to have chronic conditions such as hypertension or diabetes that increase their risk of pregnancy complications (IOM, 2009). The full report is available online. You can order a copy, download a pdf or read it on-screen at: <www.nap.edu/catalog.php?record_id=12584#at> The committee responsible for the new guidelines was asked to: • review evidence concerning the relationships between weight gain patterns before, during and after pregnancy and maternal and child outcomes; • consider factors within a life-stage framework associated with outcomes such as lactation performance, postpartum weight retention, cardiovascular and other chronic diseases; • recommend revisions to existing guidelines where necessary; and • help implement the guidelines and recommendations by suggesting methods to implement them via education of the consumer, practitioner, and with public health strategies. (Note: this course will cover only the sections of the report that pertain to the guidelines for weight gain.) The new guidelines are not very different from those published in 1990, but supporting research for the 1990 recommendations has increased tremendously. One major change is a shift in focus from preventing LBW and SGA babies to preventing excessive weight gain and LGA babies. While there is still concern about inadequate weight gain and LBW and SGA babies, more women have problems of gaining too much weight, having LGA babies and retaining the excess weight. This change in focus will need to be incorporated into prepregnancy, pregnancy and post-partum counseling. Some of the concluding remarks of the committee are very enlightening. They include: Although the guidelines developed as part of this committee process are not dramatically different from those published previously (IOM, 1990), fully implementing them would represent a radical change in the care provided to women of childbearing age. Included would be preconceptional services, such as counseling on diet and physical activity to all overweight and obese women of childbearing age to reach a healthy weight prior to conception. Also included would be counseling on diet, physical activity to all pregnant and postpartum women will the goal of achieving weight gain within the guidelines and eliminating postpartum weight retention. And: The increase in overweight and obesity among American women of childbearing age and failure of many pregnant women to gain within the [1990] guidelines alone justify this radical change in care as women clearly require assistance to achieve the recommendations in this report in the current environment. 81 Sexual & Reproductive Health And further: These new guidelines are based on observational data, which consistently show that women who gained within the [1990] guidelines experienced better outcomes of pregnancy than those who did not. OPTIMAL WEIGHT GAIN How much weight should a pregnant woman gain? Before the 1960s, 15 lb was considered adequate. The amount jumped to 25 lb after 1971. Now optimal weight gain varies from woman to woman, based on pre-pregnancy BMI. To determine optimal weight gain, we must know how much weight is gained during the course of pregnancy and where it is gained. The chart below breaks down the components of weight gain into maternal tissues and fetal tissues by trimester. Components of Weight Gain Cumulative gain (lb) at end of each trimester Tissue Fetus Placenta Amniotic Fluid (Fetal Subtotal) First Second Third Negligible Negligible Negligible -- 2.2 0.6 0.9 3.7 8.3 1.6 2.0 11.9 Uterus Breast Blood Volume Extracellular Fluid (Maternal Subtotal) 0.7 0.2 0.7 0 1.6 1.8 0.7 2.8 0 5.3 2.4 1.1 3.0 6.1 12.6 Total Gain Fat Stores 1.6 9 24.5 8.5 TOTAL GAIN 33 Source: Brown JE, JNE 24:21-5, 1992. As you can see, during the first trimester there is little weight gain in fetal tissues. Most of the gain is in the maternal tissues — about 1.6 lb. In the second trimester the fetal tissues add approximately 3.7 lb, while the maternal tissues have added 5.3 lb, for a total gain of 9 lb (for mother and fetus combined) at the end of the second trimester. By the end of the third trimester the fetal tissues have tripled in size to 11.9 lb. Maternal tissues have increased to 12.6 lb. Sexual & Reproductive Health 82 The total gain for the pregnancy is 24.5 lb for both the maternal and fetal tissues. An additional 8.5 lb of fat is stored for energy use during lactation, for a total weight gain of 33 lb. Other sources have total gain closer to 28 to 30 lb, when you factor in a smaller baby, less gain in maternal tissues (King, 2000) and less fat gain (Lederman, et al., 1997; IOM 2002). The second determining factor is pre-pregnancy weight. One of the earlier studies that looked at pregnancy weight, weight gain and infant mortality is the Collaborative Perinatal Project of the National Institutes of Neurological and Communicative Disorders and Stroke. This study followed 53,518 pregnancies in 12 US hospitals between 1959 and 1966, recording events of gestation, labor, delivery, and weight of offspring until 8 years of age (Naeye, 1979, 1990). This study was done before the use of BMI to classify pre-pregnancy weight; instead it uses percentage of ideal body weight (IBW). The optimal weight gain, i.e. the lowest perinatal mortality rate, differed for women who were underweight (up to 90 percent of IBW), normal weight (90 to 135 percent of IBW) or overweight (above 135 percent of IBW) before they got pregnant. • Normal weight women, 90 to 135 percent of IBW, had the lowest perinatal mortality rate when they gained over 20 lb. At a 10 lb weight gain, the death rate was 18 per 1,000 live births; with a 22 to 25 lb gain, it was 10 per 1,000 live births. As weight gain increases, there is a slight increase in death rate, but not anywhere near as high as with lower weight gains. • Women weighing less than 90 percent of IBW, who gained only 10 lb during pregnancy, had the highest perinatal mortality rate, 25 deaths per 1,000 live births. As the weight gain increased to 30 lb, the perinatal mortality rate decreased to the lowest of all groups, five deaths per 1,000 live births. Women who are underweight prior to pregnancy have babies that weigh less than women who are normal or overweight prior to pregnancy (IOM, 1990; Brown, et al., 1992; Abrams, et al., 2000). • Obese women — more than 135 percent of IBW — had the lowest perinatal mortality rate at 15 lb weight gain. As weight gain increased, so did the perinatal death rate, from a low of 16 per 1,000 live births to a high of 21 per 1,000 live births. In the intervening years, research has clearly shown a relationship between pre-pregnancy weight, GWG and pregnancy outcome (IOM, 2009). In fact, a key finding of the 2009 IOM report is that pre-pregnancy BMI is an independent predictor of many adverse outcomes of pregnancy and women should try to enter pregnancy with a normal weight. The adverse outcomes differ based on pre-pregnancy weight and GWG. Caulfield, et al., (1998) found that when analyzing weight gain within the IOM recommended ranges, and outcome, based on pre-pregnancy BMI, that the risk for SGA births declined as weight gain increased, but the risk for large-for-gestational age births increased. For underweight women, the biggest risk is inadequate weight gain (less than 20 pounds) leading to SGA, increased fetal and infant deaths, and decreased fetal growth Sexual & Reproductive Health 83 (IOM, 2009). In an evidence based review of the literature for the Agency for Healthcare Research and Quality (AHRQ), Viswanathan, et al., (2008) found strong evidence that weight gain below IOM recommendations increased preterm births, SGA and LBW babies. There is moderate evidence that weight gain below IOM recommendation in all pre-pregnancy weight groups decreases the likelihood of a woman breastfeeding. For overweight and obese women, the risk of inadequate GWG is a lesser risk than is excessive weight gain (more than 20 lb). Too much weight gain during pregnancy may lead to LGA babies, macrosomia, increased incidence of preeclampsia, diabetes, Caesarean deliveries and post-partum weight retention (IOM, 2009). Women entering pregnancy with a BMI in the normal range have the lowest risk for adverse pregnancy outcomes. Since 1976, the incidence of obesity in the US in women 12 to 44 years of age has doubled. According to the National Center for Health Statistics, between 1999 and 2004 twothirds of women of childbearing years are overweight (BMI 25 or higher) and one-third are obese (BMI 30 or higher) (IOM, 2009). More women of racial and ethnic minorities are obese. Weight gain during pregnancy has also changed in the last 20 years. Between 1990 and 2005 there has been an increase in the number of women gaining less than 16 lb and more than 40 lb, and a decrease in the number of women gaining within the recommended rand of 16 to 40 lb (IOM, 2009). In the same time period a larger proportion of women gaining more than 40 lb was white women, while the larger proportion gaining less than 15 lb was among black and Hispanic women (IOM, 2009). In determining the optimal weight gain for each pre-pregnancy classification, the IOM committee had to find the right balance between preventing SGA babies on the one hand and preventing LGA babies on the other. Nohr (2008) studied the effects of pre-pregnancy BMI and GWG on SGA, LGA and birth weight among 60,000 Danish women. The relative risk of delivering a SGA baby for women who gained less than normal, 22 lb, versus a normal gain of 22 to 33 lb, based on pre-pregnancy weight classification was 2.1 for underweight women, 1.7 for normal weight, 1.6 for overweight and 1.3 for obese women. The risk for LGA babies associated with a very high weight gain, over 44 lb, versus a medium weight gain of 22 to 33 lb, was 3.7 for underweight women, 2.6 for normal women, 2.0 for overweight women and 1.8 for obese women. This study by Nohr suggests there is a dampening effect of GWG on birth weight with increasing pre-pregnancy BMI, and that there is less SGA and more LGA with increasing GWG (IOM, 2009). In establishing the new weight gain guidelines, the IOM committee determined the range of GWG associated with the lowest prevalence of outcomes of greatest concern. The only pre-pregnancy weight classification that changed was the obese category (BMI 30 or higher) going from a recommendation of 15 lb to a recommendation of 11 to 20 lb (IOM, 2009). The weight gain recommendations for each pre-pregnancy classification are discussed below, along with adolescents and twin and multiple fetus. 84 Sexual & Reproductive Health EVALUATING PRE-PREGNANCY WEIGHT To determine which pre-pregnancy weight classification a woman falls into, you must assess her weight for height by calculating BMI. Appendix #4 has a chart that can be used in lieu of the BMI formulas below. Formula #2 Formula #1 BMI = weight (kg) height (m) 2 x 100 BMI = weight (lb) height (in)2 x 703 In an evidence-based review of outcomes of maternal weight gain, Viswanathan, et al., (2008) concluded that there is insufficient evidence that any method other than standard BMI is more predictive of pregnancy outcomes. The 2009 IOM pregnancy weight gain guidelines use the World Health Organization (WHO) cutoff points for categorizing BMI. There are four weight categories: underweight, normal weight, overweight and obese. For each pre-pregnancy weight classification there is a recommended range of total weight gain during pregnancy and the rate of weight to gain in the second and third trimester of pregnancy. The chart below shows these recommendations. Recommended Weight Gain by Prepregnancy Weight Rates of Weight Gain** 2nd and 3rd Trimester Mean (range) Mean (range) Range in lbs kg/week lbs/week 28 - 40 0.51 1 (0.44-0.58) (1-1.3) Total Weight Gain Prepregnancy BMI* Low or underweight (<18.5 kg/m2) Range in Kg 12.5 - 18 Normal weight (18.5-24.9 kg/m2) 11.5 - 16 25 - 35 0.42 (0.35-0.50) 1 (0.8-1) High or overweight (25.0-29.9 kg/m2) 7 - 11.5 15 - 25 0.28 (0.23-0.33) 0.6 (0.5-0.7) Obese (≥30.0 kg/m2) 5-9 11 - 20 0.22 (0.17-0.27) 0.5 (0.4-0.6) * BMI classification uses WHO standards **Calculations assume a 0.5-2 kg (1.1-4.4 lbs) weight gain in the first trimester. Adapted from: Weight gains during pregnancy: Reexamining the guidelines, NAS, 2009. Sexual & Reproductive Health 85 WEIGHT GAIN RECOMMENDATIONS NORMAL WEIGHT Normal weight women — BMI 18.5 to 24.9 — should gain a minimum of 25 lb and a maximum of 35 lb during pregnancy. Women should be encouraged to gain within the recommended range and not gain more, as is the trend, as it can lead to poorer outcomes — large babies, cesarean section and postpartum weight gain (Caulfield, et al., 1998; Suitor, 1997; Baeten, et al., 2001; Jensen, 2003; IOM, 2009). This range should satisfy even the most compulsive weight-watchers. Doctors who are sticklers on weight gain may intimidate women into feasting, then starving themselves to “make weight.” This is a bad habit. Restricting calories deprives the fetus of nutrients essential for development. The rate of gain is as important as the total gained. A 2 to 4 lb gain is recommended during the first trimester. (Remember, the total increase in maternal and fetal tissues is only 1.5 to 2 lb.) For the second and third trimesters an average weekly gain of 1 lb, with a range of 0.8 to 1 lb, is recommended. It is not uncommon for a woman to find out she’s pregnant, and begin to “eat for two,” doubling her intake. The recommended additional calories required (340 and 452), only adds about one 8 oz glass of skim milk, one slice of bread, an apple, and 1 to 2 oz of lean meat or poultry. A woman dramatically increasing her intake can gain 8 to 12 lb in the first trimester. Slowing down excessive weight gain, more than 4 to 5 lb a month during the first trimester, is appropriate. Excess weight gained the first trimester is probably fat, and does not benefit the fetal or maternal tissues. This woman should still gain 0.5 to 1.5 lb per week depending upon pre-pregnant weight status. Early in the second trimester weight gain can also be slowed somewhat, but not in the third trimester, as that is the time the fetus has a greatest need for calories, when it triples its weight. A caloric restriction is to be avoided during the third trimester. WEIGHT GAIN RECOMMENDATIONS UNDERWEIGHT Underweight women — a BMI of 12.5 to 18 — should gain 28 to 40 lb. Another way to look at it is to gain to their IBW, plus an additional 25 lb. According to Lederman et al., (1997), underweight women who gain the recommended amount of weight have an increase in total body fat and, at term, have a body fat content similar to normal weight women at 14 weeks of pregnancy. Underweight pregnant women should be encouraged to begin gaining weight as soon as possible. The rate of gain is approximately 5 lb the first trimester and 1.0 lb per week in the second and third trimesters, with a range of 1 to 1.3 lb per week. Individualize the weight gain for all underweight women, making it reasonable for them. Most nutrients are passively diffused across the placenta, and if the concentration in maternal blood is lower than in fetal blood, the fetus will not get them. The underweight woman has the greatest risk of this happening. Sexual & Reproductive Health 86 In addition, her stores of nutrients are probably lower than the normal and overweight woman, so she must rely on what she gets from her diet. Pregnant women who are underweight at conception and delivery, as well as underweight women who do not gain adequately during pregnancy, are at increased risk for LBW babies, premature babies and delivery complications (Ehrenberg, et al., 2003; Viswanathan, et al., 2008; IOM, 2009). For many women, it is difficult to gain the recommended amount of weight during pregnancy. If necessary, counseling may need to be arranged, especially if women are averse to gaining weight for social or personal reasons. They need to understand that they have the greatest risk for poor outcome if they do not gain weight. Underweight women need to be monitored more closely than any other group. (A section on Counseling is included later in this chapter.) Consider the additional demands for calories, protein and nutrients that pregnancy places on the body. An underweight woman has the smallest reserves, so failure to gain indicates that inadequate nutrients are being consumed, depriving the fetus of essential nutrients for growth and development. WEIGHT GAIN RECOMMENDATIONS OVERWEIGHT/OBESE Unfortunately, as we have seen, the number of overweight and obese women in the US keeps increasing, which is a major concern of healthcare professionals. It also has ramifications for women coming into pregnancy overweight or obese. The IOM recommended weight gain for overweight women with a BMI between 25 and 29.9 is 15 to 25 lb — the same as the 1990 recommendation. The recommended rate of gain is 0.6 lb per week, with a range of gain from 0.5 to 0.7 lb per week, which is slightly lower than the 0.67 lb per week recommended in 1990. For obese women, with a BMI 30 or higher, the total weight gain recommended is 11 to 20 lb, with a weekly gain the second and third trimester of 0.5 lb, with a range of 0.4 to 0.6 lb. There is discussion in the medical community over how much weight obese women should gain. Some believe pregnant women need to gain 25 lb, no matter the prepregnant weight; others believe a 15 lb gain is acceptable. Others say no gain may be appropriate. Women who are overweight or obese prior to pregnancy and gain the IOM-recommended amount of weight, do not put on as much fat as women who are normal weight or underweight prior to pregnancy (Lederman, et al., 1997). In fact, obese women who gain 15 lb may put on no fat. Since it is lean tissue and not fat that is associated with infant birth weight, it may not matter that these women do not gain any fat during pregnancy (Lederman, et al., 1999). Pre-pregnancy weight is the initial consideration. Is the woman only slightly overweight, or does she fall into the obesity classification? Next, the quality of the diet needs to be assessed. How much is she eating and is it nutritionally sound? Women can eat an enormous quantity of food and still not meet their nutrient needs if the food is of poor quality. The calories may be adequate but the nutrients may not be sufficient. Sexual & Reproductive Health 87 In a severely obese woman with a diet that is nutritionally sound, providing adequate calories, protein and nutrients, no weight gain or a small gain may be appropriate. In a woman who is not meeting her nutrient needs, some gain is desirable. Women who are only slightly obese should still gain a minimum of 10 to 15 lb. Many obese women have pre-pregnancy medical conditions that complicate the pregnancy, e.g. hypertension, diabetes, pyelonephritis, and obstructive sleep apnea (Cesario, 2003; IOM, 2009). Obesity during pregnancy can also cause complications such as hiatal hernia, markedly elevated gastric emptying times, urinary tract infections, excessive edema, pregnancy-induced hypertension, gestational diabetes, Caesarean delivery, increased bleeding and wound complications. The chart below shows the complication rates for various conditions in obese pregnant women (Naye, 1990). Complications in Obese Women Perinatal mortality rates(deaths/1000 births) for various risk factors Pregnancy Risk Factor Thin Normal Overweight Maternal Age <18 years Age 35-50 years Diabetes Hypertensive disorders Low weight gain Smoking 7.8 1.4 1.2 4.9 12.9 18.4 7.0 4.8• 1.6 4.8 5.6• 21.0 3.6• 12.2• 1.4 5.2 10.0¶ 22.3¶ 10.5¶ 23.4• 11.1• 10.9• 13.6 39.3• Fetal Preterm Born 24-30 weeks Born 31-37 weeks Full term births Major congenital defects 30.4 16.2 14.2 6.9 4.8 34.4¶ 18.7¶ 15.7 13.9• 7.8• 40.6• 22.7• 17.8¶ 15.4• 8.6• 79.7• 46.2• 33.5• 41.2• 14.4• 37.3 48.3• 55.9• 120.9• All cases BMI: Thin = <20; Normal = 20-24; Overweight = 25-30; Obese = >30 kg/mm2 • = p < 0.001 ¶ = p <0.05 Obese (Naeye, 1990) Some of the complications are due to the physiological changes of pregnancy superimposed on the already-strained physiology of the woman. For instance, insulin resistance, which normally increases during pregnancy, is further increased in obese women (ADA, 2009). Compared to normal weight women, overweight pregnant women have a two-fold increase in the risk for gestational diabetes which increases to eight-fold if the pregnant woman is obese (Chu, et al., 2007). Sexual & Reproductive Health 88 Some of the complications in overweight and obese women that can be lessened with appropriate weight gain include: diabetes mellitus, hypertension, thromboembolism, caesarean delivery, macrosomia, preeclampsia, eclampsia and post-partum weight retention (Baeten, et al., 2001; IOM, 2009), even if the woman has normal glucose tolerance (Jensen, et al., 2003). Newborns of obese women have a higher perinatal morbidity and mortality rate (ADA, 2009). Overweight women who gain less than 15 lb have a perinatal mortality rate two times higher than overweight women gaining at least 15 lb (Naeye, 1979, 1990). Regardless of weight gain, Naeye (1990) found that as maternal pre-gravid weight increased — from thin to obese — perinatal mortality rates increased from 37 deaths per 1,000 births in thin women, to 121 deaths per 1,000 births in obese women. The outcome of this research was duplicated by Baeten and coworkers (2001) who found that the incidence of gestational diabetes, preeclampsia, eclampsia, macrosomia and Caesarean delivery all increased with increasing pre-pregnancy weight. Unlike Naeye, Baeten found no difference in the incidence of preterm deliveries, LBW babies and SGA babies between weight groups. It seems that the risk for SGA babies tends to decrease as the pre-pregnancy weight of the mother increases, while the risk of LGA babies increases by 60 percent in obese women, compared to women of normal pre-pregnancy weight (Ehrenberg, et al., 2004). Congenital defects appear to increase with increasing pre-pregnancy weight. Naeye (1990) showed increased perinatal deaths from congenital defects in his study. Prentice and Goldberg (1996) conclude that there is a two-fold increase in the risk for NTD in obese pregnant women (defined as BMI above 31) taking folic acid supplements. In a populationbased study, Watkins and colleagues (2003) found that maternal obesity, defined as a BMI 30 or higher, increased births to babies with spina bifida, omphalocele, heart defects and multiple anomalies. There was an association between being overweight before pregnancy, defined as a BMI of 25 to 29.9, with heart defects and multiple anomalies. Complications that are increased in babies born to obese women include: macrosomia, intrauterine growth retardation, stillbirths, congenital malformations, increased risk of neural tube defects, increased risk of fetal death and higher rates of childhood obesity (ACOG, 2005; Cesario, 2003; ADA, 2009). Increasingly, women who have had bariatric surgery are becoming pregnant. While the procedure may dramatically impact the pregnancy, many women who have had bariatric surgery have had normal pregnancies with good outcomes (ACOG, 2005). (Note: Chapter Eight will discuss bariatric surgery in more detail. The Nutrition Dimension course Treating Severe Obesity is also recommended.) A massive weight loss during pregnancy is to be avoided. Some obese women do lose weight and have perfectly normal, healthy babies, but there are potential problems. When the body loses weight, fat becomes a major source of energy. A by-product of fat metabolism is ketones. As ketones build up in the blood, the acidity (pH) can change. There is concern whether the ketones can affect the development of the fetal brain. Sexual & Reproductive Health 89 Another problem is that fat cells of the body store drugs, toxins and other harmful substances. If too many fat cells are broken down, and these harmful substances are dumped into the blood, the fetus may be affected. While this is hard to determine or prove beyond a doubt, it another reason for discouraging pregnant women — no matter how obese — to lose much weight. Counseling for overweight and obese pregnant women needs to be individualized. The 2009 IOM weight gain guidelines are just that — guidelines. Ideally, women should try to lose weight before they become pregnant. If they do not, pregnancy is a time when women are very receptive to nutritional counseling, and this presents an opportunity for improvement. An obese woman is more likely to want to change her diet during pregnancy. Find ways to cut out calories that do not provide nutrients. Amazingly, obese women can improve their diets, lose a small amount of weight and produce a healthy baby. Even a small weight gain with a healthy diet can have a good outcome. COUNSELING PRINCIPLES Pregnancy weight gain counseling isn't rocket science. Stick to these principles for best results: • Discuss a weight gain goal, set as a range; • Help plan menus and snacks that will assist in meeting her weight gain goal; • Describe where the weight that she gains goes; • Discuss the importance of adequate gain for the health of mother and baby; • Provide positive reinforcement for adequate gain; and • Offer supportive resources to help her return to her pre-pregnancy weight after the baby is born. In an interesting study, Mumford, et al., (2008) found that women who were restrained eaters, dieters or weight cyclers had weight gains during pregnancy either above or below IOM recommendations. Women who were normal, overweight or obese gained more than recommended. Underweight women gained less than recommended. WEIGHT GAIN IN ADOLESCENTS Adolescence is a time of rapid physical growth. Nutrition needs increase significantly to support this growth and to promote and preserve nutrient stores. The extra energy and nutrient demands of pregnancy place pregnant adolescents at nutrition risk. The primary factor that increases nutrition risk is the amount of uncompleted growth at the time of conception. The least physically mature pregnant teens (those who are still growing) have not had time to store nutrients for their own body tissues and systems because they use nutrients for growth and development. Do adolescents continue to grow during pregnancy? And if so, do the nutrition needs of the growing pregnant teen compromise either the mother’s or baby’s needs? Numerous studies that have been conducted provide some insights. Sexual & Reproductive Health 90 Growth slows down after a young woman has had her first menstrual period, but may continue for four more years. Therefore, menarche is a marker for completed growth but not an absolute predictor. Growth during pregnancy has been masked by a tendency of all pregnant women to shrink during pregnancy (1/4 inch over 6 months). Therefore, some growth studies of pregnant adolescents have measured leg lengths to determine growth. Larger increments of growth were observed in younger adolescents, 12 to 15 years, than in older adolescents, 15 years and older (Scholl and Hediger, 1993). Several studies have found that growing pregnant adolescents have babies with lower birth weights than non-growing adolescents and pregnant adults. Scholl and colleagues (1994) found that, after 28 weeks gestation, the still-growing pregnant teens continued to accrue fat stores and gained more weight than non-growing teen mothers or mature women. However, the still-growing mothers had infants with lower birth weights. The weight gain distribution of pregnant adolescents differs from pregnant adults. When pregnant adolescents gain the same amount as pregnant adults, the baby and placenta are smaller in adolescents. Pregnant adolescents, particularly those at younger ages, tend to gain more weight than do pregnant adults. This may be due to increased fluid volume, because these younger pregnant adolescents also have smaller babies. Pregnant adolescents also have a greater weight gain velocity from the beginning of pregnancy (Hediger, et al., 1990). Rees and coworkers (1992) found that adolescent mothers giving birth to infants weighing 3000 to 4000 gm had a rate of gain that equaled the highest amount recommended in the NAS/IOM report. This suggests that restricting the natural gain of adolescents to recommended rates may result in smaller than optimal gains. The provisional recommendations from the NAS/IOM report were to gain 0.36 to 0.53 kg/week. The young women in this study gained 0.588 kg/week. The study concludes that weight gain recommendations for adolescents may ultimately be higher than for adults. However, in reviewing the literature, the Expert Work Group did not recommend encouraging weight gain in the upper end of the range (Suitor, 1997). Adolescents, especially the younger ones, tend to be underweight and do not like to gain weight. Much of the aversion to weight gain has to do with peer pressure and not wanting to be fat. Unfortunately, many teenage mothers are themselves not fully grown. While many teens may gain inadequately, others gain excessively — more than 40 lb. In a study of adolescent weight gain, Howie, et al. (2003) found that 27 percent of all adolescent mothers gained excessively compared to 18 percent of older women, across all pre-pregnancy weights. In 2005, adolescents younger than 20 years were more likely to gain excessively than women over 35 years (IOM, 2009). It is important that teens gain adequately since they have additional risk factors that can complicate pregnancy. Berenson, et al. (1997) found that pregnant girls under 18 were more likely to deliver babies weighing less than 2500 gm, as well as have babies that were significantly lighter, if they gained 20 lb or less. Risk factors that contributed to the inadequate weight gain in teens were: physical assault/battering during pregnancy, a sexually transmitted disease during pregnancy and an unplanned pregnancy. Sexual & Reproductive Health 91 According to the 2009 IOM guidelines, there is insufficient evidence that the GWG guidelines used for adults need to be modified for adolescents (IOM, 2009). The reason is that younger girls would be in a lower BMI category than they would be using pediatric growth charts. Therefore, the recommended weight gain would be higher than if the growth charts were used. The committee decided this was okay, since younger girls need to gain more weight than adults to have a baby the same size. They also felt that using growth charts in obstetric practices would be difficult. A study that investigated the pre-pregnancy weight classification of pregnant adolescents using the IOM criteria versus age- and sex-specific BMI charts for girls and adolescents, found that 23.5 percent of the pregnant adolescents were misclassified using IOM criteria (Fernandez and Olson, 2008). Most of the misclassifications were girls at a healthy weight or at risk of being overweight. The concern is that by recommending more GWG than needed, these girls are at risk for post-partum weight retention. The authors recommend using the CDC age- and sex-specific BMI charts for pregnant adolescents. TWIN AND MULTIPLE PREGNANCIES In the US, less than 3 percent of all births are multiples, yet they account for 13 percent of all preterm births, 15 percent of all very preterm births, 21 percent of LBW births and 25 percent of all VLBW births (Luke, 1999). From 1980 to 1998 the rate of triplet and higher order births increased approximately 400 percent (MMWR, 2009). Physiologically, the uterine circulation is greater in multiple pregnancies and the levels of maternal hormones are higher, most likely to adjust to the physiological adaptations and weight gain with twins or multiples. Little research exists on the weight gain recommendations for multiple pregnancies. We know that many of the LBW twins and multiples experience shorter gestation periods, because of the mother not being able to carry the babies to term. How much the shorter gestation period has to do with weight gain is not clearly understood. Luke (1996) studied 924 women who delivered twins. Mothers with ideal pregnancy outcomes (defined as 2500 to 2800 gm birth weight and gestation of 35 to 38 weeks), smoked significantly less and gained more weight. Weight gains of 35 lb or more were significantly associated with an ideal outcome. To achieve at least a 35 lb weight gain, women expecting twins should gain a minimum of 1 lb/week. The 1990 IOM report recommends woman carrying twins has a weight gain of 35 to 45 lb, with a rate of gain of 1.5 lb per week during the second and third trimester. Luke (1999) and the American Dietetic Association (2002) suggests that women carrying twins eat 3500 kcal/day and gain 24 lb by 24 weeks and 40 to 45 lb at term. Women carrying triplets should eat 4500 kcal/day and gain 36 lb by week 24. The recommended total weight gain for triplets is 50 lb (Brown, 2000; JADA, 2002). These calorie and weight gain recommendations are based on literature that suggests that weight gain before 20 to 24 weeks is important in the ultimate outcome and birth weight of multiples (Luke, 1999). Sexual & Reproductive Health 92 Based on data from her studies, Luke and Hediger (2003) determined the optimal rates of weight gain, for women pregnant with twins, based on pregravid weight. This information is found in Appendix #5. The 2009 IOM report states that like singleton pregnancies, pre-pregnancy BMI is a factor in weight gain recommendations for the best outcomes in twin and multiple fetus pregnancies. With a lack of good data to determine recommendations the committee came out with provisional recommendations for all pre-pregnancy weight classes except underweight women, as there was not enough data. The following are the new guidelines for weight gain for women with multiple fetuses: • normal weight: 37 to 45 lb (17 to 25 kg) • overweight: 31 to 50 lb (14 to 23 kg) • obese: 25 to 42 lb (11 to 19 kg) Weight gain in twin and multiple pregnancies is difficult, especially if a woman does not know early in her pregnancy that she is carrying more than one fetus. She may begin to gain weight more rapidly than if she had only one fetus, and so may begin to restrict her intake to slow her rate of gain. Early diagnosis of twins and multiples is an important part of adequate weight gain. MONITORING WEIGHT GAIN Weight gain is a good indicator of how a pregnancy is progressing. Monitoring weight gain, and pegging it as insufficient or excessive, is difficult with just a list of numbers. A Prenatal Weight Gain Grid is invaluable in monitoring weight gain. To work with the Case Studies in this chapter, four weight gain grids, designed using the 2009 IOM guidelines, are provided. One, for normal-weight women (shown on the next page), has the upper, lower and mid-range of the recommended weight gain plotted. The horizontal axis shows the week of gestation; the vertical axis is weight gained or lost. The grids for underweight, overweight and obese women also have three lines with the upper, lower and mid-range of recommended weight gain plotted. (For use in your practice, Appendices #6 and #7 may be copied. Appendix #6 is a weight gain grid for normal-weight women. Appendix #7 is a grid for any pre-pregnancy weight classification. In Appendix #7, the line for underweight women corresponds with the highest recommended weight gain — 40 lb. The line for normal weight women is the mid-range of recommended gain — 30 lb, while the line for overweight women corresponds to the minimum recommended gain — 15 lb. Creating a grid for all pre-pregnancy weight classifications will simplify, for some, the need to have three or four grids. You can also find weight gain grids online.) To use the chart, a woman’s pre-pregnancy weight is put by the “0” on the vertical (Weight Gain) axis. Weight gain (or loss) is plotted for each week of gestation, or when the woman has her doctor’s appointments and is weighed. Sexual & Reproductive Health 93 Normal Weight Prenatal Weight Gain Grid 45 (20.4) Weight Gain in Pounds (kg) 40 (18.1) 35 (15.9) 30 (13.6) 25 (11.3) 20 (9.0) 15 (6.8) 10 (4.5) 5 (2.2) 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 Duration of Pregnancy (weeks) Using the sample data below, determine the BMI then plot the weight gain on the sample prenatal weight gain grid provided above. • Jane weighs 125 lb and is 5'4" tall. Her BMI is approximately 21. That puts her in the normal pre-pregnancy weight classification. At her first visit to the doctor, at 11 weeks gestation, she weighed 129 lb. As shown on the next page, Jane’s pre-pregnancy weight of 125 lb goes on the weight gain axis next to “0.” Then find 11 weeks gestation along the horizontal axis (weeks of gestation) and move up the line until you come to 4 lb (her gain so far during the pregnancy). Put a mark on the line at that point. The weights for the entire pregnancy are plotted. Pre-pregnancy weight: 125 Pre-pregnancy height: 5'4" BMI_______________ % of Desirable Weight______________ Week 8: 127 lb Week 12: 129 lb Week 16: 133 lb Week 20: 137 lb Week 24: 143 lb Week 26: 145 lb Week 28: 147 lb Week 30: 149 lb Week 32: 153 lb Week 34: 155 lb Week 36: 155 lb Week 37: 157 lb Week 38: 158 lb 94 Sexual & Reproductive Health Normal Weight Prenatal Weight Gain Grid 45 (20.4) 35 (15.9) 30 (13.6) X Jane's Weight Gain 25 (11.3) Weight Gain in Pounds (kg) 40 (18.1) 20 (9.0) X X X X 15 (6.8) X 10 (4.5) Reference Woman's Weight Gain Range X 5 (2.2) XX X X X X 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 Duration of Pregnancy (weeks) As you can see, Jane's weight gain was slightly above the upper limits of normal. She began to gain rapidly around week 26, but tapered off so that her final gain was 30 lb. This is within the recommended range of 25 to 30 lb. If, however, her weight continued to rise rapidly, you would want to monitor her for hypertension or other problems. Not all pregnancies follow the grid pattern; every woman gains differently. The visual representation alerts the health practitioner to problems while they are still possible to correct. (A chart outlining recommended weight gain and questions to help uncover the reasons for inappropriate weight gain follows the Case Studies.) It is important that the gain rate stays approximately parallel to grid lines — the same slope, in other words. A slightly higher or lower gain is not cause for alarm if there is a progressive increase in weight. Marked or persistent deviations should be investigated. Parker and Abrams (1992) concluded that weight gain grids do not indicate how far a woman's gain pattern can deviate from the norm without causing a problem for the pregnancy. Carmichael, et al., (1997) found that many women who had good pregnancy outcomes would have been suspected of being at risk for poor outcome on the basis of their weight gain alone. In some of the case studies to follow, the prenatal weight gain grid differs from the ones previously shown, because each grid is based on the pre-pregnancy BMI of the pregnant woman. The chart is plotted the same as the one shown above and is used the same way, to monitor weight gain and compare the pattern of gain against the line. 95 Sexual & Reproductive Health CASE STUDY #1 Mary is 5'5" tall, with a pre-pregnancy weight of 105 lb. Her BMI is 17.5. Being underweight, she would need to gain 28 to 40 lb. In this case, the upper end of the recommended gain is appropriate, since she is considerably underweight, not marginal. Mary had nausea and vomiting in the first trimester. Her weights were: Week 11: 101 lb Week 20: 103.5 lb Week 28: 105 lb Week 16: 102 lb Week 24: 104 lb Week 32: 104 lb The weights are plotted on a weight gain grid for underweight pre-pregnancy BMI shown below. By week 11, when Mary was seen by her doctor, she had lost 4 lb. This should have set off alarms, since she was underweight to begin with. By week 16 the nausea and vomiting were gone and were not contributing to weight loss, so Mary did begin to regain some of her lost weight. But she gained slowly and was never above her pre-pregnancy weight — she gained no weight during her pregnancy, and had a spontaneous premature delivery of a stillborn baby. The most common causes of this problem are a refusal to gain weight, a physical problem interfering with weight gain, a psychological problem (one might investigate a history of anorexia or bulimia) or lack of food because of socioeconomic conditions. Underweight Prenatal Weight Gain Grid - Case Study #1 40 (18.1) 30 (13.6) 25 (11.3) 20 (9.0) 15 (6.8) 10 (4.5) Spontaneous Premature Delivery Mary's Weight Loss 5 (2.2) 0 Weight Gain in Pounds (kg) 35 (15.9) X -5 (-2.2) 1 4 7 10 13 X 16 X 19 X 22 25 X 28 Duration of Pregnancy (weeks) X 31 34 37 40 96 Sexual & Reproductive Health CASE STUDY #2 Debbie is 5'5", with a pre-pregnancy weight of 165 lb and her BMI is 27.5. Her recommended gain is 15 to 25 lb, since she is overweight. Her weights were: Week 14: 176; Week 18: 180; Week 22: 186; Week 26: 195; Week 30: 201; Week 34: 209, plotted below on a prenatal weight gain grid for overweight women. By Debbie’s first visit she had gained 11 lb. A diet history should have been done immediately to determine the cause of the excess weight gain, with appropriate recommendations to slow the gain. Indeed, Debbie had slowed her weight gain by her next visit, gaining only 4 lb. Then, at week 22, she had gained 6 more pounds — not excessive, but enough to look for dietary problems. At week 26, Debbie had a 7 lb gain, recording a 13 lb gain in two visits. At this point, if her diet history failed to account for the additional weight, water retention should be suspected. She should be checked for preeclampsia, particularly if the weight shoots up around week 22 to 30, when blood pressure is also likely to increase. Sometimes the weight gain is due to diet, sometimes not. The practitioner must not prejudge a woman's eating habits. If this excessive weight gain was due to diet, the goal would be to meet a more acceptable pattern, as labeled “acceptable” on the prenatal weight gain grid. The goal is to slow down the rate of the gain in the late second and third trimester, while maintaining adequate gain for the growth needs of the fetus. Overweight Prenatal Weight Gain Grid - Case Study #2 45 (20.4) X Weight Gain in Pounds (kg) 40 (18.1) 35 (15.9) 30 (13.6) 25 (11.3) 20 (9.0) Probable Preeclampsia X X Debbie's Weight Gain X 15 (6.8) X X 10 (4.5) 5 (2.2) 0 1 4 7 10 13 16 19 22 25 28 Duration of Pregnancy (weeks) 31 34 37 40 97 Sexual & Reproductive Health CASE STUDY #3 Ethel is 5'7" tall, with a pre-pregnancy weight of 118 lb and a BMI of 18.5. Her BMI is just at the cutoff between normal and underweight. So we classify her as borderline, and use either the upper limit of the normal pre-pregnancy weight, or the guidelines for pre-pregnancy underweight. You can use either the underweight or normal weight prenatal weight gain grids. Below and on the next page is Ethel's weight plotted using both an prenatal weight gain grid for underweight women and one for normal weight women so you can see how the weight gain pattern looks on both charts. Ethel has nausea and vomiting during the first trimester, losing 5 lb by her first visit to the doctor. She should be monitored to ensure proper gain. Her weights were: Week 11: 113 lb Week 26: 130 lb Week 36: 144 lb Week 15: 117 lb Week 30: 133 lb Week 38: 145 lb Week 19: 122 lb Week 32: 137 lb Week 23: 126 lb Week 34: 140 lb After losing in the first trimester, Ethel made up the loss: she gained the lost 5 lb, plus an additional 27 lb. Her total weight gain was in the mid-range for normal prepregnant weight and the lower end for prepregnant underweight women. This is an acceptable weight gain. Underweight Prenatal Weight Gain Grid - Case Study #3 40 (18.1) Weight Gain in Pounds (kg) 35 (15.9) 30 (13.6) X X 25 (11.3) X 20 (9.0) X 15 (6.8) X X 10 (4.5) X 5 (2.2) X 0 Ethel's Weight Gain X -5 (-2.2) X 1 4 7 10 13 16 19 22 25 28 Duration of Pregnancy (weeks) 31 34 37 40 98 Sexual & Reproductive Health Normal Weight Prenatal Weight Gain Grid - Case Study #3 45 (20.4) 35 (15.9) 30 (13.6) 25 (11.3) Reference Woman's Weight Gain Range 20 (9.0) Weight Gain in Pounds (kg) 40 (18.1) X X X X 15 (6.8) X X 10 (4.5) X 5 (2.2) X 0 Ethel's Weight Gain X X -5 (-2.2) 1 4 7 10 13 16 19 22 25 28 31 34 37 40 Duration of Pregnancy (weeks) CASE STUDY #4 Samantha is 5'6" and had a pre-pregnancy weight of 229 lb with a BMI of 37. That puts her in the obese pre-pregnancy weight classification. By her first doctor visit, at week 12, she had already lost 14 lb. Her weights, plotted on the next page, were: Week 12: 215 lb Week 28: 214 lb Week 35: 218 lb Week 16: 214 lb Week 30: 214 lb Week 36: 218 lb Week 20: 214 lb Week 32: 216 lb Week 37: 219 lb Week 24: 213 lb Week 34: 216 lb Week 38: 220 lb Samantha lost a lot of weight early, then considerably slowed down her loss, and in the third trimester regained some of the lost weight. While this is not an ideal situation, it is acceptable for an obese woman, as long as the diet is nutritionally sound. The concern is that she not go into ketosis, which may be harmful to the fetus. When a lot of weight is lost early in the pregnancy, one way to indicate that is to put the pregnancy weight on the weight gain axis next to the number of pounds that were lost, and draw a line down to the zero weight mark at the proper week gestation, as shown. The weight gained or lost during the rest of the pregnancy is counted from the zero mark. 99 Sexual & Reproductive Health Obese Prenatal Weight Gain Grid - Case Study #4 25 (11.3) 15 (6.8) 10 (4.5) 5 (2.2) 0 -5 (-2.2) -10 (-4.5 Samantha's Weight Loss Weight Gain in Pounds (kg) 20 (9.0) -15 (-6.8) X X X X X X X X XX XX -20 (-9.0) 1 4 7 10 13 16 19 22 25 28 31 34 37 40 Duration of Pregnancy (weeks) CASE STUDY #5 Casey is 5'6" tall and weighed 170 lb, with a BMI of 27.5. She is considered overweight. As you can see from the weight gain grid below, her weight gain pattern closely follows the recommendations for an overweight pregnant woman. . Overweight Prenatal Weight Gain Grid - Case Study #5 35 (15.9) 25 (11.3) Casey's Weight Gain 20 (9.0) Weight Gain in Pounds (kg) 30 (13.6) X 15 (6.8) X X 10 (4.5) X X 5 (2.2) 0 X X X 1 4 7 10 13 X 16 19 22 25 28 Duration of Pregnancy (weeks) 31 34 37 40 Sexual & Reproductive Health 100 The prenatal weight gain grids will help you determine if the amount and pattern of weight gain is acceptable, excessive or inadequate. Proper weight gain is an important component of a successful pregnancy outcome. The chart below outlines what may be an inadequate gain and questions to ask to help determine the cause of inappropriate weight gain. Advice from health care professionals is important. When surveyed, 2,237 women reported on their pre-pregnancy weight, advice on how much weight to gain and how much they actually gained during pregnancy (Cogswell, et al., 1999). Twenty seven percent said they had been given no advice on how much weight to gain, 14 percent were advised to gain less than IOM recommendations and 22 percent were advised to gain more than IOM recommendations. Advised and target weight gains were strongly associated with actual weight gain. The next chapter will cover the types of foods necessary to ensure adequate calories and proper nutrition. Weight Gain Problems Inadequate gain BMI ≥18.5: gain less than 2.2 lb/month 2nd & 3rd trimester Inadequate gain BMI <18.5: individualize Inadequate gain obese women: less than 1 lb 2nd & 3rd trimester Excessive gain: gain more than 6.5 lb/month 2nd & 3rd trimester for all weight classifications Source: Nutrition During Pregnancy, National Academy of Sciences, 1990; JADA, 2002) Problems: What to ask Weight Gain Too Slow • Are measurement & recording accurate? • Is the overall pattern acceptable? • Does she have nausea and vomiting? • Was there edema on a previous visit that's resolved? • Does she have money & access to food? • Is she resisting weight gain? • Does she have an eating disorder? • Does she understand the relationship of weight gain to the infant's health? • Is she: Smoking? Drinking? Using drugs? • Does she have any medical problems? • Is she exercising & not eating enough? Weight Gain Too Fast • Are measurement & recording accurate? • Is the pattern acceptable? • Does she have edema? Is the weight water? • Is she carrying twins? Triplets? • Does she have gestational diabetes? • Has she decreased her activity & not her food intake? • Has her food intake increased dramatically? • Is she eating high-fat & sugar foods? • Is she overeating? Is she bored? Depressed? Stressed? • Has she been counseled about gain? Sexual & Reproductive Health 101 Chapter Seven Diet Assessment for Pregnancy The last three chapters of this course discuss the relationship of nutrition to the outcome of pregnancy. To ensure a good diet, nutritional requirements must be translated into dietary needs — what foods, and how much of those foods, will meet nutritional needs. As a professional, it is important to know not only what a pregnant woman should be eating, but also how to determine the adequacy of her diet. This chapter will explain the components of a good diet. It contains diet-assessment tools which have been proven useful in determining the nutritional adequacy of a pregnant woman’s diet. Professionals are encouraged to copy them from the Appendices for use with their clients. DIETARY GUIDELINES There is no right way or wrong way to eat during pregnancy, as long as nutritional needs are met. A diet needs to address the cultural, economic and lifestyle needs of the pregnant woman. Urging a woman to eat a diet that is not personalized dramatically increases the chance of noncompliance. With creativity and patience, a nutritionally sound diet can be achieved for all women. Remember, both the amounts of nutrients and the timing are important. During the first trimester, vitamins and minerals are more important than calories, particularly zinc, folic acid, vitamins B6 and B12. The need for calories, iron and calcium increases in the second and third trimester. Adequate weight gain is the best way to monitor caloric intake. Regardless of other, more specific recommendations, if a woman is not gaining enough weight, her caloric intake should be increased — using healthy foods and limiting empty-calorie foods, of course. Sexual & Reproductive Health 102 MYPYRAMID FOR MOMS The USDA Food Guide Pyramid, now called MyPyramid, is designed to individualize the amount of food, based on an individual’s age, gender and activity. It can be found at: <www.mypyramid.gov> When it first came out it was not applicable for pregnant and lactating women. Now, there is an interactive section — MyPryamid for Moms — for pregnancy an breastfeeding that is quite extensive and interactive. A pregnant woman can get an individualized meal plan based on her age, height, weight, due date, pre-pregnancy weight (BMI) and activity level. This information is entered into a calculator on the site, and a meal plan appears on the screen. The meal plan is broken down into trimesters, with a daily caloric level and amount of food to eat in five food groups. The calorie level and amount of food in the foods groups changes each trimester. Note that the amount of food to eat in each group is given in household measures — ounces and cups — and not the number of servings per day. The food groups are the same as MyPyramid for the general population. Let's look at what you get when using MyPryamid for Moms. For our example we will use a 27-year-old pregnant woman, due in seven months. Her height is 5'5", with a pre-pregnancy weight of 165 lb. She does 30 to 60 minutes of activity daily. Below is an individualized chart from MyPyramid for Moms based on the information we entered. A more detailed chart can be found in Appendix #9A. MyPyramid for Moms Your calorie needs may be more or less than the average. Check with your health care provider to make sure you are gaining weight appropriately. To learn more about weight gain during pregnancy, click here. To see how your food choices compare to your Plan go to the MyPyramid Menu Planner. The calories and amounts of food you need change with each trimester of pregnancy. Your Plans are based on 2400, 2800, and 2800 calorie food intake patterns. They may show different amounts of food for different months, to meet your changing nutritional needs. Changing the amount of calories you eat each trimester also helps you gain weight at the correct rate. 1st Trimester 8 oz 2nd Trimester 10 oz 3rd Trimester 10 oz Vegetables 3 cups 3 1/2cups 3 1/2 cups Fruits 2 cups 2 1/2 cups 2 1/2 cups Milk 3 cups 3 cups 3 cups Meat & Beans 6 1/2 oz 7 oz 7 oz Grains* *Aim for making at least half of grains whole grains. Sexual & Reproductive Health 103 Once the meal plan is in place, another section, MyPyramid Menu Planner for Moms, lets the woman enter what she is eating into the calculator and compares it to what is in her meal plan. There are numerous reports she can print out to see how well she is eating on a daily or weekly basis. In addition, there is a report that shows ways to improve her diet, information on specific foods and which foods to include in her diet to help her reach her goals. Another section offers information sheets and tips on various nutrition topics. As you become familiar with the site, you will find there are many layers to it and lots of very valuable information. MyPyramid uses the concept of leader nutrients — foods within each group that provide specific nutrients. By eating enough food from each group, a person’s daily nutrient needs are sure to be met. As we discuss each food group, the leader nutrients are also listed in the chart pertaining to that food group. The chart below summarizes general dietary recommendations for pregnant women. It is in household measures to be consistent with MyPyramid. Each food group, and recommendations, will be discussed below. The amount of fiber per serving is also included. Appendix #8 lists healthy choices of nutrient-dense foods from each food group to meet the dietary recommendations during pregnancy. Dietary Guidelines for Pregnancy Food Group Recommended # of servings daily* Total Fiber per serving Meat & Meat Alternatives¶ 6-8 ounces 0-9 Milk, Yogurt & Cheese 3 - 4 cups 0 Fruits 2 - 3 cups 3-5 Vegetables 3 - 4 cups 3-5 Breads & Cereals 6 - 11 ounces 2-3 Fat, Oils & Sweets Based on needs 0 *Individualize based on weight gain needs and nutritional status of the mother. More foods from the “fats, oils and sweets” group can be used if nutrient intake is adequate and caloric intake is inadequate and may contain some fiber. ¶Refers to the meat, poultry, fish, dry beans, eggs & nuts group. Plant sources contain fiber; animal sources do not. CALORIES The caloric content of diets will vary, based on individual choices. Eating the minimum number of servings from each food group does not assure the correct caloric intake. Intakes can vary by as much as 1800 kcal/day, from 1200 to 3000 kcal/day, based on food choices. Some women will need to increase the amount eaten in each food group to gain an adequate amount of weight, while others will need to alter the types of foods they Sexual & Reproductive Health 104 consume to avoid an excessive weight gain. Individualizing these dietary recommendations based on the likes, dislikes and needs of your clients will help them succeed in planning and implementing the proper pregnancy diet. Of course, it cannot be said too often: “empty” calories are of little or no benefit to either the mother or fetus. If, however, adequate nutrition is being obtained, foods from the fats, oils and sweets group can add needed calories if used sparingly. MEAT/MEAT ALTERNATIVES The meat and meat-alternatives group provides sources of protein, iron, niacin, thiamin, vitamins B6 and B12, folic acid, magnesium and zinc. The recommended amount to eat is 6 to 8 oz a day. The chart below lists some foods in this group and the nutrients provided. Remember to caution about consumption of fish, as discussed in Chapter Four. Meat, Poultry, Fish, Dry Beans, Eggs & Nuts Nutrients Protein, iron, riboflavin, niacin, vitamins B6 & B12, phosphorus, zinc Food Meat, fish, poultry Canned tuna, salmon Eggs, Hot dogs, Luncheon meats Protein, iron, thiamin, folic acid, vitamins B6 & E, phosphorus, magnesium, zinc, fiber Peanut butter, Nuts Dried beans, peas, lentils, cooked Tofu Recommendation: 6-8 ounces/day (eat at least 1 source of plant foods daily to decrease fat and cholesterol and to increase fiber) It does not matter if the protein source is animal or plant; the nutrients will be adequate if the recommended amounts are eaten. If the diet is higher in animal protein, the fat and cholesterol content is higher. For this reason, it is best to choose at least one plant source of protein a day, as plant proteins have quite a bit more fiber. Legumes contain 9 gm of fiber per serving. Most pregnant women get adequate protein in their diets; low-income women are most at risk due to an overall lack of food. Vegetarians can get enough protein in their diet and usually do, although vegans, who eat no animal products whatsoever, must be more careful in planning a diet adequate in protein and include plant protein sources daily. Iron absorption differs between diets containing mostly animal vs. mostly plant foods. The iron in animal protein is in the heme form, which is better absorbed than the non-heme form in plants. Vegetarians, therefore, may have enough dietary iron, but the Sexual & Reproductive Health 105 amount absorbed may be inadequate, since the phytates in plant foods bind the nonheme iron. Eating iron and vitamin C -rich foods together increases iron absorption. DAIRY GROUP Milk and milk products are major sources of calcium, riboflavin, protein, vitamin B12 and magnesium. The recommendation is three to four cups per day. The chart below lists the leader nutrients in this food group. To decrease the fat content of the diet, low-fat (1 percent) or non-fat milk dairy products are preferred over whole milk products. If however, the pregnant woman has an inadequate weight gain and she likes dairy products, the extra calories from whole or 2 percent milk may help her gain weight and can be encouraged. The need of the fetus for adequate calories supersedes the long-term consideration of cholesterol limitation. Milk, Yogurt & Cheese Nutrients Food Calcium, Vitamin D, Riboflavin, Protein, Magnesium, Vitamins: A, E, B6, B12 Milk: Whole, 2%, 1%, non-fat Reconstituted skim or evaporated, buttermilk Cheese, Cheese spread Cottage cheese, Cream soup Ice cream, Pudding & custard, Yogurt Recommendation: 3-4 cups/day • Use low-fat or nonfat milk dairy products If a woman is lactose-intolerant, options are available to her to make sure she gets enough calcium. Fermented milk products such as yogurt, kefir, buttermilk, cottage cheese and cheese may be tolerated, even though milk is not. If the intolerance is doserelated, small amounts may not cause diarrhea, gas, cramping, etc. Foods other than dairy products provide calcium, as shown on the next page. The amount of calcium in foods equivalent to one 8 oz glass of milk is provided by: 8 oz (2 cups) of tofu, 2/3 cup of tofu processed with calcium, 1.5 cups of dark green leafy vegetables, or 3/4 cup of amaranth (a grain), 10 oz fortified rice milk or 1 to 1.5 oz of soy cheese. Other good sources of calcium are almonds, sesame seeds, canned salmon and sardines (including the bones). Foods with calcium added are now available: orange juice, breakfast cereals, yogurt, Wonder Bread®, milk, cheese etc. The added calcium dramatically increases the calcium content of the foods that have naturally occurring calcium and adds a source of calcium to foods that do not usually contain calcium. For example, the calcium in milk may increase from 300 mg/cup to 600 mg/cup. You need to read the label to find out exactly how much calcium is added and the total amount per serving. The milk in Sexual & Reproductive Health 106 deluxe coffee drinks (preferably decaffeinated) can add up to quite a bit of calcium. Organic milk may or may not have vitamin D added, so read the label. An alternative for individuals with a lactose intolerance, as discussed in Chapter Five is the lactase enzyme, Lactaid® . If all else fails, a calcium supplement can be taken to ensure adequate calcium intake, with calcium carbonate the preferable form. Tums®, an antacid, is inexpensive calcium carbonate, but remember that calcium can interfere with iron absorption. Also, pregnant women should not drink unpasteurized milk as it may have bacteria harmful to pregnancy. Calcium Content of Foods Serving Size Calcium, mg Dairy Milk, whole, non-fat, low-fat 8 oz Lactaid milk™ 8 oz Yogurt, low-fat 8 oz low-fat fruited 8 oz Buttermilk 8 oz Cottage cheese 1/4 C. Cheddar cheese 1 oz Swiss cheese 1 oz Parmesan cheese 1 Tbsp. Ice cream 1/2 C. Frozen yogurt 1/2 C. Sour cream 2 Tbsp. Cream cheese 1 oz Pudding, vanilla 1 C. Legume Products Soymilk, unfortified Soymilk, fortified Soy cheese Tofu, not processed w/calcium Tofu, processed w/calcium Green soybeans Soy beans Navy beans 290 300 415 345 316 167 210 272 100 88 100 34 23 298 8 oz 10 8 oz 200-500 1 oz 200-300 3.5 oz 1/2 C. 1/2 C. 1/2 C. 1/2 C. 150 258 131 86 64 Serving Size Calcium, mg Grains, Seeds & Nuts Rice milk, fortified Amaranth Farina Sunflower seeds Sesame seeds Almonds Tahini 8 oz 1 C. 1 C. 1 oz 2 Tbsp. 1/2 C. 2 Tbsp. 240 275 147 20 160 160 128 Vegetables and Fruit Kale 1/2 C. Turnip greens 1/2 C. Collard greens 1/2 C. Bok choy 1/2 C. Mustard greens 1/2 C. Broccoli 1/2 C. Figs 5 medium 90 99 74 79 75 70 135 Seafood Sardines, canned w/bones 3.5 oz Salmon, canned w/bones 3.5 oz 370 200 Other Blackstrap molasses Calcium-fortified OJ 140 240 1 Tbsp. 6 oz FRUIT/VEGETABLE GROUPS The major nutrients in the fruit and vegetable food group are: vitamins A, C, folic acid and fiber. We also know that fruits and vegetables are high in antioxidants. The recommended amount to eat per day is two to three cups of fruits and three to four cups for vegetables. Fruits are preferred over fruit juice, although one serving of juice per day is acceptable. The charts below list the foods that are good sources of each nutrient and the amount considered a serving. Sexual & Reproductive Health 107 The color of the fruit or vegetable is a giveaway to the major nutrient found in it. Dark green vegetables are the best source of folic acid, while containing some vitamin C. The yellow and orange fruits and vegetables contain vitamin A or its plant version, beta-carotene. The citrus fruits are the major source of vitamin C. It is recommended to eat a variety of colors of fruits and vegetables, including one dark green and one deep orange fruit or vegetable daily. Since folic acid and vitamin C are water-soluble, they are destroyed by heat and water. Boiling will destroy 60 to 90 percent of these vitamins. Recommend foods that contain folic acid and vitamin C be eaten in their raw state. Fruits & Vegetables FRUITS Nutrients Food Vitamins A & C Fiber, Folic acid Potassium Citrus fruits/juices Cantaloupe, Strawberries Tangerines, Banana, Apricots Canned fruits, dried fruits Recommendation: 2 - 3 cups/day Emphasize fruit over juice; one good source of vitamin C /day VEGETABLES Nutrients Food Vitamin C, Fiber Broccoli, cabbage, Peppers/tomatoes Folic acid, Vitamin A Magnesium, Iron Broccoli, asparagus, Brussels sprouts Greens: spinach, beet, mustard, turnip Dark leafy lettuce Fiber, various vitamins and minerals Carrots, artichokes, eggplant, cucumber, squash, acorn squash, beets, cauliflower etc Recommendation: 3 - 4 cups/day Eat a variety of colors of vegetables to ensure good nutrient intake There are many other fruits and vegetables not listed in the charts above. That does not mean women are not supposed to eat them, only that they are not as good sources of vitamins A, C and folic acid. Use the remaining fruits and vegetables to fill the daily recommended amount of vegetables. Not only do fruits and vegetables provide vitamins and minerals, they are an excellent source of fiber, both dietary and functional fiber, containing 3 to 5 gm of total Sexual & Reproductive Health 108 fiber per serving. During pregnancy, with increased constipation, the more fiber included in the diet the better — especially dietary fiber which increases fecal bulk. BREADS/CEREALS GROUP Breads, cereals, rice and pasta contain good sources of thiamin, niacin, iron and zinc. As with fruits and vegetables, foods in this group contain fiber. The type of breads and cereals chosen dramatically affects fiber content of the diet. Whole grain products are a much better source of fiber than white or processed grain products. The chart below lists the types and amounts of foods considered a bread serving. Breads & Cereals Nutrients Thiamin, Niacin Iron, Riboflavin Phosphorus, Fiber Food Bread Hot cereals, grains (oats, rye, barley, millet, amaranth, etc.) Ready-to-eat cereals Macaroni, noodles, spaghetti, rice, cooked Cornbread, Roll, muffin, biscuit, tortilla Crackers, Bun, bagel, English muffin Recommendation: 7-11 ounces/day Make half your servings whole grains, as they are higher in fiber and magnesium, zinc, folic acid, vitamins B6 and E A minimum of 7 oz per day is recommended from the breads and cereals group, with 4 oz being whole grain products. Increasing the amount eaten to 8 to 11 oz per day is a good way to increase nutrient-dense calories for weight gain and for fiber. Each ounce of breads and cereals contains an average of 2 to 3 gm of total fiber. If the bread or cereal is whole grain with seeds and nuts, it may contain more fiber. If a woman consumes 8 oz per day of breads and cereals, she can consume 16 to 24 gm of fiber a day, getting close to her recommended intake of 28 gm per day. Of all the food groups, this one is most likely to be adequate. FATS, OILS AND SWEETS An additional category is the fats, oils and sweets group, which includes foods that are sources of sugar, fat, salt, alcohol or other foods as shown on the next page. These foods are not totally off limits. The goal is to eat the recommended amount from the other groups first, then add these foods to reach the desired calorie level. If you do consume these foods, concentrate on the plant oils and nuts and fish as they are the healthiest fats and oils. 109 Sexual & Reproductive Health Excesses of fat, cholesterol and sodium, and a deficiency of fiber, are possible even if someone eats from each of the food groups every day. To avoid this problem, become familiar with the types of food in each group that contain sugar, fat and sodium and those that are high in fiber. The food groups most likely to be inadequate in the diet are milk and milk products and fruits and vegetables, indicating inadequate intakes in calcium, magnesium and folic acid. Other nutrients that have been found to be low in the diets of pregnant women include: calories, vitamin B6, zinc, copper and iron. Fats, Oils & Sweets Includes foods that are: • high in sugar, fat, salt, cholesterol, alcohol and/or caffeine • high in calories and/or low in nutrients • not essential or necessary in the diet Sugar Cake, pie, cookies, donuts, sweet rolls, candy, soft drinks, jelly, syrup, desserts, sugar, honey Fat Salt margarine, oils, salad dressing, cream, butter, cream cheese, gravy, sauces Potato and corn chips, pretzels, pickles, olives, bouillon, soy sauce, steak sauce, salt, seasoned salt, canned goods, luncheon meats, cured ham This concept of "food groups" is not perfect, but it is a start. MyPyramid emphasizes grains, fruits and vegetables in an effort to help people reduce dietary cholesterol and fat and increase total fiber. Non-dairy sources of calcium (e.g., grains) are emphasized since the recommendation for milk is decreased to three servings/day. Plant proteins are encouraged. A good resource for nutritional information is the March of Dimes website: <www.Marchofdimes.com> FEEDBACK FORM If a woman has not used a food group or exchange system to keep track of her intake, it may be confusing for her at first. To help her plan her diet and keep track of what she is eating, a feedback form is useful (sample on the next page). This form provides spaces to write in the total amount of food from each food group she should have in one day. To determine how much a pregnant woman should eat, you or the client can get this information from MyPyramid for Moms individualized meal plan then transfer it to the feedback form. Or you can create the meal plan yourself. To keep track of what she eats, the woman checks off a box within the food group. Each box indicates either 1 oz or 1 cup, based on the food group. At the end of the day Sexual & Reproductive Health 110 she counts how much of each food group she has eaten, writes that in the column provided, and compares it to what is recommended for her, in the adjacent column. At the end of the day, the pregnant woman knows how her diet compares to what is recommended. A feedback form is a consciousness raising tool, helping make women aware of what they are eating compared to what they should be eating. Appendix #9 is a sample of a food plan from MyPyramid for Moms. A blank Feedback form, called "A Daily Food Guide" is included in Appendix #9A; it can be duplicated for use with your clients. Sample Feedback Form For Daily Food Guide FOOD GROUP Meat/Protein* Animal x x x x Plant Milk x x Fruits x x Vegetables x x x x x Breads/Cereals x x x x x Whole grain x x x x x Fats, oils, sweets x x x Vit. A,C (fruit/veg) x x I ate: My total should be: (4) _____ (3) _____ 4 _____ 2 _____ 0 _____ 1 _____ 3 _____ 3 _____ 2 _____ 3 _____ 1 _____ 4 _____ 3 _____ 3 _____ 7 _____ 8 _____ 5 _____ ** _____ 3 _____ ** _____ Record the amount of food that you ate today in each food group. Each box equals either one ounce or one cup, based on the food group. The total amount eaten in each group should equal or exceed what you are allowed in your personal meal plan, developed for you by your nutrition counselor or MyPyramid. *The amount eaten in these groups is counted by the recommended sub-groups and the total for the group is in parentheses. Example: meat/protein total recommended is 3, shown in parentheses, with 2 servings of animal and one serving of plant food recomended. **The number of servings in this group is based on your caloric needs and varies from day to day. Sexual & Reproductive Health 111 ASSESSING THE DIET How do you determine if the diet is adequate? The best way is a diet assessment using some form of diet history. A 24-hour recall, asking the woman to list everything she ate or drank for the prior 24 hours, is a good method, but it has drawbacks: it’s time consuming, the portion sizes recorded are usually not accurate, the period used is probably not typical. Also, many people can't remember what they ate. (Often, people want to “do right” and will make their diet look better. Any method that relies on memory and honesty is subject to this problem, so the counselor must impress upon her that accuracy is essential for proper assessment, and that no judgment or blaming will take place.) A food frequency chart is another diet history method that asks the number of times per week that foods are consumed. No serving sizes are requested, so it’s hard to get exact amounts of nutrients consumed. Also, the specific foods (such as the types of fruits or vegetables) may or may not be requested. It is helpful to examine the completed food frequency form with the client to find out if the fruits and vegetables are high in vitamins A and/or C, if the meat eaten is fried or broiled, if the breads are whole grain or white and if the dairy products eaten are whole, low-fat or non-fat. What the food frequency form does give is an idea of the individual’s pattern of eating. The types of foods typically consumed gives an indication of missing groups of foods, inadequate consumption of groups of foods or excesses of “other” foods. Because diets tend to fall into patterns over time, this information is valuable — more so, in my opinion, than the details of a 24-hour recall. Depending upon your clientele, this form may be more appropriate to use since it is easier to fill out than a 24-hour recall. A sample food frequency form is included in Appendix #10. To use this form, the patient puts a check mark in the column that best represents the number of times per week that a food is eaten. At the bottom of the page the totals are tallied. The diet history shown on the next page, Diet Assessment #1, is an example of a completed food frequency record. In the sample, the meat total includes beef, pork, ham, hamburger, hot dogs and luncheon meats; breads and cereals includes breakfast cereals, grains, breads, rolls, biscuits, tortillas and crackers. Sample weekly totals have been completed for you. Once the weekly totals are completed, add up the totals for each food group, and divide the total by seven to get an idea of the average number of servings eaten each day, then compare it to the recommended number of servings for that food group. According to the Healthy Eating Index-2005 (USDA, CNPP, 2008), the food groups most likely to be adequate are Grains and Meat/Beans. Far below the maximum were dark green and orange vegetables, legumes and whole grains. So when completing your assessment, pay close attention to the groups that tend to be lacking in American diets. Sexual & Reproductive Health 112 DIET ASSESSMENT #1 The average number of times a week a food is eaten for Diet Assessment #1 is: Meat, poultry, fish, dry beans, eggs & nuts = meat 7 poultry 3 fish 0 legumes 1 eggs 1 12 times/week 12 times/week ÷ 7 days/week = 1.7 times/day on average This is below the recommended 6-8 ounces/day. Milk, yogurt & cheese = dairy products 5 servings/week 5 times/week ÷ 7 days/week = .71 times/day This is below the recommended 3-4 cups/day. Fruits = fruits 4 4 times/week ÷ 7 = .57 times/day This is below the recommended 2 to 3 cups/day Vegetables = vegetables 7 7 times/week ÷ 7 = 1 time/day This is below the recommended 3 to 4 cups/day. Breads, cereals, rice & pasta = breads/cereals 26 rice and pasta 6_ 32 times/week 32 times/week ÷ 7 = 4.5 times/day This is below the recommended 7 to 11 ounces/day. The fats, oils and sweets group is represented by sodas, alcohol, cakes, pies, chips, ice cream, candy and fats. In Diet Assessment #1 the weekly number of times fat is eaten is 21 (3 per day), and 32 times “junk” foods are eaten, over 4.5 times/day. The food frequency form gives us the following information to assess this diet: The diet is low in meat and meat alternatives, milk products, fruits, vegetables, breads and cereals. Protein, calcium, vitamin C, folic acid, vitamin A, B vitamins, iron, magnesium and fiber are possibly inadequate, while fat and sugar are high. Calories are probably adequate due to the high consumption of calorie-dense “junk food.” It is obvious that there are problems with the diet. Many of the desirable foods checked are in the infrequent columns, particularly milk and milk products and fruits and vegetables. Undesirable “junk” foods, with a lot of calories, fat and sugar, are in the more frequently used columns. In short, it is the opposite of what is recommended. If you do not have time to add up the weekly totals for each type of food, just scanning the form and looking where the Xs fall can give you valuable information. For desirable foods, the Xs should be in the columns on the left. For undesirable foods, the Xs should be in the columns indicating infrequent use, on the right. Dividing the form into food groups and scanning for the Xs gives a quick assessment of the diet that can Sexual & Reproductive Health 113 be shown immediately to the client in an informal interview. It is a good visual representation, and even the least motivated client can be implored to “move those Xs over.” The pregnant woman eating this diet needs nutritional counseling. Recommendations would include increasing protein, milk and milk products, breads and cereals and fruits and vegetables, while decreasing the other foods. This will increase intake of nutrients and decrease calories (helpful if she is gaining weight excessively). Diet Assessment #1 Please check the column that shows how often you eat the following foods. Check only one column for each food. Your answers will be used for educational purposes. 2-4 times a day Beef, pork, ham, hamburger Luncheon meats, hot dogs Chicken, turkey, poultry Fish, seafood Eggs Dried peas or beans (legumes) Peanut butter Nuts Cereals (dry or cooked) Grains Breads, rolls, biscuits Tortillas Crackers Pasta, noodles, spaghetti, macaroni Milk Cheese Yogurt, pudding, custard Fruits Fruit juices Vegetables Water Added fat Coffee, tea, cocoa Sodas, fruit flavored drinks Alcohol: beer, wine, whiskey Candy, sweets Cakes, pies, cookies, donuts, sweet rolls Potato chips, pretzels, corn/tortilla chips Ice cream Weekly Totals: 7 Meat __________________ 3 Poultry ________________ 0 Fish ___________________ 1 Legumes _______________ 1 Eggs __________________ 26 Bread & Cereals _________ 6 Rice & Pasta ____________ Once daily 2-4 times a week Once weekly Hardly ever or never X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 4 7 Fruits & Juices* ___________ Cakes, pies ____________ 7 7 Vegetables* _______________ Chips ________________ 5 1 Dairy products ____________ Ice cream _____________ 7 7 Water ____________________ Candy ________________ 7 21 Sodas ___________________ Fats __________________ 3 53 Alcohol __________________ Other ________________ *Ask types to determine if they are high in vitamins A or C Sexual & Reproductive Health 114 The key to successful nutritional counseling is to find specific changes to recommend, within the client's budget and cultural constraints. It is better if the patient can come up with the suggestions for diet changes as she is more likely to follow the diet. Too often counselors tell clients what they think is best for them and lose sight of many other possibilities and options for these clients. DIET ASSESSMENT #2 Diet Assessment #2 Please check the column that shows how often you eat the following foods. Check only one column for each food. Your answers will be used for educational purposes. 2-4 times a day Beef, pork, ham, hamburger Luncheon meats, hot dogs Chicken, turkey, poultry Fish, seafood Eggs Dried peas or beans (legumes) Peanut butter Nuts Cereals (dry or cooked) Grains Breads, rolls, biscuits Tortillas Crackers Pasta, noodles, spaghetti, macaroni Milk Cheese Yogurt, pudding, custard Fruits Fruit juices Vegetables Water Added fat Coffee, tea, cocoa Sodas, fruit flavored drinks Alcohol: beer, wine, whiskey Candy, sweets Cakes, pies, cookies, donuts, sweet rolls Potato chips, pretzels, corn/tortilla chips Ice cream Weekly Totals: Meat __________________ 8 Poultry ________________ 4 1 Fish ___________________ 7 Legumes _______________ 1 Eggs __________________ 31 Bread & Cereals _________ 5 Rice & Pasta ____________ Once daily 2-4 times a week Once weekly Hardly ever or never X X X X X X X X X X X X X X X X X X X X X X X X X X X X Fruits & Juices* ___________ Cakes, pies ____________ 0 7 Vegetables* _______________ Chips ________________ 7 15 7 3 Dairy products ____________ Ice cream _____________ 7 3 Water ____________________ Candy ________________ 18 20 Sodas ___________________ Fats __________________ 4 49 Alcohol __________________ Other ________________ *Ask types to determine if they are high in vitamins A or C Sexual & Reproductive Health 115 Looking only at the position of the Xs indicates milk/milk products and fruits and vegetables are low and the “other” foods are too high. For instance, All of the foods in the meat/beans/protein category are eaten two to four times a week or once a week, with the exception of legumes, which are eaten daily. Milk and milk products are consumed two to four times a week and cheese once a day. Fruits and vegetables are in the "hardly ever or never" column. The average number of times a day that foods are eaten are: meat, poultry, fish, dry beans, eggs & nuts – 3 milk, yogurt & cheese – 1 fruits and vegetables – 1 breads, cereals, rice & pasta – 5.1 other – 7 fats – 2.9 This woman is not getting enough milk products, breads and cereals and fruits and vegetables. Her meat and meat alternate intake is adequate. Too much “junk food” is consumed. She is eating chips two to four times a day, so her sodium intake may be high, especially if she uses high-sodium meats and canned foods. Other dietary problems include too much fat and too little fiber. DIET ASSESSMENT #3 Let’s evaluate one more diet, Assessment #3, charted on the following page. Try analyzing it before reading the evaluation that follows. This diet is the best of all we’ve evaluated. The average number of times/day from each group: meat, poultry, fish, dry beans, eggs & nuts – 2.6 milk, yogurt & cheese – 4.7 fruits and vegetables – 5.6 breads, cereals, rice & pasta – 8.2 other – 0.43 fats – 1 There is little to recommend to improve this diet. Even though protein seems a little low, with the amount of dairy products and breads and cereals in the diet, it is most likely adequate. Check the types of foods consumed to make sure the fat content is not too high. Also check to see if the bread and cereals are whole grain, contributing to the fiber intake. If weight gain is adequate, indicating adequate caloric intake, then this diet is fine. Sexual & Reproductive Health 116 Diet Assessment #3 Please check the column that shows how often you eat the following foods. Check only one column for each food. Your answers will be used for educational purposes. 2-4 times a day Beef, pork, ham, hamburger Luncheon meats, hot dogs Chicken, turkey, poultry Fish, seafood Eggs Dried peas or beans (legumes) Peanut butter Nuts Cereals (dry or cooked) Grains Breads, rolls, biscuits Tortillas Crackers Pasta, noodles, spaghetti, macaroni Milk Cheese Yogurt, pudding, custard Fruits Fruit juices Vegetables Water Added fat Coffee, tea, cocoa Sodas, fruit flavored drinks Alcohol: beer, wine, whiskey Candy, sweets Cakes, pies, cookies, donuts, sweet rolls Potato chips, pretzels, corn/tortilla chips Ice cream Weekly Totals: 1 Meat __________________ 4 Poultry ________________ 3 Fish ___________________ 7 Legumes _______________ 3 Eggs __________________ 48 Bread & Cereals _________ 10 Rice & Pasta ____________ Once daily 2-4 times a week Once weekly Hardly ever or never X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 18 0 Fruits & Juices* ___________ Cakes, pies ____________ 21 1 Vegetables* _______________ Chips ________________ 33 1 Dairy products ____________ Ice cream _____________ 18 0 Water ____________________ Candy ________________ 0 7 Sodas ___________________ Fats __________________ 1 3 Alcohol __________________ Other ________________ *Ask types to determine if they are high in vitamins A or C EATING PATTERN It has been suggested that the optimal eating pattern for women is three meals and two snacks per day (IOM, 1990). Siega-Riz et al. (2001) found that pregnant women who ate fewer than three meals and two snacks had a 30 percent higher risk for delivering preterm babies. In addition, women who went for longer than 13 hours a day without Sexual & Reproductive Health 117 eating had a three-fold greater risk of delivering preterm babies, less than 34 weeks gestation, than pregnant women who ate within 13 hours in a day. The mechanism behind this finding appears to be related to the neuropeptide corticotropin-releasing hormone (CRH). Hermann et al. (2001) found that fasting (or not eating food) for more than 13 hours increased maternal CRH levels compared to not eating for less than 13 hours. The researchers also found an inverse relationship between maternal CRH levels and gestational age at delivery. This may explain why pregnant women who eat infrequently may give birth to more preterm babies. It may be prudent to recommend that pregnant women eat fairly often during the day and have a snack at bedtime. Hobel and colleagues (2003) review the relationship between psychosocial and nutritional stress on poor pregnancy outcome and explain in detail the relationship between food intake and poor pregnancy outcome. SUMMARY It should be obvious by now that although there are specific dietary recommendations for pregnant women, a nutrition counselor has the ability to fine-tune those recommendations to meet the specific needs of his or her clients. Tools to assist in the evaluation of a diet and to assist a woman follow her diet are integral parts of helping women eat optimally while pregnant. For motivated clients, encourage them to use the MyPyramid site, as it contain lots of good information that you know if reliable. Keep the following questions in mind as you assess the diet of your clients: • Which nutrient needs are being met? • Which food practices should be reinforced? • What aspects of the food practices most need improvement? • Which practices should be discouraged or eliminated? These questions can help guide your interactions with your client. Too often as counselors we try to make too many changes in the diet all at once. It may be that a client can only change one, two or three behaviors. Which ones will have the most impact? Once those are determined, work on those, then go on to others if possible. Other concerns that determine if a client can meet her nutritional needs concern her financial and social situation as well as cultural and ethnic practices. You can counsel a client all you want, but if she cannot buy, store or prepare food, what good will it do? You need to know if she has money for food, can get to the store, has a refrigerator, stove and/or oven. Do not be timid or feel like you are prying if you have to ask uncomfortable questions. How you phrase questions may determine how honest a response you get. The chart on the next page lists food programs for lowincome women that will supplement their diet. Cultural and ethnic food practices must also be considered when counseling clients about dietary practices. With an increasingly varied ethnic population, understanding the food preferences and social aspects of food can increase the likelihood that your Sexual & Reproductive Health 118 suggestions for improving the nutritional quality of the diet will be followed. Also, many women are now vegetarians and should be reassured that they can meet all their nutritional needs but may need to include a wider range of foods or an increase amount of certain foods. Most importantly, be practical. Look for ways to improve diets that are easy to follow, do not take a lot of time, and fit into the lifestyle of your client. Nutrition Services & Programs for Pregnant Women Commodity Supplemental Food Program (CSFP): Services and benefits: Monthly canned or packaged foods & opportunities for nutrition education. Eligibility: Household income <185% of federal poverty level. Website: www.fns.usda.gov/fdd/programs/csfp Expanded Food and Nutrition Education Program (EFNEP): Services and benefits: Provides individual & group education & training on food & nutrition & getting the most for your food dollar. Many programs also offer a special series for pregnant teens. Eligibility: Households w/children under 19 years of age w/income <125% of federal poverty level are eligible if found to be at nutritional risk. Supplemental Nutrition Assistance Program (formerly the Food Stamp Program): Services and benefits: Food vouchers, cards, or checks to purchase foods at participating grocery stores. Eligibility: Households w/low income & w/resources (aside from income) of <$2000. Formal application must be made to a local public assistance or social services agency. Website: www.fns.usda.gov/snap Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): Services and benefits: Monthly food packages, nutrition education, & referrals for health care and other services. Eligibility: Household income less than 185% of federal poverty level & be certified to be at nutritional risk. Website: www.fns.usda.gov/wic Other sources of nutrition services and information in the community may exist. Some of these services may be provided for a minimal charge or even for free while other services are billed just like other medical appointments. Look for these services in the community: • Public health nutritionists in city, county or state health departments • Nutrition specialists with Agricultural Extension Service Programs associated with state universities • Dietitians employed at local community hospitals, medical clinics, health centers, and in private practice. Sexual & Reproductive Health 119 Chapter Eight: Special Diet Problems, Supplementation & Exercise Monitoring the pregnant woman's dietary intake throughout her pregnancy is an important component of a successful outcome. Special dietary issues may appear during pregnancy that were not evident in an initial screening or early in the pregnancy. The chart below lists several problems associated with inadequate intake. Special Dietary Problems • Food security - limited access to food (low income) • Food safety • Avoidance of foods – intolerance, fads, cultural practice • Adherence to vegan diet • Substance abuse – alcohol, tobacco, illicit drugs • Restricted weight gain • Pica • Attitude, feelings about pregnancy • Lifestyle precludes adequate nutrient intake • Nausea, vomiting, constipation, heartburn, leg cramps • Herbal and alternative products • Clinical information indicating nutritional risk: – over- or underweight – anemia – bariatric surgery – multiple gestation – adolescence – health issues Sexual & Reproductive Health 120 WEIGHT GAIN When evaluating the diets of pregnant women, be on the lookout for any weight gain problem. One of the most common symptoms is gaining too much weight — any gain in excess of 6.5 lb per month is too much, especially in repeat pregnancies. A woman who weighed 120 lb at the beginning of her first pregnancy may find herself at 160 lb at the end of her second or third. These women need help to find ways to cut calories, but not nutrients. Finding and eliminating hidden fat in the diet decreases calories without changing nutrient composition. Typical sources of excess or hidden fats are: meat, whole milk, salad dressings, mayonnaise, butter, margarine, crackers, fried foods, nuts, meats, marinades, sauces and gravies etc. Appendix #8, “Healthy Food Choices,” can help women choose foods that have more nutrients and fewer calories. The opposite problem is gaining too little weight — less than 2.2 lb per month. Inadequate gain is an indication of insufficient calories and nutrients. While excess gain can be a problem for the mother, inadequate gain is more a problem for the fetus. Solutions need to be found so the mother can increase her intake. Usually, non-fat and low-fat dairy products are recommended for pregnant women. In the case of inadequate weight gain, the rule may need to be broken — whole milk dairy products are recommended as a source of extra calories. After delivery, the woman can switch back to low-fat dairy products. A good suggestion is to mix up a pitcher of a nutrient-packed beverage that can be sipped throughout the day. An example is a milk shake with added egg (cooked), yogurt and fruit. Adding instant breakfast preparations to milk is another option. Using fruit juice as the base is preferable for some women. The idea is to find something that can be made easily and ingested throughout the day, and which is high in nutritive value. Be imaginative! But with the continuous carbohydrate ingestion, be careful about dental decay. If a woman is having problems with her weight gain, she should be screened for an eating disorder such as anorexia nervosa or bulimia or a problem with food that will prevent her from gaining adequate weight and increase her risk for a LBW or SGA baby (Conti, et al., 1998). These diseases affect a woman's dietary intake and her ability to gain weight while pregnant. If this is the case, the woman may need more help than you can give her and a referral to a psychologist or clinic may be necessary. Also consider that inadequate weight gain may be linked to disordered eating that may not be a typical eating disorder. Fairburn et al. (1992) found that 80 percent of women have aversions to food that do not interfere with adequate weight gain in pregnancy, while 53 percent have cravings for specific foods. In this study of 100 women, three had a clinically diagnosed eating disorder that was non-specific. In these three cases the women had an easier time gaining weight early in the pregnancy and more difficulty later on, probably fearful of not losing the weight once the pregnancy was over. There was no relationship in this study between eating disorders and poor pregnancy outcome. This was a small, voluntary study and may not have included women with more serious eating disorders Sexual & Reproductive Health 121 The chart below lists symptoms that might indicate an eating disorder is present. A more complete discussion of eating disorders can be found in Nutrition Dimension courses: Diet, Weight Control & Eating Disorders and Treating Eating Disorders. Prenatal Screening for Eating Disorders Anorexia Nervosa • weighs less than 85% of desirable prepregnancy weight • no weight gain • history of poor appetite or large weight loss • unrealistic expectations for weight during pregnancy Bulimia • history of large weight fluctuations • nausea/vomiting whether pregnant or not • history of binge/purge behavior • awareness of bulimia in self or others • laxative or diuretic abuse • fixation with body shape/weight • oral health screening Adapted from “Nutrition During Pregnancy and the Postpartum Period”, Calif Dept of Health, 1990. NAUSEA AND VOMITING Some weight gain problems are worsened by nausea and vomiting which can make the woman reluctant to eat or affect absorption of nutrients. Nausea and vomiting affect half of all pregnant women, usually beginning early in the pregnancy and disappearing by week 12, but these symptoms can last until week 20. Nausea and vomiting may be difficult to treat, since hormonal changes are usually presumed to be the cause. Other theories as to the cause of nausea and vomiting include: lower blood sodium; alterations in brain chemoreceptors; altered metabolism; slower emptying of the stomach and heightened senses. Increased estrogen causes a sensitivity to smells, called hyperolfaction, not experienced in nonpregnant women. These smells may be to food or to items found in a women's normal environment, such as cleaning chemicals, dogs, mold, coffee, garbage, perfume, soaps etc. Many pregnant women cite sensitivity to smells as the trigger to their problems. Hyperolfaction may be a cue to pregnant women to seek cleaner, quieter, and more temperate environments (Erick, 1995). It may also explain why some women experience relief from their nausea when hospitalized but find that the nausea recurs once they are back in their usual environments. While the symptoms of nausea and vomiting range from unpleasant to life-threatening, there are remedies that work, although highly individualized. With good detective work and an open mind, solutions can be found for most women. Appendix #13 lists some solutions for nausea and vomiting. An excellent reference is Miriam Erick's book, No More Morning Sickness, A Survival Guide For Pregnant Women, or her client education resource: Take Two Crackers and Call Me in the Morning! Brookline, MA: Grinnen-Barrett Publishing, 1995. Sexual & Reproductive Health 122 A newer reference by Miriam Erick is Managing Morning Sickness: A Survival Guide for Pregnant Women. Bull Publishing, 2004. Another book that may be helpful is by Elizabeth Kaledin, The Morning Sickness Companion. St Martins, Griffen & Thomas Dunne Books, 2003. A woman with a severe or prolonged nausea and vomiting problem should have her weight gain monitored closely. In many normal weight or overweight women, a slight weight loss in the first trimester is rapidly made up once the problem disappears. Women most at risk are those who are underweight at onset, have severe or prolonged nausea and vomiting, lose weight during the first trimester, and don’t regain or gain adequately thereafter. Potassium lost through vomiting can be replaced by eating foods rich in potassium, such as bananas, oranges, prunes, potatoes, cantaloupe and legumes. At least one serving per day of a potassium-rich food will replace losses. Since food intake (and consequently nutrient intake) is down at this time, women should take a multi-vitamin and mineral supplement. Severe and prolonged nausea and vomiting can progress to hyperemesis gravidarum (HG), a condition affecting 0.5 to 1 percent of all pregnant women (Leduc, 1997). HG usually begins before the 20th week of gestation with intractable vomiting, severe enough to cause weight loss, dehydration, electrolyte imbalance, ketonuria and acid-base imbalances. These can all lead to hospitalization and the need for nutrition support — tubefeeding or total parenteral nutrition. In some women, adequate treatment can prevent the need for nutrition support, but in others it may not (Erick, 1997). It is important to try to keep food in the stomach. An empty stomach increases nausea and vomiting, making it harder for the woman to eat. Once the vomiting begins, it may be difficult to stop. Eating smaller meals that are rich in easily digestible carbohydrates, at more frequent intervals, and avoiding any foods that increase the symptoms are good tips. However, some women may crave different types of foods, such as those that are sweet, salty, crunchy, bitter, sour, mushy, hard, spicy, hot, cold, thin or thick. The goal is to gain adequate weight, with the healthiest diet possible. If there is an aversion to healthy foods, getting calories in, no matter the source, is critical even if it means eating “junk” foods. A woman can supplement vitamins and minerals, but not calories. Erick (1995) says that one of the solutions that works best for some of her patients is potato chips and lemonade! Women who are troubled with nausea and vomiting are at risk of damaging the enamel on their teeth because the acid in the vomit can soften dental enamel. The best advice is to have them rinse their mouths out with 1 cup of water mixed with 1/2 teaspoon of baking soda, to neutralize the acid. Vitamin B6 is sometimes prescribed for nausea and vomiting, but caution should be used when taking this vitamin. The RDA is 2.2 mg/day, but women are often advised to take up to 50 to 100 mg/day. At that level, vitamin B6 acts like a drug. Side effects in women — especially peripheral nerve damage— have been documented at 100 mg/day, and it is likely that the fetus is affected, too, although this has not been proven. Avoid megadosing with vitamin B6. Sexual & Reproductive Health 123 Ginger, a folk remedy, has been used for centuries to alleviate nausea during pregnancy. In 2004, a study from Australia found that ginger, early in pregnancy, is as effective as vitamin B6 in reducing nausea and vomiting in pregnant women and is safe to use (Smith, et al., 2004). Other studies have reviewed the literature and found that ginger does appear safe for pregnant women (Boone and Shields, 2005; Borrelli, et al., 2005). HEARTBURN AND CONSTIPATION Heartburn is caused by the relaxation of the cardio-esophageal sphincter, allowing stomach acid to be regurgitated into the esophagus. This condition is worse late in the pregnancy, and is most noticeable when a woman is lying down or bending over. To prevent the problem or decrease the symptoms, it is best to avoid high-fat meals, since they delay gastric emptying. Highly seasoned foods or foods that increase gastric acidity can cause a problem and should be avoided. A more complete list of solutions can be found in Appendix #11. If antacids are used, calcium in the antacid may interfere with iron absorption. To minimize this problem, take antacids on an empty stomach and at a different time than iron. Constipation is another common problem in pregnancy. The causes can be many — decreased peristalsis of the GI tract, inadequate intake of fiber and fluids, stress, medications and calcium and iron supplementation. To help with this problem you may recommend increasing dietary fiber and fluid, increasing exercise or taking a commercially available laxative, such as Metamucil®. See Appendix #11. LEG CRAMPS Leg cramps, affecting 15 to 30 percent of all pregnant women, are most common during the second half of pregnancy and usually occur at night. Causation is unknown, but an imbalance of calcium, phosphorus and magnesium, with elevated serum phosphorus levels and decreased serum calcium and magnesium, is suspected. Inadequate calcium and magnesium intake, and excessive phosphorus intake, may be the cause. Limiting foods high in phosphorus — animal foods, dairy products, carbonated beverages and phosphate-containing supplements — should help balance dietary calcium and phosphorus. Conversely, eating magnesium-rich foods — legumes, dark green leafy vegetables and whole grain products — will elevate serum magnesium. Several studies have shown that supplementing pregnant women affected by leg cramps with non-phosphate-containing calcium salts increases total serum calcium levels and improves leg cramps. This clinical correlation is far from perfect since other controlled and double-blind studies have failed to indicate a correlation between leg cramps and either intake of dairy products or type of calcium supplement used. The most effective treatment for leg cramps is to discourage women from pointing their toes during sleep or stretching. Gentle flexing of the feet will provide relief for many women. If dietary intake of calcium is <600 mg, a supplement is recommended for general dietary adequacy. However, the supplement may not provide relief from the leg cramps. A list of solutions for leg cramps can be found in Appendix #11. Sexual & Reproductive Health 124 NON-NUTRITIVE SWEETENERS The FDA has approved five non-nutritive sweeteners as food additives: saccharin, aspartame, acesulfame-K (potassium), sucralose and neotame. The position paper Position of the American Dietetic Association: Use of Nutritive and Nonnutritive Sweetners (JADA, 2004) is an excellent review of the topic and the individual nonnutritive sweetners. In regard to pregnancy, the authors conclude: In summary, the studies on the effects of nonnutritive sweeteners on reproductive abilities in females and males, as well as on the developing fetus have been reviewed and these sweeteners deemed safe by numerous regulatory bodies and expert communities around the world. Thus, the consumption of acesulfame potassium, aspartame, saccharin, sucralose and neotame within acceptable daily intakes is safe during pregnancy. • Saccharin (Sweet 'N Low® or Sugar Twin®) crosses the placenta and is distributed to fetal tissues, so there has been concern about its safety. However, the National Toxicology Program of the National Institutes of Health and the California Environmental Protection Agency recommended that saccharin no longer be classified as a carcinogen (JADA, 2004). The amount of saccharin can not exceed: 12 mg/fluid ounce in a beverage, 20 mg in packaged amounts and 30 mg/serving in processed foods (JADA, 2004). • Aspartame, (Nutra-sweet,® Equal®) is made from two amino acids, aspartic acid and phenylalanine. Some infants have a metabolic defect, phenylketonuria (PKU), preventing them from metabolizing phenylalanine. Concern exists whether a fetus with PKU can be harmed by the mother ingesting too much aspartame. In studies looking at fetal transfer of the metabolites of aspartame, it was found that if placental transfer did occur, it was not clinically significant (JADA, 2004). The FDA has established an Acceptable Daily Intake (ADI) of 50 mg/kg body weight/day (JADA, 2004). According to a review of all the available data on aspartame, Magnuson and colleagues (2007) concluded that aspartame is safe at the current levels of consumption, which averages 4.9 mg/kg body weight/day, with high users consuming 13.3 mg/kg body weight/day, nowhere near the ADI. • Acesulfame-K, known as Sunett® or Sweet One® is 200 times sweeter than sucrose, can withstand high cooking/baking temperatures, does not provide any energy and is not metabolized by the body. Little acesulfame-K is used in foods due to its intense sweetness; it is often used in combination with other sweeteners. The ADI established by the FDA is 15 mg/kg body weight per day (JADA, 2004). • Sucralose, known as Splenda®, is 600 times sweeter than sucrose, provides no energy, is not well absorbed by the body and is stable when exposed to high heat. Sucralose has been deemed safe in humans after the FDA reviewed 110 studies in humans and animals (JADA, 2004). The ADI is 5 mg/kg body weight per day (JADA, 2004). • Neotame is another approved nonnutritive sweetener, 13,000 times sweeter than sucrose. At high doses, there is no apparent effect on pregnant women and their fetus. Sexual & Reproductive Health 125 The FDA has established an ADI of 2 mg/kg body weight per day (JADA, 2004). • Stevia, the newest nonnutritive sweetener approved for use in the US, is derived from the leaves of a South American herb (Stevia rebaudiana). It has taken a long time for FDA approval. In 1991, FDA banned stevia as an “unsafe food additive.” When the 1994 Diet Supplement, Health and Education Act was passed, the FDA had no choice but allow stevia be sold as a supplement, since it was from an herb. Use was limited, as most of the available products had a bitter taste. In 2008, the FDA approved two stevia sweetners, Truvia® and SweetLeaf.® Only 95 percent pure steviol glycosides (sweet extracts from the stevia plant) are approved for use in food and beverages and these do not have the bitter taste. Truvia will be used in drinks manufactured by Coca-cola. SweetLeaf is from Wisdom Natural Brands of Phoenix, AZ. You can also find stevia in health food stores. The ADI of stevia is 2 mg/kg body weight/day (Damarck, 2009). Research done on animals has proven stevia safe. However there is very little research on pregnant women. Since the FDA approval of stevia products is relatively new, it will be interesting to see what information will become available about its effect on pregnant women and if the recommendations for use in pregnancy will change. While nonnutritive sweetners are safe, moderation of sugar substitutes is suggested for any pregnant woman. Beverages containing nonnutritive sweeteners should not replace beverages with important nutrients. CAFFEINE Caffeine is a central nervous system stimulant. It can cause insomnia, nervousness, irritability, anxiety and disturbances in heart rate and rhythm. Caffeine also acts on the kidney to produce diuresis. Caffeine does cross the placenta, and so has the potential to affect the fetus, which cannot metabolize caffeine effectively. In pregnant women, the liver is slower to detoxify caffeine, so it stays in the blood longer, increasing the potential of placental transfer to the fetus. Unfortunately, the studies published to date conflict with one another. Two 1993 JAMA studies also came to contradictory conclusions on the effects of caffeine on outcome of pregnancy. Some studies have found decreased birth weights, increased number of LBW babies and increased spontaneous abortions. One showed that high levels (over 600 mg/day) can cause spontaneous abortion and premature births, but other variables such as smoking were not taken into account. Other studies add to the debate. Fenster, et al., (1998) linked increased risk of spontaneous abortion with caffeine intake, while Klebanoff, et al., (1999) found that only extremely high levels of caffeine increase the risk for spontaneous abortions. Signorello and McLaughlin (2004), in a review of the literature, concluded the evidence was equivocal that caffeine intake increased spontaneous abortions. Another study, based on hundreds of telephone interviews, found no association between caffeine intake and preterm delivery (Pastore and Savitz, 1995). Caffeine intake was estimated from coffee, tea, colas, and non-cola caffeinated soft drinks. In a review of Sexual & Reproductive Health 126 the literature to date, Golding (1995) found no association between caffeine consumption and congenital malformations or preterm delivery. Two studies published in 2006 found no relationship between caffeine intake and congenital anomalies (Browne, 2006) and the risk of preterm delivery (Chiaffarino, et al, 2006). Hinds and colleagues (1996) had similar conclusions to Golding when reviewing the effects of caffeine on pregnancy outcome variables. She concluded that: ...heavy caffeine use, >300 mg/day, is associated with small reductions in infant birth weight. However, overwhelming evidence indicated that caffeine is not a human teratogen and that caffeine appears to have no effect on preterm labor and delivery. The CARE Study Group (2008) did find that caffeine consumption throughout pregnancy was associated with decreased birth weight. This was true when caffeine consumption was greater than 300 mg/day compared with less than 100 mg/day. Giannelli, et al., (2003) found that a caffeine intake above 300 mg/day increased the risk for miscarriage. Wisborg (2003) concluded that “Drinking coffee during pregnancy is associated with an increased risk of stillbirth but not with sudden infant death.” Women consuming 0 to 3 cups of coffee per day did not have more stillbirths. Pregnant women consuming 4 to 7 cups per day had an 80 percent increase, and women consuming more than 8 cups per day had a 300 percent increase in stillbirths. Weng (2008) found that women who consumed 200 mg or more per day of caffeine had twice the chance of having a miscarriage as women who did not consume any caffeine. However, Savitz and colleagues (2008) did not find any increase in miscarriages, in women who drank between 200 and 350 mg of caffeine a day. The best recommendation at present is to reduce caffeine intake to the equivalent found in two cups of coffee, approximately 150 to 300 mg of caffeine. The March of Dimes recommends no more than 200 mg of caffeine, the amount found in 12 oz of coffee. The chart on the following page lists the caffeine content of selected beverages and drugs. Note serving sizes: A 16 oz cup of coffee is actually 2 cups, not 1. Many energy drinks that contain caffeine are 12 oz or more, not 8 oz. Changing habits is not easy. If a woman needs one vice, caffeine intake appears the least likely to do harm, certainly less than drinking alcohol or smoking cigarettes. It may be easier on the mother to have a cup of coffee a day, than to worry about it or give it up. Sexual & Reproductive Health 127 Caffeine Content of Selected Items Item Coffee (5 oz cup) Brewed, drip Brewed, percolator Instant Decaffeinated Starbucks, tall Cappuccino, short Tea (8 oz cup) Regular bag Regular loose Instant Iced Tea, bottled Chocolate Milk chocolate Dark chocolate mg/serving 60-180 cup 40-170/cup 30-120/cup 3/cup 375/12 oz 35/8 oz 46/cup 40/cup 30/cup 70/cup 15/12 oz 1-15/oz 5-35/oz Item Beverages Coca Cola Pepsi Diet Rite Dr. Pepper Mountain Dew Tab Chocolate milk Hot chocolate/cocoa Drugs Aspirin Excedrin, Anacin No-Doz Vivarin Cafergot Darvon mg/serving 65/12 oz 62/12 oz 33/12 oz 61/12 oz 55/12 oz 45/12 oz 2-7/8 oz 6-42/cup 32/pill 60/pill 100/pill 200/pill 100/pill 32/pill BARIATRIC SURGERY The number of women having bariatric surgery is increasing dramatically — 13,365 in 1998 to approximately 72,177 in 2002 (IOM, 2009). Therefore the number of women becoming pregnant who have had this type of surgery is increasing. Pregnancy after bariatric surgery appears safe, with no significant differences in the complications between women who have had gastric bypass surgery and those who have not (WHRNP, 2004). In a study of 298 women who gave birth after bariatric surgery, the authors found an increase in Cesarean delivery (Sheiner, et al., 2004). A newer study suggests that the health risks of pregnancy are decreased in women who have had bariatric surgery, compared to women who are obese (Roye, et al., 2008). This study did not find any increased risk to fetal outcome. Guelinckx, et al., (2009) did find improved fertility and reduced risk of gestational diabetes, hypertensive disorders of pregnancy and macrosomia in pregnant women after surgery compared to morbidly obese pregnant women. However, there was an increase in intrauterine growth restriction and the potential for nutritional deficiencies that could affect both mother and infant. Women who have had an adjustable gastric banding procedure are at risk of unexpectedly becoming pregnant after weight loss following surgery. To achieve a successful pregnancy after bariatric surgery, there are nutritional issues that must be addressed, such as type of procedure, length of time since surgery, previous pregnancies and any complications or adverse outcomes, age and any comorbid conditions. Sexual & Reproductive Health 128 Vertical-banded gastroplasty (VBG) and other gastric restriction surgeries known as “restrictive surgeries” were approved by the FDA for use in the US in 2001. The goal of restrictive surgeries is to reduce the size of the stomach and to slow gastric emptying. The effect is to physically limit the volume and rate of food intake by reducing the stomach to a small pouch, usually 30 ml in size but sometimes as small as 15 mL. The Roux-en-Y gastric bypass surgery (RYGB), which is more popular, reduces the size of the stomach and bypasses the duodenum and proximal jejunum by attaching the jejunum directly to the small pouch created in the stomach. The effect is to physically limit the volume and rate of food intake, as well as to limit the absorptive capacity of the small intestine. These changes in anatomy substantially impact food and nutrient intake. RYGB is known as a malabsorptive/restrictive procedure. The restriction is a result of a very small stomach pouch (less than 20 mL). The degree of malabsorption depends on the length of the intestine that is bypassed. At a minimum, the duodenum and upper jejunum are circumvented. The period of rapid weight loss following bariatric surgery — up to six months after surgery — is the worst time for a woman to become pregnant and is the most challenging nutritionally. Once weight loss has slowed and intake has stabilized —usually 12 to 16 months post-surgery — it is much safer to become pregnant. If you are assessing or counseling a pregnant woman after bariatric surgery, you must determine the following: • Adequacy of the diet. Is the woman getting adequate calories, protein, fluid, vitamins and minerals? With the reduced stomach size, she may need to eat six to eight times per day. It is essential she eat protein foods with high biological value protein, since the volume of food she can eat is decreased. • Adequate weight gain. Is the woman gaining appropriately? This can be tricky, as she may still be losing weight, but eating sufficiently for herself and her baby. Close supervision of weight gain or loss compared to her intake is essential. • Malabsorption of vitamins and minerals. If the woman had a RYGB, she will most likely malabsorb iron, vitamin B12, vitamin D, calcium and folate (IOM, 2009). It is essential to evaluate her nutritional status with lab work to see if she is deficient and needs additional supplements. A routine vitamin and mineral supplement is essential as well. The bottom line is that women who have had bariatric surgery can deliver normal, healthy babies, without complications, but they must pay close attention to their diet, under the supervision of a dietitian or other health professional. Sexual & Reproductive Health 129 FOOD SAFETY Pregnant women are considered to be at increased risk for food-borne disease. During pregnancy, plasma levels of immunosuppressive hormones increase — particularly during the third trimester — to enable the maternal immune system to coexist with the fetus. This can put both the mother and fetus at risk. Organisms that pregnant women are most susceptible to are listed in the chart below. Tips for keeping food safe are found on the following page. Some of the organisms, Listeria in particular, can be deadly to the mother and fetus. Listeria has also been found in deli meats and hot dogs, so these should be well heated before eating. Other organisms such as Campylobacter, Staphylococcus, and Salmonella cause severe gastrointestinal problems, including dehydration and blood volume depletion, which are dangerous to the fetus. Toxoplasma, a parasite, can be found in under cooked meat and unwashed fruits and vegetables. Taking proper precautions with food purchasing, handling, preparation and storage can help prevent food-borne illness. The chart on the following page offers suggestions. Additionally, wash all fruits and vegetables under running water, avoid cleaning cat litter boxes (if you have to, wear gloves), and if gardening, wear gloves. Information is also available at: <www.womenshealth.gov.> and <www.mypyramid.govmypyramid/moms/food_safety.html> Food-borne Bacteria BACTERIA Salmonella (>2,000 types) Campylobacter jejuni Yersinia enterocolitica Listeria monocytogenes Vibrio sp. Staphylococcus aureus Clostridium perfringens Clostridium botulinum Escherichia coli 0157:H7 FOOD SOURCE Mostly foods of animal origin: meat, poultry, dairy, raw milk, eggs Raw milk, meats, clams, eggs Chocolate milk, tofu, ice cream Soft cheese, coleslaw, celery, raw milk, lettuce, seafood, deli meats Raw seafood Meat & dairy products, fish, poultry, cream sauces & salads, puddings, custards, cream-filled bakery items Meat & poultry products Canned food, luncheon meats, lobster, smoked fish, ham Raw or rare ground beef, unpasteurized milk Sexual & Reproductive Health 130 Keeping Food Safe Shopping Cold Storage Thawing Food Preparation Serving Food & Handling Leftovers Listeria • Don't buy cans or jars with dents, cracks or bulging lids. • Don't buy broken boxes or packages. • Don't buy raw cheese or milk and unpasteurized juice ;do not use raw eggs or products with raw eggs and do not use raw sprouts. • Keep perishable food cold. • Refrigerate perishable food as soon as you get it home. • Store canned goods in cool, dry place for use within 1 year. Never put above stove, under sink or in a garage or damp basement. • Don't thaw on counter. Bacteria grow quickly at room temperature. • Thaw food in refrigerator the night before or in microwave just before cooking. • Keep work area clean and cook thoroughly. • Wash hands, utensils and cutting boards in hot soapy water before preparing food and after handling raw meat or poultry. • Cook meat to at least 160° F. (Poultry juices run clear; fish flakes with fork). • Cook ground beef to well-done (brown). Do not serve pink ground beef. Use a thermometer to check the temperature of ground beef. • Never leave food at room temperature over 2 hours. • Promptly refrigerate food after meals; don't let it sit out. Divide food into small containers for quick cooling in refrigerator. • Remove stuffing from poultry. Refrigerate separately. • For buffets, keep cold food on ice or use small serving dishes and replenish from the refrigerator. • For hot foods, use a heating dish or reheat small servings from refrigerator and replenish buffet. • Can grow at refrigeration temperatures of 40°F or below. • Use all perishable precooked or ready-to-eat items as soon as possible. • Clean the refrigerator regularly. • Use a refrigerator thermometer to keep temperature 40°F or below. • Do not eat hot dogs, luncheon meats, deli meats unless reheated until steaming hot. Do not eat semi-soft cheeses, patés, meat spreads, raw milk or refrigerated smoked seafood (unless the seafood is cooked). USDA; Food Safety Inspection Service: www.fsis.usda.gov/index.htm Sexual & Reproductive Health 131 HERBS Herbal teas and other herbal remedies have been part of folk medicine for centuries. Some people turn to herbal teas to reduce their caffeine intake. Many herbal teas may be safe but some have been demonstrated to have potentially harmful side effects such as diarrhea, vomiting, depressed breathing and even miscarriage. Potentially dangerous herbs include lobelia, sassafras, coltsfoot, comfrey, and pennyroyal (Tyler, 1993). To be safe, pregnant women should choose only herbal teas containing ingredients ordinarily found in their diets (orange rind and cinnamon would be better choices, for example, than chamomile or hibiscus). Encourage them to buy name brand products that are packaged in filter tea bags; these companies have histories of quality control. To avoid displacing more nutritious beverages, herbal tea consumption should be limited to two 8 oz servings per day (Lesan, 1990). A note of caution about the use of herbal products during pregnancy: Many women feel that herbs are natural products and therefore safe during pregnancy while drugs are not. This is not the case. Herbs affect the physiology of the body and may not be safe for pregnant women. Also, since herbs are regulated as dietary supplements, therefore they are not tested for safety or efficacy. Foote and Rengers (2000) review the safety of herbs during pregnancy and clearly show problems with their use. Pennyroyal is an abortive agent and comfrey contains a hepatotoxic substance. Both of these herbs have been proven unsafe for pregnancy. The American Herbal Products Association (AHPA) has a Botanical Safety Handbook, which offers safety criteria classifications, including "not to be used during pregnancy." Included are herbs such as black cohosh, chasteberry, dong quai, ephedra, feverfew, goldenseal and kava-kava. Appendix #15 lists herbs considered not appropriate for use during pregnancy, and provides other resources for information on herbs. The National Institutes of Health, has a National Center for Complementary and Alternative Medicine and is a great resource on herbs. The url is: nccam.nih.gov. Unless proven safe, herbs should not be used during pregnancy. For a complete discussion of herbs, see the Nutrition Dimension course Herbal Supplements. ADOLESCENT PREGNANCY Pregnant adolescents have had a higher incidence of infant mortality and low birth weight babies than older pregnant women. A combination of increased nutrient needs and lifestyle factors affecting nutrient intake accounts for an increase in poor pregnancy outcome. The mother's age, in itself, is not a determining factor. Adolescents who conceive soon after menarche may still be growing, but they have babies similar in weight to those borne by adults (IOM, 2009). If a pregnant adolescent has a second pregnancy, the baby weighs less (IOM, 2009). It appears that the fat being mobilized in the pregnant teen goes to her growth, not her baby (IOM, 2009). What earlier weight gain guidelines for adolescents failed to take into account was that many pregnant teens gain more weight compared to older pregnant adults (Howie, et al., 2003). The concern is that the increased weight gain, like adults, does lower the Sexual & Reproductive Health 132 incidence of LBW, but can also lead to an increase in macrosomic babies, postpartum weight retention, and obesity later in life. This concern was born out by Nielsen, et al., (2006) who showed that when 815 African American adolescents increased their GWG from below to within the 1990 IOM guidelines, outcomes were improved. Any additional weight gain was not beneficial, especially if the adolescent was overweight or obese prior to pregnancy. The 2009 IOM report does not recommend a modification of gestational weight gain guidelines for females below 20 years of age, but states: Adolescents who follow adult BMI cutoff points will likely be categorized in a lighter group and thus advised to gain more; however, younger adolescents often need to gain more to improve birth outcomes. Weight gain should be monitored closely. The nutrients most often lacking in their diets are calcium, iron, zinc, vitamins A, D, B6, riboflavin, folic acid and total energy. Many of these deficiencies are a result of poor eating habits. The most challenging aspect of managing pregnant teens is lifestyle. Factors that can interfere with adequate nutrient intake include substance abuse, erratic eating habits, fad diets, peer pressure, income, access to food, living situation, etc. The chart below summarizes nutrition-related risk factors for adolescents. Working with pregnant teens often means becoming a combination of psychologist, mother-surrogate and best pal, not an absolute authority. Many teens will change their eating habits when shown the importance to the fetus, but iron and calories may remain inadequate. Dietary changes must be done within the context of their everyday lives and fit with their lifestyles. Pregnant adolescents, like other adolescents, tend to eat what is available and convenient. The nutritious foods they need are not always easily available to them at places and times when they do eat. It is also important to realize that pregnant adolescents often lack a stable and continuous food supply. Nutrition Risk Factors for Adolescents • Low prepregnancy weight for height • Indications of malnutrition • Inadequate pregnancy weight gain • Excessive prepregnancy weight (indication of poor eating habits) • Anemia • Unhealthy lifestyle » substance abuse » eating disorders » poor dietary habits » smoking • Pica, food intolerances, allergies, fad diets, increased snacking • Decreased food preparation skills and limited access to food prep facilities • Unfavorable reproductive history • Chronic diseases • Socioeconomic factors affecting intake; no stable access to food; peer pressure Sexual & Reproductive Health 133 Prenatal Supplements High-risk Women • Adolescent • Heavy cigarette smoking • Alcohol or substance abuse • Inadequate dietary folic acid • Iron deficiency anemia • Vegetarian, especially vegans • Bariatric surgery • Poor quality diet • Under 25 and not consuming adequate calcium • Lactose-intolerant • Multiple fetuses Nutrient Vitamin B6 Vitamin C Vitamin D* Vitamin E Folic acid Amount 2 mg 50 mg 200 IU 15 IU 400 mcg Guidelines for Use • Contain nutrients in amounts shown below • Begin in the second trimester • Free of artificial colorings • Take between meals or at bedtime • Vegans (complete vegetarians) may need 400 IU vitamin D & 2 mcg B12 • Bariatric surgery may increase need for supplements, based on lab tests Nutrient Iron (ferrous) Zinc Copper Calcium Magnesium Amount 30 mg 15 mg 2 mg 250 mg 100-320 mg *Women living above the 35º lattitude — Boston, San Franscisco, Chicago — will need up to 800-1,000 IU additional Vitamin D. SUPPLEMENTATION Most pregnant women are prescribed vitamin supplements by their doctor. Not all prenatal vitamins are alike; levels of nutrients vary. The most important nutrients to be supplemented are iron, folic acid, vitamin B6, vitamin D (cholecalciferol), vitamin E, pantothenic acid, calcium, magnesium, zinc, copper, and possibly selenium. Not all physicians recommend vitamin and mineral supplements. If the diet is adequate, only folic acid, iron and vitamin D are recommended. However, women in a high-risk group, listed in the chart above, may be recommended supplements along with the recommendations for a prenatal supplement. All other nutrients should be included at or near 100 percent of the RDA for pregnant women. The importance of supplementing in low-income women was shown by Scholl et al., (1997). The risk for preterm and very preterm deliveries was reduced two- to fourfold when low-income urban women took a vitamin and mineral supplement in the first and second trimester. The risk for LBW and very LBW births was reduced six- and seven-fold when these women supplemented the first and second trimester. The authors conclude that supplementation in this group has the potential to decrease morbidity and mortality in infants. Sexual & Reproductive Health 134 Hasan, et al., (2009) found that the use of any vitamin supplement early in pregnancy was associated with a decreased risk of miscarriage, but note that this may also be due to healthier behaviors in the women who supplement. Problems can arise from improper supplementation. Minerals interact with one another, decreasing absorption and/or serum levels. Zinc, copper, iron, calcium, and magnesium all are known to interact; there are other possible interactions, not yet proven, such as zinc with folate, and vitamin E with iron. If several nutrients must be supplemented, the safest course is to recommend a multivitamin and mineral, with additional calcium and iron if necessary. (How to supplement has been covered in previous chapters.) Megadoses should be avoided during pregnancy, particularly vitamin A, as it can harm the fetus. Accutane®, a drug used to treat acne, is a vitamin A retinoid analog. Use of this drug during pregnancy can cause severe birth defects. Similarly, megadoses of preformed vitamin A (which is fat-soluble and stored in the body) should be avoided entirely. Supplementing with many nutrients increases the chances of interactions. It is preferable to space supplements out throughout the day. Unfortunately, since many women have trouble remembering to take supplements, the risk of accidental overdosing increases. One multi-vitamin supplement is better than many individual supplements. There is a tip sheet on supplements during pregnancy at <Mypyramid.gov> Other nutritional supplements, such as protein powder, instant breakfasts or other food supplements, may be necessary for an undernourished woman. If biochemical, anthropometric and clinical data indicate poor nutritional status or malnutrition, start some form of nutritional therapy right away. If in doubt, start. Treating with food supplements cannot do much harm; the potential benefit far outweighs any risk. PICA Pica is a pathological craving for foods or non-food substances. Despite research, the etiology of pica remains a mystery. Numerous theories have been proposed that include nutritional, psychological, cultural, pharmacological and disease as the cause. In some cultures it is expected that pregnant women eat various substances. Clay, corn starch, laundry starch, ice, dirt and baking soda are the most common non-food substances eaten by women in the US. In an interesting observational report of 300 postpartum women in a hospital serving low-income women, Cooksey (1995) found that 194 of them (65 percent) ate one or more pica substances during pregnancy. Of those with pica, 152 ate ice or freezer frost by itself or along with other substances. Substances eaten included dirt, clay, cigarette ashes, ice, freezer frost, flour, baking powder, cornstarch and powdered milk. One woman ate three to four 8 lb bags of crushed ice daily; another ate 5 quarts of freezer frost while another ate two cans of baking powder daily. In addition to pica, Cooksey found 40 of 280 women (14 percent) having olfactory cravings — cravings to smell specific substances. Substances women craved included gasoline, bleach, ammonia, aerosol air freshener, aerosol disinfectant, pine oil cleaning Sexual & Reproductive Health 135 solution, rubbing alcohol, nail polish remover, powder cleanser, chalk, body powder, concrete chips and powder detergent. These olfactory cravings occurred separate from or in conjunction with pica. Cooksey speculated that a change in a pregnant woman's sense of smell might account for some of the olfactory cravings. Estimates of the incidence of pica vary from 10 percent to 68 percent; the number practicing pica has apparently been constant since the 1970s, according to Horner, et al., (1991). The women with the highest incidence are African Americans who live in rural areas and have a family history of pica. In a rural, socioeconomically disadvantaged area, Corbett (2003) found that 38 percent of the pregnant women in two rural clinics practiced pica. The incidence was highest in African American women. The material consumed was similar to that found in other studies: dirt, clay and starch. Magnesium carbonate ingestion was reported as well. This practice seems to be either unique to this population or not reported elsewhere. Magnesium carbonate is sold in a block, about the size of a 35-mm film box. It can be bought on either side of the USMexico border, where it is sold in pharmacies to be used for heartburn or as a laxative. Pregnant women consuming a number of “bricks” a day ingest too much magnesium, which potentially could be harmful. No studies have been done to look at this issue. Pica can interfere with nutritional status by decreasing the amount of nutritious foods eaten and by reducing the bioavailability of minerals, especially iron, zinc, magnesium and potassium (Danford, 1982). The most common side effects of pica include anemia and toxemia, with zinc deficiency seen in dirt and clay eaters. It may be that eating specific foods or other substances causes the deficiency or that an iron or other deficiency causes the pica (Danford, 1982). Hemoglobin levels have been found to be lower in women with pica than those without, but birth weight does not seem to be affected (Rainville, 1998). Other complications may be due to the substance eaten, and include hypertension, bezoars, intestinal perforations, maternal bowel obstruction, achlorhydria, dental injury, constipation and hemolytic anemia. Clay, laundry starch or cornstarch bind iron and other minerals, making them unavailable for absorption. If enough non-food substances replace calories, nutrient intake will decrease. Ice and freezer frost, also commonly ingested, can cause a decrease in total food intake, leading to inadequate weight gain in extreme cases. Some substances can be toxic and teratogenic to the fetus. Culture and tradition seem to play a big part in pica. Old wives’ tales extol the benefits to the baby of eating clay daily. I've heard women tell stories of family members insisting that they eat clay, even keeping it in the refrigerator for them, and how women from the rural South who have relocated to another part of the country have clay sent to them from home. When women move away from the culture or society that accepts pica as a normal part of pregnancy, the food behavior usually disappears, indicating that it is, indeed, a social phenomenon rather than a dietary or physiological condition. If a woman had pica, and anemia results, treat the anemia, then counsel her to try to decrease the non-food consumption. It is only necessary to stop the behavior if the item consumed is dangerous, like sink cleaner, or if it interferes with adequate caloric Sexual & Reproductive Health 136 intake and weight gain. Decreasing the behavior is more achievable. For some women it is easier to substitute an acceptable food for the non-food item. For others, chewing gum or another non-food activity works. Screening all pregnant women for pica is important to determine those women who can do potential harm to themselves and the unborn baby. Many women may want to be asked but will not bring it up themselves, thinking it is “crazy.” Ask nonjudgmental questions like, “Many women eat things like clay, starch, or baking soda when they are pregnant. Do you?” If the answer is yes, explore how much they eat and then screen for nutritional deficiencies. VEGETARIAN DIETS Well-planned vegan and lacto-ovo-vegetarian diet can meet nutritional needs during pregnancy (JADA, 2003). Nutritional care of pregnant women who are lacto-ovovegetarian differs little from that of nonvegetarians. A vegan diet requires more careful planning to include a variety of foods. Pregnant vegans who eat a limited variety of foods place themselves at nutritional risk and jeopardize their baby's future health. Lacto-ovo-vegetarians should give special attention to intakes of iron, folic acid, vitamin D and zinc during pregnancy (JADA, 2003). In addition, pregnant vegetarians should include fish for the Ω-3 DHA. If they do not, then they need to include good sources of alpha-linolenic acid, such as flax seed, canola oil, soybean oil or walnuts. Dietary planning for vegans should emphasize consuming adequate calories and foods rich in the problem nutrients — iron, folic acid, vitamin D, calcium, zinc, vitamin B12 and protein. The diet of pregnant vegans should be supplemented with a reliable source of vitamin B12 and also vitamin D if exposure to the sun is limited. Supplements of folic acid are also advised as well as a multi-vitamin and mineral supplement. Although certain vegetarian diets can be healthy, the food choices of some vegetarians may not be so healthy. Vegetarian diets that are haphazard or monotonous will not provide proper nutrition. In a recent companion paper to the ADA position statement on vegetarian diets (2003), Messina and colleagues present a Vegetarian Food Guide Pyramid that can easily be used by vegans and lacto-ovo-vegetarians. The pyramid emphasizes calcium-rich choices in each food group. Food groups used in the guide are grains; legumes, nuts and other protein-rich foods; vegetables; fruits; and fats. Appendix #16 shows the Vegetarian Food Guide Pyramid along with modifications for pregnancy. EXERCISE Exercising alleviates many discomforts of pregnancy: backaches, fatigue, indigestion, swelling, leg cramps and hemorrhoids; may help sleep better, improve posture and help prevent or treat gestational diabetes. Exercising also prepares the muscles used in giving birth. The benefits of regular exercise of moderate to somewhat hard levels of intensity include: reduced fat deposition and retention, shorter and less complicated labors, higher energy levels during and after pregnancy and quicker postpartum recovery. Sexual & Reproductive Health 137 The medical community is moving from a somewhat restrictive attitude concerning exercise during pregnancy to one that is much more liberal. In 2002, the American College of Obstetricians and Gynecologists (ACOG) published exercise guidelines for pregnancy, which state that if not contraindicated, exercise during pregnancy, in a wide range of recreational activities, appears to be safe, such as walking, swimming, bicycling and aerobics (low-impact and water are preferred). Strength training is recommended as it may help prevent some of the aches and pains common in pregnancy and make your muscles stronger. The absolutely contraindicated activities during pregnancy include scuba diving and water-skiing; other activities that should be avoided include downhill skiing, highaltitude sports, hockey, gymnastics and horseback riding (Hyatt, et al., 2003). Information on pregnancy and exercise is available on the ACOG website: <www.acog.org/publications/patient_education/bp119.cfm> There is a synergy between nutrition and exercising. The body seems to utilize nutrients better when a woman exercises. The emotional and psychological sense of well-being is an added benefit. A woman who feels better during her pregnancy is more likely to take better care of herself. The chart below summarizes exercise during pregnancy (Dewey and McCrory, 1994; Hyatt, et al., 2003; USDA 2005). Exercise During Pregnancy • Incorporate 30 minutes or more of moderate-intensity physical activity on most, if not all, days of the week. • Engage in activities that you enjoy, are safe, are not compromised by a change in balance and center of gravity and can be modified as the pregnancy progresses. These can be either weightbearing or non-weightbearing. • Avoid activities with a high risk of falling or abdominal trauma. • The frequency and duration of the exercise should be tailored to your needs and your level of fitness. • Increase frequency and intensity very gradually if inactive prior to pregnancy. • Avoid exercising in the supine position after the first trimester. • Avoid exercising in hot, humid environments. • Maintain maternal core temperature below 38° C. • Drink liquids before , during and after exercise to ensure adequate hydration. • Avoid exercising when fatigued and take frequent rest periods to minimize potential fetal stress. • Warm up for 5 - 10 minutes with light exercise and stretch your muscles. At the end of your exercise, cool down for 5-10 minutes, including stretching. Sexual & Reproductive Health 138 Physical changes to the body during pregnancy need to be taken into consideration when designing an exercise program. The increases in hormones cause a slackening of abdominal muscles and relaxation of joints. Undue stress on these areas of the body should be avoided. The positive aspect of exercising is that common problems can be alleviated. In pregnancy, the increase in the size and weight of the uterus pulls the spine into an exaggerated curve. Muscles in the lower back then tense, causing backache. The neck gets tense from slumped shoulders. Improper weight distribution causes leg and foot exhaustion. Exercising, maintaining correct posture and strengthening selective muscles can decrease pregnancy discomfort. Numerous exercise courses for pregnant women are available. By the end of pregnancy, maternal oxygen consumption is 16 to 32 percent above nonpregnant norms. During exercise, cardiovascular adjustments are made that include a reduction in uterine blood flow, concentration of hemoglobin and hematocrit and increased oxygen extraction from blood. Even though less blood flows to the uterus, it appears that oxygen consumption by the fetus remains constant. Thus, there is an increase in the percentage of oxygen that is transported to the fetus. Measurements of fetal response to exercise have found that it is not in distress — exercising does not seem to harm it. There is one exception, however: an increase in maternal body temperature can harm the fetus. This means that exercise should be moderate, and saunas, hot tubs and steam baths should be avoided. Clothing that “breathes” will help keep body temperature down. Studies show lower birth weights of babies born to women who exercised before pregnancy. The lower birth weight may by an indication that caloric intake is not adequate to meet the demands of both pregnancy and exercise. Therefore, a pregnant woman who exercises regularly and fairly heavily, may need to increase calories above the recommended additional 300 per day. Sexual & Reproductive Health 139 Chapter Nine: Medical Complications Major medical complications of pregnancy include hypertensive disorders of pregnancy and diabetes. Hypertensive disorders are the most common medical complications of pregnancy and include chronic hypertension, gestational hypertension, and preeclampsia. Chronic hypertension is found in 1 to 5 percent of pregnant women. The diagnosis is based a history of hypertension before pregnancy or an elevation in blood pressure to at least 140/90 mm Hg before 20 weeks gestation (Sibai, et al., 1995). These women are at increased risk for preeclampsia, abruptio placentae and morbidity and mortality of the fetus. Treatment includes drugs to control blood pressure. While diuretics and dietary salt restrictions are prescribed, their use is highly controversial as it can further restrict plasma volume expansion. Gestational hypertension (also known as pregnancy-induced hypertension or PIH) is defined as an elevation in blood pressure after 20 weeks gestation in women who did not have elevated blood pressure prior to pregnancy. In these women, the pregnancy outcome is excellent without drugs. The increase in blood pressure may be an early sign of preeclampsia, may indicate chronic hypertension or be a transient increase only during pregnancy. Preeclampsia is by far the most serious hypertensive disorder of pregnancy, with the potential for serious complications and an estimated 7 to 8 percent of all pregnant women suffer from it (JADA, 2002). Preeclampsia is defined as the development of increased peripheral vascular resistance, reduced cardiac output, reduced plasma volume, and decreased glomerular filtration rate with retention of salt and water (Newman and Fullerton, 1990; Roberts, et al., 2003; Hawfield and Freedman, 2009). By the 14th week of gestation there are changes in the vascular system, before the onset of other clinical symptoms — hypertension, edema and proteinuria — which occur after the 20th week gestation. Sexual & Reproductive Health 140 In normal pregnancies, peripheral vascular resistance decreases as plasma volume expands. In preeclampsia, plasma volume does not expand appropriately and peripheral vascular resistance does not decrease. The result is decreased cardiac output and plasma volume, coupled with higher peripheral vascular resistance which reduces perfusion of the placenta, kidneys, liver and brain. The circulation and exchange of nutrients between the mother and fetus is impaired. The fetus can suffer intrauterine growth retardation from a lack of oxygen and nutrients. If placental insufficiency is severe enough, fetal hypoxia is possible. Endothelial dysfunction (vasospasm, altered vascular permeability, altered fatty acid composition) may explain the hyperlipemia, antioxidant deficiency, coagulation defects, ischemia and infarctions of the uterus and placenta seen in preeclampsia (Sibai, et al., 1995, Williams, et al., 1995; Mutter and Karumanchi, 2008). The placenta plays an important role in the development of preeclampsia, especially the endothelial dysfunction. Certain anti-angiogenic soluble proteins produced by the placenta are increased, interfering with the pro-angiogenic proteins responsible for the growth of new or existing blood vessels and the proper functioning of the placenta (Mutter and Karumanchi, 2008; Hawfield and Freedman, 2009). What causes the increased production of these anti-angiogenic proteins is not known. However, the increase in these proteins occurs before the clinical symptoms of preeclampsia and could be used as a tool to identify the disease before the clinical symptoms appear. Risk factors and complications are shown below. Preeclampsia Risks and Complications Risk Factors (General) • Nulliparous under 20 or over 35 • Diabetes/insulin resistance • Chronic hypertension • Hyperhomocysteinemia • Previous pregnancies • Lower socioeconomic class • Lack of education • Poor nutrition • Deficient prenatal care • Emotional stress • BMI (obesity) • Vitamin D deficiency • Darker skin Complications — Maternal • Convulsions • Cerebral hemorrhage • Abruptio placentae • Pulmonary edema • Renal failure • Liver failure • Death Complications — Fetal • Severe growth retardation • Hypoxia • Prematurity • Death Sexual & Reproductive Health 141 The risk of preeclampsia increases with increased BMI (O'Brien, et al., 2003). Specifically, for each 5 to 7 kg/m2 increase in BMI, the risk of preeclampsia doubled. The cause of preeclampsia has been and still is hotly debated. Since the incidence of the disorder is higher in malnourished women and in women with fewer financial and educational resources, nutritional links to the disease have been investigated. Proposed theories as to the cause of preeclampsia include: • changes in the production and/or ratio of various prostaglandins that increase vasoconstriction and decrease vasodilation; • the relationship of dietary calcium and blood pressure; • inadequate amounts of omega-3 fatty acids; • increased oxidative stress with inadequate antioxidants (vitamins C and E, selenium) (Zhang, et al., 2002; Chappell, et al., 2002; Scholl, et al., 2005); • alterations in placental and endothelial growth factors and their receptors (Polliotti, et al., 2003; Hawfield and Freedman, 2009 ); • inflammation; • cytokine production; and • elevated homocysteine (Roberts, et al., 2003) More recently, a maternal deficiency of vitamin D is being investigated as an independent risk factor for preeclampsia (Bodnar, et al., 2007). To date, no certain cause has been determined. However, the last 5 to 10 years has seen the focus of research turn to oxidative stress as a primary factor in preeclampsia and the role of specific nutrients in the prevention of preeclampsia. CALCIUM, MAGNESIUM AND PREECLAMPSIA Hypertension has traditionally been linked to excessive dietary sodium and treatment was a low-sodium diet and diuretics. However, in pregnant women this worsens the condition. Research has shown that in some individuals, low serum calcium contributes to elevated blood pressure, and in pregnant women is linked to preeclampsia. Guatemala, with rampant malnutrition, has low levels of preeclampsia. In theory, this should not be the case, since malnutrition seems to increase the rate of preeclampsia. Upon further investigation, we find that Guatemalan women are malnourished, with calorie, protein and nutrient deprivation, but they have adequate levels of calcium. Tortillas, a staple in their diet, are soaked in calcium-rich lime. Therefore, calcium is one of the few nutrients in adequate supply in the diet of Guatemalans. The same is true in Ethiopia, where a grossly inadequate diet nevertheless contains adequate calcium, and preeclampsia is low. Belizian and Villar (1980) believe that dietary calcium prevents preeclampsia by maintaining serum calcium levels, which stabilizes blood pressure. Remember, 80 percent of all calcium is required in the third trimester, when there tends to be an elevation in blood pressure. It’s possible that sufficient calcium in the diet can prevent the rise in blood pressure. Bucher, et al., (1996) looked at 14 published studies on the relationship of calcium supplementation during pregnancy on blood pressure, preeclampsia and pregnancy out- Sexual & Reproductive Health 142 come. He found that the data supported the conclusion that calcium supplementation during pregnancy reduces systolic and diastolic blood pressure and preeclampsia. Carroli and colleagues (1994) reviewed six clinical trials and found that calcium supplementation reduced the risk of all types of hypertension in pregnancy by 50 percent and reduced the incidence of preeclampsia between 45 and 74 percent. Other studies have looked at the relationship of calcium intake to preeclampsia and suggest that increased calcium intake reduces the incidence of preeclampsia. Ito, et al., (1994) found that 10.9 percent of women supplemented with calcium developed preeclampsia versus 16.9 percent of those not given calcium. Purwar, et al., (1996) found a decrease in the incidence of preeclampsia in women supplemented with 2 gm of elemental calcium a day. In the placebo group 29.03 percent of the women developed preeclampsia versus 8.24 percent in the calcium-supplemented group. On the other hand, Sanchez-Ramos, et al., (1995) found no change in the incidence of preeclampsia in women supplemented with 2 gm of calcium per day. A total of 13 clinical trials and four meta-analyses have investigated the relationship of calcium, blood pressure and preeclampsia and suggest that calcium supplementation reduces the incidence of preeclampsia. Many of these studies were conducted in other countries on women with a much lower calcium intake than women in the US. The designs of these studies varied, making it difficult to compare their results. To clarify the relationship, a clinical intervention trial by the National Institute of Health, Calcium for Preeclampsia Prevention (CPEP) was conducted at five university US medical centers (Levine, et al., 1997) to determine if supplementing women with 2 gm of calcium a day reduced the incidence of preeclampsia. A total of 4,589 women between 13 and 21 weeks gestation were randomly assigned to the control group or the experimental group. The study concluded that calcium supplementation did not reduce the incidence or severity of preeclampsia, nor did it reduce the incidence of gestational hypertension. These results were true for women with the lowest mean daily calcium intake of 422 mg/day, similar to women in developing countries. It is important to put the results of this study in perspective. While calcium supplementation itself does not prevent preeclampsia, adequate calcium during pregnancy is still essential for the developing fetus. In some pregnant women, increasing dietary calcium or supplementing the diet may in fact reduce blood pressure during pregnancy (Roberts, 1997). In a review of studies, Ritchie and King (2000) also concluded that at present there is not enough evidence to recommend routine calcium supplements to reduce blood pressure, but that certain populations may benefit, such as pregnant teens, women at risk for PIH and women with inadequate calcium intake. Hofmeyr, et al., (2006) reviewed 12 studies of calcium supplementation and hypertensive disorders of pregnancy, finding that calcium supplementation reduced the risk of preeclampsia by almost one-half. The reduced risk was greatest for women at highest risk of preeclampsia and with the lowest intake of calcium. These results contradict earlier studies showing no effect of calcium supplementation, and opens the question of whether supplementation replaces a deficient nutrient, or is a therapeutic treatment. Sexual & Reproductive Health 143 Altered serum magnesium levels have also been implicated in the development of preeclampsia, as many preeclamptic women have hypomagnesemia. Magnesium activates numerous enzymes, including those involved in membrane transport and integrity, muscle contraction, vasodilation and vasoconstriction, and blood coagulation. Generally, magnesium inhibits smooth muscle contraction (heart, arteries and uterus), promoting vasodilation. Hypomagnesemia is associated with increased blood pressure and increased peripheral vascular resistance. The ratio of prostacyclins (vasodilators) to thromboxanes (vasoconstrictors) is profoundly altered in women with low serum magnesium. (See below for a more complete discussion of prostaglandins and preeclampsia). In the US, the average intake of magnesium is 250 mg/day. The DRI for pregnant women is 350 to 400 mg/day (based on age). Too much dietary protein, calcium, phosphorus or vitamin D can increase the need for magnesium, as more magnesium is lost in the urine. To prevent the possibility of hypomagnesemia contributing to preeclampsia, make sure the diet contains a minimum of 320 mg of magnesium per day by including whole grains, peanut butter, dark green vegetables and soy products. PROSTAGLANDINS AND PREECLAMPSIA Fatty acids are the precursors of prostaglandins, substances that regulate many functions of the body, such as platelet production, stickiness of platelets and their ability to clot, constriction and dilation of arteries and immune functions. The fatty acids we eat become part of the membrane of each and every cell. The development of preeclampsia may be a problem in the ratio of two prostaglandins — prostacyclin and thromboxane, as shown below. Prostacyclin I2 (PGI2) is a potent vasodilator produced by the endothelial cells of the vascular bed (arteries, veins). Beginning early in pregnancy, there is an increase in prostacyclin synthesis. Thromboxane A2 (TXA2), a potent vasoconstrictor produced by platelets from Ω-6 fatty acids, also increases during pregnancy. There is a balance between these two prostaglandins that prevents too much or too little vasoconstriction or vasodilation. Prostaglandins & Preeclampsia Prostacyclin I2 • Vasodilator • Synthesis increases in normal pregnancies • Synthesis does not increase normally in preeclamptic women Thromboxane A2 • Vasoconstrictor • Increases platelet production • Increases blood clotting • Synthesis increases in normal pregnancies Sexual & Reproductive Health 144 Pregnant women who develop preeclampsia have a much smaller increase in prostacyclin production than other pregnant women, while the TXA2 production continues to increase (Fitzgerald, et al., 1987a, 1987b; Baker, et al., 1996; Walsh, 2004). The decreased prostacyclin production can be measured as early as 11 weeks gestation, preceding the clinical signs of preeclampsia. The decreased PGI2 may indirectly cause the symptoms of preeclampsia, either by altering the sensitivity of tissues to other vasoactive compounds or by altering the ratio of PGI2 to TXA2 in favor of vasoconstriction. Increased vasoconstriction makes the heart work harder pumping blood, thus increasing blood pressure. Platelets from preeclamptic women have more unsaturated fatty acids incorporated into the cell membrane than normal pregnant women (Garzetti, et al., 1993). This is significant since TXA2 is produced from unsaturated Ω-6 fatty acids. An abundance of these fatty acids will cause an increased production of the vasoconstricting TXA2, which may cause or exacerbate rises in blood pressure seen in preeclampsia. In an attempt to find ways to alter the ratio of PGI2 to TXA2 that would increase vasodilation, the use of low-dose aspirin was investigated. Wallenburg et al. (1986) and Beaufils et al. (1985) were able to block the chronic formation of TXA2, preventing preeclampsia, with relatively low doses of aspirin, which blocks the cyclooxygenase enzyme necessary to convert fatty acids to TXA2. Later studies have had mixed results. Hauth et al. (1993) and Sibai et al. (1993) found a reduced occurrence of preeclampsia in women taking 60 mg of aspirin. A larger, multi-center trial Collaborative Low-dose Aspirin Study in Pregnancy (CLASP), found an insignificant reduction in the incidence of preeclampsia. Aspirin did, however, significantly reduce the likelihood of a preterm delivery. It should also be noted that in these studies the compliance rate for aspirin was low, and could have altered the study results (Walsh, 2004). In a newer study, Vainio and colleagues (2004) showed that pregnant women with pregnancy-induced hypertension had an abnormal ratio of prostacyclin to thromboxane, which was normalized on low dose aspirin. The Ω-3 fatty acid content of cells may influence the risk for preeclampsia. Williams and coworkers (1995) measured the polyunsaturated fatty acids in the erythrocytes (red blood cells) of 22 preeclamptic women and 40 pregnant women with a normal pregnancy. They found that women with the lowest levels of Ω-3 fatty acids were 7.6 times more likely to have preeclampsia compared to those women with the highest levels of Ω-3 fatty acids. A 15 percent increase in the ratio of Ω-3 to Ω-6 fatty acids decreased the risk of preeclampsia by 46 percent. Velzing-Aarts and colleagues (1999) found a significant decrease in the long chain Ω-3 content of the umbilical veins and arteries of preeclamptic women, 21 and 23 percent lower than the control women. Platelet long chain Ω-3 fatty acids were marginally lower in the preeclamptic women. A very interesting finding from the Velzing-Aarts study was that other fatty acids were also out of balance. Women consuming adequate amounts of Ω-6 fatty acids had lower amounts of the long chain Ω-6 fatty acids and higher amounts of long chain Ω-9 Sexual & Reproductive Health 145 fatty acids (monounsaturated) than control women. This points to the possibility that preeclamptic women have abnormal transplacental transfer of long chain PUFA, leading to the abnormal ratios that favor production of the vasoconstrictive TXA2, and/or inadequate intake of Ω-3 fatty acids. The only way to increase cellular levels of Ω-3 fatty acids is to consume more in your diet. Chapter Three and Appendix #14 list dietary sources. The chart below summarizes the benefits of Ω-3 fatty acids. Ω-3 Fatty Acids & Preeclampsia Effect of Ω-3s: • Improves PGI2 to TXA2 ratio • Decreases TXA2 production • Increases TXA3 production • Increases dilation of vessels • Appears to be beneficial in preeclampsia How to increase cellular Ω-3s • Average 300 to 400 mg of fish oils daily (fish 3 times a week) or • Average 500 to 1500 mg of vegetable sources daily by using canola oil, green vegetables OXIDATIVE STRESS AND PREECLAMPSIA Oxidative stress is an imbalance between prooxidants and antioxidants, with either an increase in production of prooxidants — free radicals or reactive oxygen species — or a decrease in antioxidants, leading to cellular damage. In pregnancy, the placenta is the main source of free radical production and antioxidant synthesis. In preeclampsia, the balance is upset, with more free radicals than antioxidants, leading to systemic oxidative stress (Perkins, 2006). Prooxidants are biologically active molecules that function as vasoconstrictors, as well as triggering platelet production which leads to formation of microthrombi (mini blood clots). The end result is a decreased perfusion of the placenta and other organs, and decreased circulating plasma volume (Roberts, et al, 2003). To investigate the impact of oxidative stress on preeclampsia, Scholl and colleagues (2005) measured urinary levels of isoprostane 8-iso-prostaglandin F2α — a metabolite that indicates oxidative damage to lipids and measured the overall antioxidant power of the pregnant women. The study found a five-fold increase in preeclampsia with increased isoprostane excretion and a three-fold decrease in preeclampsia with increased antioxidant power. These changes were found before clinical symptoms of preeclampsia were present. Increased isoprostane excretion was related to diet, specifically fat intake and included energy-adjusted fat, polyunsaturated fat and PUFA — Ω-3 and Ω-6. No dietary link to antioxidant power was found, which may be a function of the small study size. Lipids, especially PUFA, are easily oxidized. As the amount increases in the diet, so does the need for antioxidants, which may explain the finding of the link between dietary fats and increased oxidative stress. Sexual & Reproductive Health 146 Nutrients that are under clinical investigation for their role in preventing or promoting preeclampsia include: vitamins C, E, D, selenium, zinc, copper, glutathione, fats and Ω-3 fatty acids. Presently, the results of studies investigating vitamin C and vitamin E have been equivocal. In a Cochrane Database Review, the authors found that antioxidant supplementation reduced the risk of preeclampsia (Rumbold, et al., 2005). Other studies have found that supplementation with vitamins C and E does not prevent preeclampsia (Rumbold, 2006) and increased the number of low birthweight babies (Poston, et al., 2006). • Vitamin D. Low vitamin D levels may be involved in preeclampsia, since the physiological alterations in preeclampsia by be directly or indirectly affected by vitamin D and include: placental implantation, abnormal angiogenesis, excessive inflammation, immune dysfunction and hypertension (Bodnar, et al., 2007; Vills, et al., 2009). Pregnant women with lower serum vitamin D concentrations early in their pregnancies were found more likely to develop preeclampsia with a serum vitamin D level 15 percent lower than controls. In the US there is a high frequency of women who are overtly vitamin D deficient or vitamin D insufficient (Bodnar, et al., 2007). In Norway, Haugen et al., (2009) found that pregnant women who supplemented 400 to 600 IU/day (10 to 15 mcg) had a 27 percent lower incidence of preeclampsia than pregnant women who did not supplement vitamin D. A multivitamin and mineral supplement may also decrease the incidence of preeclampsia (Bodnar, et al, 2006; Catov, et al., 2008) At the present time there is no definitive cause of preeclampsia. Until there is, the best advice is to eat a varied diet, including foods that are rich in vitamins, minerals and phytochemicals (plant foods) to ensure adequate antioxidant intake and supplement with a multi-vitamin and mineral and vitamin D. • Treatment. As mentioned, treating preeclampsia with sodium restriction and diuretics can do more harm than good. Even with edema present, the plasma volume of a preeclamptic is less than that of a pregnant woman without the disease. Life-threatening complications for both the mother and fetus can result from the use of diuretics. They are not indicated for preeclampsia. In fact, strict salt restriction can reduce the intake of fat, protein, and calcium: it also tends to reduce the energy intake, limits maternal weight gain and reduces maternal fat stores (vanBuul, et al., 1995). The best treatment is simple enough: a balanced diet, prenatal vitamin supplement, decreased activity, frequent monitoring of blood pressure and urine, and bed rest with the patient positioned on her left side, which decreases the pressure of the baby on vital organs and promotes diuresis. This positioning can lower blood pressure without any other intervention. In addition, adequate amounts of Ω-3 fatty acids, calcium, vitamins C, E and D, and plant foods rich in antioxidants are recommended. DIABETES Insulin was discovered in 1921 and made available for treatment of diabetics shortly thereafter. Before that, few diabetics could conceive. If they did, the perinatal mortality rate was high: it has been estimated at 42 percent. Sexual & Reproductive Health 147 If diabetes is diagnosed and treated, the rate of maternal complications approaches that of the normal population. Perinatal mortality has decreased as well. New research shows that the better the glucose control during pregnancy, the better the outcome. Untreated diabetes can have devastating consequences, shown in the chart below. Risk factors that require further testing are: family history of diabetes; previous poor outcome of pregnancy — stillbirth, prematurity, malformed infant, macrosomia (over 9 to 10 lb at birth) perinatal death; hypertension; hydramnios in present pregnancy; obesity; over age 35; and glycosuria. Tolstoi and Josimovich (1999) have an excellent review of the etiology and management of gestational diabetes. Complications of Diabetes Maternal Fetal • Changing insulin requirements • Preeclampsia • Polyhydramnios (more than 2000 mL amniotic fluid at birth) • Postpartum hemorrhage • Progression of retinopathy • Progression of nephropathy • Stillbirths and neonatal deaths • Macrosomia • Prematurity • Traumatic deliveries • Hypoglycemia • Polycythemia • Jaundice • Respiratory distress syndrome • Congenital anomalies • Hypocalcemia • Pathophysiology. Pregnancy, by itself, alters metabolism. The main energy source that is utilized by the fetus is glucose. (Amino acids are supplied to the fetus for some energy, but mostly for protein needs.) The mother’s metabolism makes adjustments to provide for the needs of the fetus as well as supplying her own needs. To do that, the mother begins to burn fat as her source of energy. The changes in metabolism, discussed in detail in Chapter Four, are: lower fasting blood glucose (10 to 20 mg/dL less than nonpregnant women); increased free fatty acids (which are higher during normal pregnancy); elevated plasma ketones; lower plasma insulin; increased insulin resistance; and increased plasma cholesterol and triglycerides. Two to three times as much insulin is needed during pregnancy. This insulin resistance is a result of the hormones produced for pregnancy (estrogen and progesterone). Another hormone, human placental lactogen (HPL), is a potent insulin antagonist. HPL enhances fat mobilization and reduces maternal glucose utilization and protein degradation so the fetus has a plentiful supply of glucose and amino acids. Insulinase, produced by the placenta, degrades insulin, reducing its supply even further. Diabetes causes additional metabolic abnormalities in pregnancy. In the mother, there is a relative insulin deficiency, due to resistance of the tissues, decreased production and degradation of insulin. Elevations in plasma glucose, free fatty acids, triglycerides and branched-chain amino acids result from the insulin deficiency. Sexual & Reproductive Health 148 If the diabetes is uncontrolled during pregnancy, the metabolic abnormalities can potentially cause serious harm to the mother and the fetus. Alterations in fetal metabolism as a result of maternal diabetes include an increase in the amount of energy fuels available, and hyperinsulinemia, the cause of macrosomia. Screening for diabetes is extremely important to prevent complications. ONSET PRIOR TO PREGNANCY Women with carbohydrate intolerance during pregnancy are divided into two classifications: those previously diagnosed with diabetes mellitus (pregestational diabetics) and those with no prior knowledge of carbohydrate intolerance (gestational diabetics). Approximately 0.2 to 0.3 percent of all pregnancies include pregestational diabetes requiring insulin; 2 to 3 percent are women with gestational diabetes. In the nonpregnant adult, distinguishing between Type 1 (insulin-dependent) diabetes mellitus or Type 2 (non-insulin-dependent) diabetes mellitus is important because it affects treatment. This is not necessarily true for pregnant women, as treatment for Type 1 and 2 pregestational diabetics who become pregnant is similar. Most Type 2 women require insulin when pregnant. The distinction for pregnant diabetics is whether or not they are using insulin, which dramatically alters nutritional treatment. GESTATIONAL DIABETES Gestational diabetes (GDM), also called gestational carbohydrate intolerance (GCI), is a carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy. This definition applies whether or not insulin is used and whether or not the carbohydrate intolerance persists after the pregnancy is over. Ninety percent of pregnant diabetics have gestational diabetes. Research indicates that 35 percent of all women who develop gestational diabetes had no previously identifiable risk factors, so it was recommended that all pregnant women be screened. Now, women who meet all the following criteria do not need to be screened: under age 25; normal pre-pregnancy body weight; no first-degree relative with diabetes; are not Hispanic, Native American, Asian American or African American; no history of abnormal glucose tolerance and no history of poor obstetrical outcome. A woman with risk factors should be tested during her initial prenatal visit. Others should be screened for gestational diabetes between weeks 24 and 28, when it usually appears. There are two approaches to screening for GDM (Diabetes Care, 2009). Initial screening is the oral administration of 50 gm of glucose. The test is considered positive if the blood sugar is either above 140 mg/dL after 1 hour and catches about 80 percent of women with GDM. Or the test can be considered positive if the blood sugar is above 130 mg/dL after 1 hour and catches about 90 percent of women with GDM. If the first screening is abnormal, a three-hour oral glucose tolerance test (OGTT) with 100 gm of glucose should be done. Diabetes is diagnosed if two or more values in the chart on the following page are elevated, even if the fasting level is normal (Am. Diabetes Assoc., 2009). 149 Sexual & Reproductive Health Once diagnosed, the treatment goal is to prevent hyperglycemia, defined as fasting plasma glucose equal to or above 95 mg/dL, and either one-hour postprandial plasma glucose equal to or below 140 mg/dL, or two-hour postprandial plasma glucose equal to or below 120 mg/dL (Am. Diabetes Assoc, 2009). Diet manipulation has been the treatment for most gestational diabetics. Practitioners have been treating gestational diabetics with insulin if hyperglycemia persists. Gestational Diabetes Diagnosis Plasma Glucose Fasting 1 Hour 2 Hour 3 Hour 100 gm test 95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl 5.3 mmol/L 10.0 mmol/L 8.6 mmol/L 7.8 mmol/L Diabetes Care 32 (supp ): S13, 2009 NUTRITIONAL MANAGEMENT DIABETIC PREGNANCIES The American Diabetes Assn. publishes guidelines for the management of diabetes in Diabetes Care (online at: <http://care.diabetesjournals.org/>). The latest recommendations were published in 2006, with an update in 2009. The overall recommendations that are related to pregnancy are to base your treatments on nutritional assessment of the individual and set up a nutrition plan that will meet the following goals: • Individualize medical nutrition therapy (MNT) based on pre-pregnancy weight and height to provide adequate energy and nutrients to meet the needs of pregnancy and to be consistent with established blood glucose goals. • Avoid ketonemia from ketoacidosis or starvation. • Focus your MNT for gestational diabetes on food choices for appropriate weight gain, normoglycemia, and absence of ketosis. • Restrict calories for obese women (BMI above 30). A 30 to 33 percent calorie restriction to 25 kcal/kg actual weight per day and restriction of carbohydrate to 35 to 40 percent of calories is recommended. • Maintain as near normal blood glucose levels as possible, adding insulin if diet alone does not control hyperglycemia. As you can see, these guidelines do not prescribe how to divide calories among carbohydrate, protein and fat. That is left to the skill of the practitioner. In addition, gestational diabetics need to test their blood sugars, even if they are not taking insulin. That is the only way to individualize the diet and determine if they need further intervention. Sexual & Reproductive Health 150 As a place to start, I will present a management strategy that has worked for many pregnant diabetics. The goals and guidelines for nutritional treatment of diabetic pregnancies used here were developed by either “Sweet Success"™ a program developed by the Calif. Diabetes and Pregnancy Program of the Calif. Dept. of Health Services, or the Joslin (Mass.) Diabetes Center (2005). The goals are: • Normal weight gain, based on prepregnant weight and IBW; • Caloric intake of 25 to 30 kcal/kg of pre-pregnancy IBW during the first and early second trimester; • Caloric intake of 25 to 35 kcal/kg of pre-pregnancy IBW during the late second and third trimester; Diet for Gestational Diabetes • First and early second trimester: 25-30 kcal/kg ideal body weight • Late second and third trimester: 25-35 kcal/kg ideal body weight • Blood sugar control: ≤95 mg/dLfasting ≤140 mg/dL 1 hour postprandial ≤120 mg/dL 2 hours postprandial • Limit simple sugars, sweets, refined, highly processed carbohydrates. • Emphasize complex carbohydrates, high fiber foods. • Eat 3 meals and 2 to 4 snacks. Space snacks and meals >2 hours apart. • Common carbohydrate guidelines: 2 carbohydrate choices (30 gm) at breakfast, 3-4 choices (45 to 60 gm) at lunch and evening meal, and 1-2 choices (15 to 30 gm) for snacks. • Limit snacks if they consistently elevate blood sugar levels. • Add protein to meals,snacks to provide calories and satisfy appetite Recommendations include: avoid all simple sugars, sweets and refined carbohydrates; limit carbohydrate at each meal; and emphasize complex carbohydrates and fiber. Notice that fat and protein intake is higher than usually recommended. Since carbohydrate intake is lower due to carbohydrate intolerance and insulin resistance, the percentage of fat and protein increases. To prevent excess weight gain, recommend lean meats and non-fat or low-fat dairy products. The calories and carbohydrates should be distributed over three meals and snacks. Some protein should be included at meals and snacks to prevent postprandial excessive glucose. When designing a diet for gestational diabetics keep in mind that insulin resistance is greater early in the morning. Breakfast should contain no more than 15 to 30 gm of carbohydrate. Carbohydrates that are quickly absorbed, such as fruit, fruit juices, bagels, potatoes and highly refined and processed cereals, are not desirable. Use slowerabsorbable complex carbohydrates: high-fiber foods, whole grain breads, cereal, crackers, brown rice, pasta, legumes and vegetables. Sexual & Reproductive Health 151 If hyperglycemia persists in the morning, consider eliminating all fruit, juices and milk at breakfast. As the pregnancy progresses, hormonal influences increase glucose intolerance. The amount and types of carbohydrate tolerated at 28 weeks may not be tolerated at 35 weeks, and the diet should be adjusted accordingly. Also, exercise should be encouraged to help with the insulin resistance and blood sugar control (Tolstoi and Josimovich, 1999; Franz, et al., 2002.). Don’t be held back by culturally and socially acceptable foods for breakfast. If it works, use it. The chart on the previous page summarizes dietary recommendations for gestational diabetics. Dietary intervention for gestational diabetics decreases maternal and fetal complications and perinatal mortality. Patients must be educated and followed to maximize compliance and minimize complications, but the effort is worthwhile. If insulin is required to treat gestational diabetes, nutritional management will be different than described above, based on the insulin regime. Snacks must be added to prevent hypoglycemia and liberalization of carbohydrate intake is possible. NUTRITIONAL MANAGEMENT PREGESTATIONAL DIABETES Women with pregestational diabetes are harder to manage during pregnancy. As the pregnancy progresses, insulin resistance and carbohydrate intolerance increase, changing insulin requirements and dietary needs. These diabetics need constant monitoring and support as insulin needs change frequently and nausea and vomiting may complicate management. Oral hypoglycemic agents are small molecules that readily cross the placenta and are not recommended for use by pregnant women. Insulin, a large molecule that will not cross the placenta, is the treatment of choice for pregnant diabetic women. The goal for treatment is maintaining the hemoglobin A1c one percent above normal (Am Diabetes Assoc, 2003a). The recommended weight gain, rate of gain and caloric needs for a pregestational diabetic are the same as the non-diabetic pregnant woman. Nutritional recommendations are summarized in the chart on the next page. Remember, these guidelines are a place to start, but each diet needs to be individualized. The recommended percentage of calories from carbohydrate is: breakfast, 10 to 15 percent; morning snack, 10 percent; lunch, 20 to 25 percent; afternoon snack, 15 percent; dinner, 25 percent; bedtime snack, 15 percent. Carbohydrates must be adequate to prevent ketosis — approximately 175 gm/day. Because these women are taking insulin to control blood glucose, dietary carbohydrate can be as high as 50 to 55 percent of total calories. Emphasis should be placed on complex carbohydrates and soluble fiber. Simple sugars should be restricted and the use of highly processed breakfast cereals discouraged. Fresh fruit should be encouraged instead of fruit juices. Sexual & Reproductive Health 152 Diet for Pregestational Diabetes Nutritional Recommendations • First and early second trimester: 25-30 kcal/kg ideal body weight • Late second and third trimester: 25-35 kcal/kg ideal body weight • Distribution of total calories: 45-50% carbohydrate 20-25% protein 30-35% fat • Distribute calories between 3 meals and 3 snacks to cover insulin. • All food must be eaten to cover insulin. • Avoid simple sugars. • Achieve normoglycemia. Maintain blood sugars: ≤105 mg/dl fasting; ≤155 mg/dl one hour postprandial and ≤130 mg/dl two hours postprandial. • Avoid ketosis. May need to check for ketones. • Avoid excessive weight gain. Choose low-fat, high fiber foods. Protein requirements are calculated at 0.8 gm/kg with an additional 25 gm/day, approximately 20 to 25 percent of total calories. The fat content of the diet is 30 to 35 percent of total calories, less than 10 percent saturated fat, with an emphasis on the use of monounsaturated and polyunsaturated fats. Calories, carbohydrates, fat and protein are evenly distributed throughout the day to cover insulin needs, divided into three meals and two to three snacks. Any pregnant woman with pregestational diabetes should have a Registered Dietitian or Certified Diabetes Educator design a diet specifically for her. Each diet prescription is individualized according to the specific needs of the pregnant woman, including pre-pregnancy weight, insulin regime, exercise plan and dietary likes and dislikes. Follow-up must be provided, especially late in pregnancy when insulin resistance is greatest. Home monitoring of blood glucose is a necessary part of treatment. Insulin needs can change constantly, due to the pregnancy hormones. In late pregnancy, glucose levels rise dramatically after a meal. This may necessitate increasing the number of doses of regular insulin, rather than increasing the total amount of insulin in one or two doses a day. Home monitoring assists the health professionals in determining the proper amount and type of insulin required. It is important to check blood sugars a minimum of four times a day: fasting, before a meal, after a meal and at bedtime. Some clinics test women as many as seven times a day. Don't forget to recommend exercise, as it will help control blood sugar levels. PREGNANCY, HIV AND AIDS When the AIDS epidemic began over 25 years ago, women had a one in four chance of passing the virus to their child. Now, in developed countries, that rate has dropped from 25 percent to 1.5 percent, a stunning achievement (Nielsen, 2006). Even with the best treatment, transmission does occur, but not very often. Two major concerns about HIV-infected women becoming pregnant are the effect Sexual & Reproductive Health 153 of pregnancy on the disease, and transmission of the virus to the fetus. Hocke, et al., (1995) showed that pregnancy did not cause a progression of HIV. In the US, pregnancy does not appear to affect viral load or progression of HIV (ADA, 2002). Transmission (referred to as vertical transmission) of the HIV virus from mother to child can occur by two routes during pregnancy: intrauterine (in utero); or intrapartum (at delivery). Women who have not had any drug treatment during pregnancy can still receive treatment during delivery, which was found to decrease the transmission to the child (Nielsen, 2006; Public Health Service Task Force, 2006). A landmark study, the AIDS Clinical Trial Group (ACTG), showed that transmission from mother to fetus could be reduced by two-thirds by treating HIV-infected pregnant women with 100 mg zidovudine (INN) (also called azidothymidine (AZT) and (ZDV), tradenamed Retrovir® ), five times a day during the pregnancy initiated at 14 to 34 weeks, with IV zidovudine during labor, and oral zidovudine given to the child for six weeks after birth (Connor, et al., 1994). Without drug treatment the transmission rate is between 15 and 40 percent; with treatment the transmission rate can go as low as 1.5 percent (ADA, 2002; Public Health Service Task Force, 2006; Nielsen, 2006 ). Adding protease inhibitors to the drug treatment may be able to reduce the transmission rate even lower to 0.9 percent (Morris, et al., 2005). A number of studies now suggest that the viral load may be a predictor of which women are more likely to transmit the HIV. Dickover, et al., (1996) showed that at delivery the number of HIV RNA copies was strikingly different between women who transmitted the virus to their fetus and those who did not. No woman who had fewer than 20,000 copies of HIV RNA transmitted the virus. All women with more than 80,000 copies of HIV RNA did transmit the virus to their fetuses. Of 22 women who took zidovudine and reduced viral load from an average of 43,043 RNA copies/mL to 4,238 copies/mL at delivery, none transmitted the virus. Landesman and colleagues (1996) showed that, at delivery, women with membranes ruptured for more than four hours had increased maternal-fetal HIV transmission. C-sections reduce the rate of HIV transmission from mother to fetus and are now offered to HIV-positive women. While C-sections do significantly decrease transmission of HIV to the child, they do not eliminate the risk entirely. Now researchers are trying to determine if there is a link between certain antiretroviral drugs and LBW and preterm deliveries. At the present time, there is no definitive answer (Public Health Service Task Force, 2006). According to Peckham and Newell (2000), nutrition intervention does not reduce transmission of HIV, but there does seem to be benefit from nutrition intervention on increasing maternal well-being, pregnancy outcome and infant health. Breast milk can serve as a means of transmitting HIV virus from mother to baby (ADA, 2002). After reports that 22 infants were infected from breast milk, Ruff, et al., (1994) found HIV-1 DNA in 70 percent of breast milk specimens from HIV-positive women up to four days after delivery, declining to approximately 50 percent at six to 12 months postpartum. Some HIV-positive women had no detectable levels in breast milk. Sexual & Reproductive Health 154 Studies are now looking at ways to decrease transmission of HIV in breast milk, especially in developing countries. The use of antiretrovirals may help decrease transmission via breast milk (Nielsen, 2006). The Public Health Service Task Force (PHSTF) has published recommendations for use of antiretroviral drugs in pregnancy to reduce perinatal HIV transmission: these are available on the Internet (PHSTF, 2006). The gold standard of antiretroviral drug therapy in HIV/AIDS is a combination of drugs that includes protease inhibitors. The PHSTF states: “Pregnancy should not preclude the use of optimal therapeutic regimes. However, recommendations regarding the choice of antiretroviral drugs for treatment of infected pregnant women are subject to unique considerations.” The considerations include changes in dosing, the effect of the drug on the pregnant woman and the short- and long-term effects on the fetus and the newborn. The most commonly used antiretroviral in pregnancy is zidovudine, and many physicians and researchers believe it should be included in the drug regime. Some women may already be on antiretrovirals when they discover they are pregnant, which may require that they stop for a while. Other women may not be on them and present for treatment early or late in their pregnancy. So treatment options for antiretrovirals will depend on each woman's situation and her reaction to the drugs used. A list of antiretrovirals and pregnancy-related information can be found in the PHSTF document (2006) and the Canadian Consensus guidelines for the care of HIV-positive pregnant women: putting recommendations into practice (Burdge et al., 2003). Currently, there are no special nutritional recommendations for pregnant women with HIV. It is important that they be well fed to prevent any nutritional deterioration of their immune system and to provide adequate nutrients to the fetus. Use of higher levels of supplementation may also be warranted, as we know that HIV-infected nonpregnant individuals have higher nutrient needs and incidence of vitamin deficiencies. In addition, pregnancy itself causes changes in cell-mediated immunity, characterized by a decrease in CD4 T cells and decreasing the ratio of CD4 : CD8 T cells, which is also a characteristic of AIDS. Inadequate diet can further depress immunity. Nutrients of concern are protein, calories, zinc, vitamin B6, folic acid, vitamin C and iron. The drugs women are taking during pregnancy have may side effects, including anemia, nausea and vomiting, aminotransferase elevations (increased liver enzymes) and hyperglycemia. Many of these side effects need nutrition intervention. Also, remember to talk with these women about GI upsets that may limit food intake; proper food handling, as they are immunocompromised; any problems with chewing due to dental problems; sores in their mouth from candidiasis, or other swallowing problems Solutions to these problems can dramatically increase intake and lead to a healthier pregnancy. Sexual & Reproductive Health 155 Chapter Ten: Alcohol, Tobacco & Other Drugs Consumption of alcohol during pregnancy can affect the outcome of pregnancy. Both the amount of alcohol consumed and the timing of consumption affect the fetus, resulting in congenital anomalies and/or growth retardation. The exact mechanism causing the adverse outcome is unknown. Approximately 13 percent of pregnant women consume alcohol, with three percent drinking heavily or binge drinking (Bertrand, et al, 2004). Alcohol is detoxified by the liver. Ethanol is broken down to acetaldehyde, then to acetic acid, and eventually to carbon dioxide and water, as shown below. The liver can only detoxify so much alcohol at a time; it takes five to six hours to detoxify the alcohol in 4 oz of whiskey or 2.5 pints of beer. If more alcohol is present than the liver can detoxify, it will continually circulate until the liver is able to detoxify it. Alcohol Detoxification Mother ingests alcohol Alcohol Fetus Fetus Fetus Liver Acetaldehyde Acetic Acid CO2 + H2O Sexual & Reproductive Health 156 Food slows down the absorption of alcohol into the blood. Anyone who has had a drink on an empty stomach knows the effects of alcohol are felt more quickly than with food. Slowing down alcohol absorption into the blood gives the liver more time to detoxify it, so that there is less circulating in the blood. The alcohol concentration of the blood is determined by how much alcohol is consumed, the period of time in which it is consumed and whether emptying time is slowed by food. Alcohol crosses the placenta and concentrates in fetal tissues. How much alcohol and/ or metabolites are necessary to damage the fetus is not known. The less alcohol is consumed during pregnancy, the less that crosses the placenta, and consequently the less risk to the fetus. Complications of alcohol use and abuse during pregnancy have been linked to reduced birth weight, prematurity, stillbirth, miscarriage, increased perinatal morbidity and mortality, increased incidence of malformations, functional disturbances, mental retardation, behavioral and developmental delays and abnormalities, and fetal alcohol syndrome (FAS). FETAL ALCOHOL SYNDROME One thousand to 6,000 babies are born with FAS each year (Bertrand, et al., 2004), Infants born with FAS have developmental deficiencies in major organs (especially the heart and brain) and psychomotor disturbances. Many are mentally retarded, with neurological impairment, a small head, poor coordination, hyperactivity and irritability. Growth impairment and facial alterations include decreased head circumference, a flattened nose, small upper lip and eyes set close together. Other congenital anomalies may also be present. Amounts of alcohol insufficient to cause FAS may still result in growth problems, sometimes called fetal alcohol effect. Alcohol consumption may explain the abnormalities seen in infants born to mothers abusing alcohol, as indicated in the chart below. Effects of Alcohol on Development By Trimester First Trimester Second Trimester Third Trimester Hyperplasia Rapid cell division Organs/tissues develop: CNS, heart, eyes, arms, legs, ears, teeth, palate, external genitalia Hyperplasia Hypertrophy Organs/tissues continue to develop: ears, CNS, eyes, teeth, external genitalia Brain begins to develop Hypertrophy Fetus grows rapidly Rapid bone growth and mineralization Brain develops Organs/tissues continue to develop: eyes, CNS, external genitalia Effects of alcohol Major morphological abnormalities Abnormalities of FAS seen in organs/tissues Physiological defects Minor morphological abnormalities Growth impaired Physiological defects Minor morphological abnormalities Growth impaired Sexual & Reproductive Health 157 The central nervous system is most affected from weeks 2 to 6; the heart from 2.5 to 5.5 weeks; and ocular development from 3.5 to 7 weeks. The defects seen in FAS affect organs whose development is mostly completed by the 10th to 12th week of gestation. The organs affected in FAS develop so early that many women may not realize they are pregnant in time to stop consuming alcohol. Tragically, great damage may be done to the fetus before the mother has an opportunity to prevent it. Alcohol consumption later in pregnancy may not have the same effects as early in pregnancy. In a study conducted by Rosett et al. (1983), women who drank heavily throughout pregnancy had a higher incidence of intrauterine growth retardation (IUGR) and congenital anomalies. Rare and moderate drinkers throughout pregnancy had no difference from the control group. Women who reduced heavy drinking before the third trimester had offspring whose growth was similar to rare and moderate drinkers but with a higher frequency of abnormalities, similar to the heavy drinkers throughout pregnancy. It appears that drinking in the later stages of pregnancy interferes with growth, while drinking early in pregnancy affects organ development. Some of the adverse effects of alcohol on pregnancy outcome may result from altered dietary intake and impaired metabolism, absorption and utilization of nutrients. Women who abuse alcohol have reduced intake of many nutrients, including calories, protein, essential fats and vitamins and minerals. Intestinal transport of amino acids, calcium and some vitamins is altered with alcohol. The liver, busy detoxifying alcohol, may have impaired metabolism of nutrients. Reduced serum levels of zinc have been documented in pregnant women at delivery (McClain and Su, 1983). Alcohol may also impair placental transport of some nutrients. Other metabolic changes include decreased Vitamin A storage in the liver (Leo and Kieber, 1982) and impaired uptake and utilization of folate (Halsted, et al., 1971). Thiamin malabsorption may also occur. As discussed earlier, deficiencies or inadequacies in specific nutrients can cause adverse outcomes of pregnancy. It is possible that, in some women, the effects of alcohol are mediated by changes in nutrient intake and/or utilization. How much alcohol can cause damage? We know that drinking more than four drinks per day throughout pregnancy can cause FAS. In addition, heavy alcohol consumption increases the risk of mental retardation and learning disabilities (ADA, 2002). One or two drinks, timed just right, may be enough to cause less severe complications, such as impaired fetal growth, lower Apgar scores and reduced fertility in women (ADA, 2002). The Centers for Disease Control estimates that there are three times the number of babies born with alcohol-related damage, referred to as fetal alcohol effects (FAE) than with FAS. These children have some but not all, of the physical or mental defects of FAS (Institute of Medicine, 1996). There is no safe level of drinking during pregnancy. While four or five drinks a day causes FAS, drinking moderately or even lightly can cause fetal alcohol effects, which causes physical and/or mental defects. Light drinking, such as one or two drinks a week, in some studies has shown behavioral and learning problems (March of Dimes, 2006). Sexual & Reproductive Health 158 In an interesting study, Baer, et al., (2003) investigated the relationship of alcohol consumption by parents during pregnancy and the drinking habits of their children at age 21. Family history of alcohol intake, maternal smoking, caffeine and drug use were all measured. The authors found that 14 percent of women who drank heavily during pregnancy (five or more drinks per day on more than one occasion) had offspring with alcohol problems. Only 4.5 percent of children of women who drank infrequently or not at all had drinking problems. The authors concluded that prenatal exposure to alcohol is a risk factor for development of drinking problems. There is widespread awareness of the risks of drinking alcohol during pregnancy. But some women drink, regardless of the potential consequences, and some who drink deliver normal children. Nevertheless, abstinence is the only absolutely safe recommendation. Women who are pregnant or trying to get pregnant should be counseled to avoid alcohol altogether as any alcohol will increase risk to the fetus. SMOKING Cigarette smoking adversely effects pregnancy outcome. Studies show maternal smoking retards fetal growth. A smoker is twice as likely to deliver a low birth weight (LBW) baby (USDHHS, 2004). There is also an increased risk of preterm delivery and perinatal mortality (ADA, 2002). The good news is that in general, smoking during pregnancy declined from 19.5 percent in 1989 to 11 percent in 2004 (USDHHS, 2004). If all pregnant women stopped smoking, there would be an estimated 11 percent reduction in stillbirths and a 5 percent reduction in newborn deaths (USDDHS, 2004). A large Danish study with over 2,000 singleton pregnancies found that smoking was the most important risk factor for intrauterine growth retardation (Nordentoft, et al., 1996). The effects of daily drinking, poor maternal school education, and poor social support variables were insignificant in the final risk model. The effect of cigarette smoking is dose-related: as the number of cigarettes smoked increases, birth weight decreases. There is also a possibility that cigarette smoking is teratogenic. Maternal pre-pregnancy weight and prenatal weight gain may mediate the effects of cigarette smoking on birth weight. Hellerstedt et al. (1997) found that no level of gestational weight gain in obese women will eliminate the effects of cigarette smoking on birth weight. In this study Hellerstedt compared the weight gain of normal weight and obese smokers and nonsmokers, to the IOM recommendations, and the birthweight of their babies. For obese women, whatever their weight gain, the risk for LBW and small for gestational age (SGA) babies was five times higher in smokers than nonsmokers. In normal weight women, there was no increased risk for LBW babies, but the risk for SGA births was significantly elevated in the smokers compared to the nonsmokers. The cause of the growth retardation may be the direct effect of toxic substances such as cyanide and carbon monoxide in tobacco smoke. It may also be caused by the vasoconstricting effects of nicotine or a decreased placental zinc to cadmium ratio or a decrease in uteroplacental blood flow. Sexual & Reproductive Health 159 Cigarette Smoking & Pregnancy Cigarette smoke (5% carbon monoxide (CO)) Hb has higher affinity for CO than oxygen Hb + CO = carboxyhemoglobin (COHb) Hb bound to CO releases oxygen at lower partial pressure Decreases oxygen-carrying capacity of the blood Chronic hypoxia of maternal and fetal tissues Maternal Increases in: • Ventilation • Cardiac output • Hgb/Hct Fetal • Increase in Hgb/Hct • Decrease in O2 use • Redistribution of blood Placental • Increased size & surface area • Increased vascularity • Decreased diffusion distance Another possibility is that the mother is not eating enough food to compensate for the decreased efficiency of metabolism caused by carbon monoxide and the increased metabolic rate caused by nicotine. Cigarette smoke contains more than 2,000 compounds, with 5 percent carbon monoxide (CO). Hemoglobin (Hb) has 210 times greater affinity for CO than for oxygen. Hb and CO form carboxyhemoglobin (COHb), which is incapable of transporting oxygen. Increased CoHb decreases the oxygen-carrying capacity of the blood and results in hypoxia to maternal, fetal and placental tissues, as seen in the chart above. Tobacco smoke has other dangers. Cyanide is detoxified in the body. One of three possible routes of detoxification involves vitamin B12. Thus, using vitamin B12 to detoxify cyanide lowers serum B12 which has been implicated in premature delivery, IUGR, anemia and smaller babies. All of these problems have been identified in women who smoke cigarettes during pregnancy. Other nutrients found to be lower in the serum of smokers are beta carotene, vitamin C, folic acid and some amino acids. Pregnant smokers may require increased amounts of these nutrients. The vitamin C requirement may double for heavy smokers (≥ 20 cigarettes/day). A prenatal supplement, with perhaps an additional 200 mg of Vitamin C for pregnant smokers, is indicated if their diet is otherwise adequate. The effects of smoking are reversible if the habit is given up during pregnancy. The sooner the woman quits, the better for birth weight. If a woman quits smoking in her Sexual & Reproductive Health 160 first trimester, she is no more likely to have a low birthweight baby than a non-smoker. Ideally, no woman should smoke while pregnant. If she does, try to get her to cut down as much as possible or refer her to a smoking cessation program. Unfortunately, just telling some pregnant woman that their babies may weigh 150 to 350 gm less will not convince them to stop or cut back. It is often effective to approach the subject from the standpoint of the direct effect on the fetus. Every time a pregnant woman puffs on a cigarette, so does the fetus, as evidenced by a momentary stop in fetal heartbeat. The fetal heart rate may also increase. This can be easily demonstrated to her with a stethoscope. TV ads portraying a fetus puffing on a cigarette are particularly striking, as well. Nutrition can only go so far in reducing the risks of smoking. Typically, a smoker will be less than conscientious about her diet and may use another substance — caffeine or alcohol. If you can't get her to quit or cut down, work on the diet issues and recommend a multivitamin supplement, since smoking puts her in a high-risk category. Remember, risks are cumulative. If a mother smokes and drinks, the effect on the fetus will be more pronounced than if she does only one. DRUGS Studying the effect of drugs on fetuses is difficult. Animal studies are not reliable indicators of teratogenicity due to species differences; short-term studies do not always detect defects that emerge later. The defects resulting from exposure to drugs are dependent to a large extent on gestational timing, and to a lesser extent on drug dosage, which in itself is difficult to determine in pregnancy. Physiological changes of pregnancy alter drug metabolism. Pregnancy causes decreased gastric tone and motility, decreased hydrochloric acid in the first two trimesters (increasing during the third trimester), decreased albumin-binding capacity of drugs (so more “free” drugs circulate) and increased excretion of drugs by the kidneys (due to increased renal perfusion and filtration), which may accelerate clearance of drugs from the body. Faster drug clearance may decrease effectiveness of the drugs. Drugs are transferred across the placenta by simple diffusion, which is dependent upon the chemical properties of the drug and the concentration of free drugs. The longer the blood level of a drug is maintained, the greater the chance it will cross the placenta. The larger the dose, the greater the concentration. While a drug taken in small doses might not cross the placenta, in a large dose, it may well do so. Drugs can act as teratogens by causing abortions, malformations, altered fetal growth, functional deficits, carcinogenesis or mutagenesis. There are many pathways a drug can take to be a teratogen: • Inhibition of certain important enzymes; • Mutation of genes; • Changes in cell membrane integrity; • Competition for protein binding sites; • Interactions with other drugs/teratogens. Sexual & Reproductive Health 161 The timing of drug exposure is crucial. During the first 10 weeks of gestation (during hyperplasia), the developing organ systems are highly susceptible to drugs. Later, during hypertrophy, growth problems can occur, but organs are still susceptible to interference from drugs. Drugs can affect pregnancy in other ways. Aspirin and other salicylates can prolong pregnancy and increase blood loss at delivery. Aspirin inhibits the production of a prostaglandin that initiates uterine contraction, delaying labor. Aspirin adversely affects platelet function by blocking the cyclooxygenase enzyme necessary for the production of thromboxane that regulates platelet function. A good resource for information on teratogens during pregnancy and lactation is the Organization of Teratology Information Specialists (OTIS) and their web site: <www.OTISpregnancy.org> MEDICATION DURING PREGNANCY During pregnancy, 62 percent of pregnant women take at least one drug; 25 percent take an opiate and 13 percent take a psychotropic drug (Cheney, 2003). Over-the-counter drugs are also commonly used by pregnant women (Black, et al., 2003). Many pregnant women must take medication to control a disease or disorder, such as asthma, hypertension, lupus, arthritis, seizures or other disorders. Failure to take the medication may put both the mother and the baby at risk. However, taking the medication has its own risks. Unfortunately, it is difficult to do research on medications during pregnancy. You can't do studies that potentially harm a baby. Therefore most studies of pregnant women are retrospective, unless women must take medication and you can study them prospectively during their pregnancy. For instance, severe asthma during pregnancy has the potential to be a life-threatening event for both the mother and fetus. Complications from asthma during pregnancy include low birth weight infants, fetal hypoxia and intrauterine growth retardation (Cheney, et al., 2003). Drugs are a necessity to control this disease, yet there is only one published study on asthma medications during pregnancy (Schatz, et al., 2001). Many women have successfully used asthma medications during pregnancy. A registry for pregnant women using asthma medication does exist (Meadows, 2001). The purpose of this and other registries is to collect and pool data on the course of pregnancies and outcomes in women using medications. Fluoxetin (Prozac®) has been used by pregnant women to treat depression for over 10 years without teratogenic effects (Cheney, et al., 2003). While short-term side effects have not been seen, long-term effects on offspring are unknown. Common over-the-counter medications that appear safe include acetaminophen, chlorpheniramine, kaolin and pectin. Other medications, such as histamine H2-receptor blockers, pseudoephedrine and atropine/diphenoxylate should be used with caution (Black, et al., 2003). Sexual & Reproductive Health 162 To help clinicians prescribe medications to pregnant women, the FDA has established Pregnancy Categories A, B, C, D, and X. • Category A consists of the safest drugs. These drugs have no proven harm to the fetus in the first trimester (or later trimesters) in controlled studies. • Category B refers to drugs that have been tested on animals and found safe, but there are no human studies yet. Basically, more information is needed. • Category C drugs have adverse effects on fetal animals, but no information is available on humans. • Category D is reserved for drugs that have been found to have human fetal risks, but the benefits may outweigh the risks. These drugs may be used when the life of the mother is at risk and there is no alternative but to use the drug. • Category X is for drugs that are proven harmful to the fetus and the risk of using the drug clearly outweighs any benefit. Using this information may be a bit more difficult than it appears. For example, Acyclovir® has been used in the treatment of HIV/AIDS for 10 years and is considered “safe.” It is designated Category C. A much newer drug also used to treat HIV/AIDS, Famciclovir,® is designated Category B. In addition, many feel this labeling system is an oversimplification. Many drugs labeled Category C (no data on pregnancy) may in fact be as harmful as, or more harmful than, a drug labeled Category X. The FDA is working on a new drug labeling system for pregnancy that would replace the letter categories. It is still being developed. Before taking any drugs, including over-the-counter drugs, a pregnant woman should consult with a pharmacist or her prenatal care provider and carefully weigh the risks and benefits. Is the drug absolutely necessary? If so, it may be more harmful not to take it. If the drug is not necessary, it may be better to wait. Other questions to ask are: • Is there an alternate drug that may be less harmful? • Is there a particular time during the pregnancy I should not take this drug? • Do you know the correct dose during pregnancy? STREET DRUGS It is difficult to get an accurate count of the number of pregnant women using drugs such as cocaine, heroin, amphetamines, morphine, methadone, benzodiazepines, barbiturates and marijuana. Screening is difficult and is not routine. In the 1980s and 1990s, an epidemic of “crack babies” in urban areas attests to the scope of the problem. Problems in pregnancy may be related to the direct effect of the drug on the fetus or an indirect effect related to maternal self-neglect — inadequate nutrient intake, malnutrition, poor health, poor hygiene, smoking or poor prenatal care. When determining the effects of drugs on pregnancy outcome, it is not always easy to separate the effects of the drugs themselves from the poor care the mother takes of herself during pregnancy. The chart on the following page summarizes the potential complications for the mother and the fetus/infant from the use of street drugs. Sexual & Reproductive Health 163 Complications from Drug Use Maternal Fetal/Infant Spontaneous abortion or intrauterine death Preeclampsia and abruptio placentae Malnutrition Placental insufficiency Premature labor Uterine irritability and meconium staining Congenital infection Increased perinatal mortality — neonatal deaths, stillbirths Birth asphyxia Cerebral hemorrhage Growth retardation Hypoglycemia Irritability Myocardial infarction Necrotizing enterocolitis Precipitous delivery Prematurity Congenital anomalies Increased incidence of SIDS Intrauterine growth retardation Cocaine — in whatever form — is a central nervous system stimulant, causing increased heart rate, hypertension and vasoconstriction. Reductions in uterine blood flow secondary to the vasoconstriction may cause fetal hypoxia and reduced nutrient supply to the fetus, resulting in many of the complications seen in babies born to mothers using cocaine, such as growth retardation — reduced birth weight, length, head circumference and microcephaly. Other complications include congenital malformations, CNS abnormalities, neurodevelopmental defects, sudden infant death syndrome (SIDS) and feeding intolerance. Feeding problems may be due to physiological and structural problems or may result from the neurodevelopmental defects causing poor organizational responses and poor visual attention. Marijuana use in pregnant women has been investigated. The active ingredient in marijuana is Δ9-tetrahydrocannabinol (THC), which is fat-soluble and crosses the placenta. Therefore, the exposure to the fetus may be prolonged. Smoking marijuana causes increases in carboxyhemoglobin, which may decrease oxygen delivery to the fetus (as discussed in the section on tobacco smoke), impairing growth. Women who have smoked a lot of marijuana in the past may also place infants at risk, especially if they have a poor food intake. As fat stores are mobilized, the active ingredient, THC, is released from the fat stores into the blood and across the placenta. It is difficult to make specific recommendations for nutrition intervention in pregnant women using street drugs, since little is known about the nutrition-related effects of these drugs. Drug abuse is endemic in our society and the use of nutrition and diet to aid recovery is coming into the forefront. When interviewing a pregnant women, it is important to screen for the use of drugs, and specifically mention alcohol, as many women do not consider this a drug. The National Center for Education in Maternal and Child Health (1997) publishes Screening for Substance Abuse During Pregnancy: Improving Care, Improving Health. This document contains information and tools on how to screen pregnant women for alcohol Sexual & Reproductive Health 164 and drugs as well as how to ask questions in a manner that is more likely to get a truthful response. The screening tools in the document are very short and easy to use. The publication can be downloaded from <www.mchlibrary.info/pubs/pdfs/subabuse.pdf> Many other publications, screening tools and articles are available on the NCEMCH library relating to maternal and child health issues. Another resource is the ACOG (American College of Obstetricians and Gynecologists) prevention tool kit: Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit. It can be downloaded at: <www.acog.org/departments/healthissues/FASDToolKit.pdf> It is important to assist all women in following the nutrition guidelines presented in this course as best they can, and possibly increasing their intake due to the poor nutritional status coming into pregnancy. However, women worrying about money for their next fix, women hung over from an alcohol binge, or women who have indulged in hallucinogens for years may not be too concerned about their diet or too interested in hearing about “rules.” Refer them to appropriate resources for recovery. Sexual & Reproductive Health 165 Case Study Please read through the following case study and answer the questions from the material provided. A discussion of the case follows. (If you anticipate sharing this coursebook, please do not write in the book. Photocopy the pages and work on the copies.) “Rita” (the name is fictitious) was referred to the clinic to see a dietitian. Her doctor is concerned about her rapid weight gain and feels she should go on a weight reduction diet. Since she is close to term, he feels that too much weight may make labor and delivery more difficult. The following information is in Rita’s chart: Name: Rita Height: 5'4" Age: 36 Pre-pregnancy weight: 145 lb FAMILY HISTORY Mother - elevated blood pressure PATIENT’S HISTORY Rheumatic fever as a child Heart murmur as a child Anemia - diagnosed 2 years ago No alcohol or cigarette use Onset of menses - 12 years of age Birth control: OCAs (stopped one year ago) IUD, no history of infection OBSTETRICAL HISTORY Gravida 3, Para 2 2001 - Birth to 6 lb, 1 oz female, no complications 2002 - Birth to 7 lb, 5 oz male, water retention 25th week PRESENT PREGNANCY Pre-pregnancy weight: 145 lb Present weight: 182 at 35 weeks gestation Hgb: 10.3 then 11.5 Sexual & Reproductive Health WEIGHTS Pre-pregnancy: 10 Weeks: 19 Weeks 21 Weeks 24 Weeks 29 Weeks 35 Weeks 166 145 157 160 168 176 182 182 24-HOUR RECALL DIET HISTORY (This is her entire intake for the 24-hour period.) 5:30 pm Roast beef 2 oz Green beans 1/4 cup Baked potato 1 medium Butter 2 tsp Cookies 5 - 10 Apple 2 medium SOCIOECONOMIC INFORMATION Married, husband at home; 2 children at home, 1 male, 1 female Income less than $550 per week 12th grade education level Complete the following, using the information provided above: 1. Plot Rita’s weight gain on the weight gain grid provided on the next page. 2. Assess Rita for any nutritional risks and write those below. 3. Determine how much weight Rita should gain and the rate of gain. 4. Make dietary recommendations to be sent to her physician, giving your rationale for these recommendations. Sexual & Reproductive Health 167 Prenatal Weight Gain Grid Name: ___________________________________________ 60 58 Date: _________________ Weeks Gestation: ____________ 56 Age: _________________ Height: ____________________ 54 Prepregnant Weight: ________________________________ 52 50 Desirable Weight: __________________________________ 48 % Weight for Height: _____________ BMI: _____________ 46 Weight Classification: _______________________________ 44 Weight Gain Recommendation: ________________________ 42 40 38 36 34 32 30 28 26 en m 24 wo t h 22 en ig om we r w 20 ht de un eig w r 18 fo al rm o n 16 en for wom t h 14 eig erw v o 12 for men o w 10 bese for o 8 6 4 2 0 -2 -4 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 Weeks Gestation Weight in Pounds 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 -2 -4 Sexual & Reproductive Health 168 CASE STUDY DISCUSSION “Rita” is 36 years old. Her previous pregnancies are unremarkable, with the exception of water retention with her last child. Her first child was not low birth weight, but was small. She had rheumatic fever as a child. With a heart murmur, one could suspect that there could be some heart damage. There is a family history of elevated blood pressure on her mother’s side. Her low income could signal financial problems that influence her diet and food availability. With this pregnancy she was anemic, although her hemoglobin increased. Her weight gain was satisfactory during the 1st trimester and early in the 2nd. Her weight gain increased dramatically in the second half of pregnancy, beginning around the 20th week and ending the 29th week. In 6 weeks, Rita gained 16 lb, an excessive amount. Her diet history shows inadequacy in all nutrients. The caloric intake is approximately 800 to 850 kcal, which could not produce the rapid weight gain. Is she misrepresenting her diet history or has she radically altered her diet because her doctor was upset with her dramatic weight gain? Since Rita’s weight gain is not due to diet, it must be water gain. With Rita’s history of water retention during her last pregnancy, rheumatic fever and her mother’s history of elevated blood pressure, her weight gain could be from preeclampsia. She was evaluated and diagnosed with preeclampsia. Treatment for Rita is to decrease activity and eat well. Rita’s diet must be improved. Calories, protein and nutrients must be increased. Rita’s weight gain was due to water, masking a poor weight gain due to an inadequate diet. Calories are important, particularly since it is the 3rd trimester and the fetus is growing rapidly. A prenatal supplement is called for, with the inadequate diet and the anemia earlier in pregnancy. The nutrients most important at this late stage in the pregnancy are calories and protein for growth; calcium for blood pressure regulation and fetal skeletal growth; iron for blood losses at delivery; magnesium for vasodilation and other vitamins and minerals at recommended levels. Also consider increasing her long chain fatty acids (DHA) to ensure proper brain and eye development. If she is unable to eat foods high in Ω-3 fatty acids, you can supplement with fish oil capsules or dietary flax seed oil. References 169 © 2009, Nutrition Dimension, Inc. CHAPTER ONE ________IOM (Institute of Medicine) Food and Nutrition Board. Dietary Reference Intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin and choline. National Academy Press, Washington DC, 1998. Ashby C, Carr L, Cook, et al. Alteration of platelet serotonergic mechanism and monoamine oxidase activity in premenstrual syndrome. Biol Psychiatry 24:225-33, 1988. Atkinson D. Vitex agnus castus: a review. Positive Health. Complementary Medicine magazine. <www.positivehealth.com/ permit/Articles/Herbal/atkin23.htm> accessed 7/19/2006. Bendich A. The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms. J Am Coll Nur 19(1):3-12, 2000. Barnhart KT, Freeman EW, Sondheimer SJ. A clinician’s guide to the premenstrual syndrome. Office Gynecology 79(6):1457-1472, 1995. Berman M, Taylor M, Freeman E. Vitamin B in premenstrual syndrome. JADA 90(6):859-861, 1990. Bertone-Johnson ER, Hankinson SE, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med 165;1246-52, 2005. Bianchi-Demicheli F, Ludicke F, et al. Premenstrual dysphoric disorder: current status of treatment. Swiss Med Wkly 132:574-578, 2002. Brown J, O'Brien PM, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cohrane Database Syst Rev. Apr 15;(2): CD001396, 2009. Budeiri D, Li Wan Po A, Dornan JC. 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Hepatic vitamin A depletion in alcoholic liver injury, NEJM, 307:597-601, 1982. _______"Drinking alcohol during pregnancy". March of Dimes <www.marchofdimes.com/printableArticles/> accessed 10-12-06, 2006. McClain CJ, Su LC. Zinc deficiency in the alcoholic: a review. Alcoholism 7:5-10, 1983. Meadows M. Pregnancy and the Drug Dilemma. FDA Consumer Magazine www.fda.gov/fdac/features/2001/ 301_preg.html#catagories _______National Academy of Sciences, Institute of Medicine, Nutrition During Pregnancy, Part I: Weight Gain; Part II: Nutrient Supplements. National Academy Press, Washington DC, 1990. Nordentoft M, Lou HL, Hansen D, et al. IUGR and premature delivery: the influence of maternal smoking and psychosocial factors. Am J Public Health 86:347-354, 1996. _______Nutrition Recommendations and principles for people with diabetes mellitus. JADA 94(5):504-506, 1994. Rayburn W and Zuspan F. Drug Therapy in Obstetrics and Gynecology. Appleton-Century-Crofts, Norwalk CT, 1982. Rice-Asaro M, Wasek N, et al. Nutritional concerns for children born to drug abusing women. Nutr Focus 5(4):1 6, 1990. Rosett H, et al. Patterns of alcohol consumption and fetal development. Obstet and Gynecol 61(5):539, 1983. Schatz M, Harden K, et al. Developmental follow-up in 15-month-old infants of asthmatic vs. control mothers. Pediatr Allergy Immunol 12(3):149-53, 2001. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: Practical prenatal detection of risk-drinking. Am J Obstet Gyn 160(4):863-870, 1989. _______US Dept. of Health and Human Services. A Guide to Substance Abuse Services for Primary Care. Clinicians. Improvement Protocol (TIP) Series. Chapter 24. 1997. _______US Dept. of Health and Human Services. Screening for substance abuse during pregnancy: Improving care. improving health. www.mchlibrary.info/pubs/PDFs/subabuse.pdf _______The health consequences of smoking: A report of the surgeon general-2004. USDHHS Office on Smoking and Health, Atlanta Georgia, 2004. Ventura SJ, Hamilton BE, Mathews TJ, et al. Trends and Variations in Smoking During Pregnancy and Low Birth Weight: Evidence From the birth Certificate, 1990-2000. Pediatrics 111(5):1176-1180, 2003. Wright JT, et al. Alcohol consumption, pregnancy and low birth weight. Lancet 1:633, 1983. Appendix #1 183 Risk Factors Affecting Pregnancy Outcome Use as a checklist with prenatal clients to determine nutritional risks Prepregnancy weight status _____ underweight _____ overweight Rate of weight gain _____ inadequate _____ excessive Biochemical indices _____ low hemoglobin _____ low hematocrit _____ high blood sugar _____ proteinuria Conditions associated with nutritional risk _____ adolescence _____ 5 or more previous pregnancies _____ 12 months or less between delivery and conception _____ breastfeeding during pregnancy _____ multiple pregnancy _____ hyperemesis gravidarum _____ preeclampsia _____ gestational diabetes Diabetes (before pregnancy): _____ Type 1 (non-insulin dependent) _____ Type 2 (insulin dependent) © 2009, Nutrition Dimension, Inc. Current medical/obstetrical complications _____ hypertension _____ diabetes _____ heart disease _____ renal disease _____ liver disease _____ cancer _____ bariatric surgery _____ other medical condition(s) Other factors _____ low income _____ substance abuse _____ alcohol use _____ caffeine intake _____ smoking _____ medications (over-the-counter) _____ prescription medications _____ excessive vitamin/mineral supplements _____ eating disorder _____ pica _____ psychological problems _____ cultural food issues _____ frequency of food intake Inadequate intake of: _____ meat and meat alternates _____ milk and milk products _____ breads and cereals _____ vitamin A fruits and vegetables _____ vitamin C fruits and vegetables _____ other fruits and vegetables Diet inadequate in: _____ protein _____ calories _____ folic acid _____ zinc _____ vitamin B6 _____ vitamin B12 _____vitamin C _____vitamin A _____calcium _____magnesium _____ fiber _____ Ω-3 fatty acids Diet excessive in: _____ calories _____ fat _____ sodium Remember, how you ask a question is important if you want an honest answer. Nutrition During Pregnancy and Lactation, National Academy Press, 1992, is an excellent reference. It has many good ways to ask questions that are nonjudgmental. Appendix #2 184 Recommended Dietary Allowances Vitamins¶ © 2009, Nutrition Dimension, Inc. FUNCTIONS Pregnancy RDA Tolerable Intake Levels (UL)1 VITAMIN C Tooth & bone formation, healthy gums, collagen, immunity, anti-oxidant THIAMIN (B1) Energy production; growth and functioning of nerve tissue, memory and emotional stability 1.4 mg Unknown RIBOFLAVIN (B2) Energy production, synthesis of fats and amino acids; cell growth 1.4 mg Unknown NIACIN Energy production, synthesis & breakdown of fats, carbohydrates and proteins; synthesis of cholesterol, red blood 'cells + others 18 mg 35 mg VITAMIN B6 Synthesis and breakdown of amino acids; multiplication of cells; production of RBCs, immune cells, neurotransmitters 1.9 mg FOLATE DNA, RNA synthesis, new cell growth, red blood cells VITAMIN B12 Growth, red blood cells, nervous system, detox smog & tobacco smoke VITAMIN A Vision, skin, immunity, resistance to infection, antioxidant, cancer prevention VITAMIN D Formation of bones, teeth and cartilage; aids absorption of calcium & phosphorus VITAMIN E (alpha-tocopherol) Antioxidant – protects unsaturated fats in cells from damage VITAMIN K Formation of blood clotting factors BIOTIN Coenzyme for metabolic reactions 30 μg* CHOLINE Structural interity of cell membranes; cell signaling; lipid & cholesterol transport and metabolism 450 mg* PANTOTHENIC ACID Component of coenzyme A and fatty acid metabolism ≤ 18 yrs 80 mg 19-50 yrs 85 mg 2000 mg ≤ 18 yrs 80 mg 19-50 yrs 100 mg 600 μg DFE 1000 μg 2.6 μg Unknown ≤ 18 yrs 750 μg 19-50 yrs 770 μg 5 μg* (200 IU) 15 mg ≤ 18 yrs 75 μg* 19-50 yrs 90 μg* 6 mg* ¶ Note: Values are RDA unless followed by an asterisk. An asterisk denotes an AI value. * AI (Adequate Intake) value, not RDA 1 Reference: IOM, Dietary Reference Intakes, National Academy Press 1997, 1998, 2000, 2001, 2002 Above 20,000 I.U. 50 μg 1000 μg Unknown Unknown 3.5 gm Unknown Appendix #3 185 Recommended Dietary Allowances Minerals¶ FUNCTIONS Tolerable Intake Levels (UL)1 CALCIUM Formation of bones and teeth; nerve impulses; activating/relaxing smooth muscles; blood clotting IRON Part of red blood cells; carries oxygen within the body; involved in energy production, immunity MAGNESIUM Energy production; muscle relaxation; nerve transmission; heart functions; dental health SODIUM Involved in nerve impulse, muscle action, water and acid-base balance none Unknown POTASSIUM Involved in water balance, regulating muscle actions, starting glycogen and protein synthesis none 18 gm ZINC Essential for DNA, RNA, protein synthesis, skin growth, wound healing, immune function, taste COPPER © 2009, Nutrition Dimension, Inc. Pregnancy RDA Red blood cell formation; energy production; immunity; protective wrapping around nerves; aids formation of bone and collagen ≤18 yrs 1300 mg* 19-50 yrs 1000 mg* 2,500 mg ≤18 yrs 27 mg 19-50 yrs 27 mg 45 mg ≤18 yrs 400 mg 19-30 yrs 350 mg 31-50 yrs 360 mg 350 mg of supplemental mg ≤18 yrs 13 mg 19-50 yrs 11 mg 1000 ug ≤ 18 yrs 34 mg 19-50 yrs 40 mg ≤ 18 yrs 8 mg 19-50 yrs 10 mg 60 μg 400 μg ≤18 yrs 29 μg* 19-50 yrs 30 μg* Unknown SELENIUM Antioxidant; protects against free radicals; enhances vitamin E CHROMIUM Component of glucose tolerance factor (GTF) which helps get glucose into the cell; indirectly affects level of fats in the blood MANGANESE Metabolism of amino acids, DNA, RNA, fatty acids, cholesterol; formation of bones, teeth 2 mg* ≤ 18 yrs 9 mg 19-50 yrs 11 mg IODINE Regulates metabolism 220 μg FLUORIDE Inhibit and reverse dental caries 3 mg* ≤ 18 yrs 900 μg 19-50 yrs 1,100 μg 10 mg PHOSPHORUS Component of membranes; buffers; storage and transfer of energy; activation of catalytic proteins MOLYBDENUM Enzyne cofactor ≤18 yrs 1,250 mg 19-50 yrs 700 mg 50 μg ¶ Note: Values are RDA unless followed by an asterisk. An asterisk denotes an AI value. * AI (Adequate Intake) value, not RDA 1 Reference: IOM, Dietary Reference Intakes, National Academy Press 1997, 1998, 2000, 2001, 2002 UL for minerals: Boron 20 mg/day; Vanadium 1.8 mg/day; Nickel 1 mg/day 3.5 gm ≤ 18 yrs 1.7 mg 19-50 yrs 2 mg Appendix #3A 186 Recommended Dietary Allowances Macronutrients Functions ENERGY Essential for the body's functions: respiration, circulation, metabolism, body temperature etc. PROTEIN Part of every cell: Necessary for growth, maintenance of tissue and tissue repair; horomone production; immune function; fluid-electrolyte balance; ace-base balance; tranport of nutrients; energy; and blood clotting FATTY ACIDS Ω-3 alpha-linolenic acid Ω-6 linoleic acid General: Part of cell membranes; prostaglandins: immunity, inflammation, blood clotting Ω-3 (DHA): Development of fetal nervous system and retina. Pregnancy RDA ≤18 years:(calories) 1st trimester: 2368 2nd trimester: 2708 3rd trimester: 2820 19-50 years: (calories) 1st trimester: 2403 2nd trimester: 2743 3rd trimester: 2855 1.1 gm/kg/day or Dietary Fiber: Increases fecal bulk, aids laxation and ameliorates constipation. Functional Fiber: delays gastric emptying; increases sensation of fulness; may reduce prostprandial blood glucose; reduce serum cholesterol levels © 2009, Nutrition Dimension, Inc. CARBOHYDRATES Provide energy to the cells, especially the brain. Simple sugars: monosaccharides, disaccharides Complex carbohydrates: polysaccharides (starches, grains etc) Carbohydrates, protein fats and alcohol all provide energy Meat, fish, poultry, eggs, cheese, dairy products, legumes, grains, rice, soy, seeds, vegetables 0.8 gm/kg/day + 25 gm/day 13 gm* 1.4 gm* Optimal ratio: 1 to 5 Ω-3 to Ω-6 FIBER Food Sources 28 gm (Total Fiber) Total Fiber = Dietary fiber and Functional fiber Ω-3 fatty acids: Fish, canola oil, flaxseed, English walnuts, soybeans, soybean oil Ω-6 fatty acids: Meat, dairy products, eggs, vegetable oils (sunflower, corn, safflower) Dietary Fiber: Part of the plant structure. Found in bran, grains, vegetables, legumes, nuts, seeds Functional Fiber:Isolated or extracted from plant source includes: gums, pectins, oligosaccharides. Found in grains, vegetables, plant foods 175 gm/day ¶ Note: Values are RDA unless followed by an asterisk. An asterisk denotes an AI value. * AI (Adequate Intake) value, not RDA 1 Reference: IOM, Dietary Reference Intakes, National Academy Press 2002 Simple sugars: table sugar, lactose, fructose Complex: grains, starches found in breads, pasta, cereals, legumes 187 Appendix #4 Body Mass Index Chart Height (inches) Weight (lbs) 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 17.3 18.4 19.5 20.6 21.7 22.7 23.8 24.9 16.7 17.8 18.8 19.9 20.9 22.0 23.0 24.1 16.2 17.2 18.2 19.2 20.2 21.2 22.2 23.2 15.6 16.6 17.6 18.6 19.5 20.5 21.5 22.5 14.2 15.1 16.0 16.8 17.7 18.6 19.5 20.4 13.7 14.6 15.5 16.3 17.2 18.0 18.9 19.8 13.3 14.2 15.0 15.8 16.7 17.5 18.3 19.2 12.9 13.7 14.5 15.3 16.2 17.0 17.8 18.6 12.5 13.3 14.1 14.9 15.7 16.5 17.2 18.0 12.2 12.9 13.7 14.5 15.2 16.0 16.7 17.5 11.8 12.6 13.3 14.0 14.8 15.5 16.3 17.0 26.0 27.1 28.2 29.2 30.3 31.4 32.5 33.6 34.7 35.7 36.8 37.9 39.0 40.1 41.2 42.2 43.3 44.4 45.5 46.6 47.6 48.7 49.8 50.9 52.0 25.1 26.1 27.2 28.2 29.3 30.3 31.4 32.5 33.5 34.5 35.6 36.6 37.7 38.7 39.7 40.8 41.8 42.9 43.9 45.0 46.0 47.1 48.1 49.2 50.2 24.3 25.3 26.3 27.3 28.3 29.3 30.3 31.3 32.3 33.4 34.4 35.4 36.4 37.4 38.4 39.4 40.4 41.4 42.5 43.5 44.5 45.5 46.5 47.5 48.5 23.5 24.4 25.4 26.4 27.4 28.3 29.3 30.3 31.3 32.3 33.2 34.2 35.2 36.2 37.1 38.1 39.1 40.1 41.0 42.0 43.0 44.0 45.0 45.9 46.9 22.0 22.9 23.8 24.7 25.6 26.5 27.5 28.4 29.3 30.2 31.1 32.0 33.0 33.9 34.8 35.7 36.6 37.5 38.4 39.4 40.3 41.2 42.1 43.0 43.9 21.3 22.2 23.0 23.9 24.8 25.7 26.6 27.5 28.4 29.3 30.1 31.0 31.9 32.8 33.7 34.6 35.5 36.2 37.2 38.1 39.0 39.0 40.8 41.7 42.6 20.6 21.5 22.3 23.2 24.1 24.9 25.8 26.6 27.5 28.3 29.2 30.1 30.9 31.8 32.6 33.5 34.4 35.2 36.1 36.9 37.8 38.7 39.5 40.4 41.2 20.0 20.8 21.7 22.5 23.3 24.2 25.0 25.8 26.6 27.5 28.3 29.1 30.0 30.8 31.6 32.5 33.3 34.1 35.0 35.8 36.6 37.5 38.3 39.1 40.0 19.4 20.2 21.0 21.8 22.6 23.4 24.2 25.0 25.8 26.7 27.5 28.3 29.1 29.9 30.7 31.5 32.3 33.1 33.9 34.7 35.5 36.3 37.2 38.0 38.8 18.8 19.6 20.4 21.2 21.9 22.7 23.5 24.3 25.1 25.9 26.6 27.4 28.2 29.0 29.8 30.6 31.4 32.1 32.9 33.7 34.5 35.3 36.1 36.8 37.6 18.3 19.0 19.8 20.5 21.3 22.1 22.8 23.6 24.3 25.1 25.9 26.6 27.4 28.2 28.9 29.7 30.4 31.2 32.0 32.7 33.5 34.2 35.0 35.8 36.5 17.7 18.5 19.2 20.0 20.7 21.4 22.2 22.9 23.6 24.4 25.1 25.9 26.6 27.3 28.1 28.8 29.6 30.3 31.0 31.8 32.5 33.3 34.0 34.7 35.5 245 250 255 260 55.0 56.1 57.2 58.3 53.1 54.1 55.2 56.3 51.3 52.3 53.3 54.4 49.5 50.5 51.5 52.6 47.9 48.9 49.8 50.8 15.1 16.1 17.0 18.0 18.9 19.9 20.8 21.7 22.7 23.6 24.6 25.5 26.5 27.4 28.4 29.3 30.3 31.2 32.1 33.1 34.0 35.0 35.9 36.9 37.8 38.8 39.7 40.7 41.6 42.6 43.5 44.4 45.4 46.3 47.3 48.2 49.2 14.6 15.6 16.5 17.4 18.3 19.2 20.1 21.1 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 18.0 19.1 20.2 21.3 22.4 23.6 24.7 25.8 26.9 28.0 29.2 30.3 31.4 32.5 33.7 34.8 35.9 37.0 38.1 39.3 40.4 41.5 42.6 43.8 44.9 46.0 47.1 48.2 49.4 50.5 51.6 52.7 53.9 44.9 45.8 46.7 47.6 43.4 44.3 45.2 46.1 42.1 43.0 43.8 44.7 40.8 41.6 42.5 43.3 39.6 40.4 41.2 42.0 38.4 39.2 40.0 40.8 37.3 38.0 38.8 39.6 36.2 37.0 37.7 38.4 11.5 12.2 12.9 13.6 14.4 15.1 15.8 16.5 17.2 18.0 18.7 19.4 20.1 20.8 21.5 22.3 23.0 23.7 24.4 25.1 25.9 26.6 27.3 28.0 28.7 29.4 30.2 30.9 31.6. 32.3 33.0 33.7 34.5 35.2 35.9 36.6 37.3 © 2009, Nutrition Dimension, Inc. 80 85 90 95 100 105 110 115 BMI = weight (kg) height (M)2 (Convert pounds to kilograms by dividing by 2.2. Example: 143 lbs. divided by 2.2 = 65 kg) Source: NAS, Nutrition During Pregnancy, 1990. Appendix #5 188 Optimal Weight Gain for Twin Pregnancies Rates of Weight Gain (pounds/week) Prepregnancy BMI 0-20 Weeks 20-28 Weeks 28 Weeks to delivery Underweight: BMI <19.8 1.25 - 1.75 1.50 - 1.75 1.25 Normal: BMI 19.8 - 26.0 1.0 - 1.50 1.25 - 1.75 1.0 Overweight: BMI 26 - 29 1.0 - 1.25 1.0 - 1.50 1.0 Obese: BMI >29 0.75 - 1.0 0.75 - 1.25 0.75 © 2009, Nutrition Dimension, Inc. Cumulative Weight Gain (pounds) Prepregnancy BMI 0-20 Weeks 20-28 Weeks 28 Weeks to delivery Underweight: BMI <19.8 25 - 35 37 - 49 50 - 62 Normal: BMI 19.8 - 26.0 20 - 30 30 - 44 37- 54 Overweight: BMI 26 - 29 20 - 25 28 - 37 31 - 50 Obese: BMI >29 15 - 20 21 - 30 25 - 42 Adapted from Luke B, Hediger ML, Nugent C, et al. Body mass index specific-weight gains associated with optimal birthweights in twin pregnancies. J Repro Med. 48:217-224, 2003. Weight Gain During Pregnancy: Reexamining the Guidelines, IOM and NRC, National Academies Press, 2009. Appendix #6 189 Prenatal Weight Gain Grid Normal Prepregnancy Weight © 2009, Nutrition Dimension, Inc. 60 58 Date: _________________ Weeks Gestation: ____________ 56 Age: _________________ Height: ____________________ 54 Prepregnant Weight: ________________________________ 52 50 Desirable Weight: __________________________________ 48 % Weight for Height: _____________ BMI: _____________ 46 Weight Classification: _______________________________ 44 Weight Gain Recommendation: ________________________ 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 -2 -4 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 Weight in Pounds Name: ___________________________________________ Weeks Gestation IOM, Weight Gain During Pregnancy, Reexamining the guidelines, 2009. Appendix #7 190 © 2009, Nutrition Dimension, Inc. Prenatal Weight Gain Grid Name: ___________________________________________ 60 58 Date: _________________ Weeks Gestation: ____________ 56 Age: _________________ Height: ____________________ 54 Prepregnant Weight: ________________________________ 52 50 Desirable Weight: __________________________________ 48 % Weight for Height: _____________ BMI: _____________ 46 Weight Classification: _______________________________ 44 Weight Gain Recommendation: ________________________ 42 40 38 36 34 32 30 28 26 en 24 om tw h 22 en ig om we r w 20 ht de un eig w r 18 fo al rm o n 16 n for ome w t 14 eigh erw v o 12 for men o w 10 bese for o 8 6 4 2 0 -2 -4 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 Weight in Pounds 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 -2 -4 Weeks Gestation IOM, Weight Gain During Pregnancy, Reexamining the guidelines, 2009. 191 Appendix #8 Healthy Food Choices Milk & Milk Products 3-4 cups/day Meat & Meat Alternates 6-8 oz/day Fruits 2-3 cups/day Vegetables 3-4 cups/day © 2009, Nutrition Dimension, Inc. Breads & Cereals 7-11 ounces/day SMARTEST CHOICES USE SPARINGLY Nonfat milk Lowfat milk (1%) Buttermilk Plain lowfat yogurt Skimmed milk cheese Low fat cottage cheese Nonfat milk mozarella, ricotta, farmer's, feta cheese Whole milk Reduced fat (2%) Fruit-flavored yogurt Cream Cream soups Regular cheese Creamed cottage cheese Beef: flank, round, lean cuts Pork: leg, ham (smoked) Lamb: leg, sirloin, shank Fish: tuna (in water), fish Lean luncheon meat Poultry: chicken, turkey (breast) Cornish hen (no skin) Dried beans, peas (kidney, lima, soy, lentils, navy) Tofu Nuts, seeds, peanut butter* Rib roast, chuck, brisket Bacon, ribs, loin Tuna in oil Cold cuts, hot dogs, sausage Capon, duck, goose Fried meats Fresh fruit, unsweetened canned fruit & juice Canned syrup, sweetened juice, nectars, juice drinks Fresh, frozen or canned vegetables Avocadoes, olives Unsweetened dry or cooked cereal Whole grain or enriched bread Rice, pastas, noodles Tortillas Potatoes Bread sticks, whole grain crackers, rice cakes Bagels Graham crackers Sugar- or honey-coated, granola Sweet rolls, pastries, coffeecake, croissants Fried rice, fettucini Tortilla chips French fried, creamed, chips Snack crackers * Use with moderation. Contain high amount of fat (unsaturated), but can add lots of calories. © 2009, Nutrition Dimension, Inc. Appendix #9 192 Appendix #9A 193 Daily Food Guide Feedback Form Food Group Recommended amount per day (in ounces and cups) Meat & Meat Alternates _______________ Milk & Milk Products _______________ Fruits _______________ Vegetables _______________ Breads & Cereals _______________ Fats, Oils & Sweets _______________ Specific Recommendations FEEDBACK FORM Food Group I ate: My total should be: _____ _____ Animal _____ _____ Plant _____ _____ Milk _____ _____ Fruits* _____ _____ _____ _____ _____ _____ _____ _____ Breads/Cereals* _____ _____ Whole grain _____ _____ _____ _____ Meat/Protein* Vit. A, C fruit Vegetables* Vit. A, C vegetable Fats, Oils & Sweets** © 2009, Nutrition Dimension, Inc. Amount Eaten Record the amount of food that you ate today in each food group. Each box equals either one ounce or one cup, based on the food group. The total amount eaten in each group should equal or exceed what you are allowed in your personal meal plan, developed for you by your nutrition counselor. *The amount eaten in these groups is counted by totaling the recommended sub-groups along with the main group. **The number of servings in this group is based on your caloric needs and varies from day to day. Appendix #10 194 Food Frequency Form Please check the column that shows how often you eat the following foods. Check only one column for each food. Name___________________________ Date____________________________ 2-4 Times a Day Once Daily 2-4 Times a Week Once Weekly Hardly Ever or Never © 2009, Nutrition Dimension, Inc. Beef, pork, ham, hamburger Luncheon meats, hot dogs Chicken, turkey, poultry Fish, seafood Eggs Dried peas or beans (legumes) Peanut butter Nuts Cereals (dry or cooked) Grains Breads, rolls, biscuits Tortillas Crackers Rice Pasta, noodles, spaghetti, macaroni Milk Cheese Yogurt, pudding, custard Fruits Fruit juices Vegetables Water Added Fat Coffee, tea, cocoa Sodas, fruit flavored drinks Alcohol: beer, wine, whiskey Candy, sweets Cakes, pies, cookies, donuts, sweet rolls Potato chips, pretzels, corn/tortilla chips Ice cream WEEKLY TOTALS: Meat ___________________ Poultry __________________ Fish ____________________ Legumes ________________ Eggs ___________________ Breads & cereal ___________ Rice & pasta _____________ Fruits & juices* ___________ Vegetables* ______________ Dairy products ____________ Water ___________________ Sodas __________________ Alcohol _________________ Cakes, pies ______________ Chips ___________________ Ice cream ________________ Candy __________________ Fats ____________________ Other ___________________ *Ask types to determine if they are high in vitamin A or C Appendix #11 195 Solutions to Common Pregnancy Problems PROBLEM Inadequate Weight Gain Heartburn © 2009, Nutrition Dimension, Inc. Constipation Leg Cramps SOLUTION • Exercising and not eating enough - add food and calories to your diet • Nausea and vomiting - see Appendix #13 • Afraid to gain weight - talk with a professional to help you gain the weight you need • Increase to the maximum the servings of foods from the Food Guide Pyramid • To increase calories in your diet: eat foods with more fat; eat small meals more often; drink high-calorie, nutritious beverages such as yogurt smoothies, milkshakes, juice drinks; eat sweets and high-calorie desserts once all your requirements for nutritious foods are met • Have your diet analyzed to determine what you may be missing if you are unable to increase your food intake • Keep food or beverages nearby at all times to eat or drink throughout the day • Set a timer to remind yourself to eat • Eat 4-6 times a day instead of 3 meals a day • Avoid getting too full • Drink liquids between meals if you feel too full • Avoid greasy, highly seasoned food and coffee and cigarettes • Wear clothing that is loose around the waist • Do not lie down immediately after a meal • Sleep and rest with your head slightly elevated • Sip water, milk or juice when you have heartburn • Take a walk, sit up, or sit quietly and breathe deeply when you have heartburn • Use antacids that do not contain aluminum • Eat high fiber foods: fruits, vegetables, whole grain, dried peas and beans, nuts • Eat oatmeal, applesauce, legumes and barley to soften the stool • Drink plenty of water, six 8 oz glasses per day • Exercise daily to stimulate your intestines • Iron supplements can cause constipation. Determine if you can decrease your dose. If not, take with prune juice • Use bulk-producing laxatives, such as Metamucil or Effersyllium, as they are not absorbed into the body • Raise your feet on a stool during bowel movements to reduce straining • Check with your doctor before using any over-the-counter laxatives as there may be ingredients harmful to your baby • Eat foods high in calcium: milk, yogurt, cheese, pudding, sardines, canned salmon, tofu, almonds, baked beans, tortillas treated with lime, broccoli, amaranth • Eat foods high in magnesium: avocado, beans (garbanzo, kidney, navy, pinto, soy), broccoli, greens, bran or whole wheat cereal, peanuts, peanut butter, tofu, whole wheat bread, whole wheat muffins, sesame butter (tahini) and lima beans • Avoid excess phosphate in animal products such as meat and milk and in carbonated beverages (soda) and processed foods • Supplement calcium (600 mg) and magnesium (320 mg) if diet is inadequate • Do not use calcium phosphate as a supplement Appendix #12 196 Folate Content of Selected Foods © 2009, Nutrition Dimension, Inc. Food Common Measure Folate (mcg) Beverages Orange juice Pineapple juice Tomato juice Peach Nectar Apple juice 4 fl oz 4 fl oz 4 fl oz 4 fl oz 4 fl oz 55 30 25 2 0.5 Fruits Avocado Orange Papaya Blackberries Raspberries Grapefruit Canteloupe or strawberries Banana Pear Pineapple, canned Peaches, canned Grapes or watermelon Apple 1/2 medium 1 medium 1 cup 1 cup 1 cup 1 medium 1 cup 1 medium 1 medium 1 cup 1 cup 1 cup 1 medium 60 40 53 49 32 24 27 22 15 12 8 4 0.5 Legumes (dried peas & beans) Lentils, cooked Pinto beans, cooked Lima beans, baby, cooked Black beans, cooked Kidney beans, cooked Navy beans, cooked Split peas, cooked Miso, fermented soybeans Tempeh Tofu, raw, firm 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 358 294 273 25 229 163 127 91 86 74 Vegetables Spinach, cooked Asparagus, cooked Green peas, cooked Broccoli, cooked Lettuce, raw Green beans, cooked Squash, zucchini Corn on the cob Sweet potato, cooked Potato, baked Carrots, raw 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 ear 1 cup 1 medium 1 medium 262 190 94 78 75 41 30 38 35 22 10 Dairy Products, Eggs & Margarine Milk, all kinds Egg, whole Ricotta cheese Yogurt, plain, nonfat Cheese, cottage Cheese, parmesan, grated 8 fl oz 1 medium 1 cup 1 cup 1 cup 1 cup 15 23 32 28 30 8 Fish/Seafood Crab or mussels, cooked Tuna, canned Most other fish 1 cup 1/2 cup 4-6 oz 65 4 5-15 Food Common Measure Folate (mcg) Meat and Poultry Liver, chicken, cooked Liver, beef or pork, cooked Chicken giblets, cooked Beef or pork, cooked Frankfurter Chicken or turkey, cooked Turkey, cooked Sausage Bacon 1 cup 1 oz 1 cup 1 oz 1 1 oz 1 oz 1 1 slice 1077 62 545 2 2 2 2 0.5 0.3 Breads/Crackers¶ Roll, hard English muffin Bread (various kinds) Roll, hamburger Muffin Bagel Tortilla, corn Cornbread Crackers (various kinds) 1 1 1 slice 1 1 1 1 1 2"x2" square 1 40 20 8-16 15 15 13 6 5 0.3-1 Cereals (non-sugar coated) Total Product 19 Grape-nuts All-Bran Raisin Bran Bran Chex Wheaties Rice Krispies Oat Bran Oatmeal, cooked Malt-o-Meal, cooked Cheerios 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 466 466 402 301 130-201 143 102 100 48 9 5 5 Pasta & Grains Wheat germ, crude Brewers yeast, dry Amaranth, uncooked Quinoa, dry Flour, rye, dark Cornmeal, dry* Flour, wheat & whole grain* Flour, white* Millet, cooked Rice, wild, cooked Bulgur, cooked Couscous, cooked Barley, pearled, cooked Spaghetti, cooked* Macaroni, cooked* Rice, brown/white, cooked 1 cup 1 Tbsp 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 324 313 95 83 77 66/220 53/64 32/192 46 43 33 27 26 17/98 10/95 8/6 Snack Foods Chocolate chip cookie Danish pastry Cake donut Apple pie 1 1 1 1 slice 7 43 21 37 ¶Some of these products are made from enriched flour, some are not. The folic acid content will vary based on the type of flour used. * These foods have two values. The first value is for an unenriched version of the product the second is for the enriched version of the product; which has folic acid added. Appendix #13 197 Handling Nausea & Vomiting During Pregnancy The Problem Many women experience nausea and vomiting with their pregnancy. For some women the problem is minor and stops by the 12th to 20th week of pregnancy. Other women experience more severe problems that do not go away and continue to get worse. Outlined here are strategies to deal with the problem and to prevent problems from occurring. Remember, the physical and hormonal changes of pregnancy are causing the nausea/vomiting and it will go away. How To Get Started Identify what may trigger your nausea. Some examples include: • smells — food, cooking food, coffee, perfume, soap, animals, mold, etc. • motion — abrupt movements, rocking, jarring, bumpy rides, etc. • tastes — specific foods such as meat, fried foods, spicy foods • fatigue Keep a journal to help identify problem areas for you. You will often find that a solution appears to you once you know what the problem is. Include the following in your journal or log: • time of day • activity • noise • trigger (if you can identify it) • food eaten • food desired • beverages, including water • how you felt • notes for yourself Determining What to Eat There is no right way or wrong way to eat if you are battling nausea and vomiting.The goal is to eat foods and drink beverages that stay down. Always ask yourself what you want to eat or what sounds good to you, and then eat it. Foods can have a variety of characteristics that may help you identify what you want to eat: • flavor — sweet, sour, bitter, salty, spicy, bland • consistency — thin, thick, lumpy, smooth, hard • texture — crunchy, soft • temperature — hot, cold, room temperature © 2009, Nutrition Dimension, Inc. Figure out if certain foods work for you at certain times of the day or under certain circumstances. There are no rules or restrictions for what works. If you want potato chips for breakfast, eat them! Try to let go of your preconceptions to find solutions. Preventing Problems If your nausea does not go away, do the following: 1. Take a multivitamin and mineral supplement to provide nutrients you are not getting in your diet. 2. See a Registered Dietitian (RD) who can analyze your diet and intake and help you with it. 3. Monitor your weight and weight gain. This is the biggest problem that can affect the fetus. The RD or your health care provider will monitor your weight as well to determine if there is a problem. 4. Dehydration can be a problem with poor fluid intake and vomiting. Try to find beverages that you can tolerate. If you are experiencing problems, see your health care provider. Appendix #14 198 Sources of Omega-3 Fatty Acids 100 gm (3.5 oz) portion sizes © 2009, Nutrition Dimension, Inc. Food Total Fat (gm) Total saturated (gm) Total Total monounsaturated polyunsaturated (gm) (gm) 18:3 (gm) 20:5† (gm) 22:6† (gm) Cholesterol (mg) Anchovy, european Bluefish Catfish, channel Cod, Atantic Eel, european Flounder, unspecified Halibut, Pacific Herring, Pacific Mackerel, Atlantic Ocean perch Pollock Sablefish Salmon, chinook Salmon, pink Snapper, red Swordfish Trout, rainbow Tuna, albacore Whitefish, lake Crab, Dungeness Crayfish Lobster, northern Shrimp, unspecified Clam, littleneck Mussel, blue Oyster, Pacific Scallop, Atlantic Squid, unspecified 4.8 6.5 4.3 .7 18.8 1.0 2.3 13.9 13.9 1.6 1.0 15.3 10.4 3.4 1.2 2.1 3.4 4.9 6.0 1.0 1.4 .9 1.1 .8 2.2 2.3 .8 1.1 1.3 1.4 1.0 .1 3.5 .2 .3 3.3 3.6 .3 .1 3.2 2.5 .6 .2 .6 .6 1.2 .9 .1 .3 .2 .2 .1 .4 .5 .1 .3 1.2 2.9 1.6 .1 10.9 .3 .8 6.9 5.4 .6 .1 8.1 4.5 2.1 .2 .8 1.0 1.2 2.0 .2 .4 .2 .1 .1 .5 .4 .1 .1 1.6 1.6 1.0 .3 1.4 .3 .7 2.4 3.7 .5 .5 2.0 2.1 1.7 .4 .2 1.2 1.8 2.2 .3 .3 .2 .4 .1 .6 .9 .3 .4 — — Tr Tr .7 Tr .1 .1 .1 Tr — .1 .1 .2 Tr — .1 .2 .2 — Tr — Tr Tr Tr Tr Tr Tr 0.5 .4 .1 .1 .1 .1 .1 1.0 .9 .1 .1 .7 .8 .3 Tr .1 .1 .3 .3 .2 .1 .1 .2 Tr .2 .4 .1 .1 0.9 .8 .2 .2 .1 .1 .3 .7 1.6 .1 .4 .7 .6 .5 .2 .1 .4 1.0 1.0 .1 Tr .1 .1 Tr .3 .2 .1 .2 — 59 58 43 108 46 32 77 80 42 71 49 — — — 39 57 54 60 59 158 95 147 — 38 — 37 — Beef, roast Chicken, raw, white* Pork, fresh, ham Linseed oil Canola oil Soybean oil Salad dressing** Salad dressing** Margarine** Avocados Beans, dry Lentils Soybeans, dry Walnuts, English Broccoli Spinach 23.0 1.7 20.8 100.0 100.0 100.0 35.7 79.4 60.8 17.3 1.5 1.2 21.3 61.9 .4 .4 10.0 .4 7.5 9.4 6.8 14.4 6.0 11.8 14.1 2.6 .2 .2 3.1 5.6 Tr Tr 10.8 .4 9.7 20.2 55.5 23.3 8.3 22.7 26.0 11.2 .1 .2 4.4 14.2 Tr Tr .9 .4 2.2 66.0 33.3 57.9 19.8 41.3 18.1 2.0 .9 .5 12.3 39.1 .2 .1 0.3 Tr .2 53.3 11.1 6.8 2.5 4.2 1.6 .1 .6 .1 1.6 6.8 .1 .1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 73 58 74 0 0 0 0 59 0 0 0 0 0 0 0 0 †Plants and meats do not contain 20:5 and 22:6 fatty acids — means no data available. Tr=<0.05 grams per 100 grams of food. *Chicken is white meat, raw, without the skin. **The amount of fat and Ω-3 fats is dependent upon the ingredients in these products. Salad dressings and margarine do not contribute significantly to the Ω-3 content of the American diet. Source: Table on the content of Ω-3 fatty acids and other fat components in selected foods, USDA, Nutrition Research Data Branch, Human Nutrition Information Service, HNIS/PT-103, 1986. Appendix #15 199 Medicinal Herbs Considered Not Appropriate for Use During Pregnancy or Lactation Agnus Castus Asafoetida Bogbean Broom Calamus Chamomile, Roman Cola Cornsilk Dong Quai Eupatorium Foxglove Germander Ground Ivy Heliotropium Horsetail Juniper Mandrake Melilot Nettle Petasites Pokeroot Queen's Delight Rhubarb Senna Squill Uva-Ursi Wormwood Aloes Aristolochia Boldo Buchu Calendula Chaparral Coltsfoot Crotalaria Dogbane Euphorbia Frangula Ginseng Eleuthero Groundsel Hops Horseradish Life Root Maté Mistletoe Osha Plantain Poplar Ragwort Rue Shepherd's Purse St. John's Wort Vervain Yarrow Angelica Avens Boneset Buckthorn Cascara Cohosh, Black Comfrey Damiana Ephedra Fenugreek Fucus Ginseng, Panax Guarana Horehound, Black Hydrocotyle Licorice Male Fern Motherwort Passionflower Pleurisy Root Prickly Ash Raspberry Sassafras Skunk Cabbage Tansy Wild Carrot Yellow Dock Apricot Kernel Blue Flag Borage Burdock Chamomile, German Cohosh, Blue Cottonroot Devil's Claw Eucalyptus Feverfew Gentian Goldenseal Hawthorne Horehound, White Jamaican Dogwood Lobelia Meadowsweet Myrrh Pennyroyal Podophyllum Pulsatilla Red Clover Scullcap Stephania Tonka Bean Willow Yohimbe © 2009, Nutrition Dimension, Inc. Exclusion from this list should not be construed as a recommendation for safety. Unless proven safe, herbs should not be used during pregnancy. Foote J and Rengers B. Nutrition in Complementary Care. A Dietetic Practice group of the ADA. Volume 2(2). Winter, 2000. Additional Resources about Herbs: Alternative Medicine Foundation: American Botanical Council: Consumer Healthcare Products Association: Consumerlab.com: Council for Responsible Nutrition: Herb Research Foundation: National Center for Complementary and Alternative Medicine: National Institutes of Health: Office of Dietary Supplements: Supplement Watch: United States Pharmacopoeia: www.amfoundation.org www.herbalgram.org www.chpa-info.org www.consumerlab.com www.crnusa.org www.herbs.org http://nccam.nih.gov http://dietary-supplements.info.nih.gov www.supplementwatch.com www.usp.org Appendix #16 200 Vegetarian Food Pyramid Fats: 2 servings Legumes, nuts & other protein-rich foods: 5 servings Grains: 6 servings Medium fruit, 1 Cut up or cooked fruit, 1/2 cup (125 mL); Fruit juice, 1/2 cup (125 mL); Dried fruit, 1/4 cup (60 mL) Cooked vegetables, 1/2 cup (125 mL); Raw vegetables, 1 cup (250 mL); Vegetable juice, 1/2 cup (125 mL) m- ric hf ood s: 8 Bok cho c mus ollards, y, broc coli, tard Chin g 1 cu reens, ese cabb kale or p( ag r Forti fied aw 2 cup 250 mL okra coo e, , toma ked, s (50 ), or Cow to ju s mi 1/2 ice 1 0 mL); lk c / 2 cu Tem up (125 or yog p (1 pe u m Alm 25 m ond h or cal L); Che rt or for s L) 1/2 esame t s 1/4 cu cium-se ese 3/4 tified s o t a p o y t cup h (125 ini, 2 tb (60 mL ofu 1/2 c z (21 gm milk, up sp ); ) mL) ; So (30 mL Almond (125 m ; ynut L s 1/4 ); Cooke butter o ); r d 1 oz cup (60 soybean (28 mL) gm) s calc ium -for tifie d br eakf ast cere al Vegetables: 4 servings lciu Fort if juice ied 1 (125 / 2 cup m Figs L); ,5 Fruits: 2 servings Ca fruit oil, margarine, or mayonnaise, 1 tsp (5mL) ser vin gs Cooked beans, peas, or lentils, 1/2 cup (125 mL); Tofu or tempeh, 1/2 cup (125 mL); Nut or seed butter, 2 tbsp (30 mL); Nuts, 1/4 cup (60 mL); Meat analog, 1 oz (28 gm); Egg 1 Bread, 1 slice; Cooked grain or cereal, 1/2 cup (125 mL); Cooked grain or cereal, 1/2 cup (125 mL); Ready-to-eat cereal, 1 oz (28 gm) Modification to the Food Guide Pyramid During pregnancy include the following:* B12 - rich foods 4 servings Beans/nuts/seeds/ eggs 7 servings Calcium-rich foods 8 servings *The number of servings in each group is the minimum amount needed. The minimum number of servings from other groups is not different from the Vegetarian Food Guide above. Additional foods can be chosen from any of the groups in the Vegetarian Food Guide to meet energy needs. © 2009, Nutrition Dimension, Inc. Recommendations for Pregnant Vegetarians Pregnant lacto-ovo-vegetarians: • Emphasize dietary iron, folate, vitamin D and zinc • Daily iron and folic acid supplement Pregnant vegans: • Emphasize calories, iron, folic acid, vitamin D, calcim, zinc, vitamin B12 and protein • Daily iron and folic acid supplement and vitamin D if sunlight exposure is limited • Reliable source of vitamin B12 daily Examination 201 NW109 Answer each question by checking the correct answer online or filling the circle corresponding to the correct answer on the answer sheet. There is one best answer for each question. If you want a record of your answers, photocopy the answer sheet or record your choices on another piece of paper. Do not detach the examination from the book. This exam has 40 questions. 1. The onset of the symptoms of PMS occurs: a. at the beginning of the menstrual cycle b. at the end of the menstrual cycle c. 7 to 14 days prior to menstruation d. 21 days prior to menstruation e. 2 to 3 days prior to ovulation 2. Which of the following nutrients has solid evidence that supplementation can reduce symptoms of PMS, including water retention, mood changes and food cravings? a. magnesium b. evening primrose oil c. complex carbohydrates d. calcium e. vitamin B6 3. Which active ingredient in the herb chasteberry improves fluid retention in PMS? a. opiods b. estrogen-like substance c. progesterone-like substance d. β-endorphins e. flavonoids 4. Norethisterone, an older progestogen, and levonorgestrel, found in OCA have what effect on serum lipids? a. increase total cholesterol and HDL cholesterol b. decrease total cholesterol and increase free fatty acids c. decrease total cholesterol and free fatty acids d. increase LDL cholesterol and decrease HDL cholesterol e. have no measurable effect © 2009, Nutrition Dimension/Gannett Education, Inc. 5. The hormone dose in oral contraceptives is higher now than when first introduced. a. True b. False 6. Two nutrients whose requirement increases while using oral contraceptives are: a. calcium and folic acid b. vitamin A and B6 c. vitamin B6 and folic acid d. iron and zinc e. vitamin D and selenium Exam, cont’d 202 NW109 7. Women using oral contraceptives have a lower risk for venous thromboembolytic disease, including deep vein thrombosis and pulmonary embolism, than women who are pregnant. a. True b. False 8. Of the following supplemental levels of vitamin B6, which is considered safe? a. no level is safe b. 100 mg c. 250 mg d 500 mg e. 600 mg 9. The most important controllable factors determining the perinatal mortality rate are: a. prenatal care and adequate nutrition b. giving birth in a hospital and vitamin supplements c. sophisticated medical equipment and hospital births d. socioeconomic status and adequate nutrition e. education level and attitude 10. A mother, underweight prior to pregnancy, who does not gain adequately during pregnancy, will deliver an infant who is at higher risk for: a. macrosomia, coronary heart disease and cancer b. low birth weight, coronary heart disease and diabetes c. macrosomia, diabetes and autoimmune disease d. hypertension, cancer and heart failure © 2009, Nutrition Dimension/Gannett Education, Inc. 11. The plasma volume expands during pregnancy by 20 to 100 percent. Why is this plasma volume expansion critical? a. to ensure an adequate supply of white blood cells b. for adequate perfusion of the placenta c. for digestion and absorption of nutrients d. to ensure adequate hormonal production e. to form the baby’s blood supply 12. Which of the following metabolic changes occur during pregnancy? a. shift to glucose as a primary energy source for the mother b. shift to the use of fat as a primary energy source for the mother c. decreased sensitivity of maternal tissues to insulin d. a and c e. b and c 13. Which nutrient(s) does the fetus use as its primary energy source? a. fat b. protein c. glucose d. a, b, and c e. a and b Exam, cont’d 203 NW109 14. Which nutrients are transported across the placenta against a concentration gradient, allowing the mother to become deficient if her intake is inadequate? a. calcium, B6, zinc b. amino acids, calcium, iron, DHA c. zinc, iron, folic acid, DHA d. iron, folic acid, B6 e. all minerals 15. What recommendation would you give to a pregnant woman who wants to eat fish to meet her Ω-3 fatty acid requirement? a. Eat two servings per week of fish that are low in mercury, such as salmon, shrimp and light tuna. b. Eat two servings per week of fish that are low in mercury, such as shark and swordfish. c. Eat one serving of fish a day or intake is inadequate to meet the needs of the mother and fetus. d. Do not eat any fish, as all fish is unsafe to eat. 16. If a pregnant woman has edema, she should always limit her salt intake. a. True b. False 17. Which nutrients are critical during the first trimester of pregnancy? a. magnesium and folate b. iron and zinc c. zinc and folate d. calcium and zinc e. copper and iron 18. NC is 19 years old, in her 16th week of pregnancy and smokes 1.5 packs of cigarettes a day. At the clinic her hemoglobin is 10.3 gm/dl and her hematocrit is 31 percent. Is she anemic? a. No b. Yes © 2009, Nutrition Dimension/Gannett Education, Inc. 19. Which of the following was the main reason for the publication of new weight gain guidelines in 2009 by the Institute of Medicine: a. The amount of weight gain necessary for a healthy pregnancy had been too low. b. An increase in small-for-gestational age babies indicating women were not gaining enough weight during pregnancy. c. The complications of pregnancy were increasing due to improper weight gain recommendations. d. Women are now gaining too much weight during pregnancy, having large-for-gestational age babies and retaining excess weight. 20. A pregnant woman who is underweight at conception should gain how many pounds? a. 15 to 22 b. 20 to 29 c. 25 to 34 d. 28 to 40 e. as much as possible Exam, cont’d 204 NW109 21. CR is 5'7" and weighed 115 lb prior to pregnancy. At the end of her second trimester CR had gained a total of 12 lb — 5 lb her first trimester and 7 lb the second trimester. Which of the following statements best reflects her weight gain so far? a. the weight gained both trimesters is adequate b. not enough weight was gained during the first trimester c. the weight gain during the second trimester was inadequate d. the weight gained both trimesters is inadequate 22. Excessive weight gain, above IOM recommendations, increases maternal body fat and can lead to what potential problem? a. increased risk for large for gestational age babies b. decreased heart rate c. glucose intolerance in the fetus d. excess water retention e. it doesn't matter how much a woman gains, the more the better 23. It is impossible for a pregnant vegetarian to get adequate nutrients from the diet: a. True b. False 24. If an obese women with a BMI of 39 prior to pregnancy gains only two pounds by the beginning of the third trimester, what do you recommend? a. that she immediately gains at least a pound a week. b. that she gains at least 15 pounds in the third trimester c. that she gains as much weight as the fetus will weigh d. do not worry about weight gain if her diet is adequate in calories, protein and other nutrients e. that she increases her intake to at least six meals a day so she begins to gain weight © 2009, Nutrition Dimension/Gannett Education, Inc. 25. Which of the following foods has the same amount of calcium as an 8 oz glass of milk? a. 2 cups tofu b. 1 cup amaranth c. 1.5 cups dark green leafy vegetables d. all of the above e. none of the above 26. Which of the following food groups are most likely to be inadequate in the diet of pregnant women? a. fruits, meats and meat alternates b. vegetables, fats, oils & sweets c. milk & milk products, fruits & vegetables d. milk & milk products, breads & cereals e. meat and meat alternates, breads & cereals 27. Which of the following is recommended to prevent heartburn during pregnancy? a. avoid high-fat meals b. avoid spicy foods c. don't lie down after eating d. a, b and c Exam, cont’d 205 NW109 28. Exercising during pregnancy causes what physiological alteration? a. decreased respiration b. decreased uterine blood flow with less oxygen supply to the fetus c. increased kidney filtration d. decreased uterine blood flow and no change in oxygen to the fetus e. increased incidence of anemia 29. Which of the following nutrients may interfere with each other when supplemented? a. protein and vitamin C b. vitamin B12 and calcium c. iron and zinc d. zinc and vitamin C 30. Iron supplementation is necessary for all pregnant women during the first trimester. a. True b. False 31. How much supplemental vitamin D is safe for pregnant women? a. 200 IU b. 800 IU c. 2,000 IU d. 5,000 IU e. 10,000 IU 32. Which of the following is NOT a clinical symptom of preeclampsia? a. elevated blood pressure b. elevated cholesterol level c. protein in the urine d. edema e. all are symptoms © 2009, Nutrition Dimension/Gannett Education, Inc. 33. A client of your develops preeclampsia. Which of the following nutrients should you make sure are in her diet in adequate amounts? a. Ω-6 fatty acids, vitamin C and vitamin E b. Ω-3 fatty acids, vitamin D and plant foods c. Ω-6 fatty acids and plant foods d. Ω-3 fatty acids, dairy foods and protein 34. Although you must individualize the diet of a pregnant diabetic woman, what percentage of calories from carbohydrate appear to give the best glucose control for gestational diabetic women? a. 35 to 40 percent b. 40 to 45 percent c. 45 to 50 percent d. 50 to 55 percent e. 55 to 60 percent Exam, cont’d 206 NW109 35. Gestational diabetes is characterized by which of the following metabolic changes? a. increased insulin resistance b. decreased total cholesterol c. decreased serum ketones d. decreased insulin resistance e. high blood pressure 36. Maternal smoking during pregnancy has what effect on the outcome of pregnancy? a. none b. low birth weight babies c. malformed babies d. neural tube defects e. nicotine withdrawal 37. Smokers have lower serum levels and may need to supplement: a. vitamin C b. folic acid c. zinc d. a and b e. b and c 38. Zidovudine can decrease transmission of the HIV virus from mother to fetus by how much? a. 2/3 b. 1/2 c. 1/3 d. 1/4 e. 1/8 © 2009, Nutrition Dimension/Gannett Education, Inc. 39. The best recommendation we can make to pregnant women regarding caffeine intake during pregnancy is to reduce caffeine intake to two cups of coffee a day or the equivalent amount of caffeine — 150 mg to 300 mg per day. a. True b. False 40. Which of the following physiological changes of pregnancy alter drug metabolism? a. decreased gastric tone and motility b. decreased hydrochloric acid secretion c. decreased albumin-binding capacity of drugs d. increased excretion of drugs by kidneys e. all of the above