Download Nutritional Concerns During Pregnancy – Well

Substance Abuse and Nutrition:
Imperfect Together
Alyce Thomas, RD
Perinatal Nutrition Consultant
Dept. of Obstetrics and Gynecology
St. Joseph’s Regional Medical Center
Paterson, NJ
1
Outline







Potential Effects of Substance Use on Nutritional
Status
Specific Risks Associated with Substance Use in
Pregnancy
Components of Nutrition Assessment
Assessing Dietary Intake
Nutrients of Major Concern in Pregnancy
Nutrition-related Concerns of Substance Abuse in
Pregnancy
Nutrition Interventions
2
Potential Effects of Substance
Use on Nutritional Status






Appetite suppression
Poor food choices
Reduced nutrient intake
Impaired nutrient absorption/metabolism
Inadequate weight loss/gain
Gastrointestinal discomforts
3
Nutritional Risks Associated with
Substance Use






Alcohol
Cocaine
Heroin
Marijuana
Tobacco
Caffeine
4
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage,
utilization and excretion of nutrients

Alcohol affects maternal and fetal
nutrition
5
Calorie Content




Carbohydrates
Protein
Fat
Alcohol




4 kcal/gram
4 kcal/gram
9 kcal/gram
7 kcal/gram
6
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage,
utilization and excretion of nutrients

Alcohol affects maternal and fetal
nutrition
7
Gastrointestinal Tract
8
Central Nervous System
9
Nutrients Affected by Alcohol






Protein
Carbohydrates
Lipids
Vitamins
Minerals
Water
10
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage,
utilization and excretion of nutrients

Alcohol affects maternal and fetal
nutrition
11
Alcohol Affects to Fetus





Impairs placental nutrient transport
 Glucose transport necessary for fetal brain
development
Prenatal insulin resistance may lead to glucose
intolerance later in life
Folate and zinc deficiency may lead to neural
tube teratogenesis
Animal studies found that the effect of alcohol
was not as severe when maternal diet adequate in
zinc
12
Cocaine




Little is known about effects of cocaine on
maternal and fetal nutrition
Interferes with appetite
Causes maternal and fetal vasoconstriction
→ fetal hypoxia
 nutrient supply → IUGR
13
Growth patterns of infants exposed to
cocaine and other drugs in utero
Author: Harsham et al
Setting: Northern California
Sample: 31 infants exposed to drugs in utero
Outcome:
1. Birth weight, birth length were significantly lower
than NCHS
2. By 6 months, no significant differences for weight,
but differences in length
J Amer Diet Assoc 1994;94(9):999
14
Heroin



Associated with  birth weight, prematurity and
IUGR
Common symptom of opiate abuse: constipation
May be poorly nourished




Vitamin deficiencies
Iron deficiency anemia
Folic acid deficiency anemia
May experience food cravings
15
Marijuana


Associated with  birth weight and length
Conflicting study results have not shown
any nutrition-related effects of marijuana
use in pregnancy



Weight gain ?
Weight loss ?
No difference in women who smoked
marijuana and those who did not
16
Tobacco



Decreased birth weight associated with
maternal smoking
Associated with IUGR
Nutrition-related effects



Lower availability of calories
↑ iron requirements
 availability of certain nutrients (B12, amino
acids, vitamin C, folate, zinc
17
Caffeine



Affects the CNS 15 minutes after ingestion
Caffeine intake > 300 mg/day linked to ↑ 1st
trimester abortions
Moderate to heavy caffeine linked to:




Lower birth weight
↑ risk of preterm labor
Delayed conception
 absorption and ↑ urinary losses of vitamin B1, zinc,
iron and calcium
18
Caffeine Content of Selected Beverages
8-oz.
Mg.
 Coffee, drip
115-175
 Coffee, brewed
80-135
 Coffee, espresso
100
 Coffee, instant
65-100
 Tea, iced
47
 Tea, brewed
60
 Tea, green
15
 Hot cocoa
14
 Coffee, decaf
3-4
12 oz.
Mg.
 Red Bull
 Pepsi One
 Mountain Dew
 Diet Coke
 Pepsi
 Coke
 Snapple teas
 Slim Fast
80
55.5
55
45.6
37.5
34
31.5
20
(chocolate flavored)

Sprite
0
19
Nutrition Assessment

Medical history – past and present




Obstetrical history
Psycho/social/economic history
Nutrition history
Weight
20
Medical/Obstetric History








Age
Estimated due date
Present history
Previous obstetric history
Past medical history
Family history of chronic illness
Medications or nutrient supplements
Physical signs of nutritional deficiencies
21
Psycho/Socio/Economic History








Financial status
Current living conditions
Relationship with family
Cultural/religious background
Food availability
Participation in food programs
Work/school schedule
Educational level
22
Nutrition Assessment





Pre-pregnancy
weight/usual weight
Current height
Appetite
Recent appetite
changes
Current diet or food
plan




Cravings/allergies/
intolerance
Pica
Medications – herbal,
dietary supplements
PNV, OTC
Alcohol – drink or
cook
23
Nutrition Assessment





Snack patterns
Dental problems
Raw or undercooked
protein foods
GI discomforts
Fluid intake





Substance use
Ptyalism
Physical activity
Planned method of
infant feeding
Foods eaten away
from home
24
Assessing Dietary Intake





Referral Form
Nutrition Questionnaire
Food Frequency Questionnaire
24-Hour Recall
Food Record
25
Why Is Weight Gain Important?




Effects fetal growth and length of gestation
Inadequate weight gain associated with ↑
prematurity &low birth weight (LBW)
LBW major determinant for morbidity and
mortality
LBW associated with ↑ risk of CVD, DM,
HTN and obesity in later years
26
Body Mass Index
BMI
IOM
NHLBI
WHO
Underweight
< 19.8
< 18.5
< 18.5
Normal
> 19.8 – 26.0 18.5 – 24.9
18.5 – 24.9
Overweight
>26.0 – 29.0
25.0 – 29.9
25.0 – 29.9
Obesity
> 29.0
> 30.0
> 30.0
27
Recommended Weight Gain

Underweight

28 – 40 lb.

Normal weight

25 – 35 lb.

Overweight

15 – 25 lbs.

Obese

Individualize
28
Components of Weight Gain

Baby



Placenta
Amniotic fluid



7½ lb.
1½ lb.
2 lb.
Mother





Breasts
Uterus
Body fluids
Blood
Maternal Stores





2 lb.
2 lb.
4 lb.
4 lb.
7 lb.
29
Inadequate Weight Gain







Measurement error
Disordered eating
Restrictive eating or
dieting
Pica
Depression/stress
Inadequate food access
GI Discomforts
30
Excessive Weight Gain






Measurement error
Smoking cessation
Infrequent large
meals
↑ calorie intake
Physical inactivity
Multiple gestation



Depression/stress
Binge eating
Pica
31
32
Nutrient Concerns During Pregnancy





Carbohydrates
Fiber
Protein
Fat
Calcium





Magnesium
Vitamin D
Iron
Folate
Zinc*
33
Carbohydrates




Choose fiber rich fruits,
vegetables and whole
grains
Limit intake of foods
with added sugar
Fiber recommendation –
14 gm/1000 calories
Discretionary calories

Not to exceed allowance
for calorie level
34
Protein

Dietary Reference
Intake for protein in
pregnancy: 71
gm/day

+ 25 gm after 1st
trimester
35
Fats

< 10% of calories from saturated
fats

< 300 mg/day dietary cholesterol

Keep trans fats as low as possible

Total fat intake: 20 to 35% of
total calories mostly from
unsaturated fats
36
Essential Fatty Acids

Omega-3 (linolenic
acid)




All fish and seafood
Egg yolks
Soybeans
Canola, flaxseed and
olive oils

Omega-6 (linoleic
acid)



Walnuts, peanuts,
almonds
Seeds, such as
sunflower
Corn, safflower and
sunflower oils
37
Calcium, Vitamin D and Magnesium

Calcium


Vitamin D



Deposited in fetal skeleton mainly in 3rd trimester
Required for calcium homeostasis
Maternal deficiency associated with neonatal rickets
Magnesium


Regulates calcium absorption and relaxes smooth
muscle
Main foods sources: unprocessed whole grains
38
Folate



600 mcg in pregnancy
↑ up to 4 mg if previous
NTD or anti-seizure meds
Food sources



Fortified and whole grain
breads and cereals
Dark, green, leafy
vegetables
Avocado, oranges
39
Iron

Iron deficiency is very common in women


Pre-pregnant requirements: 15 – 18 mg/d
Pregnancy requirements: 27 mg/d

CDC recommends 30 mg/d supplement at initial
prenatal visit

Food sources

Heme iron rich or non-heme iron with facilitators
40
Zinc

Essential for fetal growth & development




Affects protein synthesis
Aids absorption of B-complex vitamins
Deficiencies: congenital anomalies, IUGR,
prematurity
Food sources: meat, fish, eggs, shellfish
41
42
43
Food Groups to Encourage

Eat 2 cups of fruits
and 2½ cups of
vegetables daily

Vegetables


Dark green, orange,
legumes, starchy
vegetables, other
vegetables
Fruits

Fresh, frozen,
canned, dried
44
Food Groups to Encourage
Whole Grains
 Important for fiber and
other nutrients

Recommend > 3 oz.
equivalents/d

½ of all grains should be
whole grains
45
Milk and Milk Products

Pregnancy
Requirements


> 3 servings/day
Milk alternatives



Yogurt
Lactose-free milk
Non-dairy calciumcontaining alternatives
46
Pregnancy and Vegetarian
Nutritional Concerns
 Calories
 Iron
 Zinc
 Calcium and Vitamin D
 Vitamin B12
 Fats
47
Tips for Common GI Discomforts
of Pregnancy

Nausea and Vomiting

Heartburn

Constipation

Ptyalism
48
Food Safety
Avoid in pregnancy

Raw or unpasteurized milk products

Raw or soft cooked eggs

Raw or rare meat products

Unpasteurized juices or milk products
49
Food Safety

Wash hands, utensils and cutting
surfaces after handling food

Cook foods thoroughly

Wash raw fruits and vegetables
before eating

Separate uncooked meat products
from other foods

Chill perishable foods promptly
50
Breastfeeding and Substance Abuse

AAP recommends
exclusive breastfeeding
for 1st 6 months of life

Healthy People 2010:
75% women
breastfeeding in early
postpartum period
Recommendations for
substance abusing
women?

51
Breastfeeding and Substance Abuse





Most illegal drugs contraindicated to
breastfeeding
Smoking – separate room from baby, after
breastfeeding
Alcohol – no more than 1 –2 drinks per
week
Caffeine – AAP considers safe
Limit to < 2 cups/day
52
Treatment of Neonatal Abstinence Syndrome with
Breastmilk Containing Methadone
Author: Ballard
Setting: Children’s Hospital, Cincinnati, OH
Sample: 6 infants exposed to methadone
Observations:
1.Feeding breastmilk associated with  withdrawal symptoms
2.Frequent small doses from breastmilk shown to be more
effective than large dose
3.Breastmilk may be most effective method in providing
methadone to infants
J Perinal Neonat Nurs 2002;15(4):76
53
Nutrition and Detoxification

“Nutrition intervention, provided by a
qualified dietetic practitioner is an essential
component of the treatment and recovery
from chemical dependency.”
American Dietetic Association Position Statement - 1990
54
Nutrition and Detoxification







Assess nutritional status
Obtain weight history
GI disturbances
Adequate fluids
Regularity of meal times
Taste and presentation important
Avoid substitute addictions!!
55
Multidisciplinary Team








Physicians
Psychiatrists/psychologists
Case managers
Nurses
Social workers
Mental health/behavioral health workers
Substance abuse counselors
Dietetic practitioners ?
56
Nutrition Education is Positively Associated with
Substance Abuse Treatment Program Outcomes
Author: Grant et al
Setting: Cross-sectional survey
Sample: 152 registered dietitians
Outcome:
1. Positive associations found when nutrition education services
incorporated into substance abuse tx programs
2. Group education/substance abuse education improved ASI
scores improved
3. Individual nutrition/substance abuse education ASI scores
improved by 99% (P<.05)
J Am Diet Assoc 194;94(9):999
57
Brief Intervention



10 – 15 minutes sessions of counseling delivered
by non-alcohol abuse specialists
Shown to be low cost, effective treatment
alternative for alcohol use
Uses time-limited, self-help strategies to promote
reductions in alcohol use in nondependent
individuals or to facilitate referral to specialized
treatment programs in alcohol-dependent persons
58
Brief Intervention for Alcohol Use
by Pregnant Women
Author: O’Connor, Whately
Setting: WIC Program in Southern California
Sample: 250 pregnant women who reported drinking alcohol
Outcome:
1. Women in brief intervention group were 5x more likely to report abstinence
after intervention
2. Newborns from brief intervention had higher birth weights and birth lengths
3. Fetal mortality rates were 3x lower (0.9%) in intervention group
4. In both groups, women reduced their drinking substantially
Am J Public Health 2007;97:252
59
Summary





Use of legal and illegal substances can affect the
nutritional status in pregnancy
Positive nutrition may improve pregnancy
outcome
All pregnant substance abusing should receive
comprehensive nutrition assessment and
counseling by a qualified dietetic practitioner
Nutrition services and education should be part of
the multidisciplinary care
Breastfeeding not totally contraindicated in
substance use
60