Download Nutrition in Pregnancy

Nutrition in Pregnancy
Joanne Kurtz, RD
July 2013
Prenatal Nutrition Objectives
►
Highlight nutrients of concern during pregnancy
►
Discuss food safety considerations
►
Assess rate of weight gain
►
Assess risk of malnutrition
►
Review health professional and pt education resources/
websites
 V drive, online
Sally’s Intake
New diag preg
GA 8wks
Very excited and curious about
eating well to support her
pregnancy
► No known food allergies
► Feels she eats well
► Curious to know if current diet
adequate to support pregnancy
►
Breakfast
 Special K cereal with 2% milk or
oatmeal
 Starbucks Venti Coffee with milk
►
Lunch
 Subway turkey sub or sushi
 Water
►
Afternoon
 Fat free yogurt or granola barSmall coffee w/milk
►
Supper
 4 oz chicken or beef
 Usually corn, peas or beans
 1 cup white pasta, rice or potato
 Water or juice
►
Evening
 Popcorn, chips or crackers
►
►
►
Comment on Sally’s intake
nutrient intake.
What questions could you ask to
get a better sense of her
nutritional status?
Rate of Weight Gain
Sally
con’t
…
► GA
16wks
► Feels great
► Always hungry!!!
► Had gained 18 lbs to date
 Pre -Pregnancy BMI 24
► Wonders
about whether this is appropriate
Maternal weight and weight gain
during pregnancy
►
Weight-related problems should be addressed before
pregnancy to optimize maternal and fetal health
►
Low pre-pregnancy weight is associated with preterm
birth and giving birth to a SGA infant
►
Women who enter pregnancy with BMI over 25 are at
increased risk of a poor pregnancy outcome like GDM,
complicated delivery or LGA*
Weight gain during pregnancy
►
The IOM guidelines are based on observational data,
which consistently show that women who gain within
the recommended range experience better
pregnancy outcomes
►
Total weight gain recommended assume a gain of
between 0.5 and 2 kg (1.1 – 4.4 lbs) in the first
trimester [IOM 2009].
►
Slight weight loss due to mild nausea or vomiting is
common
Recommended Weight Gain
Rates of Weight Gain 2nd
and 3rd trimester per
week (lbs/wk)
BMI
Target
18.5 to 24.9
25 to 35
lbs
1
(0.8-1.0)
< 18.5
28 to 40
lbs
1
(1.0-1.3)
25 to 29.9
15 to 25
lbs
0.6
(0.5-0.7)
>30
11 to 20
lbs
0.5
(0.4-0.6)
IOM guidelines, 2009
Obesity and Pregnancy
►
What is optimal wt gain?
►
GWG is strongest predictor of wt retention
►
Obese women (BMI>35) who lose wt in pregnancy may
have decreased or unaffected risk of C-sections, LGA
babies, pre-eclampsia etc. (but increased risk of SGA in
obesity class III?)
Obstet Gynecol 2011;117:1065–70
Maternal Characteristics
GWG
(kg)
Less than
0
0-4.9
BMI
30-34.9
4.1%
BMI
35-39.9
7.9%
BMI
40 or higher
14.6%*
9.4%
14.6%
17.4%
5-9 *
26.7%
29.1%
28.3%
59.8%
48.4%
39.6%
(guidelines)
More
than 9
Tracking weight gain in the
second and third trimesters
► If
an abnormal pattern of weight gain is
observed:
 consider adequacy and consistency of fetal growth
 presence of medical problems (ie. edema)
 modifiable factors (ie. overeating or a sedentary
lifestyle)
► Focus
should be on normalizing rate of weight
gain going forward.
Multiple gestations
► The
IOM (2009) provides the following provisional
gestational weight gain guidelines for women
carrying twins:
 normal weight women should gain a total of between 17
to 25 kg (37–54 lbs),
 overweight women, a total of between 14 to 23 kg (31–
50 lbs), and
 obese women, a total of between 11 to 19 kg (25 – 42
lbs).
Women at Increased Nutritional Risk
New Vegetarians and/or vegans
► Teens
► Under or over wt pre pregnancy
► Yo yo dieters
► Multiple pregnancy
► N/V post 1st trimester
► Last pregnancy <2yrs ago
► Financial difficulties
► New Canadians
► Special dietary concerns
 Multiple food allergies or intolerances
►
Canada Prenatal Nutrition Program
(Buns in the Oven)
Confidential and
FREE!
► Geared towards
pregnant teens and
high risk women
► Healthy eating and
cooking activities
► Breastfeeding support
► Postnatal/ parenting
information support
►
► Offers:
 Milk coupons and food
to take home
 Child care
 Bus tickets
 RNs and RDs to answer
questions
OttawaYoungParents.com for locations and contact info
Nutrients of Concern in
Pregnancy
►Energy
►Iron
►Folate
►Omega
3 fatty acids
►Calcium
►Vitamin D
A Healthy Diet
CFG provides the info needed on
healthy eating during pregnancy
•
•
•
•
•
•
Whole grains
Fruits and vegetables
Low fat milk products
Fatty fish (twice per week)
Small amounts of healthy fat
Lean meats and meat alternatives
Energy
1st trimester (no extra kcal needed)
2nd trimester (+300 kcal/d) – extra snack
3rd trimester (+500 kcal/d)
►Equivalent
to an extra 2-4 food guide servings/d
►Consider adding snacks to diet or extra food with
meals




1 cup of milk + 1 fruit
¼c of trail mix and ¾ cup of low fat yogurt
½ a pita with ¼ cup hummus
Small banana with 2 tbsp peanut butter and 1 sm tortilla
Iron in pregnancy
►
Increased needs to support the rise in maternal red
blood cell mass.
►
Increased RBC supplies the growing fetus and
placenta, and supports normal brain development in
the fetus.
►
During the third trimester, the fetus builds iron
stores for the first six months of life.
►
Most pregnant women in North America have
trouble getting the iron they need through diet
alone
Iron in Pregnancy
►
(RDA) for iron during pregnancy is 27 mg per day.
This is the average amount of iron most healthy
pregnant women need each day to meet their iron
needs.
►
Eating according to Canada’s Food Guide and taking
a daily multivitamin that has 16 to 20 mg of iron will
support a healthy pregnancy (Health Canada).
►
Most prenatal vitamin contains RDA for iron
 This will not correct a deficiency
IOM 2001
Folate During pregnancy
► Essential
for normal development of spine,
brain and skull of the fetus, especially in first
four weeks of pregnancy
► Supports
the pregnant woman’s expanding
blood volume and growing maternal and fetal
tissues
► Addition
of folic acid to white flour, enriched
pasta, and enriched corn meal has been
mandatory in Canada since November 1998.
Folate Preconception
►
RDA is 600 mcg (0.6mg) per day to maintain normal folate
status during pregnancy.
►
Intake of folic acid from fortified foods is estimated to be no
more than 100 to 200 mcg per day
  Diet alone insufficient to meet folic acid needs
►
SOGC recommend 0.4-1mg folic acid
 Most prenatal multivitamins now have 1mg
►
Supplementing with folic acid between pregnancies can help
reduce the risk of NTDs in subsequent births.
Health Canada 2009, SOGC
Folic Acid- SOGC CPG-2007
Target population
Preconception +
1st trimester
2nd and 3rd tri +
lactation
Pts with NO health risk + planned
pregnancy
0.4-1 mg
0.4-1 mg
High risk pts:
►DM
►Obesity BMI >35
►Family Hx of or previous pregnancy
with NTD
►Compliance or lifestyle issues
►Smokers
►PCOS
►Malabsorption disorders (ie. IBD)
►Who take antiepileptic drugs, folate
antagonists (methotrexate,
sulfonamides)
►Ethnic groups (Sikh, Celtic,
Northern Chinese)
5 mg
0.4-1 mg
In addition to a diet
high in folate
Folate rich foods
► Spinach,
broccoli, peas, brussel sprouts,
asparagus
► Fortified grains
► Lentils, chick peas
► Corn
► Oranges
Omega 3 fatty acids
►
Important for neurodevelopment, visual acuity in fetus and
possible decreased incidence of depression in mom
 Primary source fatty fish: salmon, trout, sardines, halibut
 Omega-3 eggs, fortified yogurt
►
Encourage 150g (2 servings) of fish each week
There is currently insufficient evidence to recommend fish
oil supplements* (DHA and/or EPA) during pregnancy
to enhance later child development. [Health Canada]
Methyl Mercury in utero
►
“epidemiological studies have demonstrated ... subtle
impacts on fine motor function, attention span, verbal
learning and memory of children that were exposed to
methylmercury in utero.”
►
The health effects of exposure to methyl mercury for a
fetus or young child can include a decrease in IQ, delays in
walking and talking, lack of coordination, blindness and
seizures.
Fish consumption
Limit to 5oz per month
► frozen/fresh tuna, Shark
► Swordfish
► Marlin
► Orange roughy
► Escolar
Limit to 300g (10oz) per week
► Canned white albacore tuna* (300g/wk)
Canned light tuna is low in mercury and safe
Encourage consumption of fatty fish- omega 3s DHA and EPA
extremely important in last trimester and first two years of life
Calcium and Vitamin D
►
Calcium needs are the same as pre-pregnancy
(1000mg for >18yo, 1300mg for <18yo)
►
Supplementation is not necessary if
 2 servings of milk products/d >19yo
 3 servings of milk products/d < 18yo
►
Prenatal may not be not sufficient to meet calcium
needs (~250-300mg)
►
Some groups discuss 600-2000 IU of Vit D [Health Canada
2010, CPS 2007]
 Prenatal has ~400-800IU
Food safety
considerations
Safe, avoid or limit
Food safety considerations
Avoid:
► Flaxseed (ground or oil)
 Safe in amounts commonly in food ie- flaxseed bread ok
Raw sprouts
Unpasteurized juices and ciders
► Soft, unpasteurized cheeses
► Deli meats, patés, smoked seafood, raw meats/fish/eggs
► Saccharin and cyclamates
►
►
 Sugar Twin or Sweet n Low sugar substitutes
►
Alcohol
Limit
► Caffeine 300mg
 (1.5 cups of coffee)
 Prolonged half life in pregnancy
Herbal beverages/supplements
Safe
► Citrus
Peel
► Ginger
► Rosemary
► Echinacea
► Peppermint
► Orange
Peel and
► Rosehip
► Red
Raspberry leaf
There is either insufficient or documented adverse
effects with all other herbal supplements and should be
avoided during pregnancy
Nausea and Vomiting
Eat what’s appealing
► Possible comforting solutions







►
Separate solids from liquids
Small, frequent meals of bland foods
Consider preferred textured foods
Avoid having an empty stomach
Rise slowly from bed
Try a few soda crackers before getting out of bed
Avoid high fat or strong odorous foods
Ginger
 0.5 to 1.0 g/day (split into three to four equal doses) [SOGC]
 Can purchase over the counter
►
Vitamin B6 Supplement
 25-75mg/d
Sally’s Intake
►
►
►
►
►
►
New dx preg
GA 8wks
Very excited and curious
about eating well to
support her pregnancy
No known food allergies
Feels she eats well
Curious to know if current
diet adequate to support
pregnancy
►
Breakfast
 Special K cereal with 2% or
oatmeal
 Small coffee with milk
►
Lunch
 Subway or sushi
 Water
►
Afternoon
 Fat free yogurt or granola barSmall coffee w/milk
►
Supper
 +/-4 oz chicken or beef
 Usually corn, peas or beans
 1 cup white pasta, rice or potato
 Water or juice
►
Evening
 Popcorn, chips or crackers
What would you
suggest?
Recommendations
► Iron-rich
protein choices daily
► Calcium rich choices
► Avoid sushi, deli meat (reheat)
► Increase fruit, veg, whole grains (fibre,
folate)
► Choose nutrient dense foods
► Supplements?
Nutrition Resources
► Ottawabreastfeeds.ca
► Motherisk.org
► Ottawa
Public Health
► SOGC
► Public
Health Agency of Canada
► V drive- Programs- FM OBS Info- Prenatal
Nutrition
► Health Canada http://www.hc-sc.gc.ca/fn-an/nutrition/index-eng.php
 http://www.hc-sc.gc.ca/fn-an/securit/chemchim/environ/mercur/index-eng.php