NUTRITION THROUGH THE LIFESPAN (C) 2010 AoCH. Use without expressed permission is strickly prohibited. PRE-PREGNANCY AND PREGNANCY TEXT CH 15 (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Pregnancy can be a very special time for a couple. Along with the responsibility of shaping a child’s health and personality comes the prospective exhilaration of watching the child develop and grow. These parents often feel an overriding desire to produce a healthy baby, which opens them up to new nutrition and health information. The parents-to-be usually want to do everything possible to maximise their chances of having a robust, lively newborn. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Producing a healthy baby is not just a matter of luck. True, some aspects of foetal and newborn health are beyond a parent’s control. Still, conscious decisions about health, social and nutritional factors significantly affect the baby’s health and future. What the parents do relates directly to the likelihood of having a healthy newborn. Then choosing to breastfeed the infant adds further benefit. Wardlaw: Perspectives In Nutrition. 4th Edition Fertility is achieved and maintained by carefully orchestrated, complex processes that can be disrupted by a number of factors related to body composition and dietary intake. Of particular interest is the gestational time of chemical exposure, nutritional deficiency or excesses as exposure to these at the various embryonic and feotal developmental stages influences the genetic expression and predisposes the infant to diseases later in life. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Influencing Factors Weight outside of the HWR places both genders at risk of altered fertility Overweight & obese men – low sperm count and altered hormonal function o In women – altered menstrual regularity, ovary function • Altered foetal development – increased risk of diseases in adulthood. The health status of each parent o o o o Different diseases places them at risk, more so the mother CVD and circulation, diabetes, Blood pressure, PCOS Stress, emotional issues Bowel function Exposure to environmental, and internal metabolic toxins. o o o o The type of work they do, Where they live Stress Medication, recreational drugs including caffeine, smoking OTC, stimulants – V drinks etc Type of foods eaten o Adequate total nutritional intake and macronutrient ratio o Adequate vitamins and minerals • o o In particular Iodine, folate, B12, zinc, iron Water EFA BGL control Hormonal balance Study in South Hampton Shows… Few women adhere to the nutrition and lifestyle recommendations for planning a pregnancy. No significant improvements in compliance in relation to smoking and diet among women in the time leading up to pregnancy. Folic acid was taken in sufficient quantities by only a small percentage of women, and supplementation in the periconceptional period is considered important for the prevention of neural tube defects. Study cont Almost half of those who became pregnant within three months reported drinking at levels above the recommended limit for those planning a pregnancy that was in operation at the time of the study Only 7.6% of those who became pregnant within three months were not drinking any alcohol at the time of the interview, and it is only these women who would comply fully with the current recommendations for alcohol intake Greater efforts are needed to improve compliance with the recommendations BMJ 2009;338:b481 Highlights the need for screening of all females of reproductive age to help maximise understanding and nutrition One Food Example The following points are taken from Wolmuth, H, Pharmacognosy and Medicinal Plant Pharmacology pp.20-21 Caffeine containing beverages are widely consumed, the physiological effects of this alkaloid have been the focus of much research. Some of the more interesting effects of caffeine are: Caffeine in 1 – 2 cups of coffee stimulates the central nervous system, promotes clear and fast thinking and it reduces mental tiredness and sleepiness. Larger doses: 2 – 3 cups of coffee or more have a negative impact on contraction, thought processes and muscle coordination and can cause tachycardia, insomnia, nausea, anxiety and headache. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Caffeine stimulates skeletal muscle, increasing muscle contractility and reducing muscle fatigue. Caffeine is considered to be a performance enhancing drug in sport. Caffeine is metabolised in the liver and has a half-life in healthy adults of 3 – 4 hours. The half life is doubled in women who take the OCP and during the later stage of pregnancy. In the newborn, caffeine has a half-life of 80 hours. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Consumption of coffee up to one hour after a meal can reduce the absorption of iron from the meal by up to 39%. Caffeine increases both total serum cholesterol and LDLcholesterol. Caffeine stimulates the secretion of gastric acid and pepsin coffee drinkers were found an increased risk of developing peptic ulcer than non-coffee drinkers. Caffeine increases the basal metabolic rate by 10 – 25% the reason for its inclusion in slimming pills. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Caffeine increases the risk of spontaneous abortion: a study involving 3000 American women showed that a caffeine intake of 150mg daily doubled the risk of spontaneous abortion late in the first trimester and in the second trimester. In women with a history of spontaneous abortion, caffeine increased the risk four-fold. Caffeine enters the breast milk; irritability and poor sleeping habits in lactating infants can be caused by maternal caffeine intake (the very long half-life of caffeine in neonates means that caffeine is likely to accumulate). (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Pre-conception nutritional status Women who avoid known risks and eat well before (during and after) pregnancy tend to have larger, healthier babies and experience fewer complications Poor nutrition can result in low birth weight babies who have impaired intelligence and a greater risk of disease both earlier and later in life The quality of the father’s sperm can be influenced by both nutritional and toxic factors (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Cont. Excessive burdens of toxic metals such as lead, mercury and cadmium can adversely influence the quality of sperm and subsequent conception. Effects of xenoestrogens, particularly in men alters fertility and is contributing to the change in population distribution. Environmental or recreational toxins also contributes to altered sperm development, DNA strength and overall wellbeing o Smoking and alcohol can increase the number of sperm abnormalities and can reduce sperm count Female impaired fertility Brown,J. 2008, Nutrition through the life cycle 3rd Edition, Thomson USA P.53 Recent oral contraceptive use (within 2 months) Anorexia nervosa / bulimia nervosa Amenorrhea High coffee / caffeine intake High fibre intake Vegetarian diets (controversial but a strong hormonal connection) Age > 35 years Pelvic inflammatory disease (PID) STDs, particularly Chlamydia Endometriosis Poor iron status (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Male impaired fertility Brown,J. 2008, Nutrition through the life cycle 3rd Edition, Thomson USA P.53 Inadequate zinc status Inadequate antioxidant status Heavy metal exposure lead, mercury, cadmium, manganese Halogen (in some pesticides) and glycol exposure (in antifreeze and de-icers) Xenoestrogen exposure (in DDT, PCB’s) Chromosomal abnormalities in sperm Sperm defects Excessive heat to testes Steroid abuse Poor Vitamin D status (controversial) (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Shared Factors of Infertility Brown,J. 2008, Nutrition through the life cycle 3rd Edition, Thomson USA P.53 Weight loss > 15% of normal weight Negative energy balance Inadequate body fat Excessive body fat, especially central fat Extreme levels of exercise High alcohol intake Endocrine disorders hypothyroidism, Cushing’s disease, altered sex and supporting sex hormones Structural abnormalities of the reproductive tract Coeliac disease Severe stress STD’s Diabetes (C) 2010 AoCH. Use without expressed permission is strickly prohibited. High Risk Pregnancies text pg 521:526 Definition: a pregnancy characterised by indicators that make it likely the birth will be surrounded by problems such as premature delivery, difficult birth, retarded growth, birth defects and early infant death. View table 15-3 The more factors that apply, the higher the risk to mother and foetus. Risk Factors for Pregnancy Low socioeconomic status Malnutrition, limited food choices/groups. Mother’s age – adolescents and older women Lifestyle choices, Some medications Previous medical conditions such as o o Diabetes all types Hypertension Developing during pregnancy o o o Gestational diabetes Transient hypertension during presentation Pre-eclampsia and eclampsia Nutrition & contraceptives Brown,J. 2008, Nutrition through the life cycle 3rd Edition, Thomson USA P.59 Oral contraceptives o o o o o Contraceptive injections (Depo-provera) o o o o ↑ blood levels of HDL cholesterol ↑ blood levels of triglycerides (30%) and LDL cholesterol ↑ risk of venous thromboembolism (Blood clots) ↓ blood levels of vitamin B12 (33%) ↑ blood levels of copper (34- 55%) related to the ↑ risk of clots Weight gain ↑ blood levels of LDL and insulin ↓ blood levels of HDL cholesterol ↓ bone density Contraceptive implants (Norplant) o Weight gain (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Potential Nutritional risk factors Poor diet, including too little folate or poor iron intake ↑ the risk of embryonic development of neural tube defects B Vitamins: in particular B6, B12 and folate. B6 for the growth and development of the baby’s nervous system; B12 for cell growth and normal development; folate for DNA synthesis, increased blood volume, cell division and healthy tissue development. Multiple pregnancies, long term use of the OCP and anaemia increase the B12 requirements. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Vitamin C: tissue development; absorption of iron; interaction with other nutrients; prevention of pre-eclampsia. (p.116) Calcium: healthy teeth and bones; particularly important for women under 25 (p.470 and notes) Vitamin D: bone and teeth development via calcium absorption; RDI 400I.U. (p.727) Vitamin E: prevention of pre-eclampsia, high blood pressure and the build up of free radicals (p.116) Magnesium: pain and discomfort of leg cramps (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Examples of Interactions Peri-nutrition and Adult Diabetes Conceptual framework for how maternal diet and micronutrient status may affect the development of chronic disease in the offspring. Christian P , Stewart C P J. Nutr. 2010;140:437-445 ©2010 by American Society for Nutrition Over or incorrect supplement use including excessive vitamin A intake ↑ the risk the fetus will develop facial or heart abnormalities High maternal blood levels of lead ↑ the risk of mental retardation Iodine deficiency ↑ the risk that children will experience impaired mental and physical development (page 574 and notes) Iron deficiency ↑ the risk of early delivery and the development of iron deficiency within the first few years of life Nutrient imbalance: e.g. a) elevated copper suppresses zinc and can miscarriage b) refined carbohydrates and excess sugar reduced levels of zinc, B complex and chromium, candida and high acidity levels (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Poor management of diabetes or hypertension Poorly controlled glucose levels early in pregnancy Increase the risk of foetal malformations Excessive infant size at birth The development of diabetes in the offspring later in life o Women with gestational diabetes tend to be overweight or obese and excess central body fat. All forms of hypertension in pregnancy are related to inflammation, oxidative stress and damage to the endothelium Over time, oxidative stress within the endothelium leads to endothelial dysfunction (C) 2010 AoCH. Use without expressed permission is strickly prohibited. o Preeclampsia is a syndrome characterised by: • • • o Consequences of endothelial dysfunction include Impaired blood flow An increased tendency for the blood to clot Plaque formation Oxidative stress, inflammation and endothelial dysfunction Blood vessel spasm and constriction Increased blood pressure Nutritional preventative measures for preeclampsia: • • • Calcium has been shown to Magnesium Vitamin C and E (C) 2010 AoCH. Use without expressed permission is strickly prohibited. o A number of nutritional and other environmental factors are related to oxidative stress (Brown,J. 2008, Nutrition through the life cycle 3 Edition, Thomson USA rd .p131): • • • • • • Trans fats Inadequate intake of antioxidants nutrients (vitamin C, E, carotinoids, selenium) and antioxidant phytochemicals from plants Habitual consumption of high-glycaemic-index carbohydrates, elevated blood glucose levels Excess body fat Physical inactivity smoking (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Smoking low birth weight more susceptible to respiratory illness Environmental toxins: may cross the placenta and affect its health. Be wary of lead, cadmium, aluminium, copper, mercury, nickel (used in body piercing) and home renovations. Aspartame use: Phenylalanine (Nutrasweet and Equal) can affect foetal brain development in some people. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Age younger than 18: considered high risk pregnancies Body weight and weight gain: obesity hypertension, diabetes, complications during delivery and birth defects. Inadequate weight gain low birth weight and often is a sign of poor nutritional status Prenatal ketosis: lows foetal brain development. Be wary of crash diets or fasting. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Listeria infection: can spontaneous abortions or serious blood infections. Be wary of unpasteurised milk, soft cheeses made from raw milk and raw cabbage. Homocysteine: elevated levels can cause recurrent miscarriage o o in 26 out of 84 Dutch patients (study group) who experienced placental abruption and foetal growth retardation as compared to 7% of 46 controls. Serum and red cell folate, serum vitamin B12 and B6 were significantly lower in the study group compared with the controls. (Goddijn-Wessel, TAW., Wouters, MGAJ., Molen, EFvd., Spuijbroek,MDEH., Steegers-Theunissen, RPM., Blom,HJ., Boers, GHJ., ESkes, TKAB. 1996, ‘Hyperhomocysteinaemia: a risk factor for placental abruption or infarction’, European Journal of Obstetrics & Gynaecology and Reproductive Biology, vol.66, no.1, pp.23-29) (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Radiation: a) ionizing radiation i.e. flying, x-rays and radioactive materials b) non-ionizing i.e. computers, mobile phones, microwaves, ultraviolet light, radar c) electromagnetic i.e. waterbeds, electric blankets, clock radios, fuse boxes. Taxoplasmosis: avoid contact with cats litter, garden soil, potting mix, and raw or uncooked meat (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Stress Drug use HIV or AIDS Medications Excessive caffeine intake Job related hazards MERCURY Brain development begins early in foetal life and continues into adolescence. The developing brain, therefore, is uniquely susceptible to exposure to neurotoxic compounds. Mercury is one of those neurotoxins that particularly affects this brain development. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. How does it all work? Mercury is released into the environment largely from fossil fuels (mainly coal) and from incinerators This inorganic mercury becomes airborne and may be carried for miles before being deposited in soil or water This inorganic form of mercury is then converted to a toxic form (methylmercury) by chemical reactions or by bacteria This MeHg is then absorbed by aquatic micro-organisms that are eaten by fish This then accumulates up the aquatic food chain Humans are exposed through fish consumption and transmission occurs from mothers to infants. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Both natural and manmade emissions are metabolised into forms more directly harmful to human beings. All forms of mercury are toxic, but the various forms are more or less available for absorption by animals and humans. Methylmercury, the organic form of mercury often found in fish, is easily absorbed by the body and is highly toxic. It is the main form of mercury found in the brain. Elemental mercury is highly volatile, and inhaling elemental mercury vapour can present a serious health risk, as often occurs when mercury metal is spilled indoors. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. • Common bacteria of the soil and water have adapted to the presence of mercury. They have developed methods to detoxify its organic compounds and salts to the elemental form of mercury. Elemental mercury can be transported long distances via the atmosphere. Once it reaches inland aquatic environments however, elemental mercury can again accumulate and be transformed into methylmercury, the toxic form that bioaccumulates in fish, animals, and humans. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Mercury compounds are a significant threat to human health, particularly to pregnant women, women of childbearing age, developing foetuses and breast-fed infants. Chien,LC., Han,BC., Hsu,CS., Jiang,CB., You,HJ., Shieh,MJ., Yeh,CY. 2006, ‘Analysis of the health risk of exposure to breast milk mercury in infants in Taiwan’, Chemosphere, article in press They concluded that even though fish has recognised health benefits, to reduce the body burden of mercury in their infants, women of childbearing age, should be concerned about mercury levels accumulated in fish. Chien,LC., Han,BC., Hsu,CS., Jiang,CB., You,HJ., Shieh,MJ., Yeh,CY. 2006, ‘Analysis of the health risk of exposure to breast milk mercury in infants in Taiwan’, Chemosphere, article in press (C) 2010 AoCH. Use without expressed permission is strickly prohibited. In Australia, fish that contain higher levels of mercury include: Shark Ray Swordfish Barramundi Gemfish Orange roughy Ling Southern bluefin tuna. Fish that contain lower levels of mercury include: Shellfish including prawns, lobsters and oysters Salmon Canned tuna. http://www.disability.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Mercury_in_fish?open (C) 2010 AoCH. Use without expressed permission is strickly prohibited. The authors of this 2006 study found that while breast milk concentrations of mercury were high They were significantly lower in those who took vitamins than those who didn’t They decreased with selenium intake This confirms previous studies: In Austria, a significant positive correlation was found between breast milk mercury concentration and vitamin supplementation. Chien,LC., Han,BC., Hsu,CS., Jiang,CB., You,HJ., Shieh,MJ., Yeh,CY. 2006, ‘Analysis of the health risk of exposure to breast milk mercury in infants in Taiwan’, Chemosphere, article in press (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Moral: be aware of potential environmental sources of heavy metals and advise the client of these. Consider sources of EFA, and possibly a certified tested supplement to minimise contamination (C) 2010 AoCH. Use without expressed permission is strickly prohibited. Activity Based on the information you have learnt, make a list of recommendations you might give a client either male or female if they came to see you for pregnancy What Can Be Done Encourage all of pregnancy age to consider a healthy lifestyle. In particular couples who are seeking pre- or periconception care to ensure their lifestyle, eating, stress and overall health is optimised. Allow a minimum of 3 months pre conception to prepare and optimise sperm and uterine health. Endorse the use of other contraceptive methods during this time to minimise the risk of accidental conception. Dietary Recommendations Women Cereals Vegies Fruit Diary Lean Meat etc Extras 19-60 4-9 5 2 2 1 0-2.5 60+ 4-7 5 2 2 1 0-2 Pregnant 4-6 5-6 4 2 1.5 0-2.5 Lactating 5-7 7 5 2 1 1-2.5 Text pg 517 Structured Recommendations Nutritional requirements, while they increase, foods must be nutrient rich – fresh, lean foods, along with healthy oils. Energy requirements increase in the 2nd trimester by 1400Kj/day and 1900Kj/day in the 3rd trimester Protein increase by 14 g/day in the 2nd and 3rd trimesters EFA from fish, polyunsaturated oils Achieve and maintain a healthy body weight Be physically active Receive regular medical care Manage chronic conditions Avoid harmful influences Cont.. Follow the dietary guidelines for all Australians – so adjust the client’s eating plan to match this. Consider their stage of pregnancy and increase identified nutrients and energy. Encourage adequate water intake. Limit foods/chemicals that could interfere with health Help the client to structure a workable meal plan to meet their dietary needs and their food tolerances. Adapt as the pregnancy develops. Educate and support your client with adverse discomforts and symptoms as suggested on pg 520 of text. Consider a good multivitamin suitable for pregnancy.