11/01/2002
• Nutrition Counseling
• Lifestyle concerns with nutritional
implications:
– alcohol
– caffeine
– smoking
– drugs
– artificial sweeteners
– oral health
– exercise
General strategies for providing
effective nutritional care
• Assess nutritional status
– anthropometric
– biochemical
– social
– medical
– dietary
Dietary Assessment:
Selection of Methods
• Avoid collecting information that won’t
be used:
• What is the language skill and literacy level of
the woman?
• How will I use the information? How accurate
and detailed does it need to be?
• What is the standard that will be used for
comparison?
• What resources do I have for collecting,
analyzing and interpreting the data?
Essential Steps for Patient Education
(IOM Implementation Guide)
•
•
•
•
Identify the problem(s)
Develop a tentative clinical objective
Discuss objective with the woman
If woman does not perceive as a
problem offer personalized information
Essential Steps for Patient Education
(IOM Implementation Guide) Cont.
• With the woman:
– Identify behaviors that support or impede
achievement of the clinical objective
– Assess barriers to behavioral change &
strategize about removing barriers
– Plan one or two behavior changes
– Help to reduce barriers with referrals or
information
– Offer feedback and reinforcement for
success
Referrals to Food and
Nutrition Programs
• WIC
• Temporary emergency food assistance
program or food banks
• Food stamp program
• Cooperative Extension- Expanded Food
and Nutrition Program
Cultural factors affecting diet and pregnancy
outcome in Mexican-Americans (Gutierrez, J. J Adolesc
Health. 1999 Sep;25(3):227-37.
• N=48 primigravida adolescents aged
13-18 who self identified as MexicanAmerican.
• Questions:
• In some parts of Mexican culture food is
classified into “hot” such as pork or “cold” such
as fruit juices to balance good health. Do you
practice or follow such classification?
• Some people believe that cravings during
pregnancy should be satisfied or the infant may
be marked by whatever food was craved. What
do you think?
Cultural factors affecting diet and pregnancy
outcome in Mexican-Americans
(Gutierrez, J of
Adolescent health, in press)
• Questions (cont.)
• Some people believe that nausea and vomiting
during pregnancy should be treated by drinking
flour and water, cornstarch and lemon juice, or
chamomile tea. What do you think?
• Do you believe that heartburn is caused by
eating chili?
• Some people believe that during pregnancy, if
the woman sleeps too much it causes the baby
to stick to the uterus. What do you think?
Hot & cold
No
Yes
Cravings
No
Yes
Nausea
No
Yes
Chili
No
Yes
Sleep/Uterus
No
Yes
Group I
N=14
3-12 mos.
Group II
n-19
12-48 mos
Group III
N=13
84-216 mo
8
6
14
5
13
0
7
7
9
10
11
2
6
16
6
15
2
1
6
8
9
10
9
4
4
10
2
17
8
5
Seven Domains of Cultural
Competence
Cultural Competence: A Journey
http://www.bphc.hrsa.gov/culturalc
ompetence/Default.htm#1
1. Values and attitudes
Promoting mutual respect . . .
awareness of the varying degrees of
acculturation . . . a client-centered
perspective . . . acceptance that beliefs
may influence a patient’s response to
health, illness, disease and death. . .
2. Communications styles
Sensitivity . . awareness . . . knowledge
. . . alternatives to written
communication .
3. Community/consumer participation
Continuous, active involvement of
community leaders and members . . .
involved participants are invested
participants, health outcomes improve. .
4. Physical environment, materials,
resources
Culturally and linguistically friendly
interior design, pictures, posters, and
artwork as well as magazines,
brochures, audio, videos, films. . .
literacy sensitive print information . . .
congruent with the culture and the
language . . .
5. Policies and procedures
Written policies, procedures, mission
statements, goals, objectives
incorporating linguistic and cultural
principles . . . clinical protocols,
orientation, community involvement,
outreach. . . multicultural and
multilingual staff reflecting the
community . .
6. Population-based clinical practice
Culturally skilled clinicians avoid
misapplication of scientific knowledge . .
. avoid stereotyping while appreciating
the importance of culture . . . know their
own world views . . . learn about
populations . . . understand
sociopolitical influences . . . practice
appropriate intervention skills and
strategies . .
7. Training and professional
development
Requiring training . . . nature of cultural
competence training . . duration and
frequency of professional development
opportunities . . .
Ethnomed
http://healthlinks.washington.edu/clinical/e
thnomed/
Southeast Asian
“Traditional practices are heavily based in concepts of
"hot" and "cold" conditions. Younger women may no
longer follow traditional practices but the family (mother
or mother-in-law) may insist on following traditions and it
is important to understand how an individual woman and
the greater family compromise.”
Southeast Asian Pregnancy
Foodways - Ethnomed
• "Cold" foods are needed for the "hot" condition of
pregnancy according to Chinese categories.
• There are a wide range of foods which are felt
beneficial or harmful between cultural groups.
• Bean sprouts/green peas avoided - thought to cause
SAB (Vietnamese)
• Homemade rice wine, herbal medicines, coconut
juice are taken to help give the baby good quality
skin. Beer is thought to make the delivery easier
(Cambodian)
• Drinking milk and gaining too much weight will make
baby fat and difficult to deliver (all SE Asian)
Southeast Asian Postpartum
Foodways - Ethnomed
• Maternal diet balanced between "hot" (alcohol,
ginger, black pepper & some high protein) and "cold"
(fruits, vegetables, some seafood). No sour foods
(cause incontinence), no raw foods. Pork felt very
nutritious.
• Cold ice water offered post delivery in the hospital
may be seen as unhealthy.
• Inability to follow traditional post-partum practices is
thought to cause later health problems, especially
abdominal pain in women (which may occur months
or even years later). Once a woman becomes sick
from symptoms thought due to violation of "d'sai
kchey", she is sick for the rest of her life.
(Cambodian)
East Africa Pregnancy FoodwaysEthnomed
“Related women and women within a neighborhood
have very strong ties among each other in East African
communities. In some cultures, such as that of ethnic
groups from Ethiopia, women have a daily coffee ritual
where they gather each day in homes to share coffee
and talk. This daily gathering of women established
support networks for pregnancy, postpartum help, and
child care.”
East Africa Pregnancy
Foodways- Ethnomed
• Women try to have good nutrition and
particularly may increase meat in their
diet.
• Flax seed flour is mixed with warm
water before delivery and drunk by the
woman to help produce an easy
delivery.
East African Post-Partum
Foodways - Ethnomed
• Traditionally women rest in bed for 40
days postpartum and are attended by
other women who prepare nutritious
food and do housework.
• Special teas, soups, and porridge are
provided for the mother.
• Flax seed porridge with honey is
commonly given to mothers postpartum.
Adolescent Development (Drake
P. J Obset. Gynacol. Neonatal Nursing, 1996)
Adolescent Development (Drake
P. J Obset. Gynacol. Neonatal Nursing, 1996)
Early (11-14)
Middle (15-17)
Late (18-20)
Concrete, Egocentric,
confused about body
and sexuality, peer
oriented, need to
establish independence
may conflict with need
for support
Begins to be capable of
seeing connection
between behavior and
health, emerging sense
of self, may affirm adult
identity through
pregnancy
Increased ability for
abstract thinking and
planning, greater
comfort with body
image, stronger sense
of self may facilitate role
as mother, may be able
to enlist support of
father of baby
Responding to Developmental
Differences of Adolescence: Goal Setting
Early
Middle
Late
Limited –
may be
unable to
formulate
realistic
goals
Improving –
may
formulate
grandiose,
unrealistic
goals
Often able to
set goals –
may not be
interested in
doing so
Responding to Developmental
Differences of Adolescence: Professional
Approaches
Early
Middle
Late
Offer simple,
concrete
choices
Respect need
to make
independent
decisions,
encourage
negotiation
with adults
Offer opinions
as one adult to
another, serve
as sounding
board
Adverse effects of substance
use determined by:
•
•
•
•
•
•
Timing
Dosage
Duration
Number of substances
Environment (nutrition, health status)
Individual susceptibility
Effects of substance abuse
include:
• Increased health problems, including
risk of AIDS
• Compromised nutritional status/weight
gain
• Higher rates of OB complications
• Psychosocial/economic/legal problems
• Parenting difficulties
• Higher rates of child abuse/neglect
Alcohol: Background
 Per capita alcohol consumption has risen
through the second half of this century in the
US
 70% of individuals between the ages of 20
and 34 consume alcohol
 Alcohol consumption peaks in the 20-40 year
old group
 5 to 7% of women are reported to drink
heavily in the first months of pregnancy
Alcohol: Background, cont.
 Women are at disadvantage because less
gastric first pass metabolism due to lower
levels of alcohol dehydrogenate in intestinal
mucosa
 Fetus has no alcohol dehydrogenase activity
 Alcohol crosses placenta easily by passive
diffusion – fetal levels mimic maternal levels
 The amniotic fluid acts as a reservoir for
alcohol.
FAS Diagnostic Criteria- Fetal Alcohol Study Group
of the Research Society on Alcoholism
• Prenatal and/or postnatal growth retardation
(<10th % ca)
• Central nervous system involvement
(neurologic abnormality, developmental delay
or intellectual impairment)
• Characteristic facial dysmorphology with at
least 2 of these 3 signs:
 Microcephally ( OFC < 3rd %ile)
 Micoopthalmia and/or short palpevral fissures
 Poorly developed philtrum, thin upper lip, and or
flattening of the maxillary area
FAS, cont.
Other organ systems often involved.
Some with nutritional implications:
 Cleft palate
 Eustachian tube dysfunction
 Array of cardiac, renal, and skeletal defects that
may require surgical repair
FAE – Fetal Alcohol Effects or
PFAE
• Exhibit some components of FAE, but
not all
• Most common sign is retarded growth
both pre and postnatal
• Can have significant developmental and
behavioral components
FAS/FAE Incidence
 FAS – 1.9 per 1000 births, 25 per 1000
among women who drink heavily
 FAE – 3 to 5 per 1000 births, 90 per 1000
among women who drink heavily
 FAS is leading cause of mental retardation in
the western world
Pathophysiology
• Combination of
– Toxic effects of ethanol and it’s derivatives
– Nutritional factors
– Genetic predisposition
Toxic effects
• Both alcohol and derivative acetaldehyde
directly damage developing and mature
nervous systems
• Impair nucleic acid synthesis
• Disrupts protein synthesis
• Cell membrane narcosis
• High maternal alcohol levels associated with
dehydration, fetal hypoxia and acidosis,
placental pathology and dysfunction, and
endocrine disturbances.
Nutrition Related Effects of
Alcohol
• Poor nutritional status of mother
• Reduced placental transfer of zinc and folic
acid associated in animal models
• Alcohol impairs absorption, utilization, and
metabolism of nutrients
• Poor zinc status has been associated with
adverse effects of alcohol many studies
Bottom Line
No amount of alcohol can be said to be
safe in pregnancy.
Caffeine
• History:
– Rat based studies with high levels of caffeine
found adverse pregnancy outcomes
– Early 1980s US FDA issued advisory about
adverse effects of caffeine in pregnancy
– Further research found little association, FDA
concludes that no strong evidence, urges
moderation
– 1996 IOM review for WIC advised removing
excessive caffeine intake from WIC risk criteria
– 1998 - USDA removed as WIC risk criteria
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Consumption:
– In US 70-95% of pregnant women
consume caffeine - average intake is 99185 mg/day
– 5-30% of pregnant women consume >300
mg/day
– Heavy caffeine intake more likely in women
who smoke and those with lower education
levels
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Metabolism
– methylxantines cross the placenta to the
fetus where an equilibrium is achieved
between maternal and fetal plasma
– half-life of caffeine in pregnancy changes
from 5.2 to 18.1 hours in T2 and T3 and
returns to non-pg levels a few weeks pp
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Birthweight:
– consistent negative association across
studies between birthweight and caffeine
consumption > 300 mg/day.
– This affect appears to be due to IUGR not
preterm birth
– Data for intakes between 151 and 300 mg
are conflicting
– Few adverse effects at intakes < 150 mg
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Preterm Labor and Delivery
– “Generally, there appears to be no
relationship between caffeine consumption
during pregnancy and premature labor and
delivery in humans.”
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Spontaneous Abortions
– High caffeine intake prior to and during
pregnancy was associated in several
studies. Many studies failed to control for
smoking, alcohol intake or parity
– Study results are inconclusive and
contradictory
– Further research needed to determine if a
true causal relationship exists.
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review,
1996)
• Congenital Malformations
– Finnish registry of congenital malformation
study found no increased incidence even
when women consumed < 6 cups of coffee
a day.
– No association is supported by current
research
The Effects of Caffeine on Pregnancy
Outcome Variables (Hinds et al. Nutrition Review, 1996
• Clinical applications
– Caffeine intake should be limited to
between 150 mg and 300 mg per day
– Women in the last trimester and those who
smoke are most susceptible to adverse
effects.
Motherisk Update
April, 2000
Motherisk’s recent meta-analysis
suggests that the risks for miscarriage
and fetal growth retardation increase
only with daily doses of caffeine above
150 mg/d, equivalent to six typical cups
of coffee a day. It is possible that some
of this presumed risk is due to
confounders, such as cigarette smoking
Smoking
• 25-30% of US women smoke during
pregnancy; down from 40% in 1967
• Cochran review found that 30 trials of
intensive intervention programs in
pregnant women lead to smoking
cessation in 6.6-9.2% of women.
Adverse Outcomes of
Smoking
• Twice the risk of LBW
• Lower birthweight (~200g)
• Perinatal: Moderately increased risk of
preterm delivery, perinatal mortality,
spontaneous abortion
• Long term: modest reduction in long
term growth and intellectual
development of fetus.
Nutritional Risks Associated
with Smoking
• No breakfast (38% of smokers vs. 18%
of non-smokers)
• Lower dietary intakes of fruits and
vegetables, protein, zinc, riboflavin,
thiamin, iron
Nutritional Risks Associated
with Smoking, cont.
• Smoking appears to:
– decrease the availability of dietary energy
– increase requirement for iron
– reduce availability of B12, amino acids,
vitamin C, folate, and zinc
• Lower serum vitamin C, B6, E, folate,
beta carotene
Norkus et al. FASEB, 1989 and Ann
NY Acad Sci 1987
Smokers
Non-Smokers
Cord vit. C (mg/dl)
0.61
1.68
Placental vit. C
10.1
20.9
(mg/dl)
0.2
0.3
Maternal plasma
carotene (g dl
Cord carotene
19
44
7
20
(mg/dl)
Cord vit. E
(g dl
Vitamin C and PROM
• PROM occurs in 8-10 % of all
pregnancies
• Vitamin C is required for collagen
synthesis
• Maternal plasma and placental vitamin
C is lower in women with PROM
Nutritional Risks Associated
with Smoking, cont.
• Increased carboxyhemoglobin in
smokers blood leads to increased cutoff
point for anemia.
• Women who smoke may have lower
prepregnancy weights and may have
lower pregnancy weight gains.
Annotation: Cigarette Smoking, Nutrition,
and Birthweight (Rasmussen & Adams, AJPH, 1997)
• “Smoking and maternal weight gain are
independent, additive predictors of
birthweight.”
• “It does not appear that encouraging smokers
to gain more weight than nonsmokers with a
similar BMI will eliminate the negative effects
of smoking on birthweight.”
• Women who quit smoking in pregnancy are at
increased risk of excessive weight gain.
• Women who smoke are at increased risk of
poor dietary intake.
• Therefore….
Annotation: Cigarette Smoking, Nutrition,
and Birthweight (Rasmussen & Adams, AJPH, 1997)
“…individualized nutrition counseling is
recommended in addition to smoking
cessation.”
Illicit Drugs: Nutritional
Implications
• Estimates of 10% of US newborns
exposed to one or more illicit drugs in
utero
• Illicit drug use strongly associated with
inadequate weight gain, anemia, poor
dietary habits
• Knight et al. (FASEB, 1992) found lower
serum ferritin, folate, vitamin C and B12
levels in women when cord blood
reflected illicit drugs
Illicit Drugs: Nutritional
Implications
• Cocaine:
– associated with fewer meals, increased
alcohol and caffeine and fat intake
– 32% also classified as eating disordered
• Methadone
– diarrhea, constipation, nausea, anorexia,
and dry mouth
• Heroin
– altered glucose tolerance - delayed
glucose response
Position of the American Dietetic Association:
Use of nutritive and nonnutritive sweeteners
(1998)
• Use of nutrition sweeteners that have
GRAS status is acceptable during
pregnancy.
• Saccharin can cross the placenta and
may remain in fetal tissues because of
slow fetal clearance - It has been
suggested that women consider careful
use of saccharin during pregnancy.
Position of the American Dietetic Association:
Use of nutritive and nonnutritive sweeteners
(1998)
• Aspartame: issue relates to fetal exposure to
aspartic acid, phe, or methanol.
– Animal models show no changed fetal exposure to
aspartic acid with aspartame
– Maternal bolus of aspartame at the 99th %ile of
intake results in peak plasma phe level 10-20%
below levels associated with neurological
problems
– Plasma response of methanol and formate are not
significant after aspartame load
• “Use of aspartame within FDA guidelines appears
safe for pregnant women.”
Position of the American Dietetic Association:
Use of nutritive and nonnutritive sweeteners
(1998)
• Safety of acesulfame-K use during
pregnancy has been determine with rat
studies.
• No change observed in fertility, size of
litter, body weight, growth or mortality at
high levels (3% of diet)
Oral Health: Major Concepts
(1999, Fact sheet from Academy of General Dentistry)
• Increased risk for gingivitis (red,swollen,
tender gums that are more likely to bleed)
associated with increased estrogen and
progesterone
• Periodontal disease increases risk for
preterm delivery
• Frequent consumption of high cho foods may
be used to combat nausea
• Neutralize the acid caused by vomiting by
making a paste of baking soda and water.
After 30 seconds, rinse, brush and floss.
Pregnancy Gingivitis
• 30-75% of women experience gingival
changes such as edema, hyperplasia,
redness, and bleeding
• Hormonal changes cause greater
reaction to dental plaque
• Women who are plaque and
inflammation-free at beginning of
pregnancy have only 0.03 chance of
gingivitis
Periodontitis
• Definition: an infection caused by specific
bacterial plaque that involves loss of bone,
fiber, and gum tissue attachment for the tooth.
• Smoking associated with increased
prevalence and severity of periodontitis
• Periodontal infections caused by gramnegative pathogens are associated with
increase in preterm delivery and/or PROM one mediating factor is prostaglandin
production triggered by bacterial products.
Periodontitis (cont.)
• Pathogens and bacterial products may
translocate and inhibit normal clearance
of enteric organisms from genitourinary
tract.
• Overgrowth of gram negative bacteria
and infection can be associated with
preterm birth.
Oral Health:
Recommendations
• Frequent dental cleanings (3 to 6 months)
• Daily oral care routines including brushing
and flossing at least twice daily and after
eating
• Use of toothpastes and rinses with fluoride
• Consider cariogensis in food choices and
patterns.
• Offer smoking cessation programs
Exercise
• Benefits:
– improved or maintained fitness
– reduces anxiety and depression
– eases pregnancy discomforts such as
constipation, backache, fatigue and
varicose veins
Exercise
• Contraindications
– previous experience of preterm labor
– ob complications including vaginal
bleeding, incompetent cervix, ruptured
membranes, compromised fetal growth
– Hx of medical problems (hypertension,
heart disease, etc.) requires health care
provider approval
Exercise
• Effects on Fetus:
– no evidence that exercise has adverse
effects on fetus or risk of miscarriage or
birth defects
– does not increase risk of premature labor
in low risk pregnancies
– does not slow fetal growth or subsequent
childhood growth or intellectual
development
Exercise
• Changes with pregnancy
– tolerance for strenuous exercise decreases
as pregnancy progresses
• work of breathing increases as enlarging uterus
crowds the diaphragm
• oxygen needs increase
– if lying flat on back after the 4th month, risk
of compression of vena cava with dizziness
and interference with blood flow to the
uterus
Exercise
Changes with pregnancy, cont.
– may have increased efficiency of heat
dissipation
– altered sense of balance with shift in center
of gravity
– high hormonal levels associated with lax
connective tissue and increased joint
susceptibility
Exercise during pregnancy and the postpartum
period. ACOG Committee on Obstetric Practice.
January 2002
“The current Centers for Disease Control and Prevention
and American College of Sports Medicine
recommendation for exercise, aimed at improving the
health and well-being of nonpregnant individuals,
suggests that an accumulation of 30 minutes or more of
moderate exercise a day should occur on most, if not all,
days of the week. In the absence of either medical or
obstetric complications, pregnant women also can adopt
this recommendation.”
Exercise during pregnancy and the postpartum
period. ACOG Committee on Obstetric Practice.
January 2002
• Exercise may be beneficial in primary
prevention of GDM
• Avoid
– supine position (may result in obstruction
of venous return)
– motionless standing
– exertion above 6,000 feet altitude
Avoid
• Sports with high potential for trauma:
ice hockey, soccer, basketball
• Increased risk of falling: gymnastics,
downhill skiing, vigorous racket sports,
horseback riding
• Scuba diving (increased risk of
decompression sickness)
Postpartum
• Physiological changes persist 4 to 6
weeks postpartum
• Return to vigorous exercise should be
gradual
• Return to physical activity may be
protective against postpartum
depression if exercise is stress
relieving- not inducing