Week 4

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11/01/2002
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• Nutrition Counseling
• Lifestyle concerns with nutritional implications
• alcohol
• caffeine
• smoking
• drugs
• artificial sweeteners
• oral health
• exercise

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General strategies for providing effective
nutritional care

• Assess nutritional status
• anthropometric
• biochemical
• social
• medical
• dietary

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Dietary Assessment Selection of Methods

• Avoid collecting information that wont 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?

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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

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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

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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

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Cultural factors affecting diet and pregnancy
outcome in Mexican-Americans (Gutierrez, J. J
Adolesc Health. 1999 Sep25(3)227-37.

• N48 primigravida adolescents aged 13-18 who self
  identified as Mexican-American.
• 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?

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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?

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Seven Domains of Cultural Competence

• Cultural Competence A Journey
  http//www.bphc.hrsa.gov/culturalcompetence/Defaul
  t.htm1

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1. Values and attitudes

• Promoting mutual respect . . . awareness of
  the varying degrees of acculturation . . . a
  client-centered perspective . . . acceptance that
  beliefs may influence a patients response to
  health, illness, disease and death. . .

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2. Communications styles

• Sensitivity . . awareness . . . knowledge . .
  . alternatives to written communication .

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3. Community/consumer participation

• Continuous, active involvement of community
  leaders and members . . . involved participants
  are invested participants, health outcomes
  improve. .

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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 .
  . .

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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 . .

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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 . .

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7. Training and professional development

• Requiring training . . . nature of cultural
  competence training . . duration and frequency of
  professional development opportunities . . .

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Ethnomed

• http//healthlinks.washington.edu/clinical/ethnome
  d/

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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.
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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)

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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)

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East Africa Pregnancy Foodways- Ethnomed
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.
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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.

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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 post-partum.

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Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
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Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
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Responding to Developmental Differences of
Adolescence Goal Setting
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Responding to Developmental Differences of
Adolescence Professional Approaches
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Adverse effects of substance use determined by

• Timing
• Dosage
• Duration
• Number of substances
• Environment (nutrition, health status)
• Individual susceptibility

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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

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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

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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.

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FAS Diagnostic Criteria- Fetal Alcohol Study
Group of the Research Society on Alcoholism

• Prenatal and/or postnatal growth retardation
  (
• Central nervous system involvement (neurologic
  abnormality, developmental delay or intellectual
  impairment)
• Characteristic facial dysmorphology with at least
  2 of these 3 signs
• Microcephally ( OFC
• Micoopthalmia and/or short palpevral fissures
• Poorly developed philtrum, thin upper lip, and or
  flattening of the maxillary area

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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

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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

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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

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Pathophysiology

• Combination of
• Toxic effects of ethanol and its derivatives
• Nutritional factors
• Genetic predisposition

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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.

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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

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Bottom Line

• No amount of alcohol can be said to be safe in
  pregnancy.

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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

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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 99-185 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

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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

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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

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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.

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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.

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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
• No association is supported by current research

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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.

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Motherisk UpdateApril, 2000

• Motherisks 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

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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.

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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.

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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

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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

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Norkus et al. FASEB, 1989 and Ann NY Acad Sci
1987
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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

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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.

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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.

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Annotation Cigarette Smoking, Nutrition, and
Birthweight (Rasmussen Adams, AJPH, 1997)

• individualized nutrition counseling is
  recommended in addition to smoking cessation.

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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

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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

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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.

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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.

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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)

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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.

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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

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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 gram-negative
  pathogens are associated with increase in preterm
  delivery and/or PROM - one mediating factor is
  prostaglandin production triggered by bacterial
  products.

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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.

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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

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Exercise

• Benefits
• improved or maintained fitness
• reduces anxiety and depression
• eases pregnancy discomforts such as constipation,
  backache, fatigue and varicose veins

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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

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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

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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

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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

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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.
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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

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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)

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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

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