Title: WEEK 5
1Lecture 4, 2006
High Risk Pregnancies Counseling the Pregnant
Woman
2High Risk Pregnancies
- Disordered Eating
- Hypertensive Disorders
- Gestational Diabetes
3Disordered Eating Pregnancy Prevalence
- Few data on prevalence of disordered eating in
pregnancy - Difficult to adequately capture this information
from women. Women may have needs for secrecy and
denial so information about history of eating
disorders is often not given to health care
providers during pregnancy - Some published numbers for disordered eating in
the population ((Mitchell et al. J midwifery
womens health, 2006) - Prevalence of binge eating disorder 1.2-4.5
- Prevalence of anorexia nervosa in young females
is 0.03 - About 25 of individuals with anorexia nervosa
develop a chronic course.
4Diagnostic Criteria Anorexia Nervosa (American
Psychiatric Association)
- Refusal to maintain body weigh at or above normal
weight for age and height - Intense fear of gaining weight or becoming fat,
even through underweight - Disturbance in the way in which ones body weigh
or shape is experiences, - Undue influence ob body weigh or self-evaluation
or denial of the seriousness of current low body
weight - In postmenarcheal females, amenorrhea (absence of
at least three consecutive menstrual cycles)
5Diagnostic Criteria Bulimia Nervosa (American
Psychiatric Association)
- Recurrent episodes of binge eating. An episode of
binge eating is characterized by both of the
following - In a discrete period of time, eating an amount of
food definitely larger than most people would eat - A sense of lack of control over eating during the
episode - Recurrent inappropriate compensatory behavior
such as self-induced vomiting, misuse of
laxatives, diuretics, enemas or other
medications. - Binge eating and inappropriate compensatory
behaviors occur at least twice a week for 3
months - Self-evaluation is unduly influenced by body
shape and weight - The disturbance does not occur exclusively during
anorexia nervosa.
6Diagnostic Criteria Not otherwise specified
(American Psychiatric Association)
- For females, all the criteria for AN are met,
except that the individual has regular menstrual
cycles. - All criteria for AN is met, except the weight is
WNL, despite significant weight loss - Regular use of inappropriate compensatory
behaviors in an individual of normal weight after
eating small amounts of food - Repeated chewing and spitting out food, but not
swallowing - Binge-eating disorder recurrent episodes of
binge eating in the absence of regular use of
compensatory behaviors characteristic of BN
7Disordered Eating Pregnancy
- Results of published studies are inconsistent
- Developmental tasks of pregnancy are often about
the same issues that arise in some women with
eating disorders - Body changes
- Alterations in roles
- Concerns about a womans own mothering and needs
for psychological separation.
8Pregnancy and Eating Disorders A review and
clinical Implications (Franko and Walton, Int.J.
Eating Disorders, 1993)
- British report on 6 of 327 women who had attended
eating disorder clinic and got pregnant - Median BMI was 16.8 (range 14.9-18.1)
- Median length of time with AN was 15 years (range
11-17) - Average weight gain was 8 kg (range 5-14)
-recommendations for low BMI are 13-18 - Poor third trimester fetal growth was found in
all 5 babies who were monitored - Babies had some catch up in infancy
9Pregnancy Outcome and Disordered Eating (Abraham
et al J Psychosom Obstet Gynecol, 1994)
- 24 women reported previous problems with
disordered eating. - These women had higher rates of antenatal
complications such as IUGR, PIH, edema, GDM,
vaginal bleeding (plt0.05) - These women also were more likely to have infants
with birthweights lt 25th ile (plt0.02)
10Bulimia Symptoms and other risk behaviors during
pregnancy in women with Bulimia Nervosa (Crow et
al, Int J Eat Disord, 2004)
- 129 participants in a long-term follow up study
of women who had been treated for BN at the
University of Minnesota - 322 pregnancies
11Crow et al., 2004
122 Studies from Sweden.
13Pregnancy and neonatal outcomes in women with
eating disorders (Kouba et al. Obstet Gynecol,
2005)
- Recruited women from 13 Swedish prenatal clinics
screened and diagnosed eating disorders. - 68 controls 49 nulliparous, nonsmoking women
diagnosed with - 24 AN
- 20 BN
- 5 NOS
- Mean duration of eating disorders was 9 years
(range 3-15) - 16 (33) of women with hx of eating disorders had
received TX - 11 (22) of women with eating disorders had a
relapse during pregnancy that led to contact with
a psychologist or psychiatrist.
14Kouba, 2005
15Kouba, 2005
16Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)
- Birth register study
- 1000 primiparous women who were discharged from
hospital with dx of AN from 1973-1996 who gave
birth 1983-2002 - All non AN births (827,582)
- Birthweights lower (p0.005) in AN group
- Mean AN, 3387
- General population mean, 3431
- Longer hospital say for AN (gt 6 months) not
associated with different outcomes - No difference in SGA and any other negative birth
outcomes for mother or baby
17Birth outcomes and pregnancy complications in
women with a history of AN (Ekeus et al, BJOG,
2006)
- Authors explanation of findings
- Our findings may be a result of gradual
improvement in the care process, both AN and
maternity care. - A country with a satisfactory maternity
surveillance, outcome of pregnancy and delivery
may be just as good for women with a hx of AN as
for the general population. - OR..the fertility problems associated with AN
mean that pregnancy will only occur in less
severe cases
18Postpartum eating and Body Image for all Women
- It is of note that in a general population of
postpartum women, eating disorder behaviors
increase markedly in the first 3 months
post-partum and remain high for the next 9
months. - Some women actually first experience clinical
eating disorders during this time.
19Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)
- N97, prospective cohort study of primip. women
followed during pregnancy and at 3 and 6 mos pp. - Eating Disorder Examination (EDE) restraint,
eating concern, shape concern, weight concern and
global scores about state over last 28 days - Repeated measures ANOVA indicated that changes in
eating disorder pathology pp were largely due to
changes in body weight.
20Eating Habits and Attitudes in the Post Partum
Period (Stein et al. Psychosomatic Med., 1996)
p lt0.05, plt 0.01, plt0.001
21An observational study of mothers with eating
disorders and their infants ( Stein et al., J
Child Psychol Psychiat, 1994)
- 2 groups of primips
- Index group, women who had met EDE criteria for
disordered eating during pp period, n34 - Control group, balanced for SES, age, and childs
gender, n24 - At one year
- EDE
- Childs growth
- Structured observation of child and mother at
task and mealtime
22Mealtime Behaviors ( Stein et al., J Child
Psychol Psychiat, 1994)
23Play Behaviors ( Stein et al., J Child Psychol
Psychiat, 1994)
24Discussion ( Stein et al., J Child Psychol
Psychiat, 1994)
- Index mothers were more intrusive than control
mothers - About 1/3 of the index infants and one of the
control infants had growth faltering - Regression analysis models to predict infant
weights were best fit when included - maternal height,
- infant birthweight
- conflict during meals
- mothers concern about own body shape
25www.anred.com
- You could become depressed and frantic because of
weight gain during pregnancy. You might feel so
out of control of your life and body that you
would try to hurt yourself or the unborn baby.
You might worry and feel guilty about the damage
you could be causing the baby.
26- Some women with eating disorders welcome
pregnancy as a vacation from weight worries. They
believe they are doing something important by
having a baby and are able to set aside their
fear of fat in service to the health of the
child. Others fall into black depression and
intolerable anxiety when their bellies begin to
swell. Most fall somewhere between these two
extremes.
27- You might underfeed your child to make her thin,
or, you might overfeed her to show the world that
you are a nurturing parent. Power struggles over
food and eating often plague families where
someone has an eating disorder. You could
continue that pattern with your child.
28- Motherhood is stressful. If you are not strong in
your recovery, you will be tempted to fall back
on the starving and stuffing coping behaviors
that are so familiar to you. Ideally, as you
begin raising a family, you will already have
learned, and will have had practice using, other
more healthy and effective behaviors when you
feel overwhelmed.
29- Also, eating disordered women make poor role
models. Your influence could lead your daughters
to their own eating disorders and your sons to
believe that the most important thing about women
is their weight.
30Clinical Implications
- Careful screening and monitoring
- Possible use of self administered, computer
assisted screening tool - Psychotherapy may be indicated
- Interventions are not evidence based at this
time, but based on case studies individual
counselors experiences
31Clinical Interventions Psychosocial
- Making the fetus as real as possible to the
patient very early. - Empathetically addressing fears of weight gain
and feelings of being out of control - Assurance about normal weight gain and patterns
of pp weight loss - Education of significant others
32Clinical Interventions Nutrition
- Frequent weigh-ins, lectures about weight gain,
and even well-meaning comments my clinical staff
can be triggers for increasing the frequency of
eating disordered behaviors. (Mitchell et al. J
midwifery womens health, 2006) - If appropriate
- Discuss and provide materials about nutrients and
food in pregnancy - Design individual food plan
- Determine optimal range of weight gain
- Discuss hydration shifts in pregnancy and need
for fluid
33Clinical Interventions Exercise
- Assess exercise level
- Suggest joining exercise groups and new mothers
groups to normalize experience of weight concerns
34Clinical Intervention Infant Feeding
- Offer assistance with parenting concerns
- Offer information about infant feeding
- infants ability to self regulate
- attention to infant cues signals
- use of food as reward or control mechanism
35Bulik Hypothesis (Int J Eat Disord, 2005)
- Preterm birth is associated with threefold
increase in risk of AN - Neurodevelopmental insults in premature infants
could contribute to delayed oral-motor growth and
onset of early eating problems. - Women with low prepreg BMI inadequate nutrition
during gestation have increased risk for preterm
delivery cycle of risk is established.
36Hypertensive Disorders During Pregnancy
- Incidence
- Definitions
- Etiology/pathophysiology
- Nutritional Implications
37N A T I O N A L I N S T I T U T E S O F H E A
L T H N A T I O N A L H E A R T , L U N G , A N D
B L O O D I N S T I T U T E
WORKING GROUP REPORT ON HIGH BLOOD PRESSURE IN
PREGNANCY
July 2000
38Incidence
- Second leading cause of maternal mortality in US
- 15 of maternal deaths (disseminated
intravascular coagulation, cerebral hemorrhgae,
hepatic failure, acute renal failure) - Hypertensive disorders occur in 6 to 8 of
pregnancies - Contribute to neonatal morbitity and mortality
39High risk
- First pregnancy and under age 17 or over 35
- Family history of hypertension
- Poor nutritional status
- Smoking
- Overweight
- Other health problems such as renal disease,
diabetes - Multiple gestation
- Some Fetal anomalies
40Chronic Hypertension
- Known hypertension before pregnancy or rise in
blood pressure to gt 140/90 mm Hg before 20 weeks - Hypertension that is diagnosed for the first time
during pregnancy and that does not resolve
postpartum is also classified as chronic
hypertension.
41Gestational Hypertension
- Hypertension in pregnancy is present when
diastolic BP is 90 or greater, systolic BP is 140
or greater - the use of BP increases of 30 mm Hg systolic and
15 mm Hg diastolic has not been recommended -
women in this group not likely to have increased
adverse outcomes - ¼ of women with gestational htn advance to
preeclampsia
42Preeclampsia
- Preeclampsia is defined as the presence of
hypertension accompanied by proteinuria - In the absence of proteinuria the disease is
highly suspect when increased blood pressure with
headache, blurred vision, and abdominal pain, or
with abnormal laboratory tests, specifically, low
platelet counts and abnormal liver enzymes.
43Proteinuria
- Proteinuria is defined as the urinary excretion
of 0.3 g protein or greater in a 24-hour
specimen. - This will usually correlate with 30 mg/dL (1
dipstick) or greater in a random urine
determination with no evidence of urinary tract
infection. - because of the discrepancy between random protein
determinations and 24-hour urine protein in
preeclampsia it is recommended that the diagnosis
be based on a 24-hour urine if at all possible
44Findings that increase the possibility of
Eclampsia and indicate need for FU Severe
Preeclampsia
45(No Transcript)
46Edema
47Dx of Preeclampsia Superimposed on Chronic Htn.
48Eclampsia
- Occurrence in a woman with preeclampsia, of
seizures that can not be attributed to other
causes - Rare 4 of women with preeclampsia advance to
eclampsia
49Etiology
- Not fully understood
- Primary pathophysiology is placental function
- Secondary pathophysiology involves endothelial
cell dysfunction due to factors released because
of insufficient placental blood supply
50Characterized by
- Vasospasm
- Activation of the coagulation system
- Perturbations in systems related to volume and
blood pressure control
51Pathogenic Mechanisms
- Delivery is only known cure - research has
focused on placenta - failure of the spiral arteries (terminal branches
of uterine artery) to remodel - alterations in immune response at the maternal
interface - increase in inflammatory cytokines in placenta
and maternal circulation, natural killer cells,
and neutrophil activation
52Pathophysiology
- Decreased blood flow
- Decreased renal blood flow, decreased GFR, Na
retention - Tissue hypoxia
- Damage to organs multi-organ disease affecting
the liver, kidneys, and brain
53Pathophysiology
- Decreased blood volume
- Decreased placental blood flow may occur 3-4
weeks before increased BP - Hypoxia
- Decreased nutrient delivery
54Outcomes
- Increased LBW and IUGR for infant
- There is mounting evidence that children born to
mothers whose blood pressure was elevated during
pregnancy are at greater risk for elevated blood
pressure during childhood and adolescence - Also long term maternal health may be affected by
consequences of maternal damage to renal and CV
systems.
55Focus of Possible Interventions
- Smooth muscle contraction
- Prostaglandin synthesis
56Calcium
- Epi studies suggest inverse relation between
dietary calcium and PIH - Intraerythrocyte calcium levels and intracellular
calcium ion conc. increased in women with
pre-eclampsia - HO Ca supplementation reduced serum parathyroid
hormone reduced intracellular Ca conc. in
vascular smooth muscle cells and reduces response
to pressure stimuli - Several RCT have found reduced risk of PIH with
Ca supplementation to prevent (not treat) PIH.
57Calcium, cont.
- Recent meta-analysis found Ca intake of 1.5-2 g
associated with sig. reductions in systolic and
diastolic BP without adverse effects. - Question remains does lowering BP have effect on
pathophysiology of PIH?
58Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)
- 12 studies met criteria
- Randomized trials comparing at least one gram
daily of calcium during pregnancy with placebo. - RR of high blood pressure with Ca supplements
0.70 (95 CI, 0.57-0.86) - RR of preeclampsia with Ca supplements 0.48
(95 CI, 0.33-0.69)
59Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems (2006)
- 5 trials of Ca supplements in high risk women
- RR 0.22 (95 CI, 0.12-0.42)
- 7 trials in women with low baseline Ca
- RR 0.22 (95 CI, 0.18-0.70)
60Cochrane Calcium supplementation during
pregnancy for preventing hypertensive disorders
and related problems updated 2006
- Reviewers conclusions
- Calcium supplementation appears to almost halve
the risk of pre-eclampsia, and to reduce the rare
occurrence of the composite outcome 'death or
serious morbidity'. There were no other clear
benefits, or harms.
61Cochrane Magnesium supplementation in
pregnancy updated 2001
- There is not enough high quality evidence to show
that dietary magnesium supplementation during
pregnancy is beneficial.
62Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)
- Theory
- Ratio of omega 6 and omega 3 fa may modify
processes related to PIH such as platelet and
leukocyte reactivity, vasodilation, and
inflammatory processes. - Study design
- small case control, n22 cases, 40 controls
- adjusted for parity and pre-pregnancy BMI
63Omega-3 Fatty Acids In Maternal Erythrocytes and
Risk of Preeclampsia (Williams et al,
Epidemiology, 1995)
- Results
- Women with the lowest tertile of n-3 in
erythrocytes had odds ratio of 7.6 (95
CI1.4-40.6) for developing preeclampsia.
64Cochrane Marine oil, and other prostaglandin
precursor, supplementation for pregnancy
uncomplicated by preeclampsia or intrauterine
growth restriction (2006)
- 6 trials
- No clear difference in the RR of preeclampsia
between groups - 2 trials, lower risk of giving birth before 34
weeks - RR 0.69 (95 CI 0.49-0.99)
65Antioxidants and Preeclampsia Definitions
- Antioxidants any substance that, when present in
low concentrations compared to that of an
oxidizable substrate, significantly delays or
inhibits oxidation of that substrate - Free radical scavengers include vitamin C
(ascorbate), vitamin E (tocopherols), carotenoids
- Antioxidant enzymes include glutathione
peroxidase, superoxide dismutase and catalase,
which are dependent on the presence of co-factors
such as selenium, zinc and iron
66Antioxidants and Preeclampsia Possible Mechanisms
- Placental underperfusion may mediate a state of
oxidative stress. - Oxidative stress, coupled with an exaggerated
inflammatory response, may result in the release
of maternal factors that result in inappropriate
endothelial cell activation and endothelial cell
damage - Supplementing women with antioxidants may
increase their resistance to oxidative stress,
and hence could limit the systemic and
uteroplacental endothelial damage seen in
pre-eclampsia
Cochrane, 2005
67Cochrane Antioxidants for preventing
pre-eclampsia (2005)
- 7 trials involving 6082 women
- Only 3 of 7 were rate high quality
- All randomized and quasi-randomized trials
comparing one or more antioxidants with either
placebo or no antioxidants during pregnancy for
the prevention of pre-eclampsia, and trials
comparing one or more antioxidants with another,
or with other interventions.
68Cochrane Antioxidants for preventing
pre-eclampsia (2005)
- Supplementing with any antioxidants during
pregnancy compared to control - RR of preeclampsia 0.61 (95 CI, 0.50,0.70)
- RR SGA 0.64 (95 CI, 0.47,0.87)
- Increased risk of preterm birth RR 1.38 (95 CI,
1.04,1.82)
69Cochrane Antioxidants for preventing
pre-eclampsia (2005)
- These results should be interpreted with
caution, as most of the data come from poor
quality studies. Nevertheless, antioxidant
supplementation seems to reduce the risk of
pre-eclampsia. There also appears to be a
reduction in the risk of having a
small-for-gestational-age baby associated with
antioxidants, although there is an increase in
the risk of preterm birth. Several large trials
are ongoing, and the results of these are needed
before antioxidants can be recommended for
clinical practice.
70Other Nutrition Related Factors
- Na Pregnant women with proteinuric hypertension
have lower plasma volume Na. restriction is
associated with accelerated volume depletion
not recommended - Energy and Protein intake increases not found
to be useful - Weight reduction or limited gain in pregnancy
not found to be useful
71Position StatementGestational Diabetes Mellitus
American Diabetes Association2004
72Definition
- Gestational diabetes mellitus (GDM) is defined as
any degree of glucose intolerance with onset or
first recognition during pregnancy. The
definition applies whether insulin or only diet
modification is used for treatment and whether or
not the condition persists after pregnancy. It
does not exclude the possibility that
unrecognized glucose intolerance may have
antedated or begun concomitantly with the
pregnancy.
73Prevalence
- 7 of all pregnancies are complicated by GDM in
US - more than 200,000 cases annually in US
- prevalence may range from 1 to 14 of all
pregnancies, depending on the population studied
and the diagnostic tests employed.
74Diagnosis
- Assess risk at first visit
- If high risk (marked obesity, personal history of
GDM, glycosuria, or a strong family history of
diabetes) GTT ASAP - Women of average risk should have testing
undertaken at 2428 weeks of gestation - Low-risk status requires no glucose testing
75Low Risk Criteria
- Age lt25 years
- Weight normal before pregnancy
- Member of an ethnic group with a low prevalence
of GDM - No known diabetes in first-degree relatives
- No history of abnormal glucose tolerance
- No history of poor obstetric outcome
76Non GTT dx
- A fasting plasma glucose level gt126 mg/dl (7.0
mmol/l) or a casual plasma glucose gt200 mg/dl
(11.1 mmol/l) meets the threshold for the
diagnosis of diabetes, if confirmed on a
subsequent day, and precludes the need for any
glucose challenge
77One-step Approach
- Perform a diagnostic oral glucose tolerance test
(OGTT) without prior plasma or serum glucose
screening - May be cost-effective in high-risk patients or
populations (e.g., some Native-American groups).
78Two-step approach
- Initial screening by measuring the plasma or
serum glucose concentration 1 h after a 50-g oral
glucose load - Diagnostic OGTT on that subset of women exceeding
the glucose threshold value on the GCT
79Table 1 Diagnosis of GDM with a 100-g oral
glucose load
mg/dl mmol/l
Fasting 95 5.3
1-h 180 10.0
2-h 155 8.6
3-h 140 7.8
Two or more of the venous plasma concentrations
must be met or exceeded for a positive diagnosis.
The test should be done in the morning after an
overnight fast of between 8 and 14 h and after at
least 3 days of unrestricted diet ( 150 g
carbohydrate per day) and unlimited physical
activity. The subject should remain seated and
should not smoke throughout the test.
80Infant Concerns in GDM
- Higher risk of
- neural tube defects
- birth trauma
- hypocalcemia
- hypomagnsemia
- hyperbilirubinemia
- prematurity syndromes
- subsequent childhood and adolescent obesity and
risk of diabetes
81Infant Concerns, cont.
- Macrosomia in infant due to high glucose levels
from mother and fetal insulin response leading to
increased fat deposition, associated with
complications at delivery. - Hypoglycemia of infant following delivery due to
high fetal insulin levels at delivery and sudden
withdrawal of maternal glucose transfer
82Maternal Concerns
- Higher risk of
- hypertension
- preeclampsia
- urinary tract infections
- cesarean section
- future diabetes
83Nutritional Therapy in GDM
- Goals
- prevent perinatal morbidity and mortality by
normalizing the level of glycemia - prevent ketosis
- provide adequate energy and nutrients for
maternal and fetal health - dependent on maternal body composition
84Monitoring
- Daily self-monitoring of blood glucose (SMBG)
- Urine glucose monitoring is not useful in GDM.
Urine ketone monitoring may be useful in
detecting insufficient caloric or carbohydrate
intake in women treated with calorie restriction.
85Monitoring
- Blood pressure and urine protein monitoring to
detect hypertensive disorders. - Increased surveillance for pregnancies at risk
for fetal demise is appropriate - Assessment for asymmetric fetal growth by
ultrasonography to assess need for insulin
86Nutrition Management
- All women with GDM should receive nutritional
counseling, by a registered dietitian when
possible - For obese women (BMI gt30 kg/m2), a 3033 calorie
restriction (to 25 kcal/kg actual weight per
day) has been shown to reduce hyperglycemia and
plasma triglycerides with no increase in
ketonuria - Restriction of carbohydrates to 3540 of
calories has been shown to decrease maternal
glucose levels and improve maternal and fetal
outcomes
87Insulin
- Insulin therapy is recommended when MNT fails to
maintain self-monitored glucose at the following
levels - Fasting whole blood glucose 95 mg/dl (5.3
mmol/l) - Fasting plasma glucose 105 mg/dl (5.8 mmol/l)
- 1-h postprandial whole blood glucose 140 mg/dl
(7.8 mmol/l) - 1-h postprandial plasma glucose 155 mg/dl (8.6
mmol/l) - 2-h postprandial whole blood glucose 120 mg/dl
(6.7 mmol/l) - 2-h postprandial plasma glucose 130 mg/dl (7.2
mmol/l) - Oral glucose-lowering agents have generally not
been recommended during pregnancy
88Exercise
- Programs of moderate physical exercise have been
shown to lower maternal glucose concentrations in
women with GDM
89Long Term
- Reclassification of maternal glycemic status
should be performed at least 6 weeks after
delivery - If glucose levels are normal post-partum,
reassessment of glycemia should be undertaken at
a minimum of 3-year intervals - education regarding lifestyle modifications that
lessen insulin resistance, including maintenance
of normal body weight through MNT and physical
activity.
90Long Term
- Avoid medications that worsen insulin resistance
(e.g., glucocorticoids, nicotinic acid) - Seek medical attention if develop symptoms
suggestive of hyperglycemia. - Use family planning to assure optimal glycemic
regulation from the start of any subsequent
pregnancy
91Counseling the Pregnant Woman
92General strategies for providing effective
nutritional care
- Assess nutritional status
- anthropometric
- biochemical
- social
- medical
- dietary
93Dietary 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?
94Essential 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
95Essential 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
96Referrals to Food and Nutrition Programs
- WIC
- Temporary emergency food assistance program or
food banks - Food stamp program
- Cooperative Extension- Expanded Food and
Nutrition Program
97Family Food Hotline
- http//www.familyfoodline.org/
- Order outreach cards
- 1-888-4-food-wa
98Cultural 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?
99Cultural 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?
100(No Transcript)
101Seven Domains of Cultural Competence
- Cultural Competence A Journey
http//www.bphc.hrsa.gov/culturalcompetence/Defaul
t.htm1
1021. 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. . .
1032. Communications styles
- Sensitivity . . awareness . . . knowledge . .
. alternatives to written communication .
1043. Community/consumer participation
- Continuous, active involvement of community
leaders and members . . . involved participants
are invested participants, health outcomes
improve. .
1054. 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 .
. .
1065. 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 . .
1076. 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 . .
1087. Training and professional development
- Requiring training . . . nature of cultural
competence training . . duration and frequency of
professional development opportunities . . .
109Ethnomed
- http//healthlinks.washington.edu/clinical/ethnome
d/
110Southeast 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.
111Southeast 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)
112Southeast 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)
113East 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.
114East 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.
115East 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.
116Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
117Adolescent Development (Drake P. J Obset.
Gynacol. Neonatal Nursing, 1996)
118Responding to Developmental Differences of
Adolescence Goal Setting
119Responding to Developmental Differences of
Adolescence Professional Approaches