11/01/2002. Nutrition Counseling Lifestyle concerns with nutritional implications: –alcohol...

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 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?

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?

Group IN=14

3-12 mos.

Group IIn-19

12-48 mos

Group IIIN=13

84-216 moHot & cold No Yes

86

145

130

Cravings No Yes

77

910

112

Nausea No Yes

616

615

21

Chili No Yes

68

910

94

Sleep/Uterus No Yes

410

217

85

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/ethnomed/

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 (motheror 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)

“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 ethnicgroups 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

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 post-partum.

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 bodyand sexuality, peeroriented, need toestablish independencemay conflict with needfor support

Begins to be capable ofseeing connectionbetween behavior andhealth, emerging senseof self, may affirm adultidentity throughpregnancy

Increased ability forabstract thinking andplanning, greatercomfort with bodyimage, stronger senseof self may facilitate roleas mother, may be ableto enlist support offather of baby

Responding to Developmental Differences of Adolescence: Goal Setting

Early Middle Late

Limited –may beunable toformulaterealisticgoals

Improving –mayformulategrandiose,unrealisticgoals

Often able toset goals –may not beinterested indoing so

Responding to Developmental Differences of Adolescence: Professional

ApproachesEarly Middle Late

Offer simple,concretechoices

Respect needto makeindependentdecisions,encouragenegotiationwith adults

Offer opinionsas one adult toanother, serveas soundingboard

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 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



• 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



• 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



• Preterm Labor and Delivery– “Generally, there appears to be no

relationship between caffeine consumption during pregnancy and premature labor and delivery in humans.”



• 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.



• 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


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 UpdateApril, 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(mg/dl)

10.1 20.9

Cord vit. E (mg/dl) 0.2 0.3

Maternal plasmacarotene (g dl

19 44

Cord carotene(g dl

7 20

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.


(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.”


(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 gram-negative 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

11/01/2002. Nutrition Counseling Lifestyle concerns with nutritional implications: –alcohol...

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