Sierra Medina

Assignment #1 – Nutrition During Pregnancy Case Study Due: Friday, June 26 by 7:00 p.m. Colorado Time - MT

25 points

DIRECTIONS Please type out your responses and number your answers for each question. Your responses should be concise and reflect a lot of thought. Assignments must be typed and submitted on time with proper format and correct grammar, spelling and punctuation. Assignments will be accepted up to 1 week past the due date and 2 points will be deducted from your final score for each day an assignment is overdue. Include a reference list of those citations that you used for your answers (including class notes and textbook; points will be deducted if you do not include a reference list). The case studies should be emailed to the instructor by the above due date by 7 p.m. Colorado Time; points will be deducted if late. Please transfer all attachments into word or pdf files before emailing your assignment. For questions #2 and #12, you can fax (970-351-1489); scan and email; or mail your pregnancy weight gain chart to Alena Clark. If mailing the chart, it must be postmarked by Friday, June 26 to: Dr. Alena Clark; Dietetics Program; University of Northern Colorado; Campus Box 93; Greeley, CO; 80639. DO NOT MAIL OR FAX YOUR ENTIRE CASE STUDY!

VISIT 1: Michelle is a 16 year-old Hispanic female who is currently 18 weeks pregnant. She lives with her mother, younger sister, and two younger brothers in a townhome in Littleton, Colorado. She has not yet received prenatal care because she says that her family has little money and she is scared to tell her mother and boyfriend that she is pregnant. Her mom works all day and sometimes works in the evenings as well. When Michelle is not in school, she takes care of her younger siblings.

Michelle is experiencing nausea and vomiting throughout the day. She complains of fatigue, headaches and she can’t pay attention at school.

After asking more questions, you discover that Michelle smokes 1/2 pack of cigarettes/day and that her mom and boyfriend also smoke. She smokes when she gets bored and when she’s “hanging out” with her boyfriend. She states that she has cravings for salty foods and ice chips. Michelle is not taking prenatal vitamins.

Michelle’s pre-pregnancy weight was 110 pounds. Her height is 5’4.” Her current weight is 111 pounds and her hemoglobin is 10.7 gm/dl.

QUESTIONS FOR VISIT 1 (12 points): 1. (1 pt) What was Michelle’s pre-pregnancy BMI? Show your calculations.

110lb x1kg

= 50kg2.2lb

5ft x12in

+ 4 = 64in x0.025m

= 1.6m1ft 1in

50kg= 19.5kg/m2

(1.6m)2

!1

Sierra Medina

2. (1 pt) Plot Michelle’s weight gain on the pregnancy weight gain chart found on Blackboard. How does her weight compare with where her weight should be? Use IOM Guidelines. Michelle is below the recommended weight gain for gestational age by 5.5-11lbs, and probably should be on the higher end as she is still growing and developing at this age. Her current weight at this first visit is 111 lbs with 1lb gained, and should be between over 6-12lbs putting her somewhere near 116-122lbs.

3. (2 pts) How much total weight should Michelle gain: a. during her first trimester? Michelle should gain between 3-8lbs, again probably on the higher end for her own growth and development. b. during her entire pregnancy? Why?

She needs to gain between 25-35lbs to ensure adequate nutrition for the baby’s growth and development as well as for her own health and growth. The baby needing enough energy to develop and grow to 6-8lbs, for her breast changes by 1-2lbs, 3-4lbs for blood volume and 3-4lbs for body fluids, 1-2lbs for the placenta, and 1-2lbs for her uterus, 2-3lbs for amniotic fluid, and 8-10lbs of fat and protein stores.4

4. (1 pt) Describe 3 suggestions you could give to Michelle to help decrease her nausea and vomiting. I would suggest eating small meals frequently throughout the day or whenever possible; separate food from liquid intake; and to avoid odors and foods that might trigger nausea and vomiting, including cessation of smoking as that can sometimes be a trigger as well.1

5. (1 pt) Why is iron important during pregnancy? Does Michelle have iron-deficiency anemia? Why or why not?

Iron is important for the production of hemoglobin in order to deliver oxygen to other tissues in the mother, placenta and fetus for adequate growth and function. Taking into consideration her age, location and habit of smoking, Michelle would be considered to have iron-deficiency anemia. At 5,351ft elevation in Littleton, CO, 2,351ft above 3,000ft requires an increase of 0.2g/dL per 1000ft, adding 0.4702g/dL to the recommended 10.55g/dL for her gestational age, and smoking requires an additional 0.3g/dL, so the CDC/s gestational age-specific cutoff for anemia in pregnancy would put her at 11.32g/dL, while she is at 10.7g/dL, and therefore suffering from iron-deficiency anemia, which might further explain her pagophagia. 1

6. (1 pt) Write a statement you could say to Michelle to explain the risks of smoking during pregnancy. List 2 suggestions you could provide to Michelle to help her stop (or at least decrease) smoking.

Cigarette smoke contains thousands of dangerous chemicals that pollute the only source of oxygen available to your baby. This can cause health problems, leaving it underdeveloped and susceptible to illnesses that would require more assistance from you and healthcare providers after he/she is born. The sooner you quit, or can reduce your intake, the more oxygen is available to help your baby to grow properly, so you can both try to avoid the consequences after birth. Talking to a doctor, and in finding the support of your mother and boyfriend for quitting and not smoking around you can help you in taking this step for yours and your child’s future. Finding a distraction during boredom or to combat any cravings for cigarettes can also help if you feel the need. 8

!2

Sierra Medina

7. (1 pt) Describe 2 risks of pregnancy at a young age. Does Michelle exhibit these?

Pregnancy at a young age can increase the risk of iron-deficiency anemia, which due to lifestyle factors and altitude, she does, and is also at high risk for reduced educational achievement, as exhibited by her inability to pay attention in school and responsibilities with younger siblings at home with a full-time working mother, with the addition of another child, will increase her distraction from education. 1

8. (1 pt) Is Michelle at high risk for delivering a LBW infant? Why or why not?

Michelle is at a high risk for delivering a LBW infant due to her own age, low weight gain, smoking habit, and iron-deficiency anemia early in pregnancy which increases the risk of preterm delivery and low-birthweight infants by two to three times.1,5 9. (2 pts) List and describe 2 nutrition-related and/or medical programs you could refer Michelle and her family to help with their food insecurity and healthcare. Women, Infants, and Children (WIC) can assist in food security, nutrition education and counseling for her and possibly her siblings depending on their age, as well as provide healthcare referrals, and a breast pump if she chooses to breastfeed afterwards. SNAP can also further assist her mother and siblings for dietary needs. 3,7 Medicaid can also help provide medical insurance to cover her prenatal care.

10. (1 pt) At this time in her pregnancy, list 3 changes you would suggest to Michelle to improve her nutritional status. I would suggest Michelle seek prenatal care, and assistance, the support of her mother and boyfriend as soon as possible, to begin taking a prenatal vitamin to help provide her child with the nutrients lacking due to her age, smoking habit and low gestational weight, as well as to cease or decrease smoking as much as possible to reduce the risks associated with the combination of factors surrounding her pregnancy.

VISIT 2: Michelle returns to see you at 28 weeks gestation. She now weighs 123 pounds. She is concerned about her weight gain and feels like she is getting fat. Her nausea and vomiting have resolved, but she is now experiencing bad heartburn after eating. She doesn’t like milk and dislikes eating breakfast.

Michelle is now receiving prenatal care and is taking a prenatal vitamin daily. She continues to smoke, but has cut back to 3-4 cigarettes/day. She wants to learn more about breastfeeding because “it will help me to lose weight”.

Her 24 hour dietary recall is as follows: 11 am: 3 chocolate doughnuts 2 pieces of sausage (cooked in microwave) 1 bottle of OJ Food from convenience store near school

2:00 Monster Energy Drink & Twix candy bar Food from convenience store near school

5:00 1 cheeseburger (3 oz) Large fries with ketch-up Large Coke Food from a fast food restaurant

!3

Sierra Medina

9:00 1 cup vanilla ice cream & 1 banana Eaten at home with boyfriend and little sister

QUESTIONS FOR VISIT 2 (13 points): 11. (1 pt) What trimester is Michelle?

Michelle is in her third trimester.

12. (1 pt) Plot Michelle’s weight gain at 28 weeks on the pregnancy weight gain chart from question 1. Has she gained the appropriate amount of weight given her pre-pregnancy BMI? Why or why not?

Michelle has not gained the appropriate amount of weight given her pre-pregnancy BMI, and is at least 2.5-9lbs below the recommended weight for gestational age, having gained 13lbs in total.

13. (1 pt) Describe 2 recommendations to alleviate heartburn during pregnancy.

Eating small meals and avoiding any foods that trigger heartburn may help to alleviate heartburn after eating. 1

14. (4 pts) A handout is available on Blackboard (“MyPlate for Moms”) that describes what Michelle should be eating based on the MyPlate recommendations. Based on these recommendations, is Michelle’s diet adequate for her pregnancy? Why or why not? Please provide at least 5 reasons why it is or is not adequate.

Michelle has not consumed any vegetables or many nutrient dense foods which can help provide the vitamins and minerals needed to help her and her baby to continue to grow and develop, and may not be consuming sufficient energy requirements (excluding empty calories) based on food choices, without additional nutritional info . portion sizes etc. provided. She is not consuming enough water or liquids throughout the day to help transport nutrients and support cell function. She is consuming more than enough saturated fats and not enough unsaturated or omega-3 fatty acids for fetal neural tissue development based on given food choices. She has some fruit intake which is a good start for vitamin and fiber content with a serving of orange juice and a banana. She is consuming some protein, which is beneficial for protein synthesis, although not the healthiest choices in terms of the amount of fat as well as the fatty acid profiles with the sausage and cheeseburger. 1

15. (2 pt) In consideration of her living conditions, available resources and current diet (see question 14), describe 6 suggestions you could provide to Michelle to help her improve her prenatal diet.

I would suggest that, given her current diet and living conditions, she seek assistance from WIC, or SNAP to help provide healthy choices for her and her family at home; to be aware of and improve her choices at the convenience store located near school, such as selecting whole grain cereal and bread products, perhaps crackers and peanut butter, fruits and yogurt parfaits, trail-mix with walnuts for something sweet instead of candy bars etc.; that she drink water throughout the day; for her to select lean meats, such as grilled chicken, fish and salads, fruit selections at fast food restaurants wherever possible; to carry snacks to school for between classes or in-class if possible;

!4

Sierra Medina

and perhaps to take a nutrition/home economic/cooking class if available at school to assist in self-reliance for nutritious food options while at home.

16. (1 pt) What positive comments/encouragement could you talk about with Michelle at this time? I would like to congratulate her for the improvements she’s made on taking steps towards receiving prenatal care, taking her prenatal vitamins and reducing her cigarette use, as well as for the weight gain, and encourage her to continue to make adjustments to her diet and lifestyle, and to continue to attend and work hard in school, which will all benefit her and her baby for the rest of their lives.

17. (1 pt) What would you tell Michelle about breastfeeding (2-3 sentences)?

Breastfeeding can help you to lose a fraction of the weight, but still requires a healthy diet and some activity now and postpartum can help prepare you to do so. It will help your baby to grow and reduce the instance of illness which can give you some flexibility and is essentially free. You can receive a breast pump from WIC to store your milk and allow for more time flexibility while still benefiting you and your baby. 2,6

18. (1 pt) List 2 additional questions you would like to ask Michelle to help you with your counseling session with her.

In order to examine any areas where additional resources are necessary to improve the desire and ease of making positive dietary choices, I would ask open-ended questions towards the subject of:

1. What is school like for her at the moment i.e. are things different from the beginning of her pregnancy, she able to concentrate, and does she require additional help in her studies? Is she able to eat i.e. store snacks in her locker or backpack to consume throughout the day to help with growth and concentration?

2. What is her support system at home like at the moment i.e. is there food available, and are there healthy choices available? Does she have time to do homework or rest with her responsibilities with her siblings? Do her boyfriend and mother have any influence or consideration of her reduction of smoking, and if they have any influence on her self-esteem towards the changes taking place in her body i.e. comments on postpartum weight loss, current gain, attractiveness etc.

!5

Sierra Medina

#2,12

!6

Sierra Medina

Reference List

1. Brown JE. Nutrition During Pregnancy, Conditions and Interventions. In: Nutrition Through the Life Cycle, 5th ed. Stamford, CT: Cengage; 2014: 87-163.

2. Brown JE. Nutrition During Lactation, Conditions and Interventions. In: Nutrition Through the Life Cycle, 5th ed. Stamford, CT: Cengage; 2014: 164-225.

3. Brown JE. Nutrition Basics. In: Nutrition Through the Life Cycle, 5th ed. Stamford, CT: Cengage; 2014: 1-49.

4. Clark A. Maternal Weight Gain & Pregnancy Outcomes. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed June 25, 2015.

5. Clark A. Nutrition Assessment And Guidance In Pregnancy. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed June 25, 2016.

6. Clark A. Breastfeeding Unit. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed June 25, 2015.

7. United States Department of Agriculture Food and Nutrition Service. Women, Infants and Children (WIC). Breastfeeding Promotion and Support in WIC. http://www.fns.usda.gov/wic/breastfeeding-promotion-and-support-wic. Published 2014. Accessed June 25, 2015.

8. Woolston C. Quitting smoking during pregnancy: Five keys to success. http://www.babycenter.com/0_quitting-smoking-during-pregnancy-five-keys-to-success_1405724.bc. Accessed June 25, 2015.

!7