mnnc postpartum nutrition and exercise · 2020-02-07 · nutrition & exercise objectives at the...

Session Name 8/9/2019

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INSTRUCTOR: RACHEL VENCE

OUTLINE: MICHELLE MEDINA, MSN, WHNP, CNM

Postpartum Nutrition & Exercise

OBJECTIVES

At the conclusion of this session the student will be able to:

Possess greater understanding of basic nutrition and the nutrition needs for post-partum

Review goals for weight loss and promotion of breastfeeding

Increased awareness and understanding of nutrition needs for women with diabetes postpartum

MNNC - 2018 - POSTPARTUM NUTRITION & EXERCISE 2

GOALS OF NUTRITION IN POSTPARTUM PERIOD

Optimize maternal & infant nutrition

Supplement vitamin/mineral stores as needed

Support appropriate weight loss

Promotion and support of breastfeeding



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MACRONUTRIENTSFOUR BASIC NUTRIENTS

BY CHOOSING THE HEALTHIEST FORMS OF EACH OF THESE NUTRIENTS & EATING THEM IN THE PROPER BALANCE, YOU ENABLE YOUR BODY TO FUNCTION AT IT’S OPTIMAL LEVEL

Water Carbohydrates Proteins Fats

MNNC - 2018 - POSTPARTUM NUTRITION & EXERCISE4

WATER

Water helps your body:

Keep your temperature normal

Lubricate & cushion joints

Protect your spinal cord & other sensitive tissues

Get rid of wastes through urination, perspiration, & bowel movements


CARBOHYDRATES

Provide energy

Carbohydrates are your body's main fuel source

During digestion, sugars & starches are broken down into simple sugars absorbed into your bloodstream, as blood glucose glucose enters your body's cells with the help of insulin & is used by your body for energy

Extra glucose is stored in your liver, muscles & other cells for later use, or is converted to fat



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CARBOHYDRATES (CONT.)

Protecting against disease

Whole grains & dietary fiber from whole foods help reduce your risk of cardiovascular diseases

Fiber also protects against obesity & type 2 diabetes & is essential for optimal digestive health

Controlling weight

Eating plenty of fruit, vegetables & whole grains can help you control your weight Bulk & fiber content aids weight control by helping you feel full on fewer calories

Very few studies show that a diet rich in healthy carbohydrates leads to weight gain or obesity



Dietary Guidelines for Americans recommends that carbohydrates make up 45-65% of your total daily calories

Most carbohydrates occur naturally in plant-based foods, such as grains

Common sources of naturally occurring carbohydrates include:

Fruits

Seeds

Nuts

Legumes

Vegetables

Grains

MilkMNNC - 2018 - POSTPARTUM NUTRITION & EXERCISE 8


Beans, peas & lentils are the most versatile & nutritious foods available

Typically low in fat & high in folate, potassium, iron, magnesium, & contain beneficial fats & fiber

A good source of protein & a healthy substitute for meat, which has more saturated fat and cholesterol



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TIPS FOR EATING ”GOOD” CARBOHYDRATES

Emphasize fiber-rich fruits & vegetables

Choose whole grains

Stick to low-fat dairy products

Limit added sugars (<10%)


FIBER

Fiber is a material found only in plant food

Our digestive systems cannot digest or break down fiber

Whole grains, fruits, & vegetables are all excellent sources of fiber

High-fiber foods –

Tend to be low in fat & calories

Take longer to chew allowing more time to realize that you are full

By absorbing water, fiber creates bulk & can help you feel full

Slows glucose absorption, preventing spikes in blood sugar

MNNC - 2018 - POSTPARTUM NUTRITION & EXERCISE

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GRAINS Food made from wheat, rice, oats, cornmeal, barley or another cereal grain is a

grain product

Bread, pasta, oatmeal, breakfast cereals, tortillas, & grits

Grains are divided into Whole Grains & Refined Grains

Whole grains contain the entire grain kernel, the bran, germ, & endosperm

Examples include: Whole-wheat flour, bulgur (cracked wheat), oatmeal, whole cornmeal & brown rice

Refined grains have been milled, a process that removes the bran & germ

This is done to give grains a finer texture and improve their shelf life, but it also removes dietary fiber, iron, & many B vitamins

Some examples of refined grain products are:

White flour, de-germed cornmeal, white bread & white rice


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PROTEIN

Curbing hunger by stabilizing blood glucose

Loosing/maintaining weight

Improves ability to learn & concentrate

Reduces brain fog

Boost energy levels

Speeding recovery after exercise

Reducing muscle loss

Building lean muscle

Support your muscles and bones and support the absorption of important nutrients



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PROTEIN

All foods made from meat, poultry, seafood, beans, peas, eggs, processed soy products, nuts, & seeds

Protein is needed in your diet to help your body repair cells & make new ones

Protein is important for growth & development in children, teens, & pregnant women

Unlike carbohydrates & fat, your body does not store protein it has no reservoir to draw from when you’re running low

When proteins are digested, they leave behind amino acids, which the human body needs


FATS

SOURCES OF SATURATED FAT IN THE US


SATURATED FAT

All foods containing fat have a mix of specific types of fats Even healthy foods like chicken & nuts have small amounts of saturated fat

Saturated fat is mainly found in animal foods, but a few plant foods are also high in saturated fats, such as coconut, coconut oil, palm oil, & palm kernel oil

The Dietary Guidelines for Americans recommends getting less than 10% of calories each day from saturated fat

The American Heart Association goes even further, recommending limiting saturated fat to no more than 7% of calories

To reduce your risk for heart disease, cut back on saturated fat & trans fat by replacing some foods high in saturated fat with unsaturated fat or oils



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TRANS FATS

Trans fatty acids are made by heating liquid vegetable oils in the presence of hydrogen gas & a catalyst, a process called hydrogenation

Partially hydrogenating vegetable oils makes them more stable & less likely to become rancid This process also converts the oil into a solid, which makes them function as margarine or shortening

Partially hydrogenated oils can withstand repeated heating without breaking down, making them ideal for frying fast foods

Trans fats are also naturally found in beef fat & dairy fat in small amounts


TRANS FATS (CONT.)

Trans fats are worse for cholesterol levels than saturated fats because they raise LDL & lower HDL

Create inflammation – which has been implicated in heart disease, stroke, diabetes, & other chronic conditions

Contribute to insulin resistance

Each additional 2% of calories from trans fat consumed daily increases the risk of Coronary Heart Disease by 23 %




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UNSATURATED FATS

Liquid at room temperature, considered beneficial fats because they can improve blood cholesterol levels, ease inflammation, stabilize heart rhythms, & play a number of other beneficial roles

Predominantly found in foods from plants, such as vegetable oils, nuts, & seeds

There are two types of “good” unsaturated fats:

Monounsaturated fats

Polyunsaturated fats


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UNSATURATED FATS (CONT.)

Monounsaturated fats-

found in high concentrations in:

Olive, peanut, & canola oils

Avocados

Nuts such as almonds, hazelnuts, & pecans

Seeds such as pumpkin & sesame seeds


UNSATURATED FATS (CONT.)

Polyunsaturated fats –

Found in high concentrations in:

Sunflower, corn, soybean, & flaxseed oils

Walnuts

Flax seeds

Fish

Canola oil – though higher in monounsaturated fat, it’s also a good source of polyunsaturated fat



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OMEGA 3 FATTY ACIDS

Omega 3 poly-unsaturated fatty acids include docosahexaenoic acid (DHA), elcosapentaenoic acid (EPA) & alpha-linoleic acid (ALA)

An important type of polyunsaturated fat

The body can’t make these, so they must come from food

Fish & seafood are the highest sources of DHA & EPA

An excellent way to get omega-3 fats is by eating fish 2-3 times a week of low-mercury & preferably fatty fish

Leafy, green vegetables, canola, soybean oil, walnuts, flaxseeds & their oils as well as algae are the richest sources of ALA


Micronutrients:

Nutrients required by the body in small amounts, vital to development & disease prevention

Vitamins Folic acid: 500 mcg/day for lactating mothers. Most multivitamin supplements contain >400 mcg

Minerals

Minerals Calcium: 1000 mg/day (RDA for 19-50 years)

Iron: decrease back to non-pregnant levels after 6 weeks


FRUITS & VEGETABLES

Vegetables may be raw or cooked; fresh, frozen, canned, or dried/dehydrated; & may be whole, cut-up, or mashed

Vegetables are organized into 5 subgroups, based on their nutrient content

Dark green vegetables

Starchy vegetables

Red & orange vegetables

Beans and peas

Other vegetables

Fruits may be fresh, canned, frozen, or dried, & may be whole, cut-up, or pureed

Organic, fresh fruits and vegetables are always the better choice



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NUTRITIONAL NEEDS

Energy intake: Minimum of 1800 kcal/day to meet energy requirements of lactation while promoting weight loss

Milk production estimated energy output is 500 kcal extra first 6 months, then 400 kcal extra the second 6 months

Many of your nutrient needs remain the same as with pregnancy but some increase Carbohydrate – 175 210g with breastfeeding

Protein – Unclear 71g same as with pregnancy

Water Aim for 13 cups a day

Vitamin needs increase as you are now trying to meet the needs of yourself & your infant

Continue to take PNV for 6 months


HEALTHY EATING WITH BALANCED NUTRITION

When putting together a meal plan, include a variety of the following foods:

Grains – whole-grain pasta, breads, brown rice

Vegetables – spinach, tomatoes & other colorful vegetables

Protein – lean meat, chicken, fish, eggs, lentils & beans

Fruit- fresh, colorful fruits

Dairy – yogurt, milk & cheese

Fats – avocado, walnuts, olive oil


WEIGHT LOSS

Most women lose most of the weight they have gained

Greatest weight loss occurs in the first 3 months after childbirth

10-13 lbs at time of birth

7-11 additional lbs lost in the first week

Weight loss slows down after 6 months

Goal weight loss if breastfeeding

Average of 1-2 lbs a week is normal healthy weight loss to maintain adequate milk production



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RETURNING TO EXERCISE

Return to exercise slowly -

Start with something low impact and simple — such as a daily walk

Start with 10 min then gradually increase the intensity & length of your sessions, slowly add resistance to a bike, or incrementally increase the incline if you’re working out on the treadmill

Aim get at least 150 min (or 30 min, 5 days/week) of moderate intensity, aerobic exercise + 2 days/week of muscle/strength training activities


RETURNING TO EXERCISE (CONT.)

Be reasonable

Listen to your body

Too much exercise when the body is healing can be more harmful than helpful

Looks for fitness classes and trying to incorporate baby into the routine

Always stop the exercise if you feel pain & rest for 1-2 minutes

If the pain persists, contact your personal trainer or physician

Always do needed stretches prior to exercising in order to bring the body back into a state of balance

Always stop the exercise at the point where you feel that you could only do 2 more repetitions with good form (-2 reps)


ACOG RECOMMENDATIONS

Recommended that you get at least 150 minutes (30 min, 5 days/week or smaller intervals) of moderate-intensity aerobic activity (moving large muscle groups: walking/biking) every week

Mod-intensity: moving enough to raise your heart rate and start sweating You can still talk normally, but you cannot sing

Aim to do muscle –strengthening activities at least 2 days/week

Examples include yoga, Pilates, lifting weights, sit-ups, & push-ups

Appropriate exercise level will depend on each woman’s medical history, obstetrical course, level of fitness, & recovery



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ACOG RECOMMENDATIONS (CONT.)

Some women may be able to start an exercise routine within days of delivery; others may need to wait 4-6 weeks

If you have stitches, make sure the exercise is light and there is little pain or discomfort during exercise

Exercises to restore abdominal muscle tone after a cesarean section can begin as soon as abdominal soreness diminishes, sometimes even days after birth

Pelvic tilts, planks and a variety of yoga moves are a great way to reintroduce engaging core muscles without too much strain

Abdominal strength is important for maintaining proper posture, as well as attaining adequate pelvic control


0-6 WEEKS


Pelvic tilt Try the pelvic tilt a few times a day to strengthen your abdominal muscles

Lie on your back on the floor with your knees bentFlatten your back against the floor by tightening your abdominal muscles & bending your pelvis up slightlyHold for up to 10 seconds repeat five times & work up to 10

to 20 repetitions


Use this exercise to tone your pelvic floor muscles, which support the uterus, bladder, small intestine & rectum

Contract your pelvic floor muscles, as if you're attempting to stop urinating midstream

Hold for up to 10 seconds & release, relaxing for 10 seconds between contractions.

Aim for at least three sets of 10 repetitions a day


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7-12 WEEKS

Low impact, moderate exercise

Yoga

Swimming

Pilates

PiYo

Light weight training



TESTING FOR DIASTASIS RECTI

Place two fingers on top of the where the worst part of the abdominal split has occurred. Have client do a modified crunch a few times

If anything pushes the finger out away from the body the client may need surgery, refer your client out and begin abdominal exercises once they are cleared for abdominal exercises

If the fingers remain in place or get sucked in, perform the following exercises

If you have a split & you pass the test or have been cleared for abdominal exercise, perform the next two exercises



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ABDOMINAL WORK FOR DIASTASIS RECTI –UPPER ABDOMINALS

1. Sit with legs bent, feet shoulder width apart

2. Round the spine into flexion to isometrically contract the upper abdominals. Cross the right arm over the chest, dorsiflex the left hand and reach that arm straight toward the right knee. Keep your feet on the floor

3. With a limited end range of motion, reach the left hand toward the right knee, moving only about 4-6 inches across. Chin tucked & exhale during the entire movement, looking toward your left hand

4. Inhale at the start and exhale through the movement. Repeat 10-30 times and switch sides

Do at least 3 sets of as many as you can do

If it is too hard, you are curling too far back


DIASTASIS RECTI – LOWER ABDOMINALS

1. Lie on your back, place a small book or pad about an inch and a half thick under your hips, at the base of the pelvis- Left leg crossed over right and pick your feet up off the floor

2. Cross your arms, with elbows in line with the shoulders, arms over the chest

3. With a limited end range of motion, draw your left knee toward your right elbow, reaching only about 4-6 inches, exhale throughout the entire movement

4. Inhale at the start & repeat 10-30 times on each side for 3 sets


EXERCISE & BREASTFEEDING

Exercise isn't thought to have any adverse effects on breast milk volume or composition, nor is it thought to affect a nursing infant's growth

Some research suggests that high-intensity exercise might cause lactic acid to accumulate in breast milk and produce a sour taste a baby might not like rare

If vigorous exercise is a priority during the first few months of breast-feeding, consider feeding your baby before your workout or pumping before your workout and feeding your baby the pumped breast milk afterward

Alternatively, exercise first & then take a shower, express a few milliliters of breast milk &, after a half-hour or an hour, offer the breast

Wear a supportive bra &, if you're breast-feeding, nursing pads in case your breasts leak

At risk for plugged ducts if lifting weights or doing other repetitive arm movements

If this happens cut back and start again more slowly. STAY HYDRATED!!


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BREASTFEEDING CONSIDERATIONS WITH DMWomen with DM while breastfeeding (particularly type 1) are at risk for hypoglycemia as glucose is preferentially shunted towards production of breastmilk

May need snacks to prevent hypoglycemia in the early postpartum period and throughout lactation

Avoid exercise if BG level >250 mg/dl to prevent ketoacidosis d/t increased activity & counter-regulatory hormones

Type 1 Diabetes:

Advise frequent BG testing, including 1 hr after breastfeeding for the first 3 days postpartum

Nocturnal hypoglycemia common

If BG <100 mg/dl prior to breastfeeding, eat a 15g CHO snack with protein to prevent hypoglycemia

Episodes of hypoglycemia can also cause temporary release of epinephrine which can cause temporary decrease in milk production

Type 2 Diabetes:

Continue to check BG levels, especially if on glyburide or insulin


RELAXIN

During pregnancy, the

hormone relaxin is

present in 10 times its

normal concentration

in the female body &

can remain high for up

to five months after

giving birth

Relaxes the joints in

the pelvis so baby has

room to pass through

the birth canal

Also causes abnormal

elasticity & motion in

many other joints of

the body, causing

inflammation & pain

This can lead to

injury if exercise is

too aggressive after

giving birth

Therefore, creating

strength & stability

in the body is very

important


HOW TO RELIEVE SCIATICA

The following yoga poses & exercises can help relieve sciatic nerve pain: Downward dog Spinal rotation Baby cradle Upward dog Piriformis release with ball and foam roller Twisted warrior Anything that helps with SI joint pain

Acupuncture Movement – light cardiovascular exercise Myofascial release



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DOWNWARD DOG – OPENS BACK & RELIEVES TENSION Come onto the floor on your hands & knees, set your knees

directly below your hips & your hands slightly forward of your shoulders. Spread your fingers, gripping the mat & turn your toes under

Exhale & lift your knees away from the floor, keeping the knees slightly bent & the heels lifted away from the floor

Lengthen your tailbone, pressing your hips up toward the ceiling. Lift the front of your thighs & activate the inner thigh

Relax the belly if you feel any discomfort in the abdomen.

Open the shoulder blades by turning the palms out as if opening a jar

Relax the head & look toward your belly button

If you cannot get the heels to the floor, bend your knees

Hold this pose for 5 breaths.MNNC - 2018 - POSTPARTUM NUTRITION & EXERCISE 46

SPINAL ROTATION

Lie on your back with knees bent and feet placed wider than your hips

Drop both knees to the left, and look right, keeping the shoulders on the floor

Hold this pose for 5 breaths

Repeat on other side

This can be done with a block between the knees for more support


BABY CRADLE

Sit with one leg extended and place the foot of the opposite leg in the crease of the elbow

Keep the chest lifted as you place the other arm outside the knee, as if you were cradling a baby

Gently rock side to side for 5-10 breaths

Repeat on other side



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UPWARD DOG

Lie prone on the floor, stretch your legs back with the tops of your feet on the floor

Bend your elbows & spread your palms on the floor beside your waist, so that your forearms are almost perpendicular to the floor

Inhale & press your inner hands firmly into the floor & slightly back, as if you were trying to push yourself forward along the floor.

Then, straighten your arms and simultaneously lift your torso up

Contract your thighs firm & slightly turned inward, buttocks tight & tops of the feet on the floor

The arms are firm & turned out so the elbow creases face forward, gaze forward

Hold this pose for 1-5 breaths


PIRIFORMIS RELEASE

• Sit with one leg crossed over the other & place a small tennis ball, yoga tune-up alpha ball (this is best) or any type of myofascial release ball under your hip near pocket area

• Roll around on the ball back & forth for 20-30 seconds

• Switch sides

• Repeat 3-5 times


TWISTED WARRIOR

From standing, feet shoulder width apart, hands on your hips, step your left foot back 3-4 feet & angle your left foot to about 11:00 (30 degrees)

Keep your right foot pointing forward. With your left heel firmly anchored to the floor & the outer edge of the foot connecting to the mat, exhale & bend your right knee over the right ankle so the shin is perpendicular to the floor

If it is hard to keep the heel down, lift it off the floor

Keep your hips square to the front of the mat

Raise your arms & reach actively through the little-finger sides of the hands toward the ceiling

Squeeze your shoulder blades together & relax your shoulders away from your ears

Reach your left hand across the right leg & place it on a block, reach the right arm straight up



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PIGEON – OPENS HIPS & RELEASES EMOTIONS, CAN HELP WITH SCIATICA

• Begin on all fours.

• Cross your left leg so that the bottom of your foot is against your right knee

• Slowly lengthen your right leg straight behind you, keeping the top of the foot on the floor

• Align your hips so they are square, flex your left foot to protect your knee

• Place your hands beneath your shoulders & press into the floor to lift your upper torso & raise your chest while keeping your shoulders down & away from the side of your head

• Hold for 3 to 5 breaths

• Uncross your left leg, straighten & shake it, then repeat on other side


PRONE COBRA


• Lie on stomach & extend upward, rotating your palms out & squeezing your shoulder blades together

• Make sure that the shoulders are externally rotated, not internally rotated

• Squeeze your buttocks & keep your feet on the floor.

• Hold without extending your head back, chin slightly tucked, to lengthen through the back of the neck

• Hold this for 3 minutes

Work your way up holding as long as you can, then

resting for half the time you held

SEATED FORWARD FOLDREDUCES BACK & HEAD ACHES

Sit with legs together & move the fleshy part of bottom out of way

Bending from hips, bring your torso toward thighs

Exhale & try to grab the toes or place your hands on your thighs

If you cannot reach your toes, may use a strap around your feet

Hold for 5-10 breaths



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STANDING WIDE-LEGGED FORWARD BEND

Stand in mountain pose, hands on hips & jump or walk your feet 4-5 feet apart, depending on your flexibility

Make sure your feet are slightly pigeon toed

Exhale & bend forward from the hip joints, not from the waist, with airplane arms

Tighten the legs by drawing up on your knee caps as you descend

Continue to lengthen through the torso & backs of the legs & place your palms on the floor in line with your shoulders

Hold for 5 breaths

A twist can be added to open the side body


CHILD’S POSE REDUCES STRESS, BACK & HEAD ACHES

Kneel on the floor, touch your big toes together & sit on your heels, then separate your knees as wide as your hips

Exhale & lay your upper body between your thighs. Open across the back of your pelvis & lengthen your tailbone & gently place your forehead on the floor & relax your arms at your sides

Hold this pose for 5 breaths or a few minutes


OVERCOMING BARRIERS

When you're caring for a newborn, finding time

for exercise can be challenging

When you're caring for a newborn, finding time

for exercise can be challenging

Hormonal changes can make you emotional &

some days you might feel too tired for a full

workout

Hormonal changes can make you emotional &

some days you might feel too tired for a full

workout

But don't give up! But don't give up!

Exercise after pregnancy is not easy but it can do wonders for your well-being, as well as give you the

energy you need to care for your newborn

Exercise after pregnancy is not easy but it can do wonders for your well-being, as well as give you the

energy you need to care for your newborn



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TIPS FOR STICKING WITH IT!

Looks for fitness classes and trying to incorporate baby into the routine

Vary routine

Get a workout buddy


EXERCISE AFTER PREGNANCY

One of the best things one can do for themselves

Regular exercise after pregnancy can:

Promote weight loss, particularly when combined with reduced calorie intake

Improve cardiovascular fitness

Strengthen & tone abdominal muscles

Boost energy level

Relieve stress

Promote better sleep

Including physical activity in ones daily routine helps you set a positive example for their child now & in the years to come


REFERENCES

American Dietetic Association, Dietitians of Canada. Position of the American Dietetic Association and Dietitian of Canada: dietary fatty acids. J Am Diet Assoc. 2007; 107 (9): 1599-1611.

ASPEN Core Curriculum. Cimbalik, C, Paauw, J, Davis A. Pregnancy and Lactation. 2007; 383-404. Acad Nutr Diet. 2014; 114:1099-1103.

Association or Reproductive Health Professionals. http://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/postpartum-counseling/diet. Updated July 2013.

American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Exercise-After-Pregnancy . Updated June 2015.

Balch, P. A., CNC. (2010). Prescription for Nutritional Healing(Fifth ed.). New York, NY: Penguin Group. CDAPP Sweet Success Guidelines for Care. State program guide, 2015 Geetha Rao. Nutrition, Diabetes and Pregnancy after Bariatric Surgery. CDAPP webinar, 2016



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REFERENCES CONTINUED

Prebiotics and Probiotics: Creating a Healthier You. EatRight.org. Reviewed by T Wolfram. 2016

Riley, L., & Nelson, S. (2006). You & Your Baby Healthy Eating During Pregnancy. Des Moines, IW: Meredith Books.

Stuebe, AM et al. Duration of Lactation and Incidence of Type 2 Diabetes. JAMA 2005; 294: 2601-2610

https://www.cdc.gov/healthywater/drinking/nutrition/index.html

https://www.hsph.harvard.edu/nutritionsource/types-of-fat/

https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/exercise-after-pregnancy/art-20044596


mnnc postpartum nutrition and exercise · 2020-02-07 · nutrition & exercise objectives at the...

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