Nutrition in Nutrition in PregnancyPregnancyJoanne Kurtz, RDJoanne Kurtz, RD

July 2013July 2013

Prenatal Nutrition Prenatal Nutrition ObjectivesObjectives

► Highlight nutrients of concern during pregnancyHighlight nutrients of concern during pregnancy

► Discuss food safety considerationsDiscuss food safety considerations

► Assess rate of weight gainAssess rate of weight gain

► Assess risk of malnutritionAssess risk of malnutrition

► Review health professional and pt education Review health professional and pt education resources/ websitesresources/ websites V drive, onlineV drive, online

Sally’s IntakeSally’s Intake

► New diag preg► GA 8wks► Very excited and curious

about eating well to support her pregnancy

► No known food allergies► Feels she eats well► Curious to know if current

diet adequate to support pregnancy

Comment on Sally’s intake Comment on Sally’s intake nutrient intake.nutrient intake.

What questions could you What questions could you ask to get a better sense ask to get a better sense of her nutritional status?of her nutritional status?

► Breakfast Special K cereal with 2% milk or

oatmeal Starbucks Venti Coffee with milk

► Lunch Subway turkey sub or sushi Water

► Afternoon Fat free yogurt or granola bar-

Small coffee w/milk

► Supper 4 oz chicken or beef Usually corn, peas or beans 1 cup white pasta, rice or

potato Water or juice

► Evening Popcorn, chips or crackers

Rate of Weight GainRate of Weight Gain

Sally Sally con’tcon’t … …

►GA 16wksGA 16wks►Feels greatFeels great►Always hungry!!!Always hungry!!!►Had gained 18 lbs to dateHad gained 18 lbs to date

Pre -Pregnancy BMI 24Pre -Pregnancy BMI 24

►Wonders about whether this is Wonders about whether this is appropriateappropriate

Maternal weight and weight Maternal weight and weight gain during pregnancygain during pregnancy

► Weight-related problems should be addressed before pregnancy to optimize maternal and fetal health

► Low pre-pregnancy weight is associated with preterm birth and giving birth to a SGA infant

► Women who enter pregnancy with BMI over 25 are at increased risk of a poor pregnancy outcome like GDM, complicated delivery or LGA*

Weight gain during Weight gain during pregnancypregnancy

► The IOM guidelines are based on observational data, which consistently show that women who gain within the recommended range experience better pregnancy outcomes

► Total weight gain recommended assume a gain of between 0.5 and 2 kg (1.1 – 4.4 lbs) in the first trimester [IOM 2009].

► Slight weight loss due to mild nausea or vomiting is common

Recommended Weight GainRecommended Weight Gain

BMIBMI TargetTargetRates of Weight Gain Rates of Weight Gain 22ndnd and 3 and 3rdrd trimester trimester per week (lbs/wk)per week (lbs/wk)

18.5 to 18.5 to 24.924.9

25 to 35 25 to 35 lbslbs

11

(0.8-1.0)(0.8-1.0)

< 18.5< 18.5 28 to 40 28 to 40 lbslbs

11

(1.0-1.3)(1.0-1.3)

25 to 29.925 to 29.9 15 to 25 15 to 25 lbslbs

0.60.6

(0.5-0.7)(0.5-0.7)

>>3030 11 to 20 11 to 20 lbs lbs

0.50.5

(0.4-0.6)(0.4-0.6)

IOM guidelines, 2009

Obesity and PregnancyObesity and Pregnancy

► What is optimal wt gain?What is optimal wt gain?

► GWG is strongest predictor of wt retentionGWG is strongest predictor of wt retention

► Obese women (BMI>35) who lose wt in pregnancy may Obese women (BMI>35) who lose wt in pregnancy may have decreased or unaffected risk of C-sections, LGA have decreased or unaffected risk of C-sections, LGA babies, pre-eclampsia etc. (but increased risk of SGA in babies, pre-eclampsia etc. (but increased risk of SGA in obesity class III?)obesity class III?)

Obstet Gynecol 2011;117:1065–70

Maternal CharacteristicsMaternal Characteristics

GWGGWG

(kg)(kg)BMI BMI

30-34.930-34.9BMI BMI

35-39.935-39.9BMI BMI

40 or 40 or higherhigher

Less Less than 0than 0

4.1%4.1% 7.9%7.9% 14.6%*14.6%*

0-4.90-4.9 9.4%9.4% 14.6%14.6% 17.4%17.4%

5-9 *5-9 *(guidelines)

26.7%26.7% 29.1%29.1% 28.3%28.3%

More More than 9than 9

59.8%59.8% 48.4%48.4% 39.6%39.6%

Tracking weight gain in the Tracking weight gain in the second and third trimesterssecond and third trimesters

► If an abnormal pattern of weight gain is If an abnormal pattern of weight gain is observed:observed: consider adequacy and consistency of fetal consider adequacy and consistency of fetal

growthgrowth presence of medical problems (ie. edema)presence of medical problems (ie. edema) modifiable factors (ie. overeating or a modifiable factors (ie. overeating or a

sedentary lifestyle)sedentary lifestyle)

► Focus should be on normalizing Focus should be on normalizing rate rate of of weight gain going forward. weight gain going forward.

Multiple gestationsMultiple gestations

► The IOM (2009) provides the following The IOM (2009) provides the following provisional gestational weight gain provisional gestational weight gain guidelines for women carrying twins:guidelines for women carrying twins:

normal weight women should gain a total of normal weight women should gain a total of between 17 to 25 kg (37–54 lbs),between 17 to 25 kg (37–54 lbs),

overweight women, a total of between 14 to 23 overweight women, a total of between 14 to 23 kg (31–50 lbs), andkg (31–50 lbs), and

obese women, a total of between 11 to 19 kg (25 obese women, a total of between 11 to 19 kg (25 – 42 lbs).– 42 lbs).

Women at Increased Nutritional Women at Increased Nutritional RiskRisk

► New Vegetarians and/or vegansNew Vegetarians and/or vegans► TeensTeens► Under or Under or over wtover wt pre pregnancy pre pregnancy► Yo yo dietersYo yo dieters► Multiple pregnancyMultiple pregnancy► N/V post 1N/V post 1stst trimester trimester► Last pregnancy <2yrs agoLast pregnancy <2yrs ago► Financial difficultiesFinancial difficulties► New CanadiansNew Canadians► Special dietary concernsSpecial dietary concerns

Multiple food allergies or intolerancesMultiple food allergies or intolerances

Canada Prenatal Nutrition Canada Prenatal Nutrition Program Program (Buns in the Oven)(Buns in the Oven)

► Confidential and Confidential and FREE!FREE!

► Geared towards Geared towards pregnant teens and pregnant teens and high risk womenhigh risk women

► Healthy eating and Healthy eating and cooking activitiescooking activities

► Breastfeeding Breastfeeding supportsupport

► Postnatal/ parenting Postnatal/ parenting information supportinformation support

► Offers:Offers: Milk coupons and Milk coupons and

food to take homefood to take home Child careChild care Bus ticketsBus tickets RNs and RDs to RNs and RDs to

answer questions answer questions

OttawaYoungParents.com for locations and contact info

Nutrients of Concern Nutrients of Concern in Pregnancyin Pregnancy

►EnergyEnergy►IronIron

►FolateFolate►Omega 3 fatty acidsOmega 3 fatty acids

►CalciumCalcium►Vitamin DVitamin D

A Healthy Diet A Healthy Diet

CFG provides the info needed on CFG provides the info needed on healthy eating during pregnancyhealthy eating during pregnancy

• Whole grainsWhole grains• Fruits and vegetablesFruits and vegetables• Low fat milk productsLow fat milk products• Fatty fish (twice per week)Fatty fish (twice per week)• Small amounts of healthy fatSmall amounts of healthy fat• Lean meats and meat alternativesLean meats and meat alternatives

EnergyEnergy

11stst trimester (no extra kcal needed) trimester (no extra kcal needed)22ndnd trimester (+300 kcal/d) – extra snack trimester (+300 kcal/d) – extra snack33rdrd trimester (+500 kcal/d) trimester (+500 kcal/d)

►Equivalent to an extra 2-4 food guide Equivalent to an extra 2-4 food guide servings/d servings/d

►Consider adding snacks to diet or extra Consider adding snacks to diet or extra food with mealsfood with meals

1 cup of milk + 1 fruit1 cup of milk + 1 fruit ¼c of trail mix and ¾ cup of low fat yogurt¼c of trail mix and ¾ cup of low fat yogurt ½ a pita with ¼ cup hummus½ a pita with ¼ cup hummus Small banana with 2 tbsp peanut butter and 1 sm Small banana with 2 tbsp peanut butter and 1 sm

tortillatortilla

Iron in pregnancyIron in pregnancy

► Increased needs to support the rise in maternal Increased needs to support the rise in maternal red blood cell mass.red blood cell mass.

► Increased RBC supplies the growing fetus and Increased RBC supplies the growing fetus and placenta, and supports normal brain placenta, and supports normal brain development in the fetus.development in the fetus.

► During the third trimester, the fetus builds iron During the third trimester, the fetus builds iron stores for the first six months of life.stores for the first six months of life.

► Most pregnant women in North America have Most pregnant women in North America have trouble getting the iron they need through diet trouble getting the iron they need through diet alonealone

Iron in PregnancyIron in Pregnancy

► (RDA) for iron during pregnancy is (RDA) for iron during pregnancy is 27 mg27 mg per per day. This is the average amount of iron most day. This is the average amount of iron most healthy pregnant women need each day to healthy pregnant women need each day to meet their iron needs.meet their iron needs.

► Eating according to Canada’s Food Guide and Eating according to Canada’s Food Guide and taking a daily multivitamin that has 16 to 20 taking a daily multivitamin that has 16 to 20 mg of iron will support a healthy pregnancy mg of iron will support a healthy pregnancy (Health Canada).(Health Canada).

► Most prenatal vitamin contains RDA for iron Most prenatal vitamin contains RDA for iron This will not correct a deficiencyThis will not correct a deficiency

IOM 2001

Folate During pregnancyFolate During pregnancy

► Essential for normal development of Essential for normal development of spine, brain and skull of the fetus, spine, brain and skull of the fetus, especially in first four weeks of pregnancyespecially in first four weeks of pregnancy

► Supports the pregnant woman’s Supports the pregnant woman’s expanding blood volume and growing expanding blood volume and growing maternal and fetal tissuesmaternal and fetal tissues

► Addition of folic acid to white flour, Addition of folic acid to white flour, enriched pasta, and enriched corn meal enriched pasta, and enriched corn meal has been mandatory in Canada since has been mandatory in Canada since November 1998.November 1998.

Folate PreconceptionFolate Preconception

► RDA is 600 mcg (0.6mg) per day to maintain normal RDA is 600 mcg (0.6mg) per day to maintain normal folate status during pregnancy. folate status during pregnancy.

► Intake of folic acid from fortified foods is estimated Intake of folic acid from fortified foods is estimated to be no more than 100 to 200 mcg per dayto be no more than 100 to 200 mcg per day Diet alone insufficient to meet folic acid needsDiet alone insufficient to meet folic acid needs

► SOGC recommend 0.4-1mg folic acid SOGC recommend 0.4-1mg folic acid Most prenatal multivitamins now have 1mgMost prenatal multivitamins now have 1mg

► Supplementing with folic acid between pregnancies Supplementing with folic acid between pregnancies can help reduce the risk of NTDs in subsequent can help reduce the risk of NTDs in subsequent births.births.

Health Canada 2009, SOGC

Folic Acid- SOGC CPG-2007Folic Acid- SOGC CPG-2007Target population Preconception + Preconception +

11stst trimester trimester22ndnd and 3 and 3rdrd tri + tri +

lactationlactation

Pts with NO health risk + planned pregnancy

0.4-1 mg0.4-1 mg 0.4-1 mg0.4-1 mg

High risk pts:►DM►Obesity BMI >35►Family Hx of or previous pregnancy with NTD►Compliance or lifestyle issues►Smokers►PCOS►Malabsorption disorders (ie. IBD)►Who take antiepileptic drugs, folate antagonists (methotrexate, sulfonamides)►Ethnic groups (Sikh, Celtic, Northern Chinese)

5 mg 0.4-1 mg0.4-1 mg

In addition to a diet high in folate

Folate rich foodsFolate rich foods

►Spinach, broccoli, peas, brussel Spinach, broccoli, peas, brussel sprouts, asparagussprouts, asparagus

►Fortified grainsFortified grains►Lentils, chick peasLentils, chick peas►CornCorn►OrangesOranges

Omega 3 fatty acids Omega 3 fatty acids ► Important for neurodevelopment, visual acuity in fetus and

possible decreased incidence of depression in mom Primary source fatty fish: salmon, trout, sardines, halibut Omega-3 eggs, fortified yogurt

► Encourage 150g (2 servings) of fish each week

There is currently insufficient evidence to recommend fish oil supplements* (DHA and/or EPA) during pregnancy

to enhance later child development. [Health Canada]

Methyl Mercury in uteroMethyl Mercury in utero

► ““epidemiological studies have demonstrated ... epidemiological studies have demonstrated ... subtle impacts on fine motor function, attention subtle impacts on fine motor function, attention span, verbal learning and memory of children that span, verbal learning and memory of children that were exposed to methylmercury in utero.”were exposed to methylmercury in utero.”

► The health effects of exposure to methyl mercury The health effects of exposure to methyl mercury for a fetus or young child can include a decrease in for a fetus or young child can include a decrease in IQ, delays in walking and talking, lack of IQ, delays in walking and talking, lack of coordination, blindness and seizures.coordination, blindness and seizures.

Fish consumptionFish consumption

Limit to 5oz per month► frozen/fresh tuna, Shark► Swordfish► Marlin► Orange roughy► Escolar

Limit to 300g (10oz) per week► Canned white albacore tuna* (300g/wk)

Canned light tuna is low in mercury and safe

Encourage consumption of fatty fish- omega 3s DHA and EPA extremely important in last trimester and first two years of life

Calcium and Vitamin DCalcium and Vitamin D► Calcium needs are the same as pre-pregnancy

(1000mg for >18yo, 1300mg for <18yo)

► Supplementation is not necessary if 2 servings of milk products/d >19yo 3 servings of milk products/d < 18yo

► Prenatal may not be not sufficient to meet calcium needs (~250-300mg)

► Some groups discuss 600-2000 IU of Vit D [Health Canada 2010, CPS 2007]

Prenatal has ~400-800IU

Food safety Food safety considerationsconsiderations

Safe, avoid or limitSafe, avoid or limit

Food safety considerationsFood safety considerationsAvoid:Avoid:► Flaxseed (ground or oil) Flaxseed (ground or oil)

Safe in amounts commonly in food ie- flaxseed bread okSafe in amounts commonly in food ie- flaxseed bread ok► Raw sproutsRaw sprouts► Unpasteurized juices and cidersUnpasteurized juices and ciders► Soft, Soft, unpasteurizedunpasteurized cheeses cheeses► Deli meats, patés, smoked seafood, raw Deli meats, patés, smoked seafood, raw

meats/fish/eggsmeats/fish/eggs► Saccharin and cyclamatesSaccharin and cyclamates

Sugar Twin or Sweet n Low sugar substitutesSugar Twin or Sweet n Low sugar substitutes► AlcoholAlcohol

LimitLimit► Caffeine 300mg Caffeine 300mg

(1.5 cups of coffee)(1.5 cups of coffee) Prolonged half life in pregnancyProlonged half life in pregnancy

Herbal Herbal beverages/supplementsbeverages/supplements

SafeSafe► Citrus PeelCitrus Peel► GingerGinger► RosemaryRosemary► EchinaceaEchinacea

► PeppermintPeppermint► Orange Peel and Orange Peel and ► RosehipRosehip► Red Raspberry Red Raspberry

leafleafThere is either insufficient or documented adverse

effects with all other herbal supplements and should be avoided during pregnancy

Nausea and Vomiting Nausea and Vomiting Eat what’s appealingEat what’s appealing► Possible comforting solutionsPossible comforting solutions

Separate solids from liquidsSeparate solids from liquids Small, frequent meals of bland foodsSmall, frequent meals of bland foods Consider preferred textured foodsConsider preferred textured foods Avoid having an empty stomachAvoid having an empty stomach Rise slowly from bedRise slowly from bed Try a few soda crackers before getting out of bedTry a few soda crackers before getting out of bed Avoid high fat or strong odorous foodsAvoid high fat or strong odorous foods

► Ginger Ginger 0.5 to 1.0 g/day (split into three to four equal doses) [SOGC]0.5 to 1.0 g/day (split into three to four equal doses) [SOGC] Can purchase over the counterCan purchase over the counter

► Vitamin B6 SupplementVitamin B6 Supplement 25-75mg/d 25-75mg/d

Sally’s IntakeSally’s Intake

► New dx preg► GA 8wks► Very excited and

curious about eating well to support her pregnancy

► No known food allergies► Feels she eats well► Curious to know if

current diet adequate to support pregnancy

What would you What would you suggest?suggest?

► Breakfast Special K cereal with 2% or

oatmeal Small coffee with milk

► Lunch Subway or sushi Water

► Afternoon Fat free yogurt or granola bar-

Small coffee w/milk

► Supper +/-4 oz chicken or beef Usually corn, peas or beans 1 cup white pasta, rice or

potato Water or juice

► Evening Popcorn, chips or crackers

RecommendationsRecommendations

► Iron-rich protein choices dailyIron-rich protein choices daily►Calcium rich choicesCalcium rich choices►Avoid sushi, deli meat (reheat)Avoid sushi, deli meat (reheat)► Increase fruit, veg, whole grains (fibre, Increase fruit, veg, whole grains (fibre,

folate)folate)►Choose nutrient dense foods Choose nutrient dense foods ►Supplements?Supplements?

Nutrition ResourcesNutrition Resources

► Ottawabreastfeeds.caOttawabreastfeeds.ca► Motherisk.orgMotherisk.org► Ottawa Public HealthOttawa Public Health► SOGCSOGC► Public Health Agency of CanadaPublic Health Agency of Canada► V drive- Programs- FM OBS Info- Prenatal V drive- Programs- FM OBS Info- Prenatal

NutritionNutrition► Health Canada- Health Canada-

http://www.hc-sc.gc.ca/fn-an/nutrition/index-eng.phphttp://www.hc-sc.gc.ca/fn-an/nutrition/index-eng.php http://www.hc-sc.gc.ca/fn-an/securit/chem-chim/http://www.hc-sc.gc.ca/fn-an/securit/chem-chim/

environ/mercur/index-eng.php environ/mercur/index-eng.php