Nutritional challenges for women who use alcohol and other drugs in pregnancy.

1. Nutritional challenges for women who use alcohol and other drugs in pregnancy. Amy Sanders Dietitian The Royal Women’s Hospital VAADA Conference 13th February 2007

2. Overview • Role of dietitian • Nutritional needs of pregnant women • Impact of D&A use • Barriers to accessing care • Nutrition audit • Nutritional recommendations • Health promotion strategies

3. Women’s Alcohol and Drug Service • Specialised maternity and drug and alcohol service for women with complex drug issues. • Multidisciplinary team: • Midwifes, social workers, psychologist • Specialist support from obstetricians, pediatrician, pharmacist, dietitian, psychiatrist and housing worker. • “A Multi disciplinary team working collaboratively can achieve optimal pregnancy, birth and parenting outcomes for each woman and her family”(National clinical guidelines 2006)

4. Role of Dietitian • Optimise the nutritional status for healthier pregnancy • Screens all clients - weekly outpatient clinics • Inpatient methadone stabilisation program • Health professional training days • Attends team meetings • Few dietitians working in this area of need ? • Lack of published nutrition guidelines • Need to advocate for equal service opportunities.

5. Referral indicators • Anaemia (iron, folate, B12) • Malnourished, thin women • Lack of weight gain or too much weight gain • Nausea, vomiting, constipation, appetite problems • Poor baby growth • Veiled, dark skinned women • Vegetarians • Previous GDM or PCOS • History disordered eating • Recent pregnancies • Multiple pregnancies  Most of our women with D+A issues fit nearly all of these referral indicators !!

6. Nutritional needs of pregnancy • Specific nutrient requirements - protein, iron, folate, calcium and other vitamins and minerals • Awareness of listeria, mercury and fish, Vitamin A, caffeine • Optimal nutrient stores • Adequate maternal weight gain • High risk women  refer to dietitian • Simple dietary advice specific to individual needs.

7. Nutritional effects of D+A use • Appetite suppression •  nutrient uptake •  nutrient bioavailability •  nutrient losses/malabsorption • Altered nutrient synthesis, activation and utilisation • Impaired nutrient metabolism and absorption •  nutrient destruction •  metabolic requirements of nutrients • Delayed gastric emptying Eg. Marijuana ↓ zinc Cigarettes ↑ iron Alcohol ↑ thiamine Amphetamines ↑ metabolic rate Opiates ↓ GI motility

8. Symptoms of pregnancy and D+A use

9. ‘Lifestyle’ effects of D+A use • Limited finances • Homelessness • Poor self care • Reliance on take away foods • Chaotic meal patterns • Poor food safety practices • Reduced self awareness of hunger-satiety

10. Nutritional challenges iron folate bowels housing $$ dental BMR nutrient deficiency Vit C stress thin LOA Poor nutritional status calcium Pregnancy demands N+V Effects of drug use Lifestyle Factors anemia food skills over weight Compromises nutritional status Effects maternal health + fetal outcome

11. Barriers for care • Food insecurity • Poor nutrition knowledge & skills • Knowledge of nutrition services available • Suitability of appointment times • Tiredness, anxiety, depression • Stage of change

12. Nutrition audit • n = 50 pregnant women attending WADS (March 04-05) • Average age 29 years • Polydrug use + • 62% on methadone (n =31) • 24% buprenorphine (n = 12) • 56% illicit drugs (heroin) • 86% smoking tobacco • 56% cannabis use • 18% alcohol use

13. Nutrition audit • First clinic contact - 19 wks (average) • First dietitian contact - 22 wks (average) • Range 7 - 38 weeks • Average 4 sessions with dietitian • Range 0 - 10 sessions • Equates to monthly reviews • Average gestation delivered 37.8wks • Average infant birth weight 2849g

14. Nutrition recommendations Underweight women • 40% underweight pre preg (BMI <20) Risks • Underweight → strong predicator of poor pregnancy outcome (↑ prematurity,↑ LBW) • Low BMI → more dependent on nutritional intake to achieve good weight gain. Recommendations • Assess pp BMI • Discuss normal weight gain and monitor • Dietary advice - ↑ meal regularity, ↑ snacks, ↑nutrient dense foods, trial oral nutritional supplements.

15. Nutrition recommendations Maternal weight gain • Suboptimal wt gain (9kg) • Slow in 2nd trimester • 25% poor wt gain (<5kg)  LBW <2.5kg Risks • Adequate weight gain = optimal pregnancy outcome • Low maternal wt gain ↑ LBW Recommendations • Monitor weight • Aim 12.5 – 18kg total weight gain (low BMI)

16. Nutrition recommendations Iron Deficiency • 33% early pregnancy & 60% later pregnancy Risks • ↑ preterm delivery, ↑ fetal growth retardation • Tiredness  access to care • ↑ risk infection, poor concentration Recommendations • Routine ferritin • Iron therapy - monitor tolerance/compliance. • ↑ dietary iron & consider factors affecting absorption

17. Nutritional recommendations Vitamin D deficiency • 6 of 7 women deficient • Recent data - 58% deficient (n =34) Risks • Infants dependant on maternal Vitamin D status • May affect infant skeletal growth Recommendations • Test Vitamin D • Supplement deficient mother & baby if breastfed • Encourage small amounts of sunlight exposure

18. Nutritional recommendations Nutritional Supplements • 66% iron, 58% folate, 28% multivitamins, 14% VitB Barriers • Women confused what to take • Financial costs • Poor compliance → GI effects Recommendations • Advise on appropriate supplementation – mv + iron • Avoid high doses Vitamin A & herbal preparations • Consider cheaper alternatives

19. Nutritional recommendations GI Symptoms • Constipation most severe problem (50%) • 22% laxatives, 20% fibre supplements Risks •  desire to eat→  quality of diet Recommendations • ↑ dietary fibre & ↑ fluids • Fibre supplements, then laxatives • Review iron therapy • Encourage gentle daily exercise

20. Nutritional recommendations GI Symptoms • Nausea and vomiting common (40%) • 12% antiemetics Risks • Dehydration, electrolyte imbalances, nutrient intake • Loss of 5% pp weight → negative implications Recommendations • Small frequent meals, adequate fluids, avoid empty stomach, avoid rich/spicy/fatty foods • Review of pharmacotherapy & antiemetics

21. Nutritional recommendations • Dietary Ax • 12% diet adequate for pregnancy • Poor iron intake (50%) • Irregular meals • High reliance takeaway food • Poor fruit and vegetable intake • Recommendations • Simple practical meal and snack ideas • Encourage regular meal pattern/snacking • ↑ Iron rich foods • Budget eating, shopping and cooking hints • Healthier takeaway choices

22. Health Promotion Strategies • Dietitian to screen all women • Educate: - nutrition for pregnancy - listeria, mercury, caffeine, VitA - drug effects on nutrition - symptom management • Recommend multivitamins • Assistance with crisis food support, community food programs, budget shopping • Refer to dental services • Monitor weight, biochem, symptoms & diet • Multidisciplinary team meeting

23. Health Promotion Strategies • Specific nutrition resources • “Healthy pregnancy hints” & “Eating well and pregnancy” • Visual displays • Nutrition posters & food/product displays • Oral nutritional supplement • Sustagen®, Ensure ®, Enlive Plus® • Recipe books - quick easy meals • Cooking classes

24. Conclusion • Women attending a maternity D+A unit are at high nutritional risk • Nutritional deficiencies can be caused by a number of direct & indirect effects of drug use. • These women do not tend to seek nutritional support but are keen for advice • Dietitians can assist multidisciplinary teams to promote better nutrition. • By optimising nutritional status in pregnancy we can improve health outcomes for women and babies.

25. Further information • Women’s Alcohol and Drug Service • womens.ads@rwh.org.au • (03) 9344 3631 • Nutrition Department, The Royal Women’s Hospital • amy.sanders@rwh.org.au • (03) 9344 2116