Prenatal Nutrition

1. Prenatal Nutrition Allison Little, RD, CDE Queen’s Family Health TeamOctober 8, 2014

2. Objectives • Understand the importance of weight gain, nutrition and special dietary considerations during pregnancy • Identify patients at high nutritional risk that would benefit from further nutritional assessment and counseling with a Registered Dietitian • Identify appropriate prenatal resources/referrals to local community programs and services

3. Case: Sara 27 yo female Started taking a prenatal vitamin, but often forgets Enjoys eating for two but is concerned about her weight gain of 4 kg and wonders if that is normal for 9 weeks of pregnancy (Pre-pregnancy BMI= 34) Concerned about food safety especially during pregnancy and wonders if becoming a vegetarian is a good idea Limited income and isolated from friends, often lonely. Her husband works 12 hr days

4. Questions to Consider Is Sara’s wt gain /pre-pregnancy BMI a concern? What is Sara’s gestational wt gain goal? How do you convince Sara that gaining wt is normal during pregnancy? What are your suggestions for helping with taking her prenatal vitamin? Should a higher dose of folic acid be recommended?

5. Questions to Consider Are there any suggestions to help improve her diet? Are there any community programs/services you would recommend? Would you refer her to the QFHT dietitian?

6. Weight Gain RecommendationsSingleton Pregnancies, according to pre-pregnancy BMI

7. Pre-Pregnancy BMI and Pregnancy Outcomes Normal BMI (18.5-24.9) promotes health reduces incidence of disease minimizes maternal, fetal and newborn risks

8. Pre-Pregnancy BMI and Pregnancy Outcomes Higher BMI associated with poor pregnancy outcomes gestational diabetes C-section large-for-gestational age infants (> 90 %ile for gestational age) preterm birth infants less likely to be breastfed and more likely to be overweight

9. Pre-Pregnancy BMI and Pregnancy Outcomes Low BMI (<18.5) at risk for poor pregnancy outcomes low birth weight pre-term birth small-for-gestational age infants (<10%ile for wt for gestational age) failure to initiate breastfeeding

10. Myth or Truth? An excessive rate of weight gain defined as >2 kg in the first trimester is a red flag for gestational diabetes

11. Excessive Gestational Weight Gain Wt gain of > 2 kg in the 1st trimester increases risk for GDM (BMI >25) Increased wt gain at risk for: C-section LGA infant Postpartum wt retention Having overweight or obese children Encourage women to continue to gain wt based on their pre-pregnancy BMI

12. Inadequate Gestational Weight Gain Poor gestational weight gain may result in a preterm, SGA or LBW infant More common: Born outside of Canada Lower household income Previous children Poor wt gain due to: Poor appetite Food aversions Nausea/vomiting

13. Supporting a Healthy Weight Gain During Pregnancy

15. Myth or Truth? Canada’s Food Guide is designed to meet the nutritional needs of all Canadians including the prenatal population

16. Myth or Truth? Since I am eating for two I need to eat twice as much food

17. Additional Energy During Pregnancy

18. How to Meet Additional Energy Needs(350-450 calories/d) Eat a small snack Examples: • piece of fruit + yogurt • slice of toast + peanut butter AND Slightly larger meal Examples: • add fresh fruit to meal • extra serving of grains or meat • adding nuts/seeds to salad

19. My Food Guide Servings Tracker: Pregnant Female Aged 19-50:

20. Nutrient Needs During PregnancyRecommended Dietary Allowances for Women 19-50 years

21. Folic Acid/ Folate What? B vitamin, folate or folacin in foods folic acid supplemental version Why? normal development of the spine, brain and skull of fetus When? especially during the first 4 weeks of pregnancy

22. NTDs and Folic Acid Supplementation To reduce the risk of NTDs Health Canada recommends that all women of childbearing age: Take supplemental folic acid at least 3 months prior to becoming pregnant and continue throughout pregnancy and breastfeeding Take a multivitamin containing 400 μg (0.4 mg) of folic acid each dayin addition to following the eating pattern of Eating Well with Canada's Food Guide and consume foods high in folate for adequate folate intake .

23. Dietary Sources of Folate Vegetables and Fruit: dark green vegetables (e.g., okra, asparagus, spinach, Romaine lettuce, broccoli, brussel sprouts, parsley, green peas and seaweed); beets; avocado; orange; orange juice; and, corn Grain Products: enriched bread, pasta and other grain products Meat and Alternatives: eggs; sunflower seeds, peanuts, dried peas, beans and, lentils

24. Myth or Truth? Some women may need to take more than 0.4 mg supplemental folic acid each day

25. High Dose Folic Acid Supplementation Health Canada recommends 4-5 mg per day of folic acid for women who have the following risk factor(s): personal or family history of NTDs or other congenital anomalies medications that interfere with folate alcohol abuse malabsorption and gastric bypass surgery liver disease kidney dialysis *High dose folic acid should be taken at least 3 months before conception and continue until 10-12 weeks of pregnancy

26. High Dose Folic Acid Supplementation Health Canada recommends 4-5 mg per day of folic acid for women who have the following risk factor(s) AND who have a red blood cell (RBC) folate concentration of less than 906 nmol/L: obesity diabetes impaired glucose metabolism hyperinsulinemia

27. High Dose Folic Acid Supplementation Health Canada recommends 1-5 mg per day of folic acid for women who have the following risk factor(s) associated with low dietary intake of folate AND who have a RBC folate concentration of less than 906 nmol/L: poor dietary quality low socio-economic status chronic dieting or restricted diet (e.g., low carbohydrate diets) do not commonly select folic acid fortified foods or use cooking methods which destroys naturally occurring folate smoking

28. High Dose Folic Acid Supplementation CAUTION! Limit to one multivitamin supplement/day due to increased risk of excess vitamin A (teratogenic properties if intake above UL) Folic acid supplement should be taken in combination with a vitamin B12 containing multivitamin due to the potential masking of vitamin B12 deficiency

29. Iron What? critical component of hemoglobin Why? supports maternal increased RBC mass (2nd and 3rd trimester) supports normal fetal brain development builds iron stores in fetus for first 6 months of life Concerns high prevalence of iron deficiency anemia (3rd trimester)

30. Adverse Effects of Anemia Fetal death Intrauterine growth retardation Preterm birth Low birth weight

31. Iron Supplementation Health Canada recommends pregnant women use a daily supplement that contains 16-20 mg of iron and follow Eating Well with Canada's Food Guide for adequate iron intake. Women with pre-existing ID/IDA should be assessed todetermine how much additional iron they need from supplements.

32. ID and IDA in Pregnancy

33. Managing IDA Personal conversation with Sherri Elms, RPh Iron tolerability is dose related (the more elemental Fe you give, the more GI intolerance) Increase tolerability: start low and increase slowly Renal Unit at KGH: Ferrous Gluconate 300 mg (35 mg elemental Fe/tab) -Ferrous Gluconate 300mg po hs x 1 wk then -Ferrous Gluconate 600mg po hs x 1 wk then -Ferrous Gluconate 900mg po hs there after If poor tolerance to increasing dose, return to previous dosing If reach this dose and you want to increase the amount of Fe given, change to Ferrous Fumarate 300mg (100mg elemental Fe/tab)

34. Response to Treatment Increase of Hgb levels by 10 g/L or an increase in Hct of 3%x 4wks of iron treatment Continue iron supplementation x3-6 mos after ID corrected

35. Dietary Sources of Iron Heme iron Foods of animal origin (except milk, milk products, eggs) Better absorbed and less affected by dietary factors that hinder absorption Non-heme iron Plant based foods Harder to absorb Absorption influenced with foods (enhancers and inhibitors)

36. Dietary Sources of Iron Vegetables and Fruit(non-heme) cooked spinach; edamame; baked potato with skin; bok choy; and, dried fruit Grain Products(non-heme) enriched grain products including cereals (e.g., instant oatmeal, cream of wheat, and cold cereals); breads and pasta; quinoa; barley; and, whole grain oats Milk and Alternatives(non-heme) fortified soy beverage

37. Dietary Sources of Iron Meat and Alternatives: heme – clams; oysters; mussels; blood pudding; goat; beef; shrimp; sardines; duck; lamb; canned light tuna; turkey; chicken; and, pork non-heme – pumpkin, squash and sesame seeds; tofu; beans; lentils; tahini; almonds; and, eggs Other: blackstrap molasses *pregnant women should avoid liver consumption due to its high Vit A content

38. Potential Dietary Interactions To improve iron absorption: include meat, fish or poultry in meals use vitamin C-rich foods with foods with non-heme iron avoid drinking coffee or tea with meals or within 1-2 hours before or after eating avoid taking calcium supplements or calcium-containing antacids with meals take the multivitamin that contains iron on an empty stomach with vitamin C-rich juice and separate from other supplements

39. Special Dietary Considerations Caffeine, Herbs and Herbal Products Fish Consumption and Safety Foodborne Illness

40. Myth or Truth? Herbal teas are safer to drink than coffee during pregnancy

41. Caffeine, Herbs and Herbal Products Excess Caffeine risks: Low birth weight Miscarriage Limit caffeine intake to 300 mg/d 2 (8 oz) cups coffee 6 (8 oz) cups of tea 6-8 (12oz -355mL) cans cola Energy drinks are not recommended for pregnant or breastfeeding women

42. Caffeine, Herbs and Herbal Products Most herbs and herbal products (supplements, teas, beverages) NOT recommended SAFE: Limit herbal beverages to 2-3 cups/day Bitter orange/orange peel Echinacea (specific dose amounts for 3 products) Peppermint Red raspberry leaf Rose hip Rosemary

43. Fish Consumption and Safety Benefits of Fish High quality protein and many essential nutrients (e.g., vitamin D, iodine, iron and zinc) Lower in saturated fats and higher in omega-3 fatty acids called docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) Fatty fish best source of DHA and EPA DHA plays an important role in the growth and development of the brain, eyes and nervous system of the fetus and infant

44. Fish Consumption and Safety Risks of Eating Fish May contain mercury and low levels of other harmful contaminants e.g., Polychlorinated Biphenyls (PCBs) Exposure of the fetus/young children to high levels of mercury may have negative effects on their learning, walking and talking Prenatal PCB exposure may have negative effects on the neurological development of the baby

45. Fish Consumption and Safety Recommendations for Choosing Fish Consume at least two Food Guide servings (150 g or 5 oz) of fish each week Choose fish very low/low in mercury and high in omega-3 fats Salmon Trout Herring Mackerel Sardines Remove the fat and skin before cooking fish

46. Fish Consumption and Safety Fish Oil Supplements DHA and EPA supplements (algal, fish, krill or seal oils) Look for a Natural Product Number (NPN) Not considered equivalent to eating fish - insufficient evidence to conclude their effects on infant development Intake of up to 3 grams of EPA plus DHA per day considered safe during pregnancy Contraindicated: bleeding disorders, blood thinning medications Avoid taking fish liver oils, especially taking a MV containing vitamin A due to risk of birth defects

47. Myth or Truth? It is safe to eat sushi while pregnant

48. Foodborne Illness Pregnant women at greater risk of contracting foodborne illnesses Developing baby is at greater risk of experiencing serious health effects Food poisoning can cause miscarriage, stillbirth, premature delivery of a low-birth-weight infant, or the death of a newborn baby Very important for pregnant women to follow safe food handling practices Pregnant women should avoid high risk foods for foodborne illness: deli meats; hot dogs; raw or lightly cooked eggs or egg products; raw or undercooked meat or poultry; raw seafood; refrigerated smoked seafood; raw or unpasteurized dairy products; all soft cheese; raw sprouts; refrigerated pâtés and meat spreads; and, unpasteurized fruits juice and cider

49. Prenatal Resources Queen’s Family Health Team Pre-natal Package Provided by nurse/NPs at each prenatal visit Contact: Liz Hughson, RN

50. Local Prenatal Programs and Services KFL&A Public Health: Food For You, Food For Two Free weekly drop-in program for pregnant women Amherstview and Napanee Group health teaching & peer support FREE groceries, prenatal vitamins 1:1 counselling with RD and PHN