11/01/2002

1. 11/01/2002

2. Nutrition Counseling • Lifestyle concerns with nutritional implications: • alcohol • caffeine • smoking • drugs • artificial sweeteners • oral health • exercise

3. General strategies for providing effective nutritional care • Assess nutritional status • anthropometric • biochemical • social • medical • dietary

4. Dietary Assessment: Selection of Methods • Avoid collecting information that won’t be used: • What is the language skill and literacy level of the woman? • How will I use the information? How accurate and detailed does it need to be? • What is the standard that will be used for comparison? • What resources do I have for collecting, analyzing and interpreting the data?

5. Essential Steps for Patient Education(IOM Implementation Guide) • Identify the problem(s) • Develop a tentative clinical objective • Discuss objective with the woman • If woman does not perceive as a problem offer personalized information

6. Essential Steps for Patient Education(IOM Implementation Guide) Cont. • With the woman: • Identify behaviors that support or impede achievement of the clinical objective • Assess barriers to behavioral change & strategize about removing barriers • Plan one or two behavior changes • Help to reduce barriers with referrals or information • Offer feedback and reinforcement for success

7. Referrals to Food and Nutrition Programs • WIC • Temporary emergency food assistance program or food banks • Food stamp program • Cooperative Extension- Expanded Food and Nutrition Program

8. Cultural factors affecting diet and pregnancy outcome in Mexican-Americans(Gutierrez, J. J Adolesc Health. 1999 Sep;25(3):227-37. • N=48 primigravida adolescents aged 13-18 who self identified as Mexican-American. • Questions: • In some parts of Mexican culture food is classified into “hot” such as pork or “cold” such as fruit juices to balance good health. Do you practice or follow such classification? • Some people believe that cravings during pregnancy should be satisfied or the infant may be marked by whatever food was craved. What do you think?

9. Cultural factors affecting diet and pregnancy outcome in Mexican-Americans(Gutierrez, J of Adolescent health, in press) • Questions (cont.) • Some people believe that nausea and vomiting during pregnancy should be treated by drinking flour and water, cornstarch and lemon juice, or chamomile tea. What do you think? • Do you believe that heartburn is caused by eating chili? • Some people believe that during pregnancy, if the woman sleeps too much it causes the baby to stick to the uterus. What do you think?

11. Seven Domains of Cultural Competence Cultural Competence: A Journey http://www.bphc.hrsa.gov/culturalcompetence/Default.htm#1

12. 1. Values and attitudes Promoting mutual respect . . . awareness of the varying degrees of acculturation . . . a client-centered perspective . . . acceptance that beliefs may influence a patient’s response to health, illness, disease and death. . .

13. 2. Communications styles Sensitivity . . awareness . . . knowledge . . . alternatives to written communication .

14. 3. Community/consumer participation Continuous, active involvement of community leaders and members . . . involved participants are invested participants, health outcomes improve. .

15. 4. Physical environment, materials, resources Culturally and linguistically friendly interior design, pictures, posters, and artwork as well as magazines, brochures, audio, videos, films. . . literacy sensitive print information . . . congruent with the culture and the language . . .

16. 5. Policies and procedures Written policies, procedures, mission statements, goals, objectives incorporating linguistic and cultural principles . . . clinical protocols, orientation, community involvement, outreach. . . multicultural and multilingual staff reflecting the community . .

17. 6. Population-based clinical practice Culturally skilled clinicians avoid misapplication of scientific knowledge . . . avoid stereotyping while appreciating the importance of culture . . . know their own world views . . . learn about populations . . . understand sociopolitical influences . . . practice appropriate intervention skills and strategies . .

18. 7. Training and professional development Requiring training . . . nature of cultural competence training . . duration and frequency of professional development opportunities . . .

19. Ethnomed http://healthlinks.washington.edu/clinical/ethnomed/

20. Southeast Asian “Traditional practices are heavily based in concepts of "hot" and "cold" conditions. Younger women may no longer follow traditional practices but the family (mother or mother-in-law) may insist on following traditions and it is important to understand how an individual woman and the greater family compromise.”

21. Southeast Asian Pregnancy Foodways - Ethnomed • "Cold" foods are needed for the "hot" condition of pregnancy according to Chinese categories. • There are a wide range of foods which are felt beneficial or harmful between cultural groups. • Bean sprouts/green peas avoided - thought to cause SAB (Vietnamese) • Homemade rice wine, herbal medicines, coconut juice are taken to help give the baby good quality skin. Beer is thought to make the delivery easier (Cambodian) • Drinking milk and gaining too much weight will make baby fat and difficult to deliver (all SE Asian)

22. Southeast Asian Postpartum Foodways - Ethnomed • Maternal diet balanced between "hot" (alcohol, ginger, black pepper & some high protein) and "cold" (fruits, vegetables, some seafood). No sour foods (cause incontinence), no raw foods. Pork felt very nutritious. • Cold ice water offered post delivery in the hospital may be seen as unhealthy. • Inability to follow traditional post-partum practices is thought to cause later health problems, especially abdominal pain in women (which may occur months or even years later). Once a woman becomes sick from symptoms thought due to violation of "d'sai kchey", she is sick for the rest of her life. (Cambodian)

23. East Africa Pregnancy Foodways- Ethnomed “Related women and women within a neighborhood have very strong ties among each other in East African communities. In some cultures, such as that of ethnic groups from Ethiopia, women have a daily coffee ritual where they gather each day in homes to share coffee and talk. This daily gathering of women established support networks for pregnancy, postpartum help, and child care.”

24. East Africa Pregnancy Foodways- Ethnomed • Women try to have good nutrition and particularly may increase meat in their diet. • Flax seed flour is mixed with warm water before delivery and drunk by the woman to help produce an easy delivery.

25. East African Post-Partum Foodways - Ethnomed • Traditionally women rest in bed for 40 days postpartum and are attended by other women who prepare nutritious food and do housework. • Special teas, soups, and porridge are provided for the mother. • Flax seed porridge with honey is commonly given to mothers post-partum.

26. Adolescent Development (Drake P. J Obset. Gynacol. Neonatal Nursing, 1996)

27. Adolescent Development (Drake P. J Obset. Gynacol. Neonatal Nursing, 1996)

28. Responding to Developmental Differences of Adolescence: Goal Setting

29. Responding to Developmental Differences of Adolescence: Professional Approaches

30. Adverse effects of substance use determined by: • Timing • Dosage • Duration • Number of substances • Environment (nutrition, health status) • Individual susceptibility

31. Effects of substance abuse include: • Increased health problems, including risk of AIDS • Compromised nutritional status/weight gain • Higher rates of OB complications • Psychosocial/economic/legal problems • Parenting difficulties • Higher rates of child abuse/neglect

32. Alcohol: Background • Per capita alcohol consumption has risen through the second half of this century in the US • 70% of individuals between the ages of 20 and 34 consume alcohol • Alcohol consumption peaks in the 20-40 year old group • 5 to 7% of women are reported to drink heavily in the first months of pregnancy

33. Alcohol: Background, cont. • Women are at disadvantage because less gastric first pass metabolism due to lower levels of alcohol dehydrogenate in intestinal mucosa • Fetus has no alcohol dehydrogenase activity • Alcohol crosses placenta easily by passive diffusion – fetal levels mimic maternal levels • The amniotic fluid acts as a reservoir for alcohol.

34. FAS Diagnostic Criteria- Fetal Alcohol Study Group of the Research Society on Alcoholism • Prenatal and/or postnatal growth retardation (<10th % ca) • Central nervous system involvement (neurologic abnormality, developmental delay or intellectual impairment) • Characteristic facial dysmorphology with at least 2 of these 3 signs: • Microcephally ( OFC < 3rd %ile) • Micoopthalmia and/or short palpevral fissures • Poorly developed philtrum, thin upper lip, and or flattening of the maxillary area

35. FAS, cont. Other organ systems often involved. Some with nutritional implications: • Cleft palate • Eustachian tube dysfunction • Array of cardiac, renal, and skeletal defects that may require surgical repair

36. FAE – Fetal Alcohol Effects or PFAE • Exhibit some components of FAE, but not all • Most common sign is retarded growth both pre and postnatal • Can have significant developmental and behavioral components

37. FAS/FAE Incidence • FAS – 1.9 per 1000 births, 25 per 1000 among women who drink heavily • FAE – 3 to 5 per 1000 births, 90 per 1000 among women who drink heavily • FAS is leading cause of mental retardation in the western world

38. Pathophysiology • Combination of • Toxic effects of ethanol and it’s derivatives • Nutritional factors • Genetic predisposition

39. Toxic effects • Both alcohol and derivative acetaldehyde directly damage developing and mature nervous systems • Impair nucleic acid synthesis • Disrupts protein synthesis • Cell membrane narcosis • High maternal alcohol levels associated with dehydration, fetal hypoxia and acidosis, placental pathology and dysfunction, and endocrine disturbances.

40. Nutrition Related Effects of Alcohol • Poor nutritional status of mother • Reduced placental transfer of zinc and folic acid associated in animal models • Alcohol impairs absorption, utilization, and metabolism of nutrients • Poor zinc status has been associated with adverse effects of alcohol many studies

41. Bottom Line No amount of alcohol can be said to be safe in pregnancy.

42. Caffeine • History: • Rat based studies with high levels of caffeine found adverse pregnancy outcomes • Early 1980s US FDA issued advisory about adverse effects of caffeine in pregnancy • Further research found little association, FDA concludes that no strong evidence, urges moderation • 1996 IOM review for WIC advised removing excessive caffeine intake from WIC risk criteria • 1998 - USDA removed as WIC risk criteria

43. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Consumption: • In US 70-95% of pregnant women consume caffeine - average intake is 99-185 mg/day • 5-30% of pregnant women consume >300 mg/day • Heavy caffeine intake more likely in women who smoke and those with lower education levels

44. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Metabolism • methylxantines cross the placenta to the fetus where an equilibrium is achieved between maternal and fetal plasma • half-life of caffeine in pregnancy changes from 5.2 to 18.1 hours in T2 and T3 and returns to non-pg levels a few weeks pp

45. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Birthweight: • consistent negative association across studies between birthweight and caffeine consumption > 300 mg/day. • This affect appears to be due to IUGR not preterm birth • Data for intakes between 151 and 300 mg are conflicting • Few adverse effects at intakes < 150 mg

46. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Preterm Labor and Delivery • “Generally, there appears to be no relationship between caffeine consumption during pregnancy and premature labor and delivery in humans.”

47. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Spontaneous Abortions • High caffeine intake prior to and during pregnancy was associated in several studies. Many studies failed to control for smoking, alcohol intake or parity • Study results are inconclusive and contradictory • Further research needed to determine if a true causal relationship exists.

48. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Congenital Malformations • Finnish registry of congenital malformation study found no increased incidence even when women consumed < 6 cups of coffee a day. • No association is supported by current research

49. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996 • Clinical applications • Caffeine intake should be limited to between 150 mg and 300 mg per day • Women in the last trimester and those who smoke are most susceptible to adverse effects.

50. Motherisk UpdateApril, 2000 Motherisk’s recent meta-analysis suggests that the risks for miscarriage and fetal growth retardation increase only with daily doses of caffeine above 150 mg/d, equivalent to six typical cups of coffee a day. It is possible that some of this presumed risk is due to confounders, such as cigarette smoking