Supporting good maternal nutrition and infant feeding practice

1. Supporting good maternal nutrition and infant feeding practice Annie S. Anderson Centre for Public Health Nutrition Research Division of Medicine, University of Dundee a.s.anderson@dundee.ac.uk

2. For discussion…. • Pre-conceptual and maternal nutrition- does it matter? • How can we support good nutritional intake in women of child bearing age? • Infant feeding-consensus views • How can we promote desirable infant feeding practices? Public Health programme Guidance to improve the nutrition of pregnant and breastfeeding mothers and children Draft guidelines published by NICE (http://guidance.nice.org.uk/page.aspx?o=421712)

3. Pre-conceptual nutrition – the vulnerable • In Scotland in 2005, 4133 babies were born to mothers aged < 20 years, and 9689 aged 20 to 24 years. • It is likely a high % of these pregnancies were unplanned • Should we be worried about the nutritional status of young women?

4. National Diet and Nutrition Survey (2000/01) women aged 19 to 24 years • 4% consumed the recommended 5 portions/ Fruit and Veg day. Mean consumption was 1.6 portions/day. • 36% exceeded the maximum recommendation food energy from NMESugars(≤11% food energy) with mean intakes at 14.2%. • 83% consumed more than 6g Salt/day (estimated by urinary sodium)

5. Scottish Health Survey (2003)% women aged 16 to 24 years exceeding government guidelines for alcohol

6. Dietary insights suggest… • Energy dense diet (high sugar, high salt, low fruit and veg, HIGH Calorie diet) • Nutrient low (low in minerals and vitamin)

7. National Diet and Nutrition Survey (NDNS) (2000/01) Women aged 19 to 24 years Iron 42% had iron intakes below the LRNI. • 7% were anaemic as indicated by haemoglobin concentrations below 12.0g/dl • 16% had low iron stores as indicated by serum ferritin concentrations below 15ug/l • 27% showed biochemical evidence of low iron status (transferrin saturation below 15%). Vitamin D 28% had low biochemical status for vitamin D (plasma 25 OHD<25 nmol/l)

8. NDNS Women (aged 19 to 50 years) % with intakes below LRNI Hoare & Henderson, 2004

9. Energy dense diet…

10. Scottish Health Survey (2003) 2006, Tayside 2.3% underweight, 26.0% overweight, 17.2% obese of 2785 women

11. Risks associated with maternal obesity Fetal risks • First trimester and recurrent miscarriage • Infant birth defects e.g. NTD • Stillbirth • Neonatal death Maternal risk • Gestational diabetes • Pre-eclampsia • Thromboembolism • Gallstones • Cesearian section, post partum haemorrhage • Anaesthetic risk • Postpartum risks (would healing)

12. Pre- conceptual and Maternal nutrition- does it matter? Fertility Under weight and obesity • Neurological development of fetus Folic acid and Neural tube defects Obesity and birth defects Alcohol intakes and Fetal Alcohol Syndrome • Growth during pregnancy Low Birth Weight babies • Subsequent adult health “Programming” of chronic disease

13. How can we support good nutritional intake in women of child bearing age? • Interventions that improve mothers nutritional status are likely to have the most impact before conception and during EARLY pregnancy. • Promoting healthy eating may improve knowledge but little evidence on what leads to behaviour change

14. What interventions (other than those about folic acid) improve nutritional status of women of child bearing age who are planning or might become pregnant? No well designed nutrition intervention studies that aimed to measure improvements in nutrition prior to becoming pregnant undertaken in non-pregnant women in developed countries were found. Three studies that might have been relevant but each study was found to have flaws The difficulties included a lack of statistical power and very high drop out rates.

15. Folic acid There is evidence from a large survey of health professionals that folic acid advice is not perceived by them as being part of general health advice for women of child bearing age. The survey also found that many health professionals have gaps in their knowledge about the appropriate dosage and timing of folic acid for women.

16. Folic Acid It is probable that • wide spread media campaigns • brief interventions and and the provision of free supplements • advice about when to take supplements will increase the use of folic acid Folate and disease prevention • http://www.sacn.gov.uk/reports/#

17. What can be done to engage with women of child bearing age? • Contraceptive AND ante-natal clinics • Teen/Drop in centres Nurture, pamper, beauty • Nutrition and care for middle aged and young women combined (mums and daughter opportunities) Hairdressers, Pubs, Clubs • Reward/incentives for positive behaviour

18. What can be done to engage with women of child bearing age? 2005

19. Nutrition and Pregnancy

20. How can we support good nutritional intake during pregnancy Education and counselling on general nutrition advice- little impact on behaviour (except with food supplements) Dietary food supplements – minimal effect (birth weight) maternal weight gain Encourage intake of one portion of oily fish per week. (e.g mackerel) Alcohol- identify intakes, monitor intakes Health education programmes and individual advice on use of Vitamin D supplements

21. Engaging with pregnant women • Ante-natal clinics • Ante- natal classes • 43% Scottish women • 26% of women in “routine and manual occupations” • 12% of women who have “never worked” (Bolling et al, 2007 Infant feeding Survey, 2005)

22. Wrieden WL & Symon AThe development and evaluation of a nutrition education intervention for pregnant teenage women (food for life).J Hum Nutr Diet. 2003 Apr;16(2):67-71 The 16 (of the 120 invited) women who attended found the courses helpful but objective evaluation of dietary intake was not possible because of poor compliance.

23. Pregnantwomen • on benefits • under the age of 18 • Milk • Fresh Fruit and vegetables • Vitamins (per day)70 milligrams of vitamin C • 10 micrograms of vitamin D3 • 400 micrograms of folic acid

24. Post Partum issues

25. Post partum weight loss • Short term weight loss of 1kg/week achieved through diet and physical activity has no detrimental effect on milk quantity and quality • There is evidence that diet and exercise programmes are effective in enabling some post partum women to lose weight gained during pregnancy

26. Infant feeding

27. Breast Feeding • Immunological features • Anti-infective agents • Growth factors • Modulators of intestinal growth • Reduction in diarrhoea • Reduction in respiratory infection • Colonic function • Reduction in atopic disease • Greater likelihood of higher IQ at 7 ½ years • Lower Obesity risk for baby in later life • Lower Maternal breast cancer risk

28. Breast feeding targets (2005) “more than 50% of women should still be breastfeeding their babies at 6 weeks of life”

29. Breast feeding by age and SIMD quintile

30. Maternal and Child Nutrition programme To review the existing evidence on the effectiveness of public health interventions to promote the initiation, and increase the duration of breastfeeding.

31. Maternal and Child Nutrition programme • Peer Support • Volunteer counsellors • Postnatal support worker • Professional support • Lactation consultant • Group breastfeeding education in ante-natal period

32. Maternal and Child Nutrition programme • Knowledge and skills needed to promote and support breastfeeding. • Monitor the number of mothers initiating breastfeeding and feeding at 6 weeks • Provide assistance to initiate and maintain effective peer support programmes on breastfeeding, particularly where the rates of breastfeeding initiation and duration are low. • Provide increased support in areas with low rates of breastfeeding among infants aged 6 weeks and over.

33. Beyond breast feeding… • How can we promote desirable infant feeding practices?

34. Nutrition in infancy will impact on … • Poor Growth/Failure to thrive • Rapid growth/ risk of high weight • gain leading to obesity • Infection • Poorer gut development • Eczema/allergy • More wheeze/respiratory illness

35. Desirable infant feeding practices • the timing of the first introduction of any solid foods • the timing of the introduction of particular foods • meeting the infants’ nutritional needs through introducing a variety of foods • protecting oral health through choosing appropriate foods and drink

36. Vitamin D supplements • Pregnant and breastfeeding women, and children up to the age of 5, should receive vitamin D supplements to reduce the risk of a deficiency (rickets). • Exposure of the skin to sunlight is the main source of vitamin D but, during the winter, there is not enough sunlight on the appropriate wavelength. • Those who are dark-skinned, or who remain covered when outside, are at particular risk.

37. Age of introduction of solid food in Scotland (1995,2000,2005)

38. Age of introduction of solid food by UK mothers SES “routine and manual” (2000,2005)

39. What influences the timing of solid food foods to infants? • living in a deprived area • the opinions of the infant’s maternal grandmother • personal disagreement with the advice to wait until the baby was 4 months • lack of encouragement from friends to wait until the baby was 4 months • being in receipt of free samples of manufactured food. Mother perception that the infant was hungry and not settling Alder EM et al (2004)

40. Intervention directions • Emphasis on support- health visitors, peers, community “Peer support intervention designed to improve infant feeding practices can increase feeding knowledge, confidence in following advice and was valued by recipients and volunteers”

41. Intervention directions Encourage parents and carers to make home-prepared foods for infants in particular, foods without added salt or sugar • Repeated exposure to a target food enhances acceptance of same, similar and target foods • encourage families to aim to eat the same food at the same time ( note fruit and vegetable) Issues around Lifestyle programmes for Life skills…. Shopping, budgeting, food prep, storage and cooking

42. Vitamin D NICE Evidence to suggest that health education programmes on the prevention of vitamin D deficiency … • Improve knowledge about vitamin D • Increase uptake of supplements • Reduce number of hospital admissions with rickets and osteomalacia

43. Vitamin D- possible strategies • Ante- natal clinics information and advice on the benefits of vitamin D and vitamin D supplements. • Healthy Start supplement • Identify and support women who are at greater risk of vitamin D deficiency to take a vitamin D supplement during pregnancy.

44. Conclusions Pre-conceptual and maternal nutrition New issues obesity, nutrition vulnerability, alcohol, Good nutritional intake in women of childbearing age Healthy start – only a fraction Folic acid- hopeful signs Alcohol- monitoring Vitamin D –back on horizon Oily fish – advice needed Infant feeding The challenge of breast feeding at 6 weeks How can we promote desirable infant feeding practices? Support –professional, lay, peer Food based skills and family food work Uptake of supplements