NURS-354 Final: Lecture 9 (Nutrition in Childbearing)

Nutritional Risk Factors (continued)

1.) Abnormal pre-pregnancy weight. 2.) Eating disorders. 3.) Pica. 4.) Multiparity. 5.) We may refer clients to a dietician for more support & ideas to maximize nutrition.

Eating Disorders

1.) Anorexia nervosa. → Fear of weight gain; distorted body image; perceive themselves as fat even if very thin; very restrictive dietary intake; often excessive exercise; extremely underweight. 2.) Bulemia nervosa. → Bingeing and purging (vomiting, laxatives and diuretics); often normal weight. 3.) Orthorexia nervosa. → Eating habits that reject a variety of foods for not being "pure" enough; fixation on "righteous eating"; experts think there are similarities between the constant worry about food seen in orthorexia as in eating disorders like bulimia and anorexia nervosa. 4.) All are about food and control. 5.) Pregnant women with eating disorders at risk for a variety of complications resulting in lack of nutrients to the fetus. Increased risk for miscarriage, low birth weight, birth defects & perinatal mortality. 6.) Pregnancy can be a very difficult time for women with a history of eating disorders.

General Nutrition in Pregnancy

1.) Avoid "empty calorie" foods. 2.) Sugar substitutes are considered safe for pregnancy. 3.) Drink 8-12 (8 ox) glasses of fluid daily (4-6 should be water). 4.) Sodas and diet sodas in moderation. 5.) Be careful of energy drinks as excessive intake can cause: → Hypertension, palpitations, anxiety, HA, agitation, tremors, seizures and altered mental state. → Caffeine can be as high as 300 mg (higher than recommended for preg.).

My Plate Recommendations

1.) Balancing Calories: → Enjoy your food, but eat less. → Avoid oversized portions. 2.) Foods to Increase: → Make half your plate fruits and vegetables. → Make at least half your grains whole grains. → Switch to fat-free or low-fat (1%) milk. 3.) Foods to Reduce: → Compare sodium in foods like soup, bread, and frozen meals ― and choose the foods with lower numbers. → Drink water instead of sugary drinks.

Food Safety During Pregnancy and Lactation (review)

1.) Do not eat shark, swordfish, mackerel, and tile fish. 2.) Do not eat raw or undercooked fish, meats, poultry, or eggs. 3.) Avoid luncheon meats and hotdogs. → Listeria (avoid or heat it up). 4.) Avoid soft cheeses. 5.) Do not consume pâté or meat spreads or raw (unpasteurized) milk products.

Food Safety During Pregnancy Deli Meats: Listeria

1.) Listeria mono cytogenesis a type of bacteria that is found in water and soil. 2.) Listeria has been found in uncooked meats, uncooked vegetables, unpasteurized milk, foods made from unpasteurized milk, and processed foods. 3.) Listeriais killed by pasteurization and cooking. 4.) There is a chance that contamination may occur in ready-to-eat foods such as hot dogs and deli meats because contamination may occur after cooking and before packaging. 5.) Cold cuts are now sprayed with a food additive that helps prevent Listeria before packaging. 6.) Be cautious when eating hot dogs, luncheon meats, or deli-meats unless they are properly reheated to steaming (or 160 degrees F). 7.) If exposed increased risk of: → Miscarriage, preterm birth & newborn infection.

Alcohol & Drugs

1.) No known safe level of alcohol consumption in pregnancy. 2.) Associated with Fetal Alcohol Syndrome. → A group of birth defects which include: ⤷ Facial anomalies. ⤷ CNS disorders including mental retardation, hyperactivity, delayed gross motor skills, etc. ⤷ Grown restriction. 3.) Drugs: → Only class A medications. → No recreational drugs.

Pre-pregnancy Weight

1.) Pre-pregnancy weight is an important factor. 2.) There are increased risks for women who are under or overweight prior to pregnancy. → Underweight: ⤷ Increased risk of having a low birth weight baby. → Obese: ⤷ Women are at increased risk for gestational diabetes, preeclampsia, cesarean birth & more difficult birth. ⤷ Babies born to obese women are at increased risk of: congenital anomalies, stillbirth, prematurity, macrosomia & childhood obesity.

Nutrition and Lactation

1.) Prenatal vitamins are taken during and after delivery and continued while the woman is breastfeeding. 2.) Lactating women: → 500 kcal/day over non-pregnant needs. → Lactating women require additional calories and protein than needed during pregnancy. → Protein recommendation 65 g/day for 6 months, then 62 g/day after. 3.) 8-10 glasses of water or other fluids needed for lactation (restrict caffeine intake). 4.) Adolescent population, underweight women, vegans and those with eating disorders need to consult with a nutritionist and MD for dietary specifications.

Prevention of Iron Deficiency Anemia

1.) Prevention: → Recommendation that all pregnant women start on 30 mg/day at beginning of pregnancy (in PNV) & eat iron rich diet. 2.) If anemia diagnosed: → Increased to 60-120 mg PO daily routine supplemental iron therapy. → Reevaluate at 1 month postpartum.

Pica

1.) Psycho behavioral disorder defined as the persistent craving and eating of substance having little or no nutritional value or craving nonfood articles as food. 2.) Several hypothesis stating that there is a deficiency in a mineral or nutrient such as iron or calcium. 3.) A cause used to be contributed to anemia but now, anemia is considered a result of this disorder. 4.) Follow-up with MD is imperative and pt must stop behavior immediately. Try to be non- critical; give options like powdered milk or popsicles. 5.) Patients may be seen craving/ingesting the following: → Chalk. → Clay. → Cornstarch. → Lead paint flakes. → Dirt. → Ice. → Powdered laundry starch. → Corn starch. → Freezer frost. → Soap. → Baking powder. → Burned matches. → Ashes.

Folic acid (folate) & Neural tube defects

1.) Research supports that most neural tube defects could be prevented if folic recommendations were followed. 2.) The CDC recommends that ALL women of childbearing age (15-45) consume 400 mcg of folic acid daily. 3.) As nearly ½ of all US pregnancies are unplanned, and neural tube defects occur very early in pregnancy (often before people even realize they are pregnant). 4.) It is a B vitamin found in green leafy veggies, beans, fruits, liver, peanuts & whole grain breads and cereals. 5.) Mother must supplement with Folate (400mcg/day) at least 1 month before conception to at least 13 weeks after conception to decrease chances of neural tube defects.

Foodborne Illnesses

1.) Salmonella & Listeria are two bacteria which pose a threat to pregnant women and their fetuses. 2.) Recommendation: → Pregnant women should avoid eating or tasting foods which may contain raw or undercooked eggs including raw cookie dough, cake batter, homemade dressings, ice cream, eggnog and hollandaise sauce.

Adjustments for Height and Teens

1.) Short stature (<62" or 157cm): → Review of literature did not support gaining at lower end of range for pre-pregnant BMI. 2.) Teens: → Gain at the upper end of the range for their pre pregnant BMI.

Nutritional Risk Factors

1.) Socioeconomic status. 2.) Adolescence. → Risk for eating disorders due to body image. 3.) Vegetarian diet. → Diet may be lacking in specific vitamins or protein. 4.) Lactose intolerance. → Increase soy, soy-milk and lactase milk. 5.) Anemics.

My Plate

1.) The US department of HHS and the US department of Agriculture offer an online tool: choosemyplate.gov 2.) Helps pregnant women customize an eating plan based on age, weight, height, physical activity and gestational age. 3.) Emphasizes the quality of food (not just more calories); nutrient rich to make sure the metabolic needs are being met.

Recommended Weight Gain During Pregnancy

1.) Weight before pregnancy: → Normal weight (BMI 18.5-24.9). → Underweight (BMI <18.5). → Overweight (BMI 25-29.9). → Obese (BMI >30). → Twin pregnancy. 2.) Total gain: → 25-35 lbs (11.5-16 kg). → 28-40 lbs(12.5-18 kg). → 15-25 lbs(7-11.5 kg). → 15 lbs(at least 7 kg). → 35-45 lbs(16-20.5 kg).

#1 Sample Question

The client, who was an appropriate weight for height at the time she became pregnant is 20 weeks' pregnant and has gained a total of 12 pounds. She is concerned about weight gain. What is the best reply by the nurse? A.) I'll tell the doctor that you are worried. He will tell you what to do. B.) Your weight gain is about average for this point in your pregnancy. What concerns you about it? C.) You really have gained a lot. I will consult the nutritionist for you. D.) A lot of your weight gain is probably fluid. Why don't you decrease your salt intake and see if that will help?

Nutritional Basics During Pregnancy

1.) Energy: → 300 calories more after 1st trimester. 2.) Carbohydrates: → The body's primary source of energy and fiber; if intake is inadequate, body will use protein, which can lead to ketosis. → Examples: bread, pasta, cereal, rice, fruits and veggies. 3.) Protein: → Increased needs for pregnancy of 71 g per day (big increase; 46 g/day for non-preg). → Important to provide amino acids fetal devpt. and maternal needs. → Examples: meat, fish, eggs, dairy, beans, soy products, lentils & nut butters. 4.) Fat: → 20-30% of total caloric intake. → Essential fatty acids and omega-3 fatty acids important for CNS development of fetus. → Examples: oily fish, soybean, canola and flaxseed oil, walnuts. 5.) Dairy: → 2-3 servings daily (cheese, milk, yogurt). 6.) Vitamin A, D, E, K (fat soluble): → Excess toxic; no megadosing. Recommend prenatal vitamin (PNV).

Weight Gain Distribution During Pregnancy (approximately)

1.) Fetus, placenta, amniotic fluid. → 11 pounds. 2.) Uterus. → 2 pounds. 3.) Increased blood volume. → 4 pounds. 4.) Breast tissue. → 3 pounds. 5.) Maternal stores. → 5-10 pounds.

Supplementation

1.) Food is the best source of nutrients. 2.) All pregnant clients should be taking a prenatal vitamin (contains folic acid). 3.) Some women may also require iron. 4.) Expectant women who are lactose intolerant or vegetarians may require additional supplementation. 5.) Teach that pregnant woman should take only their prescribed prenatal vitamin as others may have amounts of some vitamins that are too high & may interfere with the absorption of other nutrients.

Psychosocial Considerations

1.) Food sharing as a symbol of friendliness, warmth & social acceptance in many cultures. 2.) Food as symbolic of maternalism (taking care of family). 3.) Socioeconomic factors: low income families at risk for inadequate intake of nutrients. 4.) Food as a substitute for the expression of emotions ("eating your feelings: if depressed or anxious). 5.) Traditional adage of "eating for two" may lead to overeating.

Nutrition & Lactation

1.) Generally there are no foods to avoid while lactating. 2.) However, some women are worried their babies may be affected by certain foods (get gassy or fussy). If they're worried, they can avoid those foods. 3.) Frequent offenders: → Onions, cabbage, chocolate, spices, turnips. 4.) Caffeine-avoid excessive amounts. 5.) Smoking-decreases appetite/speeds metabolism, increased risk of SIDS. 6.) Alcohol-consult MD although an occasional drink may be allowed.

Healthy People 2020 Nutrition Recommendations

1.) Good nutrition helps pregnant women support the healthy development of their infants. 2.) Regular physical activity throughout pregnancy can help women control their weight, make labor more comfortable, and reduce their risk of postpartum depression. 3.) Staying at a healthy body weight can help women reduce their risk of complications during pregnancy.

Inappropriate Weight Gain

1.) Insufficient weight gain in pregnancy can cause: → Low birth weight baby (less than 2500 g, or 5.5lbs). → Prematurity. → Problems with breastfeeding. 2.) Excessive weight gain is associated with: → Increased baby weight (macrosomia). → Cesarean birth. → Low Apgar scores. → Hypoglycemia. → Increased weight gain retention in children which may lead to overweight children.

Caffeine in Pregnancy

1.) Intake of caffeine should be limited to 200mg/day. 2.) Caffeine changes the absorption or excretion of calcium, thiamine and iron. 3.) Nurse should discuss typical amounts of caffeine with pt: → A 6-oz cup of brewed coffee contains 100 mg. → Tea contains 36 mg. → Cola beverages contain 35-50 mg/12 oz. → Cocoa contains 4 mg/6 oz.

Iron & Pregnancy

1.) Iron deficiency is one of the most common disorders in pregnancy. 2.) Associated with: → Increased risk of preterm birth, low-birth weight babies, increased maternal & newborn mortality, may also impact fetal/neonatal brain development. 3.) Many women need to supplement, but don't like to -Why? → (May cause GI upset, constipation & black stools). 4.) Teaching: → Take iron on an empty stomach (but may cause GI discomfort). → Take with orange juice or vitamin C. → Take at bedtime. → Do not take with calcium supplements, milk, tea or coffee as these substances decrease absorption. → High iron foods: meat, dark green leafy veggies, eggs, whole-grain breads and cereals, dried fruits, legumes, shellfish, molasses.

Calories and Energy Need

1.) Kilocalorie: → A unit of measure for energy. → It is the amount of energy needed to raise the temperature of 1 kg of water from 1 degree C. 2.) Caloric needs for pregnancy: → 2200 calories/day. → No increase in calories necessary for the first trimester unless the pt was severely underweight or had severe hyperemesis. → 300 kcal increase daily over pre-pregnancy requirements during the 2nd and 3rd trimester. → Approximately one additional serving of milk, one additional serving of bread or cereal, one additional serving of fruits or veggies, one additional serving of protein. → If pt. is an adolescent, one additional serving of dairy food is required. Why?

Developing Cultural Competence: Dietary Practices

1.) Kosher diet followed by many Jewish people. → No eating pork or shellfish. → Prohibition of consuming milk and dairy products in same meal. → Kosher foods marked on packaging; meats slaughtered in a specific way (blessed with a rabbi present). 2.) Many Muslims avoid pork, and meats that are eaten must be halal, or approved by Islamic law. 3.) Traditional Chinese may consume "thousand year-old" eggs (preserved for 4-5 weeks); viewed as health promoting. 4.) Italian, Greek, Native American homes may eat/display or wear garlic or onions to prevent illness. 5.) Some Hispanic homes have a balance between foods considered to be hot and cold. 6.) Some Asian cultures prefer hot liquids to promote healing.

Food Precautions: Mercury in Fish

1.) Large fish such as shark, swordfish, marlin, tilefish & mackerel have high levels of mercury which can damage the fetal CNS. These fish should be avoided during pregnancy. 2.) Shrimp, salmon, herring, trout, pollack & catfish are considered low-mercury fish & consumption should be limited during pregnancy to no more than 12 oz. (in two meals) per week. 3.) Canned tuna: chunk light lower in mercury than white. Recommendation is up to 6 oz per week. 4.) Raw fish should be avoided (toxoplasmosis)

Pregnancy Weight Gain

Expected Weight Gain Pattern: 1.) Approximately 1-5 lbs during 1st Trimester and 1 lb per week during remainder of pregnancy. 2.) Important to evaluate pattern of weight gain to diagnose or rule out potential complications. 3.) Very typical test questions to calculate appropriate weight gain. 4.) Note: Remember, most women are sensitive about this, so as an RN when you're doing these calculations, as long as they're within a couple pounds of their expected weight gain, it's okay.

Food Safety During Pregnancy Deli Meats: Listeria (continued)

To prevent listeria infection, the FDA advises the following for pregnant women: 1.) Maintain refrigerator temp at 40 deg F or below, and the Freezer at 0 deg F. 2.) Refrigerate or freeze prepared foods, leftovers and perishables within 2 hours of eating or preparation. Discard food left out at room temp for longer than 2 hours. 3.) Do not eat hot dogs and luncheon meats unless they are reheated and steaming hot. 4.) Avoid soft cheeses like feta, brie, Camembert, queso fresco & blanco, and blue cheese unless the label states they are made with pasteurized milk. 5.) Do not eat refrigerated pates or meat spreads that contain unpasteurized milk; don't drink unpasteurized milk. 6.) Avoid eating refrigerated smoked seafood like salmon, cod, tuna or mackerel unless it is in a cooked dish or casserole. Canned or shelf-stable pates, meat spreads and smoked seafood are considered safe.