PRENATAL NUTRITION October 10, 2023 Brittany Smith MS, RDN, LDN Nutrition Specialist, ECU Family Medicine Center Kathryn M Kolasa PhD, RDN, LDN Professor Emerita, Brody School of Medicine, ECU Dukes McCoy MS ECU Dietetic Intern 1.7.2013 This session was an education session for Family Medicine Faculty and Residents, ECU Family Medicine, Brody School of Medicine ‹#› Objectives Review weight gain guidelines during pregnancy and concerns (e.g. pica, food insecurity). Summarize basic guidelines for prenatal nutrition. Discuss the importance of choline in the maternal diet and what you can tell your patients about choline. Examine dietary recommendations for gestational diabetes. Discuss prenatal vitamins and minerals. NASEM - Nutrition during pregnancy and lactation: Exploring new evidence: Proceedings of a workshop National Academies of Sciences, Engineering, and Medicine 2020. Washington, DC: The National Academies Press. Prenatal Nutrition https://doi.org/10.17226/25831 First update by the Institute of Medicine since 1990 report Nutrition During Pregnancy. KM Kolasa, ECU Fam Med, 2023 ACOG Expert Review, 2022 – The importance of nutrition in pregnancy and lactation: Lifelong consequences. https://doi.org/10.1016/j.ajog.2021.12.035 Marshall NE, Abrams B, Barbour LA et al. The importance of nutrition in pregnancy and lactation: lifelong consequences. ACOG. 2022; doi.org/10.1016/j.ajog.2021.21.035 The NASEM documents were the most authoritative describing appropriate weight gain guidelines and dietary supplement guidelines. The ACOG review is the first of its kind from ACOG. We also distributed an overview of prenatal care published in the American Family Physician in 2023. This type of article has been published at intervals in Am Fam Phys but this is the most extensive discussion of weight gain, diet quality and dietary supplements. (see reference list for the citation) 3 Give weight gain (total and rate) advice Women with overweight and obesity often blame their size based on the weight they gained with children (some even name the pounds). The association between obesity and higher risk for severe COVID-19 should make us consider where we can work smarter to prevent obesity and severe infections in the future CDC weight gain trackers and advice for patients at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-gain.htm#trackers KM Kolasa, ECU Fam Med, 2023 It is important to give patients a weight tracker. There are a variety of trackers available on the web. 4 Pre-Pregnancy BMI Category BMI (kg/m2) Total Weight Gain (lbs) Rate of Gain in 2nd and 3rd Trimester (lbs/wk) Underweight < 18.5 28 -40 1 (1 - 1.5) Normal Weight 18.5 - 24.9 25 - 35 1 (0.8 - 1) Overweight 25 - 29.9 15 - 25 0.6 (0.5 - 0.7) Obese (all classes) > 30 11 - 20 0.5 (0.4 - 0.6) Weight Gain in Pregnancy ASSESS/ADVISE IOM, 2009 https://nap.nationalacademies.org/catalog/12584/weight-gain-during-pregnancy-reexamining-the-guidelines KM Kolasa, ECU Fam Med, 2023 O weight gain and weight loss can be safe during pregnancy The weight gain guidelines were issued in 2009 and have not changed although there has been discussion about the safety of zero weight gain and/or weight loss by women starting their pregnancy in the obese class. There is not firm consensus but there is evidence that no weigh gain and supervised healthy weight loss can be accomplished without harming mom or baby. It is equally important but less talked about, to help women lose their weigh gain after delivery. 5 Time Finances Access to healthy/safe food Food Insecurity Other Considerations FOOD SAFETY – greater susceptibility to foodborne illness WIC SNAP Local food banks (organized by county in Krames) Community meal programs RDN BARRIERS USE OF AVAILABLE RESOURCES SCREENING FOR FOOD INSECURITY IN THE CLINICAL SETTING Within the last 12 months, I worried that food would run out before I got money to buy more. Within the last 12 months, the food I bought just didn’t last and I didn’t have money to get more. A response of “sometimes” or “always” to either or both questions indicates a positive screen for FI U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. B Smith, ECU Fam Med, 2023 N/V/D/C Pica Aversions NO raw or undercooked meat, poultry, seafood, eggs. NO pre-made meat or seafood salads. Deli meat should be heated to steaming. NO unpasteurized juices, milks, cheeses (soft cheeses like queso, brie, feta), or raw sprouts Food Insecurity can lead to both excess weight gain (eating high calorie low nutrients foods when available) and/or too little weight gain with just a lack of calories. Assess for Food Insecurity. Make sure those who screen positive are signed up for WIC and SNAP benefits 6 Psychiatric eating disorder or hunger or cultural habit? The most common effects of pica can be classified as Nutritional deprivation Inadequate caloric intake leading to insufficient weight gain Excessive caloric intake leading to excess weight gain Toxicity Other effects such as obstruction, parasitic infection and dental injury Amount of Pica Substances Consumed Amount of Pica Substances Consumes Dirt, Soil, Clay 0.7-2.42 oz (20 - 40 g) Laundry Starch Up to 1 pound per day Ice Several glasses to several kilograms Magnesium Carbonate 4 - 5 blocks (1 block is usually 2oz) Pica: What do you do? Know what is in your area. KM Kolasa, ECU Fam Med, 2023 Pica can lead to too high or too low intake 7 Eating starch Test for anemia Monitor for excessive weight gain Monitor for elevated blood sugar levels Refer to RDN for MNT Fatigue, muscle weakness Ask about dirt and clay Test for anemia, hypokalemia Possible Next Steps after Identifying Pica Eating dirt, clay, paint chips Consider tests for anemia, lead, hypokalemia Examine teeth Monitor weight gain Refer to dietitian (RDN) for MNT Lead levels > 5mcg/dL Counsel to eliminate source of exposure Refer to RDN for MNT (ensure diet meets recs for Fe, Ca, Vitamins C and D Lead levels > 45mcg/dL Consider chelation therapy Eating ice Test for anemia Monitor weight gain Examine teeth Refer to RDN for MNT Sensitive or broken teeth Ask about dirt and clay and ice Constipation Ask about dirt and clay Corbett Webb R, Kolasa KM. Nutr Today. 2014;49(3):101-108 KM Kolasa, ECU Fam Med, 2023 PICA Assessment and Counseling Mnemonic Wait for the patient to reply. Ask how consumption helps her. Consumption of clay might soothe stomach upset during morning sickness, provide minerals like calcium., comply with mother or other relatives or friends’ insistence, calm heart burn, satisfy a craving, and prevent excess weight gain. P Patient-centered. Ice is the most coming item ingested in the US. But ask about other items like dirt, baked clay, or laundry or corn starch. I Ice. Monitor both your own and the patient’s verbal and non-verbal communication. C Communication. If hematocrit/hemoglobin level is low, ask about total diet and about pica. A Anemia Corbett Webb R, Kolasa KM. Nutr Today. 2014;49(3):101-108 KM Kolasa, ECU Fam Med, 2023 Its always been a chicken and egg question. Does the pica cause the anemia or does the anemia lead to women craving and looking for something that will “treat” it. 9 Optimum nutrition is important to meet the mother’s increased nutrient requirements, support fetal growth and development, and improve pregnancy outcomes. Summary of the findings and recommendations from a 2020 workshop exploring the relationship between nutrition and maternal and fetal outcomes during pregnancy and lactation NASEM - Nutrition during pregnancy and lactation: Exploring new evidence: Proceedings of a workshop National Academies of Sciences, Engineering, and Medicine 2020. Washington, DC: The National Academies Press. DGA 2020-2025, Chapter 5: Women who are Pregnant or Lactating https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf Core nutrition recommendations are the same as for women who are not pregnant Consume a variety of fruits and vegetables, whole grains, dairy, lean & plant protein, and healthy fats Limit calories from refined grains, added sugars, and saturated fat Focus on nutrient-rich forms of whole foods, while considering preference, lifestyle, tradition, culture, budget, and tolerance (nausea, vomiting, food aversions) In the US, many women who are pregnant have diets that are below recommendations for healthful food groups while exceeding recommendations for added sugars, saturated fat, and sodium Basic Guidelines from the DGA B Smith, ECU Fam Med, 2023 Basic Guidelines from the DGA - Supplementation Nutrient needs should primarily be met through a healthful diet, but this can be difficult Recommend a daily Prenatal Vitamin (PNV) in addition to a healthy diet for all women who are planning to become or are pregnant Especially to help meet requirements for nutrients that are essential but often lacking in the diets of even healthy (and food secure) pregnant women Folate Iron Iodine Vitamin D Calcium Choline Omega-3s/DHA B12* Summary of the findings and recommendations from a 2020 workshop exploring the relationship between nutrition and maternal and fetal outcomes during pregnancy and lactation NASEM - Nutrition during pregnancy and lactation: Exploring new evidence: Proceedings of a workshop National Academies of Sciences, Engineering, and Medicine 2020. Washington, DC: The National Academies Press. DGA 2020-2025, Chapter 5: Women who are Pregnant or Lactating https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf B Smith, ECU Fam Med, 2023 1.7.2013 Best to avoid restrictive diets that limit variety and exclude food groups (keto, paleo, etc) Certain nutrients which are important in fetal growth and development are commonly consumed in inadequate amounts among even healthy, food secure women – folate, iron, iodine, vitamin D, calcium, choline, omega-3s (DHA), and in some populations, vitamin B12. ‹#› Key Short-Fall Nutrients FOLIC ACID 400-800 mcg/d 1 month preconception to at least 12 weeks gestation Key nutrient in brain functioning and development and preventing neural tube defects IRON 27 mg/d Anemia: +40-200mg/d Include in your PNV rec Necessary for blood volume expansion and fetal development IODINE 220-250 mcg/d Supports neurocognitive development and TH synthesis Absorption of non-heme iron is enhanced with heme and Vitamin C Include in your PNV rec Risk of deficiency if not regularly consuming dairy, eggs, seafood, or iodized salt May be best not to exceed 500mcg/d B12 2.6 mcg/d Most women are likely meeting RDA Populations at risk of deficiency are those who exclude or limit animal sources Include in your PNV rec U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. B Smith, ECU Fam Med, 2023 Leafy greens, legumes, fortified breakfast cereal Fortified breakfast cereal, meats, legumes, leafy greens Iodized salt, dairy products, seaweed, seafood (cod) Animal products (fish, meat, poultry, eggs, dairy), nutritional yeast, fortified breakfast cereals 1.7.2013 Function and food sources of common short-fall nutrients ‹#› Key Short-Fall Nutrients Vitamin D 15 mcg/d (600 IU) Supports maternal and fetal bone health Deficiencies are associated with risk of pre-eclampsia and LBW Calcium 1000-1300 mg/d Supports maternal and fetal bone health and may reduce risk of pre-eclampsia and pre-term delivery Omega-3/DHA 1.4g/d / 300mg/d Supports fetal brain, eye, and CNS development Dairy is one of the best sources in the SAD - recommend that women are meeting the DGA (3 servings/day) To meet DHA requirements, recommend weekly consumption of at least 1-2 servings of low-mercury fatty fish like salmon, herring, and sardines Choline 450mg/d Replenish mom’s stores, and support fetal growth and brain and spinal cord development No consensus on routine supplementation. Supplementation is necessary in cases of deficiency Found in small amounts in food, and largely missing from PNV Some research suggests greater benefit with intake ~900mg/d U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. B Smith, ECU Fam Med, 2023 Fatty fish, fortified milks and breakfast cereals Dairy, fortified nondairy milk/juice, fish (with bones), tofu, leafy greens Fatty fish, sardines, enriched eggs or fortified milk Eggs, soybeans, meat, dairy 1.7.2013 Function and food sources of common short-fall nutrients Seafood (at least 8 and up to 12oz/week of low-mercury fish). The unintended consequence of focusing on avoiding mercury in fish is that women stopped eating any seafood. They need it for DHA. ‹#› A WORD ON Vegan/Vegetarian Diets Properly planned plant-based diets can be safe during pregnancy Take special care to ensure nutrient adequacy through foods and supplements Iron and Zinc: ensure adequate in a prenatal vitamin (PNV) B12: 25mcg/d supplement or in fortified foods Iodine: ensure at least 150mcg in your PNV DHA: 200-300mg from a supplement Calcium: encourage calcium-fortified foods Choline: will likely benefit from a supplement Protein Vitamin D: will likely benefit from a supplement Refer to an RDN for nutrition counseling U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. B Smith, ECU Fam Med, 2023 Diet assessment to ensure adequate intake of nutrients that are almost exclusively found in animal-derived foods. Refer to an RDN for diet assessment and to develop a safe vegetarian diet plan during pregnancy. 14 CHOLINE An essential nutrient throughout the lifespan, but especially critical during pregnancy Endogenous synthesis not adequate to meet increased demands during pregnancy Needed for cell membrane structure and signaling, lipid transport and metabolism, gene expression, and production of neurotransmitters (ACh) Early brain development Supplementation in the 3rd trimester is associated with better cognitive function in infants at 1yo and into school years Associated with reduce risk of neural tube defects, independent of folate intake Associated with reduced stress reactivity, which can lower risk of depression, T2DM, HTN, and immunological disorders Support development and function of the placenta Korsmo HW, Jiang X, Caudill MA. Choline: Exploring the Growing Science on Its Benefits for Moms and Babies. Nutrients. 2019; 11(8):1823. https://doi.org/10.3390/nu11081823 B Smith, ECU Fam Med, 2023 1.7.2013 ‹#› CHOLINE - INTAKES Amount assumed to ensure adequacy 450mg/d AI Average intake among women 278mg/d U.S. intake An estimated 90-95% of pregnant women consume 70% of pregnant women take a supplement, at least some of the time Inadequate and/or excessive intake of nutrients during pregnancy is associated with adverse maternal and offspring health outcomes Strongest evidence for nutrients that are both low in the diet and for which supplementation will make a difference (AJCN; 2023;117:823-829) During 1st trimester, don’t need added iron unless anemic Added iron: dose of 30mg/d, about week 12 of gestation If anemic, dose of 60-120mg/d Cut back by 30mg when lab values are WNL Change brands if not well tolerated (325mg ferrous sulfate = 65g elemental iron) Vitamin A (preformed) Vitamin D Folate/Folic acid Calcium Iron Omega-3 fatty acids Prenatal Vitamin-Mineral Supplement and IRON SUPPLEMENT Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition During Pregnancy: Part I Weight Gain: Part II Nutrient Supplements. Washington (DC): National Academies Press (US); 1990. 14, Iron Nutrition During Pregnancy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235217/ KM Kolasa, ECU Fam Med, 2023 Brittany (10/223): prenatal vitamins currently sold in the Fam Med pharmacy ($4 for Medicaid). The Major vitamins have 400IU vitamin D, folic acid, iron, B12, and some calcium, but no iodine, DHA, or choline. The M-Natal vitamins contain folic acid, iron, B12, 400IU Vit D, and some calcium, but also no iodine, DHA, or choline. It was thought the high doses of folic acid could mask vitamin B12 deficiency or pernicious anemia. Thus prenatals that had more than 1 gram of folic acid were available only by prescription in many states. This has not been found to be true with the fortification of many foods with folic acid to prevent neural tube defect 23 MOTHERS’ PLATE and SHOPPING GUIDE MOTHERS’ HANDOUTS Available free for use on ECU ScholarShip In English and Spanish FOOD SAFETY TIPS RECIPES using nutrient-rich foods Guide for women with Gestational Diabetes B Smith, ECU Fam Med, 2023 http://hdl.handle.net/10342/8944 http://hdl.handle.net/10342/8946 http://hdl.handle.net/10342/8943 http://hdl.handle.net/10342/8941 1.7.2013 The MOTHeRS Project was developed at East Carolina University, Brody School of Medicine. Kay Craven was the lead investigator of the component to address food insecurity among women living in rural areas. The project demonstrate that screening for and addressing food insecurity through the direct provision of medically tailored emergency food bags is both feasible and acceptable in an ambulatory clinical setting. The materials can be used with other pregnant women and are found on the ECU Repository The Scholarship. There is no copyright and providers should feel free to use with their patients. Plate and Guide: http://hdl.handle.net/10342/8944 Food Safety: http://hdl.handle.net/10342/8946 Recipes: http://hdl.handle.net/10342/8943 GDM: http://hdl.handle.net/10342/8941 ‹#› References Abridged List Ordered by Nutrient Content in Household Measure, Source: USDA National Nutrient Database for Standard Reference Legacy, Choline, total (mg). USDA ARS. Updated 2018. https://www.nal.usda.gov/sites/www.nal.usda.gov/files/choline.pdf American Dietetic Association. ADA Nutrition Care Manual. Chicago: American Dietetic Association (ADA); 2005. Choline and Lecithin Supplements Review ConsumerLab.com. Updated April 2023. https://www.consumerlab.com/reviews/choline-review/choline/?search=Choline%20(many%20forms) Choline Fact Sheet for Health Professionals. NIH ODS. Updated June 2022. https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/ Houchins J. Choline during pregnancy: New study shows lasting cognitive benefit for children. The Incredible Egg. Published February 2022. https://www.incredibleegg.org/articles/choline-during-pregnancy Korsmo HW, Jiang X, Caudill MA. Choline: Exploring the Growing Science on Its Benefits for Moms and Babies. Nutrients. 2019; 11(8):1823. https://doi.org/10.3390/nu11081823 Marshall NE, Abrams B, Barbour LA et al. The importance of nutrition in pregnancy and lactation: lifelong consequences. ACOG. 2022; doi.org/10.1016/j.ajog.2021.21.035 NASEM - Nutrition during pregnancy and lactation: Exploring new evidence: Proceedings of a workshop National Academies of Sciences, Engineering, and Medicine 2020. Washington, DC: The National Academies Press. Ramirez SI. Prenatal Care: An evidence-based approach. AM Fam Phys. 2023;108(3):139-150. Sauder KA, Couzens GL, Bailey RL. et al. Selecting a dietary supplement with appropriate dosing for 6 key nutrients in pregnancy. Am J Clin Nutr. 2023;117(4):823-829. Tsirou E, Grammatikopoulou MG, Theodoridis X, et al. Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal. Journal of the Academy of Nutrition and Dietetics. 2019;119:1320-1339. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. Wallace TC, Blusztajn JK, Caudill MA, Klatt KC, Natker E, Zeisel SH, Zelman KM. Choline: The Underconsumed and Underappreciated Essential Nutrient. 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