Healthy Eating for a Healthy Pregnancy

1. Healthy Eating for a Healthy Pregnancy Allison Little, RDQueen’s Family Health Team December 4, 2013

2. Objectives At the end of the session, participants will be able to: Educate patients on appropriate weight gain, food choices, supplementation and food safety for a healthy pregnancy Identify patients at high nutritional risk that would benefit from further nutritional assessment and counseling with a Registered Dietitian Provide appropriate prenatal resources/referrals to community programs

3. Importance of Healthy Eating During Pregnancy Meet increased nutrient and energy needs Prevent or minimize common pregnancy-related problems Ensure healthy birth weight Reduce risk of birth defects

4. Case: Sara Sara is a 27 yo female who is here to see you for her first prenatal visit. She is very happy to be expecting and has a long list of questions for you. You wonder how you will ever get through your assessment never mind have time to ask about her nutritional concerns.

5. Sara’s Nutrition Concerns 1) Started taking a prenatal vitamin, but recently has been experiencing N/V so skipping her prenatal vitamin some days and is not eating that well. 2) She 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-preg BMI=34). 3) Sara is concerned about food safety especially during pregnancy and wonders if becoming a vegetarian is a good idea. 4) She is on a limited income and isolated from friends, often lonely. Her husband works 12 hr days.

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

7. Questions to Consider Are there any suggestions that you would make to help improve her diet? What strategies would you recommend to cope with N/V? What resources would you share? Are there any community programs you would recommend? Would you refer her to the dietitian?

8. Rate of Gestational Weight Gain

9. High Pre-PregnancyBMI’s • High prevalence of obesity in prenatal population (33% of Canadian women with BMI>/=25, PHAC 2009) • Higher BMI associated with poor pregnancy outcomes • gestational diabetes • C-section • large-for-gestational age infants • preterm birth • infants less likely to be breastfed and more likely to be overweight • Occurs more often: First pregnancy, Aboriginal, <secondary education, <25 yrs old

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. True Excessive rate of weight gain is a red flag for GDM and indicates need for further discussions about eating well and staying active during pregnancy.

12. Low Pre-PregnancyBMI’s • 10% of Canadian women have a low pre-pregnancy BMI < 18.5 • Low BMI associated with: • preterm birth • small-for- gestational-age infant • Most common: • More than one pregnancy • Born outside of Canada • Lower SES

13. Supporting a Healthy Weight GainDuring Pregnancy 1. Set a wt gain goal based on pre-pregnancy BMI • Pregnancy Weight Gain Calculator (Health Canada): http://www.hc-sc.gc.ca/fn-an/nutrition/prenatal/bmi/index-eng.php 2. Talk to women about gestational wt gain • Healthy Weight Gain During Pregnancy (Health Canada): http://www.hc-sc.gc.ca/fn-an/alt_formats/pdf/nutrition/prenatal/hwgdp-ppspg-eng.pdf

14. Supporting a Healthy Weight GainDuring Pregnancy 3. Encourage healthy eating and physical activity

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

16. True Canada’s Food Guide is designed to meet the nutrient and energy needs of all Canadians including pregnant women with some modifications With supplementation of folic acid and iron With additional calories

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

18. The Truth about Eating inPregnancy… Women only need a little extra food in the 2nd and 3rd trimesters Two or three extra food guide servings each day is often enough Think ‘twice as healthy’ vs. ‘twice as much’

19. Energy Needs in Pregnancy

20. To Meet Extra Energy Needs(350-450 calories) Focus on the food guide and promote variety Add a small snack: • piece of fruit + yogurt • slice of toast + peanut butter And a slightly larger meal: • add fresh fruit to meal • extra serving of starch or meat • adding nuts, seeds to salad

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

22. Physical Activity • Benefits: • Help to reach appropriate wt gain • Maintain muscular and cardiovascular fitness • Reduce risk of gestational diabetes and pre-eclampsia • Decrease physical complaints (back pain)

23. Nutrient Needs in PregnancyRecommended Dietary Allowances for Women 19-50 years

24. Iron in Pregnancy Importance • critical component of hemoglobin • to support maternal increased RBC mass • to support normal fetal brain development • to allow the fetus to build iron stores for first 6 months of life Concerns • High prevalence of iron deficiency anemia

25. To Meet Iron Needs DuringPregnancy Health Canada recommends pregnant women... • Follow Canada’s Food Guide • Consume iron rich foods (heme and non-heme iron) • Take multivitamin with 16-20 mg of iron daily

26. Heme and Non-Heme Iron Heme Iron • Clams • Beef • Organ Meats Non-heme Iron • Legumes, eggs • Breads, cereals • Dark leafy greens • Some seeds and nuts

27. Improving Iron Absorption • have vitamin C foods with non-heme iron rich foods e.g. an orange with breakfast cereal • have tea or coffee between meals • include heme sources of iron whenever possible e.g. spaghetti with meatballs

28. Myth or Truth? High dose folic acid supplementation is needed for all pregnant women.

29. Folic Acid/ Folate What? • B vitamin, folate or folacin in foods • folic acid supplemental version Why? • role in cell growth • needed for the normal development of the spine, brain and skull of fetus When? • Especially during the first 4 weeks of pregnancy

30. Folic Acid SupplementationDuring Pregnancy If no health risks: • Follow CFG, consume high folate foods • 0.4-1.0 mg folic acid /day 2-3 months preconception, continue throughout pregnancy and lactation

31. What Food Groups Provide Folate? Vegetables and fruit • Choose at least one dark green vegetable each day (asparagus, romaine, avocado, broccoli, spinach, peas, oranges, cantaloupe, banana) Fortified Grains • whole grains (cereals, pasta, breads)

32. Who Needs High Dose Folic AcidSupplementation? 1. Low dietary intake of folate AND elevated folate requirement • Poor dietary quality, chronic dieting, low carbohydrate diets, low SES • Ethnic food selection/preparation e.g. stewing 2. Elevated folate requirements • History of NTD/congenital anomalies • Medications/alcohol that interfere with folate metabolism • Malabsorption, gastric bypass, Liver/renal disease 3. Uncertain disease etiology • Obesity, Diabetes, Impaired Glucose Metabolism, Hyperinsulinemia

33. How Should High Dose Folic AcidSupplementation Be Provided? Preconception to 10 -12 weeks gestation • 4-5 mg/day folic acid + multivitamin with B12 At 10-12 weeks pregnancy • transition to daily multivitamin supplement with 0.4 mg folic acid daily for duration of pregnancy and lactation CAUTION • Ensure patients DO NOT take more than one MVT daily (Vit A risk)

34. Omega-3 Fatty Acids: ALA – Alphalinolenic Acid • Vegetable oils, nuts and seeds EPA – Eicosapentaenoic Acid DHA – Docosahexaenoic Acid • Fatty fish

35. Fish and Omega-3 Fatty Acids • Health Canada recommends all women eat at least 150 g (2 Food Guide Servings) of cooked fish each week • Choose fish with low levels of contaminants • Salmon • Trout • Herring • Haddock • canned light tuna

36. Contaminants Methyl mercury • toxic to the CNS, with the developing infant brain being particularly sensitive • all fish accumulate methyl mercury from h20 • carnivorous fish also accumulate methyl mercury from prey, therefore contain higher levels

37. Fish with High Level ofContaminants • Limit albacore tuna: 300 g (10 ounces) /wk ~2 cans (170 g each) Women who are pregnant, may become pregnant or breastfeeding • Limit high level mercury fish: • fresh and frozen tuna • Shark • Swordfish • marlin, • orange roughy • escolar No more than 2 FG servings/mo

38. What if Your Patient Does NotEat Fish? Encourage ALA sources • Ground flaxseed • Hempseed • Tofu • Soybeans • Flax oil • Walnuts DHA Enriched Foods • Omega 3 Eggs

39. Bottom Line on Fish: • Encourage women to eat two Food Guide Servings of fish each week. • Inform women about fish to eat and fish to limit. • Emphasize a food based approach to obtaining omega-3 fats.

40. Prevention of Pre-eclampsia Prevention • Healthy pre-pregnancy body wt • Avoid interpregnancy wt gain • Ca 1-2g/d in high risk women or low Ca intake (<600 mg/d) No benefit • Na restriction • Antioxidant vitamins

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

42. Foods to Avoid DuringPregnancy May be contaminated by bacteria: • raw fish, especially shellfish • undercooked meat, poultry and seafood (hotdogs, deli meats, pates, smoked meats and fish) • unpasteurized milk and milk products (including soft and semi-soft cheeses), ciders • raw sprouts (especially alfalfa) • Practice food safety, wash hands

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

44. Caffeine and Herbal Teas Limit caffeineintake to 300mg each day • Coffee: 500mL (2 cups) per day • Teas: 1000 mL (4 cups) per day Herbal Teas SAFE: 2-3 cups per day • citrus peel, ginger, lemon balm, orange peel, rosehip, red raspberry, peppermint AVOID: • chamomile, aloe, coltsfoot, juniper berries, pennyroyal, buckthorn bark, comfrey, duck roots, Labradortea, sassafras, lobelia and senna leaves

45. Nausea and Vomiting Why? • occurs as a result of hormone changes • can be made worse by certain smells, and by movements Coping strategies: • Avoid having an empty stomach • Small frequent meals • Get out of bed slowly and eat soon afterward • Drink fluids between mealsvs with meals • Choose cold foods • Get plenty of fresh air • Smelling fresh-cut lemons • Avoid smoke, strong odours, alcohol and caffeine

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

47. Prenatal Resources/Websites KFL&A Public Health Order resources from KFL&A PH and other providers www.kflapublichealth.ca/Re sourceOrderForm.aspx#Eati ng_Well

48. Prenatal Resources/Websites • Best Startwww.beststart.org Healthy Eating for a Healthy Baby • Public Health Agency of Canadahttp://www.phac-aspc.gc.ca/index-eng.php The Sensible Guide for a Healthy Pregnancy • Government of Canada http://www.canada.ca/home.html Safe Food Handling for Pregnant Women Health Canada http://www.hc-sc.gc.ca/index-eng.php Pregnancy Weight Gain Calculator Healthy Weight Gain During Pregnancy

49. KFL&A Public HealthFood For You, Food For Two Free “drop-in” program for pregnant women Amherstview and Napanee Group health teaching & peer support Free groceries, prenatal vitamins RD and PHN available for 1:1 counselling

50. KFL&A Public Health