Training Goals

1. Basic SS Training Medical Nutrition TherapyBySharmila Chatterjee Msc,MS,RD,CDE(CDAPP Coordinator, Region 9)Email: schatterjee@ucsd.edu

2. Training Goals • Identify the Guidelines for Care as the primary resource • Describe the role of the registered dietitian: medical nutrition therapy • Describe carbohydrate foods and the impact they have on blood sugars • Identify lifestyle modifications for prevention of DM/complications of DM

3. Medical Nutrition Therapy (MNT) is a key component of glycemic control

4. Goals of Medical Nutrition Therapy • Individualized, balanced meal plan • Evidence-based recommendations • Adequate maternal and fetal nutrition • Vitamin/mineral supplementation as needed • Appropriate weight gain • Normoglycemia • Promotion and support of breastfeeding

5. Components of Nutrition Assessment • Clinical data • Medical history • Activity level • Plan for infant feeding

6. Clinical Data • Measured height and weight (w/o shoes) • Preconception weight • Preconception BMI • Weight history

7. Clinical Data (cont.) • Available labs • Hgb/Hct • OGTT • A1c • Medical history • Post gastric bypass • PCOS • Medications: current/historical use

8. Food Patterns • Food intake history • Inadequate intake • Overnutrition • Food allergies, intolerances • Unusual food habits: pica • Supplements • Complementary medicines • Common complaints • Dental history • Cultural foods

9. Psychosocial Factors • Limited income/food assistance (WIC) • Substance abuse • Language/cultural background • Religious practices • Eating disorders • Literacy level • Social support • Employment

10. Goals at Initial RD Visit • Treatment initiated • Initial individualized meal plan • Initial individualized exercise routine • Patient comprehension • Assessment completed • Weight gain goals determined • Weight gain plotted

11. Preconception Weight Goals • All women are encouraged to achieve a desirable body weight before conception • Preconception BMI should be used in determining weight category

12. Determining Preconception BMI • BMI = weight (lbs.) x 703 height (in.) x height (in.) • BMI = weight (kg.) height (meters) x height (meters)

13. Body Mass Index/Wt Gain Goals(Based on 2009 IOM Guidelines)

14. Recommended Rate of Weight Gain/Week(Based on 2009 IOM Guidelines)

15. Weight Gain Grids • The forms are located at http://www.cdph.ca.gov/pubsforms/forms/Pages/MaternalandChildHealth.aspx • CDPH 4472 B1     Prenatal Weight Gain Grid:  Pre-pregnancy Underweight Range • CDPH 4472 B2     Prenatal Weight Gain Grid:  Pre-pregnancy Normal Weight Range • CDPH 4472 B3     Prenatal Weight Gain Grid:  Pre-pregnancy Overweight Range • CDPH 4472 B4     Prenatal Weight Gain Grid:  Pre-pregnancy Obese Weight Range

16. Newer Research re Weight Gain for Obese Women • Kiel, et al 2007 • Obese women w/singleton pregnancy n=120,170 • Relationship between weight gain and preeclampsia, C-section, SGA and LGA

17. Kiel et al: Outcomes • Lowest risk for adverse outcomes:

18. Newer Research re Weight Gain for Obese Women, Cont’d • Bodnar et al, 2010 • Obese women with singleton pregnancies (n=3254) • Relationship between wt. gain and adverse outcomes (SGA, LGA, spontaneous and medically indicated preterm births)

19. Bodnar, et al Cont’d • Lowest risk for adverse outcomes

20. Preconception Energy Needs Energy needs are based on preconception weight Calculate energy needs using the Institute of Medicine (IOM) estimated energy requirement (EER) formula

21. EER Formula 14-18 yrs old: EER = [135.3 - (30.8 x A)] + PA x [(10.0 x Wt) + (934 x Ht)] 19 yrs or older: EER = [354 - (6.91 x A)] + PA x [(9.36 x Wt) + (726 x Ht)]

22. EER Formula • A = age (years) • PA = physical activity coefficient • Wt = weight (kg) • Ht = height (meters)

23. Physical Activity Coefficients

24. Prenatal Energy Needs • 1st trimester (0-12wks) energy needs remain the same as during preconception • 2nd and 3rd trimester energy requirements increase

25. Energy Needs for Pregnancy Based on Gestational Age IOM formula to calculate energy needs for pregnant women who have normal weight pregravid: • 1st trimester = Adult EER + 0 • 2nd trimester = Adult EER + 160 kcal (8 kcal/wk x 20 wk) + 180 kcal • 3rd trimester = Adult EER + 272 kcal (8 kcal/wk x 34 wk) + 180 kcal

26. Energy Needs for Overweight and Obese Women No consensus on determining energy needs for overweight and obese pregnant women • Minimum 1800 kcal for adequate nutrition • Careful clinical monitoring to ensure adequate intake

27. Exercise in Pregnancy • Offspring of 20 women who exercised were compared with offspring of 20 physically active control subjects. • Offspring of the women who exercised weighed less and had less subcutaneous fat mass. • Groups had similar motor, integrative and academic readiness skills. (Clapp JF, 1996)

28. Exercise During PregnancyACOG Committee Opinion No. 267 • In the absence of either medical or obstetric complications, > 30 min of moderate exercise on most, if not all days of the week is recommended • Exercise may be beneficial in primary prevention of GDM • Exercise may be “a helpful adjunctive therapy” for GDM when euglycemia is not achieved by diet alone (ACOG, 2002)

29. Macronutrient Recommendations during Pregnancy • Calories gradually increase from 13+ wks • Protein – 1.1 g/kg/day or additional 25g/day (from 2nd trimester) • Carbohydrates – min. of 130 gm/day in 1st trimester and 175 gm/day in 2nd and 3rd • Fat – focus on monounsaturated fats as main source

30. Micronutrient Recommendations during Pregnancy • Fiber – 25-35 g/day • Sodium – • Average Intake (AI) for women under 50 yrs: 1.5g/day • Upper limit: 2.3 g/day • Patients with HTN and nephropathy: no more than 2000mg sodium/day

31. Micronutrient Recommendations during Pregnancy • Folic acid • Preconception: 400 mcg/day • Pregnancy: 600 mcg/day • Hx of NTD: 4000 mcg/day • Tolerable upper limit: • 14-18yr olds: 800 mcg/day • > 19yrs old: 1000 mcg/day

32. Micronutrient Recommendations during Pregnancy • Vitamin D • Considered a hormone, not a vitamin • RDA for pregnancy and lactation: 600 IU/day (15 micrograms/day) • Tolerable Upper Limit for pregnancy and lactation: 4000 IU/day

33. Vitamin D • Optimal blood levels of 25(OH)D controversial • IOM: 20 ng/ml sufficient for good bone health • Ginde et al, 2010 (NHANES data) • At least 33% of pregnant women deficient in vitamin D (using 20 ng/ml as target)

34. Vitamin D Supplementation During Pregnancy • Wagner, et al 2010 • Evaluation of effectiveness of high doses vitamin D in reducing pregnancy risks • In the group taking 4000 IU/day • Lowest rates of preterm labor, preterm birth, infection • Researchers recommendation: 4000 IU/day to maintain level of 40 ng/ml

35. Calcium • RDA for pregnancy/lactation • 14-18yrs old: 1300 mg/day • 19-50 y.o.: 1000 mg/day • >50 y.o.: 1200 mg/day • Preferable source is food • 600 mg in most supplements • Maximum absorption: 200-300 mg TID

36. Vitamin and Mineral Supplements • Zinc: 15 mg/day • Copper: 2 mg/day • Folic acid: 600 mcg/day • Iron: 30 mg/day at first prenatal visit • For vegans, 600 IU vitamin D and 2 mcg vitamin B12

37. Other Substances during Pregnancy • Caffeine- limited to 200 mg/day (2 – 6oz cups of coffee) • Herbs- safety unknown • Limit herbal teas. Potentially contraindicated: gingko biloba, ginseng, echinacea, St. John’s wort and concentrated herbal garlic extract

38. Other Substances during Pregnancy: DHA • Found in wild fatty fish (salmon, herring, sardines, freshwater trout) and some fortified foods (milk, bread, yogurt) • Inadequate DHA from food: supplement containing at least 200 mg of DHA • Several prenatal supplements include DHA, either from fish oil or other sources

39. Toxins to Avoid • Salmonella • Avoid raw eggs • Listeriosis • Avoid raw sprouts, unpasteurized milk and cheeses • Cook all meat, fish and poultry thoroughly • Heat deli and luncheon meats until steaming • Drugs and alcohol • Avoid • If questions contact CTIS at www.ctispregnancy.org

40. Toxins to Avoid • Mercury and PCBs • Avoid shark, swordfish, king mackerel and tilefish • Limit other fish and shellfish to 12 oz/wk • Albacore tuna – limit to 6 oz/wk

41. Nonnutritive Sweeteners • FDA approved • Saccharin • Aspartame • Acceptable daily intake: 50 mg/kg body wt • Actual intake @ 90th percentile: 2-3 mg/kg BW • Acesulfame potassium (acesulfame K) • Sucralose • Pregnancy and lactation: no adverse effects in animals

42. Stevia and Rebaudioside A • Rebaudioside A aka Reb A • Truvia, PureVia • Highly processed derivative of stevia • Received GRAS status from FDA • Stevia: Natural Medicines Comprehensive Database indicates there is insufficient evidence for its safety in pregnancy

43. Comparisons 43

44. Nutritive Sweeteners • Agave • CHO/kcal content similar to table sugar • Sweeter than table sugar • Possibly lower glycemic index • Likely safe when consumed in usual amounts • Likely unsafe during pregnancy due to contraceptive effects that could lead to miscarriage

45. Sugar Alcohols/Polyols GRAS • Reduced risk dental caries • Laxative effect • Half the kcal of sucrose • Calculating the CHO of foods containing polyols: subtract half the sugar alcohol grams from the total CHO grams

49. Working the Meal Plan into Real Life

50. Sweet Success Nutrition Guidelines for GDM • Spread carbohydrate load over 3 small meals and 3 or more snacks. CHO not well tolerated at breakfast. Flexible CHO intake with the use of insulin • Fruit: 2 or more servings daily, not at breakfast • Milk: 3-4 servings daily, not at breakfast; 2%, 1% fat or nonfat in portion sizes of 4-8 oz during meals or snacks • Bread/starch: as low as 15-20 gms at breakfast; a minimum of 7 gms of protein and 15-30 gms of carb at bedtime snack