“Pregnancy may be the most sensitive period of the life cycle in which intervention may reap the greatest benefits.”
A. Prentice164
Two programs that have been shown to substantially improve pregnancy outcomes are highlighted in this section. First is the intervention program offered by the Montreal Diet Dispensary (MDD); second is the Supplemental Nutrition Program for Women, Infants, and Children (WIC).
The Montreal Diet Dispensary
The Montreal Diet Dispensary (MDD) has served low-income, high-risk pregnant females with nutritional as-sessment and intervention services since the early 1900s.
Part of the rationale for the WIC program in the United States was based on the successes of the MDD program.
The program is located in a large, comfortable house (see Illustration 4.20) in urban Montreal. Clients are warmly welcomed into a nonthreatening, relaxed setting.
Developed as an adjunct to routine prenatal care, the MDD intervention strategy has four major components:
1. Assess the usual dietary intake and risk profile of each pregnant woman, including calories, protein, and selected vitamin and mineral adequacy; also assess stress level.
2. Determine individual nutritional rehabilitation needs based on results of the assessment.
been found to decrease the symptoms of nausea and vom-iting in pregnancy:
Vitamin B
● 6 (pyridoxine) supplements given in a 10–25 mg dose every 8 hours reduce the sever-ity of nausea in many women.232 The upper limit for vitamin B6 intake during pregnancy is 100 mg per day.
Multivitamin supplements taken prior to and early
●
in pregnancy may decrease the occurrence of nau-sea and vomiting.233
Ginger in doses of 1 gram a day for 4 days may
●
decrease nausea and vomiting.214
Use of moderate doses of vitamins in a multivitamin supplement, and vitamin B6 in doses under the Tolerable Upper Intake Level, appear safe. Further research is needed before a definitive statement can be made regarding the safety of ginger use during pregnancy.
Heartburn
Pregnancy is accompanied by relaxation of gastrointestinal tract muscles. This effect is attributed primarily to proges-terone. Relaxation of the muscular valve known as the car-diac or lower esophageal sphincter at the top of the stomach is thought to be the principal reason for the 40–80% in-cidence of heartburn in women during pregnancy.234 The loose upper valve may allow stomach contents to be pushed back into the esophagus.235
Management of Heartburn Dietary advice for the prevention and management of heartburn includes:
Ingest small meals frequently.
●
Do not go to bed with a full stomach.
●
Avoid foods that seem to make heartburn worse.
●
Elevating the upper body during sleep, and not bending down so your head is below your waist, also reduce gastric reflux. Antacid tablets, which act locally in the stomach, are often recommended, but sodium bicarbonate (baking soda) and heartburn pills usually are not.234
Constipation
Relaxed gastrointestinal muscle tone is thought to be pri-marily responsible for the increased incidence of consti-pation and hemorrhoids in pregnancy. One way to prevent these maladies is to consume approximately 30 grams of dietary fiber daily.234 (Food sources of fiber are listed in Table 1.5c in Chapter 1.) Laxative pills are not recom-mended for use by pregnant women, but soluble fiber in products such as Metamucil, Citrucel, and Perdiem are considered safe and effective for the prevention and treat-ment of constipation.234 Women should drink a cup or more of water along with the fiber supplement.
Illustration 4.20 The Montreal Diet Dispensary.
Judith Brown
33411_04_Ch04_p087-133.indd 130
33411_04_Ch04_p087-133.indd 130 4/30/10 3:40:40 PM4/30/10 3:40:40 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
perinatal mortality than is the case for similar women not receiving MDD services.236,237
The program is cost-effective in relation to savings on newborn critical care, and programs based on MDD services have spread across Canada. Expenditures per cli-ent average $450. The program is primarily supported by Centraide of Greater Montreal, provincial and federal programs, and other contributions.238
The WIC Program
The WIC program represents an outstanding example of a successful public program intended to serve the nu-tritional needs of low-income women and families. It is cited as a model program in several other chapters and is described in Chapter 1.
In operation since 1974, WIC provides nutritional assessment, education and counseling, food supplements, and access to health services to over 6 million partici-pants. WIC serves low-income pregnant, postpartum, and breastfeeding women, and children up to 5 years of age who are at nutritional risk. Supplemental food provided to women includes milk, ready-to-eat cereals, dried beans, fruit juice, and cheese; some programs offer vouchers for farmer’s markets.
Participation in WIC is related to reduced rates of iron-deficiency anemia in pregnancy, higher-birth-weight infants, decreased low-birth-weight infants, and lower rates of iron-deficiency anemia in women after deliv-ery. For each dollar invested in WIC, approximately $3 in health care costs are saved. Internet addresses leading to additional information about WIC are listed in the resources section at the end of this chapter.
3. Teach clients the importance of optimal nutrition and about changes that should be made through practical examples.
4. Provide regular follow-up and supervision.
The MDD dietitians are carefully trained and hold the interests of their clients first in their hearts. They treat cli-ents with respect, openness, and affection; they also address client needs, such as transportation or emergency food or housing. Staff interactions with clients are nonjudgmental in nature and include positive feedback and praise for di-etary changes and other successes of clients.
The initial client visit to the MDD takes about 75 minutes, and follow-up visits are scheduled at 2-week intervals for 40 minutes each. Women are iden-tified as undernourished if their protein intake falls be-low that recommended for pregnancy, and an additional protein allowance is added to the diet. Women who are underweight are given an additional daily allowance of 20 grams protein and 200 calories for each additional pound of weight gain needed to achieve a maximum of 2 pounds per week. Women identified as being under excessive stress (such as having a partner in jail, be-ing homeless, or bebe-ing abused) receive an additional allowance of protein and calories and lots of positive attention. Food supplements, including milk and eggs, and vitamin supplements are provided to women who need them.
Impact of MDD Services Multiple studies have shown that women receiving MDD services have higher-birth-weight infants (1107 grams), fewer low-birth-weight infants (250%), and infants with lower rates of
Key Points
1. Nutritional status before and during pregnancy can modify the health of women during pregnancy, as well as the current and future health of infants.
2. The United States spends more money on health care than any other country, yet its birth outcomes are far from the best internationally. Improved maternal nutrition could help improve the health status of U.S. newborns.
3. A woman’s body prepares in advance for up-coming physiological events related to placental growth and fetal growth and development (such as proliferation of cells in organs and tissues of the placenta and fetus, and rapid increases in fetal weight). Consequently, nutritional needs must be met prior to the physiological changes.
4. Functions of the placenta include hormone and enzyme production, nutrient and gas exchange between mother and fetus, and removal of waste products from the fetus.
5. The placenta does not block all harmful sub-stances from entering the fetus.
6. The fetus is not a parasite. It cannot take what-ever nutrients it needs from the mother’s body.
7. Variations in fetal growth and development are generally not due to genetic causes but rather to environmental factors such as energy, nutrient, and oxygen availability, and to conditions that interfere with genetically programmed growth and development.
8. Energy and nutrient availability is considered the major intrauterine environmental factor that al-ters expression of fetal genes. This phenomenon represents the major mechanism that underlies the relationship between maternal nutrition and later disease risk.
9. Pregnancy weight gain affects birth weight and long-term health outcomes. Weight gain recommenda-tions are based on prepregnancy weight status.
33411_04_Ch04_p087-133.indd 131
33411_04_Ch04_p087-133.indd 131 4/30/10 3:40:41 PM4/30/10 3:40:41 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Review Questions
A. The next four questions pertain to the following case:
Tony was born at 35 weeks of pregnancy and weighed 2075 grams. His waist circumference was low relative to his weight and length. Tony was hos-pitalized for an infection at 4 months of age.
1. Tony was born preterm.
True False
2. How much did Tony weigh in pounds and ounces?
lbs oz
3. Tony was proportionately small for gestational age.
True False
4. Tony was hospitalized during the perinatal period.
True False
5. High intakes of regular coffee or caffeine during pregnancy are strongly related to preterm delivery.
True False
6. Vegan diets are NOT recommended for pregnancy because they generally fail to provide sufficient
protein to support normal growth and develop-ment of the fetus.
True False
7. The amount of iron absorbed from supplements decreases as the amount of iron in the supplement increases.
True False
8. The Institute of Medicine recommends that all pregnant women take a multivitamin and mineral supplement during pregnancy.
True False
B. Use the conversion factors listed in the “Conventional Units to SI Units” table in Appendix C to convert the following conventional unit measures to SI units.
9. 52 ng/mL vitamin D (25 hydoxyvitamin D) 5 nmol/L
10. 86 ng/mL ferritin 5 pmol/L 11. 402 ng/mL red cell folate 5 nmol/L 10. Excessive weight gain is related to postpartum
weight retention.
11. Caloric adequacy during pregnancy can be esti-mated by weight gain.
12. High-quality vegetarian diets promote a healthy course and outcome of pregnancy.
13. Consumption of the omega-3 fatty acids, EPA and DHA, promote visual and intellectual develop-ment in offspring, and increase gestational dura-tion somewhat. Most U.S. women consume too little EPA and DHA during pregnancy.
14. Key nutrients of particular importance during pregnancy are folate, vitamin D, calcium, iron,
iodine, and EPA and DHA. Antioxidants from plant food also play key roles in maintaining maternal and fetal health.
15. Not all pregnant women need a multivitamin and mineral supplement during pregnancy. Women at risk of deficiencies do.
16. In general, exercise is beneficial to the course and outcome of pregnancy.
17. Certain foodborne illnesses in pregnant women can threaten fetal survival.
18. Some of the common discomforts of pregnancy, such as nausea and vomiting and constipation, can be ameliorated by nutritional measures.
Resources
Pregnancy Resources and Information
Visit the Women’s Health Resource Center for access to journal articles and summaries; information on pregnancy, growth, and development; and health care and diversity information.
Website: www.medscape.com
The Bureau of Maternal and Child Health website provides information on programs for pregnant women, hot topics, and announcements of new publications.
Website: http://mchlibrary.info
The National Library of Medicine website offers extensive cov-erage of scientific journal articles, summaries, and educational resources from a variety of reputable organizations on preg-nancy, nutrition, diet, and disorders of pregnancy.
Website: www.nlm.nih.gov/medlineplus
Fish Advisories
This site links to local freshwater fish advisories.
Website: www.epa.gov/waterscience/fish/states.htm Continuing Education Presentations
American Society for Nutrition members can sign in at www.
nutrition.org and go to this page to access a presentation at the 2009 Experimental Biology meetings on “Nutritional Experi-ences in Early Life as Determinants of the Adult Metabolic Phenotype.”
Website: development/videotaped-symposia-from-asn-annual-meeting-at-experimental-biology-2009
33411_04_Ch04_p087-133.indd 132
33411_04_Ch04_p087-133.indd 132 4/30/10 3:40:41 PM4/30/10 3:40:41 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Food Safety
Food safety information for mothers-to-be is available from the FDA.
Website: www.cfsan.fda.gov/~pregnant/pregnant.html Pregnancy Information
The American Pregnancy Association offers a search tool for information about pregnancy by topic (e.g., pregnancy calendar, ovulation calendar, paternity testing information, finding a health care professional).
Website: http://www.americanpregnancy.org Pregnancy Food Guides
Obtain a “MyPyramid for Moms” menu plan and dietary analyses at this site.
Website: www.mypyramid.gov/mypyramidmoms/
pyramidmoms_plan.aspx
“Eating Well with Canada’s Food Guide” provides women with the information they need to eat well during pregnancy.
Website: www.hc-sc.gc.ca/fn-an/nutrition/prenatal/index-eng.php Natality Statistics
The Centers for Disease Control and Prevention offers “ Wonder,”
a single-point access to public health reports and health statistics.
Website: wonder.cdc.gov
U.S. Government
The U.S. government’s site provides information on food and nutrition programs and eligibility; links to scientific references;
and information about the nutrition needs of infants, children, adults, and seniors.
Website: www.nutrition.gov WIC
The USDA provides access to information about the WIC pro-gram, the WIC Works Food Safety Resource List, and other resources.
Website: www.fns.usda.gov/wic/aboutwic Dietary Analysis
Select “MyPyramid Tracker” and run dietary intake records one day at a time. Analyzes diet by food groups and selected nutrients.
Website: www.mypyramid.gov
This USDA site is the best one for food composition data.
Website: www.ars.usda.gov/nutrientdata
33411_04_Ch04_p087-133.indd 133
33411_04_Ch04_p087-133.indd 133 4/30/10 3:40:41 PM4/30/10 3:40:41 PM
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.