There are numerous resources that offer nutritional guidelines, however, both midwives and their clients need to be careful not to follow nutritional advice that may not be research-based or medically sound.
For example, there are many Web sites that claim to offer nutritional advice but are actually just fronts for private companies peddling the latest fad diet or diet pills and tonics.
In 2000, the Office of Disease Prevention and Health Promotion of the Department of Health and Human Services in conjunction with the USDA’s Center for Nutrition Policy and Promotion released the most recent General Dietary Guidelines for Americans. These guidelines have been published since 1980 and are revised every five years by law based on the recommendations from a scientific ad- visory group composed of 11 nongovernmental ex- perts. These latest guidelines are grouped within three areas called the “ABCs” of good health: (1) Aiming for fitness by aiming for a healthy weight and being physically active each day; (2) Buildinga healthy base by using the Food Pyramid (Figure 6- 1) to guide food choices, choosing a variety of grains, fruits, and vegetables daily, and by keeping food safe to eat through proper food preparation and storage; and (3) Choosingsensibly by choosing a diet that is low in saturated fat and cholesterol and moderate in total fat, choosing beverages and foods to moderate intake of sugars, choosing and
CAGE Alcoholism Screening Questionnaire
TABLE 6-22
C Have you ever felt you need to Cut down on your drinking?
A Have people Annoyed you by criticizing your drinking?
G Have you ever felt bad or Guilty about your drinking?
E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye- opener)?
Source:Mayfield, D., McLeod, B., and Hall, P. The CAGE question- naire: validation of a new alcoholism instrument. Am. J. Psych.
131:1121–1123, 1974.
preparing foods with less salt, and moderating in- take of alcoholic beverages.
While most components of these guidelines enjoy support from health and nutrition experts, the use of the USDA’s Food Pyramid to guide food choice remains controversial. Many health profes- sionals believe that the Food Pyramid, which was released in 1992, is a great improvement over the preexisting model of four food groups of equal weight: (1) meat, poultry, fish; (2) grains; (3) dairy;
(4) fruits and vegetables. Some of these same pro- fessionals feel, however, that the Food Pyramid is nonetheless still flawed. They argue that the USDA, due to pressure from meat and dairy lobbying groups, still places too high a focus on meat and dairy products [94]. In 1991, the Physicians Committee for Responsible Medicine proposed a redefinition of the main food groups as (1) fruits, (2) grains, (3) vegetables, and (4) legumes. They proposed that meat and dairy be optional and that servings from these two groups should, in any case, be smaller than those proposed by the government.
These proposed changes were based on research data that demonstrate that the American diet, which is high in animal fat and protein and low in fiber, increases the risk of obesity, cancer, and heart disease. More recently, Dr. Walter Willett, chair of the Harvard School of Medicine Department of Nutrition and one of the lead researchers for the Nurses’ Health Study, has proposed the adoption of a new, research-based food pyramid (Figure 6-2).
Dr. Willett argues that the USDA Food Pyramid is
flawed in that it treats all fats as equally bad, all complex carbohydrates as equally good, and all proteins as equal in nutritional value. Furthermore, he believes that it promotes too high an intake of dairy products [95].
While the USDA dietary guidelines and ap- proved health claims for food packaging have been continuously updated to incorporate new research findings, the Food Pyramid has not. As a result, some of these guidelines and claims seem to contra- dict the USDA Food Pyramid. It is not surprising, therefore, that the public is often confused about what foods they should choose to maintain good health. In general, the midwife should help women assess whether their current diet is appropriate to ensure adequate intake of all necessary nutrients while maximizing intake of foods, such as fruits and vegetables, that promote health and minimizing those, such as saturated fats, that promote disease.
The section below includes a more detailed sum- mary of research-based dietary guidelines and screening recommendations that can be used by midwives when conducting nutritional evaluation, education, and counseling.
Women should be reminded that proper nutri- tion begins with exclusive breastfeeding starting, if it is not medically contraindicated, in the first few hours after birth and continuing through five to six months of life before supplemental foods are intro- duced. It is also essential to stress that healthy eat- ing habits begin in infancy and are reinforced through childhood and adolescence. Parents should
Fats, Oils and Sweets USE SPARINGLY
Milk, Yogurt and Cheese Group 2-3 SERVINGS
Vegetable Group 3-5 SERVINGS
Meat, Poultry, Fish, Dry Beans, Eggs and Nuts Group 2-3 SERVINGS
Fruit Group 2-4 SERVINGS
Bread, Cereal, Rice and Pasta Group 6-11 SERVINGS
KEY
Fat (naturally occurring and added) Sugars (added)
These symbols show fats and added sugars in foods.
FIGURE 6-1 U.S. Department of Agriculture’s Food Pyramid.
Source:USDA and the U.S. Department of Health and Human Services, 1992.
be aware that one of the best ways to ensure that their children eat appropriately is to eat appropri- ately themselves. This guarantees that the proper foods will be available in the home and that their children have a positive model to imitate. Proper nutrition requires planning and knowledge of what constitutes a healthy diet. Midwives can provide es- sential education on these topics to their clients both as part of their routine well-woman care visits and their prenatal and postpartum care. Midwives should also provide nutritional advice that will help women prevent nutritionally related disorders and certain chronic diseases. This advice should include the following:
• Eat a variety of foods and strive to obtain most if not all of necessary nutrients from dietary sources rather than from supplements. You can use one of the food pyramids discussed earlier (Figures 6-1 and 6-2) as a guide on what pro- portions of each food group you should strive to consume daily. Remember that not all foods are of nutritional value. Sugars, sweets (soft drinks, candies, cakes, and cookies), some types of oils, foods high in saturated fats (cream, lard, butter), and alcoholic beverages supply
what are often referred to as “empty” calories for they are of little or no nutritional value.
• Eat a diet that provides a healthy balance of nu- trients. Regardless of the actual number of calo- ries required by an individual, it is recommended that for a healthy, nonpregnant, and nonlactat- ing woman, approximately 15 percent of total energy intake be in the form of protein, at least 55 percent in the form of carbohydrates, and 30 percent or less in the form of fat. As was men- tioned in an earlier section, less than 30 percent of fat intake should be in the form of saturated fats, which should account for less than 10 per- cent of total caloric intake. It is also recom- mended that less than 10 to 15 percent of total caloric intake should be in the form of sugars.
• Engage in an exercise program or in regular physical activity beyond that required for activ- ities of daily living, including work.
• Quit smoking. Enrollment in a smoking cessa- tion program can help in this endeavor, as may, in some circumstances, pharmacological agents.
• Maintain a healthy weight. BMI tables are help- ful to determine what this weight should be.
• Moderate or eliminate alcohol intake. Women should strive not to drink more than one drink
Alcohol in Moderation
(unless contraindicated)
Daily Exercise and Weight Control White
Rice, White Bread, Potatoes and Pasta, Sweets Use Sparingly
Red Meat, Butter
Dairy or Calcium Supplement, 1-2 times/day
Fish, Poultry, Eggs 0-2 times/day
Whole Grain Foods (at most meals)
Plant oils, including olive, canola, soy, corn, sunflower, peanut, and other vegetable oils Vegetables
(in abundance)
Nuts, Legumes, 1-3 times/day
Fruits, 2-3 times/day Multiple Vitamins
for Most
FIGURE 6-2 Dr. Walter Willett’s Food Pyramid.
Source:Reprinted with permission of Simon & Schuster Source, a division of Simon & Schuster Adult Publishing from Eat, Drink, and Be Healthyby Walter C. Willett, M.D. Copright © 2001 by the President and Fellows of Harvard College.
per day (12 ounces of regular beer, 5 ounces of wine, 1.5 ounces of 80-proof distilled spirits).
• Eat a diet that is low in fat, particularly one that is low in saturated fat and cholesterol.
More specifically, your fat intake, which should be no more than 10 percent of your total caloric intake, should include the following:
• Less saturated fat (found in meat, full-fat dairy products, and tropical oils)
• More monounsaturated fats (found in olive oil and avocados)
• More polyunsaturated omega-3 oils (fish, walnuts, and flaxseed and canola oils)
• Fewer transfatty acids (found in hydro- genated oils)
• Eat a diet rich in a variety of fruits and veg- etables. You should strive to consume at least five servings of fruits and vegetables every day. The majority of these servings should be of fresh fruits and vegetables.
• Eat fish containing omega-3 fatty acids—par- ticularly tuna, salmon, or swordfish—at least once a week. Other good sources of these heart- protective substances are flaxseed oil, canola oil, and English walnuts.
• Maximize your intake of complex carbohy- drates and minimize your intake of simple sug- ars (white sugar, brown sugar, raw sugar, honey, and syrups). Good sources of starches include breads, cereals, pasta, rice, dry beans and peas, and starchy vegetables such as pota- toes, corn, and lima beans. Minimize white bread, rice, and potatoes.
• Maximize your intake of good sources of fiber, including whole grain breads and cereals, pasta, and vegetables and fruits with edible skins, such as apples and squash.
• Minimize intake of foods that supply mostly
“empty” calories and few necessary nutrients.
These include sugars, sweets, fats and oils, and foods high in sugars, fats and oils, and alco- holic beverages.
• Minimize your intake of salt and sodium. Be particularly careful of “hidden” sources of salt and sodium, such as deli meats and canned soups and vegetables.
During all well-woman visits, the midwife should also assess a woman’s weight-for-height sta- tus and determine if she is underweight, appropri- ate weight, or overweight. The midwife should also assess abdominal circumference and waist-to-hip ratio as explained earlier in the chapter. Blood pres- sure measurements should be checked on every woman and the midwife should inquire about di-
etary practices and exercise habits. Table 6-23 pro- vides a list of questions that can be used to elicit im- portant information regarding a woman’s nutrition and eating habits. The midwife can ask the woman to fill out a food and exercise diary for the three days to one week before her well-woman visit to fa- cilitate nutritional counseling. Midwives should also conduct nutritionally related screening tests as indicated (see the following section on screening) and determine the appropriateness of any current dietary supplementation or the need for the initia- tion of dietary supplementation.
If serious nutritional problems are detected or suspected, the midwife should refer the woman to a registered dietician or other nutrition professional who can conduct the necessary assessment and in- terventions. It may also be necessary, as in the case of profound anemias or eating disorders, to refer the woman to a physician. Midwives can also refer women as appropriate to WIC or other food pro- grams.
Screening
The Department of Health and Human Service’s Public Health Service has created the U.S.
Preventive Services Task Force (USPSTF), which conducts ongoing review of research on a variety of health conditions and concerns affecting the U.S.
population. This task force periodically issues rec- ommendations on preventive health measures, in- cluding screening to help guide clinicians who provide preventive health services to their patients.
The nutrition-related screening recommendations made by the USPSTF are summarized below.
Lipid Screening (Cholesterol and Triglycerides) The third, and most recent, USPSTF report recommends that women 45 years old or older have their choles- terol levels tested routinely. The USPSTF does not, however, specify how frequently screening should occur and leaves that to the discretion of health care providers. Midwives should determine if their clients who are 45 years old or older have had a recent (within the last five years) cholesterol screening and order one if necessary. For younger women, screen- ing is recommended if there are risk factors for heart disease, such as smoking, diabetes, high blood pres- sure, or a family history of heart disease or high cho- lesterol. In addition to obtaining a total cholesterol level (TC), the level of HDL cholesterol should also be measured. There is currently insufficient evi- dence, according to the USPSTF, to recommend for or against routinely measuring triglycerides.
Plasma Glucose The USPSTF does not make a recom- mendation for or against the routine screening for non-insulin-dependent diabetes mellitus (NIDDM) in nonpregnant, asymptomatic women. Screening for this condition is up to practitioner discretion;
nevertheless, based on the possibility of reducing the risk of complications from hyperglycemia through exercise and diet, screening those at high risk for NIDDM is probably warranted. Individuals at risk
for NIDDM include those who are obese (particu- larly obese clients older than 45), those with a strong family history of diabetes, and those who are Native American, African American, or Hispanic.
Fasting plasma glucose is considered the optimal screening test for NIDDM. The frequency of testing is up to the practitioner. The midwife should inquire if clients at risk for NIDDM have been recently screened and order a fasting plasma glucose if indi- Guideline Questions for a Nutritional Assessment
TABLE 6-23
Measure weight, height, and blood pressure and calculate BMI.
Ask the following:
1.Are you currently taking any medications or undergoing treatment for any health problem?
2.Do you smoke? If so, how much do you smoke in one day?
3.Do you drink alcohol at all? If so, how much do you drink in one day? In one week? (Use CAGE Questionnaire if appro- priate.)
4.Do you use any street drugs?
5.Do you exercise? If so, how often and for how long? What type of exercise?
6.How many meals do you eat in one day?
7.How often do you snack during the day?
8.How many times do you eat out during one week? (Include all carry-out and fast food.)
9.How many glasses of fluid do you drink in one day? How many glasses of water do you drink in one day?
10.Are you allergic to any foods? If so, what happens when you eat this particular food?
11.Are you on a diet? If so, what kind of diet? How long have you been on it and with what results?
12.Do you take any of the following:
• Multivitamins
• Calcium supplement
• Iron supplement
• Folic acid supplement
• Diet pills
• Laxatives
• Power drinks/diet drinks (such as Ensure, Slimfast, etc.)
13.Which of the following terms would you use to describe your current weight?
• High
• Just right
• Low
14.Do you or a first-degree family member (mother, father, brothers, or sisters) suffer from any of the following medical conditions?
• Hypertension (high blood pressure)
• Diabetes (high blood sugar)
• Heart disease
• Kidney disease
• Liver disease
• Anemia, sickle cell disease
• Immune disorder such as lupus or HIV infection
• Cancer
• Crohn’s disease, irritable bowel syndrome, ulcerative colitis
Ask patient to conduct a three-day diet/exercise recall by doing the following:
1.Write down everything you eat AND drink in one day including all snacks (no matter how small).
2.Write down any physical activity beyond your activities of daily living (for example, include a half-hour walk but do not include housework or walking done during your job).
cated. Screening should definitely be conducted in women who are symptomatic.
Hematocrit and Hemoglobin Routine screening of nonpregnant women for anemia is not recom- mended by the U.S. Preventive Services Task Force.
Hemoglobin and hematocrit levels should be drawn for women with signs and/or symptoms of anemia.
Bone Densitometry While the USPSTF recommends that all postmenopausal women be counseled on the risks for osteoporosis and on the importance of smoking cessation, regular exercise and adequate calcium intake, the task force has found that there is insufficient evidence to recommend for or against routine screening for osteoporosis with bone den- sitometry in postmenopausal women. Women who are at high risk for osteoporosis may desire bone densitometry to help determine whether or not to initiate estrogen prophylaxis and or other pharma- cologic interventions aimed at treating or prevent- ing osteoporosis and/or osteoporosis-related fractures.
Supplementation
There is much controversy both within and outside of the health professional community regarding the appropriateness and need for dietary supplements.
The debate over vitamin supplementation is made more complicated by the numerous studies that seem to indicate on the one hand that intake of cer- tain vitamins, minerals, or other substances in ex- cess of the recommended dietary allowance may be protective against certain diseases, and the warn- ings that megadoses of vitamins and minerals can be harmful on the other hand. Most nutrition ex- perts do seem to agree that a balanced diet com- posed of a variety of foods will provide a healthy, nonpregnant, nonlactating adult woman with all the necessary nutrients. There do appear, however, to be some exceptions to this rule, when even a healthy adult woman may need to supplement her diet. Women of reproductive age, for example, need folic acid in excess of what is consumed in the usual American diet in order to prevent certain birth de- fects in their infants. Similar cases include women who bleed excessively during menstrual periods who may need additional iron to prevent anemia and vegetarians who may need to supplement nu- trients such as calcium, iron, zinc, and vitamin B12 that are either more readily or exclusively available from animal products. Other individuals who may
need supplements are those with certain illnesses or diseases or on certain medications, like diuretics, that may deplete them of necessary nutrients.
Women who are at risk for or already suffering from osteoporosis may need to take supplemental calcium and/or vitamin D.
It is more difficult to make recommendations on supplementing a healthy, well-balanced diet in a healthy adult. As more and more studies are re- leased that suggest that certain vitamins and/or vi- tamin precursors are linked to a reduction in the risk of diseases such as cancer, women are increas- ingly likely to seek the advice of health profession- als on the need for supplementation. An increasing amount of evidence, for example, seems to suggest that intake of vitamin E in amounts far in excess of the current RDA is protective against heart disease [96]. Based in part on findings such as these, the American Medical Association (AMA) has recently recommended that all adults take one multivitamin daily. They say that this practice is justified “by the known and suspected benefits of supplemental fo- late and vitamins B12, B6, and D in preventing car- diovascular disease, cancer, and osteoporosis, and because multivitamins at that dose are safe and in- expensive” [97].
Although the passage in 1994 of the Dietary Supplement Health and Education Act has made it possible for the government to establish standards regarding dietary supplements and for persons on their own or in conjunction with a health care provider to decide whether to supplement their diet, certain factors must be kept in mind. In particular, both clients and health care providers must be care- ful to avoid overdosing. It is a common misconcep- tion that overdosing on vitamins and minerals is difficult if not impossible and that the body will simply eliminate any excess of these substances through the urine. In truth, megadoses of certain vi- tamins and minerals can be risky. For example, ex- cess intake of vitamin A during the first few months of pregnancy has been found to be associated with birth defects, excess intake of vitamin E can inter- fere with blood clotting, and very high doses of folic acid can mask symptoms of a vitamin B12 defi- ciency.
In order to properly advise women on the need for supplementation, midwives should try to keep current on changes in RDAs as well as on recom- mendations made by government agencies or by well-respected professional organizations. Midwives can also use the following guidelines in advising clients regarding dietary supplementation [98]: