Nutritional Evaluation. Eating Healthy During Pregnancy. Foodborne Illnesses. Pregnancy Goals 7/29/2014

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1 Eating Healthy During Pregnancy Erin Feldman, RD, CSP Cedars Sinai Medical Center Los Angeles Goal: Optimize maternal, fetal and infant health History Medical Help to discover habits, eating disorders and diseases which may indicate nutrition related health risks Nutritional Substance use and abuse Cigarettes, alcohol and illicit drugs may affect intake of an adequate and balanced diet Stimulants may increase energy requirement Use of vitamin, mineral or herbal supplements Vitamin A in high doses can be teratogenic and should be avoided (>10,000 IU/day) Limit liver consumption Nutrition Folic Acid Reduce risk of neural tube defects Special diets or dietary restrictions (including eating disorders) May lead to nutritional deficiencies and inadequate weight gain Food resources Financial issues that may impact the purchase, storage or preparation of adequate amounts of nutritional food WIC Physical Measurements of height, weight and calculating the body mass index BMI to determine if weight is healthy A pre pregnancy BMI of is normal Pregnancy Goals Foodborne Illnesses Appropriate weight gain Appropriate physical activity Intake of a varied diet Appropriate vitamin and mineral supplementation Avoidance of alcohol, tobacco and other harmful substances Safe food handling Can cause maternal disease, congenital disease, premature labor, miscarriage and fetal death Frequent hand washing Consume fully cooked meats, fish, poultry and eggs Avoid unpasteurized dairy products Rinse fresh fruit and vegetables under running water well before eating Avoid consuming raw sprouts (alfalfa, clover, radish, and mung bean) Bacteria gets in through cracks in the shell and it is almost impossible to wash out Sanitize countertops 1 teaspoon liquid chlorine bleach/quart of water dry for 10 minutes Wash hands, food preparation surfaces, cutting boards, dishes and utensils that come in contact with raw meat, poultry or fish with hot, soapy water 1

2 Prevent infections Pregnancy and Weight Gain Toxoplasmosis Undercooked or cured meat, soil contaminated fruit or vegetables and contaminated unfiltered water Listeria monocytogenes Processed deli meats, hot dogs, soft cheeses, smoked seafood, meat spreads and pate Brucellosis Raw milk, cheeses made from unpasteurized (raw) milk or raw meat Recommendations for singleton pregnancy (Institute of Medicine (IOM) Body Mass Index (BMI) <18.5 kg/m2 (underweight) weight gain lbs Underweight women with low weight gain during pregnancy may be at higher risk of having a low birth weight infant, preterm birth and recurrent preterm birth BMI 18.5 to 24.9 kg/m2 (normal weight) weight gain lbs BMI kg/m2 (overweight) weight gain lbs BMI >30.0 kg/m2 (obese) weight gain lbs Obese women are at increased risk of having a larger for gestational age infant, postterm birth, and other pregnancy complications High blood pressure, large baby, future problems for mother if weight is not lost Where does the weight go? Too much weight gain Baby: 8 pounds Placenta: 2 3 pounds Amniotic fluid: 2 3 pounds Breast tissue: 2 3 pounds Blood supply: 4 pounds Stored fat for delivery and breastfeeding: 5 9 pounds Larger uterus: 2 5 pounds Total: pounds Eat the appropriate portion size and avoid second helpings Choose low fat dairy products Exercise Consider swimming or walking daily Use low fat cooking methods Limit sweets and high calorie snacks Limit sweet and sugary drinks Not enough weight gain Vitamins and Minerals Eat more frequently Try eating five to six times per day Choose nutrient and calorically dense foods such as dried fruit, nuts, crackers with peanut butter and ice cream Add a little extra cheese, honey, margarine, avocado or peanut butter to the foods that you are eating Risk of deficiencies Multiple gestation, heavy smokers, adolescents, vegetarians, substance abusers and women with lactase deficiency Daily Multivitamin Iron 30mg Calcium at least 250mg Folate at least 600 mcg Other important nutrients Vitamins A, B complex, E, C, D and zinc 2

3 Calories Increase daily calories by 340/day in the second trimester and 450/day in the third trimester ( My pyramid for Mom s ) Protein Goal is 1.1 gram/kg/day (non pregnant = 0.8 gm/kg/day) Carbohydrate 175 grams/day (non pregnant = 130 grams/day) Iron Necessary for fetal and placental development Help build resistance to stress and disease, help avoid tiredness, weakness, irritability and depression Best source is heme, enhance absorption of nonheme with vitamin C rich foods Increase iron intake by 15 30mg/day Goal is 27 mg/day Food and prenatal vitamin Whole grains, lean beef and pork, dried fruit and beans, sardines and green leafy vegetables Iron deficiency anemia mg additional iron daily Nutrition Recommendations Calcium Help build strong bones and teeth, allows the blood to clot normally, nerves to function properly, and the heart to beat normally 1000mg/day (1300mg for year old girls) Same recommendation for pregnant and lactating women Dairy products, dark leafy greens, fortified cereals, breads, fish, fortified orange juice, almonds and sesame seeds Absorption increases during pregnancy Vitamin D 600IU/day Can supplement with up to 2000IU/day if deficient Fatty fish (mackerel, sardines, salmon), liver, egg yolks and fortified milk Folic Acid Used to make extra blood your body needs during pregnancy For Neural tube defect (NTD) prevention March of Dimes suggests 70% of all NTD can be avoided with appropriate folic acid intake 1 month before and 2 3 months after conception supplement with mcg/day Recommended Daily Allowance (RDA) of 600 mcg thereafter Lentils, kidney beans, green leafy vegetables (spinach, kale, romaine lettuce, broccoli), citrus fruits, nuts and beans, fortified breads, cereals, pasta, rice and flours Zinc Important for normal fetal growth Risk for deficiency Active Inflammatory Bowel Disease and acrodermatitis enteropathica Excess Supplementation Common dietary restrictions Self prescribed supplements Overuse Vitamin or mineral toxicities Iron Selenium Vitamin A (>10,000 IU/day may be teratogenic) Avoid multivitamin that contains more than 5000IU (1500mcg) ACOG recommends 770 mcg daily Leafy green vegetables, deep yellow or orange vegetables, milk and liver Vitamin D (can cause hypercalcemia) Vegetarian/Vegan May lack iron, essential amino acids, trace minerals (zinc), vitamin B 12, vitamin D and Calcium or omega 3 fatty acids Consider fortified vegetarian food products Non dairy milk, meat analogs, juices and breakfast cereals Gluten free diet Safe, but may result in inadequate intake of thiamin, riboflavin, niacin, folate and iron 3

4 Lactose intolerance Ensure adequate calcium and vitamin D intake with fortified non dairy food sources or supplements Fish intake Mercury exposure can cause severe central nervous system damage, as well as milder intellectual, motor, and psychosocial impairment. Avoid eating shark, swordfish, king mackerel or tilefish Consume up to 12 ounces/week of fish and shellfish that are lower in mercury Shrimp, canned light tuna, salmon, pollock and catfish Limit albacore tuna to 6 ounces/week Caffeine intake Limit consumption to less than mg per day to potentially reduce the risk of possible adverse reproductive effects (miscarriage, preterm birth, impaired fetal growth) Two 5 ounce cups of coffee or three 5 ounce cups of tea Artificial sweeteners Acceptable Daily Intake (ADI) amount of a food additive that can be ingested daily over a lifetime without appreciable health risk ADI for Aspartame 50mg/kg/day Diet Coke contains 131 mg aspartame per 355 ml can, 1 Equal packet contains 33mg Average intake of artificial sweeteners is usually below the ADI Unpasteurized milk and dairy products May contain pathogens that could lead to maternal, fetal, and neonatal infection, miscarriage, preterm birth and stillbirth Avoid these products Raw or undercooked meat, unwashed fruit and vegetables, cold processed meats Contamination of these food products by bacteria or parasites can lead to maternal, fetal and neonatal infection, with potentially serious consequences Herbal supplements and alternative therapies >10% of women report herbal use during pregnancy Most common products are herbal teas, chamomile, ginger, echinacea, and ephedra Avoid use No control over the strength or purity of the individual herbs; herbal preparations can interact with commonly prescribed medications and lead to dangerous side effects. Omega 3 fatty acids Nausea and vomiting of pregnancy (NVP) Hormonal shifts may be the potential cause Delayed gastric motility Small, frequent meals Avoid smells and food textures that cause nausea Bland, cold foods high in carbohydrates and low in fat are usually best tolerated Sour and tart liquids such as lemonade are often tolerated better than water Acupressure bands, ginger and special supplements ( pregipops ) and vitamin B6 supplementation DHA Helps boost brain development and vision Pregnancy RDA: 300mg Coho Salmon, farmed, 3 ounces cooked 740mg Blue crab, 3 ounces cooked 196mg Canned light tuna, drained, 3 oucnes 190mg Catfish, 3 ounces cooked 116mg Fortified eggs 85 mg 200 mg 4

5 A Healthy Meal Plan for Pregnancy Food Group Serving Size Servings per Day Grains (breads, cereals, rice, pasta) 1 ounce = 1 slice of bread, 1 cup of At least 5 ounces every day ready to eat cereal, or ½ cup of cooked rice, cooked pasta or cooked cereal Vegetables 1 cup = 1 cup of raw or cooked At least 2 ½ cups every day vegetable or vegetable juice, or 2 cups of raw leafy greens Fruits 1 cup = 1 cup of fruit or 100% fruit At least 1 ½ cups every day juice, or ½ cup of dried fruit Dairy (milk, yogurt, cheese) 1 cup = 1 cup of milk or yogurt, 1 ½ At least 3 cups every day ounces of natural cheese, or 2 ounces of processed cheese Protein (Meat, poultry, fish, meat 1 ounce = 1 ounce of meat, poultry At least 5 ounces every day subs) or fish, ¼ cup cooked dry beans, 1 egg, 1 tablespoon of peanut butter, or ½ ounce of beans, nuts or seeds Fats and Oil 1 teaspoon = 1 teaspoon oil, 1 tablespoon mayonnaise based salad dressing, 1/3 ounce of nuts, ½ tablespoon peanut butter, 1 teaspoon margarine At least 5 tablespoons every day A Healthy Meal Plan for Pregnancy Summary Sample 1 day menu Breakfast Lunch Dinner 2 cups fortified cereal 1 whole orange Hot Beverage Small bagel 1 2 ounces hard cheese Whole sandwich with 3 ounces tuna, lettuce, tomato, mayonnaise 1 cup carrot and celery sticks Fresh apple 8 ounces of fat free or 1% milk 8 ounces tomato or vegetable juice 3 4 ounces roast beef 1 cup mashed potatoes ½ cup broccoli 1 cup tossed salad with dressing Dinner roll ½ c. sliced peaches 3 graham cracker sheets 2 tablespoons peanut butter A woman s nutritional status can significantly influence fetal, infant and maternal health outcomes Avoid nutrient deficiencies take prenatal vitamins Healthy weight gain Stay physically active Follow food safety guidelines Do not diet! 5