Advanced Diploma in Nutrition
Advanced Diploma in Nutrition
Part-One: Nutrition during the pregnancy cycle
By Michelle Loughlin Registered Dietitian
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
Nutrition and Pregnancy
consequences on their child’s health of poor nutrition during pregnancy. Professionals need We all know that pregnancy is the beginning of training in both these areas so they can offer inthe life cycle and is a really exciting and special formed and practical advice on food (not just time for expecting mothers and partners. In re- nutrients). (1) ality, for most expecting mothers the pressures of feeding their children all of the right food can Up to 50% of pregnancies are likely to be unbe confusing and overall complicated. So when planned, so all women of childbearing age need progressing in your career as a nutrition advisor to be aware of the importance of a healthy diet. it is important that you are aware of how nutri- Nutritional interventions for women who aretional needs vary throughout the pregnancy cy- or who plan to become- pregnant are likely to cle. That is pre-conception, pregnancy, lactation have the greatest effect if delivered before conception and during the first 12 weeks. (1) and weaning all the way to toddlers. Women who are overweight or obese before they conceive have an increased risk of compliNutrition Pre-Conception cations during pregnancy and birth. This poses health risks for both mother and baby in the Women of child-bearing age should achieve and longer term. There is also evidence that matermaintain a good nutritional status prior to connal obesity is related to health inequalities, parception to help minimize health risks to both ticularly socioeconomic deprivation, inequalmothers and infants. Many women may not be ities within ethnic groups and poor access to aware of the importance of preconception numaternity services (1). trition and supplementation or have access to nutrition information. One of the biggest areas of pregnancy which is overlooked is that of pre-conception. However nutrition pre- conception is vitally important to the formation of a healthy foetus and can impact on nutrition down the line and so it is important to be aware of. More and more preconception nutrition research is showing that food and healthy nutrition are tied to fertility health. There are nutritional needs for both men and women. Additionally, there are nutritional things which can be consumed that can hinder fertility. It has been noted that some dietary advice given by those responsible for the care of mothers and pre-school children is not evidence-based and that information provided by health professionals is not always consistent. Confusion about national nutrition policy relating to mothers, infants and children needs to be addressed. In addition, women who are preparing for pregnancy need help to understand the long-term
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
Fertility and Body Weight “Pre-pregnancy overweight is at an all-time high. Of women who could become pregnant, 33% are considered obese (body mass index [BMI] of 30 or higher) and 62% are overweight (BMI of 25 or higher). The majority of U.S. adults are unaware of how health and lifestyle factors, including obesity, influence reproductive health and childbearing. A healthy body weight (BMI between 19.8 and 26) improves a woman’s chances of conception, while excess body fat or insufficient amounts interfere with her fertility. Evidence suggests it may be more difficult for overweight and underweight women to conceive by means of high-tech methods such as in vitro fertilization, too. In addition, overweight male partners may lengthen a couple’s time to conception. Starting pregnancy at a healthy weight translates into a lower risk of complications for mom and her baby during pregnancy and delivery, including hypertension, gestational diabetes, caesarean section, preterm labour and delivery, and stillbirth. Women who are overweight and obese at the time of conception are more likely to have a child with a structural defect, including neural tube defects. Women who are overweight are more prone to type 2 diabetes before pregnancy and run a greater risk of developing gestational diabetes. In addition, women who enter into pregnancy when overweight tend to stay overweight for the duration of their pregnancy, increasing the likelihood of complications during pregnancy and delivery.”(2) Conversely, excessive maternal weight during pregnancy is associated with large for gestational age infants, macrosomia, a higher caesarean section risk, in addition to a greater incidence of neonatal infection, hypoglycaemia and respiratory distress. Additionally, large for gestational age infants are at a greater risk of developing
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PART-ONE: Nutrition during the pregnancy cycle
childhood obesity, and hence a spectrum of metabolic complications in childhood and later life. Furthermore, rates of miscarriage are higher in obese women, as is gestational diabetes, hypertension and deep vein thrombosis (Institute of Obstetricians and Gynaecologists et al, 2011). Obese women are also at risk of small for gestational age babies in particular if they have other complications such as hypertension.
Healthy weight pre-pregnancy In a prospective study Clark et al 1998 showed that adherence to a weight loss and exercise programme by anovulatory overweight women brought about spontaneous ovulation, conception and a successful pregnancy outcome in the majority of subjects. (3) When planning a pregnancy, weight loss is advised to achieve a healthy BMI of 20-25kg/m², However consumption of an energy deficient diet immediately prior to conception or during pregnancy can disadvantage the foetus if it results in nutrient deficiencies.
Diabetes Pre-pregnancy “About 1.85 million American women aged 18 to 44 are affected by diabetes, mostly type 2, according to a 2004 National Centre for Health Statistics report. Women with either type 1 or type 2 diabetes are three times more likely to deliver a baby with a birth defect compared with those without diabetes, are more likely to miscarry, and run a greater risk of having pregnancy end in infant death, among other complications, according to a 2005 practice bulletin from the American College of Obstetricians and Gynaecologists. Macrosomia is also more common among children born to women with poorly controlled diabetes throughout pregnancy; large babies may have medical problems at birth and run a greater risk of becoming overweight and developing type 2 diabetes later in life, according to the CDC.
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Advanced Diploma in Nutrition According to the American Diabetes Association, an estimated 57 million Americans are at risk for developing diabetes because they have pre-diabetes. Elevated blood glucose concentrations prior to pregnancy may be a sign of what’s to come once conception occurs, as they often portend gestational diabetes and post-pregnancy type 2 diabetes. Pre-conceptual diabetes management has the potential to reduce the risk for pregnancy loss and congenital malformations for about 113,000 births per year, according to the CDC report. A complete blood count screens for potential problems, such as pre-diabetes, that women can head off prior to pregnancy.” (2)
Neural Tube Defects
pregnancy, often before a woman knows she’s pregnant. Although folic acid is not a guarantee that a woman will have a healthy pregnancy, taking folic acid can help reduce a woman’s risk of having a pregnancy affected by Spina bifida. Because half of all pregnancies in the United States are unplanned, it is important that all women who can become pregnant take folic acid before and during pregnancy. Spina bifida can range from mild to severe. Some people have little or no noticeable disability. Others are limited in the way they can move or function. They even might be paralyzed (unable to walk or move parts of the body). Even so, with the right care, most people affected by Spina bifida will be able to grow up to lead full and productive lives.” (4)
Neural Tube Defects refer to a group of birth de- According to the centre of disease control, each year in the United States: fects involving the spine or brain There are 3,000 pregnancies affected by Spina • Spina bifida: Occurs when a baby’s spine does bifida or anencephaly, which are neural tube denot form properly. Part of the spinal cord may fects (NTDs) caused by the incomplete closing be outside the bones of the spine (vertebrae) and of the spine and skull. is often not properly formed. This can lead to varying degrees of muscle weakness, paralysis, loss of sensation in the legs, and/or poor bladder and bowel control. Some babies with Spina bifida also develop fluid on the brain (hydrocephalus) which occasionally causes brain damage. • Anencephaly: is a neural tube defect in which the top part of the skull and brain fail to form properly. Babies with anencephaly may be miscarried, stillborn, or die shortly after birth. • Encephalocele: is another less common neural tube defect. This occurs when part of a baby’s skull does not form properly, and part of the brain is outside of the skull. Babies with this type of neural tube defect usually do not survive. Babies who do survive may have physical and mental handicaps. “Spina bifida happens in the first few weeks of
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition An estimated 1,000 more babies are born healthy birth defects. Starting today is the best option! since fortification. Dosages may need to be increased where there is a family history of neural tube defects, epilepsy 50% to 70% of these NTDs could be prevented if or diabetes. It is important to discuss the correct women took 400 mcg of folic acid daily, before dose of folic acid to be taken with your doctor. and during pregnancy. (4) Hispanic/Latina Women have the highest rate Folic acid Vs Folate among women having a child affected by these birth defects. (4) Folic acid is the synthetic form of the B vitamin folate and is approximately 1.7 times more bioRisk factors for developing Neural tube defects available than folate and therefore has a greatinclude insufficient amounts of folic acid in the er efficiency in impacting folate levels. Folic diet both pre- and post-conception, having Type acid has been added to foods such as enriched 1 diabetes and certain medications for epilepsy. breads, pastas, rice and cereal. In addition to getting 400mcg of folic acid from supplements and Importance of Folic acid fortified foods, women should be encouraged to Folic acid is a B vitamin which plays a key role eat a diet rich in folate. As it is a water soluble in the prevention of neural tube defects during vitamin, you can’t store it and should therefore pregnancy. All women, but especially those who aim to eat folate rich foods on a daily basis. want to become pregnant, need 400 micrograms (mcg) of folic acid every day. Birth defects of the Folate Content of Some Common brain and spine (anencephaly and Spina bifiFoods da) happen in the first few weeks of pregnancy, often before a woman finds out she’s pregnant. Dark green vegetables like broccoli and spinAlso, half of all pregnancies in the United States ach and dried legumes such as chickpeas, beans are unplanned. These are two reasons why it is and lentils are naturally good sources of folate. important for all women who can get pregnant In Canada, folic acid is added to all white flour, to be sure to get 400 mcg of folic acid every day, enriched pasta and cornmeal products. even if they aren’t planning a pregnancy any time soon. By the time a woman realizes she’s The following table will show you which foods pregnant, it might be too late to prevent these are sources of folate. Vegetables
Food
Edamame/baby soybeans cooked Okra, frozen, cooked Spinach, cooked Artichoke, cooked Turnip greens, collards, cooked Broccoli, cooked Asparagus, cooked Brussels sprouts, frozen, cooked Lettuce, (Romaine, mesclun) Escarole or endive, raw Beets, cooked Potato, with skin, cooked
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Serving size 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 4 spears 6 sprouts 250 mL (1 cup) 250 mL (1 cup) 125 mL (½ cup) 1 medium
PART-ONE: Nutrition during the pregnancy cycle
Folate (mcg) 106-255 142 121-139 79-106 68-93 89 80-88 83 65-80 75 72 48-66
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Advanced Diploma in Nutrition Spinach, raw
250 mL (1 cup)
61
Avocado Papaya Orange juice
½ fruit ½ fruit 125 mL (½ cup)
81 58 58
Pasta, egg noodles, enriched, cooked Pasta, white, enriched, cooked Bagel, plain Bread, white Bread, whole wheat
125 mL (½ cup) 125 mL (½ cup) ½ bagel (45 g) 1 slice (35 g) 1 slice (35 g) This food group contains very little of this nutrient
138 83-113 101 60 18
Beans, cranberry/roman, cooked Lentils, cooked Peas (chickpeas, black-eyed, pigeon) cooked Beans (mung, adzuki), cooked Beans (pink, pinto, navy, black, white, kidney, great northern), cooked Sunflower seeds, without shell Meatless (fish sticks, meatball, chicken), cooked Soy burger/vegetarian meatloaf or patty, cooked Soy nuts
175 mL (¾ cup) 175 mL (¾ cup) 175 mL (¾ cup)
271 265 138-263
175 mL (¾ cup) 175 mL (¾ cup)
234-238 157-218
60 mL (¼ cup) 75 g (2 ½ oz)
77-81 59-77
75 g (2 ½ oz)
59
60 mL (¼ cup)
59
Liver (turkey, chicken), cooked Liver (lamb, veal), cooked Liver (beef, pork), cooked
75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz)
420-518 262-300 122-195
Yeast extract spread (vegemite or marmite)
30 ml (2 Tbsp)
371
Fruits
Grain Products
Milk and Alternatives Meat Alternatives
Organ Meats
Miscellaneous
Source: “Canadian Nutrient File 2010” www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php
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Calcium pre-pregnancy
Iron pre-conception
• 1,000mg/day if considering getting pregnant Preparing for pregnancy includes building healthy bones. If there is not enough calcium in the pregnancy diet, the foetus may draw calcium from the mother’s bones, which can put women at risk for osteoporosis later in life. Three servings of milk or other dairy products each day equals about 1,000 milligrams of calcium.
Research suggests that iron stores at the time of conception are a strong indicator of a woman’s risk for iron-deficiency anaemia later in pregnancy, when iron needs to be increased dramatically. Iron deficiency during pregnancy may raise the risk for preterm delivery. Testing blood levels of ferritin, a reflection of stored iron in the body, is the best way to determine iron-deficiency anaemia. (2)
PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
Food Sources of Iron Information about Iron
• Iron is a mineral that is important for good health. • Iron carries oxygen to all parts of your body. • Low iron levels can leave you tired, pale-looking and irritable. How much Iron Should I Aim For?
Aim for an intake of *milligrams (mg)/day
Age in Years Men 19 and older Women 19-50 Women 51 and older Pregnant women 19-50 Breastfeeding women 19-50
8 18 8 27 9
Stay below* mg/day 45 45 45 45 45
*This includes sources of iron from food and supplements.
Vegetarians need almost twice the daily recommended amount of iron compared with non-vegetarians. Iron from plant-based foods is not absorbed as well by our bodies as animal food sources.
Iron Content of Some Common Foods You can find iron in both animal and plant foods. • Animal sources (called “heme iron”) include meat, fish and poultry. Our bodies easily absorb this type of iron. • Plant sources (called “non-heme iron”) include dried beans, peas and lentils and some fruits and vegetables. • In Canada, grain products like flour, pasta and breakfast cereals are fortified with iron. Our bodies better absorb this type of iron when taken along with meat/chicken/fish or a source of vitamin C. Vitamin C rich foods include citrus fruits and juices, cantaloupe, strawberries, broccoli, tomatoes and peppers.
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition The following table will show you which foods are sources of iron.
Food
Vegetables and Fruits Spinach, cooked Tomato puree Edamame/baby soybeans, cooked Lima beans, cooked Asparagus, raw Hearts of palm, canned Potato, with skin, cooked Snow peas, cooked Turnip or beet greens, cooked Prune juice Apricots, dried Beets, canned Kale, cooked Green peas, cooked Tomato sauce Grains Products Oatmeal, instant , cooked Cream of wheat, all types, cooked Cereal, dry, all types Granola bar, oat, fruits and nut Cracker, soda Oat bran cereal, cooked Pasta, egg noodles, enriched, cooked Milk and Alternatives Yogurt, soy Meats and Alternatives Duck, cooked Moose or venison, cooked Beef, various cuts, cooked Ground meat (beef, lamb), cooked Lamb, various cuts, cooked Chicken, various cuts, cooked Pork, various cuts, cooked Ground meat (turkey, chicken, pork), cooked Turkey, various cuts, cooked Organ Meats Liver, pork ,cooked* Liver (chicken, turkey, lamb), cooked* Kidney, lamb, cooked Liver, beef ,cooked* Kidney (beef, veal, pork), cooked Fish and Seafood Octopus, cooked Oysters, cooked
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Serving size
Iron (mg)
125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 6 spears 125 mL (½ cup) 1 medium 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 60 mL (¼ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup)
2.0-3.4 2.4 1.9-2.4 2.2 2.1 2.0 1.3-1.9 1.7 1.5-1.7 1.6 1.6 1.6 1.3 1.3 1.3
175 mL (¾ cup) 175 mL (¾ cup) 30 g (check product label for serving size) 1 bar (32 g) 6 crackers 175 mL (¾ cup) 125 mL (½ cup)
4.5-6.6 5.7-5.8 4.0-4.3 1.2-2.7 1.5-2.3 2.0 1.3
175 mL (¾ cup)
2.0
75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz)
1.8- 7.4 2.5-3.8 1.4-3.3 1.3-2.2 1.3-2.1 0.4-2.0 0.5-1.5
75 g (2 ½ oz)
0.8-1.2
75 g (2 ½ oz)
0.3-0.8
75 g (2 ½ oz)
13.4
75 g (2 ½ oz)
6.2-9.7
75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz)
9.3 4.9 2.3-4.4
75 g (2 ½ oz) 75 g (2 ½ oz)
7.2 3.3-9.0
PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition Seafood (shrimp, scallops, crab), cooked Sardines, canned Clams, canned Fish (mackerel, trout, bass), cooked Tuna, light, canned in water Meat Alternatives Tofu, cooked Soybeans, mature, cooked Lentils, cooked Beans (white, kidney, navy, pinto, black, roman/cranberry, adzuki), cooked Pumpkin or squash seeds, roasted Peas (chickpeas/garbanzo, blackeyed, split), cooked Tempeh/fermented soy product, cooked Meatless (sausage, chicken, meatballs, fish sticks), cooked Baked beans, canned Nuts (cashews, almonds, hazelnuts, macadamia, pistachio nuts), without shell Eggs, cooked Sesame seeds, roasted Meatless, luncheon slices Hummus Almond butter Miscellaneous Blackstrap molasses Yeast extract spread (marmite or vegemite)
75 g (2 ½ oz)
2.2-2.3
75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz) 75 g (2 ½ oz)
1.7-2.2 2.0 1.4-1.7 1.2
150 g (¾ cup) 175 mL (¾ cup) 175 mL (¾ cup)
2.4-8.0 6.5 4.1-4.9
175 mL (¾ cup)
2.6-4.9
60 mL (¼ cup)
1.4-4.7
175 mL (¾ cup)
1.9-3.5
150 g (3/4 cup)
3.2
75 g (2.5 oz)
1.5-2.8
175 mL (¾ cup)
2.2
60 ml (¼ cup)
1.3-2.2
2 large 15 mL (1 Tbsp) 75 g (2.5 oz) 60 mL (¼ cup) 30 mL (2 Tbsp)
1.2-1.8 1.4 1.4 1.4 1.2
15 mL (1 Tbsp) 30 mL (2 Tbsp)
3.6 1.4
*Pregnant women should limit intake of liver to one serving every two weeks. Source: “Canadian Nutrient File 2010” www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php
Caffeine pre-pregnancy Caffeine is a mildly addictive stimulant which is found naturally occurring in foods and drinks such as coffee, tea and cocoa. Caffeine is also used as an additive in soft drinks, energy drinks, some chewing gums and medications. It is therefore possible that pregnant and lactating women may consume caffeine from multiple sources. If planning a pregnancy it is a good time to begin to wean yourself off caffeine as it is not advisable during pregnancy. 200-300mg caffeine/day may reduce fertility. Caffeine can also affect the
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PART-ONE: Nutrition during the pregnancy cycle
body’s ability to absorb nutrients such as iron and calcium. The table below outlines the caffeine content of beverages and foods that are the common sources of caffeine in the Irish diet. From this table the daily limit of 200mg of caffeine can still include as much as one cup of brewed coffee and two cups of tea per day.
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Advanced Diploma in Nutrition Food or Drink
Coffee, brewed Coffee, instant Coffee, decaffeinated Espresso Tea, brewed Snapple (fruit ad diet versions) Pepsi Pepsi Max Diet Coke Coke Caffeine-free Coke 7-up (diet and regular) Red Bull Hot cocoa Milk chocolate Dark chocolate Coffee flavoured ice-cream
Portion Size
1 cup 1 cup 1 cup 1 shot 1 cup 1 bottle (480ml) 1 bottle (500ml) 1 bottle (500ml) 1 bottle (500ml) 1 bottle (500ml) 1 bottle (500ml) 1 bottle (500ml) 1 can (250ml) 1 cup 1 bar 1 bar 1 scoop
Information adapted from the Centre for Science in the Public Interest The exact amount of caffeine will vary according to cup size, brewing methods and brand of tea or coffee. 1 cup =200ml; 1 shot=30ml;1 bar=45g;1 scoop=60g *taken from the food Safety Authority Ireland (5)
Caffeine Content (mg)
111mg (range 102-200mg) 78mg (range 27-173mg) 4mg (range 3-12mg) 40mg (range 30-90mg) 44mg (range 40-120mg) 42mg 32mg 30mg 64mg 48mg 0mg 0mg 80mg 8mg 11mg 31mg 16mg (range 15-17mg)
Alcohol and Fertility A study by Jensen et al 1998 showed that a woman’s alcohol intake is associated with decreased fertility, even among women with a weekly alcohol intake corresponding to five or fewer units. The effects of alcohol consumption during the pre-conception period on the outcome of pregnancy are unknown. The Food standards agency recommend that women trying to conceive should consume no more than 1-2 units of alcohol per week. Alcohol is particularly problematic during the first trimester, when cell differentiation is taking place and organs are developing at a rapid pace. Alcohol is capable of causing irreversible harm to a developing foetus through the deprivation of oxygen and nutrients necessary for normal development. (2)
Exercise Pre-Pregnancy Regular exercise before pregnancy is beneficial to both mother and baby. Researchers at the University of Washington surveyed 688 mothers and found that those who performed the most vigorous exercise in the year before pregnancy were 81% less likely to develop gestational diabetes, a condition linked to abnormally large babies and difficult labour, than their sedentary
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition peers, while moderate exercisers had a 59% lower risk. The benefit held up even when the mother was overweight. A study published in 2002 in the Maternal and Child Health Journal found that a group of physically active women had a 30% to 50% lower risk for pregnancies affected by neural tube defects, even when they did not take multivitamins prior to conception and irrespective of their weight. According to the Dietary Guidelines for Americans, adults require a minimum of 30 minutes of exercise on most days for weight maintenance (provided calorie intake is in line with calories burned), 60 minutes on most days to manage body weight and prevent gradual weight gain, and 60 to 90 minutes to maintain weight loss.
Male Fertility Unfortunately the effects of diet in men pre-conception are poorly researched. Most studies have been carried out on animals and the relevance to humans are unclear. It is hard to pinpoint one factor that causes infertility as confounding factors related to lifestyle such as smoking, alcohol and diet and socioeconomic status may effect sperm quality, fertility or pregnancy outcomes. General nutritional guidelines such as obtaining a healthy weight, eating a balanced diet and limiting alcohol intake may have a beneficial effect on fertility.
Nutrition Guidelines When Planning a Pregnancy 1. Eat a well-balanced diet 2. Supplement diet with 400mcg folic acid 3. Eat fish twice weekly, one oily fish 4. Limit alcohol to 1-2 units/week 5. Eat plentiful iron and calcium (3)
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PART-ONE: Nutrition during the pregnancy cycle
Nutrition during Pregnancy The extra nutritional requirements imposed by pregnancy must be met by dietary intake and body stores. Foetal growth depends on the health and nutritional status of the mother before conception, the degree of energy demands placed on her during pregnancy and the growth, energy and nutrient demands of the products of conception at different stages of gestation, but it is worth remembering that there are a number of ways in which the nutrient supply to the foetus may be regulated. Evidence is definitely conflicting but there is some research to suggest that nutrient intake of mothers during early and late pregnancy influence placental and foetal growth can be detrimental to the foetus in later life. (3) Optimal nutrition should be obtained to ensure proper nutrition for mother and baby. Nutrition during pregnancy effects not only foetal development, but also the risk of chronic diseases for that infant in adulthood. Poor in utero nutrition can increase adult risk of cardiovascular disease, high blood pressure, obesity and metabolic syndrome. Even babies with seemingly normal birth weight have increased risk of cardiac death in later life if malnourished in utero (1). Maternal diet can influence the type of foetal adipose tissue, which may explain the baby’s risk of developing insulin resistance and subsequent diabetes in later life. The fuel-mediated in utero hypothesis suggests that increased glucose and lipid intake during pregnancy results in obesity in later life for the baby. Some studies suggest that bad nutrition during pregnancy can lead to health conditions in later life such as: • CVD • Hypertension • Obesity • Type 2 diabetes • Some cancers
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Advanced Diploma in Nutrition It is thought to be due to impaired uterine growth and development. If this impairment occurs at a critical period, it will have a permanent adverse effect on the structure, physiology and function of a range of foetal organs and tissues. An increased risk of CVD and other degenerative diseases has been associated with foetal growth restriction, but it is unlikely that in healthy, well-nourished women any dietary modification during pregnancy can prevent low birth weight or the risk of degenerative diseases in later life. (3)
that these women are prescribed a higher dose folic acid to be given with prescription (4000micrograms / 4 milligrams) (HSE, 2010). Care should be taken when placing women on this higher dose of folic acid due to increased risk of colorectal adenomas with prolonged high dose intake (Cole BF et al, 2007; Fife J et al, 2009) for women taking anti-seizure medication the requirement for folic acid may be different and they should be advised to consult their doctor (FSAI, 2011). GPs should prescribe 5 milligrams of folic acid a day for women who are planning a pregnancy, or are in the early stages of pregnancy, if they: • (or their partner) have a neural tube defect • Have had a previous baby with a neural tube defect • (or their partner) have a family history of neural tube defects • Have diabetes. (Reference- http://www.nice.org.uk/guidance/PH11/chapter/4-Recommendations)
Folic acid requirements are increased in pregnancy because of the rapidly dividing cells in the foetus and elevated urine losses. The neural tube usually closes by day 28 of pregnancy. (6)
Vitamin A and Pregnancy Folic Acid during Pregnancy A daily supplement of 400 micrograms (400µg/0.4mg) folic acid as recommended prior to conception and for the first 12 weeks of pregnancy, There is evidence to support the supplementation of obese women with a higher dose of folic acid (CMACE, 2010; Institute of Obstetricians and Gynaecologists et al, 2011) as the incidence of congenital malformations, including NTDs, are higher in obese women compared with normal weight women (Rasmussen et al, 2008). Currently the HSE recommends
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“Vitamin A is essential for normal maintenance and functioning of body tissues, and for growth and development, including during pregnancy when the foetus makes demands on the mother’s vitamin A stores, and during the postpartum period when the new-born is growing rapidly. Although the increased requirement during pregnancy is relatively small, in many countries where vitamin A deficiency (VAD) is endemic, women often experience deficiency symptoms such as night blindness that continue during the early period of lactation Providing a diet adequate in vitamin A-neither too little nor too much-is the safest solution to
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Advanced Diploma in Nutrition meeting needs during pregnancy and lactation. The Organization currently recommends that the relatively small increased need for vitamin A during pregnancy should be met through diet, or through a supplement not exceeding 10 000 IU daily throughout pregnancy. Where habitual vitamin A intakes exceed at least three times the RDA (about 8000 IU or 2400 pg RE), there is no demonstrated benefit from taking a supplement. On the contrary, the potential risk of adverse effects increases with higher intakes-above about 10 000 IU-if supplements are routinely ingested.” (WHO) (7) Although normal foetal development requires sufficient vitamin A intake, very high of preformed vitamin A (retinoic acid) supplementation has been associated with miscarriage and birth defects and affect the central nervous system and craniofacial, cardiovascular and thymus development.
observational data in the USA are widely used as a guide and evidence suggests that women who gain weight within these ranges have better outcomes (1) Recommendations usually based on pre-pregnancy BMI (Institute of Medicine 1990)
Pre-pregnancy BMI >26 19.8-26 <19.8
Healthy weight gain <11.5kg 11.5-16kg 17-18kg
The USA guidelines are slightly different and recommend: • 1-4lbs weight gain during 1st 3 months • 2-4lbs per month during 4th-9th month (2nd and 3rd trimester) • Those with normal BMI gain 25-35pounds in total.
Guidance level for safe intake of retinol = Both gaining too much weight and too little 1000ug RE/day (WHO, 1998) weight can be detrimental to baby. There is no NB Synthetic derivatives such as etretinate and isotretinoin (Accutane) are known to cause serious birth defects and should not be taken during pregnancy. Isotretinoin an analogue of retinol used for the treatment of acne has been associated with miscarriage and congenital malformations. Because isotretinoin is mainly prescribed to teenagers and pregnancies are more likely to be unplanned at this age, the risk of giving birth to offspring with congenital malformations may be increased. In recent years there has been significant concern at the dramatic rise in the vitamin A content of animal liver.
Weight Gain during Pregnancy There is no international consensus on appropriate weight gain per weight category in pregnancy (Alavi et al, 2013, NICE 2010). However, in the absence of such data the institute of medicine guidelines (2009) which are based on
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PART-ONE: Nutrition during the pregnancy cycle
need to eat for 2. The World Health Organisation recommend that women eat an extra 200calories-300calories a day in the third trimester. The European Food Safety Authority recommend, based on a well-nourished woman with a normal BMI, an additional 70kcal per day in the 1st trimester, 260 kcal extra per day in the second and 500kcal a day in the third trimester (EFSA, 2013). Adequate energy intake is essential to promote optimal growth of the foetus while providing adequate energy for the mother. Inadequate maternal energy intake will result in reduced maternal weight gain during pregnancy, which in turn may result in restricted foetal growth and later infant development. Inadequate weight gain during pregnancy is associated with small for gestational age infants and preterm delivery (1) conversely, excessive maternal weight during pregnancy is associated with large for gestational age infants, macrosomia, a higher caesarean
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Advanced Diploma in Nutrition
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition section risk, in addition to a greater incidence of Particular attention should be paid to women neonatal infection, hypoglycaemia and respira- who are at risk of inadequate protein intake or tory distress. suboptimal protein choices. Women who have experienced nausea or vomiting of pregnancy WHO estimate total energy cost of pregnancy are likely to have reduced their intake of proas 76,500Kcal (FAO/WHO/UNU 2004) tein rich foods due to aversions resulting from vomiting in early pregnancy. Vegetarian womHealthy Eating during Pregnancy en should be encouraged to consume adequate protein sources during pregnancy by increasing Pregnant women should be advised to follow their intake of foods rich in protein including the recommendations of the food pyramid. beans, lentils, chick peas, tofu, dairy products Irish studies have shown that less than 50% of and eggs. Vegetarian women should be advised pregnant women meet the recommendations on the importance of adequate protein sources for each individual group of the food pyramid to ensure optimal intake of essential amino ac(Oâ&#x20AC;&#x2122;Neill et al, 2011) and less than 1% of the ids, for example combining cereals and legumes national population meet requirements for all in a meal. The adequacy of dietary iron intake groups (SLAN, 2008). Within the Irish popula- should also be addressed within this group. tion, there is over consumption of foods at the Women following a vegan diet may need dietettop of the food pyramid where guidelines rec- ic review to ensure nutritional adequacy. (3) ommend 1 or less servings a day (SLAN, 2008).
Protein- 2 servings/day
Fat
Dietary fat is an important energy source, and Protein is needed for the development of a healthy provides and aids in the absorption of fat solubaby and forms the structural basis for all new cells ble vitamins. However, high fat diets should be and tissues in the mother and foetus. avoided during pregnancy due to the risk of excessive weight gain (FSAI, 2011). Most women will meet their requirements for protein as the typical population intakes are adDHA equate for pregnancy with two servings of protein a day. The European Food Safety Authority (EFSA) recommends that all pregnant women should consume an additional 700-1400mg/week of DHA (EFSA, 2010). This is in addition to the requirement of 1750mg/week combined EPA and DHA. This increased intake can be achieved by consuming 1-2 portions of oil-rich fish per week (FSAI, 2011). The best sources of DHA are trout, salmon, mackerel, arctic char and sardines (FSAI, 2011).
What about mercury? Certain types of fish can be a source of environmental contaminants such as methyl mercury. High levels of methyl mercury may be harmful
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition to the developing foetus. Therefore pregnant women should avoid the consumption of marlin, shark, ray and swordfish and limit consumption of tuna to one serving of fresh tuna (150g), or two 240g cans of tinned tuna per week. (8)
Iron The evidence surrounding iron requirements during pregnancy are not consistent. Some studies have shown the benefit of taking supplements, whereas other studies have suggested that the extra iron which is needed during pregnancy can be achieved through diet alone.
WHO recommend 30-60mg of elemental iron/day from beginning of pregnancy (9)
This is a matter which will need to be discussed on an individual basis and in conjunction with a doctor. Iron supplements may be unnecessary in all pregnant women and can cause constipation. However, Low iron stores before pregnancy are a risk for developing iron deficiency anaemia. It is estimated that 41.8% of pregnant women worldwide are anaemic. At least half of this anaemia burden is assumed to be due to iron deficiency. A pregnant woman is considered to be anaemic if her haemoglobin concentration during the first and third trimester of gestation is lower than 110 g/L, at sea level; in the second trimester of pregnancy, the haemoglobin concentration usually decreases by approximately 5 g/L (3). When anaemia is accompanied by an indication of iron deficiency (e.g. low ferritin levels), it is referred as iron deficiency anaemia. (10) Note: Despite its high iron content, it is important to advise pregnant woman that liver is not recommended due to its high vitamin A content. â&#x20AC;&#x153;The developing foetus requires a large red blood cell mass to provide sufficient oxygen for development and growth. There is a positive association with its intake and birth weight (Alwan et al, 2011). Iron requirements increase
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PART-ONE: Nutrition during the pregnancy cycle
progressively after 25 weeks to combat the lower oxygen environment in the womb (Dewey and Chaparro, 2007). Late cord clamping at delivery can reduce the risk of infantile anaemia (Chaparro et al, 2006). However, it remains vital that the iron intakes of the mother are sufficient throughout pregnancy to meet the increased requirement for fetal growth (Health Canada, 2009), while maintaining adequate maternal stores. Appropriate use of supplementation and iron rich diet has the potential of reducing incidence of anaemia in pregnancy and subsequent adverse outcomes (Barroso et al, 2011) therefore the threshold for iron supplementation in pregnancy should be low.â&#x20AC;? (3) See pre- conception for iron sources in the diet
Calcium3 servings calcium rich food/day Calcium is the most abundant mineral in the body and is essential for many diverse processes, including bone formation, muscle contraction, and enzyme and hormone functioning. Most of the bodyâ&#x20AC;&#x2122;s calcium is found in the bones and teeth; approximately 1% is present in the intracellular structures, cell membrane and extracellular fluids (8). Calcium absorption increases during pregnancy. A dietary intake of 1200 mg/ day of calcium for pregnant women is recommended by WHO and the Food and Agriculture Organization of the United Nations (FAO). Inadequate consumption of this nutrient by pregnant women can lead to adverse effects in both the mother and the foetus, including osteopenia, tremor, paraesthesia, muscle cramping, tetanus, delayed foetal growth, low birth weight and poor foetal mineralization. Various studies have suggested that calcium supplementation during pregnancy has a beneficial effect on reducing the risk of pregnancy-induced hypertension. Excessive consumption of calcium may increase the risk of urinary stones and urinary tract infection, and reduce the absorption of other essential micronutrients
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Age in Years Men and Women 19-50 Women 51-70 Men 51-70 Men and Women 71 and older Pregnant and Breastfeeding Women 19 and older
Aim for an intake of milligrams (mg)/day
Stay below * mg/day
1000 1200 1000 1200
2500 2000 2000 2000
1200
2500
*This includes sources of calcium from food and supplements.
Calcium Content of Some Common Foods Milk and milk alternatives are excellent sources of calcium. If you do not include milk or milk alternatives in your diet, there are other foods which contain calcium as well. This table will show you which foods are a source of calcium.
Vegetables
Food
Calcium (mg)
Collards, frozen, cooked Spinach, frozen, cooked Collards, cooked Turnip greens, frozen, cooked Spinach, cooked Turnip greens, cooked Kale, frozen, cooked
125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup) 125 mL (½ cup)
189 154 141 132 129 104 95
Orange juice, fortified with calcium
125 mL (½ cup) This food group contains very little of this nutrient.
155
250 mL (1 cup) 250 mL (1 cup)
370 321-324
250 mL (1 cup)
291-322
24 g (4 Tbsp) of powder will make 250mL of milk
302
Fruit
Grains Products
Milk and Alternatives
Buttermilk Soy beverage, fortified with calcium 3.3% homo, 2%, 1%, skim, chocolate milk Dry powdered milk
Cheese
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Serving Size
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Advanced Diploma in Nutrition Gruyere, swiss, goat, low fat cheddar, mozzarella Processed cheese slices (swiss, cheddar, low fat swiss or cheddar) Cheddar, colby, edam, gouda, mozzarella, blue Ricotta cheese Cottage cheese
Miscellaneous
Yogurt, plain Yogurt, fruit bottom Yogurt, soy Yogurt beverage Kefir
Fish and Seafood
Sardines, Atlantic, canned in oil, with bones Salmon (pink/humpback, red/sockeye), canned, with bones Mackerel, canned Sardines, Pacific, canned in tomato sauce, with bones Anchovies, canned
Meat Alternatives
Tofu, prepared with calcium sulfate Beans (white, navy), canned or cooked Tahini/sesame seed butter Baked beans, canned Almonds, dry roasted, unblanched
Other Goat's milk or rice beverage, fortified with calcium Blackstrap molasses
50 g (1½ oz)
396-506
50 g (1½ oz)
276-386
50 g (1½ oz)
252-366
125 mL (½ cup) 250 mL (1 cup)
269-356 146-217
175 g (¾ cup) 175 g (¾ cup) 175 g (¾ cup) 200 mL 175 g (¾ cup)
292-332 221-291 206 190 187
75 g (2 ½ oz)
286
75 g (2 ½ oz)
179-208
75 g (2 ½ oz)
181
75 g (2 ½ oz)
180
75 g (2 ½ oz)
174
150 g (¾ cup)
234-347
175 mL (¾ cup)
93-141
30 mL (2 Tbsp) 175 mL (¾ cup) 60 mL (¼ cup)
130 89-105 93
250 mL (1 cup)
319-345
15 mL (1 Tbsp.)
179
Source: “Canadian Nutrient File 2010”. www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php
Vitamin D and Pregnancy Vitamin D supplementation is not recommended during in pregnancy to prevent the development of Pre-eclampsia and its complications. In addition, due to the limited evidence currently available to directly assess the benefits and harms of the use of vitamin D supplementation alone in pregnancy for improving maternal and infant health outcomes, the use of this intervention during pregnancy as part of routine antenatal care is also not recommended. In cases of
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PART-ONE: Nutrition during the pregnancy cycle
documented deficiency, vitamin D supplements may be given at the current RNI (5 μg (200 IU) per day as recommended by WHO/FAO (37) or according to national guidelines). Vitamin D may be given alone or as part of a multiple micronutrient supplement, to improve maternal serum vitamin D concentrations. The benefit of this intervention for other maternal or birth outcomes remains unclear. (12) Dietary sources of vitamin D include both food and dietary supplements. Vitamin D occurs naturally in oily fish such as salmon, mackerel and herring, cod liver oil, and egg yolk.
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Advanced Diploma in Nutrition There is no evidence that vitamin D supplements at the doses recommended, in addition to what is normally consumed in the diet, are harmful. (11)
Morning Sickness
• Eat slowly, drink fluids between meals rather than with meals • Eat small frequent meals, do not eat large meals before bedtime • Sleep well propped up, not lying flat
Gestational Diabetes
About 70% of women suffer from sickness, usually in early pregnancy. It usually disappears by “Pregnant women who have never had diabetes the end of 4th month. before but who have high blood glucose (sugar) To relieve symptoms try: levels during pregnancy are said to have gestational diabetes. According to a 2014 analysis by • Eat small and frequent meals the Centres for Disease Control and Prevention, • Avoid strong smells or flavours the prevalence of gestational diabetes is as high • Try dry toast, crackers, breakfast cereals, fruit, as 9.2%. veg throughout day • Eat less fatty and sugary foods We don’t know what causes gestational diabetes, but we have some clues. The placenta supports the baby as it grows. Hormones from the Constipation and Pregnancy placenta help the baby develop. But these hor35-40% of women suffer from constipation mones also block the action of the mother’s insulin in her body. This problem is called insulin during pregnancy. resistance. Insulin resistance makes it hard for Relieve by: the mother’s body to use insulin. She may need up to three times as much insulin. • Increasing fluid- 6-8 cups/day • Increase fibre intake • Stop iron supplements
Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose Heartburn: cannot leave the blood and be changed to energy. Glucose builds up in the blood to high levels. • Symptoms usually get worse at the end of preg- This is called hyperglycaemia. nancy Gestational diabetes affects the mother in • 30-50% of pregnant women suffer from heart late pregnancy, after the baby’s body has been burn formed, but while the baby is busy growing. Because of this, gestational diabetes does not cause Relieve by: the kinds of birth defects sometimes seen in babies whose mothers had diabetes before preg• Avoid chocolate, fatty foods, alcohol and mint, nancy. especially before bedtime - they tend to relax oesophageal muscle so that acid from the stomach However, untreated or poorly controlled gestaregurgitates up into the oesophagus more easily tional diabetes can hurt your baby. When you • Avoid acidic and spicy foods that may irritate have gestational diabetes, your pancreas works mucosa (tomato, citrus fruits and juices, vine- overtime to produce insulin, but the insulin gar, hot pepper, etc.) does not lower your blood glucose levels. Al• Milk and dairy products can temporarily re- though insulin does not cross the placenta, glulieve the symptoms of heartburn
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition cose and other nutrients do. So extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby’s pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat. This can lead to macrosomia, or a “fat” baby. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth. Because of the extra insulin made by the baby’s pancreas, new-borns may have very low blood glucose levels at birth and are also at higher risk for breathing problems. Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.” (13)
Breastfeeding- Benefits Colostrum is the first milk your breasts produce during pregnancy. Most mothers don’t even know it’s there unless they leak a bit toward the end of the pregnancy. Your body starts making it about three to four months into pregnancy, and it may leak from your breasts while you’re pregnant.
What colostrum lacks in volume it makes up for in power. Some people refer to colostrum as “high octane” milk. It’s full of antibodies and immunoglobulins, which not only help protect new-borns as they come into our world of bacteria and viruses, but also has a laxative effect that helps them expel the tarry first stools called meconium. When you feed your baby colostrum, which may appear as clear fluid or be a deep golden colour, it’s as though you’re giving him his first vaccination. Someone once estimated that if human colostrum could be commercially manufactured with all the same antibodies and immunoglobulins in it, it would cost somewhere around $80 an ounce. Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is recommended by WHO as the perfect food for the new-born, and feeding should be initiated within the first hour after birth. Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.
Facts (WHO) 1. If every child was breastfed within an hour of birth, given only breast milk for their first six months of life, and continued breastfeeding up to the age of two years, about 800 000 child lives would be saved every year (WHO) 2. Globally, less than 40% of infants under six months of age are exclusively breastfed 3. WHO recommends exclusive breastfeeding for the first six months of life 4.Breast milk is the ideal food for new-borns
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition and infants. It gives infants all the nutrients they need for healthy development. It is safe and contains antibodies that help protect infants from common childhood illnesses such as diarrhoea and pneumonia, the two primary causes of child mortality worldwide. Breast milk is readily available and affordable, which helps to ensure that infants get adequate nutrition.
• Pregnancy uses up your iron stores. During breastfeeding, you need to rebuild your iron stores with iron-rich foods • Increased need for folate, Vit A and Vit C
Breastfeeding and Weight Loss
• Breastfeeding may make it easier to lose weight because you are using extra calories to feed your 5. Breastfeeding also benefits mothers. Exclu- infant sive breastfeeding is associated with a natural • Women who breastfeed exclusively for more (though not fail-safe) method of birth control than 3 months tend to lose more weight than (98% protection in the first six months after those who do not birth). It reduces risks of breast and ovarian • Those who continue breastfeeding beyond 4-6 cancer later in life, helps women return to their months may continue to lose weight pre-pregnancy weight faster, and lowers rates of obesity. Be patient and allow time to lose the extra weight. Follow a balanced diet and exercise reg6. Beyond the immediate benefits for children, ularly. breastfeeding contributes to a lifetime of good health. Adolescents and adults who were breast- Weight Monitoring of Baby fed as babies are less likely to be overweight or obese. They are less likely to have type-2 diabe- As a minimum, ensure babies are weighed at tes and perform better in intelligence tests. birth and in the first week, as part of an overall assessment of feeding. Thereafter, healthy babies 7. Why not infant formula? should usually be weighed at 8, 12 and 16 weeks Infant formula does not contain the antibodies and at 1 year, at the time of routine immunisafound in breast milk. tions. If there is concern, weigh more often, but (Taken from the World Health Organisation) no more than once a month up to 6 months of age, once every 2 months from 6–12 months of Nutrition Requirements When age and once every 3 months over the age of 1 year.
Breastfeeding
• Increased fluid requirements-feel thirstier, try drinking a glass of water every time you breastfeed • Limit caffeine as it passes through the milk to baby- 2to 3 cups a day should be ok • Alcohol- do not drink alcohol until your baby has a regular breastfeeding pattern • Wait at least 4 hours after a single alcoholic drink before breastfeeding • Or, express breast milk before having a drink • You need around four serves of calcium-rich foods daily to protect your bone strength. Calcium is another major ingredient in breast milk
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Ensure infants are weighed using digital scales which are maintained and calibrated annually, in line with medical devices standards (spring scales are inaccurate and should not be used). Commissioners and managers should ensure health professionals receive training on weighing and measuring infants. This should include: how to use equipment, how to document and interpret the data, and how to help parents and carers understand the results and implications. Ensure support staff are trained to weigh infants and young children and to record the data accurately in the child health record held by the parents. (14) www.shawacademy.com
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Weaning - introduction of solids
Three signs baby is ready for their first food Every baby is an individual, but there are three Solids are not recommended earlier than 6 clear signs which, together, show a baby is ready months for breastfed infants and 4-6 months for solid foods alongside breast milk or infant for formula-fed infants, as they can displace the formula. It is very rare for these signs to appear infantâ&#x20AC;&#x2122;s intake of breast milk or formula. For ex- together before your baby is six months old. ample, if a very young baby is fed a few spoons of pureed apple, he/she may not have room in 1. They can stay in a sitting position and hold their stomach to take sufficient amounts of milk. their head steady. Early introduction of foods other than breast milk or formula, to the baby, may increase their 2. They can co-ordinate their eyes, hands and risk of childhood obesity, wheezing or allergies, mouth so that they can look at the food, pick it as they are difficult for the very young baby to up and put it in their mouth, all by themselves. digest. 3. They can swallow food. Babies who are not ready will push their food back out, so they get more round their face than they do in their mouths.
Weaning Guidelines 1. Foods should be pureed and of a soft, runny consistency without lumps 2. Introduce one food at a time leaving a few days between the addition of each new food 3. Introduce iron rich foods from 6 monthsmeat, iron-fortified cereals 4. Use gluten free cereals until 6 months 5. Cereals, fruits, veg are suitable first foods- mix with expressed breast milk, formula or cooled boiled water to mix foods 6. High energy needs- use full fat dairy until age 2 7. Limit high sugar, high fat foods 8. Where there is a family history of allergy or atopsy, breastfeeding should be encouraged 9. Breast milk or infant formula remain the central part of the diet until the baby is eating solid foods well or is about 12 months old
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PART-ONE: Nutrition during the pregnancy cycle
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Stage 1- introducing complementary foods (4-6 months) Suitable foods: pureed meat, peas and beans Pureed fruit and veg, pureed potato
Foods to avoid: peanuts, unpasteurised cheese (will state made with “raw milk” on label) undercooked eggs
Stage 3- 9-12 months
Suitable foods: Increase the variety of foods in Gluten free cereals e.g. baby rice- pureed with the baby’s diet. Most family foods are now suitbreast milk, formula milk, boiled water or water able from cooking vegetables Consistency: chunky, mashed texture, moving Consistency- pureed and a soft consistency to food chopped into bite-size pieces. Serve without lumps. Start with a thin puree and make some finger foods that can be picked up for thicker as baby learns to take food from a spoon self-feeding Suitable drinks- breast milk or formula milk
Suitable drinks: continue to give breast milk/ formula milk
Cooled boiled water if necessary
Cooled boiled water, well-diluted unsweetened Foods to avoid- gluten containing foods e.g. pure fruit juice at mealtimes. Dilute 1 measure bread, pasta, wheat, rye, oats, barley, and break- of pure juice to 4 to 5 measures of cooled, boiled fast cereals, yogurts, fromage frais, cheese, pea- water nuts, eggs Foods to avoid: peanuts, unpasteurised cheese (will state made with “raw milk” on label) unStage 2 > 6 months dercooked eggs Suitable foods: can now include:
Remember when weaning:
Well cooked eggs, other breakfast cereals (containing gluten) bread and pasta, cheese (pas- Always stay with baby when eating teurised) e.g. grated cheese Introduce drinks from a feeding beaker or cup from about 6 months Yoghurt Pasteurised cow’s milk can be used in small Allow children to use their fingers to eat food and help to feed themselves amounts Consistency: minced or mashed
Avoid adding food to baby’s bottle
Suitable drinks: continue to give breast milk/ Avoid adding sugar or salt to food formula milk Avoid using packet sauces, soup or stock cubes Cooled boiled water, well-diluted unsweetened as the salt content is high pure fruit juice at mealtimes. Dilute 1 measure of pure juice to 4 to 5 measures of cooled, boiled water
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PART-ONE: Nutrition during the pregnancy cycle
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PART-ONE: Nutrition during the pregnancy cycle
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Dental Caries
• Those from lower socio-economic groups • Those who didn’t brush their teeth or started at a later age • Whose teeth were brushed less frequently than twice a day • Who always brushed their own teeth compared to those who had an adult help them • Who used a bottle, dinky feeder or dummy • Who ate more sugary foods and drinks
It is important to care for children’s teeth from the very start. Both tooth decay and tooth erosion are common in young children. Prolonged use of a bottle can result in ‘Nursing Bottle Syndrome’, where the teeth decay from the prolonged contact with the milk or juice in the bottle. Introduce a cup or beaker from about 6 months and aim to stop bottle feeding from 12 months of age. Tooth decay in first teeth can be The survey found that often the mother’s didn’t very painful and can affect the development of understand fully the link between dental caries permanent teeth. and diet. Also if the mother didn’t drink much water she was unlikely to offer the child water Tooth decay is linked with the frequency and the and some considered it cruel to give water as amount of sugar contained in the foods taken. opposed to a fruit drink. This is clearly a matter which needs to be highlighted further among These foods include table sugar, sweets, honey, the public. cakes, chocolate, biscuits, bars, soft drinks and squashes. Pre-school children (1-4 years) If sugary foods and drinks are provided, it is General dietary guidelines for adults do not apimportant that they should be given with meals ply to children under 2 years. rather than between meals. Many snack foods contain sugar and can cause tooth decay so it is Growth Faltering important to choose wisely. • Failure to thrive: a state of undernutrition due to inadequate caloric intake, inadequate caloric Tooth erosion is a wearing away of the enam- absorption, or excessive caloric expenditure el. It is caused by high consumption of acidic • Inadequate growth or inability to maintain foods, fizzy drinks and undiluted fruit juice. growth Children who drink fizzy drinks or fruit squash- • Seen in 5-10% of children in primary care setes once or more a day are twice as likely to suffer tings from tooth erosion as children who consume • Defined as weight for height that falls below these drinks less often. Using a straw for these the 5th percentile drinks can reduce the damage as the drink goes • Causes: biologic, psychosocial and environtowards the back of the mouth. mental processes can lead to undernutrition • A careful history and physical examination However, limiting these drinks is a better solu- can identify most causes tion. Children should be encouraged to use their teeth to chew. Give foods such as raw ap- Children in this age group grow at twice the rate ples, carrots, crusts, toast and other foods in a of children in the older group. However, is not form that encourages chewing. as fast as the initial growth from birth. ChilDental Caries: dren between 1 and 2 years usually gain 2.5kg A survey carried out in the UK found that those in weight. Thereafter children usually gain 2kg who suffered were most likely: a year. (3)
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PART-ONE: Nutrition during the pregnancy cycle
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Nutritional Requirements Carbohydrate Include one from at this group at meals and snacks • 1-3 years: 4 servings • 3-5 years: 4-6 servings/day In the USA: fibre requirements = age + 5-10g/ day. The reason fibre is not recommended for children is because high fibre diets are bulky and young children may not be able to eat enough to get all of the nutrients they need. Also phytates which are found in cereals may adversely affect mineral absorption and trigger deficiencies in those with marginal intakes. (3) Tips to vary carbohydrate consumption: • Wholemeal or white bread, scones or toast with butter or margarine. • Porridge or breakfast cereals with milk. Choose iron-fortified cereals. Choose types without sugar, honey or chocolate coating. Cereals with nut pieces are not suitable for young children because of the risk of choking. Read the list of ingredients carefully. • Boiled potatoes, pasta, rice, bread or other foods from the bottom shelf of the Food Pyramid provide the foundation for the meal. Include a food from this shelf at every meal, every day. • Wholemeal breads can be used for sandwiches – one slice wholemeal and one slice white bread makes a colourful sandwich for children.
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
Fruit and Vegetables: • 1-3 years- 2-4 servings • 3-5 years- 4+ servings • Frozen or canned are just as good as fresh How to increase consumption: 1. Blend veg and add to sauces 2. Make them interesting and appealing 3. Offer them at every meal as a dessert 4. Serve veg with a delicious dip 5. Challenge them to eat a different coloured fruit or veg daily 6. Children learn by example- eat fruit and veg in front of them
Healthy snack ideas: Snack Ideas Fruit- seedless grapes, apple pieces, pineapple chunks, mandarins
Toast cut into fingers
Milk- flavoured or plain, milk puddings
Breakfast cereal and milk
Yoghurts- natural or fruit
Crackers and cheese (unsalted)
Homemade milkshakeusing yoghurt, milk and fruit
Bread- rolls, baps, pitta, baguettes
Raw veg (carrot sticks, broccoli, celery) with dip
Scones- plain, fruit or wholemeal
Cheese slices, cubes or strings
Cold meat slices
Milk and dairy products • Aim for 3 servings a day • Also a source of protein and energy • Not advised to give children low fat dairy products • Alternative calcium sources must be sought if not including dairy in the diet • Goat’s milk or calcium- enriched soya milk and their products can be directly substituted for cow’s milk. • Follow on or toddler milk may be useful for preventing iron deficiency in those who are eating poorly and can be directly substituted for cow’s milk.
Meat, Fish and alternatives • Good source of protein and Iron • 1-2 servings- meat or fish • 2-3 servings- those who only eat eggs, nuts and pulses • Fish: 1 oily and 1 other fish during the week • Avoid large fish such as shark, marlin and swordfish which may have large levels of mercury and advised instead to choose smaller fish e.g. sardines, mackerel • Nuts: children under 5 should not be offered whole nuts as they are a choking hazard. Use nut butters or chopped nuts instead.
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PART-ONE: Nutrition during the pregnancy cycle
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Drinks Fluids are important for children - up to 6 cups of fluid should be encouraged each day, such as water or diluted pure fruit juice. Water and milk are the most tooth-friendly drinks to have between meals. Encourage children to drink water if they are thirsty. Water quenches thirst and does not damage teeth. Water from a water softening system can contain high levels of sodium (salt) and should not be given to young children. Water for infants less than twelve months should be boiled and cooled before use. In some areas, the water may need to be boiled for older children also. All water from mains or group water supply is tested regularly. If you are concerned about your tap water, discuss it with the Environmental Health Officer in your health board. If sweet drinks are used occasionally, offer these drinks only with meals and in small amounts so children do not fill up with drinks rather than eating solid food. It is recommended that drinks be given by cup rather than from a feeding bottle over 12 months of age. Continued bottle-feeding after 1 year may lead to excess milk consumption, reduced capacity for solid foods and thus “faddy eating”. It may also contribute to dental problems such as “Nursing Bottle Syndrome”. Constipation can be a result of a low fluid intake. Encourage up to 6 cups of fluid per day. Physical activity can help prevent constipation.
Do Reduce sugar in the diet Eat/drink sugar with meals Water and milk are best drinks to have between meals Introduce a feeding cup >6months Stop bottle feeding from 12 months Make brushing teeth fun
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Don’t Do not give sweet drinks in a baby bottle Do not dip the bottle teat in sugar Do not put food such as rusks in baby’s bottles Do not put children to bed with a bottle Do not dip soother in sugar or honey Do not give sugary foods and drinks as snacks Avoid acidic foods and drinks
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Breast milk
Drink type
Infant or follow-on formula Specialised infant formula Whole cow’s milk Low-fat milk Skimmed milk Goat’s or sheep’s milk
Flavoured milk
Drink Type
Soya drinks
Tap water Bottled water
Pure unsweetened fruit juice
Fruit drinks, juice drinks and squashes
Fizzy drinks
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PART-ONE: Nutrition during the pregnancy cycle
Suitability
A mother should be encouraged to continue breastfeeding as long as she wishes. Breastfeeding with suitable complementary foods into the 2nd year continue to benefit the mother and baby Not necessary >12months if diet contains sufficient iron-rich foods Only use under medical supervision Suitable for most children >12months Not suitable for children < 2 years. Children need some fat in the diet. Can be introduced after 2 years if the child is a good eater Not suitable for children <5 years- low energy content Not suitable for children under 12 months of age due to inappropriate Nutrient content. Although these drinks may be seen as less allergenic than cow’s milk or providing special nourishment, there is no scientific Evidence to support these claims.
Suitability
Ok > 12 months with meals as usually sweetened- tooth decay Not suitable for children under 12 months. If children are given soya drinks, make sure it’s under medical supervision, that the drink has added calcium and is only given at mealtimes because of the high Sugar content. Encouraged as a drink frequently during the day Not recommended- can contain high levels of minerals E.g. sodium. Ensure water <20mg Sodium (Na)/litre. Fizzy water in large amounts can be acidic and harm teeth Good source of Vitamin C and can help absorb iron. Usually contain natural sugars and can be acidic, dilute 1 part juice to 4-5 parts water and drink with meals Avoid. Sugary and acidic. Harmful to teeth. Sugar-free alternatives contain sweeteners and should be diluted well 1 part squash to 8 parts water Avoid- sugary and acidic. Diet drinks are also harmful to teeth
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Advanced Diploma in Nutrition
Peanut Allergy • Usually severe. Avoid consumption of food containing nuts or nut products or food that has come into contact with them • Prepare food for those with peanut allergy separate to other food where necessary • Avoid peanut butter • Avoid prepared foods that contain nuts or may contain nuts or nut flour • Check food labels • Children with allergies should carry identification • Children with a family history of asthma, eczema, hay fever or food allergy should avoid peanuts and peanut products until the age of 3 years
rather than a bottle. Carers should involve older children in helping to prepare food, and in helping to set and clear tables. Use mealtimes as an opportunity to talk about food and where food comes from. Encourage good table manners. Children can learn from the carer about table manners and can practice their speaking and listening skills. Avoid distractions such as television. If a carer eats at the same time as the children, it is important that they set a good example and be a role model by following healthy eating guidelines, sitting at the table to eat and promoting a positive attitude to healthy food. Make the eating area colourful and bright. Give children sufficient time to eat. Do not force children to eat.
Iron
Food Neophobia
Babies have iron stores up until 6 months. AfWhen humans show avoidance to new foods. ter that it must be obtained from the diet. See Food refusal and fussy eating. pre-pregnancy for dietary sources. Many children go through phases of refusing to eat certain foods or foods that are served in Develop Healthy Eating Patterns The pre-school years are a great time to help certain ways. Sometimes they will eat very little children form positive attitudes towards food at some meals. This is often a way of showing and physical activity and to develop good eat- independence and is very common in children ing habits. Ongoing encouragement is necessary under the age of five. Children can refuse food to promote a positive body image. During the for a variety of reasons and these can include: weaning stages, infants are introduced to new tastes and textures. They will handle the food • Poor appetite as a way of learning about it and may tip it out • Disliking the particular food of the bowl, smear it around the high chair tray • Illness and play with it in other ways. This is all part • Limited food appeal of the learning experience. Children may want • Emotional upset to and should be encouraged to eat most food • Manipulative behaviour and drink by himself or herself as they develop Children’s health will not suffer if they do not eating skills. Children aged 2-5 years should be eat a healthy, varied diet for a short while. If you allowed to serve themselves, under supervision, think a food fad is becoming a problem, then during meals as this may encourage them to try discuss this with the parents. The parents can different kinds of foods. Child-sized utensils, talk to their Doctor, Public Health Nurse, Praccrockery, tables and chairs may also make it tice Nurse or Dietitian. easier for children to feed themselves and learn Some researchers believe that it is inborn. Food to eat independently. However, all young chilneophobia often is seen in children who are shy dren should be supervised while eating and asand have high anxiety. The good news is that sisted or encouraged as needed. A feeding cup children with food neophobia often like foods is recommended for children over 12 months after they get through the trauma of trying them.
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition The important thing is to be supportive as they try new foods and reassure them that they don’t have to like it. Respect the child’s opinion about the food, rather than pressuring them to like it Sometimes a new food needs to be offered multiple times before a toddler will try it. Seeing family members eat the food helps the toddler to realise that it is a safe food to eat and they will be more likely to try it. As a toddler becomes older there can be issues with foods that they perceive to be disgusting and so won’t try them. Contamination is also a problem such as putting their favourite food on the same plate as a food that they hate may mean that they think the food is contaminated. This usually happens after the age of 3.
Salt • 2 grams for children aged 1–3 years • 3 grams for those aged 4–6 years • Watch out for bread, breakfast cereals, and processed foods- high in salt! What are children Likely to be deficient in? • Calcium- particularly if they consume little to no dairy products • Vitamin C • Vitamin A • Folic acid • Vitamin B6 • Iron-requirements vary by age, rate of growth, iron stores, increasing blood volume, and rate of absorption from food sources. • Both the American Medical Association and the American Dietetic Association recommend that healthy children should get all their nutrients from foods rather than vitamin supplements. • No risk if parent gives a standard paediatric multivitamin.
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
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PART-ONE: Nutrition during the pregnancy cycle
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Advanced Diploma in Nutrition
References: (1) http://www.nice.org.uk/guidance/PH11/chapter/3-Considerations (2) http://www.todaysdietitian.com/newarchives/120108p26.shtml (3) Manual of dietetic practice, 4th edition, Briony Tomas and Jacki Bishop (4) http://www.cdc.gov/ncbddd/spinabifida/facts.html (5) http://www.fsai.ie/faqs/caffeine_and_pregnancy.html (6) http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1 (7) http://whqlibdoc.who.int/hq/1998/WHO_NUT_98.4_eng.pdf?ua=1 (8) The European Food Safety Authority (EFSA) (9) http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1 (10) http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Minerals/Food-Sources-ofIron.aspx (11) http://www.nice.org.uk/guidance/PH11/chapter/3-Considerations (12) http://apps.who.int/iris/bitstream/10665/85313/1/9789241504935_eng.pdf?ua=1 (13) http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html#sthash.y6V0nsnk.dpuf (14) http://www.nice.org.uk/guidance/PH11/chapter/4-Recommendations (15) http://health.gov.ie/wp-content/uploads/2014/03/Food-and-Nutrition-Guidelines-for-PreSchool-Services.pdf
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PART-ONE: Nutrition during the pregnancy cycle
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