Nutrition Risk in Pregnancy

Assessment:
There are many situations that may lead to compromise of nutritional status just prior to or at the onset of pregnancy. Given that 96% of US women have diets that do not follow the Food Guide Pyramid, many women may be at risk. This list includes items where there is not only a nutritional risk, but also a benefit to nutrition intervention. Risks prior to pregnancy should be monitored, as these risks typically do not disappear, but rather may diminish during pregnancy. At the same time, additional risks may develop due to compromised intake or increased nutritional needs. What appear to be even small concerns should be put into the context of nutritional status.

Common Nutritional Risk Factors Prior to or at Onset of Pregnancy

Pre-pregnancy Underweight (BMI<19.8) Pre-pregnancy Obesity (BMI >29.0) Is younger than 15 or has a gynecological age of less than 2 years (< 2 years of menarche) Recent, non-therapeutic weight loss of >5% body weight in less than one month or 7.5% in the past three Frequent diets to lose weight in the last six months Eating disorder current or history of Anemia (<11.0 Hgb) High parity and a young age (less than 20 with three or more pregnancies carried to 20 weeks) Conception within 16 months of the delivery of an infant with birthweight > 500 grams or 20 weeks gestation Faddish food habits; e.g. avoids types or categories of foods; long eating spans; other aversions Vegetarian diet that is not properly planned Has a metabolic disease such as diabetes or inborn error of metabolism (e.g phenylketonuria)

Other chronic condition affecting absorption or utilization of nutrients as well as treatment/medications that interact with nutrients pay special attention to serious gastrointestinal disorders such as Crohns disease and short bowel syndrome; food allergies; lupus erythematosus; prolonged infections; HIV; hypothyroidism; cystic fibrosis; asthma; renal disease; serious dental disease Depression; bi-polar disorder; schizophrenia History of bariatric or gastric bypass surgery Is currently breastfeeding a child Poor obstetrical history that includes poor fetal development Is economically deprived or lives far from a grocery store Elevated blood lead level Substance use (alcohol, illegal drugs, tobacco) Low income/poverty or food insecurity

Nutrition Problems During Pregnancy

Inappropriate weight gain: o Women with low pregravid weight failing to gain 1 # per week after 12 weeks o Loss > 2 # after 13 weeks o Gain < 4# or > 7# per month Nausea and vomiting of pregnancy; constipation; heartburn Serious or significant food aversions including faddish food habits Reported/suspected poor diet quality (often noticed through weight changes, but not always) Faddish food habits Anemia (<9.9 Hgb in any trimester) Multifetal gestation Pregnancy induced conditions such as gestational diabetes; Hyperemesis gravidarum Poor folic acid, calcium, iron intake due to aversions, pica or cravings Use of herbal remedies that may not be safe during pregnancy (See ADA position paper) Food-borne illness Substance use (alcohol, illegal drugs, tobacco) Elevated blood lead level

Created by Improving Pregnancy Care in Vermont (Lisa Richardson, MS, RD, LDN, North Carolina Division of Public Health. 2004). Vermont Child Health Improvement Program, Burlington, VT

Talking About Nutrition

Intervention:
Knowledge is important! Talking about weight gain recommendations is more likely to achieve the Institute of Medicine goals. Set goals together. Frequency of eating is an important indicator for outcome and diet quality. Provide ideas of snacks that are not high calorie nor high fat. Dont overlook readiness to change! Make sure she is ready to talk about it especially if it is a problem. Ask about food security issues not just hunger. Poor income leads to purchase of non-nutrient dense foods that have lots of calories! Overweight and/or high weight gain can go along with lack of access to food. Trigger questions are a great way to get the conversation going. A few simple, open-ended questions can garner a lot of information. Some good examples are below. 1. Have you made any changes to the way you eat since you found out you are pregnant? a. No How many times a day do you eat? Do you intend to make any changes in the near future or because of your pregnancy? If concerned you can ask: what kinds of foods do you usually eat; are there foods that you avoid? b. Yes - Tell me about them. Did someone tell you to do this? How many times a day do you eat? Are you eating a lot more, a little more, a lot less or a little less. 2. Today, you weight was _________How do you feel about that number? a. Have you recently gained or lost a lot of weight? 3. How much weight do you think you should gain during this pregnancy? a. According to how much you weighed before pregnancy, your goal should be__________. Do you think that is something that you can do? 4. Do you always have enough money to buy the food you need? 5. Does the food you buy last and do you (or your household) have enough money to buy more? a. Have you or anyone in your household ever cut the size of your meals or skipped them because there wasn't enough money for food? Refer red flags to nutritional counselor, WIC, Food Stamps, or food pantries as needed and available. Refer to social worker, as available, and nutritional counselor for assistance with stress and more intense nutritional counseling. Refer to a mental health professional and a nutritional counselor if an eating disorder is suspected.

Closing the Nutrition Circle

Follow-up:
Assess weight, appetite, changes to diet, and access to food at every visit, and encourage continued, steady gains. Plot changes in weight on a graph, and look for trends that might indicate inappropriate weight gain. Follow-up on referrals, and continue ongoing re-assessment for changes in nutritional status.

Created by Improving Pregnancy Care in Vermont (Lisa Richardson, MS, RD, LDN, North Carolina Division of Public Health. 2004). Vermont Child Health Improvement Program, Burlington, VT.

VERMONT CHILD HEALTH IMPROVEMENT PROGRAM I MPROVEMENT