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Healthy Mother, Healthy Infant:

Healthy Mother, Healthy Infant:. Achieving Optimal Pregnancy Outcomes Through Nutritional Intervention . Presentation Background. Information on nutrition for women is abundant

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Healthy Mother, Healthy Infant:

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  1. Healthy Mother, Healthy Infant: Achieving Optimal Pregnancy Outcomes Through Nutritional Intervention

  2. Presentation Background • Information on nutrition for women is abundant • But gaps persist between recommended daily amounts of nutrients and actual consumption—whether or not a woman is pregnant • Challenging situation for health care professionals (HCPs) • Recommended Dietary Allowances established by Food and Nutrition Board of the Institute of Medicine offer opportunity for consensus on nutrition counseling • Much broader education is still needed

  3. Presentation Background • Contemporary OB/GYN convened panel of clinicians, with support from Xanodyne Pharmaceuticals, Inc. • The Council for Nutrition During Pregnancy • Members have special interest and expertise in nutrition during pregnancy • Discussed challenges in the field of prenatal nutrition • Need for standardized definitions and terminology • Value of professionally endorsed intake guidelines • Overall importance of nutrition for women • Specific role of folic acid, iron, omega-3 fatty acids • Optimal maternal/fetal health and pregnancy outcomes • Presentation is based on the panel discussion

  4. Mary Ann Barnes, MD Assistant Director Family Medicine Residency Program St. Elizabeth Medical Center Covington, Kentucky Robert DiSilvestro, PhD Professor of Human Nutrition The Ohio State University College of Education and Human Ecology Columbus, Ohio Osman M. Galal, MD, PhD Professor, Community Health Sciences University of California, Los Angeles School of Public health Secretary General International Union of Nutritional Sciences Los Angeles, California Andrea S. Lukes, MD, MHSc President and CEO Carolina Women’s Research and Wellness Center Albermarle, North Carolina Consulting Assistant Professor Duke University Medical Center Durham, North Carolina Karen M. McGirr, RN, MSN, CNM Coordinator Fetal Care Center of Cincinnati Cincinnati, Ohio Beth Reardon, MS, RD, LDN Director of Integrative Nutrition Carolina Women’s Research and Wellness Center Albermarle, North Carolina The Council for Nutrition During Pregnancy

  5. Nutritional Adequacy During Pregnancy:Four Important Reasons for This Review • It is essential for HCPs and patients to understand the significance of nutritional adequacy throughout a woman’s life, and especially during pregnancy. • HCPs must take responsibility for raising patient and partner awareness of the particular importance of folic acid, iron, and omega-3 fatty acids to maternal and fetal health and optimal outcomes of pregnancy. HCP= health care professional

  6. Nutritional Adequacy During Pregnancy:Four Important Reasons for This Review • It is important that HCPs recognize the applied—not just theoretical—value of the Recommended Dietary Allowances and other professional recommendations so that we can plan and monitor an appropriate nutritional program for an expectant mother. • HCPs must fully recognize and be able to educate patients about the risks posed by nutrient deficiency to the fetus during gestation, especially with respect to cognitive development and the potential for chronic disease later in life. HCP= health care professional

  7. Defining the Terms

  8. Definitions of Terms to Be Used • Absorption: The uptake of substances into or across tissues, eg skin, intestine, renal tubules1 • Adequate intake (AI): The recommended average daily intake based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate; used when an RDA cannot be determined2 • Dietary reference intakes (DRIs): A set of reference values that serve as standards for nutrient intakes for healthy persons in the United States and Canada, used for planning and assessing nutrient intake3 • Elemental iron: The amount of iron in a supplement that is available for absorption4 1. Dorland’s Medical Dictionary. www.merksource.com/pp/us/cns/cns_hl_dorlands.2. IOM. www.iom.edu/CMS/3788/4574/45105.aspx.3. IOM. www.iom.edu/CMS/3788/4574.aspx.4. NIH. http://dietary-supplements.info.nih.gov/factsheets/iron.asp.

  9. Definitions (cont’d) • Essential nutrient: “…any substance normally consumed as a constituent of food which is needed for growth and development and the maintenance of healthy life and which cannot be synthesized in adequate amounts by the body”1 • Fortification: “…The addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups.”1 • Iron deficiency anemia: Condition in which hemoglobin is <11 g/dL2 • Macronutrients: Proteins, fats, carbohydrates, and water3 • Micronutrients: Vitamins and minerals4 • Nutraceutical: A food or food component that may provide medicinal or health benefits, including disease prevention and treatment5 1. FAO/WHO Food Standards Programme. Codex Alimentarius. www.codexalimentarius. net/web/index_en.jsp. 2. CDC. MMWR. 1998;47(RR-3):1-363. Dorland’s Medical Dictionary. www.merksource.com/pp/us/cns/cns_hl_dorlands.4. Bartley KA. Am J Clin Nutr. 2005;81(suppl):1188S-1193S. 5. ANA. www.ana-jana.org/nut_info_details.cfm?NutInfoID=4.

  10. Definitions (cont’d) • Nutrition: Ingestion, assimilation, and utilization of nutrients, food, and food components** • Prenatal vitamin: A combination product used to supplement the diet and avoid nutritional deficiencies prior to, during, and after pregnancy** • Recommended Dietary Allowances (RDAs): The average daily intake of a nutrient determined to be sufficient to meet the needs of 98% of the healthy members of a specific age and gender group in the United States1 • Supplementation: Nutrients added to the usual diet** • Tolerable upper intake level (UL): The maximum amount of a nutrient likely to pose no risk of adverse health effects to almost all individuals in the general population1 **Definition agreed upon for purpose of panel discussion.1. IOM. www.iom.edu/CMS.3788/4574/45105.aspx.

  11. The Impact of Nutrition Throughout a Woman’s Life

  12. Importance of Adequate Nutrition • Optimizes completion of adolescent growth • Establishes nutrient reserves before pregnancy • Protects maternal/fetal health during pregnancy • Maintains adequate nutritional status after menopause • Combats chronic and/or life-threatening disease Adapted with permission from The American Journal of Clinical Nutrition. Bartley KA et al. Am J Clin Nutr. 2005;81(suppl):1188S-1193S.

  13. Impact of Nutrition on Morbidity and Mortality in Women

  14. Major Causes of Death in Women • Cardiovascular disease1 • Leading cause of death among women in the United States • Responsible for 39% of deaths in American women • Fatality rates within one year of a heart attack average 38% in women (versus 24% in men) • 2003: 484,000 women died of heart disease, compared with 268,000 deaths from all forms of cancer combined • Diabetes2 • Strikes about 10 million women; one-third are unaware of it • Women with diabetes are at greater risk for heart attack, and at a younger age, than women without diabetes • The dangers of diabetes extend to the fetus • Complications increase potential for miscarriage and birth defects • Cancer3 • Remains a leading cause of death in women • 2005: Took 275,000 lives 1. AHA. www.americanheart.org/presenter.jhtml?identifier=107. 2. ADA. www.diabetes.org/type-1-diabetes/women-diabetes.jsp.3. ACS. www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf.

  15. Professional Organizations Recommend Nutritional Intervention to Fight Disease • American Heart Association (AHA)1 • Eat foods rich in omega-3 fatty acids • American Diabetes Association (ADA)2 • Maintain normal body mass index • American Cancer Society (ACS)3 • Eat whole versus refined grains, 5 or more servings of fruits and vegetables daily, and limited amounts of processed and red meats 1. AHA. www.americanheart.org/presenter.jhtml?identifier=107. 2. ADA. www.diabetes.org/type-1-diabetes/women-diabetes.jsp. 3. ACS. www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf.

  16. Pregnancy-Related Morbidity and Mortality in the United States

  17. Infant Morbidity and Mortalityin the United States • Even though deaths have declined, United States has the 27th poorest infant mortality rate among industrialized nations1 • 1970: 20 deaths/1000 live births • 2000: 6.9 deaths/1000 live births • Birth defects affect 120,000 babies/year2 • Responsible for 22% of deaths • Neural tube defects (NTDs) affect 1300 babies/year;primary cause of spina bifida and related disorders • Preterm birth: About 12% of infants2 1. USD HHS. www.hhs.gov/news/press/2002pres/infant.html. 2. MOD. www.marchofdimes.com/prihec/4439-1206.asp.

  18. Mortality During Pregnancy • Mortality ratios increased from 7.2 to 12.9 (per 100,000 births) between 1987 and 19971,2 • Black women were affected most2 • Hemorrhage, embolism, and preeclampsia caused most deaths1 1. Berg C et al. Obstet Gynecol. 1996;88:161-167.2. Berg C et al. Obstet Gynecol. 2003;101:289-296.

  19. Maternal Morbidity • Maternal health issues increase risk and contribute to poor outcome1 • Adverse pregnancy outcomes threaten maternal/infant survival • Maternal diet affects fetal stress tolerance1 • Poor nutritional status, infection, and personal stress limit the mother’s ability to support fetal development1 • Iron deficiency anemia (IDA) is common and contributes to poor maternal/fetal outcomes2 1. Jackson AA et al. J Nutr. 2003;133:1589S-1591S. 2. CDC. MMWR. 1998;47(RR-3):1-36.

  20. Healthy Pregnancy, Healthy Outcomes:The Role of Nutrition

  21. Nutritional Issues During Pregnancy • How much should a pregnant woman eat? • How much weight gain is healthy? How much is too much? • Which vitamins are necessary? • Is diet enough, or does a pregnant woman need more nutrients than are available through her daily food choices? • Which nutrients are most important during pregnancy? At what point? Why?

  22. Importance of Micronutrient Balance During Pregnancy • Examples of important micronutrients during pregnancy: vitamin A, vitamin D, folic acid, iron, calcium, zinc • Deficiency can be especially dangerous to mother and fetus • Impaired maternal/fetal immunity,1 vision disturbance,1 osteoporosis,2,3 hypertension2,3 • Stillbirth, birth defects, decreased cognitive development1 • Bartley KA et al. Am J Clin Nutr. 2005;81:1188S-1198S. • Holick MF. South Med J. 2005;98:1024-1027. • Lips P. Prog Biophys Mol Biol. 2006;92:4-8.

  23. Importance of Macronutrient Balance During Pregnancy • Fats, protein, carbohydrates, water • Adequate intake essential to healthy pregnancy • Excessive intake may cause maternal obesity and associated morbidity • Hypertension, gestational diabetes • Maternal obesity also linked to birth defects1 • NTDs, congenital heart disease, intestinal malformations NTDs=neural tube defects Bartley KA et al. Am J Clin Nutr. 2005;81:1188S-1198S.

  24. Benefits of Nutritional Intervention

  25. Nutritional Intervention: Benefits of of Achieving Nutritional Adequacy

  26. Establishing Nutritional Adequacy During Pregnancy Organizations and Recommendations

  27. The Role of Organizations in Promoting Prenatal Nutrition • American College of Obstetricians and Gynecologists (ACOG): Issues basic nutritional advice for pregnant women1 • Institute of Medicine (IOM): Originated RDAs;2 established guidelines to support a favorable outcome of pregnancy3 • World Health Organization (WHO): The United Nations’ specialized agency; formulates health policy, conducts global health surveillance4 1. ACOG. www.acog.org/publications/patient_education/bp001.cfm. 2. IOM. www.iom.edu/CMS/3788/42135/44011/44197.aspx. 3. IOM. www. nap.edu/openbook/0309041384/html/R1.html 4. WHO. www.euro.who.int/document/373182.pdf.

  28. General Nutritional Recommendations During Pregnancy: ACOG • Pregnancy particularly increases nutrient requirements for folic acid and iron • If diet is insufficient, provide vitamin/mineral supplementation to raise intake to RDAs for pregnant women ACOG. www.acog.org/publications/patient_education/bp001.

  29. General Nutritional Recommendations During Pregnancy: IOM • Established the RDAs1 • Most authoritative source of information on adequate nutrient levels for healthy populations • Established tolerable ULs1 • Encourages appropriate weight gain and nutritional intake during pregnancy2 1. IOM. www.iom.edu/CMS/3788/42135/44011/44197.aspx. 2. IOM. www.nap.edu/openbook/0309041384/html/R1.html. IOM=Institute of Medicine ULs=upper intake levels

  30. Designed to meet the nutritional needs of 98% of the healthy population Specific for age, gender,pregnancy status Establishment of RDAs IOM. www.iom.edu/CMS/3788/42135/44011/44197.aspx. NRC, CDA. Recommended Daily Allowances. 10th ed. 1989.

  31. General Nutritional Recommendations During Pregnancy: WHO • A balanced diet draws from 5 distinct food groups • Discourages excessive weight gain • “Eating for 2” does NOT mean doubling intake • Folic acid is essential before conception and during early pregnancy • Insufficient iron intake can lead to anemia • Women should consult a physician before/when taking any supplements WHO=World Health Organization WHO. www.euro.who.int/document/e73182.pdf.

  32. Prenatal Powerhouses Folic Acid, Iron, Omega-3 Fatty Acids

  33. Pregnancy and the Powerhouse Nutrients • Folic acid supplementation reduces the incidence of NTDs by 36% (0.4 mg/d) and 82% (4 mg/d)1 • Folic acid and iron deficiency are risk factors for preterm birth, anemia, and infant mortality2,3 • Folic acid and iron supplementation are the most widely used nutritional interventions during pregnancy4 • Omega-3 fatty acid supplementation ensures appropriate fetal and neonatal development • Brain growth and central nervous systems (CNS) maturation5 NTDs=neural tube defects 1. ACOG. Practice Bulletin No. 44, July 2003. 2. MOD. www.marchofdimes.com/professionals/14332_1151.asp. 3. Bartley KA et al. Am J Clin Nutr. 2005;81(suppl):1188S-1193S. 4. Jackson AA et al. J Nutr. 2003;133(suppl 2):1589S-1591S. 5. Hornstra G. Am J Clin Nutr. 2000;7(suppl):1262S-1269S.

  34. Folate/Folic Acid

  35. Folic Acid and NTDs • About 1 out of every 1000 US babies are born with an NTD1 • Consuming supplemental folic acid reduces the incidence of NTDs • 0.4 mg/d could reduce NTDs by as much as 70%2 • 5 mg/d, taken through the first trimester, could prevent 85% of NTDs3 • Folic acid works to prevent NTDs only if taken before conception and during early pregnancy2 NTDs=neural tube defects 1. CDC. www.cdc.gov/ncbddd/bd/mp.htm. 2. MOD. www.marchofdimes/professionals/14332_1151.asp. 3. Wald NJ. N Engl J Med. 2004;350:101-103.

  36. Folic Acid: Risk/Benefit Ratio of Achieving Nutritional Adequacy NTDs=neural tube defects • MOD. www.marchofdimes.comprofessionals/14332_1151.asp. • Brouwer IA et al. Nutrition ResRev. 2001;14:267-293.

  37. Folate/Folic Acid:Estimated Intakes

  38. Adapted with permission from The American Journal of Clinical Nutrition. Graphs present data obtained from the third National Health and Nutrition Examination Survey (NHANES; 1988-1994) in men (squares) and women (circles) aged 19-30 years. Each graph represents the distribution of estimated folate intakes relative to the Institute of Medicine's estimated average requirement (EAR; an intake below which, on a population basis, inadequate intake may be a concern). The top graph (unmodified data) represents natural folate intakes (in micrograms) prior to government mandated fortification of foods with synthetic folic acid (ie, during NHANES III). The bottom graph (modified data) represents NHANES III data modified to account for synthetic folic acid fortification of foods and dietary supplements, as well as for the reported increase in bioavailability of synthetic folic acid relative to natural folate. Briefly, NHANES III food data was updated to account for synthetic folic acid fortification and synthetic folic acid intakes were multiplied by 1.7 (the bioavailability correction factor) then added to natural folate intakes to calculate estimated dietary folate equivalents (represented above in micrograms). According to these data, 67%-95% of the population met or surpassed the new estimated average folate intake requirement; however, 68%-87% of women of childbearing age had intakes below the recommended intake of 400 µg/d. Folate/Folic Acid: Estimated Intakes • Some subgroups get >0.4 mg/d folate • 68%-87% of women of childbearing age have synthetic folic acid intakes below the recommended level of 0.4 mg/d Lewis C et al. Am J Clin Nutr. 1999;70:198-207.

  39. Folate/Folic Acid: Diet Is Not Enough • 50% of folate from food is not absorbed1 • Bioavailability is greater for synthetic folic acid than for naturally occurring folate2 • Flour must be fortified with at least 0.14 mg folic acid per 100 g of cereal grain3 • Diet alone is often insufficient to meet folate demands of pregnancy and nursing4 • Folate levels in young women have dropped5 • Brouwer IA et al. Nutrition ResRev. 2001;14:267-293. • Lewis C et al. Am J Clin Nutr. 1999;70:198-207. • WaldNJ. N Engl J Med. 2004;350:101-103. • Sherwood KL et al. J Nutr. 2006;136:2820-2826. • CDC. MMWR. 2007;55:1377-1380.

  40. Folate/Folic Acid: Recommended Intakes

  41. Intake Guidelines for Folate/Folic Acid 1. Wald NJ. N Engl J Med. 2004;350:101-103. 2. ACOG. www.acog.org/publications/patient_education/bp001.cfm. 3. ACOG. ACOG Practice Bulletin No. 44, July 2003. 4. NRC, CDA. Recommended Dietary Allowances. 10th ed. 1989. 5. USFDA. www.fda.gov/fdac/features/796_fol.html. 6. WHO. www.euro.who.int/Document/e73182.pdf. IOM=Institute of Medicine NTDs=neural tube defects WHO=World Health Organization

  42. ACOG Recommendation for Folate Supplements in Pregnancy • 0.4 mg/d should reduce the risk of NTDs by 36% • 4 mg/d should reduce the risk of NTDs by 82% NTDs=neural tube defects • ACOG. Practice Bulletin No. 44, July 2003.

  43. Dose-Response Relationship Between Folic Acid and Reduced Incidence of NTDs 52% Data from 13 published studies that assessed the effect of folic acid supplementation on serum folate concentration and from the results of a large cohort study that assessed the risk of neural tube defects according to serum folate concentrations were assembled into a two-stage dose-response model by Wald et al. By specifying the relationship between dietary folic acid and plasma folate concentrations, and the relationship between plasma folate concentrations and the risk of neural tube defects, the model predicts the effects of a given amount of supplemental folic acid intake and the associated risk reduction for neural tube defects. The model predicts that (1) increases in folic acid intake reduce the risk nural tube defects and (2) that background plasma folate concentrations influence the effect of folic acid supplementation (higher background levels reflect lower reductions in risk). The data presented above represent background serum folate concentrations of 5 ng/mL. Wald NJ et al. Lancet. 2001;358:2069-2073. Wald NJ. N Engl J Med. 2004;350:101-103. NTDs=neural tube defects

  44. Iron

  45. Importance of Iron in Pregnancy • Iron intake during pregnancy is essential • Supports full-term pregnancy, normal birth weight1-3 • Protects against IDA (Hb <11 g/dL), leading to poor maternal health, developmental delays, behavioral deficits2,3 • 11% of nonpregnant woman aged 16-49 years are iron deficient4 • 3%-5% also had IDA4 IDA=iron deficiency anemia • Bartley KA, et al. Am J Clin Nutr. 2005;81:1188-1198. • Jackson AA et al. J Nutr. 2003;133(suppl 2):1589S-1591S. • CDC. MMWR. 1998;47(RR-3):1-36. • Berg CJ et al. Obstet Gynecol. 2003;101:289-296.

  46. IDA • IDA is a common complication of pregnancy • Severe IDA may be associated with1: • Premature delivery • Low birth weight • Factors unique to pregnancy that contribute to IDA include2: • Intrauterine growth retardation • Increased blood volume • Fetal demands • Blood loss during delivery IDA=iron deficiency anemia 1. CDC. MMWR. 1998;47(RR-3):1-36.2. NIHODS. http://ods.od.nih.gov/factsheets/iron/asp.

  47. Iron Demand During Pregnancy • Normal iron requirement for adult women is 18 mg/d • Requirement escalates to 27 mg/d during pregnancy • Gestational increase in blood volume • Fetal demands • Blood loss during delivery • Demand may not be met • Average US diet supplies only 15 mg/d of iron; the body’s iron stores are insufficient NIHODS. http://ods.od.nih.gov/factsheets/iron/asp.

  48. Recommended Intake Levels of Iron During Pregnancy Recommended Iron Intake (mg/d) 30 IOM=Institute of Medicine CDC=Centers for Disease Control and Prevention UL=tolerable upper intake level 1. NRC, CDA. Recommended Daily Allowances. 10th ed. 1989. 2. AAP/ACOG. Guidelines for Perinatal Care. 5th ed. 2002. 3. CDC. MMWR. 1998;47(RR-3):1-36.

  49. Iron: Risk/Benefit Ratio of Achieving Nutritional Adequacy 1. Bartley KA et al. Am J Clin Nutr. 2005;81(suppl):1188S-1193S. 2. NIH. www.dietary-supplements.info.nih.gov/factsheets/iron.asp.

  50. Types and Absorption of Iron Supplements • The form of iron affects absorption and tolerance • Heme iron can be absorbed at >30%1 • Ferrous sulfate absorption averages 2.5% to 3%1 • Chelated iron appears to be better absorbed/tolerated than ferrous sulfate2 • RDA values established for iron account for variation in bioavailability Percentage of Elemental Iron in Iron Supplements 1. NIHODS. www.info.nih.gov/factsheets/iron.asp. 2. Bovell-Benjamin AC et al. Am J Clin Nutr. 2000;71:1563-1569.

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