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Nutritional challenges for women who use alcohol and other drugs in pregnancy. Amy Sanders Dietitian The Royal Women’s Hospital VAADA Conference 13 th February 2007. Overview. Role of dietitian Nutritional needs of pregnant women Impact of D&A use Barriers to accessing care

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nutritional challenges for women who use alcohol and other drugs in pregnancy

Nutritional challenges for women who use alcohol and other drugs in pregnancy.

Amy Sanders

Dietitian

The Royal Women’s Hospital

VAADA Conference 13th February 2007

overview
Overview
  • Role of dietitian
  • Nutritional needs of pregnant women
  • Impact of D&A use
  • Barriers to accessing care
  • Nutrition audit
  • Nutritional recommendations
  • Health promotion strategies
women s alcohol and drug service
Women’s Alcohol and Drug Service
  • Specialised maternity and drug and alcohol service for women with complex drug issues.
  • Multidisciplinary team:
      • Midwifes, social workers, psychologist
      • Specialist support from obstetricians, pediatrician, pharmacist, dietitian, psychiatrist and housing worker.
  • “A Multi disciplinary team working collaboratively can achieve optimal pregnancy, birth and parenting outcomes for each woman and her family”(National clinical guidelines 2006)
role of dietitian
Role of Dietitian
  • Optimise the nutritional status for healthier pregnancy
  • Screens all clients - weekly outpatient clinics
  • Inpatient methadone stabilisation program
  • Health professional training days
  • Attends team meetings
  • Few dietitians working in this area of need ?
  • Lack of published nutrition guidelines
  • Need to advocate for equal service opportunities.
referral indicators
Referral indicators
  • Anaemia (iron, folate, B12)
  • Malnourished, thin women
  • Lack of weight gain or too much weight gain
  • Nausea, vomiting, constipation, appetite problems
  • Poor baby growth
  • Veiled, dark skinned women
  • Vegetarians
  • Previous GDM or PCOS
  • History disordered eating
  • Recent pregnancies
  • Multiple pregnancies

 Most of our women with D+A issues fit nearly all of these referral indicators !!

nutritional needs of pregnancy
Nutritional needs of pregnancy
  • Specific nutrient requirements

- protein, iron, folate, calcium and other vitamins and minerals

  • Awareness of listeria, mercury and fish, Vitamin A, caffeine
  • Optimal nutrient stores
  • Adequate maternal weight gain
  • High risk women  refer to dietitian
  • Simple dietary advice specific to individual needs.
nutritional effects of d a use
Nutritional effects of D+A use
  • Appetite suppression
  •  nutrient uptake
  •  nutrient bioavailability
  •  nutrient losses/malabsorption
  • Altered nutrient synthesis, activation and utilisation
  • Impaired nutrient metabolism and absorption
  •  nutrient destruction
  •  metabolic requirements of nutrients
  • Delayed gastric emptying

Eg. Marijuana ↓ zinc

Cigarettes ↑ iron

Alcohol ↑ thiamine

Amphetamines ↑ metabolic rate

Opiates ↓ GI motility

lifestyle effects of d a use
‘Lifestyle’ effects of D+A use
  • Limited finances
  • Homelessness
  • Poor self care
  • Reliance on take away foods
  • Chaotic meal patterns
  • Poor food safety practices
  • Reduced self awareness of hunger-satiety
nutritional challenges
Nutritional challenges

iron

folate

bowels

housing

$$

dental

BMR

nutrient

deficiency

Vit C

stress

thin

LOA

Poor nutritional

status

calcium

Pregnancy

demands

N+V

Effects of

drug use

Lifestyle

Factors

anemia

food

skills

over

weight

Compromises nutritional status

Effects maternal health + fetal outcome

barriers for care
Barriers for care
  • Food insecurity
  • Poor nutrition knowledge & skills
  • Knowledge of nutrition services available
  • Suitability of appointment times
  • Tiredness, anxiety, depression
  • Stage of change
nutrition audit
Nutrition audit
  • n = 50 pregnant women attending WADS (March 04-05)
  • Average age 29 years
  • Polydrug use +
    • 62% on methadone (n =31)
    • 24% buprenorphine (n = 12)
    • 56% illicit drugs (heroin)
    • 86% smoking tobacco
    • 56% cannabis use
    • 18% alcohol use
nutrition audit13
Nutrition audit
  • First clinic contact - 19 wks (average)
  • First dietitian contact - 22 wks (average)
      • Range 7 - 38 weeks
  • Average 4 sessions with dietitian
      • Range 0 - 10 sessions
      • Equates to monthly reviews
  • Average gestation delivered 37.8wks
  • Average infant birth weight 2849g
nutrition recommendations
Nutrition recommendations

Underweight women

  • 40% underweight pre preg (BMI <20)

Risks

  • Underweight → strong predicator of poor pregnancy outcome (↑ prematurity,↑ LBW)
  • Low BMI → more dependent on nutritional intake to achieve good weight gain.

Recommendations

  • Assess pp BMI
  • Discuss normal weight gain and monitor
  • Dietary advice - ↑ meal regularity, ↑ snacks, ↑nutrient dense foods, trial oral nutritional supplements.
nutrition recommendations15
Nutrition recommendations

Maternal weight gain

  • Suboptimal wt gain (9kg)
  • Slow in 2nd trimester
  • 25% poor wt gain (<5kg)  LBW <2.5kg

Risks

  • Adequate weight gain = optimal pregnancy outcome
  • Low maternal wt gain ↑ LBW

Recommendations

  • Monitor weight
  • Aim 12.5 – 18kg total weight gain (low BMI)
nutrition recommendations16
Nutrition recommendations

Iron Deficiency

  • 33% early pregnancy & 60% later pregnancy

Risks

  • ↑ preterm delivery, ↑ fetal growth retardation
  • Tiredness  access to care
  • ↑ risk infection, poor concentration

Recommendations

  • Routine ferritin
  • Iron therapy - monitor tolerance/compliance.
  • ↑ dietary iron & consider factors affecting absorption
nutritional recommendations
Nutritional recommendations

Vitamin D deficiency

  • 6 of 7 women deficient
  • Recent data - 58% deficient (n =34)

Risks

  • Infants dependant on maternal Vitamin D status
  • May affect infant skeletal growth

Recommendations

  • Test Vitamin D
  • Supplement deficient mother & baby if breastfed
  • Encourage small amounts of sunlight exposure
nutritional recommendations18
Nutritional recommendations

Nutritional Supplements

  • 66% iron, 58% folate, 28% multivitamins, 14% VitB

Barriers

  • Women confused what to take
  • Financial costs
  • Poor compliance → GI effects

Recommendations

  • Advise on appropriate supplementation – mv + iron
  • Avoid high doses Vitamin A & herbal preparations
  • Consider cheaper alternatives
nutritional recommendations19
Nutritional recommendations

GI Symptoms

  • Constipation most severe problem (50%)
  • 22% laxatives, 20% fibre supplements

Risks

  •  desire to eat→  quality of diet

Recommendations

  • ↑ dietary fibre & ↑ fluids
  • Fibre supplements, then laxatives
  • Review iron therapy
  • Encourage gentle daily exercise
nutritional recommendations20
Nutritional recommendations

GI Symptoms

  • Nausea and vomiting common (40%)
  • 12% antiemetics

Risks

  • Dehydration, electrolyte imbalances, nutrient intake
  • Loss of 5% pp weight → negative implications

Recommendations

  • Small frequent meals, adequate fluids, avoid empty stomach, avoid rich/spicy/fatty foods
  • Review of pharmacotherapy & antiemetics
nutritional recommendations21
Nutritional recommendations
  • Dietary Ax
  • 12% diet adequate for pregnancy
  • Poor iron intake (50%)
  • Irregular meals
  • High reliance takeaway food
  • Poor fruit and vegetable intake
  • Recommendations
  • Simple practical meal and snack ideas
  • Encourage regular meal pattern/snacking
  • ↑ Iron rich foods
  • Budget eating, shopping and cooking hints
  • Healthier takeaway choices
health promotion strategies
Health Promotion Strategies
  • Dietitian to screen all women
  • Educate: - nutrition for pregnancy

- listeria, mercury, caffeine, VitA

- drug effects on nutrition

- symptom management

  • Recommend multivitamins
  • Assistance with crisis food support, community food programs, budget shopping
  • Refer to dental services
  • Monitor weight, biochem, symptoms & diet
  • Multidisciplinary team meeting
health promotion strategies23
Health Promotion Strategies
  • Specific nutrition resources
      • “Healthy pregnancy hints” & “Eating well and pregnancy”
  • Visual displays
      • Nutrition posters & food/product displays
  • Oral nutritional supplement
      • Sustagen®, Ensure ®, Enlive Plus®
  • Recipe books - quick easy meals
  • Cooking classes
conclusion
Conclusion
  • Women attending a maternity D+A unit are at high nutritional risk
  • Nutritional deficiencies can be caused by a number of direct & indirect effects of drug use.
  • These women do not tend to seek nutritional support but are keen for advice
  • Dietitians can assist multidisciplinary teams to promote better nutrition.
  • By optimising nutritional status in pregnancy we can improve health outcomes for women and babies.
further information
Further information
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