Substance Abuse and Nutrition: Imperfect Together

1. Substance Abuse and Nutrition: Imperfect Together Alyce Thomas, RD Perinatal Nutrition Consultant Dept. of Obstetrics and Gynecology St. Joseph’s Regional Medical Center Paterson, NJ

2. Outline Potential Effects of Substance Use on Nutritional Status Specific Risks Associated with Substance Use in Pregnancy Components of Nutrition Assessment Assessing Dietary Intake Nutrients of Major Concern in Pregnancy Nutrition-related Concerns of Substance Abuse in Pregnancy Nutrition Interventions

3. Potential Effects of Substance Use on Nutritional Status Appetite suppression Poor food choices Reduced nutrient intake Impaired nutrient absorption/metabolism Inadequate weight loss/gain Gastrointestinal discomforts

4. Nutritional Risks Associated with Substance Use Alcohol Cocaine Heroin Marijuana Tobacco Caffeine

5. Alcohol Alcohol contains calories!! Interferes with digestion, storage, utilization and excretion of nutrients Alcohol affects maternal and fetal nutrition

6. Calorie Content Carbohydrates Protein Fat Alcohol 4 kcal/gram 4 kcal/gram 9 kcal/gram 7 kcal/gram

7. Alcohol Alcohol contains calories!! Interferes with digestion, storage, utilization and excretion of nutrients Alcohol affects maternal and fetal nutrition

8. Gastrointestinal Tract

9. Central Nervous System

10. Nutrients Affected by Alcohol Protein Carbohydrates Lipids Vitamins Minerals Water

11. Alcohol Alcohol contains calories!! Interferes with digestion, storage, utilization and excretion of nutrients Alcohol affects maternal and fetal nutrition

12. Alcohol Affects to Fetus Impairs placental nutrient transport  Glucose transport necessary for fetal brain development Prenatal insulin resistance may lead to glucose intolerance later in life Folate and zinc deficiency may lead to neural tube teratogenesis Animal studies found that the effect of alcohol was not as severe when maternal diet adequate in zinc

13. Cocaine Little is known about effects of cocaine on maternal and fetal nutrition Interferes with appetite Causes maternal and fetal vasoconstriction → fetal hypoxia  nutrient supply → IUGR

14. Growth patterns of infants exposed to cocaine and other drugs in utero Author: Harsham et al Setting: Northern California Sample: 31 infants exposed to drugs in utero Outcome: Birth weight, birth length were significantly lower than NCHS By 6 months, no significant differences for weight, but differences in length J Amer Diet Assoc 1994;94(9):999

15. Heroin • Associated with  birth weight, prematurity and IUGR • Common symptom of opiate abuse: constipation • May be poorly nourished • Vitamin deficiencies • Iron deficiency anemia • Folic acid deficiency anemia • May experience food cravings

16. Marijuana • Associated with  birth weight and length • Conflicting study results have not shown any nutrition-related effects of marijuana use in pregnancy • Weight gain ? • Weight loss ? • No difference in women who smoked marijuana and those who did not

17. Tobacco • Decreased birth weight associated with maternal smoking • Associated with IUGR • Nutrition-related effects • Lower availability of calories • ↑ iron requirements •  availability of certain nutrients (B12, amino acids, vitamin C, folate, zinc

18. Caffeine • Affects the CNS 15 minutes after ingestion • Caffeine intake > 300 mg/day linked to ↑ 1st trimester abortions • Moderate to heavy caffeine linked to: • Lower birth weight • ↑ risk of preterm labor • Delayed conception •  absorption and ↑ urinary losses of vitamin B1, zinc, iron and calcium

19. Caffeine Content of Selected Beverages 8-oz. Mg. 12 oz. Mg. Coffee, drip 115-175 Coffee, brewed 80-135 Coffee, espresso 100 Coffee, instant 65-100 Tea, iced 47 Tea, brewed 60 Tea, green 15 Hot cocoa 14 Coffee, decaf 3-4 • Red Bull 80 • Pepsi One 55.5 • Mountain Dew 55 • Diet Coke 45.6 • Pepsi 37.5 • Coke 34 • Snapple teas 31.5 • Slim Fast 20 (chocolate flavored) • Sprite 0

20. Nutrition Assessment • Medical history – past and present • Obstetrical history • Psycho/social/economic history • Nutrition history • Weight

21. Medical/Obstetric History Age Estimated due date Present history Previous obstetric history Past medical history Family history of chronic illness Medications or nutrient supplements Physical signs of nutritional deficiencies

22. Psycho/Socio/Economic History Financial status Current living conditions Relationship with family Cultural/religious background Food availability Participation in food programs Work/school schedule Educational level

23. Nutrition Assessment Pre-pregnancy weight/usual weight Current height Appetite Recent appetite changes Current diet or food plan Cravings/allergies/ intolerance Pica Medications – herbal, dietary supplements PNV, OTC Alcohol – drink or cook

24. Nutrition Assessment Snack patterns Dental problems Raw or undercooked protein foods GI discomforts Fluid intake Substance use Ptyalism Physical activity Planned method of infant feeding Foods eaten away from home

25. Assessing Dietary Intake • Referral Form • Nutrition Questionnaire • Food Frequency Questionnaire • 24-Hour Recall • Food Record

26. Why Is Weight Gain Important? Effects fetal growth and length of gestation Inadequate weight gain associated with ↑ prematurity &low birth weight (LBW) LBW major determinant for morbidity and mortality LBW associated with ↑ risk of CVD, DM, HTN and obesity in later years

27. Body Mass Index

28. Recommended Weight Gain Underweight Normal weight Overweight Obese 28 – 40 lb. 25 – 35 lb. 15 – 25 lbs. Individualize

29. Components of Weight Gain Baby Placenta Amniotic fluid Mother Breasts Uterus Body fluids Blood Maternal Stores 7½ lb. 1½ lb. 2 lb. 2 lb. 2 lb. 4 lb. 4 lb. 7 lb.

30. Inadequate Weight Gain Measurement error Disordered eating Restrictive eating or dieting Pica Depression/stress Inadequate food access GI Discomforts

31. Excessive Weight Gain Measurement error Smoking cessation Infrequent large meals ↑ calorie intake Physical inactivity Multiple gestation Depression/stress Binge eating Pica

33. Nutrient Concerns During Pregnancy Carbohydrates Fiber Protein Fat Calcium Magnesium Vitamin D Iron Folate Zinc*

34. Carbohydrates Choose fiber rich fruits, vegetables and whole grains Limit intake of foods with added sugar Fiber recommendation – 14 gm/1000 calories Discretionary calories Not to exceed allowance for calorie level

35. Protein Dietary Reference Intake for protein in pregnancy: 71 gm/day + 25 gm after 1st trimester

36. Fats < 10% of calories from saturated fats < 300 mg/day dietary cholesterol Keep trans fats as low as possible Total fat intake: 20 to 35% of total calories mostly from unsaturated fats

37. Essential Fatty Acids Omega-3 (linolenic acid) All fish and seafood Egg yolks Soybeans Canola, flaxseed and olive oils Omega-6 (linoleic acid) Walnuts, peanuts, almonds Seeds, such as sunflower Corn, safflower and sunflower oils

38. Calcium, Vitamin D and Magnesium Calcium Deposited in fetal skeleton mainly in 3rd trimester Vitamin D Required for calcium homeostasis Maternal deficiency associated with neonatal rickets Magnesium Regulates calcium absorption and relaxes smooth muscle Main foods sources: unprocessed whole grains

39. Folate 600 mcg in pregnancy ↑ up to 4 mg if previous NTD or anti-seizure meds Food sources Fortified and whole grain breads and cereals Dark, green, leafy vegetables Avocado, oranges

40. Iron Iron deficiency is very common in women Pre-pregnant requirements: 15 – 18 mg/d Pregnancy requirements: 27 mg/d CDC recommends 30 mg/d supplement at initial prenatal visit Food sources Heme iron rich or non-heme iron with facilitators

41. Zinc • Essential for fetal growth & development • Affects protein synthesis • Aids absorption of B-complex vitamins • Deficiencies: congenital anomalies, IUGR, prematurity • Food sources: meat, fish, eggs, shellfish

44. Food Groups to Encourage Eat 2 cups of fruits and 2½ cups of vegetables daily Vegetables Dark green, orange, legumes, starchy vegetables, other vegetables Fruits Fresh, frozen, canned, dried

45. Food Groups to Encourage Whole Grains Important for fiber and other nutrients Recommend > 3 oz. equivalents/d ½ of all grains should be whole grains

46. Milk and Milk Products Pregnancy Requirements > 3 servings/day Milk alternatives Yogurt Lactose-free milk Non-dairy calcium-containing alternatives

47. Pregnancy and Vegetarian Nutritional Concerns Calories Iron Zinc Calcium and Vitamin D Vitamin B12 Fats

48. Tips for Common GI Discomforts of Pregnancy Nausea and Vomiting Heartburn Constipation Ptyalism

49. Food Safety Avoid in pregnancy Raw or unpasteurized milk products Raw or soft cooked eggs Raw or rare meat products Unpasteurized juices or milk products

50. Food Safety Wash hands, utensils and cutting surfaces after handling food Cook foods thoroughly Wash raw fruits and vegetables before eating Separate uncooked meat products from other foods Chill perishable foods promptly