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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. Outline. Potential Effects of Substance Use on Nutritional Status

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substance abuse and nutrition imperfect together

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

outline
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

potential effects of substance use on nutritional status
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

nutritional risks associated with substance use
Nutritional Risks Associated with Substance Use

Alcohol

Cocaine

Heroin

Marijuana

Tobacco

Caffeine

alcohol
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage, utilization and excretion of nutrients

Alcohol affects maternal and fetal nutrition

calorie content
Calorie Content

Carbohydrates

Protein

Fat

Alcohol

4 kcal/gram

4 kcal/gram

9 kcal/gram

7 kcal/gram

alcohol1
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage, utilization and excretion of nutrients

Alcohol affects maternal and fetal nutrition

nutrients affected by alcohol
Nutrients Affected by Alcohol

Protein

Carbohydrates

Lipids

Vitamins

Minerals

Water

alcohol2
Alcohol

Alcohol contains calories!!

Interferes with digestion, storage, utilization and excretion of nutrients

Alcohol affects maternal and fetal nutrition

alcohol affects to fetus
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

cocaine
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

growth patterns of infants exposed to cocaine and other drugs in utero
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

heroin
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
marijuana
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
tobacco
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
caffeine
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
caffeine content of selected beverages
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
nutrition assessment
Nutrition Assessment
  • Medical history – past and present
    • Obstetrical history
  • Psycho/social/economic history
  • Nutrition history
  • Weight
medical obstetric history
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

psycho socio economic history
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

nutrition assessment1
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

nutrition assessment2
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

assessing dietary intake
Assessing Dietary Intake
  • Referral Form
  • Nutrition Questionnaire
  • Food Frequency Questionnaire
  • 24-Hour Recall
  • Food Record
why is weight gain important
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

recommended weight gain
Recommended Weight Gain

Underweight

Normal weight

Overweight

Obese

28 – 40 lb.

25 – 35 lb.

15 – 25 lbs.

Individualize

components of weight gain
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.

inadequate weight gain
Inadequate Weight Gain

Measurement error

Disordered eating

Restrictive eating or dieting

Pica

Depression/stress

Inadequate food access

GI Discomforts

excessive weight gain
Excessive Weight Gain

Measurement error

Smoking cessation

Infrequent large meals

↑ calorie intake

Physical inactivity

Multiple gestation

Depression/stress

Binge eating

Pica

nutrient concerns during pregnancy
Nutrient Concerns During Pregnancy

Carbohydrates

Fiber

Protein

Fat

Calcium

Magnesium

Vitamin D

Iron

Folate

Zinc*

carbohydrates
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

protein
Protein

Dietary Reference Intake for protein in pregnancy: 71 gm/day

+ 25 gm after 1st trimester

slide36
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

essential fatty acids
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

calcium vitamin d and magnesium
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

folate
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

slide40
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

slide41
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
food groups to encourage
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

food groups to encourage1
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

milk and milk products
Milk and Milk Products

Pregnancy Requirements

> 3 servings/day

Milk alternatives

Yogurt

Lactose-free milk

Non-dairy calcium-containing alternatives

pregnancy and vegetarian
Pregnancy and Vegetarian

Nutritional Concerns

Calories

Iron

Zinc

Calcium and Vitamin D

Vitamin B12

Fats

tips for common gi discomforts of pregnancy
Tips for Common GI Discomforts of Pregnancy

Nausea and Vomiting

Heartburn

Constipation

Ptyalism

food safety
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

food safety1
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

breastfeeding and substance abuse
Breastfeeding and Substance Abuse

AAP recommends exclusive breastfeeding for 1st 6 months of life

Healthy People 2010: 75% women breastfeeding in early postpartum period

Recommendations for substance abusing women?

breastfeeding and substance abuse1
Breastfeeding andSubstance Abuse
  • Most illegal drugs contraindicated to breastfeeding
  • Smoking – separate room from baby, after breastfeeding
  • Alcohol – no more than 1 –2 drinks per week
  • Caffeine – AAP considers safe
  • Limit to < 2 cups/day
treatment of neonatal abstinence syndrome with breastmilk containing methadone
Treatment of Neonatal Abstinence Syndrome with Breastmilk Containing Methadone

Author: Ballard

Setting: Children’s Hospital, Cincinnati, OH

Sample: 6 infants exposed to methadone

Observations:

Feeding breastmilk associated with  withdrawal symptoms

Frequent small doses from breastmilk shown to be more effective than large dose

Breastmilk may be most effective method in providing methadone to infants

J Perinal Neonat Nurs 2002;15(4):76

nutrition and detoxification
Nutrition and Detoxification
  • “Nutrition intervention, provided by a qualified dietetic practitioner is an essential component of the treatment and recovery from chemical dependency.”

American Dietetic Association Position Statement - 1990

nutrition and detoxification1
Nutrition and Detoxification
  • Assess nutritional status
  • Obtain weight history
  • GI disturbances
  • Adequate fluids
  • Regularity of meal times
  • Taste and presentation important
  • Avoid substitute addictions!!
multidisciplinary team
Multidisciplinary Team
  • Physicians
  • Psychiatrists/psychologists
  • Case managers
  • Nurses
  • Social workers
  • Mental health/behavioral health workers
  • Substance abuse counselors
  • Dietetic practitioners ?
nutrition education is positively associated with substance abuse treatment program outcomes
Nutrition Education is Positively Associated with Substance Abuse Treatment Program Outcomes

Author: Grant et al

Setting: Cross-sectional survey

Sample: 152 registered dietitians

Outcome:

Positive associations found when nutrition education services incorporated into substance abuse tx programs

Group education/substance abuse education improved ASI scores improved

Individual nutrition/substance abuse education ASI scores improved by 99% (P<.05)

J Am Diet Assoc 194;94(9):999

brief intervention
Brief Intervention
  • 10 – 15 minutes sessions of counseling delivered by non-alcohol abuse specialists
  • Shown to be low cost, effective treatment alternative for alcohol use
  • Uses time-limited, self-help strategies to promote reductions in alcohol use in nondependent individuals or to facilitate referral to specialized treatment programs in alcohol-dependent persons
brief intervention for alcohol use by pregnant women
Brief Intervention for Alcohol Use by Pregnant Women

Author: O’Connor, Whately

Setting: WIC Program in Southern California

Sample: 250 pregnant women who reported drinking alcohol

Outcome:

Women in brief intervention group were 5x more likely to report abstinence after intervention

Newborns from brief intervention had higher birth weights and birth lengths

Fetal mortality rates were 3x lower (0.9%) in intervention group

In both groups, women reduced their drinking substantially

Am J Public Health 2007;97:252

summary
Summary
  • Use of legal and illegal substances can affect the nutritional status in pregnancy
  • Positive nutrition may improve pregnancy outcome
  • All pregnant substance abusing should receive comprehensive nutrition assessment and counseling by a qualified dietetic practitioner
  • Nutrition services and education should be part of the multidisciplinary care
  • Breastfeeding not totally contraindicated in substance use