Nutrition Issues: Women's Life Stages Learning Objectives Identify nutrition issues for a women: –During pregnancy focusing on high risk –In midlife to.

Nutrition Issues: Women's Life Stages

Learning Objectives

• Identify nutrition issues for a women:

– During pregnancy focusing on high risk

– In midlife to reduce chronic disease risk

– In older age to address multiple medical and/or social problems

• Assess Weight, Activity, Variety and Excess for each age cycle and determine when refer for medical nutrition therapy with Registered Dietitian (RD) is needed.

Pregnancy Issues

Weight

• Pregnancy: 1-2 lb mo 1st trimester; 0.5-2 lb week in 2nd & 3rd Trimester

• Midlife: Weight distribution & risks relate to metabolic syndrome.

• Older Age: Unintentional weight loss > 10 lb at risk

Activity

• Pregnancy: impact weight-baring activity > fetal distress.

• Midlife: Weight-baring activity risk of osteoporosis.

• Older Age:. Assess for unsteady gait.

Variety Pregnancy: Calcium iron, protein, fiber/water, and folate

• Midlife: Metabolic syndrome, N-3 fatty acids; calcium intake, vegetables• Older age: Absorption/nutrient requirements; Calcium/Vit D, Vit B-12, and

zinc supplements may be needed.

Excess • Pregnancy: Screen for cravings, EtOH intake, • Midlife: CHO & lipids, meat & calcium excretion • Older Age: Food/EtOH behaviors to cope with loneliness.

American Dietetic/Diabetes Association Exchange System Overview

Exchange Calories CHO Protein Fat

Starches (1/2 C 1 oz) 80 15 g 2 g trace

Fruit (1/2 C) 60 15 g 0 g 0

Milk (8 oz) 90-160

12 g 8 g Tr-8 g

Vegetables (1/2 C) 25 5 g 2 g 0

Meat (per oz) 55-100 0 g 7 g 3-8g

Fat (tsp) 45 0 g 0 g 5g

FREE FOOD < 15 calories per serving FREE FOOD < 15 calories per serving

Quick Carbohydrate Counting

One Carbohydrate choice = 15 grams based on the ADA’s Exchange system

Exchange groups included are:

- Starch (1/2 cup, slice of bread)

- Fruit (1/2 cup)

- Milk (1 cup)

- Other Carbs (varies by concentration)

Glycemic Indexing Issues

GDM Carbohydrate ~40-45% of EnergyMeat, Cheese, Vegetables- not measured

Breakfast 30 grams: 1 starch + 1 milk

½ cup oatmeal and 1 cup milk

Morning snack

15 grams: 1 milk or 1 starch or ½ of each

4 oz milk and 2 crackers

Lunch 45-60 grams: 2 starches, 1 milk and 1 fruit

Sandwich, 1 cup of milk and a piece of fruit

Afternoon Snack

15 grams: 1 milk or 1 fruit

1 diet yogurt or 1 piece of fruit

Dinner 45-60 grams: 2 starches

1 cup of pasta (with meat) vegetables, small apple and 1 cup of milk

Night Snack

15-30 grams: 1 milk and 1 starch

Crackers (with cheese) and milk

Recommended Weight Gain based on Prepregnancy BMI*

• BMI< 19.8 kg/m2 28-40 pounds

• BMI 19.8-26 kg/m2 25-35 pounds

• BMI > 26 kg/m2 15-25 pounds

*American Diabetes Association Guide to Medical Nutrition Therapy

Weight Gain Recommendations for Pregnant Women

(Overweight Cuts Weight Gain Rx in Half)

Normal weight

3-5 pounds per month 1st trimester

• 1-2 pounds per week 2nd and 3rd trimesters

Overweight• 11/2 - 21/2

pound per month 1st trimester

• 1/2 -1 pound per week in 2nd and 3rd trimesters

Nutrition-Related Pregnancy ProblemsRates in the United States

• Hypertension ~ 12-22%• Preeclampsia ~ 6-8%

• Gestational Diabetes~ 2-14% • Anal fissures/external hemorrhoids disease

occur ~ 35% of pregnancies. • Postpartum Iron Deficiency rates:

30% if < 130% of poverty level

7% if > 130% of poverty level • Neural tube Defects ~ 4000 annually

Tight Glucose Control in GDMReduction in Adverse Outcome

GDM Non-diabetic Neonatal Outcome Conventional Intensive Control

N = 1316 1145 4922 Macrosomia > 4000 g 13.6% 7.1% 8.1% Intensive Care 25%

4.4 days 6.3%

2.8 days 4.7%

2.8 days Polycythemia 12% 0.7% 1.4% Hypocalcemia 4.0% 0.3% NA Hypoglycemia 20.0% 3.8% 2.5% Respiratory Support 4.2% 1.4% 0.5% Shoulder Dystocia 1.4% 0.4% 0.5% Langer O, et al. Am J Ob Gyn 1994;170:1036-46.

Midlife Issues

Dietary Approach to Stop Hypertension DASH Daily Recommendations

7-8 Serving - grains, emphasis on whole grains

4-5 Serving - vegetables

4-5 Servings - Fruits

2-3 Servings - low-fat dairy products

< 2 Servings - Meats

2-3 Servings Oils

* Eat 4-5 servings of nuts, seeds and dried bean per week

Limit intake of sweets to 5 per week

Midlife CVD Risk for WomenMetabolic Syndrome

Synonyms

• Insulin resistance syndrome

• (Metabolic) Syndrome X

• Dysmetabolic syndrome

• Multiple metabolic syndrome

Metabolic Syndrome Therapeutic Objectives

• To reduce underlying causes– Overweight and obesity– Physical inactivity

• To treat associated lipid and non-lipid risk factors– Hypertension– Prothrombotic state– Atherogenic dyslipidemia (lipid triad)

Specific Dyslipidemias:

Possible Causes of Elevated Triglycerides

• High carbohydrate diets (>60% of energy intake)

• Several diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome)

• Certain drugs (corticosteroids, estrogens, retinoids, higher doses of beta-blockers)

• Various genetic dyslipidemias

• Lipoprotein pattern: atherogenic dyslipidemia (high TG, low HDL, small LDL particles)

• Baseline triglycerides: 200 mg/dL– Lifestyle option:

• Weight loss EtoH and Carbohydrate

– Supplement options:• Niacin• Omega-3 fatty acids

• LDL-cholesterol goal: <100 mg/dL

Diabetic Dyslipidemia

Older Age Issues

Older Age Assessment of Nutritional Risk

• Unintentional weight loss or BMI < 22 kg/m2

• Serum Albumin < 3.5 mg/dL• Unintention reduction in cholesterol or < 150 mg/dL• Reduced calorie or protein intake• Difficult swallowing and/or gastric reflux• Decreased appetite or ability to eat/obtain food• Depression• Economic Issues

Treatment Options for Low Weight in Older Adults

• Liquid suppmements

• Medications that stimulate appetite and weight gain

• Vitamin/mineral supplementation

• Referral to RD and social service

• Use enteral nutrition before considering TPN

Congestive Heart FailureNutritional Evaluation

• Fluid retention (pedal edema or ascities)

• All blood levels in relation to fluid retention

• Serum electrolytes (high sodium and low potassium)

• Hypotension

• Protein (risk of cardiac cachexia)

Treatment of Congestive Heart Failure

• Reduce sodium to < 2400 mg; DASH diet

• Check adequacy of protein and calorie intake

• Check fluid status daily (sign of edema and daily weights)

• Stablize before surgery and invasive medical procedures monitor afterwards

Nutrition Referral Issues

• Integrate nutrition into your overall workup by briefly assessing weight, activity, variety and excess.

• Refer women to RD for in-depth Medical Nutrition Therapy consultation if: 1. You identify a nutrition-related problem

and

2. Patient is ready to address the problem.