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 uteroAuthor: Harsham et al

Setting: Northern California

Sample: 31 infants exposed to drugs in utero

Outcome:

1. Birth weight, birth length were significantly lower than NCHS

2. 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. 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

12 oz. Mg. 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 IndexBMI IOM NHLBI WHO

Underweight < 19.8 < 18.5 < 18.5

Normal > 19.8 – 26.0 18.5 – 24.9 18.5 – 24.9

Overweight >26.0 – 29.0 25.0 – 29.9 25.0 – 29.9

Obesity > 29.0 > 30.0 > 30.0

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

32

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

42

43

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 EncourageWhole 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 VegetarianNutritional 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 SafetyAvoid 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

51

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?

52

Breastfeeding and Substance 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

53

Treatment of Neonatal Abstinence Syndrome with Breastmilk Containing MethadoneAuthor: Ballard

Setting: Children’s Hospital, Cincinnati, OH

Sample: 6 infants exposed to methadone

Observations:

1.Feeding breastmilk associated with withdrawal symptoms

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

3.Breastmilk may be most effective method in providing methadone to infants

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

54

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

55

Nutrition and Detoxification Assess nutritional status Obtain weight history GI disturbances Adequate fluids Regularity of meal times Taste and presentation important Avoid substitute addictions!!

56

Multidisciplinary Team Physicians Psychiatrists/psychologists Case managers Nurses Social workers Mental health/behavioral health workers Substance abuse counselors Dietetic practitioners ?

57

Nutrition Education is Positively Associated with Substance Abuse Treatment Program OutcomesAuthor: Grant et al

Setting: Cross-sectional survey

Sample: 152 registered dietitians

Outcome:

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

2. Group education/substance abuse education improved ASI scores improved

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

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

58

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

59

Brief Intervention for Alcohol Use by Pregnant WomenAuthor: O’Connor, Whately

Setting: WIC Program in Southern California

Sample: 250 pregnant women who reported drinking alcohol

Outcome:

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

2. Newborns from brief intervention had higher birth weights and birth lengths

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

4. In both groups, women reduced their drinking substantially

Am J Public Health 2007;97:252

60

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