Supporting good maternal nutrition and infant feeding practice Annie S. Anderson Centre for Public Health Nutrition Research Division of Medicine, University of Dundee [email_address]

For discussion…. Pre-conceptual and maternal nutrition- does it matter? How can we support good nutritional intake in women of child bearing age? Infant feeding-consensus views How can we promote desirable infant feeding practices? Public Health programme Guidance to improve the nutrition of pregnant and breastfeeding mothers and children Draft guidelines published by NICE ( http:// guidance.nice.org.uk/page.aspx?o =421712 )

Pre-conceptual and maternal nutrition- does it matter?

How can we support good nutritional intake in women of child bearing age?

Infant feeding-consensus views

How can we promote desirable infant feeding practices?

Public Health programme Guidance to improve the nutrition of pregnant and breastfeeding mothers and children

Draft guidelines published by NICE ( http:// guidance.nice.org.uk/page.aspx?o =421712 )

Pre-conceptual nutrition – the vulnerable In Scotland in 2005, 4133 babies were born to mothers aged < 20 years, and 9689 aged 20 to 24 years. It is likely a high % of these pregnancies were unplanned Should we be worried about the nutritional status of young women?

In Scotland in 2005, 4133 babies were born to mothers aged < 20 years, and 9689 aged 20 to 24 years.

It is likely a high % of these pregnancies were unplanned

Should we be worried about the nutritional status of young women?

National Diet and Nutrition Survey (2000/01) women aged 19 to 24 years 4% consumed the recommended 5 portions/ Fruit and Veg day. Mean consumption was 1.6 portions/day. 36% exceeded the maximum recommendation food energy from NMESugars (≤11% food energy) with mean intakes at 14.2%. 83% consumed more than 6g Salt /day (estimated by urinary sodium)

4% consumed the recommended 5 portions/ Fruit and Veg day. Mean consumption was 1.6 portions/day.

36% exceeded the maximum recommendation food energy from NMESugars (≤11% food energy) with mean intakes at 14.2%.

83% consumed more than 6g Salt /day (estimated by urinary sodium)

Scottish Health Survey (2003) % women aged 16 to 24 years exceeding government guidelines for alcohol

Dietary insights suggest… Energy dense diet (high sugar, high salt, low fruit and veg, HIGH Calorie diet) Nutrient low (low in minerals and vitamin)

Energy dense diet (high sugar, high salt, low fruit and veg, HIGH Calorie diet)

Nutrient low (low in minerals and vitamin)

National Diet and Nutrition Survey (NDNS) (2000/01) Women aged 19 to 24 years Iron 42% had iron intakes below the LRNI. 7% were anaemic as indicated by haemoglobin concentrations below 12.0g/dl 16% had low iron stores as indicated by serum ferritin concentrations below 15ug/l 27% showed biochemical evidence of low iron status (transferrin saturation below 15%). Vitamin D 28% had low biochemical status for vitamin D (plasma 25 OHD<25 nmol/l)

Iron

42% had iron intakes below the LRNI.

7% were anaemic as indicated by haemoglobin concentrations below 12.0g/dl

16% had low iron stores as indicated by serum ferritin concentrations below 15ug/l

27% showed biochemical evidence of low iron status (transferrin saturation below 15%).

Vitamin D

28% had low biochemical status for vitamin D (plasma 25 OHD<25 nmol/l)

NDNS Women (aged 19 to 50 years) % with intakes below LRNI Hoare & Henderson, 2004 2 10 Zinc 3 11 Iodine 16 34 Potassium 10 26 Magnesium 4 12 Calcium 28 50 Iron 5 19 Riboflavin 6 22 Vitamin A Not Receiving benefits Receiving benefits Nutrient

Energy dense diet…

Scottish Health Survey (2003) 2006, Tayside 2.3% underweight, 26.0% overweight, 17.2% obese of 2785 women 21.9 21.0 18.2 13.4 Obese >30.0 38.4 32.4 29.2 25.5 Overweight 25.0 to 30.0 1.6 1.1 2.3 5.4 Underweight <18.5 45 to 54 years (%) 35 to 44 years (%) 25 to 34 years (%) 16 to 24 years (%) BMI (kg/m2)

Risks associated with maternal obesity Fetal risks First trimester and recurrent miscarriage Infant birth defects e.g. NTD Stillbirth Neonatal death Maternal risk Gestational diabetes Pre-eclampsia Thromboembolism Gallstones Cesearian section, post partum haemorrhage Anaesthetic risk Postpartum risks (would healing)

Fetal risks

First trimester and recurrent miscarriage

Infant birth defects e.g. NTD

Stillbirth

Neonatal death

Maternal risk

Gestational diabetes

Pre-eclampsia

Thromboembolism

Gallstones

Cesearian section, post partum haemorrhage

Anaesthetic risk

Postpartum risks (would healing)

Pre- conceptual and Maternal nutrition- does it matter? Fertility Under weight and obesity Neurological development of fetus Folic acid and Neural tube defects Obesity and birth defects Alcohol intakes and Fetal Alcohol Syndrome Growth during pregnancy Low Birth Weight babies Subsequent adult health “ Programming” of chronic disease

Fertility

Under weight and obesity

Neurological development of fetus

Folic acid and Neural tube defects

Obesity and birth defects

Alcohol intakes and Fetal Alcohol Syndrome

Growth during pregnancy

Low Birth Weight babies

Subsequent adult health

“ Programming” of chronic disease

How can we support good nutritional intake in women of child bearing age? Interventions that improve mothers nutritional status are likely to have the most impact before conception and during EARLY pregnancy . Promoting healthy eating may improve knowledge but little evidence on what leads to behaviour change

Interventions that improve mothers nutritional status are likely to have the most impact before conception and during EARLY pregnancy .

Promoting healthy eating may improve knowledge but little evidence on what leads to behaviour change

What interventions (other than those about folic acid) improve nutritional status of women of child bearing age who are planning or might become pregnant? No well designed nutrition intervention studies that aimed to measure improvements in nutrition prior to becoming pregnant undertaken in non-pregnant women in developed countries were found. Three studies that might have been relevant but each study was found to have flaws The difficulties included a lack of statistical power and very high drop out rates .

No well designed nutrition intervention studies that aimed to measure improvements in nutrition prior to becoming pregnant undertaken in non-pregnant women in developed countries were found.

Three studies that might have been relevant but each study was found to have flaws

The difficulties included a lack of statistical power and very high drop out rates .

Folic acid There is evidence from a large survey of health professionals that folic acid advice is not perceived by them as being part of general health advice for women of child bearing age. The survey also found that many health professionals have gaps in their knowledge about the appropriate dosage and timing of folic acid for women.

There is evidence from a large survey of health professionals that folic acid advice is not perceived by them as being part of general health advice for women of child bearing age.

The survey also found that many health professionals have gaps in their knowledge about the appropriate dosage and timing of folic acid for women.

Folic Acid It is probable that wide spread media campaigns brief interventions and and the provision of free supplements advice about when to take supplements will increase the use of folic acid Folate and disease prevention http://www.sacn.gov.uk/reports/#

It is probable that

wide spread media campaigns

brief interventions and and the provision of free supplements

advice about when to take supplements

will increase the use of folic acid

Folate and disease prevention

http://www.sacn.gov.uk/reports/#

What can be done to engage with women of child bearing age? Contraceptive AND ante-natal clinics Teen/Drop in centres Nurture, pamper, beauty Nutrition and care for middle aged and young women combined (mums and daughter opportunities) Hairdressers, Pubs, Clubs Reward/incentives for positive behaviour

Contraceptive AND ante-natal clinics

Teen/Drop in centres

Nurture, pamper, beauty

Nutrition and care for middle aged and young women combined (mums and daughter opportunities)

Hairdressers, Pubs, Clubs

Reward/incentives for positive behaviour

What can be done to engage with women of child bearing age? 2005

Nutrition and Pregnancy

How can we support good nutritional intake during pregnancy Education and counselling on general nutrition advice- little impact on behaviour (except with food supplements) Dietary food supplements – minimal effect (birth weight) maternal weight gain Encourage intake of one portion of oily fish per week. (e.g mackerel) Alcohol- identify intakes, monitor intakes Health education programmes and individual advice on use of Vitamin D supplements

Education and counselling on general nutrition advice- little impact on behaviour (except with food supplements)

Dietary food supplements – minimal effect (birth weight) maternal weight gain

Encourage intake of one portion of oily fish per week. (e.g mackerel)

Alcohol- identify intakes, monitor intakes

Health education programmes and individual advice on use of Vitamin D supplements

Engaging with pregnant women Ante-natal clinics Ante- natal classes 43% Scottish women 26% of women in “routine and manual occupations” 12% of women who have “never worked” (Bolling et al, 2007 Infant feeding Survey, 2005)

Ante-natal clinics

Ante- natal classes

43% Scottish women

26% of women in “routine and manual occupations”

12% of women who have “never worked”

(Bolling et al, 2007 Infant feeding Survey, 2005)

Wrieden WL & Symon A The development and evaluation of a nutrition education intervention for pregnant teenage women (food for life). J Hum Nutr Diet. 2003 Apr;16(2):67-71 The 16 (of the 120 invited) women who attended found the courses helpful but objective evaluation of dietary intake was not possible because of poor compliance.

Pregnant women on benefits under the age of 18 Milk Fresh Fruit and vegetables Vitamins (per day) 70 milligrams of vitamin C 10 micrograms of vitamin D3 400 micrograms of folic acid

Pregnant women

on benefits

under the age of 18

Post Partum issues

Post partum weight loss Short term weight loss of 1kg/week achieved through diet and physical activity has no detrimental effect on milk quantity and quality There is evidence that diet and exercise programmes are effective in enabling some post partum women to lose weight gained during pregnancy

Short term weight loss of 1kg/week achieved through diet and physical activity has no detrimental effect on milk quantity and quality

There is evidence that diet and exercise programmes are effective in enabling some post partum women to lose weight gained during pregnancy

Infant feeding

Breast Feeding Immunological features Anti-infective agents Growth factors Modulators of intestinal growth Reduction in diarrhoea Reduction in respiratory infection Colonic function Reduction in atopic disease Greater likelihood of higher IQ at 7 ½ years Lower Obesity risk for baby in later life Lower Maternal breast cancer risk

Immunological features

Anti-infective agents

Growth factors

Modulators of intestinal growth

Reduction in diarrhoea

Reduction in respiratory infection

Colonic function

Reduction in atopic disease

Greater likelihood of higher IQ at 7 ½ years

Lower Obesity risk for baby in later life

Lower Maternal breast cancer risk

Breast feeding targets (2005) “ more than 50% of women should still be breastfeeding their babies at 6 weeks of life”

Breast feeding by age and SIMD quintile

Maternal and Child Nutrition programme To review the existing evidence on the effectiveness of public health interventions to promote the initiation, and increase the duration of breastfeeding.

To review the existing evidence on the effectiveness of public health interventions to promote the initiation, and increase the duration of breastfeeding.

Maternal and Child Nutrition programme Peer Support Volunteer counsellors Postnatal support worker Professional support Lactation consultant Group breastfeeding education in ante-natal period

Peer Support

Volunteer counsellors

Postnatal support worker

Professional support

Lactation consultant

Group breastfeeding education in ante-natal period

Maternal and Child Nutrition programme Knowledge and skills needed to promote and support breastfeeding. Monitor the number of mothers initiating breastfeeding and feeding at 6 weeks Provide assistance to initiate and maintain effective peer support programmes on breastfeeding, particularly where the rates of breastfeeding initiation and duration are low. Provide increased support in areas with low rates of breastfeeding among infants aged 6 weeks and over.

Knowledge and skills needed to promote and support breastfeeding.

Monitor the number of mothers initiating breastfeeding and feeding at 6 weeks

Provide assistance to initiate and maintain effective peer support programmes on breastfeeding, particularly where the rates of breastfeeding initiation and duration are low.

Provide increased support in areas with low rates of breastfeeding among infants aged 6 weeks and over.

Beyond breast feeding… How can we promote desirable infant feeding practices?

How can we promote desirable infant feeding practices?

Nutrition in infancy will impact on … Poor Growth/Failure to thrive Rapid growth/ risk of high weight gain leading to obesity Infection Poorer gut development Eczema/allergy More wheeze/respiratory illness

Poor Growth/Failure to thrive

Rapid growth/ risk of high weight

gain leading to obesity

Infection

Poorer gut development

Eczema/allergy

More wheeze/respiratory illness

Desirable infant feeding practices the timing of the first introduction of any solid foods the timing of the introduction of particular foods meeting the infants’ nutritional needs through introducing a variety of foods protecting oral health through choosing appropriate foods and drink

the timing of the first introduction of any solid foods

the timing of the introduction of particular foods

meeting the infants’ nutritional needs through introducing a variety of foods

protecting oral health through choosing appropriate foods and drink

Vitamin D supplements Pregnant and breastfeeding women, and children up to the age of 5 , should receive vitamin D supplements to reduce the risk of a deficiency (rickets). Exposure of the skin to sunlight is the main source of vitamin D but, during the winter, there is not enough sunlight on the appropriate wavelength. Those who are dark-skinned, or who remain covered when outside, are at particular risk.

Pregnant and breastfeeding women, and children up to the age of 5 , should receive vitamin D supplements to reduce the risk of a deficiency (rickets).

Exposure of the skin to sunlight is the main source of vitamin D but, during the winter, there is not enough sunlight on the appropriate wavelength.

Those who are dark-skinned, or who remain covered when outside, are at particular risk.

Age of introduction of solid food in Scotland (1995,2000,2005)

Age of introduction of solid food by UK mothers SES “routine and manual” (2000,2005)

What influences the timing of solid food foods to infants? Alder EM et al (2004) living in a deprived area the opinions of the infant’s maternal grandmother personal disagreement with the advice to wait until the baby was 4 months lack of encouragement from friends to wait until the baby was 4 months being in receipt of free samples of manufactured food. Mother perception that the infant was hungry and not settling

living in a deprived area

the opinions of the infant’s maternal grandmother

personal disagreement with the advice to wait until the baby was 4 months

lack of encouragement from friends to wait until the baby was 4 months

being in receipt of free samples of manufactured food.

Mother perception that the infant was hungry and not settling

Intervention directions Emphasis on support- health visitors, peers, community “ Peer support intervention designed to improve infant feeding practices can increase feeding knowledge, confidence in following advice and was valued by recipients and volunteers”

Emphasis on support- health visitors, peers, community

“ Peer support intervention designed to improve infant feeding practices can increase feeding knowledge, confidence in following advice and was valued by recipients and volunteers”

Intervention directions Encourage parents and carers to make home-prepared foods for infants in particular, foods without added salt or sugar Repeated exposure to a target food enhances acceptance of same, similar and target foods encourage families to aim to eat the same food at the same time ( note fruit and vegetable) Issues around Lifestyle programmes for Life skills…. Shopping, budgeting, food prep, storage and cooking

Encourage parents and carers to make home-prepared foods for infants in particular, foods without added salt or sugar

Repeated exposure to a target food enhances acceptance of same, similar and target foods

encourage families to aim to eat the same food at the same time ( note fruit and vegetable)

Issues around Lifestyle programmes for Life skills…. Shopping, budgeting, food prep, storage and cooking

Vitamin D NICE Evidence to suggest that health education programmes on the prevention of vitamin D deficiency … Improve knowledge about vitamin D Increase uptake of supplements Reduce number of hospital admissions with rickets and osteomalacia

NICE

Evidence to suggest that health education programmes on the prevention of vitamin D deficiency …

Improve knowledge about vitamin D

Increase uptake of supplements

Reduce number of hospital admissions with rickets and osteomalacia

Vitamin D- possible strategies Ante- natal clinics information and advice on the benefits of vitamin D and vitamin D supplements. Healthy Start supplement Identify and support women who are at greater risk of vitamin D deficiency to take a vitamin D supplement during pregnancy.

Ante- natal clinics

information and advice on the benefits of vitamin D and vitamin D supplements.

Healthy Start supplement

Identify and support women who are at greater risk of vitamin D deficiency to take a vitamin D supplement during pregnancy.

Conclusions Pre-conceptual and maternal nutrition New issues obesity, nutrition vulnerability, alcohol, Good nutritional intake in women of childbearing age Healthy start – only a fraction Folic acid- hopeful signs Alcohol- monitoring Vitamin D –back on horizon Oily fish – advice needed Infant feeding The challenge of breast feeding at 6 weeks How can we promote desirable infant feeding practices? Support –professional, lay, peer Food based skills and family food work Uptake of supplements

Pre-conceptual and maternal nutrition

New issues obesity, nutrition vulnerability, alcohol,

Good nutritional intake in women of childbearing age

Healthy start – only a fraction

Folic acid- hopeful signs

Alcohol- monitoring

Vitamin D –back on horizon

Oily fish – advice needed

Infant feeding

The challenge of breast feeding at 6 weeks

How can we promote desirable infant feeding practices?

Support –professional, lay, peer

Food based skills and family food work

Uptake of supplements