NCDA 2014-2015 Webinar Series

Nutrition in the Childbearing Years: Practical Application For RD's in

Maternal Wellness

Lindsey Hurd, MS RD LDN IBCLC

Housekeeping

• Technical

• Muted phones

• Q&A’s

• Polling

• Evaluation Survey

• CPE

• Availability of Resources

Webinar Series, 2014-15 Date Speaker Title

December 12, 2014 Lindsey Hurd, MS, RD, LDN,

IBCLC

Nutrition in the child bearing Years:

Practical Application for RD’s in Maternal

Wellness

January 9, 2015 Mario Spano MS RD, CSCS,

CSSD

Protein for Healthy Aging

February 13, 2015 Carla Spencer, MBA, RD, LC,

CN

Chronic Kidney Disease and Counseling

May 8, 2015 Ali Hall, JD Motivational Interviewing

June 12, 2015 Barbara Truitt, RD LD/N

Getting to know the Academy Code of

Ethics, 2nd edition

* NCDA members only

Speaker Introduction

• Lindsey Hurd is a Registered Dietitian and International Board Certified Lactation Consultant:

– Birth Doula trained through DONA International

– Owner of Angel Food Lactation & Nutrition, LLC (Wilmington, NC).

www.angelfoodlactationandnutrition

Webinar Learning Objectives

• Learning Objectives: – Describe role of maternal health and disease in the

outcome of pregnancy and lactation.

– Cite current recommendations for nutrient needs for mom in the perinatal period.

– Discuss nutrition therapy to improve maternal wellbeing and improve perinatal outcome.

• Suggested CPEU Codes: – 4000 Wellness and Public Health, 4130 Pregnancy,

4140 Lactation

Next Steps

Utilize resources

Complete the short evaluation survey

Once complete, we can email CPE certificates

Access any handouts and links to the archived version of the Webinar www.eatrightnc.org/

Look for future Webinars

Webinar Series Contacts

•Q & A NCDA or Webinar questions, contact:

NCDA main office:

NCDA@caphill.com

3801 Lake Boone Trail, Suite 190

Raleigh, NC 27607

Phone:919-232-0100

Fax: 919-779-5642

Webinar questions, contacts: Shirley Gerrior , PhD, RD, LDN, shirley_gerrior@msn.com

Esther Granville, MS RD LDN, esther granville@gmail.com

Nutrition in the Childbearing Years: Practical Application for RD’s in Maternal Wellness

Lindsey Hurd, MS, RD, LDN, IBCLC

www.angelfoodlactationandnutrition.com angelfoodnutrition@gmail.com

All Content copyright of Angel Food

Lactation & Nutrition, LLC, 2014

Objectives

• Maternal Conditions – Insulin Resistance – Weight Management – GI Conditions

• Flavor Learning – Effect of maternal diet on lactation/milk supply

• Lactogenic Foods • Postpartum Nutrition

– Weight Loss – Exercise and Nutrition

• Take Home – Role of perinatal practitioner

Where Do We Start??

Nutrition Down and Dirty…

Pre-Conception and Perinatal Recovery Focus

• Assess nutrient status of the body – Treat any deficiencies

– Focus on key nutrients

• Reach or maintain YOUR healthy weight – Improve overall eating and environmental habits

– Balanced meals with appropriate carbohydrate, fat and protein intake

• Reduce or remove toxins in our diet – Processed foods, meats, alcohol, sugar

substitutes, mercury

• Find Exercise!

Myth #2: Mom’s Health Doesn’t Effect Milk Composition or Supply

Insulin

• Early Pregnancy

– Increased insulin sensitivity

– The body is in an anabolic (storage) state

– Lipid, protein and glycogen stores accumulate

• Late Pregnancy

– Increased insulin resistance

– The body is in a catabolic (breakdown) state Lipid, protein and glycogen stores are utilized

– Elevated blood glucose and amino levels. In severe cases may cause gestational diabetes.

Insulin

• Lactation

• Main role in regulating nutrient fluctuation to the mammary gland

– Re-routes nutrients away from traditional storage to make them more available for milk synthesis

– Involved in Glandular Development

• T1D- in pregnancy, prolactin and human placental lactogen can be lower – possibly affecting mammary gland development and

lactation

Insulin

• After birth the body’s metabolic needs change dramatically altering insulin needs

• This can slow lactogenesis II by up to 24 hours depending on how quickly adjustments in insulin replacement

• Significant fluctuations in insulin can decrease milk production at anytime during lactation.

• Tight control of blood sugar and insulin levels can help women

• T2D/GDM- Insulin resistance- may cause insufficient glandular tissue

Obesity

• In mom’s with low supply, lower prolactin surges were found in response to nursing or pumping even with similar levels to non-obese mothers at the onset of lactation

• In animal experiments, over eating and excessive weight has been related to poor mammary growth both before and during pregnancy…. – Mammary gland development in puberty can be the

onset of poor development

– Hypothyroidism and PCOS could be cause of obesity and therefore effect supply

• Obesity increases risk of insulin resistance

Obesity

• Lactation is a calorically demanding state

– To accommodate, we increase energy consumption, decrease energy expenditure, traffic nutrients to the mammary gland, and enhance de novo synthesis of lipids

• Obesity is often described as a metabolically inflexible state

– Impaired ability to regulate responses to metabolic challenges

• Fasting, exercise, over feeding

Obesity

• A high fat diet increases trafficking of dietary lipids to adipose, liver, and mammary gland while decreasing de novo lipogenesis in the tissues and lowering TEE

– Does not effect milk production

• In animal studies, obese dams consuming a high fat diet failed to utilize excessive dietary fat intake

– production of milk fat is compromised

Obesity

• In the dark cycle dietary fat was trafficked to the liver and remobilized resulting in increased fat oxidation in the light cycle

– Did not happen in obese dams

• This impaired metabolic regulation blunted the diversion of dietary nutrients to the mammary gland for milk production

– Lower milk energy output and reduced TEE resulted in a positive energy imbalance during lactation

– Can impact neonatal metabolism

Maternal and Infant Immunity

Maternal and Infant Immunity

http://www.sciencedirect.com/science/article/pii/S0264410X03003

384

What if Mom’s GI Health Is Compromised?

Intestinal Permeability • Pathological increase in the permeability of the

intestinal mucosa- also called leaky gut syndrome – Causes increased absorption of endotoxins, antigens,

inflammatory mediators, intact bacteria, intact proteins

• Causative Factors – Mucosal Inflammation and Oxidative Stress – Stress – Alcohol consumption – Cow’s milk Intolerance – NSAID’s – Intestinal Infections – Small Intestine Bacterial overgrowth

http://lyndabuitrago.com/stress-and-your-gut-part-2/

Intestinal Permeability

• Related Conditions

– Chronic Fatigue Syndrome

– Ulcerative Colitis and Crohn’s Disease

– Celiac Disease

– Diarrhea-predominant irritable bowel syndrome

– Food Allergy

– Atopic Dermatitis, eczema

– Various other autoimmune or inflammatory diseases of the joints (ex. arthritis)

Intestinal Permeability

• Abnormally increased IP is characteristically similar to Inflammatory Bowel Disease (IBD) such as Crohn’s and Ulcerative colitis (UC)

– Intestinal inflammation and mucosal oxidative stress

• Alterations in tight junction proteins, reduction in tight junction strands, and strand breaks is characteristic of Crohn’s Disease

• Epithelial barrier leaks occur from tight junction protein changes, microerosions, and up-regulated epithelial apoptosis is characteristic of UC

So What Do We Do Now??

Nutrition Therapy

Begin with little improvements

that make the most impact!

Dietary Origins of Inflammation

• Gut inflammation

– Poor diet with little fiber intake

– Stool stasis

– Lack of probiotics or maintenance of intestinal microflora

– Excessive antibiotic use

– Unbalanced Omega 6 to Omega 3 ratio

Nutrition Therapy

• Polyunsaturated Fatty Acids – Omega 6 Fatty Acids

• GLA

– Omega 3 Fatty Acids • EPA, DHA

• Incorporated in the membrane phospholipids fraction of human mucosal epithelial cells

• Reduce mucosal permeability defects caused by inflammatory cytokines

Omega 3 Sources

• flaxseed/flaxseed oil

• chia seeds

• sardines

• cod liver oil

• nuts (walnuts, almonds, pistachios)

• dark leafy greens

• tuna and wild salmon

Omega 6 Sources

• olives/olive oil • Sunflower/safflower oil • Nuts • Soy • chicken • eggs • Avocado • pumpkin seeds • acai berries

• Increased Omega 3 EPA/DHA in colon phospholipids reduces inflammation and tissue injury

• Appropriate ratio should promote an environment more tolerable to immunological challenge

Omega 3 To Omega 6 Ratio

Microbiome

• Probiotics

– Intestinal microflora

• Postnatally acquired organ

• Probiotics reduce small bowel permeability

• Improves intestinal barrier function and decreases GI symptoms in children with atopic dermatitis

• Prenatal and postnatal probiotic supplementation reduces infant risk of eczema

Where To Get It?

Prebiotics

• Fiber

• Soluble fiber vs. Insoluble fiber

– Soluble is fermented by colonic microflora, promoting the growth of Bifidobacteria

– Fermentation of dietary fiber is the primary source of short chain fatty acids

• Important energy source for epithelial cells and is key in colonic homeostasis

• Inhibits inflammation, reduces oxidative stress, and maintains normal barrier function of the colonic mucosa

• Probiotics combined with fiber significantly reduces C-reactive protein levels

Where To Get It?

Myth #3: Mom’s Diet Doesn’t Alter Milk Composition

Maternal Fat Intake

• During the 3rd trimester, fetal accretion of DHA in the brain and nervous system are at its greatest velocity

– Accumulation of about 65mg DHA per day

• During lactation, infants will consume an average of 80mg DHA per liter of breast milk

• Preterm infants miss the peak accretion time and therefore require more DHA to meet their needs

Omega 3 To Omega 6 Ratio

• Infant and maternal plasma stores of Omega 3 to 6 are significantly correlated – Assessed fetal cord blood and maternal plasma

– Maternal DHA supplementation increased infant plasma and red blood cell DHA

• Fatty acid accumulation begins in pregnancy – placental transfer

– Fetal swallowing of amniotic fluid • Process develops GI phospholipid composition

• Maternal diet alters amniotic fluid PUFA composition – Favorable inflammatory GI environment at birth

• Maternal breast milk also reflects maternal PUFA intake

– Promotion of inflammatory GI environment continues into lactation

– Omega 6 content of breast milk has increased 2 fold since the 1950’s

– Current levels of DHA in the US are among the lowest worldwide

• 0.2% to 0.3% compared to 0.8% in societies with high fish intake

Omega 3 To Omega 6 Ratio

• Consume at least 200mg/day of DHA from preconception through lactation

• Avoidance of excessive Omega 6 and saturated fats – 20% of DHA is secreted into breast milk and can

be achieved within one week

– 25% of the dietary saturated fat (palmitic and oleic acids) are secreted into the breast milk

– The remaining percentage is derived from the maternal body stores or adipose tissue

How Do I Apply This?

Myth #4: Food Choices Aren’t Detected In My Milk

Psychological Signaling

• Breast milk transitions in taste during a feeding and between feedings to aid in psychological signaling – As a feeding progresses, milk increases in fat

content, signifying the end of a feeding

– FF infants lack this change in flavor

• Psychological Signaling plays an important role in the development of food regulation – Develops the chemosensory receptors in feeding,

to control intake later in life • Ex. We know dinner is over after we have dessert

Flavor Learning • 3 Chemical Senses Combine to create a Flavor

– Taste- Taste stimuli dissolved by saliva are detected by receptors on the tongue

• Sweet, salty, bitter, sour, umami (savory)

– Smell- Olfactory receptors are stimulated by chemicals or odorants that have been dissolved by mucus

• Very important in flavor recognition

– Chemosensory Irritation- Chemical stimuli receptors and free nerve endings from sensations cause oral perceptions like heat, coolness, pain, tickling, tingling, and itching

• Capsaicin, menthol, mustard seeds, black pepper

The Flow of Flavor Preference

Flavors in Amniotic Fluid

Flavors in Breast Milk

Flavors of Weaning

Foods

Flavors of Adult Foods

Fetus

Nursing Infant and Weaning

Infant

Weaning Infant

Child/Adult

The sensory environment begins in utero through foods the mother consumes in

pregnancy. In lactation, infants are exposed to these flavors through mothers

milk, acting as the flavor bridge until the infant begins the introduction to solid

foods. This process increases acceptability of foods into adulthood.

The Key is Maternal Diet! Mom must consume healthy foods to expose

baby to them.

Maternal Junk Food Intake

• Maternal junk food intake can alter the development of the reward pathway of offspring in animal studies – Decreases expression of opioid receptors

– Results in desensitization of endogenous opioids in offspring

• Reduces ability of an opioid receptor antagonist to suppress intake – Affect food choices from weaning into adulthood

– Drives an increased intake of palatable foods to achieve the same stimulation of opioid pathway

Myth #5:Breastfeeding Is All I Need To Lose My ‘Baby Weight’

Caloric Intake

• In a moderately restricted diet approx. 1800 calories per day

– Production and milk energy output were comparable

– No short term effects on milk volume or protein and lactose were found

• High fat diet increased the milk fat concentration and content by 13% and 15% respectively when compared with a high carb diet

– Resulted in a higher caloric content

– Greater negative energy balance

Caloric Intake

• Diet providing 1800-2200 calories/day is ideal for appropriate weight loss and maintenance of lactation

– Guidelines for additional calories could be excessive

– Balancing fat and carbohydrate intake offers the ideal blend for metabolic function

– Ideal to follow hunger cues vs. counting calories

Exercise

• Decreased availability of dietary glucose and fat has been observed with mild or low intensity chronic exercise altering lactation performance

– Increased milk protein composition and decreased lactose composition due to altered maternal glucose metabolism

• Women who were untrained noticed this more drastically vs. trained women, especially when performing high intensity exercise

Exercise

• Start slow and maintain good dietary habits!!

• Low intensity chronic exercise increases mobilization of mammary gland fat reserves, increasing milk fat concentration

• Consuming a moderate carbohydrate diet, 40-50% of daily intake and moderate fat diet, 20-25% is ideal for weight loss, accommodating exercise habits, and maintaining lactation performance

Weight Loss To Protect Your Milk Supply:

• Wait until 2 months postpartum to initiate intentional weight loss

• Look to lose ½ - 1 ½ pounds per week

• Never drop below 1500-1800 calories per day

• Avoid ‘quick fix’ diets and work toward a healthier lifestyle

• Slowly begin to incorporate exercise and activity into your day

• Breastfeed!!!

When Is This Helpful?

• Many families are focusing on improving healthful habits and establishing a lifestyle promoting wellness, especially as they start a family

• This information is best used for women interested the role of nutrition in the perinatal period and in establishing their child’s nutritional habits, one who is determined to breastfeed – NOT the women who is unsure of her motivation

to breastfeed

Action Steps

• Encourage moms to view nutrition as an important contribution to their growing baby’s health throughout pregnancy and lactation

• Encourage mom to select healthful foods to contribute to flavor learning

• Discuss ways to find healthful habits prior to introducing solids and family meals

• Seek appropriate professional help for families with special dietary needs

Resources • A Matsuno, K Esrey, H Perrault, K Koski. Low intensity exercise and varying proportions

of dietary glucose and fat modify milk and mammary gland compositions and pup growth. J Nutr. 1999; 129: 1167-1175.

• M Mohammad, A Sunehad, M Haymond. Effect of dietary macronutrient composition under moderate hypocaloric intake on maternal adaptation during lactation. Am J Clin Nutr. 2009; 89:1821-1827.

• J Gugusheff, Z Ong, B Muhlhausler. A maternal “junk food” diet reduces sensitivity to the opioid antagonistnaloxone in offspring postweaning. FASEB J. 2013; 27: 1275-1284.

• J Wahlig, E Bales, M Jackman, G Johnson, J McManaman, P MacLean. Impact of high-fat diet and obesity on energy balance and fuel utilization during the metabolic challenge of lactation. Obesity. 2012; 20: 65-75.

• K Dewey. Maternal and fetal stress are associated with impaired lactogenesis. J. Nutr. 2001; 131:3012S-3015S.

• N Hursts Recognizing and treating delayed or failed lactogenesis II. J Midwifery Wom Heal. 2007; 52(6): 588-594.

• M Neville, J Morton. Physiology and endocrine changes underlying human lactogenesis II. J. Nutr. 2001; 131:3005S-3008S.

• R Mannel, P Martens, M Walker. Core Curriculum for Lactation Consultant Practice. 2013.

• Pictures and diagrams obtained from google images and respective websites referenced.

Questions?

All Content copyright of Angel Food

Lactation & Nutrition, LLC, 2014