Nutrition intervention

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Working from nutrition diagnoses, areas for nutrition intervention that will positively alter behaviors, reduce risks, and improve and/or promote the health of the mother and fetus can be identified. Pregnancy can provide a unique opportunity to improve AN or BN behaviors if interventions focus on fetal nutritional requirements [45, 47, 55], fetal growth and development [45, 46], and relationships among maternal body weight gain, shape changes, and fetal growth [47]. Planning individualized, patient-focused care, activities, and expected outcomes is essential. The overall goal of nutrition intervention is to "promote the consumption of foods that will best meet the nutritional requirements of pregnancy, essential for fetal growth and development, within the context of the woman's often uncontrolled [or overly restricted] eating" [60, p 452].

The primary objective for AN is to gradually increase energy intake to support a positive energy balance to allow repletion of the mother while meeting fetal energy demands. An intake of 130% of estimated energy needs is initially recommended. Reaching this goal should be attained through incremental increases of 100-200 kcal per day approximately twice per week. In the first trimester, additional kilocalories are not needed to support fetal growth and development; however, maternal weight gain of one to two pounds per week may be expected due to repletion of maternal energy stores. During the second and third trimesters, energy intake should increase beyond maternal repletion needs to supply requirements of the fetus (see Table 9.2). Frequent recalculation of estimated energy needs is necessary to adjust for changes in body composition, basal metabolic rate, and energy expenditure, including physical activity.

The primary objective for BN is to disrupt binge eating-purging episodes and eating restraint so that intake becomes more consistent, and to stop other compensatory behaviors to achieve a stable energy and nutrient supply. In the first trimester, when additional energy is not required, body weight stabilization is critical. Approximately 100-130% of estimated energy needs are recommended, depending on prepregnancy BMI, weight fluctuations, and energy expenditure of physical activity. Through the second and third trimesters, additional energy intake should match recommended increases. In those women with BN who are also overweight or obese, dietary recommendations specific to these conditions should also be considered when setting energy intake levels (see Chap. 5, "Obesity and Pregnancy").

As stated above, macronutrient distribution of total energy in both AN or BN should be made up of 45-65% carbohydrate, 10-35% protein, and 20-35% dietary fat or lipids. Adjustments may be needed based on food aversions, gastrointestinal complaints, continued binge eating-purging episodes, or other issues.

Vitamin and mineral supplementation is warranted in pregnant women with AN or BN. A prenatal supplement that meets but does not exceed 100% of the Dietary Reference Intake for micronutrients for adult women is suggested to allow for consumption of food-based nutrients and to avoid excessive intakes that may potentially occur from binge eating. A thorough discussion of prenatal supplements is found in Chap. 14.

The registered dietitian should involve the patient in menu planning and food selection. Emphasis on specific micronutrient intake is important to stress the relationship of these nutrients to optimal fetal growth and development.

Nutrition education is a vital intervention component. Most women with eating disorders are well versed in nutrition facts and knowledge. However, they may be less aware of nutrition needs for healthy pregnancies. Discussion of micronutrient requirements and roles of these nutrients in fetal growth and development may redirect the mother's preoccupation with body weight and shape to fetal needs for intrauterine health. Other important nutrition education topics are listed in Table 9.6.

Table 9.6

Nutrition Education Topics during Pregnancy in Women with Anorexia Nervosa or Bulimia Nervosa

  • Body weight gain: where does this weight go?
  • Pregnancy outcomes with maternal malnutrition: what are the risks?
  • Behavioral strategies to improve eating and intake
  • Menu planning, food choices, and portion sizes
  • Differences between nutrients from foods and from prenatal supplements
  • Folate intake and neural tube defect
  • Meeting fetal nutrient needs with a vegetarian diet
  • Alcohol intake: what are the effects?
  • Caffeine intake: what are the effects?
  • Distinguishing morning sickness from self-induced vomiting
  • Severe vomiting, prolonged morning sickness, and hyperemesis gravidarum
  • Managing constipation, diarrhea, hemorrhoids, and heartburn
  • Pica practices
  • Exercise recommendations
  • Postpartum body weight loss: what can be expected?
  • Planning for lactation
  • Energy and nutrient needs of lactation
  • Postpartum eating: maintaining healthy habits

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