AMANDA CRANE, DIETETIC INTERNDANA CULLEN, RD

KARA WATTS, RD CSPMAY 20 , 2015

Developing a Tool for Healthy Eating on a Budget during

Pregnancy

Acknowledgements

I would like to acknowledge my project preceptors, Dana Cullen and Kara Watts for the overwhelming help, support and feedback I have been provided with throughout the development of this project.

Thank you!

Overview

IntroductionProject PurposeProject Development MethodsResultsDiscussion

Future DirectionsConclusion

Introduction

Nutrition During Pregnancy

Major role in fetal growth and developmentMaternal weight gain important for mom and

baby Fetus- birth defects, NEC, infections and more (1-3)

Mother- weight retention, hypertension, gestational diabetes (1-3)

Weight gain recommendations (see table)Increased caloric needs (see table)

340 in second trimester 452 in third trimester

March of Dimes, 2014.American Dietetics Association, 2009.

Academy of Nutrition and Dietetics, 2014.

IOM Weight Gain Recommendations

Institute of Medicine, 2009.

Pre-Pregnancy BMIBMI (kg/m2)

(WHO)Total Weight Gain

Range (lb)

Rates of Weight Gain 2nd and 3rd

Trimester (Mean Range in lbs/wk)

Underweight <18.5 28-40 1 (1-1.3)

Normal Weight 18.5-24.9 25-35 1 (0.8-1.0)

Overweight 25-29.9 15-25 0.6 (0.5-0.7)

Obese (includes all classes) >30 11-20 0.5 (0.4-0.6)

Twin Pregnancy

Normal 18.5-14.9 37-54 -

Overweight 25-29.9 31-50 -

Obese >30 25-42 -

Weight Gain for Multiples

Luke, B., Eberlein, T, 1999.

Type of PregnancyWeight Gain by 24

Weeks (lbs.)Total Weight Gain

(lbs.)Average Length of Gestation (weeks)

Triplets 36 50-60 32

Quadruplets 50 65-80 30

Weight Gain and Calorie Needs

Swinney, 2013.

Pre-Pregnancy BMI BMI CategoryRecommended Average Weekly

Weight Gain

Extra Calories per Day (kcal)

<18.5 Underweight 1.2 lb 450

18.5-24.5 Normal Weight 1 lb. 350

25-29.5 Overweight 0.6 lb 210

>30 Obese 0.5 lb 175

Common Pregnancy-Related Side Effects

Nausea (5)

Avoid greasy or fried foods, high-protein meals and snacks, small frequent meals

Heartburn (5)

Small, frequent meals, avoid acidic, greasy and fried foods, remain upward position after eating

Constipation (5)

10 glasses water per day, high-fiber foods, probiotics/kefir

Gestational Diabetes (6,7)

Portion control, balanced diet, consistent carbohydrate, tight blood glucose control

Food Myths and Facts

Caffeine (8)

Limit 200 mg per dayAlcohol (9,10)

No safe amount recommendedHerbs (11,12)

Some safer than others, herbs not regulatedFish (9,13,14)

Up to 12 ounces per week, limit shark, tilefish, swordfish, mackerel

Vegetarianism/Veganism (15, 16)

Can be followed if well-plannedArtificial Sweeteners (17)

Avoid saccharin, insufficient evidence available to determine safety

Health Literacy

Definition: “The reading and numerical skills that enable patients to be involved in the care of their own health”

Safeer R, 2005.

Health Literacy

Patients lacking health literacy have more health care related problems

About 47% of adults have difficulty comprehending complex health information from provider

Average reading level of adults: 8th-9th gradeFlesch-Kincaid Reading Ease tool: scores below

30= “very difficult”

Wilson M, 2009.Dollahite J, Thompson C, McNew R, 1996.

Shopping on a Budget

Monthly average food budget for a family of four: With children aged 2-5: $724-$895 With children aged 6-11: $858-$1,068

WIC program income criteria for Virginia: Pregnant women: annual income <$29,101 Family of four: annual income <$44,123

In 2015, total of 22,736,980 households participated in SNAP program

USDA, 2007. USDA, 2014.

Virginia Department of Health, 2014.

Project Purpose

The chief purpose of this project was to develop a compilation of handouts to educate pregnant women in need of additional nutrition information For health care providers practicing in maternal

health A simple, comprehensive educational tool does not

exist regarding budget-friendly healthy dietary choices for pregnant mothers

1. IDENTIFY THE NEED2. RESEARCH

3. PROJECT DEVELOPMENT4. PROJECT ASSESSMENT

Project Methods

1. Identify the Need

Project preceptors, Dana Cullen and Kara Watts identified the need for an educational tool

Areas of need were identified: Most important nutrition topics Frequently asked questions

2. Research

Literature review of current nutrition evidence and practice was conducted

Collection of existing handoutsHealth topics lacking educational materials

Vegan/Vegetarianism Top Ten Things to Know about Nutrition during

Pregnancy

2. Research (cont.)

Most important topics related to nutrition during pregnancy were identified: Healthy Eating during Pregnancy Shopping on a Budget during Pregnancy Nutritional Remedies for Common Side-Effects Food Safety Iron and Folate

3. Developing the Materials

New handouts were created using Microsoft Word

Content derived from existing handouts, literature review and other credible sources

Sixth-eighth grade reading levelEasy-to-understand informationUVA and WIC branding guidelines

4. Assessment of the Handouts

Many edits and revisions made from project preceptors Content Appearance Readability

Flesch-Kincaid Grade Level tool used Sixth-Eighth grade reading level

Compatibility Word and PDF UVA and WIC

Results

Healthy Eating on a Budget Educational Tool

Comprehensive manual comprised of 8 different handouts was created: Healthy Eating on a Budget during Pregnancy Manual

(compatible for use at UVAHS or WIC) Handouts\Manual Handouts\Final Versions of Handouts\

UVA Manual\UVA Manual 1.docx Handouts\Manual Handouts\Final Versions of Handouts\

WIC Manual\WIC Manual.docx

Individual Handouts

Ten Things to Know about Nutrition during Pregnancy Reading level: 5.4

Healthy Eating during Pregnancy Reading level: 7.8

Shopping on a Budget during Pregnancy Reading level: 4.8

Foods to Help Control Side Effects Reading level: 6.3

Food Safety during Pregnancy Reading level: 7.7

Iron Reading level: 7.5

Folate Reading level: 6.9

Vegan/Vegetarian Diets during Pregnancy Reading Level: 6.8

Discussion

Discussion Points

Many handouts exist regarding nutrition during pregnancy (over 37 collected) WIC UVA High-Risk Obstetrics Clinic Patient Education Repository

Existing handouts are often overwhelming and contain great detail

The new handouts are simple and easy to follow, not overwhelming

Appropriate for the target populationProvides a “snapshot” if neededAll handouts contained into one manual

Discussion (cont.)

Challenges Manipulating content for appropriate reading level Condensing sentences Medical jargon and terms Spacing, tables, colors, branding guidelines

Future Directions

Implementation To be used primarily by RDs Available for other health care providers Electronic and hard copies available

Assessment Evaluating the effectiveness of the handouts could be

done in the future Clarity Usefulness Awareness or behavior change

Monitoring how often the handouts are used

Future Directions (cont.)

Revisions Updates and changes to handouts based on patient

feedback Additional handouts for further or different topics New information based on updated research

Summary

Nutrition plays a major role in fetal growth and development

Proper maternal weight gain has an impact on fetal health outcomes

Health literacy is an important aspect to effective patient care

Many families have only a limited monthly budget for groceries

Questions?

Thank You!

References

1. Low birthweight. March of Dimes website. http://www.marchofdimes.org/baby/low-birthweight.aspx. Updated October 2014. Accessed December 2014.

2. American Dietetic Association. Position of the American Dietetic Association and American Society for Nutrition: Obesity, Reproduction, and Pregnancy Outcomes. J Am Diet Assoc. 2009;109:918-927.

3. Academy of Nutrition and Dietetics. Position of the academy of nutrition and dietetics nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014;114:1099 1103.

4. Institute of Medicine. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, D.C: National Academies Press; 2009.

5. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013. 6. Luke, B., Eberlein, T. When You’re Expecting Twins, Triplets, or Quads. New York, NY:

HarperCollins Publishers, Inc., 1999. 7. American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. Am J

Obstet Gynecol. 2013;(137):1-11. 8. Academy of Nutrition and Dietetics. Position of the academy of nutrition and dietetics

nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014;114:1099 1103. 9. Patra J, Bakker, R., Irving, H., Jaddoe, V.W.V., Malini, S., Rehm, J. Dose-response relationship

between alcohol consumption before and during pregnancy and the risks of low birth weight, preterm birth and small-size-for-gestational age (SGA)- a systematic review and meta-analyses. BJOG 2011;118:1411-1421.

10. American College of Obstetricians and Gynecologists. At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol. 2011;118:383–8.

11. Herbs and Pregnancy. American Pregnancy Association website. http://americanpregnancy.org/pregnancy-health/herbs-and-pregnancy/. Updated January 2014. Accessed December 2014.

References (cont.)

12. Schweitzer, A. Dietary supplements during pregnancy. J Perinat Educ. 2006;15(4):44-45.

13. Kaiser LL Campbell C.G., Ames, I.A. Practice paper of the academy of nutrition and dietetics: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014.

14. Fish: What Pregnant Women and Parents Should Know. U.S Food and Drug Administration website. http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htm. Published June 2014. Accessed December 2014.

15. American Dietetics Association. Position of the american dietetic association: vegetarian diets. J Am Diet Assoc. 2009;109:1266-1282.

16. Koebnick, C., Hoffman, I., Dagnelie, P.C., Heins, U.A., Wickramasinghe, S.N., Ratnayaka, I.D., Gruendel, S. et al. Long-term ovo-lacto vegetarianism diet impairs vitamin B-12 status in pregnant women. J Nutr. 2004;3319-3326.

17. Whitehouse, C.R., Boullata, J., McCauley, L.A. The potential toxicity of artificial sweeteners. AAOHN 2008;56:251-259.

18. Safeer R, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3)463-468.

19. Wilson M. Readibility and patient education materials used for low-income populations. Clin Nurse Spec. 2009;23(1)33-40.

20. Dollahite J, Thompson C, McNew R. Readibility of printed sources of diet and health information. Patient Educ Couns. 1996;27:123-134.

References (cont.)

21. Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, November 2014. United States Department of Agriculture web site. http://www.cnpp.usda.gov/sites/default/files/CostofFoodNov2014.pdf. Published 2007. Accessed December 2014.

22. Eligibility. Virginia.gov Virginia Department of Health website. http://www.vahealth.org/dcn/General%20Info/eligibility.htm. Updated May 20, 2014. Accessed December 2014.

23. Supplemental Nutrition Assistance Program (SNAP). United States Department of Agriculture website. http://www.fns.usda.gov/snap/eligibility. Published October 3, 2014. Accessed January 2015.

24. UVA Branding Guidelines. UVA Health System website. http://www.uvabrand.com/chart-and-graph-colors.html Accessed March 2015.