Developing a Tool for Healthy Eating on a Budget during Pregnancy

Final Paper

Amanda Crane, 2014-2015 UVA Health System Dietetic Intern

Project Preceptors

Dana Cullen, RD and Kara Watts, RD, CSP

[1]

Table of Contents

Abstract………………………………………………………………………….…………..page 3

Literature Review………………………………………………………………….………...page 5

Project Development Methods………………………………………….………....…….…page 26

Project Presentation…………………………………………………………………..…….page 28

References……………………………………………………………………...….....…….page 31

Appendix…………………………………………………………………………...………page 34

[2]

ABSTRACT

Introduction: A well-balanced maternal diet comprised of nutrient-rich foods containing a wide

variety of vitamins and minerals as well as adequate hydration is highly important for fetal

growth and development. Poor nutrition can lead to negative health complications such as

inappropriate weight gain, impaired development and inadequate birth weight for the fetus, and

obesity, diabetes and hypertension for the mother.

Health information is often misunderstood by patients. This can ultimately lead to

confusion, information discrepancies and patient non-compliance. For effective management of

good nutrition during pregnancy, health care providers should take into consideration the

education and literacy level of their patients.

Given the aforementioned information, the need for a concise yet informative educational

tool regarding nutrition during pregnancy was established.

Purpose: The objective of the project was to create educational materials for nutrition during

pregnancy for patients at the University of Virginia Health System (UVA Health System) and

Women, Infants and Children (WIC).

Methods: A literature review of practice and evidence for nutrition during pregnancy was first

completed. A collection of handouts and brochures were then taken from the UVA Health

System High-Risk Obstetrics clinic and the Virginia Department of Health WIC office. From the

information gathered, new handouts were developed and existing materials were updated. The

readability of the handouts was determined by the Flesch-Kincaid reading ease scale. The new

handouts were written at the sixth-eighth grade reading level. The UVA Health System and WIC

branding guidelines were followed while developing the handouts. After edits were made by

[3]

Registered Dietitians (RDs) practicing in the field of maternal health, final versions were saved

electronically as a portable document format (PDF) or Word document.

Summary: Nutrition plays a crucial role in health outcomes for the growing fetus during

pregnancy. The development of this simple yet concise and informative educational tool will

benefit expectant mothers and health care professionals in the field of maternal health.

[4]

LITERATURE REVIEW

Overview of the Importance of Health and Nutrition during Pregnancy

In 2006, the percentage of babies born prematurely reached an all-time high of 12.8% which was

a 30% increase from the past two decades1. Babies born prematurely are at increased risk for

birth defects, health complications, morbidity and mortality.1-2 Although not all pregnancy-

related health complications can be avoided, lifestyle approaches for a healthy pregnancy can

play a vital role. A balanced, nutritious maternal diet becomes the foundation for a healthy

pregnancy. The benefits received from a healthy pregnancy will extend to both mother and the

growing child and will last well into the future.

Developing Fetus

Proper nutrition is of utmost importance for the developing fetus during pregnancy. The fetus

thrives off the mother’s nutrient supplies which are used for growth and development. Poor

nutrient intake during pregnancy creates an increased risk to the fetus for underdeveloped organs

and inadequate birth weight.2 Infants born under or above the weight recommendation for their

gestational age are likely to experience negative long-term health outcomes later in life.2

Growth and Development

The developing fetus is reliant upon mother’s nutrient stores and without a rich supply,

certain organs and structures may develop abnormally. In the first trimester of pregnancy, the

foundation for fetal development is constructed. During this time, the maternal diet does not

necessarily require additional calories.2 However, diet quality becomes meaningful and will

remain an integral part of pregnancy.

The first trimester is the period in which development from a zygote to a fetus occurs. A

group of cells containing deoxyribonucleic acid (DNA) forms into a fetus containing the

[5]

neural tube, heart, arms, legs and organs throughout these twelve weeks. A rich nutrient

supply is essential to the formation of these structures with primary emphasis on the neural

tube. This will eventually become the brain and spinal cord and proper development depends

heavily upon a reliable supply of folate and other nutrients.2

The second trimester is when motility and structural functions are developed. Kicking

movements, urination, hearing, increased fat stores and growth of muscle and reproductive

organs are all occurring during this period. This is a time when hydration and good-quality

macronutrients are crucial. Key nutrients will help the fetus to achieve these essential

functions and adequate hydration will ensure enough amniotic fluid and blood supply are

received during this time.2

During the final trimester intake of sufficient nutrients and calories become important to

the mother as the most weight will be gained by the baby during this period. The final

development of the lungs, brain, nervous system and fat stores will be completed during this

time. Also occurring will be the accrual of nutrient stores and bone hardening. Because of

significant fetal developments such as brain growth and fat accumulation, it is essential the

fetus receives a healthy amount of high-quality macronutrients from the maternal diet,

particularly dietary fat in monounsaturated and polyunsaturated forms.2

Birth Weight

Birth weight is a useful indicator of health status for the newborn. Adequate maternal

weight gain during pregnancy is critical, as this contributes to the health of the newborn.

Infant birth weight that is too high or too low can be reflective of future complications. Low

birth weight (LBW), a weight less than 2,500 grams or 5.5 pounds, can be a major risk factor

for mortality as well as long term health and developmental complications.3 Complications

[6]

such as necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity and

respiratory distress syndrome can be endured if the baby is born at a low birth weight or

prematurately.4 In addition, the infant born at a low birth weight can experience diabetes,

heart disease, hypertension, metabolic syndrome and obesity later in life.4 Comparatively, a

large for gestational age (LGA), baby is larger and heavier than 90% of babies born at the

same gestational age and can also lead to poor health outcomes later in life such as increased

risk for metabolic syndrome.5 Both outcomes are indicative of the importance of achieving

appropriate weight gain during pregnancy.

Maternal Requirements

Nourishment and weight gain are essential to the health of an expectant mother. Under or over-

nourishment can lead to negative health outcomes, inappropriate weight gain, and complications

to fetal development. Therefore, it is key for expectant mothers to maintain and achieve

sufficient nutrient intake throughout the duration of a pregnancy.

Key Nutrients

A balanced amount of wholesome nutrients in the maternal diet is vital for ensuring a healthy

pregnancy and for reducing the risk for maternal complications during and after pregnancy.

Complications such as obesity, cardiovascular disease, bone health, impaired cognition, immune

function and diabetes are all potential conditions that can be encountered by mother if adequate

nutrition is not achieved during pregnancy.6

In the first trimester, a well-balanced diet becomes and will remain of high importance to the

mother. The quality rather than quantity and consumption of fruits, vegetables, protein, whole

grains, monounsaturated and polyunsaturated fats and dairy products are critical to the maternal

[7]

diet in the first trimester. This is the time maternal stores will be used for building the placenta

and blood supply.2

During the second trimester, hydration becomes essential to ensure sufficient amniotic fluid

volume for the fetus. Fluid intake of 10 glasses or about 80 ounces is recommended during

pregnancy.2 Caloric needs increase during the second trimester and the specific amount will

depend on pre-pregnant Body Mass Index (BMI) (see Table 1).2

Pre-Pregnancy BMI BMI Category Recommended 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

Table 1. Recommended Weight Gain2

Brain development and accumulation of nutrient and fat stores are continuing for the growing

fetus during the third trimester.2 Intake of high-quality fat from monounsaturated and

polyunsaturated fatty acids as well as certain vitamins and minerals become key components to

the maternal diet during this time.2 Foods rich in calcium, magnesium, potassium, iodine,

Vitamin D, B Vitamins and Docosahexaenoic acid (DHA) are all important to consume.2

Recommended Weight Gain

The Institute of Medicine (IOM) has established recommended weight gain ranges for

pregnancy based on BMI categories. The updated guidelines from 2009 for singleton and twin

pregnancies are shown in Table 2. The recommendations now include information related to

[8]

BMI categories as well as a more narrow range for obese women.7 Luke and Eberlein 8

established suggested weight gain for expecting mothers of triplets and quadruplets. This

information is outlined in Table 3.

Sufficient weight gain during pregnancy is not only important to the fetus but also to the

mother. An increased amount of weight gain during pregnancy exposes the mother to health

consequences such as weight retention, gestational diabetes mellitus, and hypertension.6

Additionally, inadequate maternal weight gain during pregnancy can also contribute to

negative fetal outcomes such as birth defects and infections.4 Appropriate weight gain related

to pre-pregnant BMI is extremely relevant for maternal and fetal health status. Adhering to a

healthy diet during pregnancy can contribute to a successful pregnancy.

Table 2. New Recommendations for Total and Rate of Weight Gain during Pregnancy by Pregnancy BMI7

Pre-Pregnancy BMI BMI (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 -

Table 3. Optimal Weight Gain Patterns during Pregnancy8

[9]

Type of Pregnancy Weight Gain by 24 Weeks (lbs.)

Total Weight Gain (lbs.)

Average Length of Gestation (weeks)

Triplets 36 50-60 32

Quadruplets 50 65-80 30

Nutritional Guidelines during Pregnancy

A number of nutritional recommendations and guidelines have been established to ensure

satisfactory nutrient intake for a healthy pregnancy. These recommendations relate mostly to the

types of foods to consume, serving sizes and essential vitamins and minerals.

Food Groups

An extensive amount of research focused on maternal health and pregnancy has been

published containing recommendations for types of foods to consume and in what quantities.

General recommendations include consuming a diet rich in whole grains, fruits and vegetables,

dairy products, lean meats and healthy fats.9 Although many different resources provide varying

amounts of each food group to consume, the Academy of Nutrition and Dietetics (AND)

recommends a diet consisting of 45-60% carbohydrate, 10-35% protein, 20-35% total fat, less

than 10% saturated fat and 28 grams fiber during pregnancy (based on a 2,099+340 kcal diet).9

Recommended Caloric Intake

The recommended caloric intake for pregnant women is based upon pre-pregnant BMI and

activity level. Table 1 (see page 8) outlines the amount of extra calories suggested per day during

the second and third trimesters. This highlights the average increased caloric intake during

pregnancy for a singleton pregnancy. The Dietary Reference Intakes suggest a more specific

caloric intake amount of 340 calories per day in the second trimester and 452 calories per day in

the third trimester.9 For women with a normal BMI carrying multiples, 40-45 calories per

kilogram (kcal/kg) of pre-pregnancy body weight is recommended.9 However, specific and

[10]

individualized weight gain during pregnancy should be discussed with a health care team

including a physician and RDs.

Serving Sizes

For expecting mothers, the serving sizes for each type of food will be different depending

on how much total weight is to be gained. Table 4 outlines the average serving sizes for each

food group per trimester. These guidelines were established from the Eating Expectantly Diet

which uses MyPlate and carbohydrate counting principles.10

Table 4. Serving Sizes of Food Groups from Eating Expectantly Diet2

Food Group First Trimester Second Trimester Third TrimesterCarbs 6 servings 9 servings 9 servings

Vegetables 2.5 cups/ 625 ml 3 cups/ 750 ml 3 cups/ 750 ml

Fruits 2 cups/ 500 ml 2 cups/ 500 ml 2 cups/ 500 ml

Protein 6 oz./ 190 g 7 oz./ 220 g 7 oz./220 g

Dairy3 cups/ 750 ml 3 cups/ 750 ml

3-4 cups/750-1,000 ml

Fats and Oils 5 teaspoons 7 teaspoons 7 teaspoons

Splurge Calories 200 calories 200 calories 200 calories

Total Calories 2,000 2,340 2,450

Vitamins and Minerals

A number of vitamins and minerals are recommended for pregnant women to consume before

and during pregnancy to support fetal development. The vitamins and micronutrients of

particular interest for a healthy pregnancy include folic acid, iron and prenatal vitamins. Other

vitamins of importance can be obtained through the diet and include calcium, potassium vitamin

D, C, E and B vitamins.6

Folic Acid

[11]

Folic Acid plays a key role in the prevention of neural tube defects, preterm delivery and

fetal growth retardation.11 Because of the large role folate plays in the prevention of these

adverse conditions, it is recommended that women of child-bearing age consume at least 400

micrograms of folic acid even if not currently planning on becoming pregnant.11 During

pregnancy, the recommendation for folic acid increases to 600 mcg and during lactation, 500

mcg is recommended.11 Intake of food sources rich in folate are recommended to consume as

part of a balanced diet. Food sources containing at least 78 g of folate equivalent (20% of the

Daily Value) are shown in Table 5.

Table 5. Selected Food Sources of Folate and Folic Acid11

Food Micrograms of Dietary Folate Equivalent per

serving (mcg)

Percent Daily Value (%)

Spinach, boiled ½ cup 131 33

Black-eyed peas (cowpeas), boiled, ½ cup 105 26

Breakfast cereals, fortified with 25% of the DV 100 25

Asparagus, boiled, 4 spears 89 22

Spaghetti, cooked, enriched 83 21

Brussel sprouts, frozen 78 20

Prenatal

Prenatal vitamins are important to take prior to conception as well as throughout

pregnancy. Taking a prenatal vitamin during pregnancy can decrease the risk for birth defects

and low birth weight.2 Another benefit to prenatal vitamins is their function as a multivitamin

containing the major vitamins required for healthy fetal development. A prenatal vitamin

typically contains DHA, Choline, Iodine, Vitamin D and Calcium. Each of these vitamins and

minerals play central roles in maintaining healthy pregnancy outcomes.2

[12]

Iron

Iron is an essential micronutrient for growth and development of maternal and fetal

functions during pregnancy. Iron deficiency-anemia is the most common micronutrient

deficiency, and if encountered in the first two trimesters, can increase the risk of preterm labor,

low birthweight and infant mortality.6 Iron is needed to support the increased blood supply and

prevent iron deficiency anemia. The recommended Dietary Allowance during pregnancy is 27

mg.12 Iron can be consumed through foods and dietary supplements and is better absorbed when

taken with ascorbic acid (vitamin C).12 Caution is advised when taking iron with calcium, as this

will compete for iron absorption.12 Various types of iron will be absorbed more efficiently than

others; for instance, in food sources, heme iron has a higher bioavailability compared to

nonheme iron and in regard to dietary supplements, ferrous iron is more bioavailable compared

to ferric iron.12 Iron-rich foods (see Table 6) can be consumed as part of a healthy and well-

balanced maternal diet during pregnancy.

Table 5. Selected Food Sources of Iron12

Food Milligrams of Iron (mg)

Percent Daily Value (%)

Breakfast cereals, fortified with 100% of the DV for iron, 1 serving

18 100

White beans, canned, 1 cup 8 44

Lentils, boiled and drained, ½ cup 3 17

Spinach, boiled and drained, ½ cup 3 17

Tofu, firm, ½ cup 3 17

Tomatoes, canned, stewed, ½ cup 2 11

Cravings

[13]

Changes in the perception of food such as cravings or aversions may be experienced during

pregnancy. Cravings for various foods or even a lack of desire for favorable foods can be a result

of dietary needs, hormones and blood glucose changes.2

Food and Non-food Items

Throughout pregnancy, women may experience cravings for various, unique items for a

number of reasons. Cravings may be due to fluctuations in hormones which may cause aversions

or sensitivity toward certain foods.2 Drops in blood glucose may create cravings, especially for

high-carbohydrate or sweet, decadent foods such as chocolate or ice cream. Excessive

consumption of these types of foods could potentially lead to weight gain.2 Additionally, cravings

may also be due to a lack of a certain vitamin or mineral in the diet.2 Iron is a common

deficiency which can result in craving dirt or ice.2 Cravings for and consumption of non-food or

non-nutritive food items could potentially lead to nutrient deficiencies and overconsumption of

unhealthy foods could ultimately lead to weight gain. Choosing more nutrient-dense foods can be

a healthier alternative and will provide quality nutrients the body is craving.

Common Misconceptions Related to Food and Nutrition during Pregnancy

Pregnancy can be a time in which an overwhelming amount of information is absorbed by an

expecting mother. Controversial topics and misconceptions related to alcohol exposure, fish

consumption, artificial sweeteners, vegetarianism, herbal supplements and caffeine consumption

currently exist and are relevant to nutrition during pregnancy. Exposure to misleading

information or information passed through generations can easily create concerns or questions

about certain pregnancy-related nutrition topics.

Alcohol

[14]

Historically, alcohol has been a component to diet that is strictly avoided during

pregnancy due to the risk of neurological and physical developmental impairments of fetal

alcohol syndrome. Recently, some research has examined the effects of light to moderate alcohol

consumption on birth outcomes. A systematic review by Patra et al.13 looked at the association

between risk of low birth weight and alcohol consumption. This article reviewed 36 studies

about the risk for low birth weight, preterm birth and small for gestational age (SGA) and

alcohol exposure of up to 1 drink per day. The findings stated there were no effects on SGA up

to 10 grams (about 1 drink) per day, and no effects on preterm birth with up to 18 grams (about

1.5 drinks) per day. In conclusion however, an increased risk for negative birth outcomes was

seen with heavy alcohol consumption but no effect was seen when compared with light to

moderate consumption.13

The American College of Obstetricians and Gynecologists (ACOG) states that even

moderate consumption of alcohol during pregnancy may have a negative impact on the fetus’s

cognitive, psychomotor and emotional status.14 The abstinence of alcohol consumption during

pregnancy is strongly supported by the ACOG due to the harmful effects of fetal alcohol

syndrome.14 Despite the research studies performed, insufficient evidence exists to determine any

safe level of alcohol consumption during pregnancy; therefore, alcoholic beverages should be

avoided.

Fish

Although fish can be included as part of a well-balanced maternal diet, questions often

arise concerning mercury levels and types of fish that are safe to consume. The 2010 Dietary

Guidelines for Americans recommend 8 to 12 ounces of fish can be safely consumed per week

by pregnant women.13 However, cooking temperatures and the type of fish should be considered

[15]

before consumption. Fish should be cooked to the safe temperature of 165 degrees Fahrenheit

prior to consumption.9 Fish containing high-levels of mercury such as tilefish, shark, swordfish

and mackerel should be avoided and white albacore tuna should be limited to 6 ounces per week.

Other fish caught from lakes, rivers and streams should be limited to 6 ounces per week and fish

advisories should be followed.15 Overall, fish can be safely consumed during pregnancy as long

as adherence is made to the recommended guidelines regarding safe minimum cooking

temperature and types of fish to consume.

Artificial Sweeteners

The question of artificial sweeteners’ safety during pregnancy has been raised. Currently,

insufficient evidence exists to support a recommendation for consumption of artificial

sweeteners during pregnancy. An overview report by Whitehouse et al.16 found that side effects

from using artificial sweeteners can range from headaches to cancer. Concerning the use during

pregnancy, one study by Garland et al16 observed increased levels of adiposity and increased liver

triglycerides as well as anemia and decreased growth in rats exposed to saccharin. However,

many of the studies included by Garland et al16 were completed on animals and therefore the

association to humans still requires much research.16 Although the Food and Drug Administration

(FDA) has approved non-nutritive sweeteners as acceptable during pregnancy, The Evidence

Analysis Library (EAL) contains limited evidence to support the use of artificial sweeteners for a

healthy pregnancy or for the management of Gestational Diabetes Mellitus (GDM). The EAL

also recommends avoiding saccharin during pregnancy.9 Further evidence is needed to make

more specific recommendations regarding the consumption and safety of artificial sweeteners

during pregnancy.

Vegetarianism

[16]

Common concerns for vegetarianism and pregnancy relate mostly to nutrient

deficiencies. As with vegetarian diets for non-pregnant women, an accurately planned vegetarian

diet during pregnancy is paramount for preventing nutrient deficiencies particularly due to

increased nutrient needs during pregnancy. The position of the American Dietetic Association

(now the Academy of Nutrition and Dietetics) states that, “well-planned vegetarian diets are

appropriate for individuals during all stages of the life cycle including pregnancy, lactation,

infancy, childhood and adolescence and for athletes.”17 However, studies show potential nutrient

deficiencies in the vegetarian diet during pregnancy. A study by Koebnick et al.18 compared

levels of vitamin B-12 between pregnant women adhering to long-term ovo-lacto vegetarian

diets and pregnant women consuming the common Western diet. The results showed an

increased risk of vitamin B-12 deficiency in women adhering to a long-term vegetarian diet

compared to those who consumed an average Western diet.18 Many other factors including

proper education and vitamin supplements can also contribute to the success of vegetarian diet

during pregnancy. The overall recommendation remains that a vegetarian diet can be safely

followed throughout pregnancy if the diet is planned properly.

Herbal Supplements

As per the American Pregnancy Association, herbal therapies could be considered safe or

unsafe depending on the source. Noting that some herbs such as ginger root or peppermint leaf

can help with nausea and vomiting, some herbs such as dong quai or blue cohosh could

potentially stimulate the uterus and cause preterm labor.19 Table 6 highlights various herbs which

may not be safe to consume during pregnancy and the potential complications for pregnancy.

The risk of these complications could lead to miscarriage, uterine contractions and preterm birth.

This group recommends consulting with the primary care physician prior to trying any herbal

[17]

remedies.19 In addition to the questionable safety of some herbs, the manufacturing process of

herbs is not regulated by the industry or government.20 Packaging, ingredient concentrations and

the possibility of contamination are not regulated by governing agencies and contributes to the

questionable safety of herbal supplements.20 In conclusion, the evidence regarding the safety and

efficacy of herbal supplement use during pregnancy still remains unclear and further studies are

needed before a safe recommendation can be made.

Table 6. Herbs to Avoid While Pregnant19

Caffeine

Caffeine avoidance has traditionally been recommended during pregnancy. According to

ACOG, preterm birth or miscarriage is not associated with a caffeine intake less than 200 mg per

day.6 Although this amount has not been associated with birth complications, exact caffeine

levels can be difficult to determine. With the rise in popularity of caffeinated beverages and

energy drinks, establishing a safe level or amount to consume may be challenging. When

comparing the caffeine content of 20 espresso beverages, the caffeine amount varied between 51

and 322 mg per serving for each beverage.9 Additionally, the caffeine found in energy drinks can

also vary significantly, ranging from 80 mg in 8.3 ounces to 505 mg in 24 fluid ounces.9 These

[18]

Herb Potential Side EffectSaw Palmetto Has hormonal activity

Goldenseal May cross the placenta

Dong Quai Uterine stimulant and relaxant effects

Pay D’Arco Contraindicated for pregnancy

Blue Cohosh Uterine stimulant and can induce labor

factors can make it very difficult to determine which beverages contain a safe amount of caffeine

to consume.  The Academy of Nutrition and Dietetics recommends decaffeinated beverages as a

safer and more reliable beverage option to consume during pregnancy.9 Keeping caffeine limited

to the recommendation of 200 mg per day seems to be safe during pregnancy but caution and

awareness of caffeine levels in other caffeinated-beverages should be taken.

Pregnancy Complications and Special Considerations Related to Nutrition

Despite the variety of complications endured during pregnancy, many are directly

impacted by nutrition and can be managed by food intake. The common pregnancy-related

complications include morning sickness, heartburn, constipation and Gestational Diabetes

Mellitus (GDM) and can be managed or exacerbated by certain foods.

Morning Sickness

Morning sickness is typically encountered during the first trimester when hormones such as

estrogen and human chorionic gonadotropin begin to surge. These hormones are actually helpful

and may reduce the risk of miscarriage.2 Generally, avoidance of foods which trigger symptoms

of nausea and vomiting and consumption of foods which do not trigger symptoms seems to be

appropriate when experiencing morning sickness. Increasing fluids during nausea and vomiting

episodes is essential as dehydration is dangerous during pregnancy.2 Morning sickness can be

combatted in many ways. Some examples include avoiding heavy or spicy and greasy foods and

taking a B-6 supplement.9 Other remedies include consuming small, frequent meals and

consuming more protein with meals and snacks. These actions will prevent the stomach from

fully emptying as well as prevent a feeling of nausea.2

Constipation

[19]

Constipation is a common side effect experienced during pregnancy and is recognized as

stool that is hard, dry, painful or difficult and having three or fewer bowel movements per week.

This can be caused by the increase in progesterone which slows intestinal movement of food or

by the increased pressure on intestines and rectum.2 Consuming at least ten glasses of water and

increasing intake of high-fiber foods such as fruits, vegetables and whole grains can help prevent

constipation.2 In addition, including probiotics from foods such as yogurt and kefir or a

supplement can help to increase digestive motility.2

Heartburn or Acid Reflux

Acid reflux or heartburn can occur during pregnancy due to compression on the stomach from

the growing fetus. Progesterone also relaxes the esophageal sphincter which allows for the reflux

of food and stomach acid into the esophagus.2 Consuming fat-free or low-fat milk or yogurt may

aid in digestive motility and alleviate heartburn. Avoidance of greasy or spicy foods, tomatoes,

citrus foods or products, carbonated drinks and caffeine may also help with symptoms of acid

reflux.2 Frequent, smaller meals can help to prevent the stomach from filling and then refluxing

into the esophagus. Eating while sitting up and remaining sitting or standing after food

consumption may also combat the unpleasant side effects of acid reflux.2

Gestational Diabetes Mellitus (GDM)

GDM is a complication associated with pregnancy. Approximately 6-7% of pregnancies are

complicated with diabetes mellitus (DM) and of this percentage, 90% are cases of GDM.21 DM is

a condition of carbohydrate intolerance that presents or unveils during pregnancy.21 GDM is

often discovered in pregnancy as a result of the body’s reaction to insulin levels. During

pregnancy, the body’s cells adapt by becoming slightly insulin resistant.21 This occurs as an

effort to increase blood glucose to make more nutrients available to the baby.21

[20]

The risk of complications such as hypertension, preeclampsia and cesarean delivery are all

increased during pregnancy with a diagnosis of GDM. In addition, risk of developing DM later

in life is seen in 50% of women with GDM.21 Fetal risk factors include macrosomia, neonatal

hypoglycemia hyperbilirubinemia, shoulder dystocia and birth trauma.21

Tight blood glucose control is needed to manage GDM. This can be managed through dietary

adjustments such as carbohydrate counting. Additionally, increasing fiber intake may help

regulate postprandial glucose.12 One study by Fraser et al.22 found that a daily intake of 50 grams

of fiber resulted in a lower postprandial glucose response compared to daily fiber intake of 12

grams. Finally, the type of fat consumed may play a role in reducing glucose intolerance. One

study found that increased body fat as well as a decreased ratio of dietary polyunsaturated to

saturated fat impacted glucose tolerance. By increasing this ratio, adequate glucose control may

be an associated outcome.22

Breastfeeding

Breastfeeding provides optimal nutrition to the newborn as well as supports healthy growth and

development. The benefits of breastfeeding are significant and extend to both mother and the

newborn.

Newborn Benefits

Breastfeeding allows mothers to deliver optimal nutrition to the newborn. The

composition of breast milk has unique characteristics making it the perfect match for the

newborn. Human milk contains a variety of key nutrients and vitamins such as essential fatty

acids, carbohydrates, medium-chain triglycerides, long-chain polyunsaturated fatty acids and

cholesterol as well as calcium, phosphorus, magnesium, iron and zinc in an easily-digestible

form.23 Breast milk can also help to prevent childhood morbidity and mortality by protecting

[21]

from infections such as otitis media, respiratory tract infections, gastroenteritis and other acute

conditions. In addition, infants who are breast fed have a decreased risk for chronic conditions

such as type 2 diabetes, overweight and obesity, heart disease and childhood leukemia as well as

increased cognitive development compared to formula-fed infants.23 The benefits for the

newborn extend far beyond the months that breastfeeding is performed.

Maternal Benefits

The benefits of breastfeeding to mother include both short and long-term health outcomes

as well as biological, physical, and psychological benefits. Physiological and biological

advantages of breastfeeding include protection against health conditions such as breast cancer,

type 2 diabetes and hip fractures.23 In addition, breast feeding can aid in weight and fat loss

postpartum as well as help to lower blood pressure and prevent iron deficiency. The

psychological benefits of breastfeeding include maternal bonding with the newborn, decreased

rates of depression and increased sleep duration which all impact many other aspects to health.23

Finally, breastfeeding provides great financial and economic relief to mother and the family.

Breastfeeding allows mothers to reduce health-care costs for mother and child and prevents the

need to purchase expensive formulas.23 The benefits to breastfeeding are embedded into many

aspects of maternal well-being.

Common Concerns and Barriers

Many barriers faced while breastfeeding come from an emotional, cultural and

physiological standpoint. Emotional and psychological barriers to breastfeeding include lack of

confidence for breastfeeding, lack of support from health professionals, embarrassment, sole

responsibility for infant nutrition and concerns with breastfeeding at work or school.2,24 In some

[22]

cultures, it is recommended to practice both breastfeeding and formula feeding techniques to

deliver the best nutrients so the newborn grows to be large in size.25

Health Literacy

One of the primary goals of health care providers is to provide the most thorough and complete

care to patients. Consideration to health literacy should be given by the health care provider to

ensure patients have thoroughly understood the information and recommendations provided.

Health literacy is defined as the reading and numerical skills that enable patients to be involved

in the care of their own health.26 Patients lacking in health literacy often have more health care

related issues such as difficulty controlling chronic illnesses and are less likely to participate in

disease prevention and health promotion activities.26 The importance of providing health

information at the health literacy level of the patient is key to successful and effective care.

Importance of Health Literacy with Educational Materials

Health education materials need to be thoroughly evaluated prior to being provided to

patients. The average reading level of most adults is between eighth and ninth grade, yet most

health care materials are written at a tenth grade level or higher.26 Additionally, about 47% of

adults have difficulty comprehending complex information given by health care providers.27 It is

very important to conduct an evaluation of the level at which health education materials are

written prior to distribution. The Flesch-Kincaid scale and the Simple measure of Gobbledygook

(SMOG) are tools that can be used to evaluate the reading level of text. The SMOG tool

evaluates text based on a US grade-school level. The Flesch Reading Ease (FRE) tool calculates

a score from 0-100 with scores below 30 being “very difficult” to read.27 Both of these tools can

be used to determine the health literacy level of health education materials.

[23]

A study completed by Dollahite et al.28 compared the reading level of 209 pamphlets

taken from various professional health organizations, commercial organizations, government

agencies and educational institutions. The research concluded that 68% of educational materials

were written at a level of ninth-grade or higher and 11% were written at or below the sixth-grade

level.28 The materials containing information written at a higher level overall (grade 9.1-10.3 and

58.9 or below on the FRE) originated from professional health organizations such as the

American Institute for Cancer Research and government agencies such as the FDA.28 Whereas,

materials obtained from educational institutions such as the University of Wisconsin resulted in

lower mean readability levels (grades 7.0-9.4 and 60.5-67.9 respectively).28 Health literacy

considerations of the patient as well as educational materials are highly relevant to the

effectiveness of how care is being provided by the health care system as a whole.

Shopping on a Budget

Saving money and budgeting food expenses are daily considerations made by many families.

Grocery and other food costs for the household have to be taken into account when planning out

this percentage from a disposable income. The monthly average food budget for a family of four

including children between the ages of 2-5 years using a low-moderate food cost plan is between

$723.70-$894.80 and is $857.70-$1,067.50 for a family of four with children between the ages of

6-11 years.29 This is the price endured by most Americans to support a healthy diet made using

foods prepared at home.

Although government programs such as WIC provide health and nutrition assistance to

families and pregnant women who qualify for the program, guidelines exist which can prevent

these individuals in financial need from qualifying to receive WIC benefits. In the state of

Virginia, pregnant women do not qualify for WIC benefits if their annual income exceeds

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$29,101 and an annual income exceeding $44,123 for a family of four.30 In addition to WIC,

other government-funded programs such as Supplemental Nutrition Assistance Program (SNAP)

provide nutrition assistance to families. For the fiscal year of 2015, 22,736,980 households

participated in this program.31 A number of eligibility requirements such as income, resources,

deductions, employment requirements, and immigrant eligibility must be met for a family to

receive SNAP benefits, which unfortunately excludes many tight-budgeted individuals and

families.31 Financial hardships can have an impact on the quality and quantity of foods purchased

from a grocery store. Thus, the need for ways in which healthy foods can be purchased while on

a budget exists.

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PROJECT DEVELOPMENT METHODS

The need for a comprehensive and concise educational tool related to nutrition during

pregnancy was identified by Registered Dietitians, Dana Cullen, RD and Kara Watts, RD, CSP,

practicing in the field of maternal health. A review of the literature for specific nutrition needs

during the perinatal period was performed. The results yielded a comprehensive collection of

up-to-date and existing data on various pregnancy-related nutrition topics including: maternal

and fetal weight gain recommendations, maternal and fetal health complications related to lack

of or excess weight gain during pregnancy, nutritional guidelines throughout each trimester,

vitamins and minerals of importance, common nutritionally-relevant side effects of pregnancy,

misconceptions about food, breastfeeding, health literacy and grocery shopping on a budget.

Existing and frequently used educational materials from the UVA High-Risk Obstetrics

Clinic and the Virginia Department of Health WIC Office was then collected. Determining

which topics to use as the foundation for the handouts involved input from project preceptors.

This information was determined through the consideration of frequently asked questions from

patients, analysis of the literature review, and evaluation of commonly used educational

materials such as handouts and pamphlets. Based on these factors, new handouts were created

and outdated handouts were updated.

The new educational materials were written using language suitable for sixth to eight

grade reading level. The reading level of the text was determined through the use of the Flesch-

Kincaid reading level scale under an editing feature within Microsoft Word which uses the

Flesch-Kincaid readability scale to generate a reading ease score as well as reading grade level.

For the purposes of the handouts, the researchers chose to use the Flesch-Kincaid grade level

score. The handouts were then reviewed and assessed by project preceptors who provided

[26]

suggestions and revisions in regard to content and text. Finalized versions of the materials were

saved as a Microsoft Word document. After approval of the finalized editions of the handouts,

two versions of each handout were created following UVA and WIC branding guidelines

respectively. The individual handouts were then compiled into one Word Document to create the

manual. This document was then converted into a PDF file and saved. The final result included

two sets of the same manual each with different formats adhering to the institution’s branding

guidelines. Once the manual was developed, reviewed and approved, two electronic versions

were saved and printed. The electronic and hard copies serve as templates for additional copies

to be made or for editing purposes in the future.

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PROJECT PRESENTATION

The results from our project generated the development of an educational tool to be used

by health care providers in the field of maternal health as well as a variety of patient populations

including high-risk pregnancy, expectant mothers and pregnant women receiving nutrition

assistance through programs such as WIC. The completed project consists of an educational

manual saved in PDF and Word Document formats and contains individual handouts to be saved

or printed off as needed. The manual, entitled, “Healthy Eating on a Budget during Pregnancy”

contains the following handouts: “Ten Things to Know about Nutrition and Pregnancy”,

“Healthy Eating and Weight Gain during Pregnancy”, “Shopping on a Budget during

Pregnancy”, “Foods to Help Control Side Effects”, “Food Safety during Pregnancy”, “Iron and

Pregnancy”, “Folate and Pregnancy” and “Vegan and Vegetarian Diets during Pregnancy”. All

handouts are displayed in the Appendix on page 34.

A number of resources and criteria were utilized to obtain information to include in each

handout; however, the literature review was the major source for basic information. The “Ten

Things to Know about Nutrition and Pregnancy” handout was made for the purpose of providing

a ‘snapshot’ or synopsis of nutrition during pregnancy. This handout will be most beneficial to

mothers who might not be interested in an abundance of information and are solely interested in

the basic facts. Input from project preceptors was utilized to define the most important facts to

include about nutrition during pregnancy. The reading level of this handout is 5.4.

The “Healthy Eating and Weight Gain” handout was designed to inform patients and

health care providers about the general weight gain guidelines (established by the Institute of

Medicine), the importance of gaining the appropriate amount of weight, the importance of good

nutrition during pregnancy, estimated energy requirements and nutrient serving suggestions for

[28]

the maternal diet. This handout serves as another document to recommend to patients if general

guidance is needed regarding nutrition during pregnancy. This handout generated a reading level

of 7.8.

The handout, “Shopping on a Budget during Pregnancy” utilized existing handouts

provided at the Charlottesville WIC office. This handout provided a number of recipes for

expectant mothers to make using healthy ingredients included in the WIC package for pregnant

women. The purpose of this handout is to provide patients with healthy and easy recipes to make

using affordable ingredients. The reading level of this handout is suitable for a grade level of 4.8.

The purpose of the “Foods to Help Control Side Effects” handout is to educate patients

and health care providers about which foods can be consumed to ease uncomfortable side effects

of pregnancy and which foods might aggravate these symptoms. Current handouts were utilized

to gather this information. This handout will be useful for patients experiencing any degree of

pregnancy side effects. The reading level of this handout is 6.3.

For the “Food Safety” handout, our goal was to educate patients and health care providers

about the increased risk for foodborne-illness which occurs with pregnancy. This handout can be

used to educate patients about how to handle, consume, prepare and shop for food safely to

reduce the risk for exposure harmful bacteria and pesticides found in food. In addition a list of

foods to avoid during pregnancy is also included in this handout. This handout generated a

reading level of 7.7.

The “Iron and Pregnancy” and “Folate and Pregnancy” handouts were developed using

input from project preceptors in regard to important nutrients to consume during pregnancy as

well as common concerns patients have for nutrient and supplement intake. The existing

handout, “Iron” was revised and updated and was a major source of information for the new

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handout. The folate handout was a newly created document. Both handouts utilized information

collected from the Office of Dietary Supplements sector of the National Institutes of Health.

These handouts can be used for patients inquiring about food sources of iron and folate. The

reading level of the iron handout is 7.5 and 6.9 for the folate handout.

The vegan and vegetarian handout was created as a request from project preceptors due to

the occurrence of vegetarian and vegan lifestyle choices in this population and the concern about

whether this diet can be safely followed during pregnancy. Information for this handout was

obtained from existing handouts and current literature. The purpose of this handout is to educate

patients and health care providers about the importance of following a well-planned vegan and

vegetarian diet as well as specific micro and macronutrients to include in the diet during

pregnancy. The reading level of this handout is suitable for a grade level of 6.8.

The manual will be implemented by health care providers at the UVA Health System in

the High-Risk Obstetrics Clinic and the Virginia Department of Health WIC office where it will

be distributed to patients. The ultimate goal of this educational tool is to create awareness of the

importance of nutrition during pregnancy and help patients make healthy dietary choices to

promote proper fetal growth and development during pregnancy. In the future, assessment

regarding patient adherence to the information and guidelines provided by the manual could

potentially be assessed at follow-up visits.

[30]

REFERENCES

1. Healthy Babies are Worth the Wait. March of Dimes website. http://www.marchofdimes.org/professionals/healthy-babies-are-worth-the-wait.aspx. Accessed December 2014.

2. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013.

3. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2013. Rockville, Maryland: U.S. Department of Health and Human Services, 2013.

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

5. 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.

6. 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.

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

8. Luke, B., Eberlein, T. When You’re Expecting Twins, Triplets, or Quads. New York, NY: HarperCollins Publishers, Inc., 1999.

9. 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.

10. What Should I Eat? For Moms. USDA Choose My Plate website. http://www.choosemyplate.gov/food-groups/downloads/resource/pregnancyposter.pdf. Accessed December 2014.

11. Folate Dietary Supplement Fact Sheet. National Institutes of Health Office of Dietary Supplements website. http://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. Updated December 14, 2014. Accessed December 2014.

12. Iron Dietary Supplement Fact Sheet. National Institutes of Health Office of Dietary Supplements website. http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/. Updated April 08, 2014. Accessed December 2014.

13. 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

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weight, preterm birth and small-size-for-gestational age (SGA)- a systematic review and meta-analyses. BJOG 2011;118:1411-1421.

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

15. 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.

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

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

18. 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.

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

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

21. American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. Am J Obstet Gynecol. 2013;(137):1-11.

22. 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.

23. American Dietetic Association. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. J Am Diet Assoc. 2009;109:1926-1942.

24. StoryM. Stang, J. Nutrition and the Pregnant Adolescent: A Practical Reference Guide Minneapolis, MN: Center for Leadership, Education and Training in Maternal and Child Nutrition, University of Minnesota, 2000.

25. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services Office of the Surgeon General; 2011.

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

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

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

29. 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.

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

31. 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.

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APPENDIX

Manual: “Healthy Eating on a Budget during Pregnancy”

Handout: “Ten Things to Know about Nutrition and Pregnancy”Flesch-Kincaid Reading Level: 5.4Resources: 1. Cullen, Dana RD, Watts, Kara RD, CSP,2. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013.

Handout: “Healthy Eating and Weight Gain during Pregnancy”Flesch-Kincaid Reading Level: 7.8Resources: 1. Healthy Babies are Worth the Wait. March of Dimes website. http://www.marchofdimes.org/professionals/healthy-babies-are-worth-the-wait.aspx. Accessed December 2014.2. Institute of Medicine. Weight Gain during Pregnancy: Reexamining the Guidelines. Washington, D.C: National Academies Press; 2009.3. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013.

Handout: “Shopping on a Budget during Pregnancy”Flesch-Kincaid Reading Level: 4.8Resources:1. 10 Tips for Eating Right Affordably. Eat Right website. http://www.eatright.org/resource/food/planning-and-prep/eat-right-on-a-budget/10-tips-for-eating-right-affordably Published January 16 2014.2. “Mom Meals” Recipe Book. Thomas Jefferson Health District.3. “Healthy Snack Ideas” handout. Oregon Health and Sciences University.4. “Grocery Store Shopping: Best Bang for Your Buck and Body” handout. University of Virginia Health System

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Handout: “Foods to Help with Side Effects”Flesch-Kincaid Reading Level: 6.3Resources:1. “Constipation: What You Can Do” handout. Steps to Take.2. “Heartburn: What You Can Do” handout. Steps to Take 3. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013.4. “Tips for Controlling Nausea during Pregnancy” handout.

Handout: “Food Safety during Pregnancy”Flesch-Kincaid Reading Level: 7.71. “Food Safety” handout. Oregon Health and Sciences University. 2. Food Safety for Moms to be. Food and Drug Administration website. Last Updated November 28 2011.3. Playing it Safe with Eggs: Food Facts. Food and Drug Administration website. Last Updated March 30 2015.4. Swinney B. Eating Expectantly. El Paso, TX: Healthy Food Zone Media; 2013.

Handout: “Iron and Pregnancy”Flesch-Kincaid Reading Level: 7.5Resources:1. Cullen, Dana RD, Watts, Kara RD, CSP.2. Iron Dietary Supplement Fact Sheet. National Institutes of Health Office of Dietary Supplements website. http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/. Updated April 08, 2014. Accessed December 2014. 3. “Iron” handout. University of Virginia Health System. April 2000.

Handout: “Folate and Pregnancy”Flesh-Kincaid Reading Level: 6.9Resources:1. Cullen, Dana RD, Watts, Kara RD, CSP.2. Folate Dietary Supplement Fact Sheet. National Institutes of Health Office of Dietary Supplements website. http://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. Updated December 14, 2014. Accessed December 2014.

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Handout: “Vegan and Vegetarian Diet during Pregnancy” Flesch-Kincaid Reading Level: 6.81. Cullen, Dana RD, Watts, Kara RD, CSP.2. Mangels, R. Pregnancy and the Vegan Diet. Simply Vegan. Accessed March 2015. 3. Vegetarian Diets for Pregnancy. Physicians Committee website. Accessed March 2015.

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