1. Nutrition Issues: Women's Life Stages Learning Objectives Identify nutrition issues for a women: –During pregnancy focusing on high risk –In midlife to reduce chronic disease risk – In older age to address multiple medical and/or social problems Assess Weight, Activity, Variety and Excess for each age cycle and determine when refer for medical nutrition therapy with Registered Dietitian (RD) is needed.

2. Pregnancy Issues

3. Weight Pregnancy: 1-2 lb mo 1 st trimester; 0.5-2 lb week in 2 nd & 3 rd Trimester Midlife: Weight distribution & risks relate to metabolic syndrome. Older Age: Unintentional weight loss > 10 lb at risk Activity Pregnancy:  impact weight-baring activity > fetal distress. Midlife: Weight-baring activity  risk of osteoporosis. Older Age:. Assess for unsteady gait. Variety Pregnancy: Calcium iron, protein, fiber/water, and folate Midlife: Metabolic syndrome, N-3 fatty acids; calcium intake, vegetables Older age: Absorption/nutrient requirements; Calcium/Vit D, Vit B-12, and zinc supplements may be needed. Excess Pregnancy: Screen for cravings, EtOH intake, Midlife: CHO & lipids, meat & calcium excretion Older Age: Food/EtOH behaviors to cope with loneliness.

4. American Dietetic/Diabetes Association Exchange System Overview Exchange CaloriesCHOProteinFat Starches (1/2 C 1 oz) 8015 g2 gtrace Fruit (1/2 C) 6015 g0 g0 Milk (8 oz) 90-16012 g8 gTr-8 g Vegetables (1/2 C) 255 g2 g0 Meat (per oz) 55-1000 g7 g3-8g Fat (tsp) 450 g 5g FREE FOOD < 15 calories per serving

5. Quick Carbohydrate Counting One Carbohydrate choice = 15 grams based on the ADA’s Exchange system Exchange groups included are: - Starch (1/2 cup, slice of bread) - Fruit (1/2 cup) - Milk (1 cup) - Other Carbs (varies by concentration) Glycemic Indexing Issues

6. GDM Carbohydrate ~40-45% of Energy Meat, Cheese, Vegetables- not measured Breakfast30 grams: 1 starch + 1 milk ½ cup oatmeal and 1 cup milk Morning snack 15 grams: 1 milk or 1 starch or ½ of each 4 oz milk and 2 crackers Lunch45-60 grams: 2 starches, 1 milk and 1 fruit Sandwich, 1 cup of milk and a piece of fruit Afternoon Snack 15 grams: 1 milk or 1 fruit 1 diet yogurt or 1 piece of fruit Dinner45-60 grams: 2 starches 1 cup of pasta (with meat) vegetables, small apple and 1 cup of milk Night Snack 15-30 grams: 1 milk and 1 starch Crackers (with cheese) and milk

7. Recommended Weight Gain based on Prepregnancy BMI* BMI< 19.8 kg/m 2 28-40 pounds BMI 19.8-26 kg/m 2 25-35 pounds BMI > 26 kg/m 2 15-25 pounds *American Diabetes Association Guide to Medical Nutrition Therapy

8. Weight Gain Recommendations for Pregnant Women (Overweight Cuts Weight Gain Rx in Half) Normal weight 3-5 pounds per month 1st trimester 1-2 pounds per week 2nd and 3rd trimesters Overweight 11/2 - 21/2 pound per month 1st trimester 1/2 -1 pound per week in 2nd and 3rd trimesters

9. Nutrition-Related Pregnancy Problems Rates in the United States Hypertension ~ 12-22% Preeclampsia ~ 6-8% Gestational Diabetes~ 2-14% Anal fissures/external hemorrhoids disease occur ~ 35% of pregnancies. Postpartum Iron Deficiency rates: 30% if < 130% of poverty level 7% if > 130% of poverty level Neural tube Defects ~ 4000 annually

10. Tight Glucose Control in GDM Reduction in Adverse Outcome

11. Midlife Issues

12. Dietary Approach to Stop Hypertension DASH Daily Recommendations 7-8 Serving - grains, emphasis on whole grains 4-5 Serving - vegetables 4-5 Servings - Fruits 2-3 Servings - low-fat dairy products < 2 Servings - Meats 2-3 Servings Oils * Eat 4-5 servings of nuts, seeds and dried bean per week Limit intake of sweets to 5 per week

13. Midlife CVD Risk for Women Metabolic Syndrome Synonyms Insulin resistance syndrome (Metabolic) Syndrome X Dysmetabolic syndrome Multiple metabolic syndrome

14. Metabolic Syndrome Therapeutic Objectives To reduce underlying causes –Overweight and obesity –Physical inactivity To treat associated lipid and non-lipid risk factors –Hypertension –Prothrombotic state –Atherogenic dyslipidemia (lipid triad)

15. Specific Dyslipidemias: Possible Causes of Elevated Triglycerides High carbohydrate diets (>60% of energy intake) Several diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome) Certain drugs (corticosteroids, estrogens, retinoids, higher doses of beta-blockers) Various genetic dyslipidemias

16. Lipoprotein pattern: atherogenic dyslipidemia (high TG, low HDL, small LDL particles) Baseline triglycerides:  200 mg / dL –Lifestyle option: Weight loss  EtoH and Carbohydrate –Supplement options: Niacin Omega-3 fatty acids LDL-cholesterol goal: <100 mg/dL Diabetic Dyslipidemia

17. Older Age Issues

18. Older Age Assessment of Nutritional Risk Unintentional weight loss or BMI < 22 kg/m 2 Serum Albumin < 3.5 mg/dL Unintention reduction in cholesterol or < 150 mg/dL Reduced calorie or protein intake Difficult swallowing and/or gastric reflux Decreased appetite or ability to eat/obtain food Depression Economic Issues

19. Treatment Options for Low Weight in Older Adults Liquid suppmements Medications that stimulate appetite and weight gain Vitamin/mineral supplementation Referral to RD and social service Use enteral nutrition before considering TPN

20. Congestive Heart Failure Nutritional Evaluation Fluid retention (pedal edema or ascities) All blood levels in relation to fluid retention Serum electrolytes (high sodium and low potassium) Hypotension Protein (risk of cardiac cachexia)

21. Treatment of Congestive Heart Failure Reduce sodium to < 2400 mg; DASH diet Check adequacy of protein and calorie intake Check fluid status daily (sign of edema and daily weights) Stablize before surgery and invasive medical procedures monitor afterwards

22. Nutrition Referral Issues Integrate nutrition into your overall workup by briefly assessing weight, activity, variety and excess. Refer women to RD for in-depth Medical Nutrition Therapy consultation if: 1. You identify a nutrition-related problem and 2. Patient is ready to address the problem.