Key learning points:
– There is a clear connection between the nutritional status and weight of the mother and unborn child, it’s important to make every contact count
– Dietary assessment, advice and body weight measurement should be integral parts of the first midwifery visit and routinely reviewed during pregnancy
– Weight gain in pregnancy should be no more than around 25-35lbs for a women of BMI status
Around 62% of all adults in the UK were classed as overweight or obese in 2013 and around a third of children aged 10-11 are also in this category1. So it is no wonder that diabetes levels have doubled in the past two decades2,3 and more than a quarter of five year-olds have tooth decay from eating sweets, sugary foods and drinks.4 For around half of us, diets are too high in saturated fats and sugar, and for some, low in essential micronutrients such as iron, folate and iodine.5 In addition, our lifestyles have changed, with less physical exercise and exposure to sunshine, which contribute to obesity and vitamin D deficiency.
Over £5bn is spent by the NHS each year dealing with health problems associated with excess body weight,6 and despite a decline in recent years, cardiovascular disease remains the biggest cause of death in the UK.7 Public health bodies have taken a number of measures to improve the national diet. Initiatives such as Healthy Start, the Change4Life programme, action on food labelling and the Public Health Responsibility Deal, have had limited impact.8-10 We know that what happens to children in their earliest years, and even before birth, is critical to health in adult life so by the time children start school, poor diet and sedentary lifestyle may have already laid the foundation for later ill health.11
Furthermore, poorly nourished mothers are more likely to give birth to babies who are more likely to suffer ill health in later life.12 Deficiencies of folate or excesses such as of alcohol in the maternal diet can have harmful effects on foetal and infant neuro-development13,14. Clearly, if we are to halt this process we need to act earlier.
Act earlier in the life cycle to influence change
A newborn baby depends on its mother for nutrition. Maternal health and nutritional status before conception, through pregnancy and during lactation are critical determinants for the health and development of the unborn baby and growing infant. Some nutrients are especially important at particularly stages of pregnancy.
The period between conception and weaning may be seen as a ‘critical period’, when the way a foetus is nourished in the womb and how a baby is fed after birth, can determine his or her immediate health, growth and development, but also ‘programme’ later health and risk of disease. There is emerging evidence of an ‘intergenerational effect’ whereby a child born poorly nourished may carry adverse health consequences into adulthood and pass them on to the next generation.15
Early life – a window of opportunity
Early life is therefore an important window of opportunity, when the potential health and life chances of infants and children can be maximised, and the risks of poor health, growth and development can be minimised.
The first 1,000 days of life, the period between conception and second birthday is crucial window, where one can focus on a ‘life-course’ approach to optimising health.16 Maternal health and nutrition during pregnancy, in line with the UK cross-party 1,001 Critical Days Manifesto, which calls for a holistic approach to antenatal and postnatal health services from conception to the toddler years.17
What additional nutritional needs does an expectant mother have during pregnancy
Based on current evidence there are four areas in which poor maternal diet and lifestyle can affect the health of offspring in early life and have long-term adverse health consequences particularly in pregnant mothers that are in the obese category (folate and vitamin D deficiency). The first of these are the specific nutrients which have a key role in the health of the baby. A low status in these vitamins below could have an adverse effect on the health of the baby. (See box)
The role of the community midwife in educating mothers and the benefits of doing so
Research of 150 healthcare professionals, including midwives found that while many recognised the important role they had to play in informing mothers about nutritional advice, supplements and weight gain, many felt a lack of confidence in their knowledge of this subject.
It is generally accepted that new mothers are more receptive to lifestyle changes that could benefit them or their baby. We need to adopt the mantra of ‘every woman, every time’.
There is a gap between healthcare policy and effective implementation which may be due to many obstacles in the path of healthcare practitioners seeking to offer dietary and lifestyle advice and nutritional support to parents and parents-to-be and the public.
These barriers include:
Overstretched frontline staff. It is estimated that there would be approximately 38,478 women giving birth in the UK each year with a BMI ≥35; This equates to one in 20 maternities. At a time when the proportion of complex births is rising18 and the rate of maternal obesity is increasing19; over a third of HCPs say they have insufficient time to offer effective nutritional support to pregnant women20.
Insufficient and/or inadequate resources – while parents-to-be are seen as a receptive audience to dietary and lifestyle advice, HCPs feel they need better information and resources to help advise them. Factsheets, apps, quick reference cards and videos are regarded as helpful ways of delivering dietary advice20.
Inadequate training of healthcare practitioners – on nutritional advice in pregnancy. More than one third of HCPs do not receive training on lifestyle advice during pregnancy, over half are unaware of NICE guidelines on nutrition in pregnancy20, and many lack confidence in giving specific nutritional advice to parents – 69% do not discuss supplements with pregnant women20. Weight management can be particularly troublesome as some midwives and health visitors do not want to ‘get off on the wrong foot’ with parents they have only just met. Routine weighing is not mandatory, and only 18% of HCPs feel very confident in raising the topic of weight management during pregnancy.20
Resources for midwives
Using the new Healthy Eating in Pregnancy Factsheet, community midwives can work with mums to start a healthy conversation around the benefits of being a healthy weight and not gaining too much weight in pregnancy, they can also talk about the need for a good diet and impact this has on the health of both them and their child. A recent report Early Nutrition for Later Health; Time to Act
Earlier, published by the Infant and Toddler Forum sets out the framework for encouraging healthcare professionals to act earlier in the life-course of a person, to ensure they have the healthiest start to life.
For this to happen the following elements are critical:
– Guidelines on weight management during pregnancy.
– Redoubling of efforts to improve numbers of midwives and health visitors and their knowledge of the importance of early life to lifelong health.
– Training in nutrition for HCPs working with women throughout preconception, pregnancy and beyond.
Pregnancy, and planning for pregnancy, is an ideal opportunity for encouraging positive dietary and lifestyle behaviour change as women are often motivated to adapt their food intake and lifestyle choices to do the best for their unborn child.
Health professionals should offer consistent, evidence-based dietary and lifestyle advice throughout the pregnancy; including on weight gain and supplementation which are important around pregnancy.
Links and information
The Infant and Toddler Forum (ITF) is a group of experts in the fields of child health, dietetics, nutrition, obstetrics and midwifery.
The ITF is celebrating 10 years of providing free educational resources to healthcare professionals and parents on providing good nutrition, information on supplements, advice on feeding and portion sizes (which is award winning).
It is supported by an unrestricted educational grant from Danone Nutricia Early Life Nutrition. It is important to note that the ITF is not aligned to any brand. The views and outputs of the Forum remain independent of DNELN and its commercial interests.
To download the report, Early Nutrition for Later Health: Time to Act Earlier visit: www.infantandtoddlerforum.org
A free factsheet on Healthy Eating in Pregnancy for HCPs is available from the following link: www.infantandtoddlerforum.org/media/upload/pdf-downloads/5.1_Pregnancy_F...
1. Public Health England, UK and Ireland prevalence and trends on obesity, adults and children Adults and Children in UK and Ireland: http://www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_... (Accessed December 2014)
2. Diabetes UK, Key statistics on diabetes. http://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-in-t... (Accessed October 2014)
3. Selvin E, Parrinello CM, et al. Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med. 2014:160(8):517–25
4. Public Health England. National Dental Epidemiology Programme for England: Oral health survey of five-year-old children. 2012
5. Bates B, Lennox A et al. National Diet and Nutrition Survey Headline results from Years 1-4 (combined) of the Rolling Programme (2008/2009 – 2011/12).
6. Department of Health and Jane Ellison MP. Reducing obesity and improving diet. https://www.gov.uk/government/policies/reducing-obesity-and-improvingdiet/ (Accessed October 2014) Link does not work
7. British Heart Foundation. Heart statistics. http://www.bhf.org.uk/research/heart-statistics.aspx (Accessed October 2014)
8. The Lancet UK Policy Matters. Maternal Vitamin D supplementation via the Healthy Start programme. http://ukpolicymatters.thelancet.com/maternalvitamin-d-supplementation-v... (Accessed October 2014)
9. Department of Health. Change4Life one year on. http://webarchivenationalarchives.gov.uk/20130107105354/http://www.dh.go... DH_112529 (Accessed October 2014)
10. Petticrew M, Eastmure E et al. The Public Health Responsibility Deal: how should such a complex public health policy be evaluated? J Public Health.2013:35(4):495-501
11. Rudolf M. Tackling Obesity Through the Healthy Child Programme: A Framework for Action. 2009. http://www.noo.org.uk/uploads/doc/vid_4865_rudolfTacklingObesity1_210110... (Accessed October 2014)
12. Berti C, Cetin I et al. Pregnancy and infants’ outcome: nutritional and metabolicimplications. Crit Rev Food Sci Nutr. 2014
13. Greenberg JA, Bell SJ et al. Omega-3 Fatty Acid supplementation during pregnancy. Rev Obstet Gynecol. 2008;1(4):162–9
14. Ingrid B. Helland, MD, Lars Smith et al. Maternal Supplementation With Very-Long-Chain n-3 Fatty Acids During Pregnancy and Lactation Augments Childrens’ IQ at 4 Years of Age. Paediatrics. 2003:39-44
15. Norta B, Gigante D et al. Intergenerational effect of weight gain in childhood on offspring birthweight. Int J Epidemiol. 2009: 38(3): 724-32
16. Horton R, LoS. Nutrition: a quintessential sustainable development goal. The Lancet. 2013:382(9890):371-2
17. Leadsom A, Field F et al. The 1001 Critical Days: The Importance of the Conception to Age Two. http://www.andrealeadsom.com/ downloads/1001cdmanifesto.pdf (Accessed October 2014)
18. Parliament UK. NHS midwives shortage remains despite increasing numbers. http://www.parliament.uk/business/committees/committees-a-z/commonsselec... (Accessed October 2014)
19. British Nutrition Foundation. Nutrition and Development: Short and long-term consequences for health. Oxford: Wiley-Blackwell; 2013
20. OnePoll. Early nutrition surveys of mothers/mothers-to-be and healthcare professionals. August 2014. Data on file
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