maternal nutrition for the best start in in lif life Dr Mastura - - PowerPoint PPT Presentation

Promoting healthy maternal nutrition for the best start in in lif life

Dr Mastura Ismail Consultant Family Medicine Specialist

Symposium 1 : Maternal, Infant & Young Child Nutrition 34th Scientific Conference of the Nutrition Society of Malaysia

Outline presentation

• Facts on pregnancies
• Pre-pregnancy Care
• Nutrition requirement in pregnancy
• Consequences poor nutrition
• Gestational Diabetes in pregnancy
• Programs to promote healthy nutrition
• Challenges

FACTS

• 4 out of 10 women report

that their pregnancies are unplanned

• Perinatal deaths are 50%

higher among babies born to adolescent mothers

• Up to 10% of pregnancies

among women with untreated gonococcal infections result in perinatal death

FACTS

• Maternal undernutrition and

iron-deficiency anemia account for at least 20% of maternal mortality

• Female genital mutilation

increases the risk of neonatal death by 15% - 55%

• In the absence of interventions,

rates of HIV transmission from mother to child are between 15 and 45%

Early prenatal care is not enough, and in many cases it is too late!

TIME FOR PARADIGM SHIFT!

HEALTHY MOTHER

HEALTHY BABY

FROM

TIME FOR PARADIGM SHIFT!

HEALTHY WOMEN HEALTHY MOTHER HEALTHY BABY

TO

Process of identifying risk factors to pregnancy outcome Social Behavioural environmental Biomedical Risk reduction through counselling, education and appropriate intervention PLANNED PREGNANCY

PREPREGNANCY CARE

We Currently Intervene Too Late Critical Periods of Development

1933 1935 1940 1946 1950 1957 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2009 2010 2011 2012p MMR 1080 960 770 670 530 280 240 200 150 80 60 40 20 46.9 28.1 28.1 27 26.1 26.2 25.6

200 400 600 800 1000 1200

MMR MALA LAYSIA 1 1933 – 2012p

Source of data : Department of Statistics : Family Health Development Division, Ministry of Health

Perbandingan Kadar Kematian Ibu di Malaysia dengan Matlamat MDG 5

Source of Data: BPKK,KKM Increased 2 x

STATUS OF BODY WEIGHT (CURRENT WEIGHT AT FIRST ANTENATAL BOOKING VISIT) FOR MATERNAL DEATH CASES (ALL CAUSES): MALAYSIA 2012-2013

Non Communic icable le Dis iseases and Obstetric ic compli licatio ions

NCDs are highly prevalent in Malaysia with an incidence of 33.5% in pregnancy

National Obstetric Registry 2011 - 2012 OD: Odds Ratio CI: Confidence Interval ; P value is based on simple logistics regression

Non Communicable Dis iseases and fetal complications

National Obstetric Registry 2011 - 2012 OD: Odds Ratio CI: Confidence Interval ; P value is based on simple logistics regression

Components of Preconception Care Maternal assessment

• Family planning and pregnancy

spacing

• Family history
• Genetic history (maternal and

paternal)

• Medical, surgical, pulmonary and

neurologic history

• Current medications

(prescription and OTC)

• Substance use, including alcohol,

tobacco and illicit drugs

• Nutrition
• Domestic abuse and violence *
• Immunity and immunization

status

• Risk factors for STDs
• Obstetric history
• Gynecologic history
• General physical exam
• Assessment of Socioeconomic,

educational, and cultural context

CPG Management of Diabetes in Pregnancy

In the local setting, the BMI criteria for overweight is 23.0-27.4 kg/m2 and obesity is ≥27.5 kg/m2. There is no recommendations on total and rates of weight gain for local population. However, targeting GWG to the lower range in Table 1 may be recommended to improve pregnancy outcomes.

19

Vitamin A (800 µg/d retinol): Vitamin D (15 µg/d): Vit C (80 µg/d): Vit B1 (1.4mg/d), B2 (1.4 mg/d,

Vit B3 18 mg/d):

Vit B6 (1.9 mg/d): Vit B12 (4.5 µg/d):

Folic acid (Vit B9) (RDA-600 µg/d) : Zinc (RDA- 10 mg/d) :

+19 g/day +13 g/day

Vitamin A (850µg/d): Vitamin B6 (2 mg/d): Folic acid (500µg/d) Vitamin B12 (5 mg/d): Vitamin C (95 mg/d):

Diagnosis of GDM and Overt Diabetes Mellitus

ToT CPG Management of Diabetes in Pregnancy 33

ToT CPG Management of Diabetes in Pregnancy

ALGORITHM A: SCREENING AND DIAGNOSIS OF DIABETES IN PREGNANCY

34

Carbohydrate-controlled Meal Plan

• The ideal macronutrients distribution for pregnant women

with diabetes is not known. Macronutrient distribution should be individualised.

• A general recommendation to promote a balance diet of

total energy requirement:  45-60% CHO  15-20% protein  25-35% fat

ToT CPG Management of Diabetes in Pregnancy 35

Antenatal

ToT CPG Management of Diabetes in Pregnancy

• Metformin is safe and recommended after failed 1 - 2

weeks of MNT

• Insulin is indicated to achieve glycaemic target
• Pre-eclampsia prophylaxis: Low dose aspirin (75 - 150 mg

daily) from 12 weeks of gestation until term.

• Retinal and renal assessment

36

Postpartum

• OGTT should be performed at 6 weeks after delivery to detect

diabetes and pre-diabetes. If the result is negative, annual screening should be performed

• with abnormal postpartum modified glucose tolerance test,

metformin and intensive lifestyle intervention should be considered to prevent diabetes

• breastfeeding of at least 3 months or longer should be

encouraged to reduce the risk of diabetes

ToT CPG Management of Diabetes in Pregnancy 37

Blood glucose target

ToT CPG Management of Diabetes in Pregnancy 38

Fetal Surveillance

ToT CPG Management of Diabetes in Pregnancy 39

Timing of deliveries

Condition Timing Pre-existing diabetes without complications between 37+0 and 38+6 weeks with maternal or fetal complications before 37+0 weeks GDM

• n diet alone with no complications

before 40+0 weeks

• n oral antidiabetic agents or insulin

between 37+0 and 38+6 weeks with maternal or fetal complications before 37+0 weeks

ToT CPG Management of Diabetes in Pregnancy 40

Programmes and efforts in in promoting healthy maternal nutrition during pregnancy and la lactation

• The 11th Malaysia Plan 2016-2020 and National Strategic Plan for

Non-Communicable Disease 2016-2025 are key Government strategies

• The third National Plan of Action for Nutrition Malaysia (NPANM III,

2016-2025) has identified various programmes and activities to tackle the existing double burden of malnutrition.

• The Health Ministry’s (MOH) Anti-Obesity Taskforce has also proposed

several policy options to be implemented.

Global Monitoring Framework for Maternal, Infant and Young Child Nutrition

The Sustainable Development Goals (SDGs) 2030

Global Action Plan for the Prevention & Control of NCDs 2013-2020

National blueprints and policies used as references in the preparation NPANM III, 2016-2025.

National Plan of Action for Nutrition Malaysia (NPANM III, 2016-2025)

• Identified 46 nutrition indicators
• Under following specific areas

I. Promoting Maternal, Infant and Young Child Nutrition (10); II. Promoting Healthy Eating and Active Living (11); III. Preventing and Controlling Nutritional Deficiencies (9) and IV. Preventing and Controlling Obesity and Diet-related NCDs (16).

Technical Working Groups (TWGs)

• 1. Policy
• 2. Dietary Guidelines
• 3. Training
• 4. Research
• 5. Promotion and
• 6. Food and Nutrition Security

MOH is responsible for monitoring all the implementation of activities

Stakeholders for th the im implementation of f th the proposed programmes and activities

• Strategic, multi–stakeholder, multi-sectoral collaboration and cooperation

approach to effectively tackle the double burden of malnutrition.

• Whole-government approach, involving several key ministries, as well as

engaging other key stakeholders, including civil society and private sector entities.

• MOH’s Nutrition Division, along with the Food Safety & Quality Division,

NCD Division and the Health Education Division, in playing a lead role to implement the NPANM III activities.

• Supporting other ministries and agencies, agriculture, education, and

housing and local government etc, all of which should also develop their

• wn nutrition and lifestyle-related activities.
• Relevant professional bodies, as well as corporate companies

Nutrition Programmes and Activities Related to Pregnant Women and In Infants

• Nutrition Surveillance on Pregnant Women and Infants
• Nutrition Education for Mothers
• Nutrition Counselling for Pregnant and Lactating Women
• Breastfeeding Promotion
• Baby Friendly Hospital & Clinic initiatives
• Breastfeeding mothers support group
• Code of ethics for the marketing of infant foods and related products
• Cooking Demonstration on diet
• Supplementary Feeding Program for pregnant and lactating mothers
• Anaemia Prevention Program
• Iodine Deficiency Prevention Program

Nutrition Month Malaysia, which began in 2002

• To promote nutrition to the community at large,

Nutrition promotion programmes for specific target groups, especially infants, children and pregnant and lactating women.

• Educational materials for the public: recipe books,

leaflets and booklets.

• Malaysia Nutrition Leadership Programme

Data required for the development and im implementation of f the strategies and pla lans

• Research studies to provide evidence-based data to support the

formulation of sound public health policies.

• For example, a large nationwide MyBreakfast Study of primary and

secondary school children provided useful data such as body mass index (BMI), physical activity and food consumption pattern.

• In the Healthy Kids Programme, we developed and evaluated a nutrition

education module for promoting healthy eating among primary school children.

• In MyNutriStudy, studied the nutritional status, food habits and cognitive

performance of preschool children.

• Organising national and international scientific conferences and seminars

contributing to the professional development of nutrition scientists.

Challenges

• Establishment of the National Institute of Nutrition (NIN) was put on

hold because MOH focusing on the establishment and development

• f Nutrition Division
• Shortage of nutritionist at government health sector
• WHO: 10 allied health professionals for every 100,000

population.

• Currently : about three nutritionists and dietitians for every

100,000 population. More outreach activities need to be carried out especially targeting at the vulnerable groups such as infants and young children.

Challenges

• Inadequate intervention among school children
• Implementation of Baby Friendly Hospital Initiative (BFHI) was

unfavourably taken up by the private hospitals.

• Poor public awareness :Findings of national surveys showed that most
• f the Malaysians are still not able to fully understand and translate

the concept of the Food Pyramid into practices – hence need to do massive education

• use of social and mass media as a communication medium to

promote healthy eating messages to the public must be optimized

• Reaching out to food operators/providers to provide healthy meals

Specific challenges:

• 1. Lack of ministries and multi-stake holders coordination: Need to

develop Road Map that allow adequate coordination

• 2. Financial shortfall and lack of sustainable financial commitment
• 3. Lack of capacity- esp human resource
• 4. Lack of monitoring and evaluation