Question

Background

You work as a nutrition consultant with a group of midwives. Today you are meeting with Laura, a 34 year old woman who is 30 weeks pregnant. Laura has had one previous pregnancy that resulted in the birth of a 9.7 pound healthy baby, Sarah, who is now 16 months old. Laura is married, and her husband, David, is with her at this visit. David works full time as a Physician Assistant, but the practice that he works for has recently been purchased by a health plan and he is unsure about his job's future right now. Laura works half time as a legal secretary.

Laura and David carefully planned for their first pregnancy. They were married several years ago, but waited to have their first child until they were financially secure enough that Laura could work part time after the baby came. They both made a point of making healthy food choices and avoiding alcohol when they were trying to conceive their first child. They attended both a preconception health education class and a prepared childbirth class.

Sarah proved to be a challenging baby. She is only now beginning to sleep through the night. She had "colic" symptoms until she was almost 6 months old. Laura and David felt strongly about breastfeeding, and had been to classes and read books about breastfeeding. However, they encountered some difficulties with breastfeeding for the first few weeks. These included sore nipples, a breast infection, and a perceived lack of an adequate milk supply. When Laura went back to work 3 months post partum Sarah eagerly took bottles of formula while her mother was at work. Despite Laura's plan to maintain exclusive breastfeeding and pumping of breastmilk for several months, Sarah was soon just nursing a couple of times a day, and stopped nursing altogether 2 to 3 weeks after Laura discovered that she was pregnant again.

Laura and David had wanted another child at some point, but this current pregnancy was not intended. Although they have accepted the pregnancy, they state that they have concerns about the effect that a new baby will have on Sarah, their marriage, and their finances.

Laura and David have good health insurance coverage, but Laura has only been seen 4 times for prenatal care for this pregnancy.

Anthropometric Data

Just prior to this pregnancy, Laura was 175 pounds (lbs). She is 61 " tall. She gained 55 lbs her first pregnancy, and lost 20 before becoming pregnant again. Today she is 200 lbs.

Health History

Laura's health history is unremarkable. Her blood pressure today is within normal limits. She denies use of drugs, tobacco.

Laura states that she does not like to exercise. She joined a health club a few years ago, but stopped going after about 6 weeks because she felt out of place and she thought that it was boring. She started a walking program after her first pregnancy with another new mother from her mom’s group, but her friend moved away and Laura doesn’t like to walk alone.

At the beginning of both of her pregnancies Laura experienced considerable nausea and occasional vomiting as well as overwhelming fatigue. Today Laura complains of the onset of several pregnancy discomforts that also bothered her toward the end of her first pregnancy. These include heartburn, intermittent diarrhea and constipation, fatigue, and edema in her ankles.

Supplements

Laura is occasionally taking a standard prenatal vitamin and mineral supplement that contains 30 mg per day of elemental iron. She feels that this supplement has contributed to some of her pregnancy related discomforts. David has recently been to a continuing education conference on nutrition and reproductive health. There were several vendors of nutritional supplements who displayed products at the conference. He is asking your advice today about fish oil, zinc, and calcium supplements in pregnancy.

Dietary Intake

Before the visit you asked Laura to keep three day food records. She brings them with her today. (See second to last page of this document). She states that this pattern is typical for a weekday when she works mornings. Saturdays are variable depending on what errands need to be done, but usually one or two meals are at a fast food place. On Sundays Laura goes out with David and Sarah after church for a large breakfast at Denny's (fried eggs, bacon, toast, hash browns) and then has a pizza meal in the evening.

LAURA’S TRACKED DIET (3 DAYS)

Day One	Day Two	Day Three
Breakfast 2 c. Coffee with cream	Breakfast 2 c. Coffee with cream	Breakfast 2 c. Coffee with cream
Break at Work Donut Decaf Coffee with cream	Break at Work Donut Decaf Coffee with cream	Break at Work Donut Decaf Coffee with cream
Lunch Tuna sandwich (water packed albacore tuna, mayo, pickle relish, white bread) 12 oz unpasturized Whole milk Potato chips ½ sandwich leftover from Sarah's lunch	Lunch Tuna sandwich (water packed tuna, mayo, pickle relish, white bread) unpasteurized Whole Milk ½ c pretzels ¼ sandwich leftover from Sarah	Lunch Tuna sandwich (water packed tuna, mayo, pickle relish, white bread) 1 c Apple slices 12 oz unpasteurized Whole Milk ½ leftover sandwich from Sarah
Snack with Sarah 10 Triscuit Crackers 2 oz Cheddar Cheese slices Unpasteurized Apple Juice - 12 oz	Snack with Sarah 10 Triscuit Crackers 2 oz Cheddar Cheese slices Unpasteurized Apple Juice - 12 oz	Snack Sarah 10 Triscuit Crackers 2 oz Cheddar Cheese slices Unpasteurized Apple Juice – 12 oz
Dinner 1/3 a large chicken and spinach Pagliachi Pizza 12 oz beer	Dinner 1 ½ c. Spaghetti ¾ c tomato sauce with ground beef 1 ½ c Salad with iceberg lettuce, carrots, and tomatoes 2 Tbsp. Ranch Dressing 2 thick slices buttered garlic bread 12 oz whole unpasteurized milk	Dinner 1 Ham and Cheese "Hot Pocket" ½ c Green Peas 20 French Fries 12 oz whole milk 1c. Hagen Daas Ice Cream with Dove Chocolate Sauce
Peppermint tea 12 oz	Peppermint tea 12 oz	Peppermint tea 12 oz

Questions

1. Based on a casual overview of Laura’s diet, what concerns do you have about her nutrition – list five specific things she is consuming and explain why these are not ideal.
2. What impacts might her weight status have on this pregnancy?

Answer 1

An overview on Laura's diet includes,

a) Dietary pattern were inadequate...she needs more nutrients, calories and proteins in their diet than consuming only junk foods.

b) Her present weight is around 200lbs,meaning she is obese and consuming drinks and foods like coffee and cream, donut, pizza, white bread, pickle and sandwich may double her weight during the pregnancy period.

Impacts on her weight status:

1. Due to increase weight, she may have end up with gestational diabetes. The prevalence of gestational diabetes among pregnant women are common among many parts of the world. The occurrence of gestational diabetes in mother also affects the new born baby. So, to avoid gestational diabetes, she must follow a strict and nutrient full diet and should also do mild exercises to reduce weight.