34th Scientific Conference of the Nutrition Society of Malaysia Symposium 1 : Maternal, Infant & Young Child Nutrition Promoting healthy maternal nutrition for the best start in in lif life Dr Mastura Ismail Consultant Family Medicine Specialist
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! FROM HEALTHY MOTHER HEALTHY BABY
TIME FOR PARADIGM SHIFT! TO HEALTHY WOMEN HEALTHY MOTHER HEALTHY BABY
Process of identifying risk factors to pregnancy outcome Social Biomedical PREPREGNANCY Behavioural CARE environmental Risk reduction through counselling, education and appropriate intervention PLANNED PREGNANCY
We Currently Intervene Too Late Critical Periods of Development
1933 – 2012 p MMR MALA LAYSIA 1 1200 50 Perbandingan Kadar Kematian Ibu di Malaysia 45 setiap 100,000 kelahiran hidup dengan Matlamat MDG 5 40 1000 35 30 25 800 20 15 10 600 5 0 1991 1995 2000 2005 2007 2009 2010 2011 2012p 2013 2014 2015 Matlamat (MDG 5) 44 40 35 30 28 26 23.5 21 18.5 16 13.5 11 Pencapaian 44 46.9 28.1 27.9 29 27 26.1 26.2 25.6 400 Source of data : Department of Statistics : Family Health Development Division, Ministry of Health 200 0 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
STATUS OF BODY WEIGHT (CURRENT WEIGHT AT FIRST ANTENATAL BOOKING VISIT) FOR MATERNAL DEATH CASES (ALL CAUSES): MALAYSIA 2012-2013 Increased 2 x Source of Data: BPKK,KKM
Non Communic icable le Dis iseases and Obstetric ic compli licatio ions OD: Odds Ratio CI: Confidence Interval ; P value is based on simple logistics regression NCDs are highly prevalent in Malaysia with an incidence of 33.5% in pregnancy National Obstetric Registry 2011 - 2012
Non Communicable Dis iseases and fetal complications OD: Odds Ratio CI: Confidence Interval ; P value is based on simple logistics regression National Obstetric Registry 2011 - 2012
Components of Preconception Care Maternal assessment • Family planning and pregnancy • Domestic abuse and violence * spacing • Immunity and immunization • Family history status • Genetic history (maternal and • Risk factors for STDs paternal) • Medical, surgical, pulmonary and • Obstetric history neurologic history • Gynecologic history • Current medications • General physical exam (prescription and OTC) • Assessment of Socioeconomic, • Substance use, including alcohol, educational, and cultural context tobacco and illicit drugs • Nutrition
In the local setting, the BMI criteria for overweight is 23.0-27.4 kg/m 2 and obesity is ≥ 27.5 kg/m 2 . 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 CPG Management of Diabetes in Pregnancy
Vit B12 (4.5 µg/d): Vitamin A (800 µg/d retinol): Vitamin D (15 µg/d): Vit B1 (1.4mg/d), B2 (1.4 mg/d, Vit B3 18 mg/d): Vit B6 (1.9 mg/d): Vit C (80 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): Vitamin B12 (5 mg/d): Folic acid (500µg/d) Vitamin C (95 mg/d):
Diagnosis of GDM and Overt Diabetes Mellitus ToT CPG Management of Diabetes in Pregnancy 33
ALGORITHM A: SCREENING AND DIAGNOSIS OF DIABETES IN PREGNANCY 34 ToT CPG Management of Diabetes in Pregnancy
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 • 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 ToT CPG Management of Diabetes in Pregnancy 36
Postpartum o 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 o with abnormal postpartum modified glucose tolerance test, metformin and intensive lifestyle intervention should be considered to prevent diabetes o 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 without complications between 37+0 and 38+6 weeks Pre-existing diabetes with maternal or fetal complications before 37+0 weeks on diet alone with no complications before 40+0 weeks GDM on 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 The Sustainable Development Goals Maternal, Infant and Young Child Nutrition (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 own 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
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