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Better Start Bradford Networking Event

Welcome

Better Start Bradford

Welcome to the Better Start Bradford Family

Better Start Bradford Networking Event

Welcome

Current Recommendations and advice: Promoting a healthy diet during pregnancy and early years

time for another drink

Bradford Nutrition: The local hot potatoes and how we can manage them

Final Thoughts

Networking & Information

Current recommendations and advice:

Promoting a healthy diet during

pregnancy and the early years

Dr Helen Crawley

May 2016

Where should we get advice – and

what are the key things to

consider?

• Who should we take advice from?

• What are the key things we should

focus on to improve nutrition from pre-

conception to five years?

• What works – and what support is there

out there for you?

Maternal and child nutrition

Implementing NICE guidance

2nd edition March 2012

NICE public health guidance 11

NICE Quality Standards (98)

2015• NICE quality standards are a concise set of

prioritised statements designed to drive

measurable quality improvements in the 3

dimensions of quality – patient safety, patient

experience and clinical effectiveness – for a

particular area of health or care.

• https://www.nice.org.uk/guidance/qs98/

chapter/List-of-quality-statements

Who do we listen to?

• There are global codes and conventions

which have been set up to protect

women and children

What does this mean?

• This means that in public health we

work within the WHO Code of

marketing of breastmilk substitutes

and relevant WHA resolutions - and

do not use any materials, resources or

information produced by a company

which makes breastmilk substitutes, or

markets food for infants under 6

months.

http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/guide_int_code_health_professionals.pdf

Nutrition matters

• We are in a new era of understanding

about the importance of nutrition in

determining inter-generational health.

•

@ www.oldi

• @ www.oldies.com/artist-songs/Barry-

White/ringtones

• es.com/artist-songs/Barry-White/ringtones

Unfit for pregnancy?

• Young women in the UK are

the most malnourished

group of the population

• They typically have low

status of a wide range of

nutrients, some are too thin

and many too fat, most eat

too few fruits and vegetables

and dietary variety may be

limited.

Young women in low income

households

• Studies show young women in low

income households:

• Have high fat, salt and sugar intakes.

• 1/3 have very low intakes of iron, zinc,

potassium, riboflavin.

• Intakes of vitamin A, calcium,

magnesium and iodine are frequently

very low.

• If they smoke diet is often worse.

Does it matter?

• Children born to poorly nourished parents are

unlikely to reach their full potential.

• Iodine deficiency disorders are the

commonest cause of learning disabilities

worldwide

• If a woman has little or no dairy foods and

does not eat fish it is unlikely she will have

adequate iodine status in the UK – new data

suggests this is becoming a significant

problem among some young women in

particular.

• Low maternal iodine status was associated with an

increased risk of suboptimum scores for verbal IQ at age

8 years, and reading accuracy, comprehension and

reading score at age 9 years

• Results suggested a worsening trend in cognitive

outcome with decreasing maternal status

• Possible in-utero effect of sub-optimal iodine status

2013;382:331-37

Folic acid and vitamin D • An association between the development of

neural tube defects (NTD) and folic acid was

first suggested more than 35 years ago – and

has been recommended for women planning

a pregnancy – and in the first 12 weeks of

pregnancy since 1992.

• Recommendations that all women should

take vitamin D in pregnancy and when

breastfeeding have been in place since 2003

– new recommendations are due this July to

increase amount suggested, and timing in

infancy.

Healthy Start

• The UK revised welfare food scheme – revamped in 2006 to offer vouchers to buy milk, vitamins and fruit and vegetable to low income families and women under 18 years.

• Food vouchers worth £3.10 a week, £6.20 for infants in first year.

• Also free vitamins for pregnant and nursing women and children 1-4 years.

• Universally free in some areas. Bradford?

Finding out more about

Healthy Start

What is the ideal outcome of a

pregnancy?

• Delivery of a full-term healthy infant with a birth weight of 3.1-3.6kg

• Avoidance low birth weight

(< 2.5kg)

• Prevention of maternal mortality, complications of pregnancy, labour and delivery

• Preventing pre- and perinatal morbidity and mortality

Risk factors for LBW

• Nutritional status of mother: short stature, low pre-pregnancy BMI, low gestational weight gain

• Low dietary micronutrient intake

• Smoking, substance abuse, hard physical work

• Poorer prenatal care

• Multiple births

• Psychosocial factors (stressful life events, low social support, depression)

• Many of these are more common among low SE groups

What is the evidence for a

nutritional link to LBW?

• Low gestational weight gain in women who are underweight or normal weight before pregnancy is associated with risk of LBW

• The optimum weight gain for best fetal outcome has been found in studies of many women, to be 10-14kg with an average of 12kg

• NICE antenatal guidance (clinical guidance 62) updated 2016

• NICE Quality Standards (QS22) in 2012

Obesity in pregnancy

• Obesity causes major difficulties throughout pregnancy and in terms of outcome

• Increases gestational diabetes, hypertension, pre-eclampsia, congenital defects, increases chance of abnormal labour and complications – particularly maternal death

• Women obese pre-pregnancy are at greatest risk

• Obese mothers have larger babies and babies born at >4.5kg are also at increased risk of mortality, morbidity

• NICE guidance (PH27, 2011) on obesity before, during and after pregnancy

Alcohol ….

• The Chief Medical Officers’ 2016

guideline is

• If you are pregnant or planning a

pregnancy, the safest approach is not to

drink alcohol at all, to keep risks to your

baby to a minimum.

• Drinking in pregnancy can lead to long-

term harm to the baby, with the more

you drink the greater the risk.• https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48

9795/summary.pdf

• Women who find out they are pregnant

after already having drunk during early

pregnancy, should avoid further drinking,

but should be aware that it is unlikely in

most cases that their baby has been

affected.

• https://www.gov.uk/government/uploads/system/uploads/attachment

_data/file/489795/summary.pdf

Dietary advice in

pregnancy?

Advice to

• Avoid certain foods and drinks

• Limit certain foods/ingredients

• Take some supplements

• Eat ‘a normal healthy diet’ – What does

this look like?

How much does it cost?

How to support dietary

change?

• Behaviour change is complex – but we

know people find it easier to make

changes if they are:

• Involved in the discussion

• Given practical skills

• Given confidence

2016 launch Lancet

Breastfeeding series

http://www.thelancet.com/series/breastfeeding

Unequivocal evidence

• Essential for health of the

infant short and longterm

• Determines population

development

• Protects mother’s health

• And important in terms of

sustainability and health of

the planet.

“When Britain has one of the lowest rates of

breastfeeding you have to ask the question why? Are

British women educated enough about breastfeeding,

or are there other reasons or barriers getting in the

way?’

Risks of not breastfeeding?

Using breastmilk substitutes is associated with a

number of specific health hazards to which

breastfed babies are not exposed. These include:

• the possibility of over- or under-concentrating

formula milk during reconstitution

• the potential for infection introduced by using

substitute milk products, bottles, teats, and other

vessels

• potential risk from ingredients and contaminants

in formula/infant milks

UK recommendations

• In 2003 the UK adopted the WHO

recommendation that babies should be

exclusively breastfed for the first 6

months of life – 26 weeks

• Supported by UNICEF, WHO and all major

health agencies

Currently 90% maternity services and 82%

health visitor settings are registered/accredited

with Unicef Baby Friendly.

Who else offers support and

guidance?

Infant formula

• The Infant Formula and Follow on

Formula Regulations (2007) determine

the composition of infant milks.

• Most claims made to differentiate products

are made for unnecessary ingredients –

and to avoid being miseld, people should

only seek independent information on

infant milks.

Formula milk safety

• Powdered milks must

be made up safely as

they are not sterile.

• There are clear

guidelines for this

published by

DH/FSA/UNICEF

(2011)

Complementary feeding

• UK advice says:

• Introduce complementary food

alongside breast milk at ‘about’ 6

months of age in the first year of life

• Breastfeed throughout first year and as

long after that as mother wishes

• ‘about 6 months’

• Despite current rumours, this is unlikely

to change

Impact of poor nutrition in

early life• Growth stunting

• Poorer immune system

• Impaired cognitive development

• Childhood obesity and type 2

diabetes

• Tooth decay

• Poorer development oromotor

skills

• Fussiness around food type and

texture leading to more limited

diets

Introducing solids

Key factor is ‘readiness for solids’

www.nhs.uk/start4life/solid-foods

Key messages:• Between 6 months and 1 year babies need to get used to lots

of different flavours and textures and learn to feed

themselves.

• Simple ‘family’ foods low in salt and sugar are fine –

meat, fish, eggs, pulses, fruits, vegetables, starchy roots,

cereals should be main components of meals. Diet quality

matters.

• Milk or water to drink

• Appetites will vary day to day and week to week

• Keep offering foods even if not eaten

• Elements of baby led weaning – but needs to meet individual

needs

• Commercial baby foods are poor value for money and are

generally too soft and too sweet.

Fussy eating

• Parental attitudes to

feeding children in many

western countries

becoming anxiety driven

• Concern that children ‘not

liking’ food is a problem,

leading to medicalisation of

early feeding and search

for ‘solutions’

• This has been stimulated

by baby food industry.

Tiny Tastes programme

• Developed by

psychologists at

UCL

(www.weightconcern

.com)

• Uses principles of

repeated exposure

and familiarisation

Who to take nutrition advice

from?

• Code compliant, policy based

organisations/programmes.

• Dietitians or AfN registered nutritionists with a

specialism in public health.

• Schemes which support eating well in early

years settings should be free of commercial

involvement – e.g. HENRY, Food for Life EY

Award

Things to look out for:

• A ‘Healthy Weight,

Healthy Nutrition’

training pack will be

cascaded to HV

nationally during

2016/2017 by The

Institute of Health

Visiting.

Childhood obesity strategy

• No-one knows when this

will come out – will have to

include some statements

related to pre-conception

to five

• In the meantime we have

the WHO ECHO

recommendations which

provide a clear framework

for action

www.firststepsnutrition.org

helen@firststepsnutrition

@1stepsnutrition

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Better Start Bradford Networking Event

Bradford Nutrition –

the local hot potatoes and how

we can manage them.Clare Gelder

Principal Dietitian

Aim

• To provide an overview of local nutritional

issues affecting women of child bearing age

and young children in Bradford

• Consider the and the management strategies as

well as the difficulties faced when dealing with

these issues

Learning Outcomes

At the end of the session, delegates will have an

understanding of ;

– The common nutritional problems observed in

these population groups

– How these issues are managed

– Strategies and practical interventions

– Signposting to further resources and support

Drivers for Change• National Institute for Health & Care Excellence

– Antenatal care CG62

– Antenatal & Postnatal Mental Health CG45

– Diabetes CG63,

– Maternal and Child nutrition PH11

– Quitting smoking in pregnancy PH26

– Weight Management before, during and after pregnancy PH27

– Pregnancy & complex social factors CG110

• Every Baby Matters Strategy

Nutritional issues in

women and pregnancy

Bradford

• The average number of babies per mother in

Bradford is 2.24 (2013: 8,039 babies born)

• National Total Fertility Rate is 1.82

(Office National Statistics, 2014)

• In the UK: 1 in 5 women diagnosed

‘clinically obese’ in pregnancy

• In Bradford its 1 in 4 women

Bradford Infant Mortality

• 8,322 live births district wide (B&A)

• Infant Mortality Rate (IMR) is the number of deaths

under 1 years old per 1000 live births.

• National = 4.0. Bradford = 5.8 (2016 health profile)

• Was 7.0 (2010-2012)

• Bradford was 8.3 (2005-7), 7.9 (2008-10) 5.1 (2014-15)

• 69 infant deaths in 2010, 59 recorded 2010-12

• 58% births in poorest 40% of Bradford

Importance of good nutrition in

pregnancy

• ↓ risk of foetal and maternal deficiencies

• ↑ chance of healthy pregnancy (mother and

baby)

• Preparation for breastfeeding

• Improved development and long term health

(mother and child)

Preparing for pregnancy

Women with BMI 30 or more• Encourage weight loss before pregnancy

• Discuss health risk

• Highlight benefits of weight loss

• Support from weight loss programmes

• Aim for 5-10% weight loss initially

• Encourage a BMI in healthy range

• Advise folic acid supplements

Pregnancy

Women with BMI 30 or more• Biggest risk is from being obese rather than weight

gained during pregnancy

• Dieting is NOT recommended

• Appropriate weight gain:

Pregnancy:

Women with BMI 30 or more• Discuss health risks

• Benefits of healthy diet and physical activity

for mum and baby

• Address concerns – diet and activity

• Advice from a reputable source

• Offer referral to a dietitian

• Dispel myths – eating for two

• Healthy Start Scheme

After childbirth:

Women with BMI 30 or more• 6-8 week postnatal check - opportunity to discuss weight

• If not ready, offer further appointment in 6 months

• Realistic expectations for weight loss

• Take account of demands of caring and health issues

• Family support

• Encourage breastfeeding

• Physical activity – check with GP/midwife first

• Support from structured weight management groups

Effective weight loss programmes –

before and after pregnancy

• Based on balanced, healthy diet

• Encourage regular physical activity

• Incorporate behaviour change advice

• Identify and address people’s barriers

• Practical and tailored to individuals

• Sensitive to the person’s concerns

• Realistic weight loss of 0.5 – 1 kg per week

Who is at risk of vitamin D deficiency?• Those with someone else in the family with vitamin D deficiency

• People from South Asian, African, African Caribbean and Middle Eastern backgrounds

• Those that have a low exposure to sunlight due to wearing concealing clothing or spending time indoors

• Teenagers (growth spurt)

• Strict sunscreen users

• People who are obese (BMI>30)

• Pregnant or breastfeeding women

• Breastfed and some formula fed babies

• Children during periods of rapid growth such as in infancy

• Children with chronic conditions (malabsorption, juvenile idiopathic arthritis, rheumatic conditions, chronic steroid use, diabetes, disability and reduced mobility)

• People on medications interfering with Vit D metabolism: phenytoin, carbamazepine, steroids, rifampicin

Discretionary Vitamin D

Supplementation Policy

• All pregnant women booked with a midwife in

B+A receive free vitamin D supplements

• All infants in B+A receive free vitamin D

supplements from birth to 6 months(some will continue to receive free up to 2 years)

Healthy Start vitamin tablets and

drops are the preparation of choice

Gestational Diabetes

• TBC

Nutritional issues in the

under 5’s

Reason for Referral to Dietetics

Based on referrals in to dietetics 15/16, BD3, 4, 5

Childhood obesity

• 20% under 5’s (OW/O)

• Associated with fussy eating, early weaning and

deprivation

• Genetics

• Lifestyle factors (activity, labour and time saving

devices and choice of leisure activities)

Solution

• Healthy, balanced diet and adequate activity

Rickets

• 67 cases of Rickets were diagnosed between 2007 and 2010

(NHS B&A, 2010).

• 20 cases were diagnosed between 2012 and 2015

(Source: SystmOne).

These figures are suggestive of a decrease in the

incidence of Rickets

Iron Deficiency Anaemia

• 40% of under 5’s in Bradford (diet)

• Immigrants and deprived areas (most effected)

• Infections, poor weight gain, development and cognitive delay and behavioural disorders

• Late weaning, inappropriate weaning, early weaning and excessive cows milk

Solution

• Improving maternal nutrition, appropriate weaning and a balanced diet

Faddy Eating

• High prevalence (70% of 2yr olds)

• Deprived areas most effected

• Decreases with age (by 5yrs 1%)

• Associated with Vit D and Iron deficiency and late or inappropriate weaning

• Frequent drinks, snacking behaviour, lack of routine, unclear boundaries, neophobia, parental expectations and anxieties, parental depression,

Faddy Eating

Solution

• Parental education – meal routine, portion sizes and

menu planning

• Realistic expectations – children are not little adults

• Reassurance – most children grow out of faddy eating

behaviours

• Consistency – parental confidence, establish new

norms

• Peer support for children – positive role models

• Healthy Start vitamin supplements

Faltering growth

• Commonly, infants may show some weight

faltering in the first 2 years of life but it can

also affect older children.

• Under-nutrition accounts for 95% of the

faltering growth causes e.g. impaired

absorption, increased requirements,

insufficient energy given.

• 5% of the faltering growth comes from major

organic disease.

Faltering Growth Pathway

• It is estimated that of the children who have

faltering growth, only 5% will have significant

safeguarding concerns, e.g. abuse, neglect

• Children who are severely undernourished

from whatever cause may suffer long term

growth, developmental, behavioural and

emotional problems.

Faltering Growth Pathway

• Developed in Bradford as part of the EBM

working group on nutrition

• To be rolled out to GP and HV asap

• Provides a clear schematic of what to do and

when

Complimentary Feeding

• Exclusive breastfeeding for six months confers

several benefits on the infant and the mother,

• Complementary foods should be introduced at

6 months of age (26 weeks) while continuing

to breastfeed.

• The DH Guidelines recommend the

introduction of solid food ‘at around six

months’

Weaning - Born in Bradford

• Older, better educated mums -> less chips and potatoes.

• Later weaning -> less processed meat.

• Breastfeeding, older mums, higher education -> more vegetables.

• Similar for fruit.

• Older mothers -> less sweet snacks.

• Later weaning, older mums, better education -> less savoury snacks.

• Earlier weaning, younger mums, less education -> more sugar-sweetened

drinks.

• Overweight & older mothers -> low-sugar drinks.

* Adjusted for maternal age, parents’ education, ethnic group, energy intake, &

infant age

Pink Sahota, BiB, 2013

Complimentary feeding

Solution:

•Consistent messages from practitioners

•Promotion of best practice weaning

•Access to complimentary feeding workshops for

all

Poor Oral Health

• Bradford rates higher than national average

• Higher incidence in deprived areas

• Poor oral hygiene + sugary food/drinks

Solution

• Brushing teeth x2 daily, fluoride toothpaste and

avoiding sugary food/drink between meals

Conclusion

• There are many problems faced in the BSB

relating to nutrition

• Many solutions require education of workers

and volunteers to ensure consistent messages

• Need to tap in to the experts to ensure best

practice is driven forward

Thank You for listening

Any Questions?

Better Start Bradford Networking Event

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Welcome to the Better Start Bradford Family

Would you like to be involved with our CAMPAIGN between 6th-10th June 2016?

Come and talk to us at the information stand.