Maternity Program
This curriculum is designed to provide flexibility and easy entry points depending on when in their pregnancy the client starts.
Start with Week 1: Introduction then proceed to the relevant trimester. Not all modules may be relevant to all patients. Some modules are shorter, and may be combined with others or the rest of the time may be used to discuss any diet particulars that a patient is concerned with, especially in the case of GDM.
This curriculum is designed for a healthy or low-risk GDM singleton pregnancy. Higher risk moms, moms of multiples, and moms with special diets (vegetarian, vegan) will require modified recommendations.
Visits are intended to be twice/month if started in the first trimester, with optional weekly GDM visits if and when the patient is diagnosed.
Welcome to Prenatal Nutrition!
Week 1: Introduction
Topic: Introduction to prenatal nutrition and building rapport
Description:
This session will serve as the first 60-minute visit with their RD or a 30-minute follow-up with an already established client/RD. Information gathering and an introduction to the program will be included.
Sub-topics:
Review importance of nutrition during the prenatal period.
Establish entry point into curriculum based on gestational age and any pertinent diagnosis.
Metrics:
Health history, family history, medications, smoking status, social history if first patient visit. Update this information if this is an established patient.
Estimated due date (EDD)
Height
Pre-pregnancy weight
Current weight
Use to determine weight category and appropriate weight gain chart.
Bloodwork results, if available
Blood pressure
Nutriquiz and/or Perinatal Food Group Recall
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
Session Outline
Complete any introductory items pertinent to the initial visit.
Use the following questions as discussion starters:
What does having a healthy pregnancy mean to you?
What are your main concerns for your pregnancy? Are there any topics you are hoping to address?
Review of nutrition during pregnancy
Nutrition during pregnancy helps keep weight gain in a healthy range, ensure optimal growth and development of your baby, and help to prevent or manage conditions like gestational diabetes, when an expectant mother develops diabetes..
That being said, your appetite may not always cooperate! If you are dealing with severe nausea, for example, sometimes the goal is just to eat and stay hydrated.
Hydration is particularly important. It aids digestion, helps form the amniotic fluid around baby, and helps waste leaves the body. Hydration can also affect energy levels!
:Foods to avoid
There are some foods that need to be avoided during pregnancy.
Per:
Raw and undercooked meat, fish, or eggs, including sushi, over-easy eggs, etc.
Unpasteurized products such as milk, eggs, cheese.
Raw sprouts
Herbal products, including teas. There is not enough research to say whether herbal products are safe during pregnancy.
More than 200 mg caffeine. This is the amount in ~16 oz of regular coffee.
Nonfood items. There is a condition called Pica that compels some pregnant women to consume non-food items like coffee grounds or laundry products. Let your doctor know if you are having cravings for non-food items.
Alcohol. There is no safe amount of alcohol during pregnancy.
Artificial sweeteners. There is not enough research to support
, such as swordfish or albacore tuna. High mercury fish
Calorie and nutrient needs gradually increase over the course of your pregnancy. We will review specific needs each trimester, but here are some key nutrients:
Folic acid
Prevents neural tube defects
400-600 mcg/day
Top food sources: dark leafy greens, beans, peanuts, sunflower seeds, fruits, whole grains, seafood, fortified foods
Iron
Prevents iron-deficiency anemia and risk of hemorrhaging
27 mg/day
Top food sources: beans, lentils, spinach, beef, chicken
Vitamin C (citrus, broccoli, fortified foods) helps increase absorption
Calcium
Brain and nervous system development and preserves mom’s bones
12,00 - 1,300 mg/day
Top food sources: dairy, winter squash, fortified foods, canned fish (with bones), beans/lentils
Vitamin D
Nutrient regulation and healthy bones
600 IU/day
Top food sources: oily fish, fortified foods, egg yolk, some mushrooms.
DHA
Brain development
200 mg/day
Top food sources: fatty fish, seafood, fortified foods
Iodine
Thyroid synthesis
220 mcg/day
Top food sources: seaweed, fish and shellfish, iodized salt, eggs, chicken
Choline
Tissue and neuro-development
450 mg/day
Top foods sources: meat, poultry, fish, dairy, eggs
Have you heard about WIC?
WIC stands for women, infants, and children and is a program for children under 6 in the US and pregnant and postpartum mothers. It provides monthly healthy food benefits, nutrition education, help with finding other resources, and breastfeeding help.
It’s income-based. If you think you might be eligible, more information can be found here: https://www.fns.usda.gov/wic
Wrap-up and next steps
Ask if client would like to keep a food journal to see where there might be things she can add. She can keep a traditional journal or use something like this:
Ask if patient has any final questions.
Week 2: Nutrition in the First Trimester
Topic: Key micro- and macronutrients in the first trimester
Description:
Key nutrients for the first trimester will be reviewed, along with a symptom and intake check-in.
Sub-topics:
Review of important nutrients and their food sources
Symptom check
Intake check
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
While all nutrients are important to pregnancy and we’ve discussed the most important, today we’ll just highlight a few for the first trimester.
Nutrients
Calories - no extra calories are needed above baseline for the first trimester of a singleton pregnancy. If you were tracking calories to lose weight prior to pregnancy, a calorie increase is required.
Carbohydrates - low carb/keto-style diets are not recommended for pregnancy. The minimum amount of carbohydrates per day are 175 g/day for pregnancy. Ideally we want to include whole grain sources, as fiber can help with common pregnancy complaints like constipation.
You may have a different carbohydrate plan if you are managing conditions like diabetes or pre-diabetes.
Eating too little carbohydrates could cause you to miss out on some key nutrients and cause you to feel sluggish.
Protein - protein is needed to support the production of baby’s organs and tissues.
Review lean protein sources - lean meats, beans, soy, nut butters.
Use DRI app or .36 g/# for calculation if needed
Fat - Fat is needed for baby’s development and to help certain vitamins be absorbed.
Most of your fat intake should come from unsaturated sources - plant sources like nuts, seeds, fish, and seafood.
Omega 3s such as those found in seafood and walnuts are especially important
Nutrient spotlight: Folic acid
We discussed last time how important folic acid is. It’s crucial to preventing neural tube defects.
The neural tube is formed in the early weeks of pregnancy, so that’s when folic acid intake is most crucial.
Foodsmart app recipe suggestion: Kale and Black Bean Rice Bowl
Use MyPlate Pregnancy plan for discussion around food groups:
**This can also be used as an alternative to discussing specific nutrients if that is what the patient prefers.
Wrap-up
SMART goal for increasing intake of any of the above-named nutrients, or another goal.
Questions?
Week 3: Constipation and Morning Sickness
Topic: Morning sickness and constipation management
Description:
Review strategies for managing pregnancy-related nausea and constipation
Sub-topics:
Symptom check
Intake check
Constipation management
Nausea management
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
Are you experiencing constipation?
Constipation during early pregnancy can be caused by hormones (progesterone), food and water intake, and/or prenatal vitamins or other supplements.
Symptoms of constipation:
Infrequent bowel movements (<3x/week)
Hard, dry stools
Lumpy stool, potentially painful to pass
Sometimes constipation can lead to fissures or hemorrhoids.
Strategies
Bulk up on fiber
Fiber is present in whole grains, fruits, vegetables, nuts and seeds.
Recommendations range from 25-35 grams per day.
Fiber should be increased slowly to avoid unpleasant side effects like excess flatulence or bloating.
Try one fiber-rich swap at a time.
If you are unable to consume enough fiber, discuss a fiber supplement with your doctor.
Drink plenty of water.
There are no specific water guidelines for pregnancy, but it’s recommended to drink at least 13 8-oz cups of water per day.
Another recommendation is to drink until your first morning urine is very lightly straw-colored, however your prenatal vitamin may make this difficult to discern.
If you are also dealing with nausea, then taking small sips of water may be a better option.
Eat small frequent meals and snacks. This can also be a helpful nausea strategy.
Try to stay active as much as you can. If it’s had to manage longer stretches of exercise, aim for multiple 5-minute bouts of exercise or walking throughout the day.
Are you experiencing nausea or morning sickness?
Despite its name, morning sickness does not necessarily occur only in the morning. Many pregnant women experience nausea throughout the day, but it does seem to be more intense in the mornings.
Nausea during pregnancy can be one of the first signs of pregnancy or not start until a few weeks in. It typically peaks at around 9 weeks and disappears or significantly lessens after the beginning of the second trimester, but may continue throughout pregnancy for some women.
Hyperemesis gravidarum is an extreme form of pregnancy-related nausea. It can cause weight loss and dehydration and occasionally requires brief bouts of hospitalization. Symptoms include:
Vomiting more than 3-4 times per day
Vomiting causes dizziness or lightheadedness
Dehydration (thirst, dry mouth, fast heartbeat, low urine output)
Losing 10 pounds or more
Strategies:
Switch prenatal vitamins if needed. There may be formulations that are easier on your stomach. Discuss options with your doctor or midwife.
Eat small frequent meals throughout the day. It can also help to drink fluids separately from solids.
Keep snacks and water by your bed. An empty stomach often makes the nausea worse.
Avoid strong smells as best as you can.
Discuss options such as ginger, acupressure, and acupuncture with your provider.
Wrap-up
SMART goal for constipation or nausea management or any other topic of interest.
Questions?
Week 4: Physical Activity
Topic: Physical activity
Description:
Physical activity guidelines for pregnancy will be reviewed and a SMART goal for physical activity will be set
Sub-topics:
Symptom check
Intake check
Physical activity benefits
Exercise recommendations
Exercise plan
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
What is your current exercise or physical activity program?
What are the benefits of staying active during pregnancy?
Helps with constipation
Improves mood and reduces the risk of postpartum depression
Promotes healthy weight gain
Potentially decreases risk of gestational diabetes and helps manage blood sugar if you do have diabetes
Potentially reduces the risk of preeclampsia
Strengthens your heart and blood vessels
Helps with muscle and joint pain
Can help with labor and delivery and subsequent recovery
Exercise recommendations
150 minutes per week of moderate-intensity aerobic exercise
Moderate intensity is 5-6 on a 1-10 exertion scale, or being able to carry on a conversation but not sing
This can simply mean a 30-minute brisk walk 5 days/week
If you regularly exercised at a vigorous level prior to pregnancy, you are typically able to continue.
Exercise safety
Always discuss your physical fitness plans with your doctor in case adjustments need to be made.
During pregnancy your joints are looser and your balance and oxygen needs change. General safety precautions to prevent falls or over-exertion are needed.
Stay hydrated prior to exercising.
Avoid high impact activities (jumping, contact sports) and activities that may result in a fall.
Avoid laying on your back or standing still for long periods of time.
This article has warning signs for when to stop exercising and call your doctor or midwife:
Exercise ideas
What did you enjoy doing prior to pregnancy? Have you needed to make any adjustments?
If you are new to exercise, start off slowly - even 5 minutes can be a great start. Exercise can also be broken up into chunks throughout the day.
There are a lot of great prenatal workout videos and apps. Try some and see what you like best.
Other great activities are walking, hopping on the stationary bike, and water workouts and swimming,
Make an exercise plan.
Help patient make an exercise plan using a worksheet or notebook. Help them tailor it to their current fitness level, restrictions, and goals.
Wrap-up
Questions
Week 5: Nutrition in the Second Trimester
Topic: Key macro and micronutrients for the second trimester
Description:
Key nutrients and their food sources for the second trimester will be reviewed.
Sub-topics:
Symptom check
Intake check
Constipation management
Nausea management
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
You often feel better in the second trimester if the first trimester was tough!
Nutrients
Calories - starting in the second trimester we need to stat increasing those calories! At this point we need around 350 more calories per day.
Some examples include:
1 cup whole-grain cereal, 8 oz low-fat milk, and half a banana
1 pear, 6 whole-grain crackers, and 1 oz cheese
Foodsmart app recipe suggestion: Mango-Coconut Green Smoothie
Carbohydrates and Fats - there are no specific increased needs - just proportional to slightly increased calorie recommendation
Protein - starting in the second trimester, around 25 more grams of protein per day is needed above baseline.
Review protein sources if needed and discuss ways for patient to increase their intake if needed.
Use DRI app or .36 g/# for baseline calculation
Nutrient spotlight: Iron
Your body produces more red blood cells during pregnancy, so iron (an important component of your red blood cells) needs are dramatically increased!
Iron is needed by other organs and tissues in your body, but when you are iron-deficient, your body prioritizes your blood at the expense of other things.
Iron-deficiency anemia is one of the most common pregnancy conditions, and can increase your risk of hemorrhage and potentially impact baby’s growth and development.
High iron foods include meats, beans, and fortified foods. Your body absorbs animal sources of iron best, but taking or eating iron with Vitamin C (citrus, greens, broccoli) can help increase absorption.
Foodsmart app recipe suggestion: Marmalade Chicken (with a side of broccoli!)
Wrap-up
SMART goal for increasing intake of any of the above-named nutrients, or another goal.
Questions?
Week 6: Cravings and Aversions
Topic: Managing cravings and aversion
Description:
Review strategies for managing food/non-food craving and aversions.
Sub-topics: n/a
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
Cravings
Cravings often come along with the increase in appetite and decrease in nausea that happens in the second trimester.
Many pregnant women report cravings for salty and sweet foods.
It’s thought that indulging in frequent cravings could lead to excess weight gain and risk of complications like gestational diabetes, but a small study showed that this wasn’t the case.
In any case, indulging in your cravings occasionally can absolutely fit into your prenatal meal plan, but it can be helpful for you and baby if you eat snack foods, candy, baked goods, and desserts in moderation.
Also keep food safety in mind - this is not the time to give into a craving for sushi or rare steak.
Pica is a craving for not food items or food items in their raw form like flour or cornstarch. Pica is thought to potentially be caused by nutrient deficiencies. Talk to your doctor ASAP if you are experiencing these types of cravings.
Strategies for keeping cravings in check:
Continue to focus on eating small frequent meals throughout the day so you don’t get too hungry (or hangry!).
Eat a wide variety of foods. Avoid monotony.
Make sure meals include a balance of protein, carbohydrates, and healthy fat.
Eat slowly and mindfully when you do indulge.
Options for specific cravings:
Crunchy
Whole grain pita crackers and hummus
Veggie sticks and ranch dip made with Greek yogurt and seasoning
Cheese and whole grain crackers
Trail mix
Creamy
Frozen yogurt
Flavored refrigerated yogurt
Smoothie
Chocolate
Fudge bar
Low-fat chocolate milk
Chocolate-dipped fruit
Aversions
It’s very normal for your appetite and food likes/dislikes to change during pregnancy.
This is thought to be due to hormones.
Your aversions may also change, so don’t assume that something you can’t tolerate now will cause issues in the future.
Food aversions start in the early weeks and peak toward the beginning of the second trimester.
:Common food aversions include
coffee/tea
meat
fatty food
spicy food
eggs
Review the various food groups (grains, meats/proteins, vegetables, fruits, and dairy) and make sure you are able to eat at least a few items from each category. Extra supplementation may be warranted for extreme cases of aversion!
Wrap-up
SMART goal for managing cravings, or another goal.
Questions?
Week 7: Give Your Baby’s Growing Brain a Boost!
Topic: Nutrients for optimal brain development
Description:
Review nutrients and their food sources important for baby's brain development.
Sub-topics:
Quick overview of fetal brain development
What nutrients are important for brain development?
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
One of the most amazing parts of pregnancy is the development of the brain and nervous system, setting the stage for their first word all the way to their high school graduation and beyond. In fact, the brain continues developing through 25 years of age!
When does the brain develop?
First Trimester: The basis of your baby’s brain and spinal cord develops in the first few weeks of pregnancy. The neural tube closes at around 6 weeks and a rudimentary brain forms. The nervous system also forms and the sense of touch is developed by the end of the first trimester.
Second Trimester: This is when sucking, swallowing, and the sense of taste develop. The nerves are coated in myelin and the brainstem matures.
Third Trimester: Brain development is happening in full force and the brain becomes more indented versus smooth. The cerebral cortex (responsible for cognitive functions such as thinking and memories) also completes its development.
What nutrients support optimal brain development?
DHA/Omega-3s
Folic acid
Choline
Niacin (vitamin B3)
Vitamin B6
Is there anything that needs to be avoided?
Maternal stress has been shown to potentially impact fetal brain development.
Stress can be caused by a number of factors. How would you describe your stress right now? Are there any concrete steps you can take to relieve stress? What resources do you need?
What foods give baby’s brain a boost?
Eggs
Salmon and other fatty-fish (remember to choose low mercury options)
Peanuts
Beans
Leafy greens
Chicken and turkey
Foods fortified with any of the above nutrients.
Foodsmart app recipe suggestion: Black Bean and Salmon Tostadas
Wrap-up
SMART goal for increasing intake of any of the above-named nutrients or foods, or another goal.
Questions?
Week 8: Hydration
Topic: Staying hydrated
Description: Review water recommendations and develop strategies for meeting hydration goals.
Sub-topics:
How much water do I need during pregnancy?
Hydration strategies
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
Staying hydrated
Think of water as a nutrient, same as carbs, fats, or vitamins.
Water keeps your body temperature in the normal range for good health. It also helps transport nutrients and waste around and out of the body. It lubricates your tissues and cushions and protects baby via the amniotic fluid. It’s also the basis of breast milk! Staying hydrated also can help with energy levels, as being dehydrated can cause you to feel run down. It can also help with some of the swelling that can crop up during pregnancy.
During pregnancy the recommended amount of water is ~13 8-oz cups of water per day, and potentially more if you are very active or live in a very hot climate.
If your prenatal vitamin or other supplements do not artificially color or darken your urine, a good sign of hydration is light straw-colored morning urine.
Plain water is preferable, but there are some other options:
Eating high-water fruits and vegetables such as watermelon, berries, or cucumber.
Infusing water with mint, strawberries, citrus fruits, or ice cubes made from juice.
Seltzer water
Hot water with lemon
100% juice in moderation
Wrap-up
SMART goal for increasing water intake.
Questions?
Week 8a: Gestational Diabetes Part 1
Topic:
Introduction to gestational diabetes management
Description: Assist client in understanding nutritional management of GDM and goals they are able to make in conjunction with primary care recommendations.
Sub-topics:
What is gestational diabetes?
What are some basic diet recommendations for gestational diabetes?
Creating a GDM plan
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Diabetes distress survey
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
What do you know about gestational diabetes?
What recommendations did your doctor give you?
What is gestational diabetes?
It’s a common type of diabetes discovered in pregnancy.
Risk factors include family history/genetics, history of gestational diabetes in previous pregnancies, overweight/obesity, low levels of physical activity, and polycystic ovary syndrome. *Risk factors do NOT mean direct cause.
It’s a condition where your body cannot use the hormone insulin properly. When you eat food, your body breaks the food down to a usable simple sugar called glucose, Your cells use insulin to take the glucose in for energy. If you don’t have enough insulin or aren’t able to use it properly, the glucose builds up in your blood.
When gestational diabetes is unrecognized, it can lead to a baby with a very large birthweight, more difficult labor and delivery (with associated complications), and birth complications such as stillbirth.
This is not meant to scare you, but to present the importance of managing blood sugar when you have gestational diabetes.
What is involved in gestational diabetes management?
Diet
Exercise
Medication
Self-monitoring of your blood glucose
Blood glucose monitoring
Your doctor should have given you suggestions of when to check your blood sugar.
Checking your morning, or “fasting”, blood sugar is an important marker of overall blood sugar management.
You want this level <=90 mg/dl
Checking your blood sugar 1 hour after the start of a meal helps you see how the foods you ate at that meal are affecting you.
You want this level <=130 mg/dl.
It’s not only about keeping blood sugar in the recommended ranges (which sometimes might not happen, especially while you are learning in the beginning). It’s also about avoiding sharp spikes and dips.
Exercise
If you haven’t started a physical activity program, now is a good time to start! It can help you manage your blood sugar throughout the day.
Walking after a meal can be particularly effective.
You can start small and build up.
Diet
We will get into more details about your diet next time, but let’s review the plate method for now.
Use this as a guide:
Carbohydrates (grains, potatoes, corn, sweets, milk, fruit) are the foods that cause your blood sugar to rise.
We cannot avoid them altogether, but we do need to be careful with what we eat.
It can take some trial and error.
An easy way to do this is to follow the plate method.
Make sure half of your plate is non-starchy vegetables like broccoli, spinach, cucumbers, tomatoes.
The rest of your plate should include ¼ protein (meat, beans, tofu, eggs), ¼ carbohydrate, and 1 food if you wish.
Snacks should always include a protein.
Next time we will discuss more specifics for meals, including carbohydrate ranges, and management of high and low blood sugars.
Wrap-up
Encourage patient to create 2 GDM-focused SMART goals.
Questions?
Week 8b: Gestational Diabetes Part 2
Topic: Review of carbohydrate recommendations for GDM
Description: Will review carbohydrate recommendations and management of hyper- and hypoglycemia.
Sub-topics:
What is gestational diabetes?
What are some basic diet recommendations for gestational diabetes?
Creating a GDM plan
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Diabetes distress survey
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
Review/check-in
Brief review of BG record and treatment plan.
Review goals set in last session
Any questions or concerns?
Carbohydrates
As we discussed last time, carbs are mainly used by the body as energy in the form of blood glucose. It’s the only source of energy our brains use.
Carbohydrates are often counted in grams. These can be found on the nutrition facts label or in a list of common foods.
Use for plan details.
We want our carbohydrates to be paired with protein or fat foods and to include fiber order to slow down their digestion time. This helps blood sugar rise slower.
Fiber is a carbohydrate we don’t digest and is found in whole foods like beans, nuts and seeds, fruits, whole grains, and vegetables.
This is how we want to break down our carbohydrates through the day:
Breakfast - 15 grams of carbohydrate (paired with protein and nonstarchy vegetables)
Lunch and dinner - 30-45 grams carbohydrate, 0-1 servings of dairy, 0-1 pieces of fruit, unlimited non-starchy vegetables, and protein
Snacks should be 15-30 grams of carbohydrate and protein
3 meals and 3 snacks, ~3 hours apart will help keep blood sugar from spiking or nosediving.
Hypoglycemia
Sometimes blood sugar can drop too low (usually <70 mg/dl). Symptoms include shakiness, brain fog, sweating, weakness, and extreme hunger.
Severe hypoglycemia can lead to coma or death or impair your ability to drive.
Hypogycemia information can be found here:
It’s often treated with 15 grams of quick-acting carbohydrate like glucose tabs, jelly beans, or juice/soda.
Hyperglycemia
Hyperglycemia is high blood sugar. It can often rise in times of illness or extreme stress, even without eating a high carbohydrate meal.
It’s often symptomless unless severe, but symptoms can include intense thirst, frequent urination, fatigue, and weakness.
Your doctor may have specific instructions for sick days or blood sugar above a certain level.
You may also have been given ketone testing strips. Ketones are a product of fat breakdown and what your body uses when it cannot access sugar (such as when insulin is not working properly). Ask your doctor when it would be appropriate to monitor for ketones.
Wrap-up
Encourage patient to create 2 additional GDM-focused SMART goals.
Questions?
Week 9: Nutrition in the Third Trimester
Topic: Key nutrients and other nutrition topics in the third trimester
Description: Key nutrients in late pregnancy will be reviewed, along with food sources.
Sub-topics:
What nutrient recommendations change in the third trimester?
Heartburn and acid reflux
Optional: GDM check-in
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
GDM review (optional)
Blood sugar check-in
SMART goal review
GDM questions?
Third trimester nutrition
You’re in the home stretch! You may find that you have a lower appetite or get fuller easier.
You may need to really lean into small, frequent meals or snacks.
Hydration is also key, especially if you are prone to edema or swelling.
Calories: Calorie needs are now 450 calories over baseline.
An extra 100 calories can come from 1 tablespoon of nut butter, 1 oz cheese, 1 small yogurt with fruit, veggies with 4 tablespoons of hummus
Protein and fat: Do not increase over second trimester recommendations
DHA and continued brain development
Brain development is in full force now.
Omega-3 fats, especially DHA, are key for this process.
DHA is mainly found in fatty fish and seafood.
200 mg/day is ideal.
It is stored in the body.
3 oz of salmon has over 1 gram of DHA.
If you do not consume animal products, discuss a supplement with your doctor.
Heartburn and reflux
Heartburn can occur at any point during pregnancy, but the growing belly and pressure on your organs in later pregnancy can increase your chances of experiencing heartburn
Avoiding typical heartburn-causing foods can help - spicy foods, acidic foods like tomato sauce, caffeine, and very fatty or fried foods. You might have your own triggers, so pay attention to those.
The best remedy for heartburn is walking or at least staying upright after eating.
Keep the head of your bed higher than the bottom. You can accomplish this with pillows or other supports.
Wrap-up
SMART goal for increasing intake of any of the above-named nutrients or foods, or another goal.
Questions?
Week 10: Physical Activity and Well-being Check-in
Topic: Revisiting physical activity
Description:
Discuss physical activity in the context of late pregnancy and revisit the SMART goal set in Week 4.
Sub-topics:
Some physical activity considerations and benefits in late pregnancy
Well-being check-in
Optional: GDM check-in
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
GDM review (optional)
Blood sugar check-in
SMART goal review
GDM questions?
Exercise in the third trimester
What is your current workout/movement routine?
Is there anything you find particularly difficult currently?
Exercise is still very helpful late in pregnancy, but it can also become increasingly difficult for many people.
High impact and jumping is definitely off the table at this point.
Having a carbohydrate-based snack prior to working out can be important for managing blood sugar levels (even for those without gestational diabetes). Examples include whole grain crackers or a banana.
It’s also important to pay attention to warning signs that you need to stop (and potentially call your doctor):
Feeling dizzy
Shortness of breath
Chest pains
Intense contractions
Bleeding
Well-being check-in
How are you feeling?
What is your appetite like?
How are you doing managing stress or anxiety?
Wrap-up
SMART goal for increasing intake of any of the above-named nutrients or foods, or another goal.
Questions?
Week 11: Options for Feeding Your Baby
Topic: Infant feeding options
Description:
Discuss with patient their infant feeding goals, review the benefits of breastfeeding, and discuss optimal infant feeding practices like feeding on demand, proper formula preparation, and starting to breastfeed or pump early and often.
Sub-topics:
Review benefits of breastfeeding
Top tips for the early days of breastfeeding and who/when to reach out to if there are problems
Formula-feeding tips
Metrics:
Weight (plot on prenatal weight gain chart)
Bloodwork results, if available
Nutriquiz and/or
Blood pressure
Resources:
(client to use as a FYI and resource through their pregnancy)Nutrition.gov for Pregnancy
Your Quick Guide to Pregnancy
/app for quick calorie and micro/macronutrient calculationsDRI Calculator website
Your Guide to Breastfeeding:
Formula preparation guidelines:
When to call a lactation consultant:
Session Outline:
Check in - symptom check, consistency with vitamins, does patient have any nutrition questions?
GDM review (optional)
Blood sugar check-in
SMART goal review
GDM questions?
Have you thought about how you are going to feed your baby? **Review only the information that corresponds to the patient’s infant feeding decision.
Benefits of breastfeeding:
Lower risk of asthma, obesity, type 1 and 2 diabetes, and SIDS, along with short-term illnesses like stomach viruses and ear infections.
Lowers your risk of breast and ovarian cancers, type 2 diabetes, osteoporosis, cardiovascular disease, postpartum depression,and thyroid cancer.
Helps your uterus contract back to normal more quickly.
Populates baby’s gut bacteria early with healthy microbes, setting the stage for long-term health.
Breastfeeding
Taking a prenatal breastfeeding class and/or meeting with a lactation consultant during pregnancy can help immensely with some of the basics of breastfeeding and what to expect in the early days.
Find out the policies and procedures regarding birth and breastfeeding of your doctor or midwife and the hospital or birthing center you will be using.
Breastfeeding immediately after birth:
Ideally baby will be placed skin-to-skin, where the first breastfeeding can happen.
Your first milk is called colostrum, and is perfect for your tiny baby’s tiny belly. Offer the breast (or pump if you are unable/choose not to put baby at the breast) often.
Ask for help early and often!
You may be sore at first, but breastfeeding should never result in intense pain.
If you have gestational diabetes, it might be worth hand-expressing colostrum out now to be used as a supplement should baby need one. More info can be found here: https://firstdroplets.com/
Bookmark the following websites for trustworthy breastfeeding info:
Resources for medications/supplements and breastfeeding:
Milk supply
Milk is produced in milk glands throughout your breast. These glands started growing during puberty and continued to grow and proliferate during pregnancy, and will continue to grow during your breastfeeding journey and with each subsequent pregnancy and birth!
While hormones drive some milk production in the beginning, milk production is mainly driven by supply and demand.
Moms who offer the breast early and often (or pump early and often if they are not breastfeeding) typically get their milk supply off to a great start, but it’s never too late to get your milk production in top shape.
Milk supply can be affected by certain medical conditions, surgical history, and medications. There is a list of resources below for help with determining medication and breastfeeding risk, and your doctor and lactation consultant can help with strategies if you do encounter problems. Some medical conditions that cause low supply, like iron-deficiency anemia, are easily remedied.
Formula preparation
There are 3 types of formula - ready-to-feed, concentrate, and powder.
Any formula that is in its final form needs to be refrigerated within 1-2 hours.
Once baby’s mouth has touched the bottle, it needs to be tossed within the hour.
Follow all instructions on the container for formula prep.
Warm water is often recommended as the powder dissolves easier.
Boiling and slightly cooled water is recommended for very young and immune-compromised infants, as the almost-boiling water is hot enough to kill cronobacter bacteria in the non-sterile powdered formula. This is a rare but dangerous bacteria. More information can be found here: https://www.healthychildren.org/English/ages-stages/baby/formula-feeding/Pages/How-to-Safely-Prepare-Formula-with-Water.aspx
Formula can be prepped ahead of time for refrigeration, but needs to be used within 24-48 hours.
Bottle feeding
Whether you are feeding formula or breast milk via bottle, it’s important to use techniques that avoid overfeeding.
Baby’s stomach is small, and even at their highest intake don’t typically take in more than 4 oz per feed if allowed to pace themselves (although formula-fed babies sometimes do get up to 5-6 ounces naturally).
Keep baby upright during feeds, let them accept the bottle into their mouth, and keep the bottle horizontal (even if there is air in the nipple - it won’t cause excess gas). Give baby breaks every few minutes by tipping the bottle down and letting baby draw it back in when he or she is ready. This paced bottle feeding technique can help slow feeds down and allow baby the space to not overfeed. Visuals can be found here: https://mommylabornurse.com/paced-bottle-feeding/
Wrap-up
SMART goal
Questions?