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:

Body Mass Index Weight Gain (single pregnancy)

<18.5 12.5-18 kg

18.5-24.9 11.5-16kg

25-29.9 7-11.5kg

>30 5-9kg

US National Academy of Science 2009

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

Vitamin D deficiency

Year Total Incidence per 1,000

2012/13 2,073 19.2

2013/14 3,039 28.4

2014/15 3,002 28.2

Prevalence of vitamin D deficiency in 15-44 year old

females in the Bradford district

(source: SystemOne)

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

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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

0 10 20 30 40 50 60 70 80 90 100

allergy & intolerance

dietary counselling and asessment

faltering growth

obesity

vitamin/mineral deficency

autism

constipation

other

Number

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

How common is vitamin D deficiency?

Year Total Incidence per 1,000

2012/13 64 1.3

2013/14 129 2.6

2014/15 255 5.2

Incidence of vitamin D deficiency in children age 0-5

years in the Bradford district

(source: SystemOne)

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

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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?