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Older, Pregnant Vegetarian Woman

Authors: Marisol Perez Madeline Holloway Jessica Ramirez Megan Rodewald Nutrition 304 November 28, 2012 Mee Young Hong

Introduction During recent years vegetarian diets have become popular and increased among individuals for a wide array of reasons such as ethical considerations towards animals, religious

preferences and health concerns. A vegetarian diet usually eliminates most meat products from their diet and typically base their diet on plant-based food sources such as; fruits, legumes, grains and nuts. The nutritional adequacy of a plant-based diet depends on the food choices, nutrition knowledge, and availability of food of the individual. When a vegetarian diet is appropriately planned it can meet the recommendations for all nutrients and promote a healthy diet which in turn can lowers the risk of many chronic diseases (Craig and others, 2010). When a vegetarian woman decides to becomes pregnant there are many nutritional and health concerns that she must take into consideration for the well-being of the fetus. Prenatal maternal nutrition is an important factor that may impact the fetal brain development and later neurodevelopment of the fetus (Hernandez-Martinez and others, 2011). The individual selected is a 42 year old, female. She is a pregnant vegetarian, and is of Jewish descent. The individual did not know she was pregnant in her first trimester, and recently found out she is pregnant, and beginning her second trimester. She is 54 (162.5 cm) and weighs 135# (61 kg). Her BMI is 23.2 (normal). She has not yet noticed any weight gain since conceiving. Her ideal body weight (not during pregnancy), is 120# (54.5 kg), which indicates in a non-pregnant state the individual is 112% of her ideal body weight (overweight). The individual needs 1930 kCal/day during her second and third trimester (calculated using MifflinSt. Jeor to establish BEE x ambulatory factor (1.3) + 300 kCal for pregnancy during second and third trimester). It is recommended the individual consume 58.8 - 70 g/protein/day. The individual is married, and this is her second child. Her and her husband both work, and together have an annual income of $80,000. They reside in San Diego, where the climate is mostly warm year-round. The individual and her family are Jewish and even though she does not eat meat, she prepares kosher meat meals for her family. Both the individual and her husband

have college level education individuals husband received a bachelors degree, and the individual received a high school level education. Poorer-quality diets are associated with pregnant women who are younger, less educated, had more children and who have higher prepregnancy BMI (Rifas and others, 2009). They have a fixed income and the individual came seeking nutritional guidance in November, and is expected to deliver in May. The individual is mildly-active and complains of sometimes feeling like she doesnt have enough energy. She never eats meat of any kind, and rarely, though sometimes, eats animal products (dairy, eggs). The individual states that until finding out she was pregnant, she had not been taking any vitamin or mineral supplements, but has since began taking prenatal vitamins. The individual is of older age, 42 years, which poses as a health risk due to her pregnant state. She is a busy working mother of two who manages a retail store. Due to her busy life as a mother and a manager she tends to eat out most of the time. Her food choices consist of refined carbohydrates foods such as white pastas, breads, potatoes, cheese and tends to snack on highly salted mixed nuts (almonds, pecans) or chips. The individual ensures to have a traditional jewish meal for her family every night; consisting of foods such as goulash (meat stew), kugel (baked noodle casserole), and knish (mashed potatoes covered in dough and fried); to name a few. The individual and her family indulge in traditional jewish pastries every night. Such pastries include: babka (chocolate filled egg bread), bagels (boiled/baked), rugelach (cream cheese pastry bites). After her meals she tend to feel lethargic and sleepy. She attempts to remain somewhat active and walks her dog for a about 30 min/day for 2-3 days a week. Individual tends to feel overly exhausted and out of energy after her walks. Pregnancy is a period of intense growth for both the fetus and the mother, and adequate nutrition during this period of development is essential. The nutritional status of a mother

directly influences the outcome of her pregnancy and health of her baby.The nutrients of concern in a vegetarian diet include protein, Vitamin D, Vitamin B12, n-3 fatty acids, calcium, iron and zinc; although vegetarian diets can meet the recommendations for the these nutrients the use fortified foods and supplements are useful to prevent deficiencies for the mother and baby (Craig and others, 2010). A vegetarian diet can also have beneficial effects for the individual and baby receiving such diet; vegetarian diets usually provide a low intake of saturated fat, cholesterol, and a high intake of phytochemicals and dietary fiber (Craig and others, 2010). A 2012 study published by Molecular and Nutrition Foods Research suggests, maternal diets that are supplemented with increases fat sources may affect the development of hypothalamic structures, and hence predisposition to obesity (Sanchez and others 2012). Due to the fact that iron is a major nutrient of concern for pregnant vegetarian women, it is critical to monitor prenatal maternal nutrition. Human studies have shown that prenatal and postnatal iron deficiency is a risk factor for behavioral, emotional and cognitive development of a fetus (Hernandez-Martinez and others, 2011). All nutrients are important for the neurological cell growth and development but some appear to have greater effects during the late fetal and neonatal time periods (Hernandez-Martinez and others, 2011). Anemia, muscular hypotonia and failure to thrive are common conditions observed in babies with vegan mothers. Neurological abnormalities are often irreversible and may be associated with delayed myelinization in the MRI. If cobalamin deficiency is suspected, substitutions should be started at an early stage to avoid damage to the fetus (Schlabach and others, 2007). There are various factors that must be taken into account when designing a meal plan for any individual, but especially individuals who have unique dietary needs. Whether a dietary plan has to be designed around an individual's medical needs, food preferences or religious beliefs- it

is prudent for dieticians to familiarize themselves with the individual. Background information on an individual, their habits and lifestyle choices as well as their day to day routine must be collected by a dietician in order to create a meal plan that is customized for each individuals requirements. Realistic expectations must also be kept in mind in order to devise a meal plan that the individual will be able to adhere to. The vegetarian population is growing which means it is critical for nutrition experts to become that much more knowledgeable and aware of the dietary needs and recommendation that are necessary for that population to maintain a well-balanced and healthy lifestyle; especially when pregnancy and other such medical conditions are involved.

Menu Plan: Breakfast

Monday Open faced banana sandwich: 1 slice cracked wheat toast, 3 Tbs almond butter, 1 medium banana, 1 C orange juice

Lunch
Hummus pita: 4 Tbsp hummus spread, 1 medium wheat pita with 3 oz cucumber, 3 oz sweet peppers, 2 oz avocado, 2 oz mushrooms, 1 C

Dinner
Couscous kale salad: 4 oz couscous with 1 small roasted squash, 1 chopped persimmon and 4 oz garbanzo beans, 1 oz pecans, 1 slices

Snacks
1 apple, 1C soy milk 1 serving nonfat greek yogurt

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spinach, 1 medium tomato, 2 oz banana chips Tuesday Cereal and berries: 1 serving fortified cereal, 1 C fresh berries, 1 C almond milk, 1 C decaf hot tea Oatmeal: C oatmeal, 2 Tbsp peanut butter, 2 Tbsp raisins, 1 C soy milk Lentils and toast: 2 servings lentils, 1 slice sprouted wheat, 1 C fruit banana/citrus smoothie Baked sweet potato fries, broccoli, collard green salad. 2 watermelon slices, 12 oz diet soda pumpkin bread, 8 oz unsweetened decaf iced tea Quinoa salad: C quinoa, chopped tomato cucumber salad, 3 C tofu, C vegan cheese 1 handful dry roasted almond, cashew, cranberry mix

Wednesday

Borscht; 2 C Cabbage Borscht soup mixed veggies included, 1C coleslaw w/fruits and nuts Couscous with roasted vegetables: C couscous, C chard, 1 C vegetable broth, 1 T balsamic vinegar, pinch salt, 1 clove garlic. 1 C brussel Sprouts, 3 T olive oil, pinch sea salt, pinch pepper, 1 C decaf iced tea Vegetarian patty and soup: 1 C carrot soup, potato-black bean burger with green peas, half onion sliced, 4 scallions diced, 1 slice vegan cheese

2 oz kosher, vegan cheese, 1 handful whole wheat crackers

Thursday

Continental breakfast: 3 oz greek yogurt, C berries, C bananas, 1 slice sprouted wheat toast, 1 C orange juice

Bean salad with brussel sprout and portobello wraps: 2 cups lima, garbanzo, black bean salad, grilled brussel sprouts, with 1 portobello mushroom wrapped in 1 whole wheat tortilla

2 pieces of dark chocolate 1 C decaf hot herbal tea

Friday

Oatmeal bake: 1/3 C oats, 1 C soy milk, 1/2 cup pumpkin, 1/2 tbsp chia seeds, pinch of sea salt, 1/2 tsp cinnamon, 1/4 tsp ginger, 8 oz fortified OJ Green smoothie: 1 C soy milk, 1 medium banana, 2 C spinach, 1 oz chia seeds, 2 Tbsp peanut butter

Vegetarian wrap: C hummus, 1 whole wheat tortilla, cucumber, lettuce, olive oil, lemon juice, salt and pepper with 1 C beans and 2 oz avocado

C pita chips and 1/8 C hummus

Saturday

Mushroom, kale, onion risotto: 1/4 cup uncooked millet, 1 Tbsp olive oil, 1/2 onion, 1 garlic clove, 4 oz sliced crimini mushrooms, 1 tbsp minced fresh rosemary, 1 tbsp

Vegetarian burrito: cup black organic canned beans, chopped onion, avocado, 1 tsp of cayenne pepper, 1 whole wheat tortilla, 8 oz iced herbal tea

1 medium apple

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soy sauce, 2 oz dry cornstarch, 1 C fresh chopped kale

Sunday

Sweet potato breakfast casserole: 1/4 cup oats, 1 C almond milk, 1/2 small sweet potato, 1 banana, 1 tbsp chia seeds, 1 Tbsp pure maple syrup, 1/3 cup chopped pecans, 1 tbsp Earth Balance, 1/8 cup brown sugar

Cherry tomato pasta salad: 3 oz whole wheat pasta, C cherry tomatoes, 1 C okra, C brussel sprouts, 1 C chopped broccoli in a bed of romaine and spinach salad sprinkled with 2 tbs of olive oil, 1C strawberry/banana smoothie

Pasta and salad: 1 serving large salad with 1 oz low fat cheese, I cup of whole grain pasta, c kidney beans 1/2c chickpeas included in salad, 12 oz diet soda

Cranberry and Apple Strudel 3oz

Nutrient analysis:
kCal Pro (g) CHO (g) Fat (g) *Ca (mg) *Fe (mg) Fiber (g) Vit C (mg) Vit A (ug) *Vit D (IU) Na (mg) Folat e (ug) *Vit B12 (ug) *Zinc (mg)

DRI

1930-2430

59-70

340

44-78

1000

27

28

75

770

4000

2300

600

2.4

11

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Mon 2339 78.4 347.6 85.6 961.7 34.4 52.6 294.3 589.5 451.6 1609.9 800 9.1 25.4

% DRI

96

112

102

110

96

123

188

392

77

11

70

133

379

231

Sat

2534

108.3

403.6

64.5

1108.6

43.3

85.3

203.3

927.5

439.2

1490.7

630

9.1

33.2

% DRI

104

155

119

82.3

111

160

305

271

120

11

65

105

379

302

* Values expressed in Monday and Saturday include prenatal vitamin supplements below

Prenatal Vitamins include:

folic acid (mcg) Vit. D (IU) Ca+ (mg) Vit. C (mg) Thia

min (mg)
3

Ribofl avin (mg)

niacin (mg)

Vit B12 (mcg)

Vit E (mg)

Zinc (mg)

Iron (mg)

n-3 (mg)

Amt in 1 dose

400

400

200-300

70

20

10

15

17

250

Menu Costing for One Day: Low-Cost Plan

USDA Food Cost Plan October 2012: $202.90 Budgeted Amount For One Week: $46.80 Budgeted Amount For One Day: $6.67

Food Item

Brand Name

Purchase Size Purchase Price

Serving Size

Cost Per Serving

9 Soy Milk Banana Spinach Chia Seeds Peanut butter Millet Olive Oil White Onion Garlic Crimini Mushroom Fresh Rosemary Soy Sauce Corn Starch Kale Black Beans White Onion Avocado Cayenne Pepper Whole Wheat Tortilla Herbal Tea Apple Pantry Essentials Tia Rosa Stash O Organics O Organics Kikkoman Argo Silk Chiquita Fresh Express Spectrum Laura Scudders Arrowhead Mills Star 64 oz 1 banana 9oz bag 12 oz 16 oz 4.5 Cups (28 ounces) 17 oz 1 Onion 1 bulb 8 oz .66 oz 10 oz 16 oz 16 oz 15 oz 1 Onion 1 Avocado 7 oz 12 Tortillas 13 tea bags 1 apple $2.49 $.32 $1.89 $6.99 $4.99 $4.49 $6.49 $.38 $.50 $1.89 $2.79 $2.99 $1.99 $1.99 $1.33 $.38 $.88 $1.99 $2.19 $2.50 $.46 8 oz 1 banana 4.5 oz 1 oz 2T C 1 tbsp (.5 oz) Onion 1 Clove 4 oz .03 oz .5 oz .2 oz 1 Cup (2 oz) cup Onion 1/2 Avocado 1 tsp 1 Tortilla 1 tea bag 1 apple $.31 $.32 $.95 $.58 $.31 $.28 $.19 $.19 $.05 $.95 $.01 $.15 $.02 $.25 $.33 $.19 $.44 $.05 $.18 $.19 $.46

Total for One Day: $6.40

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Discussion and Summary Pregnancy is a critical period in which a fetus develops, and it is essential a pregnant woman receives adequate nutrients during this time. Prenatal maternal nutrition is an important factor that may impact the fetal brain development and later neurodevelopment of the fetus (Hernandez-Martinez and others, 2011). Nutrients of concern during pregnancy are: protein, vitamin D, vitamin A, vitamin B12, folate, calcium, n-3, iron and zinc. The defined individual practice is that of a vegetarian diet and although vegetarian diets can meet the recommendations for the these nutrients, the use fortified foods and supplements are useful to prevent deficiencies for the mother and baby (Craig and others, 2010). During pregnancy is is essential vitamin A intake does not exceed 5000 IU or for the mother to take 770 ug/d, vitamin D intake is 15 ug/d,

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calcium intake is 1000 mg/d and iron is 27 mg/d. During the two day menu analysis, the individual receives over 100% of her recommended protein intake, which is an increased value from the recommended protein intake of a 30 year old pregnant woman, due to her increased maternal age. Fifty-seven percent to sixty-four percent of the individuals diet is composed of carbohydrate, which meets the carbohydrate recommendation of between 50% and 60% of total kCals, in order to ensure fetal brain growth. The individual received between 96% and 111% of recommended calcium. She also received between 123% and 160% of recommended iron, which is imperative because studies have shown prenatal and postnatal iron deficiency is a risk factor for behavioral, emotional and cognitive development of a fetus (Hernandez-Martinez and others, 2011). The individual received between 77% and 120% of the recommended Vitamin A, between 105% and 133% of recommended folate, 379% of recommended vitamin B12 and 231% to 302% of recommended zinc. The individual received 11% of recommended vitamin D from her diet, with 15 minutes of exposure to sunlight 2 days a week, her recommended intake will be met. The individuals diet will be supplemented with prenatal vitamins, which will ensure imperative dietary nutrients for fetal development are met. The prenatal supplement include folic acid, vitamin D, calcium, vitamin C, vitamins B1 and B2, vitamin B12, vitamin E, zinc, iron and n-3. Essential Fatty acids (n-3) are nutrients of concern for both pregnant and vegetarian individuals. EPA and DHA (n-3), are linked with higher intelligence, normal development of the retina and the central nervous system which is crucial for proper fetal development (sanders,1999). It is recommended during pregnancy that the mother consumes 13g of linoleic acid and 1.3g linolenic acid. Adequate intake would be 250 mg or UL of 3g. Due to the fact that most vegetarians have low EPA and DHA (n-3) intake, supplementation and prenatal maternal

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nutrition is highly beneficial during pregnancy. The values of nutrients are based off FitDay program and are adjusted to reflect the individual taking prenatal vitamins. During the first trimester of her pregnancy, the individual practiced a high fat, highly processed diet. It was critical the individual stray away from processed foods, and move towards a healthier and well-balanced vegetarian diet. When planning her meals, it was essential to include high protein, vegetarian options that were easy to make and stay within her budget. It was also crucial to omit foods in the menu plan that are linked with foodborne illness. The individual is a vegetarian, and therefore limiting the amount of mercury containing fish, is not an issue. The meals provided have a minimal preparation time, around 15 to 25 minute. The individual attributed her lack of preparing home cooked meals for herself, to lack of preparation time, so it was essential the meals were designed for someone with a limited amount of preparation and cooking time. The majority of her meals involve throwing raw ingredients together for a salad or sandwich, or putting ingredients in the blended or oven and toaster for cooking. Cooking techniques such as roasting and preparing raw vegetables are used in order to retain the nutrient content of food. Vegetarian diets can have beneficial effects for the individual and baby because vegetarian diets usually provide a low amount of saturated fat, cholesterol, and a high intake of phytochemicals and dietary fiber (Craig and others, 2010). There is a large amount of variety in her meals in order for the individual, and her family, to stick to the meal plan given. Meals include inspirations from various cultures such as the Mediterranean, Mexican, American and Jewish. The individual is of Jewish descent, and practices eating Jewish foods with her family regularly, so it was imperative to include Jewish cuisine such as Borscht and an occasional pastry snack in to her meal plan. According to the Center for Nutrition Policy and Promotion, the Low-Cost Food Plan for

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October 2012 was $202.90. This gave the individual a budgeted amount of $6.67 per day to spend on food and groceries. The individuals meal plan for Saturday not only met all necessary DRIs but also stayed within the low-cost budget. The total cost per serving for Saturday was $6.40 which was $.37 less than her budget. The spinach and chia seeds yielded the highest cost per serving, however, they contributed greatly to the vitamin A and iron, fiber and protein percentages respectively. In conclusion, planning a vegetarian diet is of critical concern to ensure the mother and the infants nutrition is fully met and to avoid any deficiencies among both individuals. Broadly defined, a vegetarian is someone who does not eat meat or poultry. Our prospective individual was able to maintain a wholesome meal plan that met many of the essential vitamin and nutrients, however, because of her lack of meat intake she did not meet many important vitamins that are contained in poultry and meat. A prenatal vitamin was added to her diet to supplement for the lack of certain nutrients such as n-3 fatty acids that are widely found in fish and dairy products. Altogether, a dietician would need to individualize a meal plan to ensure that DRIs are met for this particular individual. Follow up methods would be to monitor the progress and development of her and the infant. This can be done by follow up phone calls, routine blood analysis and routine nutritional and pregnancy checkups.

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References Craig JW. [Nutrition Concerns and Health Effects of Vegetarian Diets]. American Journal of Nutrition in Clinical Practice. 2010 Dec; 25(6) : 613-620. Available from Pubmed. Accessed October 29, 2012. Hernandez-Martinez C, Canals J, Aranda N, Ribot B, Escribano J, Arija V.[Effects of iron deficiency on neonatal behavior at different stages of pregnancy] Early Human Development. (2011) March; 87(3): 165-169. Available from Scopus. Accessed October 30, 2012. Rifas-Shiman DSL, Rich-Edwards JW, Kleinman KP, Oken E, Gillman MW. [Dietary quality during pregnancy varies by maternal characteristics in Project Viva: a US cohort]. Journal of the American Dietetic Association. 2009 Jun; 109(6): 1004-11. Available from: PubMed. Accessed October 30, 2012. Sanchez J, Priego T, Garcia AP et al. [Maternal supplementation with an excess of different fat sources during pregnancy and lactation differentially affects feeding behavior in offspring: Putative role of the leptin system]. Mol Nutr Food Res. 2012 Nov; 56(11):1715-28. Available from: PubMed. Accessed October 30, 2012. Schlapbach LJ, Schutz B,Nuoffer JM, Brekenfeld C,Muller G, Fluri S. "[Floppy Baby with Macrocytic Anemia and Vegan Mother]." Praxis. 2007; 96(35): 1309-1314. Available

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from: PubMed. Accessed October 30, 2012.