MICHIGAN STT

IIIIIIIIIIIZIIII

 

IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

30 1 055 9593

This is to certify that the

thesis entitled

NUTRITIONAL INTAKE OF WOMEN
DIAGNOSED WITH PRETERM LABOR

presented by

Mary Patricia Fuehr

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Nursing

Major professor

Date September 15, 1993

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

UBRARY
Michfgan State
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

 

 

r

 

DATE DUE DATE DUE DATE DUE

JII

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If—T I:
=-- I:
I _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUTRITIONAL INTAKE OF WOMEN DIAGNOSED
WITH PRETERM LABOR

By

Mary Patricia Fuehr

A THESIS
Submitted to
Michigan State University _
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing
1993

 

ABSTRACT

NUTRITIONAL INTAKE OF WOMEN DIAGNOSED
WITH PRETERM LABOR

By

Mary Patricia Fuehr

Some investigators feel inadequate nutrition can be linked to the
development of preterm labor. This study was a retrospective chart
review describing the nutritional intake of 202 non-smoking women, with
single gestations, who were diagnosed with preterm labor and referred to
a preterm labor monitoring program.

The charts revealed adequate nourishment with weight gain more than
adequate for gestational age, however macronutrient intake was below the
recommended levels. Micronutrient intake was more than 100 percent of
RDA, except for magnesium. Supplementation occurred in 94 percent of
the records. A significant difference in calcium intake between African
Americans and Caucasians was found. Significant differences in
ingestion of macronutrients were found when comparing body mass index
(BMI) categories.

Early nutritional counseling, including BMI calculation and
assessment of nutrient intake is recommended for all pregnant women.

More research into ethnic and cultural eating patterns and nutrient

intake of all pregnant women is recommended.

Copyright by
Mary Patricia Fuehr
1993

 

ACKNOWLEDGEMENTS

Special recognition is given to three groups of people who
encouraged me through this process.

First, my thesis committee of Millie Omar, Linda Beth Tiedje, and my
chair, Rachel Schiffman. They encouraged me to be concise, stay on
target and most important to hang in there. A special thanks to Rachel
who has read so many drafts she can probably recite the study verbatim.

Gabriele Kende served as a consultant and provided me with her
nutritional expertise for which I am grateful. Chiung Ying Cheng used
her statistical skills to help with data analysis.

A second thank you to Healthdyne Perinatal Services and Lisa
Johnston and the Perinatal Nutritional Services Staff for completing the
arduous task of providing me with the diet histories.

A final acknowledgement to my family who kept patiently asking,
"Aren't you done with that paper yet?" I can finally say, "yes!--(and

you can have the computer back now)”.

iv

TABLE OF CONTENTS

Page

Introduction ............................ '1
Problem Statement .......................... 5
Concepts . . . . . . . . . . . ................... 6
Review of Literature ........................ 8
Theoretical Framework ........................ 16
Methods ............................... 19
Design ............................. 19
Sample ............................. 19
Operational Definitions ..................... 20
Instrument ........................... 21
Data Collection ......................... 25
Data Analysis .......................... 26
Human Subjects Protection .................... 27
Assumptions ......................... '. . 27
Limitations ........................... 28
Results ............................. 28
Sample Characteristics ..................... 28
Nutritional Characteristics ................... 30
Calories, Macronutrients and Micronutrients ........... 3o

33

Group Comparisons ........................

V

Discussion ............................. 39

Relation to Conceptual Framework .................. 44
Implications for Advanced Practice . . . . . . . . . . . . . . . . . 47
Implications for Research ...................... 50
LIST OF REFERENCES .......... A ............... 53
APPENDIX A ............................. 62
APPENDIX B ............................. 63
APPENDIX C ............................. 67
APPENDIX D ............................. 73
APPENDIX E . . ........................... 74

vi

List of Figures

Figure Page

1 A Hypothesis for the Multifactorial Etiology of Preterm Labor . . 18

vii

 

 

List of Tables

Table Page

Sample Characteristics ..................... 29
Body Mass Index (BMI) and Weight Gain by Body Mass Index . . . . 31
Three Day Mean, Standard Deviation, Range, and Percent of
Recommended Amounts of Nutrients ................ 32
Micronutrients from Food Expressed as a Percent of RDA or PNS
Recommendation ........................ '. 34
Mean Percent of Recommended and RDA Ingested by Racial Groups . . 35
Mean Percent of Recommended and RDA Ingested by Gestational Age . 37

Mean Percent of Recommended Ingested Calories and Macronutrients

by Body Mass Index (BMI) .................... 38

viii

 

 

Introduction

Maternal nutrition, until the last thirty years, has been a largely
unresearched topic. There have been many gaps and weaknesses in
knowledge about maternal nutrition and its impact on pregnancy outcome.
This study will focus on some of the factors which contribute to
maternal nutrition status in women with a high risk pregnancy. The
question to be addressed is "What is the nutritional intake of women
diagnosed with preterm labor?"

It was not until the mid-1960's that a renewed interest in infant
mortality led to a reappraisal of diet in pregnancy. The Food and
Nutrition Board of the Institute of Medicine reported on maternal
nutrition and the course of pregnancy in 1970 (National Research
Council, 1970). This report helped stimulate an expansion of research
in the field of nutrition and obstetrics. Teaching of perinatal
nutrition to students in the health care professions escalated. There
was a renewed interest in applied nutrition by obstetrical and pediatric
clinicians. The Food and Nutrition Board's report remains a major
source of research information on the role of nutrition and pregnancy.
One of the principal findings of this report was that studies of diet in
pregnancy were limited and fragmentary in nature. This report called
for long-term longitudinal studies on diet in pregnancy (Worthington-
Roberts & Rodwell—Williams, 1989). ~

One of the outgrowths of the Food and Nutrition Board's 1970 report
was the Women, Infants and Children's (W1C) Program, introduced by the
federal government in 1973. WIC's purpose is to provide food as an
adjunct to health care during critical times of growth and development.

Low income pregnant women, infants and children up to five years of age

1

 

 

 

2
who are nutritionally at risk are eligible to receive nutrition
education and health services as well as food coupons from the W1C
program. The W1C program had grown to a one billion dollar program by
1987 (Worthington-Roberts & Rodwell-Williams, 1989).

A milestone was reached when joint guidelines from the American
College of Obstetricians and Gynecologists (ACOG) and the American
Dietetics Association (ADA) for assessment of maternal nutrition were
released in 1978 (Worthington-Roberts & Rodwell-Williams, 1989). ACOG
addressed diet in pregnancy in its 1982 Standards for Obstetric—
Gynecologic Services (American Colleges of Obstetricians &
Gynecologists, 1982). The Third Edition of Guidelines for Perinatal
Care (American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists (1992)) advocates for routine assessment
of dietary practices for all pregnant women as well as individualizing
weight gain goals and identifying nutritional risk factors. However,
many physicians are not trained in nutritional assessment and counseling
of obstetric patients; many have not even been taught the basics of
nutrition. Nutritional counseling, therefore, has often been delegated
to nursing. The Nurses Association of the American College of
Obstetrics and Gynecology (NAACOG), (now the Association of Women's
Health, Obstetric and Neonatal Nurses (AWHONN)), Standards for Nursing
Care of Women and Newborns (1991) included nutrition and diet counseling
as an integral part of general pregnancy education and counseling. The
Institute of Medicine's (10M) Subcommittee on Nutritional Status and
Weight Gain During Pregnancy in 1990, recommended."routine assessment of
dietary practices for all pregnant women in the United States" (ION,

1990, p.19) and felt that improvement of dietary quality through use of

3
nutritious foods is strongly preferred to supplementation. This points
to the importance of evaluating dietary quality as well as quantity when
assessing nutritional status in the pregnant woman. It also underscores
the importance of real food over vitamin supplements.

Observations of human undernutrition and its effects on pregnancy
have been limited. Many studies focused on famine conditions during war
or malnutrition in third world countries. Statistics compiled during’
the 18 month period of acute starvation during the siege of Leningrad in
1942 showed a doubling of fetal mortality and a sharp increase in the
rate of preterm delivery (Orstead, Arrington, Kamath, Olson 8 Kohrsk,
1985). Forty-one percent of the births during the Leningrad siege were
premature. During the siege, the diet consisted of a daily bread ration
of 250-500 gm. which was the primary ingredient of the diet. Following
the siege, when food rations increased, the prematurity rate dropped to
six percent.

During the six month Dutch famine of 1944-1945 there was a striking
decrease in mean birth weight of ten percent (Kristal 8 Rush, 1984).

The daily rationed diet provided less than 700 calories. The Dutch
study found no increase in prematurity, but the weights were lowest for
babies exposed to the famine during the entire last half of the
pregnancy. These findings contradict the concept that the fetus is
protected by the mother when nutritional status is less than optimal and
supports the hypothesis that poor nutrition in the latter part of
pregnancy affects fetal growth.

The perinatal mortality rate in Great Britain declined during World
War II despite the poor environmental conditions. A possible

explanation is that pregnant women were given priority status for food

4
rationing (Worthington-Roberts 8 Rodwell—Williams, 1989). In recent
years, Garbaciak, Richter, Miller and Barton (1985) stated that
"undernourished patients are at risk for anemia and preterm labor” and
suggest that close attention be paid to diet and weight gain during
pregnancy.

In spite of the availability of nutritional supplementation programs
and other improvements in prenatal care, nine percent of all neonates in
the United States continue to be born before 37 completed weeks
gestation and six percent of all neonates are born before 36 completed
weeks of gestations (Main, 1988). According to March of Dimes
statistics (Perinatal Association of Michigan, 1993), the United States
has fallen from let to 24th in the world in infant mortality. This
drop to 24th in world ranking comes at a time when infant mortality in
the U.S. has decreased from 1,008 per 100,000 live births in 1987 to 908
per 100,000 live births in 1990 (National Center for Health Statistics,
1991). The factors most associated with this infant mortality rate are
low birth weight and the complications arising from preterm delivery.
Infant mortality for disorders related to short gestation and
unspecified low birth weight increased from 88 deaths per 100,000 live
births in 1987 to 95.1 deaths per 100,000 live births in 1990 (National
Center for Health Statistics, 1991).

Preterm birth accounts for more than half of very low birth weight
infants. The National Center for Health Statistics (National Center for
Health Statistics, 1990) reported that in 1988, 65 percent of very low
birth weight infants (less than 1500 gms) were born between 20 to 27
weeks gestation. Some of the factors that are linked with preterm

delivery may also contribute to low birth weight in infants delivered at

5
term. Unless more progress is made in decreasing infant mortality, it
is estimated that 440,000 infants will die between 1987 and the year
2000.
Problem Statement

The effects of being born prematurely can last a lifetime. Some
infants will suffer more severe handicaps, such as cerebral palsy,
mental retardation, hearing or vision loss; many others are at risk for
subtle long-term learning disabilities. 0f the very low birth weight
babies, those less than 3 lbs. 4 02., 15-20 percent will suffer major
handicaps and another 15-25 percent will have subtle learning and
behavior disorders. Costs for special education for learning and
behavior disorders alone reached $371 million in 1988 in the United
States ("Born Too Small“, 1992). Walker (1991) stated that the cost of
caring for a low birth weight infant can reach as much as $500,000. Low
birth weight babies are often rehospitalized, with an average cost of
approximately $55,000 per child. The Washington Business Group on
Health states that each prevented low birth weight delivery can save the
U.S. health system between $14,000 and $30,000 (Walker, 1991).

The National Commission to Prevent Infant Mortality (1988) has
determined that in order to reverse the trend in infant mortality more
attention must be paid to prevention of preterm birth during pregnancy.
Prevention of preterm birth is one of the major goals of perinatal
medicine and nursing. Nurses in advanced practice often are primary
care providers for pregnant women. They are in a position to help
deveIOp programs which can help decrease the rate of preterm labor and

delivery in this country.

6

Many factors have been hypothesized to contribute to the etiology of
preterm labor (Bragonier, Cushner, 8 Hobel, 1984). Among those are
nutritional deprivation, short stature and low prepregnancy weight.
These factors were explored in this paper. The research area addressed
by this paper was a description of the nutritional intake and
anthropometric measurements of women diagnosed with preterm labor.

Concepts

Preterm Labor The physiology of labor is not clearly understood.
It includes interactions of hormones and prostaglandins which lead to
cervical softening, and triggers uterine contractions. Coordinated
uterine contractions and cervical dilatation are responsible for the
delivery of the infant. The definition of preterm labor is not precise
but usually includes subjective and objective symptoms. There is a
range of subjective symptoms which may be associated with preterm labor
and can include uterine or abdominal cramping, backache (constant or
intermittent), pelvic pressure, or just "feeling bad“. Objective
symptoms can include cervical dilatation or softening, cervical
effacement, an increase in vaginal discharge and documented regular
uterine contractions (Iams, Stilson, Johnson, Williams, & Rice, 1990).
Preterm labor is a result of these events, which normally occur at term
(after 37 weeks gestation), being triggered earlier than 36 completed
weeks of gestation (Fuchs, Fuchs, & Stubblefield, 1993). In this study
the definition of preterm labor was made by individual physicians and
resulted in referral to a preterm labor monitoring program.

Nutritional Intake encompasses food intake, quality as well as
quantity, and refers to the interaction between food and person. A

broad definition includes an interaction and balance of food components

7
as they relate to health and disease. Physiologically, nutrition is a
process by which food materials are ingested, digested and utilized at
the cellular level. Quantity of food intake refers to total calories
consumed. Calories are the expression of energy value of food. Food
intake can be broken down into macronutrients of proteins, fats and
carbohydrates, and the micronutrient components of vitamins and minerals
such as calcium, magnesium, zinc, iron, and folic acid.

The quality of food intake is assessed by studying the nutrient
analysis of macro and micronutrients. While someone may take in a
sufficient quantity of calories, the diet may be deficient in quality if
the proper proportion between micro and macronutrients is lacking.
During pregnancy, the quantity of ingested nutrients can be assessed by
looking at anthropometric measures such as the amount of weight gained
during pregnancy. Quality of diet before pregnancy can also be a factor
when assessing nutritional intake. Prepregnant weight, in relation to
maternal height can give an indication of preconceptual nutritional
status.

Nutrition also concerns itself with social, economic, cultural and
psychological factors related to food and eating. For the purposes of
this study nutritional assessment was limited to describing nutritional
intake in terms of calories, the macronutrients of protein, fat, and
carbohydrates, and the micronutrients of calcium, magnesium, zinc, iron
and folic acid. Anthropometric measures of body mass index, and

gestational weight gain were also described.

8
Review of Literature
There have been few studies linking dietary factors with the

development of preterm labor or preterm delivery. Some of the studies
which were specifically concerned with diet during pregnancy and
prematurity are almost 40 years old. A number of studies have
implicated dietary factors as a cause of low birthweight in term
infants. Brown (1989) states that much less is known about nutritional
risk factors for prematurity than low birth weight but believes that
interventions that would decrease the risk of delivering a low birth
weight term infant could also result in a reduction of premature
deliveries. I

Lechtig et al. (1985), Mora, deParades, and Wagner (1979), and
Tontrisin, Booranasubkajorn, Hongumarn, and Thewtong (1986), showed that
supplementation of the diet in pregnancy caused a reduction in the
incidence of low birthweight term infants. Supplements varied from dry
skim milk, enriched bread, and vegetable oils to specific protein
formula supplements. However, these studies were conducted in the
developing countries of Guatamala, Colombia, and Thailand respectively,
and did not report any effects on the rate of prematurity.

Primrose and Higgins (1971) studied a total of 1544 women between
1963 and 1970 in two Montreal maternity clinics and found that
nutritional counseling and dietary supplementation (eggs, milk and
orange juice) brought the incidence of low birth weight down to that for
the rest of Canada (Worthington—Roberts & Rodwell-Williams, 1989). In a
study involving 768 poor black pregnant women in New York, an unexpected
finding was that a high protein supplement (i.e., more than 20 percent

of total calories from protein) was associated with an increase in

 

9
preterm delivery, intrauterine growth retardation and neonatal
mortality. When supplements which provided less than 20 percent of
calories from protein were consumed, there was an increase in birth
weight (Gormican, Valentine, 8 Satter, 1980). Thus, not only the type
of supplements, but composition and amounts of supplements must be
monitored closely for potential adverse as well as beneficial effects.
An early U.S. study (McGanity et al., 1954) of 2046 women implicated
a low intake of Vitamin C as a possible factor in premature delivery.
The dietary habits of 404 pregnant low income women in a rural
midwestern state studied by Jeans, Smith and Stearns (1955) showed that
those women who experienced a high incidence of preterm delivery had a
diet low in calories, protein, calcium, iron, and A and B vitamins. In
the later 1950's in the U.S., two concerns arose in the U.S. about
nutritional research. There was skepticism about the accuracy of
estimates of dietary intake. The second concern raised was the
following question, "Is the study of nutritional intake really
research?". These concerns led to disinterest and disillusionment
regarding studies of nutritional status and pregnancy (Worthington-
Roberts 8 Rodwell-Williams, 1989).
The Institute of Medicine's Subcommittee on Dietary Intake and

Nutrient Supplements During Pregnancy of the National Academy of

Sciences (hereafter referred to as the subcommittee) compiled data on
nutrient intake studies of pregnant women in the 1980's (Institute of
Medicine (IOM), 1990). The subcommittee reported that there were
relatively few studies during the last decade of the nutrient intake of
pregnant women and that none of these studies focused on length of

gestation or infant birth weight. In these studies, the average intake

 

10
of eight nutrients (vitamins 86, D, E, folacin, and iron, calcium, zinc
and magnesium) were found to be below the Recommended Daily Allowance
(RDA) for pregnant women. The subcommittee found that these studies of
pregnant women consisted of small samples, and were heavily represented
by low—income women. In addition, different nutrient bases were used by
different investigators which may have had an effect on estimates of
intakes of some nutrients. Accurate consumption may also have been_
underestimated because of the food intake assessment methods employed.
Despite these study limitations, the subcommittee did not recommend
routine supplementation of most nutrients (10M, 1990) but did suggest
further investigation into the intake of certain nutrients.

The subcommittee (10M, 1990) recommended that research and
nutritional assessment focus on the following nutrients: folates, zinc
and iron. Folates are a group of compounds with structures and
properties similar to folic acid and are vital to the metabolism of
several amino acids and cell replication. Deficiency of folate may
impair cell growth and replication and may result in fetal and placental
anomalies. Folate deficiency has inconsistently been associated with
spontaneous abortion, preterm delivery and low birth weight. Folate
deficiency early in pregnancy has also been linked with neural tube
defects. Folate requirements rapidly escalate during late pregnancy.
Colman et al. (1975) have suggested that the added burden of pregnancy
increases the risk and prevalence of folate deficiency. Iyengar and
Fajalakshmi (1975) discovered an increase in infant birth weight when
using folic acid supplements in women with suboptimal folic acid levels.
Huber, Wallins and DeRusso (1988) analyzed dietary folacin intake in a

sample of 566 women. Only 8.5 percent of the women received adequate

ll
folic acid intake from diet alone. Pregnant women tend to consume less
than the RDA of 400 mg/day and if not supplemented will have a steady
decrease in serum and erythrocyte folate levels (10M, 1990). The
subcommittee considers it prudent to supplement diet with low amounts of
folate if there is any question of adequacy of intake. Preconceptual
folate supplementation is recommended for women who have given birth to
an infant with a neural tube defect.

Zinc is another element for which adequate intake has been
questioned in some individuals. Zinc is involved in protein and nucleic
acid metabolism and in fundamental process of cell differentiation and
replication. Naeye and Peters (1978) studied amniotic fluid infections
and found that zinc deficiency predisposes one to amniotic fluid
bacterial infection which may lead to chorioamnionitis.
Chorioamnionitis has been suggested as a cause of preterm labor.
Tafari, Ross, Naeye, Galask, and Zaar (1977) found that zinc was needed
for antimicrobial activity of a polypeptide that renders amniotic fluid
antimicrobial in late pregnancy. The authors suggested that zinc
deficiency causes a decrease in antimicrobial activity. Animal studies
(ewe and guinea pig) have shown preterm delivery as a likely
complication of maternal zinc deficiency (Apgar, 1987).

In humans there have been few reported severe cases of zinc
deficiency. Mild zinc deficiency has had poorly defined effects on
humans. Hambridge et al. (1983) and Hunt et al. (1987) found that
dietary zinc intake levels were below that of the RDA's for women in
early and late pregnancy. Plasma zinc levels also declined throughout
pregnancy. Cherry et al. (1987) reported that a group of adolescent

teens who received zinc supplementation had a lower incidence of preterm

. 12
delivery. In a study of 476 pregnant women in Alabama, Neggers et al.
((1990) revealed that low zinc levels early in pregnancy were associated
with an increased incidence of low birth weight. Prevalence of low
birth weight was eight times higher among women with serum zinc in the
lowest quartile than for women with serum zinc in the highest quartile.
The subcommittee (1990) concluded that sample sizes of these studies
were inadequate to definitely assess the effect of zinc on fetal growth.

Measurement of zinc levels outside a research lab are complex and
difficult to perform. Zinc is often measured in plasma, hair and urine
besides dietary intake. Zinc levels also may be affected by the
hemodilutional effect of plasma volume expansion which occurs normally
in pregnancy. Dawson, Albers, and McGanity (1989) and Yadrick, Kenney
and Winterfeldt (1989) observed that a large iron supplementation (more
than 60 mg/day) appears to depress plasma zinc and should be avoided.
Based on those studies, the subcommittee (1990) recommends zinc
supplementation for women who are given more than 30 mg of daily
supplemental iron.

Perhaps the nutrient which has received the most attention during
pregnancy is iron. Iron is a mineral which is essential for the
production of hemoglobin. Hemoglobin is a protein in the red blood
cells which delivers oxygen to the tissues and carries the iron molecule
in its nucleus. Iron also synthesizes iron enzymes which enable cells
to utilize oxygen to produce energy. During pregnancy increased iron is
needed to supply fetal and placental growth as well as to increase red
blood cell mass and to enable the fetus to store 4-6 months of iron
reserves. The World Health Organization estimates that 51 percent of

pregnant women are anemic compared with 35 percent among women in

13
general. Most of the anemia is attributed to iron deficiency. There is
a possibility that the risk of prematurity may be increased with iron
deficiency. The subcommittee (10M, 1990) advises a low dose iron
supplement, i.e., 30 mg. per day, beginning at the twelfth week of
pregnancy as well as a diet that contains enhancers of iron absorption
such as meat and ascorbic acid.

There have been other nutrients which have been found to be lacking
in the diets of some pregnant women. These include calcium, and
magnesium. The Institute of Medicine (1990) reported on a study
conducted by Spatling and Spatling in Switzerland. A group of women
receiving 360 mg/day Of magnesium experienced half as many preterm
births as those receiving a placebo. While low magnesium intake is
common during pregnancy, more research on magnesium supplementation is
recommended. Rush et al. (1988) reported that both calcium and
magnesium were below the RDA for each nutrient in a study of W1C and
non-W1C recipients of mixed ethnic backgrounds. A study by Brennan,
Kohrs, Nordstron, Sauvage, and Shank (1983) revealed that among low
income African American women both magnesium and calcium were
approximately 67-75 percent of the RDA for both nutrients. Villar et
al. (1988) suggest that although lactose intolerance is more prevalent
in African American and Hispanic women, this condition abates during
pregnancy. In Villar's study, 44 percent of those who were classified
as maldigesters had become lactose digesters by term. The subcommittee
(10M, 1990) found no evidence that routine supplementation of calcium is
beneficial to pregnant women in the U.S. The subcommittee (10M, 1990)

also reported that the average pregnant woman living in the United

14
States probably meets the RDA's for protein, thiamine, riboflavin,
niacin, and vitamins A, B 12 and C.

It is evident from the previous discussion that there are
conflicting views as to the results of low dietary intake of certain
nutrients during pregnancy. There have also been a number of studies
conducted in the U.S. and Western Europe from 1947-1983 which suggest
that there may not be any association between dietary intake and preterm

delivery. Vasilenko (1992) in reviewing literature related to nutrition
i and duration of gestation concluded that studies of undernutrition are
inconclusive and suggests that any association between undernutrition
and duration of gestation is small. These results could be due to the
fact that dietary measurement is difficult. Available techniques have
limited validity and reliability and are subject to bias. An
observational study of nutrition during pregnancy does not separate the
effects of poor environment or other factors from the effects of
undernutrition (Vasilenko, 1992). Diet is only one aspect of an
individual's behavior and covaries with social and environmental factors
which affect perinatal outcome (Kristal 8 Rush, 1984).

Dietary intake is one of several variables that influence nutrient
stores in the pregnant woman. Besides nutritional intake, there are
other indices which reflect maternal nutritional status and may affect
pregnancy outcome. Maternal height and weight are also indicators of
available nutrient stores which can support the pregnancy. There are
some reliable data on associations between these maternal indices and
duration of gestation (Orstead, et al. 1985; Mitchell 8 Lerner, 1989;
Seidman, Ever-Hadani, 8 Gale, 1989). Prepregnant body weight may

directly affect infant birth weight. Severe maternal underweight before

15
pregnancy has been correlated with a higher prematurity rate.
Kaltreider (1963) found that those women who were underweight for their
height had a higher prematurity rate. Naeye (1979) found that very thin
women who also had a low weight gain during pregnancy had a high
perinatal mortality rate of 154/1,000 live births. Edwards, Alton,
Barrada, and Hakanson (1979) studied 354 underweight women and found
that they had almost twice the prematurity rate (23% vs. 14%) than women
of normal weight. Mitchell and Lerner (1987) conducted a retrospective
study of 1,080 singleton pregnancies in middle class women and found
that initial maternal weight and gestational weight gain was
significantly associated with gestational age at delivery. Their
findings indicated that women who were very underweight (<80% of
Metropolitan Relative Weight) had more preterm infants.

The IOM Subcommittee on Nutritional Status and Weight Gain During
Pregnancy (10M, 1990) addressed the issue of body mass index (BMI) and
weight gain during pregnancy. Body mass index is the ratio of body
weight to height. The IOM recommends that those women with a low BMI
((19.8) should gain 28-40 pounds during pregnancy with a gain of one
lb/wk during the second and third trimesters. Women of normal weight
should have a target weight gain of 25—35 lbs, with one lb/wk during the
second and third trimesters. Overweight women with a high BMI (>26.0-
29.0) are encouraged to gain a total of 15-25 pounds with a gain of .5-
.75 lb/wk in the second and third trimester. Obese women with a BMI of
>29.0 are targeted for a weight gain of at least 15 lbs. (IOM, 1990).
The IOM's calculations are based on prepregnant weights. Chez, King,
Niebyl, and Pitkin (1989) consider BMI to be most clinically useful in

evaluating prepregnant nutritional status and recommend that height and

16
weight be accurately determined at the first prenatal visit so that 8M1
can be determined.

Other risk factors which have been associated with preterm delivery
are behavioral, demographic, socioeconomic and medical. It is estimated
that 13-20% of all preterm births can be attributed to maternal smoking.
Use of alcohol and addictive drugs can adversely affect gestational age
at delivery. Multiple gestations are at risk for preterm labor and
delivery. Women under 19 years of age or over 40 years of age, who are
unmarried, with limited education, and race other than white, are at
risk for preterm birth. Medical risks include uterine anomalies,
hypertension, diabetes, and uterine infections (Bragonier, Cushner 8
Hobel, 1984; Kramer, 1987; Main, 1988). These risk factors are
acknowledged but will not be considered in the scope of this paper.

The review of literature has shown that there have been few studies
of the nutrient intake of pregnant women in the U.S. in the past decade.
There is even less information regarding nutritional intake of women
diagnosed with a complication of pregnancy such as preterm labor. This
study is intended to add to the knowledge base of nutritional risk
factors which may be present in women diagnosed with preterm labor. If
nutritional risk factors can be identified in preterm labor, the nurse
in advanced practice may be able to design strategies to minimize,
offset or eliminate these risk factors.

Theoretical Framework

As stated earlier the question to be studied is: What is the
nutritional intake of a woman diagnosed with preterm labor? Hobel
(Bragonier, Cusher 8 Hobel, 1984) suggested a framework that includes

nutritional deprivation as a variable which may be linked with the

17
development of premature or preterm labor. Hobel outlined the
relationships between various characteristics that may contribute to the
onset of preterm labor. Figure 1 is an adaptation of Hobel's framework
and Hobel postulated that an interaction of personal characteristics,
maternal behaviors and social conditions triggers physiological events
that lead to preterm labor. Hobel has taken the interactions one step
further and divided them into stages which ultimately lead to preterm
labor. This framework can assist nurses in advanced practice in a
primary care setting in designing and implementing preterm labor
prevention programs. While there are certain characteristics which
cannot be altered, (i.e., age, stature, race), there are other lifestyle
factors which can be modified, and nutritional preconceptual, as well as
prenatal, counseling by the Clinical Nurse Specialist (CNS) can help the
client to make positive alterations in those factors and reduce her risk
of premature labor. The focus of this study is on Stage 1 factors (see
Figure 1) of nutritional intake, and anthropometric measures of height
and weight that contribute to nutritional status. Some demographic
information including, occupation, age, race, education level, marital
status, gestational age, and obstetric history are used to describe the
sample.

Nutritional deprivation is listed as a maternal behavior that can.
stimulate catecholamine release. Catecholamine release can lead to
uterine irritability and subsequent preterm labor. Low prepregnancy
weight is a personal-maternal characteristic which is reTated to
nutritional deprivation. Both nutritional deprivation and low

Prepregnancy weight are Stage 1 factors.

18

:33: a a .ESwEm S one: 58 3.3.4

 

 

 

 

 

 
   

 

 

 

 

.693 582m
A, a: owSm
woman—U .8530 8385
888on / 458:: 8:3 gnaw
f V b. . . . D f .5393:— Emoas <5
cog—E .5585 ©8888 All 83—3— uEEa—oaooao A.
umsm
j v Beam .8 88558 a
Beanie»: .33...
855502 Ho 9:3...»— ”SQ—Sim
955m 859500325 33 gm mamOU
8544-88.35 8:8 82:: 88
858W w. .5 ate... Seaman .85
gm 8:853— S 0955 ~ow5m
a»? glue—mam g4 \ vow—3%?
........... 4 m a. . , / /_ _ was .282 wag—cm
of. Bosnia» .. . .
gag—«gag

 

use 592...... >838 arenas... 2.. 8.. «8582 < ._ 28E

19

Stage I is considered a silent stage of preterm labor. Stage 1
behaviors and characteristics lead to the Stage II biochemical changes
which in turn progress to Stage III, or the symptomatic stage. In Stage
III, uterine irritability leads to cervical changes and preterm (or
premature) labor. Each stage varies in length. Bragonier, Cushner and
Hobel (1984) state that the ability of the client to cope with or alter
the effects of her behaviors or personal characteristics may determine
if there is any progression beyond the first stage.

Methods
Design

This study was a descriptive secondary data analysis of three—day
diet diaries and diet histories which were completed by women diagnosed
with preterm labor. This study described the caloric intake as well as
macronutrient (protein, fat, and carbohydrates) and micronutrient intake
(calcium, magnesium, iron, zinc and folic acid) compiled from these
diaries. The diet history form contained demographic information,
prepregnant weight, current weight, height, occupation and information
on vitamin supplementation and Special diets. Patient information
records supplied information on subject age, race, education, marital
status, gestational age and occupation.

Sam];

The sample was a convenience sample of 202 records of women
diagnosed with preterm labor who completed diet histories and diet
diaries between the months of March and October, 1992. Diet diaries
were completed upon admission to Healthdyne Perinatal Services' Prenatal
Monitoring Program. Gestational age on admission ranged from 17 weeks

to 35 weeks. The records represented women from all areas of the United

20
States served by Healthdyne Perinatal Services. In order to control for
other factors (smoking, multiple gestations, teenage pregnancies) which
have been positively associated with preterm deliveries, this sample was
restricted to singleton gestations in women who were non-smokers and at
least 20 years of age. These women were referred by their physicians to
Healthdyne Perinatal Services for home uterine activity monitoring in
Healthdyne's Prenatal Monitoring Program (see Appendix A for a
description of the Healthdyne Prenatal Monitoring Program). .One
component of the prenatal monitoring program is dietary analysis.
Barbara Zino, RD (personal communication, June, 1992) of Perinatal
Nutritional Services (PNS) estimated the response rate to the dietary
analysis program to be 50-60 percent of the clients referred.
ngrationa] definitions

Preterm labor. The definition of preterm labor is not precise but
usually includes a range of subjective and objective symptoms. Preterm
labor was operationalized in this study by physician diagnosis and
subsequent referral to Healthdyne Perinatal Services Prenatal Monitoring
Program.

Nutritional intake. Nutritional intake was defined in terms of
quality of diet as well as quantity of diet. Both quantity of diet and
quality of diet measures were taken from the analysis of the three-day
diet diaries, the diet history and patient information reports. All
three were supplied by PNS and copies appear in Appendix 8. Quantity
and quality of diet were operationalized using the caloric intake,
specific macronutrients and micronutrients which were analyzed by PNS
from the three day diet diary and recorded on the dietary analysis

forms. Included with caloric intake are the micronutrients of calcium,

21
magnesium, iron, zinc, and folic acid, and the macronutrients of fats,
carbohydrates and protein. Individual records reported each nutrient as
an average daily intake (based on the three-day diet recall) and as an
average daily percent of either Healthdyne's recommended amount or the
Recommended Daily Allowance (RDA) for pregnant women. Micronutrients
were additionally recorded in bar graph format which separated average
daily percent of micronutrient intake into food and supplemental vitamin
sources (Appendix B). Intake was described for the entire sample as
well as subgroups based on race and gestational age.

Anthropometric measures can be indicators of both quantity and
quality of nutritional intake. The measures used in this study were
Body Mass Index (BMI) and weight gain during pregnancy. The formula for
BMI is weight (Kg.)/height (m.) x 100. BMI was calculated by the
investigator based on the prepregnant weight and height recorded on the
diet_history form and patient information record. Categories used by
the investigator were: 1) low BMI at calculated levels less than 19.80;
2) normal 8M1 at calculated levels between 19.80-26.0; 3) high BMI at
calculated levels between 26.01-29.00; and 4) obese BMI at levels
greater than 29.00. These categories were based on recommendations of
the IOM (1990) and Chez et al. (1991). Amount of weight gained during
pregnancy was obtained by subtracting the prepregnant weight as recorded
on the diet history or patient information record from the weight
recorded at completion of the diet diaries.

Instrument

The most frequently used technique to characterize diet is the

twenty-four-hour diet diary (Rush 8 Kristal, 1982). This method is

simpler and less costly than other methods, such as a food frequency

22
questionnaire. It is easy to integrate this method into prenatal care
and causes minimal inconvenience to the person. The client estimates
all portion sizes for foods ingested throughout the day and records
them. In some studies clients are encouraged to be as specific as
possible on the brands of foods consumed since many computer food data
bases incorporate a number of brand—name foods.

Completion of three consecutive twenty-four-hour diet diaries is a
routine part of the assessment of all clients referred to Healthdyne
Perinatal Services Preterm Labor Monitoring Program. Appendix C
outlines the procedures for completion of the three-day diet diary and
contains samples of diet intake forms, instruction sheets and
standardized measurement guides which are given to each client. The
original guidelines and data base for Healthdyne's Perinatal Nutritional
Service (PNS) were developed in 1988 by three consulting dietitians.

The 1980 National Academy of Science (NAS) handbook of Recommended Daily
Allowances (RDA) was originally used in calculating nutrient amounts.
The PNS data base was updated in 1989 to reflect the most recent changes
in the RDAs.

A single twenty-four hour diet recall may be an invalid or
unreliable estimate of long~term eating patterns. There may be day-to-
day differences in food intake behavior. Rush and Kristal (1982) found
that women consume more food on Sundays than on other days during the
week. They also state that each additional day recorded makes a
substantial contribution to reliability and accuracy of the one day
intake. Several authors (Bergman, Boyungs 8 Erickson, 1990; Rush 8
Kristal, 1982; Schlundt, 1988), state that for the purpose of assessing

nutrient intake, 3-14 days per subject is adequate. Gersovitz, Madden

23
and Smicklas-Wright (1978) studied a seven day recording of food intake
in a group of 65 elderly subjects and found that the validity of the
records declined by the fifth, sixth and seventh days. Krall and Dwyer
(1987) found that a three day diary came close to estimating nutrient
intake and accounted for daily variation in amount of food intake.

In general, assessment of dietary intake can identify nutritionally
unsound diet practices. Many researchers (Rush 8 Kristal, 1982; Suitor,
Gardner, 8 Willett, 1989) agree that a three day diet diary is a useful
tool for screening nutritional intake behavior. Others (Nelson, Black,
Morris, 8 Cole, 1989) believe that at least seven days of recording are
necessary to more accurately reflect dietary intake. However, they
acknowledge that client compliance and interest are likely to decrease
the longer they are asked to keep food diaries.

The question of validity and reliability of quantitative historical
estimates of nutrient intake during pregnancy was studied by Rush and
Kristal (1982). Validity of nutrient intake measurement depends on the
accuracy of measurement and description of food consumed. In a review
of the literature on the accuracy of self-reports of food intake,
Stunkard and Waxman (1981) found a strong linear relationship between
investigator observation of food intake and a self-reported diary of
food intake. The twenty—four hour diet diary yielded estimates of
caloric and protein consumption that were within 10 percent of actual
intake.

Validity also depends on the translation of foods into their
nutrients. Nutrient calculations are limited by the extent of food
composition data bases. The number of ethnic and dietary variations in

the United States may make accurate calculation of nutrients difficult.

. 24
Addition of food items to existing data bases will help improve the
usefulness of the data base. Healthdyne's PNS current food data base,
(Barbara Zino, RD, personal communication, June, 1992), has
approximately 25,000-30,000 entries and has been updated to reflect the
1989 RDA's for pregnant women. The data base contains a wide variety of
prenatal vitamins and mineral preparations, and all major fast foods.

Reliability is the ability of an instrument to give the same results
when used repeatedly in the same situation. Reliability of a diet diary
is a function of behavioral variability, i.e., people eat differently on
different days, and of the error inherent in the measurement.
Measurement error can be reduced by training the interviewers, by
standardizing protocols and by careful coding of records; however, all
error cannot be eliminated (Rush 8 Kristal, 1982). Rush and Kristal
(1982) obtained at least three twenty-four hour diet diaries in a group
of 520 pregnant women. Their conclusion was that repeated twenty—four
hour diet diaries were reliable enough for large scale field studies in
pregnancy. The registered nurses who are responsible for instructing
the subjects in completion of the three day diet diary for Healthdyne's
Prenatal Monitoring Program have been trained using Healthdyne's -
standardized protocols.

Primary data which is received by PNS from patient information
records, diet history forms (Appendix B) and diet diary forms (Appendix
C) is entered into the PNS database and analyzed. Data which was
received by the investigator was secondary, resulting from the PNS
analysis of the primary data. Daily caloric intake recommendations were
individualized for each record and based on height, weight, frame size,

activity level and singleton gestation. The recommended amounts of

25
protein, fat and carbohydrate were extrapolated from the individualized
recommended daily caloric need based on recommendations by the American
Diabetic Association. The suggested caloric distribution is as follows:
protein--20 percent of daily caloric requirement, fat-~30 percent of
daily caloric requirement, and carbohydrate—~50 percent of daily caloric
requirement.

Ingestion of the micronutrients of calcium, zinc, iron and folic
acid were compared to the 1989 Recommended Daily Allowances (RDA) for
pregnant women. The RDA amounts for these micronutrients were taken
from the Recommended Daily Allowance (10th ed.) published by the
National Academy of Sciences. The RDA for calcium is 1200 mg/day, for
zinc 15 mg/day, for iron 30 mg/day, and folic acid is 400 ug/day. The
RDA for magnesium is 300 mg, however the PNS dieticians use 320 mg/day
as the recommendation (Lisa Johnson, Perinatal Nutritional Services,
personal communication, March 16, 1993). The summary report (Appendix
8) lists the micro and macronutrients as the average daily amount
ingested for the three day period, the RDA or recommended amount for
each nutrient, and the average RDA or recommended percentage for each
individual. Ingested nutrients were also represented in a bar graph and
compared to recommended or RDA amounts.

Data Collection

Secondary data was collected and obtained from the diet analysis
summary, the diet history form, and patient information report from each
record. Primary data was collected between March and October, 1992.
The data collector was a clerical employee hired by Healthdyne's PNS
office in Marietta, Georgia. The data collector screened diet summary

reports, diet history forms and patient information reports. Sample

26

screening criteria were provided to the data collector by the principal
investigator. Those reports that met the criteria were copied and sent
to the principal investigator. Any information identifying an
individual was obliterated before transmittal to the principal
investigator. The principal investigator had access to the Perinatal
Nutritional Services Department and the data collector through Lisa
Johnston, manager of Healthdyne's Perinatal Nutritional Services
division. A letter of support from Healthdyne is included in Appendix
D.
Data Analysis

The demographic data included: prepregnant weight, height, current
weight, age, current gestational age, race, obstetrical history, and
occupation. Body mass index was calculated using prepregnant weight and
height. Descriptive statistics (frequencies, percents, means and
standard deviations) were used to characterized the study population.
Dietary variables which were analyzed included: appetite, special diets,
vitamin supplementation, calories and macronutrients of protein, fat and
carbohydrates. The micronutrients analyzed were calcium, magnesium,
zinc, iron, and folic acid. The range, means and standard deviation for
each micro and macronutrient were calculated and also described as mean
percentage of the RDA. Percentages of micronutrients obtained from food
sources only (disregarding the percent contributed by vitamin/mineral
supplements) were also reported.

One way analysis of variance was used to compare ingested calories,
macronutrients and micronutrients in relation to racial categories,
gestational age at time of completion of the diaries, and BMI

categories.

27
flamaa_§gbja§t§*£rotection

Individual subject identity was not known to the investigator and
the investigator had no contact with the subjects. Individuals had
coded identification numbers. No special consents for participation
were obtained since gathering the three-day diet diaries is part of the
routine assessment of clients referred to Healthdyne's Prenatal
Monitoring Program. Approval was obtained from the University Committee
on Research Involving Human Subjects at Michigan State University to
conduct the study (Appendix E).

Assumptions

Accuracy of measurement of food intake is subject dependent.
Uniform instruction on measurement to each subject in a group should
increase the accuracy for that group of subjects. Since subjects in
this study were assumed to have been given uniform instruction based on
Healthdyne protocols, any errors in reporting or recording food intake
were assumed to be random It was also assumed that subjects were as
accurate and truthful as possible in recording their intake, height and
weight. It was further assumed that food intake behavior was not
altered during the recording of the three-day diet recall.

Once recorded, the foods must be assessed for nutrient composition.
Chemical analysis of food samples has been used to prepare standard
tables of nutrient composition of food. The food tables give a
reasonable close estimate of chemical analysis for macronutrients of
protein, fats, carbohydrates, and total calories. More SOphisticated
laboratory measures are needed for the most accurate measurement of

micronutrients such as iron, zinc, and folic acid. The assumption was

28
that food tables used to estimate macronutrients and micronutrients were
as accurate as possible.

This was a convenience sample of women diagnosed with preterm labor
who completed the three-day diet diary. Their responses may be
different from those who do not complete the diet diary; therefore, the
findings may not be applicable to all women with preterm labor.

Another limitation for this study was the method used by PNS to
calculate the recommended amounts of protein, carbohydrates, fats and
magnesium ingested. PNS bases their recommendations for daily intake of
protein, carbohydrates, and fats on the American Diabetic Association's
recommendations for caloric distribution. In contrast, there is no RDA
for carbohydrate and fat intake, while 60 gm is considered the RDA for
protein (IOM, 1990). Caloric intake was individualized by PNS and used
height, weight, activity level and number of fetuses were used by PNS to
determine a recommended daily caloric intake. All micronutrients,
except magnesium, reflect the RDA established by the 10M (1990). PNS
recommends a daily intake of 320 mg of magnesium per day in contrast to
the RDA of 300 mg per day. The use of PNS calculations is a limitation
which may cause confusion.

Results
Sample Characteristics

Table 1 is a summary of sample characteristics. This sample of
women represented in the records was relatively older, mainly Caucasian,
and married with an average education level of two years beyond high
school. Over 60 percent listed occupations that indicated they worked

outside the home environment. Many (30%) of the women were experiencing

Table l.
Sampla Characteristics (N=202)

29

 

Mean

 

 

 

 

_§Q_ 83899
Age (yrs) 29.25 4.64 20-43
Gestational Age (wks) 27.33 4.29 17-35
Education (yrs) (n-164) 13.95 2.41 9-24
Frequency Percentage
OCCUPATION
Sales, clerical and service 58 28.7
Professional (includes technical
managerial and administrative) 55 27.2
Homemaker 51 25.2
Other (students) 15 7.4
Laborer 10 5.0
Crafters 3 1.5
Missing 10 5.0
RACE
Caucasian 147 72.8
African American 33 16.3
Hispanic . 14 6.9
Asian 3 1.5
Missing 5 2.5
MARITAL STATUS
Married 173 85.6
Single 25 12.4
Divorced 2 1.0
Missing 2 1.0
OBSTETRIC HISTORY
Gravida 1 39 19.3
Gravida 2 61 30.2
Gravida 3 48 23.8
2 Gravida 4 54 26.8
Term Deliveries
0 124 61.3
1 50 24.8
2 2 28 13.9
Preterm Deliveries
o 136 67.3
1 50 24.8
2 2 16 7.9

 

30

their second pregnancy, although almost as many were experiencing their
fourth or greater pregnancy. Thirty-two percent had at least one prior
preterm delivery.
Nutritional Characteristics

A wide range of prepregnant weights was represented; from 84 pounds
to 356 pounds. Heights spanned 59 inches to 72 inches with the mean
reported at 64.5 inches. Body mass index (BMI) calculations (Table 2)
show that 53 of the 202 records would be considered low 8M1 prior to the
pregnancy. BMI calculations, as depicted in Table 2, illustrate that
all groups were within five pounds of the lower target amount of weight
gain for the entire pregnancy as set by the Institute of Medicine
(1990).

One hundred sixty-eight records (83.2%) listed appetite as excellent
or good; 31 (15.3%) categorized appetite as fair while only three (1.5%)
described appetite as poor. Fourteen (7.4%) were on a special diet such
as diabetic, low sodium, and vegetarian. One hundred and ninety records
(94.1%) indicated the ingestions of some type of vitamin or mineral
supplement. There were 20 different brand names of prenatal vitamins
identified in the records. Fifty-two records (25.7%) included iron as
an additional supplement.
Calories, Macronutrientsgand Micronutrients

Table 3 gives a summary of average daiTy intake of calories,
macronutrients and micronutrients based on the three day diet recall.
Macronutrient intake was close to 100 percent of recommended amount with
protein intake the lowest and fat intake the highest. It should be
remembered that the values for macronutrients were calculated by PNS

based on American Diabetic Association recommendations for caloric

31

:.. a. nue =M .nd Wei-ht ain , Bod Ma

nd--

 

 

 

 

an talus freemx Percent
Low BMI <19.79 53 26.2
Normal BMI 19.80—26.00 110 54.5
High BMI 26.01-29.00 20 9.9
Obese 29.01> 19 9.4
Waight gain by BMI

8M1 'IOM Racommended Mean lbs saga
Low 26-40 lbs 20.94 7.93
Normal 25-35 lbs 20.31 9.46
Overweight 15—25 lbs . 21.90 12.85
Obese < 15 lbs 12.05 10.48

 

‘ Institute of Medicine, 1990

32

Table 3.
Ib£§§_Q§¥ Mean. Standard Deviation. Ranqe and Percent gf Racommenggg

 

Amgunts of Nutrignts (Ns202)

 

 

 

 

been 5821 83099 fi.B§£s

Calories 1941.96 456.90 979-3818 ' 84.86
Macronutrients 22.89;;
Protein (gm) 83.75 22.00 43-168 72.90
Fat (gm) 71.79 22.11 25-159 94.20
Carbohydrates (gm) 241.38 69.85 88-604 83.97
' Micronutrients b% Rec
Calcium (mg) 1215.53 482.00 122-2629 104.09
Magnesium (mg) 206.00 84.65 67-581 81.21
Zinc (mg) 29.61 7.74 3-59 197.40
Iron (mg) 97.67 53.09 8-416 325.74
Folic Acid (mcg) 1240.68 390.06 61-3700 310.16

 

‘% based on recommendations of PNS for calories and American Diabetic
Association for caloric distribution among macronutrients.
based on RDA (except magnesium which is a PNS recommended value)

33
breakdown. There is no RDA for carbohydrate and fat ingestion but 60 gm
is recognized as an RDA for protein, while 2,500 calories is considered
RDA (10M, 1990). All micronutrients except magnesium were ingested at
levels greater than 100 percent of the RDA.

There was a small number of records (10) in which there was no
routine vitamin/mineral supplementation documented. An overview of
these ten records indicate that micronutrient intake was below the RDA
for all categories except iron.

Since so many were taking vitamin/mineral supplements (94%),
micronutrients were also described in terms of the percentage of RDA
from food sources only. This was done to help ascertain the quality of
the diet. The results were divided into five categories as described in
Table 4. The results indicate that food choices made a minimal
contribution to fulfilling the RDA's for zinc and iron. Only 17.3
percent and 3 percent of the sample were able to ingest at least 75
percent of the RDA for zinc and iron respectively from food. Twenty-
eight percent of the sample reported ingesting foods that supplied 75
percent or more of the daily RDA for folic acid. Calcium and magnesium
ingestion fared better; 40 percent and 53 percent of the records showed

a food intake of at least 75 percent of the RDAs for these two

nutrients.

Group Comparisons

Comparisons were made between racial classifications, gestational
age, body mass index and percent of RDA for macro and micronutrients
, /
using analysis of variance followed by Scheffe post hoc tests if

appropriate. Table 5 illustrates ingested nutrients based on race.

34

.amu\me cum mo o=F~> mza no woman x E=_mocmmmm

 

 

“.5 2 o; N mo 2 I: a new 3 x2: A
“.mw NM ”NM“ Hm ewe“ 2N ~.om Hm ~.m~ mm xoo~-xo~
o.~m ms “.9“ mmfi ~.m~ hm ~.mm mm m.- me am51x~m
8.5 m_ a m cm No“ m.e~ om m.¢~ ma xom-xo~
m a m o.~ N c.~ N xmu w

x c x c
opo< owpou cos“ x ucw~c amswmmcmmn mawupaw <amx

 

 

umocmaamUm
m mza Lo <om we “smegma a ma ummmmc xu noon soak mucmPguzcogupz

 

.v opnmh

wen xpucmu_ewcm_m mnsoem oz» awash +

35

 

 

m_m»-cm oo; amen omwmsum an umcwscmumu mm acmgmm mo. v a mm“ .m we .thMiwiu
. . . u_u< owpoa
mo.a~ o~.mom me.mm ma.mom -.¢m mm.mm~ No.eo# “W.MMM cooH
mm.m ~_.Hm~ -._e~ o_.mmm m~.meH m¢.mmm, mm.¢m oo.mmH o=w~
No.5m m~.mm~ ae.H~ Se.mo~ e~.~e mm.om~ e~.mm mm.~m s=_ao=maz
am.m_ m_.m~ a~.am No.~m Na.~m mm.- am.m~ am.o-+ se=_opau
mm.- ~_.om No.4m o¢.mm Nm.~N ma ~m+ ma mm auco_a»==oeo_=
. . . . m a; x 0 one
ao.- om.~m mm.om o".~m -.m~ ma ma m~.m~ mo.em a a a g game
Nana a_.mm w~.mm mm No“ we on me as mo.~m MM.MW cpoooaa
mg 8 am No me mu am me an MN mm Na mm m au=o_au==oaoa=
82.8 Hm.- e~.mm ea.mm ao.mm hm.fim me.oN Le.mm ao_aopau
am x, cm x mm x mm x
Amuev Aafiuav Ammucv Aaafincv
c~_m< o_=~amw: cauPLms<icmu_ge< =m_mmo=mu

 

 

mazogu meumm >5 teammucm <om nemlumucuasoumm go “cause; :mgm

.m mfinah

36
Caucasians ingested significantly more calcium than the African-American
subjects. All other comparisons were non-significant.

Although there is a wide variation in the number of subjects in each
racial grouping, it is interesting to note that the Asian group ingested
much less fat, iron and protein on average than the Caucasian, African-
American or Hispanic groups. Hispanics were the only group to consume
more than 30 percent of calories from fat.

Records were divided into four gestational age groups and compared
for mean percentage of ingested recommended amounts and RDAs. There
were no significant differences between the four groups (Table 6). As
in earlier groupings macronutrient intake was below 100 percent
recommended amount and micronutrient intake was greater than 100 percent
RDA except for magnesium.

Table 7 illustrates the significant differences in macronutrient
intake when comparisons are made based on 8M1. The low BMI group
ingested significantly more calories and carbohydrates than the other
three groups. The normal BMI group ingested significantly more calories
and carbohydrates than the high BMI and obese groups. In regard to
protein, the low BMI group ingested significantly more protein than the
high BMI and obese group. Those with a normal BMI ingested
significantly more protein than the high BMI group. Fat intake was
significantly higher in the low BMI group than in the high BMI and obese
groups. The normal BMI group ingested more fat than the high BMI group.

There were no significant differences in micronutrient intake between

any of the BMI groups.

 

NH.oo am.~m~ em.am ma.m_m mm.aa~ Nm.o~m em.eo Hm.~om awoa owpoa
m~.~ma mm.oom am.a- um.-m La.~a~ e~.aam ma.ma~ ma.am~ coe_
Am.~m ae.ao~ mm.me Le.~o~ mo.mm am.oa_ Nm.om Hm.~aa o=2~

4, am.- oo.m~ m~.m~ -.om ~m.mm m~.am mo.- mm.~m e=_ao=maz

as La.am mm.m°_ mm.mm °~.~o_ Le.~e N~.oSH ¢~.Hm m~.aa anopau

mucm «Luz—3.5 :—
o~.a~ ¢~.mm am.m~ oo.mm so.m~ Hm.mm om.m~ mm.Nm mooaaexzonoau
“8.3m om.oo~ om.~m mm.ma Ha.~m ofi.om aH.m~ oa.mm baa
om.m_ o~.- ma.a~ mm.~a em.m~ a_.me mm.mH am.ao =_oooea
mucw wsuacogum:
H~.m~ _~.mm mo.- we.am om.a~ Na.mm mm.m~ ma.am mowao_au
om came om came om cams om :mmE
ax; em-~o.~m ax; «m-_o.m~ ax: m~-_o.a~ ax; ¢~-o~
.mHn=V a .aa Avenue m .88 Lemucv N .88 Aoeucv _ .aa «cm x

 

 

mu< Pacowumummu an vmummccm (om use omucmesoomm mo acmocmm smug

.0 open...

8
3

com_gma5ou Amwwmsumv

mo.vua .~m~.m be +

.owamg d acmuwwwcmwm a mnpzoppow

oo; “man no woman Congo sumo sock acmgmwowo xpucmuwwwcmwm mom a an cmumowvcw maaogu

mo.- m~.em Ho.mH om.mm Nm.H~ mo.mma mo.- em.wm « +Ao~.o~umv
mmumguagongau
mm.nm mm.~m so.- mm.mo em.o~ N~.¢m mm.mm mm.~ofir +A~o.mndv
and
Ho.m~ mo.mo mm.- Ho.mm mm.m~ ofi.¢~« ms.m~ Rm.mn a +A¢~.mumv
cameos;
mm.- mm.mm -.¢~ om.mo mo.- w~.¢mn ~¢.m~ -.wm « +A¢¢.-umv
mmwgopmu
om games om xcmws om gamma om gamma
_ Aa_u=v AONucv Amofiucv Ammucv
Hzm mmmoo Hzm saw: Hzm pascoz Hzm 3o;

 

 

flmzm. xmvcm mam: zoom >n mucmwcuscogumz ummlmmwgopmu teammac~ voucmssoomz ea acmucma cmma

.u m—nmh

39
Discussion

The characteristics of this sample are unique and cannot be
generalized to the general population of women diagnosed With preterm
labor. Additionally, the response rate to the dietary analysis of 50-60
percent of women referred to Healthdyne's Prenatal Monitoring Pregram
indicates that the results of this study can not be generalized to the
population of women who are referred to Healthdyne for preterm labor I
monitoring.

Many of the recent studies regarding maternal nutrition and
pregnancy have focused on outcome data such as duration of gestation, or
infant birth weight (Huber et al., 1988; Klebanoff, Shiono, Berendes, 8
Rhoades, 1989; Kristal 8 Rush, 1984; Neggers et al., 1990; Offringa 8
Boersma, 1987). Some have focused on weight gain and infant birth
weight (Abrams 8 Parker, 1990; Hedinger, Scholl, Belsky, Ances, 8
Salmon, 1989; Mitchell 8 Lerner, 1989; Orstead et al., 1985; Seidman et
al., 1989; Suitor, 1989). This study was one of description of
nutritional intake of women diagnosed with preterm labor and made no
attempt to relate nutritional intake or anthropometric measures to
pregnancy outcome. Because this study does not include pregnancy
outcome, it is difficult to correlate it with any of the studies of
maternal nutritional intake or maternal weight gain and subsequent
length of gestation or infant birth weight.

This sample generally appears to be well-nourished prior to the
pregnancy with 110 records (54.5%) exhibited a BMI in the normal range,
while 53 records (26%) were classified as low BMI. The remaining 20
percent were grouped in the high or obese categories. Prepregnant

weight was used to calculate BMI in this study. Prepregnant weight can

40
be a difficult variable to accurately measure and women may over or
underestimate their actual prepregnant weight.

All BMI groups were within five pounds of the target weight gain for
the entire pregnancy indicating more than adequate weight gain for the
current gestational age. The low BMI group had a significantly
increased caloric and macronutrient intake over the other 8M1 groups and
the concern for adequate weight gain in underweight women is not present
in this sample. Therefore, this sample of women with a low BMI should
be at lower risk for delivering a preterm infant. The high and obese
BMI groups both had lower caloric and macronutrient intake than the
other groups. Perhaps these groups at the extremes of the BMI range had
received nutritional counseling during the pregnancy which may have
influenced food selection as well as reported weight gain.

Many nutrition studies of pregnant women in the U.S. (Abrams,
Newman, Key, 8 Parker, 1989; Brennan et al., 1983; Cherry et al., 1987;
Jeans et al., 1955; Rush et al., 1988; Wen, Goldenberg, Cutter, Hoffman,
8 Cliver, 1990) have focused on women of lower sociodemographic status.
Demographics of this study show a mean education level of almost two
years post high school. Over 60 percent of the records listed
occupations which point to employment outside the home; it can be
assumed that this p0pulation was not from a lower socio-economic
background. Eighty-five percent were married, which could indicate the
support of a significant other.

In answer to the research question posed by this study it appears
that the nutritional intake of this group of women with preterm labor
was adequate in many areas. Daily caloric intake was below what PNS

recommended and also below RDA recommendations, however, carbohydrate

41
and fat intake was adequate. Protein intake was below the amount
recommended by PNS, but exceeded the 60 gm/day RDA as recommended by IOM
(1990). Deficiencies in protein were therefore artifact and may be due
to the manner in which PNS calculated recommendations for protein.

Micronutrient intake was above the RDA, except for magnesium, due
mainly to vitamin supplementation. Ninety-four percent of the records
indicated at least prenatal vitamin supplementation. All of the 20
prenatal vitamins named in the records contain 100 percent or more of
RDA for iron, zinc and folic acid.

Macronutrient ingestion by race show Hispanics ingesting slightly
more than 30 percent of daily caloric intake from fat. Asians ingested
lower amounts of protein and fat and higher amounts of carbohydrates
than the other groups. This may reflect characteristic cultural food
patterns as illustrated by Worthington-Roberts and Rodwell-Williams
(1989).

Micronutrient intake showed some variations. Calcium, when it is
included as a part of a prenatal vitamin supplement, varied in amounts
from 200-300 mg. Calcium intake overall was above the RDA, probably
because the sample was predominantly Caucasian. Racial breakdown
revealed a significant difference in intake between Caucasians and
African—American women with the Caucasian group ingesting more calcium.
Hispanics also consumed calcium at a rate below the RDA. This supports
other findings that Hispanic and African-Americans often have a lower
calcium intake. In the Brennan et al. (1983) study, low income African-
American and Hispanic women consumed 67-75 percent RDA of calcium. In
the present study, African-American women consumed 82 percent RDA and

Hispanic women consumed 89 percent RDA of calcium. It cannot be

42
determined from collected information if these women were low-income,
however, the overall sample is believed to be middle class. This
indicates that low calcium intake may be prevalent among all social
classes. Villars (1988) states that while lactose intolerance is more
prevalent in African—American and Hispanic women this condition abates
during pregnancy. Lactose intolerance cannot be determined in reviewing
these records. However, a decreased calcium intake could be related to
lactose intolerance or cultural eating patterns.

A magnesium intake of less than 100 percent RDA is common in
pregnancy according to the Institute of Medicine (1990). Lack of
specific food choices may contribute to this deficienCy since magnesium
is found in grains, seafood and green vegetables. In addition,
magnesium is not a component of most prenatal vitamins. The RDA for
magnesium is 300 mg/day while PNS used 320 mg/day. This sample had
daily magnesium intake below both PNS recommended amount and the RDA and
gives credence to the prevalence of low magnesium intake during
pregnancy. Magnesium is also found in drinking water which was not
assessed in the daily diet intake.

Another method of exploring nutritional intake on the micronutrient
level is to review the percent of RDA consumed from food sources without
regard to vitamin/mineral supplementation. Table 4 reveals that 46 A
percent of the sample derived 75 percent or less of the RDA for
magnesium from food. Zinc intake from food was also low with 54.5

percent of the sample ingesting 50 percent or less of RDA. Hambridge et
al. (1983) and Hunt (1987) also reported zinc intake less than RDA in

their studies of pregnant women. These results also support the IOM

43
(1990) review of study findings in the 1980's that folic acid, iron,
calcium, zinc, and magnesium intakes were below the RDA's for pregnancy.

Eighty percent of the sample derived 50 percent or less of the RDA
of iron from food, however, the mean intake of iron per day was 97 mg
for the overall sample, with all ethnic groups ingesting at least 250
percent of RDA. This would indicate iron supplementation of about 60.
mg/day. When iron is supplemented at levels of 30 mg/day the IOM (1990)
recommends additional zinc supplementation. High iron supplements
(greater than 60 mg/day) may be associated with plasma zinc suppression
(Dawson et al., 1989; Yadrick et al., 1989) and should be avoided.

Folic acid is another nutrient which is consumed in amounts
substantially less than the RDA. Only 27 percent of this sample
ingested 76 percent or more of the folic acid RDA from food sources.
This supports the Huber et al. (1988) study of folic acid intake in a
population which was predominantly white, middle class and age 20 or
older. They found that less than ten percent of those women received
adequate folic acid intake from diet alone. The comparisons between
nutrient intake in Tables 3 and 4 illustrates the important role that
prenatal vitamins plan in ensuring adequate nutritional intake.

In summary, this is a sample of older, educated, married, middle-
class, non-smoking women with singleton gestations who have been
diagnosed with preterm labor. Over 50 percent had a normal pre-pregnant
BMI. Most recommended amounts of nutrients were met by this sample
through a combination of food and vitamin/mineral supplementation. The
literature has singled out deficiencies in the nutritional intake (from
food sources) of folic acid, iron, and magnesium for most pregnant

women. African-American and Hispanic women have been shown, in the

44

literature, to have a lower intake of calcium. _This sample seems to
reflect those deficiencies. Because of vitamin supplementation, 194
subjects were able to ingest the recommended amounts of all
micronutrients except magnesium. The small number of non-vitamin users
(10) consumed less than 100 percent RDA for all micronutrients except
iron. Overall, weight gain was adequate for the current gestational
age.
Balation to Conceptual Framework

Hobel (Bragonier et al., 1984) hypothesized that there are a number

 

of personal-maternal characteristics which contribute to the development
of preterm labor. Among those are young/old age, short stature, low
prepregnancy weight, black race, unmarried status and low socioeconomic
status. The sample characteristics are the antithesis to Hobel's
criteria. The mean age was 29 years; mean height was 64.5 inches; mean
prepregnant weight was 135 lbs; and the most frequent BMI was normal.
Racially, 147 (72.8%) were Caucasian and 33 (16.3%) were African—
American. One hundred seventy-three (85.6%) were married. Although
questions regarding income were not addressed, it was determined that
this sample probably did not represent a low socioeconomic strata. This
conclusion was based on occupation and education level of the sample.
Hobel (Bragonier et al., 1984) also addressed maternal behaviors
which may contribute to the devel0pment of preterm labor. Hobel's
(Bragonier et al., 1984) list of maternal behaviors include nutritional
deprivation, smoking, alcohol and drug use, work/fatigue, change in
residence, short pregnancy interval, poor hygiene and coitus. Although
this sample excluded smokers, it is not known by reviewing the records

if alcohol or drugs were used. The three-day diet recalls indicate

45
that, at least during collection of diet information, there was no
alcohol intake reported. It is known that work/fatigue can contribute
to stress and it is certainly plausible that this sample may have
experienced one or both. This study did not address work/fatigue. It
also did not address social support which, if inadequate in Hobel's
estimation, contributes to a large degree of the stress in pregnancy.
Giotta (not associated with Hobel) (1993) links high psychosocial stress
with preterm labor and feels that stress may interfere with nutritional
status. The vast majority of the sample was married; however, marriage
only indicates the presence of a spouse and says nothing about the
presence of social support. Other behaviors not addressed in this study
were change in residence, pregnancy interval, hygiene or coitus.

Perhaps the inclusion criteria for this study (singleton gestation,
at least 20 years of age and non-smokers) excluded women with Hobel's
personal-maternal characteristics which may contribute to preterm labor.
The diagnosis of preterm labor is also not universally agreed upon and
there is no clear cut criteria for entry into Healthdyne's Preterm Labor
Program. The criteria for preterm labor in this sample was based solely
on physician diagnosis. Physician diagnosis of preterm labor varies.
Therefore the criteria used for determining preterm labor in this sample
may be different from preterm labor which Hobel describes.

It is interesting to note that in the most recent edition of Preterm

Birth (Fuchs et al., 1993), Hobel's model is no longer included in the

 

discussion of etiology of preterm labor. Important predisposing factors
for low birth weight and preterm delivery are discussed. Some of the
factors are genetics, ethnicity, illness, malnutrition and food

deprivation (with emphasis on the pattern of maternal weight gain),

46

anemia, short pregnancy interval, and employment. When focusing on
nutritional factors alone, Stubblefield (1993) cites low maternal weight
(less than 50 kg) and poor weight gain (less than 400 gm/wk) late in
pregnancy as associated with an increase in preterm delivery in a study
of indigent women in Alabama (Wen, Goldenberg, 8 Cutter, 1990).

Maternal factors such as age (young or old), low socioeconomic
status, smoking, cardiac disease, and uterine abnormalities may
predispose one to preterm labor. There are also placental factors,
fetal factors and iatrogenic factors that may contribute to the
development of preterm labor. However, the discussion of predisposing
factors provides few clear relationships between the factors and
pregnancy outcome. In fact, Fuchs (Fuchs et al., 1993) states that none
of the predisposing factors will necessarily lead to preterm labor and
that one half of the cases of preterm labor have no identifiable
predisposing factors. It is this investigator's feeling that many of
the factors first hypothesized by Hobel (Bragonier et al., 1984) and
later discussed by Stubblefield (Fuchs et al., 1993) and Fuchs (Fuchs et
al., 1993) do play a role in preterm labor, but it is unclear which ones
weigh more heavily in the development of preterm labor. More research
focusing on the predisposing factors is necessary. This author also
agrees with Stubblefield (Fuchs et al., 1993) who advocates for
”societal transformations" in the U.S. if medical solutions to prevent
preterm birth are to succeed (Fuchs et al., 1993, p.35).

The focus of this study was nutritional intake and anthr0pometric
measures of women diagnosed with preterm labor. In describing
nutritional intake this study was looking for nutritional deprivation.

Although there are areas of deficiency in some nutrients for this

47

sample, the results of this study do not point to nutritional
deprivation, short stature or low prepregnant weight as put forth by
Hobel in 1984. These results also do not support Stubblefield's (Fuchs
et al., 1993) hypothesis that low maternal weight or poor weight gain
can predispose one to preterm labor. It should be remembered that the
demographics of this study were different from those cited by
Stubblefield (Fuchs et al., 1993).

Implications for Advanced Practice

Even though the overall nutritional intake of this sample was
adequate, there are some implications for advanced nursing practice.
Because of specialized training, the Clinical Nurse Specialist (CNS) is
in an ideal position to impact nutrition as it relates to the
development of preterm labor. The role characteristics of clinician,
assessor, counselor, collaborator, educator and change agent will be
well utilized in nutritional assessment.

The CNS should provide nutritional counseling to all women as part
of preconceptual counseling.l If there is no opportunity for
preconceptual nutritional guidance, the CNS should devote a good portion
of the first prenatal visit to nutritional counseling. Early assessment
of nutritional intake and weight status allows more time for
intervention. Those with low weight for height may be at increased risk
for preterm labor and could possibly benefit from nutritional
supplementation programs or in—depth nutritional counseling. Assessment
should include calculation and recording of BMI at the first prenatal
visit. Ideally there will be a prepregnant weight available in the'
client's chart, if not, questioning the client as to her weight before

she became pregnant with the current pregnancy may have to suffice. A

48
weight graph should be utilized and each subsequent weight recorded on
the graph. It is recommended that weight graphs be standardized. The
graph should contain guidelines for desirable weight gain based on BMI.
Weight gain goals should be based on BMI. Weight gain should be
assessed at every visit since early and late inadequate weight gain has
been associated with preterm birth. I

Assessment should also include the use of at least two twenty-four
hour diet diaries in order to determine the adequacy of diet in all
pregnant women. The CNS should be familiar with food sources of macro
as well as micronutrients. Knowledge of the rec0mmended daily intake of
macronutrients and micronutrients during pregnancy is essential for the
CNS. Based on the findings of this study the CNS should pay particular
attention to ensuring adequate caloric intake in order for the client to
achieve desired weight gain. Referral to a dietitian or nutritionist
for in depth nutritional counseling would certainly be appropriate for
women with identified deficiencies. Awareness of characteristic
cultural food patterns in the community is also important in formulating
individual dietary guidelines. The CNS needs to be aware of cultural
differences in nutritional intake as well as individual food preferences
and intolerances.

Protein intake should also be monitored with each prenatal visit
using 60 gm/day RDA as a guide. Dietary sources of protein should be
encouraged rather than the use of high protein supplements. Beside
using the RDA for protein as a guideline it would be helpful if dietary
counseling followed guidelines established by the U.S. Public Health
Services (U.S. Department of Health and Human Services, Public Health

Service, 1990). These guidelines call for a reduction in dietary fat to

49
30 percent of daily caloric intake or less and an increase in the amount
of complex carbohydrates eaten each day.

Magnesium is a micronutrient whose intake should be assessed in all
pregnant women. The CNS should be particularly familiar with food
sources of this nutrient (i.e., grains, seafood and green vegetables)
since routine vitamin supplements do not contain magnesium and most
pregnant women ingest magnesium in amounts below the RDA. Calcium is
another micronutrient whose intake should be evaluated especially in
African-American and Hispanic women. When evaluating calcium intake the
CNS should ask about the presence of lactose intolerance and strategize
with clients ways to insure adequate calcium intake especially in the
case of lactose intolerance.

Adequacy of micronutrient intake relies heavily on prenatal vitamin
supplementation. If prenatal vitamins have been prescribed it is
important to assess two things: 1) How often is the client taking
prenatal vitamins? and 2) For how long has the client been taking
prenatal vitamins? Pattern of vitamin supplement intake needs to be
assessed at each prenatal visit.

If no supplementation has been prescribed or the client is not
taking supplementation on a daily basis, it is imperative that adequacy
of micronutrient intake be established by using diet diaries.
Consideration should be given to prescribing supplementation if food
sources are inadequate to meet micronutrient demands. If additional
iron supplementation has been prescribed an awareness of iron's
depressant effects on plasma zinc is necessary. Zinc supplementation

may be needed for those women who take more than 30 mg/day of iron.

50
Collaboration or consultation with a dietitian may be helpful during the
assessment of nutritional intake.

Again, the CNS needs to be familiar with food sources of the
micronutrients and should strive to ensure adequacy of micronutrient
intake through diet. Nutritional follow up should be done at each
prenatal visit. Tracking pregnancy outcomes is one method of assessing
the effectiveness of early and frequent nutritional counseling. In the
event of a preterm delivery, documented nutritional information may
suggest the role that nutritional intake had in contributing to the
unexpected outtome.

In regard to diet analysis as performed by PNS, it would be helpful
for PNS to modify their recommendations for macronutrient intake.
Caloric intake should be based on RDA for pregnancy and BMI calculations
should be performed for each client. Protein intake recommendations
should be modified to reflect the RDA of 60 gm per day. Limiting fat
intake to 30 percent or less of daily caloric intake is prudent. These
modifications would provide consistency with RDA and IOM guidelines and
avoid protein overload. PNS micronutrient guidelines mirror the RDA
except for magnesium. Consideration should be given to modifying the
recommended intake of magnesium to 300 mg/day to be consistent with the
RDA. ’

Implications for Research

Further research on women diagnosed with preterm labor should be
outcome based addressing the influence of BMI, weight gain, and
nutritional status on the length of gestation. Studies should be

controlled for variables such as socioeconomic status, ethnic

51
background, age, smoking, number of fetuses, and the presence of
maternal disease or uterine abnormalities.

Because prenatal vitamin supplementation is so prevalent the
interaction among nutrients should also be addressed such as the effects
of iron supplementation on zinc stores, and the optimum intake of
nutrients without producing toxicity should be determined. More
sophisticated laboratory analyses of nutrition status, such as measuring
serum levels of nutrients, although expensive, is to be encouraged. The
body may have a compensating mechanism for inadequate nutrient intake.
For instance, the IOM (1990) suggests that the body metabolizes
magnesium more efficiently when intake is low. Knowing more about
metabolism of nutrients may establish true deficiency from an intake
deficit.

Ethnic differences in nutritional intake should also be studied with
large samples from the African-American, Hispanic, Asian and Native
American populations. Studies should be controlled for socioeconomic
status in order to ascertain if there are different patterns of food
and/or vitamin intake in different socioeconomic groups.

Comparison of nutritional intake between groups of women who have
not been diagnosed with preterm labor and those with preterm labor may
help determine if there isia relationship between nutritional intake and
preterm labor. The nutritional intake of smokers, both those who have
been diagnosed with preterm labor and those without preterm labor,
should be compared. Comparing the nutritional status of smokers and
non-smokers may also prove beneficial. .0utcome data on these groups

should also be included.

52

Maternal nutrition during pregnancy continues to be inadequately
studied. This study suggests that some women with preterm labor are not
nutritionally deprived in spite of caloric and magnesium intakes which
were below the RDA. Prenatal vitamins had a significant role in
assuring adequate intake of iron, zinc and folic acid. Weight gain was
adequate for all BMI groups. No attempt was made to investigate the
outcome of these pregnancies in terms of gestational age or birthweight.

Another area of research to be addressed is in defining preterm
labor. By studying individual physician diagnoses (as utilized in this
study) inconsistencies and discrepancies in the definition of preterm
labor may be revealed. Until there is a more consistently followed
approach to the diagnosis of preterm labor, predisposing factors for
preterm labor could be meaningless.

This study did little to clear up the controversy regarding nutrient
intake and its contribution to the develooment of preterm labor. It did
point to the importance of vitamin supplementation in assuring adequate
micronutrient intake. Further research is recommended. Frameworks
other than Hobel's which could be utilized are Roy's Adaptation Model,
Orem's Self-Care Model or the Health Belief Model. '

Clinically, the nurse in advanced practice may be able to positively
impact pregnancy outcome by early and consistent evaluation of
nutritional intake and weight gain. Familiarity with the cultural
eating patterns of the community is important. Knowledge of the impact
of vitamin supplementation on adequate micronutrient intake is
essential. Further research into the body's metabolism of nutrients

could provide insight on true nutritional deficiency.

53
List of References

Abrams, 8., Newman, V., Key, T., 8 Parker, J. (1989). Maternal weight
gain and preterm delivery. Qbstatrjga ang Gynegglogy, 15, 577-583.

Abrams, 8., 8 Parker, J. (1990). Maternal weight gain in women with
good pregnancy outcome. Qbstetrigs and Gynacoiggy, Z§(1), 1-7.

American Academy of Pediatrics 8 American College of Obstetricians and
Gynecologists. (1992). Guidelines for Perinatal Care (3rd Ed.).
Washington, D.C.: AAP, ACOG.

American College of Obstetricians and Gynecologists. (1982). Standards
for Obstetric and Gynecologic Services (5th Ed.). Washington, D.C.:
ACOG.

Apgar, J. (1987). The effect on the guinea pig of low zinc intake
during pregnancy. Proceedings of the Federation of the Amerigap
Society of Experimental Biology, ifi. 747.

Bergman, E.A., Boyungs, J.C., 8 Erickson, M.L. (1990). Comparison of
food frequency questionnaire and a three day diet record. Journal of
the American Dietetic Association, 99(10), 1431-1432.

Born too soon. (Sept. 6, 1992). Lansinq,State Journal, Section A.

Bragonier, J.R., Cushner, I.M., 8 Hobel, C.J. (1984). Social and
personal factors in the etiology of preterm birth. In F. Fuchs and
P.G. Stubblefield (Eds.), Preterm birth: Causesapreventioptapg
management (pp. 64-75). New York, NY: Macmillian Publishing
Company.

Brennan, R., Kohrs, M., Nordstrom, J., Sauvage, J., 8 Shank, R. (1983).
Comparison of diets of low-income pregnant women: Comparison of

analyzed with calculated values. Journa] of the American Dietetic
Association. Bi. 538-545.

54

Brown, J.E. (1989). Improving pregnancy outcomes in the United States:
The importance of preventive nutrition services. aggtpal_g£_tpa
Amayigap_fljatatic Association, 89(5), 631—633.

Cherry, F., Sandstead, H., Bazzano, G., Johnson, L., Bunce, H., Milne,
D., 8 Mahalko, J. (1987). Zinc nutriture in adolescent pregnancy:
Response to zinc supplementation. Proceedings of the Federationtof
tha American Society of Exoerimental Biology, to, 748.

Chez, R., King, J., Niebyl, J., 8 Pitkin, R.M. (1991). Advising
pregnancy women about nutrition. Contempgtary Obstetrics apg
Gynecology. January, 1991, 80-97.

Colman, N., Larsen, J.V., Barker, M., Barker, E.A., Green, R., 8 Metz,
J. (1975). Prevention of folate deficiency by food fortification,
III the effect in pregnant subjects of varying amounts of added
folic acid. American Journal of Clinical Nutrition, 28, 465-470.

Oawon, E.B., Albers, J., 8 McGanity, W.J. (1989). Serum zinc changes
due to iron supplementation in teenage pregnancy. American Jouzpal
of Clinical Nutrition, to, 838-852.

Edwards, L.E., Alton, I.R., Barrada, M.l., 8 Hakanson, E.Y. (1979).
Pregnancy in the underweight female. American Journal of Obstetrics
and Gynecoloqy, 135, 297.

Fuchs, A.R., 8 Fuchs, F. (1993). Endocrinology of term and preterm

' labor. In A. Fuchs, F. Fuchs, and P. Stubblefield (Eds.), Etgtgym
birth: Causes. prevention, and management (2nd ed.). New York, NY:
McGraw-Hill, Inc.

Fuchs, A.R., Fuchs, F., 8 Stubblefield, P.G. (Eds.) (1993). Eyatggm
birth: Causes. prevention. and manageaapt (2nd ed.). New York, NY:

McGraw-Hill, Inc.

55

Garbaciak, J.A., Richter, M., Miller, S., 8 Barton, J.J. (1985).
Maternal weight and pregnancy complications. American Journal of
Obatetrigs and Gynecology, 188, 238.

Gershovitz, M., Madden, J.P., 8 Smicklas—Wright, H. (1978). Validity of
a twenty-four hour diet recall and seven day record for group

comparisons. Journal of the American Dietetic Association, 18, 48—
5‘5 .

Giotta, M.P. (1993). Nutrition during pregnancy: Reducing obstetrical
risk. Journal of Perinatal and Neonatal Nursing, 8(4), 1-12.

Gormican, A., Valentine, J., 8 Satter, E. (1980). Relationships of
maternal weight gain, prepregnant weight and infant birthweight.
Journal of the American Dietetic Association, 11, 662-667.

Hambridge, K.M., Krebs, N.F., Jacobs, M.A., Favier, A., Guyette, L., 8
Ikle, D.N. (1983). Nutritional status during pregnancy: A
longitudinal study. American Journal of Clinical Nutrition, 81,
429-442.

Hediger, M., Scholl, T., Velsky, D., Ances, 1., 8 Salmon, R. (1989).
Patterns of weight gain in adolescent pregnancy: Effect on
birthweight and preterm delivery. Obstetrics and Gynecology, 15(1),

6-11.

Huber, A.M., Wallins, L.L., 8 DeRusso, P. (1988). Folate nutriture in

pregnancy. Journal of the Amerigan Dietetic Association, 88, 791-

795.

56
Hunt, I.F., Murphy, N.J., Martner-Hewes, R.M., Faraju, 8., Swendsaid,
M.E., Reynolds, R.D., Sanchez, A., 8 Mejia, A. (1987). Zinc,
vitamin 8-6 and other nutrients in pregnant women attending prenatal

clinics in Mexico. Americah Journal of Clinical Nutrition, 58, 563-
569.

Iams, J.D., Stilson, R., Johnson, F.F., Williams, R.A., 8 Rice, R.
(1990). Symptoms that precede preterm labor and premature rupture

of membranes. American Journal of Obstetrics and Gynecology, 188,
486—490.

Institute of Medicine (U S.). Subcommittee on Nutritional Status and

Weight Gain During Pregnancy. (1990). Nutrition duringapreqnancy:

 

Part 1; Weight gain: Part II. Nutrient supplements. Washington,

D.C.: National Academy Press.

Iyengar, L., 8 Rajalakshmi, K. (1975). Effect of folic acid
supplementation on birth weights of infants. American Journal of
Obstetrics and Gynecology, 182, 332-336.

Jeans, P.C., Smith, M.8., 8 Stearns, G. (1955). The incidence of
prematurity in relation to maternal nutrition. Journal of the
American Dietetic Association, 81, 576.

Kaltreider, D.F. (1963). Effects of height and weight on pregnancy and
the newborn. Springfield, IL: Charles C. Thomas.

Kaltreider, D.F., 8 Kohl, S. (1980). Epidemiology of preterm delivery.
Clinics in Obstetrics and Gynecology, 88(1), 17-30.

Klebanoff, M.A., Shiono, P.H., Berendes, H.W., 8 Rhoads, G.G. (1989).

Facts and artifacts about anemia and preterm delivery. Journal of

thg Amarjtan Magical §ocigty, 281(4), 511-515.

57
Krall, S., 8 Dwyer, B. (1987). Validity of food frequency questionnaire

and a food diary in short term recall. ur al of the Ameri an
ietetic As ociation, 81, 1374,

Kramer, M. (1987). Intrauterine growth and gestational duration
determinants. Pediatrics, 88, 502.
Kristal, A.R., 8 Rush, D. (1984). Maternal nutrition and duration of

gestation: A review. Clinics in Obstetrics and Gynecolpgy, 21(3),
553-561.

Lechtig, A., Habicht, J.P., Delgado, H., Klein, R.E., Yarborough, C., 8
Martorell, R. (1975). The effect of food supplementation during
pregnancy on birthweight. Pediatrics, 88, 508—520.

Liebermann, E., Ryan, k.J., Monson, R.R., 8 Schoenbaums, S.C., (1987).
Risk factors accounting for racial differences in the rate of
preterm birth. New England Journal of Medicine, 317(12), 743—748.

McGanity, W.J., Cannon, R.O., Bridgeforth, E.D., Martin, M.P., Densen,
P.N., Newbill, J.S., McClellan, G.S., Christie, A., Peterson, J.C.,
8 Darby, W.J. (1954). Vanderbilt cooperative study of maternal and
infant nutrition: The relationship of obstetrical performance to
nutrition, American Journal of Obstetrics and Gynecology, 81, 501.

Madden, J.P., Goodman, S.J., 8 Guthrie, H.A. (1976). Validity of the.
twenty—four hour recall. Journal of the Americah Dietetic
Association, 88, 143.

Main, D. (1988). The epidemiology of preterm birth. Clinical
Obstetrics and Gynecology, 81(3), 521-532.

Mitchell, M.C., 8 Lerner, E. (1987). Factors that influence the outcome

of pregnancy in middle class women. Journal of the Americam

Dietetic Association, 81, 731.

58

Mitchell, M. 8 Lerner, E. (1989). Weight gain and pregnancy outcome in
underweight and normal weight women. qurnal of the Amarigan
ngtatig Agapgiatjon, 88(5), 634-641.

Mora, J.O., deParades, 8., 8 Wagner, M. (1979). Nutritional
supplementation and outcome of pregnancy and birthweight. Amerjgap
Qgprna! pf tljpical Nutrition, 81, 455-462.

The Nurses Association of the American College of Obstetricians and
Gynecologists (NAACOG). (1991). NAACOG standards for the nursing
garaygf women and newborns (4th ed.). Washington, D.C.: Author.

National Research Council (NRC). (1989). Recommended Dietary Allowancea
(10th ed.). Report of the Subcommittee on the Tenth Edition of the
RDAs, Food and Nutrition Board, Commission on Life Sciences.
National Academy Press, Washington, D.C.

Naeye, R.L. 8 Peters, E.C. (1978). Amniotic fluid infections with
intact membranes leading to perinatal death: A prospective study.
Pediatrics, 81, 171.

National Center for Health Statistics. (1991). Annual summary of
births, marriages, divorces and deaths: Unites States, 1990. [ital

' §tatistics Report, 88(13). Hyattsville, MD: Public Health Service.

National Center for Health Statistics. (1990). Vital Statistics of
U.S., 1988, 1, Natality. DHHS Pub. No. (PHS)90-1100, Public Health
Service. Washington, D.C., U.S. Government Printing Office.

National Commission to Prevent Infant Mortality (NCPIM). (January,
1988). Infantymortality: Care for our children. care foriggy

futurg. Washington, D.C.: National Academy Press.

59
National Research Council. (1970). Maternal nutrition and the cour§a_of

 

pragnancy. Report of the Committee on Maternal Nutrition, Food and
Nutrition Board. Washington, D.C.: National Academy of Sciences.

Neggers, Y.H., Cutter, G.R., Acton, R.T., Alvarez, J.O., Bonner, J.L.,
Goldenberg, R.L., Go, R., 8 Roseman, J.M. (1990). A positive
association between maternal serum zinc concentration and birth
weight. American Journal of ClinicaJ Nutrition, 81, 678-684.

Nelson, M., Black, A., Morris, J., 8 Cole, T. (1989). Between and
within subject variation in nutrient intake from infancy to old age:
Estimating the number of days required to rank dietary intakes with
desired precision. American Journal of Clinical Nutrition, 88, 155-
167.

Offringa, P., 8 Boersma, E. (1987). Will food supplementation in
pregnant women decrease neonatal mortality? Human Nutrition:
glinical Nutrition, 81, 311-315.

Orstead, M.S., Arrington, D., Kamath, S.K., Olson, R., 8 Kohrs, M.8.
(1985). Efficacy of prenatal nutrition counseling: Weight gain,
infant birth weight and cost effectiveness. Journal of the American
Dietetic Association, 88, 40-45.

Perinatal Associates of Michigan Staff. (1993, January). March of Dimes
Campaign for Healthier Babies: The Big Picture. Newsletter at the
Eerinatal Association of Michigan.

Primrose, T., 8 Higgins, A. (1971). A study of human antepartum

nutrition. Journal of Reproductive Medicine, 7, 257..

 

Rush, 0., 8 Kristal, A. (1982). Methodologic studies during pregnancy:
The reliability of the twenty-four hour dietary recall. American

Journal of Clinica] Nutrition, 88, 1259-1268.

 

60

Rush, 0., Sloan, N., Leighton, J., Alvir, J., Horvitz, D., Seaver, G.,
Garbowski, G., Johnson, 5., Kulka, R., Holt, M., Devore, J., Lynch,
J., Woodside, M., 8 Shanklin, D. (1988). National WIC evaluation:
Evaluation of a special supplementation food program for women,
infants, and children versus a longitudinal study of pregnant women.
Amamigan Journal of Clinical Nutrition, 38, 439—483.

Schlundt, O.G. (1988). Accuracy and reliability of nutrient intake
estimates. gggtgal of Nutrition, 118, 1432. _

Seidman, D.S., Ever-Hadini, P., Gale, R. (1989). The effect of maternal
weight gain in pregnancy on birth weight. ObStetrics and Gynecology,
71(2), 240-246. ’

Stubblefield, P. (1993). Causes and prevention of premature birth: An
overview. In A. Fuchs, F. Fuchs, and P. Stubblefield (Eds.), Preterm

 

birth: Causes._prevention and management (2nd ed.) (pp. 3-41). New
York, NY:' McGraw-Hill, Inc.

Stunkard, A.J., 8 Waxman, M. (1981). Accuracy of self-reports of food
intake. Journal of the American Dietetic Association, 18, 547-551.

Suitor, C.J., Gardner, J., 8 Willett, W.C. (1989). A comparison of food
frequency and diet recall methods in studies of nutrient intake of
low-income pregnant women. Journal of the American Dietetic
Association, 88, 1786.

Tafari, N., Ross, S.M., Naeye, R.L., Galask, R.P., 8 Zaar, 8. (1977).
Failure of bacterial growth inhibition by amniotic fluid, American
Journal of Obstetrics and Gynecology, 118, 187.

Tontrison, K., Booranasubkajorn, V., Hongumarn, A., 8 Thewtong, D.
(1986). Formulation and evaluation of supplementary foods for Thai

pregnant women. American Journa1_of Clinjgal Nutrition, 88, 931-939.

61

U.S. Department of Health and Human Services, Public Health Service.
(1990). Healthy People 2000, National health promotion and disease
prevention objectives, Nutrition Today, 18(6), 29-39.

Vasilenko, P. (1992, unpublished paper). Macronutrients and
micronutrients and premature labor/delivery.

Villar, J., Kestler, P., Castillo, P., Juarez, A., Menendez, R., 8
Solomons, N. (1988). Improved lactose digestion during pregnancy: A
case of physiologic adaptation. Obstetrics and Gynecology, 11, 697-
700.

Walker, C.K. (1991). Healthy babies for healthy companies. Business
and Health, May, 1991. 29-35.

Wen, S., Goldenberg, R., Cutter, G., Hoffman, J., 8 Cliver, S. (1990).
Intrauterine growth retardation and preterm delivery: Prenatal risk
factors in an indigent population. American Journal of Obstetrics
amd Gynecology, 162, 213-218.

Worthington-Roberts, 8., & Rodwell-Williams, s. (1989). Nutrition in
ptagpancy and laptation (4th Ed ), St. Louis, MO: Times Mirror/Mosby
College Publishing Company.

Yadrick, M.K., Kenney, M.A., 8 Winterfeldt, E.A. (1989). Iron, Copper,
and zinc status: Response to supplementation with zinc or zinc and

iron in adult women. American Journal of Clinigal Nutrition, 88,

145-150.

APPENDIX A

62
Appendix A

Healthdyne's Prenatal Monitoring Program was initiated in 1987 in an
effort to help physicians in the management of pregnant women at risk
for preterm delivery. This program was established to facilitate early
detection of preterm labor so that early, and possibly more effective,
treatment could be initiated in the attempt to avoid a preterm delivery.
Components of Healthdyne's Prenatal Monitoring Program are: two daily
one hour recording sessions of uterine activity monitoring, recording of
blood pressure and pulse during each monitoring session, daily weight
measurement, and completion of a three day diet recall upon initial
referral to the Prenatal Monitoring Program.

Each client receives individual training in her home on the different
components of the Prenatal Monitoring Program by a Registered Nurse who
has received special training as a Healthdyne patient educator. The
daily uterine activity monitoring sessions are transmitted via telephone
lines and reviewed by specially trained perinatal nurses in Healthdyne
Perinatal Centers throughout the country. .The three day diet recall is
completed by each patient and returned to Healthdyne's Perinatal
Nutritional Services office in Marietta, Georgia.

Daily telephone nursing contact is established with each patient at
which time the results of the monitoring sessions are discussed with the
patient, blood pressure, pulse and weight values are obtained, and the
patient is queried regarding subjective symptoms of premature labor.
Physicians are notified if results of uterine monitoring sessions, or
blood pressure, pulse or weight parameters are above thresholds set by
the physician. Development of subjective symptoms of preterm labor are

also reported to the physician.

 

APPENDIX B

 

63

HEALTH DYNE PERINATAL SERVICES

 

 

 

 

DIETARY ANALYSIS
2/19/93
PATIENT: 45 45 45 45 45 AGE: 26
ANALYSIS BEGIN DATE: 7/16/92 WEIGHT: 163 lbs.
ANALYSIS END DATE: 7/18 92 HEIGHT: 5' 7'
PREGNANT NUM OFFETUS 8:1 FRAME: M
NUTRIENTS QUANTITY RDA/RECOMMENDED %RDA
t CAIDRIES 1782.67 Cal 2506.74 Cal 71.11%
a PROTEIN 55.33 grams 125.34 graze 44.15%
:1 TOTAL FAT 72.33 grams 83.56 grains 86.57%
a PAT SAT 19.67 grams 27.85 grams 70.61%
a FAT MONO 18.33 grams 27.85 grams 65.82%
a FAT POL! 7.33 grams 27.85 grails 26.33%
a CARBOHYDRATE 211.33 gran: 313.34 grass 67.44%
b FIBER 8.00 grams 30.00 grams. 26.67%
c CAPPEINE 88.67 I98 300.00 .98 29.56%
d CHOLESTEROL 96.67 age 300.00 :93 32.22%
. SODIUM 1388.67 .93 3000.00 .98 46.29%
POTASSIUM 1923.33 I98 3500.00 lags 54.95%
CALCIUM ' 580.00 .98 1200.00 1198 48.33%
PEOSPHORUS 483.67 :98 1200.00 .93 40.31%
MAGNESIUM 220.00 11198 320.00 :93 68.75%
ZINC 17.37 .93 15.00 1198 115.78%
IRON 128.00 legs 30.00 I193 426.67%
VITAHIN A 8276.00 10 4000.00 IO 206.90%
VITAMIN D 441.33 10 400.00 It! 110.33%
VITAMIN E 27.16 :93 10.00398 271.57%
TEIANIN 3.28 ago 1.50 393 218.89%
RIBOPIAVIN 3.76 ago 1.60 :93 234.79%
VITAMIN 86 11.14 3198 2.20 .98 506.36%
VITAMIN 812 8.91 1.19 2.20 119 405.00%
VITAMIN C 148.00 legs 70.00 1193 211.43%
NIACIN 35.46 11193 17.00 :93 208.61%
POLATE 1058.33 119 400.00 ug 264.58%
IODINE 150.00 119 175.00 119 85.71%
NUTRIENT % CAIDRIES DAILY GOAL
TOTAL FAT 37.90% 30%
PROTEIN 12.89% 20%
CARBOHYDRATE 49 . 21% 50%
111001101. .00% 0%

e Ieeed en melon by Anette-n bltetlc Aeec. fer celerle dletrIbutIen.
5 arm: mum by heelth m ere 25-35 on. ef fiber «filly.
e lo Melon for caffeine Inteke «trim m.
OtherwieemlntekeeISOOner leeelflhre.heebeene1ueeted.
d A cheleeterel Intake of lees tho Why le M for

Indlvlchele with Mir blood cholesterol.

e tut-ted Ital-n regain-Int 500 u, lees then 3 are. Welly M.
f Min. clergy/protein reconstitution for elmleton nestetlone

derived on the heels of prey-mt body weldot ,ege, end ectlvlty levele.

mm. “It: Energy regain-ante my remit-e Indlvtdael edjuetnent to
wt mien weiflit geln ”In. w.

64

 

mhzm_m.52 I I
I I I . . I . I . I S .
. . I . . . . II. I .. I. I ... ., I I I I . I
I I a I I I . I I I I I a I I u .o o I I I
a u _ t x M 8 I I 8 u A . a a a m c I g I o a a a
I < o < < u N < u u u a o < _ I u a
I I I I I I . I I I . I I I I I I . I I . I I I I
I I I I I I I h I I w I .. I u I I o w u 2 I u I . I I o
. I 3
. , _. W nun III III .
. .. H I I I: I: I... U
I , .. .7... I II: . «on

 

 
 

«mod

I I I I“ . . no, 2..

I I I I .,.I I a: .
I. I,” I I 5 I... .
. ,, ._ .I as I: 3 E III.
I , _ I I II I I.. III.
.I , .. 7.. . 1,. ._ . no. .
. , M . . .3 . .

V U V v V

, \
a
.-
.-

O

I
0
g A A A A A

 

 

 

 

——————— — _ §I
-....: III. J., I. II. .-.. «8...
2 mg . :22: .2. I . . .82 6:: I m Emu no. 232 .._.z<zommm
.c. A .II a .EIGIm: . . I. «awry Im...<o.oz_ozm mIm>4<z<
IIIEIIII «35 IIIRIuIIIIIJIfiRaM

, om\m.\~ .

m_w>._<2< >m<hm5
wmoSmmm ._<._..<Z_mmn_ mz>aI._.._<m:

ammOmzh I O <

65

muml puma HML‘IHDYNE’

9

10.
11.

12.

PERINATAL aenwcsa PERINATAL NUTRITIONAL seawces
DIET HISTORY FORM

 

 

Whétisywooapafion?_ fi Manx I
Are you on comm bodast?__Yos__No No you on path! bedresn_Yas __No
Ityouaremtmbed'aalsyuracflvlyloval_m___modeme_high
layouappefite __W_good7___m__pdon
Neyouaflergicmwm yas_'no

"yesmleaseistg
NeMmemWWaafl/«WWJ_M

IIyes.pIeaselist .
Areyouhavinganypmbletmwiflr .
Hearmmn? ' Eyes—00mm Ireqmnfly
Nausea? fl: Ifyes;_oceasgonanyM
CIWIWII J5 -— IV”- —m:*°q
Diarrhea? fl—
Neywmmyspeddcfiet? ya no
“mm(mmMmammmmndeywan)

*

VTasflIisdietpresaibedbyaWJ__m CalodeLovel:_
HaveyourecelvaddetmbyaWJ._m

Doyousmoke? __yes __no .
Pleasefistmyvflanin/nimapplanulsywaamwyumghdudingmedm
;youplanto Braaslbed?_Waed?__Boflfl__HaV600ldeddedW
' i1 ' “storm! .
Thankyouforywrcoopetahm. 000m , E . ¢ )
HealthdynePerinagalNutritimaISetvicasDepam

. 23-7734
1050 PUMP“. Iummmmdfiflmm FAX404-4

 

383

'15!
I

 

I mm
to: m
——

mus:
h
mm on

66

p.633: [afar-tin up."

 

 

 

 

mm:
cannot:
um: .
out mom: was as
DP:
9:: man:
man: 7110/92 as ”W'“
moan: 7114192 m...“
mm m lemma 11mm as m: e
' ' may. mm was: I
. "” 15 not canon. - e
" s 5' 4- mm nuns: I
are! m an: t
ominous: m «amass u
'2 I :I - t : m: 0
. 0 mm .o
m: I § tuna» o
a , : mm: o
' g antenatal: _ o
' unmann- ‘I an: r
«nu:
mm to: team: me: 1015 ° :.
I ’ mm
aw: MIA m m. WEWWW.CKJ I
mum r r 5 II ° mum mun/om. cm: 7
m m r 7 1401.90 1’ . mm. W: I
m r 7 no m: u
17 v r 3 mm: mm: a
La: l a I gm: . 1
m: I «Immune: a
, mic tanner mama: u
a»! may: on: . new > 18 Ian: I:
I - WA mm: I:
clean: Imam. Mats: I
. [35: U
mam mum: a
mutation: '
mm ' up] a. I Dooe I M 5m. 5
mm
7mm I 0 line I 1 k ‘ " "

 

APPENDIX C

67
APPENDIX C

At an initial home visit, all clients are instructed in completion of

the three-day diet recall forms. Particular attention is directed to

the accurate completion of these recall forms. Clients are told that

the more accurate they are in the estimation of food portions and recall

of name brands of foods, the more accurate their analysis will be. The

toll-free number for the Healthdyne dietitians at Perinatal Nutritional

Services (PNS) is included in the client information packet in case the

client has any questions regarding the completion of the diet recall

forms. .
The clients are asked to complete the three-day diet recall food

records and return them to the PNS office within seven days. A pre-

addressed postage paid envelope is given to the client for return of the

completed diet recalls. In addition, the client's primary nurse, who

reviews her daily uterine monitoring information, encourages the client
to complete the diet recall forms and return them on a timely basis.

The Healthdyne dietitians send reminder post-cards to patients if the

diet recalls are not received after 10 days. The patients primary nurse

is also informed if diet recall forms are not returned to PNS so that

she may encourage the patient to complete the diet recall.

The completed diet recall, and a diet history form are mailed to the

Perinatal Nutritional Services office in Marietta, Georgia. The diet

history form includes demographic and dietary information about the

client. Each form is reviewed by the staff at PNS for completeness and

accuracy. A telephone call will be made to the patient by one of the

PNS staff members if additional information is required.

68

The foods on the recall forms are then entered into Healthdyne's

computerized nutritional data base. Comparison of nutritional intake

with Recommended Daily Dietary Allowances (RDA) (established by National

Research Council of the National Academy of Sciences) is completed for

27 different nutrient components of the diet. These RDA's are

individualized for each client according to height, weight, frame size,

age and number of fetuses.

A summary report is generated. This report includes a bar graph that

compares the average daily intake of each nutrient component with the
RDA of that component, a numerical table of intake values for each
nutrient, and suggestions for correcting deficiencies. A copy of this

report is sent to the client's prescribing physician and to the primary

nurse at the individual perinatal center.

69

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

m_.

 

 

 

 

 

.8 . _ Ba .88; .593 .o .85 .3863 ca 523 £62. uoo. E82 2 83¢ 22: use 30> =
>82 “83.311! 11623283333238228

own—(umma 25: 325.3 mm»... h2:05.<.. 2m...- ooQ. mafia msE.
. 8.35 one 232
E22 c8862).
1 89.5 855288 Easeisss
A , v 23:52 23...; 22.3
I ”23 . ”Egan

.85 8.26: no 828285.

t MX<PZ_ Pm_0 >n=<0 nuns-awn ._<._.<Z.amn

 

BEES: __.___ g.

7O

 

 

 

5 .0088 030 0030 a 0.800.. E 60 8.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

:00... F 2000...
05.092: .00. F 00:» F 0005 20:0...
0030. 300m; .000 0030.0 08 F 0033 .00:
00:8 3:032 030 F Eczuanm
0.50:0... .03. 0 05305 cocoi
:28 30063030 60.082 .8333 030 F 023 0030.. 2:0: Ea 00.0
00080801 020 0.0.89.0 0 000.000
0050 F c0E0._
.02 F .0o3m
:0E0_ 000 .0030 55> 030 F 00.. 0030: 0.002.“. Ea oo.~
00.20002 .3 0 8.00 .05
00.... 50:0... 00.2.0002 5000 F 30.0.00
”50:80.2 F 50.3060: 3.0.30.3: E0 onuwF
05.090... 5.; .0238. 00:» F 0005
*F .0 QF 5::
x: 5.3 05 .0 in 30.0%
=0: 0:: WI .03. m E35
.02 N .008
.003. 0c- an... 55> A822; 5.00m .50 F 33009 02.00
005.00 . >28. camwo 03o QF .52. b.0055 0&0: Eu 09>
00.000... 30: 330.8 out. 2.30:3 Ea: 000m 00-... 0E...
“WE—258

03.0000 00 38380 0:0 00.0.03 00 00 0. >.._. .0020 2050.6 05 30:8 0000....

Adam

09.00 .00... 60000.0... .500 0580000 £00000 .500 .0... 02.00000 0:0 00.000... 003 F. 30.. 0:0 03.0.0 .0 80 30> 80: 002
05 .0 50:05 .0. 00>. 05 0.00.05 .00? 0.00.0 .0 80 30> 3.3080 05 0:0 .00; ES. 000. 05 30;: .0050 000 0.5. 05 0.00.05

50; 00 03030200... 0:0 03.00.2003 3.0555503... .3 0000.300
0:0 000. >_co .0: 0003.05 0.5 0.5.0 030 .00 30> 83396 050.80. 00 .53 30> 50.55 :0 .00..» 3.0.5 .50 >500 0 m. 02..

"wad—Hunga—

71

PP&‘ Q,

PERINATAL SERVICES PERINATAL NUTRITIONAL SERVICES

lamina: HEIIJHDYNE' k

DIETARY ANALYSIS PROGRAM

Good giyitiobal habits p an Imponanx‘ role dining egnancy. Healthdyne Diem-y“
Anflymndedpedwmghfiwduflmofmmgnflmnwludmingmm.

Yourfoodrecordsarc byco tannin} totheRecommended
Allowances, mmarmfldmmmmumnpomm
recommendations. ‘ _

Toobuintbcmoaminfixmdoqwcrequutthefoflowingz
. 1) Reviewthemuamgifidemdctmhineporfionsim
2). hytobeaoan-ae. lndndceveaythingyouatanddxinkforthreedays.
' 3) linenlyoneday’sinnkeoneadisbeet.

) Mega). moombmonfioodflaserolegsoupastews,

5) Please'daaibeanycthnicfoods(0rientaLMcxican.Italian.etc.).
6) mummmwumawuum
7) Coupktetbeendosedbietflistotyl-‘Otm.
Inordcrfor wreceivethemoszbenefitfromtbcbic Analysis” Programweasktbat
ymmmgllfisft‘fiemfoodmrdsandrcmmwithinggdm Rancmbenohzxenplexe

theDict gFormandremalongwiththcoomplctcdfoodreoords. lfyou
quations, the 00le Dietitians are available Mon-Fri. 9—5 EST. Our tollofree

ThankyouforyonrcoOpention. Wclookfonvard to-helpingywhaveabalthybaby!

iesowPI-aJu-Fbogmmaoouqmuza-m-Rx M7704

 

72

«Mum HML‘IH THDYNE

PERINATAL SERVICES PERINATAL NUTRITIONAL SERVICES

DIETARY ANALYSIS PROGRAM
MEAS GUIDE
mmwmmohenmedunalm
Amati!) - 3W(GP)
lflnidonnoemoz) - ths
1°19“) - 8602
1&0!) - 2c
IMW) ' 29‘
Italian - 4g:
l/4pound - 4oz
HELPFULHINTS. .
- mnmtoedmmmmwmmbwmthum
. You-nasal siae(Soz)oranmg(10oz).Itwillbe
1:0th ”3 the
.- mfigmmummmfnmzom intake.
. Emmdfingomandummmeabondnmuythcw
. of and
thmnbitis ism/3130:: mpalmkldudingfiogas

. Mcuppdpahnismlflmpora4oasening.

- dream: board asklbcmmfindouthow ounces
awwmmm(w%

«sown-a. mmmmwommmomm

 

APPENDIX D

 

73

millm HEALTHDYNE’

PESINATAL SERVICES PERINATAL NUTRITIONAL SERVICES

January 3, 1993

To: University Human Subjects Chlaittee and
Signa Theta Tau

Healthdyne Perinatal Nutritional Services fully supports the
research to study the nutritional status of women diagnosed
with preterm labor. The study will he retrospective and we
will provide Pat Fuehr with the necessary information. The
data will he collected by the our staff based on the study
criteria. Any questions should he directed to Lisa
Johnston. -

Sincerely,

Lisa Johnston

Manager, Nutritional Services
LJ/tr

cc: Pat Fuehr

tame-unynmanuhRunnymnxnmas7qwmaannnonuuuaannu

 

APPENDIX E

 

74

MICHIGAN STATE UNIVERSITY

 

 

 

‘

OFFICE 0‘ VIC! "C9013" '0. IBMICN EAST MNSING 0 IKEIGAN 0 “II-IO“
AND OM" (X "I! GRADUATE KIIOOI.

January 29. I993

TO: M. Patricia Fuehr
4316 Manitou Dn've

0km Ml 48864
RE: M I: 93-016 ,
TITLE: A DESCRIPTION OF THE NUTRITIONAL STA'IUS OF PREGNANT WOMEN
bum WITH mm LABOR.
CATEGORY: I-B '
“REVISION 330m NIA

APPROVAL mm' ' Jan-y as. 1993

MkaMthW-mm WWQWIMW
ummnmamhmm.

UCRIKS ' ° ' _
WmWWMUQyM(m¢%MWm)M
'hmafiadsduhgfiemofh-ut. _
"vaunted-1ylineup.phandoaotheaiflehoufiud(511)3$S-21florFAX(511) 336-1171.

Shandy. .

 

DBijm

0:: Dr. Rachel Sdiifl'man

usua-waWW,I-mbc

 

 

GRN STATE UNIV. LIBRRR

IIHIW 2IIIQHIIJWIILI Ill! LllllllLHlHlllMHls