Physical Therapy and Nutrition: Optimizing Pregnancy and Development

Jul 19, 2019
 

As physical therapists (PTs), we are far removed from the delivery room. Many of us help women after delivery through relieving post-delivery trauma, core strengthening, or general wellness to return to pre-pregnancy function/fitness status. Many of us also help women struggling with lower back pain, plantar fasciitis, and other ailments prior to delivery. A few of us also work in the neonatal intensive care and hospitals helping newborn children.  We also have large section of our professional organization, the American Physical Therapy Association (APTA), dedicated to helping children through pediatric PT. As such, we as PTs are nicely positioned to help counsel women and families on how to optimize delivery, recovery, and possibly infant and children's nutrition.

In The Womb

Many ailments and complications can arise during pregnancy. From lower back pain and posture issues, the musculoskeletal issues appear to be very straight forward for PT management. But what about some of the more serious issues? Could these be prevented via nutrition and could PTs play a role in educating patients on ideal nutrition?

Some of the complications with the biggest risks with pregnancy includes pre-term delivery and pre-eclampsia. The frequency of preterm births is about 12–13% in the USA and 5–9% in many other developed countries. These figures are on the rise, especially in USA, where reasons for indicated preterm births include pre-eclampsia or eclampsia.

Pre-term delivery is when a baby is delivered before 37 weeks of gestation. Babies delivered pre-term are smaller, may be at risk for developmental delays, and could be exposed to a more prolonged stay in a medical facility (e.g. NICU).  Believe it or not, the chances of pre-term delivery can be greatly reduced through lifestyle factors such as diet and exercise. 

For instance, one study found that pre‐pregnancy body mass index (BMI) was a strong effect modifier for developing pre-term labor. As PTs we know that with movement comes calories burned and potential weight loss -- but there's more than just movement as a way for prevention. In the following study, the more a pregnant subject adhered to a Mediterranean pattern of diet (e.g. mostly whole vegetables, fresh fruits, whole grains, and minimal processed foods and meat) there was a marked decreased risk of preterm deliver, even in those patients who were overweight and obese women (adjusted odds ratio 0.7, 95% confidence interval 0.6, 0.9) (Saunders, Lauren, et al. "Effect of a Mediterranean Diet during Pregnancy on Fetal Growth and Preterm Delivery: Results From a French Caribbean Mother–Child Cohort Study (TIMOUN)." Paediatric and perinatal epidemiology 28.3 (2014): 235-244.). Another large prospective cohort study found similar evidence, citing the odds were reduced for preterm birth by 39% and early preterm birth by 72% when more whole-plants (e.g. more than 5 servings daily), less meat, and almost no processed foods were consumed (Mikkelsen, Tina B., et al. "Association between a Mediterranean-type diet and risk of preterm birth among Danish women: a prospective cohort study." Acta obstetricia et gynecologica Scandinavica 87.3 (2008): 325-330.).

Pre-eclampsia is another complication often seen in patients with pregnancy. Pre-eclampsia presents with high blood pressure, swelling of hands and feet, and protein in the urine. Pre-eclampsia can progress to eclampsia, where the pregnant mother has severe seizures which can kill both the mother and fetus. Pre-eclampsia also puts the fetus at risk of pulmonary, kidney, vascular, and neurodevelopmental pathologies, which can kill the soon-to-be child. And as mentioned above, pre-eclampsia can lead to pre-term delivery. As such, reducing the odds of pre-eclampsia ought to be a major focus of any healthcare provider, even a PT, working with patients that are pregnant.

The most recent research links pre-eclampsia with high scores on a dietary pattern characterized by processed meat, salty snacks, and sweet drinks. The increased risk for pre-eclampsia being almost 21% higher in those eating such a pattern above versus a plant-rich diet (OR for tertile 3 vs. tertile 1: 1.21; 95% CI: 1.03, 1.42). These findings suggest that a dietary pattern characterized by high intake of vegetables, plant foods, and vegetable oils decreases the risk of preeclampsia, whereas a dietary pattern characterized by high consumption of processed meat, sweet drinks, and salty snacks increases the risk. (Brantsæter, Anne Lise, et al. "A dietary pattern characterized by high intake of vegetables, fruits, and vegetable oils is associated with reduced risk of preeclampsia in nulliparous pregnant Norwegian women." The Journal of nutrition 139.6 (2009): 1162-1168.).

Why do plants help in preventing pre-eclampsia? It could be that a fiber rich diet helps to stimulate gut bacterial changes that helps to regulate T cell development and other fetal responses (Hu, Mingjing, et al. "Decreased maternal serum acetate and impaired fetal thymic and regulatory T cell development in preeclampsia." Nature Communications 10.1 (2019): 3031.). Also, whole plant foods are rich in vitamins and elements, such as calcium, which has been shown to reduce pre-eclampsia ((Hofmeyr, G. Justus, et al. "Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems." Cochrane database of systematic reviews 8 (2010). While calcium supplementation seems wise, it also puts the patient and fetus at risk for lead contamination, which is not good developmentally. Moreover, cow's milk is not recommended for infants, as studies have shown it can increase the risk of type 1 diabetes and childhood obesity. It appears the more fat, sugar, and processed foods consumed it promotes negative gut bacterial changes, weight gain, and ultimately pre-eclampsia -- such lifestyle factors can be changed.

So what does all this mean for a PT? It appears the diet can be significant contributor to both pre-eclampsia and pre-term labor. While a 21% reduction in pre-eclampsia seems small, consider the added benefits of eating more fruits and vegetables. In particular, the risk of pediatric wheeze, diabetes, neural tube defects, orofacial clefts, and some pediatric tumors seems to be reduced by maternal intake of adequate amounts of vegetables, fruits, and selected antioxidants (Pistollato, Francesca, et al. "Plant-based and plant-rich diet patterns during gestation: Beneficial effects and possible shortcomings." Advances in Nutrition 6.5 (2015): 581-591.). Moreover, a 30-70% reduction in pre-term labor odds by eating plant-based is a major reduction and one PTs can easily "sell" to their pregnant patients with minimal to no risks. Simply asking a patient to describe their diet, offering them to take the DietID assessment (a 30 second app for diet assessment), and then educating them on eating more plants can confer major benefits to both baby and mom.  After all, what's the downside to eating more fruit and vegetables? 

Infancy

There's a much to-do about what a baby should or should not be consuming. You can thank the media, advertising, and large food companies for all confusion. The reality of the matter is that food for infancy, especially for children before soft foods are introduced, ought to be very easy: mother's milk.

Appreciate that breastfeeding is more than feeding: it is time for bonding, touch, soothing, and sensory input. Ideally most breastfeeding should be done from infant mouth to breast. Skin contact early during the breastfeeding process is vital. When breastfeeding becomes challenging, expressed milk into bottles can be cooled/frozen and re-thawed at a later time. The time from expression to frozen should be minimized to reduce bacterial growth and spoilage. Reheating the milk after freezing or cooling should be done cautiously so as to not damage essential proteins and fats. 

Breast milk also confers amazing benefits for the infant gut biome and passive immunity. Researchers have found that within the first 6 weeks of life, the infant microbiota undergoes substantial reorganization, which is primarily driven by body site and not by mode of delivery. (Chu, Derrick M., et al. "Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery." Nature medicine 23.3 (2017): 314.). We know that preterm infants have an under-developed gut biome;  studies have shown that hospitalized preterm infants receiving breast milk may develop a normal microbiota resembling that of term infants. (Korpela, Katri, et al. "Intestinal microbiota development and gestational age in preterm neonates." Scientific reports 8.1 (2018): 2453.). 

Mother's milk has a perfect balance of fats, sugars, proteins, and hormones to help a baby grow. Appreciate that human's mother milk is vastly different than cow's milk, which has far more and different hormones, growth factors, and nutrient structure. Here is a snippet from the World Health Organization:

"that mothers milk provides all the energy and nutrients that the infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year, and up to one-third during the second year of life.

Breast milk promotes sensory and cognitive development, and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses such as diarrhoea or pneumonia, and helps for a quicker recovery during illness.

Breastfeeding contributes to the health and well-being of mothers; it helps to space children, reduces the risk of ovarian cancer and breast cancer, increases family and national resources, is a secure way of feeding and is safe for the environment." http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

In the end, the debate over what infants should consume should end: it's mother's milk. This fact is fully supported by the World Health Organization and can easily be conveyed by a pediatric PT working in hospital, clinic or home.

Infancy into Early Childhood

The list of potential diagnoses seen in pediatric PT is very long. In our 3rd course, Specialized Nutrition for PTs, we go into depth about several of these diseases and how diet plays a role in patients management (e.g. PKU, ezcema, sickle cell). A few we will highlight here are autism, childhood obesity, and heart disease (yes, heart disease).

The list for the theories for autism seem to get longer. One possible mechanism of autism are casomorphins liberated from cow’s [milk protein], known as beta-casein. Such casomorphin may be “a risk factor for delay in psychomotor development and other diseases such as autism.” (Kost, Natalya V., et al. "β-Casomorphins-7 in infants on different type of feeding and different levels of psychomotor development." Peptides 30.10 (2009): 1854-1860.) As such, some clinicians a recommend a dairy-free diet. Evidence from a systematic review supports a dairy free (and possibly a gluten free) diet as long as acute symptomatic changes are seen with the substance(s) withdrawal (Mulloy, Austin, et al. "Gluten-free and casein-free diets in the treatment of autism spectrum disorders: a systematic review." Research in Autism Spectrum Disorders 4.3 (2010): 328-339.).  Going dairy-free may also confer benefits in preventing type I diabetes, as seen by published studies from Finland. Being dairy-free is obviously also consistent with a predominant whole-food, plant-based diet.

Obesity during the phase of childhood is a major concern for many nations. Large amounts of evidence cites how a whole-food, plant-based diet can easily keep weight down during childhood. One such study is the Adventist study focused on children and obesity. The authors found the frequency of consumption of grains, nuts, and vegetables were inversely related to the risk of being overweight and dairy increased the risk. Specifically, the odds ratio (with 95% confidence intervals) for children in the highest quartile or tertile of consumption compared with the lowest quartile or tertile were as follows:

  • grains 0.59(0.41-0.83);
  • nuts 0.60(0.43-0.85);
  • vegetables 0.67(0.48-0.94);
  • and, dairy 1.36(0.97, 1.92).
  • (Matthews, Vichuda L., Michelle Wien, and Joan Sabaté. "The risk of child and adolescent overweight is related to types of food consumed." Nutrition Journal 10.1 (2011): 71.)

Another large review study confirmed much of the above study's findings citing:

" that a plant-based diet seems to be a sensible approach for the prevention of obesity in children. Plant-based diets are low in energy density and high in complex carbohydrate, fiber, and water, which may increase satiety and resting energy expenditure. Plant-based dietary patterns should be encouraged for optimal health and environmental benefits. Food policies are warranted to support social marketing messages and to reduce the cultural and economic forces that make it difficult to promote plant-based dietary patterns." (Sabaté, Joan, and Michelle Wien. "Vegetarian diets and childhood obesity prevention." The American journal of clinical nutrition 91.5 (2010): 1525S-1529S.)

It's no wonder that the Journal of Geriatric Cardiology summarized that whole-food, plant-based diets are ideal diets for the treatment and prevention of childhood obesity! (Turner-McGrievy, Gabrielle, Trisha Mandes, and Anthony Crimarco. "A plant-based diet for overweight and obesity prevention and treatment." Journal of geriatric cardiology: JGC14.5 (2017): 369.)

So, what's a PT to do? Many physical therapists and personal trainers know the movement strategies and exercise physiology involved with weight loss. Some dietary strategies include the elimination of access to sugary drinks, nutrient-lacking junk food, and a focus on the access to raw/cooked fruits/vegetables. PTs in schools can petition school districts to provide for better food choices for their students. PTs can help educate families regarding where to purchase healthy food options, like farmer's markets, and what a healthy plant-based meal looks like. More evidence is emerging and PTs are encouraged to promote and facilitate plant-based diets in their practice settings for kids (Sabaté, Joan, and Michelle Wien. "Vegetarian diets and childhood obesity prevention–." The American journal of clinical nutrition 91.5 (2010): 1525S-1529S.). 

You likely thought we made a mistake including heart disease in our pregnancy and pediatric article -- well, you'd be wrong, as heart disease actually starts in childhood. So what's the data on heart disease and children? A multi-center cooperative study, Pathobiological Determinants of Atherosclerosis in Youth (PDAY), was organized in 1985 to examine the relationship of the risk factors for adult cardiovascular heart disease (CHD) to preclinical atherosclerotic lesions in youth. Fourteen participating centers collected arteries, blood, other tissue, and data from 3,000 persons 15-34 years of age who died from external causes and were autopsied in forensic laboratories (McGill, Jr HC, et al. "Atherosclerosis in youth." Minerva pediatrica 54.5 (2002): 437-447.). The author's findings showed the raised lesions of the coronary arteries are associated positively with non-HDL cholesterol concentration, hypertension, obesity (in men), and blood glucose concentration; and inversely, with HDL cholesterol concentration. A diet rich in cholesterol and saturated fats most related to raising non-HDL cholesterol, while HDL was boosted through exercise. What's probably more telling from these authors paper is their conclusion: "These results suggest that long-range prevention of CHD should begin in adolescence or at least in young adulthood with control of the major established risk factors for adult CHD." As PTs we need to be intervening and preventing heart disease earlier -- not doing so could be considered omission in our practice.

Enjoyed what you've read here? Well, there's more to be found in our board-approved, online continuing education classes. From nutrition basics, sports nutrition, supplements, dietary assessments, to PT section-specific nutrition (e.g. ortho, neuro, oncology), our courses cover a wide range of topics in a fashion that uses evidence and a multimedia interface. We offer 3 progressions of classes on nutrition relevant to physical therapy practice: Introduction to Nutrition for PTs (IN), Nutrition Assessment and Prescription for PTs (NAP), and Specialized Nutrition for PTs (SNP). Complete all 3 courses and pass the final exam to become a CNPT! Our courses are approved by a component of the APTA, the Florida Physical Therapy Association (FPTA), for 3 CEH each.  Click and enroll today!

 

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Disclaimer: The above article is written as opinion piece and does not convey specific legal and/or practice act advice. Students and participants need to check their State laws, practice act, and other legal restrictions before implementing nutrition interventions or assessments. The consumer of this article and our courses acknowledge that the State laws, practice acts, and restrictions can and do change. The Nutritional Physical Therapy team cannot be held liable for changes to such laws: the student, PT, or person engaged in such nutrition actions are responsible for examining laws and regulation as they see fit.

 

Keywords: pediatric, nutrition, PT, prevention, online course, continuing education, CEU, CEH

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