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Influência da dieta e da amamentação na variação de peso pós-gestacional Rosely Sichieri Instituto de Medicina Social-UERJ, Rio de Janeiro, Brasil

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Apresentação em tema: "Influência da dieta e da amamentação na variação de peso pós-gestacional Rosely Sichieri Instituto de Medicina Social-UERJ, Rio de Janeiro, Brasil"— Transcrição da apresentação:

1 Influência da dieta e da amamentação na variação de peso pós-gestacional Rosely Sichieri Instituto de Medicina Social-UERJ, Rio de Janeiro, Brasil

2 SUMÁRIO Breve revisão dos estudos epidemiológicos Breve revisão dos estudos epidemiológicos Retenção de peso * lactação Retenção de peso * lactação Estudos no Brasil Estudos no Brasil Outros países Outros países Nurses Health Study II Nurses Health Study II Consumo alimentar Consumo alimentar Validade do questionário de frequência Validade do questionário de frequência Associação com retenção de peso Associação com retenção de peso Importância para ações de saúde pública Importância para ações de saúde pública

3 Estudos sobre aleitamento Revisão - Dorea, 1997 Revisão - Dorea, 1997 N=26 estudos N=26 estudos Anos: Anos: Vários países (n): Vários países (n): USA (10);USA (10); Guatemala- Brasil- Indonésia- Nigéria- Gâmbia- Taiwan- Canadá- Austrália (1) Guatemala- Brasil- Indonésia- Nigéria- Gâmbia- Taiwan- Canadá- Austrália (1) Reino Unido – Paises Baixos – Suécia - Filipinas (2) Reino Unido – Paises Baixos – Suécia - Filipinas (2) Aos 3 meses: média de variação do peso pós-parto Aos 3 meses: média de variação do peso pós-parto -14.2% - +10% -14.2% - +10%

4 Gâmbia (Prentice, 1991) Média de variação do peso pós-parto (kg/mês) DRY WET 0-3 meses meses

5 Impact of breastfeeding on maternal nutritional status. ( Dewey KG, 2004) Of six observational studies in which postpartum weight change was estimated (rather than measured directly), only one showed an association with breastfeeding. By contrast, six of the seven studies in which postpartum weight change was measured showed greater weight or fat loss in women who breastfed longer, particularly at 3 to 6 months postpartum. Of six observational studies in which postpartum weight change was estimated (rather than measured directly), only one showed an association with breastfeeding. By contrast, six of the seven studies in which postpartum weight change was measured showed greater weight or fat loss in women who breastfed longer, particularly at 3 to 6 months postpartum. It appears that breastfeeding does enhance the rate of weight loss postpartum, but the effect is relatively small and may not be detectable in studies that lack adequate statistical power, have imprecise data on postpartum weight change, or do not account for the exclusivity and/or duration of breastfeeding. It appears that breastfeeding does enhance the rate of weight loss postpartum, but the effect is relatively small and may not be detectable in studies that lack adequate statistical power, have imprecise data on postpartum weight change, or do not account for the exclusivity and/or duration of breastfeeding.

6 Lactation and weight retention (Janney CA, et al. AJCN, 1997) Only longitudinal analysis can detect differences in weight retention among lactating vs. no lactating. Only longitudinal analysis can detect differences in weight retention among lactating vs. no lactating. Lactating women had greater weight loss in the early post-partum Lactating women had greater weight loss in the early post-partum Weight retention kg mo

7 Constraints in most studies Interaction between pre-pregnancy BMI, parity and lactation has not been explored in most studies Interaction between pre-pregnancy BMI, parity and lactation has not been explored in most studies Inadequate control of physical activity and Inadequate control of physical activity and smoking smoking Inadequate measurement of lactation by combining the lactation performance of all pregnancies, when main question is: Inadequate measurement of lactation by combining the lactation performance of all pregnancies, when main question is: For each pregnancy how long BF should be to reduce the weight gain related to parity?

8 Age-adjusted prevalence of BMI >25 by breastfeeding quartiles among parous women in Brazil, 1996 Coitinho D, Sichieri R, Benício MH Weight and height were measured in a national sample of parous women Weight and height were measured in a national sample of parous women eligible population 3,761 women with 1 or + children <=5 y eligible population 3,761 women with 1 or + children <=5 y Weight pre-pregnancy reported Exclusive BF %

9 Sequence of multivariate linear regression models of BMI 793 primiparous women from the Demographic and Health Survey, Brazil * 1. socio-economic/geographic variables (geographic region or residence, urban/rural area of residence, purchasing power score - A, B, C, D or E and years of education); 2. demographic variables (current age, age squared and ethnic group); 3. previous BMI; 4. reproductive variables (age at first birth, time since last birth, days of predominant breastfeeding, parity and interactions Variable pModelR2R2 Region (Others x North/Northeast) -0.83< Previous BMI (continuous) 0.83< Age at first birth (continuous) Time since last birth (continuous) 0.02< Breastfeeding (days, continuous)

10 Weight change related to parity and breastfeeding among 2,338 parous women in Brazil BMI pre-pregnancy effect modification BMI pre-pregnancy effect modification BF * BMI and it explain most of the change BF * BMI and it explain most of the change >BMI BMI < BF effect Also interaction with parity Also interaction with parity parity kg

11 Breastfeeding and postpartum weight retention in a cohort of Brazilian women ( Kac et al. J Clin Nutr ) Retenção média de 3.1 kg. Retenção média de 3.1 kg. Para mulheres com menor percentual de gordura (22%) aleitamento por 6 meses, comparado com 1 mês reduz em kg a retenção de peso pós parto. Para mulheres com menor percentual de gordura (22%) aleitamento por 6 meses, comparado com 1 mês reduz em kg a retenção de peso pós parto. Para as mulheres com maior percentual de gordura o efeito vai se reduzindo: Para as mulheres com maior percentual de gordura o efeito vai se reduzindo: 25% - 1,7 25% - 1,7 28% 1,2 28% 1,2 35% 0,04 kg. 35% 0,04 kg.

12 Prospective assessment of exclusive breastfeeding in relation to weight change in women. (Sichieri et al, IJO 2003) Cohort of the Nurse's Health Study II. Cohort of the Nurse's Health Study II. Idade 24 a 40 anos em baseline. Idade 24 a 40 anos em baseline. Nulíparas na baseline. Nulíparas na baseline. Um filho na baseline. Um filho na baseline. Ficaram grávidas entre 1990 e Ficaram grávidas entre 1990 e nulíparas nulíparas com 1 filho com 1 filho.

13 Lifetime breastfeeding history Fu 1997 Fu 1997 For each birth women were asked if they had breastfed for at least a month and if so they were asked to report the month they started giving formula For each birth women were asked if they had breastfed for at least a month and if so they were asked to report the month they started giving formula Starting to give formula was assumed as a proxy for the end of exclusive BF period. Starting to give formula was assumed as a proxy for the end of exclusive BF period. - never BF = answer no to the question Did you breastfed at least one month?

14 Smoking prevalence women nulliparous at baseline % Breast-feeding duration

15 Age-adjusted weight change nulliparous at baseline-smokers excluded never >=12mo

16 Nulliparous Primiparous BMI >25 BMI <=25 BMI>25

17 Nulliparous Adjusted for age and activity change 91 and 93 BMI<25 BMI>25

18 Conclusion Lactation among normal weight woman may reduce the postpartum weight retention, but the effect is too limited ( 1kg) to be considered as an advantage of breastfeeding. Lactation among normal weight woman may reduce the postpartum weight retention, but the effect is too limited ( 1kg) to be considered as an advantage of breastfeeding. No effect for overweight women pre-pregnancy. No effect for overweight women pre-pregnancy. Since moderate weight loss through diet and exercise in overweight lactating women did not impair infant growth (Lovelady et al.N Engl J Med 2000) breastfeeding guidelines could be less emphatic about the weight loss effect of lactation. Since moderate weight loss through diet and exercise in overweight lactating women did not impair infant growth (Lovelady et al.N Engl J Med 2000) breastfeeding guidelines could be less emphatic about the weight loss effect of lactation.

19 Consumo alimentar e variação de peso pós-gestacional Avaliação prospectiva da relação entre a dieta nos períodos gestacional e da lactação e o peso no pós- parto. Rio de Janeiro, Brasil. Investigadora principal: Maria Beatriz Trindade de Castro Dietary patterns among postpartum women treated at a municipal health center in Rio de Janeiro, Brazil. (Cad Saúde Publica. 2006) Dietary patterns among postpartum women treated at a municipal health center in Rio de Janeiro, Brazil. (Cad Saúde Publica. 2006) Banco de dados: Gilberto Kac Banco de dados: Gilberto Kac

20 PortionsFrequency 3 or + times/ day 1 – 2 times/ day 1 times/ day 5-6 times/ week 3-4 times/ week 1 -2 times/ week 1-3 times/ month Never Rice 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) Beans 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) Pasta 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) Manioc flour 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) French breads 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) Crackers 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) Sweet Biscuits Sweet Biscuits 1 ( ) 2 ( ) 3 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( )

21 Validade ???do QFC em gestantes 103 pregnant women attending the maternity of a public hospital in the city of Rio de Janeiro answered one 24-hour recall. Seven items of the FFQ were reported less them 3% in the 24-hour recall and were excluded: corn pudding, popcorn, corn, lemon, passion flower, wine and spirits. This 72-item questionnaire was applied to 312 pregnant women.

22 Consumption of selected foods among pregnant women % frequency of intake 24-hour recall (n=103) FFQ (n=312) 1,2 or 3 times/d times/w Rice Beans Pasta French bread Crackers Sweet biscuits Potatoes Lettuce Tomato Carrots

23 Cont...Consumption of selected foods among pregnant % frequency of intake 24-hour recall (n=103)* FFQ (n=331) 1,2 or 3 times/d times/w Papaya Banana Orange Apple Milk Cheese Chicken Sodas * For those reported for at least 4%.

24 A sub-sample of 65 pregnant women who answered the FFQ 2-3 days after delivering and had blood collected during deliver. A sub-sample of 65 pregnant women who answered the FFQ 2-3 days after delivering and had blood collected during deliver. Plasma folate was determined by radioisotope dilution assay (RIDA) with the DualCount kit (Diagnostic Products, USA). Plasma folate was determined by radioisotope dilution assay (RIDA) with the DualCount kit (Diagnostic Products, USA). Erythrocyte folate was also determined by RIDA with the Folate kit (Diagnostic Products, USA). All assays were run in duplicate. Erythrocyte folate was also determined by RIDA with the Folate kit (Diagnostic Products, USA). All assays were run in duplicate.

25 Means of folic acid intake Erythrocyte folate < 160 (n=19) > 160 (n=45) P-value Diet Supplement + diet

26 Biochemical markers Folic acid supplement Yes (n=7) No (n=54) P-value Erythrocyte Serum

27 Material e Métodos 709 mulheres convidadas 479 aceitaram participar Critérios de Elegibilidade: - Idade reprodutiva: 15 a 45 anos - Entrevista até o 30º dia do pós-parto; - Sem doenças crônicas pré-existentes; - Gestação não gemelar (> 35 SG). Critérios de Exclusão: - 47 mulheres com idade < 18 anos; - 2 consumo > 6000 kcal. 430 participantes 15 dias: 430 mulheres (100%) 6 meses: 311 mulheres (72,3%) 9 meses: 283 mulheres (65,8%) 2 meses: 380 mulheres (88,4%)

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29 Resultados Preliminares

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31 A dieta hiperproteica (consumo >1,2 g de proteína por kg de peso) durante o ciclo reprodutivo parece favorecer a perda de peso no pós-parto.

32 Mensagem de Saúde Pública Amamentar é o melhor. Amamentar é o melhor. Indiscutível como mensagem para a saúde da criança, mas essa mensagem única seria adequada para as mães? Indiscutível como mensagem para a saúde da criança, mas essa mensagem única seria adequada para as mães?

33 Conclusões As recomendações nutricionais no pós-parto devem levar em consideração tanto o estado nutricional materno pré- gestacional, como o ganho de peso durante a gestação, o que nem sempre ocorre. As recomendações nutricionais no pós-parto devem levar em consideração tanto o estado nutricional materno pré- gestacional, como o ganho de peso durante a gestação, o que nem sempre ocorre. No pós-parto, grande parte dos profissionais de saúde ficam preocupados em garantir o aporte energético da nutriz visando o aleitamento materno, e não sabem o efeito deste no ganho de peso, muitas vezes excessivo à longo prazo. No pós-parto, grande parte dos profissionais de saúde ficam preocupados em garantir o aporte energético da nutriz visando o aleitamento materno, e não sabem o efeito deste no ganho de peso, muitas vezes excessivo à longo prazo. Pequenas restrições de energia não comprometem a lactação. Pequenas restrições de energia não comprometem a lactação. A identificação de padrões de consumo de possam facilitar a perda de peso poderá melhorar as recomendações. A identificação de padrões de consumo de possam facilitar a perda de peso poderá melhorar as recomendações.


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