Influência da dieta e da amamentação na variação de peso pós-gestacional Rosely Sichieri Instituto de Medicina Social-UERJ, Rio de Janeiro, Brasil sichieri@ims.uerj.br

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

Estudos sobre aleitamento Revisão - Dorea, 1997 N=26 estudos Anos: 1967-1995 Vários países (n): →USA (10); → Guatemala- Brasil- Indonésia- Nigéria- Gâmbia- Taiwan- Canadá- Austrália (1) → Reino Unido – Paises Baixos – Suécia - Filipinas (2) Aos 3 meses: média de variação do peso pós-parto -14.2% - +10%

Gâmbia (Prentice, 1991) Média de variação do peso pós-parto (kg/mês) DRY WET 0-3 meses +0.70 -0.50 4-6 meses +0.45 -0.80

Impact of breastfeeding on maternal nutritional status 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. 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.

Lactation and weight retention (Janney CA, et al. AJCN, 1997) Weight retention kg 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 mo

Constraints in most studies Interaction between pre-pregnancy BMI, parity and lactation has not been explored in most studies Inadequate control of physical activity and smoking 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?

Weight and height were measured in a national sample of parous women 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 eligible population 3,761 women with 1 or + children <=5 y Weight pre-pregnancy reported % Exclusive BF

Sequence of multivariate linear regression models of BMI 793 primiparous women from the Demographic and Health Survey, Brazil 1996. Variable  p Model R2 Region (Others x North/Northeast) -0.83 <0.001 1 0.01 Previous BMI (continuous) 0.83 3 0.44 Age at first birth (continuous) 0.02 0.003 4   Time since last birth (continuous) Breastfeeding (days, continuous) -0.004 0.04 0.48 * 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

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

Breastfeeding and postpartum weight retention in a cohort of Brazilian women (Kac et al. J Clin Nutr. 2004) Retenção média de 3.1 kg. Para mulheres com menor percentual de gordura (22%) aleitamento por 6 meses, comparado com 1 mês reduz em -0.44 kg a retenção de peso pós parto. Para as mulheres com maior percentual de gordura o efeito vai se reduzindo: 25% - 1,7 28% 1,2 35% 0,04 kg.

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. Idade 24 a 40 anos em 1989 - baseline. Nulíparas na baseline. Um filho na baseline. Ficaram grávidas entre 1990 e 1991. 1538 - nulíparas. 2810 - com 1 filho.

Lifetime breastfeeding history 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 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?”

Smoking prevalence women nulliparous at baseline % Breast-feeding duration

Age-adjusted weight change nulliparous at baseline-smokers excluded never

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

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

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. 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.

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) Banco de dados: Gilberto Kac

Portions Frequency 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 Pasta Manioc flour French breads Crackers Sweet Biscuits

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.

Consumption of selected foods among pregnant women % frequency of intake 24-hour recall (n=103) FFQ (n=312) 1,2 or 3 times/d + 5-6 times/w Rice 94.2 65.6 89.1 Beans 82.5 78.4 93.9 Pasta 16.5 4.0 32.9 French bread 86.4 70.0 75.8 Crackers 43.6 15.7 18.7 Sweet biscuits 30.1 14.8 16.9 Potatoes 46.6 53.9 Lettuce 13.6 22.4 Tomato 8.7 21.1 25.0 Carrots 54.0 12.8 39.0

Cont...Consumption of selected foods among pregnant % frequency of intake 24-hour recall (n=103)* FFQ (n=331) 1,2 or 3 times/d + 5-6 times/w Papaya 4.0 12.7 14.8 Banana 5.8 21.8 27.0 Orange 24.7 29.0 Apple 6.8 8.4 11.4 Milk 66.0 66.6 70.6 Cheese 29.3 25.2 51.4 Chicken 32.0 9.7 66.8 Sodas 38.3 21.4 26.4 * For those reported for at least 4%.

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). Erythrocyte folate  was also determined by RIDA with the Folate kit (Diagnostic Products, USA). All assays were run in duplicate.

Means of folic acid intake Erythrocyte folate < 160 (n=19) > 160 (n=45) P-value Diet 577 727 0.11 Supplement + diet 576 765 0.04

Biochemical markers Folic acid supplement Yes (n=7) No (n=54) P-value Erythrocyte 260 156 0.05 Serum 17.8 7.8 0.003

Material e Métodos 479 aceitaram participar 430 participantes 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). 709 mulheres convidadas 479 aceitaram participar Critérios de Exclusão: 47 mulheres com idade < 18 anos; 2 consumo > 6000 kcal. 430 participantes 15 dias: 430 mulheres (100%) 2 meses: 380 mulheres (88,4%) 6 meses: 311 mulheres (72,3%) 9 meses: 283 mulheres (65,8%)

Resultados Preliminares

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.

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

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. 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. A identificação de padrões de consumo de possam facilitar a perda de peso poderá melhorar as recomendações.