Influência da dieta e da amamentação Influência da dieta e da amamentação na variação de peso pós-gestacionalna variação de peso pós-gestacional

Rosely SichieriRosely SichieriInstituto de Medicina Social-UERJ, Rio de Instituto de Medicina Social-UERJ, Rio de Janeiro, BrasilJaneiro, Brasilsichieri@ims.uerj.brsichieri@ims.uerj.br

SUMÁRIOSUMÁRIO Breve revisão dos estudos epidemiológicosBreve revisão dos estudos epidemiológicos

Retenção de peso * lactaçãoRetenção de peso * lactação Estudos no BrasilEstudos no Brasil Outros paísesOutros países Nurse’s Health Study IINurse’s Health Study II

Consumo alimentarConsumo 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 públicaImportância para ações de saúde pública

Estudos sobre aleitamentoEstudos sobre aleitamento

Revisão - Dorea, 1997Revisão - Dorea, 1997 N=26 estudosN=26 estudos Anos: 1967-1995Anos: 1967-1995 Vários países (n): Vários países (n):

→→USA (10); USA (10);

→ → Guatemala- Brasil- Indonésia- Nigéria- Gâmbia- Guatemala- Brasil- Indonésia- Nigéria- Gâmbia- Taiwan- Canadá- Austrália (1) Taiwan- Canadá- Austrália (1)

→→ Reino Unido – Paises Baixos – Suécia - Filipinas Reino Unido – Paises Baixos – Suécia - Filipinas (2)(2)

Aos 3 meses: média de variação do peso pós-partoAos 3 meses: média de variação do peso pós-parto

-14.2%-14.2% - - +10%+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 KGDewey KG, , 2004)2004)

Of six observational studies in which postpartum Of six observational studies in which postpartum weight change was estimated (rather than measured weight change was estimated (rather than measured directly), only one showed an association with directly), only one showed an association with breastfeeding. By contrast, six of the seven studies breastfeeding. By contrast, six of the seven studies in which postpartum weight change was measured in which postpartum weight change was measured showed greater weight or fat loss in women who showed greater weight or fat loss in women who breastfed longer, particularly at 3 to 6 months breastfed longer, particularly at 3 to 6 months postpartum. postpartum.

It appears that breastfeeding does enhance the rate It appears that breastfeeding does enhance the rate of weight loss postpartum, but the effect is relatively of weight loss postpartum, but the effect is relatively small and may not be detectable in studies that lack small and may not be detectable in studies that lack adequate statistical power, have imprecise data on adequate statistical power, have imprecise data on postpartum weight change, or do not account for the postpartum weight change, or do not account for the exclusivity and/or duration of breastfeeding.exclusivity and/or duration of breastfeeding.

Lactation and weight retentionLactation and weight retention(Janney CA, et al. AJCN, 1997)(Janney CA, et al. AJCN, 1997)

Only longitudinal Only longitudinal analysis can detect analysis can detect differences in weight differences in weight retention among retention among lactating vs. no lactating vs. no lactating.lactating.

Lactating women had Lactating women had greater weight loss in greater weight loss in the early post-partumthe early post-partum

0

1

2

3

4

5

6

7

8

9

0 4 8 12

botlle-fed

breast6mo

Weight retention kg

mo

Constraints in most studiesConstraints in most studies Interaction between pre-pregnancy BMI, parity and Interaction between pre-pregnancy BMI, parity and

lactation has not been explored in most studieslactation has not been explored in most studies

Inadequate control of physical activity andInadequate control of physical activity and

smokingsmoking

Inadequate measurement of lactation by combining the Inadequate measurement of lactation by combining the lactation performance of all pregnancies, when main lactation performance of all pregnancies, when main question is: question is:

For each pregnancy how long BF should be to reduce the For each pregnancy how long BF should be to reduce the weight gain related to parity?weight gain related to parity?

Age-adjusted prevalence of BMI Age-adjusted prevalence of BMI >>25 by 25 by breastfeeding quartiles among parous women in breastfeeding quartiles among parous women in

Brazil, 1996Brazil, 1996Coitinho D, Sichieri R, Benício MHCoitinho D, Sichieri R, Benício MH

Weight and height Weight and height were measured in a were measured in a national sample of national sample of parous womenparous women

eligible population eligible population

3,761 women with 1 3,761 women with 1 or + children <=5 yor + children <=5 y

Weight pre-pregnancy Weight pre-pregnancy reportedreported

20

22

24

26

28

30

32

34

36

2 days 20 days 75 days 76 +

Exclusive BF

%

Sequence of multivariate linear regression models of BMI 793 primiparous women from the Demographic and Health

Survey, Brazil 1996.

* 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 p Model R2

Region (Others x North/Northeast)

-0.83 <0.001 1 0.01

Previous BMI (continuous)

0.83 <0.001 3 0.44

Age at first birth (continuous)

0.02 0.003 4  

Time since last birth (continuous)

0.02 <0.001 4  

Breastfeeding (days, continuous)

-0.004 0.04 4 0.48

Weight change related to parity and Weight change related to parity and breastfeeding among 2,338 parous women in breastfeeding among 2,338 parous women in

BrazilBrazil

BMI pre-pregnancy BMI pre-pregnancy effect modification effect modification

BF * BMI and it explain BF * BMI and it explain most of the changemost of the change

>BMI < BF effect>BMI < BF effect

Also interaction with Also interaction with parityparity

-1,2

-1

-0,8

-0,6

-0,4

-0,2

0

1 2 3

120 days

paritykg

Breastfeeding and postpartum weight Breastfeeding and postpartum weight retention in a cohort of Brazilian womenretention in a cohort of Brazilian women

((Kac et al.Kac et al. J Clin Nutr. 2004 J Clin Nutr. 2004)) Retenção média de 3.1 kg. Retenção média de 3.1 kg.

Para mulheres com menor percentual de Para mulheres com menor percentual de gordura (22%) aleitamento por 6 meses, gordura (22%) aleitamento por 6 meses, comparado com 1 mês reduz em -0.44 kg a comparado com 1 mês reduz em -0.44 kg a retenção de peso pós parto.retenção de peso pós parto.

Para as mulheres com maior percentual de Para as mulheres com maior percentual de gordura o efeito vai se reduzindo: gordura o efeito vai se reduzindo:

25% - 1,725% - 1,7 28% 1,228% 1,2 35% 0,04 kg.35% 0,04 kg.

Prospective assessment of exclusive Prospective assessment of exclusive breastfeeding in relation to weight change in breastfeeding in relation to weight change in

women.women. (Sichieri et al, IJO 2003)(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 1989 - baseline.Idade 24 a 40 anos em 1989 - baseline. Nulíparas na baseline. Nulíparas na baseline. Um filho na baseline.Um filho na baseline. Ficaram grávidas entre 1990 e 1991.Ficaram grávidas entre 1990 e 1991. 1538 - nulíparas.1538 - nulíparas. 2810 - com 1 filho.2810 - com 1 filho.

Lifetime breastfeeding historyLifetime breastfeeding history Fu 1997 Fu 1997 For each birth women were asked if they For each birth women were asked if they

had breastfed for at least a month and if so had breastfed for at least a month and if so they were asked to report the month they they were asked to report the month they started giving formulastarted giving formula

Starting to give formula was assumed as a Starting to give formula was assumed as a proxy for the end of exclusive BF period.proxy for the end of exclusive BF period.

- never BF = answer no to the question “ Did - never BF = answer no to the question “ Did you breastfed at least one month?”you breastfed at least one month?”

Smoking prevalenceSmoking prevalencewomen nulliparous at baselinewomen nulliparous at baseline

0

2

4

6

8

10

12

14

never 1-3 mo 4-7 mo 8-11 mo 12+

%

Breast-feeding duration

Age-adjusted weight changeAge-adjusted weight change nulliparous at baseline-smokers nulliparous at baseline-smokers

excludedexcluded

545556575859

6061626364

1989 1991 1993

never

>=12mo

52

54

56

58

60

62

64

BMI <=25

1989 1991 1993never 78,2 85 861-3 mo 80 85 86,74-7 mo 77,8 85 868-11 mo 79,6 85 83,812+ mo 77,3 84 85,9

72

74

76

78

80

82

84

86

88

1989 1991 1993

never1-3 mo 4-7 mo8-11 mo12+ mo

Nulliparous Primiparous

BMI >25

54

55

56

57

58

59

60

61

62

63

64

76

78

80

82

84

86

88

1989 1991 1993

BMI <=25

BMI>25

52

54

56

58

60

62

64

76

78

80

82

84

86

88

1989 1991 1993

never

1-11 mo

12+ mo

Nulliparous Adjusted for age and activity change 91 and 93

BMI<25

BMI>25

ConclusionConclusion Lactation among normal weight woman may Lactation among normal weight woman may

reduce the postpartum weight retention, but the reduce the postpartum weight retention, but the effect is too limited ( 1kg) to be considered as effect is too limited ( 1kg) to be considered as an advantage of breastfeeding.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 Since moderate weight loss through diet and

exercise in overweight lactating women did not exercise in overweight lactating women did not impair infant growth (impair infant growth (Lovelady et al.N Engl J Lovelady et al.N Engl J Med 2000) bMed 2000) breastfeeding guidelines could be reastfeeding guidelines could be less emphatic less emphatic about the weight loss effect of about the weight loss effect of lactation.lactation.

Consumo alimentar e variação de peso Consumo alimentar e variação de peso pós-gestacional pós-gestacional

Avaliação prospectiva da relação entre a dieta nos Avaliação prospectiva da relação entre a dieta nos períodos gestacional e da lactação e o peso no pós-períodos gestacional e da lactação e o peso no pós-

parto. parto. Rio de Janeiro, Brasil.Rio de Janeiro, Brasil.

Investigadora principal: Investigadora principal: Maria Beatriz Trindade de Maria Beatriz Trindade de CastroCastro

Dietary patterns among postpartum women treated at Dietary patterns among postpartum women treated at a municipal health center in Rio de Janeiro, Brazil.a municipal health center in Rio de Janeiro, Brazil.

(Cad Saúde Publica. 2006) (Cad Saúde Publica. 2006)

Banco de dados: Gilberto KacBanco de dados: Gilberto Kac

PortionsPortions FrequencyFrequency

3 or + 3 or + times/ times/

dayday

1 – 2 1 – 2 timestimes/ day/ day

1 1 timestimes/ day/ day

5-6 5-6 times/ times/ weekweek

3-4 3-4 times/ times/ weekweek

1 -2 1 -2 timetimes/ s/ weeweekk

1-3 1-3 timestimes/mon/mon

thth

NeveNever r

RiceRice 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( )

11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

BeansBeans 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

PastaPasta 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

Manioc Manioc flourflour

11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

French French breadsbreads

11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

CrackerCrackerss

11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

Sweet Sweet BiscuitsBiscuits

11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 11 ( ) ( ) 22 ( ) ( ) 33 ( ) ( ) 44 ( ) ( ) 55 ( ) ( ) 66 ( ) ( ) 77 ( ) ( ) 88 ( ) ( )

Validade ???do QFC em Validade ???do QFC em gestantesgestantes

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 Consumption of selected foods among pregnant womenwomen

% frequency of intake% frequency of intake

24-hour recall 24-hour recall

(n=103)(n=103)

FFQ (n=312)FFQ (n=312)

1,2 or 3 times/d1,2 or 3 times/d + 5-6 times/w+ 5-6 times/w

RiceRice 94.294.2 65.665.6 89.189.1

Beans Beans 82.582.5 78.478.4 93.993.9

PastaPasta 16.516.5 4.04.0 32.932.9

French breadFrench bread 86.486.4 70.070.0 75.875.8

CrackersCrackers 43.643.6 15.715.7 18.718.7

Sweet biscuitsSweet biscuits 30.130.1 14.814.8 16.916.9

PotatoesPotatoes 46.646.6 16.916.9 53.953.9

LettuceLettuce 13.613.6 18.718.7 22.422.4

TomatoTomato 8.78.7 21.121.1 25.025.0

CarrotsCarrots 54.054.0 12.812.8 39.039.0

Cont...Consumption of selected foods among Cont...Consumption of selected foods among pregnantpregnant% frequency of intake% frequency of intake

24-hour recall 24-hour recall

(n=103)*(n=103)*

FFQ (n=331)FFQ (n=331)

1,2 or 3 1,2 or 3 times/dtimes/d

+ 5-6 times/w+ 5-6 times/w

PapayaPapaya 4.04.0 12.712.7 14.814.8

BananaBanana 5.85.8 21.821.8 27.027.0

OrangeOrange 4.04.0 24.724.7 29.029.0

AppleApple 6.86.8 8.48.4 11.411.4

MilkMilk 66.066.0 66.666.6 70.670.6

CheeseCheese 29.329.3 25.225.2 51.451.4

ChickenChicken 32.032.0 9.79.7 66.866.8

SodasSodas 38.338.3 21.421.4 26.426.4

* For those reported for at least 4%.

A sub-sample of 65 pregnant women who A sub-sample of 65 pregnant women who answered the FFQ 2-3 days after delivering answered the FFQ 2-3 days after delivering and had blood collected during deliver.and had blood collected during deliver.

Plasma folate was determined by radioisotope Plasma folate was determined by radioisotope dilution assay (RIDA) with the DualCount kit dilution assay (RIDA) with the DualCount kit (Diagnostic Products, USA). (Diagnostic Products, USA).

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

Means of folic acid intake Means of folic acid intake

Erythrocyte folateErythrocyte folate

< 160 < 160 (n=19)(n=19)

>> 160 160 (n=45)(n=45)

P-valueP-value

Diet Diet 577577 727727 0.110.11

Supplement + dietSupplement + diet 576576 765765 0.040.04

Biochemical markersBiochemical markers

Folic acid supplementFolic acid supplement

Yes Yes (n=7)(n=7)

No No (n=54)(n=54)

P-valueP-value

ErythrocyteErythrocyte 260260 156156 0.050.05

Serum Serum 17.817.8 7.87.8 0.0030.003

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%)

Valores médios preditos do peso (kg) em função do tempo de pós-parto. Comparação entre os valores das variáveis preditoras (consumo de

macronutrientes no pós-parto) iguais e menores que a mediana com os valores superiores a mediana .

60,5

61,0

61,5

62,0

62,5

63,0

63,5

64,0

Visita 1 Visita 2 Visita 3 Visita 4

Resultados Preliminares

Distribuição dos valores de variação de peso no pós-parto entre as mulheres com dieta hiperproteica ou não

na gestação.

0

1

2

visita 1 visita 2 visita 3 visita 4

Ocasião

Dif

ere

nç

a d

e p

es

o

ptn101=0 ptn101=1

Distribuição dos valores de variação de peso no pós-parto entre as mulheres com uma dieta hiperproteica ou não no

pós-parto.

0

1

2

3

visita 1 visita 2 visita 3 visita 4

Ocasião

Pes

o

ptn201=0 ptn201=1

A dieta hiperproteica (consumo A dieta hiperproteica (consumo

>1,2 g de proteína por kg de peso) >1,2 g de proteína por kg de peso)

durante o ciclo reprodutivo parece durante o ciclo reprodutivo parece

favorecer a perda de peso no pós-parto.favorecer a perda de peso no pós-parto.

Mensagem de Saúde PúblicaMensagem de Saúde Pública

Amamentar é o melhorAmamentar é o melhor..

Indiscutível como mensagem para a Indiscutível como mensagem para a saúde da criança, mas essa saúde da criança, mas essa mensagem única seria adequada mensagem única seria adequada para as mães?para as mães?

ConclusõesConclusões As recomendações nutricionais no pós-parto devem levar As recomendações nutricionais no pós-parto devem levar

em consideração tanto o estado nutricional materno pré-em consideração tanto o estado nutricional materno pré-

gestacional, como o ganho de peso durante a gestação, o gestacional, como o ganho de peso durante a gestação, o

que nem sempre ocorre. que nem sempre ocorre.

No pós-parto, grande parte dos profissionais de saúde ficam No pós-parto, grande parte dos profissionais de saúde ficam

preocupados em garantir o aporte energético da nutriz preocupados em garantir o aporte energético da nutriz

visando o aleitamento materno, e não sabem o efeito deste visando o aleitamento materno, e não sabem o efeito deste

no ganho de peso, muitas vezes excessivo à longo prazo. no ganho de peso, muitas vezes excessivo à longo prazo.

Pequenas restrições de energia não comprometem a Pequenas restrições de energia não comprometem a

lactação.lactação.

A identificação de padrões de consumo de possam facilitar a A identificação de padrões de consumo de possam facilitar a

perda de peso poderá melhorar as recomendações.perda de peso poderá melhorar as recomendações.