Premature Birth

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Premature Birth DHA Enriched Functional Foods

• Phase II - Nutrition Education Intervention
• Garry Auld, PhD, RD
• auld_at_cahs.colostate.edu

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Funding

• Premature birth and docosahexaenoic acid enriched
  functional foods USDA, Initiative for Future
  Agriculture and Food Systems Program (IFAFS)
  Grant 00-52102-9633
• Omega Tech, Inc Martek, Inc
• Hidden Villa Ranch

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Phase II

• Goal match effective clinic DHA intake
• Formative Evaluation
• Focus Groups with Target Audience
• Education Materials (develop test)
• WIC Implementation
• Recruit, initial education messages materials
• CSU monthly mail follow-up

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Focus Group Objectives

• Motivators/Barriers to eating during pregnancy
• Customary (DHA) Foods
• Information sources and preferences
• Preferred format for education materials
• 8 FG (2 in Spanish)
• 47 participants
• 66 Hispanic/Latina 28 African American

Marx and Auld, 2003
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Healthy Foods to Eat During Pregnancy

• In general, participants felt that eating a
  variety of foods, as a part of a balanced diet
  was healthy
• In my house, we eat a variety of everything.
  Its all healthy because all foods have different
  things that are right for your body.
• Fruits and vegetables
• Protein foods

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Motivators to Eating Healthy During Pregnancy

• Primary
• Nutrition and development of a healthy baby
• Specific vitamins and minerals
• Folic acid Calcium
• No one mentioned DHA
• Secondary
• Healthy foods essential to weight gain
• African-American women - avoidance of heartburn
• Spanish Language women - disease prevention

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Foods Avoided During Pregnancy

• Food with a high fat content/fried foods
• Fast food
• Candy/sweets
• (Fewer mentioned) Salty foods or Caffeine
• Why avoid?
• Excess weight gain
• Increase disease risk (mom/baby)
• Genl not healthy

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Common Foods (DHA rich?)

• Eggs
• Canned tuna (7 out of 8 focus groups)
• Sardines, salmon and mackerel (primarily
  African-American women)

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Frequency of Consuming DHA Targeted Foods

• 380 food frequency questionnaires completed
• Obtained from FG and Clinical Trial participants
• weeks
• FFQ validated against initial RBC DHA from Phase
  I trial

Marx and Auld, 2003
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Clinic staff verified frequency and amount
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Validation of FFQ
n 380 p .000 r .39
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Mean DHA Intake (from FFQ)
ISSFAL Recommendation 300 mg/day CSFII Average
Intake in US 100 mg/day
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Proportion with Common DHA Sources
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Primary Source of DHA
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Intake of DHA Rich Foods

• Motivators to consuming more
• Knowledge of the benefits to baby
• Yes, I will eat it. If they tell me that tuna
  is good and it will benefit the baby.
• New and easy ways to prepare the foods
• Barriers
• Smell and taste
• I love tuna fish, but if you put it in my face
  when I am pregnant, youre gonna get thrown up
  on.
• Cost
• Unfamiliar with foods, especially DHA eggs

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Encouraging DHA Consumption

• What would be a good way of providing
  information to encourage you to eat more of the
  foods that contain DHA?
• Recipes
• I think ways of preparing the foods maybe with
  sauces or something that would help them go down
  easier.
• Cooking demonstrations
• Coupons or WIC vouchers
• Maybe if they (Gold CircleTM brand eggs) were on
  our WIC list we would try them because they would
  be there.
• Planners/calendars, short readings, magnets

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Omega-3 for Baby and Me

• Health Belief Model
• Increase motivation information, logo, reminders
• Decrease barriers coupons, recipes
• Perceived susceptibility recruitment, some
  calendar information
• Recipe Development Criteria
• 300 mg in one serving (2 Gold CircleTM eggs)
• Quick and easy to prepare
• Wide variety of inexpensive, widely accepted
  ethnic foods
• Include breakfast, lunch and dinner recipes
• Provide variety in fish preparation
• Well pronounced flavor to disguise the
  taste/smell of fish

Troxell et al, 2005
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• Taste Testing
• Recipes tested by CSU research team
• Would tester would make the recipe?
• Should recipe be included in intervention?
• 3 recipes tested in target population in clinics
• Used salmon, tuna, sardines
• 90 thought recipes should be included in
  intervention
• Kept 12 4 egg, 4 salmon, 2 sardine, 2 tuna

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Nutrition Education Materials

• WIC insert (1 page)
• 9 month Calendar
• Backbone of the nutrition education intervention
• Explanation of what DHA is
• Something relevant to mother AND baby
• Nutrition/health tip of the month
• Stickers
• personalize calendar (events, appointments,
  delivery date etc)
• Recipes
• Magnetic Clip and Recipe Holder with Logo
• Nylon Pouch with dividers for coupons, stickers,
  recipes
• Shopping Lists

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• Store coupons for Gold CircleTM eggs
• Canned fish provided at recruitment
• salmon, tuna, sardines
• CSU mailed egg coupons 2 recipes/mo

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EPA/FDA Advisory on Methyl Mercury in Fish

• Pregnant Women
• No More Than 6 oz (cooked) /week
• AVOID Tile Fish, Shark. Sword Fish, King
  Mackerel, AlbacoreTuna
• Pulled Tuna cans recipes

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Results
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WIC Participants

• 178 women with complete delivery data
• 136 Hispanic (76)
• 25 White (14)
• 14 African American (8)
• 3 Other (2)

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Gestational Length Nutrition Educ. vs
Supplementation
a,b
b
b
a
Model adjusted for Ethnicity, Prepregnancy
BMI Values with different superscripts are
significantly different (p.026)
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Summary of ComparisonPhase I and Phase II DHA
Trials

• Significant 4 day increase in gestational length
• Nutrition education as effective as functional
  food supplements
• 60 g (NS) increase in birth weight
• Lower than expected fetal growth rate for 4 days
  ( 130 g)
• No effect on head circumference, birth length
• Compliance not confirmed with blood work in
  Phase II

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Post-Delivery Follow-up

• Tracked use of egg coupons
• Phone Interviews

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191 participants 2049 coupons redeemed 11
dozen per participant 6 eggs/wk
available
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Interview Results
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Why such apparent success?

• Straight forward behavior change
• Foods already eating
• Simply asked to eat more often and focus on
  omega-3 options
• Stressed benefit to baby
• The primary motivator from FG
• Decreased obvious barriers
• Coupons (cost) recipes (preparation)

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Implications for WIC

• Should WIC consider changes to food package?
  During which trimesters? Breastfeeding?
• Omega-3 intervention potential to double WIC
  effectiveness
• Currently WIC intervention results in 1 oz
  increase in birth weight
• Primary complaint (from interviews) or barrier
  to eating more Gold CircleTM eggs was having too
  many WIC egg coupons

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Colleagues and Graduate Students

• Kenneth GD Allen. PhD
• Jennifer Anderson, PhD, RD
• Mary Harris, PhD, RD
• John Wilson, MPh
• Melanie Reece, PhD
• Jan French, MS, CNM
• James McGregor,MD

• Marsha Wheeler, MD
• Shannon Burke, MD
• Robyn Foster, MS
• Ruth Inglis-Widrick, MS
• Nadia Marx, MS
• Shannon Seal, MS RD
• Heather Troxell, MS
• Katy Warren, MS

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Premature Birth DHA Enriched Functional Foods

• Phase II - Nutrition Education Intervention
• Garry Auld, PhD, RD