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For even the most carefree of women, pregnancy can be a time filled with stress, anxiety and second-guessing your choices.

Particularly when it comes to diet. In addition to the familiar, 'can I eat this?' (often the answer is no), most women constantly question their diet and eating decisions.

Am I eating too much? Am I eating enough? Am I getting enough iron/calcium/protein? Am I eating too much sugar? Have I gained too much/not enough weight?

And, for those busy mums chasing a toddler while growing another human being, will my baby continue to grow if I subsist on a diet of Vegemite toast and my child's leftovers?

Associate Professor Heather Yeatman, Head of UOW's School of Health and Society, says healthy mums equals healthy bubs, with good nutrition and appropriate gestational weight gain providing a baby with the vital building blocks for life.

In theory, it is as simple as eating the right food, at the right time, in the right amounts. But Professor Yeatman says the crowded marketplace of confusing messaging, compounded by, in many cases, inadequate knowledge on behalf of health professionals, means the message is not getting through.

Research is currently underway at UOW into the many facets that contribute to good nutrition both prior to and during pregnancy. If diet and exercise were not a priority before falling pregnant, those next nine months (well, 10 actually, but who's counting?) are the ideal time to reconsider.

The next nine months

Professor Yeatman, who is also Vice-President of the Public Health Association of Australia, says the population in general is plagued by poor nutrition, which should be an oxymoron considering the plentiful array of good food that is available to people in Western society.

"There are two issues at play here. The whole population suffers from bad dietary patterns. Very few people are eating the recommended amount of fruit and vegetables, and there is too much processed food available," Professor Yeatman says. "Poor diet is the leading cause of the burden of disease.

"Pregnancy is of particular note, because babies have special needs and the mother's diet directly impacts on the baby's development. In fact, a mother's diet during pregnancy affects the baby's risk of chronic disease later in life. The risk of later becoming overweight and heart disease is increased."

^{Professor Heather Yeatman. Photo: Paul Jones}

During pregnancy, however, women are particularly motivated to eat well and provide the best for their growing babies. They are an engaged audience, willing to make lasting changes for their health and that of their family.

"This is a group who are open to shifting their dietary patterns. They want to make changes that will have a lasting impact on both their baby and their family as a whole. They use pregnancy as an opportunity to set up healthy patterns for the future," Professor Yeatman says.

Yet, for the most part, they do not have the necessary tools. PhD candidate Khlood Bookari, working alongside Professor Yeatman in the School of Health and Society, is exploring the level of nutrition knowledge during pregnancy. After surveying 400 pregnant women across Australia, she found 65 per cent were not aware of the basic nutrition recommendations set out by the .

"Most pregnant women are failing to meet basic nutritional recommendations because they eat too much meat and dairy and not enough fruit, vegetables and cereals," Khlood says. "Although the majority of pregnant women were highly motivated to maintain a healthy diet and reported trying to do so, the dietary patterns of pregnant women were poor.

"None of the pregnant women reported dietary intakes that met the recommendations for all five food groups. About 93 per cent failed to meet recommended intakes for vegetables, 90 per cent failed to meet recommendations for fruit, 52 per cent ate too much meat and 30 per cent ate too much dairy."

Pregnant women's nutrition knowledge was significantly associated with women's reported adherence with fruit, vegetables, and bread and cereals recommendations. There were also considerable misconceptions related to recommended intakes of the five food groups (fruit, vegetables, bread and cereals, dairy foods and meat food groups), the practical details of dietary guidelines, such as how many serves are recommended a day, nutrient content of certain foods, and the importance of key nutrients.

This was compounded in women who came from poor socio-economic backgrounds or who had low levels of education. The results confirm a notable lack of knowledge among pregnant women about guidelines of appropriate gestational weight gain. Khlood says she was surprised by the gap that existed between the reality and perception of pregnant women's nutritional knowledge.

"Although pregnant women were highly motivated and confident of their ability to sustain a healthy diet and understand dietary recommendations, they demonstrated poor knowledge and poor adherence to guidelines. This misjudgment in women's own understanding of nutrition information may lessen their opportunity to seek access to accurate information," Khlood says.

"Health professionals may also miss opportunities to provide evidence-based dietary information and support especially if they assume that pregnant women are well informed about the dietary guidelines and are consuming a healthy diet, as women appear to be confident and well educated."

The ideal time for pregnant women to absorb information relating to diet is during the first trimester. Often, by the third trimester, dietary patterns are ingrained and it is too late to make a meaningful impact.

"It is possible that pregnant women are more conscious about nutrition and actively seek nutrition information in the early stage of pregnancy," Khlood explains. "This could be partially attributed also to women's mistaken beliefs that during the last stage of pregnancy their dietary habits no longer had effects on their own or their baby's health and so nutrition information was no longer relevant."

Khlood's findings mirror the experiences of Catherine Lucas, an Accredited Practising Dietician and PhD candidate in UOW's School of Medicine, who has spent the past few years researching the importance of nutrition for women who are pregnant and breastfeeding - in particular the necessity of iodine as a micronutrient - as well as gestational weight gain.

It is clear Catherine is passionate about this area of research. It stems, she says, from the fact that such a small shift can make such a significant difference to an infant's life. She too has found that pregnant women are willing to alter their dietary behavior for the benefit of their baby, yet are either unsure about how to instigate the necessary changes or are unable to make sense of the plethora of information available online.

"Good nutrition in pregnancy is so important, it can really change a child's life from the day they are born and into adulthood," Catherine says. "During pregnancy, women are receiving an extra level of health care, and they are really engaged, so it is the ideal time to get the message out there.

"But it can be a really stressful time for women, particularly if they are also working full time, have other children, are trying to organise childcare. They can feel like they don't want to add any other worries to their list."

 ^{PhD student Catherine Lucas. Photo: Paul Jones}

The prevalence of iodine in the diet is an area that really interests Catherine. Insufficient iodine intake has been linked to poor cognitive development in children, although the impact varies from country to country depending on the amount of iodine that naturally occurs in the soil and the extent to which the benefits of iodine supplements have been marketed in the public health sphere.

"Even a mild iodine deficiency during pregnancy has been linked to reduced intellectual outcomes in children of primary school age," Catherine says. "It is one of the leading cause of mental impairment worldwide, but it is very preventable."

Seafood is one of the richest sources of iodine - as well as the essential omega 3 fatty acids. However, there is often hesitancy among pregnant women to eat fish due to concerns over food safety and mercury levels. Yet fish and seafood can be consumed safely by ensuring they are cooked well and served hot, and by limiting high mercury varieties such as flake and marlin.

The role of midwives

If pregnancy is the ideal time in which to change a woman's dietary habits, yet most expectant mothers are confused about or unaware of the nutritional guidelines they should be following, what is the missing link? How can we bridge the divide between theory and practice? The link lies in the health practitioners who are on the pregnancy frontline: midwives.

Professor Yeatman and Jamila Arrish, a PhD candidate in the School of Health and Society, have been investigating the knowledge base of midwives when it comes to such areas as nutrition and weight gain. And much like the mothers-to-be with whom they work, they've discovered midwives have a significant gap - in both expertise and confidence - when advising women on diet-related issues.

Their research identified that most midwives do not know how much weight a woman of normal weight should gain during pregnancy, nor do they have intimate knowledge of the Australian nutrition guidelines recommended for pregnant women. Nutrition in general is not a subject they feel comfortable discussing with women.

Jamila was not surprised by the findings, but she says this knowledge gap must be addressed for the long-term health of women and their babies.

"Midwives are one of the key providers of antenatal care in Australia. They have contact with pregnant women who are usually motivated to change their diet for the sake of their babies," Jamila says. "This represents a great opportunity to promote healthy eating and try to influence women's dietary behaviours.

"Good nutrition may help prevent or ease pregnancy symptoms, such as nausea, vomiting and constipation. Good nutrition and appropriate gestational weight gain may also reduce the incidence of pregnancy complications such as gestational diabetes and preeclampsia. It may also ensure that the baby is born with a healthy weight and set the stage for good future health."

In order to provide the correct information to women, however, midwives must first receive the appropriate advice and training. This information, Jamila says, should be considered a fundamental part of a midwives' knowledge base, but it must be provided during midwifery courses and in the workforce.

"Continuous support from midwifery organisations and health services would be helpful by providing regular updates related to nutrition for practising midwives, especially in areas where they are found to have lower levels of knowledge and confidence," she explains. "Basic nutrition knowledge and skills need to be include in midwifery programs to support future midwives being competent and confident in providing nutrition advice to pregnant women."

^{PhD student Jamila Arrish. Photo: Paul Jones}

The researchers all agree that the risk of not receiving appropriate nutritional guidance is that pregnant women turn to the internet for advice. This can take them down the rabbit hole of dietary knowledge, a place teeming with mistruths, information that is not evidence-based and fiction masquerading as fact, often trumpeted by celebrity chefs.

"If they don't get this support from midwives, they often chat to their friends, who may also lack the knowledge, or they look online, where they will find a lot of misinformation, such as suggestions they follow the Paleo diet. At best, they are confused. At worst, it could harm their baby's health," Professor Yeatman says.

However, as all pregnant women know, there are times when you want to have that piece of cake - or chocolate, or milkshake - without being overcome by feelings of guilt.

"It is a balancing act between giving pregnant women good advice and not shaming them for their decisions," Catherine says.