 La presentación está siendo grabada ahora. Muy bien. Tengo el honor de presentar a Marlene Malayanes. I have the pleasure to introduce Marlene Malayanes. Ella es una obstreta salivrista, con grado de doctor en Ciencias de Salud Pública y Magista en Salud Pública, con experiencia asistencial docente de investigación. Marlene Malayanes is a registered methwife. She has a doctorate in health science and she has a master in public health. She works in a public system. She is a teacher and she is a researcher. Su línea de investigación actuales son la nutrición materna y el uso de las fases de datos nacionales para el estudio de investigación en el ayun materno perinatal. Currently she is working on nutrition research. Actualmente me desempeño como obstreta asistencial en el hospital nacional y polito unano en Lima, Perú. Currently she is working as a registered methwife en el hospital nacional y polito unano en South America, Lima, Perú. Ella es docente en la Universidad San Martín de Porres. She is also a faculty member at the University of San Martín de Porres en Lima, Perú, as well as a teacher in Universidad de César Vallejo. Yo casi no me enseñé en la escuela de polvo de César Vallejo. Muy bien, tengo el honor de presentar a Marlene y Marlene, puedes empezar en cualquier momento. Antes de empezar, Wilkner, I'll be writing the slides in English. If you can see at the bottom of your screen, there's going to be a closed caption and you're going to be able to see the translation in English in that chat box. Please let me know if you don't, so I can fix the problem. At the bottom of the chat box, you'll be able to see what the translation will be in English. Please let me know if you have a problem with those people who can't speak Spanish. As the majority of us are Spanish speakers, you'll be able to understand the translation, but we have a community in Turkey and I think there are other people as well, so I'll be translating the slides. Very well, Marlene, I'm going to give you the slides to present. Hello, good evening, can you hear me well? Yes, Marlene, we can hear you very well. Perfect, good evening, colleagues from Peru and the world. It's a pleasure for me to be part of this first time at this international conference. Basically, I'm here to present you a work of research done, a part of a work, and the second part of our role as colleagues within this topic, which is Maternal Nutrition. The presentation has been titled, Eat for Two or Eat for Two, which was the initial part of the research that I'm telling you. And I added the role of professional obstetrics in the nutritional advice of women in fertility. Because as I was telling you, I think this is a topic that although we have a certain approach, sometimes we are not developing it fully or as we should. I'm going to introduce you to the topic and we could move on to the next slide. Good. The information system of the nutritional state, which is known for its centuries as 100, and the family health and development survey, the famous Endes that we all know, they make a tendency to malnutrition by excess. It is so that the overweight in gestants has increased by 6% since 2009 to 2013. And as you can see, the figures have gone from 30.4 to 36.3%. And the overweight and obesity in women in fertility has exceeded 15% in 20 years. 43% in 1996 versus 58.1% in 2016. The nutritional state of women before and during pregnancy increases morbidity and maternal mortality. As we all know, as we have learned in our training. Now, looking at the figures that I just shared, we realize that overweight and obesity are becoming a problem of public health. We also know that in other states, the problem of overweight and obesity is even higher. Industrialization and other current changes makes us do less physical activity, we have unhealthy diet, and we are going to the overweight. Although in pregnancy it may be the only stage where women are given a license to eat everything and for both, it is actually an opportunity where as professionals in obesity we must take into account the importance of a good diet. And that's where the title of my presentation came from, eating for both or eating for both. That we have probably heard in our daily life with our patients or even among family members or ourselves. Although many women are controlling our weight, when we are pregnant, it is the stage where we get angry and eat everything we want and we say that we are fat because we are pregnant and that justifies it. So I was wondering how to do it. If this woman did not receive a healthy weight before, why do you do it during pregnancy? Well, the rehearsal includes two parts, as I had mentioned. The first, related to the results of an investigation, publication sending, and of which I am the main author, with another patient, here we work in a faculty, a student who is now a colleague, and the author, Dixie Roa, who is a colleague from the University of San Martín. And well, this publication has been accepted already for publication in the magazine of gynecology and obstetrics, the Cuban magazine of gynecology and obstetrics, for which I am sharing part of the information. And the second, a discussion about the role that we perform as obstetrics professionals in the nutritional advice, before, during, and after the pregnancy. Finally, I will give a brief conclusion that aims to give concise ideas in relation to the topic that we have presented. Investigation for action. At the beginning, I will tell you that the faculty of obstetrics and gynecology of the University of San Martín de Porres, a place where I am a teacher and researcher, has as one of its lines of research representation and nutrition. And as one of its semantics, in that line, the nutrition of the woman in reproductive and pregnant age. In that line, I have been developing for a few years. The last work carried out is placed in an article that I mentioned that was already accepted for its publication, called Masa Corporal Pre-Gestational Index, Ganance of Gestational Weight and Retention of Postpartum Weight. Here on table one, which is the table that I am going to share with you about some results, maybe the format is a bit small, but we are going to keep talking so that you can take a closer look at these data in this research. It has a small sample, there were not many participants, as you can see there, we have 91 participants. And we evaluated several variables, but one of the most important is the Masa Corporal Pre-Gestational Index, Ganance of Gestational Weight and Retention of Postpartum Weight. I am going to narrate these results and if any person has any doubt or wants to make any reference about the painting, I am going to leave the painting there because what I am going to narrate is referring to this research. The Masa Corporal Pre-Gestational Index, the results show that the results are that one of each two women began her pregnancy with overweight and obesity, slightly inferior to other national studies. We are comparing these results with studies that were done based on population, based on studies, and even in those results from Peru, the index of overweight and obesity were greater. It should be noted that this group of women is from a health hospital and as we work in Peru, we know, they are usually people who have social security, workers or couples of workers and with an educational level in this sample with a higher completeness and to justify these results because this group of educated women usually has all health standards, women with education, more education has better health results, especially maternal health. However, studies with population North American, European and Asian, different from the characteristics of the Peruvian woman, reveal a lower proportion of women with overweight or obesity at the beginning of pregnancy. It is known that a high prevalence of unhealthable and inappropriate body weight before conception between women at the age of 30 is a problem of public health. This has been related with poor results of birth, especially the fetal macrosomia and the low weight at birth and both have negative and lasting impacts on health, and the economic results of a person implicitly in the whole country. You will realize that this little sample, the women who had an adequate weight above 91 which was the total weight, was 42. We see that in this picture, the average of body weight index in these women with adequate weight was 22.3 and if we look at the right side we see that people with low weight are really few and sometimes we had the old conception that in our country, for the subject of poverty, that for many years we have dragged from what we have been coming out in recent years we had the problem of nutrition or low weight. This problem is more sectorized in children. In adult people, there are few women who have been evaluated with this problem. The problem is going towards the abundance of weight and obesity which are obviously not good values. The ideal is that the majority of women before they are pregnant should have adequate weight for the size they have. Here we have the average of both overweight and obese women. In general, if we see the average of women evaluated in general, we had a average of 25.23 as body weight index. Another evaluated variable was the gain of gestational weight. We know that the gain without appropriate weight during pregnancy is related to health problems for the mother and with deficient results at birth. In addition to affecting physical health, other negative affections have been described. In a short time, hospital costs are greatly increased. In a long time, problems are related to the child's development at a low educational level in the labor market. Their prevention is an objective of public policies in many countries, as I mentioned at the beginning. Our results show that the average of gain of gestational weight decreased according to the increase in body weight index and that the adequate weight increase was significantly greater for women with low weight than for the rest of the groups. Only one of each two women with overweight gained adequate weight during pregnancy and seven of each 10 women gained excessive weight during pregnancy. Taking as reference the parameters recommended by the American Medical Institute. As you can see, we have the variable gain of gestational weight and this picture is divided by groups weight over weight obesity. If we take into account the average of weight gained in each group, if we take into account where it increased in low weight patients, which is quite logical because women are the ones who are recommended to gain weight. With normal weight, it was the second group that increased weight in average. And this has to be taken with care because those women are the ones I was referring to in the issue of eating for two or eating for two. They are women who at the beginning of pregnancy are with a weight within the adequate parameter of normality. However, during pregnancy it can be that at this moment the woman who has a license to eat more than the count as she already feels, she notices and everyone tells her that she is within the normality then she eats more than she should and that additional weight we are going to see in the next variable that we are going to study in this same research. We realize that women with overweight obesity were the ones who gained less and it is also understood by the same reason that I just mentioned. When a woman knows that she is in obesity it is also obvious because of her physical characteristics and it is not let's say it is quite common that when she access the hospital services whether in the prenatal control or in the pregnancy many people tell her that her overweight is not healthy so in some way that group is the one who feels in general that she eats less but nevertheless not so less if we realize what are the appropriate values for the increase in weight in that group and as I mentioned here the results 7 out of 10 of these women gained excessive weight more than what was recommended well here we see that excessive weight 70% that is what 7 out of 10 said in this research and the variable maybe the most important because there is little information about it is the retention of postpartum weight well it has been written that this retention constitutes a nutritional problem for women with obesity and this should be combined with factors such as pre-stational body mass index the gain of weight the diet intake the lack of physical activity the lack of lactation tobaccoism and parity being the gain of gestational weight the most relevant factor according to the studies published in longitudinal studies they have shown a relationship between the gain of gestational weight and the subsequent maternal obesity and they indicate that the gain of gestational weight along with the retention of weight per year after birth are associated with obesity in the long term the results in our research indicate that the average retention of postpartum weight was greater for women with normal weight than for the rest of the groups as you can see here the retention of weight here if we look at these women is the one we were talking about a while ago the ones that eat by two we see here that in the group of women with normal weights and they start their pregnancy with adequate weight according to the IMC standards we see that these women are the ones that retain more and then what is happening that these women who feel that they are with adequate weight when they retain weight they are precisely going to a pregnancy, we are talking about they repeat a next pregnancy and a next pregnancy as well the most probable is that these women who started their first pregnancy with adequate weight end up in the group of women with overweight and obesity if we look here we did two evaluations we took the first one we took it with a continuous quantitative variable and here are the average we divided and we also evaluated the variable the retention of less than 1 kg and greater than 1 kg and the of less than 5 kg less or equal to 5 kg and greater than 5 kg because in the research that we have reviewed we had those two parameters and well, also comment on this point that despite that I am obsessed that I have 20 years working the clinical practice I never had let's say, I had no idea how much was the weight between normal meals that a woman should have at the end of pregnancy after a year or after 6 months the research that we have done made the evaluation after 6 months it is a bit complicated as you will understand to follow a patient many patients move they do not leave exact directions it is complicated to do this type of research because we had to do a follow-up after 6 months to these women and that is why the sample is small it was complicated to do it in a larger sample and to find out what is the normal weight or the overweight how much should the woman after the birth after 6 months or the year after the birth we found that there is no weight between proper meals of retention by consulting with nutritionists dedicated to the maternal area we saw that a healthy woman who starts the pregnancy is allowed to act after 6 months to really elect should not have no gain it is justified there is no retained weight between normal meals what does this mean if a woman starts the pregnancy with 55 kilos after 6 months or the year after the birth she should take her weight back of 55 kilos that is why there are evaluations there is no standard for all the researches that we reviewed we found researches that took less than 1 kilo as I mentioned and less than 5 kilos and we see here in this picture that women in total as a group we see that women with more than 1 kilo we are talking about the majority group who taking as the minimum parameter of more than 1 kilo and if we take as the other parameter which is 5 kilos we see that practically half of women in this research at 6 months had retained at least 5 kilos of weight and we are seeing that it is one of each the half of women increases in weight a considerable weight as we are seeing here in the evaluation well for the general population of women she just mentioned that at 83.5% she retained more than 1 kilo and at 52.7% she retained more than 5 kilos finally we made a comparison between the pre-stational body index and the body index at 6 months after birth and we saw that the increase was 2.32 kilos per square meter being the significant average for all the categories of IMC that is low weight normal weight, obesity and weight retention with statistical significance so you see here in this evaluation of IMC women who started their pregnancy with low weight all of them after 6 months in low weight they were in the normal weight group which seems to be good the women who started the pregnancy with normal weight with normal weight we realize that less than half 42.9% remained with normal weight and the half and a little more the next category which is overweight and a small percentage came even to be categorized as obese so here is the problem this is precisely one of the most important variables because it is evident that if we do not do something during the pregnancy if we do not take care of the weight of women in the pregnancy what we are doing is favoring these women increase this weight in each subsequent pregnancy with a lot of concern that the women who started the pregnancy with overweight only almost half remained overweight but the most concern is that a third of them went to the next category that is obesity as I show you these results I think they have to call us to pay attention that this group of women is really in danger because if you do nothing if you modify your life simply because of pregnancy a third of these women is going to be obese and of the obese women who were evaluated all of them were in the obese group and here as you know they were not evaluated they were only evaluated as a group of women it is very likely that some of these women will go from one category of obesity one, two or three very well as here are the statistical values here I share another table of changes from the IMC pre-stational to the IMC postpartum as we see here under weight IMC pre-stational 17.73 went up to six months as average 19.65 the patients with normal weight also went up in average in this evaluation the same happened with the overweight and the same happened with the obese that is, nobody saves all the women groups at the six months of evaluation and they have increased their body mass index and here are the means that we have already told you about the evaluation of each group of the right according to the weight retention greater than one kilo or greater than five kilos well, these are the results that I have just shared on the table I will leave them there to talk more calmly with more relevant results and the second part of my exposure and I have ten minutes left for that is the role of the professional obstetrics in nutritional advice and well, as I told you I will turn the presentation not only to share the results of this research that will be published and that will be complete in the Cuban magazine of gynecology and obstetrics in 2018 because it caused me a lot of concern, as I said I am a colleague, but I also do the essential part, the clinical part and I have not repaired an important that is this topic and the little we do for these women or for these women in 2016 the technical guide for nutritional advice in the framework of the health and health care of the pregnant woman that the evolution of the nutritional state and nutritional advice contribute to prevent a set of risks associated with the inadequate nutrition and nutrition of the mother understanding that nutritional advice is an educational process communication between professional nutritionist or professional of capacity and qualified in nutritional advice and the opposite ideally with the presence of family families with the purpose of analyzing a terminal situation and helping to make decisions about it based on the results of the nutritional evaluation and the analysis of the practices to ensure an adequate nutritional state and this is a concept that I just read precisely that it is in the guide itself at this point we could debate in relation to some questions how are professional nutrition sufficient to cover the demands of specialized attention for all instances at the national level talking about our country, Peru are there any qualifications to make a methodological advice well done are they qualified to make the evaluation of the nutritional state have the competencies to make a good nutritional advice these have been the motivating questions that made the development a little more systematic and that turns it to what we are going to talk about well, I will try to answer these motivating questions that I mentioned to you I will start by sharing relevant information professional nutrition in Peru are 1.43% of all professional writers for various work modalities Ministry of Health of Peru this information is public and it is in a document that I share in the bibliography which is a document made by the Ministry of Health by the Human Resources Observatory in that same report it indicates that the 16.22% of health professionals are obstetrics that is, 11 times more and we all work exclusively in the infant maternal area we are a specialization in that area and that is where we work so pregnancy is a valuable opportunity where we should invest in the importance of a good diet since we are the professionals that usually take the first contact with pregnant women both in prenatal and not pregnant women in family planning consultations and reproductive health but what is around our competencies in the nutritional area that is a point let's say that we should talk about it too we are qualified to do it review the study plan of the main schools and faculties that form obstetrics in our country we find at least a course related to dietetic nutrition in all of them also one or more courses related to health education and or educational technologies so we can say that in pregrade in the professional training of the obstetrics it acquires two basic competencies the first related to the methodology for an effective consultancy because most of the work we do is promotional preventive activity especially at the first level of attention a lot of what we do has led to increase health and prevent sickness and the second related to basic concepts nutrition and dietetic these two competencies will contribute to those needs initially described and especially considering that more than half of women start pregnancy with overweight as shown in the national studies and also the study that I have shared so we are facing a problem of public health for the country which we must face as part of the multidisciplinary health team revaling our important performance in basic nutrition evaluation during prenatal attention which allows us to recognize the abnormality and derive it to the specialist in nutrition and also the priority that includes the evaluation and nutrition advice in the attention we pay to women in fertility pre-conceptional and post-conceptional all women in fertility who plan to get pregnant must know their nutritional status and the risks to which they could get pregnant if pregnant at that time so the need to count with specialists in nutrition in all health establishments of reference in order to attend those women derived from less complex establishments where we are that we do that evaluation and we derive them another shocking result is the retention of the weight per quarter because here our work will focus on informing the pregnant women that during pregnancy the weight should be increased according to their initial state and not eat for two that is to say not to ingest the double of used calories but to eat for two that is to say a healthy diet in this stage and the nutritional requirements necessary for good fetal development well then with let's say with everything we have talked about now I have made the conclusions of this work and it would be that the overweight and obesity in women has increased in Peru the excess weight gain during pregnancy are important predictors of overweight women in fertile age being able to preserve throughout life as we have mentioned in this study and in the references that we have made other researches in more time one of which the gain of weight during pregnancy and the return to healthy weight to culminate in lactation should be an objective of the obstetrics within the entire management of the pregnant woman for them they must apply their competences in basic nutritional value and nutritional advice effective well colleagues I have finished the presentation and here in this slide are the bibliographic references and I would like that those who are interested are the link of the majority of the references there are important documents that we should review as these reports are the nutritional system of the 100 the AENDs and other researches made in our country about this topic and also information at an international level that have worked this study variable which seems to me quite let's say important within our work and I would like to consult both on the research or general opinion they can do it and especially I would like to contact colleagues from other parts of the world or from the interior of the country with which we could do research on this theme that they are interested and that they can the colleagues who work at the first level of attention is easier to follow well, it's never easy because both in Lima and in Provincia let's say the work we do sometimes it's quite complicated very tedious and it's difficult because women in the stage of pregnancy is where they come to us after this stage in the conference usually they are lost we already found them in the consultations of health control of vaccination and sometimes we don't have access because we don't work in those sectors but we must remember that these women if it's true, they end up in the pulperium then they go to a next period they are still in the vast majority of women in reproductive age women in fertile age which must be attended by us and the weight as we have manifested in all this presentation and within the considerations that we must have in the entire care of the staff thank you all and now for the questions and Marlene very well Marlene thank you very much Marlene Marlene has finished her presentation so you can ask questions or maybe we will ask you some questions because you are the only one in the room who is from Turkey I guess so thank you Marlene for your presentation and we saw some applause and happy faces I was talking in English to see if there are other colleagues who have questions or to ask them about how they work in nutrition and in general the obstetrician in your country that's true so Ilfner from Turkey we just said that the Nidwas should be an important in this moment especially in the nutrition thank you Marlene thank you Zana one woman one woman and two Medwes Ilfner ask us some questions actually so you stay there that will be fantastic we can ask you some questions about how you practice in Turkey I was saying that maybe many of us have questions for her about the obstetrician in Turkey before we move on to that question I don't know if someone from the audience has a question for Marlene let's wait for someone from Manitos to write if you are a little bit ashamed you can read your question in the chat and also Zana the last one the idea of this presentation is to meet with colleagues from other latitudes in the same country in distant places where they are interested in this topic and if they would like to participate in a joint research because it would be interesting to study what happens inside the country we know that Peru is a country where we have a lot of diversity coast, Sierra Selva and what is happening in the rest of the country if you come to ENDES it gives us national information ENDES does not deal with the retention of weight by birth I would like to that some colleague who is in the rural area has access to Peruvians of other characteristics outside Lima who is interested in doing this segment we could do joint work I am still interested in this line of research and sometimes to tell colleagues that when we do not do research sometimes it seems to us like a difficult plan we can not do it we do not encourage that is why I am here to tell you that what we do here at the University of San Bernardino is to encourage them to do research ourselves as teachers we are investigating and that is why I would like to also share this enthusiasm for research to other colleagues in other parts of Peru and why not the colleague of Turkey or any colleague who has information that can do a database together to see what is going on with other women very well I am translating Marlene has just called the midwives to join her research she is very curious to know how the midwives work nutrition and diet counseling in other countries I do not know if you have anything to say about that I am in the prenatal appointment discussed about that I am asking if she has any special space in her prenatal consultations where they discuss about counseling this has a question has observed a relationship between anemia and low weight gain very good question in the research that I shared a moment ago with other studies I was not analysing these variables but I have read a lot about anemia and low weight that was the question if there was a relationship between low weight and anemia yes I have read these variables there are studies that relate low weight and anemia anemia is another topic but it is also a very important topic that in this prenatal appointment in our country there is a lot of public policies to try to reduce it especially the children because we have been dragging anemia in the pregnancy anemia in the small children that bring a series of complications throughout life this variable was not worked for this research but I do know and if the colleague who asked the question I will leave my email besides Susana if you allow me because I have a lot of information in this field that I have worked and if you are interested in the topic I can give you a document, a paper about it very good, thank you if you want to answer your email Marlene is going to add her email address in the chat box so if anyone has any questions for her please feel free to write midwifery school students in general are described in turkey nutrition first our colleague from Turkey tells us that obstetrician schools generally study nutrition courses in the students that's interesting and if you to see in the big cities and in the small cities as well I ask if it is the same in the big cities or rural areas in your country so if someone wants to go to Turkey to be able to meet the Turkish midwives yes precisely in that observation that our colleague from Turkey actually here in our country as I was telling you for this presentation I reviewed the curriculum of the main universities that form obstetrics in our country in Peru and all of them have courses related to it as well like the college has done in dietetic nutrition that is, all of us have been trained to take this subject maybe it is a course more of the training that we have but if we are not updating, if we are not reading about it there are some very interesting very good, very well done by the Ministry of Health especially by the organization within the Ministry of Nutrition and we have to know we have to read it and we also want to revaluate that part of the activity that we do, if it is true our activity in consultation or in hospital attention sometimes it is usually like recharged we must remember that in our training a plus an important point that differentiates us is that we must promote health and health prevention the subject of nutrition if we contribute in something and improve these indicators if we do not do anything what is going to happen here in 20 years is that our women are going to do all of us, we are going to be in the group of overweight and sometimes the subject of being a mother in everyday life when we have a friend and we say why did you get overweight and she says I have not had a child in a way we justify socially it is justified the subject to retain weight because you have been pregnant and it is not like that we are already saying that it is not like that and we really must clarify that point of our managers from their first control on how people are doing yes thank you very much sorry I cut you but we are in 10 minutes and our next exposer is in the tail but I thank you very much for the presentation Iltner