THE NATIONAL PRECONCEPTION CURRICULUM AND RESOURCES GUIDE FOR CLINICIANS

Tool Kit

NEW PRECONCEPTION CARE CLINICAL TOOLKIT

Tool

”Welcome

Scope of Problem

  • Nutritional problems among U.S. women of reproductive age are reflected in high rates of overweight and obesity and in eating disorders which can lead to underweight and nutrient deficiencies:
    • According to the National Health and Nutrition Examination Survey, the following are among the nutrient deficiencies common in women of reproductive age:
      • Iron deficiency – 11%
      • Hypovitaminosis D (serum 25-hydroxyvitamin D =37.5 nmol/L)
        • 42% for non-Hispanic black women
        • 4.2% for Non-Hispanic white women
      • Consumption of
      • 81% for Non-Hispanic black women
      • 79% for Hispanic women
      • 60% for non-Hispanic white women
  • According to National Survey of Family Growth (2002):
    • Overweight (BMI 25.0 – 29.9 kg/m2) – 25%
    • Obese (BMI = 30 kg/m2) – 23%, with 10% of these meeting criteria for class II or class II obesity (= 35 kg/m2)
  • U.S. women who are of low-income are at increased risk for nutritional deficiencies and imbalances due to poor access to quality foods.

Preconception Significance

  • A woman’s nutritional status including her BMI and her intake of individual nutrients are important influences on pregnancy outcomes including:
    • Fertility
    • Birth defects
    • Low birth weight and preterm delivery
    • Maternal complications such as gestational diabetes and gestational hypertension
    • Operative births
  • Nutrients important to the prevention of birth defects, such as folate, are not protective following the period of organogenesis (17-56 days after conception); thus, prevention strategies must be in place before conception.

Risk Identification Strategies

  • As a part of primary care visits, assess women’s nutritional status through measurement of BMI, assessment of nutrient intake from diet and supplementation and activity levels.

Risk Reduction Strategies

  • Counsel all women of reproductive age to:
    • Ingest 0.4 mg of synthetic folic acid daily from fortified foods and/or supplements and consume a balanced, healthy diet of folate-rich foods;
    • Achieve adequate intake of other key nutrients including
      • Vitamin D: 600 IU daily
      • Calcium: 1000 mg daily
      • Iron: 15-18 mg daily
      • Iodine 150 mg daily
    • An over-the-counter generic multivitamin in addition to a balance diet will provide assurance that the woman is obtaining adequate amounts of these essential nutrients and of folic acid;
      • However, a multivitamin does not include sufficient calcium to meet a woman’s daily needs.
    • Achieve or maintain the healthiest BMI possible.
    • Additional preconception folic acid is recommended for women at especially high risk for pregnancies complicated by neural tube defects:
      • Known high risk populations
        • Prior pregnancy complicated by a NTD;
        • Personal or family history of NTD,
        • Insulin-dependent DM,
        • Seizure disorder especially if treated with valproic acid or carbamazepine.
      • The precise dose required to reduce the risk of NTDs in these women is unknown:
        • The most consistent recommendation is 4.0 mg starting one month prior to attempting pregnancy and continued through the first 3 months of gestation.
        • This high dose requires a prescription and should not be recommended if the woman is not at risk of pregnancy.
      • Obese women also have a higher risk of NTDs.
        • While a higher dose of folic acid (e.g. 1.0-4.0 mg) prior to conception might afford greater protection for these women, no national guidelines have yet been published specifically endorsing this recommendation because there is insufficient data at this time.

Important Talking Points

  • The nutritional status of an adult woman is the culmination of nutrient intake, metabolism, and energy expenditures over the course of her lifetime starting with her nutritional status at her own birth.
  • Irrespective of pregnancy desires, nutritional status is a key influence on a woman’s morbidity and mortality risks across her life span making assessing and addressing nutrition a key component of all primary care visits.
  • Every woman, irrespective of pregnancy desires, should be counseled to supplement a healthy diet which includes folate rich foods with a folic acid at 400 ug (0.4 mg).
  • Most women and clinicians dislike addressing weight as it often feels awkward and judgmental. Framing conversation about weight status and goals a part of every woman’s primary care and preventive care may help de-stigmatize the topic.
  • Working with women to set nutrition goals which are achievable through a series of small steps and acceptable to personal, cultural and social circumstances is likely to be more successful than recommending a specific BMI which may, initially, be seen as too daunting for the woman, the clinician and the practice.
  • Referral to weight loss programs, to peer support groups and to internet resources may be useful in helping women achieve improved nutritional status.

Diet

  • Key Points:
    • Counsel all women to consume a healthy diet based on vegetables, legumes, fruits, whole grains, lean meat, poultry, fish and dairy foods to ensure adequate intake of the range of nutrients important for fertility and optimum health.
    • Assess all women for nutritional adequacy of their diet and should be advised to take daily a folic acid-containing multivitamin supplement for the purpose of supporting healthy reproductive health outcomes, including reducing the risk of neural tube defects.
    • Counsel women to avoid fad diets in the months leading up to conception.

RESOURCES

Information for healthcare professionals on the MyPlate approach to making healthier food choices:http://www.choosemyplate.gov/information-healthcare-professionals.html

A patient education tool for healthy eating and physical activity: www.hrsa.gov/womenshealth/wellness/mybrightfutureadulttool.pdf.

Vitamins & Supplements In General

  • Key Points:
    • Ask women about their use of dietary supplements (e.g., vitamins, minerals, traditional remedies, herbal products, weight loss products) and should be advised about what is and is not known about their safety and efficacy.
    • Counsel women against ingesting supplements in excess of the RDAs unless prescribed:
      • Counsel women about achieving intake of the nutrients given in the following rows of this table as deficiencies are associated with poor women’s health and pregnancy outcomes.

RESOURCES

Dietary reference intakes and fact sheets: http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes

Folic Acid

  • Key Points:
    • Advise women to ingest 0.4 mg (400 ug) of synthetic folic acid daily from supplements and/or fortified food sources (such as highly-fortified breakfast cereals) AND to consume folate-rich foods daily (e.g., green, leafy vegetables).
  • RECOMMENDATIONS FOR SPECIAL POPULATIONS OF WOMEN:
    • Additional preconception folic acid is recommended for women at especially high risk for pregnancies complicated by neural tube defects:
    • Additional preconception folic acid
    • Prior pregnancy complicated by a NTD;
    • Personal or family history of NTD,
    • Insulin-dependent DM,
    • Seizure disorder especially if treated with valproic acid or carbamazepine.
  • The precise dose required to reduce the risk of NTDs in these women is unknown:
    • The most consistent recommendation is 4.0 mg starting one month prior to attempting pregnancy and continued through the first 3 months of gestation. 
    • This high dose requires a prescription and should not be recommended if the woman is not at risk of pregnancy.
  • Family Planning (timing of conception):
    • Women should be counseled to consume a daily folic acid-containing multivitamin for at least 3 months prior to conception.

RESOURCES

U.S. Public Health Service Recommendation: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5113a1.htm

Dietary reference intake and fact sheet for folic acid: http://fnic.nal.usda.gov/food-composition/vitamins-and-minerals/folic-acid

Vitamin D

  • Key Points:
    • Advise women to ingest the RDA for vitamin D, which is 600 IU daily, through fortified food sources (such as fortified dairy and soy beverages) and/or multi-vitamins (most multivitamins contain 400 – 600 IU of vitamin D).

RESOURCES

Dietary reference intake and fact sheet for Vitamin D: http://fnic.nal.usda.gov/food-composition/vitamins-and-minerals/vitamin-d

Calcium

  • Key Points:
    • Advise women to ingest the RDA for calcium, which is 1000 mg daily, through fortified food sources (such as fortified dairy and soy beverages) and/or supplements.

RESOURCES

Dietary reference intake and fact sheet for calcium: http://fnic.nal.usda.gov/food-composition/vitamins-and-minerals/calcium

Iron

  • Key Points:
    • Advise women to ingest the RDA for iron daily through food sources and/or supplements, which is:
      • 15 mg daily for teens 14-18 years of age
      • 18 mg daily for women 19-50 years of age through food
  • Screen women for iron deficiency according to their risk factors:
    • Women without risk factors should be screened every 5-10 years
    • Women with risk factors should be screened annually

RESOURCES

Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR 1998;47 (No. RR-3).

Essential Fatty Acids

  • Key Points:
    • Encourage women to eat a diet rich in essential fatty acids, including omega-3 and omega-6 fatty acids. Essential fatty acids are found in oily fish, flax seeks, walnuts, and some vegetable oils.
    • Regarding fish consumption, advise women to consume 8 to 12 ounces of a variety of seafood weekly, but due to high mercury levels in some fish:
      • Limit weekly consumption of canned albacore tuna to = 6 ounces
      • Avoid consuming swordfish, king mackerel, shark, and tilefish

RESOURCES

United States EPA Recommendation for Fish Consumption: http://water.epa.gov/scitech/swguidance/fishshellfish/outreach/advice_index.cfm

Quick guide to mercury content of fish: http://www.nrdc.org/health/effects/mercury/walletcard.PDF

Iodine

  • Key Points:
    • Advise women to ingest the recommended minimum daily intake of iodine, 150 ug daily, which is typically achieved through use of iodized salt.
    • Women with iodine deficiency should be counseled about the risks of this condition to pregnancy outcomes and about the importance of correcting the deficiency prior to conceiving a pregnancy.

RESOURCES

Dietary reference intake for iodine: http://www.nap.edu/catalog/10026.html

Issues Related To Weight Status

  • Key Points:
    • Women should have their BMI calculated at least annually. Those with a BMI = 25 kg/m2 should undergo assessment for co-morbidities (diabetes or impaired glucose tolerance, hypertension, hyperlipidemia, sleep apnea) and other cardiovascular risks (e.g., personal or family history of gestational diabetes and/or coronary artery disease, waist circumference > 35 inches).
    • For women who are postpartum or who have recently given birth, counsel about the importance of weight retained from previous pregnancies as an important contributor to higher than optimal BMI in women of childbearing age. Counsel about the importance of return to pre-pregnancy body weight within 6 – 12 months of birth through healthy eating behaviors and physical activity.
    • Specific preconception care guidance varies according to the woman’s BMI classification, as given in the rows of this table (below).
  • Family Planning (timing of conception):
    • Given the benefits of achieving a healthy body weight status prior to conception, counsel women about the importance of pregnancy timing in relation to achievement of a healthy weight status AND provide women with a safe and effective method of contraception to help them delay pregnancy until a healthy (or healthier) weight status has been achieved.

RESOURCES

A BMI calculator: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

Underweight (BMI < 18.5 kg/m2)

  • Key Points:
    • Counsel women about the short- and long-term risks to their own health (e.g., heart irregularities, osteoporosis, amenorrhea, infertility) and the risks to future pregnancies, including increased risk for preterm birth, intrauterine growth restriction, and low birth weight.
    • Assess for eating disorders and distortions of body image.
    • Those who are unwilling to consider and achieve weight gain may require referral for further evaluation of eating disorders.
  • Family Planning (timing of conception):
    • Counsel women about the importance of gaining weight to achieve a healthy body weight status prior to conception.
    • Contraceptive considerations for underweight women:

RESOURCES

Screening for eating disorders by primary care providers: http://www.nationaleatingdisorders.org/screening-eating-disorders-primary-care-physicians

Healthy Weight (BMI: 18.5 - 24.9 kg/m2)

  • Key Points:
    • Counsel women about the importance of maintaining her weight in this healthy range through adequate physical activity (at least 30 minutes daily) and a healthy diet.

Overweight (BMI 25 - 29.9 kg/m2)

  • Key Points:
    • Counsel women about the risks to her own health (e.g., increased risks for type 2 diabetes mellitus, hypertension, heart disease, gallbladder disease, breast and uterine cancer), the risks for exceeding the overweight category (if BMI = 30 kg/m2), and the risks to future pregnancies, including increased risk for infertility and neural tube defects.
    • Offer specific behavioral strategies to decrease caloric intake and increase physical activity and encourage enrollment in a structured weight loss programs.
    • Discuss nutritional concerns for women who are restricting caloric intake: The lower the caloric content of a diet, the more likely it is to be low in essential nutrients. Diets less than 1,200 kcal per day are likely to require vitamin and mineral supplementation. Even diets with greater than 1,200 kcal per day may necessitate supplementation with calcium, folic acid, and vitamin D, given the difficulty in meeting the recommended dietary intakes for these nutrients through diet alone. Overweight and obese women are more likely to be lacking in folic acid and vitamin D, and deficiencies of these vitamins have important reproductive consequences.
    • IF BMI 27 – 29.9 kg/m2 with co-morbidities, consider pharmacotherapy for weight loss
  • Family Planning (timing of conception):
    • Counsel women about the importance of losing weight to achieve a healthy body weight status prior to conception.

RESOURCES

American College of Preventive Medicine Adult Obesity Clinical Reference: http://www.acpm.org/?AdultObesity_ClinRef#Guidelines

American College of Preventive Medicine Adult Obesity “Time Tool”: http://www.acpm.org/?AdultObesity_Clinici 

Missouri Council for Activity and Nutrition Provider Toolkit for Adult Overweight & Obesity: health.mo.gov/living/healthcondiseases/obesity/pdf/Toolkit_Adult.pdf

Obese (BMI : 30 kg/m2)

  • Key Points:
    • In addition to above, follow existing evidence-based clinical guidelines for the management of obesity, which are summarized in an in-depth clinical reference and as a “time tool” for the clinical visit
    • Consider pharmacotherapy if BMI > 30 kg/m2 regardless of co-morbidities
    • Consider bariatric surgery if BMI > 30 kg/m2 with co-morbidities or BMI > 40 kg/m2 regardless of co-morbidities
  • Family Planning (timing of conception):
    • Counsel women about the importance of losing weight to achieve a healthy body weight status prior to conception.
    • Contraceptive considerations for obese women:
      • There are few trials of contraceptive efficacy involving overweight and obese women; however, there are concerns of decreased efficacy related to weight for the:
        • Combined oral contraceptives – for women > 70 kg
        • Contraceptive patch – for women > 90 kg
  • According to the CDC Medical Eligibility Criteria for Contraception
    • Current forms of contraception are either Category 1 (progesterone-only pills, injection, implant, IUDs), meaning the method can be used without restriction, or Category 2 (combined oral contraceptives, patch, ring), meaning that the advantages generally outweigh the theoretical or proven risks.
      • Post-bariatric surgery, these categories do not change if the patient underwent a restrictive procedure; however, if the patient underwent a malabsorptive procedure, both combined oral contraceptives and progesterone-only pills are considered Category 3 (theoretical or proven risks generally outweigh the benefits).

RESOURCES

American College of Obstetricians and Gynecologists Practice Bulletin on Pregnancy After Bariatric Surgery: http://www.aafp.org/afp/2010/0401/p905.html

Obesity and contraception: Emerging issues http://www.medscape.com/viewarticle/720094

 

 

 

 

 

 

Centers for Disease Control and Prevention: Preconception Clinical Care for Women: Nutrition (2013).
http://www.cdc.gov/preconception/careforwomen/nutrition.html.

Weight Control Information Network: Tips for Primary Care Providers on Talking to Your Patients about Weight Loss (2012).
http://win.niddk.nih.gov/publications/PDFs/TalkingWPAWL.pdf.

US Department of Health and Human Services: Steps for Initiating Conversations about Weight Loss with your Patients (2002).
http://www.nhlbi.nih.gov/health/prof/heart/obesity/aim_kit/steps.pdf.

Centers for Disease Control and Prevention: BMI Calculator (2011).
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html.

US Preventive Services Task Force Recommendations for Promoting a Healthy Diet and Physical Activity in Adults (2012).
http://annals.org/article.aspx?articleid=1355698.

Information for healthcare professionals on the MyPlate approach to making healthier food choices: http://www.choosemyplate.gov/information-healthcare-professionals.html

American College of Preventive Medicine: Adult Obesity Time Tool (2009).
http://www.acpm.org/?AdultObesity_Clinici

 

Weight-Control Information Network: Changing Your Habits: Steps to Better Health (2008).
http://www.win.niddk.nih.gov/publications/PDFs/Changing_Your_Habits.pdf

Weight-Control Information Network: Just Enough for You: Portion Control (2009).
http://win.niddk.nih.gov/publications/PDFs/justenough.pdf

March of Dimes: Folic Acid Information for Patients (2013).
http://www.marchofdimes.com/pregnancy/folicacid_indepth.html.

U.S. Department of Agriculture.. Choose My Plate (2013).
http://www.choosemyplate.gov/. This site is full of empowering and informative information for addressing healthy food choices, weight loss and maintenance, etc.

American College of Obstetricians and Gynecologists (ACOG). (2009) Bariatric Surgery and Pregnancy. ACOG Practice Bulletin No 105. Obstetrics and Gynecology, 113, 1405-1413.

American College of Obstetricians and Gynecologists (ACOG). (2013). Obesity in Pregnancy. ACOG Committee Opinion No. 549 . Obstetrics and Gynecology, 121, 213-217.

Centers for Disease Control (1992). Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. Morbidity and Mortality Weekly Report, 41 (RR-14).

Centers for Disease Control and Prevention (2010). U.S. Medical Eligibility Criteria for Contraceptive Use. (Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition). Morbidity and Mortality Weekly Report, 59(RR04): 1-6.

Dunlop, A.L. Narayan, D. &, Lam, V. (2011). Preparing for pregnancy: special considerations for the obese woman. In: Conway DL. Pregnancy in the Obese Woman. Hoboken, NJ: Blackwell Publishing,

Dunlop, A.L., Gardiner, P.M., Shellhaas, C.S., et al. (2008) The clinical content of preconception care: the use of medications and supplements among women of reproductive age. American Journal of Obstetrics and Gynecology 199 (6B), 367-373.

Gardiner, P.M., Nelson, L., Shellhass, C.S., et al. (2008). The clinical content of preconception care: nutrition and dietary supplements. American Journal of Obstetrics and Gynecology 199 (6B), S345-356.

Moos, M.K., Dunlop A.L., Jack, B.W., et al. (2008). Healthier women, healthier reproductive outcomes. American Journal of Obstetrics and Gynecology 199 (6B), S280-9.

Physical Activity Guidelines Advisory Committee (2008). Physical Activity Guidelines Advisory Committee Report, Washington, DC: U.S. Department of Health and Human Services.

Snow, V., Barry, P., Fitterman, N., Qaseem, A. & Weiss, K. (2005). Pharmacologic and surgical management of obesity in primary care: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 142, 525-31.

U.S. Department of Agriculture and U.S. Department of Health and Human Services (December, 2010). Dietary Guidelines for Americans, (7th ed), Washington, DC: U.S. Government Printing Office.

Women’s and Children’s Health Policy Center (1998). The nutritional status and needs of women of reproductive age. Perinatal and Women’s Health Issue Summary No. 6. Washington, DC: Health Resources and Services Administration.