Nutrition At Risk/Unsure

[symple_toggle title="Scope of Problem" state="closed"]

• 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 <400 mcg folic acid daily
    • 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.

[/symple_toggle][symple_toggle title="Preconception Significance" state="closed"]

• 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.

[/symple_toggle][symple_toggle title="Risk Identification Strategies" state="closed"]

• 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.

[/symple_toggle][symple_toggle title="Risk Reduction Strategies" state="closed"]

Counsel all women of reproductive age to:

• Ingest 400 mcg 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 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 -4 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.

[/symple_toggle][symple_toggle title="Important Talking Points" state="closed"]

• 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 vitamin containing 400 mcg of folic acid.
• 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.

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[symple_toggle title="Diet" state="closed"]

• Key Points:
  • Counsel all women to consume a healthy diet based on vegetables, legumes, fruits, whole grains, lean meant, poultry, fish, and dairy foods to ensure adequate intake of the range of nutrients important for their own health and for their fertility.
  • Advise all women to start or continue supplementing their diet with a daily over-the-counter multivitamin (which will include the recommended amount of folic acid and all of the nutrients above except calcium) to support her own health and healthy reproductive outcomes.
  • 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:http://www.hrsa.gov/womenshealth/wellness/mybrightfutureadulttool.pdf

[/symple_toggle][symple_toggle title="Vitamins & Supplements" state="closed"]

• Key Points:
  • Advise women to ingest 400 mcg of synthetic folic acid daily from fortified foods and/or supplements and consume a balanced, healthy diet of folate rich foods.
    • This amount of folic acid is found in all the over-the-counter multivitamins, making them a safe and inexpensive way to afford this recommendations.
    • Stress that this strategy provides protection against some birth defects, especially neural tube defects, but the benefit is only realized if the supplement is begun before pregnancy.
  • Ask women about all other vitamin and mineral supplements they use.
    • Encourage women to take one over-the-counter multivitamin daily to assure exposure to key nutrients (compatible with meeting folic acid recommendation).
    • If a woman is taking multiple vitamin and mineral supplements, caution her that excesses of some nutrients will impact the body’s ability to use other nutrients, thereby causing unintended, potentially dangerous consequences.
  • Ask women about their use of other dietary products (e.g. traditional remedies, herbal products, weight lost products):
    • Advise that these products are generally not regulated so their safety for the woman and her fetus, which is likely to be more susceptible to any harms, are unknown.
    • The safest choice is to avoid these products before, during, and beyond pregnancy.
  • Review information relevant to specific nutrients below.

RESOURCES

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

[/symple_toggle][symple_toggle title="Folic Acid" state="closed"]

• Advise women to ingest 400 mcg 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 certain populations:
  • Additional preconception folic acid is recommended for women at especially high risks for pregnancies complicated by neural tube defects:
    • 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 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 becoming pregnant.
      • Obese women also have a higher risk of NTDs:
        • While a higher dose of folic acid (e.g. 1 – 4 mg) prior to conception might afford greater protection for these women, no national guidelines have yet been published specifically endorsing this recommendation.
    • Family planning (timing of conception):
      • Women should be counseled to take a daily folic-acid containing multivitamin for at least 3 months prior to attempted 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

[/symple_toggle][symple_toggle title="Vitamin D" state="closed"]

• 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 multi-vitamins 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

[/symple_toggle][symple_toggle title="Calcium" state="closed"]

• 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

[/symple_toggle][symple_toggle title="Iron" state="closed"]

• 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
  • 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).

[/symple_toggle][symple_toggle title="Essential Fatty Acids" state="closed"]

• Key Points:
  • Encourage diet rich in essential fatty acids, including omega-3 and omega:
    • Found in oily fish, flax seeds, walnuts, and some vegetable oils
  • Relative to fish consumption, advise women to consume 8 to 12 ounces of a variety of seafood weekly. To avoid high mercury exposure:
    • Limit weekly consumption of canned albacore tuna to = 6 ounces
    • Avoid 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

[/symple_toggle][symple_toggle title="Iodine" state="closed"]

• Key Points:
  • Advise women to ingest 150 ug of iodine daily, the recommended minimum daily intake.
    • 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 stopping their method of contraception.

RESOURCES

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

[/symple_toggle][symple_toggle title="Issues Related To Weight Status" state="closed"]

• Key Points:
  • Women should have their BMI calculated at least annually.
  • If BMI = 25 kg/m2:
    • Assess 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).
• Specific preconception care guidance varies according to the woman’s BMI classification (see below).
• Family Planning (timing of 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

[/symple_toggle][symple_toggle title="Underweight (BMI < 18.5 kg/m2)" state="closed"]

• 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 healthier weight before stopping method of contraception.
  • Contraceptive considerations for underweight women: CDC Medical Eligibility Criteria for Contraception identifies no methods to be avoided in underweight women.
    • However, the FDA safety information for DepoProvera (medroxyprogesterone acetate) notes that bone loss is a known adverse effect and may not be completely reversible.and that women with low BMIs are at increased risk for osteoporosis there may be other contraceptive options that should be considered first.

RESOURCES

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

[/symple_toggle][symple_toggle title="Healthy Weight (BMI: 18.5 - 24.9 kg/m2)" state="closed"]

Key Points:

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

[/symple_toggle][symple_toggle title="Overweight (BMI: 25 - 29.9 kg/m2)" state="closed"]

• Key Points:
  • Looking forward to pregnancy is a good opportunity to achieve the healthiest weight possible for a woman’s own future health and for the health of her future child.
  • Overweight has many health consequences which can complicate pregnancy and the future life course for her and her children including:
    • Type 2 diabetes mellitus;
    • Hypertension;
    • Heart disease;
    • Gallbladder disease;
    • Breast and uterine cancers;
    • Risks to future reproduction, including infertility and neural tube defects;
    • Gateway to obesity.
  • Encourage woman to set a realistic weight goal and timeframe.
  • Offer specific behavioral strategies to decrease caloric intake and increase physical activity (this is a topic that many clinicians struggle with: see the resources below for some guidance on addressing this topic in an efficient and effective manner).
  • Encourage enrollment in a structured weight loss programs.
    • Caution to avoid fad diets
    • If possible, refer to a nutritionist
  • Calorie restricted diets may make it difficult to consume all of the essential nutrients.
    • Underscore importance of taking a multivitamin daily
    • In addition, recommend calcium supplementation
  • IF BMI 27 – 29.9 kg/m2 with co-morbidities, consider pharmacotherapy for weight loss.
  • The American College of Physicians recommends these options for women who choose adjunctive drug therapy from the following list based on: side effect profile, co-morbidities and desires or risks of pregnancy:
    • Sibutramine (pregnancy category C drug; no longer available in the US)
    • Orlistat (pregnancy category X drug)
    • Phentermine (pregnancy category X drug)
    • Diethlpropion (pregnancy category B drug)
    • Fluoxetine (pregnancy category C drug)
    • Bupropion (pregnancy category C drug)
  • An effective method of contraception is essential for women choosing pharmacotherapy as part of their weight loss program.
• Family Planning (timing of conception):
  • Counsel all women about the advantages of continuing their method of contraception until they have achieved their desired weight.
  • If a woman is using one of the pharmacotherapies, explain:
    • The drug has not been proven safe in pregnancy, even during the earliest weeks
    • She should continue an effective method of contraception to avoid harms to her future child.

 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:http://health.mo.gov/living/healthcondiseases/obesity/pdf/Toolkit_Adult.pdf

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

[/symple_toggle][symple_toggle title="Obese (BMI: 30 kg/m2)" state="closed"]

• Key Points:
  • In addition to all of the key points for “overweight” outlined 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.
    • 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.
    • Following bariatric surgery:
      • This contraceptive guidance does 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 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:http://health.mo.gov/living/healthcondiseases/obesity/pdf/Toolkit_Adult.pdf

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

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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.