10
Nutrition Referrals and Resources

Referral to a Registered Dietitian

To promote continuity of care, consider giving the woman a two-way referral form to carry with her (to facilitate communication between the dietitian and other caregivers). The form might include places for the primary care provider to record the purpose of the referral as well as the woman's weight, height, BMI, and hemoglobin or hematocrit and places for the dietitian to record key contents of the visit and the behavioral changes which the woman agreed to attempt to make.

What the woman can expect at the visit:

  • Questions about what she eats, some of her attitudes toward food and supplements, and her daily activities (including exercise).

  • Sometimes a request for some record keeping, such as 3-day food records.

  • Discussion of goals for improving her nutrition.

  • Some specific goals for changing behaviors-goals that are compatible with her situation and preferences.

  • Written, pictorial, or taped information pertinent to the problem (e.g., an individualized eating plan, recipes, guidelines for what to do when eating out, or strategies for more comfortably meeting nutrient needs).

  • Recommendations for follow-up with the dietitian or the primary care provider or both.



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10 Nutrition Referrals and Resources Referral to a Registered Dietitian To promote continuity of care, consider giving the woman a two-way referral form to carry with her (to facilitate communication between the dietitian and other caregivers). The form might include places for the primary care provider to record the purpose of the referral as well as the woman's weight, height, BMI, and hemoglobin or hematocrit and places for the dietitian to record key contents of the visit and the behavioral changes which the woman agreed to attempt to make. What the woman can expect at the visit: Questions about what she eats, some of her attitudes toward food and supplements, and her daily activities (including exercise). Sometimes a request for some record keeping, such as 3-day food records. Discussion of goals for improving her nutrition. Some specific goals for changing behaviors-goals that are compatible with her situation and preferences. Written, pictorial, or taped information pertinent to the problem (e.g., an individualized eating plan, recipes, guidelines for what to do when eating out, or strategies for more comfortably meeting nutrient needs). Recommendations for follow-up with the dietitian or the primary care provider or both.

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Eligibility for Federal Food and Nutrition Programs and Program Benefits Program Eligibility Benefits Special Supplemental Food Program for Women, Infants, and Children (WIC) Local phone number: ______—__________ Pregnant women, postpartum women (up to 6 months), breastfeeding women (up to 1 year), infants, and children (aged <5 years); must be certified to be at nutritional risk, and household income must be determined to be ≤185%/a of the federal poverty levelb Individualized food packages provided monthly. These include foods such as milk, cheese, eggs, fruit juice, cereal, peanut butter or legumes, infant formula, and infant cereal Nutrition education Referrals Commodity Supplemental Food Program (CSFP) Local phone number: ______—__________ Pregnant women, breastfeeding women, other postpartum women, infants and children (aged <6 years); household income must be determined to be ≤185%a of the federal poverty level Monthly canned or packaged foods including fruits, vegetables, meats, infant formula, farina, beans, other as available Food Stamp Program Local phone number: ______—__________ U.S. citizens, recognized refugees with visa status, and legal aliens-all from households with low income and with resources (aside from income) of ≤$2,000 (≤$3,000 with at least one elderly personc); eligibility is determined after formal application to local public assistance or social services agencies Food vouchers, cards, or checks to purchase foods at participating food markets

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Program Eligibility Benefits Temporary Emergency Food Assistance Program (TEFAP) Local phone number: ______—__________ Households with income ≤150%a of the federal poverty level Quarterly distribution: cheese, butter, rice, occasionally flour, cornmeal, and dry milk. Emergency food milk. Emergency food available once per month: dairy products, rice, flour, corn meal Nutrition Assistance Program (NAP) for Puerto Rico Local phone number: ______—__________ Residents of Puerto Rico who meet eligibility rules similar to those for the Food Stamp Program Cash to be used by recipients to supplement their food budget Food Distribution Program on Indian Reservations (FDPIR) Local phone number: ______—__________ American-Indian households living on or near reservations Monthly canned or packaged foods, including fruits, vegetables, meats, beans, grains, flour, cereal, juice, pasta, egg mix, milk, cheese, peanut butter, honey, butter, oil, and shortening Cooperative Extension-Expanded Food and Nutrition Education Program (EFNEP)d Local phone number: ______—__________ Households with children aged <19 years, with income ≤125% of the federal poverty level; at nutritional risk Education and training on food and nutrition Source: Adapted from Boisvert-Walsh and Kallio, with permission.20 a Some states have lower cutoff values. b The federal poverty level is computed yearly. The cost of the U.S. Department of Agriculture's Thrifty Food Plan is multiplied by three and adjusted for family size and the current consumer price index. c Elderly are those aged ≥60 years. d EFNEP is not available in all communities.

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Examples of comments or questions for the health care provider to raise at follow-up: Find something positive to reinforce: It sounds like you're making a good start in increasing your energy intake to help your baby grow. If no note is in the medical record, ask: Did you meet with the dietitian after our last visit to get help with X? If yes (or if there is a record of the visit): It's good that you took the time to see the dietitian. Did you bring your referral form with you today? If the referral form has been filled out: Tell me what you have done about X (the first behavioral change written in the plan). Do you have any questions about X? Y? Z? If there is no referral form: What did you agree to do to accomplish X? How is it going? Ask some specific questions related to the problem, such as: Are you still uncomfortable after eating? Referral to WIC Help low-income pregnant or postpartum women receive WIC benefits without unnecessary delay. When referring women to WIC, provide the following information: the reason for the referral; hemoglobin or hematocrit; medical risks, if any; height and weight; and special formulas required, if any, and the rationale for their use. Your local WIC agency can provide you with their standard referral forms, or you can send the information on forms of your choice or on your official stationery. Providing this information expedites the delivery of appropriate services and food packages for mothers and their infants and children. Encourage eligible pregnant and lactating women to take advantage of the information about breastfeeding and about healthful eating that WIC now provides.

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Health Services Resources The Maternal and Child Health Program (MCH), authorized under Title V, Social Security Act, resides in the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services and works in partnership with state health agencies, professional groups, and providers to improve the health of mothers, children, and families. State units of MCH and other HRSA programs promote health through standard setting and quality assurance, specialized consultation and technical assistance, interagency collaboration, and arrangements for direct service delivery. Nutrition services are available through each state health system as one component of comprehensive MCH care. MCH can assist you with local Local Consultation and Technical Assistance Contact your state or local department of public health for guidance or information related to maternal and child nutrition. Local health department phone number name   State health department (Title V MCH Nutritionist) phone number name State MCH hotline phone number

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polices and referral systems for WIC, Medicaid, prenatal care access, genetic screening, perinatology centers for consultation on special conditions, therapeutic nutrition counseling, and others. The National Center for Education in Maternal and Child Health (NCEMCH) maintains a reference collection of maternal and child health program materials; responds to information requests; provides technical assistance in educational resource development, program planning, and topical research; and provides other information services. It can also assist you in locating your state MCH representatives. NCEMCH can be reached at (703) 524-7802. Selecting and Using Educational Materials Materials from any source should be reviewed and evaluated before they are used in clinical practice. The following questions help to choose the best materials to use for a particular situation. Does the material include favorable images of the subgroups in your patient population? Do the visual images match the verbal message? Are the visual images appropriate for the age, ethnic background, and socioeconomic status of the women you serve? Is the information presented from a positive perspective? (You can do it.) Is it action oriented? Is the information accurate and up to date? Is it consistent with the other messages you give? Is the material free of subtle sales messages (e.g., if you fail at breastfeeding, there is always formula)? Are the recommendations practical considering the characteristics and resources of the women you serve? (For example, do they pose reasonable demands in terms of cost, time, cooking skills, and cooking and storage facilities?)

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Is written material appropriate for the reading level of the women you serve? (Consider the number of syllables in the words, the number of words in the sentences, the familiarity of key words, the type size, and the format.) Materials for low-literacy audiences should focus on the most critical patient behaviors—what to do and when to do it. Do the materials fit the women's stage in the change process? For example, if the women are not ready to take action, materials should not emphasize how to take action. Consider the following guidelines to promote effective use of the materials selected. Use as few materials as possible to convey and reinforce your messages. Introduce the materials by briefly emphasizing the importance of the messages and giving an overview of what to expect. Where possible, ask for the woman's reaction to the messages. Do you think this (the recommendation)is something that you can do? Use materials to support your oral recommendations and to provide detail, such as the reasons why a particular woman should stop smoking or ways to stop.

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Sources of Information About Nutritional Care During the Perinatal Period The publications listed here are just a sampling of many useful resources. Those marked "Available from NMCHC" can be obtained from the National Maternal and Child Health Clearinghouse, 8201 Greensboro Drive, Suite 600, McLean, VA 22102 (703) 821-8955 ext. 254—usually at no cost. There is a charge for most of the other publications. General The following examples of manuals incorporate recommendations from the Institute of Medicine report Nutrition During Pregnancy.1 They contain information to assist health care providers in the delivery of maternal nutrition services. Alton, I., and M. Caldwell. 1990. Guidelines for Nutrition Care During Pregnancy (and revision packet). Region V, U.S. Public Health Service, U.S. Department of Health and Human Services, Chicago, IL. Available from NMCHC. Committee for Nutrition During Pregnancy and the Postpartum Period. Asarian, J., E. Gunderson, D. Lee, V. Newman, N. Sullivan, and D. Walker. 1990. Nutrition During Pregnancy and the Postpartum Period: A Manual for Health Care Professionals. Maternal and Child Health Branch, WIC Supplemental Food Branch, California Department of Health Services, 714 P Street, Room 740, Sacramento, CA 95814. 304 pp. Story, M., ed. 1990. Nutrition Management of the Pregnant Adolescent: A Practical Reference Guide. March of Dimes Birth Defects Foundation, White Plains, N.Y.; U.S. Department of Health and Human Services, Rockville, MD.; and U.S. Department of Agriculture, Alexandria, VA. 182 pp. Available through March of Dimes.

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Examples of Prenatal Nutrition Materials Suitable for Adolescents or Young Adults Division of Nutritional Sciences, Cornell University. 1988. A Smart Start: Nutrition for Life. Division of Nutritional Sciences, Cornell University, Ithaca, NY. Healthy Infant Outcome Project. 1988. Hey Baby: How to Eat and Gain Right to Grow the Best Baby Possible. Regents of the University of Minnesota, Minneapolis, MN. Available from Public Health Nutrition, University of Minnesota, Box 197 Mayo Building, 420 Delaware Street, SE, Minneapolis, MN 55455. Maternal and Infant Health. 1990. Healthy Foods, Healthy Baby. Philadelphia Department of Public Health, Philadelphia, PA. 28 pp. Available from NMCHC. Examples of Materials for Women with Gestational Diabetes Mellitus The first two items listed below are examples of patient education materials that are suitable for women with reading skills above the sixth grade level. The last two publications were designed for women with limited literacy skills. ADA (American Diabetes Association). 1989. Gestational Diabetes: What to Expect. Diabetes Information Service Center, Alexandria, VA. 76 pp. DHHS (U.S. Department of Health and Human Services). 1989. Understanding Gestational Diabetes: A Practical Guide to a Healthy Pregnancy. NIH Publ. No. 89-2788. Public Health Service, National Institutes of Health, National Institute of Child Health & Human Development, Bethesda, MD. 46 pp. Morin, G.K., and J.O. Joynes. 1988. Healthy Eating. Diabetes Center, Inc., P.O. Box 739, Wayzata, MN 55391. Nemanic, A., G.K. Morin, and J.O. Joynes. 1988. What Is Diabetes? Diabetes Center, Inc., P.O. Box 739, Wayzata, MN 55391. The following publication was designed to be used by professionals in dental and other health clinics to help Navajo women with gestational diabetes control their blood sugar (and thereby decrease their susceptibility

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to periodontal disease). It serves as an example of a culturally sensitive teaching tool. Pelican, S., O. Platero, G. Crawford, and D. Wise. Undated. Diabetes During Pregnancy: How to Keep the Balance. Indian Health Service Diabetes Program, 2401 Twelfth Street, NW, Albuquerque, NM 87102. 55 pp. Information About Drugs Berkowitz, R., D. Coustan, and T. Mochizuki. 1986. Handbook for Prescribing Medications During Pregnancy, 2nd ed. Little, Brown, and Co., Boston. Briggs, G.F., R.K. Freeman, and S.J. Yaffe. 1990. Drugs in Pregnancy and Lactation, 3rd ed. Williams and Wilkins, Baltimore. 732 pp. Niebyl, J.R. (ed.) 1988. Drug Use in Pregnancy, 2nd ed. Lea & Febiger, Philadelphia. 245 pp. Information About Smoking Cessation Programs Windsor, R.A. 1990. The Handbook to Plan, Implement and Evaluate Smoking Cessation Programs for Pregnant Women. March of Dimes Birth Defects Foundation, 1275 Mamaroneck Avenue, White Plains, NY 10605. 59 pp. Information About Breastfeeding The following are among many good publications for professionals. Coates, M.-M. 1990. The Lactation Consultant's Topical Review and Bibliography of the Literature on Breastfeeding. La Leche League International, Franklin Park, IL. 188 pp. (Includes many useful citations.) FNS (Food and Nutrition Service). 1988. Promoting Breastfeeding in WIC: A Compendium of Practical Approaches. U.S. Department of Agriculture, Alexandria, VA. FNS (Food and Nutrition Service). 1990. WIC Breastfeeding Promotion Study and Demonstration. Phase IV Report, Volume I. U.S. Department of Agriculture, Alexandria, VA.

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Jolley, S. 1990. Breastfeeding Triage Tool. Seattle-King County Department of Public Health, 110 Prefontaine Avenue South, Suite 500, Seattle, WA 98104. 94 pp. Lawrence, R.A. 1989. Breastfeeding: A Guide for the Medical Profession, 3rd ed. C.V. Mosby, St. Louis, MO. 652 pp. NCEMCH (National Center for Education in Maternal and Child Health). 1989. Breastfeeding: Catalog of Products from Projects Supported by the Bureau of Maternal and Child Health and Resources Development 1989. NMCHC, Washington, DC. 56 pp. Spisak, S., and S.S. Gross. 1991. Second Follow-up Report: The Surgeon General's Workshop on Breastfeeding and Human Lactation. National Center for Education in Maternal and Child Health, Washington, DC. 119 pp. Available from NMCHC. Yannicelli, S. A.E. Ernest, M.R. Neifert, and E.R.B. McCabe. 1988. Guide to Breastfeeding the Infant with PKU, 2nd ed. U.S. Department of Health and Human Services, Rockville, MD. 34 pp. Available from NMCHC. Examples of Breastfeeding Projects to Assist Health Professionals Best Start Breastfeeding Promotion Clearinghouse, 3500 E. Fletcher Avenue, Suite 308, Tampa, FL 33613; (800) 277-4975 or (318) 972-2119. Project Director: Carol A. Bryant, Ph.D. Offers a variety of breastfeeding promotion materials, technical assistance, and professional training materials; provides guidance on materials and program development for low literacy and minority populations. Study Group on Human Lactation and Breastfeeding, Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 777, Rochester, NY 14642; (716) 275-0088. Project Director: Ruth A. Lawrence, M.D. Provides reliable information for professionals on matters relating to human lactation and breastfeeding, including information on medications during lactation. WellStart/San Diego Lactation Program, 4062 First Avenue, San Diego, CA 92103; (619) 295-5192. Project Director: Audrey J. Naylor, M.D., Dr. P.H. Offers a variety of educational programs for health professionals.

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