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2 The Preconception/Interconception Visit Checklist Gathering Information Questions Administer nutrition questionnaire and check medical records to determine factors that may affect nutritional status and needs Indications of an eating disorder? Pregnancy planned? Physical Examination General appearance Weight and height: determine body mass index category Anemia: Hemoglobin <12.0 g/dl (nonsmokers) Basic Guidance The Dietary Guidelines Physical activity Weight maintenance or normalization Avoidance or cutting back on the use of harmful substances
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Addressing Problems Assist with access to food Treat disorders requiring diet therapy Treat anemia: For iron deficiency anemia-60 to 120 mg of elemental iron daily; at a different time of day, give 15 mg of zinc and 2 mg of copper as part of a vitamin/mineral supplement Consider folate supplementation to help prevent recurrent neural tube defects Combat the use of harmful substances
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The Preconception/Interconception Visit The preconception/interconception visit may be conducted when a woman of childbearing potential has a routine health care visit. The major goals of nutrition-related care are to identify women who are at nutritional risk and to provide appropriate nutrition management. For women who are actively preparing for pregnancy and want additional information, see Tab 3, “The First Prenatal Visit." It is assumed that before meeting with the health care provider the woman will complete a nutrition questionnaire. If the woman has difficulty reading or other special circumstances apply, the questions should be asked in person in the woman's native language, using an approach that encourages unguided responses.
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Gathering Information Check the medical record and the nutrition questionnaire to identify relevant questions and avoid unnecessary repetition. Useful sociodemographic data includes maternal age, ethnic background, marital status, and evidence of low income. History—Sample Questions Sociodemographic, Obstetric, Medical, and Life-Style Factors What vitamins, minerals, or other supplements are you taking? How much? How often? Why? Have you had anemia, "low blood," or "low iron"? Are you breastfeeding now? Are you planning to become pregnant in the next year? Weight Status How do you feel about your current weight? Have you ever been underweight? Overweight? What, if anything, did you do about it? If an eating disorder is suspected, ask: Does it bother you to know that you are going to be weighed? If yes, When you know you will be weighed, do you ever eat less? Force yourself to vomit? Use laxatives or diuretics? Exercise a lot? Have you recently gained or lost weight? How much? How fast? Were you trying to lose weight? If yes, Using what type of plan?
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Dietary Practices See Questions 2 through 5 and 11 through 13 on the nutrition questionnaire. Use of Harmful Substances See Questions 15 through 17 on the nutrition questionnaire. Physical Examination General Appearance Check for healthy gums, teeth, throat, and skin; overall physique; and amount and distribution of body fat. Observe the woman for signs of depression, poverty, battering, and poor hygiene. Weight-for-Height Status (Tab 1 contains recommended tools.) Measure height without shoes. Measure weight. Determine relative weight-for-height using body mass index (BMI) (see BMI chart in Tab 1). Laboratory Evaluation Determine the hemoglobin or hematocrit value. If applicable, correct the value for smoking (Tab 1, page 16) or altitude (Tab 9, page 110) or both. Perform additional tests if appropriate. According to the history and physical examination, it may be advisable to do a lipid screen, a glucose screen, or other indicated blood or urine analyses.
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Explanations History Sociodemographic, Obstetric, Medical, and Life-Style Factors Nondietary factors may influence a woman's nutrient requirements, affect her ability to achieve adequate nutrition, signal previous problems with nutrition during pregnancy or lactation, or indicate the need for special approaches to care. Excessive use of vitamin and mineral supplements is to be avoided. Vitamin A at high levels is a documented teratogen, and women considering pregnancy should be encouraged to discontinue vitamin A supplements, especially at dosages exceeding 800 RE (~4,000 IU) daily. Supplemental folate taken periconceptionally appears to help prevent neural tube defects in women who have previously had an affected pregnancy.12 Preventing or resolving anemia is encouraged as part of general health promotion. A currently breastfeeding woman who is considering becoming pregnant has increased nutritional requirements. A woman who is planning a pregnancy can be given specific health and nutrition guidelines. Weight Status A woman's perceptions of her weight status may influence her nutrition now as well as during pregnancy Rapid, substantial weight loss may decrease a woman's ability to conceive, as may obesity Preoccupation with weight, widely fluctuating weight, or excessive exercise or dieting signals the need to assess the woman for a potential eating disorder.
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Dietary Practices Women who have poor appetites, who skip meals often, or who are purposely limiting their food intake may eat too little food to support a moderate body weight. Women on special diets for medical conditions may need assistance from a dietitian to modify food intake in support of their own health and a healthy pregnancy Women who omit a major food group from their diets may have inadequate intakes of nutrients supplied by that food group. Use of Harmful Substances The use of cigarettes, smokeless tobacco, alcoholic beverages, or illegal drugs is a health risk for women regardless of whether they are pregnant. Furthermore, it may adversely affect nutrition. (See box on the next page.) See "Information About Drugs," Tab 10, for sources of information about prescription medications and over-the-counter products. Physical Examination General Appearance Signs of an eating disorder include dental enamel erosion, little subcutaneous fat, and (rarely) swollen parotid glands and callouses on the knuckles. Untreated dental disease, depression, battering, and other problems may interfere with adequate nutrient intake. Poor hygiene may be suggestive of life circumstances that interfere with adequate nutrient intake.
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For the Health Professional: Potential Nutrition-Related Effects of Tobacco, Alcohol, and Illegal Drugs Impaired fetal growth. Many mechanisms may be involved. Low maternal food intake. This may be related to decreased appetite (e.g., cocaine and amphetamines are appetite suppressants), substitution of the substance (e.g., alcohol) for food, lack of money to spend on food, or any combination of these. Increased nutrient requirements, for example: Cigarette smoking increases the metabolism and thus the need for vitamin C. Alcohol impairs the absorption or utilization of several nutrients and may impair the placental transport of certain nutrients. Concern about body size. Some women who quit smoking or who quit using other harmful substances may become anxious about gaining too much weight. Weight-for-Height Status Obesity increases the risk of developing many chronic diseases and complications of pregnancy. Low weight-for-height increases the risk of delivering a low birth weight baby. Laboratory Evaluation A positive screen for anemia (hemoglobin <12.0 g/dl, nonsmokers), elevated blood lipids, or other abnormal conditions call for additional testing or intervention.
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Basic Guidance General Affirm something positive, such as: I'm glad to see that you exercise regularly. It's a good habit with many health benefits. Encourage healthful eating practices and exercise to achieve or maintain a healthy weight (BMI within the normal range shown on page 13). Using appropriate materials, provide guidance on sound eating practices based primarily on the Dietary Guidelines and indicate that these practices also help prevent chronic diseases such as cancer and heart disease. Basic Dietary Guidance There are numerous ways to achieve desirable dietary intakes of nutrients and of other beneficial food components such as fiber. An appropriate guide encourages the woman to aim for intakes such as those described in the Dietary Guidelines13: 2 servings of fruit; 3 of vegetables; 6 to 11 of grains; 2 of low-fat meat, fish, or poultry or of legumes; and 2 to 3 of low-fat, calcium-rich milk products such as low-fat milk, cheese, or yogurt. Vegetables can be grouped with fruits if desired, legumes can be counted as vegetables, and potatoes or viandas (starchy vegetables used by some Hispanics) can be substituted for grains. The actual number of servings suggested is of less importance than finding a guide to which the women can relate—one that includes practical and culturally acceptable suggestions for eating well. (To many people, one serving of rice or pasta would equal four servings of the size [1/2 cup] described in most nutrition education materials.)
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For the Woman Recommendations for All Women Based on Dietary Guidelines for Americans Eat a variety of foods. Choose a diet low in fat, saturated fat, and cholesterol. This reduces the risk of chronic disease and may help you manage your weight. Keeping fat intake under control also helps make room for foods that are rich in vitamins and minerals. Aim to have 2 servings daily of low-fat meat, fish, or poultry or of legumes. Also aim to have 2 to 3 servings of low-fat, calcium-rich milk products such as low-fat milk, cheese, or yogurt. One cup of milk or yogurt is an example of one serving. Choose a diet with plenty of vegetables, fruits, juices, and grain products. Choose whole-grain products at least part of the time. Aim to have 2 or more servings of fruit or juice, 3 or more servings of vegetables, and 6 to 11 servings of grains each day. One slice of bread and 1/2 cup of rice, fruit, or vegetables are examples of one serving. Use sweets, sugars, and soft drinks only in moderation. Use salt and salty foods only in moderation. This helps prevent or control hypertension. However, restricted salt intake is not believed to be useful for the prevention or control of hypertension during pregnancy.
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For the Woman: Special Recommendations Before Pregnancy Maintain a healthy weight. Regular physical activity will help. If you need to gain or lose weight, do so gradually (no more than 1 to 2 lb/week). If you are trying to become pregnant and you ordinarily drink alcoholic beverages, omit alcohol or cut way back on the amount you drink. Use of Medications, Supplements, and Harmful Substances Discourage the use of any kind of medication or supplement unless it is prescribed or approved by a physician who knows the woman is planning to become pregnant. Discourage the use of cigarettes, smokeless tobacco, alcoholic beverages, and illegal drugs. Addressing Problems Problems with Access to Food Provide assistance or refer the woman so that she can obtain assistance with food, housing, insurance, and income support programs. (See Tab 10 for information about federal food and nutrition assistance programs.)
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Low Food or Nutrient Intake Help the woman develop a concrete plan for eating enough food to achieve or maintain a healthy weight. (See Tabs 7 and 8.) Engage her in identifying acceptable food sources of needed nutrients. Jointly decide on strategies for increasing nutrient intake from foods. Disorders Requiring Diet Therapy For women with common nutrition-related conditions (e.g., obesity, low body weight, or lactose intolerance), do one or more of the following: Provide individual or group counseling. Refer the woman to a dietitian. If a woman has diabetes mellitus, phenylketonuria, renal disease, serious gastrointestinal disease, or other conditions requiring diet therapy, she should receive care from an experienced physician and dietitian. These providers should be consulted about appropriate follow-up care. (See "Referral to a Registered Dietitian," Tab 10.) Women with eating disorders require comprehensive care by a specialized team. Anemia If the hemoglobin is below 12.0 g/dl (nonsmokers), consider determining the serum ferritin. A low serum ferritin (<20 µg/liter)14 indicates that the anemia is due to iron deficiency. For hemoglobin levels below 12.0 g/dl, start a therapeutic regimen of approximately 60 to 120 mg/day of ferrous iron, and give a multivitamin/mineral supplement that contains ~15 mg of zinc and ~2 mg of copper. See Tab 9.
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Consider other causes of anemia if it has not improved after 1 month. When the anemia has resolved, discontinue the high-dose iron. If a low-dose of iron is needed because a chronic condition (such as heavy menstrual periods) originally caused the anemia, the iron can be provided with an iron-containing multivitamin/ mineral preparation or the iron can be given alone. Use of Harmful Substances Provide reinforcement for any constructive steps that have already been taken, provide assistance with quitting, and refer the woman for further evaluation or enrollment in an intensive treatment program as needed. If a pregnancy is planned, encourage the woman to view stopping or cutting down on substance use as a gift to her unborn child. Assist women in recovery to develop a sense of reasonable amounts of food to eat, especially if they are concerned about weight fluctuations. History of Delivering an Infant with a Neural Tube Defect The Centers for Disease Control recommends that if a woman has had a pregnancy involving a fetus or infant affected with a neural tube defect, she should consult her physician as soon as she plans a pregnancy “Unless contraindicated, they should be advised to take 4 mg per day of folic acid starting at the time they plan to become pregnant. Women should take the supplement from at least 4 weeks before conception through the first 3 months of pregnancy The dose should be taken only under a physician's supervision."15 Folate supplementation after the third month of pregnancy does not protect against neural tube defects.
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