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Basic and Special Nutrition Services for Women in the Preconceptional, Prenatal, and Postpartum Periods

Nutrition services are fundamental to the primary health care of women. This chapter covers the delivery of basic nutrition services and of nutrition services for women with conditions requiring special care. It also addresses the personnel and the knowledge and skills necessary to deliver high-quality, patient-centered services.

The maternal and child health unit of the health department in each state offers assistance with standard setting and quality assurance, specialized consultation and technical assistance, inter-agency collaboration, and direct service delivery, as well as with local policies and referral systems for the Special Supplemental Food Program for Women, Infants, and Children (WIC), Medicaid, prenatal care access, perinatology centers for consultation on special conditions, and therapeutic nutrition counseling.

The role of WIC in the provision of nutrition services merits special mention and clarification. WIC can and does play an important role in promoting adequate nutrient intake and in facilitating access to proper prenatal and postpartum health care services. However, WIC is not intended to provide comprehensive nutrition services. Some WIC nutritionists or other "competent professional authorities" a do not have the advanced training or experience needed to provide special nutrition services

a  

"Competent professional authority," according to federal regulations, is the term applied to "an individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental food."1



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Nutrition Services in Perinatal Care 3 Basic and Special Nutrition Services for Women in the Preconceptional, Prenatal, and Postpartum Periods Nutrition services are fundamental to the primary health care of women. This chapter covers the delivery of basic nutrition services and of nutrition services for women with conditions requiring special care. It also addresses the personnel and the knowledge and skills necessary to deliver high-quality, patient-centered services. The maternal and child health unit of the health department in each state offers assistance with standard setting and quality assurance, specialized consultation and technical assistance, inter-agency collaboration, and direct service delivery, as well as with local policies and referral systems for the Special Supplemental Food Program for Women, Infants, and Children (WIC), Medicaid, prenatal care access, perinatology centers for consultation on special conditions, and therapeutic nutrition counseling. The role of WIC in the provision of nutrition services merits special mention and clarification. WIC can and does play an important role in promoting adequate nutrient intake and in facilitating access to proper prenatal and postpartum health care services. However, WIC is not intended to provide comprehensive nutrition services. Some WIC nutritionists or other "competent professional authorities" a do not have the advanced training or experience needed to provide special nutrition services a   "Competent professional authority," according to federal regulations, is the term applied to "an individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental food."1

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Nutrition Services in Perinatal Care (see "Overview of Special Services" later in this chapter); moreover, the WIC program is not funded at a level sufficient to provide the special nutrition services needed by some high-risk women. DELIVERY OF BASIC NUTRITION SERVICES Physicians, midwives, nurse practitioners, and other primary care providers can and should integrate basic nutritional care into the care of all expectant and new mothers. Preconceptional care may be provided as part of a woman's routine health care, in family planning clinics, and during visits specifically to address planning for pregnancy. Excluding delivery, nearly all prenatal care is provided in physicians' or midwives' offices or in prenatal clinics. There is increasing interest, however, in the use of supplemental home visits for high-risk families.2–5 Most commonly, postpartum care is first provided in the hospital; subsequently, it may be provided in the physician's office or health center, and, in some cases, in the patient's home as well. Overview of Basic Services Chart 3-1 lists the nutritional care activities that need to be part of the routine care of all women—regardless of their level of nutritional risk, socioeconomic status, health status, or type of primary care provider. The publication Nutrition During Pregnancy and Lactation: An Implementation Guide6 contains suggestions for integrating these activities into routine care. Special nutritional care activities for the relatively few women with complex health problems are discussed later in this chapter. If referral to a dietitian or other specialists, or both, is necessary, open lines of communication are essential between the primary care providers and the specialist so that all members of the health care team are in agreement about and reinforce the nutritional advice given to the pregnant woman. Documentation, an important form of communication, appears to need more attention: Peoples-Sheps and colleagues7 report that although 98% of a large sample of prenatal care records included flow charts for weight, only 38% of them included a separate item for nutritional assessment, 19% an item for nutrition education, and 51% an item for alcohol use.

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Nutrition Services in Perinatal Care Personnel The attending physician, midwife, or nurse should be capable of providing the basic nutritional care measures identified in Chart 3-1. Contacts with a dietitian are encouraged because these health care providers are specially qualified to provide a full range of nutrition services—including the extensive assessment, individualized diet modifications, or other specialized approaches required for a number of nutrition problems. In many instances dietitians are neither members of the obstetrical practice nor on site in the care delivery setting. Thus, it is essential to have a method for identifying women who need special nutrition services and referring them to a dietitian. If referral is not possible because of transportation barriers or other obstacles, alternative methods of consulting with the dietitian should be arranged. Through in-service or continuing education programs, dietitians can assist health care team members with the basic nutritional care activities listed in Chart 3-1. This is especially important if a dietitian will not be directly involved in the care of women with gestational diabetes mellitus or lactose intolerance. Dietitians can also provide guidance concerning appropriate nutrition education materials for use in waiting rooms, prenatal classes, parenting classes, hospitals (e.g., on closed-circuit television), or other venues. The effectiveness of nutritional care may be substantially increased by an expanded health care team that provides outreach activities, home visits, and streamlined services, or that uses other strategies to increase the utilization of prenatal care by disadvantaged women. 8 Such activities involve visiting nurses, social workers, dietitians, case managers, trained community health workers, peer counselors, and others.9 The support of breastfeeding needs special attention. Because breastfeeding support has not been a standard part of the curriculum for health care providers, the provider who is best qualified in a particular setting is likely to be one who has participated in a program that provides specialized training and guided experience. (For more information about breastfeeding support, see Chapter 4.) If none of the health care providers in a particular setting is bilingual, trained interpreters should be available by special arrangement to assist with assessment, counseling, and educational activities for patients who are uncomfortable communicating in English. Often, community health workers can be trained to provide this service. With proper training, such workers may also perform a variety of outreach activities and other services for expectant and new mothers (see, e.g., Tindall 10).

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Nutrition Services in Perinatal Care CHART 3-1 Basic Nutritional Care Activities for Expectant and New Mothers Basic nutritional care activities in support of pregnancy, lactation, and women's health are listed below. They are covered in more detail in Nutrition During Pregnancy and Lactation: An Implementation Guide. 6 Physicians, physicians' assistants, midwives, nurses, nurse-practitioners, dietitians, and other primary care providers should all participate in integrating these activities into routine care. Assessment • Weigh at each visit; measure height and estimate nonpregnant body mass index at the first visit. • Monitor and interpret data such as hemoglobin level, blood pressure, and weight change. • Collect data on attitudes, current dietary practices, cooking facilities, housing, and other factors pertinent to nutritional status. • Consider the above information to identify women at risk of nutritional problems, that is, those who require more thorough assessment or intervention, or both. Health Maintenance • Provide information, education, or counseling concerning the following: – diet and fluid intake, weight, managing gastrointestinal discomforts and other common nutrition-related problems, the safe and appropriate use of vitamin-mineral supplements, and avoiding or stopping the use of harmful substances;a – adjusting dietary intake for relatively common situations such as prescribed bedrest or twin pregnancies; – breastfeeding, considering the mother and infant as a unit. • Recommend a low-dose (30 mg) iron supplement to all pregnant women beginning in the second trimester of pregnancy.11

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Nutrition Services in Perinatal Care Interventions • Conduct detailed assessments as needed to develop strategies for adjusting nutrient or energy intake or for following up on undesirable changes in weight. • Provide nutritional counseling for women with commonly occurring conditions such as lactose intolerance, gestational diabetes mellitus controlled by diet and exercise, iron-deficiency anemia, mild gastrointestinal disorders, obesity, low weight for height, and inadequate prenatal weight gain; or, if possible, refer the woman to a dietitian for this service. • Recommend nutrient supplements if indicated by the assessment. • Monitor the woman's progress, and revise the plan of care as indicated. • Refer the woman, as necessary, to community resources (see Chart 3-2 for federal food and nutrition programs). • Provide or refer the woman for special nutrition services if she has a health condition that requires complex nutritional care. Such conditions include insulin-requiring diabetes mellitus, certain gastrointestinal diseases, chronic renal failure, and phenylketonuria. For the treatment of eating disorders, the involvement of an experienced eating disorders team is advisable. Follow up on recommendations from nutrition specialists, and confer with them as needed. • Assist the woman in quitting substance use, or refer her to a special treatment program and follow up as needed. • Provide special assistance with breastfeeding if the woman wants to breastfeed and has twins, triplets, a premature infant, an infant with a congenital anomaly, or other circumstances that affect feeding or nutrient requirements; or help her obtain this assistance from a lactation specialist. a This includes alerting women to advisories regarding environmental contaminants in the food supply.

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Nutrition Services in Perinatal Care Chart 3-2 Eligibility for Federal Food and Nutrition Programs and Program Benefitsa Program Eligibility Benefits Special Supplemental Food Program for Women, Infants, and Children (WIC) 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%b of the federal poverty levelc Monthly individualized food packages that include such foods as milk, cheese, eggs, fruit juice, cereal, peanut butter or legumes, infant formula, and infant cereal     Nutrition education     Referrals Commodity Supplemental Food Program (CSFP) Pregnant women, breastfeeding women, other postpartum women, infants, and children (aged <6 years); household income must be determined to be ≤185%b of the federal poverty level Monthly canned or packaged foods including fruits, vegetables, meats, infant formula, farina, beans, other as available Food Stamp Program 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 persond ); eligibility is determined after formal application to local public assistance or social services Food vouchers, cards, or checks to purchase foods at participating food markets Temporary Emergency Food Assistance Program (TEFAP) Households with income ≤150%b of the federal poverty level Quarterly distribution: cheese, butter, rice, occasionally flour, cornmeal, and dry milk. Emergency food available once per month: dairy products, rice, flour, cornmeal Nutrition Assistance Program (NAP) for Puerto Rico 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

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Nutrition Services in Perinatal Care Program Eligibility Benefits Food Distribution Program on Indian Reservations (FDPIR) 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 Programee Households with children aged <19 years, with income ≤125% of the federal poverty level; at nutritional risk Education and training regarding food and nutrition a Adapted from Boisvert-Walsh and Kallio, with permission.9 b Some states have lower cutoff values. c 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. d Elderly are those aged ≥60 years. e This program is not available in all areas.

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Nutrition Services in Perinatal Care Knowledge Base and Clinical Skills A broad base of knowledge and skills (see below) is needed for the delivery of basic nutrition services in support of pregnancy and lactation. Encouraging all health care providers to develop this core of knowledge and skills will facilitate the delivery of consistent, effective nutrition services. The focus of such knowledge and skills should be on the early identification of complex nutritional problems, treatment and monitoring of patients, and appropriate referrals. More detail can be found in Nutrition During Pregnancy and Lactation: An Implementation Guide.6 Knowledge and Understanding The effects of pregnancy and lactation on recommended nutrient intakes. Appropriate ways to increase dietary intake of nutrients. Guidelines for nutrient supplementation. How restricting the intake of basic food groups affects nutrient intake. Recommendations for weight change during pregnancy and lactation and their rationale. Principles and techniques of healthful weight management. Benefits offered by federally funded food assistance programs for low-income women (see Chart 3-2) and by other community resources, as well as procedures for accessing those resources. The techniques of breastfeeding and methods for overcoming common obstacles to successful breastfeeding. Basic dietary adjustments for problems that often occur during and after pregnancy. Assessment Skills Accurately measure height and weight. Classify women by nonpregnant body mass index. Provide basic assessment of dietary practices. Interpret information from the patient's history (including diet), laboratory data, and physical examination, and use it to identify women at high risk for nutrition problems before, during, and after pregnancy.

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Nutrition Services in Perinatal Care Monitor and interpret weight changes during pregnancy and post partum. Health Maintenance Skills Provide basic nutrition education about pregnancy and lactation to individuals and groups. Assist women to set realistic goals and behavioral objectives targeted toward improving or maintaining their nutritional status. Effectively communicate the benefits of breastfeeding, techniques for establishing and maintaining breastfeeding, and strategies for overcoming common obstacles to successful lactation. Provide guidance concerning appropriate weight management. Educate or counsel women concerning the appropriate use of supplements. Intervention Skills Following established guidelines or protocols, provide basic individualized diet counseling for improving nutrient intake, managing common dietary problems, and addressing inadequate or excessive weight gain. Advise on the appropriate use of nutrient supplements for special circumstances. Assist the woman to arrange for adequate access to food and other needed resources. Arrange for appropriate referral to a dietitian for more thorough assessment and intervention. Work with translators, interpreters, or peer counselors as needed for effective care delivery. Management of the Organization and Delivery of Nutritional Care Provide organized in-service education to the health care team (including community outreach workers and peer counselors) concerning the rationale for and the effective delivery of basic nutrition services. Participate in evaluation of the overall quality of nutrition services and in identification of appropriate adjustments in care delivery. Develop strategies for achieving consistent educational messages and nutritional care practices by various health team members and for triggering appropriate follow-up when there is a change in providers.

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Nutrition Services in Perinatal Care DELIVERY OF SPECIAL NUTRITION SERVICES Certain medical conditions are managed to a large extent by diet modifications or other special forms of nutritional support, and frequent monitoring and revision of the care plan may be needed when the woman is pregnant or lactating. Such conditions usually require specialized nutritional care management by a registered dietitian with experience in pregnancy and lactation as well as in the health problem in question. High-risk conditions that indicate the need for specific diet therapies include the following: hyperemesis gravidarum; preexisting diabetes mellitus and gestational diabetes (if insulin is required); serious liver or renal disease; acquired immune deficiency syndrome (AIDS) or other severe unresponding infection; serious gastrointestinal disorders (such as those caused by Crohn's disease or gastric bypass surgery) that lead to inadequate intake or malabsorption; genetic disorders that affect nutrition, such as cystic fibrosis and inborn errors of metabolism; and serious eating disorders. Conditions that sometimes entail complicated management include gestational diabetes mellitus treated with diet and exercise, high risk of preterm birth, suspected fetal growth restriction, substance abuse, multifetal gestations, and hypertension. The assessment, planning, and counseling skills of the experienced dietitian may be quite helpful in the care of women with these conditions. Overview of Special Services In addition to providing the basic services listed in Chart 3-1, facilities that serve women who have complex nutritional problems should provide the services listed in Chart 3-3. Treatment of many of the disorders listed in the chart involves frequent calculation of the need for and intake of specific nutrients and development and implementation of an individualized nutritional care plan. The plan should be coordinated with the mother's total care and updated frequently.

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Nutrition Services in Perinatal Care Personnel Highly trained professionals are needed to meet the nutrition challenges posed by pregnancy or lactation complicated by serious health problems. Caring for these women requires a team approach and typically involves a physician, nurse, and dietitian, all of whom have expertise in the care of pregnant and lactating women. For special circumstances, the team will need to be expanded. For example, a physical or occupational therapist may provide necessary services to pregnant or lactating women with certain disabilities, a pharmacist is a valuable addition to a team caring for a pregnant woman who requires parenteral nutrition, and an experienced social worker or public health nurse may help the seriously stressed pregnant woman to marshall the resources she needs for satisfactory management of her condition at home. The following lists appropriate qualifications for providers of special nutrition services for expectant and new mothers. The physician is an obstetrician or a family physician with special training or experience in obstetrics. The nurse, nurse-practitioner, and midwife have training and experience in obstetrics. The dietitian meets the requirements for registration of the Council for Dietetic Registration and for licensure (where required) and has advanced clinical experience or graduate-level nutrition training that includes extensive clinical experience in prenatal and postpartum care. The pharmacist (when needed in support of alternative feeding methods) has an advanced degree in pharmacy or advanced training and supervised experience in nutritional support. Outreach workers and peer counselors (when needed to facilitate access to and utilization of care) have completed structured in-service education sessions tailored to local needs and have met the criteria for the program that they will be serving.

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Nutrition Services in Perinatal Care CHART 3-3 Special Nutritional Care Activities for Expectant and New Mothers with Complex Needsa • For women who are considering becoming pregnant, provide information on the dietary modifications recommended for the periconceptional period and on the special nutrition-related measures needed to support a healthy pregnancy. • For women who are attempting to conceive, provide assessment-based dietary counseling. • Coordinate the nutritional care of pregnant and lactating women who have complex medical or surgical problems. – Assess nutritional status. – Estimate special nutrient and energy requirements. – With the patient (when applicable), plan diet modifications as needed. – Develop and implement nutritional care plans in collaboration with others on the health care team. This may include consideration of alternative nutrient delivery methods; use of special food products, nutrient supplements, or enzymes; referral to home health services or to agencies that provide income support or assistance with food and nutrition resources; or any of a wide array of other services that enable the woman to improve her nutritional status. – Provide counseling for dietary modifications, and follow up as needed. – Instruct other team members (including home visitors, the patient, and the family or significant others, as appropriate) in the special procedures needed to achieve the recommended intakes. – Assist with special needs related to breastfeeding (see Chapters 4 and 5). – Monitor progress and adjust plans as needed. This may include adapting diet modifications or special feedings over time to respond to the changing needs of the fetus or to the changing milk intake of the breastfed infant. –Provide instructional resources for special dietary modifications, and monitor their use.

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Nutrition Services in Perinatal Care   – Collaborate with the eating disorders team as appropriate to promote nutrient intake adequate for a healthy pregnancy and for both maternal and infant needs during breastfeeding. – Establish effective means of communication to promote consistent, uninterrupted care in inpatient, outpatient, and community settings. • Provide consultation services for other providers. • Provide in-service education for health professionals, and help to plan and participate in community education programs. • Provide leadership in developing activities to monitor and improve the quality and efficiency of the nutrition services being provided. • Evaluate the results of nutrition interventions for use in program planning. a These activities and services should be available in addition to those listed in Chart 3-1. Knowledge Base and Clinical Skills The team that provides nutrition services for women with special nutritional needs must have the knowledge and skills listed earlier for providers of basic nutrition services, as well as the knowledge and skills listed below. Knowledge and Understanding Physiologic and metabolic changes associated with pregnancy and lactation and the diagnostic implications of these changes for high-risk conditions. Effects of chronic and acute disease on the course and nutrient requirements of pregnancy and lactation. Food-drug-nutrient interactions. Principles of diet modification for pregnant and lactating women who have chronic disease or other serious health problems. Principles of enteral and parenteral feeding during pregnancy and lactation.

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Nutrition Services in Perinatal Care Assessment Skills Obtain a comprehensive nutrition history. Estimate the woman's nutritional requirements, taking into consideration the effects of health problems and medications on energy balance and nutrient absorption, utilization, and excretion. Compare estimated nutrient requirements with nutrient intake from diet, alternative feeding methods, and vitamin-mineral supplements. Assess the extent to which social or financial problems must be considered in developing a workable care plan. Intervention Skills Set goals for achievable outcomes, and develop an individualized nutritional care plan to reach those goals, including diet or special feedings, specific behavioral objectives, other interventions, referrals, and monitoring methods and other forms of follow-up. Provide nutrition counseling that considers the woman's food habits, changing nutrient requirements, medical or surgical condition, and financial and other constraints and assets. Use counseling strategies suited to the woman's capabilities or those of other primary caretakers at home. Monitor the woman's nutritional status and responses to interventions, and recommend changes in the plan of care as indicated. Incorporate new knowledge into nutritional care plans and into educational programs for providers. Facilitate the family's access to and use of community services, home health, income support, and food and nutrition resources. Function effectively within the framework of a multidisciplinary care team. Management of the Organization and Delivery of Nutritional Care Facilitate continuity of nutritional care as the woman moves from the preconceptional period through the prenatal, postpartum, and interconceptional periods—coordinating activities with those of available community services and agencies as needed. Develop and implement explicit strategies for achieving consistent nutritional care by various providers. Communicate to other professionals and families the importance of nutrition and of special nutritional interventions in the promotion or improvement of health.

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Nutrition Services in Perinatal Care Organize in-service education programs for care providers to address complex nutritional problems during and after pregnancy. Plan and implement activities to evaluate the quality of nutritional care and the safety and effectiveness of the nutrition program. SUMMARY Basic nutrition services can and should be integrated into the routine health care of expectant and new mothers by physicians, midwives, nurses, and dietitians. Experts should be involved in providing prenatal and postnatal services to women with health problems that require complex diet modification or nutritional support. This ordinarily requires a coordinated effort by an experienced multidisciplinary team composed of a physician, a nurse, a dietitian, and perhaps several other specialists. REFERENCES 1. Food and Nutrition Service, U.S. Department of Agriculture. 1985. Part 246.2—Special Supplemental Food Program For Women, Infants and Children: definitions. Federal Register 50(30):6121. 2. Chapman, J., E. Siegel, and A. Cross. 1990. Home visitors and child health: analysis of selected programs. Pediatrics 85:1059–1068. 3. National Commission to Prevent Infant Mortality. 1989. Home Visiting: Opening Doors for America's Pregnant Women and Children. National Commission to Prevent Infant Mortality, Washington, D.C. 4. Olds, D.L., and H. Kitzman. 1990. Can home visitation improve the health of women and children at environmental risk? Pediatrics 86:108–116. 5. General Accounting Office. 1990. Home Visiting: A Promising Early Intervention Strategy for At-Risk Families. GAO Publ. No. HRD-90-83. General Accounting Office, Washington, D.C. 6. Institute of Medicine. 1992. Nutrition During Pregnancy and Lactation: An Implementation Guide. Report of the Subcommittee for a Clinical Applications Guide, Committee on Nutritional Status During Pregnancy and Lactation. Food and Nutrition Board. National Academy Press, Washington, D.C. 7. Peoples-Sheps, M.D., W.D. Kalsbeek, E. Siegel, C. Dewees, M. Rogers, and R. Schwartz. 1991. Prenatal records: a national survey of content. Am. J. Obstet. Gynecol. 164:514–521. 8. Macro Systems, Inc. 1990. One-Stop Shopping for Perinatal Services: Identification and Assessment of Implementation Methodologies. National Center for Education in Maternal and Child Health, Washington, D.C. 9. Hill, I.T., and J. Breyel. 1989. Coordinating Prenatal Care. National Governors' Association, Washington, D.C. 10. Tindall, J.A. 1989. Peer Counseling: In-Depth Look At Training Peer Helpers, 3rd ed. Accelerated Development Inc., Muncie, Ind.

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Nutrition Services in Perinatal Care 11. Institute of Medicine. 1990. Nutrition During Pregnancy: Weight Gain and Nutrient Supplements. Report of the Subcommittee on Nutritional Status and Weight Gain During Pregnancy and the Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 12 Boisvert-Walsh, C., and J. Kallio. 1990. Reaching out to those at highest risk. Pp. 63–84 in M. Kaufman, ed. Nutrition in Public Health. Aspen Publishers, Rockville, Md.