By Randee Masicola, DNP, APRN-CNP, WHNP-BC and member of the NPWH Board of Directors
Are you giving evidence-based information to your patients who are planning a pregnancy or who could become pregnant about diet that includes supplements to consider and foods to avoid?
What are the most critical things to tell them when your time with patients is limited? What are some resources you can give them as they walk out the door?
It is particularly important to discuss food safety with all women who could become pregnant as many women do not seek care prenatal care until they are well into their first trimester.
Overall Diet: How to Eat Healthy
It is crucial that women who could become pregnant are educated on the safety of their food choices and the required nutrients needed to improve chances of a healthy pregnancy outcome. Education starts with explaining the basics of daily fruit and vegetables and limiting high fat choices. Include background on the five food groups, healthy portion sizes, as well as any insight gathered form a 24-hour diet recall. Discuss replacing fast food with healthy convenient options to help patients make better choices within their own lifestyle.
Resource: Choicemyplate.gov, the federally funded campaign, is a great place to start
Fish – What to Eat and What to Avoid
It is important to talk with women about the benefits and risks of fish in their diet. Fish is an excellent source of low fat protein and can be help in the growth and development of the fetus. It contains Omega-3 fatty acids which have proven to be essential for healthy fetal brain development. But women need to be counseled on the safe levels of methyl mercury in fish and warned about potential risks during pregnancy. A variety of birth defects have been linked to high levels of mercury in a pregnant woman’s diet.
- Mercury can be found in many bottom-dwelling fish including king maceral, shark, and orange roughy.
- Canned tuna fish has a very low mercury content and is safe but is recommend no more than 2-3 times a week. Albacore tuna has a higher mercury content.
- Raw fish like sushi, as well as all raw and undercooked meats, should not be ingested due to the risk of parasites or bacteria.
A fabulous resource on Education of safe fish options and quantities, as well as up-to-date information for providers and patients is available on the FDA website (https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm393070.htm).
Dairy: What to Avoid
Share with your patients the value of calcium in milk and cheese, but recommend they avoid unpasteurized milk and soft cheeses including Brie, Feta, Camembert, Roquefort, and even Queso due to the risk of E coli, Listeria, and/or Salmonella contamination.
Vitamins and Minerals: When Supplements Are Needed
All women who could become pregnant need to take a multivitamin with at least 400mcg of folic acid. The United States Preventative Service Task Force (USPSTF) reaffirmed its 2009 recommendation in 2017 that all women who are planning or capable of pregnancy should be recommended to take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid and received its highest recommendation (USPSTF, 2017).
Folic acid supplementation should be started at least one month prior to conception. It can significantly reduce the risks of neural tube defects, like spina bifida and anencephaly (USPSTF, 2017).
Women with a history of having a child with a neural tube defect are encouraged to take 4-5mg of folic acid daily prior to conceiving which has shown to decrease risk of defects in following pregnancies (Toriello, 2011).
The recommended daily iron allowance for reproductive age women is 27mg of iron a day (ACOG, 2015). Most women will get this in their daily diet without supplementation. However, the growing blood supply of the placenta and fetus and the increased oxygenation needs of mother and the fetus result in a woman’s need for 50% more iron while pregnant. (ACOG, 2015). The fetus uses the mothers iron stores for growth and development, commonly leaving the mother depleted.
Women already at risk or who have been identified as anemic should be counseled on appropriate iron supplementation and foods high in iron to include in their daily diet.
Red meats, spinach and raisins are common foods high in iron which is better absorbed when consumed with vitamin C rich foods like citrus fruits and tomato sauce.
Let your patients know that most women can increase calcium in their diet without supplementation. Supplementation of calcium is only recommended to achieve a daily uptake of 1000 mg/day in pregnant women, and if supplements are required, patients should be instructed to only take 500mg at a time at breakfast and again at dinner to increase absorption.
Calcium is an essential element for embryo growth. It is responsible for building strong bones and teeth for the fetus
Maintaining appropriate consumption can decrease risk of preeclampsia, preterm birth and low birth weight (Hofmeyr, 2010). The best source of calcium is through diet and can usually be achieved with dairy products and other foods rich in calcium; for example, calcium-fortified orange juice and cereals, sardines, green beans and sunflower seeds.
Liquids: How to Stay Hydrated
Hydration is essential for general health, however, women who could become pregnant should be advised about what beverages to avoid.
- 6-8 glasses of water should be recommended a day.
- Caffeine and artificial sweeteners, unfortunately, have limited evidence, so many national organizations give a blanket statement to limit or drink these beverages in moderation, recommending only 1-2 cups a day.
- Alcohol should be completely avoided as it is a known teratogen.
- Soda, due to the high sugar calorie count, should also be discussed and alternatives provided.
Preconception education goes beyond counseling women who are planning a pregnancy to include all women who could become pregnant. Evidence-based information about nutritional needs is an important component of this education that can occur at any office visit. This information is critical to improve health prior to pregnancy and to promote healthy pregnancies and pregnancy outcomes.
WHNPs can utilize available evidence-based web sites and written resources to streamline the information provided within the limited time we have with each patient.
American College of Obstetricians and Gynecologists. The importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion No. 313, September 2005. Obstet Gynecol. 2005;106:665–6. (Reaffirmed 2017)
Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L. (2010). Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD001059.
Toriello, H. V. (2011). Policy and Practice Guideline Committee of the American College of Medical Genetics. Policy statement on folic acid and neural tube defects. Genet Med. 2011;13(6):593-596.
United States Preventative Services Task Force (2017). Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189