Achieving and maintaining a healthy nutritional status during the preconceptual period is essential for increased fertility and achieving a favorable pregnancy. Factors such as maintaining a healthy bodyweight and consuming adequate amounts of folate and omega-3 fatty acids improve outcomes, while exposure to alcohol, caffeine, and environmental toxins can negatively impact health (King, 2016). Unfortunately, many women don’t realize the importance of adopting healthy behaviors before conception and this can be quite dangerous due to the fact that a mother may not know exactly when she gets pregnant (Williams, Zapata, D’Angelo, Harrison, Morrow, 2011).
The average American diet consists mainly of energy-dense foods rich in sugar, starch, and saturated fats, while being deficient in fruits, vegetables, whole grains, and lean meats. This unhealthy way of eating, leads to overweight, obesity, and multiple nutritional deficiencies. An increasing prevalence of obesity has become one of the most important global health threats. Obesity is highly prevalent amongst women of childbearing age (Guelinckx, Devlieger, Beckers, Vansant, 2008). Almost two thirds of childbearing age women in the United States are currently overweight or obese (Kulie, 2011).
In addition to the increased risk of cardiovascular disease, kidney disease, cancer, and diabetes, women who are obese are more likely to develop pregnancy related complications such as hypertensive disorders, gestational diabetes, and C-section deliveries (Hillemeire et al., 2011). Pre-pregnancy obesity has been identified as an independent risk factor for neonatal and maternal morbidity and mortality (Guelinckx, 2008). According to the 2009 Institute of Medicine recommendations, women should enter pregnancy with a normal body mass index (BMI) between 18.5–24.9 kg/m2 (Guendelman, 2013).
All women of reproductive age are advised to consume a balanced, healthy diet consisting of fruits, vegetables, whole grains, nuts, seeds, and legumes. To promote optimal fetal and maternal health, two key nutrients folate and omega-3 fatty acids are recommended during the preconception phase.
Folate & Folic Acid
Folate is a water soluble B vitamin that is naturally found foods such as fruits, dark green leafy vegetables, legumes, nuts, dairy products, grains, and meat. Foods such as spinach, Brussels sprouts, asparagus, and yeast contain some of the highest levels of folate (Office of Dietary Supplements, 2016). Folic acid is the synthetic form of folate that is fortified in foods and is available as a dietary supplement. Low levels of folate can result in the accumulation of homocysteine and the inability for the body to repair DNA (Martiniak, Heuer, & Hoffman, 2015).
Neural tube defects (NTD) are diseases related to folic acid deficiencies and affects over 2,500 infants born in the United States every year. NDT are birth defects of the spine, brain, or spinal cord. The two most common NTD are anencephaly and spina bifida. These defects happen within the first month of pregnancy, usually before the mother even knows she’s pregnant. Treating NTD costs about 85 million dollars in healthcare annually. It is recommended that all women who could potentially become pregnant consume at least 400 mcg of folic acid per day from food sources and dietary supplements (Position health pregnancy). There is strong evidence that suggests that folic acid supplementation of 400 mcg per day can reduce NTD by up to 70% (Bixenstine, Cheng, Cheng, Conner, & Mistry, 2015). Despite folic acid recommendations, very few women take folic acid daily before pregnancy. According to Bixenstine et al., the most common reasons that women don’t take folic acid before pregnancy are that they didn’t think they needed it or they were not planning on becoming pregnant (Bixenstine et al., 2015).
Omega-3 fatty acids
Another nutrient that is widely recommended during the preconception period is omega-3 fatty acids. Omega-3 fatty acids are lipids that are not created in the body and must be ingested through the diet or by supplementation. They are required for physiological functions such as energy storage, cell proliferation, regulation of inflammation, and cell membrane development. Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are the most biologically active forms of omega-3 fatty acids. DHA is mainly found in marine plants and cold water fatty fish, but can also be supplemented in over the counter vitamins (Parker-Little & Klein, 2009). DHA in particular is the critical component to cell membranes in the retina and brain, where it is involved in neurotransmitter metabolic (Coletta, Bell, & Roman, 2010). The rapid brain and retinal membrane development of a fetus is reliant on the mother’s supply of DHA where it is transfer via the placenta. It is recommended that women in the preconception period as well as in pregnancy consume 100-300 mg of DHA per day (Parker-Little & Klein, 2009).
In addition to consuming a healthy diet with proper supplementation, women of child bearing age should avoid the overconsumption of alcohol, caffeine, and environmental contaminates due to the potential detrimental effects they may pose on health.
In the United States, prenatal alcohol consumption is one the leading causes of neurodevelopmental issues in children. Alcohol should not be consumed by women who are planning to become pregnant. Women who drink alcohol before pregnancy are at an increased risk of continuing alcohol consumption after pregnancy. Prenatal alcohol abuse is associated with increased risks of birth defects, spontaneous abortions, and prenatal and postnatal growth retardation (Lossi, Imam, Dean, & Bhutta, 2014).
According to the American College of Obstetricians and Gynecologists, women who are planning to become pregnant should not consume more than 200 mg of caffeine a day (Procter & Campbell, 2014). This is equivalent to drinking 12 oz. of coffee. There has been mixed results concerning excessive daily intake of caffeine before pregnancy and increased risk of spontaneous abortion. The mechanisms and association in which high caffeine intake affects maternal outcomes is not fully understood (Lossi, Imam, Dean, & Bhutta, 2014).
It’s estimated that about 3% of fetal developmental defects are attributed to exposure to chemical contaminates. Substances such as pesticides, heavy metals, organic solvents, and polychlorinated biphenyl (PCB) are common culprits. These chemicals are commonly found in food products and can lead to low infant birth weight, preterm birth, still births, spontaneous abortions, childhood cancer, and mental delays (Lossi, Imam, Dean, & Bhutta, 2014).
Mercury is a potent neurotoxin and exposure can lead to fetal neurological disorders. Mercury is a metal released in the atmosphere by coal generated power plants and by waste incineration. Mercury is often run-off in waterways where it accumulates in the flesh of fish. As large fish eat smaller fish, mercury concentrations magnify up the food chain. Large predatory fish such as tuna, sharks, swordfish, tilefish, and marlin all contain high levels of mercury and should be avoided by women of childbearing age (Sathyanarayana, Focareta, Dailey, & Buchanan, 2012).
Lead is another toxic metal that can pose major problems in women in the preconception phase. According to Sathyanarayana et al., 1% of women of child bearing age have a serum lead level greater than 5 mcg/dL. This can cause result in fetal lead exposure and impaired fetal growth. Serum lead levels greater than 10 mcg/dL are associated with the increased risk of gestational hypertension, premature delivery, and low birth weight. Lead exposure can be reduced by never eating non-food items such as soil, clay, and paint chips and avoiding jobs that may involve lead exposure (Sathyanarayana, Focareta, Dailey, & Buchanan, 2012).
Over a billion pounds of pesticides are used annually in the United States to kill bugs, weeds, mold, and rodents. Exposures to pesticides by preconceptual women are usually by the consumption of contaminated foods. Ingestion of pesticides such as PCB is associated with decreased fertility, obesity, and fetal neurological defects. Strategies to avoid pesticide consumption are to rinse fresh fruits and vegetables thoroughly and reduce the consumption of processed and canned foods (Sathyanarayana, Focareta, Dailey, & Buchanan, 2012).
Approximately 30% of women of child bearing age in the United States smoke cigarettes (Collins & Rossi, 2015). Women who smoke tobacco should be informed to stop completely prior to pregnancy. Smoking is associated with numerous complications such as placenta previa, low birth rate, cleft lip, and spontaneous abortion (Preconception Care, 2015).
Preconception counseling during routine healthcare visits for women of childbearing age is important to optimize maternal and infant outcomes in the event of a pregnancy. Unfortunately, many women of child bearing age don’t seek preconception care or may not have access to it. Currently 50% of all pregnancies in the United States are unplanned. This makes it important not only education women that are planning to become pregnant, but to also target all women of child bearing age to identify potential fetal and maternal risk that can negatively affect pregnancy. Despite most healthcare professionals such as gynecologist and obstetricians recommending preconception care to women planning a pregnancy, some of the barriers include the lack of time during office visits, third party reimbursement, and consumer awareness (Williams, 2011). Other sociology barriers include being unmarried, low income, lower education level, and no health insurance. Women that experience any one of these barriers have a 50% reduction in the odds of receiving preconception counseling. The efforts that can be taken to improve the rates of preconception counseling for these women include enhancing services offered at community health centers, providing health fairs, and training and educating healthcare providers on how to incorporate preconception health components into routine health visits (Williams, 2011).
Suboptimal preconception nutrition and risky lifestyle behaviors can pose many health risks to women during the preconception phase. During routine medical visits for women of child bearing age, healthcare providers should screen for risk factors that can impact future pregnancies and provide interventions to help optimize health. Childbearing goals should be individualized and should aim to achieve a healthy body weight, proper eating habits and supplementation, and avoiding harmful substances and lifestyle behaviors.
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