Routine use of feeding practices that may result in impaired nutrient status, disease, or health problems. These practices, with examples, are outlined below. Refer to Justifications and References for this criterion.

Participant Category and Priority Level

Category	Priority
Pregnant Woman	4
Breastfeeding Woman	4
NonBreastfeeding Woman	6

Inappropriate Nutrition Practices for Women	Examples of Inappropriate Nutrition Practices (including but not limited to)
427A Consuming dietary supplements with potentially harmful consequences	Examples of dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences: Single or multiple vitamins; Mineral supplements; and Herbal or botanicalsupplements/remedies/teas
427B Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery.	Strict vegan diet; Low-carbohydrate, high-protein diet; Macrobiotic diet; and Any other diet restricting calories and/or essential nutrients.
427C Compulsively ingesting non-food items (pica).	Non-food items: Ashes; Baking soda; Burnt matches; Carpet fibers; Chalk; Cigarettes; Clay; Dust; Large quantities of ice and/or freezerfrost; Paint chips; Soil; and Starch (laundry and cornstarch).
427D Inadequate vitamin/mineral supplementation recognized as essential by national public health policy.	Consumption of less than 27 mg of iron as a supplement daily by pregnant woman. Consumption of less than 150 μg ofsupplemental iodine per day by pregnant and breastfeeding women. Consumption of less than 400 mcg of folic acidfrom fortified foods and/or supplements daily by non-pregnant woman.
427E Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms.	Potentially harmful foods: Raw fish or shellfish, including oysters, clams, mussels, and scallops; Refrigerated smoked seafood, unless it is an ingredient in a cooked dish, such as a casserole; Raw or undercooked meat or poultry; Hot dogs, luncheon meats (cold cuts), fermentedand dry sausage and other deli-style meat or poultry products unless reheated until steaming hot; Refrigerated pâté or meatspreads; Unpasteurized milk or foods containing unpasteurized milk; Soft cheeses such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as made with pasteurized milk; Raw or undercooked eggs or foods containing rawor lightly cooked eggs including certain salad dressings, cookie and cake batters, sauces, and beverages such as unpasteurized eggnog; Raw sprouts (alfalfa, clover, and radish); or Unpasteurized fruit or vegetable juices.

Justification for 427A

427A Consuming dietary supplements with potentially harmful consequences.

Women taking inappropriate or excessive amounts of dietary supplements, such as single or multivitamins or minerals, or botanical (including herbal) remedies or teas, are at risk for adverse effects such as harmful nutrient interactions, toxicity and teratogenicity (1, 2). Pregnant and lactating women are at higher risk secondary to the potential transference of harmful substances to their infant.

Most nutrient toxicities occur through excessive supplementation of particular nutrients, such as, vitamins A, B-6 and niacin, iron and selenium (3). Large doses of vitamin A may be teratogenic (4). Because of this risk, the Institute of Medicine recommends avoiding preformed vitamin A supplementation during the first trimester of pregnancy (4). Besides nutrient toxicities, nutrient-nutrient and drug-nutrient interactions may adversely affect health.

Many herbal and botanical remedies have cultural implications and are related to beliefs about pregnancy and breastfeeding. The incidence of herbal use in pregnancy ranges from 7-55 % with echinacea and ginger being the most common (1). Some botanical (including herbal) teas may be safe; however, others have undesirable effects during pregnancy and breastfeeding. Herbal supplements such as, blue cohash and pennyroyal stimulate uterine contractions, which may increase the risk of miscarriage or premature labor (1, 5). The March of Dimes and the American Academy of Pediatrics recommend cautious use of tea mixtures because of the lack of safety testing in pregnant women (6).

Justification for 427B

427B Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery.

Women consuming highly restrictive diets are at risk for primary nutrient deficiencies, especially during critical developmental periods such as pregnancy. Pregnant women who restrict their diets may increase the risk of birth defects, suboptimal fetal development and chronic health problems in their children. Examples of nutrients associated with negative health outcomes are:

Low iron intake and maternal anemia and increased risk of preterm birth or low birth weight (7, 8).

Low maternal vitamin D status and depressed infant vitamin D status (9).

Low folic acid and NTD (10, 11, 12).

Low calorie intake during pregnancy may lead to inadequate prenatal weight gain, which is associated with infant intrauterine growth restriction (IUGR) (13) and birth defects (10, 11, 14). The pregnant adolescent who restricts her diet is of particular concern since her additional growth needs compete with the developing fetus and the physiological changes of pregnancy (14).

Strict vegan diets may be highly restrictive and result in nutrient deficiencies. Nutrients of potential concern that may require supplementation are:

Riboflavin (15, 16)

Iron (15)

Zinc (15, 17)

Vitamin B12 (15, 16, 18)

Vitamin D (15, 16, 18)

Calcium (15, 16, 18, 19,)

Selenium (16)

The pregnant adolescent who consumes a vegan diet is at even greater risk due to her higher nutritional needs (16, 18). The breastfeeding woman who chooses a vegan or macrobiotic diet increases her risk and her baby’s risk for vitamin B12 deficiency (18). Severe vitamin B12 deficiency resulting in neurological damage has been reported in infants of vegetarian mothers (18).

With the epidemic of obesity, treatment by gastric bypass surgery has increased more than 600% in the last ten years and has created nutritional deficiencies not typically seen in obstetric or pediatric medical practices (20). Gastrointestinal surgery promotes weight loss by restricting food intake and, in some operations, interrupting the digestive process. Operations that only reduce stomach size are known as “restrictive operations” because they restrict the amount of food the stomach can hold. Examples of restrictive operations are adjustable gastric banding and vertical banded gastroplasty. These types of operations do not interfere with the normal digestive process (21).

Some operations combine stomach restriction with a partial bypass of the small intestine; these are known as malabsorptive operations. Examples of malabsorptive operations are Roux-en-y gastric bypass (RGB) and Biliopancreatic diversion (BPD). Malabsorptive operations carry a greater risk for nutritional deficiencies because the procedure causes food to bypass the duodenum and jejunum, where most of the iron and calcium are absorbed. Menstruating women may develop anemia because not enough iron and vitamin B12 are absorbed. Decreased absorption of calcium may also contribute to osteoporosis and metabolic bone disease (21). A breastfeeding woman who has had gastric bypass surgery is at risk of vitamin B12 deficiency for herself and her infant (22).

Justification for 427C

427C Compulsively ingesting non-food items (pica).

Pica, the compulsive ingestion of non-food substances over a sustained period of time, is linked to lead poisoning and exposure to other toxicants, anemia, excess calories or displacement of nutrients, gastric and small bowel obstruction, as well as, parasitic infection (23). It may also contribute to nutrient deficiencies by either inhibiting absorption or displacing nutrient dense foods in the diet.

Poor pregnancy outcomes associated with pica-induced lead poisoning, include lower maternal hemoglobin level at delivery (24) and a smaller head circumference in the infant (25). Maternal transfer of lead via breastfeeding has been documented in infants and can result in a neuro-developmental insult depending on the blood lead level and the compounded exposure for the infant during pregnancy and breastfeeding (26, 27, 28).

Justification for 427D

427D Inadequate vitamin/mineral supplementation recognized as essential by national public health policy.

The Recommended Dietary Allowance (RDA) for pregnant women is 27mg of iron per day (29). The Centers for Disease Control and Prevention recommends iron supplementation for all pregnant women to prevent iron deficiency (30); however, pregnant women should seek guidance from a qualified health care provider before taking dietary supplements (31).

During pregnancy and lactation the iodine requirement is sharply elevated. The RDA for iodine during pregnancy is 220 μg and 290 μg during lactation (29). Severe iodine deficiency during pregnancy can cause cretinism and adversely affect cognitive development in children (32). Even mild iodine deficiency may have adverse affects on the cognitive function of children (33). Since the 1970s, according to the 2001- 2002 National Health and Nutrition Examination Surveys (NHANES), there has been a decrease of approximately 50% in adult urinary iodine values. For women of child bearing age, the median urinary iodine value decreased from 294 to 128 μg per liter (34). The American Thyroid Association recommends that women receive prenatal vitamins containing 150 μg of iodine daily during pregnancy and lactation (35). The iodine content of prenatal vitamins in the Unites States is not mandated, thus not all prenatal vitamins contain iodine (36). Pregnant and breastfeeding women should be advised to review the iodine content of their vitamins and discuss the adequacy of the iodine with their health care provider. Non-pregnant women of childbearing age who do not consume adequate amounts of folic acid are at greater risk for functional folate deficiency, which has been proven to cause neural tube defects (NTDs), such as spina bifida and anencephaly (37-40).

Folic acid consumed from fortified foods and/or a vitamin supplement in addition to folate found naturally in food reduces this risk (12). The terms “folic acid” and “folate” are used interchangeably, yet they have different meanings. Folic acid is the synthetic form used in vitamin supplements and fortified foods (12, 38, 39). Folate occurs naturally and is found in foods, such as dark green leafy vegetables, strawberries, and orange juice (12).

Studies show that consuming 400 mcg of folic acid daily interconceptionally can prevent 50 percent of neural tube defects (12). Because NTDs develop early in pregnancy (between the 17th and 30th day) and many pregnancies are not planned, it is important to have adequate intakes before pregnancy and throughout the childbearing years (14). NTDs often occur before women know they are pregnant. It is recommended that all women capable of becoming pregnant consume a multivitamin containing 400 mcg of folic acid daily (39-41). It is important that breastfeeding and non-breastfeeding women participating in the WIC Program know about folic acid and foods that contain folate to encourage preconceptional preventive practices (38).

Justification for 427E

427E Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms.

Food-borne illness is a serious public health problem (42). The causes include pathogenic microorganisms (bacteria, viruses, and parasites) and their toxins and chemical contamination. The symptoms are usually gastrointestinal in nature (vomiting, diarrhea, and abdominal pain), but neurological and “non-specific” symptoms may occur as well. Over the last 20 years, certain foods have been linked to outbreaks of foodborne illness. These foods include: milk (Campylobacter); shellfish (Norwalk-like viruses); unpasteurized apple cider (Escherichia coli O 157:H7); eggs (Salmonella); fish (ciguatera poisoning); raspberries (Cyclospora); strawberries (Hepatitis A virus); and ready-to-eat meats (Listeria monocytogenes).

Listeria monocytogenes can cause an illness called listeriosis. Listeriosis during pregnancy can result in premature delivery, miscarriage, fetal death, and severe illness or death of a newborn from the infection (43). Listeriosis can be transmitted to the fetus through the placenta even if the mother is not showing signs of illness.

Pregnant women are especially at risk for food-borne illness. For this reason, government agencies such as the Centers for Disease Control and Prevention, the USDA Food Safety and Inspection Service, and the Food and Drug Administration advise pregnant women and other high risk individuals not to eat foods as identified in the definition for this criterion (42, 43).

The CDC encourages health care professionals to provide anticipatory guidance, including the “four simple steps to food safety” of the Fight BAC campaign, to help reduce the incidence of food-borne illnesses.

References

1. Tiran D. The use of herbs by pregnant and childbearing women: a risk-benefit assessment. Complementary Therapies in Nursing and Midwifery. November 2003. 9(4):176-181.

2. Position of the American Dietetic Association: Nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2002 October; 102(10):1479-1490.

3. Position of the American Dietetic Association: Food fortification and dietary supplements. J Am Diet Assoc. January 2001.

4. Langkamp-Henken B, Lukowski MJ, Turner RE, Voyles LM. High levels of retinol intake during the first trimester of pregnancy result from use of over-the-counter vitamin/mineral supplements. J Am Diet Assoc. September 2000.

5. March of Dimes (homepage on the Internet). New York: Herbal Supplements: their safety, a concern for health care providers. [cited May 26, 2004] Available from: http://www.marchofdimes.com.

6. American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook. 5th Ed. Kleinman, Ronald, editor. Washington DC: American Academy of Pediatrics; 2004.

7. Recommendations to prevent and control iron deficiency in the United States. MMWR [serial on the Internet]. 1998 April [cited 2004 March 12]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm.

8. Rasmussen, K. M. Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth, length of gestation and perinatal mortality? American Society for Nutritional Sciences. 2001; 590S-603S.

9. Scanlon KS, editor. Vitamin D expert panel meeting; October 11-12, 2001; Atlanta, Georgia. Available from: http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/Vitamin D Expert Panel Meeting.pdf.

10. Carmichael SL, Shaw GM, Schaffer DM, Selvin S. Diet quality and risk of neural tube defects. Medical Hypotheses. 2003; 60(3):351-355.

11. Shaw GM, Todoroff K, Carmichael SL, Schaffer DM, Selvin S. Lowered weight gain during pregnancy and risk of neural tube defects among offspring. Int. J. Epidemiology 2001; 30:60-65.

12. American Academy of Pediatrics, Committee on Genetics. Folic acid for the prevention of neural tube defects. Pediatrics.1999; 104(2):325-327.

13. Strauss RS, Dietz WH. Low maternal weight gain in the second and third trimester increases the risk for intrauterine growth retardation. American Society for Nutritional Sciences. 1999; 988-993.

14. Scholl TO, Hediger ML, Ances IG. Maternal growth during pregnancy and decreased infant birth weight. Am. J. Clin. Nutr. 1990; 51:790-793.

15. Position of the American Dietetic Association and Dietitians of Canada: Vegetarian diets. J Am Diet Assoc. 2003; 103(6):748-765.

16. Larsson CL, Johansson GK. Dietary intake and nutritional status of young vegans and omnivores in Sweden. Am. J. Clin. Nutr. 2002; 76:100-106.

17. Bakan R, Birmingham CL, Aeberhardt L, Goldner EM. Dietary zinc intake of vegetarian and nonvegetarian patients with anorexia nervosa. International Journal of Eating Disorders. 1993; 13(2):229-233.

18. Specker, Bonny L., Nutritional concerns of lactating women consuming vegetarian diets. Am. J. Clin. Nutr. 1994:59(suppl):1182-1186.

19. Heaney RP, Dowell MS, Rafferty K, Bierman J. Bioavailability of the calcium in fortified soy imitation milk, with some observation on method. Am. J. Clin. Nutr. 2000; 71:1166-1169.

20. Steinbrook, R. Surgery for severe obesity. New Engl. J. Med. 2004; 350(11):1075-9.

21. National Institute of Diabetes and Digestive and Kidney Diseases. Gastrointestinal surgery for severe obesity. [cited August 18, 2004] Available from: http://www.niddk.nih.gov/health/nutrit/pubs/gastric/gastricsurgery.htm.

22. Grange DK, Finlay JL. Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass. Pediatr. Hematol Oncol. 1994; 11(3):311-8.

23. Corbett RW, Ryan C, Weinrich SP. Pica in pregnancy: does it affect pregnancy outcomes? American Journal of Maternal and Child Nursing. 2003; 28(3):183-189.

4. Rainville AJ. Pica practices of pregnant women are associated with lower maternal hemoglobin level at delivery. J Am Diet Assoc. 1998; 98(3): 293-6.

25. Institute of Medicine. WIC nutrition risk criteria: a scientific assessment. 1996; 270-272. 26. Gulson, Brian L., et al., Relationships of lead in breast milk to lead in blood, urine, and diet of infant and mother. Environmental Health Perspectives. 1998:106(10): 667-674.

27. Ping-Jian L, Ye-Zhou S, Qian-Ying W, Li-Ya G, Yi-Land W. Transfer of lead via placenta and breast milk in human. Biomedical and Environmental Sciences. 2000; 13:85-89.

28. Canfield, RL, Henderson, C, Cory-Slecha, D, Cox, C, Jusko, T, Lanphear, B. Intellectual impairment in children with blood lead concentrations below 10 mcg per deciliter. New Engl. J. Med. 2003; 348(16):1517-1526.

29. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, Boron, chromium, cooper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium and zinc. Food and Nutrition Board. Washington, DC: National Academy Press; 2001.

30. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998:47: RR-3.

31. U.S. National Library of Medicine and National Institutes of Health. Drugs and supplements: iron. Medline Plus. http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-iron.html#Safety. Accessed May 2009.

32. Zimmerman MB. Iodine deficiency in pregnancy and effects of maternal iodine supplementation on the offspring: a review. Am. J. Clin. Nutr. 2009:8(suppl): 668S-72S.

33. de Escobar DM, Obregόn MJ, del Rey FF. Maternal thyroid hormones early in pregnancy and fetal brain development. Best Pract. Res. Clin. Endoriconl. Metab. 2004; 18:225-48.

34. Caldwell KL, Miller GA, Wang RY, Jain RB, Jones, RL. Iodine status of the U.S. population, National Health and Nutrition Examination Survey 2003-2004. Thyroid 2008; 18:1207-14.

35. Becker DV, Braverman LE, Delange F, et al. Iodine supplementation for pregnancy and lactation – United States and Canada: recommendations of the American Thyroid Association. Thyroid 2006; 16:949-51.

36. Leung AM, Pearce EN, Braverman, LE. Iodine content of prenatal vitamins in the United States. New Engl. J. Med. 2009; 360:9.

37. Centers for Disease Control and Prevention, Division of Birth Defects and Developmental Disabilities. Folic acid and the prevention of spina bifida and anencephaly: 10 years after the U.S. Public Health Service recommendation. MMWR 2002; 51: (RR-13)1-3.

38. Centers for Disease Control and Prevention. National Center for Environmental Health, Division of Birth Defects and Developmental Disabilities. Preventing neural tube birth defects: a prevention model and resource guide. Atlanta: CDC, 1998.

39. Centers for Disease Control and Prevention. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992; 41: RR-14.

40. Evans MI, Llurba E, Landsberger EJ, O’Brien JE, Harrison HH. Impact of folic acid fortification the United States: markedly diminish high maternal serum alpha-fetoprotein values. Am. Col. Obstetr. Gynecol. 2004; 103(3):447.

41. Chacko MR, Anding R, Kozinetz CA, Grover JL. Neural tube defects: knowledge and preconceptional prevention practices in minority young women. Pediatrics. 2003; 112(3):536-542.

42. Centers for Disease Control and Prevention. Diagnosis and management of foodborne illness: a primer for physicians. MMWR 2001; 50: RR-2.

43. Food Safety and Inspection Service, USDA. Listeriosis and pregnancy: what is your risk? [cited August 11, 2004] Available from: http://www.fsis.usda.gov.

Websites for Additional Information

427A References - Supplements/Herbs

http://www.marchofdimes.com
http://www.dietary-supplements.info.nih.gov/
http://www.vm.cfsan.fda.gov/
http://www.herbalgram.org

427B References - Highly Restrictive Eating/Nutrient Malabsorption

http://www.eatright.org
http://www.nimh.nih.gov
http://www.llu.edu/llu/vegetarian/
http://www.nal.usda.gov/fnic/pubs/bibs/gen/vegetarian.htm
http://www.gastric-bypass-treatment.com/long-term-weight-loss-surgery-compications.aspx

427C References - Non-Food Ingestion

http://www.nieh.nih.gov/
http://www.epa.gov/ 427.4 References - Folic Acid
http://www.cdc.gov/
http://www.aap.org/
http://www.iom.edu/

427E References - Listeriosis

http://www.cdc.gov/foodsafety
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/listeriosis_g.htm
http://www.cfsan.fda.gov
http://www.foodsafety.gov
http://www.fightbac.org
http://www.ific.org