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Anemia in Women in the MN WIC Program - acog anemia in pregnancy treatment

Anemia in Women in the MN WIC Program IntroductionGood morning! We’re excited for the opportunity to share some information about Anemia in pregnant and postpartum women in the MN WIC program. I’m Rebecca Gruenes, MN WIC Nutrition & Clinic Services Unit Supervisor and presenting along with me today is Joni Geppert, Nutrition Epidemiologist, Maggie Donohue, State WIC Consultant and Sandy Sather, State WIC Consultant. If you have questions at anytime during the webinar, please use the chat feature at the bottom of your screen and we will address questions at the end of the presentation.ObjectivesWe’ll be focusing on Anemia in Women in MN WIC, national and state WIC data, discussing Nutrition Assessment and WIC’s role, and approaches to Anemia using Participant Centered Services. We are grateful for all the individuals that contribute to the WIC Program in Minnesota including WIC participants and families, our local agency WIC staff, and our state WIC staff that work together to provide quality Nutrition Services and program information across MN.Why Does Iron Deficiency Anemia in Women Matter?Why does iron deficiency anemia in pregnant and postpartum women matter?Iron deficiency anemia during and after pregnancy can cause health problems for both mother and infant that can persist into the future. In addition, iron deficiency anemia in pregnant women can be long lasting and persist through subsequent pregnancies.Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW. Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. BMJ [Internet]. 2013; 346]:f3443 doi: 10.1136/bmj.f3443 [PMC free article] [PubMed].Pregnant WomenAnemia during pregnancy can cause fatigue, which makes following a healthy lifestyle more difficult during pregnancy. Anemia can also make it harder to fight infections. Iron supplementation during pregnancy may decreases risk for maternal mortality, although the mechanism for this is not known, possibly due to decreased risk of infection. Maternal Anemia and Birth OutcomesMaternal anemia effects birth outcomesIron deficiency anemia, especially early during pregnancy, is associated with higher rates of prematurity and subsequent low birth weight. Increased risk may be as high as 28% for preterm birth and 25% for low birth weight. Supplementation with iron during pregnancy reduces the risk of low birth rate by 19%. Iron deficiency anemia during the third trimester can affect iron stores in the newborn that may persist through the first year of life. Iron deficiency anemia in young children can affect development with potential lifelong consequences. Iron deficiency anemia may increase the risk of stillbirthPostpartum AnemiaIron deficiency anemia after pregnancy is associated with postpartum depression, especially early in the postpartum period, decreased milk supply, and predisposition for anemia in subsequent pregnanciesDiagnosis of Anemia During Pregnancy and PostpartumAnemia is diagnosed using low hemoglobin, hematocrit, mean cellular volume or MCV, or ferritin. Iron deficiency anemia accounts for 75 to 95% of anemia during pregnancy.Ferritin is the preferred method during pregnancy as it measures immediate iron status as compared to hemoglobin which measures iron status over the last 28 days. Ideally ferritin measurement should start in the first trimester at prenatal visits with the women’s health care provider and should be assessed ever trimester.Archives Of Gynecology And Obstetrics [Arch Gynecol Obstet] 2017 Dec; Vol. 296 (6), pp. 1229-1234. Date of Electronic Publication: 2017 Sep 22.Rigmby, FB et al. Anemia and Thrombocytopenia in Pregnancy. Medscape 2016Low Hemoglobin by Trimester & Postpartum for non smokersThe hemoglobin cutpoints for anemia vary by trimester. The cutpoints for smokers and those living at higher altitudes are somewhat higher than these.Importance of Nutrition AssessmentIt is easy for us to focus on hemoglobin when counseling pregnant and postpartum women. However, even more important than hemoglobin screening is the dietary assessment done in the WIC clinic.By the time anemia is diagnosed, anemia has been present at the cellular level for some time, whereas an assessment of current intake can identify the risk for iron deficiency much earlier. WIC is the expert at assessing adequate intake of iron and making suggestions on how to improve nutrition. Not all anemia is due to iron deficiency, but adequate iron intake is important for all women. Pre-Pregnancy Risk Factors for Iron Deficiency AnemiaThe risk factors for iron deficiency anemia prior to pregnancy include:Higher pre-pregnancy BMIHistory of anemiaHeavy pre-pregnancy menstrual flowShort inter-pregnancy interval making it difficult to have adequate maternal iron storesPoor dietLead exposure. Lead competes for absorption with iron.Food insecurityRisk Factors for Iron Deficiency Anemia during PregnancyRisk factors for iron deficiency anemia during pregnancy include:Poor intake, Vomiting frequentlyPicaInadequate multivitamin/mineral supplementIron, Folate, B12, Vitamin A, Copper deficienciesFood insecurityBeing a teen due to increased iron needs for the mothers own growthMultiple births (twins, triplets, etc.)Infections (HIV, malaria, schistosomiasis, h pylori)Risk Factors for Postpartum AnemiaRisk factors for postpartum anemia include:Anemia during the third trimesterBlood loss during delivery, which although it is not caused by nutrient intake, it can be helped by a healthy diet.Inadequate multivitamin/mineral supplementWeight status either overweight or underweightAnd Food insecurity. Food insecurity is a potent risk for anemia in families. We frequently find that families are relying on a few lower cost and less nutrition rich foods for both parents and children. Parents will skip meals to make sure that children have access to food. WIC not only provides food, but can help families connect to community resources. Symptoms of AnemiaSymptoms of anemia include:FatigueHeadacheRestless legs syndrome, making sleep difficultCold intoleranceReduced resistance to infectionGlossy tongueAngular stomatitis or sores in the corner of the mouth. Supplementation During PregnancyThe American College of Obstetrics and Gynecology recommends 27 mg of iron during pregnancy, the RDA is 18 mg for non pregnant women. They recommend 600 mcg of Folic acid during pregnancy and 400 mcg prior to pregnancy to prevent neural tube defects. Anemia Among Pregnant Women 1990 to 2016Anemia among pregnant women has been increasing both Nationwide for all pregnant women and for pregnant women seen in MN WIC. The rate for MN WIC appears to be increasing more rapidly than the national rate. World Health Organization, Global Health Observatory Data Repository/World Health Statistics ( HYPERLINK "http://apps.who.int/gho/data/node.main.1?lang=en" apps.who.int/gho/data/node.main.1?lang=en ).Data in the WIC programWhen you are looking for information on Anemia in the MN WIC program, go to the reports and data section on our website and click on center for the Health Indicators Summary. In this area, there are links to the most recent anemia tables and maps, as well as printable reports by county, CHB and city. For local agency and grantee anemia information, go to the documents section on infoview, and open up the folders section. Anemia is under the nutrition ed plan folder and also the growth and anemia folder.Anemia in MN WICAnemia during pregnancy and postpartum has not improved over the past ten years. This means that WIC is needed now more than ever to identify, prevent and ameliorate anemia. Anemia During Pregnancy in MN WICPregnancy anemia or anemia at any time during pregnancy varies by race/ethnicity & appears to be rising. Similar patterns of anemia are found in pregnancy to that of childhood with higher rates in African American, American Indian and Asian groups. Postpartum Anemia in MN WICPostpartum anemia also varies by race/ethnicity with Asian women have the highest rates followed by American Indian and Black/African-American women.Anemia by Black Cultural Identity, MN WIC 2015 to 2017 (RF 201)When counseling participants with anemia, it is important to be mindful of cultural food practices and preferences. When we look at our Minnesota data by Black cultural identity, individuals identifying as multigenerational Black African American, Kenyan or Kenyan American, and Sudanese or Sudanese American have higher rates of anemia during and after pregnancy. These data were collected form 2015 to 2017 by participating WIC agencies. This report is by risk code and can be run in infoview by agency.Anemia by Asian Cultural Identity MN WIC 2015 to 2017 (RF 201)Similarly Asian groups also vary in Anemia rates by cultural identity, with higher rates found in the KaREN/Karenni- KaREN/Karenni American and Laotian-Laotian American groups for pregnant women and for Hmong-Hmong American women during the postpartum period. ConclusionIn conclusion:Anemia during pregnancy and postpartum has potentially serious complications for both mother and infant.Anemia varies by location, race/ethnicity and cultural identity with significant health disparities found in non White groups.WIC plays an important role in assessing diet quality, encouraging adequate vitamin-mineral supplementation, providing nutrition education and preventing and ameliorating anemia. The Nutrition assessment and nutrition education provided by WIC are key to reducing disparities in anemia. Nutrition AssessmentOur next topic is Nutrition Assessment. What does “Nutrition Assessment” mean in the WIC context?A WIC Nutrition assessment is defined as:The process of obtaining and synthesizing relevant and accurate information in order to assess a WIC participant’s nutrition status and risk, This process enables WIC CPAs to design appropriate nutrition education and counseling that address the needs and interests of the WIC participant.Also, the assessment helps the CPA to make appropriate referrals and when possible to tailor the food packageThis process of obtaining relevant and accurate information must be done using participant centered skills Nutrition Assessment – ContextPart of the nutrition assessment is the specific context of the participant. Today we are talking about women participants – WIC women participants are either currently or were recently pregnant.Therefore pregnancy is the context of the nutrition assessment that we will be discussing today. Not only will the objective information about the woman (such as her height, weight, and hemoglobin) need to be considered but also information about her health and experiences related to the pregnancy. For example, what has she been eating? How has her weight changed? Is she taking a prenatal vitamin? Does it contain iron? What other factors are influencing these things? Has she had significant nausea and vomiting? Is she extremely fatigued? Is she happy and excited about the pregnancy? All of these things need to be part of the nutrition assessment. Anemia is IncreasingOur charge here today is to talk about anemia among women enrolled in the MN WIC program. As Joni described, anemia among women enrolled in WIC has been increasing over the past several years and is a significant problem for many women enrolled in WIC.Joni also described some of the possible consequences of anemia.So you can see that addressing anemia is an important and valuable thing for WIC CPAs to do. WIC is in a position to help individual women avoid or reduce anemia and thus help them have a healthier pregnancy.Why Does Anemia DevelopSo, why do pregnant women develop anemia?Pregnancy is a time of tremendous growth and as we discussed with children, rapid growth is a risk factor for anemia.Additionally, during pregnancy there is an expansion of blood volume and this adds to the need for dietary iron because iron is one of the fundamental building blocks of hemoglobin – which of course is one of the main components of blood.Additional iron is needed to build tissues for the baby and for the mother and this adds up to a significant need for additional iron.So much so, all pregnant women are expected to need supplemental iron, it is not expected that they will be able to consume adequate dietary iron and this is why all pregnant women are encouraged to take a prenatal vitamin/mineral supplement that contains iron.However, diet remains very important in iron nutrition. Because of the way the human body manages iron, we cannot simply give an iron pill and assume our work is done. Iron Balance – It’s ComplicatedAt this point we need to take a step back to talk about how the body handles iron. Iron is handled differently than other nutrients. This is because the body doesn’t have a way to eliminate iron if too much iron is present in the body. The control of iron balance is through absorption. The body will increase absorption when more iron is needed – for example during pregnancy and growth. At the same time, the human body will decrease the amount of iron that is absorbed as the amount of iron consumed increases. I am saying that, as increasing amounts of iron are consumed, a smaller percentage of the iron will be absorbed.So you can see that some of the approaches that we take with pregnant women – that is, increasing the amount of iron available (through encouraging iron rich foods and through giving supplemental iron) these approaches have diminishing returns. As you give more iron, a smaller percentage is absorbed.And as you know some women experience side effects from iron supplements, and generally, as larger doses are given the side effects increase.Iron Supplement Side EffectsOf course we have all heard about or experienced the negative effects of taking iron.The most commonly cited problems include nausea, vomiting and constipation.And when you think about pregnancy, you know many women experience nausea, vomiting and constipation even without iron supplementation. Many pregnant women are very reluctant to do anything that might increase these pregnancy problems, and as I said earlier, larger doses are more likely to cause more severe symptomsSo we can understand why women don’t always do as we recommend, but there are approaches that may help reduce the side effects. A little later Rebecca is going to talk about the new nutrition education cards.One of the cards specifically addresses prenatal vitamins and provides some tips for taking a prenatal vitamin even if you don’t feel well.Heme and Non-Heme IronThis is all complicated enough,Pregnant women need more iron but as we give them larger doses, they experience more side effects and a smaller percentage of the iron is absorbed.AND… as you know from your basic human nutrition, there are two types of iron.Heme and Non-Heme ironThe iron in some foods is more easily absorbed compared to the iron in other foods or the iron in supplements.Heme iron is the iron found in blood and muscle tissues and this iron is more easily absorbed compared to the iron found in other foods which is known as non-heme ironNon-heme iron is found in meat, in plant foods and supplements. Non-heme iron is less well absorbedHeme iron is more readily absorbed, non-heme iron is less well absorbedNutrition Assessment in PracticeNow let’s put some of this nutrition assessment into practice….On a population basis, which group is more likely to be anemic?Vegetarians or people who eat both plants and animals?Vegetarians are more likely to be anemic because they do not eat meat which itself is a source of iron and the iron in meat (Heme iron) is more absorbable compared to non-heme iron.If you have a participant who tells you she is vegetarian or a participant who reports that she eats little meat, you will need to keep this in mind as you do the assessment – she may be more likely to be anemicInhibitors of Iron AbsorptionGoing back to human nutrition and thinking about iron nutrition, the picture is further complicated by the fact that some foods enhance the absorption of iron while others inhibit iron absorption.Foods that inhibit absorption include:- Phytates found in cereals and grains especially bran and seeds- Polyphenols also inhibit absorption and these are found MAINLY in tea- Calcium which as you know is found in milk and milk products andAnimal Protein – Animal protein is a little complicated because it’s presence can increase the absorption of non-heme iron, except for the protein in milk and eggs which can decrease absorption of iron)So going back to our assessment of a vegetarian diet. The diet will have less iron, it won’t have the most absorbable iron and it won’t have the enhancing effect of meat protein.Information GatheringDoing nutrition assessment well means that you will recognize that the participant may be consuming some foods that will work against her iron statusYou won’t tell her to avoid all grains and to not drink milk… but you need to think about these things as you discover her usual eating pattern and her favorite foodsYou will keep this information in the back of your mindIron Absorption EnhancersAs some foods and nutrients inhibit iron absorption, there are foods that improve iron absorption What are some iron absorption enhancers? everyone knows this one…Ascorbic Acid or vitamin C Ascorbic Acid can be very powerful and important in improving iron absorption because it can counteract the effects of the iron inhibitors and it can improve absorption of the non-heme iron that is found in plantsMuscle tissue (or meat as most of us think of it) is also very important in getting adequate iron. Meat provides heme and non-heme iron and the protein found in meat enhances the absorption of non-heme ironMany Things Influence Iron StatusAll these different factors may influence a woman’s ability to have enough iron in order to avoid anemia and thus should be considered when doing a diet assessment.WIC CPAs will need to assess how much iron is being consumed, what form iron is being consumed (Heme, non-heme) and what inhibitors or enhancers might be present.Nutrition AssessmentBut don’t let all this talk about heme and non-heme or enhancers or inhibitors become overwhelming, the nutrition education workgroup has created a great card that takes this information and puts it into simple steps. This is the “EATING MORE: IRON” card The card explains the concepts on the front and then on the back, it describes commonly consumed food combinations that will improve the iron availability. The card provides practical straightforward information that will be useful to participants.Factors Affecting ConsumptionSo far, as we have discussed nutrition assessment, we have mainly focused on the sources of iron and what factors may enhance or inhibit absorptionBut possibly more important … what other factors may be influencing a woman’s intake of iron? There are many factors that might make it difficult to consume adequate iron These include:NauseaVomitingHeartburnFatigueLimited money Lifestyle factors (forgetting to take) Beliefs and customs (vegan or vegetarian diet, religious limits on specific foods or ingredients – gelatin, concerns that supplements may cause baby to be large)Often these factors work together to reduce the participant’s ability to consume adequate ironFactors Affecting ConsumptionWe will consider these factors a few at a time:Begin with nausea, vomiting and heartburn, any of these conditions may make the idea of taking a giant vitamin, eating meat or drinking orange juice seem distastefulJust the idea may make the nausea, vomiting and heartburn worse.Among the new Pregnancy cards are two cards that specifically address heartburn and upset stomach and another that addresses nausea and vomitingIf Nausea vomiting and heartburn are a problem, you will keep this in mind as you begin to think about nutrition education.Factors Affecting ConsumptionLikewise or at different times during the pregnancy other factors may be more important. For example:Pregnant women are often tired and may be forgetful because of the fatigue and may simply forget to take the vitamin (or even to eat at all). And making dinner might seem like a monumental task when she would prefer to just go to bedAnd aside from pregnancy fatigue, often our participants and any parent with young children, may have so much going on that they may simply forget what seems super important to us. Things like taking a vitamin may not be as high a priority as getting out of the house in the morning so everyone gets to where they need to be so she doesn’t lose her job or fail to make it to her WIC appointment which could jeopardizing her WIC benefitsThis leads us to limited resources, which may also play a role…Money can be a factor that gets in the way of taking a prenatal vitamin or eating a diet rich in meat – we may need to find out if resources are preventing her from purchasing her prenatal vitamins, or if she shies away from meat because it can be more expensive.Often these factors work together to make getting enough iron difficult.Another new nutrition education card, is the PRENATAL VITAMINS card. This card does a really nice job addressing many of the aspects that get in the way of taking a prenatal vitamin.Factors Affecting ConsumptionReligious beliefs and customs may prevent some women from taking vitamins and or may limit some specific foods – for example, some women feel they cannot take a prenatal vitamin because they need to avoid gelatin and they believe that all prenatal vitamins contain gelatin. Customs that may limit iron intake could be following a strict vegan diet or even a less restrictive vegetarian diet.Again, the information gathered must be kept in mind as you consider her nutrition status and begin to think about the nutrition education and referrals that might be helpful.Tying it TogetherIn summaryNutrition assessment related to iron is complicated because there are many different factors that need to be considered. But you have the knowledge, skills and training needed to do a good nutrition assessment so that you can now provide nutrition education and referrals that will help the participant have a healthy successful pregnancy.I will now turn the discussion over to Sandy who will talk about nutrition educationParticipant Centered ServicesNow we will transition to how to use PCS counseling skills for anemia interventions. To provide appropriate counseling, we must start with a good assessment. Maggie shared the importance of nutrition assessment for a woman with low hemoglobin. With the nutrition assessment, you identify health conditions, dietary concerns or behavioral practices which maybe contributing to a woman’s low hemoglobin. The May webinar Anemia in Infants and Children Participating in the MN WIC Program included an overview of the Participant Centered Services approach to counseling. Here is a quick summary of the PCS approach to counseling. PCS emphases collaboration with the participant to:Uncover the participant’s own motivations for adopting healthy behaviors. Help the participant feel confident in their abilities and in their role as parents.Promote participant autonomy, what they change is up to themActively involve the participant in goal setting and problem solving; and,Share information and strategies to help participants achieve their goals.PCS SkillsToday we will once again demonstrate the PCS skill Explore, Offer, Explore with emphasis on 2 additional techniques: Probing or Probing questions and Goal SettingExplore Offer ExploreWe discussed Explore, Offer, Explore in depth on the May webinar. This is a quick refresher on how to use the technique. Start with the first Explore: Explore the participant’s knowledge base about the topic. Start with questions about what the participant already knows about the topic or has already tried. What have you heard about anemia? What are some things you have tried to improve your iron level? Next is the offer. You offer information. Always ask permission before offering. Do you mind if I share what other women find helpful when they have nausea? Would it be ok if we look at current recommendations for prenatal vitamins? And thirdly, another explore. You explore what the participant thinks about the information offered. What thoughts do you have about the information? Based on these ideas, what could you see yourself doing? ProbingOur Role Play today will also focus on Probing. Probing provides a deeper understanding of an issue or topic. Participants often don’t share all the information up front. To make sure you have a clear understanding of what was said, you will sometimes need to follow up with additional questions to get more information from the participant. Follow-up questions or reflective statements help you obtain a thorough assessment. Low hemoglobin is a High Risk condition for WIC. A thorough assessment helps the CPA to provide the best, individualized services to a woman with low hemoglobin. Times to ProbeThink about times when you need to probe for more information from a participant. Examples might include:When someone gives you a short answer. You ask a participant how she is doing with eating fruits and vegetables. She responds “not well”. What does that mean? Does she eat any fruits and vegetables at all? Does she eat some fruits but no vegetables? You might probe more when there is emotion. A pregnant woman tells you “I am really worried about my weight gain”. You wonder, does she feel she is gaining too much weight, or not enough weight? Does she have good understanding of appropriate weight gain during pregnancy?Probe when you don’t think you have the whole story. A pregnant woman says “Prenatal vitamins really bother me”. You might explore how the prenatal vitamins bother her. Does it cause nausea? Constipation? Something else?Probe when there is a potential nutrition risk. “I have nausea and vomiting with this pregnancy so I don’t feel like eating” You wonder, how severe is the nausea? How often is she experiencing nausea and vomiting? Is she able to keep any food and beverage down? In these situations, it is important to probe for more information. Assure you have a clear understanding of the participant’s perceptions or concerns before launching into offering information. How to ProbeThere are different ways to probe for more information. You may use open-ended questions to probe for additional information. Open-ended questions encourage deeper conversation and allow the staff member to gather more information from the participant. You mentioned that the prenatal vitamin is making you nauseous. What things have you already tried to help with the nausea? 2. Use “tell me more”. Ask the participant to tell you more about what she just said. Tell me more about the prenatal vitamins bothering you.3. Reflect on a participant’s statement. Restate what the participant said so she knows that you’ve heard her and to encourage her to say more. For example, you might reflect “You are concerned about your weight gain.” or “Your nausea and vomiting is making it hard to eat”. The participant will usually open up and tell you more. These are some examples for probing. What are some ways that you probe for additional information? Scenario – LindseyHere is the scenario for the Role Play. Lindsey has a pregnancy certification appointment today. This what we learned during the Nutrition Assessment. Lindsey is 24 years old and 14 weeks gestation. She is gravida 2, parity 1. Her son is 2 years old. Her BMI is in Normal range, weight gain within normal limits. Hgb is 10.1. Her first Prenatal visit with the health care provider is scheduled for 2 days from today. She bought a gummy prenatal vitamin and is taking it a few times a week. Lindsey reports that she was very nauseous through most of her previous pregnancy and really worried that will occur again with this pregnancy. She eats breakfast and lunch with her son. Lindsey usually doesn’t eat much in the morning due to nausea. She works at a convenience store from 4pm to 12 midnight so usually grabs something quick there for supper, like a slice of pizza, nachos or a hot dog. She was relying on pop and energy drinks to get her through her shift, but quit those beverages once she realized she was pregnant.Nutrition Assessment ResultsThe Nutrition Assessment revealed a number of topics that we could discuss:Nausea is impacting her eating, she is not eating much in the morning.She is eating convenience foods with lower nutritional quality for supper.Her hemoglobin is low and she is not taking a prenatal vitamin with iron.And there is something positive – she stopped drinking pop and energy drinks!Let’s focus on prenatal vitamins for the Role PlayRole PlayHere is the Role Play using Explore Offer Explore. Listen for the Probes!CPA: What have you heard about prenatal vitamins?Lindsey: Yeah, I need to get better at taking a vitamin every day. With my last pregnancy, the prenatal vitamin my doctor prescribed made me feel awful.CPA: The prenatal vitamin bothered you. Could you tell me more about that?Lindsey: I took the vitamin with breakfast and I would vomit it right back up. I couldn’t keep anything down the rest of the morning. I was kind of nauseous the rest of the day. CPA: That does sound awful! You took the vitamin in the morning with food. What other ways did you try the prenatal vitamin?Lindsey: My mom said crackers help with nausea so I ate crackers when I took the vitamin. Didn’t help. I gave up on the prenatal vitamin. I bought a gummy vitamin and that worked so much better. I have been so nauseous with this pregnancy that I just take a gummy vitamin occasionally. CPA: Tell me a little more about the nausea with this pregnancy.Lindsey: I am really sick in the morning. It is hard to get out of bed. I have been eating a small breakfast, like just ? piece of toast. Doesn’t usually stay down. By about 10 am, I feel somewhat better so I eat a piece of fruit. I can eat lunch and supper ok. I have been trying to eat healthier snacks at work instead of chips.CPA: Your nausea is worse in the morning and gets better by afternoon. I am glad to hear you are trying to eat in the morning, even small amounts of food can help with nausea. I would like to explore some ways that you could take the prenatal vitamin. Would it be ok if I shared some information about prenatal vitamins with you? Lindsey: okCPA: During pregnancy, it is hard to get enough of some vitamins and minerals from food alone. Prenatal vitamins help provide those nutrients. Your hemoglobin was low today, meaning you may not be getting enough iron. That can be common in pregnancy. Your body is making lots of blood to support your pregnancy. Plus you are building a baby which takes iron too! Prenatal vitamins help provide the extra iron needed to make blood. I have a card with prenatal vitamin information, could I share it with you? Lindsey: Sure. I am taking my gummy a few times a week. Should I take that every day? CPA: The gummy vitamin is a good source of some vitamins. Iron is not included in gummies because it would make the gummy taste awful. Plus, iron would be toxic if a child got into the gummy vitamins and ate them like candy. Here is a card with information about prenatal vitamins. This card shows that a prenatal vitamin should have 27 mg of iron. Lindsey: I am just not sure about taking a prenatal vitamin, they made me so nauseous with my last pregnancy. CPA: You did have a rough time with nausea during your last pregnancy. This card has some things you could try to help take the prenatal vitamin when you are dealing with nausea. Let’s look at the ideas listed here in this section. You could try taking the prenatal vitamin at a different time of day.Taking the vitamin with food can help prevent nauseaYou could try cutting the pill in half and take half in the morning and the other half later in the day.Some women find it helpful to chew gum or suck on hard candy after taking the prenatal vitaminDo you think you could try any of these ideas? Lindsey: Probably the first one. I could try taking it another time of day.CPA: What time of day might work best for you?Lindsey: Probably at suppertime, if I can remember it then. CPA: sounds like a great idea! Nausea often is better in the evening. Plus, taking it with food can be helpful. What might help you to remember the Prenatal vitamin at supper? Lindsey: I can set a reminder on my phone to take it during my supper break at work.CPA: Good idea! Lindsey: I only have the gummies vitamins right now. I don’t have any regular prenatal vitamins.CPA: Ask your doctor for a prescription for prenatal vitamins. Your Medical Assistance will cover the prenatal vitamin. This card shows the three important nutrients that should be in your prenatal vitamin - Iron, Folic Acid and Iodine. What are your thoughts about this information on prenatal vitamins?Lindsey: I am really surprised that my gummy does not have iron. I can’t afford to pay for the prenatal vitamins, I’ll have to ask my doctor for the prescription. CPA: Prenatal vitamins are a good way to get the extra iron you need during pregnancy. Sounds like you are thinking about trying a regular prenatal. Would you like to set a goal for prenatal vitamin use? Lindsey: I’ll try taking a prenatal vitamin at suppertime every night. CPA: That is a great plan for keeping you and your baby healthy! I like your idea to set a reminder on your phone. Let me summarize what we talked about today. You will ask your doctor for a prescription for a prenatal vitamin with iron. Once you have the vitamin you will take the vitamin at supper every night. Do I have that right?Lindsey: YesCPA: Your son has a WIC appointment on September 27th. I’ll check in with you then to see how the prenatal vitamin is working for you. Review the Role PlayA few things to note from this role play:You may go through the Explore, Offer, Explore cycle more than once depending on the participant’s interest and motivation. For example: I could have had explored the issue of nausea more. Or we could have talked about healthier choices for supper and snacks.I didn’t bombard Lindsey with lots of suggestions. I ended the discussion by summarizing the information to help Lindsey remember the key points.Review the Role PlayLet’s review the probes in the Role Play. Did you hear the following probes? The prenatal vitamin bothered you. Could you tell me more about that?What other ways did you try the prenatal vitamin?Tell me a little more about the nausea with this pregnancy.The Probes helped provide a deeper understanding of the mom’s nausea and difficulty with taking the prenatal vitamin. In this Role Play, a Goal was set “to try taking the prenatal vitamin at suppertime everynight”Goal SettingWhy set goals? People who set goals for themselves are more likely to achieve behavior change than those who do not set goals. Goals provide a target to aim for and help establish priorities. People who achieve goals feel pride which motivates them to achieve even more. I want to point out Two key points about goal settingFirst, it needs to be the participant’s goal! Participants are more likely to take action when it is their idea and when they come up with the goals and action steps themselves. If a participant is not interested in making any behavior changes, requiring them to have a goal or setting a goal for the participant is fruitless. They will not remember the goal or work towards it. In fact, trying to force a change when the participant is not ready may build resistance to change. In those cases, the best approach maybe to reinforce a positive behavior they are currently doing. Secondly, Goals should be clear and specific. We go into more detail about that later. Change TalkHow can you help a participant set a goal that is meaningful for them? Listen for Change Talk. How do you identify Change Talk? Listen carefully for a participant’s own reasons for making a change. It signals that a person is thinking about an attitude or a behavior change. Listen to talk about desires, ability, reasons, fears and needs. Participants might say: “I wish” “I want to” “I need to” “I could” “It is important”. Those key phases indicate that the participant is considering change.Remember Lindsey saying, “I need to get better at taking a vitamin every day.” Might that be Change Talk? Yep!Listen for Change TalkThat was a very brief overview of Change Talk! Let’s put it into practice Here are some Examples of Change TalkI am trying to eat healthier snacks instead of chipsI love pop, I wish I could cut down!I need to be better with waterHere are some ideas of how to move from Change Talk to Goal TalkWhat are your plans for eating healthier snacks?What changes would you like to make in terms of your eating? You mentioned you might be drinking too much pop so should that be something you can work on?Sounds like you are thinking about trying to drink more water.Questions to Evoke Goal SettingWith some participants, there may be no apparent Change Talk. How do you help guide the participant towards a goal? Here are some potential questions that may spark a goal for a participant. Are there any foods you currently are not eating that you would like to try?Anything new that you are working on for yourself?What changes would you like to make in terms of your eating or activity?Although the best ideas come from the participant, they may need advice and suggestions from you. It is ok to offer ideas and suggestions if needed. Sharing ideas and resources based on the participants needs and interests may help them take action. You can offer a menu of possible options. Remember back to the role-play, I offered Lindsey a menu of ways to try taking a prenatal vitamin. After offering possible options, follow-up with questions to help participants identify what may work best for them. You might ask:What do you think about these ideas?Would any of these ideas work for you?What would work best for you?These questions help guide the participant to setting a goal relevant to their needs and motivations. Refining GoalsNow your participant has an idea for a goal. Here are some tips for refining the goal:Keep it simple and specific. A specific goal provides the participant with a clear picture of what the outcome should be and so they know when they have achieved the goal. In our role play, Lindsey was eating convenience foods at her place of employment for supper. If Lindsey had said “I want to eat healthier at suppertime”, we could have probed to find out what “eating healthier” means to her. Ask, What are your plans for eating healthier at supper time? After discussing Lindsey’s thoughts about eating healthier, she may be able to come up with a specific goal such as “I will bring my supper to work 3 times a week”Think small. Small changes can lead to big changes. Don’t try to change too many things at one time. For our example, Lindsey is going to focus on eating healthier suppers 3 times a week. More than 3 times a week might be overwhelming for her. Goals should be measurable. A measurable goal helps the participant assess progress and see the change as it occurs. The goal “bring supper to work 3 times a week” is measurable. Lindsey can measure her progress towards meeting the goal.An attainable goal has an outcome that the participant can achieve. Can Lindsey bring her supper to work 3 times a week? If not, then this would not be an attainable goal. If “3 times a week” is not realistic, maybe Lindsey should start with bringing supper once a week. Or maybe she would like to start with a goal to work on eating healthier snacks. We want the participant to be successful and meet their goal. It helps the participant feel successful and strive for additional goals.Support Goal SettingLet the participant know you support them. Even if you don’t think the goal the participant set should be their top priority, it is their goal. Be encouraging and supportive! Remember, even small goals are important. If a participant meets their goal to decrease from 3 cans of pop a day to 2 cans of pop a day, they will feel successful and strive for greater goals. Reflect on the goal and how they can be successful. You might say “You are determined to cut back on pop. Limiting pop to 2 times a day is doable for you!” Let the participant know you will check back on how the goal is working for her. For example, you might say:“I’ll check in with you on your goal when you come into WIC in September.”Follow-up with the participant at their next visit. Check in on how the goal is working for them.Refine the goal if they are struggling with it. Maybe Lindsey found it was not possible to take her supper to work 3 times a week. You could explore healthier supper options available at the convenience store. If they have been successful with the goal in any way, affirm that. Use their successes as a springboard to additional goals or behavior changes. Wow, you did a great job of decreasing your pop intake from 3 cans to 2 cans! What are your thoughts about additional changes? Goal Setting is OptionalRemember, goal setting is not effective if the participant is not interested. Goal setting is just one tool in our PCS Toolbox. If you sense a participant is not ready to make any behavior changes, affirm the positive aspects of her nutrition and health and move on. Let’s imagine Lindsey, from our role play, was not ready to make any changes. We could affirm the change that she stopped drinking energy drinks and pop. Or acknowledge that she is trying to eat frequently which will help with her nausea. Maybe when we see her next time, she will be feeling better and ready to make some changes.ResourcesThere are a number of resources available to assist you with serving women with anemia.We have PCS tools on the MN WIC websiteThere are also Nutrition Education Plan resources on our websiteNew Nutrition Education Cards are rolling out this summerPCS ResourcesThere are a number of resources available for WIC staff to learn more about Participant Centered Services. On the MDH WIC website, select Information for Local Agencies. The icon for Participant Centered Services is located in the lower right hand side of the icons. PCS ResourcesHere is the PCS page. I would like to point out the PCS Skills and Resources link, second from left on the bottom. The Minnesota WIC PCS Webinars from 2016 are found on this page. Check out the Goal Setting webinar from March 2016 for a much more in-depth look at the topic. Also available on the PCS Skills and Resources link is the Step by Step Program: Client-Centered Skills for WIC Counselors by Molly Kellogg. The program includes a module called Listening for Change Talk. Listening for Change Talk is an important skill that takes practice. This module is very helpful. If you need the password to access the Step by Step program, contact your state consultant. PCS ResourcesNext let’s find the Nutrition Education Plan resources. On the MDH WIC website, select Information for Local Agencies. The icon for Nutrition is located in the center of the top row of the icons. On the Nutrition page, select the link to the Nutrition Education Plan Resources.Nutrition Education Plan ResourcesHere is the Nutrition Education Plan Resources page. All the reports, tools and other resources from the 2018-2019 Nutrition Education Plan are found here. A recording of this webinar will be posted on this page when it is ready. The May webinar Anemia in Infants and Children participating in the Minnesota WIC Program is already posted here. Nutrition Education CardsAll of the Nutrition Education Cards are being updated. Cards are announced in the Wednesday Update as they become available. There are a number of cards that will be helpful as you counsel women with anemia. Lets look at 4 of them. The first card shown is Eating well during pregnancy – this card discusses basic nutrition needs during pregnancy. The second card is Prenatal Vitamins – This card includes space on the bottom of the second side to place a label. We are encouraging you, as a local agency to investigate which brands of prenatal vitamins are readily available in your area that meet the requirements for iron, folic acid and iodine. Those brands can be printed on a label and adhered to the card. Some participants need gelatin free vitamins. You might include brand names of gelatin free vitamins on the label also. Nausea and Vomiting during pregnancy is the third card shown – We know that nausea and vomiting can impact a woman’s nutrition status. The card suggests strategies for managing nausea and vomiting. And the last card we will talk about is Eating more iron – This card provides an overview of increasing dietary sources of iron. All of these cards are now available to order from BrushArt. See the July 25th Wednesday Update for details. Steele County Public HealthNow we are excited to share some strategies from local agencies for Anemia Prevention in WIC participants. The first activity is from Steele County Public Health. Lisa Waypa, Steele County WIC Coordinator shares the following information: Steele County Public Health received a grant from Blue Cross Blue Shield to pay for prenatal vitamins. Staff time for the activity is paid with the MCH grant. The vitamins are offered as a public health service, not just for WIC even though it is used in WIC. They are offered to women of childbearing years who are not taking a vitamin and say they can’t afford them. We do encourage them to get a prescription from their doctor so they can get them on their own with insurance coverage. Our charting in HuBERT indicates that we referred the participant to the program. ?Women pick the vitamins up from a pharmacy across the street from the WIC office in Owatonna. If you have questions about their project, contact Lisa.Thanks for sharing this innovative approach to providing prenatal vitamins in Steele County!Olmstead County WICThe next activity is from Wendy O’Leary, Olmsted County WIC Coordinator. Wendy has been presenting information about WIC and Anemia to key groups in Olmsted County. Here is what Wendy shared:Annually, the Olmsted County WIC Coordinator is invited to present an overview of the WIC program and its emerging issues to our Public Health Services Advisory Board.? In April, I took advantage of this opportunity and focused on two areas of concern:? decreasing WIC caseload and our increasing anemia rates.?? Additionally, I emphasized the impact these concerns have on our community’s health outcomes.? This information, along with personal client stories, made an impression on this group.? Especially interested were a county commissioner and our public health medical consultant.? They requested and encouraged that I get before other groups to share this information and have opened doors to do so.? Since that presentation, I have met with representatives from United Way, Cradle to Career, and Community Health Services, which is a local medical clinic.? At each presentation I was well-received and awareness about WIC and its emerging concerns was greatly increased by these community health professionals and advocates.? These experiences show that collaboration with community partners has the potential to impact important health outcomes for WIC participants and the community at large, and to encourage new systems for WIC referrals and sharing of information.Thanks Wendy for your efforts to share about WIC and our nutrition goals!MDH WIC is developing a Fact Sheet about Anemia in MN WIC. The Fact Sheet can be used to initiate conversations with medical providers and others in your community. Questions??Continuing EducationOne Continuing Education Credit has been approved by the Commission of Dietetic Registration for this live webinar and the recorded webinar. A Certificate of Completion will be emailed to everyone registered for the webinar. The recording will be announced in the Wednesday Update when it posted to the MDH WIC website. EndThank you Thank you for joining us for this webinar. We’ve included our contact information on this last slide. Please reach out to anyone of us for follow up on questions or for more information.

How to prevent anaemia in pregnancy? Encourage breast feeding of infants. Encourage exclusive breast feeding of infants (without supplementary liquid, formula, or food) for 4-6 months after birth. When exclusive breast feeding is stopped, encourage use of an additional source of iron (approximately 1 mg/kg per day of iron), preferably from supplementary foods. More items...