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A Pregnant Women Who Underconsumes Iodine During Pregnancy Is Likely to Have a Baby Who Suffers From

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Nutrient requirements increase during pregnancy and lactation, especially for certain micronutrients such every bit folate, iron, iodine, and copper. ane To prevent possible nutrient inadequacies, clinicians and dietitians routinely recommend or prescribe prenatal supplements. The U.S. Preventive Services Task Force recommends that women who are planning or capable of pregnancy have 400–800 micrograms/twenty-four hours of folic acrid, 2 and several health organizations recognize the importance of dietary supplements to come across requirements of specific nutrients. 3,4 Appropriately, the prevalence of dietary supplement employ among pregnant women is substantially higher than that among the full general population. five–vii Yet, a contempo written report on total usual food intakes (from both foods and supplements) amid U.South. meaning women that used data from the National Health and Nutrition Test Survey (NHANES) 2001–2014 concluded that a meaning proportion (more than 10%) of pregnant women are not consuming enough of some nutrients (eg, vitamins A, B6, C, D, and E, folate, calcium, iron, magnesium, and zinc), even though 70% reported the apply of dietary supplements. 8 Although virtually no pregnant women had intakes above the Tolerable Upper Intake Level from food sources alone, dietary supplement utilize increased the proportion of those with intakes higher up the Tolerable Upper Intake Level (ie, potentially at risk of adverse effects owing to excessive intakes) of some nutrients, especially atomic number 26 and folic acid. eight

Thus, the use of dietary supplements should exist carefully planned to compensate for underconsumed nutrients, every bit well as to avoid exceeding the Tolerable Upper Intake Level. However, little is known from a national perspective nearly food-specific supplement employ during pregnancy, and fifty-fifty less is known for lactating women. A few previous studies using national data focused on only those supplements containing folic acid, iron, or iodine during pregnancy and lactation. 5,seven,9,x Furthermore, although differences in whatsoever dietary supplement utilize past age, family income, and trimester were noted among pregnant women in the NHANES 1999–2006 analysis, 5 owing to pocket-sized sample sizes, stratified analyses past specific types of supplements were not possible. Lastly, the motivations for supplement employ (ie, whether based on the recommendation of a wellness care provider or by the woman's own decision) of meaning and lactating women have not previously been reported.

The primary aim of the present study was to describe the prevalence of nutrient-specific dietary supplement use and mean daily nutrient intakes from supplements among pregnant and lactating women in the United States, using the NHANES 1999–2014 data. Nosotros too examined dietary supplement utilise past historic period, family income, and trimester inside pregnant women, and motivation for supplement use.

METHODS

The National Health and Nutrition Examination Survey examines a nationally representative, cantankerous-sectional sample of the U.S. civilian, noninstitutionalized population, selected past using a complex, multistage probability design. eleven The National Wellness and Nutrition Test Survey is conducted by the National Centre for Health Statistics, and its protocol was approved by the Research Ethics Review Board at the National Heart for Health Statistics; further review for data analysis was non required. Since 1999, NHANES has operated as a continuous survey and includes an in-home interview, in which sociodemographic and dietary supplement use information is collected, followed by a health exam conducted in a mobile examination heart within 1–3 weeks, at which pregnancy and lactation information is collected. Survey participants could select English language or Spanish as the language of interview or could request a translator. We combined data from the 1999–2014 NHANES for this analysis because the sample size for pregnant and lactating women is very pocket-size for each 2-year survey bike, peculiarly after 2007; NHANES oversampled pregnant women during 2000–2006 to increase the precision of their estimates. 11 The National Center for Health Statistics recommends combining at least 4 years of information to improve the reliability and stability of estimates. 12

During the health examination, pregnancy and lactation status was assessed using the reproductive health questionnaire administered by interview on women 12 years and older in tandem with a urinary pregnancy test on women aged viii–59 years. Current pregnancy status was determined based on both self-written report and urine pregnancy test results, and lactation status was determined by cocky-written report of currently breastfeeding a kid. Still, owing to risks of violating anonymity, pregnancy and lactation status is publicly released by NHANES only for women 20–44 years of age since 2007; women of other ages were therefore excluded from this analysis. Women aged 20–49 years had a response rate of 69–81% for the health examination beyond survey cycles. 13 Among women who participated in the mobile examination heart examination (northward=39,755), we excluded those younger than 20 years (northward=18,130), those older than 44 years of age (northward=11,910), and those missing dietary supplement use information (northward=viii). Therefore, the final analytical sample consisted of 9,707 reproductive-anile women categorized as pregnant (n=1,314), lactating (n=297), or nonpregnant and nonlactating women (n=eight,096). Women who were concurrently significant and lactating (northward=26) were included in the lactating group because pregnancy during lactating represents a peculiarly enervating nutritional condition 14 and nutrient requirements for lactating women are higher for most nutrients than for pregnant women. 1

During the in-home interview, data on historic period, sex, race and ethnicity, educational attainment, family income, and marital status was collected through a computer-assisted personal interview. Age was used equally a continuous variable or as a categorical variable: 20–34 years and 35–44 years. Self-reported race and ethnicity used in this analysis were every bit defined in NHANES: non-Hispanic white, non-Hispanic black, Hispanic, and "other race." According to National Center for Health Statistics analytical guidelines the "other" race category is not presented separately but is included in all other estimates. Educational attainment was categorized as less than loftier school graduate, high schoolhouse graduate or equivalent, and some college or college. The family income-to-poverty ratio was calculated by National Middle for Health Statistics as the ratio of annual family income to the poverty guideline to represent family income level. The family income-to-poverty ratio is categorized as 130%, 131–350%, and more than 350%; a family unit income-to-poverty ratio of 130% is an income eligibility criterion for several federal nutrition assist programs (eg, Supplemental Nutrition Assistance Plan). Marital status was classed every bit married or living with partner, previously married, or never married. In addition, the trimester of pregnancy (first, second, or 3rd trimester) was coded based on the self-reported month of pregnancy on the reproductive health questionnaire but was available just during 1999–2012. Of the i,314 pregnant women in these survey cycles, 461 were missing this information, mostly because they did not self-report pregnancy during the questionnaire interview merely had positive urinary pregnancy examination results.

Dietary supplement data were collected through a thirty-day questionnaire in conjunction with a product inventory in the participants' homes. Participants were asked to show the interviewer the containers and labels of any supplements used over the previous 30 days when available, likewise as to report blazon, frequency, duration, and amount taken for each supplement. After data collection, trained nutritionists at National Center for Health Statistics matched the products reported to the NHANES Dietary Supplement Database that contains data on the serving sizes and nutrient contents (according to the product label's supplement facts console).

Nosotros classified dietary supplement products as follows: 1) multi-vitamin-mineral, any product containing three or more vitamins and one or more minerals; two) single- or multi-vitamin, whatever product containing at least one vitamin without mineral or botanical ingredient; iii) single- or multi-mineral, any production containing at least i mineral without vitamin or botanical ingredient; 4) botanical, whatever production with at least one botanical ingredient without vitamin or mineral; and 5) others, such as calcium plus vitamin D and fatty acid products. five,15 In add-on, nosotros identified prenatal products co-ordinate to the conception type; products were coded as prenatal when the product name stated prenatal or the label indicated that information technology is for employ by pregnant women. From the NHANES 2007–2008 cycle and across, for each supplement reported, participants were asked whether they are taking the supplement for their own reasons or because a doc or health intendance provider recommended to. Based on this information, we categorized meaning and lactating women as those who took at least 1 supplement of any kind or prenatal utilize based on a health care provider's recommendation and those who took products on their ain.

Specific food-containing supplements were categorized based on their ingredients as recommended 16 ; for example, if a product contained folic acid or Metafolin (l-methylfolate), it was identified as folic acid–containing supplements. Mean daily intake of nutrients from each supplement was calculated based on the nutrient corporeality per serving every bit stated on the product label, the number of servings consumed as reported past the participant, and the number of days taken in the past 30 days as reported past the participant. A total average daily nutrient intake from individual supplements consumed was summed for each participant. This analysis did not include sodium, potassium, fiber, poly peptide, fats, and carbohydrates because these nutrients are rarely included in dietary supplements.

The population distributions of supplemental nutrient intakes are often skewed, 17 and so nosotros presented estimated ways and medians of food intake from dietary supplements among users in conjunction with the current recommended dietary allowance (RDA), Adequate Intake, and Tolerable Upper Intake Level, established by the Food and Nutrition Board of the Establish of Medicine (now known every bit the National Academy of Medicine). 1 The RDA is the average daily intake level sufficient to meet the food requirement of near all healthy individuals in a detail life phase group (eg, pregnant women, lactating women, women aged xix–thirty years, and women aged 31–50 years) and, therefore, serves a goal for dietary intake for good for you individuals. 18 When the amount of evidence on a nutrient is non enough to set the RDA, an Adequate Intake is set based on estimates of food intake past a grouping (or groups) of people that are assumed to accept Adequate Intakes. The RDA and Adequate Intake are presented hither every bit reference points, simply they are non used to estimate the population prevalence of intakes at potential risk for inadequacy. The Tolerable Upper Intake Level is the highest average daily nutrient intake level that is unlikely to pose risk of agin health furnishings to almost all individuals. xviii Folate is unique in that the unit of measurement for the RDA is microgram dietary folate equivalents to accept into account the unlike bioavailability of different folate sources, whereas the Tolerable Upper Intake Level applies only to folic acrid, a synthetic form of folate from fortified foods and supplements, but not to food folate. 19 Because we examined simply folic acid consumed as supplements, we presented the RDA in micrograms of folic acid using the conversion factor of 1 microgram dietary folate equivalent=0.half-dozen micrograms folic acid, 19 assuming supplements were consumed with food. This assumption has been made in the most recent Food and Drug Assistants guideline for labeling. 20

Statistical analyses were performed using SAS 9.3 and SAS-callable SUDAAN 11.one software. All analyses used survey procedures that business relationship for the complex survey design, incorporating the 16-twelvemonth examination weights synthetic for the combined survey menstruation. Weighting takes into account of the differential probabilities of option (including oversampling), survey nonresponse, and differences in distributions between final sample and the target population; therefore, using the sampling weights produces nationally representative estimates. 12 Standard errors (SEs) were estimated using Taylor Series Linearization. Percentages and SEs of the categorical variables (eg, sociodemographic characteristics and dietary supplement use) and means and SEs of the continuous variables (eg, historic period and nutrient intake) were examined for pregnant, lactating, and nonpregnant and nonlactating women. Differences in distributions of sociodemographic characteristics among subgroups were assessed using Satterthwaite-adapted Wald χ2, and a P<.05 was considered statistically significant. Differences in the prevalence of dietary supplement employ and mean nutrient intakes amidst subgroups were assessed using pairwise comparisons, and a Bonferroni-adjusted P<.017 (ie, .05/3 subgroups) was considered statistically significant. Linear trends were tested using orthogonal polynomials; a P<.05 was considered to be statistically significant.

RESULTS

In 1999–2014, pregnant and lactating women tended to be younger than nonpregnant and nonlactating women (P<.017) (Tabular array 1). The majority of pregnant and lactating women were non-Hispanic white, had some college education or college, and married or living with partner. Seventy-seven percent of meaning and 70.three% of lactating women used 1 or more dietary supplements, significantly higher than the 44.8% of nonpregnant and nonlactating women (P<.017). In particular, 64.4% of pregnant and 54.two% of lactating women used a prenatal product, primarily multi-vitamin-minerals, defined as having at to the lowest degree three vitamins and at least ane mineral. The prevalence of any supplement use was significantly higher in older pregnant women (88.1%) than in younger pregnant women (75.2%) (P<.05) (Fig. i). Among pregnant women, both any supplement use and prenatal supplement use increased with increasing income (P<.001) (Fig. 2). During 1999–2012, when trimester data was available, the prevalence of prenatal supplement use was 52.iv% among women in the first trimester and increased to 80.0% among those in the second trimester, remaining stable at lxxx.4% amid those in the third trimester (Table 2).

T1
Tabular array ane.:

Sociodemographic Characteristics of and Dietary Supplement Apply by Women 20–44 Years of Age by Pregnancy and Lactation Status in the United States, NHANES, 1999–2014

F1
Fig. ane.:

Prevalence of dietary supplement use by younger (xx–34 years of age) and older (35–44 years of age) pregnant women in the United States, National Wellness and Nutrition Exam Survey, 1999–2014. *†Estimates are significantly different from each other at P<.05.Jun. Dietary Supplements During Pregnancy and Lactation. Obstet Gynecol 2020.

F2
Fig. 2.:

Prevalence of dietary supplement use by family income-to-poverty level amongst pregnant women (twenty–44 years of historic period) in the United States, National Wellness and Nutrition Examination Survey, 1999–2014. *Pregnant linear trend across family income-to-poverty ratio categories (P<.001).Jun. Dietary Supplements During Pregnancy and Lactation. Obstet Gynecol 2020.

T2
Table two.:

Prevalence of Dietary Supplement Apply by Trimester of Pregnancy Among Pregnant Women 20–44 Years of Historic period in the Usa, NHANES, 1999–2012 (n=790)

During 2007–2014, when NHANES collected the motivations for supplement use, 47.iv% of pregnant women took at least one dietary supplement based on a health care provider's recommendation, and 16.ane% of pregnant women reported the employ based on their own decision (Fig. 3). Similarly, among lactating women, 39.viii% took at least i dietary supplement because of a wellness care provider'due south recommendation, and 22.eight% made the decision on their ain. Amidst nonpregnant and nonlactating women, xi.5% took supplements based on a health care provider's recommendation, 30.half dozen% took on their own.

F3
Fig. 3.:

Prevalence of reasons for dietary supplement use among pregnant and lactating women (xx–44 years of historic period) in the United states of america, National Wellness and Nutrition Test Survey, 2007–2014 (n=330). Women who used at least ane dietary supplement production based on the recommendation of a health intendance provider were classed as recommended by a health care provider. Information on the reason for dietary supplement apply was available only in 2007–2014.Jun. Dietary Supplements During Pregnancy and Lactation. Obstet Gynecol 2020.

More than than threescore% of significant and lactating women used supplements containing thiamin; riboflavin; niacin; folic acid; vitamins B-6, B-12, C, and D; calcium; iron; selenium; and zinc (Table 3). The prevalence of pregnant and lactating women who took supplements that independent the following nutrients was relatively low: choline (5–8%), iodine (18–20%), magnesium (26–28%), phosphorus (five–half-dozen%), and selenium (x–12%).

T3
Table 3.:

Percentages of Women 20–44 Years of Historic period Using Dietary Supplements Containing Specified Micronutrients by Pregnancy and Lactation Status in the U.s.a., NHANES, 1999–2014

The estimated daily hateful intakes of micronutrients from dietary supplements among users are presented in Table four. Mean intakes of thiamin; riboflavin; niacin; folic acid; vitamins B6, B12, and C, fe; and zinc from supplements alone were at or above their respective RDAs among pregnant and lactating supplement users. In item, dietary supplements contributed a mean daily intake of 787 micrograms/day of folic acid, nine.2 mg/day of vitamin B6, 10 micrograms/solar day of vitamin D, 366 mg/day of calcium, 38.4 mg/day of iron, 74.vi mg/day of magnesium and eighteen.ii mg/day of zinc amidst meaning supplement users. Few differences in mean micronutrient intakes amid users were observed betwixt meaning and lactating women. The estimated median intakes from supplements were lower than the ways in general, reflecting that the distribution was skewed to the correct, but like patterns by pregnancy and lactation condition were observed among median intakes (Appendix one, available online at https://links.lww.com/AOG/B704).

T4
Table 4.:

Mean Daily Micronutrient Intakes From Dietary Supplements Alone Amid Users of Dietary Supplements Containing the Specified Nutrient, by Pregnancy and Lactation Status in the United States, NHANES 1999–2014

Between 1999–2002 and 2011–2014, the prevalence of dietary supplement apply remained stable among pregnant and lactating women non only in terms of any supplement used but also in specific production categories and specific nutrient-containing supplement used (Appendix 2, available online at https://links.lww.com/AOG/B704). Nevertheless, among nonpregnant and nonlactating women, the use of supplements containing iodine (23% in 1999–2002 to 15% in 2011–2014; P<.001) and iron (32% in 1999–2002 to 25% in 2011–2014; P<.001) decreased over fourth dimension.

Give-and-take

More than 70% of pregnant and lactating women anile xx–44 years in the United States reported the use of at to the lowest degree one dietary supplement, primarily prenatal supplement. Consistent with previous findings, supplement apply was substantially higher among pregnant and lactating women, compared with nonpregnant and nonlactating women. five–7 The majority of meaning women consumed supplements that independent a wide range of nutrients, with the daily mean intake of selected vitamins and minerals from supplements reaching or exceeding the RDA. The number and corporeality of nutrients included in prenatal supplements are not standardized, but almost all products contain one or more than nutrients at levels that are as much as the RDA or more. 21 Therefore, it is important to examine nutrients from supplements, likewise as from foods and beverages. Recently, Bailey et al viii estimated the total usual food intakes adjusting for inside-person variation from the 2 24-hour dietary recalls (including supplements) among pregnant women in the NHANES 2001–2014 and compared those to the dietary reference intakes. A significant number of significant women had usual intakes below the Estimated Boilerplate Requirements (ie, were at risk of inadequacy) for vitamins A (16%), B6 (11%), C (12%), D (46%), and E (43%); folate (16%); fe (36%); calcium (13%); magnesium (48%); and zinc (eleven%). Very few met or exceeded the Adequate Intake for choline (8%). The findings of the nowadays written report indicate that some of these underconsumed nutrients, namely, magnesium and choline, are not commonly supplemented during pregnancy and lactation, whereas other nutrients (ie, vitamins A, B6, C, D and Due east; folate; iron; calcium; and zinc) are consumed from supplements past more than 40% of pregnant and lactating women.

Folate is an especially important food during the periconceptional period because it helps the fetus form the neural tube, only it might not be consumed plenty from food sources alone. 22 Therefore, to assistance foreclose neural tube defects, the U.S. Preventive Services Chore Force recommends all women who are planning or capable of pregnancy to take a supplement containing 400–800 micrograms of folic acid each day, emphasizing a month before formulation through 2–three months of pregnancy as the critical period. ii Unfortunately, we establish that approximately xxx% of pregnant women in their showtime trimester did not have whatever folic acrid from supplements. Women in their second and third trimesters were more than probable to consume any supplement than those in their showtime trimester, confirming earlier findings past others. v It may be possible that women in their early pregnancy are not aware of their pregnancy or associated recommendations 23 or have difficulties with oral intake attributable to pregnancy-related nausea and vomiting. 24 Nonetheless, mean daily folic acrid intake among users was 787±30 micrograms, which indicates that some users consumed more recommended amounts; indeed more than xl% of the meaning supplement users exceeded the Tolerable Upper Intake Level in 2001–2014. 8 The Tolerable Upper Intake Level was prepare based on the exacerbation of the neurologic damage of vitamin B12 deficiency. nineteen Moreover, the health effects, if any, of high folic acid intake during pregnancy on fetal evolution remain largely unknown; some data from creature studies and epidemiologic studies raise potential cause for business organisation, every bit summarized by Lamers et al. 25

For iron, the World Health Organization recommends daily supplementation with xxx–60 mg of iron for pregnant women to forbid maternal anemia, puerperal sepsis, preterm birth, and depression nascence weight throughout pregnancy. 26 Specifically for the U.Due south. population, the Centers for Disease Control and Prevention recommends thirty mg/twenty-four hours of iron supplementation for all pregnant women. 27 We found that 72.iii% of pregnant women were using fe-containing supplements, which contributed 38.4 mg/mean solar day on average among users. This explains the earlier findings of Bailey et al 8 that, among pregnant women who took supplements, the prevalence of inadequate iron intake was eighty.3% when just nutrient sources were considered, but decreased to 13.ix% when dietary supplements were included. At the same time, the prevalence of intakes above the Tolerable Upper Intake Level increased from 0% to 40.2% when including supplements. The Tolerable Upper Intake Level for iron was primarily based on gastrointestinal distress every bit an adverse issue. 28 Among pregnant women who were not using supplements, almost all (95.3%) were at chance of iron inadequacy. eight Lactating women had a similar pattern of iron-containing supplement utilize as pregnant women.

Iodine plays a critical function in fetal brain development, specially during early on pregnancy. 28 Data on iodine intake from nutrient sources is not available in NHANES, simply an assay of urinary iodine concentration data from the 2001–2006 NHANES concluded that the iodine status of pregnant women was borderline sufficient; that of lactating women was mostly sufficient; and some women, especially those who did non consume dairy products, were at adventure for iodine insufficiency based on the World Health Organization criteria. 29 To prevent possible insufficiency, the American Thyroid Association recommends that all women who are pregnant, lactating, and planning of pregnancy to supplement 150 micrograms of iodine/solar day. thirty,31 Although most prenatal products contain approximately 150 micrograms of iodine, 10,21 iodine-containing supplement apply very depression amidst pregnant women (twenty.four% consuming 116 micrograms/24-hour interval from supplements on average) and lactating women (17.5% consuming 104 micrograms/twenty-four hours from supplements on average) in the United States. 7,10,29

Motivations for supplement apply take been collected in NHANES since 2007. In 2007–2014, about two-thirds of pregnant and 60% of lactating supplement users took at least i production based on a health care provider'due south recommendation. These findings were as expected because it is common practice for clinicians and dietitians to recommend or prescribe a prenatal supplement; furthermore, a prescription by a health professional person is required for reimbursement by private and public insurance programs. In 1999–2006, 37% and 28% of meaning women (15–39 years) used prescription and over-the-counter prenatal supplements, respectively. ten Given the wide variety of supplement product formulations bachelor, it is of import for wellness care providers to help individuals review all products they are taking to ensure that condom but not excessive intakes of nutrients are provided. 32,33 Women who are not using prenatal supplements may need encouragement, because some barriers to prenatal supplement use have been documented among minority women identified, including adverse effects, forgetting to consume, and perceiving prenatal supplements as unnecessary or ineffective. 34 Our results on income differences suggest that limited financial resource may also affect prenatal supplement apply amidst pregnant women. 35 Clear and open communication about the benefits of prenatal supplements as well as concerns and alternatives may help improve prenatal supplement use. 34

About 9 of 10 pregnant women at 35–44 years of age were using dietary supplements. One possible caption for the higher prevalence of supplement utilise in older pregnant women is that they may receive more prenatal and perinatal care, considering pregnancy at 35 years or older is associated with a college risk of complications. 36,37 In add-on, older pregnant women had higher educational attainment and higher family income and were more likely to exist married or living with a partner than their younger counterparts (Appendix 3, bachelor online at https://links.lww.com/AOG/B704), all of which have been previously associated with higher supplement use. 5,6

The strengths of this written report include statistically reliable estimates of dietary supplement use among pregnant and lactating women in the United states produced by combining viii cycles of NHANES data reflecting sixteen years. The National Health and Diet Examination Survey collects high-quality data on supplement use by using a 30-mean solar day questionnaire along with an in-dwelling house inventory in which approximately 80% of all supplement products reported were shown to trained interviewers. The prevalence of supplement utilise has been largely stable among women of reproductive age during 1999–2014, and the NHANES dietary supplement databases were updated for every survey cycle. Withal, it should be noted that the number of pregnant women was much smaller in 2007–2014 cycles, compared with 2000–2006 cycles when pregnant women were oversampled, which may take afflicted the precision of the trend analyses. In addition, the number of lactating women was small even after combining multiple cycles, which contributed to the big SEs and imprecision of estimates. There is a need to further examine supplement use during lactation with a larger sample. Some other limitation is that the NHANES database relies on manufacturer'southward label declarations, which may exceed the label declarations twenty% or more than. 38 Studies supporting the Dietary Supplement Ingredient Database have been chemically analyzing the nutrient contents of dietary supplements, including prenatal supplements. This database should be used to adjust labeled amounts in futurity enquiry once it'due south completely developed. 38 Piddling is known about the reporting bias and measurement error structure of dietary supplements. 17 Future studies may also examine biomarkers in relation to supplement apply. five,10 Lastly, NHANES did not collect data about multiple gestational pregnancies or adventure factors, such as history of neural tube defects and MTHFR cistron polymorphism, which should be considered when assessing individual'due south nutritional needs.

In decision, the majority of pregnant and lactating women in the United States took at to the lowest degree one dietary supplement at some fourth dimension during their pregnancy, which contributed many nutrients (eg, thiamin; riboflavin; niacin; folic acid; vitamins B6, B12, and C; iron; and zinc) in doses in a higher place the RDAs among users. Although folic acid and iron supplementation is recommended during pregnancy, some supplement users may consume high doses that atomic number 82 to excessive intakes. However, some of these high doses may be appropriate when they were recommended by health intendance providers attributable to special medical conditions. The use of supplements containing iodine, magnesium, and choline was relatively low amid all women of reproductive age, regardless of pregnancy or lactation status. Less than one-half significant and lactating women were taking at least one supplement based on a health intendance provider's recommendation. Health care professionals should be aware of and communicate information about nutrition and dietary supplement utilize, especially for folic acid and atomic number 26. The American Higher of Obstetricians and Gynecologists and the American Society for Reproductive Medicine recommend that women who present for prepregnancy counseling should be screened for their nutrition and supplements to ensure they are coming together the RDAs for essential nutrients. 33 However, the everyman prevalence of dietary supplement employ remains among women in the first trimester of pregnancy.

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