1. Healthy Before Pregnancy
March of Dimes
NC Preconception Health Campaign
These slides contain notes, speaking points, and other activities to enhance the lesson. Words written in Times are meant to be read aloud. All other notes are for your reference, and may be read aloud if desired.

2. Multivitamins: Take them for life Lesson Plan 2

3. Birth defects: The big picture
1 in 33 U.S. babies is born with birth defects (120,000)
Most common include:
Heart defects
Cleft lip/palate
Down syndrome
Spina bifida (neural tube defect)
There are thousands of birth defects and we only know the reason for about 30 percent of them. Only some are preventable and many others are not.
Birth defects are a leading cause of babies dying before their first birthday in the US and the 5th leading cause of years of potential life lost. .

4. Birth defects that can be prevented
Neural tube defects (NTDs)
Spina bifida
Anencephaly
Neural tube defects (NTDs) are birth defects of the brain and spinal cord.
Spina bifida is the most common permanently disabling birth defect in the US.
Source: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

5. How do NTDs occur?
The brain and spine start as a tiny pancake of tissue
It folds inward and makes a tube
Around 28 days after conception the tube “zips” up
If the tube does not close completely a hole is left and an NTD is formed
A neural tube defect (NTD) is a birth defect that occurs when the neural tube, the embryonic structure that grows into the brain and spine, fails to properly close around 28 days after conception. At this stage, the embryo is about 2-3 mm. (Show students how big with dime or grain of rice)
The neural tube begins as a tiny pancake of tissue, consisting of the neural groove, neural fold and neural crest. First, it folds inward. Then the tube fastens or zippers up. When the zipper does not close completely, a small hole is left and an NTD is formed. As the fetus develops, the hole will not close.
The exact place of the defect along the neural tube will determine the type of NTD that develops. The higher the defect the greater the disability.
Note:
To illustrate how early the neural tube closes in pregnancy hand out a few pennies. Ask them to take a closer look at their penny; and ask how big is an embryo when a neural tube defect occurs? It is about the same size as the numbers on the date on a penny. 

6. Neural tube defects
Approximately 200 pregnancies are affected by an NTD each year in North Carolina
2,500-3,000 U.S. babies are born each year with an NTD
Another 1,500 are still born, spontaneously miscarried or terminated
The chances of having a child with a neural tube defect for those without a family history are approximately 1/500-1/1000 or .1-.2%
Once a couple has had a child with a specific NTD their chances of having a child with a NTD increase to 1/30 or 3%. This means that there is about a 97% chance that a neural tube defect will NOT occur in a future pregnancy.
Note:
To illustrate this, put 200 grains of rice in a clear plastic bag (snack size or smaller). Pass the bag around the audience and mention that this is how many pregnancies in NC are affected by neural tube defects. Also mention that a single grain of rice is about how big an embryo is when neural tube defects occur.

7. Main message
If all women consumed the recommended amount of folic acid before and during early pregnancy, up to 70 percent of all NTDs could be prevented
The U.S. Public Health Service recommends that ALL women of child- bearing years take 400 micrograms (mcg) of folic acid every day

8. Spina bifida
Spina bifida occurs when the lower end of the developing neural tube fails to close (just days after conception).
What is the size of the embryo at this time?
Answer on next slide.
Source:

9. Answer:
About the size of President Roosevelt’s ear or the size of grain of rice.

10. Spina bifida
Photo source: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

11. Spina bifida diagnosis
Disabilities may include:
Paralyzed legs
Loss of bowel control
Loss of bladder control
Learning disabilities
The type and degree of disability or death is affected by the size, location and whether it is open or closed. Most infants will survive. Some infants will be paralyzed for life and may require assistance with functions such as going to the bathroom.
Bottom line: Up to 70% of these cases could prevented by taking a multivitamin every day.
Note:
Some hospitals such as UNC have started doing in-utero surgeries. It cannot alleviate the problem but minimizes disability.

12. Quality of life
80-90 percent of infants who are born with spina bifida will live.
Thanks to advancements in treatment and prevention, those born with this challenging birth defect are living longer, more productive lives than was dreamed of just 20 years ago. 
Many children with spina bifida will lead productive lives, but there are significant impacts on their quality of life.
Source: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

13. Anencephaly
Anencephaly is a fatal condition in which the upper end of the neural tube fails to close.
The brain either never completely develops or is totally absent.
The most lethal and severe NTD is anencephaly.
Source: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

14. Anencephaly Prognosis Miscarriage (spontaneous loss) Stillbirth
Neonatal death
Note:
You may need to define these terms for your students:
Spontaneous loss: Miscarriage is the spontaneous loss of a pregnancy before the 20th week.
Stillborn: A stillbirth occurs when a fetus, which has died in the uterus, during labor or delivery, exits a woman's body. The term is often used in distinction to live birth or miscarriage. Most stillbirths occur in full-term pregnancies.
Neonatal death: death of a live-born infant within the first 28 days of life (first four weeks).

15. North Carolina has a higher rate of NTDs than the national average
North Carolina has a higher rate of NTDs than the national average. Within NC, NTD rates are higher in certain regions and within certain populations such as Latinos.
Let me tell you a story…About 10 years ago the Western part of NC had the highest NTD rates in the state, which means they were some of the highest rates in the country. And the U.S. has higher rates than most other industrialized countries, so the rates in Western N.C. were very high. After a radio campaign and the work of some talented health educators who visited doctors’ offices, health departments, schools and community groups, women started taking daily multivitamins and the NTD rates decreased by 80%! This is one of the best success stories in the field of public health and especially within birth defects prevention.
Note:
This map is based mostly on the 1980 study by CDC, as well as historical observations. The surveillance data also support this, but it is easy to misinterpret this info unless you know how the various states collect their data, case definition, etc. It is safe to say that NC and the Southeast generally have higher rates than most other states, but it is impossible to come up with any sort of specific 'ranking' that is valid. It is based on data from a number of years combined. There is no way to know how we (or any other state) ranks in NTDs because there is no uniform national data available.

16. Who’s at risk?
All women capable of becoming pregnant are at risk of having a baby with an NTD BUT…
Latina women are at a much higher risk
Many of the foods we eat are fortified with folic acid but many traditional Hispanic foods are missing the folic acid. Also, Latinas are less likely to have heard about folic acid, to know it can prevent birth defects, or take multivitamins containing folic acid before pregnancy.

17. Prevalence of neural tube defects by type
North Carolina, (excl. TABs < 20 weeks)
Through education we are starting to see the NTD rate go down in NC. We need high school students to start taking daily multivitamins to further improve. In this 10 year time span the NTD rates down in Western NC decreased by 80%; and 40% statewide. Each one of these colors represents a different type of NTD.
Bottom line: the NTD rates are still too high--more females need to be in the habit of taking a daily multivitamin.
Note:
2003 increase is believed to be due to low-carb diet craze

18. Other birth defects Folic acid may also protect against:
Development of infant heart defects
Cleft lip with/without cleft palate
Note:
Norwegian study found that taking more than 400 mcg folic acid a day decreased risk of cleft lip with/without cleft palate by 33 percent.
Photo source: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

19. Prevention: It’s all about timing
The U.S. Public Health Service recommends that all females who have started menstruation take a daily multivitamin with 400 mcg of folic acid
If all women consumed the 400 mcg of folic acid before and during early pregnancy, up to 70 percent of all NTDs could be prevented
The spinal cord “closes” between 6-8 weeks (or days) gestation so most women don’t even know they are pregnant yet. It often takes missing two periods for a female to notice and think that she might be pregnant.
So, the recommendation is for all females of childbearing age to be in the habit of taking a multivitamin every day (just in case).
Activity: Ask half of the class to stand up (or raise their hands). Tell students that when they have their first babies, at least that many will likely be unintended (unplanned).

20. Take a multivitamin every day
Two-thirds of U.S. women do not consume enough folic acid and/or folate!
Activity: Ask every 3rd female in class to stand up to illustrate this point.

21. How can you get enough folic acid?
Food (folate)
Leafy green vegetables, orange juice, beans
Fortified food (folic acid)
Cereals, breads, nutrition bars
Multivitamins!
In order to receive 400 mcg of folic acid the equivalent of 800 mcg of folate must be eaten in foods. This means you would have to eat a whole loaf of bread every day to get enough.
If you won’t take a multivitamin, eating a bowl of breakfast cereal that has 100 percent of the daily value of folic acid is the next best option. Its important to drink the milk after eating the cereal. Check the label on the box.
Bottom line: taking a multivitamin every day is key.

22. Folate
Folate is an essential nutrient that humans cannot easily synthesize and is found naturally in foods.
Absorption depends on the food itself, how it is cooked, and individual’s ability to metabolize folate.
Notes:
You may need to define synthesize for your students:
cause to undergo the process of producing a chemical compound (usually by the union of simpler chemical compounds)
Another term to use is bioavailability:
the ability to be absorbed by a living organism. Or the extent to which a compound is available for intake by organisms.
(Example: Folic acid has more bioavailability than the naturally occurring folate.)

23. Fit folic acid into your life!
Taking a pill is better than eating a vitamin in its natural food form
Folic acid is most absorbable in a multivitamin or supplement (compared to folate found in foods)
Eating a healthy diet is always important, but a multivitamin is the most absorbable, dependable and preferred way to get the daily dose of folic acid.

24. The FDA takes action: 1996
Ordered “enrichment” of all flour or grain products, 140 mcg per 100g of grain product
Approved the use of health claims on products that contain significant amounts of folic acid
However, these efforts have proven to be insufficient for full prevention of birth defects
After FDA action was taken for grain fortification the incidence of NTD’s in the US decreased by 19 percent.

25. Some cereals that contain 100% of the daily value of folic acid
General Mills Harmony
Total
Product 19
Quaker Oats Cinnamon Crunch
Cheerios Plus
Smart Start
To get the most folic acid from your cereal, you’ll want to drink the milk, too. Folic acid is water-soluble, so it dissolves into the milk.
For informational purposes only. The March of Dimes does not endorse or recommend any brand, manufacturer or type of cereal product.
For a complete list go to

26. Multivitamins: So what’s in it for me?
Fills in the nutrition gaps
Some studies suggest that folic acid has other benefits
May protect against heart disease, stroke and certain cancers
May protect against other birth and heart defects
Take a multivitamin and enjoy life as a smart, happy, healthy and physically active adolescent! They are beneficial to females and males.
Many vitamins and minerals are essential for living and that most women do not eat well enough to get what they need every day from food.
That’s where vitamins come in: they help fill in the nutrition gaps. Plus there are some specific nutrients like folic acid, vitamin D and vitamin C that are good for you. With so many vitamins needed, who wants to take several pills each day? Multivitamins solve this problem by combining all the vitamins you need into one easy pill.
Remember, eating smart is still important. Vitamins can’t fill in the gap of burgers, fries and soda!

27. Multivitamins!
If you’re at the store looking at the vitamin section, it seems like there are hundreds of multivitamins to choose from. How do you pick one that’s right for you? With so many on the shelf, it can be hard to make a choice. Here are some tips:
If you have been taking a children’s multivitamin it may be time to change to an adult version.
Read the label. Look for products with no more than 100% Daily Value (DV) for the nutrients list. Be sure it has 400 mcg of folic acid. Don’t expect it to have a lot of calcium as it would make the pill too big to swallow.
Check the percentage and avoid high doses. Some vitamins and minerals are toxic at high doses. They can build up over time and you may not notice a problem right away. Also, some can cause problems in your future children if taken in improper amounts while pregnant.
Look for USP on the label. This means that your pills have the exact amount of nutrients the label says they have.
Store brands and generics can be as good as name brands. Read the label to compare if you are not sure
Avoid the extras. Some vitamins have herbs, enzymes or amino acids in them. These add unneeded cost. If you have questions about herbs, talk to your health care provider. No-frills vitamins are good. Time release, “high potency,” herbal fillers and the like will just cost you a lot more money without gain for your health. Just stick with the standard multivitamins and you’ll be doing your body, and your wallet, a big favor.
Check the use by or expiration date. Food should be fresh and so should your vitamins.
For illustrative purposes only. The March of Dimes does not endorse or recommend any brand, manufacturer or type of multivitamin or supplement.

28. Tips on taking multivitamins
Combine taking a multivitamin with another everyday activity, such as brushing your teeth.
Place your bottle of multivitamins where you’re likely to see it.
Try chewable multivitamins if you have trouble swallowing regular multivitamins.
Try taking a multivitamin with food or at night if it upsets your stomach.
Buy generic multivitamins: They can be as effective as name brands and often cost less.
Check the expiration date on the bottle.

29. Other important research may benefit adults
Studies show that folic acid may reduce:
Cardiovascular disease
Alzheimer's
Cervical cancer
Colon cancer
Stroke
Notes:
A meta-analysis of 27 studies relating homocysteine - JAMA, 10/4/ :
July of JAMA had an article about Alzheimer's.
Folate is a co-factor for the enzymes that synthesize DNA & RNA and is required for the synthesis of homocysteine to methionine.
High levels of the amino acid homocysteine are independently associated with an increased risk of heart disease and stroke. It has been shown that taking folic acid lowers homocysteine levels in both men and women, but it is not yet known whether folic acid supplementation also lowers the risk of heart disease and stroke.
Folic acid is now one of the top 200 drugs prescribed. Many pharmacists have reported to us that they are seeing it given for prevention of cardiac disease.