Healthy Diet and Nutrition Education Program among Women of Reproductive Age : A Necessity of Multilevel Strategies or Community Responsibility

Article type: Review Article Background: Reproductive years represent a major proportion of women‟s life. This review focuses on recommended nutritional considerations, physical activity pattern as well as the effect of nutrition education (NE) on behavior modification and health outcomes of women of reproductive age using either singlelevel, multiple-level or community-level interventions. Methods: For this narrative review, numerous searches were conducted on databases of PubMed, Science Direct and Google Scholar search engine using the keywords women, reproductive age, NE, interventions, community-based. Results: Even though single intervention is effective, multiple intervention programmes in addition to behavior modification components are even more successful in terms of modified behaviors and health outcomes. Moreover, community based interventions using multilevel strategies are further useful for improved health outcomes and behavior modification. Conclusion: NE programmes have been effective in positive behavior modification measured in terms of eating pattern and health quality. Thus, it is recommended that health professionals use multiple intervention strategies at community level to ensure improved outcomes. Political support is also required to create culturally sensitive methods of delivering nutritional programmes. Finally, as policy is dependent on program cost, nutritional programmes need to combine methods of cost analysis to show cost effectiveness of supplying adequate nutrition for women throughout the lifecycle. Article history: Received: Dec 24 2014 Accepted: Apr 26 2015 e-published: Jul 07 2015


Introduction
Across all cultures, a healthy baby and mother are cherished dreams and hopes of all families. 1owever, besides emphasizing on pregnancy and birth outcomes, considering the different stages of women"s health, that is, during infancy, adult life, preconception period, pregnancy, lactating phase (a life course perspective) is essential to reduce risk of any pregnancy related complications and deaths as well as to eradicate disparities through enhanced health promotion and disease prevention. 2 For instance, an adequate nutrition before the reproductive years helps to ensure achievement of proper adolescent growth, sufficient nutrient store during reproductive years for a healthy pregnancy and an appropriate nutritional status especially to maintain skeletal health during the postmenopausal period.Hence, the need for maintaining optimal food habits throughout a woman"s lifetime is essential to optimize both her and her offspring"s health. 3Women should also be exposed to health topics and encouraged to participate in health promotion programmes so as to promote healthy eating habits and thus achieve optimal nutritional status. 4 Considerations include diet quality as well as body mass index (BMI).
Nutrition education (NE) is an essential consideration to optimise health of women of reproductive age in addition to pregnancy outcomes.NE programmes are important as they target at enhancing subjects" dietary intakes by promoting behavioral changes such as food choice and cooking ability, goal-setting, motivation, and support the efforts for a change. 5For instance, Dean et al. discussed that preconception nutrition-specific interventions in particular increased folic acid and multivitamins supplements among pregnant women resulted in positive pregnancy outcomes. 6Furthermore, Rao demonstrated an improvement in haemoglobin level through a nutrition awareness program comprising of informal meeting sessions, cookery activities to disseminate knowledge about use of iron rich foods and kitchen garden activity. 7ecent evidence also draws attention to the need to contemplate the wide-ranging spectrum of social, cultural and economic factors, as well as the significance of engaging family members to optimize health of women of reproductive age when designing health interventions. 8The objectives of this paper are: 1. To outline recommended healthy lifestyle behaviors such as nutrition, physical activity and alcohol consumption 2. To discuss the effectiveness of nutrition education programs aiming at improving diet, physical activity and overall health of women of reproductive age

Methods
For this review, scientific information from published papers was analyzed.Searches were conducted using various databases[such as Google scholar, PUBMED, Ebscohost, Google scholar, Science Direct etc.] using the following search terms: "women of reproductive age", "pregnant", "postpartum", "diet", "physical activity", "nutrition education" and "intervention".To be able to ascertain probable relationships, scientific evidence from cross-sectional, prospective cohort and experimental studies were also considered.

Ethical issues
There is no need for ethical clearance or any issues pertaining to same as long as statistics from governmental database or related information are not being used.Study also does not deal with any sensitive information pertaining to human, invasive procedures, informed consent.

Malnutrition
Nutrient-related deficiency diseases, which can result to intrauterine growth retardation and other vitamins and minerals deficiency disorders, are manifested worldwide.As postulated by Kulasekaran, women of reproductiveage are particularly susceptible to malnutrition due to various social (for example low income level and illiteracy) and biological factors. 9Malnutrition is mainly a matter of concern for women of reproductive age as a poor nutritional status not only impedes her own health but the health of her offspring is also at risk. 10

Obesity
Obesity is a growing threat to women of childbearing age. 11In women of reproductive age, the prevalence of grade I (BMI 30-34.9kg/m 2 ) and grade II (BMI 35-39.9kg/m 2 ) obesity has doubled since 1979 and that of grade III (BMI> 40 kg/m 2 ) obesity has increased threefold over the same period. 12any women are likely to maintain a considerable amount of weight postpartum, predisposing them to become overweight or obese with increasing age.As discussed by Paden and Avery, the BMI of women 15 years post pregnancy can be independently associated with factors such as pre-pregnancy BMI, weight gain during pregnancy, and weight loss in the first year postpartum. 13Postpartum weight retained from earlier pregnancies is also an important factor to a high BMI among women of reproductive age. 4 In an effort to en-courage proper weight gain during pregnancy, the Institute of Medicine, 14 developed prenatal weight gain recommendation which is guided by the woman"s pre-pregnancy BMI (Table 1).

Underweight
Although health risk factors and death have been mostly associated with overweight and obesity, underweight is equally related to excess deaths. 15In many countries (e.g. in Africa and South Asia), women of reproductive age having a BMI below the normal range is widespread, where some prevalence estimates of under-nutrition are as high as 27-51%. 16Being underweight is associated with several health risks such as a poor nutritional status, heart irregularities, osteoporosis, amenorrhea, and infertility.Pregnant women with a low BMI are at a greater risk for preterm delivery, low birth weight, and fetal growth restrictions. 4,17

Diet
Women of reproductive age have the same dietary requirements as the general population whereas pregnant and lactating women have additional nutritional recommendations. 18For example; another 100 kcal/day in addition to dietary intake that allows a constant pre-pregnancy weight is generally satisfactory while, in later months of pregnancy, an additional 200 kcal/day is occasionally suggested.In order to meet these guidelines, simple carbohydrates should be restricted while complex carbohydrates in the form of starches, legumes, seeds and bread should be limited to reasonable quantities.Useful protein sources can be meat, fish, cheese and dairy products (source of calcium), supplemented with small amounts of butter and vegetable fats. 19cronutrients are critical for women"s health during reproductive years and during pregnancy as well as during adolescence and post-menopausal period. 3The adverse effects of micronutrient deficiencies on the health and birth outcome of women are well known.Although poor dietary intake is a common cause of micronutrient deficiencies, other individual causes including genetics, nutrient and drugs interactions, poor absorption, as well as certain diseases can lead to such deficits.In particular, deficiencies of calcium, iron, folate, zinc, thiamine, riboflavin, and vitamins A, D, B-6 and B-12 are very frequent and of concern among women of reproductive age. 5 Possible reasons for these micronutrients deficiencies are low income level and lack of education about healthy practices like healthy eating patterns. 20Deficiencies in these indispensable nutrients increase the of predisposal to adverse pregnancy outcomes such as neural tube defects, early fetal loss, preeclampsia, and maternal mortality. 3,21The best known recommendation for women anticipating pregnancy, is 400μg of folic acid supplements per day to avert the risk of neural tube defects 16 while pregnant women need to increase their daily intake to 600μg. 22

Physical activity and alcohol consumption
Along with proper diet, other lifestyle patterns such as regular physical activity (PA) and reduced alcohol consumption are also indispensable among women of reproductive age.Regular PA has to be established preconceptionally so as to prevent several complications of pregnancy. 23In addition, exercise prior to pregnancy help woman to control weight and prevent mood swings during pregnancy as well as minimize the likelihood of depression post pregnancy. 13Women are recommended to practice regular PA for 30 to 60 minutes per day for 5 or more days per week. 23he US Centers for Disease Control and Prevention published preconception references to promote knowledge of healthy lifestyles practices and to discourage health risk behaviors (e.g., cigarette smoking and alcohol consumption). 24Alcohol exposure during the prenatal period is one of the main sources of neurodevelopmental deficits among children, as well as those of fetal alcohol spectrum disorder (FASD). 25In 2007, it was recommended that women should avoid consuming more than one or two units which is equivalent to 8-16 g of alcohol, once or twice a week. 18Studies have shown that a significant number of women who are engaged in risky behaviors such as substance abuse continue to enter pregnancy, thus increasing their risk for negative pregnancy outcomes.For instance, in 2002, as reported by Atrash et al. 1 11.4% of pregnant women smoked during pregnancy, while 10.1% of pregnant women and 54.9% of women with a high pregnancy risk consumed alcohol.Furthermore, Green-Raleigh 26 reported that women not planning a pregnancy were more prone to unhealthy lifestyle including cigarette smoking and alcohol consumption during pregnancy while women intending a pregnancy were keener to adopt healthy behaviors in terms of vitamin and mineral supplements.

Nutrition Education Programs during Preconception
Nutrition education (NE) which consists of 3 phases (Fig. 1) has been defined as "any combination of educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and well-being.NE is delivered through multiple venues and involves activities at the individual, community, and policy levels". 27itable preconception care is essential to ensure a healthy pregnancy and pregnancy outcomes. 28In order to be successful, preconception care has to consider different factors pertaining to the woman"s health.For instance, Curtis et al. 29 proposed some of these considerations: a methodical risk assessment process to identify the medical, family, and reproductive health record of the woman, her nutritional status, societal constraints and/or any case of drug or substance abuse.Worldwide, the significance of preconception health and care has been supported for a healthy mother and child.Boulet et al. 30 further emphasize that preconception programs and policies exist for almost three decades now, which indicate the significance of preconception intervention programs to ensure healthy pregnancy outcomes.

Importance and effectiveness of nutrition education programs during preconception
Women being an important pillar of the society especially in developing countries, women"s health should be given significant consideration which will assist in attaining the fourth and fifth goals of the millennium development program. 30As put forth by Curtis et al., 29 many studies have supported the effectiveness of preconception care in terms of encouraging healthy behavioral practices, and controlling medical and other associated health risk factors to optimize both mother"s health and pregnancy outcomes.For instance, as proposed by Bastani et al. 31 counseling during preconception about healthy diet and lifestyle can be the optimum time to encourage adequate daily iron and folic acid intake.NE programs endeavor to alter participants" dietary intakes by remodeling behavioral factors, food choices and cooking skills, goal-setting, inspiration, and reinforce the change efforts. 5"The CDC and its Select Panel have formulated four goals for health preconception" which are as follows: 32 • Improve the knowledge, attitudes, and behaviors of men and women related to preconceptional health.
• Assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.
• Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconceptional period that can prevent or minimize health problems for a mother and her future children.
• Reduce the disparities in adverse pregnancy outcomes

Nutrition and Physical Activity Intervention Studies among Women of Reproductive Age
Sweet and Fortier 33 recently discussed that although the benefits of participating in the recommended levels of physical activity and adhering to dietary recommendations have been confirmed for each separate health behavior, research indicates that "the combined effects of all diet and physical activity related behaviors that affect health directly and via their effects on obesity have a much larger total effect than any separate pathway".The authors have also reported that multiple health behavior interventions have been effective at promoting required physical activity level and have encouraged positive dietary behaviors changes in terms of higher fruit and vegetable consumption and diminished fat intake, which have in turn, help in weight loss.However, the effectiveness of multiple health interventions is still a matter of reflection.

Nutrition interventions
A randomized control trial 34 consisted of 633 women aged 18-40 years who were contemplating pregnancy within 1 year, were provided with preconception counseling (PCC).A questionnaire was sent to all women 2 months after delivery, enquiring about their pregnancy outcome and about their behavior before and during pregnancy.The authors reported that among the 211 women who received PCC, more women were initiated to folic acid supplements prior to pregnancy and reduced their alcohol consumption 3 months before pregnancy.The main limitation of this study is the small number of women attending PCC.Guelinckx et al. 35 evaluated the effects of an educational intervention program in Belgium among 115 obese pregnant women recruited before 15 th week of gestation.The results indicated that nutrition counseling during pregnancy could improve dietary intake in terms of decreased saturated fat intake, increased protein, calcium and vegetable intake.The limitation in this study is that since the study population was not nutritionally vulnerable, it was inappropriate to consider the pregnancy outcomes.Although both studies had limitations, the major strength of these two studies is that both considered women before pregnancy and indeed found positive effects of preconception counseling on diet and other lifestyle behavior.
Steptoe et al. 36 measured the effect of brief behavioral counseling in general practice on patients" consumption of fruits and vegetables in adults from a low-income setting.Post intervention, fruit and vegetable intake increased by 1.5 and 0.9 portions per day in the behavioral and nutrition groups.An increase in the number (42% and 27%) of participants eating five or more portions a day was reported in both groups.][39] The advantage of the studies by Steptoe et al. 36 and Heneman et al. 37 is that they demonstrated the effectiveness of the NE among low-income groups.Campbell et al. 40 evaluated the effect of a tailored nutrition education CD-ROM program consisted of a targeted video soap opera, dietary assessment, and individually designed dietary feedback and strategies for change for participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).The authors reported that no differential effect for dietary intake variables.Although the sample size of these studies were more or less the same, the results observed differed.The disparity observed between the four studies and that by Campbell et al. 40 could be due to several limitations such as (i) the use of two different methods of data collection, (ii) use of a brief food frequency only for dietary assessment and also due to (iii) inability to evaluate the influence of other sources of nutrition education participants could have obtained during the study phase.

Multiple health behavior interventions
Previous studies assessed the combined effect of a physical activity and nutrition intervention among women of reproductive age.Two of the interventions reported a positive effect on dietary intake (e.g.replacing high fat foods with low fat alternatives such as fruits and vegetables) and physical activity level (PAL) 41,42 while the other intervention reported favorable trends in the reduction of excessive weight gain and PAL 43 in the short term (4-12 months).In a prospective cohort study, Inskip et al. 17 reported that out of 238 women who became pregnant during the first three months of the study period, those who intended a pregnancy were to some extent more inclined to follow recommendations as compared to those not planning a pregnancy.Approximately the same number of women from both groups was found to take fruits, vegetables and folic acid as recommended and also had reduced alcohol intake.Pregnant women were also likely to undertake strenuous exercise in the past three months.
Furthermore, Liu et al. 44 demonstrated the positive influence of changes in nutrition and health knowledge, as well as enhancement of dietary behaviors in general, for example intake of fruits, vegetables, soybean and soybean products among women in intervention groups.Sweet and Fortier 33 suggested that in multiple health behavior interventions, changing a particular behavior could encourage changes in other health behavior, thus further benefiting the use of multiple health behavior interventions.

Physical Activity interventions
Earlier studies investigated the influence of interventions to enhance physical activity level among women of reproductive age.Albright et al. 45 and Fahrenwald et al. 46 carried out the physical activity intervention among mothers for 8-weeks and reported an increased level of PA post the intervention.Cramp and Brawley 47 and Miller et al. 48alongside with encouraging PA, they included ways of overcoming barriers to promote PA in the intervention.They demonstrated that the groups, who received exercise treatment in addition to the behavioral intervention, had higher PAL following the intervention.It can thus be concluded that while only exercise programs resulted in improvements to exercise participation, the inclusion of behavioral intervention produced greater improvement in overall physical activity, barrier efficacy and proximal outcome expectations.Findings from major interventions studies among women to assess effect of health intervention programs are summarized in Table 2.

Interventions at community level
Community responsibility, specifically, continuous care between the home and different set-ups is another important consideration in the endeavor of optimizing health of women of reproductive age. 49According to Barry et al. 50there is pertinent evidence that health promotion programmes consisting of behavior change strategies, home visits, and participatory campaigns can be helpful in ensuring the health of mothers during the reproductive age.Schiffman et al. 51 further postulate the importance of a Family-Community Care involves services which encompasses both the family and community to harmonise with the social and cultural milieu of particular communities.-The intervention self-efficacy scores for both FV were significantly greater.Ha and Caine-Bish, 2009 38 Kent, Ohio, United States N = 80 (College students aged 18-24 years, 88% females) -3-day food records were collected, verified, and analyzed before and after the intervention.-Consumption of: total vegetable, fresh vegetable, starchy vegetable, French fries, vegetable juice, total fruit, fresh fruit, canned fruit, and fruit juice.
-Participants significantly increased consumption of total fruits and vegetables (P<.005).-Intake of French fries decreased significantly (P<.05).

Campbell et al.
2004 40 North Carolina N = 307 (20% were pregnant and 50% were minorities e.g.African American and other) -Pre-post, randomly assigned to intervention and control -Total fat and fruit and vegetable intake, knowledge of low-fat and infant feeding choices, self-efficacy, and stages of change.
-Intervention group members increased self-efficacy (P< .01)and scored significantly higher (P< .05) on both low-fat and infant feeding knowledge compared with controls.-No differential effect was observed for dietary intake variables.-Prospective cohort study Folic acid supplement intake, alcohol consumption, smoking, diet, and physical activity before pregnancy 238 who became pregnant within 3 months of the study were only marginally more likely to comply with recommendations for those planning a pregnancy than those who did not become pregnant in this period.Women in both groups were equally likely to have recommended fruits, vegetables, and folic acid intake and drank four or fewer units of alcohol a week.Liu et al. 2009 44 Hubei, China N= 302

Multiple health behavior interventions
randomized controlled trial nutrition and health knowledge, dietary behavior, health behavior and health problems during the postpartum period Women in the intervention groups exhibited significantly greater improvement in overall dietary behaviors such as consumption of fruits, vegetables, soybean and soybean products as well as nutrition and health knowledge than those in the control groups.
The incidence of constipation, leg cramp or joint pain and prolonged lochia rubra was significantly lower in the intervention groups as compared with the control groups.This encourages the adoption of healthy lifestyle practices at family as well as community level.A study demonstrated the effectiveness of a nutrition education programme among pregnant women in Iran. 52For instance, a major increase in the nutritional knowledge level of pregnant women was noted with a rise from 3% to 31% post the nutritional education intervention, irrespective of maternal age and educational attainment. 52In line with this, a recent study shows the effectiveness of community-based efforts, in particular gathering of mothers which were intended to promote healthy behaviors, are efficient and can be extrapolated to a larger population. 53On the other hand, Perumal et al. 54 reported that nutrition knowledge, attitudes, and dietary score were not significantly different between women attending and notattending antenatal care clinic attending.However, they found that regular visits to antenatal care clinics were notably related with improved health knowledge among mothers.

Conclusion
Adequate nutrition and healthy lifestyle behaviors such as physical activity and alcohol consumption are to be given significant consideration among women of reproductive age to optimize the health of their babies as well as their own health.There is strong evidence from published studies, which demonstrate that nutrition, and physical activity interventions have had a positive impact on behaviors of women of reproductive age resulting in optimistic health outcomes.It has been found that multiple health intervention strategies have been more successful in modifying health behaviors of women of reproductive age.As demonstrated by the social ecological model, several factors may obstruct women of reproductive age in their endeavour to practice healthy behaviours.Thus, it is important that all family members should be equally involved in health promotion programmes as a support for improved dietary and physical activity practices for women.Nutrition education conducted at community level, for instance in hospitals, and area health centres contribute to positive health behavior modifications.Thus, health professionals should aim at multiple health interventions at community level to have better outcomes.Political support for a broad-based approach to nutrition should further be considered to encourage the practical application of research.

40 --
Randomized control trial -Knowledge on pregnancy-related risk factors and preventive measures and change in their behavior before and during pregnancy -Knowledge of women who received preconception counseling (PCC) exceeded that of women who did not.-After PCC, significantly more women started using folic acid before pregnancy and reduced alcohol use during the first 3 months of pregnancy Guelinckx et al. 2010 35 Belgium N = 115 (pregnant women) -Randomized control trial -Dietary habits, physical activity, gestational weight gain Nutrition counseling was associated with improvements in dietary intake specifically decreased saturated fat intake, increased protein, calcium and vegetable intake Steptoe et al. 2003 36 London, England N = 271 (61% females aged 18-70) -Pre-post, parallel group randomized controlled trial -Self-reported number of portions of fruits & vegetables eaten per day -Consumption of fruits and vegetables increased from baseline to 12 month.-The proportion of participants eating 5 or more portions/day increased by 42% and 27% in both groups.Heneman et al. 2005 37 California, USA N = 38 (Females aged 20-45) -Pre-post, randomized participants into threegroup parallel arm study -Diet change -The contract group had significantly increased acceptance of vegetable consumption.-They also significantly increased fruit consumption.Richards et al. 2006 39 South Dakota, USA N= 437 (75% females aged 18-24) -Pre-post, randomized control intervention -Daily consumption of fruits and vegetables at baseline and post intervention -Fruits & vegetables consumption increased for intervention group.

Table 1 :
Recommended total weight gain in pregnant women by pre pregnancy BMI (in kg/m 2 )

Table 2 :
Findings from interventions studies among women to assess effect of health intervention programmes