Editorials

Exercise During Pregnancy: What Do We Really Know?

SUSAN SNYDER, M.D.
BERNADETTE PENDERGRAPH, M.D.
Harbor-UCLA Medical Center
Torrance, California

As a result of a number of recent studies on exercise in pregnancy, the debate over the risks of aerobic exercise in pregnancy has waned. In January 2002, the American College of Obstetricians and Gynecologists (ACOG) issued an opinion report stating that "In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise a day on most, if not all, days of the week is recommended for most pregnant women."1 While common sense and a number of smaller observational studies and controlled trials support this recommendation, a Cochrane review,2 published in the same month as the ACOG opinion, concluded that there is insufficient evidence of benefit or harm to mother or fetus to make a recommendation regarding aerobic exercise in pregnancy. According to the review, the available studies were too small, flawed in their design, and inconsistent in their methodology and outcome measures to support a recommendation. Specific benefits of regular exercise to mother and fetus have yet to be confirmed.

The recent ACOG Committee Opinion signals a welcome interest in the benefits of regular aerobic exercise in pregnancy and a trend away from focusing on a variety of theoretic risks to mother and baby. In terms of positive benefits, the Cochrane reviewer found that women who exercised regularly during pregnancy subjectively improved their body image and maintained or improved their physical fitness. No other benefits (or risks) were supported by the currently available studies. Parameters studied include mode of delivery, length of labor, growth parameters, preterm birth, and Apgar scores.

Despite the limitations of current evidence, several studies suggest that smaller babies are born to women who exercise vigorously during pregnancy, as a result of restriction of neonatal fat mass. It also has been suggested that these leaner babies may be less likely to become obese children and adults.3 At the very least, pregnancy is a time when women have regular contact with physicians and may be open to general lifestyle changes that might benefit them. Excess weight gain during pregnancy and postpartum weight retention are associated with increased rates of maternal obesity eight to 10 years later.4

Given the current epidemic of obesity and the associated rising incidence in rates of the metabolic syndrome and type II diabetes, it would seem that well-designed, large-scale prospective clinical trials of exercise in pregnancy should be high on the national research agenda, in line with priorities established by Healthy People 2010. Long-term follow-up of the exercising women and their infants could help to clarify the real benefits versus the risks of exercise during pregnancy and allow future recommendations to be based on evidence rather than expert opinion.

For many women, the perceived benefits of physical fitness and enhanced body image provide enough reason to continue to exercise during pregnancy. However, little has been published about the acceptability of exercise in pregnancy to women of diverse cultural backgrounds. Given the high prevalence of obesity and overweight among women in some population subgroups,5 it even may be desirable to provide extra encouragement to exercise during pregnancy, as well as in general. However, successful implementation of the recent ACOG recommendations will require that women find the idea of exercising during pregnancy to be culturally acceptable. Therefore, understanding the attitude of women from diverse backgrounds toward exercise in pregnancy is important.

Given ACOG's statement that potential risks are rare in properly screened pregnant women who avoid extreme environmental conditions and activities that can lead to abdominal trauma, moderate aerobic exercise appears to be a safe, affordable way to improve a woman's sense of well-being during pregnancy. The shift in attitude away from viewing aerobic exercise as a potential hazard to healthy pregnant women is a breath of fresh air. We look forward to the day when sound evidence supports more definitive guidelines about exercise in pregnancy.

REFERENCES

1. ACOG Committee Obstetric Practice. ACOG Committee Opinion, No. 267, January 2002: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171-3.

2. Kramer MS. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev 2004;(1): CD000180.

3. Magann EF, Evans SF, Weitz B, Newnham J. Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women. Obstet Gynecol 2002;99:466-72.

4. Rooney BL, Schauberger CW. Excess pregnancy weight gain and long term obesity: one decade later. Obstet Gynecol 2002;100:245-52.

5. The surgeon general's call to action to prevent and decrease overweight and obesity. 2001. U.S. Department of Health and Human Services. Public Health Service, Office of the Surgeon General. Rockville, Md. Accessed online February 6, 2004, at: http://www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf.

Susan Snyder, M.D., is associate clinical professor of family medicine at the David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, Calif. She also is the director of the Primary Care Faculty Development Center at Harbor-UCLA Medical Center in Torrance, Calif.

Bernadette Pendergraph, M.D., is a faculty member in the family medicine residency program at Harbor-UCLA Medical Center, Torrance, Calif., where she coordinates the sports medicine curriculum.

Address correspondence to Susan Snyder, M.D., Harbor-UCLA Medical Center, Department of Family Medicine, 1403 W. Lomita Blvd., Suite 102, Harbor City, CA 90710. Reprints are not available from the authors.

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Confidential Reproductive Care for Adolescents

IAN BENNETT, M.D., PH.D.
PETER CRONHOLM, M.D., M.S.C.E.
RICHARD NEILL, M.D.
LARISSA CHISM, M.D.
University of Pennsylvania
Philadelphia

Primary care physicians provide the majority of reproductive health care services for minors.1 As family physicians, we need to emphasize the primary role of the family as an irreplaceable health resource. Ideally, parents play an integral and supportive role in the health of their children. However, in the case of reproductive issues, there are times when parental involvement would be detrimental to care, and confidentiality becomes paramount. Thus, family physicians who provide reproductive health care to adolescents face the complex issues of confidentiality and consent. Furthermore, these issues extend to other adolescent health concerns, including substance abuse, mental health, and sexual orientation. Whether or not physicians choose to provide confidential health care to minors, a basic understanding of this topic and applicable state laws is needed to ensure that care is provided in a manner consistent with ethical and legal responsibilities.

While the majority of physicians support confidential health care when adolescents request it,2 many may not be aware of the evidence of associated health benefits. Perceived lack of confidentiality is a barrier to medical care for minors. Among adolescents exhibiting symptoms suggesting health problems, approximately one third reported foregoing care.3 Among female adolescents receiving contraceptive services at Title X family planning clinics (where confidentiality is assured for minors), 59 percent stated that they would stop seeking any health services if parental notification requirements were imposed.4 Adolescent patients often avoid seeking appropriate care or break continuity of care with a primary care physician, particularly for reproductive health needs, unless assurance of confidentiality is provided.5 Conversely, adolescents are more likely to discuss sexually transmitted diseases, pregnancy prevention, and other sensitive topics when confidentiality is assured proactively by their health care professional.6

Family physicians may be unaware of the legal protections for minors who seek confidential care and the exceptions that exist to the usual parental consent requirements. The need for confidential health care for minors has been recognized by the legal system in the United States. There are many federal and state laws and regulations that provide some exceptions to the general requirement for parental consent to provide medical care to minors (typically for reproductive health, mental health, substance abuse, and emergency services). Most state courts recognize concepts such as the "mature" or "emancipated" minor to determine the right to consent for all medical care and often use specific criteria to determine this (e.g., marriage, high school graduation, pregnancy).7

In general, the right to confidentiality follows from the right to consent to care for particular procedures or services. Under circumstances in which physicians object to maintaining confidentiality in the care of an adolescent, it is ethically and legally necessary to make this clear to the patient before services are provided. If an adolescent requests confidentiality and the physician is unwilling to provide it, this must be made clear to the patient immediately, and the physician should offer a referral to an alternative provider. For example, health clinics funded by Title X legislation are available throughout the United States and are mandated to provide confidential sexual health services to minors. It is not acceptable to provide care and later disclose these services against the wishes of the patient. The only exceptions to this are mandatory reporting of suspected child abuse or when minors are suspected to pose a danger to themselves or others.

The American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists have issued policy recommendations that endorse providing confidential care to adolescents when not doing so would lead to adverse health outcomes.8-10 These recommendations encourage parental participation when appropriate, with the caveat that the participation should not stand in the way of needed care.

The policy recommendations emphasize that the best way to protect the health of adolescent patients is to provide meaningful and timely anticipatory guidance to parents and children, with an eye toward improving family communication and supporting adolescents in their developmentally appropriate transition to independence. When that is not possible or desirable, however, we need to be aggressive in protecting the confidentiality of our adolescent patients. Their health depends on it.

REFERENCES

1. Udry JR, Bearman PS, for The National Longitudinal Study of Adolescent Health. Carolina Population Center, University of North Carolina at Chapel Hill. Accessed online February 6, 2004, at: http://www.cpc.unc.edu/projects/addhealth.

2. Harvey LK, Shubat SC. Physician opinion on health care issues: 1987. Chicago, Ill: American Medical Association, 1987.

3. Ford CA, Bearman PS, Moody J. Foregone health care among adolescents. JAMA 1999;282:2227-34.

4. Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA 2002;288: 710-4.

5. Klein JD, Wilson KM, McNulty M, Kapphahn C, Collins KS. Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. [erratum appears in J Adolesc Health 1999;25:312]. J Adolesc Health 1999;25:120-30.

6. Thrall JS, McCloskey L, Ettner SL, Rothman E, Tighe JE, Emans SJ. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med 2000; 154:885-92.

7. English A, Simmons PS. Legal issues in reproductive health care for adolescents. Adolesc Med 1999; 10:181-94.

8. AAFP Statement of Policy on Adolescent Health Care: American Academy of Family Physicians. 2003. Accessed online February 6, 2004, at: http://www.aafp.org/x6613.xml.

9. Counseling the adolescent about pregnancy options. Committee on Adolescence. American Academy of Pediatrics. Policy statement. Pediatr 1998; 100:938-40.

10. Health care for adolescents. American College of Obstetricians and Gynecologists. ACOG Committee on Adolescent Health Care. 2003.

David H. Holben, Ph.D., R.D., L.D., is associate professor and director, Didactic Program in Dietetics, at Ohio University College of Health and Human Services, Athens.

Wayne Myles, D.O., practices at Albany Family Medicine, Albany, Ohio, and is part-time faculty at Ohio University College of Osteopathic Medicine, Athens.

Address correspondence to David H. Holben, Ph.D., R.D., L.D., Ohio University College of Health and Human Services, School of Human and Consumer Sciences, Grover Center W324, Athens, OH 45701. Reprints are not available from the authors.

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Food Insecurity in the United States: Its Effect on Our Patients

DAVID H. HOLBEN, PH.D., R.D., L.D.
Ohio University College of Health and Human Services
Athens, Ohio

WAYNE MYLES, D.O.
Albany Family Medicine
Albany, Ohio, and
Ohio University College of Osteopathic Medicine Athens, Ohio

The term "food security" refers to the concept of people having access to enough food, including the ready availability of nutritionally adequate, safe foods for an active, healthy life and the ability to acquire these foods in socially acceptable ways.1 When individuals and families have limited access to food or if their ability to obtain food is limited or uncertain (food insecurity), they often resort to the use of emergency food supplies, or they beg, steal, or scavenge for food.1

Standardized measures of U.S. household food security status are included in the Census Bureau's Current Population Survey and other large national surveys.2,3 In 2001, 10.7 percent of U.S. households were unable to secure adequate amounts of food; and in 2002, that number rose to 11.1 percent, representing 12.1 million households and 34.9 million people, including 13.1 million children.4

For the practicing physician, a thorough history is key to uncovering and then assisting patients experiencing food insecurity. Generally, households unable to secure adequate amounts of food have limited resources, and lack access (because of limited resources, lack of transportation, living in remote areas, or limited access to food stores). To cope, these people depend on food assistance programs, substitute less expensive alternatives for nutritious foods, seek assistance from emergency feeding programs (e.g., soup kitchens and food pantries), and skip meals.5 The households that are at higher risk of being unable to secure adequate amounts of food are those whose income falls below the official poverty line; those headed by a single woman with children; those with black or Hispanic members; those with children; and those located in central cities or rural areas, or in southern and western states.4

When persons lack access to proper food, physical impairment, psychologic suffering, and sociofamilial disturbance may result.6 In fact, having adequate food is vital to achieving the U.S. Healthy People 2010 objectives.7

Among adults, poor or fair self-rated health and physical limitations, poorer functional health status, and depression were associated with the inability to secure adequate amounts of food. An increase in disordered eating patterns and a decrease in consumption of fruit, vegetable, or dairy consumption was also noted. Food insecurity has been associated with decreased caloric intake, as well as decreased intake of nutrients, including antioxidants. Paradoxically, food insecurity has been associated with a greater body mass index and obesity among women.8,9 It has been speculated that the relationship of obesity and food insecurity may be mediated by the low cost of energy-dense foods and reinforced by the pleasing taste of sugar and fat.10

Although inability to secure adequate amounts of food may not have immediate health effects, the risk of chronic disease appears to increase in patients experiencing food insecurity.8,9

Family physicians should be aware that their patients may have difficulty complying with prescribed treatments simply because of issues related to food insecurity. Unfortunately, patients often are faced with difficult decisions. One report prepared for America's Second Harvest11 revealed that 30 percent of emergency food clients were faced with the choice of paying either for food or for medicine or medical care. In addition, 45 percent were faced with choosing to pay for food or for utilities or heating fuel, and 36 percent had to choose between paying for food or rent or mortgage payments.11

While family physicians face time constraints when interacting with patients, to improve patient access to food, physicians should inquire about weight loss and dietary habits resulting from having limited resources. Examples of dietary habits that may result include relying on only a few kinds of low-cost foods, not eating a variety of foods or "balanced" meals, eating less or cutting meal size, skipping meals, and not eating when hungry. Several other factors also should be considered during an office visit to facilitate food security (Table 1). Knowing and understanding the culture of the community will guide additional points to consider in the office visit. Some practices involve other health professionals, including registered dietitians and social workers, who can assist in helping patients to secure adequate amounts of food.

TABLE 1 Food Security Factors to Consider During an Office Visit Factors Possible resources/treatment plan considerations Availability of resources necessary for implementing the prescribed medical care Money for medication or food; availability of appliances (refrigerator, freezer); availability of utilities (natural or propane gas, electric, water); availability of transportation Participation in food assistance programs Federal programs (Food Stamps, National School Lunch, Special Supplemental Nutrition Program for Women, Infants, and Children); food pantries, soup kitchens, community gardens, and other non-Federal programs Other means of acquiring food Gardening, hunting for game or fish Nutrition education to help preserve food resources and reduce food waste Meal planning and purchasing tips; label-reading tips (meaning of manufacturers' expiration codes and other dates on packages); food safety education (e.g., safe food preservation tips)

Ultimately, referrals may be necessary to assist the patient in securing adequate food. A variety of programs are available across the United States, and others are unique to particular communities (Table 2). An understanding of the household structure will assist physicians in making appropriate referrals. For example, a physician may see a young adult male whose spouse is pregnant and whose elderly father lives with the family. Using a current list of community programs, it would be appropriate to advise the patient that his wife may be eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children, and that his father may be eligible for service from Meals on Wheels.

TABLE 2 Food Assistance Programs Programs Program summary, referral information, and Web site addresses Child and Adult Care Food Program Provides nutritious meals and snacks to children and adults who receive day or after-school care away from home and to children residing in homeless shelters. Usually administered by the state education agency. Refer clients directly to programs in the community. Web address: http://www.fns.usda.gov/cnd/CARE/CACFP/cacfphome.htm Expanded Food and Nutrition Education Program Helps limited-income families and youth acquire knowledge, skills, attitudes, and behavior changesnecessary to maintain nutritionally sound diets and enhance personal development (basic nutrition, food preparation, resource management). Refer clients to the county extension office. Web address: http://www.reeusda.gov/f4hn/efnep/efnep.htm Food Distribution Programs such as: Child Nutrition Commodity Support; Nutrition Services Incentive Program (formerly the Nutrition Program for the Elderly); Commodity Supplemental Food Program; Food Assistance in Disaster Situations; Food Distribution Program on Indian Reservations; the Emergency Food Assistance Program; State Processing Program; Nutrition Assistance Program for Puerto Rico, American Samoa, and the Northern Marianas; and Homeless Children Nutrition Program Overall, these programs support the nutrition safety net through commodity distribution and other nutrition assistance to low-income families, emergency feeding programs, Indian reservations, and the elderly. Refer clients to local food banks and pantries or other agencies/organizations, including faith-based groups, where supplemental foods are distributed. Your local food bank can be accessed through America's Second Harvest. Web addresses: http://www.secondharvest.org http://www.fns.usda.gov/fdd http://www.fns.usda.gov/fns/menu/programs.htm Food Stamp Program Enables low-income families to buy nutritious food with coupons and Electronic Benefits Transfer cards. Food stamp recipients spend their benefits to buy eligible food in authorized retail food stores. Refer patients to the local food stamp office. Web address: http://www.fns.usda.gov/fsp National Meals on Wheels Foundation Dedicated to the delivery of meals to homebound senior citizens and those at congregate sites. Programs are organized by a variety of groups, including local communities, churches, charitable organizations, and concerned citizens. Refer clients directly to programs. The Area Agency on Aging may be helpful. Web address: http://www.nationalmealsonwheels.org National School Lunch and School Breakfast Programs Provides nutritionally balanced, low-cost or free breakfasts and lunches to children enrolled in public and nonprofit private schools and residential child care institutions. Also provides snacks served in after-school educational and enrichment programs for children through 18 years of age. Refer patients to local schools. Web addresses: http://www.fns.usda.gov/cnd/lunch/default.htm and http://www.fns.usda.gov/cnd/breakfast/default.htm Senior Farmers' Market Nutrition Program Provides low-income seniors with coupons that can be exchanged for eligible foods (fresh, nutritious, unprocessed fruits, vegetables, and fresh-cut herbs) at farmers' markets, roadside stands, and community-supported agriculture programs during the harvest season. Refer clients to local programs. The Area Agency on Aging may be helpful. Web address: http://www.fns.usda.gov/wic/seniorFMNP/SFMNPmenu.htm Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and WIC Farmers' Market Nutrition Program Provides supplemental foods, nutrition education and counseling, and access to health services to low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to 5 years of age, who are found to be at nutritional risk. As part of the WIC Farmers' Market Nutrition Program, a variety of fresh, nutritious, unprepared, locally grown fruits, vegetables, and herbs may be purchased with coupons. Refer patients to the local WIC agency. Web addresses: http://www.fns.usda.gov/wic and http://www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm Summer Food Service Program Provides nutritious breakfasts, lunches, and snacks to ensure that children in lower-income areas continue to receive nutritious meals during long school vacations when they do not have access to school lunch or breakfast. Refer children to local summer programs. Area schools may have information about available programs. Web address: http://www.summerfood.usda.gov

Community involvement by family physicians also can benefit patients. Initiating the development of a food pantry within a medical clinic or personally assisting the local food bank with a food drive or food recovery project (http://www.usda.gov/news/pubs/gleaning/content.htm) can benefit patients and the community.

Finally, continuing to learn about food insecurity and how it negatively impacts patients is vital. In addition to participating in continuing medical education on the topic, practicing physicians can access information through several organizations (Table 3).

TABLE 3 Food Security Information Resources Information available online Center for Hunger and Poverty (http://www.centeronhunger.org) Community Food Security Coalition (http://www.foodsecurity.org) Food Research and Action Center (http://www.frac.org) Food Security in the U.S. Briefing Room (http://www.ers.usda.gov/briefing/foodsecurity) World Hunger Year (http://www.worldhungeryear.org) U.S. Department of Agriculture Community Food Security Initiative (http://www.reeusda.gov/food_security/foodshp.htm) World Hunger Site (http://www.thehungersite.com)

REFERENCES

1. Life Science Research Office. Federation of American Societies for Experimental Biology. Core indicators of nutritional state for difficult to sample populations. J Nutr 1990;102:1559-60.

2. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measure household food security, revised 2000. Alexandria, Va.: U.S. Dept of Agriculture, Food and Nutrition Service, 2000.

3. USDA Economic Research Service. Food Security in the United States Briefing Room. Available at: http://www.ers.usda.gov/briefing/foodsecurity.

4. Nord M, Andrews M, Carlson S. Household food security in the United States, 2001 (FANRR35). Alexandria, Va.: Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, 2003. Accessed online January 3, 2004, at: http://www.ers.usda.gov/publications/FANRR35.

5. Andrews M, Nord M, Bickel G, Carlson S. Household food security in the United States, 1999 (FANRR-8). Alexandria, Va.: Food and Rural Economics Division, Economic Research Service, U.S. Dept. of Agriculture, 2000.

6. Hamelin AM, Habicht JP, Beaudry M. Food insecurity: consequences for the household and broader social implications. J Nutr 1999;129:525S-8S.

7. Healthy People 2010. Available at: http://www.health.gov/healthypeople.

8. Olson CM, Holben DH. Position of the American Dietetic Association on domestic food and nutrition security. J Am Diet Assoc 2002;102:1840-7.

9. Holben DH. An overview of food security and its measurement. Nutrition Today 2002;37:156-62.

10. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr 2004;79:6-16.

11. Kim M, Ohls J, Cohen R. Hunger in America, 2001. National report prepared for America's Second Harvest. Princeton, N.J.: Mathematica Policy Research, 2001.

Ian Bennett, M.D., Ph.D., and Peter Cronholm, M.D.,M.S.C.E., are clinical professors; Richard Neill, M.D., is assistant professor; and LaRissa Chism, M.D., is a medical student, in the Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia.

Address correspondence to Ian Bennett, M.D., Ph.D., Department of Family Practice and Community Medicine, 2nd floor, Gates Bldg., Hospital of the University of Pennsylvania, 3400 Spruce St., Phila-delphia, PA 19104.

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