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The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Michigan:
Physical Activity
Nutrition and Nutrition
Physical and
Activity
Women’s Health: Summary
Figure 1: Prevalence of women aged 18-44
years with self-reported positive indicators, or
Summary of Key Points (2010 MI-PRAMS and 2011
those which would ideally increase over time with
MI-BRFSS data presented in these factsheets)
improved health; 2011 MIBRFSS and 2010 MI

PRAMS.
Most women aged 18-44 years did not
have adequate fruit and vegetable
Adequate Fruit and
Vegetable
Consumption *
consumption, prenatal multivitamin use,
22.1
or physical activity
Prenatal Multivitamin
Use ^

29.2
While prenatal multivitamin use was
achieving and exceeding the HP 2020
Adequate Physical
Activity *
18.7
Goal, several significant disparities were
evident based on age, race, health
0
10
20
30
Percent
40
50
insurance status, educational attainment,
and household income
Figure 2: Prevalence of women aged 18-44
years with self-reported negative indicators, or

The total prevalence of adequate physical
those which would ideally decrease over time
activity did not achieve the HP 2020 Goal,
with improved health; 2011 MI BRFSS and 2010
and significant disparities were evident
MI PRAMS.
based on race, health insurance status,
educational attainment, and household
Overweight or
obese *
26.9
income
28.7
Overweight
Prenatal
overweight or
obese ^
23.8

overweight (23.8%) or obese (21.3%) at the
21.3
Obese
0
10
20
30 40
Percent
Over 46% of Michigan women were
50
60
time they became pregnant

The prevalence of prenatal obesity was
higher among black women compared to
* MI-BRFSS: women aged 18-44 years
^ MI-PRAMS: women aged 18-44 years having a live birth
white women
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Michigan:
Physical Activity
Nutrition and Nutrition
Physical and
Activity
Overview of Preconception Health
Why is Preconception Health Important?
Preconception health refers to the
health and well-being of women
prior to becoming pregnant either for
the first time or with subsequent
pregnancies. Improving the
preconception health of women can improve maternal and infant health outcomes.1,2,3
Preconception health encompasses biomedical,

Fruit and Vegetable Consumption

Folic Acid Supplementation

Overweight and Obesity

Exercise and Physical Activity
For information regarding data sources, please reference
the “Preconception Health in Michigan: Nutrition and
Physical Activity” factsheet subtitled “Data Sources.”
Healthy People 2020 Goals
behavioral, and social factors. In 2010, nearly
The Healthy People 2020 (HP
45% of Michigan mothers delivering live births
2020) Goals are a set of science-
reported that the pregnancy was unintended
based goals created by a national multi-
(PRAMS data). Additionally, many women do
disciplinary group with the objective of improving
not seek prenatal care until eight weeks of gesta-
the health and well-being of all people in the
tion or later, at which time the period that carries
United States.3 In the factsheets, the HP 2020
the highest risk for the fetus has already
Goal is represented by a dashed line and an
passed.3 Education and awareness of improved
arrow demonstrating whether it is more desirable
health of all women of reproductive age can help
to be above or below the goal.
improve future pregnancy outcomes.
References
Preconception Health Indicators
1.
Centers for Disease Control and Prevention. Recommendations to improve preconception health and
health care—United States. MMWR 2006; 55
(RR06):1-23
2.
Broussard DL, et al. Core state preconception
health indicators: a voluntary, multi-state selection
process. Matern. Child Health J. 2011; 15(2):158168.
3.
United States Department of Health and Human
Services. “Healthy People 2020.” 2013. Available
online: http://www.healthypeople.gov/2020/
default.aspx. Accessed May 10, 2013.
A national committee of state
program leaders and epidemiologists has identified broad health
domains related to preconception
health, and has proposed specific
health indicators based on currently measurable
data for women of reproductive age.2 Indicators
are used to monitor public health status and help
Suggested Citation
assess progress toward national and state goals.
Vanos H, Larder C, Fussman C, McKane P, Wahl R.
Michigan Department of Community Health.
“Preconception Health in Michigan: Nutrition and Physical
Activity.” 2013.
The information in these factsheets encompasses the Nutrition and Physical Activity Domain:
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Nutrition and
and Physical
Physical Activity
Activity
Fruit and Vegetable Consumption
Overview: Low birth weight and prematurity are
dent, none achieved
associated with maternal dietary inadequacy
statistical significance
before becoming pregnant. The diets of mothers
with low birth weight infants are frequently
deficient in fruits and vegetables.1 Fruits and
vegetables are important sources of vitamins,
including folic acid and Vitamin A, which are
essential for healthy fetal development. Growth
of the placenta and fetus is most susceptible to
Trends Over Time: Prevalence has slightly
increased over the years of 2002-2009
Figure 1: Prevalence of women aged 18-44
years with self-reported adequate fruit and vegetable consumptiona by year, 2002-2011 Michigan BRFSS.
40
the effects of maternal nutrition during the
pre-implantation period through the first few
30
Percent
weeks of gestation.2 Typically, this occurs before
pregnancies are confirmed. Women of reproductive age, especially those planning to become
pregnant, can maximize future pregnancy health
20
10
by eating a well balanced diet including fruits,
0
2000
vegetables, and foods containing calcium,
2002
2004
2006
2008
2010
2012
2
protein, iron, Vitamin C, and folic acid.
Preconception Health Indicator: Percentage of
women aged 18-44 years who consume fruits
(including juice) and vegetables at least 5 times
Due to BRFSS methodology changes, 2011 BRFSS
estimates cannot be compared to BRFSS estimates from
previous years.
a
Consumption of fruits (including juice) and vegetables at least 5
times per day
per day
References
HP 2020 Goal: Increase the contribution of fruits
1.
Brundage SC. Preconception health care. Am. Fam.
Physician 2002; 65(12):2507-2515
2.
Gardiner PM, Nelson L, et al. The clinical content of
preconception care: nutrition and dietary supplements. Am. J. Obstet. Gynecol. 2008; 199(6 suppl
2):s345-56
and vegetables to the diets of the population
aged 2 years and older
Key Points (MI-BRFSS, 2011)

Most women aged 18-44 years did not
Suggested Citation
have adequate fruit and vegetable
Vanos H, Larder C, Fussman C, McKane P, Wahl R.
Michigan Department of Community Health.
“Preconception Health in Michigan: Nutrition and Physical
Activity.” 2013.
consumption

Although disparities in the data were evi-
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Fruit and Vegetable Consumption
Figure 2: Prevalence of women aged 18-44
years with self-reported adequate fruit and
vegetable consumptiona by age group, 2011 MI
-BRFSS
Figure 3: Prevalence of women aged 18-44
years with self-reported adequate fruit and
vegetable consumptiona by race, 2011 MIBRFSS
50
50
40
40
29.8
23.8
Black
Other
30
21.2
22.1
17.9
20
Percent
Percent
27.4
30
22.1
20.6
Total
White
20
10
10
0
0
Total
18‐24
25‐34
35‐44
Figure 4: Prevalence of women aged 18-44
years with self-reported adequate fruit and
vegetable consumptiona by educational attainment, 2011 MI-BRFSS
Figure 5: Prevalence of women aged 18-44
years with self-reported adequate fruit and
vegetable consumptiona by household income,
2011 MI-BRFSS
40
20.9
40
23.6
30
27.7
25.4
30
16.7
Percent
Percent
22.1
20
10
22.1
19.3
Total
< $25,000
19.6
20
10
0
0
Total
Less than High school
high school graduate
Some
college
College
graduate
$25,000 ‐
$49,000
$50,000 +
a
Consumption of fruits (including juice) and vegetables at least 5 times per day
HP 2020 Goal: Increase the contribution of fruits and vegetables to the diets of the population aged 2 years
and older
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Folic Acid Supplementation
Overview: Maternal nutrition in the preconcep-

tion period and during pregnancy is critically
Prevalence of folic acid supplementation
was lower than the HP 2020 Goal in wom-
1
important for fetal development. There is a
en:
considerable amount of evidence that synthetic
folic acid supplementation in the preconception
period and early gestation has protective
mechanisms against several congenital malformations,
1,2,3

Aged 18-24 years

Who were Black

Enrolled in Medicaid
and is also associated with
or with no health
decreased risk for low birth weight and small for
insurance
1
gestational age. With dietary supplementation,
certain congenital malformations called neural
tube defects (such as spina bifida) can be

With low educational attainment

With low household income
decreased by 60-70%.3,4 Folate is important for
Trends Over Time: Prevalence has been
the synthesis of DNA and protein, and for
constant and consistently achieving and exceed-
2
regulation of DNA expression. For optimal
ing the HP 2020 Goal over the years of 2004-
protective effects, it is recommended that women
2010.
begin folic acid supplementation at least three
months prior to conception.4
Preconception Health Indicator: Percentage of
References
1.
Timmermans S, et al. Periconception folic acid supplementation, fetal growth and the risks of low birth
weight and preterm birth: the Generation R study.
Brit. J. Nutr. 2009:;102(5):777-785.
2.
Boxmeer JC, et al. Preconception folic acid treatment affects the microenvironment of the maturing
oocyte in humans. Fertil. Steril. 2008; 89(6):17661770.
3.
Persad VL, et al. Incidence of open neural tube defects in Nova Scotia after folic acid fortification. Can.
Med. Assoc. J. 2002; 167(3):241-245.
4.
Centers for Disease Control and Prevention. Recommendations to improve preconception health and
health care—United States. MMWR 2006; 55
(RR06):1-23
women aged 18-44 years having a live birth who
took a multivitamin or prenatal vitamin daily
during the month before conception
Healthy People 2020 Goal: Increase the
proportion of women delivering a live birth who
took a multivitamin/folic acid prior to pregnancy
to 33.1%
Key Points (MI-PRAMS, 2010)

Most women aged 18-44 did not have
Suggested Citation
adequate folic acid supplementation one
Vanos H, Larder C, Fussman C, McKane P, Wahl R.
Michigan Department of Community Health.
“Preconception Health in Michigan: Nutrition and Physical
Activity.” 2013.
month prior to conception
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Folic Acid Supplementation
Figure 1: Prevalence of women aged 18-44
years having a live birth with self-reported prepregnancy multivitamin or prenatal vitamin
usea by age group, 2010 MI-PRAMS
Figure 2: Prevalence of women aged 18-44
years having a live birth with self-reported prepregnancy multivitamin or prenatal vitamin
usea by race, 2010 MI-PRAMS
60
40.1
50
50
34.9
40
40
29.2
30
HP 2020
Goal 33.1 %
20
Percent
Percent
40.5
60
13.9
31.5
29.2
30
HP 2020
Goal 33.1%
19.3
20
10
10
0
0
Total
18‐24
25‐34
35‐44
Total
Figure 3: Prevalence of women aged 18-44
years having a live birth with self-reported prepregnancy multivitamin or prenatal vitamin
usea by educational attainment, 2010 MI- PRAMS
White
Black
Figure 4: Prevalence of women aged 18-44
years having a live birth with self-reported prepregnancy multivitamin or prenatal vitamin
usea by household income, 2010 MI-PRAMS
60
60
45.8
45.9
50
50
40
30
24.0
HP 2020
Goal 33.1%
Percent
40
29.2
23.8
15.2
30
20
10
10
0
26.1
29.2
20
HP 2020
Goal 33.1%
18.4
0
Total
Less than High school
high school graduate
Some
college
College
graduate
Total
< $25,000
$25,000 ‐
$49,000
$50,000 +
Figure 5: Prevalence of women aged 18-44 years having a
live birth with self-reported pre-pregnancy multivitamin or
prenatal vitamin usea by health insurance, 2010 MI-PRAMS
50
37.4
40
29.2
Percent
Percent
Other
30
HP 2020
Goal 33.1%
17.3
19.0
a
Consumption of a multivitamin or prenatal vitamin daily for one month prior
to conception. This is an estimation of
folic acid intake.
20
10
0
Total
Uninsured Medicaid
Private
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Overweight and Obesity
Overview: In the past 20 years, the prevalence
Healthy People 2020 Goal: Reduce the propor-
of obesity in pregnant women and women of
tion of adults who are obese to 30.6%
reproductive age has increased in many highincome countries.1
Key Points (MI-PRAMS, 2010)

Maternal overweight has been associated with
years having a live birth were classified
increased risk of cesarean section and post-
as either overweighta (23.8%) or obeseb
operative complications for those deliveries,
(22.6%) at the time they became pregnant
gestational diabetes, and hypertension. Infants
of overweight mothers are more likely to be
Over 46% of Michigan women aged 18-44

The prevalence of prenatal obesity was
admitted to neonatal intensive care units com-
higher among Black women compared to
pared to normal-weight mothers.2
White women
In obese women, stillbirth is nearly twice as likely
1
compared to normal-weight women. Maternal
a
BCS ≥ 25 and < 30 based on self-reported height and weight
BCS ≥ 30 based on self-reported height and weight
b
obesity has been associated with numerous
Trends Over Time: Prevalence of prenatal over-
other poor perinatal outcomes, including preterm
weight and obesity has been constant over the
delivery, cesarean section, heart defects, neural
years of 2004-2010, and obesity has achieved
tube defects, macrosomia (excessive birth
(remained below) the HP 2020 Goal.
weight), low Apgar scores, perinatal mortality,
gestational diabetes, hypertension and
References
preeclampsia, and
1.
Vasudevan C, Renfrew M, McGuire W. Fetal and
perinatal consequences of maternal obesity. Arch.
Dis. Child Fetal Neonatal Ed. 2011; 96(F):378-382
2.
Galtier-Dereure F, Boegner C, Bringer J. Obesity
and pregnancy: complications and cost. Am. J. Clin.
Nutr. 2000; 71(5):1242s-1248s.
3.
Centers for Disease Control and Prevention. Recommendations to improve preconception health and
health care—United States. MMWR 2006; 55
(RR06):1-23
thromboembolic disease.1,2,3 These risks
can be decreased with
appropriate weight loss
and nutrition in the preconception period.3
Preconception Health Indicator: Percentage of
women aged 18-44 years with a Body Mass Index (BMI; weight in kg/height in m2) ≥ 25 but < 30
(overweight) or BMI ≥ 30 (obese)
Suggested Citation
Vanos H, Larder C, Fussman C, McKane P, Wahl R.
Michigan Department of Community Health.
“Preconception Health in Michigan: Nutrition and Physical
Activity.” 2013.
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Overweight and Obesity
Figure 1: Prevalence of women aged 18-44
years having a live birth who were overweighta
or obeseb at the time they became pregnant
by age group, 2010 MI-PRAMS
Figure 2: Prevalence of women aged 18-44
years having a live birth who were overweighta or obeseb at the time they became
pregnant by race, 2010 MI-PRAMS
50
24.1
50
31.4
30
HP 2020 Goal
30.6% obese
26.0
21.4
20.2
23.8
22.6
40
22.9
21.4
Overweight
Obese
20
30
23.8
22.6
25.8
9.9
23.7
21.1
Overweight
Obese
20
10
10
0
0
Total
18‐24
35‐34
35‐44
Total
Figure 3: Prevalence of women aged 18-44
years having a live birth who were overweighta
or obeseb at the time they became pregnant
by educational attainment, 2010 MI-PRAMS
White
Black
Other
Figure 4: Prevalence of women aged 18-44
years having a live birth who were overweighta or obeseb at the time they became
pregnant by household income, 2010 MIPRAMS
30.4
40
HP 2020 Goal
30.6% obese
40
24.9
26.3
24.0
30
23.8
20.6
22.6
23.6
22.8
30
20
Overweight
Obese
Percent
18.1
Percent
29.7
HP 2020 Goal
30.6% obese
Percent
Percent
40
HP 2020 Goal
30.6% obese 24.725.7
25.2
22.9
23.8
22.6
23.5
19.3
20
Overweight
Obese
10
10
0
Total
a
Less than high
school
High school
graduate
Some college College graduate
0
Total
<$25,000 $25,000 ‐ $50,000 +
$49,000
BCS ≥ 25 and < 30 based on self-reported height and weight; bBCS ≥ 30 based on self-reported height and weight
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Exercise and Physical Activity
Overview: Physical activity can help individuals
minutes per week of vigorous intensity, or an
maintain a healthy weight, and can also impact
equivalent combination, and also participate in
several other aspects of health. It can help lower
muscle strengthening activities on two or more
blood pressure, reduce the risk for heart attack,
days per week, to 20.1%.
stroke, type 2 diabetes, several forms of cancer,
Key Points (MI-BRFSS, 2011)
and osteoporosis, and reduce symptoms of

depression and anxiety.1
have adequate physical activity
Physical activity during the preconception period
has been associated with decreased risk of ges-
Most women aged 18-44 years did not

Prevalence of adequate physical activity
tational diabetes.2,3,4 Gestational diabetes has
was significantly lower than the HP 2020
been associated with a predisposition to post-
Goal in women:
partum type 2 diabetes in mothers.2 Additionally,
gestational diabetes and glucose intolerance
during pregnancy can
increase risk of
cesarean section,
childhood obesity, and
diabetes in children
and young adults.3,4

With low household income
3.
Baptiste-Roberts K, Ghosh P, Nicholson WK.
Pregravid physical activity, dietary intake, and glucose intolerance during pregnancy. J. Womens
Health 2011; 20(12):1847-1851
4.
tensity for 150+ minutes per week, or 75+
With low educational attainment
Retnakaran R, et al. Pre-gravid physical activity and
reduced risk of glucose intolerance in pregnancy: the
role of insulin sensitivity. Clin. Endocrinolo. 2009; 70
(4):615-622
lent combination of the two
aerobic physical activity of at least moderate in-

2.
activity for 75+ minutes per week, or an equiva-
Increase the proportion of adults who engage in
With no health insurance
Centers for Disease Control and Prevention.
“Healthy weight—it’s not a diet, it’s a lifestyle!” 2011.
Available online: http://www.cdc.gov/healthyweight/
physical_activity/index.html. Accessed May 13,
2013.
who engage in either moderate physical activity
Healthy People 2020 Goal:

1.
in leisure-time physical activity, the percentage
for 150+ minutes per week or vigorous physical
Who were Black
References
Preconception Health Indicator:
Among women aged 18-44 years who participate

Tobias DK, et al. Physical activity before and during
pregnancy and risk of gestational diabetes mellitus:
a meta-analysis. Diabetes Care 2011; 34(1):223229
Suggested Citation Vanos H, Larder C, Fussman C,
McKane P, Wahl R. Michigan Department of Community
Health. “Preconception Health in Michigan: Nutrition and
Physical Activity.” 2013.
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Exercise and Physical Activity
Figure 1: Prevalence of women aged 18-44
years who participated in adequate aerobic
physical activitya by race, 2011 MI-BRFSS
Figure 2: Prevalence of women aged 18-44
years who participated in adequate aerobic
physical activitya by health insurance, 2011 MIBRFSS
30
30
20.7
18.7
20
10
13.9
HP 2020
Goal 20.1%
Percent
Percent
20
11.6
HP 2020
Goal 20.1%
19.5
18.7
12.1
10
0
0
Total
White
Black
Other
Figure 3: Prevalence of women aged 18-44
years who participated in adequate aerobic
physical activitya by educational attainment,
2011 MI-BRFSS
Total
No Health
Insurance
Health Insurance
Figure 4: Prevalence of women aged 18-44
years who participated in adequate aerobic
physical activitya by household income, 2011
MI-BRFSS
40
30
22.4
26.3
30
20
8.8
20
13.0
HP 2020
Goal 20.1%
Percent
Percent
18.7
17.0
18.7
19.6
HP 2020
Goal 20.1%
11.5
10
10
0
0
Total
a
Less than High school
high school graduate
Some
college
College
graduate
Total
< $25,000
Either moderate physical activity for 150+ minutes per week or vigorous physical activity for 75+ minutes per
week, or an equivalent combination of the two, and muscle strengthening activities on two or more days per week
(of those reporting leisure physical activity)
$25,000 ‐
$49,999
$50,000+
The Health of Women and Girls Factsheet Series
Preconception Health in Michigan
Preconception Health in Michigan
Nutrition
Physical
Activity
Michigan:
Physical Activity
Nutrition and
and Nutrition
Physical and
Activity
Data Sources
Michigan Behavior Risk Factor Surveillance
respond by mail. Data are self-reported and sub-
System (MI-BRFSS)
ject to recall bias.1 However, yearly findings can
BRFSS is a joint effort of the
CDC and state health depart-
be applied to 98% of residents who deliver a live
birth in Michigan.4
ments, and is available in all 50
states. It is a telephone health
survey of adults aged 18 years
and older, whom are selected by random-digit
dialing.1 BRFSS methodology recently changed
to include cell phone only respondents.2 BRFSS
serves as a data source regarding health risk
behaviors, preventive health practices, and
References
health care access. Data are all self-reported, so
1.
Broussard DL, et al. Core state preconception
health indicators: a voluntary, multi-state selection
process. Matern. Child Health J. 2011; 15(2):158168.
2.
Centers for Disease Control and Prevention.
“BRFSS 2011 Survey Data and Documentation.”
2013. Available online: http://www.cdc.gov/brfss/
annual_data/annual_2011.htm. Accessed May 21,
2013.
3.
Larder C, MI PRAMS Epidemiologist. Personal communication, May 14, 2013.
4.
Grigorescu et al. Preconception Health Assessment
Work Group. “Preconception Health in Michigan.”
2011.
this surveillance method is subject to recall bias
as people may not remember previous behaviors
or health conditions. However, BRFSS is
regarded as having moderate to high validity
(accuracy).1
Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS)
PRAMS is a joint effort of the CDC
and state health departments, and
is available in 40 states and New
York City.3 It is a mailed questionnaire sent to a stratified, random
sample of women with a live birth in the previous
2-6 months3, gathering data on maternal
attitudes, experiences, health behaviors and
conditions, and health care access.1 Telephone
follow-up is conducted for women who do not
Suggested Citation
Vanos H, Larder C, Fussman C, McKane P, Wahl R.
Michigan Department of Community Health.
“Preconception Health in Michigan: Nutrition and Physical
Activity.” 2013.