Introduction. The primary purpose of this study was to learn if new recommendations for prenatal supplements of docosahexaenoic acid (DHA) and choline have been implemented into care by physicians who care for pregnant women in rural Kansas communities. Both nutrients are inadequate in the diet of most pregnant women in the United States and not all prenatal supplements provide DHA and choline. Methods. A cross sectional web-based survey was developed and provided by University of Kansas Medical Center (KUMC) students to 44 rural Kansas clinics believed to have physicians who provide obstetrical care. Questions about DHA and choline were embedded in a larger survey focused on prenatal care. A total of 29 surveys were returned, however, only 21 were completed by physicians who provided obstetrical care. Results. DHA (3/21) and choline (0/21) were rarely singled out for recommendation in contrast to folic acid (16/21) and iron (14/21). Participants stated that most women sought prenatal care during the first trimester of their pregnancy and indicated that they recommended prenatal vitamins at the first visit. Eleven gave patients a prescription for prenatal vitamins.  The remaining patients either chose traditional over the counter prenatal vitamin capsules or less traditional chewable (gummy) vitamins, which provide lower concentrations of nutrients.  Common barriers to nutritional counseling were limited resources and time constraints. Clinicians assessed their confidence and ability to provide nutritional counseling as moderate and competent, respectively. Conclusions. New nutritional recommendations for DHA and choline have not been implemented into standard of care in rural Kansas.

Objectives Iodine (I) is an essential nutrient for fetal neurodevelopment through its role in thyroid function. Like I, fluoride (F) is a halogen and urinary F concentration (UFC) has been linked to increased thyroid stimulating hormone (TSH) in non-pregnant adults with I deficiency. We hypothesize that F and I may interact in their role on thyroid function among pregnant women. Methods Pregnant women (n = 966) provided urine between 12- and 20-weeks gestation. UIC was measured by the modified Sandell-Kolthoff reaction and UFC by a F-sensitive electrode. Enzyme-linked immunosorbent assay (ELISA) was used to measure plasma TSH. Associations between 1) UIC and TSH, 2) UFC and TSH, and 3) I status, UFC, and TSH were estimated using generalized linear models with gamma distribution and log link. Potential interactions between I status and UFC in association with TSH was also investigated. Results The cohort UIC (median: 154.2 µg/L, IQR: 92.9,271.7) indicated a population with marginally adequate I status by WHO criteria. Nearly half (n = 464, 48%) were I insufficient (UIC ≤ 150 µg/L). Median UFC (0.832 mg/L, IQR: 0.495, 1.29) was above the benchmark used to determine risk for child cognition (0.2 mg/L) (Grandjean et al., Risk Anal 2021; doi: 10.1111/risa.13767). Higher UIC was associated with increased TSH (β = 0.0003, SE = 0.0001, p = 0.01). UFC was not related to TSH (p = 0.13); however, a significant interaction between UIC and UFC was observed (p = 0.01). When analyzing only I insufficient participants, UFC and TSH were inversely associated (β = 0.1488, p = 0.0004). No association between UFC and TSH was observed for I adequate participants (p = 0.63). Conclusions Changes in TSH in relation to UIC and UFC were counter to our hypothesis as the relationship between UFC and TSH was inverse and only in I insufficient participants. Future research should explore if TSH is the best indicator of thyroid function in pregnancy and the mechanisms underlying the effects of pre-and postnatal F exposure on child cognition. Funding Sources The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (R01 HD083292).

Objectives The EAR and RDA for iodine (I) intake in pregnancy are 160 and 220 µg/d, respectively; however, dietary I intake by United States (US) pregnant women is unknown. Several professional organizations have recommended a supplement of 150 µg/d during pregnancy, though, the current use of prenatal supplements with I is also unknown. Our objective was to determine I intake from diet and supplements and relate I intake to I status, measured by urinary I concentration (UIC). Methods Pregnant women (n = 966) were interviewed about their dietary intake by the Diet History Questionnaire 2.0 or multiple 24-hour recalls at baseline and their dietary I intake was estimated using the USDA, FDA and ODS-NIH Database for the Iodine Content of Common Foods (ICCF). Participants were interviewed monthly until delivery to assess I intake from prenatal supplements. Urine samples were collected between 12–20 weeks of gestation, and UIC was measured by the modified Sandell-Kolthoff reaction. A chi-square test compared groups with insufficient and adequate I status to the proportion who met the EAR for I intake. Results The group median intake of I from diet was below the EAR (108.8 µg/d) however, median intake increased to 188.5 µg/day when supplemental I was included. Seventy-three % of participants (707/966) had a dietary intake below the EAR and 45% (436/966) remained below the EAR after including supplemental I. The group median UIC of 154.2 µg/L indicated a population with marginally adequate I status by WHO standards. Almost half (48%) had a UIC considered to be I insufficient (≤150 µg/L) by WHO. Although slightly more than half (55%, 529/966) were taking a supplement containing I, only 27% (259/966) were taking the recommended 150 µg/d. Iodine status was significantly associated with EAR intake, with 52.1% (227/436) of those with an intake below the EAR being I insufficient (UIC ≤ 150 µg/L) compared to 44.7% (237/530) of those with an I intake above the EAR (p = 0.0229). Conclusions While consuming a prenatal supplement with I improved the proportion of participants with an intake above the EAR, nearly 45% of the group who consumed more than the EAR had insufficient I status. Funding Sources The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (HD R01083292).