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  • 1. GUIDELINES FOR GESTATIONALWEIGHT GAIN IN THE OBESENancy F. Butte, PhD
  • 2. OBESITY AND GESTATIONALWEIGHT GAIN (GWG)• Obesity among reproductive-aged women (20-39 y) in the US(Flegal, 2012)Overweight BMI≥25 50.7% Class II BMI≥35 17.2%Class I BMI≥30 31.9% Class III BMI≥40 4.3%• Obese women at increased risk for congenital anomalies,stillbirths, miscarriage, GDM, hypertension, preeclampsia,complications L&D, macrosomia• Majority of obese women gain weight outside guidelines• Low and high GWG in obese women associated withsubstantial risks for mother and her child• Intentional or unintentional weight loss in some pregnant obesewomen, yet benefits/risks uncertain
  • 3. PREVALENCE OF OVERWEIGHT, OBESITY ANDEXTREME OBESITY AMONG WOMEN20-39 Y, US 1963-2004
  • 4. RISKS ASSOCIATED WITH LOWAND HIGH GWG IN OBESELow GWGInfant RisksPreterm birthLow birth weight /SGAFetal distressHigh GWGMaternal RisksPreeclampsiaGestational diabetesC-sectionPostpartum weight retentionAbdominal adiposityInsulin resistanceDepressionInfant RisksHigh birth weight /LGAFetal distressOverweight later childhood
  • 5. WEIGHT GAIN DURINGPREGNANCY REEXAMININGTHE GUIDELINESInstitute of Medicine andNational Research Council,2009 National Academyof Sciences
  • 6. STUDY OBJECTIVESReview evidence on the relationship between weight gainpatterns before, during and after pregnancy and maternaland childhealth outcomesRecommend revisions to the existing guidelines, wherenecessary, including the need for specific pregnancy weightguidelines for underweight, normal weight, and overweightand obese women and adolescents and women carryingtwins or higher-order multiplesConsider a range of approaches to promote appropriateweight gainIdentify gaps in knowledge and recommend researchpriorities
  • 7. 50% 59% 73% 70%DISTRIBUTION OF GWG RELATIVE TO1990 GUIDELINES BY PREPREGNANCYBMI CATEGORY (PRAMS, 2002-3)Outside Guidelines:
  • 8. THEORETICAL COMPONENTS OF GWGComponent Increase at term (kg)Fetus 3.40 (2.5 – 5.0)Placenta 0.65Amniotic fluid 0.80Maternal tissue (uterus, mammary glands) 1.38Blood (plasma and red cell volume) 1.45Maternal stores (fat) 3.35 (loss – gain)Extracellular extravascular fluid 1.48 (with edema, 4.7)TOTAL 12.5Hytten and Chamberlain (1991)
  • 9. MATERNAL OUTCOMES OF GWGOutcome category Evidence ratingAntepartum outcomesMaternal discomforts of pregnancy, hyperemesis,abnormal glucose metabolism, hypertensive disorders,gallstonesWeakIntrapartum outcomesPROM, preterm labor, post-term pregnancy, inductionof labor, length of labor, mode of delivery, VBAC,vaginal lacerations, shoulder dystocia, cephalopelvicdisproportion, labor/delivery complicationsWeak (except moderatefor cesarean delivery)Postpartum outcomesLactation, fat accrual, short-, intermediate- and long-term weight retention, interpregnancy weight retention,premenopausal breast cancerWeak or no evidence(except moderate forintermediate-termweight retention)Viswanathan M, et al. AHRQ Publ. No. 08-E09, 2008
  • 10. MATERNAL OUTCOMES OF GWGOutcome category Evidence ratingAntepartum outcomesMaternal discomforts of pregnancy, hyperemesis,abnormal glucose metabolism, hypertensive disorders,gallstonesWeakIntrapartum outcomesPROM, preterm labor, post-term pregnancy, inductionof labor, length of labor, mode of delivery, VBAC,vaginal lacerations, shoulder dystocia, cephalopelvicdisproportion, labor/delivery complicationsWeak (except moderatefor cesarean delivery)Postpartum outcomesLactation, fat accrual, short-, intermediate- and long-term weight retention, interpregnancy weight retention,premenopausal breast cancerWeak or no evidence(except moderate forintermediate-termweight retention)Viswanathan M, et al. AHRQ Publ. No. 08-E09, 2008
  • 11. MATERNAL OUTCOMES OF GWGOutcome category Evidence ratingAntepartum outcomesMaternal discomforts of pregnancy, hyperemesis,abnormal glucose metabolism, hypertensive disorders,gallstonesWeakIntrapartum outcomesPROM, preterm labor, post-term pregnancy, inductionof labor, length of labor, mode of delivery, VBAC,vaginal lacerations, shoulder dystocia, cephalopelvicdisproportion, labor/delivery complicationsWeak (except moderatefor cesarean delivery)Postpartum outcomesLactation, fat accrual, short-, intermediate- and long-term weight retention, interpregnancy weight retention,premenopausal breast cancerWeak or no evidence(except moderate forintermediate-termweight retention)Viswanathan M, et al. AHRQ Publ. No. 08-E09, 2008
  • 12. INFANT OUTCOMES OF GWGOutcome category Evidence ratingBirth outcomesPreterm birth, birth weight, low birth weight,macrosomia, large-for-gestational age, small-for-gestational age, Apgar scoreStrong (except weakfor Apgar score)Postnatal outcomesPerinatal mortality, neonatal hypoglycemia,neonatal distress, hyperbilirubinemia, neonatalhospitalization, other infant morbidity, infant BMI,other infant growthWeakViswanathan M, et al. AHRQ Publ. No. 08-E09, 2008
  • 13. REEXAMINING GWG GUIDELINESConsidered outcomes for the mother, not just theinfant, and the inevitable trade-offs between themCommissioned new analyses• Ellen Nohr: DNBC (1996-2002), extension of trade-offanalyses• Amy Herring: NIMHS (1988), black andwhite women• Cheryl Stein: NYC subsample (1995-2003), black and whitewomen• Jim Hammitt: quantitative risk analysis
  • 14. REEXAMINING GWG GUIDELINESConsidered outcomes for the mother, not just theinfant, and the inevitable trade-offs between themCommissioned new analyses• Ellen Nohr: Danish National Birth Cohort (1996-2002),extension of trade-off analyses• Amy Herring: National Maternal and Infant Health Survey(1988), black and white women• Cheryl Stein: New York City subsample (1995-2003), blackand white women• Jim Hammitt: quantitative risk analysis
  • 15. REEXAMINING GWG GUIDELINESBalanced the trade-offs between maternal andinfant outcomes• Maternal outcomes• Postpartum weight retention• Unscheduled cesarean delivery• Infant outcomes• SGA• LGA• Preterm birth• Childhood obesity
  • 16. GWG-SPECIFIC RISKS FOR PREGNANCYOUTCOMES BY PREPREGNANCY BMI CATEGORYAMONG PRIMIPAROUS WOMEN
  • 17. IOM 2009 GWGRECOMMENDATIONSPrepregnancy BMIcategoryTotal weight gain(lb, kg)Rate of weight gain2ndand 3rdtrimester(lb/wk, kg/wk)Underweight(< 18.5 kg/m2)28-40, 12.5-18 1.0 (1.0-1.3),0.51 (0.44-0.58)Normal-weight(18.5-24.9 kg/m2)25-35, 11.5-16 1.0 (0.8-1.0),0.42 (0.35-0.50)Overweight(25.0-29.9 kg/m2)15-25, 7-11.5 0.6 (0.5-0.7),0.28 (0.23-0.33)Obese**(≥ 30.0 kg/m2)11-20, 5-9 0.5 (0.4-0.6),0.22 (0.17-0.27)*Calculations assume a first-trimester weight gain of 1.1-4.4 lb (0.5-2.0 kg)** 1990 IOM Recommendation: for obese women (BMI>29), weight gain at least 6.8 kg (15 lb)
  • 18. PROVISIONAL GWG GUIDELINESFOR TWIN PREGNANCYPrepregnancy BMI category Weight gain at termNormal-weight 37-54 lb,17-25 kgOverweight 31-50 lb,14-23 kgObese 25-42 lb,11-19 kg*Based on the interquartile (25th-75thpercentile) of gains of women whodelivered twins at term (37-42 wk gestation) with birth weights ≥ 2,500 gNote: Insufficient data are available to offer a guideline for underweight women
  • 19. GWG-SPECIFIC RISKS PREGNANCYOUTCOMES AMONG SUBTYPESOF NORMAL-WEIGHT WOMEN
  • 20. RECOMMENDATIONSFORSPECIAL POPULATIONSShort stature: no modificationYoung age: no modification; use adult BMI tablesRacial/ethnic subgroups: no modificationPrimiparity: no modification, but trade-off should bestudied furtherSmokers: no modification, but stop smoking
  • 21. COMPARISON OF NATIONALGWG GUIDELINESAlavi N et al.; Obesity Rev 14:68-85, 2013
  • 22. COMPARISON OF NATIONALGWG GUIDELINESAlavi N et al.; Obesity Rev 14:68-85, 2013Search 70 countries18% (13) countries had GWG guidelines31% (4) adopted the 2009 IOM guidelinesCanada, Finland, Australia, New Zealand23% (3) similar to IOM guidelines46% (6) different GWG guidelinesNo guidelines specify for obesity severity
  • 23. COMPARISON OF PRAMS GWG* AND2009 IOM GUIDELINES BYPREPREGNANCY BMI*PRAMS: Pregnancy Risk Assessment Monitoring System (CDC) and state health departments
  • 24. DISTRIBUTION OF GWG BY OBESE CLASSMAGEE OBSTETRIC MEDICAL ANDINFANT (MOMI) DATABASE 2003-2008.Bodnar L; Am J Clin Nutr 2010;91:1642–8.Excessive GWG declinedand GWL increased withobesity severity
  • 25. CLASS 1 OBESITYBodnar L; Am J Clin Nutr 2010;91:1642–8.GWL ∞ elevated risk of SGA, iPTB, and sPTB;High GWG ∞ elevated risk of LGA and iPTB
  • 26. CLASS 2 OBESITYBodnar L; Am J Clin Nutr 2010;91:1642–8.GWL ∞ elevated risk of sPTB;High GWG ∞ elevated risk of LGA and iPTB
  • 27. CLASS 3 OBESITY: WHITE & BLACKWOMENBodnar L; Am J Clin Nutr 2010;91:1642–8.GWL ∞ elevated risk of SGA (white women only)High GWG ∞ elevated risk of LGA and iPTB
  • 28. GESTATIONAL WEIGHT LOSS(GWL) IN OBESEObese pregnant women lose weight more often than normal-weightwomen11% vs. 0.1% (Edwards 1996)9% vs. 0.2% (Bianco 1998)8.3% obese, 19% morbidly obese vs. 1.9% (Dietz 2006)Incidence of GWL increases with obesity severityObservations studies (Beyerlein 2011, Blomberg 2011, Hinkle 2010)Decreased risks: pre-eclampsia,C-section, LGAIncreased risks: SGA infants
  • 29. MATERNAL AND NEONATALOUTCOMES AMONG OBESE WOMENWITH GWL (BLOMBERG 2011)Database: Swedish Medical Birth Registry 1993-2008data on 46,595 obese womenOutcomes: C-section, SGA, LGA, pre-eclampsia, deliverycomplications, Apgar scores, fetal distressFindings: GWL compared with women gaining 5-9 kgClass I: GWL ∞ decreased risk of C-section, LGA &increased risk of SGAClass II: GWL ∞ decreased risk of C-section, LGAClass III: GWL ∞ decreased risk of C-section, LGA& increased risk of SGA
  • 30. GWL/GWG IN OBESE AND ASSOCIATIONWITH FETAL GROWTH (HINKLE 2010)Database: 2004–2006 Pregnancy Nutrition Surveillance Systemdata from 122,327 obese mothersOutcomes: GWG and SGA, LGA, sPTB, iPTB by severity of obesityFindings:Class I:GWL ∞ increased risk of SGAGWG (0.1 to 4.9 kg) not ∞ SGA2SDClass II/ III: GWL∞ decreased risk of LGAGWL/GWG ∞ (-4.9 to +4.9 kg) not ∞ SGA2SD
  • 31. ASSOCIATION OF GWL/GWGWITH SGA (HINKLE 2010)
  • 32. ASSOCIATION OF GWL/GWGWITH LGA (HINKLE 2010)
  • 33. ASSOCIATION OF GWL AND PREGNANCYOUTCOMES (BEYERLEIN 2011)Database: Bavarian obstetric records from 2000–2007 on709,575 singleton birthsOutcomes: Pre-eclampsia, nonelective C-section, preterm delivery,SGA/LGA, perinatal mortalityFindings:Class I: GWL ∞decreased risk of C-sectionClass II: GWL ∞ decreased risk pre-eclampsia, LGAClass III: GWL ∞ decreased risk LGA, pre-eclampsia, C-sectionGWL ∞ increased risks of SGA births in obese class I/II (NS class III)
  • 34. COCHRANE REVIEWAntenatal interventions for reducing weight in obese womenfor improving pregnancy outcome (Furber 2013)Objective: To evaluate effectiveness of interventions that reduceweight in obese pregnant womenResults: no RCT or quasi-random studies identifiedConclusion:Until the safety of weight loss in obese pregnant women canbe established, there can be no practice recommendationsfor these women to intentionally lose weight during thepregnancy period.Further study is required to explore the potential benefits, or harm,of weight loss in pregnancy when obese before weight lossinterventions in pregnancy can be designed.
  • 35. THE CHALLENGES AHEADConceive at a normal prepregnancy BMI• Requires preconceptional counseling, contraception, and, forsome women, weight lossGain within the IOM Guidelines• Inform women and their health care providers of theguidelines• Provide individualized assistance with meetingthe guidelines• Monitor GWG, guidance on diet and exercise
  • 36. MODEL CHARTS THAT CAN BEADAPTED FOR USE INCOUNSELING WOMEN
  • 37. GWG CALCULATORDynamic energy-balance model to predict GWG that resultsfrom changes in energy intakeDiana M Thomas et al. AmJClinNutr 2012;95:115-22.www.pbrc.edu/the-research/tools/gwg-predictor/
  • 38. EDUCATIONALMATERIALS
  • 39. IMPLEMENTATION OF WEIGHTGAIN & PREGNANCY GUIDELINES
  • 40. WEIGHT GAIN TRACKER
  • 41. CONCLUSIONSIn contrast to the 1990 IOM GWG recommendations of at least6.8 kg, the new 2009 IOM recommendations provide a GWGrange of 5 to 9 kg for obese womenInsufficient evidence to provide specificrecommendations by obese severityData are emerging on child/maternal outcomes associated withminimal weight gain 0.1-4.9 kg in obese women (class II/III);Weight loss in obese pregnant women may have some benefits,yet a small increased risk for SGAIn the absence of RCT and robust evidence of benefits or harms,weight loss during pregnancy in obese is not recommendedGiven the profound effect of maternal obesity on fetal outcomes,effective weight management prior to conception is needed
  • 42. • Kathleen Rasmussen, ChairCornell University• Barbara AbramsUniversity of California-Berkeley• Lisa BodnarUniversity of Pittsburgh• Claude BouchardPennington Biomedical ResearchCenter• Nancy ButteBaylor College of Medicine• Patrick CatalanoCase Western Reserve University• Matthew GillmanHarvard University• Fernando GuerraSan Antonio Metropolitan Health District• Paula JohnsonBrigham and Women’s Hospital• Michael LuUniversity of California-Los Angeles• Elizabeth McAnarneyUniversity of Rochester• Rafael Perez-EscamillaUniversity of Connecticut• David SavitzMount Sinai School of Medicine• Anna Maria Siega-RizUniversity of North Carolina-Chapel HillStaff: Ann Yaktine, Study Director, Heather Del Valle, Research Associate, Jenny Datiles, Senior ProjectAssistant, Linda Meyers, Director FNB, Rosemary Chalk, Director BCY&F,Anton Bandy, Financial AssociateCOMMITTEE TO REEXAMINEIOM PREGNANCY WEIGHTGUIDELINES