Weight Management in Pregnancy and Postpartum

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Presentation at the Annual Convention of the Philippine Society for the Study of Overweight and Obese 5 September 2009

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Weight Management in Pregnancy and Postpartum

  1. 1. Weight Management in Pregnancy and Postpartum Iris Thiele Isip Tan MD, FPCP, FPSEM MS Health Informatics (cand.) Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, UP-Philippine General Hospital 5 September 2009
  2. 2. Outline How much weight gain can be allowed in pregnancy? Can weight gain be safely limited in pregnancy? Can we apply the Institute of Medicine (IOM) recommendations locally? How can postpartum weight retention be addressed?
  3. 3. How much weight gain can be allowed in pregnancy?
  4. 4. Weight gain during pregnancy 12.5 kg British cohort of >3800 primigravidae eating without restriction Product of conception Fetus, placenta, amniotic fluid Maternal tissue expansion Uterus, breasts, blood volume Maternal fat reserve
  5. 5. IOM recommendations for total weight gain by pre-pregnancy BMI1 Recommended Weight for height category total gain (lb) Low (BMI<19.8) 28-40 Normal (BMI 19.8-26) 25-35 High (BMI >26-29)2 15-25 1 Higher end of range for adolescents and black women and lower end of range for short women (<1.57 m) 2 Recommended target weight gain for obese 1990 women (BMI>29) is 15 lb
  6. 6. “The energy cost of pregnancy could be met without increase of food intake by economy of activity.” Hytten & Leitch, The physiology of human pregnancy (1971) Energy requirements = TEE1 + energy deposition2 1 Total energy expenditure 2 Energy deposition = Δ in body CHON/fat Butte et al Am J Clin Nutr 2004;79:1078-87
  7. 7. Incremental energy requirements during pregnancy: TEE & energy deposition Low BMI Normal BMI High BMI (n = 17) (n = 34) (n = 12) Energy requirements estimated at 0, 9, 22, 36 wk of pregnancy and 27 wk postpartum Butte et al Am J Clin Nutr 2004;79:1078-87
  8. 8. Energy costs* differed by BMI group Mean total fat gain: 3.7 kg (2.4-5.9 kg) Low BMI Normal BMI High BMI Fat gain 5.3 kg 4.6 kg 8.4 kg n=12 n=34 n=17 Weight gain All gained 3.5 kg 4.6 kg within IOM above IOM * Estimated at 0, 9, 22, 36 wk of pregnancy and 27 wk postpartum Butte et al Am J Clin Nutr 2004;79:1078-87
  9. 9. Incremental energy needs in pregnancy Based on women with normal BMI 1st trimester: negligible 2nd trimester: 350 kcal/d 3rd trimester: 500 kcal/d Butte et al Am J Clin Nutr 2004;79:1078-87
  10. 10. Too much vs too little low birth weight intrauterine growth retardation macrosomia prematurity CS rate diabetes hypertension weight retention
  11. 11. IOM recommendations for weight gain by pre-pregnancy BMI 2009 Rates of weight gain* Total weight Prepregnancy BMI 2nd and 3rd trimester gain (lbs) (lbs/week) Underweight 1 <28-40 BMI <18.5 (1-1.3) Normal weight 1 25-35 BMI 18.5-24.9 (0.8-1) Overweight 0.6 15-25 BMI 25.0-29.9 (0.5-0.7) Obese 0.5 11-20 BMI >30.0 (0.4-0.6) * Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
  12. 12. Twin pregnancy IOM recommendations for weight gain Prepregnancy BMI Recommended total gain Normal 17-25 kg (37-54 lbs) Overweight 14-23 kg (31-50 lbs) Obese 11-19 kg (25-42 lbs) 2009
  13. 13. Can weight gain be safely limited in pregnancy?
  14. 14. Stepped-care behavioral intervention to prevent excessive weight gain Recruited before 20 wk gestation Standard care Intervention Standard care Normal weight Normal weight Counseling on well- BMI 19.8-26 BMI 19.8-26 balanced diet n = 31 n = 30 Take vitamin/iron supplement Standard care Intervention Overweight Overweight Outcome BMI >26 BMI >26 proportion of women n = 22 n = 27 exceeding IOM recommendation Polley et al Int J Obes 2002;26:1494-1502
  15. 15. Stepped-care behavioral intervention to prevent excessive weight gain Excessive gain: individualized nutrition and behavioral counseling Too little gain: consult MD outside study Appropriate gain: given encouragement Biweekly newsletters Personalized weight gain graph every visit Written information Appropriate weight gain in pregnancy Exercise & healthful eating during pregnancy Polley et al Int J Obes 2002;26:1494-1502
  16. 16. Women with total weight gain exceeding IOM recommendations Control Intervention Total weight gain >IOM 100% p = 0.09 75% p <0.05 50% 25% 58% 59% 33% 32% 0% Normal Overweight Polley et al Int J Obes 2002;26:1494-1502
  17. 17. Weight changes during pregnancy by treatment group and BMI category Standard care Intervention Below IOM Normal weight Normal weight Within IOM Above IOM 16.4 + 4.8 kg 15.4 + 7.1 kg 100 (6.8-30.9) (2.7-32.7) Standard care Intervention 75 Overweight Overweight 10.1 + 6.2 kg 13.6 + 7.2 kg (-0.9-26.4) (1.4-29.1) % 50 25 0 Standard Standard Intervention Intervention Normal wt Overweight Normal wt Overweight Polley et al Int J Obes 2002;26:1494-1502
  18. 18. Misperceived pre-pregnancy body weight status and gestational weight gain Project Viva cohort Accurate n=1537 Overassessor assessor Normal weight Normal weight n = 131 (9%) n = 898 (58%) Accurate Underassessor assessor Overweight/obese Overweight/obese n = 70 (5%) n = 438 (28%) “How would you classify your weight just prior to this pregnancy?” Herring et al BMC Pregnancy & Childbirth 2008;8:54
  19. 19. Misperceived pre-pregnancy body weight status and excessive weight gain Project Viva cohort Accurate Overassessor n=1537 assessor Normal weight Normal weight OR 2.0 Comparator (95% CI 1.3-3.0) Accurate assessor Underassessor Overweight/obese Overweight/obese OR 2.9 OR 7.6 (95% CI 2.2-3.9) (95% CI 3.4-17) Test the benefit of interventions to correct weight misperception. Herring et al BMC Pregnancy & Childbirth 2008;8:54
  20. 20. Advice on target weight gain WISH cohort (Women and Infants Starting Healthy) n=1460 Before 20 wks 24-28 wks 32-36 wks 8-12 wks postpartum “How much weight “How many pounds do you think you were you told to gain should gain during from the beginning to this pregnancy?” the end of pregnancy?” Outcome Variable target weight gain medically advised weight gain Stotland et al Obstet Gynecol 2005;105:633-8
  21. 21. Maternal target weight gain vs pre-pregnancy BMI Maternal target weight gain Below IOM Within IOM Above IOM 120 *p<0.001 vs normal 90 24* 47 60 % 85 75 80 30 51* 0 Low Normal High Obese Prepregnancy BMI Stotland et al Obstet Gynecol 2005;105:633-8
  22. 22. Target weight gain vs MD advice Maternal target weight gain Below IOM Within IOM Above IOM 120 90 28 60 61 % 85 77 80 30 36 0 Below IOM Within IOM Above IOM No advice MD Advice Stotland et al Obstet Gynecol 2005;105:633-8
  23. 23. Predictors of target weight gain Above IOM Pre-pregnancy BMI >26 Multiparity Lower age Provider advice to gain above IOM Below IOM Latina ethnicity Lower maternal education Low pre-pregnancy BMI Provider advice to gain below IOM Stotland et al Obstet Gynecol 2005;105:633-8
  24. 24. Can we apply the Institute of Medicine recommendations locally?
  25. 25. Mean pregnancy weight gain among women in developing countries Bangladesh 4.8 East Java 6.0 Lower IOM Gambia 7.3 cut-off Guatemala 7.0 India 7.0 Kenya 4.1 Taiwan 7.6 12.5 kg Thailand 8.9 Philippines 8.5 0 3 6 9 12 kg Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72
  26. 26. Cebu Longitudinal Health and Nutritional Health Survey (CLHNS) cohort (n = 1367) DETERMINANTS OF PREGNANCY WEIGHT GAIN 15 : Cebu subpopulation. n=877 First Trimester - Cummings, 1934 - - Stander & Pastore. 1940 2 Cebu vs Western - . a Scott & Benjamin. 1948 - Tompkins & Wiehi, 1951 - - Thomson & Billewicz. It 1 populations 12 . . . . . Hytten & Leitsch, 1971 Brown et al., 1986 o Slow weight gain in 0) -1 9. C Ce 0) the first trimester -2’ . 0) 0 6 Catch up in the 0 2 4 6 C Ce 22nd-24th weeks a) D) Second Trimester 3 Thereafter, markedly C 0 lower weight gain 0) 10 15 20 25 30 35 40 -C 0) Weeks gestation ci) FIG 3. Pattern of maternal weight gain in developed countries corn- Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72 pared with the Cebu subpopulation. Reprinted with permission from C
  27. 27. ever, when mean weekly weight gains are compared (Table 3), Third Trimester women with any overlap of pregnancy and lactation gained 12 weight at a significantly higher rate during the third trimester (0.31 Cebu Longitudinal Health and Nutritional 10 ± 0.22 vs 0.22 ± 0.28 kg/wk among women with no Health Survey (CLHNS) cohort (n = 1367) overlap). 8 6’ 10.0’ 4, 9.0 Cebu 2. 8.0 --- Maharashtra 29 30 31 32 33 34 Gujarat Cebu vs Indian 7.0 Weeks gestation C Ce 0) 6.0 5.0 population of pregnancy. FIG 5. Pattern of weight gain for status and by trimester the Cebu subp Regression l Weight status based on body mass index values: 0 = 0) Gained more weight ci) 18.5-25, U = > 25. a) 3.0 in second half of 2.0 pregnancy Results of the multivariate and 5. Regression analyses regressions are for the first trimeste 1.0 entire population or subpopulation were com effects of including women with a wider rang intervals. Similar results were obtained, sugg -1 minants ofweight gain are similar over the ful 0 10 20 30 40 represented in the sample. For consistency we Weeks gestation based on the subpopulation only. Controlling week when weight was measured, higher firs FIG 4. Pattern of maternal weight gain in India compared with the Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72 Cebu subpopulation. ---, Maharashtra, n = 514. ---,Gujarat, n = 559. gains were significantly associated with low p
  28. 28. How can postpartum weight retention be addressed?
  29. 29. Predictors of postpartum weight retention Gestational weight gain Ethnicity Parity High pre-pregnancy weight Gunderson & Abrams, Epidemiol Rev 2000;2:261-74
  30. 30. Lactation and postpartum weight retention Longitudinal study 110 women recruited in 3rd trimester Postpartum follow-up Fully breastfeeding 0.5 mo 2 mo 4 mo Partly breastfeeding Infant weaned or bottle-fed 6 mo 12 mo 18 mo Janney et al Am J Clin Nutr 1997;66:1116-24
  31. 31. Predicted weight-retention curves over time vs lactation practice WEIGHT RETENTION 1121 12â!¢ ● Bottle feeding only ■ Fully breast-feeding at 2 wk, 10â!¢ 8 partly breast-feeding at 2 .@ 6 mo, bottle-feeding or infant C .2 4. weaned at 4, 6, 12, 18 mo C a 2 a Fully breast-feeding for 6 mo and bottle-feeding or 0â!¢ a -2â!¢ weaned at 12 and 18 mo -4. -6@ Fully breast-feeding for 6 mo, partly breast-feeding 2 4 6 8 10 12 14 16 18 20 for 12 mo and bottle- Time (mo sInce parturltlon) feeding or weaned at 18 mo FIGURE 1. Predictedweight-retention urvesovertime for four lacta c tionpractices:bottle-feeding only(â! fullybreast-feeding 2 wk, partly ¢); at Janney et al Am J Clin Nutr 1997;66:1116-24 breast-feeding at 2 mo, and bottle-feeding or infant weaned at 4, 6, 12, and Dow
  32. 32. Limited effect of lactation on weight retention Women who bottle-fed their infants retained more weight over time Slower rates of weight loss with cessation of breast- feeding or shift to partly “ ... warrant minimal breast-feeding emphasis on breast-feeding as a means of minimizing postpartum weight retention.” Janney et al Am J Clin Nutr 1997;66:1116-24
  33. 33. TV, walking and diet AND postpartum weight retention Project Viva cohort n=902 TV viewing, Questionnaire walking and diet Initial prenatal visit 6 months 12 months postpartum postpartum Oken et al Am J Prev Med 2007;32(4):305-11
  34. 34. % of total energy Total fat 37% TV, walking and diet Trans fat 1.1% at 6 mos postpartum TV viewing 1.7 Moderate activity yoga, bowling, Walking 0.7 stretching, skating Vigorous activity Moderate activity 0.2 jogging, swimming, cycling, skiing, Vigorous activity 0.2 aerobics class 0 0.5 1.0 1.5 2.0 2.5 hours/day Oken et al Am J Prev Med 2007;32(4):305-11
  35. 35. Odds of retaining >5 kg at 1 year postpartum Per daily hour of walking Per hour of TV OR 0.66 (0.46,0.94) viewing OR 1.24 (1.06,1.46) Per 0.5% energy from trans fat OR 1.33 (1.09,1.62) Mean wt retained 0.6 kg (-17.3 to 25.5) 12% of retained at least 5 kg Oken et al Am J Prev Med 2007;32(4):305-11
  36. 36. OR 0.23 (95% CI 0.08-0.66) of retaining at least 5 kg Walk at Watch least 30 Eat less <2 hours minutes trans fat of TV (below the median) Oken et al Am J Prev Med 2007;32(4):305-11
  37. 37. Sleep duration and postpartum weight retention Project Viva cohort n=940 Assessed at 6 and 12 mo “In the past month, how Duration of sleep vs many hours of sleep do weight retention >5 kg you get in an average at 1 year postpartum 24-h period?” “In the past month, do you feel that you are getting enough sleep?” Gunderson et al Am J Epidemiol 2008;167:178-187
  38. 38. Sleeping < 5 hours/day at 6 mos postpartum strongly associated with Distribution of sleep duration retaining > 5 kg at 1 year n=940 postpartum < 5 h/day > 8 h/day 12% < 5 h/day 6 h/day 24% OR 3.13 OR 0.99 6 h/day (95%CI 1.42,6.94) (95%CI 0.50,1.97) 30% 7 h/day > 8 h/day 34% Comparator OR 0.94 p=0.012 (95%CI 0.50-1.78) 7 h/day Gunderson et al Am J Epidemiol 2008;167:178-187
  39. 39. How much weight gain can be allowed in pregnancy? IOM recommendations for weight gain by pre-pregnancy BMI 2009 Rates of weight gain* Total weight Prepregnancy BMI 2nd and 3rd trimester gain (lbs) (lbs/week) Underweight 1 <28-40 BMI <18.5 (1-1.3) Normal weight 1 25-35 BMI 18.5-24.9 (0.8-1) Overweight 0.6 15-25 BMI 25.0-29.9 (0.5-0.7) Obese 0.5 11-20 BMI >30.0 (0.4-0.6) * Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
  40. 40. Can weight gain be safely limited in pregnancy? ? Intervention increased weight gain below IOM in normal weight women Correct misperceptions about pre-pregnancy BMI Advise target gain accurately
  41. 41. Can we apply the IOM recommendations locally? Filipinas gain less during pregnancy than their Western counterparts Need for more data
  42. 42. How can postpartum weight retention be addressed? Avoid excessive gestational weight gain Breastfeeding has some limited effects on weight retention Advise women to lead a healthy lifestyle postpartum
  43. 43. Thank You http://www.endocrine-witch.info

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