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Implementation of the Gestational Weight Gain Guidelines - Grand Rounds

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This presentation discusses the importance of meeting pregnancy weight gain recommendations. The complications associated with excess weight gain are discussed and strategies to help patients adhere …

This presentation discusses the importance of meeting pregnancy weight gain recommendations. The complications associated with excess weight gain are discussed and strategies to help patients adhere to guidelines are presented. For more information please contact Dr. Zachary M Ferraro @DrFerraro or via email info@DrFerraro.ca


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  • 1. Gestational Weight Gain – Implementation of the IOM Recommendations Zach Ferraro, PhD Kristi Adamo, PhD Kara Nerenberg, MD, MSc MFM / OB Med Combined Rounds October 11, 2013
  • 2. Objectives 1. Understand the adverse effects of pregravid obesity on maternal-fetal outcomes 2. Recognize that excessive GWG is an independent and modifiable risk factor for adverse outcomes 3. Summarize the recent IOM report on how to best implement & enforce evidence-based GWG recommendations 4. Understand that weight gain is not a behaviour; it’s an outcome 5. Be able to discuss SMART goals with patients to help them meet guidelines by establishing healthful behaviors 6. Discuss practical implementation & tools available to aid HCP and patients with weight management
  • 3. The Complexity of Obesity & Weight Gain E balance Many determinants of positive energy balance and unhealthy body weight UK Foresight Initiative, 2007
  • 4. Obesity in Female Adults- 2008 ~ 55% of North American women of childbearing age are OW or OB < 5% to > 55% * 1.8 billion are of childbearing age (26% of world population)
  • 5. BMI on the Rise FIGURE 2-1 Prevalence of overweight, obesity, and extreme obesity among U.S. women 20–39 years old (ages 20–35 through NHANES 1988–1994), 1963–2004. NOTE: BMI = body mass index; NHANES = National Health and Nutrition Examination Survey. SOURCE: Lu, 2013.
  • 6. Risks associated with overweight/obese pregnancy Adamo et al. Int. J. Environ. Res. Public Health 2012, 9(4), 1263-1307
  • 7. The Ottawa and Kingston (OAK) Birth Cohort
  • 8. 2009 IOM GWG Recommendations IOM 2009
  • 9. Excess Body Weight Prepregnancy OaK cohort Prepregnancy BMI N= 4321 56.20 60.0 50.0 40.0 % Underweight, <18.5 Normal, 18.5-24.9 23.72 30.0 Overweight, 25-29.9 16.17 Obese, ≥30 20.0 10.0 3.91 .0 Underweight, <18.5 Normal, 18.524.9 Overweight, 25-29.9 Obese, ≥30 Ferraro et al 2011.
  • 10. Adherence to IOM Guidelines, % 78 80 72 70 60 53 47 50 % Under 40 Met 36 Exceed 27 30 21 17 20 17 17 11 10 4 0 Underweight, <18.5 Normal, 18.5-24.9 Overweight, 25-29.9 Obese, ≥30
  • 11. Overweight, obesity and neonatal size at birth Baby Size by Pre-pregnancy BMI OaK cohort n=4321 90 84 79 76 80 73 70 60 We see a shift in birthweight distribution without increase in SGA 50 SGA % AGA 40 LGA 30 21 21 20 14 8 10 8 7 6 3 0 UW NW BMI category OW OB
  • 12. Likelihood of having a BIG baby * ** ** ** * **p<0.001, *p<0.05 controlling for gestational age, smoking, parity, maternal age Ferraro et al. Journal of Maternal-Fetal & Neonatal Medicine 2012; 25(5):538-542
  • 13. Odds of Macrosomia - Double Trouble... Likelihood of having an LGA baby *controlled for gestational age, smoking, parity, maternal age Reference to Normal weight pre-pregnancy and meeting 2009 IOM Guidelines Ferraro et al. Journal of Maternal-Fetal & Neonatal Medicine 2012; 25(5):538-542
  • 14. Pregnant and Overweight/Obese: So what?
  • 15. Maternal adiposity: perinatal and long-term outcomes Lawlor et al. 2012 Nature Reviews Endocrinology
  • 16. What about GWG?
  • 17. GWG in women with BMI > 30 and Neonatal Birthweight As GWG increases so too does the proportion of neonates born LGA or macrosomic Vesco, Obstet Gynecol; 2011
  • 18. GWG and LGA or macrosomia as GWG increases so too does the proportion of neonates born LGA or macrosomic regardless of obesity class Hinkle, AJCN; 2010
  • 19. What is the Problem?
  • 20. Birth weight and subsequent risk of child obesity Yu, Obesity Reviews; 2011
  • 21. Excessive gestational weight gain risk for childhood overweight: a meta-analysis Protects against obesity Promotes obesity  The pooled estimate for the association between excessive GWG and childhood overweight yielded an odds ratio (OR) of 1.38 (95% confidence interval [CI]: 1.21–1.57)  Provide evidence for at least a 21% risk for childhood overweight related to excessive GWG Nehring et al, Pediatric Obesity 2012
  • 22. Intergenerational Cycles Adamo et al. Int. J. Environ. Res. Public Health 2012, 9(4), 1263-1307
  • 23. Take home points  Obesity and excess GWG directly & independently alter birthweight  Risk of obesity+comorbidities later in life  Excess GWG increases risk for PPWR  Intergenerational effects  Maternal &fetal health compromised   Mom- ↑ risk for GDM, T2D, CVD Baby- ↑ risk for obesity & CVD as kids (Fraser et al., 2010)
  • 24. Why are so many patients exceeding recommendations?  Let’s ask the patient what information they are receiving….  And then let’s ask the provider what they messages they deliver
  • 25. A patient-provider discrepancy? VS. Ferraro et al 2011 Obstetric Medicine Ferraro et al 2013 International Journal of Women’s Health
  • 26. Bias toward Obese Pregnant Women  11% admitted to making insensitive comments to obese pregnant women  31% admitted to making derogatory comments about obese pregnant women to colleagues (p=0.02)      Obstetricians (46%) Family Physicians (39%) Midwives (36%) Nurses (14%) Dietitians (0%)  66% believe more derogatory comments are made about obese pregnant women vs non–obese pregnant women (p=0.002)      Obstetricians (81%) Family Physicians (69%) Midwives (92%) Nurses (52%) Dietitians (14%) Grohman, Obstet Med 2012 Slide – Courtesy of Dr. E. Keely
  • 27. What do women know about BMI & GWG?  74% of women underestimated their BMI category  64% of obese women and 40% of overweight women overestimated their recommended GWG  Poor knowledge of risks of obesity      28% identified BP problems 51% identified GDM 14% identified pp weight retention 71% back pain <5% C-section, preterm delivery, pregnancy complications Shub, BMC Res Notes 2013 Slide – Courtesy of Dr. E. Keely
  • 28. What can be done to help moms & care providers manage GWG? Oken et al 2013 Maternal Child Health
  • 29.  MDs believed GWG had ‘‘a lot’’ of influence on pregnancy and child health outcomes   Most said excessive GWG was a big problem in their practice   Inadequate GWG was rare EMR calc GWG at each visit     Their patients did not consider it important A ‘‘growth chart’’ to plot actual vs. recommended Alerts identify out-of-range gains Features to remind them to counsel patients about weight Additional decision support tools within EMRs would be well received by many clinicians and may help improve the frequency and accuracy of GWG tracking and counseling Oken et al 2013 Maternal Child Health
  • 30. The latest from the IOM
  • 31. Patient Case Preconception Counseling
  • 32. Patient Case  38 G0 primary infertility x 12 months  Rfr: “Risks to her and offspring given medical problems”  PMHx:  BMI 50  Heterozygous FVL (sup phlebitis on OCP)
  • 33. How to improve outcomes?  Preconception  Weight reduction  Reduce risks of congenital anomalies – folic acid  Optimize associated medical conditions  During Pregnancy     Limit GWG Screening/monitoring for hyperglycemia, hypertension Prevention of GDM, VTE, preeclampsia – ASA, Ca, exercise Safest possible delivery  Postpartum  Breastfeeding  Weight loss / retention Slide – Courtesy of Dr. E. Keely
  • 34. Patient Case Now pregnant
  • 35. Achievement of IOM Targets:
  • 36. What works?  Improving Diet quality  Appropriate kcal intake  Engaging in Physical Activity  Reducing Sedentary Time  All the above?
  • 37. Physical activity intervention alone helps manage GWG Streuling, BJOG 2011
  • 38. Clinical dietary intervention prevents excessive GWG Tanentsapf et al 2011
  • 39. Healthy eating & physical activity reduce GWG Streuling, AJCN 2010
  • 40. Exercise is medicine…  And it doesn’t take much FIGURE 2-3 Kaiser Permanente walking prescription. SOURCE: Conry, 2013
  • 41. Lifestyle prescription
  • 42. IOM posters for clinic use:  Pregnancy weight gain guidelines poster  Available at http://www.iom.edu/h ealthypregnancy
  • 43. Myths…  +Physical activity will harm me and/or my baby Ferraro et al., British Journal of Sports Medicine 2012.
  • 44. CON 5 As  Remember weight is NOT a behavior  It’s an outcome  Must understand ‘cause’ of ex GWG (4Ms)  Use SMART goals to reinforce behaviours  E.g., I will eat 250kcal less/day and walk for 30mins  Not: I will meet the IOM guidelines or eat less, move more
  • 45. Provider tools for weight management  Available at: http://www.obesitynetwork.ca/5As  Become a member of CON for FREE at www.obesitynetwork.ca
  • 46. We know what works…. Let’s make it work
  • 47. Pedagogy & Medicine     Psychopathobiology of obesity Motivational Interviewing Interdisciplinary care NEJM 369;15:1389-40. October 10, 2013.
  • 48. Points for discussion: 1. Are we adequately counseling women on GWG targets? - Behaviour change? 2. Are we measuring /tracking GWG? - rate of gain 3. Do we need to change our practice? 4. How to change our practice?
  • 49. Thank you.  IOM Link  http://www.iom.edu/AboutIOM/Making-aDifference/Kellogg/HealthyPregnancy. aspx  Follow me @DrFerraro for frequent discussion on this topic