Pregnancy and Obesity: A Review and Agenda for Future Research

Healthy Moms, a randomized trial to promote and evaluate weight maintenance among obese pregnant women: study design and rationale

BACKGROUND

Obesity and excessive weight gain during pregnancy are associated with adverse pregnancy outcomes. Observational studies suggest that minimal or no gestational weight gain (GWG) may minimize the risk of adverse pregnancy outcomes for obese women.

OBJECTIVE

This report describes the design of Healthy Moms, a randomized trial testing a weekly, group-based, weight management intervention designed to help limit GWG to 3% of weight (measured at the time of randomization) among obese pregnant women (BMI≥30 kg/m(2)). Participants are randomized at 10-20 weeks gestation to either the intervention or a single dietary advice control condition.

PRIMARY OUTCOMES

The study is powered for the primary outcome of total GWG, yielding a target sample size of 160 women. Additional secondary outcomes include weight change between randomization and one-year postpartum and proportion of infants with birth weight>90th percentile for gestational age. Statistical analyses will be based on intention-to-treat.

METHODS

Following randomization, all participants receive a 45-minute dietary consultation. They are encouraged to follow the Dietary Approaches to Stop Hypertension diet without sodium restriction. Intervention group participants receive an individualized calorie intake goal, a second individual counseling session and attend weekly group meetings until they give birth. Research staff assesses all participants at 34-weeks gestation and at 2-weeks and one-year postpartum with their infants.

SUMMARY

The Healthy Moms study is testing weight management techniques that have been used with non-pregnant adults. We aim to help obese women limit GWG to improve their long-term health and the health of their offspring.

Weight gain in pregnancy: is less truly more for mother and infant?

Although more than 50% of women gain weight above the Institute of Medicine (IOM) guidelines for weight gain in pregnancy and excessive weight gain is an independent risk factor for significant maternal and neonatal morbidity and offspring obesity, there is little consensus over the ideal weight gain during pregnancy. Surprisingly, the 2009 IOM guidelines varied minimally from the 1990 IOM guidelines, and many critics advocate lower weight gain recommendations. This review explores the energy costs of pregnancy, the relationship between gestational weight gain and birth weight, and considers what gestational weight gain minimizes both large-for-gestational age as well as small-for-gestational age infants. An extensive examination of the current data leads this author to question whether the current weight gain recommendations are too liberal, especially for obese pregnant women.

Racial and ethnic disparities in preconception risk factors and preconception care

OBJECTIVE

At-risk drinking, cigarette smoking, obesity, diabetes, and frequent mental distress, as well as their co-occurrence in childbearing aged women, are risk factors for adverse pregnancy outcomes. This study estimated the prevalence of these five risk factors individually and in combination among nonpregnant women aged 18-44 years by demographic and psychosocial characteristics, with a focus on racial and ethnic disparities.

METHODS

Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) on nonpregnant women aged 18-44 years (n=54,612) were used to estimate the prevalences of five risk factors, pairs of co-occurring risk factors, and multiple risk factors for poor pregnancy outcomes.

RESULTS

The majority of women had at least one risk factor, and 18.7% had two or more risk factors. Having two or more risk factors was highest among women who were American Indian and Alaska Native (34.4%), had less than a high school education (28.7%), were unable to work (50.1%), were unmarried (23.3%), and reported sometimes, rarely, or never receiving sufficient social and emotional support (32.8%). The most prevalent pair of co-occurring risk factors was at-risk drinking and smoking (5.7%).

CONCLUSIONS

The high proportion of women of childbearing age with preconception risk factors highlights the need for preconception care. The common occurrence of multiple risk factors suggests the importance of developing screening tools and interventions that address risk factors that can lead to poor pregnancy outcomes. Increased attention should be given to high-risk subgroups.

Prepregnancy obesity: determinants, consequences, and solutions

Obesity among women of childbearing age is of paramount importance because of its association with multiple adverse health outcomes for the mother and fetus once a woman becomes pregnant. Obesity is more prevalent among women of lower socioeconomic status and of color who often times lack health insurance. This health disparity that exists within a framework of repeating cycle of risk emphasizes the urgency for accelerating the discovery of solutions for the obesity problem among women of childbearing age.

Downsizing pregnancy complications: a study of paired pregnancy outcomes before and after bariatric surgery

BACKGROUND

Overweight and obesity have been shown to be associated with increased adverse pregnancy outcomes. Weight reduction improves maternal health status and reduces the risk of pregnancy complications, as well as long-term consequences. Our objective was to compare the pregnancy outcomes of the same women who delivered before and after bariatric surgery.

METHODS

A retrospective study comparing pregnancy outcomes, of the same women, delivered before and after a bariatric surgery was conducted. The observed deliveries occurred from 1988 to 2008 at Soroka University Medical Center, the sole tertiary hospital in the southern region of Israel.

RESULTS

The present study included 288 paired pregnancies: 144 deliveries before and 144 after bariatric surgery. A significant reduction in the prepregnancy and predelivery maternal body mass index was noted after bariatric surgery (36.37 ± 5.2 versus 30.50 ± 5.4 kg/m(2), P < .001; and 40.15 ± 4.92 versus 34.41 ± 5.42 kg/m(2), P < .001; respectively). Only 8 patients (5.6%) were admitted during their pregnancy for bariatric complications. Pregnancy complications, such as hypertensive disorders (31.9% versus 16.6%; P = .004) and diabetes mellitus (20.8% versus 7.6%; P = .001), were significantly reduced after bariatric surgery. The rate of cesarean deliveries because of labor dystocia was significantly lower after bariatric surgery (5.6% versus 2.1%, P < .05). Using a multiple logistic regression model, controlling for maternal age, the reduction in hypertensive disorders (odds ratio .4, 95% confidence interval .2-.8) and diabetes mellitus (odds ratio .15, 95% confidence interval .1-.4) remained significant.

CONCLUSION

A significant decrease in pregnancy complications, such as hypertensive disorders and diabetes mellitus, is achieved after bariatric surgery.

Medical and behavioral evaluation of patients with obesity

Obesity may be the most significant medical problem that health care providers will face over the coming decades. Physicians must aggressively address this chronic disease, providing both preventive and therapeutic care. Since this topic has not been traditionally taught in medical school or residency training, physicians and other health providers will need to acquire the knowledge, skills, and attitudes necessary to be effective obesity care providers. Performing a detailed initial assessment, including an obesity focused history, physical examination, and selected laboratory and diagnostic tests is fundamental to the process of care.

Maternal obesity support services: a qualitative study of the perspectives of women and midwives

BACKGROUND

Twenty percent of pregnant women in the UK are obese (BMI ≥ 30 kg/m2), reflecting the growing public health challenge of obesity in the 21st century. Obesity increases the risk of adverse outcomes during pregnancy and birth and has significant cost implications for maternity services. Gestational weight management strategies are a high priority; however the evidence for effective, feasible and acceptable weight control interventions is limited and inconclusive. This qualitative study explored the experiences and perceptions of pregnant women and midwives regarding existing support for weight management in pregnancy and their ideas for service development.

METHODS

A purposive sample of 6 women and 7 midwives from Doncaster, UK, participated in two separate focus groups. Transcripts were analysed thematically.

RESULTS

Two overarching themes were identified, 'Explanations for obesity and weight management' and 'Best care for pregnant women'. 'Explanations' included a lack of knowledge about weight, diet and exercise during pregnancy; self-talk messages which excused overeating; difficulties maintaining motivation for a healthy lifestyle; the importance of social support; stigmatisation; and sensitivity surrounding communication about obesity between midwives and their clients. 'Best care' suggested that weight management required care which was consistent and continuous, supportive and non-judgemental, and which created opportunities for interaction and mutual support between obese pregnant women.

CONCLUSIONS

Women need unambiguous advice regarding healthy lifestyles, diet and exercise in pregnancy to address a lack of knowledge and a tendency towards unhelpful self-talk messages. Midwives expressed difficulties in communicating with their clients about their weight, given awareness that obesity is a sensitive and potentially stigmatising issue. This indicates more could be done to educate and support them in their work with obese pregnant women. Motivation and social support were strong explanatory themes for obesity and weight management, suggesting that interventions should focus on motivational strategies and social support facilitation.

The potential role of intragastric balloon in the treatment of obese-related infertility: personal experience

The prevalence of people who are overweight or obese has increased dramatically in high-income countries over the past 20 years. There is a strong association between obesity and infertility, and weight loss can result in increased fecundity in obese women. The aim of this study is to demonstrate the potential role of intragastric balloon in the treatment of obese-related infertility. This is a retrospective study. A chart review of 27 obese women seen between September 2003 and July 2008 was performed. They all presented with the diagnosis of infertility and had undergone endoscopic intragastric balloon positioning. Among these women who tried unsuccessfully to become pregnant before weight loss, 15 became pregnant afterward. The pregnancies proceeded without complications and ended with live births. An improvement in the fertility status after weight loss has been described, although data on fertility after weight loss following bariatric surgery are still limited. The results obtained in our experience are not different from data reported in literature for bariatric surgery. Therefore, balloon treatment might be effective in young infertile obese women who wish to become pregnant.

Postpartum behaviour as predictor of weight change from before pregnancy to one year postpartum

Background

Postpartum weight retention affects many women and increases the risk of becoming overweight. The research objective was to study modifiable factors contributing to weight change at one year postpartum.

Methods

In this prospective cohort, postpartum behavior, such as physical activity, sedentary behavior, sleep, and intake of total energy, total fat and saturated fatty acids of 118 Dutch women were assessed in 2003/2004 by self-report at 6 weeks, 6 and 12 months postpartum. Mean postpartum scores were computed for the behavioral measures. In linear regression models it was determined which factors were associated with average weight change from before pregnancy to one year postpartum. Furthermore, factors associated with substantial postpartum weight retention (≥ 5 kg) were also studied in logistic regression models.

Results

At one year postpartum, the average weight of participants had increased by 0.9 kg (SD 4.4). Moreover, 20% of the women retained ≥ 5 kg. Women who perceived themselves more physically active than others were almost ten times less likely to retain ≥ 5 kg than women who perceived themselves equally active (OR = 0.11, 95%CI: 0.02 - 0.66). Exceeding the guideline for saturated fatty acid intake (OR = 3.40, 95%CI: 1.04 - 11.11), total gestational weight gain (OR = 1.14/kg, 95%CI: 1.01 - 1.27), and not having completed post high school education (OR = 5.13, 95%CI: 1.66 - 15.90) increased the odds of retaining ≥ 5 kg.

Conclusions

Since one in five women had substantial weight retention postpartum, effective interventions for the prevention of weight retention are much needed. Future studies should evaluate whether interventions focusing on the identified modifiable postpartum factors are successful in reducing weight retention after childbirth.

Recommendations for weight gain during pregnancy in the context of the obesity epidemic

The Institute of Medicine and the National Research Council have issued new guidelines for gestational weight gain as well as recommendations for action and research that call for "a radical change in the care provided to women of childbearing age." For the first time, these guidelines consider the outcomes of both mother and child during and after delivery and the trade-offs between them. The recommendations call for women to begin pregnancy at a healthy weight and to gain within the guidelines, a goal not previously achieved. They also call for individualized preconceptional, prenatal, and postpartum care to help women attain a healthy weight, gain within the guidelines, and return to a healthy weight. Scientific evidence was inadequate to provide specific guidelines by obesity class or to support a public health recommendation to reduce the guidelines below 5-9 kg (11-20 lb) for obese women.

Understanding the causal factors of obesity using the International Classification of Functioning, Disability and Health

PURPOSE

Behavioural, personal, psychological, sociodemographic, environmental, biological and childbearing factors have been associated with obesity among women. This study quantitatively explored the effects of these factors on predicting body mass index (BMI) in U.S. women using the International Classification of Functioning, Disability and Health (ICF) and determined the effectiveness of using the ICF with population-level data.

METHODS

We used the ICF Core Sets for Obesity, and data from the 1999-2006 National Health and Nutrition Examination Survey (NHANES) in a sample of 8766 U.S. women to quantify the impact of all associated causal factors. Linear regression was used in the analyses.

RESULTS

Body image perceptions (42%) was the most significant contributor, followed by hypertension (12%), general health condition (11%), diabetes/borderline diabetes (10%), arthritis (9%) and performing vigorous activity (9%).

CONCLUSIONS

To decrease obesity prevalence rates in U.S. women, obesity prevention and treatment programmes should parallel the contributory effects of its most significant causal factors of psychological, biological and behavioural. In addition, more research and data are needed to explore the relationship between BMI in women and the multiple influencing factors by going beyond the more frequently available information of age, gender, race, education, income and parity.

Maternal high fat feeding and gestational dietary restriction: effects on offspring body weight, food intake and hypothalamic gene expression over three generations in mice

Excessive gestational weight gain and maternal obesity have both been associated with increased incidence of obesity and metabolic disorder in offspring in both humans and animal models. The objectives of this study were to determine (1) whether mild gestational food restriction during the third trimester (GFR) would alter food intake and growth parameters of offspring, (2) whether effects of GFR depended on diet (high fat [HF] vs chow), (3) whether effects of excessive gestational weight gain (WG) would become magnified across generations, and (4) whether diet and GFR would alter hypothalamic gene expression in adult offspring. Three generations of female C57BL/6 mice were fed chow or HF diet, mated at 11 weeks of age and assigned to ad libitum feeding or 25% GFR. Offspring were fed the same diet as their mothers. Results showed (1) maternal gestational WG was positively correlated with offspring WG. (2) HF offspring weighed less (p<0.01) at weaning (WWT) but gained more during the 8 weeks after weaning than chow-fed offspring (p<0.05), resulting in higher final body weights (BW) (p<0.01). (3) HF males from GFR mothers had higher WWT (p<0.05), but subsequent WG and final BW were less (p<0.05) compared to males from ad lib mothers. (4) In the HF group, GFR also resulted in decreased FI (p<0.05) and FE (p<0.07) in offspring, compared to offspring from ad lib mothers. (5) In generation 3, hypothalamic expression of tyrosine hydroxylase was lower in HF males from GFR mothers compared to HF males from ad lib mothers (p<0.05). In conclusion, gender and maternal GFR had independent effects on growth and FI, and hypothalamic gene expression was dependent on both gender and maternal GFR in HF offspring. Even mild food restriction of obese mothers during pregnancy may have beneficial effects in reducing the risk or degree of obesity in offspring.

'Not waving but drowning': a study of the experiences and concerns of midwives and other health professionals caring for obese childbearing women

OBJECTIVE

to explore the experiences and concerns of health professionals who care for childbearing women who are obese.

BACKGROUND

obesity is increasing nationally and internationally and has been described as an epidemic. A number of studies have highlighted the risks associated with obesity during childbirth, yet few studies have investigated the experiences and concerns of midwives and other health professionals in providing care to these women.

DESIGN

a descriptive qualitative study using focus groups and face-to-face interviews to collect data. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis.

SETTING

three maternity units in New South Wales, Australia.

PARTICIPANTS

participants included 34 midwives and three other health professionals.

FINDINGS

three major themes emerged from the data analysis: 'a creeping normality', 'feeling in the dark' and 'the runaway train'. The findings highlight a number of tensions or contradictions experienced by health professionals when caring for childbearing women who are obese. These include, on the one hand, an increasing acceptance of obesity ('a creeping normality'), and on the other, the continuing stigma associated with obesity; the challenges of how to communicate effectively with pregnant women about their weight and the lack of resources, equipment and facilities ('feeling in the dark') to adequately care for obese childbearing women. Participants expressed concerns about how quickly the obesity epidemic appears to have impacted on maternity services ('the runaway train') and how services to meet the needs of these women are limited or generally not available.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

it was clear in this study that participants felt that they were 'not waving but drowning'. There was concern over the fact that the issue of obesity had moved faster than the health response to it. There were also concerns about how to communicate with obese women without altering the relationship. Continuity of care, training and skills development for health professionals, and expansion of limited services and facilities for these women are urgently needed.

Excessive gestational weight gain and postpartum weight retention among obese women

OBJECTIVE

To evaluate the incremental effect of weight gain above that recommended for term pregnancy (15 pounds) on postpartum weight retention at 1 year among obese women.

METHODS

In a retrospective cohort study, we identified 1,656 singleton gestations resulting in live births among obese women (body mass index at or above 30 kg/m) between January 2000 and December 2005 in Kaiser Permanente Northwest. Pregnancy weight change (last available predelivery weight minus weight at pregnancy onset) was categorized as less than 0, 0-15, greater than 15 to 25, greater than 25 to 35, and greater than 35 pounds. Postpartum weight change (weight at 1 year postpartum minus weight at pregnancy onset) was defined as less than 0, 0-10, and greater than 10 pounds.

RESULTS

Total gestational weight gain was -33.2 (weight loss) to +98.0 pounds (weight gain). Nearly three fourths gained greater than 15 pounds, and they were younger and weighed less at baseline than women who gained 15 pounds or less. Pregnancy-related weight change showed a significant relationship with postpartum weight change. For each pound gained during pregnancy, there was a 0.4-pound increase above baseline weight at 1 year postpartum. In adjusted logistic regression models, the risk of a postpartum weight greater than 10 pounds over baseline was twofold higher for women gaining greater than 15 to 25 pounds compared with women gaining 0-15 pounds (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.54-3.10), fourfold higher for women gaining greater than 25 to 35 pounds (OR 3.91, 95% CI 2.75-5.56), and almost eightfold higher for women gaining greater than 35 pounds (OR 7.66, 95% CI 5.36-10.97).

CONCLUSION

Incremental increases in gestational weight gain beyond the current recommendation for obese women substantially increase the risk of weight retention at 1 year postpartum.

LEVEL OF EVIDENCE

II.

Correlates of absolute and excessive weight gain during pregnancy

OBJECTIVE

Factors associated with weight gain during pregnancy that may be linked to maternal overweight and obesity were examined.

METHODS

In this observational study, 144 women reported on demographics, (prepregnancy) body weight, and lifestyles in self-reported questionnaires at 30 weeks gestation. Body weight at the end of pregnancy (self-reported at 6 weeks postpartum) was used to determine total gestational weight gain. Multivariate prediction models were developed to identify factors associated with total gestational weight gain and excessive gestational weight gain (i.e., higher weight gain than recommended by the Institute of Medicine).

RESULTS

Women gained 14.4 (+/-5.0) kg during pregnancy. Obese women gained almost 4 kg less than normal weight women. Pregnant women judging themselves to be less physically active or women who reported increased food intakes during pregnancy gained significantly more weight. Over one third of women (38%) gained more weight than recommended. Being overweight, judging yourself to be less physically active than others, and a perceived elevated food intake during pregnancy were significantly associated with excessive weight gain (odds ratio [OR] = 6.33, 95% confidence interval [CI]: 2.01-19.32; OR = 3.96, 95% CI: 1.55l, 10.15; and OR = 3.14, 95% CI: 1.18, 8.36, respectively). A higher age at menarche and hours of sleep reduced the odds for excessive weight gain (OR = 0.75, 95% CI: 0.57, 0.99; and OR = 0.35, 95% CI: 0.57, 0.93, respectively).

CONCLUSIONS

Mean hours of sleep, perceived physical activity, and measures of food intake at 30 weeks gestation were identified as modifiable behavioral correlates for excessive gestational weight gain. Strategies to optimize gestational weight gain need to be explored, with a focus on the identified factors.

Pregnancy outcome in patients following different types of bariatric surgeries

BACKGROUND

The objective of this study was to investigate pregnancy outcome of patients following different types of bariatric surgery.

METHODS

A population-based study includes all pregnancies of patients with bariatric surgeries delivered during 1988-2008. Pregnancy outcome was compared between the different types of surgeries.

RESULTS

This retrospective study included 449 deliveries: 394 deliveries following pure restrictive operations-laparoscopic gastric banding (LAGB; n = 202), silastic ring vertical gastroplasty (SRVG; n = 136), and vertical-banded gastroplasty (VBG; n = 56)-and 55 deliveries following restrictive and malabsorptive Roux-en-Y gastric bypass (RGB). While no significant differences were noted between the groups regarding body mass index (BMI) before the bariatric operations or prepregnancy BMI, patients following LAGB had significantly higher BMI before delivery (36.8 +/- 5.9 kg compared to the SRVG 33.4 +/- 6.0, VBG 34.2 +/- 5.4, and RGB 34.9 +/- 6.8 groups; p < 0.001). Following LAGB, patients had higher weight gain during pregnancy (13.1 +/- 9.6 kg) compared to the SRVG (8.8 +/- 7.4), VBG (8.5 +/- 8.0), and RGB (11.6 +/- 9.6; p < 0.001) groups. The interval between operation and pregnancy was shorter in the LAGB group (22.8 months) compared to the SRVG (41.0) and the VBG (42.1) groups and was significantly higher in the RGB group (57.4; p < 0.001). Birth weight was significantly higher among newborns of patients following RBG (3,332.8 +/- 475.5 g) compared to the restrictive procedures (3,104.3 +/- 578.7 in the LAGB, 3,086.7 +/- 533.1 in the SRVG, and 3,199.2 +/- 427.2 in the VBG groups). No significant differences in low birth weight (<2,500 g) or macrosomia (>4,000 g), or low Apgar scores or perinatal mortality were noted between the groups.

CONCLUSION

There is no difference in the affect on pregnancy outcome among the different forms of bariatric surgeries; all procedures have basically comparable perinatal outcome.

Maternal obesity and the risk of infant death in the United States

BACKGROUND

Maternal obesity (defined as prepregnancy body mass index [BMI] >or=30 kg/m) is associated with increased risk of neonatal death. Its association with infant death, postneonatal death, and cause-specific infant death is less well-characterized.

METHODS

We studied the association between maternal obesity and the risk of infant death by using 1988 US National Maternal and Infant Health Survey data. A case-control analysis of 4265 infant deaths and 7293 controls was conducted using SUDAAN software. Self-reported prepregnancy BMI and weight gain were used in the primary analysis, whereas weight variables in medical records were used in a subset of 4308 women.

RESULTS

Compared with normal weight women (prepregnancy BMI = 18.5-24.9 kg/m) who gained 0.30 to 0.44 kg/wk during pregnancy, obese women had increased risk of neonatal death and overall infant death. For obese women who had weight gain during pregnancy of <0.15, 0.15 to 0.29, 0.30 to 0.44, and >or=0.45 kg/wk, the adjusted odds ratios of infant death were 1.75 (95% confidence interval = 1.28-2.39), 1.42 (1.07-1.89), 1.59 (1.00-2.51), and 2.87 (1.98-4.16), respectively. Nonobese women with very low weight gain during pregnancy also had a higher risk of infant death. The subset with weight information from medical records had similar results for recorded prepregnancy BMI and weight gain. Maternal obesity was associated with neonatal death from pregnancy complications or disorders relating to short gestation and unspecified low birth weight.

CONCLUSIONS

Maternal obesity is associated with increased overall risk of infant death, mainly neonatal death.

Maternal obesity: a review of interventions

BACKGROUND

Obesity has become a serious global public health issue and has consequences for nearly all areas of medicine. Within obstetrics, obesity not only has direct implications for the health of a pregnancy but also impacts on the weight of the child in infancy and beyond. As such, maternal weight may influence the prevalence and severity of obesity in future generations. Pregnancy has been identified as a key time to target a weight control or weight loss strategy to help curb the rapidly growing obesity epidemic. In addition, if delivered sensitively, pregnancy may be a good time to target health behaviour changes by using the extra motivation women tend to have at this time to maximise the health of their child.

AIM

This study reviews the current evidence for interventions to promote weight control or weight loss in women around the time of pregnancy. A comprehensive review of medical research--PubMed, Embase, Ovid Medline and the Cochrane Clinical Trials register--showed that despite numerous reports of the prevalence and complications of maternal obesity, few intervention strategies have been suggested.

CONCLUSION

This study finds that there is a deficiency of appropriately designed interventions for maternal obesity and it concludes by highlighting areas for developing a more effective strategy.

The state of obesity management for women giving birth in Atlantic Canada

OBJECTIVES

The purpose of this survey was to gain insight into the status of birthing facilities across Atlantic Canada regarding obesity management. Specifically, we were interested in learning about the reported number of obese women entering birthing facilities, if body mass index (BMI) was determined from weight and height, and whether this was used to diagnose maternal obesity or not. Clinical, delivery, or equipment-related challenges and the state of existing or planned policies or guidelines specific to this high-risk population were also sought.

METHODS

An online, cross-sectional survey (audit), distributed via email to key staff members at birthing facilities in Atlantic Canada, including nurse managers, nurse practitioners, registered staff nurses and obstetrician-gynecologists.

RESULTS AND CONCLUSIONS

Twenty-two responses were received from 38 invitees (57% response rate), representing half the birthing facilities in Atlantic Canada. Despite the fact that the majority of facilities recorded maternal height and pre-pregnancy weight upon admission, these measurements were not used to calculate and document maternal BMI, nor to make a diagnosis of maternal obesity. More troubling, no birthing facilities in our survey had guidelines or care plans in place to deal with this high-risk population, and two-thirds of those surveyed had no plans for their creation in the near future. While maternal obesity was considered a problem, a third of respondents reported no direct access to properly sized lifts or transfer devices in their units. This study provides a useful baseline for monitoring improvements in the care of obese women giving birth in Atlantic Canada.

The joint effects of maternal prepregnancy body mass index and age on the risk of gastroschisis

Young maternal age has been associated with an increased risk of gastroschisis, while high maternal weight status has been associated with a decreased risk. We were interested in investigating the joint effect of these two risk factors to identify thresholds in risk associated with body mass index (BMI) for a given age. Data from the National Birth Defects Prevention Study included 464 case infants with gastroschisis and 4842 healthy controls. A generalised additive model with a bivariate spline for continuous maternal age and prepregnancy BMI was used to model the probability of gastroschisis. The bivariate spline in BMI and maternal age was significantly associated with gastroschisis (P = 0.0001) after adjustment for study centre, maternal race/ethnicity, education, income and number of persons supported by income, smoking, alcohol use, vitamin use, vasoconstrictor medication use and gestational diabetes. The data indicate that women who are younger and who have lower BMI are at the greatest risk; a woman with a BMI of 17 who gives birth at age 15 has 7 times the odds (adjusted odds ratio = 7.0 [95% CI 4.2, 11.5]) of having an offspring with gastroschisis compared with a woman of age 24 with a BMI of 23. Furthermore, there was an interaction between maternal age and BMI for this risk. The increased risk of low maternal age and prepregnancy BMI associated with gastroschisis appears to suggest an aetiological role related to biological immaturity for this particular birth defect.

The clinical content of preconception care: nutrition and dietary supplements

Women of child-bearing age should achieve and maintain good nutritional status prior to conception to help minimize health risks to both mothers and infants. Many women may not be aware of the importance of preconception nutrition and supplementation or have access to nutrition information. Health care providers should be knowledgeable about preconception/pregnancy-related nutrition and take the initiative to discuss this information during preconception counseling. Women of reproductive age should be counseled to consume a well-balanced diet including fruits and vegetables, iron and calcium-rich foods, and protein-containing foods as well as 400 microg of folic acid daily. More research is critically needed on the efficacy and safety of dietary supplements and the role of obesity in birth outcomes. Preconception counseling is the perfect opportunity for the health care provider to discuss a healthy eating guideline, dietary supplement intake, and maintaining a healthy weight status.

Dietary restraint and gestational weight gain

OBJECTIVE

To determine whether a history of preconceptional dieting and restrained eating was related to higher weight gains in pregnancy.

DESIGN

Dieting practices were assessed among a prospective cohort of pregnant women using the Revised Restraint Scale. Women were classified on three separate subscales as restrained eaters, dieters, and weight cyclers.

SUBJECTS

Participants included 1,223 women in the Pregnancy, Infection, and Nutrition Study.

MAIN OUTCOME MEASURES

Total gestational weight gain and adequacy of weight gain (ratio of observed/expected weight gain based on Institute of Medicine recommendations).

STATISTICAL ANALYSES PERFORMED

Multiple linear regression was used to model the two weight-gain outcomes, while controlling for potential confounders including physical activity and weight-gain attitudes.

RESULTS

There was a positive association between each subscale and total weight gain, as well as adequacy of weight gain. Women classified as cyclers gained an average of 2 kg more than noncyclers and showed higher observed/expected ratios by 0.2 units. Among restrained eaters and dieters, there was a differential effect by body mass index. With the exception of underweight women, all other weight status women with a history of dieting or restrained eating gained more weight during pregnancy and had higher adequacy of weight gain ratios. In contrast, underweight women with a history of restrained eating behaviors gained less weight compared to underweight women without those behaviors.

CONCLUSIONS

Restrained eating behaviors were associated with weight gains above the Institute of Medicine's recommendations for normal, overweight, and obese women, and weight gains below the recommendations for underweight women. Excessive gestational weight gain is of concern because of its association with postpartum weight retention. The dietary restraint tool is useful for identifying women who would benefit from nutritional counseling prior to or during pregnancy with regard to achieving targeted weight-gain recommendations.

The effect of obesity on heart rate (heart period) and physiologic parameters during pregnancy

Obesity and excess gestational weight gain (EGWG) in pregnancy increase the risk for adverse maternal and infant outcomes. Along with careful monitoring of weight gain during pregnancy, early identification of a maladaptive response to the changes of pregnancy may help to avoid adverse outcomes. Simple physiologic markers such as resting heart rate (HR), heart period (HP), and blood pressure (BP) may be powerful predictors of cardiovascular adaptation to pregnancy. This article summarizes the current state of the science regarding the effect of obesity (body mass index [BMI] > or =30 kg/m(2)) and EGWG in pregnant women at rest in laboratory settings. The impact of differences in weight gain (kg and BMI) on pregnancy outcomes is also examined. A search was conducted for articles published from 1985 to 2006 reporting data on body weight and HR or HP at rest from randomized controlled trials or controlled trials conducted in laboratory settings involving pregnant women at low or high risk for adverse pregnancy outcomes who were obese or had EGWG. A meta-analysis was conducted on the 23 studies meeting inclusion criteria to explore the relation of BMI to HR, HP, and physiologic parameters. Autonomic responsiveness was found to be diminished in obese women with a BMI > 30 kg/m(2) and in women with high risk for adverse pregnancy outcomes, which may indicate a maladaptive autonomic response that is imbalanced and disorganized and that reduces adaptation to environmental demands.

Antisocial behavioral syndromes and body mass index among adults in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To describe associations of antisocial behavioral syndromes, including DSM-IV antisocial personality disorder (ASPD) and conduct disorder without progression to ASPD ("CD only"), and syndromal antisocial behavior in adulthood without CD before age 15 (AABS, not a codable DSM-IV disorder), with body mass index (BMI) status in the general US adult population.

METHODS

This report is based on the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43093; response rate, 81%). Respondents were classified according to whether they met criteria for ASPD, AABS, "CD only," or no antisocial syndrome, and on current BMI status based on self-reported height and weight. Associations of antisocial syndromes with BMI status were examined using multinomial logistic regression.

RESULTS

Among men, antisociality was not associated with BMI. Among women, ASPD was significantly associated with overweight and extreme obesity; AABS was associated with obesity and extreme obesity; and "CD only" was significantly associated with overweight, obesity, and extreme obesity.

CONCLUSIONS

Assessment of antisocial features appears warranted in overweight, obese, and extremely obese women, and assessment of BMI status appears indicated in antisocial women. Prevention and treatment guidelines for overweight and obesity may need revision to address comorbid antisociality, and interventions targeting antisociality may need to include attention to weight concerns.

Bariatric surgery and adolescent gynecology

PURPOSE OF REVIEW

This review summarizes the impact of bariatric surgery on gynecologic complications in the context of the extremely obese adolescent and reviews contraceptive considerations before and after adolescent bariatric surgery.

RECENT FINDINGS

Eighteen percent of children and adolescents have a body mass index greater than the 95th percentile, with 4% of adolescents being greater than the 99th percentile. Gynecologic morbidities identified in obese adolescents include anovulatory complications such as acute menorrhagia, polycystic ovary syndrome and endometrial hyperplasia, and cancer. When conventional dietary and behavioral therapy fail to result in weight loss, specific criteria have been identified to justify bariatric surgery in extremely obese adolescents. Bariatric surgery in adult women often results in resumption of ovulatory menses, resolution of clinical and laboratory evidence of hyperandrogenism, and return of fertility. Adolescents are at risk for unintended pregnancies, and there are special concerns regarding pregnancy in bariatric patients. Specific contraceptive methods have particular potential risks, benefits, and drawbacks for use in obese adolescents.

SUMMARY

Clinicians who provide care for extremely obese adolescents must be aware of the potential for gynecologic morbidities including polycystic ovary syndrome, dysfunctional bleeding and endometrial hyperplasia, expected gynecologic and fertility outcomes of weight loss surgery for teens, as well as the implications on contraceptive options.

Caring for Obese Pregnant Women

Women who are overweight or obese during their childbearing years are at an increased risk for pregnancy-induced hypertension, gestational diabetes, labor induction, cesarean births, and failed vaginal birth after cesarean. During the postpartum, they experience increased rates of puerperal infection and decreased rates of breastfeeding initiation or continuation. Their infants are at higher risk for having congenital anomalies or being stillborn. Nurses can use this knowledge to adapt the care they provide and to encourage health-promoting behaviors.