Implementation of the new institute of medicine gestational weight gain guidelines

Low back pain in pregnant women: A necessary or an avoidable evil?

OBJECTIVES

The aim of this study was to determine the prevalence, the main features and the potential risk factors of LBP in pregnant women.

METHODS

This cross-sectional study included 173 pregnant women in the third trimester. Non-inclusion criteria were severe mental disability and known previous history of musculoskeletal diseases. The participants were categorised into two groups: women with pregnancy-related LBP and pain-free women. Demographic, socio-professional, clinical and obstetrical data were compared between the two groups using the appropriate statistical tests.

RESULTS

The mean age was 32.2 ± 5.4 years [17-45]. Among them, 108 (62.4%) reported one or more episodes of LBP during at least 7 days, mostly in the third semester (n = 71). The presence of LBP was significantly associated with history of LBP in previous pregnancies and jobs requiring prolonged standing. Active jobs and the presence of gestational complications were significantly more common in pain-free women. In the multivariate analysis, LBP was independently predicted by the history of LBP in previous pregnancies and the absence of gestational complications.

CONCLUSIONS

The association of LBP with gestational complications as a protective factor has not yet been reported in previous studies. These complications are a common cause of hospitalisation, which represents a period of relative rest during pregnancy. Our results revealed that history of LBP in previous pregnancies, sedentary lifestyle prior to pregnancy and prolonged standing are the main risk factors of LBP. In contrast, rest and avoidance of physical overstrain during pregnancy may be protective factors.

Monitoring gestational weight gain: setting up a regional surveillance system in Italy

BACKGROUND

In many countries, including Italy, there are few national data on pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG), despite these being important predictors of maternal and neonatal health outcomes. This dearth of information makes it difficult to develop and monitor intervention policies to reduce the burden of disease linked to inadequate BMI status and/or GWG in pregnant women. This study describes the setting up and initial implementation of a regional surveillance system on pre-pregnancy BMI and GWG.

METHODS

Between 1 January 2017 and 31 December 2018, anthropometric data were collected from all pregnant women accessing public health services in the Friuli Venezia Giulia region (Italy) for first ultrasound check (T1) and at delivery (T2). Anthropometric data collected at T1 (self-reported pre-pregnancy weight and measured weight and height) and T2 (measured weight and self-reported pre-pregnancy weight and height) were compared.

RESULTS

The system was able to reach 43.8% of all the women who gave birth in the region, and provided complete data for 6400 women of the 7188 who accessed the services at T1. At the beginning of pregnancy 447 (7.0%) women were underweight, 4297 (67.1%) had normal weight, 1131 (17.7%) were overweight and 525 (8.2%) had obesity. At delivery, 2306 (36.0%) women were within the appropriate weight gain range, while for 2021 (31.6%) weight gain was insufficient and for 2073 (32.4%) excessive. Only minor differences were observed between measured and self-reported anthropometric data.

CONCLUSIONS

The surveillance system offers an overview of the weight status of women during pregnancy. About 1/3 of women entered pregnancy with unsatisfactory BMI and 2/3 did not achieve the recommended weight gain. This surveillance system can be an effective tool to guide public health interventions.

Dietary Pattern Influences Gestational Weight Gain: Results from the ProcriAr Cohort Study-São Paulo, Brazil

The maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) influence maternal and infant outcomes. This study identified patterns of habitual dietary intake in 385 pregnant women in São Paulo and explored their associations with excessive weight gain (EGWG). Weight at the first visit (<14 weeks) was used as a proxy for pre-pregnancy weight. Food consumption was assessed using the 24HR method, administered twice at each gestational trimester, and dietary patterns were identified by principal component analysis. Three dietary patterns were identified: “Vegetables and Fruits,” “Western,” and “Brazilian Traditional.” Descriptive data analysis was performed using absolute and relative frequencies for each independent variable and multilevel mixed-effects logistic regression was used to analyze excessive gestational gain weight (EGWG) and dietary patterns (DP). The Brazilian Traditional dietary pattern showed a protective effect on EGWG (p = 0.04) and age > 35 years (p = 0.03), while subjects overweight at baseline had a higher probability of EGWG (p = 0.02), suggesting that the identification of dietary and weight inadequacies should be observed from the beginning of pregnancy, accompanied by nutritional intervention and weight monitoring throughout the gestational period to reduce risks to the mother and child’s health.

2009 IOM guidelines for gestational weight gain: how well do they predict outcomes across ethnic groups?

Objective: To determine whether the Institute Of Medicine's (IOM) 2009 guidelines for weight-gain during pregnancy are predictive of maternal and infant outcomes in ethnic minority populations.Methods: We designed a population-based study using administrative data on 181,948 women who delivered live singleton births in Washington State between 2006-2008. We examined risks of gestational hypertension, preeclampsia/eclampsia, cesarean delivery, and extended hospital stay in White, Black, Native-American, East-Asian, Hispanic, South-Asian and Hawaiian/Pacific islander women according to whether they gained more or less weight during pregnancy than recommended by IOM guidelines. We also examined risks of neonatal outcomes including Apgar score <7 at 5 min, admission to NICU, requirement for ventilation, and a diagnosis of small or large for gestational age at birth.Results: Gaining too much weight was associated with increased odds for gestational hypertension (adjusted OR (aOR) ranged between 1.53-2.22), preeclampsia/eclampsia (aOR 1.44-1.81), cesarean delivery (aOR 1.07-1.38) and extended hospital stay (aOR 1.06-1.28) in all ethnic groups. Gaining too little weight was associated with decreased odds for gestational hypertension and delivery by cesarean section in Whites, Blacks and Hispanics. Gaining less weight or more weight than recommended was associated with increased odds for small for gestational age and large for gestational age infants respectively, in all ethnic groups.Conclusions: Adherence to the 2009 IOM guidelines for weight gain during pregnancy reduces risk for various adverse maternal outcomes in all ethnic groups studied. However, the guidelines were less predictive of infant outcomes with the exception of small and large for gestational age.Abbreviations: GWG: Gestational weight gain; IOM/NRC; Institute of Medicine and National Research Council; NICU: Neonatal intensive care need for ventilation; SGA: Small for gestational age; LGA: Large for gestational age; BERD: Birth Events Records Database; CHARS: Comprehensive Hospital Discharge Abstract Reporting System; ICD: International Classification of Disease; LMP: Last menstrual period; OR: Odds ratio.

Experiences regarding nutrition and exercise among women during early postpartum: a qualitative grounded theory study

BACKGROUND

Excess gestational weight gain has long- and short-term implications for women and children, and postpartum weight retention is associated with an increased risk of long-term obesity. Despite the existence of dietary and exercise guidelines, many women struggle to return to pre-pregnancy weight. Experiences of women in tackling postpartum weight loss are poorly understood. We undertook this study to explore experiences related to nutrition, exercise and weight in the postpartum in women in Ontario, Canada.

METHODS

This was a nested qualitative study within The Be Healthy in Pregnancy Study, a randomized controlled trial. Women randomized to the control group were invited to participate. Semi-structured focus groups were conducted at 4-6 months postpartum. Focus groups were audio recorded, transcribed verbatim, coded and analyzed thematically using a constructivist grounded theory approach.

RESULTS

Women experienced a complex relationship with their body image, due to unrealistic expectations related to their postpartum body. Participants identified barriers and enablers to healthy habits during pregnancy and postpartum. Gestational weight gain guidelines were regarded as unhelpful and unrealistic. A lack of guidance and information about weight management, healthy eating, and exercise in the postpartum period was highlighted.

CONCLUSION

Strategies for weight management that target the unique characteristics of the postpartum period have been neglected in research and in patient counselling. Postpartum women may begin preparing for their next pregnancy and support during this period could improve their health for subsequent pregnancies.

TRIAL REGISTRATION

NCT01689961 registered September 21, 2012.

Maternal anthropometry: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015

BACKGROUND

Pre-pregnancy nutritional status and weight gain during pregnancy have short- and long-term consequences for the health of women and children. This study was aimed at evaluating maternal height,- and overweight or obesity at the beginning of the pregnancy and gestational weight gain, according to socioeconomic status and maternal skin colour of mothers in Pelotas, a southern Brazilian city, in 1982, 1993, 2004 and 2015.

METHODS

In 1982, 1993, 2004 and 2015, the maternity hospitals in Pelotas were visited daily, all deliveries were identified and mothers who lived in the urban area of the city were interviewed. Maternal weight at the beginning of the pregnancy was self-reported by the mother or obtained from the antenatal card. Maternal height was collected from the maternity records or measured by the research team. Overweight or obesity was defined by a body mass index ≥25 kg/m2. Gestational weight gain was evaluated according to the Institute of Medicine guidelines.

RESULTS

In the four cohorts, we evaluated 19 931 women. From 1982 to 2015, the prevalence of overweight or obesity at the beginning of the pregnancy increased from 22.1% to 47.0% and height increased by an average of 5.2 cm, whereas gestational weight gain did not change. Socioeconomic status was positively associated with maternal height, and the difference between the poorest and the wealthiest decreased. Overweight or obesity was lower among those mothers in the extreme categories of family income.

CONCLUSIONS

Over the 33-year span, mothers were taller at the beginning of the pregnancy, but the prevalence of overweight or obesity more than doubled.

Lifestyle Interventions in Overweight and Obese Pregnant or Postpartum Women for Postpartum Weight Management: A Systematic Review of the Literature

Excessive gestational weight gain (GWG) and postpartum weight retention (PPWR) may predispose women to the development of obesity. The objective of this systematic review was to evaluate the effectiveness of lifestyle interventions in overweight or obese pregnant and/or postpartum women for managing postpartum weight up to 2 years after giving birth. Eighteen randomised controlled trials were included (2559 participants) and divided into three categories according to the timing of the intervention: pregnancy only (n = 3), postpartum only (n = 12) and pregnancy and postpartum (n = 3). The intervention duration varied from 10 weeks to 10 months and included diet only (n = 5) or diet and physical activity (n = 13). Seven postpartum only interventions reported significant improvements in postpartum weight when compared to the control group. Most of these interventions were short and intensive, lasting 10–16 weeks. One pregnancy only and one pregnancy and postpartum intervention reported reduced PPWR at 6 months. Nine trials did not report an effect of the intervention on postpartum weight. However, of these, four reported associations between GWG and PPWR. This review suggests that successful postpartum weight management is achievable with intensive lifestyle interventions starting in the postpartum period; however, there is insufficient evidence to conclude whether interventions starting in pregnancy are effective. Larger trials utilising comparative methodologies in the pregnancy and postpartum periods are required to inform the development of targeted strategies preventing PPWR or reducing postpartum weight.

Optimal gestational weight gain: prepregnancy BMI specific influences on adverse pregnancy and infant health outcomes

OBJECTIVE

The Institute of Medicine (IOM) 2009 gestational weight gain (GWG) guidelines are based on prepregnancy body mass index (BMI) categories. We intended to refine optimal GWG for each prepregnancy BMI unit in relation to the risk of small- and large-for-gestational-age (SGA and LGA) births, cesarean section (C-section) and infant death.

STUDY DESIGN

We used data from 836,841 Ohio birth records from 2006 to 2012, and applied generalized additive models to calculate optimal GWG by prepregnancy BMI unit.

RESULTS

The suggested optimal GWG was generally similar to IOM 2009 GWG guidelines for prepregnancy BMIs <25 kg m^-2, but higher for prepregnancy BMIs 25 to 32 kg m^-2 and lower for BMIs 38 to 50 kg m^-2. The suggested optimal GWG was 14 to 18.5, 13 to 17, 11.5 to 16, 8.5 to 12.5, 4 to 10, 3 to 7, 1.5 to 6 and 1.5 to 4.5 kg for prepregnancy BMIs 15, 20, 25, 30, 35, 40, 45 and 50 kg m^-2, respectively.

CONCLUSION

This research suggests that GWG recommendations may be refined at individual prepregnancy BMI levels.

Translation of fetal abdominal circumference-guided therapy of gestational diabetes complicated by maternal obesity to a clinical outpatient setting

OBJECTIVE

To evaluate the effectiveness of fetal abdominal circumference-guided therapy for gestational diabetes (GDM) in an outpatient population characterized by highly-prevalent maternal obesity.

METHODS

Data for this translational retrospective cohort study come from medical records. Fetal abdominal circumference was assessed by ultrasound in late second trimester, and sex- and gestational age-specific percentiles assigned. Taking fetal abdominal circumference percentile as a marker for adequacy of fetal growth, maternal glucose targets were set accordingly: loose, moderate or tight. Associations between mother's targets and neonatal outcomes (small for gestational age (SGA), large for gestational age (LGA), macrosomia, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia) were assessed using unconditional logistic regression, controlling for pre-gravid body mass index (BMI) and gestational weight gain.

RESULTS

In 419 consecutive pregnancies complicated by GDM, neonatal outcomes compared favorably with previous randomized trials of intensive GDM management. Importantly, adverse outcomes were observed less often than might be expected in an obese GDM population. BMI did not have an independent effect on neonatal outcomes.

CONCLUSIONS

Ultrasound-guided therapy of GDM, in general clinic use, can limit excess macrosomia and LGA, even in a population with significant maternal obesity.

A population-based comparison between actual maternal weight gain and the Institute of Medicine weight gain recommendations in singleton pregnancies

OBJECTIVE

To compare the actual maternal weight gain to that recommended by the Institute of Medicine (IOM) in term singleton gestations.

METHODS

We used data from the Slovenian National Perinatal Information System to select singleton pregnancies born at ≥38 weeks during the period from 2003 to 2012. We calculated the frequencies of mothers who gained less than, more than, and as recommended by the IOM according to their pregravid body mass index (BMI). We also compared the fetal size parameters in under- and over-gainer to those who gained weight as recommended by the IOM.

RESULTS

We selected 173,715 patients who delivered at ≥38 weeks. Of these patients, the recommended weight gain was achieved by 56,868 (32.7%, 95% CI 32.5, 32.9) only, 82,617 (47.6%, 95% CI 47.3, 47.8) were over-gainers, and 34,230 (19.7%, 95% CI 19.5, 19.8) gained less than recommended. Neither undergaining nor overgaining were always synonymous with adverse fetal outcomes.

CONCLUSIONS

Roughly two-thirds of singleton mothers did not gain weight during pregnancy according to the IOM recommendations. Inappropriate maternal weight gain, however, was not always associated with adverse fetal outcomes and this implies that a tailored approach rather than strict adherence to the IOM recommendations may be more practical.

Gestational Weight Gain Trend and Population Attributable Risks of Adverse Fetal Growth Outcomes in Ohio

BACKGROUND

The trend of gestational weight gain (GWG) in relation to the Institute of Medicine (IOM) guidelines and the population attributable risks (PARs) of GWG on fetal growth outcomes remain unclear.

METHODS

We analysed Ohio birth certificates from 2006 to 2012 to examine GWG trend by prepregnancy body mass index, to calculate the risk of small- and large-for-gestational age (SGA and LGA), and macrosomia (birthweight >4000 g or >4500 g) infants, and to estimate the PARs of GWG below or above the guidelines.

RESULTS

Of 869,531 women who delivered singleton live births at 22-44 weeks of gestation, 4.5% were underweight, 48.9% were normal weight, 23.9% were overweight, and 22.7% were obese before pregnancy. About 36.5% of underweight, 52.6% of normal weight, 72.5% of overweight, and 62.4% of obese women gained weight above the guidelines, with only slight changes from 2006 to 2012. Also, 34.9% of underweight, 20.1% of normal weight, 16.3% of overweight, and 27.0% of obese women gained weight below the guidelines. The PAR of GWG below or above the guidelines was -13% for SGA, 32.6% for LGA, 28.1% for macrosomia >4000 g, and 48.3% for macrosomia >4500 g, mostly driven by currently GWG above the guidelines in normal weight, overweight, and obese women.

CONCLUSIONS

A high percentage of pregnant women gained weight outside of the current IOM GWG guidelines; however, changes from 2006 to 2012 were small. GWG above the IOM guidelines significantly contributed to a large proportion of LGA and macrosomic infants in the general population.

Maternal pre-pregnancy BMI, gestational weight gain, and infant birth weight: A within-family analysis in the United States

In the United States, the high prevalence of unhealthy preconception body weight and inappropriate gestational weight gain among pregnant women is an important public health concern. However, the relationship among pre-pregnancy BMI, gestational weight gain, and newborn birth weight has not been well established. This study uses a very large dataset of sibling births and a within-family design to thoroughly address this issue. The baseline analysis controlling for mother fixed effects indicates maternal preconception overweight, preconception obesity, and excessive gestational weight gain significantly increase the risk of having a high birth weight baby, respectively, by 1.3, 3 and 3.9 percentage points, while underweight before pregnancy and inadequate gestational weight gain increase the low birth weight incidence by 1.4 and 2 percentage points. The benchmark results are robust in a variety of sensitivity checks. Since poor birth outcomes especially high birth weight and low birth weight have lasting adverse impacts on one's health, education, and socio-economic outcomes later in life, the findings of this research suggest promoting healthy weight among women before pregnancy and preventing inappropriate weight gain during pregnancy can generate significant intergenerational benefits.

Trends in gestational weight gain: the Pregnancy Risk Assessment Monitoring System, 2000-2009

OBJECTIVE

Achieving adequate gestational weight gain (GWG) is important for optimal health of the infant and mother. We estimate current population-based trends of GWG.

STUDY DESIGN

We analyzed data from the Pregnancy Risk Assessment Monitoring System for 124,348 women who delivered live infants in 14 states during 2000 through 2009. We examined prevalence and trends in GWG in pounds as a continuous variable, and within 1990 Institute of Medicine (IOM) recommendations (yes/no) as a dichotomous variable. We examined adjusted trends in mean GWG using multivariable linear regression and GWG within recommendations using multivariable multinomial logistic regression.

RESULTS

During 2000 through 2009, 35.8% of women gained within IOM GWG recommendations, 44.4% gained above, and 19.8% gained below. From 2000 through 2009, there was a biennial 1.0 percentage point decrease in women gaining within IOM GWG recommendations (P trend < .01) and a biennial 0.8 percentage point increase in women gaining above IOM recommendations (P trend < .01). The percentage of women gaining weight below IOM recommendations remained relatively constant from 2000 through 2009 (P trend = .14). The adjusted odds of gaining within IOM recommendations were lower in 2006 through 2007 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and 2008 through 2009 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) relative to 2000 through 2001.

CONCLUSION

Overall, from 2000 through 2009 the percentage of women gaining within IOM recommendations slightly decreased while mean GWG slightly increased. Efforts are needed to develop and implement strategies to ensure that women achieve GWG within recommendations.

Preventing maternal and early childhood obesity: the fetal flaw in Australian perinatal care

Almost half of Australian women of child-bearing age are overweight or obese, with a rate of 30-50% reported in early pregnancy. Maternal adiposity is a costly challenge for Australian obstetric care, with associated serious maternal and neonatal complications. Excess gestational weight gain is an important predictor of offspring adiposity into adulthood and higher maternal weight later in life. Current public health and perinatal care approaches in Australia do not adequately address excess perinatal maternal weight or gestational weight gain. This paper argues that the failure of primary health-care providers to offer systematic advice and support regarding women's weight and related lifestyle behaviours in child-bearing years is an outstanding 'missed opportunity' for prevention of inter-generational overweight and obesity. Barriers to action could be addressed through greater attention to: clinical guidelines for maternal weight management for the perinatal period, training and support of maternal health-care providers to develop skills and confidence in raising weight issues with women, a variety of weight management programs provided by state maternal health services, and clear referral pathways to them. Attention is also required to service systems that clearly define roles in maternal weight management and ensure consistency and continuity of support across the perinatal period.

Pregnancy and Postpartum Related Weight Counseling Practices of U.S. Obstetrician-Gynecologists: Results from the Doc Styles Survey, 2010

OBJECTIVE

To describe factors and provider characteristics associated with weight-related counseling practices among U.S. obstetrician-gynecologists (OB/GYNs).

METHODS

Data were from a 2010 cross-sectional survey of 250 OB/GYNs. The OB/GYNs were asked how often they used pre-pregnancy body mass index (BMI) to determine the appropriate range of gestational weight gain (GWG), counseled pregnant patients on appropriate rate of GWG, and counseled postpartum patients on weight loss or maintenance. They were also asked how often they counseled pregnant and postpartum patients on five weight-related behaviors [consumption of Fruits and Vegetables (FV), Sugar-Sweetened Beverages (SSB), or high-fat or sugary foods, breastfeeding, and Physical Activity (PA)].

RESULTS

Less than half of providers reported "always" using BMI to determine appropriate GWG (42%); however 65% reported "always" counseling about appropriate GWG rate. About one-third of providers reported counseling about postpartum weight loss or maintenance (38%).Providers reported counseling pregnant and postpartum patients on all weight-related behaviors only 58% and 27% of the time, respectively. Providers with normal BMI had a greater odds of counseling pregnant patients on FV consumption (adjusted odds ratio (aOR): 3.2; 95% confidence interval (CI): 1.5-7.0) and postpartum patients on FV (aOR: 1.9; 95% CI: 1.1-3.6) compared to overweight/obese providers. Providers who exercised regularly had a greater odds of counseling pregnant and postpartum patients on SSB (aOR: 2.2; 95% CI: 1.1-4.8, and aOR: 2.6; 95% CI: 1.4-4.9, respectively) compared to those providers not exercising regularly. Providers who used podcasts for continuing medical education(CME) had a greater odds of providing counseling on several behaviors, including postpartum patients on FV consumption (aOR: 3.1; 95% CI: 1.3-7.2).

CONCLUSIONS

Improvements can be made in weight-related counseling practices of OB/GYNs for both pregnant and postpartum patients. Strategies to improve counseling practices, such as podcasts for CME, could be investigated further.

Patient-provider communication about gestational weight gain among nulliparous women: a qualitative study of the views of obstetricians and first-time pregnant women

BACKGROUND

In 2009 the Institute of Medicine updated its guidelines for weight gain during pregnancy, in part because women of childbearing age now weigh more pre-pregnancy and tend to gain more weight during pregnancy than women did when the previous set of guidelines were released in 1990. Women who begin pregnancy overweight or obese and women who gain weight outside IOM recommendations are at risk for poor maternal and fetal health outcomes. With these concerns in mind, we examined what obstetricians communicate about gestational weight gain to their pregnant patients and how nulliparous patients perceive weight-related counseling from their obstetricians.

METHODS

We conducted one-on-one, semi-structured interviews with 19 nulliparous women and 7 obstetricians recruited from a single clinic at a large academic medical center in the United States. Interviews were transcribed verbatim and analyzed inductively using thematic analysis.

RESULTS

We identified 4 major themes: 1) Discussions about the amount and pace of gestational weight gain: obstetricians reported variation in the frequency and timing of weight-related discussions with patients while most patients said that weight was not emphasized by their obstetricians; 2) The content of communication about nutrition and physical activity: obstetricians said they discuss nutrition and activity with all patients while most patients reported that their obstetrician either discussed these topics in general terms or not at all; 3) Communication about postpartum weight loss: obstetricians said that they do not typically address postpartum weight loss with patients during prenatal visits while patients had concerns about postpartum weight; and 4) Patient feelings about obstetrician advice: most patients said that their obstetrician does not tend to offer "unsolicited advice", instead offering information in response to patient questions or concerns. Women were divided about whether they desired more advice from their obstetrician on weight gain, nutrition, and activity.

CONCLUSIONS

Our analysis revealed discrepancies between obstetricians' and patients' perceptions of their weight-related clinical interactions. Our findings suggest that there is a missed opportunity to use prenatal visits as opportunities to discuss healthy eating and exercise during pregnancy, the postpartum period, and beyond. Additional research on the design, implementation, and testing of interventions to address prenatal nutrition and physical activity is warranted.

Provider advice about pregnancy weight gain and adequacy of weight gain

To explore the association between health care provider advice about weight gain and gestational weight gain. Using data from a prospective cohort study, we explored the association between provider advice about weight gain in pregnancy with weight gain adequacy among 1,454 pregnant women. Provider advice was measured by maternal self-report at 27-30 weeks' gestation. Linear and Poisson regression were used to explore associations. Seventy-eight percent of the women gained outside current recommendations. Fifty-one percent reported receiving weight gain advice from a health care provider. Adjusted Generalized Linear Model (GLM) estimates showed weak effect of provider advice on inadequate or excessive gain (Relative Risk (RR) 0.96, 95% CI 0.74, 1.26 for inadequate gain and RR 1.01, 95% CI 0.97, 1.06 for excessive gain). There is a need for more women to hear about their targeted weight gains during pregnancy and the present advice that exists does little to influence actual gains. Further studies are warranted to find better strategies for providers to motivate their patients to gain weight within the appropriate ranges.

Social inequality in excessive gestational weight gain

OBJECTIVE

Optimal gestational weight gain (GWG) leads to better outcomes for both the mother and child, whereas excessive gains can act as a key stage for obesity development. Little is known about social inequalities in GWG. This study investigates the influence of education level on pre-pregnancy body mass index (BMI) and GWG.

DESIGN

Register-based population study.

SETTING

Sweden

PARTICIPANTS

Four thousand and eighty women born in Sweden who were a part of the third generation Uppsala Birth Cohort Study. Register data linkages were used to obtain information on social characteristics, BMI and GWG of women with singleton first births from 1982 to 2008.

MAIN OUTCOME MEASURE

Pre-pregnancy BMI and the Institute of Medicine's (IOM) categories of GWG for a given pre-pregnancy BMI. RESULTS were adjusted for calendar period, maternal age, living arrangements, smoking, history of chronic disease and pre-pregnancy BMI when appropriate.

RESULTS

Although most women (67%) were of healthy pre-pregnancy BMI, 20% were overweight and 8% were obese. Approximately half of all women in the sample had excessive GWG, with higher pre-pregnancy BMI associated with higher risk of excessive GWG, regardless of education level; this occurred for 76% of overweight and 75% of obese women. Lower educated women with a healthy pre-pregnancy BMI were at greater risk of excessive GWG-odds ratio 1.76 (95% confidence interval 1.28-2.43) for elementary and odds ratio 1.32 (1.06-1.64) for secondary compared with tertiary educated, adjusted for age and birth year period. Nearly half of women with an elementary or secondary education (48%) gained weight excessively.

CONCLUSION

Education did not provide a protective effect in avoiding excessive GWG among overweight and obese women, of whom ∼75% gained weight excessively. Lower educated women with a BMI within the healthy range, however, are at greater risk of excessive GWG. Health professionals need to tailor their pre-natal advice to different groups of women in order to achieve optimal pregnancy outcomes and avoid pregnancy acting as a stage in the development of obesity.

Limiting excess weight gain in healthy pregnant women: importance of energy intakes, physical activity, and adherence to gestational weight gain guidelines

Few studies have investigated if compliance with energy intakes, physical activity, and weight gain guidelines attenuate postpartum weight retention (PPWR) in mothers attending prenatal classes. We investigated whether (a) daily energy intakes within 300 kcal of estimated energy requirements (EERs), (b) walking more than 5000 steps/day, (c) targeting the recommended weight gain goals for prepregnancy BMI, and/or (d) achieving weekly or total gestational weight gain (GWG) recommendations minimized PPWR in 54 women attending prenatal classes in Montreal/Ottawa, Canada. Participants completed a validated pregnancy physical activity questionnaire (PPAQ), 3 telephone-validated 24-hr dietary recalls, and wore a pedometer for one week. PPWR was measured 6 weeks after delivery. Results showed that 72% had healthy prepregnancy BMIs. However, 52% consumed >300 kcal/day in excess of their EER, 54% exceeded recommended GWG, and more overweight (93%) than normal weight women (38%) cited nonrecommended GWG targets. Following delivery, 33% were classified as overweight, and 17% were obese. Multiple logistic regressions revealed that women targeting “recommended weight gain advice” were 3 times more likely to meet total GWG recommendations (OR: 3.2, P < 0.05); women who complied with weekly GWG goals minimized PPWR (OR: 4.2, P < 0.02). In conclusion, appropriate GWG targets, lower energy intakes, and physical activity should be emphasized in prenatal education programs.

Evaluating body mass index-specific trimester weight gain recommendations: differences between black and white women

INTRODUCTION

We compared the gestational weight gains of black and white women with the 2009 Institute of Medicine (IOM) recommendations to better understand the potential for successful implementation of these guidelines in clinical settings.

METHODS

Prenatal and birth data for 2760 women aged 18 to 40 years with term singleton births from 2004 through 2007 were abstracted. We examined race differences in mean trimester weight gains with adjusted linear regression and compared race differences in the distribution of women who met the IOM recommendations with chi-square analyses. We stratified all analyses by prepregnancy body mass index.

RESULTS

Among normal-weight and obese women, black women gained less weight than white women in the first and second trimesters. Overweight black women gained significantly less than white women in all trimesters. For both races in all body mass index categories, a minority of women (range 9.9%-32.4%) met the IOM recommended gains for the second and third trimesters. For normal-weight, overweight, and obese black and white women, 49% to 80% exceeded the recommended gains in the third trimester, with higher rates of excessive gain for white women.

DISCUSSION

Less than half of the sample gained within the IOM recommended weight gain ranges in all body mass index groups and in all trimesters. The risk of excessive gain was higher for white women. For both races, excessive weight gain began by the second trimester, suggesting that counseling about the importance of weight gain during pregnancy should begin earlier, in the first trimester or prior to conception.

Review on the impact of pregnancy and obesity on influenza virus infection

A myriad of risk factors have been linked to an increase in the severity of the pandemic H1N1 2009 influenza A virus [A(H1N1)pdm09] including pregnancy and obesity where death rates can be elevated as compared to the general population. The goal of this review is to provide an overview of the influence of pregnancy and obesity on the reported cases of A(H1N1)pdm09 virus infection and of how the concurrent presence of these factors may have an exacerbating effect on infection outcome. Also, the hypothesized immunologic mechanisms that contribute to A(H1N1)pdm09 virus severity during pregnant or obese states are outlined. Identifying the mechanisms underlying the increased disease severity in these populations may result in improved therapeutic approaches and future pandemic preparedness.

Guidelines and interventions for obesity during pregnancy

BACKGROUND

Obesity is a growing worldwide epidemic among women of reproductive age, including pregnant women. The increased prevalence of obesity has been accompanied by an increase in gestational weight gain. Maternal obesity has deleterious consequences for both mother and child.

OBJECTIVE

To review the recent guidelines from the National Institute for Health and Clinical Excellence and the Institute of Medicine regarding gestational weight gain and interventions to treat obesity during pregnancy.

METHODS

Guidelines on gestational weight gain from these organizations, as well as reports of gestational weight gain in the published literature, are summarized.

RESULTS

Many normal and overweight parturients exceed the recommendations in the guidelines, which may contribute to postpartum obesity.

CONCLUSION

Lifestyle changes, including dieting and increased activity, may help to limit excessive gestational weight gain but the optimal strategy remains unclear.

Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women

Background

Excessive weight gain during pregnancy and subsequent postpartum weight retention may contribute to the epidemic of obesity among women of childbearing age. Preventing excessive gestational weight gain (GWG) to optimize maternal, fetal and infant wellbeing is therefore of great importance. A number of dietary interventions in this area has been conducted with inconsistent results, which has made it difficult to identify effective strategies to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. The primary objective of this review was to evaluate the effect of dietary interventions for reducing GWG. The secondary objective was to examine the impact of these interventions on different child and maternal health outcomes.

Method

The PUBMED, the Cochrane Central Register of Controlled Trials (CENTRAL) and the LILACS databases were searched for relevant articles. All published randomized controlled trials (RCT) and quasi-randomized controlled trials (QCT), with concurrent controls, on dietary interventions during pregnancy were considered. Results were presented using relative risk (RR) for categorical data and weighted mean difference (WMD) for continuous data. Data were primarily analyzed with a fixed-effect model and a random-effects model was used in the presence of heterogeneity. No date and language restrictions were applied.

Results

In total, 13 studies were included in this review and 10 trials contributed data on total GWG. Dietary intervention significantly reduced total GWG (n = 1434; WMD = -1.92 kg; 95% CI = -3.65/-0.19; p = 0.03), weight retention at six months postpartum (n = 443; WMD = -1.90 kg; 95% CI = -2.69/-1.12; p < 0.0001) and incidence of cesarean section (n = 609; RR = 0.75; 95% CI = 0.60/0.94; p = 0.013). However, dietary intervention had no significant effect on weight retention at six weeks postpartum, birth weight, preeclampsia, gestational diabetes and preterm birth.

Conclusion

Dietary advice during pregnancy appears effective in decreasing total GWG and long-term postpartum weight retention, but so far there is limited evidence for further benefits on infant and maternal health.

Maternal nutrition and perinatal outcomes

Diet and patterns of eating during pregnancy can affect perinatal outcomes through direct physiologic effects or by stressing the fetus in ways that permanently affect phenotype. Supplements are not a magic nutritional remedy, and evidence of profound benefit for most supplements remains inconclusive. However, research supports calcium supplements to decrease preeclampsia. Following a low glycemic, Mediterranean-type diet appears to improve ovulatory infertility, decrease preterm birth, and decrease the risk of gestational diabetes. Although women in the United States have adequate levels of most nutrients, subpopulations are low in vitamin D, folate, and iodine. Vitamin D has increasingly been shown to be important not only for bone health, but also for glucose regulation, immune function, and good uterine contractility in labor. To ensure adequate vitamin and micronutrient intake, especially of folate before conception, all reproductive age women should take a multivitamin daily. In pregnancy, health care providers need to assess women's diets, give them weight gain recommendations based on their body mass index measurement, and advise them to eat a Mediterranean diet rich in omega-3 fatty acids (ingested as low-mercury risk fatty fish or supplements), ingest adequate calcium, and achieve adequate vitamin D levels through sun exposure or supplements. Health care providers should continue to spend time on nutrition assessment and counseling.

Prenatal nutrition: a practical guide for assessment and counseling

Adequate nutrition during the periconceptional and prenatal periods is important for healthy pregnancy outcomes. By enhancing maternal nutritional status, health care providers can help pregnant women lower their risk of certain pregnancy complications and decrease their children's risk of adverse birth outcomes and later chronic disease. Use of evidence-based tools and recommendations will assist in the assessment of pregnant women's diets and streamline the counseling session to optimize their nutritional status. This article contains a review of the literature related to nutrition intervention studies during pregnancy that were designed to improve habits or achieve target weight gains and nutrition recommendations specific for the pregnancy state, as well as tools/resources for the health care provider for implementation of these recommendations into their busy practices.