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Weight Management in Pregnancy and PostpartumIris Thiele Isip Tan MD, FPCP, FPSEMMS Health Informatics (cand.)Clinical Associate Professor, UP College of MedicineSection of Endocrinology, Diabetes & MetabolismDepartment of Medicine, UP-Philippine General Hospital
5 September 2009
Outline
How much weight gain can be allowed in pregnancy?
Can weight gain be safely limited in pregnancy?
Can we apply the Institute of Medicine (IOM) recommendations locally?
How can postpartum weight retention be addressed?
How much weight gain can be allowed in pregnancy?
Weight gain during pregnancy
Product of conception
Fetus, placenta, amniotic fluid
Maternal tissue expansion
Uterus, breasts, blood volume
Maternal fat reserve
12.5 kg British cohort of >3800 primigravidae eating without restriction
IOM recommendations for total weight gain by pre-pregnancy BMI1
Weight for height categoryRecommended total gain (lb)
Low (BMI<19.8) 28-40Normal (BMI 19.8-26) 25-35High (BMI >26-29)2 15-25
1 Higher end of range for adolescents and black women and lower end of range for short women (<1.57 m)
2 Recommended target weight gain for obese women (BMI>29) is 15 lb1990
“The energy cost of pregnancy could be met without increase of food intake by economy of activity.”
Hytten & Leitch, The physiology of human pregnancy (1971)
Energy requirements = TEE1 + energy deposition2
1 Total energy expenditure2 Energy deposition = Δ in body CHON/fat
Butte et al Am J Clin Nutr 2004;79:1078-87
Incremental energy requirements during pregnancy: TEE & energy deposition
Low BMI (n = 17)
Normal BMI (n = 34)
High BMI (n = 12)
Energy requirements estimated at 0, 9, 22, 36 wk of pregnancy and 27 wk postpartum
Butte et al Am J Clin Nutr 2004;79:1078-87
Energy costs* differed by BMI groupMean total fat gain: 3.7 kg (2.4-5.9 kg)
Low BMI 5.3 kg
Normal BMI 4.6 kg
High BMI 8.4 kg
3.5 kg 4.6 kg Weight gain within IOM
All gained above IOM
Butte et al Am J Clin Nutr 2004;79:1078-87
n=17
n=34n=12
* Estimated at 0, 9, 22, 36 wk of pregnancy and 27 wk postpartum
Fat gain
Incremental energy needs in pregnancy
Based on women with normal BMI
1st trimester: negligible
2nd trimester: 350 kcal/d
3rd trimester: 500 kcal/d
Butte et al Am J Clin Nutr 2004;79:1078-87
low birth weight
intrauterine growth retardation
prematurity
Too much vs too little
macrosomia⬆ CS rate
diabeteshypertension
weight retention
IOM recommendations for weight gain by pre-pregnancy BMI
* Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
2009
Prepregnancy BMI Total weight gain (lbs)
Rates of weight gain* 2nd and 3rd trimester
(lbs/week)
UnderweightBMI <18.5
<28-401
(1-1.3)
Normal weightBMI 18.5-24.9
25-351
(0.8-1)
OverweightBMI 25.0-29.9
15-250.6
(0.5-0.7)
ObeseBMI >30.0
11-200.5
(0.4-0.6)
Twin pregnancyIOM recommendations for weight gain
Prepregnancy BMI Recommended total gain
Normal 17-25 kg (37-54 lbs)
Overweight 14-23 kg (31-50 lbs)
Obese 11-19 kg (25-42 lbs)
2009
Can weight gain be safely limited in pregnancy?
Stepped-care behavioral intervention to prevent excessive weight gain
Standard careNormal weight
BMI 19.8-26n = 31
InterventionNormal weight
BMI 19.8-26n = 30
Standard care Overweight
BMI >26n = 22
InterventionOverweight
BMI >26n = 27
Recruited before 20 wk gestation
Standard care
Counseling on well-balanced diet
Take vitamin/iron supplement
Polley et al Int J Obes 2002;26:1494-1502
Outcome proportion of women
exceeding IOM recommendation
Stepped-care behavioral intervention to prevent excessive weight gain
Written informationAppropriate weight gain in pregnancyExercise & healthful eating during pregnancy
Biweekly newsletters Personalized weight gain graph every visit
Appropriate gain: given encouragement
Too little gain: consult MD outside study
Excessive gain: individualized nutrition and behavioral counseling
Polley et al Int J Obes 2002;26:1494-1502
Women with total weight gain exceeding IOM recommendations
0%
25%
50%
75%
100%
Normal Overweight
59%33% 32%
58%
Control Intervention
Tota
l wei
ght
gai
n >
IOM
p <0.05
⬇⬆
p = 0.09
Polley et al Int J Obes 2002;26:1494-1502
Weight changes during pregnancy by treatment group and BMI category
Standard careNormal weight16.4 + 4.8 kg
(6.8-30.9)
InterventionNormal weight15.4 + 7.1 kg
(2.7-32.7)
Standard care Overweight
10.1 + 6.2 kg(-0.9-26.4)
InterventionOverweight
13.6 + 7.2 kg(1.4-29.1)
0
25
50
75
100
Below IOMWithin IOMAbove IOM
%
Standard Normal wt
Standard Overweight
Intervention Overweight
Intervention Normal wt
Polley et al Int J Obes 2002;26:1494-1502
Misperceived pre-pregnancy body weight status and gestational weight gain
Herring et al BMC Pregnancy & Childbirth 2008;8:54
Accurate assessor
Normal weightn = 898 (58%)
OverassessorNormal weight
n = 131 (9%)
Accurate assessor
Overweight/obesen = 438 (28%)
UnderassessorOverweight/obese
n = 70 (5%)
Project Viva cohort n=1537
“How would you classify your weight just prior to this pregnancy?”
Misperceived pre-pregnancy body weight status and excessive weight gain
Herring et al BMC Pregnancy & Childbirth 2008;8:54
Accurate assessor
Normal weightComparator
OverassessorNormal weight
OR 2.0 (95% CI 1.3-3.0)
Accurate assessorOverweight/obese
OR 2.9 (95% CI 2.2-3.9)
UnderassessorOverweight/obese
OR 7.6 (95% CI 3.4-17)
Project Viva cohort n=1537
Test the benefit of interventions to correct weight misperception.
Advice on target weight gain
Stotland et al Obstet Gynecol 2005;105:633-8
WISH cohort (Women and Infants Starting Healthy) n=1460
☎ ☎ ☎ ☎Before 20 wks 24-28 wks 32-36 wks 8-12 wks postpartum
“How much weight do you think you should gain during this pregnancy?”
“How many pounds were you told to gain from the beginning to the end of pregnancy?”
Outcome target weight gain
Variable medically advised
weight gain
Maternal target weight gain vs pre-pregnancy BMI
0
30
60
90
120
Low Normal High Obese
807585
47
Below IOM Within IOM Above IOM
Prepregnancy BMI
Maternal target weight gain
51*
24*
%
Stotland et al Obstet Gynecol 2005;105:633-8
*p<0.001 vs normal
Target weight gain vs MD advice
Stotland et al Obstet Gynecol 2005;105:633-8
0
30
60
90
120
Below IOM Within IOM Above IOM No advice
7780
8561
Below IOM Within IOM Above IOM
MD Advice
Maternal target weight gain
36
28
%
Predictors of target weight gain
Above IOMPre-pregnancy BMI >26Multiparity Lower age Provider advice to gain above IOM
Below IOMLatina ethnicityLower maternal educationLow pre-pregnancy BMIProvider advice to gain below IOM
Stotland et al Obstet Gynecol 2005;105:633-8
Can we apply the Institute of Medicine recommendations locally?
Mean pregnancy weight gain among women in developing countries
Bangladesh
East Java
Gambia
Guatemala
India
Kenya
Taiwan
Thailand
Philippines
0 3 6 9 12
8.58.9
7.64.1
7.07.07.3
6.04.8
kg
12.5 kg
Lower IOM cut-off
Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72
Cebu Longitudinal Health and Nutritional Health Survey (CLHNS) cohort (n = 1367)
DETERMINANTS OF PREGNANCY WEIGHT GAIN
15
12
9.
: Cebu subpopulation. n=877
- Cummings, 1934
- - Stander & Pastore. 1940
- . a Scott & Benjamin. 1948
- Tompkins & Wiehi, 1951
- - Thomson & Billewicz. It. . . . . Hytten & Leitsch, 1971
Brown et al., 1986
369
0)
C
Ce0)
0)
0
C
Cea)
2
1
o
-1
-2’
6
0
.
0 2 4 6 8 10 12
Second TrimesterD)
C
0)
-C
0)
ci)
C
a) 13 16
ever, when mean weekly weight gains are compared (Table 3),
women with any overlap of pregnancy and lactation gained
weight at a significantly higher rate during the third trimester
(0.31 ± 0.22 vs 0.22 ± 0.28 kg/wk among women with no
overlap).
19 22 25 28
12
10
8
6’
4,
2.
10.0’
9.0
8.0
7.0
C 6.0Ce0) 5.0
0)ci)
3.0
a) 2.0
1.0
3
0
10 15 20 25 30 35 40
Weeks gestation
FIG 3. Pattern of maternal weight gain in developed countries corn-
pared with the Cebu subpopulation. Reprinted with permission from
National Academy of Sciences (24).
First Trimester
-1
0 10 20 30 40
Weeks gestation
FIG 4. Pattern of maternal weight gain in India compared with the
Cebu subpopulation. ---, Maharashtra, n = 514. ---,Gujarat, n = 559.
-, Cebu, n = 877. (Five-point rolling mean for Maharashtra and Gu-
jarat.) Reprinted with permission from Anderson MA. The relationship
between maternal nutrition and child growth in rural India. PhD dis-
sertation, Tufts University, April 1989: 30.
Third Trimester
29 30 31 32 33 34 35 36 37
Weeks gestation
FIG 5. Pattern of weight gain for the Cebu subpopulation by weight
status and by trimester of pregnancy. Regression lines fitted to the data.
Weight status based on body mass index values: 0 = < I 8.5, #{149}= normal,
18.5-25, U = > 25.
Results of the multivariate regressions are found in Tables 4
and 5. Regression analyses for the first trimester with either the
entire population or subpopulation were compared to test the
effects of including women with a wider range of nonpregnant
intervals. Similar results were obtained, suggesting that deter-
minants ofweight gain are similar over the full range of intervals
represented in the sample. For consistency we present the results
based on the subpopulation only. Controlling for gestational
week when weight was measured, higher first trimester weight
gains were significantly associated with low prepregnant BMI, a
nonpregnant interval > 6 mo, and higher parity. Together, these
variables accounted for 1 1% of the variability in weight gain.
The significant effect of BMI is consistent with the descriptive
results showing that underweight women gain more rapidly in
by o
n A
ugust 2
8, 2
009
ww
w.a
jcn.o
rgD
ow
nlo
aded fro
m
Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72
Cebu vs Western populations
Slow weight gain in the first trimester
Catch up in the 22nd-24th weeks
Thereafter, markedly lower weight gain
Cebu Longitudinal Health and Nutritional Health Survey (CLHNS) cohort (n = 1367)
Siega-Riz & Adair, Am J Clin Nutri 1993;57:365-72
Cebu vs Indian population
Gained more weight in second half of pregnancy
DETERMINANTS OF PREGNANCY WEIGHT GAIN
15
12
9.
: Cebu subpopulation. n=877
- Cummings, 1934
- - Stander & Pastore. 1940
- . a Scott & Benjamin. 1948
- Tompkins & Wiehi, 1951
- - Thomson & Billewicz. It. . . . . Hytten & Leitsch, 1971
Brown et al., 1986
369
0)
C
Ce0)
0)
0
C
Cea)
2
1
o
-1
-2’
6
0
.
0 2 4 6 8 10 12
Second TrimesterD)
C
0)
-C
0)
ci)
C
a) 13 16
ever, when mean weekly weight gains are compared (Table 3),
women with any overlap of pregnancy and lactation gained
weight at a significantly higher rate during the third trimester
(0.31 ± 0.22 vs 0.22 ± 0.28 kg/wk among women with no
overlap).
19 22 25 28
12
10
8
6’
4,
2.
10.0’
9.0
8.0
7.0
C 6.0Ce0) 5.0
0)ci)
3.0
a) 2.0
1.0
3
0
10 15 20 25 30 35 40
Weeks gestation
FIG 3. Pattern of maternal weight gain in developed countries corn-
pared with the Cebu subpopulation. Reprinted with permission from
National Academy of Sciences (24).
First Trimester
-1
0 10 20 30 40
Weeks gestation
FIG 4. Pattern of maternal weight gain in India compared with the
Cebu subpopulation. ---, Maharashtra, n = 514. ---,Gujarat, n = 559.
-, Cebu, n = 877. (Five-point rolling mean for Maharashtra and Gu-
jarat.) Reprinted with permission from Anderson MA. The relationship
between maternal nutrition and child growth in rural India. PhD dis-
sertation, Tufts University, April 1989: 30.
Third Trimester
29 30 31 32 33 34 35 36 37
Weeks gestation
FIG 5. Pattern of weight gain for the Cebu subpopulation by weight
status and by trimester of pregnancy. Regression lines fitted to the data.
Weight status based on body mass index values: 0 = < I 8.5, #{149}= normal,
18.5-25, U = > 25.
Results of the multivariate regressions are found in Tables 4
and 5. Regression analyses for the first trimester with either the
entire population or subpopulation were compared to test the
effects of including women with a wider range of nonpregnant
intervals. Similar results were obtained, suggesting that deter-
minants ofweight gain are similar over the full range of intervals
represented in the sample. For consistency we present the results
based on the subpopulation only. Controlling for gestational
week when weight was measured, higher first trimester weight
gains were significantly associated with low prepregnant BMI, a
nonpregnant interval > 6 mo, and higher parity. Together, these
variables accounted for 1 1% of the variability in weight gain.
The significant effect of BMI is consistent with the descriptive
results showing that underweight women gain more rapidly in
by o
n A
ugust 2
8, 2
009
ww
w.a
jcn.o
rgD
ow
nlo
aded fro
m
━ Cebu
--- Maharashtra┉ Gujarat
How can postpartum weight retention be addressed?
Predictors of postpartum weight retention
Gestational weight gain
Ethnicity
Parity
High pre-pregnancy weight
Gunderson & Abrams, Epidemiol Rev 2000;2:261-74
Lactation and postpartum weight retention
Janney et al Am J Clin Nutr 1997;66:1116-24
Longitudinal study
110 women recruited in 3rd trimesterPostpartum follow-up
0.5 mo 2 mo 4 mo
6 mo 12 mo 18 mo
Fully breastfeeding
Partly breastfeeding
Infant weaned or bottle-fed
.
ExplanatoryvariablesRegression .
coefficientSEPvalueMonths
sinceparturitionâ!”0.600.12<0.001(months
since parturition)20.020.005<0.001Months
fullybreast-feedingâ!”0.170.090.08(months
fullybreast-feeding)20.040.01<0.01Months
partlybreast-feedingâ!”0.420.250.09(monthspartlybreast-feeding)20.090.050.07Intercept@1.040.71â!”
LACTATION AND WEIGHT RETENTION 1121
TABLE 4
Prediction of weight retention over time (0.5â!”18mo after parturition) by
lactation practice in a longitudinal regression model using both linear
and quadratic terms'
12â!¢
10â!¢
8
6
4.
2
0â!¢
-2â!¢
-4.
-6@
.@
C
.2Caa
a
In = 110.
2 A random intercept was indicated in the model.
marital status. Lactating women had greater rates of weight
loss than nonlactating women, particularly in the early post
partum period. Not only were lactating women more likely to
return to their prepregnancy weights but they were also more
likely to return to their prepregnancy weights at an earlier date.
Women who were older, unmarried, or had greater weight gain
during pregnancy were less likely to obtain their prepregnancy
weights.
By analyzing the role of lactation on postpartum weight
retention longitudinally, our study extended the findings of
previous investigators. With longitudinal analytic methodology
there is greater precision and power to detect differences in
weight retention among lactating and nonlactating women than
there is with cross-sectional analysis, which models weight
change over a specified time interval. With longitudinal data
analysis, the variance structure can be defined within a subject.
Hence, the within- and between-subject variances are incorpo
rated into the model, providing greater precision to detect
differences between subjects. Additionally, efficient estimates
are obtained because data from all time periods rather than one
specified time period are used (40).
2 4 6 8 10 12 14 16 18 20
Time (mo sInce parturltlon)
FIGURE 1. Predictedweight-retentioncurvesovertimefor four lactationpractices:bottle-feedingonly(â!¢);fullybreast-feedingat 2 wk,partlybreast-feeding at 2 mo, and bottle-feeding or infant weaned at 4, 6, 12, and
18 mo (U); fully breast-feedingfor 6 mo and bottle-feedingor infantweaned at 12 and 18 mo (A); and fully breast-feeding for 6 mo, partly
breast-feeding for 12mo, and bottle-feeding or infant weaned at 18mo (V).
For example, if data from this study were reanalyzed cross
sectionally with retained weight at 12 mo as the outcome
variable and lactation practices as one-time covariates (months
fully breast-feeding and months partly breast-feeding during
the first postpartum year), weight gain during pregnancy, age,
and marital status but not lactation practices would be signif
icant predictors of postpartum weight retention. By 1 y after
parturition, absolute differences in weight retention in lactating
compared with nonlactating women were smaller than differ
ences observed between women with different ages, marital
status, or weight gained during pregnancy. Although different
lactation practices had different patterns of weight retention,
TABLES
Predictors of weight retention over time (0.5â!”18mo after parturition) in a longitudinal regression model with main effects and interaction terms'
Regression coefficient
â!”¿ 1.690.072
â!”¿ 0.26
0.04
â!”¿ 0.53
0.12
0.65
0.50
8.41
0.04
â!”¿ 0.0019
0.96
â!”¿ 0.04
â!”¿ 24.31
Explanatoryvariables SE P value
<0.001
<0.01<0.01<0.01
0.030.02
<0.001
<0.001
<0.001
0.010.02
<0.001
<0.001
Main effects
Months since parturition
(monthssinceparturition)2Monthsfullybreast-feeding(months fully breast-feeding)2
Months partly breast-feeding
(months partly breast-feeding)2
Weight gained during pregnancy (kg)
Age (y)Marital status2
Interaction terms
Age X months since parturition
Age X (monthssinceparturition)2Marital status X months since parturition
Marital status X (months since parturition)2
Intercepts
0.46
0.02
0.10
0.01
0.240.05
0.04
0.12
1.90
0.02
0.00080.24
0.013.71
â!˜¿ n= 110.
2 0, married; 1, unmarried.
3 A random intercept was not indicated in the model.
by o
n A
ugust 2
8, 2
009
ww
w.a
jcn.o
rgD
ow
nlo
aded fro
m
Predicted weight-retention curves over time vs lactation practice
Janney et al Am J Clin Nutr 1997;66:1116-24
● Bottle feeding only
Fully breast-feeding at 2 wk, partly breast-feeding at 2 mo, bottle-feeding or infant weaned at 4, 6, 12, 18 mo
Fully breast-feeding for 6 mo and bottle-feeding or weaned at 12 and 18 mo
▲
■
▲Fully breast-feeding for 6 mo, partly breast-feeding for 12 mo and bottle-feeding or weaned at 18 mo
Limited effect of lactation on weight retention
Women who bottle-fed their infants retained more weight over time
Slower rates of weight loss with cessation of breast-feeding or shift to partly breast-feeding
Janney et al Am J Clin Nutr 1997;66:1116-24
“ ... warrant minimal emphasis on breast-feeding
as a means of minimizing postpartum weight retention.”
TV, walking and diet AND postpartum weight retention
Oken et al Am J Prev Med 2007;32(4):305-11
Project Viva cohort n=902
Initial prenatal
visit
12 months postpartum
QuestionnaireTV viewing,
walking and diet
6 months postpartum
TV, walking and diet at 6 mos postpartum
TV viewing
Walking
Moderate activity
Vigorous activity
0 0.5 1.0 1.5 2.0 2.5
0.2
0.2
0.7
1.7
hours/dayOken et al Am J Prev Med 2007;32(4):305-11
Moderate activity
yoga, bowling, stretching, skating
Vigorous activity
jogging, swimming, cycling, skiing, aerobics class
% of total energy
Total fat 37% Trans fat 1.1%
Odds of retaining >5 kg at 1 year postpartum
Per hour of TV viewing OR 1.24 (1.06,1.46)
Per daily hour of walking OR 0.66 (0.46,0.94)
Per 0.5% energy from trans fat OR 1.33 (1.09,1.62)
Oken et al Am J Prev Med 2007;32(4):305-11
12% of retained at least 5 kg Mean wt retained 0.6 kg (-17.3 to 25.5)
OR 0.23 (95% CI 0.08-0.66) of retaining at least 5 kg
Watch <2 hours
of TV
Walk at least 30 minutes
Eat less trans fat (below the
median)
Oken et al Am J Prev Med 2007;32(4):305-11
Sleep duration and postpartum weight retention
Gunderson et al Am J Epidemiol 2008;167:178-187
Project Viva cohort n=940 Assessed at 6 and 12 mo
“In the past month, how many hours of sleep do you get in an average 24-h period?”
“In the past month, do you feel that you are getting enough sleep?”
Duration of sleep vs weight retention >5 kg at 1 year postpartum
Sleeping < 5 hours/day at 6 mos postpartum strongly associated with retaining > 5 kg at 1 year postpartum
Gunderson et al Am J Epidemiol 2008;167:178-187
Distribution of sleep duration n=940
24%
34%
30%
12%
< 5 h/day
6 h/day
7 h/day
> 8 h/day
< 5 h/dayOR 3.13
(95%CI 1.42,6.94)
6 h/dayOR 0.99
(95%CI 0.50,1.97)
7 h/dayComparator
p=0.012
> 8 h/dayOR 0.94
(95%CI 0.50-1.78)
How much weight gain can be allowed in pregnancy? IOM recommendations for weight gain by pre-pregnancy BMI
* Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
2009
Prepregnancy BMI Total weight gain (lbs)
Rates of weight gain* 2nd and 3rd trimester
(lbs/week)
UnderweightBMI <18.5
<28-401
(1-1.3)
Normal weightBMI 18.5-24.9
25-351
(0.8-1)
OverweightBMI 25.0-29.9
15-250.6
(0.5-0.7)
ObeseBMI >30.0
11-200.5
(0.4-0.6)
Can weight gain be safely limited in pregnancy?
? Intervention increased weight gain below IOM in normal weight women
Correct misperceptions about pre-pregnancy BMI
Advise target gain accurately
Can we apply the IOM recommendations locally?
Filipinas gain less during pregnancy than their Western counterparts
Need for more data
How can postpartum weight retention be addressed?
Avoid excessive gestational weight gain
Breastfeeding has some limited effects on weight retention
Advise women to lead a healthy lifestyle postpartum
Thank Youhttp://www.endocrine-witch.info