weight management in pregnancy and postpartum

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


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


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


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

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


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


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


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)


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*

%


*p<0.001 vs normal

Target weight gain vs MD advice


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


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

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8, 2

009

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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)


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

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ugust 2

8, 2

009

ww

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aded fro

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━ Cebu

--- Maharashtra┉ Gujarat

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)[email protected]â!”

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.

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Predicted weight-retention curves over time vs lactation practice


● 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


“ ... 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


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)


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)


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)


? 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


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

http://www.endocrine-witch.info

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weight management in pregnancy and postpartum

Health & Medicine

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