Pregnancy and Obesity: Recommendations for

Nutrition

Lisa Richardson, MS, RD, LDN

Nutrition Program Consultant

NC Division of Public Health

Factors and Variables: Pregnancy and Nutrition Pregnancy BMI Gestational weight gain pattern Maternal age Maternal birth weight Parity Stature Hormonal regulators Genetics Short interval pregnancy Smoking Illicit drug use Alcohol use Rural Residency Education (low and high) Literacy Income (low to high) Work and employment Caloric intake Intake of specific foods: dairy, fish, fruits and veggies; fiber, chocolate Fetal birth defects Specific nutrients: vitamin D, zinc, iron, calcium, B6 Multiple gestation Nausea, vomiting, constipation, heartburn Food avoidance, aversion or craving Bariatric surgery Food intolerances Cultural/religious beliefs Food security

Frequency of eating Pica Domestic violence Stress Social support, including partner status Glycemic load Distance to grocery store Race/ethnicity Body image Disordered eating Attitude about weight gain Fat intake Carbohydrate intake Fatty acid intake Provider advice Pregnancy intendedness Energy intake (high or low) Type of provider Type of prenatal care Consumption of sweets Age of menarche Nutrition knowledge Anemia Medical conditions (many!) Medications (many!) Illness and infections Birth spacing Physical activity Weight-loss or Gain in last six months

Nutrition Goals1. Energy and macro-nutrient intake that supports

weight gain sufficient to minimize risks and maximize short and long term health outcomes for mother and infant.

2. Micro-nutrient intake which optimizes mother and infant well-being.

3. Avoidance of alcohol, tobacco, environmental toxins, and other harmful substances.

4. Practice safe-food handling to avoid illness.

Our Goal today…. At least three nutrition topics or issues

that are:evidenced-based and informed to reduce

risks or maximize outcomesobtainable and achievable for most women possible to be integrated into my practice

starting next Tuesday?

Influence of Pregnancy Weight on Maternal and Child Health, IOM, 2007

Note: Fetal link added by LR

Energy and Weight Gain Influence of Pregnancy Weight on

Maternal and Child Health Workshop Report Nation Research Council and Institute for Medicine

Total Gain in Pregnancy

Nationally, about 45% gain outside the IOM ranges (CDC PNSS, 2004)

Gain early in pregnancy not associated with fetal growth, but is associated with post partum weight retention

Total gain can be misleading!

BMI and Pregnancy

Currently no specific valid reference standards for pregnancy!!

Applied BMI ranges to the Institute of Medicine’s Weight Gain Recommendations:

Height for Weight Categories

Low <19.8Normal 19.8 – 26.0High 26.0 – 29.0Obese above 29.0

IOM Weight Categories

Low = 90% Ideal Body Weight Normal = 91-119% Ideal Body Weight High = 120 – 135% Ideal Body Weight Obese = > 135%

1959 Metropolitan Life Insurance Company Weight

Tables

No Relationship!IOM “Ideal” Body Weight Categories

Low <19.8Normal 19.8 – 26.0High 26.0 – 29.0Obese > 29.0

CDC BMI ValuesUnderweight >18.5Average 18.5 – 24.9Overweight 25.0 – 29.9Obese > 29.9

Total Weight Gain

Alone it does not provide etiological information!

Varies widely with “good” outcomes Misleading: rate and timing of gain matters Monday morning quarter back!

What do we tell a woman when still totaling?

Influence of Pregnancy Weight on Maternal and Child Health, IOM, 2007

Weight Gain Fat is most variable component (water, fat,

protein) Amount of fat gain is more strongly

associated with total weight gain than any other componentComponent of gain that most contributes to

higher BMI later in life Biological regulators include genetics,

leptin, and insulin

Can we talk? “Many women, report incorrect advice about

gestational weight gain and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain.”

Stotland et al, Obstet Gynecol 2005

Women given no advise or advised to gain less than 22 pounds more likely to have inadequate gain Taffel and Keppel 1986

Advised and target weights are associated strongly with actual. Strychar et al, JADA March 2000

Selected Expected Maternal Metabolic Adjustments blood levels: glucose, amino acids, and insulin blood levels: free fatty acids, ketones, triglycerides

and cholesterol “Accelerated starvation”

Shift from glucose to fat as energy source Favor of fat deposition – first 20 weeks due to increase

insulin production and conversion of glucose to glycogen Mobilization of that fat in last 20 weeks Decreased responsiveness of tissues to insulin Basal metabolic rate increases – at widely variable rates

among women, typically by 16 weeks

Metabolism, Obesity and Pregnancy Increases in basal metabolic rate (BMR) is a

major cost of energy in pregnancy “striking variability” in metabolic response seen

between women even with adjustments in activity: Some decrease 1st & 2nd trimester Others, particularly higher BMI increase throughout

Energetic adaptations won’t reflect optimal nutritional considerations

Classifying Obese Weight Status

BMI Grade I: 30.0 – 34.9 Grade II: 35.0 – 39.9 Grade III: 40.0 & over

Example 63”, weight: 168 – 196# 197# - 224# Above 225#

Metabolic Syndrome, Dx Criteria National Cholesterol Education Program

At least three of the following:Central abdominal obesity

> 35 inches in women

Triglyceride > 150 mg/dlReduced HDL-C <50 mg/dlElevated BP >130 systolic or >85 diastolicFasting glucose >100 mg/dl

Insulin Resistance

Muscle, fat and liver cell function is not as expected for a given amountHydrolysis of triglycerides in fat cellsReduced glucose uptake by musclesReduced glucose storage in the liver

Metabolic Syndrome and Risk of Placental Dysfunction (PD) Retrospective cohort 1.03 million women in

Ontario between 1990 – 2002 7.3% with PD Progressive increase in the risk of PD with

features of metabolic syndrome over none One = 3.1 Two OR 5.5 Three OR 7.7

Ray et al Journal of Medicine Canada Dec 2005

Visceral Fat and Metabolic Risks

Ultrasound estimation of subcutaneous and visceral fat thickness during early pregnancy along with fasting glucose, insulin, triglyercides, total cholesterol, and HDL-C, and BP

30 women Visceral fat thickness correlated better with

insulin sensitivity, insulinemia, and triglycerides than pregravid BMI Bartha et al, Obesity Sept 2007

Vitamin D3

Positive correlation of 25-(OH) vitamin D concentrations with insulin sensitivityMaghbooli at al, Diabetes/Metabolism

Research and Reviews July 2007

Preeclampsia and Metabolic Syndrome

Metabolic score is independently realted to developing preeclampsia, particularly severe disease Mazar at al Oct 2007

2 and 6 fold increase in NTD risk with 1 or 2 features (respectively) of metabolic syndrome Ray et al

The Calcium for Preeclampsia Prevention Group showed that even within normal ranges, plasma glucose levels one hour after 50-g load were positively correlated with preeclampsia

2st trimester insulin ersistence independently assocaition with preeclampsia risk , Wolf et al 2002

Keeping Insulin and Glucose Steady Start where the patient is!

Low glycemic load diet - akin to gestational diabetes with less restrictions on specific meals

Fewer sweetened beverages and soft drinks

More higher fiber foods, especially fruits and vegetables

Less to no highly processed carbohydrates (cornflakes, instant potatoes, grits, white potato, rice)

No more than 4 ounces juice a day

30 – 60 minutes exercise every day, even better if after larger meal of day

Don’t skip meals or go more than 13 hours without eating

Recommendations Talk about weight gain every visit

The number and where this falls with current recommendations

Promote a lifestyle:To keep glucose and insulin steadyFocus on energy balance behaviors

Consider vitamin D status