Pregnancy and Obesity: the nutrition link Kelli Hughes, RD, CDEUVA Health System

Obejctives

To review 2009 IOM Guidelines for weight gain during pregnancy

To review adherence to current recommendations

To discuss determinants for gestational weight gain

To discuss social predictors of excess gestational weight gain

To discuss possible nutrition interventions to prevent excess gestational weight gain

Institute of Medicine Guidelines

Optimal infant birth weight 3000 – 4000 g

Decreased risk of mortality Originally published in 1990; revised in

2009 Potential impact of contemporary issues

required change Increased incidence of obesity Increased incidence of multiples Increased incidence of gastric bypass Lack of outcome studies – except for birth

weight

What’s changed since 1990 IOM guidelines

Huge increase in the prevalence of maternal overweight and obesity

Low (<16 lb) and high (>40 lb gestational weight gain (GWG) have become more common

Dieting during pregnancy has doubled GWG in excess of recommendations is

associated with significant postpartum weight retention Nohr et. al.

Increased risk of overweight and obesity in the child Oken et. al., Moeiria, et. al.

IOM Guidelines 2009

Category Pre-pregnancy BMI Recommended weight gain

Under weight <18.5 28-40 lbs

Normal weight 18.5-24.9 25-35 lbs

Overweight 25-29.9 15-25 lbs

Obesity 30+ 11-20 lbs

Adolescents, African Americans and smokers should gain at the top of the range

How much do women gain?

46% gain more than is recommended (2004)

23% gain less than is recommended 31% gain within guidelines Overweight and obese women 2X as

likely to exceed the upper limit Underweight women are most likely to

have minimal gains Diet and physical activity are related to

excessive gestational weight gain (GWG)

-IOM report 2007

Outcomes associated with excess GWG in obese women

Incidence of pregnancy complications not significantly associated with weight change during pregnancy in many studies

With weight gain of >25 lbs some studies show increased risk of Pre-eclampsia Impaired glucose tolerance C-section Postpartum hemmorrhage

Pre-existing obesity is an independent risk factor for complications

Excess postpartum weight retention and associated health risks

Increased risk of overweight children – conflicting evidence

-Olson et. al., Nohr et. al., Abrams et. al., Arendas, Cedergren 2006

GWG and Gestational Diabetes

Few studies to date GWG above IOM recs

higher frequency of c-section Higher odds of needing medical

therapy (insulin) Higher odds of preterm delivery Higher odds of LGA infant More antenatal admissions

-Cheng et. al.

GWG and GDM

GWG below IOM recs: More likely to maintain diet control Less likely to have LGA infants Lower incidence of NICU admissions

-Cheng, et al

Determinants of excess gestational weight gain

BMI >26 Energy balance

Higher energy intake late in pregnancy More snacking Less physical activity

Different foods: Increased dairy and sweets < 3 fruits and vegetables a day Glycemic index High fat

Wells et al 2006, Olson et al 2003, Olafsdoltir et al 2006,

Clapp 2002

Social predictors of excess gestational weight gain

Socioeconomic status Decreased physical activity Provider advise – advised/targeted

weight gain correlated with actual weight gain

No advise associated with weight gain outside of the guidelines

-Stotland et al 2006, Olson et al 2003

Nutrition Intervention Data

Conflicting results with community intervention

Nine month intervention Grey-Donald et al: social learning theory included modeling of

the behavior change, skill training, contracting, and self-monitoring

the investigators carried out in the community include radio broadcasts, information pamphlets, supermarket tours and cooking demonstrations, exercise walking groups, and individualized nutrition counseling

No statistical difference in GWG

Nutrition Intervention Data

Olson et al followed women from early pregnancy to one year postpartum

Intervention included: Monitoring weight gain with grids Patients received: five action

promoting newsletters; postcards about GWG, diet and physical activity; health checkbook for goal setting and monitoring

Statistically significant reduction in GWG only among low-income women

Systematic healthcare intervention

Policies and procedures for recording, tracking and discussing GWG vary greatly

Efforts can be inconsistent There is little data Correlation between patients

being given guidelines and following them suggests the need for a systematic approach

Nutrition Intervention: Challenges

Talking about weight with patients Changing what a pregnant woman

eats Patient buy-in RD contact with pregnant women Consistency in routine prenatal

care Lack of time for education during

appointments No show rates for non-MD

providers

Nutrition Intervention: Possibilities

Discussion of weight gain guidelines Set a weight gain goal with patients Track weight gain with patients Follow-up at every appointment Target specific behaviors and habits

Drinks Portion control Meal patterns Types of food: glycemic index, veggies, fat

Set goals for change

Nutrition Intervention: Drinks

Ask what they drink Sweet tea, regular soda, juice, whole

milk Educate

150 kcals per 8 oz = 600 kcals in a dollar menu sweet tea

Calculate calories consumed per day from drinks with patient

Alternatives: brainstorm! set goal for trying another sugar free, calorie free choice

Nutrition Intervention: Portions

Hunger scale 1-5 Order “small” when eating out Eat on a smaller plate Eat half and assess true hunger Plate method

¼ of plate is starch ¼ of plate is protein ½ of plate is non-starchy veggies

Nutrition Intervention: Meal Patterns

Does the patient eat breakfast? Are they food secure? Do they eat one huge meal at the

end of the day? Ask questions Help plan when, what and how to

eat Refer to WIC, if appropriate, to see

RD and get food benefit

Nutrition Intervention: Types of food

Patient education on: Glycemic index 3 or more veggies per day Sweets and other options that may

satisfy Set goals, write them down, follow

up

Nutrition Intervention: How?

Every obese, pregnant person sees an RD!

Calculate pre-pregnant BMI with patients, discuss implications and refer as appropriate

Group classes on the same day and as part of patient appointments

Get everyone to WIC who is qualified Know patient pay scale range – pay

range one at UVA = $3 for 75 min. visit with an RD

Talk about it at every visit

QUESTIONS???kch5m@virginia.edu