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Gestational Weight Gain – Implementation of the IOM
Recommendations
Zach Ferraro, PhD
Kristi Adamo, PhD
Kara Nerenberg, MD, MSc
MFM / OB Med Combined Rounds
October 11, 2013
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Objectives 1. Understand the adverse effects of pregravid obesity on maternal-fetal outcomes
2. Recognize that excessive GWG is an independent and modifiable risk factor for adverse outcomes
3. Summarize the recent IOM report on how to best implement & enforce evidence-based GWG recommendations
4. Understand that weight gain is not a behaviour; it’s an outcome
5. Be able to discuss SMART goals with patients to help them meet guidelines by establishing healthful behaviors
6. Discuss practical implementation & tools available to aid HCP and patients with weight management
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The Complexity of Obesity & Weight Gain
UK Foresight Initiative, 2007
Many determinants of positive energy balance and unhealthy body weight
E balance
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Obesity in Female Adults- 2008
< 5% to > 55%
* 1.8 billion are of childbearing age (26% of world population)
~ 55% of North American women of childbearing age are OW or OB
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BMI on the Rise
FIGURE 2-1 Prevalence of overweight, obesity, and extreme obesity among U.S. women 20–39 years old (ages 20–35 through NHANES 1988–1994), 1963–2004. NOTE: BMI = body mass index; NHANES = National Health and Nutrition Examination Survey. SOURCE: Lu, 2013.
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Risks associated with overweight/obese pregnancy
Adamo et al. Int. J. Environ. Res. Public Health 2012, 9(4), 1263-1307
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The Ottawa and Kingston (OAK) Birth Cohort
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2009 IOM GWG Recommendations
IOM 2009
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Excess Body Weight Pre-pregnancy
.0
10.0
20.0
30.0
40.0
50.0
60.0
Underweight,<18.5
Normal, 18.5-24.9
Overweight,25-29.9
Obese, ≥30
%
OaK cohort Prepregnancy BMI N= 4321
Underweight, <18.5
Normal, 18.5-24.9
Overweight, 25-29.9
Obese, ≥30
3.91
56.20
23.72
16.17
Ferraro et al 2011.
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Adherence to IOM Guidelines, %
0
10
20
30
40
50
60
70
80
Underweight, <18.5 Normal, 18.5-24.9 Overweight, 25-29.9 Obese, ≥30
21
17
4
11
53
36
17 17
27
47
78
72
%
Under
Met
Exceed
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Overweight, obesity and neonatal size at birth
0
10
20
30
40
50
60
70
80
90
UW NW OW OB
21
8 7 6
76
84
79
73
3
8
14
21
%
BMI category
Baby Size by Pre-pregnancy BMI OaK cohort n=4321
SGA
AGA
LGA
We see a shift in birthweight distribution
without increase in SGA
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Likelihood of having a BIG baby
*
**
*
** **
**p<0.001, *p<0.05
controlling for gestational age,
smoking, parity, maternal age Ferraro et al. Journal of Maternal-Fetal & Neonatal Medicine 2012; 25(5):538-542
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Odds of Macrosomia - Double Trouble...
*controlled for gestational age,
smoking, parity, maternal age
Ferraro et al. Journal of Maternal-Fetal & Neonatal Medicine 2012; 25(5):538-542
Likelihood of having an LGA baby
Reference to Normal weight pre-pregnancy and meeting 2009 IOM Guidelines
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Pregnant and Overweight/Obese: So what?
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Maternal adiposity: perinatal and long-term outcomes
Lawlor et al. 2012 Nature Reviews Endocrinology
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What about GWG?
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GWG in women with BMI > 30 and Neonatal
Birthweight
Vesco, Obstet Gynecol; 2011
As GWG increases so too does the proportion of neonates born LGA or
macrosomic
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GWG and LGA or macrosomia
as GWG increases so too does the proportion of neonates born LGA
or macrosomic regardless of obesity class
Hinkle, AJCN; 2010
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What is the Problem?
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Birth weight and subsequent risk of child obesity
Yu, Obesity Reviews; 2011
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Excessive gestational weight gain risk for childhood overweight: a meta-analysis
The pooled estimate for the association between excessive GWG and childhood overweight yielded an odds ratio (OR) of 1.38 (95% confidence interval [CI]: 1.21–1.57)
Provide evidence for at least a 21% risk for childhood overweight related to excessive GWG
Nehring et al, Pediatric Obesity 2012
Promotes obesity Protects against obesity
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Intergenerational Cycles
Adamo et al. Int. J. Environ. Res. Public Health 2012, 9(4), 1263-1307
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Take home points
Obesity and excess GWG directly & independently alter birthweight
Risk of obesity+comorbidities later in life
Excess GWG increases risk for PPWR
Intergenerational effects
Maternal &fetal health compromised Mom- ↑ risk for GDM, T2D, CVD
Baby- ↑ risk for obesity & CVD as kids (Fraser et al., 2010)
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Why are so many patients exceeding recommendations?
Let’s ask the patient what information they are receiving….
And then let’s ask the provider what they messages they deliver
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A patient-provider discrepancy?
Ferraro et al 2013 International Journal of Women’s Health
VS.
Ferraro et al 2011 Obstetric Medicine
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Bias toward Obese Pregnant Women
11% admitted to making insensitive comments to obese pregnant women
31% admitted to making derogatory comments about obese pregnant women to colleagues (p=0.02) Obstetricians (46%)
Family Physicians (39%)
Midwives (36%)
Nurses (14%)
Dietitians (0%)
66% believe more derogatory comments are made about obese pregnant women vs non–obese pregnant women (p=0.002) Obstetricians (81%)
Family Physicians (69%)
Midwives (92%)
Nurses (52%)
Dietitians (14%)
Grohman, Obstet Med 2012
Slide – Courtesy of Dr. E. Keely
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What do women know about BMI & GWG?
74% of women underestimated their BMI category
64% of obese women and 40% of overweight women
overestimated their recommended GWG
Poor knowledge of risks of obesity
28% identified BP problems
51% identified GDM
14% identified pp weight retention
71% back pain
<5% C-section, preterm delivery, pregnancy
complications Shub, BMC Res Notes 2013
Slide – Courtesy of Dr. E. Keely
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What can be done to help moms & care providers manage GWG?
Oken et al 2013 Maternal Child Health
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MDs believed GWG had ‘‘a lot’’ of influence on pregnancy and child health outcomes Their patients did not consider it important
Most said excessive GWG was a big problem in their practice Inadequate GWG was rare
EMR calc GWG at each visit A ‘‘growth chart’’ to plot actual vs. recommended
Alerts identify out-of-range gains
Features to remind them to counsel patients about weight
Additional decision support tools within EMRs would be well received by many clinicians and may help improve the frequency and accuracy of GWG tracking and counseling
Oken et al 2013 Maternal Child Health
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The latest from the IOM
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Patient Case
Preconception Counseling
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Patient Case
38 G0 primary infertility x 12 months
Rfr: “Risks to her and offspring given medical problems”
PMHx:
BMI 50
Heterozygous FVL (sup phlebitis on OCP)
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How to improve outcomes?
Preconception Weight reduction
Reduce risks of congenital anomalies – folic acid
Optimize associated medical conditions
During Pregnancy Limit GWG
Screening/monitoring for hyperglycemia, hypertension
Prevention of GDM, VTE, preeclampsia – ASA, Ca, exercise
Safest possible delivery
Postpartum Breastfeeding
Weight loss / retention
Slide – Courtesy of Dr. E. Keely
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Patient Case
Now pregnant
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Achievement of IOM Targets:
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What works?
Improving Diet quality
Appropriate kcal intake
Engaging in Physical Activity
Reducing Sedentary Time
All the above?
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Physical activity intervention alone helps manage GWG
Streuling, BJOG 2011
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Clinical dietary intervention prevents excessive GWG
Tanentsapf et al 2011
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Healthy eating & physical activity reduce GWG
Streuling, AJCN 2010
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Exercise is medicine…
FIGURE 2-3 Kaiser Permanente walking prescription. SOURCE: Conry, 2013
And it doesn’t take much
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Lifestyle prescription
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IOM posters for clinic use:
Pregnancy weight gain guidelines poster
Available at http://www.iom.edu/healthypregnancy
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Myths…
+Physical activity will harm me and/or my baby
Ferraro et al., British Journal of Sports Medicine 2012.
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CON 5 As
Remember weight is NOT a behavior
It’s an outcome
Must understand ‘cause’ of ex GWG (4Ms)
Use SMART goals to reinforce behaviours
E.g., I will eat 250kcal less/day and walk for 30mins
Not: I will meet the IOM guidelines or eat less, move more
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Provider tools for weight management
Available at: http://www.obesitynetwork.ca/5As
Become a member of CON for FREE at www.obesitynetwork.ca
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We know what works…. Let’s make it work
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Pedagogy & Medicine
Psychopathobiology of obesity
Motivational Interviewing
Interdisciplinary care
NEJM 369;15:1389-40. October 10, 2013.
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Points for discussion:
1. Are we adequately counseling women on GWG targets?
- Behaviour change?
2. Are we measuring /tracking GWG?
- rate of gain
3. Do we need to change our practice?
4. How to change our practice?
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Thank you.
IOM Link
http://www.iom.edu/About-IOM/Making-a-Difference/Kellogg/HealthyPregnancy.aspx
Follow me @DrFerraro for frequent discussion on this topic