Weight Gain During Pregnancy Reexamining the Guidelines (2009) / Chapter Skim
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4 Determinants of Gestational Weight Gain The total amount of weight gain during pregnancy is determined by many factors. Aside from physiological factors (discussed in Chapter 2)
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112 WEIGHT GAIN DURING PREGNANCY ences on health behavior and outcome, and the epidemiological model, which describes a triad of epidemiologic factors to model the complex and interrelated factors contributing to the increasing rate of obesity in the United States and other countries. One of the triad components describes an "obesogenic" environment as "the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations" (Swinburn and Egger, 2002)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 113 SOCIAL/BUILT/NATURAL AND LIFE-STAGE ENVIRONMENT Societal/Institutional: media, culture and acculturation, health services, policy Environmental: altitude, environmental toxicants, natural and man-made disasters Neighborhood/Community: access to healthy foods, opportunities for physical activity Interpersonal/Family: family violence, marital status, partner and family support MATERNAL FACTORS Genetic characteristics Developmental programming Epigenetics Sociodemographic, e.g., age, race or ethnicity, socioeconomic status, food insecurity Anthropometric and Physiological, e.g., prepregnancy BMI, hormonal milieu, basal metabolic rate Medical, e.g., pre-existing morbidities, hyperemesis gravidarum, anorexia nervosa and bulimia nervosa, bariatric surgery, multiple births Psychological, e.g., depression, stress, social support, attitude toward weight gain Behavioral, e.g., dietary intake, physical activity, substance abuse, unintended pregnancy ENERGY BALANCE/NUTRIENT Food, energy, nutrient intake TOTAL AND OVERALL PATTERN OF GESTATIONAL WEIGHT GAIN indicates possible modification of effect indicated by arrow on which it abuts indicates possible causal influences FIGURE 4-1 Schematic summary of determinants associated with GWG. Figure 4-1.eps impact a woman's eating habits during pregnancy, is necessary for developing effective weight gain recommendations.
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114 WEIGHT GAIN DURING PREGNANCY affect consumption behavior. Other studies have shown that the media can promote sedentary behaviors, such as television watching, that may adversely affect energy balance (Gortmaker et al., 1996, 1999; Robinson, 1999; IOM, 2005; Epstein et al., 2008)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 115 protein foods, folate, vitamin C, iron, and zinc, compared to the dietary intake of white non-Latinas and U.S.-born Latinas. Other researchers have also documented increased risk for adverse birth outcomes, including preterm birth and low birth weight, among U.S.-born women compared to foreign-born women of the same ethnic origin (Ventura and Taffel, 1985; Scribner and Dwyer, 1989; Cabral et al., 1990; Kleinman et al., 1991; Rumbaut and Weeks, 1996; Singh and Yu, 1996; Fuentes-Afflick and Lurie, 1997; Jones and Bond, 1999; Callister and Birkhead, 2002; Baker and H ellerstedt, 2006)
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116 WEIGHT GAIN DURING PREGNANCY individual and social characteristics of the provider as contrasted with those of the pregnant woman, and racial/ethnic and socioeconomic disparities in weight gain advice. Policy For the purpose of this report, policy is defined broadly to include principles, guidelines, or plans adopted by an organization to guide decisions, actions, and other matters.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 117 Another example of policy influencing GWG is the Special Supplemental Food Program for Women, Infants, and Children (WIC)
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118 WEIGHT GAIN DURING PREGNANCY inconsistent (Dar et al., 1992; Wolff et al., 2007)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 119 were available. These findings were independent of income level; however, the study did not report on GWG.
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120 WEIGHT GAIN DURING PREGNANCY V entura (1994) , found that unmarried mothers were more likely than married mothers to gain less than 7.3 kg during pregnancy.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 121 as age and race/ethnicity; physiological factors, some of which are also discussed in depth elsewhere in this report, and genetic factors known to impact GWG and those that may impact GWG because of their known influence on birth weight; and developmental and epigenetic programming in the mother, which may influence how a woman responds later in life. Sociodemographic Factors Gestational Weight Gain in Adolescents Adolescent pregnancy has been associated with increased risk of preterm delivery, low birth weight, SGA births, and increased risk of neonatal mortality, although reported risk associations vary (Chen et al., 2007)
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122 WEIGHT GAIN DURING PREGNANCY et al., 1988)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 123 and of higher parity than non-obese subjects. The obese subjects also had higher rates of chronic hypertension, diabetes, and inadequate GWG.
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124 WEIGHT GAIN DURING PREGNANCY TABLE 4-1 Effect of Chronological Maternal Age on GWG Weight Coefficient Number Gain of Variation, Reference Age (yrs) Racial/Ethnic Group in Sample (kg)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 125 In their review of birth records of 913,320 singleton births in New York City from 1995 to 2003, Stein (information contributed to the committee in consultation with Stein [see Appendix G, Part III]
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TABLE 4-3 Gestational Weight Gain (pounds) by Selected Characteristics Among Women Delivering Full-term, 126 Singleton Births (underweight women excluded)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 127 Food Insecurity Food insecurity is closely tied to socioeconomic status and is therefore discussed here even though it is arguably a modifiable factor. Several studies have identified a relationship between food insecurity, defined as "whenever the availability of nutritionally adequate and safe food or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain" (Anderson, 1990)
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128 WEIGHT GAIN DURING PREGNANCY Genetic Characteristics The role of DNA sequence variation in the regulation of body weight is being investigated in many laboratories worldwide, but few investigators are focusing their attention on the genetics of weight gain during pregnancy. The committee was unable to identify studies dealing with the heritability of GWG.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 129 adequate statistical power was available to identify the effects of alleles or genotypes with a small effect size. Genetics and Birth Weight Gestational weight gain is associated with the weight of the infant at birth even though there may not always be a cause and effect relationship and despite the fact that reverse causation often cannot be excluded.
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130 WEIGHT GAIN DURING PREGNANCY Importantly, variation in birth weight is influenced by a number of other factors in addition to the genetic makeup of the newborn. Several studies have identified maternal genotype as another important factor.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 131 GCK HNF1B HNF4A 100 Decrease 100 Decrease 100 Increase 550g 900g 790g Centile Birth Weight 80 80 80 60 60 60 40 40 40 20 20 20 0 0 0 mutation no mutation no mutation no mutation mutation mutation Fetus Fetus Fetus FIGURE 4-2 The impact on birth weight of a fetus inheriting three common maturity-onset diabetes in the young (MODY) gene mutations.
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132 WEIGHT GAIN DURING PREGNANCY mutation carriers compared to nonmutated family members (Figure 4-2)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 133 a number of genome-wide association studies with comprehensive panels of markers, particularly in cohorts with large sample size and substantial numbers of small- and large-for-gestational age infants. It will also be critical in the future to design studies that will make it possible to define the maternal and fetal alleles at key genes that associate with increased risk for GWG outside recommended ranges in the context of maternal dietary and physical activity habits.
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134 WEIGHT GAIN DURING PREGNANCY growing, the committee was unable to identify studies that directly examined the influences of programming on GWG in the mother. Consequences of high GWG to the child that may be related to developmental programming are discussed in Chapter 6.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 135 cal factors: (1) prepregnancy BMI, (2)
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TABLE 4-4 Gestational Weight Gain (pounds) by Prepregnancy BMI Among Mothers Delivering Full-term, 136 Singleton Births, PRAMS, 2004-2005 ≤ 14 15-24 25-34 35-44 ≥ 45 (n = 8,442)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 137 activity or thermogenesis along with high variability in BMR during pregnancy, that offering prescriptive energy intake recommendations would be impractical because it is impossible to know how an individual woman's metabolism will respond. Durnin (1991)
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138 WEIGHT GAIN DURING PREGNANCY creased in the third trimester. When adjusted for fat-free mass (FFM)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 139 components of maternal metabolism and may exert an indirect effect on GWG through their effects on maternal insulin sensitivity. Leptin is produced in relatively large quantities by the placenta and is transferred primarily into the maternal circulation (Hauguel-de Mouzon et al., 2006)
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140 WEIGHT GAIN DURING PREGNANCY disease activity at conception. Fonager et al.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 141 dysfunctional perception of body weight and shape (Wisner et al., 2007) , and both may affect GWG.
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142 WEIGHT GAIN DURING PREGNANCY 1998 to approximately 72,177 in 2002 (Santry et al., 2005; Davis et al., 2006)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 143 Twins and Higher Order Pregnancy As discussed in Chapter 3, the presence of multiple fetuses in a pregnancy has an influence on total GWG. In comparison to a singleton birth the additional components of the products of a twin gestation (fetus, placenta, and amniotic fluid)
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144 WEIGHT GAIN DURING PREGNANCY posits.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 145 intake. The finding suggests that stress did not affect food intake in these subjects, rather it impacted the utilization of calories and nutrients from the foods consumed to support pregnancy.
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146 WEIGHT GAIN DURING PREGNANCY the attitude score was not significantly related to GWG. The investigators also reported that maternal attitude toward weight gain was influenced by prepregnancy BMI, with thin women tending to have positive attitudes and obese women negative attitudes about GWG.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 147 1975) showed that energy/protein restriction was associated with a significant reduction in weekly maternal weight gain (weighted mean difference of 255 [95% CI: -436.56 to -73.0]
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148 WEIGHT GAIN DURING PREGNANCY fewer servings during pregnancy. More recently, Olafsdottir et al.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 149 maternal outcomes (Morris and Johnson, 2005; Gavard and Artal, 2008)
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150 WEIGHT GAIN DURING PREGNANCY Some observational studies suggest that maintaining an active lifestyle or adding physical activity to the normal daily schedule of the pregnant woman may attenuate GWG. Clapp and Little (1995)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 151 activity level (PAL) and BMI on GWG in 223 healthy Swedish women.
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152 WEIGHT GAIN DURING PREGNANCY and behavioral characteristics to determine associations with inadequate or excessive GWG. This analysis found no significant association between smoking and drinking and GWG outside the IOM (1990)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 153 and Mott (1988) found in a cohort of 6,015 primiparous women that not desiring a pregnancy was not a significant predictor of very low prenatal weight gain.
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154 WEIGHT GAIN DURING PREGNANCY Women Incarcerated During Pregnancy The U.S. Department of Justice estimates that women offenders account for about 16 percent of the total corrections population (Bureau of Justice Statistics, 1999)
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 155 2. Married women are more likely to have appropriate GWG than unmarried women.
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156 WEIGHT GAIN DURING PREGNANCY facilitators and barriers to adoption of GWG recommendations by health care providers in their clinical practice; • Partner and family influences on GWG; • Influences of genetic factors, epigenetic events, and developmental programming on GWG; • How GWG affects birth outcomes, postpartum weight retention, and overweight and obesity in later life among adolescents and older women. Findings from these studies should be used to re evaluate the appropriateness of GWG recommendations for these women; • Determining whether maternal biomarkers such as leptin, adi ponectin, and other markers of insulin sensitivity can be used to enhance clinical prediction of adverse birth outcomes and guide fur ther interventions for women with GWG outside the recommended ranges.
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 157 ACOG (American College of Obstetricians and Gynecologists)
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158 WEIGHT GAIN DURING PREGNANCY Bergmann M
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 159 Cameron R
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160 WEIGHT GAIN DURING PREGNANCY Clapp J
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 161 Ducarme G., A Revaux, A
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162 WEIGHT GAIN DURING PREGNANCY Frongillo E
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 163 Groth S
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164 WEIGHT GAIN DURING PREGNANCY Hickey C
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 165 Jones M
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166 WEIGHT GAIN DURING PREGNANCY Lederman S
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 167 McFarlane J., B Parker and K
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168 WEIGHT GAIN DURING PREGNANCY Orstead C., D Arrington, S
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 169 Rumbaut R
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170 WEIGHT GAIN DURING PREGNANCY Singh G
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DETERMINANTS OF GESTATIONAL WEIGHT GAIN 171 Vilming B
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172 WEIGHT GAIN DURING PREGNANCY Wolff M
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