Caroline Anne Peck, MD, MPH, FACOG

1
Colorado Department of Public Health and
Environment

• Caroline Anne Peck, MD, MPH, FACOG
• Maternal, Child and Adolescent Health/Office of
  Family Planning Branch,
• California Department of Health Services and
• County of Sacramento Department of Public Health

2
Acknowledgements
Cassius Lockett, PhD County of Sacramento
Department of Public Health Stephanie Beaudette,
MEd, RD Colorado Department of Public Health and
Environment Siobhan M. Dolan, MD, MPH March of
Dimes Sonja Rasmussen, MD, MS CDC CityMatCH /
NACCHO
3
Obesity Trends Among U.S. AdultsBRFSS, 1991-2002
2002
No Data lt10 1014
1519 2024 gt 25
4
Obesity among US Adults, 1991 and 2001


Obese
Based on self-reported weight and height
Mokdad et al., JAMA 1999 JAMA 2003
5
Prevalence of Obesity and Overweight Among US
Women Aged 20-39, 1999-2002
Obese 29.1
Under/Average Weight 45.5
Overweight 25.4
Overweight 25.4
Data from the National Health and Nutrition
Examination Survey (based on actual measurement
of height and weight)
Hedley et al., JAMA 2004
6
Prevalence of Overweight and Obesity Among US
Women Aged 20-39 Years, 1999-2002, By
Racial/Ethnic Group
Hedley et al., JAMA 2004
7
Demographics Sacramento County 2003

• Population increase of 20 from 1993 to 2003
• Hispanic population is the fastest growing

8
Obesity Sacramento County 2001

• For Adults gt 18
• 37 are Overweight (182,000 people)
• 21.4 are Obese (314,000 people)

9
Obesity in WomenSacramento County 2001
10
Weight Gain Recommendations in Pregnancy
11
Body Mass Index (BMI)

• Body Mass Index is an indicator that measures
  weight for height
• BMI Weight in kg
• (Height in meters) ²
• Underweight
• Normal
• Overweight
• Obese

12
1990 Institute of MedicinePregnancy Weight Gain
Recommendations

• Underweight BMI (lt19.8) 28-40 pounds
• Normal BMI (19.8-26) 25-35 pounds
• Overweight BMI (26-29) 15-25 pounds
• Obese BMI (gt29) 15 pounds
• BMI category based on pre-pregnancy weight
  height, measured in kg/m2

13
1990 Institute of MedicinePregnancy Weight Gain
Recommendations

• First trimester average gain of 2-4 lbs
• Second and third trimester
• Low BMI slightly more than 1 lb/week
• Normal BMI 1 lb/week
• High BMI 2/3 lb/week
• Aim for a steady rate of weight gain for all
  pre-pregnancy BMI categories

14
1990 Institute of MedicinePregnancy Weight Gain
Recommendations

• Excessive Weight Gain
• All pregnant women, all trimesters
• gt 7 pounds /month
• Multifetal pregnancies
• No upper limit specified

15
1990 Institute of MedicinePregnancy Weight Gain
Recommendations
Inadequate Weight Gain

• Weight loss gt 2 pounds in the 2nd or 3rd
  trimester

16
Systematic Review of IOM Guidelines

• Weight gain within IOMs recommended ranges are
  associated with better pregnancy outcomes than
  are weight gains outside these ranges
• No evidence that pregnancy weight gain within
  the IOMs ranges is a cause of substantive
  postpartum weight retention

Abrams et al, Am J Clin Nutr, 2000
17
How are California Women Doing with Pregnancy
Weight Gain?

• Only 41 reported gaining weight within their
  target range
• 32 of respondents gained weight below their
  target range
• 27 of respondents gained weight above their
  target range
• Respondents classified as Overweight and Obese
  reported the highest percentage of weight gain
  above their target ranges (50 and 78 )

1997 California Womens Health Survey
18
How Well do California Women Think They are Doing
With Pregnancy Weight Gain?

• Self-assessments by women of appropriate
  gestational weight gain are poor (roughly 70 )
  across all BMI groups
• 88 of women whose gestational weight gain was
  higher than appropriate believed it was either
  just right or too little

2000 California Womens Health Survey
19
What is the Impact of Overweight and Obesity in
Mothers on Birth Outcomes?

20
Adverse Outcomes Associated with Maternal Obesity

• Maternal complications
• Infertility
• GDM, PIH
• Cesarean Section
• Fetal/Neonatal complications
• Congenital malformations
• Prematurity
• Macrosomia
• Stillbirth, Neonatal death

21
Adjusted Odds Ratios for Pregnancy
Complications by Maternal BMI
Adjusted for maternal age, smoking, education,
marital status, trimester prenatal care began,
payer, and weight gain during pregnancy BMIlt20.0
(lean) reference group
Baeten et al., Am J Public Health 2001
22
Antenatal Complications by Degree of Maternal
Obesity
Cedergren, Obstet Gyn 2004
23
Labor and Delivery Complications by Degree of
Maternal Obesity
Cedergren, Obstet Gyn 2004
24
Neonatal Outcomes by Degree of Maternal Obesity
Cedergren, Obstet Gyn 2004
25
Odds for SGA or LGA Infant
by Degree of Maternal Obesity
Cedergren, Obstet Gyn 2004
26
Odds for Pre-/Post-term Infant
by Degree of Maternal Obesity
Cedergren, Obstet Gyn 2004
27
Adjusted Odds Ratios for Pregnancy
Complications by Maternal BMI

• Adjusted for age, race, education, marital
  status, parity, ART, gestational
• age, birthweight

Weiss et al, AJOG 2004
28
Adjusted Odds Ratios for Pregnancy
Complications by Maternal BMI

• Adjusted for age, race, education, marital
  status, parity, ART, gestational
• age, birthweight

Weiss et al, AJOG 2004
29

• Adjusted for age, race, education, marital
  status, parity, ART, gestational
• age, birthweight

Weiss et al, AJOG 2004
30
Adjusted Odds Ratios for Pregnancy Complications
by Maternal BMI in Glucose Tolerant Women
Adjusted for GTT result, age, weight gain,
gestational age, parity smoking, race clinical
center
Jensen, AJOG, 2003
31
Fetal and Neonatal Death by Maternal BMI
Reference Underweight (BMI lt 20)
Cnattingius et al., N Engl J Med 1998
32
Fetal Death by Maternal BMI in Pregnancies
Without Obesity-Related Diseases
Adjusted for age, height, parity, SES, exercise,
smoking, alcohol and coffee intake
Aagaard Nohr et al, Obstet Gynecol, 2005
33
Birth Defects Associated with Maternal Obesity

• Neural tube defects
• Heart defects
• Ventral wall defects
• Multiple congenital anomalies

34
Maternal BMI and Neural Tube Defects

• Adjusted OR for NTD of 1.2
• per 10 kg incremental rise in maternal weight

Ray et al, Obstet Gynecol, 2005
35
Maternal BMI and Birth Defects
Watkins et al, Pediatrics, 2003
36
Maternal BMI and Cardiovascular Birth Defects
Cedergren, Obes Res, 2003
37
Possible Mechanisms

• Increased nutrient requirement (e.g., folate)
  among obese women
• Metabolic abnormalities associated with obesity
• Hyperglycemia
• Elevated insulin levels
• Elevated estrogen levels
• Elevated lipid levels
• Undiagnosed diabetes
• Nutritional deficits in obese women (e.g.,
  related to dieting behaviors)

38
What is the Impact of Underweight in Mothers
on Birth Outcomes?

39
Low Maternal BMI and Poor Weight Gain During
Pregnancy

• Increased risk of
• Preterm delivery
• Low birthweight
• Carmichael and Abrams 89865-73, 1997
• Schieve et al. Ob Gyn 96194-200, 2000
• Sebire et al. BJOG 10861-66, 2001
• Ehrenberg et al. AJOG 1891726-30, 2003

40
Consider Multiple Confounders

• Smoking
• Drug Use
• Alcohol Use
• Nutritional Deficiency
• Parity
• Short Interval Between Pregnancies

41
Risk Factors for Preterm Labor/Delivery

• Best predictors
• Multi-fetal gestation
• History of preterm labor/delivery

• multifetal pregnancy
• maternal age (lt17 and gt35 years)
• African American race
• low SES
• unmarried
• previous fetal or neonatal death
• 3 spontaneous losses
• uterine abnormalities
• incompetent cervix
• genetic predisposition

• low pre-pregnant weight
• obesity
• infections
• bleeding
• anemia
• major stress
• lack of social supports
• tobacco use
• illicit drug use
• alcohol abuse
• folic acid deficiency

42
WEIGHT MATTERSFor the health of mothers and
babies
43
Clinic Practices
44
First Prenatal Visit Determine the Pre-pregnancy
BMI Category

• Measure or ask for each womans height
• Ask about each womans pre-pregnancy weight
• Determine the pre-pregnancy BMI category for each
  woman by using the BMI/gestational wheel or a BMI
  chart

45
BMI/Gestational Wheel
46
When Pre-pregnancy Weight is Unknown

• Use the womans estimated pre-pregnancy weight if
  it is reasonable
• Estimate the womans BMI category based on her
  current weight. Most women will not change an
  entire BMI category.

47
Weight Gain Counseling

• Discuss the appropriate pregnancy weight gain for
  each woman
• Identify the goal of a slow steady weight gain

48
(No Transcript)
49
(No Transcript)
50
Weight Gain Counseling

• Appropriate weight gain is necessary for the
  normal development of the baby
• If a woman is gaining appropriately, let her know
  she is doing a great job!

51
If Inappropriate Weight Gain is Identified

• Rule out weight gain errors
• Allow for open communication regarding weight
  gain by providing respectful statements such as
  As your provider, I feel I should tell you

52
Nutrition Counseling

• Important for all women
• Especially important for overweight/obese women
• Resources
• CPSP Coordinator / Steps to Take
• WIC
• Sacramento County Pregnancy Resource Guide

53
Other Recommendations

• Ensure adequate intake of micronutrients
  (particularly iron and folic acid)
• Abstain from tobacco, alcohol and drug use
• Get adequate exercise
• Encourage breastfeeding

54
Exercise During Pregnancy ACOG Guidelines

• In the absence of either medical or obstetric
  complications, gt 30 minutes of moderate exercise
  on most, if not all, days of the week is
  recommended
• Exercise may be beneficial in primary prevention
  of gestational diabetes
• Exercise may be a helpful adjunctive therapy
  for gestational diabetes mellitus when euglycemia
  is not achieved by diet alone

ACOG Committee Opinion No. 267, Obstet Gynecol
99171, 2002
55
Providers Can

• Determine Pre-pregnancy BMI for all women and set
  pregnancy weight gain goals
• Discuss weight gain on an ongoing basis
• Refer to a dietician for nutrition counseling as
  soon as inadequate or excessive weight gain is
  detected

56
Clinic Staff Can.

• Plot weight gain at each visit on the prenatal
  weight gain grid
• Monitor weight gain trends each visit
• Counsel and refer as appropriate each visit

57

• Worth the Weight
• Is
• Worth the Time!!!
• 1.23.06