1. Effects of Gestational Weight Gain on the Obesity Cycle Jamie Creason and Joyce Lin 9/25/12 PH 206

2. Agenda Guidelines for Weight Gain Racial Disparities in Weight Gain Effects of Inadequate Weight Gain Effects of Excessive Weight Gain Discussion Interventions http://www.babytidings.com/clipart/pregnancy.html

3. “Obesogenic” environment “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations” (Swinburn and Egger, 2002). Includes physical, economic, policy, and sociocultural factors that can influence eating and physical activity behaviors. Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council. "4 Determinants of Gestational Weight Gain." Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: The National Academies Press, 2009.

4. Pattern of Gestational Weight Gain http://journal.diabetes.org/clinicaldiabetes/V17N41999/images/pg171f1.gif

5. BMI and GWG 27% fetus, 27% fat stores Decreased need for weight gain if mother overweight Late pregnancy ↑ insulin resistance  spare glucose for fetus – More pronounced if mother overweight, obese

6. Institute of Medicine Guidelines, 1990 and 2009

7. Adherence to Guidelines <1/3 achieve IOM recommended gains Majority gain above IOM recommended levels % of women gaining outside of IOM increasing Herring, Rose, Skouteris, Oken. Optimizing weight gain in pregnancy to prevent obesity in women and children. Diabetes, Obesity and Metabolism 14: 195–203, 2012.

8. Trends in GWG based on 2009 IOM guidelines by race-ethnicity (PNSS) Headen, Davis, Mujahid, Abrams. Racial-Ethnic Differences in Pregnancy-Related Weight. Adv. Nutr. 3: 83–94, 2012

9. Inadequate GWG SGA (<2500 gm), later obesity, cardiovascular disease, diabetes, poor neuro development sets in motion a ‘survival phenotype’ undergo catch-up growth or rapid weight gain Dutch Hunger Winter of 1944–1945 Under-Nutrition experimental rat studies

10. Causes of Inadequate GWG Racial-ethnic influences Socioeconomic status Age Genetics Access to information

11. Socioeconomic status Women with less than 12 years of education more likely to gain < 15 lb Proximity to produce and other healthy foods Marital status/ partner violence Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council. "4 Determinants of Gestational Weight Gain." Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: The National Academies Press, 2009.

12. Age Adolescents do not have IOM range Often still growing Higher risk of SGA, low birth weight Older women have lower cumulative GWG in 3 rd trimester Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council. "4 Determinants of Gestational Weight Gain." Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: The National Academies Press, 2009.

13. Genetic Risk of SGA 4.7x greater for SGA moms 3.5x greater for SGA dads 16x greater if both were SGA Adkins 1, Somes 2, Morrison et al. Association of Birth Weight With Polymorphisms in the IGF2, H19, and IGF2R Genes 1 2 Pediatric Research (2010) 68, 429–434; doi:10.1203/PDR.0b013e3181f1ca99

14. Birth weight as a function of maternal weight gain and pre-pregnancy BMI Modified from Abrams and Laros (1986). American Journal of Obstetrics and Gynecology 154(3), Prepregnancy weight, weight gain, and birth weight, pp. 503–509. Copyright Elsevier (1986).Abrams and Laros (1986)

15. http://www.bocyf.org/king_presentation.pdf

16. Excessive GWG Wt gain higher > IOM guidelines, based on maternal prepregnancy BMI Mothers – complications during delivery, PPWR Infants: – higher adiposity, LGA (>90 th %ile, >4000 gm (9 lbs) – increased risk childhood obesity, chronic diseases, like DM, CVD – Higher GWG linked with other diseases such as asthma, leukemia, hypertension

17. Inadequate GWGExcessive GWG Prepregnancy BMI Maternal diet/nutrition Income, SES Race-ethnicity Maternal age, parity Clinician advice or lack of Smoking genetics Prepregnancy BMI Maternal diet/nutrition Physical activity level Income, SES Race-ethnicity Maternal age, parity Clinician advice or lack of Maternal health conditions (depression) genetics Determinants of GWG

18. TIME TO DISCUSS!!! 1. How should public health professionals tackle issue of GWG? -both inadequate and excessive 2. How can we achieve balance between inadequate & excessive GWG during pregnancy? -On both a population and individual level -What kinds of interventions etc 3. What can be done to appropriately address the cultural and racial disparities in GWG?

19. Studies Inconclusive for the most part Healthier diet + physical activity = lower GWG ↑ energy, fat, saturated fat, dairy, protein intake associated with ↑ GWG Vegetarian diet (1 st trimester)+ PA associated with lower GWG Stuebe, Oken, Gillman Associations of diet and physical activity during pregnancy with risk for excessive gestational weight gain. Am J Obstet Gynecol 2009;201:58.e1-8

20. Limitations Most are observational studies Not enough randomized controlled trials  can’t establish causation Ethical limitations for experimental studies  animal studies ∙ Issues with validity of findings

21. Possible Interventions WIC and RD services Promote physical activity, healthier diet Clinic visits/prenatal care Better provider training on counseling women on wt gain Better tracking of maternal wt gain Targeting obesity in the general population, especially pre-pregnant women http://www.epi.umn.edu/let/pubs/img/Ch09-Alton-Weight.pdf

22. Areas for more Research Epigenetics Health care providers’ knowledge, attitude, and behavior Track and target attention to racial/ethnic and SES disparities in GWG What is the optimal amount of weight gain? Class II and III pre-pregnancy obesity

23. Hull HR, Thornton JC, Ji Y, et al. Higher infant body fat with excessive gestational weight gain in overweight women. Hull HR, Thornton JC, Ji Y, et al.

24. GWG and Obesity Cycle Complex interplay of factors: Environmental Biological Social

25. Approaching the Issue Intervention efforts to change health behavior or outcome, such as GWG, should address not only “downstream” individual-level phenomena and “mainstream” factors (e.g., population-based interventions), but also “upstream,” societal-level phenomena (e.g., public policies) (IOM, 2000).