1. Pregnancy and Obesity: the nutrition link Kelli Hughes, RD, CDE UVA Health System

2. Obejctives To review 2009 IOM Guidelines for weight gain during pregnancy To review 2009 IOM Guidelines for weight gain during pregnancy To review adherence to current recommendations To review adherence to current recommendations To discuss determinants for gestational weight gain To discuss determinants for gestational weight gain To discuss social predictors of excess gestational weight gain To discuss social predictors of excess gestational weight gain To discuss possible nutrition interventions to prevent excess gestational weight gain To discuss possible nutrition interventions to prevent excess gestational weight gain

3. Institute of Medicine Guidelines Optimal infant birth weight Optimal infant birth weight 3000 – 4000 g 3000 – 4000 g Decreased risk of mortality Decreased risk of mortality Originally published in 1990; revised in 2009 Originally published in 1990; revised in 2009 Potential impact of contemporary issues required change Potential impact of contemporary issues required change Increased incidence of obesity Increased incidence of obesity Increased incidence of multiples Increased incidence of multiples Increased incidence of gastric bypass Increased incidence of gastric bypass Lack of outcome studies – except for birth weight Lack of outcome studies – except for birth weight

4. Whats changed since 1990 IOM guidelines Huge increase in the prevalence of maternal overweight and obesity Huge increase in the prevalence of maternal overweight and obesity Low ( 40 lb gestational weight gain (GWG) have become more common Low ( 40 lb gestational weight gain (GWG) have become more common Dieting during pregnancy has doubled Dieting during pregnancy has doubled GWG in excess of recommendations is associated with significant postpartum weight retention Nohr et. al. 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. Increased risk of overweight and obesity in the child Oken et. al., Moeiria, et. al.

5. 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 Overweight25-29.9 15-25 lbs Obesity30+ 11-20 lbs Adolescents, African Americans and smokers should gain at the top of the range

6. How much do women gain? 46% gain more than is recommended (2004) 46% gain more than is recommended (2004) 23% gain less than is recommended 23% gain less than is recommended 31% gain within guidelines 31% gain within guidelines Overweight and obese women 2X as likely to exceed the upper limit Overweight and obese women 2X as likely to exceed the upper limit Underweight women are most likely to have minimal gains Underweight women are most likely to have minimal gains Diet and physical activity are related to excessive gestational weight gain (GWG) Diet and physical activity are related to excessive gestational weight gain (GWG) -IOM report 2007

7. Outcomes associated with excess GWG in obese women Incidence of pregnancy complications not significantly associated with weight change during pregnancy in many studies 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 With weight gain of >25 lbs some studies show increased risk of Pre-eclampsia Pre-eclampsia Impaired glucose tolerance Impaired glucose tolerance C-section C-section Postpartum hemmorrhage Postpartum hemmorrhage Pre-existing obesity is an independent risk factor for complications Pre-existing obesity is an independent risk factor for complications Excess postpartum weight retention and associated health risks Excess postpartum weight retention and associated health risks Increased risk of overweight children – conflicting evidence Increased risk of overweight children – conflicting evidence -Olson et. al., Nohr et. al., Abrams et. al., Arendas, Cedergren 2006

8. GWG and Gestational Diabetes Few studies to date Few studies to date GWG above IOM recs GWG above IOM recs higher frequency of c-section higher frequency of c-section Higher odds of needing medical therapy (insulin) Higher odds of needing medical therapy (insulin) Higher odds of preterm delivery Higher odds of preterm delivery Higher odds of LGA infant Higher odds of LGA infant More antenatal admissions More antenatal admissions -Cheng et. al.

9. GWG and GDM GWG below IOM recs: GWG below IOM recs: More likely to maintain diet control More likely to maintain diet control Less likely to have LGA infants Less likely to have LGA infants Lower incidence of NICU admissions Lower incidence of NICU admissions -Cheng, et al

10. Determinants of excess gestational weight gain BMI >26 BMI >26 Energy balance Energy balance Higher energy intake late in pregnancy Higher energy intake late in pregnancy More snacking More snacking Less physical activity Less physical activity Different foods: Different foods: Increased dairy and sweets Increased dairy and sweets < 3 fruits and vegetables a day < 3 fruits and vegetables a day Glycemic index Glycemic index High fat High fat Wells et al 2006, Olson et al 2003, Olafsdoltir et al 2006, Clapp 2002

11. Social predictors of excess gestational weight gain Socioeconomic status Socioeconomic status Decreased physical activity Decreased physical activity Provider advise – advised/targeted weight gain correlated with actual weight gain Provider advise – advised/targeted weight gain correlated with actual weight gain No advise associated with weight gain outside of the guidelines No advise associated with weight gain outside of the guidelines -Stotland et al 2006, Olson et al 2003

12. Nutrition Intervention Data Conflicting results with community intervention Conflicting results with community intervention Nine month intervention Grey-Donald et al: 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

13. Nutrition Intervention Data Olson et al followed women from early pregnancy to one year postpartum Olson et al followed women from early pregnancy to one year postpartum Intervention included: Intervention included: Monitoring weight gain with grids 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 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 Statistically significant reduction in GWG only among low-income women

14. Systematic healthcare intervention Policies and procedures for recording, tracking and discussing GWG vary greatly Policies and procedures for recording, tracking and discussing GWG vary greatly Efforts can be inconsistent Efforts can be inconsistent There is little data There is little data Correlation between patients being given guidelines and following them suggests the need for a systematic approach Correlation between patients being given guidelines and following them suggests the need for a systematic approach

15. Nutrition Intervention: Challenges Talking about weight with patients Talking about weight with patients Changing what a pregnant woman eats Changing what a pregnant woman eats Patient buy-in Patient buy-in RD contact with pregnant women RD contact with pregnant women Consistency in routine prenatal care Consistency in routine prenatal care Lack of time for education during appointments Lack of time for education during appointments No show rates for non-MD providers No show rates for non-MD providers

16. Nutrition Intervention: Possibilities Discussion of weight gain guidelines Discussion of weight gain guidelines Set a weight gain goal with patients Set a weight gain goal with patients Track weight gain with patients Track weight gain with patients Follow-up at every appointment Follow-up at every appointment Target specific behaviors and habits Target specific behaviors and habits Drinks Drinks Portion control Portion control Meal patterns Meal patterns Types of food: glycemic index, veggies, fat Types of food: glycemic index, veggies, fat Set goals for change Set goals for change

17. Nutrition Intervention: Drinks Ask what they drink Ask what they drink Sweet tea, regular soda, juice, whole milk Sweet tea, regular soda, juice, whole milk Educate Educate 150 kcals per 8 oz = 600 kcals in a dollar menu sweet tea 150 kcals per 8 oz = 600 kcals in a dollar menu sweet tea Calculate calories consumed per day from drinks with patient Calculate calories consumed per day from drinks with patient Alternatives: brainstorm! set goal for trying another sugar free, calorie free choice Alternatives: brainstorm! set goal for trying another sugar free, calorie free choice

18. Nutrition Intervention: Portions Hunger scale 1-5 Hunger scale 1-5 Order small when eating out Order small when eating out Eat on a smaller plate Eat on a smaller plate Eat half and assess true hunger Eat half and assess true hunger Plate method Plate method ¼ of plate is starch ¼ of plate is starch ¼ of plate is protein ¼ of plate is protein ½ of plate is non-starchy veggies ½ of plate is non-starchy veggies

19. Nutrition Intervention: Meal Patterns Does the patient eat breakfast? Does the patient eat breakfast? Are they food secure? Are they food secure? Do they eat one huge meal at the end of the day? Do they eat one huge meal at the end of the day? Ask questions Ask questions Help plan when, what and how to eat Help plan when, what and how to eat Refer to WIC, if appropriate, to see RD and get food benefit Refer to WIC, if appropriate, to see RD and get food benefit

20. Nutrition Intervention: Types of food Patient education on: Patient education on: Glycemic index Glycemic index 3 or more veggies per day 3 or more veggies per day Sweets and other options that may satisfy Sweets and other options that may satisfy Set goals, write them down, follow up Set goals, write them down, follow up

21. Nutrition Intervention: How? Every obese, pregnant person sees an RD! Every obese, pregnant person sees an RD! Calculate pre-pregnant BMI with patients, discuss implications and refer as appropriate Calculate pre-pregnant BMI with patients, discuss implications and refer as appropriate Group classes on the same day and as part of patient appointments Group classes on the same day and as part of patient appointments Get everyone to WIC who is qualified 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 Know patient pay scale range – pay range one at UVA = $3 for 75 min. visit with an RD Talk about it at every visit Talk about it at every visit

22. QUESTIONS??? kch5m@virginia.edu