Original Article
JOURNAL OF WOMEN’S HEALTH Volume 00, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4984
Counseling About Weight Gain Guidelines and Subsequent Gestational Weight Gain Brian H. Wrotniak, PT, PhD,1,2 Shoshone Dentice,1 Kathleen Mariano, DNS, RN/CPNP,3 Erin M. Salaam, PT,1 Ashley E. Cowley, PT,1 and Erin M. Mauro, PT1
Abstract
Background: The purpose of this study was to investigate what percentage of postpartum women were informed about how much weight to gain during pregnancy, the accuracy of the weight gain recommendations based on the 2009 Institute of Medicine (IOM) gestational weight gain (GWG) recommendations and whether being informed was associated with greater likelihood of meeting the recommendations. Methods: This was a cross-sectional study of postpartum women interviewed in maternity recovery rooms at two large urban hospitals. Body mass index was obtained from medical records, and adherence to gestational weight gain guidelines was determined based on the 2009 IOM recommendations. Results: One hundred thirty four women with a mean pregravid body mass index of 28.0 kg/m2 were studied. Sixty-seven percent of participants reported receiving weight gain recommendations. A greater percentage of healthy weight women (78.6%) reported being informed of a GWG recommendation than overweight (53.8%) or obese women (64.9%), (chi-squared = 6.6, p = 0.04). Of the women given information about gestational weight gain, 40 (54.8%) received GWG recommendations consistent with the IOM and 33 (45.2%) received discrepant information. The accuracy of the GWG recommendation varied based on weight status. Women of healthy weight were much more likely to be given information in accordance with the IOM recommendations (86.8%) than women who were overweight (12.5%) or obese (26.3%) (chi-squared = 33.5, p < 0.001). Meeting the IOM recommendations did not differ depending on whether women were told how much weight to gain during pregnancy. Conclusions: Women who are overweight or obese are less likely to be informed about weight gain recommendations than healthy weight women, and nearly half of women receive information inconsistent with the IOM recommendations. There may be a need for further practitioner education on GWG recommendations and increased patient counseling to help promote healthy weight gain during pregnancy.
pregnancy and significantly less women with overweight and obesity meet the IOM weight gain recommendations (24.6% and 22.8%, respectively).2,7,8 As GWG continues to increase across all subgroups of pregnant women,4 so does the risk for negative maternal and neonatal outcomes2,9 including excess postpartum weight retention10 and future obesity in the offspring.11 Although the recommendations were publicized with a guide to assist health care professionals with implementation, previous literature suggests that providers vary widely in the advice they give their patients about gestational weight gain.5,12 The American College of Obstetrics and Gynecologists recommends that providers educate patients using the IOM recommendations, but there is insufficient information
Introduction
I
n 2009, the Institute of Medicine (IOM) gestational weight gain (GWG) recommendations were updated in response to the increasing prevalence of obesity among American women.1,2 Obesity in women of childbearing age has doubled over the past 30 years3 and continues to grow.4 More than half of pregnant women in the United States enter pregnancy as either overweight or obese.3 Studies have shown that women who begin their pregnancy overweight or obese are far more likely to exceed the weight gain guidelines than women of healthy weight.5,6 Less than half of underweight and healthy weight women (40.7% and 37.5%, respectively) gain the recommended amount of weight during 1 2
Center for Health Behavior Research and 3School of Nursing, D’Youville College, Buffalo, New York. Women & Children’s Hospital of Buffalo, Buffalo, New York.
1
2
on how, or if, providers relay the information to their patients.1,2 A survey of practicing U.S. obstetricians indicated that although more than 85% reported providing GWG education to their patients, only 64% gave specific advice based on the patient’s pregravid body mass index (BMI).13 Other research indicates that as many as one-third of pregnant women report receiving no weight gain recommendations from their provider.5 The purpose of this study was to investigate what percentage of postpartum women were informed about how much weight to gain during pregnancy, the accuracy of the weight gain recommendations based on the current IOM guidelines, and the likelihood of adhering to those guidelines based on whether women were informed about gestational weight gain. We hypothesized that women informed about the GWG guidelines would be more likely to meet the recommendations than women who did not receive GWG recommendations. Materials and Methods
Adult women of all socioeconomic status, race, and ethnicity were recruited from two large teaching hospitals in Western New York, including one suburban and one urban site. We selected large teaching hospitals because women would be more likely to be receiving postpartum care from a diverse number of obstetricians rather than other area hospitals or smaller medical facilities where women would be more likely to be under the care of a select group of obstetricians with similar practices. Participants were recruited in the recovery room of each hospitals. Eligibility criteria included women aged ‡18 years, full term pregnancy of 37–41 weeks gestation, fluency in English, and the intellectual ability to read and comprehend the content of the research study. Women with multiple fetuses, gestational diabetes mellitus, missing self-reported pregravid or predelivery weight, preeclampsia, emergency delivery, or who smoked during pregnancy were excluded from the study. All women were provided written informed consent and all procedures were conducted in accordance with the ethical standards for human subjects’ research. The research study was approved by the Institutional Review Boards at D’Youville College, Women’s and Children’s Hospital of Buffalo, and Millard Fillmore Suburban Hospital in Buffalo, New York. Participant demographic information collected included marital status, maternal education level and employment status, household income, ethnicity, and race. Objectively measured pregravid height and weight from each woman’s medical record was used when available (n = 106) to compute pregravid BMI. Women provided self-reported height and weight which was used to determine pregravid BMI when objective data was not available (n = 28). Pregravid BMI was computed as (weight in kilograms)/(height in meters2). Pregravid BMI was used to classify women’s weight status as underweight (200,000
All subjects (n = 134)
Subjects counseled (n = 90)
Subjects not counseled (n = 44)
28.5 – 5.1 28.0 – 6.9 163.6 – 7.4 74.4 – 18.3 86.9 – 16.7 12.7 – 7.3
28.4 – 5.3 27.7 – 7.3 163.7 – 7.6 73.5 – 18.8 86.6 – 17.3 13.1 – 6.7
28.9 – 4.6 28.6 – 6.3 163.4 – 6.9 76.2 – 17.3 87.5 – 15.8 11.8 – 8.5
68.0 20.9 11.1
64.4 24.4 11.2
76.7 14.0 9.3
89.6 10.4
90.0 10.0
88.6 11.4
41.0 58.2 0.7
42.2 56.7 1.1
38.6 61.4 0.0
0.7 6.0 19.4 21.6 25.4 26.9
1.1 6.7 17.8 23.3 18.9 32.2
0.0 4.5 22.7 18.2 38.6 15.9
57.5 14.2 2.2 12.7 13.4
61.1 8.9 1.1 14.4 14.4
51.2 25.6 2.3 9.3 11.6
13.5 17.3 12.0 12.0 17.3 12.0 10.5 2.3 0.0 3.0
12.4 18.0 12.4 9.0 19.1 12.4 12.4 1.1 0.0 3.4
15.9 15.9 11.4 18.2 13.6 11.4 6.8 4.5 0.0 2.3
Values are mean – standard deviation for continuous variables and % for categorical variables. BMI, body mass index.
guidance not in compliance with IOM, 31 of them (94%) were told to gain more weight than the IOM recommends. Additionally, of the 33 who received non-IOM guidance, 8 (24%) met the target they were given, while 9 (27%) gained less, and 16 (48%) gained more. When examining whether the accuracy of information provided to women about GWG varied by weight status, we found that healthy weight women (86.8%) were much more likely to be provided with gestational weight gain recommendations that were consistent with the IOM’s guidelines than women who were overweight (12.5%) or obese (26.3%) (v2 = 33.5, p < 0.001). Among the 134 women, 33 (24.6%) gained an insufficient amount of weight based on the 2009 IOM recommendations, 38 (28.4%) met the weight gain recommendations, and 63 (47.0%) exceeded the recommendations ( p = 0.003). By weight status, 50% of underweight, 25% of healthy weight,
74% of overweight, and 51% of obese women exceeded the weight gain recommendations (Table 3). Meeting the IOM recommendations did not depend on whether or not women were provided with a gestational weight gain recommendation (v2 = 0.5, p = 0.8) (Table 2). In order to assess whether there was a quantitative difference in the amount of over gain by being informed about the IOM guidelines, we examined the degree of over gain among women exceeding the guidelines. We found that the average weight gain for women informed about the recommendations was 17.6kg which did not differ ( p = 0.863) from weight gain for women not informed of the recommendations (17.8 kg). The results were unchanged when we examined the relationship between being informed and adherence to the GWG recommendations using only the women who were provided with a GWG recommendation that matched the IOM GWG guidelines
4
WROTNIAK ET AL.
Table 2. Category of Gestational Weight Gain for Women Who Were Informed Versus Not Informed About How Much Weight to Gain During Pregnancy
GWG Category
Informed about a GWG guideline, n (%)
Not informed about a GWG guideline, n (%)
21 (23.3%)
12 (27.3%)
27 (30.0%)
11 (25.0%)
42 (46.7%)
21 (47.7%)
Insufficient weight gain Recommended weight gain Excessive weight gain
Meeting the Institute of Medicine recommendations did not depend on whether or not women were provided with a gestational weight gain recommendation (v2 = 0.5, p = 0.8). GWG, gestational weight gain.
compared with women who did not receive any GWG recommendation (v2 = 5.4, p = 0.07). When we examined whether meeting the GWG recommendations differed by weight status, we found that 42% of healthy weight, 12.8% of overweight and 24.3% of obese women met the weight gain recommendations (v2 = 24.4, p < 0.01). Discussion
The results of this study indicate that one third of women reported receiving no recommendations from their health care provider about how much weight to gain during their pregnancy. Moreover, almost half of women (45.2%) who reported receiving a GWG recommendation received information that was inconsistent with the 2009 IOM GWG guidelines. These findings are similar to other research demonstrating that women receive a GWG recommendation less than half the time,14 and that women are told inappropriate weight gain targets for their BMI.15 Although we hypothesized that women who received GWG recommendations would be more likely to meet them compared with women not provided GWG information, this was not the case. Women across all weight categories exceeded appropriate weight gain regardless of having been informed of a GWG recommendation. It is interesting to note that when women were provided with GWG recommendations that matched the IOM recommendations, only 25% of women exceeded the recommendations, compared with 48% of women not
provided with any recommendation. This finding should be interpreted with caution and verified in future research since our sample size was small for this analysis. The IOM recommendations were revised in response to the increasing prevalence of obesity in women and emphasize the use of BMI-specific GWG ranges to improve health outcomes for mother and child.2 Women who enter pregnancy overweight or obese are 2 to 6 times more likely to exceed recommended GWG than women of healthy weight,16–18 have an incorrect understanding of personal gestational weight gain targets,19 and report being given GWG recommendations that are inconsistent with the IOM.12,20 These disparities are evident in our findings, as significantly more women that were categorized as overweight or obese reported receiving discrepant information than women of healthy weight. This may be an indication that women who are overweight and obese perceive themselves as healthy weight and ignore the GWG recommendations, that health care providers are uncomfortable discussing weight, or that providers feel that GWG counseling is ineffective in heavy patients. Our findings suggest a need for increased provider education on BMI-specific GWG recommendations and strategies for effectively managing overweight and obesity in patients. In our study, almost half of women exceeded the IOM recommendations. Additionally, our finding that 25% of healthy weight, 74% of overweight, and 51% of obese women exceed the weight gain recommendations aligns with other research that suggests that up to one third of healthy weight women and more than half of overweight women are gaining in excess of the IOM recommendations.21,22 These findings are clinically relevant because excessive GWG is associated with increased risk of gestational diabetes,23 preeclampsia,24 postpartum weight retention in the mother,25 and long-term obesity in children.7,11 A study by Linne and colleagues26 indicated that 46% of healthy weight women who gained excessive weight during pregnancy were overweight at their 15-year follow up evaluation. Women who shed postpartum weight within 6 months following delivery have less long-term weight retention at 10-year follow up than those who fail to lose pregnancy weight following delivery.27 Excessive weight gain is concerning because it is a strong independent predictor of long-term development of overweight or obesity in women following pregnancy;28 thus, fueling the obesity epidemic and increasing the risk for future adverse health conditions.29 The results of our study suggest that future strategies are needed to address the number of women who do not receive
Table 3. Weight Gain and Percentage of Women Who Gained Insufficient, Recommended, and Excessive Weight Gain During Gestation by Pregravid BMI Insufficient weight gain group
All subjects weight gain, kg Pregravid BMI mean (SD) Underweight Healthy weight Overweight Obese
13.7 13.5 14.9 9.9
SD, standard deviation.
(7.3) (5.3) (6.3) (9.6)
n (%) 1 18 5 9
(50.0%) (32.1%) (12.8%) (24.3%)
Recommended weight gain group
Weight gain, kg mean (SD) 8.6 8.3 (2.8) 5.1 (2.8) - 3.6 (8.4)
n (%) 0 24 5 9
(0%) (42.9%) (12.8%) (24.3%)
Excessive weight gain group
Weight gain, kg mean (SD) 13.6 (1.5) 8.5 (1.3) 7.4 (1.2)
n (%) 1 14 29 19
(50.0%) (25.0%) (74.4%) (51.4%)
Weight gain, kg mean (SD) 18.9 20.1 (4.3) 17.7 (4.5) 15.9 (4.6)
ADHERENCE TO GESTATIONAL WEIGHT GAIN GUIDELINES
information, or receive discrepant information, on how much weight to gain during pregnancy. Guidelines alone may be an ineffective approach to change30 or this may be an indication that the GWG guidelines have not been clearly disseminated to the medical community29 and that health care providers are unclear on how to use the BMI-specific approach to calculate weight goals and therefore, provide discrepant information to their patients.31 Other research suggests that there may be a lack of agreement with the clinical guidelines or that patient– provider communication issues or literacy barriers may exist.32 Compounding the issue, when the 1990 IOM guidelines were released, insufficient weight gain and low birth weight were the primary focus. However, the increasing prevalence of obesity in women of childbearing years has drawn attention to the negative effects of over-gaining during pregnancy.33 The updated 2009 IOM report resulted in changes that altered BMI categorization per the World Health Organization guidelines and established for the first time a GWG recommendation for women with obesity. This may have caused confusion within the obstetric community, and providers may not yet have a clear understanding of the updated recommendations or are not yet up to speed with implementing the new guidelines. Providers may also simply be unaware of the changes leading them to classify BMI categories incorrectly.12,34 Strengths of the study include the use of objectively measured predelivery weight for a majority of subjects. A second strength of this study is the use of a diverse sample of women seen at two large teaching hospitals. Additionally, this study provides new information about how well women are being informed about and adhering to the GWG guidelines, how being informed about the GWG guidelines is associated with meeting the guidelines, differences in meeting GWG recommendations by weight status, and differences in how providers provide GWG recommendations based on women’s weight status. There are several limitations to this study. The sample size was relatively small. Further, patients may have been exposed to GWG recommendations from other sources besides health care providers that may have influenced their GWG and perceptions of healthy weight gain. Likewise, the time of gestation when women received the recommendations could have affected the degree of weight gain. However, since 73% of women reported receiving their recommendations from their obstetrician/gynecologist, we believe this information was provided early in their pregnancy. Another limitation is that some women’s pregravid weight (21% of the sample) was unavailable from the medical record and was selfreported and therefore may have been underreported. We found no evidence to suggest that the 28 women with selfreported pregravid weights reported lower than actual weight based on the finding that there was no statistically significant difference in gestational weight gain among women who selfreported pregravid weight compared with women who had their pregravid weight objectively measured. In addition, if some women who were overweight were incorrectly misclassified as healthy weight, this would have biased results toward a more exaggerated estimate of meeting the GWG recommendations, and the percentage of women meeting the GWG guidelines may be lower than reported here. An additional limitation is that we did not have any way to verify whether the information women reported being told or not
5
told by their providers was accurate. Thus, this may have resulted in inflated responses by some women of the recommendations they were provided, particularly if their weight gain was high. Some women may in fact be being informed (and informed correctly) of the IOM recommendations, but not retaining this information. Future research is needed to better ascertain the difference and to develop more powerful strategies for women to retain/and or be informed about the recommendations. Conclusion
Women across all subgroups, particularly those who were in the overweight or obese categories, reported receiving inadequate GWG advice and gaining weight that exceeded the IOM recommendations. Due to the clinical impact of excess GWG and postpartum weight retention, it is pertinent that clinicians address weight gain goals early in pregnancy and monitor weight gain closely. Further, promoting healthy lifestyle physical activity and nutrition along with achieving a healthy weight, should begin even before women become pregnant as well as interconception at the postpartum visit to increase the likelihood of a healthy pregnancy. Moreover, providers should be encouraged to provide timely, accurate advice using the current IOM recommendations. Women who receive guidelines that align with the IOM, and who set weight gain goals with their health care provider, have been shown to gain weight within the recommended ranges.35 Thus, additional practitioner education on GWG and BMIspecific ranges, coupled with training in behavior-based goal setting, may help providers effectively promote accurate GWG recommendations and increase patient adherence for a healthy pregnancy. Author Disclosure Statement
No competing financial interests exist. References
1. Institute of Medicine (IOM) and National Research Council (NRC). Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academies Press, 2009. 2. Institute of Medicine and National Research Council. Leveraging action to support dissemination of pregnancy weight gain guidelines: Workshop summary. Washington, DC: The National Academies Press, 2013. 3. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491–497. 4. Fisher SC, Kim SY, Sharma AJ, Rochat R, Morrow B. Is obesity still increasing among pregnant women? Prepregnancy obesity trends in 20 states, 2003–2009. Prev Med 2013;56:372–378. 5. Stotland NE, Haas JS, Brawarsky P, Jackson RA, FuentesAfflick E, Escobar GJ. Body mass index, provider advice, and target gestational weight gain. Obstet Gynecol 2005;105:633– 638. 6. Schieve LA, Cogswell ME, Scanlon KS. Maternal weight gain and preterm delivery: Differential effects by body mass index. Epidemiology 1999;10:141–147. 7. Oken E, Taveras EM, Kleinman KP, Rich-Edwards JW, Gillman MW. Gestational weight gain and child adiposity
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at age 3 years. Am J Obstet Gynecol 2007;196:322, e321– 328. Catalano PM. Increasing maternal obesity and weight gain during pregnancy: The obstetric problems of plentitude. Obstet Gynecol 2007;110:743–744. Jain NJ, Denk CE, Kruse LK, Dandolu V. Maternal obesity: Can pregnancy weight gain modify risk of selected adverse pregnancy outcomes? Am J Perinatol 2007;24:291–298. Butte NF, Ellis KJ, Wong WW, Hopkinson JM, Smith EO. Composition of gestational weight gain impacts maternal fat retention and infant birth weight. Am J Obstet Gynecol 2003;189:1423–1432. Wrotniak BH, Shults J, Butts S, Stettler N. Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study. Am J Clin Nutr 2008;87:1818–1824. Herring SJ, Platek DN, Elliott P, Riley LE, Stuebe AM, Oken E. Addressing obesity in pregnancy: What do obstetric providers recommend? J Womens Health (Larchmt) 2010;19:65–70. Power ML, Cogswell ME, Schulkin J. Obesity prevention and treatment practices of U.S. obstetrician-gynecologists. Obstet Gynecol 2006;108:961–968. Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR. Practitioner advice and gestational weight gain. J Womens Health (Larchmt) 2011;20:585–591. Tovar A, Chasan-Taber L, Bermudez OI, Hyatt RR, Must A. Knowledge, attitudes, and beliefs regarding weight gain during pregnancy among Hispanic women. Matern Child Health J 2010;14:938–949. Brawarsky P, Stotland NE, Jackson RA, et al. Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain. Int J Gynaecol Obstet 2005;91:125–131. Chasan-Taber L, Schmidt MD, Pekow P, Sternfeld B, Solomon CG, Markenson G. Predictors of excessive and inadequate gestational weight gain in Hispanic women. Obesity 2008;16:1657–1666. Wells CS, Schwalberg R, Noonan G, Gabor V. Factors influencing inadequate and excessive weight gain in pregnancy: Colorado, 2000–2002. Matern Child Health J 2006;10:55–62. Stotland NE, Gilbert P, Bogetz A, Harper CC, Abrams B, Gerbert B. Preventing excessive weight gain in pregnancy: How do prenatal care providers approach counseling? J Womens Health (Larchmt) 2010;19:807–814. Cogswell ME, Scanlon KS, Fein SB, Schieve LA. Medically advised, mother’s personal target, and actual weight gain during pregnancy. Obstet Gynecol 1999;94:616–622. Keppel KG, Taffel SM. Pregnancy-related weight gain and retention: Implications of the 1990 Institute of Medicine guidelines. Am J Public Health 1993;83:1100–1103. Olson CM, Strawderman MS, Hinton PS, Pearson TA. Gestational weight gain and postpartum behaviors associated with weight change from early pregnancy to 1 y postpartum. Int J ObesRelat Metab Disord 2003;27:117–127.
23. Jensen DM, Ovesen P, Beck-Nielsen H, et al. Gestational weight gain and pregnancy outcomes in 481 obese glucosetolerant women. Diabetes Care 2005;28:2118–2122. 24. DeVader SR, Neeley HL, Myles TD, Leet TL. Evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstet Gynecol 2007;110:745–751. 25. Gunderson EP, Abrams B, Selvin S. The relative importance of gestational gain and maternal characteristics associated with the risk of becoming overweight after pregnancy. Int J Obes Relat Metab Disord 2000;24:1660–1668. 26. Linne Y, Dye L, Barkeling B, Rossner S. Long-term weight development in women: A 15-year follow-up of the effects of pregnancy. Obes Res 2004;12:1166–1178. 27. Rooney BL, Schauberger CW. Excess pregnancy weight gain and long-term obesity: One decade later. Obstet Gynecol 2002;100:245–252. 28. Gore SA, Brown DM, West DS. The role of postpartum weight retention in obesity among women: a review of the evidence. Ann Behav Med 2003;26:149–159. 29. Artal R, Lockwood CJ, Brown HL. Weight gain recommendations in pregnancy and the obesity epidemic. Obstet Gynecol 2010;115:152–155. 30. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Medical J Aust 2004;180:S57–S60. 31. Simas TA, Liao X, Garrison A, Sullivan GM, Howard AE, Hardy JR. Impact of updated Institute of Medicine guidelines on prepregnancy body mass index categorization, gestational weight gain recommendations, and needed counseling. J Womens Health (Larshmt) 2011;20: 837–844. 32. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 20 1999;282:1458–1465. 33. Viswanathan M, Siega-Riz AM, Moos MK, et al. Outcomes of maternal weight gain. Evid Rep Technol Assess 2008:1– 223. 34. Wilkinson SA, Poad D, Stapleton H. Maternal overweight and obesity: A survey of clinicians’ characteristics and attitudes, and their responses to their pregnant clients. BMC Pregnancy Childbirth 2013;13:117. 35. Tovar A, Guthrie LB, Platek D, Stuebe A, Herring SJ, Oken E. Modifiable predictors associated with having a gestational weight gain goal. Matern Child Health J 2011;15:1119–1126.
Address correspondence to: Brian Wrotniak, PT, PhD Women and Children’s Hospital of Buffalo D’Youville College 320 Porter Avenue Buffalo NY 14201 E-mail: [email protected]
JOURNAL OF WOMEN’S HEALTH Volume 00, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4984
Counseling About Weight Gain Guidelines and Subsequent Gestational Weight Gain Brian H. Wrotniak, PT, PhD,1,2 Shoshone Dentice,1 Kathleen Mariano, DNS, RN/CPNP,3 Erin M. Salaam, PT,1 Ashley E. Cowley, PT,1 and Erin M. Mauro, PT1
Abstract
Background: The purpose of this study was to investigate what percentage of postpartum women were informed about how much weight to gain during pregnancy, the accuracy of the weight gain recommendations based on the 2009 Institute of Medicine (IOM) gestational weight gain (GWG) recommendations and whether being informed was associated with greater likelihood of meeting the recommendations. Methods: This was a cross-sectional study of postpartum women interviewed in maternity recovery rooms at two large urban hospitals. Body mass index was obtained from medical records, and adherence to gestational weight gain guidelines was determined based on the 2009 IOM recommendations. Results: One hundred thirty four women with a mean pregravid body mass index of 28.0 kg/m2 were studied. Sixty-seven percent of participants reported receiving weight gain recommendations. A greater percentage of healthy weight women (78.6%) reported being informed of a GWG recommendation than overweight (53.8%) or obese women (64.9%), (chi-squared = 6.6, p = 0.04). Of the women given information about gestational weight gain, 40 (54.8%) received GWG recommendations consistent with the IOM and 33 (45.2%) received discrepant information. The accuracy of the GWG recommendation varied based on weight status. Women of healthy weight were much more likely to be given information in accordance with the IOM recommendations (86.8%) than women who were overweight (12.5%) or obese (26.3%) (chi-squared = 33.5, p < 0.001). Meeting the IOM recommendations did not differ depending on whether women were told how much weight to gain during pregnancy. Conclusions: Women who are overweight or obese are less likely to be informed about weight gain recommendations than healthy weight women, and nearly half of women receive information inconsistent with the IOM recommendations. There may be a need for further practitioner education on GWG recommendations and increased patient counseling to help promote healthy weight gain during pregnancy.
pregnancy and significantly less women with overweight and obesity meet the IOM weight gain recommendations (24.6% and 22.8%, respectively).2,7,8 As GWG continues to increase across all subgroups of pregnant women,4 so does the risk for negative maternal and neonatal outcomes2,9 including excess postpartum weight retention10 and future obesity in the offspring.11 Although the recommendations were publicized with a guide to assist health care professionals with implementation, previous literature suggests that providers vary widely in the advice they give their patients about gestational weight gain.5,12 The American College of Obstetrics and Gynecologists recommends that providers educate patients using the IOM recommendations, but there is insufficient information
Introduction
I
n 2009, the Institute of Medicine (IOM) gestational weight gain (GWG) recommendations were updated in response to the increasing prevalence of obesity among American women.1,2 Obesity in women of childbearing age has doubled over the past 30 years3 and continues to grow.4 More than half of pregnant women in the United States enter pregnancy as either overweight or obese.3 Studies have shown that women who begin their pregnancy overweight or obese are far more likely to exceed the weight gain guidelines than women of healthy weight.5,6 Less than half of underweight and healthy weight women (40.7% and 37.5%, respectively) gain the recommended amount of weight during 1 2
Center for Health Behavior Research and 3School of Nursing, D’Youville College, Buffalo, New York. Women & Children’s Hospital of Buffalo, Buffalo, New York.
1
2
on how, or if, providers relay the information to their patients.1,2 A survey of practicing U.S. obstetricians indicated that although more than 85% reported providing GWG education to their patients, only 64% gave specific advice based on the patient’s pregravid body mass index (BMI).13 Other research indicates that as many as one-third of pregnant women report receiving no weight gain recommendations from their provider.5 The purpose of this study was to investigate what percentage of postpartum women were informed about how much weight to gain during pregnancy, the accuracy of the weight gain recommendations based on the current IOM guidelines, and the likelihood of adhering to those guidelines based on whether women were informed about gestational weight gain. We hypothesized that women informed about the GWG guidelines would be more likely to meet the recommendations than women who did not receive GWG recommendations. Materials and Methods
Adult women of all socioeconomic status, race, and ethnicity were recruited from two large teaching hospitals in Western New York, including one suburban and one urban site. We selected large teaching hospitals because women would be more likely to be receiving postpartum care from a diverse number of obstetricians rather than other area hospitals or smaller medical facilities where women would be more likely to be under the care of a select group of obstetricians with similar practices. Participants were recruited in the recovery room of each hospitals. Eligibility criteria included women aged ‡18 years, full term pregnancy of 37–41 weeks gestation, fluency in English, and the intellectual ability to read and comprehend the content of the research study. Women with multiple fetuses, gestational diabetes mellitus, missing self-reported pregravid or predelivery weight, preeclampsia, emergency delivery, or who smoked during pregnancy were excluded from the study. All women were provided written informed consent and all procedures were conducted in accordance with the ethical standards for human subjects’ research. The research study was approved by the Institutional Review Boards at D’Youville College, Women’s and Children’s Hospital of Buffalo, and Millard Fillmore Suburban Hospital in Buffalo, New York. Participant demographic information collected included marital status, maternal education level and employment status, household income, ethnicity, and race. Objectively measured pregravid height and weight from each woman’s medical record was used when available (n = 106) to compute pregravid BMI. Women provided self-reported height and weight which was used to determine pregravid BMI when objective data was not available (n = 28). Pregravid BMI was computed as (weight in kilograms)/(height in meters2). Pregravid BMI was used to classify women’s weight status as underweight (200,000
All subjects (n = 134)
Subjects counseled (n = 90)
Subjects not counseled (n = 44)
28.5 – 5.1 28.0 – 6.9 163.6 – 7.4 74.4 – 18.3 86.9 – 16.7 12.7 – 7.3
28.4 – 5.3 27.7 – 7.3 163.7 – 7.6 73.5 – 18.8 86.6 – 17.3 13.1 – 6.7
28.9 – 4.6 28.6 – 6.3 163.4 – 6.9 76.2 – 17.3 87.5 – 15.8 11.8 – 8.5
68.0 20.9 11.1
64.4 24.4 11.2
76.7 14.0 9.3
89.6 10.4
90.0 10.0
88.6 11.4
41.0 58.2 0.7
42.2 56.7 1.1
38.6 61.4 0.0
0.7 6.0 19.4 21.6 25.4 26.9
1.1 6.7 17.8 23.3 18.9 32.2
0.0 4.5 22.7 18.2 38.6 15.9
57.5 14.2 2.2 12.7 13.4
61.1 8.9 1.1 14.4 14.4
51.2 25.6 2.3 9.3 11.6
13.5 17.3 12.0 12.0 17.3 12.0 10.5 2.3 0.0 3.0
12.4 18.0 12.4 9.0 19.1 12.4 12.4 1.1 0.0 3.4
15.9 15.9 11.4 18.2 13.6 11.4 6.8 4.5 0.0 2.3
Values are mean – standard deviation for continuous variables and % for categorical variables. BMI, body mass index.
guidance not in compliance with IOM, 31 of them (94%) were told to gain more weight than the IOM recommends. Additionally, of the 33 who received non-IOM guidance, 8 (24%) met the target they were given, while 9 (27%) gained less, and 16 (48%) gained more. When examining whether the accuracy of information provided to women about GWG varied by weight status, we found that healthy weight women (86.8%) were much more likely to be provided with gestational weight gain recommendations that were consistent with the IOM’s guidelines than women who were overweight (12.5%) or obese (26.3%) (v2 = 33.5, p < 0.001). Among the 134 women, 33 (24.6%) gained an insufficient amount of weight based on the 2009 IOM recommendations, 38 (28.4%) met the weight gain recommendations, and 63 (47.0%) exceeded the recommendations ( p = 0.003). By weight status, 50% of underweight, 25% of healthy weight,
74% of overweight, and 51% of obese women exceeded the weight gain recommendations (Table 3). Meeting the IOM recommendations did not depend on whether or not women were provided with a gestational weight gain recommendation (v2 = 0.5, p = 0.8) (Table 2). In order to assess whether there was a quantitative difference in the amount of over gain by being informed about the IOM guidelines, we examined the degree of over gain among women exceeding the guidelines. We found that the average weight gain for women informed about the recommendations was 17.6kg which did not differ ( p = 0.863) from weight gain for women not informed of the recommendations (17.8 kg). The results were unchanged when we examined the relationship between being informed and adherence to the GWG recommendations using only the women who were provided with a GWG recommendation that matched the IOM GWG guidelines
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WROTNIAK ET AL.
Table 2. Category of Gestational Weight Gain for Women Who Were Informed Versus Not Informed About How Much Weight to Gain During Pregnancy
GWG Category
Informed about a GWG guideline, n (%)
Not informed about a GWG guideline, n (%)
21 (23.3%)
12 (27.3%)
27 (30.0%)
11 (25.0%)
42 (46.7%)
21 (47.7%)
Insufficient weight gain Recommended weight gain Excessive weight gain
Meeting the Institute of Medicine recommendations did not depend on whether or not women were provided with a gestational weight gain recommendation (v2 = 0.5, p = 0.8). GWG, gestational weight gain.
compared with women who did not receive any GWG recommendation (v2 = 5.4, p = 0.07). When we examined whether meeting the GWG recommendations differed by weight status, we found that 42% of healthy weight, 12.8% of overweight and 24.3% of obese women met the weight gain recommendations (v2 = 24.4, p < 0.01). Discussion
The results of this study indicate that one third of women reported receiving no recommendations from their health care provider about how much weight to gain during their pregnancy. Moreover, almost half of women (45.2%) who reported receiving a GWG recommendation received information that was inconsistent with the 2009 IOM GWG guidelines. These findings are similar to other research demonstrating that women receive a GWG recommendation less than half the time,14 and that women are told inappropriate weight gain targets for their BMI.15 Although we hypothesized that women who received GWG recommendations would be more likely to meet them compared with women not provided GWG information, this was not the case. Women across all weight categories exceeded appropriate weight gain regardless of having been informed of a GWG recommendation. It is interesting to note that when women were provided with GWG recommendations that matched the IOM recommendations, only 25% of women exceeded the recommendations, compared with 48% of women not
provided with any recommendation. This finding should be interpreted with caution and verified in future research since our sample size was small for this analysis. The IOM recommendations were revised in response to the increasing prevalence of obesity in women and emphasize the use of BMI-specific GWG ranges to improve health outcomes for mother and child.2 Women who enter pregnancy overweight or obese are 2 to 6 times more likely to exceed recommended GWG than women of healthy weight,16–18 have an incorrect understanding of personal gestational weight gain targets,19 and report being given GWG recommendations that are inconsistent with the IOM.12,20 These disparities are evident in our findings, as significantly more women that were categorized as overweight or obese reported receiving discrepant information than women of healthy weight. This may be an indication that women who are overweight and obese perceive themselves as healthy weight and ignore the GWG recommendations, that health care providers are uncomfortable discussing weight, or that providers feel that GWG counseling is ineffective in heavy patients. Our findings suggest a need for increased provider education on BMI-specific GWG recommendations and strategies for effectively managing overweight and obesity in patients. In our study, almost half of women exceeded the IOM recommendations. Additionally, our finding that 25% of healthy weight, 74% of overweight, and 51% of obese women exceed the weight gain recommendations aligns with other research that suggests that up to one third of healthy weight women and more than half of overweight women are gaining in excess of the IOM recommendations.21,22 These findings are clinically relevant because excessive GWG is associated with increased risk of gestational diabetes,23 preeclampsia,24 postpartum weight retention in the mother,25 and long-term obesity in children.7,11 A study by Linne and colleagues26 indicated that 46% of healthy weight women who gained excessive weight during pregnancy were overweight at their 15-year follow up evaluation. Women who shed postpartum weight within 6 months following delivery have less long-term weight retention at 10-year follow up than those who fail to lose pregnancy weight following delivery.27 Excessive weight gain is concerning because it is a strong independent predictor of long-term development of overweight or obesity in women following pregnancy;28 thus, fueling the obesity epidemic and increasing the risk for future adverse health conditions.29 The results of our study suggest that future strategies are needed to address the number of women who do not receive
Table 3. Weight Gain and Percentage of Women Who Gained Insufficient, Recommended, and Excessive Weight Gain During Gestation by Pregravid BMI Insufficient weight gain group
All subjects weight gain, kg Pregravid BMI mean (SD) Underweight Healthy weight Overweight Obese
13.7 13.5 14.9 9.9
SD, standard deviation.
(7.3) (5.3) (6.3) (9.6)
n (%) 1 18 5 9
(50.0%) (32.1%) (12.8%) (24.3%)
Recommended weight gain group
Weight gain, kg mean (SD) 8.6 8.3 (2.8) 5.1 (2.8) - 3.6 (8.4)
n (%) 0 24 5 9
(0%) (42.9%) (12.8%) (24.3%)
Excessive weight gain group
Weight gain, kg mean (SD) 13.6 (1.5) 8.5 (1.3) 7.4 (1.2)
n (%) 1 14 29 19
(50.0%) (25.0%) (74.4%) (51.4%)
Weight gain, kg mean (SD) 18.9 20.1 (4.3) 17.7 (4.5) 15.9 (4.6)
ADHERENCE TO GESTATIONAL WEIGHT GAIN GUIDELINES
information, or receive discrepant information, on how much weight to gain during pregnancy. Guidelines alone may be an ineffective approach to change30 or this may be an indication that the GWG guidelines have not been clearly disseminated to the medical community29 and that health care providers are unclear on how to use the BMI-specific approach to calculate weight goals and therefore, provide discrepant information to their patients.31 Other research suggests that there may be a lack of agreement with the clinical guidelines or that patient– provider communication issues or literacy barriers may exist.32 Compounding the issue, when the 1990 IOM guidelines were released, insufficient weight gain and low birth weight were the primary focus. However, the increasing prevalence of obesity in women of childbearing years has drawn attention to the negative effects of over-gaining during pregnancy.33 The updated 2009 IOM report resulted in changes that altered BMI categorization per the World Health Organization guidelines and established for the first time a GWG recommendation for women with obesity. This may have caused confusion within the obstetric community, and providers may not yet have a clear understanding of the updated recommendations or are not yet up to speed with implementing the new guidelines. Providers may also simply be unaware of the changes leading them to classify BMI categories incorrectly.12,34 Strengths of the study include the use of objectively measured predelivery weight for a majority of subjects. A second strength of this study is the use of a diverse sample of women seen at two large teaching hospitals. Additionally, this study provides new information about how well women are being informed about and adhering to the GWG guidelines, how being informed about the GWG guidelines is associated with meeting the guidelines, differences in meeting GWG recommendations by weight status, and differences in how providers provide GWG recommendations based on women’s weight status. There are several limitations to this study. The sample size was relatively small. Further, patients may have been exposed to GWG recommendations from other sources besides health care providers that may have influenced their GWG and perceptions of healthy weight gain. Likewise, the time of gestation when women received the recommendations could have affected the degree of weight gain. However, since 73% of women reported receiving their recommendations from their obstetrician/gynecologist, we believe this information was provided early in their pregnancy. Another limitation is that some women’s pregravid weight (21% of the sample) was unavailable from the medical record and was selfreported and therefore may have been underreported. We found no evidence to suggest that the 28 women with selfreported pregravid weights reported lower than actual weight based on the finding that there was no statistically significant difference in gestational weight gain among women who selfreported pregravid weight compared with women who had their pregravid weight objectively measured. In addition, if some women who were overweight were incorrectly misclassified as healthy weight, this would have biased results toward a more exaggerated estimate of meeting the GWG recommendations, and the percentage of women meeting the GWG guidelines may be lower than reported here. An additional limitation is that we did not have any way to verify whether the information women reported being told or not
5
told by their providers was accurate. Thus, this may have resulted in inflated responses by some women of the recommendations they were provided, particularly if their weight gain was high. Some women may in fact be being informed (and informed correctly) of the IOM recommendations, but not retaining this information. Future research is needed to better ascertain the difference and to develop more powerful strategies for women to retain/and or be informed about the recommendations. Conclusion
Women across all subgroups, particularly those who were in the overweight or obese categories, reported receiving inadequate GWG advice and gaining weight that exceeded the IOM recommendations. Due to the clinical impact of excess GWG and postpartum weight retention, it is pertinent that clinicians address weight gain goals early in pregnancy and monitor weight gain closely. Further, promoting healthy lifestyle physical activity and nutrition along with achieving a healthy weight, should begin even before women become pregnant as well as interconception at the postpartum visit to increase the likelihood of a healthy pregnancy. Moreover, providers should be encouraged to provide timely, accurate advice using the current IOM recommendations. Women who receive guidelines that align with the IOM, and who set weight gain goals with their health care provider, have been shown to gain weight within the recommended ranges.35 Thus, additional practitioner education on GWG and BMIspecific ranges, coupled with training in behavior-based goal setting, may help providers effectively promote accurate GWG recommendations and increase patient adherence for a healthy pregnancy. Author Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Brian Wrotniak, PT, PhD Women and Children’s Hospital of Buffalo D’Youville College 320 Porter Avenue Buffalo NY 14201 E-mail: [email protected]
