Guest Post: Everything You Must Know About Pregnancy and Weight GainThursday, February 13, 2014
Today’s post is from Zach Ferraro, PhD, a former CON-SNP National Executive member (2008-12), CON Boot Camper (2008) and Inaugural recipient of CON Rising Star Award (2012). Currently, Zach is a clinical research associate in the Division of Maternal-Fetal Medicine at the Ottawa General Hospital and PT Professor in Human Kinetics at the University of Ottawa. He is also a member of the CON 5 As for pregnancy working group.
Regular readers of these pages will recall that the intrauterine environment plays a vital role in healthy neonatal development and is directly influenced by maternal nutrition, physical activity, xenobiotics and pregnancy weight gain. This interaction is commonly referred to as ‘fetal programming’ or more appropriately termed fetal plasticity. That is, the ability of the developing fetus to grow and respond to external stimuli whether intrauterine or environmental. Thus, all prenatal exposures, positive and negative, have the potential to affect the short- and long-term health of the child.
It is now well-established that excess gestational weight gain (GWG) is an independent predictor of large for gestational age (LGA) neonates and postpartum weight retention (PPWR) in the mother. Simply, moms who gain greater than the recommended amount of weight, according to their pre-pregnancy BMI, subsequently carry this excess weight forward into the next pregnancy causing a rightward shift in their BMI after delivery. In addition, babies born large (LGA) tend to track their excess weight throughout life and are at greater risk of becoming obese as adults. Although the mechanisms explaining these associations are far from unraveled, both LGA and PPWR exacerbate what is referred to as the intergenerational cycle of obesity.
So what can care providers do to help minimize the ill-effects of excessive GWG? Several lifestyle interventions during pregnancy are reported in the literature and have yielded mixed results. This is largely due to heterogeneity in intervention type (diet or physical activity or psychological support or all the above) and intensity (intensive clinical intervention vs. hands off approach). We, in addition to others, have also reported that knowledge transfer between patients and providers may be partially responsible for the limited treatment effects seen in some interventions. Nonetheless, in the absence of any between group differences in GWG guideline adherence and maternal-fetal outcomes between lifestyle intervention and standard care, it is important to remember that healthy living behaviours were not harmful and may have resulted in increased fitness and/or alterations in body composition (which is rarely if at all ever measured). Thus, healthy living trumps numbers on the scale, something readers of these pages are all too familiar with.
Given the many known benefits of appropriate GWG how can we help providers implement, and patients adhere to, recommendations and in turn improve maternal-fetal outcomes? In the fall of 2013 the Institute of Medicine (IOM) chaired a workshop entitled “Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines” to help address this important clinical issue. A link to the 97 page report can be found at the end of the post. During the workshop the IOM heard from clinical experts, scientists, researchers and public health advocates on topics ranging from communicating the pregnancy weight gain guidelines, how to support behaviour change, implementing the guidelines, an overview of the importance of the first 1000 days and collaborating to increase messaging and uptake of the guidelines. Following the workshop it was concluded that strong and consistent messaging was required to assist with patient-provider uptake. Additionally, several resources including physical activity and GWG prescription pads were shared as examples of tools care providers could use with patients. A conceptual model, GWG poster, an easy-to-read information pamphlet, GWG tracker, 5 common myths heard from expectant mothers, and an interactive online tool were also highlighted.
To conclude the IOM committee recommended adopting a ‘before, between and beyond’ approach to connect pregnancy care with general health care to take advantage of the adage ‘prevention before conception’. Changing the structure of prenatal care was suggested to encourage visits earlier in pregnancy as a way that reflects each woman’s unique situation and risk profile; noting that the reversal of early excessive GWG is challenging at best. Lastly, recommendations to motivate women to adopt healthy behaviours by initiating a dialogue between patient and provider were suggested to leverage action across the continuum of prenatal care. It is important to note that many of these recommendations are included within the soon to be released CON 5 As for Healthy Pregnancy Weight Gain.
As the GWG research continues to mount and novel prenatal interventions using sophisticated technology attempt to facilitate behaviour change, care providers and patients require immediate tools/strategies to help improve maternal-fetal outcomes. In addition to the CON 5 As for Pregnancy, providers can be confident recommending routine physical activity (in those without contraindications), nutritional guidance and caloric literacy given that the caloric requirements of pregnancy are modest (~300 kcal/day in term 2 and 3), encouraging a food diary and physical activity log and tracking GWG on their own using the tools provided within the report. Collectively, patients and providers can work together with open dialogue to ensure optimal health and wellness for mom and baby.
You can follow Dr. Zach Ferraro on twitter @DrFerraro for frequent discussion on the topic. More details can be found at www.DrFerraro.ca
Institute of Medicine (2013). Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines
Ferraro ZM, Boehm K, L Gaudet, KB Adamo. Counseling about gestational weight gain and healthy lifestyle during pregnancy: Canadian maternity care providers’ self-evaluation. International Journal of Women’s Health. 2013:5 629-636.
Ferraro ZM, N. Barrowman D. Prud’homme, MW. Walker, M. Rodger, SW. Wen, KB. Adamo. Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index. Journal of Maternal-Fetal & Neonatal Medicine. 2012;25(5):538-542.
Institute of Medicine (2009). Weight Gain During Pregnancy: Reexamining the Guidelines
Thursday, February 13, 2014
Research is always interesting in that it is a summary of many individual experiences. Care is needed, then, in generalizing research outcomes to every individual. The statement “moms who gain greater than the recommended amount of weight, according to their pre-pregnancy BMI, subsequently carry this excess weight forward into the next pregnancy causing a rightward shift in their BMI after delivery” is an absolute statement, rather than saying “are most likely to”. I caution that there is the occasional individual for whom this does not apply, of which I have personal experience. My BMI is 25 which falls just into the overweight range. Within my 3 pregnancies, I gained 70 lbs, 60 lbs, and 42 lbs. In my last pregnancy my daughter was only 6lb 12 oz, despite a weight gain well over what would have been recommended based on my BMI. For me, a gain of 42 lbs in pregnancy was not suffucient to have a baby grow to an optimum weight, despite being much higher than normal. As well, I did lose all my pregnancy weight after my children were born with no heroic measures, indicating that my gain was normal for me in pregnancy. So while I absolutely agree that for the vast majority of clients a weight gain greater than guidelines can contribute to a less postive outcome for both mother and baby, I caution in generalizing it to all and suggest that greater weight gain deserves a closer attention to lifestyle behaviours without an absolute assumption that the greater weight gain is negative.
Thursday, February 13, 2014
I entered my first (of 3) pregnancy at a healthy weight of 140. I am 5’7″ tall. During the 6th month of that pregnancy I had my first experience of having absolutely insatiable hunger. I could eat until my stomach was so full it hurt and still feel hungry. I ate very healthy food — just a lot of it. Even though I exercised a lot, and had plenty of emotional support, I gained 44 lbs during the pregnancy.
I lost about 25 with birth and lactation, and gained about 20 with each subsequent pregnancy and birth. I had gestational diabetes with the 3rd pregnancy, and developed type 2 diabetes 7 years later.
The feeling of insatiable hunger is now very familiar to me. I believe it is part of insulin resistance. I don’t think weight gain during pregnancy is always controllable through diet, physical activity, and psychological support. I think my weight gain during pregnancy was the first overt warning flag that I was on my way to having type 2 diabetes, and I think we simply don’t know yet how to control that type of weight gain effectively.