*Y.C.* Improving Healthy Gestational Weight Gain to Help Mother and Child

Needs Statement
Institute of Medicine Guidelines
The Institute of Medicine (IOM) recommends that women, according to their pre-pregnancy BMI, classified as underweight gain 28-40lbs, normal weight gain 25-35lbs, overweight gain 15-25lbs, and obese gain 11-20lbs (1). According to the 2008 Pregnancy Nutrition Surveillance System, only 32.5% of pregnant women accomplished the ideal gestational weight gain, 25% did not gain enough and 42.5% gained too much weight (2). The median weight retention of 1.54lbs has been reported among women who gained the IOM’s recommended amount during pregnancy as compared to a weight retention of 4.84lbs among women who gained more than the recommended amount during pregnancy (3).If the proportion of women gaining appropriate weight during pregnancy is a minority, it is clear something must be done.
Inadequate Gestational Weight Gain
The Healthy People 2010 goal 16.12 aims to increase the number of women in the United States who gain weight within the recommended ranges put forth by the Institute of Medicine (4). A direct effect of gestational weight gain less than the IOM recommendation is low birth weight (LBW) of the infant, defined as less than 2,500 grams, and it is responsible for about 14% of LBW infants in the U.S. (5). According to data from the Healthy People 2010 goals 7.6% of U.S. infants born in 1998 were born LBW with African Americans having the highest incidence at 13% followed by non-Hispanic (7.8%), Asian or Pacific Islander (7.4%), American Indian or Alaska Native (6.8%), white (6.5%), and Hispanic (6.4%) (4). Low birth weight directly contributes to risk infant mortality and is negatively correlated, as birth weight decreases risk increases (6). Complications associated with low birth weights include: neurodevelopmental condition, congenital anomalies, and lower respiratory tract infections (6). A correlation has been proven between pre-pregnancy weight and low birth weight, separately from the affects of gestational weight gain, meaning some women go into pregnancy already at a disadvantage (7). In the 2007 Pregnancy Nutrition Surveillance Report, 10.9% of the women that participated were classified as underweight prior to pregnancy (8).
Excessive Weight Gain and Consequences for Overweight Mothers
Overweight BMI pre-pregnancy also has a significant effect, independent of gestational weight gain, on high birth weights [defined as >4,000grams (9)], or macrosomia, increasing the infants’ risk of perinatal morbidity and mortality (10). In 2007, 15.2% of pregnant women had a pre-pregnancy BMI classification of overweight and 30.2% were classified as obese (2). According to the findings of the Pediatric Nutrition Surveillance 2008 Report, 6.4% of infants born were classified as high birth weight (9). American Indians or Alaska Natives had the highest prevalence of high birth weight infants with 9.1% followed by whites (7.5%), Hispanics (6.6%), Asian or Pacific Islanders (4.5%) and African Americans (4.1%) (9). Overweight women have also been found to have a greater risk of preeclampsia, gestational diabetes, and cesarean deliveries [31.1% of U.S. births in 2006 (11)] (8). The number of women who were overweight before getting pregnant rose by 5.6% to 44.5% from 1998 to 2007 (8). Women who were overweight before pregnancy are six times more likely to exceed the IOM recommendations (12).Women that exceed the IOM recommendations on average retain twice as much weight post-partum as women who gain within the ranges (12). Many women cite pregnancy as what instigated their obesity (3). A study found that 73% of women treated for obesity reported 22+ lbs weight retention after pregnancy (3). Some factors influencing post-pregnancy weight retention have been found to be: gestational weight gain, race/ethnicity, pre-pregnancy weight, number of births, and breastfeeding (3). Very high weight increases after pregnancy were three times more often in black women than white women and many studies found a larger weight increase post-partum in black women than in white women (3).First time pregnancies, as compared to women who have had previous pregnancies, have higher rates of gestational weight gain and post-partum weight change (3). Women who have pregnancies in quick succession are at the highest risk of increased weight retention after pregnancy (3).?)
Mean gestational weight gain and obesity rates have increased in the United States over the last twenty years (3). An estimated $30-$50 billion is spent annually in the U.S. on weight loss and management (3). The most significant increase in prevalence of overweight has been among reproductive age women (3). Attention to weight gain during pregnancy is critical, especially considering the risk to both mother and child when too much weight is gained. Obesity in women specifically can lead to “reduced fertility, endometrial cancer, osteoarthrosiss of the spine and knee,…gout, dyslipidemia, osteoarthritis, cholelithiasis, and obstructive apnea” (3). It is estimated that the U.S. will spend $16 billion in healthcare costs over the next 25 years in treating issues related to overweight women above 40 (3).Gestational weight gain within the IOM guidelines has been associated with healthier fetal and maternal outcomes (12).
Socioeconomic Implications
Factors unrelated to pre-pregnancy BMI status or weight gain during pregnancy largely contribute to birth weight outcomes. Socioeconomic status has been shown to play a role in gestational weight gain as women with less than 12 years of education have a higher prevalence of low gestational weight gain than women with 13 or more years of education (13). Regular growth processes in teenagers result in a longer time frame of weight gain during pregnancy and pregnancy itself may alter the teen mother’s growth (14). Birth rate for US teenagers 15-19 years was 42.5 births per 1000 in 2007, rising 5% from 2005 (11). The birth rate for American Indian or Alaska Native teenagers aged 15-19 rose to 59 per 1000, a 7% increase in 2007 from 2006 (11). While the rate of non-Hispanic white and African American teenagers increased, the only group to experience a decrease in 2007 was Hispanic teenagers with a 2% decrease to 81.7 per 1000 (11).
Consequences and Necessity for Improvements
Given the above information, it is clear that improvements in appropriate gestational weight gain amounts, within the IOM’s recommended ranges, is crucial to maternal and infant health. Inadequate and excessive weight gains during pregnancy both have serious albeit different effects. In 2008, only 32% of pregnant women gained weight within the ideal range (2); leaving 68% of the pregnant population in need of an educational intervention on gestation weight gain in order to achieve optimal health for mother and child. There still are many misconceptions, such as needing to eat for two and negative effects of exercise, among pregnant women as to what healthy practices actually are during pregnancy (15).One study found that only 60% of the participants received gestational weight gain recommendations from their doctors that were within the appropriate IOM limits (15).The majority of underweight or normal weight women received appropriate recommendations while the majority of overweight/obese women received excessive recommendations (15).Though prevalence of inadequate gestational weight gain is highest among Asian/Pacific Islander (30.7%), Hispanic (27.8%), and African American (27.2%) populations and prevalence of excessive gestational weight gain is highest among multiple races (48.4%) and whites (47.2%), no race has the majority of their women gaining within the IOM recommended ranges during pregnancy (2). A population that would benefit greatest from more pre-natal care education on healthy gestational weight gains cannot be distinguished by race; the entire US population of pregnant women needs more information on the matter.
Goals and Objectives
Goal
1. To increase the incidence of women who gain the appropriate amount of weight during pregnancy, according to the IOM recommended ranges for each BMI category, in three obstetric offices in the metropolitan area of San Francisco.
2. To develop a nutritional component of gestational care that could be easily implemented by physicians’ offices at a low time and monetary cost and could remain sustainably a part of their administered routine care.
Objectives
1) To increase the incidence of women who gain the appropriate amount of weight during pregnancy, according to the IOM recommended ranges for each BMI category, in three obstetric offices in the metropolitan area of San Francisco.
a) To provide accurate information and proper education to pregnant women during prenatal care on special dietary conditions and changes during pregnancy and potential health consequences to mother and child if appropriate gestational weight is not gained. To discredit myths and misconceptions regarding weight gain and physical activity during pregnancy.
b) To integrate weight tracking into routine prenatal exams. To make appropriate weight gain an important focus during prenatal exams.
2) To develop a nutritional component of gestational care that could be easily implemented by physicians’ offices at a low time and monetary cost and could remain sustainably a part of their administered routine care.
a) To hire a part time registered dietitian to meet with each pregnant patient one time during prenatal care.
b) To train nurses and support staff on appropriate timing and amounts of gestational weight gain and proper methods for readdressing weight gain goals with patients when necessary.
Methods
Sample (Hypothetical Example of how/where the Program could be applied)
This intervention will be conducted in San Francisco, due to its diversity in race, age, and socioeconomic status, in order reach a broad spectrum of pregnant women. Three obstetric offices providing prenatal care to women in San Francisco have been chosen, the offices of “Dr. Johnson”, “Dr. Roberts”, and “Dr. Smith.” The offices are located in different neighborhoods of the city with varying ethnicities, ages, educational levels, and socioeconomic levels of their clients. Dr. Johnson works in a free obstetric clinic whose clientele is primarily African American and Hispanic low income women of varying ages. Dr. Roberts’s office accepts private insurance as well as governmental health insurances such as PCAP Medicaid, and his client base is women of all ethnicities and socioeconomic statuses. Dr. Smith’s obstetric office only accepts private insurances and offers other services to pregnant women, such as an in-office chiropractor specializing in working with pregnant women. The majority of his clients are wealthy, white women. The intervention will be the incorporation of efficient pregnancy-specific nutrition counseling and weight tracking into the routine prenatal exams. The sample will be all willing patients of these three doctors who begin prenatal care during a two year period. Through this educational intervention at a minimal time and monetary cost to the physicians, theses pregnant mothers will be better prepared to gain appropriate weight during pregnancy.
Project Design
This intervention will be conducted in three phases: assessment and education with a Registered Dietitian after the first prenatal care appointment, weight tracking and reassessment on a needs basis at each consecutive prenatal appointment, and evaluation of knowledge acquired through this intervention and pregnancy outcome after delivery. Each patient that begins prenatal care at any of these three offices at any point during the two year intervention will be asked to sign a consent form to be a participant in this program. Only the women who give birth before the end of the first year and a half period will be included in the evaluation portion of the full program. Women who are still pregnant at the termination of the tracking portion of the intervention will still receive the education and tracking up to the two year mark and tracking will continue only at the discretion of each doctors’ office.
Phase 1: Dietitian Education
One registered dietitian will be used for all three offices on a rotating schedule through the duration of this program. At each office the dietitian will be responsible for meeting with each new pregnant patient for 45 minutes some time after their first prenatal exam with the doctor and before their second exam. During this meeting the dietitian will conduct a routine nutritional assessment of the client to acquire information on patient’s eating habits, family history, personal and professional environment, and health related knowledge. The dietitian will then educate the patient on the following topics:
• An appropriate gestational weight gain range, based on IOM recommendations, specific to the client’s pre-pregnancy BMI and current health status and the distribution of when the weight should be gained throughout the three trimesters
• Appropriate and inappropriate foods and substances to be consumed during pregnancy and the importance of adequate nutrition for the health of the mother and child. Multi vitamin supplementation will also be discussed.
• The importance of physical activity during gestation and which exercises are generally easiest and safest for pregnant women. Special attention will be paid to addressing misconceptions about physical activity throughout pregnancy.
The dietitian will only meet with each client for one session. After each session the dietitian will write a very brief weight gain plan for each client that will be kept in their file and available to the staff responsible for tracking patients’ progress. The dietitian will also be responsible for the initial training of all support staff in each office to ensure consistency in procedures at each site during the program.
Phase 2: Tracking
The nurses and relevant support staff in each physician’s office will be responsible for the tracking portion of the intervention. The registered dietitian will be responsible for training all staff at each office that will be involved in the intervention so to ensure consistency in procedures. Training will take place one time at each office and shall last about three hours. During these training sessions the registered dietitian will cover the following information.
• Basics of the interventions: why it’s being conducted, how IOM recommendations are calculated, and anticipated study outcomes
• Consistent methodology of weighing patients and tracking each patient’s weight on an IOM Gestational Weight Gain Grid
• Appropriate actions to take for patients whose weight is within the goal range and patients whose weight is above or below the goal range
After all pertinent support staff has been trained they will begin the weight tracking procedures with all patients who have had their nutrition consultation. For each prenatal exam after the nutrition consultation the support staff will weigh each patient at the beginning of the appointment using a standardized model of scale. They then will mark the patient’s weight on an IOM Gestational Weight Gain Grid in front of the patient. If the weight falls within the recommended range, they will congratulate the patient and encourage them to continue what they are doing. If the patient’s weight is above or below the recommended range, they will inform the client of how far from the goal range their weight is and review the recommended amount and timing of weight gain during pregnancy pertinent to the patient. They will then encourage decreasing or increasing the patient’s intake and/or exercise as necessary.
Phase 3: Outcome Evaluation
Formative Evaluation
In order to evaluate the success of the educational component of the intervention, a questionnaire will be administered before the initiation of the program and again after each patient has given birth. The pre-intervention questionnaire will be included in the packet of consent forms each woman will receive after her first prenatal exam and will include such questions as:
1. Have you been pregnant before and received prenatal care?
2. How much weight do you believe you should gain during the course of your pregnancy? Why do you believe you should gain this amount?
3. Do you believe there are any foods you should eat more or less of while pregnant? Which foods and why?
4. Do you believe there are any nutrients you need more or less of while pregnant? Which nutrients and why?
5. Do you believe you should or should not be physically active while pregnant? Why or why not?
6. Where have you acquired the majority of your knowledge about pregnancy from?
Summative Evaluation
At each patient’s first follow up appointment after giving birth, the second questionnaire will be administered for the woman to fill out and give to the nurse or other support staff. It will have the same questions as above but will also include some questions to assess each woman’s personal view of her success and pregnancy outcome. The new questions will include:
1. Do you feel you reached your total weight gain goal during pregnancy?
2. Do you believe you gained weight at your goal intervals during your pregnancy?
3. Do you feel (whether you did or did not accomplish your weight gain goals) you had an effect on your health or your baby’s health?
Measurements
Evaluation of the first goal of this intervention will be the ongoing process of regular weight tracking at each prenatal exam. Tracking the weight gain of each patient will serve to assess the incidence of women achieving the recommended gestation weight gain amount as a result of this intervention.
Impact
The last component of the evaluation of the intervention will be the outcome of each patient’s pregnancy. Given all the associated health risks to the infant if the mother does not accomplish the recommended gestational weight gain, birth outcome will be the final assessment component of the program’s success. As part of the initial consent given by each patient, each infant’s birth weight, developmental status at birth, and weight and ability to thrive at first neonatal check up will be made available to the program director.
Data Analysis
The project director will work with a statistician at the end of the program to assess the program’s success. Data analysis will be performed on all of the above evaluative areas which include: knowledge acquired based on comparison of formative and summative questionnaires, incidence of patients obtaining gestational weight gain within IOM recommended ranges, and outcomes of successful births.
Adjustments
The idea for this intervention arose from the need specific to the United States. The research conducted was primarily pertinent to the United States and the intervention approach was created specific to the United States. In the United States obesity has been a growing national problem and the parameters of the above scenario focus strongly on a strategy to effectively lessen this problem; unfortunately the recent years have been showing obesity to be developing as a world-wide issue ailing all levels of countries. That being said, this program was designed with flexibility in mind for easy implementation in different countries where the primary issues of maternal health may be different. For example, in countries where the primary food sources are perhaps not very nutrient dense, the information given during the one session with the dietitian could emphasize strategies for maximizing the limited nutrients available. This program is designed to be practical and cost efficient to implement. The session with the material to be covered by the dietitian during the nutrition session can be written and easily designed to meet the needs specific to the population upon which this intervention is being conducted.
Sources
1. Committee to Reexamine IOM Pregnancy Weight Guidelines, (2009, May). Weight Gain During Pregnancy: Reexamining the Guidelines. Retrieved January 18, 2010, from Institute of Medicine: http://www.iom.edu/~/media/Files/Report%20Files/2009/Weight-Gain-During-...
2. "CDC's Pediatric and Pregnancy Nutrition Surveillance System." Centers for Disease Control and Prevention. Center for Disease Control and Prevention, 2008. Web. 5 Feb. 2010. Tables 2 and 20. .
3. Erica P Gunderson and Barbara Abrams. 2000, Epidemiology of Gestational Weight Gain and Body Weight Changes After Pregnancy, Epidemiologic Reviews, 261-274
4. (2001, January 30). Healthy People 2010: 16 Maternal, Infant, and Child Health. Retrieved January 11, 2010, from Centers for Disease Control and Prevention and Health Resources and Services Administration: http://healthypeople.gov/Document/HTML/Volume2/16MICH.htm
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6. National Academy of Sciences. Preventing low birthweight: report of the Committee to Study the Prevention of Low Birthweight. Washington, DC: National Academy Press, 1985. [via CDC source #17]
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9. Polhamus B, Dalenius K, Mackintosh H, Smith B, Grummer-Strawn L. Pediatric Nutrition Surveillance 2008 Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
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12. Shelby M. Asbee, MD, Todd R. Jenkins, MD, Jennifer R. Buttler, MD, John Hite, DPM, MS, Mollie Elliot, RN, BSN, and Allyson Rutledge, LDN, RD. 2009 Preventing Excessive Weight Gain During Pregnancy Through Dietary and Lifestyle Counseling, American College of Obstetrics and Gynocology, 305-312
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15. Ellen Althuizen, M.Sc., Mireille N.M. van Poppel, Ph.D., Jacob C. Seidell, Ph.D., Willem van Mechelen, M.D., Ph.D. 2009, Correlates of Absolute and Excessive Weight Gain During Pregnancy, Journal of Women’s Health, 1559-1566