| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, the Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia; Office of Scientific Analysis and Support, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Washington, DC.
Address reprint requests to: Mary E. Cogswell, DrPH, RN Division of Nutrition and Physical Activity Centers for Disease Control and Prevention Mail Stop K-25, 4770 Buford Highway Atlanta, GA 30341-3724 E-mail: mec0{at}cdc.gov
 |
Abstract |
|---|
Top
 Abstract Materials and MethodsResultsDiscussionReferences |
|---|
Methods: Predominantly white, middle-class women participating in a mail panel reported their prepregnancy weights, heights, and advised and target weight gains on a prenatal questionnaire (n = 2237), and their actual weight gains on a neonatal questionnaire (n = 1661). Recommended weight gains were categorized for women with low body mass index (BMI) (less than 19.8 kg/m2) as 25–39 lb; for women with average BMI (19.8–26.0 kg/m2) as 25–34 lb; and for women with high BMI (more than 26.0–29.0 kg/m2) and very high BMI (more than 29.0 kg/m2) as 15–24 lb.
Results: Twenty-seven percent of the women reported that they had received no medical advice about pregnancy weight gain. Among those who received advice, 14% (95% confidence interval [CI] 12%, 16%) had been advised to gain less than the recommended range and 22% (95% CI 20%, 24%) had been advised to gain more than recommended. The odds of being advised to gain more than recommended were higher among women with high BMIs and with very high BMIs compared with women with average BMIs. Black women were more likely than white women to report advice to gain less than recommended. Advised and target weight gains were associated strongly with actual weight gain. Receiving no advice was associated with weight gain outside the recommendations.
Conclusion: Greater efforts are required to improve medical advice about weight gain during pregnancy.
In 1990, the Institute of Medicine (IOM) of the National Academy of Sciences recommended that weight gain during pregnancy should vary by prepregnancy weight for height as measured by body mass index (BMI).1 The IOM recommended that women with low BMI (less than 19.8 kg/m2) gain 28–40 lb, women with average BMI (19.8–26.0 kg/m2) gain 25–35 lb, women with high BMI (more than 26.0–29.0 kg/m2) gain 15–25 lb, and women with very high BMI (above 29.0 kg/m2) gain at least 15 lb. The American Academy of Pediatrics and ACOG adopted the IOM recommendations in 1992,2 but little information is available on advised or actual weight gain since the 1990 IOM recommendations.
As part of a Food and Drug Administration panel study on infant feeding practices, pregnant women were asked about advised and actual weight gains and how many pounds they thought they should gain (target weight gain). These data allowed us to examine whether advice on weight gain from health care professionals, women’s target weight gain, and actual weight gain corresponded with the 1990 IOM recommendations. We also determined which factors influenced advised and actual weight gains.
|
Materials and Methods |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
We examined data from the prenatal and neonatal questionnaires, which were administered by mail. Respondents were ineligible for follow-up if they indicated on the prenatal questionnaire that they were not pregnant (n = 182), that their expected delivery data was more than 3 months away (n = 99), or that their infant had already been born (n = 16). These exclusions left 2858 women, of whom 2358 (82%) responded. After the prenatal questionnaires were administered, subjects were ineligible for follow-up if they reported by telephone that their infants weighed less than 5 lb at birth, multiple infants were born, medical problems prevented the mother from feeding her infant for more than 1 week, the infant stayed in the intensive care unit for more than 3 days, the infant had medical problems that affected feeding, the mother or infant died, or the infant was born too early for the neonatal questionnaire to be administered on time. Neonatal data, including birth weight, were unavailable on these infants.
Prepregnancy weight and height, advised weight gain, and target weight gain were assessed in the prenatal questionnaire. Women’s reported advised weight gain was determined by the question, "How many pounds did your health professional say you should gain from the beginning to the end of this pregnancy?" The respondents checked one of several categories: 0–9 lb, 10–14 lb, 15–19 lb, 20–24 lb, 25–29 lb, 30–34 lb, 35–39 lb, 40 lb or more, or "No health professional told me how many pounds I should gain." Women’s reported target weight gain was determined by the question, "How many pounds do you think you should gain from the beginning to the end of this pregnancy?" Again, the respondents checked off a weight gain category. Women’s actual weight gain during pregnancy was determined by a question on the neonatal questionnaire, "How much weight did you gain during this pregnancy?"
Prepregnancy weight and height were converted into kilograms and meters using standard conversion factors, and prepregnancy BMI was defined as (weight in kilograms)/(height in meters)2. Prepregnancy BMI was categorized as low, average, high, or very high according to the IOM recommendations.1
Advised, target, and actual weight gains were classified into categories that corresponded as closely as possible to the 1990 IOM guidelines, considering the restricted response categories on the questionnaire. We defined the recommended weight gain as 25–39 lb for women with low BMI, 25–34 lb for women with average BMI, and 15–24 lb for women with high BMI. In the IOM guidelines, there is no upper limit on weight gain for women with very high BMI, so for the purpose of this study, we defined the upper limit of weight gain during pregnancy among women with very high BMI as 24 lb.
Other variables of interest included women’s height, age, race, education, marital status, parity, time of entry into prenatal care, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and total household income per number of persons in the household (as a continuous variable). All of these variables were determined from questions in the prenatal questionnaire.
For the analysis of advised and target weight gains, we excluded women who did not report weight or height, health professional advice, or target weight gain (n = 69). We excluded 52 additional women who had missing information for any of the sociodemographic and clinical characteristics. Our final sample included 2237 women. Compared with women who were excluded (n = 918) from the total sample because of ineligibility on the prenatal questionnaire or nonresponse, a smaller proportion of women included were unmarried (12% versus 22%), had less than a high school education (4% versus 9%), and were minorities (4% versus 8%) (P = .001).
For the analysis of actual weight gain during pregnancy, women were ineligible if they were missing data on the neonatal questionnaires (n = 557) or did not respond to questions regarding weight gain during pregnancy (n = 19). These exclusions left 1661 women. A greater proportion of women included in our sample reported no advice about weight gain during pregnancy (28% versus 23%), and among those who received advice, a smaller proportion reported advice below the recommendations (12% versus 17%) (P < .05).
We examined the distribution of maternal characteristics by advised weight gain. Differences in distributions were assessed using 
2 test. Because many of the characteristics were associated with each other, we calculated adjusted odds ratios (ORs) using multiple logistic regression to examine which characteristics were independently associated with advised or actual weight gain. We calculated adjusted ORs and 95% confidence intervals (CIs) for less than the recommended weight gain relative to the recommended weight gain and for more than the recommended weight gain relative to the recommended weight gain. For example, adjusted ORs were defined as the odds of receiving advice to gain less than the recommended weight during pregnancy relative to receiving advice to gain within the recommended weight range for women with a given characteristic (eg, unmarried) compared with these same odds for women without the given characteristic (eg, married), holding all other factors constant.
We found no statistically significant interactions (P < .05) between advised weight gain and WIC participation or mother’s education. We were unable to examine the interactions between advised weight gain and race or BMI because of the small samples of black, underweight, and overweight women. Therefore, no interaction terms were included in the final models. Logistic regression models were appropriate as assessed by goodness-of-fit tests.4 We used SAS (SAS Institute, Cary, NC)5 for all statistical analyses.
|
Results |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
The distribution of maternal characteristics varied by category of advised weight gain during pregnancy (Table 1
). Among women who reported receiving no advice, a greater percentage were 35 or more years of age, had a parity of 1 or more, and did not participate in WIC compared with women who reported advice (P < .05). Among women who reported advice about weight gain during pregnancy, the majority of women who were advised to gain more than the recommended amount had high or very high BMI (80.2%) (P < .05). There also were significant differences in the distribution of education, marital status, prenatal care, and WIC participation by category of advised weight gain (P < .05).
|
).
A greater proportion of women actually gained below or above the recommended category than was either advised or targeted. Twenty-three percent (95% CI 21%, 25%) of women gained less and 42% (95% CI 40%, 44%) gained more than recommended. Advised weight gain was associated with actual weight gain (Table 1).
When other maternal characteristics were held constant, black women were five times more likely than white women to report advice to gain less than recommended relative to advised gain within the recommended amount (Table 2). Advice to gain less than recommended also was associated independently with entry into prenatal care after the first trimester and participation in WIC. Advice to gain more than recommended was associated with having high and very high BMI. No other characteristics were significantly associated with reported advice to gain weight outside the recommended ranges after adjustment.
|
). Women who were advised to gain less than the recommended weight were 3.6 times (95% CI 2.3, 5.5) more likely to report an actual weight gain that was less than recommended than were women who were advised to gain within the recommended ranges. Women who were advised to gain more than the recommended ranges were 3.6 times (95% CI 2.4, 5.5) more likely to gain more than the recommended weight than were women who were advised to gain within the recommended range. Women who had not been advised about weight gain were more likely to gain outside the recommended ranges than were women who were advised to gain within the recommended ranges. The associations between target and actual weight gain were even stronger.
|
|
Discussion |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
Black women were more likely than white women to report advice to gain less than the recommended amount regardless of differences in prepregnancy BMI, education, marital status, prenatal care initiation, WIC participation, or income. This finding is consistent with previous studies of advised and actual weight gain6,10,11 and is of concern because black women are at greater risk of delivering low birth weight (LBW) infants than are white women.12 Gaining less than the recommended amount increases the risk of LBW infants.10,13
The association between WIC participation and receiving advice to gain less than the recommended weight should be interpreted with caution. Participation in WIC is not a direct indication of advised weight gain from a WIC nutritionist, and participation was not associated with personal target or actual weight gains (analyses not shown). In addition, WIC participation might be a proxy for income. We adjusted for income, and although this diminished the association between WIC participation and advised weight gain, it did not eliminate it. Further studies should assess which health care professionals (eg, obstetricians, midwives, WIC nutritionists) give advice about weight gain and what advice they give.
Several characteristics of the Food and Drug Administration Infant Feeding Practices Study should be considered when interpreting our results. As in previous studies,6,14 these data were self-reported and thus are subject to reporting error. Errors in reporting prepregnancy weight, height, professional advice, and weight gain during pregnancy might have led to reduced strength in the observed association between advised and actual weight gains. Reporting error in confounding variables such as prepregnancy weight might have led to partial loss of the ability to control for these factors. Questions regarding professional advice and target weight gains were asked during the third trimester, and responses might have been influenced by the amount of weight gained up to the time of the questionnaire. The answers to questions about advised and target weight gains are less likely to be influenced by the women’s actual weight gain in the current study, however, than if they had been asked at the same time as actual weight gain, as was done in previous studies.6,14 Future studies should attempt to ascertain advised and target weight gains in the first trimester and measure actual weight gain to further limit potential bias in the associations.
The socioeconomic status of participants in the mail panel was higher than that of the nation in general and was enhanced by the exclusion of participants who were ineligible or had missing data. The exclusion of LBW infants, sick infants, and preterm infants might have decreased the percentage of mothers who reported low weight gain during pregnancy. Despite the differences between the mail panel and the general population, the receipt of weight gain advice for white women and the associations between advised and actual weight gains were similar to those for the U.S. population in 1988.8 The small samples of black, underweight, or overweight women and of women with less than a high school education limited our analyses of the associations between advised and actual weight gains in these subgroups.
The current study was conducted a year after dissemination of implementation materials15 and publication of the third edition of Guidelines for Perinatal Care2 by the American Academy of Pediatrics and ACOG. Physician practice may have changed since 1993 because the guidelines were disseminated more widely. Although there is no information on medically advised weight gain after 1993, one study suggested that there was little change from 1990 to 1996 in the proportion of low-income pregnant women who actually gained within the IOM recommended ranges, but there was a shift in women gaining outside the recommendations. Specifically, a greater proportion of women in 1996 were gaining more than the IOM recommended and a smaller proportion were gaining less than the IOM recommended.16
Although some questions remain regarding the optimal range of weight gain for specific groups,10,13 most experts agree that BMI-specific recommendations for weight gain during pregnancy are associated with favorable birth outcomes.10,13,17 Barriers to counseling women about appropriate weight gain during pregnancy based on their prepregnancy BMI and to women’s hearing and recalling advice about weight gain during pregnancy need to be identified and addressed. By giving appropriate advice about weight gain, health care professionals can influence weight gain during pregnancy and improve infant birth weight and health.
|
Footnotes |
|---|
Received December 28, 1998. Received in revised form April 7, 1999. Accepted April 15, 1999.
|
References |
|---|
|
Top
AbstractMaterials and MethodsResultsDiscussionReferences |
|---|
2. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 3rd ed. Elk Grove Village, Illinois, and Washington DC: American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 1992.
3. Scariati PD, Grummer-Strawn LM, Fein SB, Yip R. Risk of diarrhea related to iron content of infant formula: Lack of evidence to support the use of low-iron formula as a supplement for breastfed infants. Pediatrics 1997;99(3):e2. URL: http://www.pediatrics.org/cgi/content/full/99/3/e2.
4. Hosmer DW, Taber S, Lemeshow S. The importance of assessing the fit of logistic regression models: A case study. Am J Public Health 1991;81:1630–5.
5. SAS Institute Inc. Volumes 1 and 2: SAS/STAT user’s guide, version 6. 4th ed. Cary, North Carolina: SAS Institute, 1989.
6. Taffel SM, Keppel KG, Jones GK. Medical advice on maternal weight gain and actual weight gain: Results from the 1988 Maternal and Infant Health Survey. Ann N Y Acad Sci 1993;678: 293–305.[Abstract]
7. Cogswell ME, Serdula MK, Hungerford DW, Yip R. Gestational weight gain among average weight and overweight women: What is excessive? Am J Obstet Gynecol 1995;172:705–12.[Medline]
8. Keppel KG, Taffel SM. Pregnancy-related weight gain and retention: Implications of the 1990 Institute of Medicine guidelines. Am J Public Health 1993;83:1100–3.
9. Parker JD, Abrams B. Differences in postpartum weight retention between black and white mothers. Obstet Gynecol 1993;81: 768–74.[Medline]
10. Schieve LA, Cogswell ME, Scanlon KS. An empiric evaluation of the Institute of Medicine’s pregnancy weight gain guidelines by race. Obstet Gynecol 1998;91:878–84.[Abstract]
11. Caulfield LE, Witter FR, Stoltzfus RJ. Determinants of gestational weight gain outside the recommended ranges among black and white women. Obstet Gynecol 1996;87:760–6.[Abstract]
12. Ventura SJ, Martin JA, Mathews TJ, Clarke SC. Advance report of final natality statistics, 1994. Monthly Vital Statistics Report, vol. 44, no. 11 (suppl). Hyattsville, Maryland: National Center for Health Statistics, 1996.
13. Caulfield LE, Stoltzfus RJ, Witter FR. Implications of the Institute of Medicine weight gain recommendations for preventing adverse pregnancy outcomes in black and white women. Am J Public Health 1998;88:1168–74.
14. Taffel SM, Keppel KG. Advice about weight gain during pregnancy and actual weight gain. Am J Public Health 1986;76: 1396–9.
15. Institute of Medicine. Nutrition during pregnancy and lactation: An implementation guide. Report of the Subcommittee for a Clinical Applications Guide, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. Washington DC: National Academy Press, 1992.
16. Schieve LA, Cogswell ME, Scanlon KS. Trends in pregnancy weight gain within and outside ranges recommended by the Institute of Medicine in a WIC population. Matern Child Health J 1998;2:111–6.[Medline]
17. Suitor CW. Maternal weight gain: A report of an expert work group. Arlington, Virginia: National Center for Education in Maternal and Child Health, 1997.
This article has been cited by other articles:
|
|
 |
|
  H. A. Ricciotti State of the Art Reviews: Nutrition and Lifestyle for a Healthy Pregnancy American Journal of Lifestyle Medicine, April 1, 2008; 2(2): 151 - 158. [Abstract] [PDF]
|
|
|
|
 |
|
 L. Rode, H. K. Hegaard, H. Kjaergaard, L. F. Moller, A. Tabor, and B. Ottesen Association Between Maternal Weight Gain and Birth Weight Obstet. Gynecol., June 1, 2007; 109(6): 1309 - 1315. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. L. Rooney, C. W. Schauberger, and M. A. Mathiason Impact of Perinatal Weight Change on Long-Term Obesity and Obesity-Related Illnesses Obstet. Gynecol., December 1, 2005; 106(6): 1349 - 1356. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. E. Stotland, J. S. Haas, P. Brawarsky, R. A. Jackson, E. Fuentes-Afflick, and G. J. Escobar Body Mass Index, Provider Advice, and Target Gestational Weight Gain Obstet. Gynecol., March 1, 2005; 105(3): 633 - 638. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
