Transcript Nutrition in Pregnancy and Lactation

Pregnancy and
Obesity: the
nutrition link
Kelli Hughes, RD, CDE
UVA Health System
Obejctives
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To review 2009 IOM Guidelines for weight
gain during pregnancy
To review adherence to current
recommendations
To discuss determinants for gestational
weight gain
To discuss social predictors of excess
gestational weight gain
To discuss possible nutrition interventions to
prevent excess gestational weight gain
Institute of Medicine Guidelines
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Optimal infant birth weight
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3000 – 4000 g
Decreased risk of mortality
Originally published in 1990; revised in 2009
Potential impact of contemporary issues
required change
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Increased incidence of obesity
Increased incidence of multiples
Increased incidence of gastric bypass
Lack of outcome studies – except for birth weight
What’s changed since 1990 IOM
guidelines
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Huge increase in the prevalence of maternal
overweight and obesity
Low (<16 lb) and high (>40 lb gestational
weight gain (GWG) have become more
common
Dieting during pregnancy has doubled
GWG in excess of recommendations is
associated with significant postpartum weight
retention Nohr et. al.
Increased risk of overweight and obesity in
the child Oken et. al., Moeiria, et. al.
IOM Guidelines 2009
Category
Pre-pregnancy BMI
Recommended weight gain
Under weight
<18.5
28-40 lbs
Normal weight
18.5-24.9
25-35 lbs
Overweight
25-29.9
15-25 lbs
Obesity
30+
11-20 lbs
Adolescents, African Americans and smokers
should gain at the top of the range
How much do women gain?
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46% gain more than is recommended (2004)
23% gain less than is recommended
31% gain within guidelines
Overweight and obese women 2X as likely to
exceed the upper limit
Underweight women are most likely to have
minimal gains
Diet and physical activity are related to
excessive gestational weight gain (GWG)
-IOM report 2007
Outcomes associated with excess
GWG in obese women
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Incidence of pregnancy complications not significantly
associated with weight change during pregnancy in many
studies
With weight gain of >25 lbs some studies show increased risk
of
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Pre-eclampsia
Impaired glucose tolerance
C-section
Postpartum hemmorrhage
Pre-existing obesity is an independent risk factor for
complications
Excess postpartum weight retention and associated health risks
Increased risk of overweight children – conflicting evidence
-Olson et. al., Nohr et. al., Abrams et. al., Arendas, Cedergren 2006
GWG and Gestational Diabetes
Few studies to date
 GWG above IOM recs
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higher frequency of c-section
 Higher odds of needing medical therapy
(insulin)
 Higher odds of preterm delivery
 Higher odds of LGA infant
 More antenatal admissions
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-Cheng et. al.
GWG and GDM
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GWG below IOM recs:
More likely to maintain diet control
 Less likely to have LGA infants
 Lower incidence of NICU admissions
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-Cheng, et al
Determinants of excess
gestational weight gain
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BMI >26
Energy balance
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Higher energy intake late in pregnancy
More snacking
Less physical activity
Different foods:
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Increased dairy and sweets
< 3 fruits and vegetables a day
Glycemic index
High fat
Wells et al 2006, Olson et al 2003, Olafsdoltir et al 2006,
Clapp 2002
Social predictors of excess
gestational weight gain
Socioeconomic status
 Decreased physical activity
 Provider advise – advised/targeted
weight gain correlated with actual
weight gain
 No advise associated with weight gain
outside of the guidelines
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-Stotland et al 2006, Olson et al 2003
Nutrition Intervention Data
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Conflicting results with community
intervention
Nine month intervention Grey-Donald et al:
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social learning theory included modeling of the
behavior change, skill training, contracting, and
self-monitoring
the investigators carried out in the community
include radio broadcasts, information pamphlets,
supermarket tours and cooking demonstrations,
exercise walking groups, and individualized
nutrition counseling
No statistical difference in GWG
Nutrition Intervention Data
Olson et al followed women from early
pregnancy to one year postpartum
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Monitoring weight gain with grids
 Patients received: five action promoting
newsletters; postcards about GWG, diet
and physical activity; health checkbook for
goal setting and monitoring
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Statistically significant reduction in
GWG only among low-income women
Systematic healthcare
intervention
Policies and procedures for recording,
tracking and discussing GWG vary
greatly
 Efforts can be inconsistent
 There is little data
 Correlation between patients being
given guidelines and following them
suggests the need for a systematic
approach
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Nutrition Intervention:
Challenges
Talking about weight with patients
 Changing what a pregnant woman eats
 Patient buy-in
 RD contact with pregnant women
 Consistency in routine prenatal care
 Lack of time for education during
appointments
 No show rates for non-MD providers
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Nutrition Intervention:
Possibilities
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Discussion of weight gain guidelines
Set a weight gain goal with patients
Track weight gain with patients
Follow-up at every appointment
Target specific behaviors and habits
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Drinks
Portion control
Meal patterns
Types of food: glycemic index, veggies, fat
Set goals for change
Nutrition Intervention: Drinks
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Ask what they drink
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Sweet tea, regular soda, juice, whole milk
Educate
150 kcals per 8 oz = 600 kcals in a dollar
menu sweet tea
 Calculate calories consumed per day from
drinks with patient
 Alternatives: brainstorm! set goal for
trying another sugar free, calorie free
choice
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Nutrition Intervention: Portions
Hunger scale 1-5
 Order “small” when eating out
 Eat on a smaller plate
 Eat half and assess true hunger
 Plate method
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¼ of plate is starch
 ¼ of plate is protein
 ½ of plate is non-starchy veggies
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Nutrition Intervention:
Meal Patterns
Does the patient eat breakfast?
 Are they food secure?
 Do they eat one huge meal at the end
of the day?
 Ask questions
 Help plan when, what and how to eat
 Refer to WIC, if appropriate, to see RD
and get food benefit
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Nutrition Intervention:
Types of food
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Patient education on:
Glycemic index
 3 or more veggies per day
 Sweets and other options that may satisfy
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Set goals, write them down, follow up
Nutrition Intervention: How?
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Every obese, pregnant person sees an RD!
Calculate pre-pregnant BMI with patients,
discuss implications and refer as appropriate
Group classes on the same day and as part
of patient appointments
Get everyone to WIC who is qualified
Know patient pay scale range – pay range
one at UVA = $3 for 75 min. visit with an RD
Talk about it at every visit
QUESTIONS???
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