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Pregnancy weight gain: still controversial^1,2,3,4

¹ From the Division of Public Health Biology and Epidemiology, University of California, Berkeley; the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco; and the Department of Health Studies, University of Chicago.

² Presented at the symposium Maternal Nutrition: New Developments and Implications, held in Paris, June 11–12, 1998.

³ Supported by the US Department of Defense Women's Health Research Program (DAMD 17-96-2-6014) and the US Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau (MCJ-069180-05).

⁴ Reprint not available. Address correspondence to B Abrams, 140 Warren Hall, Division of Public Health Biology and Epidemiology, School of Public Health, University of California, Berkeley, CA 94720. E-mail: barbara{at}socrates.berkeley.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

 
During the 20th century, recommendations for maternal weight gain in pregnancy were controversial, ranging from rigid restriction to encouragement of ample gain. In 1990, the Institute of Medicine (IOM) recommended weight-gain ranges with the primary goal of improving infant birth weight. These guidelines were widely adopted but not universally accepted. Critics have argued that the IOM's recommendations are unlikely to improve perinatal outcomes and may actually increase the risk of negative consequences to both infants and mothers. We systematically reviewed studies that examined fetal and maternal outcomes according to the IOM's weight-gain recommendations in women with a normal prepregnancy weight. These studies showed that pregnancy weight gain within the IOM's recommended ranges is associated with the best outcome for both mothers and infants. However, weight gain in most pregnant women is not within the IOM's ranges. All of the studies reviewed were observational and there is a compelling need to conduct experimental studies to examine interventional strategies to improve maternal weight gain with the objective of optimizing health outcomes.

Key Words: Weight gain • pregnancy • birth weight • postpartum weight • preterm delivery • maternal health • Institute of Medicine

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

 
During the past 50 y, recommendations for pregnancy weight gain have been highly controversial in the United States. During the first half of the century, American obstetricians restricted weight gain during pregnancy to prevent toxemia, difficult births, and maternal obesity. Williams' Obstetrics (1), a prestigious American textbook, stated in 1966 that "Excessive weight gain in pregnancy is highly undesirable for several reasons; it is essential to curtail the increment in gain to 25 lb (12.5 kg) at most or preferably 15 lb (6.8 kg). The experienced obstetrician is convinced of the complications, both major and minor, caused by excessive weight gain in pregnancy. Although restriction of the gain in weight to 20 lb (9.1 kg) may be difficult in many cases, requiring careful dietary control and discipline, it is a highly desirable objective."

This policy of severe weight restriction was challenged in the 1960s, when experts began to recognize that the relatively high rates of infant mortality, disability, and mental retardation seen in the United States were a function of low birth weight. In 1970, a review of the scientific evidence by the National Academy of Sciences concluded that the usual practice of restricting maternal weight gain was associated with increased risk of low birth weight. The National Academy of Sciences Committee on Maternal Nutrition concluded that a weight-reduction program that distorts normal prenatal gain should not be followed during pregnancy and increased the formal recommendation for pregnancy weight gain to 9–11.4 kg (2).

A few years after the policy of weight-gain restriction was lifted, average prenatal weight gain in US women increased from 9 to 12 kg; in some settings, averages were as high as 14 kg. The results of studies conducted from 1942 to 1983 of mean pregnancy weight gain and mean birth weight in full-term infants are shown in Figure 1 (3, 4). These crude data clearly show that after weight-gain recommendations were liberalized, there was an increase in the means of both pregnancy weight gain and infant birth weight.

View larger version (56K): [in this window] [in a new window]   FIGURE 1. Studies reporting pregnancy weight gain and birth weight by the range of years in which the data were collected. Adapted from reference 4.

This new national recommendation concerning pregnancy weight gain was widely adopted, but not universally accepted. In 1996, Johnson and Yancey (5) critiqued the IOM's recommendations, arguing that these recommendations were unlikely to improve perinatal outcomes and would increase negative consequences to both infant and mother (5). Feig and Naylor (6), who contend that evidence of benefit of the IOM's recommendations is weak and that wide dissemination of these recommendations could do more harm than good, recently echoed these concerns. They recommend a weight-gain range of 7–11.5 kg for women with a normal prepregnant BMI, which is roughly equivalent to recommendations from 30 y ago.

It is important to consider the underlying issues in this controversy. Those who question the IOM's weight-gain recommendations believe that the goal of the IOM's Committee on Maternal Nutritional Status during pregnancy and lactation to increase the upper limit of acceptable maternal weight gain to increase birth weight is misguided. Instead, they fear that weight gains within the IOM's recommended ranges will produce overgrown newborns at increased risk of being born by cesarean delivery and obese mothers (5, 6).

An additional concern relates to the routine monitoring of maternal weight gain as part of clinical practice. Despite the widespread measurement of maternal weight gain during pregnancy, almost no data have been published assessing the usefulness or negative consequences of weighing women. Two studies that retrospectively assessed the sensitivity and specificity of this indicator concluded that maternal weight gain alone is neither a sensitive nor a specific predictor of poor pregnancy outcome (7, 8). Because the amount of total weight gain is widely variable among women with good pregnancy outcomes (9, 10), and because the perinatal outcomes of interest are multifactorial in origin, no one should expect that weight gain alone is a perfect diagnostic or screening tool. Nonetheless, as will be discussed below, weight gains outside the IOM's recommended ranges are associated with twice as many poor pregnancy outcomes than are weight gains within the ranges. In addition, the results of numerous studies suggest that deviations in maternal weight gain can act as useful markers of biological and social factors that relate to poor pregnancy outcome.

In a study of the determinants of pregnancy weight gain in 3870 women, Caulfield et al (11) found that women with low weight gains are more likely to be young, short, thin, less educated, smokers, and black than are women with weight gains within the IOM's recommended ranges, and that women with excessive weight gains are more likely to be tall, heavy, primiparous, hypertensive, and white. Hickey et al (12), who studied 806 high-risk women in Alabama, reported an increased risk of low weight gain in white women who had poor scores on psychosocial scales measuring trait anxiety, depression, mastery, and self-esteem, although they found no such effect in black women. Other studies showed that physical abuse, poor financial support, alcohol consumption, smoking, poor diet, and poor compliance with prenatal care are associated with low or high weight gain in pregnancy (13–15). These findings suggest that monitoring weight gain in pregnancy might help clinicians to target nutritional, medical, and social services to women at high risk of poor pregnancy outcome. Unfortunately, we could identify no published experimental studies that examined whether it is possible to manipulate pregnancy weight gains and change pregnancy outcomes. Without the results of well-designed experimental trials, clinical protocols for managing weight gain in pregnancy cannot easily satisfy the criteria for evidence-based medicine. Whatever the arguments, the IOM's weight-gain recommendations have been widely adopted in the United States. However, published studies suggest that only 30–40% of American women actually have weight gains within the IOM's recommended ranges (11, 16, 17).

In this article, we focus on only one aspect of the controversy surrounding optimal maternal weight-gain ranges, namely the relation between the 1990 IOM guidelines and infant and maternal health outcomes. The data cited come from a systematic review of all studies published between 1990 and 1997 that specifically examined birth weight, preterm delivery, cesarean delivery, or postpartum weight retention relative to the IOM's recommended weight-gain ranges. Although there are many other groups who deserve consideration, we concentrated primarily on mature women who began pregnancy with a normal BMI and carried one fetus.

	PREGNANCY WEIGHT GAIN AND FETAL OUTCOMES

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

 
Preterm birth
Small infant size at birth is a function of both poor growth and shortened gestation, with most adverse outcomes occurring in the most immature infants. At the time the IOM report was published in 1990, there was some evidence that a low rate of pregnancy weight gain was associated with preterm birth (4). Since the report was published, much more evidence has emerged to support this finding.

A study of low-income women in Alabama used the lower limit of the IOM's recommended range to define low weight gain during the third trimester in nonobese women (18). After a variety of other risk factors were controlled for, women with a low rate of weight gain during the third trimester had a statistically significant higher risk of spontaneous preterm delivery than did women without a low weight gain in the third trimester (odds ratio: 2.46; 95% CI: 1.53, 3.92). When the data were stratified by race, the odds ratio was 1.98 (95% CI: 1.16, 3.41) for African American women and 4.05 (95% CI: 1.41, 11.66) for white women. A similar relation between a low rate of gain and preterm birth was reported in a primarily Hispanic cohort in Los Angeles (19).

A critical review of the relation between pregnancy weight gain and spontaneous preterm delivery concluded recently that 11 of the 13 methodologically sound studies published between 1980 and 1996 showed an association between a low rate of pregnancy weight gain and an increased risk of preterm birth (20). Although the biological mechanism underlying this association is unknown, it appears that a rate of pregnancy weight gain below the lower limit of the IOM's recommended ranges, especially in late pregnancy, may be related to a higher risk of preterm birth.

Fetal growth
Weight gain in pregnancy is also related to fetal growth. Too little gain is associated with reduced fetal growth, ie, low birth weight (<2500 g) or small-for-gestational-age infants (<10th percentile of weight for a given gestation). Excessive maternal weight gain is associated with large infants, ie, macrosomia (defined as >4000 or >4500 g) or large-for-gestational age infants (defined as >10th percentile of weight for a given gestation) who have a higher risk of birth injury and other problems. In Figure 2, the association between birth weight and pregnancy weight gain is illustrated according to self-reported total pregnancy weight gain in low-income women with a normal prepregnancy weight included in the US Centers for Disease Control and Prevention's Pregnancy Nutrition Surveillance System (21). The data in Figure 2 show a steady decrease in the incidence of low birth weight as mean pregnancy weight gain increases. In addition, these data provide evidence that the incidence of high birth weight, defined in this case as >4500 g, did not dramatically increase until pregnancy weight gains exceeded 16 kg, the upper limit of the IOM's recommended ranges. Overall, the best birth weight outcomes were found in women whose weight gains were within the IOM's ranges.

View larger version (15K): [in this window] [in a new window]   FIGURE 2. Incidence of low and high birth weight by pregnancy weight gain in 33809 normal-weight women, 1990–1991. Adapted from reference 21.

View larger version (17K): [in this window] [in a new window]   FIGURE 3. Relations between pregnancy weight gain (1 lb = 2.2 kg) and 3 pregnancy outcomes, unadjusted for other factors. Reprinted with permission from reference 22. P values represent differences in the proportion of low birth weight, macrosomia, and cesarean delivery between successive categories of maternal weight gain.

View larger version (19K): [in this window] [in a new window]   FIGURE 4. Incidence of small-for-gestational-age infants, large-for-gestational-age infants, and cesarean delivery for women from San Francisco with normal prepregnancy weights and pregnancy weight gains below (<12.4 kg), within (12.5–16 kg), and above (>16 kg) the weight-gain recommendations of the Institute of Medicine (IOM) in 6690 pregnancies. Adapted from reference 17.

	PREGNANCY WEIGHT GAIN AND MATERNAL OUTCOMES

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

 
Overall, the data on fetal outcomes and labor complications seem to suggest that optimal outcomes were found in mothers with weight gains within the IOM's recommended ranges. However, fetal outcome and route of delivery are not the only indicators of a healthy pregnancy. For generations, obstetricians have worried that pregnancy increases the risk of obesity in women. With increasing rates of obesity in the United States, postpartum weight retention is an important factor to consider when assessing maternal health and pregnancy outcome. Studies reviewed by the IOM's Committee on Maternal Nutrition in 1990 suggested an average weight retention of 1 kg per birth, although it should be remembered that the mean pregnancy weight gain in these studies was lower than is currently seen in the United States (4).

Postpartum weight retention
An analysis of the 1988 National Maternal and Infant Health Survey examined the association between pregnancy weight gain and weight 10–18 mo postpartum in women who gave birth to live singleton infants at term (>37 wk gestation) (26). The sample of women with a normal prepregnancy BMI was divided into 3 groups according to pregnancy weight gain below, within, and above the IOM's recommended ranges. As shown in Figure 5, white women who gained within or below the IOM's recommended ranges had similar weight-retention distributions, but women who gained >16 kg were much more likely to retain >6 kg postpartum. Black women show a greater increase in postpartum weight retention with increasing pregnancy weight gain and in all categories of weight gain are more likely to retain 6 kg than are white women. Among women with weight gains within the IOM's recommended ranges, the median retained weight was 1 kg for white women and 3 kg for black women. Although weight retention was more likely in women with weight gains above the IOM's recommended ranges, even in this group, 45% of white women and 25% of black women had either lost weight or retained <1.5 kg at 10–18 mo postpartum. These data suggest that weight retention is more of a problem for women who gain excessive amounts of weight. Furthermore, although black women are known to be at greater risk of inadequate pregnancy weight gain and low birth weight (4), in this study they tended to retain more postpartum weight.

View larger version (39K): [in this window] [in a new window]   FIGURE 5. Weight retention 10–18 mo postpartum compared with prepregnancy weights of black (n = 133000) and white (n = 859000) women with normal prepregnancy weights and pregnancy weight gains below (<12.4 kg), within (12.5–16 kg), and above (>16 kg) the weight-gain recommendations of the Institute of Medicine (IOM). Adapted from reference 26.

View larger version (23K): [in this window] [in a new window]   FIGURE 6. Percentage of US women with normal prepregnancy weights who retained >9 kg 10–24 mo postpartum relative to prepregnancy weight, by maternal race and pregnancy weight gain above or below the recommended upper cutoff of the weight-gain recommendations of the Institute of Medicine (IOM). Adapted from reference 27.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

For example, a study of trimester weight gain and birth weight was conducted in almost 3000 white San Franciscan women. Rate of weight gain was estimated for each trimester and birth weight was regressed on each of the trimester weight gains, along with several covariables (30). Each kilogram of pregnancy weight gain during the first, second, and third trimesters was associated with a statistically significant increase in birth weight of 18, 33, and 17 g, respectively. Thus, weight gain in the second trimester was more strongly associated with fetal growth than was weight gain in the first or third trimester. The importance of the weight-gain pattern for birth weight and preterm delivery was also shown in other populations (18, 19, 31, 32). These studies suggest that there may be crucial times in pregnancy when weight gain most influences birth weight and thus crucial times when weight restriction would be harmful.

The pattern of weight gain in pregnancy also has implications for postpartum weight change. A small Canadian study found that women with high postpartum weight retention were more likely to have gained excessively during the first 20 wk of pregnancy than were those who retained less weight, irrespective of their BMI (33).

We need to continue to ask critical questions about weight gain and pregnancy to ensure that we are providing the best guidance and care to pregnant women. We need to address the criticisms that have been leveled at the clinical use of weight-gain recommendations, and weight monitoring during pregnancy. Given the sensitivity of Western women to weight and body-image issues, we need to discover and validate experimentally effective and thoughtful interventions to support women's nutritional and other needs during pregnancy.

In conclusion, we identified no published scientific evidence to support the concept that weight gain within the IOM's recommended ranges is harmful for either mothers or their infants. The studies reviewed here, although observational, consistently indicate a greater risk of low birth weight and preterm birth with pregnancy weight gains below the IOM's recommended ranges and a greater risk of macrosomia, cesarean delivery, and postpartum weight retention with weight gains in excess of the IOM's ranges. Overall, the data support the conclusion that, for women who begin pregnancy with a normal BMI, pregnancy weight gain within the IOM's recommended ranges is associated with the best outcome for both mother and infant. We also found no evidence supporting the concept that routine weighing of pregnant women should be discontinued or that restricting weight gain in normal pregnancy is either safe or beneficial.

Given the data reviewed here, it is distressing to note that most US women seem to not gain weight within the target ranges recommended by the IOM. Until rigorous evidence is available to allow a scientifically based consensus that current recommendations and clinical practices surrounding weight gain in pregnancy should be changed, we should determine the best interventions to help pregnant women achieve the currently recommended weight gain, with the objective of ensuring the best possible outcome for their infants and themselves.

	REFERENCES

TOP ABSTRACT INTRODUCTION PREGNANCY WEIGHT GAIN AND... PREGNANCY WEIGHT GAIN AND... DISCUSSION REFERENCES

 

1. Eastman N, Hellman L. Williams' obstetrics. 13th ed. New York: Appleton-Century-Crofts, 1966:326.
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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Citation Map Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Abrams, B. Articles by Pickett, K. E Search for Related Content PubMed PubMed Citation Articles by Abrams, B. Articles by Pickett, K. E Agricola Articles by Abrams, B. Articles by Pickett, K. E