Weight gain recommendations and consequences of noncompliance

In 1990, the IOM issued recommendations for weight gain during pregnancy based on prepregnancy weight status [3]. The goal of these recommendations was to optimize neonatal birth weight to between 3 and 4 kg and prevent the morbidity and mortality associated with low birth weight (LBW). According to these recommendations, an underweight woman (based on WHO BMI criteria above) should gain 28-40 lb (12.5-18 kg), a normal weight woman should gain 25-35 lb (11.5-16 kg), an overweight woman should gain 15-25 lb (7-11.5 kg), and an obese woman should gain less than or equal to 15 lb (7 kg). Recently, these recommendations have been criticized for being too liberal and not making allowances for women who gain excessive amounts of weight during pregnancy.

Evidence is mounting that significant numbers of women, particularly overweight and obese women, are not adhering to IOM guidelines. In an investigation of over 120,000 women enrolled in Women, Infants, and Children (WIC) clinics over a 6-year period, Schieve et al. [55] found that the percentage of women reporting a pregnancy weight gain greater than the IOM recommendations increased significantly from 41.5 to 43.7%. In 2005, Jain et al. [56] examined data from the New Jersey Pregnancy Risk Assessment Monitoring System (n = 7,661) and found that nearly 64% of overweight women and 78% of obese women were noncompliant with IOM recommendations (e.g., overgained).

This lack of adherence to weight gain recommendations during pregnancy should be cause for concern. Excessive gestational weight gain has been shown to be a risk factor for maternal and neonatal complications, independent of prepregnancy BMI. For example, among the 7661 pregnant women in New Jersey examined by Jain et al. [56], women who gained greater than 35 lb during pregnancy increased their risk of macrosomia and delivery by cesarean section by 60-180% and had lower rates of breastfeeding by 30%. In another study, Hilson et al. [57] showed that mothers who exceeded IOM weight gain recommendations failed to initiate and/or sustain breastfeeding in all categories of prepregnancy BMI.

Excessive gestational weight gain may lead to child adiposity. In a recent prospective study of over 1,000 mother-child pairs, mothers with greater gestational weight gain had children with greater BMI and skin fold thicknesses (triceps and subscapular) at 3 years of age [58]. This association was independent of parental BMI, maternal glucose intolerance, breastfeeding duration, gestational age at delivery, and birth weight. Children of mothers who gained more weight also had higher systolic blood pressure, a cardiovascular risk factor that has been shown to track into adulthood.

Poor adherence to weight gain recommendations may also have serious ramifications for a woman's health in midlife. Weight gain during pregnancy, weight loss at 6 months postpartum, and prepregnancy BMI all predicted BMI 15 years later [59]. Data from the National Maternal and Infant Health Survey showed that among the women who gained more than the recommended weight during pregnancy, greater than 30% retained an average of 2.5 kg at 10-18 months postpartum as opposed to retention of 1 kg among women who gained at the recommended level [60]. In a longer-term study, Rooney et al. [61] followed 540 women for ~8 years after childbirth and found that women who gained more than the IOM recommended weight during pregnancy retained 2 kg above their prepregnancy weight more at 8 years postpartum compared with those who complied with weight guidelines. These researchers also showed that at the mean age of 42 years, obese women weighed 34 lb more than when they became pregnant. Given that obesity is a risk factor for chronic diseases, these findings suggest that interventions are needed to improve adherence to IOM recommendations and to help women achieve a healthful weight postpartum.

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