CityMatCH / NACCHO Emerging Issues in Maternal and Child Health Conference Call Impact of Healthy Weight in Mothers on Birth Outcomes August 19, 2004 Siobhan M. Dolan, MD, MPH Assistant Medical Director March of Dimes Birth Defects Foundation, White Plains, NY Assistant Professor of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine, Bronx, NY

Obesity Trends Among U.S. Adults BRFSS, No Data 25%

% Obese *Based on self-reported weight and height Mokdad et al., JAMA 282:1519, 1999; JAMA 289, 76, 2003 Obesity* among US Adults, 1991 and 2001

Prevalence of Obesity and Overweight Among US Women, age 20-39, Data from the National Health and Nutrition Examination Survey (based on actual measurement of height and weight) Hedley et al., JAMA 291: 2847, 2004 Overweight 25.4% Obese 29.1% Under/ Average Weight 45.5%

Preterm Births United States, Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2004 Percent Healthy People Objective March of Dimes Objective 27 Percent Increase

Risk Factors for Preterm Labor/Delivery The best predictor of having a preterm birth is multifetal gestation or history of preterm labor/delivery Other risk factors: –multifetal pregnancy –maternal age ( 35 years) –black race –low SES –unmarried –previous fetal or neonatal death –3+ spontaneous losses –uterine abnormalities –incompetent cervix –genetic predisposition –low pre-pregnant weight –obesity –infections –bleeding –anemia –major stress –lack of social supports –tobacco use –illicit drug use –alcohol abuse –folic acid deficiency

Preterm Births (<37 weeks) by Maternal Race/Ethnicity, US, 2001 Percent Preterm is less than 37 weeks gestation Hispanics can be of any race Source: National Center for Health Statistics, 2000 final natality data Prepared by March of Dimes Perinatal Data Center, 2002

Prevalence of Overweight and Obesity Among US Women Aged Years, , By Racial/Ethnic Group Hedley et al., JAMA 291: 2847, 2004

What is the Impact of Healthy Weight in Mothers on Birth Outcomes? What is the impact of obesity and overweight on birth outcomes? What is the impact of underweight on birth outcomes?

Body Mass Index (BMI) is an indicator that measures weight for height. Body Mass Index (BMI) The American Formula for Calculating BMI BMI = ( ) X 703 Weight in Pounds (Height in inches) x (Height in inches) Source: National Center for Chronic Disease Prevention and Health Promotion, CDC

Body Mass Index (BMI) The BMI calculator is available online at: Example: A woman who weighs 140 lbs and is 5 ft 6 in tall has a BMI of Normal A women who weighs 140 lbs and is 5 ft 2 in tall has a BMI of Overweight For adults over 20 years old

Body Mass Index (BMI) weight in pounds BMI

Adverse Outcomes Associated with Maternal Obesity Infertility Maternal complications Fetal, neonatal death Labor and delivery complications Birth weight/prematurity Psychomotor development Congenital malformations

Adjusted* Odds Ratios for Pregnancy Complications by Maternal BMI Baeten et al., Am J Public Health 91;436, 2001 *Adjusted for maternal age, smoking, education, marital status, trimester prenatal care began, payer, and weight gain during pregnancy; BMI<20.0 (lean) reference group

Maternal Morbid Obesity and Risk of Adverse Pregnancy Outcome Prospective population-based cohort study in Sweden Maternal height and weight recorded in early pregnancy on 805,275 women Perinatal outcome of singletons born to women without insulin-dependent diabetes mellitus evaluated Cedergren, Obstet Gyn 103:219, 2004

Large numbers of obese women –69,143 with mild obesity (BMI ) –12,698 with moderate obesity (BMI ) –3,480 with morbid obesity (BMI> 40) Normal weight category (BMI ) used as referent Maternal age, parity, smoking, year of birth, and maternal education included as covariates Cedergren, Obstet Gyn 103:219, 2004 Maternal Morbid Obesity and Risk of Adverse Pregnancy Outcome

Antenatal Complications by Degree of Maternal Obesity Cedergren, Obstet Gyn 103:219, 2004

Labor and Delivery Complications by Degree of Maternal Obesity Cedergren, Obstet Gyn 103:219, 2004

Neonatal Outcomes by Degree of Maternal Obesity Cedergren, Obstet Gyn 103:219, 2004

Odds for SGA or LGA Infant by Degree of Maternal Obesity Cedergren, Obstet Gyn 103:219, 2004

Odds for Pre-/Post-term Infant by Degree of Maternal Obesity Cedergren, Obstet Gyn 103:219, 2004

Fetal and Neonatal Death by Maternal BMI Cnattingius et al., N Engl J Med 338:147, 1998 Reference group – Lean (BMI < 20)

Mean Psychomotor Scores by BMI Neggers et al., Acta Obstet Gynecol Scand 82:235, 2003 * * ** *p=0.006, **p=0.004 Adjusted for birth weight, gestational age, age, home environment, preschool status, mother’s receptive language ability, age, smoking and alcohol intake, and zinc supplementation

Risk for Birth Defects

Studies of Maternal Obesity and NTDs

Birth Defects Associated with Maternal Obesity Neural tube defects Heart defects Ventral wall defects Multiple congenital anomalies Cleft lip +/- palate?

Possible Dose-Response Relationship between Maternal BMI and Risk for Birth Defects Watkins et al., Pediatrics 111:1152, 2003 Odds Ratio per Incremental Unit Increase in BMI for Women of Average Weight or Heavier was 1.08 (95% CI: , p=0.0001)

Possible Mechanisms Increased nutrient requirement (e.g., folate) among obese women Metabolic abnormalities associated with obesity Hyperglycemia Elevated insulin levels Elevated estrogen levels Elevated lipid levels Undiagnosed diabetes Nutritional deficits in obese women (e.g., related to dieting behaviors)

What is the Impact of Healthy Weight in Mothers on Birth Outcomes? What is the impact of obesity and overweight on birth outcomes? What is the impact of underweight on birth outcomes?

Low Maternal BMI and Poor Weight Gain During Pregnancy Increased risk for: –Preterm delivery –Low birthweight »Carmichael and Abrams 89:865-73, 1997 »Schieve et al. Ob & Gyn 96: , 2000 »Sebire et al. BJOG 108:61-66, 2001 »Ehrenberg et al. AJOG 189: , 2003

Consider Multiple Confounders Smoking Drug Use Alcohol Use Nutritional deficiency Parity Short interpregnancy interval

Risk Factors for Preterm Labor/Delivery The best predictor of having a preterm birth is multifetal gestation or history of preterm labor/delivery Other risk factors: –multifetal pregnancy –maternal age ( 35 years) –black race –low SES –unmarried –previous fetal or neonatal death –3+ spontaneous losses –uterine abnormalities –incompetent cervix –genetic predisposition –low pre-pregnant weight –obesity –infections –bleeding –anemia –major stress –lack of social supports –tobacco use –illicit drug use –alcohol abuse –folic acid deficiency

Recommendations WEIGHT MATTERS !!! For your health and the health of your children

Weight Matters During Preconception Care Counsel women about increased risks Encourage assessment of BMI (CDC website) and weight loss when needed: –Balanced diet, Folic acid –Exercise Screening for hypertension and diabetes mellitus recommended

Weight Matters During Prenatal Care Counsel women about increased risks Discuss recommended weight gain during pregnancy Discuss healthy exercise and nutrition options during pregnancy Discourage dieting during pregnancy Screen for hypertension and diabetes as recommended

Institute of Medicine 1990 Recommendations for Weight Gain in Pregnancy

This is not recommended!

Exercise During Pregnancy: ACOG Guidelines In the absence of either medical or obstetric complications, >= 30 minutes of moderate exercise on most, if not all, days of the week is recommended Exercise may be beneficial in primary prevention of gestational diabetes Exercise may be “a helpful adjunctive therapy” for gestational diabetes mellitus when euglycemia is not achieved by diet alone ACOG Committee Opinion No. 267, Obstet Gynecol 99:171, 2002

Other Recommendations Ensure adequate intake of micronutrients (particularly iron and folic acid) – unknown if higher dose of folic acid helpful Abstain from smoking and alcohol use Get adequate exercise Encourage breastfeeding

Special Thanks Sonja A Rasmussen, MD, MS National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta