Newsletters

Pregnancy and Weight; Too Little, Too Much, and Just Right
by Sharon K. Eskam, M.D., F.A.C.O.G

Pregnancy is a complicated and emotional time for most women.  Even the most excited and invested women may feel a twinge of panic about how the approaching bundle of joy is going to change their bodies, their lives and their relationships

Weight issues are rampant in our society, and pregnant women are not immune to the pressure to be thin. Some may decide that any weight gain is too much, and may take measures to avoid the recommended weight gain for fear of how their partners may respond, or of how the pregnancy may change their bodies.  On the other hand, Some may decide that since they are “eating for two” (even if one is the size of a potato), they may throw caution to the wind and indulge in extreme eating and satisfying cravings.  This may result in large babies, gestational diabetes and unwanted weight for later. In turn, a small proportion may indulge in risky or addictive behaviors that were patterns before the pregnancy, and that may result in fetal growth restriction, fetal harm or other problems in the pregnancy.

Weight at birth reflects the intrauterine experience: it is a good indicator not only of a mother's health and, nutritional status, but also reflects the newborn's chances for survival, growth, long-term health and psychosocial development. While the more common of the two problems is too much weight gain, the more serious is too little weight gain.

Complications of Too Little
Too little weight gain and low birth weight (LBW)—also termed small for gestational age (SGA) or intrauterine growth restriction (IUGR)—can be serious problems which affect not only fetal growth but long term outcomes including brain growth and development.  Jeffrey R. Kaiser, M.D., M.A., and a group of scientists at the University of Arkansas for Medical Sciences (UAMS) are studying how to determine whether very low birth weight infants are in danger of brain injuries in the first days of life. This group has found that some very low birth weight babies have difficulty maintaining a constant flow of blood to the brain, which can lead to brain damage that causes long-term learning and behavioral problems or cerebral palsy. This problem is called impaired cerebral auto-regulation.

“Despite significant improvements in survival for very low-birth weight babies, they are still at high risk of long-term health problems because of impaired cerebral auto- regulation," claims Dr. Kaiser.

Other problems SGA or IUGR babies commonly have include decreased oxygen levels; low Apgar scores; meconium aspiration which can lead to difficulty breathing; hypoglycemia; difficulty maintaining normal body temperature; and polycythemia.

While there are several uncontrollable fetal causes of SGA (ranging from multiple gestation to prematurity and infection to birth defects) the mother’s own health can produce an SGA infant. However, we, as providers can have an impact on controllable maternal causes for SGA, including:

• High blood pressure
• Chronic kidney disease
• Advanced diabetes
• Heart or respiratory disease
• Malnutrition, anemia
• Substance use
• Cigarette smoking

Special Considerations for Patients with an Eating Disorder
Anorexia nervosa and bulimia nervosa are rarely diagnosed during pregnancy—as women who have these conditions are usually unable to ovulate—but many cases come to light later, usually after seeking treatment for their eating disorders at specialist clinics. The evidence which is available suggests that serious eating disorders are rarely precipitated during pregnancy; in fact, bulimic symptoms frequently improve temporarily, but the course of anorexia is less vulnerable to change.

There is a clear need for accurate prevalence rates of eating disorders in pregnancy to be derived in order that this issue can be addressed and so that obstetricians can be advised of the clinical risks and the possible benefits of psychiatric intervention.

Complications of Too Much Weight Gain
Too much weight can also lead to complications, such as Large for Gestational Age (LGA), gestational diabetes, shoulder dystocia, and an increased rate in cesarean and operative deliveries.  LGA babies have birth weights greater than the 90th percentile for their gestational age; 4500 grams for babies born to diabetic mothers and 5000 grams. for those born to non-diabetic moms.  There is growing evidence that obese babies are more likely to grow into obese children and adults and are at greater risk for health problems such as diabetes.

One area of good news is that breast feeding seems to discourage obesity and diabetes in later life.

Encouraging pregnant moms not to exceed recommended weight gain is a sensitive area. I encourage providers to tell their patients that it is not necessary to "eat for two" during pregnancy. It's true that pregnant women need extra calories from nutrient-rich foods to nourish the fetus, but the general need is to consume only an additional healthy 100 to 300 calories per day than the patient did before becoming pregnant.

For the pregnant mom concerned about excess weight gain, provider should suggest their patients:

• Add fiber whenever possible; it helps regulate blood sugar and helps prevents constipation.
• Avoid processed and glycemic foods. 
• Trade white flour for fiber-rich whole grains.
• Choose 2% or skim milk.
• Eat whole fruits instead of just pure juice.
• Add a salad to lunch and supper.
• Eat small frequent meals.
• Know that exercise is safe and healthy in pregnancy, but patients should keep their heart rates below 140 beats per minute and avoid overheating.
• Eat fish one to two times weekly.  Farm raised fish are safe; avoid the larger salt water fish (shark, swordfish) species.
• Consume lean protein as an important part of a pregnancy diet.
• Drink plenty of water.

Promoting the Best Outcomes: Promising Strategies for Providers
Early and regular prenatal care can help identify those pregnancies at risk (both too little and too much weight gain), and begin regimens to diminish the effects of maternal disease. For all pregnant patients, providers should follow a simple five-step process to promote appropriate weight gain:

• ASK: What are her weight gain goals/concerns?
• ASSESS: BMI determination and plotting on grid
• ADVISE: Provide strong, clear, personalized weight-gain information based on BMI category
• ASSIST:  Problem solve and educate on components of weight gain
• ARRANGE: Refer as appropriate

It is also important to encourage the patient’s partner and family to be sensitive to a healthy weight gain in pregnancy and to be supportive of the patient. Recognize that patients who are at high-risk for medical problems associated with inappropriate weight gain are at high-risk for making poor life choice issues as well. Begin early counseling and education and refer patients to local resources early if poor weight gain is noted.

The Wyoming Department of Health has developed several resources for providers to help promote healthy babies.

• Implement Healthy Babies are Worth the Weight (HMWW) in your practice or clinic. HBWW is a social marketing campaign which provides materials and guidance in an effort to reduce the risk of inadequate weight gain during pregnancy. HBWW offers tools for healthcare providers, including patient education posters and brochures (in English and Spanish), a gestation wheel with BMI calculator, and prescription pads with individual weight gain recommendations.
• Refer at-risk patients to community based programs such as the Women, Infants and Children (WIC) program and Best Beginnings. These programs help moms realize the importance of good nutrition during pregnancy and provide access to nourishing foods.
• Refer Wyoming EqualityCare (Medicaid) clients to Healthy Together!...Healthy Additions program where they can also receive 24 hour/7 days a week support from a nurse, as well as education material and help coordinating medical and non-medical needs.
• Finally, along with nutrition, patients also need to understand the role of substance abuse in pregnancy. Providers should address substance abuse with all patients educating them about the teratogenic nature of nicotine, methamphetamines, and alcohol.

In closing, the good news is that inadequate maternal weight gain—as well as maternal high risk behaviors—are modifiable with education and encouragement.  Providers, public health nurses, health coaches and even family members have a responsibility to help pregnant women realize that the choices they make directly affect their children for the rest of their lives. I like to say, “Pregnancy for the mom is nine months; what happens during pregnancy is for the rest of the baby’s life.”