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					                         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

                    sdolan@marchofdimes.com
                          914-997-4788
Obesity Trends Among U.S. Adults
                  BRFSS, 1991-2002
           1991                           1995




                            2002




No Data   <10%     10%–14      15%–19%   20%–24%   > 25%
Obesity* among US Adults,
      1991 and 2001
          25
                                           20.9
          20
% Obese




          15            12
          10
            5
            0
                      1991                2001
*Based on self-reported weight and height
          Mokdad et al., JAMA 282:1519, 1999; JAMA 289, 76, 2003
   Prevalence of Obesity and Overweight
  Among US Women, age 20-39, 1999-2002

       Under/                               Obese
                                             Obese
Under/ Average
       Average                           (BMI >= 30)
                                             29.1%
Weight Weight
        45.5%                               22%
     (BMI < 25)
        56%

                                            Overweight
Data from the National Health                 Overweight
                                             (BMI 25-
 and Nutrition Examination                    Overweight
                                                25.4%
  Survey (based on actual                      29.9)
                                                 25.4%
 measurement of height and                     22%
           weight)

                                Hedley et al., JAMA 291: 2847, 2004
                                                        Preterm Births
                                                   United States, 1982-2002
                            Percent
                     14
                                                                     12.1
                     12                                  10.7
                                    9.5                                      10.1
                     10
                                                                                         7.6
                       8
                       6
                       4
                       2
                       0
                                  1982                   1992        2002    2007       2010
                                                                            March of    Healthy
                                       27 Percent Increase                  Dimes       People
                                                                            Objective   Objective
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
  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               –low pre-pregnant weight
     –maternal age (<17 and >35          –obesity
         years)                          –infections
     –black race                         –bleeding
     –low SES                            –anemia
     –unmarried                          –major stress
     –previous fetal or neonatal death   –lack of social supports
     –3+ spontaneous losses              –tobacco use
     –uterine abnormalities              –illicit drug use
     –incompetent cervix                 –alcohol abuse
     –genetic predisposition             –folic acid deficiency
                         Preterm Births (<37 weeks)
                       by Maternal Race/Ethnicity, US, 2001
           Percent
    18                                   17.5

                                                                13.2
                                                                                      11.4       11.9
    12            11.0                                                     10.3


      6




      0
                  White                  Black               Native       Asian or   Hispanic   All Races
                                                            American       Pacific
                                                                          Islander
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 20-39 Years, 1999-2002, By Racial/Ethnic Group
  Percent of Women

                     80
                     70
                     60                                 Non-Hispanic
                     50                                 White
                     40
                                                        Non-Hispanic
                     30
                                                        Black
                     20
                     10                                 Mexican-
                      0                                 American
                          Overweight     Obese
                           and Obese   (BMI>=30)
                          (BMI>=25)
                                             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)

   Body Mass Index (BMI) is an indicator that measures weight
   for height.


              The American Formula for Calculating BMI

                                             Weight in Pounds
              BMI = (            (Height in inches) x (Height in inches)           ) X 703



Source: National Center for Chronic Disease Prevention and Health Promotion, CDC
                    Body Mass Index (BMI)

                                                  For adults over 20 years old

                                                 BMI                Weight Status
                                                 Below 18.5         Underweight
                                                 18.5 – 24.9        Normal
                                                 25.0 – 29.9        Overweight
                                                 30.0 and Above Obese


Example:
A woman who weighs 140 lbs and is 5 ft 6 in tall has a BMI of 22.6 - Normal
A women who weighs 140 lbs and is 5 ft 2 in tall has a BMI of 25.6 - Overweight

The BMI calculator is available online at: www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm
         Body Mass Index (BMI)


                    BMI
Height
inches
          20         25           30    35
 60      102         128          153   179
 64      116         145          174   204
 68      131         164          197   230
 72      147         184          221   258
               weight in pounds
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
                               5
         Adjusted Odds Ratio


                               4
                                                                              Normal
                                                                              (BMI 20.0-24.9)
                               3
                                                                              Overweight
                                                                              (BMI 25.0-29.9)
                               2                                              Obese
                                                                              (BMI >= 30.0)

                               1

                               0
                                   Gestational   Preeclampsia    Eclampsia
                                    diabetes
*Adjusted for maternal age, smoking, education, marital status, trimester prenatal care began, payer,
               and weight gain during pregnancy; BMI<20.0 (lean) reference group

                                             Baeten et al., Am J Public Health 91;436, 2001
Maternal Morbid Obesity and Risk of Adverse Pregnancy
                      Outcome

• Prospective population-based cohort study in
  Sweden 1992-2001
• 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
Maternal Morbid Obesity and Risk of Adverse Pregnancy
                      Outcome

• Large numbers of obese women
   – 69,143 with mild obesity (BMI 29.1-35)
   – 12,698 with moderate obesity (BMI 35.1-40)
   – 3,480 with morbid obesity (BMI> 40)
• Normal weight category (BMI 19.8-26) used as referent
• Maternal age, parity, smoking, year of birth, and maternal
  education included as covariates



                             Cedergren, Obstet Gyn 103:219, 2004
                           Antenatal Complications
                       by Degree of Maternal Obesity
                      4.0
Adjusted Odds Ratio



                                                      Mild
                      3.0                             Moderate
                                                      Morbid
                      2.0


                      1.0


                      0.0
                            Preeclampsia   Abruptio      Placenta      Stillbirth > 28
                                           placenta       previa            weeks
                                                 Cedergren, Obstet Gyn 103:219, 2004
                        Labor and Delivery Complications
                         by Degree of Maternal Obesity
                      4.0
                                                          Mild
Adjusted Odds Ratio



                                                          Moderate
                      3.0
                                                          Morbid


                      2.0


                      1.0


                      0.0
                            Cesarean   Shoulder     Postpartum           Labor
                            Delivery   dystocia     hemorrhage         Induction
                                            Cedergren, Obstet Gyn 103:219, 2004
                                 Neonatal Outcomes
                            by Degree of Maternal Obesity
                      4.0
                                              Mild
Adjusted Odds Ratio



                                              Moderate
                      3.0
                                              Morbid

                      2.0


                      1.0


                      0.0
                             Meconium     Fetal distress    Low Apgar           Early
                             aspiration                       score           neonatal
                                                                               death
                                                   Cedergren, Obstet Gyn 103:219, 2004
                             Odds for SGA or LGA Infant
                            by Degree of Maternal Obesity
                      4.0
                                  Mild
Adjusted Odds Ratio



                                  Moderate
                      3.0
                                  Morbid

                      2.0


                      1.0


                      0.0
                                   SGA                         LGA
                                          Cedergren, Obstet Gyn 103:219, 2004
                            Odds for Pre-/Post-term Infant
                            by Degree of Maternal Obesity
                      4.0
                                   Mild
Adjusted Odds Ratio




                      3.0          Moderate
                                   Morbid

                      2.0


                      1.0


                      0.0
                                < 37 weeks                at 42 weeks
                                             Cedergren, Obstet Gyn 103:219, 2004
Fetal and Neonatal Death                     by Maternal BMI

             3
                          Late Fetal Death
Odds Ratio




                          Early Neonatal Death
             2


             1


             0
                 Normal         Overweight        Obese
                          Pre-pregnancy BMI
                  Reference group – Lean (BMI < 20)
                  Cnattingius et al., N Engl J Med 338:147, 1998
                   Mean Psychomotor Scores by BMI
                                  100
         Mean psychomotor score                                                        Underweight
                                                        **                             (BMI<19.8)

                                        *                       **                     Normal (BMI
                                               *                                       19.8-26.0)

                                  75                                                   Overweight
                                                                                       (BMI 26.1-
                                                                                       29.0)
                                                                                       Obese
                                                                                       (BMI>29.0)


                                  50
                                          General      Differential    Differential
                                        intellectual   ability non-   ability verbal
                                           ability        verbal
                                               *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
                                    Neggers et al., Acta Obstet Gynecol Scand 82:235, 2003
Risk for Birth Defects
Studies of Maternal Obesity
         and NTDs
             4.0


             3.0
Odds Ratio




             2.0                  1.9       1.9       2.0                   1.9
                        1.8                                                           1.8       1.7
                                                                1.4
             1.0


             0.0
                   Waller et Shaw et    Watkins Werler et   Kallen,   Shaw et     Shaw et Hendricks
                    al., '94 al., '96    et al., al., '96    '98       al., '00    al., '00 et al.,
                                          '96                                                '01
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


      Odds Ratio per Incremental
    Unit Increase in BMI for Women
   of Average Weight or Heavier was
  1.08 (95% CI: 1.03-1.10, p=0.0001)


                  Watkins et al., Pediatrics 111:1152, 2003
                  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 96:194-200, 2000
           » Sebire et al. BJOG 108:61-66, 2001
           » Ehrenberg et al. AJOG 189:1726-30, 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               –low pre-pregnant weight
     –maternal age (<17 and >35          –obesity
         years)                          –infections
     –black race                         –bleeding
     –low SES                            –anemia
     –unmarried                          –major stress
     –previous fetal or neonatal death   –lack of social supports
     –3+ spontaneous losses              –tobacco use
     –uterine abnormalities              –illicit drug use
     –incompetent cervix                 –alcohol abuse
     –genetic predisposition             –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

  BMI       Description       Weight Gain

 <19.8      Underweight          28-40 lb
                              (12.7-18.2 kg)
19.8-26.0     Normal             25-35 lb
                              (11.4-15.9 kg)
26.1-29.0    Overweight          15-25 lb
                              (6.8 lb 11.4 kg)
 >29.0         Obese              >15 lb
                                 (>6.8 kg)
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

				
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