Download Gestational weight gain

Euro Weight Loss-2015
Frankfurt, Germany
August 18 – 20, 2015
Greta Krešić
POSTPARTUM WEIGHT
RETENTION AS A RISK
FACTOR FOR DEVELOPMENT
OF MIDLIFE OBESITY
Greta Krešić,
Associate professor
University of Rijeka, Croatia
Content
• Pregnancy-related weight
• Postpartum weight retention (PPWR)–risk for later
development of obesity
• Predictors of postpartum weight retention
– Gestational weight gain (GWG)
– Parity
– Age
– Ethnicity
– Smoking
Influence of breast-feeding on PPWR –
– Lactation
prospective study in Croatia
Pregnancy-related weight
• Pregnancy - excess weight- retention of the gained weight
- strong risk factor for new or persistant obesity
• Excess weight
– risk factor for type 2 diabetes,
– dyslipidemia, and
– cardiovascular diseases
• Parous women - 3 to 4 times more likely to develop
obesity in the 5 years after childbirth compared to
nonparous women
Why do women gain weight in pregnancy?
• The weight gained in a normal pregnancy = biologic
processes that promote faetal growth.
• A general picture can be described:
– 27% resides in the fetus,
– 20% includes the placenta, amniotic fluid and uterus,
– 3% comprises breast weight,
– 23% is made up of blood volume and extravascular
fluid,
– 27% consists of maternal fat stores
Early to mid-pregnancy
Underweight and normal
Overweight or obese
weight women
women
– fat in hips, back, and
– No rise in peripheral
upper thighs,
insulin sensitivity
– important as a caloric
– Little or no additional
reserve for late pregnancy
fat is accrued
and lactation.
• Insulin secretion and
sensitivity rise
• Increased lipogenesis and
fat accumulation
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Late pregnancy
• Insulin resistance increases among all mothers
• Weight gain slows
• Normal physiologic adaptation-shifts maternal energy
metabolism from carbohydrate to lipid oxidation and thus
spares glucose for the faetus
Postpartum weight retention (PPWR)
• Weight change after delivery minus pre-pregnancy
weight
– weight gain during gestation (preconception
through gestation),
– early postpartum weight loss (delivery to 6 wk
postpartum)
– later postpartum weight change (after 6 wk
postpartum)
• Based on the time after delivery:
– Short term: <11 wk
– Intermediate: 3 mo to 3 y
– Long term: >3 y
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Postpartum weight retention (PPWR)
• Average estimates of postpartum weight retention:
0.5 to 3.0 kg/6–18 months postpartum
• 14–20% of women are 5 kg heavier at this period than
they were before becoming pregnant
• The excess weight gained in one pregnancy - cumulative
effect on weight gain in subsequent pregnancies =
amplifying the trajectory of weight gain and risk of
obesity in a woman’s lifetime
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Pregnancy-related factors that may predict
development of obesity
Melzer & Schutz (2014)
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1. Gestational weight gain
The strongest predictor of PPWR - high gestational
weight gain - increases postpartum weight retention
• Related to a two- to three-fold increase in the risk
of becoming overweight after delivery
• Weight increase during the first trimester – the
most important explanatory variable
–Women with gestational weight gain above the IOM
recommendations retain significantly more weight post
partum than do women with weight gain within or
below the recommendations, independent of prepregnancy BMI or body fat at baseline
•
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• Gestational weight gain greater than that recommended
tends to consist of fat
– Women with an average weight gain ~ 12 kg gain
~ 3 kg of adipose tissue.
– Women with excessive pregnancy weight gain
(>20 kg) ~ 11 kg of adipose tissue.
– Most of the adipose tissue is placed subcutaneously
– Excess gestational weight gain and failure to lose
weight in an appreciable time are indicators of
obesity in midlife up to 15 years after pregnancy
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Excessive gestational weight gain
and outcomes for mother and baby
• Maternal complication:
– Obesity risk
– Pre-eclampsia, caesarean section, instrumental
delivery, large-for gestational age births
• Neonatal complication:
– Low five-minute Apgar score, seizure,
hypoglycaemia, polycythaemia, meconium
aspiration syndrome
– Infant weight at birth
– Childhood obesity risk
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Gestational weight gain (GWG) and obesity risk
in mother
• Sigmoidal pattern- the majority of weight
gained in the 2nd and early 3rd trimesters of
pregnancy
• Lower gains - protective against
postpartum maternal weight retention and
obesity
• Women with higher gains remain heavier;
– women with average gains of 17.7 kg vs. 13.1 kg
had higher BMI and more central adiposity that
persisted 16 years after the index pregnancy
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Influence of GWG on infant weight at birth
• A higher rate of maternal weight gain in the second
trimester - higher infant weight at birth
– association is particularly strong among women with
a low or normal pregravid BMI.
• Among women who are overweight or obese,
gestational weight gain is a less strong predictor of
faetal growth
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Influence of GWG on childhood obesity
• Higher gestational weight-higher offspring
weight at birth, in childhood, during
adolescence, and as adults
• Maternal over-nutrition have a direct influence
on several aspects of offspring physiology,
including appetite, metabolism, activity levels,
increased faetal adipose tissue deposition
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In the context of current obesity epidemic,
how much weight gain in pregnancy is ideal?
• Pregnancy weight gain guidelines—In 2009, the
Institute of Medicines (IOM) updated earlier guidelines
on weight gain during pregnancy (1990)
• IOM used available data to determine the most
favorable amount of weight gain considering short and longer-term outcomes:
– extremes of birth weight (expressed as small-or large
-for gestational age),
– cesearean delivery,
– preterm birth,
– postpartum weight retention, and
– child obesity
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IOM recommended amounts of gestational
weight gain by weight class
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Trends in pregnancy weight gain
• ~ 30-40% of pregnannt women gain GW within IOM
recommendations
• ~ 20-40% of pregnannt women gain GW above IOM
recommendations
• Lower weight gain- lower fetal growth= later obesity,
cardiovascular disease and diabetes
IOM Report:
• „Survival phenotype
”. today are heavier; a greater
Women
percentage of them are entering
pregnancy overweight or obese, and
many are gaining too much weight
during pregnancy
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• Meta-analysis of long-term and short-term effects of GWG in
accordance with IOM recommendation on post-partum weight
retention
• Of 1770 search hits, 9 observational studies remained suitable for the
analysis.
• Follow up: <0.5; 0.5-1; 1-3 and >=15 years.
• Women with GWG above the recommendations retained additional
3.06 kg after 3 y and 4.72 kg after 15 y postpartum compared to
women with GWG within IOM recommendation
• Inadequate GWG was associated with less PPWR (-2.99 kg); <6 mo
after pregnancy.
• This association faded over time and became nonsignificant (-1.41 kg)
after 15 y.
• The obtained results have shown that PPWR increased after longer
time spans after delivery irrespective of whether GWG had been below
within, or above the guidelines.
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• Association between GWG and PPWR using a
bias-adjusted method
• The IOM categories of “inadequate,” “adequate,” and
“excess” were used to define GWG.
• The time span for PPWR was divided into three periods
(<1 year, 1 year to 9 years, and 15 years)
• 12 studies met the eligibility criteria
• Women with an inadequate GWG had a significantly
lower mean PPWR of -2.14 kg (95%CI, -2.61 to -1.66) than
women with an adequate GWG, who had a mean PPWR
of 3.15 kg (95%CI, 2.47 to 3.82) up to 21 years postpartum
21
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PPWR according to recommendations for weight gain
(Mannan et al., 2013)
GWG outside of the Institute of
Medicine recommendations can
lead to both short-term and
long-term postpartum weight
imbalance
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2. The influence of pre-pregnancy BMI on PPWR
• Women who are overweight or obese before
pregnancy - gain less weight - postpartum weight
increase is greater!
• Although underweight and normal weight women
gained more weight during pregnancy, they lost more
kg during the late postpartum period (2 ys).
• Gestational weight gain has a consistent relationship to
postpartum weight loss, whereas pre-pregnancy BMI
shows not to be associated with postpartum weight
loss.
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Other factors influencing PPWR
3. Parity
• Each successive birth, adds on an average, about 1kg
of postpartum body weight above that normally gained
with age
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Melzer & Schutz (2014)
Other factors influencing PPWR
4. Age
• Adolescent pregnancy - associated with subsequent
obesity.
• Adolescents who are obese before their first
pregnancy often become even more obese some
3 years after pregnancy.
• Other risk factors of becoming overweight:
– maternal age 24–30 versus>30 years;
– high gestational gain;
– short interval from menarche to first birth
(<8 years);
– young age at menarche (<12 years).
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Other factors influencing PPWR
5. Ethnicity
• Black women reported much more postpartum
weight increase than did White women.
• Higher energy intake, higher percentage fat in diet
and lower physical activity levels in Black postpartum
mothers, compared with White mothers, may
contribute to their greater weight retention.
27
Other factors influencing PPWR
6. Smoking
• Women who stop smoking have significantly higher
pregnancy weight gain
• Smokers who continue smoking during pregnancy
gain less weight during pregnancy than do
non-smokers.
• Apart from pregnancy weight gain, only smoking
cessation can be considered as a predictor for
persistent weight gain after 1 year postpartum
(The Stockholm Pregnancy and Weight Development Study)
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Other factors influencing PPWR
7. Lactation
• Some studies suggest that lactation has a role in
weight reduction after delivery, many others
report no such relationship
– These are thought to be due to differences in
study quality
• Better-quality studies on the impact of
breastfeeding on maternal postpartum weight loss
reported greater weight or fat loss in women
who breastfeed longer (particularly at 3–6
months postpartum).
29
• 37 prospective studies and 8 retrospective studies.
• The majority of studies reported little or no
association between BF and weight change (n=27,63%) or
change in body composition (n=16, 89%), although this
seemed to depend on the measurement time points and BF
intensity.
• 4 studies demonstrated a positive association between BF
and weight change.
• The authors have concluded that although the available
evidence challenges the widely held belief that BF promotes
weight loss, more robust studies are needed to reliably
assess the impact of BF on postpartum weight management.
30
Krešić, G. : Prospective study in Croatia:
C
Changes in dietary intake and body-weight in lactating and
non-lactating women during 6 months postpartum
Background
• Women in Croatia (Croatian Adult Health Survey)
– Overweight: 33.60%
– Obese: 20.60%
– Increased waist circumference: 51.13%
• Important life stage for women- concern about diet
and weight
• Part of a comprehensive study…
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The aims of the study were:
To investigate how weight retention during 6 months
postpartum was affected by:
1) type of feeding;
2) time since parturition;
3) gestational weight gain;
4) total energy intake;
5) energy intake derived from fat.
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Subjects
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Study design and data collection
• Lactating and non-lactating women :
– 3 home visits= 3 measurement waves
– 1m±1w, 3m±1w; 6m±1w postpartum
• Lactating = full breast feeding+mixed feeding
• Non-lactating=formula-feeding
• In each wave:
– Dietary evaluation (2x24 h-recalls)
– Body composition measurements
– Milk sampling
• Statistical analysis
– Group & time dimensions
– Multivariate longitudinal linear regression
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Conclusions of the study
• Breastfeeding per se must be sustained for six
months for a significant impact on weight loss
• After three months, non-lactating women
stopped losing weight, while lactating women
at six months after delivery retained
significantly less weight in comparison with
non-lactating women.
• Gestational weight gain and dietary intake
were also predictors of weight retention
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Meet the eminent gathering once again at
Euro Weight Loss-2016
Vienna, Austria
September 19-21, 2016
Euro Weight Loss – 2016
Website:http://weightloss.global-summit.com/eu
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