Siobhan M. Dolan, MD, MPH Assistant Medical Director

1. CityMatCH / NACCHO Emerging Issues in Maternal and Child Health Conference CallImpact of Healthy Weight in Mothers on Birth OutcomesAugust 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

3. 1991 1995 Obesity Trends Among U.S. AdultsBRFSS, 1991-2002 2002 No Data <10% 10%–14 15%–19% 20%–24% > 25%

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

5. Prevalence of Obesity and Overweight Among US Women, age 20-39, 1999-2002 Obese 29.1% Under/ Average Weight 45.5% Overweight 25.4% Overweight 25.4% Data from the National Health and Nutrition Examination Survey (based on actual measurement of height and weight) Hedley et al., JAMA 291: 2847, 2004

6. Preterm BirthsUnited States, 1982-2002 Percent March of Dimes Objective Healthy People Objective 27 Percent Increase 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

7. 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 (<17 and >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

8. 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

9. Prevalence of Overweight and Obesity Among US Women Aged 20-39 Years, 1999-2002, By Racial/Ethnic Group Hedley et al., JAMA 291: 2847, 2004

11. 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?

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

13. Body Mass Index (BMI) For adults over 20 years old 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

14. Body Mass Index (BMI) BMI weight in pounds

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

16. Adjusted* Odds Ratios for Pregnancy Complications by Maternal BMI *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

17. 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

18. 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

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

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

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

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

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

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

25. Mean Psychomotor Scores by BMI ** ** * * *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

26. Risk for Birth Defects

27. Studies of Maternal Obesity and NTDs

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

29. 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

30. 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)

31. 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?

32. 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

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

34. 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 (<17 and >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

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

36. 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

37. 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

38. Institute of Medicine 1990Recommendations for Weight Gain in Pregnancy

39. This is not recommended!

40. 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

41. 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

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