Expert Review ajog.

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1 56
2 Gestational weight gain 57
3 Q15 Q1 Michelle A. Kominiarek, MD, MS; Alan M. Peaceman, MD 58
4 59
5 60
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“H ow much weight should I gain
during this pregnancy?” is a
question many women ask prenatal care
Prenatal care providers are advised to evaluate maternal weight at each regularly
scheduled prenatal visit, monitor progress toward meeting weight gain goals, and
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providers today. The answer to this provide individualized counseling if significant deviations from a woman’s goals occur.
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important question has changed Today, nearly 50% of women exceed their weight gain goals with overweight and obese
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dramatically over the past century. In the women having the highest prevalence of excessive weight gain. Risks of inadequate
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1950s, one recommendation was for weight gain include low birthweight and failure to initiate breast-feeding whereas the
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women to limit weight gain to 10-14 lb risks of excessive weight gain include cesarean deliveries and postpartum weight
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so as to avoid complications such as retention for the mother and large-for-gestational-age infants, macrosomia, and child-
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“toxemia” at a time when 10% of women hood overweight or obesity for the offspring. Prenatal care providers have many
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with eclampsia died.1 In recognition of resources and tools to incorporate weight and other health behavior counseling into
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high neonatal and infant mortality rates routine prenatal practices. Because many women are motivated to improve health
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in the United States during the 1960s, the behaviors, pregnancy is often considered the optimal time to intervene for issues related
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Committee on Maternal Nutrition2 to eating habits and physical activity to prevent excessive weight gain. Gestational weight
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highlighted the positive association be- gain is a potentially modifiable risk factor for a number of adverse maternal and neonatal
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tween weight gain and birthweight and outcomes and meta-analyses of randomized controlled trials report that diet or exercise
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increased the weight gain goal to 20-25 lb interventions during pregnancy can help reduce excessive weight gain. However, health
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for all women. The 1990 “Nutrition behavior interventions for gestational weight gain have not significantly improved other
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during Pregnancy”3 document also maternal and neonatal outcomes and have limited effectiveness in overweight and obese
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supported increased weight gain so as to women.
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optimize birthweight, but also provided
26 Key words: gestational weight gain, health behavior interventions, motivational inter- 81
specific recommendations according to a
27 viewing, perinatal outcomes, pregnancy 82
woman’s prepregnancy weight and
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restricted weight gain in women with
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higher prepregnancy weights. Now,
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amidst an obesity epidemic, the focus is and health behavior management op- and last prenatal visit just prior to
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on meeting, not exceeding, weight gain tions to achieve optimal weight gain in delivery. Yet in practice, oftentimes
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goals so as to avoid complications such pregnancy. Regardless of a woman’s these measurements vary such that a
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as cesarean delivery and macrosomia.4 prepregnancy weight, the American self-reported prepregnancy weight is
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This article reviews weight gain goals, Congress of Obstetricians and Gyne- used to calculate total GWG. Addi-
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the risks of not meeting weight goals, cologists (ACOG) currently recom- tional challenges arise when prenatal
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mends that providers measure a care begins after the first trimester. In
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woman’s height and weight at the first these situations, one recommendation
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From the Department of Obstetrics and prenatal visit to calculate a body mass is to use the self-reported prepreg-
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Gynecology, Division of Maternal-Fetal index (BMI) and then counsel women nancy weight to calculate both total
40 Medicine, Northwestern University Feinberg 95
on gestational weight gain (GWG) goals GWG and GWG goals. Although
41 School of Medicine, Chicago, IL. 96
and the need to limit excessive GWG to women typically underestimate their
42 97
Received Feb. 27, 2017; revised May 4, 2017; achieve optimal pregnancy outcomes.5 weight by 5 lb, >80% of women
43 accepted May 16, 2017. 98
According to “Guidelines for Perinatal remained in the same BMI category in
44 This article was supported by grant number 99
Care,”6 health care providers should one study of self-reported weight in
45 K23HD076010 from the Eunice Kennedy 100
Shriver National Institute of Child Health and also evaluate maternal weight at each reproductive-age women.7 In another
46 101
Human Development (M.A.K.). The funding regularly scheduled visit, monitor study that evaluated GWG from a self-
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source had no involvement in the literature progress toward meeting GWG goals, reported prepregnancy and a measured
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review, writing the report, or decision to submit and provide specific individualized first-trimester weight value, the pro-
49 for publication. 104
counseling if significant deviations from portions of women gaining below, at,
50 The authors report no conflict of interest. 105
goals occur. and above the guidelines was the same
51 106
Corresponding author: Michelle A. Kominiarek, from either approach.8 Use of self-
52 MD, MS. mkominia@nm.org 107
How is GWG measured and reported weight introduces bias into
53 0002-9378/$36.00 108
assessed? GWG measurements, but it appears to
54 ª 2017 Elsevier Inc. All rights reserved. 109
http://dx.doi.org/10.1016/j.ajog.2017.05.040 Ideally, total GWG is calculated as the be a small difference and no other
55 110
difference between weight at the first practical solutions are available.

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111 167
112 that all women gain 1.1-4.4 lb (0.5-2 kg) 168
TABLE 1 in the first trimester.
113Q14 2009 Gestational weight gain guidelines (National Academy 169
114 of Medicine)4 What are the components of weight
170
115 171
Total weight Rate of weight gain in second gain?
116 Prepregnancy BMI gain at term and third trimester, mean (range) 172
117 Energy intake and energy expenditure 173
Underweight, <18.5 kg/m2 12.5e18 kg 0.51 (0.44e0.58) kg/wk typically determine energy balance. En-
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28e40 lb 1 (1e1.3) lb/wk ergy requirements increase in pregnancy
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120 Normal weight, 18.5e24.9 kg/m2 11.5e16 kg 0.42 (0.35e0.50) kg/wk by approximately 200, 300, and 400 kcal/ 176
121
25e35 lb 1 (0.8e1) lb/wk d in the first, second, and third tri- Q3 177
122 Overweight, 25.0e29.9 kg/m2 7e11.5 kg 0.28 (0.23e0.33) kg/wk mesters, respectively, but these values 178
123 15e25 lb 0.6 (0.5e0.7) lb/wk vary depending on BMI, as determined 179
124 Obese, 30.0 kg/m2 5e9 kg 0.22 (0.17e0.27) kg/wk by studies that evaluate basal metabolic 180
125 11e20 lb 0.5 (0.4e0.6) lb/wk rate by calorimetry, total energy 181
126 BMI, body mass index. expenditure by doubly labeled water, 182
127 Kominiarek. Gestational weight gain. Am J Obstet Gynecol 2017. and individual physical activity.12,13 183
128 Furthermore, a recent systematic re- 184
129 view of energy intake and GWG suggests 185
In terms of the final pregnancy weight discussion of healthy behaviors and that women report smaller daily in-
130 186
measurement, women can also be GWG and their relationships to preg- creases in caloric intake (475 kJ/d or 113
131 187
reweighed at the time of delivery, nancy outcomes. kcal/d) during pregnancy and propose
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especially if several weeks have passed that the current guidelines may be pro-
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134
since a weight measurement. In gen- What are the GWG guidelines? moting excessive GWG.14 In a typical 190
eral, all weight and height measure- The current GWG guidelines are based pregnancy characterized by 25 lb or 11
135 191
ments should be performed in light on the NAM 2009 document, “Weight kg total GWG and delivery at 40 weeks,
136 192
clothing without shoes. In epidemio- Gain during Pregnancy: Reexamining the products of conception (placenta,
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logical studies that examine the rela- the Guidelines”4 (Table 1). The primary fetus, amniotic fluid) comprise approx- ½T1 194
138
139
tionship between GWG and pregnancy differences between the initial NAM imately 35% of the total GWG.15 In 195
outcomes, typical measurements of 1990 guidelines and the current ones are: general, GWG is composed of water, Q4 196
140
GWG include the total value (eg, kg or (1) the use of World Health Organiza- protein, or fat in the fetus, placenta,
141 197
142
lb), an average rate in the second or tion categories instead of Metropolitan uterus, and amniotic fluid, maternal 198
third trimester (eg, kg/wk or lb/wk), Life Insurance Company ideal weight- blood volume, mammary gland, and
143 199
or an adequacy ratio (ratio of total for-height standards for BMI cate- maternal adipose tissue. The minimal
144 Q2 200
observed GWG to the National Acad- gories; (2) ranges of GWG rates for the amount of GWG required for fetal
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emy of Medicine [NAM] guidelines second and third trimesters; and (3) growth and deposits of maternal energy
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based on prepregnancy BMI and specific goals for women with a pre- for postpartum lactation is estimated at 8
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gestational age at delivery). pregnancy BMI 30 kg/m2. The goals kg. The first-trimester weight gain of
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The routine measurement of weight for women with obesity are now 11-20 lb 1.1-4.4 lb is attributed to early placental
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during pregnancy in the United States is instead of at least 15 lb. The GWG development and expansion of maternal
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in contrast to prenatal care practices in guidelines for twin gestations are blood volume, not fat deposits. Fetal
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other developed countries where na- considered provisional because the evi- growth is nearly uniform until the mid-
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tional guidelines do not recommend dence to support them was more limited portion of the second trimester regard-
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routine weighing during pregnancy.9-11 compared to singletons (Table 2). In less of age, race, and fetal sex, but then ½T2 210
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For example, the National Institute for addition, there are no specific guidelines other factors including GWG account
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Health and Care Excellence guidelines in for other subpopulations such as ado- for the final determinant of birthweight. 212
the United Kingdom do not recommend lescents, women of short stature, racial-
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repeated weighing during pregnancy as a ethnic minorities, and women with Epidemiology and trends in GWG in
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matter of routine, unless clinical man- higher classes of obesity. Of note, the the United States
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160
agement can be influenced or if nutrition guidelines are based on observational Deputy et al16 reported on GWG ade- 216
is a concern.9 Furthermore, there are no data of associations between GWG and quacy in a study using the Pregnancy
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national guidelines for GWG in the maternal and neonatal outcomes. For Risk Assessment Monitoring System for
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United Kingdom. Routine weighing is twin gestations, the guidelines reflect the women with full-term singleton de-
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not only considered an acceptable prac- 25-75th percentile interquartile range of liveries from 28 states. Prepregnancy
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tice in the United States, it is inexpensive, cumulative weight gain among women BMI was a self-reported value and total
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widely available, and perhaps the first who delivered twins weighing 2500 g at GWG was obtained from the birth cer-
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opportunity for providers to start the 37-42 weeks. The guidelines also assume tificate files. After weighting, the final Q5

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224 sample size represented approximately 280
30% of births in the United States from TABLE 2
225 2009 Gestational weight gain guidelines (National Academy of 281
2010 through 2011. In their analysis,
226
20.9% and 47.2% of all women had Medicine) for twin gestations4 282
227 283
inadequate or excessive GWG, respec- Prepregnancy BMI Total weight gain, lb Total weight gain, kg
228 284
229½F1 tively16 (Figure). Overweight and obese Underweight, <18.5 kg/m 2
Insufficient information Insufficient information 285
230 class I (BMI 30-34.9 kg/m2) women had 2
286
Normal weight, 18.5e24.9 kg/m 17e25 37e54
231 the highest prevalence of excessive GWG 287
(64.1% and 63.5%, respectively). Overweight, 25.0e29.9 kg/m2 14e23 31e50
232 288
Although underweight women were Obese, 30.0 kg/m 2
11e19 25e42
233 289
234
Q6 least likely to exceed GWG goals Guidelines for twin gestations are considered provisional and based on interquartile (25the75th percentiles) range of 290
(adjusted odds ratio [aOR], 0.50; 95% cumulative weight gain among women who delivered twins who weighed 2500 g at 37e42 wk gestation.60
235 BMI, body mass index.
291
236 confidence interval [CI], 0.40e0.61), 292
class II and III obese women had higher Kominiarek. Gestational weight gain. Am J Obstet Gynecol 2017.
237 293
238 odds for both excessive GWG (aOR, 294
239 2.31; 95% CI, 1.94e2.75; and aOR, 2.07; 295
240 95% CI, 1.63e2.62, respectively) and racial-ethnic associations with GWG, the GWG goals so as to prevent the 296
241 inadequate GWG (aOR, 1.25; 95% CI, but noted that the odds varied by well-described association between 297
242 1.01e1.55; and aOR, 1.86; 95% CI, BMI. For example, the odds for inade- inadequate GWG and small-for- 298
243 1.45e2.36, respectively) compared to quate GWG were primarily found in gestational-age infants with relative 299
244 normal-weight women. Given that the black, Hispanic, and Asian normal- risks approaching 2-3. Several epidemi- 300
245 prevalence of overweight and obese weight women (aOR, 1.45; 95% ologic studies consistently show a linear 301
246 women aged 20-39 years is 58.5% ac- CI, 1.19e1.77; aOR, 1.29; 95% CI, and direct relationship between GWG 302
247 cording to National Health and Nutri- 1.07e1.56; and aOR, 1.31; 95% CI, and fetal growth; however, other factors 303
248 tion Examination Survey data from 2011 1.08e1.58, respectively) compared to including maternal BMI influence this 304
249 through 2012 and that overweight and normal-weight white women, but not in relationship.22 There are also well- 305
250 obese women have the highest preva- other BMI categories. described associations between inade- 306
251 lence of excessive GWG, the trends in In terms of parity, nulliparas typically quate weight gain and perinatal 307
252 excessive GWG are predicted to gain more weight than multiparas. For mortality. In a study of 100,000 records 308
253 continue.17 example, normal-weight, overweight, from the National Center for Health 309
254 There are known racial-ethnic vari- and obese nulliparas had higher odds for Statistics from linked birth/infant death 310
255 ances in weight among reproductive-age excessive GWG compared to multiparas data files in 2002, infants born to women 311
256 women with the highest prevalence of (aOR, 1.31; 95% CI, 1.18e1.46; aOR, with inadequate weight gain had 312
257 overweight among non-Hispanic blacks 1.24; 95% CI, 1.04e1.48; and aOR, 1.26; increased odds for infant death up to 1 313
258 (80.0%) followed by Hispanics (69.5%), 95% CI, 1.03e1.54, respectively).16 year after birth (odds ratio, 2.23; 95% CI, 314
259 whites (55%), and Asians (26.2%), also Enrollment in supplemental nutrition 1.84e2.70) compared to women with 315
260 according to National Health and program for Women, Infants, and Chil- normal weight gain.23 Other reported 316
261 Nutrition Examination Survey data from dren or in Medicaid; first-trimester risks of inadequate GWG include a fail- 317
262 2011 through 2012.17 Although minority prenatal care; alcohol consumption ure to initiate breast-feeding; however 318
263 women are more likely to enter a preg- during pregnancy; prepregnancy the relationship between low GWG and 319
264 nancy as overweight or obese compared depression; and partner abuse were not preterm birth is mixed.4 Part of the dif- 320
265 to whites, in general, Hispanic and black associated with excessive GWG in any ficulty in studying the association be- 321
266 women are more likely to have inade- BMI category in the same study.16 The tween preterm birth and GWG is that the 322
267 quate GWG and less likely to have NAM conceptual framework for the total GWG of a term gestation cannot be 323
268 excessive GWG compared to whites.18-20 GWG guidelines includes other social, compared with that of a preterm birth, 324
269 For example, in a study of birth records environmental, and maternal factors, thus GWG rates or adequacy ratios are 325
270 from 2007 through 2010 in Colorado, many of which have not been studied or used instead. The relationship between 326
271 Hispanic and black women had inadequately studied, as potentially GWG and preterm birth has been sum- 327
272 increased odds for inadequate GWG associated with either inadequate or marized as having a U-shaped distribu- 328
273 (aOR, 1.08; 95% CI, 1.04e1.11; and excessive GWG.4 tion with inadequate and excessive GWG 329
274 aOR, 1.12; 95% CI, 1.06e1.19, respec- increasing the risk of preterm birth 330
275 tively) and decreased odds for excessive Risks of inadequate and excessive among underweight and normal-weight 331
276 GWG (aOR, 0.84; 95% CI, 0.81e0.86; weight gain women.4 332
277 and aOR, 0.96; 95% CI, 0.90e1.00, The initial NAM 1990 guidelines for In the 2 decades since the first NAM 333
278 respectively) compared to non-Hispanic GWG “Nutrition during Pregnancy”3 GWG guidelines were written, several 334
whites.21 Deputy et al16 also examined emphasized the importance of meeting changes occurred in the demographic of

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365 Q13 Prevalence of gestational weight gain adequacy by prepregnancy body mass index.16 421
366 Kominiarek. Gestational weight gain. Am J Obstet Gynecol 2017. 422
367 423
368 424
369 425
370 women in the United States. This in- metabolic syndrome.24 Most impor- later in life in the offspring. This research 426
371 cludes women having pregnancies at tantly, the weight gain that occurs during is evolving, but providers should 427
372 older ages, more frequent occurrences of the first pregnancy, especially if it is consider that maternal nutrition during 428
373 medical complications such as chronic excessive and not lost after delivery, is pregnancy may have lifelong conse- 429
374 hypertension and pregestational dia- likely to influence future pregnancy quences for the offspring including 430
375 betes, greater racial-ethnic diversity, outcomes. In this sense, it is important neurocognitive outcomes.28-30 431
376 increasing GWG overall regardless of to target nulliparas in our counseling Because overweight and obese women 432
377 prepregnancy BMI, and the national about avoiding excessive GWG. have the greatest prevalence of excessive 433
378 epidemic of obesity. As such, the upda- The neonatal risks of excessive GWG GWG and already enter a pregnancy at 434
379 ted guidelines now focus on meeting, but include large-for-gestational-age infants risk for adverse outcomes, we may as- 435
380 not exceeding, the goals due to the risks and macrosomia. Other reported risks of sume that it is most important for these 436
381 of excessive GWG. The maternal risks of excessive GWG include low 5-minute women to meet the GWG goals. How- 437
382 excessive GWG include cesarean de- Apgar scores, seizures, hypoglycemia, ever, women of all BMI categories 438
383 liveries and postpartum weight reten- polycythemia, and meconium aspiration encounter greater morbidity when GWG 439
384 tion.4 Associations among excessive syndrome.25,26 Of greater concern are is excessive. Swank et al31 evaluated the 440
385 GWG, gestational diabetes, and pre- the reported associations between categorical change in BMI as a function 441
386 eclampsia have been reported, but the excessive GWG and long-term outcomes of prepregnancy BMI and several preg- 442
387 evidence for these associations is more such as childhood overweight or nancy outcomes from a database of 443
388 limited. Other proposed long-term obesity.27 Several theories also suggest women who delivered singleton gesta- 444
389 metabolic consequences of excessive that in utero nutrition may impact tions in California. Although overweight 445
390 GWG for women include type 2 dia- chronic diseases such as diabetes, hy- women had the highest odds of devel- 446
betes, cardiovascular disease, and pertension, and other metabolic diseases oping gestational hypertension or

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447 503
448 preeclampsia with excessive change in outcomes would not only better inform attributed to improved health behaviors 504
449 BMI, normal-weight women also had a our GWG guidelines, but also help during pregnancy. As noted in Deputy 505
450 nearly 3-fold increased risk for gesta- design optimal interventions for GWG et al,16 women with class II and III 506
451 tional hypertension or preeclampsia according to a woman’s BMI category. obesity are at greater risk for inadequate 507
452 compared to women with no change in GWG and it is possible that weight loss 508
453 BMI.31 In similar types of analysis from Is weight gain less than the partially contributes to this finding. 509
454 the same database in California, the guidelines appropriate for women Given the lack of high-level evidence to 510
455 adjusted odds for cesarean delivery and with a higher BMI? support low GWG or weight loss during 511
456 macrosomia (birthweight >4000 g) also Conventional wisdom is that pregnancy pregnancy, until further studies are 512
457 increased as change in BMI increased for is a time for weight gain so as to meet available, women with a prepregnancy 513
458 all BMI categories.32,33 Of note, normal- maternal and fetal needs. The current BMI 30 kg/m2 should aim to gain a 514
459 weight women had the greatest odds for GWG guidelines have 1 range of values total of 11-20 lb during pregnancy. 515
460 macrosomia with excessive change in for all women with a prepregnancy BMI 516
461 BMI (aOR, 3.85; 95% CI, 3.59e4.13) >30 kg/m2 suggesting that a women with Practical approaches to assist 517
462 and a >2-fold odds for cesarean delivery a BMI of 30 kg/m2 should gain the same providers and patients in meeting 518
463 compared to no change in BMI.32,33 weight as one with a BMI of 50 kg/m2. GWG goals 519
464 It is difficult to discern which Several observational studies, most of Motivational interviewing 520
465 factoreprepregnancy BMI or GWGeis which were published since 2009, The ACOG recommends motivational 521
466 associated with greater risk for adverse describe improved maternal outcomes interviewing, a patient-centered coun- 522
467 outcomes when excessive GWG occurs such as cesarean deliveries, preeclamp- seling style for eliciting behavior change 523
468 in women with obesity. For example, sia, and operative vaginal deliveries, in by having patients explore and resolve 524
469 prepregnancy obesity increases the risks obese women who either gain less than ambivalence about behavior change, as 525
470 for preeclampsia, gestational diabetes, the GWG guidelines or who lose weight an approach to achieve positive health 526
471 cesarean deliveries, and abnormal fetal during a pregnancy.37-44 However, in outcomes for patients who have alcohol, 527
472 growth.34 Excessive GWG also is associ- some, but not all studies, inadequate tobacco, or weight management issues.48 528
473 ated with the same risks. Magriples GWG (as defined by the 2009 NAM In contrast to typical provider-patient 529
474 et al35 studied the relationship between criteria or <15 lb weight gain by the interactions whereby sound and logical 530
475 BMI and GWG on birth outcomes in 1990 NAM criteria) or weight loss has advice is given and often resisted, moti- 531
476 low-risk girls and women age 14-25 been associated with a higher propor- vational interviewing aims to help pa- 532
477 years, and predominantly nulliparous tion of low-birthweight and small-for- tients identify the thoughts and feelings 533
478 and non-Hispanic black. In multivariate gestational-age infants than for women that cause them to continue unhealthy 534
479 analysis, prepregnancy BMI was a greater with adequate GWG, although in behaviors and help them develop new 535
480 predictor of cesarean delivery than GWG adjusted analyses the risks were either thought patterns to assist in behavior 536
481 (aOR for cesarean delivery in obese attenuated or there were no differences change. The 4 core skills with motiva- 537
482 women, 2.30; 95% CI, 1.48e3.58; and in birthweight outcomes in women with tional interviewing include open-ended 538
483 aOR for cesarean delivery with excessive GWG lower than the guidelines.8,45,46 questions, affirmations, reflections, and 539
484 GWG, 1.51; 95% CI, 0.98e2.33).35 The The higher proportions of low birth- summaries. For example, instead of a 540
485 interaction of prepregnancy weight and weight in women with inadequate GWG provider stating, “At only 32 weeks, you 541
486 GWG was examined by Abrams and compared to women with adequate have exceeded your weight gain goals. 542
487 Laros36 from deliveries in the 1980s GWG may be attributed to obese women This increases your risk for cesarean 543
488 whereby low GWG was defined as <7 kg having lower occurrences of low birth- delivery and high birthweight,” an 544
489 and excessive GWG defined as >20 kg. weight than normal-weight women. In alternate approach to the problem is to 545
490 There was a progressively stronger cor- one study from the Swedish Medical say, “I notice your weight gain is high. 546
491 relation between GWG and birthweight Birth Registry, the occurrence of small- Tell me about your diet and exercise this 547
492 in underweight (prepregnancy BMI <18 for-gestational-age infants in obese pregnancy.” Additional examples of core 548
493 kg/m2), ideal weight (prepregnancy BMI women who lost weight (1.7-3.8%) was motivational interviewing skills are 549
494 19-22 kg/m2), and moderately over- lower or equal to values typically re- given in Table 3. Studies show that when ½T3 550
495 weight women (prepregnancy BMI 23- ported in Sweden (3.6%).42 Additional a patient is allowed to talk and the pro- 551
496 28 kg/m2). In contrast, for women with a studies have shown decreased neonatal vider actively listens and reflects back to 552
497 prepregnancy BMI >28 kg/m2, there was fat mass, lean mass, and head circum- the patient what they hear, no more than 553
498 no correlation between GWG and ference in overweight or obese women 3 minutes are added to the encounter.49 554
499 birthweight, suggesting that prepreg- who gained 5 kg.47 In the majority of There is also evidence to support the 555
500 nancy weight was a stronger predictor of these studies, we do not know the cir- efficacy of motivational interviewing in 556
501 birthweight than GWG at higher BMIs.36 cumstances of the weight loss, ie, GWG interventions. A systematic review 557
502 Knowing the relationships among pre- whether it was accompanied by maternal and meta-analysis of trials designed to 558
pregnancy BMI, GWG, and pregnancy illness, a result of intentional dieting, or limit GWG evaluated the theoretical and

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560 TABLE 3 616
561 Examples on how to use motivational interviewing core skills with gestational weight gain76 617
562 618
Core skill Definition Example
563 619
564 Open-ended questions Open-ended questions keep conversation going. What concerns you about your weight gain? 620
One word answers such as “yes” or “no” are not Has your weight gain caused any problems this pregnancy?
565 621
possible. Question explores ambivalence (about GWG) Tell me about your family member’s/friend’s experience
566 and further analyzes discrepancy (about meeting or with weight gain in her pregnancy. 622
567 not meeting GWG goals). What eating habits or physical activities work well for you? 623
568 How do you think your family/friends hinder your progress 624
569 in meeting your weight gain goals? 625
570 Affirmations Affirmations are statements that acknowledge You really care about your health and your fetus’ health. 626
571 effort, values, skills, and strengths. They accentuate Despite all changes going on during this pregnancy, 627
572 positive aspects of goal behavior. you are still finding time to exercise. 628
Despite feeling discouraged about your weight gain,
573 you aren’t giving up. 629
574 That must have been challenging. 630
575 631
Reflections Simple reflections let patient know that you You’re not concerned about your weight gain.
576 understood what they said. You’re frustrated because your weight gain is 632
577 Double-sided reflections state both sides of higher/lower than it should be. 633
578 argument that patient makes. On one hand you are more tired this pregnancy and need to 634
579 Reflections that change focus alter topic from rest, but on other hand you want to stay active so that 635
580 one that patient is unwilling to discuss at that you remain healthy too. 636
time to something else. This is not something you want to talk about right now.
581 Do you want to talk about other things in your life 637
582 that are interfering with your goals? 638
583 Summaries Summarizing highlights most important You mentioned that you.as well as.
639
584 parts of conversation. So, this is what you’ve said so far. 640
585 What do you think you want to do? 641
586 Did I leave anything out? 642
587 GWG, gestational weight gain. 643
588 Kominiarek. Gestational weight gain. Am J Obstet Gynecol 2017. 644
589 645
590 646
591 647
592 intervention components of each trial. tational-weight-gain/) that estimates in the third trimester. Furthermore, a 648
593 Of the trials that had a theory for the energy needs during each trimester recent systemic review and meta-analysis 649
594 behavior change, motivational inter- required to achieve GWG goals. The only of randomized controlled trials (RCT) of 650
595 viewing was cited as 1 of 4 strategies (also required input variables are maternal exercise in women of normal weight 651
596 among provision of information, age, height, and weight at conception. showed that occurrences of preterm 652
597 behavioral self-monitoring, and provi- Calories and GWG goals are presented birth were similar (4.5% vs 4.4%; RR, Q7 653
598 sion of rewards contingent on successful on the same template and women can 1.01; 95% CI, 0.68e1.50) in the arm 654
599 behavior) as key for successful GWG use this visual tool for caloric intake exposed to 35-90 minutes 3-4 times per 655
600 interventions.50 Resources for providers guidance. week of aerobic exercise compared to the 656
601 to learn more about motivational inter- Women typically decrease their activ- control arm. More importantly, women 657
602 viewing include textbooks, videos, jour- ity levels during pregnancy. The ACOG in the exercise arm had higher occur- 658
603 nal articles, and workshops (reference recommends 30 minutes of moderate rences of vaginal delivery and lower oc- 659
604 list below). exercise per day on most, if not all, days currences of gestational diabetes, and no 660
605 of the week for pregnant women, in the differences in low birthweight, thus giv- 661
606 Dispelling myths absence of medical or obstetric contra- ing providers and patients additional 662
607 Many women believe that pregnancy indications.51 Women can continue to evidence on the safety and benefits of 663
608 means eating for 2, and consequently derive the health-related benefits of ex- exercise during pregnancy.52 664
609 they nearly double their caloric intake. ercise (eg, decreased risk of cardiovas- 665
610 There are several online resources that cular disease and diabetes) during Goal setting, GWG plots, and 666
611 can assist providers in determining daily pregnancy. Providers can counsel electronic medical records 667
612 calories during pregnancy. One example women that it is safe to begin or continue Goals can be motivational and goal 668
613 is the calculator from Pennington most forms of exercise, although they setting has shown promise in promoting 669
614 Biomedical Research Center (www.pbrc. may need to adjust their regimens to diet and physical activity behavior 670
edu/research-and-faculty/calculators/ges avoid dehydration and fatigue, especially change in nonpregnant individuals. The

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672 overall strategy of goal setting has also among obstetrician-gynecologists, fam- individual circumstances, the improve- 728
673 been reviewed in the context of health ily medicine physicians, and certified ments in health behaviors including diet 729
674 behavior interventions aimed to prevent nurse midwives.54 These results were and exercise habits are paramount to 730
675 excessive GWG through modification of encouraging, but additional research is achieving GWG goals and deserve 731
676 diet and/or physical activity. Among in- needed to determine how interfaces with greater emphasis during pregnancy as 732
677 terventions reporting positive results for EMR and GWG counseling can translate weight gain may have several compo- 733
678 GWG, a combination of individualized into improved patient outcomes. nents and may not be equivalent among 734
679 diet and physical activity goals, self- women who consume the same diet. 735
680 monitoring, and performance feedback Problem list Nonetheless, several RCT of enhanced 736
681 indicators were active components of the Providers often hesitate to identify GWG counseling, special diets (eg, low 737
682 intervention.53 Using this information, weight as a problem. Like blood pres- glycemic index, diabetic, low calorie, low 738
683 providers can set activity goals for their sure, weight is a data point collected at fat, low carbohydrate), exercise (eg, 739
684 patients by recommending 30 minutes nearly every prenatal visit, and it should walking, dancing, aerobics), or both di- 740
685 of daily physical activity, encouraging not be neglected. As an example, listing etary and exercise combinations have 741
686 women to monitor their own activity obesity as a problem in the medical re- been reported either in individual or 742
687 with logs or step counts calculated by cord has been shown to significantly group sessions with varying doses of 743
688 pedometers or activity monitoring de- increase the likelihood (92.9% vs 56.6%, intervention. The most recent Cochrane 744
689 vices, and then giving them feedback on P < .001) that the provider will take ac- review on the topic of the effectiveness 745
690 their progress. tion at follow-up visits.55 The same may and safety of diet, exercise, or both in- 746
691 With respect to GWG, prenatal care also be true for low or excessive GWG, terventions for preventing excessive 747
692 providers should know the GWG goals both of which have International Statis- GWG describes 49 RCT with 11,444 748
693 and be clear in their communication tical Classification of Diseases, 10th Revi- women. Based on high-quality evidence, 749
694 about GWG goals so that women know sion codes for documentation and billing diet or exercise reduced the frequency of 750
695 the expectations and do not vary from purposes. excessive GWG by 20% (RR, 0.8; 95% 751
696 provider to provider at different prenatal CI, 0.73e0.87), while only minimally 752
697 care visits. For many women, a plot of Multidisciplinary approach increasing the risk for inadequate GWG 753
698 GWG over successive prenatal visits with Weight management outside of preg- (RR, 1.14; 95% CI, 1.02e1.27) based on 754
699 the upper and lower boundaries formed nancy typically involves a multidisci- moderate-quality evidence.57 755
700 by the 2009 NAM guidelines may pro- plinary approach with teams of Criticisms of health behavior in- 756
701 vide a useful visual for their GWG nutritionists, exercise physiologists, terventions for GWG include attenuated 757
702 progress. Many electronic medical re- medical subspecialists, and health effects in overweight and obese women 758
703 cords (EMR) have the capability of coaches.56 A similar approach is recom- and that many women still exceed the 759
704 creating these graphs specific to each mended in pregnancy with nutritional GWG in these RCT. For example, in a 760
705 woman’s BMI, but paper versions are advice offered to all women and addi- RCT of a low-glycemic index diet during 761
706 also accessible (http://www.cdph.ca.gov/ tional counseling provided when GWG pregnancy to prevent macrosomia as the 762
707 pubsforms/forms/Pages/MaternalandChi is low or excessive, where these resources primary outcome, normal-weight 763
708 ldHealth.aspx). These graphs also high- are available. women had a reduction in excessive 764
709 light that a smaller amount of weight GWG (15% vs 26%, P ¼ .02), yet obese 765
710 gain occurs in the first trimester and that Health behavior and lifestyle women did not experience the same 766
711 weight gain increases at a greater rate in interventions for GWG benefit (60% vs 57%, P ¼ .8) compared 767
712 the second and third trimesters. Pregnancy is a time when women may be to the control group.58 Unfortunately, 768
713 Lindberg and Anderson54 tested the motivated to improve their health be- most of the health behavior in- 769
714 effectiveness of an intervention to haviors, it is often considered the terventions either designed specifically 770
715 improve the consistency and accuracy of optimal time to intervene not only for for overweight or obese women or that 771
716 GWG counseling with best practice issues related to substance use such as included overweight and obese women 772
717 alerts built into an EMR. The alert pro- tobacco and alcohol cessation, but also in the study design among women of 773
718 vided individualized total GWG goals, related to eating habits and physical ac- all BMI categories have not demonstrated 774
719 GWG goals per week of gestation, a tivity so as to prevent excessive GWG. a significant impact on GWG.58-67 775
720 scripted template for provider coun- GWG is a potentially modifiable risk Notable exceptions include 2 more 776
721 seling and documentation in a smart set, factor for a number of adverse maternal recent RCT. The Lifestyle in Pregnancy 777
722 and a patient education handout. Ac- and neonatal outcomes. Pregnancy is not study offered dietary guidance, free 778
723 cording to a retrospective chart review a time for weight-loss medications or membership in a fitness center, and per- 779
724 before and after the intervention, the bariatric surgery, so the emphasis of in- sonal coaching. Obese women had 780
725 rate of GWG counseling in agreement terventions to date are on health behav- reduced mean GWG compared to the 781
726 with the 2009 NAM guidelines improved iors and lifestyle changes such as dietary control group (7.0 vs 8.6 kg, P ¼.01), but 782
(2.6% before vs 51% after, P < .001) control and exercise. Depending on the there were no differences in excessive

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784 GWG (35.4% vs 46.6%, P ¼ .06) and the intervention or adult-onset outcomes of 7. Brunner Huber LR. Validity of self-
840
infants in the intervention group had the offspring are needed to evaluate reported height and weight in women of
785 reproductive age. Matern Child Health J 841
786 higher birthweights.68 The Treatment of whether benefits really exist. 2007;11:137-44. 842
787 Obese Pregnant Women study random- 8. Johnson J, Clifton RG, Roberts JM, et al. 843
788 ized obese women to a physical activity Conclusion Pregnancy outcomes with weight gain above or
844
789 intervention with or without a dietary Significant changes have occurred in the below the 2009 Institute of Medicine guidelines.
845
intervention and found that the physical guidelines for GWG goals over the past Obstet Gynecol 2013;121:969-75.
790 9. National Institute for Health and Clinical 846
791 activity intervention decreased GWG by a century. GWG remains a complex, yet Excellence. Weight management before, during, 847
792 mean of 1.38 kg (P ¼ .04) in a multivar- critical variable in prenatal care man- and after pregnancy. July 2010. NICE public 848
793 iate analysis and that women were more agement as it is one of the few modifiable health guidance 27.
849
likely to meet GWG goals (49-55% risk factors for adverse perinatal out- 10. Institute of Obstetricians and Gynecologists
794 850
795 intervention arms vs 37% control, P ¼ comes and aberrations have the potential Royal College of Physicians of Ireland. Obesity
851
and pregnancy clinical practice guideline.
796 .01).69 to influence short- and long-term Guideline no. 2, June 2011, revised June 2013. 852
797 It is hypothesized that health maternal and offspring health. Given 11. The Australian and New Zealand College of 853
798 behavior interventions in overweight the increasing prevalence and negative Obstetricians and Gynecologists. C-Obs 49
854
or obese women are less likely to in- consequences of excessive GWG, pre- management of obesity in pregnancy. 2013. Q9
799 12. Butte NF, Wong WW, Treuth MS, Ellis KJ, 855
800 fluence GWG due to the physiological venting excessive GWG is becoming 856
O’Brian Smith E. Energy requirements during
801 adaptations that occur in a normal increasingly important for prenatal care pregnancy based on total energy expenditure 857
802 pregnancy (ie, decreased insulin sensi- providers and patients. Several studies and energy deposition. Am J Clin Nutr 2004;79: 858
803 tivity), the short time period between regarding GWG and perinatal outcomes 1078-87.
859
initiation of lifestyle changes and de- have been published since the 2009 13. Thomas DM, Navarro-Barrientos JE,
804 Rivera DE, et al. Dynamic energy-balance model 860
805 livery, and difficulties in significantly NAM guidelines and it is likely that this 861
predicting gestational weight gain. Am J Clin
806 increasing physical activity as preg- evidence will be systematically reviewed Nutr 2012;95:115-22. 862
807 nancy progresses.70 It is also possible and updated guidelines provided, espe- 14. Jebeile H, Mijatovic J, Louie JC, Prvan T, 863
808 that overweight or obese women cially for high-risk women such as those Brand-Miller JC. A systematic review and met-
864
809 require a more intensive or higher dose with obesity. Future research regarding aanalysis of energy intake and weight gain in
865
of a health behavior program to in- GWG should include measurements of pregnancy. Am J Obstet Gynecol 2016;214:
810 465-83. 866
811 fluence GWG or other pregnancy out- psychosocial determinants of GWG 15. Pitkin RM. Nutritional support in obstetrics 867
812 comes compared to normal-weight along with the more commonly and gynecology. Clin Obstet Gynecol 1976;19: 868
813 women. The health behavior or life- measured nutrition and exercise vari- 489-513.
869
style changes need to occur earlier for ables. The design of health behavior in- 16. Deputy NP, Sharma AJ, Kim SY, Hinkle SN.
814 Prevalence and characteristics associated with 870
815 overweight and obese women, ideally terventions for overweight or obese 871
gestational weight gain adequacy. Obstet
816 prior to pregnancy and in conjunction women deserves greater focus with Gynecol 2015;125:773-81. 872
817 with weight loss prior to pregnancy to respect to their content and timing so as 17. Ogden CL, Carroll MD, Kit BK, Flegal KM. 873
818 achieve both GWG goals and optimal to improve GWG and other outcomes in Prevalence of childhood and adult obesity in the
874
pregnancy outcomes. these women and their offspring. - United States, 2011-2012. JAMA 2014;311:
819 806-14. 875
820 When the results of multiple health 876
18. Krukowski RA, Bursac Z, McGehee MA,
821 behavior intervention studies have been REFERENCES West D. Exploring potential health disparities in 877
822 examined cumulatively in meta- 1. Ferguson JH, Keaton AG. Special leaflets for excessive gestational weight gain. J Womens 878
823 analyses, the interventions have not use in controlling toxemia and excessive weight Health (Larchmt) 2013;22:494-500.
879
significantly influenced other perinatal gain in pregnancy. Am J Public Health Nations 19. Liu J, Gallagher AE, Carta CM, Torres ME,
824 Moran R, Wilcox S. Racial differences in gesta- 880
outcomes such as such as cesarean de- Health 1950;40:194-200.
825 2. US National Research Council; Committee on tional weight gain and pregnancy-related hy- 881
826 livery, preterm birth, macrosomia, pertension. Ann Epidemiol 2014;24:441-7. 882
Maternal Nutrition. Maternal nutrition and the
827 shoulder dystocia, hypoglycemia, course of pregnancy. Washington (DC): National 20. Hunt KJ, Alanis MC, Johnson ER, 883
828 hyperbilirubinemia, and birth Academy of Sciences; 1970. Mayorga ME, Korte JE. Maternal pre-pregnancy
884
829 trauma.57,71-74 The limitations of these 3. Institute of Medicine. Nutrition during preg- weight and gestational weight gain and their
885
trials point to the need for more nancy. Washington (DC); 1990. association with birthweight with a focus on Q8
830 4. Institute of Medicine. Weight gain during racial differences. Matern Child Health J 886
831 research.75 If the efforts of intensive 2013;17:85-94. 887
pregnancy: reexamining the guidelines. Wash-
832 health behavior interventions during ington (DC); 2009. 21. Pawlak MT, Alvarez BT, Jones DM, 888
833 pregnancy can improve GWG, yet have 5. American College of Obstetricians and Gy- Lezotte DC. The effect of race/ethnicity on
889
834 no influence on other perinatal out- necologists. Weight gain during pregnancy. gestational weight gain. J Immigr Minor Health
890
comes, then another causative link needs Committee opinion no. 548. Obstet Gynecol 2015;17:325-32.
835 2013;121:210-2. 22. Galjaard S, Pexsters A, Devlieger R, et al. 891
836 to be evaluated to justify ongoing efforts 892
6. American Academy of Pediatrics, American The influence of weight gain patterns in preg-
837 to control GWG. However, long-term College of Obstetricians and Gynecologists. nancy on fetal growth using cluster analysis in an 893
838 outcomes such as maternal weight 5 or Guidelines for perinatal care. 7th ed. Washington obese and nonobese population. Obesity (Silver
894
10 years after participating in an (DC); 2012. Spring) 2013;21:1416-22.

8 American Journal of Obstetrics & Gynecology MONTH 2017

REV 5.4.0 DTD
YMOB11687_proof
9 June 2017
2:27 pm
ce
 ajog.org Expert Review
895 951
23. Davis RR, Hofferth SL. The association be- in Sweden. Int J Gynaecol Obstet 2006;93: 53. Brown MJ, Sinclair M, Liddle D, Hill AJ,
896 tween inadequate gestational weight gain and 269-74. Madden E, Stockdale J. A systematic review 952
897 infant mortality among US infants born in 2002. 39. Kiel DW, Dodson EA, Artal R, Boehmer TK, investigating healthy lifestyle interventions 953
898 Matern Child Health J 2012;16:119-24. Leet TL. Gestational weight gain and pregnancy incorporating goal setting strategies for pre- 954
899 24. Gilmore LA, Klempel-Donchenko M, outcomes in obese women: how much is venting excess gestational weight gain. PLoS 955
Redman LM. Pregnancy as a window to future enough? Obstet Gynecol 2007;110:752-8. One 2012;7:e39503.
900 956
health: excessive gestational weight gain and 40. Beyerlein A, Schiessl B, Lack N, von Kries R. 54. Lindberg SM, Anderson CK. Improving
901 obesity. Semin Perinatol 2015;39:296-303. Optimal gestational weight gain ranges for the gestational weight gain counseling through 957
902 25. Hedderson MM, Weiss NS, Sacks DA, et al. avoidance of adverse birth weight outcomes: a meaningful use of an electronic medical record. 958
903 Pregnancy weight gain and risk of neonatal novel approach. Am J Clin Nutr 2009;90: Matern Child Health J 2014;18:2188-94. 959
904 complications: macrosomia, hypoglycemia, and 1552-8. 55. McArtor RE, Iverson DC, Benken D, 960
hyperbilirubinemia. Obstet Gynecol 2006;108: 41. Flick AA, Brookfield KF, de la Torre L, Dennis LK. Family practice residents’ identifica-
905 961
1153-61. Tudela CM, Duthely L, Gonzalez-Quintero VH. tion and management of obesity. Int J Obes
906 26. Stotland NE, Cheng YW, Hopkins LM, Excessive weight gain among obese women Relat Metab Disord 1992;16:335-40. 962
907 Caughey AB. Gestational weight gain and and pregnancy outcomes. Am J Perinatol 56. Montesi L, El Ghoch M, Brodosi L, Calugi S, 963
908 adverse neonatal outcome among term infants. 2010;27:333-8. Marchesini G, Dalle Grave R. Long-term weight 964
909 Obstet Gynecol 2006;108:635-43. 42. Blomberg M. Maternal and neonatal out- loss maintenance for obesity: a multidisciplinary 965
27. Oken E, Taveras EM, Kleinman KP, Rich- comes among obese women with weight gain approach. Diabetes Metab Syndr Obes 2016;9:
910 966
Edwards JW, Gillman MW. Gestational weight below the new Institute of Medicine recom- 37-46.
911 gain and child adiposity at age 3 years. Am J mendations. Obstet Gynecol 2011;117: 57. Muktabhant B, Lawrie TA, Lumbiganon P, 967
912 Obstet Gynecol 2007;196:322.e1-8. 1065-70. Laopaiboon M. Diet or exercise, or both, for 968
913 28. Lau C, Rogers JM, Desai M, Ross MG. Fetal 43. Oken E, Kleinman KP, Belfort MB, preventing excessive weight gain in pregnancy. 969
914 programming of adult disease: implications for Hammitt JK, Gillman MW. Associations of Cochrane Database Syst Rev 2015;6: 970
prenatal care. Obstet Gynecol 2011;117: gestational weight gain with short- and longer- CD007145.
915 971
978-85. term maternal and child health outcomes. Am 58. Walsh JM, McGowan CA, Mahony R,
916 29. Jensen ET, van der Burg JW, O’Shea TM, J Epidemiol 2009;170:173-80. Foley ME, McAuliffe FM. Low glycemic index diet 972
917 et al. The relationship of maternal prepregnancy 44. Kominiarek MA, Hibbard J. Gestational in pregnancy to prevent macrosomia (ROLO 973
918 body mass index and pregnancy weight gain to weight gain and obesity: is 20 pounds too study): randomized control trial. BMJ 2012;345: 974
919 neurocognitive function at age 10 years among much? J Womens Health (Larchmt) 2011;20: e5605. 975
Q10 children born extremely preterm. J Pediatr 2017. 1405. 59. Callaway LK, Colditz PB, Byrne NM, et al.
920 976
30. Hochner H, Friedlander Y, Calderon- 45. Bodnar LM, Siega-riz AM, Simhan HN, Prevention of gestational diabetes: feasibility is-
921 Margalit R, et al. Associations of maternal Himes KP, Abrams B. Severe obesity, gesta- sues for an exercise intervention in obese 977
922 prepregnancy body mass index and gestational tional weight gain, and adverse birth outcomes. pregnant women. Diabetes Care 2010;33: 978
923 weight gain with adult offspring car- Am J Clin Nutr 2010;91:1642-8. 1457-9. 979
924 diometabolic risk factors: the Jerusalem Peri- 46. Vesco KK, Sharma AJ, Dietz PM, et al. 60. Guelinckx I, Devlieger R, Mullie P, 980
natal Family Follow-up Study. Circulation Newborn size among obese women with weight Vansant G. Effect of lifestyle intervention on di-
925 981
2012;125:1381-9. gain outside the 2009 Institute of Medicine etary habits, physical activity, and gestational
926 31. Swank ML, Caughey AB, Farinelli CK, et al. recommendation. Obstet Gynecol 2011;117: weight gain in obese pregnant women: a ran- 982
927 The impact of change in pregnancy body mass 812-8. domized controlled trial. Am J Clin Nutr 2010;91: 983
928 index on the development of gestational hyper- 47. Catalano PM, Mele L, Landon MB, et al. 373-80. 984
929 tensive disorders. J Perinatol 2014;34:181-5. Inadequate weight gain in overweight and obese 61. Hui A, Back L, Ludwig S, et al. Lifestyle 985
32. Swank ML, Caughey AB, Farinelli CK, et al. pregnant women: what is the effect on fetal intervention on diet and exercise reduced
930 986
The impact of change in pregnancy body mass growth? Am J Obstet Gynecol 2014;211:137. excessive gestational weight gain in pregnant
931 index on macrosomia. Obesity (Silver Spring) e1-7. women under a randomized controlled trial. 987
932 2014;22:1997-2002. 48. American College of Obstetricians and Gy- BJOG 2012;119:70-7. 988
933 33. Swank ML, Caughey AB, Farinelli CK, et al. necologists. Motivational interviewing: a tool for 62. Jeffries K, Shub A, Walker SP, Hiscock R, 989
934 The impact of change in pregnancy body mass behavior change. Committee opinion no. 423. Permezel M. Reducing excessive weight gain in 990
index on cesarean delivery. J Matern Fetal Obstet Gynecol 2009;113:243-6. pregnancy: a randomized controlled trial. Med J
935 991
Neonatal Med 2014;27:795-800. 49. Beckman HB, Frankel RM. The effect of Aust 2009;191:429-33.
936 34. Gunatilake RP, Perlow JH. Obesity and physician behavior on the collection of data. Ann 63. Asbee SM, Jenkins TR, Butler JR, 992
937 pregnancy: clinical management of the obese Intern Med 1984;101:692-6. White J, Elliot M, Rutledge A. Preventing 993
938 gravida. Am J Obstet Gynecol 2011;204: 50. Hill B, Skouteris H, Fuller-Tyszkiewicz M. excessive weight gain during pregnancy 994
939 106-19. Interventions designed to limit gestational weight through dietary and lifestyle counseling: a 995
35. Magriples U, Boynton MH, Kershaw TS, gain: a systematic review of theory and meta- randomized controlled trial. Obstet Gynecol
940 996
et al. The impact of group prenatal care on analysis of intervention components. Obes Rev 2009;113:305-12.
941 pregnancy and postpartum weight trajectories. 2013;14:435-50. 64. Jackson RA, Stotland NE, Caughey AB, 997
942 Am J Obstet Gynecol 2015;213:688.e1-9. 51. American Congress of Obstetricians and Gerbert B. Improving diet and exercise in preg- 998
943 36. Abrams BF, Laros RK Jr. Prepregnancy Gynecologists. Physical activity and exercise nancy with Video Doctor counseling: a ran- 999
944 weight, weight gain, and birth weight. Am J during pregnancy and the postpartum period. domized trial. Patient Educ Couns 2011;83: 1000
Obstet Gynecol 1986;154:503-9. Committee opinion no. 650. Obstet Gynecol 203-9.
945 1001
37. Bianco AT, Smilen SW, Davis Y, Lopez S, 2015;126:e135-42. 65. Phelan S, Phipps MG, Abrams B, Darroch F,
946 Lapinski R, Lockwood CJ. Pregnancy outcome 52. Di Mascio D, Magro-Malosso ER, Schaffner A, Wing RR. Randomized trial of a 1002
947 and weight gain recommendations for the Saccone G, Marhefka GD, Berghella V. Exercise behavioral intervention to prevent excessive 1003
948 morbidly obese woman. Obstet Gynecol during pregnancy in normal-weight women and gestational weight gain: the Fit for Delivery 1004
949 1998;91:97-102. risk of preterm birth: a systematic review and Study. Am J Clin Nutr 2011;93:772-9. 1005
38. Cedergren M. Effects of gestational weight meta-analysis of randomized controlled trials. 66. Polley BA, Wing RR, Sims CJ. Randomized
950 1006
gain and body mass index on obstetric outcome Am J Obstet Gynecol 2016;215:561-71. controlled trial to prevent excessive weight gain

MONTH 2017 American Journal of Obstetrics & Gynecology 9

REV 5.4.0 DTD
YMOB11687_proof
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1007 1063
in pregnant women. Int J Obes Relat Metab review of randomized trials. BJOG 2010;117: School Rd NE, Suite 1, Albuquerque, NM
1008 Disord 2002;26:1494-502. 1316-26. 87112; (505) 345-6100. 1064
1009 67. Dodd JM. Dietary and lifestyle advice for 74. Oteng-Ntim E, Varma R, Croker H, 1065
Online
1010 pregnant women who are overweight or obese: Poston L, Doyle P. Lifestyle interventions for 1066
1011 the LIMIT randomized trial. Ann Nutr Metab overweight and obese pregnant women to Motivational Interviewing Network of Trainers 1067
2014;64:197-202. improve pregnancy outcome: systematic review (MINT) is an international organization of trainers
1012 1068
68. Vinter CA, Jensen DM, Ovesen P, Beck- and meta-analysis. BMC Med 2012;10:47. in motivational interviewing. Their central interest
1013 Nielsen H, Jorgensen JS. The LiP (Lifestyle in 75. Flynn AC, Dalrymple K, Barr S, et al. Dietary is to improve the quality and effectiveness of 1069
1014 Pregnancy) study: a randomized controlled interventions in overweight and obese pregnant counseling and consultations with clients about 1070
1015 trial of lifestyle intervention in 360 obese women: a systematic review of the content, behavior change. There is a calendar of available 1071
1016 pregnant women. Diabetes Care 2011;34: delivery, and outcomes of randomized 2-day training sessions, some of which are 1072
2502-7. controlled trials. Nutr Rev 2016;74:312-28. offered on-line. Available at: http://www.
1017 1073
69. Renault KM, Norgaard K, Nilas L, et al. The 76. Miller WR, Rollnick S. Motivational inter- motivationalinterviewing.org/about_mint Q12
1018 Treatment of Obese Pregnant Women (TOP) viewing: preparing people for change. 2nd ed. Health Sciences Institute motivational inter- 1074
1019 study: a randomized controlled trial of the effect New York: Guilford Press; 2002. viewing training for health care. Available at: Q11 1075
1020 of physical activity intervention assessed by http://www.healthsciences.org/Motivational-Int 1076
1021 pedometer with or without dietary intervention in erviewing-Health-Coach-Training. 1077
obese pregnant women. Am J Obstet Gynecol REFERENCES FOR MOTIVATIONAL INTERVIEWING
1022 Journals 1078
2014;210:134.e1-9.
1023 70. Catalano P, deMouzon SH. Maternal Books Burton AM, Agne AA, Lehr SM, Davis NJ, 1079
1024 obesity and metabolic risk to the offspring: why Miller WR, Rollnick S. Motivational interviewing: Willett LL, Cherrington AL. Training residents in 1080
1025 lifestyle interventions may have not achieved the preparing people for change. 2nd ed. New York obesity counseling: incorporating principles of 1081
1026 desired outcomes. Int J Obes (Lond) 2015;39: (NY): Guilford Press; 2002. motivational interviewing to enhance patient 1082
642-9. Rollnick S, Miller WR, Butler C. Motivational centeredness. J Grad Med Educ 2011;3:
1027 1083
71. Tanentsapf I, Heitmann BL, Adegboye AR. interviewing in health care: helping patients 408-11.
1028 Systematic review of clinical trials on dietary in- change behavior. New York (NY): Guilford Press; Karlsen K, Humaidan P, Sorensen LH, 1084
1029 terventions to prevent excessive weight gain 2008. Alsbjerg B, Ravn P. Motivational interviewing: a 1085
1030 during pregnancy among normal weight, over- part of the weight loss program for overweight 1086
weight and obese women. BMC Pregnancy Videos and obese women prior to fertility treatment.
1031 1087
Childbirth 2011;11:81. Miller WR. Motivational interviewing. Albu- Gynecol Endocrinol 2013;29:839-42.
1032 1088
72. Campbell F, Johnson M, Messina J, querque (NM): University of New Mexico; 1989. Lindhardt CL, Rubak S, Mogensen O, et al.
1033 Guillaume L, Goyder E. Behavioral interventions Available from the author at the Department of Healthcare professionals experience with moti- 1089
1034 for weight management in pregnancy: a sys- Psychology, University of New Mexico, Albu- vational interviewing in their encounter with 1090
1035 tematic review of quantitative and qualitative querque, NM 87131; (505) 277-4121. obese pregnant women. Midwifery 2015;31: 1091
1036 data. BMC Public Health 2011;11:491. Hester RK, Handmaker NS. Motivating pregnant 678-84. 1092
73. Dodd JM, Grivell RM, Crowther CA, women to stop drinking. Albuquerque (NM): Rollnick S, Butler CC, Kinnersley P, Gregory J,
1037 1093
Robinson JS. Antenatal interventions for over- Behavior Therapy Associates; 1997. Available Mash B. Motivational interviewing. BMJ
1038 weight or obese pregnant women: a systematic from Behavior Therapy Associates, 9426 Indian 2010;340:c1900. 1094
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