Thai Journal of Obstetrics and Gynaecology

July 2016, Vol. 24, pp. 161-168

OBSTETRICS

Comparison of Gestational Weight Gain Recommendations

between Study from Thai Population and U.S. Institute of
Medicine

Korranat Thanaratsiriworakul, M.D.,

Narongwat Suriya, M.D.,
Panya Sananpanichkul, M.D.

Department of Obstetrics and Gynecology, Prapokklao Hospital, Chanthaburi 22000, Thailand

Abstract

Objectives: To identify the suitable recommendations of weight gain for Thai pregnant women with
normal birth weight neonate.
Materials and Methods: This retrospective study was performed by reviewing 1,657 medical records
of singleton pregnant women who delivered normal birth weight healthy neonates at the
Department of Obstetrics and Gynecology, Prapokklao Hospital during July 1st, 2013 – June
30th, 2014. Pre-pregnancy BMI was categorized according to U.S. Institute of Medicine (IOM)
2009. Gestational weight gain and pregnancy outcomes were compared using IOM and Thai
Siriraj Hospital recommendations. One-way ANOVA was used to compare continuous data and
Chi-square test was used to compare discrete data among two groups.
Results: Mean gestational weight gain of our population in underweight, normal weight,
overweight, and obese groups were 13.73±5.43 kg, 13.52±5.63 kg, 11.35±5.65 kg, and 8.81±
7.41 kg, respectively. Significant difference of maternal age, pre-pregnancy BMI, gestational
weight gain and neonatal birth weight were found among groups (p<0.001). About one-third
of both underweight group and normal weight group gained the appropriate weight based on
the IOM recommendations whereas two-thirds of both groups gained the appropriate weight
using Thai Siriraj recommendations. While the performances of both sets of recommendations
were similar in obese women, the Thai Siriraj recommendations performed better in the
overweight group, In total, 56.3% of women and 34.8% of women could gain weight within the
recommendations of Thai Siriraj and IOM respectively while the neonatal outcomes of both
groups of women were comparable.
Conclusion: Thai Siriraj recommendations for weight gain during pregnancy appear to be more
suitable for our population than the U.S. IOM ones.

Keywords: Gestational weight gain, normal birth weight, U.S. IOM recommendations, Thai Siriraj
recommendations

Correspondence to: Panya Sananpanichkul, M.D., Department of Obstetrics and Gynecology, Prapokklao
Hospital, Chanthaburi 22000, Thailand, Phone: +66 18623992, E-mail: panysanan@yahoo.com

VOL. 24, NO. 3, JULY 2016 Thanaratsiriworakul K, et al., Comparison of Gestational Weight Gain Recommendations 161
between Study from Thai Population and U.S. Institute of Medicine
เปรียบเทียบคำ�แนะนำ�การเพิ่มของน้ำ�หนักขณะตั้งครรภ์ระหว่างคำ�แนะนำ�จากการศึกษาในกลุ่ม
ประชากรไทยกับคำ�แนะนำ�ของ U.S. Institute of Medicine

กรณัฏฐ ธนรัฐศิริวรกุล, ณรงควัฒน สุริยะ, ปญญา สนั่นพานิชกุล

วัตถุ​ประสงค: เพื่อศึกษาว่าคำ�แนะนำ�ใดเกี่ยวกับการเพิ่มน้ำ�หนักระหว่างตั้งครรภ์ที่เหมาะสมกับหญิงตั้งครรภ์ชาวไทยซึ่งคลอดทารก
น้ำ�หนักปกติ
วัสดุและวิธีการ: การศึกษาย้อนหลังจากข้อมูลในเวชระเบียนของหญิงตั้งครรภ์เดี่ยวสุขภาพดี ตั้งครรภ์ครบกำ�หนด และคลอดทารก
น้ำ�หนักปกติ (2,500-4,000 กรัม) จำ�นวน 1,657 ฉบับ แบ่งเป็น 4 กลุ่มตามดัชนีมวลกายก่อนการตั้งครรภ์ ได้แก่ น้ำ�หนักน้อยกว่าปกติ
(ดัชนีมวลกายน้อยกว่า 18.5 กก./ม2), น้ำ�หนักปกติ (ดัชนีมวลกาย 18.5-24.9 กก./ม2), น้ำ�หนักมากกว่าปกติ (ดัชนีมวลกาย 25.0-
29.9 กก./ม2), และอ้วน (ดัชนีมวลกายตั้งแต่ 30 กก./ม2 ขึ้นไป) ทำ�การบันทึกข้อมูลและนำ�มาเปรียบเทียบวิเคราะห์ระหว่างคำ�แนะนำ�
ของ Institute of Medicine แห่งสหรัฐอเมริกาและคำ�แนะนำ�ของโรงพยาบาลศิริราช ประเทศไทย
ผลการศึกษา: ค่าเฉลี่ยของน้ำ�หนักที่เพิ่มขึ้น คือ 13.73±5.43 กก., 13.52±5.63 กก., 11.35±5.65 กก. และ 8.81±7.41 กก. สำ�หรับ
หญิงตั้งครรภ์น้ำ�หนักน้อยกว่าปกติ น้ำ�หนักปกติ น้ำ�หนักมากกว่าปกติ และอ้วน ตามลำ�ดับ ผลลัพธ์ต่างๆ ได้แก่ อายุหญิงตั้งครรภ์ ดัชนี
มวลกายก่อนการตั้งครรภ์ น้ำ�หนักที่เพิ่มขึ้น และน้ำ�หนักทารกแรกคลอด มีความแตกต่างกันอย่างมีนัยสำ�คัญทางสถิติ จากการศึกษา
พบว่าประมาณ 1 ใน 3 ของหญิงตัง้ ครรภ์น้ำ�หนักน้อยกว่าปกติและน้ำ�หนักปกติ มีน้ำ�หนักเพิม่ ขึน้ ระหว่างการตัง้ ครรภ์ตามคำ�แนะนำ�ของ
Institute of Medicine แห่งสหรัฐอเมริกา ในขณะที่ประมาณ 2 ใน 3 ของทั้งสองกลุ่มมีน้ำ�หนักเพิ่มได้เหมาะสมกับคำ�แนะนำ�ของ
โรงพยาบาลศิริราชประเทศไทย สาหรับกลุ่มอ้วน นั้น คำ�แนะนำ�ทั้งสองชุดแนะนำ�ได้ดีใกล้เคียงกัน แต่คำ�แนะนำ�ของไทย เหมาะสมกว่า
ในกลุ่มน้ำ�หนักตัวมาก เมื่อเปรียบเทียบระหว่างคำ�แนะนำ�จากสหรัฐอเมริกากับของโรงพยาบาลศิริราช ประเทศไทย พบว่าจำ�นวนของ
หญิงตั้งครรภ์ชาวไทยมีน้ำ�หนักเพิ่มขึ้นระหว่างตั้งครรภ์ตามคำ�แนะนำ�ของประเทศไทย (56.3%) มากกว่าของสหรัฐอเมริกา (34.8%)
สรุป: คำ�แนะนำ�สำ�หรับการเพิ่มน้ำ�หนักระหว่างตั้งครรภ์ของโรงพยาบาลศิริราช ประเทศไทย น่าจะเหมาะสมกับหญิงตั้งครรภ์ชาวไทย
มากกว่าคำ�แนะนำ�ของ Institute of Medicine แห่งสหรัฐอเมริกา

162 Thai J Obstet Gynaecol VOL. 24, NO. 3, JULY 2016

Introduction
Gestational weight gain means the amount of
weight gain during pregnancy(1). It is an important factor
for both maternal and infant outcomes(2, 3). Inappropriate
gestational weight gain has effects on health and this
infer that a low weight gain should also be avoided to
optimize birth outcomes(4). Excessive gestational weight
gain can lead to many obstetric complications, such as
pregnancy induced hypertension, gestational diabetes,
and risk of cesarean section(5). Pre-pregnancy body
mass index (BMI) is also an important factor in
pregnancy outcomes such as fetal macrosomia in
overweight and obese women(6, 7) and low birth weight
in underweight women(8-11).
In 2009, the U.S. Institute of Medicine (U.S.IOM)
recommended appropriate gestational weight gain
according to pre-pregnancy BMI in order to deliver a
normal birth weight neonate(12, 13). Pregnant women
should gain their weight of 12.5-18 kg, 11.5-16 kg,
7-11.5 kg, and 5-9 kg according to pre-pregnancy BMI
classified as underweight (<18.5 kg/m 2 ), normal
weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-
25.9 kg/m2), and obesity (BMI ≥30 kg/m2), respectively.
In USA, pregnant women who gained their weight less
than U.S.IOM recommendations were shown to be
associated with low birth weight neonate(14-16). On the
other hand, pregnant women who gained more weight
than recommended were shown to be associated with
fetal macrosomia(16-19).
Thai Siriraj recommendations for gestational
weight gain in Thai population were published in 2014(20).
In that study, more women would be classified as
gaining weight appropriately than using IOM
recommendations with similar pregnancy outcomes.
In addition, these pregnant women had less
complications such as fetal macrosomia, cesarean
section, preeclampsia compared with those who gained
more or less than recommended(20). The current study
aimed to compare the pattern of gestational weight gain
of our population (Prapokkloa hospital: A hospital-based
study) with the U.S.IOM and Thai Siriraj recommendations.
Materials and Methods
VOL. 24, NO. 3, JULY 2016 Thanaratsiriworakul K, et al., Comparison of Gestational Weight Gain Recommendations
between Study from Thai Population and U.S. Institute of Medicine
This study was a retrospective study. The data
were collected from medical records of 1,657 singleton
pregnant women who delivered at the Department of
Obstetrics and Gynecology, Faculty of Medicine,
Prapokkloa Hospital between July 1st, 2013 and June
30 th, 2014. The study protocol was approved by
Prapokklao Institute Review Board.
Inclusion criteria were Thai singleton pregnant
women who delivered between 37 and 41+6 weeks’
gestation of a normal neonates with birth weight
between 2,500 and 4,000 grams (g). Gestational weight
gain was measured as the maternal weight at delivery
minus pre-pregnancy weight or weight at the initial of
pregnancy (kg). The pre-pregnancy weight was defined
as the body weight prior to pregnancy by self-report at
first antenatal visit. Pre-pregnancy BMI was calculated
as weight divided by height squared (kg/m2). Cases with
incomplete data were excluded. All subjects were
divided into 4 groups according to U.S.IOM 2009(13),
underweight (BMI <18.5 kg/m2), normal weight (BMI
18.5-24.9 kg/m2), overweight (BMI 25.0-25.9 kg/m2),
and obesity (BMI ≥30 kg/m 2). According to Thai
gestational weight gain recommendation(20), optimal
gestational weight gain for each pre-pregnancy BMI
group was categorized as follows: 10-18 kg for the
underweight group, 8-16 kg for normal weight group,
6-14 kg for the overweight group and 4-8 kg for the
obese group.
Maternal age (year), gestational age at delivery
(weeks), parity, maternal height (cm), pre-pregnancy
weight (kg), gestational weight gain (kg), mode of
delivery, neonatal birth weight (grams), and Apgar score
at 1 minute and 5 minutes were recorded. Statistical
analysis was performed using SPSS software version
19.0. Mean, standard deviation, and percentage were
used to analyze. One-way ANOVA test was used to
compare differences in maternal age, maternal height,
pre-pregnancy BMI, gestational age at delivery,
gestational weight gain, and neonatal birth weight.
Chi-squared test was used to compare discrete data
among groups for parity, mode of delivery, and Apgar
score. P-value of less than 0.05 was considered to be
statistically significant difference.
163
Result
From medical record review, there were 1,657
pregnant women who met our inclusion criteria.
Demographic data of the participants were shown in
Table 1. Most of themhad normal weight (58.12%).
Table 2 compared the characteristics of sample
classified by pre-pregnancy BMI. Significant difference
was found among groups of all variables. The data
showed that pre-pregnancy underweight women were
significant younger than others (p<0.001). Regarding
to gestational weight gain, pre-pregnancy obese group
had less weight gain than others (p<0.001) while there
was no difference in gestational weight gain between
underweight and normal pre-pregnancy BMI groups
(p<0.001). Neonatal birth weight of pre-pregnancy
underweight group was found to be lowest (p<0.001).

Table 1. Population’s characteristics.

Characteristics (mean±SD) /n (%)

Maternal age(year) 26.94±7.0
Nulliparous 607 (36.6)
Pre-pregnancy weight (kg) 55.15±12.07
Height (cm) 158±5.81
Pre-pregnancy body mass index groups
Underweight 328 (19.79)
Normal weight 963 (58.12)
Overweight 260 (15.69)
Obesity 106 (6.4)
Weight gain during pregnancy (kg) 12.92±5.88
Gestational age at delivery (weeks) 38±1.0
Mode of delivery
Normal labor 1015 (61.26)
Cesarean section 595 (35.91)
Vacuum extraction 26 (1.57)
Forceps extraction 19 (1.15)
Breech assisting 2 (0.12)
Neonatal birthweight (grams) 3103±335.63

Table 2. Characteristics of the study population classified by pre-pregnancy BMI.

underweight normal weight overweight Obesity P

(n=328) (n=963) (n=260) (n=106)
mean ± SD mean ± SD mean ± SD mean ± SD
Age (year) 23.9±6.1 26.9±7.11 29.8±6.79 29.3±5.46 <0.001*
Pre-pregnancy BMI (kg/m ) 2
17.06±1.12 21.32±1.79 26.89±1.56 33.78±3.51 <0.001*
Gestational weight gain (kg) 13.73±5.43 13.52±5.63 11.35±5.65 8.81±7.41 <0.001*
Neonatal birth weight (grams) 2998.1±318.19 3108±339.05 3182±314.76 3189±325.85 <0.001*
*p<0.05 was considered to be statistical significance, One way ANOVA test was used to compare between groups.

164 Thai J Obstet Gynaecol VOL. 24, NO. 3, JULY 2016

 All data were compared between two regimens
as showed in Table 3. When using U.S.IOM
recommendations for total maternal weight gain during
pregnancy, 34.76% of underweight group and 37.28%
of normal weight group gained their weight within the
recommended ranges. About half of women in
overweight and obese groups gained their weight over
the recommendations (49.62% and 44.34%,
respectively). Using Thai Siriraj recommendations,
majority of underweight (56.10%), normal weight
(60.33%), and overweight groups (54.23%) gained their
weight within the recommended ranges. Approximately
half of obese women were classified by both sets of
recommendations as gaining weight over recommended
(IOM vs Thai Siriraj = 44.34% vs 52.83%). In addition,
in the underweight and normal weight groups, both
regimes rendered exactly the same proportions of
women who gained more than recommended.
Comparison of demographic characteristics and
pregnancy outcomes of women who gained weight
appropriately by both sets of recommendations was
shown in Table 4.
Maternal age, parity, pre-pregnancy weight, pre-
pregnancy BMI, gestational age at delivery, mode of
delivery, and Apgar score were not significantly different
among both groups. Two small differences between
women in U.S.IOM and Thai Siriraj recommendations
were the gestational weight gain (U.S.IOM: Thai Siriraj
= 13:12), and neonatal birth weight (U.S.IOM: Thai
Siriraj = 3,126: 3,084 g).

Table 3. Comparison between the U.S.IOM and Thai Siriraj recommendation of gestational weight gain in each
BMI group.

Maternal BMI group

n=1657
underweight normal weight overweight obesity
(n=328) (n=963) (n=260) (n=106)

Guideline U.S. Thai U.S. Thai U.S. Thai U.S. Thai

Under the 144 74 343 121 58 46 29 23
Recommendation (43.90) (22.56) (35.62) (12.56) (22.31) (17.69) (27.36) (21.70)
n (%)
Appropriate to 114 184 359 581 73 141 30 27
Recommendation (34.76) (56.10) (37.28) (60.33) (28.08) (54.23) (28.30) (25.47)
n (%)
Over the 70 70 261 261 129 73 47 56
Recommendation (21.34) (21.34) (27.10) (27.10) (49.62) (28.08) (44.34) (52.83)
n (%)
U.S., U.S. Institute of Medicine recommendation(13)
U.S.IOM recommendation for underweight, normal weight, overweight, obese groups were 12.5-18 kg, 11.5-16 kg, 7.5-11 kg,
5-9 kg, respectively.
Thai, Thai Siriraj hospital recommendation(19)
Thai Siriraj hospital recommendation for underweight, normal weight, overweight, obese groups were 10-18 kg, 8-16 kg,
6-14 kg, 4-8 kg, respectively.

VOL. 24, NO. 3, JULY 2016 Thanaratsiriworakul K, et al., Comparison of Gestational Weight Gain Recommendations 165
between Study from Thai Population and U.S. Institute of Medicine
Table 4. Comparison of demographic characteristics and pregnancy outcomes between pregnant women whose
gestational weight gain adhered to recommendation from U.S.IOM and Thai Siriraj.

Characteristics Using U.S.IOM 2009 Using Thai Siriraj hospital P

recommendation recommendation
n=576 (34.76%) study 2014
mean±SD n=933 (56.31%)
mean±SD
Maternal age(year) 27.25±6.88 27.24±6.98 0.985
Parity, n (%)
0 200 (34.72%) 317 (33.98%)
≥1 376 (65.28%) 616 (66.02%) 0.823
Pre-pregnancy weight (kg) 54.31±10.39 53.79±9.94 0.338
Height (cm) 157±5.73 157±5.52 0.145
Body mass index (kg/m2) 21.82±3.40 21.73±3.79 0.640
Gestational age at delivery (weeks) 38±1.14 38±1.11 0.685
Gestational weight gain (kg) 13.20±2.59 12.09±2.73 <0.001*
Neonatal birth weight (grams) 3126±321.99 3084±324.01 0.014*
Mode of delivery, n (%)
Vaginal delivery 380 (65.97%) 614 (65.81%)
Cesarean section 196 (34.03%) 319 (34.19%) 0.955
Apgar
At 1 min, n (%)
<7 11 22
≥7 565 911 0.718
At 5 min, n (%)
<7 2 5
≥7 574 928 0.715
*p<0.05 was considered to be statistical significance

Discussion appropriate gestational weight gain has been

Proper gestational weight gain is one of the
dominant factor for optimal pregnancy outcomes.
Excessive weight gain can lead to an unhealthily large
fetus(21). Large fetuses (>4,000 g) have many risks such
as shoulder dystocia, birth trauma, hypoglycemia, and
stillbirth(22-25). On the other hand, poor weight gain has
been linked to low birth weight (<2,500 g) which
increase risks of perinatal morbidity, mortality (26),
neonatal death, long-term learning and cognitive
problems in adolescents(27-29). Appropriate gestational
weight gain is one aspect that brings about good
maternal and fetal outcomes. According to U.S.IOM,
recommended for any pre-pregnancy BMI group(13).
Asian population have different anthropometry from
American population (30, 31). Several authors have
reported new recommendations appropriate for their
population(32). In 2014, Siriraj Hospital reported new
recommendations for gestational weight gain and
claimed that they were more suitable for Thai people
than U.S.IOM(20).
In our study, significant differences between pre-
pregnancy BMI groups were found. Pre-pregnancy
women in underweight group were younger than others.
Obese women had the largest fetuses than others

166 Thai J Obstet Gynaecol VOL. 24, NO. 3, JULY 2016

(p<0.001). There were some previous studies reporting
the association between pre-pregnancy BMI and
neonatal birth weight(9-11). If appropriate gestational
weight gain associates with the good pregnancy
outcome, all pregnant women should gain their weight
following the recommendations. In our study, our
population could comply with the Thai Siriraj
re c o m m e n d a t i o n s b e tte r t h a n t h e U. S. I O M
recommendations in all groups except for obese group.
Comparison of demographic characteristics and
pregnancy outcomes between pregnant women whose
gestational weight gain was within the recommendations
from U.S.IOM and Thai Siriraj was shown in Table 4.
There were two slightly significant differences between
groups (gestational weight gain and neonatal birth
weight). Although neonatal birth weight was statistically
different among groups, it was deemed non-clinically
different. Moreover, Apgar score at 5 minute which
predict neonatal outcome(33) was comparable. Our
population could comply with the Thai Siriraj
recommendations more than U.S.IOM recommendation
(Thai Siriraj: U.S.IOM= 56.3%: 34.8%).
Our data suggest that target gestational weight
gain recommended by U.S.IOM have to be adjusted for
Thai pregnant women. This can be explained by
difference of anthropometry between Thai and U.S.
population. This result is similar to a previous study in
Taiwanese women and IOM 2009 might need some
adjustment because, compared to the previous IOM
recommendations in 1990, IOM 2009 recommendations
are associated with lower risk of LGA but higher risk of
SGA(34). In our study, the overweight and obese women
tended to gain more weight than recommended. Other
studies also reported similar findings in women with a
high BMI(35, 36).
We concluded that U.S.IOM recommendations
may be less suitable for Thai pregnant women than Thai
Siriraj recommendations for a woman to deliver a
normal birth weight neonate.
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