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WEIGHT GAIN
PREGNANCY
DURING
REEX A M I N I N G T H E G U I D E L I N E S
Kathleen M. Rasmussen and Ann L. Yaktine, Editors
Committee to Reexamine IOM Pregnancy Weight Guidelines
Food and Nutrition Board
Board on Children, Youth, and Families
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for their
special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSH250200446009I TO HHSH240G5806 be-
tween the National Academy of Sciences and U.S. Department of Health and Human Services
Health Resources and Services Administration; Contract No. 200-2007-M-21619 between
the National Academy of Sciences and Centers for Disease Control and Prevention Division
of Nutrition, Physical Activity and Obesity; Contract No. N01-OD-4-2139 TO 192 between
the National Academy of Sciences and National Institutes of Health Eunice Kennedy Shriver
National Institute of Child Health and Human Development; Contract No. N01-OD-4-2139
TO 192 between the National Academy of Sciences and National Institutes of Health National
Institute of Diabetes and Digestive and Kidney Diseases; Contract No. HHSP23300700522P
between the National Academy of Sciences and U.S. Department of Health and Human Ser-
vices Office on Women’s Health; Contract No. HHSP23320070071P between the National
Academy of Sciences and U.S. Department of Health and Human Services Office of Disease
Prevention and Health Promotion; and Contract No. 21-FY07-576 between the National
Academy of Sciences and March of Dimes. Additional support came from U.S. Department
of Health and Human Services Office of Minority Health and the National Minority AIDS
Council. Any opinions, findings, conclusions, or recommendations expressed in this publica-
tion are those of the author(s) and do not necessarily reflect the view of the organizations or
agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Weight gain during pregnancy : reexamining the guidelines / Kathleen M. Rasmussen and
Ann L. Yaktine, editors ; Committee to Reexamine IOM Pregnancy Weight Guidelines,
Food and Nutrition Board and Board on Children, Youth, and Families.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-309-13113-1 (hardback)
1. Pregnant women—Weight gain. I. Rasmussen, Kathleen M. II. Yaktine, Ann L. III.
Institute of Medicine (U.S.). Committee to Reexamine IOM Pregnancy Weight Guidelines.
[DNLM: 1. Prenatal Care—United States. 2. Weight Gain—United States. 3. Practice
Guidelines as Topic—United States. 4. Pregnancy—United States. 5. Pregnancy
Complications—prevention & control—United States. WQ 175 W419 2009]
RG559.P39 2011
618.2′4—dc22 2009033438
Additional copies of this report are available from the National Academies Press, 500 Fifth
Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in
the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.
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Copyright 2009 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The serpent adopted as a logotype by
the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche
Museen in Berlin.
Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2009.
Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: The National
Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
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the National Research Council.
www.national-academies.org
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COMMITTEE TO REEXAMINE
IOM PREGNANCY WEIGHT GUIDELINES
KATHLEEN M. RASMUSSEN (Chair), Professor of Nutrition, Division
of Nutritional Sciences, Cornell University, Ithaca, NY
BARBARA ABRAMS, Professor, School of Public Health, University of
California–Berkeley
LISA M. BODNAR, Assistant Professor, Department of Epidemiology,
University of Pittsburgh, PA
CLAUDE BOUCHARD, Executive Director and George A. Bray Chair in
Nutrition, Pennington Biomedical Research Center, Baton Rouge, LA
NANCY BUTTE, Professor of Pediatrics, Baylor College of Medicine,
Houston, TX
PATRICK M. CATALANO, Chair, Department of Obstetrics and
Gynecology, Case Western Reserve University, Cleveland, OH
MATTHEW W. GILLMAN, Professor, Department of Ambulatory Care
and Prevention, Harvard Medical School and Harvard Pilgrim Health
Care, Boston, MA
FERNANDO A. GUERRA, Director of Health, San Antonio
Metropolitan Health District, TX
PAULA A. JOHNSON, Executive Director, Connors Center for Women’s
Health and Gender Biology, Chief, Division of Women’s Health,
Brigham and Women’s Hospital, Boston, MA
MICHAEL C. LU, Associate Professor of Obstetrics, Gynecology, and
Public Health, Schools of Medicine and Public Health, University of
California–Los Angeles
ELIZABETH R. McANARNEY, Professor and Chair Emerita,
Department of Pediatrics, School of Medicine and Dentistry,
University of Rochester, NY
RAFAEL PÉREZ-ESCAMILLA, Professor of Nutritional Sciences &
Public Health, Director, NIH EXPORT Center for Eliminating Health
Disparities Among Latinos, University of Connecticut, Storrs
DAVID A. SAVITZ, Charles W. Bluhdorn Professor of Community
& Preventive Medicine, Director, Epidemiology, Biostatistics, and
Disease Prevention Institute, Mount Sinai School of Medicine, New
York, NY
ANNA MARIA SIEGA-RIZ, Associate Professor, Department of
Epidemiology, School of Public Health, University of North
Carolina–Chapel Hill
Study Staff
ANN L. YAKTINE, Senior Program Officer
HEATHER B. DEL VALLE, Research Associate
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M. JENNIFER DATILES, Senior Program Assistant
ANTON BANDY, Financial Officer
GERALDINE KENNEDO, Administrative Assistant
LINDA D. MEYERS, Food and Nutrition Board Director
ROSEMARY CHALK, Director, Board on Children, Youth, and Families
i
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Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with proce-
dures approved by the National Research Council’s (NRC’s) Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
Haywood Brown, Department of Obstetrics and Gynecology, Duke
University Medical Center, Durham, NC
Cutberto Garza, Boston College, MA
Susan Gennaro, William F. Connell School of Nursing, Boston Col-
lege, MA
William Goodnight, Department of Obstetrics and Gynecology, Divi-
sion of Maternal-Fetal Medicine, University of North Carolina–
Chapel Hill School of Medicine
Erica P. Gunderson, Division of Research, Kaiser Permanente, Oak-
land, CA
Maxine Hayes, Department of Health, State of Washington,
Tumwater
ii
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iii REVIEWERS
Lorraine V. Klerman, The Heller School for Social Policy and Man-
agement, Brandeis University, Waltham, MA
Kristine G. Koski, School of Dietetics and Human Nutrition, McGill
University, Ste. Anne de Bellevue, Quebec, Canada
Charles Lockwood, Department of Obstetrics, Gynecology, and
Reproductive Sciences, Yale University School of Medicine, New
Haven, CT
Dawn Misra, Division of Epidemiology and Biostatistics, Department
of Family Medicine and Public Health Sciences, Wayne State
University School of Medicine, Detroit, MI
Jose M. Ordovas, Nutrition and Genomics Laboratory, Jean Mayer
USDA Human Nutrition Research Center on Aging, Tufts Uni-
versity, Boston, MA
Roy M. Pitkin, University of California–Los Angeles (Professor
Emeritus)
David Rush, Friedman School of Nutrition Science and Policy (Pro-
fessor Emeritus), Tufts University, Boston, MA
Jeanette South-Paul, Department of Family Medicine, University of
Pittsburgh, PA
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before
its release. The review of this report was overseen by Neal A. Vanselow,
Tulane University, Professor Emeritus and Nancy E. Adler, Departments of
Psychiatry and Pediatrics and Center for Health and Community, University
of California–San Francisco.
Appointed by the NRC and Institute of Medicine, they were responsible
for making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of
this report rests entirely with the authoring committee and the institution.
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Preface
In the last century, many answers have been given by health profession-
als to the question “how much weight should I gain while I am pregnant?”
In the early 1900s, the answer was often only 15-20 pounds. Between 1970
and 1990, the guideline for weight gain during pregnancy was higher, 20-25
pounds, and in 1990, with the publication of Nutrition During Pregnancy,
it went higher still for some groups of women. This most recent guideline
reflected new knowledge about the importance of maternal body fatness
before conception, as measured by body mass index, for the outcome of
pregnancy. It had become clear that heavier women could gain less weight
and still deliver an infant of good size. Since that time, the obesity epidemic
has not spared women of reproductive age. In our population today, more
women of reproductive age are severely obese (obesity class III; 8 percent)
than are underweight (3 percent), and their short- and long-term health
has become a concern in addition to the size of the infant at birth. Clearly
the time had come to reexamine the guidelines for weight gain during
pregnancy.
To prepare for this possibility, the National Research Council and
the Institute of Medicine held a workshop in 2006 to evaluate the avail-
ability of data that could be used to reexamine the current guidelines.
Based on the outcome of this workshop, numerous federal agencies (U.S.
Department of Health and Human Services Health Resources and Services
Administration; Centers for Disease Control and Prevention Division of
Nutrition and Physical Activity and Obesity; National Institutes of Health
Eunice Kennedy Shriver National Institute of Child Health and Human
ix
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x PREFACE
Development; National Institutes of Health National Institute of Diabetes
and Digestive and Kidney Diseases; U.S. Department of Health and
Human Services Office on Women’s Health; U.S. Department of Health
and Human Services Office of Disease Prevention and Health Promotion;
March of Dimes; with additional support from U.S. Department of Health
and Human Services Office of Minority Health and the National Minority
AIDS Council) agreed to sponsor the work of this committee.
The committee was asked to review the determinants and a wide range
of short- and long-term consequences of variation in weight gain during
pregnancy for both the mother and her infant. Based on the outcome of
this review, the committee was asked to recommend revisions to the current
guidelines if this was deemed to be necessary. In addition, the committee
was asked to consider the approaches that might be necessary to promote
appropriate weight gain and to identify gaps in knowledge and make rec-
ommendations about priorities for future research.
Although many studies relevant to the committee’s charge have been
published since 1990 and the Agency for Healthcare Research and Quality
(AHRQ) completed its report Outcomes of Maternal Weight Gain while
the committee was gathering data, many gaps in knowledge remained.
To address this problem, the committee held a public session with project
sponsors, and two workshops. We are grateful to those who participated in
these sessions for sharing their experience and wisdom. We are also grate-
ful to a number of individuals who supplied data to the committee: Raul
Artal, Amy Branum, Marie Cedergren, Aimin Chen, K.S. Joseph, Sharon
Kirmeyer, Joyce Martin, Alan Ryan, and Andrea Sharma, with special
thanks to Patricia Dietz. The committee also commissioned additional
analyses of data from both Denmark and the United States. We thank our
consultants, Amy Herring, Ellen Aagaard Nohr, and Cheryl Stein for these
analyses and for their contributions to the committee’s work. The commit-
tee also felt that it was important to understand what would be involved
in analyzing the trade-off between mother and infant in risk of adverse
outcomes of variation in weight gain during pregnancy. To accomplish this,
we commissioned such an analysis based on the data at hand. We thank
our consultant, James Hammitt, for conducting these analyses and for his
contribution to the committee’s work.
The committee’s 14 members gave freely of their expertise and volun-
teered their time and energy in all aspects of the preparation of this report,
from developing its intellectual framework, writing the text, and deliberat-
ing about the recommendations and conclusions of the report. Their efforts
merit our sincere gratitude.
The committee received excellent staff support from Ann Yaktine,
Study Director, Heather Del Valle, Research Associate, and Jennifer Datiles,
Senior Program Assistant. Their effort on our behalf is sincerely appreci-
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xi
PREFACE
ated. We also thank Leslie Pray for technical editing and Florence Poillon
for copyediting. Both the Director of the Food and Nutrition Board, Linda
Meyers, and the Director of the Board on Children, Youth, and Families,
Rosemary Chalk, contributed their wisdom and support to this effort, and
we thank them for it.
Kathleen M. Rasmussen, Chair
Committee to Reexamine IOM Pregnancy Weight Guidelines
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Contents
SUMMARY 1
1 Setting the Stage for Revising Pregnancy Weight Guidelines:
Conceptual Framework 13
2 Descriptive Epidemiology and Trends 25
3 Composition and Components of Gestational Weight Gain:
Physiology and Metabolism 71
4 Determinants of Gestational Weight Gain 111
5 Consequences of Gestational Weight Gain for the Mother 173
6 Consequences of Gestational Weight Gain for the Child 195
7 Determining Optimal Weight Gain 241
8 Approaches to Achieving Recommended Gestational
Weight Gain 263
9 Open Session and Workshop Agendas 281
10 Committee Member Biographical Sketches 287
APPENDIXES*
A Acronyms and Abbreviations, Glossary, and
Supplemental Information 295
B Supplementary Information on Nutritional Intake 315
*
Appendixes A through G are not printed in this book, but can be found on the CD at the
back of the book or online at http://www.nap.edu/catalog.php?record_id=12584.
xiii
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xi CONTENTS
C Supplementary Information on Composition and
Components of Gestational Weight Gain 329
D Summary of Determinants of Gestational Weight Gain 365
E Results from the Evidence-Based Report on Outcomes of
Maternal Weight Gain 389
F Data Tables 641
G Consultant Reports 707
INDEX 843
