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

Board on Children, Youth, and Families

INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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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. iom.edu. 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- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of 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