TABLE D-1 Summary of Literature on Determinants of Gestational Weight Gain
Determinants |
Findings/Interpretations |
Comments |
References |
Societal/Institutional |
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Media |
The committee was unable to identify studies that examined specifically the media’s influence on gestational weight gain. |
Media may exert its effects on gestational weight gain indirectly by influencing prepregnancy BMI and other biological determinants, as well as eating habits and sedentary behaviors that are established well before pregnancy. |
Gortmaker et al., 1996 |
Gortmaker et al., 1999 |
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Robinson, 1999 |
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Kunkel, 2001 |
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Hastings et al., 2003 |
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Epstein et al., 2008 |
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Culture and Acculturation |
The committee was unable to identify studies that examined specifically the effects of culture and acculturation factors on gestational weight gain. |
Cultural norms and beliefs can influence dietary behavior and physical activities, thereby affecting energy balance and gestational weight gain. Acculturation is generally associated with more unhealthy behaviors, including dietary intake, and higher rates of overweight and obesity. |
Ventura and Taffel, 1985 |
Scribner and Dwyer, 1989 |
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Cabral et al., 1990 |
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Kleinman et al., 1991 |
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Rumbaut and Weeks, 1996 |
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Singh and Yu, 1996 |
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Fuentes-Afflick and Lurie, 1997 |
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Schaffer et al., 1998 |
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Jones and Bond, 1999 |
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King, 2000 |
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Callister and Birkhead, 2002 |
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Lizarzaburu and Palinkas, 2002 |
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Hubert et al., 2005 |
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Baker and Hellerstedt, 2006 |
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Hernandez-Valero et al., 2007 |
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Fuentes-Afflick and Hessol, 2008 |
Health Services |
The committee found insufficient evidence to evaluate the influence of prenatal weight gain advice on actual gestational weight gain. |
Studies limited by self-selection bias, recall bias, differences in time during gestation when nutrition advice was given, variation in content and frequency of advice, the pairing of advice with other food or nonfood interventions, individual and social characteristics of the provider as contrasted with those of the pregnant woman, and racial-ethnic and socioeconomic disparities in weight gain advice given to women. |
Rush, 1981 |
Orstead et al., 1985 |
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Olds et al., 1986 |
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Bruce and Tchabo, 1989 |
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Brown et al., 1992 |
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Morris et al., 1993 |
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Hickey, 2000 |
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Policy |
Examples include IOM guidelines, WIC programs, and policy recommendations to restrict food/beverage marketing to young children. IOM guidelines appear to influence what women believe to be appropriate weight gain during pregnancy. A national evaluation of WIC programs found a reversal of low weight gain in early pregnancy and greater total weight gain during pregnancy among women who enrolled in WIC compared with controls. |
The impact of the IOM guidelines on actual gestational weight gain may be limited in part because many health professionals are providing no or inappropriate advice about weight gain during pregnancy. More research on implementation of gestational weight gain guidelines is needed. |
Rush et al., 1988 |
Cogswell et al., 1999 |
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ACOG, 2005 |
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Power et al., 2006 |
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Stotland et al., 2005 |
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Joyce et al., 2008 |
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Environmental |
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Altitude |
Jensen and Moore (1997) did not find any significant difference in gestational weight gain among women residing at 3,000 to 5,000 feet, 5,000 to 7,000 feet, 7,000 to 9,000 feet, and 9,000 to 11,000 feet. |
The decline in birth weight associated with increase in altitude appears to be independent of gestational weight gain. |
Jensen and Moore, 1997 |
Determinants |
Findings/Interpretations |
Comments |
References |
Environmental Toxicants |
The committee was unable to identify studies that examined specifically the effects of exposures to environmental toxicants on gestational weight gain. |
More research is needed on the relationships among environmental toxicants, gestational weight gain, and fetal growth. |
Dar et al., 1992 |
Wolff et al., 2007 |
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Natural and Man-made Disasters |
The committee was unable to identify studies that examined specifically the effects of natural or man-made disasters on gestational weight gain. |
Disasters can affect gestational weight gain by influencing resource availability (including food supply), healthcare access, and stress levels. |
Weissman et al., 1989 |
Cordero, 1993 |
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Glynn et al., 2001 |
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Lederman et al., 2004 |
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Eskenazi et al., 2007 |
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Landrigan et al., 2008 |
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Neighborhood/Community |
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Access to Healthy Foods |
The committee found no direct evidence for the influence of neighborhood or community factors such as access to healthy foods on gestational weight gain. |
Laraia et al. found pregnant women who live more than four miles from a supermarket had a two-fold greater risk of falling into the lowest Diet Quality Index quartile compared to women who lived ≤ 2 miles from a supermarket, but the authors also did not report on gestational weight gain. |
Laraia et al., 2004 |
Lane et al., 2008 |
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Opportunities for Physical Activity |
Laraia et al. (2007) found that social spaces were associated with decreased odds for inadequate or excessive gestational weight gain. |
Neighborhood environments can influence gestational weight gain by providing access to healthy foods and opportunities for physical activities. |
Laraia et al., 2007 |
Interpersonal/Family Determinants |
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Family Violence |
Several studies demonstrated lower weight gain and greater risk of inadequate weight gain among abused pregnant women. |
More research is needed. |
McFarlane et al., 1996 |
Siega-Riz and Hobel, 1997 |
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Boy and Salihu, 2004 |
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Moraes et al., 2006 |
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Marital Status |
Several studies found married women were more likely to gain within the IOM recommended weight gain range than single or separated/divorced women. |
More research is needed. |
Kleinman et al., 1991 |
Ventura, 1994 |
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Olsen and Strawderman, 2003 |
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Partner and Family Support |
The committee found insufficient evidence at this time to establish a relationship between partner support and gestational weight gain. |
More research is needed. |
Stevens-Simon et al., 1993b |
Parker et al., 1994 |
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Gutierrez, 1999 |
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Dipietro et al., 2003 |
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Non-modifiable Maternal Factors |
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Genetic Characteristics |
The committee was unable to identify studies of familial aggregation or heritability of gestational weight gain. Presently it is not possible to conclude firmly on the role of specific genes and alleles on gestational weight gain. |
Several studies have examined the effects of ADRB3 and Pro12Ala gene polymorphisms on gestational weight gain with mixed results. Studies lacked adequate statistical power to identify the effects of alleles or genotypes with a small effect size. |
Festa et al., 1999 |
Yanagisawa et al., 1999 |
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Alevizaki et al., 2000 |
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Dishy et al., 2003 |
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Tsai et al., 2004 |
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Fallucca et al., 2006 |
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Tok et al., 2006 |
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Epigenetics and Developmental Programming |
The committee was unable to identify studies that examined specifically the influence of epigenetic events and developmental programming on gestational weight gain. |
More research is needed. |
Fraga et al., 2005 |
Determinants |
Findings/Interpretations |
Comments |
References |
Prepregnancy BMI |
Gestational weight gain is generally inversely proportional to prepregnancy BMI. Chu et al. (2009) found that maternal pre pregnancy obesity was the strongest factor affecting maternal weight gain in pregnancy, with obese women reporting the lowest gestational weight gain. |
An important strategy for optimizing gestational weight gain is to help women achieve a healthy weight before pregnancy. |
Voigt et al., 2007 |
Chu et al., 2009 |
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Preexisting Morbidities |
The committee found no direct evidence for pre-existing morbidities as determinants of gestational weight gain. |
More research is needed on the influence of preconceptional health status of woman on gestational weight gain. |
Fonager et al., 1998 |
Non-modifiable Maternal Factors |
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Sociodemographic Factors: |
Several studies have demonstrated higher gestational weight gain among adolescents than adults; the relationships of adolescent gestational weight gain to birth outcomes, post-partum weight retention, and subsequent risk for overweight/obesity remain unclear and requires further research. |
The committee found that data generated between the IOM (1990) report and the present support the recommendation that “until more is known, adolescents less than two years post-menarche should be advised to stay within the IOM-recommended, BMI-specific weight range without either restricting weight gain or encouraging weight gain at the upper end.” |
Hediger et al., 1990 |
Adolescents |
Howie et al., 2003 |
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Nielsen et al., 2006 |
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Chen et al., 2007 |
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Groth, 2007 |
Sociodemographic Factors: |
Several studies reported higher prepregnancy BMI and lower gestational weight gain among older women. |
The contributions of gestational weight gain to birth outcomes, postpartum weight retention and subsequent overweight/obesity among older women remain unclear and require further research. |
Gross et al., 1980 |
Older Women |
Endres et al., 1987 |
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Cnattingius et al., 1992 |
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Prysak et al., 1995 |
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Fretts, 2005 |
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Joseph et al., 2005 |
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Reddy et al., 2006 |
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Delpisheh et al., 2008 |
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Sociodemographic Factors: |
The committee found that few of the studies reviewed considered the influence of the many possible determinants of gestational weight gain among different racial/ethnic groups or alternatively, adjusted for race/ethnicity in their analyses. |
|
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Race/Ethnicity |
|
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Sociodemographic Factors: |
Several studies have reported an association between food insecurity and overweight/obesity. Olson and Strawderman (2008) found that women who were both obese and food insecure in early pregnancy were at greatest risk of major gestational and postpartum weight gain, suggesting that food insecurity may play a role in gestational weight gain. |
Food restriction or deprivation, whether voluntary or involuntary, results in a variety of changes including the preoccupation with food and eating. Food-insecure households also tend to purchase calorie-dense foods that are often high in fats and added sugars in adaptation to their food insecurity |
Anderson, 1990 |
Food Insecurity |
Polivy, 1996 |
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Frongillo et al., 1997 |
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Olson, 1999 |
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Townsend et al., 2001 |
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Adams et al., 2003 |
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Basiotis and Lino, 2003 |
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Crawford et al., 2004 |
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Drewnowski and Darmon, 2005 |
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Wilde and Peterman, 2006 |
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Jones and Frongillo, 2007 |
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Olson and Strawderman, 2008 |
Determinants |
Findings/Interpretations |
Comments |
References |
Potentially Modifiable Maternal Factors |
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Physiological Factors: |
Gestational weight gain may be related to changes in insulin sensitivity during pregnancy which depends on maternal pregravid metabolic status. Both leptin and adiponectin are correlated with various components of maternal metabolism such as energy expenditure and adiposity, and may influence gestational weight gain by affecting maternal insulin sensitivity. |
|
Swinburn et al., 1991 |
Insulin, Leptin, and Hormonal Milieu |
Catalano et al., 1993 |
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Catalano et al., 1998 |
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Highman et al., 1998 |
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Catalano et al., 1999 |
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Kirwan et al., 2002 |
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Cnop, 2003 |
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Okereke et al., 2004 |
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Retnarkaran et al., 2004 |
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Williams et al., 2004 |
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Winzer et al., 2004 |
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Hauguel-de Mouzon et al., 2006 |
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Pinar et al., 2008 |
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Physiological Factors: |
BMR can influence total energy expenditure and gestational weight gain. Several studies have shown increased BMR during pregnancy, but change in BMR varies according to pregravid BMI. |
Wide variability in BMR change during pregnancy has been observed and makes recommendations related to energy intake difficult. |
Prentice et al., 1983 |
Basal Metabolic Rate (BMR) |
Forsum et al., 1985 |
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Lawrence et al., 1985 |
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Durnin, 1991 |
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Goldberg et al., 1993 |
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Butte et al., 2004 |
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Medical Factors: Hyperemesis Gravidarium |
Several studies have demonstrated lower gestational weight gain and birth weight among women with hyperemesis gravidarum. |
|
Gross et al., 1989 |
Goodwin et al., 1992 |
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Vilming and Nesheim, 2000 |
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Furneaux et al., 2001 |
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Goodwin, 2002 |
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Jewell and Young, 2003 |
Medical Factors: Anorexia Nervosa and Bulimia |
Sollid et al. (2004) found increased preterm delivery & SGA among women with eating disorders but did not obtain information on gestational weight gain. Kouba et al. (2005) found anorexic women gained less weight and had lower birth weight infants. |
|
Sollid et al., 2004 |
Kouba et al., 2005 |
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Wisner et al., 2007 |
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Bulik et al., 2008 |
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Medical Factors: Bariatric Surgery |
Three studies reported a decrease in gestational weight gain during a subsequent pregnancy in women who had bariatric surgery. |
Incidence of gestational diabetes and hypertensive disorders is lower in pregnancy following bariatric surgery; The effect of bariatric surgery on the risk of fetal macrosomia and birth weight are inconclusive. |
Gurewitsch et al., 1996 |
Marceau et al., 2004 |
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Skull et al., 2004 |
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Dixon et al., 2005 |
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Santry et al., 2005 |
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Davis et al., 2006 |
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Ducarme et al., 2007 |
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Psychological Factors: Depression |
The committee found that evidence in support of a relationship between depressive symptoms and gestational weight gain is inconclusive. |
Studies limited by lack of generalizability and control for confounding. Difficult to establish cause-effect from cross-sectional studies. |
Cameron et al., 1996 |
Casanueva et al., 2000 |
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Abraham et al., 2001 |
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Walker and Kim, 2002 |
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Dipietro et al., 2003 |
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Bodnar et al., 2009 |
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Psychological Factors: Stress |
The committee found no robust association between stress and gestational weight gain. |
|
Picone et al., 1982 |
Orr et al., 1996 |
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Rondo et al., 2003 |
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Brawarksy et al., 2005 |
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Dominguez et al., 2005 |
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Psychological Factors: Social Support |
The committee found inconclusive evidence for the role of social support in gestational weight gain. |
|
Casanueva et al., 1994 |
Hickey et al., 1995 |
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Olson and Strawderman, 2003 |
Determinants |
Findings/Interpretations |
Comments |
References |
Psychological Factors: Attitude Toward Low Weight Gain |
The committee found mixed evidence for the influences of maternal attitude on actual gestational weight gain. |
This relationship may vary according to maternal prepregnancy BMI. |
Palmer et al., 1985 |
Stevens-Simon et al., 1993a |
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Copper et al., 1995 |
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Behavioral Factors: Dietary Intake |
Several studies have demonstrated a relationship between energy intake and gestational weight gain. |
Dietary intake of certain types of foods may also influence gestational weight gain, but more research is needed. |
Campbell, 1975 |
Campbell, 1983 |
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Bergmann, 1997 |
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Clapp, 2002 |
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Lagiou et al., 2004 |
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Olafsdottir et al., 2006 |
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Deierlein et al., 2008 |
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Behavioral Factors: Physical Activity |
Several studies have demonstrated an inverse relationship between the level of physical activity and gestational weight gain. |
There is a need for appropriately powered randomized clinical trials designed to clarify the relationship between volume and intensity of physical activity regimens (dose) and maternal weight gain in women with various levels of pre-pregnancy BMI. |
Lokey et al., 1991 |
Ohlin and Rossner, 1994 |
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Clapp and Little, 1995 |
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Sternfeld et al., 1995 |
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Stevenson, 1997 |
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Abrams et al., 2000 |
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Hinton and Olson, 2001 |
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Kramer and Kakuma, 2003 |
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Siega-Riz et al., 2004 |
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Morris and Johnson, 2005 |
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Artal et al., 2007 |
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Haakstad et al., 2007 |
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Lof et al., 2008 |
Behavioral Factors: Substance Abuse |
Several studies examining associations between decreasing GWG and amount of reported smoking show inconclusive results. More recently, Furuno et al. (2004) found no significant difference in mean GWG between smoking and non-smoking mothers but did find an increased risk for low GWG among smokers. Little information is available about effects of alcohol consumption on GWG. Smith et al. (2006) found that those who used amphetamine in the first two trimesters but ceased use by the third trimester gained significantly more weight than either women who used throughout pregnancy or non-exposed women (p = 0.019), suggesting the anorexic effects of methamphetamine are limited to continuous use, and there may be a rebound in weight gain if the mother stops use. |
The major effects of substance use (cigarette smoking, alcohol and drug use) on birth outcomes (e.g., birth defects, SGA) appear to be independent of gestational weight gain. |
Rush, 1974 |
Hanson et al., 1978 |
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Garn et al., 1979 |
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Haworth et al., 1980 |
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Papoz et al., 1982 |
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Little et al., 1986 |
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Graham et al., 1992 |
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Stevens-Simon and McAnarney, 1992 |
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Wolff et al., 1993 |
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Jacobsen et al., 1994 |
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Adriananse et al., 1996 |
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Bagheri et al., 1998 |
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Wagner et al., 1998 |
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Seckler-Walker and Vacek, 2003 |
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Furuno et al., 2004 |
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Ogunyemi and Hernandez-Loera, 2004 |
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Smith et al., 2006 |
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Wells et al., 2006 |
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Behavioral Factors: Unintended Pregnancy |
The committee found data concerning the effect of unintended pregnancy on gestational weight gain to be conflicting. |
|
Marsiglio and Mott, 1988 |
Hickey et al., 1997 |
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Siega-Riz and Hobel, 1997 |
|||
Kost et al., 1998 |
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Wells et al., 2006 |
Determinants |
Findings/Interpretations |
Comments |
References |
Energy Balance |
The committee found that there remains a dearth of information to relate dietary intake or physical activity to gestational weight gain even though they are primary determinants of weight gain in nonpregnant individuals. |
|
|
Vulnerable Populations: Seasonal Migrant Workers |
Pregnancy Nutrition Surveillance System (PNSS) found that migrant women had lower gestational weight gain than nonmigrant women; however, the prevalence for adverse birth outcomes (low birth weight, very low birth weight, preterm birth, and small for gestational age) was similar for both groups. |
|
Reed et al., 2005 |
Vulnerable Populations: Military |
The committee was unable to identify studies that specifically examined gestational weight gain among women in military service. |
|
Magann and Nolan, 1991 |
O’Boyle et al., 2005 |
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Haas and Pazdernik, 2006 |
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Vulnerable Populations: Incarcerated Women |
The committee was unable to identify studies that specifically examined gestational weight gain among women who are incarcerated. |
Several studies suggest that birth outcomes of incarcerated pregnant women may be better, suggesting certain aspects of the prison environment, such as shelters and regular meals, may be protective particularly for high-risk pregnant women. |
Safyer and Richmond, 1995 |
Martin et al., 1997a |
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Martin et al., 1997b |
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Bell, 2004 |
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