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Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines; Rasmussen KM, Yaktine AL, editors. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington (DC): National Academies Press (US); 2009.

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Weight Gain During Pregnancy: Reexamining the Guidelines.

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DSummary of Determinants of Gestational Weight Gain

Table D-1 summarizes the literature that is referenced and discussed in Chapter 4, Determinants of Gestational Weight Gain.

TABLE D-1Summary of Literature on Determinants of Gestational Weight Gain

 MediaThe 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
Robinson, 1999
Kunkel, 2001
Hastings et al., 2003
Epstein et al., 2008
 Culture and AcculturationThe 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, 1985Scribner and Dwyer, 1989
Cabral et al., 1990
Kleinman et al., 1991
Rumbaut and Weeks, 1996
Singh and Yu, 1996
Fuentes-Afflick and Lurie, 1997
Schaffer et al., 1998
Jones and Bond, 1999
King, 2000
Callister and Birkhead, 2002
Lizarzaburu and Palinkas, 2002
Hubert et al., 2005
Baker and Hellerstedt, 2006
Hernandez-Valero et al., 2007
Fuentes-Afflick and Hessol, 2008
 Health ServicesThe 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
Olds et al., 1986
Bruce and Tchabo, 1989
Brown et al., 1992
Morris et al., 1993
Hickey, 2000
 PolicyExamples 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
ACOG, 2005
Power et al., 2006
Stotland et al., 2005
Joyce et al., 2008
 AltitudeJensen 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
 Environmental ToxicantsThe 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
 Natural and Man-made DisastersThe 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
Glynn et al., 2001
Lederman et al., 2004
Eskenazi et al., 2007
Landrigan et al., 2008
 Access to Healthy FoodsThe 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
 Opportunities for Physical ActivityLaraia 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
 Family ViolenceSeveral 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
Boy and Salihu, 2004
Moraes et al., 2006
 Marital StatusSeveral 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
Olsen and Strawderman, 2003
 Partner and Family SupportThe 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
Gutierrez, 1999
Dipietro et al., 2003
Non-modifiable Maternal Factors
 Genetic CharacteristicsThe 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
Alevizaki et al., 2000
Dishy et al., 2003
Tsai et al., 2004
Fallucca et al., 2006
Tok et al., 2006
 Epigenetics and Developmental ProgrammingThe 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
 Prepregnancy BMIGestational 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
 Preexisting MorbiditiesThe 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
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
Howie et al., 2003
Nielsen et al., 2006
Chen et al., 2007
Groth, 2007
Sociodemographic Factors:
 Older Women
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
Endres et al., 1987
Cnattingius et al., 1992
Prysak et al., 1995
Fretts, 2005
Joseph et al., 2005
Reddy et al., 2006
Delpisheh et al., 2008
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.
Sociodemographic Factors:
 Food Insecurity
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 insecurityAnderson, 1990
Polivy, 1996
Frongillo et al., 1997
Olson, 1999
Townsend et al., 2001
Adams et al., 2003
Basiotis and Lino, 2003
Crawford et al., 2004
Drewnowski and Darmon, 2005
Wilde and Peterman, 2006
Jones and Frongillo, 2007
Olson and Strawderman, 2008
Potentially Modifiable Maternal Factors
Physiological Factors:
 Insulin, Leptin, and Hormonal Milieu
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
Catalano et al., 1993
Catalano et al., 1998
Highman et al., 1998
Catalano et al., 1999
Kirwan et al., 2002
Cnop, 2003
Okereke et al., 2004
Retnarkaran et al., 2004
Williams et al., 2004
Winzer et al., 2004
Hauguel-de Mouzon et al., 2006
Pinar et al., 2008
Physiological Factors:
 Basal Metabolic Rate (BMR)
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
Forsum et al., 1985
Lawrence et al., 1985
Durnin, 1991
Goldberg et al., 1993
Butte et al., 2004
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
Vilming and Nesheim, 2000
Furneaux et al., 2001
Goodwin, 2002
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
Wisner et al., 2007
Bulik et al., 2008
Medical Factors: Bariatric SurgeryThree 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
Skull et al., 2004
Dixon et al., 2005
Santry et al., 2005
Davis et al., 2006
Ducarme et al., 2007
Psychological Factors:
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
Abraham et al., 2001
Walker and Kim, 2002
Dipietro et al., 2003
Bodnar et al., 2009
Psychological Factors:
The committee found no robust association between stress and gestational weight gain.Picone et al., 1982Orr et al., 1996Rondo et al., 2003Brawarksy et al., 2005Dominguez et al., 2005
Psychological Factors: Social SupportThe committee found inconclusive evidence for the role of social support in gestational weight gain.Casanueva et al., 1994
Hickey et al., 1995
Olson and Strawderman, 2003
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
Copper et al., 1995
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
Bergmann, 1997
Clapp, 2002
Lagiou et al., 2004
Olafsdottir et al., 2006
Deierlein et al., 2008
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
Clapp and Little, 1995
Sternfeld et al., 1995
Stevenson, 1997
Abrams et al., 2000
Hinton and Olson, 2001
Kramer and Kakuma, 2003
Siega-Riz et al., 2004
Morris and Johnson, 2005
Artal et al., 2007
Haakstad et al., 2007
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
Garn et al., 1979
Haworth et al., 1980
Papoz et al., 1982
Little et al., 1986
Graham et al., 1992
Stevens-Simon and McAnarney,1992

Wolff et al., 1993
Jacobsen et al., 1994
Adriananse et al., 1996
Bagheri et al., 1998
Wagner et al., 1998
Seckler-Walker and Vacek, 2003
Furuno et al., 2004
Ogunyemi and Hernandez-Loera, 2004

Smith et al., 2006
Wells et al., 2006
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
Siega-Riz and Hobel, 1997
Kost et al., 1998
Wells et al., 2006
Energy BalanceThe 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 non-pregnant individuals.
Vulnerable Populations:
Seasonal Migrant Workers
Pregnancy Nutrition Surveillance System (PNSS) found that migrant women had lower gestational weight gain than non-migrant 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:
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
Haas and Pazdernik, 2006
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
Martin et al., 1997b
Bell, 2004


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Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK32822


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