Maternal Weight and CareA LANDSCAPE REVIEW

PREPARED BY NICOLE LEE

Outline

Weight during pregnancy

Risk factors and outcomes

Maternal care cost drivers

Evidence on weight management

Recommendations for moving forward

Weight during pregnancy

IOM recommendations for GWG

2009 revisions

Preconception assessment and counseling, 1stTri monitoring and charting, 3rdTri intervention, postpartum counseling

Total weight gain for twins: normal weight (37-54 lbs)

overweight (31-50 lbs)

obese (25-42 lbs)

ACOG physical activity guidelines: 150 minutes/ week

Weight gain per week

Underweight

Normal weight

Overweight

Obese

singletons

BMI < 18.5 BMI 18.5 > 25

BMI 25 > 30

BMI > 30

1st trimester

1.1-4.4 lbs 0.5-4.4 lbs

2nd & 3rd trimesters

1-1.3 lbs 0.8-1 lb 0.5-0.7 lb 0.4-0.6 lb

Total gain

28-40 lbs 25-35 lbs

15-25 lbs 11-20 lbs

Siega-Riz, Deierlein, & Stuebe 2011

State of GWG

43% of pregnant women are overweight or obese according to CDC

At any given time, between a third to half of pregnant women have higher than normal BMI

Between a third to a half of pregnant women will exceed IOM guidelines for GWG

Average weight gain 12.5 kg, mostly in 2nd/3rd trimesters

Average postpartum weight retention: 11.8 lbs

Gunderson & Abrams, 1999; Fontaine et al, 2012; Ruifrok, et al, 2014; Guelinckx et al, 2008; Nicholson & Baptiste-Roberts, 2014; Walsh et al, 2014; Cohen & Koski, 2013

Risk factors and outcomes

Factors associated with weight gain

BMI negatively correlated with weight gain; obese women gain less, normal and overweight women gain more

1st trimester BMI associated with 3rd tri estimated fetal weight; both associated with birth weight

Predictors: accelerated water gain (not fat), high energy intake

Negative behavioral factors: eating dairy and fried foods, low body image

Positive behavioral factors factors: vigorous physical activity, vegetarians, increased sleep, older menarche

No typical demographic profile, but excessive gain more likely to occur in:

Adolescents (or younger ages), nulliparous women, smokers, women with multiple gestations

Suitor, 1997; Bogaerts et al, 2012; Stewart, Wallace & Allan, 2012; Brawarsky et al, 2005; Daemers et al, 2013; Stuebe et al, 2009; Althuizen et al, 2009; Segel et al, 2011

Outcomes associated with gain

Maternal complications: Higher risk of gestational diabetes, gestational hypertension/preeclampsia, hemorrhage,

venous thrombo-embolism, higher leptin concentrations

Strong link to post-partum and long-term weight retention

Fetal outcomes: Higher fetal weights and fetal adiposity, higher risk of fetal macrosomia, LGA

Neonatal complications Low Apgar score, higher risk of seizure, long-term risk for later obesity

Higher risk of preterm birth, doubled risk of stillbirth, threefold higher need for intensive care

Service outcomes: Increased odds of caesarean deliveries, longer duration of hospital stay

Crane et al, 2009; Stotland et al, 2006; Guelinckx et al, 2008; Heslehurst et al, 2008; Chung et al, 2011; Walsh et al, 2014; Cohen & Koski, 2013

Cost Drivers

Costs, charges, and expenditures

In 2008, charges to Medicaid for pregnancy and delivery totaled $22 billion and charges to private insurers totaled $30 billion

Average cost of having a baby was $8,802 (2004), with Cesarean sections costing $3000 more on average

Mean charge for a live birth has risen from $7,687 in 2002 to over $10,000 in 2010

Infants with health problems are only 25% of births, but account for 40% of all maternal and infant care costs

Chollet, Newman & Sumner, 1996; Wier & Andrews, 2011; “The Healthcare Costs of Having a Baby”, 2007; Huynh et al., 2013

Costs continued

Main cost drivers:

inpatient care (vs. home based or birth center)

multiple births, in vitro fertilization

complicated cesarean sections, high-risk pregnancy

preterm birth, low birth weight

complications due to conditions such as hypertension, diabetes, anemia, and cancer

Preterm infant costs 3x as high as full-term infants (prenatal costs 2x as high)

Cost of pregnancy-related complications that led to preterm birth was as high as $326,953 for an infant born at 25 weeks

Huynh et al., 2013; Chollet, Newman & Sumner, 1996

Composition of costs

9% of total costs occur before delivery, 67% occur at delivery, and 25% occur post-partum

50% of total charges and payments due to facility fees and a third due to physicians’ professional fees

The higher cost of Cesarean sections includes $2,090 in additional hospital expenditures and $723 in additional professional fees

Prenatal expenditure averaged $2000, with half due to office-based visits and half due to medications

“The Healthcare Costs of Having a Baby”, 2007; Machlin & Rhode, 2007; Chollet, Newman & Sumner, 1996

Costs of excessive weight gain

Maternity costs significantly increase with rising levels of BMI

In France: cost of hospitalization in overweight women 5x greater than that for normal weight women, and their infants require NICU admissions 3x more than normal weight women

Obesity associated with increases in length of stay (0.55 day), charges ($2015), and costs ($1805)

Obesity increases odds of requiring oxytocin or epidurals due to increased odds of caesarean deliveries higher costs

Higher BMI associated with more prenatal tests, more ultrasounds, more medications, increased length of stay and more prenatal visits

Denison et al, 2013; Galtier-Dereure, Boegner, & Bringer, 2000; Chu et al, 2008; Heslehurst et al, 2008; Trasande et al, 2008

Evidence on weight management

Programs, interventions, and trials

Randomized controlled trials have had mixed results of program effects on GWG

LIMIT (Australia): planning session, individual meal plans/recipes, food substitutions, goal setting, progress self-monitoring in workbook, problem solving of barriers, calls and face to face

Results: did not reduce risk of LGA, but had a shorter postnatal stay

Taiwan: individualized dietary/PA plan, 6 face to face counselling sessions, goal setting and personal weight graphs, self monitoring of PA and diet

Average GWG was 14 kg vs. 16.2 kg (control), Tx group sig lower post-partum weight retention (2.3 kg vs. 5.1 kg)

Dodd et al, 2014a; Dodd et al, 2014b; Huang, Yeh, & Tsai, 2011; Jackson et al, 2011; Phelan et al, 2011; Absee et al, 2009; Polley et al, 2002; Hui et al, 2006

Programs, interventions, and trials

Video Doctor: tailored counselling about nutrition, exercise and weight gain; interactive and computerized, behavioral risk assessments, motivational interviewing

Changes seen in behavior but no effect on GWG (late enrollment). Better diet (fruits/veggies), decreased sugar and fat intake, increased nutrition knowledge, 30 min increase in exercise

UPitt: information on appropriate weight gain and exercise and nutrition, newsletters, personal graph, encouragement, additional intervention for those exceeding with structured goals.

Tx group had lower % of women who exceeded guidelines (33% vs. 58%), averaged 8 lbs post-partum weight retention, reduced fat consumption in both groups

North Carolina: 1 meeting with RD for counseling, recommendations on diet and exercise and IOM guidelines. Results: Tx group gained less than control (29 lbs vs. 36 lbs).

Dodd et al, 2014a; Dodd et al, 2014b; Huang, Yeh, & Tsai, 2011; Jackson et al, 2011; Phelan et al, 2011; Absee et al, 2009; Polley et al, 2002; Hui et al, 2006

Behaviors to target

Daily steps taken (walking) associated with GWG in one study, but others did not find suggest no effect

Women more likely to gain at appropriate rate with >8.5 MET-hours/week

Self-efficacy or readiness for lifestyle change improved with scheduling strategies

Most successful interventions have

Targeted goals, verbal feedback, and visualization of success

Calorie restriction, meal replacements/ structured meal plans,

High physical activity goals, behavior therapy

Regular weight monitoring, regular food intake monitoring, and consistent patient-provider contactCohen, Plourde, & Koski 2013; Ruifrok et al, 2014; Cohen, Plourde, & Koski 2010; Gaston, Cramp, & Prapavessis, 2012; Phelan et al, 2011; Brown et al, 2011

Provider perspectives

51% of women receive weight gain advice from provider (weakly associated with GWG)

White women less likely to be counseled; smokers more likely to be counseled; overweight more likely to be counseled

Many providers say they counsel on weight gain, but most say their training is inadequate on the subject

Most providers weigh women at first visit only, frequency of weighing throughout pregnancy is inconsistent but more likely for complicated pregnancies

Providers feel weight gain is not a priority topic and wait too long to address it; smoking, substance abuse and mood are higher priority

Barriers: knowledge level of new guidelines, lack of resources, patient cost, short visits, believes counselling is low impact, don’t want to tell patients they’re “fat”

Siega-Riz, Deierlein, & Stuebe 2011

Patient engagement barriers

While most would change and intend to be healthy, only 50% have confidence in ability

Barriers cited in unsuccessful programs (or barriers to change in general)

Not able to get time off work, distance and transportation

Lack of social support, self-conscious

Pregnancy related symptoms (i.e. fatigue or nausea)

Lack of inexpensive alternatives, low cooking skills

Interest in post-partum weight loss only

Sui, Turnbull, Dodd 2013; Lee et al, 2012

Mobile weight management

Pregnancy Weight

Google Play: Pregnancy Weight Calculator, I’m Expecting Pregnancy Sprout

iTunes: Pregnancy Pounds, Ovia Pregnancy, Pregnancy Weight Gain Calculator, Wyhealth Due Date Plus, Pregnancy Weight Monitor

Weight Management (general)

Google Play: Coach.me Instant Coaching, My Diet Coach, Prenatal Workouts

iTunes: Pregnancy Weekly Workout, Tactio, Dietbet, Inlivo, Lose It!,

Recommendations

Useful metrics

Average rate of weight gain (kg/week)

Total gestational weight gain (kg or lbs) or net weight gain at birth

% in BMI categories

O/E ratio of weight gain

Total proportional weight gain

Suggested approach

60% of pregnant women are concerned with weight gain or need extra support staying within guidelines

Go beyond basic information – be tailored and culturally relevant to target audience

Messaging

Focus on health of the baby and relief of uncomfortable symptoms

Highlight feeling good about self

Encourage healthy worry about weight now rather than later

Emphasize a lifestyle change with small, manageable but personalized steps

Leslie, Gibson, & Hankey 2013; Sui, Turnbull, & Dodd, 2013; Lee et al, 2012

Suggested product design/features

Most women like to see a chart to calculate weight progress against recommendations

Goal setting with multimedia/web resources (preferably localized)

Activity (steps/walking) tracking

Recipes and meal planning

Encouragement from friends or similar women

Personalized feedback messages from “the provider”

Ongoing postnatal advice

Thank you!

Questions?