Current Commentary

Weight Gain Recommendations in Pregnancy

and the Obesity Epidemic
Raul Artal,

MD,

Charles J. Lockwood,

MD,

and Haywood L. Brown,

Excessive gestational weight gain and obesity have been

recognized as independent risk factors for maternal and
fetal complications of pregnancy with significant lifelong
consequences. These associations call into question the
recently released Institute of Medicine (IOM) gestational
weight gain recommendations, particularly for obese
women. The IOM recommendation of a single standard of
weight gain for all obesity classes is also of concern,
because higher body mass index levels are associated with
more severe pregnancy complications, such as preeclampsia and gestational diabetes. The IOM recommendations
retained the 1990 focus on the theoretical association
between poor gestational weight gain and low birth weight
(LBW). Low gestational weight gain may often be a consequence and not the cause of LBW, and there is a lack of
evidence in developed countries that dietary supplementation increases birth weight. Current obstetric practice
allows for accurate and timely diagnosis of and intervention for LBW. We submit that gestational weight gain
recommendations should be more individualized especially for obese women. Obese pregnant women should
not be precluded from partaking in healthy lifestyle modifications in pregnancy that include physical activities,
modified, judicious diets, and limited weight gain.
(Obstet Gynecol 2010;115:1525)

he epidemic of obesity in the Western world, particularly the United States, continues unabated.1
Sixty-six percent of U.S. adults were classified as overFrom the Department of Obstetrics, Gynecology and Womens Health, Saint
Louis University School of Medicine, St. Louis, Missouri; Department of
Obstetrics, Gynecology and Reproductive Sciences, Yale University School of
Medicine, New Haven, Connecticut; and Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
Corresponding author: Raul Artal, MD, Saint Louis University School of
Medicine, 6420 Clayton Road, Suite 290, St. Louis, MO 63117; e-mail:
artalr@slu.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2009 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/10

152

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MD

weight or obese in 2004, including 29% of reproductive-age women (20 39 years). Obesity affects a
disproportionate percentage of Mexican-American
(36%) and African-American (50%) women. As a
chronic disease, obesity contributes to more than
100,000 deaths per year and is recognized as a leading
cause of premature mortality in women in the United
States.2 Excessive gestational weight gain and obesity
have been recognized as independent risk factors for
maternal and fetal complications of pregnancy. This
association calls into question the recently released
recommendations by the Institute of Medicine (IOM).3
We do not concur with the committee recommendations for reasons detailed below. Since the first publication by the IOM in 1990 of its gestational weight
gain recommendations, there has been a 70% increase
in the prevalence of prepregnancy obesity. A large
percentage of obese individuals will experience comorbidities in their life span. As many as 76% of
African-American women enrolled in an outpatient
weight loss program had one or more comorbidities.4
Among the major medical comorbidities are hypertension, cardiovascular disease, diabetes mellitus, hyperlipidemia, metabolic syndrome, thromboembolic
events, and cancers. Pregnancy-related, obesity-associated morbidities include diabetes, macrosomia, cesarean delivery, preeclampsia, and congenital anomalies. Most concerning is the parallel increase in
gestational diabetes.5
The recently published IOM recommendations
for gestational weight gain are virtually identical to
those published in 1990, with one exception: obese
women (body mass index [BMI] greater than 30) are
now recommended to gain 1120 lb compared with
the previous recommendations of at least 15 lb.3 The
IOM committee did not stratify the recommendations
for different obesity classes (ie, class I [BMI 30 34.9],
class 2 [BMI 3539.9], and class 3 [BMI greater than
40]). Compared with data from two decades ago, the
rate of individuals with a BMI greater than 30 and,
more significantly, the rates of adults with a BMI

OBSTETRICS & GYNECOLOGY

greater than 40 (morbid obesity or class 3) have

significantly increased. The National Health and Nutrition Examination Survey reported in 20032004
that 28.9% of women of reproductive age (20 39
years) were obese, and 8% were morbidly obese.
Recommending a single standard of weight gain for
all obesity classes is of concern because higher BMI
levels are associated with more severe comorbidities
and have long-term adverse health implications.6
An association has been established among excessive gestational weight gain, pregnancy complications, and retention of weight after pregnancy.79
More than 60% of previous gravidas become overweight with their subsequent pregnancies. Weight
gain during pregnancy and the effect on subsequent
weight gain are causes of a permanent increase in
weight for every BMI category and are significant
contributors to the obesity epidemic and associated
comorbidities in the United States.8,10 Excessive gestational weight gain has been implicated in an intergenerational vicious cycle of obesity as overweight
or obese women give birth to macrosomic daughters,
who are more likely to become obese themselves and
deliver large neonates.9
The expert multidisciplinary panel commissioned
by the IOM to address gestational weight gain recommendations compiled a comprehensive review of the
literature that provided the background for the recently published recommendations.3 The current and
previous recommendations were based on expert
opinion, observational studies, and population-based
small and large cohort studies. The 2009 IOM committee retained the same scientific approach and
epidemiologic conventions used in their 1990 report.
The recommendations were in part driven by a
theoretical association between poor gestational
weight gain and low birth weight (fetal growth restriction). However, low gestational weight gain often may
be a consequence of a medical or obstetric condition
and not the cause of low birth weight. Further, the
recommendations do not consider the long-term effects of excess pregnancy-associated weight gain. Gestational weight gain should reflect a balance between
an optimal outcome for the fetus and mother alike.
Hence, we have concern about the recommendation
of additional weight gain for all classes of obese
gravidas. Reaffirmation of the IOM 1990 recommendations has the potential to amplify pregnancy-related
risk for mother and fetus and long-term morbidities
for women.
The challenge in establishing optimal weight gain
recommendations in pregnancy for the general population is by and large because of the great variability

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in gestational weight gain found even among women

with similar ages, BMI, socioeconomic status, ethnic
and cultural background, tobacco use, and levels of
physical activity. Thus, if for no other reason, recommendations for gestational weight gain should be individualized and based on clinical judgment as recognized
by the panel, especially for obesity classes IIII.
Currently, the wide use of ultrasonography and
other innovations allow for a more accurate and
timely diagnosis, testing, and intervention for fetal
growth restriction. The IOM committees adherence
to its previously published recommendations that
focus on theoretical prevention of low birth weight
due to deficient nutrition is biologically insupportable
given affluent Western diets. Indeed, undernutrition
in pregnancy, if it has any effect, will be observed in
those women who are underweight. Poor gestational
weight gain is unlikely to affect birth weights in
overweight and obese women. Moreover, even under
the most nutritionally deprived conditions, such as
occurred during the World War II famine in Leningrad and Holland, women who maintained diets of
less than 1,000 cal/d experienced reduced birth
weights of only 440 600 g.11,12
For obese or overweight pregnant women, comorbidities are significantly more common, including
a higher prevalence of diabetes, hypertension, operative deliveries, and macrosomia and neonatal complications.13,14 Studies have consistently demonstrated
that increased prepregnancy BMI followed by excessive weight gain in pregnancy are significant risk
factors for developing gestational diabetes and preeclampsia; conversely, limited weight gain in overweight or obese pregnant women decreases the risk of
these complications.13,1517 Large prospective studies
assessing lifestyle modifications of weight loss and
exercise interventions in pregnancy are not available.
However, clinical experience and numerous reports
have been accumulated in the past two decades to
indicate that gestational weight gain increases the risk
for maternal and fetal morbidities, particularly for
obesity classes II and III.
Dye et al15 used a central New York Regional
Perinatal data system for a population cohort study
that included 14,367 pregnant women. This study
reported a prevalence of gestational diabetes mellitus
of 4 6% for obesity class I, 6 8% for obesity class II,
and 10 12% for obesity class III. This study also
reported that lifestyle modifications in pregnancy,
such as physical activities, have a preventive role in
the development of gestational diabetes mellitus in
obese pregnant women. In another population-based
cohort study, derived from 120,251 Missouri birth

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153

certificates (1990 2001), Kiel et al16 reported that for

class II and III obese pregnant women, gestational
weight gain of less than the recommended 1120 lb is
associated with a significantly lower risk of preeclampsia, cesarean delivery, and large-for-gestational-age
birth, whereas the risk for low birth weight increased
significantly for these patients only when weight loss in
pregnancy exceeded prepregnancy weight by 10 lb.
Moreover, this study was not controlled for other causes
for inadequate gestational weight gain known to affect
fetal growth (eg, cigarette smoking, socioeconomic status, use of illegal substances).
In another recently published study, it was reported that obese pregnant women who gained 15 lb
or more during pregnancy experienced more pregnancy-related comorbidities compared with those
who gained fewer than 15 lb.17 In a 2007 large
Swedish population cohort study that included nearly
300,000 women, it was reported that limited gestational weight gain (less than 6 kg) was associated with
better pregnancy outcomes for overweight and obese
women with BMIs higher than 30.13
The IOM committee also reemphasized an historic concern that restricting weight gain in pregnancy
could result in ketonuria or ketonemia, causing adverse fetal neurodevelopmental effects. This cause
and effect concern has been discredited. The issue of
maternal ketonuria and potential effects originates in
one single study.14 The study was criticized for its
improper design because the data were obtained from
different hospitals, with a nurse obtaining a single
sample of urine for ketone testing on the day of
delivery; also, maternal IQ, the major predictor of
child IQ, was not evaluated. Subsequent studies also
have suggested no effect on the neuropsychological
development of offspring of women who experienced
ketonuria during pregnancy.18
The optimal diet prescription for pregnant women
should provide adequate calories and nutrients to
support fetal growth. The diet should be tailored for
women of different classes of obesity by recommending a nutrient-dense caloric intake in the range of
2,000 2,500 cal/d. This caloric intake results in a
gestational weight gain of 10 lb or less and, in some,
a net negative weight gain. Limited weight gain in
obese pregnant women has the added potential for
setting the foundation for a healthier lifestyle over the
lifespan of women, including interconceptionally and
during subsequent pregnancies.19
Although a vigorous exercise and weight loss program perhaps should not be the goal during pregnancy,
obese and morbidly obese women should not be precluded from partaking in healthy lifestyle modifica-

154

Artal et al

tions in pregnancy, which include physical activities

and judiciously modified diets and limited weight
gain. Such interventions, although limited, have been
used safely and successfully in overweight and obese
women.19
Similar to smoking-cessation programs, pregnancy
provides a unique and ideal opportunity for behavior
modification given high motivation and enhanced access to medical supervision. All women should try to
avoid excess weight gain during pregnancy, with the
goal of normalizing the BMI between pregnancies to
minimize risk of adverse outcomes in future pregnancies and an improvement in general long-term health.
Pregnancy is an optimal time for health care providers to offer their resources to decrease maternal
obesity and comorbidities, thus affecting current and
future generations.
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