Inadequate maternal weight gain during pregnancy is the largest contributor to the number of singleton low weight births. Inadequate weight gain is also the only factor contributing to low birthweight that is highly modifiable.

The National Academy of Sciences in conjunction with the Institute of Medicine produced a report titled Nutrition During Pregnancy¹ in 1990 outlining recommendations for weight gain in pregnancy. The Subcommittee on Nutrition Status and Weight Gain During Pregnancy reviewed scientific evidence to formulate recommendations for total weight gain and rate of weight gain for the most optimal birth and maternal outcomes.

• Weight gain recommendations are based on a women's pre-pregnancy body mass index (BMI), an assessment of weight for height.
• There are four categories of weight for height with corresponding weight gain recommendations.

Rate of weight gain is as important as total weight gain. Strive for consistent gains.

Background Documents

• Nutrition During Pregnancy: Weight Gain, Nutrient Supplements
  Institute of Medicine, National Academy of Sciences-1990
• Tipping the Scales: Weighing in on Solutions to the Low Birth Weight Problem in Colorado - August 2000
  Colorado Department of Public Health and Environment
• Low Birth Weight: Analysis and Recommendations - 1995
  The Future of Our Children
• Weight Gain During Pregnancy: Colorado Pregnancy Risk Assessment Monitoring System (PRAMS), 1997-2000.
• The Health Status of Colorado's Maternal and Child Health Population, June 2005
• Reducing Low Birthweight by Resolving Risks: Results from Colorado's Prenatal Plus Program
  American Journal of Public Health, November 2005, Vol. 95, No. 11, 1952-1956.

Recommended Strategies

The Institute of Medicine (IOM) as defines inadequate maternal weight gain:

Low weight gain at any point in pregnancy, such that:

• A pregnant women's weight plots beneath the appropriate weight gain line for her respective pre-pregnancy weight category per IOM recommendations.

OR

A low rate of weight gain, such that in the 2nd and 3rd trimesters (singleton pregnancies):

• Normal/Overweight women gain less than (
• Obese women gain less than (

Recommendations for Individual Providers:

There are several promising strategies that health care providers can implement in their practice to work toward increasing the number of women that gain adequately in pregnancy.

Determine a client's body mass index and track weight gain.

• Obtain and record client's height and either pre-pregnancy weight or early first trimester weight on client record.
• Using the client's height and weight, determine her body mass index (BMI) category. BMI and corresponding weight gain recommendations can be calculated at www.healthy-baby.org/HowMuchWeight.htm.
• Determine and advise the client of their BMI category and recommended weight gain range.
• Discuss the distribution of weight gain during pregnancy

Some women feel that after they have gained about 8 pounds for a baby that the rest of their weight gain will be fat. Discuss an appropriate rate of weight gain, approximately 1 pound per week in the second and third trimester.

• Plot client's weight on a prenatal weight gain grid. A weight gain grid will allow for a quick assessment of weight gain and early identification of inadequate weight gain. Prenatal weight grids are commonly used in the WIC program.
• Monitor weight gain trends at each appointment. If significant weight changes occur, determine if they are due to dietary habits of if they are a measurement error.

Counseling Guidelines

For clients with inadequate weight gain:

Determine if the weight gain is a measurement error or actual.

Explore reasons for inadequate weight gain: weight loss or gaining below appropriate BMI grid line.

Share information on the management of morning sickness if applicable. General guidelines for this would include avoiding offensive odors, avoid large meals and skipping meals, drink fluids between meals rather than with meals.

Does the client have body image concerns and having a difficult time dealing with her increasing weight gain? If so, revisit the section on where the weight goes. Discuss the importance of eating enough food to nourish herself and her baby.

Does the client have adequate access to food? Refer to WIC (Women Infants and Children), for nutrition education and food vouchers. Obtain information from social workers on local food pantries and food banks if you are not familiar with these resources in your area.

Has the client's activity level increased significantly? Does she now need to walk to a bus stop or to work when she previously did not?

Are other problems within the home or stress interfering with preparing and consuming enough food? Refer to a social worker or counselor for support.

Does the client smoke? Smoking not only decreases the woman's appetite but will also increase her metabolism. Stress the benefits to her health in addition to her child's growth and health if she stops smoking.

For clients gaining appropriately:

Continue to plot weights on weight gain grid and monitor for trends.

Reinforce current efforts with weight gain and discuss rate of weight gain.

For clients with excessive weight gain:

• Explore reasons for excessive weight gain, greater than 6 ½ pounds gain per month or 4-week period.
• Determine if the weight gain is a measurement error or actual.
• If weight gain was validated, rule out edema.
• Has the client had a significant decrease in her activity level?
• Advise client to avoid / reduce intake of juice, soft drink or other sweetened beverages. Hot pretzels, air popped popcorn, Popsicles or reduced calorie puddings are all good alternatives to chips and ice cream.
• Encourage more fresh fruit and vegetable consumption to provide a feeling of fullness. Encourage 6-8 glasses of water a day. Often people eat when they are actually thirsty.

Resources

• www.healthy-baby.org
• A Healthy Baby is Worth the Weight
• Women's Health home page
• Smoking and Pregnancy
• Maternal and Child Health County Data Sets
• Pregnancy Risk Assessment Monitoring System (PRAMS)