8/9/2012
Postpartum Weight Management
Angel Hopson, RN, MSN/MPH
Los Angeles County Department of Public Health
Reproductive Health Programs
Obesity has reached epidemic proportions!
Epidemic: an outbreak or sudden rapid spread, growth, or development.
Merriam‐Webster Collegiate Dictionary
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
1
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Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
2
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Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
3
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Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
4
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Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
5
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Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
6
8/9/2012
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
7
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Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
8
8/9/2012
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
The Fat Cell is an Endocrine Cell
Cholesterolester Transfer
Protein (CETP)
Lactate
Prostaglandin
Phospholipid Transfer
Protein (PLTP)
Angiotensinogen
Leptin
Prostacyclin
Adiponectin
Monobutyrin
Fat Cell
Galactin-12
Free Fatty Acids
TNF-α
Plasminogen Activator
Inhibitor (PAI-1)
IL-6
Lipoprotein
Lipase (LPL)
Adispsin (ASP)
(complement D)
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Overweight & Obesity
Energy intake exceeds energy expenditure
Overweight & Obesity
• Familial/Genetic
• Environmental
• Psychological
• Socio‐cultural
• Physiological
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Why Does Weight Matter?
Villamor & Cnattingius,Lancet 2006; 368(9542):1164-1170
Outcomes of Gestational Weight Gain
Postpartum:
• Moderate associate between excess weight gain (esp. if obese) and failure to initiate breastfeeding
9Decreased prolactin
9Need more stimulation, more support
• Moderate association between low GWG and failure to initiate breastfeeding
Viswanathan M, et al. AHRQ Publ. No. 08‐E09, 2008
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Postpartum Weight Retention
• Strong association between excess GWG and postpartum weight retention
• Concern that postpartum weight retention moves mother into higher pre‐pregnant BMI category for next pregnancy
• Long term health a concern if higher BMI
9 Increased rate of GDM, preeclampsia, PIH,
cesarean delivery
9 HTN, DM, CHD, osteoarthritis, sleep apnea, etc.
Viswanathan M, et al. AHRQ Publ. No. 08‐E09, 2008
Postpartum Weight Retention
• Women gaining in excess of IOM guidelines:
9Average weight retention was 15‐20 pounds
940% of these women retained >20 pounds
• Obese women gaining ≤ IOM guidelines had postpartum weight less than pre‐pregnancy
2009 IOM Prenatal Weight Gain Guidelines
BMI categories Total 1990 2009 Weight gain
Underweight < 19.8 < 18.5 28‐40 lbs
Normal
19.8‐26 18.5‐24.9 25‐35
Overweight
>26‐29
25‐29.9
15‐25
Obese
>29
≥ 30.0
1990 ‐ At least 15
2009 ‐ 11‐20
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Rate of Weight Gain
First Trimester
Weekly in 2nd & 3rd
Trimester
Underweig
ht (<18.5)
4.4 pounds
(2.2‐6.6)
1 pound (1.0‐1.3)
Normal (18.5‐24.9)
4.4 pounds 0.9 pounds (0.8‐1)
(2.2‐6.6)
Overweight 4.4 pounds 0.6 pounds (25.0‐29.9)
(0.5‐0.7)
(2.2‐6.6)
Obese (≥30.0)
3.3 pounds 0.5 pounds (0.4‐0.6)
(1.1‐4.4)
Prevalence of overweight, obesity and
extreme obesity among women 20-39* y old:
US, 1963-2004
60
Proportion of women (%)
2
Overweight (BMI > 25 kg/m )
2
Obese (BMI > 30 kg/m )
Extreme obesity (BMI > 40 kg/m2)
50
NHANES
1999-2000,
2001-02
2003-04
40
30
NHANES
1963-65,
1966-70
NHANES
1976-80
20
NHANES
1971-74
NHANES
1988-94
10
0
1965
1975
1985
1995
2005
Year of survey
From: Health, United States, 2005 and Ogden CL, et al.
JAMA 2006;295:1549.
*Ages 20-35 through NHANES 1988-94
Obesity & Health Consequences
•
•
•
•
•
•
•
•
Hypertension Dyslipidemia Type 2 diabetes Coronary heart disease, stroke Cholescystitis and cholelithiasis Gout, osteoarthritis Obstructive sleep apnea
Some types of cancer (endometrial, breast, prostate, and colon) 13
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Obesity & Pregnancy Consequences
•
•
•
•
•
•
•
•
•
Preeclampsia
Hypertension
Gestational diabetes
Embolism and deep vein thrombosis
Increased blood loss during delivery
Prolonged first stage of labor
Increase rate of cesarean delivery
Increased risk of post‐op infection
Increased risk for maternal death
Cesarean Concerns
Obesity & Health Consequences in
Birth Outcomes
•
•
•
•
•
•
Increase risk for birth defects
Macrosomia Neonatal hypoglycemia
Preterm fetal loss/miscarriage
Stillbirth
Infant/Neonatal death
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What can we do?
•
•
•
•
•
•
Use recommended weight gain guidelines
BMI on all women at initial visit
Offer nutritional counseling Encourage local exercise programs
Gestational diabetes screens first trimester
Discuss potential pregnancy complications
True or False: You are eating for two
3 Goals for Postpartum Weight Management
• Prevent Weight Gain
• Produce Weight Loss
• Maintain Healthy Weight
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Best Opportunities
•
Pre‐pregnancy •
Pregnancy
•
Postpartum
Pre‐Pregnancy
Every Woman California
www.everywomancalifornia
•
•
•
•
•
•
Nutrition
Physical activity
Chronic disease prevention/control
Family planning
Vitamin/Folic acid supplementation
Stress/Depression
Pregnancy
•
•
•
•
•
•
•
Assess BMI at initial visit
Nutrition/Physical activity history
Discuss recommended weight gain
Physical activity options
Barriers
Work together to set goals
Follow‐up !!!
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8/9/2012
Postpartum Weight Management Goals
• Exclusive Breastfeeding
• Develop Healthy eating patterns
• Choose nutritious snacks
• Get regular physical activity
• Decrease television, Computer use and video game time The Healthy Plate
Carbs
Vegetables
Protein
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8/9/2012
• Last socially acceptable target of discrimination
• 389 health professional specializing in obesity given Implicit Associations Test
• Significant pro‐thin, anti‐fat implicit bias
• Obesity carries a pervasive and powerful stigma
• Challenge: ameliorate damaging attitudes
Schwarz et al, Obesity Research (2003) 11: 1033-1039
Key Points to Remember
•
•
•
•
Obesity is multi‐factorial
Be sensitive in your approach
Be supportive
Empower women to take an active role toward change
• Know your community resources 18
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Thank You!
Angel Hopson, RN, MSN/MPH
(213) 639‐6457
[email protected]
Los Angeles County Department of Public Health
Reproductive Health Programs
References
• Los Angeles County Department of Public Health MCAH Programs Reproductive Health
• Every Woman California www.everywomancalifornia
• Safe Motherhood Initiative Obesity and Pregnancy
• Mayo Clinic www.mayoclinic.com/health/weight‐loss‐after‐pregnancy
• USDA http://www.choosemyplate.gov/healthy‐eating‐tips/ten‐tips.html
• Institute of Medicine http://www.iom.edu/Reports/2009/Weight‐Gain‐
During‐Pregnancy‐Reexamining‐the‐Guidelines.aspx
• National Institutes of Health www.ncbi.nlm.nih.gov/pubmed/11787735
• March of Dimes, California Chapter www.marchofdimes.com/ca
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