posits. Webb et al. (2009) found that pregnant women who gained in excess of the ranges recommended by IOM (1990) were more likely to have high depressive symptoms than women who met the weight gain recommendations. Casanueva et al. (2000) conducted a case-control study to test for associations between maternal depressive symptoms and fat deposition among Mexican pregnant adolescents. They used body weight and anthropometric measures of skinfold thickness to determine fat deposition beginning at 20 weeks gestation through 4 weeks postpartum. The results of this study indicated an association between depressive symptoms and excessive fat deposition in Mexican adolescents. In cross-sectional studies, high depressive symptoms have been associated with negative attitudes about GWG (Stevens-Simon et al., 1993b; Dipietro et al., 2003). Women who are concerned before and during pregnancy about their weight gain have higher depressive scores in the week following delivery (Abraham et al., 2001).

Not all studies have shown a positive association between depression and either high or low GWG. For example, Cameron et al. (1996) studied a biracial sample of 132 women in mid-gestation and found a positive association between GWG and depression score for white women with high self-esteem, a negative correlation with depression score and third-trimester weight among white women with low self-esteem, and no association between depression score and GWG among black women. Walker and Kim (2002) analyzed data from a longitudinal study of postpartum weight patterns in low-income women and found that depressive symptoms were not significantly associated with GWG. Collectively, however, the majority of studies indicate that low and high GWG may be a marker of depression during pregnancy. Trends in depression among women of child-bearing age are shown in Chapter 2.

Stress

The committee found a lack of consistent evidence in support of a relationship between stress and GWG. The impact, however, of psychosocial factors such as stress on GWG and postpartum weight retention may be underestimated as a result of the limitations in measurement and data analysis; most of the available evidence is observational, and estimates of the impact of stress are confounded by the different kinds of effects that can occur depending on how an individual responds.

Picone et al. (1982) examined the influence of psychological stress as a factor in GWG and pregnancy outcome in a controlled prospective study of a group of 60 women utilizing an urban prenatal clinic. Psychological stress was assessed using a social readjustment rating scale from the Holmes-Rahe life events questionnaire. The investigators found a correlation between higher stress scores and lower GWG, independent of nutrient or caloric



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