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Session 1: Communicating the Pregnancy Weight Gain Guidelines

KATHLEEN RASMUSSEN, CORNELL UNIVERSITY

The newest data for full-term singleton births in the United States offer context for the committee’s work in developing products to disseminate the Institute of Medicine (IOM) pregnancy weight gain guidelines. These 2010 data were derived from an analysis conducted by the Centers for Disease Control and Prevention (CDC) of data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS data are not nationally representative, because they cover only 28 states and the city of New York, but they are the best data available on the topic.

Figure 3-1 shows a graph of PRAMS data on the proportion of women meeting the IOM weight gain guidelines. As can be seen, only a minority of women gained within the guidelines. Among underweight and normal-weight women (40.7 percent and 37.5 percent, respectively, gained within the guidelines), while overweight and obese women were far less likely to gain the recommended amount of weight (24.6 and 22.8 percent, respectively). The most common outcome was to gain more weight than recommended by the guidelines (as 64 percent of overweight women and 58.7 of obese women did). Based on similar data the 2009 Committee to Reexamine IOM Pregnancy Weight Guidelines anticipated that women were not gaining within the recommend ranges when it revised the pregnancy weight gain guidelines.



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3 Session 1: Communicating the Pregnancy Weight Gain Guidelines KATHLEEN RASMUSSEN, CORNELL UNIVERSITY The newest data for full-term singleton births in the United States offer context for the committee’s work in developing products to dissem- inate the Institute of Medicine (IOM) pregnancy weight gain guidelines. These 2010 data were derived from an analysis conducted by the Centers for Disease Control and Prevention (CDC) of data from the CDC’s Preg- nancy Risk Assessment Monitoring System (PRAMS). PRAMS data are not nationally representative, because they cover only 28 states and the city of New York, but they are the best data available on the topic. Figure 3-1 shows a graph of PRAMS data on the proportion of wom- en meeting the IOM weight gain guidelines. As can be seen, only a mi- nority of women gained within the guidelines. Among underweight and normal-weight women (40.7 percent and 37.5 percent, respectively, gained within the guidelines), while overweight and obese women were far less likely to gain the recommended amount of weight (24.6 and 22.8 percent, respectively). The most common outcome was to gain more weight than recommended by the guidelines (as 64 percent of overweight women and 58.7 of obese women did). Based on similar data the 2009 Committee to Reexamine IOM Pregnancy Weight Guidelines anticipated that women were not gaining within the recommend ranges when it re- vised the pregnancy weight gain guidelines. 19

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20 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 3-1 Proportion of women meeting gestational weight gain recommen- dations, full-term, singleton births in 2010, PRAMS preliminary data. NOTE: Pregnancy Risk Assessment Monitoring System (PRAMS), 28 states and New York City included. SOURCE: Sharma, 2013. The three bars on the right, showing data for women in obesity clas- ses 1, 2, and 3, reflect data that were not available to the 2009 committee. The committee’s obesity recommendations were derived primarily from data for women in obesity class 1. Depending on which class of obese women is being considered, as few as 18 percent and as many as 25.4 percent gained within the guideline, while half or more of the women in each class gained more than the recommended amounts. Nearly one-third (32.4 percent) of women in obesity class 3 gained less than the recom- mended amount (that is, less than 5 kilograms, or about 11 pounds). The committee did not have sufficient information when it developed the guidelines to say whether such a lower-than-recommended weight gain had a net risk or a net benefit. Data to answer this question are now being collected. These new data confirm the conclusions in the committee’s report, namely that the preponderance of women are gaining outside of the guidelines and most of those women are gaining more weight than recommended. One of the motivations for taking action to disseminate the guidelines is that the majority of women need help gaining within the guidelines, and it will be important to think holistically about this issue if this goal is to be achieved.

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SESSION 1 21 The dissemination committee’s work was guided by a conceptual model that identifies various ways to affect a woman’s choice to gain within the guidelines and to influence her behavior. As illustrated in Fig- ure 3-2, the first step in the model is the committee’s report on weight gain during pregnancy (lower left). This report has been used in many ways, including shaping the opinions and actions of professional socie- ties. If a professional society adopts a committee’s recommendations, then it provides an opportunity to create a standard of care. New practic- es do not penetrate medical care unless they become a standard of care; therefore, professional societies play a key role once they have adopted the guidelines because they can educate health teams and develop staff training tools. In turn, the health care teams teach women how to gain within the recommended guidelines. Standards of care also influence two other parts of the medical care system that the committee carefully considered—the electronic health record and the medical payment system. From the conceptual model, the committee found that it would not be able to influence the process by which federal agencies formulate rules about health records and the med- ical payment system as it relates to the Patient Protection and Affordable Care Act (ACA). The committee also learned that electronic health rec- ords are created by just a few providers in the country. Many of the available electronic health records already have components to record obstetrics visits, but hospitals may be choosing not to use them. The right side of the model illustrates women learning about the guidelines. They learn from their health care providers, the media, Inter- net resources, mobile applications, and information in the doctor’s office. Once women have learned about the guidelines, it is up to them to try to gain within the recommendations. In making such an effort, a woman must recognize what an appropriate weight is for herself, learn what she weighs now and what an appropriate target weight would be, and then choose to modify her behaviors to accomplish the goal. Various factors—family and friends, the eating environment in the United States, the sociocultural context, and advertising—will all influence a woman’s choice whether to try to gain within the guidelines and also her ability ultimately to achieve that goal for herself. The materials that the commit- tee developed are designed to address many parts of the learning process.

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22 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 3-2 Pregnancy weight gain guidelines dissemination conceptual model. NOTE: Available at http://www.iom.edu/healthypregnancy. Rasmussen concluded her remarks and introduced the next speaker, Anna Maria Seiga-Riz. Seiga-Riz, a member of the Committee on Im- plementation of the IOM Pregnancy Weight Gain Guidelines, is associate professor in the Department of Epidemiology with a joint appointment in the Department of Nutrition in the School of Public Health at the Univer- sity of North Carolina, Chapel Hill. ANNA MARIA SEIGA-RIZ, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL The 2009 committee report that recommended the weight gain guide- lines emphasized the importance of two actions—informing women and health care providers about the guidelines and helping women maintain their weight gain within the guidelines—and these two actions were the focus of the products developed by the dissemination committee. These products were designed to be visually appealing and easy to understand so that women at all different educational levels could relate to them, and the information within them was simplified to make it easier for prenatal

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SESSION 1 23 providers to remember. The committee developed the following prod- ucts, which are available to the public free of charge on the IOM website (http://www.iom.edu/healthypregnancy):  A poster summarizing the weight gain guidelines (see Figure 3-3).  A pamphlet for providers. This pamphlet is small so that it can fit in a pocket, and it includes a summary card. The pamphlet in- tentionally does not provide all the details of the guidelines, but rather it highlights the most important information for women. Focus groups with women reveal that they hear a variety of mes- sages from their clinicians; if providers use this pamphlet as the basis for their messages, then the result should be that women will start to receive more consistent messages. The pamphlet in- cludes information on the different weight statuses, how much weight should be gained in the first trimester, and what the rates of weight gain should be in the second and third trimesters. If clinicians want additional information, then they can refer to the 2009 report.  A pamphlet for women (see Figure 3-4). This pamphlet high- lights questions that women often ask and provides quick an- swers. The pamphlet also includes a simple graphic that illus- trates how much weight a woman should gain based on her weight entering pregnancy.  A weight gain tracker (see Figure 3-5). This tracker, published in English and in Spanish, is compact so that a woman can keep it in her pocket and bring it to her visits. It provides information about how much weight women should gain during pregnancy, and it allows women to monitor their own weight gain. The weight tracker could be a useful aid when patients and clinicians or nutritionists talk about weight gain and behaviors that may be pushing the woman above or below what she should be gaining.  A “five common myths” chart (see Figure 3-6). This piece, available in English and Spanish, helps to dispel common mis- conceptions held by pregnant women, such as needing to “eat for two.”  An interactive infographic (see Figure 3-7). The committee worked closely with a company to develop an attractive tool that will provide quick information for women in different body mass index (BMI) status groups. The infographic, which is accessible

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24 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES from multiple platforms such as computers, tablets, and smartphones, includes an audio capability so that a woman can ask specific questions concerning weight gain relative to her own weight status and receive advice from a clinician (http:// resources.iom.edu/Pregnancy/WhatToGain.html). The infographic is a new type of product for the IOM, but it answers a need that women have for simple information that is relevant to them spe- cifically and that is delivered in a highly appealing manner. QUESTION-AND-ANSWER SESSION Rasmussen opened the floor to questions. One participant noted that she has clients who are living in motels, cooking on hot plates, and put- ting food in a cooler outside because they have very limited refrigeration. A cookbook to help women in these circumstances would be very useful, she said. Another participant applauded the development of the interactive infographic, noting that women in her state report that they really like self-directed educational tools, such as Text4Baby, which allow them to decide what questions to ask and what information to receive. They are then free to follow up with their clinicians on issues of particular interest to them. REFERENCE Sharma, A. 2013. How much weight should you gain when you’re pregnant? Presented by K. Rasmussen at Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines: A Workshop. National Academies, Washington, DC, March 1. Available at http://www.iom.edu/~/media/ Files/Activity%20Files/Children/Dissemination%20of%20Pregnancy% 20Weight/2013-MAR-01/3%20RASMUSSEN%20Session%20I%201.pdf (ac- cessed June 12, 2013).

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SESSION 1 25 FIGURE 3-3 Pregnancy weight gain guidelines poster. NOTE: Available at http://www.iom.edu/healthypregnancy.

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26 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 3-4 Images from the pamphlet for women. NOTE: Available at http://www.iom.edu/healthypregnancy.

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SESSION 1 FIGURE 3-5 Pregnancy weight gain tracker. NOTE: Available at http://www.iom.edu/healthypregnancy. 27

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28 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 3-6 Pregnancy weight gain myths and facts chart. NOTE: Available at http://www.iom.edu/healthypregnancy.

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SESSION 1 29 FIGURE 3-7 Screen from the interactive infographic. NOTE: Available at http://www.iom.edu/healthypregnancy.

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