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Keynote Addresses

MICHAEL LU, HEALTH RESOURCES AND SERVICES ADMINISTRATION

In 2007 the Institute of Medicine (IOM) convened a Committee to Reexamine IOM Pregnancy Weight Guidelines. The catalyst for the committee’s work was the recognition that the circumstances surrounding pregnancy weight gain had changed radically from when the IOM’s first pregnancy weight gain guidelines were released in 1990. At that time the primary concern was preventing low birth weight. In 2007, however, the United States was experiencing an obesity epidemic, and pregnancy weight gain was seen as potentially a major driver of the weight gain occurring among women of childbearing age.

The average weight of American women has been increasing for a long time, but the increase has been particularly pronounced since 1990. Over the past 20 years, the percentage of American women of childbearing age who are overweight or obese has nearly doubled. Today, more than half are overweight, and about one-third are obese (see Figure 2-1).

Thus, more American women are entering pregnancy overweight or obese than ever before. In addition, the proportion of women who gain too much weight during pregnancy also has increased since 1990. Today, 1 in 5 American women gain more than 40 pounds during pregnancy, with the largest increase seen among non-Hispanic white women.



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2 Keynote Addresses MICHAEL LU, HEALTH RESOURCES AND SERVICES ADMINISTRATION In 2007 the Institute of Medicine (IOM) convened a Committee to Reexamine IOM Pregnancy Weight Guidelines. The catalyst for the committee’s work was the recognition that the circumstances sur- rounding pregnancy weight gain had changed radically from when the IOM’s first pregnancy weight gain guidelines were released in 1990. At that time the primary concern was preventing low birth weight. In 2007, however, the United States was experiencing an obesity epidemic, and pregnancy weight gain was seen as potentially a major driver of the weight gain occurring among women of childbearing age. The average weight of American women has been increasing for a long time, but the increase has been particularly pronounced since 1990. Over the past 20 years, the percentage of American women of childbearing age who are overweight or obese has nearly doubled. Today, more than half are overweight, and about one-third are obese (see Figure 2-1). Thus, more American women are entering pregnancy overweight or obese than ever before. In addition, the proportion of women who gain too much weight during pregnancy also has increased since 1990. Today, 1 in 5 American women gain more than 40 pounds during pregnancy, with the largest increase seen among non-Hispanic white women. 5

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6 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 2-1 Prevalence of overweight, obesity, and extreme obesity among U.S. women 20–39 years old (ages 20–35 through NHANES 1988–1994), 1963–2004. NOTE: BMI = body mass index; NHANES = National Health and Nutrition Examination Survey. SOURCE: Lu, 2013. This trend is particularly troubling among women who enter pregnancy overweight or obese. Today, nearly two-thirds of women who are overweight and nearly half of women who are obese gain more than the recommended amount of weight during pregnancy. This is important because the more weight a pregnant woman gains during pregnancy, the more weight she will retain postpartum. This is true for retention of 10 to 20 pounds beyond 6 months postpartum. It also is true for women of all races and ethnicities and all levels of pre-pregnancy body mass index (BMI). Women who gain above the guidelines tend not to return to their pre-pregnancy weight. Overweight and obese women who gain within the guidelines are more able to maintain a postpartum weight that is at or below their pre-pregnancy weight. Excessive gestational weight gain has consequences for both mother and child. Mothers with a high gestational weight gain are at an increased risk both of cesarean delivery and of postpartum weight retention (see Figure 2-2). The child’s birth weight is strongly associated with the mother’s gestational weight gain; that is, mothers with a lower gestational weight gain are more likely to give birth to babies who are small for their gestational age, while mothers with a higher gestational weight gain generally give birth to children who are large for their gestational age. Some evidence supports an association between gestational weight gain and preterm birth, with a lower gestational

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KEYNOTE ADDRESSES 7 FIGURE 2-2 The greater the gestational weight gain, the greater the postpartum weight retention. SOURCE: Lu, 2013. weight gain associated with preterm birth among underweight women and, to a lesser extent, normal-weight women as well. Excessive gestational weight gain and its co-morbidities (e.g., increased blood pressure) also have implications for childhood obesity. In particular, a number of studies have found that a higher weight gain by the mother during pregnancy is associated with childhood obesity in her offspring. The association between high maternal systolic blood pressure and higher weight in children years later could indicate that pre- pregnancy BMI has some effect on fetal developmental programming (Wen et al., 2011). This evidence suggested a framework for the approach used by the committee tasked with revising the 1990 guidelines. Those earlier guide- lines had no upper limit for the amount of weight that obese women should gain during pregnancy, recommending only that obese women should

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8 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES gain at least 15 pounds. The committee examined a number of analyses that looked at the trade-offs between the outcomes associated with lower versus higher gestational weight gain, including a study that recommended weight loss for class III obese women. Other analyses found that the risk of the infant being small for gestational age (SGA) goes down as the mother’s gestational weight gain goes up. For overweight and obese women, the absolute risk of SGA does not change as weight gain increases. By contrast, in women of all pre-pregnancy BMI categories, greater weight gains during pregnancy are associated with greater weight retention after birth. The 2009 guidelines look quite similar to the old guidelines, with two major exceptions. First, the new guidelines use the World Health Organization BMI categories, so women no longer change their BMI categories when they become pregnant. Second, the committee recommended a pregnancy weight gain of between 11 and 20 pounds for obese women instead of recommending a weight gain of at least 15 pounds with no upper limit. It should be noted that the recommended weight gain range for obese women was derived from data for women with a BMI between 30 and 35. There were insufficient data to create recommendations specifically for heavier classes of obese women, and further research may suggest that lower gain might be desirable for these heavier women. Finally, the guidelines are not modified for short stature, young age, racial or ethnic subgroups, primiparity, or smoking, and they include some provisional recommendations on the rate of weight gain and on twin pregnancies that are based on limited data. The 2009 guidelines emphasize two priorities for future action: (1) help women gain within the guidelines and (2) help women achieve a healthy weight before pregnancy and get back to a healthier weight after pregnancy. Concerning “gain within the guidelines,” the committee recognized that the guidelines were not going to be easy to follow. About 1 in 5 pregnant women gains more than 40 pounds during pregnancy. Data from the Pregnancy Risk Assessment Monitoring System show that overweight and obese women gain on average about 10 pounds more than the midpoint of their recommended range and that more than half— and probably closer to two-thirds—of overweight and obese women gain more than the upper limit of their recommended range. Getting them to gain within the IOM guidelines will be a major challenge. As for helping women achieve a healthy weight before pregnancy and get back to a healthier weight after pregnancy, achieving this goal

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KEYNOTE ADDRESSES 9 will require a radical change in the care of women of childbearing age, not only during pregnancy but also before pregnancy, between pregnancies, and beyond pregnancy. A number of federal agencies are already taking action consistent with these two priorities. Since 2005 the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), along with other partners, have led a movement to improve preconception health and health care in the United States. The Office of Minority Health has already launched a campaign to promote women’s preconception health through peer education in minority communities. The Centers for Medicare & Medicaid Services recently convened an expert panel on interconception care, and the Food and Nutrition Service at the U.S. Department of Agriculture has launched a project on the role of improving periconception nutrition. The federal action that is likely to have the greatest impact on women’s health care is the Patient Protection and Affordable Care Act (ACA). The act puts an end to the discriminatory practice of charging women higher premiums because of their gender. It also prohibits the practice of denying coverage for pre-existing conditions, such as breast cancer or having had a cesarean section, and lifetime limits on benefits are no longer allowed. These provisions are expected to expand access to health care for millions of women with chronic conditions. Through Medicaid expansion and subsidies for women who lack employer- sponsored health insurance, the ACA is designed to expand access to health care coverage for nearly 90 million previously uninsured women. The implementation of the ACA provisions on clinical preventive services for women means that an additional 47 million women will have the opportunity to gain access to preventive health services, including coverage for gestational diabetes, intimate partner violence, HIV screening and counseling, counseling on sexually transmitted infections, human papillomavirus DNA testing, Food and Drug Administration– approved contraceptive products, and breastfeeding support. Well-women visits, including preconception and interconception care also are included, which provides an extraordinary opportunity to improve women’s health not only during pregnancy but also before pregnancy, between pregnancies, and beyond pregnancy.

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10 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES JEANNE CONRY, KAISER PERMANENTE MEDICAL GROUP AND PRESIDENT-ELECT OF THE AMERICAN CONGRESS OF OBSTETRICIANS AND GYNECOLOGISTS Most women try to conceive at least once, and many women have more than one pregnancy, and of those women who get pregnant, many experience complications during their pregnancies. As a result, pregnancy is a time when clinicians have various opportunities to talk with women about a range of health issues, including the importance of achieving and maintaining a healthy weight. As an organization that represents 56,000 physicians and the women they serve, the American Congress of Obstetricians and Gynecologists (ACOG) has a key role to play in helping women gain weight appropriately during pregnancy. ACOG has powerful tools for educating clinicians, such as its well-known evidence-based guidelines for care and its webinars, meetings, online learning opportunities, newsletter, and journal. It also partners with the American Board of Obstetricians and Gynecologists, which provides an opportunity to incorporate new information, including the new IOM pregnancy weight gain guidelines, into the annual tests that obstetricians and gynecologists (OB-GYNs) must take to maintain their board certification. The goal of reproductive health care is to produce healthy women, healthy mothers, and healthy babies, but the United States is currently comparable to a third-world country in terms of maternal mortality. In some states, maternal mortality has tripled in the past decade. In California, huge racial disparities exist; for example, an African American woman is four times more likely to die from a pregnancy-related cause than a white woman. Many factors are related to maternal mortality, with obesity and the preconception health of the woman being significant components. The National Maternal Health Initiative of the Department of Health and Human Services is focused on improving the health of women once they become pregnant. However, because 50 percent of pregnancies are unplanned, it is critically important for health care providers to help non- pregnant women be healthy at all times over their reproductive lives. All physicians, no matter their specialty (e.g., internists, family physicians, or neurologists), should collaborate in goal-directed conversations with women about their overall health and their reproductive goals, and these conversations should be ongoing, for a woman may have very different reproductive goals at age 18 than at 25 or 32. Conry offered an example from her own medical group to illustrate the importance of sharing information among health care providers and

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KEYNOTE ADDRESSES 11 of discussing reproductive goals in the context of overall health care decision making. In an effort to determine how to improve the care of women with diabetes, the medical group’s staff obtained the names of every woman with diabetes in the medical group, determined what medications each was taking, and assessed each woman’s hemoglobin A1C as an indication of her blood sugar control over the previous 3 months. The names and accompanying information were sent to the women’s gynecologists, with the suggestion that they review what forms of contraception the women were using. This information influenced contraception decisions for a number of women in the practice. It is critical for women to begin pregnancy at a healthy weight, Conry said, but as the data indicate, this is not happening. OB-GYNs have a powerful advantage because they have a captive audience during pregnancy and the postpartum period. They can then work with women and focus on the message that weight gain during pregnancy can affect not only the pregnancy but the woman’s health throughout the rest of her life. However, conversations about weight can often be difficult. Patients may be reluctant to acknowledge that obesity is an issue for them, and clinicians may find it difficult to present information and discuss issues in a non-judgmental way. Despite these difficulties, however, education and counseling can provide a critical foundation for women as they make decisions about their health over the short and the long term (see Box 2-1). A key aspect of educating and counseling patients is to pick a few strong messages and be consistent and relentless in giving them to all patients. The value of exercise should be one of the messages. Conry said that she talks about the frequency, intensity, and timing of exercise with each of her patients. The Kaiser Permanente Medical Group has a walking group of 6,000 people in the Roseville, California, area that receives messages on walking and information about events. A physician walks with the group every Wednesday because it is important for the walkers to see that physicians believe that walking and exercise and healthy choices are important. A second important message is that not all behavioral changes have to be major changes. Changing behaviors in small increments is often a more successful strategy. To reinforce these messages, Conry and the physicians in the Kaiser Permanente Medical Group use two prescription pads. One is a walking prescription (see Figure 2-3), which physicians use to note expectations and goals for each patient. Each pregnant patient also receives a pre- scription on appropriate weight gain with tips (see Figure 2-4).

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12 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES BOX 2-1 The Power of Goal-Directed Counseling and Motivation During her first pregnancy, one of Conry’s patients, age 22, gained 60 pounds. She lost 10 pounds after the pregnancy, but then gained another 60 pounds during her second pregnancy 2.5 years later, for a total weight gain of 110 pounds. During the two pregnancies, she and Conry had many discussions about her weight gain. The following year, the patient came for an appointment, and she had lost all of the weight. She explained that she had had an experience that finally gave her the motivation she needed to put all that she had learned from Conry into practice. She said, “I went in to Kmart to buy some toys for the kids. I went past the women’s section, and I thought, ‘I’m going to try on a pair of pants.’ I went in and tried on elastic-waistband pants. I looked at myself in the mirror and said, ‘Oh, my. I’m 30 years old and I’m wearing elastic-waistband pants. This cannot be.’” The next morning, the patient got up 15 minutes before her children, got the treadmill out of the garage, and started walking. Over the course of a month, she progressed to half an hour. The following month she was walking an hour a day. Within a year she had set—and achieved—a goal of running a marathon. The key to the change was that the patient found a powerful motivation, which allowed her to put into action what she had learned from Conry. Conry concluded the story by expressing the belief that many women put their children first, but helping them understand that putting themselves up a notch higher to improve their health does not displace the children. Rather, it is actually an investment in their children. QUESTION-AND-ANSWER SESSION Following the keynote addresses, the floor was opened for questions and discussion. The discussion covered three primary topics: time constraints and centered pregnancy, working with the family as a whole, and restructuring the postpartum visit. Time Constraints and Centered Pregnancy One participant asked Lu and Conry to comment on the time constraints that many obstetricians experience. As a result of these time constraints, other staff members in the office often are the ones who talk with patients about such issues as weight and exercise. The participant also asked them to comment on the pregnancy-centering programs that Dr. Conry discussed.

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KEYNOTE ADDRESSES 13 FIGURE 2-3 Kaiser Permanente walking prescription. SOURCE: Conry, 2013.

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14 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 2-4 Kaiser Permanente prescription for a healthy pregnancy. SOURCE: Conry, 2013.

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KEYNOTE ADDRESSES 15 Conry agreed that time constraints are an issue. However, she said that within a 15-minute visit she calculates the patient’s BMI, asks her what she thinks her weight should be, and talks with her about diet and exercise. She conducts those conversations while doing other things, such as a breast or pelvic exam. She also has other personnel reinforce these messages during other parts of the visit, such as the weigh-in. Conry suggested that one way to maximize the office visit is to have staff members conduct a follow-up phone call to see how the patient is doing with respect to the diet and exercise expectations laid out in the visit. Finally, she noted that chronic disease management approaches may be a useful model. For example, the success with hypertension that has occurred in the United States in recent years is due not only to increased knowledge about hypertension and to improved medications, but also to the fact that patients are in programs in which their blood pressure is measured, desired outcomes are made clear, and patients are followed to track progress on those outcomes. Lu added that everything people have learned over the past 30 years indicates that quality improvement is not only about making individuals work harder, but also about making the systems work smarter. A critical way to make the systems work smarter is to have a team approach and make sure that everybody on the team is putting his or her top strengths to good use. He also noted that although physicians have a major role to play in health promotion, other types of health professionals are better at certain aspects of health education (e.g., nutrition education) than physicians. It therefore is important to think about how to create a team that can provide comprehensive, holistic care for women. Health reform may provide opportunities for stakeholders to think about developing and designing new systems of care that might provide the kind of quality that everyone deserves. In response to the question about pregnancy centering, Conry stated that the research is positive about what centering on pregnancy might offer and that it would be useful to help medical groups and medical practices understand that this focused way to approach pregnancy may help. Working with the Family One participant said that in public health programs serving women and children, clinicians are appropriately focused on the purpose of the visit when a client comes in for prenatal care. However, the participant asked whether Lu and Conry could suggest ways for clinicians to seize

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16 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES opportunities in other visits, such as family planning or child health, to talk to the family as a whole about issues that affect the entire family. For example, a well-child visit could provide an opportunity to set some goals with the family and the mother about weight and about moving toward a healthy weight. The participant also stated that public health programs have good reimbursement for children and for the pregnancy, but the coverage only goes to 60 days postpartum in the Medicaid package. Public health is challenged by not having a source of funding to serve women who are interested in focusing on their weight management during the interconception period. Conry responded to the first question by acknowledging that practitioners in different specialties work separately and that it is difficult to ensure that everyone is providing the same messages in different health visit contexts. Lu responded to the second question by stating that the ACA will make a difference for postpartum coverage. The challenge will be to determine what decisions the states will make and how to ensure that the resources needed to help women achieve a healthy weight after pregnancy become available either through the health care marketplace or through Medicaid expansion. If states do not choose those options, then an alternative route is to consider pursuing an “1115” waiver1 for interconception care. Restructuring the Postpartum Visit One participant, a family physician, said that she was particularly interested in Lu’s “before, between, and beyond” remarks. Family physicians are trained to focus on the continuity of care, and one thing that has held them back is the structure and content of the postpartum exam. The medical model for the visit is well established, but the idea of making it a more preventive, holistic visit during which clinicians address a woman’s long-term weight, exercise goals, and related issues is appealing. The participant asked Lu and Conry for ideas about how to move toward best practices on this issue. 1 A waiver to Section 1115 of the Social Security Act allows states to use federal Medicaid funds in ways that are not otherwise allowed under federal rules. These waivers give states a mechanism for carrying out experimental, pilot, or demonstration projects that expand coverage or provide new services.

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KEYNOTE ADDRESSES 17 Conry agreed that it would be valuable to make the postpartum visit a sustained, holistic experience. She described an ACOG grant in California funded by the March of Dimes that examined postpartum visit redesign. ACOG collaborated with family physicians, internists, OB- GYNs, nurses, and many others to redesign the content of the visit so that it would be determined by algorithms that took into account events occurring during the pregnancy and labor. This project may provide a useful model for postpartum follow-up. In addition, HRSA’s National Maternal Health Initiative also provides an opportunity for groups to look at how the postpartum visit may be redesigned. Lu added that successful efforts will include many types of providers—OB-GYNs as well as family practitioners, nurse midwives and nurse practitioners, health educators, and registered dietitians— coming together to help support weight gain within guidelines during pregnancy as well as to achieve a healthy weight before pregnancy and return to a healthy weight after pregnancy. Such a goal will involve considering the redesign of prenatal care, preconception and inter- conception care, and the postpartum visit so that issues important to women’s health in the long term can be addressed. In continuing the conversation about the nature of the postpartum visit, a participant observed that maternal mortality can be defined in two ways. One looks at events that occur in the first 42 days postpartum, while the other includes events occurring during the first year after a delivery. Pregnancy-related causes of death may occur during that entire first year. It is possible that postconceptional care also should occur over that whole first year and that clinicians should see the women multiple times during that period. Conry agreed and noted that a large ACOG program is currently developing definitions and recommendations about postconceptional care. However, reimbursement is a major factor. In a health maintenance organization a patient can see a physician multiple times, and her benefits are covered. In contrast, only one visit is covered under Medicaid. Lu added that HRSA’s National Maternal Health Initiative, which would be launched on Mother’s Day 2013, will be relevant. The initiative, a major national program to improve maternal health, focuses on five components. The first, and probably the most important, is improving women’s health not only during pregnancy, but also before pregnancy, between pregnancies, and beyond pregnancy. The initiative also focuses on the quality and safety of maternity care, public education and increasing public awareness, developing better public health and community systems, and improving research and surveillance. HRSA has

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18 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES been discussing ways to improve data collection and surveillance with CDC, the National Center for Health Statistics, ACOG, and other partners to improve research with the National Institutes of Health and the National Institute of Child Health and Human Development, all with the goal of improving maternal health and reducing maternal mortality and morbidity in this country. Rasmussen thanked Lu and Conry for their inspiring and thought- provoking remarks and opened the next segment of the workshop. REFERENCES Conry, J. 2013. Keynote address. Presented 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-01/2%20CONRY%20Keynote% 202.pdf (accessed June 12, 2013). Lu, M. 2013. Keynote address. Presented 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-01/1%20LU%20Keynote.pdf (ac- cessed June 12, 2013). Wen, X., E. W. Triche, J. W. Hogan, E. D. Shenassa, and S. L. Buka. 2011. Prenatal factors for childhood blood pressure mediated by intrauterine and/or childhood growth? Pediatrics 127(3):e713–e721.