In the "old days," the ob.gyn. focused on a limited period in a patient’s life. Perhaps we only saw a patient for annual exams and then for a more intense time prior to and during pregnancy, and then for a checkup post partum where we may have examined our patients only for complications of the pregnancy and delivery and not much more. Although we may have included some counseling on maintaining a healthy pregnancy, many of us relied on a patient’s primary care physician to provide ongoing support.
Today, however, we must take a more active role in helping our patients establish and maintain a healthy lifestyle. Despite the increased insurance coverage under the ACA and the expansion of Medicaid, a woman’s ob.gyn. may be the only health care practitioner she will see on a routine basis. Many women do not visit a general practitioner for routine physical examinations, but women will see their ob.gyn. for regular exams. We can use these annual or biannual office visits to help women set goals to live a healthy life, approaching each patient as a whole person who needs comprehensive care throughout her reproductive life and beyond.
For patients who are overweight or obese, we may focus on helping them reduce their body mass index and blood pressure and encourage them to stay fit. We also should do everything we can to ensure that if a woman has had gestational diabetes, she’s doing what she can to reduce her risk of developing type 2 diabetes after pregnancy. For these patients, we should consider testing their blood glucose every 1-2 years during the annual checkup.
Healthy weight in pregnancy: to gain or to lose?
Whether or not an ob.gyn. practice implements a screening program and more intensive obesity and diabetes counseling, we all will face the same question: How much weight should my patient gain to have a healthy baby? Interestingly, in the first half of the 20th century, ob.gyns. were discouraged from recommending that their pregnant patients gain very much weight. Indeed, the 13th edition of "Williams Obstetrics" (New York: Appleton-Century-Crofts, 1966, p. 326) stated that obstetricians should limit their patients from gaining more than 25 pounds during gestation, and that the ideal weight gain was 15 pounds.
This guidance was called into question by a 1970 National Academy of Sciences report, "Maternal Nutrition and the Course of Pregnancy," which indicated a strong link between infant mortality and low maternal pregnancy weight. Further evidence suggested a need for new standards and, in 1990, the IOM issued recommendations on women’s nutrition during pregnancy (Nutrition During Pregnancy, Weight Gain and Nutrient Supplements. Washington, D.C.: National Academy Press, 1990). (See table.)
Americans consume 31% more calories today than they did 40 years ago. Because of this, a woman’s need to gain weight to improve the outcome of her pregnancy is significantly reduced. The calories that many people include in their diets often come from high-fat, sodium-loaded, processed foods. We also have become a more sedentary society, spending our days at a computer, browsing the internet, watching TV, and opting to drive rather than to walk. Taking these factors into account, revising the recommendations for weight gain seemed crucial. In 2009, the IOM revised its guidance on healthy weight gain in pregnancy, and these ranges are currently widely accepted by obstetricians today (iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx). (See table.)
With the obesity and diabetes epidemics on the rise, we may need to update the 2009 IOM guidelines again – and very soon. Isolated studies have indicated that, for women who are severely obese, moderate weight loss during pregnancy may improve pregnancy outcomes. These findings remain controversial, but the "heavy" burden of diabetes and obesity on the U.S. health care system in general, and the need to reduce obstetrical complications that accompany deliveries in patients who are overweight or obese and diabetic, means that we as a community may need to reexamine our practices and approaches much more closely.
"Food" for thought
We all know of patients who, once they become pregnant, begin justifying a greater intake of food as "eating for two." Many women may use their pregnancy as an excuse to overindulge in unhealthy foods or to forgo the gym and other regular exercise regimens. Recommending basic steps to change a patient’s lifestyle can make an incredible difference in improving maternal and fetal health outcomes.
Summary recommendations for healthy pregnancy
• A low-glycemic diet, combined with moderate exercise, can reduce or eliminate many of the negative consequences of obesity on pregnant women and their babies.