Prepregnancy BMI
BMI (kg/m2)
Recommended total weight gain range (lb)
Rates of weight gain (2nd and 3rd trimester) (mean range in lb/week)
Underweight
<18.5
28–40
1 (1–3)
Normal weight
18.5–24.9
25–35
1 (.8–1)
Overweight
25.0–29.9
15–25
0.6 (0.5–0.7)
Obese (includes all classes)
≥30.0
11–20
0.5 (0.4–0.6)
Guidelines for Perinatal Care, issued by both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), recommends that all health encounters during a woman’s reproductive years include counseling to improve future pregnancy outcomes [7]. The Centers for Disease Control and Prevention (CDC) recommends that all primary care clinicians integrate preconception counseling into every health-care encounter [8]. Given the fact that overweight and obesity can have such negative impacts on the health of a woman and her child, and understanding that about 50 % of pregnancies in the USA are unplanned, preconception care should occur during every visit with an overweight or obese woman.
Approaching the Patient Who Is Overweight or Obese
Because of the social stigma attached to overweight and obesity, diagnosis and discussion may need to be handled with greater tact than a discussion about hypertension, but it does need to happen. Much research has focused on the impact of using appropriate terminology when discussing overweight and obesity with patients [9]. What appears to be consistent is that women do not respond in a consistent way to descriptors of their weight. Using terminology that describes the impact of weight on health appears to be acceptable to patients, and this approach may be the most comfortable. In the end, however, as long as derogatory language is not used, any discussion is better than ignoring the topic altogether. Cultural competency must also play a role in the discussion of weight with patients. Different cultures have varying attitudes toward overweight, so the provider may be making recommendations that are counter to a patient’s perspective. Understanding the patient’s background, home environment, stressors, and socioeconomic status is important before the provider embarks on recommendations to change behavior.
Clinical Assessment at the Health Visit
Body Mass Index
BMI (Table 3.1) [3] should be calculated at each health visit and reviewed as a vital sign in the same fashion as blood pressure is addressed. BMI is calculated as
Electronic medical records can often be enabled to calculate BMI automatically when height and weight are entered. A standard workflow in which actual weight is measured at each visit and BMI is calculated ensures providers have this additional “vital sign.”
Waist Circumference and Waist to Hip Ratio
Because central or abdominal obesity is associated with cardiovascular disease and death, waist circumference or waist to hip ratio (WHR) can be another measure to include in a preconception visit [9]. There are no specific prenatal guidelines related to these other measures of adiposity. However, these measures can provide long-term guidance about the risk of diabetes and cardiovascular disease.
Type 2 Diabetes and Lipid Screening
Screening for diabetes and dyslipidemia can be considered for the overweight or obese woman. The diagnosis of type 2 diabetes is important for pregnancy care. Type 2 diabetes is associated with a threefold increase in the prevalence of birth defects, but this risk can be reduced with proper management of diabetes before conception [10, 11]. Hemoglobin A1C levels should be in the lower range of normal (<6.1 %) prior to conception [10]. If a woman is newly diagnosed during the preconception visit, she will need a comprehensive medical evaluation with a primary care clinician or endocrinologist and referred for ophthalmic evaluation. A lipid panel would be indicated if the diagnosis of diabetes is made and may also been performed in the overweight or obese woman without diabetes. While dyslipidemia may not change obstetrical management, medications for lipid management are contraindicated in women who are attempting pregnancy, those who are currently pregnant, and lactating women. Therefore, obese women with abnormal lipids will need to be aware of the contraindications of medical therapy during the preconception and perinatal periods.
Folic Acid Supplementation
All reproductive-aged women are encouraged to take a 4 mcg daily dose of folic acid before pregnancy and at least through the first 4 weeks of pregnancy. Women who are obese have been found to have an increased risk for neural tube defects compared to women in a normal BMI range [12], but studies have not clearly demonstrated that an increased dose of folic acid would be appropriate for this population. At the very least, educating the patient about this additional risk to her offspring as a result of maternal obesity might offer additional motivation to take the recommended dose of preconception folic acid and to achieve a healthy weight before conception.
Screening for Obesity in Adults
The US Preventive Services Task Force (USPSTF) recommends screening all adults for obesity and states that clinicians should offer or refer patients with a BMI of 30 mg/m2 or greater to intensive, multicomponent behavioral interventions [13]. The American College of Preventive Medicine (ACPM) has also issued a practice statement about recommended counseling for overweight adults. Like most other organizations, the ACPM does not endorse any specific behavioral therapy or pharmacotherapy, but instead recommends individualized programs based on the available evidence [14]. There are two components to successful behavioral interventions. The first is to understand the relative effectiveness of different programs and recommend the intervention most likely to be successful for a given patient. The second is to engage the patient in a manner that will most likely lead to an activated patient who is likely to change her behavior.
Interventions for Lifestyle Modifications
Interventions for lifestyle modification have been shown time and again to be successful in reaching clinically relevant outcomes in diverse groups of women. For example, three large randomized controlled clinical trials of primary prevention of type 2 diabetes in three different countries have all demonstrated that maintenance of 3–5 kg (7–10 lb) of weight loss through diet and physical activity reduced the incidence of type 2 diabetes in high-risk individuals by 40–60 % over 3–4 years [15–17]. The largest study randomized over 3,000 patients to control, use of metformin, or lifestyle intervention (achieve and maintain 7 % or greater weight loss through a low-calorie, low-fat diet and at least 150 min of moderate physical activity per week) [17]. Over 3 years, the lifestyle intervention group lost an average of 5.6 kg, and the incidence of diabetes was reduced by 58 % [17]. While the outcomes in these studies were focused on prevention of diabetes, they demonstrated that lifestyle modification was indeed a worthwhile intervention in high-risk women. In a systematic review, Powell et al. reviewed and identified nine lifestyle modification trials. In the successful trials, weekly interventions resulted in the greatest weight reduction among participants, but after the initial intensive phase, monthly or bimonthly contact appeared to maintain 60–80 % of the initial weight loss [18].
Table 3.2
Applying the transtheoretical model (TTM)
Stage of change | Description of patient | Ways to assist patient |
|---|---|---|
Precontemplation | No plans to change behavior(s) | Motivational interviewing (can be used throughout) |
Does not believe behavior leads to adverse health outcomes | Ask patient’s permission to discuss behavior/issues | |
Contemplation | May begin to understand relationship between behavior and adverse consequences on her health | Ensure patient has knowledge and skills to change behavior |
Address doubts in self-efficacy | ||
Preparation | Commits to behavior change | Encourage family/friend involvement |
Makes concrete, actionable plans | Help her recognize potential obstacles | |
Advise her that relapses may occur | ||
Action | Makes change in lifestyle or acquires healthy new behaviors | Provide encouragement |
If relapse, identify ways to reduce risk of future relapse (avoid unhealthy triggers) | ||
Maintenance | Continues to implement lifestyle change | Ongoing evaluation, though less frequent |
Works to prevent relapse | Provide encouragement | |
Demonstrate empathy |
The evidence does demonstrate that lifestyle modification works, but it is certainly not without significant challenges. It is important, therefore, to utilize tools that have been demonstrated to facilitate behavioral change. Understanding models of behavior change and implementing patient activation tools can help women’s health providers as they care for overweight and obese women.
Models of Behavioral Change
Providers of women’s health care can apply social cognitive theory (SCT) to behavioral change counseling. SCT has been employed as the theoretical basis for a multitude of behavioral interventions. It supposes that three factors—environment, person, and behavior—interact and a change in one affects the other two [19]. A provider may be limited in the ability to alter the patient’s physical or social environment, but can make recommendations on how the patient can modify her surroundings or with whom she interacts. The “person” variables include behavioral capability (knowledge and skills to engage in the behavior), outcomes expectancies, observational learning, and perceived self-efficacy. Having the patient set realistic weight loss goals can increase perceived self-efficacy early on in the process. The transtheoretical model is the foundation of many of the behavioral interventions used in clinical medicine, and it assumes that all individuals transition through five stages of change in the process of altering a behavior: precontemplation, contemplation, preparation, action, and maintenance (Table 3.2) [20]. These models are important and useful, but successful behavioral change also requires activated patients. Motivational interviewing is one tool to achieve that goal.
Motivational Interviewing
The goal of motivational interviewing (MI), first described by William Miller in 1983, is to use reflective listening and other tools to allow the patient to move through stages of change as described in the TTP [21]. The following are the key points of motivational interviewing [22]:
1.
Motivation to change is elicited from the client.
2.
It is the patient’s task to articulate and resolve her ambivalence about the behavior.
3.
Direct persuasion is not an effective method for resolving the ambivalence.
4.
The counseling style is quiet and eliciting.
5.
The provider is directive in helping the patient examine and resolve ambivalence.
6.
Readiness to change is a fluctuating product of interpersonal interaction.
7.
The therapeutic relationship is more like a partnership than expert/recipient roles.
The key skills can be summarized by the OARS acronym: (1) open-ended questions, (2) affirm, (3) reflect, and (4) summarize.
In a meta-analysis of 72 RCTs, motivational interviewing had a significant and clinically relevant effect in changing behaviors in about 75 % of the studies [23]. MI has been shown to be effective in studies of smoking cessation, unhealthy alcohol and drug use, and high-risk sexual behaviors [24]. It has also been studied in overweight and obesity. In an observational study of 40 primary care physicians, examining 461 of their provider-patient encounters, investigators found that use of motivational interviewing techniques during recorded patient visits was associated with statistically significant increases in amount of weight lost 3 months after the encounter [25]. Such techniques included verbalizing an understanding of the patient’s perspective, understanding motivation or lack of motivation, helping patients to find their own solutions and their own internal motivation to change, and assuring the patient that he or she has freedom to change. Other behaviors consistent with MI included praising, collaborating, and evoking “change statements” from patients [25].
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