Greta Krešić

Euro Weight Loss-2015Frankfurt, Germany

August 18 – 20, 2015

POSTPARTUM WEIGHT RETENTION AS A RISK FACTOR FOR DEVELOP-

MENT OF MIDLIFE OBESITY

Greta Krešić, Associate professor

University of Rijeka, Croatia

Content

• Pregnancy-related weight• Postpartum weight retention (PPWR)–risk for later

development of obesity• Predictors of postpartum weight retention

– Gestational weight gain (GWG)– Parity– Age– Ethnicity– Smoking– Lactation

Influence of breast-feeding on PPWR – prospective study in Croatia

Pregnancy-related weight

• Pregnancy - excess weight- retention of the gained weight- strong risk factor for new or persistant obesity

• Excess weight– risk factor for type 2 diabetes, – dyslipidemia, and – cardiovascular diseases

• Parous women - 3 to 4 times more likely to develop obesity in the 5 years after childbirth compared to nonparous women

Why do women gain weight in pregnancy?

• The weight gained in a normal pregnancy = biologic processes that promote faetal growth.

• A general picture can be described: – 27% resides in the fetus, – 20% includes the placenta, amniotic fluid and

uterus,– 3% comprises breast weight, – 23% is made up of blood volume and extravascular

fluid, – 27% consists of maternal fat stores

6

Early to mid-pregnancy

Underweight and normal weight women

– fat in hips, back, and upper thighs,

– important as a caloric reserve for late preg-nancy and lactation.

• Insulin secretion and sensitivity rise

• Increased lipogenesis and fat accumulation

Overweight or obese women

– No rise in peripheral insulin sensitivity

– Little or no additional fat is accrued

Late pregnancy

• Insulin resistance increases among all mothers• Weight gain slows • Normal physiologic adaptation-shifts maternal energy

metabolism from carbohydrate to lipid oxidation and thus spares glucose for the faetus

8

Postpartum weight retention (PPWR)

• Weight change after delivery minus pre-preg-nancy weight– weight gain during gestation (preconcep-

tion through gestation),– early postpartum weight loss (delivery to

6 wk postpartum) – later postpartum weight change (after 6

wk postpartum)• Based on the time after delivery:

– Short term: <11 wk– Intermediate: 3 mo to 3 y– Long term: >3 y

9

Postpartum weight retention (PPWR)

• Average estimates of postpartum weight retention: 0.5 to 3.0 kg/6–18 months postpartum

• 14–20% of women are 5 kg heavier at this period than they were before becoming pregnant

• The excess weight gained in one pregnancy - cumu-lative effect on weight gain in subsequent pregnan-cies =

amplifying the trajectory of weight gain and risk of obesity in a woman’s lifetime

10

Pregnancy-related factors that may predict development of obesity

Melzer & Schutz (2014)

11

1. Gestational weight gain

• The strongest predictor of PPWR - high gestational weight gain - increases post-partum weight retention • Related to a two- to three-fold increase in the

risk of becoming overweight after delivery • Weight increase during the first trimester – the

most important explanatory variable–Women with gestational weight gain above the IOM recommendations retain significantly more weight postpartum than do women with weight gain within or below the recommenda-tions, independent of pre- pregnancy BMI or body fat at baseline

12

• Gestational weight gain greater than that recom-mended tends to consist of fat– Women with an average weight gain ~ 12 kg

gain ~ 3 kg of adipose tissue.– Women with excessive pregnancy weight gain

(>20 kg) ~ 11 kg of adipose tissue. – Most of the adipose tissue is placed subcuta-

neously– Excess gestational weight gain and failure to lose

weight in an appreciable time are indicators of obesity in midlife up to 15 years after preg-nancy

13

Excessive gestational weight gain and outcomes for mother and baby

• Maternal complication: – Obesity risk– Pre-eclampsia, caesarean section, instru-

mental delivery, large-for gestational age births

• Neonatal complication:– Low five-minute Apgar score, seizure,

hypoglycaemia, polycythaemia, meconium aspiration syndrome

– Infant weight at birth – Childhood obesity risk

Gestational weight gain (GWG) and obesity risk in mother

• Sigmoidal pattern- the majority of weight gained in the 2nd and early 3rd tri-mesters of pregnancy

• Lower gains - protective against postpartum maternal weight retention and obesity

• Women with higher gains remain heav-ier; – women with average gains of 17.7 kg vs.

13.1 kg had higher BMI and more central adiposity that persisted 16 years after the index pregnancy

14

15

Influence of GWG on infant weight at birth

• A higher rate of maternal weight gain in the second trimester - higher infant weight at birth – association is particularly strong among women

with a low or normal pregravid BMI. • Among women who are overweight or obese,

gestational weight gain is a less strong pre-dictor of faetal growth

16

Influence of GWG on childhood obesity

• Higher gestational weight-higher offspring weight at birth, in childhood, during adolescence, and as adults

• Maternal over-nutrition have a direct in-fluence on several aspects of offspring physiology, including appetite, meta-bolism, activity levels, increased faetal adipose tissue deposition

17

In the context of current obesity epidemic, how much weight gain in pregnancy is ideal?

• Pregnancy weight gain guidelines—In 2009, the Institute of Medicines (IOM) updated earlier guidelines on weight gain during pregnancy (1990)

• IOM used available data to determine the most favorable amount of weight gain considering short - and longer-term outcomes: – extremes of birth weight (expressed as small-or

large-for gestational age), – cesearean delivery, – preterm birth, – postpartum weight retention, and– child obesity

18

IOM recommended amounts of gestational weight gain by weight class

19

Trends in pregnancy weight gain

• ~ 30-40% of pregnannt women gain GW within IOM recommendations

• ~ 20-40% of pregnannt women gain GW above IOM recommendations

• Lower weight gain- lower fetal growth= later obesity, cardiovascular disease and diabetes

• „Survival phenotype”.IOM Report: Women today are heavier; a greater percentage of them are entering pregnancy overweight or obese, and many are gaining too much weight during pregnancy

20

• Meta-analysis of long-term and short-term effects of GWG in accordance with IOM recommendation on post-partum weight retention

• Of 1770 search hits, 9 observational studies remained suitable for the analysis.

• Follow up: <0.5; 0.5-1; 1-3 and >=15 years.• Women with GWG above the recommendations retained ad-

ditional 3.06 kg after 3 y and 4.72 kg after 15 y postpartum compared to women with GWG within IOM recommendation

• Inadequate GWG was associated with less PPWR (-2.99 kg); <6 mo after pregnancy.

• This association faded over time and became nonsignificant (-1.41 kg) after 15 y.

• The obtained results have shown that PPWR increased after longer time spans after delivery irrespective of whether GWG had been below within, or above the guidelines.

21

• Association between GWG and PPWR using a bias-adjusted method

• The IOM categories of “inadequate,” “adequate,” and “excess” were used to define GWG.

• The time span for PPWR was divided into three peri-ods (<1 year, 1 year to 9 years, and 15 years)

• 12 studies met the eligibility criteria • Women with an inadequate GWG had a signifi-

cantly lower mean PPWR of -2.14 kg (95%CI, -2.61 to -1.66) than women with an adequate GWG, who had a mean PPWR of 3.15 kg (95%CI, 2.47 to 3.82) up to 21 years postpartum

22

23

PPWR according to recommendations for weight gain (Mannan et al., 2013)

GWG outside of the Institute of Medicine recommenda-tions can lead to both short-term and long-term post-partum weight imbalance

24

2. The influence of pre-pregnancy BMI on PPWR

• Women who are overweight or obese before pregnancy - gain less weight - postpartum weight increase is greater!

• Although underweight and normal weight wo-men gained more weight during pregnancy, they lost more kg during the late postpartum period (2 ys).

• Gestational weight gain has a consistent relation-ship to postpartum weight loss, whereas pre-pregnancy BMI shows not to be associated with postpartum weight loss.

25

Other factors influencing PPWR 3. Parity

• Each successive birth, adds on an average, about 1kg of postpartum body weight above that nor-mally gained with age

Melzer & Schutz (2014)

26

Other factors influencing PPWR 4. Age

• Adolescent pregnancy - associated with sub-sequent obesity.

• Adolescents who are obese before their first pregnancy often become even more obese some 3 years after pregnancy.

• Other risk factors of becoming overweight:– maternal age 24–30 versus>30 years; – high gestational gain; – short interval from menarche to first birth

(<8 years); – young age at menarche (<12 years).

27

Other factors influencing PPWR 5. Ethnicity

• Black women reported much more postpartum weight increase than did White women.

• Higher energy intake, higher percentage fat in diet and lower physical activity levels in Black postpartum mothers, compared with White mothers, may contribute to their greater

weight retention.

28

Other factors influencing PPWR 6. Smoking

• Women who stop smoking have significantly higher pregnancy weight gain

• Smokers who continue smoking during preg-nancy gain less weight during pregnancy than do non-smokers.

• Apart from pregnancy weight gain, only smoking cessation can be considered as a predictor for persistent weight gain after 1 year postpartum (The Stockholm Pregnancy and Weight Development Study)

29

Other factors influencing PPWR 7. Lactation

• Some studies suggest that lactation has a role in weight reduction after delivery, many oth-ers report no such relationship – These are thought to be due to differences

in study quality• Better-quality studies on the impact of

breastfeeding on maternal postpartum weight loss reported greater weight or fat loss in women who breastfeed longer (particularly at 3–6 months post-partum).

30

• 37 prospective studies and 8 retrospective studies. • The majority of studies reported little or no

association between BF and weight change (n=27,63%) or change in body composition (n=16, 89%), although this seemed to depend on the measurement time points and BF intensity.

• 4 studies demonstrated a positive association between BF and weight change.

• The authors have concluded that although the available evidence challenges the widely held belief that BF promotes weight loss, more robust studies are needed to reliably assess the impact of BF on postpartum weight management.

31

Krešić, G. : Prospective study in Croatia: CChanges in dietary intake and body-weight in lactating and non-lactating women during 6 months postpartum

Background• Women in Croatia (Croatian Adult Health Survey)

– Overweight: 33.60%– Obese: 20.60% – Increased waist circumference: 51.13%

• Important life stage for women- concern about diet and weight

• Part of a comprehensive study…

32

The aims of the study were:

To investigate how weight retention during 6 months postpartum was affected by: 1) type of feeding; 2) time since parturition;3) gestational weight gain; 4) total energy intake;5) energy intake derived from fat.

33

Subjects

34

Study design and data collection

• Lactating and non-lactating women : – 3 home visits= 3 measurement waves– 1m±1w, 3m±1w; 6m±1w postpartum

• Lactating = full breast feeding+mixed feeding• Non-lactating=formula-feeding• In each wave:

– Dietary evaluation (2x24 h-recalls)– Body composition measurements– Milk sampling

• Statistical analysis– Group & time dimensions– Multivariate longitudinal linear regression

35

36

37

38

39

40

Conclusions of the study

• Breastfeeding per se must be sustained for six months for a significant impact on weight loss

• After three months, non-lactating women stopped losing weight, while lactating women at six months after delivery retained significantly less weight in comparison with non-lactating women.

• Gestational weight gain and dietary intake were also predictors of weight retention

Euro Weight Loss – 2016 Website: http://weightloss.global-summit.com/

europe/

Meet the eminent gathering once again at

Euro Weight Loss-2016Vienna, Austria

September 19-21, 2016

Euro Weight Loss – 2016 Website:http://weightloss.global-sum-

mit.com/europe/

Meet the eminent gathering once again at

Euro Weight Loss-2016Vienna, Austria

September 19-21, 2016

Thank you for your atten-tion!