WIC 133 High Maternal Weight Gain

Pregnant Women:

1. A high rate of weight gain, such that in the 2nd and 3rd trimesters, for singleton pregnancies (1):

Note: A BMI table is attached to assist in determining weight classification. Also, until research supports the use of different BMI cut-offs to determine weight status categories for adolescent pregnancies, the same BMI cut-offs will be used for all women, regardless of age, when determining WIC eligibility (1). (See Justification for a more detailed explanation.)

2. High weight gain at any point in pregnancy, such that using an Institute of Medicine (IOM)‐based weight gain grid, a pregnant woman’s weight plots at any point above the top line of the appropriate weight gain range for her respective prepregnancy weight category (see below).

Breastfeeding or Non-Breastfeeding Women (most recent pregnancy only):

Total gestational weight gain exceeding the upper limit of the IOM’s recommended range (2) based on Body Mass Index (BMI) for singleton pregnancies, as follows (1):

Note: A BMI table is attached to assist in determining weight classification. Also, until research supports the use of different BMI cut-offs to determine weight status categories for adolescent pregnancies, the same BMI cut-offs will be used for all women, regardless of age, when determining WIC eligibility (1). (See Justification for a more detailed explanation.)

Women with excessive gestational weight gains are at increased risk for cesarean delivery and delivering large for gestational age infants that can secondarily lead to complications during labor and delivery. There is a strong association between higher maternal weight gain and both postpartum weight retention and subsequent maternal obesity. High maternal weight gain may be associated with glucose abnormalities and gestational hypertension disorders, but the evidence is inconclusive (1).

Childhood obesity is one of the most important long‐term health outcomes related to high maternal weight gain. A number of epidemiologic studies show that high maternal weight gain is associated with childhood obesity as measured by BMI (1).

The 2009 Institute of Medicine (IOM) report: Weight Gain During Pregnancy: Reexamining the Guidelines (1) updated the pregnancy weight categories to conform to the categories developed by the World Health Organization and adopted by the National Heart, Lung and Blood Institute in 1998 (2). The reexamination of the guidelines consisted of a review of the determinants of a wide range of short‐and long‐term consequences of variation in weight gain during pregnancy for both the mother and her infant. The IOM prenatal weight gain recommendations based on prepregnancy weight status categories are associated with improved maternal and child health outcomes (1).

Included in the 2009 IOM guidelines is the recommendation that the BMI weight categories used for adult women be used for pregnant adolescents as well. More research is needed to determine whether special categories are needed for adolescents. It is recognized that the IOM cut‐offs for defining weight categories will classify some adolescents differently than the CDC BMI‐for‐age charts. For the purpose of WIC eligibility determination, the IOM cut‐offs will be used for all women regardless of age. However, due to the lack of research on relevant BMI cut‐offs for pregnant and postpartum adolescents, professionals should use all of the tools available to them to assess these applicants’ anthropometric status and tailor nutrition counseling accordingly.

For twin gestations, the 2009 IOM recommendations provide provisional guidelines: normal weight women should gain 37‐54 pounds; overweight women, 31‐50 pounds; and obese women, 25‐42 pounds. There was insufficient information for the IOM committee to develop even provisional guidelines for underweight women with multiple fetuses (1). However, a consistent rate of weight gain is advisable. A gain of 1.5 pounds per week during the second and third trimesters has been associated with a reduced risk of preterm and low‐birth weight delivery in twin pregnancy (3). In triplet pregnancies the overall gain should be around 50 pounds with a steady rate of gain of approximately 1.5 pounds per week throughout the pregnancy (3). Education by the WIC nutritionist should address a steady rate of weight gain that is higher than for singleton pregnancies. For WIC eligibility determinations, multi‐fetal pregnancies are considered a nutrition risk in and of themselves (Risk #335, Multi‐Fetal Gestation), aside from the weight gain issue.

The supplemental foods, nutrition education, and counseling related to the weight gain guidelines provided by the WIC Program may improve maternal weight status and infant outcomes (4). In addition, WIC nutritionists can play an important role, through nutrition education and physical activity promotion, in assisting postpartum women achieve and maintain a healthy weight.

Clarification:

• Risk code 133 High Maternal Weight Gain is considered high risk when assigned to a pregnant participant. See Justification section for reasons.
• Postpartum participants assigned this risk code are not considered high risk, but support for healthy habits remains important.

The objectives and intervention strategies should include:

• Assist participant in maintaining healthy and competent eating habits during pregnancy.
• Monitor weight changes.
• Assess for nutritional adequacy of the participant’s dietary intake.
• Identify when additional intervention may be warranted and make appropriate referrals as necessary (e.g., medical referral).

Assessment and Counseling for Risk Code 133

Complete a thorough assessment of all topics in the chart below before beginning counseling. Individualize and prioritize counseling based on risk and the participant’s interest and readiness for change, utilizing a weight inclusive approach.

Refer to the chart below for Risk Code 133 assessment and counseling tips:

Guidance about Follow-up for Risk Code 133

• Assess the most effective follow-up approach. Before increasing the frequency of WIC check-ins and/or monitoring weight changes, consider the participant’s current medical care, ability to attend WIC appointments, and actual benefit of increased weighing.
• For participants who would benefit from supportive check-ins, consider following up 1-2 months after the certification to provide the greatest opportunity for positive impact before advanced pregnancy.
• The high risk designation may be resolved by the Competent Professional Authority (CPA) if the participant is showing steady appropriate? weight gain, adequate nutritional intake, and has no other related or high risk factors. Document the reasons for resolving the high risk status.

References:

Burnette, Blair PhD. (2023). Intuitive Eating: Promoting Positive Attitudes and Behaviors within Families [Prerecorded webinar]. University of Minnesota School of Public Health; accessed via: MDH Learning Center

The Centers for Disease Control and Prevention (CDC) defines a trimester as a term of three months in the prenatal gestation period with the specific trimesters defined as follows in weeks:

• First Trimester: 0-13 weeks
• Second Trimester: 14-26 weeks
• Third Trimester: 27-40 weeks

Further, CDC begins the calculation of weeks starting with the first day of the last menstrual period. If that date is not available, CDC estimates that date from the estimated date of confinement (EDC). This definition is used in interpreting CDC’s Prenatal Nutrition Surveillance System data, comprised primarily of data on pregnant women participating in the WIC Program.

1. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines (Prepublication Copy). National Academy Press, Washington, D.C.; 2009. www.nap.edu. Accessed June 2009.

2. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication No. 98-4083; 1998 [cited 2017 Dec 1]. Available from: www.nhlbi.nih.gov.

3. Brown JE and Carlson M. Nutrition and multifetal pregnancy. J Am Diet Assoc. 2000; 100:343-348.

3. Van der Post JAM, Painter RC, Grooten IJ, Roseboom TJ, Pontesilli M, Mol BWJ, van Eijsden M, Vrikjkotte Bodnar TGM. Weight loss in pregnancy and cardiometabolic profile in childhood: findings from a longitudinal birth cohort. Maternal & Child Health Journal. 2014.

4. Institute of Medicine (IOM); Committee on Scientific Evaluation of WIC Nutrition Risk Criteria. WIC nutrition risk criteria: A scientific assessment. Washington, DC: National Academy Press; 1996.

Additional References

1. Carmichael S, Abrams B, Selvin S. The pattern of maternal weight gain in women with good pregnancy outcomes. Am.J.Pub.Hlth. 1997; 87; 12:1984‐1988.

2. Brown JE, Schloesser PT. Pregnancy weight status, prenatal weight gain, and the outcome of term twin gestation. Am. J. Obstet. Gynecol. 1990; 162:182-6.

3. Parker JD, Abrams B. Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine. Obstet Gynecol, 1992; 79:664-9.

4. Siega-Riz AM, Adair LS, Hobel CJ. Institute of Medicine maternal weight gain recommendations and pregnancy outcomes in a predominately Hispanic population. Obstet Gynecol, 1994; 84:565- 73.

5. Suitor CW, editor. Maternal weight gain: a report of an expert work group. Arlington, Virginia: National Center for Education in Maternal and Child Health; 1997. Sponsored by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services.

6. Waller K. Why neural tube defects are increased in obese women. Contemporary OB/GYN 1997; p. 25‐32.

(1) Adapted from the Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). NIH Publication No. 98-4083.