Obesitas en zwangerschap Prevalentie, determinanten en interventies Roland Devlieger, MD, PhD Dienst Verloskunde-Gynaecologie UZ Leuven
“Venus in front of the mirror” PP Rubens, 1613
Jaarverslagen UZ Leuven 1993-2002 Gewichtstoename tijdens zwangerschap 15 14,5
Gewichtstoename (kg)
14 13,5 13 Gewichtstoename eerste zwangerschap 12,5
Gewichtstoename tweede zwangerschap Gewichtstoename derde zwangerschap
12 11,5 11 10,5 10 1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Jaartal
S. Housman, B. Spitz, R. Devlieger 2003
Overview
• The “size” of the problem – In the world – In Flanders (SPE)
• Complications • Management
Health Survey Belgium 2008 33% overweight (BMI 2529,9kg/m²) ; 14% obese (BMI ≥ 30 kg/m²)
Prevalentie van obesitas
Obesitasprevalentie Belgie ♀
♂
4.6 %
2.1 %
Normaal 19.8 – 26.0 kg/m²
60.3 %
50.4 %
Overgewicht 26.1 kg - 29.9 kg/m²
23.5 %
37.6%
Obesitas > 30.0 kg/m²
11.6 %
9.9%
Ondergewicht
<18.9 kg/m²
1 vrouw op 3 • Vaak in reproductieve leeftijd •
VCP 2004
Prevalence of overweight and obese women in pregnancy
% overweight WHO
China 2002-2003
% obese WHO
Denmark 1992-1996 Copenhagen 1998-2001 Australia, Melbourne 1999-2001 Sweden 1992-1993 % overweight WHO
Australia, Melbourne 1999-2001 Brazil 1991-1995
% obese WHO
Belgium 2006 Brazil 1991-1995 Italy 1999-2001
Finland China 1989-2001 2002-2003 UK 2002-2004 Copenhagen 1998-2001 USA, Cleveland Ohio 1997-2001 Denmark 1992-1996 Finland 1989-2001 0
5
10
15
20
25
30
35
40
45
50
Italy 1999-2001
Guelinckx et al, Obesity Reviews, 2008 Sweden 1992-1993
Studiecentrum Perinatale Epidemiologie (SPE) Perinatal data from all deliveries in region of Flanders since 25 years 2008: request for addition of three items: -maternal weight at start of pregnancy -maternal height -maternal weight at end of pregnacy BMI (kg/m²) GWG (kg) Linked with socio-demographic data from „Vlaams Agentschap Zorg en Gezondheid‟
Objective: to study the prevalence and distribution of prepregnancy BMI and GWG for the region of Flanders related to sociodemographic characteristics.
Exclusion criteria Total deliveries in 2009 n= 66 312 • • • • •
Missing data concerning maternal height and weight, n=9153 Preterm deliveries, n = 3137 Maternal height, < 1.4 or > 1.96 m Maternal prepregn weight, < 35 or > 154 kg GWG, > 50 kg or > 26 kg weight loss
54 022 women eligible for analysis
Complications?
La dystocie de l‟épaule
Complications of obesity in pregnancy
Conception Decreased fertility Fertility treatment less succesful
Embroyonic period Increaded miscarriage risk Increased risk for fetal maformations
Fetal period Abnormal fetal growth Decreased detection of fetal anomalies
Pregnancy
Delivery
Gestational diabetes Hypertensive disorders of pregnancy Increased risk Depression Infections Respiratory problems
Increased risk induction of labour, instrumental delivery, CS Increased risk for anaesthetic complications Intrapartum monitoring difficulties Higher risk for birth trauma
Postpartum Increased risk PPH Increased risk Thrombosis Decreased breastfeeding levels Increased risk wound infection Increased weight retention Increased risk Type 2 DM
Childhood Increased risk childhood obesity
Adulthood Increased risk metabolic syndrome
Guelinckx et al, Obesity Reviews 2009
Pregnancy and obesity Maternal diet 2
Gestational Weight Gain (GWG) 3
Prepregnancy BMI 1
Pregnancy outcome
1
Villamor et al. Lancet 2006; 2 Kaiser L et al al. J Am Diet Assoc 2008; 3 Viswanathan et al. Evid Rep Technol Assess 2008
Behandeling • Voor • Tijdens • Na • De zwangerschap
Preconceptional treatment of obesity
Physical activity
Medication
Obesity
Diet
Surgery ?
Is it safe? Who should benefit?
Bariatric surgery Types : RESTRICTIVE MALABSORPTIVE COMBINED
• • • •
LAGB Vertical gastroplasty Roux-en-Y gastric Bypass Biliopancreatic diversion – Duodenal switch
21 DeMaria, E.J., Bariatric surgery for morbid obesity. N Engl J Med, 2007. 356(21): p. 2176-83
SOS-study
Sjöström et al, NEJM 2007
Effects on reproduction: summary Improvement
Worsening
No effect
No data
Fertility Hypertensive disorders GDM LGA Excessieve GWG SGA Surgical complications Nutritional deficiencies Prematurity? Caesarean section Prematurity?
Miscarriages Weight retention lactation
Effect of weight loss on fertility Decreased resorbtion oral contraceptives
Increased fertility Reversal of anovulation
Increased attractivity
• G2P1, 34 weken
PABAS: pregnancy after bariatric surgery
Fat soluble vitamin levels 1st trimester Reference value
Restrictive procedure
Malabsorptive procedure
P-value
N = 15
N = 20
368 ± 116
397 ± 85
0.399
87 % 13 %
89 % 11 %
0.626
26 ± 15
23 ± 14
0.700
57 % 36 % 7%
71 % 7% 22 %
0.143
12 ± 2
12 ± 2
0.542
100 %
100 %
0.5 ± 0.3
0.4 ± 0.3
0.233
20 % 80 %
11 % 89 %
0.409
Vitamin A (µg/l) Mean ± SD
300 - 650
Normal Deficient 25-OH-Vitamin D (µg/l)
Mean ± SD
7.0 – 60.0
Normal Deficient < 20 µg/l Deficient < 7 µg/l Vitamin E (mg/l) Mean ± SD
5.0 – 20.0
Normal Vitamin K (nmol/l) Mean ± SD Normal Deficient
0.8 – 5.3
Aanbevelingen voor opvolging van zwangerschap na LAGB Preconceptioneel
Post-operatieve opvolging van nutritionele status Inschakelen diëtiste in verband met gezond dieet Betrouwbare contraceptie tot ongeveer 1 jaar na zwangerschap Inname supplementen foliumzuur, ijzer en vitamine B 12
Prenataal
Vroege start en regelmatige opvolging in verband met nutritionele status en bandvolume Voedingssupplementen op maat van de patiënt In geval van braken het volume van de band te verminderen Op 14 weken evalueren en het volume van de band aanpassen afhankelijk van de gewichtsevolutie van de patiënte Op 36 weken overwegen het volume van de band te verminderen Echografische opvolging van foetale groei en eventuele afwijkingen hierop Alert zijn op symptomen van intestinale obstructie Testen op zwangerschapsdiabetes
Post-partum
Post-partum opvolging nutritionele status Inschakelen diëtiste in verband met gezond dieet en om gewichtsverlies te begeleiden Informeer de pediater over de ingreep van de moeder en de mogelijke complicaties voor de neonaat Aanraden van borstvoeding
Guelinckx, Devlieger, Vansant et al, 2009
“Treatment” of Obesity during pregnancy? •Reduced in pregnancy •Some PA contra-indicated Physical activity
•Contra-indicated in pregnancy
Surgery
Obesity
Medication
Diet
•Poor diet, espescially in the obese •Intervention studies show benefit •No effect on pregnancy outcome
•No registered safe products
• Prospective longitudinal study N = 142 • 4 BMI categories • Evaluation of diet quality during each trimester
Guelinckx et al, submitted
www.uzleuven.be/voeding en zwangerschap
• Website
www.uzleuven.be/voedingtijdenszwangerschap
Definitions and Guidelines Prepregnancy BMI category
Underweight
Total Weight Gain
Rate of Weight Gain in the Second and Third Trimesters, Mean (range)
12.5 – 18 kg
0.51 (0.44-0.58) kg/wk
11.5 – 16 kg
0.42 (0.35-0.50) kg/wk
7 – 11.5 kg
0.28 (0.23-0.33) kg/wk
5 – 9 kg
0.22 (0.17-0.27) kg/wk
(<18.5 kg/m²)
Normal Weight (18.5-24.9 kg/m²)
Overweight (25.0-29.9 kg/m²)
Obese (≥30 kg/m²)
Institute of Medicine Gestational Weight Gain Recommendations (2009)
Gewichtscurven per BMI categorie
Guelinckx I et al. Gynecol Obstet Invest 2010;69:57-61
Ideale gewichtstoename tijdens de zwangerschap BMI > 29,0 kg/m² Zwangerschapsduur
Gewicht kg
Gewichts -toename
41 40 38 36
32 (30-34) 28 (28-32)
24 (24-28) 20 (18-22)
16 12 (11-14)
8 Startgewicht
88.5 87.7 87.9
15.5 14.7 14.9
84 82.2
11 9.2
81.2
8.2
77.4
4.4
77.7 74.9 75 73
4.7 1.9 2
Gewichtstoename in kg 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 -1 -2 -3 -4 -5 -6 -7
© R. Devlieger – G. Vansant
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
…./…./….
Zwangerschapsduur in weken …./…./….
Gewichtstoename bij meting = gewicht bij een meting – startgewicht gemiddelde gewichtstoename aanbevolen spreidingsgebied
RCT: effect of life-style advice Obese ♀ N = 195
Control group N = 65
Drop outs N= 9
Passive group N = 65 Brochure
Drop outs N= 8
# deliveries N = 51
Guelinckx et al, Am J Clin Nutr 2010
Active group N = 65 Broch-Dietician
Drop outs N=16
# deliveries N = 45
# deliveries N = 38
No influence on obstetrical outcome measures Controls
Brochure
Intervention
51
45
38
Weight gain (kg)
10.2 ± 7.2
11.0 ± 6.9
10.3 ± 5.9
ns
Hypertention (N,%) Preeclampsia (N,%)
15 (55.6) 4 (13.8)
10 (33.3) 1 (3.4)
12 (44.4) 1 (3.4)
ns ns
Inductions (N,%) Cesarean section (N,%)
13 (43.3) 4 (12.9)
12 (37.5) 10 (29.4)
18 (60.0) 7 (22.6)
ns ns
Birth weight (kg) Macrosomia (N,%)
3.4 ± 0.4 2 (6.5)
3.5 ± 0.5 4 (11.8)
3.5 ± 0.5 5 (16.1)
ns ns
N
p
Guelinckx et al, Am J Clin Nutr 2010
Meta analysis: effect of life-style on GWG
(Streuling et al., American J. Clinical Nutrition, 2010; 92;678-687)
Topics of debate • Combination of weight monitoring, dietary and physical activity strategies (Streuling et al. 2010) • Frequency of contact with health care provider: interventions to reduce GWG – early in pregnancy (or preconceptional) (Phelan et al. , 2011)
• Targeting on psychological factors and motivation (Skouteris et al. , 2010)
Psychosocial aspects of Obesity in women of reproductive age (1)
Time of measurements PREGNANCY Trimester 1
T 1: Inclusion < 15 weeks
T 2: Before Session 1 < 15 weeks
Session 1
T 3: After Session 1 < 15 weeks
Trimester 2
T 4: Before Session 2 18 – 22 weeks
Session 2
T 5: After Session 2 18 – 22 weeks
T 6: Before Session 3 24 – 28 weeks
Trimester 3
T 7: After Session 3 24 – 28 weeks
Session 3
T 8: Before Session 4 30 – 34 weeks
T 9: After Session 4 30 – 34 weeks
Session 4 Bogaerts et al, 2011
Measuring instruments • Questionnaire
sociodemographic, medical, pregnancy related and history of psychological related variables
• State and Trait Anxiety Inventory (STAI) (Spielberger,1970) – State anxiety: feelings at particular moment in time – intensity (not at all, somewhat, moderatly so, very much so) – Trait anxiety : general feelings – frequency (almost never, sometimes, often, almost always)
• Edinburgh Depression Scale (EDS) (Cox, 1987) -
Intensity of depressive symptoms within previous 7 days
• Medical records (hospital)
Levels and evolution of State and Trait anxiety State anxiety (SAI)
Trait anxiety (TAI)
40,0
40,0
39,0
39,0
38,0
normal weight
37,0
38,0 normal weight
37,0
obese
36,0
36,0
35,0
35,0
34,0
34,0
33,0
obese
33,0 1
2 Trimester
3
1
2 Trimester
3
Levels and evolution of Depressed Mood Depressed mood 9,0 8,0 7,0 6,0
5,0 normal weight
4,0 3,0 2,0 1,0 0,0 1
2
Trimester
3
obese
Conclusion (1) Pregnant obese women higher levels of anxiety compared to normal weight pregnant women
STATE anxiety:
TRAIT anxiety:
Miscarriage in history (+)
Smoking behavior (+) Parity by trimester (+)
Maternal education (-) Marital state (single, +) Ethnicitiy (+) History of stressful family events (+)
Maternal education (-) Marital state (single, +) Ethnicity (+) History of stressful family events (+)
Conclusion (2) Pregnant obese women higher levels of depressive symptomatology compared to normal weight pregnant women Depressed mood: Multigravidae (+) Ethnicitiy (+) History of stress (+)
Amianto, F., Lavagnino, L., Abbate-Daga, G. & Fassino, S. (2011). The forgotten psychosocial dimension of the obesity epidemic. The Lancet, 378, 9805,
Motivational interview
Preconceptional treatment of obesity
Physical activity
Medication
Obesity
Diet
Surgery
Treatment of obesity after pregnancy • Weight retention between pregnancies determines risk of next pregnancy • Breast-feeding associated with less weight retention • Breast-feeding practice suboptimal in obese population
Bogaerts et al, 2008; Villamor et al, 2008 ; Guelinckx et al, 2011
Treatment of obesity after pregnancy
• Website • Brochure • Registratiesysteem
Conclusies – Eén derde van de zwangeren is te zwaar
– Maternale obesitas en overdreven gewichtstoename zijn mee bepaald door socio-demografische factoren en beïnvloeden de zwangerschapsuitkomst – Zwangerschap is een belangrijke “window of opportunity” om de levenstijl van vrouwen te verbeteren. De impact van deze interventies op lange termijn blijft echter aan te tonen – Zwangerschap bij obesitas en na bariatrische chirurgie vergt een gerichte multidisciplinaire aanpak
Dank Isabelle Guelinckx Annick Bogaerts Sarah Bel Sander Galjaard Sarah Pauwels Rivka Turcksin Annelies Matheussen Guy Martens Evelien Martens Greet Vansant Andre Van Assche Dirk Timmerman Deelnemende ziekenhuizen en artsen, vroedvrouwen en patiënten!
Studiecentrum Perinatale Epidemiologie (SPE)
