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Published in final edited form as: J Obstet Gynaecol. 2020 Oct 20;41(6):864–869. doi: 10.1080/01443615.2020.1803242

Factors associated with early gestational weight gain among women with pre-pregnancy overweight or obesity

Rebecca L Emery a, Maria Tina Benno b, Rachel P K Conlon b, Marsha D Marcus b, Michele D Levine b
PMCID: PMC8055717  NIHMSID: NIHMS1668559  PMID: 33078645

Abstract

The present study aimed to document the prevalence of and identify factors associated with excessive gestational weight gain (GWG) in early pregnancy among women with pre-pregnancy overweight or obesity. Women with pre-pregnancy overweight or obesity (n = 247) were recruited between 12 and 20 weeks of gestation and completed questionnaires and were weighed to estimate early GWG. Nearly one-third of women met (17%, n = 42) or exceeded (13%, n = 33) guidelines for total GWG in early pregnancy. Univariate analyses showed race, income, and pre-pregnancy weight status to be significantly related to GWG category in early pregnancy (p < .009). Only race and pre-pregnancy weight status remained significant in a multivariate model, with Black women and women with pre-pregnancy obesity having higher odds of having met or exceeded guidelines for total GWG in early pregnancy compared with White women and women with pre-pregnancy overweight (p < .04). These findings highlight the need for early intervention to reduce weight-related complications among pregnant women.

Keywords: Gestational weight gain, pregnancy, overweight, obesity

Introduction

Excessive gestational weight gain (GWG) is associated with serious health repercussions for women and children (Margerison Zilko et al. 2010; Goldstein et al. 2017, 2018; Qarmach et al. 2018). To reduce the disease burden associated with excessive GWG, the Institute of Medicine (IOM) reissued guidelines for GWG based on pre-pregnancy body mass index (BMI; Rasmussen and Yaktine 2009). However, 47–68% of women exceed these guidelines (Goldstein et al. 2017; Emery et al. 2018), with extensive evidence documenting that women with pre-pregnancy overweight or obesity are especially likely to gain excessive gestational weight relative to women with pre-pregnancy normal weight (Wrotniak et al. 2015; Samura et al. 2016; Nunnery et al. 2018).

Although the majority of previous studies have focussed on overall GWG, a growing body of work suggests that timing of GWG has important implications for pregnancy outcomes regardless of pre-pregnancy BMI. For example, women who gain excessive gestational weight in the first half of pregnancy are at unique risk for gestational hypertension and preeclampsia (Macdonald-Wallis et al. 2013), hyperglycaemia (Herring et al. 2009), gestational diabetes (MacDonald et al. 2017), and foetal macrosomia (Carreno et al. 2012; Catov et al. 2015; Feghali et al. 2019). Longitudinal evidence further indicates that excessive GWG in the first half of pregnancy is associated with greater postpartum weight retention for up to seven years following delivery (Walter et al. 2015), as well as an increased risk of overweight and obesity in children during the first four years of life (Karachaliou et al. 2015).

Accordingly, identifying factors associated with excessive GWG in the first half of pregnancy may have important implications for targeted prenatal interventions aimed at reducing weight-related complications among women and children. However, previous work in this area has been sparse and inconsistent (Herring et al. 2009; Karachaliou et al. 2015; Walter et al. 2015; Cheney et al. 2017; Feghali et al. 2019), making it difficult to clearly distinguish women at risk for excessive GWG in the first half of pregnancy. Given emerging findings linking pre-pregnancy overweight or obesity to a heightened likelihood of gaining excessive gestational weight in the first half of pregnancy (Cheney et al. 2017), there is particular need to clarify factors that place women with pre-pregnancy overweight or obesity at risk for accelerated weight gain early in pregnancy. The present study therefore aimed to document the prevalence of and identify factors associated with excessive GWG in the first half of pregnancy among women with pre-pregnancy overweight or obesity. For this study, we focussed on factors previously linked to differential risk for excessive GWG (Hill et al. 2013; Wright et al. 2013; Huynh et al. 2014; Samura et al. 2016; Kominiarek et al. 2018; Nunnery et al. 2018), including sociodemographic (i.e. age, race, relationship status, education, income), pregnancy-related (i.e. parity, pregnancy intent, pre-pregnancy BMI), and psychiatric (i.e. depressive symptoms, perceived stress) factors.

Materials and methods

Participants and procedures

Pregnant women (n = 257) were recruited from obstetric clinics for a longitudinal, observational study examining psychosocial determinants of GWG. Women were eligible if they had a pre-pregnancy BMI ≥25 kg/m2, were ≥14 years old, had a singleton pregnancy, and were at 12–20 weeks of gestation. The exclusion criteria were use of weight-affecting medications, participation in weight-management programming, type 1 diabetes, or psychiatric symptoms requiring immediate treatment (e.g. suicidality).

After a brief phone screen, all eligible women came to the clinic for an in-person baseline assessment, during which they completed questionnaires and height and weight measurements. Study procedures were approved by the University of Pittsburgh Institutional Review Board and all women provided written informed consent. Only data collected at the baseline assessment are presented herein.

Measures

Sociodemographic variables

Women self-reported sociodemographic information at the baseline assessment, including age, race, income, education, and relationship status.

Pregnancy-related variables

Women self-reported pregnancy-related information at the baseline assessment, including parity and whether their current pregnancy was intentional, using single-item, researcher-designed questions (Levine et al. 2013).

Pre-pregnancy BMI

Women self-reported their pre-pregnancy weight during the initial phone screen. During the baseline assessment between 12 and 20 weeks of gestation, height was measured in-person via calibrated stadiometer. Pre-pregnancy BMI was calculated as weight in kilograms divided by height in metres squared using self-reported pre-pregnancy weight obtained during the initial phone screen and measured height at the baseline assessment. Women were dichotomised according to whether their pre-pregnancy weight status fell within the overweight (BMI 25.0–29.9) versus obese (BMI ≥30) range.

Early GWG

Early GWG was calculated as the difference between baseline weight, measured via a digital scale, and self-reported pre-pregnancy weight obtained during the initial phone screen. Women were divided into GWG categories according to whether they had an early GWG that was below, within, or had exceeded IOM guidelines for total GWG based on their pre-pregnancy BMI. Specifically, women with pre-pregnancy overweight who had an early GWG of <15 pounds, 15–25 pounds, or >25 pounds were respectively categorised as being below, within, or having exceeded IOM guidelines for total GWG. Meanwhile, women with pre-pregnancy obesity who had an early GWG of <11 pounds, 11–20 pounds, or >20 pounds were respectively categorised as being below, within, or having exceeded IOM guidelines for total GWG. In addition, rate of early GWG was calculated as the ratio of early GWG to weeks of gestation at baseline and was measured continuously.

Psychiatric variables

Women reported depressive symptoms and perceived stress at the baseline assessment respectively using the Centre for Epidemiological Studies Depression Scale (Radloff 1977) and the Perceived Stress Scale (Cohen et al. 1983), which have demonstrated adequate reliability and validity in pregnant women (Maloni et al. 2005; Solivan et al. 2015).

Statistical analysis

Women with missing sociodemographic data were excluded from analysis (n = 4). Of the remaining women, only a small number identified as belonging to a racial group other than White or Black (n = 6) and were excluded from analysis to maintain adequate cell size. The final analytic sample included 247 women.

Analyses were conducted using IBM SPSS Statistics for Windows, Version 25.0 (IBM, Armonk, NY). Descriptive statistics were initially calculated to describe the sample. Chi-square tests and univariate ANOVAs were first used to examine relationships between GWG category in early pregnancy and demographic, pregnancy-related, and psychiatric variables. Significant effects were further probed using post-hoc analyses and were adjusted for multiple comparisons using the Bonferroni correction. Significant variables were retained and simultaneously entered into a multinomial logistic regression model to determine independent effects on GWG category in early pregnancy, with reference to women who were below IOM guidelines for total GWG in early pregnancy.

Results

Sample characteristics are displayed in Table 1. Women had gained an average of 8.36 ± 14.16 pounds at a rate of 0.55 ± 0.92 pounds per week in early pregnancy. Notably, 17% (n = 42) of women were within and another 13% (n = 33) had exceeded IOM guidelines for total GWG in early pregnancy. Women who were within IOM guidelines for total GWG in early pregnancy gained 16.31 ± 3.24 pounds at a rate of 1.03 ± 0.27 pounds per week, whereas women who had exceeded these guidelines in early pregnancy had gained 32.96 ± 12.66 pounds at a rate of 2.13 ± 0.96 pounds per week.

Table 1.

Sample characteristics (n = 247).

Mean ± SD or % (n)
Sociodemographic variables
Age in years 28.41 ± 5.47
Race
 Blacka 53% (131)
 White 47% (116)
Education
 ≤High school degree 33% (82)
 >High school degree 67% (165)
Annual Income
 <$30,000 66% (162)
 ≥$30,000 34% (85)
Relationship status
 Single 17% (41)
 In a relationship 83% (206)
Pregnancy-related variables
Gestational age in weeks 15.67 ± 2.45
Pregnancy intent
 Intentional 46% (114)
 Unintentional 54% (133)
Parity
 Nulliparous 36% (89)
 Parous 64% (158)
Pre-pregnancy BMI
 Obese 55% (135)
 Overweight 45% (112)
Early GWG category
 Below IOM guidelines 70% (172)
 Within IOM guidelines 17% (42)
 Exceeded IOM guidelines 13% (33)
Psychiatric variables
Depressive symptoms 12.25 ± 9.85
Perceived stress 20.74 ± 8.78
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BMI: body mass index; GWG: gestational weight gain; IOM: Institute of Medicine.

a

Women in this category included those who identified their race as Black (n = 112) or Black multiracial (n = 19).

As shown in Table 2, univariate analyses found race, income, and pre-pregnancy BMI to be significantly related to GWG category in early pregnancy (p < .009). Post-hoc analyses indicated that, compared with women who were below guidelines for total GWG in early pregnancy, those who exceeded these guidelines were more likely to be Black, have an annual income less than $30,000, or have pre-pregnancy obesity (p < .05).

Table 2.

Univariate analyses of variables related to early gestational weight gain categories (n = 247).

Below IOM guidelines Within IOM guidelines Exceeded IOM guidelines
Mean ± SD or % (n) Mean ± SD or % (n) Mean ± SD or % (n) p
Sociodemographic variables
Age in years 28.23 ± 5.33 29.60 ± 6.01 27.80 ± 5.54 .28
Race <.001
 Blacka 43% (74) 71% (30) 82% (27)
 White 57% (98) 29% (12) 18% (6)
Education .10
 ≤High school degree 71% (122) 59% (25) 46% (15)
 >High school degree 29% (50) 41% (17) 54% (18)
Annual income .009
 <$30,000 61% (104) 69% (29) 88% (29)
 ≥$30,000 39% (68) 31% (13) 12% (4)
Relationship status .08
 Single 15% (25) 14% (6) 30% (10)
 In a relationship 85% (147) 86% (36) 70% (23)
Pregnancy-related variables
Gestational age in weeks 15.49 ± 2.45 16.14 ± 2.29 15.97 ± 5.55 .22
Pre-pregnancy BMI <.001
 Obese 46% (80) 69% (29) 79% (26)
 Overweight 54% (92) 31% (13) 21% (7)
Pregnancy intent .80
 Intentional 46% (79) 50% (21) 42% (14)
 Unintentional 54% (93) 50% (21) 58% (19)
Parity .32
 Nulliparous 38% (65) 38% (16) 24% (8)
 Parous 62% (107) 62% (26) 76% (25)
Psychiatric variables
Depressive symptoms 11.61 ± 9.63 13.31 ± 10.31 14.21 ± 10.37 .29
Perceived stress 20.17 ± 8.99 21.40 ± 9.01 22.88 ± 7.04 .23
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Boldface indicates statistical significance (p < .05). BMI: body mass index; GWG: gestational weight gain; IOM: Institute of Medicine.

a

Women in this category included those who identified their race as Black (n = 112) or Black multiracial (n = 19).

In the multinomial logistic regression model, race, income, and pre-pregnancy weight status were retained as predictors of GWG category in early pregnancy. As shown in Table 3, race and pre-pregnancy weight status remained significant predictors of women who were likely to be within or have exceeded IOM guidelines for total GWG in early pregnancy relative to those who were below these guidelines. Black women had 4.16 (95% CI [1.61, 10.76], p = .0003) and 3.92 (95% CI [1.33, 11.57], p = .01) higher odds of being within or having exceeded IOM guidelines for total GWG in early pregnancy than did White women. Women with pre-pregnancy obesity had 2.21 (95% CI [1.03, 4.75], p = .04) and 2.98 (95% CI [1.18, 7.49], p = .02) higher odds of being within or having exceeded IOM guidelines for total GWG in early pregnancy than did women with pre-pregnancy overweight.

Table 3.

Multinomial regression analysis assessing variables related to early gestational weight gain categories.

Within IOM guidelines
 Exceeded IOM guidelines
OR (CI) p OR (CI) p
Race
 Blacka 4.16 (1.61, 10.76) .003 3.92 (1.33, 11.57) .01
 White 1.00 1.00
Annual income
 <$30,000 0.49 (0.18, 1.28) .14 1.52 (0.42, 5.50) .52
 ≥$30,000 1.00 1.00
Pre-pregnancy BMI
 Obese 2.21 (1.03, 4.75) .04 2.98 (1.18, 7.49) .02
 Overweight 1.00 1.00
Open in a new tab

Significant variables from the univariate analysis were retained and entered simultaneously into the multinomial regression model. Women who were below IOM guidelines for total gestational weight gain were the referent group. Boldface indicates statistical significance (p < .05). BMI: body mass index; CI: confidence interval; IOM: Institute of Medicine; OR: odds ratio.

a

Women in this category included those who identified their race as Black (n = 112) or Black multiracial (n = 19).

Discussion

The present study documents wide variability in early GWG among women with pre-pregnancy overweight or obesity. Importantly, these data indicate that a substantial number of women will gain most of the total recommended gestational weight in the first half of pregnancy. Although the majority of women in the present study remained below IOM guidelines for total GWG in the first half of pregnancy, one-third had already met or exceeded these guidelines, a rate similar to previous studies (Catov et al. 2015; Cheney et al. 2017). These women had an accelerated rate of weekly weight gain in the first half of pregnancy (1.52 ± 0.86 pounds per week) that was more than double that recommended for the second half of pregnancy (0.44–0.66 pounds per week), when weight gain is expected to be highest (Rasmussen and Yaktine 2009).

Although univariate analyses showed race, income, and pre-pregnancy weight status to be related to GWG in the first half of pregnancy, only race and pre-pregnancy weight status remained significant in the multivariate model. Black women and women with pre-pregnancy obesity were specifically found to have the highest likelihood of meeting or exceeding IOM guidelines for total GWG in the first half of pregnancy. These findings are similar to those of others examining diverse populations of pregnant women (Gould Rothberg et al. 2011; Cheney et al. 2017). However, it is worth noting that several additional reports have found Black women and women with pre-pregnancy obesity to actually have lower rates of excessive GWG in the first half of pregnancy compared with their White and overweight counterparts (Herring et al. 2009; Karachaliou et al. 2015; Feghali et al. 2019). Thus, a more complete understanding of GWG patterns and the pre-pregnancy characteristics, including race and weight status, that can be used to identify women at heightened risk for early excessive GWG is needed.

These results ultimately highlight the importance of efforts to promote appropriate weight prior to pregnancy and to address weight gain early in pregnancy to reduce weight-related complications, particularly among Black women and women with pre-pregnancy obesity. Pregnant women report rarely receiving counselling from obstetric providers about GWG guidelines (Phelan et al. 2011; Emery et al. 2018; Whitaker et al. 2020) or strategies for achieving recommended GWG (Nikolopoulos et al. 2017). For example, we previously found that only 35% of women with pre-pregnancy overweight or obesity received specific advice from their healthcare provider regarding GWG guidelines in pregnancy, of whom fewer than half were instructed to gain weight within the recommended range for their pre-pregnancy BMI (Emery et al. 2018). Moreover, the majority of previous interventions aimed at preventing excessive GWG have had only moderate success (Peaceman et al. 2018; Shieh et al. 2018). Interventions that provide early education to women regarding IOM guidelines and help them gain weight within those recommendations over the entire course of pregnancy are therefore needed. However, given that early involvement in gestational weight management programming may not be feasible or effective for all women, preconception and interconception weight loss interventions focussed on promoting lifestyle changes prior to pregnancy may be especially useful for improving weight outcomes before and during pregnancy, particularly among women with obesity (Weisman et al. 2011; Ockhuijsen et al. 2012).

It is also important to acknowledge that Black women enter pregnancy with notable health disparities relative to their White counterparts, including higher rates of obesity and lower socioeconomic status, that partly reflect lifelong exposure to institutional and societal racism (Bowers et al. 2013; Chambers et al. 2018). Healthcare in the United States has been broadly criticised for perpetuating systemic racism (Feagan and Bennefield 2014), and standard obesity treatment has, for the most part, failed to adequately address racial and cultural differences in weight-related health and behaviours (Byrd et al. 2018). As such, interventions designed to prevent early excessive GWG among Black women must be tailored to their unique needs and circumstances and account for their racial and cultural differences and exposure to systemic racism (Herring et al. 2009).

The present findings should be considered in the context of certain limitations. First, this study used a cross-sectional design and is therefore not able to provide information on how GWG in the first half of pregnancy relates to overall GWG, though previous reports describe a strong link between the two (De Jersey et al. 2012). Second, we used retrospective report of pre-pregnancy weight, which may have resulted in miscalculations of pre-pregnancy BMI or early GWG. However, the use of self-reported pre-pregnancy weight is common in studies of GWG and has been shown to be largely concordant with measured pre-pregnancy weight (Natamba et al. 2016). Third, all women included in this study had pre-pregnancy overweight or obesity and were recruited from an urban hospital setting. As such, these findings may not be generalisable to women with pre-pregnancy underweight or normal weight or to those living in rural communities. Finally, although the sample was comparable to or larger than those of other studies of GWG, replication in additional groups is desirable.

Despite these limitations, the present study adds to a growing body of literature documenting that a notable amount of women are gaining excessive gestational weight early in pregnancy, which itself is associated with a heightened likelihood of experiencing pregnancy complications and adverse birth outcomes (Herring et al. 2009; Carreno et al. 2012; Macdonald-Wallis et al. 2013; Catov et al. 2015; MacDonald et al. 2017; Feghali et al. 2019), as well as future obesity risk (Walter et al. 2015). Although the predictors of total GWG may differ from those identified in early pregnancy, these preliminary results underscore the relevance of identifying women at highest risk for early excessive GWG and the need for prompt intervention. However, given that race is not modifiable and pre-pregnancy weight status can only be altered prior to pregnancy, future research is needed to identify specific psychological factors beyond depressive symptoms and perceived stress or behavioural mechanisms that contribute to excessive GWG in the first half of pregnancy before tailored interventions can be developed. Additional work examining modifiable risk factors, particularly among Black women and women with pre-pregnancy obesity, that contribute to excessive GWG in the first half of pregnancy is therefore warranted and will be necessary to inform intervention efforts aimed at promoting appropriate GWG across the entire course of pregnancy.

IMPACT STATEMENT.

What is already known on this subject?

Women with pre-pregnancy overweight or obesity who gain excessive gestational weight early in pregnancy are at unique risk for pregnancy complications and adverse birth outcomes.

What do the results of this study add?

The present study adds to a growing body of literature documenting that a notable amount of women are gaining excessive gestational weight early in pregnancy. The present study further documents that Black women and women with pre-pregnancy obesity are at particular risk of gaining excessive gestational weight early in pregnancy.

What are the implications of these findings for clinical practice and/or further research?

Additional work examining modifiable risk factors, particularly among Black women and women with pre-pregnancy obesity, that contribute to excessive gestational weight gain (GWG) in the first half of pregnancy is warranted and will be necessary to inform interventions aimed at promoting weight loss during the preconception and interconception periods or encouraging appropriate GWG across the entire course of pregnancy.

Acknowledgments

Funding

This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development under R01 HD068802. The research presented in this paper is that of the authors and does not reflect the official policy of the NIH. The NIH played no role in the study design, data collection, or analysis and interpretation of results presented herein. MDM is on the Scientific Advisory Board of Weight Watchers, Inc. The authors report no additional conflicts of interest.

Footnotes

Disclosure statement

The research presented in this paper is that of the authors and does not reflect the official policy of the NIH. The NIH played no role in the study design, data collection, or analysis and interpretation of results presented herein. MDM is on the Scientific Advisory Board of Weight Watchers, Inc. No potential conflict of interest was reported by the author(s).

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