Hospital–Community Intervention Prevents Excess Weight Gain in Women Overweight at Start of Pregnancy
Key findings
- This quasi-experimental study compared excess gestational weight gain before and after implementation of a systematic intervention in which Massachusetts General Hospital partnered with affiliated community health centers
- In two predominantly low-income populations, about 65% of women entered pregnancy with BMI in the overweight or obese range, and about half of those women gained more weight than recommended by National Academy of Medicine guidelines
- Among women with pre-pregnancy BMIs in the overweight range, the post-implementation group was less likely to gain excess weight than the pre-implementation group (46% vs. 56%; OR, 0.69; 95% CI, 0.49–0.99; P = .05)
- No similar associations were observed among women entering pregnancy with normal weight or obesity
Excessive weight gain during pregnancy is well established as a strong risk factor for postpartum weight retention and obesity. Researchers at Massachusetts General Hospital have created a systematic hospital–community partnership, called the First 1,000 Days, to prevent obesity in mother–child pairs.
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When implemented at two community health centers in Massachusetts, the program reduced the prevalence of excess gestational weight gain among women who began their pregnancies with body mass index (BMI) in the overweight range. Tiffany Blake-Lamb, MD, MSc, of the Department of Obstetrics and Gynecology at Mass General, Elsie M. Taveras, MD, MPH, chief of the Division of General Academic Pediatrics at MassGeneral Hospital for Children, and colleagues describe the program in Obstetrics & Gynecology.
Program Components
The First 1,000 Days program is a joint effort of Mass General and affiliated community health centers. It includes:
- Training of clinical hospital staff, administrators, community health workers and representatives from the Women, Infants and Children (WIC) and home visiting programs to standardize obesity prevention efforts
- Gestational weight gain tracking facilitated by decision supports in the electronic health record
- At the first prenatal visit, universal screening for adverse health behaviors and sociocontextual factors (depression, stress, lack of social support and limited access to healthful food and exercise)
- Educational materials (posters and booklets in multiple languages, text messaging and short videos)
- For women at high risk of excess gestational weight gain based on their pre-pregnancy BMI or excess first-trimester weight gain, individual health coaching and navigation to public health programs (e.g., WIC) and community resources (e.g., housing, food banks, low-cost gyms)
The program's systems-level interventions start when women initiate prenatal care and support mothers, their partners and mother–partner or father–child pairs throughout the first 24 months of the child's life.
Study Design
The program was offered in two community health centers near Mass General that principally serve low-income, racial/ethnic minority people. Delivery data were collected before the intervention began (September 1, 2015, to August 31, 2016) and afterward (March 1, 2017, to May 31, 2018). There were 643 women in the first group and 928 in the latter. Only women who delivered a singleton infant were included.
65.2% of women in the pre-implantation group and 66.1% in the post-implementation group entered pregnancy with a BMI in the overweight or obesity range.
For this study, the primary outcome of interest was the percentage of women with weight gain greater than the 2009 Institute of Medicine (now known as the National Academy of Medicine) guidelines according to pre-pregnancy BMI.
Primary Outcome
Among women with pre-pregnancy BMIs in the overweight range, the post-implementation group was less likely to gain excess weight than the pre-implementation group (46% vs. 56%). After adjustment for gestational age, race/ethnicity and public insurance, overweight women in the post-implementation group were at 31% less risk of excess weight gain (OR, 0.69; 95% CI, 0.49–0.99; P = .05).
The program had no effect on excess weight gain among women who started pregnancy with normal weight (BMI < 25) or obesity (BMI ≥ 30).
Secondary Outcomes
The lowest prevalence of excess gestational weight gain was observed among women who received individual-level coaching and patient navigation, in addition to the systems-level components.
Program implementation was not associated with any adverse maternal or neonatal outcomes.
Conclusion
This study suggests the need for more intensive, evidence-based gestational weight management approaches for women entering pregnancy with obesity. It may be that individualized interventions are more effective than system-level changes—that would help explain why excess weight gain was not reduced among women of normal weight, who were not eligible for individualized services.
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