Current Diabetes Reports (2020) 20:11

https://doi.org/10.1007/s11892-020-1296-1

DIABETES AND PREGNANCY (M-F HIVERT AND CE POWE, SECTION EDITORS)

Gestational Weight Gain: Update on Outcomes and Interventions

Macie L. Champion 1 & Lorie M. Harper 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review Gestational weight gain is a modifiable risk factor for adverse perinatal outcomes. After the Institute of
Medicine (IOM) released updated recommendations for gestational weight gain in 2009, a multitude of studies were released
examining the recommendations, particularly for women with obesity. As the obesity epidemic continues, many physicians are
interested in minimizing gestational weight gain for all women. Our aim was to review the evidence for the association of
gestational weight gain and perinatal outcomes, particularly for weight gain outside the IOM guidelines.
Recent Findings Gestational weight gain is associated with several adverse perinatal outcomes including fetal growth, preterm
delivery, cesarean delivery, gestational diabetes, hypertensive disorders of pregnancy, and infant mortality as well as with long-
term offspring metabolic health outcomes. Multiple randomized controlled trials have been conducted evaluating the efficacy of
lifestyle intervention on gestational weight gain, and while lifestyle interventions may alter gestational weight gain, they have not
been associated with improvement in perinatal outcomes. Weight loss during pregnancy is associated with decreased risks of
macrosomia and cesarean delivery; however, given an association with low birth weight, it is not currently recommended.
Summary Excessive gestational weight gain is known to be associated with multiple adverse fetal and maternal outcomes.
Lifestyle interventions during pregnancy may be helpful in decreasing excessive weight gain, but have not shown to be beneficial
for most adverse pregnancy outcomes. More research is needed before making recommendations for weight loss in women with
obesity during pregnancy.

Keywords Weight gain . Obesity . Gestational diabetes . Pregnancy

Introduction In 2009, the Institute of Medicine (IOM) (now the US

Through the first half of the twentieth century, the recommen-
dations surrounding gestational weight gain were to limit
weight gain to 20 pounds or less in order to prevent fetal
macrosomia and the development of pregnancy-induced hy-
pertensive disorders [1]. In the 1970s and through 1990, the
recommendation was a weight gain of 20–25 pounds for every
pregnant woman [2, 3].
This article is part of the Topical Collection on Diabetes and Pregnancy
* Macie L. Champion
mchampion@uabmc.edu
Lorie M. Harper
Lmharper@uabmc.edu
1
Division of Maternal Fetal Medicine. Department of Obstetrics and
Gynecology, Center for Women’s Reproductive Health at the
University of Alabama at Birmingham, 1700 6th Ave S,
Birmingham, AL 35233, USA
National Academy of Medicine, NAM) published revised
guidelines for gestational weight gain, noting that the US pop-
ulation had changed since the last revision, with a higher
prevalence of obesity and a lower prevalence of underweight
women. These guidelines make specific recommendations for
each pre-pregnancy BMI class based on the World Health
Organization definitions [3]. In creating these guidelines, the
IOM focused on the association of gestational weight gain
with key maternal and infant outcomes, including cesarean
delivery, gestational diabetes, pregnancy-induced hyperten-
sion, postpartum weight retention, infant size, preterm birth,
and childhood obesity. These recommendations are based on
evidence that supports the association between gestational
weight gain, birth weight, and postpartum weight retention
[3, 4].
The current recommendations for weight gain are stratified
by pre-pregnancy BMI and can be applied to women of short
stature, pregnant adolescents, and racial and ethnic minorities
(Table 1). The Institute of Medicine Guidelines additionally
comment on twin gestations, recommending that normal
 11 Page 2 of 10 Curr Diab Rep (2020) 20:11

Table 1 Recommendations for gestational weight gain during singleton pregnancy

IOM [3] LifeCycle Project [5]

Pre-pregnancy body Pre-pregnancy Total weight Weight gain rates in second and Total weight Absolute risk reduction in
mass index (kg/m2) weight category gain range (kg) third trimesters (kg) gain range (kg) adverse composite outcome†

< 18.5 Underweight 12.5–18 0.45 (0.45–0.58) 14–16 0.07% (0.04–0.09)

18.5–24.9 Normal Weight 11.5–16 0.45 (0.36–0.45) 10–18 0.02% (0.01–0.03)
25–29.9 Overweight 7–11.5 0.27 (0.23–0.32) 2–16 0.02% (0.01–0.04)
≥ 30 Obese* 5–9 0.23 (0.18–0.27)
30–34.9 – – 2–6 0.08% (0.04–0.11%)
35–39.9 – – 0–4 0.14% (0.06–0.22%)
≥ 40 – – 0–6 0.10% (0–0.2%)

*Includes all classes of obesity

†
Adverse composite outcome defined as the occurrence of any one of the following: preeclampsia, gestational hypertension, gestational diabetes,
cesarean delivery, preterm birth, small for gestational age, and large for gestational age. Absolute risk reduction calculated as occurrence of composite
adverse outcome within the ideal weight range versus outside of it per BMI category

weight women gain 17–25 kg, overweight women gain 14–
23 kg, and women with obesity gain 11–19 kg at term [3].
This review will focus on literature assessing gestational
weight gain below and above these guidelines compared with
that within these guidelines.
Since 2009, these guidelines have been subject to a signif-
icant amount of scrutiny. Recently, the LifeCycle Project eval-
uated maternal and childhood outcomes associated with pre-
pregnancy BMI and gestational weight gain [5]. Pregnancy
and birth cohorts that included mothers with singleton live-
born children between 1989 and 2015, data on pre-pregnancy
or early pregnancy BMI, and at least 1 offspring measurement
were invited to participate. Of 50 cohorts invited, 39 agreed to
participate and 25 (n = 196,670) were included in the main
study sample; four hospital-based cohorts were included as
an external validation sample. In this study, the absolute risk
of any adverse pregnancy outcome (preeclampsia, gestational
hypertension, gestational diabetes, cesarean delivery, preterm
birth, small for gestational age, large for gestational age) in-
creased across BMI categories but was minimally related to
gestational weight gain. Nonetheless, optimal gestational
weight gain ranges were calculated for each BMI category to
determine the weight range associated with the lowest risk of
adverse outcome. For underweight, normal weight, and over-
weight women, recommendations were largely overlapping
with the IOM recommendations (Table 1); weight gain meet-
ing recommendations was associated with a small absolute
risk reduction in the composite adverse outcome. The
LifeCycle project stratified by obesity category and generally
identified less weight gain as ideal, with small absolute risk
reductions in the composite adverse outcome [5].
A systematic review and meta-analysis published in 2015
showed that weight loss during pregnancy for women with
obesity is associated with lower risks of LGA, macrosomia,
and cesarean; however, this weight loss was also associated
with increased risk for SGA and low birth weight.
Additionally, weight loss was not associated with a reduction
in the risk of gestational diabetes or preeclampsia. Even in
women with obesity, gestational weight loss is not currently
recommended [6].
In the following text, gestational weight gain above, below,
or within the guidelines will refer to the 2009 IOM guidelines,
as these have been studied thoroughly over the last decade.
Mechanisms and Patterns of Gestational Weight Gain
Pregnancy is characterized by multiple metabolic changes,
with an additional caloric requirement of 85 kcal/day in the
first trimester, 285 kcal/day in the second trimester, and
475 kcal/day in the third trimester [7]. Throughout pregnancy,
the maternal basal metabolic rate continues to increase,
reaching 10 to 20% above non-pregnancy levels by term [2].
Weight gain increases as pregnancy progresses. On aver-
age, the slowest weight gain occurs during the first trimester
(0.18 kg/week). The fastest weight gain occurs in the second
trimester at 0.54 kg/week with rates slightly decreasing during
the third trimester, 0.49 kg/week [8]. During the first trimester,
a disproportionate amount of weight gained is fat, whereas
weight gained in later trimesters related to the weight of the
fetus, extravascular fluid, and maternal fat stores [2].
Approximately half of the weight gained during pregnancy
is attributed directly to the fetoplacental unit (fetus, placenta,
amniotic fluid, gravid uterus) and another 25% is associated
with the increase in blood volume, extravascular volume, and
breast tissue (Fig. 1). The remainder of weight gain can be
attributed to metabolic alterations that occur to increase ma-
ternal accumulation of cellular water, fat, and protein [9].
Curr Diab Rep (2020) 20:11
Fig. 1 Weight gain (g) based on
pregnancy-related components [2,
9] Maternal Fat
Stores, 3345, 27%
Extravascular
Fluid, 1480, 12%
Weight gain that occurs beyond these factors leads to maternal
fat accretion [2].
The stratification of gestational weight gain recommenda-
tions based on pre-pregnancy BMI is based on changes in
energy consumption that occur in patients with obesity [10].
Women with obesity require less weight gain due to increased
fat deposition, which causes energy costs of pregnancy to be
much lower than that of women without obesity [11].
Considerations for Reviewing Studies of Gestational
Weight Gain
Studying gestational weight gain is difficult. Patients cannot
be randomized to gain a certain amount of weight; they can
only be randomized to interventions designed to impact
weight gain. Consequently, studies examining the association
of gestational weight gain with adverse pregnancy outcomes
are largely observational and may be limited by confounding;
many of the larger epidemiologic studies are retrospective and
based on administrative (birth certificate data), which may
lead to some amount of misclassification bias. Additionally,
large cohorts based on administrative data are unable to ex-
amine the timing of weight gain in association with adverse
outcomes.
Another point to consider when reading or performing co-
hort studies of gestational weight gain is the measurement of
gestational weight gain. Because weight gain is dependent on
the amount of time somebody is pregnant, gestational weight
gain is best measured and classified by weight gain per week
rather than by total for a pregnancy. For example, a woman
who delivers at 24 weeks will necessarily have gained less
than the IOM recommendations for the entire pregnancy but
may have gained an appropriate amount per week. Examined
only by the entire pregnancy, lower gestational weight gain
Page 3 of 10 11
Fetus, 3400, 27%
Placenta, 680, 5%
Amniotic Fluid,
800, 6%
Blood Volume, Uterus, 970, 8%
1450, 12% Breasts, 405, 3%
will naturally be associated with preterm delivery, low birth
weight, and even infant mortality. But the association will
only be true if this weight gain is classified by weight gain
per week. Additionally, to simplify the time problem, many
are tempted to only study term patients when studying gesta-
tional weight gain. However, excluding preterm patients
(spontaneous preterm delivery and indicated preterm delivery
for complications such as fetal growth restriction and pre-
eclampsia) will eliminate and/or reduce the association of ges-
tational weight gain with these complications.
Randomized controlled trials, being unable to assign wom-
en to a certain gestational weight gain, study lifestyle inter-
ventions. Presumably, lifestyle interventions lead to decreased
gestational weight gain (or weight gain within the IOM guide-
lines), which then hypothetically leads to improvements in
perinatal outcomes. Adherence to lifestyle interventions may
vary by patient, resulting in significant cross-over and
diminishing the effect size of trial results. While many trials
of lifestyle intervention focus their primary outcome on ges-
tational weight gain, gestational weight gain is only a surro-
gate marker for the real outcome of interest (perinatal out-
comes). Randomized trials of lifestyle interventions should
be powered to detect important perinatal outcomes associated
with gestational weight gain, rather than gestational weight
gain itself.
Gestational Weight Gain Above the IOM Guidelines
in Observational Studies
Gestational weight gain above the IOM guidelines is associ-
ated with gestational diabetes, pregnancy-induced hyperten-
sion, cesarean delivery, postpartum weight retention,
macrosomia, and childhood obesity.
 11 Page 4 of 10
Gestational Diabetes
Gestational diabetes is hyperglycemia that develops during
pregnancy. Physiologic changes of pregnancy lead to a mild
fasting hypoglycemia followed by postprandial hyperglyce-
mia and hyperinsulinemia [12], allowing for sustained post-
prandial supply of glucose to the fetus throughout pregnancy
[13]. The mechanism of development of insulin resistance is
incompletely understood, but may be mediated by estrogen
and progesterone as well as increasing levels of placental
lactogen [14, 15].
Gestational weight gain above the IOM guidelines is a
known risk factor for the development of gestational diabetes
[16–20]. Women who gain weight above the IOM guidelines
have up to a 50% increased risk of development of gestational
diabetes throughout pregnancy [18]. However, composition of
weight gain varies by trimester, with disproportionate gain of
gestational weight gained as fat in the first trimester [21]. The
risk of development of gestational diabetes increases with in-
creasing weight gained throughout pregnancy, but the associ-
ation is stronger with weight gained in the first trimester.
Women who gain ≥ 0.41 kg/week in the first trimester of
pregnancy have an 80% increased risk of development of
gestational diabetes when compared with those who gained
< 0.40 kg/week [18]. High rates of gestational weight gain,
especially in early pregnancy, are associated with an increased
risk of gestational diabetes [19].
Hypertensive Disorders of Pregnancy
Hypertensive disorders of pregnancy (gestational hyperten-
sion, preeclampsia, HELLP, eclampsia) may be associated
with gestational weight gain. Multiple studies have demon-
strated an association between gestational weight gain above
the IOM guidelines and hypertensive disorders of pregnancy
[21–23, 24•]. Some have questioned the cause-and-effect as-
sociation of gestational weight gain above the IOM guidelines
with hypertensive disorders of pregnancy given the associa-
tion of increased edema and fluid retention with pregnancy-
induced hypertension, which could potentially confound ac-
curate assessment of weight gain. This was proposed by
Magnus et al. in a summary of preeclampsia research pub-
lished by the Norwegian Institute of Public Health [25].
However, a secondary analysis performed of a randomized
controlled trial in Norway showed that patients who ultimately
developed preeclampsia had larger weight gain in all three
trimesters, including early in pregnancy when edematous
changes from preeclampsia are less likely to be present. This
study also confirmed the association between gestational
weight gain above the IOM guidelines and development of
preeclampsia (OR 3.54, 95% CI 1.95–10.91, p = 0.028) [26].
A meta-analysis of 23 studies demonstrated an association
between gestational weight gain above the IOM guidelines
Curr Diab Rep (2020) 20:11
and hypertensive disorders of pregnancy (pooled odds ratio
1.79, 95% CI 1.61–1.99) [24•]. A study published in the
American Journal of Obstetrics and Gynecology in 2013
showed that increased gestational weight gain in early preg-
nancy (prior to 18 weeks gestational age) was independently
associated with development of gestational hypertension and
preeclampsia, an association which did not differ based on
pre-pregnancy BMI [21]. Additionally, a study published in
the Journal of Maternal-Fetal and Neonatal Medicine in 2015
showed twofold higher odds of pregnancy-induced hyperten-
sion in patients with excessive gestational weight gain com-
pared with those with appropriate gestational weight gain (OR
2.52, 95% CI 1.2–3.9, p = 0.012) [23].
Cesarean Delivery
Gestational weight gain above the IOM guidelines is associ-
ated with an increased odds of cesarean delivery, with a
pooled odds ratio in a meta-analysis of 1.30 (95% CI 1.25–
1.35) [24•]. The risk of cesarean delivery is increased even in
the absence of fetal macrosomia [27]. The risk of cesarean
delivery was greatest for those who began pregnancy under-
weight and decreased with increasing BMI class with OR
1.45, absolute risk difference 6% for women who were under-
weight. Ultimately, the absolute risk difference was only sig-
nificant for those who were underweight prior to pregnancy
[24•].
Macrosomia
Fetal macrosomia is caused by a variety of factors; however,
weight gain during pregnancy is the most significant modifi-
able risk factor associated with fetal macrosomia [28]. Fetal
macrosomia carries significant risks to both the woman and
her fetus. Women with macrosomic fetuses are primarily at
increased risk of cesarean delivery due to labor abnormalities
[29, 30]. Macrosomic fetuses also put women at increased risk
of vaginal lacerations and postpartum hemorrhage [31]. Fetal
macrosomia leads to an increased risk of shoulder dystocia,
with inherent risks of brachial plexus injury, clavicular frac-
ture, and hypoxic ischemic injury [32]. Additionally,
macrosomic fetuses are more likely to have depressed 5 min
Apgar scores and have prolonged admission to neonatal in-
tensive care units [33].
Gestational weight gain above the guidelines is consistent-
ly associated with macrosomia, regardless of pre-pregnancy
BMI category. A systematic review and meta-analysis (which
included only studies with > 500 women to be able to ade-
quately stratify by BMI category) of 23 studies (n =
1,309,136) found that women gaining above recommended
had a 1.95 (OR 1.79–2.11) odds of a macrosomic infant com-
pared with women gaining within guidelines; these odds
Curr Diab Rep (2020) 20:11
ranged from 1.63 for those with a pre-pregnancy BMI ≥ 30 kg/
m2 to 2.31 for those that were underweight [24•].
Persistent Weight Retention
Pregnancy weight gain is composed of multiple components,
with the most significant at term being the fetus, maternal
extravascular fluid, and maternal stores. Within the confines
of recommended weight gain, maternal fat stores contribute to
approximately 3400 g of gestational weight gain (Fig. 1) [9].
Weight gain that extends beyond the IOM recommended
thresholds is likely due to increased maternal fat accumulation
[2].
Weight gain during pregnancy is a known risk factor for
continued weight retention after pregnancy [34–37]. Women
with weight gain higher than the IOM recommended amount
have been shown to have excessive postpartum weight reten-
tion at 3, 8, and 11 years postpartum [38, 39]. Excessive
weight gain and failure to lose weight postpartum are associ-
ated with risk of obesity and subsequent complications asso-
ciated with obesity later in life [39–41].
A study performed evaluating IOM guideline‑based weight
gain and subsequent BMI showed that women with gestation-
al weight gain above recommendations had significantly
higher weight at subsequent follow-up visits. Gestational
weight gain correlated directly with BMI at 15-year follow-
up even after adjusting for confounders [42].
Childhood Obesity
Fetal growth is directly associated with the future BMI of
the offspring [43]. Excessive maternal weight gain leads
to alteration of the intrauterine environment which is
known to influence fetal growth, but may also lead to
persistent programming of the child’s weight and subse-
quent poor health outcomes in the offspring [44]. Children
of mothers with excess gestational weight gain have more
adiposity at 3 years of age which is an association inde-
pendent of parental BMI, maternal glucose tolerance,
breastfeeding duration, fetal and infant growth, and child
behavior [45]. Children of mothers who gained more
weight also had higher systolic blood pressures and higher
BMIs in early childhood which continued throughout
childhood into young adulthood [45–47]. Maternal gesta-
tional weight gain is associated with BMI and risk of
obesity in adolescence and in early adulthood [47].
Additionally, the timing of gestational weight gain influ-
ences future health of offspring. Greater gestational
weight gain in the first and second trimesters—but not
the third trimester—is associated with higher BMI and
adiposity in childhood [48].
Page 5 of 10 11
Interventions for Prevention of Excessive Gestational
Weight Gain
Results of the LifeCycle project suggest that women would
ideally have a normal BMI prior to conception, as women
with the lowest risks had a low to normal BMI and a moderate
to high gestational weight gain (defined as 26.0 kg–27.9 kg)
while the highest risks were seen in women with a high BMI
and high gestational weight gain (defined as 20.0 to 21.9 kg)
[5]. However, as most pregnancies are unplanned, many
women do not have the opportunity to lose weight prior to
pregnancy. Additionally, delaying conception to achieve a
normal BMI may not result in higher rates of healthy singleton
term pregnancies [49].
Randomized trials vary in terms of the population included
(women with obesity, women with prior macrosomic infant,
women with history of gestational diabetes) and in the inter-
vention studied (diet, exercise, combination, in-person visits,
text messaging, mobile apps). While this is not a systematic
review, we review below several large, well-done randomized
trials.
Cochrane Review A Cochrane review published in 2015 (prior
to the majority of studies listed below) included 49 random-
ized controlled trials of 11,444 women [50]. Study interven-
tions varied between diet only, exercise only, or combination
of diet and exercise and were compared with standard care.
The intervention reduced the risk of excessive gestational
weight gain (pooled relative risk 0.80, 95% CI 0.73–0.87),
but the intervention group was more likely to experience
low gestational weight gain (pooled relative risk 1.14, 95%
CI 1.02–1.27). There was no difference in the incidence of
preeclampsia between intervention and control groups (RR
1.14, 95% CI 1.02 to 1.27) nor in cesarean delivery (RR
0.95, 95% CI 0.88–1.03). However, the effect estimate sug-
gests a small difference (5%) in favor of interventions with
regard to cesarean delivery. There was no statistically signif-
icant difference with regard to preterm birth (RR 0.91, 95% CI
0.68 to 1.22), infant macrosomia (RR 0.93, 95% CI 0.86 to
1.02), or other poor neonatal outcomes including shoulder
dystocia, neonatal hypoglycemia, hyperbilirubinemia, or birth
trauma. With regard to neonatal macrosomia, however, the
effect estimate suggested a small difference (7%) in favor of
intervention, with the largest effect occurring in the exercise-
only intervention group. Additionally, infants had a decreased
risk of respiratory distress syndrome if their mothers were
included in the intervention groups (RR 0.47, 95% CI 0.26–
0.85) [50].
ROLO The ROLO study randomized women with a prior
macrosomic infant (> 4000 g) at less than 18-week gestation
to either no dietary intervention (n = 398) or a low glycemic
index diet (n = 383) [51]. Glycemic index was calculated from
 11 Page 6 of 10
food diaries and compliance was assessed with a question-
naire administered at 34 weeks. Although the intervention
resulted in a lower glycemic index diet, less gestational weight
gain (total 12.4 ± 4.4 vs 13.7 ± 4.9, p = 0.017), and fewer
women gaining above the recommended amount (38% vs
48%, p = 0.01), the primary outcome of birthweight was not
significantly different between groups (4034 ± 510 vs 4006 ±
497, p = 0.449). No differences were detected in gestational
diabetes, cesarean delivery, anal sphincter injury, preterm de-
livery, or shoulder dystocia [51].
e-moms roc The e-moms roc randomized controlled trial test-
ed three online behavior change tools: a weight gain tracker,
diet and physical activity goal setting, and self-monitoring
tools. Women included in the study were 18–35 years old with
a BMI 18.5–34.9 kg/m2 with singleton gestations < 20 weeks
[52]. Women in the intervention group (n = 1126) received
online access and mobile app access to the behavior change
tools; women in the control group (n = 563) received access to
a control website that provided general health information
including tips, articles, and frequently asked questions. The
proportion of women with excessive gestational weight gain
(the primary outcome) was not significantly different between
groups (48.1% vs 46.2%, p = 0.12); perinatal outcomes were
not reported. Of note, the intervention arm required adherence
of 46.1%, much lower than other trials that evaluated similar
interventions, which may have contributed to the null findings
of this trial [52].
GeliS The GeliS study was a cluster-randomized controlled,
open intervention trial performed at five administrative areas
in south-eastern Germany that included women with a BMI
18.5‑40 kg/m2 at < 12 weeks of gestation [53]. Women ran-
domized to the intervention group (n = 1139) received three
individual face-to-face counseling sessions and one postpar-
tum session delivered by trained midwives, gynecologists, or
medical assistants. Counseling sessions encouraged a bal-
anced diet, physical activity, and self-monitoring of weight
gain. The control group (n = 1122) received general informa-
tion leaflets about a healthy lifestyle in pregnancy. This study
was powered based on the primary outcome of gestational
weight gain. The number of women with excessive gestational
weight gain was not different between the intervention and
control groups, respectively (45.1% vs 45.7%, p = 0.789)
nor was total gestational weight gain (14.1 ± 5.3 kg vs 14.1
± 5.2 kg, p = 0.838). The intervention did not reduce gesta-
tional diabetes between the intervention and control groups
(10.8% vs 11.1%, p = 0.383) or hypertension (9.5% vs 6.4%,
p = 0.060). Preterm labor was decreased in the intervention
group (1.6% vs 2.9%, p = 0.006) but not preterm birth (7.1%
vs 6.0%, p = 0.319). While birth weight was decreased slight-
ly with intervention (unadjusted effect size − 50.2 g (95% CI
− 80.6 to − 19.7 g, p = 0.001)), macrosomia was not reduced
Curr Diab Rep (2020) 20:11
(1.3% in the intervention group vs 0.6% in the control group,
p = 0.268) [53].
Healthy Beginnings This randomized controlled trial was one
of the LIFE-Moms consortium (see below) [54]. This trial
included women between 9 and 16 weeks and included wom-
en with a BMI ≥ 25 kg/m2, HbA1c < 6.5%, and a singleton
pregnancy. Participants randomized to the control group (n =
127) received “enhanced usual care,” which consisted of rou-
tine prenatal care, a 20-min welcome visit with information
about healthy eating, physical activity, and IOM recommen-
dations for gestational weight gain as well as study newsletters
with general information about prenatal health. The interven-
tion group (n = 129) received enhanced usual care, behavioral
lifestyle intervention with face-to-face counseling every
2 weeks until 20 weeks and then monthly until delivery, a
structured meal plan, partial meal replacement plan (products
provided free of charge), a pedometer with a goal of 10,000
steps/day, and a personalized graph of their weight gain. This
study was appropriately powered (≥ 80%) to detect a ≥ 20%
difference in gestational weight gain between groups. The
intervention was associated with reduced total gestational
weight gain (9.4 ± 6.9 vs 11.2 ± 9.0 kg, p = 0.03) and fewer
women exceeding gestational weight gain recommendations
(41.1% vs 53.9%, p = 0.03). Perinatal outcomes of preterm
delivery, cesarean, preeclampsia, gestational diabetes, and
macrosomia did not differ between groups [54].
LIFE-Moms LIFE-Moms was a consortium of seven clinical
centers, a research coordinating unit, and the National
Institutes of Health performing a prospective meta-analysis
of interventions for gestational weight gain [55]. Each clinical
center conducted a separate randomized trial to test strategies
to modify gestational weight gain in diverse populations. All
participants were over 18 years with a singleton pregnancy
between 9 and 16 weeks of gestation, a BMI ≥ 25 kg/m2, no
evidence of diabetes (HbA1c < 6.5%), and no history of eating
disorders or bariatric surgery. Individual trials may have im-
plemented additional exclusion criteria. A total of 1150 were
randomized in the seven trials: 579 to intervention and 571 to
standard of care. Overall, gestational weight gain was reduced
with intervention (8.1 ± 5.2 vs 9.7 ± 5.4 kg, < 0.001) and the
primary outcome of excessive gestational weight gain per
week was reduced (pooled odds ratio 0.52, 95% CI 0.40–
0.67). The secondary perinatal outcomes were not reduced
by the intervention (pregnancy-induced hypertension, pre-
eclampsia, gestational diabetes, cesarean, or preterm deliv-
ery); however, this analysis was not powered to detect a dif-
ference in secondary outcomes [55].
In sum, randomized control trials demonstrate that interven-
tions can decrease gestational weight gain but may not impact
perinatal outcomes. Studies of long-term impacts on both ma-
ternal and child health are needed. As most trials were powered
Curr Diab Rep (2020) 20:11
to detect only a change in either gestational weight or the percent
of women gaining more than recommended, this may represent
a sample size issue. However, as pointed out in the Cochrane
meta-analysis, the effect sizes on perinatal outcomes by inter-
vening on gestational weight gain are likely to be small [50] .
Gestational Weight Gain Below the IOM Guidelines
While much attention is focused on the consequences of ges-
tational weight gain above guidelines, clinicians and patients
must be aware of the risks of gestational weight gain below the
guidelines as well. Despite lower rates of large for gestational
age infants and macrosomia, pregnancies complicated by in-
adequate gestational weight gain are associated with an in-
creased risk of intrauterine growth restriction, preterm birth,
and perinatal mortality [56]. There is a significant association
between inadequate gestational weight gain and infant death.
A study performed in 2002 showed an infant mortality rate of
1.15% in infants of mothers with inadequate gestational
weight gain, 123% higher than odds for the reference group
of infants whose mothers had adequate weight gain [57]. A
similar study performed in 2014 confirmed the association
between inadequate gestational weight gain and neonatal
death, reporting a mortality risk of 3.9% among infants of
mothers with inadequate gestational weight gain during preg-
nancy, compared with 1.2% in infants of mothers with ade-
quate gestational weight gain. This association was most pro-
nounced in women with underweight pre-pregnancy BMI
(OR 6.18, 95% CI 2.45–15.56), and fell with increasing pre-
pregnancy BMI (normal weight OR 1.47, 95% CI 1.08–2.01;
overweight OR 2.11, 95% CI 1.30–3.42; obese OR 1.01, 95%
CI 0.63–1.64) [56].
Should Women with Obesity Lose Weight
During Pregnancy?
Pregnancy is often cited as an ideal time for positive changes in
maternal health behaviors as well as a time when women are
receiving regular healthcare [58, 59, 60•]. Given the known
relationship between gestational weight gain above recommend-
ed and adverse perinatal outcomes, along with the long-term
maternal health effects of obesity, physicians and women alike
are exploring the possible benefits of weight loss during
pregnancy—up to 8% of pregnant women report attempting to
lose weight during pregnancy while 15% of women with BMI
≥ 40 kg/m2 actually lost weight during pregnancy [61, 62].
A systematic review and meta-analysis including cohort,
case-control, cross-sectional studies, and randomized controlled
trials published in 2015 examined the association between ges-
tational weight loss and pregnancy outcomes in women with
obesity and found that although weight loss was associated with
lower risks of large for gestational age infants, macrosomia, and
cesarean (pooled ORs ranging from 0.57 to 0.73), it was also
Page 7 of 10 11
associated with increased risks of small for gestational age and
low birth weight, even in women with a BMI ≥ 40 kg/m2.[6]. No
benefits were found for reducing the risk of preeclampsia or
gestational diabetes. The systematic review did not explore the
impact on preterm birth [6], although at least one study has
reported an increase in preterm delivery in women with obesity
who lose weight during pregnancy [62].
There is biologic plausibility that weight loss, even in
women with obesity, would be associated with adverse out-
comes. Weight loss (through calorie restriction, exercise, or
surgery) influences circulating metabolites, including in-
creases in ketone bodies (acetoacetate, 3-hydroxybutyrate, 2-
hydroxyisobutarate) [63]. The known association of
ketoacidosis (an extreme form of increased ketonemia) and
adverse perinatal outcomes (including stillbirth), and the sus-
ceptibility of pregnant women to starvation ketoacidosis
should alert physicians to the potential harms of gestational
weight loss, even in women with obesity [64, 65]. In a large
prospective cohort study of women fasting for a month during
pregnancy during Ramadan, fasting was associated with an
increase in ketonuria and with decreased birth weight [65].
Further research is needed before gestational weight loss can
be recommended even in women with class III obesity.
Conclusion
In observational studies, excess gestational weight gain is as-
sociated with several key adverse perinatal outcomes includ-
ing fetal growth, preterm delivery, cesarean delivery, gesta-
tional diabetes, hypertensive disorders of pregnancy, and in-
fant mortality as well as to long-term offspring outcomes in-
cluding childhood obesity and adiposity. Overall, lifestyle in-
terventions appear effective at reducing gestational weight
gain, but have not been shown to be effective at improving
pregnancy outcomes. Additionally, estimates from meta-
analyses of RCT results suggest the impact of lifestyle inter-
ventions during pregnancy on perinatal outcomes may be lim-
ited, if any. Further research is needed before lifestyle inter-
ventions aiming to limit gestational weight gain below the
IOM guidelines or promoting weight loss should be recom-
mended during pregnancy in women with obesity.
Acknowledgments All individuals who contributed to this work have
met standard criteria for authorship.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
 11 Page 8 of 10
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