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This document is based in large part on information from the United States Institute of Medicine 2009 report 'Weight Gain during Pregnancy: Re-examining the Guidelines'. The full report is available on the National Academies Press website.
Poor dietary habits, inactivity, and being under- or overweight can negatively affect maternal and fetal health. Counselling during the time preceding a pregnancy - the preconception period - or between pregnancies can help a woman improve her eating and physical activity habits. These changes can have a positive and lasting effect on the health of the mother and her baby.
A woman's weight status before pregnancy is used to set recommendations for proper weight gain during pregnancy (see Recommended gestational weight gain).
Weight status is assessed using the body mass index (BMI). The BMI is a ratio of weight-to-height that is calculated by dividing weight in kilograms by height in meters squared (kg/m2). The BMI signals the long term health risks associated with being under- or overweight. There are four categories of BMI ranges in the Canadian weight classification system (Health Canada [HC], 2003):
NOTE: These adult BMI cut-offs are not recommended for the assessment of weight status in adolescence (HC, 2003); however, they may be used to establish an appropriate gestational weight gain goal in teen pregnancies (Institute of Medicine [IOM], 2009).
Current evidence suggests that when a woman enters pregnancy with a normal BMI, both she and her baby have better health and less chance of disease (IOM, 2009). According to national survey data, sixty percent of Canadian women entered pregnancy within this BMI range (see Table 1, Appendix A).
Women of childbearing age living in Canada today are significantly heavier than in the past (Tjepkema, 2005). One third of Canadian women entered pregnancy with a BMI equal or greater than 25 (see Table 1, Appendix A).
Observational data show that women with a higher BMI are more likely to have poor health and poor pregnancy outcomes. For instance, women with a high BMI are more likely to develop gestational diabetes mellitus (Torloni et al., 2008) and have a caesarean delivery (Chu et al., 2007; Margerison Zilko et al., 2010).Women who have a higher pre-pregnancy BMI are more likely to have a large-for-gestational age infantFootnote 2 (Viswanathan et al., 2008; Margerison Zilko et al., 2010) or an infant with a birth-weight of more than 4000 to 4500 g (8.8-9.9 lbs) at birth (Viswanathan et al., 2008). More recent evidence also points to a potential increased risk of preterm birth in women with a high pre-pregnancy BMI (McDonald et al., 2010).
Infants of these women are less likely to be breastfed (Amir & Donath, 2007) and more likely to be overweight in childhood (as measured by BMI) (Margerison Zilko et al., 2010).
It is estimated that less than 10 percent of Canadian women enter pregnancy at a low BMI (see Table 1, Appendix A). However, low pre-pregnancy BMI remains a public health concern. Observational data show that women with a BMI less than 18.5 are at risk for poor health and poor pregnancy outcomes. For example, low pre-pregnancy weight is linked to preterm birth (Viswanathan et al., 2008) and giving birth to a small-for-gestational-age infantFootnote 3 (Viswanathan et al., 2008; Margerison Zilko et al., 2010).
Women with a low pre-pregnancy BMI may reduce these risks by gaining the recommended amount of gestational weight (see Table 2, Appendix A).
A variety of factors including personal choices, as well as genetics and our social, cultural, physical and economic environments can make it harder for women to adopt healthy lifestyle practices (Canadian Institute for Health Information [CIHI], 2006). Health professionals play an important role in supporting women who may be faced with barriers to eating well and being active during the childbearing years.
By engaging women before they get pregnant, health professionals can help them adopt a healthy lifestyle and prepare for pregnancy.
Throughout pregnancy, maternal body weight is used as a general indicator of the health of the mother and the developing fetus. The placenta, fetus and amniotic fluid account for about 35 percent of the total pregnancy weight gain (Pitkin, 1976). The rest comes from increased blood and fluids, tissues of the breast and uterus, and fat stores (see Table 3, Appendix A). Most weight gain in pregnancy occurs in the second and third trimesters, with minimal weight gain in the first trimester (IOM, 2009).
Although pre-pregnancy BMI largely determines gestational weight gain, there are many other factors that can affect a woman's weight such as genetic characteristics, underlying health issues, socioeconomic status and attitude toward weight gain.
The amount a woman gains can also depend on her living and working environment, including cultural norms and beliefs, access to healthy foods, opportunities for physical activity, family and partner support.
These and other factors should not be overlooked as they can hinder or enhance a woman's ability to gain an appropriate amount of weight during her pregnancy.
Health Canada uses the U.S. Institute of Medicine 2009 recommendations when advising women about gaining weight as part of a healthy pregnancy (see Table 2, Appendix A). The IOM suggests a different range of weight gain for each pre-pregnancy BMI category.
Women who have healthy babies gain varying amounts of weight during pregnancy. However, observational data consistently show that women who gain the recommended amount of weight have better pregnancy outcomes than others (IOM, 2009). This does not mean that every woman who gains more or less than the recommended amount of weight will have an unhealthy pregnancy. Many other factors (such as smoking, maternal age and underlying illness) can affect pregnancy outcomes.
The IOM recommendations take into account population trends that are similar in Canada and the U.S., such as the increase in pre-pregnancy BMI and in the rates of caesarean delivery (Tjepkema, 2005; Public Health Agency of Canada [PHAC], 2008; IOM, 2009) and generally apply to all healthy Canadian women with a singleton pregnancy.
Women carrying twins or multiple fetuses have more maternal tissues and higher fetal weight, and should therefore gain more weight (see Table 4, Appendix A). There is little information on weight gain for women carrying three or more babies (IOM, 2009). It seems reasonable that these women will need to gain more weight than those carrying twins.
In both the U.S. (Chu et al., 2009) and Canada (see figure a, Appendix B), many women gain more weight than the recommended amounts. Women who gain too much weight during pregnancy are more often (Lowell & Miller, 2010):
Based on observational data, women who gain more weight in pregnancy tend to retain excess weight for up to 3 years postpartum (Viswanathan et al., 2008). Women who gain too much weight also tend to have large-for-gestational age infants or infants whose birth weight is greater than 4000 to 4500 g (8.8-9.9 lbs) (Viswanathan et al., 2008; Crane et al., 2009; Margerison Zilgo et al., 2010).
Observational studies also show that women who have babies whose birth weight is more than 4500 g (9.9 lbs) face higher risks of longer labour and birth, birth traumaFootnote 7, birth asphyxiaFootnote 8, caesarean birth, and increased risk of perinatal mortalityFootnote 9 (Zhang et al., 2008).
Recent population-based studies suggest a link between higher gestational weight gains and children who are overweight (as measured by BMI) (Oken et al., 2007; Oken et al., 2008; Wrotniak et al., 2008; Margerison Zilgo et al., 2010; Schack-Nielsen et al., 2010).
Babies born at higher birth-weights may also be at increased risk for type 2 diabetes later in life (Harder et al., 2007).
Large-for-gestational age births are more common among First Nations women, particularly those who develop gestational diabetes (Rodrigues et al., 2000).
Not gaining enough weight in pregnancy is less common than gaining too much weight in both the United States (Chu et al., 2009) and Canada (see figure a, Appendix B). Gaining less weight than recommended is more common if a woman (Lowell & Miller, 2010):
Women who do not gain enough weight in pregnancy may have an infant born preterm, a small-for-gestational age infant or a low birth-weight infantFootnote 10 (Viswanathan et al., 2008). These infants face more risk of neonatal morbidity and mortality, physical and cognitive disabilities, and chronic health problems later in life (Goldenberg & Culhane, 2007). In addition, women who do not gain enough weight are less likely to initiate breastfeeding (Viswanathan et al., 2008).
Considering the risks linked to poor gestational weight gain, women should not avoid gaining weight or try to lose weight during pregnancy.
Health professionals can use weight monitoring tools (see figure b, Appendix B) to assess the progress of pregnancy, track a woman's weight gain over time and identify unusual patterns of weight gain earlier in pregnancy. These tools look at the overall pattern of weight gain, as the rate of gain is highly variable. A single measure is not enough to determine whether weight gain is on track (IOM, 2009).
These tools assume that women gain weight consistently during their second and third trimesters. However, women often gain more weight in the second than they do in the third trimester of pregnancy. This is true across pre-pregnancy BMI categories, except BMIs of 30 or greater (IOM, 2009). The rate of weight gain can also vary depending on the woman's age and ethnicity (IOM, 2009).
Women who have good pregnancy outcomes gain about 1 to 2 kg (2 to 4 lbs) in the first trimester (IOM, 2009). Nausea and vomitingFootnote 11, which are common early in a pregnancy, may cause women to lose a small amount of weight. However, some women may eat less to avoid gaining weight. Women who lose more than 5-10% of their pre-pregnancy weight should be assessed.
Similarly, women who gain a large amount of weight in the first trimester (much more than 2 kg or 4 lbs) should be assessed. These women may be at increased risk for gestational diabetes, particularly women with a pre-pregnancy BMI greater than 25 (Hedderson et al., 2010).
After their first trimester, women put on weight steadily, as they gain lean and fat tissues. Erratic patterns of weight gain and weight gains that vary from the recommended amounts should be evaluated.
If a woman's pattern of weight gain falls well below or above the recommended amount, the health professional can work with the woman to bring her weight gain back to the suggested rate of gain through the rest of the pregnancy. The following steps can be used to help assess the underlying causes:
While there is not a strong evidence base for interventions that work reliably to help women meet the recommended weight gain ranges, or avoid postpartum weight retention (IOM, 2009), the following section offers ideas to help women meet the recommendations for healthy weight gain during pregnancy. These ideas build on the IOM's recommendations and Health Canada's advice on eating well and being active. The challenge for health professionals will be to help pregnant women create healthy attitudes and beliefs about their changing bodies, while encouraging them to maintain healthy eating and activity patterns.
Weight gain during pregnancy can be a sensitive topic for many women and health care providers may be reluctant to discuss it (Stotland et al., 2010). However, health professional advice can influence how much weight a woman gains during pregnancy (IOM, 2009). By communicating the recommended weight gain ranges early in the pregnancy, health care providers can improve a woman's chances of reaching the recommendations. Engaging women early can also help support their decision to breastfeed (Lu et al., 2001).
When women learn what to expect about weight changes that take place during pregnancy, they may not feel as anxious about these changes.
Eating well and being active provides benefits that go well beyond a woman's immediate well-being to support future pregnancies and ensure a better health status later in life.
Most women know that they need to eat more food when they are pregnant to support their baby's growth and development but they do not always know how much more. Women are commonly told they are "eating for two". In reality, women who eat for two will eat too much and gain more weight than is needed. Usually, pregnant women only need modest increases in energy (calories) and greater increases in vitamin and mineral intake (IOM, 2009).
Being active during pregnancy may help women gain an appropriate amount of weight (IOM, 2009; Stuebe et al., 2009). It may also make it easier for them to accept the physical changes that go with pregnancy (Davies et al., 2003). Additionally, physical activity in pregnancy may help women maintain muscular and cardiovascular fitness, reduce the risk of gestational diabetes or pre-eclampsia, and decrease physical complaints like back pain (Davies et al., 2003).
Health professionals play an important role in encouraging healthy women with uncomplicated pregnancies to build physical activity into their daily life, without major risks to themselves or to their unborn child.
Special advice for women with a pre-pregnancy BMI less than 18.5
You may need to change your messages about eating well and being active for women with a low pre-pregnancy BMI, particularly if they are still in their teens, if they have abnormal eating behaviours (Berkman et al., 2006), or if they spend too much time exercising.
After pregnancy, gradual weight loss through breastfeeding and keeping up a healthy and active lifestyle should be emphasized.
Weight loss following pregnancy is variable. Women who gain more than the recommended range for their pre-pregnancy BMI are more likely to keep excess weight up to 3 years after birth (Vishwanathan et al., 2008). Many other factors can also affect a woman's efforts to lose weight after pregnancy such as pre-pregnancy BMI, household income, ethnicity, energy intake, and infant feeding practices (Chung et al., 2007).
Women who retain excess weight or gain weight in the postpartum period are at greater risk of experiencing complications during their next pregnancy, and at increased risk of long term maternal health complications. These women may need extra time and support to lose weight. They may also need nutrition counselling with a Registered Dietitian, peer support, or improved access to opportunities for physical activity, such as access to programs that provide child care at no or low cost.
|Less than 18.5 (underweight)||18.5 to 24.9 (normal weight)||25.0 to 29.9 (overweight)||30.0 or more (obese)|
Table 1 footnotes
Data source: Canadian Maternity Experiences Survey, 2006-2007
|15 to 19 years old||11.8a||67.3||14.9||6.0a|
|20 to 24 years old||10.7||56.6||19.0||13.7|
|25 to 29 years old||5.2||58.3||21.4||15.1|
|30 to 34 years old||5.5||59.1||21.7||13.8|
|35 to 39 years old||4.5Table 1 footnote a||63.4Table 1 footnote b||19.9Table 1 footnote c||12.3Table 1 footnote c|
|40+ years old||3.8Table 1 footnote d||58.4Table 1 footnote b||29.0Table 1 footnote c||8.8Table 1 footnote a,Table 1 footnote c|
|Pre-pregnancy BMI||MeanTable 2 footnote a rate of weight gain in the 2nd and 3rd trimester||Recommended total weight gainTable 2 footnote b|
Table 2 footnotes
|BMI < 18.5||0.5||1.0||12.5 - 18||28 - 40|
|BMI 18.5 - 24.9||0.4||1.0||11.5 - 16||25 - 35|
|BMI 25.0 - 29.9||0.3||0.6||7 - 11.5||15 - 25|
|BMI ≥ 30.0Table 2 footnote c||0.2||0.5||5 - 9||11 - 20|
|Weight from||Grams||Pounds and ounces|
Table 3 footnotes
|Fetus||3294 g||7 lbs 4 oz|
|Placenta||644 g||1 lb 7 oz|
|Amniotic fluid||795 g||1 lb 12 oz|
|Blood volume||1442 g||3 lbs 3oz|
|Uterus||970 g||2 lbs 2 oz|
|WaterTable 2 footnote a||1496 g||3 lbs 5 oz|
|Breasts||397 g||14 oz|
|Fat stores||3345 g||7 lbs 6 oz|
|Total weight gain||12.4 kg||27 lbs 4 oz|
|Pre-pregnancy BMITable 4 footnote a||Recommended total weight gainTable 4 footnote b|
Table 4 footnotes
|BMI 18.5 - 24.9||17 - 25||37- 54|
|BMI 25 - 29.9||14 - 23||31 - 50|
|BMI ≥ 30||11 - 19||25 - 42|
The following figures compare the distribution of weight gain in pregnancy to the recommended weight gain range (pink zone) based on women's pre-pregnancy BMI (estimates and 95% confidence intervals are shown).
Health Canada has prepared sample weight gain tracking charts that can be adapted and used to assess the progress of a woman's gestational weight gain. Five graphics are available: a combined chart with all four BMI categories and four individual charts (one for each of the 4 BMI categories).
NOTE: These sample graphics were prepared based on provisional charts put forward by the IOM in its 2009 report Weight Gain during Pregnancy: Reexamining the Guidelines.
A woman's weight status before pregnancy (her pre-pregnancy body mass index or BMI) should be used to determine an appropriate gestational weight gain goal.
Calculate a woman's pre-pregnancy BMI using this formula:
BMI = pre-pregnancy weight* in kilograms
(height in metres)2
*In absence of accurate pre-pregnancy weight, use a woman's weight in the first trimester as an estimate.
You can also use the BMI chart provided here.
Example: A woman whose weight is 69 kg before pregnancy and is 173 cm tall has a pre-pregnancy BMI of approximately 23.
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Health Canada sincerely thanks the members of the Expert Advisory Group on National Nutrition Pregnancy Guidelines who generously gave their time and expertise to help prepare this resource:
We gratefully acknowledge Dr. Rhonda Bell from the University of Alberta who prepared a background paper to inform the work to revise the gestational weight gain recommendations.
Health Canada would also like to thank the many stakeholders who took part in the consultation including Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada, and Dr. Bill Ehman, representative of the College of Family Physicians of Canada.
The term 'normal' is used to describe the 'least risk' BMI category. The term 'healthy' was also considered but not retained since it could incorrectly imply an assurance of good health for all people within the specified BMI range. Overall health is also dependent on the presence of other risk factors such as genetic predisposition, individual weight history and age, as well as influencing factors such as health behaviours (HC, 2003).
An infant whose weight is above the 90th percentile for gestational age
An infant whose weight is below the 10th percentile for their gestational age
The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that women be encouraged to enter pregnancy with a BMI less than 30, and ideally less than 25 (Davies et al, 2010).
Print resources on preparing for a healthy pregnancy are also available from the Society of Obstetricians and Gynaecologists of Canada ( Healthy Beginnings, 4th edition) and the Public Health Agency of Canada ( The Sensible Guide to a Healthy Pregnancy).
For a more in-depth look at potential determinants of pregnancy weight gain, see Chapter 4 of the 2009 IOM report Weight Gain during Pregnancy: Reexamining the Guidelines.
Physical injury to an infant during the birth process
Failure to start regular respiration within a minute of birth
Infant mortality between delivery and discharge
Birth weights less than 2500 g or 5.5 lbs
To manage nausea and vomiting of pregnancy, refer to the Clinical Practice Guidelines and client handout from the SOGC
Health Canada provides advice for limiting exposure to mercury from certain fish (HC, 2009c).
The Canada Prenatal Nutrition Program is developed and delivered in partnership with the provinces and territories, and with First Nations and Inuit communities. The services provided include food supplementations, nutritional counselling, breastfeeding support, education, referral and counselling on health and lifestyle issues.