Obesity During Pregnancy in Clinical Practice

13. Obesity Screening Recommendations and Emerging Policies

Wanda Nicholson¹

(1)

Department of Obstetrics and Gynecology, Diabetes and Obesity Core, Center for Women’s Health Research, University of North Carolina School of Medicine, Chapel Hill, NC, USA

Wanda Nicholson

Email: wanda_nicholson@med.unc.edu

Abstract

Screening for obesity is recommended by several expert committees and organizations, such as the United States Preventive Services Task Force, the American College of Obstetricians and Gynecologists, NIH, and the Canadian Task Force. Numerous national and regional health policies have been developed to prevent obesity and promote healthy lifestyle behaviors in adults and children. Health system-sponsored programs, community gardens, and public posting of the caloric and fat content of foods in restaurants are a sample of current efforts to stem the current epidemic of obesity.

Keywords

ObesityScreeningRecommendationsPolicyPregnancyWeight

“To Win We Have to Lose,” from Weight of the Nation, Confronting America’s Obesity Epidemic [1]

Introduction

Screening for obesity is a critical step in prevention and treatment. Evidence in support of obesity screening is the reduction in adverse pregnancy-related outcomes, diabetes, cardiovascular morbidity, and mortality. The United States Preventive Services Task Force [2]; the American Congress of Obstetricians and Gynecologists [3]; the National Heart, Lung, and Blood Institute [4]; and the Canadian Task Force [5] are organizations that provide recommendations for screening and management of obesity in adults. In this chapter, we focus on the individual obesity screening recommendations from committees of experts and current initiatives in the United States to facilitate lifestyle modifications among women with obesity.

The United States Preventive Services Task Force [6] is an independent, nonfederal panel of experts in prevention and evaluation of scientific evidence; scientific and logistical support for the Task Force is provided by the Agency for Healthcare Research and Quality (AHRQ). The 16 volunteer Task Force members include physicians specializing in Internal Medicine, Family Medicine, Obstetrics and Gynecology, and Pediatrics, as well as nurse practitioners and experts in behavioral health. Most members are active primary care clinicians; many are respected researchers and distinguished professors as well. The American Congress of Obstetricians and Gynecologists (ACOG) is a nonprofit national organization of obstetricians and gynecologists providing obstetrical and gynecological care to women across the life span. ACOG provides a series of practice bulletins and committee opinions on pregnancy care, gestational weight gain, motivational interviewing, and general counseling on lifestyle modifications. The National Heart, Lung, and Blood Institute is part of the National Institutes of Health. NHLBI focuses on the conduct and funding of the downstream consequences of obesity, including cardiovascular disease and the metabolic syndrome. In 1998, the NHLBI, in collaboration with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and a convened expert panel, published an extensive evidence report on the identification, prevention, and management of obesity [4]. The Canadian Task Force [7], established by the Public Health Agency of Canada, develops clinical practice guidelines that support primary care providers in delivering preventive services.

Recommendations for Screening by Expert Committees

Measuring body mass index is the first step to determine the degree of adiposity. The BMI is relatively easy and reliable and correlates with percentage of body fat and body fat mass. Also, BMI is used to identify adults at increased risk for morbidity and mortality. For example, women who are overweight or obese are at increased risk of type 2 diabetes and cardiovascular disease, even within the context of a normal waist circumference (Table 13.1).

Table 13.1

Classification of overweight, obesity, waist circumference, and disease risks

Adapted from: National Institutes of Health [10]

BMI body mass index

^aDisease risk for type 2 diabetes, hypertension, and cardiovascular disease (CVD)

Guidelines for the screening and evaluation of overweight and obesity have been published by a number of organizations including the National Heart, Lung, and Blood Institute (NHLBI) [4], the World Health Organization (WHO) [8], and the United States Preventive Services Task Force [2, 5, 9] (Table 13.2). NHLBI [10] recommends screening adults for obesity with BMI and waist circumference and risk factor assessment. Subsequent intervention is then based upon overall risk assessment [4]. The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese (BMI >30 kg/m²) adults. The Canadian Task Force on Preventive Health Care recommends measuring BMI and waist circumference in all adults. The American College of Obstetricians and Gynecologists recommends measuring BMI in all adult women as part of routine gynecologic and well woman visits [3]. Overweight or obese women should then be counseled about the healthy eating and increasing physical activity.

Table 13.2

Summary of screening recommendations from expert committees

NHLBI the National Heart, Lung, and Blood Institute, NIH National Institutes of Health, BMI body mass index

Current Initiatives to Prevent Obesity

Multiple national, regional, and state initiatives to promote lifestyle modifications among women and their families have grown over the past decade. These initiatives, spearheaded by the White House, CDC, healthcare organizations, and state health agencies, focus on educating adults about the adverse health consequences of obesity and the importance of healthy eating and physical activity. The long-term goal of these policy initiatives is to increase the availability of low-cost healthy foods, promote safe neighborhood venues for physical activity, and promote knowledge about the caloric and fat content of foods.

National Initiatives

The “Let’s Move!” campaign [11], launched by the First Lady, Michelle Obama, combats child obesity by promoting family-centered interventions. The campaign identifies strategies to create a healthy start for children, empower parents and caregivers in setting an example of healthy eating, advocate for healthy foods in school cafeterias, increase the availability of healthy foods, and promote physical activity. Several subprograms within the Let’s Move! campaign target adults through faith-based organizations and promote physical activity and regular exercise, in particularly high-risk populations, including Native Americans and Alaskan natives. The campaign (“Let’s Move! In the Clinic”) promotes professional partnerships between the program and healthcare professionals.

The National Diabetes Prevention Program [12], supported by the CDC, is designed to bring to communities evidence-based lifestyle change programs for weight loss and prevention of type 2 diabetes. The program is based on the Diabetes Prevention Program research study led by the National Institutes of Health and supported by Centers for Disease Control and Prevention. The lifestyle program in this study showed that making modest behavior changes (increasing healthy food choices and physical activity to at least 150 min per week) helped male and female participants to lose 5–7 % of their body weight and reduced the risk of developing type 2 diabetes mellitus. Participants work with a lifestyle coach in a group setting to receive a 1-year lifestyle change program. Current efforts are focused on translating the program into diverse clinical settings (i.e., health departments, healthcare organizations, private clinics) and communities.

Reducing Sweetened Beverages and Posting Caloric Content

In 2012, the state of New York banned the sale of oversized sugary drinks at restaurants, street carts, and movie theaters in an effort to reduce the rising rate of obesity in the city [13]. Recent studies have shown a strong association between the number of sweetened beverages consumed, reduced physical activity, and obesity [14]. Moreover, economic models suggest that a tax on sweetened beverages would reduce the consumption of sweetened beverages by 15 % [15]. The initiative limits the containers for the sale of sugary drinks to 16 oz or less. Consumers are able to purchase larger-sized beverages if they desire, but the standard size is <16 oz.

Additionally, many cities and states have now required that restaurants post the caloric and fat content of their meals on menus and menu boards [16].

Regional- and Community-Oriented Initiatives

Ready, Set, Thrive! [17] is an example of a community-based program that is often supported by regional healthcare organizations. Sponsored by Kaiser Permanente Sacramento, the Kaiser Permanente Walk to Thrive Program is an ongoing mall walking club open to local communities and Kaiser employees in Sacramento, California. Physicians and other staff members at Kaiser host the early morning mall walking events to promote healthy habits to lower weight and blood pressure, and reduce cholesterol [17].

Conclusions

Several organizations have made recommendations for screening for obesity in adults. There are areas of emphasis that vary across organizations. For example, the Task Force’s recommendation for screening is based on evidence that behavioral interventions are successful at weight reduction. In contrast, NHLBI recommends obesity screening and provides specific recommendations for lifestyle modification as well as additional clinical assessment of future medical risks. Regardless of the specific guideline that is followed, screening for obesity prior to and after pregnancy has the potential to substantially reduce the epidemic of obesity among women of childbearing age and the adverse pregnancy consequences that they may endure. Current initiatives to promote lifestyle modifications, improve health eating, and enhance venues for physical activity are gaining traction and have the potential to substantially reduce the percentage of women with obesity.

References

1.

To Win We Have to Lose,” from the 2013 Weight of the Nation, Confronting America’s Obesity Epidemic. http://theweightofthenation.hbo.com/. Accessed on 16 Sep 2013.

2.

Moyer VA, U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373.PubMed

3.

ACOG Committee on Gynecologic Practice. The role of the obstetrician–gynecologist in the assessment and management of obesity. Obstet Gynecol. 2005;106:895–9.CrossRef

4.

The Practical Guide: Identification E, and Treatment of Overweight and Obesity in Adults http://www.nhlbi.nih.gov.libproxy.lib.unc.edu/guidelines/obesity/prctgd_c.pdf. Accessed on 2 July 2013.

5.

Lau DC, Obesity Canada Clinical Practice Guidelines Steering Committee and Expert Panel. Synopsis of the 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. Can Med Assoc J. 2007;176(8):1103.CrossRef

6.

The United States Preventive Services Task Force Home Page. www.unitedstatespreventiveservicestaskforce.org. Accessed on 24 Sep 2013.

7.

The Canadian Task Force on Preventive Health Care. http://canadiantaskforce.ca/. Accessed on 24 Sep 2013.

8.

Report on Obesity. World Health Organization Technical Report Service. 2000;894:1–253.

9.

Lyznicki JMYD, Riggs JA, Davis RM. Council on scientific affairs, American medical association obesity: assessment and management in primary care. Am Fam Physician. 2001;63(11):2185.PubMed

10.

National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults–the evidence report. Obes Res. 1998;6:515.

11.

The Let’s Move Campaign. America’s Move to Raise a Healthier Generation of Kids. www.letsmove.com. Accessed on 24 Sep 2013.

12.

The National Diabetes Prevention Program. http://www.cdc.gov/diabetes/prevention/. Accessed on 24 Sep 2013.

13.

Michelle Castillo. NYC refreshes anti-sugary drink campaign with new ads. CBS News on-line. / 2013. http://www.cbsnews.com/8301-204_162-57587576/. Accessed on 24 Sep 2013.

14.

Duffey KJ, Gordon-Larsen P, Steffen LM, Jacobs Jr DR, Popkin BM. Drinking caloric beverages increases the risk of adverse cardiometabolic outcomes in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr. 2010;92(4):954–9.PubMedCrossRef

15.

Wang YC, Coxson P, Shen YM, Goldman L, Bibbins-Domingo K. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes. Health Aff (Millwood). 2012;31(1):199–207.CrossRef

16.

The Requirements to Post Calorie Counts on Menus in NYC Food Services Establishments. Section 81.50 of the New York City Code. http://www.nyc.gov/html/doh/downloads/pdf/cdp/calorie_compliance_guide.pdf.

17.

The Kaiser Permanente of Sacramento “Walk to Thrive” Campaign. https://kpwalktothrive.org/. Accessed on 24 Sep 2013.