Feasibility and Initial Efficacy Evaluation of a Community-Based Cognitive-Behavioral Lifestyle Intervention to Prevent Excessive Weight Gain During Pregnancy in Latina Women

Factors Associated With Inadequate Gestational Weight Gain: A Prospective Multicenter Cohort Study

Inadequate gestational weight gain (GWG) is associated with birth weight and premature birth and is a primary problem in Asia, particularly in Japan. This study aimed to identify the risk factors associated with inadequate GWG, focusing on women's target GWG and advised GWG by healthcare professionals. A questionnaire for women in their second trimester inquired about their target GWG and advice regarding GWG by healthcare professionals. Of the 626 participants, 52.6% were classified in the inadequate GWG group. Inadequate GWG was associated with a prepregnancy body mass index (BMI) < 18.5 kg/m2 and weight below the prepregnancy weight in the second trimester. Among the multiparas, inadequate GWG was associated with an individual target GWG below the guideline, with no advice from healthcare professionals, and with an advised GWG below the guideline. Among the primiparas, there were no significant differences in the individual targets or advised GWG. Healthcare professionals must understand the latest guidelines regarding GWG and apply them when advising women. The importance of preconception care in achieving a BMI of at least 18.5 kg/m2 before pregnancy is also suggested.

Effects of Two Group Prenatal Care Interventions on Mental Health: An RCT

INTRODUCTION

Perinatal depression and anxiety cost the U.S. health system $102 million annually and result in adverse health outcomes. Research supports that cognitive behavioral therapy improves these conditions, but barriers to obtaining cognitive behavioral therapy have prevented its success in pregnant individuals. In this study, the impact of a cognitive behavioral therapy-based intervention on anxiety, depression, stress, healthy lifestyle beliefs, and behaviors in pregnant people was examined.

STUDY DESIGN

This study used a 2-arm RCT design, embedded in group prenatal care, with one arm receiving a cognitive behavioral therapy-based Creating Opportunities for Personal Empowerment program and the other receiving health promotion content.

SETTING/PARTICIPANTS

Black and Hispanic participants (n=299) receiving prenatal care from 2018 to 2022 in New York and Ohio who screened high on 1 of 3 mental health measures were eligible to participate.

INTERVENTION

Participants were randomized into the manualized Creating Opportunities for Personal Empowerment cognitive behavioral therapy-based program, with cognitive behavioral skill-building activities delivered by advanced practice nurses in the obstetrical setting.

MAIN OUTCOME MEASURES

Outcomes included anxiety, depression, and stress symptoms using valid and reliable tools (Generalized Anxiety Disorder scale, Edinburgh Postnatal Depression Scale, and Perceived Stress Scale). The Healthy Lifestyle Beliefs and Behaviors Scales examined beliefs about maintaining a healthy lifestyle and reported healthy behaviors.

RESULTS

There were no statistically significant differences between groups in anxiety, depression, stress, healthy beliefs, and behaviors. There were significant improvements in all measures over time. There were statistically significant decreases in anxiety, depression, and stress from baseline to intervention end, whereas healthy beliefs and behaviors significantly increased.

CONCLUSIONS

Both cognitive behavioral therapy and health promotion content embedded in group prenatal care with advanced practice nurse delivery improved mental health and healthy lifestyle beliefs and behaviors at a time when perinatal mood generally worsens.

TRIAL REGISTRATION

This study is registered with clinicaltrials.gov NCT03416010.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review

Importance

Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified.

Objective

To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care.

Data Sources

Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020.

Study Selection

Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included.

Data Extraction and Synthesis

Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers.

Main Outcomes and Measures

The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care).

Results

Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG.

Conclusions and Relevance

These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

Implementation of Antenatal Lifestyle Interventions Into Routine Care: Secondary Analysis of a Systematic Review

IMPORTANCE

Lifestyle interventions in pregnancy optimize gestational weight gain and improve pregnancy outcomes, with implementation recommended by the US Preventive Services Task Force. Yet, implementation research taking these efficacy trials into pragmatic translation remains limited.

OBJECTIVE

To evaluate success factors for implementing pregnancy lifestyle interventions into antenatal care settings in a meta-analysis, using the penetration, implementation, participation, and effectiveness (PIPE) impact metric.

DATA SOURCES

Data from a previous systematic review that searched across 9 databases, including MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database, were obtained, in 2 stages, up to May 6, 2020.

STUDY SELECTION

Randomized clinical trials reporting gestational weight gain in singleton pregnancies.

DATA EXTRACTION AND SYNTHESIS

The association of penetration, implementation, and participation with effectiveness of antenatal lifestyle interventions in optimizing gestational weight gain was estimated using random-effects meta-analyses. The Cochrane risk of bias tool, version 1.0, was used to assess risk of bias.

MAIN OUTCOMES AND MEASURES

Penetration (reach), implementation (fidelity), participation, and effectiveness of randomized clinical trials of lifestyle interventions in pregnancy.

RESULTS

Ninety-nine studies with 34 546 participants were included. Only 14 studies reported penetration of target populations. Overall, 38 studies (38.4%) had moderate fidelity, 25 (25.2%) had high fidelity, and 36 (36.4%) had unclear fidelity. Participation was reported in 84 studies (84.8%). Lifestyle interventions were associated with reducing gestational weight gain by 1.15 kg (95% CI, -1.40 to -0.91 kg).

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that, despite the large body of evidence on efficacy of lifestyle interventions during pregnancy in optimizing gestational weight gain, little guidance is available to inform implementation of this evidence into practice. There is a need to better elucidate implementation outcomes in trial design alongside pragmatic implementation research to improve the health of women who are pregnant and the next generation.

Exercise interventions for weight management during pregnancy and up to 1 year postpartum among normal weight women and women with overweight and obesity: An updated systematic review

Background

Given the increased occurrence of pre-gravid obesity in recent years, and the implications of maternal obesity for maternal and offspring health, it is evident that there is a continued need to investigate antenatal and postnatal weight management strategies and to provide evidence-based advice for exercise-based interventions. Given the small number of studies (n = 5) included in an original systematic review by our group in 2015, it was important to add to the dataset by assessing data published since 2015, in order to provide a more in-depth view of current knowledge.

Objective

To provide an updated systematic review on studies employing exercise interventions for weight management in pregnant and postpartum women.

Methods

A systematic review of randomised controlled trials evaluating the effects of an exercise intervention on gestational weight gain and postpartum weight management in normal weight women, and women with overweight and obesity was conducted. PubMed, Scopus, Central Register of Controlled Trials and Web of Science were searched for studies published between September 2013 and June 2021. No restrictions were set on type, intensity, duration, or frequency of exercise intervention. Only studies that targeted body weight or mass as a primary outcome were included.

Results

Thirteen studies were included in this review: 11 during and two following pregnancy. Exercise significantly reduced gestational weight gain in five of the pregnancy studies and induced significant weight loss in one of the postpartum studies. Across studies, there were large disparities in exercise modality, frequency, and duration, although moderate intensity exercise was consistently employed.

Conclusions

Some studies showed positive effects of exercise on weight management during and following pregnancy. While there is still no consensus on effective exercise intervention approaches, it is crucial that physical activity, of any safe form, is recommended to encourage healthy weight management during this time.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Effective psychological therapies to improve lifestyle behaviors in (pre)pregnant women: A systematic review

Poor lifestyle behaviors impact (pre)pregnant women by affecting pregnancy outcomes and offspring health. This systematic review provides an overview of psychological therapies to support lifestyle behavior changes among (pre)pregnant women. Scientific databases were searched from their inception to 20 December 2020 for studies investigating the effects of psychological therapies on improvements in lifestyle behaviors. Studies were eligible if they included (pre)pregnant women, examined the effects of a psychological therapy on at least one lifestyle behavior and used a control group receiving usual pregnancy care or a non-psychological intervention. Lifestyle behaviors of interest were dietary intake, physical activity, smoking, alcohol consumption, drug use, body weight loss and body weight gain during pregnancy. Pregnancy complications were included as outcome measures. Motivational interviewing (MI) (n = 21), cognitive behavioral therapy (CBT) (n = 8), incentive-based contingency management (IBCM) (n = 9), mindfulness (n = 1) and hypnosis (n = 1) were investigated as lifestyle behavior interventions. The findings revealed that MI was effective in reducing (self-reported) smoking and alcohol consumption and restricting gestational weight gain (GWG). CBT was only studied as an intervention to restrict GWG and the results predominantly confirmed its effectiveness. IBCM showed the strongest effect on reducing smoking and substance use. The studies using hypnosis or mindfulness to reduce smoking or restrict GWG, respectively, showed no associations. The use of psychological therapies to improve lifestyle behaviors among (pre)pregnant women is new and the scientific proof is promising. Before wide implementation is legitimated, more evidence is needed on the consequences of lifestyle change for pregnancy outcomes.

A Qualitative Study of Motivators, Strategies, Barriers, and Learning Needs Related to Healthy Cooking during Pregnancy

Nutrition during pregnancy has lifelong impacts on the health of mother and child. However, this life stage presents unique challenges to healthy cooking and eating. Cooking interventions show promising results, but often lack theoretical basis and rigorous evaluation. The objective of this formative, qualitative study was to explore motivators, strategies, and barriers related to healthy cooking during pregnancy. Pregnant individuals’ preferences for a cooking education program were also explored. We conducted five focus groups with pregnant individuals (n = 20) in Southeast Michigan in 2019. Focus groups were audio-recorded and transcribed verbatim, then double coded by two members of the research team. Mean gestational age was 18.3 ± 9.6 weeks. Common motivators included feeding other children, avoiding pregnancy complications, promoting fetal growth, and avoiding foodborne illness. Challenges included pregnancy symptoms, navigating nutrition recommendations, mental energy of meal planning, family preferences, and time constraints. Strategies employed were meal planning and including a variety of foods. Participants identified organizational strategies, recipes, nutrition information, and peer support as important components of a cooking intervention during pregnancy. This study characterized multiple challenges to healthy home cooking during pregnancy, providing novel insight to inform the development of cooking skills education programs during this important life stage.

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

OBJECTIVE

To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

DATA SOURCES

Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

STUDY SELECTION

Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating with dual review.

MAIN OUTCOMES AND MEASURES

Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms.

RESULTS

Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited.

CONCLUSIONS AND RELEVANCE

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

Cultural adaptations of cognitive behavioural therapy for Latin American patients: unexpected findings from a systematic review

The current literature extensively recommends making cultural adaptations to psychological therapies, in order to address the differences in values, beliefs and attitudes that patients from different ethnic groups might hold. Although this approach has shown positive outcomes in some settings, it is not well established yet whether such adaptations are needed for all therapies and in all cultures. Therefore, the main aim of this study was to systematically review the literature regarding culturally adapted and ‘conventional’ cognitive behavioural therapy (CBT) for Latin American patients, within Latin American and non-Latin American countries. Sixty empirical studies regarding the effectiveness of culturally adapted and conventional CBT were included in this review. The included studies were carried out in Latin American and non-Latin American countries. The information from all studies was synthesized and assessed, including intervention effect sizes, patient retention rates, methodological quality of the papers, and the type of cultural adaptation made to the therapy. There were no differences between the sets of studies in terms of effectiveness, retention rates, methodological quality, or proportion of statistically significant interventions. Most of the cultural adaptations were peripheral or unspecified. The evidence to date indicates that both conventional and culturally adapted CBT offer the same benefits for Latin American patients in terms of effectiveness and retention rates. Rather than focusing on cultural adaptations, clinicians are encouraged to improve the way they deliver CBT through training and supervision.

Key learning aims

(1)

Preventing Excess Gestational Weight Gain and Obesity in Pregnancy: the Potential of Targeting Psychological Mechanisms

PURPOSE OF REVIEW

Overweight and obesity are now the most common high-risk conditions in pregnancy in the United States and increase risk of adverse outcomes during pregnancy, delivery, and the postpartum. Importantly, excess gestational weight gain is highly predictive of maternal postpartum weight retention and risk of overweight and obesity in mothers and their children later in life. This makes pregnancy a unique window of opportunity in the fight against obesity across the lifespan. This narrative review critically evaluates research on the efficacy of interventions targeting excess gestational weight gain, highlighting the potential of targeting psychological mechanisms to facilitate positive weight-related behavior change specifically in pregnancy. The PUBMED and PsycInfo databases were searched for relevant articles, including meta-analyses, systematic reviews, and randomized controlled trials with the primary or secondary aim of reducing gestational weight gain.

RECENT FINDINGS

There is currently no gold standard for preventing excess gestational weight gain, especially in women with pre-pregnancy overweight and obesity. Existing interventions primarily target diet and physical activity but lack broad empirical support and typically have only modest effects on weight gain in pregnancy, with few successfully preventing excess weight gain. Furthermore, interventions that successfully target gestational weight gain have minimal positive impact on weight- and diet-related maternal and fetal health outcomes. A growing evidence points to the utility of targeting psychological mechanisms in the prevention of excess gestational weight gain, including cognitive and affective factors, food cravings, and self-efficacy. Given the lack of broad evidence to support the efficacy of interventions targeting diet and physical activity, there is a notable need for research to develop and evaluate interventions targeting psychological factors that could positively impact diet- and weight-related behavioral change in pregnancy.

Impact of preconception, pregnancy, and postpartum culinary nutrition education interventions: a systematic review

CONTEXT

Frequent consumption of home-prepared meals is associated with higher diet quality in children and adults. Therefore, increasing the culinary skills of women and couples during their childbearing years may be an effective strategy for the prevention of overweight and obesity.

OBJECTIVE

To determine the impact of culinary nutrition-education interventions for women with or without their partners during preconception, pregnancy, or postpartum (PPP) on parental cooking skills, nutrition knowledge, parent/child diet quality, or health outcomes.

DATA SOURCES

Eligibility criteria were defined using a PICOS framework. A systematic search strategy was developed to identify eligible studies and was implemented in 11 electronic databases. Reference lists of selected systematic reviews were manually searched for additional studies.

DATA EXTRACTION

Study characteristics and outcomes were extracted from eligible studies by 1 reviewer and checked by a second reviewer.

DATA ANALYSIS

A narrative synthesis of the findings of eligible studies was prepared including descriptive statistics. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and Synthesis Without Meta-Analysis in systematic reviews reporting guideline.

RESULTS

A total of 6951 articles were identified from the search strategy and 31 studies during pregnancy or postpartum were included. By category, the number of studies with a favorable outcome per total number of studies measuring outcome were as follows: parental food/cooking skills (n = 5 of 5), nutrition knowledge (n = 6 of 11), parent/child diet quality (n = 10 of 19), infant feeding (n = 6 of 11), eating behavior (n = 2 of 5), maternal (n = 2 of 5) and child anthropometry (n = 6 of 10), mental health and development n = (2 of 3), and clinical indictors (n = 1 of 1).

CONCLUSIONS

Culinary nutrition-education interventions during pregnancy and the postpartum period show promise in improving cooking skills, diet quality, and a variety of health-related outcomes. The precise effect of these interventions during PPP is limited by the quality and heterogeneity of study designs to date.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020154966.

Changing behaviour in pregnant women: A scoping review

OBJECTIVES

Behaviour change programmes (BCPs) for pregnant women are frequently implemented as part of health promotion initiatives. At present, little is known about the types of behaviour change programmes that are being implemented and whether these programmes are designed and delivered in accordance with the principles of high quality maternity care. In this scoping review, we provide an overview of existing interventions related to behaviour change in pregnancy with a particular emphasis on programmes that include empowerment components to promote autonomy and woman-led decision-making.

METHODS

A systematic search strategy was applied to check for relevant papers in August 2017 and again in October 2018.

RESULTS

Thirty studies met the criteria for inclusion. These studies addressed weight management, smoking cessation, general health education, nutrition, physical activity, alcohol consumption and dental health. The main approach was knowledge gain through education. More than half of the studies (n = 17) included three or more aspects of empowerment as part of the intervention. The main aspect used to foster women`s empowerment was skills and competencies. In nine studies midwives were involved, but not as programme leaders.

CONCLUSIONS

Education for knowledge gain was found to be the prevailing approach in behaviour change programmes. Empowerment aspects were not a specific focus of the behaviour change programmes. This review draws attention to the need to design interventions that empower women, which may be beneficial through their live. As midwives provide maternal healthcare worldwide, they are well-suited to develop, manage, implement or assist in BCPs.

Changes in Maternal Body Mass Index, Weight Gain and Outcome of Singleton Pregnancies from 2000 to 2015: A Population-based Retrospective Cohort Study in Hesse/Germany

Introduction Maternal obesity and excessive gestational weight gain (GWG) affect the outcomes of women and their offspring. Our aim was to evaluate population-based data from Germany.

Material and Methods Data from 583 633/791 514 mother-child pairs obtained from the perinatal database in Hesse for the period from 2000 to 2015 were used after excluding incomplete or non-plausible datasets. Early-stage pregnancy maternal body mass index (BMI) and GWG were evaluated. Significant outcome changes were calculated using linear or logistic regression models.

Results The mean maternal age increased from 29.9 to 31.28 years; GWG increased from 445.1 to 457.2 g/week (p < 0.01). Similarly, rates for both overweight and obesity rose from 31.5 to 37.5% (p < 0.001). Cesarean section rates rose from 22.8 to 33.2% (p < 0.001) and rates of postpartum hemorrhage increased from 0.6 to 1% (p < 0.001). There was no significant change in the rates for stillbirth or perinatal mortality (p = 0.92 and p = 0.53 respectively), but there was an increase in the rates of admissions to neonatal intensive care units from 7.8 to 9.5% (p < 0.0001). The percentage of newborns with an Apgar score of < 7 at 5 minutes increased from 1 to 1.1% (p < 0.01) and the rate of neonates with an umbilical artery pH of < 7.1 rose from 1.7 to 2.4% (p < 0.01).

Conclusions In just 15 years, pre-pregnancy BMI and GWG rates of women with singleton pregnancies have increased, and this increase has been accompanied by a significant rise in the rate of cesarean sections and a significant worsening of short-term maternal and neonatal outcomes. It is time to discuss the risks and the short-term and more worrying long-term consequences for mothers and their offspring and the future impact on our healthcare system.

Supporting women of childbearing age in the prevention and treatment of overweight and obesity: a scoping review of randomized control trials of behavioral interventions

BACKGROUND

Women of childbearing age are vulnerable to weight gain. This scoping review examines the extent and range of research undertaken to evaluate behavioral interventions to support women of childbearing age to prevent and treat overweight and obesity.

METHODS

Eight electronic databases were searched for randomized controlled trials (RCT) or systematic reviews of RCTs until 31st January 2018. Eligible studies included women of childbearing age (aged 15-44 years), evaluated interventions promoting behavior change related to diet or physical activity to achieve weight gain prevention, weight loss or maintenance and reported weight-related outcomes.

RESULTS

Ninety studies met the inclusion criteria (87 RCTs, 3 systematic reviews). Included studies were published from 1998 to 2018. The studies primarily focused on preventing excessive gestational weight gain (n = 46 RCTs, n = 2 systematic reviews), preventing postpartum weight retention (n = 18 RCTs) or a combination of the two (n = 14 RCTs, n = 1 systematic review). The RCTs predominantly evaluated interventions that aimed to change both diet and physical activity behaviors (n = 84) and were delivered in-person (n = 85).

CONCLUSIONS

This scoping review identified an increasing volume of research over time undertaken to support women of childbearing age to prevent and treat overweight and obesity. It highlights, however, that little research is being undertaken to support the young adult female population unrelated to pregnancy or preconception.

The role of biocultural approaches in assessing interventions for maternal weight and gestational weight gain

Public health and other researchers express growing concern for the role of maternal adiposity and gestational weight gain in driving the obesity epidemic and health disparities based on race and class. Biocultural scholars must continue to contribute to conversations on how best to address issues of population health including the developmental context of obesity, drawing from both evolutionary and social theory. I discuss a number of intervention studies designed to address gestational weight gain in low-income and minority women and consider the degree to which they address the social, political, and economic context, and developmental history of mothers. I further examine the potential for these interventions, focused on the individual behavior of mothers, to contribute to stigma based on socially defined race, class, and body shape and size, and to draw attention away from the powerful economic interests that contribute to and benefit from the obesity epidemic. I end with a discussion of the value of developmental systems theory for thinking critically about obesity and other health interventions.

Sociocultural and interpersonal influences on latina women's beliefs, attitudes, and experiences with gestational weight gain

Latinos are the largest and fastest-growing minority group in the U.S., and Latina women represent the largest portion of minority births, having the highest birth rate in the U.S. for over 20 years. In addition, Latina women are at increased risk of entering pregnancy being overweight or having obesity and gaining excess gestational weight. Excess gestational weight gain (GWG) has short- and long-term adverse health outcomes for the woman and her child. Although culturally tailored interventions show promise toward promoting healthy GWG among Latina women, findings from current interventions have had mixed results, suggesting the need for further tailoring to meet the needs of this heterogeneous population group. This qualitative study was designed to explore first-time pregnant, low-income Latina women’s beliefs, attitudes, and experiences with GWG. The study employed qualitative research using semi-structured interviews conducted with 23 first-time pregnant Latina women between 22 and 36 weeks of gestation. Interviews were conducted by trained bilingual staff, transcribed verbatim, and analyzed using thematic analysis. Results showed that participants were uncertain if their GWG was within a healthy range. Although the majority of participants knew that GWG should be limited, they were not sure what the amount should be. In addition, the majority of participants reported attitudes of acceptance of and resignation to excessive GWG as being part of pregnancy. Several women appeared to believe that they did not have control over their weight gain during pregnancy. Moreover, analysis identified that sociocultural and interpersonal factors such as social support influence the beliefs, attitudes, and experiences with GWG of the low-income, majority immigrant Latina women who participated in this study. Study findings can be used to further tailor prenatal care practices and interventions aimed at altering modifiable risk factors associated with excess GWG among Latinas. Future interventions designed for low-income, immigrant Latina women that consider sociocultural influences on women’s beliefs and attitudes related to GWG, as well as the influence of social support networks on women’s health behaviors during pregnancy, will likely be more effective in preventing excessive GWG.

A Scoping Review of Positive Lifestyle and Wellness Interventions to Inform the Development of a Comprehensive Health Promotion Program: "HealthPro"

Background. Lifestyle medicine has emerged as a transformational force in mainstream health care. Numerous health promotion and wellness programs have been created to facilitate the adoption of increased positive, modifiable health behaviors to prevent and lessen the effects of chronic disease. This article provides a scoping review of available health promotion interventions that focus on healthy adult populations in the past 10 years. Methods. We conducted a scoping review of the literature searching for health promotion interventions in the past 10 years. Interventions were limited to those conducted among healthy adults that offered a face-to-face, group-based format, with positive results on one or more health outcomes. We then developed a new health promotion intervention that draws on multiple components of included interventions. Results. Fifty-eight articles met our inclusion criteria. Physical activity was the primary focus of a majority (N = 47) of articles, followed by diet/nutrition (N = 40) and coping/social support (N = 40). Conclusions. Efficacious health promotion interventions are critical to address the prevention of chronic disease by addressing modifiable risk factors such as exercise, nutrition, stress, and coping. A new intervention, discussed is this article, provides a comprehensive approaches to health behavior change and may be adapted for future research.

Mental and physical support (MAPS) for moms: preliminary findings from a prenatal health support program

BACKGROUND

The low incidence of exercise during pregnancy and the high rates of prenatal depression indicate more opportunities are needed for mothers to engage in exercise and obtain health-related support and education. MAPS (mental & physical support) was developed to support mothers' psychological and physical health during pregnancy. MAPS consisted of physical activity classes 2×/week followed by either a speaker or group discussion regarding a parenting or health-related topic. The primary purpose of this study was to determine if the format was feasible prior to developing a main scale randomized trial.

METHODS

Program measurements included a pre/post survey, post-program focus group, attendance logs and scales for exercise, self-efficacy, and social support.

RESULTS

Findings indicated the program format is well-received by participants; however, issues in attendance warrant program format alterations. Further, larger scale studies and the addition of a control group are needed.

CONCLUSION

This format offers practitioners an effective strategy for supporting pregnant women's physical and psychological health.

PEARLS randomized lifestyle trial in pregnant Hispanic women with overweight/obesity: gestational weight gain and offspring birthweight

BACKGROUND

Inappropriate gestational weight gain (GWG) has been associated with adverse perinatal events. High rates of GWG have been reported among Hispanic women. Observational studies indicate that dietary and physical activity interventions during the prenatal period may improve maternal and infant health, but very few randomized trials have been conducted among high-risk overweight/obese Hispanic women. Accordingly, we conducted a lifestyle intervention among high-risk pregnant women and evaluated its impact on achieving appropriate GWG and on improving birthweight.

METHODS

Eligible overweight/obese women presenting at the University Hospital in Puerto Rico with a singleton pregnancy before 16 gestational weeks were recruited and randomized to lifestyle intervention (n=15) or control group (n=16). The lifestyle intervention focused on improving physical activity and diet quality and optimizing caloric intake. We evaluated the impact of the lifestyle intervention on achieving appropriate GWG and on infant birthweight. Poisson and linear regression analyses were performed.

RESULTS

The primary intent to treat analysis showed no significant effect on achievement of appropriate GWG/week through 36 weeks in the intervention group (4/15 women) when compared with the control group (3/16 women) (adjusted incidence rate ratio =1.14; 95% CI: 0.20, 6.67). Although not statistically significant, women in the intervention group (6/15) were 1.7 times more likely to achieve appropriate weekly GWG until delivery when compared with controls (4/16 women) (adjusted incidence rate ratio = 1.67; 95% CI: 0.40, 6.94). We observed lower adjusted birthweight-for-length z-scores in the intervention compared with the control group among male newborns with z-score difference -1.74 (-3.04, -0.43), but not among females -0.83 (-3.85, 2.19). These analyses were adjusted for age and baseline body mass index.

CONCLUSION

Although larger studies are required to determine whether women with obesity may benefit from prenatal lifestyle interventions targeting GWG, our results are suggestive of the intervention improving adherence to established Institute of Medicine guidelines.

Attenuating Pregnancy Weight Gain-What Works and Why: A Systematic Review and Meta-Analysis

Excessive maternal gestational weight gain (GWG) contributes to generational obesity. Our aim was to explore efficacy and intervention characteristics (trimester, duration, frequency, intensity, and delivery method) of interventions to prevent excessive GWG. CINAHL, Cochrane, EMBASE, LILACS, MEDLINE, PsycINFO, and Scopus were searched up to May 2018 (no date or language restrictions). Keywords and MeSH terms for diet, GWG, intervention, lifestyle, maternal, physical activity, and pregnancy were used to locate randomized-controlled trials (RCTs). The Cochrane Collaboration tool for assessing risk of bias was applied. Eighty-nine RCTs were included. Meta-analysis (60 trials) estimated that women in diet only (WMD: -3.27; 95% CI: -4.96, -1.58, p < 0.01), physical activity (PA) (WMD: -1.02; 95% CI: -1.56, -0.49, p < 0.01), and lifestyle interventions (combining diet and PA) (WMD: -0.84; 95% CI: -1.29, -0.39, p < 0.01) gained significantly less weight than controls. The three eHealth interventions favored neither intervention nor control (WMD: -1.06; 95% CI: -4.13, 2.00, p = 0.50). Meta-regression demonstrated no optimal duration, frequency, intensity, setting, or diet type. Traditional face to face delivery of weight management interventions during pregnancy can be successful. Delivery via eHealth has potential to extend its reach to younger women but needs further evaluation of its success.

Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation

BACKGROUND

Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.

OBJECTIVES

To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).

REVIEW METHODS

Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.

RESULTS

Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI -0.92 to -0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate -0.10 kg, 95% CI -0.14 to -0.06 kg) and multiparity (summary estimate -0.73 kg, 95% CI -1.24 to -0.23 kg).

LIMITATIONS

The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.

CONCLUSION

Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.

FUTURE WORK

The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003804.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

How to improve health literacy to reduce short- and long-term consequences of maternal obesity?

Aim: To demonstrate the global challenge of maternal obesity and to propose models to increase awareness and health literacy. Methods: The regional perinatal data base and the international literature were reviewed to demonstrate the rising rates of maternal overweight and obesity causing major public health problems in low and high-resourced countries. A preliminary systematic review analyzing interventions in maternal obesity and a fact box based on a recent Cochrane review on dietary interventions were performed. Results: Between 2000 and 2015, the regional rates of maternal overweight and obesity have significantly increased, and the rate of morbid maternal obesity has even doubled. Pregnant women were insufficiently informed about the health risks and international recommendations for weight gain associated with pre-pregnancy body mass index. Scientific publications and guidelines of professional boards have not yet interrupted the vicious cycle of transgenerational transfer of associated health risks for the offspring. For the first time we propose a fact box to translate the results from a Cochrane review about dietary interventions into a transparent information for health care providers and patients which could help to improve awareness. Conclusions: Improving health literacy and translating clinical science into models which are understandable by policy makers, health care providers and parents is a challenge mainly if health risks are modifiable during gestation and could prevent the increasing burden of obesity for future societies.

Family Support and Family Negativity as Mediators of the Relation between Acculturation and Postpartum Weight in Low-Income Mexican-Origin Women

BACKGROUND

Obesity presents a significant health concern among low-income, ethnic minority women of childbearing age.

PURPOSE

The study investigated the influence of maternal acculturation, family negativity, and family support on postpartum weight loss among low-income Mexican-origin women.

METHODS

Low-income Mexican-origin women (N=322; 14% born in the U.S.) were recruited from a prenatal clinic in an urban area of the Southwest U.S. Acculturation was assessed during a prenatal home visit (26-38 weeks gestation), and post-birth family support and general family negativity were assessed at 6 weeks postpartum. Objective maternal weight measures were obtained at five time points across the first postpartum year.

RESULTS

Higher acculturation predicted higher family support and family negativity. Higher family support predicted decreasing weight across the first postpartum year, and higher family negativity predicted higher weight at 6 weeks postpartum and increasing weight across the first postpartum year. In combination, family negativity and support mediated the impact of acculturation on postpartum weight gain.

CONCLUSIONS

Cultural and family-related factors play a significant role in postpartum weight gain and loss for low-income Mexican-origin women.

Maternal conception of gestational weight gain among Latinas: A qualitative study

OBJECTIVE

Interventions to support healthy gestational weight gain are often ineffective. The objective was to develop a model of how pregnant Latinas-who have a higher risk of poor maternal and neonatal weight-related outcomes-conceptualize healthy gestational weight gain, providing guidance for future interventions.

METHOD

Ten focus groups with 50 pregnant Latinas were conducted by a native Spanish-speaking female moderator. On the basis of participant responses, we used grounded theory to inductively develop a personal conceptual framework for gestational weight gain.

RESULTS

Commonly identified barriers to being active and healthy eating included negative emotions, body image, physical discomfort, low energy, and lack of motivation. Women identified sociocultural issues such as a sense of isolation from family (among immigrants) and the degree of perceived social support as important contributors to health behaviors. Two personal health schemas emerged from participant responses. The "mother-child health schema" describes the degree to which participants recognized the interrelatedness of health needs for baby and for themselves. The "attention to gestational weight gain schema" describes how a respondent's attention to and perceived importance of gestational weight gain influences health-related behaviors during pregnancy.

CONCLUSIONS

Women's sociocultural and interpersonal context influence weight-related behaviors through the lens of personal health schemas. Understanding how cognitive aspects relate to traditional behavioral determinants suggests several opportunities for intervention, such as focusing on healthy behaviors instead of numerical targets for healthy weight gain. Although derived from Spanish-speaking Latin-American women, these results may also be potential leverage points for other minority groups. (PsycINFO Database Record

Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials

Objective To synthesise the evidence on the overall and differential effects of interventions based on diet and physical activity during pregnancy, primarily on gestational weight gain and maternal and offspring composite outcomes, according to women's body mass index, age, parity, ethnicity, and pre-existing medical condition; and secondarily on individual complications.Design Systematic review and meta-analysis of individual participant data (IPD). Data sources Major electronic databases from inception to February 2017 without language restrictions.Eligibility criteria for selecting studies Randomised trials on diet and physical activity based interventions in pregnancy.Data synthesis Statistical models accounted for clustering of participants within trials and heterogeneity across trials leading to summary mean differences or odds ratios with 95% confidence intervals for the effects overall, and in subgroups (interactions).Results IPD were obtained from 36 randomised trials (12 526 women). Less weight gain occurred in the intervention group than control group (mean difference -0.70 kg, 95% confidence interval -0.92 to -0.48 kg, I²=14.1%; 33 studies, 9320 women). Although summary effect estimates favoured the intervention, the reductions in maternal (odds ratio 0.90, 95% confidence interval 0.79 to 1.03, I²=26.7%; 24 studies, 8852 women) and offspring (0.94, 0.83 to 1.08, I²=0%; 18 studies, 7981 women) composite outcomes were not statistically significant. No evidence was found of differential intervention effects across subgroups, for either gestational weight gain or composite outcomes. There was strong evidence that interventions reduced the odds of caesarean section (0.91, 0.83 to 0.99, I²=0%; 32 studies, 11 410 women), but not for other individual complications in IPD meta-analysis. When IPD were supplemented with study level data from studies that did not provide IPD, the overall effect was similar, with stronger evidence of benefit for gestational diabetes (0.76, 0.65 to 0.89, I²=36.8%; 59 studies, 16 885 women).Conclusion Diet and physical activity based interventions during pregnancy reduce gestational weight gain and lower the odds of caesarean section. There is no evidence that effects differ across subgroups of women.

Determinants of the self-efficacy of physical activity for maintaining weight during pregnancy: The application of the health belief model

INTRODUCTION

Pregnancy is one of the high-risk periods for women's health that the lack of attention to healthy behaviors such as weight control behaviors can lead to adverse consequences on the health of women and also the fetus. Therefore, the aim of this paper was to explore the determinants of weight control self-efficacy among pregnant women using Health Belief Model (HBM).

MATERIALS AND METHODS

In this cross-sectional study were enrolled 202 pregnant women referring to Health Care Center in Isfahan city, Iran. Sampling method was multistage random. A researcher-made instrument based on HBM structures was used after confirming the valid and reliable. Data were analyzed by software SPSS 21 and descriptive statistics were represented with (frequency, mean and standard deviation) and analytical (Pearson correlation, independent t and liner regression) at the significant level of <0.05.

RESULTS

The average age of participants was 27.80 ± 5.08. HBM structures were able explained 31% of variance of weight control self-efficacy. Also, of the studied structures, perceived benefits, perceived barriers were statistically significant predictors of weight control self-efficacy, within which perceived barriers (β = 0.391) was the most significant predictor.

CONCLUSION

The findings of current study showed that the HBM model could be as a suitable framework to identify effective factors for designing educational intervention to improve weight control behaviors among pregnant women.

Gestational Weight Gain: Results from the Delta Healthy Sprouts Comparative Impact Trial

Introduction. Delta Healthy Sprouts trial was designed to test the comparative impact of two home visiting programs on weight status, dietary intake, and health behaviors of Southern African American women and their infants. Results pertaining to the primary outcome, gestational weight gain, are reported. Methods. Participants (n = 82), enrolled early in their second trimester of pregnancy, were randomly assigned to one of two treatment arms. Gestational weight gain, measured at six monthly home visits, was calculated by subtracting measured weight at each visit from self-reported prepregnancy weight. Weight gain was classified as under, within, or exceeding the Institute of Medicine recommendations based on prepregnancy body mass index. Chi-square tests and generalized linear mixed models were used to test for significant differences in percentages of participants within recommended weight gain ranges. Results. Differences in percentages of participants within the gestational weight gain guidelines were not significant between treatment arms across all visits. Conclusions. Enhancing the gestational nutrition and physical activity components of an existing home visiting program is feasible in a high risk population of primarily low income African American women. The impact of these enhancements on appropriate gestational weight gain is questionable given the more basic living needs of such women. This trial is registered with ClinicalTrials.gov NCT01746394, registered 4 December 2012.

Assessing the Impact of De Novo Social Ties within Health Intervention Settings: New Questions for Health Behavior Intervention Research

Recent developments in the study of health and social networks have focused on linkages between health outcomes and naturally occurring social relations, such as friendship or kinship. Based on findings in this area, a new generation of health behavior intervention programs have been implemented that rely on the formation of new social relations among program participants. However, little is known about the qualities of these de novo social relations. We examined the social networks of 59 participants within a randomized controlled trial of an intervention designed to prevent excessive gestational weight gain. We employed exponential random graph modeling techniques to analyze supportive relationships formed between participants in the intervention arm, to detect unique effects of program participation on the likelihood of forming ties. Program participation had a positive effect on the likelihood of forming supportive social relations, however, in this particular timeframe we did not detect any additional effect of such relations on the health behaviors or outcomes of interest. Our findings raise two critical questions: do short-term group-level programs reliably lead to the formation of new social relations among participants; and do these relations have a unique effect on health outcomes relative to standard methods of health behavior intervention?