Mental disorders in motherhood according to prepregnancy BMI and pregnancy-related weight changes--A Danish cohort study

Overview of metabolomic aspects in postpartum depression

Along with the typical biochemical alterations that occur during pregnancy, certain metabolic changes might be associated with the development of several psychiatric disorders, including postpartum depression (PPD), which is the most common type of psychiatric disorder during pregnancy or first postpartum year, and it develops in about 15% of women. Metabolomics is a rapidly developing discipline that deals with the metabolites as the final products of all genetically controlled biochemical pathways, highly influenced by external and internal changes. The aim of this paper was to review the published studies whose results suggest or deny a possible association between the fine regulation of the metabolome and PPD, enabling conclusions about whether metabolomics could be a useful tool in defining the biochemical pathways directly involved in the etiology, diagnosis and course of PPD. Beside numerous hormonal changes, a lot of different metabolic pathways have been discovered to be affected in women with PPD or associated with its development, including alterations in the energy metabolism, tryptophan and amino acid metabolism, steroid metabolism, purine cycle, as well as neurotransmitter metabolism. Additionally, metabolomics helped in defining the association between PPD and the exposure to various endocrine disrupting metabolites during pregnancy. Finally, metabolome reflects different PPD therapies and exposure of fetus or breastfed infants to pharmacotherapy prescribed to a mother suffering from PPD. This review can help in creating the picture about metabolomics' broad application in PPD studies, but it also implies that its potential is still not completely used.

Dietary treatment postpartum in women with obesity reduces weight and prevents weight gain: a randomised controlled trial

BACKGROUND

Women with pre-pregnancy obesity have an increased risk of retaining or gaining weight postpartum and may benefit from weight loss treatment. However, evidence is lacking for weight loss strategies in women with BMIs in the higher obesity classes. A dietary treatment for postpartum weight loss resulted in a 10% weight reduction in lactating women with a mean BMI of 30 kg/m2. We aimed to examine the effects of this dietary treatment on changes in weight, markers of lipid and glucose metabolism, waist and hip circumference and postpartum weight retention (PPWR) in postpartum women with higher BMIs than tested previously.

METHODS

At baseline, approximately 8 weeks postpartum, 29 women with a mean (SD) BMI = 40.0 (5.2) kg/m2 were randomised to a 12-week dietary treatment (n 14) or to a control treatment (n 15). Measurements were made at baseline and after 3 and 12 months. Data was analysed using mixed model.

RESULTS

The mean weight change in the diet group was -2.3 (3.1) kg compared to 1.7 (3.1) kg in the control group after 3 months (P = 0.003) and -4.2 (5.6) kg compared to 4.8 (11.8) kg in the control group after 12 months (P = 0.02). The dietary treatment led to reduced waist circumference (P < 0.04) and PPWR (P < 0.01) compared to the control treatment at both time points. The treatment lowered fasting blood glucose at 12 months (P = 0.007) as the only effect on markers of lipid and glucose metabolism.

CONCLUSION

The dietary treatment postpartum reduced weight and prevented weight retention or weight gain in women with obesity.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov (NCT03579667) 06/07/2018. In a randomised, controlled trial, 29 postpartum women with obesity were allocated to a dietary treatment or a control treatment. The dietary treatment reduced weight and prevented postpartum weight retention or weight gain after 12 months. Reference: Adapted from "Randomized, Placebo-Controlled, Parallel Study Design (2 Arms, Graphical)", by BioRender.com (2022). Retrieved from https://app.biorender.com/biorender-templates .

Mental Health during the Interpregnancy Period and the Association with Pre-Pregnancy Body Mass Index and Body Composition: Data from the INTER-ACT Randomized Controlled Trial

Mental health problems and obesity are two common complications during pregnancy and postpartum. The preconception period is considered an appropriate period for prevention. Therefore, insights into interpregnancy mental health and the impact on weight and body composition are of interest to developing effective weight management strategies. The primary aim of this study is to assess the difference in women's mental health during the interpregnancy period and the association with pre-pregnancy body mass index (BMI) and body composition. The secondary aim is to study whether this association is affected by socio-demographic factors, interpregnancy interval and sleep. The study is a secondary analysis of the INTER-ACT e-health-supported lifestyle trial. Women were eligible if they had a subsequent pregnancy and mental health measurements at 6 weeks after childbirth and at the start of the next pregnancy (n = 276). We used univariate analyses to assess differences in mental health and performed regression analysis to assess their association with pre-pregnancy BMI and body composition at the start of the next pregnancy. Our results show a statistically significant increase in anxiety and depressive symptoms between 6 weeks after childbirth and the start of the next pregnancy (sSTAI-6 ≥ 40: +13%, p =≤ 0.001; GMDS ≥ 13: +9%, p = 0.01). Of the women who were not anxious at 6 weeks after childbirth (sSTAI < 40), more than one-third (39%) developed anxiety at the start of the next pregnancy (p =≤ 0.001). Regression analysis showed that sense of coherence (SOC-13) at the start of the next pregnancy was independently associated with women's pre-pregnancy BMI and fat percentage. We believe that the development of preconception lifestyle interventions that focus on both weight reduction and support in understanding, managing and giving meaning to stressful events (sense of coherence) may be of added value in optimizing women's preconception health.

Mental health after childbirth and the impact on postpartum weight retention and body composition. Data from the INTER-ACT randomized controlled trial

OBJECTIVE

To study the evolution of maternal mental health during the first year after childbirth in women with previous excessive gestational weight gain, and the relationship with postpartum weight retention and body composition.

METHODS

Anthropometric and mental health data of 505 women of the INTER-ACT RCT control group were collected and assessed using descriptive statistics and mixed model analyses.

RESULTS

At 6 weeks postpartum 28% of women reported depressive symptoms, 46% anxiety, 47% low sense of coherence and 48% low quality of life. From 6 weeks to 12 months postpartum there was a monthly increase (+0.38, p = .003) in anxiety and a monthly decrease (-0.39, p = .008) in quality of life. High levels of depressive symptoms at 6 weeks postpartum predicted higher body fat (+0.9%, p = .01) and higher waist circumference (+1.3 cm, p = .02) in the first year postpartum. High sense of coherence at 6 weeks postpartum predicted lower body fat (-0.8%, p = .01) the first year postpartum.

CONCLUSIONS

In women with a history of excessive gestational weight gain, the first year after childbirth is characterized by a high prevalence of mental health problems in which levels of anxiety and quality of life deteriorate over time. Moreover, high levels of depressive symptoms and low sense of coherence in the first weeks postpartum predict unfavourable body composition outcomes in the year after childbirth.

Pregestational overweight and obesity and symptoms of postpartum depression: Data from the Birth in Brazil Study

BACKGROUND

Relationship between pregestational overweight and obesity and symptoms of postpartum depression (PPD) has been documented in developed countries. In middle and low-income countries the studies are scarce and the pattern of findings is more mixed. Our objective is to assess the effect of pregestational overweight and obesity on development symptoms of PPD in a nationwide Brazilian study.

METHODS

The study included 23,894 puerperal women, from 2011 to 2012. The Edinburgh Postnatal Depression Scale (EPDS) was applied from 6 to 18 months postpartum, with ≥13 points as the cutoff. Classification of pregestational nutritional status followed the method recommended by the Institute of Medicine. Confounding variables were identified using directed acyclic graph (DAG), and propensity score estimated the effect of nutritional status on PPD symptoms.

RESULTS

Prevalence of PPD was 26.3%. Women with excess weight represented nearly 32% of the sample. In the crude analysis, women with pregestational obesity showed 23% higher odds of developing symptoms of PPD when compared to those with normal weight (OR=1.23 CI 95% 1.04-1.45). There was a loss of statistical significance after propensity score analysis (OR=1.14 CI 95% 0.91-1.42).

LIMITATIONS

The symptoms of PPD were measured in a single moment, and sensitivity analysis revealed the existence of omitted or non-measured variables potentially modifying these estimates.

CONCLUSIONS

Although we did not find a relationship between pregestational nutritional status and depressive symptoms, the results are important because of the problem's magnitude. Future studies should aim at a more comprehensive understanding of the complex relationship between the variables.

Effects of supervised exercise training during pregnancy on psychological well-being among overweight and obese women: secondary analyses of the ETIP-trial, a randomised controlled trial

OBJECTIVES

Women with high body mass index (BMI) have increased risk for symptoms of anxiety and depression during pregnancy and postpartum. In this prespecified secondary analysis from the exercise training in pregnancy trial, our aim was to examine effects of supervised exercise during pregnancy on psychological well-being in late pregnancy and postpartum among women with a prepregnancy BMI ≥28 kg/m².

DESIGN

Single-centre, parallel group, randomised controlled trial.

SETTING

University Hospital, Norway.

PARTICIPANTS

Ninety-one women (age 31.2±4.1 years, BMI 34.5±4.2 kg/m²), 46 in the exercise group, 45 in the control group, were included in the trial.

INTERVENTION

The exercise group was offered 3 weekly supervised exercise sessions (35 min of moderate intensity walking/running and 25 min of resistance training), until delivery.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Primary analyses were based on intention to treat, with secondary perprotocol analyses. To assess psychological well-being, we used the 'Psychological General Well-Being Index' (PGWBI) at inclusion (gestational week 12-18), late pregnancy (gestational week 34-37) and 3 months postpartum. We assessed postpartum depression using the 'Edinburgh Postnatal Depression Scale' (EPDS).

RESULTS

Numbers completed data collection: late pregnancy 72 (exercise 38, control 36), postpartum 70 (exercise 36, control 34). In the exercise group, 50% adhered to the exercise protocol. Baseline PGWBI for all women was 76.4±12.6. Late pregnancy PGWBI; exercise 76.6 (95% CI 72.2 to 81.0), control 74.0 (95% CI 69.4 to 78.5) (p=0.42). Postpartum PGWBI; exercise 85.4 (95% CI 81.9 to 88.8), control 84.6 (95% CI 80.8 to 88.4) (with no between-group difference, p=0.77). There was no between-group difference in EPDS; exercise 2.96 (95% CI 1.7 to 4.2), control 3.48 (95% CI 2.3 to 4.7) (p=0.55).

CONCLUSIONS

We found no effect of supervised exercise during pregnancy on psychological well-being among women with high BMI. Our findings may be hampered by low adherence to the exercise protocol.

TRIAL REGISTRATION NUMBER

NCT01243554.

Yummy Mummy - The ideal of not looking like a mother

BACKGROUND

Pregnancy and childbirth are important life experiences that entail major changes, both physically, psychologically, socially and existentially for women. Motherhood transition and the accompanying bodily changes involve expectations of body image that are simultaneously naturally and socially produced and culturally informed by public, private and professional discourses about motherhood transition.

PROBLEM

Much focus is levelled at the antepartum body in maternity services whereas the postpartum body seems left alone, although bodily dissatisfaction is of concern for many mothers, whose expectations of bodily appearance postpartum are sharp and explicit.

AIM

To explore Danish first-time mothers' experiences of their body postpartum, focusing on body image.

METHODS

Eleven first-time mothers participated in semi-structured interviews related to the postpartum body image. Data was analysed thematically.

FINDINGS

Four themes: (1) Reverting the body: on bouncing back and losing weight; (2) Picturing me: on standards of beauty and ideal bodies; (3) Redefining earlier self-images: on meta-reproachment of the body; (4) Idealisation of not looking like a mother: on societal pressure to think positively. Findings were discussed through the theoretical concepts by Scheper-Hughes and Lock: the body as both individual, social and political.

CONCLUSION

Despite nuanced reflections over the body as subject and object, women identified beauty as a personal trait dependent on visual appearance. Bodily beauty was identified as something individual, yet standardised. Women felt strengthened through motherhood but looking like a mother was not considered worth pursuing. To allow for women's contradictory perspectives, caregivers are advised to communicate reflexively about the postpartum body.

The association between body mass index and postpartum depression: A population-based study

BACKGROUND

Postpartum depression (PPD) reportedly affects between 6.5-19% of all new mothers. Identifying those at greatest risk for PPD has implications for prevention, early detection and intervention. While the relationship between extremes of body mass index (BMI) and depression has been frequently studied, the association between BMI and PPD is less understood.

METHODS

Prospective cohort of all women with live singleton births in Sweden 1997-2008. We calculated the relative risk (RR) for PPD in relation to each woman's BMI and depression history. PPD diagnosis was based on a clinical diagnosis of depression within the first postpartum year.

RESULTS

First trimester BMI measurements were available for 611,506 women. Low BMI (< 18.5) RR_adj = 1.52, [95% CI: 1.30-1.78] and high BMI (> 35) RR_adj = 1.23, [95% CI: 1.04-1.45] were associated with increased PPD risk. Women with a depression history had an increased risk with low BMI (RR_adj = 1.51, [95% CI: 1.17-1.95]).

LIMITATIONS

Only first births were analyzed, potentially underestimating PPD incidence. Clinical data from health registries offers limited resolution regarding the specificity of diagnoses and incomplete sensitivity if women do not seek care.

CONCLUSIONS

First trimester of pregnancy BMI is associated with PPD risk. This risk is further modified by depression history. While low BMI places all women at risk for PPD, being overweight increases risk of PPD only in women without a history of depression. Future research should explore potentially modifiable mechanisms involved in the relationship between PPD and BMI and should also examine interventional strategies for pregnant women at the extremes of BMI and/or with a depression history.

Association Between Antenatal and Postpartum Depression and Anxiety with Weight Retention 1 Year After Childbirth: A Longitudinal Study

This was an observational, longitudinal study investigated the association between anxiety and depression in trimesters of pregnancy and early postpartum with weight retention 1 year after childbirth. Sixty-two pregnant women aged 18-35 years with a BMI of 35 or higher and 245 pregnant women with normal BMI (BMI 18.5-24.9 kg/m²) were recruited at their initial prenatal visit in the health centers. The Edinburgh Postnatal Depression Scale (EPDS) and Beck Anxiety Inventory (BAI-II) were completed in five time points, the first, second, third trimester of pregnancy, 6-8 weeks and 12 months after delivery. Pre-pregnancy weight and weight retention at 1 year postpartum was measured. A significant relationship was found between first trimester (adjusted mean difference: aMD 3.416; 95% CI 1.392-5.441) and postpartum (aMD 3.042; 95% CI 0.538-5.547) depression as well as first trimester's anxiety (aMD 3.050; 95% CI 0.631-5.470) with weight retention at 1 year after childbirth.

Examining Nonparticipation in the Maternal Follow-up Within the Danish National Birth Cohort

A follow-up questionnaire on maternal health was distributed within the Danish National Birth Cohort (established in 1996-2002) 14 years after the index birth. Responses were obtained from 41,466 (53.2%) of 78,010 eligible mothers. To ensure the appropriate use of these data, the possibility of selection bias due to nonparticipation had to be evaluated. We estimated 4 selected exposure-outcome associations (prepregnancy weight-depression; exercise-degenerative musculoskeletal conditions; smoking-heart disease; and alcohol consumption-breast cancer). We adjusted for several factors associated with participation and applied inverse probability weighting. To estimate the degree of selection bias, we calculated relative odds ratios for the relationship between the baseline cohort and the subset participating in the Maternal Follow-up. Participating women were generally healthier, of higher social status, and older than the baseline cohort. However, selection bias in the chosen scenarios was limited; ratios of the odds ratios ranged from -14% to 5% after adjustment for age, parity, social status, and, if the variable was not the exposure variable, prepregnancy body mass index, exercise, smoking, and alcohol consumption. Applying inverse probability weighting did not further reduce bias. In conclusion, while participants differed somewhat from the baseline cohort, selection bias was limited after factors associated with participation status were accounted for.

Impact of Pregestational Weight and Weight Gain during Pregnancy on Long-Term Risk for Diseases

OBJECTIVE

The aim of this study was to analyse the impact of maternal BMI at start of pregnancy and maternal weight gain during pregnancy on the risk of various diseases later in life.

METHODS

In a population-based cohort from southern Sweden, women with at least one delivery registered in the Swedish Medical Birth Register ten or more years before answering a health questionnaire were identified (n = 13,608). Complete data were found in 3,539 women.

RESULTS

Women with BMI >25 at start of pregnancy had increased risk of developing obesity (OR 21.9), diabetes (OR 6.4), cardiac disease (OR 2.7), endocrine diseases (OR 2.3), and other morbidity (OR 1.4), compared with women of normal weight. A high weight gain (>15 kg) during pregnancy was associated to later risk of overweight (OR 2.0) and obesity (OR 2.2), but not diabetes, cardiac disease, or endocrine diseases. A positive association was found between low weight gain and the risk of developing psychiatric disorders (OR 1.6).

CONCLUSIONS

A high BMI at start of pregnancy significantly increased the risk of several diseases later in life. However, a high weight gain during pregnancy was only significant for future overweight and obesity. These findings have implications for both pregestational intervention and post gestational follow up of obese and overweight women.

Depressive symptoms in women's midlife in relation to their body weight before, during and after childbearing years

OBJECTIVE

This study aimed to examine how weight and weight changes related to pregnancy were associated with depressive symptoms 11-16 years after childbirth.

METHOD

We followed 16,998 first-time mothers from the Danish National Birth Cohort up till 16 years after birth and estimated associations between depressive symptoms and pre-pregnancy body mass index (BMI) (kg m-2), weight changes in different time periods, and BMI-adjusted waist circumference 7 years after birth (WCBMI, cm). Depressive symptoms were estimated by the Center for Epidemiologic Studies Depression 10-item scale. Multiple logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals.

RESULTS

Compared with normal-weight, we found that underweight, overweight and obesity were associated with greater odds of depressive symptoms (1.29, 1.24 and 1.73, respectively). Compared with weight change ±1 BMI unit during the total follow-up period, greater odds for depressive symptoms were observed with weight loss (OR 1.14, 0.96-1.36) or gain of 2-2.99 kg m-2 (OR 1.11, 0.92-1.33) or gain of ≥3 kg m-2 (OR 1.68, 1.46-1.94). WCBMI > 2.2 cm was associated with greater odds of depressive symptoms (OR 1.16, 0.99-1.36) than waist circumference as predicted by BMI.

CONCLUSION

Low and high pre-pregnancy BMI, weight changes and WCBMI larger than predicted were associated with more depressive symptoms in midlife.

Cortisol metabolism, postnatal depression and weight changes in the first 12 months postpartum

BACKGROUND & OBJECTIVES

Postnatal depression correlates with postpartum weight retention, and dysregulated cortisol metabolism is evident in depressed individuals. Cortisol metabolism, BMI and metabolic phenotype are robustly associated, but the role of cortisol metabolism in postnatal mental health and weight loss has never been examined.

DESIGN

A longitudinal observation.

PATIENTS

Forty nine healthy women with uncomplicated pregnancy.

MEASUREMENTS

BMI and urinary steroid metabolites at 1 week and 1, 3, 6 and 12 months postpartum. Validated urinary steroid metabolite ratios were measured to determine the activities of 11β-hydroxysteroid dehydrogenases (11β-HSD) that interconvert inactive cortisone and active cortisol and the 5α-reductases that clear cortisol to its inactive metabolites. Postnatal depression symptoms were measured at 1, 6 and 12 months.

RESULTS

Low 5α-reductase activity was associated with greater weight loss across the first year, independent of demographics, breastfeeding and depression. Postpartum BMI change was unrelated to postnatal depression at any time. Symptoms of postnatal depression were related to higher cortisol metabolite production at 12 months, independent of demographics and breastfeeding.

CONCLUSIONS

Greatest weight loss in the postpartum year was associated with lower conversion of cortisone to cortisol and lower conversion of cortisol to its metabolites, supporting previous work that demonstrates the facilitative role of lower 5α-reductase and 11β-HSD-1 in weight loss. Greater depression symptoms were associated with higher cortisol metabolite production rates. Whilst weight and mental health are both associated with dysregulation of the HPA axis, there may be different pathways towards depressed and obese phenotypes in healthy postpartum samples.

Body image mediates the depressive effects of weight gain in new mothers, particularly for women already obese: evidence from the Norwegian Mother and Child Cohort Study

Background

Multiple studies show that obesity and depression tend to cluster in women. An “appearance concern” pathway has been proposed as one basic explanation of why higher weights might lead to depression. The transition to motherhood is a life phase in which women’s body image, weight, and depressive risk are in flux, with average weight increasing overall during this period. Examination of how these factors interact from pre- to post-pregnancy provides a means to test how body image plays a key role, as proposed, in causally shaping women’s depressive risk.

Methods

Tracking 39,915 pregnant women in the Norwegian Mother and Child (MoBA) Cohort Study forward 36 months after their deliveries, we test the moderating and mediating effects of body image concerns on the emergence of new mothers’ depressive symptoms by using a binary logistic regression model with a discrete-time event history approach and mediation analysis with bootstrapping.

Results

For women with high pre-pregnancy body mass index (BMI), weight gain heightens their depressive symptoms over time. Body image concerns mediate the association between weight gain and the development of depressive symptoms regardless of weight status. However, the mediation effect is more evident for women with higher pre-pregnancy BMI. Conversely, better body image is highly protective against the transition to mild or more severe depressive symptoms among new mothers, but only for women who were not classified as obese prior to their pregnancies.

Conclusions

These findings support a role for body image concerns in the etiology of depressive symptoms during the transition to motherhood. The findings suggest body image interventions before or during pregnancy could help reduce risks of depression in the early postpartum period and well beyond.