The Associations of Weight Status and Body Attitudes with Depressive and Anxiety Symptoms Across the First Year Postpartum

The effectiveness of interventions on improving body image for pregnant and postpartum women: a systematic review of randomized clinical trials

BACKGROUND

Body image dissatisfaction, leading to a variety of negative emotions and adverse pregnancy or birth outcomes. Studies on body image interventions for pregnant and postpartum women have been reported, yielding mixed results. Existing evidence lacks a comprehensive review of the effectiveness of body image interventions for pregnant and postpartum women.

OBJECTIVE

The aim of this study was to systematically review interventions which aimed at improving body image during pregnancy and postpartum in women of childbearing age, and further to explore their effectiveness.

METHODS

A comprehensive literature search was conducted using electronic databases, including PubMed, Embase, Web of Science, Cochrane Library, CINAHL, SinoMed, CNKI, and Wanfang Database, to retrieve relevant studies. Body image was reported employing descriptive analysis, whereas the Cochrane Handbook tool was used to evaluate the quality and potential bias of each included study.

RESULTS

Following established inclusion and exclusion criteria, 11 studies were identified from an initial 1,422 records for further analysis, involving 1290 participants. This systematic review grouped body image interventions into lifestyle interventions and psychological interventions based on their content. These interventions yielded more pronounced positive effects on improving body image in pregnant and postpartum women when compared to control groups. And, the statistical difference on psychological interventions is more significant on the whole.

CONCLUSIONS

Our work offers a comprehensive overview of the effectiveness of body image interventions for pregnant and postpartum women. Psychological interventions are considered to be a suitable measure to improve body image for pregnant or postpartum women. Additional research and practical applications are recommended to enhance the mental health and well-being of perinatal women.

TRIAL REGISTRATION

PROSPERO registry: CRD42024531531.

Pregorexia: a systematic review and meta-analysis on the constructs of body image dissatisfaction and eating disturbances by gestational age in the peripartum

PURPOSE

Pregorexia is a phenomenon posited to occur in the peripartum, characterized by an attempt to counter pregnancy's physiological changes in body shape through reduced calorie intake or increased physical activity.

METHODS

In this pre-registered systematic review and meta-analysis, body image dissatisfaction and eating psychopathology in the peripartum according to gestational age were formally assessed. PubMed was searched up to May 2023. Selection criteria were represented by studies on body image concerns or eating psychopathology in the peripartum (up to 1 year after delivery). The population needed to include women from the general population or among patients with a history of (or current) eating disorder. For the meta-analysis, 17 studies were included: 10 for body image dissatisfaction (2625 individuals overall), 7 for eating behaviors (2551 individuals overall). The interplay between body image and the following themes was examined in depth: the adoption of breastfeeding, peripartum depression, sociocultural influences on body image, sexual disturbances, experiencing or reporting an altered food intake.

RESULTS

Progressive dissatisfaction with body image during pregnancy by gestational age was observed, stably elevated for at least 12 months postpartum. Eating psychopathology was observed as elevated only at 12 months in the postpartum, but not during pregnancy.

DISCUSSION

The current work offers normative values of body image satisfaction and eating psychopathology in the peripartum by gestational age. The relevance of current results was discussed, in order to inform both current clinical practice and future public policies.

LEVEL OF EVIDENCE

Level I-Evidence obtained from: systematic reviews and meta-analyses.

The relationship between body dissatisfaction and postpartum depressive symptoms: A cross-sectional study

BACKGROUND

Women are least satisfied with their bodies during the postpartum period. There is a potential correlation between body dissatisfaction and depressive symptoms post delivery.The aim of this study was to explore the relationship of appearance and body areas satisfaction with depressive symptoms and examine the risk factors of depressive symptoms at 4-6 weeks postpartum.

METHODS

A total of 330 postpartum women participated in the study. Body dissatisfaction was measured using the Appearance Evaluation (AE) scale and Body Areas Satisfaction Scale (BASS), while depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), 4-6 weeks postpartum.

RESULTS

The prevalence of postpartum depressive symptoms among postpartum women was 40 % while 12.1 % of the women had thoughts of self-harm. Those with depressive symptoms or thoughts of self-harm had lower AE and BASS scores. Body dissatisfaction was significantly associated with factors such as postpartum weight retention of >5 kgs, no exercise, lower education level, and cesarean delivery. The three body areas that women were most dissatisfied with were weight, mid-torso, and lower torso. Education level, delivery method, and BASS score significantly predicted postpartum depressive symptoms.

LIMITATIONS

The selection bias might have occurred if those with depressive symptoms neglected routine postpartum care visits due to emotional distress.

CONCLUSIONS

The results indicate an association between body dissatisfaction and depressive symptoms at 4-6 weeks postpartum. Awareness of this relationship and focus on these risk factors will help healthcare providers plan peripartum programs to decrease the likelihood of postpartum depressive symptoms.

Measurement instruments for parental stress in the postpartum period: A scoping review

BACKGROUND

Parenting stress is a particular type of stress that is conceptualized as a negative psychological response to the numerous obligations associated with raising children. Despite a considerable increase in research on parenting stress, little attention has been given to the ways parenting stress are measured.

OBJECTIVES

This scoping review aimed to provide an overview of available instruments measuring parental stress and to describe their psychometric properties.

METHODS

We conducted a scoping review in accordance with international guidelines for scoping reviews. The main search strategy was searches in seven electronic databases. Pairs of reviewers selected relevant studies based on predetermined inclusion and exclusion criteria. Studies had to report one or more psychometric properties of an instrument measuring stress in parents with children 0-12 months. For each included study, we collected information relevant to the review question, guided by the COnsensus based Standards for the selection of health status Measurement INstruments (COSMIN). Finally, we collated, summarized, and reported the findings descriptively.

RESULTS

From 2164 unique record, 64 studies from 24 countries were included. They described 15 instruments, of which four were generic and eleven parental-specific self-administered instruments. Only two studies examined parental stress among fathers. Eleven of the studies were validation studies, but they only described seven of the 15 instruments. Internal consistency was the only information provided by 73.4% of the included studies. None of the instruments had information on all measurement properties as per the COSMIN criteria, and there was no information about measurement error, responsiveness, or interpretability for any of the 15 instruments.

DISCUSSION

There are presently 15 instruments with some associated psychometric information being used to measure parental stress among parents with young children, but the amount of information on the instruments' psychometric properties is slight. There is a need for further research.

The Association between Weight-related Variables and Postpartum Depressive Symptoms

Objectives: Postpartum depressive symptoms (PPDS) are common, and weight-related variables may be risk factors. In this study, we examined associations between weight-related variables and PPDS in postpartum women. Methods: Participants who gave birth within the past 12 months completed an online survey assessing various weight-related variables and PPDS. We examined associations between weight-related variables and PPDS using regression models. Results: Participants (N=315) were 30.1±3.9 years of age and 5.6±3.7 months postpartum. A majority were white (96.2%), married (87.9%), and had a bachelor's degree or higher (70.5%). Having a higher pre-pregnancy body mass index (BMI) and current BMI, lower weight loss at 6 months postpartum, and substantial postpartum weight retention were associated with higher PPDS. There was no relationship between total gestational weight gain, IOM weight gain category, excess weight gain, postpartum weight retention, and pre-pregnancy-to-postpartum change in BMI, and postpartum depressive symptoms. Conclusions: Understanding factors associated with postpartum depressive symptoms can help to develop and implement appropriate screenings/follow-ups and interventions among those at greatest risk. Given the potential connection to PPDS, there is a need for interventions aimed at promoting healthy pre-conception weight and helping women to lose excess pregnancy weight during the postpartum period.

Practice nurse-supported weight self-management delivered within the national child immunisation programme for postnatal women: a feasibility cluster RCT

BACKGROUND

Pregnancy is a high-risk time for excessive weight gain. The rising prevalence of obesity in women, combined with excess weight gain during pregnancy, means that there are more women with obesity in the postnatal period. This can have adverse health consequences for women in later life and increases the health risks during subsequent pregnancies.

OBJECTIVE

The primary aim was to produce evidence of whether or not a Phase III trial of a brief weight management intervention, in which postnatal women are encouraged by practice nurses as part of the national child immunisation programme to self-monitor their weight and use an online weight management programme, is feasible and acceptable.

DESIGN

The research involved a cluster randomised controlled feasibility trial and two semistructured interview studies with intervention participants and practice nurses who delivered the intervention. Trial data were collected at baseline and 3 months later. The interview studies took place after trial follow-up.

SETTING

The trial took place in Birmingham, UK.

PARTICIPANTS

Twenty-eight postnatal women who were overweight/obese were recruited via Birmingham Women's Hospital or general practices. Nine intervention participants and seven nurses were interviewed.

INTERVENTIONS

The intervention was delivered in the context of the national child immunisation programme. The intervention group were offered brief support that encouraged self-management of weight when they attended their practice to have their child immunised at 2, 3 and 4 months of age. The intervention involved the provision of motivation and support by nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. The role of the nurse was to provide regular external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a record card in their child's health record ('red book') or using the online programme. The behavioural goal was for women to lose 0.5-1 kg per week. The usual-care group received a healthy lifestyle leaflet.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of a Phase III trial to test the effectiveness of the intervention, as assessed against three traffic-light stop-go criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme).

RESULTS

The traffic-light criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity. In the qualitative studies, participants indicated that the intervention was acceptable to them and they welcomed receiving support to lose weight at their child immunisation appointments. Although nurses raised some caveats to implementation, they felt that the intervention was easy to deliver and that it would motivate postnatal women to lose weight.

LIMITATIONS

Fewer participants were recruited than planned.

CONCLUSIONS

Although women and practice nurses responded well to the intervention and adherence to self-weighing was high, recruitment was challenging and there is scope to improve engagement with the intervention.

FUTURE WORK

Future research should focus on investigating other methods of recruitment and, thereafter, testing the effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12209332.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 49. See the NIHR Journals Library website for further project information.

Manipulating the sensation of feeling fat: The role of alexithymia, interoceptive sensibility and perfectionism

OBJECTIVE

Feeling fat reflects difficulties in processing emotions and is an important aspect of body image and eating disorders. The current study aimed to develop a novel social comparison manipulation to induce feeling fat and to explore personality traits that may increase an individual's vulnerability.

METHODS

At time 1254 healthy females (24.14 years, BMI = 23.77) completed the feeling fat subscale of the Body Attitudes Questionnaire, as well as self-report measures of alexithymia, interoceptive sensibility, physical appearance comparison and perfectionism online.

RESULTS

Greater tendency to feel fat was significantly associated with difficulty identifying and describing feelings (alexithymia), poorer interoceptive sensibility, higher socially-prescribed perfectionism, and greater engagement in physical appearance comparisons. At time 2, a subset of 107 participants (22.39 years, BMI = 23.85) were randomly assigned to a condition: negative social comparison, positive social comparison, negative general, or neutral (as a control). Participants in the negative social comparison condition reported significantly greater increases in feeling fat compared to the control condition, but only when they were also high in alexithymia or socially-prescribed perfectionism.

DISCUSSION

Current findings provide new insights into the potential mechanisms underpinning feeling fat and highlight how a novel social comparison manipulation can be used to induce the sensation of feeling fat.

The impact of pre-pregnancy BMI on maternal depressive and anxiety symptoms during pregnancy and the postpartum period: A systematic review and meta-analysis

BACKGROUND

Studies have reported conflicting results on the association between maternal pre-pregnancy weight and adverse mental health outcomes during pregnancy and the postpartum period. This systematic review and meta-analysis aim to provide the current state of evidence concerning the association between maternal pre-pregnancy BMI and the risk of antenatal and postnatal depressive and anxiety symptoms.

METHODS

PubMed, EMBASE, Web of Science and Scopus databases were searched from their inception through August 31, 2020. Observational studies assessing the association between maternal pre-pregnancy BMI and risk of depression and/anxiety during pregnancy and the postpartum period were included. We used random-and quality-effects meta-analyses to estimate risks. Subgroup, sensitivity and meta-regression analyses were performed.

RESULTS

Pre-pregnancy obesity was associated with a 33% increased risk of antenatal depressive symptoms (pooled OR = 1.33 [95% CI; 1.20-1.48]). The pooled ORs for the association between underweight, overweight and obesity and postnatal depressive symptoms were 1.71 [95% CI; 1.27 - 2.31], 1.14 [95% CI; 1.0 - 1.30] and 1.39 [95% CI; 1.23 - 1.57], respectively. Low to moderate level of between-study heterogeneity was noted. The association between pre-pregnancy BMI and perinatal anxiety symptoms remain uncertain.

CONCLUSIONS

Pre-pregnancy obesity was associated with an increased risk of maternal depressive symptoms both in pregnancy and the postpartum period. The findings suggest that women with both high and low pre-pregnancy weight may benefit from receiving mental health screening and interventions during prenatal care.

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.

Pregnancy-Related Weight and Postpartum Depressive Symptoms: Do the Relationships Differ by Race/Ethnicity?

Background: There are significant racial/ethnic disparities in the prevalence of postpartum depression. Prior research in the general population suggests that weight status is related to depression and that this relationship varies by race/ethnicity. However, few studies have investigated whether race/ethnicity moderates the relationship between pregnancy-related weight and postpartum depressive symptoms (PPDS). The objective of this study is to examine the relationship between pregnancy-related weight and maternal PPDS overall and by race/ethnicity. Materials and Methods: This study used data from the Early Childhood Longitudinal Study-Birth Cohort (n ≈ 6950). Ordinary least-squares and logistic regression was used to examine whether pregnancy-related weight, including preconception weight status and gestational weight gain (GWG), was associated with PPDS measured using the Center for Epidemiologic Studies-Depression Scale (CES-D). Stratified analyses were used to assess whether these relationships varied by race/ethnicity. Results: Preconception obesity (body mass index [BMI] ≥30 kg/m²) was associated with higher levels of PPDS (β = 0.601, 95% confidence interval [CI], 0.149-1.053). GWG adequacy was not associated with PPDS. Among non-Hispanic (NH) whites, preconception obesity was positively associated with PPDS (β = 1.016, 95% CI, 0.448-1.584). In contrast, among Hispanics, preconception overweight (25 kg/m² ≤ BMI <30 kg/m²) was associated with lower levels of PPDS (β = -0.887, 95% CI, -1.580 to -0.195). There were no statistically significant relationships between pregnancy-related weight and PPDS among NH black or Asian women, but both groups were significantly more likely than NH whites to report PPDS. Conclusion: Whether and how pregnancy-related weight is associated with PPDS varies by race/ethnicity. Addressing preconception weight could help reduce overall levels of PPDS among NH whites but would likely fail to mitigate racial/ethnic disparities in postpartum mental health.

An application of psychosocial frameworks for eating disorder risk during the postpartum period: A review and future directions

The postpartum period may be a particular window of vulnerability for eating disorder symptoms given changes to body shape and weight that women experience. However, no quantitative studies have identified risk factors for postpartum eating disorder symptoms, and current psychosocial frameworks of risk may be missing key elements unique to this period. This manuscript reviews existing quantitative and qualitative literature regarding the developmental trajectory of eating disorder symptoms during the perinatal period and proposes an application of three psychosocial models of eating disorder risk (objectification theory, the tripartite influence model of body image and eating disturbances, and social comparison theory) to the postpartum period. Drawing on quantitative and qualitative literature, this paper identifies novel postpartum-specific factors that should be included for consideration in psychosocial models (e.g., self-oriented body comparison and pressure to achieve a prepregnancy weight and shape). This review is the first to theorize potential postpartum-specific risk factors for postpartum eating disorder symptoms. Prior models of eating disorder risk omit key psychosocial factors that are unique to the postpartum period. Other limitations of prior research relate to measurement and methodology. This critical window of vulnerability has been largely ignored in the quantitative literature and necessitates further research.