Breast-feeding and postpartum weight retention: a systematic review and meta-analysis

Impact of breastfeeding on risk of glucose intolerance in early postpartum after gestational diabetes

Aims

To determine the impact of breastfeeding on the risk of postpartum glucose intolerance in women with gestational diabetes.

Methods

Sub-analysis of two multi-centric prospective cohort studies (BEDIP-N and MELINDA) in 1008 women with gestational diabetes. Data were collected during pregnancy and at a mean of 12 weeks postpartum. Multivariate logistic regression was used to estimate the effect of breastfeeding on glucose intolerance, with adjustment for ethnicity, education, income, professional activity and BMI.

Results

Of all participants, 56.3% (567) breastfed exclusively, 10.1% (102) gave mixed milk feeding and 33.6% (339) did not breastfeed. Mean breastfeeding duration was 3.8 ± 2.4 and 3.7 ± 2.1 months in the breastfeeding and mixed milk feeding groups (p=0.496). The rate of glucose intolerance was lower in both the breastfeeding [22.3% (126)] and mixed milk feeding [25.5% (26)] groups compared to the no breastfeeding group [29.5% (100)], with an adjusted OR of 0.7 (95% CI 0.5-1.0) for glucose intolerance in the breastfeeding group compared to no breastfeeding group and an adjusted OR of 0.7 (95% CI 0.4-1.2) for the mixed milk feeding group compared to the no breastfeeding group. Postpartum, breastfeeding women had a lower BMI, less often postpartum weight retention, lower fasting triglycerides, less insulin resistance and a higher insulin secretion-sensitivity index-2 than the mixed milk feeding and no breastfeeding group. The mixed milk feeding group was more often from an non-White background, had a lower blood pressure and lower fasting triglycerides compared to the no breastfeeding group.

Conclusions

Breastfeeding (exclusive and mixed milk feeding) is associated with less glucose intolerance and a better metabolic profile in early postpartum in women with gestational diabetes.

The impact of a lifestyle intervention on postpartum weight retention among US Hispanic women with overweight and obesity

Introduction

To evaluate the effect of a culturally-modified, motivationally-targeted, individually-tailored lifestyle intervention on postpartum weight retention among Hispanic women with overweight/obesity.

Materials and methods

Proyecto Mamá was a randomized controlled trial conducted in western Massachusetts (2014-2020). Hispanic women with overweight/obese pre-pregnancy BMI (n = 148) were randomized in early pregnancy to a Lifestyle Intervention (LI) or a Health & Wellness (HW) comparison arm. The LI was based upon theoretical concepts, used a low-cost, high-reach strategy, and focused on healthy exercise and diet with follow-up through 12-months postpartum. The primary outcome of change in weight was calculated as the difference between pre-pregnancy weight and 6-week, 6-month, and 12-month postpartum weight. The secondary outcome was achievement of 5 % weight reduction from pre-pregnancy weight. Retention was 68.2 % in the overall postpartum period and 31.0 % at 12-months.

Results

In intent-to-treat analyses, compared to the HW arm, there was no difference in postpartum weight retention at 6-weeks (0.0 kg, 95 % CI: -3.4, 3.5), 6-months (-1.8 kg, 95 % CI: -5.6, 2.0), or 12-months (-2.0 kg, 95 % CI: -7.0, 3.1). In a secondary complete case analysis, compared to the HW arm, the LI arm had 5.5 times higher odds of meeting the postpartum weight reduction goal (aOR = 5.5, 95 % CI: 1.7, 17.9) adjusting for pre-pregnancy weight.

Conclusions

A lifestyle intervention among at-risk Hispanic women with overweight/obesity had no overall impact on postpartum weight, but a beneficial impact among those who completed the trial. Future studies should focus on increasing the feasibility and acceptability of the intervention in this at-risk population.

Influence of Breastfeeding on the State of Meta-Inflammation in Obesity-A Narrative Review

Obesity has become an emerging health issue worldwide that continues to grow in females of reproductive age as well. Obesity, as a multisystem and chronic disease, is associated with metabolic inflammation, which is defined as chronic low-grade systemic inflammation mediated by, i.a., adipose tissue macrophages. Lactation has been proven to have a beneficial influence on maternal health and could help restore metabolic balance, especially in the state of maternal obesity. In this review, we aimed to analyze the influence of breastfeeding on chronic low-grade meta-inflammation caused by obesity. We performed a comprehensive literature review using the PubMed, Science Direct, and Google Scholar electronic databases. For this purpose, we searched for "metabolic inflammation"; "meta-inflammation"; "obesity"; "breastfeeding"; "fetal programming"; "energy metabolism"; "postpartum"; "immunity"; "immune system"; and "inflammation" keyword combinations. While the clinical impact of breastfeeding on maternal and offspring health is currently well known, we decided to gain insight into more specific metabolic effects of adiposity, lipid, and glucose homeostasis, and immunological effects caused by the activity of cytokines, macrophages, and other immune system cells. Further research on the immunological and metabolic effects of breastfeeding in obese patients is key to understanding and potentially developing obesity therapeutic strategies.

Latin American and the Caribbean Code Against Cancer 1st edition: Weight, physical activity, diet, breastfeeding, and cancer

In Latin America and the Caribbean a considerable proportion of the population have excess body weight, do not meet the recommendations of physical activity and healthy diet, and have suboptimal rates of breastfeeding. Excess body weight is associated with at least 15 cancer sites, physical activity protects against three cancers, with some evidence suggesting a protective effect for eight more cancer sites, and sedentary behavior probably increases the risk of five cancer sites. Fiber and wholegrains protect against colorectal cancer, high intake of fruits and vegetables could reduce the risk of aerodigestive cancers; processed and red meat increase the risk of colorectal cancer; and very hot beverages are associated with esophageal cancer. Moreover, sugar-sweetened beverages and ultra-processed foods are a convincing cause for excess body weight, increasing cancer risk through this pathway, with some emerging evidence suggesting also direct pathways. Breastfeeding protects against breast cancer, and could protect against ovarian cancer. Taking this evidence into account, the Latin America and the Caribbean Code Against Cancer recommends the general public to maintain a healthy body weight, be physically active and limit sedentary behavior, eat a healthy diet (eat plenty of vegetables, fruits, wholegrains and legumes; avoid sugar-sweetened beverages and processed meat; and limit ultra-processed foods, red meat and very hot beverages), and breastfeed. Moreover, the Latin America and the Caribbean Code Against Cancer also includes a set of public policy recommendations for cancer prevention to inform policy makers and civil society about the need of policies to shape healthy environments and create opportunities to facilitate the adoption of the recommendations directed to the public.

A Postpartum Weight Loss-focused Stepped-care Intervention in a Military Population: A Randomized Controlled Trial

OBJECTIVE

Postpartum weight retention is associated with adverse health among both civilian and military women.

PURPOSE

The current study evaluated a stepped-care weight management intervention, Moms Fit 2 Fight, adapted for use in a pregnant and postpartum military population.

METHODS

Active duty women and other TRICARE beneficiaries (N = 430) were randomized to one of three conditions: gestational weight gain only (GWG-only) intervention (n =144), postpartum weight loss only (PPWL-only) intervention (n =142), or a combined GWG + PPWL intervention (n = 144). Those participants who received the PPWL intervention (i.e., the PPWL-only and GWG+PPWL conditions) were combined consistently with the pre-registered protocol and compared to those participants who did not receive the PPWL intervention in the primary analyses. Primary outcome data (i.e., postpartum weight retention) were obtained at 6-months postpartum by unblinded data collectors, and intent-to-treat analyses were conducted.

RESULTS

Retention at 6-months postpartum was 88.4%. Participants who received the PPWL intervention retained marginally less weight (1.31 kg) compared to participants that received the GWG-only intervention (2.39 kg), with a difference of 1.08 kg (p = .07). None of the measured covariates, including breastfeeding status, were significantly associated with postpartum weight retention. Of the participants who received the PPWL intervention, 48.1% participants returned to their pre-pregnancy weight at 6-months postpartum, with no significant differences compared to those who received the GWG-only intervention.

CONCLUSIONS

A behavioral intervention targeting diet and physical activity during the postpartum period had a trend for reduced postpartum weight retention.

CLINICAL TRIAL INFORMATION

The trial is registered on clinicaltrials.gov (NCT03057808).

The relationship between pregnancy count and duration of breast-feeding with metabolic syndrome (Fasa Persian cohort study)

BACKGROUND

Changes that occur during pregnancy and after that during breastfeeding induce some symptoms similar to metabolic syndrome (MetS) risk factors. This study aims to determine the relationship between pregnancy, as well as the duration of breastfeeding and MetS controlling the effect of other risk factors like hypertension, glucose intolerance, triglyceride, central obesity, and reduction of high-density lipoprotein in women of Fasa Persian Cohort Study.

MATERIALS AND METHODS

In this cross-sectional study, 5015 women aged 35-70 years were investigated in the Sheshdeh region from 2016 to 2021, and the information related to the disease symptoms was collected through questionnaires, examinations, and laboratory tests. MetS was calculated based on two guidelines according to adult treatment panel III (ATP III) and international diabetes federation (IDF) methods. For reporting the data, the odds ratio with its 95% confidence interval was used. In order to eliminate the effect of confounders, logistic regression was used.

RESULTS

Prevalence of MetS showed a descending trend in women with up to two pregnancies and it reached 22.6% and 22.4% using ATPIII and IDF methods respectively, while with an increase in the number of pregnancies of more than two, MetS prevalence was ascending. The prevalence of MetS did not have any specific trend across various breastfeeding duration groups. Multivariate analysis approved that the odds ratio of developing MetS in comparison with women who had two pregnancies was significantly increasing trend when the pregnancy counts increased.

CONCLUSION

The chance of developing MetS based on both IDF and ATP III methods after adjustment for confounding effects would grow with an increase in the number of pregnancies to more than two and breast-feeding of more than seven years. It is recommended that women with more than two pregnancies or the long duration of breast-feeding women undergo a specialized examination to investigate and control MetS problems so that future diseases could be prevented.

Predictors of excess body weight concurrently affecting mother-child pairs: a 6 year follow-up

BACKGROUND

We examined the predictors of excess body weight (EBW) concurrently affecting mother-child pairs after delivery during 6 years of follow-up.

METHODS

Prospective cohort study conducted on 435 mother-child pairs. Data were collected at four time points: at birth in the maternity hospital; 1-2 years old, 4-5 years old and 6 years old at the participant's home. Poisson regression analysis was used to examine the predictors of maternal-child EBW: mothers with excessive gestational weight gain (GWG) and large-for-gestational age (LGA) baby (>90th percentile) at baseline and mothers with body mass index (BMI) ≥ 25 kg/m2 and a child > 85th percentile.

RESULTS

The adjusted analysis showed that the risk of mother-child pairs concurrently having EBW increased with increasing pre-pregnancy BMI (RR = 2.4 and RR = 3.3 for pre-pregnancy BMI 25-30 and ≥30 kg/m2, respectively, P < 0.01). Excessive GWG and LGA infants were also significant predictors of EBW concurrently affecting mother-child pairs (RR = 2.2 and RR = 2.3, respectively, P < 0.01).

CONCLUSION

Excessive pre-pregnancy BMI, excessive GWG and LGA status were strong predictors of EBW concurrently affecting mother-child pairs over 6 years of follow-up. Public policies must be established primarily before/during pregnancy to avoid an EBW cycle in the same family over the years.

Postpartum weight retention and its association with socio-demographic and obstetrics correlates: A cross-sectional hospital-based preliminary survey in India

BACKGROUND AND AIMS

Postpartum weight retention can predispose women to an elevated risk of obesity and associated complications. The study aims to assess the magnitude of postpartum weight retention and its association with socio-demographic and obstetrics correlates.

METHODS

A cross-sectional survey was carried out in February and March 2022 via telephonic interviews. Convenience sampling technique was used for recruiting postpartum women in first three months, four to six months and beyond six months post-delivery (date of delivery January 2021 to January 2022). Chi² test and regression analysis were employed to study the association of socio-demographic and obstetrics correlates with postpartum weight retention.

RESULTS

The final sample comprised 505 postpartum women with a mean age of 29 ± 4 years. The mean postpartum weight retention was 4.96 ± 3.64 kg, 5.38 ± 3.93 kg and 5.80 ± 3.95 kg in the first three months, four to six months and beyond six months post-delivery respectively. In the first three months, socio-economic status and gestational weight gain were associated with weight retention (p < 0.05). In four-six months, type of family, education qualification, and gestational weight gain were associated with weight retention (p < 0.05). Beyond six months post-delivery, gestational weight gain was associated with postpartum weight retention (p < 0.05).

CONCLUSION

The findings provide preliminary data on the magnitude of weight retention in Indian postpartum women. Postpartum women are at an increased risk of weight retention with the overall shift to a higher body mass index category as compared to the pre-pregnancy period. It is crucial to timely screen women at risk and implement weight management strategies.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

INTRODUCTION

Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.

METHODS

The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.

RESULTS

The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.

CONCLUSION

The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Associations of breastfeeding history with metabolic syndrome and cardiovascular risk factors in community-dwelling parous women: The Japan Multi-Institutional Collaborative Cohort Study

OBJECTIVE

The aim of the present study was to investigate the associations between breastfeeding and the prevalence of metabolic syndrome in community-dwelling parous women and to clarify whether the associations depend on age.

METHODS

The present cross-sectional study included 11,118 women, aged 35-69 years. Participants' longest breastfeeding duration for one child and their number of breastfed children were assessed using a self-administered questionnaire, and their total breastfeeding duration was approximated as a product of the number of breastfed children and the longest breastfeeding duration. The longest and the total breastfeeding durations were categorized into none and tertiles above 0 months. Metabolic syndrome and cardiovascular risk factors (obesity, hypertension, dyslipidemia, and hyperglycemia) were defined as primary and secondary outcomes, respectively. Associations between breastfeeding history and metabolic syndrome or each cardiovascular risk factor were assessed using multivariable unconditional logistic regression analysis.

RESULTS

Among a total of 11,118 women, 10,432 (93.8%) had ever breastfed, and 1,236 (11.1%) had metabolic syndrome. In participants aged <55 years, an inverse dose-response relationship was found between the number of breastfed children and the prevalence of metabolic syndrome; multivariable-adjusted odds ratios for 1, 2, 3, and ≥4 breastfed children were 0.60 (95% confidence interval [CI]: 0.31 to 1.17), 0.50 (95% CI: 0.29 to 0.87), 0.44 (95% CI: 0.24 to 0.84), and 0.35 (95% CI: 0.14 to 0.89), respectively. The longest and total breastfeeding durations of longer than 0 months were also associated with lower odds of metabolic syndrome relative to no breastfeeding history in participants aged <55 years. In contrast, all measures of breastfeeding history were not significantly associated with metabolic syndrome and cardiovascular risk factors in participants aged ≥55 years old.

CONCLUSIONS

Breastfeeding history may be related to lower prevalence of metabolic syndrome in middle-aged parous women.

Association of lactation with maternal risk of type 2 diabetes: A systematic review and meta-analysis of observational studies

AIM

To investigate the association between lactation and maternal risk of type 2 diabetes, including a potential graded association according to lactation duration.

METHODS

A systematic review and meta-analysis of observational studies that investigated the reported association between lactation (irrespective of duration, intensity or mode) and maternal risk of type 2 diabetes was conducted.

RESULTS

A total of 22 studies (17 cohort studies and five cross-sectional studies) were included in this systematic review, and 16 contributed to the meta-analysis. Studies that investigated the association of lactation with risk of type 2 diabetes in the first months after birth in women with gestational diabetes reported conflicting results. Studies with a longer follow-up showed a graded protective association for lactation and the risk of type 2 diabetes, with a potentially larger risk reduction in women with gestational diabetes than in those without gestational diabetes. Overall, ever versus never lactation was associated with a 27% lower risk of type 2 diabetes (RR 0.73, 95% CI [0.65, 0.83]). Each additional month of lactation was associated with a 1% lower risk of type 2 diabetes (RR 0.99, 95% CI [0.98, 0.99]). However, the overall quality of the studies was modest.

CONCLUSIONS

Lactation is associated with a significantly reduced risk of maternal type 2 diabetes over the life course, particularly in women with gestational diabetes. The protective effect seems to increase with longer duration of lactation. Further research is warranted to understand whether this association is modified by exposure to other risk factors.

The Association of Lactation Duration with Visceral and Pericardial Fat Volumes in Parous Women: The CARDIA Study

BACKGROUND

Lactation is associated with lower risks for cardiovascular disease in women. Organ-related adiposity, which plays significant roles in the development of cardiometabolic diseases, could help explain this observation. We evaluated the association of lactation duration with visceral (VAT) and pericardial (PAT) fat volumes in women.

METHODS

Data were obtained from 910 women enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study (1985-1986) without diabetes prior to pregnancy who had ≥1 birth during 25 years of follow-up and had VAT and PAT measured from computed tomographic scans in 2010-2011. Cumulative lactation duration across all births since baseline was calculated from self-reports collected at periodic exams.

RESULTS

At baseline, the average age of women (48% black, 52% white) was 24 ± 3.7 years. After controlling for baseline age, race, smoking status, body mass index, fasting glucose, family history of diabetes, fat intake, total cholesterol, physical activity, and follow-up covariates (parity, gestational diabetes), the mean fat volumes across categories of lactation [none (n = 221), 1-5 months (n = 306), 6-11 months (n = 210), and ≥12 months (n = 173)] were 122.0, 113.7 105.0, and 110.1 cm3 for VAT and 52.2, 46.7, 44.5, and 43.4 cm3 for PAT, respectively. Changes in body weight from the first post-baseline birth to the end of follow-up mediated 21% and 18% of the associations of lactation with VAT and PAT, respectively.

CONCLUSIONS

In this prospective study, longer cumulative lactation duration was associated with lower VAT and PAT volumes, with weight gain partially mediating these associations.

Reducing Postpartum Weight Retention: A Review of the Implementation Challenges of Postpartum Lifestyle Interventions

Postpartum weight retention (PPWR) is a strong predictor of obesity in later life with long term health consequences in women. Suboptimal lifestyle behaviours (e.g., diet and physical activity) contribute to PPWR. Postpartum lifestyle interventions are known to be efficacious in reducing PPWR; however, there are challenges to their successful implementation. To inform implementation, this narrative review provides an overview of the factors that contribute to PPWR, the efficacy of existing postpartum lifestyle interventions and key determinants of effective implementation using the Consolidated Framework for Implementation Research (CFIR) across intervention characteristics, implementation process, individual characteristics and outer and inner setting. We then suggest strategies to improve the translation of evidence into large-scale interventions that deliver on health impact in postpartum women. We have identified gaps that need to be addressed to advance postpartum lifestyle research, including the involvement of postpartum women and community members as key stakeholders for optimal reach and engagement, more complete reporting of intervention characteristics to optimize translation of evidence into practice, capacity building of health professionals and guidelines for postpartum lifestyle management.

Full Breastfeeding Modifies Anthropometric and Body Composition Indicators in Nursing Mothers

Background: It has been observed that breastfeeding mobilizes the deposits of fat that accumulate during pregnancy and promotes weight loss through energy expenditure. The purpose of this study was to demonstrate that full breastfeeding (FBF) reduces anthropometric and body composition indicators in women between the 8th and the 16th week postpartum. Methods: In a nonrandom cohort study, 170 mothers at the Hospital Civil de Guadalajara, Guadalajara, México, were enrolled: FBF 74, partial breastfeeding (PBF) 57, and human milk substitutes (HMS) 39. Anthropometric indicators and body composition were measured at the 8th and 16th week postpartum. We performed analysis of variance to compare body composition according to the type of feeding and paired Student's t-test to compare the changes from the 8th to 16th week postpartum. Results: We found that FBF mothers had a trend to lower arm fat area and triceps skinfold than PBF and HMS mothers at 8 and 16 weeks postpartum. We observed a decrease in weight (p = 0.004), weight/age index (p = 0.003), body mass index (p = 0.003), hip circumference (p = 0.037), and lean mass (p = 0.003) from 8 to 16 weeks postpartum in mothers who offered FBF. The mid-upper arm circumference, the arm total area, and their z-score increased in the three feeding groups. Conclusions: Our results show that FBF mothers had some lower adiposity from 8 to 16 weeks postpartum compared with the result observed among PBF mothers and those who utilized HMS.

Changes in maternal anthropometric measurements in the first postpartum month and associated factors

OBJECTIVE

Maternal anthropometry offers a rapid, inexpensive, and non-invasive method for assessing nutritional status during pregnancy. We aimed to assess the changes in maternal anthropometric measurements in the first month after delivery and to investigate the factors associated with longitudinal changes in maternal postpartum nutritional status.

DESIGN

This prospective longitudinal study included 147 mothers who were on the 5th postpartum day applied to outpatient clinics, from January 2018 through January 2020. Each mother completed a structured questionnaire and baseline anthropometric measurements were performed at the postpartum 5th day and re-evaluated at the end of the first month after delivery.

PARTICIPANTS

Mother-infant pairs (n = 147).

RESULTS

At the end of the first postpartum month, maternal body weight (relative change -5.1%, 95% CI: -5.6%;-4.6%), muscle mass ratio (-1.6%, 95% CI: -2.4%;-0.9%) and body fluid ratio (-2.4%, 95% CI: -3.1%;-1.7%) decreased, whereas fat mass ratio increased (10.3%, 95% CI: 9.0%;11.6%).There was a significant association between infants' feeding type and maternal BMI, weight, muscle mass ratio, body fluid ratio, triceps, and biceps skinfold thickness in mothers (p < .05). We also found a significant relationship between maternal smoke exposure and BMI, maternal weight, fat-mass ratio (p < .05).

CONCLUSIONS

There are some important alterations in maternal anthropometric parameters during the postpartum period. This study will help further our understanding of the factors influencing changes in maternal body composition after delivery.

Dietary patterns of Chinese puerperal women and their association with postpartum weight retention: Results from the mother-infant cohort study

Dietary intake may affect maternal health, but it remains unclear about puerperal dietary intake and its association with maternal health. This study investigated the dietary patterns and their related factors and association with postpartum weight retention (PPWR) in Chinese puerperal women. Participants were from the mother-infant cohort study, in which both mothers and infants were followed up from childbirth to the next 2 years, in seven cities around China. Maternal puerperal dietary patterns were derived by a food frequency questionnaire and principal component analysis (PCA) within 1 month postpartum. PPWR was assessed by the difference of weight at 42 days and 6 months postpartum minus the pre-pregnancy weight. Of 503 postpartum women, four dietary patterns were identified, including 'plant food' pattern (rice and vegetables as dominant foods), 'diverse' pattern (starchy roots, fruit, livestock meat and aquatic products), 'traditional northern' pattern (poultry, eggs and soup) and 'marine-flour' pattern (flour, coarse food grains and marine fish). The diverse pattern was associated with professional puerperal family care and counselling service (p < .05). PPWRs at 42 days and 6 months postpartum were 6.37 and 4.70 kg averagely. The plant food dietary pattern tended to be associated with higher 42-day PPWR (β = .105, p < .05), and diverse pattern was associated with lower 6-months PPWR (β = -.137, p < .05). Conclusively, this study presented four dominant dietary patterns in Chinese postpartum women and showed a lower PPWR in adherence to diverse dietary pattern. The results would provide evidence to furtherly guide dietary practice and improve maternal health.

Maternal obesity and its determinants: A neglected issue?

Maternal obesity is a global public health concern that affects every aspect of maternity care. It affects the short-term and long-term health of the mother and her offspring. Obese pregnant mothers are at an increased risk of developing complications during antenatal, intrapartum, and postnatal periods. Maternal complications include gestational diabetes mellitus, hypertensive disorder in pregnancy, pre-eclampsia and eclampsia, increased rate of cesarean delivery, pulmonary embolism, and maternal mortality; fetal complications include congenital malformation, stillbirth, and macrosomia. Moreover, both mother and infant are at an increased risk of developing subsequent non-communicable diseases and cardiovascular problems later in life. Several factors are associated with the likelihood of maternal obesity, including sociodemographic characteristics, obstetric characteristics, knowledge, and perception of health-promoting behavior. Gaining a sound understanding of these factors is vital to reaching the targets of Sustainable Developmental Goal 3-to reduce global maternal mortality and end preventable deaths of children under 5 years of age-by 2030. It is essential to identify pregnant women who are at risk of maternal obesity in order to plan and implement effective and timely interventions for optimal pregnancy outcomes. Importantly, maternal obesity as a significant pregnancy risk factor is largely modifiable.

Lifestyle information and access to a commercial weight management group to promote maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility RCT

Background

Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.

Objectives

The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.

Design

The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.

Setting

The setting was a single centre in an inner city setting in the south of England.

Participants

Participants were women with body mass index scores of > 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation.

Main outcome measures

Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.

Results

Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (> 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.

Limitations

The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.

Conclusions

It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women’s weight management as assessed at 12 months postnatally, with probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN39186148.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Relationship between maternal body mass index with the onset of breastfeeding and its associated problems: an online survey

Background

Obesity is a worldwide public health problem that demands significant attention. Several studies have found that maternal obesity has a negative effect on the duration of breastfeeding and delayed lactogenesis. The World Health Organization has classified Body Max Index (BMI) as normal weight (normoweight) (BMI:18.5–24.9), overweight (BMI:25–29.9), obesity grade I (30.0–34.9), obesity grade II (BMI: 35.0–39.9) and obesity grade III (BMI ≥ 40.0). The objective of this study is to describe the relationship between maternal BMI and breastfeeding rates, as well as breastfeeding-associated problems and discomfort in women assisted by the Spanish Health System.

Methods

To this end, a cross-sectional observational study aimed at women who have been mothers between 2013 and 2018 in Spain was developed. The data was collected through an online survey of 54 items that was distributed through lactation associations and postpartum support groups between March and June 2019. Five thousand eight hundred seventy one women answered the survey. In the data analysis, Crude Odds Ratios (OR) and Adjusted Odds Ratios (AOR) were calculated through a multivariate analysis through binary and multinomial regression.

Results

A linear relationship was observed between the highest BMI figures and the reduction of the probability of starting skin-to-skin contact (AOR for obesity type III of 0.51 [95% CI 0.32, 0.83]), breastfeeding in the first hour (AOR for obesity type III of 0.58 [95% CI 0.36, 0.94]), and exclusive breastfeeding to hospital discharge (AOR for obesity type III of 0.57 [95% CI 0.35, 0.94]), as compared to women with normoweight.

Conclusions

Women with higher BMI are less likely to develop successful breastfeeding than women with normoweight.

Mode of first delivery and postpartum weight retention at 1 year

BACKGROUND

The prevalence of obesity in the US has increased markedly in women in their reproductive years over the past 3 decades, partially due to higher rates of postpartum weight retention. This was a prospective cohort study that investigated mode of delivery as an independent risk factor for postpartum weight retention at 1 year postpartum.

METHODS

Data from 2500 first-time mothers, aged 18-35 with singleton pregnancies were included in this analysis. Postpartum weight retention was measured at 1 year after delivery and was defined as weight at 1 year compared to weight just before becoming pregnant. Logistic regression models assessed the association between mode of first delivery and subsequent weight retention of 10 pounds or more, adjusting for key confounders including pre-pregnancy body mass index, gestational weight gain, age, education, poverty status, smoking, race/ethnicity, gestational age, pregnancy complications, breastfeeding and exercise habits during pregnancy and in the first year after delivery.

RESULTS

At 12 months after delivery the women who had delivered by cesarean were more likely to have a postpartum weight retention of 10 pounds or more (27.9%), than those who had delivered vaginally (22.2%), unadjusted OR 1.35 (95% CI 1.11-1.65, p=.003). Even after controlling for confounding variables, mode of delivery remained significantly associated with postpartum weight retention of 10 pounds or more, adjusted OR 1.30 (95% CI 1.04-1.62, p=.02).

CONCLUSIONS

Cesarean delivery at first childbirth is associated with increased risk of weight retention of 10 pounds or more at 1 year postpartum.

Why young women gain weight: A narrative review of influencing factors and possible solutions

Significant weight gain occurs in women during young adulthood, which increases risk of diseases such as diabetes, cardiovascular disease, and many cancers. This review aims to inform future individually targeted weight gain prevention programmes and summarizes possible targets: key life events, mediators that influence energy intake and physical activity levels, and moderators that could identify groups of women at greatest risk. Life events affecting weight include pregnancy and motherhood, smoking cessation, marriage and cohabiting, attending university, and possibly bereavement. Research has identified successful methods for preventing weight gain associated with pregnancy and motherhood, which could now be used in practice, but evidence is inconclusive for preventing weight gain around other life events. Weight gain is mediated by lack of knowledge and skills around food and nutrition, depression, anxiety, stress, satiety, neural responses, and possibly sleep patterns and premenstrual cravings. A paucity of research exists into altering these to limit weight gain. Moderators include socioeconomic status, genetics, personality traits, and eating styles. More research is required to identify at-risk females and engage them in weight gain prevention. There is a need to address evidence gaps highlighted and implement what is currently known to develop effective strategies to limit weight gain in young women.

Parity, lactation, and long-term weight change in Mexican women

One post-partum behaviour that may be protective against post-partum weight retention and long-term weight gain among women of reproductive age is lactation because of its potential role in resetting maternal metabolism after pregnancy. However, most of the evidence focuses on weight retention at 6, 12, or 24 months post-partum, and data beyond 2 years after birth are sparse, and findings are inconclusive. Therefore, our aim was to assess the association of parity and mean duration of lactation per child with long-term weight change in Mexican women. We assessed the association of parity and mean duration of lactation per child with long-term weight change in 75,421 women from the Mexican Teachers' Cohort. Several multivariable regression models were fit to assess these associations. We also examined the non-linear association between duration of lactation and weight change using restricted cubic splines. We found that parous women (≥4 children) gained 2.81 kg more (95% CI [2.52, 3.10]) than did nulliparous women. The association between mean duration of lactation per child and weight change appeared to be non-linear. Women who breastfed on average 3-6 months per child had lower gain weight (-1.10, 95% CI [-1.58, -0.47 kg]) than had women who did not breastfeed. This association was linear up to 6 months of lactation per child. Our findings suggest that parity alters weight-gain trajectory in women and that lactation could reduce this alteration. These findings are important in the prevention of excessive weight gain through reproductive years and their future health implications.

Exposure to traffic noise and gestational weight gain and postpartum weight retention: a cohort study

OBJECTIVES

Transportation noise has been associated with markers of obesity. We aimed to investigate whether road traffic and railway noise were associated with weight gain during and after pregnancy.

METHODS

Among the women participating in the Danish National Birth Cohort, 74 065 reported on weight before and during the pregnancy (gestational week 30) and 52 661 reported on weight before and 18 months after pregnancy. Residential address history from conception to 18 months after pregnancy was obtained in national registers, and road traffic and railway noise were modelled for all addresses. Associations between noise and gestational weight gain (GWG) and postpartum weight retention (PPWR) were analysed using the linear and log-binomial regression.

RESULTS

A 10 dB(A) higher road traffic noise was associated with an increase in GWG of 3.8 g/week (95% CI 2.3 to 5.3) and PPWR of 0.09 kg (95% CI 0.02 to 0.16). For PPWR, this association seemed confined to women who were overweight (0.17 kg, 95% CI 0.02 to 0.32) or obese (0.49 kg, 95% CI 0.26 to 0.73) before pregnancy. Further adjustment by nitrogen dioxide reduced GWG risk estimates and slightly increased PPWR risk estimates. Railway noise ≥65 dB(A) was associated with an increase in GWG of 4.5 g/week (95% CI -2.7 to 11.6) and PPWR of 0.26 kg (95% CI -0.09 to 0.60) compared with levels <55 dB(A).

CONCLUSIONS

Our findings suggest that road traffic noise is associated with weight gain during and after the pregnancy, which adds to the literature linking transportation noise to adiposity.

Breastfeeding and postpartum weight loss

PURPOSE OF REVIEW

Postpartum weight retainment is common in women, increasing the long-term likelihood of overweight and/or obesity. On the other hand, breastfeeding entails a high energy cost that contributes to the total energy expenditure of the mother, increasing the chances of a negative energy equilibrium that could potentially lead to weight loss. This review explores this association as depicted in the latest literature available.

RECENT FINDINGS

Several studies reported a positive association between breastfeeding and postpartum weight loss while others reported no significant association. Several potential mechanisms, metabolic pathways and determinants have been described.

SUMMARY

Even though several studies support the potentially beneficial role of breastfeeding in postpartum weight loss, more studies with robust designs are needed to reach a reliable conclusion. Healthcare providers should encourage breastfeeding, not only for its health benefits for both the mother and the offspring but also for its potential role in weight loss.

Association between parity and persistent weight gain at age 40-60 years: a longitudinal prospective cohort study

OBJECTIVES

Physiological metabolic adaptations occur in the pregnant woman. These may persist postpartum and thereby contribute to an unfavourable cardiovascular disease (CVD) risk profile in parous women. The aim of the current study is to assess time-dependent changes of cardiometabolic health in parous women compared with nulliparous women.

DESIGN AND SETTING

We studied data of 2459 women who participated in the Prevention of Renal and Vascular End-stage Disease study, a population-based prospective longitudinal cohort for assessment of CVD and renal disease in the general population.

PARTICIPANTS

We selected women ≥40 years at the first visit, who reported no new pregnancies during the four follow-up visits. All women were categorised in parity groups, and stratified for age.

OUTCOME MEASURES

We compared body mass index (BMI), high-density lipoprotein (HDL) cholesterol, blood pressure as continuous measurements and as clinical relevant CVD risk factors among parity groups over the course of 6 years using generalised estimating equation models adjusted for age.

RESULTS

The BMI was significantly higher in women para 2 or more in all age categories: per child, the BMI was 0.6 kg/m² higher. corresponding with 1.5-2.0 kg weight gain per child. HDL cholesterol was significantly lower in women para 2 or more aged 40-49 and 50-59 years: per child, the HDL cholesterol was up to 0.09 mmol/L lower. Blood pressure did not differ among parity groups in any of the age categories.

CONCLUSIONS

Higher parity is associated with higher BMI, lower HDL cholesterol and a higher prevalence of cardiovascular risk factors, which is constant over time. These findings warrant for prospective research assessing determinants of cardiometabolic health at earlier age to understand the role of pregnancy in the development of CVD in women.

High-intensity breastfeeding improves insulin sensitivity during early post-partum period in obese women with gestational diabetes

AIM

To investigate whether high-intensity breastfeeding (HIB) reduces insulin resistance during early post-partum period in women with gestational diabetes (GDM), independent of post-partum weight change (PWC).

MATERIALS AND METHODS

In this multicentre prospective study, we included Japanese women with GDM who underwent a 75-g oral glucose tolerance test (OGTT) during early post-partum. We measured plasma insulin during OGTT to obtain a homeostasis model of assessment of insulin resistance (HOMA-IR). We defined the condition in which infants were fed by breastfeeding alone or greater than or equal to 80% of the volume as HIB, and other statuses, including partial and nonbreastfeeding, as non-HIB. We investigated the association between post-partum HOMA-IR and the breastfeeding status after adjusting for confounders including PWC.

RESULTS

Among 222 women with GDM who underwent the OGTT at 7.9 ± 2.3 weeks post-partum with a PWC of -7.8 ± 3.4 kg, although the rate of abnormal glucose tolerance (prediabetes and diabetes) did not differ between the groups (33% vs 32%), the HOMA-IR in the HIB women (n = 166) was significantly lower than that in the non-HIB women (n = 56) (1.12 ± 0.85 vs 1.72 ± 1.43, P = 0.0002). The effect of the HIB was independently associated with lower HOMA-IR after adjusting for confounders including PMC. However, the subgroup analysis according to their pre-pregnancy obesity states showed that the effect was seen only in the obese subjects (BMI ≥ 25).

CONCLUSIONS

In obese Japanese women with GDM, HIB has a significant effect in reducing insulin resistance during early post-partum, independent of the post-partum weight loss.

[Health effects of breastfeeding on the mother]

We evaluated the effect of breastfeeding on maternal health outcomes. We distinguished between long-term effects (breast carcinoma, ovarian carcinoma, endometrial carcinoma, osteoporosis, and type 2 diabetes mellitus) and short-term effects (lactational amenorrhea, postpartum depression, and postpartum weight change).Predominant breastfeeding increases the duration of lactational amenorrhea, which has a short-term effect on the reduction of fertility. There are many studies that show that breastfeeding is protective against breast, ovarian carcinoma, and endometrial carcinoma. The effects depend on the duration of breastfeeding. There is evidence that breastfeeding reduces the risk of type 2 diabetes and metabolic syndrome and cardiac diseases. However, an association between breastfeeding and bone mineral density or maternal depression or postpartum weight change was not clearly evident.

The Relationship Between Intuitive Eating and Postpartum Weight Loss

Objective Postpartum weight loss is challenging for new mothers who report limited time and difficulties following traditional weight loss methods. Intuitive eating (IE) is a behavior that includes eating based on physical hunger and fullness and may have a role in encouraging weight loss. The purpose of this study was to examine the relationship between IE and postpartum weight loss. Methods Women 12-18 months postpartum completed a questionnaire regarding weight changes surrounding pregnancy, exercise, breastfeeding and intuitive eating using the Intuitive Eating Scale. Latent growth curve modeling was utilized to determine the relationship between IE, breastfeeding, weight gain during pregnancy, and postpartum weight trajectories. Results Participants (n = 50) were 28.5 ± 4.9 years old, had an average pre-pregnancy BMI of 26.4 ± 6.8 and the majority were married, and non-Hispanic white. The conditional model revealed that more intuitive eating practices predicted greater postpartum BMI decreases (Est. = -0.10, p < .05) when controlling for breastfeeding duration, exercise duration, and initial BMI and pregnancy BMI changes. Greater pregnancy BMI increases were associated with more rapid postpartum BMI decreases (Est. = -0.34, p < .001) while breastfeeding duration, exercise and initial BMI were not related. Conclusions for Practice Postpartum weight retention is a challenge for many women. Following a more intuitive eating approach to food consumption may encourage postpartum weight loss without the required weighing, measuring, recording and assessing dietary intake that is required of traditional weight loss programs. IE could offer an alternative approach that may be less arduous for new mothers.

Postpartum Weight Retention Risk Factors in a Taiwanese Cohort Study

OBJECTIVE

Excess postpartum weight retention (PPWR) is related to long-term weight gain. Therefore, this study was conducted to identify the risk factors for PPWR to provide guidance for preventive strategies.

METHODS

This cohort study surveyed 461 women who gave birth at a medical center between March 2014 and March 2016. The participants completed a questionnaire within 1 month of delivery, and their 6-month postpartum weight was tracked.

RESULTS

The results showed that the mean pre-pregnancy BMI was 21.4 ± 3.3 kg/m2, and the mean gestational weight gain (GWG) was 12.8 ± 4.1 kg. The mean PPWR was 4.6 ± 3.5 kg at 1 month and 2.1 ± 3.3 kg at 6 months. Multivariate analysis revealed that GWG (adjusted OR: 1.92 (1.70-2.17)), pre-pregnancy BMI (adjusted OR: 0.85 (0.77-0.94)), and exclusive breastfeeding (adjusted OR: 0.55 (0.32-0.94)) were significantly correlated with a 1-month PPWR higher than the median value. In addition, GWG (adjusted OR: 1.30 (1.22-1.39)) and exclusive breastfeeding (adjusted OR: 0.37 (0.24-0.58)) were significantly correlated with a 6-month PPWR higher than the median value.

CONCLUSION

Our findings indicate that the key to reducing PPWR is to control GWG and engage in exclusive breastfeeding.

Modifiable risk factors of maternal postpartum weight retention: an analysis of their combined impact and potential opportunities for prevention

BACKGROUND/OBJECTIVES

Pregnancy triggers a physiological change in weight status. Postpartum weight retention in the childbearing years can substantially alter a woman's weight gain trajectory, with several potential contributing factors identified. Most research has relied on women's recall of pre-pregnancy weight during pregnancy or later, and not considered risk factors in combination. Using measured pre-pregnancy weight, this study aimed to examine the associations of maternal postpartum weight retention with parity, pre-pregnancy BMI, excessive gestational weight gain (GWG), maternal serum vitamin D concentration and dietary Glycaemic Index in early and late pregnancy, and breastfeeding duration, including analysis of the combined impact of potentially modifiable risk factors.

SUBJECTS/METHODS

Prospective cohort study of 12 583 non-pregnant women aged 20-34 years in Southampton (UK) who were assessed prior to pregnancy, with those who subsequently became pregnant followed up in early and late gestation, and after delivery (n=2559 in the final sample). Linear regression models examined potential predictors of weight retention in adjusted individual and multivariate analyses, and as a risk factor score.

RESULTS

Compared with pre-pregnancy weight, 73% of women retained some weight at 6 months postpartum (mean (s.d.): 3.5 (6.2) kg). In the adjusted multivariate model, women who were primiparous, had a lower pre-pregnancy BMI, excessive GWG, a lower early pregnancy vitamin D concentration and breastfed for <6 months had greater weight retention 6 months postpartum (P<0.05 for all variables). For each additional modifiable risk factor (excessive GWG, low vitamin D concentration in early pregnancy and short breastfeeding duration; scale 0-3), women retained an additional 2.49 kg (95% CI: 2.16, 2.82; P<0.001).

CONCLUSIONS

Having a greater number of modifiable risk factors was associated with greater weight retention 6 months postpartum. Initiatives supporting women to target these risk factors in the years prior to, during and after pregnancy could impact on their weight gain trajectory and later risk of adverse weight-related outcomes.

Breast-feeding duration for the prevention of excess body weight of mother-child pairs concurrently: a 2-year cohort study

OBJECTIVE

To examine the association between breast-feeding duration and the risk of excess body weight (children >85th percentile, mothers BMI≥25·0 kg/m2) concurrently in mother-child pairs two years after delivery.

DESIGN

Prospective cohort study in Joinville, Brazil. Multivariable logistic regression was used to examine the independent relationship between breast-feeding duration and risk of excess body weight.

SETTING

Brazilian public maternity hospital.

SUBJECTS

Three hundred and five mother-child pairs.

RESULTS

At 2-year follow-up, 23·6 % of mother-child pairs had excess body weight. Children breast-fed for <2 months were more likely to have excess body weight than children breast-fed for ≥6 months (OR=2·4; 95 % CI 1·1, 5·1). Breast-feeding for <2 months was also associated with a greater likelihood of maternal excess body weight compared with those who breast-fed for ≥6 months (OR=2·9; 95 % CI 1·1, 8·1). There was a progressive increase in the likelihood of mother-child pairs having excess body weight as breast-feeding duration decreased. In addition to breast-feeding duration, other independent determinants of excess body weight were pre-pregnancy weight, gestational weight gain and number of pregnancies in mothers, and birth weight in children.

CONCLUSIONS

Breast-feeding for a longer duration has a parallel protective effect on the risk of excess body weight in mother-child pairs two years after birth. Since members of the same family could be influenced by the same risk factors, continued promotion and support of breast-feeding may help to attenuate the rising prevalence of overweight in mother-child pairs.

Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond

OBJECTIVES

To provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to women through their lifecycle.

OUTCOMES

Optimal nutrition through the female lifecycle was evaluated, with specific focus on adolescence, pre-conception, pregnancy, postpartum, menopause, and beyond. The guideline begins with an overview of guidance for all women, followed by chapters that examine the evidence and provide recommendations for the promotion of healthy nutrition and body weight at each life stage. Nutrients of special concern and other considerations unique to each life stage are discussed in each chapter.

EVIDENCE

Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in supporting the recommendations made in this document.

VALUES

The quality of evidence was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. CHAPTER 2: GENERAL FEMALE NUTRITION: Summary Statements Recommendations CHAPTER 3: ADOLESCENCE NUTRITION: Summary Statements Recommendations CHAPTER 4: PRE-CONCEPTUAL NUTRITION: Summary Statement Recommendations CHAPTER 5: NUTRITION IN PREGNANCY: Summary Statements Recommendations CHAPTER 6: POSTPARTUM NUTRITION AND LACTATION: Summary Statements Recommendations CHAPTER 7: NUTRITION DURING MENOPAUSE AND BEYOND: Summary Statement Recommendations.