Maternal obesity: a review of interventions

Maternal exercise opportunity before, during, and after pregnancy alters maternal care behavior and offspring development and survival, but has few effects on offspring physical activity or body composition

Early-life experiences, especially during critical periods of development and growth, can have long-lasting effects on adult phenotypes. Parents are a crucial part of the offspring early-life environment, particularly in mammals (e.g., via pregnancy), and parental behaviors (e.g., maternal exercise) can modify the early-life environment experienced by offspring. Such changes might be beneficial or detrimental, depending on how they affect offspring development and growth or interact with other key parental behaviors (e.g., nursing). We used mice from a long-term artificial selection experiment for high voluntary wheel-running behavior to determine whether maternal exercise opportunity affected (1) maternal physical activity, (2) maternal care behavior, or (3) offspring physical activity and body composition. Eighty prospective dams (40 from 4 selectively bred High Runner [HR] lines and 40 from 4 non-selected Control [CON] lines) were housed with continuous wheel access starting two weeks prior to breeding and ending 10 days postpartum, after which dams were housed without wheels until offspring weaning (21 days postpartum). An additional 100 dams (50 HR, 50 CON) were housed without wheels. Prospective dams from HR lines ran more revolutions/day (mainly by running faster) than those from CON lines when individually housed and in the days leading up to, but not after, birth. During postpartum days 1-5, HR and CON dams with wheels tended to exhibit less maternal behavior than those without (PWheel = 0.0672). During post-partum days 6-10, HR dams with wheels continued to exhibit less maternal behavior than those without, whereas CON dams with wheels exhibited more than those without (PLinetype*Wheel = 0.0218). The proportion of dams giving birth did not differ among groups. However, CON dams with wheels were less likely to have litter death between birth and weaning than those without wheels, whereas the opposite was true for HR dams (PLinetype*Wheel = 0.0447). Both HR and CON dams with wheels had litters with a higher proportion of females at weaning than those without wheels (PWheel = 0.0129). Maternal wheel access had few statistically significant effects on offspring, but may have resulted in developmental delays (e.g., delayed eye opening and decreased lean mass at weaning and sexual maturity). Additionally, maternal wheel access and sex may have interacted to affect wheel-running distance (PSex*Wheel = 0.0683) and duration (PSex*Wheel = 0.0926); female offspring from dams with wheels ran fewer revolutions per day, by running fewer minutes per day, than from dams without wheels, whereas males ran more. However, maternal exercise had no statistically significant effects on offspring food consumption (mass-adjusted), home-cage activity, open-field behavior, the reproductive characteristics of offspring, their adult body composition, nor relative organ masses; nor did maternal wheel access have statistically significant effects on grand-offspring food consumption, body composition or voluntary exercise behavior. Overall, our results provide some support for maternal exercise opportunity altering maternal care behavior. Altered maternal care could explain the observed trends in offspring survival, development, and voluntary exercise behavior. However, these effects did not have apparent long-lasting impacts on offspring or grand-offspring body composition or reproductive characteristics.

Digital preconception interventions targeting weight, diet and physical activity: A systematic review

AIM

Optimising preconception health increases the likelihood of conception, positively influences short- and long-term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period.

METHODS

We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi-experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face-to-face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted.

RESULTS

Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre-post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web-based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss.

CONCLUSION

More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.

Body-mass index and obesity in infertile couples in southwest China

To investigate body mass index (BMI) of infertile couples and analyze its related influencing factors in Southwest China, so as to prevent and control the obesity. We analyzed the data of a total number of 8877 infertile couples who received treatment in our assisted reproductive center from October 2012 to March 2022. The mean age and BMI of men and women were 33.5 years, 23.9 kg/m2 and 31.6 years, 21.9 kg/m2. The prevalence of overweight (BMI 25-29.9) was 30.9% in men and 14.7% in women, 3.7% of men and 1.6% of women were obese (BMI ≥ 30), while 3.6% of men and 10.8% of women were underweight (BMI<18.5). Multivariable linear regression analysis indicated that the age and educational background of both women and men had an impact on BMI. In our study, the proportion of male obesity and overweight is much higher than that of female. On the other hand, the proportion of females with low weight was higher than that of males. The age and educational background of men and women have a certain correlation with BMI.

20α-Hydroxysteroid Dehydrogenase Expression in the Human Myometrium at Term and Preterm Birth: Relationships to Fetal Sex and Maternal Body Mass Index

The mechanism by which human labor is initiated in the presence of elevated circulating progesterone levels remains unknown. Recent evidence indicates that the progesterone-metabolizing enzyme, 20α-hydroxysteroid dehydrogenase (20α-HSD), encoded by the gene AKR1C1, may contribute to functional progesterone withdrawal. We found that AKR1C1 expression significantly increased with labor onset in term myometrium, but not in preterm myometrium. Among preterm laboring deliveries, clinically diagnosed chorioamnionitis was associated with significantly elevated AKR1C1 expression. AKR1C1 expression positively correlated with BMI before labor and negatively correlated with BMI during labor. Analysis by fetal sex showed that AKR1C1 expression was significantly higher in women who delivered male babies compared to women who delivered female babies at term, but not preterm. Further, in pregnancies where the fetus was female, AKR1C1 expression positively correlated with the mother's age and BMI at the time of delivery. In conclusion, the increase in myometrial AKR1C1 expression with term labor is consistent with 20α-HSD playing a role in local progesterone metabolism to promote birth. Interestingly, this role appears to be specific to term pregnancies where the fetus is male. Upregulated AKR1C1 expression in the myometrium at preterm in-labor with clinical chorioamnionitis suggests that increased 20α-HSD activity is a mechanism through which inflammation drives progesterone withdrawal in preterm labor. The link between AKR1C1 expression and maternal BMI may provide insight into why maternal obesity is often associated with dysfunctional labor. Higher myometrial AKR1C1 expression in male pregnancies may indicate fetal sex-related differences in the mechanisms that precipitate labor onset at term.

Obesity Induces an Impaired Placental Antiviral Immune Response in Pregnant Women Infected with Zika Virus

Obesity is increasing in incidence worldwide, especially in women, which can affect the outcome of pregnancy. During this period, viral infections represent a risk to the mother, the placental unit, and the fetus. The Zika virus (ZIKV) outbreak in Brazil has been the cause of congenital Zika syndrome (CZS), with devastating consequences such as microcephaly in newborns. Herein, we analyzed the impact of maternal overweight/obesity on the antiviral factors' expression in the placental tissue of Zika-infected mothers. We accessed placentas from women with and without obesity from 34 public health units (São Paulo) and from Zika-infected mothers with and without obesity from the Clinical Cohort Study of ZIKV pregnant women (Rio de Janeiro, Brazil). We first verified that obesity, without infection, did not alter the constitutive transcriptional expression of antiviral factors or IFN type I/III expression. Interestingly, obesity, when associated with ZIKV infection, showed a decreased transcriptional expression of RIG-I and IFIH1 (MDA-5 protein precursor gene). At the protein level, we also verified a decreased RIG-I and IRF-3 expression in the decidual placenta from the Zika-infected obese group, regardless of microcephaly. This finding shows, for the first time, that obesity associated with ZIKV infection leads to an impaired type I IFN downstream signaling pathway in the maternal-fetal interface.

Developing a lifestyle intervention program for overweight or obese preconception, pregnant and postpartum women using qualitative methods

The time period before, during and after pregnancy represents a unique opportunity for interventions to cultivate sustained healthy lifestyle behaviors to improve the metabolic health of mothers and their offspring. However, the success of a lifestyle intervention is dependent on uptake and continued compliance. To identify enablers and barriers towards engagement with a lifestyle intervention, thematic analysis of 15 in-depth interviews with overweight or obese women in the preconception, pregnancy or postpartum periods was undertaken, using the integrated-Promoting Action on Research Implementation in Health Services framework as a guide to systematically chart factors influencing adoption of a novel lifestyle intervention. Barrier factors include time constraints, poor baseline knowledge, family culture, food accessibility, and lack of relevant data sources. Enabling factors were motivation to be healthy for themselves and their offspring, family and social support, a holistic delivery platform providing desired information delivered at appropriate times, regular feedback, goal setting, and nudges. From the findings of this study, we propose components of an idealized lifestyle intervention including (i) taking a holistic life-course approach to education, (ii) using mobile health platforms to reduce barriers, provide personalized feedback and promote goal-setting, and (iii) health nudges to cultivate sustained lifestyle habits.

Gestational potential space hypothesis: Evolutionary explanation of human females body fat redistribution

Homo sapiens, as well as other primates, developed the evolutionary advantage of storing excess energy as body fat, primarily in the readily accessible visceral fat compartment when food is plentiful for use during scarcity. However, uniquely to female humans, a second transient dimorphic phenotypic change begins at menarche and is reversed by menopause. It is the diversion of visceral fat stores from the abdominal cavity to the gluteofemoral region. The evolutionary purpose for this remains unclear. The author proposes the gestational potential space hypothesis: that such fat diversion is for the reproductive purpose of increasing the potential abdominal space available for gestation and reducing the intra-abdominal pressure. This hypothesis is supported by the basic laws of physics and increased rates of maternal and fetal complications experienced by those with visceral adiposity.

Pregnant Women Living with Obesity: A Cross-Sectional Observational Study of Dietary Quality and Pregnancy Outcomes

Good maternal nutrition is key to optimal maternal and foetal health. A poor-quality diet is often associated with obesity, and the prevalence and severity of maternal obesity has increased significantly in recent years. This study observed dietary intakes in pregnant women living with obesity and assessed the quality of their diet. In total, 140 women with a singleton pregnancy, aged > 18 years and BMI ≥ 35 kg/m², were recruited from antenatal clinics, weighed and completed food diaries at 16-, 28- and 36-weeks' gestation. Clinical data were recorded directly from the women's medical records. Nutrient intake was determined using 'Microdiet^TM', then compared to Dietary Reference Values (DRVs). Energy intakes were comparable with DRVs, but intakes of sugar and saturated fatty acids were significantly higher. Intake of fibre and several key micronutrients (Iron, Iodine, Folate and Vitamin D) were significantly low. Several adverse obstetric outcomes were higher than the general obstetric population. Women with obesity, often considered 'over nourished', may have diets deficient in essential micronutrients, often associated with poor obstetric outcomes. To address the intergenerational transmission of poor health via poor diets warrants a multi-disciplinary approach focusing away from 'dieting' onto positive messages, emphasising key nutrients required for good maternal and foetal health.

Effects of calorie restriction plus fish oil supplementation on abnormal metabolic characteristics and the iron status of middle-aged obese women

The increasing prevalence of obesity and sedentary lifestyles has led to a higher incidence of metabolic syndrome (MetS) worldwide as well as in Taiwan. Middle-aged women are at a greater risk of MetS, type 2 diabetes, and cardiovascular disease than men because they have more subcutaneous fat and larger waist circumferences compared with men with equal visceral fat levels. In this study, we investigated the effects of calorie restriction (CR) and fish oil supplementation (CRF) on middle-aged Taiwanese women with MetS. An open-label, parallel-arm, controlled trial was conducted for 12 weeks. A total of 75 eligible participants were randomly assigned to the CR or CRF group. Both the dietary intervention groups were further divided into two age groups: ≤45 and >45 years. Changes in MetS severity, inflammatory status, iron status, and red blood cell fatty acid profile were evaluated. A total of 71 participants completed the trial. Both dietary interventions significantly ameliorated MetS and improved the participants' inflammatory status. CR significantly increased the total iron-binding capacity (TIBC) whereas CRF increased hepcidin levels in women aged >45 years. Furthermore, CRF significantly increased the n-6/n-3 and arachidonic acid/docosahexaenoic acid ratios. Both interventions improved the anthropometric and MetS characteristics, including body weight, blood glucose and triglyceride levels, and the score of the homeostasis model assessment of insulin resistance and quantitative insulin sensitivity check index. In conclusion, the 12-week dietary interventions improved the abnormal metabolic status of middle-aged obese women. CRF was demonstrated to be more effective in ameliorating postprandial glucose level and TIBC in women aged >45 years than in those aged ≤45 years.

Eating for Two? Protocol of an Exploratory Survey and Experimental Study on Social Norms and Norm-Based Messages Influencing European Pregnant and Non-pregnant Women's Eating Behavior

The social context is an important factor underlying unhealthy eating behavior and the development of inappropriate weight gain. Evidence is accumulating that powerful social influences can also be used as a tool to impact people's eating behavior in a positive manner. Social norm-based messages have potential to steer people in making healthier food choices. The research field on nutritional social norms is still emerging and more research is needed to gain insights into why some people adhere to social norms whereas others do not. There are indications stemming from empirical studies on social eating behavior that this may be due to ingratiation purposes and uncertainty reduction. That is, people match their eating behavior to that of the norm set by their eating companion(s) in order to blend in and be part of the group. In this project, we explore nutritional social norms among pregnant women. This population is particularly interesting because they are often subject to unsolicited advice and experience social pressure from their environment. In addition, their pregnancy affects their body composition, eating pattern, and psychosocial status. Pregnancy provides an important window of opportunity to impact health of pregnant women and their child. Nevertheless, the field of nutritional social norms among pregnant women is understudied and more knowledge is needed on whether pregnant women use guidelines from their social environment for their own eating behavior. In this project we aim to fill this research gap by means of an exploratory survey (Study 1) assessing information about social expectations, (mis)perceived social norms and the role of different reference groups such as other pregnant women, family, and friends. In addition, we conduct an online experiment (Study 2) testing to what extent pregnant women are susceptible to social norm-based messages compared to non-pregnant women. Moreover, possible moderators are explored which might impact women's susceptibility to social norms as well as cultural aspects that co-determine which social norms and guidelines exist. The project's findings could help design effective intervention messages in promoting healthy eating behavior specifically targeted to European pregnant women.

The effect of weight management interventions that include a diet component on weight-related outcomes in pregnant and postpartum women: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

What are the effects of weight management interventions that include a diet component on weight-related outcomes in pregnant and postpartum women?The primary objective of this systematic review is to evaluate the effectiveness of weight management interventions which include a diet component and are aimed at limiting gestational weight gain and postpartum weight retention in women.The second objective of this systematic review is to investigate included intervention components with respect to effect on weight-related outcomes. This may include, but is not limited to: length of intervention, use of face-to-face counselling, group or individual consultations, use of other interventions components including exercise, use of goals and use of support tools like food diaries, coaching, including email or text message support.

BACKGROUND

Around half of all women of reproductive age are either overweight or obese, with women aged 25-34 years having a greater risk of substantial weight gain compared with men of all ages. Excessive gestational weight gain (GWG) and postpartum weight retention (PPWR) may play a significant role in long term obesity. Having one child doubles the five- and 10-year obesity incidence for women, with many women who gain excessive weight during pregnancy remaining obese permanently. Excessive GWG and/or PPWR can also significantly contribute to short- and long-term adverse health outcomes for mother, baby and future pregnancies.Maternal obesity increases the risk of pregnancy related complications such as pre-eclampsia, gestational diabetes mellitus, stillbirth and the rate of caesarean section. Childhood obesity is a further long term complication of maternal obesity for offspring, which may persist in to adulthood. Excess GWG is also a risk factor for PPWR both in the short and long-term. Nehring et al. conducted a meta-analysis with over 65,000 women showing that, compared to women who gained weight within recommendations during pregnancy, women with GWG above Institute of Medicine weight gain recommendations, retained an additional 3.1 kg and 4.7kg after three and greater than or equal to 15 years postpartum, respectively. The health risk associated with PPWR is highlighted in a study of 151,025 Swedish women followed between 1992 and 2001.The study identified the risk of adverse pregnancy outcomes for those who gained three or more units of Body Mass Index (kg/m2) between consecutive pregnancies (an average of two years) was much higher compared with women whose BMI changed from -1.0 and 0.9 units. Long-term chronic disease risk may also be affected by PPWR as weight retention at the end of the first year post-partum has been found to be a predictor of maternal overweight 15 years later.With around 14-20% of women retaining 5kg or more 12 months postpartum, the risk of developing conditions like diabetes, metabolic syndrome and cardiovascular disease may be increased. It becomes evident that interventions which aim to support attainment of healthy weight both in the antenatal and postpartum periods are key health priorities for women during this life stage.Lifestyle factors of overweight, having poor diet quality, and not undertaking enough moderate-to-vigorous physical activity are amongst the top five predictors of mortality in women. Additionally it is noted that, for many women, pregnancy and the postpartum period are associated with a reduction in physical activity. It is known that a combination of poor dietary choices, an increase in sedentary time and reduction in physical activity are all contributors to the development of overweight and obesity. With this in mind, current research has focused on lifestyle interventions to limit GWG and PPWR. Thangaratinam et al. reviewed 44 randomized controlled trials (7278 women) where interventions including diet, physical activity or both were evaluated for their influence on maternal weight during pregnancy. Results indicate that all were significantly effective in reducing GWG compared with the control group. More specifically, dietary interventions were the most effective in reducing weight gain, with a mean weight loss of -3.84kg compared with -0.72kg and -1.06kg for physical activity and the mixed (diet plus physical activity) approach, respectively. This finding is supported by Hill and colleagues' recent systematic review of theory based interventions to limit GWG. Included studies in this review reported an underpinning theory base and were classified as adopting a dietary, physical activity or mixed approach. Hill et al. concluded that studies which included a diet intervention were significantly more effective at limiting GWG.In 2011 Tanentsapf et al. reviewed the effect of dietary interventions alone for reducing GWG in normal weight, overweight and obese pregnant women. This review analysed 13 randomized controlled trials and quasi-randomized controlled trials with a dietary intervention to prevent excessive GWG in women. The review concluded that dietary interventions during pregnancy were effective in reducing GWG with an effect of -1.92kg (n=1434) compared with the control group.Tanentsapf et al. identified that trials differed in the conduct of the interventions with various diet and non-diet related components utilised. Dietary approaches were highly variable with some trials focusing only on calorie restriction and others included additional target macronutrient distribution for intake. Some trials further provided feedback based on maternal weight gain guidelines. Interventions also varied in delivery method with a variety of modes used, including face-to-face, individual or group consultations and/or written correspondence. The frequency of communication, despite the type or mix, also changed from trial to trial with additional methods via telephone, posted materials, feedback or food diaries utilised. The inclusion of physical activity in addition to diet intervention was also common. Whilst the recent review by Tanentsapf et al. identified that dietary interventions are effective in reducing GWG, the review did not investigate the impact that different intervention components, delivery methods or dietary counselling approaches had on gestational weight management. It remains unclear as to which intervention components optimize GWG in women.The impact of lifestyle interventions has also been investigated in the postpartum period. The recent systematic review from van der Pligt et al. reported seven of 11 studies reviewed were successful in limiting PPWR. As with studies aimed at limiting GWG, interventions included in van der Pligt et al.'s review differed greatly in their conduct. Six of these seven studies included both dietary and physical activity components for the intervention, with the final successful study including a diet only intervention. Five of the successful studies recruited overweight or obese women only. Intervention time varied considerably in successful studies with some running for as little at ten days, and others up to six months.Bertz et al. demonstrated that their 12-week behavior modification intervention which targeted diet alone or diet and exercise, including two individual sessions with a dietitian and physical therapist, provision of scales for weight self-monitoring and bi-weekly text messages was successful in achieving significant weight loss following the intervention, and sustained at one year. The diet intervention and the diet and exercise intervention yielded significant weight loss compared to the control. Following 12 weeks a reduction of -8.3 +/- 4.2kg for diet intervention and -6.9 +/- 3.0kg for diet and exercise was observed. Additionally after one year, the diet intervention showed -10.2 +/- 5.7kg reduction and -7.3 +/- 6.3kg for the diet and exercise intervention (p<0.001). Colleran et al. also found significant weight change results by implementing a 16-week intervention which consisted of weekly individual sessions with a dietitian regarding calorie restriction, two additional home visits regarding exercise, weekly food diary completion and email support. The intervention group had greater weight loss compared to the control group (-5.8kg +/- 3.5kg vs -1.6kg +/- 5.4kg). It can be seen that various methods have been utilized in investigating the impact of diet and physical activity interventions on PPWR. The review by van der Pligt et al. highlights the impact successful lifestyle interventions can have on postpartum weight change. However, this review did not investigate the different intervention strategies utilized. It remains unclear as to the optimal setting, delivery method, diet strategy, contact frequency or intervention length to limit PPWR.Previous systematic reviews for both GWG and PPWR have focused on the effectiveness of lifestyle interventions as a whole for weight management in pregnant and postpartum women. And despite Tanentsapf et al.'s focus on dietary interventions for GWG, much is still unknown about the effectiveness of differing diet interventions over the antenatal and postpartum period. Specifically, the impact of differing diet intervention strategies on maternal weight gain is not known. Firstly, this systematic review will focus on whether weight management interventions which include a dietary component are effective in pregnant and postpartum women. In addition to this, this review will investigate the different intervention strategies utilized and their effectiveness in maternal weight management. A search of systematic review protocol databases has shown that there is no current review underway for this topic.

Body Mass Index Changes during Pregnancy and Perinatal Outcomes - A Cross-Sectional Study

OBJECTIVE

 To evaluate the relation between changes the body mass index (BMI) percentile, reflected in the Atalah curve, and perinatal outcomes.

METHODS

 A cross-sectional study with 1,279 women was performed. Data regarding gestational weight, sociodemographic characteristics and perinatal outcomes were collected through medical charts, prenatal card and interviews in the postpartum period. Women could be classified according to the Atalah curve in the following categories: low weight, adequate weight, overweight, and obese. The BMI was calculated at the first and at the last prenatal care visits, and these values were compared.

RESULTS

 An increase in the BMI category according to the Atalah classification occurred in 19.9% of pregnant women, and an increase of 3.4, 5.8 and 6.4 points of BMI were found for women respectively classified in the adequate weight, overweight and obese categories at the first prenatal visit. Women with high school education presented a lower chance of increasing their BMI (odds ratio [OR] 0:47 [0.24- 0.95]). Women who evolved with an increase in the the Atalah classification were associated with cesarean section (OR 1.97-2.28), fetal macrosomia (OR 4.13-12.54) and large for gestational age newborn (OR 2.88-9.83).

CONCLUSION

 Pregnant women who gained enough weight to move up in their BMI classification according to the Atalah curve had a higher chance of cesarean section and macrosomia. Women classified as obese, according to the Atalah curve, at the first prenatal visit had a high chance of cesarean section and delivering a large for gestational age newborn.

Behaviour change in overweight and obese pregnancy: a decision tree to support the development of antenatal lifestyle interventions

OBJECTIVE

Antenatal healthy lifestyle interventions are frequently implemented in overweight and obese pregnancy, yet there is inconsistent reporting of the behaviour-change methods and behavioural outcomes. This limits our understanding of how and why such interventions were successful or not.

DESIGN

The current paper discusses the application of behaviour-change theories and techniques within complex lifestyle interventions in overweight and obese pregnancy. The authors propose a decision tree to help guide researchers through intervention design, implementation and evaluation. The implications for adopting behaviour-change theories and techniques, and using appropriate guidance when constructing and evaluating interventions in research and clinical practice are also discussed.

CONCLUSIONS

To enhance the evidence base for successful behaviour-change interventions during pregnancy, adoption of behaviour-change theories and techniques, and use of published guidelines when designing lifestyle interventions are necessary. The proposed decision tree may be a useful guide for researchers working to develop effective behaviour-change interventions in clinical settings. This guide directs researchers towards key literature sources that will be important in each stage of study development.

The early origins of obesity and insulin resistance: timing, programming and mechanisms

Maternal obesity is associated with an increased risk of developing gestational diabetes mellitus and it also results in an increased risk of giving birth to a large baby with increased fat mass. Furthermore, it is also contributes to an increased risk of obesity and insulin resistance in the offspring in childhood, adolescence and adult life. It has been proposed that exposure to maternal obesity may therefore result in an 'intergenerational cycle' of obesity and insulin resistance. There is significant interest in whether exposure to maternal obesity around the time of conception alone contributes directly to poor metabolic outcomes in the offspring and whether dieting in the obese mother before pregnancy or around the time of conception has metabolic benefits for the offspring. This review focusses on experimental and clinical studies that have investigated the specific impact of exposure to maternal obesity during the periconceptional period alone or extending beyond conception on adipogenesis, lipogenesis and on insulin signalling pathways in the fat, liver and muscle of the offspring. Findings from these studies highlight the need for a better evidence base for the development of dietary interventions in obese women before pregnancy and around the time of conception to maximize the metabolic benefits and minimize the metabolic costs for the next generation.

Healthcare professionals experience with motivational interviewing in their encounter with obese pregnant women

OBJECTIVE

to explore and describe how healthcare professionals in the Southern Region of Denmark experienced motivational interviewing as a communication method when working with pregnant women with obesity.

DESIGN

a qualitative, descriptive study based on face-to-face interviews with 11 obstetric healthcare professionals working in a perinatal setting.

METHODS

a thematic descriptive method was applied to semi-structured interviews. The healthcare professional's experiences were recorded verbatim during individual semi-structured qualitative interviews, transcribed, and analysed using a descriptive analysis methodology.

FINDINGS

motivational interviewing was found to be a useful method when communicating with obese pregnant women. The method made the healthcare professionals more aware of their own communication style both when encountering pregnant women and in their interaction with colleagues. However, most of the healthcare professionals emphasised that time was crucial and they had to be dedicated to the motivational interviewing method. The healthcare professionals further stated that it enabled them to become more professional in their daily work and made some of them feel less 'burned out', 'powerless' and 'stressed' as they felt they had a communication method in handling difficult workloads.

CONCLUSION

healthcare professionals experienced motivational interviewing to be a useful method when working perinatally. The motivational interviewing method permitted heightened awareness of the healthcare professionals communication method with the patients and increased their ability to handle a difficult workload. Overall, lack of time restricted the use of the motivational interviewing method on a daily basis.

Pre-pregnancy maternal overweight and obesity increase the risk for affective disorders in offspring

Maternal pre-pregnancy obesity has been linked with an increased risk for negative emotionality and inattentiveness in offspring in early childhood. The aim of this study was to examine the association between maternal pre-pregnancy body mass index (BMI) and the development of affective problems (dysthymic disorder, major depressive disorder) throughout childhood and adolescence. In the Western Australian Pregnancy Cohort (Raine) Study, 2900 women provided data on their pre-pregnancy weight, and height measurements were taken at 18 weeks of gestation. BMI was calculated and categorized using standardized methods. Live-born children (n = 2868) were followed up at ages 5, 8, 10, 14 and 17 years using the Diagnostic and Statistical Manual of Mental Disorders-oriented scales of the Child Behavior Checklist (CBCL/4-18). Longitudinal models were applied to assess the relationships between maternal pre-pregnancy BMI and affective problems from age 5 through 17. There was a higher risk of affective problems between the ages of 5 and 17 years among children of women who were overweight and obese compared with the offspring of women in the healthy pre-pregnancy weight range (BMI 18.5-24.99) after adjustment for confounders, including paternal BMI. Maternal pre-pregnancy overweight and obesity may be implicated in the development of affective problems, including depression, in their offspring later in life.

Pre-pregnancy obesity compromises obstetric and neonatal outcomes

OBJECTIVE

Obesity is an important issue among fertile women as it may affect obstetric and neonatal outcomes.

METHODS

Obstetric and neonatal outcomes of primiparous women were retrospectively analyzed in non-obese (n=11387) and obese (n=943) women. A subgroup analysis was performed in obese women divided into three groups: Grade I obesity (Group A, n=654), Grade II obesity (Group B, n=192), and Grade III obesity (Group C, n=97). Odds ratios (OR) were expressed with the corresponding 95% confidence intervals (CI).

RESULTS

The incidence of gestational diabetes (non-obese, 1.9%; obese, 7.6%; Group C, 19.6%) and preeclampsia (non-obese, 3.3%; obese, 13.5%; Group C, 17.5%) increased with rising weight. The risk of non-elective cesarean section was significantly higher in obese women than in non-obese women (21.7% vs. 13.2%). The risk of extreme preterm birth (before 28 weeks of gestation) doubled in the Grade I obesity group (OR, 2.1; 95% CI, 1.4-3.2) and nearly tripled in women with body mass index ≥35 kg/m2 (OR, 2.9; 95% CI, 1.7-4.9).

CONCLUSION

Pre-pregnancy obesity is associated with higher incidences of gestational diabetes and preeclampsia. Our study shows that obese women have a higher risk of non-elective cesarean section and preterm birth.

Maternal Obesity Management Using Mobile Technology: A Feasibility Study to Evaluate a Text Messaging Based Complex Intervention during Pregnancy

BACKGROUND

Maternal obesity and excessive gestational weight gain (GWG) are on the rise with negative impact on pregnancy and birth outcomes. Research into managing GWG using accessible technology is limited. The maternal obesity management using mobile technology (MOMTech) study aimed at evaluating the feasibility of text messaging based complex intervention designed to support obese women (BMI ≥ 30) with healthier lifestyles and limit GWG.

METHODS

Participants received two daily text messages, supported by four appointments with healthy lifestyle midwife, diet and activity goal setting, and self-monitoring diaries. The comparison group were obese mothers who declined to participate but consented for their routinely collected data to be used for comparison. Postnatal interviews and focus groups with participants and the comparison group explored the intervention's acceptability and suggested improvements.

RESULTS

Fourteen women completed the study which did not allow statistical analyses. However, participants had lower mean GWG than the comparison group (6.65 kg versus 9.74 kg) and few (28% versus 50%) exceeded the Institute of Medicine's upper limit of 9 kg GWG for obese women.

CONCLUSIONS

MOMTech was feasible within clinical setting and acceptable intervention to support women to limit GWG. Before further trials, slight modifications are planned to recruitment, text messages, and the logistics of consultation visits.

Preconception care: nutritional risks and interventions

INTRODUCTION

There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and micronutrient deficiencies all contribute to excess maternal and fetal complications during pregnancy.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on maternal, newborn and child health (MNCH) outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Maternal pre-pregnancy weight is a significant factor in the preconception period with underweight contributing to a 32% higher risk of preterm birth, and obesity more than doubling the risk for preeclampsia, gestational diabetes. Overweight women are more likely to undergo a Cesarean delivery, and their newborns have higher chances of being born with a neural tube or congenital heart defect. Among nutrition-specific interventions, preconception folic acid supplementation has the strongest evidence of effect, preventing 69% of recurrent neural tube defects. Multiple micronutrient supplementation shows promise to reduce the rates of congenital anomalies and risk of preeclampsia. Although over 40% of women worldwide are anemic in the preconception period, only one study has shown a risk for low birth weight.

CONCLUSION

All women, but especially those who become pregnant in adolescence or have closely-spaced pregnancies (inter-pregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimizing maternal body mass index and micronutrient reserves. Increasing coverage of nutrition-specific and nutrition-sensitive strategies (such as food fortification; integration of nutrition initiatives with other maternal and child health interventions; and community based platforms) is necessary among adolescent girls and women of reproductive age. The effectiveness of interventions will need to be simultaneously monitored, and form the basis for the development of improved delivery strategies and new nutritional interventions.

Developing a clinical care pathway for obese pregnant women: A quality improvement project

PROBLEM

Obesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) ≥ 30 kg/m(2), defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted.

AIM

To plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI ≥ 35 kg/m(2) at their first antenatal visit.

PROJECT SETTING

The project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia.

SUBJECTS

Eighty-two women with a BMI ≥ 35 kg/m(2) were eligible for the alternative care pathway, offered between January and December 2010.

INTERVENTION

The alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation.

FINDINGS

Despite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening.

Breast-feeding in relation to weight retention up to 36 months postpartum in the Norwegian Mother and Child Cohort Study: modification by socio-economic status?

OBJECTIVE

We investigated the association between full breast-feeding up to 6 months as well as partial breast-feeding after 6 months and maternal weight retention at 6, 18 and 36 months after delivery in the Norwegian Mother and Child Cohort Study (MoBa), conducted by the Norwegian Institute of Public Health.

DESIGN

Cohort study. Information on exposure and outcome was collected by questionnaire.

SETTING

Norway.

SUBJECTS

Women at 6 months (n 49 676), 18 months (n 27 187) and 36 months (n 17 343) postpartum.

RESULTS

Longer duration of full breast-feeding as well as partial breast-feeding was significantly related to lower weight retention at 6 months. At 18 months full breast-feeding (0-6 months) and partial breast-feeding for 12-18 months were significantly related to lower weight retention. At 36 months only full breast-feeding (0-6 months) was significantly related to lower weight retention. For each additional month of full breast-feeding, maternal weight was lowered by 0·50 kg/month at 6 months, 0·10 kg/month at 18 months and 0·14 kg/month at 36 months (adjusted for pre-pregnant BMI, pregnancy weight gain, age and parity). Partial breast-feeding resulted in 0·25 kg/month lower maternal weight at 6 months. Interactions were found between household income and full breast-feeding in relation to weight retention at 6, 18 and 36 months, indicating most benefit among women with low income.

CONCLUSIONS

The present study supports the hypothesis that full breast-feeding contributes to lower postpartum weight retention and shows that the effect is maintained for as long as 3 years postpartum.

Training in motivational interviewing in obstetrics: a quantitative analytical tool

OBJECTIVE

To examine whether a 3-day training course in motivational interviewing, which is an approach to helping people to change, could improve the communication skills of obstetric healthcare professionals in their interaction with obese pregnant women.

DESIGN

Intervention study.

SETTING

The Region of Southern Denmark.

METHODS

Eleven obstetric healthcare professionals working with obese pregnant women underwent a 3-day course in motivational interviewing techniques and were assessed before and after training to measure the impact on their overall performance as well as the effect on specific behavioral techniques observed during interviews.

FINDINGS

With a few exceptions, the participants changed their behavior appropriate to the motivational interviewing technique. The participants made more interventions towards the principles of motivational interviewing (adherent and nonadherent interventions). Furthermore, the participants asked fewer closed and more open questions before training in motivational interview. In the assessment of proficiency and competency, most of the participants scored higher after the training in motivational interviewing.

CONCLUSIONS

Training in motivational interviewing improves healthcare professionals' proficiency and competency when communicating with obese pregnant women, albeit that the effect was not universal.

Interventions to reduce and prevent obesity in pre-conceptual and pregnant women: a systematic review and meta-analysis

BACKGROUND

The increasing prevalence of obesity in pregnant women is associated with adverse maternal and neonatal outcomes, and increased costs to healthcare, the economy and broader society.

OBJECTIVES

To assess the efficacy of behavioural interventions for managing gestational weight gain (GWG) in the pre-conceptual and pregnancy period in overweight, obese and morbidly obese women.

SEARCH METHODS

A search was performed for published studies in the English language, from date? 2000-31 December 2012 in five electronic databases; PubMed, Scopus, Cochrane Library, CINAHL and PsycINFO.

SELECTION CRITERIA

Studies were included if they compared the efficacy or effectiveness of a particular behavioural intervention in pregnant or pre-conceptual women with standard maternity care. Studies that included women with co-morbid conditions such as diabetes mellitus and polycystic ovarian syndrome were excluded to help isolate the effect of the intervention.

RESULTS

Fifteen studies involving 3,426 participants were included. One study (n = 692) focused on the pre-conceptual period and the remaining 14 (n = 2,734) in the pregnancy period. Pooled mean difference for GWG indicated a lower GWG in the intervention groups when compared to standard maternity care groups (n = 1771, mean difference (MD) -1.66 kg, 95% CI -3.12 to -0.21 kg). With respect to the types of participants, considerable heterogeneity between studies was shown in the obese subgroup [Tau(2) = 15.61; Chi(2) = 40.80, df = 3 (P<0.00001); I(2) = 93%].

CONCLUSIONS

Behavioural interventions in pregnancy may be effective in reducing GWG in obese women without comorbid conditions, but not overweight or morbidly obese women. Behavioural interventions had no effect on postpartum weight loss or retention, gestation week of delivery and infant birth weight in overweight, obese and morbidly obese women.

Rescue of glucocorticoid-programmed adipocyte inflammation by omega-3 fatty acid supplementation in the rat

BACKGROUND

Adverse fetal environments predispose offspring to pathologies associated with the metabolic syndrome. Previously we demonstrated that adult offspring of dexamethasone-treated mothers had elevated plasma insulin and pro-inflammatory cytokines, effects prevented by a postnatal diet enriched with omega (n)-3 fatty acids. Here we tested whether prenatal glucocorticoid excess also programmed the adipose tissue phenotype, and whether this outcome is rescued by dietary n-3 fatty acids.

METHODS

Offspring of control and dexamethasone-treated mothers (0.75 μg/ml in drinking water, day 13 to term) were cross-fostered to mothers on a standard (Std) or high n-3 (Hn3) diet at birth. Offspring remained on these diets post-weaning, and serum and retroperitoneal fat were obtained at 6 months of age (n = 5-8 per group). Serum was analysed for blood lipids and fatty acid profiles, adipocyte cross sectional area was measured by unbiased stereological analysis and adipose expression of markers of inflammation, glucocorticoid sensitivity and lipid metabolism were determined by RT-qPCR analysis.

RESULTS

Serum total fatty acid levels were elevated (P < 0.01) in male offspring of dexamethasone-treated mothers, an effect prevented by Hn3 consumption. Prenatal dexamethasone also programmed increased adipose expression of Il6, Il1b (both P < 0.05) and Tnfa (P < 0.001) mRNAs regardless of fetal sex, but again this effect was prevented (for Il6 and Il1b) by Hn3 consumption. Offspring of dexamethasone-treated mothers had increased adipose expression of Gr (P = 0.008) and Ppara (P < 0.05) regardless of sex or postnatal diet, while 11bHsd1 was upregulated in males only. The Hn3 diet increased Ppard expression and reduced adipocyte size in all offspring (both P < 0.05) irrespective of prenatal treatment.

CONCLUSIONS

Prenatal glucocorticoid exposure programmed increased expression of inflammatory markers and enhanced glucocorticoid sensitivity of adipose tissue. Partial prevention of this phenotype by high n-3 consumption indicates that postnatal dietary manipulations can limit adverse fetal programming effects on adipose tissue.

Results of a randomized controlled trial to promote physical activity behaviours in mothers with young children

OBJECTIVE

Increasing levels of physical activity in mothers have long-term health benefits for the mother and family. The study aimed to evaluate the effect of a six-month, physical activity RCT for mothers of young children.

METHODS

Women were recruited via playgroups and randomly assigned to intervention (n=394) or control group (n=322). The intervention group received a six-month multi-strategy programme delivered via playgroups in Perth, Australia. measures were mean minutes per week of moderate (M) and vigorous (V) intensity physical activity (PA), and number of days/week of muscle strength exercises.

RESULTS

The intervention had a significant effect on mean time for vigorous (p=0.008), moderate (p=0.023) and total physical activity (p=0.001) when compared to the control group. The intervention group increased their vigorous activity by a mean of 24min/week, moderate activity by 23min/week and total physical activity by 72min/week.

CONCLUSIONS

A relatively minimum home based intervention was able to demonstrate modest but statistically significant improvements in physical activity in a hard to reach group. These changes if maintained over a longer period are likely to improve the health of mothers and have a positive impact on their partners and children. Australian and New Zealand Clinical Trials Registry ACTRN12609000735257.

Weight loss before conception: A systematic literature review

The prevalence of overweight and obesity in women has increased during the last decades. This is a serious concern since a high BMI before conception is an independent risk factor for many adverse outcomes of pregnancy. Therefore, dietary counseling, intended to stimulate weight loss in overweight and obese women prior to conception has recently been recommended. However, dieting with the purpose to lose weight may involve health risks for mother and offspring. We conducted a systematic literature review to identify papers investigating the effects of weight loss due to dietary interventions before conception. The objective of this study is to assess the effect of weight loss prior to conception in overweight or obese women on a number of health-related outcomes in mother and offspring using studies published between January 2000 and December 2011. Our first literature search produced 486 citations and, based on predefined eligibility criteria, 58 were selected and ordered in full text. Two group members read each paper. Fifteen studies were selected for quality assessment and two of them were considered appropriate for inclusion in evidence tables. A complementary search identified 168 citations with four papers being ordered in full text. The two selected studies provided data for overweight and obese women. One showed a positive effect of weight loss before pregnancy on the risk of gestational diabetes and one demonstrated a reduced risk for large-for-gestational-age infants in women with a BMI above 25 who lost weight before pregnancy. No study investigated the effect of weight loss due to a dietary intervention before conception. There is a lack of studies on overweight and obese women investigating the effect of dietary-induced weight loss prior to conception on health-related variables in mother and offspring. Such studies are probably lacking since they are difficult to conduct. Therefore, alternative strategies to control the body weight of girls and women of reproductive age are needed.

The Maternal Obesity Management (MOM) Trial Protocol: a lifestyle intervention during pregnancy to minimize downstream obesity

BACKGROUND

Maternal obesity and/or high gestational weight gain (GWG) are associated with downstream child obesity. Pregnancy represents a critical period for prevention as women are highly motivated and more receptive to behavior change.

OBJECTIVE

This pilot study was developed to test the feasibility of intervening with the mother, specifically keeping her GWG within the Institute of Medicine (IOM) limits, with the intended target of preventing obesity in her child downstream. We are testing the practicality of delivering a structured physical activity and nutrition intervention to pregnant women during gestation and then following mom and baby to 24 months of age.

STUDY DESIGN

This study is a two-arm, parallel group, randomized controlled trial being conducted in Ottawa. Pregnant women, with pregravid BMI >18.5, between 12 and 20 weeks gestation are randomized to one of two groups: intervention (n=30) who receive the MOM trial Handbook (guide to healthy gestation) plus a structured physical activity and nutrition program, or a standard clinical care control group (n=30). The intervention lasts 25-28 weeks (6 months) depending on anticipated delivery date, with follow-up assessment on mother and child at 3, 6, 12 and 24 months post-delivery.

SIGNIFICANCE

Pregnancy, a critical time of growth, development and physiological change, provides an opportunity for early lifestyle intervention. The goal of identifying an effective lifestyle program for the gestational period that leads to healthy fetal development and subsequently normal weight offspring, less likely to develop obesity and its co-morbidities, is unique and could possibly attenuate the inter-generational cycle of obesity.

Obesity and postpartum depression: does prenatal care utilization make a difference?

To identify (1) the association between pre-pregnancy BMI (PP-BMI) and PPD symptoms, and (2) the association between PP-BMI and PPD symptoms after considering PNC utilization as a moderating variable. Data from the 2004 and 2005 Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed from 15 states. The study design utilized two risk-adjustment approaches. One approach included all women in the dataset and used statistical analyses to risk-adjust for pregnancy risk status, and the other approach, through a sensitivity analysis, modified the design of the study by truncating the sample to include only women with healthy pregnancies. An initial association was seen between obesity and PPD symptoms, and PNC and PPD symptoms in the multivariate analyses. However, the inclusion of case-mix variables into the multivariate models removed these associations. Overall, for both approaches, there was no indication of a moderating effect of PNC utilization. Results also revealed that many of the women were significantly affected by a variety of high-risk maternal morbidity (case-mix) variables. Although PNC is important for the health of mothers and babies, it does not appear to moderate the association of PP-BMI and PPD symptoms. However, since this study revealed associations between several high-risk maternal morbidities (included as case-mix variables), and PPD symptoms, it is recommended that future research further investigate the possible association of these morbidities with PPD symptoms. For practice, it is suggested that PNC providers focus on their patients, and establish suitable interventions accordingly.

A systematic review investigating healthy lifestyle interventions incorporating goal setting strategies for preventing excess gestational weight gain

BACKGROUND

Excess gestational weight gain (GWG) is an important risk factor for long term obesity in women. However, current interventions aimed at preventing excess GWG appear to have a limited effect. Several studies have highlighted the importance of linking theory with empirical evidence for producing effective interventions for behaviour change. Theorists have demonstrated that goals can be an important source of human motivation and goal setting has shown promise in promoting diet and physical activity behaviour change within non-pregnant individuals. The use of goal setting as a behaviour change strategy has been systematically evaluated within overweight and obese individuals, yet its use within pregnancy has not yet been systematically explored.

AIM OF REVIEW

To explore the use of goal setting within healthy lifestyle interventions for the prevention of excess GWG.

DATA COLLECTION AND ANALYSIS

Searches were conducted in seven databases alongside hand searching of relevant journals and citation tracking. Studies were included if interventions used goal setting alongside modification of diet and/or physical activity with an aim to prevent excess GWG. The PRISMA guidelines were followed and a two-stage methodological approach was used. Stage one focused on systematically evaluating the methodological quality of included interventions. The second stage assessed intervention integrity and the implementation of key goal setting components.

FINDINGS

From a total of 839 citations, 54 full-text articles were assessed for eligibility and 5 studies met the inclusion criteria. Among interventions reporting positive results a combination of individualised diet and physical activity goals, self-monitoring and performance feedback indicators were described as active components.

CONCLUSION

Interventions based on goal setting appear to be useful for helping women achieve optimal weight gain during pregnancy. However, overweight and obese women may require more theoretically-designed interventions. Further high quality, theoretically-designed interventions are required to determine the most effective and replicable components for optimal GWG.

Strategies to Promote Physical Activity During Pregnancy: A Systematic Review of Intervention Evidence

Physical activity during pregnancy has been associated with significant health benefits, however most women in the United States do not meet current guidelines. This systematic review evaluates evidence for interventions to improve physical activity during pregnancy in order to identify best practices and inform future research. Electronic databases (PubMed, CINAHL, SportDISCUS, Embase, ERIC, Psych Info and ISI Web of Science) were searched in July 2011 for peer-reviewed journal articles. Studies were included if they were English-language randomized control trials that measured the efficacy of an intervention targeted to pregnant women and designed to change physical activity as a primary or secondary outcome. Out of 777 studies identified through the systematic search, nine interventions were identified for inclusion by multiple reviewers. Data was abstracted using an abstraction form modeled after the "Guide to Community Preventive Services." Of the nine interventions included in the review, three reported statistically significant positive results for physical activity. While interventions included a variety of strategies and techniques, none were uniquely associated with positive outcomes. Overall this review suggests that little is known about the efficacy of interventions for physical activity during pregnancy. We provide several recommendations for future research and intervention design.

Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis

BACKGROUND

Overweight and obesity pose a big challenge to pregnancy as they are associated with adverse maternal and perinatal outcome. Evidence of lifestyle intervention resulting in improved pregnancy outcome is conflicting. Hence the objective of this study is to determine the efficacy of antenatal dietary, activity, behaviour or lifestyle interventions in overweight and obese pregnant women to improve maternal and perinatal outcomes.

METHODS

A systematic review and meta-analyses of randomised and non-randomised clinical trials following prior registration (CRD420111122 http://www.crd.york.ac.uk/PROSPERO) and PRISMA guidelines was employed. A search of the Cochrane Library, EMBASE, MEDLINE, CINAHL, Maternity and Infant care and eight other databases for studies published prior to January 2012 was undertaken. Electronic literature searches, study selection, methodology and quality appraisal were performed independently by two authors. Methodological quality of the studies was assessed according to Cochrane risk of bias tool. All appropriate randomised and non-randomised clinical trials were included while exclusions consisted of interventions in pregnant women who were not overweight or obese, had pre-existing diabetes or polycystic ovarian syndrome, and systematic reviews. Maternal outcome measures, including maternal gestational weight gain, gestational diabetes and Caesarean section, were documented. Fetal outcomes, including large for gestational age and macrosomia (birth weight > 4 kg), were also documented.

RESULTS

Thirteen randomised and six non-randomised clinical trials were identified and included in the meta-analysis. The evidence suggests antenatal dietary and lifestyle intervention in obese pregnant women reduces maternal pregnancy weight gain (10 randomised clinical trials; n = 1228; -2.21 kg (95% confidence interval -2.86 kg to -1.59 kg)) and a trend towards a reduction in the prevalence of gestational diabetes (six randomised clinical trials; n = 1,011; odds ratio 0.80 (95% confidence interval 0.58 to 1.10)). There were no clear differences reported for other outcomes such as Caesarean delivery, large for gestational age, birth weight or macrosomia. All available studies were assessed to be of low to medium quality.

CONCLUSION

Antenatal lifestyle intervention is associated with restricted gestational weight gain and a trend towards a reduced prevalence of gestational diabetes in the overweight and obese population. These findings need to be interpreted with caution as the available studies were of poor to medium quality.

Can we modify the intrauterine environment to halt the intergenerational cycle of obesity?

Child obesity is a global epidemic whose development is rooted in complex and multi-factorial interactions. Once established, obesity is difficult to reverse and epidemiological, animal model, and experimental studies have provided strong evidence implicating the intrauterine environment in downstream obesity. This review focuses on the interplay between maternal obesity, gestational weight gain and lifestyle behaviours, which may act independently or in combination, to perpetuate the intergenerational cycle of obesity. The gestational period, is a crucial time of growth, development and physiological change in mother and child. This provides a window of opportunity for intervention via maternal nutrition and/or physical activity that may induce beneficial physiological alternations in the fetus that are mediated through favourable adaptations to in utero environmental stimuli. Evidence in the emerging field of epigenetics suggests that chronic, sub-clinical perturbations during pregnancy may affect fetal phenotype and long-term human data from ongoing randomized controlled trials will further aid in establishing the science behind ones predisposition to positive energy balance.

Obesity in pregnancy: implications for the mother and lifelong health of the child. A consensus statement

Obesity among pregnant women is becoming one of the most important women's health issues. Obesity is associated with increased risk of almost all pregnancy complications: gestational hypertension, preeclampsia, gestational diabetes mellitus, delivery of large-for-GA infants, and higher incidence of congenital defects all occur more frequently than in women with a normal BMI. Evidence shows that a child of an obese mother may suffer from exposure to a suboptimal in utero environment and that early life adversities may extend into adulthood. In September 2009, ILSI Europe convened a workshop with multidisciplinary expertise to review practices and science base of health and nutrition of obese pregnant women, with focus on the long-term health of the child. The consensus viewpoint of the workshop identified gaps and gave recommendations for future research on gestational weight gain, gestational diabetes, and research methodologies. The evidence available on short- and long-term health impact for mother and child currently favors actions directed at controlling prepregnancy weight and preventing obesity in women of reproductive ages. More randomized controlled trials are needed to evaluate the effects of nutritional and behavioral interventions in pregnancy outcomes. Moreover, suggestions that maternal obesity may transfer obesity risk to child through non-Mendelian (e.g. epigenetic) mechanisms require more long-term investigation.

Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials

BACKGROUND

Excessive gestational weight gain (GWG) increases the risk of a number of adverse pregnancy outcomes and was recently identified as a potential risk factor for childhood obesity. It is therefore of interest whether GWG can be modified by an intervention combining dietary counseling and physical activity.

OBJECTIVE

The objective was to review published data on interventions to reduce GWG by modulating diet and physical activity during pregnancy.

DESIGN

We systematically reviewed 4 databases and bibliographies of various publications supplemented by a hand-search for relevant articles published in English or German and performed a meta-analysis to quantify the effect estimate by a random-effects model.

RESULTS

Four randomized controlled trials and 5 nonrandomized trials with a total of 1549 women enrolled were identified as being relevant. Meta-analyses of all 9 trials indicated a lower GWG in the intervention groups, with a standardized mean difference of -0.22 units (95% CI: -0.38, -0.05 units). We observed no indication for publication bias.

CONCLUSIONS

Interventions based on physical activity and dietary counseling, usually combined with supplementary weight monitoring, appear to be successful in reducing GWG. The results are of particular interest with respect to the objective of preventing excessive GWG.

Efficacy of therapeutic patient education in chronic diseases and obesity

OBJECTIVE

To evaluate the clinical, methodological and reporting aspects of systematic reviews and meta-analyses in order to determine the efficacy of therapeutic patient education (TPE).

METHODS

A thorough search of the medical and nursing literature recorded in MedLine database from 1999 to August 2009 was conducted using the keywords: patient education, efficacy, diabetes, asthma, COPD, hypertension, cardiology, obesity, rheumatology, and oncology.

RESULTS

Thirty five relevant meta-analyses were identified and initially selected for critical analyses (598 studies concerning approximately 61,000 patients). The detailed description of the educative intervention was present in 4% of articles whereas in 23% the interventions were briefly described. In the majority of studies, the educative interventions were only named (49%) or totally absent (24%). The majority of studies reported improvement of patient outcomes due to the TPE (64%), 30% of studies reported no effect of TPE and 6% of the analysed reviews and meta-analyses reported worsening of measured outcomes.

CONCLUSION

Patient education could improve patient outcomes. The high benefit from TPE was shown by articles with detailed description of educational intervention as well as by those who report multidimensional and multidisciplinary educational intervention.

PRACTICE IMPLICATIONS

The impact of therapeutic patient education on health outcomes is 50-80%.

Obesity in pregnancy: outcomes and economics

Maternal obesity is an important aspect of reproductive care. It is the commonest risk factor for maternal mortality in developed countries and is also associated with a wide spectrum of adverse pregnancy outcomes. Maternal obesity may have longer-term implications for the health of the mother and infant, which in turn will have economic implications. Efforts to prevent, manage and treat obesity in pregnancy will be costly, but may pay dividends from reduced future economic costs, and subsequent improvements to maternal and infant health. Decision-makers working in this area of health services should understand whether the problem can be reduced, at what cost; and then, what cost savings and health benefits will accrue in the future from a reduction of the problem.

Multiparity is associated with high motivation to change diet among overweight and obese postpartum women

BACKGROUND

Pregnancy is associated with weight gain and obesity. The aim of this study was to identify the effect of parity and other factors on motivation to change diet to lose weight in a cohort of overweight and obese postpartum women.

STUDY DESIGN

Active Mothers Postpartum is a randomized, controlled trial aimed at postpartum weight reduction. At baseline, we measured motivation to change diet to lose weight among 491 overweight/obese postpartum women. Logistic regression was used to model the effect of parity on motivation to change diet at baseline while adjusting for potential confounders including age, race, education, body mass index category, and breastfeeding status.

RESULTS

Approximately two thirds (68%) of participants were highly motivated to change their diet to lose weight. In the multivariable model, women with three or more children had 2.5 times the odds of high motivation compared with primigravid women, and women not breastfeeding had 1.6 times the odds of high motivation compared with any breastfeeding.

CONCLUSION

Although risk for obesity is incurred starting with a woman's first pregnancy, women in this study were more motivated to change their diet to lose weight after their third pregnancy. Further research is needed to understand how to best capitalize on the high motivation in women with several children as well as how to improve motivation for primigravid women and women who are breastfeeding.