Preventing Excessive Gestational Weight Gain and Postpartum Weight Retention.

V O’Dwyer, F McAuliffe.

National Maternity Hospital, Holles street, Dublin 2.

Pregnancy and the postpartum period are unique opportunities to promote healthy lifestyle choices including a healthy diet and regular exercise. This is especially important for those who are overweight or obese. Women are weighed at their first antenatal visit and body mass index (BMI) calculated, but not all hospitals routinely weigh women throughout pregnancy. A qualitative Dublin study examined experiences of routine weighing during antenatal care. This study found that women expected to be weighed during pregnancy and postpartum. The benefits of this included providing reassurance and minimising postpartum weight retention. Furthermore, women were eager to receive more information about healthy lifestyle interventions and gestational weight gain (GWG) from healthcare professionals1. It has been shown that women with a BMI ≥ 25kg/m2 make food choices and physical activity behavioural choices based on a number of factors including social support, food modelling, social facilitation and obesogenic environment. They will also make positive choices in an effort to achieve a good pregnancy outcome2. Gestational weight gain guidelines were published by the Institute of Medicine in 2009. These recommendations are based on BMI at the first antenatal visit. They suggest lower GWG for women who are overweight and obese compared with those with a normal BMI prior to pregnancy. However, it has been shown that obese women are more likely to exceed their recommended GWG of 5-9kg compared with those with a normal BMI, whose recommended GWG is 12.5-18kg3. A systematic review showed that low educational attainment was also likely to be associated with women gaining outside the Institute of Medicine recommendations for GWG. Thus it was suggested that healthcare providers should provide additional support to these pregnant women to reduce the gap in health inequalities between those of high and low socioeconomic status4.

Most pregnant women in Ireland are overweight based on their BMI at the first antenatal visit. In an Irish study of 10,524 mothers the mean postpartum BMI was 25.7 ± 5.4 kg/m2 and 16.8% of the women were obese. Postpartum maternal obesity levels were associated positively on univariable analyses with lower household income and earlier completion of full-time education. On multivariable analysis, maternal obesity was associated with increasing parity in lower income households suggesting the problem gets worse with each pregnancy5. So how do we prevent GWG and postpartum weight retention? A randomised control trial examining the effect of a low glycaemic index diet on pregnancy outcomes including gestational weight gain showed that women in the intervention arm gained significantly less weight in pregnancy (12.2 vs. 13.7kg; p=0.01).6 Furthermore, they continued this positive lifestyle intervention to three months postpartum. This resulted in greater weight loss from pre-pregnancy to three months postpartum than the control group (1.3 vs. 0.1 kg, p = 0.022)7. Encouraging a positive lifestyle change during pregnancy and postpartum requires a multidisciplinary approach including general practitioners, obstetricians and dieticians. But what is the best forum to deliver this support? A recent study has used positive lifestyle interventions in conjunction with web based technology in an effort to improve pregnancy outcomes for mother and baby by reducing the incidence of gestational diabetes mellitus.

The PEARS study, a randomised controlled trial in women with a BMI ≥25kg/m2 used a healthy lifestyle package including a motivational counselling session to encourage behaviour change, low glycaemic index, nutritional advice and daily physical activity prescription delivered before 18 weeks gestation, as well as a smart phone app to provide ongoing healthy lifestyle advice and support throughout pregnancy8. A recent cluster randomised controlled trial evaluated an internet based intervention in addition to standard weight loss management strategies to promote postpartum weight loss in low income women. The weight loss programme included a recommended calorie intake ranging from 1200 to 1800 calories per day based on study entry weight, with 300 additional calories for mothers who were breastfeeding. Exercise was gradually increased to 30 minutes or more on most days. There was an interactive web based strategy used over a 12-month period which provided weekly lessons with automated feedback, an online diary, a weight and physical activity tracker, videos, and a message board. Four weekly text messages notified participants of new website content and provided motivation and feedback. Advantages of this trial were its long duration compared with previous studies, and the interactive web based technology was available in English and Spanish. Limitations of the study were that pre-pregnancy weight was self-reported as was dietary intake during the study. Of the 371 participants those in the intervention arm lost more weight (0.9 vs 3.2kg) and were more likely to return to pre-pregnancy weight by increasing physical activity and decreasing calorie intake compared with the control group9.

Women who are overweight or obese are at increased risk of pregnancy complications including hypertensive disorders of pregnancy, gestational diabetes mellitus (GDM) and venous thromboembolism. They are also more likely to require pregnancy interventions such as induction of labour caesarean section. For those that develop gestational diabetes mellitus they are cared for by a multidisciplinary team and given advice regarding diet to ensure good glycaemic control. All women with GDM have a glucose tolerance test at 6 weeks postpartum to check for Type 2 diabetes. Even if this is normal these women are at increased risk of developing Type 2 diabetes within 10 years. A new clinic at the National Maternity Hospital has been set up to help women with a BMI >30kg/m2 and a history of GDM to lose weight prior to their next pregnancy. Women are seen by an obstetrician and an endocrinologist at this clinic. Interventions used include providing information about the benefits of weight loss and treatment options of a supervised diet and exercise regime or medications over a three month period. This will hopefully prevent pregnancy complications and interventions and improve their long term health.

The average woman is beginning pregnancy with a BMI in the overweight category. Retaining gestational weight gain will push some of these women into the obese BMI category. Obesity is associated with adverse health outcomes such as diabetes and cardiovascular disease. It is therefore important that women lose weight postpartum and return to their pre-pregnancy weight. Using diet and exercise interventions with the addition of web based tools can facilitate this positive lifestyle change and improve long-term health.

Vicky O’Dwyer, National Maternity Hospital, Holles street, Dublin 2.
Phone number: 016373100

1. O’Dwyer V, O’Toole F, Darcy S, Farah N, Kennelly MM, Turner MJ. Maternal obesity and gestational weight gain. J Obstet Gynaecol. 2013 Oct; 33(7): 671-4.
2. O’Brien EC, Alberdi G, McAuliffe FM. The influence of socioeconomic status on gestational weight gain: a systematic review. J Public Health (Oxf). 2017 Apr 7:1-15.
3. Turner MJ, Layte R. Obesity levels in a national cohort of women 9 months after delivery. Am J Obstet Gynecol. 2013 Aug;209(2):124.e1-7.
4. Allen-Walker V, Mullaney L, Turner MJ, Woodside JV, Holmes VA, McCartney DM, McKinley MC. How do women feel about being weighed during pregnancy? A qualitative exploration of the opinions and experiences of postnatal women. Midwifery. 2017 Jun; 49: 95-101.
5. Walsh JM, McGowan CA, Mahony R, Foley ME, McAuliffe FM.Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised controlled trial. BMJ 2012 Aug 30; 345: e5605.
6. Horan MK, McGowan CA, Gibney ER, Donnelly JM, McAuliffe FM. Maternal diet and weight at 3 months postpartum following a pregnancy intervention with a low glycaemic index diet: results from the ROLO randomised control trial. Nutrients. 2014 Jul 23; 6(7): 2946-55.
7. O’Brien OA, Lindsay KL, McCarthy M, McGloin AF, Kennelly M, Scully HA, McAuliffe FM. Influences on the food choices and physical activity behaviours of overweight and obese pregnant women: A qualitative study.
Midwifery. 2017 Apr; 47: 28-35.
8. Kennelly MA, Ainscough K, Lindsay K, Gibney E, Mc Carthy M, McAuliffe FM.
Pregnancy, exercise and nutrition research study with smart phone app support (Pears): Studyprotocol of a randomized controlled trial.
Contemp Clin Trials. 2016 Jan; 46: 92-9.
9. Phelan S, Hagobian T, Brannen A, Hatley KE, Schaffner A, Munoz-Christian K, Tate DF. Effect of an internet based program on weight loss for low-income postpartum women. Jama 2017; 317 (23): 2381-91.