Edited by: Katherine Samaras, St Vincent's Hospital Sydney, Australia
Reviewed by: Sally Abell, Monash University, Australia; Tinh-Hai Collet, Lausanne University Hospital (CHUV), Switzerland
This article was submitted to Obesity, a section of the journal Frontiers in Endocrinology
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Overweight and obesity are increasing steadily in all age groups worldwide, especially in low- and middle income countries (
Pre-pregnancy obesity-related risks to women and offspring.
Before conception | Menstrual cycle dysregulation, anovulation and infertility ( |
– |
Pregnancy | Miscarriage ( |
Congenital defects ( |
Delivery | Cesarean sections Labor induction, surgical complications and failures of epidural analgesia ( |
Stillbirth ( |
Postpartum | Difficulties in initiating and sustaining breastfeeding ( |
Systematic transfer to monitoring in case of GDM (risk of hypoglycemia) ( |
Long-term | Postpartum weight retention and inter-pregnancy obesity ( |
Childhood obesity and premature metabolic syndrome ( |
Large for gestational age neonates have a 50% risk of developing obesity and a metabolic syndrome between 6 and 11 years of age (
In 2016, a world report from the Non-Communicable Diseases Risk Factor Collaboration indicated that age-standardized prevalence of obesity increased from 3.2% in 1975 to 10.8% in 2014 in men, and from 6.4 to 14.9% in women (
Ideally, total GWG is calculated as the difference between body weight at the first trimester and last antenatal visit prior delivery (
Excessive GWG is a known risk factor for multiple adverse outcomes such as GDM, pregnancy-induced hypertension, preeclampsia, stillbirth, macrosomia, and post-partum hemorrhage (
Inter-pregnancy weight gain, which may be due to PPWR or additional weight gain between gestations, is also associated with adverse pregnancy outcomes (
Despite the growing evidence that maternal obesity and excessive GWG are risk factors for major obstetrical complications, poor subsequent maternal and child health, and for the transmission of obesity to the next generations (
In 1990, the U.S.A. IOM produced guidelines for GWG which were been updated in 2009 (Table
The United States of America Institute of Medicine Recommendations (2009) for total weight gain during pregnancy, by pre-pregnancy body mass index.
Underweight | <18.5 | 12.7–18 (28–40) |
Normal weight | 18.5–24.9 | 11.3–15.9 (25–35) |
Overweight | 25–29.9 | 6.8–11.3 (15–25) |
Obesity (classes I, II, III) | >30 | 5–9 (11–20) |
Pregnant women with obesity often lack knowledge about related complications during pregnancy, and communication with healthcare providers is often experienced as stressful, confusing and judgmental (
The aim of the following overview of systematic reviews and meta-analyses was to identify lifestyle interventions that have shown to be effective in controlling GWG, PPWR and thus improve maternal and child outcomes, in order to inform health care professionals and policy makers.
A review of international systematic reviews and meta-analyses published in all languages between 1st January 2009 (year of publication of the revised IOM guidelines) (
Systematic reviews or meta-analyses that evaluated dietary, physical activity, well-being or a multi-component interventions in pregnancy or postpartum were included. They selected only randomized controlled trials (RCT), or provided a separate analysis for RCTs. The main outcome measures were GWG, or GWG above the IOM guidelines, PPWG or postpartum weight loss (PPWL). Studies could include healthy women from any BMI class or parity, with a singleton pregnancy. Comparators are standard care or minimal care or no intervention.
The Medline, Pubmed, Web of Science and the Cochrane Library databases were used with a combination of the following keywords: (“obesity” OR “overweight” OR “weight gain” OR “weight retention” OR “weight loss” OR “weight management” OR “weight control”) AND (“pregnan*” OR “gestation” OR “obstetrics” OR “post-partum” OR “postpartum” OR “postnatal” OR “post pregnancy” OR “post childbirth” OR “following pregnancy” OR “following childbirth”) AND (“lifestyle” OR “behavior” OR “exercise” OR “physical activity” OR “fitness” OR “diet*” OR “nutrition” OR “food” OR “well-being” OR “mental health” OR ”psychological health”).
Finally, the keywords (“outcome*” OR “complication*” OR “co-morbidities” OR “gestational diabetes” OR “hypertension” OR “pre-eclampsia” OR preeclampsia” OR “hemorrhage” OR “hemorrhage” OR “prematurity” OR “stillbirth” OR “macrosomia” OR “large for gestational age” OR ”small for gestational age” OR “dystocia” OR “congenital defect*” OR “neonatal complication*”) were combined to the primary search to assess effects of interventions on maternal or fetal/neonatal outcomes.
The search was performed by one person (NFL) in the context of a Master's project in Global Health Policy at the London School of Hygiene and Tropical Medicine, University of London. The specificity of the search was increased using search filters for systematic reviews or meta-analyses (Pubmed). The references obtained in the articles were scanned to ensure a complete collection of the relevant systematic reviews and meta-analyses, however no additional articles were found.
The following data were extracted from the selected systematic reviews and meta-analyses: “a priori” design, search strategy and data, inclusion criteria for selected studies, included studies, countries, participant's characteristics, recruitment, type of interventions, methods of delivery, comparator, outcome measures, quality assessment, analysis, methods used to combine findings, weighted mean difference or risk ratio (and 95% confidence interval), reported quality of evidence, conclusions, source of support and conflicts of interest (for either the review and included primary study authors).
Reviews had to report an objective assessment of the methodological quality of studies to assess the risk of bias, as well as heterogeneity and sensitivity analysis (Guidelines of the US National Heart, Lung and Blood Institute) (
The Ethics Committee of the London School of Hygiene and Tropical Medicine of the University of London considered that this research did not require approval.
The search from the standardized computer databases yielded 3,116 articles (Figure
Flow diagram of the systematic reviews retrieved for the review.
Twelve antenatal and six postpartum reviews of lifestyle interventions on GWG or PPWR were identified (Table
Summary of effects of lifestyle interventions on gestational weight gain and postpartum weight loss.
Streuling et al. ( |
12 | Any BMI | 906 | 33 | 75 | C | −0.61 | −1.17 to −0.06 | 25 |
Elliot-Sale et al. ( |
3 | Any BMI | 214 | 28 | 64 | D | −2.22 | −3.14 to −1.30 | 0 |
da Silva et al. ( |
18 | Any BMI | 3,203 | 30 | 68 | D | −1.1 | −1.53 to −0.69 | 0 |
Perales et al. ( |
29 | Any BMI | Not reported | 16 | 36 | D | n.a. | ||
Muktabhant et al. ( |
3 | Any BMI | 444 | 40 | 91 | A | −1.8 | −3.36 to −0.24 | 76 |
Thangaratinam et al. ( |
30 | Any BMI | 3,140 |
41 | 93 | A | −1.40 | −2.09 to −0.71 | 80 |
Shepherd et al. ( |
16 | Any BMI | 5,052 | 42 | 95 | A | −0.89 | −1.39 to −0.40 | 43 |
International Weight Management in Pregnancy Collaborative ( |
33 | Any BMI | 11,410 | 33 | 75 | C | −0.7 | −0.92 to −0.48 | 0 |
O'Brien et al. ( |
4 | Any BMI | 446 | 30 | 68 | D | −1.25 | −2.39 to 0.11 | 42 |
Lau et al. ( |
7 | OW/OB | 1,652 | 36 | 82 | B | −0.63 | −1.07 to −0.20 | 14 |
Choi et al. ( |
7 | OW/OB | 721 | 30 | 68 | D | −0.91 | −1.76 to −0.06 | 8 |
Flynn et al. ( |
13 | OW/OB | 4,276 | 27 | 61 | D | NA | ||
Elliot-Sale et al. ( |
2 | Any BMI | 214 | 28 | 64 | D | −1.74 ( |
−3.59 to 0.10 | 0 |
Berger et al. ( |
13 | Any BMI | 1,310 | 32 | 73 | C | n.a. | ||
Nascimento et al. ( |
11 | Any BMI | 769 | 33 | 75 | C | −2.57 | −3.66 to−1.47 | 66 |
Lim et al. ( |
32 | Any BMI | 1,892 | 29 | 66 | D | −2.3 | −3.22 to −1.39 | 84 |
Lau et al. ( |
3 | OW/OB | 251 | 36 | 82 | B | −3.6 | −6.59 to −0.62 | 84 |
Choi et al. ( |
4 | OW/OB | 547 | 30 | 68 | D | −1.22 | −1.89 to −0.56 | 25 |
Summary of effects of lifestyle interventions during pregnancy on relative risks of maternal and neonatal outcomes.
Streuling et al. ( |
12 | Any BMI | 906 | C | ||||||||
Elliot-Sale et al. ( |
3 | Any BMI | 214 | D | ||||||||
da Silva et al. ( |
18 | Any BMI | 3,203 | D | 0.67 |
0.51 |
||||||
Perales et al. ( |
57 | Any BMI | Not reported | D | Reduced risk (4/14 RCTs, aerobic + resistance training), weak. | Reduced risk (1/12 RCTs, aerobic + resistance training), weak. | Reduced risk (3/15 RCTs, aerobic + resistance training), weak. | Reduced risk (3/21 RCTs, aerobic + resistance training), weak. | ||||
Muktabhant et al. ( |
3 | Any BMI | 444 | A | 0.70 |
0.89 |
||||||
Thangaratinam et al. ( |
30 | Any BMI | Subroup analysis |
A | Diet |
Diet |
Diet |
Diet |
||||
Shepherd et al. ( |
16 | Any BMI | 6,633 | A | 0.85 |
0.95 |
0.89 |
0.56 (0.33–0) | ||||
International Weight Management in Pregnancy Collaborative ( |
33 | Any BMI | 11,410 | C | 0.91 |
|||||||
O'Brien et al. ( |
4 | Any BMI | 446 | D | 0.34 |
|||||||
Lau et al. ( |
7 | OW/OB | 1,652 | B | ||||||||
Choi et al. ( |
7 | OW/OB | 721 | D | ||||||||
Flynn et al. ( |
13 | OW/OB | 4276 | D |
Participants were healthy women with a singleton pregnancy or postpartum. Both nulliparous and multiparous women were included. Most antenatal studies recruited participants at less than 20 weeks' gestation. The 15 reviews comprised of five to 65 RCTs, and involved 251 to 11,410 women. Three reviews in pregnancy (
Twelve reviews examined the effectiveness of interventions that aimed to change lifestyle (diet, physical activity or both) in pregnant women with any BMI (
Antenatal physical activity interventions generally consisted of 20–70 min of exercise per day at light to moderate intensity, 2–5 days per week. Selected trials included supervised (
Six reviews examined the effectiveness of interventions that aimed to improve lifestyle (diet, physical activity or both) in postpartum women with any BMI (
The comparator in each of the 12 reviews in pregnancy was “usual or standard care.” In the six postpartum reviews, “usual or minimal care,” true control (no intervention) or an alternative concomitant intervention (information printouts) were used as comparators.
Eleven reviews in pregnancy examined the same primary outcome measures (GWG, excessive GWG according to the IOM recommendations); one review selected GDM as the primary outcome measure, but included GWG as a secondary outcome (
The six postpartum reviews examined PPWR or PPWL as the primary outcome. Two studies assessed maternal outcomes: cardio-metabolic risks (
The R-AMSTAR assessment results for each review are shown in Table
The bias associated with the included trials varied widely across the reviews. Random sequence generation was at low risk of bias for the majority of included studies. Allocation concealment was generally of low or unclear risk of bias. Performance bias was high risk for the majority of the trials, mostly due to the difficulty of blinding study personnel and participants in lifestyle interventions. Detection bias also varied across the reviews, with lower risk of bias for objective outcomes (e.g., body weight). There was an unclear or high risk of attrition bias especially in postpartum trials (drop-out up to 50%). Selective reporting bias was generally unclear or high risk in a large proportion of trials in each review. The proportion of trials with low risk of other biases varied across the reviews.
Four reviews assessed the overall quality of the evidence using the GRADE method (
The summary of effects of antenatal and postpartum lifestyle interventions on GWG (
Systematic reviews and meta-analysis that assessed the effect physical activity interventions in pregnancy.
Streuling 2011 (SR+MA) |
12 RCTs on GWG. | Any BMI | Light-moderate intensity supervised |
Significant reduction of GWG |
No dose-dependent effect. | |
da Silva 2017 (SR+MA) |
18 RCTs on maternal/ infant outcomes (51 cohort studies excluded) | Any BMI | Moderate intensity supervised PA; |
Significant reduction of GWG |
Reduced RR of GDM (0.67, 0.49–0.92; |
|
Perales 2016 (SR) ( |
57 RCTs on maternal health or perinatal outcomes | Any BMI | 15 trials aerobic exercises; 4, resistance exercises; 30 combined; 8 counseling. 49 RCTs included supervised PA; 23 of them examined effects of supervised PA on GWG. |
Weak evidence for reduced GWG or for higher likelihood of GWG within IOM guidelines after aerobic or aerobic + resistance exercises or counseling. | Combined aerobic and resistance training: strong evidence for improved cardiorespiratory fitness and reduced urinary incontinence. Weak evidence for reduced GDM, |
|
Elliott-Sale 2015 |
3 RCTs on GWG, from 1990 only | Any BMI | Light-moderate intensity supervised PA; combined aerobic and resistance exercises; frequency 3–5 days/week; 45–60 min. Duration: 12–33 week. | Significant reduction of GWG (−2.22 kg; −3.14 to −1.3, |
Methodological quality varied considerably across trials. Small number of RCTs. |
Systematic reviews and meta-analysis that assessed the effect of multi-component interventions in pregnancy.
Muktabhant 2015 (Cochrane SR+MA) ( |
65 RCTs on GWG | All BMI | Dietary counseling (healthy diet or low-fat or low glycemic load or low-energy diet), supervised or unsupervised exercise, or diet and exercise combined. Duration: from the 1st-2nd to the 3rd trimester. | Reduced risk for excessive GWG (RR 0.80, 0.73–0.87; |
Reduced RR of gestational HTA (0.70, 0.51–0.96; |
|
Thangaratinam 2012 |
34 RCTs on GWG | All BMI (11/34 trials included OW/OB women) | Balanced diet: proteins (15–20%), fat (max. 30%), carbohydrates (50–55%) with low glycemic index; light to moderate intensity PA (resistance training, weight-bearing exercises, walking) or multi-component interventions (using behavioral change techniques and feed-back on weight gain). | Subgroup analysis (excluding women with pre-existing diabetes or GDM; 30 RCTs): Overall reduction of GWG (−1.4 kg, 95% CI −2.09 to −0.71; |
Diet only interventions: significant decrease of risk of gestational HTA (RR 0.30, 95% CI 0.10–0.88) and preterm delivery (0.26, 0.09–0.74). |
|
Shepherd 2017 |
23 RCTs for preventing GDM | All BMI | Combined diet and PA interventions. | Significant reduction of GWG |
Reduced risks of cesarean section (0.95, 95% CI 0.88–1.02; 6,089 women; 14 RCTs; moderate-quality evidence) and respiratory distress syndrome (0.56, 0.33–0; 2,411 women, 2 RCTs). Trend toward a reduction of the risk of GDM (RR 0.85; 0.71–1.01; 6,633 women; 19 RCTs; Tau2 = 0.05; |
|
i-WIP 2017 (SR+MA) |
36 RCTs on maternal and child outcomes. | All BMI (13/36 trials included OW/OB women) | Diet, physical activity or multi-component interventions. | Significant reduction of GWG (−0.70 kg, −0.92 to −0.48 kg, |
High-quality evidence that interventions reduced the risk of cesarean section (RR 0.91, 0.83–0.99, |
|
O'Brien 2016 (SR+MA) |
12 RCTs on GWG. | All BMI | Written information on diet and physical activity + phone calls or regular weighting; visits with a dietician combined with an exercise program 3–5 days/week in 4 trials. |
Significant reduction of GWG (−1.25 kg; −2.39 to 0.11; |
Wide variation in the type of intervention, the number of contacts, and the intensity. Reduced RR for hypertension (RR 0.34, 0.13–0.91, I2 0%; 243 women; 2 RCTs). No effect on GDM, preeclampsia, preterm birth, macrosomia or SGA. | |
Lau 2017 (SR+MA) ( |
7 RCTs on GWG. | OW/OB | E-based lifestyle interventions (theoretical or conceptual frameworks). Duration: 4 week to 12 months. 7 trials conducted a follow-up up to 12 months. | Significant reduction of GWG |
Interventions incorporating in-person ( |
|
Choi 2013 (SR+MA) |
7 RCTs | OW/OB | 5 RCTs included supervised light-moderate PA activity 3 days/week or multi-component supervised physical activity 1x/week + diet counseling. Duration: from the 1st-2nd to the 3rd trimester. | Significant reduction of GWG (−0.91 kg; −1.76 to −0.06; |
Supervised physical activity plus diet showed a significant greater effect on GWG (−1.17 kg; −2.14 to −0.21; |
|
Flynn 2016 (SR) |
13 RCTs on GWG. | OW/OB | Diet only or multi-component diet and PA interventions. National recommendations (energy intake 18–24 kcal/kg in 2 trials); individual feedback and alternative healthy choices. Duration 12–30 weeks. | Multi-component interventions: Significant reduction of GWG in 5 of 10 trials in all women and in one trial including only OB women. Diet only interventions: significant reduction in the 3 trials. | Considerable variation in the methodological design of dietary interventions. No evidenced-based approach for any specific dietary regimen. |
Systematic reviews and meta-analysis that assessed the effect of multi-component diet and physical activity interventions in postpartum.
Elliott-Sale 2015 |
2 RCTs | All BMI | Individual walking; frequency 4–7 days/week; 45 min; duration 12 weeks. | No significant effect on PPWL |
||
Lau 2017 (SR + MA)(80) | 5 RCTs on PPWL | OW/ OB | E-based lifestyle interventions (diet, physical activity and weight management components; theoretical or conceptual frameworks); behavioral goals, counseling and skill training, self-monitoring, feed-back. Duration 4 weeks to 12 months. | Significant PPWL (−3.60 kg; 95% CI 6.59–0.62; |
Significant increase of MVPA at 6 and 13 weeks, and 12 months postpartum (via subjective measures). Significant reduction of caloric intake at 12–20 weeks and 12 months postpartum using the diet-related software measures. No effect on maternal or neonatal complications. | |
Berger 2014 (SR)(85) | 13 RCTs on PPWR |
All BMI | Nutrition, exercise or combined diet and PA interventions. Individual counseling, informational pamphlets, telephone calls, text messages, pedometer. Duration 3 to 9 months. | No effect in the 4 good quality RCTs (combined diet and PA). The 4 fair to good quality RCTs reported greater weight loss (from−4.9 to−0.17 kg) in the combined intervention group vs standard care. No effect of diet of PA alone. | No effect on metabolic risk factors or inflammatory biomarkers. Significant reduction of waist-to-hip ratio in one PA trial. | |
Nascimento 2014 |
11 RCTs on PPWL | All BMI |
Supervised (4 trials) or unsupervised PA (7 trials; heart rate monitor or pedometer, personalized counseling, correspondence programs, text messages, phone calls, web). Walking or general aerobic exercises were recommended. Resistance exercises combined with walking in one trial. Healthy diet or calorie restricted diet. Duration: 10 to 52 weeks. | Significant PPWL (−2.57 kg; 95% CI −3.66 to −1.47; |
Contributors: Heart rate monitor or pedometer (−4.09 kg; 95% CI −4.94 to −3.25; |
|
Lim 2015 (SR+MA)(83) | 46 studies on PPWL (32 RCTs/ 14 observational studies). | All BMI |
Diet, PA or both. 22 RCTs had only a PA component. In-person participation, self-monitoring, individual or group setting, use of technology, home- or center-based intervention. Duration: 11 days to 36 months. | Significant PPWL (−2.30 kg; 95% CI−3.22 to−1.39, I2 84%; 1892 women; 32 RCTs). | Contributors: Combined diet and PA intervention versus PA only (−2.59 kg; 95% CI −3.54 to −1.64; |
|
Choi 2013 (SR+MA)(77) | 4 RCTs on PPWL | OW/OB | Individual or group sessions on diet and PA; goals setting, self-monitoring, pedometer, telephone call. Restriction of energy intake in 3 trials. Walking; moderate-vigorous intensity; frequency 4–5 times/weeks 30–45 min.; duration 10 to 13 weeks. Supervised in 1 trial. | Significant PPWL (−1.22 kg; 95% CI −1.89 to −0.56; |
Contributors: personalized prescription of PA; goals setting. |
Physical activity interventions were effective in significantly reducing GWG (mean weighted difference, MD −2.2 to −0.61 kg (
The summary of effects of antenatal interventions on maternal, fetal or neonatal outcomes is presented in Table
There was no information in women with overweight or obesity. Though one high-quality review showed in a subgroup analysis that physical activity interventions were effective in significantly reducing GWG (weighted MD −1.35, 95% CI −1.80 to −0.89) in the mixed risk group (all BMI) but not in the high-risk group (women with overweight/obesity or at risk of GMD) (
Eight systematic reviews (nine with meta-analysis) included diet and physical activity interventions either as a single or a multi-component program (Table
In pregnant women from all BMI classes, multi-component diet and physical activity interventions were effective in reducing GWG (weighted MD −1.8 to −0.7 kg,
In pregnant women with overweight or obesity, a significantly reduced GWG (weighted MD −0.91 to −0.63 kg,
Multi-component diet and physical activity interventions were effective in decreasing the risk of pregnancy-induced hypertension (−66 to −30%; low to very low-quality evidence) (
In women with overweight or obesity, multi-component diet and physical activity interventions were effective in decreasing the risks of pregnancy-induced hypertension (−70%, low-quality evidence) (
Diet only interventions (balanced diet, with low glycemic load) resulted in significantly greater reductions in the risks of GDM (−61%, low-quality evidence), pregnancy-induced hypertension (−70%, low-quality evidence), and preterm delivery (−74%, low-quality evidence) in women from all BMI classes and in pregnancy-induced hypertension (−70%, low-quality evidence) in women with overweight/obesity (
Six systematic reviews (five with meta-analysis) included physical activity (
In women from all BMI classes, one review showed that physical activity interventions (12-week progressive walking protocol in 2 RCTs) resulted in non-significant changes in PPWL (
In women from all BMI classes, combined diet (healthy diet or calorie restricted diet) and physical activity intervention were effective in reducing PPWR (weighted MD −2.6 to −2.3 kg, very low-quality evidence) (
In women with overweight or obesity, combined diet and physical interventions (e-based or individual/ group sessions) were effective to reduce PPWL (weighted MD −3.6 to −1.22 kg, moderate to very low-quality evidence) (
None of the systematic reviews examined effects of lifestyle interventions on quality of life or psychological health during pregnancy or postpartum.
Multi-component dietary and lifestyle interventions are effective in decreasing GWG and the likelihood of weight gain above the IOM guidelines in women of all BMI classes, without any reported maternal or fetal/neonatal adverse effect. Regular light to moderate intensity physical activity during pregnancy reduce GWG, however interventions including a balanced diet with a low glycemic load, are associated with the greatest reduction. Multi-component diet and physical activity interventions decrease the risks of pregnancy-induced hypertension, cesarean section and neonatal respiratory distress syndrome. Diet in particular is associated with greater reduction of the risk of GDM, pregnancy-induced hypertension and preterm delivery, compared with any other intervention. There is no evidence for effects on outcomes related to fetal weight, morbidity and mortality.
In women with overweight and obesity, multi-component diet and physical activity interventions are effective in reducing the risks of pregnancy-induced hypertension, macrosomia and neonatal respiratory distress syndrome. In addition, diet only interventions are effective in decreasing the risks of GDM and pregnancy-induced hypertension in this population. After delivery, multi-component diet and physical activity interventions are effective in reducing PPWR in women of all BMI classes, but no other effect on maternal or infant outcomes are reported.
Pregnancy is a time when women may be motivated to change their health behaviors. A healthy diet and regular physical activity are currently recommended during pregnancy in healthy weight pregnant women (
An increased energy intake during the 2nd and the 3rd trimester is usually recommended (
The epigenetic profile of the developing fetus is sensitive to environmental influence. Maternal diet has been shown to influence DNA methylation patterns in offspring, but research in humans is limited (
Women typically reduce their physical activity level during pregnancy (
The effects of antenatal interventions on maternal and fetal morbidities and mortality remained unclear. This review of reviews demonstrates that there is low-quality evidence that multi-component diet and physical activity interventions decrease the likelihood of pregnancy-induced hypertension, cesarean section and neonatal respiratory distress syndrome in women from all BMI classes. Furthermore, diet-based interventions were shown to be effective in decreasing the risks of GDM and pregnancy-induced hypertension in women with overweight and obesity. These findings are of particular importance to primary care providers, as pre-pregnancy obesity is an independent risk factor for serious maternal complications (
Although the quality of evidence remain low, the available evidence suggests that antenatal multi-component lifestyle interventions are also effective in reducing the risk of macrosomia and neonatal respiratory distress syndrome in women with overweight and obesity (
Combined diet and physical activity lifestyle interventions are effective to reduce GWG, with evidence from this review showing a decrease by 20–28% in the risk for GWG above the IOM guidelines, although the magnitude of effects on weight is small (−1.8 to −0.7 kg). So weight loss prior pregnancy is probably needed to achieve both GWG goals and optimal pregnancy outcomes (
Whilst bariatric surgery is currently the most cost-effective treatment resulting in substantial weight loss in carefully selected patients, it should only be considered for those patients with severe obesity, or help with co-morbidity management (
The postpartum period is also a window of opportunity to encourage women to lose excessive weight at a time when they are usually motivated. This evidence review shows that interventions that include both diet and physical activity components, and comprise individualized support and self-monitoring are more likely to be successful in reducing PPWR in all BMI categories. However the optimal approach to reduce PPWR remains uncertain. Ostbye et al. observed that home-based interventions provided a less burdensome and more practical approach than clinic-based attendance (
The ACOG recommends a gradual return to physical activity 4–6 weeks after Childbirth (
Our review of systematic reviews and meta-analyses provides a comprehensive and up to date (up to January 2018) overview of the current reviewed evidence. A rigorous quality assessment was undertaken by two independent reviewers for each review (R-AMSTAR). The quality assessed in each systematic review ranged between high to very low for the benefit observed with GWG and PWWR, but low for other important maternal or neonatal outcomes. The low evidence rating was explained by significant heterogeneity observed in the effect size, risk of publication and related biases, and deficiencies in the quality of the study. There were large differences in the types of interventions and participants, mode of delivery, timing of the measurements and implementation of intervention, dose of intervention, and how it was monitored and supervised. Most included studies were also carried out in middle-high and high-income countries and it is not clear whether these findings are applicable to low income settings.
Future research should focus on: the optimal dose (type, frequency, intensity and duration) as well as the level of supervision in interventions that aim to reduce GWG and PPWR; measurements of psychosocial determinants of GWG and PPWR; interventions in various groups based on BMI, age, ethnicity, socioeconomic status, parity, and risk status in pregnancy; the sustainability and long term effects of the interventions on the mother and child; the cost-effectiveness of the interventions and their feasibility in terms of incorporation into clinical settings; and strategies to improve the adherence and compliance of lifestyle interventions. Trials should be more systematically designed evaluated and reported. The optimal amount of weight gain or loss during pregnancy that would minimize maternal and fetal complications remains a topic of discussion (
The burden of obesity not only threatens global health care systems but also the potential to cripple national economies and global development (
A multi-component approach including a balanced diet, with low glycemic load, and light to moderate physical activity, 30–60 min per day 3–5 days per week, should be recommended from the first trimester of pregnancy and maintained during the postpartum. As there is no evidence that the interventions evaluated in this review are associated with adverse maternal or fetal outcomes, we conclude that that desirable outcomes of lifestyle interventions outweigh possible harms. Dietary interventions appear to be most effective in reducing GWG and co-morbidities such as gestational hypertension and preterm birth in the general population, but also pregnancy-induced hypertension, GDM and macrosomia in women with obesity. We hope that this evidence review will serve as a basis to inform new policies on maternal and child health to halt the intergenerational cycle of obesity.
NF-L contributed to the conception and design of the study, conducted the review of reviews, assessed the quality of studies, drafted and revised the manuscript. CS and LE provided input into the conduct of the study, the grading of evidence and the interpretation of data. BM contributed to the review of maternal and fetal complications associated with obesity and excessive GWG and to the interpretation of data. All authors contributed to the manuscript revision, read and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Pierre Dayer, Alain Golay, Bijan Farpour and the Private Foundation of the Geneva University Hospitals for their support.
Body Mass Index
Cardiovascular disease
Gestational diabetes mellitus
Gestational weight gain
Gestational weight loss
Hypertension
Intra-uterine growth retardation
Institute of Medicine
Large for gestational age
Non-communicable disease
Obesity
Overweight
Physical activity
Post-partum weight loss
Post-partum weight retention
Preterm birth
Randomized controlled trial
Small for gestational age
World Health Organization.