Over thepast two decades there has been a dramatic increase in the prevalence of obesity affecting both developedand developing countries(Stüber et al., 2015). A prevalence of more than 1.9 billion adults aged18 years and older, were overweight in 2016 and more than 650 million out ofthem were obese (World Health Organization, 2017).
“In 2015 in England 58% of women and 68% of menwere overweight or obese” (NHS Digital, 2017). This increased presence of obesity is considered to be amajor health problem since it is a key contributing factor for cardiovasculardisease, type 2 diabetes and furthermore, is related worldwide with a highermorbidity (Stüber et al., 2015). Obesity is defined by the Body mass index measurement(BMI); this commonly used measurement refers to the individual’sweight in kilograms divided by the square of the individual’s height in meters(World Health Organization,2017). Herewith, obesity is defined as a BMI greater than or equal to 30 kg/m2.
An individual with a BMIgreater or equal to 40 kg/m2 is considered to have an extreme form of obesity. Itis important to underline that it is an overabundance in adipose tissue thatinfluences the health consequences of obesity, and not the size of theindividual’s body that matters (Leddy, Power & Schulkin, 2008). An example for this areweightlifters; who tendto have a high BMI, however, this is not because of an excess infat but due to a high muscle mass. These individuals are therefore, notspecifically at risk of metabolic health problems, as obesepeople with the same BMI would be (Leddy et al., 2008). Regarding the prevalence ofobesity in pregnancy in the UK, only 4,99% of women with a BMI equal to 35 orhigher, which refers to class 2 and class 3 obesity, where class 2 obesityrefers to severe obesity and class 3 to morbid obesity, give birth at 24 weeksof gestation or later.
This refers to approximately 38,478maternities each year. Further to that, pregnant women classified with a BMIequal or higher than 40, who are considered to be morbidly obese, are defined as only 2% of all women giving birth. Moreover, only 0,19% give birth when having aBMI equal or higher than 50, which refers to women who are supermorbidly obese (Maternalobesity in the UK, 2010).Approximately “20% of pregnant women who attended their first appointment” in the UK, “were classedas obese”, this was seen in the statistics from the Health and Social CareInformation Centre (HSIC, 2015, as cited in Midirs, 2016). These statistics are worrying and show not only how problematic obesity is worldwide, but also howsignificant the problem of obesity in pregnancy has become.
Multiplecomplications for the mother as well as for the offspring are associated withthe increasing prevalence of preconception weight issues and excessivegestational weight gain (GWG) (Stüberet al., 2015). TheInstitute of Medicine (IOM) has devised a set of guidelines recommendinggestational weight gainsfor women with normal BMI, overweight and obese women before conception. Over the past years, a substantialnumber of women have beenexceeding these pregnancy weight gain recommendations (Rauch et al.,2013). Around “50% of women start their pregnancy being overweight or obese”,and approximately “50% of women gain excess pregnancy weight”. This makesmaternal obesity and excessive gestational weight gain key contributors to theglobal obesity epidemic (Hure et al., 2012; Kowal et al.
, 2012; Rasmussen andYaktine, 2013; McPhie et al., 2015, as cited in Hill et al., 2017). Manypregnancy-related problems increase as the level of obesity increases resulting in possible “miscarriage,hypertensive disorders such as pre-eclampsia, gestational diabetes mellitus,infections, thromboembolism, instrumental and traumatic deliveries, woundinfection and endometritis” (Thangaratinam et al., 2012). Obese pregnant women encounterincreased risks of complications at the time of labour and delivery. Thusthe rate of successful vaginal delivery decreases, often leading to caesarean deliveries. Having anexcessive gestational weight gain during pregnancy is associated with anincreased risk for the mother to maintain the weight gained, which indicates apersistent obesity post-pregnancy, as well as an increased risk of obesity in herchildren.
With this, both the “mother and the offspring are at increased riskregarding short- and long-term obesity” (Siega-Riz et al., 2009; Mannan et al.,2013; Cohen et al., 2014, as cited in Hill et al., 2017). Maternal healthduring pregnancy, therefore, is ofvital importance as it has a significantimpact on thedevelopment of the foetus during pregnancy, as well as on the child’s healthlater on in life. Further unfavourable outcomes for the foetus, include “stillbirths and neonatal deaths, pretermbirths, neonatal unit admission, macrosomia, congenital abnormalities andchildhood obesity with associated long-term risks”, as mentioned above(Thangaratinam et al., 2012).
All of these issues emphasize the importance ofthe health-care system, and the need to expand the facility for supplementary supervision and resources in both primary and secondary care settings(Thangaratinam et al., 2012). Preventing and treating obesity andgestational weight gain in thispopulation is of major concern in order to prevent the negative outcomes forthe mother as well as for the infant.
It is widely believed that pregnancy is a “teachable moment”, in whichwomen are inspired to change their health behaviour such as adjusting theirdiets and engaging in physical activities (Phelan, 2010), in order to increase healthy outcomes for their expectedchild. A period in which women consider having greater interaction withhealthcare professionals of paramount importance and therefore an ideal time to promote healthy behaviouralchanges. Lifestyles interventions have been designedwhere the aim is to improve some of the patient’s unhealthy habits in order toimprove their health outcomes.
However, some intrinsic barriers are encountered. Suchbarriers during the life stage of a pregnant woman include the lack of time for habitsto become routine (a mere 3 months; as “lifestyleinterventions tend to begin at the end of the first trimester and end early inthe third trimester”) (Hill et al., 2017), challenging demands such as physiologicalsituations, financial, relationship, and social situations (Hill et al.
, 2017).Another set of barriers is the difficulty in transferring information tothe mother so that she can recognize the potential risks associated with being overweight and obese during pregnancy and becauseof this, to trigger behavioural changes successfully. Due to the different intrinsicbarriers pregnant women are facing, lifestyle interventions, with a focus onlifestyle change have mixed outcomes. As a direct result of this, it isimperative to deliverthese lifestyle interventions individually in a supportive environment, inwhich the healthy challenges of the pregnant women are encouraged and rewarded,to help modify theirbehaviour (Hill et al.
, 2017). Weight management strategiesare developed in order to target the increasing prevalence of obesity within the population. A focus of these strategies has been set on pregnancydue to the fact that pregnancy is seen as a crucial time to target weightmanagement (Thangaratinamet al., 2012). Due to a diversity in intervention types to limit gestational weight gain, such as “diet or physical activity, psychological support, orcombinations” hereof, and a diversity in the intensity of interventions, like “intensiveclinical intervention or hands-off approaches”; mixed findings regarding theiroutcomes are noticeable (Saskatchewan Prevention Institute, 2014). A set ofrecommendations from the literature findings, suggest that in order to makeinterventions more effective, strategies must consider the engagement oftrained and prepared prenatal care providers, providing continuing informationto the pregnant women and advisingthem on healthy weight gainduring pregnancy (Campbell et al., 2011).
This can be achieved by providing nutritional guidance,information regarding physical activities, recommendations to preserve a fooddiary and physical activity record, and most importantly not forgettingthe “tracking of gestationalweight gain” (Ferraro, 2014, as cited in Saskatchewan Prevention Institute,2014). Communication between pregnant women and prenatal care providers areimportant in order to consider each woman’s situation. Motivating women beforeand throughout the whole pregnancy to adopt healthy behaviours is crucial (Instituteof Medicine, 2009). Regarding the interventions,the common dietary ones are composed of a balanced diet of proteins,carbohydrates, fat and the upkeep of a food diary.
As for the “physicalactivity-based interventions”, these consist of “walking for 30 minutes,weight-bearing exercises and light-intensity resistance training” (Thangaratinam et al., 2012). Ameta-analysis regarding the effectiveness of lifestyle interventions such as dietarycontrol or physical activity in pregnancy and outcomes for the foetus haveshown that a reduction in gestational weight gain was greater in the dietaryintervention group (Thangaratinamet al., 2012).
Regarding the estimates for the birth weights of the infants, a remarkable decrease has been measured in the intervention group and thisfor all the lifestyle interventions (Thangaratinam et al., 2012). Resulting from the evaluation of the effect ofinterventions in pregnancy on obstetric outcomes, 29 randomised trialsconcluded that a significant general decrease in the occurrence of pre-eclampsiawas seen resulting from weight management interventions.
A significantreduction in gestational hypertension and pre-eclampsia resulted from dietary interventionswith this intervention having the largest effect (Thangaratinam et al., 2012).Moreover, a remarkable decrease in preterm births and in the tendency to reducethe occurrence of gestational diabetes, resulted from dietary interventions. Asfor caesarean section or induction of labour, no distinction was found betweenthe groups (Thangaratinamet al., 2012).However, a rational hypothesis for interventions in order to reducenegative outcomes for the mother as well as for her offspring would be toreduce weight preceding the pregnancy, this because most of the negativeoutcomes of overweight or obese women during pregnancy show associations withpre-pregnancy BMI (Nohr et al.
, 2008, as cited in Oteng-Ntim, 2009). Despite the fact that it is recognized that thewoman’s weight preceding the pregnancy has a significant impact on the healthof both the mother and her offspring, numerous pregnancies are unplanned (Finerand Zolna, 2016, as cited in Hill et al., 2017), therefore targeting a definedpopulation is difficult. Additionally, only a small number of women would consulta health care provider before conceiving, and a smaller number of women wouldagree to delay their conception in order to lose weight (Birdsall, Vyas, Khazaezadeh, & Oteng-Ntim, 2009). However, messages and programs promoting healthyweights to women of childbearing age should not be dismissed and should ratherbe encouraged. In order to prevent maternalobesity and excessive gestational weight gain, three key guides regardingfuture research for interventions and care are recommended (Hill et al.
, 2017).Firstly, “the promotion of maternal health”. In particular overweight andobesity prevention, this involves three approaches. The first one isencouraging weight management in order to start pregnancy at a healthy BMI. Thesecond approach is the prevention of excessive gestational weight gain throughsuitable targeted interventions that are unified into the women’s usual care.
Andfinally, the promotion of postpartum weight management in order to have healthypost-pregnancy BMI, and to return to a healthy pre-pregnancy BMI. Researchersshould concentrate on acknowledging that preconception is a distinctive life stage.Intervention in the preconception period will provide more possibilities forhabit adoption, which is crucial for the emergence of appropriate healthylifestyles changes that can be continued throughout the pregnancy (Hill et al.,2017).
A second key guidance, regardsadopting an adjusted approach through audience segmentation since it is importantto recognize the impact the environment has on women’s abilities to commenceand preserve healthy lifestyle behaviours before and throughout pregnancy. Inorder to identify suitable opportunities to intervene with health promotionstrategies that will have significant outcomes, it is necessary to identify themain preconception and pregnancy audience segments, and to investigate andreport their distinctive criterion such as psychosocial, health, demographic andlifestyle characteristics (Hill et al., 2017).A third and final key guidance, is the importance of a combination ofregulation, encouragement and extensive educational strategies that areindividually targeted. The related policies must go deeper towards theprevention of maternal obesity in order to achieve long-term practical changesin clinical care. It is crucial for the research, policy and practice toconsider the clinical, social and environmental backgrounds in which women are.This, in order to attain durable changes in the patient’s outcomes (Hill etal., 2017).
More research is necessary to understand what components prompt differentgroups of women to tackle their preconception weight. It is important to define and control thespecific challenges in this life stage. Innovation is needed in order tooutline personalized intervention strategies based on what has been mentionedpreviously. The occurrence of maternal obesity and its associated comorbiditiescontinue to increase at a frightening rate, this accompanied by considerablepublic health implications.
Therefore, it is important that all of this shouldbe associated with multiple obesity prevention efforts in the community, inorder to increase healthy weight goals throughout the system.