Author: Prasanna Basnet
OBJECTIVES: To analyze the impact of excessive weight gain during pregnancy on postpartum weight retention and long term obesity. To investigate the evidences that help to reduce postpartum weight retention and long-term obesity among women.
KEY WORDS: Obesity, pregnancy, Postpartum weight retention, Overweight mother, Excessive weight increase in gestational period, Maternal weight gain, Minority ethnic obese women, calorie intake, Obese childbearing age women
OVERVIEW: Obesity is a chronic problem and becoming pandemic throughout the world. Women occupies magnificent portion of the obese population and a crucial time for them to gain excessive weight is during pregnancy and postpartum. The chances of postpartum weight retention remain high among the women who gained more than recommended weight during the pregnancy in comparison to the normal weight gained pregnant women. The behavioral and lifestyle changes play a key role in preventing postpartum weight retention and obesity in women. It is critical for the pregnant and postpartum women to understand the importance of high fiber breads, fruits, vegetables, berries, and restriction in intake of high fat and high sugary diet. Only participating in physical activity do not seem to result any effect in the maintenance of recommended pregnancy weight gain, but diet alone can bring significant effect on balancing the weight. Additionally, diet plus exercise assists to decrease the excessive pregnancy weight gain by improving the cardio-respiratory fitness. These interventions do not cause any effect on breast feeding, but help postpartum women to return to pre-pregnancy weight decreasing the probability of future obesity.
Nursing Research for Evidence Based Practice
In the recent days, not only in America, but also around the world numbers of overweight and obese people have substantially increased. Obesity has affected significant proportion of population of the United States from children to adult regardless of their age and gender. For that reason I am immensely interested in the topic obesity, which is the major and sizzling health issue of today throughout the world. More specifically, I am greatly concerned in the women's excessive weight gain during pregnancy and retention of this weight after the childbirth leading to obesity.
Postpartum Weight Retention: Development of Obesity in Women
"Current national data illustrate that 82.1 percent of Black women and 75.7 percent of Hispanic, 59.5 percent of White women are obese"(Ogden, Caroll, Kit, & Flegal 2012). "Maternal obesity is not only linked with higher rates of cesarean section and high-risk obstetrical conditions such as diabetes and hypertension, but it is also the reason for endometrial cancer, cervical cancer, breast cancer, and perhaps ovarian cancer" (Kulie, et al., 2011). Boothe et al. (2011) described that in the United States about two thirds of women of reproductive age are overweight or obese. Obese mothers are 67 percent more likely to have a child with autism than normal-weight mothers without diabetes or hypertension, and are more than twice as likely to have a child with another developmental disorder (Sacramento, 2012). Since obesity is the irrefutable cause for the several chronic diseases and magnificent proportion of women are obese, it is critical to find the root cause for the women's obesity.
In most of the culture women is given special care during the pregnancy and breastfeeding period. Almost all the people more or less know that women should gain weight during pregnancy. However, limited numbers of people are trying to control the excessive weight gain during pregnancy, which ultimately can yield short-term and long-term impact in maternal and child's health. Centers for Disease Control and Prevention (2012) revealed that 57% of women gained more weight during pregnancy than the recommended weight gain. It is also apparent that women are not being able to lose weight after the childbirth. There can be several contributing factors behind the excessive weight gain during and after the pregnancy. Usually, women are encouraged to eat high calorie foods to gain weight during pregnancy and for milk secretion during breastfeeding. University of Rochester Medical Center (2011) depicted that in spite of the excessive caloric intake, 40% of obese women are deficient in iron, 24 percent in folic acid and four percent in B12, which is crucial for healthy pregnancy. Additionally, "overweight and obese women before the pregnancy is likely to gain weight by two to six times more during their pregnancy compared to other BMI groups. These women are also predisposed to higher postpartum weight gain and retention after pregnancy"(Gunderson, 2009).
In view of the fact that significant numbers of women are obese and weight gain of women are associated with the pregnancy, the reason for the obesity among women is essential to be identified. In addition, implementation of appropriate guidelines in order to prevent this condition should also be made. Maternal obesity is associated with various chronic diseases, which does not only deteriorate the health of women, but also upshot the economical burden by increasing the cost of healthcare needed to treat the chronic diseases. Gore, Brown, and West (2003) explained that unnecessary weight gain in pregnancy has the strongest support as risk factors for excessive postpartum weight retention, which is particularly prevalent among minority women. The big chunk of national economy is already invested for the treatment of chronic diseases. Overall medical cost related to obesity for U.S. adults was estimated to be as high as $147 billion" (Centers for Disease Control and Prevention, 2011).
"Nurses have a responsibility to be knowledgeable about the health status of the community and existing threats to health and safety. The availability and accessibility of high quality health services to all people require both interdisciplinary planning and collaboration" (ANA, 2010). Despite the fact that women are gaining excessive weight than recommended and weight retention after childbirth is prevalent in significant proportion of women population, it is not evident that the strategy that we are adopting is functioning properly. Conversely, at this moment the considerable percentage of women with obesity and obesity related diseases in the country is becoming overwhelming issue. Since excessive weight gain in pregnancy is also one of the reasons for obesity in women population, nurses can take part to prevent this issue through the practice change.
Nurses with advanced degree should be able to identify if there is something that is not working in the system and should try to change that practice through scientifically sound evidence, not just blindly adopting the tradition in order to improve the health of the patients. Laureate Education, Inc. (2012h) depicted that we can change the old practice that we have been doing from the long time by keeping ourselves up-to-date on the research which will guide us for better patient care. Nurses have emphasized the preventive approach by actively taking part in the prevention of disease. Understanding the cause of maternal obesity and educating mother can enormously influence the positive health of women. Hence, nurses play a key role in addressing this healthcare issue of women by changing the existing practice after identifying the root causes.
I have been grown up seeing mother in my family, neighborhood and hospital, who became overweight and obese after the childbirth. So, these questions were already in my mind which made me inquisitive to identify the reason and solution for this problem. After I analyzed questions, researching the reliable resources from the internet, I found that excessive weight gain during pregnancy can bring complication to both mothers and child. Additionally, it is also related to the postpartum retention of weight. Indeed, obesity is the overwhelming problem of today's world and studies have shown that tremendous numbers of women are obese and overweight. Hence, I think significant change in life of women can happen through the modification in nursing practice. Reviewing the previously conducted studies and comparing the findings of research helped me identify the problem's likelihood in our society, country and across the world.
Summary of Literature Review
During my search, I found several scholarly articles that revealed the excessive weight gain during the pregnancy and postpartum is directly related with maternal obesity, which can be a major cause of different chronic diseases in women. Excessive weight gain during pregnancy is not only associated with multiple maternal and neonatal complications, but also significantly increases risk of children being overweight in early childhood and postpartum weight retention (Muktabhant, 2012). Skouteris, et al. (2012) mentioned that during pregnancy, women go through phase of significant physiological and physical changes, which lead women at risk of gaining excessive weight. Noroozi, Pakhahad and Rastegari (2010) depicted that there is a meaningful relationship between postmenopausal obesity and the number of pregnancies. Women who had three or more pregnancies were more obese than those women who had fewer pregnancies. So, the effective interventions in pregnancy to prevent excessive gestational weight gain and postpartum weight retention need to be immediately designed.
The existing evidence focused on the diet alone or diet and exercise are the important factors for addressing the weight gain during and after the pregnancy. I found several scholarly papers which were centered on the diet, exercise, psychological and behavioral issues for controlling maternal obesity. “Dietary and lifestyle interventions in pregnancy could reduce maternal weight gain and improve outcomes for both mother and baby. Interventions based on diet were most effective” (Centre for Reviews, 2012). Even though, there are numerous aspects that contribute excessive weight gain during pregnancy and postpartum, diet plays the key role. The balanced diet individualized to the needs of the mother could reduce weight gain in pregnancy by 4kg on average without any evidence of adverse maternal or fetal outcomes (Centre for Reviews, 2012). Hence, overweight and obesity in women should be targeted by the healthcare providers, which can be lucrative to maternal health and help in controlling chronic diseases that are related to the obesity. Postpartum weight retention was minimal in participants who had involved in follow-up visit during six weeks postpartum in comparison to the women who had not involved in follow-up visit or with lower follow up rate (Schmitt, Nicholson, & Schmitt, 2007). Thus, average postpartum weight retention of the women can be decreased within short period of time of postpartum period if they are continuously participated in follow up visit. It may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardio-respiratory fitness and preserves fat-free mass, while diet alone reduces fat-free mass (Amorin, 2012). At the time of pregnancy, pregnant women are expected to interact frequently with healthcare providers for the antenatal check up or to seek advice regarding their pregnancy and weight gain. Ostbye et al. (2012) concluded that eating less healthy foods and being less physically active put overweight and obese women at risk of gaining more weight after a pregnancy. Healthcare providers can encourage women for healthy weight management during this antenatal visit which enhances in succeeding their pregnancies without complications. The improvement in health status of the mother by gaining healthy weight not only index risk free pregnancy, but also positively impact the subsequent children (Skouteris, et al., 2012). Dietary and physical activity counseling to postpartum women during their routine visit significantly help them to return to their pre-pregnancy weight (Nutrition Journal, 2013)
Although I was able to locate several research articles based on the weight gain during pregnancy more than recommended and postpartum weight retention, strong recommendation through single major of eliminating the issue from the root was not adequately discovered. Also, there is scarcity of adequate studies which related correlation of post partum weight retention with future or long-term obesity in women. Despite the strong evidence which was found that diet as the means of solution to the problem during my literature review, there was not enough sturdy substantiation for the negative and positive impact of diet control in mother and fetus/child health. Amorin (2012) depicted that future trials will require to detect potential effects on milk volume, plasma prolactin concentration and infant length and weight gain. In addition, Kramer (2008) revealed protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the developing fetus. Centre for Reviews (2010) revealed that there was no difference between intervention and control groups in the proportion of women gaining weight within the Institute of Medicine (IOM) recommendations. Since the adequate nutrition is crucial for mother and child's health and the recommended adequate proportion of the food that should be consumed during pregnancy and postpartum need to be established.
Furthermore, future research should be conducted to determine how much proportion of food is adequate for a pregnant woman that do not contribute to gain weight, but help maintain healthy mother and fetus/child. Amorin (2012) described that for women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Many researchers only prioritized the weight retention of women until 12 months after delivery, so more research need to be done in order to find out if the postpartum weight retention is resulting long-term obesity among women. Skouteris, et al. (2012) depicted that “no intervention has been published that has targeted behavioral changes in relation to eating and physical activity as well as changes in psychological factors such as motivation, confidence, mood, and body image concerns, with the aim of preventing excessive gestational weight gain and 12-month postpartum weight retention” (p. 7-8). Therefore, in order to implement the evidence into practice more studies need to be conducted considering various factors which contributes excessive weight gain during pregnancy and postpartum. Moreover, appropriateness for the consumptions of amount of diet recommended by the Institute of Medicine (IOM) for the pregnant and breast feeding women should be analyzed properly to control excessive weight gain and complications due to maternal obesity.
In conclusion, there are sufficient articles that enlighten the fact of excessive weight gain during pregnancy that results complications in maternal and child health. In contrary, limited resources are found that provides strong correlation pregnancy and postpartum weight gain leads to long-term obesity in women. Even though, there are cultural, psychological and behavioral factors that enhance the weight gain during pregnancy, changing the intake of diet substantially help reduce the unnecessary gaining of weight during pregnancy and postpartum. The combination of diet and exercise assist not only in balancing the normal weight gain, but also improve the maternal cardio-respiratory fitness. Understanding the reasons behind the unmet social support may be beneficial for the overweight postpartum women to promote healthy behaviors (Boothe et al., 2011). Hence, amount of diet and psychological support provided during pregnancy and postpartum plays crucial role in the maternal weight gain and obesity.
Summary of the Findings and Use of Evidence into Nursing Practice
To summarize the findings from the literature review, no effect has been observed in the weight of pregnant and postpartum women who participated in physical exercise to lose weight in comparison to the women who did not involve in any exercise. However, participation in either diet or diet plus exercise program helped significant loss of weight than the women of control group. There was no difference in the magnitude of weight loss between diet and diet plus exercise group and the interventions seemed not to affect breastfeeding performance adversely. Encouraging women for the intake of high fiber bread, fruits, vegetable, berries and restricting intake of high sugary diet assist women to reduce the postpartum weight retention. Changing the diet does not impact the breastfeeding and health of mother and child. Nurse should give emphasis to improve food intake of the pregnant and postpartum women by implementing appropriate strategies in nursing practice through counseling and education to maintain healthy weight. Behavioral intervention by stressing dietary change into nursing practice resulted significant achievement without other risk compared with other interventions. In contrast, involving only in excessive physical activity to control weight gain during pregnancy has reduced the birth weight and risk of exceeding IOM guidelines” (Heslehurst, 2012).
The unnecessary weight gain at the time of pregnancy and not being able to return to pre- pregnancy stage even after delivering baby negatively affect the health of mother and children. Promoting healthy weight management around a given pregnancy is likely to favorably influence a woman’s health entering her succeeding pregnancies, thus improving the health status not only in her index pregnancy, but also subsequent children (Skouteris et al., 2012). However, Kramer (2008) revealed protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the developing fetus. Across the interventions, those based on diet were most effective, which could reduce maternal weight gain and improve outcomes of mother and baby (Centre for Reviews, 2012). Thus, additional study should be conducted to covert the findings of research into evidence-based practice. Noroozi, Pakhahad and Rastegari (2010) depicted that there is a meaningful relationship between postmenopausal obesity and the number of pregnancies. Women who had three or more pregnancies were more obese than those women who had fewer pregnancies. Furthermore, no significant weight loss had been seen among women who only exercised, but women participating in diet or diet plus exercise lost more weight (Linne, Lourenco & Amorim, 2012).
Outcomes of the Evidence-Based Practice
Postpartum obesity is one of the major factors that contribute obesity in women. Fifty seven percentage of women gained more weight during pregnancy than the recommended weight gain (Centers for Disease Control and Prevention, 2012). However, various evidences suggested and proved that the diet and physical activity reduce the probability of postpartum weight gain. Since obesity increases the risk for diabetes, hypertension, cancer, kidney disorder and other chronic diseases, excessive weight gain during pregnancy and weight retention during postpartum deteriorate the health of women leading to become the victim of chronic diseases. If pregnant and postpartum women are provided adequate education and counseling about the consumption of diet and physical activity, this will certainly improve the health of women maintaining healthy weight. In contrary, if the evidence focused on the strategies for returning to pre pregnancy weight after delivering baby are ignored, the obesity of women will continue even after the postpartum period. Ultimately, the number of women with chronic diseases will increase and eventually upshot the economical burden by increasing the cost of healthcare needed to treat the chronic diseases.
Obesity is the chronic health problem and the numbers varies significantly according to the race, sex and age. More importantly, it has been confirmed that the cost of healthcare in the United States is skyrocketing because of growing number of people with chronic diseases. Since huge amount of national money is already invested for the management of obesity related chronic diseases, the possible root cause for the obesity need to be explored in order to minimize the overall cost of healthcare and to prevent the occurrence of chronic diseases.
Women occupies significant portion of the obese population. The crucial time for women to gain excessive weight is pregnancy. Most of the culture encourages women to eat more because it is perceived that consuming more calories during pregnancy determines the health of mother and baby. As a result, women consume more calories than necessary, which ultimately increases the probability to develop gestational diabetes, other medical complications and also postpartum weight retention. The excessive weight gain during pregnancy does not only jeopardize the health of mother resulting obesity and chronic disease during and after the postpartum period, but also endanger the health of the newborn. Hence, behavioral and lifestyle changes play a key role in preventing postpartum weight retention and obesity in women. As the period of pregnancy is critical for mother and child’s health, extensive dieting and vigorous physical exercise can also be detrimental. The nurses should educate and counsel pregnant and postpartum women for the intake of high fiber breads, fruits, vegetables, berries, and encourage them to restrict the intake of high sugary diet during each routine visit. It is also essential to teach them the importance of physical activity during their leisure time, which will keep their heart healthy. These interventions do not cause any effect on breast feeding, but help postpartum women to return to pre-pregnancy weight decreasing the probability of future obesity.
Amorin Adegboye, A. (2012). Diet or exercise, or both, for weight reduction in women after childbirth: Cochrane Database of Systematic Reviews, (2). doi: 10.1002/14651858.CD005627.pub2.
Boothe, A. S., Brouwer, R. N., Carter-Edwards, L., & Østbye, T. (2011). Unmet Social Support for Healthy Behaviors Among Overweight and Obese Postpartum Women: Results from the Active Mothers Postpartum Study. Journal Of Women's Health (15409996), 20(11), 1677-1685. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1089/jwh.2010.2509
Centers for Disease Control and Prevention. (2011). Chronic disease prevention and health promotion. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/obesity.htm
Centers for Disease Control and Prevention. (2012). Pregnancy complications: Reproductive Health. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcomplications.htm
Centre for Reviews (2010). Interventions during pregnancy to reduce excessive gestational weight gain: a systematic review assessing current clinical evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system (Structured abstract). An International Journal of Obstetrics and Gynaecology, 117(11). DARE-12011000525 1327-1334.
Centre for Reviews (2012). Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta‐analysis of randomized evidence (Structured abstract). Bmj, 344. DARE-12012024318
Flegal, K. M., Carroll, M. D., Kit, B.K., & Ogden, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999-2010. Journal of the American Medical Association, 307(5), 483-497.
Gore, S. A., Brown, D. M., and West D.S. (2003).The role of postpartum weight retention in obesity among women: a review of the evidence. National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14534032
Gunderson, P. E. (2009). Childbearing and obesity in women: weight before, during, and after pregnancy. National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930888/#R3
Heslehurst, N.(2012). Diet and physical activity intervention reduce pregnancy weight gain compared with control, with dietary interventions having the greatest effect: Systematic review and Meta analysis. Evidence- Based Nursing.doi:10.1136/eb-2012-100889
Kramer, M. (2008). Energy/protein restriction for high weight-for-height or weight gain during pregnancy. Cochrane Database Of Systematic Reviews, (3),
Kulie T, Slattengren A, Redmer J, Counts H, Eglash A, Schrager S.(2011). Obesity and Women's Health: An Evidence-Based Review. Retrieved from http://www.jabfm.org/content/24/1/75.long. DOI: 10.3122/jabfm.2011.01.100076
Laureate Education, Inc. (Executive Producer). (2012h). Overview of evidence-based practice. Baltimore, MD: Author.
Linne, c., Lourenco, M. and Amorim, A. (2012). Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database of Systematic Reviews, (2),
Muktabhant, B. (2012). Interventions for preventing excessive weight gain during pregnancy: Cochrane Database of Systematic Reviews. (4). doi: 10.1002/14651858.CD007145.pub2.
Noroozi, M. Rastegari, Z. and Pakhahad, Z. (2010). Type of body fat distribution in postmenopausal women and its related factors. Iranian Journal of Nursing and Midwifery Research. 15(1): 27–31. PMCID: PMC3093032
Nutrition Journal (2013). Reducing postpartum weight retention: A pilot trial in primary health care. Retrieved from http://www.nutritionj.com/content/6/1/21
Ostbye, T., Peterson, B. L., Krause, K. M., Swamy, G. K., & Lovelady, C. A. (2012). Predictors of Postpartum Weight Change among Overweight and Obese Women: Results from the Active Mothers Postpartum Study. Journal of Women's Health (15409996), 21(2), 215-222. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1089/jwh.2011.2947
Schmitt, N., Nicholson, W., & Schmitt, J. (2007). The association of pregnancy and the development of obesity - results of a systematic review and meta-analysis on the natural history of postpartum weight retention. International Journal of Obesity (2005), 31(11), 1642-1651.
Skouteris, H., McCabe, M., Milgrom, J., et al. (2012). Protocol for a randomized controlled trial of a specialized health coaching intervention to prevent excessive gestational weight gain and postpartum weight retention in women: the HIPP study: BMC Public Health. 1278. doi:10.1186/1471-2458-12-78