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.
Feasibility Analysis
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.
Summary
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.
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