All postpartum women
Postpartum women with BMI ≥30
NICE
6–8-week postnatal check:
6–8-week postnatal check:
Ask those who are overweight and obese or who have concerns about their weight if they would like any further advice and support now – or later
Explain the increased risks that being obese poses to them and, if they become pregnant again, their unborn child
Provide clear, tailored, consistent, up-to-date, and timely advice about how to lose weight safely after childbirth
Encourage them to lose weight
Ensure women have a realistic expectation of the time it will take to lose weight gained during pregnancy
Offer a structured weight loss program or a referral to a dietitian or an appropriately trained health professional
Discuss benefits of a healthy diet and regular physical activity
Provide women who are not yet ready to lose weight with information about where they can get support when they are ready
Advice on healthy eating and physical activity should be tailored to her circumstances
Use evidence-based behavior change techniques to motivate and support women to lose weight
Advise women, their partners, and family to seek information and advice from a reputable source
Encourage breastfeeding
Provide details of appropriate community-based services
Encourage women to breastfeed
Provide advice on recreational exercise:
1. A mild exercise program consisting of walking, pelvic floor exercises, and stretching may begin immediately
2. After complicated deliveries, or lower segment caesareans, a medical caregiver should be consulted before resuming prepregnancy levels of physical activity, usually after the first checkup at 6–8 weeks after giving birth
Emphasize the importance of participating in physical activities, such as walking, which can be built into daily life
ACOG
Rapid return to prepregnancy activities is acceptable after an uncomplicated pregnancy and delivery
No recommendations based on BMI
Moderate weight reduction after delivery does not interfere with lactation or neonatal weight
Postpartum exercise may help to reduce postpartum depression symptoms
Refer to consultation with a weight specialist before the next pregnancy
Discuss healthy lifestyle behaviors at each visit
Current recommendations for postpartum dietary interventions and physical activity interventions in the United Kingdom were developed by the National Institute for Health and Clinical Excellence (NICE) [20]. NICE recommendations are developed based on available evidence of effectiveness (including cost-effectiveness), fieldwork data, and incorporating the perspectives of multiple stakeholders (e.g., patients, clinicians) and experts. The recommendations include components of effective aspects of care for obesity in general and identify key dietary, exercise, and behavioral principles, such as eating a low-fat diet, encouraging regular physical activity, and identifying and addressing barriers to behavioral change. In slight contrast to ACOG, NICE provides specific recommendations for postpartum counseling and support to prevent weight retention in overweight or obese women (Table 8.1). NICE recommends that clinicians discuss the need for weight loss with all postpartum women and expand the discussion to include the adverse effects of maternal obesity on pregnancy outcomes for any future pregnancy. Clinicians are encouraged to provide ongoing counseling with their practice or to refer the patient to a dietary expert for further behavioral modification. If patients have not yet committed to making lifestyle modifications, it is recommended that clinicians provide a 6-month follow-up visit to reevaluate the patient’s readiness for weight loss. Of particular relevance are the NICE community-based service guidelines. These guidelines encourage communities to create and sustain affordable recreational exercise facilities and to increase the availability of cost-efficient healthy foods. Also, the NICE provides guidelines for health professionals to improve their ability to talk with their patients about weight loss and to provide dietary and exercise counseling. The NICE recommendations are continually updated based on available evidence for effectiveness and expert review.
Evidence for Postpartum Interventions to Promote Weight Loss
Interventions that integrate exercise and dietary changes have been shown to achieve weight loss in middle- and older-aged adults [PREMIER [6], Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) [21], Diabetes Prevention Program (DPP) [22]], though evidence for their efficacy in postpartum women is limited. The paucity of recommendations for postpartum care in the United States may be due, in part, to the small number of clinical trials that compare the effectiveness and safety of dietary and exercise interventions, small sample size, limitations in study design, and a lack of participants that are generalizable to diverse populations of US women. Reducing postpartum weight retention can decrease the proportion of women that develop pregnancy-related hypertension or gestational diabetes in a subsequent pregnancy. Alternatively, if women have completed childbearing, reducing postpartum weight retention can lower the risk of long-term metabolic abnormalities or cardiovascular disease. The PREMIER trial was a National Heart Lung and Blood (NHLBI)-funded intervention designed for adults with Stage 1 hypertension. The intervention was successful in lowering blood pressure and was also found to lower weight. The Diabetes Prevention Program [5] was a clinical study sponsored by the Centers for Disease Control and Prevention (CDC). Subsequent trials have focused on translating these interventions into various settings [23]. Administered through the CDC’s Division for Heart Disease and Stroke Prevention, the WISEWOMAN program [21] provides low-income, underinsured, or uninsured women, age 40–64, with lifestyle intervention and referral services in an effort to prevent cardiovascular disease.
We conducted a review of clinical trials comparing diet and exercise interventions for the reduction in postpartum weight retention. Our goal was to identify fair-to-good quality RCTs based on the United States Preventive Services Task Force quality criteria [24] and to assess studies for the use of evidence-based intervention components proven effective in general populations. Twelve trials [25–35] published between 1998 and 2011 met the quality criteria (Table 8.2). Eight trials were conducted in the United States, one in Taiwan [31] and one in Honduras [26] and one in Greece [23] and the United Kingdom [32]. The trials also compared different types of interventions using different modes of delivery. Seven trials compared an in-person diet and exercise intervention to standard postpartum care. Three trials compared the effects of exercise interventions to standard postpartum care; two were supervised while one was self-directed. One trial compared the effect of individual dietetic counseling and facilitated group sessions with standard postpartum care. The mode of delivery of the interventions varied from mail correspondence to in-person individual and group sessions to telephone follow-up.
Table 8.2
Results from 12 randomized controlled trials of diet and exercise interventions
Author, year, country (reference) | Intervention arms | Intervention enrollment/duration | Study sample, N | Race/ethnicity | Weight change, kg (standard deviation) |
|---|---|---|---|---|---|
Diet plus exercise interventions | |||||
Leermakers and Wing 1998, USA [34] | Intervention (I): Correspondence lessons, group sessions, and telephone follow-up | 8 mos | Non-lactating postpartum women | 3 % nonwhite | I: −7.8 ± 4.5 |
Control (C): usual care, brochure | 6 mos | N = 90 | C: −4.9 ± 5.4 | ||
(P = 0.03)a | |||||
O’Toole et al., 2003, USA [33] | I: Structured diet + exercise with weekly in-person sessions × 12 wks, biweekly sessions × 8 wks, and monthly sessions up to 1 year | 6 wks to 6 mos | Postpartum women who were overweight or obese prior to pregnancy | 1 AA | I: −4.8 ± 1.7 |
C: One session, self-directed | 6–10 mos | N = 40 | C: −0.8 ± 2.3 | ||
(P < 0.001) | |||||
Craigie et al. 2011, UK [32] | I: Two face-to-face counseling sessions, with telephone follow-up for reinforcement and resources for pamphlet | 6–18 mos | Low-income, overweight, and obese postpartum women | 3 nonwhite participants | I: −7.3 |
C: Information pamphlet | 3 mos | N = 52 | C: −1.3 | ||
(P < 0.05) | |||||
SD-NR | |||||
Huang and Tsai 2011, Taiwan [31] | I: Individualized dietary and physical activity plans, including 6 in-person pregnancy sessions and 3 postpartum sessions | 1 day | Pregnant and postpartum women Taiwanese women; 1 day postpartum | Taiwanese | I: −0.9 ± 5.1 |
C: Usual care | 6 mos | N = 189 | C: −0.36 ± 4.9 | ||
(P = 0.25) | |||||
Lovelady et al. 2000, USA [30] | I: Caloric restriction and exercise intervention, including 4 exercise sessions, lasting 43 min with goal of 65–80 % heart rate | 5 wks | Overweight postpartum women with BMI 25–30 kg/m2, exclusively breastfeeding | 3.5 % AA | I: −1.6 ± 2.0 |
C: Usual care | 2.5 mos | N = 40 | C:0.2 ± 2.2 | ||
(P = 0.018) | |||||
Ostbye et al. 2009, USA [29] | I: 8 healthy eating classes, 10 physical activity classes, and 6 telephone counseling sessions over 9 mos | 2 mos | Overweight or obese postpartum women | I: 45 % AA | I: −11.21 |
C: Usual care | 9 mos | N = 450 | C: 45 % AA | C: −11.04 | |
(P-value NR) | |||||
SD-NR | |||||
Davenport et al. 2011, USA [35] | I: Diet + low-intensity exercise | 8 wks | Overweight or obese women who retained >5 kg after delivery | Intervention groups: 85–90 % white | I: −5.0 ± 2.9 moderate intensity |
I: Diet + moderate-intensity exercise | 4 mos | N = 60 | No AA
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