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Dietary component of lifestyle interventions helps obese pregnant women

Randomised controlled trial
Dietary component of lifestyle interventions helps obese
pregnant women
Julie A Quinlivan
Commentary on: Vinter CA, Jensen DM, Ovesen P, Beck-Nielsen H, Jørgensen JS. The LiP (Lifestyle in
Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women.
Diabetes Care 2011;34:25027.
Approximately 30% of pregnant women in developed
countries are overweight or obese.
Maternal obesity is a
major risk factor for maternal and fetal complications,
including maternal and fetal mortality, miscarriage, ges-
tational diabetes mellitus, pregnancy-induced hyperten-
sive disorders, infection, thromboembolic disease,
induction of labour, macrosomia, caesarean section and
In 2009, the Institute of Medicine revised its recom-
mendations for weight gain in pregnancy advising that
overweight and obese women should restrict gestational
weight gain to 1525 lb (6.811.3 kg) and 1120 lb
(4.99 kg), respectively.
The question then became how
to achieve this.
A meta-analysis of dietary intervention trials reported
that dietary interventions, especially when repeated
throughout pregnancy, were effective in reducing gesta-
tional weight gain in obese pregnant women by 6.5 kg
compared to control.
Another meta-analysis of physical
intervention trials also reported a small, but signicant,
reduction in gestational weight gain of 0.61 kg com-
pared to control.
A meta-analysis of all intervention
types reported a 1.42 kg reduction in gestational weight
gain with any intervention compared to control.
The LiP (Lifestyle in Pregnancy) Study contributes to the
evaluation of lifestyle interventions for obese pregnant
women by combining dietary and exercise interventions.
In this Danish trial, obese pregnant women were rando-
mised to a lifestyle intervention that included dietary
guidance, free membership in tness centres, physical
testing and personal coaching or to a control group.
They were also offered four dietary sessions. Interven-
tion commenced early in pregnancy with enrolment into
the trial at 1014 weeks gestation. Randomisation was
adequate. It was not possible to blind participants but
data extraction was blinded.
The key nding was that the combined lifestyle inter-
vention was associated with a signicantly lower
median gestational weight gain (7.0 vs 8.6 kg, p=0.01).
However, the Institute of Medicines recommendations
on gestational weight gain still exceeded by 35.4% for
women in the intervention group.
One concern was of the 1224 obese women attending
for care, 238 were excluded because of chronic illness
and adverse obstetric history. This reects the burden of
chronic disease in overweight mothers. A further 317
women, nearly half of those eligible, declined to partici-
pate in the trial. This suggests that the subgroup of
women involved in the trial may be motivated towards
lifestyle interventions.
Given this, it is disappointing that so few took
advantage of the free exercise interventions offered.
Dietary interventions were associated with reasonable
compliance with 92% of the women in the intervention
arm completing all four dietetic counselling sessions. In
contrast, only 56% of women in the intervention group
attended the aerobic classes for at least half of the
It was disappointing that motivated pregnant obese
women did not attend the exercise component of the
intervention despite being personalised and free. Poor
compliance, limited efcacy and cost will probably limit
exercise interventions being implemented broadly into
antenatal care.
In contrast, previous randomised trials have established
that obese pregnant women are generally compliant with
dietary interventions.
It has been established that
dietary interventions can reduce mean gestational weight
gain to Institute of Medicine (IOM) levels.
The LiP study
supports these observations with reasonable compliance
with the dietary component of the intervention.
Given the cost of exercise interventions, it would
appear that dietary approaches offer the greatest oppor-
tunity for change at a population level and should be
the focus of future research. One thing is certain, we
need to nd solutions in a hurry; otherwise we are con-
demning future generations to an explosion of chronic
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management of overweight and obesity in adults. Canberra:
Commonwealth of Australia, 2003.
2. Institute of Medicine. Weight gain during pregnancy:
reexamining the guidelines. Report brief. May 2009.
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in obese pregnant women to restrict gestational weight gain to
Institute of Medicine recommendations: a meta-analysis.
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4. Streuling I, Beyerlein A, Rosenfeld E, et al. Physical activity and
gestational weight gain: a meta-analysis of intervention trials.
BJOG 2011;118:27884.
Department of Obstetrics and
Gynaecology, University of Notre
Dame Australia, Joondalup,
Western Australia, Australia
Womens and Childrens
Research Institute, University of
Adelaide, Joondalup, Western
Australia, Australia
Correspondence to:
Professor Julie A Quinlivan
Joondalup Health Campus, Suite
106 Private Consulting Rooms,
Joondalup, Western Australia
6027, Australia;
Evidence-Based Medicine February 2013 |volume 18 |number 1 |ebmed.18.1.e4
5. Thangaratinam S, Rogozinska EM, Jolly K, et al. Effects of
interventions in pregnancy on maternal weight and obstetric
outcomes: meta analysis of randomised evidence. BMJ
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8. Quinlivan JA, Lam LT, Fisher J. A randomized trial of a
four-step multidisciplinary approach to the antenatal care of
obese pregnant women. Aust N Z J Obstet Gynaecol 2011;51
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Evidence-Based Medicine February 2013 |volume 18 |number 1 |ebmed.18.1.e4
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... In reviewing the various meta analyses of randomised trials for interventions in pregnancy for overweight and obese pregnant women, dietary interventions are effective whereas physical exercise and mixed interventions are less so [26][27][28][29] . Furthermore, dietary interventions are cheaper and have greater acceptability to pregnancy women. ...
Full-text available
The rising tide of obesity has seen the prevalence of overweight and obese women presenting for antenatal care approach 50% in recent years. In addition, many pregnant women have gestational weight gain in excess of Institute of Medicine guidelines and develop obesity as a result of pregnancy. Both variables impact adversely upon pregnancy outcome. Individualised programs are not financially viable for cash strapped health systems. This review outlines an evidence-based, public health approach to the management of obesity in pregnancy. The interventions are affordable and in randomised and epidemiological trials, achieve benefits in pregnancy outcome. © 2014 Baishideng Publishing Group Inc. All rights reserved. Core tip: Public health approaches are feasible and effective to manage obesity in pregnancy. In primary care settings, women planning pregnancy should have their body mass index monitored in their medical record and receive nutrition advice, have comorbidities of depression and smoking addressed, receive influenza vaccination and education on gestational weight gain targets. Once pregnant, hospital management should focus on monitoring gestational weight gain to Institute of Medicine targets according to the patient’s booking body mass index, combined with screening for diabetes, hypertensive and growth disorders. Following birth, care should handed back to primary care for ongoing weight interventions.
Full-text available
To evaluate the effects of dietary and lifestyle interventions in pregnancy on maternal and fetal weight and to quantify the effects of these interventions on obstetric outcomes. Systematic review and meta-analysis. Major databases from inception to January 2012 without language restrictions. Randomised controlled trials that evaluated any dietary or lifestyle interventions with potential to influence maternal weight during pregnancy and outcomes of pregnancy. Results summarised as relative risks for dichotomous data and mean differences for continuous data. We identified 44 relevant randomised controlled trials (7278 women) evaluating three categories of interventions: diet, physical activity, and a mixed approach. Overall, there was 1.42 kg reduction (95% confidence interval 0.95 to 1.89 kg) in gestational weight gain with any intervention compared with control. With all interventions combined, there were no significant differences in birth weight (mean difference -50 g, -100 to 0 g) and the incidence of large for gestational age (relative risk 0.85, 0.66 to 1.09) or small for gestational age (1.00, 0.78 to 1.28) babies between the groups, though by itself physical activity was associated with reduced birth weight (mean difference -60 g, -120 to -10 g). Interventions were associated with a reduced the risk of pre-eclampsia (0.74, 0.60 to 0.92) and shoulder dystocia (0.39, 0.22 to 0.70), with no significant effect on other critically important outcomes. Dietary intervention resulted in the largest reduction in maternal gestational weight gain (3.84 kg, 2.45 to 5.22 kg), with improved pregnancy outcomes compared with other interventions. The overall evidence rating was low to very low for important outcomes such as pre-eclampsia, gestational diabetes, gestational hypertension, and preterm delivery. Dietary and lifestyle interventions in pregnancy can reduce maternal gestational weight gain and improve outcomes for both mother and baby. Among the interventions, those based on diet are the most effective and are associated with reductions in maternal gestational weight gain and improved obstetric outcomes.
Full-text available
Maternal obesity and excessive gestational weight gain (GWG) are major short- and long-term risk factors for maternal and fetal complications. The objective was to study whether a lifestyle intervention based on a brochure or on active education can improve dietary habits, increase physical activity (PA), and reduce GWG in obese pregnant women. In this randomized controlled trial, 195 white, obese pregnant women [age: 29 + or - 4 y; body mass index (in kg/m(2)); 33.6 + or - 4.2] were randomly assigned into 3 groups: a group that received nutritional advice from a brochure, a group that received the brochure and lifestyle education by a nutritionist, and a control group. Nutritional habits were evaluated every trimester through 7-d food records. PA was evaluated with the Baecke questionnaire. Energy intake did not change during pregnancy and was comparable in all groups. Fat intake, specifically saturated fat intake, decreased and protein intake increased from the first to the third trimester in the passive and active groups compared with an opposite change in the control group. Calcium intake and vegetable consumption increased during pregnancy in all groups. PA decreased in all groups, especially in the third trimester. No significant differences in GWG and obstetrical or neonatal outcome could be observed between the groups. Both lifestyle interventions improved the nutritional habits of obese women during pregnancy. Neither PA nor GWG was affected.
To estimate whether antenatal dietary interventions restrict maternal weight gain in obese pregnant women without compromising newborn birth weight. PubMed and Cochrane Controlled Trials Register were searched using free-text search terms: pregnancy, obesity, overweight, dietary intervention, lifestyle, and randomis(z)ed controlled trial through March 2011 in a similar search strategy to that used in a previous systematic review. We included randomized controlled trials in which antenatal dietary intervention was provided to pregnant women who were overweight or obese at booking. We extracted 263 abstracts or reports, from which 39 full-text articles were reviewed. Four randomized controlled trials were identified involving 537 women. The results suggested that there was a significant pool treatment effect (z=11.58, P<.001), because antenatal dietary intervention programs were effective in reducing the total gestational weight gain by 6.5 kg. Despite this, antenatal dietary interventions did not alter newborn birth weight (z=0.18, P=.859). Antenatal dietary interventions in obese pregnant women can reduce maternal weight gain in pregnancy without an effect on newborn birth weight.
 Obesity is common in pregnancy and results in morbidity to mother and newborn.   To evaluate whether a four-step multidisciplinary protocol of antenatal care for overweight and obese women would reduce the incidence of gestational diabetes.  Pregnant women were approached at their first antenatal visit, and body mass index (BMI) was calculated to determine whether they were overweight or obese (BMI > 25). Eligible women were randomised to standard obstetric antenatal care or four-step multidisciplinary antenatal care. Clinic protocol included (i) continuity of obstetric provider; (ii) weighing on arrival at each visit; (iii) a five brief minute intervention by a food technologist who asked about the women's eating habits of the previous day, provided information on reading food labels, shopping lists of affordable foods available from local shops and recipes for a healthy pregnancy diet; and (iv) clinical psychology management to assess symptoms of depression and anxiety, stressful life events and determine whether psychological factors were involved in eating patterns. Labour and delivery data were audited from the medical records to determine the final incidence of gestational diabetes. The primary outcomes were gestational diabetes and weight gain.  The intervention was associated with a significant reduction in the incidence of gestational diabetes (6 versus 29%, OR 0.17 95% CI 0.03-0.95, P = 0.04). It was also associated with reduced weight gain in pregnancy (7.0 versus 13.8 kg, P < 0.0001). Despite this, birthweight of newborns was similar [3.5 (0.1) kg versus 3.4 (0.1) kg P = 0.16].   A four-step management plan adopted with obese women reduces the incidence of gestational diabetes.
high gestational weight gain (GWG) has been found to be associated with a number of adverse perinatal and long-term outcomes. we aimed to perform a systematic review and meta-analysis to find out whether physical activity in pregnancy might help avoid high GWG. a literature search in relevant databases and an additional search by hand through bibliographies of various publications were performed. we included randomised controlled trials on healthy women, with increased physical activity as the only intervention. GWG had to be documented for the intervention and control group separately. two reviewers independently extracted data and performed quality assessment. Data from the included trials were combined using a random-effects model. The effect size was expressed as mean difference (MD). of 1380 studies identified, 12 trials met the inclusion criteria. In seven trials, GWG was lower in the exercise group compared with the control group, whereas five trials showed a lower GWG in the control groups. The meta-analysis resulted in an MD of GWG of -0.61 (95% CI: -1.17, -0.06), suggesting less GWG in the intervention groups compared with the control groups. We found no indication for publication bias or dose effects. in summary, our analyses suggest that physical activity during pregnancy might be successful in restricting GWG.
Although obesity in pregnancy continues to be associated with ongoing health problems, many clinicians have been reluctant to place nondiabetic, obese, pregnant women on a monitored, calorie-appropriate nutritional regimen for fear of fetal growth restriction, low birth weight, or starvation ketosis. A total of 257 patients were enrolled in the randomized study, with a loss-to-follow-up rate of 9.73%. Patients were assigned randomly to either the control (unmonitored) group (n=116), consisting of conventional prenatal dietary management, or to the study (monitored) group (n=116), which was prescribed a balanced nutritional regimen and were asked to record in a diary all of the foods eaten during each day. Women were eligible for the study if they were pregnant with a single fetus between 12 and 28 weeks of gestation and had a prepregnancy body mass index of more than 30 kg/m2. The primary outcome was to compare perinatal outcomes in the control vs the study groups. The secondary measure was to compare outcomes in adherent and nonadherent patients in the study group. Omnibus MANOVA showed statistically significant differences between the study and control groups regarding 3 variables: (1) gestational hypertension, p < .46; (2) mother's last weight before delivery, p < .001; and (3) mother's 6-week postpartum weight, p < .001. Patients gaining 15 pounds or more during their pregnancy showed statistically significant differences between the groups for 8 variables. Obese pregnant women may be placed on a healthy, well-balanced, monitored nutritional program during their antepartum course without adverse perinatal outcomes.
Can gestational weight gain in obese women be restricted by 10-h dietary consultations and does this restriction impact the pregnancy-induced changes in glucose metabolism? A randomized controlled trial with or without restriction of gestational weight gain to 6-7 kg by ten 1-h dietary consultations. Fifty nondiabetic nonsmoking Caucasian obese pregnant women were randomized into intervention group (n=23, 28+/-4 years, prepregnant body mass index (BMI) 35+/-4 kg m(-2)) or control group (n=27, 30+/-5 years, prepregnant BMI 35+/-3 kg m(-2)). The weight development was measured at inclusion (15 weeks), at 27 weeks, and 36 weeks of gestation. The dietary intakes were reported in the respective weeks by three 7-day weighed food records and blood samples for analyses of fasting s-insulin, s-leptin, b-glucose, and 2-h b-glucose after an oral glucose tolerance test were collected. The women in the intervention group successfully limited their energy intake, and restricted the gestational weight gain to 6.6 kg vs a gain of 13.3 kg in the control group (P=0.002, 95% confidence interval (CI): 2.6-10.8 kg). Both s-insulin and s-leptin were reduced by 20% in the intervention group compared to the control group at week 27, mean difference: -16 pmol l(-1) (P=0.04, 95% CI: -32 to -1) for insulin and -23 ng ml(-1) (P=0.004, 95% CI: -39 to -8) for leptin. At 36 weeks of gestation, the s-insulin was further reduced by 23%, -25 pmol l(-1) (-47 to -4, P=0.022) and the fasting b-glucose were reduced by 8% compared with the control group (-0.3 mmol l(-1), -0.6 to -0.0, P=0.03). Restriction of gestational weight gain in obese women is achievable and reduces the deterioration in the glucose metabolism.
Australia) Clinical practice guidelines for the management of overweight and obesity in adults. Canberra: Commonwealth of Australia
NHMRC (Australia) Clinical practice guidelines for the management of overweight and obesity in adults. Canberra: Commonwealth of Australia, 2003.
Weight gain during pregnancy: reexamining the guidelines
  • Institute Of Medicine
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Report brief. May 2009.