1Department of Psychiatry, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine,
2Present address: Department of Psychology, University of Florida, Gainesville, Florida.
3Department of Psychology, Drexel University, Philadelphia, Pennsylvania.
4Departments of Public Health and Obstetrics/Gynecology, Temple University, Philadelphia, Pennsylvania.
This project was supported, in part, by funding from the National Institute of Diabetes and Digestive and Kidney
Diseases to D.B.S. (K23 DK60023-04 and R03 DK067885) and K.C.A. (R01 DK056732-05), as well as funding from Na-
tional Institute of Child Health and Human Development to D.B.N. (R01 HD3 8856-04).
JOURNAL OF WOMEN’S HEALTH
Volume 15, Number 6, 2006
© Mary Ann Liebert, Inc.
Pregnancy and Obesity: A Review and Agenda for
DAVID B. SARWER, Ph.D.,1KELLY C. ALLISON, Ph.D.,1LAUREN M. GIBBONS, B.A.,1,2
JESSICA TUTTMAN MARKOWITZ, M.S.,3and DEBORAH B. NELSON, Ph.D.4
At present, more than 60% of American women of childbearing age are either overweight or
obese. As the obesity epidemic in the United States and many other countries continues to grow
unchecked, there is greater interest in the relationship between obesity and other major health
issues. This paper reviews the literature on the relationship between obesity and pregnancy. We
begin with a discussion of the relationship between excess body weight and fertility and then
turn to the relationship between maternal body weight and pregnancy-related complications.
The role of pregnancy as a possible risk factor for the development of obesity is noted. The stud-
ies investigating the efficacy of behavioral interventions to control excessive weight gain during
pregnancy or help women lose weight after childbirth are then reviewed. The paper concludes
with an agenda for future research examining the relationship between obesity and pregnancy.
over the past 20 years.1Currently, approximately
two thirds (65.1%) of Americans ?20 years of age
have a body mass index (BMI) ? 25 kg/m2and
are considered overweight. Nearly one third
(30.5%) are considered obese (BMI ? 30 kg/m2),
and 4.9% are extremely obese (BMI ? 40 kg/m2).1
From 1999 to 2002, 29.1% of women of child-
bearing age (20–39 years) were classified as
HE PREVALENCE OF OVERWEIGHT and obesity in
the United States has increased dramatically
obese,1and an additional 25.4% of women in this
age cohort were overweight. Rates of overweight
and obesity among women of childbearing age
also differ by ethnic group. For example, 49% of
non-Hispanic white women and 70% of non-His-
panic black women between 20 and 39 years of
age are overweight or obese.
In 2003, there were over 4 million live births in
the United States.2With rates of overweight and
obesity in women of childbearing age exceeding
60%, ?2 million infants likely were born to over-
weight or obese mothers in 2003. These alarmingly
high rates of overweight and obesity among wo-
men of childbearing age raise several pertinent
questions. First, does overweight or obesity influ-
ence fertility? Second, is maternal obesity associ-
ated with increased risk of complications during
pregnancy? Third, does weight gain during preg-
nancy put women at risk for the development of
obesity? Finally, are there effective strategies to
help women control weight gain during pregnancy
or effectively lose weight during the postpartum
period? This paper reviews the literature in these
areas and discusses subsequent research priorities.
OBESITY AND REPRODUCTIVE
In the late 1990s, Pettigrew and Hamilton-Fair-
ley3and Norman and Clark4published compre-
hensive reviews of the relationship between obe-
sity and reproductive functioning. We provide a
brief review of this literature, focusing on stud-
ies completed since that time, as well as a detailed
discussion of the effect of intentional weight loss
Body weight and reproductive development
Changes in body mass and composition are be-
lieved to be major factors in the regulation of fe-
male pubertal development.5–8Menarche typi-
cally occurs earlier for obese compared with
normal weight girls.9,10Additionally, obesity in
childhood and early adulthood has been shown
to increase the risk of menstrual problems.11,12
Obesity and fertility
As seen in Table 1, obesity is believed to be as-
sociated with several adverse effects on fertility.
The relationship between obesity and fertility
problems has been found in most,13–19but not
For example, among 2527 married, infertile
nurses, women with a BMI ? 32 kg/m2were sig-
nificantly more likely to suffer from ovulatory in-
fertility (relative risk [RR] ? 2.7, 95% CI 2.0-3.7)
than normal weight women.22In a subsequent
study, after controlling for reproductive dysfunc-
tion and several other confounding factors, inves-
tigators found a significant association between
obesity and delayed conception (defined as a time
to pregnancy exceeding 9.5 months of unprotected
intercourse) in women who smoked.23(The rela-
tionship was not found in women who did not
smoke.) In addition, the mean time to pregnancy
for normal weight women (BMI 20–24.9 kg/m2)
was 7.4 months, compared with 11.1 months for
obese women, although this difference did not
reach statistical significance (p ? 0.057).
Body fat distribution (as measured by waist/
hip ratio or waist circumference), beyond obesity,
may negatively impact reproductive functioning
and fertility.18,24,25Excess body fat, particularly ab-
dominal fat, has been found to be associated with
irregular menstrual cycles, several hormone-sen-
sitive cancers, increased risk of miscarriage, and
reduced fertility.8This relationship also appears to
exist for women who seek artificial insemination.
After controlling for age, BMI, reasons for artifi-
cial insemination, cycle length and regularity,
smoking, and parity, waist/hip ratio yielded the
highest independent significant contribution to the
probability of conception per cycle.25
Although the specific mechanisms are not well
understood, the impact of excessive adipose tis-
sue on neuroendrocrine functioning, including
insulin resistance, hyperinsulinemia, and hyper-
androgenism, is believed to negatively influence
fertility.8,26Adipose tissue is crucial for the stor-
age of lipid-soluble steroids, such as androgens,
and therefore plays an important role in the reg-
ulation of sex hormone availability. Estrogen pro-
duction correlates significantly with percent body
fat.27The concentration of sex hormone-binding
globulin (SHBG) is negatively correlated with
BMI.28Further, insulin resistance and subsequent
hyperinsulinemia have been linked not only to
obesity29but also to reproductive dysfunction.30
Several peptides related to energy intake and
PREGNANCY AND OBESITY
TABLE 1.ADVERSE EFFECTS OF OBESITY
ON FERTILITY IN WOMEN
Irregular menstrual cycles
Potential pathophysiological role in the development of
polycystic ovary syndrome (PCOS)
Decreased conception rates after fertility treatments
Increased morbidity in pregnancy
Increased risk of miscarriage
Worsened outcomes of preterm deliveries
regulation, particularly leptin and ghrelin, have
been associated with reproductive development
and fertility. Functional leptin receptors have
been detected on the surface of ovarian follicular
cells, and studies have suggested that leptin may
exert a direct inhibitory effect on ovarian func-
tion.31–33As discussed in several reviews, high
leptin levels may serve as a potential link between
BMI and reproductive disorders.22,34–40
Excess weight has been found to lower con-
centrations of SHBG and increase androgen se-
cretion.41Pasquali et al.8found a negative corre-
lation between ghrelin and both androgen levels
and insulin resistance, leading to speculation that
ghrelin may somehow mediate the relationship
between the insulin system and hyperandrogen-
emia in obese individuals.
Perhaps the most common mechanism for the
relationship between obesity and fertility difficul-
ties is polycystic ovarian syndrome (PCOS).42
PCOS is the most common endocrinological disor-
der, affecting 1%–5% of women.43Approximately
50% of women with PCOS are obese.43,44PCOS is
characterized by hyperandrogenism (e.g., acne, hir-
sutism, male pattern balding, elevated serum,
adrenal, or ovarian androgen concentrations), men-
strual irregularities, and chronic anovulation.44The
production of follicular cysts characteristic of PCOS
often produces long-term absences of ovulation.
The etiology of PCOS is unknown; however, a his-
tory of excess body weight typically precedes or
coincides with the development of PCOS, leading
to speculation that obesity plays a role in the de-
velopment of hyperandrogenism.43
Weight loss and fertility
Weight loss is often recommended as the first
line of treatment for overweight or obese women
with fertility problems.14,15,41,45An extensive lit-
erature has found that moderate weight loss im-
proves menstrual regularity, ovulation, and in-
fertility.3,15,45–59Similarly, at least four studies
have documented improvements in reproductive
parameters and fertility outcome following
weight loss in women with PCOS.53,60–62Two of
the studies suggest that a weight loss of at least
5% is necessary to improve markers of infertility
with this disorder.53,60Weight loss of this mag-
nitude is attainable for the majority of women
treated in behavioral weight loss programs (us-
ing either balanced deficit diets of 1200–1500
kcal/day or low-calorie diets of approximately
1000 kcal/day) or with pharmacotherapy.63,64
The studies that have investigated the relation-
ship between intentional weight loss and im-
proved fertility are quite encouraging. However,
methodological limitations with many of the in-
vestigations, including small sample sizes, lack of
appropriate control groups, and poorly charac-
terized weight loss interventions, give some
pause to the strength of the relationship between
weight loss and improved fertility.
OBESITY AND COMPLICATIONS
Several obesity-related pregnancy complica-
tions have increased in the past decade. For ex-
ample, the cesarean section rate in the United
States rose to the highest recorded level (27.6%)
in history in 2003.2Preterm and low birth weight
levels also rose to 12.3% and 7.9%, respectively,
of all births in 2003, reaching the highest level in
the past 30 years.2The rates of pregnancy-asso-
ciated hypertension and diabetes, the most fre-
quently reported medical risk factors in preg-
nancy, also have risen steadily from 1990 to
2002.65These rising rates of adverse pregnancy
outcomes and comorbidities occur at a time of an
escalating prevalence of overweight and obesity
among reproductive age women. As concluded
in several recent reviews,43,66,67obesity and BMI
have been independently associated with an in-
creased risk of a number of these pregnancy com-
plications, including preeclampsia, congenital
malformations, preterm labor and delivery, ce-
sarean sections, and high maternal and infant
Spontaneous abortion and stillbirth
Obesity has been linked to an increased risk of
miscarriage.4,72 In a study of 1644 obese and 3288
normal weight women, obese women had a sig-
nificantly higher incidence of early (6–12 weeks
gestation; OR 1.2, 95% CI 1.01-1.46) and recurrent
early miscarriages (more than 3 prior miscar-
riages; OR 3.5, 95% CI 1.03-12.01) compared with
normal weight women.72Although investigators
failed to control for comorbid conditions, such as
PCOS or gestational diabetes, others have posited
that obesity is an independent risk factor for early
In a study of 24,505 single pregnancies in Den-
SARWER ET AL.
mark, obesity was associated with a significantly
greater risk of stillbirth (OR 2.8, 95% CI 1.5-5.3)
and neonatal death (OR 2.6, 95% CI 1.2-5.8) com-
pared with women of normal weight.74The risks
of stillbirth and neonatal death remained signifi-
cantly elevated even after adjusting for maternal
smoking, alcohol and caffeine intake, age, height,
parity, gender of child, and education level and
after excluding women with hypertensive disor-
ders or diabetes mellitus. Another recent Danish
study of 54,505 pregnant women found that the
risk for fetal death among obese women was sig-
nificantly higher as gestational age advanced
(28–36 weeks gestation: OR 2.1, 95% CI 1.0-4.4;
37–39 weeks gestation: OR 3.5, 95% CI 1.9-6.4;
40? weeks gestation; OR 4.6, 95% CI 1.6-13.4).75
Overweight women (BMI 25 ? 30) were also at
increased risk for fetal death after 28 weeks.
Gestational diabetes mellitus (GDM)
GDM may be the most significant obesity-re-
lated pregnancy complication, occurring in
3%–5% of all pregnancies.76Normal pregnancy is
characterized by increased insulin resistance and
reduced sensitivity to insulin action as a conse-
quence of placental production of lactogen and
progesterone.76Insulin resistance is most pro-
found in the third trimester, when GDM most fre-
quently occurs.77Factors associated with the de-
velopment of GDM include maternal age of ?35
years, obesity, prior history of cesarean section,
and history of prior neonatal death. The last two
factors may also be markers of the association be-
tween GDM and obesity.78As found in the
Nurses Health study, prepregnancy BMI ? 30
kg/m2was a significant risk factor for the devel-
opment of GDM (RR 2.9, 95% CI 2.2-3.9).79
Women with poorly controlled GDM at deliv-
ery are at increased risk of respiratory distress,
preeclampsia, premature rupture of membranes,
preterm delivery, cesarean section, and increased
risk of fetal death during the last 4–6 weeks of
gestation.78,80,81Infants of women with GDM are
also more likely to weigh ?4000 g at delivery and
have shoulder dystocia.78,80,81Obesity and dia-
betes history appear to contribute independently
to heightened risk of large-for-gestational age in-
fants82and cesarean section.83A recent study of
4001 women with GDM receiving either insulin
or dietary therapy found that obese women were
at higher risk of adverse perinatal outcomes than
normal weight women.84
The experience of GDM can have negative ef-
fects on the health of both mothers and newborns.
Fifteen to fifty percent of women diagnosed with
GDM will remain glucose intolerant or develop
diabetes mellitus (DM) postpartum.76,85 Congen-
ital anomalies, including complex cardiac defects,
skeletal malformations, anencephaly, and spina
bifida, occur in 6%–12% of infants born to dia-
betic mothers.86Maternal diabetes also is associ-
ated with an increased risk of childhood and ado-
lescent obesity and type 2 diabetes.87–89
Women with DM diagnosed before pregnancy
appear to be at even greater risk for many of these
adverse outcomes. Both maternal obesity and, to
a lesser degree, excessive weight gain during
pregnancy were independent risk factors for ad-
verse maternal and neonatal outcomes among
women with prepregnancy DM, with the excep-
tion of shoulder dystocia/cephalopelvic dispro-
In a meta-analysis of 13 investigations including
over 1.3 million women, the risk of preeclampsia
rose by 0.54% for each 1 kg/m2increase in BMI
and approximately doubled with each 5–7 kg/m2
increase.92These results suggest a rather strong
relationship between increased risk of preeclamp-
sia and increasing body weight. Many of the stud-
ies included in this meta-analysis did not control
for the presence of hypertension, GDM, or other
potential confounds that may have contributed to
the elevated rates of pregnancy complication.
However, a recent study controlling for these co-
morbidites still found a relationship between obe-
sity and preeclampsia.93
Several studies have suggested that the risk for
congenital malformation, especially of the neuro-
logical type, is heightened for fetuses born to
obese mothers.94–101Maternal nutritional factors,
such as a high glycemic index diet, have been as-
sociated with risk for neural tube defects, such as
spina bifida and anencephaly, in women with
BMIs ? 29 kg/m2, even after excluding women
with a history of diabetes.98Additionally, heart
defects and the occurrence of multiple anomalies
were more common among infants born to over-
weight (heart defects: OR 2.0, 95% CI 1.2-3.1; mul-
tiple anomalies: OR 1.9, 95% CI 1.1-3.4) and obese
women (heart defects: OR 2.0, 95% CI 1.2-3.4;
PREGNANCY AND OBESITY
multiple anomalies: OR 2.0, 95% CI 1.0-3.8) com-
pared with mothers with a normal BMI.99
Preterm delivery and cesarean section
Obesity also appears to be associated with
preterm delivery in some but not all studies.93,102
Obese women who gained in excess of 0.65
kg/week during pregnancy, the upper quartile
for weight gain, were at an increased risk for
preterm delivery (?37 weeks gestation).102Inde-
pendent of GDM, obesity has been related to an
increased rate of cesarean sections.69,83,90,103–105
The risk for all-cause cesarean sections rose with
prepregnancy BMI and was highest among obese
women (rate 55.3%; OR 3.5, 95% CI 1.4-8.6).90
Fourteen percent, or one in seven, cesarean sec-
tions in Utah between 1991 and 2001 was attrib-
uted to excess body weight.93Cesarean section is
associated with increased healthcare costs106,107
as well as higher maternal107and neonatal mor-
Additional pregnancy complications
Several large, international studies suggest a
relationship between BMI and other pregnancy-
related complications. Overweight and obese wo-
men are more likely to suffer from hypertension,
toxemia, urinary infections, labor induction, and
increased length of hospitalization, as well as
macrosomia in the child.93,104,109–112These condi-
tions appear to occur with even greater frequency
among mothers with extreme obesity,69who now
represent approximately 5% of the United States
population.1For example, women weighing in
excess of 300 lbs were more likely to experience
GDM and preeclampsia than women weighing
100–149 lbs.107The heaviest women also were
more likely to have a macrosomic infant and have
their infant treated in the NICU. Obesity inde-
pendently contributed to heightened risk for de-
livering a macrosomic infant, after controlling for
the presence of DM.82
PREGNANCY AS A RISK FACTOR FOR
DEVELOPMENT OF OBESITY
Although an extensive body of literature has
demonstrated a relationship between obesity and
fertility problems as well as pregnancy-related
complications, far less attention has been paid to
the management of excess body weight during or
after pregnancy.113Many women anecdotally re-
port weight gain during pregnancy as a major cat-
alyst in the subsequent development of obe-
sity.114It appears that many pregnant women
struggle to control their weight gain during preg-
nancy or are not successful in reducing their
weight back to prepregnancy levels.
Weight gain recommendations during pregnancy
In 1990, the Institute of Medicine (IOM) rec-
ommended that women with a BMI of 19.9–26.0
kg/m2gain approximately 25–35 lbs (11.3–15.9
kg); with a BMI of 26.1–29.0 kg/m2gain 15–25
lbs (6.8–11.4 kg); and with a BMI ? 29 kg/m2
gain no more than 15 lbs (6.8 kg) during the
course of pregnancy.115In addition, it was rec-
ommended that women with a BMI ? 19.9
kg/m2gain 28–40 lbs (13–18 kg).115These IOM
recommendations were subsequently criticized
for being too liberal and for failing to consider
the potential adverse effects of excessive weight
gain during pregnancy appropriately.116,117
More recently, both the American College of Ob-
stetricians and Gynecologists (ACOG)118and the
National Institute of Diabetes and Digestive and
Kidney Diseases119(NIDDK) provided revised
recommendations (Table 2). Unfortunately, no
specific recommendations were provided for wo-
men with extreme obesity (BMI ? 40 kg/m2). Al-
though these recommendations are a likely re-
sponse to the obesity epidemic, it is not known
if expectant mothers are aware of them or if prac-
titioners routinely use these guidelines in clini-
SARWER ET AL.
TABLE 2.WEIGHT GAIN RECOMMENDATIONS DURING PREGNANCY BY WEIGHT STATUS
Weight statusAppropriate weight gain
Underweight (BMI not specified)
Normal weight (BMI ? 25 kg/m2)
Overweight (BMI ? 25 kg/m2, ?30 kg/m2)
Obese (BMI ? 30 kg/m2)
27–40 lbs (12.2–18.1 kg)
25–35 lbs (11.3–15.9 kg)
15–25 lbs (6.8–11.3 kg)
?15 lbs (?6.8 kg)
Adapted from NIH Publication No. 02-5130, 2002.
Several studies have suggested that a substan-
tial number of women exceed the IOM’s recom-
mendations of adequate weight gain.120–123In an
investigation of over 120,000 women enrolled in
Women, Infants, and Children (WIC) clinics over
a 6-year period, Schieve et al.122found that the
percentage of women reporting a pregnancy
weight gain greater than the IOM recommenda-
tions increased from 41.5% to 43.7% (p ? 0.001).
As women typically underreport their weight
gain both during pregnancy and at delivery, these
percentages may be even higher.124
The NIDDK also provided specific dietary and
physical activity recommendations for pregnant
women.119During the first 3 months of pregnancy,
women are instructed not to increase daily caloric
consumption. During the final two trimesters, wo-
men who were at a normal weight before their
pregnancy and those who are pregnant with a
single child are instructed to consume an addi-
tional 300 kcal/day. Women who were over-
weight or obese at the time of conception and
those who are pregnant with multiple children
are encouraged to consult with their doctor for
specific caloric intake and weight gain recom-
mendations. Thus, there currently are no formal
dietary recommendations for American women
of childbearing age who are obese.
Failure to follow these weight gain recom-
mendations, at least intuitively, is a likely con-
tributor to the development of obesity and many
of the pregnancy-related complications dis-
cussed. Several factors likely contribute to wo-
men’s difficulty in following these recommenda-
tions. As Brownell and Horgen125have argued,
we now live in a toxic food environment, in which
the availability of high-calorie and high-fat foods
makes the development of excessive body weight
inevitabile for millions of Americans. The effects
of this environment may be exaggerated in preg-
nant women, as pregnancy may be one of the few
times that women feel less pressure from our
thin-obsessed society to restrict food intake. Re-
liance on takeout foods, fast food, and other
preprepared foods, a central component of the
toxic food environment, is, in some respects, a
logical by-product of the workaholic, stress-filled
American way of life. Many people inappropri-
ately eat in response to stress,126–128and a recent
study found that pregnant women between 24 and
32 weeks’ gestation who reported high stress, anx-
iety, and fatigue consumed more carbohydrates,
fats, and protein and less vitamin C and folate.129
In addition, two forms of disordered eating are
linked to overweight and obesity: binge eating
disorder (BED) and night eating syndrome
(NES).130BED involves consuming very large
amounts of food while experiencing a loss of con-
trol. This occurs, on average, twice per week and
is associated with guilt, disgust, or embarrass-
ment. NES is characterized by a shift in the cir-
cadian pattern of food intake, such that at least a
quarter of daily caloric intake is consumed after
the evening meal, there are awakenings during
the night accompanied by the ingestion of food
(at least three times per week), and there is little
appetite for breakfast the next morning.131To our
knowledge, no studies have examined the rela-
tionship between BED or NES and pregnancy.
The age of onset for both of these disorders is dur-
ing early adulthood, when most pregnancies oc-
cur, and both conditions could contribute to ex-
cessive weight gain during pregnancy. During
the postpartum period, NES may be induced or
exacerbated by the nocturnal feeding demands of
infants; new mothers may eat during the night
when they are awake with their infants. All these
issues await empirical study.
WEIGHT RETENTION AFTER
Although our discussion thus far intuitively
suggests that women may experience significant
weight retention after childbirth, the empirical
evidence is inconclusive. A review of nine stud-
ies suggested that the average postpartum weight
retention was 0.5–3 kg but could be as high as
17.7 kg.132These studies used a number of
methodologies to assess body weight, with fol-
low-up ranging from the first trimester of a sub-
sequent pregnancy to 10 years. Thus, the ability
to draw firm conclusions from them is limited.
Other studies have suggested that the more
weight women gain during pregnancy, the more
likely they will retain weight postpartum, in both
the short133and long term.134,135For example,
Rooney and Schauberger134followed 540 women
for an average of 8.5 years after childbirth. Wo-
men who gained less than the IOM-recom-
mended weight during pregnancy increased their
weight 4.1 kg from their prepregnancy weight.
Those who gained the recommended amount of
weight were 6.5 kg heavier than their prepreg-
nancy weight, and those who gained more than
PREGNANCY AND OBESITY
the IOM recommendations were 8.4 kg heavier
than their prepregnancy weight.
Linne et al.135similarly assessed women’s
weight before, during, and 1 and 15 years after
pregnancy. Prepregnancy BMI was not associated
with long-term weight retention, but weight re-
tention 1 year after pregnancy did predict weight
retention 15 years later. In addition, women who
were classified as high weight gainers during
pregnancy (average gain ? 18.8 kg) were more
likely to shift from being normal weight at
prepregnancy to being overweight at 15-year fol-
CONTROLLING EXCESSIVE WEIGHT
GAIN DURING PREGNANCY
A sizable body of research has investigated the
efficacy of behavioral and pharmacological treat-
ment for obesity.64,136,137Only two investigations,
to our knowledge, have studied the potential util-
ity of interventions designed to control weight
gain during pregnancy. This relative dearth of re-
search may be an artifact of preobesity epidemic
history, when the IOM recommendations focused
more on maximizing weight gain during preg-
nancy to avoid the development of birth defects
associated with malnutrition. In one investiga-
tion, 120 women with a prepregnancy BMI ? 19.8
kg/m2were assigned to a behavioral intervention
or control group.138The behavioral intervention
consisted of clinic visits where the women were
weighed and provided with written information
about appropriate weight gain, exercise, and
healthy eating during pregnancy. After each visit,
if the woman’s weight gain was within the IOM
guidelines for her pregnancy stage, she would re-
ceive positive feedback and be encouraged to
continue with healthy eating and physical activ-
ity. Women who exceeded the IOM weight gain
guidelines during pregnancy were given more in-
tensive care in the form of additional nutrition in-
formation and behavioral counseling. The control
group received the standard nutrition counseling
provided by medical staff and counselors, which
emphasized a well-balanced diet and multivita-
Normal weight women in the intervention
group were significantly less likely to exceed the
weight gain recommendations compared with
normal weight women in the control group (63%
vs. 94%). For overweight women, however, the
intervention did not seem to be effective. Ap-
proximately two thirds of overweight women in
each treatment group exceeded the weight gain
A more recent study investigated the efficacy
of a psychoeducational intervention for control-
ling weight gain during pregnancy in both aver-
age weight and overweight women.139Partici-
pants were mailed materials on healthy weight
gain, nutrition, and exercise during pregnancy.
Participants’ medical providers were offered op-
tional training about healthy weight gain during
pregnancy. Women receiving this intervention
were compared with control participants who
were of both average weight and overweight.
The proportion of participants gaining more
than the recommended amount did not differ by
group (41% in the intervention group vs. 45% in
the control group). In low-income women, how-
ever, there was a significant intervention effect.
Low-income participants in the intervention
group, regardless of their prepregnancy weight
status, were less likely to gain more than the rec-
ommended amount of weight compared with
those in the control group (52% vs. 33%).139
Considering the results of these two studies to-
gether, weight control interventions for pregnant
women appear to be particularly effective for the
prevention of excessive weight gain among aver-
age weight women and those from lower socioe-
conomic status groups. Both interventions ap-
peared to be less effective for restricting weight
gain for overweight women. The reasons for
these divergent results are unknown. Clearly,
additional study of interventions designed to im-
prove adherence to weight gain recommenda-
tions during pregnancy is needed.
FACILITATING WEIGHT LOSS DURING
A limited number of studies have investigated
strategies by which women lose weight during
the postpartum period. Leermakers et al.140re-
cruited women who had given birth within the
past 12 months and who exceeded their prepreg-
nancy weight by at least 6.8 kg. Participants were
assigned to either a control group, in which they
received one informational brochure on healthy
eating and exercise, or an intervention group. The
intervention consisted of a correspondence pro-
gram in which women had two in-person coun-
SARWER ET AL.
seling sessions and received written material by
mail. They were encouraged to follow a low-calo-
rie (1000–1500 kcal/day), low-fat (20% of daily in-
take) diet and to exercise regularly. Women also
received 16 lessons on nutrition, exercise, and be-
havior change strategies by mail and were con-
tacted by phone at least biweekly.
The intervention group lost significantly more
weight during the postpartum period (7.8 ? 4.5
kg) compared with the control group (4.9 ? 5.4
kg). In addition, women in the intervention group
were more likely to reach or weigh less than their
prepregnancy weight. As reported in most weight
loss studies, self-monitoring of food intake was
significantly associated with weight loss.140
In addition to developing interventions to help
women lose weight after pregnancy, it is impor-
tant to understand the strategies women use to
lose weight on their own. Pregnant women, re-
gardless of their current weight, report a strong
interest in using exercise to help them lose weight
during the postpartum period.141Only obese wo-
men reported interest in dieting, most commonly
through self-help programs, to lose weight dur-
ing the postpartum period. Despite women’s
preference for participating in a less structured,
self-directed weight loss program, women who
participate in a structured program for 12 weeks
postpartum are more likely to lose weight than
those who do not.142
BARRIERS TO POSTPARTUM
Without question, postpartum women face
unique challenges to weight control not faced by
other women. One such barrier is lack of sleep.
The postpartum period is associated with signif-
icant sleep disruption.143This period begins im-
mediately after birth and continues until the baby
sleeps through the night. Three recent studies
have linked sleep debt with obesity and potential
for weight gain.144–146In a survey study of 1001
primary care patients, Verona et al.144reported a
linear relationship of decreasing sleep with in-
creasing weight up to a BMI of 40 kg/m2. Those
with extreme obesity slept at levels comparable
to those of less obese persons.
Insufficient sleep appears to be associated with
changes in hormones associated with weight reg-
ulation. Sleep deprivation has been associated
with decreased leptin, increased ghrelin, and in-
creased hunger and appetite, particularly for high-
carbohydrate, energy-dense foods.145Among those
who slept an average of 5 hours per night com-
pared with those who slept 8 hours per night, ghre-
lin levels were 15% higher and leptin levels 15%
lower.146Taken together, these studies suggest that
obese women who are up at night caring for their
newborns may be especially susceptible to weight
gain or, perhaps, resistant to postpartum weight
Lack of exercise may also be a barrier to post-
partum weight control. Devine et al.147conducted
in-depth, qualitative interviews with 36 women
from pregnancy through postpartum and found
that those who plan on exercising and focusing
on weight loss postpartum tend to lose more
weight than those who do not make physical ac-
tivity or weight loss a priority. Sampselle et al.148
examined physical activity levels in 1003 women
who were 6 weeks postpartum. Women who self-
reported higher levels of activity postpartum re-
tained significantly less weight at 6 weeks than
those who reported lower levels of activity (3.9
kg vs. 5.1 kg). Some evidence suggests that obese
women may feel self-conscious and not able to
keep pace when exercising with normal weight
women,149a factor that should be considered
when implementing postpartum exercise pro-
Lactation may facilitate weight loss for the first
few months after childbirth, but it does not ap-
pear to have a significant long-term effect on
weight unless breastfeeding continues past 12
months.150–153For example, Janney et al.150com-
pared women who did not breastfeed with those
who breastfed for at least 6 months. They found
that those women who were breastfeeding re-
tained less weight than those who were not, but
at 1 year follow-up, the difference between the
groups was small and was only statistically sig-
nificant if assessed longitudinally.
Marital status, age, and smoking also may in-
fluence postpartum weight control efforts,150–151
and dietary changes may occur postpartum. A re-
cent study suggested that among low-income wo-
men, mean daily servings of grains, vegetables,
and fruit declined following childbirth, whereas
the percent intake of fat and sugar increased.154
These changes were more pronounced among
women who bottle-fed rather than breastfed their
Although difficult to study, the increased time
demands and sense of responsibility associated
PREGNANCY AND OBESITY
with caring for an infant should not be ignored.
These issues may have a profound impact on
mood and quality of life. For some postpartum
women, changes in mood may be quite serious.
Postpartum depression affects 10%–15% of moth-
ers.155Prior history of depression, depression or
anxiety during pregnancy, lack of social support,
and stressful life events have been consistently re-
lated to postpartum depression.155–157In general,
the relationship between depression and obesity
is complex,158and the unique relationship among
postpartum depression, weight retention, and
obesity is unknown.
CONCLUSIONS AND DIRECTIONS FOR
As discussed in this review, a sizable body of
literature has demonstrated the detrimental
health effects of obesity on reproductive func-
tioning, fertility, and pregnancy outcome. The
mechanisms by which weight influences repro-
ductive functioning are not well understood and
warrant additional study. Numerous studies,
however, have suggested that modest weight
losses may be associated with improvements in
fertility, although methodological concerns call
into question both the validity and generalizabil-
ity of these findings. Future studies examining
the effect of weight loss on improved fertility
should strive to include state-of-the-art dietary
and behavioral interventions as typically found
in the obesity literature.63,64
As also described in this review, obesity has
been related to several pregnancy-related com-
plications. The relationship between obesity and
the development of GDM and its complications
seems particularly compelling. Given the current
obesity epidemic and the potential increased risk
of adverse pregnancy outcomes, pregnant wo-
men and their physicians should work together
to limit excessive weight gain during pregnancy.
This may be particularly important for women
with an elevated BMI at the time of conception
and for those with a strong family history of obe-
sity. A smaller number of studies have begun to
investigate pregnancy as a catalyst for the devel-
opment of obesity in some women. Although in-
tuitively appealing, the role of pregnancy (or
multiple pregnancies) in the development of obe-
sity awaits further study.
Only a limited number of studies have inves-
tigated the efficacy of interventions designed to
either control excessive weight gain during preg-
nancy or facilitate weight loss during the post-
partum period. Studies designed to prevent ex-
cessive weight gain during pregnancy appeared
to be particularly effective for average weight (as
compared with overweight) women and those
from lower socioeconomic status groups.
Compared with behavioral weight control tri-
als found in the obesity literature, the behavioral
interventions initiated during pregnancy or the
postpartum period can be classified as minimal
interventions at best. New, creative treatment ve-
hicles, such as the use of phone, Internet-based
programs, or personal digital assistants, might
help overcome some of the potential barriers to
participating in and adhering to a behavioral
weight control program during or after preg-
nancy. Future studies also need to overcome the
significant challenge of addressing a number of
barriers to postpartum weight control, including
fatigue, sleep disruption, lactation, and other ob-
stacles to self-care that a newborn creates.
This review also highlights some previously
neglected areas of research. Relatively little is
known about the relationship between extreme
obesity and fertility and pregnancy complica-
tions. Over 100,000 Americans with extreme obe-
sity were projected to have undergone bariatric
surgery in 2003, and ?80% of them were wo-
men.159Patients interested in becoming pregnant
postoperatively are typically encouraged to wait
until they have reached their maximum weight
loss (one third of initial body weight, on average),
approximately 18 months after bariatric surgery,
and to seek the care of a high-risk obstetrician.118
At present, potential fertility problems or preg-
nancy-related complications in these women are
not well documented. After surgery, patients are
instructed to consume approximately 1000–1200
kcal/day and to take a daily multivitamin and
monthly vitamin B12supplements. Anecdotal re-
ports and some clinical evidence suggest that a
large minority of patients do not follow these nu-
tritional recommendations.160These may be par-
ticularly salient issues for the growing number of
extremely obese adolescent girls and young wo-
men who are now seeking bariatric surgery and
likely desire to have children in the future.
Little is known about the relationship between
obesity and postpartum depression. Given the
complex relationship between obesity and de-
pression in general, future study of this issue is
SARWER ET AL.
warranted. For these and other areas, closer col-
laboration among obstetricians, obesity specialists,
and endocrinologists may lead to the development
of new and more effective methodologies to study
and treat obesity prior to and throughout preg-
nancy, as well as in the postpartum period.
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