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Pregnancy and PostpartumLifestyle intervention before conception
Dr Nicola HeslehurstSenior Lecturer in Maternal Nutrition
Newcastle University, UKEmail: [email protected]
Twitter: @NHeslehurst
Evidence-base:
Definitions and prevalence
Determinants
Risks in pregnancy and postnatally
Weight bias/obesity stigma in pregnancy
Overview: Pregnancy and Postpartum
Maternal obesity
BMI before pregnancy
Early pregnancy BMI (1st trimester)
General population BMI criteria
Gestational weight gain
Weight gained during pregnancy
Fetus, placenta, fluids, fat mass
BMI shouldn’t be recalculated in late pregnancy
Definitions
Europe Obesity Prevalence: Women
Source: World Obesity Federation Interactive Map
Global Priority
• Pre-pregnancy, maternal and infant nutritional status varies … according to demographic and socioeconomic factors
• Poor maternal nutritional conditions … during fetaldevelopment and early life … increased risk of NCDs and obesity throughout the life-course
• The importance of the intergenerational impact of nutrition leads to new policy challenges and raises critical questions about protecting and promoting public health through maternal and infant nutrition
Evidence-base:
Definitions and prevalence
Determinants
Risks in pregnancy and postnatally
Weight bias/obesity stigma in pregnancy
Overview: Pregnancy and Postpartum
Obesity causation is complex:
Social
Environmental
Physiological
Political
Economic (including industry)
Behavioural
Psychological
And more ...
Maternal Obesity Inequalities
Wider context of health and behaviour
Wider context of health and behaviour Mothering norms, societal expectations (and legislations)
Food industry, marketing, taxation
Money, maternity benefits, maternity leave
Health professionals practice, training, availability of services
Partners/family reinforce pregnancy myths
Diet and Physical Activity
Deprivation
Food insecurity
700,000 more women than men in poverty
Women are most likely to be living in food insecure households
Half of mothers under the age of 25 skipped meals in order to feed their children
Lone parents, especially women, most likely to be accessing food banks and have the highest gap between income and adequate living standards
(Heslehurst et al 2010, JustFair.co.uk, O’Connell et al 2019, The Food and You Survey, 2017)
Maternal Obesity Inequalities (UK)
BMI >30.0 kg m2 BMI 30.0 to 34.9 kg m2
BMI 35.0 to39.9 kg m2
BMI 40.0 to 49.9 kg m2 BMI >50.0 kg m2
Most deprived
aOR 2.20 (95% CI 2.13, 2.28)
aOR 1.96 (95% CI 1.88, 2.03)
aOR 2.71 (95% CI 2.54, 2.89)
aOR 2.97 (95% CI 2.69, 3.29)
aOR 4.69 (95% CI 3.20, 6.87)
Maternal Obesity Inequalities (UK)
(Heslehurst et al 2014)
Maternal Obesity Inequalities (UK)
(Heslehurst et al 2014)
Ethnic group Odds ratio (95% CI)
White Reference
South Asian 1.72 (1.66-1.79)
Pakistani 2.19 (2.08-2.31)
Bangladeshi 1.15 (1.06-1.24)
Indian 1.49 (1.39-1.60)
Black 1.70 (1.62-1.78)
Mixed 0.79 (0.72-0.87)
Chinese or Other Ethnic Group 0.63 (0.58-0.69)
Maternal Obesity Inequalities (Global)
• Women and children in LMICs at increased risk of obesity
• Women (pregnant and childbearing age) and children migrating from LMICs to HICs remain at high risk• Inadequate macro- and micro-nutrients, dietary and physical activity behaviours
• Increased levels of obesity in pregnant women and women of childbearing age
• Increased obesity among children of women who have migrated
(Ngongalah et al. 2018, Ngongalah et al unpublished)
Evidence-base:
Definitions and prevalence
Determinants
Risks in pregnancy and postnatallyObesity and gestational weight gain
Weight bias/obesity stigma in pregnancy
Overview
Gestational diabetes
Obesity class 1: OR 3.01 (95% CI 2.34, 3.87)
Obesity class 2/3: OR 5.55 (95% CI 4.3, 7.2)
Post-term birth
Obesity class 1: OR 1.38 (95% CI 1.31-1.46)
Obesity class 2: OR 1.57 (95% CI 1.50-1.64)
Obesity class 3: OR 1.76 (95% CI 1.69-1.83)
Stillbirth
Obesity class 1: RR 1.46 (95% CI 1.37-1.55)
Obesity class 2: RR 1.78 (95% CI 1.67-1.91)
Obesity class 3: RR 2.19 (95% CI 2.03-2.36)
Caesarean
Large for Gestational Age (LGA)
Preeclampsia
Preterm birth
Maternal infection
Congenital anomalies
Antenatal/postnatal depression
Reduced breastfeeding
Childhood obesity
Risks - pregnancy and postnatal
(Aune et al 2014, Goldstein et al 2017, Heslehurst et al 2008/2018, Marchi et al 2015, Stothard et al. 2009, Torloni et al 2009, Heslehurst et al 2019)
BMI 40 kg/m2 more than twice as likely to have stillbirth than BMI 20 kg/m2
BMI of 20 – 4 stillbirths in every 1000 births
BMI of 40 - 9 stillbirths in every 1000 births
Or
BMI of 20 - 996 livebirths in every 1000 births
BMI of 40 - 991 livebirths in every 1000 births (Aune et al 2014)
Absolute RiskBMI 20 kg/m2
BMI 25 kg/m2
BMI 30 kg/m2
BMI 35 kg/m2
BMI40 kg/m2
StillbirthRR (95% CI)
Reference group
1.20(1.14-1.26)
1.46 (1.37-1.55)
1.78 (1.67-1.91)
2.19 (2.03-2.36)
Anna talking about frightening risk communication
“It does frighten you coz I went home and sat and cried my eyes out when they’ve said to me ‘you’re gonna have a massive baby’, because I’ve panicked about how I’m gonna get her out”
Nulliparous woman talking about accusatorial approach to risk communication
“I was so excited, after years of struggling to become pregnant, I finally met my midwife. After approximately 10 minutes into the conversation, she suddenly said. ‘Don’t expect to be able to breastfeed when your BMI is so high’. I felt slammed up against the wall, did not really hear more of the conversation. I was devastated.”
(Heslehurst et al 2015, Lindhart et al 2013)
Women’s Experiences
Maternal BMI and Child Obesity
Maternal pre-pregnancy BMI
Odds Ratio (95% CI)
Interpretation
Recommended BMI
1.00 Reference group
Overweight 1.89 (1.62, 2.19)
89% increased odds of child obesity
Obese 3.64 (2.68, 4.95)
264% increased odds of child obesity
(Heslehurst et al, 2019)
Maternal BMI and Child Diabetes
(Lahti-Pulkkinen et al, 2019)
• n=118,201 children
T2DM:
• Maternal overweight HR 1.39 (95% CI 1.06, 1.83)
• Maternal obesity HR 3.48 (95% CI 2.33, 5.06)
Lack of international agreement
USA Institute of Medicine Guidelines (2009)
How much gestational weight gain?
Gestational Weight Gain: SGA/LGA
(Fauchner et al 2015)
Gestational weight gain with best outcomes for LGA and SGA:• Class 1 obesity = 5-9kg• Class 2 obesity = 1 to <5kg• Class 3 obesity = 0kg
23 studies
n = 1,309,136 women
Patterns of gestational weight gain
(Goldstein et al. 2018)
Gestational weight gain and postnatal weight retention
• PWR up to 21 years
• n=67,853 women
• Excessive GWG (for any pre-pregnancy BMI) compared with women who gained the recommended weight in pregnancy for their BMI
• 3.48kg weight retention
(Rong et al 2014)
Gestational weight gain and child obesity
(Mamum et al 2014)
• Excessive GWG• RR 1.40 (95% CI 1.23, 1.59)
• <5 years • RR 1.91 (95% CI1.21, 3.02)
• 5 to <18 years • RR 1.32 (95% CI 1.14, 1.53)
• 18+ years • RR 1.47 (95% CI 1.21, 1.77)
Evidence-base:
Definitions and prevalence
Determinants
Risks in pregnancy and postnatally
Weight bias/obesity stigma in pregnancy
Overview
Health professionals – impact on practice?
Spend less time with patients, fewer health-related discussions, patients perceived as: noncompliant, overindulgent, lazy, unintelligent, lacking in self-control, weak-willed, dishonest and unsuccessful
(Obesity Action Coalition 2016c, Puhl and Heuer 2009)
Study with midwives:
“…an underlying perception that obesity is unacceptable; something that just requires will power and some participants indicated feelings of repulsion. In focus groups, participants talked about ‘fat’ women, and members of one group were critical of the ‘normalising’ of obesity: ‘now they’ve got a shop with all the real fat clothes, they’re all sharing their dress styles like the rest of us.’ Concern was also expressed about obese women gaining weight between each pregnancy: ‘they just come back fatter, it’s disgusting’ ” (Schmied et al 2011)
Weight Bias and Health Professionals
Stigma experienced outside pregnancy reinforced by health professionals in pregnancy (e.g. greedy, lazy, not intelligent)
Feeling judged, guilt, blamed – bad parent
Feeling dismissed by health professionals
Humiliating comments – e.g. bodies being unattractive
Avoid confronting health professionals about treatment – impact on antenatal care
(Nyman et al 2010, Lavendar and Smith 2016, Furber and McGowan 2011, Heslehurst et al 2015,
Keenan and Stapleton 2010, Phelan et al 2015)
Weight Bias in Pregnancy
Denise talking about language
“because she couldn’t get a good picture, I was just about to say ‘oh is it because I’m overweight?’, and the way she turned around and said ‘there’s obviously a lot of you to get through’, which I thought was the only bad thing … it was the way she said it, I mean she could have said like obviously ‘it’s harder’, but she just said ‘there’s a lot of you to get through’”
Anita talking about non-verbal language
“you can tell when some people have an issue they don’t say anything but they don’t like to touch you”
Melanie talking about her experience of stereotypes
“I think there’s just something wrong with the way that people who are overweight are viewed in this country by everybody, whether you are pregnant or not…there’s just an assumption that you’re a bit thick, and that’s why you are overweight”
(Heslehurst et al 2013, Heslehurst et al 2015, Mills et al 2015)
Women’s Experiences
Lisa talking about past experiences with health professionals
“Whenever I was seeing the doctor, I would go in to see them for something different but the first thing they’d say is “your weight’s too high”. “I know my weight is too high, I’m not here to see you about my weight, I’m here about this”… they would almost always have a go and it really upset me to the point where I ended up losing my temper with the doctor one day, “I don’t really care about my weight, I’m not here about my weight, I’m here for something else, get off my back, I’ll get it sorted out in my own time”… I didn’t go and see another doctor for ages because well, [I thought] they’re going to mention my weight and I don’t want to go … I was constantly sick of the doctor going on at me all the time about it, I was like “I know I’m fat, I know I need to lose weight you’re not going to help by having a go at us”
(Heslehurst et al 2013)
Women’s Experiences
Positive Communication Experiences
Surprise
Joy
Treated like everyone else
Decreased discomfort
Tension eased
Affinity
Relaxed
Proud to be pregnant
Strength and power
Self-esteem
Motivation
(Heslehurst et al 2015, Merrill and Grassley 2008, Nyman et al 2010)
Encouraged
Key Messages
Maternal obesity is a clinical and public health priority
1st 1000 days, opportunity to alter fetal environment
There are obesity-related risks
in pregnancy, postnatally and life-long
for both mother and baby
Obesity development is complex and should not be overly simplified to diet and physical activity behaviours
Inequalities are key
Weight bias and obesity stigma are prevalent in maternity services
What is preconception?
Preconception interventions – what is the evidence?
Overview: Preconception Interventions
Preconception Interventions: who is the target group?
• Developing interventions requires knowing the target population
• Different life stages have different:• Determinants of obesity• Motivations to change behaviours• Stakeholders to support intervention delivery• Messages specific to pregnancy • Opportunities for interventions are different
Preconception Interventions: who is the target group?
Discuss:• When thinking about “preconception”
who do you think about?• Who is the target group(s) for
preconception interventions?• Why?
Preconception Interventions: who is the target group?
(Barker et al. Lancet 2018; 391: 1853–64)
Preconception Obesity Interventions: who is the target group?
Bariatric surgery before pregnancy
Fertility treatment
Accessing preconception
care
Post-natal/ inter-
pregnancy
Infant feedingPre-schoolSchool
* * *
* Men
Evidence-base:
What is preconception?
Preconception interventions – what is the evidence?
BMI and fertility treatment
Preconception bariatric surgery
Overview: Preconception Interventions
Preconception interventions• Systematic searches for evidence
Cochrane Review: Directed preconception health programs and interventions for improving pregnancy outcomes for women who are overweight or obese.
“We identified no studies that met the inclusion criteria for this review” (Ospray et al 2015)
“few interventions in the preconception period are targeted at maternal obesity.”… “health services are organised around prevention of unintended pregnancy in family-
planning clinics or screening for and managing medical disorders in pregnancy, with little attention being given to planning and preparation for pregnancy”
(Hanson et al 2016)
“We did not identify enough good quality studies conducted in the preconception period to enable us to perform a meta-analysis or draw firm conclusions about effectiveness”
(Barker et al 2018)
(Barker et al 2018)
(Barker et al 2018)
Maternal weight at 20 years, maternal pre-pregnancy weight (n=1,756)Reference group: Moderate weight gain 0.0 to 0.55 kg/year
• Weight Loss: <0.0 kg/year • Small for Gestational Age (BMI<25) OR 1.76 (95% CI 1.10–2.81)
• High weight gain: ≥0.55 kg/year (n = 715) • Gestational diabetes OR of 1.9 (95% CI 1.1–3.3)
(Diouf et al 2011)
Pre-pregnancy weight change before pregnancy (observational data)
Inter-pregnancy weight change: GDM (observational data)
“Across all BMI categories, mothers with significant weight gain (i.e., moving from a lower BMI category into a higher category) had an increased risk for the development of diabetes [GDM and T2DM]… Mothers who maintained their inter-pregnancy BMI weight category or who moved to a lower BMI category had reduced risk [GDM and T2DM] ” (Whiteman et al 2011)
• Recommended BMI to Obese BMI: OR 3.21 (95% CI 2.76–3.73) (n=232,272)• Increase ≥3 BMI units: RR 2·09 (95% CI 1·68–2·61) (n=151,025)• Increase ≥2 BMI units: OR 2.25 (95% CI 1.33–3.78) (n=7,897)
(Bogaerts et al 2013, Villamor and Cnattingius 2006, Whiteman et al 2011)
Inter-pregnancy weight change: hypertensive disorders (observational)Preeclampsia:• Increase ≥3 BMI units: RR 1·78 (95% CI 1·52–2·08) (n=151,025)• Increase ≥3 BMI units: OR 1.85 (95% CI 1.12-3.04) (n=12,740)
Recurrent preeclampsia: • Increase BMI: RR 1.29 (95% CI 1.20–1.38) (n=17,773)• Decrease BMI: RR 0.70 (95% CI 0.60–0.81) (n=17,773)
Pregnancy induced hypertension:• Increase ≥2 BMI units: OR 3.76 (95% CI 2.16–6.57) (n=7,897)• Increase ≥3 BMI units: RR 1·76 (95% CI 1·39–2·23) (n=151,025)• Increase ≥3 BMI units: OR 1.82 (95% CI 1.40-2.36) (n=12,740)
(Bogaerts et al 2013, Mostello et al 2010, Villamor and Cnattingius 2006, Wallace et al 2014)
Inter-pregnancy weight change: labour and birth (observational)
Caesarean delivery• Increase ≥3 BMI units: RR 1·32 (95% CI 1·22–1·44) (n=151,025)
Emergency caesarean delivery• Increase ≥3 BMI units: OR 1.78 (95% CI 1.35-2.35) (n=12,740)
Induced labour• Decrease ≥1 BMI units: OR 1.21 (95% CI 1.01-1.46) (n=12,740)
Preterm birth• Decrease ≥1 BMI units: OR 1.46 (95% CI 1.08-1.97) (n=12,740)
(Villamor and Cnattingius 2006, Wallace et al 2014)
Inter-pregnancy weight change: Perinatal mortality (observational)
Stillbirth • “Stillbirth risks increased linearly with increased BMI gain… In overweight women (BMI
≥25kg/m2), weight loss before pregnancy reduced risk of neonatal mortality”
• Increase ≥3 BMI units: RR 1·63 (95% CI 1·20–2·21) (n=151,025)• Increase ≥4 BMI units: RR 1·55 (95% CI 1·23–1·96) (n= 456 711)
Infant mortality• Increase ≥4 BMI units: RR 1·29 (95% CI 1·00–1·67) (n= 456 711)
(Villamor and Cnattingius 2006, Cnattingius and Villamor 2016)
Inter-pregnancy weight change: Birth weight (observational)
Large for gestational age (LGA)• Increase ≥3 BMI units: RR 1·87 (95% CI 1·72–2·04) (n=151,025)• Increase ≥2 BMI units: OR 1.37 (95% CI 1.21–1.54) (n=10,444)• Increase ≥3 BMI units: OR 1.70 (95% CI 1.36-2.13) (n=12,740)• Decrease ≥2 BMI units: OR 0.61 (95% CI 0.52–0.73) (n=10,444)• Decrease ≥1 BMI units: OR 0.57 (95% CI 0.42-0.76) (n=12,740)
Small for gestational age (SGA)• “Interpregnancy BMI change was not related to SGA infant risk, except for weight loss of
>8 BMI units” (n=10,444)• Decrease ≥1 BMI units: OR 1.65 (95% CI 1.33-2.04) (n=12,740)
(Jain et al 2013, Villamor and Cnattingius 2006, Wallace et al 2014)
Fertility treatment: IVF meta-analysis (observational data)
(Rittenberg et al 2011)
33 studies, n=47,967 cycles of treatment
Women with obesity versus recommended BMI:
• Clinical pregnancy RR 0.87 (95% CI 0.80 to 0.96)
• Live birth RR 0.80 (95% CI 0.71 to 0.90)
• Miscarriage RR 1.43 (95% CI 1.22 to 1.67)
Fertility intervention: IVF pregnancies
(Best et al 2017)RR 1.59 (95% CI 1.01 to 2.50)
Fertility intervention: IVF live births
(Best et al 2017)RR 1.54 (95% CI 0.93 to 2.56)
Fertility intervention: natural conceptions
(Best et al 2017)
RR 2.20 (95% CI 0.98 to 4.93)
Fertility intervention: IVF conceptions
(Best et al 2017)
RR 1.06 (95% CI 0.53 to 2.13)
Fertility intervention: miscarriage
(Best et al 2017)RR 0.91 (95% CI 0.82 to 1.01)
Is this strong enough evidence to refuse/delay fertility treatment on the basis of BMI until women have lost weight?
Preconception bariatric surgery: meta-analysis of maternal outcomes
(Kwong et al 2017)
20 studies, 2.8 million women
• Gestational diabetes: OR 0.20 (95% CI 0.11–0.37), number needed to benefit=5
• Gestational hypertension OR 0.38 (95% CI 0.19–0.76), number needed to benefit=11
• All hypertensive disorders OR 0.38 (95% CI 0.27–0.53), number needed to benefit=8
• Postpartum hemorrhage OR 0.32 (95% CI 0.08–1.37), number needed to benefit=21
• Caesarean delivery OR 0.50 (95% CI 0.38–0.67), number needed to benefit=9
• Pre-eclampsia - no differences
Preconception bariatric surgery: SGA
(Akhter et al 2019)
All surgery: OR 1.87 (95% CI 1.61, 2.17)
Malabsorbtive: OR 2.72 (95% CI 2.32, 3.20)
Restrictive: OR 1.25 (95% CI 0.62, 2,51)
Preconception bariatric surgery: LGA
(Akhter et al 2019)
All surgery: OR 0.51 (95% CI 0.39, 0.67)
Malabsorbtive: OR 0.24 (95% CI 0.14, 0.41)
Restrictive: OR 0.59 (95% CI 0.30, 1.14)
Preconception bariatric surgery: preterm
(Akhter et al 2019)
All surgery: OR 1,57 (95% CI 1.36, 1.79)
Malabsorbtive: OR 1.14 (95% CI 0.89, 1.46)
Restrictive: OR 0.88 (95% CI 0.58, 1.34)
Preconception bariatric surgery: post-term birth
(Akhter et al 2019)
Overall: OR 0.46 (95% CI 0.35, 0.60)
Preconception bariatric surgery: perinatal mortality
(Akhter et al 2019)
Overall: OR 1.38 (95% CI 1.03, 1.65)
Preconception bariatric surgery: congenital anomalies
(Akhter et al 2019)
Overall: OR 1.29 (95% CI 1.04, 1.59)
Preconception bariatric surgery: NICU
(Akhter et al 2019)
Overall: OR 1.41 (95% CI 1.25, 1.59)
Key Messages
Preconception is agreed to be an important time for intervention
Earlier than 1st 1000 days, opportunity to alter fetal environment
BUT – there is a lack of good quality intervention evidence
Observational evidence - inter-pregnancy weight change impacts on subsequent pregnancy, opportunity to intervene
Restricting fertility treatment based on BMI – ethical?
Preconception bariatric surgery
Opportunity to improve maternal pregnancy outcomes
Preconception care essential to prevent adverse perinatal outcomes
