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Interventions to Reduce or Prevent Obesity in Pregnant Women: A Systematic Review
Health Technology Assessment, No. 16.31
S Thangaratinam, E Rogozińska, K Jolly, S Glinkowski, W Duda, E Borowiack, T Roseboom, J Tomlinson, J Walczak, R Kunz, BW Mol, A Coomarasamy, and KS Khan.
Author Information and AffiliationsSouthampton (UK): NIHR Journals Library; 2012 Jul.
Abstract
Background:
Around 50% of women of childbearing age are either overweight [body mass index (BMI) 25–29.9 kg/m2] or obese (BMI ≥ 30 kg/m2). The antenatal period provides an opportunity to manage weight in pregnancy. This has the potential to reduce maternal and fetal complications associated with excess weight gain and obesity.
Objectives:
To evaluate the effectiveness of dietary and lifestyle interventions in reducing or preventing obesity in pregnancy and to assess the beneficial and adverse effects of the interventions on obstetric, fetal and neonatal outcomes.
Data sources:
Major electronic databases including MEDLINE, EMBASE, BIOSIS and Science Citation Index were searched (1950 until March 2011) to identify relevant citations. Language restrictions were not applied.
Review methods:
Systematic reviews of the effectiveness and harm of the interventions were carried out using a methodology in line with current recommendations. Studies that evaluated any dietary, physical activity or mixed approach intervention with the potential to influence weight change in pregnancy were included. The quality of the studies was assessed using accepted contemporary standards. Results were summarised as pooled relative risks (RRs) with 95% confidence intervals (CIs) for dichotomous data. Continuous data were summarised as mean difference (MD) with standard deviation. The quality of the overall evidence synthesised for each outcome was summarised using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and reported graphically as a two-dimensional chart.
Results:
A total of 88 studies (40 randomised and 48 non-randomised and observational studies, involving 182,139 women) evaluated the effect of weight management interventions in pregnancy on maternal and fetal outcomes. Twenty-six studies involving 468,858 women reported the adverse effect of the interventions. Meta-analysis of 30 RCTs (4503 women) showed a reduction in weight gain in the intervention group of 0.97 kg compared with the control group (95% CI −1.60 kg to −0.34 kg; p = 0.003). Weight management interventions overall in pregnancy resulted in a significant reduction in the incidence of pre-eclampsia (RR 0.74, 95% CI 0.59 to 0.92; p = 0.008) and shoulder dystocia (RR 0.39, 95% CI 0.22 to 0.70; p = 0.02). Dietary interventions in pregnancy resulted in a significant decrease in the risk of pre-eclampsia (RR 0.67, 95% CI 0.53 to 0.85; p = 0.0009), gestational hypertension (RR 0.30, 95% CI 0.10 to 0.88; p = 0.03) and preterm birth (RR 0.68, 95% CI 0.48 to 0.96; p = 0.03) and showed a trend in reducing the incidence of gestational diabetes (RR 0.52, 95% CI 0.27 to 1.03). There were no differences in the incidence of small-for-gestational-age infants between the groups (RR 0.99, 95% CI 0.76 to 1.29). There were no significant maternal or fetal adverse effects observed for the interventions in the included trials. The overall strength of evidence for weight gain in pregnancy and birthweight was moderate for all interventions considered together. There was high-quality evidence for small-for-gestational-age infants as an outcome. The quality of evidence for all interventions on pregnancy outcomes was very low to moderate. The quality of evidence for all adverse outcomes was very low.
Limitations:
The included studies varied in the reporting of population, intensity, type and frequency of intervention and patient complience, limiting the interpretation of the findings. There was significant heterogeneity for the beneficial effect of diet on gestational weight gain.
Conclusions:
Interventions in pregnancy to manage weight result in a significant reduction in weight gain in pregnancy (evidence quality was moderate). Dietary interventions are the most effective type of intervention in pregnancy in reducing gestational weight gain and the risks of pre-eclampsia, gestational hypertension and shoulder dystocia. There is no evidence of harm as a result of the dietary and physical activity-based interventions in pregnancy. Individual patient data meta-analysis is needed to provide robust evidence on the differential effect of intervention in various groups based on BMI, age, parity, socioeconomic status and medical conditions in pregnancy.
Funding:
The National Institute for Health Research Health Technology Assessment programme. (HTA no. 09/27/06).
Contents
- NIHR Health Technology Assessment programme
- List of abbreviations
- Executive summary
- 1. Background
- 2. Systematic review methods
- 3. Effectiveness of the interventions
- Study selection
- Quality of included studies
- Effect of the interventions on weight-related outcomes
- Effect of the interventions on obstetric maternal outcomes
- Effect of the interventions on fetal and neonatal morbidity and mortality
- Effect of interventions on neonatal anthropometric measurements at birth
- Subgroup analyses
- Summary
- 4. Adverse effects of interventions
- 5. Grading of Recommendations Assessment, Development and Evaluation (GRADE) findings
- 6. Discussion
- Acknowledgements
- References
- Appendix 1 List of reviews evaluating the effect of weight management interventions on maternal and fetal outcomes
- Appendix 2 Search strategies
- Appendix 3 Clinical characteristics of the randomised controlled trials evaluating the effect of diet, physical activity and a mixed approach for weight management in pregnancy on maternal and fetal outcomes
- Appendix 4 Risk of bias in randomised controlled trials included in the effectiveness review
- Appendix 5 Quality assessment of individual non-randomised studies evaluating the effectiveness of weight management interventions in pregnancy
- Appendix 6 Quality assessment of the observational studies evaluating the effectiveness of weight management interventions in pregnancy
- Appendix 7 Clinical characteristics of the randomised controlled trials included in the review of adverse effects
- Appendix 8 Risk of bias summary of the randomised controlled trials included in the review of adverse effects
- Appendix 9 Quality assessment of the observational studies evaluating the adverse effects of weight management interventions in pregnancy
- Appendix 10 Clinical characteristics and findings of the observational studies evaluating the adverse effects of weight management interventions in pregnancy
- Appendix 11 Delphi ranking of maternal and fetal weight management outcomes according to their importance in the management of maternal weight in pregnancy
- Appendix 12 Grading the quality of randomised evidence for the primary and clinically important outcomes for the effectiveness of weight management interventions in pregnancy
- Appendix 13 Grading the quality of evidence for the primary and clinically important outcomes for the effectiveness of dietary interventions in pregnancy
- Appendix 14 Grading the quality of evidence for the primary and clinically important outcomes for the effectiveness of physical activity interventions in pregnancy
- Appendix 15 Grading the quality of evidence for the primary and clinically important outcomes for the effectiveness of mixed approach interventions in pregnancy
- Appendix 16 Grading the quality of evidence for the adverse outcomes of diet in pregnancy
- Appendix 17 Grading the quality of evidence for the adverse outcomes of physical activity in pregnancy
- Appendix 18 Data extraction form for effectiveness of interventions for weight management in pregnancy
- Appendix 19 Data extraction form for adverse effects of weight management interventions in pregnancy
- Appendix 20 Review protocol
- Health Technology Assessment programme
Suggested citation:
Thangaratinam S, Rogozińska E, Jolly K, Glinkowski S, Duda W, Borowiack E, et al. Interventions to reduce or prevent obesity in pregnant women: a systematic review. Health Technol Assess 2012;16(31).
Declaration of competing interests: none
The research reported in this issue of the journal was commissioned by the HTA programme as project number 09/27/06. The contractual start date was in May 2010. The draft report began editorial review in June 2011 and was accepted for publication in November 2011. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design.The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.
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