Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence

S Thangaratinam, E Rogozinska, K Jolly, S Glinkowski, T Roseboom, J W Tomlinson, R Kunz, B W Mol, A Coomarasamy, K S Khan, S Thangaratinam, E Rogozinska, K Jolly, S Glinkowski, T Roseboom, J W Tomlinson, R Kunz, B W Mol, A Coomarasamy, K S Khan

Abstract

Objective: 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.

Design: Systematic review and meta-analysis.

Data sources: Major databases from inception to January 2012 without language restrictions.

Study selection: Randomised controlled trials that evaluated any dietary or lifestyle interventions with potential to influence maternal weight during pregnancy and outcomes of pregnancy.

Data synthesis: Results summarised as relative risks for dichotomous data and mean differences for continuous data.

Results: 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.

Conclusions: 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.

Conflict of interest statement

Competing interest: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f1_default.jpg
Fig 1 Identification of studies in systematic review of effects of dietary and lifestyle interventions in pregnancy on maternal and fetal outcomes
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f2_default.jpg
Fig 2 Quality of randomised controlled trials included in systematic review of dietary and lifestyle interventions in pregnancy on maternal and fetal outcomes
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f3_default.jpg
Fig 3 Mean difference in gestational weight gain (kg) with dietary and lifestyle interventions in pregnancy
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f4_default.jpg
Fig 4 Mean difference in birth weight (g) with dietary and lifestyle interventions in pregnancy
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f5_default.jpg
Fig 5 Relative risk of effect on size for gestational age with dietary and lifestyle interventions in pregnancy
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f6_default.jpg
Fig 6 Relative risk of effects of weight management interventions in pregnancy on maternal outcomes
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790038/bin/thas001765.f7_default.jpg
Fig 7 Relative risk of effects of weight management interventions in pregnancy on fetal and neonatal outcomes

References

    1. NHS Information Centre. Health survey for England 2006: CVD and risk factors adults, obesity and risk factors children. NHS Information Centre, 2008.
    1. Thangaratinam S, Jolly K. Obesity in pregnancy: a review of reviews on the effectiveness of interventions. BJOG 2010;117:1309-12.
    1. Ramachendran J, Bradford J, McLean J. Maternal obesity and pregnancy complications: a review. Aust N Z J Obstet Gynaecol 2008;48:228-45.
    1. Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer. The seventh report of the confidential enquiries into maternal deaths in the United Kingdom. CEMACH, 2007.
    1. Drake AJ, Reynolds RM. Impact of maternal obesity on offspring obesity and cardiometabolic disease risk. Reproduction 2010;140:387-98.
    1. National Audit Office. Tackling obesity in England. Stationery Office, 2001.
    1. Jackson RA, Stotland NE, Caughey AB, Gerbert B. Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial. Patient Educ Couns 2011;83:203-9.
    1. NICE. Public health guidance 27. Dietary interventions and physical activity interventions for weight management before, during and after pregnancy. National Institute for Health and Clinical Excellence, 2010.
    1. Streuling I, Beyerlein A, von Kries. Can gestational weight gain be modified by increasing physical activity and diet counselling? A meta-analysis of interventional trials. Am J Clin Nutr 2010;92:678-87.
    1. Campbell F, Messina J, Johnson M, Guillaume L, Madan J, Goyder E. Systematic review of dietary and/or physical activity interventions for weight management in pregnancy. NICE Centre for Public Health Excellence, 2009.
    1. Rasmussen KM, Yatkine AL, eds. Weight gain during pregnancy: re-examining the guidelines. Committee to Reexamine Institute of Medicine Pregnancy Weight Guidelines 2009.
    1. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.0.1. Cochrane Collaboration, 2008.
    1. Khan KS, ter Riet G, Glanville J, Sowden AJ, Kleijnen J. Undertaking systematic reviews of research on effectiveness. CRD’s guidance for carrying out or commissioning reviews. 2nd ed. NHS Centre for Reviews and Dissemination, University of York, 2001.
    1. Khan KS, Kunz R, Kleijnen J, Antes G. Systematic reviews to support evidence-based medicine: how to review and apply findings of systematic reviews. Br J Anaesth 2003;91:767-8.
    1. Thangaratinam S, Rogozinska 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 (in press).
    1. Glasziou P, Chalmers I, Altman D, Bastian H, Boutron I, Brice A, et al. Taking healthcare interventions from trial to practice. BMJ 2010;341:c3852.
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Schunemenn HJ. GRADE: What is “quality of evidence” and why is it important to clinicians? BMJ 2008;336:995-8.
    1. Sterne JAC, Egger M, Smith GD. Systematic reviews in health care: investigating and dealing with publication and other biases in meta-analysis. BMJ 2001;323:101-5.
    1. Review Manager (Computer program). Version 5.1. Nordic Cochrane Centre. Cochrane Collaboration, 2011.
    1. StataCorp. Stata Statistical Software: release 8. StataCorp LP, 2003.
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
    1. Cochrane Adverse Effects Sub-Group of the Cochrane Non-Randomised Study Methods Group. Including adverse effects in systematic reviews: interim recommendations. Cochrane Group, 2011.
    1. Loke YK, Price D, Herxheimer A. Systematic reviews of adverse effects: framework for a structured approach. BMC Med Res Methodol 2007;7:32.
    1. Badrawi H, Hassanein MK, Badraoui MHH, Wafa YA, Shawky HA, Badrawi N. Pregnancy outcome in obese pregnant mothers. J Perinat Med 1992;20:203.
    1. Bechtel-Blackwell DA. Computer-assisted self-interview and nutrition education in pregnant teens. Clin Nurs Res 2002;11:450-62.
    1. Briley C, Flanagan NL, Lewis N. In-home prenatal nutrition intervention increased dietary iron intakes and reduced low birthweight in low-income African-American women. J Am Diet Assoc 2002;102:984-7.
    1. Clapp IJF. Diet, exercise, and fete-placental growth. Arch Gynecol Obstet 1997;260:101-8.
    1. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477-86.
    1. Gomez TG, Delgado JG, Agudelo AA, Hurtado H. Diet effects on the perinatal result of obese pregnant patient. [Spanish]. Rev Colomb Obstet Ginecol 1994;45:313-6.
    1. Khoury J, Henriksen T, Christophersen B, Tonstad S. Effect of a cholesterol-lowering diet on maternal, cord, and neonatal lipids, and pregnancy outcome: a randomized clinical trial. Am J Obstet Gynecol 2005;193:1292-301.
    1. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361:1339-48.
    1. Ney D, Hollingsworth DR, Cousins L. Decreased insulin requirement and improved control of diabetes in pregnant women given a high-carbohydrate, high-fiber, low-fat diet. Diabetes Care 1982;5:529-33.
    1. Quinlivan JA, Lam LT, Fisher J. A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women. Aust N Z J Obstet Gynaecol 2011;51:141-6.
    1. Rae A, Bond D, Evans S, North F, Roberman B, Walters B. A randomised controlled trial of dietary energy restriction in the management of obese women with gestational diabetes. Aust N Z J Obstet Gynaecol 2000;40:416-22.
    1. Thornton YS, Smarkola C, Kopacz SM, Ishoof SB. Perinatal outcomes in nutritionally monitored obese pregnant women: a randomized clinical trial. J Natl Med Assoc 2009;101:569-77.
    1. Wolff S, Legarth J, Vangsgaard K, Toubro S, Astrup A. A randomized trial of the effects of dietary counseling on gestational weight gain and glucose metabolism in obese pregnant women. Int J Obes 2008;32:495-501.
    1. Baciuk EP, Pereira RI, Cecatti JG, Braga AF, Cavalcante SR. Water aerobics in pregnancy: cardiovascular response, labor and neonatal outcomes. Reprod Health 2008;5:10.
    1. Barakat R, Lucia A, Ruiz JR. Resistance exercise training during pregnancy and newborn’s birth size: a randomised controlled trial. Int J Obes 2009;33:1048-57.
    1. Barakat R, Cordero Y, Coteron J, Luaces M, Montejo R. Exercise during pregnancy improves maternal glucose screen at 24-28 weeks: a randomised controlled trial. Br J Sports Med 2011. Sep 26, epub ahead of print.
    1. Bell RJ, Palma SM. Antenatal exercise and birth-weight. Aust N Z J Obstet Gynaecol 2000;40:70-3.
    1. Cavalcante SR, Cecatti JG, Pereira RI, Baciuk EP, Bernardo AL, Silveira C. Water aerobics II: maternal body composition and perinatal outcomes after a program for low risk pregnant women. Reprod Health 2009;6:1.
    1. Clapp JF, III, Kim H, Burciu B, Lopez B. Beginning regular exercise in early pregnancy: effect on fetoplacental growth. Am J Obstet Gynecol 2000;183:1484-8.
    1. Erkkola R. The influence of physical exercise during pregnancy upon physical work capacity and circulatory parameters. Scand J Clin Lab Invest 1976;6:747-9.
    1. Erkkola R, Makela M. Heart volume and physical fitness of parturients. Ann Clin Res 1976;8:15-21.
    1. Garshasbi A, Faghih ZS. The effect of exercise on the intensity of low back pain in pregnant women. Int J Gynaecol Obstet 2005;88:271-5.
    1. Haakstad L, Bo K. Exercise in pregnant women and birth weight: a randomized controlled trial. BMC Preg Childbirth 2011;11:66.
    1. Hopkins SA, Baldi JC, Cutfield WS, McCowan L, Hofman PL. Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity. J Clin Endocrinol Metab 2010;95:2080-8.
    1. Khaledan A, Sh, Motahari Tabari NS, Ahmad Shirvani M. Effect of an aerobic exercise program on fetal growth in pregnant women. HAYAT: J Faculty Nurs Midwifery 2010;16:78.
    1. Lee G, Challenger S, McNabb M, Sheridan M. Exercise in pregnancy. Mod Midwife 1996;6:28-33.
    1. Marquez-Sterling S, Perry AC, Kaplan TA, Halberstein RA, Signorile JF. Physical and psychological changes with vigorous exercise in sedentary primigravidae. Med Sci Sports Exerc 2000;32:58-62.
    1. Ong MJ, Guelfi KJ, Hunter T, Wallman KE, Fournier PA, Newnham JP. Supervised home-based exercise may attenuate the decline of glucose tolerance in obese pregnant women. Diabetes Metab 2009;35:418-21.
    1. Prevedel T, Calderon I, DM, Adami H-O, RM. Maternal and perinatal effects of hydrotherapy in pregnancy. Rev Bras Ginecol Obstet 2003;25:53-9.
    1. Santos IA, Stein R, Fuchs SC, Duncan BB, Ribeiro JP, Kroeff LR, et al. Aerobic exercise and submaximal functional capacity in overweight pregnant women: a randomized trial. Obstet Gynecol 2005;106:243-9.
    1. Sedaghati P, Ziaee V, Ardjmand A. The effect of an ergometric training program on pregnants weight gain and low back pain. Gazzetta Medica Italiana Archivio per le Scienze Mediche 2007;166:209-13.
    1. Yeo S, Steele NM, Chang MC, Leclaire SM, Ronis DL, Hayashi R. Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders. J Reprod Med 2000;45:293-8.
    1. Asbee SM, Jenkins TR, Butler JR, White J, Elliot M, Rutledge A. Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial. Obstet Gynecol 2009;113:305-12.
    1. Bung P, Artal R, Khodiguian N, Kjos S. Exercise in gestational diabetes. An optional therapeutic approach? Diabetes 1991;40(suppl 2):182-5.
    1. Ferrara A, Hedderson MM, Albright CL, Ehrlich SF, Quesenbery CP, Peng TP, et al. A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors. A feasibility randomized control trial. Diabetes Care 2011;34:1519-25.
    1. Guelinckx I, Devlieger R, Mullie P, Vansant G. Effect of lifestyle intervention on dietary habits, physical activity, and gestational weight gain in obese pregnant women: a randomized controlled trial. Am J Clin Nutr 2010;91:373-80.
    1. Huang TT, Yeh CY, Tsai YC. A diet and physical activity intervention for preventing weight retention among Taiwanese childbearing women: a randomised controlled trial. Midwifery 2011;27:257-64.
    1. Hui A, Back L, Ludwig S, Gardiner P, Sevenhuysen G, Dean H, et al. Lifestyle intervention on diet and exercise reduced excessive gestational weight gain in pregnant women under a randomised controlled trial. BJOG 2011;119:70-7.
    1. Hui AL, Ludwig SM, Gardiner P, Sevenhuysen G, Murray R, Morris M, et al. Community-based exercise and dietary intervention during pregnancy: a pilot study. Can J Diabetes 2006;30:169-75.
    1. Jeffries K, Shub A, Walker SP, Hiscock R, Permezel M. Reducing excessive weight gain in pregnancy: a randomised controlled trial. Med J Aust 2009;191:429-33.
    1. Kulpa PJ, White BM, Visscher R. Aerobic exercise in pregnancy. Am J Obstet Gynecol 1987;156:1395-403.
    1. Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. Am J Clin Nutr 2011;93:772-9.
    1. Polley BA, Wing RR, Sims CJ. Randomized controlled trial to prevent excessive weight gain in pregnant women. Int J Obes 2002;26:1494-502.
    1. Vinter CA, Jensen DM, Ovesen P, Beck-Nielsen H, Jorgensen JS. The LiP (Lifestyle in Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women. Diabetes Care 2011;34:2502-7.
    1. Carmichael SL, Shaw GM, Schaffer DM, Laurent C, Selvin S. Dieting behaviors and risk of neural tube defects. Am J Epidemiol 2003;158:1127-31.
    1. Clapp JF, III. The course of labor after endurance exercise during pregnancy. Am J Obstet Gynecol 1990;163:1799-805.
    1. Clapp JF, III, Capeless EL. Neonatal morphometrics after endurance exercise during pregnancy. Am Obstet Gynecol 1990;163:1805-11.
    1. Dale E, Mullinax KM, Bryan DH. Exercise during pregnancy: effects on the fetus. C J Appl Sport Sci 1982;7:98-103.
    1. De Rooij SR, Painter RC, Holleman F, Bossuyt PM, Roseboom TJ. The metabolic syndrome in adults prenatally exposed to the Dutch famine. Am J Clin Nutr 2007;86:1219-24.
    1. Gregory PB, Rush D. Iatrogenic caloric restriction in pregnancy and birthweight. Am J Perinatol 1987;4:365-71.
    1. Hatch MC, Shu XO, McLean DE, Levin B, Begg M, Reuss L, et al. Maternal exercise during pregnancy, physical fitness, and fetal growth. Am J Epidemiol 1993;137:1105-14.
    1. Knudsen VK, Orozova-Bekkevold IM, Mikkelsen TB, Wolff S, Olsen SF. Major dietary patterns in pregnancy and fetal growth. Eur J Clin Nutr 2008;62:463-70.
    1. Lenders CM, Hediger ML, Scholl TO, Khoo CS, Slap GB, Stallings VA. Effect of high-sugar intake by low-income pregnant adolescents on infant birth weight. J Adolesc Health 1994;15:596-602.
    1. Lenders CM, Hediger ML, Scholl TO, Khoo CS, Slap GB, Stallings VA. Gestational age and infant size at birth are associated with dietary sugar intake among pregnant adolescents. J Nutr 1997;127:1113-7.
    1. Lumey LH, Stein AD, Kahn HS, Romijn JA. Lipid profiles in middle-aged men and women after famine exposure during gestation: the Dutch Hunger Winter Families Study. Am J Clin Nutr 2009;89:1737-43.
    1. Magann EF, Evans SF, Weitz B, Newnham J. Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women. Obstet Gynecol 2002;99:466-72.
    1. Neugebauer R, Hoek HW, Susser E. Prenatal exposure to wartime famine and development of antisocial personality disorder in early adulthood. JAMA 1999;282:455-62.
    1. Ravelli AC, van der Meulen JH, Michels RP, Osmond C, Barker DJ, Hales CN, et al. Glucose tolerance in adults after prenatal exposure to famine. Lancet 1998;351:173-7.
    1. Ravelli GP, Stein ZA, Susser MW. Obesity in young men after famine exposure in utero and early infancy. N Engl J Med 1976;295:349-53.
    1. Roseboom TJ, van der Meulen JH, Osmond C, Barker DJ, Ravelli AC, Bleker OP. Plasma lipid profiles in adults after prenatal exposure to the Dutch famine. Am J Clin Nutr 2000;72:1101-6.
    1. Roseboom TJ, van der Meulen JH, Osmond C, Barker DJ, Ravelli AC, Schroeder-Tanka JM, et al. Coronary heart disease after prenatal exposure to the Dutch famine, 1944-45. Heart 2000;84:595-8.
    1. Schramm WF, Stockbauer JW, Hoffman HJ. Exercise, employment, other daily activities, and adverse pregnancy outcomes. Am J Epidemiol 1996;143:211-8.
    1. Stanner SA, K Bulmer, C Andrès, O E Lantseva, V Borodina, V V Poteen, et al. Does malnutrition in utero determine diabetes and coronaryè heart disease in adulthood? Results from the Leningrad siege study, a cross sectional study. BMJ 1997;315:1342-8.
    1. Stein AD, Kahn HS, Rundle A, Zybert PA, van der Pal-de Bruin, Lumey LH. Anthropometric measures in middle age after exposure to famine during gestation: evidence from the Dutch famine. Am J Clin Nutr 2007;85:869-76.
    1. Vujkovic M, Ocke MC, Van Der Spek PJ, Yazdanpanah N, Steegers EA, Steegers-Theunissen RP. Maternal western dietary patterns and the risk of developing a cleft lip with or without a cleft palate. Obstet Gynecol 2007;110:378-84.
    1. Yazdy MM, Liu S, Mitchell AA, Werler MM. Maternal dietary glycemic intake and the risk of neural tube defects. Am J Epidemiol 2010;171:407-14.
    1. Painter RC, De R, Sr., Bossuyt PM, Osmond C, Barker DJ, Bleker OP, et al. A possible link between prenatal exposure to famine and breast cancer: a preliminary study. Am J Hum Biol 2006;18:853-6.
    1. De Rooij SR, Painter RC, Phillips DI, Osmond C, Tanck MW, Bossuyt PM, et al. Cortisol responses to psychological stress in adults after prenatal exposure to the Dutch famine. Psychoneuroendocrinology 2006;31:1257-65.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, for the PRISMA group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535.
    1. Clarke PE, Gross H. Women’s behaviour, beliefs and information sources about physical exercise in pregnancy. Midwifery 2009;20:133-41.
    1. Gross H, Bee PE. Perceptions of effective advice in pregnancy. The case of activity. Clin Eff Nurs 2004;8:161-9.
    1. Ray JG, Diamond P, Singh G, Bell CM. Brief overview of maternal triglycerides as a risk factor for pre-eclampsia. BJOG 2006;113:379-86.
    1. Qiu C, Coughlin KB, Frederick IO, Sorensen TK, Williams MA. Dietary fiber intake in early pregnancy and risk of subsequent preeclampsia. Am J Hypertens 2008;21:903-9.
    1. NICE clinical guideline 43. Obesity. NICE, 2006. .
    1. Lambert PC, Sutton RJ, Abrams KR, Jones DR. A comparison of summary patient-level covariates in meta-regression with individual patient data meta-analysis. Clin Epidemiol 2002;55:86-94.
    1. Thomson SG, Higgins JP. Treating individuals 4: can meta-analysis help target interventions at individuals most likely to benefit? Lancet 2005;365:341-6.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir