Healthy Weight and Weight Gain In Pregnancy: Behavioral Counseling Interventions -- Pregnant persons


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Specific Recommendations

The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy.

Frequency of Service

Throughout pregnancy

Risk Factor Information

Pregnancy


Clinical

Practice Considerations

Patient Population Under Consideration

This recommendation applies to pregnant adolescents and adults in primary care settings.

Definitions

The USPSTF uses the following terms to define healthy weight gain associated with pregnancy. These weight gain guidelines are for singleton pregnancies.

  • Gestational weight gain is defined as the change in weight from before pregnancy (prepregnancy or during the first trimester) to the weight measured prior to delivery.5 The National Academy of Medicine (formerly known as the Institute of Medicine) recommendations for healthy GWG are 28 to 40 lb in the prepregnancy underweight category, 25 to 35 lb for the normal prepregnancy weight category, 15 to 25 lb for the prepregnancy overweight category, and 11 to 20 lb for the prepregnancy obese category.5
  • Prepregnancy weight categories are based on the World Health Organization categories for nonpregnant persons: underweight (body mass index [BMI] <18.5 [calculated as weight in kilograms divided by height in meters squared]), normal or healthy weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI ≥30).5-7

Behavioral Counseling Interventions

Effective behavioral counseling interventions to promote healthy weight gain in pregnancy are associated with decreased risk of gestational diabetes mellitus, emergency cesarean delivery, infant macrosomia, and LGA infants.1 Behavioral counseling interventions varied in included components. Some interventions had an individual focus on nutrition, physical activity, or lifestyle and behavioral change. Other interventions had multiple components. The most common types of behavioral counseling interventions included active or supervised exercise or counseling about diet and physical activity.1 Interventions generally started at the end of the first trimester or the beginning of the second trimester and ended prior to delivery. Intervention sessions lasted from 15 to 120 minutes and ranged from fewer than 2 to 12 or more contacts. Interventionists were highly diverse and included clinicians, registered dietitians, qualified fitness specialists, physiotherapists, and health coaches. Trials used various delivery methods (face-to-face, computer, internet, or telephone).1

Effective behavioral counseling interventions often referred participants to various interventionists in different settings (eg, local community fitness center). Participants were counseled on healthy diet and exercise through individual or group education sessions. Some interventions provided medically supervised group exercise classes with or without counseling.1 Behavioral counseling interventions with 12 or more contacts were more effective for some outcomes (mean GWG, excess GWG, and infant macrosomia) than interventions with fewer contacts.1 There is not enough evidence to determine whether specific components of these interventions were independently related to intervention effectiveness.

Implementation

Primary care clinicians can deliver effective in-person behavioral counseling interventions or refer patients to behavioral counseling interventions in other settings. For more information about behavioral counseling interventions, see Table 2.

Additional Tools and Resources

The following resource may help clinicians implement this recommendation.

  • The Community Preventive Services Task Force recommends multicomponent interventions that use technology-supported coaching or counseling to help nonpregnant adults lose weight and maintain weight loss.25
  • The Community Preventive Services Task Force recommends exercise programs during pregnancy to reduce the development of gestational hypertension.26

Other Related USPSTF Recommendations

The USPSTF recommends screening for obesity in adults and offering or referring those with a BMI of 30 or greater to intensive, multicomponent behavioral weight loss interventions.27 The USPSTF also has recommendations on screening for gestational diabetes mellitus28 and behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with and without cardiovascular risk factors.29,30

 

Table 2. Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy(a)

  Active/supervised exercise, high intensityb Counseling
High intensity Moderate intensity Low intensity
Mode of delivery Structured, supervised exercise classes. Individual or group counseling in person, online, or over the telephone. Individual or group counseling in person or over the telephone. Individual sessions as part of usual antenatal care, or 1 to 2 brief extra sessions.
Intensity One to 3 times per week (average, 45-60 min)
  • Sessions ranged from once a week to once a month, lasting from 30 min to 2 h.
  • Interventions may have included telephone call or email follow-up 1 to 2 times per week; eHealth interventions offered online or text message support.
  • Sessions ranged from once a month to once a trimester, lasting from 15 to 45 min.
  • Interventions may have included phone call “booster” sessions and toolkits with educational materials or physical activity accessories for participants
Part of usual antenatal care, or 1 to 2 brief extra sessions.
Intervention content Classes included aerobic, resistance, and flexibility exercises based on ACOG recommendations for exercise during pregnancy. Intervention participants generally used free weights, resistance equipment, or both. Counseling focused on nutrition, goal-setting, physical activity, and behavioral and social support strategies. Few interventions followed evidence-based, structured curricula. Counseling focused on recommendations for healthy eating and/or or physical activity based on ACOG recommendations. Counseling focused on maintaining healthy weight and often included personalized graphs with weight gain guidance based on NAM recommendations.
Example interventions

Bacchi et al,8 2018
Barakat et al,9 2019
Phelan et al,10 2018 (Healthy Beginnings)
Ruiz et al,11 2013
Sagedal et al,12 2017 (Norwegian Fit for Delivery)

Altazan et al,13 2019 (Expecting Success/SmartMoms)
Cahill et al,14 2018 (PreGO)
Gallagher et al,15 2018 (LIFT)
Renault et al,16 2014 (TOP)
Al Wattar et al,]]17]] 2019 (ESTEEM)
Bogaerts et al,18 2013
Bruno et al,19 2017
Phelan et al,20 2011 (Fit for Delivery)
Assaf-Balut et al,21 2017
Rauh et al,22 2013 (FeLIPO)
Ronnberg et al,23 2014
Materials and practicec Lifestyle Interventions for Expectant Moms
https://lifemoms.bsc.gwu.edu/
DASH Eating Plan
https://www.nhlbi.nih.gov/health-topics/dash-eating-plan
WebCite Healthy Food, Exercise, and Weight for Your Pregnancy
https://www.webcitation.org/6QR3k6uaM
SmartMoms Intervention Lessons
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352352/bin/
12884_2019_2196_MOESM1_ESM.docx
ESTEEM Study Patient Information Sheet
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650045/
bin/pmed.1002857.s005.docx

ESTEEM Trial Intervention Fact Sheets and Educational Presentation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650045/
bin/pmed.1002857.s006.docx
ESTEEM Recipe Ideas
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650045/
bin/pmed.1002857.s007.docx
Oldways
https://oldwayspt.org/traditional-diets/mediterranean-diet
Healthy Weight Gain During Pregnancy
https://webassets.nationalacademies.org/
whattogain/
Population Pregnant adolescents and adults.
Practice settings Primary care or primary care–referable settings and routine prenatal care settings, including obstetrics-gynecology or midwifery clinics and hospitals.
Interventionists Midwives, health educators, physical therapists, fitness specialists, or clinical and registered dietitians. Interventionists had professional certification in their respective fields, education regarding study goals and processes, training on standard study curricula, or some combination thereof.
Demonstrated benefit Gestational weight gain interventions were associated with decreased risk of gestational diabetes mellitus, emergency cesarean delivery, macrosomia, large for gestational age infants, and reduced postpartum weight retention at 12 mo. Gestational weight gain interventions were also associated with modest reductions in mean gestational weight gain and decreased likelihood of exceeding NAM recommendations for gestational weight gain.

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; NAM, National Academy of Medicine (formerly the Institute of Medicine).
a Adapted from supplemental eTable 2 in Cantor et al1 and a modified Template for Intervention Description and Replication (TIDieR) checklist.24
b Intervention intensity categorized as low (≤2 contacts), moderate (3-11 contacts), or high (≥12 contacts).
c Links to resources are available in the article PDF.
Supplement. US Preventive Services Task Force (USPSTF) Grades and Levels of Evidence


Rationale

Importance

The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons.1 Obesity rates during pregnancy increased from 13% in 1993 to 24% in 2015.1 In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%).1,2 Prepregnancy obesity is higher in Alaska Native/American Indian (36.4%), Black (34.7%), and Hispanic (27.3%) women compared with White women (23.7%). Asian women have the lowest rates of obesity (7.5%).1,3 Excess weight at the beginning of pregnancy and excess gestational weight gain (GWG) have been associated with adverse maternal and infant health outcomes such as a large for gestational age (LGA) infant, cesarean delivery, or preterm birth.1

USPSTF Assessment of Magnitude of Net Benefit

The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess GWG in pregnancy have a moderate net benefit for pregnant persons (Table 1).

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4

Table 1. Summary of USPSTF Rationale

Rationale Assessment
Effectiveness of counseling to change behavior
  • The USPSTF found adequate evidence that behavioral counseling interventions that limit excess gestational weight gain improve health outcomes (ie, gestational diabetes, emergency cesarean delivery) among pregnant persons and their infants (ie, macrosomia, large for gestational age). Macrosomia and large for gestational age in infants are intermediate outcomes associated with important health outcomes in infants.
  • The USPSTF found adequate evidence that recurring behavioral counseling interventions demonstrated reductions in intermediate outcomes, including gestational weight gain and postpartum weight retention, at 12 mo. There was also adequate evidence of a lower likelihood of gaining weight in excess of the National Academy of Medicine gestational weight gain recommendations in pregnant persons.
  • The overall magnitude of the benefit of behavioral counseling interventions for heathy weight gain in pregnancy to improve maternal and infant health outcomes is moderate.
Harms of counseling The USPSTF found adequate evidence to bound the potential harms of effective behavioral counseling interventions as no greater than small, based on the nature of the interventions, the low likelihood of serious harms, and the available information from studies reporting few harms. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.
USPSTF assessment The USPSTF concludes with moderate certainty that effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons.

Abbreviation: USPSTF, US Preventive Services Task Force.


Others

Supporting EvidenceScope of Review The USPSTF commissioned a systematic review1,31 to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess GWG. The USPSTF has not previously made a recommendation on this topic. Benefits of Counseling Interventions to Change Behavior Sixty-four randomized clinical trials and 4 nonrandomized controlled intervention studies evaluated interventions to promote healthy weight gain and limit excessive GWG during pregnancy. Study sample sizes ranged from 50 to 2261; the total number of participants in all included studies was 25,789. The mean reported age ranged from 18 to 33 years.1,31 None of the studies exclusively enrolled pregnant adolescents or pregnant adults of advanced maternal age. BMI inclusion criteria varied across the trials; there were participants with overweight or obesity (19 trials), those with obesity only (13 trials), those with mixed weight status (34 trials), and those with normal weight only (1 trial). Twenty-eight of the 68 included studies (41%) enrolled more than 20% of patients from diverse backgrounds, including persons who are socioeconomically disadvantaged, racial/ethnic populations, rural populations, or others. Twenty-two studies provided an intervention with an activity component, while 45 studies offered counseling-only interventions. The mean weight loss after the interventions was approximately 1 kg across the trials.1,31 Maternal Health Outcomes Gestational weight gain interventions were associated with statistically significant reductions in risk of gestational diabetes mellitus (43 trials; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; I2 = 16.4%; absolute risk difference [ARD], −1.6% [95% CI, −2.5% to −0.7%]) and emergency (unscheduled) cesarean delivery (134 trials; RR, 0.875 [95% CI, 0.754 to 0.986]; I2 = 0%; ARD, −2.24% [95% CI, −4.20% to 0.03%]). There was no association between GWG interventions and gestational hypertension, total number of cesarean deliveries, preeclampsia, postpartum hemorrhage, perineal trauma, or maternal death.1,31 Stratified analyses showed statistically significant interactions between the mixed BMI category and perineal trauma, active interventions and gestational hypertension, high-intensity interventions and gestational hypertension, and intervention intensity and perineal trauma. Infant Health Outcomes Gestational weight gain interventions were associated with decreased risk of infant macrosomia (25 trials; RR, 0.77 [95% CI, 0.65 to 0.92]; I2 = 38.3%; ARD, −1.9% [95% CI, −3.3% to −0.7%]) and LGA in infants (26 trials; RR, 0.89 [95% CI, 0.80 to 0.99]; I2 = 0%; ARD, −1.3 [95% CI, −2.3% to −0.3%]).1,31 However, the interventions were not associated with changes in growth rates during the first year of life or in risk of preterm birth, neonatal death or stillbirth, shoulder dystocia, admission to the neonatal intensive care unit, or respiratory distress syndrome. Stratified analyses showed statistically significant interactions between intervention intensity and infant macrosomia (P = .03 for interaction) but no effect on other infant outcomes by BMI category, intervention type, or intervention intensity.1,31 Evidence suggested that some specific pregnancy-related intermediate outcomes are associated with health outcomes. Macrosomia and LGA in infants were associated with an increased risk of maternal and infant complications during birth. Maternal Weight Outcomes Gestational weight gain interventions were associated with 1 kg less weight gain across all prepregnancy weight categories (55 trials; pooled mean difference [MD], −1.02 kg [95% CI, −1.30 to −0.75 kg]; I2 = 60.3%). High-intensity interventions (≥12 contacts) were associated with greater effects (28 trials; pooled MD, −1.47 kg [95% CI, −1.78 to −1.22 kg]; I2 = 13.0%) than were moderate-intensity interventions (3-11 contacts) (18 trials; pooled MD, −0.32 kg [95% CI, −0.71 to −0.04 kg]; I2 = 17.6%) or low-intensity interventions (≤2 contacts) (9 trials; pooled MD, −0.64 kg [95% CI, −1.44 to 0.02 kg]; I2 = 48.4%; P < .001 for interaction). There was no significant interaction between intervention type or baseline BMI category and effects on GWG. Interventions were also associated with a lower likelihood of GWG in excess of the National Academy of Medicine recommendations (39 trials; RR, 0.84 [95% CI, 0.78 to 0.90]; I2 = 63.2%; ARD, −7.7% [95% CI, −11.0% to −4.6%]), with greater effect size for active interventions (P < .001 for interaction) and high-intensity interventions (P < .001 for interaction). There was no significant interaction between BMI category and effects on likelihood of excess weight gain. Gestational weight gain interventions were not associated with increased likelihood of adherence to National Academy of Medicine recommendations for GWG (ie, neither gaining excessive weight nor failing to gain sufficient weight) or postpartum weight retention at less than 6 months but were associated with reduced postpartum weight retention at 12 months (10 trials; pooled MD, −0.63 kg [95% CI, −1.44 to −0.01 kg]; I2 = 65.5%).1,31 Harms of Counseling Interventions to Change Behavior The USPSTF found limited evidence on harms because most studies were not designed to evaluate harms. Twelve studies evaluated the effects of GWG interventions on maternal anxiety and depression and showed mixed results.1 The association between GWG interventions and small for gestational age size in infants was not statistically significant (20 trials; RR, 0.94 [95% CI, 0.80 to 1.10]; I2 = 0%; ARD, −0.4% [95% CI, −1.7% to 1.0%]).1 Gestational weight gain interventions were not associated with maternal death (2 trials); however, there were low event rates and few trials.1,31 Response to Public Comments A draft version of this recommendation statement was posted for public comment on the USPSTF website from December 8, 2020, to January 11, 2021. Comments asked for clarification of the patient population. The USPSTF revised the Practice Considerations section to clarify that the patient population under consideration included pregnant adolescents and adults and to more clearly define “healthy” weight. Comments asked for more clarification about effective interventions. The USPSTF provided examples of effective behavioral counseling interventions that can be used in practice in Table 2.Research Needs and GapsThere are several important evidence gaps. Studies are needed that provide more information on the following. The effectiveness of interventions on additional short- and long-term maternal and infant health outcomes. The specific components of intensive behavioral interventions, including the optimal frequency, length of sessions, and number of sessions needed for an intervention to be effective. Whether interventions should be tailored to promote healthy weight gain in populations of pregnant persons of advanced maternal age (eg, older than 34 years); adolescents; diverse populations such as non-Hispanic Black, Alaska Native/American Indian, and Hispanic persons; and populations with increased rates of overweight and obesity.3 Recommendations of OthersThe American College of Obstetricians and Gynecologists recommends that clinicians provide counseling on the risks of obesity in pregnancy and provide resources or refer persons of reproductive age to weight-reduction interventions before conception.7,32-37 The National Academy of Medicine recommends counseling about healthy weight gain during pregnancy and adherence to its recommendations about GWG.5


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