Over adults aged 18 years and older, were overweight

Over the
past two decades there has been a dramatic increase in the prevalence of obesity affecting both developed
and developing countries
(Stüber et al., 2015). A prevalence of more than 1.9 billion adults aged
18 years and older, were overweight in 2016 and more than 650 million out of
them were obese (World Health Organization, 2017). “In 2015 in England 58% of women and 68% of men
were overweight or obese” (NHS Digital, 2017). This increased presence of obesity is considered to be a
major health problem since it is a key contributing factor for cardiovascular
disease, type 2 diabetes and furthermore, is related worldwide with a higher
morbidity (Stüber et al., 2015). Obesity is defined by the Body mass index measurement
(BMI); this commonly used measurement refers to the individual’s
weight in kilograms divided by the square of the individual’s height in meters
(World Health Organization,
2017). Herewith, obesity is defined as a BMI greater than or equal to 30 kg/m2. An individual with a BMI
greater or equal to 40 kg/m2 is considered to have an extreme form of obesity. It
is important to underline that it is an overabundance in adipose tissue that
influences the health consequences of obesity, and not the size of the
individual’s body that matters (Leddy, Power & Schulkin, 2008). An example for this are
weightlifters; who tend
to have a high BMI, however, this is not because of an excess in
fat but due to a high muscle mass. These individuals are therefore, not
specifically at risk of metabolic health problems, as obese
people with the same BMI would be (Leddy et al., 2008). Regarding the prevalence of
obesity in pregnancy in the UK, only 4,99% of women with a BMI equal to 35 or
higher, which refers to class 2 and class 3 obesity, where class 2 obesity
refers to severe obesity and class 3 to morbid obesity, give birth at 24 weeks
of gestation or later. This refers to approximately 38,478
maternities each year. Further to that, pregnant women classified with a BMI
equal or higher than 40, who are considered to be morbidly obese, are defined as only 2% of all women giving birth. Moreover, only 0,19% give birth when having a
BMI equal or higher than 50, which refers to women who are super
morbidly obese (Maternal
obesity in the UK, 2010).
Approximately “20% of pregnant women who attended their first appointment” in the UK, “were classed
as obese”, this was seen in the statistics from the Health and Social Care
Information Centre (HSIC, 2015, as cited in Midirs, 2016).

These statistics are worrying and show not only how problematic obesity is worldwide, but also how
significant the problem of obesity in pregnancy has become. Multiple
complications for the mother as well as for the offspring are associated with
the increasing prevalence of preconception weight issues and excessive
gestational weight gain (GWG) (Stüber
et al., 2015). The
Institute of Medicine (IOM) has devised a set of guidelines recommending
gestational weight gains
for women with normal BMI, overweight and obese women before conception. Over the past years, a substantial
number of women have been
exceeding these pregnancy weight gain recommendations (Rauch et al.,
2013). Around “50% of women start their pregnancy being overweight or obese”,
and approximately “50% of women gain excess pregnancy weight”. This makes
maternal obesity and excessive gestational weight gain key contributors to the
global obesity epidemic (Hure et al., 2012; Kowal et al., 2012; Rasmussen and
Yaktine, 2013; McPhie et al., 2015, as cited in Hill et al., 2017). Many
pregnancy-related problems increase as the level of obesity increases resulting in possible “miscarriage,
hypertensive disorders such as pre-eclampsia, gestational diabetes mellitus,
infections, thromboembolism, instrumental and traumatic deliveries, wound
infection and endometritis” (Thangaratinam et al., 2012). Obese pregnant women encounter
increased risks of complications at the time of labour and delivery. Thus
the rate of successful vaginal delivery decreases, often leading to caesarean deliveries. Having an
excessive gestational weight gain during pregnancy is associated with an
increased risk for the mother to maintain the weight gained, which indicates a
persistent obesity post-pregnancy, as well as an increased risk of obesity in her
children. With this, both the “mother and the offspring are at increased risk
regarding short- and long-term obesity” (Siega-Riz et al., 2009; Mannan et al.,
2013; Cohen et al., 2014, as cited in Hill et al., 2017). Maternal health
during pregnancy, therefore, is of
vital importance as it has a significant
impact on the
development of the foetus during pregnancy, as well as on the child’s health
later on in life. Further unfavourable outcomes for the foetus, include “stillbirths and neonatal deaths, preterm
births, neonatal unit admission, macrosomia, congenital abnormalities and
childhood obesity with associated long-term risks”, as mentioned above
(Thangaratinam et al., 2012). All of these issues emphasize the importance of
the health-care system, and the need to expand the facility for supplementary supervision and resources in both primary and secondary care settings
(Thangaratinam et al., 2012).  Preventing and treating obesity and
gestational weight gain in this
population is of major concern in order to prevent the negative outcomes for
the mother as well as for the infant.

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It is widely believed that pregnancy is a “teachable moment”, in which
women are inspired to change their health behaviour such as adjusting their
diets and engaging in physical activities (Phelan, 2010), in order to increase healthy outcomes for their expected
child. A period in which women consider having greater interaction with
healthcare professionals of paramount importance and therefore an ideal time to promote healthy behavioural
changes. Lifestyles interventions have been designed
where the aim is to improve some of the patient’s unhealthy habits in order to
improve their health outcomes. However, some intrinsic barriers are encountered. Such
barriers during the life stage of a pregnant woman include the lack of time for habits
to become routine (a mere 3 months; as “lifestyle
interventions tend to begin at the end of the first trimester and end early in
the third trimester”) (Hill et al., 2017), challenging demands such as physiological
situations, financial, relationship, and social situations (Hill et al., 2017).
Another set of barriers is the difficulty in transferring information to
the mother so that she can recognize the potential risks associated with being overweight and obese during pregnancy and because
of this, to trigger behavioural changes successfully. Due to the different intrinsic
barriers pregnant women are facing, lifestyle interventions, with a focus on
lifestyle change have mixed outcomes. As a direct result of this, it is
imperative to deliver
these lifestyle interventions individually in a supportive environment, in
which the healthy challenges of the pregnant women are encouraged and rewarded,
to help modify their
behaviour (Hill et al., 2017).

Weight management strategies
are developed in order to target the increasing prevalence of obesity within the population. A focus of these strategies has been set on pregnancy
due to the fact that pregnancy is seen as a crucial time to target weight
management (Thangaratinam
et al., 2012). Due to a diversity in intervention types to limit gestational weight gain, such as “diet or physical activity, psychological support, or
combinations” hereof, and a diversity in the intensity of interventions, like “intensive
clinical intervention or hands-off approaches”; mixed findings regarding their
outcomes are noticeable (Saskatchewan Prevention Institute, 2014). A set of
recommendations from the literature findings, suggest that in order to make
interventions more effective, strategies must consider the engagement of
trained and prepared prenatal care providers, providing continuing information
to the pregnant women and advising
them on healthy weight gain
during pregnancy (Campbell et al., 2011). This can be achieved by providing nutritional guidance,
information regarding physical activities, recommendations to preserve a food
diary and physical activity record, and most importantly not forgetting
the “tracking of gestational
weight gain” (Ferraro, 2014, as cited in Saskatchewan Prevention Institute,
2014). Communication between pregnant women and prenatal care providers are
important in order to consider each woman’s situation. Motivating women before
and throughout the whole pregnancy to adopt healthy behaviours is crucial (Institute
of Medicine, 2009).

Regarding the interventions,
the common dietary ones are composed of a balanced diet of proteins,
carbohydrates, fat and the upkeep of a food diary. As for the “physical
activity-based interventions”, these consist of “walking for 30 minutes,
weight-bearing exercises and light-intensity resistance training” (Thangaratinam et al., 2012). A
meta-analysis regarding the effectiveness of lifestyle interventions such as dietary
control or physical activity in pregnancy and outcomes for the foetus have
shown that a reduction in gestational weight gain was greater in the dietary
intervention group (Thangaratinam
et al., 2012). Regarding the estimates for the birth weights of the infants, a remarkable decrease has been measured in the intervention group and this
for all the lifestyle interventions (Thangaratinam et al., 2012). Resulting from the evaluation of the effect of
interventions in pregnancy on obstetric outcomes, 29 randomised trials
concluded that a significant general decrease in the occurrence of pre-eclampsia
was seen resulting from weight management interventions. A significant
reduction in gestational hypertension and pre-eclampsia resulted from dietary interventions
with this intervention having the largest effect (Thangaratinam et al., 2012).
Moreover, a remarkable decrease in preterm births and in the tendency to reduce
the occurrence of gestational diabetes, resulted from dietary interventions. As
for caesarean section or induction of labour, no distinction was found between
the groups (Thangaratinam
et al., 2012).

However, a rational hypothesis for interventions in order to reduce
negative outcomes for the mother as well as for her offspring would be to
reduce weight preceding the pregnancy, this because most of the negative
outcomes of overweight or obese women during pregnancy show associations with
pre-pregnancy BMI (Nohr et al., 2008, as cited in Oteng-Ntim, 2009). Despite the fact that it is recognized that the
woman’s weight preceding the pregnancy has a significant impact on the health
of both the mother and her offspring, numerous pregnancies are unplanned (Finer
and Zolna, 2016, as cited in Hill et al., 2017), therefore targeting a defined
population is difficult. Additionally, only a small number of women would consult
a health care provider before conceiving, and a smaller number of women would
agree to delay their conception in order to lose weight (Birdsall, Vyas, Khazaezadeh, & Oteng-Ntim, 2009). However, messages and programs promoting healthy
weights to women of childbearing age should not be dismissed and should rather
be encouraged.

In order to prevent maternal
obesity and excessive gestational weight gain, three key guides regarding
future research for interventions and care are recommended (Hill et al., 2017).
Firstly, “the promotion of maternal health”. In particular overweight and
obesity prevention, this involves three approaches. The first one is
encouraging weight management in order to start pregnancy at a healthy BMI. The
second approach is the prevention of excessive gestational weight gain through
suitable targeted interventions that are unified into the women’s usual care. And
finally, the promotion of postpartum weight management in order to have healthy
post-pregnancy BMI, and to return to a healthy pre-pregnancy BMI. Researchers
should concentrate on acknowledging that preconception is a distinctive life stage.
Intervention in the preconception period will provide more possibilities for
habit adoption, which is crucial for the emergence of appropriate healthy
lifestyles changes that can be continued throughout the pregnancy (Hill et al.,
2017).

A second key guidance, regards
adopting an adjusted approach through audience segmentation since it is important
to recognize the impact the environment has on women’s abilities to commence
and preserve healthy lifestyle behaviours before and throughout pregnancy. In
order to identify suitable opportunities to intervene with health promotion
strategies that will have significant outcomes, it is necessary to identify the
main preconception and pregnancy audience segments, and to investigate and
report their distinctive criterion such as psychosocial, health, demographic and
lifestyle characteristics (Hill et al., 2017).

A third and final key guidance, is the importance of a combination of
regulation, encouragement and extensive educational strategies that are
individually targeted. The related policies must go deeper towards the
prevention of maternal obesity in order to achieve long-term practical changes
in clinical care. It is crucial for the research, policy and practice to
consider the clinical, social and environmental backgrounds in which women are.
This, in order to attain durable changes in the patient’s outcomes (Hill et
al., 2017).

More research is necessary to understand what components prompt different
groups of women to tackle their preconception weight.  It is important to define and control the
specific challenges in this life stage. Innovation is needed in order to
outline personalized intervention strategies based on what has been mentioned
previously. The occurrence of maternal obesity and its associated comorbidities
continue to increase at a frightening rate, this accompanied by considerable
public health implications. Therefore, it is important that all of this should
be associated with multiple obesity prevention efforts in the community, in
order to increase healthy weight goals throughout the system.