Background
Methods
Criteria for considering studies for this review
Types of studies
Types of participants
Types of interventions
Types of outcome measures
Search methods for identification of studies
Data collection and analysis
Selection of studies
Data extraction and management
Data synthesis
Assessment of study quality, bias and evidence grading
Data synthesis
Results
Results of the search
Description of 13 included trials
Author, yr, Country | Description of treatment arms | *Enrollment period; **duration | Sample population, N | Age (y) | Race/ethnicity | Study quality |
---|---|---|---|---|---|---|
Nutrition and Exercise Interventions
| ||||||
Bertz, 2012, Sweden, in-person [30] | Intervention (I): 3 intervention arms and 1 control arm (D) dietary modifications reduce caloric intake by 500Kcal/day; (E): exercise only- exercise to achieve 45 min brisk walk 4d/week; (DE): combined diet and exercise; Control (C): Usual care | 10-14 weeks postpartum; 12 weeks | 63 lactating, overweight/obese primiparous; N = 68 | 33 | Swedish | Good |
Colleran, 2012,US, in-person [32] | Intervention (I): postpartum counseling on diet and exercise plus on-line resources; Control (C): Usual care + diet and nutrition print handouts | 4-6 weeks;16 weeks | 31 women, ≥23 years and < 37 years, singleton pregnancy | 31 | NR | Fair-to-good |
(−5.8 ± 3.5 kg) (7%) compared with the C (−1.6 ± 5.4 kg) (3%) (P = 0.03). | ||||||
Leermakers 1998, US, in-person [31] | Intervention (I): Correspondence lessons, group sessions and telephone follow-up Control (C): Usual care + informational brochure | 8 mos; 6 mos | Non-lactating postpartum women; N = 90 | 31 | 3% non-white | Fair-to-good |
O’Toole, 2003 US, in-person [36] | I: Structured diet + exercise with weekly in-person sessions x 12 wks, bi-weekly sessions x 8 wks, and monthly sessions up to 1-year | 6 wks-6 mos; 6–10 mos | Postpartum women who were overweight or obese prior to pregnancy; N = 40 | 31 | 1 AA | Good |
C: One in-person session followed by self-directed program | ||||||
Craigie 2011, United Kingdom, in-person [28] | I: Information pamphlet + two face to face counseling sessions, with telephone follow-up for reinforcement and resources C: Information pamphlet | 6-18 mos; 3 mos | Low income, overweight and obese postpartum women; N = 52 | 30 | 3 non-white participants | Fair |
Huang, 2011, Taiwan, in-person [25] | I: Individualized dietary and physical activity plans, including 6 pregnancy sessions and 3 postpartum sessions C: Usual care | 1 day; 6 mos | Pregnant and postpartum women Taiwanese women; 1 day postpartum; N = 189 | 32 | Taiwanese | Fair-to-good |
Lovelady 2000, US, in-person [37] | I: Caloric restriction and exercise intervention, including 4 exercise sessions, lasting 43 minutes with goal of 65-80% heart rate C: Usual care | 5 wks; 2.5 mos | Overweight postpartum women with BMI 25–30 kg/m2, exclusively breastfeeding; N = 40 | 32 | 3.5% AA | Fair-to-good |
Ostbye, 2009, US, in-person [29] | I: 8 healthy eating classes, 10 physical activity classes and 6 telephone counseling sessions over 9 mos. C: Usual care | 2 mos; 9 mos | Overweight or obese postpartum women; N = 450 | 31 | I: 45% AA | Good |
C:45% AA | ||||||
Davenport, 2011, US, in-person [33] | I: Diet + low intensity exercise | 8 wks; 4 mos | Overweight or obese women who retained > 5 kg after delivery; N = 60 | 33 | Intervention groups: 85-90% white | Fair-to-good |
I: Diet + moderate intensity exercise | ||||||
No AA | ||||||
C: Historical controls matched for age, BMI, and parity | Other race: NR | |||||
Exercise-only Interventions
| ||||||
Zourladani, 2011, Greece [15] | I: Instructor led 1-hour exercise class with aerobic activity and strength training 3 times per wk for 12 wks. | 4-6 wks; 3 mos | Primiparous postpartum women; N = 40 | 31 | Greek | Fair |
C: No intervention | ||||||
Maturi, 2011, Iran [14] | Tailored pedometer-based walking program with baseline counseling session, cell phone and text reminders and telephone feedback; C: Usual Care | 6wks-6mos; 3 mos | Lactating, normal or overweight postpartum women; N = 66 | 25 | Iranian | Fair-to-poor |
Dewey, 1994, US [34] | I: Individually tailored and supervised aerobic activity to achieve 60-70% heart rate reserve. 45 min-5 times a wk | 6-8 wks; 3 mos | Exclusively breastfeeding postpartum women; N = 33 | 30 | No AA | Fair-to-good |
C: No intervention | ||||||
Nutrition-only Interventions
| ||||||
Krummel, 2010, US [23] | I: Counseling with dietitian, and 10 facilitated discussion groups, monthly personalized feedback on self-monitoring records | 30 wks; 12 mos | Postpartum women enrolled in WIC; N = 151 | 27 | 10% non-white; | Fair-to-poor |
C: Self directed |
Quality of included trials
Results of included trials
Nutrition and exercise interventions
Author, yr | Weight (kg) SD | BMI (kg/m2) | Adiposity |
---|---|---|---|
Nutrition and Exercise interventions | |||
Bertz (2012) [30] | Weight (12 weeks) | Fat mass: | |
D: −8.3 ± 3.0 | D: −2.9 ± 1.5 | D: −6.9 ± 3.4 | |
E: −2.4 ± 3.2 | E: −0.8 ± 1.0 | E: −1.8 ± 3.0 | |
DE: −6.9 ± 3.0 | DE: −2.5 1.0 | DE: −6.2 ± 3.1 | |
C: −0.8 ± 3.0; P < 0.001 | C: −0.3 1.1; P < 0.001 | C: −0.7 ± 3.1 | |
Weight (1 year): | 1 year: | ||
D: −10.2 ± 5.7 | D: −3.6 ± 2.0 | D: −9.2 ± 5.6 | |
E: −2.7 ± 5.9 | E: −0.9 ± 2.0 | E: −2.5 ± 5.9 | |
DE: −7.3 ± 6.3 | DE: −2.6 ± 2.2 | DE: −6.0 ± 7.0 | |
C: −0.9 ± 6.6; P < 0.001 | C: −0.3 ± 2.4; P < 0.001 | C: −1.8 ± 6.2 | |
Colleran (2012) [32] | I: −5.8 (SE:3.5) | I: 0.9 (SE 1.5) | |
C: −1.6 (SE:5.4); | C: 2.1 (SE1.4); | ||
P <0.01 | P <0.01 | ||
Leermakers (1998) [31] | I: −7.8 ± 4.5 | ||
C: −4.9 ± 5.4 | |||
(Pa = 0.03) | |||
Lovelady (2000) [37] | I: −4.8 ± 1.7 | I: −1.8 ± 0.6 | Skinfold thickness; all 6 measures (P < 0.01)b
|
C: −0.8 ± 2.3 | C: −0.3 ± 0.9 (P < 0.01) | ||
(P < 0.001) | |||
O’Toole (2003) [36] | I: −7.3 | ||
C: −1.3 | |||
(P < 0.05) | |||
SD-NR | |||
Ostbye (2009) [29] | I: −0.9 ± 5.1 | ||
C: −0.36 ± 4.9 | |||
(P = 0.25) | |||
Craigie (2011) [28] | I: −1.6 ± 2.0 | Waist circumference | |
C:0.2 ± 2.2 | I: −4.4 ± 3.5 | ||
(P = 0.018) | C: −2.8 ± 4.5 | ||
(P = 0.23) | |||
% body fat | |||
I: −1.5 ± 0.8 | |||
C: −0.5 ± 1.4 | |||
(P = 0.32) | |||
Huang (2011) [25] | I: −11.21 | ||
C: −11.04 | |||
(P-value NR) | |||
SD-NR | |||
Davenport (2011) [33] | I: −5.0 ± 2.9 | I: −1.8 | Waist-to-Hip Ratio |
Diet + moderate intensity exercise; | moderate intensity | I: −0.05 | |
I: −1.5 | I: −0.03 | ||
I: −4.2 ± 4.0 | low intensity | C: 0.0 | |
Diet + low intensity exercise; | C: 0.0 | SD:NR | |
Historical controls: | SD-NR | (P < 0.05)a
| |
−0.1 ± 3.3 | (P < 0.05)a
| ||
(P < 0.01)a
| |||
Exercise-only interventions
| |||
Dewey (1994) [34] | I: −1.6 | ||
C: −1.6 | |||
(p > 0.05) | |||
SD-NR | |||
Zourladani (2011) [27] | I: −3.3 | ||
C: −1.3 | |||
(P = 0.667) | |||
SD-NR | |||
Maturi (2011) [26] | I: −2.1 | I: −0.81 | Waist-to-Hip Ratio |
C: 0 | C: 0.1 | I: −0.02 | |
(P < 0.001) | (P < 0.001) | C: 0.01 | |
SD-NR | SD-NR | (P = 0.02) | |
SD-NR | |||
Diet-only interventions
| |||
Krummel (2010) [35] | I: −2.9 ± 11.8 | I: −0.54 ± 1.9 | |
C: −2.9 ± 10.7 | C: −0.54 ± 1.8 (P > 0.05) | ||
(P > 0.05) |
Exercise-only interventions
Adverse effects of post-partum behavioral interventions
Overall strength of evidence
Outcome | Strength of evidence | Intervention | Conclusions |
---|---|---|---|
Weight | Low | Nutrition and Exercise | Four good quality RCTs had inconsistent findings. Three of the four fair-to-good quality studies reported greater weight loss in the intervention group compared to standard postpartum care, but the RCTs were short (≤9 months) in duration and had limited generalizability to racial and ethnic minority groups. |
Low | Exercise only | Results were inconclusive for comparison of exercise-only interventions with standard postpartum care, with low risk for bias, but moderate imprecision and inconsistency in the dire study findings. | |
Insufficient | Nutrition only | Only one RCT for comparison of diet-only with standard postpartum care, with high attrition rates and differential loss to follow-up between treatment groups. | |
Adiposity | Low | All interventions | Few studies included adiposity and there is inconsistency in adiposity measures across studies. One comparison showed a reduction in skinfold thickness; two comparisons reported a statistically significant reduction in waist-to-hip ratios, but estimate of effect were imprecise due to small sample sizes. |
Cardio-metabolic | Insufficient | All interventions | One RCT compared lipid and glucose levels between women receiving a nutrition and exercise intervention and historical controls |
Biological markers | Insufficient | All interventions | Only one RCT was included for the outcome of adiponectin. Findings from the intervention group were compared to non-randomized historical controls. |
Discussion
Recommendations | ||
---|---|---|
All Post-partum Women | Post-partum women with BMI ≥ 30 | |
NICE | 6–8-week postnatal check | 6-8 week postnatal check |
In women who are overweight, obese or who have concerns about their weight, ask if they would like any further advice and support now – or later. If yes, make an appointment within the next 6 months for advice and support. | Explain the increased risks that being obese poses to them and, if they become pregnant again, their unborn child. | |
Provide current advice about how to lose weight after childbirth. | Encourage them to lose weight. | |
Ensure women have a realistic expectation of the time it will take to lose weight gained during pregnancy. | Offer a structured weight-loss program or a referral to a dietitian or an appropriately trained health professional. | |
Discuss benefits of a healthy diet and regular physical activity, | ||
Advice on healthy eating and physical activity should be tailored to individual patient circumstances. | ||
Provide Women who are not yet ready to lose weight with information about where they can get support when they are ready. | ||
Advise women to seek information from reliable sources | ||
Provide details of appropriate community-based services | ||
Encourage women to breastfeed. | ||
Use evidence-based behavior change techniques to motivate and support women to lose weight. | ||
Provide advice on recreational exercise from the Royal College of Obstetrics and Gynecology: | ||
A mild exercise program of walking and stretching may begin immediately; after complicated deliveries, or lower segment caesareans, a medical provider should be consulted before resuming pre-pregnancy levels of physical activity. | Encourage breastfeeding | |
Emphasize importance of physical activities that can be built into daily life. | ||
ACOG | Rapid return to pre-pregnancy activities is acceptable after an uncomplicated pregnancy and delivery | No recommendations based on BMI |
Moderate weight reduction after delivery does not interfere with lactation or neonatal weight | ||
Postpartum exercise may help to reduce postpartum depression symptoms | ||
Refer to weight specialist before the next pregnancy | ||
Discuss healthy lifestyle behaviors at each visit. |