American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Maternal morbid obesity and the risk of adverse pregnancy outcome. Determinants of excessive gestational weight gain in urban, low-income women. A Low Glycaemic Index Diet in Pregnancy Induces DNA Methylation Variation in Blood of Newborns: Results from the ROLO Randomised Controlled Trial Gestational weight gain and postpartum behaviors associated with weight change from early pregnancy to 1 y postpartum Excessive weight gain and hypertensive disorders of pregnancy in the obese patient* Effects of a Gestational Weight Gain Restriction Program for Obese Pregnant Women: Children's Weight Development during the First Five Years of Life. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. A randomized study of the effects of aerobic exercise by lactating women on breast-milk volume and composition. Association of maternal gestational weight gain with short- and long-term maternal and child health outcomes. Inadequate weight gain in overweight and obese pregnant women: what is the effect on fetal growth? Postpartum Weight Retention Risk Factors and Relationship to Obesity at 1 Year
Overweight and obesity affects more than 66 % of the adult population and is associated with a variety of chronic diseases . Weight reduction reduces health risks associated with chronic diseases and is therefore encouraged by major health agencies . Guidelines of the National Heart , Lung , and Blood Institute ( NHLBI ) encourage a 10 % reduction in weight , although considerable literature indicates reduction in health risk with 3 % to 5 % reduction in weight . Physical activity ( PA ) is recommended as a component of weight management for prevention of weight gain , for weight loss , and for prevention of weight regain after weight loss . In 2001 , the American College of Sports Medicine ( ACSM ) published a Position St and that recommended a minimum of 150 min wk(-1 ) of moderate-intensity PA for overweight and obese adults to improve health ; however , 200 - 300 min wk(-1 ) was recommended for long-term weight loss . More recent evidence has supported this recommendation and has indicated more PA may be necessary to prevent weight regain after weight loss . To this end , we have reexamined the evidence from 1999 to determine whether there is a level at which PA is effective for prevention of weight gain , for weight loss , and prevention of weight regain . Evidence supports moderate-intensity PA between 150 and 250 min wk(-1 ) to be effective to prevent weight gain .  Moderate-intensity PA between 150 and 250 min wk(-1 ) will provide only modest weight loss . Greater amounts of PA ( > 250 min wk(-1 ) ) have been associated with clinical ly significant weight loss .  Moderate-intensity PA between 150 and 250 min wk(-1 ) will improve weight loss in studies that use moderate diet restriction but not severe diet restriction . Cross-sectional and prospect i ve studies indicate that after weight loss , weight maintenance is improved with PA > 250 min wk(-1 ) . However , no evidence from well- design ed r and omized controlled trials exists to judge the effectiveness of PA for prevention of weight regain after weight loss .  Resistance training does not enhance weight loss but may increase fat-free mass and increase loss of fat mass and is associated with reductions in health risk . Existing evidence indicates that endurance PA or resistance training without weight loss improves health risk . There is inadequate evidence to determine whether PA prevents or attenuates detrimental changes in chronic disease risk during weight gain OBJECTIVE To evaluate whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcomes . METHODS In a prospect i ve population -based cohort study , 3,480 women with morbid obesity , defined as a body mass index ( BMI ) more than 40 , and 12,698 women with a BMI between 35.1 and 40 were compared with normal-weight women ( BMI 19.8 - 26 ) . The perinatal outcome of singletons born to women without insulin-dependent diabetes mellitus was evaluated after suitable adjustments . RESULTS In the group of morbidly obese mothers ( BMI greater than 40 ) as compared with the normal-weight mothers , there was an increased risk of the following outcomes ( adjusted odds ratio ; 95 % confidence interval ) : preeclampsia ( 4.82 ; 4.04 , 5.74 ) , antepartum stillbirth ( 2.79 ; 1.94 , 4.02 ) , cesarean delivery ( 2.69 ; 2.49 , 2.90 ) , instrumental delivery ( 1.34 ; 1.16 , 1.56 ) , shoulder dystocia ( 3.14 ; 1.86 , 5.31 ) , meconium aspiration ( 2.85 ; 1.60 , 5.07 ) , fetal distress ( 2.52 ; 2.12 , 2.99 ) , early neonatal death ( 3.41 ; 2.07 , 5.63 ) , and large-for-gestational age ( 3.82 ; 3.50 , 4.16 ) . The associations were similar for women with BMI s between 35.1 and 40 but to a lesser degree . CONCLUSION Maternal morbid obesity in early pregnancy is strongly associated with a number of pregnancy complications and perinatal conditions . LEVEL OF EVIDENCE BACKGROUND Factors influencing excessive weight gain in pregnancy have not been well-studied among urban , low-income women . METHODS This prospect i ve cohort study of 94 prenatal care patients at a large university hospital in Philadelphia examined associations of modifiable midpregnancy behaviors and nonmodifiable or early pregnancy factors with  excessive gestational weight gain . Data were collected through question naires and medical record abstract ion from 2009 to 2011 . FINDINGS The majority of women were African American ( 83 % ) and all ( 100 % ) received Medicaid . Nearly two thirds ( 60 % ) were overweight or obese in early pregnancy and 41 % experienced excessive gain . In multivariable logistic regression analyses , significant predictors of excessive gestational weight gain included high early pregnancy body mass index ( odds ratio [ OR ] , 4.20 ; 95 % confidence interval [ CI ] , 1.43 - 12.34 for overweight/obese vs. normal weight ) , nulliparity ( OR , 3.35 ; 95 % CI , 1.17 - 9.62 for nulliparity vs. multiparity ) , and clinician advice discordant with Institute of Medicine guidelines ( OR , 5.88 ; 95 % CI , 1.04 - 33.32 for discordant vs. concordant advice ) . Watching under 2 hours of television daily ( OR , 0.18 ; 95 % CI , 0.03 - 1.03 ) , and engaging in regular physical activity during pregnancy ( OR , 0.35 ; 95 % CI , 0.11 - 1.09 ) were suggestive of a reduced risk of excessive gain . CONCLUSIONS In this sample of urban , low-income women , high early pregnancy body mass index , nulliparity , and discordant clinician advice were directly associated with excessive gestational weight gain , with a trend toward decreased risk for viewing fewer hours of television and engaging in regular physical activity . Intervening on these targets may optimize gestational weight gain and promote long-term maternal health The epigenetic profile of the developing fetus is sensitive to environmental influence . Maternal diet has been shown to influence DNA methylation patterns in offspring , but research in humans is limited . We investigated the impact of a low glycaemic index dietary intervention during pregnancy on offspring DNA methylation patterns using a genome-wide methylation approach . Sixty neonates were selected from the ROLO ( R and omised cOntrol trial of LOw glycaemic index diet to prevent macrosomia ) study : 30 neonates from the low glycaemic index intervention arm and 30 from the control , whose mothers received no specific dietary advice .  DNA methylation was investigated in 771,484 CpG sites in free DNA from cord blood serum . Principal component analysis and linear regression were carried out comparing the intervention and control groups . Gene clustering and pathway analysis were also explored . Widespread variation was identified in the newborns exposed to the dietary intervention , accounting for 11 % of the total level of DNA methylation variation within the data set . No association was found with  maternal early-pregnancy body mass index ( BMI ) , infant sex , or birthweight . Pathway analysis identified common influences of the intervention on gene clusters plausibly linked to pathways targeted by the intervention , including cardiac and immune functioning . Analysis in 60 additional sample s from the ROLO study failed to replicate the original findings . Using a modest-sized discovery sample , we identified preliminary evidence of differential methylation in progeny of mothers exposed to a dietary intervention during pregnancy OBJECTIVES : ( 1 ) To describe the relative importance of gestational weight gain , postpartum exercise , food intake and breastfeeding to weight change from early pregnancy to 1 y postpartum ; and ( 2 ) to identify subgroups of women at greatest risk for major weight gain surrounding childbearing . DESIGN : A prospect i ve cohort study of women who registered for obstetrical care in a hospital and primary care clinic system serving a 10 county area of upstate New York . SUBJECTS : A total of 540 healthy adult women who gave birth to full-term singleton infants . MEASUREMENTS : Sociodemographic characteristics , exercise , food-related behaviors and breastfeeding were assessed using the medical record and a mailed question naire .  Body weight was measured at prenatal visits and 1 y postpartum . Weight retained and major weight gain ( 4.55 kg ) at 1 y postpartum were the main outcomes . ANALYSIS : Linear and logistic regression analyses were conducted . RESULTS : Women were on average 1.51±5.95 kg heavier at 1 y postpartum than they were in early pregnancy . Nearly 25 % of women experienced a major weight gain of 4.55 kg or more at 1 y postpartum . Gestational weight gain , exercise frequency , change in food intake and breastfeeding were each significantly related to postpartum weight retention . With the exception of breastfeeding , all of these factors were also associated with major weight gain .  Women under 20 y or over 40 y at delivery , and single women retained significantly more weight .  Lower income women with gestational weight gains above the Institute of Medicine ( IOM ) range retained 3.73 kg more than lower income women who gained within the range . They were also 4.7 times more likely to experience major weight gain with childbearing . The impact of exceeding the IOM gestational weight gain guidelines was three times greater in lower income women than it was in higher income women . CONCLUSION : Gestational weight gain , postpartum exercise frequency , and food intake are significantly associated with weight change from early pregnancy to 1 y postpartum and major weight gain with childbearing . Lower income women who gain more weight in pregnancy than the IOM recommends are at high risk for major weight gain with childbearing Abstract Objective : To evaluate the association between  excessive weight gain and pregnancy-related hypertension ( PRH )  among obese women ( body mass index ( BMI ) ≥30 kg/m2 ) . Methods : We performed a case control study among women with ( n = 440 ) and without ( n = 600 ) PRH from 2005 to 2007 . Height and weight were recorded at initial and final prenatal visits . 695 women had BMI recorded at ≤18 weeks of gestation , of which 257 ( 36.9 % ) were obese . Obese women were divided into three categories based on 2009 Institute of Medicine ( IOM ) guidelines : ( 1 ) below recommended amount ( under weight gain – UWG ) ; ( 2 ) more than recommended ( excessive weight gain – EWG ) or ( 3 ) within recommended amount ( normal weight gain – NWG ) . PRH was defined as gestational hypertension , mild or severe preeclampsia . Patients with and without PRH were prospect ively identified . The association between weight gain category and development of PRH was analyzed . Results : We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30 kg/m2 compared to BMI < 30 kg/m2 ( OR 1.64 , 95 % CI 1.2–2.2 , p = 0.002 ) . Among obese women , we noted a 2-fold higher odds of having PRH with EWG compared to NWG ( OR 2.52 , 95 % CI 1.2–3.9 , p = 0.012 ) . The increased odds persisted after adjusting for race , chronic hypertension and diabetes , and length of gestation ( AOR 2.61 , 95 % CI 1.4–4.9 , p = 0.003 ) . Among obese women with PRH , those with EWG had a 76 % decreased odds of having severe disease compared to NWG ( OR = 0.242 [ 0.07–0.79 ] , p = 0.019 ) . Conclusion : We have demonstrated that EWG among obese patients  increases overall risk of PRH BACKGROUND Maternal prepregnancy obesity ( BMI ≥30 kg/m(2 ) ) and excessive gestational weight gain ( GWG ) have shown a strong positive association with a higher BMI and risk of obesity  in the offspring . The aim of this study is to estimate the effect of a GWG restriction program for obese pregnant women on the children 's BMI at 5 years of age and weight-for-length/height ( WL/H ) development from 2 months of age until 5 years of age . METHODS This was a follow-up study of 302 children ( 137 children in an intervention group and 165 children in a control group ) whose mothers participated in a weight gain restriction program during pregnancy . RESULTS BMI at five years of age did not differ between girls and boys in the intervention and control group . The degree of maternal GWG , < 7 kg or ≥7 kg , did not affect the offspring 's WL/H. Compared with Swedish reference data , just over half of the children in both the intervention and control group had a BMI within the average range , whereas slightly more than one-third of the children had a higher BMI . CONCLUSION Despite a comprehensive gestational intervention program for obese women containing individual weekly visits and opportunity to participate in aqua aerobic classes , there were no differences between BMI or weight development among the offspring at 5 years of age in the intervention and control group The purpose of the research project was to examine the effects of exercise , social support and depression on postnatal women who reported experiencing postnatal depression . A 12-week r and omized , controlled trial was conducted investigating the effects of an exercise intervention group ( a pram-walking programme for mothers and their babies ) compared to a social support group ( non-structured sessions , similar to a playgroup ) .  Participants in both groups had given birth in the past 12 months . Pretest data of physical fitness and structured question naires were compared to post-test effects . The primary outcomes were to reduce the depressive symptomatology and improve fitness levels of participants in the pram-walking group . Secondary outcomes were to improve the social support levels of the participants in both groups and explore women 's views about the programmes . It was hypothesized that the pram-walking group participants would improve their feelings of depression and fitness levels compared to the social support group , but that both groups would improve their perceived levels of social support . The results showed that mothers in the pram-walking intervention group improved their fitness levels and reduced their level of depressive symptomatology significantly more than the social support group . There were no significant changes to social support levels for both groups . Therefore , a direct association between improvement in fitness was related to improvement in depression for the pram-walking group . However , it is also suggested that other factors in combination with improvements in fitness influenced improvements in depression levels . It is recommended that pram-walking programmes for mothers with postnatal depression be implemented as pilot research into existing available services BACKGROUND The potential risks and benefits of regular exercise during lactation have not been adequately evaluated . We investigated whether regular aerobic exercise had any effects on the volume or composition of breast milk . METHODS Six to eight weeks post partum , 33 sedentary women whose infants were being exclusively breast-fed were r and omly assigned to an exercise group  ( 18 women ) or a control group ( 15 women ) . The exercise program consisted of supervised aerobic exercise ( at a level of 60 to 70 percent of the heart-rate reserve ) for 45 minutes per day , 5 days per week , for 12 weeks . Energy expenditure , dietary intake , body composition , and the volume and composition of breast milk were assessed at 6 to 8 , 12 to 14 , and 18 to 20 weeks post partum . Maximal oxygen uptake and the plasma prolactin response to nursing were assessed at 6 to 8 and 18 to 20 weeks . RESULTS The women in the exercise group expended about 400 kcal per day during the exercise sessions but compensated for this energy expenditure with a higher energy intake than that recorded by the control women ( mean [ + /- SD ] , intake , 2497 + /- 436 vs. 2168 + /- 328 kcal per day at 18 to 20 weeks ; P < 0.05 ) . Maximal oxygen uptake increased by 25 percent in the exercising women but by only 5 percent in the control women ( P < 0.001 ) . There were no significant differences between the two groups in maternal body weight or fat loss , the volume or composition of the breast milk , the infant weight gain , or maternal prolactin levels during the 12-week study . CONCLUSIONS In this study , aerobic exercise performed four or five times per week beginning six to eight weeks post partum had no adverse effect on lactation and significantly improved the cardiovascular fitness of the mothers OBJECTIVE The purpose of this study was to investigate the associations between  gestational weight gain ( GWG ) and small- and large-for-gestational-age ( SGA , LGA ) , cesarean delivery , child overweight , and maternal postpartum weight retention  in a diverse sample of women in the Unites States . STUDY DESIGN We estimated associations between GWG ( continuous and within categories defined by the Institute of Medicine ) , maternal prepregnancy body mass index , and each outcome in 4496 births in the National Longitudinal Survey of Youth 1979 , which was a prospect i ve cohort . RESULTS GWG ( kilograms ) was associated with decreased risk of SGA and increased risk of LGA , cesarean delivery , postpartum weight retention , and child overweight independent of maternal demographic and pregnancy characteristics . Gain above the Institute of Medicine guidelines was associated with decreased risk of SGA and increased risk of all other outcomes . CONCLUSION Excessive gain may have long-term consequences for maternal and child body size , but the benefits of lower gain must be balanced against risk of SGA OBJECTIVE We sought to evaluate inadequate gestational weight gain and fetal growth among overweight and obese women . STUDY DESIGN We conducted an analysis of prospect i ve singleton term pregnancies in which 1053 overweight and obese women gained > 5 kg ( 14.4 ± 6.2 kg ) or 188 who either lost or gained ≤5 kg ( 1.1 ± 4.4 kg ) . Birthweight , fat mass , and lean mass were assessed using anthropometry . Small for gestational age ( SGA ) was defined as ≤10th percentile of a st and ard US population . Univariable and multivariable analysis evaluated the association between weight change and neonatal morphometry . RESULTS There was no significant difference in age , race , smoking , parity , or gestational age between groups . Weight loss or gain ≤5 kg was associated with SGA , 18/188 ( 9.6 % ) vs 51/1053 ( 4.9 % ) ; ( adjusted odds ratio , 2.6 ; 95 % confidence interval , 1.4 - 4.7 ; P = .003 ) . Neonates of women who lost or gained ≤5 kg had lower birthweight ( 3258 ± 443 vs 3467 ± 492 g , P < .0001 ) , fat mass ( 403 ± 175 vs 471 ± 193 g , P < .0001 ) , and lean mass ( 2855 ± 321 vs 2995 ± 347 g , P < .0001 ) , and smaller length , percent fat mass , and head circumference . Adjusting for diabetic status , prepregnancy body mass index , smoking , parity , study site , gestational age , and sex , neonates of women who gained ≤5 kg had significantly lower birthweight , lean body mass , fat mass , percent fat mass , head circumference , and length . There were no significant differences in neonatal outcomes between those who lost weight and those who gained ≤5 kg . CONCLUSION In overweight and obese women  weight loss or gain ≤5 kg is associated with increased risk of SGA and decreased neonatal fat mass , lean mass , and head circumference OBJECTIVE : To explore risk factors for postpartum weight retention at 1 year after delivery in predominantly low-income women . METHODS : Data were collected from 774 women with complete height and weight information from participants in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Community Child Health Network , a national five-site , prospect i ve cohort study . Participants were enrolled primarily in the hospitals immediately after delivery .  Maternal interviews conducted at 1 , 6 , and 12 months postpartum identified risk factors for weight retention and included direct measurement of height and weight at 6 and 12 months . Logistic regression assessed the independent contribution of postpartum weight retention on obesity . RESULTS : Women had a mean prepregnancy weight of 161.5 lbs ( body mass index [ BMI ] 27.7 ) . Women gained a mean of 32 lbs while pregnant and had a 1-year mean postpartum weight of 172.6 lbs ( BMI 29.4 ) . Approximately 75 % of women were heavier 1 year postpartum than they were prepregnancy , including 47.4 % retaining more than 10 lbs and 24.2 % more than 20 lbs . Women retaining at least 20 lbs were more often African American , younger , poor , less educated , or on pubic insurance . Race and socioeconomic disparities were associated with high prepregnancy BMI and excessive weight gain during pregnancy , associations that were attenuated by breastfeeding at 6 months and moderate exercise . Of the 39.8 with normal prepregnancy BMI , one third became overweight or obese 1 year postpartum . CONCLUSION : Postpartum weight retention is a significant contributor to the risk for obesity 1 year postpartum , including for women of normal weight prepregnancy . Postpartum , potentially modifiable behaviors may lower the risk . LEVEL OF EVIDENCE :
Background : Maternal obesity , excessive gestational weight gain ( GWG ) and post-partum weight retention ( PPWR ) constitute new public health challenges , due to the association with negative short- and long-term maternal and neonatal outcomes .
The aim of this evidence review was to identify effective lifestyle interventions to manage weight and improve maternal and infant outcomes during pregnancy and postpartum .