Discussion
obesity, Anxiety, anxiety, depressive, depressive symptoms, depression
OBESITY, PREGNANCY INDUCED HYPERTENSION, OBESE, GESTATIONAL DIABETES
To our knowledge, this is the first RCT evaluating the effect of a postpartum lifestyle intervention, including a mental health component on levels of anxiety, depression, SOC and QoL during the first year after childbirth in women with pre-existing excessive GWG. We found that the INTER-ACT lifestyle intervention was associated with an improvement in the number of women with depressive symptoms, or low SOC at 6 months after intervention, but only in normal weight women. Mixed models revealed that both our intervention as well as the pre-pregnancy BMI category and QoL at baseline were associated with levels of depressive symptoms throughout the first year after childbirth. Women with pre-pregnancy obesity showed an increase in EPDS between baseline and end of intervention, but an decrease afterwards. Women with normal/overweight pre-pregnancy BMI showed a significant decrease in depressive symptoms between baseline and end of intervention, followed by an increase till 6 months follow-up. A higher QoL at baseline had a significant positive effect on levels of depression, mainly in women with pre-pregnancy normal weight and overweight. The evolution of SOC depended on pre-pregnancy BMI, the amount of excessive GWG and the QoL at 6 weeks after childbirth. Women with a normal pre-pregnancy BMI reported better levels of SOC, compared to normal weight women of the control arm. Women with pre-pregnancy obesity reported worser levels of SOC if they received the INTER-ACT intervention compared to the control arm. Lower levels of excessive GWG (1kg vs 5kg) and a higher QoL at baseline had a significant positive effect on SOC.Previous studies focusing on lifestyle interventions in the general population showed that women with obesity experience a lack of motivation, and therefore less adherence to treatments [Anxiety (sSTAI-6) increased over time. These findings are in line with our previous research [The mental health component of the INTER-ACT intervention focused on stressors and social support. Lack of social support is often identified as a major cause of adverse mental health [The fact that the INTER-ACT intervention is limited to social support and stressors, and we did not select women based on the presence of mental health problems, may be a reason for the absence of large effects of mental health improvement after receiving the INTER-ACT intervention. Indeed, as shown in Stress and depression appear to be predictors of poor adherence to lifestyle interventions [The strengths of this study were the study design (a multicentre RCT with long-term follow-up), the large study group and the analysis of four different mental health outcomes. Nevertheless, there were also some limitations in this study. The mental health questionnaires were completed prior to the coaching session, so the effect of the coaching session at that time point was not yet apparent in the mental health outcomes. A second limitation is that we presume that our control arm may have been triggered by the regular home visits they received as part of the data-collection (anthropometrics). During the measurements conversations on diet, physical activity and mental well-being were not initiated, however, we believe that by home visits and interaction with mothers, a trigger may have occurred that can have an effect on the mental well-being. A third limitation is that our results cannot be fully generalized to the entire population of postpartum women as our sample mainly consisted of working women (92%) who held at least a bachelor’s degree (71%). A fourth limitation is that within the INTER-ACT trial, power analysis was driven solely by the primary outcome: a composite outcome of occurrence of pregnancy- and birth related problems (pregnancy induced hypertension, gestational diabetes, caesarean section and large for gestational age babies). As a result, there may be a lack of statistical power in current analyses that focus on mental health outcomes, especially in the pre-pregnant obese women. This might limit the statistical evidence of the inter-act intervention on mental health, but can induce as well rather chance findings such as e.g. the significant difference in GMDS between the intervention and control arm at 6 months follow-up in the normal-weight women.