Weight Management Over The Reproductive Years for Adult Women With Obesity 2020-08-26T18:33:06-04:00

Weight Management Over The Reproductive Years for Adult Women With Obesity

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This chapter addresses the management of weight related to three phases of a woman’s reproductive years – precon­ception, during pregnancy and postpartum – for adult wom­en with obesity. Although these reproductive periods are addressed separately, it is important to consider that these phases represent the continuum of weight management over the reproductive years in women with obesity. During these time periods, women frequently access the healthcare system, thus providing clinicians with health promotion opportunities which may have positive impacts on the short- and long-term health of both the woman and her children. Discussion of the obstetric and anesthetic management for women with obesity during pregnancy is beyond the scope of this clinical practice guideline.

These recommendations pertain to the management of weight over the reproductive years for adult women with obesity (i.e., body mass index [BMI] ≥30 kg/m2) with a singleton pregnancy, who are ≥ 18 years of age and do not have pre-existing diabetes or gestational diabetes.

  1. General advice: We recommend primary care providers should discuss weight management targets specific to the reproductive years with adult women with obesity: precon­ception weight loss (Level 3, Grade C),1–4 gestational weight gain of 5 kg–9 kg over the entire pregnancy (Level 4, Grade D);5 postpartum weight loss of – at minimum – gestational weight gain (Level 3, Grade C)6,7 to reduce the risk of adverse outcomes in the current or in a future pregnancy.
  2. Combined behaviour change interventions: Primary care providers should offer behaviour change interventions, including both nutrition and physical activity, to adult women with obesity who are considering a pregnancy (Level 3, Grade C),7,8 who are pregnant (Level 2a, Grade B)915 and who are postpartum (Level 1a, Grade A)16 in order to achieve weight targets.
  3. Nutrition counselling alone: We recommend primary care providers encourage and support pregnant women with obesity to consume foods consistent with a healthy dietary pattern in order to meet their target gestational weight gain (Level 3, Grade C).17
  4. Physical activity counselling alone: We recommend pri­mary care providers encourage and support pregnant women with obesity who do not have contraindications to exercise during pregnancy to engage in at least 150 minutes per week of moderate intensity physical activity to assist in the manage­ment of gestational weight gain (Level 3, Grade C).1821
  5. Pharmacotherapy: Healthcare providers should not pre­scribe metformin for managing gestational weight gain in women with obesity (Level 1b, Grade A).22–24 We suggest no weight management medications during pregnancy or breast­feeding (Level 4, Grade D).25
  6. Breastfeeding: We recommend women with obesity be offered additional breastfeeding support due to decreased rates of initiation and continuation (Level 3, Grade C).26

The reproductive years, including before, during and after pregnancy, bring many additional challenges for women with obesity in maintaining a healthy weight beyond eating well and being physically active. It is important for women with obesity to seek advice and support from their healthcare pro­viders on strategies to optimize their own health outcomes, as well as those of their children, over both the short and long-term.

The strategies described in this chapter include:

  1. Entering pregnancy at a lower BMI;
  2. Targeting weight gain during the entire pregnancy to 5 kg– 9 kg; and
  3. Returning to at least the pre-pregnancy BMI in the year after delivery.

Preconception Period

Background

A woman’s preconception health status, particularly the control of pre-pregnancy medical co-morbidities, has been demonstrat­ed to markedly impact the maternal, obstetrical and fetal health outcomes during pregnancy.27,28 While many pregnancies are unplanned, a preconception consultation offers women consid­ering a pregnancy the opportunity to engage in discussions with their healthcare providers about their individualized health risks during pregnancy, and to make informed decisions. In addition, the preconception period is a time when interventions can be implemented to reduce the risks of common adverse pregnancy outcomes.27,28

As outlined in Table 1, for women with obesity who become pregnant, a BMI of ≥ 30 kg/m2 has been consistently associat­ed with the following: infertility,29,30 congenital malformations,31 and numerous clinically important adverse pregnancy outcomes (in a dose-response relationship by BMI) including hypertensive disorders of pregnancy, gestational diabetes, Caesarean delivery, preterm birth, etc.2,31–33 While there remains a paucity of data to specifically guide clinicians on how best to counsel women with obesity about these pregnancy-associated health risks, emerging data demonstrate that weight management prior to pregnancy may reduce many of the above risks.1 Discussion of specific nu­tritional supplementation (e.g., folic acid) and obstetrical care is beyond the scope of this clinical practice guideline.

Clinical strategies and resources to achieve preconception weight management for women with obesity

Combined behavioural interventions: There are few trials spe­cifically conducted in women with obesity planning a pregnancy. Agha et al.’s systematic review8 of randomized controlled trials (RCTs) in preconception women with overweight or obesity found that combined behavioural health interventions (i.e., nutrition and physical activity) were associated with significant reductions in gestational weight gain once pregnant. This is similar to the findings of Krukowski et al.7 who examined the effectiveness of a combined behavioural health intervention (combined nutrition and physical activity) beginning in the preconception period or up to 10 weeks’ gestational age. The study found that women with obesity in the intervention arm had reduced gestational weight gain at 36 weeks’ gestation. In addition, as outlined in the post­partum period section, the use of combined behaviour change in­terventions in the postpartum period was associated with greater postpartum weight loss, which may impact the health outcomes of future pregnancies.

Pharmacotherapy: At present, the fetal effects of several phar­macologic agents used for the purpose of weight management are not known. Therefore, in general, it is not recommended that these agents be used during pregnancy. Consideration should be given to stopping these medications prior to pregnancy to limit exposure to the developing fetus.25

Table 1: Associations between obesity, gestational weight gain and adverse clinical outcomes over thereproductive (preconception, antenatal, and postpartum) periods

Pregnancy/antenatal period

Background

Women with obesity have an increased risk of numerous adverse maternal, obstetrical and fetal outcomes during pregnancy, as outlined in Table 1. One promising strategy to reduce or prevent these adverse outcomes is through the achievement of the recom­mended guidelines for gestational weight gain during pregnancy (see below), though this remains an area of active study.

The current recommended guidelines for weight gain during pregnancy for uncomplicated singleton pregnancies were pub­lished by the Institute of Medicine (IOM) in 20095 and adopted by Health Canada in 201054 (Table 2). These recommendations were developed based on the findings of numerous observational studies. These studies consistently demonstrate that gestational weight gain above or below these recommended ranges is associ­ated with several important adverse clinical outcomes for women and their offspring including: birthweight, large for gestational age, small for gestational age, Caesarean delivery, preterm deliv­ery, postpartum maternal weight retention, and childhood obe­sity.51 However, the data on the association between gestational weight gain and small-for- gestational-age infants remain contra­dictory.40,43,50,51

Several factors influence gestational weight gain for women with obesity, including depression,55 health behaviours,56 patient ex­pectations and knowledge,57 educational attainment/socioeco­nomic status,58 maternal age, parity and ethnicity.59 Importantly, obesity prior to pregnancy is also an independent risk factor for excess gestational weight gain.60–63 Although there are no data specifically for women with obesity, there is evidence that advice from a prenatal healthcare provider is both desired by women64 and can positively influence gestational weight gain.65

Considerations for weight management during pregnancy for women with obesity

Women with a singleton pregnancy can expect to gain approxi­mately 8.5 kilograms during the course of a full-term pregnancy, regardless of the increase in their own adipose tissue mass, as a result of the following physiologic increases in weight: term baby (approximately 3 kg); the placenta; amniotic fluid; uterine muscle; increase in intravascular blood volume; and the increase in total body water volume. For women with obesity, this weight gain amount is just below the upper limit of the IOM/Health Canada recommendations for optimal gestational weight gain (5kg–9 kg throughout the entire pregnancy). As a result, weight management can be challenging for women with obesity, and should therefore be addressed at the first prenatal appointment and throughout pregnancy. An evidence-based point-of-care tool, The 5As of Healthy Pregnancy Weight Gain, is available to support primary care providers in discussing healthy pregnancy weight gain with women.66

Table 2: Gestational weight gain recommendations (Institute of Medicine, 2009)

Advice from prenatal healthcare providers positively influences women’s achievement of gestational weight gain targets.67–70 Further, pregnant women report that they want to discuss gesta­tional weight gain with their healthcare providers.71–73 Although Canadian data show that most healthcare providers reported rou­tinely weighing pregnant women, only a minority routinely dis­cussed the actual weight results.74,75 Weight-related discussions are often perceived by healthcare providers as sensitive in nature and are therefore often avoided.76–79 This hesitation in raising the topic could be mitigated to some extent by having a good pa­tient-provider relationship.80 Primary care providers have a lon­gitudinal relationship with their patients and are therefore in an advantageous position to be able to support women with obesity to achieve the recommended targets for gestational weight gain. A theoretical framework that is highly relevant to primary care clinicians is the Patient-Centred Clinical Method,81 comprised of four interactive domains:

  1. Exploring women’s experience of changes in weight during pregnancy;
  2. Understanding women’s proximal and distal contexts;
  3. Finding common ground on the best approach to support appropriate weight gain during pregnancy; and
  4. Enhancing the patient-clinician relationship.

From a patient-centred perspective, it is key to address the first two domains. Otherwise, the provider’s recommendations are of­ten neither meaningful nor able to be translated into patient be­haviour change. (See the Effective Psychological and Behavioural Interventions for People Living with Obesity chapter).

Clinical strategies and resources to achieve recommended gestational weight gain targets for women with obesity

Based upon the above, a number of interventions and models of care could be helpful to women with obesity during pregnancy, when approached from a patient-centred perspective.

Nutrition counselling: When implemented early in pregnancy, nutrition counselling can assist women with obesity in managing their pregnancy weight gain. Wolff et al.17 randomized pregnant women with obesity to either an intervention arm (n=23), con­sisting of 10 one-hour sessions with a trained dietitian, or usual care (n=27). The sessions focused on providing advice on eating a healthy diet according to Danish national dietary recommenda­tions, with the use of food records to identify unhealthy eating patterns and to give individualized feedback for improvement. At 36 weeks’ gestation, the mean gestational weight gain for the intervention group was 6.6 kg, compared to a mean gestational weight gain of 13.3 kg for the control group (p=0.002).

Physical activity: Physical activity (a term used synonymously with exercise in this chapter) during pregnancy has been shown to be beneficial to women with obesity in managing their preg­nancy weight gain (2019 Canadian Guideline for Physical Activity Throughout Pregnancy). Daly et al.20 compared total gestational weight gain at 36 weeks’ gestation between 88 pregnant women assigned to either an intervention consisting of intensive, medical­ly supervised exercise or to usual care. Fewer women in the exer­cise intervention group gained weight in excess of the guidelines compared to women in the control group (23.5% versus 45.2%; p<0.05). Barakat et al.19 compared total gestational weight gain between pregnant women randomized to an exercise intervention or to standard care as an analysis of a secondary outcome in a RCT. The intervention consisted of 50- to 55-minute training sessions (three days per week) from nine to 11 weeks’ gestation until 38 to 39 weeks’ gestation (85 sessions in total). Among women with obesity (n=54), 44.0% of women in the intervention group expe­rienced excess gestational weight gain compared with 51.7% of women in the control group. In a case-control study undertaken by Claesson et al.,21 the intervention consisted of motivational talks to assist with behaviour change and regular exercise (aqua aerobics). The intervention group experienced significantly lower weight gain than the control group (8.7 kg vs 11.3 kg; p<0.001).

Combined behavioural interventions: A comprehensive ap­proach targeting both nutrition and exercise has been shown to be effective in managing gestational weight gain. Vinter et al.13 randomized 360 women with obesity at 10 to 14 weeks’ ges­tation to a comprehensive lifestyle intervention or standard care (Lifestyle in Pregnancy Study: LiP). Women in the intervention group received four 30- to 60-minute diet counselling sessions delivered by trained dietitians and were encouraged to be mod­erately physically active for 30 to 60 minutes daily. At 35 weeks’ gestation, women in the intervention group had gained signifi­cantly less weight than women in the control group (7.4 kg versus 8.6 kg, p=0.014).

Petrella et al.14 randomized 38 women with obesity to a therapeu­tic lifestyle changes program consisting of 1800 kcal/day and 30 minutes of physical activity of moderate intensity on at least three days per week, or to usual care. At delivery, women in the inter­vention group experienced significantly lower gestational weight gain than women in the control group (6.7 kg versus 10.1 kg; p=0.047). In addition, 77.8% of women receiving the interven­tion experienced guideline-concordant gestational weight gain, compared with 30.0% of women in the control group (p=0.003).

Poston et al.10 randomly assigned 1,555 pregnant women with obesity who were between 15- and 18-weeks’ gestation to either a theory-based intensive behavioural intervention or to standard antenatal care (UK Pregnancies Better Eating and Activity Trial: UPBEAT). The intervention consisted of eight 60-minute weekly sessions addressing nutrition and physical activity by setting and achieving SMART goals. At delivery (mean gestational age 39.5 weeks for both groups), women in the intervention group had gained less weight than women in the control group (7.19 kg versus 7.76 kg, p=0.041).

Haby et al.11 conducted an RCT evaluating a prenatal lifestyle in­tervention compared to usual care for women with obesity, with gestational weight gain as one of the outcomes. The interven­tion group (n=459) received two 30-minute midwife-delivered personalized counselling sessions on food and physical activity during early pregnancy. Individualized dietary advice from a di­etitian, food discussion groups with a dietitian, aqua aerobics led by a physiotherapist, prescriptions for physical activity, walking poles, pedometers and information about community resourc­es were also available to the intervention group if desired. The control group (n=895) received usual care. Per-protocol analysis showed significantly lower gestational weight gain in the inter­vention group compared to the control group (8.9 kg vs 11.2 kg; p=0.031).

Renault et al.82 undertook an RCT with 425 women with obesity being assigned to one of three groups: physical activity plus diet, physical activity alone, or control. Both interventions resulted in less gestational weight gain than the control (p = 0.008). The me­dian gestational weight gain, compared with the control group (10.9 kg), was lower in both intervention groups: physical activity plus diet 8.6 kg (p=0.01), and physical activity alone group 9.4 kg (p=0.042).

Metformin: To date, RCT evidence for the use of metformin in the management of gestational weight gain for women with obesity who do not have diabetes is conflicting, and therefore metformin is not recommended. Although a Cochrane review by Dodd et al.83 of three studies of metformin (up to 3000 mg/day) in pregnant women with overweight or obesity found that women who received metformin may have a slightly lower gestational weight gain compared with placebo, the heterogeneity of the studies prevent­ed meaningful evaluations.

Healthcare provider behaviour: There are limited data specif­ically focused on pregnant women with obesity. Observational studies in the general population show that healthcare provider patient-centredness influences patients’ adherence to weight gain recommendations,84–86 patients’ perception of “finding common ground”,81 increased patient satisfaction and decreased burden of symptoms.87

In a qualitative Canadian study, Nikolopoulos et al. (2017)74 con­cluded that healthcare providers should initiate discussions about gestational weight gain in a patient-centred manner, specifically by “asking women how they feel about discussing weight”.

Lindberg et al.88 examined the weight outcomes before and after implementation of a ‘best practice alert’ in the electronic medical record, which provided tailored gestational weight gain goals and patient education materials based on patients’ pre-pregnancy BMI and the 2009 IOM guidelines for weight gain during pregnancy. Overall, the intervention was associated with a significant increase in the proportion of women with obesity who had guideline-con­cordant gestational weight gain.

Surveys of healthcare providers identified the following gaps requiring additional clinical support: increasing healthcare pro­vider knowledge, improving skills and self-efficacy in discussing gestational weight gain and supporting women to make positive health behaviour changes in pregnancy.74 System-related chang­es identified included flexibility in the time available for perinatal health appointments and changes in billing requirements. To ad­dress similar clinical gaps for healthcare providers in discussing weight gain in pregnancy, Alberta Health Services developed and evaluated an evidence-based, accredited online continuing med­ical education module which includes information about assess­ing, discussing and supporting healthy gestational weight gain in pregnant women. Interactive activities, self-testing and case scenarios help build capacity and provide opportunity to practice gained skills and knowledge. The module is available at https:// ecme.ucalgary.ca/programs/hpwg.

Routine weighing: To date, RCTs of routine weighing of preg­nant women during antenatal visits have not found routine weighing to be associated with significant impacts on gestational weight gain. First, a trial by Brownfoot et al.89 of an interven­tion (regular weighing in antenatal clinics) compared with control (routine care) on gestational weight gain found no difference in the proportion of participants whose gestational weight gain was above, within or below the IOM recommended ranges among women with obesity. Second, McCarthy et al.90 randomized 382 women with overweight or obesity and a singleton pregnancy, at less than 20 weeks’ gestation and without diabetes to serial self-weighing and simple dietary advice (intervention n=190) or standard prenatal care (control n=192). There was no difference in gestational weight gain, for women with obesity, between the intervention and control groups (7.40 kg versus 8.77 kg).

Postpartum period

Background

The postpartum period is recognized to begin immediately fol­lowing the birth of a baby, though its duration is not well defined. While many of the physiologic changes of pregnancy resolve by six weeks postpartum,91–93 several physiologic and psychological changes continue to exist for over a year postpartum, particularly if women continue to breastfeed.52 Thus, a period of one year after giving birth is generally considered as the working definition of the postpartum period.52

A wide range of diverse and complex factors influence mater­nal weight after pregnancy. Higher gestational weight gain is recognized as a major risk factor for postpartum weight reten­tion.12,47–49 The evidence is mixed with regard to the association between pre-pregnancy weight and postpartum weight reten­tion, as several48,94–97 but not all98–100 studies have demonstrated that having a higher pre-pregnancy BMI is associated with higher postpartum weight retention. Other factors, such as sleep pat­terns,101 psychological factors (e.g., depression, anxiety and stress symptoms),102–105 and maternal characteristics including age,48,106 ethnicity,48,99,107 parity,98,108 socioeconomic status,48,106,109 and ed­ucational attainment48,109 are associated with postpartum weight retention.

The findings that weight gain during pregnancy and the poten­tial lack of, or limited, weight loss after pregnancy increases the risk of longer-term obesity or the risk moving into a higher BMI category are consistent across studies and worldwide. Wallace and colleagues32 for example, examined inter-pregnancy weight change using data from the Aberdeen Maternity and Neonatal Databank and identified that 86% of women who were initially categorized in the obesity BMI categories gained a further 9 kg by their third pregnancy. In Ireland, Mullaney53 investigated the trajectory of postpartum weight change and found that 90% of women with obesity in early pregnancy retained obesity at four and nine months postpartum. In a prospective cohort study of Ca­nadian women,91 BMI increased by approximately 1.5 kg/m2 from pre-pregnancy to 10 to 12 weeks postpartum across all pre-preg­nancy BMI categories. A population-based study of 58,534 Ca­nadians who experienced successive pregnancies110 demonstrated that approximately 25% of women were ≥5 kg heavier at the beginning of a subsequent pregnancy, ~9% were heavier by 10 kg or more, and approximately 2% of women developed obesity after starting the previous pregnancy with a lower BMI. Retaining or gaining weight following pregnancy may also be associated with adverse pregnancy outcomes in future pregnancies. These adverse outcomes are described in the pre-conception and ante­natal sections and in Table 1.

Many of the pregnancy-related contributors to gestational weight gain, such as fluid gained during pregnancy and increased organ size (e.g. of the uterus), are lost in the first six weeks postpar­tum. After this period, postpartum weight retention is mainly due to increased fat mass.91 Despite the adverse long-term health impact of postpartum weight retention, no detailed guidelines have been established to define cut-points for excess postpartum weight retention.111 The dietary reference intakes established by the IOM (2005) 112 recommend a weight loss of approximately 0.8 kg/month in the first six months postpartum, but this amount of weight loss is not specifically for women with obesity. These guidelines are based on a review by Butte and Hopkinson (1998) of nine longitudinal studies conducted with affluent postpartum women, which showed that well-nourished women experience an average weight loss of 0.8 kg/month in the first six months postpartum. Weight stability is assumed after this period,113 and there is no consensus about the amounts or timelines for contin­ued weight loss after the first six months postpartum.

For women who entered pregnancy with obesity, a postpartum weight loss of at least the amount gained during gestation should be achieved to not increase the risk of adverse pregnancy out­comes in future pregnancy.6,114 Sorbey and colleagues6 demon­strated that postpartum weight loss by more than two BMI units protects against the development of gestational diabetes in future pregnancies among women with obesity. Postpartum weight gain increases the risk of gestational diabetes in the next pregnancy. McBain et al.114 also found that women in the overweight/obesity BMI categories were more likely to remain in the same BMI cate­gory in the next pregnancy.

Notably, evidence shows that women want an opportunity to dis­cuss postpartum weight loss with their healthcare providers, and suggests that it should be a part of standard care.73 This discussion could take place either during the six-week postnatal check-up or even during pregnancy in order for women to have the oppor­tunity to start thinking about postpartum weight loss early on.73 According to Ohlendorf (2012),115 67% of postpartum women are attempting behavioural interventions or maintaining healthy behaviour at four weeks postpartum, and 84% at eight weeks postpartum. Most (82%) postpartum women with obesity report­ed that they planned to seek information about losing pregnancy weight through their physicians and midwifes, as well as media.116

Clinical strategies and resources to achieve postpartum weight management for women with obesity

Considering the above evidence, the following clinical interventions should be considered to assist with weight management of post­partum women with obesity:

Physical activity and motivational interviewing: Physical ac­tivity and motivational interviewing during pregnancy have been shown to be beneficial to women with obesity in managing their postpartum weight loss. Claesson et al.21 undertook a study in­volving pregnant women with obesity who participated in a pro­gram to limit gestational weight gain by including regular physical activity (aqua aerobics class) and using motivational interviewing to identify and plan for individual behaviour change. Study par­ticipants had a significantly lower body weight at 10 to 12 weeks postpartum compared wiwth controls (mean with standard de­viation) (93.2 [13.32] kg versus 96.5 [14.48] kg; p=0.037). The intervention was delivered weekly during pregnancy and every six months during the two first years after childbirth. The effects of the intervention were assessed 12 and 24 months later.117 The mean weight change in the intervention group was -2.2 kg com­pared to +0.4 kg in the control group from early pregnancy to the follow-up 12 months after childbirth (p=0.046). More women in the intervention group showed sustained weight loss 24 months after delivery than women in the control group over the same time period (p=0.034). Women with obesity in the intervention group who gained less than 7 kg during pregnancy had a signifi­cantly lower weight than the controls at the 24-month follow-up (p=0.018).

Combined behavioural intervention: A comprehensive ap­proach targeting both nutrition and exercise has been shown to be beneficial for women with obesity in managing postpartum weight loss. Vesco and colleagues12 randomly assigned 114 preg­nant women with obesity to either a group-based intervention or to a usual care control group to test the effectiveness of the inter­vention on maternal weight change from randomization to two weeks postpartum. The intervention program included a combi­nation of dietary and exercise recommendations, as well as the use of behavioural self-management techniques and attendance at weekly group meetings until delivery. Control participants re­ceived one-time dietary advice. The intervention group lost more weight at two weeks postpartum compared to control group (-2.6 vs +1.2 kg, mean difference of -3.8 kg; 95% CI [-5.9-1.7]; p<0.001). However, the maternal weight-related benefits of this intervention did not persist at one year postpartum.118

Nascimento et al.16 conducted a systematic review and meta-anal­ysis to test the effect of physical exercise strategies on weight loss in postpartum women with overweight or obesity (i.e., BMI ≥ 25 kg/m2). Though the results were not separated for wom­en with BMI ≥ 25 kg/m2, combined physical activity (with clear targets) and nutrition had greatest impacts on weight loss mean difference of -4.34 kg [95% CI -5.15 to -3.52, I 2 = 0%] across all included studies.

Breastfeeding: Breastfeeding has been shown to improve a range of maternal and infant health outcomes, though the im­pacts on postpartum weight retention remain under study.31 How­ever, studies have demonstrated that women with obesity have additional challenges with breastfeeding requiring individualized support.31 Specifically, a prospective cohort study26 of 4231 post­partum women who were enrolled at the time of birth of their babies and were followed-up at three, 12, 24 and 48 months postpartum evaluated breastfeeding. Information was gathered on breastfeeding patterns and showed that the median duration of exclusive and total breastfeeding was decreased in the obesity group compared with the group with lower weight. Also, women with obesity have an increased probability of weaning their babies by three months postpartum compared with women with lower weight. Therefore, women with obesity are less likely to initiate and maintain breastfeeding26,119,120 compared with their counter­parts with lower weight, and they may require additional supports on establishing and continuing breastfeeding.26 Of note, the safe­ty of pharmacotherapy agents for weight maintenance has not yet been established during breastfeeding; therefore these agents are generally avoided.25

Gaps in the literature/future research for women with obesi­ty over the reproductive years

  1. Health outcomes in women with obesity (BMI ≥ 30 kg/m2): There remains a paucity of data specific to women with obesi­ty (BMI ≥ 30 kg/m2), as many studies aggregate women with pre-pregnancy BMI ≥ 25 kg/m2 into a single group for analysis for studies over the three reproductive periods. This is an important distinction, as women with a pre-pregnancy BMI ≥ 30 kg/m2 may have different trajectories of gestational weight gain than those whose BMI is 25–29.9 kg/m2.121,122
  2. Preconception weight management: There are emerging intervention studies on weight management preconception for women with obesity to improve fertility and obstetric outcomes. More data are needed, however, to examine how to implement these interventions into clinical practice to engage a broader range of women with obesity and their healthcare providers.
  3. Preconception counselling on pregnancy risks: Numerous observational studies have demonstrated that women with obe­sity have increased risks of several adverse pregnancy outcomes. Research is needed to identify effective counselling strategies to discuss pregnancy risks using a patient-centred approach.
  4. Classes of obesity: The current IOM/Health Canada recom­mendations for gestational weight gain for women with obesity were not stratified by obesity classes, which may be associated with different obstetrical risks.50 There remains a paucity of data regarding the impact of low weight gain or weight loss during pregnancy among women with different classes of obesity.123
  5. Low weight gain or weight loss during pregnancy: While healthcare providers commonly recommended gestational weight gain below guidelines for women with obesity, this advice is not consistent with the current recommendations. Research is needed to examine both the clinical outcomes and healthcare providers’ reasons for providing this advice.124
  6. Patient-provider relationship: The impacts of the relation­ship between healthcare providers and their patients on gesta­tional weight gain has not been extensively examined. Compared with women with lower weight, data demonstrate that providers asked fewer lifestyle questions and gave less lifestyle information to women with overweight and obesity. Point-of-care tools de­veloped based on principles of patient-centredness and pregnant women’s self-efficacy to manage gestational weight gain may be simple clinical tools, though these require further study.122
  7. Duration of pregnancy: The current recommendations for total gestational weight gain pertain to term pregnancies, typi­cally defined as 37 to 41 completed weeks’ gestation. However, evidence suggests that this group does not have homogeneous fetal outcomes.125,126 Future research needs to separate the inde­pendent effects of gestational weight gain from the independent effects of gestational age during this five-week period.
  8. Postpartum weight management: In general, there remains a paucity of specific literature to guide women with obesity and their healthcare providers on the optimal timing, rate and amount of weight loss in the postpartum period and the impacts on clin­ically important health outcomes. In addition, more research is needed to examine factors that motivate and support women with obesity to engage in and maintain weight management strategies in the postpartum period.116
Helena Piccinini-Vallis MD PhDi, Kristi Adamo PhDii, Rhonda Bell PhDiii, Leticia Pereira PhDiv, Kara Nerenberg MDv

i) Department of Family Medicine, Dalhousie University

ii) Faculty of Health Science, University of Ottawa

iii) Division of Human Nutrition, University of Alberta

iv) Department of Agricultural, Food and Nutritional Sciences, University of Alberta

v) Department of Medicine, University of Calgary; Foothills Medical Centre

A complete list of author’s competing interests can be found on the CMAJ website, HERE

Cite this Chapter

Piccinini-Vallis H., Adamo K, Bell R, Pereira L, Nerenberg K. Canadian Adult Obesity Clinical Practice Guidelines: Weight Management Over the Reproductive Years for Adult Women Living with Obesity. Available from: https://obesitycanada.ca/guidelines/reproductive. Accessed [date].

Update History

Version 1, August 4, 2020. The Canadian Adult Obesity Clinical Practice Guidelines are a living document, with only the latest chapters posted at obesitycanada.ca/guidelines.

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). For reprint and all other inquiries please contact guidelines@obesitynetwork.ca / +1-(780)-492-8361.

The summary of the Canadian Adult Obesity Clinical Practice Guidelines is published in the Canadian Medical Association Journal, and contains information on the full methodology, management of authors’ competing interests, a brief overview of all recommendations and other details. More detailed guideline chapters are published on the Obesity Canada website at www.obesitycanada.ca/guidelines.

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