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Antenatal interventions for reducing weight in obese women
for improving pregnancy outcome (Review)
Furber CM, McGowan L, Bower P, Kontopantelis E, Quenby S, Lavender T
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 1
http://www.thecochranelibrary.com
Antenatal interventions for reducing weight in obese women for improving pregnancy outcome (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .27INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Authors’ conclusions
There are no trials designed to reduce weight in obese pregnant women. Until the safety of weight loss in obese pregnant women
can be established, there can be no practice recommendations for these women to intentionally lose weight during the pregnancy
period. Further study is required to explore the potential benefits, or harm, of weight loss in pregnancy when obese before weight loss
interventions in pregnancy can be designed. Qualitative research is also required to explore dietary habits of obese pregnant women,
especially those who are morbidly obese.
P L A I N L A N G U A G E S U M M A R Y
Trials of interventions for pregnant women who are obese to lose weight and improve pregnancy outcomes.
Pregnant women who are obese risk serious complications for themselves and their children. The mother is more likely to develop
diabetes or high blood pressure or pre-eclampsia during pregnancy, and the pregnancy may end in a miscarriage or stillbirth. The baby
could have serious anomalies at birth, including spina bifida, cardiovascular anomalies, cleft lip and palate, or limb reduction anomalies.
Some obese women have premature births. At birth, the labour may be longer and other complications can lead to a caesarean birth.
The baby may also be bigger at birth than is normal, and there is evidence that the children of obese mothers go on to be obese. The
advice for obese women in managing their weight during pregnancy is that weight loss should be avoided, and weight gain should bebetween 5.0 and 9.1 kg. Yet observational studies of large numbers of pregnant women indicate that some obese women, especially
those who are heavier, lose weight during pregnancy. We do not have any clear results that indicate that losing weight when pregnant
is safe for a mother who is obese, or for her baby. This Cochrane review aimed to evaluate trials that were designed for obese pregnant
women to lose weight. No randomised controlled trials were found. We recommend that further research is conducted to evaluate the
safety of interventions for weight loss when a woman is pregnant and obese for the mother and her baby.
B A C K G R O U N D
Description of the condition
Obesity is defined as ’abnormal or excessive fat accumulation that
mayimpairhealth’( World HealthOrganization 2006). Thepreva-
lence of obesity is now at epidemic proportions, and is one of the
most important challenges of the 21st century.
Body mass index (BMI) is commonly used to measure an in-
dividual’s weight in relation to their height. It is expressed as
body weight (kg) divided by the square of height (m²). A cal-
culation of 18.5 to 24.9 (kg/m²) is desirable (normal weight),
whereas 25 to 29.9 (kg/m²) is ’overweight’, 30 (kg/m²) or above is
’obese’ (Zaninotto2006). The World Health Organization( WorldHealth Organization 2000) has further classified obesity as:
• BMI 30 to 34.9 (kg/m²) - class I obesity;
• BMI 35.0 to 39.9 (kg/m²) - class II or severe obesity;
• BMI 40 (kg/m²) and above - class III or morbid obesity.
The risks related to being obese at the start of pregnancy are sub-
stantial, and may involve the pregnancy, birth, and later life for
both the woman and her infant.
Risks in pregnancy for obese women
Compared to normal-weight women, obese women are more at
risk of pregnancies affected by congenital anomalies, including
spina bifida, cardiovascular anomalies, cleft lip and palate, and
limb reduction anomalies (Rankin 2010; Stothard 2009). Still-
birth is also more common (Chu 2007; Flenady 2011; Ovesen
2011) and there is a possibility that miscarriage is more likely
in obese women (Metwally 2008). Several studies suggest that
gestational diabetes, hypertension, and pre-eclampsia/eclampsia
are common pregnancy complications when obese (Baeton 2001;
Doherty 2006; Ovesen 2011; Sebire 2001). Also, around one-fifth
of women who are obese at the start of the pregnancy give birth to
large (macrosomic) babies (defined as greater than 4000 g or larger
than 90th
centile) (Baeton 2001; Sebire 2001; Zhang 2007).
Risks during birth for obese women
The pregnancies of obese women are longer, and prolonged ges-
tation may lead to complications at birth. Data from the Dan-
ish Birth cohort from 1996 to 2004 indicate that post-term birth
(pregnancy length longer than 294 days) is correlated with higher
pre-pregnancy BMI Oleson 2006. In clinical practice, prolonged
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pregnancies are more likely to be induced (Doherty 2008), and
inductions may be unsuccessful when obese (Kerrigan 2009).
Caesarean births are more frequent in women who are obese.
Heslehurst 2008 carried out a systematic review of the impact of
BMI on pregnancy outcomes. The results indicate significantly
reduced odds for vaginal birth when overweight, and obese. Theseresults are corroborated with the analysis of Danish births from
2004 to 2010 as those obese, andmorbidly obese, were more likely
to give birth by planned or emergency caesarean section (Ovesen
2011). Operative birth assistance is needed more often for delays
in labour when obese and compared with normal-weight women
(Kerrigan 2009; Zhang2007). Fetaldistressin labourhas also been
reported as morelikely, anda reason for emergencycaesarean birth,
in this group of women (Doherty 2006). In addition, caesarean
births maynot alwaysbe straightforward as complications of failed
epidural and spinal anaesthesia are more common in those who
are morbidly obese (Knight 2010).
Risks after birth for obese women
Complications after birth are more likely for obese women. An
increase in the incidence of postpartum haemorrhage and infec-
tions (including wound, urinary tract, perineum, chest and breast)
have been reported in obese women,when compared with normal-
weight women (Heslehurst 2008). Furthermore, excessive weight
gained during pregnancy in women who are already obese is likely
to be retained after the birth Rooney 2005, and may lead to health
complications such as diabetes andheart disease in later life (Linne
2003).
Risks to the neonate when the mother is obese
The neonates of obese women are at increased risk of increased
morbidity and mortality compared with babies born to normal-
weight women. Preterm birth is also more likely, and the time
to commence spontaneous respiration immediately after birth is
longer, more resuscitation is required, and there is more risk of
neonatal hypoglycaemia, in babies of obese women (Heslehurst
2008). Furthermore, the children of mothers who are obese at the
start of their pregnancy are likely to be overweight at the age of
three years (Olson 2009). A population-based case-control cohort
study of children aged between two and five years diagnosed with
autism spectrum disorder and developmental delays in California
2003 to 2010 indicates that maternal obesity in pregnancy may
be a risk factor for developmental delays in later life (Krakowiak
2012). Heavier women (those morbidly obese) are also more likely
to have increased risks of poor outcomes for the infant across the
childbearing continuum (Knight 2010).
Weight management for obese women in pregnancy
There is little robust evidence about optimal weight management
in pregnancy for obese women. Pregnancy weight varies between
individual women (Carmichael 1997), isnot linear(Dawes 1991),
and is related to variables such as maternal age, pre-pregnancy
body size, parity, smoking, ethnicity, hypertension, and diabetes
( Abrams 1995; Chu 2009).
Guidance on weight gain in pregnancy across all maternal weights
is contentious. Over the last 20 years, guidance for clinical staff on weight management in pregnancy has been based on recom-
mendations from the US Institute of Medicine (Medicine 1990).
These guidelines have been controversial as they were based on
research studies that lacked sufficient rigour to be scientifically
sound. These guidelines were based on population-based obser-
vational studies ( Johnson 1995), and studies that did not account
for other confounding variables (Feig 1998). In 2009, the US In-
stitute of Medicine Guidelines were revised, and the new guid-
ance based on a wider review of maternal and fetal outcomes (fe-
tal size, risk of unplanned caesarean birth, and excessive postpar-
tum weight retention) (Rasmussen 2009a ). Early guidance recom-
mended that obese pregnant women should gain a minimum of 7
kg (Medicine 1990), but in 2009, it was recommended that obesepregnant women should limit their weight gain to between 5.0 kg
and 9.1 kg (Rasmussen 2009b).
Weight loss in obese women in pregnancy
Several observational studies suggest that some obese pregnant
women gain minimal weight in pregnancy, and even lose weight.
A retrospective review of pregnancy outcomes in the US found
that 11% of obese women lost weight, or maintained their weight,
compared to 0.1% of normal-weight women (Edwards 1996).
Bianco 1998 reviewed the outcomes of pregnant women with a
BMI greater than 35 and found that 9% lost weight, or gained no
weight, compared to 0.2% of normal-weight women. Two morerecent studies show similar results. Data from 136,802 women
giving birth to singleton fetuses between 1996 and 2001 across
21 states in the US indicated that low weight gain (less than 0.12
kg/wk) was more common in those obese (8.3%, n = 1315) and
morbidly obese (19%, n = 1287),than those normalweight (1.9%,
n = 1780) (Dietz 2006). Rode 2007 analysed data from 2248
Danish women of all weights at 37 weeks of gestation and found
that 9.7% (n = 15) of obese women (n = 155) gained less than
1 kg at this stage of their pregnancy. Another study reviewing
gestational weight gain and the riskof adverse pregnancy outcomes
reported that 12 of 328 obese women in the total sample of 2011
women lost weight, compared to only one woman in each of the
normal weight (n = 1227) and overweight (n = 456) groups (Oken
2009), although these differences were not significant.
More recently, published studies exploring gestational weight gain
suggest that incidence of weight loss in pregnancy increases as
women’s weight increases; Bodnar 2010, Hinkle 2010, Beyerlein
2011 and Blomberg 2011 found that weight loss in pregnancy was
more likely in morbidly obese women.
Itis importantto note that some women deliberatelylose weightin
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pregnancy. Bish 2009 and Cohen 2009 both reported around 8%
of pregnant women of all weights attempting to lose weight using
strategies such as limiting calories and fat intake, and increasing
exercise. When their data were analysed according to BMI cate-
gory, the proportions increased to almost 13% of obese women
attempting weight loss in pregnancy (Bish 2009; Cohen 2009).
Risks associated with weight loss in obese women
during pregnancy
The current evidence related to weight loss and obstetric and
neonatal outcomes in all pregnant women is limited.
Maternal dieting and restricting food intake in the first trimester
of pregnancy may be associated with increased risk of the fetus
developing a neural tube defect (Carmichael 2003). Prolonged pe-
riods of fasting (greater than 13 hours) and not eating are also
linked to preterm birth and increased maternal corticotropin-re-
leasing hormone concentrations (Herrmann 2001). Furthermore,
extreme weight loss (greater than 15% of pre-pregnancy weight)in pregnant women suffering from hyperemesis gravidarum is as-
sociated with hospitalisation and the need for parenteral nutrition
(Fejzo 2009). These women suffered symptoms including gall-
bladder and liver dysfunction, renal failure and retinal haemor-
rhage (Fejzo 2009).
Low maternal weight gain and weight loss in pregnancy have been
associated with restrictions in fetal growth. Important evidence
is available from Holland during the winter of 1944/1945, when
food was severely limited because of a harsh winter and an em-
bargo on food transportation. Many pregnant women at the time
had food intakes of less than 1000 kcal/daily for a period of seven
months. Analysis of birth records from this period in the west-
ern Netherlands indicate that birthweight, crown-heel length, andhead circumference decreased after exposure to famine in the third
trimester (Stein 2004). An analysis of maternal weight in preg-
nancy from women based in Amsterdam who gave birth between
August 1944 and April 1946 enabled comparisons of birth param-
eters immediately before famine, during food restriction, and after
liberation. Maternal weight loss and weight gain below 0.5 kg/
week were associated with reduced birthweight, length and pon-
deral indices (Stein 1995).
Some studies associate maternal weight loss with risks of preterm
birth, small-for-gestational-age infants, and some neonatal com-
plications. Edwards 1996 found that obese women who lost
weight, or gained nothing in pregnancy, were significantly more
likely to give birth to smaller infants with birthweight less than
3000 g and be small-for-gestational age compared with obese
women who gained pregnancy weight within 1990 guidelines
(Medicine 1990). Furthermore, a systematic review suggested that
restricting protein/energy intake in overweight pregnant women,
or women who were gaining weight excessively, may harm the fe-
tus (Kramer 2003). Dewey 1994 proposed that low energy intakes
in pregnancy may result in ketosis that can affect the fetus.
Other studies indicate that weight loss or gaining no weight when
obese may be beneficial. Bianco 1998 found that the incidence
of low birthweight and small-for-gestational-age births were not
increased in women with BMI greater than 35 who either lost
weight, or gained nothing, during pregnancy.
Emerging evidence from retrospective cohort studies suggests that weight loss in pregnancy for obese women may have substantial
benefitsforboththemotherandinfant.Oken 2009 reviewed 2011
mother-child pairs in the US against five adverse outcomes related
to gestational weight gain: preterm birth, small-for-gestational-
age infant, large-for-gestational-age infant, substantial maternal
postpartum weight retention, and child obesity at age of three
years. The results indicated that the lowest predicted prevalence
of all five adverse outcomes occurred with a weight loss of 0.19
kg/week for obese women, which equates to a total loss of 7.6
kg for obese women over all of the pregnancy ( Oken 2009).
Beyerlein 2011 reviewed 709,575 births in Bavaria from 2000 to
2007 and stratified the data according to BMI category. Small
weight losses of up to 5 kg were associated with lower risks forpre-eclampsia in obese class II women and non-elective caesarean
section in obese class 1 women (Beyerlein 2011). Less large-for-
gestational-age births were also reported for obese class I women,
but an increase in small-for-gestational-age births was also noted
with weight loss for this category of obesity (Beyerlein 2011).
For women obese class III, no increase in neonatal morbidity or
mortality was observed (Beyerlein 2011).
Blomberg 2011 followed up 46,595 obese women from the
Swedish Medical Birth Registry. The data werestratified according
to obesity classes I, II and III and compared with the latest Insti-
tute of Medicine Guidelines (Rasmussen 2009b). The Blomberg
2011 analysis indicates that all obese women who lose weight in
pregnancy appear to have less risk of caesarean birth and deliver-ing large-for-gestational-age infants, and no significantly increased
risk of developing pre-eclampsia, and other complications associ-
ated with birth and for the infant normally associated with obesity
when compared with weight gains of 5.0 to 9.0 kg. The overall
incidence of large for gestational age infants was 13.2% in obese
women II and III who gained within the current recommenda-
tions for their weight (Rasmussen 2009b), and reduced to 8.8%
if weight was lost (Blomberg 2011).
For heavier women (BMI greater than 40), weight loss in preg-
nancy appears to be more advantageous. In an exploration of the
outcomes of 120,251 pregnant obese women who delivered full-
term live singleton infants where the risks of pre-eclampsia, cae-
sarean birth, small-for-gestation infants and large-for-gestation in-fants were assessed, the results indicated that a weight loss of up to
9 lbs (4kgs) may have minimal risks for women with BMI greater
than 40 (Kiel 2007). The Hinkle 2010 review also indicates that
women with BMI greater than 40 who lose weight during preg-
nancy havebetter outcomes.The lowest absoluteriskof developing
pre-eclampsia, caesarean birth, and infant size being either small-
for-gestational age or large-for-gestational age for these women
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was after a weight loss of zero to 4.1 kg (Hinkle 2010).
Clinical management of pregnancy weight in obese
women
Ideally, women with BMI greater than 30 kg/m² should plan tolose weight before conception according to the National Institute
of Health and Clinical Excellence (NICE) (NICE 2010). In the
UK, NICE 2010 recommends that pregnant women identified as
obese at initial antenatal appointments should be advised about
the potential risks of losing weight whilst pregnant, and provided
with information and support about appropriate diet and exer-
cise. NICE 2010 guidance discourages dieting when pregnant and
obese.
Description of the intervention
There are many interventions that aim to facilitate weight loss in
the non-pregnant population. These interventions areoftenmulti-
component, combining one or more techniques. Health profes-
sionals and/or personnel with a range of training and experience
deliver the interventions.
Interventions used to reduce weight in non-pregnant populations
are defined in this review to provide background information to
the types of interventions that potentially could be used in future
randomised controlled trials designed to reduce weight in obese
pregnantwomen, if sufficientevidenceis providedin observational
studies to support the safety of interventions. Interventions in the
non-pregnant population may include lifestyle interventions that
use techniques such as ’information giving’ related to lifestyle, for
example, nutrition (calorie restriction and eating behaviour mod-
ification) and exercise behaviour modification such as increasing
walking (Blackburn 2010). The delivery of information is vari-
able entailing use of written material, internet, telephone con-
tact and/or mail-based, and group-based or individualised con-
tact (Schroder 2010; Stuart 2005; Witham 2010). Psychological
interventions may also be used. These include techniques that
aim to facilitate behaviour change such as self-help, peer support,
counselling, cognitive behavioural therapy, problem-solving ther-
apy, goal setting, motivational interview techniques, and thera-
pist contact (Pollak 2010; Warziski 2009). Complementary thera-
pies such as acupressure and meditation may also be incorporated
into relevant interventions (Elder 2010; Spadaro 2008). In non-
pregnant populations pharmacological agents such as Metformin,
Sibutramine and Orlistat can be used to reduce weight (Cannon
2009; Warziski 2009), and bariatric procedures such as gastric by-
pass surgery and laparascopic adjustable banding (Richens 2010)
are also utilised in non-pregnant individuals.
Why it is important to do this review
There are currently no evidence-based guidelines for clinical staff
and women related to weight management when obese and preg-
nant. Recent recommendations from NICE in the UK state that
obese women should not diet and deliberately lose weight when
pregnant because of risk of harm to the unborn child (NICE
2010). Furthermore, a Cochrane review has indicated that there isa paucity of evidence to recommend interventions aimed at con-
trolling excessive weight gain in pregnancy (Muktabhant 2012).
However, the risks of obesity, to both the mother and infant, are
substantial when pregnant.
Some obese women lose weight when pregnant (Bianco 1998;
Bish 2009; Cohen 2009; Dietz 2006; Edwards 1996; Oken 2009),
and especially those who are heaviest (Hinkle 2010). There is
insufficient evidence of the known benefits of weight loss when
obese and pregnant, or the harm that may occur to the unborn
baby.
Deliberate attempts to lose weight are common among the non-
pregnant reproductive-aged population (Bish 2005). It is possible
therefore that some women may be dieting to lose weight aroundthe time of conception, and for the weeks prior to pregnancy
being confirmed (Cohen 2009). Furthermore, for some women
pregnancy is an opportunity to evaluate their lifestyle, and many
adjust their diet to eat more healthily for the sake of the child
(Gross 2007). Eating healthier when obese may result in weight
loss. There is a possibility that some obese women maynot disclose
their attempts at weightloss when pregnant because theyare aware
that it is socially unacceptable (Cohen 2009).
As it is clearly apparent that some obese women deliberately try to
lose weight in pregnancy (Bish 2009; Cohen 2009), the maternal
and neonatal outcomes of weight loss in pregnancy when obese
need to be established.
If weight loss in obese pregnant women is beneficial, maternaland infant outcomes may be improved. Postnatal weight retention
will be limited and this may lead to greater control over weight
management in this group in the future. This may improve health
outcomes of future pregnancies. If weightloss is beneficial to obese
pregnantwomen, the development of feasible and acceptable inter-
ventions designed to facilitate weight loss may result in decreased
costs to health services. Furthermore, interventions designed to
reduce weight in obese pregnant women should be investigated to
explore their effectiveness in achieving their aim.
If weight loss is harmful for the obese pregnant woman, the effects
should be identified so that appropriate information and advice
can be developed.
O B J E C T I V E S
To evaluate the effectiveness of interventions that reduce weight
in obese pregnant women.
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M E T H O D S
Criteria for considering studies for this review
Types of studies
We considered all published and unpublished randomised and
quasi-randomised controlled trials, comparing a weight loss inter-
vention with routine care or more than one weight loss interven-
tion. We considered cluster-randomised trials.
Types of participants
Obese pregnant women with a BMI equal to, or greater than 30
(kg/²m).
Types of interventions
All interventions that aim to reduce weight in pregnant women
who are obese such as eating and exercise behaviour modification,
or counselling.
Interventions in any setting.
Studies where the intervention is introduced in pregnancy.
We intended to undertake the following comparisons:
• one intervention versus no intervention;
• one intervention versus another intervention.
Types of outcome measures
Primary outcomes
1. Serious maternal morbidity (admission to high dependency
care) and/or death.
2. Neonatal admission to neonatal intensive care.
3. Perinatal death (including stillbirth).
Secondary outcomes
Maternal outcomes
1. Gestational diabetes.
2. Fetal distress in pregnancy or labour.
3. Postpartum haemorrhage.
4. Caesarean birth.
5. Infection (including wound, urinary tract, perineum, chest
and breast).
6. Weight (loss/gain/no change).
Neonatal outcomes
1. Birthweight less than 2500 g and less than the 10th centile
for gestational age and sex.
2. Birth weight greater than 4000 g or larger than the 90th
centile for gestational age and sex.
3. Preterm birth (birth less than 37 completed weeks of pregnancy).
4. Apgar scores less than seven at five minutes.
5. Hypoglycaemia - as defined by trialists.
Long-term outcomes
1. Maternal weight postpartum.
2. Childhood weight.
Search methods for identification of studies
Electronic searches
We contacted the Trials Search Co-ordinator to search the
Cochrane Pregnancy and Childbirth Group’s Trials Register (31
July 2012).
The Cochrane Pregnancy and Childbirth Group’s Trials Register
is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. monthly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. weekly searches of EMBASE;
4. handsearches of 30 journals and the proceedings of major
conferences;
5. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL, MEDLINE and
EMBASE, the list of handsearched journals and conference pro-
ceedings, and the list of journals reviewed via the current aware-
ness service can be found in the ‘Specialized Register’ section
within the editorial information about the Cochrane Pregnancy
and Childbirth Group.
Trials identified through the searching activities described above
are each assigned to a review topic (or topics). The Trials Search
Co-ordinator searches the register for each review using the topic
list rather than keywords.
Searching other resources
We did not apply any date restrictions.
We did not apply any language restrictions.
We included abstracts because data and details were limited.
We contacted the authors of studies to obtain further information,
where relevant.
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We used our professional contacts to seek further trial data.
Data collection and analysis
Selection of studies
Threereview authors (Christine Furber, Tina Lavender, and Linda
McGowan) independently assessed for inclusion each study that
was identified through the search strategy. We resolved any dis-
agreement through discussion.
In this version of the review we did not identify any studies for
inclusion. In updates of the review if we do identify trials which
meet our inclusion criteria we will use the methods set out in
Appendix 1 to carry out data extraction, assess bias in included
studies and analyse findings.
R E S U L T S
Description of studies
See: Characteristics of excluded studies.
See Characteristics of excluded studies.The search of the Cochrane Pregnancy and Childbirth Group’s
Trials Register retrieved 63 reports equating to 49 studies. We
applied the eligibility criteria to each study and all were excluded.
In some situations, we emailed the authors of the study to clarify the overall aim of the study. None of the studies identified aimed
to reduce weight in obese pregnant women. See Excluded studies.
Excluded studies
None of the studies retrieved aimed to reduce weight in obese
pregnant women so were not relevant to this review. In total, 38
of the 49 studies retrieved reported results of trials. Eight trials
were excluded as the participants were either not pregnant (two
studies), or not obese (six studies).
Risk of bias in included studies
No studies met the eligibility criteria for inclusion.
Effects of interventions
No studies met the eligibility criteria for inclusion.
D I S C U S S I O N
This review indicates that obesity in pregnancy is of international
concern; most of the studies retrieved from the searches were
from Europe, North America, the Nordics, and Australia and New
Zealand, and a few were conducted in Brazil and Egypt. How-
ever, no randomised controlled trials designed to reduce maternal weight in pregnant obese women were found. The majority of the
excluded randomised controlled trials including obese pregnant
women that were reviewed had outcomes which aimed to man-
age maternal weight gain within the parameters of the Institute
of Medicine Guidance (Medicine 1990), or to reduce excessive
weight gain. Others were designed to improve dietary and exer-
cise behaviours, reduce infant weight, explore pregnancy outcome,
and minimise the effects of diabetes. A range of interventions were
included in these studies including dietary, exercise, and compre-
hensive lifestyle interventions. Others included interventions that
incorporated practices in the delivery of maternity care including
regular maternal weighing in pregnancy, and continuity in the de-
livery of maternity care.Pharmacologicalagents were used in somestudies, butthey were notused to reduceweight. Furthermore,two
studies that used pharmacological interventions did not include
obese women. Metformin is currently being used in two studies to
minimise adverse outcomes for obese pregnant women (Norman
2010; Shehata 2012), however, weight loss is not a planned out-
come.
From retrospective cohort observational studies (Beyerlein 2011;
Blomberg 2011; Oken 2009) for example, it is clear that weight
loss when obese in pregnancy is not unusual, whether this is in-
tentional or not. Weight loss when obese should be monitored
carefully as although emerging observational studies of existing
data indicate that there are some improvements in outcomes suchas incidence of pre-eclampsia, caesarian section and adverse out-
comes at birth for the mother and infant, the increase in small-for-
gestational-age infants is of concern (Beyerlein 2011; Blomberg
2011).
Summary of main results
We found no relevant randomised controlled trials that were eli-
gible for this review.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
It is interesting to note from observational cohort studies that
obese pregnant women may lose weight and have better outcomes
than those who gain weight within recommended guidance, espe-
cially those who are morbidly obese. However weight loss in mor-
bidly obese pregnant women does not eliminate risks associated
7Antenatal interventions for reducing weight in obese women for improving pregnancy outcome (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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with pregnancy (Hinkle 2010; Beyerlein 2011; Blomberg 2011).
These observational studies indicate that the impact of weight loss
when obese and pregnant are complex, and also variable across
obese categories. Although there may be lesser likelihood of pre-
eclampsia, caesarean birth and a large for gestational age fetus at
term, the potential for increased risk of small-for-gestational ageinfants indicates that weight loss when pregnant and obese is not
without risk. More robust evidence of the outcomes of weight
loss when pregnant and obese across obesity categories is required
so that we can confidently understand outcomes, especially those
that impact on the neonate.
As there is no evidence from randomised controlled trials of in-
terventions during pregnancy that weight loss in obese pregnant
women is beneficial, recommendations advocating weight reduc-
tion in pregnancy when obese cannot be supported. We suggest
that until evidence is available, no practice recommendations can
be made.
Implications for research
The absence of randomised controlled trials related to reducing
weight in obese pregnant women may be a reflection of the lack of
evidence from observational cohort studies of the safety of weight
loss in this group. There is no robust evidence that indicates the
benefits, or harm, of losing weight when obese and pregnant. Un-
til evidence is available, it may not be appropriate to conduct a
randomised controlled trial designed to promote weight loss in
obese women in pregnancy. Furthermore, it is unlikely that an
ethics committee would provide favourable opinion to any such
study based on current evidence.
More understanding is required of the weight trajectory of obese women during pregnancy. Prospective observational cohort stud-
ies of obese women during pregnancy will provide more data that
explains weight changes for this group, and short and long term
outcomes.Further studies are requiredto explore the efficacy of the
latest guidance from the Institute of Medicine (Blomberg 2011;
Rasmussen 2009b), especially as this guidance has not stratified
recommendations for weight gain across all obese categories ( Artal
2010). Qualitative research will provide more insights into the
weight management strategies utilised by obese women during
pregnancy, especially those who deliberately lose weight.
A C K N O W L E D G E M E N T S
As part of the pre-publication editorial process, this review has
been commented on by four peers (an editor and three referees
who are external to the editorial team) and the Group’s Statistical
Adviser.
R E F E R E N C E S
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C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Althuizen 2006 This paper is a protocol of a study in The Netherlands. The intervention (the New Life(style) intervention
program) is not aimed at reducing weight in obese women, but at helping pregnant women to gain weight
within IOM guidelines. The authors were emailed (March 2012) and they confirmed that the study is now
complete. The author confirmed that the study was not aimed at obese women although there were no weight
restrictions on recruitment. Of the 250 women in the sample, only 8 were obese
Angel 2011 This is a brief conference abstract of a randomised controlled trial in the US. The intervention did not aim to
reduce weight in obese pregnant women so has been excluded
Asbee 2009 Brief conference abstract of a randomised controlled trial in the US. This Intervention did not aim to reduce weight in obese pregnant women but prevent excessive weight gain. It is also not clear whether the participants
were obese or not
Badrawi 1993 ThisIntervention did not aim toreduce weight inobese pregnant women but toinvestigate pregnancy outcome
when obese pregnant women were given either a 1500-2000 Kcal daily diet compared to a diet of no restriction.
The abstract reports that those on an unrestricted diet had a high rate of weight gain but there is no information
about the intervention group weight. The study is excluded as the intervention did not aim to reduce maternal
weight
Boileau 1968 This report of a randomised controlled trial in Canada included an intervention that did not aim to reduce
weight in obese pregnant women, but to evaluate the anorexic efficacy of Diethylproprion hydrochloride in
continuous release formulation. Some participants lost weight in the data. It is not clear if these women were
obese when they commenced the study as BMI was not reported. Maternal weight on entry to the study wasassessed using the author’s ’office standard’ of more than 2-3 pounds per month
Brand-Miller 2011 The intervention will not aim to reduce weight so is not applicable to this review. The intervention is a low
glycaemicdiet compared with a whole grain diet. The aim of the study is to compare the effects of the two diets.
Accessed from the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN1261000001055).
Brownfoot 2011 The intervention is maternal weight measurement recordings during routine antenatal care compared with
antenatal care that does not include weighing. The aim is to evaluate whether weighing at each antenatal visit
reduces excessive weightgainin pregnancy. Itis notclear ifobesepregnant women will be directly targeted forthe
study. As the intervention does not aim to reduce maternal weight in obese women in pregnancy, it is excluded.
Accessed from the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12610000331033).
Callaway 2010 The intervention was a highly supported individualised exercise intervention versus usual activity. The inter-
vention was not designed to reduce weight in obese pregnant women so is not relevant for this review. Although
theparticipants were reported as being obese, changes to weightor BMI are notreported in the study. The study
was a pilot to explore the feasibility of an individualised exercise programme to prevent gestational diabetes in
obese pregnant women
15Antenatal interventions for reducing weight in obese women for improving pregnancy outcome (Review)
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(Continued)
Chasen-Taber 2011 The intervention was a highly supported individualised exercise intervention versus provision of a booklet
about health and wellness in pregnancy. The intervention was not designed to reduce weight in obese pregnant
women so is not relevant for this review. Although the participants were reported as being obese, changes to weight or BMI are not reported in the study. The study was a pilot to explore the feasibility of an individualised
exercise programme to prevent gestational diabetes in obese pregnant women. This study was completed in
the US
Dodd 2011 The intervention consists of comprehensive diet and lifestyle advice based on behavioural techniques delivered
by a dietician and trained researchers.Dietary advice will be based on current Australian guidelines. The control
group receive usual antenatal care. A power calculation indicates that 2180 women are required for the study.
The authors were emailed March 2012 who confirmed that the study is now complete and results will be
published in approximately 1 year. The study is excluded as the intervention does not aim to reduce weight in
obese pregnant women
Faucher 2008 This is a conference abstract. The abstract describes a pilot intervention in portion control that is aimed to
lead to weight loss in low-income women. It is not clear if the women were obese. It is clear that pregnant women were not included in the study. The abstract is excluded as the participants were not pregnant
Guelinckx 2010 This is a randomised controlled trial including 195 obese pregnant women conducted in Belgium. Women
were randomised to 1 of 3 groups: nutritional advice from a brochure versus brochure and lifestyle advice from
a nutritionist versus usual care. Outcomes were dietary habits, physical activity, weight gain in pregnancy and
obstetric and neonatal outcomes. It is reported in the paper that gestational weight gain was not significantly
different between the groups, and did not decrease in the 2 intervention groups. The study is excluded as the
intervention did not aim to reduce weight in obese pregnant women
Haakstad 2011 This is a randomised controlled trial - assessor blinded carried out in Norway. The participants were sedentary,
nulliparous pregnant women - obese women were not directly targeted but 11 of the 105 participants were
obese. The intervention was an exercise group versus usual care. The outcomes were maternal weight gain and
proportion of women gaining above the IOM guidelines.The results indicate that there was no difference in
maternal weight gain between both groups. The study is excluded as the intervention did not aim to reduce
weight in obese pregnant women, but to prevent excessive weight gain
Harrison 2011 This was a brief conference abstract of a randomised controlled trial in Australia. The intervention was a low
intensity lifestyle designed to reduce excessive weight gain, not reduce weight, in overweight pregnant women.
The outcome was to assess the efficacy of the intervention, therefore the study has been excluded
Huang 2011 This isa randomised controlled trial in Taiwan. The participants were all pregnant women (n = 240), including
some who were obese.The intervention included individual counselling about diet and physical exercise over
2 time periods. 1 group through pregnancy till 6 months postpartum, and the other from birth till 6 months
postpartum. The aim of the study was to explore the effect of the interventions on weight retention. The results
indicate that the intervention is effective for reducing postpartum weight retention. However, the study didnot aim to reduce weight in obese pregnant women, so it has been excluded
Hui 2012 This is a randomised controlledtrial in Canada. The intervention aimed to explore the effect of an exercise and
dietary intervention on excessive gestation weight gain. The participants (n = 190) were non-diabetic pregnant
women (88 in the control group and 102 in the intervention group). Women of all BMI were recruited and
the results indicated that the intervention reduced excessive gestational weight gain. As the study did not aim
to reduce weight in obese pregnant women, it is excluded
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Jackson 2011 This is a randomised controlled trial including pregnant women of all BMI, recruited before 26 weeks of
pregnancy, n = 327 (163 in the intervention and 164 usual care). The study was conducted in the US.
The intervention was called ’Video Doctor’ - messages about diet, exercise and weight gain delivered by actor portrayed DVD delivered on a laptop in the clinic setting versus usual care. The primary outcome was
improvements in women’s diet and exercise behaviours, and weight gain was a secondary outcome. The results
indicate that there were statistically significant increases from baseline in exercise undertaken and consumption
of healthy foods, and significant decreases in unhealthy foods. There was no difference in weight gain between
the groups. The intervention did not aim to reduce weight in obese pregnant women and so has been excluded
Jeffries 2009 This is a randomised controlled trial including pregnant women of all BMI, recruited at 14 weeks of pregnancy,
n = 236 (46 of participants had BMI > 29 kg/m2). The study was conducted in Australia.The intervention
was a personalised weight measurement card and advice about optimal weight gain in pregnancy with advice
to self-record weight at 4 weekly intervals versus standard antenatal care. All women were weighed at 36 weeks
using the same hospital scale. Participants were blinded to the purpose of the study.The primary outcome was
weight gain from recruitment till 36 weeks of pregnancy. The results indicate that there was a trend of less
weight gain in the intervention group in all BMI categories of participants, except for those with a BMI >29 kg/m2. The intervention did not aim to reduce weight in obese pregnant women, but to reduce excessive
weight gain and so has been excluded
Koushkie 2003 This is a brief conference abstract describing a randomised controlled trial designed to assess the effect of an
aerobic exercise programme started in the third trimester on pregnancy outcomes. The participants were 26
pregnant women. It is not clear whether they were obese or not. The outcomes were gestational age, gestational
pregnancy weight gain, and changes in triceps skin thickness. The results indicate that there were no significant
differences between groups. No other publications related to this study have been found. The intervention did
not aim to reduce weight in obese pregnant women, and so has been excluded
Krummel 2009 This study was accessed from the ClinicalTrials.gov where it states that the trial started April 2009 in the US
(NCT00865683). The randomised trial will recruit pregnant women with a BMI greater than 25, however,
it is not clear how many are to be included in the study. The intervention is a nutritional supplement,
docosahexaenoic acid (DHA) versus placebo. The primary outcome is insulin sensitivity measured at month
3. Secondary outcome is interleukin - 6 (IL-6) measured at month 3. The authors have been emailed to find
out more about the study but no reply has been obtained. As the intervention is not designed to reduce weight
in obese pregnant women, the study is excluded
Lavender 2011 This is a pilot randomised controlled trial accessed from Current Controlled Trials (ISRCTN09432573). The
study was conducted in the UK. The intervention is a 10-week lifestyle programme incorporating behaviour
change theory versusroutine maternitycare.72 participants are to be recruited. The study is designed to explore
the feasibility and acceptability of the study, and the health of participants. Weight loss is not an outcome.
The intervention did not aim to reduce weight in obese pregnant women, and so has been excluded
Lombard 2011 This is brief conference abstract of a randomised controlled trial from Australia. The intervention was thedelivery of a self-management lifestyle plan with advice to self-weigh (n = 106). The control group (n = 99)
received normal advice about diet andexercise, and no recommendations to weigh themselves.The participants
(