Pregnancy

Abstract

Pregnancy is a time when women are at increased risk to gain substantial weight. It is also a time when women are more health conscious and may be more likely to engage in healthier behaviors. Because of these factors, women are primed to engage in lifestyle strategies to promote healthy weight gain during pregnancy. Similarly, mothers of newborns also have an increased readiness for change, making infancy an ideal time to begin obesity prevention efforts in families. Health care providers are encouraged to take advantage of the increased health awareness and the behavioral momentum that is present surrounding pregnancy in order to promote healthy lifestyle changes for both pregnant women and new mothers.

‘Although discussed less frequently, specific life events have been identified that are associated with more or less of a focus on health.’

One of the greatest struggles of health care practitioners (HCPs) who provide lifestyle management is motivating patients to engage in the behavioral change process. Numerous studies have been conducted to determine a patient’s readiness for change,^1-5 and interventions to promote readiness have been developed.^6-9 Although discussed less frequently, specific life events have been identified that are associated with more or less of a focus on health. For example, entrance into college and marriage are times when attention to health decreases, and significant weight gain is likely to occur.^10-14 Raising health awareness is important during these times; however, encouraging individuals to begin a lifestyle intervention at this stage in their life is likely to be frustrating and unproductive for both the patient and the HCP.

While certain life events may decrease one’s motivation to engage in healthy behaviors, other life events have been shown to be associated with an increase in health awareness. The onset of a serious health condition is one example of when individuals increase their health consciousness. For example, patients in remission of cancer are at risk for weight gain, yet have increased health awareness and are more likely to engage in weight management behaviors. ¹⁵ Similarly, when women become pregnant, they become more aware of their health ¹⁶ and may have greater motivation to engage in health behavior change. ¹⁷ Pregnant women have been shown to decrease use of tobacco products, reduce alcohol consumption, and limit their intake of caffeine. ¹⁶ Although these findings suggest a behavioral momentum to make lifestyle changes, other health behaviors remain unchanged. For example, pregnant women do not make significant changes to their dietary behaviors. ¹⁶

As discussed by Harvey and Riccotti ¹⁸ in this issue, pregnancy is a time when women are at increased risk for excessive weight gain that may affect future weight status. Because women are at higher risk and are more likely to engage in some healthier habits, interventions have been developed to improve the lifestyles of pregnant women^{19 -21} and mothers of infants. ²² Interventions to limit weight gain during pregnancy have been shown to prevent excessive weight gain during pregnancy and promote return to preconception weight status postpartum.^{23 -25} Once the child has been born, interventions that target mothers as primary agents of change to affect infant health have also been shown to be effective in primary prevention efforts.^22,26,27 The success of these programs demonstrates the importance of addressing health issues when individuals are most receptive to them.

Key Elements to Prevent Excessive Weight Gain in Pregnancy

Diet and physical activity have been shown to be effective at preventing excessive weight gain during pregnancy and reducing long-term retention of weight gain postpartum.^{23 -25} Effective interventions often include oral or written instructions regarding diet and exercise, setting a target for maximum weight gain, frequent monitoring of weight, and motivational interviewing.^23,24 A randomized controlled trial examined the efficacy of a behavioral intervention, Fit for Delivery, for the prevention of excessive gestational weight gain. ²⁸ As part of this program, women attended an initial clinic visit in which goals were set for maximum weight gain, physical activity, and dietary habits. All contacts occurred at their regular prenatal appointments.

Women were encouraged to increase their daily physical activity to 30 minutes most days of the week and given a calorie goal specific to their body weight. Participants engaged in daily self-monitoring of eating, exercise, and weight. Weights were graphed at each prenatal visit, and participants were provided with feedback regarding the appropriateness of their weight gain. If weight gain was found to be excessive or inadequate, more frequent counseling and support were provided. This intervention resulted in healthy-weight women being more likely to gain the recommended amount of weight during pregnancy, and all women being more likely to return to preconception weights by 6 months postpartum. ²⁸ Based on these findings, clinicians are encouraged to address healthy weight gain during pregnancy by providing a target weight, encouraging frequent monitoring, and providing feedback regarding weight gain.

Primary Prevention for Children Through Mothers

Behavioral programs delivered to mothers have been shown to be successful in promoting healthy growth in infants as well. ²² Feeding has been targeted by various interventions that focus on the many dietary transitions occurring during infancy. Specifically, within the first 3 years of a child’s life, food sources transition from exclusively milk to pureed foods and finally to a modified adult diet. ²⁹ During these transitions, children’s eating behaviors and food preferences are established. ³⁰ Overfeeding is a common problem during infancy. ³¹ This becomes further complicated as mothers, especially new mothers, are often uncertain about the adequacy of their child’s dietary consumption and growth development. The myth that a “chubby” baby is a healthy baby may further exacerbate the tendency to overfeed. To address this, physicians are encouraged to reassure mothers about the growth development of their infant and to help mothers identify cues specific to hunger and satiety. ²⁹ This is especially important for formula-fed infants. ²⁹

Sleep is another component in infants’ lives that has been targeted because unhealthy sleep patterns have been linked to obesity and higher body fat in children.^{32 -38} Sleep is also affected by feeding, especially during the first months of life when infants awaken every 2 to 4 hours to feed. ³⁹ The strategies that mothers use during their infants’ night awakenings affects the development of healthy sleep patterns. ⁴⁰ The goal in early infancy is to help infants prolong their sleep duration. Specifically, mothers are encouraged to create environmental differences between daytime and nighttime and to first attempt nonfeeding soothing techniques when responding to night awakenings. ²² Clinicians can assist with this by teaching mothers techniques for prolonging sleep duration and handling night awakenings. For example, swaddling and use of “white noise” are techniques that have been shown to improve sleep efficiency and reduce nighttime arousals. ⁴¹ Several soothing techniques that do not involve feeding, such as nonnutritive sucking, shushing, and swinging, have been found to be effective in teaching infants to return to sleep without feeding. ²⁶ Helping parents establish developmentally appropriate expectations for sleep duration between nighttime feeds may give parents the confidence to carry out nonnutritive soothing techniques without resorting to feeding and help mothers learn to discriminate their infants’ hunger cues from other distress cues.

The Impact of Stress

Increased stress makes it more difficult to successfully engage in behavior change. Significant stressors vary between patients; however, common stressful life events include marital problems, loss of a family member, and financial difficulties. Becoming pregnant and having a child are also significant life stressors. ⁴² High levels of stress are usually associated with decreased performance and confidence in one’s ability to change. ⁴³ Because of this, it is important for HCPs to recognize that information should be given simply, and small steps should be provided to make changes. To further complicate this issue, significant changes in eating habits is considered to be a significant source of life stress. ⁴² Although pregnant women may experience increased motivation to improve health, it is also a time of considerable stress that may limit the ability of the patient to make changes.

Conclusion

Pregnancy is a time when women are health conscious and may be more likely to engage in healthier behaviors. This focus on health typically persists postpartum, making pregnancy and early infancy an ideal time to begin obesity prevention efforts in families. Pregnancy provides an excellent example of a motivating life event that may lead to increased health awareness. Outside of pregnancy, patients report numerous reasons for engaging in a healthier lifestyle, but it is not possible to predict who will be successful based on stated reasons for change. ⁴⁴ Although not necessarily predictive of success, certain life events may increase the likelihood of engaging in lifestyle improvements.^15,17 Based on this, HCPs are encouraged to take advantage of the behavioral momentum that is present surrounding pregnancy and other motivating events in patients’ lives in order to promote healthy lifestyle changes.