This review reveals large methodological variability in dietary interventions to control gestational weight gain and improve clinical outcomes in overweight and obese pregnant women. This lack of consensus limits the ability to develop clinical guidelines and apply the evidence in clinical practice.

BackgroundDiet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.ObjectivesTo assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.Data sourcesMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).Review methodsResearchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.ResultsDiet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI –0.92 to –0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate –0.10 kg, 95% CI –0.14 to –0.06 kg) and multiparity (summary estimate –0.73 kg, 95% CI –1.24 to –0.23 kg).LimitationsThe findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.ConclusionDiet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.Future workThe differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.Study registrationThis study is registered as PROSPERO CRD42013003804.FundingThe National Institute for Health Research Health Technology Assessment programme.

BackgroundThe global obesity epidemic has led to increased attention on pregnancy, a period when women are at risk of gaining excessive weight. Excessive gestational weight gain is associated with numerous complications, for both mother and child. Though the problem is widespread, few studies have examined the effect of a lifestyle intervention in pregnancy designed to limit maternal weight gain. The Fit for Delivery study will explore the effectiveness of nutritional counseling coupled with exercise classes compared with standard prenatal care. The aims of the study are to examine the effect of the intervention on maternal weight gain, newborn birth weight, glucose regulation, complications of pregnancy and delivery, and maternal weight retention up to 12 months postpartum.Methods/designFit for Delivery is a randomized controlled trial that will include 600 women expecting their first child. To be eligible, women must be 18 years of age or older, of less than 20 weeks gestational age, with a singleton pregnancy, and have a Body Mass Index (BMI) ≥ 19 kg/m2. The women will be randomly allocated to either an intervention group or a control group. The control group will receive standard prenatal care. The intervention group will, in addition, receive nutritional counseling by phone, access to twice-weekly exercise sessions, and information on healthy eating and physical activity provided in pamphlets, evening meetings and an interactive website. Both groups will be monitored by weighing (including bioimpedance measurements of percent body fat), blood tests, self-report questionnaires and hospital record review.DiscussionWeight gained in pregnancy affects the health of both the mother and her unborn child, and simple models for efficient intervention are in high demand. The Fit for Delivery intervention provides concrete advice on limiting energy intake and practical training in increasing physical activity. This lifestyle intervention is simple, reproducible, and inexpensive. The design of the study reflects the realities of clinical practice, where patients are free to choose whether or not they respond to health initiatives. If we find measurable health benefits associated with the intervention, it may be an easily adopted supplement to routine prenatal care, in the prevention of obesity.Trial registrationClinicalTrial.gov, NCT01001689

Sanda B, Vistad I, Haakstad LAH, Berntsen S, Sagedal LR, Lohne-Seiler H, Torstveit MK. Reliability and concurrent validity of the International Physical Activity Questionnaire short form among pregnant women.BackgroundThe International Physical Activity Questionnaire short-form (IPAQ-SF) is frequently used to assess physical activity (PA) level in the general adult population including pregnant women. However, the reliability and validity of the questionnaire in pregnancy is unknown. Therefore, the aims of the present study were to investigate test-retest reliability and concurrent validity of IPAQ-SF among pregnant women, and whether PA is reported differently among those who fulfill (active) vs. do not fulfill (inactive) recommendations of ≥150 min of weekly moderate intensity PA in pregnancy.MethodTest-retest reliability was examined by answering IPAQ-SF twice, two weeks apart (n = 88). To assess validity, IPAQ-SF was compared to the physical activity monitor SenseWear Armband® (SWA) (n = 64). The participants wore SWA for 8 consecutive days before answering IPAQ-SF. PA level was reported as time spent in moderate-, vigorous- and moderate-to-vigorous intensity PA (MPA, VPA and MVPA) corresponding to the cut-off points 3–6, >6 and >3 Metabolic Equivalents (METs), respectively.ResultsTest-retest intraclass-correlation of MPA, VPA and MVPA ranged from 0.81-0.84 (95% Confidence Intervals: 0.69,0.90). Comparing time spent performing PA at various intensities; the mean differences and limits of agreement (±1.96 Standard Deviation) from Bland-Altman plots were−84 ± 402 min/week for MPA,−85 ± 452 min/week for MVPA and 26 ± 78 min/week for VPA, illustrating that the total group under-reported MPA by 72% and MVPA by 52%, while VPA was over-reported by 1400%. For the inactive group corresponding numbers were 44 ± 327 min/week for MPA, 52 ± 355 min/week for MVPA and 16 ± 33 min/week for VPA, illustrating that the inactive group over-reported MPA by 13% and MVPA by 49%, while VPA was not detected by SWA, but participants reported 16 min of VPA/week. In contrast, corresponding numbers for the active group were−197 ± 326 min/week for MPA,−205 ± 396 min/week for MVPA and 35 ± 85 min/week for VPA, illustrating that the active group under-reported MPA by 81% and MVPA by 60%, while they over-reported VPA by 975%.ConclusionIPAQ-SF had good test-retest reliability, but low to fair concurrent validity for MPA, VPA and MVPA compared to an objective criterion measure among pregnant women. Further, women fulfilling PA guidelines in pregnancy under-reported, while inactive women over-reported PA level.

Aiming at preventing excessive weight gain during pregnancy, 10 specific dietary recommendations are given to pregnant women in the intervention arm of the Norwegian Fit for Delivery (FFD) study. This paper presents the rationale and test-retest reliability of the food frequency questionnaire (FFQ) and a dietary score measuring adherence to the recommendations. The study is part of the ongoing FFD study, a randomised, controlled, intervention study in nulliparous pregnant women. A 43-item FFQ was developed for the FFD study. A dietary score was constructed from 10 subscales corresponding to the 10 dietary recommendations. Adding the subscales yielded a score from 0 to 10 with increasing score indicating healthier dietary behaviour. The score was divided into tertiles, grouping participants into low, medium and high adherence to the dietary recommendations. Pregnant women attending ultrasound screening at about week 19 of pregnancy were asked to complete the FFQ twice, 2 weeks apart. Of 154 pregnant women completing the first questionnaire, 106 (69%) completed the form on both occasions and was included in the study. The test-retest correlations of the score and subscales were r = 0.68 and r = 0.56-0.84, respectively (both P ≤ 0.001). There was 68% test-retest correct classification of the score and 70-87% of the subscales. In conclusion, acceptable test-retest reliability of the FFQ and the dietary score was found. The score will be used in the FFD study to measure adherence to the dietary recommendations throughout pregnancy and in the following year post-partum.

Objective: To describe changes in consumption of different types of beverages from pre-pregnancy to early pregnancy, and to examine associations with maternal age, educational level and BMI. Design: Cross-sectional design. Participants answered an FFQ at inclusion into a randomized controlled trial, the Fit for Delivery (FFD) trial, in median gestational week 15 (range: 9-20), reporting current consumption and in retrospect how often they drank the different beverages pre-pregnancy. Setting: Eight local antenatal clinics in southern Norway from September 2009 to February 2013. Subjects: Five hundred and seventy-five healthy pregnant nulliparous women. Results: Pre-pregnancy, 27 % reported drinking alcohol at least once weekly, compared with none in early pregnancy (P < 0·001). The percentage of women drinking coffee (38 % v. 10 %, P < 0·001), sugar-sweetened beverages (10 % v. 6 %, P = 0·011) and artificially sweetened beverages (12 % v. 9 %, P = 0·001) at least daily decreased significantly from pre-pregnancy to early pregnancy, while the percentage of women who reported to drink water (85 % v. 92 %, P < 0·001), fruit juice (14 % v. 20 %, P = 0·001) and milk (37 % v. 42 %, P = 0·001) at least daily increased significantly. From pre-pregnancy to early pregnancy higher educated women reduced their consumption frequency of coffee significantly more than women with lower education. Older women reduced their consumption frequency of coffee and artificially sweetened beverages and increased their consumption frequency of fruit juice and milk significantly more than younger women. Conclusions: There is a significant change in beverage consumption from pre-pregnancy to early pregnancy among Norwegian nulliparous women.

BackgroundTo develop effective health promotional and preventive prenatal programs, it is important to understand perceived barriers to leisure-time physical activity during pregnancy, including exercise and sport participation. The aims of the present study was 1) to assess the effect of prenatal lifestyle intervention on the perceived barrier to leisure-time physical activity during pregnancy and the first year after delivery and 2) identify the most important perceived barriers to leisure-time physical activity at multiple time points during and after pregnancy.MethodsThis secondary analysis was part of the Norwegian Fit for Delivery study, a combined lifestyle intervention evaluated in a blinded, randomized controlled trial. Healthy, nulliparous women with singleton pregnancy of ≤20 gestational weeks, age ≥ 18 years and body mass index ≥19 kg/m2 were recruited via healthcare clinics in southern Norway, including urban and rural settings. Participants were randomized to either twice-weekly supervised exercise sessions and nutritional counselling (n = 303) or standard prenatal care (n = 303). The principal analysis was based on the participants who completed the standardized questionnaire assessing their perceived barriers to leisure-time physical activity at inclusion (gestational week 16, n = 589) and following intervention (gestational week 36, n = 509), as well as six months (n = 470) and 12 months (n = 424) postpartum.ResultsFollowing intervention (gestation week 35.4 ± 1.0), a significant between-group difference in perceived barriers to leisure-time physical activity was found with respect to time constraints: “... I do not have the time” (intervention: 22 vs. control: 38, p = 0.030), mother-child safety concerns: “... afraid to harm the baby” (intervention: 8 vs. control: 25, p = 0.002) and self-efficacy: “... I do not believe/think that I can do it” (intervention: 3 vs. control: 10, p = 0.050). No positive effect was seen at postpartum follow-up. Intrapersonal factors (lack of time, energy and interest) were the most frequently perceived barriers, and consistent over time among all participants.ConclusionThe intervention had effect on intrapersonal perceived barriers in pregnancy, but not in the postpartum period. Perceived barriers to leisure-time physical activity were similar from early pregnancy to 12 months postpartum.Trial registrationClinicalTrials.gov: NCT01001689, registered July 2, 2009.

Introduction. The beneficial effects of physical activity during pregnancy for the mother and offspring have been reported by several studies but there are conflicting results concerning the possible effect of physical activity on the course of labor and risk of cesarean delivery. This study presents secondary analyses from the Norwegian Fit for Delivery randomized controlled trial, aiming at studying the effect of a lifestyle intervention including group exercise classes, as well as the possible influence of physical activity level in late pregnancy, on labor outcomes. Material and methods. Healthy nulliparous women with singleton pregnancy were randomized to an intervention group, n = 303 (dietary counseling and twice-weekly exercise classes) or a control group, n = 303 (standard care). The participants were analyzed both by randomization and as a cohort comparing women with lowest (quartile 1, 0 metabolic equivalent of task-hours moderate-to-vigorous physical activity/ week) (n = 140) vs. highest (quartile 4, ≥16 metabolic equivalent of task-hours moderate-to-vigorous physical activity/week) (n = 131) physical activity level in late pregnancy, assessed with the International Physical Activity Questionnaire. Result. The intervention group had a longer first stage of labor compared with the control group (293 AE 202 min vs. 257 AE 181 min, p = 0.030). No differences between the randomization groups were seen for time spent in second stage of labor, prolonged labor or mode of delivery. In the total sample, women with the highest physical activity level had lower odds ratio (OR) of acute cesarean delivery (OR 0.33, p = 0.044) than did those with the lowest physical activity-level. Conclusion. A significantly longer first stage of labor was observed in the intervention group than in the control group. A high physical activity level in late pregnancy was associated with lower odds of acute cesarean delivery compared with a low physical activity level.