Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis

  • Eugene Oteng-Ntim1, 2, 3Email author,
  • Rajesh Varma1, 3,
  • Helen Croker4,
  • Lucilla Poston3 and
  • Pat Doyle2
BMC Medicine201210:47

DOI: 10.1186/1741-7015-10-47

Received: 23 December 2011

Accepted: 10 May 2012

Published: 10 May 2012

Abstract

Background

Overweight and obesity pose a big challenge to pregnancy as they are associated with adverse maternal and perinatal outcome. Evidence of lifestyle intervention resulting in improved pregnancy outcome is conflicting. Hence the objective of this study is to determine the efficacy of antenatal dietary, activity, behaviour or lifestyle interventions in overweight and obese pregnant women to improve maternal and perinatal outcomes.

Methods

A systematic review and meta-analyses of randomised and non-randomised clinical trials following prior registration (CRD420111122 http://www.crd.york.ac.uk/PROSPERO) and PRISMA guidelines was employed. A search of the Cochrane Library, EMBASE, MEDLINE, CINAHL, Maternity and Infant care and eight other databases for studies published prior to January 2012 was undertaken. Electronic literature searches, study selection, methodology and quality appraisal were performed independently by two authors. Methodological quality of the studies was assessed according to Cochrane risk of bias tool. All appropriate randomised and non-randomised clinical trials were included while exclusions consisted of interventions in pregnant women who were not overweight or obese, had pre-existing diabetes or polycystic ovarian syndrome, and systematic reviews. Maternal outcome measures, including maternal gestational weight gain, gestational diabetes and Caesarean section, were documented. Fetal outcomes, including large for gestational age and macrosomia (birth weight > 4 kg), were also documented.

Results

Thirteen randomised and six non-randomised clinical trials were identified and included in the meta-analysis. The evidence suggests antenatal dietary and lifestyle intervention in obese pregnant women reduces maternal pregnancy weight gain (10 randomised clinical trials; n = 1228; -2.21 kg (95% confidence interval -2.86 kg to -1.59 kg)) and a trend towards a reduction in the prevalence of gestational diabetes (six randomised clinical trials; n = 1,011; odds ratio 0.80 (95% confidence interval 0.58 to 1.10)). There were no clear differences reported for other outcomes such as Caesarean delivery, large for gestational age, birth weight or macrosomia. All available studies were assessed to be of low to medium quality.

Conclusion

Antenatal lifestyle intervention is associated with restricted gestational weight gain and a trend towards a reduced prevalence of gestational diabetes in the overweight and obese population. These findings need to be interpreted with caution as the available studies were of poor to medium quality.

Background

Both developed and developing countries are experiencing a rapid increase in the prevalence of obesity [13]. In the UK, 24% of women of reproductive age are now obese (body mass index (BMI) equal or greater than 30 kg/m2) and the prevalence appears to be increasing [4]. Studies in UK women show that the rates of obesity in pregnancy have almost doubled in the last two decades [5, 6]. Recent estimates suggest the prevalence of obesity in pregnancy in the UK is at least 20% with 5% having severe or morbid obesity [7, 8].

Observational study data has linked obesity in pregnancy with adverse maternal and infant outcomes [710]. Obesity increases the risks of gestational diabetes [8, 1012], hypertensive disease (including pre-eclampsia) [8, 13, 14], thromboembolism [15, 16], infection [14, 17], Caesarean section [8, 18], congenital fetal anomalies [19], macrosomia [13], induction [20], stillbirth [12], shoulder dystocia [14] and preterm delivery [21]. Moreover, maternal obesity may impact on long-term outcomes such as the increasing weight of the child in infancy and the severity of obesity in future generations [10, 22, 23].

As most of the adverse outcomes of obese pregnancies show strong associations with pre-pregnancy BMI, it is reasonable to assume that the ideal intervention would be to reduce obesity prior to pregnancy [24]. However, this is difficult to achieve because 50% of pregnancies in the UK are unplanned and a recent study concluded that only a small proportion of women planning pregnancy follow nutrition and lifestyle recommendations [25]. As such, an intervention pre-pregnancy may reach only a small proportion of the intended women.

Alternatively, pregnancy itself may represent an ideal opportunity to target lifestyle change as women have increased motivation to maximise their own health and that of their unborn child [25]. However, evidence of benefit from published intervention studies appears limited and inconsistent [2644]. We therefore sought to determine the efficacy of combined dietary activity and behaviour support interventions in overweight and obese pregnant women by undertaking a systematic review and meta-analysis according to PRISMA (Transparent Reporting of Systematic Reviews and Meta-analyses) criteria for maternal clinical outcomes of weight gain, gestational diabetes and Caesarean section and infant outcomes, such as large for gestational age and macrosomia. Our aim was to generate data of the highest statistical power and sensitivity. Hence, in comparison with previous similar themed systematic reviews [4548], we chose to interrogate multiple databases (not restricted to English) and also separately meta-analyse randomised clinical trials (RCTs) and non-RCTs evaluating relevant clinical outcomes, including gestational diabetes and Caesarean section, which had not been attempted in prior meta-analyses.

Methods

Eligibility criteria

The eligible studies included RCTs and non-RCTs that evaluated antenatal dietary and lifestyle interventions in obese and overweight pregnant women whose outcome measures included quantitative maternal and fetal health outcomes. Systematic reviews and trials of women with existing gestational diabetes, or trials of pre-conception or postpartum interventions, were not included. Inclusion of trials was not restricted by language, publication date or country. Systematic reviews and observational studies were excluded.

Information sources

Literature searches were performed using five mainstream electronic databases (Cochrane Library, MEDLINE, EMBASE, CINAHL, Maternity and Infant care), and eight other databases (PsyclINFO via OVID SP, PyscLNFO via OVID SP, Science Citation Index via Web of Science, Social Science Citation Index via Web of Science, Global Health, Popline, Medcarib, Nutrition database).

Search strategy

The following MeSH terms, words and combinations of words, were used in constructing the systematic search: overweight OR obesity; pregnancy OR pregnancy complications OR pregnancy outcome OR prenatal care, prenatal, antenatal, intervention, randomised controlled trial, life style, "early intervention (education)", health education, education, patient education handout, patient education, exercise, exercise therapy, health promotion, diet, carbohydrate-restricted, diet, fat-restricted, diet, reducing, diet therapy, weight loss. Full details of the search strategy are shown in Table 1. The searches were unlimited by time up to January 2012 and limited to human studies and clinical trials. The systematic search was undertaken in the mainstream databases and targeted searches were conducted in the other databases.
Table 1

Search strategy utilised for MEDLINE 1946 to January 2012

Batch

Search term (MESH)

Combination

Result

1

Pregnancy Complications/OR Pregnancy/OR Pregnancy Outcome/OR Pregnancy, High Risk/

 

646,055

2

Prenatal Care/OR Pregnancy/OR Pregnancy Complications

 

647,726

3

Antenatal.mp.

 

18,393

4

Gestation intervention.mp.

 

4

5

 

1 OR 2 OR 3 OR 4

651,321

6

Overweight.mp. OR Obesity/OR Overweight/OR Body Weight/

 

249,097

7

Obesity/OR Obesity, Morbid/or Obesity.mp.

 

145,882

8

Body Weight/OR Obesity/OR Body Mass Index/or BMI.mp. OR Overweight/

 

293,584

9

 

6 OR 7 OR 8

328,089

10

 

5 AND 9

21,583

11

Diet, Fat-Restricted/OR Diet/OR Diet, Protein-Restricted/OR Diet, Carbohydrate-Restricted/OR Diet.mp. OR Diet, Reducing/OR Diet Therapy/

 

255,985

12

Life Style/

 

36,837

13

Health Education/

 

48,625

14

Patient Education as Topic/

 

63,238

15

Exercise.mp. OR Exercise/OR Exercise, Therapy/

 

192,937

16

Health Promotion/

 

43,967

17

Weight Loss/

 

19,434

18

 

11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17

601,919

19

 

10 AND 18

3,769

20

 

LIMIT 19 TO ((female or humans or pregnancy) and (clinical trial, all OR clinical trial, phase i OR clinical trial, phase ii OR clinical trial, phase iii OR clinical trial, phase iv OR clinical trial OR controlled clinical trial OR randomized controlled trial))

154

Study selection

Electronic literature searches, study selection, methodology, appropriateness for inclusion and quality appraisal were performed independently and in duplicate by two authors (E-ON and RV). Disagreements between reviewers were resolved by consensus. Included studies were divided into two groups (RCTs and non-RCTs) and separately meta-analysed.

Data collection process

Two independent reviewers extracted the data. As a first step, each paper was screened using the title and the abstract. In the next round, studies were assessed for methodological quality and appropriateness for inclusion by two reviewers working independently from the full text of the manuscript. This was done without consideration of the results.

Data items

For each included trial, data was extracted on maternal gestational weight gain; gestational diabetes; Caesarean section; large for gestational age baby (> 4 kg); and birth weight. The included studies have been summarised in Tables 2 and 3.
Table 2

A summary of the studies that met the criteria of the systematic review on lifestyle interventions in overweight and obese pregnant women: randomised trials

Author (year)

Ethnic group/Country

Participant/setting

Sample size

Intervention

Outcome measure(s)

Conclusion

Polley et al. (2002) [32]

31% black and 61% white/USA

Recruited before 20 weeks of pregnancy (normal BMI > 19.5 to 24.9; overweight BMI ≥ 25 to < 30 kg/m2)/Hospital based

120, including 49 overweight

59 in control arm; 61 in intervention arm

Exercise and nutrition information (oral and newsletter) Personalised graphs and behavioural counselling.

Gestational weight gain; gestational diabetes; Caesarean section; birthweight

No statistically significant reduction in gestational weight, prevalence of gestational diabetes, Caesarean section, or large for gestational age baby

Hui et al. (2006) [33]

Predominantly Caucasian/Canada

Less than 26 weeks pregnant (community based and antenatal clinics). All BMI categories. Mean BMI of non-intervention arm = 25.7 (SD = 6.3) and for intervention arm = 23.4(SD = 3.9)

45

21 in non-intervention arm; 24 in intervention arm

Physical exercise (group-sessions home-based exercise)

Individualized nutrition plans

Gestational weight gain

No statistically significant reduction in gestational weight gain

Wolff et al., 2008 [30]

100% Caucasian/Denmark

Obese (BMI ≥ 30 kg/m2) women enrolled at 15 weeks' gestation

50 analysed

23 in control arm; 27 in intervention arm

Intensive intervention with 10 one-hour visits with a dietician at each antenatal visit, dietary guidance provided

Gestational weight gain; gestational diabetes; Caesarean section; birthweight

Statistically significant reduction in gestational weight gain, no statistically significant reduction in prevalence of gestational diabetes or Caesarean section, or birthweight

Jeffries et al., 2009 [28]

> 90% Caucasian/Australia

Women at or below 14 weeks' gestation. All BMI categories included

286

138 in control arm; 148 in intervention arm

Personalised weight measurement card (based on Institute of Medicine guidelines). Control had only single measurement at enrolment

Gestational weight gain

No statistically significant reduction in gestational weight gain.

Ong et al., 2009 [42]

Predominantly Caucasian/Australia

Pregnant obese women recruited at 18 weeks' gestation

12

six in control arm; six in intervention arm

Personalised 10 weeks of home-based supervised exercise (three sessions per week)

Maternal aerobic fitness and gestational diabetes

No statistically significant difference in aerobic fitness or gestational diabetes

Barakat et al., 2011 [41]

100% Caucasian/Spain

All BMI categories

160

80 in control arm; 80 in intervention arm

Three group-based sessions per week, light resistance and toning exercise from the second trimester

Gestational weight gain and birthweight

No statistically significant difference in gestational weight gain and birth weight. Exercise intervention might attenuate adverse consequences of maternal BMI on newborn birth size

Asbee et al., 2009 [27]

26% African American/USA

Pregnant women recruited before 16 weeks' gestation. All BMI categories except those of BMI > 40 kg/m2

100

43 in control arm; 53 in intervention arm

One session of dietetic counselling and activity

Gestational weight gain; pregnancy outcome

Statistically significant reduction in gestational weight gain. No effect on pregnancy outcome

Thornton et al., 2009 [29]

41% African American/USA

Obese pregnant women (BMI ≥ 30 kg/m2) recruited between 12 and 28 weeks' gestation

257 randomised.

25 lost to follow up. 116 in control arm; 116 in intervention arm

Nutritional regime for gestational diabetes

Gestational weight gain; gestational diabetes; Caesarean section; pregnancy outcome

Statistically significant reduction in gestational weight gain, no statistically significant reduction in prevalence of gestational diabetes, Caesarean section or birthweight

Guelinckx et al., 2010 [26]

100% Caucasian/Belgium

Obese (BMI > 30 kg/m2) women enrolled at 15 weeks' gestation.

195 randomised

85 analysed

65 in control arm; 65 in passive arm, 65 in intervention arm

Three arms: group sessions with a dietician; written brochures; and standard care

Dietary and physical activity guidance provided by dietician and in written brochures

Nutritional habits; gestational weight gain; gestational diabetes; Caesarean section; birthweight

Improved nutritional habits; no statistically significant reduction in gestational weight gain, prevalence of gestational diabetes, Caesarean section or birthweight.

Phelan et al., 2011 [34]

67% White/USA

Pregnant women BMI between 19.8 and 40 kg/m2 recruited between 10 and 16 weeks' gestation

401 randomised.

201 in non-intervention arm; 200 in intervention arm

Exercise and nutrition information (oral and newsletter) Personalised graphs and behavioural counselling

Gestational weight gain; gestational diabetes; Caesarean section; pregnancy outcome

Significant reduction in gestational weight gain; no statistically significant reduction in prevalence of gestational diabetes, Caesarean section or birthweight

Quinlivan et al., 2011 [59]

73% white, 19% Asian/Australia

Pregnant women: overweight (BMI 25 to 29.9 kg/m2) and obese (BMI ≥ 30 kg/m2)

132 randomised.

65 in non-intervention arm; 67 in intervention arm

Attended a study- specific antenatal clinic providing continuity of care, weighing on arrival, brief dietary intervention by food technologist and psychological assessment and intervention if indicated

Gestational weight gain; gestational diabetes; birthweight

Statistically significant reduction in gestational weight gain and prevalence of gestational weight gain. No statistically significant reduction in birthweight.

Luoto et al., 2011 [43]

Predominantly white/Finland

Pregnant women at risk of gestational diabetes. All BMI ranges

399 cluster randomised.

219 in non-intervention arm; 180 in intervention arm

Attended a study-specific individual antenatal lifestyle counselling clinic including group exercise

Gestational diabetes; gestational weight gain; birthweight

Statistically significant reduction in birthweight and macrosomia but no statistically significant difference in gestational diabetes

Nascimento et al., 2011 [44]

Predominantly white/Brazil

Pregnant women of all BMI categories

82 randomised.

42 in non-intervention arm; 40 in intervention arm

Attended a group-based exercise under supervision and received a home exercise counselling

Gestational weight gain; raised blood pressure; perinatal outcome

No statistically significant difference in gestational weight gain in terms of gestational weight gain, raised blood pressure or perinatal outcome

BMI: body mass index; SD: standard deviation

Table 3

Summary of the studies that met the criteria of the systematic review on lifestyle interventions in overweight and obese pregnant women: non-randomised trials

Author (year)

Ethnic group/country

Participants/setting

Sample size

Intervention

Outcome measure(s)

Conclusion

Gray-Donald et al. (2000) [38]

Native Americans/Canada

Recruited before the 26th week of pregnancy, non-parallel recruitment of control and intervention arms.

Mean BMI = 29.6 kg/m2 (SD = 6.45) in non-intervention arm and mean BMI = 30.8 kg/m2 (SD = 6.85) in intervention arm at baseline.

219

107 in non-intervention arm; 112 in intervention arm

Dietary and weight counselling

Exercise groups provided

Gestational weight gain; gestational diabetes;

Caesarean section;

birthweight;

postpartum weight retention

No statistically significant difference in gestational weight gain, prevalence of gestational diabetes, Caesarean section or large for gestational age baby

Olson et al. (2004) [51]

96% white/USA

Recruited before third trimester. Hospital and clinic setting

BMI range: 19.8 to 29 kg/m2

498

381 in non-intervention arm; 117 in the intervention arm

Used the Institute of Medicine recommended guidelines on weight gain; 'health book' used to record diet and exercise and contained healthy eating and exercise information

Gestational weight gain; birthweight

No statistically significant reduction in gestational weight gain or prevalence of large for gestational age baby

Claesson et al. (2007) [36]

Not stated. Predominantly Caucasian/Sweden

Obese and registered at antenatal care clinic.

BMI ≥ 30 kg/m2

348

193 in non-intervention arm; 155 in intervention arm

Nutritional habits interview, weekly counselling and aqua aerobic sessions

Gestational weight gain; Caesarean section.

Statistically significant reduction in gestational weight gain; no difference in prevalence of Caesarean section

Kinnunen et al. (2007) [37]

Over 90% Caucasian/Finland

First-time pregnant women who were obese (BMI ≥ 30 kg/m2)

196

95 in non-intervention arm; 101 in intervention arm

Individual counselling at each antenatal visits. Dietary guidance and optional activity sessions.

Gestational weight gain; diet change; birthweight

No statistically significant reduction in gestational weight gain or prevalence of large for gestational age baby. Statistically significant reduction in dietary glycaemic load.

Shirazian et al., 2010 [39]

33% blacks; 67% Latino/USA

Singleton obese (≥ 30 kg/m2) pregnant women recruited in the first trimester. Historical non-intervention group.

54

28 in non-parallel control arm; 28 in intervention arm)

One-to-one counselling; six structured seminars on healthy living (healthy eating and walking)

Gestational weight gain; gestational diabetes; Caesarean section

Statistically significant reduction in gestational weight gain; no difference in prevalence of gestational diabetes

Mottola et al., (2010) [35]

Not stated/Canada

Overweight (BMI ≥ 25 to 29.9 kg/m2) and obese (BMI ≥ 30 kg/m2) pregnant women recruited before 16 weeks' gestation; historical non-intervention group.

65 matched non-parallel control of 260

Individualised nutrition plan; exercise consisted of walking (three to four times per week, used pedometers)

Gestational weight gain; Caesarean section; birthweight; peripartum weight retention

Possible reduction in gestational weight gain; no difference in prevalence of Caesarean section or large for gestational age baby; minimal effect on peripartum weight retention

BMI: body mass index; SD: standard deviation.

Risk of bias in individual studies

The quality of studies was assessed based on how the studies had minimised bias and error in their methods. We categorised the studies according to criteria based on PRISMA guidelines [49] and the Cochrane Library [50]. For example, high quality trials reported study aims; control comparison similar to the intervention group; relevant population demographics pre- and post-intervention; and data on each outcome. These study characteristics are tabulated in Tables 4 and 5. A final assessment categorised the studies as high, medium or low quality.
Table 4

Assessment of the quality of the included trials: non-randomised trials

Author (year)

Population representativeness

Adequacy of sequence generation

Masking/selection bias

Incomplete outcome data

Contamination

Sample size

Grade of quality

Gray-Donald et al. (2000) [38]

Yes: Registered from clinic

No

No

No

No: non-parallel control

219

Low

Olson et al. (2004) [51]

Yes

No

No

No

No: non-parallel control

560

Low

Claesson et al. (2007) [36]

Yes: Registered from clinic

No

No

Yes

No: selected from nearby city

315

Low

Kinnunen et al. (2007) [37]

Yes

No

No

No

Yes

55

Low

Shirazian et al., (2010) [39]

Yes

No

No

Yes

No: non-parallel control

28

Low

Mottola et al., (2010) [35]

Yes

No

No

Yes

No: non-parallel control

65

Low

Table 5

Assessment quality of included trials: randomised trials

Author (year)

Population representativeness

Adequacy of sequence generation

Masking/selection bias

Intention to treat

Incomplete outcome data

Loss to follow up

Sample size

Grade of quality

Polley et al. 2002 [32]

Yes

Yes:

No

Not reported

No

Yes

120

Low

Hui et al. (2006) [33]

Yes: from clinic

Exact method not described

No

Not reported

No

Yes

52

Low

Wolff et al., 2008 [30]

Yes

Yes: computer generated

No

Not reported

Yes

Yes

50

Low

Jeffries et al., 2009 [28]

Yes

Yes: Opaque envelope

Yes

Not reported

Yes

Yes

286

Low

Ong et al., 2009 [42]

Yes

Exact method not described

No

Not reported

No

No

12

Low

Barakat et al., 2011 [41]

Yes

Yes

Yes

Yes

Yes

Yes

160

Medium

Asbee et al. 2009 [27]

Yes

Yes

No

Not reported

Yes

No

100

Low

Thornton et al., 2009 [29]

Yes

Yes

Yes

Not reported

Yes

Yes

257

Medium

Guelinckx et al., 2010 [26]

Not reported

Randomised but not reported how

Not reported

Not reported

Yes

Not reported

99

Low

Phelan et al., 2011 [34]

Yes

Yes: Opaque envelope

Yes

Yes

Yes

Yes

401

Medium,

Quinlivan et al., 2011 [59]

Yes

Yes: Opaque envelope

Yes

Yes

Yes

Yes

124

Medium

Luoto et al., 2011 [43]

Yes

Yes

Yes

Yes

Yes

Yes

399

Medium

Nascimento et al., 2011 [44]

Yes

Yes: Opaque envelope

Yes

Yes

Yes

Yes

82

Low

Summary and analysis of studies that meet the criteria

This is shown in Figure 1 and in a tabulated format contained within Table 2 and 3.
https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig1_HTML.jpg
Figure 1

Flow diagram of study selection.

Summary measures and data synthesis

The main measure of effect of the meta-analysis was the odds ratio or standardised mean difference. The data syntheses were conducted according to the Cochrane methodology [50]. First, we used statistical meta-analysis techniques to assess the efficacy of the interventions of controlled trials. Chi-square statistics tests were used to test for heterogeneity (Q statistics) between controlled trials. When there was no significant heterogeneity, we combined effect sizes in a fixed effect statistical meta-analysis using Review Manager (RevMan; Version 5.0, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008). The meta-analyses were performed by calculating the odds ratios (for proportion data) or standardised mean differences (for scale data) using a fixed effects model. Quantitative analysis was performed on an intention-to-treat basis focused on data derived from the period of follow-up. There was heterogeneity between studies because of the smaller sample size of some of the studies (poor quality), variation of the study population and the intensity and duration of the interventional strategies being evaluated. A random effects model was used to adjust for heterogeneity.

Results

Study characteristics

The review process is outlined in Figure 1 and the selected papers summarised in Tables 2 and 3.

Fifteen trials met the inclusion criteria: 13 RCTs [2634] and six non-RCTs [35, 36, 38, 39, 51, 52]. All 19 trials were performed in developed countries: five in the USA, three in Canada, three in Australia, two in Finland and one in Denmark, Netherlands, Sweden, Spain, Brazil and Belgium (Tables 2 and 3). Five RCTs were judged to be of medium quality [27, 29, 34]. The rest were deemed low quality (Tables 4 and 5).

The pooled RCTs included a total of 1,228 participants and the pooled non-RCTs included 1,534 participants. Participants were predominantly white except in the studies by Asbee et al. [27], Gray-Donald et al. [38] and Hui et al. [33]. In the Asbee et al. study, the majority were described as being of Hispanic ethnicity [27].

For all included RCTs, the control group received no intervention or standard care. In the non-RCTs, most used non-parallel controls [35, 38, 39, 51] or controls from another centre [36]. The outcomes investigated in the trials were gestational weight gain, gestational diabetes, Caesarean section delivery, large for gestational age baby and birth weight.

Effects of the intervention on outcomes

Of the 19 controlled trials, 16 measured gestational weight gain (10 randomised, 6 non-randomised); 8 recorded gestational diabetes (6 randomised, 2 non-randomised); 10 recorded Caesarean delivery (6 randomised, 4 non-randomised); 10 measured large for gestational age (6 randomised, 4 non-randomised); and 7 measured birth weight (7 randomised). Meta-analyses for the different outcomes are shown in Tables 6 and 7, and Figures 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Table 6

Effect estimates for randomised trials of lifestyle advice versus standard care

Outcome or subgroup

Studies

Participants

Statistical method

Effect estimate

Large for gestational age

6

1,008

Odds ratio (Fixed, 95% CI)

0.91 (0.62, 1.32)

Caesarean delivery

6

663

Odds ratio (Fixed, 95% CI)

0.96 (0.68, 1.36)

Gestational diabetes

6

1,017

Odds ratio (M-H, Fixed, 95% CI)

0.80 (0.58, 1.10)a

Gestational weight gain (kg)

10

1,228

Mean difference (Fixed, 95% CI)

-2.21 (-2.86, -1.57)a

Birth weight (g)

7

1,133

Mean difference (Fixed, 95% CI)

-56.64 (-120.15, 6.88)

aStatistically significant pooled estimates. CI: confidence interval

Table 7

Effect estimates for non-randomised trials of lifestyle advice versus standard care

Outcome or subgroup

Studies

Participants

Statistical method

Effect estimate

Large for gestational age

4

1,199

Odds ratio (Fixed, 95% CI)

0.85 (0.63, 1.16)

Caesarean delivery

4

1,246

Odds ratio (Fixed, 95% CI)

1.13 (0.78, 1.64)

Gestational diabetes

2

233

Odds ratio (Fixed, 95% CI)

1.51 (0.72, 3.16)

Gestational weight gain (kg)

6

1,534

Mean difference (Fixed, 95% CI)

-0.42 (-1.03, 0.19)

CI: confidence interval

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig2_HTML.jpg
Figure 2

Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on gestational weight gain (kg).

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig3_HTML.jpg
Figure 3

Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on risk of gestational diabetes.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig4_HTML.jpg
Figure 4

Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on risk of Caesarean delivery.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig5_HTML.jpg
Figure 5

Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on risk of large for gestational age baby.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig6_HTML.jpg
Figure 6

Forest plot of randomised trials investigating the effect of lifestyle advice versus standard care on birthweight.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig7_HTML.jpg
Figure 7

Forest plot of non-randomised trials investigating the effect of lifestyle advice versus standard care on risk of large for gestational age baby.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig8_HTML.jpg
Figure 8

Forest plot of non-randomised trials investigating the effect of lifestyle advice versus standard care on risk of Caesarean section.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig9_HTML.jpg
Figure 9

Forest plot of non-randomised trials investigating the effect of lifestyle advice versus standard care on risk of gestational diabetes.

https://static-content.springer.com/image/art%3A10.1186%2F1741-7015-10-47/MediaObjects/12916_2011_Article_526_Fig10_HTML.jpg
Figure 10

Forest plot of non-randomised trials investigating the effect of lifestyle advice versus standard care on gestational weight gain (kg).

Meta-analysis of RCTs showed that combined antenatal lifestyle, dietary and activity intervention restricts gestational weight gain (Table 6 and Figure 2) and there was a trend towards reduction in the prevalence of gestational diabetes in overweight and obese women (Table 6 and Figure 3). However, meta-analysis of non-RCTs only showed weak evidence that lifestyle intervention reduces gestational weight gain (Table 7 and Figure 7) and there was no evidence for a reduction in prevalence of gestational diabetes (Table 7 and Figure 8). There was no robust evidence that lifestyle intervention is associated with a lower prevalence of Caesarean delivery or macrosomia or any alteration in birth weight (Tables 6 and 7, Figures 4,5, 6, 8, 9 and 10).

Intervention characteristics

The nature of the interventions varied widely between studies and some of the key features of the interventions are outlined in Tables 2 and 3. In summary, for the six non-RCTs, three of the interventions comprised individual and group or seminar components [36, 38, 39, 53], two were individual [35, 52] and one was unclear [51]. Of the 13 RCTs, one comprised individual and group components [33], eight were individual [2730, 32, 34] and three were group-based [26]. Where there were individual and group components, the latter were usually physical activity sessions. All of the non-RCTs included dietary and physical activity guidance, as did the majority of the randomised studies. Exceptions were two studies which included only nutritional guidance [29, 30] and one which included guidelines about weight gain and weight monitoring only [28]. The majority of studies included dietary or physical activity guidance, with one of the non-RCTs [35] and three of the RCTs [29, 3234] specifying that guidance was personalised.

Discussion

Summary of main findings

Antenatal lifestyle, dietary and activity advice for overweight and obese pregnant women restricts maternal weight gain during pregnancy and lowers the prevalence of gestational diabetes in women who are overweight or obese. However, the quality of the study designs was generally poor. The reduction in gestational weight gain was observed to be statistically significant in the meta-analysis of randomised trials (10 RCTs; n = 1,228; -2.21 kg (95% CI, -2.86 to -1.57 kg)) but non-significant in the meta-analysis of non-randomised trials (six non-RCTs; n = 1,534). No effects of antenatal lifestyle interventions were identified in obese and overweight pregnant women in relation to Caesarean delivery, large for gestational age, birth weight and macrosomia (> 4 kg).

Interpretation

There is evidence to suggest antenatal lifestyle interventions may restrict gestational weight gain and a trend towards a reduced prevalence of gestational diabetes, but there was no statistical effect on other important clinical outcomes, possibly due to inadequate power of the combined sample size. The effect on restricted weight gain and gestational diabetes was not consistent across all the trial populations and therefore cannot be generalised. There was also wide variation in the types of interventions evaluated in the studies. The majority were individual-based and most provided generic guidance comprising mainly dietary and physical activity information, with few tailoring guidelines. There was considerable heterogeneity in intervention design and no obvious patterns between intervention type and study outcomes. For the gestational weight gain and gestational diabetes outcomes, both the successful and non-successful studies included those which were personalised, combined physical activity and dietary guidance and were individual-based. Moreover, degrees of weight gain restriction achieved were modest overall. It is even harder to make conclusions regarding the specific behaviour change strategies included (for example, monitoring and goal setting) or theoretical basis of interventions since these were typically poorly reported.

Identifying specific components of successful interventions aids understanding of how interventions are having an effect and clear reporting of intervention design allows for easier replication [54]. Previous reviews have attempted to make conclusions regarding specific effective components of interventions. Suggestions that weight monitoring and setting weight goals could be useful [46] and also monitoring along with education counselling and physical activity sessions [51, 55] have been made. Another review suggested that interventions should be based on the Theory of Planned Behaviour, but the rationale for using this model over others in this population was unclear [56]. None of these reviews examined intervention components systematically. A more recent review by Gardner et al. assessed interventions targeting gestational weight gain from a psychological perspective and specifically examined intervention content and delivery methods [57]. This review comprised 10 controlled trials, all included in the current review; only two of the studies reported basing interventions on theory and the studies used, on average, five behaviour change strategies (self-monitoring, feedback provision and setting behavioural goals were the most common), but no conclusions could be drawn as to their contribution to study outcomes. Broadly consistent with this were the four studies in the current review which were not included in the review by Gardner et al. [57]. Their review questioned the evidence supporting the benefits of weight monitoring, but tentatively suggested that information provision had been underused and that it might be of benefit to have a narrower focus of intervention targets [57].

Comparison with other systematic reviews and strengths

Our study adds to a growing body of evidence that aims to evaluate lifestyle intervention as a means to minimise the adverse outcome associated with obesity in pregnancy. In comparison to other published reviews [45, 46, 56], we have adopted an original approach by broadening the literature source (multiple data sources, no language restriction), focusing on relevant clinical outcomes (such as Caesarean section, gestational diabetes, macrosomia), and improving our sensitivity by meta-analysing both RCTs and non-RCTs. Furthermore, to minimise bias, the review methodology was registered a priori (Prospero number CRD420111122 http://www.crd.york.ac.uk/PROSPERO). We therefore believe our review provides a comprehensive and reliable analysis of the current evidence and for the first time highlights that lifestyle intervention in pregnancy may reduce the prevalence of gestational diabetes.

Limitations of this systematic review

The evidence summarised in this work comes from available studies of which most are of low quality, with only four studies fulfilling a medium quality score. Hence, the evidence base is weak and calls for more robust studies. Our trial population is relatively small, the intensity and duration of the interventions of trials varied and trials were predominantly USA in origin; a phenomenon common to many public health reviews, especially on obesity. Although our focus was on antenatal lifestyle intervention for obese and overweight pregnant women, our search yielded some studies that contained a mixed group of obese and normal weight women and we excluded all the non-obese participants from our analysis. Still, this may lead to inconsistencies in measuring the effect of the intervention as well as under- or overestimating the treatment effect. Furthermore, even though our search was systematic and rigorous, we could have missed eligible studies inadvertently.

Conclusions

This review reveals that lifestyle interventions for obese and overweight women during pregnancy restrict gestational weight gain and a trend was evident towards reducing the prevalence of gestational diabetes. However, the quality of the published studies is mainly poor. This then highlights a paradox. At a time when solutions to address adverse outcome associated with maternal overweight and obesity are identified as a public health priority, we find that most of the research evidence lacks robustness to inform future evidence-based lifestyle interventions for obese pregnant women. There is thus a research gap regarding the effectiveness of lifestyle intervention in pregnancy. It is unlikely that further meta-analysis will help to refine the quality of evidence because studies demonstrated significant heterogeneity in relation to demography, outcome measurement, follow-up and degree of intervention. Hence, we conclude that there is the need for a well-designed large-scale prospective trial which examines combined antenatal lifestyle interventions in obese pregnant women that is suitably powered and incorporates robust methodology in accordance with standards set by Medical Research Council's framework for evaluating complex interventions [58]. There are two such studies which are currently ongoing called LIMIT (ACTRN 12607000161426) and UPBEAT (ISRCTN89971375). Both of these studies are appropriately powered to show convincingly whether lifestyle intervention is most likely to improve pregnancy outcome or not.

Declarations

Acknowledgements

We acknowledge Lisa Xue, Royal College of Obstetricians and Gynaecologists Librarian, for her help in acquiring most of the manuscripts in time. We also acknowledge Guy's and St Thomas' charity for supporting E-ON. This manuscript presents independent research commissioned by the National Institute for Health Research (NIHR, UK) under the programme grants for Applied Research programme RP-0407-10452. The views expressed in this manuscript are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

Authors’ Affiliations

(1)
Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust (King's Health Partners), St Thomas' Hospital
(2)
London School of Hygiene and Tropical Medicine
(3)
School of Medicine, King's College London
(4)
Department of Epidemiology and Public Health, University College London

References

  1. Haslam DW, James WP: Obesity. Lancet. 2005, 366: 1197-1209.View ArticlePubMedGoogle Scholar
  2. Low S, Chin MC, Deurenberg-Yap M: Review on epidemic of obesity. Ann Acad Med Singapore. 2009, 38: 57-59.PubMedGoogle Scholar
  3. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, Singh GM, Gutierrez HR, Lu Y, Bahalim AN, Farzadfar F, Riley LM, Ezzati M, Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Body Mass Index): National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011, 377: 557-567.PubMed CentralView ArticlePubMedGoogle Scholar
  4. Aylott J, Brown I, Copeland R, Johnson D: Tackling obesity: the foresight report and implication for local government. 2008, [http://www.idea.gov.uk/idk/aio/8268011]Google Scholar
  5. Kanagalingam MG, Forouhi NG, Greer IA, Sattar N: Changes in booking body mass index over a decade: retrospective analysis from a Glasgow Maternity Hospital. BJOG. 2005, 112: 1431-1433.View ArticlePubMedGoogle Scholar
  6. Heslehurst N, Ells LJ, Simpson H, Batterham A, Wilkinson J, Summerbell CD: Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period. BJOG. 2007, 114: 187-194.View ArticlePubMedGoogle Scholar
  7. Heslehurst N, Rankin J, Wilkinson JR, Summerbell CD: A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619 323 births, 1989-2007. Int J Obes (Lond). 2010, 34: 420-428.View ArticleGoogle Scholar
  8. Centre for Maternal and Child Enquiries: Maternal obesity in the United Kingdom: findings from a national project. 2010, [http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/CMACE/CMACE_Obesity_Report_2010_Final%20for%20printing.pdf]Google Scholar
  9. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, Regan L, Robinson S: Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord. 2001, 25: 1175-1182.View ArticlePubMedGoogle Scholar
  10. Poston L: Developmental programming and diabetes - the human experience and insight from animal models. Best Pract Res Clin Endocrinol Metab. 2010, 24: 541-552.View ArticlePubMedGoogle Scholar
  11. Yogev Y, Visser GH: Obesity, gestational diabetes and pregnancy outcome. Semin Fetal Neonatal Med. 2009, 14: 77-84.View ArticlePubMedGoogle Scholar
  12. Torloni MR, Betran AP, Horta BL, Nakamura MU, Atallah AN, Moron AF, Valente O: Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis. Obes Rev. 2009, 10: 194-203.View ArticlePubMedGoogle Scholar
  13. Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, Dietz PM: Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care. 2007, 30: 2070-2076.View ArticlePubMedGoogle Scholar
  14. O'Brien TE, Ray JG, Chan WS: Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology. 2003, 14: 368-374.View ArticlePubMedGoogle Scholar
  15. Larsen TB, Sorensen HT, Gislum M, Johnsen SP: Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study. Thromb Res. 2007, 120: 505-509.View ArticlePubMedGoogle Scholar
  16. Knight M: Antenatal pulmonary embolism: risk factors, management and outcomes. BJOG. 2008, 115: 453-461.View ArticlePubMedGoogle Scholar
  17. Usha Kiran TS, Hemmadi S, Bethel J, Evans J: Outcome of pregnancy in a woman with an increased body mass index. BJOG. 2005, 112: 768-772.View ArticlePubMedGoogle Scholar
  18. Poobalan AS, Aucott LS, Precious E, Crombie IK, Smith WC: Weight loss interventions in young people (18 to 25 year olds): a systematic review. Obes Rev. 2010, 11: 580-592.View ArticlePubMedGoogle Scholar
  19. Stothard KJ, Tennant PW, Bell R, Rankin J: Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA. 2009, 301: 636-650.View ArticlePubMedGoogle Scholar
  20. Zhang J, Bricker L, Wray S, Quenby S: Poor uterine contractility in obese women. BJOG. 2007, 114: 343-348.View ArticlePubMedGoogle Scholar
  21. Smith GC, Shah I, Pell JP, Crossley JA, Dobbie R: Maternal obesity in early pregnancy and risk of spontaneous and elective preterm deliveries: a retrospective cohort study. Am J Public Health. 2007, 97: 157-162.PubMed CentralView ArticlePubMedGoogle Scholar
  22. Poston L, Harthoorn LF, van der Beek EM: Obesity in pregnancy: implications for the mother and lifelong health of the child. A consensus statement. Pediatr Res. 2011, 69: 175-180.View ArticlePubMedGoogle Scholar
  23. Ludwig DS, Currie J: The association between pregnancy weight gain and birthweight: a within-family comparison. Lancet. 2010, 376: 984-990.PubMed CentralView ArticlePubMedGoogle Scholar
  24. Nohr EA, Vaeth M, Baker JL, Sorensen T, Olsen J, Rasmussen KM: Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. Am J Clin Nutr. 2008, 87: 1750-1759.PubMedGoogle Scholar
  25. Inskip HM, Crozier SR, Godfrey KM, Borland SE, Cooper C, Robinson SM: Women's compliance with nutrition and lifestyle recommendations before pregnancy: general population cohort study. BMJ. 2009, 338: b481.PubMed CentralView ArticlePubMedGoogle Scholar
  26. Guelinckx I, Devlieger R, Mullie P, Vansant G: Effect of lifestyle intervention on dietary habits, physical activity, and gestational weight gain in obese pregnant women: a randomized controlled trial. Am J Clin Nutr. 2010, 91: 373-380.View ArticlePubMedGoogle Scholar
  27. Asbee SM, Jenkins TR, Butler JR, White J, Elliot M, Rutledge A: Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial. Obstet Gynecol. 2009, 113: 305-312.View ArticlePubMedGoogle Scholar
  28. Jeffries K, Shub A, Walker SP, Hiscock R, Permezel M: Reducing excessive weight gain in pregnancy: a randomised controlled trial. Med J Aust. 2009, 191: 429-433.PubMedGoogle Scholar
  29. Thornton YS, Smarkola C, Kopacz SM, Ishoof SB: Perinatal outcomes in nutritionally monitored obese pregnant women: a randomized clinical trial. J Natl Med Assoc. 2009, 101: 569-577.View ArticlePubMedGoogle Scholar
  30. Wolff S, Legarth J, Vangsgaard K, Toubro S, Astrup A: A randomized trial of the effects of dietary counseling on gestational weight gain and glucose metabolism in obese pregnant women. Int J Obes (Lond). 2008, 32: 495-501.View ArticleGoogle Scholar
  31. Yeo S: A randomized comparative trial of the efficacy and safety of exercise during pregnancy: design and methods. Contemp Clin Trials. 2006, 27: 531-540.View ArticlePubMedGoogle Scholar
  32. Polley BA, Wing RR, Sims CJ: Randomized controlled trial to prevent excessive weight gain in pregnant women. Int J Obes Relat Metab Disord. 2002, 26: 1494-1502.View ArticlePubMedGoogle Scholar
  33. Hui AL, Ludwig SM, Gardiner P, Sevenhuysen G, Murray R, Morris M, Shen GX: Community based excercise and dietary intervention during pregnancy: a pilot study. Canadian Journal of Diabetes. 2006, 30: 169-175.View ArticleGoogle Scholar
  34. Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR: Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. Am J Clin Nutr. 2011, 93: 772-779.PubMed CentralView ArticlePubMedGoogle Scholar
  35. Mottola MF, Giroux I, Gratton R, Hammond JA, Hanley A, Harris S, McManus R, Davenport MH, Sopper MM: Nutrition and exercise prevent excess weight gain in overweight pregnant women. Med Sci Sports Exerc. 2010, 42: 265-272.PubMed CentralView ArticlePubMedGoogle Scholar
  36. Claesson IM, Sydsjo G, Brynhildsen J, Cedergren M, Jeppsson A, Nystrom F, Sydsjö A, Josefsson A: Weight gain restriction for obese pregnant women: a case-control intervention study. BJOG. 2008, 115: 44-50.View ArticlePubMedGoogle Scholar
  37. Kinnunen TI, Aittasalo M, Koponen P, Ojala K, Mansikkamaki K, Weiderpass E, Fogelholm M, Luoto R: Feasibility of a controlled trial aiming to prevent excessive pregnancy-related weight gain in primary health care. BMC Pregnancy Childbirth. 2008, 8: 37.PubMed CentralView ArticlePubMedGoogle Scholar
  38. Gray-Donald K, Robinson E, Collier A, David K, Renaud L, Rodrigues S: Intervening to reduce weight gain in pregnancy and gestational diabetes mellitus in Cree communities: an evaluation. CMAJ. 2000, 163: 1247-1251.PubMed CentralPubMedGoogle Scholar
  39. Shirazian T, Monteith S, Friedman F, Rebarber A: Lifestyle modification program decreases pregnancy weight gain in obese women. Am J Perinatol. 2010, 27: 411-414.View ArticlePubMedGoogle Scholar
  40. HAPO Study Cooperative Research Group: Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations with neonatal anthropometrics. Diabetes. 2009, 58: 453-459.View ArticleGoogle Scholar
  41. Barakat R, Cordero Y, Coteron J, Luaces M, Montejo R: Exercise during pregnancy improves maternal glucose screen at 24-28 weeks: a randomised controlled trial. Br J Sports Med. 2011.Google Scholar
  42. Ong MJ, Guelfi KJ, Hunter T, Wallman KE, Fournier PA, Newnham JP: Supervised home-based exercise may attenuate the decline of glucose tolerance in obese pregnant women. Diabetes Metab. 2009, 35: 418-421.View ArticlePubMedGoogle Scholar
  43. Luoto R, Kinnunen TI, Aittasalo M, Kolu P, Raitanen J, Ojala K, Mansikkamäki K, Lamberg S, Vasankari T, Komulainen T, Tulokas S: Primary prevention of gestational diabetes mellitus and large-for-gestational-age newborns by lifestyle counseling: a cluster-randomized controlled trial. PLoS Med. 2011, 8: e1001036.PubMed CentralView ArticlePubMedGoogle Scholar
  44. Nascimento SL, Surita FG, Parpinelli MA, Siani S, Pinto e Silva JL: The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomised clinical trial. BJOG. 2011, 118: 1455-1463.View ArticlePubMedGoogle Scholar
  45. Dodd JM, Grivell RM, Crowther CA, Robinson JS: Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials. BJOG. 2010, 117: 1316-1326.View ArticlePubMedGoogle Scholar
  46. Streuling I, Beyerlein A, von Kries R: Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials. Am J Clin Nutr. 2010, 92: 678-687.View ArticlePubMedGoogle Scholar
  47. Tanentsapf I, Heitmann BL, Adegboye AR: Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. BMC Pregnancy Childbirth. 2011, 11: 81.PubMed CentralView ArticlePubMedGoogle Scholar
  48. Sui Z, Grivell RM, Dodd JM: Antenatal exercise to improve outcomes in overweight or obese women: a systematic review. Acta Obstet Gynecol Scand. 2012, 91: 538-545.View ArticlePubMedGoogle Scholar
  49. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009, 339: b2700.PubMed CentralView ArticlePubMedGoogle Scholar
  50. Cochrane Handbook for Systematic Reviews of Interventions. 2011, [http://www.cochrane.org/training/cochrane-handbook]
  51. Olson CM: A call for intervention in pregnancy to prevent maternal and child obesity. Am J Prev Med. 2007, 33: 435-436.View ArticlePubMedGoogle Scholar
  52. Kinnunen TI, Pasanen M, Aittasalo M, Fogelholm M, Hilakivi-Clarke L, Weiderpass E, Luoto R: Preventing excessive weight gain during pregnancy - a controlled trial in primary health care. Eur J Clin Nutr. 2007, 61: 884-891.View ArticlePubMedGoogle Scholar
  53. Claesson IM, Brynhildsen J, Cedergren M, Jeppsson A, Sydsjo A, Josefsson A: Weight gain restriction during pregnancy is safe for both the mother and neonate. Acta Obstet Gynecol Scand. 2009, 88: 1158-1162.View ArticlePubMedGoogle Scholar
  54. Michie S, Abraham C, Eccles MP, Francis JJ, Hardeman W, Johnston M: Strengthening evaluation and implementation by specifying components of behaviour change interventions: a study protocol. Implement Sci. 2011, 6: 10.PubMed CentralView ArticlePubMedGoogle Scholar
  55. Olson CM: Achieving a healthy weight gain during pregnancy. Annu Rev Nutr. 2008, 28: 411-423.View ArticlePubMedGoogle Scholar
  56. Birdsall KM, Vyas S, Khazaezadeh N, Oteng-Ntim E: Maternal obesity: a review of interventions. Int J Clin Pract. 2009, 63: 494-507.View ArticlePubMedGoogle Scholar
  57. Gardner B, Wardle J, Poston L, Croker H: Changing diet and physical activity to reduce gestational weight gain: a meta-analysis. Obes Rev. 2011, 12: e602-e620.View ArticlePubMedGoogle Scholar
  58. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M: Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008, 337: a1655.PubMed CentralView ArticlePubMedGoogle Scholar
  59. Quinlivan JA, Lam LT, Fisher J: A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women. Aust NZJ Obstet Gynaecol. 2011, 51: 141-146.View ArticleGoogle Scholar
  60. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/10/47/prepub

Copyright

© Oteng-Ntim et al; licensee BioMed Central Ltd. 2012

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.