UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Lifestyle interventions for obese women before and during pregnancy: The
effect on pregnancy outcomes
Ruifrok, A.E.
Publication date
2014
Link to publication
Citation for published version (APA):
Ruifrok, A. E. (2014). Lifestyle interventions for obese women before and during pregnancy:
The effect on pregnancy outcomes.
General rights
It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulations
If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible.
General introduction
...
CHAPTER
General introduction
10
Background
The increasing prevalence of obesity worldwide has forced the World Health Organization (WHO) to regard this as one of the priorities for reducing the ‘Global burden of disease’.1
In addition to long-term health consequences, the rising prevalence of obesity in women worldwide has implications for their reproductive outcome, and affects their chances of pregnancy. Also, the result of pregnancy may be adversely affected by obesity.
Obesity is associated with menstrual disorders and anovulation2-4 but
fertility is also decreased in women with regular menstrual cycles who are overweight.5;6 Furthermore, women, who are overweight or obese while
undergoing assisted reproduction, have lower pregnancy rates and higher miscarriage rates.7-9 During pregnancy, obesity leads to a significant
increase in pregnancy complications10;11 and difficulties during labour.12
Infants are at greater risk of congenital abnormalities13;14 and intrauterine
demise15;16 contributing to an increase in perinatal morbidity and mortality.
Not only pre-pregnancy obesity is related to adverse outcomes. Also excessive weight gain during pregnancy is associated with an increased risk of obstetrical, maternal and foetal complications, postpartum maternal weight retention, and also with an increased risk of obesity in the offspring.17-28
Excessive gestational weight gain and the associated postpartum weight retention contribute to the prevalence of women who are overweight or obese and increase the long-term risk of body weight-associated diseases, which impose a great pressure on health care.28-31
The Institute of Medicine (IOM) guidance in the US provides recommended weight gain ranges in pregnancy for normal, overweight and obese women based on observational data.32 In the absence of
validation of these recommendations in large interventional trials, the benefits of adhering to these weight gain guidelines during pregnancy are unclear. The economic evaluation commissioned by NICE acknowledged this limitation and considered that the assumed effects of weight changes on pregnancy outcomes were subject to strong assumptions.33 Currently,
the National Institute for Health and Clinical Excellence in the United Kingdom34 does not recommend specific weight gain targets in pregnancy
in the absence of robust data validated in interventional trials. Therefore, there is a clear need for establishing the relationship between gestational weight gain and pregnancy outcomes from randomised intervention trials.
11
1
Results of Recent Trials
Pre-pregnancy InterventionsNorman et al.35 showed in their review that reducing the pre-pregnancy
weight in overweight or obese women with infertility increases the chances of both spontaneous conception and conception after ovulation induction and assisted reproduction. Weight loss achieved by a lifestyle programme – a combination of diet and physical activity – leads to an increase in spontaneous pregnancies and pregnancies after fertility treatment.36 An
RCT of Hoeger et al.37 showed that in obese women with polycystic ovary
syndrome (PCOS), not the type of treatment (metformin versus lifestyle programme versus placebo), but the amount of weight reduction was the most important factor for the resumption of ovulation. These trials show that weight loss in infertile obese women should be considered as the first treatment.
In view of the low success rate of lifestyle interventions in achieving weight loss and even lower success rate for maintaining this weight loss, drug therapy for obesity in conjunction with the continuation of lifestyle changes could be an asset in the treatment of women with infertility.
Although insulin sensitising drugs are not considered anti-obesity drugs, evidence indicates that metformin therapy might contribute to weight loss.38;39 If metformin treatment does contribute to weight loss, treatment
of women of reproductive age with obesity and infertility could improve the chances of conception.
According to a randomised controlled trial (RCT), the combination of a lifestyle modification programme with drug therapy achieves more weight loss than a lifestyle programme alone.40
Interventions during Pregnancy
Many trials have been conducted evaluating the effect of different lifestyle interventions on gestational weight gain (GWG) and adverse pregnancy outcomes, which were recently reviewed and combined in a meta-analysis.41
Dietary and lifestyle interventions in pregnancy have been shown to significantly reduce gestational weight gain, and lead to reduced risk of pregnancy complications such as pre-eclampsia, gestational diabetes mellitus, gestational hypertension and preterm delivery without any reported adverse effects.42 In a subgroup analysis, a stronger effect was
observed in obese and overweight women. Dietary interventions seem to be more effective than physical activity.42 However, it must be noted
that the compliance with the interventions was either not assessed or insufficient in some trials. Furthermore, the relationship between GWG and pregnancy complications was not investigated.
Impact on Society
Worldwide working women of childbearing age are a vital part of the working population. Given the association between obesity and
12
pregnancy complications and obesity and sick leave in general,43-46 one
might expect that obese pregnant women would have an increased risk for sick leave. However, to date, the relationship between body mass index and sick leave in pregnant women has not been investigated.
Pre-pregnancy maternal obesity, and excessive weight gain in pregnancy impose an increasing pressure on health care resources,31;47;48
due to increase chance of pregnancy complications.
A reduction of the number of maternal and neonatal complications, for instance by decreasing GWG, might result in a decrease in health care cost during and after pregnancy. Previous meta-analysis already reported positive effects of lifestyle interventions in pregnancy on maternal and neonatal health.42 A reduction of the number of maternal and neonatal
complications, might result in a decrease in health care cost during pregnancy.
Little is known about the effect of GWG and pregnancy complications. Also the budget impact of lifestyle intervention is not yet clear. The potential economic consequences of providing a lifestyle intervention for overweight and obese women in pregnancy could be helpful to stimulate policymakers to advocate implementation of lifestyle interventions in pregnancy.
Aim of the Thesis
The aim of this thesis was to assess effects of weight-reduction interventions before, and lifestyle interventions during pregnancy on pregnancy related outcomes and gestational weight gain. In addition, we aimed to estimate costs to society associated with obesity and weight gain in pregnancy, in terms of monetary costs and in terms of sick leave.
Outline of this Thesis
Obesity is associated with a decreased fertility and an increased rate of complications during pregnancy. Chapter 2 shows an overview of the possible effects of obesity on fertility and pregnancy complications in women of reproductive age. In chapter 3 of this thesis we assessed the effects of insulin sensitising drugs on weight loss compared to diet or a lifestyle programme in overweight and obese women of reproductive age.
Lifestyle interventions in obese pregnant women reduce adverse maternal outcomes of pregnancy. However, the association between differences in gestational weight gain due to interventions and the actual reduction in complications is unknown. In chapter 4, the association between gestational weight gain and pregnancy complications was assessed. The relationship between sedentary behaviour and weight (gain) has been found in women and adolescent girls outside of pregnancy.49;50
13
1
During pregnancy, women in the United States spent more than half of the monitored day in sedentary behaviour.51 However, whether the amount
of time spent sedentary influences gestational weight gain or birth weight is currently unknown.
In chapter 5, the relationship of physical activity and sedentary behaviour in pregnancy with gestational weight gain and birth weight was determined.
Being overweight or obese during pregnancy and excessive weight gain increase the chance of complications, including among others maternal death, miscarriage, pre-eclampsia, gestational diabetes mellitus, postpartum haemorrhage.12;52 This imposes a great pressure on health
care.31;47;48 In chapter 6 we evaluated the budget impact of decreasing
the risk of pregnancy complications through lifestyle interventions.
In many cost-effectiveness analyses of interventions in pregnancy, only short term effects on health care consumption and associated costs were evaluated. However, sick leave associated with obesity and/or pregnancy complications might have a great impact on costs for society. To date, the relationship between body mass index and sick leave of pregnant women has not been investigated. In chapter 7 we assessed the relationship between BMI and sick leave before, and during pregnancy and one year postpartum.
Most meta-analyses are based on aggregated average outcomes per study, thereby limiting the statistical precision of the meta-analysis. Also, due to the aggregated data there is heterogeneity within and between the studies. An individual patient data (IPD) meta-analysis would overcome this problem. This approach provides adequate power to generate valid, reliable answers and to create models for decision analytic modelling for health economic evaluation.
We therefore plan an IPD meta-analysis to evaluate the differential effects of diet and physical activity based interventions on maternal and foetal outcomes. Chapter 8 describes the protocol for this IPD meta-analysis, which is conducted in international collaboration.
IPD meta-analyses and large clinical studies provide information and insight that are used to develop clinical guidelines. Many researchers have therefore initiated multicentre studies. In some situations, the activities of these groups have led to networks, through which multiple trials have been executed over a longer period of time. The Global Obstetrics Network (GONet) was formed to link the different types of networks. The expectation is that this will lead to better studies and more efficient use of resources. Chapter 9 explains the need of international collaboration and the mission, goals and structure of GONet.
14
References
1. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894: i-xii, 1-253.
2. Green BB, Weiss NS, Daling JR. Risk of ovulatory infertility in relation to body weight. Fertil Steril 1988;50:721-6.
3. Grodstein F, Goldman MB, Cramer DW. Body mass index and ovulatory infertility. Epidemiology 1994;5:247-50.
4. Lake JK, Power C, Cole TJ. Women’s reproductive health: the role of body mass index in early and adult life. Int J Obes Relat Metab Disord 1997;21:432-438.
5. Jensen TK, Scheike T, Keiding N, Schaumburg I, Grandjean P. Fecundability in relation to body mass and menstrual cycle patterns. Epidemiology 1999;10:422-8.
6. Van der Steeg JW, Steures P, Eijkemans MJ, Habbema JD, Hompes PG, Burggraaff JM, Oosterhuis GJ, Bossuyt PM, van der Veen F, Mol BW. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008;23:324-328.
7. Wang JX, Davies M, Norman RJ. Body mass and probability of pregnancy during assisted reproduction treatment: retrospective study. BMJ 2000;321:1320-1. 8. Lintsen AM, Pasker-de Jong PC, Boer EJ de, Burger CW, Jansen CA, Braat DD,
et al. Effects of subfertility cause, smoking and body weight on the success rate of IVF. Hum Reprod 2005;20:1867-75.
9. Maheshwari A, Stofberg L, Bhattacharya S. Effect of overweight and obesity on assisted reproductive technology a systematic review. Hum Reprod Update 2007;13:433-444.
10. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004;103:219-224.
11. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, Saade G, Eddleman K, Carter SM, Craigo SD et al. Obesity, obstetric complications and cesarean delivery rate: a population-based screening study. Am J Obstet Gynecol 2004;190:1091-1097.
12. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001;25: 1175-82.
13. Waller DK, Mills JL, Simpson JL, Cunningham GC, Conley MR, Lassman MR, Rhoads GG. Are obese women at higher risk for producing malformed offspring? Am J Obstet Gynecol 1994;170:541-548.
14. Werler MM, Louik C, Shapiro S, Mitchell AA. Prepregnant weight in relation to risk of neural tube defects. J Am Med Assoc 1996;275: 1089-1092.
15. Stephansson O, Dickman PW, Johansson A, Cnattingius S. Maternal weight, pregnancy weight gain, and the risk of antepartum stillbirth. Am J Obstet Gynecol 2001;184:463-469.
16. Nohr EA, Bech BH, Davies MJ, Frydenberg M, Henriksen TB, Olsen J. Prepregnancy obesity and fetal death: a study within the Danish National Birth Cohort. Obstet Gynecol 2005;106:250-259.
17. Cedergren MI. Optimal gestational weight gain for body mass index categories. Obstet Gynecol 2007;110(4):759-764.
18. DeVader SR, Neeley HL, Myles TD, Leet TL. Evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstet Gynecol 2007;110(4):745-751.
19. Dietz PM, Callaghan WM, Cogswell ME, Morrow B, Ferre C, Schieve LA. Combined effects of prepregnancy body mass index and weight gain during
15
1
pregnancy on the risk of preterm delivery. Epidemiology 2006;17(2):170–177. 20. Hedderson MM, Gunderson EP, Ferrara A. Gestational weight gain and risk of
gestational diabetes mellitus. Obstet Gynecol 2010;115(3):597-604.
21. Olson CM. Achieving a healthy weight gain during pregnancy. Annu Rev Nutr 2008;28:411-423.
22. Rasmussen T, Stene LC, Samuelsen SO, et al. Maternal BMI before pregnancy, maternal weight gain during pregnancy, and risk of persistent positivity for multiple diabetes-associated autoantibodies in children with the high-risk HLA genotype: the MIDIA study. Diabetes Care 2009;32(10):1904-1906.
23. Siega-Riz AM, Siega-Riz AM, Laraia B. The implications of maternal overweight and obesity on the course of pregnancy and birth outcomes. Matern Child Health J 2006;10(5, Suppl): S153-S156.
24. Thorsdottir I, Torfadottir JE, Birgisdottir BE, Geirsson RT. Weight gain in women of normal weight before pregnancy: complications in pregnancy or delivery and birth outcome. Obstet Gynecol 2002;99(5 Pt 1):799-806.
25. Zhang X, Decker A, Platt RW, Kramer MS. How big is too big? The perinatal consequences of fetal macrosomia. Am J Obstet Gynecol 2008;198(5):e1–e6. 26. Oken E, Taveras EM, Kleinman KP, Rich-Edwards JW, Gillman MW. Gestational
weight gain and child adiposity at age 3 years. Am J Obstet Gynecol 2007;196(4):e1-e8.
27. Sharma AJ, Cogswell ME, Grummer Strawn LM. The association between pregnancy weight gain and childhood overweight is modified by mother’s pre pregnancy BMI [abstract]. Pediatr Res 2005;58:1038.
28. US Department of Health and Human Services. Healthy Eating and Physical Activity across your Life Span: Fit for Two: Tips for Pregnancy. NIDDK Weight Control Information Network. NIH Publication No. 02-5130. 2002.
29. Linné Y, Dye L, Barkeling B, Rössner S. Long-term weight development in women: a 15-year follow-up of the effects of pregnancy. Obes Res 2004;12(7):1166-1178.
30. Rooney BL, Schauberger CW. Excess pregnancy weight gain and long-term obesity: one decade later. Obstet Gynecol 2002;100(2): 245-252.
31. Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr 2000;71(5, Suppl): 1242S-1248S.
32. Rasmussen KM, Yatkine AL, editors. Weight gain during pregnancy: re-examining the guidelines. Committee to Reexamine Institute of Medicine Pregnancy Weight Guidelines 2009.
33. Madan J, Chilcott J. Weight Management in Pregnancy: Economic Modelling. ScHARR Public Health Collaborating Centre 2012.
34. NICE public health guidance 27. Dietary interventions and physical activity interventions for weight management before, during and after pregnancy. National Institute for Health and Clinical Excellence 2010.
35. Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004;10:267-80.
36. Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998;13:1502-1505.
37. Hoeger KM, Kochman L, Wixom N, Craig K, Miller RK, Guzick DS. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study. Fertil Steril. 2004;82(2):421-9.
16
EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
39. Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA et al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007;356:551-566.
40. Wadden TA, Berkowitz RI, Womble LG, Sarwer DB, Phelan S, Cato RK, Hesson LA, Osei SY, Kaplan R, Stunkard AJ. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med 2005;353:2111-2120.
41. Thangaratinam S, Rogozińska E, Jolly K, Glinkowski S, Duda W, Borowiack E, Roseboom T, Tomlinson J, Walczak J, Kunz R, Mol BW, Coomarasamy A, Khan KS. Interventions to reduce or prevent obesity in pregnant women: a systematic review. Health Technol Assess 2012;16(31):iii-iv, 1-191.
42. Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Roseboom T, Tomlinson JW, Kunz R, Mol BW, Coomarasamy A, Khan KS. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. BMJ 2012;344:e2088.
43. Neovius K, Johansson K, Kark M, Neovius M. Obesity status and sick-leave: a systematic review. Obes Rev 2009;10:17-27.
44. Neovius K, Neovius M, Kark M, Rasmussen F. Association between obesity status and sick-leave in Swedish men: nationwide cohort study. Eur J Public Health 2010;22:112-6.
45. Harvey SB, Glozier N, Carlton O, Mykletun A, Henderson M, Hotopf M, et al. Obesity and sickness absence: results from the CHAP study. Occupational Med 2010;60:362-8.
46. Van Duijvenbode DC, Hoozemans MJ, van Poppel MN, Proper KI. The relationship between overweight and obesity, and sick-leave: a systematic review. Int J Obes 2009;33:807-16.
47. UK: National Audit Office. Tackling obesity in England. Stationery Office, 2001. 48. 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. 49. Hu FB, Li TY, Colditz GA, Willett WC et al. Television watching and other
sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA 2003;289(14):1785-1791.
50. Costigan SA, Barnett L, Plotnikoff RC et al. The Health Indicators Associated With Screen-Based Sedentary Behavior Among Adolescent Girls: A Systematic Review. J Adolesc Health 2013;52(4):382-392.
51. Evenson KR, Wen F. Prevalence and correlates of objectively measured physical activity and sedentary behavior among US pregnant women. Prev Med 2011; 53(1-2):39-43.
52. Cnattingius S, Bergström R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998;338(3):147-52.
