A diet and physical activity intervention for preventing weight retention among Taiwanese childbearing women: a randomised controlled trial
Introduction
The increasing prevalence of overweight and obese individuals in the general population is a significant health concern in Taiwan (Department of Health, 2006). However, the National Nutritional Survey in Taiwan (Department of Health, 2002) reports that women are more likely than men to be overweight and obese (for those ⩾19 years, 42.0% vs 37.7%; for those ⩾45 years, 62.2% vs 43.0%, respectively). Furthermore, the prevalence of overweight and obese women of childbearing age is rising, with a large proportion of Taiwanese women gaining more than the recommended weight during pregnancy (Kac et al., 2004a, Kac et al., 2004b; Walker et al., 2005; Huang and Dai, 2007).
Recommended gestational weight gain (GWG) is associated with optimal fetal and maternal outcomes, whereas excessive weight gain increases the risk of pregnancy complications, infant macrosomia and caesarean birth (Abrams et al., 2000). Excessive GWG is also one of the main factors explaining high postpartum weight retention (Gunderson and Abrams, 2000; Siega-Riz et al., 2004; Huang and Dai, 2007; Kinnunen et al., 2007a, Kinnunen et al., 2007b; Huang et al., 2010). The GWG recommended by the Department of Health in Taiwan is 10–14 kg regardless of body size.
The transition to motherhood offers an opportunity to study weight concerns and weight management strategies during a period of weight fluctuation that is part of a life transition for many women. Pregnancy marks the beginning of a life stage in which women think not only of their nutritional needs and weight goals, but also of the needs of their child. During pregnancy, women were found to decrease their exercise and be more liberal with their diet, and during the postpartum period, they delayed returning to their pre-pregnancy diet and exercise practices (Devine et al., 2000).
In the postpartum period, weight retention has been associated with disappointment, surprise, symptoms of eating disorders, reduced self-esteem and depressive symptoms (Devine et al., 2000; Huang and Dai, 2007). Dissatisfaction with weight following childbirth has been positively associated with pre-pregnancy body mass index (BMI), GWG and postpartum BMI (Walker, 1998; Huang and Dai, 2007), as well as with greater long-term weight gain (Harris et al., 1997). Lifestyle factors related to excessive weight gain, eating behaviours and physical activity have played a major role in preventing and treating the overweight and obese (Wing et al., 2001). However, the role of diet and physical activity as determinants of GWG is still unclear (Siega-Riz et al., 2004; Kinnunen et al., 2007a, Kinnunen et al., 2007b). Nonetheless, behavioural interventions are needed to advise pregnant women on the recommended ranges of GWG, and to promote healthy diet and regular physical activity to prevent subsequent obesity and associated health problems (Siega-Riz et al., 2004; Huang and Dai, 2007; Kinnunen et al., 2007a, Kinnunen et al., 2007b; Huang et al., 2010). To reduce excessive weight gain in pregnancy and during the postpartum period, 15 intervention studies have been conducted in the past decade (Leermakers et al., 1998; Gray-Donald et al., 2000; Rae et al., 2000; Peterson et al., 2002; Polley et al., 2002; O’Toole et al., 2003; Olson et al., 2004; Stotland et al., 2005; Althuizen et al., 2006; Hui et al., 2006; Artal et al., 2007; Kinnunen et al., 2007a, Kinnunen et al., 2007b; Claesson et al., 2008; Onwude, 2008; Wolff et al., 2008). Of these studies, three provided postpartum interventions (Leermakers et al., 1998; Peterson et al., 2002; O’Toole et al., 2003), and only one study targeted all women (not only overweight/obese women) (Hui et al., 2006). Evidence to date does not clearly illustrate the most appropriate time to prevent weight retention. Furthermore, clinicians face the dilemma of whether to target women who are already overweight or obese, or those who are normal weight. The authors' previous findings indicated that women who were underweight before pregnancy were at risk of excessive GWG and weight retention (Huang and Dai, 2007). Therefore, GWG within the recommended range should be for all women, not just for those who are overweight or obese.
The aim of this study was to examine and compare the effect of individual counselling about diet and physical activity on childbearing women during two periods: from pregnancy through to six months post partum, and from birth through to six months post partum.
Section snippets
Design
This study had a three-group randomised intervention design. In this design, subjects were randomly assigned to three groups: (1) experimental group EP (from 16 gestational weeks to six months post partum), (2) experimental group EPP (from birth through to six months post partum), and (3) a comparison group (usual care).
Participants
To determine the sample size for this study, a power analysis was conducted. This analysis determined that to have a medium-level effect (q2=0.28) using a three-group MANOVA
Findings
Of 240 women recruited for this trial, 51 withdrew during the 12 months of study follow-up. Therefore, the final sample used for analysis was 189 women (Fig. 1). The 189 participants and 51 women who dropped out were not statistically different in age, parity, employment, education or BMI.
Discussion
Pregnancy appears to be a risk period for women to become overweight (Kac et al., 2004a, Kac et al., 2004b; Siega-Riz et al., 2004; Huang and Dai, 2007). The results of this study suggested that the diet and physical activity intervention was effective in preventing Taiwanese women's weight retention, especially if implemented during pregnancy. However, the average GWG of all groups exceeded the range recommended by the Department of Health in Taiwan. This less-than-expected effectiveness of
Limitations
This study has several limitations. First, participants were recruited from a single medical centre and studied over a relatively short period. To generalise findings to the entire postpartum population and to examine the long-term effectiveness of the intervention, future research should involve a nationally representative sample and use a longer longitudinal design (such as 10 years). Second, participants were recruited at around 16 gestational weeks, which may make participants in the
Conclusion
The implementation of a diet and physical activity intervention during pregnancy and post partum was effective in helping women in this study to reduce excessive weight retention. Health-care providers should base weight gain goals on women's body size, and monitor GWG and postpartum weight retention between follow-up visits.
To the authors' knowledge, this is the first study to intervene with women from 16 gestational weeks to six months post partum, and to target women of all body sizes during
Acknowledgements
The authors thank all of the participants for sharing their experiences. Grant supported by National Science Council, Taiwan (NSC 93-2314-B-182-079)
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