Does Partial Meal Replacement During Pregnancy Reduce 12-Month Postpartum Weight Retention?

Healthy Mom Zone Adaptive Intervention With a Novel Control System and Digital Platform to Manage Gestational Weight Gain in Pregnant Women With Overweight or Obesity: Study Design and Protocol for a Randomized Controlled Trial

BACKGROUND

Regulating gestational weight gain (GWG) in pregnant women with overweight or obesity is difficult, particularly because of the narrow range of recommended GWG for optimal health outcomes. Given that many pregnant women show excessive GWG and considering the lack of a "gold standard" intervention to manage GWG, there is a timely need for effective and efficient approaches to regulate GWG. We have enhanced the Healthy Mom Zone (HMZ) 2.0 intervention with a novel digital platform, automated dosage changes, and personalized strategies to regulate GWG, and our pilot study demonstrated successful recruitment, compliance, and utility of our new control system and digital platform.

OBJECTIVE

The goal of this paper is to describe the study protocol for a randomized controlled optimization trial to examine the efficacy of the enhanced HMZ 2.0 intervention with the new automated control system and digital platform to regulate GWG and influence secondary maternal and infant outcomes while collecting implementation data to inform future scalability.

METHODS

This is an efficacy study using a randomized controlled trial design. HMZ 2.0 is a multidosage, theoretically based, and individually tailored adaptive intervention that is delivered through a novel digital platform with an automated link of participant data to a new model-based predictive control algorithm to predict GWG. Our new control system computes individual dosage changes and produces personalized physical activity (PA) and energy intake (EI) strategies to deliver just-in-time dosage change recommendations to regulate GWG. Participants are 144 pregnant women with overweight or obesity randomized to an intervention (n=72) or attention control (n=72) group, stratified by prepregnancy BMI (<29.9 vs ≥30 kg/m2), and they will participate from approximately 8 to 36 weeks of gestation. The sample size is based on GWG (primary outcome) and informed by our feasibility trial showing a 21% reduction in GWG in the intervention group compared to the control group, with 3% dropout. Secondary outcomes include PA, EI, sedentary and sleep behaviors, social cognitive determinants, adverse pregnancy and delivery outcomes, infant birth weight, and implementation outcomes. Analyses will include descriptive statistics, time series and fixed effects meta-analytic approaches, and mixed effects models.

RESULTS

Recruitment started in April 2024, and enrollment will continue through May 2027. The primary (GWG) and secondary (eg, maternal and infant health) outcome results will be analyzed, posted on ClinicalTrials.gov, and published after January 2028.

CONCLUSIONS

Examining the efficacy of the novel HMZ 2.0 intervention in terms of GWG and secondary outcomes expands the boundaries of current GWG interventions and has high clinical and public health impact. There is excellent potential to further refine HMZ 2.0 to scale-up use of the novel digital platform by clinicians as an adjunct treatment in prenatal care to regulate GWG in all pregnant women.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66637.

Relationships among Postpartum Weight Retention, Stress, and Disinhibited Eating: A Scoping Review

Postpartum weight retention (PPWR) is a significant contributor to maternal cardiometabolic disease risk. The transition to motherhood is a stressful time period in which women report consuming food to cope, an eating behavior that is associated with PPWR. In this scoping review, we identified original research and review articles published since 2010 that examined relationships among PPWR, maternal stress, and disinhibited eating. In total, 16 articles met the inclusion criteria. Findings were inconsistent related to PPWR and stress. PPWR and disinhibited eating were not significantly correlated; however, disinhibition scores were higher during the postpartum period compared to prenatally. Stress and disinhibited eating were directly correlated in 4 studies. Our findings suggest these concepts, particularly disinhibited eating, have not been robustly examined during the postpartum period. Additionally, instruments used to measure maternal stress vary widely and should be further studied and refined.

Maternal responsiveness and toddler body mass index z-score: Prospective analysis of maternal and child mealtime interactions

Responsive feeding, where parents are guided by children's hunger and satiation cues and provide appropriate structure and support for eating, is believed to promote healthier weight status. However, few studies have assessed prospective associations between observed parental feeding and toddler growth. We characterized toddler growth from 18 to 36 months and, in a subset of families, examined whether observed maternal responsiveness to toddler satiation cues and encouraging prompts to eat at 18 and 24 months were associated with toddler body mass index z-score (BMIz) from 18 to 36 months. Participants included 163 toddlers and their mothers with overweight/obesity who had participated in a lifestyle intervention during pregnancy. Anthropometrics were measured at 18, 24, and 36 months. In a subsample, mealtime interactions were recorded in families' homes at 18 (n = 77) and 24 (n = 75) months. On average, toddler BMIz remained stable from 18 to 36 months with 31.3% (n = 51) categorized with a healthy weight, 56.4% (n = 92) with at risk for overweight and 12.3% (n = 20) with overweight. Fewer maternal prompts to eat at 18 months was associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p = .002). Higher child weight status at 12 months was also associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p < .001). Neither 24-month maternal prompts nor 18 or 24 month responsiveness to satiation cues were associated with toddler BMIz. In this diverse sample, weight status was relatively stable from 18 to 36 months. Maternal prompts to eat measured earlier in toddlerhood and prior child weight status were associated with toddler BMIz.

Effects of a lifestyle intervention on postpartum weight retention among women with elevated weight

OBJECTIVE

The effectiveness of a pregnancy and postpartum behavioral lifestyle intervention on postpartum weight retention was examined.

METHODS

Pregnant women with overweight and obesity in South Carolina were recruited into a theory-based randomized controlled trial (n = 112 intervention, n = 107 standard care), which was designed to reduce gestational weight gain and postpartum weight retention.

RESULTS

Participants (44% African American, 56% White) had a mean prepregnancy BMI of 32.3 kg/m2 and were at 12.6 weeks' gestation at baseline. From prepregnancy to 6 months post partum, intervention participants retained less weight than standard care women (mean difference: -3.6 kg, 95% CI: -5.5 to -1.8). The intervention effect was maintained at 12 months post partum (mean difference: -2.4 kg, 95% CI: -4.3 to -0.5). Intervention women had 2.3 times higher odds of having no weight retention at 6 months post partum versus standard care women (95% CI: 1.2 to 4.4). Intervention participants also had lower odds of retaining ≥5% of their prepregnancy weight after delivery (adjusted odds ratio: 0.3, 95% CI: 0.1 to 0.5 at 6 months; adjusted odds ratio: 0.3, 95% CI: 0.2 to 0.6 at 12 months).

CONCLUSION

This theory-based lifestyle intervention resulted in significantly less weight retention at 6 and 12 months after delivery among pregnant women with overweight and obesity.

Effectiveness of multimodal nutrition interventions during pregnancy to achieve 2009 Institute of Medicine gestational weight gain guidelines: a systematic review and meta-analysis

BACKGROUND

In 2009, the Institute of Medicine (IOM) published a revision to its 1990 recommendations on gestational weight gain (GWG). The objective of this review is to update a previous systematic review and meta-analysis to evaluate the effectiveness of nutrition interventions in achieving recommended GWG.

METHODS

We conducted updated literature searches in MEDLINE® (2012 through 2019), Web of Science (2012 to 6 February 2017), Embase (2016 through 2019), and Cochrane Central Register of Controlled Trials (2012 through 2019). Literature published before January 2012 was identified from a published systematic review. We included controlled trials conducted in the U.S. or Canada among generally healthy pregnant women that compared nutrition interventions with or without exercise to controls (e.g., usual care) and reported total GWG or rate of GWG based on the 2009 IOM GWG guidelines. Two independent investigators conducted screening, data extraction, and risk-of-bias (ROB) assessment. Random-effects meta-analyses were conducted when data were sufficient.

RESULTS

Eighteen unique studies were included, of which 11 were conducted in women with overweight or obesity. Nutrition interventions, compared to controls, had a similar effect on total GWG (mean difference = -1.24 kg; 95% CI [-2.65, 0.18]; I2=67.6%) but significantly decreased second and third trimester rate of GWG (-0.07 kg/week; 95% CI [-0.12, -0.03]; I2=54.7%). Nutrition interventions also reduced the risk of exceeding IOM's rate of GWG targets (pooled RR = 0.71; 95% CI [0.55, 0.92]; I2=86.3%). Meta-analyses showed no significant differences in achieving IOM's total GWG or any secondary outcome (e.g., preterm birth or small/large for gestational age) between groups. Most studies were assessed as having some or high ROB in at least two domains.

CONCLUSION

Multimodal nutrition interventions designed to meet the 2009 IOM's GWG targets may decrease the rate of GWG over the second and third trimesters but may not decrease total GWG.Key messagesExcessive gestational weight gain is associated with higher risk of many adverse maternal and fetal outcomes and represents a public health concern in the United States and Canada.Nutrition interventions designed to meet the 2009 IOM GWG guidelines may decrease the rates of GWG over the second and third trimesters but may not be effective at reducing total GWG.

Effect of prenatal lifestyle intervention on maternal postpartum weight retention and child body mass index z-score at 36 months

BACKGROUND/OBJECTIVES

We previously reported results from a randomized trial showing that a behavioral intervention during pregnancy reduced excess gestational weight gain but did not impact maternal weight at 12 months. We now examine the longer-term effects of this prenatal intervention on maternal postpartum weight retention and toddler body-mass-index z scores (BMIz) over 36 months.

SUBJECTS/METHODS

Pregnant women (N = 264; 13.7 weeks' gestation; 41.6% Hispanic) with overweight or obesity were randomized into usual care or prenatal intervention. Anthropometric assessments in mothers and toddlers occurred at baseline, 35 weeks' gestation and after delivery at 6, 12, 18, 24, and 36 months.

RESULTS

At 36 months, prenatal intervention vs. usual care had no significant effect on the proportion of participants who returned to their early pregnancy weight or below (33.3% vs. 39.5%; p = 0.12) and had no effect on the magnitude of weight retained (2.8 [0.8, 4.8] vs 3.0 kg [1.0, 4.9], respectively; mean difference = 0.14 [-3.0, 2.7]). There was also no statistically significant intervention vs. usual care effect on infant BMIz or skinfold changes over time; toddler BMIz increased by 1.4 [-1.7, 1.0] units in the intervention group and 1.6 [-1.2, 1.8] units in the usual care group from delivery to 36 months (difference = 0.16 [-0.32. 0.63]). The proportion of toddlers at risk for obesity at 36 months was similar in intervention and usual care groups (28/77 [36.4%] vs 30/80 [37.5%]; p = 0.77).

CONCLUSIONS

Compared with usual care, lifestyle intervention during pregnancy resulted in similar maternal and toddler anthropometric outcomes at 36-months postpartum in a diverse US sample of women with overweight and obesity. To sustain improved maternal weight management initiated during pregnancy, continued intervention during the postpartum years may be needed.

Eating behaviors in relation to gestational weight gain and postpartum weight retention: A systematic review

Preventing obesity is of utmost public health importance. This paper systematically reviews associations between eating behaviors and peripartum weight change. This knowledge is crucial in the development of interventions that reduce long-term obesity, often triggered and boosted in the peripartum. Through MEDLINE, EMBASE, and Web of Science, we identified 20 studies that fulfilled inclusion criteria: studies on food cravings, disinhibition, restrained, external, emotional, uncontrolled, intuitive, or mindful eating in relation to gestational or postpartum weight among adult women. Higher gestational weight gain was associated with lower intuitive eating (in 3/3 studies) and higher restrained eating (in 4/11 studies), external eating (in 2/2 studies), emotional eating (in 3/4 studies), food cravings (in 3/3 studies), and disinhibition (in 1/3 studies). No association with uncontrolled eating was found (in one study). No studies on mindful eating and gestational weight were identified. Higher postpartum weight loss was associated with higher restrained (in 2/4 studies) and intuitive eating (in 1/1 study). No associations between postpartum weight and food cravings, disinhibition, and mindful eating were found. No studies on external, emotional and uncontrolled eating, and postpartum weight were identified. Concluding, certain eating behaviors might be related to peripartum weight change.

Weight Trajectories After Delivery are Associated with Adiposity and Cardiometabolic Markers at 3 Years Postpartum Among Women in Project Viva

BACKGROUND

Postpartum weight trajectories and its implications on later cardiometabolic health are not entirely understood.

OBJECTIVES

Our objectives were: 1) to characterize maternal weight trajectories from 1 to 24 mo postpartum, 2) to determine the association of prepregnancy BMI, gestational weight gain (GWG), and pregnancy behaviors with the trajectories, and 3) to evaluate the association of weight trajectories with BMI, waist circumference (WC), lipid profile, glucose, insulin resistance, blood pressure, and inflammatory markers at 3 y postpartum.

METHODS

We studied 1359 mothers from the prospective cohort Project Viva. Using weights at 1, 6, 12, and 24 mo postpartum, we characterized weight trajectories using a latent class growth model. For objectives 2 and 3, we used multinomial logistic regression and multiple linear regression models, respectively.

RESULTS

Around 85% of women fell into a trajectory of sustained weight loss (1-12 mo) + maintenance (12-24 mo) (reference), 5.7% followed a trajectory characterized by fast weight loss + slight gain, and 9.7% fell into a trajectory of little weight loss + slight gain. Prepregnancy overweight and obesity increased the odds of falling into the fast weight loss + slight gain trajectory, compared with the reference. Prepregnancy overweight [OR 1.57 (95% CI: 1.01, 2.46)] and a higher total GWG rate [3.69 (2.90, 4.68)] increased the odds of falling into the little weight loss + slight gain trajectory, whereas a higher Prudent dietary pattern score was protective [0.73 (0.54, 0.98)]. Women in this trajectory had higher BMI, WC, weight gain from prepregnancy, low-density lipoprotein cholesterol, and inflammatory markers at 3 y postpartum.

CONCLUSIONS

Women following a trajectory of little weight loss + slight gain during the first 2 y postpartum had an adverse cardiometabolic profile 3 y after delivery. Targeting diet and GWG during pregnancy and facilitating postpartum weight loss could improve women's long-term health.

Amant M, Beyl RA, Ravussin E, Redman LM. Increased Energy Intake After Pregnancy Determines Postpartum Weight Retention in Women With Obesity

CONTEXT

This study was designed to understand causes and critical periods for postpartum weight retention by characterizing changes in body composition, energy intake, energy expenditure and physical activity in women with obesity during pregnancy and postpartum.

DESIGN

In this prospective, observational cohort study, body composition (plethysmography), energy expenditure (doubly labeled water, whole-body room calorimetry), physical activity (accelerometry), metabolic biomarkers, and eating behaviors were measured. Energy intake was calculated by the intake-balance method for pregnancy, and for 2 postpartum periods (0 to 6 months and 6 to 12 months).

RESULTS

During the 18-month observation period, weight loss occurred in 16 (43%) women (mean ± SEM, -4.9 ± 1.6 kg) and weight retention occurred in 21 (57%) women (+8.6 ± 1.4 kg). Comparing women with postpartum weight loss and weight retention, changes in body weight were not different during pregnancy (6.9 ± 1.0 vs 9.5 ± 0.9 kg, P = 0.06). After pregnancy, women with postpartum weight loss lost -3.6 ± 1.8 kg fat mass whereas women with weight retention gained 6.2 ± 1.7 kg fat mass (P < 0.001). Women with postpartum weight loss reduced energy intake during the postpartum period (compared with during pregnancy) by 300 kcal/d (1255 kJ/d), while women with weight retention increased energy intake by 250 kcal/d (1046 kJ/d, P < 0.005). There were no differences in the duration of breastfeeding, eating behavior, or metabolic biomarkers.

CONCLUSIONS

Postpartum weight gain was the result of increased energy intake after pregnancy rather than decreased energy expenditure. Dietary intake recommendations are needed for women with obesity during the postpartum period, and women should be educated on the risk of overeating after pregnancy.

Patterns of Weight Change One Year after Delivery Are Associated with Cardiometabolic Risk Factors at Six Years Postpartum in Mexican Women

Pregnancy is a contributor to the obesity epidemic in women, probably through postpartum weight retention (PPWR), weight gain (PPWG), or a combination of both (PPWR + WG). The contribution of these patterns of postpartum weight change to long-term maternal health remains understudied. In a secondary analysis of 361 women from the prospective cohort PROGRESS, we evaluated the associations between patterns of weight change one year after delivery and cardiometabolic risk factors at six years postpartum. Using principal component analysis, we grouped cardiometabolic risk factors into: (1) body mass index (BMI), waist circumference (WC), homeostatic model assessment of insulin resistance (HOMA-IR), high-density lipoprotein cholesterol (HDL-c), triglycerides (TG), and glucose; (2) systolic (SBP) and diastolic blood pressure (DBP); and (3) low-density lipoprotein cholesterol and total cholesterol. Using path analysis, we studied direct (patterns of weight change-outcomes) and indirect associations through BMI at six years postpartum. Around 60% of women returned to their pregestational weight (reference) by one year postpartum, 6.6% experienced PPWR, 13.9% PPWG, and 19.9% PPWR + WG. Women with PPWR + WG, vs. the reference, had higher BMI and WC at six years (2.30 kg/m², 95% CI [1.67, 2.93]; 3.38 cm [1.14, 5.62]). This was also observed in women with PPWR (1.80 kg/m² [0.80, 2.79]; 3.15 cm [−0.35, 6.65]) and PPWG (1.22 kg/m² [0.53, 1.92]; 3.32 cm [0.85, 5.78]). PPWR + WG had a direct association with HOMA-IR (0.21 units [0.04, 0.39]). The three patterns of weight change, vs. the reference, had significant indirect associations with HOMA-IR, glucose, TG, HDL-c, SBP, and DBP through BMI at six years. In conclusion, women with PPWR + WG are at high-risk for obesity and insulin resistance. Interventions targeting women during pregnancy and the first year postpartum may have implications for their long-term risk of obesity and cardiovascular disease.

Prenatal Intervention with Partial Meal Replacement Improves Micronutrient Intake of Pregnant Women with Obesity

A behavioral lifestyle intervention with partial meal replacement reduced excess gestational weight gain in ethnically diverse women with overweight/obesity, but the effects on micronutrient intake remained unknown. A secondary analysis of a randomized, controlled trial tested whether the intervention improved micronutrient intake relative to usual care. Pregnant women (n = 211; 30.5 years of age, body mass index, BMI, of 32.0 kg/m²) were enrolled and randomized within site and ethnicity (40% were Hispanic) into intervention (n = 102) or usual care (n = 109) groups. Two 24 h dietary recalls were conducted on random days at study entry and late pregnancy (35–36 weeks gestation). Nutrient adequacy was defined using the Estimated Average Requirement cut-point method. At study entry and including prenatal vitamins, ≥90% of participants reported inadequate intake of vitamins D and E and iron; 40–50% reported inadequate intake of calcium, protein, vitamins A, C, B₆, folate, magnesium, and zinc. From study entry to late pregnancy, the behavioral intervention with partial meal replacement increased the overall intake of vitamins A, E, and D and copper and reduced the odds of inadequate intake of calcium (odds ratio (OR) = 0.37 (0.18, 0.76)), vitamins A (OR = 0.39 (0.21, 0.72)) and E (OR = 0.17 (0.06, 0.48)), and magnesium (OR = 0.36 (0.20, 0.65)). A behavioral intervention with partial meal replacement during pregnancy improved the intake of several micronutrients in Hispanic and non-Hispanic women with overweight/obesity.

Ripple Effect of Lifestyle Interventions During Pregnancy on Untreated Partners' Weight

OBJECTIVE

Weight-loss interventions have a positive "ripple effect" on untreated partners' weight, but ripple effects in pregnancy are unknown. The objective of this study was to determine whether prenatal lifestyle interventions that reduce gestational weight gain in pregnant women have a positive ripple effect on untreated partners' weight.

METHODS

Two clinical trials with the same outcome measures randomly assigned pregnant women to a lifestyle intervention or usual care. Untreated partners were randomly assigned according to their pregnant partner's group allocation and were assessed at study entry (~13 weeks' gestation), 35 weeks' gestation, and 6 and 12 months after delivery.

RESULTS

A total of 122 partners (100% male, 23% Hispanic, 82% married, and 48% with obesity) were randomly assigned to the intervention (n = 59) or usual care (n = 63). There was no intervention or intervention-by-time interaction effect on partner weight (P = 0.795). Partner weight changes were not statistically significant (P = 0.120) from study entry to 35 weeks' gestation (mean 0.19 kg; 95% CI: -0.73 to 1.24) or to 12 months after delivery (mean 0.82 kg; 95% CI: -0.26 to 1.91).

CONCLUSIONS

There was no evidence of a ripple effect on partner weight. In a self-selected sample, partners of pregnant women appeared not to experience sympathy weight gain.