A member of the NICE guideline development group discusses the latest evidence based public health guidance on weight management in pregnancy
This article outlines the new public health guidance by the National Institute for Health and Clinical Excellence on dietary interventions and physical activity interventions for weight management for women during their reproductive years.
Many healthcare practitioners, including nurses, will welcome the guidance Weight Management Before, During and After Pregnancy, as it can be difficult to answer women’s questions, concerns and fears about weight gained during this time. Managing the weight of these patients is a particular issue for practice nurses, other primary care professionals, midwifery and health visiting staff. All have a role to play in supporting women to make healthy food and drink choices, as well as increasing their physical activity.
The extent of the problem
The increase in overweight and obese adults is well documented. Recent figures suggest that about half of all women in early pregnancy are overweight (Body Mass Index (BMI) of 25 kg/m2 or more) and of these, 16% are obese (BMI of 30 kg/m2 or more). These figures have doubled in the last 20 years and are likely to get worse unless there we make some major changes to our eating and drinking habits and levels of physical activity.
This growing problem brings increased morbidity risks during pregnancy, which include impaired glucose tolerance and gestational diabetes, miscarriage and pre-eclampsia. Additionally, babies born to obese women have a higher risk of foetal death, still birth and congenital abnormality.
Preparations for pregnancy
NICE is clear that health professionals should advise women preparing for pregnancy with a BMI of 30 on the health benefits of losing weight and the risks of obesity. To discuss these issues sensitively they should provide women guidance on what to do and set them realistic goals, such as losing 5–10% of their weight until they reach a healthy range (between 24.9 and 18.5 kg/m2). Health professionals should also use evidence-based behaviour change techniques focusing on both diet and physical activity.
Nurses need to take a sympathetic approach to helping these women lose weight as it may be difficult for them and they will need to be motivated and feel supported.
Pre-pregnancy is also the time to offer specific advice on taking daily folic acid supplements. Nurses and other health professionals should encourage self-monitoring by recommending that women check their weight and waist measurements periodically or, as a simple alternative, check the fit of their clothes.
During pregnancy, the key message is to ensure that the myth to “eat for two” is dispelled. Professionals should be clear that excess calories are required, but only during the last trimester and even then by as little as 200kcals per day - such as two extra pieces of fruit and one slice wholegrain toast. It is also important to communicate that slimming is not appropriate during pregnancy.
For women with a BMI ≥30 kg/m2 weight loss during pregnancy is not recommended. Personalised guidance on healthy eating - with appropriate assessment - and ways to become more physically active should be advised but not weight reduction. In terms of starting to increase activity, women should begin with no more than 15 minutes of continuous exercise, three times per week, increasing gradually to daily 30-minute sessions.
It is recommended that weight and height are measured by a health professional at the first contact with the pregnant woman, and that these details, as well as their calculated BMI, be recorded in the notes.
Pregnancy is not a time to scold about body size – instead healthcare professionals should be sensitive to any concerns expressed about weight and use this as an opportunity to give positive, but appropriate advice on food, drink and activity.
After pregnancy women should receive clear, tailored and consistent advice on how to decrease body weight. Motherhood can come with many demands and health problems, so advice, support and motivation should be provided at an appropriate time. It is important that women have a realistic expectation of the time it will take to lose weight gained during pregnancy. Women should be encouraged to lose weight after pregnancywhen they feel ready and able to do so.
Women with a BMI ≥30 kg/m2
Women with a BMI ≥30 kg/m2 should be offered a structured weight loss programme or referral to a dietician or other appropriately trained health professional for the information, motivation and support necessary to achieving weight loss and influencing the health of the new mother before another pregnancy.
There are many gaps in the evidence base in terms of exactly what is the optimal diet for overweight and obese women during reproductive years. However, the current guidance provides a much needed evidence based framework that nursing staff and other health professionals can act upon.
The guideline is available for download atwww.nice.org.uk/guidance/PH27
AUTHOR Professor Annie Anderson BSc, PhD, SRD, is professor of food choice, Centre for Public Health Nutrition Research, University of Dundee and a member of the NICE guideline development group