Managing Excessive Weight Gain During Pregnancy and the Postpartum Period

CLINICAL ISSUES

Managing Excessive Weight Gain During Pregnancy and the Postpartum Period Lorraine O. Walker

Childbearing is a period in the life cycle during which some women may gain weight, become overweight, or become obese. Despite guidelines issued in 1990 for gestational weight gain, many women exceed them. Women who are overweight before pregnancy are most vulnerable to excessive gestational weight gain. Prenatal interventions to prevent excessive gain have had mixed results. During the postpartum period, 14% to 20% of women may retain weight from pregnancy, which elevates risk of later health problems. Although postpartum weight loss interventions have been shown to have efficacy, these have been tested primarily with White women. Continued efforts are needed in practice and research to develop effective approaches for managing weight during pregnancy and postpartum, especially for low-income and ethnic minority women. JOGNN, 36, 490-500; 2007. DOI: 10.1111/J.1552-6909.2007.00179.x Keywords: Ethnic minority—Low income— Postpartum—Pregnancy—Weight Accepted: January 2007 Obesity is a major health problem for women in the United States, and women of childbearing age are no exception. Recent evidence from the National Health and Nutrition Examination Survey (NHANES) indicates that 16.4% of U.S. women aged 12 to 19 years are at or exceed the 95th percentile of national weight standards for children and adolescents (Ogden et al., 2006). Among adult U.S. women aged 20 to 39 years, 28.9% are obese (Ogden et al. 2006). In response to the high prevalence of obesity among U.S. women of childbearing age, the American College of Obstetrics and Gynecology (ACOG, 2005) issued a Committee Opinion entitled Obesity in Pregnancy. 490 JOGNN

The Committee Opinion enumerated the perinatal complications associated with obesity and proposed care practices for obese women during the preconception period and pregnancy. Although the ACOG Committee Opinion addressed care to manage the impact of obesity on childbearing, it did not address care to manage the impact of childbearing on women’s weight status. Compared to what is known about the effects of obesity on health (Must et al., 1999), much less is known about the effects on women’s health and well-being of retaining weight after pregnancy. Thus, the first aim of this paper is to review whether pregnancy and its associated weight gain is contributing to higher weight status among American women. Attention is given to whether ethnic disparities exist for this health outcome, especially among low-income, ethnic minority women, the health consequences associated with weight increases, the impact of breastfeeding on weight after pregnancy, risk of excessive gestational weight gain (GWG), and results from studies to prevent excessive GWG. The second aim is to describe processes of postpartum weight change (weight retention or weight gain) and the efficacy of postpartum weight loss interventions. The third aim is to propose directions for practice and future research based on the available scientific literature.

Is Childbearing Contributing to Obesity and Weight Gain? Estimates and Consequences of Childbearing-Related Weight Gain Early in the obesity epidemic, experts raised concerns that certain periods of the life span, such as

© 2007, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

pregnancy and postpregnancy, might be critical times for substantial weight gain and development of obesity (National Task Force on Prevention and Treatment of Obesity, 1994). This concern was supported by findings that women were most likely to experience a major weight gain (more than or equal to 5 body mass index [BMI] units increase) between the ages of 25 and 34 years (Williamson, Kahn, Remington, & Anda, 1990). (Note. A 1.0 increase in BMI for a woman 5'5" tall approximates a weight gain of 2.7 kg [Williamson et al., 1990]). Still, after correcting for the effects of aging and self-reporting errors in baseline prepregnant weights, Swedish investigators concluded that women in a major longitudinal study were, on average, only 0.5 kg heavier at 1 year postpartum compared to prepregnancy (Ohlin & Rossner, 1990). Data from population studies in the United States supported similar conclusions. For example, based on data from NHANES II, American women were estimated to have an adjusted gain of 0.5 kg per birth (Wolfe, Sobal, Olson, & Frongillo, 1997). Such estimates of average weight gains gave the impression that weight gain associated with childbearing was negligible. A more refined analysis of data from the Coronary Artery Risk Development in Young Adults Study showed that when women who gave birth were compared to ethnically similar nulliparous women, adjusted birthrelated gains over a 5-year period varied with parity and ethnicity: +3.0 kg for African American primiparas, −0.9 kg for African American multiparas, +1.8 kg for White primiparas, and +0.6 kg for White multiparas (Smith et al., 1994). However, use of nulliparous women as comparisons may underestimate weight gain because infertility (contributing to nulliparous status) is linked to obesity (Linne, 2004). More importantly, as numerous experts have pointed out, estimated average gains mask the wide variability associated in these estimates (Gunderson & Abrams, 1999; Lederman, 1993; Walker, 1995) and fail to identify subgroups that are vulnerable to high weight gains after pregnancy. In their integrative review, Gunderson and Abrams (1999) reported that from 14% to 20% of women retained 5 kg (11 lb) or more as a result of childbirth. Keppel and Taffel (1993) not only showed that a subset of American childbearing women had high retained weight after childbirth but also pointed out that ethnic disparities existed in the prevalence of retained weight. Their findings from the National Maternal and Infant Health Survey showed that 45% of African American women, in contrast to 25% of White women, retained nine or more pounds at 10 to 18 months postpartum. Similarly, data from a South Carolina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic showed that African American women on average retained 6.4 lb more than White women at 7 to 12 months postpartum (Boardley, Sargent, Coker, Hussey, & Sharpe, 1995). This weight reSeptember/October 2007

tention should be considered in light of its immediate and long-term impact on women’s health and well-being. Body image dissatisfaction and weight-related distress are two more immediate outcomes associated with postpartum weight retention (Walker, 1997, 1999), but these effects may be attenuated in women who breastfeed (Walker & Freeland-Graves, 1998). Long-term effects are noted in two follow-up studies that showed that postpartum retained weight is associated 15 years later with weight increases of more than 5 kg (Rooney, Schauberger, & Mathiason, 2005) and shifts from normal to overweight status (Linne, Dye, Barkeling, & Rossner, 2004). Such gains are of importance because other researchers have reported that gains of 5 kg (11 lb) or higher are associated with later increased risk of coronary heart disease in women (Willett et al., 1995). In addition, even among women with weights in the normal range (less than BMI of 25), weight gains of 1 to less than 2 BMI units between pregnancies (in part attributable to weight retention) were associated with increases in certain perinatal risks, such as hypertension (Villamor & Cnattingius, 2006). Thus, incremental gains in weight, whether wholly or partially a result of pregnancy, are of concern in childbearing-aged women.

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ncremental gains in weight, whether wholly or partially a result of pregnancy, are of concern in childbearing-aged women.

What Is the Key Factor Contributing to Childbearing-Related Weight Retention? Gestational weight gain is by far the most consistent predictor of the amount of weight women retain after childbirth (Boardley et al., 1995; Harris, Ellison, & Clement, 1999; Janney, Zhang, & Sowers, 1997; Kac, Benicio, Velasquez-Melendez, Valente, & Struchiner, 2004; Ohlin & Rossner, 1990; Olson, Strawderman, Hinton, & Pearson, 2003; Rosenberg et al., 2003; Schauberger, Rooney, & Brimer, 1992; Walker, 1996). Exceeding GWG recommendations, such as those proposed by the Institute of Medicine (IOM; Table 1) and also endorsed by ACOG (2005), is associated with higher postpartum weight retention at 6 weeks (Walker, Timmerman, Sterling, Kim, & Dickson, 2004) and at 10 to 18 months postpartum (Keppel & Taffel, 1993) and with greater likelihood of being overweight at the beginning of the next pregnancy (Gunderson, Abrams, & Selvin, 2000). Data gathered in the Pregnancy Nutrition Surveillance System (PNSS) in 2004 on low-income women participating JOGNN 491

TABLE 1

Recommended Gestational Weight Gains Based on Prepregnant BMI Prepregnant BMI

Recommended Gain (lb)

Recommended Gain (kg)

28-40 25-35 15-25 ⱖ15

12.5-18 11.5-16 7.0-11.5 ⱖ7.0

Low (underweight): BMI <19.8 Normal weight: BMI 19.8-26 High (overweight): BMI >26-29 Obese: BMI >29 Note. BMI = body mass index.

Source: Adapted from the Institute of Medicine (1992). Nutrition during pregnancy and lactation: An implementation guide. Washington, DC: National Academy Press.

in public health programs revealed the following percentages of excessive GWGs for racial/ethnic groups: nonHispanic White—47.3%, non-Hispanic African American— 42.2%, Hispanic—38.2%, Native American/Alaskan Native—44.5%, and Asian/Pacific Islander—33.6% (Centers for Disease Control and Prevention, 2006). When PNSS data were analyzed further by both ethnicity and prepregnancy BMI, across ethnic groups women with high (overweight) BMIs (see Figure 1), followed by obese women, were most likely to exceed IOM GWG recommendations (Schieve, Cogswell, & Scanlon, 1998). Of added concern are trends showing that an increasing proportion of women are already overweight at the start of pregnancy. For example, data tracking pregravid weight categories in eight counties in upstate New York (N = 79,022) showed the following shifts from 1990 to 2003: underweight declined by 14%, normal weight declined by 3%, overweight increased by 11%, and obese status

FIGURE 1

Percent of women with excessive gestational weight gain by BMI and ethnic group. Note. BMI = body mass index; NH = non-Hispanic. Based on Schieve, L. A., Cogswell, M. E., & Scanlon, K. S. (1998). An empiric evaluation of the Institute of Medicine’s pregnancy weight gain guidelines by race. Obstetrics & Gynecology, 91, 878-884.

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increased by 8%. Furthermore, upward shifts in BMI occurred among both White and African American women (Yeh & Shelton, 2005). It is also important here to consider briefly the widely held belief that breastfeeding is a protective factor against weight retention after pregnancy, especially as this may apply to low-income and ethnic minority women, who are most vulnerable to postpartum weight retention (Parker & Abrams, 1993) and overweight and obesity (Ogden et al., 2006; U.S. Department of Health and Human Services, 2000). A review of predictors of postpartum weight changes found breastfeeding to be inconsistently related to postpartum weight loss (Walker, 1995). More recent longitudinal studies of low-income, ethnically diverse samples revealed that breastfeeding did not have a significant shortterm (Walker, Sterling, Kim, Arheart, & Timmerman, 2006) or longer term (Walker, Freeland-Graves, et al., 2004) influence on postpartum weight. This may in part stem from early discontinuation of breastfeeding, increased appetite during lactation, dieting among nonbreastfeeding women, or other factors (Lederman, 2004). In a study that controlled for dieting, near-exclusive breastfeeding for at least 6 months had a positive effect (approximately 2 kg) on postpartum weight loss (Dewey, Heinig, & Nommsen, 1993). Effect of breastfeeding on postpartum weight among obese and overweight women may be limited, however, because these women are likely to breastfeed for a shorter period than nonoverweight women (Hilson, Rasmussen, & Kjolhede, 1997). Finally, although the National Heart, Lung, and Blood Institute (1998) has published clinical guidelines for weight management, pregnant and lactating women are among the groups excluded from the scope of those guidelines. Thus, carefully controlled trials are needed to provide evidence for appropriate management of weight for pregnant and postpartum women, especially women who are lactating. Given the many adjustments of the postpartum period noted in Mercer’s (1986) classic study, guidelines also need to consider the timing and circumstances of weight Volume 36, Number 5

management even if women are not lactating. Current evidence on prenatal and postpartum weight management is considered in the following sections.

Can Excessive Weight Gain During Pregnancy Be Prevented? Most interventions to prevent excessive weight gain during pregnancy have focused primarily on normalweight and overweight women to prevent the former from becoming overweight and to help the latter avoid additional postpartum weight gain. The number of studies in this area of research is still small because, until recently, inadequate GWG has been the primary prenatal weightrelated concern. To date, three interventions aimed at decreasing the prevalence of excessive weight gain during pregnancy have been conducted with the following groups of women: low-income women in Pittsburgh (Polley, Wing, & Sims, 2002), low- and middle/upper-income women in upstate New York (Olson, Strawderman, & Reed, 2004), and Cree women of James Bay, Canada (Gray-Donald et al., 2000). In the Pittsburgh study (Polley et al., 2002), 120 normalor overweight/obese African American (39%) and White (61%) low-income women were randomized to a stepped, behavioral intervention versus usual prenatal care. To qualify for the study, women had to be less than 20 weeks gestation. The goal of the intervention was to decrease occurrence of excessive GWG through information on weight gain, exercise, and nutrition during pregnancy provided orally and through newsletters, personalized weight graphs, and behavioral counseling, if needed. Among normal-weight women, 58% in the usual care group had excessive GWG at the end of pregnancy compared to only 33% in the intervention group (p < .05). Unexpectedly, among overweight/obese women, 32% in the usual care group had excessive GWG compared to 59% in the intervention group (p = .09). The Group × Weight interaction was significant, p < .01, indicating that

weight moderated or altered the effect of the intervention. The authors pointed out that many barriers limited the capacity of the low-income women in this study to adhere to the intervention program. In the upstate New York study of low- and middle/highincome women (Olson et al., 2004), 179 normal- or overweight women were enrolled in the intervention and compared to 381 historic controls. Women were enrolled in the intervention before the third trimester. The sample was 96% White. The intervention goal was to decrease excessive GWG and consisted of two tiers: (a) health provider education and use of weight grids based on the IOM recommendations in the prenatal record and (b) a variety of materials mailed to pregnant women, including newsletters, postcards for goal setting, and a “health checkbook” for recording weight and diet during pregnancy. (Intervention materials may be downloaded from the Web site given in Table 2.) In the overall sample, the percentage of women with excess GWG was 45% of historic controls and 41% for the intervention group, a nonsignificant difference. Nonetheless, among low-income women, 52% of historic controls compared to 33% of those in the intervention had excessive GWGs (p < .01). In contrast to the findings of Polley et al. (2002), normalweight and overweight low-income women both benefited from the intervention in terms of reduced occurrence of excessive GWG. The study in James Bay, Canada, involved 112 Cree women in the intervention condition and 107 historic controls (Gray-Donald et al., 2000). Because of the high incidence of diabetes in this community, the goal of the intervention was to optimize GWG, enhance dietary quality, and reduce complications. Women were enrolled in the intervention condition before the 26th week of pregnancy; nutritionists and health workers provided dietary and weight counseling that was congruent with Cree culture. Exercise groups were also provided, and the intervention was accompanied by a media campaign. No significant differences between groups were found in

TABLE 2

Weight Management Resources for Childbearing Women Resource

URL

Cornell University nutrition Web site with downloadable tools, including weight gain grids, from the prenatal weight research of Dr. Christine Olson, RD

http://www.nutritionworks.cornell.edu/home/index.cfm Register to enter the site and then go to: • Click on: Ask the Nutrition Expert • Click on: View Topic • Click on: Tools for you (or each tool is individually linked)

Nutrition During Pregnancy and Lactation: An Implementation Guide. The 1992 guide for clinicians published as a companion to Institute of Medicine (1990) gestational weight gain recommendations

Available for purchase at: http://www.nap.edu

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ntervention studies to control excessive weight gain during pregnancy are in their infancy.

Overall, these three intervention studies aimed at controlling excessive weight gain during pregnancy had results that ranged from ineffective to effective within certain subgroups. Weight status (Polley et al., 2002), income (Olson et al., 2004), and culture (Gray-Donald et al., 2000) were factors that influenced whether an intervention was efficacious in a group or subgroup, such as low-income women. Because these are some of the first studies with a focus on influencing the high end of GWG, a critical examination of them is important to furthering our knowledge of how to effectively intervene in cases of women who are gaining excessively. Because food and activity may have psychological as well as cultural importance during pregnancy (Gutierrez, 1999; Rubin, 1984), considering how to incorporate this dimension into future interventions might enhance their relevance and efficacy.

Processes of Weight Change During the Postpartum Period Given that about one in six women will retain at least 5 kg after initial postpartum changes (Gunderson & Abrams, 1999), it behooves nurses to better understand the dynamics of weight changes during the postpartum period. Being heavier during the first postpartum year than before pregnancy may be a result of more than one process (Lederman, 1993): Women may retain weight from pregnancy, may gain weight after giving birth because of lifestyle changes, or a combination of both of these processes. Measuring serial postpartum weights aids in tracking which of these processes may be at work. Such knowledge is important to determine whether interventions should focus on weight loss to reduce postpartum weight retention or on prevention of weight gain associated with lifestyle changes of being a new mother. It is also important to remember that although most women lose weight shortly after birth related to loss of excess body fluids accumulated during pregnancy, this drop is short lived and ends in the first 2 to 3 weeks postpartum (Walker et al., 2006). Subsequent weight losses, if they occur, are 494 JOGNN

likely to be smaller and reflect primarily changes in body fat (Sohlstrom & Forsum, 1995). Most available scientific evidence on serial postpartum weights is based on European samples. Figure 2 presents a hypothetical trend of weight changes from birth to 12 months postpartum, after removing weight losses attributable to infant birthweight and estimated placental and amniotic fluid weights. The weight loss between 0 and 3 months is particularly steep, as it includes early postpartum fluid losses. Still, it is apparent that the trend for weight change continues to follow a downward slope from 3 to 12 months postpartum. Figure 3 presents a contrasting pattern of BMI change patterns for a low-income sample of White, African American, and Hispanic (mostly Mexican American) women in the United States (Walker, Freeland-Graves, et al., 2004). All groups experienced a steep weight decline from birth to 6 weeks postpartum, as expected from reversal of pregnancy adaptations. Thereafter, on average, BMIs of White women had a downward slope that differed significantly from the other two groups between 3 to 6 and 6 to 12 months, whereas BMIs of African American women did not significantly change and those of Hispanic women rose slightly. Overall, the weight trends indicate that, on average, low-income, ethnic minority women did not experience weight losses after the initial fluid-related weight losses in the early postpartum weeks. Although these data are based on only low-income women (185% of poverty) who qualified for Medicaid coverage, they are of particular import because lowincome women are a group at greater risk of obesity (U.S. Department of Health and Human Services, 2000). These data indicate that childbearing, especially the postpartum Retained weight: 0-12 month postpartum 10 9 8

kg retained weight

weight at the end of pregnancy or rate of weight gain during pregnancy. In considering why the intervention was ineffective, the investigators noted that weight gain during pregnancy was valued in the Cree communities because of a period of food shortage during the 1930s and 1940s.

7 6 5 4 3 2 1 0 0 month

3 month

6 month

9 month

12 month

months postpartum FIGURE 2

Hypothetical path of postpartum weight based on European data. Note. Compiled by the author from Kanadys (1998); Ohlin and Rossner (1990); Hytten (1991).

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Postpartum BMI adjusted for covariates 32

Adjusted BMI

31 30 29 28 27 26 0-2 day

6 week White

3 month

6 month

African American

12 month Hispanic

Sawicki, and Artal (2003). Noticeably, absent was any mention of postpartum depressed mood and any impact it might have on weight and weight outcomes. Finally, the reported participant characteristics (where available) indicated that these postpartum intervention studies did not focus on predominantly low-income, ethnic minority women. Thus, there is a continuing need to test weight loss interventions that reflect sensitivity to and awareness of contextual issues that may affect weight management among low-income and ethnically diverse women during the postpartum period.

FIGURE 3

Trajectory of adjusted BMI during the first postpartum year by ethnic group. Note. BMI-body mass index. Adapted with permission of Haworth Press Inc. from Walker, L. O. et al. (2004b). Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: II. Women and Health, 40(2) 19-34.

period, may be an important transitional period of weight retention or increase, or both for low-income African American and Hispanic women. Thus, interventions targeting both weight loss and prevention of further weight gain are important during the first postpartum year, especially for low-income, ethnic minority women.

Do Postpartum Weight Loss Interventions Work? To date, four studies summarized in Table 3 tested interventions that lasted at least 10 weeks and were aimed at promoting postpartum weight loss during the first postpartum year. (Findings from a fifth study cited by Kumanyika and Obarzanek [2003] on preventing postpartum weight gain are not yet published.) Each study included use of reduced-calorie diets, three included an exercise component, and two included behavioral and motivational skills and content. Although interventions differed in duration, format, and participant breastfeeding status, each intervention resulted in significant postpartum weight loss among participating women (see Table 3, right column). Weight losses for women in the intervention groups ranged from 4.8 to 7.8 kg, with larger losses in longer interventions, and were greater than those in comparison groups. Despite their favorable outcomes, several difficulties were reported in these studies. Leermakers, Anglin, and Wing (1998) noted that, despite an exercise component in their intervention, women did not increase their energy expenditure. They suggested that this finding might indicate the difficulty women have in making behavioral changes during the first postpartum year. Several reported difficulty in retaining women in the studies; for example, 58% retention was reported at 1 year postpartum by O’Toole, September/October 2007

Where Do We Go From Here? Practice Directions Prenatal Interventions. The mixed and in some cases disappointing outcomes for prenatal interventions reported here indicate that strategies for effectively preventing excessive GWG are only beginning to evolve. Thus, the evidence for how to prevent excessive GWG comprises a combination of methods from existing studies that demonstrated benefits with selected subgroups—such as low-income White women (Olson et al., 2004), related literature, expert opinion, and clinical experience. Based on recent findings reported by Stotland et al. (2005) that 33% of women reported receiving no advice from their health providers about how much weight to gain during pregnancy and 50% of overweight women were advised to gain more than recommended by the IOM (1990, 1992), a starting point is further efforts to educate providers and pregnant women about guidelines for weight gain during pregnancy. Grids that allow providers and women to track weight gain in comparison to recommended ranges are an important tool (see IOM, 1990; resources in Table 2). The IOM (1992) booklet, Nutrition During Pregnancy and Lactation: An Implementation Guide, is a readable resource for care providers and others doing nutritional assessments and counseling of pregnant women. In prenatal education, previously developed and tested materials can aid in healthy management of weight gain and nutrition during pregnancy. Care providers should determine, however, whether such materials are suited to cultural and other characteristics of women served in their prenatal setting.

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ducating providers and pregnant women about guidelines for weight gain during pregnancy is a priority.

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TABLE 3

Postpartum Weight Management Intervention Studies Source

Design and Intervention

Participant Characteristics

Weight Outcomes

Dusdieker, Hemingway, and Stumbo (1994)

10-week, one-group intervention of reduced-calorie diet (25% less than energy requirements) and behavioral content that started at ~ 4-14 weeks postpartum; 3 frozen meals provided each week Randomly assigned to control group or 6-month intervention consisting of reduced-calorie diet (1,000-1,500 kcal), increased physical activity (walking 2 miles, 5 days a week), and behavioral content delivered through 2 group meetings, 16 mailed lessons, and telephone follow-up that started at 3-12 months postpartum Randomly assigned to a control group or a 10-week intervention of reduced-calorie diet (reduced by 500 kcal) and increased physical activity (for 45 min on 4 days a week) that started at 4 weeks postpartum Randomly assigned to self-directed group (1-hr program on diet and exercise) or structured intervention consisting of an individualized reduced-calorie diet (reduced by 350 kcal) and increased physical activity program that started at 1.5-6 months postpartum; weekly sessions for 12 weeks, then biweekly for 2 months, and then monthly to 1 year postpartum

33 breastfeeding women (no income, education, or ethnic description of sample given)

Mean weight loss during the intervention was 4.8 kg (SD = 1.2); no control group

90 nonlactating women (most college educated; 97% of sample was White)

Mean weight loss in the intervention group was 7.8 kg (SD = 4.5) compared to 4.9 kg (SD = 5.4) in the control group

40 overweight breastfeeding women (no income or education data; 82.5% were White)

Mean weight loss in intervention group was 4.8 kg (SD = 1.7) compared to 0.8 kg (SD = 2.3) in control group

40 overweight women (57% breastfeeding at enrollment; most college educated; 97.5% White)

At 1 year postpartum, mean weight loss in structured intervention group was 7.3 kg (SD not given) compared to 1.3 kg in self-directed group

Leermakers, Anglin, and Wing (1998)

Lovelady, Garner, Moreno, and Williams (2000)

O’Toole, Sawicki, and Artal (2003)

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As noted by Rubin (1984) in her classic work, foods and nutrition during pregnancy may have psychological meanings for women. Thus, women’s motivation to care for their unborn babies as well as themselves during pregnancy is an important asset when partnering with women to improve their food choices. (See Fowles [2004] for a recent review of findings on nutrition and birth outcomes.) Nutritional assessment and counseling should cover not only diet but also situational (such as lack of transportation) and psychosocial factors such as stress (Gibson, 2006) that may affect food choices. Especially among lowincome women, referral to community resources, such as WIC, may be important to increase their nutritional knowledge and access to healthy foods. Postpartum Interventions. As noted earlier, although postpartum weight loss interventions were efficacious in producing weight losses of 3 to 6 kg beyond those in the control conditions, these interventions were primarily conducted with White women. Thus, these interventions do not provide a tested evidence base for weight management programs for ethnic minority new mothers. Culturally relevant models of promoting healthy postpartum nutrition and physical activity in weight loss programs may need to be tailored to or developed for women from specific ethnic communities, such as Latinas (Kieffer, Willis, Arellano, & Guzman, 2002). Other limitations were also evident in postpartum interventions, such as difficulties with continued participation and adherence for some women. These programs, with the exception of Leermakers et al. (1998), did not address postpartum contextual factors that may interfere with weight management. During the postpartum period, women face many demands and potential sources of stress, including infant and family care, physical recovery from childbirth, and return to work. These may interfere with new mothers’ continued participation in weight loss programs and engagement in moderate or vigorous physical activity (Leermakers et al.; O’Toole et al., 2003). In addition, for a third of women, weight is not a priority during the early postpartum period (Walker, Timmerman, et al., 2004). Thus, in designing weight management programs for new mothers or in weight management counseling, readiness to begin a weight loss program (Walker, 1999), availability of family support and other resources, and women’s emotional status (depression and stress) are important areas to assess. For breastfeeding mothers, maintaining nutritional quality is a key consideration when initiating a weight loss program. Some experts indicate that among breastfeeding women, calorie-restricted diets should not begin until after 4 weeks postpartum (McCrory, 2001), and others advocate waiting until 4 to 6 months postpartum (Butte, 2000). It is also advisable that breastfeeding women who wish to start a weight loss program have nutritional consultation September/October 2007

to insure that they are meeting basic caloric needs to sustain their milk supply. As shown in the review of postpartum interventions, these have taken a variety of formats, including use of groups, mail, and telephone support. Although walking is a frequently recommended means of being active in weight loss interventions, women had difficulty increasing their physical activity (Leermakers et al., 1998). Thus, homebased activities that are of moderate intensity (King, Haskell, Young, Oka, & Stefanick, 1995) or that may be done in bouts of activity may also be helpful to some women (Dunn et al., 1999). Another alternative is a community-based group activity program, as recommended by inner-city Latinas (Kieffer et al., 2002). Furthermore, continuing contact with a health care provider may be interrupted when many low-income women experience termination of Medicaid benefits after 6 to 8 weeks postpartum. Thus, monitoring of and counseling related to weight management and behavioral changes may not be possible within the health care system. For this reason, it may be advantageous to locate weight loss programs in community health settings that can sustain them and are accessible to women on a continuing basis.

Future Research Directions With respect to interventions to prevent excessive GWG, the research is still in its infancy. Interventions that revealed some evidence of promise, for example, that led by Olson et al. (2004), which showed a reduction in prevalence of excessive gestational gain among low-income White women, need to be extended to other populations to determine their efficacy. Critical issues in such extensions include customizing approaches to cultural contexts and addressing the special needs of women who are particularly vulnerable to gaining excessively, such as overweight women. Such research will require multidisciplinary teams, including nurses, nutritionists, physicians, and other disciplines. For postpartum weight loss interventions, a critical goal is to refine and test their efficacy in the context of needs of demographic groups at special risk of obesity, such as lowincome and ethnic minority new mothers. This goal is consistent with the crosscutting research topics of the Strategic Plan for NIH Obesity Research (National Institutes of Health, 2004). This goal may be achieved by building community-based models through partnerships between childbearing women and nurses and other health care providers. It may also be achieved through customizing extant intervention models with guidance from focus groups drawn from the relevant community of women. Demonstrating the efficacy of interventions among those groups of women at particular risk of postpartum weight retention and development of overweight and obesity should be a priority. Other needed research related to maternal weight during the childbearing years is addressed in a recent JOGNN 497

publication from the National Research Council and Institute of Medicine (2007).

Conclusion The obesity epidemic has alerted nurses and other health care professionals to the significance of body weight across the life span. Nurses who care for childbearing women in clinical and community settings must expand their expertise to address the full spectrum of weight status from undernutrition to overnutrition.

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