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Draft Recommendation Statement

Healthy Weight and Weight Gain During Pregnancy: Behavioral Counseling Interventions

December 08, 2020

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This topic is being updated. Please use the link(s) below to see the latest documents available.
  • Update in Progress for Healthy Weight and Weight Gain During Pregnancy: Behavioral Counseling Interventions

Recommendation Summary

Population Recommendation Grade
Pregnant persons The USPSTF recommends that clinicians offer pregnant persons recurring behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. B

Additional Information

Tools
Related Resources
  • Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: Consumer Guide (Draft Recommendation) | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Importance

The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons.1 In 2015, almost half of all persons began pregnancy with overweight or obesity (24% and 24%, respectively).1, 2 Excess weight at the beginning of pregnancy and excess gestational weight gain (GWG) have been associated with adverse maternal and infant health outcomes, such as a large for gestational age (LGA) infant, cesarean delivery, or preterm birth.1

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The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess GWG in pregnancy have a moderate net benefit for pregnant persons (Table).

For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.3

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Patient Population Under Consideration

This recommendation applies to pregnant adults age 18 years or older in primary care settings. 

Definitions

The USPSTF uses the following terms to define weight associated with pregnancy.

  • GWG is defined as the change in weight from before pregnancy (prepregnancy or during the first trimester) to the weight measured prior to delivery.4 The Institute of Medicine’s (IOM’s) (now called the National Academy of Medicine) recommendations for healthy GWG are 28 to 40 lb in the prepregnancy underweight category, 25 to 35 lb for the normal prepregnancy weight category, 15 to 25 lb for the prepregnancy overweight category, and 11 to 20 lb for the prepregnancy obese category.4
  • Prepregnancy weight categories are based on the World Health Organization categories for nonpregnant persons: underweight (body mass index (BMI) <18.5 kg/m2), normal or healthy weight (BMI, 18.5 to 24.9 kg/m2), overweight (BMI, 25 to 29.9 kg/m2), and obese (BMI ≥30 kg/m2).4-6 

Behavioral Counseling Interventions

Behavioral counseling interventions to promote healthy weight gain in pregnancy are associated with decreased risk of gestational diabetes mellitus, emergency cesarean delivery, macrosomia, and LGA infant.1 Recurring behavioral interventions with more frequent contacts (≥12) were more effective for some outcomes (GWG, excess GWG, and macrosomia).1 Interventions generally occurred at the end of the first trimester or the beginning of the second trimester and ended prior to delivery. Interventions varied in included components. Some interventions had an individual focus on nutrition, physical activity, or lifestyle and behavioral change. Other interventions had multiple components. Intervention sessions lasted from 15 to 60 minutes. Interventionists were highly diverse and included clinicians, registered dieticians, qualified fitness specialists, physiotherapists, and health coaches. Trials used various delivery methods (face-to-face, computer, internet, or telephone).1

Effective, recurring interventions often referred participants to various interventionists in different settings (e.g., local community fitness center). Interventions were provided in person, by telephone, or in combination. Participants were counseled on healthy diet and exercise through individual or group education sessions. Some interventions provided medically supervised group exercise classes with or without counseling.1 There is not enough evidence to determine whether specific components of these interventions (e.g., an activity component) were independently related to intervention effectiveness. More intense interventions were associated with lower mean GWG and lower likelihood of exceeding IOM recommendations for GWG. Intervention intensity also had an effect on infant macrosomia.

Implementation

Primary care clinicians can deliver in-person behavioral counseling interventions or refer patients to behavioral counseling interventions in other settings. For more information about behavioral counseling interventions, see the Table. 

Additional Tools and Resources

The following resource may help clinicians implement this recommendation.

  • The Community Preventive Services Task Force recommends multicomponent interventions that use technology-supported coaching or counseling to help adults lose weight and maintain weight loss.7

Other Related USPSTF Recommendations

The USPSTF recommends screening for obesity in adults and offering or referring those with a body mass index of 30 kg/m2 or greater to intensive, multicomponent behavioral weight loss interventions.8 The USPSTF also has recommendations on screening for gestational diabetes mellitus9 and behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with and without cardiovascular risk factors.10, 11

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Scope of Review

The USPSTF commissioned a systematic review1 to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess GWG. The USPSTF has not previously made a recommendation on this topic. 

Benefits of Counseling Interventions to Change Behavior

Sixty-four randomized, controlled trials and four nonrandomized trials evaluated interventions to promote healthy weight gain and limit excessive GWG during pregnancy. Study sample sizes ranged from 50 to 2,261; the total number of participants in all included studies was 25,789. The mean reported age ranged from 18.6 to 33.8 years.1 None of the studies exclusively enrolled pregnant adolescents or pregnant adults of advanced maternal age. BMI inclusion criteria varied across the trials: overweight or obese participants (19 trials), obese participants only (13 trials), mixed weight status (34 trials), and normal weight only (1 trial). Twenty-eight of the 68 included studies (41%) enrolled more than 20% of patients from diverse backgrounds, including persons who are socioeconomically disadvantaged, racial/ethnic populations, rural populations, or others. Twenty-two studies provided an intervention with an activity component, while 45 studies offered counseling-only interventions. The mean weight loss after the interventions was approximately 1 kg across the trials.1

Maternal Health Outcomes

GWG interventions were associated with statistically significant reductions in risk of gestational diabetes mellitus (43 trials; relative risk [RR], 0.87 [95% confidence interval (CI), 0.79 to 0.95]; I2=16.4%; absolute risk difference [ARD], -1.6% [95% CI, -2.5 to -0.7]) and emergency (unscheduled) cesarean delivery (134 trials; RR, 0.875 [95% CI, 0.754 to 0.986]; I2=0%; ARD, -2.24% [95% CI, -4.20 to 0.03]). There was no association between GWG interventions and gestational hypertension, total number of cesarean deliveries, preeclampsia, postpartum hemorrhage, perineal trauma, or maternal death.1 Stratified analyses showed statistically significant interactions between the mixed BMI category and perineal trauma, active interventions and gestational hypertension, high-intensity interventions and gestational hypertension, and intervention intensity and perineal trauma.

Infant Health Outcomes

GWG interventions were associated with decreased risk of infant macrosomia (25 trials; RR, 0.77 [95% CI, 0.65 to 0.92]; I2=38.3%; ARD, -1.9% [95% CI, -3.3 to -0.7]) and LGA infant (26 trials; RR, 0.89 [95% CI, 0.80 to 0.99]; I2=0%; ARD, -1.3, [95% CI, -2.3 to -0.3]).1 However, the interventions were not associated with changes in growth rates during the first year of life or in risk of preterm birth, neonatal death or stillbirth, shoulder dystocia, admission to the neonatal intensive care unit, or respiratory distress syndrome. Stratified analyses showed statistically significant interactions between intervention intensity and infant macrosomia (p=0.03 for interaction) but no effect on other infant outcomes by BMI category, intervention type, or intervention intensity.1 Evidence suggests that there are some specific pregnancy-related intermediate outcomes that are associated with health outcomes. Macrosomia and LGA in infants are associated with an increased risk of maternal and infant complications during birth.

Maternal Weight Outcomes

GWG interventions were associated with 1 kg less weight gain across all prepregnancy weight categories (55 trials; pooled mean difference [MD], -1.02 kg [95% CI, -1.30 to -0.75]; I2=60.3%). High-intensity interventions (≥12 sessions) were associated with greater effects (28 trials; pooled MD, -1.47 kg [95% CI, -1.78 to -1.22]; I2=13.0%) than moderate-intensity (3 to 11 sessions) (18 trials; pooled MD, -0.32 kg [95% CI, -0.71 to -0.04]; I2=17.6%) or low-intensity interventions (≤2 sessions) (9 trials; pooled MD, -0.64 kg [95% CI, -1.44 to 0.02]; I2=48.4%; p<0.001 for interaction). There was no interaction between intervention type or baseline BMI category and effects on GWG. Interventions were also associated with a lower likelihood of GWG in excess of the IOM recommendations (39 trials; RR, 0.84 [95% CI, 0.78 to 0.90]; I2=63.2%; ARD, -7.7% [95% CI, -11.0 to -4.6]), with greater effect for active (p<0.001 for interaction) and high-intensity interventions (p<0.001 for interaction). There was no interaction between BMI category and effects on likelihood of excess weight gain. GWG interventions were not associated with increased likelihood of adherence to IOM recommendations for GWG (i.e., neither gaining excessive weight nor failing to gain sufficient weight) or postpartum weight retention at less than 6 months, but were associated with reduced postpartum weight retention at 12 months (10 trials; pooled MD, -0.63 kg [95% CI, -1.44 to -0.01]; I2=65.5%).1

Harms of Counseling Interventions to Change Behavior

The USPSTF found limited evidence on harms because most studies were not designed to evaluate harms. Twelve studies evaluated the effects of GWG interventions on maternal anxiety and depression and showed mixed results.1 The effect of GWG interventions on small for gestational age size in infants demonstrated no particular difference and was not statistically significant (20 trials; RR, 0.94 [95% CI, 0.80 to 1.10]; I2=0%; ARD, -0.4% [95% CI, -1.7 to 1.0]).1 GWG interventions were not associated with maternal death (2 trials); however, there were low event rates and few trials.1

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There are several critical evidence gaps. Studies are needed that provide more information on the following.

  • The effectiveness of interventions on additional short- and long-term maternal and infant health outcomes.
  • The specific components of intensive behavioral interventions and whether such components should be tailored to specific populations; research is needed on the optimal frequency, length of sessions, and number of sessions needed for an intervention to provide additional evidence on effectiveness.
  • The effectiveness of interventions to promote healthy weight gain in populations of women of advanced maternal age (e.g., older than age 34 years); adolescents; diverse populations such as non-Hispanic Black, Alaska Native/American Indian, and Hispanic women; and populations with increased rates of overweight and obesity.12
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The American College of Obstetricians and Gynecologists recommends that clinicians provide counseling on the risks of obesity in pregnancy and provide resources or refer persons of reproductive age to weight-reduction interventions before conception.6, 13, 14 The National Academy of Medicine (formerly the IOM) recommends counseling about healthy weight gain during pregnancy and adherence to IOM recommendations about GWG.4

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1. Cantor A, Jungbauer RM, McDonagh MS, et al. Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 203. AHRQ Publication No. 20-05272-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2020.
2. Deputy NP, Dub B, Sharma AJ. Prevalence and trends in prepregnancy normal weight - 48 States, New York City, and District of Columbia, 2011-2015. MMWR Morb and Mortal Wkly Rep. 2018;66:1402-1407.
3. US Preventive Services Task Force. Procedure Manual. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual. Accessed November 23, 2020.
4. Institute of Medicine and National Research Council Committee to Reexamine IOM Pregnancy Weight Guidelines. In: Rasmussen KM, Yaktine AL, eds. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academies Press; 2009.
5. World Health Organization. Body Mass Index - BMI. https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi. Accessed November 23, 2020.
6. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol. 2013;121(1):210-212.
7. Community Preventive Services Task Force (CPSTF). CPSTF Findings for Obesity. https://www.thecommunityguide.org/content/task-force-findings-obesity. Accessed November 23, 2020
8. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(11):1163-1171.
9. Moyer VA; U.S. Preventive Services Task Force. Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(6):414-420.
10. U.S. Preventive Services Task Force. Behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. JAMA. 2020;324(20):2069-2075.
11. US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2017;318(2):167-174.
12. Branum AM, Kirmeyer SE, Gregory EC. Prepregnancy body mass index by maternal characteristics and state: data from the birth certificate, 2014. Natl Vital Stat Rep. 2016;65(6):1-11.
13. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 549: obesity in pregnancy. Obstet Gynecol. 2013;121(1):213-217.
14. American College of Obstetricians and Gynecologists. Prepregnancy counseling: committee opinion no. 762. Fertil Steril. 2019;111(1):32-42.

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Rationale Assessment
Effectiveness of counseling to change behavior
  • The USPSTF found adequate evidence that recurring behavioral counseling interventions that limit excess gestational weight gain improve health outcomes (i.e., gestational diabetes, emergency cesarean delivery) among pregnant persons and their infants (i.e., macrosomia, large for gestational age). Macrosomia and large for gestational age in infants are intermediate outcomes associated with important health outcomes in infants.
  • The USPSTF found adequate evidence that recurring behavioral counseling interventions demonstrated reductions in intermediate outcomes, including gestational weight gain and postpartum weight retention, at 12 months. There was also adequate evidence of a lower likelihood of gaining weight in excess of the Institute of Medicine’s (now called the National Academy of Medicine) gestational weight gain recommendations in pregnant persons.
  • The overall magnitude of the benefit of recurring behavioral counseling interventions for heathy weight gain in pregnancy to improve maternal and infant health outcomes is moderate.
Harms of counseling
  • The USPSTF found adequate evidence to bound the potential harms of recurring behavioral counseling interventions as no greater than small, based on the nature of the interventions, the low likelihood of serious harms, and the available information from studies reporting few harms. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.Adequate evidence to bound harms of behavioral counseling interventions as no greater than small based on the absence of reported harms in the evidence, the noninvasive nature of the interventions, and the low likelihood of serious harms.
USPSTF Assessment
  • The USPSTF concludes with moderate certainty that recurring behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons.
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