Behavior Change Strategies in Randomized Controlled Trials for Maternal Excessive Gestational Weight Gain Prevention

Purpose: Excessive gestational weight gain (EGWG) is a risk factor for cardiovascular and metabolic disorders among pregnant women and their infants (Gaillard, 2015; Viteri, Whitty, Salazar, & Refuerzo, 2015). It also increases the likelihood of the mother retaining weight during postpartum and the mother and her infant being overweight or obese years after delivery (Marchi, Berg, Dencker, Olander, & Begley, 2015). Overweight and obese pregnant women are twice the risk of having EGWG than normal weight women (Deputy, Sharma, & Kim, 2016). Interventions to help pregnant women prevent EGWG have largely been focused on improving eating habit and physical activity (Muktabhant, Lawrie, Lumbiganon, & Laopaiboon, 2015). Literature, however, has been limited in describing behavior change strategies used to help overweight and obese pregnant women prevent EGWG through healthy eating and physical activity. From the implementation science perspective, the lack of synthesized strategies from multiple intervention studies may slow down the process of applying intervention findings to practice (Michie et al., 2017). This systematic review, therefore, was conducted to synthesize behavior change strategies used in published randomized controlled trials (RCTs) to prevent EGWG in overweight and obese pregnant women.

Methods: Literature search was performed in PubMed and EBSCO (Academic Search Premier, CINAHL, MEDLINE, and PsyInfo) databases using several keyword combinations, including pregnancy, EGWG, weight loss/gain, diet, nutrition, exercise and physical activity. To be included in the analysis, a study must have RCT as the design, healthy eating or physical activity or both as the intervention, overweight or obese pregnant adult women without medical problems as the subject, and gestational weight gain as a primary or secondary outcome. A total of 740 articles published by June 30, 2016 were screened. After reviewing titles, abstracts, and full texts, 23 articles reporting 23 RCTs were retained for final analysis. Two coders extracted behavior change strategies from each RCT. Extracted strategies were then grouped into five clusters, reflecting self-regulatory, environmental, and emotional aspects.

Results: The five clusters of behavior change strategies included goal setting, self-monitoring, feedback and solution, environmental modification and social support, and emotion handling. Goals were aimed at gaining weight within recommendations, healthy eating with calorie restriction and balanced macronutrient and food groups, and increasing physical activity intensity and frequency. Self-monitoring strategies described in the RCTs were related to what to monitor, how to record, and how to submit self-monitoring data. Pregnant women were asked to self-monitor diet and physical activity more often than weight. Feedback was mostly based on goal achievement. Praise was given to pregnant women if goals were achieved and if goals were not met solutions were recommended. Environmental modification strategies in the RCTs included changing health behavior within a cultural context, healthy eating options when eating out, and situational control in response to environmental changes. Providing an interactive and individualized social support system or empowering pregnant women to build a social support system in order to optimize reinforcement were other strategies. Further, emotion handling strategies included controlling periods of emotional eating and binge eating, and addressing obese pregnant women’s worries and personal questions concerning pregnancy.

Conclusion: The five clusters of behavior change strategies imply that EGWG is a multifaceted health issue. Weight management for pregnant women need to strengthen a woman’s self-regulation, social environment, and emotion handling. Overweight and obese pregnant women can be encouraged to adopt self-regulatory strategies for weight control. Care providers can also help the women prevent EGWG by modifying their environment, support, and emotion.