Guide Managing and Preventing Obesity: Behavioural Factors and Dietary Interventions

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In total, Of these, Each follow-up point demonstrated the trend in progressive loss to follow-up with time table 3 :. Therefore, of 15 studies, 17 lifestyle interventions in total were identified table 4. Interventions based on advice alone were called passive interventions and the interventions that provided physical activity and diet to the participants were called pro-active interventions. Only one study provided advice on diet alone DP11 supplemented by feedback on progress. In two studies provision of diet or physical activity was provided DP5 and DP The beginning of interventions in the pregnancy group ranged from six to 30 weeks gestation table 4.

One study DP2 had no clear statement on the delivery of the intervention to the participants. Mode of delivery was unclear in one study DP9. The rest of the 12 studies used IOM pregnancy guidelines. The impact of intervention on postpartum weight loss and retention, infant birth weight and gestational week of delivery was not reported in the pre-conceptual group.

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A rigorous quality assessment of the studies was carried out table 5. The quality assessment scores ranged from 4—12, with higher scores indicating greater quality. There was no statistically significant difference identified between the interventions and standard maternity care groups for:. The summary of meta-analysis on outcomes of interest is shown in Table 6. However, no heterogeneity was observed between studies for postpartum weight loss, gestation week of delivery and infant birth weight.

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Therefore, random-effect meta-analysis was used when reporting GWG and postpartum weight retention and fixed-effect meta-analysis was used when reporting the other three outcomes. The analysis of each study in the forest plot is described below for each outcome. The study by Thornton DP8 showed by far the strongest effect estimate of all included studies, with the pregnant women in the intervention group gaining a mean 9. The study by Wolff DP11 also showed a strong effect estimate although it was smaller with 50 participants compared to in Thornton's.

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Both studies enrolled obese participants only, which may help to explain their results. The funnel plot was fairly symmetrical for GWG indicating non-evident publication bias Figure: 3. A significant difference in the percentage of Higgins I2 in each of the subgroups was observed during the analysis. The summary of subgroup analysis of GWG outcomes is shown in Table 7. Therefore, the forest plot across all study groups included in GWG outcome analysis indicated a reduction in GWG on average in the intervention groups when compared to standard maternity care in the control groups Figure 4 below.

Poor weight management during pregnancy can have potentially adverse effects on mother and baby [6] — [7]. However, despite numerous articles on the prevalence and implications of maternal weight on the health of the mother and infant, few interventions for gestational weight gain have been suggested. Several meta-analyses [69] — [72] , have been published on gestational weight management interventions with an emphasis on diet and physical activity. However, none of the reviews have specifically identified the main features of effective interventions and their impact on maternal and neonatal outcomes.

This review summarises 15 studies 14 in the pregnant women group and only one in the pre-conceptual group involving 3, women. The systematic review results have shown that dietary and physical activity counselling at the pre-conceptual stage results in a reduction in GWG in the intervention group. However, there is currently limited information to base clinical recommendations about the efficacy of implementing interventions at this stage, since only a single study [41] was found looking at the pre-conceptual group.

Upon synthesis of the studies, the interventions produced a small but significant average reduction of 1. This is thought to be a clinically significant reduction [70] — [71]. However, further research is needed to confirm the health benefits and to determine their magnitude. The techniques that were most commonly used in the successful interventions involved physical activity and diet counselling by a dietician, physician or a midwife supplemented by motivational talks on weight management, feedback on the progress of participants and weight monitoring during pregnancy.

The frequency of diet counselling ranged from one session DP8 to sessions at each clinical visit DP7. However, the most noticeable difference of 9. In interventions where diet and physical activity counselling were not used together, intense diet counselling for up to 10 times for one hour during pregnancy DP11 , was used to increase the intensity of intervention. Therefore, for effective weight management in pregnancy intensely delivered interventions could be promising.

The interventions delivered in early pregnancy on average showed better results than those delivered later in pregnancy. Sensitivity analysis made very little difference to the overall effect estimates. The subgroup analysis of the GWG study groups yielded that women's pre-pregnancy weight, mode of delivery of the intervention and the quality of study appeared to influence the effectiveness of the intervention.

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The analysis based on the psychological contents of the intervention did not demonstrate any difference in the effect of intervention between the two groups. However, in the current NICE guidelines recommendations were made against repeated weight measurements in pregnancy unless required [73]. When the analysis was confined to high quality studies only, there was no trend of lower GWG in the intervention groups. The analysis showed that weight management interventions are more likely to impact GWG in high-risk participants. Simultaneously, it would also appear likely that the observed effects are due to the mode of delivery of the intervention rather than the intervention itself.


This shows that when interventions are based on clinical evidence and delivered by healthcare professionals, it increases the reliability of well-being for both mother and foetus [74]. However, the number and size of studies delivered in the community settings were less compared to the hospital settings. Therefore, caution is needed in their interpretation. The observed effect on GWG and postpartum weight retention showed strong heterogeneity and was unlikely to be explained by publication bias, as indicated by a symmetrical funnel plot. There was no evidence of interventions targeting GWG to impact postpartum weight loss, postpartum weight retention, gestation week of delivery and infant birth weight.

There was no data on whether babies were small for gestational age. But the outcome of the intervention may not be significant when applied to real life. Therefore, to achieve more valid results, participants and assessors should be randomised and blinded to the interventions. In two studies DP8 and DP11 only obese participants were included and their GWG was measured by last weight before delivery minus self-reported pre-pregnancy weight.

Obese participants may have overestimated their pre-pregnancy weight with the corollary of a lower GWG. On average, during pregnancy seven to eight pounds 3. In these participants, the mean GWG in the intervention group was 4. One should also bear in mind how diurnal variation in participant hydration could potentially represent a confounder in weight measurements, although it should affect groups equally in good RCTs.

Finally, since we excluded those with comorbid conditions like diabetes and hypertension, the results apply only to those without comorbidities. All the studies were conducted in high income countries only, which may not be generalisable to low and middle income countries due to lack of resources and expertise. None of the studies were conducted in the UK. The data collection and reports on findings of studies were conducted in different cultural and healthcare system settings non-NHS and may not be generalisable to the UK, which is a limitation of this research.

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  • Some studies were of poor quality and generally small with insufficient numbers of patients. In many cases the published reports were inadequate for our purpose and there was also incomplete reporting of data in some studies. The majority of the studies were reporting impacts of intervention on GWG only, so enough evidence cannot be collected for the maternal and neonatal outcomes.

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    In addition, a standardised method for measuring weight such as pre-breakfast was not deployed amongst all the studies. With the differential for GWG in intervention and control studies being so small, this could potentially be an important source of bias. Only eight out of 15 studies utilised an intention to treat analysis and none mentioned crossover and its likely impact on the validity of randomisation. The limitations of this review also stem from the methodological insufficiencies and the considerable heterogeneity in the studies and incomplete reporting of objectives due to unavailability of data.

    In addition out of 15 studies, only four had specifically reported adequate blinding of the outcome assessor. Therefore, further studies on interventions are needed based on current IOM guidelines. The search was not reviewed by a librarian and was limited to scientific papers in the English language from January to May only. This has been coupled with initiatives to offer translation services of key papers [78]. We feel that this strategy would still capture all the relevant papers.

    In the meta-analysis, non-randomized studies were also included in order to increase statistical power. However, non-randomized studies may be biased due to structural disparities between the intervention and control groups and potential hidden confounders. Also due to differences in the reporting of socio-economic status in each study, this baseline characteristic was not considered in the discussion of results.

    This systematic review of studies found that there is some evidence to determine whether interventions can moderate GWG in pregnant women. Compared to previous meta-analyses [69] — [72] there is a variation in the overall reported mean difference between the groups in this review. Other reviews stated no clear conclusion and noted that further research is needed [31] , [79] However, this review provided an important new insight into the effects of interventions to reduce GWG by quantifying the strength of the effect. Our analysis disagrees with the findings of one study [71] that physical activity combined with diet and weight monitoring seem to impact GWG and interventions confined to only one of the domains does not impact GWG.

    In our analysis interventions confined to diet only showed evidence of reduced GWG in the intervention group. More recently, Thangaratinum et al [72] found that dietary interventions were the most effective type of intervention for reducing GWG in pregnancy, as well as gestational hypertension and shoulder dystocia.

    This may be reflective of the different RCTs incorporated into the meta-analysis.