WHO recommendation on counselling on healthy eating and physical activity during pregnancy

WHO recommendation on counselling on healthy eating and physical activity during pregnancy

 

Recommendation

Counselling about healthy eating and keeping physically active during pregnancy is recommended for pregnant women to stay healthy and to prevent excessive weight gain during pregnancy.

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • A healthy diet contains adequate energy, protein, vitamins and minerals, obtained through the consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts, whole grains and fruit (1).
  • Stakeholders may wish to consider culturally appropriate healthy eating and exercise interventions to prevent excessive weight gain in pregnancy, particularly for populations with a high prevalence of overweight and obesity, depending on resources and women’s preferences. Interventions should be woman-centred and delivered in a non-judgemental manner, and developed to ensure appropriate weight gain (see further information in points below).
  • A healthy lifestyle includes aerobic physical activity and strength-conditioning exercise aimed at maintaining a good level of fitness throughout pregnancy, without trying to reach peak fitness level or train for athletic competition. Women should choose activities with minimal risk of loss of balance and fetal trauma (2).
  • Most normal gestational weight gain occurs after 20 weeks of gestation and the definition of “normal” is subject to regional variations, but should take into consideration pre-pregnant body mass index (BMI).
  • According to the Institute of Medicine classification (3), women who are underweight at the start of pregnancy (i.e. BMI < 18.5 kg/m2) should aim to gain 12.5–18 kg, women who are normal weight at the start of pregnancy (i.e. BMI 18.5–24.9 kg/m2) should aim to gain 11.5–16 kg, overweight women (i.e. BMI 25–29.9 kg/m2) should aim to gain 7–11.5 kg, and obese women (i.e. BMI > 30 kg/m2) should aim to gain 5–9 kg.
  • Most evidence on healthy eating and exercise interventions comes from high-income countries (HICs), and the GDG noted that that there are at least 40 ongoing trials in HICs in this field. The GDG noted that research is needed on the effects, feasibility and acceptability of healthy eating and exercise interventions in LMICs.
  • Pregnancy may be an optimal time for behaviour change interventions among populations with a high prevalence of overweight and obesity, and the longer-term impact of these interventions on women, children and partners needs investigation.
  • The GDG noted that a strong training package is needed for practitioners, including standardized guidance on nutrition. This guidance should be evidence-based, sustainable, reproducible, accessible and adaptable to different cultural settings.

 

Background

Pregnancy requires a healthy diet that includes an adequate intake of energy, protein, vitamins and minerals to meet maternal and fetal needs. However, for many pregnant women, dietary intake of vegetables, meat, dairy products and fruit is often insufficient to meet these needs, particularly in low and middle-income countries (LMICs) where multiple nutritional deficiencies often co-exist. In resource poor countries in sub-Saharan Africa, south-central and south-east Asia, maternal undernutrition is highly prevalent and is recognized as a key determinant of poor perinatal outcomes (4). However, obesity and overweight is also associated with poor pregnancy outcomes and many women in a variety of settings gain excessive weight during pregnancy. While obesity has historically been a condition associated with affluence, there is some evidence to suggest a shift in the burden of overweight and obesity from advantaged to disadvantaged populations (5).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (6). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (7) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (8) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (9) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), do diet and/or exercise interventions (I) compared with standard ANC (C) improve maternal and perinatal outcomes (O)?

 

Evidence summary

The evidence on the effects of healthy eating and exercise interventions was derived from a Cochrane review that included 65 randomized controlled trials (RCTs), mostly conducted in HICs (10). Thirty-four trials recruited women from the general population (i.e. women of a wide range of BMIs at baseline), 24 trials recruited overweight and/or obese women and seven recruited women defined as being at high risk of gestational diabetes. In total, 49 RCTs involving 11 444 women contributed data to the review’s meta-analyses. Diet interventions were defined as a special selection of food or energy intake to which a participant was restricted, which were most commonly “healthy eating” types of diets. Exercise interventions were defined by reviewers as any activity requiring physical effort, carried out to sustain or improve health or fitness, and these were either prescribed/unsupervised (e.g. 30 minutes of daily walking), supervised (e.g. a weekly supervised group exercise class) or both. These interventions were usually compared with “standard ANC” and aimed to prevent excessive gestational weight gain (EGWG). Most trials recruited women between 10 and 20 weeks of gestation. There as substantial variation in the number of contacts (i.e. counselling/exercise sessions), type of intervention and method of delivery. Data were grouped according to the type of intervention (i.e. diet only, exercise only, diet and exercise counselling, diet and supervised exercise) and the average effects across trials were estimated using the random effects model. Separate analyses were performed according to type of intervention and the risk of weight-related complications. Most data in the overall analyses were derived from trials of combined diet and exercise interventions.

Maternal outcomes

High-certainty evidence shows that women receiving diet and/or exercise interventions as part of ANC to prevent EGWG are less likely to experience EGWG (24 trials, 7096 women; relative risk [RR]: 0.80, 95% confidence interval [CI]: 0.73–0.87; absolute effect of 91 fewer women with EGWG per 1000 on average). Subgroup analyses were consistent with these findings. High-certainty evidence shows that diet and/or exercise interventions have little or no effect on preeclampsia risk (15 trials, 5330 women; RR: 0.95, 95% CI: 0.77–1.16). However, moderate-certainty evidence indicates that diet and/or exercise interventions probably prevent hypertension in pregnancy (11 trials, 5162 women; RR: 0.70, 95% CI: 0.51–0.96). Low-certainty evidence suggests that diet and/or exercise interventions may have little or no effect on caesarean section (28 trials, 7534 women; RR: 0.95, 95% CI: 0.88–1.03); however, low-certainty evidence from the diet and exercise counselling subgroup of trials suggests that reductions in caesarean section rates may be possible with this intervention (9 trials, 3406 women; RR: 0.87, 95% CI: 0.75–1.01). Moderate-certainty evidence indicates that diet and/or exercise interventions probably make little or no difference to induction of labour (8 trials, 3832 women; RR: 1.06, 95% CI: 0.94–1.19). Low-certainty evidence suggests that diet and/or exercise interventions may reduce the risk of gestational diabetes mellitus (GDM) (19 trials, 7279 women; RR: 0.82, 95% CI: 0.67–1.01).

Fetal and neonatal outcomes

Moderate-certainty evidence suggests that diet and/or exercise interventions probably prevent neonatal macrosomia (27 trials, 8598 women; RR: 0.93, 95% CI: 0.86–1.02), particularly in overweight and obese women receiving diet and exercise counselling interventions (9 trials, 3252 neonates; RR: 0.85, 95% CI: 0.73–1.00). However, moderate-certainty evidence indicates that diet and exercise interventions probably have little or no effect on neonatal hypoglycaemia (4 trials, 2601 neonates; RR: 0.95, 95% CI: 0.76–1.18) or shoulder dystocia (4 trials, 3253 neonates; RR: 1.02, 95% CI: 0.57–1.83). Low-certainty evidence suggests that neonatal respiratory morbidity may occur less frequently with diet and exercise counselling interventions than controls, particularly among overweight and obese women (2 studies, 2256 women; RR: 0.47, 95% CI: 0.26–0.85). Low-certainty evidence suggests that diet and/or exercise interventions may have little or no effect on preterm birth (16 trials, 5923 women; RR: 0.91, 95% CI: 0.68–1.22), and the evidence on low-birth-weight neonates is very uncertain. Perinatal mortality was not reported in the review.

 

Additional considerations

High-certainty evidence from the review also shows that low gestational weight gain is more likely to occur with these interventions (11 trials, 4422 women; RR: 1.14, CI: 1.02–1.27); the clinical relevance of this finding is not known.

The effects, acceptability and feasibility of diet and exercise interventions in LMICs has not been established.

Resources

Cost implications of diet and exercise interventions for health services are highly variable. For example, supervised diet and exercise interventions can have high associated costs, mainly due to staff costs for time spent supervising, while counselling interventions might have relatively low costs. For pregnant women, the interventions might also have resource implications in terms of transport costs, time off work and child-minding costs, particularly if the intervention requires additional antenatal visits.

Equity

Most of the evidence came from trials conducted in HICs. Recent studies have reported a shift in the burden of overweight and obesity from advantaged to disadvantaged populations (5). Such a trend increases the risk of associated pregnancy complications, as well as cardiometabolic problems, among pregnant women from disadvantaged populations. These risks might be further exacerbated among women in low-resource community settings, as these settings may not be equipped to deal with complications.

Acceptability

Qualitative evidence indicates that women in a variety of settings tend to view ANC as a source of knowledge and information and that they generally appreciate any advice (including dietary or nutritional) that may lead to a healthy baby and a positive pregnancy experience (high confidence in the evidence) (11). It also suggests that women may be less likely to engage with health services if advice is delivered in a hurried or didactic manner (high confidence in the evidence) (11). Therefore, these types of interventions are more likely to be acceptable if the interventions are delivered in an unhurried and supportive way, which may also facilitate better engagement with ANC services. Qualitative evidence on health-care providers’ views of ANC suggests that they may be keen to offer general health-care advice and specific pregnancy-related information (low confidence in the evidence) but they sometimes feel they do not have the appropriate training and lack the resources and time to deliver the service in the informative, supportive and caring manner that women want (high confidence in the evidence) (12).

Feasibility

In a number of LMIC settings, providers feel that a lack of resources may limit implementation of recommended interventions (high confidence in the evidence) (12).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified these priority questions related to this recommendation

  • What are the effects, feasibility, acceptability and equity implications of healthy eating and exercise interventions in LMICs?
  • Can an intervention package with standardized guidance on nutrition be developed that is evidence-based, sustainable, reproducible, accessible and adaptable to different cultural settings?
  • Research is needed at country level to better understand the context-specific etiology of under-nutrition. Do alternatives to energy and protein supplements, such as cash or vouchers for pregnant women, or improved local and national food production and distribution, lead to improved maternal and perinatal outcomes?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

WHO Programmes: Department of Nutrition for Health and Development

Maternal Health

 

 

References

  1. Healthy diet. Fact sheet No. 394. Geneva: World Health Organization; 2015 (http://www.who.int/ mediacentre/factsheets/fs394/en/, accessed 1 November 2016).
  2. Exercise in pregnancy. RCOG Statement No. 4. Royal College of Obstetricians and Gynaecologists. 2006:1–7 (https://www. rcog.org.uk/en/guidelines-research-services/ guidelines/exercise-in-pregnancy-statementno.4/, accessed 24 October 2016).
  3. Rasmussen KM, Yaktine AL, editors; Institute of Medicine and National Research Council. Weight gain during pregnancy: re-examining the guidelines. Washington (DC): The National Academies Press; 2009 (http://www.nationalacademies.org/hmd/ WHO recommendations on antenatal care for a positive pregnancy experience 126 Reports/2009/Weight-Gain-During-PregnancyReexaminingthe-Guidelines.aspx, accessed 29 September 2016).
  4. Tang AM, Chung M, Dong K, Terrin N, Edmonds A, Assefa N et al. Determining a global midupper arm circumference cutoff to assess malnutrition in pregnant women. Washington (DC): FHI 360/Food and Nutrition Technical Assistance III Project (FANTA); 2016 (http:// www.fantaproject.org/sites/default/files/ resources/FANTA-MUAC-cutoffs-pregnantwomen-June2016.pdf, accessed 26 September 2016).
  5. Popkin S, Slining MM. New dynamics in global obesity facing low- and middle-income countries. Obes Rev. 2013;14(2):11–20. doi:10.1111/obr.12102.
  6. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  7. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  8. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  9. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  10. Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive gestational weight gain in pregnancy. Cochrane Database Syst Rev. 2015;(6):CD007145.
  11. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  12. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on counselling on healthy eating and physical activity during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.