1. Diet Quality and Weight Change among Overweight and Obese Postpartum Women Enrolled in a Behavioral Intervention Program Spenser Parker September 20 2013

2. Abstract The prevalence of obesity has doubled and women with excessive weight retention after giving birth are at a higher risk for being overweight and obese. 400 overweight/obese women from North Carolina participated in the KAN-DO-Kids and Adults Now Defeat Obesity randomized control trial. The objective was to promote healthy weight by improving dietary and physical activity habits in preschool children of overweight or obese mothers. Also to improve diet and physical activity habits of mothers to promote postpartum weight loss. Results included no difference between intervention and control group. Women with lower BMI, a higher income, and breastfeeding had a healthier diet quality during the early postpartum period. Wiltheiss et al., 2013 pp.54-62

3. Background Prevalence of obesity more than doubled last 20 years Women of childbearing years are particularly high risk for becoming overweight or obese Almost of half of pregnant women gain more weight during pregnancy than recommended Excessive weight gain during pregnancy is associated with higher postpartum weight retention Excessive weight retention can lead to higher pregnancy weight, not breastfeeding, etc. Wiltheiss et al., 2013 pp.54-62

4. Review of Research Gore et al reviewed role of pregnancy in the effect of weight retention in postpartum women. Minority groups tended to have an increase in weight retention Pre-pregnancy weight and excessive gestational weight had the most effect on weight retention Other factors like depression, family stress, low income have shown to effect postpartum weight Interventions should focus on caloric restriction, behavioral therapy, and exercise to be the most effective Gore et al., 2003 pp.149-159

5. Review of Research Lyu et al. examined dietary intake and weight history from a prospective study from early pregnancy to 1 year postpartum 151 pregnant mothers from Taiwan participated Gestational weight gain had a significant positive correlation with weight retention. (r 0.54 @ 6 months, r 0.44 @ 1 year p<.05) Showed that women should control the amount of weight gain during gestational to decrease the weight retention in postpartum Lyu et al., 2009 pp.1828-37

6. Review of Research Other articles have stated: Exercise is effective after postpartum in weight loss and should be started during pregnancy to create a habit. Kim et al. suggested that initial BMI taken at first doctors visit, can be a predictor for postpartum weight retention up to 6 months. Hilton & Olson showed that successful interventions will be those that increase behavior specific self-efficacy through mastery experiences. For example Dietitians can strengthen exercise self-efficacy by helping postpartum mothers set realistic goals. Pruett et al. 2011, pp.100-30; Kim et al., 2008, pp.595-600; Hilton et al., 2001, pp.1430-37

7. Objective KAN-DO (Kids and Adults Now-Defeat Obesity) Primary aims of the study-promote healthy weight by improving dietary and physical activity habits in preschool children of overweight and obese mothers Secondary aims were to improve diet and physical activity habits of mothers to promote postpartum weight loss. Wiltheiss et al., 2013 pp.54-62

8. Participants 400-Overweight/Obese postpartum mothers Recruited from 14 counties in Piedmont region in North Carolina Criteria to meet Self-reported pre-pregnancy and baseline of >25 BMI Having given birth in the last 6 months Having another child age 2-5 years English speaking 18 years or older No medical conditions preventing daily physical activity Access to telephone and mailing address Wiltheiss et al., 2013 pp.54-62

9. Methods Height and weight was measured before and after intervention (2-7 postpartum for entry and end of intervention which was approx. 10 months postpartum) Lactation and Depression status addressed 0-24 scale on lactation Edinburgh Postnatal Depression Scale (score of 13) Dietary recall Telephone interviews using multiple pass 24 hour recall method In-person visit used drawings of food items to help identify portion sizes Wiltheiss et al., 2013 pp.54-62

10. Intervention Participants randomly assigned to intervention received eight monthly educational kits via mail Kits included Stress management and parenting Promoted positive healthy changes in the home Encouraged healthy behaviors in mothers and children 3 kits focused on making changes related dietary habits Participants received a 20-30 minute telephone call from a trained health coach to review each kit and address motivation to change or barriers Wiltheiss et al., 2013 pp.54-62

11. Strength of Article There was no bias in the study The sample size in the study was large, but was only women that spoke english There wasn’t strong evidence either way of a relationship or not There could be some generalizability in the article. I would give this article a grade Fair.

12. Statistical Analysis Data was analyzed two ways Cross-sectional analysis of baseline measurements Longitudinal analysis of those participants that completed the full study Analysis of variance was used to assess the relationships between dietary quality (HEI-healthy eating index 2005) Pearson’s and Spearman’s correlation analyses was used to assess the relationship between weight change, HEI score, & lactation score Change in HEI score between intervention and control was compared to find determine whether mothers in intervention significantly improved dietary quality. Wiltheiss et al., 2013 pp.54-62

13. Results 392 of the 400 completed 3 significant predictors in HEI scores BMI Lactation Household income Higher dietary quality at baseline correlated with a greater weight loss (p<.01) Baseline energy intake and weight change (p<.01) Women who breastfeed more intensity showed a significant higher energy intake at baseline (p<.002) but at follow up there was no change in groups No difference between intervention and control group in dietary quality change Wiltheiss et al., 2013 pp.54-62

14. Discussion Women in the intervention did not significantly change dietary quality Only BMI, lactation, and household income significantly impacted HEI scores Suggests that those with higher income and breastfeed choose healthy diet Still not fully clear Women who stayed home lost less weight than those that worked full time Wiltheiss et al., 2013 pp.54-62

15. Conclusion Among overweight and obese women those with higher income and breastfeed had a healthier diet quality. Women who breastfeed with higher intensity or longer duration lost more than weight from birth to 5 months than other groups and consumed more energy than other groups No differences between intervention and control arms in change in energy intake, diet quality, or weight from baseline to follow up Wiltheiss et al., 2013 pp.54-62

16. To look ahead To better assist women the focus should be on reducing total energy intake If overweight and obese women are encouraged to breastfeed then accurate information on how many extra calories are needed This intervention focused on parenting, improving family dietary intake, and increasing physical activity and showed no significant findings. Results suggest that reduced energy intake may be the best emphasis of future postpartum weight loss interventions. Wiltheiss et al., 2013 pp.54-62

17. Food for Thought What are ways to encourage women to not gain excessive weight during pregnancy? What would be your recommendation for a postpartum mother that wants to lose weight? How many calories would you decrease? Where do you think the research should go from here?

18. References Gore, S. A., Brown, D. M., & West, D. S. (2003). The role of postpartum weight retention in obesity among women: A review of the evidence. Annals of Behavioral Medicine, 26(2), 149-159. Hilton, P. S., Olson, C. M. (2001). Postpartum exercise and food intake: The importance of behavior-specific self-efficacy. Journal of the American Dietetic Association, 101(12), 1430-37. Kim, K.-H., Kim, Y. J., Lee, S., Oh, S. W., Lee, K., Park, Y., & Kim, H. J. (2008). Evaluation of plasma leptin levels & BMI as predictor of postpartum weight retention. Indian Journal of Medical Research, 128(5), 595-600. Lyu, L.-C., Lo, C.-C., Chen, H.-F., Wang, C.-Y., & Liu, D.-M. (2009). A prospective study of dietary intakes and influential factors from pregnancy to postpartum on maternal weight retention in Taipei, Taiwan. British Journal of Nutrition, 102, 1828-37. doi:10.1017/S0007114509991243 Pruett, M. D., & Caputo, J. L. (2011). Exercise guidelines for pregnant and postpartum women. Strength and Conditioning Journal, 33(3), 100-03. Wiltheiss, G. A., Lovelady, C. A., West, D. G., Brouwer, R. J. N., Krause, K. M. & Ostbye, T. (2013). Diet quality and weight change among overweight and obese postpartum women enrolled in a behavioral intervention program. Journal of the Academy of Nutrition and Dietetics, 113(1), 54-62.