Healthy Weight and Weight Gain In Pregnancy: Behavioral Counseling Interventions

The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons.¹ Obesity rates during pregnancy increased from 13% in 1993 to 24% in 2015.¹ In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%).^1,2 Prepregnancy obesity is higher in Alaska Native/American Indian (36.4%), Black (34.7%), and Hispanic (27.3%) women compared with White women (23.7%). Asian women have the lowest rates of obesity (7.5%).^1,3 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

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 1).

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁴

Patient Population Under Consideration

This recommendation applies to pregnant adolescents and adults in primary care settings.

Definitions

The USPSTF uses the following terms to define healthy weight gain associated with pregnancy. These weight gain guidelines are for singleton pregnancies.

• Gestational weight gain is defined as the change in weight from before pregnancy (prepregnancy or during the first trimester) to the weight measured prior to delivery.⁵ The National Academy of Medicine (formerly known as the Institute 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.⁵
• Prepregnancy weight categories are based on the World Health Organization categories for nonpregnant persons: underweight (body mass index [BMI] <18.5 [calculated as weight in kilograms divided by height in meters squared]), normal or healthy weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI ≥30).^5-7

Behavioral Counseling Interventions

Effective behavioral counseling interventions to promote healthy weight gain in pregnancy are associated with decreased risk of gestational diabetes mellitus, emergency cesarean delivery, infant macrosomia, and LGA infants.¹ Behavioral counseling 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. The most common types of behavioral counseling interventions included active or supervised exercise or counseling about diet and physical activity.¹ Interventions generally started at the end of the first trimester or the beginning of the second trimester and ended prior to delivery. Intervention sessions lasted from 15 to 120 minutes and ranged from fewer than 2 to 12 or more contacts. Interventionists were highly diverse and included clinicians, registered dietitians, qualified fitness specialists, physiotherapists, and health coaches. Trials used various delivery methods (face-to-face, computer, internet, or telephone).¹

Effective behavioral counseling interventions often referred participants to various interventionists in different settings (eg, local community fitness center). 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 Behavioral counseling interventions with 12 or more contacts were more effective for some outcomes (mean GWG, excess GWG, and infant macrosomia) than interventions with fewer contacts.¹ There is not enough evidence to determine whether specific components of these interventions were independently related to intervention effectiveness.

Implementation

Primary care clinicians can deliver effective in-person behavioral counseling interventions or refer patients to behavioral counseling interventions in other settings. For more information about behavioral counseling interventions, see Table 2.

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 nonpregnant adults lose weight and maintain weight loss.²⁵
• The Community Preventive Services Task Force recommends exercise programs during pregnancy to reduce the development of gestational hypertension.²⁶

Other Related USPSTF Recommendations

The USPSTF recommends screening for obesity in adults and offering or referring those with a BMI of 30 or greater to intensive, multicomponent behavioral weight loss interventions.²⁷ The USPSTF also has recommendations on screening for gestational diabetes mellitus²⁸ and behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with and without cardiovascular risk factors.^29,30

Scope of Review

The USPSTF commissioned a systematic review^1,31 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 clinical trials and 4 nonrandomized controlled intervention studies evaluated interventions to promote healthy weight gain and limit excessive GWG during pregnancy.

Study sample sizes ranged from 50 to 2261; the total number of participants in all included studies was 25,789. The mean reported age ranged from 18 to 33 years.^1,31 None of the studies exclusively enrolled pregnant adolescents or pregnant adults of advanced maternal age. BMI inclusion criteria varied across the trials; there were participants with overweight or obesity (19 trials), those with obesity only (13 trials), those with mixed weight status (34 trials), and those with 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.^1,31

Maternal Health Outcomes

Gestational weight gain interventions were associated with statistically significant reductions in risk of gestational diabetes mellitus (43 trials; relative risk [RR], 0.87 [95% 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.^1,31 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

Gestational weight gain 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 in infants (26 trials; RR, 0.89 [95% CI, 0.80 to 0.99]; I² = 0%; ARD, −1.3 [95% CI, −2.3% to −0.3%]).^1,31 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 = .03 for interaction) but no effect on other infant outcomes by BMI category, intervention type, or intervention intensity.^1,31 Evidence suggested that some specific pregnancy-related intermediate outcomes are associated with health outcomes. Macrosomia and LGA in infants were associated with an increased risk of maternal and infant complications during birth.

Maternal Weight Outcomes

Gestational weight gain 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 kg]; I² = 60.3%). High-intensity interventions (≥12 contacts) were associated with greater effects (28 trials; pooled MD, −1.47 kg [95% CI, −1.78 to −1.22 kg]; I² = 13.0%) than were moderate-intensity interventions (3-11 contacts) (18 trials; pooled MD, −0.32 kg [95% CI, −0.71 to −0.04 kg]; I² = 17.6%) or low-intensity interventions (≤2 contacts) (9 trials; pooled MD, −0.64 kg [95% CI, −1.44 to 0.02 kg]; I² = 48.4%; P < .001 for interaction). There was no significant 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 National Academy of Medicine 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 size for active interventions (P < .001 for interaction) and high-intensity interventions (P < .001 for interaction). There was no significant interaction between BMI category and effects on likelihood of excess weight gain. Gestational weight gain interventions were not associated with increased likelihood of adherence to National Academy of Medicine recommendations for GWG (ie, 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 kg]; I² = 65.5%).^1,31

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 association between GWG interventions and small for gestational age size in infants 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 Gestational weight gain interventions were not associated with maternal death (2 trials); however, there were low event rates and few trials.^1,31

Response to Public Comments

A draft version of this recommendation statement was posted for public comment on the USPSTF website from December 8, 2020, to January 11, 2021. Comments asked for clarification of the patient population. The USPSTF revised the Practice Considerations section to clarify that the patient population under consideration included pregnant adolescents and adults and to more clearly define “healthy” weight. Comments asked for more clarification about effective interventions. The USPSTF provided examples of effective behavioral counseling interventions that can be used in practice in Table 2.

There are several important 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, including the optimal frequency, length of sessions, and number of sessions needed for an intervention to be effective.
• Whether interventions should be tailored to promote healthy weight gain in populations of pregnant persons of advanced maternal age (eg, older than 34 years); adolescents; diverse populations such as non-Hispanic Black, Alaska Native/American Indian, and Hispanic persons; and populations with increased rates of overweight and obesity.³

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.^7,32-37 The National Academy of Medicine recommends counseling about healthy weight gain during pregnancy and adherence to its recommendations about GWG.⁵

The US Preventive Services Task Force members include the following individuals: Karina W. Davidson, PhD, MASc (Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York); Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Michael Cabana, MD, MA, MPH (Albert Einstein College of Medicine, New York, New York); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Esa M. Davis, MD, MPH (University of Pittsburgh, Pittsburgh); Katrina E. Donahue, MD, MPH (University of North Carolina at Chapel Hill); Chyke A. Doubeni, MD, MPH (Mayo Clinic, Rochester, Minnesota); Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Martha Kubik, PhD, RN (George Mason University, Fairfax, Virginia); Li Li, MD, PhD, MPH (University of Virginia, Charlottesville); Gbenga Ogedegbe, MD, MPH (New York University, New York, New York); Lori Pbert, PhD (University of Massachusetts Medical School, Worcester); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); Melissa A. Simon, MD, MPH (Northwestern University, Evanston, Illinois); James Stevermer, MD, MSPH (University of Missouri, Columbia); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).

Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. 

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF. 

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication. 

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services. 

Additional Information: The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.

AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

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Abbreviation: USPSTF, US Preventive Services Task Force.

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; NAM, National Academy of Medicine (formerly the Institute of Medicine).
^a Adapted from supplemental eTable 2 in Cantor et al¹ and a modified Template for Intervention Description and Replication (TIDieR) checklist.^24
b Intervention intensity categorized as low (≤2 contacts), moderate (3-11 contacts), or high (≥12 contacts).
^c Links to resources are available in the article PDF.
Supplement. US Preventive Services Task Force (USPSTF) Grades and Levels of Evidence