First-time recommendation calls for behavioral interventions to curb adverse outcomes

Pregnant women should get clinician-initiated behavioral counseling to promote healthy weight gain, and prevent excess gestational weight gain, according to the U.S. Preventive Services Task Force (USPSTF).

The new recommendation received a “B” grade, meaning that the task force “concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons,” wrote Karina W. Davidson, PhD, MASc, of the Feinstein Institute for Medical Research in New York City, and co-authors.

The most common types of behavioral counseling interventions were active or supervised exercise or counseling about diet and exercise, and generally begun at the end of the first trimester, or the beginning of the second trimester, and finished up prior to delivery, they explained in JAMA.

The task force directed clinicians to recommendations from the Community Preventive Services Task Force on technology-supported weight loss coaching or counseling for the general population and on exercise programs during pregnancy to cut the risk of gestational hypertension.

However, Davidson’s group cautioned that there “is not enough evidence to determine whether specific components of… interventions were independently related to intervention effectiveness.” A recent study found that even after a gestational diabetes mellitus (GDM) diagnosis, women made modest alterations to their diets and little-to-no changes to their exercise regimen.

In a JAMA Patient Page, Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, explained that for people who are underweight, the 2009 National Academy of Medicine (NAM) recommended amount of weight gain during pregnancy is 28 to 40 lbs., while for people at normal weight, it’s 25 to 35 lbs., and for those who overweight or obese, it’s 11 to 20 lbs. “In 2015, nearly half of pregnant people in the U.S. began their pregnancy overweight or obese,” she wrote.

The new task force recommendation echoes those from the American College of Obstetrics and Gynecology (ACOG) “that clinicians determine body mass index at intake and counsel patients on appropriate GWG, nutrition, and exercise throughout pregnancy,” noted D. Yvette LaCoursiere, MD, MPH, of the University of California San Diego, in an editorial accompanying the study.

But both the task force and ACOG “leave implementation to the clinician’s discretion. This is where challenges lie,” she pointed out. “The USPSTF recommendations will require lengthening already time-constrained prenatal visits or relying on adjunctive professionals,”—such as midwives, health educators; physical therapists; fitness specialists; and dietitians—and that level of care may not be covered by the patient’s insurance.

LaCoursiere added that there is no federal requirement for states to provide pregnant Medicaid enrollees with counseling for nutrition and physical activity. Multiple legislative actions under the Biden administration have targeted maternal and fetal health, but only one mentions nutrition: Giving states the option to offer Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits to women for two years postpartum.

She also explained that it’s still unknown what the “best methods, timing, and frequency of the high yield components…of the interventions [to] change behavior and positively influence outcomes.” In addition, “[o]nce successful interventions are identified, how can integration into clinical practice be accomplished and sustained? Barriers such as time constraints, limited clinician training in behavioral counseling, inadequate ancillary resources, and respective funding gaps may limit incorporation of these interventions into routine prenatal care,” LaCoursiere wrote.

Davidson and co-authors acknowledged that more research was needed in the areas that LaCoursiere outlined. In the meantime, agencies such as the CDC, the U.S. Department of Agriculture, and the Agency of Healthcare Research and Quality, offer some tools for implementing interventions.

For the evidence report, Amy G. Cantor, MD, MPH, Oregon Health & Science University in Portland, and co-authors looked at 68 studies (n=25,789), the vast majority of which evaluated interventions during pregnancy.

They found that gestational weight gain (GWG) interventions were linked with reductions in risk of:

  • GDM: relative risk 0.87 (95% CI 0.79-0.95), absolute risk difference (ARD) −1.6%.
  • Emergency cesarean section delivery: RR 0.85 (95% CI 0.74-0.96), ARD −2.4%.
  • Macrosomia: RR 0.77 (95% CI 0.65-0.92), ARD −1.9%.
  • Large for gestational age: RR 0.89 (95% CI 0.80-0.99), ARD −1.3%.
  • Postpartum weight retention at 12 months: mean difference, −0.63 kg or about 1.4 lbs. (95% CI −1.44 to −0.01).

However, the authors reported no significant association between GWG interventions and risk of gestational hypertension, C-section delivery, pre-eclampsia, and pre-term birth.

In addition, intervention participants had a reduced weight gain across all prepregnancy weight categories (pooled mean difference −1.02 kg, 95% CI −1.30 to −0.75) and demonstrated lower likelihood of GWG in excess of NAM recommendations (RR, 0.83, 95% CI, 0.77-0.89, ARD −7.6%).

Finally, data on “harms of GWG interventions was limited, but there was no association with increased risk of small for gestational age and no indication of serious harms,” the authors wrote.

Limitations of the evidence report included unavailable data for “important groups defined by race or ethnicity, age… or socioeconomic status,” Cantor and co-authors explained. Davidson’s group noted that more research is needed on interventions for healthy weight in pregnancy in those ages ≥34 along with “pregnant persons of diverse populations such as non-Hispanic Black, Alaska Native/American Indian, and Hispanic persons.”

  1. The U.S. Preventive Services Task Force recommends that clinicians offer pregnant women behavioral counseling interventions to promote healthy weight gain and prevent excess gestational weight gain in pregnancy.

  2. The most common types of behavioral counseling interventions were active or supervised exercise or counseling about diet and exercise, and generally begun at the end of the first trimester, or the beginning of the second trimester, and finished up prior to delivery.

Shalmali Pal, Contributing Writer, BreakingMED™

The USPSTF is funded by the Agency for Healthcare Research and Quality (AHRQ). The evidence report was funded by AHRQ. USPSTF members reported travel reimbursement and an honorarium for participating in USPSTF meetings.

Jin reported serving as JAMA associate editor.

LaCoursiere, as well as Cantor and co-authors, reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 41

Topic ID: 83,41,730,187,795,41,192,518,917,925