International Journal of Obesity (2013) 37, 814–821

& 2013 Macmillan Publishers Limited All rights reserved 0307-0565/13

www.nature.com/ijo

ORIGINAL ARTICLE
Effects of lifestyle intervention in obese pregnant women on
gestational weight gain and mental health: a randomized
controlled trial
AFL Bogaerts1, R Devlieger2, E Nuyts1, I Witters3, W Gyselaers4,5 and BRH Van den Bergh6,7,8

OBJECTIVE: Lifestyle intervention could help obese pregnant women to limit their weight gain during pregnancy and improve
their psychological comfort, but has not yet been evaluated in randomized controlled trials. We evaluated whether a targeted
antenatal lifestyle intervention programme for obese pregnant women influences gestational weight gain (GWG) and levels of
anxiety or depressed mood.
DESIGN AND SUBJECTS: This study used a longitudinal interventional design. Of the 235 eligible obese pregnant women, 205
(mean age (years): 29±4.5; body mass index (BMI, kg m  2): 34.7±4.6) were randomized to a control group, a brochure group
receiving written information on healthy lifestyle and an experimental group receiving an additional four antenatal lifestyle
intervention sessions by a midwife trained in motivational lifestyle intervention. Anxiety (State and Trait Anxiety Inventory) and
feelings of depression (Edinburgh Depression Scale) were measured during the first, second and third trimesters of pregnancy.
Socio-demographical, behavioural, psychological and medical variables were used for controlling and correcting outcome variables.
RESULTS: We found a significant reduction of GWG in the brochure (9.5 kg) and lifestyle intervention (10.6 kg) group compared
with normal care group (13.5 kg) (P ¼ 0.007). Furthermore, levels of anxiety significantly decreased in the lifestyle intervention
group and increased in the normal care group during pregnancy (P ¼ 0.02); no differences were demonstrated in the brochure
group. Pre-pregnancy BMI was positively related to levels of anxiety. Obese pregnant women who stopped smoking recently
showed a significant higher GWG (b ¼ 3.04; P ¼ 0.01); those with concurrent gestational diabetes mellitus (GDM) (b ¼ 3.54; P ¼ 0.03)
and those who consumed alcohol on a regular base (b ¼ 3.69; P ¼ 0.04) showed significant higher levels of state anxiety. No
differences in depressed mood or obstetrical/neonatal outcomes were observed between the three groups.
CONCLUSIONS: A targeted lifestyle intervention programme based on the principles of motivational interviewing reduces GWG
and levels of anxiety in obese pregnant women.

International Journal of Obesity (2013) 37, 814–821; doi:10.1038/ijo.2012.162; published online 2 October 2012
Keywords: pregnancy; gestational weight gain; randomized controlled trial; lifestyle intervention; anxiety

INTRODUCTION development in the long run.10 Complications are even higher

Depending on the studied cohorts, maternal obesity ranges when pre-conceptional obesity is combined with excessive
between 8 and 30%,1–4 with the highest prevalence reported in gestational weight gain (GWG), especially the risk for caesarean
American cohorts.1 In Belgium, one in three pregnant woman is section, macrosomia and postpartum weight retention.11–13
overweight and 10.2% are obese.5 Well documented risks Besides, long-term effects of early life environment (for example,
associated with maternal obesity include gestational diabetes maternal obesity) on cardiovascular and metabolic diseases are
mellitus (GDM), hypertension and pre-eclampsia, induction of only starting to emerge.14
labour, elective and emergency caesarean section, postpartum In order to prevent maternal and neonatal complications, the
haemorrhage, anaesthetic problems as well as infections and Institute of Medicine (IOM) recommends an adequate GWG
thromboembolic complications.1,2 Foetal risks include miscarriage, between 5 and 9 kg (11–20 lbs) for obese pregnant women.15
neural-tube defects, heart defects, macrosomia and stillbirth.6,7 However, only about 33–40% of pregnant women and even less
Maternal obesity is also associated with a lower intention, within obese pregnant women, have a weight gain in line with
initiation and continuation of breastfeeding8,9 and has a IOM recommendations.16 Timely and accurate advice from
significant impact on maternal metabolism and offspring healthcare providers regarding gestational weight gain for obese

1
Department of Healthcare Research, PHL University College, Limburg Catholic University College, Hasselt, Belgium; 2Division of Mother and Child, Department of Obstetrics and
Gynaecology, University Hospitals KU Leuven, Leuven, Belgium; 3Center of Human Genetics, University Hospitals KU Leuven, Leuven, Belgium; 4Department of Obstetrics, East
Limburg Hospital, Genk, Belgium; 5Department of Physiology, Hasselt University, Diepenbeek, Belgium; 6Department of Psychology, Tilburg University, Tilburg, The Netherlands;
7
Department of Psychology; KU Leuven, Leuven, Belgium and 8Department of Welfare, Public Health and Family, Flemish Government, Brussels, Belgium. Correspondence:
Professor R Devlieger, Division of Mother and Child, Department of Obstetrics and Gynecology, University Hospitals KU Leuven; Herestraat 49, 3000 Leuven, Belgium.
E-mail: [email protected]
Presented at the 59th Annual Meeting of the Society for Gynecologic Investigation in San Diego, CA, USA, 21–24 March 2012, and the 19th European Congress on Obesity
(ECO 2012), Lyon, France, 9–12 May 2012.
Received 16 May 2012; revised 24 August 2012; accepted 29 August 2012; published online 2 October 2012
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
815
pregnant women should be encouraged as this is a modifiable assessment was furthermore repeated in the second (between 18 and
variable.17 However, intervention studies aimed at reducing GWG 22 weeks) and third trimester (between 30 and 34 weeks) of gestation. All
in obese pregnant women are so far inconsistent and women received a weight gain chart to fill in each time they went for a
contradictory.18,19 Those that focus on physical activity, dietary prenatal visit.
advice together with intensive and frequent personal counselling Routine antenatal care was performed in accordance to the national
guideline ‘prenatal care’31 and consisted of a baseline blood analysis
seem most successful in reducing GWG.20–23 Most trials, however, during the first antenatal visit and measurement of maternal weight and
were faced with small and variable effects in the different study blood pressure measurement as well as urine screening for proteinuria at
groups. It has been proposed that this lack of effectiveness may be each antenatal visit. Maternal weight was measured with a calibrated SECA
related to the fact that psychological factors were not sufficiently (alpha model 770; Seca, Teleflex Medical bvba, Sint Stevens Woluwe,
taken into account in the intervention design.19 Moreover, earlier Belgium) accurate to 0.1 kg while women were wearing indoor clothes but
research demonstrated a positive correlation between pre- no shoes. A minimum of three ultrasound examinations during the first,
pregnancy body mass index (BMI), GWG, anxiety and depressive second and third trimester of pregnancy were scheduled. At 24–28 weeks
symptoms, suggesting an association between (pre)pregnancy of gestation, a 50-g glucose challenge test was performed to screen for
GDM in all women.
weight status and psychosocial vulnerability,24,25 often influenced
Power analysis for this study was performed on the basis of
by maternal socio-demographical factors.26 Pregnant women with epidemiological Flemish (northern part of Belgium) data of mean GWG
elevated levels of stress and anxiety consume more fats, oils, in obese pregnant women (Bogaerts et al., unpublished). An anticipated
sweets and snacks, have decreased intakes of vitamins and are difference in mean GWG of 4 kg with an s.d. of 7 in obese pregnant women
often described as ‘emo-eaters’.27 Furthermore, the quality of their was considered clinically significant. Therefore, using a 80% power and an
overall diet28 and, more specifically, their intake of fibre and alpha of 0.05, we had to include 50 women in each group to achieve
calcium decreases with an increasing maternal BMI.29 overall statistical significance.
To our knowledge, no randomized controlled trial of the effects
of a lifestyle intervention programme for obese pregnant women Subject inclusion
on the reduction of GWG that also take into account levels of Two hundred and thirty-five obese pregnant women were eligible of
anxiety and feelings of depression, has been published. Therefore, whom 30 decided not to participate. The remaining 205 obese pregnant
the main aim of the current research was to examine whether a women were randomized into three study groups. In the brochure group
prenatal lifestyle intervention programme in obese pregnant and lifestyle intervention group, respectively, six and two women were
women reduces GWG and lowers levels of anxiety and depressed excluded for different reasons (Figure 1). After exclusion, 63, 58 and 76
mood during pregnancy. obese pregnant women in the control, brochure and lifestyle intervention
groups were followed until delivery. Obese women with GDM or preterm
delivery, as well as those with missing psychological measurements
SUBJECTS AND METHODS throughout pregnancy, were not excluded but this was controlled for in
the statistical models.
Study design
This randomized controlled longitudinal trial was conducted at antenatal
units in three regional hospitals in the Belgian Flanders, between March Intervention
2008 and April 2011. None of the participating hospitals organized special A maximum of three obese pregnant women were brought together in a
antenatal care programmes for obese pregnant women at the time of the 1.5–2 h session always facilitated by the same midwife (AB). The four
study. The Central Medical Ethics Committee for Human Experimentation sessions were scheduled: (1) before 15 weeks of gestation, (2) between 18
of the Faculty of Medicine, Catholic University of Leuven and the Medical and 22 weeks, (3) between 24 and 28 weeks and (4) between 30 and 34
Ethics Committees of the three participating hospitals approved the study weeks of gestation. The sessions focused on the relation between energy
design. intake and energy expenditure based on the active and healthy food
pyramid for pregnant women. Recommendations for a healthy and
balanced diet were based on the official National Dietary Recommenda-
Participants and procedure tions and consisted of 50–55% carbohydrate intake, 30–35% fat intake and
Pre-pregnancy obesity was defined as BMI X29 kg m  2, according to the 9–11% protein energy intake.32 Theoretical insights applied to the
1990 IOM criteria. During the recruitment period, IOM changed their cut- women’s own lifestyle and eating habits using their 7-day food diary
off point for maternal obesity from 29 to 30 kg m  2.13 In order to remain were discussed; exercises in reading food labels and shopping methods
consistent with the inclusion criteria and with the data already collected, were also performed. Methods for increasing their level of physical activity
we decided not to change the cut-off level in the ongoing study. Exclusion were discussed. Principles of this lifestyle intervention programme for
criteria were: gestational age 415 weeks, pre-existing type 1 diabetes, obese pregnant women were based on the stages of the behavioural
multiple pregnancy, primary need for nutritional advice and insufficient change model of Prochaska and coworkers,33 as well as on the concept of
knowledge of the Dutch language. Obese pregnant women attending the motivational interviewing.34 This method has been shown to be effective
antenatal clinic before 15 weeks pregnancy were informed by their in diet and exercise advice in a normal weight population and also in
gynaecologist or midwife about the study. They introduced the study and obese pregnant women.21 Motivational interviewing is based on a
gave women an information sheet about the trial to be read at home. In directive method of communication with focus on intrinsic motivation.35
case of interest, the research midwife contacted the obese pregnant Motivational issues focus on developing discrepancy and exploring and
women by phone as soon as possible with demand to participate. After resolving ambivalence about making changes, without undue pressure.35
given their written informed consent and completed a baseline After every session, the women were asked to identify behaviours that
assessment on socio-demographics, lifestyle data, as well as on detailed needed to change and to set small stepwise goals from their own intention
medical and obstetrical history, they were randomly assigned into three to achieve a healthy behaviour. Personal barriers to behavioural change
groups. Randomization took place by choosing one opaque envelope were explored and as much as possible positive verbal reinforcement
containing a ticket indicating one of the three groups. Women were given to increase each pregnant woman’s self-confidence and self-efficacy.
randomly assigned to either receiving routine antenatal care (control Although the main focus was on nutritional advice and physical activity,
group), a brochure group receiving additionally a purpose-designed worries and personal questions concerning their pregnancy were also
brochure about nutritional advice and physical activity during pregnancy addressed.
with information to limit excessive GWG, or a prenatal session group,
receiving the same brochure and an additional four prenatal lifestyle
intervention sessions led by a midwife trained in motivational lifestyle Measurements
intervention (AB). An earlier trial within obese pregnant women using this Data on maternal age, education, marital state, occupation, employment,
same brochure, demonstrated improvements in dietary habits.30 ethnicity, parity, previous miscarriage, smoking and alcohol consumption,
Measurement of feelings of anxiety and depressed mood were obtained method of conception, psychological history and current feelings of
at entry into the study, before 15 weeks of gestation (baseline depression (yes/no) were obtained at the time of entry into the study and
measurement, trimester 1) in all the three groups. Psychological used to control for relevant confounding variables. In order to determine

& 2013 Macmillan Publishers Limited International Journal of Obesity (2013) 814 – 821
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
816

235 eligible obese

pregnant women

30 decided not to
participate

205 obese women

were randomized

Normal care group Brochure group Prenatal session

n=63 n= 64 group
n= 78

Exclusions: 1 moved out of

Exclusion: 1 overweight, 1
region, 2 twin, 1
miscarriage
overweight, 1 miscarriage,
1DMT1

Brochure group Prenatal session

Normal care group
n=58 group
n=63
n=76

Figure 1. Flowchart of randomization into three study groups. DMT1, diabetes mellitus type 1.

the participants’ psychological history, there were three ‘YES-or-NO’ scale was originally designed as a screening instrument for postnatal
questions referring to past events: (1) subjective feelings of depression, depression, but was also validated later for usage during pregnancy40,41
(2) feelings of anxiety and (3) stressful life events. The format of these three and named Edinburgh Depression Scale. Items are rated on a four point
questions was, ‘Before this pregnancy, was there ever a period of time Likert scale (0–3) and address the intensity of depressive symptoms in
when you (1) were feeling anxious or (2) depressed or (3) when you lost the previous seven days. A cut-off of 13 normally discriminates between
interest in pleasurable activities because of stressful life events, most of the minor and major depression.42 Cronbach’s alpha for Edinburgh Depression
day, nearly every day for at least two weeks?’. The variable ‘history of stress’ Scale was 0.82, reflecting a high internal consistency.43 To calculate
was a combined variable and considered present if at least one of the the Cronbach’s alpha, one measurement for each score was taken at
three questions above had been answered ‘YES’. random for all pregnant women to ascertain independent measurements.
Pre-pregnancy BMI was based on self-reported pre-pregnancy weight Levels of anxiety and depressed mood were calculated as a continuous
and height at entry into the study. GWG as the main outcome variable was variable.
defined by weight at delivery minus pre-pregnancy weight. GWG for The diagnosis of pregnancy-induced hypertension was defined accord-
trimester 1, 2 and 3 was defined as the difference between the weight at ing to the criteria of the International Society for the Study of Hypertension
around 14, 22 and 34 weeks of gestation and the pre-pregnancy weight. in Pregnancy as a blood pressure reading X140/90 mm hg, measured at
Anxiety symptoms were measured with the State and Trait Anxiety two occasions at least six hours apart, after 20 weeks of pregnancy in an
Inventory (Spielberger).36,37 The State and Trait Anxiety Inventory is otherwise normotensive woman.44 Pre-eclampsia was defined as the
designed to study general anxiety and is comprised of two self-report presence of pregnancy induced hypertension in combination with
scales for measuring two distinct anxiety concepts, state anxiety and trait significant proteinuria (X300 mg per 24 h)44 and included as
anxiety. Both scales contain 20 statements asking the participants to hypertensive disorder. GDM was diagnosed with the use of two or more
describe how they feel. The state-anxiety scale includes statements about abnormal plasma glucose values (at fasting 490 mg dl  1 (5 mmol l  1), at
the intensity of feelings at a particular moment in time, whereas the trait- 1 h4165 mg dl  1 (9.2 mmol l  1), at 2 h4145 mg dl  1 (8 mmol l  1) and at
anxiety scale includes statements about the frequency of general feelings. 3 h4125 mg dl  1 (6.9 mmol l  1)).45
Items are rated on a Likert scale, ranging from a score of 1 to 4. For state
anxiety, 1 means ‘not at all’, 2 means ‘somewhat’, 3 means ‘moderately so’
and 4 means ‘very much so’. Similarly, for trait anxiety 1 means ‘almost Statistical analysis
never’, 2 means ‘sometimes’, 3 means ‘often’ and 4 means ‘almost always’. Continuous variables are shown as mean±s.d. and categorical variables as
A composite score is generated for each subscale after a reversal of the number and percentages. w2-test for categorical variables, and if cells were
negative items, ranging for each scale from a minimum of 20 to a maximum too small Fisher exact test, and analysis of variance for continuous
of 80. High scores mean more state or trait anxiety. Although a cut-off point variables were used to analyse group differences. The impact of BMI on the
for high anxiety has not been properly defined, most studies consider a outcome variables was estimated using three presentations of the variable:
score above 40 as being highly anxious.38,39 The State and Trait Anxiety (1) the BMI as a continuous variable, (2) the logarithm of BMI, (3) a
Inventory is a reliable and valid self-report measure that can be used in categorical variable with three classes: class I ¼ moderately obese (BMI
pregnant women.38 The Cronbach’s alpha analyses for these measurements 29–34.9 kg m  2), class II ¼ extremely obese (BMI 35–39.9 kg m  2) and
for state and trait anxiety were high; at least 0.92 for both scales. class III ¼ morbidly obese (BMIX40 kg m  2). For every outcome variable,
Feelings of depression, that is, depressed mood during pregnancy, was the presentation of BMI that was best associated with the outcome
assessed by using the 10-item Edinburgh Postnatal Depression Scale. This variable, was retained in the later steps of the analysis. For the other

International Journal of Obesity (2013) 814 – 821 & 2013 Macmillan Publishers Limited
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
817
continuous variables, both the presentations as a continuous variable and RESULTS
as a categorical variable in classes were used to find the highest No differences regarding socio-demographic and behavioural
association with the outcome variables.
baseline characteristics were demonstrated between the three
Univariate associations were sought between the main outcome
variables: GWG, psychological variables (that is, state and trait anxiety,
study groups (Table 1).
depression), method of delivery, birth weight of the baby and possible
associated variables (that is, maternal BMI, age and education, marital Effect of lifestyle intervention on gestational weight gain
state, occupation, employment, ethnicity, parity, miscarriage in history, Analysis of variance showed a significant difference between the
alcohol consumption and smoking behaviour, method of conception,
psychological history and current psychological state, GDM, hypertensive
mean GWG of the control group of obese pregnant women
disorders in current pregnancy and gestational age). Secondly, if the (13.5±7.3 kg), the brochure group (9.5±6.8 kg) and the lifestyle
association was strong enough (Po0.20), the variable was entered in a intervention group (10.6±7 kg). Furthermore, the GWG in the
multivariate model. If the variable was significant (Pp0.05) or nearly- second and third trimesters of pregnancy as well as IOM
significant (Pp0.07) the variable remained in the model. For the outcome categories of GWG were significantly different between the three
variable GWG and birth weight, generalized linear models were made. For study groups (Table 2). The multivariate model confirmed the
levels of anxiety and depressed mood multivariate linear mixed effects significant reduction of GWG in the brochure and lifestyle
model with repeated measures were used, as every woman could have intervention group compared with the normal care group
three different outcomes (one for every trimester). Method of delivery was (Table 3). GWG significantly decreased with increasing pre-
analysed by a logistic regression.
The use of a direct likelihood model, which was the case in our analysis,
pregnancy BMI. Besides, covariates as parity, occupation, smoking
seems to be the best to deal with missing data in a longitudinal data behaviour and GDM significantly influenced GWG (Table 3).
collection within controlled trials.43 Attrition bias was analysed in this
longitudinal data collection by comparing socio-demographic differences Effect of lifestyle intervention on levels of state/trait anxiety and
as well as differences in main outcome variables between the groups with depressed mood
complete and incomplete lifestyle intervention sessions, and between
those with complete and missing data concerning psychological The multivariate models of state/trait anxiety and depressed
measurements throughout pregnancy. All analyses were performed with mood showed no significant baseline differences (trimester 1)
the SAS statistical software Enterprice Guide 4.2 (SAS Institute Inc., Cary, between the three groups. During pregnancy, a significant
NC, USA). reduction of state anxiety was shown in the lifestyle intervention

Table 1. Baseline characteristics at time of study entry (n ¼ 197)

Normal care group, n ¼ 63 Brochure group, n ¼ 58 Lifestyle intervention group, n ¼ 76 P-value

Pre-pregnancy weight (kg), mean (s.d.) 95.3 (13.7) 97.1 (13.3) 95.2 (14.6) 0.70
Height (m), mean (s.d.) 1.66 (0.06) 1.66 (0.06) 1.66 (0.06) 0.82
Pre-pregnancy BMI (kg m  2), mean (s.d.) 34.4 (4.1) 35.4 (5.2) 34.4 (4.6) 0.42
Age (years), mean (s.d.) 28.7 (4.2) 29.6 (4.9) 28.8 (4.5) 0.48
Maternal education, n (%) 0.11
Until 18 years 40 (63.5) 27 (46.6) 47 (61.8)
Bachelor/master degree 23 (36.5) 31 (53.4) 29 (38.1)
Marital state, n (%) 0.39
Married/cohabiting 60 (95.2) 57 (98.3) 75 (98.7)
Single 3 (4.8) 1 (1.7) 1 (1.3)
Occupation, n (%) 0.22
Self-employed/employee 40 (63.5) 45 (77.6) 46 (60.5)
Manual worker 15 (23.8) 6 (10.3) 17 (22.4)
No occupation 8 (12.7) 7 (12.1) 13 (17.1)
Employment, n (%) 0.30
Full-time 24 (38.7) 27 (47.4) 25 (33.8)
Part-time 20 (32.2) 14 (24.6) 18 (24.3)
Unemployed 18 (29) 16 (28.2) 31 (42)
Ethnicity, n (%) 0.83
Belgian/Dutch 49 (77.8) 47 (81) 62 (81.6)
Turkish/Moroccan 9 (14.3) 8 (13.8) 8 (10.5)
Other 5 (7.9) 3 (5.2) 6 (7.9)

Nulliparity, n (%) 28 (44.4) 24 (41.4) 39 (51.3) 0.49

Previous Miscarriage, n (%) 15 (23.8) 16 (27.6) 20 (26.3) 0.89
Alcohol consumption, n (%) 7 (11.3) 4 (7) 7 (9.6) 0.72
Smokers, n (%) 10 (15.9) 4 (7) 10 (13.3) 0.32
Assisted conception, n (%) 9 (14.3) 6 (10.3) 9 (11.8) 0.80
History of depression, n (%) 9 (14.5) 13 (23.2) 16 (22.2) 0.42
History of anxiety, n (%) 8 (12.9) 7 (12.5) 12 (16.7) 0.75
History of stressful family events, n (%) 21 (33.9) 18 (32.1) 21 (29.2) 0.84
History of stress,a n (%) 30 (48.4) 27 (48.2) 29 (40.3) 0.56
Feelings of depression at inclusion, n (%) 2 (3.3) 1 (1.9) 5 (7.2) 0.31
Abbreviation: BMI, body mass index. aStress is a composed variable and is indicated as positive if the women at least once indicated feelings of depression,
anxiety or stressful events in history.

& 2013 Macmillan Publishers Limited International Journal of Obesity (2013) 814 – 821
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
818
group, while a significant increase was shown in the normal care interval, 0.22–0.58). Significant covariates in the multivariate
group and no significant differences throughout pregnancy were model for birth weight were gestational age (b estimate ¼ 19.3;
seen in the brochure group (Figure 2; Table 4). Similar changes Po0.0001), parity (b estimate ¼ 14.7; P ¼ 0.02) and severity of
were found for trait anxiety, although they were only significant obesity (b estimate obese, class II ¼ 18.5; P ¼ 0.01 compared with
with respect to trimester 2 (for lifestyle intervention group: obese, class I).
b estimate ¼  1.68; P ¼ 0.04, for the normal care group:
b estimate ¼ 2.76; P ¼ 0.006). No differences for depressed mood
during pregnancy were observed between the three groups Table 3. Multivariate model of gestational weight gain (continuous
(P ¼ 0.76). variable)
Furthermore, of all the covariates controlled for, some had a
significant influence. For state anxiety: pre-pregnancy BMI, b- s.e. t-value P-value
maternal education, parity, a history of miscarriage or feelings of estimate
anxiety, alcohol consumption on a regular base and GDM in Intercept 57.99 13.09 4.43 o0.0001
current pregnancy reported significant influences on levels of
state anxiety (Table 4). In the multivariate trait anxiety model, Group 0.02
additionally employees demonstrated lower levels of trait anxiety Normal care group 0 — — —
(b estimate ¼  3.35; P ¼ 0.02) compared with manual workers. (ref )
In the depressive mood model, women who were self-employed Brochure group  2.45 1.18  2.07 0.04
(b estimate ¼ 2.75; P ¼ 0.05) and those without occupation Lifestyle intervention  2.89 1.08  2.67 0.008
group
(b estimate ¼ 2.60; P ¼ 0.01) demonstrated significantly increased
levels of depressed mood. Those with an assisted method of Logarithm of BMI  11.97 3.67  3.26 0.001
conception (b estimate ¼  1.88; P ¼ 0.03) on the contrary Parity  1.59 0.46  3.46 0.0007
demonstrated significant lower levels of depressed mood.
Occupation 0.0009
Manual worker (ref ) 0 — — —
Self-employed 5.61 2.25 2.49 0.01
Effect of lifestyle intervention on obstetrical and neonatal Employee  2.39 1.21  1.98 0.05
outcomes No occupation  2.05 1.65  1.25 0.21
No significant differences regarding pregnancy and birth related
outcomes were observed between the three groups (Table 2); this Smoking behaviour 0.05
was also confirmed in the multivariate models. Covariates that Non smokers (ref ) 0 — — —
Recently stopped 3.04 1.25 2.44 0.01
were associated with an increase rate of assisted method of
(pregnancy)
delivery (that is, forceps/vacuum delivery and caesarean delivery) Smokers  0.07 1.44  0.05 0.96
were maternal age (odds ratio ¼ 1.20; 95% confidence interval,
1.10–1.32) and pre-pregnancy BMI (odds ratio ¼ 1.16; 95% GDM  3.22 1.42  2.28 0.02
confidence interval, 1.08–1.26). Parity was protective for having Abbreviations: BMI, body mass index; GDM, gestational diabetes mellitus.
an assisted method of delivery (odds ratio ¼ 0.36; 95% confidence

Table 2. Gestational weight gain (GWG) and obstetrical and neonatal outcomes in obese pregnant women
Normal care group, n ¼ 63 Brochure group, n ¼ 58 Lifestyle intervention group, n ¼ 76 P-value

Gestational age (weeks), mean (s.d.) 39.5 (1.8) 39 (2.3) 39.3 (1.7) 0.58
GWG (kg (s.d.)), total mean (s.d.) 13.5 (7.3) 9.5 (6.8) 10.6 (7) 0.007
GWG, trim 1, mean (s.d.) 1.2 (2.9) 0.1 (2) 0.3 (2.7) 0.15
GWG, trim 2, mean (s.d.) 5 (4.6) 0.7 (3) 2.4 (3.6) 0.0003
GWG, trim 3, mean (s.d.) 10.2 (6.4) 6.4 (5.2) 7.9 (5.8) 0.01
GWG, categorical, n (%) 0.04
GWG, o5 kg 4 (6.3) 16 (27.6) 16 (21.1)
GWG, 5–8.9 kg 14 (22.2) 11 (19) 13 (17.1)
GWG, X9 kg 45 (71.4) 31 (53.4) 47 (61.8)
Pregnancy complications, n (%)
GDM 7 (11.1) 7 (12.1) 9 (11.8) 0.98
Pregnancy-induced hypertension 6 (9.5) 11 (19.3) 8 (10.8) 0.22
Pre-eclamptic toxicosis 4 (6.3) 7 (12.3) 2 (2.7) 0.09
Induction of labour 15 (24.2) 12 (20.7) 14 (18.7) 0.73
Method of delivery, n (%) 0.77
Vaginal 37 (58.7) 40 (69) 48 (63.2)
Vacuum/forceps 7 (11.1) 4 (6.9) 8 (10.5)
Caesarean, elective 11 (17.5) 5 (8.6) 11 (14.5)
Caesarean, emergency 8 (12.7) 9 (15.5) 9 (11.9)
Birth weight (kg, (s.d.)), mean (s.d.) 3.504 (0.583) 3.386 (0.682) 3.444 (0.503) 0.54
Apgar score 1 min, mean (s.d.) 8.6 (0.7) 8.5 (1.4) 8.3 (1.5) 0.50
Apgar score 5 min, mean (s.d.) 9.5 (0.5) 9.4 (0.9) 9.4 (1) 0.64

Abbreviations: GDM, gestational diabetes mellitus; GWG, gestational weight gain. Continuous variables (presented as means (s.d.)) were analysed by
GLM-procedure in SAS; categorical variables (presented as n values and percentages) were analysed by using the FREQ-procedure in SAS (w2 test).

International Journal of Obesity (2013) 814 – 821 & 2013 Macmillan Publishers Limited
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
819
41.0 normal care group Table 4. Multivariate model of state anxiety
brochure group
40.0 b- s.e. t-value P-value
lifestyle intervention group
39.0
estimate

38.0 Intercept 24.30 4.00 6.06 o0.0001

37.0
Group 0.02
Normal care group 0 — — —
36.0 (ref )
Brochure group 1.90 1.52 1.25 0.21
35.0 Lifestyle intervention 1.04 1.42 0.73 0.46
group
34.0
Normal care group, 0 — — —
33.0 trim 1 (ref)
Normal care group, 2.56 1.35 1.89 0.05
32.0 trim 2
1 2 3
Normal care group, 4.06 1.52 2.67 0.008
Figure 2. Levels of state anxiety by trimester in the three study trim 3
groups. Error bars are based on s.e.m.
Brochure group, trim 1 (ref) 0 — — —
Brochure care group, 1.60 1.39 1.16 0.24
trim 2
DISCUSSION Brochure care group, 2.31 1.44 1.60 0.11
To our knowledge, this is the first randomized controlled trial on trim 3
the effects of lifestyle intervention in obese pregnant women, Lifestyle intervention 0 — — —
taking into account levels of anxiety and depressed mood. We group, trim 1 (ref)
observed a significant reduction of GWG in the brochure and Lifestyle intervention  1.72 1.10  1.56 0.11
lifestyle intervention group, and a significant reduction of state group, trim 2
anxiety in the lifestyle intervention group only. Lifestyle intervention  2.12 1.16  1.83 0.06
Reduction of GWG was also observed in other interventional group, trim 3
studies20,21,46 but not in all,30,47 or only in subgroups of normal Pre-pregnancy BMI 0.28 0.11 2.58 0.01
weight women48 or low income women.49 Two recent systematic
Maternal education
reviews on preventing excessive GWG19,50 confirm inconsistent
Until 18 year (ref ) 0 — — —
interventional effects on reducing GWG, mostly due to differences Bachelor degree  4.32 1.10 3.92 0.0001
in study designs, participants and variations in methods of Master degree or  4.17 2.20  1.89 0.05
intervention.19 There is growing evidence that information alone higher
is not sufficient to produce long-term significant behavioural
changes. A combination of health education with psychological Parity
P ¼ 0 (ref ) 0 — — —
interventions should be recommended.51
P¼1 1.77 1.11 1.59 0.11
None of the published controlled interventional trials concern- P¼2  3.85 1.87  2.05 0.04
ing GWG in obese pregnant women, considered psychological PX3 1.19 2.31 0.52 0.60
factors. Only one study, a case-control interventional study,52
looked at evolution of levels of anxiety and depressed mood in Previous miscarriage 1.67 0.85 1.95 0.05
combination with a weight gain restriction programme, but found Alcohol consumption
no differences regarding psychological state between obese No consumption (ref ) 0 — — —
pregnant women in the intervention and control group, contrary Stopped, 0.64 2.69 0.24 0.81
to our results. A possible interdependence of behavioural changes independently of
in terms of weight reduction and psychological factors in terms of pregnancy
levels of anxiety can be questioned, because it seems that a Stopped, due to  1.24 1.12  1.11 0.26
decreasing level of anxiety or at least a stable degree of pregnancy
Yes 3.69 1.81 2.04 0.04
psychological comfort is important in achieving weight-related
behavioural changes in obese pregnant women. Given the History of anxiety 5.81 1.51 3.84 0.0002
significant positive influence of feeling anxious/depressed during Gestational diabetes 3.54 1.61 2.20 0.03
pregnancy on the 6 months postpartum weight retention,53 the mellitus
reduction of anxiety in the lifestyle intervention group can add
value to the prevention of postpartum weight retention and Abbreviation: BMI, body mass index.
obesity on the long run. At the same time, long term effects of
increasing psychological stress (that is, increasing levels of anxiety)
and maternal obesity should be further explored in the light those gaining more than 9 kg, no mutually difference was shown
of the effects of gene environment and development of between the three groups of obese women, so the difference
transgenerational obesity.54,55 between the groups for IOM-categories of GWG is explained by
It appears from our results that more women in the lifestyle the fact that significant more women in the two intervention
intervention group showed excessive GWG compared with those groups showed GWG less than 5 kg. In our trial, the relative risk for
in the brochure group. But when comparing group (column) excessive GWG in the brochure group and lifestyle intervention
proportions for categories of GWG, significant more women in the group compared with the control group is 0.75 and 0.86,
two intervention groups (27.6% and 21.1% for brochure and respectively, in both intervention groups. Simultaneously, the
lifestyle intervention group, respectively) gained less than 5 kg relative risk for high state anxiety (X40) in the third trimester of
compared with those in the control group. No difference was gestation in the lifestyle intervention group compared with the
shown between the two intervention groups reciprocally. For brochure and normal care group is 0.82. The number needed to

& 2013 Macmillan Publishers Limited International Journal of Obesity (2013) 814 – 821
 Reducing gestational weight gain and anxiety
AFL Bogaerts et al
820
treat with lifestyle intervention to observe one more woman with intervention group focusing on GWG. Besides, one should take
GWG o9 kg and a low state anxiety in the third trimester of into account that reduction of levels of anxiety in the lifestyle
gestation is 17. intervention group add value to implementation of a brochure
Increasing maternal pre-pregnancy BMI, GDM and regular alone. Lifestyle intervention sessions can be implemented in
consumption of alcohol during pregnancy are associated with antenatal care units where midwives are permanent working in
increased levels of state anxiety; obese pregnant women who shifts. But indeed, cost-effectiveness of counselling obese women
stopped smoking recently had a significantly higher GWG on long-term outcomes, other than GWG alone should be studied
compared with non-smokers. Moreover, all these modifiable more in depth, but was not the focus in this trial. Another
covariates create a poor metabolic10,56 and psychological57,58 limitation can be the missing psychological measurements (that is,
foetal environment, justifying the importance of lifestyle levels of anxiety and depressed mood). But no significant
intervention. Less modifiable at the time of pregnancy are a difference was found between women with or without missing
lower level of maternal education, relevant stress experiences and psychological measurements for any of the covariates that
previous miscarriages, which also contribute positively to levels of revealed significant influence in the multivariate models.
antenatal anxiety. Besides, these characteristics occur frequently in In conclusion, an intervention based on a brochure alone or
obese pregnant women (Bogaerts et al., 2012, unpublished), combined with lifestyle intervention sessions in obese pregnant
making them more vulnerable for developing perinatal mental ill- women can reduce GWG. Psychological health in terms of
health. Therefore, systematically organized multidisciplinary decreasing levels of state anxiety was only observed in the
collaboration regarding a healthy lifestyle in obese pregnant lifestyle intervention group, an added value given the increasing
women is essential, including an antenatal screening for their psycho-social vulnerability in obese pregnant women. Therefore,
psychological health. an implementation of a targeted lifestyle intervention programme
No differences were demonstrated between the three groups of based on principles of motivational interviewing can be justified in
obese pregnant women in terms of method of delivery and birth order to reduce GWG and levels of anxiety in this obstetrically
weight. This may be owing to the small trial size as our study was high risk population of obese pregnant women.
initially not powered to detect these differences. A recent meta-
analysis with the pooled results of five randomized controlled
trials of high quality examining dietary interventions to prevent CONFLICT OF INTEREST
excessive GWG demonstrated a reduction in caesarean sections The authors declare no conflict of interest.
(relative risk, 0.75; 95% confidence interval, 0.60–0.94), but no
significant effect in terms of birth weight.59 On the other hand, a
population-based cohort study using a within-subject design, ACKNOWLEDGEMENTS
showed that infants of mothers with GWG of 424 kg were 149 g We thank all the pregnant women for their participation and the gynaecologists and
heavier than those whose mothers maintained GWG at 8–10 kg, midwives from St Janshospital Genk, Jessa Hospital Hasselt and St Franciscus Hospital
independently of genetic factors.60 Small mean differences in Heusden-Zolder, Belgium, for their co-operation in enrolment of the women. We also
GWG were not associated with significant differences in birth thank M. Mead for the conscious reading of the manuscript. AB was supported by a
weight, as is often the case in previous controlled trials. PWO project from Flanders. RD is senior clinical researcher for FWO Vlaanderen
(2010–2015), and BVDB is funded by a grant of the European Science Foundation
The strength of this study is the randomized controlled design,
(EuroSTRESS programme ‘Stress and Mental Health’;2008–2011), by the Netherlands
providing the highest level of evidence.43 To our knowledge, no Organization for Scientific Research (NWO; Brain and Cognition Programme; 2008–
other randomized controlled trials focusing on psychological 2012), and by European Commission’s seventh Framework Programme (FP7/ 2007–
aspects during lifestyle intervention have looked at pregnancy 2013; BrainAGE; 2012–2017).
outcome in obese women. We used types of intervention, with
very different intensity: a low (that is, brochure group) and a more
intensive intervention group (that is, lifestyle intervention group) AUTHOR CONTRIBUTIONS
allowing us to compare evolutions of GWG and levels of anxiety in AB, RD, IW and BVdB designed the study and wrote the protocol. AB managed the
three groups of obese pregnant women. Baseline characteristics literature searches, the intervention sessions and the analyses. EN undertook the
as shown in Table 1 were comparable in the three groups of obese statistical analysis. AB wrote the first draft of the manuscript. All authors contributed
pregnant women, as well as their first psychological measurement to and have approved the final manuscript.
(that is, levels of anxiety and depressed mood), indicating
homogeneity of our study population.
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