USPSTF Backs Behavioral Counseling for Healthy Pregnancy Weight Gain

Physicians should offer all pregnant people behavioral counseling to promote a healthy weight and avoid excess weight gain, according to new recommendations from the U.S. Preventive Services Task Force (USPSTF).

In its grade B recommendations, the USPSTF stated that clinicians who provide prenatal care should offer behavioral counseling that addresses nutrition, physical activity, and lifestyle behaviors to encourage healthy weight gain during pregnancy, or should refer patients to an outside setting.

“The USPSTF 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 Davidson, PhD, MASc, of the Feinstein Institute for Medical Research at Northwell Health in Manhasset, New York, and colleagues of the task force in JAMA.

Behavioral counseling should start sometime between the end of the first trimester or the beginning of the second semester and end prior to delivery. A diverse range of clinicians can administer counseling sessions, including registered dietitians, fitness specialists, physiotherapists, or health coaches across different settings.

The task force stated that the duration of interventions can vary from 15 minutes to 2 hours, and can range in frequency from two sessions to 12 or more.

“There is not enough evidence to determine whether specific components of these interventions were independently related to intervention effectiveness,” the task force noted.

The USPSTF recommendation is based on an evidence report and systematic review of nearly 26,000 participants ages 18 to 33 from 68 studies, also published in JAMA. Forty-five studies offered counseling-only interventions, while the remaining 22 incorporated an activity component.

The report concluded that counseling and active behavioral interventions reduced risk of gestational diabetes (relative risk [RR] 0.87, 95% CI 0.79-0.95), emergency cesarean delivery (RR 0.85, 95% CI 0.74-0.96), infant macrosomia (RR 0.77, 95% CI 0.65-0.92), and large-for-gestational-age infants (RR 0.89, 95% CI 0.80-0.99).

Data also showed that behavioral counseling interventions were associated with reduced weight gain across all prepregnancy weight categories (pooled mean difference -1.02 kg, 95% CI -1.30 to -0.75). High-intensity, frequent counseling sessions (more than 12) were associated with an even greater effect size compared with interventions that offered fewer sessions (pooled mean difference -1.47 kg, 95% CI -1.78 to -1.22).

In addition to modest associations with weight gain during pregnancy, interventions were also associated with a lower likelihood of excess weight gain based on National Academy of Medicine recommendations (RR 0.84, 95% CI 0.78-0.90), with greater effect sizes for active interventions and high-intensity interventions.

There was no association between gestational weight gain interventions and hypertension during pregnancy, total number of cesarean deliveries, preeclampsia, postpartum hemorrhage, perineal trauma, or maternal death. The group observed no significant harms tied to behavioral counseling interventions.

“At first glance, the Recommendation Statement and Evidence Review indicate only a modest benefit associated with behavioral counseling on the commonly focused-on intermediate markers of maternal weight outcomes,” commented D. Yvette LaCoursiere, MD, MPH, an ob/gyn from University of California San Diego, in an accompanying editorial.

“However, the authors rightly prioritize and describe the more relevant findings that such interventions improve maternal and infant health outcomes,” she continued, adding that the interventions provide overall benefit without demonstrable risk.

In the recommendations, the USPSTF also stated that obesity rates have steadily increased among pregnant people in the U.S., rising from 13% in 1993 to 24% in 2015. During that year, almost half of all individuals began their pregnancy with overweight (24%) or obesity (24%).

The group noted that pregnancy obesity is higher among Black, Hispanic, and American Indian/Alaskan Native women compared with white and Asian women, and can lead to adverse outcomes such as large-for-gestational-age infants, cesarean delivery, or preterm birth.

LaCoursiere stated that while the existing evidence supports the use of behavioral counseling to promote healthy weight gain in pregnancy, the challenge will be to identify best practices for implementation and integration into clinical practice. Novel approaches such as telehealth and group prenatal care may allow for more successful implementation.

The task force stated that there is still a need for research to determine the effectiveness of interventions on both short-term and long-term infant and maternal health outcomes, as well as the optimal timing and frequency of behavioral counseling. Additionally, it is not clear how counseling should be altered based on age, race/ethnicity, or high rates of overweight and obesity.