Lifestyle Factors Focused on Diet and Physical Activity: Recommendations Preconception and During Pregnancy

Helena Teede, MBBS, FRACP, PhD

Lisa Moran, BSc (Hons), BND, PhD, APD

Diet, physical activity, and lifestyle have profound impacts on health across the lifespan. For reproductive-aged women, achieving a healthy lifestyle is more critical, as it affects both their health and that of the next generation. Nutrient intake and vitamin D status are important for healthy pregnancies as are screening, diagnosis, and management of lifestyle-related conditions. An energy imbalance between dietary energy consumed and physical activity or energy expended causes obesity. Obesity now causes more ill health than undernutrition and is a major contributor to the rising burden of noncommunicable diseases internationally. Adverse lifestyle and obesity are increasing infertility,[1] [2] as well as increasing noncommunicable diseases that impacts on health in pregnancy and beyond for both mothers and their children.[3] A strong focus on lifestyle to prevent and manage obesity and related conditions and to optimize weight preconception and gestational weight gain (GWG) during pregnancy is important. Relevant conditions including polycystic ovary syndrome, gestational diabetes (GDM), and type I and II diabetes (T1DM and T2DM), which are exacerbated by adverse lifestyle and obesity, also require lifestyle management. Poor lifestyle is exacerbated by mood disorders and poor or inadequate sleep. In this issue of Seminars in Reproductive Medicine, we have reviewed the literature in these areas, in reproductive-aged women from the preconception period and throughout pregnancy.

Globally, environmental and societal factors have driven a transition to adverse lifestyles including increased intake of energy-dense high-fat foods and a reduction in physical activity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization. These societal and environmental factors have driven unhealthy lifestyles and obesity with major health implications for reproductive-aged women during preconception, pregnancy, and on into long-term maternal and child health. Lifestyle behaviors occur at the individual level and require intervention. At present, the main focus is on individually targeted interventions, where a combination of diet, physical activity, and behavioral strategies are needed and where mobile health technology may assist in the future. Yet ultimately, lifestyle interventions to address this public health crisis must include societal and environmental strategies to support individual behavior and lifestyle change. Key components of lifestyle interventions preconception and in pregnancy include limiting energy intake from added fats and sugars; increasing consumption of fruit and vegetables, legumes, whole grains, and nuts; and engaging in regular physical activity. However, there are also additional dietary and physical activity considerations in pregnancy which are outlined in this issue of Seminars in Reproductive Medicine.

Preconception, there is clear evidence for a range of strategies including optimizing lifestyle and immunization status, smoking and alcohol cessation, screening, diagnosis, and optimal management of medical conditions. Within this, optimizing diet and physical activity includes ensuring adequate folate and iodine intake and optimal vitamin D status, as nutritional status preconception can affect both nutrient availability and early pregnancy development.[4] Prevention of weight gain through lifestyle modification is now an international priority, with reproductive age women a key target group. Preconception lifestyle intervention is important to prevent and manage obesity with adverse health outcomes related to maternal obesity at conception, yet recommendations vary across countries and are provided with limited practical detail.[5] Furthermore, preconception intervention is important to optimize prevention opportunities, as most women do not see a maternity care provider until the end of the first trimester.

Importantly, there is currently no universal approach to preconception health and lifestyle with public health and prevention opportunities being missed. Research is very limited and whilst preconception care guidelines do exist for some aspects of lifestyle behaviors,[5] [6] [7] [8] yet these guidelines focus on the small proportion of women with existing illness. Preconception, women are often physically well, sit outside the health system, many pregnancies remain unplanned and levels of knowledge around lifestyle and health impacts in pregnancy are limited. It will be important moving forward to increase population awareness and knowledge around the impact of preconception health and lifestyle on pregnancy outcomes. We will also need to gain insight into optimal strategies to reach and alter health behaviors and lifestyle preconception, if we are to optimize healthy pregnancy outcomes for women and the next generation.

In pregnancy, evidence around antenatal lifestyle intervention is now substantial and it is clear that benefits are achievable and that lifestyle intervention reduces excess GWG and assists in prevention of obesity. However, these lifestyle interventions appear to offer limited benefits in terms of maternal and neonatal health outcomes, again emphasizing the need to also focus on prevention and management of obesity preconception, both vital areas for future research. Key challenges in the area of lifestyle interventions in pregnancy now include establishing optimal components of these interventions, with work underway on individual patient data meta-analysis. It is additionally now important to demonstrate feasible and affordable implementation of healthy lifestyle behavior change as an integrated and low-cost component of antenatal care to enable scale-up and to drive better population health outcomes.

For conditions that are lifestyle related or require lifestyle management obesity (T1DM, T2DM, and GDM), management in pregnancy is important and generally well supported by evidence to show improved outcomes. Controversies around optimal screening, diagnosis (in the case of GDM), treatment targets, and modalities still exist in these conditions. Interactions are also present between these conditions and obesity and excess GWG. It is likely moving forward an approach to overall risk may become more relevant than a focus on individual conditions such as maternal obesity, excess GWG and or GDM; however, more research is needed in this area.

Overall, it is clear that adverse lifestyle and obesity preconception and during pregnancy have both short- and long-term health impacts for mothers and their children. Individually targeted interventions to alter diet and physical activity are important, although evidence for optimal approaches preconception is lacking and guidelines are conflicting. In pregnancy, lifestyle intervention has clear benefits in preventing excess GWG and in preventing obesity; however, maternal and neonatal pregnancy benefits remain elusive and may require additional preconception intervention to prevent and manage obesity before pregnancy. Lifestyle management of highly prevalent conditions in pregnancy including GDM is well established; however, controversies still exist in diagnostic criteria and treatment targets. Greater research is needed to inform policy and practice. Overall, policy makers, health systems managers, clinicians, and the community would benefit from greater awareness of and focus on healthy lifestyle at the individual, societal, and environmental levels, as well as the need for prevention and management of lifestyle-related conditions to improve maternal and child health during pregnancy and beyond.

• References

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• 2 Rich-Edwards JW, Spiegelman D, Garland M , et al. Physical activity, body mass index, and ovulatory disorder infertility. Epidemiology 2002; 13 (2) 184-190
• 3 Dodd JM, Grivell RM, Nguyen AM, Chan A, Robinson JS. Maternal and perinatal health outcomes by body mass index category. Aust N Z J Obstet Gynaecol 2011; 51 (2) 136-140
• 4 Ramakrishnan U, Grant F, Goldenberg T, Zongrone A, Martorell R. Effect of women's nutrition before and during early pregnancy on maternal and infant outcomes: a systematic review. Paediatr Perinat Epidemiol 2012; 26 (Suppl. 01) 285-301
• 5 Shawe J, Delbaere I, Ekstrand M , et al. Preconception care policy, guidelines, recommendations and services across six European countries: Belgium (Flanders), Denmark, Italy, the Netherlands, Sweden and the United Kingdom. Eur J Contracept Reprod Health Care 2015; 20 (2) 77-87
• 6 NICE. Dietary Interventions and Physical Activity Interventions for Weight Management before, during and after Pregnancy. London, UK: National Institute for Health and Clinical Excellence; 2010
• 7 NICE. Fertility: Assessment and Treatment for People with Fertility Problems. NICE Clinical Guideline 11. London: 2012: 8
• 8 Jack BW, Atrash H, Coonrod DV, Moos MK, O'Donnell J, Johnson K. The clinical content of preconception care: an overview and preparation of this supplement. Am J Obstet Gynecol 2008; 199 (6) (Suppl. 02) S266-S279