DOI: 10.1111/j.1471-0528.2010.02670.x www.bjog.

org

Commentary

Obesity in pregnancy: a review of reviews on the effectiveness of interventions

S Thangaratinam,a,b K Jollya
a University of Birmingham, Birmingham, UK b Birmingham Womens Hospital, Birmingham, UK Correspondence: Dr S Thangaratinam, Clinical Lecturer in Obstetrics and Gynaecology, Birmingham Womens Hospital, Birmingham B15 2TG, UK. Email s.thangaratinam@bham.ac.uk

Accepted 15 June 2010.

Please cite this paper as: Thangaratinam S, Jolly K. Obesity in pregnancy: a review of reviews on the on the effectiveness of interventions. BJOG 2010;117:13091312.

Obesity and pregnancy

The increasing prevalence of obesity is a major health problem. In 2006, about one-quarter of both men and women in the UK were reported to be obese, with a body mass index (BMI) of 30 kg/m2 or more.1 Fifty per cent of women of childbearing age are either overweight (BMI = 24.929.9 kg/m2) or obese, with 18% starting pregnancy as obese.2 Obese women have an increased risk of maternal and fetal complications. More than one-half of women who die during pregnancy, childbirth or puerperium are either obese or overweight.3 Excessive weight gain in pregnancy has also been shown to be associated with persistent retention of the weight gained in the mother beyond pregnancy. Furthermore, obesity and excess weight gain in pregnancy contribute to an increase in obesity in children at 24 years, leading to signicant resource demands on the healthcare system.4 Pregnancy offers the opportunity to manage or prevent obesity, thereby reducing morbidity and mortality for both the mother and her children. There is no specic guidance on the appropriate calorie intake in obese and overweight pregnant women. Systematic reviews help clinicians, patients and policy makers make decisions by summarising evidence. Poor-quality conduct and reporting of systematic reviews represent two of the main reasons for the limitation of their role in making practice and research recommendations. An accurate and reliable summary of the evidence with clear and transparent reporting of systematic reviews is needed to maximise their usefulness to clinicians, patients and policy makers.

gress of Obstetrics and Gynecology (ACOG)6 for the management of obesity include a healthy diet and exercise in pregnancy, with referral to a nutritionist if required. A recent review in this area found insufcient evidence to recommend specic dietary and/or physical activity interventions to moderate gestational weight gain in pregnant women.7 The latest Centre for Maternal and Child Enquiries (CMACE)/RCOG guideline on the management of obese women in pregnancy provides recommendations on the antenatal, intrapartum and postnatal care of this group of high-risk women.8 However, gestational weight gain and the role of dietary and lifestyle interventions in pregnancy were prespecied to be outside the scope of the guideline. This issue of BJOG has published two systematic reviews that report on the interventions in pregnancy aimed at reducing or preventing obesity. The review by Dodd et al.9 evaluates the benets and harm of dietary and lifestyle interventions in overweight or obese pregnant women. The review by Ronnberg et al.10 attempts to determine the quality of published trials on reducing excessive gestational weight gain in pregnancy using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.11

Transparency of reporting in systematic reviews

The reporting recommendations for improving the reporting of systematic reviews were rst detailed in the QUOROM (Quality of Reporting of Meta Analysis) statement.12 More recently, it has been updated and expanded as the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) reporting guidance for systematic reviews.13 The PRISMA statement with its 27-item checklist aims to improve the clarity and conduct of systematic reviews with transparent reporting. Such a report will allow readers to critically appraise and weigh up the potential

Current evidence on the effectiveness of interventions in reducing or preventing obesity

The recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG)5 and the American Con-

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risks and benets of an intervention. In Table 1, we appraise the two reviews based on components of the PRISMA checklist. A review with a clear focused question that includes components of the target population, intervention, comparison, outcome and study design (PICOS) helps readers to gauge the applicability of the review results. It aids the review process by dening the search strategy, evaluating any biases and conducting appropriate subgroup sensitivity analyses. The review by Ronnberg et al.10 has a narrower scope, and focuses mainly on the effect of interventions in pregnancy, mainly on weight gain, a surrogate for adverse

maternal and fetal outcomes, which limits the applicability of the ndings to practice. It is futher limited by restricting the search to only English and Scandinavian studies. Dodd et al.9 have targeted overweight or obese pregnant women, have a broader scope with a primary outcome of large-forgestational-age infant, and encompass a wide range of clinical and nonclinical outcomes. They have attempted to capture both published and ongoing trials, thereby improving the relevance of the review to practice and future research. The absence of details of the search strategy hampers the assessment of the comprehensiveness of both reviews and duplication of the search. This is relevant as Ronnberg

Table 1. Use of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidance by the systematic reviews evaluating interventions to reduce or prevent obesity in pregnancy PRISMA component Title Systematic review (Ronnberg et al.10) Identies paper as a systematic review using GRADE (Grading of Recommendations Assessment, Development and Evaluation) method Evaluates interventions on gestational weight gain in pregnant women with any body mass index Structured abstract lacking details of type of intervention (dietary and lifestyle) and numerical results Choice of excess weight gain as the primary outcome addressed insufciently Question components addressed in the review but not explicitly. Narrowly focused evaluating only weight gain in pregnancy Full search strategy not provided. Language restrictions present GRADE used to assess risk of bias Details of planned analysis including sensitivity analysis and any summary measures not provided PRISMA ow diagram provided with sufcient details Clinical characteristics of included studies reported. Presence or absence of standard maternity care details not reported. No details of any other relevant outcomes Risk of bias unclear for individual studies and across studies Results of individual studies provided as P values only Summary of ndings and implications for practice and research provided Limitations of the included studies reported, no report on the review limitations Described Systematic review (Dodd et al.9) Identies the paper as a systematic review and includes the design of primary studies Evaluates effect of interventions on fetal (primary) and maternal outcomes in obese and overweight pregnant women only Structured abstract with relevant details No results on harm of intervention

Abstract

Background Rationale Objective

Choice of birth weight as a primary outcome and relevant interventions reported adequately Explicit reporting of questions addressed in the review

Methods Search and study selection Risk of bias Planned analysis Results Study selection Study characteristics

Full search strategy not provided for either harm or benet of intervention Risk of bias assessed at study level and not at outcome level or across studies (publication bias) Planned data synthesis provided. Sensitivity analysis not planned Insufcient details of study selection process in the ow chart Clinical and methodological characteristics provided at study level and not at outcome level. Details of comparison groups and harm of interventions not known Risk of bias not reported at outcome level and across studies Relative risk of individual studies for various outcomes; summary estimate provided by meta-analysis Summarises the main ndings and implications for research and practice Study summary does not include the potential harm from the intervention or limitations of the review Described

Risk of bias Results of studies Discussion

Funding

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Obesity in pregnancy: effectiveness of interventions

et al.10 identied only a small number of citations (13) after their search. The PRISMA guidance is primarily a reporting guidance and not a quality assessment tool. It differentiates the quality assessment of studies included in the review from the risk of bias by concentrating on the evaluation of the former and reporting of the latter. The assessment of the risk of bias can be undertaken at the individual study level or at outcome level, by studying the possible effect of clinical or methodological bias on the review results. This is very relevant for the effect of interventions on patientreported outcomes. Ronnberg et al.10 focus on one outcome only and use the GRADE components to assess the risk of bias, whereas Dodd et al.9 assess the quality of each study and report a wide range of outcomes. The addition of the risk of bias assessment at the outcome level, the assessment of potential publication bias and selective reporting of outcomes within studies would have strengthened this review. The review by Ronnberg et al.10 identies a small number of studies that report maternal gestational weight gain. There was considerable heterogeneity of study design and interventions, leading them to conclude that meta-analysis was not appropriate. The lack of numerical data in their results, except P values, makes it difcult for the reader to gauge the impact of the intervention in various studies, any trends or consistency in the results. The reporting of the results of the individual studies with their summary data in the review by Dodd et al.9 aids in the assessment of the effectiveness of the intervention, including the precision and any heterogeneity of the results. Overall, the review found no signicant differences between the women who received the weight management interventions and those receiving usual care for large-for-gestational-age infant (relative risk, 2.02; 95% CI, 0.84, 4.86), mean gestational weight gain (mean difference, )3.1 kg; 95% CI, )8.32, 2.13) or any other outcome. Importantly, the two reviews reach similar conclusions. Both report the paucity in the number and quality of primary studies, making it impossible to propose any rm recommendations for clinical practice at the current time. However, they have omitted one very important component, which is the harm that may arise as a result of the intervention itself or the effect of weight loss on the mother or baby.

used the GRADE methodology for the quality assessment of studies that evaluate the effect of dietary and lifestyle interventions on the outcome excessive weight gain in pregnancy. However, details are needed about its effect across all outcomes to better understand the net benets against risks.

Implications for research and practice

The two reviews have collated the evidence on effective interventions aimed at preventing or reducing maternal obesity in pregnancy in slightly different groups of women. To gain a balanced judgment about the net benets and harm, the next step will be to evaluate the risk of harm from these interventions by a thorough systematic review. Should strong evidence of harm arising from the intervention or weight loss in pregnancy be established, the uncertainty in the benet of such interventions may be offset, meriting a strong recommendation against a particular intervention. Furthermore, the value and preferences placed by the mothers and clinicians for the different outcomes will need to be ascertained prior to making recommendations for or against a weight management intervention. This step is crucial to identify knowledge gaps and variation in preferences of the outcomes. For example, weight loss in pregnancy may be of far less importance to the mother compared with the risk of caesarean section. Lastly, the cost of the intervention, including any benets and complications, will be relevant before recommending its routine use. Large, well-conducted, prospective, randomised trials in this eld are needed to improve the robustness of the evidence. These need to describe the behavioural change intervention in sufcient detail for it to be reproducible,14 full details of the usual care, the wide range of outcomes, including harm, and the outcomes that are important to pregnant women.

Disclosure of interests
Both authors are applicants on the National Institute for Health Research Health Technology Assessment (NIHR HTA)-funded project (09/27/06) Interventions to reduce or prevent obesity in pregnant women: a systematic review of evidence synthesis.

Contribution to authorship

The GRADE approach in systematic reviews

In the GRADE methodology, the quality assessment and reporting of results are performed separately for each outcome as, even within one review, the quality of the evidence can vary between outcomes. Ronnberg et al.10 have

Both authors collaborated in writing the commentary.

Details of ethics approval

Not applicable.

Funding
None.

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Acknowledgements
None. j

References
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