Essay: Essay on chronic disease and health problems attributable to a person's diet and a lack of physical activity

Chronic disease and health problems attributable to a person’s diet and a lack of physical activity represent the most severe public health threat to the United States1. Obesity, classified as a BMI ‘ 30 kg/m2, has become the most deadly and costly underlying preventable health issue1,2. More than one-third of the entire American population is classified as obese and approximately $147 billion dollars are spent annually on medical costs associated with obesity2. In the United States more than half of all pregnant women are classified as overweight, with 36% classified as obese2-4.
In developed countries, maternal obesity is the most common risk factor for maternal morbidity and adverse outcomes for the infant which include but are not limited to: gestational diabetes mellitus, pre-eclampsia, emergency caesarean sections, sleep apnea, macrosomia, premature births, congenital abnormalities, neonatal hypoglycemia, stillbirths and childhood obesity3,5,6. Many women think that because they are pregnant and ‘eating for two’ that it doesn’t matter how much weight they gain; the added weight is healthy for the baby. This however is false; the Institute of Medicine provides recommendations for total weight gain during pregnancy based off BMI: underweight (BMI < 18.5 kg/m2) 28-40lbs, normal weight (BMI 18.5-24.9 kg/m2) 25-35lbs, overweight (BMI 25-29.9 kg/m2) 15-25lbs, and obese (‘ 30 kg/m2) 11-20lbs7,8.
Nevertheless, many pregnant women are faced with barriers to healthy eating and physical activity (PA). Numerous studies have been conducted to identify the barriers overweight and obese pregnant women encounter in order to determine the best ways to motivate for behavior change to improve maternal health and provide a healthy environment for their baby. It is important to determine the perceived barriers and enablers to healthy eating, physical activity and proper gestational weight gain because these factors indirectly affect behavior by impacting motivations9. Research has shown that among women who are overweight or obese, healthy diet and lifestyle during pregnancy has been associated with improved maternal cardiovascular function and reduced risk of a high-birth weight babies9. Additionally, PA during pregnancy has been associated with a reduced risk of gestational diabetes, premature birth, pre-eclampsia, and cesarean sections9. Pregnancy presents a unique circumstance in which women are in a transitional life event, and are thought to be more aware and responsive to modifying their behavior to make positive lifestyle changes8,10-12.
The majority of research relevant to the present study use surveys, questionnaires, in-person interviews, and open-ended questions as methods to identify barriers and enabling factors to improving gestational health in obese pregnant women4,9,13,14. Many barriers to healthy eating during pregnancy have been identified including: maternal eating habits prior to pregnancy, awareness of nutritional recommendations for pregnancy, family support, and time9. Sui et al. used the HBM to describe overweight and obese women’s opinions on behavior change during pregnancy, with a focus on diet, exercise and weight gain. The study found that the biggest barrier women perceived was time constraints, and only half the participants believed that excessive maternal weight gain was a concern9. Another study also observed that ‘getting time off of work’ was the most frequently stated barrier to accessing weight loss resources, as well as location of services8.
Fowles et al. used a positive deviance framework on low-income Latino pregnant women to examine determinants to healthy eating, with the most cited barriers including access to convenient, affordable foods and the time to buy foods and prepare meals14. This study also found that women without the support of a partner were more likely to have inadequate dietary intake than women with partners; social support being a key enabler for the women with partners to eat healthier14,15. A study utilizing the Health Belief Model, performed by Gardner et al., found pregnant women who perceived their current intake of sugar and high-fat foods to be too high and fruit and vegetables too low, were significantly more likely to intend to reduce their sugar and high-fat food consumption and increase fruit and vegetable consumption11.
Leslie et al. reported that that 60% of participants expressed concern about their gestational weight gain, and physical activity advice held more interest than dietary advice as useful resources in weight loss during pregnancy8. Additionally, Clarke et al. found that women received more PA advice from their social group than from health care professionals, therefore were more likely to believe the inaccurate lay person perception that PA should be limited in pregnancy13. This suggests that health professionals need to be more diligent in properly educating women about gestational health. However, interventions to minimize inappropriate weight gain focused solely on exercise are not likely to be as effective as an intervention with both physical activity and dietary components8.
Lack of knowledge about the proper amount of gestational weight gain, as well as the potential risks of excessive weight gain, have been found to be major barriers to healthy weight management during pregnancy. Additionally, if overweight and obese women’s attitudes towards weight gain in pregnancy are negative, they tend to have overall negative attitudes about pregnancy as well as various other negative feelings such as anxiety, depression, stress, and anger15. Shub et al. observed 353 pregnant women’s self-assessment of BMI and showed that obese women were prone to inaccurate assessment of BMI when compared to normal weight women, as only 24% of obese women accurately classified themselves as obese4. Several other studies found that women do not recognize their weight as a concern because of the ‘normalization’ of obesity, and have shown to be unaware of the consequences of excessive maternal weight gain on their baby4,8. This is a limitation for behavioral interventions because if these women do not perceive a problem with gestational weight gain, then interventions are not likely to be relevant to these women, and subsequently they will not show intentions to change their behavior8.
For the present study, the Health Belief Model (HBM) will be used to study the relationship between obese pregnant women and their beliefs, perceptions and readiness to engage in healthy eating, physical activity and gain proper gestational weight. Like prior research studies, the HBM will be used as it is one of the most widely utilized theories for addressing behaviors that evoke health concerns with motivation as its central focus. Many previous studies have looked primarily at dietary concerns or physical activity, but few have addressed both topics together. Additionally, very few have addressed the common lack of knowledge of the recommended amount of weight one should gain as indicated by BMI. It is important to explore all three together as diet, exercise and weight maintenance are interconnected. Based on the HBM, individuals will make healthy changes if they believe there is a risk to their health (perceived susceptibility), in this study due to being overweight or obese, and have awareness of the possible consequences (perceived severity). The benefits of making healthy changes (perceived benefits) must overshadow encountered barriers (perceived barriers) they might detect and be exposed to factors that prompt action (cues to action); participants must be self-confident (self-efficacy) in their ability to change their behavior9.
The purpose of this study will be to identify and target determinants of gestational diet, physical activity and appropriate gestational weight gain based off BMI at the start of pregnancy, in order to positively affect maternal morbidity and reduce neonatal complications using the precede-proceed theoretical framework for diagnostic planning and evaluation. The precede-proceed framework is a 9 phase sequence for health promotion planning that starts at the desired outcome (improved maternal and neonatal morbidity) and works backwards to determine the causes (barriers) and design appropriate interventions to achieve the desired outcome. Phases 1-5 (precede) include: social, epidemiological, behavior and environmental, educational and organizational, and administrative and policy diagnoses that use data analysis to determine and analyze the problem, classify factors that may influence behavior (predisposing, enabling, reinforcing factors), and determine capabilities and resources available. Phase 6 (proceed) is the implementation stage; described in further detail in the Methods section. Lastly, phases 7-9 are the evaluation stages which include process, impact, and outcome evaluations that will be conducted after implementation of the program.
Methods
The participants of this study will be overweight and obese pregnant women recruited from OBGYN offices in the Sentara network in Hampton Roads, VA. This will offer a diverse background of participants including different levels of socioeconomic status and ethnicity, as there are many offices in various locations across the seven cities of Hampton Roads. Sample size of the participants will be dependent on recruitment efforts, but should be no less than 100 women. The criteria for participants to be included in this study require: overweight and obese pregnant females with a BMI>25 kg/m2, no preexisting condition that could be exacerbated by pregnancy, conceived naturally, and in the first trimester of pregnancy. It is important to study these women early in their pregnancy as they have ample time to adopt new behaviors to affect maternal and neonatal health. The participants will be informed that they may freely withdraw from participation and will need to sign informed consent. Certified health counselors trained in motivational interviewing will be needed for the in-person interview phase.
The program will be broken up into 3 phases: 1. identifying barriers to healthy lifestyle while pregnant and gauging knowledge of participants via survey, 2. health counseling and in person interviews, and 3. a follow-up survey after counseling to analyze the patient’s current health status and opinions after counseling. The initial survey will include questions that address the level of social support, time constraints, location of health services in relation to residence/work, level of knowledge about healthy eating and exercise, knowledge of the proper amount of weight to gain based off BMI, self-analysis of overweight vs obese, attitude toward weight gain, medical professional advice given, perceived current health status, and average level of physical activity participation. Health counseling and in-person interviews will address the perceived barriers and benefits from the initial survey and clarify misinformation, help the participants understand the potential risk and severity of their situation, build self-efficacy by providing guidance and assisting participants in setting goals. The follow-up survey will gauge the current health status of the participant and fetus, opinions on effectiveness of health counseling, current barriers that still exist, attitude toward weight gain, and assessment of current nutrition and physical activity levels. Reminders and informative postcards to stay healthy and active will be sent via text and mail to all participants.
The descriptive questions in the surveys should be effective in evaluating the opinions and views of the participants. The in-person health counseling should be an effective method to increase self-efficacy of the participants and provide social motivation for those who may not have a strong social support at home. It will be beneficial for the participants to be able to ask questions and receive answers from qualified health professionals who will also be able to clarify any misinformation. The open-ended questions used in counseling should encourage conversation between counselor and participant to better gauge the perceived barriers and enablers the participants believe affect their decisions to live healthy lifestyles and gain weight appropriately.
Expected Results
This study should effectively identify barriers and enabling factors to a healthy lifestyle in overweight and obese pregnant women. Through health counseling and motivational interviewing, the women should feel motivated (increase self-efficacy) to make better dietary choices and know the correct recommendations for physical activity and weight gain throughout pregnancy. The results on the attitude of weight gain should be intriguing, as it was a factor not mentioned often in the literature. Realistically, there will likely be a few participants who will drop out for a variety of reasons. The overall success of the program will be dependent on the quality of the health counseling and a limited loss to follow up. A potential limitation to this study could be the lack of stratification of socioeconomic status; perhaps the program will affect one tier differently than another. Another potential limitation could be that participation in this study is on a volunteer basis and participants who volunteer are likely to be willing to change, which may not be representative of all women in the recruitment area, especially those in which behavior change would benefit the most. The goal of study is to become a model practice, and for the methods to be adopted and used for future research. The methods used could be beneficial as a foundation for dietary and physical activity intervention studies with control groups to better observe the effect of behavior modification in overweight and obese pregnant women in order to improve health of both mother and baby.
References
1. Cordain L ES, Sebastian A, Mann N, Lindeberg S, Watkins BA, O’Keefe JH, Brand-Miller J. Origins and evolution of the Western diet: health implications for the 21st century1,2. American Journal of Clinical Nutrition. 2005;81(2):341-354.
2. CDC. Obesity Facts and Statistics. 2013; http://www.cdc.gov/obesity/data/adult.html.
3. Obesity in Pregnancy. 2013:121; 213-127. http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Obesity_in_Pregnancy. Accessed 4/21/2014.
4. Shub A, Huning EY-S, Campbell K, McCarthy E. Pregnant women’s knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy. BMC Research Notes. 2013;6(1):278.
5. Poobalan AS, Aucott LS, Gurung T, Smith WCS, Bhattacharya S. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women ‘ systematic review and meta-analysis of cohort studies. Obesity Reviews. 2009;10(1):28-35.
6. Rowlands I, Graves N, de Jersey S, McIntyre HD, Callaway L. Obesity in pregnancy: outcomes and economics. Seminars in Fetal and Neonatal Medicine. 2010;15(2):94-99.
7. Weight Gain During Pregnancy: Reexamining the Guidelines. 2009; http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx. Accessed 4/22, 2014.
8. Leslie W, Gibson A, Hankey C. Prevention and management of excessive gestational weight gain: a survey of overweight and obese pregnant women. BMC Pregnancy and Childbirth. 2013;13(1):10.
9. Sui Z, Turnbull DA, Dodd JM. Overweight and Obese Women’s Perceptions About Making Healthy Change During Pregnancy: A Mixed Method Study. Matern Child Health J. 2013/12/01 2013;17(10):1879-1887.
10. Weir Z, Bush J, Robson S, McParlin C, Rankin J, Bell R. Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women. BMC Pregnancy and Childbirth. 2010;10(1):18.
11. Gardner B, Croker H, Barr S, et al. Psychological predictors of dietary intentions in pregnancy. Journal of Human Nutrition and Dietetics. 2012;25(4):345-353.
12. Campbell F, Johnson M, Messina J, Guillaume L, Goyder E. Behavioural interventions for weight management in pregnancy: A systematic review of quantitative and qualitative data. BMC Public Health. 2011;11(1):491.
13. Clarke PE, Gross H. Women’s behaviour, beliefs and information sources about physical exercise in pregnancy. Midwifery. 2004;20(2):133-141.
14. Fowles ERHJAWLO. Identifying Healthy Eating Strategies in Low-Income Pregnant Women: Applying a Positive Deviance Model. Health Care for Women International. 2005;26(9):807-820.
15. Fowles ERFSL. Healthy Eating During Pregnancy: Determinants and Supportive Strategies. Journal of Community Health Nursing. 2008;25(3):138-152.