It is often said that 'prevention is better than cure', but in the context of pregnancy, this cannot be taken as read. Because excessive gestational weight gain is probably the most important risk factor for maternal obesity, restricting the amount of weight that women gain should theoretically help to reduce the burden of obesity-related disease in women. However, restricting weight gain during pregnancy presents health care workers with a dilemma: weight restriction may help to diminish the risk of maternal obesity, but may also affect the development of the growing child. In any event, advocating weight restriction during pregnancy may be a moot point, because there is little empirical evidence to suggest that weight gain is easy to modify during pregnancy (110). Mothers routinely report difficulties in complying with dietary instructions during pregnancy (111,112) because they usually experience a 'surge of appetite' during pregnancy (113) which is difficult to overcome (Dieckmann 1952 in Hytten (113)).
Even if it were possible or beneficial to modify the amount of weight women gain during pregnancy to reduce the prevalence of maternal obesity, the association between fetal development in utero and health later on in life (114—117) should make clinicians extremely cautious when recommending weight restriction during pregnancy, even for those mothers whose gains appear excessive. Restricting weight gain during pregnancy may have undesirable consequences not only for the fetus, but for the generations that follow as the effects of inadequate biological development in utero can establish the biological parameters within which individuals will function later in life (115,117). For these reasons, it would seem more appropriate to address the problem of pregnancy-related weight gains soon after the birth, at a time when fetal growth cannot be compromised. At this time it would also be appropriate to forewarn mothers of the changes in lifestyle that accompany motherhood which can encourage further weight gain.
During the postpartum period women are offered little advice (66). Many are only likely to see a physician for a 6-week check-up, and at this time women may be receptive to advice about their own health as they recognize their responsibility for a new life (66). In this setting, it could be made clear that permanent weight gain need not be a consequence of pregnancy, and that lifestyle changes rather than biological changes may be a more important cause of pregnancy-related weight gains (66).
Helping mothers to establish appropriate exercise routines should be an important component of postpartum care. In recent years, exercise has been shown to be beneficial to health, and postpartum women are no exception (106). Unfortunately there are many barriers to regular exercise for a mother with a new baby, and perhaps other young children at home. The cost of child care and formal exercise often makes these pursuits prohibitive, and for many there are difficulties in accessing leisure facilities (65). Likewise, lack of time, particularly for working mothers, often makes participation in exercise difficult following pregnancy (65). Even walking can jeopardize personal safety and cause fear among mothers who live in areas of high crime (106). Consequently, health care providers should discuss exercise needs individually and set realistic goals that are tailed to the individual's needs (106).
Women should be given realistic advice about postpartum weight change as well as assistance in beginning or maintaining lifestyles that will promote health and an appropriate body weight. For some new mothers, dealing with the demands of an infant, running a household, and in many cases holding a job as well, make dieting and other weight loss strategies seem overwhelming (61). Health care providers should therefore have a supportive attitude to ensure that concerns about weight management are balanced with concerns about maternal self-esteem. The following five recommendations should go some way to reduce the burden of disease associated with maternal obesity:
• Women should be encouraged to eat to appetite during pregnancy by consuming a varied and balanced diet, but be advised that it is not necessary to 'eat for two' in order to provide the appropriate nutrients for their growing child.
• Mothers should be given assistance in beginning or maintaining lifestyles that will promote health and an appropriate body weight at the time of their 6-week postpartum check-up.
• Mothers should be forewarned of the changes in eating habits that often accompany pregnancy and motherhood which predispose weight gain so they can take steps to prevent these new behaviours from tracking into the future.
• Mothers should be encouraged to maintain or establish appropriate exercise routines with realistic goals that are tailored to the individual's needs.
• Mothers should be given realistic advice about postpartum weight change so that they do not have unrealistic expectations about weight loss following delivery.
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