Received: 9 March 2021 Revised: 2 June 2021 Accepted: 2 June 2021

DOI: 10.1111/obr.13310

PREGNANCY/WEIGHT MANAGEMENT

Weight management across preconception, pregnancy, and

postpartum: A systematic review and quality appraisal of
international clinical practice guidelines

Cheryce L. Harrison1,2 | Helena Teede1,2 | Nadia Khan1 | Siew Lim1 |

3 4 1 1,3
Ayushi Chauhan | Sheila Drakeley | Lisa Moran | Jacqueline Boyle

1
Monash Centre for Health Research and
Implementation, Monash University, Summary
Melbourne, Victoria, Australia This systematic review and quality appraisal evaluated clinical practice guidelines
2
Diabetes and Vascular Medicine Unit,
(CPGs) for weight management and weight-related behaviors across preconception,
Monash Health, Melbourne, Victoria, Australia
3
Department of Obstetrics and Gynaecology, pregnancy, and postpartum. CPGs published in English were identified from research
Monash Health, Melbourne, Victoria, Australia and guideline-specific databases between 2010 and 2019. Recommendations were
4
School of Global Public Health, University of
categorized into weight (body mass index screening, weight loss, weight gain preven-
North Carolina, Chapel Hill, North Carolina,
USA tion, and gestational weight gain), diet, food safety, physical activity, and behavioral
strategies. Three independent appraisers assessed CPG quality using the Appraisal of
Correspondence
Cheryce L. Harrison, Monash Centre for Guidelines Research and Evaluation II instrument. Twenty-two CPGs were included
Health Research and Implementation (MCHRI),
across preconception (n = 2), pregnancy (n = 8), postpartum (n = 2), or a combination
Locked Bag 29, Clayton, Victoria 3168,
Australia. (n = 10). Overall, 45% of CPGs were appraised as poor quality, 32% as moderate, and
Email: cheryce.harrison@monash.edu
23% as high. Evaluation of body mass index and supplementation recommendations
Funding information were most common across CPGs, alongside secondary weight management recom-
National Health and Medical Research Council;
mendations for women with obesity in fewer CPGs. Accompanying recommenda-
National Heart Foundation of Australia
tions for diet, physical activity, and behavior were highly variable between guidelines.
We report significant ambiguity in existing guidance and an absence of important
considerations, including targeting weight gain prevention and limiting excess gesta-
tional weight gain. Results emphasize the need for development of robust, compre-
hensive, and high quality guidelines on healthy lifestyle and weight management
across these formative reproductive life stages.

KEYWORDS
postpartum, preconception, pregnancy, weight management

1 | I N T RO DU CT I O N excessive weight gain (>20 kilos) in women is double that of remaining

Younger women of reproductive age represent the highest risk popula-
tion group for accelerated obesity development within the broader
global obesity crisis. This is demonstrated longitudinally with a higher
annual weight change in women compared with men across early
adulthood to mid-adulthood.1 Across this time, the likelihood of
LJ Moran and JA Boyle denote joint senior authorship.
weight stable (within 2.5 kilos1). This excess weight gain is associated
with reproductive, metabolic, and psychosocial complications, develop-
ment of major chronic disease and lower likelihood of healthy aging.1,2
Vulnerability to accelerated weight gain in women is complex
with preconception, pregnancy, and postpartum (within 12 months
of childbirth) recognized as critical contributory life stages.3
Preconception, women do not identify themselves as a distinct high-
risk group or at a specific life stage.4 However, significant life-phase

Obesity Reviews. 2021;1–23. wileyonlinelibrary.com/journal/obr © 2021 World Obesity Federation 1

2 HARRISON ET AL.
transitions during this time including leaving home, entering employ-
ment, relationship formation, and cohabitation present as increased
5
barriers to optimal lifestyle behaviors contributing to decreased
6
physical activity and increased consumption of discretionary, energy
dense foods.7 Consequently, over 50% of women commence
pregnancy with overweight or obesity.8–10 During pregnancy, 50%
of women exceed the internationally recognized Institute of Medicine
(IOM) recommendations for gestational weight gain (GWG).8 Every
kilo gained above guidelines is linked to an 10% increase in adverse
pregnancy outcomes.11 These include fetal malformations, miscar-
riage, preeclampsia, gestational diabetes, labor complications, and
increased health care costs,12 with risks exacerbated in the presence
of pre-existing obesity. Postpartum, women retain 2–5 kg per
pregnancy,13,14 and excessive GWG increases the risk of obesity
15
development threefold within two decades. Risks extend to
children, with those born to mothers with obesity twice as likely
to develop obesity in childhood, independent of maternal age,
race, parity, education, GWG, sex of child, and birthweight.16 Further,
children are also three times more likely to develop obesity later in life
when GWG exceeds guidelines, independent of maternal BMI.17
The importance of preventing weight gain across these periods
is emphasized in leading position statements and policies world-
wide. 18–20
In tandem, various clinical practice guidelines (CPGs) have
been developed to guide healthcare providers in supporting women
to engage with healthy weight related behaviors and optimize weight
across preconception, pregnancy, and postpartum. The overarching
aim of CPGs is to provide recommendations that enhance care,21
informed by best available systematic evidence. They should be
developed with multidisciplinary expertise, utilize transparent meth-
odological processes throughout, and evaluate both the quality of evi-
dence and strength of the recommendations made. However, multiple
CPGs within the same topic area can introduce variations in published
recommendations,22 and there can be discrepancies in methodological
rigor, diluting high-quality recommendations for care and increasing
22
ambiguity in practice. In turn, this may affect the knowledge, confi-
dence, and clinical practice of providers, translating to suboptimal
support and information provision to patients themselves.
Here, we present a comprehensive systematic review of CPGs for
weight management (i.e., weight maintenance, weight gain prevention,
and/or weight loss) and weight related behaviors (i.e., diet, physical
activity, and behavior recommendations) across preconception,
pregnancy, and postpartum. We sought to inform on consistency of
information, appraise the quality of CPGs using the validated AGREE
II instrument, and identify gaps to inform future related guideline
development and translation in these formative life stages.
2 | METHODS
2.1 | Protocol and registration
A protocol for this review was registered and updated accordingly
with the International Prospective Register of Systematic Reviews
(CRD42017072101). The methods of this systematic review have
been reported in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines.23
2.2 | Search strategy
A systematic search was conducted between 2010 and October 2019
across academic databases including OVID Medline, EMBASE, EBM,
and the International Prospective Register of Systematic Reviews as
well as leading national and international guideline-specific databases.
These included the Scottish Intercollegiate Guidelines Network
(SIGN), National Guideline Clearinghouse (NGC), National Institute for
Healthcare and Excellence (NICE), National Health and Medical
Research Council (NHMRC) Clinical Guidelines Portal, Guidelines
International Network (G-I-N), World Health Organization (WHO),
and National Academies.
Combined major subject heading terms and text words were used
and adapted according to the database interrogated. Separate search
strategies, tailored to the search capabilities of each website, were
developed and executed for PROSPERO and guideline specific
databases (Supporting Information S1). Major search terms included
“preconception care,” “family planning service,” “perinatal care,”
“pregnancy,” “postpartum period,” and “practice guideline,” informed
by previous systematic reviews.24,25
2.3 | Inclusion criteria
CGPs were included if they covered recommendations for weight
management (i.e., weighing, weight gain prevention, weight mainte-
nance, weight management, and/or weight loss), diet (i.e., food
groups, energy, macronutrient and micronutrient recommendations,
and food hygiene considerations where applicable), and exercise/
physical activity (i.e., type, frequency, intensity, duration, and seden-
tary behavior) and any behavioral strategies (i.e., self-management,
self-monitoring, and behavior change techniques) across preconcep-
tion, pregnancy, and/or postpartum. Pregnancy-specific information
for weight management included recommendations for management
of GWG, GWG thresholds, and routine monitoring of GWG. We
included guidelines published in English. Updated CPGs were carried
forward if two or more versions were identified. We excluded
CPGs that contained no reference list, those not national or interna-
tional in scope, and those developed or adapted for local use only.25
Position statements, consensus discussions, editorials, systematic, and
narrative reviews were excluded.
2.4 | Study selection
The title and abstract of all search outputs were independently
screened by two reviewers (NK and AC), with a randomized 10%
cross-check performed to ensure consistency between reviews. Full
HARRISON ET AL.
text of the CPG was retrieved for further assessment if the title and
abstract met the eligibility criteria or if there was uncertainty regard-
ing its eligibility. If eligibility could not be established, a third reviewer
was consulted (LM). Reference lists of included CPGs were hand-
searched as an additional method to identify further relevant CGPs.
2.5 | Data extraction
The following components of each eligible CPG were extracted by
one reviewer and cross-checked by a second author: guideline demo-
graphics including title, developing body, country of origin, year of
publication, and version or edition number. Target population, key
recommendations for weight management and health behaviors
according to inclusion criteria, and level of evidence against
recommendations, if documented, were also extracted.
2.6 | Guideline quality assessment
The quality of each eligible CPG was independently appraised by
three reviewers trained for using the AGREE II instrument. The
AGREE II instrument is a valid and reliable tool, widely used across
26
various health condition-settings to assess the quality of CPGs. The
following six domains are considered through the instrument: (1) scope
and purpose, (2) stakeholder involvement, (3) rigor of development,
(4) clarity of presentation, (5) applicability, and (6) editorial indepen-
26
dence. All appraisals were conducted on the online My AGREE Plus
platform (https://www.agreetrust.org/resource-centre/agree-plus/).
A scaled score for each domain was calculated based on the
obtained score, number of items within the domain, the number of
appraisers, and the minimum and maximum scores which could theo-
retically be obtained.26 Given individual domain scores could not be
combined to form a single overall score,26 the overall quality of each
guideline was based on the following criteria: CPGs with five to six
domains scoring >60% were considered high quality; CPGs with three
to four domains scoring >60% were considered average quality; and
CPGs with two or less domains scoring >60% were considered poor
27,28
quality, as per previous literature. The inter-rater agreement was
assessed for each appraisal using the Inter-correlation coefficient
(ICC) using IBM SPSS Statistics Version 25 software. An ICC ≥ 0.70
was considered as a “good” level of agreement based on previously
27
used scales. Guidelines with an ICC lower than 0.70 were discussed
among appraisers and items with discrepant scores were re-scored
through consensus until an ICC of 0.70 or more was achieved.
3 | RESULTS
3.1 | Literature search and guideline selection
Our search strategy identified 18,505 articles for screening after the
removal of duplicates. On screening title and abstract, 18,450 articles
3
were excluded, leaving 55 considered eligible for full-text review
(Figure 1). On cross-checking the reference lists of full-text articles
reviewed, 14 additional CPGs were identified and subsequently
included. Of the 69 articles reviewed, 47 were excluded, leaving
22 CPGs that included recommendations for weight management,
diet and physical activity across preconception (n = 2), pregnancy
(n = 8), postpartum (n = 2), or a combination (n = 10). Eligible CPGs
were checked for updates with recommendations carried forward if
applicable throughout the study period.
3.2 | Guideline characteristics
Table 1 presents the characteristics of the included CPGs. The two
preconception guidelines identified were both published in the
Unites States.29,30 Of the eight pregnancy guidelines, two originated
from the United Kingdom,31,32 two from Australia,33,34 two
from Canada,35,36 and one each from the United States37 and
Belgium,38 respectively. The two postpartum guidelines were publi-
shed in Switzerland39 and the United Kingdom.40 Ten combined
guidelines were identified, of which six encompassed preconception,
pregnancy, and postpartum care with three from the United
Kingdom41–43 and one each from United States,44 New Zealand,45
and Bahrain.46 One preconception and pregnancy combined guideline
from Canada was identified47 as well as three combined guidelines
including pregnancy and postpartum care were included from
Australia,48 the United States,49 and Canada.50
3.3 | Quality assessment
The AGREE II scores for each CPG are presented in Table 2. Overall,
the quality of the CPGs included were highly variable, and a wide
range of scores were recorded across domains with 45% overall
appraised as poor, 32% as moderate, and 23% as high quality. Of the
two preconception CPGs included, both were appraised as poor qual-
ity. Of the eight pregnancy CPGs, three were appraised as high, two
as moderate, and three as poor quality, while both postpartum guide-
lines were appraised as moderate overall. Within the 10 combined
guidelines, two were appraised as high, three as moderate, and five as
poor quality.
Within AGREE II domains (detailed Table 2), “scope and purpose”
scored the least variability and the highest scores which ranged
between 55.6% and 96.3% with 17 guidelines scoring ≥60%, indicat-
ing reasonable clarity of the purpose, clinical questions addressed, and
intended audience. “Stakeholder engagement” ranged between
18.5% and 87.0% with 11 guidelines scoring ≥60%, while “clarity of
presentation” ranged from 33.3% to 75.9% with 10 guidelines scoring
≥60%. The remaining domains including “rigor of development” (range
8.3–83.3%; n = 10 scoring ≥60%), “applicability” (11.1–61.1%; n = 3
scoring ≥60%), and “editorial independence” (0–86.6%; n = 3 scoring
≥60%) had the highest variability in scoring, with domains frequently
poorly addressed or omitted entirely.
4 HARRISON ET AL.
FIGURE 1 PRISMA diagram of included CPGs
Within the domain of stakeholder engagement, the vast majority
of CPGs (n = 18) included representation across relevant professional
bodies and organizations (e.g., general practice, obstetrics, midwifery,
pediatrics, public health, and dietetics). A minority (n = 10) provided
detail on consumer engagement and/or clearly defined the target
user. Within rigor of development, the health benefits, side effects,
and risks as well as the link between evidence and making recommen-
dations were clear across all guidelines, yet methodological consider-
ations diverged significantly, yielding variation in domain scoring
overall. Search methods used and criteria for selecting evidence were
omitted in 25% of guidelines, methods for formulating the recommen-
dations were omitted in 20%, and a procedure for updating the guide-
line was absent in 30% overall. Applicability considerations including
practical guidance, as well as barriers, facilitators, and resource
considerations required for implementation, widely varied, with 20%
(n = 5) of guidelines not addressing resource implications. Overall,
applicability was the lowest scoring domain in eight CPGs, including
three of the 20 CPGs ranked of high quality. Editorial independence
of the funding body and declaration of competing interests were the
least likely to be reported, with 35% (n = 7) and 25% (n = 5) of CPGs
respectively omitting this information.
3.4 | Extraction of recommendations
A detailed list of recommendations for weight management according
to the inclusion criteria is listed in Table 1 and summarized below by
reproductive stage. Supporting Information S2 contains a quantitative
TABLE 1 Characteristics of included clinical practice guidelines
Type Title
Preconception Preconception Care
Berghella et al Year: 2010
Country: USA
Preconception Providing quality family
planning services:
recommendations of CDC
& the U.S. Office of
Population Affairs.
Gavin et al.
Year: 2014 Country: USA
Pregnancy SOGC Clinical Practice
Guideline: Obesity in
pregnancy.
Davies et al.
Year: 2018 Country: Canada
Pregnancy CMACE/RCOG Clinical
Practice Guideline: Care
of Women with Obesity
in Pregnancy
Denison et al.
Year: 2018 Country: UK
Pregnancy SOGC Clinical Practice
Guideline: Adolescent
Pregnancy Guidelines
Fleming et al.
Year: 2015 Country: Canada
Pregnancy Clinical practice guideline
for the management of
BMI screening Weight loss GWG Weight gain prevention Diet
✓ ✓ N/A O ✓
HARRISON ET AL.
* Annually * Unspecified caloric *400mcg/day folic acid
* Bulimia/anorexia control and nutritional * 150mcg/day iodine
nervosa in low BMI counseling * 12 oz fish/week
* Advise against pregnancy
until healthy BMI
achieved
✓ ✓ N/A O ✓
* Screen for obesity *Refer intesnive * Commence folic acid
counsellling in adults supplementation
with obesity (unspecified amount)
✓ ✓ ✓ O O
*Calculate from pre- * Enter pregnancy with a *Inconsistent with IOM
pregnancy height and BMI < 30 kg/m2, and *Guidelines referenced
weight ideally Cunningham FG et al.
<25 kg/m2.
✓ ✓ O O ✓
*Prior to pregnancy *Prior to pregnancy in * 5 mg/day folic acid
* At first antenatal obese women ≥1 month before
appointment * Nutritional advice aimed conception to during
at weight loss first trimester.
postpartum *10mcg/day Vitamin D
throughout pregnancy
* Offer dietetic advice in
line with NICE public
health guidance
*Women in the postpartum
period should be offered
breastfeeding support
O O O O ✓
*Nutritional assessment
*Vitamin, food
supplementation access
to a strategy to reduce
anemia if needed
O O ✓ O ✓
5
(Continues)

TABLE 1 (Continued)
Type Title
overweight and obesity in
adults, adolescents &
children in Australia.
National Health & Medical
Research Council Year:
2013 Country: Australia
Pregnancy Antenatal care for
uncomplicated pregnancies.
National Institute for
Health and Care
Excellence
Year: 2008 (updated 2019)
Country: UK
Pregnancy Practice Paper of the
Academy of Nutrition and
Dietetics: Nutrition and
Lifestyle for a Healthy
Pregnancy Outcome
Academy of Nutrition and
Dietetics
Kaiser et al
Year: 2014 Country: USA
Pregnancy Clinical Practice Guidelines:
Pregnancy Care
National Health & Medical
Research Council Year:
2018 Country: Australia
BMI screening
✓ O
*At first antenatal
appointment
O O
✓ O
*At first antenatal visit
*Use BMI to inform
GWG
6
Weight loss GWG Weight gain prevention Diet
* Endorse 2009 IOM *Endorse Australian
guidelines Dietary Guidelines
(pregnancy)
✓ O ✓
*Weigh only when clinical *400mcg/day folic acid to
management is 12 weeks gestation
influenced *10mcg/dayVitamin D
throughout pregnancy
✓ O ✓
* Endorse 2009 IOM *400mcg/day folic acid
guidelines (unspecified duration)
*Encourage iron rich foods
and commence 30mcg
iron daily from early
pregnancy
*Address Vitamin B12 in
non-animal product
eating women
*8–12 oz seafood/week
*consume <200 mg
caffeine per day
*Calculate extra energy
requirements according
to BMI
*Energy and
macronutirient
composition
recommendations for
multiple pregnancies
✓ O ✓
* Endorse 2009 IOM *500 mcg/day folic acid
guidelines supplementation to end
At each antenatal visit: first trimester
*Offer opportunity to be *150 mcg Iodine
weighed supplementation
*Discuss weight change, throughout pregnancy
diet and level of physical *Eating the recommended
activity number of daily serves
HARRISON ET AL.
TABLE 1 (Continued)
Type Title
Pregnancy What are the recommended
clinical assessment and
screening tests during
pregnancy?
Belgian Health Care
Knowledge Centre (KCE)
Gyselaers et al
Year: 2015 Country:
Belgium
Postpartum WHO recommendations on
postnatal care of the
mother and newborn
World Health Organization
Year: 2013 Country:
Switzerland
Postpartum Postnatal care up to
8 weeks after birth
National Institute for Health
and Care Excellence
Year: 2006 (updated 2015)
Country: UK
Preconception, Clinical practice guidelines
Pregnancy & for healthy eating for the
Postpartum prevention & treatment
of metabolic & endocrine
diseases in adults.
American Association of
Clinical Endocrinologists/
The American College of
BMI screening Weight loss GWG Weight gain prevention Diet
across the five food
groups is beneficial
HARRISON ET AL.
* limiting additional
serves and avoiding
energy-dense foods may
limit excessive
weight gain in overweight/
obese women
*moderate amounts of
caffeine unlikely to
cause harm
✓ O ✓ O O
*At first consultation *Regular weighing: “a
regular [weight]
measurement would be
enough instead of “at
each consultation” and
information has to be
provided to women
concerning their weight
gain
* Amount in line with BMI
(unspecified)
O O O O ✓
*Counsel on nutrition
O O O O O
O ✓ O O ✓
Preconception: Preconception:
* Achieve a healthy BMI *400mcg/dayfolic acid
before conception Pregnancy:
Pregnancy: not provided *Calculate caloric intake
Postpartum: not provided from pre-pregnancy &
current BMI
7
(Continues)
 8

TABLE 1 (Continued)

Type Title BMI screening
Endocrinology and the
Obesity Society
Gonzalez-Campoy et al
Year: 2013 Country: USA
Preconception, Guidance for Healthy ✓ ✓
Pregnancy & Weight Gain in Pregnancy
Postpartum Ministry of Health
Carr et al. Year: 2014
Country: New Zealand
Preconception, The Food Dome: Dietary O O
Pregnancy & guidelines for Arab
Postpartum countries.
The Arab Center for
Nutrition
Musaiger AO. Year: 2012
Country: Bahrain
Weight loss GWG Weight gain prevention Diet
*Refer vegan/vegetarian
women to dietitian
*consume 1.1 g/kg of
protein/day in second
and third trimesters
* < 10% of calories should
be derived from sat fats
and <10% from PUFAs
*Avoid trans fatty acids
*<300 mg/day caffeine
*600mcg/day folic acid
*250mcg/day iodine
Postpartum:
*Instruct on breastfeeding
& nutritional
requirements
*250mcg/day iodine
✓ ✓ ✓
Preconception: Preconception: * Endorse 2009 IOM Preconception: not Preconception:
*Advice consistent with *prior to pregnancy in guidelines provided *Discuss nutritional
New Zealand Weight obese women Pregnancy: not provided choices
Management Pregnancy: not provided Postpartum: Pregnancy:
Guidelines Postpartum: *Encourage weight *Avoid dieting
Pregnancy: not provided *prior to and between maintenance between Postpartum: not provided
Postpartum: not pregnancies in obese pregnancies
provided women * Discuss healthy eating,
physical activity and
breastfeeding as
strategies
✓ O ✓
Pregnancy: Preconception:
*monitor GWG *consume iron rich foods
Pregnancy:
*Consume iron rich foods
*Commence folic acid
supplementation or
consume folate rich
foods (unspecified)
*Avoid dieting
Postpartum:
* Consume appropriate
amount of food to
HARRISON ET AL.
TABLE 1 (Continued)

Type Title BMI screening Weight loss GWG Weight gain prevention Diet
provide for sufficient
breastmilk.
HARRISON ET AL.

*Avoid restrictive diet

Preconception, The International
Pregnancy & Federation of Gynecology
Postpartum and Obstetrics (FIGO)
recommendations on
adolescent,
preconception, &
maternal nutrition: “Think
Nutrition First”
Hanson et al
Year: 2015 Country: UK
Preconception, Weight management
Pregnancy & before, during & after
Postpartum pregnancy.
National Institute for Health
and Care Excellence.
Year: 2010 Country: UK
O ✓ ✓ O ✓
Preconception: *Recommend appropriate Preconception:
*Attention be paid to GWG in relation to pre- *400mcg/day folic acid
weight and BMI as pregnancy BMI *Unspecified
modifiable risk factors supplementation/
Pregnancy: not fortified foods where
Provided necessary, especially in
Postpartum: not underweight women
provided Pregnancy:
*increase dietary energy
intake by 340–
450 kcal per day during
the second and third
trimester.
*obese women (with or
without GDM) restrict
calorie intake to 25 kcal/
kg/day or less
*400mcg/day folic acid
*30-60mg/day iron
*Other nutrients as
required (iodine,vitamin
B12, vitamin D)
Postpartum:
*Improve nutritional status
after birth (unspecified)
O ✓ ✓ O ✓
Preonception: not Preconception: *Offer women with Preconception:
provided *5–10% prior to pregnancy BMI > 30 kg/m2 referral *Folic acid
Pregnancy: if BMI>30kg/m2 to a dietitian or health supplementation
*At first antenatal visit * Additional weight loss professional for weight (unspecified)
Postpartum: not encouraged but requires management Pregnancy:
provided additional support in *Do not routinely weigh *Advise healthy eating
women with obesity Postpartum: not provided
Pregnancy: not provided
Postpartum:
*Encourage structured
weight loss programme if
BMI > 30 kg/m2

(Continues)
9
 10

TABLE 1 (Continued)

Type Title BMI screening Weight loss GWG Weight gain prevention Diet
*Discuss weight 6–8 weeks
after birth. Discuss
benefits and provide
tailored diet/physical
activity advice
Preconception, Maternal & Child Nutrition O ✓ O O ✓
Pregnancy & National Institute for Health Preconception: Preconception:
Postpartum and Care Excellence *prior to &/or after *advise healthy eating
Year: 2008 (updated 2014) pregnancy in obese *400mcg/dayfolic acid
Country: UK women via structured/ supplementation
tailored diet and exercise Pregnancy:
program *400mcg/day folic
Pregnancy: not provided acidthroughout first 12
Postpartum: not provided weeks
*Refer obese women to
dietitian
*Avoid dieting
*Encourage Healthy Start
benefit (fruit/vegetable
vouchers) if eligible
*Advise on healthy eating
including 5 portions of
fruit and vegetables/day
+ 1 portion of oily fish
(e.g., mackerel, sardines,
pilchards, herring, trout
or salmon)/week.
Postpartum:
*Encourage Healthy Start
benefit (fruit/vegetable
vouchers) if eligible
*Healthy diet important for
b/feeding but no need to
modify diet
Preconception& SOGC Clinical Practice O ✓ ✓ O ✓
Pregnancy Guideline: Guideline No. Preconception: Weight *Monitoring of gestational Preconception:
391-Pregnancy & management strategies weight gain * Commence folic acid
Maternal prior to pregnancy may and approaches for supplementation
Obesity Part 1: Pre- include dietary, gestational weight gain (unspecified amount)
conception & Prenatal exercise, medical, and management be formally Pregnancy:
Care. surgical approaches integrated into routine *400mcg/day folic acid to
Maxwell et al Pregnancy: not provided prenatal care end of trimester 1.
Year: 2019
HARRISON ET AL.
TABLE 1 (Continued)

Type Title BMI screening Weight loss GWG Weight gain prevention Diet
Country: Canada *Endorse IOM 400 IU daily Vitamin D
recommendations during pregnancy and
HARRISON ET AL.

throughout
breastfeeding
Pregnancy & SOGC Clinical Practice O O O O ✓
Postpartum Guideline: Guideline No. Pregnancy: not provided
392-Pregnancy & Postpartum:
Maternal *Women in the postpartum
Obesity Part 2: Team period should be offered
Planning for Delivery breastfeeding support
& Postpartum Care
Maxwell et al
Year: 2019
Country: Canada
Pregnancy & Australian Dietary O O ✓ O ✓
Postpartum Guidelines *Endorse 2009 IOM Preconception/Pregnancy:
National Health and guidelines *400mcg/day folic
Medical Research Council acidthroughout first 12
Year: 2013 Country: weeks Pregnancy:
Australia *Avoid dieting
Pregnancy/Postpartum:
*Limit intake of sodium
*Limit caffeine to 300 mg/
day
*Consume low fat dairy
products
* Advise on Vitamin B12
and iron
supplementation if
pregnant and vegetarian
*Consume a high fiber diet
to avoid constipation
* Fluid need is 750–
1,000 ml a day above
basic needs
*Increase vegetables/
legume intake to 7.5
serves/day when
breastfeeding
*Increase grain intake to
8.5 serves in pregnancy
and 9 serves/day when
breastfeeding
11

(Continues)
 12

TABLE 1 (Continued)

Type Title
Pregnancy & Dietary guidelines for
Postpartum Americans 2015–2020
(Eight Edition)
U.S. Department of Health
and Human Services and
U.S. Department of
Agriculture Year: 2015
Country: USA
BMI screening Weight loss GWG Weight gain prevention Diet
Preconception/Pregnancy/
Postpartum:
*150mcg/day iodine
O O ✓ O ✓
* Endorse 2009 IOM Pregnancy/Postpartum:
guidelines * 8–12 oz fish/week low in
methyl mercury
*400mcg/day folic acid
supplementation all
women capable of
pregnancy
*600mcg/day folic
acidsupplementation
during pregnancy

Abbreviations: BMI, body mass index; GWG, gestational weight gain; IOM, Institute of Medicine; NICE, The National for Health and Care Excellence.

TABLE 1 (Continued)

Type Food safety Physical activity Sedentary behavior Behavioral strategies

Preconception ✓ ✓ O O
* Avoid high mercury fish (shark, Frequency: ≥ 5 days/week
swordfish, King mackerel, or tilefish) Duration: 30–60 min
* pasteurized dairy only Intensity: not specified
* wash raw foods Type: walk, swim, yoga, jog
Preconception ✓ O O ✓
* Avoid high mercury fish * Refer obese women to counseling for
behavior change
Pregnancy O ✓ O ✓
Frequency: 4 days/week *Counseling about weight
Intensity: moderate: 102–124 beats/min gain, nutrition, and food choices
(age 20–29);
101–120 beats/min (age 30–39)
Pregnancy O O O O

Pregnancy O O O O

Pregnancy O ✓ O
*Low to moderate exercise is beneficial

(Continues)
HARRISON ET AL.
TABLE 1 (Continued)

Type Food safety Physical activity Sedentary behavior Behavioral strategies

*Higher intensities may continue if
HARRISON ET AL.

practiced preconception
*Reduce intensity in third trimester
Pregnancy ✓ ✓ O O
*Pasteurized dairy only *Start/continue moderate exercise
*Wash raw foods * Start/continue pelvic floor exercise
*Avoid raw or partially cooked eggs and *Avoid sports with risk of abdominal
meat trauma, falls or joint stress
*Avoid soft ripend cheese *Avoid scuba diving
*Avoid consumption or supplementation
(>700mcg) of vitamin A
Pregnancy ✓ ✓ O O
* Avoid high mercury fish (shark, Frequency: most days
swordfish, King mackerel, or tilefish) Duration: ≥150 min/week
*Pasteurized dairy only Intensity:
*Avoid raw or partially cooked eggs and *Start/continue moderate exercise
meat *higher intensities may continue if
*Avoid soft ripened cheese practiced
*Reheat meat to steaming hot
Pregnancy ✓ ✓ O ✓
* Avoid high mercury fish (shark Duration: 150–300 min/week * Encourage self-monitoring
Marlin, broadbill/swordfish, orange Intensity: moderate of weight gain.
roughy and catfish) Type: walking, swimming, cycling
*Avoid pre-prepared fruit/vegetables *Avoid sports with risk of abdominal
*Pasteurized dairy only trauma, falls or joint stress
*Avoid raw or partially cooked eggs and *Avoid scuba diving
meat/pre-cooked meat
*Avoid soft ripened cheese
*Avoid supplementation of Vitamin A, C
and E
*Avoid routine offering of iron
supplements
*Avoid alcohol
Pregnancy O O O O

Postpartum O ✓ O O
*Mobilize with gentle exercise (non-
specific) as soon as possible following
birth
Postpartum O ✓ O O
13

(Continues)
 (Continued)
14

TABLE 1

Type Food safety Physical activity Sedentary behavior Behavioral strategies

*Encourage gentle exercise (non-specific)

Preconception, Pregnancy O O O
& Postpartum

Preconception, Pregnancy O ✓
& Postpartum Preconception:
*discuss choices
Pregnancy:
Duration: 150 min/week
Intensity: moderate
Postpartum: not provided
Preconception, Pregnancy ✓ O
& Postpartum Preconception: not provided Preconcpetion: not provided
Pregnancy: Pregnancy:
*consume foods that are thoroughly Frequency: most days Duration: 30mins
cooked Intensity: not specified
Postpartum: not provided *Avoid sports with risk of abdominal
trauma orfalls
Postpartum: not provided
Preconception, Pregnancy O ✓
& Postpartum Preconception:
*discuss choices
Pregnancy:
Frequency: daily
Duration: 30 min
Intensity: moderate
Postpartum: not provided
Preconception, Pregnancy O ✓
& Postpartum Preconception: not provided
Pregnancy:
Frequency: daily
Duration: 30 min
Intensity: moderate
Type: swimming, brisk walking, strength
based exercise
Postpartum:
*Commence walking, pelvic floor
exercises and stretching immediately
(uncomplicated delivery)
*Resume 6-8 weeks post delivery
following clearnance (complicated
deliveries)
O ✓
Preconception:
*regular self-weighing
Pregnancy:
*regular self-weighing
Postpartum:
*regular self-weighing
O O
✓ ✓
Preconception/Pregnancy/Postparum: Preconception:
Avoid sedentarism *regular self-weighing
Pregnancy: not provided
Postpartum: not provided
✓ ✓
Preconception/Pregnancy/Postpartum: Preconception:
Avoid sedentarism *Use behaviour change
techniques in women with
obesity to support weight loss
Pregnancy:
*Refer women with obesity
to nutritional counseling
Postpartum:
*Use behaviour change
techniques in women with
obesity to support weight loss
HARRISON ET AL.
TABLE 1 (Continued)

Type Food safety Physical activity Sedentary behavior Behavioral strategies

HARRISON ET AL.

Preconception, Pregnancy O ✓ ✓ O
& Postpartum
Preconception/Pregnancy/Postpartum: Pregnancy:
Frequency: ≥5 days/week *Advise importance of avoiding
Duration: ≥30 min sedentarism
Intensity: moderate *Incorporate activity into daily life rather
Type: walk than sitting where possible
Preconception& O ✓ O O
Pregnancy Preconception:
not provided
Pregnancy:
Frequency: 3–4 days/week
Duration: ≥30 min
Intensity: low intensity: 102–124 beats/
min (20–29 years); 101–120 beats/
min (30–39 years)
Type: walk, stationary cycle, water
aerobics +/or swimming
Pregnancy & O O O ✓
Postpartum Pregnancy: not provided
Postpartum:
*Weight management counseling
(motivational interviewing)
Pregnancy & ✓ O O O
Postpartum Pregnancy:
* Avoid high mercury foods
*Limit shark, marlin or swordfish to 100 g
cooked/fortnight and no other fish
that fortnight
• Limit orange roughy (deep sea perch)
or catfish, to 100 g cooked/week only
*Avoid foods with a risk of Listeria
*Avoid raw or partially cooked eggs and
meat/pre-cooked meat
*Avoid soft ripened cheese
*Pasteurized dairy only
Postpartum: not provided
Pregnancy & ✓ O O O
Postpartum Pregnancy:

(Continues)
15
16 HARRISON ET AL.

summary of the frequency and consistency of recommendations

between CPGs. Associated level of evidence against some or all
recommendations was contained within nine of 22 CPGs included in
this review.
Behavioral strategies

3.5 | Preconception

Of the two preconception CPGs, measurement of weight, height, and

body mass index (BMI, weight[kg]/height[m2]) was recommended by
both, with one recommending annual monitoring of weight for all
reproductive aged women and screening for bulimia and anorexia
nervosa in women with a “low BMI”; however, definition of low BMI
was not provided.30 Recommendations relating to prevention of
weight gain were not identified.
Guidelines for weight management varied between the two CGPs.
Abbreviations: BMI, body mass index; GWG, gestational weight gain; IOM, Institute of Medicine; NICE, The National for Health and Care Excellence.

One guideline included weight loss recommendations only for women

Sedentary behavior

with obesity (body mass index >30 kg/m2). Recommendations for

achieving this included via formal nutritional counseling with advice not
to conceive until optimal weight is achieved.30 General recommenda-
tions for physical activity for all women included 30–60 min of exercise
(i.e., yoga, brisk walking, jogging, and cycle ergometer) at least 5 days
per week.30 The other preconception care guideline included no weight,
diet, or physical activity recommendations, citing behavioral therapy
comprising goal setting, barriers, self-monitoring, and maintenance of
behavior for sustained weight loss in women with obesity only.29

3.6 | Pregnancy
Physical activity

Eight CPGs were identified that made recommendations for the man-
agement of weight during pregnancy.31–38 Two CPGs were developed
specifically for obesity in pregnancy, one for adults with obesity, in
which pregnancy was a sub-component of the guideline and one for
adolescence with the remaining four providing recommendations for
*Avoid raw or partially cooked eggs and

general pregnancy care.

All guidelines included recommendations for the management of
*Reheat meat/luncheon meat to

weight during pregnancy, with the exception of one guideline for

*Avoid soft ripened cheese

adolescent care during pregnancy.35 Of the eight CPGs identified,

Postpartum: not provided
*Pasteurized dairy only

five recommended weight, height, and BMI measurement, most at

*Avoid raw sprouts

the first antenatal appointment to enable recommendations for

steaming hot

GWG and counsel on increased risks. Three endorsed recommenda-

Food safety

tions for GWG based on current Institute of Medicine (IOM)

meat

recommendations,33,34,37 one provided cited recommendations

inconsistent with IOM recommendations,51 one provided uncited
recommendations,38 and three provided no recommendations for
(Continued)

GWG management or referred to any GWG thresholds.31,32,35

Recommendations for weight related behaviors, including
diet, physical activity, and behavioral strategies were evaluated. Seven
of the eight CPGs identified provided dietary guidance during
TABLE 1

pregnancy, which varied substantially. The most consistent

Type

recommendations, provided in four guidelines, included folic acid

supplementation, however dose varied31–33,37 and a further four
TABLE 2 AGREE II quality appraisal and intraclass correlation (ICC) scores
HARRISON ET AL.

(1) Scope (2) Stakeholder (3) Rigor of (4) Clarity of (6) Editorial
and purpose involvement development presentation (5) Applicability independence Overall Overall
Target population Guideline (%) (%) (%) (%) (%) (%) quality ICC score
Preconception Berghella et al. Year: 2010 75.93 44.44 22.92 33.33 19.44 58.33 Poor 0.907
Gavin et al. 77.78 53.70 40.28 40.74 31.94 22.22 Poor 0.833
Year: 2014
Pregnancy Davies et al. 61.11 25.93 33.33 59.26 18.06 13.89 Poor 0.833
Year: 2018
Denison et al. 66.67 37.04 62.50 77.78 26.39 25.00 Moderate 0.856
Year: 2018
Fleming et al. Year: 2015 75.93 38.89 42.36 57.41 12.50 33.33 Poor 0.879
National Health and Medical 96.30 87.04 83.33 72.22 61.11 72.22 High 0.768
Research Council.
Year: 2013
National Institute for Health and 85.19 79.63 71.53 64.81 47.22 58.33 Moderate 0.790
Care Excellence
Year: 2008
Kaiser et al. 2014 55.56 31.48 11.11 51.85 25.00 0.00 Poor 0.832
National Health & Medical Research 88.89 83.33 74.31 75.93 52.78 83.33 High 0.712
Council Year: 2018
Gyselaers et al Year: 2015 87.04 79.63 82.64 70.37 55.56 72.22 High 0.823
Postpartum World Health Organization. Year: 92.60 61.11 65.28 48.15 31.95 52.78 Moderate 0.758
2013
National Institute for Health and 92.59 74.07 64.58 51.85 50.00 55.56 Moderate 0.723
Care Excellence
Year: 2006
Preconception, Gonzales-Campoy et al. Year: 2013 68.52 35.19 40.97 74.07 41.67 30.56 Poor 0.832
pregnancy and Carr et al. 79.63 48.15 18.75 48.15 36.11 5.56 Poor 0.863
postpartum Year: 2014
Musaiger et al. Year: 2012 55.56 18.52 8.33 57.41 11.11 0 Poor 0.879
Hanson et al. Year: 2015 57.41 46.30 15.97 66.67 37.5 86.11 Poor 0.874
National Institute for Health and 90.74 87.04 81.25 70.37 58.33 19.44 Moderate 0.759
Clinical Excellence. Year: 2010
National Institute for Health and 87.04 85.19 86.81 75.93 63.89 16.67 High 0.861
Clinical Excellence. Year: 2008

(Continues)
17
18 HARRISON ET AL.

recommending nutritional assessment or counseling to guide weight

ICC score
change during pregnancy; however, description of the content and

Overall

0.920

0.944

0.744

0.801
tools or resources, if any, to guide assessment was not provided.35–37
Three guidelines provided considerations for the preparation of foods
to avoid listeriosis as well as consideration of the consumption of fish

Moderate

Moderate
Overall
quality
and seafood due to methyl mercury levels.32,33,37 One CPG provided

Poor
High
specific guidance for energy intake requirements according to BMI as
well as macronutrient composition recommendations for multiple
independence

pregnancies.37 Detailed information about macronutrient and micro-

(6) Editorial

nutrient intake in accordance to local dietary guidelines was provided

30.56

38.89

38.89

36.11
by two CPGs.33,37 Wider considerations in the context of healthy
(%)

nutritional intake including health literacy, cultural considerations,

varying dietary practices (e.g., gluten free and vegetarian diets), and
(5) Applicability

economic constraints were provided in one CPG.37

Five guidelines made recommendations for physical activity
18.06

19.44

72.22

48.61

during pregnancy32–34,36,37 with most emphasizing the safety of exer-

(%)

cise during pregnancy and lack of association with adverse outcomes,

presentation

while three guidelines provided no recommendations during preg-

(4) Clarity of

nancy.31,35,38 Of those guidelines advising exercise, recommendations

72.22

79.63

81.48

59.26

varied. Three guidelines endorsed population guidelines including at

(%)

least 150 min of moderate physical activity per week, or activity on

most days of the week,33,36,37 while the remaining guidelines advised
development
(3) Rigor of

on intensity only. All recommended low-moderate intensity with four

66.67

63.89

79.86

57.64

guidelines recommending that high intensity and/or resistance based

(%)

exercise could be continued if previously undertaken prior to concep-

tion. Definitions for exercise intensity were not provided, with the
Note: High quality = 5 or 6 domain >60%; moderate quality = 3 or 4 > 60%; poor quality = 2 or fewer >60%.
(2) Stakeholder

exception of one guideline, developed for obesity in pregnancy,

involvement

providing target heart rate zones for moderate intensity exercise.36

Behavioral strategies for weight management were not contained
42.59

46.29

79.63

77.78

within standalone sections and rather identified within weight,

(%)

dietary, and physical activity guidance. Two guidelines each included

and purpose

one recommendation, including encouragement of self-monitoring of

(1) Scope

weight33 and unspecified counseling for GWG and nutrition.36

77.78

79.63

88.89

79.63
(%)

3.7 | Postpartum
US Dept of Health & Human Services/
National Health & Medical Research

US Dept of Agriculture. Year: 2015

Two guidelines developed specifically for postpartum care were

identified.39,40 Neither guideline provided specific recommendations
for weight management or related healthy weight behaviors during
postpartum. Guidelines tended to focus on regular physical activity in
the context of fatigue, recovery, and overall maternal wellbeing.
Maxwell et al.

Maxwell et al.

Year: 2013
Council.
Year: 2019

Year: 2019

Recommendations for postpartum nutrition were non-specific, with

Guideline

the WHO recommending nutritional assessment without purpose and

NICE recommending advice on the importance of diet postpartum
and on the intake of high fiber-rich foods and adequate intake of
(Continued)

Pregnancy & Postpartum

water in the week following birth.

Target population
Preconception &
Pregnancy

3.8 | Combined guidelines

TABLE 2

Ten CPGs were identified that made recommendations across two or

more of preconception, pregnancy, and postpartum, including six
HARRISON ET AL.
guidelines focused on nutrition,37,41,44,46,48,49 two focused on weight
management42,45 and two focused on care in women with
47,50
obesity.
Six guidelines made recommendations about weight
management despite the focus of the majority being nutrition. The
majority of nutrition focused guidelines provided non-specific recom-
mendations for preconception weight management including encour-
agement of weight loss prior to conception.44,49 One guideline 43
recommended at least 5–10% weight loss in women with obesity for
fertility benefits achieved via a structured diet, exercise, and behavior
change program with ongoing support for enhanced sustainability
long term. The two guidelines focused on weight management pro-
vided more detailed recommendations including regular monitoring of
weight prior to pregnancy in all women with45 or without42 BMI mea-
surement as part of a preconception clinical practice. Both guidelines
recommended health professionals encourage weight loss prior to
conception in women with obesity as well as self-empowerment of
women via reputable information seeking42,45 or understanding their
social determinants and socioeconomic circumstance in the context of
weight management. Professional skill building for weight manage-
ment and discussion of the risks associated with excess weight before,
during, and after pregnancy was recommended in one CGP.42
Similarly, recommendations for weight management during preg-
nancy in non-weight management focused guidelines were brief and
generic including establishment of BMI,43 regular self-monitoring,46 or
health professional management of GWG during pregnancy (both die-
48
tary guidelines) or advised GWG that was steady or within the IOM
guidelines.48,49 Both weight management guidelines42,45 rec-
ommended BMI measurement as a component of early antenatal care
yet provided differing recommendations on routine monitoring of
GWG (frequent and non-frequent monitoring) and endorsement of
IOM guidelines for GWG (endorsed or not endorsed). Additional con-
siderations for women with obesity included dietetics referral for
additional dietary support.42
Fewer recommendations for postpartum weight management
existed and varied between three available guidelines. While all advo-
cated for weight loss in the postpartum period, the first guideline rec-
ommended diet composition be non-restrictive,46 while both weight
management guidelines recommended healthy eating, regular physical
activity, and breastfeeding as strategies for minimizing weight reten-
tion as well as weight loss between pregnancies for long-term
health.42,45
Weight-related behaviors including diet, physical activity, and
behavioral recommendations varied across combined CPGs. All guide-
lines provided recommendations for dietary intake across at least one
life-stage and, in general, emphasized the importance of healthy nutri-
tion for the benefit of mother and child with or without specific
recommendations. The most consistent dietary recommendation was
intake of folate or supplementation of folic acid generally in
preparation for, and during pregnancy, recommended in eight
41–44,46–49
guidelines, with six providing specific guidance of
400 mcg/day in preconception and/or pregnancy.41,43,44,47–49 Intake
of iron-rich foods was recommended in three guidelines, especially
19
during pregnancy,46,48,49 while considerations of additional micro-
nutrients including Vitamin B12 for vegetarians/vegans was rec-
ommended in one CGP.48 Recommendations for caffeine intake
during pregnancy were provided in two guidelines, with both rec-
ommending limitation to 300 mg/day,44,48 with a third recommending
consultation with a health professional regarding intake.49 Adjustment
to energy intake during pregnancy was recommended in three guide-
lines and all differed, with one recommending an extra 1,673 kJ/day
(350–450 kCal/day) from the second trimester,41 the second rec-
ommending no change in the first 6 months of pregnancy with a minor
increase only slightly in the last 3 months of 836 kJ/day
(200 kCal/day42), and the third acknowledging increased energy
requirements during pregnancy but with no specific range provided in
the guideline.48 Consideration of food hygiene and foodborne illnesses
during pregnancy was addressed in a minority of guidelines with three
emphasizing the increased risk of listeriosis and salmonella infection
during pregnancy and the need for adequate preparation and cooking
of foods as well as high risk foods to avoid.46,48,49 Methyl mercury
intake during pregnancy and breastfeeding was addressed in two
guidelines48,49 with one guideline providing specific information about
the types and recommended amounts of seafood for consumption.48
More consistency was observed for physical activity guidance.
Preconception recommendations were provided in one guideline rec-
ommending 30 min of moderate intensity physical activity at least
5 days per week.43 During pregnancy, six CPGs all recommended
30 min of moderate intensity physical activity on most or all days,
including during pregnancy providing activities are safe (e.g., walking
and swimming).41–43,45,46 The remaining three guidelines did not pro-
vide physical activity recommendations.
Behavioral strategies were recommended in four guidelines, of
which two specifically focused on weight management during precon-
ception, pregnancy, and postpartum. Recommendations varied
between individual versus health professional approaches. Individual
approaches included regular self-monitoring of weight 41,45
provided
in two guidelines and use of behavior change techniques to promote
weight loss.42 One guideline advised on professional upskilling for use
of behavioral strategies, including knowledge in behavior change and
ability to work with patients to devise an action plan, make changes,
and review changes for improved sustainable change.42
4 | DI SCU SSION
This systematic review aimed to comprehensively evaluate CPGs for
recommendations encompassing weight management and weight-
related behaviors (diet, physical activity, and behavior strategies)
across preconception, pregnancy, and postpartum to inform care and
identify areas where gaps exist. Twenty-two CPGs met our inclusion
criteria, with the majority focusing on pregnancy (n = 8) or across the
continuum of preconception, pregnancy, and/or postpartum (n = 10).
The majority (45%) of guidelines were poor quality, with just 23%
classified as high quality. Specifically, standalone guidelines containing
weight and weight related behavior recommendations for
20
preconception and postpartum were lacking and of those identified,
all were appraised as low to moderate quality. Overall, of recommen-
dations evaluated, the most common centered around evaluation of
weight and BMI across preconception, pregnancy, and postpartum.
Accompanying recommendations for diet, physical activity and behav-
ioral strategies tended to be non-specific and highly variable between
guidelines. Our results highlight the need for the development of
evidence-based, high-quality guidelines with definitive recommenda-
tions for guiding supportive care for women across preconception,
pregnancy, and postpartum.
Health, particularly in the 3 months prior to conception, is
critical for multigenerational health outcomes for women and their
offspring.52 Our review identified nine CPGs with weight and
weight-related recommendations for preconception health. The most
consistent recommendation, found in four guidelines, advised weight
loss prior to pregnancy in women with a BMI > 30 kg/m2. Yet most
were unspecific in amount advised and how weight loss could be
achieved, with just one explicitly recommending 5–10% weight loss
and three advising “nutritional” counseling. Our previous systematic
review revealed an absence of published research on preconception
lifestyle interventions aimed at improving maternal and neonatal
outcomes with the optimal amount of weight loss for associated
24
outcomes remaining unclear. This impacts on knowledge and pro-
vision of adequate preconception care related to weight and related
healthy behaviors by primary healthcare providers, and indeed, this
was reported as a primary barrier to preconception care in a recent
53
systematic review. This underscores the critical need for robust,
high-quality efficacy-based research to address these vital knowl-
edge gaps in optimizing the health of women prior to pregnancy
and, in turn, inform future preconception CPGs. Future CPGs for
preconception health would be enhanced by broad stakeholder
engagement to provide opportunity to delineate responsibilities
across medical specialities and enable guidance that is broadly
applicable54 given women are not regularly engaged with a
55
healthcare system preconception and may seek care from a
variety of healthcare providers. This is also relevant for reproductive
aged women more broadly, given optimizing weight and weight-
related behaviors are relevant for all women who have the potential
to conceive, and therefore, raising awareness generally is imperative
from a public health perspective.
Optimized weight gain during pregnancy is prioritized by several
leading organizations, including The World Health Organization, as
critical strategies to arrest accelerated obesity development in repro-
ductive aged women. Definitive research published in JAMA of over
1 million pregnancies supports the application of IOM guidelines with
70% of women gaining outside of GWG recommendations relative to
BMI increasing risk of adverse maternal and infant, compared with
GWG within guidelines.8 Previous meta-analyses demonstrate clear
benefit in optimizing GWG with antenatal lifestyle interventions
resulting in a 1.1 kg (95% CI 1.46 to 0.74 kg) reduction in weight
and an associated 11% and 24% reduction in the odds of developing
cesarean section (0.89 and 0.83 to 0.96) and gestational diabetes
(0.76 and 0.65 to 0.89) respectively, independent of BMI, age, parity,
HARRISON ET AL.
ethnicity, pre-existing medical conditions, or intervention sub-type
(i.e., diet, physical activity, mixed, or other).56 Recent cost-effective-
ness analysis supports the implementation of low-intensity lifestyle
intervention within antenatal clinical care to optimize GWG. Com-
pared with usual care, associated costs were estimated to be close to
neutral, with an incremental cost effectiveness ratio of 1,500 AUD
per case of either GDM, hypertensive disorders of pregnancy or both,
prevented.57 Yet, despite the availability of high-quality evidence, rec-
ommendations for monitoring, and subsequent management, of GWG
varied throughout CPGs. In 18 CPGs identified, just seven CPGs
endorsed current 2009 IOM recommendations for GWG. Of those,
only two provided guidance on frequency of GWG monitoring with
advocacy for management of GWG as part of routine antenatal care.
For GWG recommendations to be successfully applied in clinical set-
tings, regular monitoring of GWG must occur. Routine monitoring of
GWG appears to be acceptable to both midwives and women in ante-
natal settings58; however, evidence shows monitoring with or without
brief advice is not adequate and additional dedicated intervention and
support are required to modify behaviors that influence weight gain,
including diet and physical activity.59,60 The majority of CPGs pro-
vided little or no physical activity or dietary guidance and none pro-
vided guidance on tailoring individual requirements if GWG is
inadequate. This is consistent with previous research reporting inade-
quacy of training and education to support women to achieve a
healthy GWG during pregnancy, as well as strategies to resolve sensi-
tivities associated with weight stigma.61 Improving applicability and
rigor of development within CPGs for pregnancy, two of the poorest
performing domains identified here, is essential in ensuring the best
available evidence is used to inform recommendations to be
implemented into routine clinical care. Resolving barriers that prevent
routine GWG monitoring as well as strategies to integrate interven-
tions to optimize GWG in standard antenatal care will strengthen
implementation initiatives required to accelerate the translation of
evidence into practice.
Postpartum and inter-conception provide an opportunity to
follow up and support women with targeted interventions to optimize
health following childbirth and between pregnancies. Our review
identified eleven CPG with recommendations for postpartum
health, with approximately half appraised as poor quality overall.
Recommendations varied across guidelines, potentially corresponding
with significant variation in quality scoring across AGREE II domains.
The most consistent recommendations centered around weight loss
following pregnancy in women with obesity through to implementing
unspecified diet, physical activity, and behavioral strategies, provided
in three guidelines. Postpartum is a critical period for accelerated
weight gain in women,62,63 with engagement in healthy diet and
physical activity behaviors difficult due to an increase in barriers
centered around the focus on the infant and child well-being, time
pressures, and increased stressors related to managing home, work,
and family balance.64 Provision of adequate postpartum care including
early identification of care providers, clear objectives that address
women's needs such as a reproductive life plan, a weight management
plan, and linking in with services for the inter-conception period is
HARRISON ET AL.
therefore key in ensuring women do not become siloed during this
life-stage and are adequately supported.
Similar to preconception, dietary and physical activity guidance
should reflect guidelines for adult populations, yet with specific con-
siderations for the postpartum period. For example, these include
minor increases to energy intake to offset caloric requirements for the
production of breast milk as well as adequate nutrition to support
breastfeeding. Physical activity guidance could consider changes due
to ligament laxity, cesarean section, and urinary incontinence. How-
ever, we only identified one CPG providing clear guidance on physical
43
activity, little guidance for caloric requirement changes required
with breastfeeding, and no recommendations for weight gain preven-
tion. Variable recommendations also existed with one guideline
recommending no change to dietary intake during breastfeeding, one
guideline providing only variation for serving sizes and one guideline
recommending increased, but unspecific dietary intake to meet
breastfeeding needs. This is reflected with the AGREE II scores for
clarity of presentation and applicability into practice being the
weakest scored domains in postpartum specific guidelines. Indeed,
ambiguity in recommendations, potentially translating to ambiguity in
care, is reflected in previous research. This is supported by many
women postpartum reporting not having their information needs met
65
for healthy eating and physical activity advice. Furthermore, services
for postpartum care are more likely to be fragmented between
obstetric, primary care, and maternal child health care. This may
impact on health provider perspectives, information provision, and
clarity of role responsibility.
To our knowledge, this is the first systematic review and
independent quality appraisal of clinical practice guidelines
encompassing weight management and weight-related behaviors
across preconception, pregnancy, and postpartum. We utilized a
robust search strategy focused on clinical practice guidelines specifi-
cally and included guidelines published from 2010, to increase the
timeframe of our search and carried forward updated guidelines
where available. General consensus recommendations include
updating guidelines every 3–6 years66 as well as a transparent plan
for updating of guidelines, especially in high growth content
areas.67,68 We note the majority (54.5%) of included guidelines were
published prior to 2015 and had not been updated. Limitations
include CPGs published in English only, preventing identification of
additional CPGs published in other languages. Our search was inter-
national in scope and not limited to specific regions, as previously
69
reported ; however, it is possible we did not detect all available
CPGs as we did not search countries individually. We extracted
information about the strength of evidence against recommenda-
tions, yet as this was variably reported, the authorship group chose
not conduct further evaluation.
Preconception, pregnancy, and postpartum are high-risk life
stages, associated with accelerated weight gain, which adversely
impacts the health of mothers and the next generation. With
increased engagement with health providers for maternal and child
health, these stages represent opportunities for health providers to
support women to optimize health behaviors and weight for improved
21
clinical and inter-generational health outcomes. In this context, we
have identified and appraised the quality of available guidelines inter-
nationally, on weight management and associated modifiable health
behaviors at these life stages. Most guidelines require updating, and
there is substantial variation in recommendations and quality of exis-
ting guidelines, with the majority inadequate in considering the quality
of evidence against the recommendations made. We report limited
preconception and postpartum guidance for health behaviors and
weight optimization. A high level of ambiguity in existing guidance
and an absence of important considerations, including targeting
weight gain prevention and limiting excess gestational weight gain as
well as practical guidance for practitioners on how to address this
during routine care, was evident. These results emphasize the need
for development of contemporary, robust, comprehensive, and
high-quality guidelines on weight management and related health
behaviors across these key reproductive life stages, to improve the
health of women and their families.
ACKNOWLEDG MENTS
CH, HT, & JAB conceptualized the project as a deliverable of
the National Health and Medical Research Council Translation Faculty
Case for Obesity Action (available at: www.nhmrc.gov.au/research/
research-translation/research-translation-faculty/ideas-research-
translation-faculty-cases). NNK and LM designed the search strategy
and data extraction methods. NNK and AC extracted the data
independently with a third reviewer engaged if discrepancies were
noted (LM). LM, NNK, and SL independently appraised all guidelines.
CH synthesised the results and drafted the manuscript. All authors
reviewed the manuscript for intellectual content and approved the
final version.
FUNDING INF ORMATI ON
The funding body had no role in the study design, data collection,
data analysis, data interpretation, or writing of the report. The
corresponding author had full access to all the data in the study and
had the final responsibility for the decision to submit for publication.
CLH is funded by a Senior Postdoctoral Fellowship from the NHMRC
Centre for Research Excellence for Health in Preconception and
Pregnancy (CRE-HiPP; APP1171142). HJT is funded by an NHMRC
fellowship funded by the Medical Research Future Fund, and JB is
also funded by an NHMRC fellowship. LM is funded by a Heart
Foundation Future Leader Fellowship. CLH and HJT acknowledge
project funding support of the NHMRC Impact Diabetes B2B
(Bump2Baby and Me) project (GNT1194234).
CONFLIC T OF INT ER E ST
The authors report no conflict of interest.
OR CID
Cheryce L. Harrison https://orcid.org/0000-0002-3154-4946
Helena Teede https://orcid.org/0000-0001-7609-577X
Siew Lim https://orcid.org/0000-0002-5333-6451
Sheila Drakeley https://orcid.org/0000-0002-3779-2377
22
Lisa Moran https://orcid.org/0000-0001-5772-6484
Jacqueline Boyle https://orcid.org/0000-0002-3616-1637
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SUPPORTING INF ORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Harrison CL, Teede H, Khan N, et al.
Weight management across preconception, pregnancy, and
postpartum: A systematic review and quality appraisal of
international clinical practice guidelines. Obesity Reviews.
2021;1–23. https://doi.org/10.1111/obr.13310