Obesity is now reaching epidemic proportions in both developed and developing countries and is affecting not only adults but also children and adolescents. Over the last 20 years, obesity has become the most prevalent nutritional problem in the world, eclipsing undernutrition and infectious disease

https://www.cmaj.ca/content/cmaj/176/8/S1.full.pdf

2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]

Background
Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress.

The effects of stress on physical activity and exercise.

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

State of the Evidence Regarding Behavior Change Theories and Strategies in Nutrition Counseling to Facilitate Health and Food Behavior Change

Background Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. Objectives The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. Search strategy We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006) and LILACS. We scanned secondary references and contacted experts in the field. Selection criteria All published and unpublished randomised controlled trials (RCT) and quasi-randomised trials of diet or exercise or both, among women during the postpartum period. Data collection and analysis Three review authors independently assessed trial quality and extracted data. Results are presented using relative risk for categorical data and weighted mean difference (WMD) for continuous data. Data were analysed with a fixed-effect model. A random-effects model was used in the presence of heterogeneity. Main results Six trials involving 245 women were included. Women who exercised did not lose significantly more weight than women in the usual care group (one trial; n = 33; WMD 0.00 kg; 95% confidence interval (CI) -8.63 to 8.63). Women who took part in a diet (one trial; n = 45; WMD -1.70 kg; 95% CI -2.08 to -1.32), or diet plus exercise programme (four trials; n = 169; WMD -2.89 kg; 95% CI -4.83 to -0.95), lost significantly more weight than women in the usual care. There was no difference in the magnitude of weight loss between diet and diet plus exercise group (one trial; n = 43; WMD 0.30 kg; 95% CI -0.60 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. Authors' conclusions Preliminary evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat-free mass, while diet alone reduces fat-free mass. This needs confirmation in large trials. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby.

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Diet or exercise, or both, for weight reduction in women after childbirth

Low-income women who are overweight and obese are at high risk for long-term retention of weight gain during pregnancy, in part because they may have poor diets and inadequate physical activity, both of which may be exacerbated by stressful situations. This study identified motivators and barriers to healthful eating and physical activity among low-income overweight and obese non-Hispanic black and non-Hispanic white mothers. Qualitative data were collected via eight focus group interviews. Eighty low-income overweight and obese non-Hispanic black (n=41) and non-Hispanic white (n=39) mothers, age 18 to 35 years, were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children sites in six counties in Michigan. Personal appearance, fit in clothes, inability to play with their children, and social support were motivating factors for healthful eating and physical activity. Stressful experiences triggered emotional eating and reduced participants' ability to practice these behaviors. Other factors—for example, wanting quick weight-loss results—made it difficult for these mothers to follow recommended healthful lifestyle practices. Nutrition educators can address these concerns by including information about ways to deal with stress and emotional eating and emphasizing the benefits of healthful eating and physical activity in their program plans.

Motivators and Barriers to Healthful Eating and Physical Activity among Low-Income Overweight and Obese Mothers

Objective This study examined factors related to stages of change for weight-management behaviors in postpartum women. Design Cross-sectional data, collected at baseline, are reported from the Mothers' Overweight Management Study (MOMS), a randomized, controlled trial conducted in postpartum women who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Subjects/Setting Subjects were a sample of WIC recipients (N=151) older than 18 years of age with a child younger than 2 years. Statistical analysis The dependent variables were the stages of change for weight-management behaviors (losing weight, avoiding high-fat foods, eating a high-fiber diet, and exercising). Demographic, health, and psychosocial variables were examined as independent variables. One-way analysis of variance was used to compare means, and χ 2 was used for proportions. Results Whereas 55% of women were in the action stage for weight loss, fewer women were in the action stage for the following weight management behaviors: avoiding high-fat foods (24%), increasing fiber (19%), and exercising three times per week (29%). Identifying pros for weight management was related to stages for losing weight, high-fat food avoidance, and exercise (F=13.4, P P P 2 =16.4, P =.003; χ 2 =11.7, P =.02). Conclusions Emphasizing the pros for weight-management behaviors, decreasing the cons for exercising, increasing confidence to select low-fat restaurant choices, and improving skills for using food labels are four strategies that nutrition professionals can use to help women become more ready to change behaviors for weight management.

Elizabeth Semmens

Papers

Stages of change for weight management in postpartum women

Lessons learned from the mothers' overweight management study in 4 West Virginia WIC offices.