ReviewObesity and anxiety during pregnancy and postpartum: A systematic review
Introduction
Obesity is increasingly common among women of reproductive age (Callaway et al., 2006, Ehrenberg et al., 2002, Vahratian, 2009). Depending on studied cohorts, prevalence rates of women who enter pregnancy obese vary from 7% to 38.5% (Briese et al., 2011, Callaway et al., 2006, Catalano and Ehrenberg, 2006, Guelinckx et al., 2008, Kerrigan and Kingdon, 2010, Kim et al., 2007, Raatikainen et al., 2006). Furthermore, childbearing contributes to the long-term development of obesity (Davies et al., 2010; Williamson et al., 1994). Excessive gestational weight gain (GWG) and postpartum weight retention (PPWR) have been discussed as important contributing factors (Gore et al., 2003, Siega-Riz et al., 2004). Excessive GWG, defined as weight gain in excess of the recommendations by the Institute of Medicine (IOM) (Institute of Medicine, 2009), is common with prevalence rates ranging from 33% to 60% (Hill et al., 2013, Olson, 2008, Webb et al., 2009). The physical health consequences of pregnancy obesity and excessive GWG are well documented. Pregnancy obesity is associated with an increased risk of perinatal and postnatal complications (e.g., gestational diabetes, preeclampsia, miscarriage (Frederick et al., 2012, Heslehurst et al., 2008, Raatikainen et al., 2006), preterm birth (Syngelaki et al., 2011)), medical complications in neonates (Blomberg and Källén, 2010, Catalano and Ehrenberg, 2006), and a higher risk of childhood obesity (Sen et al., 2012, Sullivan et al., 2011). Excessive GWG has been shown to be associated with increased birth weight and fetal growth (Siega-Riz et al., 2009) as well as childhood overweight (Nehring et al., 2013). Furthermore there is evidence that maternal obesity and high fat diet consumption during pregnancy also increase offspring vulnerability for mental or behavioral disorders (Sullivan et al., 2014, Sullivan et al., 2011). High PPWR refers to a failure to lose pregnancy-related weight after delivery. Therefore it contributes to the development of obesity among women in the childbearing age and inter-pregnancy weight gain (Bogaerts et al., 2014). It has also been found to be an important predictor of obesity in midlife (Rooney et al., 2005). If a woman is already obese at the start of pregnancy, excessive GWG and PPWR may maintain or even exacerbate obesity after delivery (Vesco et al., 2009). Thus, health problems associated with obesity may develop or persist after delivery (Abrams et al., 2000, Olson, 2008). While most research has focused on the physical health consequences of pregnancy obesity, less has been learned about mental health among obese pregnant women.
Mental disorders during pregnancy are common (Andersson et al., 2003, Vesga-López et al., 2008). A population-based Swedish study found a point prevalence of 14.1% for psychiatric disorders in the second trimester (Andersson et al., 2003). While to date, most research has been conducted in the field of pre- and postnatal depression (Grigoriadis et al., 2013, Vliegen et al., 2014), less is known about anxiety during pregnancy (Andersson et al., 2006). Prevalence rates vary depending on the explicit time of the interview during pregnancy and the cohort studied (Goodman et al., 2014a, Ross and McLean, 2006). Goodman et al., 2014a, Goodman et al., 2014b identified prevalence rates of anxiety disorders during pregnancy ranging from 4.4% to 39%. A large U.S. study based on a national survey among women with a known current or past-year pregnancy, reports a 12-month prevalence of 13% for anxiety disorders according to DSM-IV (Vesga-López et al., 2008). Symptomatic expressions of mental disorders are more common. In a prospective study by Lee et al. (2007), 54% exhibited antenatal anxiety in at least one trimester. Anxiety during pregnancy, measured on a symptom or diagnostic level, is associated with adverse effects on maternal and child health. It is associated with an increased risk of preterm birth, low birth weight (Ding et al., 2014, Martini et al., 2010), and shorter birth length (Broekman et al., 2014, Hosseini et al., 2009). It may also have an impact on fetal neurodevelopment influencing the child's cognitive and temperamental development (Dunkel Schetter and Tanner, 2012, Petzoldt et al., 2014) as well as negatively influence the bonding between mother and child (Martini et al., 2015). Furthermore, there is consistent evidence that prenatal anxiety disorders increase the risk for postpartum depression (Goodman et al., 2014a, Milgrom et al., 2008, Skouteris et al., 2009).
Studies from the general population provide evidence for a positive association between obesity and anxiety disorders (Barry et al., 2008, Becker et al., 2001, Gariepy et al., 2010, Petry et al., 2008, Zhao et al., 2009). Despite the fact that pregnant women can be considered a special risk group, due to the particular risks associated with anxiety disorders and obesity during pregnancy, only little research has been conducted on this association among this group. A first indication for a positive association between pregnancy obesity and antenatal mental health problems, including anxiety, comes from Molyneaux et al. (2014). It remains unknown, however, if excessive GWG or PPWR – factors contributing to the long-term development of obesity after pregnancy – are associated with anxiety during pregnancy or postpartum. Furthermore, little information about associations between maternal weight and postpartum anxiety is available.
The aim of our systematic review was to draw a more detailed picture of the complex association between anxiety and maternal obesity across several stages during the perinatal period. Specifically, we aimed to (1) provide an extended overview of the association between pregnancy obesity and anxiety during pregnancy or postpartum, (2) examine associations between excessive GWG and ante- or postnatal anxiety, (3) examine associations between PPWR and ante- or postnatal anxiety, and (4) describe the effects of weight gain restriction and lifestyle programs during pregnancy on anxiety.
Section snippets
Data sources
We conducted a systematic literature search for papers published between January 1990 and December 2014 in PubMed/Medline, PsychInfo, and Web of Science using the following search string:
(obes* OR overweight OR body mass index OR BMI OR body size OR adipos* OR waist circumference OR weight gain OR gestational weight gain OR weight retention OR GWG OR PPWR) AND (pregnan* OR prenatal OR antenatal OR postnatal OR postpartum) AND (anx* OR anxiety disorder OR phobia OR panic disorder). Search limits
Description of included studies
The literature search revealed 671 publications of which 238 were duplicates and were removed. The first two authors screened titles and abstracts of 435 records. Of these, 369 records did not meet the selection criteria. The remaining 66 publications were screened full-text. This process ultimately left 13 records for review (Fig. 1). Table 1, Table 2, Table 3 provide an overview of the included studies according to our research questions.
To our knowledge, the 13 records were based on eight
Discussion
We aimed to describe and critically discuss the current state of evidence concerning the association between pregnancy obesity and anxiety. Furthermore we aimed to give an initial overview of associations between anxiety and excessive GWG and PPWR, which can be considered important factors contributing to long-term obesity after pregnancy (Bogaerts et al., 2014, Rooney et al., 2005). Overall, 13 studies were included. Despite the limited number and heterogeneity of the included studies, this
Role of the funding source
There was no sponsor involved in planning or writing this review article.
Conflicts of interest
Prof. Stepan reports the following items that might be perceived as potential conflict of interest: Consultancy for Roche Diagnostics. All other authors declare that they have no competing interests.
Author contributions
MN planned the review, conducted the systematic literature search, screened the literature, extracted the data and wrote the manuscript. KL independently conducted a literature search, screened the literature, assisted in the data extraction process and critically reviewed the manuscript. HS took part in planning the review, interpreting the results and critically reviewed the manuscript. AK took part in planning of the review and the literature search, in interpreting the data and critically
Acknowledgments
None.
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