RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

PERFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. / Name of the candidate and address / Ms.Sreedevi Krishnan
1st year M.Sc(N)
Florence College of Nursing
Bangalore-43.
2. / Name of the Institution / Florence College of Nursing
3. / Course of study and subject / M.Sc Nursing
Obstetrics & Gynecological Nursing.
4. / Date of admission to the course / 04-10-2011
5. / Title of the topic / “Evaluate the effectiveness of structured teaching programme on “prevention of obesity during postnatal period” among antenatal mothers at selected hospitals, Bangalore.”

6. BRIEF RESUME OF INDENTED WORK:

INTRODUCTION

“A stitch in time saves nine”

Pregnancy is a unique, exciting and often joyous time in a woman's life. It highlights the woman's amazing creative and nurturing powers while providing a bridge to the future. Majority of pregnancies and deliveries are normal and results in a healthy mother and a healthy baby. Pregnancy is filled with physical changes and emotional changes. Hence it can be an intense time in the life of an expecting mother.1

Numerous anecdotal, cross sectional and longitudinal studies suggest that childbearing may be an important contributing factor for excessive weight gain. Factors that may predict development of obesity in later life mainly include gestational weight gain, pre pregnancy nutritional status, age, parity, race, change in life style factors, such as eating habits, less physical activity, smoking, and duration of lactation. Obesity has progressively become a global epidemic that constitutes one of the biggest current health problems worldwide. Pregnancy is a risk factor for excessive weight gain.2

WHO has defined obesity as a ‘condition of abnormal or excessive fat accumulation in adipose tissue to the extent that health may be impaired. Obesity is not equivalent to overweight. Obesity denotes excessive body fat whereas, overweight relates to fat or tissues in excess with relation to height. Studies have shown that obesity has killed more people than ‘AIDS’.3

Cultural and social eating patterns have an important role in weight gain. Some cultures consider plumpness as a sign of health and obesity as evidence of well-being. In other cultures obesity is a status symbol or an indication of affluence. Psychological factors also affect eating patterns.4

The existing concept regarding antenatal care is that pregnant women should eat food for two. The other reason for improper diet is “craving”. Some studies states that craving is healthy way of compensating the deficiencies of mother’s body. But craving for junk food, high calorie food and chocolates are risk factors for gestational weight gain. But recent studies have shown that antenatal dietary interventions in obese pregnant women can reduce maternal weight gain in pregnancy without any effect on newborn birth weight. Dietary advice during pregnancy appears effective in decreasing total gestational weight gain and long term postpartum weight retention.5The other common practice among antenatal mothers is taking rest to conserve energy for delivery. Sleep is essential for antenatal mother. But longer duration of sleep also will lead to the development of excess weight gain.6

The postpartum period is a very special phase in the life of a woman. Postnatal period starts soon after delivery till 6 weeks. Women’s body needs to heal and recover from pregnancy and childbirth. A good postpartum care and well balanced diet during the puerperal period is very important for her health. Several studies indicated that the incidences of postpartum health problems are high and these problems may be have relation to traditional and unscientific dietary and behavior practices in the postpartum period.7Breastfeeding had proven to reduce the gestational weight gain. It is estimated to increase daily energy expenditure by approximately 500 kcal and thus helps the mother to recover from gained weight.8

Taking into consideration the epidemic of obesity, with all its adverse long-term consequences, there is an increasing need to promote counseling before, during and after pregnancy on the role of diet and physical activity in reproductive health.2 Nurses play a key role in the adherence and maintenance phases of weight reduction programmes. Thus it is the responsibility of health care professionals to strongly encourage antenatal women to enroll in a structured teaching programme. Health education can bring about changes in life styles and risk factors of disease.

6.1 NEED FOR THE STUDY

Obesity has emerged as a deadly epidemic and threatens the health of the women. Obesity lowers the life expectancy. Obesity is associated with a 36% increase in in-patient and out-patient health care expenditure and a 77% increase in medication use as compared with expenditure for healthy individuals.9 Obesity is like a chronic disease, which is prevalent in both developed and developing countries.10

Obesity is defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size or an increase in fat cell number or a combination of both. It is one of the most significant contributors to ill health. It is extremely difficult to assess the size of the problem and compare the prevalence rates in different countries as no exact figures are available and also because the definitions of obesity are not standardized. However, it has been estimated to affect 20-40% of the adults in developed countries. Obesity is a health hazard and increases morbidity and mortality in general population.11

The prevalence of overweight and obesity in Indians has increased over the past two decades. National family health survey (NFHS-2) in 1998-1999 and NFHS-3 in 2005-2006 shows that prevalence of obesity among Indian women has elevated from 10.6% to 12.6%.12 Women generally have higher rate of obesity than men. Almost 62% of women are overweight, of these, 33% of women are obese. Women who are obese experience a greater number of adverse health outcomes, including an increased incidence of cardiovascular disease, breast disorders and colon cancer. It has been claimed that women’s BMI increases with successive pregnancies. The recent evidence suggests that this increase is likely to be about 1 kg per pregnancy.13

A prospective follow up study was conducted on the effect of childbearing on weight gain in women. Around 11,196 African-American women aged between 21-39 years, participated in the study. Data collected by postal questionnaire at different time period. BMI was assessed at 4 years of follow up with use of multivariable linear regression to control for important risk factors. The result showed that, BMI increased by an average of 1.6kg/m2, equivalent to a weight gain of approximately 4.4 kg. Parous women gained more weight than Nulliparous. Primiparous gained more weight than multiparas.14

A pilot study was done in community on predictors of weight gain at 6 and 18 months after childbirth, to test the contributions of life-style and stress to postpartum weight gain after controlling for sociodemographics and reproductive influences. They have excluded multigravida mothers, and those who had any medical problems or had missing weight data. The study samples were 88 predominantly white mothers at 6 months after childbirth and 75 predominantly white mothers at 18 months after childbirth. The method of data collection was longitudinal mail survey with retrospective data on gestational weight gain and prospective data on postpartum weight gain. The result of the study shows that maternal race and gestational weight gain accounted for significant amounts of variance in 6-month and 18-month postpartum weight gain. Life-style and perceived stress does not contributed significantly to postpartum weight gains. Gestational weight gain was the most important predictor of postpartum weight gain. Hence the study recommends the need for further study on high gestational weight gain.15

The institute of medicine (IOM) recommends that women with a normal pre-gravid body mass index (BMI) of 19.8 to 26 should gain 11.5 to 16 kg during pregnancy; underweight women (BMI of less than 19.8) should gain 12.5 to 18 kg; overweight women (BMI of 26 to 29) should gain 7 to 11.5 kg; and obese women (BMI of greater than 29) should gain only 6 kg.16

For many women, returning to pre-pregnancy weight is a challenge. Approximately 14–25% of women are at least 5 kg heavier 1 year after delivery, placing them at increased risk for obesity and its consequences. Identified risk factors for retaining at least 5 kg at 1 year postpartum include higher prepregnancy weight ,gestational weight gain, black race, primiparity, etc, and behaviors including inadequate sleep, low physical activity, high trans fat intake, and frequent television viewing.17

A study was conducted to find out the effect of structured diet and physical activity on prevention of postpartum weight retention. The objective of the study was to examine the impact of an individualized, structured diet and physical activity intervention on weight loss in overweight women during the first year postpartum. Around 40 overweight postpartum women were randomized to either a structured (STR) or a self-directed (SELF) intervention. The subjects in STR received individualized diet, physical activity prescriptions and 12 weeks classes. Subjects in SELF received a single 1-hour educational session about diet and activity. The study result showed that 13 samples who received STR had significant weight loss (7.3 kg,p< 0.01), a significant decrease in percent body fat (6%,p< 0.01). The 10 samples who received SELF had no significant change in weight, percent body fat, or fat-free mass. The study concluded that women who received structured education about diet and activity lost more weight than women who underwent self intervention. Thus the study suggest that healthcare professionals should strongly encourage postpartum women to enroll in a structured diet and exercise programme.18

Preventive environmental measures in homes, antenatal clinics, and community are beneficial. Primary and secondary prevention of overweight and obesity can be achieved by modifying diet and exercises. Early recognition and control measures are essential before the woman reaches an obese state. Prevention of overweight is more effective than interventions that target the correction of obesity. Strategies focused on building healthy habits related to nutrition and activity have more stable long term results as compared with strategies focused on limited behaviors. The focus on positive behaviors such as vegetable intake may be an effective strategy when planning prevention strategies.19

Nurses are valued as key individuals in promoting optimum health. Nurses can work with antenatal mothers and families on obesity related health issues and to influence them to ameliorate the problem. Nurses can play a strategic role in reducing environmental and lifestyle related health hazards through promoting a positive life style that includes exercise, stress management, weight maintenance and nutrition education. The researchers concluded that health education can play an important part in reducing the incidence of overweight, obesity and its associated complications.20

The above need for the study clearly states that, the prevention of postnatal obesity is fundamental, as if it not treated they gradually lead to obesity and related health problems. So the researcher found it is relevant to evaluate the effectiveness of structured teaching programme among antenatal mothers regarding prevention of postnatal obesity.

6.2 REVIEW OF LITERATURE

Literature whispers the words that the tongue cannot say; plays the bird song that the ears cannot apprehend; paints the mountains that the eyes cannot perceive; and summons the winds that a man cannot feel.

-Ellesta Arelei

Researchers conduct review of literature to generate a picture of what is known and not known about a particular problem. Relevant literature of only those sources that are pertinent or highly important in providing in-depth knowledge needed to study a selected problem is reviewed. The literature review indicates whether adequate knowledge exists to make changes in practice or whether additional research is needed.21

A prospective cohort study was conducted to find out the association of postpartum depression with weight retention 1 year after childbearing. The objective of the study was to examine the extension to which early postpartum depression was associated with weight retention 1 year after childbirth. Project viva was conducted for 850 women, who reported depressive symptoms at midpregnancy and 6 months postpartum. The study showed that among 850 samples 87% were not depressed during or after pregnancy, 6% experienced antenatal depression only, 3% experienced both antenatal and postpartum depression, and 4% experienced postpartum depression only. At 1 year, participants retained a mean of 0.6 kg (range −16.4 to 25.5), and 12% retained at least 5 kg. The maternal socio demographics, parity, and new onset of postpartum depression were also associated with retention of at least 5 kg [(odds ratio (OR): 2.54, 95% confidence interval (CI): 1.06, 6.09)]. The study finding showed that new-onset postpartum depression was associated with substantial weight retention in the first postpartum year. Thus the study concluded that interventions to manage depressive symptoms may help reduce excess weight retained postpartum and aid in the prevention of obesity among women.22

A study was conducted to find out the association of fewer hours of sleep at 6 months postpartum with substantial weight retention at 1 year postpartum. Data collected from 940 participants with a project viva method. Logistic regression models estimated odds ratios of SPPWR for sleep categories, controlling for sociodemographics, prenatal, and behavioral attributes. The result showed that, 124 (13%) developed substantial postpartum weight retention. Sleeping ≤5 hours/day at 6 months postpartum was strongly associated with retaining ≥5 kg at 1 year postpartum. The study showed that maternal sleep duration has impact on postpartum obesity. Thus the study concludes that interventions to prevent postpartum obesity should consider strategies to attain optimal maternal sleep duration.23

An observational study was conducted to find out the relationship between high gestational weight gain and subsequent obesity in 30 antenatal mothers in adolescent stage (<20 years), with interview and anthropometric measurements. The study group was divided into 3 sub groups according to weight gain catagories.ie, rapid (0.40kg/week), average (0.25– 0.40kg/week), and slow (0.23kg/week). The study revealed that rapid weight gain was associated with 19.9% increase in BMI, average gestational weight gain was associated with 13.2% increase, and slow gestational weight gain was associated with a 3.4% increase (difference between rapid and slow, p< 0.05).The percent increase was 17% each for the high and average gestational weight group and 12.5% for the low group. The study concluded that women who had high BMI before pregnancy tends to have high gestational weight gain and those women will be having more chance to retain that gestational weight in later period.24