A biopsychosocial approach to the interrelation between motherhood and women’s excessive weight

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Porto

Biomedical

Journal

h tt p://w w w . p o r t o b i o m e d i c a l j o u r n a l . c o m /

Review

article

A

biopsychosocial

approach

to

the

interrelation

between

motherhood

and

women’s

excessive

weight

Ana

Henriques

a,∗

_,

_Ana

_Azevedo

a,b

a_Epidemiology_Research_Unit_(EPIUnit)_–_Institute_of_Public_Health,_University_of_Porto,_Porto,_Portugal

b_Department_of_Clinical_{Epidemiology,}_Predictive_Medicine_and_Public_Health,_University_of_Porto_Medical_School,_Porto,_Portugal

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t

i

c

l

e

i

n

f

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Articlehistory: Received27November2015 Accepted16February2016 Keywords: Excessiveweight Motherhood Weightcontrol

a

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Portugalischaracterizedbyahighprevalenceofoverweightandobesityamongwomen,whoseweight increasesmostrapidlyinearlyadulthood.Individualgeneticfeaturesandbehaviours,alongwithsocial, culturalandenvironmentalfactorsinteractincomplexrelationshipswithbodyweightandwithits variationthroughouttime.Motherhoodmaytriggeranincreaseinweight,potentiallyinﬂuencingthe associationsbetweenexcessiveweightandseveralotherhealthdeterminants.Takingintoaccountthe qualityofprenatalcarewithinPortugal’shealthcaresystem,regardingcoverageandsuccessinimproved outcomes,wetheoreticallydemonstratewhypregnancyandmotherhoodshouldbeseenasopportunities forpreventionandwhyadeeperknowledgeabouttheinterplayofbiological,socialand psychologi-caldeterminantsofweightatthisstageoflifecanbeusefultodesignmoreeffectiveweightcontrol interventionstowardsthispopulation.

creativecommons.org/licenses/by-nc-nd/4.0/).

Women’sweightbefore,duringandafterpregnancy

Motherhoodis oneofthemostchallengingexperiences that canoccurinwomen’slifeand itcanbeconcomitantly distress-ingandmeaningful.Theseambivalentfeelingsarenotnecessarily aproblem,butmoreresearchisneededtounderstandtheir speci-ﬁcitiesandhowtheycaninteractwithweightmanagementinthis periodoflife.Thegrowingnumber ofobesewomenworldwide hasmanyimplications,notonlyonmother’shealthoutcomesbut alsofortheirchildren,asdemonstratedbytheassociationbetween prepregnancyobesityandcertainmajorbirthdefects1_and_a_higher

likelihoodofhavingmacrosomicinfants.2_{Additionally,}_caesarean

deliveryriskisincreasedby50%inoverweightwomenandismore thandoubleforobesewomencomparedtowomenwithnormal bodymassindex(BMI).3

Thepostpartumperiodcanbecriticalforthedevelopmentof obesityinmidlife.Evidenceconsistentlyshowsthatexcessive ges-tationalweightgain(GWG)contributestohigherpostpartumbody weight4–6_and_that_overweight_and_obese_women_have_more_than

doublethechancetoexceedtheweightgainrecommendations duringpregnancythanotherBMIgroups.2,7_Moreover,_excessive

∗ Correspondingauthor.

E-mailaddress:alhenriques@med.up.pt(A.Henriques).

GWGisassociatedwithabdominaladiposity8yearsafterdelivery, whichmayincreaseawoman’sriskofcardiovascularandmetabolic diseases.8

Several pregnancy cohort studies from developed countries havereportedindependentdirectassociationsbetween prepreg-nancybodyweightorBMIandpostpartumweightretention.9,10

However,arecentmeta-analysisanalyzedtheassociationofGWG orprepregnancyBMIwithpostpartumweightretentionand,as illustratedinFig.1,GWG,ratherthanprepregnancyBMI, deter-minestheshorter-orlonger-termpostpartumweightretention. Whenpostpartumtimespanswerestratiﬁedinto1–3months,3–6 months,6–12months,12–36monthsand≥15years,the associa-tionbetweeninadequateGWGandpostpartumweightretention fadedovertimeandbecameinsigniﬁcantafter15years.11

Most studiesconducted sofarfocus onweight changeonly until theﬁrst year postpartum, and few studies have obtained serial measurements for longer periods to assess patterns of weightchange.Characterizationoftheinterrelationshipsbetween prepregnancybodyweight,GWG andpostpartumweight reten-tion is essential for a deeper knowledge of weight changes afterpregnancyandobesityratesinchildbearingage.Giventhe modiﬁable nature of this risk factor, thepreconception, prena-tal, and postpartum periods may present critical windows to implement interventions to prevent weight retention and the developmentofoverweightandobesityinwomenofchildbearing age.12

http://dx.doi.org/10.1016/j.pbj.2016.04.003

2444-8664/©2016PublishedbyElsevierEspa ña,S.L.U.onbehalfofPBJ-AssociaçãoPortoBiomedical/PortoBiomedicalSociety.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Fig.1. Forestplotofthestudiesontheriskofpostpartumweightretentionof≥5kgforwomenwithexcessivegestationalweightgain(GWG)vs.womenwithadequate GWG.Thestudy-speciﬁcORand95%CIarerepresentedbythegreysquareandhorizontalline,respectively;thesizeofthedatamarker(greysquare)isproportionaltothe weightofthestudyinthemeta-analysis(note:weightsarefromrandom-effectsanalysis).ThecentreoftheopendiamondpresentsthepooledORanditswidthrepresents thepooled95%CI.11_Reprinted_with_the_permission_of_Cambridge_University_Press.

Increasingparitycontributestothelong-termdevelopmentof obesityinwomen13–15_but_this_relationship_differs_by_maternal_BMI

inyoungadulthood,numberofbirths,race-ethnicityandlengthof follow-up.FindingsfromarepresentativecohortfromtheUnited StatesofAmerica(USA)showedthatblackandwhiteprimiparae andmultiparaetendedtohavegreaterBMIincreasesthan nulli-paraeover10years,thisassociationbeingstrongeramongwomen withhighBMIbeforepregnancy.However,25yearslater,thesame studyshowedthat onlyblack womenwho wereoverweight at baselineanddeliveredmorethan onechildgained signiﬁcantly moreweightthanthosenotgivingbirth.16_Women_often_report

theirobesitytobetriggeredbypregnancy–asmanyas40–50% in oneSwedish study. Yet,for 30% of thewomen in the same study,pregnancywasassociatedwithweightloss.17_{Additionally,}

placeofresidence,ethnicity,aswellasindividualsocioeconomic position(SEP)andlifestylefactorscanconsiderablyexplain this association.18,19_All_of_these_data_allude_to_a_complex_{parity–weight}

relationshipforwomenwitharangeofconfoundingfactorsthatact acrossthelifecourse,withthepossibilityforfurthervariations.20

Thus, further researchis needed toconﬁrm the links between parityandweightgain,aswellasmoreinformationregarding con-foundersofthisassociationframedinsocialandcurrenteconomic conditions.

Theriskofweightgainisnotequalthroughoutallpregnancies. Inlargecohortstudies,whencomparingnulliparouswith primi-parouswomen,weightgainduetochildbearingwasgreatestafter thefirstbirth,andweightgainwasgreaterwithincreasingbaseline maternalbodyweight.Averageweightgainassociatedwith hav-ingafirstchildwas3–6kgamongwomenwhowereoverweight beforepregnancy,andabout1kgamongwomenwithnormalBMI. Afterthefirst pregnancy, weightgain is smallerin subsequent pregnancies.12,21,22_Furthermore,_multiparity_is_positively

associ-atedwithabdominalgirthfrompreconceptiontoseveralyearsafter delivery.21,23

Despite somedisparities, evidence supports that substantial weightgainassociatedwithchildbearingisanimportantrisk fac-torforthedevelopmentofoverweightandobesityinadultwomen.

Futurestudiesshouldidentifywomenmoresusceptibletobeneﬁt frominterventionstopreventweightgainandwhicharethe crit-icalperiodstointervenemosteffectively:before,duringorafter pregnancy.

Theimpactofpsychosocialdeterminantsonweight,around motherhood

Sincesocial10_and_{psychological}_{characteristics}24_have_impact

onmaternalexcessiveweight,thepsychosocialcontextshouldbe studiedindepth.Areviewoftheimplicationsofbodyimageand socioeconomicpositionisprovidedbelow.

Bodyimage

Pregnancy,due toitsconcomitantchanges in bodysize and shape,canhaveasigniﬁcantimpactonawoman’sbodyimage.25

Thisisoftentheﬁrsttimeweightgainisexpectedandaccepted andsomewomenviewbodychangesastransientanduniquetothe childbearingendeavoursotheyareabletoassimilatethesechanges withoutdistress.26

Researchresultsonbodyimageinpregnancyhavebeen con-tradictory,withsomestudieshighlightingthat womenareable toassimilatethebodilychangesofpregnancywithoutanegative shiftinbodyimagesatisfaction(BIS),27,28_and_other_studies

ﬁnd-ingadecreasedBISduringpregnancy29_and_postpartum.30_Also,

prepregnancyBMIhasanimpactonBISduringpregnancy,with overweightwomenreportinganincreaseintheirsatisfactionand womenwithnormalBMIreportingadecrease.29_Those_who_had

beenoverweightbeforetheirpregnancymayviewtheirpregnancy asexcusingthemfromunpleasantcommentsorfeeling uncomfort-ableinactivitiesexposingtheirbody,suchasswimming.31

Inthepostpartumperiod,despitesomevariation,bodyimage isgenerallymorenegative,whenwomen’sconstructionsoftheir postpartumbodyindicatethatoncethebabywasborn,theyno longer perceived any excuse to not adhere to their perceived sociallyconstructedidealsilhouette.32_Harris_and_colleagues_also

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foundthatwomenwhowerelesssatisﬁedwiththeirbodies post-partumhadsigniﬁcantlygreaterlongtermweightgainsthanthose womenwhodisplayednoincreaseindissatisfactionwiththeir bod-iesafterpregnancy.14_One_possible_reason_for_this_{disappointment}

isthatwomen(especiallyprimiparouswomen)tendtoexpectthat theirbodieswillreturntotheirpre-pregnancyweightandshape shortlyafterthebirthoftheirchild.33

Arecentreviewsynthesizedtheexistingqualitativeliterature describingwomen’sexperiencesoftheirpregnancyand postpar-tumbodyimage. Hodgkinsonandcolleagues25 _highlighted_that

women’sperceptionoftheirpregnancybodyimageisvariedand dependsonthestrategiestheyusetoprotectagainstsocial con-structionsoffemalebeauty.Womenoftenperceivedthepregnant body tobeout oftheircontrol andas transgressingthe physi-calmanifestationofthesociallyconstructedideal,againstwhich they tried to protect their BIS. Body dissatisfaction dominated thepostpartumperiod,emphasizingthewomen’sneedfor addi-tionalsupportatthismoment.Moreover,healthprofessionalsare reportedtofeeluncomfortableaboutdiscussingweightasanaspect ofbodyimageduetolackofknowledgeandfearofbeing consid-eredinsensitive.34_However,_since_during_pregnancy_women_are

morereceptivetoconversationsaboutweight-relatedaspectsof theirbodyimage,communicationskillstrainingcouldincrease pro-fessionals’conﬁdenceinexploringwomen’sbodyimageinorder toimprovetheirweightmanagementstrategiesindependentlyof theirBMI.25

WhileitseemsclearthatBISbeforepregnancyhasa consid-erableimpactonpostpartumweightchanges,furtherresearchis neededtoassessifthissameconstructcaninﬂuenceweightovera longer-term.

Socioeconomicposition

Femalereproductivehealthishighlysensitivetothephysical andsocialenvironmentthroughoutlife.Womenarecurrentlyless likelytobemarriedandmorelikelytobesingleorcohabiting,35,36

morewomenareremainingchildlessorhavingfewerchildrenand theproportionofwomen’slivesspentrearingtheirchildrenhas beenreduced.37_If_social_factors_change,_their_impact_on_women’s

reproductivelifecanalsochange;therefore,adeepstudyofthis relation,togetherwithpsychologicalandbiologicalattributes,is stillachallengetobefaced.

MaternalSEPisknowntobeastrongcorrelateofnumerous maternalandchildhealthoutcomes.LowindividualSEP(e.g. edu-cationandincome)hasbeenassociatedwithadversepregnancy andbirthoutcomes38,39_and_delayed_prenatal_care.40_A_recent_large

population-basedstudycomparedthedirectionandmagnitudeof individualandneighbourhoodsocialinequalitiesacrossmultiple maternalandchildhealthoutcomes(maternalandinfanthealth statusindicators;prenatalcare;maternalexperienceoflabourand delivery;neonatalmedicalcare;andpostpartuminfantcareand maternalperceptionsofhealthcareservices)andrevealedthatSEP measureshadstrongerassociationswithoutcomesbelongingto thehealthstatusofthemotherandinfant,asopposedtotheother groups.Themagnitudeofmaternalandchildhealthinequalities washigherwhenindividual-levelSEPwasusedthanwhen con-sideringneighbourhoodSEP.Inparticular,educationshowedthe greatestgradientscomparedtohouseholdincome,neighbourhood SEP,andcombinedSEP(combinationoflowandhighindividual andneighbourhoodSEP).41

ArelationbetweenSEPandobesityhasbeenwellestablished foralongtime,42_also_in_childbearing_women,43_with_those_who

havealowerSEPbeingtheoneswithahigherriskofbeingobese. However,somespeciﬁcitiesofthisassociationconsideringyoung adultwomenremainunclear.Inadulthood,reproductionmayhave anaddedinﬂuenceonobesityriskinwomen,althoughresearchis

lackingonhowadultinﬂuencescombine,namelysocialand psy-chologicalones,forthedevelopmentofexcessiveweightinthis particularperiod.

Additionally,researchonchildhoodgrowthhaspointedtothe possibilitythatearlylifemaybeanimportantstageinthe devel-opmentofobesityandlongitudinalstudiesconsistentlyshowthat alowerSEPinchildhoodincreasestheriskofexcessiveweightin adulthood.44_These_associations_between_childhood_SEP_and_adult

healtharealsoobservedinthecontextofmotherhood.IntheBritish 1958birth cohortstudy,45 _it _was_observed_that,_as _the_level_of

povertyinchildhoodincreases,theproportionofwomenhaving theirﬁrstbabybytheageof20alsoincreases.

Thiscontinuityindisadvantagethroughoutlifeisanimportant partofthelinkbetweenchildhooddisadvantageandpooradult health,withSEPacrosschildhoodand adulthoodemergingasa stronger predictorofadulthealth thanSEPatanyone pointin time.45

Socialtrajectoryisalifelongevolutionofthevolumeand com-positionofanindividual’scapital(social,cultural,economicand/or symbolic),combinedwithhis/herparents’assetvolumeand struc-tureandcanbedescribedasupward,downwardorstationary.46

Most of the ﬁndings concerningobesity and socioeconomic characteristicshavebeenbasedonwomen’sSEPinadulthoodbut, recently,evidenceisemergingabouttheimpactof intergenera-tionalsocialtrajectorytakingintoaccountalifecourseperspective. Inordertostudytheinﬂuenceofsocialclassinchildhood,young adulthoodandmiddleage,andintergenerationalmobility,onadult centralandtotalobesity,astudywasconductedusinga population-basedbirthcohort.Inwomenat53years,father’ssocialclasswas inverselyassociatedwithallmeasuresofobesity,bothadultsocial classes(atages26and43years)wereinverselyassociatedwithall obesitymeasuresatage53andwomenwithanupward intergener-ationalsocialmobilityhadlowerlevelsofcentralandtotalobesity comparedwiththosewhoremainedinthesamesocialclassastheir father.47

Changes in social circumstances,or intergenerational move-ment betweensocial classes,might entaila transitionin terms ofprioritiesand resourcesrelatedtoweightandappearance,or ashiftinexperienceofsocialnormsregardingtheappealof par-ticularbodytypes,48_particularly_when_considered_in_the_context

ofwomen whohave recentlygivenbirth.Knowing thatsociety inﬂuenceswomen’sperceptionofgoodorbadappearance,future studiesshouldbetterassessthesocialdeterminantsofBISin child-bearingwomen,consideringalifecourseapproach.

Motherhoodasanopportunityforprevention

Some authors defend that the preconception period should be seen as a privileged time for prediction and prevention of noncommunicablediseases,thus notonly improvingpregnancy outcomesandmaternalhealth,butalsopromotinglong-term ben-eﬁcialeffectsforboththemotherandthechild.49_Prepregnancy

weightlosscanreduceobesity-relatedcomplications,whichcan haveaconsiderableimpactonimprovingobesity-relatedperinatal complications–gestationaldiabetesmellitus,hypertensive disor-ders,macrosomia,andlargeforgestationalagebabies.50

Women’s health in Portugal hasexperienced a huge overall improvementsincethelate1970sandtheimplementationofthe National Health System, which ensures all citizens nearly free accesstoprimarycarecentresandpublichospitals.51_Moreover,

prenatalcareisoneofPortugal’shealthcaresystem’smost suc-cessfulareas,withpractically100%coverageandadequateprenatal careinthevastmajorityofpregnancies.52_However,_a_study

per-formed in the north of the country showed that, whilst good prenatalsurveillanceexists,only27%ofthepuerperalwomenhad

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• The romanticized image • The motherself • Type of mothering received • The influential ‘others’ • The ‘wished-for’ baby • Relationship with baby • Partner’s involvement • Self and others • Confidence in body • Labour as indicator of motherliness • Dealing with uncertainty • Information seeking Parental self-efficacy Concept of motherhood Mother-infant dyad Anticipated social support

Fig.2. Themesandsub-themesidentiﬁedwithinthe‘Expectationsandbeliefsaboutmotherhoodviews’.57_Reprinted_with_the_permission_of_Elsevier.

preconceptioncare.53_Also,_a_study_performed_in_mothers_of_the

GenerationXXIbirthcohortshowedanadversecardiovascularrisk proﬁlesincethepreconceptionperiod,54_supporting_the_idea_that

interventionsshouldstartearlierinchildbearingwomen.

Thelabel“teachable moment”hasbeenusedtocharacterize lifetransitionsorhealtheventsthatincreaseperceptionsof per-sonalriskandoutcomeexpectancies,promptstrongaffectiveor emotional responses, and redefine self-concept or social roles. Inotherwords,a cognitiveresponseprecedesmotivation,skills acquisitionandself-efficacythatinturn,increasethelikelihood ofceasingadverselifestyles.Additionalkeyfactorstoconsiderare predisposingfactorssuchasage,dispositionalandcultural charac-teristicsthatmayinfluenceanindividual’scognitiveandemotional response.Pregnancyhasbeenwidelyreferred toasa teachable momentbecauseofmothers’strongmotivationtoprotectthe well-beingofthefoetusandstrongsocialpressuretoavoidunhealthy habits,suchassmokingduringpregnancy.55,56

Somepsychological issues should also be highlighted when discussing a pregnancy’simpact onwomen’s life. A qualitative studyexploredbeliefsand expectationsaboutmotherhood, and the main themes are illustrated in Fig. 2. Since a discrepancy betweenwomen’sexpectationsandrealitywasfound,a psycho-logicalpreparation for motherhoodshouldbe consideredwhen preparingwomenfortheirnewrole.Suchpreparationpromotesa sensibleimageofmotherhood,theinfant,thenoveltyofthefuture andrelationshipswithothers,anddiscussingthesethemesmaybe particularlyrelevanttowomenvulnerabletopostnatal psycholog-icaladjustmentdifﬁculties.57

AccordingtoastudyperformedintheUnitedKingdombetween 1998and2003,therewasasigniﬁcantreductioninsmoking, alco-holconsumptionand intakeofcaffeinateddrinkswhen women becamepregnant,althoughlittlechangeoccurredinfruitsand veg-etablesintake.58_In_Portuguese_mothers,_although_almost_half_of

smokersceasedtobaccoconsumptionduringpregnancy, approxi-matelytwothirdsresumedsmokingwithin4yearsafterdelivery,59

leadingustobelievethat,althoughpregnancyenhancesthe per-ceivedneedofadoptinghealthylifestyles,thatdoesnotmeanthat healthyhabitswillpersistthroughouttime.Sincefertileagewomen arepronetochangehealthyhabitswhentheyreceivehealthcare provider’sadvices,60_{interventions}_to_this_segment_of_the

popula-tionshouldberestructured,focusingmoreonwomen’sintrinsic motivationsandexpectations,whichisprovedtoresultin long-lastingbehaviourchange.61

Insummary, weightmanagement before, duringand after a pregnancyhasadvantages for both mother andchild.

Monitor-ingofprepregnancyBMI,GWG,andpostpartumweightwillallow theidentiﬁcationofwomenwhoaremoresusceptibleofhaving aninadequateweightthroughoutchildbearingyears. Preconcep-tionisanimportantperiodandobesewomenshouldbetargeted forinterventionbeforetheygetpregnantfortheﬁrsttime. Like-wise,healthcareprovidersinvolvedinthecareofpregnantwomen shouldbetrainedtoprovideamoreeffectiveapproachforweight control.

Metabolicfeaturesafterpregnancy:thehealthyobesity phenotype

The numbersregarding obesity are alarming,largely due to itsassociationwithseveralcardiovascular diseases.However, a healthyobesephenotypehasbeenrecentlyidentiﬁedandthese individualsappeartobeatnoincreasedcardiovascularrisk.62,63

This clinical condition,termed benign obesityor metabolically healthyobesity,isrestrictedtoauniquesubsetoftheobese pop-ulationwhich, despiteexcessive BMI, are insulin sensitive and haveanormalbloodpressure,lipid,inﬂammationandhormonal proﬁle.62–66 _The _relevance _of _establishing _such _a _phenotype _is

underlinedbydatathatsuggeststhatweightlossamonghealthy obese may adversely impact their favourable cardiometabolic proﬁle.67

Theabsenceofauniformdeﬁnitionforthissubtypeofobesity isoneofthemainlimitationsofthistopic,withprevalences rang-ingfrom6%to37%,68–70_depending_on_the_criteria_to_deﬁne_the

phenotype.However,evenwhenuniquecriteriaareused, consider-ablevariabilityintheprevalenceofhealthyobesityisfoundacross differentEuropeancountries71_and,_to_the_best_of_our_knowledge,

therearenoestimatesforPortugal.Normally,metabolicallyhealthy obesepersonshavefamilymemberswithuncomplicatedobesity, earlyonsetobesity,fastingplasmainsulinwithinanormalrange andanormaldistributionoftheexcessfat.72_{Additionally,}_some

lifestylefeaturesareassociatedwiththismetabolicproﬁle,suchas moderateandhigherlevelsofphysicalactivityandhigherdietary quality.70

Somecontroversyexistsconsideringtherelevanceofthis phe-notype.Arecentsystematicreviewandmeta-analysisshowedthat, comparedwithmetabolicallyhealthynormalweightindividuals, obesepersonsareatanincreasedriskofadverselong-term out-comesevenintheabsenceofmetabolicabnormalities,suggesting thatthereisnohealthypatternofincreasedweight.73_Also,_another

studythatevaluatedthe3-yearincidenceofcardiometabolicrisk factorsconcludedthat anincrease inBMI duringthefollow-up

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period wassigniﬁcantly associated withthe occurrence of car-diometabolicalterations.74_More_research_concerning_this_subject

isstillneededandlongerlongitudinalanalysesshouldbeprovided inordertoclarifyiftheseindividualsareprotectedduringtheir entirelifeorwhetherhealthyobesitysimplyrepresentsdelayed onsetofobesityrelatedcardiometabolicproblems.Also,mostof thestudiesthatassessedhealthyobesityusedsamplescomprising womenabove40yearsofage66,75,76_and_information_concerning

childbearingwomenisstilllacking.

Theincreaseindepositionoffatinabdominalvisceraladipose tissue is favouredafter pregnancy,due to increasedabdominal compliance,renderingwomenmoresusceptibletoabdominal obe-sity after childbirth.13 _Abdominal _fat _{distribution,} _visceral _and

ectopicfataccumulationarealsokeycharacteristicsforthe devel-opmentofunhealthyobesity.77 _Thus,_it_would _be_interesting_to

characterizetheobesityphenotypein womenwho hada child, toassesstowhich extenttheirobesityis healthyor is convey-ing a higher risk of CVD,thus supportingor not the need for preventiveactiondirectedatthissegmentofthepopulation. Fur-therstudiesexaminingdifferentsubtypesofobesitywillallowfor understandingobesity’s heterogeneousnaturethat couldresult inmoreappropriateweightlossrecommendations,evenamong childbearingwomen.

Conclusion

Inconclusion,theaccumulatedevidencesuggeststhatthereare severalfactorsthatcouldleadachildbearingwomantobe over-weightor obeseand a biopsychosocialapproach contributesto understandtheserelationscomprehensively.

Pregnancyhasbeenwidelyreferredtoasateachablemoment andfutureresearchshouldidentifywomenmoresusceptibleto beneﬁt from interventions to prevent weight gain during this period,preferably,startingatthepreconceptionperiod.BIS, socioe-conomiceconomiccharacteristicsacrossthelifespanandmetabolic featuresshouldbeconsideredwhendesigningfutureinterventions forweightmanagementtargetingthisspeciﬁcpopulationand lon-gitudinalresearchisneededinordertoassessiftheimpactofthese variablesonweightisobservedthroughouttime.

Conﬂictsofinterest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgements

AgrantfromFundac¸ãoparaaCiênciaeTecnologiaisgratefully acknowledged(SFRH/BD/72723/2010).

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