The prevalence of obesity is rising in both developed and developing countries. Women in reproductive age are at a higher risk of developing obesity, posing a public health challenge. Worldwide, 15% to 20% women have been reported to be obese during the preconception stage. Almost half of these women (47%) gain excessive gestational weight (weight gain more than that recommended by the Institute of Medicine during pregnancy) with 20% retaining 1 to 5.5 kg of this weight during the first year of their postpartum period. Excessive gestational weight gain and weight retention during the first year post-delivery are associated with overweight or obesity in later years of life.[6,7] This predisposes women to an elevated risk of developing cardiometabolic complications such as diabetes, dyslipidaemia, hypertension, ischemic heart disease, stroke as well as certain types of cancers,[5,6,8,9] thus underpinning the need to prevent or manage obesity among women.
The management of obesity is multidisciplinary. Various lifestyle-related components such as dietary, physical activity and behavioural modifications are required to either lose weight or maintain an ideal body weight. The management of obesity during the postpartum period is challenging due to various reasons such as personal factors, socio-cultural barriers and environmental factors. At this stage, women give more priority to their infants than their own health. They usually lack time, energy and motivation to engage in their weight management process. Moreover, there exist various socio-cultural myths such as ‘doing the month’, wherein the women are advised to consume high calorie foods and restrict physical activity including the household chores for at least the first 40 days post-delivery. Postpartum women also report that they do not receive any counselling related to diet and physical activity specific to the postpartum period and hence, lack the knowledge and information about the diet and physical activity regime to be followed.
Postpartum women usually visit only the obstetricians and paediatricians after their delivery. They lack the awareness and information about visiting nutritionists, exercise physiologists and psychologists who might assist them in shedding the weight retained. Obstetricians and paediatricians may lack sufficient information about the diet and physical activity counselling to be imparted to these women. They may further lack skills of motivational interviewing. Moreover, in resource-limited settings, usually nutritionists, exercise experts and behavioural counsellors are either not available or are in such a limited number that they cannot counsel every postpartum woman. This underscores the need for the development of evidence and consensus-based recommendations related to diet, physical activity and behaviour which can be used by obstetricians and paediatricians or any other healthcare provider to holistically counsel postpartum women for their weight management.
Priorities, needs and gaps identified during the weight management process of postpartum women supported the initiative for development of the evidence and consensus-based guideline for postpartum weight management. The guideline was developed in two phases using standardised methodology as per the National Health and Medical Research Council: (i) development of recommendations and (ii) validation of recommendations. First, a list of key clinical questions was identified through literature search, expert opinion and Delphi method. Second, a literature search was carried out to gather evidence for each question. In Phase I, grading of evidence and expert opinion was sought to formulate clinical practice recommendations for each clinical question. In Phase II, the clinical practice recommendations were peer-reviewed and validated using the Delphi method and graded using the GRADE approach via the experts.
Guideline Development Groups (GDGs)
GDGs comprised the chairpersons and professional members from eminent national organisations such as Department of Science and Technology (Government of India), The Federation of Obstetric and Gynaecological Societies of India, Indian Menopause Society, Association of Physicians of India, Academy of Family Physicians of India, Association of Obstetricians and Gynaecologists of Delhi and Indian Dietetic Association. Experts and senior professors from some leading medical colleges of the country have also been part of the team of GDGs. GDGs were summoned to address the key clinical questions related to the weight management of postpartum women. The role and responsibilities of every member of a GDG comprised prioritising and finalising key clinical questions, reviewing the available evidence, providing the expert opinion, finalising the recommendation for each clinical question, validating and grading the recommendations.
Development and prioritisation of key clinical questions
An exploratory study comprising focus group discussions and in-depth interviews has been conducted among postpartum women to identify the gaps, needs and priorities of weight management among these women. A questionnaire was designed to survey a larger group of postpartum women to assess the risk factors, facilitators and barriers to postpartum weight management. The clinical areas of interest were identified and translated into the key clinical questions. The first draft of exhaustive clinical questions was categorised in four domains including the initiation of discussion for weight management, screening and risk assessment of the target population for initiation of weight management advice, management of weight and follow-up for sustainable weight loss. Online meetings were organised with GDGs to familiarise them with the process of peer-review for the development of key clinical questions. The initial draft was subjected to the peer-review process for its relevance, face validity and content validity under two levels. The first level peer-review was done by a smaller group of members consisting of four to five topic-specific experts. The amendments suggested were agreed and the modified draft was subjected to the second level of peer-review done by a larger group of experts from different disciplines, journal editors and senior professors from leading organizations. The final draft comprised 16 key clinical questions categorised in four domains and prioritised according to the need and impact on the dissemination of postpartum healthcare.
Evidence reviews to answer the clinical questions
Literature search was conducted by the evidence team to answer each clinical question to develop guideline recommendations.
Search for evidence: Broad terms related to the weight management of postpartum women were identified by the evidence team. This search string was tailored for specific search for each key clinical question. The electronic databases such as PubMed, Wiley and Google Scholar were employed to extract relevant evidence.
Selection criteria: Human studies published in English language in peer-reviewed journals were selected. Methodological filters related to the study design were not applied at this stage to ensure an extensive and exhaustive search. The evidence team further performed the title, abstract and full-text screening of articles. Any disagreements on the selection of an article were resolved by consensus among the members of the evidence team.
Eligibility criteria: Studies comprising postpartum women aged 18 years and above; practice guidelines, systematic reviews, randomised control trials, observational studies, narrative reviews; and reporting the information of interest with respect to the specific clinical question were included. The exclusion criteria included studies published in non-English language or in non-peer-reviewed journals, or having only underweight (body mass index < 18.5 kg/m2) postpartum women as participants.
Data extraction and synthesis: The data extracted included author, year of publication, country, study design characteristics and sample characteristics specific to the clinical question. The findings of the studies were reported narratively in tables to form a write-up for summary statement.
Development of clinical practice recommendations
The extracted data for each clinical question presented in narrative tables along with the summary of evidence were circulated among GDGs. Training regarding the evaluation of evidence review and development of recommendations was provided to GDGs through online meetings. The agenda of these online meetings was to describe in detail the process of the guideline development, the process of identifying evidence to formulate evidence-based recommendations, reaching to a consensus wherever there is lack of evidence to formulate consensus-based recommendations and grading the strength of recommendations. The recommendations developed were subjected to a two-level peer-review process. The first level of peer-review was done by a smaller group of four to five topic-specific members. The second level of peer-review was done by a larger expert group consisting of field experts, journal editors and senior professors of eminent organisations of the country. This led to the development of evidence-based and opinion-based recommendations.
Based on the GRADE approach, the evidence has been graded from high quality to low quality for each clinical question. The consensus among the experts has been referred to as ‘Expert Opinion’. The criteria for grading the evidence for the recommendations has been depicted in [Table 1].
Strength of recommendations
The strength of a recommendation has been provided by the GDGs based on three major factors:
- Quality of evidence,
- Benefit to harm ratio and
- Feasibility in daily clinical practice
The current recommendations are based on behavioural lifestyle modification (excluding pharmacological and surgical modalities), which might indicate less potential for harm and/or risk. Thus, the grade of the strength of a recommendation was mainly based on the feasibility, available resources and acceptability within the target population in clinical settings.
The grading of the strength of recommendations has been depicted in [Table 2].
Chapter One: Initiation of discussion for weight management
1.1 When is the right time to counsel and engage women regarding postpartum weight management?
The postpartum period is an important phase of a woman’s life. She undergoes various physiological, psychological, emotional and social changes. These changes start right from the time of conception and continue till late postpartum. Owing to these changes, weight gain is quite common and women often end up getting overweight and obese in due course of time. The variables affecting weight gain are different at various stages such as preconception, early gestation, late trimester, early postpartum, late postpartum etc. This calls for a need to engage these women in a structured weight management program at a suitable time to attain significant and sustainable results. Trying to engage women for their weight management too early might go in vain as they are adapting to the changed and demanding circumstances of early pregnancy. Similarly, sensitising and engaging women for weight management too late might lead to significant postpartum weight retention and weight gain that might get difficult to lose. Thus, it is crucial to identify the right time to counsel and engage women for postpartum weight management and foster the environment to prevent weight gain and associated comorbidities.
Summary of evidence
Several guidelines and randomised controlled trials have mentioned the time of involvement of postpartum women in weight management programmes. Several studies (especially those with physical activity-based intervention) started recruiting the participants from 6 weeks post-delivery with variable outcomes.[17–21] These studies have not specified the mode of delivery of the participants. Moreover, certain randomised controlled trials have recruited women for weight management interventions during their pregnancy at different gestational ages such as 15 weeks of gestation, less than 16 weeks of gestation, less than 20 weeks of gestation and 24 to 28 weeks of gestation to study the effects of interventions on postpartum weight. A recent randomised controlled trial has reported that there is insufficient evidence to conclude that weight management interventions starting in pregnancy are effective for postpartum weight management.
However, there is a significant association between excessive gestational weight gain and postpartum weight retention. The Institute of Medicine has published revised guidelines for gestational weight gain that are based on pre-pregnancy body mass index ranges for underweight, normal weight, overweight and obese women.
There is no head-to-head trial to compare the efficacy of an intervention plan based on the time of recruitment of postpartum women. The recommendations made by the expert group are mostly based on the consensus opinion. Early intervention may give an opportunity ‘to catch them young’ and act prophylactically rather than curative, which is far more difficult. The weight gained during pregnancy can affect the immediate and future health of a woman and her infant. Excessive gestational weight gain leads to greater postpartum weight retention. Thus, there is a need to follow an early strategic approach which sensitises these women about weight management in preconception, appropriate gestational weight gain during their pregnancy, reinforcement of appropriate lifestyle-related behaviour immediately after delivery and finally in the postpartum period if successful weight loss outcomes are not achieved. Hence, there is no specific right time to intervene for postpartum weight management, rather it should be done in a continuous manner starting from preconception to postpartum [Table 3].
1.2 What are the components of knowledge, attitude, and practices that should be evaluated to plan a personalised weight management intervention for postpartum women?
Weight management occurs with gradual behaviour change and for that appropriate knowledge, attitude and perceptions are pivotal. They influence education, motivation and extent of adherence to any intervention or treatment. It is important to have knowledge about the various health aspects which lead to change in attitude and perceptions and subsequently, gradual behaviour change.[28,29] Many studies have been done on various lifestyle-related diseases such as obesity, diabetes, hypertension and metabolic syndrome in women. These studies have found gaps in knowledge about ideal body weight, dietary practices to be followed and misconceptions about physical activity.[30–34] Even though women are aware about the negative impact of gaining weight, they face various physical, social and psychological barriers that impede their own ability to put forth the effort required for losing the excess weight. This eventually leads to frustration of weight loss-regain and paves way for distorted body image and unhealthy lifestyle practices.
Prior to the dissemination of any weight management intervention, it is crucial to identify various important aspects of lifestyle-related management that should be covered in the intervention trial. Thus, there is a need to have a thorough understanding of knowledge, attitude and perceptions about the key components of postpartum weight management such as diet, eating patterns, physical activity, lifestyle habits, motivation to lose weight etc. This will help in better planning, dissemination and evaluation of an intervention. Eventually, it will aid in achieving the targeted weight loss goals and improve quality of life.
Summary of evidence
Studies of both qualitative and quantitative nature were considered. Cross-sectional surveys had been conducted for assessment of knowledge, attitude and practices regarding the diet to be followed during the postpartum period, initiation of physical activity, perceptions about weight, myths driven by the socio-cultural environment, breastfeeding practices and attitude toward postpartum weight retention.[36,37] Besides, components of knowledge, attitude and practice for energy intake, energy expenditure, self-monitoring and self-regulation were also assessed.
In the descriptive studies, knowledge of adverse effects of obesity, family-centred lifestyle behaviours that promote unhealthy eating, specific strategies for weight loss, physical activity after childbirth, diet after childbirth, exercise classes, involvement/contribution of nutritionists and weight management programmes were evaluated. In conclusion, studies have assessed knowledge about diet and physical activity after delivery along with due focus to misconceptions and myths.[12,41,42]
Knowledge, attitude and practice are the most important part of a behavioural model. These help in measuring the extent of any known situation and add new tangents to the known reality. They help in baseline evaluation and measure the effectiveness of interventional activities and their ability to change health-related behaviours. In the absence of robust evidence from literature, these recommendations have been formulated with consensus among eminent experts across the country. Therefore, clinicians and experts providing interventions should follow them to attain comprehensive information about women’s knowledge, attitude and practices related to body weight, eating behaviour, physical activity behaviour, sleep pattern and common beliefs/myths associated with the postpartum period. This will aid in bringing about the behavioural change among these women to achieve sustainable weight loss goals. There is a need for developing a centralised module where the assessment of knowledge, attitude and practice is done with the help of randomised controlled trials to generate significant results and gather insights into its efficacy. Some questions that can be discussed to assess knowledge, attitude and practices have been summarised in [Table 4].
1.3 Which healthcare providers should counsel women for their postpartum weight management?
Postpartum women should be counselled about weight management in a strategic, localised and easily adoptable manner. The counselling process should involve dissemination of information about various lifestyle-related aspects such as general weight management advice, dietary habits, physical activity behaviour, sleep and stress management. In India, women are exposed to a plethora of unauthenticated information from friends, family members and relatives. This subsequently affects the readiness of postpartum women to engage in any weight management program. Hence, it is important to identify healthcare providers who would counsel these women. Ideally, it could be a team comprising a physician and/or a gynaecologist, a dietitian/nutritionist for medical nutrition therapy, a physical therapist for exercise and a psychotherapist to address psychological barriers and suggest coping strategies. However, despite the recent advances in the healthcare system, the doctor–patient ratio and the number of trained personnel is still low. Thus, it is crucial to decide as to who should address the participants and provide counselling for different components of weight management. This will ensure successful outcomes either by a multidisciplinary approach or by training and capacity building of auxiliary healthcare providers in resource-limited settings.
Summary of evidence
Various intervention studies for postpartum weight management conducted worldwide have used professionals from different fields of work. In some studies, dietary counselling has been provided by a qualified dietitian[19,20,43–45] and physical activity counselling provided by a physical therapist/exercise physiologist/professional coach/yoga professor,[43,46] whereas in other studies, a trained health educator/lifestyle counsellor has provided weight management counselling.[21,47] Few studies have also delivered the intervention through a behavioural counsellor.[18,21,47] At the same time, there are some studies where a team of experts including nutritionist/dietitian, exercise physiologist/exercise coach, psychologist and health educator have delivered the intervention.
Apart from the intervention studies, there are various guidelines available that suggest that counselling should be provided by the field experts such as dietary counselling being provided by a registered dietitian and physical activity counselling/recommendation should be disseminated by a registered exercise professional. Behavioural counselling is a crucial aspect for successful weight management interventions that should be delivered by behavioural health specialists. Health professionals should advise these women to seek information about diet, physical activity and breastfeeding merely from reliable and authentic sources.
Effective weight management can be done by employing various counselling techniques in different lifestyle domains. This requires a multicomponent and multidisciplinary approach. Although the consensus among the experts suggests the promotion of multicomponent and multidisciplinary approaches, in developing countries like India, it might not be feasible. The tertiary care centres are overburdened, and the obstetricians and paediatricians may not be able to intervene for postpartum weight management. Hence, efforts should be made to involve other paramedical workers such as dietitian, physical therapist, psychotherapist, physicians etc. In rural or resource-limited scenarios where a multidisciplinary team is not available, auxiliary healthcare workers like Accredited Social Health Activist (ASHA), Auxiliary nurse midwife (ANM) and Anganwadi workers can take up the role. This can be attained by skills and capacity building as well as timely training. As a result, they will not only be empowered but also these interventions will reach every nook and corner of the country. Policymakers should set up weight management clinics even in public health centres and impart knowledge about the importance of weight management interventions in the curriculum. This will eventually help in combating the problem of obesity.
1.4 What could be the effective ways of delivering pertinent information to women regarding postpartum weight management?
Counselling or delivering pertinent information in the correct way is crucial to generate awareness and bring behaviour change related to weight management among the participants. However, it can be a daunting task where the doctor to patient ratio is low, and the time and resources are limited. Further, the inadequate knowledge, attitude and practices of the participants coupled with their socio-cultural background may act as a barrier in disseminating information in a manner that is easily understood. Another challenge post-delivery could be the difficulty of reaching out to the postpartum women in physical mode, as they may not even visit the hospital/health centre for their own or baby’s health check-up. Hence, the method chosen for counselling should consider their socio-familial obligations, convenience and availability of resources. It is also important that the participants feel comfortable, and the desired information reaches them as intended. Information can be delivered effectively by employing various techniques and materials such as face-to-face counselling, telephonic counselling, text messages, social media groups and posts, audio-visual aids, emails, newsletters, printed material like pamphlets, leaflets, posters etc. The choice of the method would depend on the sensitivity of the information, the amount of information to be shared and its relevance in the socio-cultural context. Thus, there is a need to decipher various patient-friendly counselling techniques and materials that would aid in conveying the information about postpartum weight management.
Summary of evidence
Many successful postpartum weight management interventions conducted worldwide have used a combination of various counselling techniques and to disseminate information and bring about a behaviour change. These counselling techniques and materials include face-to-face individualised and group counselling,[17,20,56] telephonic counselling,[20,47] individualised diet plans and physical activity goals.[20,21] Various such as lifestyle information leaflets, physical activity booklets, diet plan booklets and pamphlets, motivational videos on healthy recipes and types of exercises and weight loss tips[17,56] have been used. Materials such as weight logbooks and web diaries[17,48,56] and equipments such as weighing scale,[48,58] pedometer[20,48,58] and measuring cups and spoons have been provided for self-monitoring. Motivational interviewing of the participants has been assured through follow-up notebooks, emails and text messages.[17,19,20,56] In-person or telephonic problem-solving sessions have been organised to overcome the barriers.[47,58] Apart from this, social media platforms such as Facebook have been used to create groups and post recipes, videos and tips for weight management.[21,47,58]
The acceptability of any information depends on its mode and way of delivery. A combination of counselling techniques should be used to provide information related to diet, physical activity and other components of weight management. The experts believed that the healthcare provider should decide the mode of counselling based on various factors including infrastructure, availability of resources, expertise of the healthcare provider, clinician to patient ratio and characteristics of the patient attending healthcare settings. The advantages and disadvantages of each method should be weighed adequately [Tables 5 and 6]. The weight management information should be based on the socio-behavioural construct and techniques like goal setting, self-efficacy, motivation, problem-solving and stimulus control should be incorporated. Digital technology should be used prudently to engage these women for weight management. Techniques like text reminders, social media posts, accountability groups on social media apps and weekly phone calls will help in adherence to the guideline and achievement of the goal. Besides, the use of digital technology can be extended for self-monitoring of diet and physical activity. Self-monitoring is the cornerstone of behavioural modification. Self-monitoring techniques like food logging as in a diary or an application, weighing oneself at least twice a week and keeping a track of weight change, log of exercise and daily step count with the use of smartphone apps and pedometers can be used for better outcomes.
Chapter Two: Screening and risk assessment of the target population for initiation of weight management advice
2.1 What body mass index cut-off and other anthropometric parameters should be considered to determine the need to initiate postpartum weight management?
Anthropometric measurements are quantitative measurements of the muscle, bone and adipose tissue to determine the composition of the body. Measurements such as weight, height, body mass index, body circumferences (waist, hip) and skinfold thickness not only play a significant role in serving as diagnostic criteria of obesity but also predict the risk of complications such as type II diabetes, cardiovascular diseases, hypertension etc. Different anthropometric measurements can be used for the assessment and identification of nutritional risk/weight gain in pregnant and postpartum women. However, each assessment method has its own merits and demerits. Furthermore, it is also pertinent to determine respective cut-off values for each method to categorise the population groups as per their nutritional status and body composition. Asian populations have a higher risk of developing comorbidities at even lower cut-off values. In the absence of any reference standards of body mass index for pregnant and postpartum women, it is crucial to ascertain what body mass index cut-offs and other anthropometric parameters can be used in clinical practice keeping in mind the feasibility and availability of resources to identify postpartum women who would be needing guidance or counselling about their weight management.
Summary of evidence
The universally recommended body mass index values for overweight (≥25 kg/m2) and obesity (≥30 kg/m2) were established based on the morbidity and mortality data from the white adult population. These recommended cut-offs have not accounted for ethnic variation in the components of body weight (body fat, muscle mass and total water), particularly observed amongst the Asian Indian population. In Asian Indians, higher body fat and higher cardiometabolic comorbidities are observed at a lower body mass index status. This raise concerns in clinical practice as these individuals who are metabolically obese and predisposed to developing hyperlipidaemia, diabetes, high blood pressure and atherosclerosis are misclassified as individuals with normal body mass index. Considering a greater cardiometabolic risk at a lower body mass index, a revision of the body mass index cut-off for Asian Indians was suggested by recommendation bodies.
Various recent randomised controlled trials conducted have carried out weight-loss interventions among overweight and obese women. Some randomised controlled trials have recruited those women whose present body mass index (body mass index at the time of commencement of intervention programme in the post-delivery period) was in the range of overweight and obese category,[17–21,56,63–65] whereas other randomised controlled trials have used pre-pregnancy body mass index lying in the range of overweight and obesity[45,47,57] as a parameter to identify women needing some kind of weight-related intervention. However, there are two randomised controlled trials that have considered the need for weight intervention programs for types of women with the postpartum body mass index lying in the range of being overweight and obese as well as women whose postpartum body mass index lies in the normal range but have a postpartum weight exceeding pre-pregnancy weight by 4.5 kg or more.[17,56] The waist circumference has been associated with cardiovascular morbidity, all-cause mortality with or without adjustment for body mass index.[66,67] Considering the importance of waist circumference in assessing the cardiometabolic risk factors in an individual, a consensus on a cut-off of waist circumference in the adult population was recommended. For women, a waist circumference of more than 88 cm was considered as an indicator of cardiometabolic risk. In Asian women, the waist circumference of 80 cm was appropriate in identifying cardiovascular risk factors in comparison to 88 cm which was internationally accepted.
Apart from this, women may lose up to 5.9 kg during childbirth, this includes the weight of the baby, amniotic fluid and placenta. In the first week post-delivery, the additional weight is lost by shedding retained fluids and by 6 weeks half of the weight gained in pregnancy is lost. This can be taken up as a time to assess the anthropometric parameters. The fat stored during pregnancy does not diminish on its own and hence, women end up retaining more than 6% of body weight even at 6 months postpartum. There are certain reference guidelines available stating that women who are overweight or obese or have concerns about their weight should be indulged in weight loss interventions.[51,72]
It is very crucial to determine the cut-off point for weight management in postpartum women. The recommendations for cut-off have been set with a regional perspective in mind. Women should be started with weight management when their body mass index is in the overweight category, as it is better to gauge them early and prevent further risk of metabolic complications. The expert group recommended initiating intervention for even those women who have normal body mass index with other suggestive features of central/abdomen obesity. The body mass index cannot truly indicate the fat mass and fat-free mass in an individual’s body and sometimes leads to overestimation or underestimation of disease risk as well. Along with this, pre-pregnancy weight status of women should not be overlooked as it is a significant predictor of postpartum obesity. Efforts should be made to seek information about the pre-pregnancy body weight or body mass index as this will assist in developing a more inclusive and robust intervention. Sensitisation for weight management should begin in preconception and overweight and obese women should be advised for gestational weight gain as per the recommendations. Postpartum women with persistent weight retention should be advised for lifestyle interventions after assessment of their anthropometric parameters at their first postnatal visit (at 6 weeks postpartum), as by this time they have shed most of their retained weight.
2.2 What are the important pregnancy-related and other medical health conditions that should be evaluated during postpartum weight management?
Various pregnancy-related complications such as gestational diabetes, gestational hypertension, preeclampsia etc. have a bidirectional relationship with obesity and can lead to the additional risk of cardiovascular complications. Apart from this, the other chronic conditions related to metabolic health such as diabetes, hypertension, thyroid disorders and renal disorders can influence the weight management regime for postpartum women and hence need to be evaluated. There are various guidelines available that have highlighted the significance of evaluation of pregnancy-related and chronic medical health conditions that can influence the postpartum weight management strategies.[72,74,75]
Prior to the formulation of weight management regimes and their dissemination to the postpartum women, it is crucial to identify various pregnancy-related and other metabolic health complications that may affect their postpartum health. Thus, there is a need to thoroughly understand the effect of different complications on the weight management regime related to dietary behaviour and physical activity levels during the postpartum period. This will assist in the development of individualised weight management strategies for postpartum women undergoing specific health conditions.
Summary of evidence
Available guidelines emphasize on identifying pregnancy-related complications as well as other medical health complications that might lead to the increased cardiometabolic risk in future and hence require attention. Pregnancy-related complications that should be evaluated include gestational diabetes mellitus[72–76]; hypertensive disorders of pregnancy[74,75] comprising gestational hypertension[72,73,76] and pre-eclampsia[72,73,76]; preterm birth[72,73,76]; placental abruption and polycystic ovary syndrome as they can be potential risk factors of weight gain and cardiometabolic complications. Anaemia should also be considered as an important complication to be addressed when formulating postpartum weight management strategies. Apart from this, chronic medical conditions such as diabetes, hypertensive disorders, thyroid disorders, renal disorders etc. of women should also be taken into consideration when engaging them in postpartum weight management, as these specific health conditions may require some alterations in their diet and physical activity regimes.
Weight management is crucial for postpartum women to protect them from developing obesity and other metabolic complications in future. Additional considerations needed to be evaluated for those women who had higher pre-pregnancy body mass index or any metabolic complications before or during pregnancy. These specific health conditions may require modifications in the weight management regime for such women including their diet and physical activity needs. The recommendations have been formulated based on the evidence-based literature and consensus among the eminent experts. Therefore, clinicians and other experts disseminating interventions should consider various pregnancy-related and other metabolic health conditions of these women to provide individualised weight management counselling specific to their health condition for postpartum weight management.
2.3 How should dietary practices be evaluated in postpartum women being engaged in weight management?
Diet is a major component of lifestyle-related factors that can lead to obesity. Pregnant and postpartum women are vulnerable to unhealthy dietary practices due to various socio-cultural myths and practices. Methods/tools used for the assessment of dietary behaviour should provide a holistic comprehension about one’s usual dietary intake, food habits and eating patterns. With this information, the nutritionist can assess the adequacy of food intake, the food groups consumed, food habits and related socioeconomic barriers. Accurate assessment of the dietary intake and practices will help in devising an individualised diet plan. Dietary practices can be evaluated either by subjective report or by objective observation. The subjective report includes open-ended surveys such as dietary recalls or records or closed-ended surveys such as food frequency questionnaires which can be either self-reported or can be done by a trained dietitian/research staff. The objective observation includes methods such as duplicate diet approach or food consumption record at household level which mandates the use of a trained research staff. The strengths and limitations of each method should be adequately weighed with respect to the socioeconomic status and the availability of resources before finalising any method. Moreover, the methods/tools used should be less time consuming with low–moderate participant burden so that authentic information is obtained. This necessitates the healthcare team to choose an optimum assessment method, that helps in acquiring accurate and reproducible data from which significant conclusions can be drawn for postpartum weight management. Thus, there is a need to identify the appropriate method/tool to assess dietary behaviour.
Summary of evidence
Various randomised controlled trials conducted recently have used different tools and methods for dietary assessment. Some interventions have used pre-developed and validated questionnaires to assess weight control practices and eating behaviour.[47,56,57,65,82] Many studies have used 24-h recall,[17,20,23] dietary records[20,83] and food frequency questionnaires[84,85] to obtain information about usual dietary intake. Some studies have used validated questionnaires to assess the fruit and vegetable intake or fat and fiber intake specifically. Apart from this, a prospective study used a combination of 24-h recall and food frequency questionnaire.
There are practice guidelines available that suggest the use of various tools and methods to assess dietary information such as 24-h recall, food records and food frequency questionnaires. They also suggest the use of self-developed questions to assess the participant’s dietary behaviour, food choices, food habits, food security, food-related cultural factors and beliefs and food-related psychological issues.
The recommendations are based on existing practice guidelines, randomised controlled trials and consensus by the experts. The assessment of energy, macronutrient and relevant micronutrient intake from all food groups, along with dietary habits are important as it would help prescribing an individualised diet plan for postpartum women. To attain adequacy in assessment of food intake and its conversion to nutrient intake, it is important to have trained personnel preferably dietitian/nutritionist and they should be willing to devote enough time for the purpose. In contrast to other lifestyle-related factors such as smoking or alcohol, dietary practices are relatively difficult to assess. It is mostly based on the perception of people about their food habits and the amount of food consumed. There is a higher risk of measurement error among the individuals in recalling a complex collection of exposure. Therefore, each method should be weighed for its advantages and disadvantages [Table 7]. Moreover, while conducting a 24-h recall, samples of commonly used standardised measuring cups, plates, ladles and spoons or various chapati size cut-outs should be shown to women to gather adequate data on food intake. Since 24-h recall and food frequency questionnaires are widely accepted tools for dietary assessment, they should be used in combination. In addition to these tools, detailed dietary behaviour should be considered in daily clinical practice. Some specific points need to be emphasised upon to obtain a detailed dietary behaviour have been mentioned in [Table 8]. Special attention should be paid to assess micronutrients such as iron, calcium and vitamin D. Iron deficiency anaemia should be assessed through haemoglobin levels and serum ferritin levels (refer Annexure 2). Dietary calcium intake can be assessed using the National Osteoporosis Foundation tool (as shown in Annexure 3). The tool assists in comparing the actual daily dietary calcium intake and the recommended daily allowance for calcium to assess the adequacy of calcium intake. Vitamin D enhances calcium absorption. Vitamin D deficiency can be assessed through serum 25-hydroxyvitamin D levels (refer Annexure 4). Apart from the dietary consumption pattern, the other dietary components related to socio-cultural myths and barriers should be assessed using developed and validated questionnaires (Annexure 1). Dietary diversity questionnaires can be used to capture the intake of various food groups along with their quantities. Such questionnaires can also be used in resource-limited settings where a registered dietitian is not available to conduct 24-h recall or use food frequency questionnaires. The dietary behaviours should be duly assessed using the combination of appropriate tools and methods to formulate robust interventions.
2.4 How should daily physical activity levels be evaluated in postpartum women being engaged in weight management?
An adequate amount of physical activity is important in postpartum weight management. It increases energy expenditure and provides various health benefits. It is pertinent to assess physical activity status of postpartum women as it will help in understanding their ability to participate in various types of physical activity. The daily activity of postpartum women can be comprehensively assessed under the following domains: exercise, occupational, household-related, leisure-related and sedentary activities. There are various techniques to assess physical activity such as self-reported questionnaires (including diaries, recall questionnaires and interviews), direct behavioural observation and physiological markers like heart rate, motion sensors and calorimetry by use of devices (accelerometer, pedometer and heart rate monitor). The selection of a method should be done by assuring that the obtained results represent normal daily activity. The selected method should be feasible, with minimal participant discomfort and should lead to significant conclusions that can be applied to a larger population. Hence, it is important to determine the objective, valid and reliable methods for the comprehensive assessment of physical activity in postpartum women.
Summary of evidence
Various randomised controlled trials conducted worldwide have assessed the physical activity levels of the participants. A variety of tools and methods have been used in different studies such as International Physical Activity Questionnaire[23,57,65,82,83] which helps in assessing habitual physical activity in a population across different socio-cultural contexts. It has two versions—a long form and a short one which can be chosen as per the feasibility. Pregnancy Physical Activity Questionnaire helps in assessing duration, frequency and intensity of physical activity among pregnant women with dedicated physical activity domains such as work-related activities, leisure-related activities, transport-related activities and sedentary activities (screen and sitting time) for a comprehensive assessment. Apart from this, Pregnancy Infection Nutrition 7-day physical activity recall and Paffenbarger Physical Activity Questionnaire have also been used to assess the duration, frequency and intensity of physical activity. In addition, some studies have used physical activity trackers, armbands and pedometers to measure step counts, energy expenditure and sleep time.[17,20,23,56] Few studies have also evaluated sedentariness by asking pre-developed questions on sitting time, television viewing etc.[65,84] One of the randomised controlled trials has used the Physical Activity Neighbourhood Environment Scale, a pre-developed and validated questionnaire to assess the physical activity environment of the participants. A valid and reliable physical activity questionnaire, that is, Madras Physical Activity Questionnaire (MPAQ), is also available to assess an individual’s physical activity level from various domains. It assesses various dimensions of physical activity such as frequency, intensity, type and duration and is suitable for the Indian population.
The recommendations on physical activity assessment during postpartum are based on existing practice guidelines, randomised controlled trials and consensus by the experts. The selection of assessment methods whether subjective or objective must be done based on the feasibility and availability of resources. Therefore, each method should be weighed for its advantages and disadvantages [Table 9]. A validated physical activity tool MPAQ has been found to be feasible for physical activity assessment of Indian population assisting in a detailed assessment of daily physical activity by comprising various components such as dedicated physical exercise, work-related activities, leisure-related activities, transport-related activities and sedentary activities. However, in resource-limited settings, where the tool might not be available, certain points should be taken into consideration while assessing the physical activity behaviour depicted in [Table 10]. Further, the focus should be laid on the type of physical activity (stretching/strengthening/aerobics/balance), intensity of physical activity (light/moderate/vigorous), duration of participation (in minutes per day) and frequency of involvement (days per week). Consensus among the experts suggested that postpartum women are saddled with childcare that often leads to stress or mental fatigue. Hence, it increases their indulgence in sedentary activities like sitting, increased screen time etc., and reduced household activities. Therefore, time spent in sedentary activities should be duly assessed. Along with this, focus should be given to assess various social, physiological and cultural barriers to physical activity faced by women. These parameters can be assessed by using a comprehensive tool designed for Indian postpartum women (Annexure 1). The healthcare provider should consider the feasibility of the assessment approach before including it into daily clinical practice.
2.5 How should psychosocial variables/health/parameters be evaluated in postpartum women being engaged in weight management?
The methods/tools used to assess psychosocial variables should cover various aspects of unhealthy behaviours that may lead to limited compliance and subsequent weight gain. The methods/tools used should be such that they evaluate participants’ self-efficacy, self-esteem, body image concerns, perceived stress due to added responsibilities and challenges and social support. Apart from this, methods/tools used should be less time consuming and have a low participant burden to obtain appropriate information. Thus, it is essential to identify which methods/tools should be used for the evaluation of psychosocial parameters.
Summary of evidence
Many randomised controlled trials have been conducted worldwide assessing different psychosocial parameters. Various developed and validated questionnaires have been used to assess different aspects of psychosocial health such as self-efficacy, self-regulation, social support, body image concerns, perceived stress, depressive symptoms, emotional coping and sleep patterns. Most commonly used validated questionnaires have been Edinburgh Postnatal Depression scale for assessing depressive symptoms,[23,25,47,56,57,82,84] body shape questionnaire and EQ-5D-5L[19,57] to evaluate body image concerns and Perceived Stress Scale to assess perceived stress.[23,56,85,86] A wide variety of tools such as Self-efficacy subscale, Self-efficacy for Physical Activity Questionnaire, Exercise Self Efficacy,[65,82] Marcus and colleague’s validated questionnaire, Self-efficacy for Diet Questionnaire and Weight Self Efficacy[65,82] have been used in various studies to assess the participants’ self-confidence to indulge in healthy behaviours. Self-regulation questionnaires such as Exercise Goal-Setting Scale and HealthStyles survey have been used to assess self-regulation for exercise and diet, respectively. Stress and emotional coping strategies have also been evaluated by various scales such as Rhode Island Stress and Coping Inventory[65,82] and validated questions related to emotional eating, physical activity and stress management. Social support in the form of emotional support, instrumental support and informational support from friends and family has also been assessed through validated questions.[56,65,85] Sleep being another crucial component of psychosocial health has been evaluated using developed and validated questionnaires such as Sleep Pattern Questionnaire, General Sleep Disturbance Questionnaire and Pittsburgh Sleep Quality Index[25,82] to measure sleep quality and habits.
The recommendations are based on the evidence obtained from randomised controlled trials and consensus by the experts. It is crucial to assess the psychosocial health of postpartum women routinely to ensure their optimal engagement in the weight management interventions. Appropriate questionnaires that are not only short and less time consuming but also help in the screening of depressive symptoms should be used (such as PHQ-2). Apart from this, various psychosocial cues such as emotional eating, sudden lack of motivation for continuing healthy behaviour and sudden loss of drive for active participation in the weight management programme should be identified to provide required psychiatric/psychologist help to such women. The mental health professional or a psychologist can then use various validated tools available such as Edinburgh Postnatal Depression scale, Perceived Stress Scale, Self-efficacy subscale, body shape questionnaire etc., for detailed evaluation of psychosocial health.
Chapter Three: Management of weight
3.1 How should stepwise weight loss goals be set for postpartum women being engaged in weight management?
Weight management is a systematic process comprising various techniques and processes to attain healthy body weight. This primarily requires goal setting to pave the way for behavioural changes which focus on gradual lifestyle changes. Weight loss goals comprise self-monitoring, increasing motivation, mental stability and accountability. These goals should be specific, measurable, attainable, relevant and time-limited (SMART). They should allow room for setbacks, reassessment and adjustment as needed. Goals can be short-term and long-term based on the weight status of the postpartum women. Clinicians should set personalised, achievable evidence-based goals after a thorough evaluation of lifestyle-related factors. Clinically significant weight loss goals, that is, a modest weight loss goal of 5% to 10% facilitate intra-hepatic and intra-abdominal fat loss. This also improves glycaemic and triglyceride levels, thereby preventing the development of cardiometabolic diseases. Thus, it is important to identify weight loss goals specific to postpartum women which not only help in their weight loss but also improve their overall health and well-being.
Summary of evidence
Various intervention studies have been conducted to bring about clinically significant postpartum weight loss among women post-delivery. However, clinically significant weight loss goals have been defined differently across these studies such as 5% or 10% weight loss from baseline after 12-week intervention,[21,97] 5% or 10% weight loss by 12 months postpartum/post-intervention,[17,57] 10% ± 3% weight loss from baseline after 16-week intervention, 5% weight loss over a 6-month period and 3% weight loss from baseline after 14-week intervention. There are studies that have reported a clinically significant weight loss goal as weekly weight loss of 0.5 kg for final weight loss of 6 kg after 12-week intervention.[19,20,82] Further, some studies that have defined clinically significant weight loss goals separately for postpartum women who have had normal pre-pregnancy body mass index and those who were in the overweight/obese body mass index category pre-pregnancy. These studies suggest that the clinically significant weight loss goal should be set for women with normal pre-pregnancy body mass index as achievement of pre-pregnancy weight by 6 months and 12 months postpartum, whereas women who were overweight or obese before pregnancy should lose an additional 5% of pre-pregnancy weight by 6 months and 12 months postpartum.
As per evidence and consensus by the experts, the goal setting process for postpartum weight loss should be SMART. The goal should be specific (i.e., losing 0.5 kg in a week or 5 cm from waist circumference in a month), it should be prompt and motivate the participants. It should be measurable and produce quantifiable results (i.e., consuming 1400 calories in a day, eating five servings of vegetables or walking 8000 steps every day). It should be attainable, where the participant has enough time and resources to achieve it (i.e., easy to cook weight loss recipes and home-based workouts for postpartum women). It should be relevant, individualised and evidence-based to achieve sustenance (i.e., planning a diet based on estimated average requirements (EAR) as per current body weight in consideration of dietary habits). It should be time-limited (i.e., weight loss target of 10% of body weight over 6 months or attaining pre-pregnancy body mass index by 6 months postpartum). The goals can be short-term and long-term, since long-term goals seem more difficult to attain, they can be fragmented into smaller goals (i.e., a woman needing to lose 20 kg of body weight may split it into smaller weight loss goals of 2 kg/month). The clinician should always formulate these goals after a thorough evaluation with a provision for setbacks. If the need arises, the goals can be adjusted by reassessment. While setting the weight loss goals, clinicians should ensure a healthy weight loss, that is, women lose their additional/retained fat mass rather than lean mass or fat-free mass. They should be advised to achieve and maintain their body mass index in the normal category (18.5–22.9 kg/m2).
3.2 In postpartum women, what type of dietary recommendations should be advised for improving weight management, anthropometric and metabolic health outcomes?
Dietary interventions are one of the most crucial components of postpartum weight management. Usually, weight reduction in other stages of life is done by consuming a calorie deficit diet; however, the postpartum period is a demanding phase as the requirement of both macronutrients and micronutrients increases for lactating women. This makes it challenging to manage postpartum weight without compromising maternal health and nutrition. The challenges further escalate as there are various diet-related myths associated with this period particularly in Indian context. It is generally believed that postpartum women should increase the quantity of food intake as they have to eat for two, that is, for the mother and infant. It is believed that mothers should be allowed to eat more than their satiety levels and should not follow any diet plan, as it will lead to reduced milk formation. Moreover, to meet the increased energy demands, mothers during this phase are usually fed ghee and other high calorie foods in the form of galactagogues such as ladoos that are rich in fat and sugar.[12,102,103] The focus is usually on intake of calorie-dense foods rather than nutrient-dense foods, which generally result in weight gain and micronutrient deficiencies in postpartum women.[104,105] Apart from this, experts have seen that mothers who experience failure of lactation or have early cessation of breastfeeding also have high calorie foods in the view of their post-delivery recovery usually on the advice of their elders. Various myths related to dietary intake in this phase may consequently lead to weight gain. Thus, there is a need for setting individualised dietary goals for postpartum weight management depending on the mother’s body mass index, breastfeeding status and physical activity levels.
Summary of evidence
Various recent randomised controlled trials have targeted the dietary habits and behaviour of postpartum women to manage their weight. Of these trials, the majority have reported significant outcomes in terms of postpartum weight loss without compromising the health of the mothers. The interventions included either all or some of the components for disseminating dietary interventions such as individualised diet plan,[19,21] macronutrient and micronutrient information, dietary composition of <30% energy from total fats, 10% to 20% energy from proteins, 50% to 60% energy from carbohydrates, ≥12.5 g fiber per 1000 kcal, individualised calorie goals ranging from 1200 to 1800 kcal/day with additional 300 kcal for those breastfeeding and a reduction in 500 kcal/day for women with body mass index in the obese category.[19,20] Other components for disseminating dietary interventions comprised covering half of the plate with vegetables at lunch and dinner, limiting sugar-sweetened beverages,[20,47] limiting high fat, salt and sugar foods,[20,47] controlling portion sizes, information on restaurant eating and label reading. However, some interventions with non-significant outcomes either reported high attrition rates or a lack of relapse prevention. These interventions with non-significant results have suggested that participants with high intervention adherence may have positive outcomes, thus benefiting these women.
Apart from intervention studies, there are various national, international and practice guidelines available for dietary management of postpartum women. These guidelines recommend macronutrient composition of diet, and requirement of micronutrients such as calcium,[49,105,106] iron, vitamin C,[49,104,106] vitamin D, vitamin B6, vitamin B12 and iodine.. The guidelines give food group specific advice such as number of servings of various food groups,[107,108,109] consumption of nutrient dense foods, covering half of the plate with fruits and vegetables and the other half with whole grains, intake of one serving of oilseeds and nuts per day and limiting foods high in fat, salt and sugar.[107,110] The guidelines also recommend healthy dietary practices such as consuming small frequent meals as three major and three minor meals,[106,107] consuming nutrient-dense snacks,[106,107] avoiding skipping meals,[49,107] using healthy cooking methods such as boiling, grilling and steaming, limiting the intake of caffeine drinks such as tea and coffee to two to four drinks per day,[104,107,110] avoiding/limiting alcohol intake,[107,108] avoiding smoking and avoiding fad diets.
Postpartum weight management can be carried out by maintaining appropriate calorie intake. Individualised calorie goals should be set for postpartum women depending on their body mass index, breastfeeding status and activity levels. Eating preferences and food habits should be taken into consideration while prescribing a diet to an individual. Breastfeeding mothers have higher calorie requirements and thus, should be provided additional 300 to 500 kcal/day. However, those not breastfeeding do not require any additional calorie intake. The calorie intake for postpartum women having body mass index in the overweight and obese category should be reduced with a maximum deficit of 500 kcal/day. The composition of calorie intake should be 50% to 60% energy from carbohydrates, 15% to 20% energy from proteins and <30% energy from total fats. Focus should be laid on consumption of complex carbohydrates and fiber rich foods rather than simple carbohydrates. High protein diet and consumption of good quality fat (monounsaturated fatty acid and omega-3 fat sources) should be encouraged. Apart from the macronutrient intake, postpartum period is usually accompanied with micronutrient deficiencies as the requirement of some micronutrients increase but their intake is generally low. It is crucial to lay emphasis on adequate intake of micronutrients such as calcium, vitamin D and iron in accordance with the EAR provided by Indian Council of Medical Research (Annexure 5). Dietary sources of calcium and iron are presented in (Annexure 6 and Annexure 7), respectively. Postpartum mothers should be encouraged to meet additional requirements of micronutrients by consuming local and seasonal fresh fruits and vegetables and using techniques such as fermentation and germination to improve micronutrient content of food. Galactagogues usually consumed during this period should be nutrient-dense rather than calorie-dense. Emphasis should be laid on consumption of galactagogues such as milk, fenugreek seeds, garlic, fennel seeds, flax seeds, sesame seeds, nuts, edible gum (gondh) and green leafy vegetables. Added fat and refined sugar in galactagogues such as ladoos and panjirees should be discouraged. Further, the intake of alcohol and caffeine should be limited or avoided as they hamper micronutrient absorption. Besides, small, frequent meals should be promoted as three major and three minor meals. Meal skipping should not be considered synonymous to intermittent fasting. Intermittent fasting is developing as a new approach to weight loss; however, it is done under medical supervision taking care of the nutritional needs of an individual. On the contrary, meal skipping refers to the lack of intake of either one or more main meals (breakfast, lunch and dinner) under no medical supervision. Meal skipping should be discouraged as this can affect the nutritional status of the mother. Crash diets and fad diets usually followed to reduce weight at a faster pace should be highly discouraged as these diets cannot be sustained upon for long run. Healthy cooking methods such as grilling, boiling and steaming should be preferred over frying as this will assist in prevention of empty calorie intake.
3.3 In postpartum women, what type of physical activity recommendations should be advised for improving weight management, anthropometric and metabolic health outcomes?
Physical activity interventions hold significance as sedentary behaviour is quite prevalent among postpartum women. Various myths related to physical activity are commonly followed around the time of pregnancy and postpartum period. It is believed that physical activity during pregnancy could be dangerous for both mother and the foetus. The inactive lifestyle during pregnancy usually persists in the postpartum period wherein postpartum women are bound to follow certain traditional customs such as ‘doing the month’ particularly in Indian settings. These women are advised to restrict physical activity including their participation in some common household chores. Consequently, women tend to decrease their activity levels post-delivery, whereas their sitting time including the screen time increases. Physical activity is crucial to lose excessive weight, especially the fat mass gained at the time of pregnancy.[113,114] Despite potential benefits of physical activity, postpartum women not only lack information about the right time to begin an exercise regime but also the type and intensity of activity to be adopted. There is a need for individualised physical activity regimes for weight management to be advised to postpartum women depending on their mode of delivery, complications, if any, and neighbourhood built-environment characteristics.
Prior to the formulation and dissemination of weight management interventions to the postpartum women, it is crucial to identify the physical activity component and evaluate its role in postpartum weight management.
Summary of evidence
Recently, various randomised controlled trials have been conducted targeting physical activity levels of postpartum women along with dietary intervention. These interventions consisted of either one or more components for disseminating physical activity advice such as basic information about physical activity, culturally sensitive videos for both indoor and outdoor activities, individualised step count goals of 5000 steps per day, recommendation to gradually increase physical activity[20,63] up to 150 min per week, encouraging women to set specific goals such as taking brisk walks or walking with the stroller. The intervention studies further include physical activity components such as reducing the sitting time and television watching to less than 2 h per day. Mixed findings have been reported, wherein few interventions have shown significant weight loss outcomes[17,20,21,47,56] while others did not report any significant findings owing to high attrition ratesor lack of relapse prevention. Yet, the combination of these dietary and physical activity interventions suggests positive weight loss outcomes with improved metabolic health for participants with high intervention adherence. A systematic review has also reported that a combination of diet and physical activity interventions are successful in bringing about significant weight loss goals as compared with the physical activity intervention alone.
Apart from the intervention studies, various international and national guidelines are available providing physical activity recommendations for postpartum women. The guidelines recommend those women with uncomplicated pregnancy and delivery to indulge in mild exercises such as walking, pelvic floor exercises and stretching as soon as post-delivery, whereas for those with complicated pregnancy or caesarean delivery, it is recommended to resume to pre-pregnancy physical activity levels after the first postpartum check-up usually done at 6 to 8 weeks post-delivery. Further, guidelines recommend these women to indulge in moderate-intensity aerobic[50,109,116] and muscle strengthening exercises[50,109,116] and gradually increase the intensity and duration of their activity.[50,109,117] Talk-tests should be used to measure the intensity of aerobic exercises.[109,118] If the speech is comfortably possible, then it is a light-intensity activity; if speech is possible with certain difficulty level, then it is a moderate-intensity activity; and if a person cannot speak much without taking a pause for breath, that is, speech is limited only to short phrases, then it is a vigorous-intensity activity. Apart from this, guidelines related to breastfeeding and physical activities are also available. It is recommended that lactating mothers should be informed that they can breastfeed their infants and indulge in a routine physical activity regime. However, they should be advised to either express/pump their breast milk or breastfeed their baby before the initiation of physical activity.[88,108]
Various myths are related to physical activity during the postpartum period. Especially in Asian countries like India, the period of confinement for the first 40 days post-delivery is usually practiced. Consequently, postpartum women land up being sedentary. It is crucial to burst myths related to physical activity specifically during the postpartum period and raise awareness among these women about the type, intensity and importance of various exercises that should be performed during this period. Depending upon the complications and mode of delivery, postpartum women should be motivated and guided to indulge in physical exercise. Women with no complications and normal delivery should be encouraged to resume physical exercise within 4 to 6 weeks post-delivery or as soon as they feel comfortable, whereas women with complications or caesarean delivery should be screened for their ability to exercise during the first postpartum visit usually held between 6 and 8 weeks postpartum. Lactating mothers should be encouraged to indulge in physical exercise. They should be informed that lactic acid content increases in breast milk when indulging in vigorous-intensity activities, whereas participating in light-moderate intensity activities does not affect their breastfeeding status and composition. However, women who tend to develop mastitis should be restricted from performing upper-body exercises. Postpartum women should be encouraged to set individualised, realistic physical activity goals such as an aim of gradually achieving 10,000 steps per day. They should be encouraged to indulge in moderate-intensity aerobic physical activity like brisk walking for at least 150 min per week (30 min per day for 5 days per week), excluding the warm-up and cool-down time and minimum of 10-min bouts per session. Women should be encouraged to start walking gradually from slow to brisk walking. They can be motivated to practise breathing exercises and gentle yoga. Kegel exercises such as contraction of pelvic floor muscles should be advised. Once they get used to the intensity or duration of a type of exercise, they should be further encouraged to increase the intensity (low to moderate to vigorous) and/or duration (progressively increase 5 min per session per week till the goal is reached). Postpartum women should also be educated about the talk-test to measure the intensity of their activity. If their speech is comfortably possible while exercising, then it is a light-intensity activity; if their speech is possible with a certain difficulty level, then they are performing a moderate-intensity activity; and if they cannot speak much without taking a pause for breath, that is, speech is limited only to short phrases, then they are getting indulged in a vigorous-intensity activity. Different physical activities that can be planned for postpartum women have been presented in [Table 11]. Sedentary behaviour of these women should also be targeted. Women should be encouraged to reduce their sitting time along with the screen time. Apart from this, various barriers are usually faced by postpartum women such as lack of time, energy, space etc. to indulge in physical exercise. In such cases, where mothers are unable to spare time separately or they do not have provision of walking tracks and fitness centres, they should be motivated to perform activities inside the house involving their infants such as walking while strolling the baby in a pram or performing abdominal exercises while lying next to the baby.
3.4 How can breastfeeding practices be useful for postpartum weight management?
Breastfeeding is known for its various health benefits not only for infants but for mothers as well.[119,120] It is recommended that the baby be breastfed exclusively for 6 months postpartum and 2 years beyond along with complementary feeding for better growth and development. Moreover, breastfeeding reduces the risk of breast cancer and ovarian cancer among mothers. Theoretically, it is believed that breastfeeding involves increased energy cost of lactation and should assist in postpartum weight loss. However, the available evidence is limited and inconsistent.[109,123] Postpartum women with failure of lactation or early cessation of breastfeeding do not require any additional calories because it might lead to positive energy balance and subsequent weight gain.
Prior to the formulation and dissemination of weight management interventions, it is crucial to identify the breastfeeding component and evaluate comprehensively its role in postpartum weight management.
Summary of evidence
Available evidence suggests that breastfeeding has various health benefits both for the offspring and the mother. However, inconsistent findings have been reported about its effect on postpartum weight loss. Some studies, systematic reviews and meta-analysis did not find any significant association between breastfeeding and postpartum weight loss,[124,125] whereas other studies reported some significant association between the duration and intensity of breastfeeding with postpartum weight loss.[123,126–133] A recent meta-analysis reported that women getting benefit from breastfeeding in postpartum weight loss are mostly those whose age is less than 30 years, who are primiparous and had normal pre-pregnancy body mass index. Hence, breastfeeding cannot be solely relied for postpartum weight loss among women aged above 30 years and who are overweight or obese. Further, evidence suggesting significant association between breastfeeding and postpartum weight loss have stressed on the need for more robust studies to rely on such findings. Certain guidelines also state that breastfeeding should not be solely relied upon for postpartum weight loss.
There are postpartum women who experience failure of lactation or early cessation of breastfeeding. Available evidence suggests that postpartum women who are not breastfeeding do not need any additional calories. Their nutrient requirements are the same as the non-pregnant non-lactating women; however, adjustments can be made according to their nutritional status.
Breastfeeding is highly recommended for both the offspring and the mother. Exclusive breastfeeding for the first 6 months postpartum and continued breastfeeding along with complementary feeding for 2 years and beyond can have health benefits for the mother and her infant. Breastfeeding is theoretically considered to involve increased energy cost; however, considering breastfeeding as the sole intervention for postpartum weight management is conflicting and hence, dietary and physical interventions should also be taken into consideration for postpartum weight loss. Moreover, the additional calorie intake of lactating women should not be supported under special conditions, wherein a mother experiences failure of lactation or early cessation of breastfeeding as this might lead to positive energy balance and ultimately weight gain. Hence, the requirement of such mothers is same as for non-pregnant, non-lactating women.
3.5 What are the behaviour modification techniques that should be incorporated in weight management advice?
Weight management interventions are usually associated with slip-ups, challenges and barriers and lack of motivation and support which may act as a hurdle for participants to achieve significant weight loss goals. The comprehensive weight management interventions not only involve the dietary and physical activity components but also take the behavioural modification into consideration.[11,27] The behavioural component of the weight management interventions should include the nutrition and exercise counselling along with identification of the barriers to healthy behaviour, problem-solving strategies, facilitation of support from family and team of healthcare providers. Behavioural modification should be such that it focuses on weight loss during interventions as well as maintenance of healthy behaviour even after the interventions are completed.[11,27]
Prior to the formulation and dissemination of weight management interventions to the postpartum women, it is crucial to identify various components related to behavioural modification that might be incorporated in weight management interventions to improve its success rates. Thus, there is a need to have a comprehensive evaluation of various aspects of behaviour modification.
Summary of evidence
Many randomised controlled trials have been conducted that have taken the behavioural strategies into consideration to enhance the adherence to diet and physical activity advice as well as to maintain this healthy eating and activity behaviour in the long run. Various components of behavioural modification have been adopted in different weight management interventions such as individualised goal setting, stimulus control, self-monitoring, problem-solving, reinforcement, social support, self-efficacy, coping strategies, knowledge and self-regulation. At the time of initiation of weight management interventions, many trials have used goal setting as a behavioural strategy to set realistic and individualised dietary and physical activity goals.[17,21,23,25,44,45,56,63,84,85] During the interventions, self-monitoring of diet, exercise and weight was adopted to ensure better compliance with the weight management regime.[21,23,25,44,45,84] Various other behavioural techniques such as motivational interviewing,[17,56,84,85] problem-solving,[21,23,56] relapse prevention,[21,25,56] coping strategies, social support[17,21,23,25,85] and reinforcement[23,86] have also been adopted during follow-ups to improve the adherence to weight management interventions. Apart from this, text messages and monthly group meetings have been planned to educate participants about calorie goals, grocery shopping, label reading and restaurant eating.
Weight management interventions must be individualised and realistic to obtain significant outcomes. Participant-specific, practical weight loss targets should be set at the time of initiation of the intervention. Further, participants should be motivated to adhere to the intervention to obtain significant weight loss outcomes. Various behavioural skills such as self-monitoring, stimulus control, problem-solving, emotional eating and relapse prevention should be imparted to the participants for better compliance to the intervention as well as to ensure the healthy lifestyle modification even after the intervention is over.
Chapter Four: Follow-up for sustainable weight management
4.1 What should be the duration, frequency, and mode of contact during the intervention and follow-up phases of the weight management program in a postpartum woman?
The intervention phase of the weight management program is the period when a participant is subjected to appropriate intervention for attaining the target body weight, whereas the period of follow-up is focused on the sustenance and perseverance of the achieved goal. The duration, frequency and mode of contact during the intervention phase and follow-up phases are pivotal for better engagement of participants, reinforcement of lifestyle-related changes and addressing barriers. The duration can be long or short, depending upon the quantum of the weight that needs to be shed to attain the target body weight. Similarly, the frequency of follow-up can be intense or subdued, depending upon the need for reinforcement and monitoring. The mode of follow-up can be face-to-face or technology-based depending on the feasibility and availability of resources. The correct selection of these components of follow-up helps in adequate and better compliance of the interventions. It also increases the overall effectiveness of the program. However, each intervention has unique objectives and methodology and is set up in different socio-cultural backgrounds. Therefore, it is crucial to determine the appropriate duration, frequency and mode of contact for follow-ups so that they are effective and do not pose an additional burden on the participants.
Summary of evidence
Many intervention studies have been conducted worldwide considering the follow-ups to ensure the success of the intervention. However, in the postpartum group, there are mixed results for the duration and frequency of follow-ups. Various successful intervention trials for weight management of postpartum women have been conducted with either two[17,20,56,57] or three follow-ups. Some of the successful interventions conducting two or three follow-ups have conducted it with a gap of 3 months to 6 months between follow-ups,[56,57] whereas others have done it 1 year after the baseline.[19,20] Available evidence indicates that the mode of follow-up in the intervention trials conducted is of two major types: personalized sessions[19,20,47,57] and e-consultations.[17,21] Both methods have also been used both in combination.
All the participants engaged in the weight management program should be closely followed during the intervention period. The expert panel believed that the clinically significant weight loss targets should remain the same for everyone. However, for women with substantial weight retention, the target should be redefined with increased duration and frequency of follow-up to help them reach the ideal body weight. Consensus and evidence suggested that the period of intervention should have gradual and realistic time periods; they may range from a minimum of 6 weeks to a maximum of 12 months or even 18 months. The effectiveness at the initial stages of intervention can be increased by having more frequent contacts (one to two times/month). Face-to-face contacts supplemented by technology in terms of bi-weekly texts, social media posts or online support groups can be used for follow-up. They help in building mutual trust between the participant and the healthcare team. As the period of follow-up is focused on the sustenance and perseverance of the achieved goal, experts suggested that the period of follow-up ideally should be lifelong as women of reproductive age are prone to obesity in all life stages ranging from conception to menopause. Apart from this, the modalities for follow-up should be feasible for both patient and the healthcare provider. During the intervention, provision of patient education should be done where knowledge and awareness about the importance of regular follow-ups should be imparted. Participants may be contacted every 3 to 6 months to enquire about their health status and should be advised to visit the healthcare centre at least once a year for routine check-ups and investigations related to obesity. This will serve not only as a preventive practice but also curative.
4.2 What advice should be given during the follow-up phase for maintenance of weight in postpartum women?
An effective follow-up is timely planned, executed through proper channels and comprises appropriate and adequate advice. The advice given during the follow-up session is crucial to ensure adherence to an interventional goal and sustain the attained goal. The advice should be evidence-based to formulate effective monitoring strategies. It should reinforce the imparted knowledge and motivation to move towards the goal and sustain the progress made. Emphasis should be given on components like identification of relapse, prevention of relapse and problem-solving strategies. The given advice should bring about a long-term behaviour change in participants so that they are able to manage appropriate weight even after the cessation of the intervention. The advice should be clear, simple and easy to follow. It should be devised by considering the participants’ characteristics, feasibility, availability of resources and all lifestyle-related factors should be given due importance.
Summary of evidence
After the commencement of intervention, it is crucial to ensure the compliance of participants with the treatment. Various successful randomised controlled trials conducted have delivered behavioural therapy during the follow-up periods. The studies have reported the setting of individualised goals and motivating the participants to do self-monitoring. Follow-up periods have been utilised by the interventions to increase the likelihood of favourable lifestyle change[19,20] by imparting skill training, problem-solving abilities, dealing with various barriers and relapse prevention training.
Apart from these randomised controlled trials, there are certain practice guidelines suggesting that a follow-up period should be utilized to burst participants’ myths associated with various aspects of lifestyle such as diet and physical activity. During this period, it is crucial to reinforce the advice delivered during the intervention and conduct motivational interviewing.
In the absence of robust evidence on this topic, majority of the advice recommendations were formulated on consensus by the experts. It is pertinent to give advice about various lifestyle factors such as diet, physical activity, stress and sleep. Behaviour change is the cornerstone of achieving success in any lifestyle-related intervention hence, during a follow-up, efforts should be made for imparting behavioural skill training such as self-monitoring, stimulus control, problem-solving and relapse prevention. Self-monitoring can be done by weighing oneself at home, measuring waist circumference, tracking calories and step counting. Stimulus control can be practised by teaching healthy food habits, portion control and mindful eating. Relapse prevention may be achieved by the provision of support groups, training for identification of triggers and development of healthy and appropriate coping mechanisms. Apart from this, the provision of health monitoring cards (comprising anthropometric measurements, biochemical parameters, clinical signs or symptoms and diagnosis) should be done for women at the time of post-delivery discharge. This will ensure a sense of accountability in both patient and healthcare provider and will increase the turnout for follow-ups as well. The action points at different anthropometric and biochemical parameters are presented in [Table 12].
Women during reproductive age are at increased risk of postpartum weight retention and weight gain.[8,139] These evidence and consensus-based weight management recommendations for postpartum women holistically cover the core components of weight management, that is, diet, physical activity and behavioural modifications. The dietary recommendations consider the appropriate combination of methods to comprehensively assess dietary behaviour of postpartum women without any added participant burden. The recommendations also take into consideration the dietary composition (macronutrient and micronutrient intake), calorie intake of lactating and non-lactating women, galactagogue consumption, meal pattern, methods of cooking and restriction of intake of HFSS foods. This will raise the knowledge of postpartum women about the quality and quantity of foods to be consumed and will assist them to correct their faulty eating habits, if any. The adoption of these guidelines will also help in bursting the diet-related socio-cultural myths that otherwise lead to weight gain.
The physical activity component encapsulated in the recommendations suggests the use of validated and reliable questionnaires to obtain the explicit information about the physical activity levels of postpartum women. The recommendations also highlight the duration, frequency, intensity and type of physical activity to be indulged in depending upon the woman’s readiness, prior physical activity status, mode of delivery, and complications, if any. Generally, postpartum women either do not wish to indulge in any kind of physical activity or if they desire to, they fail to do so due to the lack of knowledge about the time of initiation of physical activity and type of exercises they can do. These physical activity recommendations will enhance the knowledge of postpartum women about the importance of physical activity. This will also increase their awareness about the duration, intensity, frequency and type of exercises they can perform post-delivery and burst socio-cultural myths associated with being physically active during this phase.
Along with the diet and physical activity, the guideline includes behavioural recommendations related to goal setting, self-monitoring and problem-solving to empower these women to sustain their weight management efforts. Individuals may set unrealistic goals or experience slip-ups, ultimately losing interest in managing their weight. These behavioural recommendations will assist in counselling these women to set realistic weight loss goals, self-monitor their diet and physical activity and develop problem-solving abilities to ensure long-term sustenance.
Benefits for healthcare fraternity
The adoption of these evidence and consensus-based recommendations will prove to be beneficial in resource-limited settings. India, being a low-to-middle-income country does not have adequate healthcare infrastructure and facilities available in every corner of the country. Further, India has a high proportion of population belonging to the low-to-middle income strata. Such a portion of the population many a times is unable to access multi-speciality hospitals or healthcare centres and they resort to the primary healthcare centres, anganwadi centres etc., where there is a lack of comprehensive medical care team.[140,141] These recommendations may be helpful in such settings where a comprehensive team of healthcare professionals comprising obstetricians and gynaecologists, dietitians, exercise experts/physiotherapists, clinical psychologists, physicians and endocrinologists is not available.
During pregnancy, women visit the obstetricians and gynaecologists, while in the postpartum period, they visit the paediatricians and/or obstetricians. Women belonging to low socioeconomic strata may find it feasible to visit local public health centres and anganwadi centres. Due to lack of time or information and financial constraints, many postpartum women fail to visit specific field experts such as nutritionists to gain knowledge about appropriate diet, exercise physiologists for appropriate exercise regime and psychologists to help them deal with psychosocial problems, if any.[11,12,41,42] The adoption of these recommendations will empower the obstetricians, paediatricians, anganwadi workers etc. by enhancing their knowledge about various aspects of weight management such as diet, physical activity and motivational interviewing. They will further ensure effective counselling of postpartum women even if these women skip visiting specific experts related to diet, physical activity and psychology.
The adoption of these recommendations will further extend the support to healthcare professionals by assisting them in identifying the right time to counsel and engage women for their postpartum weight management. Most of the time, postpartum women are not provided with adequate dietary and physical activity advice leading to development and continuation of faulty dietary and physical activity practices. This results in gestational weight retention and weight gain.[12,41,42] The adoption of these recommendations will assist in catching hold of these women at an early stage of conception, during the entire period of pregnancy as well as post-delivery and disseminating lifestyle-related information specific to each stage.
The adoption of these recommendations will provide a coherent idea to the healthcare professionals about the duration, frequency and mode of follow-ups considering the target body weight specific to each postpartum woman as well as avoiding any added patient or doctor burden. The recommendations will further be beneficial for healthcare professionals in designing weight management modules and/or interventions encapsulating various lifestyle-related factors, right time to engage these women and follow-up periods to address the specific needs and barriers related to postpartum weight management.
Suggestions for policymakers
The evidence and consensus-based recommendations have been formulated after thorough evaluation by the experts from leading medical organisations and medical colleges of the country along with nutrition experts. The dissemination and implementation of these recommendations is crucial at the medical level, curriculum level and mass level [Box 1]. Policymakers must ensure an improved medical infrastructure and facilities to provide high-quality, evidence-based healthcare. Along with this, capacity building of healthcare providers is crucial. Healthcare providers should be provided training sessions to elevate their knowledge and information about various aspects of postpartum weight management including diet, physical activity and psychosocial problems. They should be made competent to deliver evidence-based weight management counselling to these women even in resource-limited settings. Further, there is a need to set up and generate awareness about credible weight management clinics or postpartum clinics addressing the weight-related issues of postpartum women.
It is of great significance to augment health literacy levels of postpartum women. The literacy about complications associated with obesity and significance of appropriate weight management should be disseminated at the school and college levels. National Education Policy has also emphasized on integrating the curriculum with skills and capacities including health and nutrition, as well as physical education, fitness and wellness. Importance of weight management, obesity and its impact on future health should be made part of the curriculum so that young girls become aware and have sufficient information about healthy lifestyle-related practices and having appropriate weight status by the time they reach their pregnancy and postpartum phase. Dissemination of evidence-based scientific knowledge will also assist these young women to burst socio-cultural myths associated with diet and physical activity in different stages of their life, especially the pregnancy and postpartum period.
Policymakers should create mass-awareness about postpartum weight management. Various modes of media such as print media, television etc. should be used. Print media including newspapers, leaflets and posters and television should be used to convey credible information about weight management during pregnancy and postpartum periods. Campaigns should be organised at community levels to raise awareness among women about importance of weight management and associated health benefits.
Considering its potential for widespread public health impact and general interest, the guideline (full form/short form/Executive summary) is co-published/simultaneously published fully/partly in Diabetes and Metabolic Syndrome: Clinical Research and Reviews and Journal of Midlife Health. The guideline can be submitted in some more journals for publication in future. Besides, the guideline can be published on the Government’s website and AIIMS New Delhi’s website.
Financial support and sponsorship
The study was financially supported by the SEED division, Department of Science and Technology, Government of India.
Conflicts of interest
There is no conflicts of interest.
The guideline has been developed in association with the following National Bodies and Societies: (i) Federation of Obstetric and Gynaecological Societies of India, (ii) Indian Menopause Society, (iii) Association of Physicians of India, (iv) Academy of Family Physicians of India, (v) Association of Obstetricians and Gynaecologists of Delhi and (vi) Indian Dietetic Association.
1. Chopra SM, Misra A, Gulati S, Gupta R. Overweight, obesity and related non-communicable diseases in Asian Indian girls and women. Eur J Clin Nutr 2013;67:688–96.
2. Tenenbaum-Gavish K, Hod M. Impact of maternal obesity on fetal health. Fetal Diagn Ther 2013;34:1–7.
3. Goldstein RF, Abell SK, Ranasinha S, Misso ML, Boyle JA, Harrison CL, et al. Gestational weight gain across continents and ethnicity:Systematic review and meta-analysis of maternal and infant outcomes in more than one million women. BMC Med 2018;16:1–4.
4. Institute of Medicine. Weight gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academies Press; 2009.
5. Mannan M, Doi SA, Mamun AA. Association between weight gain during pregnancy and postpartum weight retention and obesity:A bias-adjusted meta-analysis. Nutr Rev 2013;71:343–52.
6. Linné Y, Dye L, Barkeling B, Rössner S. Long-term weight development in women:A15-year follow-up of the effects of pregnancy. Obes Res 2004;12:1166–78.
7. Mamun AA, Kinarivala M, O'Callaghan MJ, Williams GM, Najman JM, Callaway LK. Associations of excess weight gain during pregnancy with long-term maternal overweight and obesity:Evidence from 21 y postpartum follow-up. Am J Clin Nutr 2010;91:1336–41.
8. McKinley MC, Allen-Walker V, McGirr C, Rooney C, Woodside JV. Weight loss after pregnancy:Challenges and opportunities. Nutr Res Rev 2018;31:225–38.
9. Kew S, Ye C, Hanley AJ, Connelly PW, Sermer M, Zinman B, Retnakaran R. Cardiometabolic implications of postpartum weight changes in the first year after delivery. Diabetes Care 2014;37:1998–2006.
10. Chopra S, Malhotra A, Ranjan P, Vikram NK, Singh N. Lifestyle-related advice in the management of obesity:A step-wise approach. J Educ Health Promot 2020;9:239.
11. Kaur D, Malhotra A, Ranjan P, Chopra S, Kumari A, Vikram NK. Weight management in postpartum women-An Indian perspective. Diabetes Metab Syndr:Clin Res Rev 2021;15:102291.
12. Kaur D, Ranjan P, Kumari A, Malhotra A, Kaloiya GS, Meena VP, et al. Awareness, Beliefs and Perspectives Regarding Weight Retention and Weight Gain among Postpartum Women in India:A Thematic Analysis of Focus Group Discussions and In-Depth Interviews. J Obstet Gynecol India 2022;72:168–74.
13. Kumari A, Ranjan P, Kaur D, Anwar W, Malhotra A, Upadhyay AD, et al. Development and Validation of a Questionnaire to Assess the Risk Factors, Facilitators, and Barriers to Postpartum Weight Management. J Obstet Gynecol India 2022;72:160–7.
14. The GRADE Working Group, GRADE Handbook for Grading Quality of Evidence and Strength of Recommendation. Vol. Version 3.2 [updated March 2009]. 2009.
15. Guidelines. NHMRC. Available from: https://www.nhmrc.gov.au/guidelines
. [Last accessed on 2021 Dec 19].
16. Chauhan G, Tadi P. Physiology, Postpartum Changes. StatPearls;2020.
17. Phelan S, Hagobian T, Brannen A, Hatley KE, Schaffner A, Muñoz-Christian K, et al. Effect of an internet-based program on weight loss for low-income postpartum women:A randomized clinical trial. JAMA 2017;317:2381–91.
18. Chang MW, Brown R, Nitzke S. Results and lessons learned from a prevention of weight gain program for low-income overweight and obese young mothers:Mothers in motion. BMC Public Health 2017;17:1–2.
19. Hagberg L, Winkvist A, Brekke HK, Bertz F, Johansson EH, Huseinovic E. Cost-effectiveness and quality of life of a diet intervention postpartum:2-year results from a randomized controlled trial. BMC Public Health 2019;19:38.
20. Huseinovic E, Bertz F, Leu Agelii M, HelleböJohansson E, Winkvist A, Brekke HK. Effectiveness of a weight loss intervention in postpartum women:Results from a randomized controlled trial in primary health care. Am J Clin Nutr 2016;104:362–70.
21. Waring ME, Simas TA, Oleski J, Xiao RS, Mulcahy JA, May CN, et al. Feasibility and acceptability of delivering a postpartum weight loss intervention via Facebook:A pilot study. J NutrEducBehav 2018;50:70–4.
22. Vesco KK, Leo MC, Karanja N, Gillman MW, McEvoy CT, King JC, et al. One-year postpartum outcomes following a weight management intervention in pregnant women with obesity. Obesity 2016;24:2042–9.
23. Wilcox S, Liu J, Addy CL, Turner-McGrievy G, Burgis JT, Wingard E, et al. A randomized controlled trial to prevent excessive gestational weight gain and promote postpartum weight loss in overweight and obese women:Health In Pregnancy and Postpartum (HIPP). Contemp Clin Trials 2018;66:51–63.
24. Sanda B, Vistad I, Sagedal LR, Haakstad LA, Lohne-Seiler H, Torstveit MK. Effect of a prenatal lifestyle intervention on physical activity level in late pregnancy and the first year postpartum. PLoS One 2017;12:e0188102.
25. Burkart S, Marcus BH, Pekow P, Rosal MC, Manson JE, Braun B, et al. The impact of a randomized controlled trial of a lifestyle intervention on postpartum physical activity among at-risk hispanic women:EstudioPARTO. PLoS One 2020;15:e0236408.
26. Dalrymple KV, Flynn AC, Relph SA, O'Keeffe M, Poston L. Lifestyle interventions in overweight and obese pregnant or postpartum women for postpartum weight management:A systematic review of the literature. Nutrients 2018;10:1704.
27. Kelley CP, Sbrocco G, Sbrocco T. Behavioral modification for the management of obesity. Prim Care 2016;43:159–75.
28. Anwar A, Hussain M, Sarwar H, Afzal M, Gilani SA. Knowledge attitude and practice about obesity and its complication in rural area of Lahore. Int J Soc Sci Manag 2018;5:187–91.
29. Oyewande AA, Ademola A, Okuneye TA, Sanni FO, Hassan AM, Olaiya PA. Knowledge, attitude and perception regarding risk factors of overweight and obesity among secondary school students in Ikeja Local Government Area, Nigeria. J Fam Med Prim Care 2019;8:1391–5.
30. Obirikorang Y, Obirikorang C, OdameAnto E, Acheampong E, Dzah N, Akosah CN, et al. Knowledge and lifestyle-associated prevalence of obesity among newly diagnosed type II diabetes mellitus patients attending diabetic clinic at KomfoAnokye Teaching Hospital, Kumasi, Ghana:A hospital-based cross-sectional study. J Diabetes Res 2016;2016:9759241. [doi:10.1155/2016/9759241].
31. Wiardani NK, Adiatmika IG, Paramita DP, Tirtayasa K. Adult women perception towards obesity and its intervention strategies in the community. Int J Health Sci 2018;2:46–60.
32. Parajuli J, Saleh F, Thapa N, Ali L. Factors associated with nonadherence to diet and physical activity among Nepalese type 2 diabetes patients;A cross sectional study. BMC Res Notes 2014;7:1–9.
33. Verma A, Mehta S, Mehta A, Patyal A. Knowledge, attitude and practices toward health behavior and cardiovascular disease risk factors among the patients of metabolic syndrome in a teaching hospital in India. J Fam Med Prim Care 2019;8:178–83.
34. Amarasekara P, de Silva A, Swarnamali H, Senarath U, Katulanda P. Knowledge, attitudes, and practices on lifestyle and cardiovascular risk factors among metabolic syndrome patients in an urban tertiary care institute in Sri Lanka. Asia Pac J Public Health 2016;28 (1Suppl):32S–40S.
35. Makama M, Awoke MA, Skouteris H, Moran LJ, Lim S. Barriers and facilitators to a healthy lifestyle in postpartum women:A systematic review of qualitative and quantitative studies in postpartum women and healthcare providers. Obes Rev 2021;22:e13167.
36. Ashok VG, Mohamed A. Knowledge, practice and attitude of postnatal mothers towards postnatal exercises in a rural area of Tamil Nadu. Indian J Forensic Community Med 2019;6:134–7.
37. Ganapathy T. Excessive gestational weight retention and weight gain in postpartum:Perception of women. Indian J Health Sci Biomed Res (KLEU) 2019;12:28–34.
38. Silfee VJ, Haughton CF, Kini N, Lemon SC, Rosal MC. Weight perceptions and weight-related behaviors among low income postpartum women. J Obes Weight Loss Medicat 2018;4:22.
39. Setse R, Grogan R, Cooper LA, Strobino D, Powe NR, Nicholson W. Weight loss programs for urban-based, postpartum African-American women:Perceived barriers and preferred components. Matern Child Health J 2008;12:119–27.
40. Ohlendorf JM, Weiss ME, Ryan P. Weight-management information needs of postpartum women. MCN Am J Matern Child Nurs 2012;37:56–63.
41. Christenson A, Johansson E, Reynisdottir S, Torgerson J, Hemmingsson E. Women's perceived reasons for their excessive postpartum weight retention:Aqualitative interview study. PLoS One 2016;11:e0167731.
42. Murray-Davis B, Grenier L, Atkinson SA, Mottola MF, Wahoush O, Thabane L, et al. Experiences regarding nutrition and exercise among women during early postpartum:A qualitative grounded theory study. BMC Pregnancy Childbirth 2019;19:368.
43. Huseinovic E, Winkvist A, Bertz F, Forslund HB, Brekke HK. Eating frequency, energy intake and body weight during a successful weight loss trial in overweight and obese postpartum women. Eur J Clin Nutr 2014;68:71–6.
44. Van der Pligt P, Ball K, Hesketh KD, Teychenne M, Crawford D, Morgan PJ, et al. A pilot intervention to reduce postpartum weight retention and central adiposity in first-time mothers:Results from the mums OnLiNE (Online, Lifestyle, Nutrition &Exercise) study. J Hum Nutr Diet 2018;31:314–28.
45. Wilkinson SA, Van der Pligt P, Gibbons KS, McIntyre HD. Trial for reducing weight retention in new mums:A randomised controlled trial evaluating a low intensity, postpartum weight management programme. J Hum Nutr Diet 2015;28:15–28.
46. Ko YL, Yang CL, Fang CL, Lee MY, Lin PC. Community-based postpartum exercise program. J Clin Nurs 2013;22:2122–31.
47. Herring SJ, Bersani VM, Santoro C, McNeil SJ, Kilby LM, Bailer B. Feasibility of using a peer coach to deliver a behavioral intervention for promoting postpartum weight loss in Black and Latina mothers. Transl Behav Med 2021;11:1226–34.
48. Nicklas JM, Zera CA, England LJ, Rosner BA, Horton E, Levkoff SE, et al. A web-based lifestyle intervention for women with recent gestational diabetes mellitus:A randomized controlled trial. Obstet Gynecol 2014;124:563–70.
49. First Steps Nutrition Modules. Module 5 – Nutrition and the Postpartum Period. 2018. Available from: http://depts.washington.edu/pwdlearn/firststeps/pdfs/mod5print.pdf
. [Last accessed on 2021 Oct 16].
51. National Institute for Health and Care Excellence. Weight management before, during and after pregnancy. 2010. Available from: https://www.nice.org.uk/guidance/ph27/chapter/Recommendations#recommendation-3-supportingwomen-after-childbirth
. [Last accessed on 2021 Oct 16].
52. Misra A, Jayawardena R, Anoop S. Obesity in South Asia:Phenotype, morbidities, and mitigation. Curr Obes Rep 2019;8:43–52.
53. Murphy KM, Mash R, Malan Z. The case for behavioural change counselling for the prevention of NCDs and improvement of self-management of chronic conditions. S Afr Fam Pract 2016;58:249–52.
54. Turner K. Counseling new mothers on weight loss:A review of the most effective strategies &suggestions for counseling. Adv Obes Weight Manag Control 2016;4:1–4.
55. Jin J. Behavioral interventions for weight loss. JAMA 2018;320:1210.
56. Bennion KA, Tate D, Muñoz-Christian K, Phelan S. Impact of an internet-based lifestyle intervention on behavioral and psychosocial factors during postpartum weight loss. Obesity 2020;28:1860–7.
57. Bick D, Taylor C, Bhavnani V, Healey A, Seed P, Roberts S, et al. Lifestyle information and commercial weight management groups to support maternal postnatal weight management and positive lifestyle behaviour:The SWAN feasibility randomised controlled trial. BJOG Int J Obstet Gynecol 2020;127:636–45.
58. Herring SJ, Cruice JF, Bennett GG, Davey A, Foster GD. Using technology to promote postpartum weight loss in urban, low-income mothers:A pilot randomized controlled trial. J Nutr Educ and Behav 2014;46:610–5.
59. Casadei K, Kiel J. Anthropometric Measurement. StatPearls; 2020.
60. Lim JU, Lee JH, Kim JS, Hwang YI, Kim TH, Lim SY, et al. Comparison of World Health Organization and Asia-Pacific body mass index classifications in COPD patients. Int J Chron Obstruct Pulmon Dis 2017;12:2465–75.
61. Nuttall FQ. Body mass index:Obesity, BMI, and health:A critical review. Nutr Today 2015;50:117–28.
62. Snehalatha C, Viswanathan V, Ramachandran A. Cutoff values for normal anthropometric variables in Asian Indian adults. Diabetes Care 2003;26:1380–4.
63. Gilmore LA, Klempel MC, Martin CK, Myers CA, Burton JH, Sutton EF, et al. Personalized mobile health intervention for health and weight loss in postpartum women receiving women, infants, and children benefit:A randomized controlled pilot study. J Womens Health 2017;26:719–27.
64. Tyldesley-Marshall N, Greenfield SM, Parretti HM, Jolly K, Jebb S, Daley AJ. The experiences of postnatal women and healthcare professionals of a brief weight management intervention embedded within the national child immunisation programme. BMC Pregnancy Childbirth 2021;21:462.
65. Napolitano MA, Harrington CB, Patchen L, Ellis LP, Ma T, Chang K, et al. Feasibility of a digital intervention to promote healthy weight management among postpartum African American/black women. Int J Environ Res Public Health 2021;18:2178.
66. Zhang C, Rexrode KM, Van Dam RM, Li TY, Hu FB. Abdominal obesity and the risk of all-cause, cardiovascular, and cancer mortality:Sixteen years of follow-up in US women. Circulation 2008;117:1658–67.
67. Jayedi A, Soltani S, Zargar MS, Khan TA, Shab-Bidar S. Central fatness and risk of all cause mortality:Systematic review and dose-response meta-analysis of 72 prospective cohort studies. BMJ 2020;370:m3324.
68. American Diabetes Association. Waist Circumference and Cardiometabolic Risk. 2007. Available from: https://care.diabetesjournals.org/content/30/6/1647
. [Last accessed on 2021 Oct 16].
69. Misra A, Vikram NK, Gupta R, Pandey RM, Wasir JS, Gupta VP. Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity. Int J Obes 2006;30:106–11.
71. Lee CF, Hwang FM, Liou YM, Chien LY. A preliminary study on the pattern of weight change from pregnancy to 6 months postpartum:A latent growth model approach. Int J Obes 2011;35:1079–86.
72. McAuliffe FM, Killeen SL, Jacob CM, Hanson MA, Hadar E, McIntyre HD, et al. Management of prepregnancy, pregnancy, and postpartum obesity from the FIGO Pregnancy and Non-Communicable Diseases Committee:A FIGO (International Federation of Gynecology and Obstetrics) guideline. Int J Gynaecol Obstet 2020;151 (Suppl 1):16–36.
73. Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, et al. Cardiovascular disease-related morbidity and mortality in women with a history of pregnancy complications:Systematic review and meta-analysis. Circulation 2019;139:1069–79.
74. The American College of Obstetricians and Gynecologists. Optimising Postpartum Care. 2021. Available from: https://www.acog.org/clinical/clinical-guidance/committeeopinion/articles/2018/05/optimizing-postpartum-care
. [Last accessed on 2021 Oct 16].
75. Centers for Disease Control and Prevention. Pregnancy Complications. 2020. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancycomplications.html
. [Last accessed on 2021 Oct 16].
76. Grieger JA, Hutchesson MJ, Cooray SD, BahriKhomami M, Zaman S, Segan L, et al. A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum. Ther Adv Reprod Health 2021;15:2633494120986544.
77. World Health Organization. Healthy Diet. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/healthy-diet
.[Last accessed on2021 Oct 16].
78. Naska A, Lagiou A, Lagiou P. Dietary assessment methods in epidemiological research:Current state of the art and future prospects. F1000Res 2017;6:926.
79. Labonté MÈ, Kirkpatrick SI, Bell RC, Boucher BA, Csizmadi I, Koushik A, et al. Dietary assessment is a critical element of health research–Perspective from the partnership for advancing nutritional and dietary assessment in Canada. Appl Physiol Nutr and Metab 2016;41:1096–9.
80. Shim JS, Oh K, Kim HC. Dietary assessment methods in epidemiologic studies. Epidemiol Health 2014;36:e2014009.
81. Dao MC, Subar AF, Warthon-Medina M, Cade JE, Burrows T, Golley RK, et al. Dietary assessment toolkits:An overview. Public Health Nutr 2019;22:404–18.
82. Evans WD, Harrington C, Patchen L, Andrews V, Gaminian A, Ellis LP, et al. Design of a novel digital intervention to promote healthy weight management among postpartum African American women. Contemp Clin Trials Commun 2019;16:100460.
83. Rauh K, Günther J, Kunath J, Stecher L, Hauner H. Lifestyle intervention to prevent excessive maternal weight gain:Mother and infant follow-up at 12 months postpartum. BMC Pregnancy Childbirth 2015;15:265.
84. Phelan S, Phipps MG, Abrams B, Darroch F, Grantham K, Schaffner A, et al. Does behavioral intervention in pregnancy reduce postpartum weight retention?Twelve-month outcomes of the Fit for Delivery randomized trial. Am J Clin Nutr 2014;99:302–11.
85. Chang MW, Nitzke S, Brown R, Resnicow K. A community based prevention of weight gain intervention (Mothers In Motion) among young low-income overweight and obese mothers:Design and rationale. BMC Public Health 2014;14:1–8.
86. Lyu LC, Hsu YN, Chen HF, Lo CC, Lin CL. Comparisons of four dietary assessment methods during pregnancy in Taiwanese women. Taiwan J Obstet Gynecol 2014;53:162–9.
87. First Steps Nutrition Modules. Module 3 - Nutrition Assessment. Available from: http://depts.washington.edu/pwdlearn/firststeps/pdfs/mod3print.pdf
. [Last accessed on 2021 Oct 16].
88. The American College of Obstetricians and Gynecologists. Physical Activity and Exercise During Pregnancy and Postpartum Period. 2020. Available from: https://www.acog.org/clinical/clinical-guidance/committeeopinion/articles/2020/04/physical-activity-andexercise-during-pregnancy-and-the-postpartum-period
. [Last accessed on 2021 Oct 16].
89. World Health Organisation. Physical activity. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/physical-activity
. [Last accessed on 2021 Oct 16].
90. Sylvia LG, Bernstein EE, Hubbard JL, Keating L, Anderson EJ. Practical guide to measuring physical activity. J Acad Nutr Diet 2014;114:199–208.
91. Anjana RM, Sudha V, Lakshmipriya N, Subhashini S, Pradeepa R, Geetha L, et al. Reliability and validity of a new physical activity questionnaire for India. Int J Behav Nutr Phys Act 2015;12:40.
92. Smith KJ, Gall SL, McNaughton SA, Cleland VJ, Otahal P, Dwyer T, et al. Lifestyle behaviours associated with 5-year weight gain in a prospective cohort of Australian adults aged 26-36 years at baseline. BMC Public Health 2017;17:54.
93. American Psychological Association. Making lifestyle changes that last. 2010. Available from: https://www.apa.org/topics/behavioral-health/healthy-lifestyle-changes
. [Last accessed on 2021 Oct 16].
94. Centers for Disease Control and Prevention. Losing weight: Getting started. 2018. Available from: https://www.cdc.gov/healthyweight/losing_weight/getting_started.html
. [Last accessed on 2021 Oct 16].
95. Mayo Clinic. Weight loss goals. 2020. Available from: https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20048224
. [Last accessed on 2021 Oct 16].
96. Ryan DH, Yockey SR. Weight loss and improvement in comorbidity:Differences at 5%, 10%, 15%, and over. Curr Obes Rep 2017;6:187–94.
97. Taylor C, Bhavnani V, Zasada M, Ussher M, Bick D, et al. Barriers and facilitators to uptake and retention of inner-city ethnically diverse women in a postnatal weight management intervention:A mixed-methods process evaluation within a feasibility trial in England. BMJ Open 2020;10:e034747.
98. Holmes VA, Draffin CR, Patterson CC, Francis L, Irwin J, McConnell M, et al. Postnatal lifestyle intervention for overweight women with previous gestational diabetes:A randomized controlled trial. J Clin Endocrinol Metab 2018;103:2478–87.
99. Ferrara A, Hedderson MM, Brown SD, Albright CL, Ehrlich SF, Tsai AL, et al. The comparative effectiveness of diabetes prevention strategies to reduce postpartum weight retention in women with gestational diabetes mellitus:The Gestational Diabetes'Effects on Moms (GEM) cluster randomized controlled trial. Diabetes Care 2016;39:65–74.
100. Ehrlich SF, Hedderson MM, Quesenberry CP Jr, Feng J, Brown SD, Crites Y, et al. Post-partum weight loss and glucose metabolism in women with gestational diabetes:The DEBI Study. Diabet Med 2014;31:862–7.
101. ICMR-National Institute of Nutrition. Short Report of Nutrient Requirements for Indians Recommended Dietary Allowances and Estimated Average Requirements – 2020. Available from: https://www.nin.res.in/RDA_short_Report_2020.html
. [Last accessed on 2021 Jun 23].
102. Kajale NA, Khadilkar AV, Chiplonkar SA, Khadilkar V. Changes in body composition in apparently healthy urban Indian women up to 3 years postpartum. Indian J Endocrinol Metab 2015;19:477–82.
103. Kajale N, Khadilkar A, Chiponkar S, Unni J, Mansukhani N. Effect of traditional food supplements on nutritional status of lactating mothers and growth of their infants. Nutrition 2014;30:1360–5.
104. Ministry of Health and Family Welfare. Guidelines for Control of Iron Deficiency Anaemia. 2013. Available from: http://www.nhm.gov.in/images/pdf/programmes/childhealth/guidelines/Control-of-Iron-Deficiency-Anaemia.pdf
. [Last accessed on 2021 Jun 23].
105. National Health Mission. National Guidelines for Calcium Supplementation During Pregnancy and Lactation. 2014. Available from: https://nhsrcindia.org/sites/default/files/2021-06/9.Guidelines%20for%20Calcium%20Supplementation%20during%20Pregnancy%20and%20Lactation.pdf
. [Last accessed on 2021 Jun 23].
106. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. The First Few Weeks Following Birth. 2021.Available from: https://ranzcog.edu.au/womens-health/patient-information-resources/firstfew-weeks
. [Last accessed on 2021 Oct 16].
107. Nutrition Education Materials Online. Healthy eating for breastfeeding mothers. 2020. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0014/152132/antenatal-brstfd.pdf
. [Last accessed on 2021 Oct 16].
108. Australian Breastfeeding Association. Diet and weight loss while breastfeeding. 2017. Available from: https://www.breastfeeding.asn.au/bf-info/common-concerns–mum/diet
. [Last accessed on 2021 Oct 16].
109. Federation of Obstetric and Gynaecological Societies of India. Postpartum phase our continued responsibility. Available from: https://www.fogsi.org/wp-content/uploads/fogsi-focus/postpartum-phase.pdf
. [Last accessed on 2021 Oct 16].
110. Fernandez Hospital. Dietary guidelines for a healthy postnatal diet. 2017. Available from: https://www.fernandezhospital.com/Uploads/Document/238/dietary_guidelines_for_a_healthy_postnatal_diet.pdf
. [Last accessed on 2021 Oct 16].
111. Pereira MA, Rifas-Shiman SL, Kleinman KP, Rich-Edwards JW, Peterson KE, Gillman MW. Predictors of change in physical activity during and after pregnancy:Project Viva. Am J Prev Med 2007;32:312–9.
112. Marshall ES, Bland H, Melton B. Perceived barriers to physical activity among pregnant women living in a rural community. Public Health Nurs 2013;30:361–9.
113. DiPietro L, Evenson KR, Bloodgood B, Sprow K, Troiano RP, Piercy KL, et al. Benefits of physical activity during pregnancy and postpartum:An umbrella review. Med Sci Sports Exerc 2019;51:1292–302.
114. Harrison CL, Brown WJ, Hayman M, Moran LJ, Redman LM. The role of physical activity in preconception, pregnancy and postpartum health. Semin Reprod Med 2016;34:e28–37.
115. Lim S, O'Reilly S, Behrens H, Skinner T, Ellis I, Dunbar JA. Effective strategies for weight loss in post-partum women:A systematic review and meta-analysis. Obes Rev 2015;16:972–87.
116. The American College of Obstetricians and Gynecologists. Exercise After Pregnancy. 2019. Available from: https://www.acog.org/womens-health/faqs/exercise-afterpregnancy
. [Last accessed on 2021 Oct 16].
117. American College of Sports Medicine. Postpartum Exercise. 2014. Available from: https://journals.lww.com/acsm-healthfitness/fulltext/2014/11000/postpartum_exercise.3.aspx
. [Last accessed on 2021 Oct 16].
118. Centers for Disease Control and Prevention. Measuring Physical Activity Intensity. 2020. Available from: https://www.cdc.gov/physicalactivity/basics/measuring/index.html
. [Last accessed on 2021 Oct 26].
119. ICMR-National Institute of Nutrition. Dietary Guidelines for Indians – A Manual. Available from: https://www.nin.res.in/downloads/DietaryGuidelinesforNINwebsite.pdf
. [Last accessed on 2021 Jun 23].
120. Centers for Disease Control and Prevention. About Breastfeeding. 2017. Available from:https://www.cdc.gov/breastfeeding/about-breastfeeding/index.html
. [Last accessed on 2021 April 9].
121. National Health Service. Benefits of breastfeeding. 2020. Available from: https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding/benefits/
. [Last accessed on 2021 Oct 18].
122. Stuebe AM, Rich-Edwards JW. The reset hypothesis:Lactation and maternal metabolism. Am J Perinatol 2009;26:81–8.
123. He X, Zhu M, Hu C, Tao X, Li Y, Wang Q, et al. Breast-feeding and postpartum weight retention:A systematic review and meta-analysis. Public Health Nutr 2015;18:3308–16.
124. Lambrinou CP, Karaglani E, Manios Y. Breastfeeding and postpartum weight loss. CurrOpin Clin NutrMetab Care 2019;22:413–7.
125. Mullaney L, O'Higgins AC, Cawley S, Kennedy R, McCartney D, Turner MJ. Breast-feeding and postpartum maternal weight trajectories. Public Health Nutr 2016;19:1397–404.
126. Dalrymple KV, Uwhubetine O, Flynn AC, Pasupathy D, Briley AL, Relph SA, et al. Modifiable determinants of postpartum weight loss in women with obesity:A secondary analysis of the UPBEAT trial. Nutrients 2021;13:1979.
127. Jarlenski MP, Bennett WL, Bleich SN, Barry CL, Stuart EA. Effects of breastfeeding on postpartum weight loss among US women. Prev Med 2014;69:146–50.
128. Jiang M, Gao H, Vinyes-Pares G, Yu K, Ma D, Qin X, et al. Association between breastfeeding duration and postpartum weight retention of lactating mothers:A meta-analysis of cohort studies. Clin Nutr 2018;37:1224–31.
129. López-Olmedo N, Hernández-Cordero S, Neufeld LM, García-Guerra A, Mejía-Rodríguez F, Gómez-Humarán IM. The associations of maternal weight change with breastfeeding, diet and physical activity during the postpartum period. Matern Child Health J 2016;20:270–80.
130. da Silva MD, Oliveira Assis AM, Pinheiro SM, de Oliveira LP, da Cruz TR. Breastfeeding and maternal weight changes during 24 months post-partum:A cohort study. Matern Child Nutr 2015;11:780–91.
131. Zanotti J, Capp E, Wender MC. Factors associated with postpartum weight retention in a Brazilian cohort. Rev Bras GinecolObstet 2015;37:164–71.
132. Tahir MJ, Haapala JL, Foster LP, Duncan KM, Teague AM, Kharbanda EO, et al. Association of full breastfeeding duration with postpartum weight retention in a cohort of predominantly breastfeeding women. Nutrients 2019;11:938.
133. Baker JL, Gamborg M, Heitmann BL, Lissner L, Sørensen TI, Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr 2008;88:1543–51.
134. Fitzpatrick T, Perrier L, Shakik S, Cairncross Z, Tricco AC, Lix L, et al. Assessment of long-term follow-up of randomized trial participants by linkage to routinely collected data:A scoping review and analysis. JAMA Netw Open 2018;1:e186019.
135. Llewellyn-Bennett R, Bowman L, Bulbulia R. Post-trial follow-up methodology in large randomized controlled trials:A systematic review protocol. Syst Rev 2016;5:1–7.
136. Hill KG, Woodward D, Woelfel T, Hawkins JD, Green S. Planning for long-term follow-up:Strategies learned from longitudinal studies. Prev Sci 2016;17:806–18.
137. McCarthy O, French RS, Roberts I, Free C. Simple steps to develop trial follow-up procedures. Trials 2016;17:1–6.
138. von Allmen RS, Weiss S, Tevaearai HT, Kuemmerli C, Tinner C, Carrel TP, et al. Completeness of follow-up determines validity of study findings:Results of a prospective repeated measures cohort study. PLoS One 2015;10:e0140817.
139. Fadzil F, Shamsuddin K, Puteh SE, Tamil AM, Ahmad S, Hayi NS, et al. Predictors of postpartum weight retention among urban Malaysian mothers:A prospective cohort study. Obes Res Clin Pract 2018;12:493–9.
140. Kasthuri A. Challenges to healthcare in India-The five A's. Indian J Community Med 2018;43:141–3.
141. Barik D, Thorat A. Issues of unequal access to public health in India. Front Public Health 2015;3:245.
142. Ministry of Human Resource Development. National Education Policy 2020. 2020. Available from: https://www.education.gov.in/sites/upload_files/mhrd/files/NEP_Final_English_0.pdf
. [Last accessed on 2021 Oct 16].
143. World Health Organization. Nutritional Anaemias: Tools for Effective Prevention and Control. 2017. Available from: http://apps.who.int/iris/bitstream/handle/10665/259425/9789241513067-eng.pdf
. [Last accessed on 2021 Oct 16].
144. Cosman F, de BeurSJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25:2359–81.
145. Aparna P, Muthathal S, Nongkynrih B, Gupta SK. Vitamin D deficiency in India. J Family Med Prim Care 2018;7:324–30.
146. Longvah T, Ananthan R, Bhaskarachary K, Venkaiah K. Indian Food Composition Tables. National Institute of Nutrition, Indian Council of Medical Research; 2017.