Abstract

The aim is, systematically examine the scientific evidences that associated environmental factors (environment, social environment, environmental planning and spatial population distribution) with the excessive gestational weight gain. A meta-analysis and systematic review carried out as per the Cochrane Handbook recommendations and following the steps recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes. The inclusion studies were done with the following PECO criteria: P-pregnant women, E-environmental factors, O-weight gain. The search procedure was conducted on the databases EMBASE, Web of Science, Cinahl, LILACS and MEDLINE (PubMed). The relationship between the socioeconomic factors of the micro-region of residence and gestational weight gain was evidenced by the linkage between residing in high-poverty neighborhoods and inadequate gestational weight gain. This study revealed the higher prevalence of excessive gestational weight gain in pregnant women those lives in urban areas. Environmental factors of the pregnant women’s residence area implicated in the excessive gestational weight gain. Our findings can therefore contribute to the development of public policies to prevent inadequate gestational weight gain.

Key words:
Pregnant Women; Gestational weight gain; Obesity; Social environment

Resumo

O objetivo é examinar sistematicamente as evidências científicas que associam fatores ambientais (meio ambiente, meio ambiente social, planejamento ambiental e distribuição espacial da população) com o excessivo ganho de peso gestacional. Trata-se de uma revisão sistemática e meta-análise realizada seguindo os passos recomendados pelo Preferred Reporting Items for Systematic Reviews and Meta-Analyzes. Os estudos de incluídos basearam-se nos seguintes critérios PECO: P-gestantes, E-fatores ambientais, O-ganho de peso gestacional. O procedimento de pesquisa foi conduzido nas bases de dados EMBASE, Web of Science, Cinahl, LILACS e MEDLINE (PubMed). A relação entre os fatores socioeconômicos da microrregião de residência e o ganho de peso gestacional foi evidenciada pela ligação entre a residência em bairros de alta pobreza e o ganho de peso gestacional inadequado. Este estudo revelou a maior prevalência de ganho de peso gestacional excessivo em gestantes que vivem em áreas urbanas. Fatores ambientais da área de residência das gestantes implicados no ganho de peso gestacional excessivo. As descobertas desse estudo podem, portanto, contribuir para o desenvolvimento de políticas públicas para evitar o ganho de peso gestacional inadequado.

Palavras-chave:
Gestantes; Ganho de peso gestacional; Obesidade; Ambiente social

Introduction

The gestation period comprises several psychobiological changes in pregnant women. One of the main alterations in pregnant women is the relative weight gain¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.. Gestational weight gain is a complex and unique biological process that is important for the growth and development of the fetus. Nevertheless, there is a proper weight gain per trimester that is considered healthy during pregnancy²2 Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: reexamining the guidelines. Washington, D.C.: National Academies Press; 2009..

Currently, overweight and obesity are major public health issues worldwide. The growing prevalence of overweight and obesity in women has resulted in an excessive weight gain during pregnancy³3 Abayomi JC, Watkinson H, Boothby J, Topping J, Hackett AF. Identification of "hot spots" of obesity and being underweight in early pregnancy in Liverpool. J Hum Nutr Diet 2009; 22(3):246-254.. In this context, studies conducted in different countries revealed a high prevalence of excessive weight gain during pregnancy¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.^,44 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190.

5 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544.^-66 Deputy NP, Sharma AJ, Kim SY, Hinkle SN. Prevalence and characteristics associated with gestational weight gain adequacy. Obstet Gynecol 2015; 125(4):773-781.. A study carried out in 2008 in different states of the United States showed that 41.8% of the gestational weight gains exceeded the recommended healthy levels⁶6 Deputy NP, Sharma AJ, Kim SY, Hinkle SN. Prevalence and characteristics associated with gestational weight gain adequacy. Obstet Gynecol 2015; 125(4):773-781.. These findings point out the need for control measures on the weight gain during the gestational period¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114..

Excessive gestational weight gain typically brings negative consequences to the maternal and neonatal health. Reports indicate adverse outcomes, such as increased risk of low birth weight, premature birth, gestational diabetes and preeclampsia due to gestational weight gain above the recommended rates⁶6 Deputy NP, Sharma AJ, Kim SY, Hinkle SN. Prevalence and characteristics associated with gestational weight gain adequacy. Obstet Gynecol 2015; 125(4):773-781.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109..

In 2009, the Institute of Medicine (IOM) developed guidelines for preventing unsuitable weight gain during pregnancy. Inadequate gestational weight gain is the one outside of the recommended IOM range, which includes both insufficient and excessive gains. These guidelines highlight the importance of knowing and acting on the risk factors that determine the nutritional status and pregestational body mass index (BMI) of pregnant women, thereby influencing on the weight gain over this period. Individual risk factors, including unhealthy diet and physical inactivity, play a role in the gestational weight gain, especially on the excessive one, as already established in the literature⁶6 Deputy NP, Sharma AJ, Kim SY, Hinkle SN. Prevalence and characteristics associated with gestational weight gain adequacy. Obstet Gynecol 2015; 125(4):773-781.^,88 Mahanta L, Choudhury M, Devi A, Bhattacharya A. On the study of pre-pregnancy Body Mass Index (BMI) and weight gain as indicators of nutritional status of pregnant women belonging to low socio-economic category: A study from Assam. Indian J Community Med 2016; 40(3):198.^,99 Zeal C, Remington P, Ndiaye M, Stewart K, Stattelman-Scanlan D. The epidemiology of maternal overweight in Dane County, Wisconsin. WMJ 2014; 113(1):24-27..

However, environmental factors could also induce excessive gestational weight gain¹⁰10 Laraia B, Messer L, Evenson K, Kaufman JS. Neighborhood factors associated with physical activity and adequacy of weight gain during pregnancy. J Urban Heal 2007; 84(6):793-806.. In general, environmental factors can be divided into physical built environment and social environment¹¹11 Belon AP, Nykiforuk C. Possibilities and challenges for physical and social environment research in Brazil: a systematic literature review on health behaviors. Cad Saude Publica 2013; 29(10):1955-1973.^,1212 Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis JF. Measuring the Built Environment for Physical Activity: State of the Science. Am J Prev Med 2009; 36(4 Supl.):S99-123.e12.. In this sense, the built environment is understood as factors that encompass the neighborhood, mixed land use, density, aesthetic attributes, availability and access to facilities¹²12 Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis JF. Measuring the Built Environment for Physical Activity: State of the Science. Am J Prev Med 2009; 36(4 Supl.):S99-123.e12., the social environment, in turn, is constituted by feelings of personal safety to policies and media that promote healthy lifestyles or not. It can also include elements related to individual living conditions, such as income, education, criminal background, social support networks, and level of confidence, which are associated with greater or lesser social disorder and social deprivation in the neighborhood¹³13 Macintyre S, Ellaway A, Cummins S. Place effects on health: how can we conceptualise, operationalise and measure them? Soc Sci Med 2002; 55(1):125-139.^,1414 Velásquez-Meléndez G, Mendes LL, Proença Padez CM. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saude Publica 2013; 29(10):1988-1996..

Reports have shown that environmental factors are associated with the prevalence of overweight and obesity in the general population because they influence on personal habits, such as diet and physical activity preferences¹⁴14 Velásquez-Meléndez G, Mendes LL, Proença Padez CM. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saude Publica 2013; 29(10):1988-1996.^,1515 Fermino RC, Reis RS, Hallal PC, Farias Júnior JC. Perceived environment and public open space use: a study with adults from Curitiba, Brazil. Int J Behav Nutr Phys Act 2013; 10:35.. These findings reveal that individual’s health status is also affected by the environmental context¹⁴14 Velásquez-Meléndez G, Mendes LL, Proença Padez CM. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saude Publica 2013; 29(10):1988-1996..

Considering the environmental influence on obesity, we hypothesized that the inadequate weight gain during pregnancy could also be influenced by the environment. Hence, this review aimed to examine the scientific evidence that correlated environmental factors with excessive weight gain in pregnant women.

Methods

Protocol and registration

This systematic review was carried out as per the Cochrane Handbook recommendations for Systematic Intervention Reviews¹⁶16 Chandler J, Higgins JP, Deeks JJ, Davenport C, Clarke MJ. Cochrane Handbook for Systematic Reviews of Interventions Version 520. Chichester (UK): John Wiley & Sons; 2017., and prepared according to the steps recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA Statement)¹⁷17 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6(7):e1000097.^,1818 Salameh JP, Bossuyt PM, McGrath TA, Thombs BD, Hyde CJ, Macaskill P, Deeks JJ, Leeflang M, Korevaar DA, Whiting P, Takwoingi Y, Reitsma JB, Cohen JF, Frank RA, Hunt HA, Hooft L, Rutjes AWS, Willis BH, Gatsonis C, Levis B, Moher D, McInnes MDF. Preferred reporting items for systematic review and meta-analysis of diagnostic test accuracy studies (PRISMA-DTA): explanation, elaboration, and checklist. BMJ 2020; 370:m2632.. The study protocol was registered in the International Prospect Register of Systematic Reviews (PROSPERO) under the identification CRD42020203988.

Search procedure and selection criteria

The search procedure was conducted on the databases EMBASE, Web of Science, Cinahl, LILACS and MEDLINE (PubMed). The lists of publications included in the review and previous systematic reviews were also reviewed. The search terms included “Pregnant Women”, “Pregnancy”, “Weight Gain”, “Obesity”, “Overweight”, “Environmental Health”, “Environment and Public Health”, “Social Environment”, “Environment Design”, “Residence Characteristics”. The included search terms were separated by Boolean operators ‘OR’ or ‘AND’. In addition, we searched the reference lists of the included studies to identify studies missed by the search strategy (Chart 1).

Criteria of Elegibility

The inclusion studies were done with the following PECO criteria (Chart 2): (1) pregnant women; (2) observational studies (cross-sectional or cohort studies); (3) studies with data on overweight and obesity in pregnant women, and related risk factors.

The exclusion criteria were: (1) clinical trials, (2) experimental studies, (3) case-control studies, (4) systematic reviews and meta-analysis, and (5) letters to the editor.

Selection of studies and data extraction

Two independent reviewers (TGFV and TPRS) examined the titles and abstracts, as well as extracted and recorded the data from each eligible report. The divergences were solved by consensus decision-making or consulting the opinion of a third and fourth reviewers (FPM and CKD).

The following information were extracted from all the selected reports: general data (title and authors, year of publication, geographical location); methods (study design, measures of association); participant characteristics (age, race/ethnicity, parity) and outcomes (excessive gestational weight gain rate and individual and environmental risk factors for the excessive weight gain during pregnancy). Regarding the analogous reports, the most recent one or that providing more information about the outcomes was taken for analysis.

Bias risk assessment

All chosen reports were evaluated for their methodological quality using the Newcastle-Ottawa scale (Ottawa Hospital Research Institute)¹⁹19 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. Ottawa Hospital Research Institute [Internet]. [cited 2022 nov 11]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.as.
http://www.ohri.ca/programs/clinical_epi... . This tool assesses 7 study aspects subdivided into 3 domains: selection (sample representativeness, sample size, non-respondents and exposure assessment), comparability (control of confounding), and outcome (outcome assessment and statistical test).

The Newcastle-Ottawa scale for cohort studies was adjusted to allow the quality assessment of the transverse studies included in the systematic review²⁰20 Modesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi G, Rapi S, Perruolo E, Parati G, ESH Working Group on CV Risk in Low Resource Settings. Panethnic Differences in Blood Pressure in Europe : A Systematic Review and Meta- Analysis. PLoS One 2016; 11(1):e0147601..

Statistical analysis

The data were eventually grouped using the meta-analysis of prevalence, which was performed using the free software Rstudio (version 3.4.4 For the statistical analyses, the packages “meta” and “metafor” in versions 4.9-4 and 2.0, respectively, were used. Within the “metafor” package, the metaprop function was used to calculate proportions. The gestational weight gain was classified as adequate (gestational weight gain within the recommended BMI range) and inadequate (gestational weight gain outside of the recommended BMI range, considering the excessive gain. Insufficient gestational weight gain was considered only for the descriptive analysis and discussion).

The fixed effects and random effects models were applied using the model for methodological heterogeneity between studies, which was evaluated using the I-square test and Q statistics. The heterogeneity between the studies was assessed by Cochran. The Q test and a P test for a trend <0.10 were considered to be statistically significant. The I2 test was performed to assess the magnitude of the heterogeneity, considered moderate if I2>25.0% and high if I2>75.0%. The test assesses the null hypothesis, that the studies evaluate the same effect, as there was heterogeneity between them (I2=96%), using the random effect model. The heterogeneity can refer to differences in participants, type of study, and so on.

Results

Initially, 3,936 articles suitable to meet the goal of this review were retrieved using the search method. After duplicate exclusion (144), 3,792 articles were selected for title and abstract analysis by two independent reviewers. Among this total, 27 articles were carefully chosen for full reading.

After the full reading step, 17 articles were excluded due to some of the following reasons: lack of environmental data and non-availability of the full text even after contacting the original authors via email. After an additional search, one more article¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114. that met the criteria was found and included in this review.

Finally, 11 articles¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.^,44 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190.^,55 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.^,1010 Laraia B, Messer L, Evenson K, Kaufman JS. Neighborhood factors associated with physical activity and adequacy of weight gain during pregnancy. J Urban Heal 2007; 84(6):793-806.^,2121 Farhangi MA. Gestational weight gain and its related social and demographic factors in health care settings of rural and urban areas in northwest Iran. Ecol Food Nutr 2016; 55(3):258-265.

22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46.

23 Mendez DD, Thorpe RJ, Amutah N, Davis EM, Walker RE, Chapple-McGruder T, Bodnar L. Neighborhood racial composition and poverty in association with pre-pregnancy weight and gestational weight gain. SSM Popul Heal 2016; 2:692-699.

24 Gallagher A, Liu J, Probst JC, Martin AB, Hall JW. Maternal obesity and gestational weight gain in rural versus urban dwelling women in South Carolina. J Rural Heal 2013; 29(1):1-11.

25 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103.^-2626 Tabet M, Nelson E, Schootman M, Chien LC, Chang JJ. Geographic variability in gestational weight gain: a multilevel population-based study of women having term births in Florida (2005-2012). Ann Epidemiol 2017; 27(7):421-428.e2. met all the inclusion criteria and 3 articles¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.^,2424 Gallagher A, Liu J, Probst JC, Martin AB, Hall JW. Maternal obesity and gestational weight gain in rural versus urban dwelling women in South Carolina. J Rural Heal 2013; 29(1):1-11. contained data relevant for inclusion in the meta-analysis of the environmental factors (Figure 1). Details of the selected articles are summarized in Table 1.

The excessive gestational weight gain ranged from 23.2% to 82.4% in studies conducted in Iran and Florida, respectively. Most of the retrieved studies were conducted in the United States. Only 3 studies were conducted in other countries, namely, Brazil, Iran and Bangladesh.

Most of the researches¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.^,55 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.^,2121 Farhangi MA. Gestational weight gain and its related social and demographic factors in health care settings of rural and urban areas in northwest Iran. Ecol Food Nutr 2016; 55(3):258-265.^,2222 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46.^,2424 Gallagher A, Liu J, Probst JC, Martin AB, Hall JW. Maternal obesity and gestational weight gain in rural versus urban dwelling women in South Carolina. J Rural Heal 2013; 29(1):1-11.

25 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103.^-2626 Tabet M, Nelson E, Schootman M, Chien LC, Chang JJ. Geographic variability in gestational weight gain: a multilevel population-based study of women having term births in Florida (2005-2012). Ann Epidemiol 2017; 27(7):421-428.e2. investigated personal and environmental factors related both to insufficient gestational weight gain and excessive gain. However, to meet the goals of this study, the pooled analysis considered only the excessive gestational weight gain to examine the associated environmental factors.

Environmental factors associated with excessive gestational weight gain

The relationship between the socioeconomic factors of the micro-region of residence and gestational weight gain was investigated using 5 articles, which indicates that there is an association between residence in high poverty-rated neighborhoods and inadequate gestational weight gain⁵5 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.^,2222 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46.^,2323 Mendez DD, Thorpe RJ, Amutah N, Davis EM, Walker RE, Chapple-McGruder T, Bodnar L. Neighborhood racial composition and poverty in association with pre-pregnancy weight and gestational weight gain. SSM Popul Heal 2016; 2:692-699.^,2525 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103.. A study conducted in the United States revealed that the relative risk of excessive gestational weight gain is 1.11 (95%CI 1.02-1.21) times higher for white pregnant women residing in high poverty-rated neighborhoods rather than in richer neighborhoods⁷7 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109..

Galin et al.²²22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46. associated the statistics of pregnant women residing in neighborhoods with high violence rates with excessive gestational weight gain (RR 1.04, 95%CI 1.03-1.05). Bandreldin et al.⁵5 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544., Mendez et al.²³23 Mendez DD, Thorpe RJ, Amutah N, Davis EM, Walker RE, Chapple-McGruder T, Bodnar L. Neighborhood racial composition and poverty in association with pre-pregnancy weight and gestational weight gain. SSM Popul Heal 2016; 2:692-699. and Mendez et al.²⁵25 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103. reported on the difference in the inadequate gestational weight gains by neighborhood racial composition and economic vulnerability of the pregnant woman’s residence neighborhood. It was shown that black or Hispanic women residing in poor neighborhoods were more prone to inadequate gestational weight gain, tending particularly to insufficient gain. Mendez et al.²⁵25 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103. showed that this relationship was significant only for the insufficient gestational weight gain.

Galin et al.²²22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46. investigated the possible correlations between the neighborhood violence rate and excessive gestational weight gain. The results showed that pregnant women residing in neighborhoods with high violence levels showed excessive weight gain compared to those residing in safer neighborhoods (RR 1.04, 95%CI 1.03-1.05).

The neighborhood’s area, violence and poverty indexes, and the distance from the pregnant woman’s residence to the supermarket were found to have a positive correlation with the excessive gestational weight gain¹⁰10 Laraia B, Messer L, Evenson K, Kaufman JS. Neighborhood factors associated with physical activity and adequacy of weight gain during pregnancy. J Urban Heal 2007; 84(6):793-806.. Other authors also showed a correlation between the excessive gestational weight gain and US nationality²⁶26 Tabet M, Nelson E, Schootman M, Chien LC, Chang JJ. Geographic variability in gestational weight gain: a multilevel population-based study of women having term births in Florida (2005-2012). Ann Epidemiol 2017; 27(7):421-428.e2., and between the inadequate gain and arsenic-contaminated water consumption and Hindu religious community⁴4 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190..

From the selected studies, 3 articles were included in the meta-analysis of prevalence because they brought relationships between excessive gestational weight gain and the pregnant woman’s home environment, considering both the urban and rural contexts. The pooled analysis revealed that the highest prevalence of pregnant women with excessive weight gain residing in urban areas, although with no statistical differences (P 51%, 95%CI 44.34-57.84, p-value=0.363) (Figure 2). It is noteworthy that few studies generate more imprecision of the measure and great heterogeneity.

Individual characteristics associated with excessive gestational weight gain

Regarding the skin color, it was found that non-white women residing in poor neighborhoods were more likely to be overweight and pre-gestational obesity and had a higher prevalence of inadequate gestational weight. These data were statistically significant only for the weight gain below the recommended IOM levels. This relationship was found when the neighborhood composition and its socioeconomic index were analyzed⁵5 Badreldin N, Grobman WA, Pool LR, Kershaw KN. 916: The association of race/ethnicity and neighborhood poverty with gestational weight gain. Am J Obstet Gynecol 2018; 218(1):S543-S544.^,2323 Mendez DD, Thorpe RJ, Amutah N, Davis EM, Walker RE, Chapple-McGruder T, Bodnar L. Neighborhood racial composition and poverty in association with pre-pregnancy weight and gestational weight gain. SSM Popul Heal 2016; 2:692-699.^,2525 Mendez DD, Doebler DA, Kim KH, Amutah NN, Fabio A, Bodnar LM. Neighborhood socioeconomic disadvantage and gestational weight gain and loss. Matern Child Health J 2014; 18(5):1095-103..

Galin et al.²²22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46. and Tabet et al.²⁶26 Tabet M, Nelson E, Schootman M, Chien LC, Chang JJ. Geographic variability in gestational weight gain: a multilevel population-based study of women having term births in Florida (2005-2012). Ann Epidemiol 2017; 27(7):421-428.e2. showed that the excessive weight gain prevails in pregnant women with higher education level rather than with low education level. The influence of the number of previous pregnancies on the excessive gestational weight gain was analyzed by Hasan et al.⁴4 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190. and Farhangi²¹21 Farhangi MA. Gestational weight gain and its related social and demographic factors in health care settings of rural and urban areas in northwest Iran. Ecol Food Nutr 2016; 55(3):258-265.. However, the results were controversial: Hasan et al.⁴4 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190. found an increased probability of inadequate gestational weight gain for multiparous women compared to the nulliparous ones (OR=1.5, 95%CI 1.2-1.9), whereas Farhangi²¹21 Farhangi MA. Gestational weight gain and its related social and demographic factors in health care settings of rural and urban areas in northwest Iran. Ecol Food Nutr 2016; 55(3):258-265. found that the weight gain was significantly higher in nulliparous women.

The pre-gestational BMI conditions also had a significant effect on the excessive gestational weight gain, revealing that women becoming overweight and obese prior to pregnancy had a higher probability of showing excessive gestational weight gain⁴4 Hasan SMT, Rahman S, Locks LM, Rahman M, Hore SK, Saqeeb KN, Khan MA, Ahmed T. Magnitude and determinants of inadequate third-trimester weight gain in rural Bangladesh. PLoS One 2018; 13(4):e0196190.^,2424 Gallagher A, Liu J, Probst JC, Martin AB, Hall JW. Maternal obesity and gestational weight gain in rural versus urban dwelling women in South Carolina. J Rural Heal 2013; 29(1):1-11.^,2626 Tabet M, Nelson E, Schootman M, Chien LC, Chang JJ. Geographic variability in gestational weight gain: a multilevel population-based study of women having term births in Florida (2005-2012). Ann Epidemiol 2017; 27(7):421-428.e2..

Discussion

The results of this study evidenced from the selected articles that environmental factors related to the pregnant women, such as socioeconomic level/poverty index of the pregnant woman’s microregion of residence, neighborhood composition, violence level, and the distance from the pregnant woman’s house to supermarket, may play a role on the excessive gestational weight gain. In the general population, such associations have been examined in several reports¹⁴14 Velásquez-Meléndez G, Mendes LL, Proença Padez CM. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saude Publica 2013; 29(10):1988-1996.^,1515 Fermino RC, Reis RS, Hallal PC, Farias Júnior JC. Perceived environment and public open space use: a study with adults from Curitiba, Brazil. Int J Behav Nutr Phys Act 2013; 10:35.^,2727 Durand CP, Andalib M, Dunton GF, Wolch J, Pentz MA. A systematic review of built environment factors related to physical activity and obesity risk: Implications for smart growth urban planning. Obes Rev 2011; 12(5):e173-e182..

The importance of describing the environmental factors that implicate in the excessive gestational weight gain is unveiled by the consolidated evidences on how excessive weight gain is linked to several negative outcomes - both for the maternal and neonatal health. Studies describe adverse results, such as increased risk of low birth weight, premature birth, gestational diabetes and preeclampsia¹1 Silva LO, Alexandre MR, Cavalcante ACM, Arruda SPM, Sampaio RMM. Ganho de peso adequado versus inadequado e fatores socioeconômicos de gestantes acompanhadas na atenção básica. Rev Bras Saude Mater Infant 2019; 19(1):107-114.^,66 Deputy NP, Sharma AJ, Kim SY, Hinkle SN. Prevalence and characteristics associated with gestational weight gain adequacy. Obstet Gynecol 2015; 125(4):773-781.^,77 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.. Nevertheless, it is observed that the debate on the influence of the environmental factors is still recent in the gestation context - the first study was published in 2007 by Laraia et al.¹⁰10 Laraia B, Messer L, Evenson K, Kaufman JS. Neighborhood factors associated with physical activity and adequacy of weight gain during pregnancy. J Urban Heal 2007; 84(6):793-806., with the aim to correlate the directly measured neighborhood their suburbs characteristics with smoking, diet quality, vigorous leisure activity before and during pregnancy, and gestational weight gain.

Chaparro et al.²⁸28 Chaparro MP, Ivarsson A, Koupil I, Nilsson K, Häggström J, Luna X, Lindgren U. Regional inequalities in pre-pregnancy overweight and obesity in Sweden, 1992, 2000, and 2010. Scand J Public Health 2015; 43(5):534-539. investigated temporal trends of overweight and obesity in pregnant women in Sweden. They found substantial differences in the prevalence of overweight and pre-gestational obesity for region²⁸28 Chaparro MP, Ivarsson A, Koupil I, Nilsson K, Häggström J, Luna X, Lindgren U. Regional inequalities in pre-pregnancy overweight and obesity in Sweden, 1992, 2000, and 2010. Scand J Public Health 2015; 43(5):534-539.. However, they did not discuss which regional characteristics could explain these prevalence differences, demonstrating the need for further research to elucidate the mechanisms related to the environment.

In this review, the selected articles showed that the pre-gestational BMI conditions are predictors of excessive weight gain during pregnancy and may be influenced by the environmental context. These results agree with the findings evidenced by Headen et al.⁷7 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109. and Galin et al.²²22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46., confirming that social and economic differences in the pregnant women’ living context, such as the poverty and violence indexes of the neighborhood, can influence on the weight gain during pregnancy⁷7 Headen I, Mujahid M, Deardorff J, Rehkopf DH, Abrams B. Associations between cumulative neighborhood deprivation, long-term mobility trajectories, and gestational weight gain. Heal Place 2018; 52:101-109.^,2222 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46..

The pooled analysis results of the urban and rural environment influences on the excessive gestational weight gain showed that the higher prevalence of excessive gestational weight gain occurred in women that live in urban areas. In this review, studies carried out in four countries with different levels of urbanization were identified. While the US and Brazil have more than 80% of their inhabitants residing in urban areas²⁷27 Durand CP, Andalib M, Dunton GF, Wolch J, Pentz MA. A systematic review of built environment factors related to physical activity and obesity risk: Implications for smart growth urban planning. Obes Rev 2011; 12(5):e173-e182.. Research conducted in the general population showed a relationship between the overweight/obesity and urban environment, among other factors, due to the eased access to foods considered unhealthy, ultra-processed and of low nutritional quality²⁹29 Cooksey-Stowers K, Schwartz MB, Brownell KD. Food swamps predict obesity rates better than food deserts in the United States. Int J Environ Res Public Health 2017; 14(11):1366..

Another result of this review was the relationship found by Galin et al.²²22 Galin J, Abrams B, Leonard SA, Matthay EC, Goin DE, Ahern J. Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range. Paediatr Perinat Epidemiol 2017; 31(1):37-46. between the neighborhood violence index and excessive gestational weight gain. For Cohen et al.³⁰30 Cohen L, Davis R, Lee V, Valdovinos E. Addressing the intersection: preventing violence and promoting healthy eating and active living. Oakland: Prevention Institute; 2010., violence and fear can influence on healthy diet and active lifestyle, two main factors related to weight gain and obesity. People who live in violent micro-regions are less likely to be physically active, have less access to healthy foods, and are more likely to suffer from psychological effects, such as stress, depression and anxiety, which lead to poor diet and physical inactivity²⁹29 Cooksey-Stowers K, Schwartz MB, Brownell KD. Food swamps predict obesity rates better than food deserts in the United States. Int J Environ Res Public Health 2017; 14(11):1366..

The relationship between the built environment, including areas for physical activity and proximity to supermarkets, and excessive gestational weight gain described by Laraia et al.¹⁰10 Laraia B, Messer L, Evenson K, Kaufman JS. Neighborhood factors associated with physical activity and adequacy of weight gain during pregnancy. J Urban Heal 2007; 84(6):793-806. has not been properly examined yet. These environmental factors have been more examined in the general population to investigate obesity¹⁴14 Velásquez-Meléndez G, Mendes LL, Proença Padez CM. Built environment and social environment: associations with overweight and obesity in a sample of Brazilian adults. Cad Saude Publica 2013; 29(10):1988-1996.^,1515 Fermino RC, Reis RS, Hallal PC, Farias Júnior JC. Perceived environment and public open space use: a study with adults from Curitiba, Brazil. Int J Behav Nutr Phys Act 2013; 10:35.. A study conducted in a medium-sized city in Brazil in 2019 demonstrated that the accessibility to public and private areas for physical activity is linked to obesity in the adult population³¹31 Silva FMO, Novaes TG, Ribeiro AQ, Longo GZ, Pessoa MC. Environmental factors associated with obesity in the adult population in a medium-sized Brazilian City. Cad Saude Publica 2019; 35(5):e00119618..

The present review becomes relevant due to the extensive bibliographic search, without restricting language and year of publication. All steps of this systematic review were conducted according to the PRISMA criteria, including the peer review at all screening stages. However, we highlight some limitations mainly associated with the features of the included articles, such as their transverse design, whose results only reflect on associations, and not on cause-effect relationships.

It is also worth mentioning that it was possible to perform a meta-analysis with only 3 of the included articles because they presented analysis of common variables. Nevertheless, the sample size differences must be considered critically in the result analysis. It is also noteworthy that the fact that few studies were included in the prevalence meta-analysis limits the assessment of heterogeneity, although the random effects model was employed. The other reports show a large variation of design, which generated different measures of association, thereby hindering the pooled analysis.

Conclusion

This study revealed the higher prevalence of excessive gestational weight gain in pregnant women that lives in urban areas, evidencing the influence of the environment on the gestational weight gain. This study also demonstrated that the environmental factors related to the living context of pregnant women influenced on the excessive gestational weight gain rates, which, in turn, may implicate in several maternal and neonatal outcomes. Our findings can therefore contribute to the development of public policies for the magnitude of inadequate gestational weight gain.

References

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