Population estimates, consequences, and risk factors of obesity among pregnant and postpartum women in India: Results from a national survey and policy recommendations

Abstract Objective To examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity in India. Methods This is a mixed‐methods study. We analyzed the National Family Health Survey (NFHS)‐4 data (2015–16) to estimate the prevalence and risk factors of obesity, followed by a desk review of literature and stakeholder mapping with interviews to develop policy guidance. Results National prevalence of obesity (defined by WHO as body mass index ≥25) was comparable among pregnant (12%) and postpartum women (13%) ≥20 years of age. A high prevalence of obesity (>40%) was observed in over 30 districts in multiple states. Older maternal age, urban residence, increasing wealth quintile, and secondary education were associated with increased odds of obesity among pregnant and postpartum women; higher education increased odds among postpartum women only (OR 1.90; 95% CI, 1.44–2.52). Dietary variables were not associated with obesity. Several implementation challenges across healthcare system blocks were observed at policy level. Conclusion Overall prevalence of obesity in India during and after pregnancy is high, with huge variation across districts. Policy and programs must be state‐specific focusing on prevention, screening, and management of obesity among pregnant and postpartum women.


| INTRODUCTION
Overweight and obesity, characterized by an adult body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 25 or more, have become a major global public health challenge with increasing rates in low-resource countries. Between 1975 and 2016, the proportion of adult women (aged ≥20 years) with obesity increased from 6% to 15% globally. 1,2 In India, the proportion of overweight/obese adult women almost doubled from 12.6% in 2006 to 20.7% in 2016. 3 In India, undernutrition (BMI <18.5) coexists with obesity. Women with undernutrition before and during pregnancy are at risk of giving birth to low birth weight babies, and these children are at higher risk of noncommunicable diseases (NCDs) and later obesity. [4][5][6] Evidence from observational studies shows that obesity before and during pregnancy is associated with adverse health outcomes for both mothers and children, perpetuating intergenerational cycles of obesity and associated NCDs. 7,8 Obesity during pregnancy is associated with an increased risk of gestational diabetes mellitus (GDM), pre-eclampsia, miscarriage, venous thromboembolism, infection, and hemorrhage in the mother. 9 Furthermore, obese women may be exposed to nutrient-poor but energy-dense diets, contributing to adverse pregnancy outcomes. 4 Intrauterine exposure to hyperglycemia (in GDM) and hypertension may negatively affect fetal development through epigenetic processes and lead to preterm birth, macrosomia, congenital abnormalities, stillbirth, and neonatal death. [10][11][12][13] Globally, maternal overweight/obesity has been reported to contribute to a 0.6 million increase in deaths and a 1.8% increase in disability-adjusted life years between 1990 and 2010. 14,15 World Health Organization (WHO) antenatal care guidelines 16  The challenges include, but are not limited to, resource constraints, gaps in the supply chain, barriers to behavior change, inadequate access to health services, policy, and governance.
Globalization and consumption of nutrient-poor, energy-dense processed foods and diets high in carbohydrates, coupled with the transition to sedentary occupations and reduced physical activity, have been major drivers of the global obesity epidemic in the last three to four decades. 18,19 Previous studies in India and other low-and middle-income countries have consistently shown positive associations between obesity and higher socioeconomic status, higher educational qualification, and improved dietary diversity scores. [20][21][22] However, there is limited evidence on risk factors for obesity in pregnancy and the postpartum period in India. Given the rising double burden of undernutrition and obesity in India, it becomes crucial to understand the prevalence of and risk factors for obesity in pregnancy and the postpartum period to develop context-specific preventative policies.
Using data from the National Family Health Survey (NFHS)-4 3 and a desk review of literature with a focus on India, the aim of the present study was to examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity. The hope is that findings will inform antenatal care services for prevention and management of obesity-related risks in India. With an already strong political commitment to health and wellness through the life cycle with the launch of Ayushman Bharat, these findings are timely.

| MATERIALS AND METHODS
The geographic scope of the current study is India. The study used a mix of analytic methods including review of literature on prevalence and consequences of obesity; analyses of NFHS-4 data (2015-16) to estimate the prevalence of and risk factors for obesity; and development of policy guidance.

| Review of literature
We undertook a desk review of papers published in India between January 2011 and November 2019. Papers were searched in PubMed using search terms pregnan*, overweight, obes*, overnutrition, high BMI, and India. Data on prevalence, determinants, and consequences available from these papers were collated using Excel version 13 (Microsoft Corp, Redmond, WA, USA) with details of date published, authors, type of study, location, duration, and outcomes of interest.

| Secondary analysis of NFHS-4 (2015-16)
Prevalence and determinants of obesity in pregnancy (<20 weeks) as (1) women at ≥20 weeks of pregnancy to avoid misclassification based on BMI cut-offs or BMI for age z score; and (2) women whose height and weight measurements were not available for calculating BMI.
Among postpartum women, those less than 2 months postpartum were excluded to avoid the effects of retaining weight after pregnancy, and those more than 6 months postpartum were also excluded. Due to the limited sample size, separate analyses for adolescents (15-19 years) were not undertaken in the current study.

| Statistical analysis
National level sampling weights were used during analysis to maximize the representativeness of the study population. Descriptive analyses were conducted to present characteristics of the study sample for women in pregnancy and the postpartum period. We developed maps depicting district-wise cases to study the variability in the prevalence of obesity at the state level. Multivariable logistic regression was used to examine associations between obesity and its correlates. For pregnant F I G U R E 1 Sampling flow chart of pregnant women (<20 weeks of pregnancy) and mothers in the postpartum period (2-6 months).
women, the models were additionally controlled for gestational age. All data were analyzed using Stata version 15.1 (StataCorp LLC, College Station, TX, USA). P<0.05 was considered statistically significant.

| Development of guidelines review grid and discussions with policymakers and implementers
A guideline review grid consisting of 10 blocks was constructed covering public health dimensions covered by the WHO and others. The blocks were: availability and accountability for guidelines; plans and financing; demand creation; leadership and governance; partnerships; information systems/monitoring and evaluation; capacity building; supply; institutionalized mechanisms research; and policy dialogue. A database of stakeholders was developed to map researchers/agencies engaged in the management of obesity using a contact list of experts from the National Centre of Excellence and Advanced Research on Diets (NCEARD), Lady Irwin College, New Delhi. A desk review of the literature was also conducted. Published and unpublished work from around 100 active stakeholders was appended to the database created through online searches.

| RESULTS
In the last decade, several researchers have investigated the prevalence of overweight and obesity and its consequences among pregnant women in community and facility settings in India, but only one study investigated the determinants. [26][27][28][29][30][31][32][33][34][35] The study cohorts spanned

| Study sample characteristics
Characteristics of the study sample are summarized in Table 1. The majority of women (~70%) were rural residents, aged 20-24 years (~50%). Around one-third of the population belonged to socially disadvantaged groups (scheduled caste, scheduled tribe, other backward classes as defined in NFHS-4). The majority of women (~80%) had access to improved drinking water, but less than half had access to sanitation facilities.

| Prevalence of overweight and obesity
The national prevalence of obesity was comparable in pregnancy (12%; 95% CI, 11.6-13.3) and in the postpartum period (13%; 95% CI, 12.4-13.8). Among pregnant women, the prevalence of obesity was over 40% in 31 districts, with the highest prevalence of 72% in Shupiyan district (Jammu and Kashmir) (Fig. 2). The prevalence of obesity among postpartum women was over 40% in 37 districts, with the highest prevalence of 61% in Pathanamthitta district (Kerala) (Fig. 3).

| Risk factors associated with obesity
The results from multivariate models of risk factors for obesity among women in pregnancy and the postpartum period are shown in Table 2.
Older maternal age (OR 6.22; 95% CI, 4.45-8.69 and OR 4.13; 95% CI, 3.01-5.66) and increasing wealth quintile (OR 6.37; 95% CI, 4.28-9.48 and OR 8.25; 95% CI, 5.89-11.56) were significantly associated with higher odds of obesity in both pregnancy and postpartum (2-6 months). (1) 10 minutes' individualized counselling to obese pregnant women by a healthcare worker on consequences of obesity during pregnancy, do's and don'ts related to diet and exercise (avoidance of calorie-dense, nutrient-poor foods, maintenance of a regular meal pattern and planning T A B L E 1 Sociodemographic characteristics of pregnant women (<20 weeks of pregnancy) and women in the postpartum period (2-6 months), India (NFHS 4, 2015-16).

No. (%) No. (%)
Age, y (2) regular home visits to assess compliance with antenatal care services   Names of districts given where prevalence of obesity is greater than 40% (BMI calculated as weight in kilograms divided by the square of height in meters).
T A B L E 2 Adjusted odds ratios of obesity (BMI ≥25) among pregnant women (<20 weeks of pregnancy) and women in the postpartum period (2-6 months), India (NFHS 4, 2015-16 improving health, dietary, and lifestyle behaviors among adolescents as the younger age of marriage in India is considerably high. In conclusion, our results indicate a comparable national prevalence of obesity among pregnant (12%) and postpartum women (13%) with a higher prevalence of obesity (>40%) in more than 30 districts