Evaluation of Weight Loss Intervention for Postpartum Weight Retention

Postpartum Weight Retention:Self-ManagementEvaluation Project

Introduction

The prevalence of obesity has steadily increased, and presently more than one third of U.S. adults are obese (Groth, Stewart, & Smith, 2018). Over 34% of women are obese at childbearing age, and African American women have the highest rate (56.9%) of obesity among racial or ethnic groups in the United States (Groth, Stewart, & Smith, 2018). Having children is a significant part of a women’s life and this is how an enormous amount of weight is gained. Gestational weight gain is associated with immediate and long-term adverse outcomes for both mother and child, including increased risk for gestational diabetes, pregnancy-related hypertension, future maternal obesity, complications during labor and delivery, and problems associated with breastfeeding (Wang, Arroyo, Druker, Sankey & Rosal, 2015).

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Excessive gestational weight gain (GWG) and postpartum weight retention (PPWR) may play a significant role in long-term obesity. Having one child doubles the 5 and 10 year obesity incidence for women, with many women who gain excessive weight during pregnancy remaining obese permanently (Spencer, Rollo, Hauck, MacDonald-Wicks, Wood, Collins, 2015).

Gestational weight gain is also higher than before. Today, nearly 50% of women exceed their weight gain goals with overweight and obese women having the highest prevalence of excessive weight gain (Kominiarek & Peaceman, 2017).

A study was conducted to evaluate the effects of an intervention weight loss diet with and without exercise for 18 weeks, as well as a maintenance period for 18 weeks, on anthropometric indices such as weight, waist circumference, body mass index, body fat and lean body mass in 206 overweight and obese females from Cyprus (Andreou, & Papandreou, 2011). There were two groups in this study. One group was Diet only (DO), followed a controlled-calorie diet program, while the other group was the diet and exercise group (DE). This group followed the same controlled calorie diet but incorporated behavioral modification techniques for food intake and exercise. In the study, the results were significant between each group. The DE group shows the client body mass index (BMI) reduced by 5.1 as opposed to 3.2 in the DO group. The study also showed 14.2 cm lower in the DE group and 8cm lower in the DO group. In the DE group, body fat was reduced to 15.5 percent while no changes were observed in the DO group.

The findings of this study were consistent with other studies and reviews showing that dieting alone may help to lose weight but that diets achieve the best long-term results when accompanied by regular exercise (Andreou, & Papandreou, 2011). A combination of a reduced-calorie diet with exercise may successfully reduce weight, lowers BMI and reduces the risks of medical problems in the future.

Method

Client

The client in this case is myself, Dolene Harrigan, as this is a self-management project. I am a 29-year-old female, currently attending Florida International University to complete my Master’s in Social Work. I work full time as a Dependency Case Manager Supervisor for a child welfare agency in Miami Dade County. I began to feel very uncomfortable with the way I look after gaining a considerable amount of weight due to pregnancy. I became a mother of my first son at age 27 and gave birth shortly after to my second son at age 28. I went from being 153 pounds pre-pregnancy to 175 pounds post pregnancy. I have experienced times of emotional abuse by being criticized by my significant other for not looking the same as I did before and not taking the initiative to work on getting back to a healthy body weight after pregnancy. However, this is not as easy as it seems to do. Being a full time mother, holding a child welfare management role which can be challenging and stressful and working on my graduate degree has not left much time to exercise, eat proper meals or even just time for myself. I developed a low self-esteem of myself because of the additional weight I gained throughout and after my pregnancy. Because I felt very uncomfortable, I would not go out and socialize with other in fear that the topic of discussion will be my weight. To help with my self-image, I did invest in a gym membership. With this, I would be forced to find time to go to the gym as it would be costing me money. I was active in the gym for about 2 months and lost a total of 5 pounds. I later lost motivation as I was not losing the weight quick enough and just continued to eat even more unhealthy snacks. I gained the 5 pounds, just previously lost, and now was not able to control my eating habits. Instead of healthy eating habits, I started eating unhealthier than I ever did in the past and feeling unmotivated to do the work to lose the weight. This contributed to my poor self-image.

On 5/14/2019, I noticed a lump on the side of my neck, which felt considerably large. I went to my primary care physician, as this was a concern for me. I completed labs and was told a week later that I developed a cyst in my neck. My physician advised this developed due to my rapid weight gain. Although it was a benign cyst, it is in my best interest to lose some weight to avoid other complications in the future. Hearing this news and thinking about my two children, they gave me the motivation to change my unhealthy behavior and live a healthier life so I can be around to see them grow up.

Setting

Since this is a self-improvement project, I observed myself on a daily basis. This intervention was carried out at home, work and in my association gym. I will be logging information during the day based on my eating habits. I will log my patterns of eating and what I eat at 12PM, 4PM, and 930PM, after my last meal. I will also be incorporating regular exercise schedule. I will be attending the association gym on Tuesdays, Thursdays and Saturdays from 5:00PM to 5:45PM each day. After each session of work out, I will log the exercises complete and time for each work out. For example, I will first start with a warm up which involves stretching my arms, legs, bending to touch my toes, and from side to side. I will complete 5 sets of workouts in a series. I will complete 15 jumping jacks, Burpee (includes going in a push up position to a jump and back to a push up position), 15 Kettlebell Swing (bending at the hips while holding the kettlebell with both hands at arm’s length down in front of you. Rocking slightly the kettlebell between your legs), 15 Dumbbell overhead Lunge, (pressing the dumbbells overhead so your palms are facing each other. Step forward into a lunge position, pause, and then bring your back leg forward to step your feet together) and running laps around the gym facility. These workouts will be timed where I will have 5 minutes to complete each work out series. I will weigh myself and the beginning and end of each week. On Mondays by 7:00AM, I will weight myself on the scale and Sunday by 9:30 PM to evaluate if weight is lost while incorporating a healthy meal plan and exercise plan, which will be recorded, on my FITBIT app.

Measures

The context of the problem was weight gain after pregnancy due to me not feeling motivated, thus developing a low self-esteem. This resulted in me becoming overweight and possibly developing additional health issues that can affect my overall quality of life. In order to assess the severity of the problem, self-report logs was being utilized to monitor the frequency of exercise and food consumption on a daily basis. My self-report logs consisted of my meal patterns and exercise workouts done before starting my intervention. My baseline information was completed during the week from May 20 to May 27, 2019. This information was included as my pre-test information in my self-reporting logs. I also completed a post-test to evaluate productivity of my study. However, my primary measure to evaluate my intervention and results was the self-monitoring logs to record my outcomes. The primary focus of my intervention and dependent variable was the frequency of weight loss with the implementation of the digital app, better eating habits and physical activity.

 In addition to the frequency, the time of day and comments was recorded in the self-report logs. Self-monitoring does have face validity and good reliability and can be sensitive to the client. With this, I was able to adjust the measure to make it easier to record and use. With self-monitoring, it is important to know that it is required to be careful with reactivity. Self-monitoring tools could increase client’s awareness of what is being done as a treatment, and can result in the client adjusting their behavior only to benefit from the recordings and increase the likelihood that the intervention results may be a favorable to the client. While the reliability of self-reported data can vary, data is being logged as soon as I complete the action. Using the digital phone app and logs seemed appropriate to monitor my weight loss. I constantly use my phone therefore, logging my information through my phone was relatively simple and not as time consuming as it would be if I would have to hand write all of that information. I have an accurate record of activity due to logs being completed at the same time.

Example of physical sheet (Meal & Workout Log):

I logged information every day at 12PM, 4PM and 9:30PM after my workouts and last meal. I would do so by opening the “Fitbit” application and my “Fitbit” wristband would sync my daily steps, heart rate, duration of exercise, etc. I recorded my weight once every three days beginning at the baseline period at around 9:00am before leaving for work. I would log my weight on the “Fitbit” application at the baseline period. Additionally, at the end of each day after syncing my “Fitbit” to the application, I would log my meals and activity for that day. I would exercise with my work out partner, my mother and she would observe and motivate me during my workouts. We would go over meal plans to make sure I stay on track with my goal of losing twenty pounds.

Procedure

Initial Assessment

Prior to gathering my baseline information, I completed an Antecedent Behavior Consequence chart so I am able to record frequency, place, situation and consequence to my unhealthy eating and weight gain.

In conjunction to the ABC chart, I observed myself eating very unhealthy mostly while I am working. With the awareness of this situation, I saw the link between me feeling an overwhelming amount of stress at work and not being able to leave the office, I resort to eating high calorie snacks and ordering a lot of take out which does not benefit my current situation. I was consuming a high amount of calories, gaining weight and losing money from takeout rather than cooking at home.

Baseline

In my situation, I became overweight after giving birth to my second child. To collect data, I used regular baseline by using self-monitoring. Base line information was collected between May 20 and May 26, 2019 record patterns. I used self-monitoring to record the frequency and time of snacks and meals eaten, what those meals consisted of and exercise patterns. The results of the baseline showed me while I am behind of the desk working; I eat at least four unhealthy snacks, which consist of chips, chocolate bars and muffins. I also found that I would buy fast food at least three times during the week, which contributed, to my unhealthy eating habits. I found that I ate these type of food especially when I am unable a lot of stress at work. I was not able to lose weight during my baseline period. Additionally, during my baseline, I used my medical record dated 5/14/2019 to view my body mass index (BMI) to review my BMI level. I found with my current weight of 175 pounds and a height of 5’4, I am at a BMI of 30.0. According to the Center of Disease Control and Prevention, a BMI of 30.0 is considered obese for my height and weight (CDC, 2011). In order to be at a normal or healthy BMI level at my height, I should be between 110 to 140 pounds.

Intervention phase

The intervention stage consisted of daily exercise and physical activity. I set goals of logging 8,000 steps a day and exercise at least three times a week for 45 minutes, (from 5:00PM to 5:45PM) each session on Tuesdays, Thursdays and Saturdays. Exercise typically of jogging, leg ups, sit-ups and cycling and other specific exercises done in series (explained previously). I used the Fitbit” wristband and the “Fitbit” phone app to monitor my weight loss by daily physical activity (steps and workouts), measure my water intake, and monitor heart rate, as well as logs calories with my food intake. I also implemented a Keto diet where Glow Meals would deliver my meals on a weekly basis on Mondays and Thursdays, which consist of breakfast, lunch, dinner and dessert. Glow Meals is an organic meal prep service based out of Hialeah, Florida. Due to my busy schedule, I thought purchasing meals from Glow Meals was the best option for me, as I did not have enough time to prepare meals on my own during the week. Additionally, the cost of the meals are low in price. Each week, there are breakfast; lunch and dinner meals for a special price of $4.95 and other meal prices are $6.75 a meal. I usually buy the meals that are on special to lower my weekly cost on the meals. The meals are being delivered twice a week for a delivery fee of $15.00 dollars for the two deliveries. My average cost for my meals each week averages about $105.00. This is affordable for me long term as before I would buy groceries on a biweekly basis and did not have much time to cook proper meals for myself. I found that I would waste money buying groceries and still buying food out. My cost weekly to buy groceries was an average of $150.00 each shopping trip. Additionally, buying food out weekly cost me an average amount of $50.00, which is a monthly expense of $200.00. I spent more money buying groceries and eating out whereas, with Glow Meals, I was spending less. With Glow Meal, I am substituting the money I would spend on groceries and having the meals already prepared and delivered to my door twice a week. For motivation, my mother participated in this project with me. She worked out with me on three times a week. She has been very influential in this process as she instill confidence in me in order to encourage me to make meaningful behavior changes in my life. To ensure that I stay on the right track in my intervention, my mother has also adapted to this change for herself. We discussed meal plans each week by choosing healthy foods on the menu that we both would enjoy and explore positive habits that promote weight loss in order to achieve desired goals and maintaining it. It was cost effective as the meals are not expensive; it is practical and easily documented. This is also a healthy approach as I will be able to lose the weight thus; my overall health status will improve.

Results

The baseline and data is illustrated in Table 1. Baseline data showed a mean of 6 meals eaten a daily with a consumption of 2115 calories each day. With the implementation of the intervention, a decreasing trend was observed which indicated a decrease of calories consumption on a daily basis. On the first day of my intervention, I eliminated the amount of meals and snacks eaten throughout the day by two, as well as lower my calorie intake within each meal. The intervention data shows a decrease in the consumption of foods eaten. As mentioned before, while working under stressful situations during the day, I would consume unhealthy snacks while I work. Within my intervention, I substitute unhealthy snacks like Cheetos and fries with snacks within my Keto diet, for example, Celery and pepper strips dipped in guacamole and Plain, full-fat Greek yogurt topped with crushed pecans which has been very easy to plan and pack with me for the day. To buy these weekly meals, I would spend approximately $40.00 a week.

Throughout the intervention phase, my consumption continued to decrease gradually. The intervention data showed a mean of five meals and a mean of 1536 with calorie consumption daily. I did not meet the goal of my pre-pregnancy weight of 153lbs; however, I came very close to it at 156lbs with staying consistent to the intervention put in place.

As illustrated in the graph, there is an observable difference between the baseline data and the intervention data. There was a gradual change in the amount of meals and calorie intake from the baseline data to the intervention phase. There was a change with slope between phases with an improvement change from the baseline to the intervention phase. The slope in the intervention phase is observed to be downwards which suggested a treatment effect as the intention was to reduce the amount of weight gained after pregnancy.

The results suggest that the treatment intervention was effective for the use of reducing the amount of weight gain during pregnancy and weight retained postpartum. Throughout the treatment, I was able to lower the amount of meals eaten and lower the amount of calories consume through the help of the FITBIT app and exercise plan and following a strict diet, which made easy with my planned meals on a weekly basis. This could suggest that the treatment was responsible for the reduction of my weight.

Conclusions

Thus far, I am able to continue my intervention as it is feasible for me to be able to incorporate during my week and not cost any financial hardship continuing the Glow Meal Plan. I am also able to maintain my exercise schedule Tuesdays, Thursdays and Saturdays in my association gym. With weight reduction, it is important to maintain the intervention to prevent myself from gaining the weight I recently lost. Maintaining a healthy diet and exercise schedule will help me maintain my current weight of 156lbs. I can say one limitation to this study is that it took place over a 35-day period. This might not have been enough time to observe accurate changes, however, my intention is to continue my intervention after this class ends, as this is something that I have invested time, money and my health depends on my losing and maintaining the weight lost by incorporating exercise and a healthy diet plan. Getting back to the range of my normal weight pre pregnancy, I notice a change in myself. I feel more confident and comfortable in the clothes I wear and the expression shown when I walk into a room full of people.

Although my mother did not record her progress as I did, she also was able to decrease her weight gain from 215lbs to 204lbs incorporating the Keto diet and exercise plan. She too continues to follow this plan in order to continue losing the weight and maintaining healthier practices like exercising while doing so. Additionally, us continuing this intervention together, we are able to motivate each other during this ongoing process. Reactivity may have occurred during the intervention since I was aware that I had to record for progress. However, this was also a motivating aspect for me as my health played a big role in my losing weight and I wanted to do well. The AB design incorporated was efficient and was able to show a reduction in my weight. Overall, I am satisfied with the changes I have made thus far and I feel like I have regain control over my body and my life.

Table 1

Name: Dolene H

This information displays the frequency of meals eaten with calorie intake each day as well weight loss during the baseline period.

Baseline Data

Table 2

Name: Dolene H

The information presented has been observed while using Group Treatment intervention along with individualized treatment (Keto Diet and an Exercise plan).

Intervention Data

Baseline Photograph of myself:

Intervention (After) Photographs of myself:

Chart:

References

• Kominiarek, M. A., & Peaceman, A. M. (2017). Gestational weight gain. American journal of obstetrics and gynecology, 217(6), 642–651. doi:10.1016/j.ajog.2017.05.040
• Monica L. Wang, Julie Arroyo, Susan Druker, Heather Z. Sankey & Milagros C. Rosal (2015) Knowledge, Attitudes and Provider Advice by Pre-Pregnancy Weight Status: A Qualitative Study of Pregnant Latinas With Excessive Gestational Weight Gain, Women & Health, 55:7, 805-828, DOI: 10.1080/03630242.2015.1050542
• Meng, Y., Groth, S. W., Stewart, P., & Smith, J. A. (2018). An Exploration of the Determinants of Gestational Weight Gain in African American Women: Genetic Factors and Energy Expenditure. Biological Research for Nursing, 20(2), 118–125. https://doi- org.ezproxy.fiu.edu/10.1177/1099800417743326
• Spencer, L., Rollo, M., Hauck, Y., MacDonald-Wicks, L., Wood, L., Hutchesson, M., Collins, C. (2015). The effect of weight management interventions that include a diet component on weight-related outcomes in pregnant and postpartum women: A systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports, 13(1), 88-98. doi:http://dx.doi.org.ezproxy.fiu.edu/10.11124/jbisrir-2015-1812
• About Adult BMI | Healthy Weight | CDC. (2011, July 1). Retrieved June 06, 2019, from https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html
• Andreou, E., Philippou, C., & Papandreou, D. (2011). Effects of an intervention and maintenance weight loss diet with and without exercise on anthropometric indices in overweight and obese healthy women. Annals of Nutrition & Metabolism, 59(2-4), 187-92. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1159/000334755