Applied Research Quality Life DOI 10.1007/s11482-013-9224-z
The Influence of Body Mass Index on the Perceived Quality of Life during Pregnancy Jelena Dotlic & Milan Terzic & Dragan Babic & Nadja Vasiljevic & Slobodanka Janosevic & Ljiljana Janosevic & Tatjana Pekmezovic
Received: 4 September 2012 / Accepted: 19 February 2013 # Springer Science+Business Media Dordrecht and The International Society for Quality-of-Life Studies (ISQOLS) 2013
Abstract Obesity contributes to various pregnancy complications and therefore, may compromise maternal quality of life. The study aim was to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) during pregnancy. Study involved every 6th woman who gave birth in the Clinic for Obstetrics and Gynecology Clinical Center of Serbia during the year 2010. Initial and end pregnancy BMIs were calculated for every woman. The parturients (604) completed the SF36 questionnaire (physical-PHC; mental-MHC; total quality of lifeTQL), Beck’s Depression Inventory, Fatigue Severity Scale, Pregnancy Symptom Scale, Multidimensional Personal Support Scale, and Acceptance of Illness Scale. Before pregnancy most women had normal or decreased weight, while at the end of pregnancy the majority were overweight or obese (p=0.000). Initial and end pregnancy weights (p<0.05) and BMIs (p<0.05) were positively correlated with depression. Depression was significantly lower in overweight compared to mildly or J. Dotlic (*) : M. Terzic Clinic for Obstetrics and Gynecology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Visegradska 26, 11000 Belgrade, Serbia e-mail:
[email protected] D. Babic : S. Janosevic Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia N. Vasiljevic Dietetic Unit, Institute of Hygiene and Medical Ecology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia L. Janosevic Clinic for ENT/MFH, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia T. Pekmezovic Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
J. Dotlic et al.
morbidly obese women during pregnancy (p<0.05). Pregnancy weight change correlated negatively with PHC (p=0.029), and positively with fatigue (p=0.030), and symptoms (p=0.011). Of all BMI categories, morbidly obese women had the worst feeling of social support (p<0.05). Pregnancy symptoms were significantly less problematic in women with normal weight compared to overweight and obese women during pregnancy (p<0.05). Assessing the impact of all investigated parameters together, we established significant models for PHC (p=0.036), depression (p=0.030), and fatigue (p=0.038). Pregnant women should be advised to keep their gestational weight gain within the normal recommended range to have a good pregnancy outcome and HRQoL. Keywords Quality of life . Depression . Fatigue . Pregnancy . BMI . Obesity
Background Data from recent literature highlight the significance of health-related quality of life (HRQoL) within the perspective of maternal health and pregnancy outcomes (Amador et al. 2008, Smith and Lavender 2011). Obesity is a significant public health issue due to its increasing worldwide prevalence in the general population and in pregnant women (Syngelaki et al. 2011). Pregnancy is a period in which physiological weight gain is expected. However, excess weight gain and maternal obesity adversely impact pregnancy outcomes and contribute to the development of life-threatening diseases, such as hypertension, diabetes mellitus, and infections (Amador et al. 2008). However, a low body mass index (BMI) is associated with an increased risk of preterm delivery (Smith et al. 2007). As a consequence of increased morbidity and mortality of both mother and child, it can be expected that HRQoL can also be affected in obese and anorectic pregnant women (Mamun et al. 2011). However, only a few studies have examined the associations among pre-pregnancy weight, weight gain during gestation, and HRQoL (Thangaratinam et al. 2012).
Objective The aim of this study was to investigate pre-conception and term-pregnancy body mass indices and their impact on health-related quality of life during pregnancy.
Methods We used a cross-sectional quantitative study design. The study group consisted of women who gave birth in the Clinic for Gynecology and Obstetrics Clinical Center of Serbia during the year 2010. The sample size was calculated (Dotlic et al. 2012). The participants were randomized, and questionnaires were offered to every 6th woman. The respondents were approached on the first postpartum day, while still an inpatient in the hospital (Dotlic et al. 2012). All women included in the study group had signed informed consent. The inclusion criteria were as follows: term singleton
Body Mass Index and Quality of Life during Pregnancy
pregnancy; vaginal delivery within the last 12–24 h; Apgar score 8 or higher; age ≥18 years, residency in Belgrade; and conversant in Serbian. The exclusion criteria were as follows: not meeting the inclusion criteria, declining participation in the study, and verified psychiatric disorders or chronic illnesses that could affect the HRQoL (Dotlic et al. 2012). Data Collection The HRQoL was assessed by the Short Form 36 (SF-36) questionnaire (TQL – total quality of life, PHC – physical health composite score, and MHC – mental health composite score), Beck’s Depression Inventory (BDI), the Fatigue Severity Scale (FSS), the Pregnancy Symptom Scale (PSS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Acceptance of Illness Scale (AIS). SF-36 is a generic HRQoL instrument that measures eight different domains of life, which are calculated as 8 scales: physical functioning, role functioning physical, bodily pain, general health, vitality, social functioning, role functioning emotional, and mental health. Based on these 8 scales, two summary scales have been constructed: the physical health composite score and the mental health composite score. The total quality of life score is calculated from PHC and MHC. Scoring and calculations are performed by averaging items within the scales and later by linear transformations of these raw scores into a 1–100 scale that facilitate comparisons across multiple scales of SF-36. Higher values indicate a better HRQoL. SF-36 was used in this study as a measuring instrument for HRQoL because there are no specific questionnaires for the evaluation of HRQoL during pregnancy. SF-36 is the most widely accepted and used generic questionnaire, with high applicability, which can give adequate data concerning the physical and mental health of respondents. We considered these aspects as the most important for pregnant women, as well, and therefore regarded SF-36 as the best available instrument for our study. The Beck Depression Inventory explores feelings and attitudes relating to general depression status and verifies the influence of depression on HRQoL. This inventory consists of 21 questions. The answers are graded from 0 to 3. The cut-off value for depression in the healthy population is a total score ≥21 (Dotlic et al. 2012). The Fatigue Severity Scale consists of 9 statements, from which an average score is determined on a seven-point scale. This scale shows sensitivity, reliability and internal consistency in the assessment of fatigue. Moreover, the scale discriminates fatigue from depression, as these two conditions may have similar symptoms. A score value ≥4 is defined as indicating clinically significant fatigue (Dotlic et al. 2012). The Multidimensional Scale of Perceived Social Support measures three different sources of support: partners, friends and family. The scale consists of 12 statements (4 per support source). The respondents rate the level of their satisfaction with received support on a scale from 1 to 7. Complete satisfaction received from all sources corresponds with the highest possible score of 84 (Dotlic et al. 2012). The Acceptance of Illness Scale contains 8 statements to which the respondent may agree or disagree. Each response is scored from 1 to 5 according to the strength of agreement, with the exception of the last statement, where the grading order is reversed. The maximum score is 40 (a higher score indicates a lower acceptance of illness) (Dotlic et al. 2012).
J. Dotlic et al.
PSS is used to evaluate which symptoms had the most impact on HRQoL during pregnancy and to what extent. PSS consists of 42 symptoms covering both physiological pregnancy and the most usual pathological conditions of pregnancy. PSS includes the period before pregnancy, the first, second and third trimesters as well as the entire antepartum course. The respondents grade each symptom from 1 (not present) to 10 (severe). The mean score is obtained by dividing the simple score (sum of all grades) by 42, with a possible range from 0 (no symptoms) to 10 (severe symptoms). The mean score of the entire antepartum course was defined as the PSS score and was used for further analyses (Dotlic et al. 2012). For the purpose of this study, we also used a standard self-administered questionnaire that examined epidemiologic and gynecologic parameters of pregnant women on admission to the Delivery Unit of our Clinic. Out of 108 items, we have analyzed 4 variables regarding body weight and height. The first question pertained to the woman’s height (cm). The other 3 concerned the women’s weight (kg): before pregnancy, i.e. at the first check-up when pregnancy was confirmed, the average weight during previous 5 years, and the weight at the end of pregnancy, i.e. on admission for delivery. Using this information, the weight change during pregnancy as well as the BMI before and at the end of pregnancy, were calculated for every woman. . The BMI was calculated using the well-known formula: BMI ¼ weightðkgÞ ðheight ðmÞÞ2 . According to their BMI values and WHO recommendations, the women were divided into 6 groups: cachexia (BMI≤15.99); underweight (BMI 16–18.49); normal weight (BMI 18.50–24.99); overweight (BMI 25.00–29.99); mild and intermediate obesity (grade I and II) (BMI 30.00–39.99); and morbid obesity (grade III) (BMI≥40) (WHO 2000). Data Analysis Adjustments for potential confounding factors were made for women’s age and depression using multiple linear regression. Methods of analytical statistics, such as the χ2 test, Kruskal-Wallis ANOVA, the Mann–Whitney U test, and the Mc Nemar test, were used for determining differences, while Spearman’s correlation tested relationships between examined women and the investigated parameters. Multiple linear regression and binary logistic regression (Enter and Step wise methods) were applied to investigate the impact of all examined parameters together on TQL, PHC, MHC, BDI and FSS. The Statistical Package for the Social Sciences (SPSS) software (Advanced Statistics, version 17.0, Chicago, IL, USA) was used for data analysis. This study was approved by the Ethics Committee of the Faculty of Medicine, University of Belgrade.
Results There were 4572 women who delivered vaginally during the year 2010 in our Clinic. After randomization and the exclusion of respondents who did not fulfill the inclusion criteria, the responses of 604 participants were analyzed. The average total quality of
Body Mass Index and Quality of Life during Pregnancy
life was 73.6 (Dotlic et al. 2012). There were no confounding effects between age, BDI, PHC, MHC and TQL, except for the possible influence of depression on the relationship between weight change during pregnancy and TQL (R=0.395; adjR2= 0.152; F=36.937; p=0.000). Age was significantly positively correlated with weight and BMI before pregnancy (ρ=0.110; p=0.007; ρ=0.109; p=0.007), but was not significantly correlated with end pregnancy weight and BMI (ρ=0.071; p=0.079; ρ= 0.073; p=0.073), or with pregnancy change (ρ=− 0.039; p=0.334). The descriptive parameters of the investigated characteristics are presented in the Table 1. TQL was highly significantly correlated with both MHC and PHC, as well as all other examined scale scores (p=0.000). Before pregnancy, highly significantly more women were of normal weight and fewer were morbidly obese, while the frequency of women in the other BMI categories did not significantly differ from the expected frequency (Table 2). At the end of the pregnancy, highly significantly more women were mildly and intermediately obese, morbidly obese or overweight, while there were highly significantly fewer cachectic and underweight women, and significantly fewer women of normal weight (Table 2). Before pregnancy, there were highly significantly more women of decreased and normal weight (71.36 %), while at the end of pregnancy there were highly significantly more women who were overweight and obese (88.079 %). Actually, the frequencies for the categories BMI≤24.99 and BMI≥25.00 were reversed before and at the end of pregnancy (χ2=482.350; p=0.000). During pregnancy, highly significantly more women increased and fewer decreased their BMI (χ2 MeN=357.003; p=0.000). Of the women, who were of normal or lower weight pre-conception, only 16.71 % remained in these BMI categories during pregnancy, while all others became overweight or obese. Of the women, who were overweight or obese pre-conception all 173 remained in the same BMI category during pregnancy. Thus, no women lost a considerable amount of weight during pregnancy. There were highly significantly fewer women who had a BMI≤24.49 before and at the end of pregnancy, while there were highly significantly more women with a BMI≥25.00 both pre-conception and at term (χ2=40.816; p=0.000). Table 1 Descriptive parameters of investigated characteristics
Characteristics
Height (cm)
Minimum Maximum Mean
Standard Deviation
152. 00
190.00
169.01
6.03
Weight before pregnancy (kg)
42.00
125.00
61.71
10.38
End pregnancy weight (kg)
50. 00
140.00
76.22
11.22
Weight change (kg)
−9.00
51.00
14.51
5.75
BMI before pregnancy (kg/m2)
11.16
67.22
23.07
8.25
End pregnancy BMI (kg/m2)
15.34
76.45
34.99
10.39
J. Dotlic et al.
Table 2 Frequency of women in different BMI categories
BMI categories
Before pregnancy
End of pregnancy
Number %
Number %
Cachectic
73
12.09 1
Underweight
119
19.70 5
0.17 0.78
Normal weight
239
39.57 66
10.93
Overweight
85
14.07 140
23.19
Mild and intermediate obesity 68
11.26 251
41.56
Morbid obesity
20
3.31
23.34
χ2
278.715
457.563
p
0.000
0.000
141
Height was not significantly correlated with either of the scale scores (Table 3). Weights, both before and at the end of pregnancy, as well as the BMI before and at the end of pregnancy, were positively and significantly correlated only with BDI scores (Table 3). A change of weight during pregnancy was positively and significantly correlated with fatigue and pregnancy symptoms, and significantly but negatively with PHC (Table 3).
Table 3 Correlations of investigated parameters and scale scores Investigated parameters
Scale scores TQL
Height Weight before pregnancy
PHC
MHC
BDI
FSS
MSPSS AIS
PSS
ρ
0.058
0.064
0.048
0.051 −0.057
0.059
0.013 −0.037
p
0.151
0.113
0.236
0.209
0.161
0.145
0.753
ρ
0.043
0.037
0.047
0.095 −0.003
0.049
p
0.295
0.369
0.250
0.020
0.232
0.951
0.364
−0.051 −0.018 0.211
0.665
ρ
0.032
0.032
0.032
0.051 −0.008
0.015
p
0.435
0.438
0.430
0.209
0.848
0.707
0.397
0.797
ρ −0.017 −0.030
0.006
0.093
0.039
0.002
−0.040
0.035
p
0.878
0.023
0.334
0.966
0.325
0.393
Pregnancy weight change ρ −0.078 −0.089 −0.050 −0.014
0.088
−0.080
0.003
0.103
0.935
0.011
Average 5 years weight End pregnancy weight
BMI before pregnancy End pregnancy BMI
0.679
0.459
p
0.056
0.029
0.221
0.722
0.030
0.051
ρ
0.040
0.033
0.046
0.094
0.002
0.042
p
0.321
0.419
−0.035 −0.010
−0.051 −0.013
0.257
0.020
0.968
0.300
0.212
0.742
ρ −0.028 −0.042 −0.003
0.091
0.050
−0.008
−0.043
0.042
p
0.025
0.217
0.841
0.287
0.304
0.492
0.303
0.946
TQL Total Quality of Life; PHC Physical Health Composite; MHC Mental Health Composite; BDI Beck’s Depression Inventory; FSS Fatigue Severity Scale; MSPSS Multidimensional Scale of Perceived Social Support; AIS Acceptance of Illness Scale; PSS Pregnancy Symptom Scale
Body Mass Index and Quality of Life during Pregnancy
There were no significant differences in the values of neither of the scale scores regarding the 6 categories of BMI assessed all together before pregnancy or at the end of pregnancy (Table 4). However, there were several significant differences between women in different BMI groups and scale scores (p<0.05). Before pregnancy, obese and morbidly obese women were more depressed than cachectic women. Obese women were also more depressed than women of normal weight. Morbidly obese women had the worst feeling of social support (Table 5). At the end of pregnancy, morbidly obese women were more depressed than the slightly and intermediately obese and they felt more tired. Overweight and morbidly obese women had more severe pregnancy symptoms than women of normal weight (Table 5). There were no other significant differences in scores between examined groups of women. When BMI was categorized as ≤24.99 and ≥25.00 there were considerable differences in the likelihood of depression. BDI scores were highly significantly lower in women with a BMI≤24.99 compared to women with a BMI≥25.00 prior to pregnancy (Table 4). As for the BMI at the end of pregnancy, also categorized as ≤24.99 and ≥25.00, there were significant differences for BDI and PSS (Table 4). Both depression and pregnancy symptoms were significantly lower in women with a BMI≤24.99 than in those with a BMI≥25.00 during pregnancy. Comparing the pre-conception and term-pregnancy BMI and BDI scores, the likelihood of depression was the lowest in women who were underweight or of normal weight before pregnancy and who were overweight during pregnancy. Conversely, depression was the highest in women who were overweight or obese before and at the end of pregnancy (W=91,327.000; Z=2.704; p=0.007). The highest TQL was also in the group of women who were of normal weight before pregnancy and overweight at the end of pregnancy, while the worst TQL was reported by obese women (mildly or morbidly) at the beginning and end of pregnancy. Still, there were no significant differences between these groups (p=0.052).
Table 4 Differences between BMI categories and scale scores Investigated parameters
Scale scores TQL
PHC
MHC BDI
FSS
Before pregnancy BMI 6 categories Z 3.422 4.044 3.481 10.045 3.385 End pregnancy BMI 6 categories BMI ≤24.99/≥25.00 before p. BMI ≤24.99/≥25.00 end p.
MSPSS AIS
PSS
10.906
3.653 1.773
p 0.635 0.543 0.626
0.074 0.641
0.053
0.600 0.880
Z 2.177 3.831 2.414
9.492 7.246
4.350
2.807 6.909
p 0.824 0.571 0.789
0.091 0.203
0.500
0.730 0.227
Z 0.445 0.357 0.584
2.562 0.673
1.608
1.644 0.117
p 0.656 0.721 0.559
0.010 0.501
0.108
0.100 0.907
Z 0.415 0.300 0.512
0.244 0.202
0.381
1.430 2.084
p 0.678 0.764 0.609
0.807 0.840
0.703
0.153 0.037
TQL Total Quality of Life; PHC Physical Health Composite; MHC Mental Health Composite; BDI Beck’s Depression Inventory; FSS Fatigue Severity Scale; MSPSS Multidimensional Scale of Perceived Social Support; AIS Acceptance of Illness Scale; PSS Pregnancy Symptom Scale; p pregnancy
J. Dotlic et al. Table 5 Significance (p) of differences in scale scores between groups of BMI categories Investigated parameters
Before Preg.
Cachectic
Underw.
Normal
Overw. Obese Preg. End
Cachectic
Underw.
Normal
Overw. Obese
Scale scores TQL
PHC
MHC
BDI
FSS
MSPSS
AIS
PSS
Underwei.
0.611
0.656
0.661
0.274
0.905
Normal
0.323
0.383
0.347
0.344
0.253
0.123
0.907
0.348
0.420
0.775
Overwei.
0.450
0.543
0.355
0.105
0.216
0.548
0.233
0.393
Obese
0.903
0.910
0.597
0.322
0.013
0.798
0.220
0.128
Morb. Ob.
0.601
0.217
0.694
0.966
0.021
0.866
0.006
0.661
0.633
Normal
0.114
0.114
0.132
0.831
0.230
0.314
0.825
0.759
Overwei. Obese
0.185
0.219
0.145
0.554
0.565
0.912
0.465
0.895
0.514
0.840
0.317
0.099
0.648
0.814
0.088
Morb. Ob.
0.709
0.354
0.138
0.780
0.087
0.909
0.018
0.597
0.990 0.887
Owerwei.
0.988
0.967
0.950
0.368
0.576
0.427
0.560
Obese
0.573
0.393
0.862
0.048
0.155
0.553
0.130
0.565
Morb. Ob.
0.942
0.606
0.536
0.066
0.544
0.003
0.708
0.758
Obese
0.605
0.490
0.768
0.263
0.396
0.890
0.342
0.709
Morb. Ob.
0.964
0.662
0.519
0.167
0.784
0.022
0.970
0.741
Morb. Ob
0.701
0.352
0.720
0.533
0.796
0.014
0.585
0.866
Underwei.
0.770
0.380
0.380
0.766
0.143
0.343
0.770
0.143
Normal
0.877
0.266
0.301
0.729
0.162
0.139
0.550
0.289
Overwei.
0.749
0.432
0.326
0.400
0.188
0.166
0.775
0.357
Obese
0.929
0.429
0.398
0.593
0.171
0.153
0.841
0.299
Morb. Ob.
0.913
0.335
0.311
0.853
0.164
0.173
0.902
0.348
Normal
0.669
0.946
0.238
0.720
0.344
0.580
0.668
0.613
Overwei.
0.488
0.875
0.242
0.815
0.189
0.802
0.930
0.892
Obese
0.548
0.893
0.326
0.817
0.352
0.596
0.941
0.985
Morb. Ob.
0.663
0.771
0.272
0.478
0.522
0.709
0.849
0.970
Owerwei.
0.569
0.406
0.750
0.178
0.332
0.240
0.192
0.017
Obese
0.651
0.482
0.836
0.766
0.940
0.846
0.223
0.065
Morb. Ob.
0.675
0.517
0.868
0.344
0.488
0.467
0.105
0.033
Obese
0.969
0.948
0.925
0.142
0.189
0.217
0.854
0.437
Morb. Ob.
0.220
0.141
0.653
0.002
0.036
0.712
0.672
0.911
Morb. Ob
0.252
0.143
0.590
0.071
0.297
0.417
0.479
0.604
TQL Total Quality of Life; PHC Physical Health Composite; MHC Mental Health Composite; BDI Beck’s Depression Inventory; FSS Fatigue Severity Scale; MSPSS Multidimensional Scale of Perceived Social Support; AIS Acceptance of Illness Scale; PSS Pregnancy Symptom Scale; preg pregnancy; underw underweight; overw overweight; morb morbidly; ob obese
When all obtained parameters were examined together (height, weight before pregnancy, 5-year average weight, weight at the end of pregnancy, BMI before and after pregnancy, and weight change during pregnancy) in the Enter method, they did not have a significant influence on TQL (R = 0.143; adjR2 = 0.006; F = 1.387; p=0.190) and MHC (R=0.118; adjR2=− 0.001; F=0.934; p=0.495). However, using
Body Mass Index and Quality of Life during Pregnancy
the Step wise method, we obtained a significant model for PHC (R=0.085; adjR2= 0.006; F=4.429; p=0.036), as follows: PHC ¼ 73:1730:284 WEIGHT CHANGE DURING PREGNANCY When impact on depression, of all examined characteristics together, was evaluated a significant model was made using the Step wise method (R=0.088; adjR2= 0.006; F=4.737; p=0.030), as follows: BDI ¼ 0:121 þ 0:003 BMI BEFORE PREGNANCY When impact on fatigue, of all examined characteristics together, was evaluated using the Step wise method, a significant model was achieved (R=0.084; adjR2= 0.007; F=4.313; p=0.038), as follows: FSS ¼ 3:179 þ 0:024 WEIGHT CHANGE DURING PREGNANCY
Discussion This paper is, to the best of our knowledge, the first to describe the relationship between BMI and HRQoL during pregnancy in Serbian women. Our results reveal that increases in BMI affect up to 88 % of pregnant women. BMI during pregnancy increased in 59.44 % of women, and that had a significant influence on physical health, fatigue and pregnancy symptoms. The 28.64 % of women, who were of high pre-conception BMI, were obese at the end of pregnancy, as well, which increased their likelihood of depression. Recent data have shown that the prevalence of overweight women in the general population of Serbia is 30.9 %, while the prevalence of obesity is 20.1 % (Vasiljevic et al. 2008). These results are similar to the prevalence of obesity recorded in other countries (Furber and McGowan 2011; Jia and Lubetkin 2005). In the examined population, there were about 14 % of overweight and about 14 % of obese women before pregnancy. Having somewhat less obese women than in the general population can be explained with the fact that obesity reduces fertility and we were studying women who were already pregnant. Moreover, the study was conducted only in the capital of Serbia – Belgrade, where socio-economic conditions are the best in the country, and the desirable weight for women is different than in the rural areas of Serbia. Both obesity and anorexia are multifactorial diseases, linked to both physical and emotional issues. Problems arising from obesity include not only the mechanical impact of excess weight and its physical restrictions, higher morbidity and mortality, but also a significant modification of the general quality of life (Vasiljevic et al. 2008; Wang et al. 2011). The challenge of management of weight problems is particularly noted in pregnant women. Despite the Institute of Medicine’s recommendations and the goal of Healthy People 2010 of optimizing weight gain during pregnancy, the number of women with appropriate gestational weight gain continues to decline, falling from 76.8 % in 1988 to 70.6 % in 2003 (Helms et al. 2006). Moreover, excess weight gain during pregnancy correlates with increased obesity postpartum (Olson et al. 2004).
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Although obesity can be a risk for obstetric complications, there are limited data on pre-pregnancy obesity trends (Hinkle et al. 2011). Being of excess weight, both before and during pregnancy, is a risk factor for mortality and morbidity of both mother and the child (Mamun et al. 2011). Maternal BMI can be a predictor of subsequent miscarriage, stillbirth, preeclampsia, gestational hypertension, gestational diabetes mellitus, delivery of large-for-gestational-age neonates, and both elective and emergency caesarean sections (Amador et al. 2008; Syngelaki et al. 2011; Smith et al. 2007). Women who are overweight and obese during pregnancy have an increased rate of macrosomia that can be limited by well-controlled weight gain during pregnancy (Di Benedetto et al. 2012). Excess gestational weight gain is associated with a longer stay in the hospital after delivery, independent of pregnancy complications and caesarean delivery (Di Benedetto et al. 2012; Koepp et al. 2012). In addition to pre-pregnancy obesity, excess gestational weight gain is another indicator of adverse pregnancy outcomes (Mamun et al. 2011). According to our study, gestational excess weight gain is also associated with a more distinct feeling of fatigue during pregnancy, more severe pregnancy symptoms and the worse physical functioning during pregnancy. Furthermore, BMI at the end of pregnancy has an impact on pregnancy symptoms. Morbidly obese or overweight women had more severe pregnancy symptoms than women of normal weight. Studies have shown that there is a significant association between BMI and HRQoL in women in the general population. Nearly all aspects of HRQoL are adversely affected by elevated BMI (Cunningham et al. 2010). The HRQL results for women may reflect both the importance of body image on mental health and the health effects of excess weight. The maximum HRQoL for women occured at a BMI of 24.5 demonstrating that BMI is negatively associated with HRQoL in both underweight and obese individuals (Garner et al. 2012). Moreover, some obese pregnant women feel humiliation and discomfort due to their size, while others have lower scores for mental health if they are malnourished during pregnancy (Furber and McGowan 2011, Li et al. 2012). According to our results, women of normal weight before pregnancy had the best HRQoL and the least likelihood of depression. However, being overweight during pregnancy had positive influence on HRQoL, while being obese deteriorated pregnancy HRQoL. We would like to note that in the study population BMI did not have significant influence on TQL, and the mean TQL was quite high. This result demonstrates that pregnant women should be evaluated in the different manner than the general population. Pregnant women are often considered, by the less medically educated people, to be eating for two (Li et al. 2012). Consequently, many women feel free to eat whenever and whatever they want, because it is good for them and the fetus. Our results show that much more should be accomplished in the education of pregnant women by their doctors. Some data show that BMI is positively associated with general health, social functioning, and emotional role (Soltoft et al. 2009). Other researchers found that being overweight was correlated with impaired physical, but not mental HRQOL (Wang et al. 2011). Meaningful impairments were observed in obese and normal weight women in four physical health scales, but only one scale of the four mental health scales (vitality scale) was affected by obesity. The physical component of the quality of life was lower only in the third trimester. Obesity at the beginning of
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pregnancy, but not weight gain, was related to low quality of life at the third trimester (Thangaratinam et al. 2012). Several studies also suggest that BMI is negatively associated with utility (Amador-Licona and Guízar-Mendoza 2012). We have found that weight gain can have a significant influence on fatigue as well as physical functioning during pregnancy. Additionally, morbidly obese women were more tired than overweight individuals. Most authors have concluded that obesity has a greater impact on physical than on mental health (Kruger et al. 2007; Jia and Lubetkin 2005; Krott and Clarke 2005). A similar study that was conducted in the same region, but on the general population, showed that, in the urban population of Belgrade, increased BMI had a much greater impact on physical rather than on mental health, and the effects were particularly distinct in obese individuals (Vasiljevic et al. 2008). This relationship is supported also by our findings. However, in some studies, the mental component of quality of life in the first and third trimesters was lower in the obese group (Thangaratinam et al. 2012). Each of the quality of life domains related to mental health as well as the mental component summary were inversely associated with changes in BMI (Amador-Licona and Guízar-Mendoza 2012). Moreover, we noted a significant relationship between likelihood of depression and BMI during pregnancy. That was one of the most persistent correlations observed for both weight and BMI before and at the end of pregnancy. The higher the BMI, the worse the feeling of depression: morbidly obese women were more depressed than the mildly and intermediately obese; obese and morbidly obese women were more depressed than cachectic women; and obese women were more depressed than women of normal weight. Additionally, morbidly obese women had the worst feeling of social support than all other BMI categories at the beginning of the pregnancy. On the other hand, at the end of pregnancy, obese women did not feel socially unsupported. This finding might be explained by the fact that it is more socially acceptable for pregnant women to gain weight, while women who are not pregnant are expected to be thin and fit. It is up to gynecologists/obstetricians to educate women that normal weight gain in pregnancy should not exceed the maximal recommended amount. In some studies, health-related quality of life, was also a predictor of weight gain, indicating a bi-directional association between obesity and the health-related quality of life (Kortt and Dollery 2011). Furthermore, we confirmed a bi-directional relationship of weight before and at the end of pregnancy and BDI. Therefore, BMI might be a predictor of depression during pregnancy or vice versa. The identification of those with poor HRQoL and a high likelihood of depression may be important for assessing the risk of future weight gain, and a focus on health-related quality of life may be beneficial in weight management strategies that can prevent obstetrical complications due to obesity. Findings such as these underline the importance of our research. The majority of studies available in the literature conserning HRQoL and BMI in the general population or in pregnant women investigated HRQoL using questionnaires. SF-36 was the most widely applied, but some researchers used the SF-12, the EuroQol EQ-5D index and the visual analogue scale (EQ VAS), or specific instruments for particular symptoms. Furthermore, those investigations assessed weight gain and BMI by measuring, height, weight and waist circumference, or by reviewing medical charts. These parameters were registered mostly at the beginning and during the third trimester of pregnancy. Multivariable linear regression was used to identify the association
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between BMI category and SF-36 scores after controlling for potential confounders (Amador-Licona and Guízar-Mendoza 2012; Jia and Lubetkin 2005; Krott and Clarke 2005). Although our study was of similar design, we used 6 scales to investigate different aspects of HRQoL, which gave us a more detailed view of investigated matter. The study had several limitations. We have tried to overcome the selection and participation biases, which could affect the validity and generalizability of the results, by calculating the necessary sample size and randomizing respondents. Moreover, there is a potential that we might not have tested all confounding variables. The crosssectional design might have inhibited the assessment of the temporal relation of variables. However, although different scales can be used for HRQOL assessment, self-reported BMI was acceptable to numerous authors (Vasiljevic et al. 2008; Huang et al. 2006; Sach et al. 2007). Further studies should be undertaken in order to more thoroughly understand this subjective and highly complex issue, which although of great importance, is still insufficiently explored.
Conclusions Before pregnancy, the majority of women were of normal or lower weight, while at the end of pregnancy, most were overweight or obese. The highest TQLs are found in women with normal weight before pregnancy and who are overweight at the end of pregnancy, while the worst TQLs are observed in women who are obese (mildly or morbidly) at the beginning and end of pregnancy. Women with higher BMIs at the beginning and end of pregnancy have a higher likelihood of depression. Pregnancy symptoms are expressed more in obese individuals, causing them additional difficulties. In addition, weight change during pregnancy enhances fatigue and deteriorates physical functioning during pregnancy. Morbidly obese women have the worst feeling of social support compared to all other BMI categories. In conclusion, pregnant women should be instructed to ensure that their gestational weight gain is in the recommended range. Acknowledgments This work was supported by a grant from the Ministry of Science and Technological Development of the Republic of Serbia (grant No. 175087).
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