The prevalence of maternal obesity and excessive weight gain in pregnancy has increased over the last decade causing a negative impact on pregnancy outcomes (Gaillard et al., 2013). Many women do not know the current recommendations for gestational weight gain and tend to gain excessive weight during pregnancy (Gaillard et al., 2013). It is essential to educate pregnant women about the importance of managing maternal bodyweight preconception, antenatal care, intrapartum, and post-partum especially in our obese population to prevent adverse outcomes in current and future pregnancies (Gaillard et al., 2013).
The purpose of this paper is to describe how the application of Nola Pender’s Theory of Health Promotion Model (HPM) may contribute to reducing maternal obesity and excessive weight gain in pregnant women. A succinct summary of the state of science is included on four recent scholarly research articles. Nola Pender’s Theory of Health Promotion Model (HPM) will be applied within the theoretical framework presented.
Keywords: Pender, health promotion model, pregnancy, obesity, excessive weight gain
Over the past several years there has been a significant increase in pregnancy obesity negatively impacting maternal and fetal outcomes. In many cases women are unaware of the potential negative outcomes related to obesity. It is crucial that clinicians educate these women about their body mass index prior to conception, intrapartum, and postpartum. Women are likely to participate in their care and follow a healthy diet during pregnancy if they understood the associated risks of obesity in pregnancy.
Nola Pender’s Health Promotion Model
Nola Pender’s Health Promotion Model (HPM) is a middle-ranged theory that focuses on ways to promote healthy behaviors to enhance the patient’s quality of life (Pender, 2011). Pender believed that the health promotion model can be used as a guide to implement appropriate interventions to help patients achieve a healthy lifestyle and ensure long term success (Pender, 2011).
The rationale for using Nola Pender’s Health Promotion Model (HPM) is to demonstrate how this theory can be used as a guide to assist women in making healthy lifestyle changes to prevent excessive weight gain during pregnancy. Appropriate weight gain during pregnancy and weight management after pregnancy minimizes the risk for preterm delivery, hypertensive disorders of pregnancy, gestational diabetes, vascular disease, and difficulty with anesthesia in current and future pregnancies (Gaillard et al., 2013).
Applying Pender’s theory will allow the advance practice nurse to determine if there are potential barriers that will interfere with implementing interventions that will affect healthy behaviors. Understanding factors that may affect healthy lifestyle interventions allows the nurse to make necessary changes to increase the patients level of wellbeing.
State of Science
The search for evidence was completed using databases such as PubMed, Google Scholar, and the UC library. Search terms included Nola Pender’s health promotion model, health promotion model, pregnancy, obesity, and excessive weight gain. Included article criteria were required to be published in peer-reviewed journals, English language, publication years range from 2013-2018, with the exception of one article that was a collection of script that was written by the theorist, full text was considered for application. Excluded were articles that were more than 5 years old, meta-analysis, and systematic or integrative reviews. Four articles were selected that met the inclusion criteria for further inquiry.
The first study, “Risk factors and outcomes of maternal obesity and excessive weight gain during pregnancy,” used a population-based prospective cohort study, that was approved by the institutions ethics board. The study examined how obesity and excessive weight gain impacts pregnancy by using a multivariate linear and logistic regression analyses. A convenience sample of qualified participants included 6,959 women and their offspring. Self-report questionnaires were completed by participants to determine pre-pregnancy maternal weight.
Obstetric data regarding birth outcomes and hypertensive disorders were obtained through medical records. Socio-demographic, lifestyle, and genetics led to maternal obesity and excessive weight gain during pregnancy associated to adverse outcomes (Gaillard et al., 2013). The participants diet and exercises habits were not included in the study causing limitations to the study maternal obesity and excessive weight gain during pregnancy. According to Facchiano and Synder’s hierarchy of evidence this study is rated a level IV because it is a cohort study and the statistical validity is weak (Facchiano & Synder, 2012).
The second study, “Loss of control over eating before and during early pregnancy among community women with overweight and obesity,” used a descriptive exploratory qualitative design approved by the institution’s ethics committee. The study explored the prevalence and changes of loss of control over eating among pregnant women (Kolko, Emery, Marcus, & Levine, 2016). A convenience sample of diverse pregnant women were recruited in obstetric clinics to assess prenatal eating behaviors. The study used a cross-sectional design and a retrospective recall.
The results of the study determined that socio-demographic were un related to the loss of control over eating. Pregnant women who reported more depressive symptoms and an increased amount of stress presumed a loss of control over eating (Kolko et al., 2016). According to Facchiano and Synder’s hierarchy of evidence this study is rated a level V, due to its qualitative design (Facchiano & Synder, 2012).
The third study, “Obesity in pregnancy: A qualitative approach to inform an intervention for patients and providers,” used a conventional qualitative study, that was approved by the institutions ethics board. The study examined the knowledge, beliefs and attitudes about nutrition, exercise, healthy life styles during pregnancy in obese racial-ethnic minority women (Kominiarek, Gay, & Peacock, 2015). A convenience sample of sixteen pregnant women were recruited to assess their view on obesity in pregnancy. The results of the study determined that the participants did not understand the term obese and the affects it has on pregnancy. According to Facchiano and Synder’s hierarchy of evidence this study is rated a level V, due to its qualitative design (Facchiano & Synder, 2012).
The fourth study, “Health promotion intervention to improve diet quality in children,” performed a study to test the relationship between Nola Pender’s Theory of Health Promotion Model to improve diet quality in children. This study used a randomized study, that was approved by the institutions ethics board. The study examined whether variables that were tested were able to be used interchangeably.
A convenience sample of 464 children were recruited to assess if the health promotion model improved diet quality in children. The results of the study determined that the participants had a higher adequacy in vegetable consumption and a higher moderation in sodium consumption (Rosario et al., 2016). According to Facchiano and Synder’s hierarchy of evidence this study is rated a level IV, due to its randomized study (Facchiano & Synder, 2012).
In summary, all four research articles were clear and easy to review and critique. One of the articles incorporated used and tested Nola Pender’s Theory of Health Promotion which can be applied to the selected topic of reducing maternal obesity and excessive weight gain in pregnancy. There were some limitations in the research studies that altered the results but they offered ways to improve them. Overall, the recommended changes to these studies can improve the quality of the study.
Application to Clinical Practice
The increased obesity rate in pregnancy supports the need for clinicians to educate their patients and make them aware of the risks that are associated with adverse outcomes. Clinicians can first assess the patients understanding of maternal weight gain during pregnancy then they can implement appropriate interventions according to the patient’s needs. Applying Nola Pender’s Theory of Health Promotion will promote positive social support that is needed for the patient to be successful in obtaining a healthy weight during pregnancy. The earlier the clinician begins to educate the patient the better the chance the patient will participate in their care.
Exploring the patient’s knowledge and daily activities will allow the clinician to provide measurable interventions. A focused survey can be used to assess the patients current diet and daily activities. Patients will receive a survey at their first prenatal appointment and then again, at their 12-week, 24-week, 36-week and 40-week prenatal appointment and then again at their six to eight-week postpartum visit.
The initial survey will ask patients to report their initial weight, diet, and daily activities. The follow up surveys will ask their current weight, how much weight they have gained so far, their diet, physical activity along with having them list any changes since their last survey. Questions will also focus on whether the patient felt the provider has adequately provided them with educational resources and followed up on their status.
The purpose of this survey is to assess whether education has affected how much weight has been gained and what the patients diet has been like and the amount of physical activity they do. The patients feedback will be anonymous so the patient feels comfortable enough to report truthfully. Documentation will reflect how the health promotion model theory has impacted interventions and determine if the patient’s goals were met.
Appropriate maternal weight gain is largely dependent on education preconception, intrapartum, and postpartum. The purpose of this paper was to examine how the application of Nola Pender’s Theory of Health Promotion can reduce maternal obesity and excessive weight gain in pregnancy. In addition to a succinct summary of the state of science on four recent scholarly research articles, a plan to apply Nola Pender’s theoretical framework in practice.
During my research I have found a correlation between obesity in pregnancy and adverse outcomes. Further research is needed to evaluate more specific causes for excessive weight gain in pregnancy leading to obesity resulting in undesirable outcomes. Nola Pender’s theory can be applied in practice to help pregnant women gain the appropriate amount of weight during pregnancy. Research and the application of Nola Pender’s theory has taught me the importance of practicing health promotion in practice.
- Facchiano, L., & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. Journal of The American Academy of Nurse Practitioners, 24(10), 579-586. doi:10.1111/j.1745-7599.2012.00748
- Gaillard, R., Durmus, B., Hofman, A., Mackenbach, J. P., Steegers, E. A., & Jaddoe, V. W. (2013, May). Risk factors and outcomes of maternal obesity and excessive weight gain during pregnancy. Obesity (Silver Spring), 21(5), 1046-55. https://doi.org/10.1002/oby.20088
- Kolko, R. P., Emery, R. L., Marcus, M. D., & Levine, M. D. (2016, September 23). Loss of control over eating before and during early pregnancy among community women with overweight and obesity. International Journal of Eating Disorders, 50(5), 582-586. https://doi.org/10.1002/eat.22630
- Kominiarek, M. A., Gay, F., & Peacock, N. (2015, August). Obesity in pregnancy: A qualitative approach to inform an intervention for patients and providers. Maternal Child Health Journal, 19(8), 1698-1712. https://doi.org/10.1007/s10995-015-1684-3
- Pender, N. J. (2011). The health promotion model manual. Retrieved from https://deepblue.lib.umich.edu/bitstream/handle/2027.42/85350/HEALTH_PROMOTION_MANUAL_Rev_5-2011.pdf?sequence=1&isAllowed=y
- Rosario, R., Araujo, A., Lopes, O., Moreira, A., Pereira, B., & Moreira, P. (2016, March 1). Health promotion intervention to improve diet quality in children. Health Promotion Practice, 18(2), 253-262. https://doi.org/10.1177/1524839916634096
- Segura, M. T., Esteban, F. J., Bartel, S., Brandi, P., Irmler, M., Beckers, J., … Campoy, C. (2017, January, 26). Maternal pre-pregnancy obesity is associated with altered placental transcriptome. PLOS ONE, 12(1). https://doi.org/10.1371/journal.pone.0169223