Dr. Piyush Ranjan MD FICP is currently working as an Additional Professor in the Department of Medicine at prestigious AIIMS, New Delhi. He has published about 100 papers in various national and international journals. He has a keen interest in Obesity, metabolic disorders and behavioural aspects of medical illnesses.
This narrative review is aimed to practically review and evaluate the existing evidence and illuminate the effectiveness of physical activity, yoga, and exercise for postpartum and midlife weight management. A comprehensive review was conducted using electronic databases such as PubMed and google scholar using search terms physical activity, exercise, yoga, postpar- tum, midlife, weight loss, weight reduction, and all the probable terms. This helped in generating evidence-based information and formulating practical physical activity prescriptions to be used by obstetricians, general clinicians, nutritionists, and other allied healthcare personnel. Overweight and obesity in postpartum and midlife women present long-term health risks and complications. Indulging in optimum physical activity comprising exercise and yoga will help in weight management, increasing muscular strength, and endurance thus improving overall health and well-being.
Keywords : Postpartum · Midlife · Physical activity · Yoga · Exercise · Weight management
The prevalence of obesity is rising increasingly in women as compared to men in all parts of the world including India [1]. More young women are getting obese and it has been found that one out of ten women is either obese or overweight at the time of pregnancy in India [2]. Women with higher pre-pregnancy body mass index (BMI) are at additional risk of having excessive gestational weight gain (GWG) which is the amount of weight gain experienced by a woman right from the time of conception to birth. This often leads to increased postpartum weight retention (PPWR) which is the difference between pre-pregnancy weight and weight after delivery [3]. Women getting obese at a younger age are exposed to the risks of obesity for a relatively longer duration and usually develop complications by their midlife [4]. Such gender-based differences in obesity trends are due to various social factors, hormonal changes, and reduced energy expenditure. Studies suggest that women in India are more physically inactive than their male counterparts and have a higher prevalence of physical inactivity as compared to western women [5].
Physical activity (PA) encompasses all bodily movements that are carried out by the muscles and requires energy. While, exercise is a type of physical activity that requires planned, repetitive, intentional, and structured movement over a period of time [6]. The benefits of exercise are beyond weight management which includes better cardiometabolic health, cardiorespiratory fitness, muscular strength, and endurance [7]. There is a lack of practical evidence-based PA and exercise recommendations for postpartum and midlife women [8]. This review aims to examine evidence to formulate such recommendations which can be used by clinicians, obstetrician-gynecologists, nutritionists, and other health personnel involved in weight management of these age groups.
Challenges in Improving Physical Inactivity and Exercises Habits
Despite the well-known benefits of PA, few women can practice the recommended levels. They encounter various intrapersonal, interpersonal, environmental, and organizational barriers (Table 1). These barriers are complex in nature and unique for each stage of life. They affect their perception, motivation, ingrain unscientific dietary and physical activity-related practices and experiences [9, 10]. Women are more indulged in household chores and family responsibilities as compared to their male counterparts, which gives them less time to focus on their health. They don't tend to indulge in leisure time and recreational physical activity. As a result, they often indulge in unhealthy ways to lose weight which may result in initial weight loss but eventually leads to relatively quick weight regain [11]. Apart from this, various myths are also prevalent in all socio-cultural environments which affect physical activity-related behavior. The birth of a child is considered a life-altering event for a woman, new mothers are often encouraged to rest for at least six weeks after delivery. Indulgence in moderate/ vigorous-intensity PA is not encouraged [9]. In midlife women, there is cultural acceptance and normalization of having overweight and obese bodies. Contrary to the western society where obesity is more prevalent in low-income groups, in India it is considered as a sign of social and economic prosperity. PA apart from household chores is considered a luxury and women often think that they have passed the stage to toil in PA for their weight management [12].
Types of Physical Activity
Regular physical activity is important for health. It not only improves cardiometabolic and cardiorespiratory health but also boosts psychosocial health by improving mood, fighting boredom, and reducing stress. There are various types of physical activity, each having unique benefits and collectively helps in improving overall well-being:
Endurance
This includes aerobic activities which are best suited to attain metabolic and cardiovascular benefits. Endurance exercises are classified by repeated isotonic movements that lead to the contractions of large skeletal muscle groups. These activities are performed on submaximal intensity till a person reaches their anaerobic threshold (sustained lactate increase and metabolic acidosis) [13]. This helps in building lean body mass and protects connective tissues and joints from damage. Along with this, the basal metabolism rate (BMR) is also boosted which helps in quicker weight loss. In midlife women, such types of activities can improve bone density and decrease the risk of osteoporosis [14]. Classical examples include brisk walking, running/jogging, swimming, bicycle riding, dancing, and climbing stairs at home/ work [15].
The different types of activities can be performed for varied intensities such as light intensity, moderate intensity, and vigorous intensity. Metabolic equivalents (METs) are a useful and standardized method for measuring the total intensity of activities. In adults, light-intensity PA can be defined as 1.6–2.9 METs, moderate as 3.0–5.9 METs, and vigorous as 6.0 METs [6]. Thus, the prescription of physical activity for any age group should be made with a combination of all types of exercise as each has its health benefits. The total time spent on PA should also be divided into intensities (Table 2) considering the METs value of each activity.
Strength
Strength building or resistance training encompasses exercises that cause the contraction of muscles against external resistance. These kinds of activities help in building strength, power, hypertrophy, and endurance [16]. External resistance in these exercises can be created by using a pair of dumbbells, bodyweight, bottles of water, bricks, resistance bands, weight machines, or any other object that can cause the contraction of muscles. Strength training is of various types such as isometric, isokinetic, isotonic, plyometric and each type has its mechanism of action and benefits. The effectiveness of each kind of activity depends upon the type of exercise undertaken, sets, repetitions, frequency, intensity, and rest [17]. The comprehensive benefits for both groups are improved muscle strength and tone, increased flexibility and balance, pain management, decreased risk of osteoporosis by improving bone density, and improved cognitive function [18]. In postpartum women, Kegels can be started immediately after delivery to strengthen the pelvic floor muscles (Table 3).
Flexibility
These exercises are based on the ability of a joint to move through its complete range of motion. It facilitates joint movement and prevents tissue damage while conducting any PA [6]. Flexibility is specific to each joint and it helps in stretching the muscles. Hence, apart from helping in daily activities, flexibility allows several other exercises as well. Classical examples of flexibility activities are various kinds of stretches, yoga, and pilates [15]. In midlife women, flexibility exercises improve their mobility, agility, balance and relieves joint pain as well. It is recommended to use flexibility exercises in combination with strength and endurance to attain maximum benefits [19].
Balance
Posture and balance are very important to conduct any type of daily activity or movement. Balancing activities help in controlling the body's position, whether stationary or moving. It is often neglected in a physical activity regimen, even though it's rehabilitative [20]. In midlife women, balance training helps in reducing the risk of falls, improves motor skills, and provides stability in joints thus preventing injuries and sprains [21]. Many women encounter balance issues in their pregnancy which sometimes continue till they are postpartum and pose a potential danger to both mother and baby. Healthcare personnel should promote activities to strengthen balance among all [22]. Some examples of balance activities are yoga, pilates, tai chi, weight shifts.
Yoga: Evidence‑Based Regimen
Yoga is an ancient, holistic Indian practice that promotes the physical, mental, and spiritual well-being of its practitioners. 'Yoga' involves the process of joining forces or discipline to align the body with the mind and together connect with the self or soul [23]. Yoga therapy is an advancing and effective tool for many physical and psychological disorders. The biophysical, mental, and spiritual benefits of yoga are gaining popularity among all age groups, and it is deemed as an effective way for weight management [24]. It is being increasingly used in all cultures due to its holistic benefits. The mind–body therapy of yoga is useful for each life stage and has varied benefits. Women can initiate yoga from their preconceptions for improved fertility and mental well-being. Yoga can be safely practiced in pregnancy and continued in postpartum period for improved healing and weight loss [25]. In midlife women, yoga helps in the prevention of various diseases and managing hormonal changes [26]. Yoga practices have many dimensions, studies have shared many components from eastern and western viewpoints such as breathing exercises, loosening practices, asanas, pranayama, meditation and relaxation, which appear to be a classic and balanced model of wellness and healing [27]. The various components of yoga are described below:
The various components of yoga have varied effects in different life stages of women which are explained below, and a specific yoga regimen is given in (Table 4) and a detailed module for each life stage is given in (supplementary table 1).
Pregnancy
During pregnancy, there is an increase in cardiac output, heart rate, and plasma volume which can be counteracted through yoga by parasympathetic activation. Yoga practices also improve autonomic response to stress in healthy pregnant women. Yoga and massage therapy has shown a significant change in improving prenatal depression and prematurity among pregnant women, as compared to standard care [38]. The major problem of low back pain especially in the lumbosacral area is also greatly benefited by stretching and strengthening yoga practices such as one hour of Hatha yoga for two and half months. Similarly, issues like sleep disturbances which are mostly overlooked can also be significantly improved by yoga [39].
Postpartum
The postpartum period helps in the healing of the new mother; hence, it should not be neglected. The various postpartum yoga techniques improve calmness, reduce irritability and anger, increase energy, lower blood pressure, reduce muscle tension, and aids in relaxation [40]. Along with this, yoga helps in the reduction of postpartum weight, body fat percentage, fat mass, and improves the basal metabolic rate. The low-intensity yoga asanas help in quick recovery, relieve postpartum depression and anxiety. It helps in strengthening the abdominal wall, pelvic muscles, improves blood flow, and balance [41].
Midlife
Midlife women experience various physiologic changes due to gradual estrogen withdrawal. This leads to narrowing of core body temperature which is majorly regulated by the sympathetic nervous system (SNS). Due to these changes women experience various vasomotor symptoms. Yoga helps in decreasing autonomic arousal which reduces SNS activation and thus helps in the reduction of vasomotor symptoms. It also helps in improving sleep disturbances, mood disorders, anxiety and improves health-related quality of life [26]. The combination of various yoga techniques like pranayama & breathing exercises, yoga asana practiced for varied duration along with chanting of Om is recommended for midlife women [42].
Prescription for Physical Activity
Physical activity prescription is useful to create dose–response benefits from it. It should be individually tailored, simple, and easy to follow. The suggested PA prescription for different life stages is given in (Table 5) and its explanation is described below:
Preconception
Women should indulge in regular PA as per the recommendations to prevent overweight and obesity. It is beneficial for the management of polycystic ovarian syndrome (PCOS), infertility, and impacts the overall quality of life [43]. Regular PA in preconception is a strong predictor of pregnancy PA which helps in the prevention of excessive GWG and resultant PPWR [44].
Early Pregnancy
In early pregnancy, women should continue their usual prepregnancy activity. Since there is an increase in ligament laxity in the first trimester which is believed to promote implantation, activities like jumping, skipping should be avoided to prevent falls and injury. Stretching should also be performed in a slow and controlled manner. While performing PA, women should maintain optimum hydration, avoid heat stress by high humidity and temperature and wear loose-fitting clothing for comfort [6, 45, 46].
Mid Trimester
Sedentary overweight or obese pregnant women should gradually increase their physical activity along with a healthy diet. This will help to maintain the energy balance, avoid excessive GWG and metabolic complications. As the pregnancy progresses venous obstruction may occur due to an enlarged uterus. Therefore, activities involving supine positions should be avoided or modified for sitting and standing position. Exercise prescription should be thoroughly modified if medical conditions like gestational diabetes mellitus, uncontrolled hypertension, hypo or hyperthyroidism, severe anemia, cardio-pulmonary disorder, and morbid obesity are present [6, 45, 46].
Late Pregnancy
As the weight gain progresses in pregnancy there is an increased load on the joints, weight supporting activities are more comfortable as compared to weight-bearing activities. The center of gravity also gets altered due to weight distribution changes and that affects the balance. Activities involving abrupt change in direction should be modified or avoided or straight activities should be done. Regular physical activity with combination strength and endurance training is recommended in all trimesters. It is associated with relatively shorter and uncomplicated labor, increased chances of vaginal delivery, reduced chances of postpartum depression, and improved maternal and fetal health [6, 45, 46].
Immediate Postpartum
Pregnant women often become inactive after childbirth. Deconditioning happens in the immediate postpartum period. Pelvic floor muscles are weakened due to childbirth therefore pelvic floor exercises should be started in the immediate postpartum period. The incidence of diastasis recti abdominis and inter-rectus distance can also be reduced by starting abdominal strengthening exercises in both vaginal and cesarean birth [6, 46, 47].
Late Postpartum
Normal physical activity can be resumed 4–6 weeks after vaginal and 6–8 weeks after cesarean delivery. Postpartum women should target moderate-intensity activities for 150 min/week. Sedentary timing (sitting, watching TV, using a mobile phone) should be limited and replaced with light-intensity activities. Encouragement should be given to increase NEAT (non-exercise activity thermogenesis) by increasing daily step count and indulgence in household activities [6, 46, 47].
Midlife Women
Midlife women should indulge in a combination of training for rehabilitation and prevention of diseases. Conditions like cardiovascular diseases, osteoporosis are significantly managed by aerobic exercises and strength training. Interval training which includes exercising at a healthy heart rate, then increasing it for short sprints and repeating it helps in reducing the severity of vasomotor symptoms [19, 48].
Tips to Improve Compliance
At all life stages each women should indulge in appropriate level of physical activity unless it is deemed unsafe by the healthcare practitioner [46]. The benefits of optimum physical activity far outweigh the potential harms. The physical activity prescription should always be based on the following points to ensure better compliance:
5A's (Assess, Advise, Agree, Assist, Arrange)
The life stage of women should be duly considered along with any possible complication or contradiction. The PA advice should be synchronized with their schedule and resources. Healthcare practitioners should teach and assist them in performing activities with correct techniques irrespective of age or health status. This ensures optimum gain and minimizes the risk of injuries. Apart from this, timely follow-ups should also be scheduled to mitigate barriers and reaffirm the PA plan [45].
Cognitive Behavioural Strategies
The various components of cognitive behavior theory should be used to formulate the PA intervention or prescription. These components help in improving efficacy and compliance. The various techniques like health risk appraisal will help in increasing intrinsic motivation. Apart from it, components like goal-setting, self-monitoring, reinforcement and incentives, problem-solving, relapse prevention, stimulus control, cognitive restructuring and motivational interviewing will also help in attaining better compliance.
Lifestyle Approach
The various physical activities should be planned with a lifestyle approach as it is associated with greater adherence while maintaining the same health benefits [49]. Lifestylerelated PA includes activities in leisure, occupational, and household physical activities. The various activities can be tailored into these categories based on the specific lifestyle, availability of time, and resources of an individual [9].
Social Support and Environment
These are multidimensional in nature and help in effectively increasing the PA levels. Social support can be given in terms of family, friends, community, apart from this social media groups can be created for the same target population to create accountability, support, and motivation [9]. The various factors in the environment such as well-lighted roads and footpaths, access to gyms, parks, neighborhood safety, levels of pollution and weather also affect compliance to PA. Hence efforts can be made to alter or mitigate the controllable factors and provide a fostering environment for PA.
Conflict of Interest The authors declare that they do not have any conflict of interest to declare.
Ethical approval We, the authors approve that the requirement for the authorship as stated have been met and we believe that the manuscript represents honest work.
