Table 1 Framework based on pre-specific categories constructed from NICE and RCOG guidelines

Address any concerns about physical activity in pregnancy

NICE: "Advise that moderate-intensity physical activity will not harm her or her unborn child."

This includes reassuring women about the safety of physical activity in pregnancy

Addressing a woman's concerns

NICE: Be "…sensitive to any concerns she may have about her weight."

Any discussion on the sensitive manner in which conversations about weight should be had and the importance of communication between the woman and healthcare professionals

Advice on benefits of healthy diet and physical activity

NICE: "Advise that a healthy diet and being physically active will benefit both the woman and her unborn child during pregnancy and will also help her to achieve a healthy weight after giving birth."

Discussions with the healthcare professional around healthy eating and being physically active that is not specific. Code as ‘Specific dietary or physical activity advice’ if specific advice is given

Behaviour change advice

“Evidence-based behaviour change advice includes: understanding the short, medium and longer-term consequences of women's health-related behaviour helping women to feel positive about the benefits of health-enhancing behaviours and changing their behaviours recognising how women's social contexts and relationships may affect their behaviour helping plan women's changes in terms of easy steps over time identifying and planning situations that might undermine the changes women are trying to make"

Only code this if it does not fit into any other code. For example, if they are provided with individualised advice, code only as ‘Practical and tailored information’. This is because this code describes the way in which advice (within the other codes) may be provided

Breastfeeding

NICE: "Midwives and other health professionals should encourage women to breastfeed. They should reassure them that a healthy diet and regular, moderate-intensity physical activity and gradual weight loss will not adversely affect the ability to breastfeed or the quantity or quality of breast milk."

RCOG: "Obesity is associated with low breastfeeding initiation and maintenance rates. Women with a booking BMI 30 kg/m2 or greater should receive appropriate specialist advice and support."

Dieting or weight loss in pregnancy

NICE: "Dieting during pregnancy is not recommended as it may harm the health of the unborn child."

RCOG: "Anti-obesity or weight loss drugs are not recommended for use in pregnancy."

Any recommendation that refers to dietary programmes/ diets that promote weight loss

Discuss her current eating habits and physical activity levels

NICE: "At the earliest opportunity, for example, during a pregnant woman's first visit to a health professional, discuss her eating habits and how physically active she is. Find out if she has any concerns about diet and the amount of physical activity she does and try to address them."

Dispelling myths

NICE: "Dispel any myths about what and how much to eat during pregnancy. For example, advise that there is no need to 'eat for two' or to drink full-fat milk. Explain that energy needs do not change in the first 6 months of pregnancy and increase only slightly in the last 3 months (and then only by around 200 cal per day)."

Explaining risks

NICE: "Explain to women with a BMI of 30 or more at the booking appointment how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy."

Do not code if risks are only stated at the beginning of the guideline (as part of the introduction). It should be clear whether risks are discussed with the woman

Height and weight at the first contact

NICE: "Measure weight and height at the first contact with the pregnant woman" "Weight, height and BMI should be recorded in notes, the woman's hand-held record and the patient information system"

Not within NICE or RCOG recommendations

Anything that is related to weight management that is not referred to by NICE or RCOG guidelines

Practical and tailored information

NICE: "Offer practical and tailored information. This includes advice on how to use Healthy Start vouchers to increase the fruit and vegetable intake of those eligible for the Healthy Start scheme (women under 18 years and those who are receiving benefit payments)."

Any guideline that indicates providing personalised or tailored advice based on the individual woman. If this is coded, check for code “Discuss her current eating habits and physical activity levels”

If women are referred to a dietician or other programme it is likely they will receive personalised advice however for the purpose of examining the guideline only and therefore, first line of care, do not code if not explicitly described that advice is personalised or tailored

Recommended weight gain ranges

NICE: "Many pregnant women ask health professionals for advice on what constitutes appropriate weight gain during pregnancy. However, there are no evidence-based UK guidelines on recommended weight-gain ranges during pregnancy.”

RCOG: "There is a lack of consensus on optimal gestational weight gain. Until further evidence is available, a focus on a healthy diet may be more applicable than prescribed weight gain targets."

Code if weight gain thresholds are given (and which ones, i.e. IOM) even if the lack of evidence on weight gain ranges is acknowledged

Referrals

NICE "Offer women with a BMI of 30 or more at the booking appointment a referral to a dietitian or appropriately trained health professional for assessment and personalised advice on healthy eating and how to be physically active."

Does not include obstetric or anaesthetic referrals for risk assessment or birth planning. Only referrals relating to weight management

Code even if guideline is not clear about who the referral is for or who/ where they are being referred

Code if weight management programmes are highlighted, for example, Slimming World, even if there isn’t a formal referral process described

Signposting to reputable sources of information

NICE "Reputable sources of information and advice about diet and physical activity for women before, during and after pregnancy include: The Department of Health's 'The pregnancy book' and 'Birth to five' and the NHS eat well website." "Advise her to seek information and advice on diet and activity from a reputable source"

Code if women are provided with a Trust leaflet/ signposted to Trust website to access content on weight management during pregnancy but do not code if these resources only detail obstetric or anaesthetic risks

Specific dietary or physical activity advice

NICE: Specific dietary advice, e.g. eat fibre rich foods, eat at least 5 portions of fruit and vegetables each day, avoid increasing calorie intake. Specific physical activity advice e.g. 150 min of exercise per week

Weighing women

NICE: "Do not weigh women repeatedly during pregnancy as a matter of routine. Only weigh again if clinical management can be influenced or if nutrition is a concern"

RCOG: “For women with obesity in pregnancy, consideration should be given to reweighing women during the third trimester to allow appropriate plans to be made for equipment and personnel required during labour and birth”

Code if women are weighed throughout pregnancy with information on recommended gestations

Code if recommendation is risk assessment weight in the third trimester as this is a weight that would influence clinical management. However, it is important to note, this is not for weight management purposes. For example, it is not for the purpose of starting a conversation with the woman about her diet and physical activity levels

Weight management postpartum

NICE: "Encourage them to lose weight after pregnancy."

RCOG: "Women should be supported to lose weight postpartum and offered referral to weight management services where these are available."

Code both those that recommend providing healthy lifestyle advice and those that signpost women to other healthcare professionals/ weight management services