Drawing on appropriate literature, provide a critical analysis of the application of health promotion philosophies, principles and approaches underpinning public health practice in relation to a relevant topic (e.g. any public health policy in the UK)

The chosen public health topic is smoking. The student has selected this subject because it is a current issue of particular relevance because of the prohibition to premises becoming smoke- free if they are open to the public, due to be enforced in England in July 2007 (Health Act 2006). Smoking is also an important topic because it has been identified as the single most significant public health problem in the UK (Royal College of Physicians 2000); approximately 114,000 smokers in the UK die as a result of smoking (Action on Smoking and Health 2005). The treatment of smoking- related conditions costs the National Health Service (NHS) up to £1.7 billion per year with an estimated cost of £1.7 million to British industry every year as the result of lost working hours caused by smoking- related illness (Gommans 2005).

According to Tannahill (1985) health promotion is a broad concept which encompasses health education and health prevention. Health education refers to working with groups and individuals to promote healthy behaviours, whereas health prevention refers to strategies which prevent ill- health such as immunisation.

Public health is defined as:

‘The science and art of preventing disease, prolonging life and promoting health through organised efforts of society’ (Acheson 1988)

This definition implies a collective approach; however public health has been criticised as being medically dominated (McPherson 2001).

Philosophies of health promotion provide a framework for exploring our rationale and justification for wanting to change health- related behaviour. Seedhouse (2002) refers to health promotion as a ‘moral endeavour’; in other words health professionals are required to make judgments about if, how and when to intervene in relation to the health behaviours of patients, clients and service users, taking into account individual needs and priorities. In some cases health behaviours affect not only the individual but others, also; this applies to the effects of secondary smoking, for example. Taking into account the secondary effects of health behaviours may impact upon the ‘moral endeavour’ of health professionals and health policy makers. Moral judgements underpin the work of health professionals; the student recalls an incident when a lady aged 100 who had smoked all of her adult life and who clearly did not have long to live, asked to be helped to smoke a cigarette. This simple act gave her pleasure and it seemed irrational and unkind not to respond to her request. Moral judgements are not always straightforward.

Philosophical principles applicable to health promotion include logic; the development of reasoned argument (Naidoo and Wills 2000a). Our arguments for changing health-related behaviour are evidence- based involving for example, the type of statistics about smoking highlighted in para 1 of this page. There is a large body of evidence which supports the argument that smoking is damaging to health and yet, as discussed further on (para.2, p.4), it can be seen that individuals do not always respond to logical reasoned argument in relation to modifying health- behaviours.

Epistemology, another philosophical principle, is concerned with the debate about truth, in this case exploring what health really means. There are different models of health including the medical and social models. The medical model is concerned with the categorisation of illness and disease and with specific medical interventions given by the ‘expert’ (the health professional) to the patient, who has traditionally been a passive recipient of this expert advice and intervention. A social model of health involves a broader interpretation of health which is influenced by a range of determinants, such as age, gender, socioeconomic factors, education and environment. Within this model, strategies to improve health status adopt a wider perspective than the medical model, seeking to address the aforementioned determinants. In relation to health promotion, the medical model might not take into consideration, factors which affect the individual’s behaviour such as their socioeconomic status. There is evidence that smoking behaviour is more prevalent among more disadvantaged socioeconomic groups (Gulliford et al 2003). It is important therefore to take into consideration this and other, factors when developing health promotion strategies and not to reduce the issue to one of the giving and receiving of information with an assumption that behaviour will be modified as a result.

Health promotion philosophies are also concerned with ethics. The theory of ethics is divided into two main categories: deontological and consequential. Deontology is concerned with our duty to behave according to a set of moral principles. On page 1, paragraph 5, the issues/ dilemmas involved for health professionals in making moral judgements, were referred to. Consequential ethics are based on the premise that a judgment about whether an action is right or wrong is dependent on its end result, in other words whether the ends justify the means. This has some interesting implications for health promotion. Further on (p.4) some health promotion strategies are discussed including a debate about the use of legislation, i.e. enforcement, to bring about health- related behavioural change. As stated earlier (para.1, p.1) this issue is of particular relevance to smoking. The argument for enforcement is that the end result of reducing smoking behaviours and resultant improvement in health status as well as savings made to the cost of healthcare, justifies the prohibition legislation.

Broad approaches to health promotion reflect the models of health referred to (para. 2 on this page) and are categorised by Naidoo and Wills (2000b) as medical/ preventative; behavioural change; educational; empowerment and social change. Within the medical approach there are three levels of prevention: primary, secondary and tertiary. To apply these specifically to smoking; the primary level aims to prevent smoking behaviour before it begins, the secondary level is concerned with preventing the recurrence of a smoking- related illness or disease by encouraging the patient to give up smoking and the tertiary level is about promoting quality of life within a chronic condition such as diabetes, in which case the message would be that the individual’s quality of life would be optimised if they do not smoke.

The behavioural approach focuses on lifestyle issues (Laverack 2004) Emphasis is placed upon the individual’s responsibility for health which does not take into account factors outwith the individual’s control and as such, this approach has been criticised for being ‘victim- blaming’ (Tones and Tilford 2001), shifting responsibility away from the government for example, in relation to individual health status.

The educational approach is less about placing responsibility on individuals in relation to their health- related behaviours and more about giving information and facilitating people to make informed choices about their lifestyle choices. This approach relates to the rational- empirical strategy described further on (para. 2, p.4) as it is based on the assumption that giving people information will lead to attitudinal and behavioural change. As will be seen, this does not always happen. This approach is also dependent on a level of concordance from the individual, for example a commitment to attend regular sessions as part of an educational programme.

The empowerment approach reflects the normative- re-educative strategy described further on (para. 4, p. 4) and entails giving people the means to have increased control over the determinants that affect their health status. This involves community participation, a collective approach which is embedded within the philosophy of public health. According to Laverack (2004) there can be different interpretations of what constitutes a ‘community’. We tend to think in terms of a geographical community; a locality. It might be more effective in health promotion terms to think of a community as a group with shared characteristics, such as young people. The reality of community participation is that it tends to be more evident among communities who are educated and higher up the socioeconomic scale. People who are disadvantaged are less lilkely to be motivated to participate in health- related programmes- they may feel marginalised and are preoccupied with the issues that their situation presents, such as concerns about housing and income; health promotion is not viewed as a priority, and smoking might be used as a means of helping them to cope with adversity (Hanson Hoffman 1998).

This leads onto the notion of the social change approach. This is quite a complex concept that involves health promotion initiating and driving social change in order to improve conditions that are conducive to health (Erben et al 2000). Social change would involve making the sorts of improvements that would place health issues more firmly on everybody’s agenda. There are many factors that contribute to social change such as legislation and shifts in ideas about codes of behaviour. For example, attitudes about sexual behaviour have changed over the years, contributing to health issues such as increased incidence of sexually transmitted disease and a rise in teenage pregnancies (Measor et al 2000). There is some indication that social attitudes to smoking have changed (Moonie 2005) which is arguably, a positive development; some smokers report that they feel like social pariahs! The social change approach is underpinned by an acknowledgement of the complexity of what influences health- related behaviours and can be linked to the social model of health, discussed in para. 2, p.2.

Specific health promotion methods are quite diverse including: giving information in a didactic manner, for example via talks to large groups; lobbying local health and Government authorities; making use of the mass media (for example there is currently a television information advertisement about the early signs of myocardial infarction); working with groups; teaching social or life skills that are related to health status; publicity events, e.g. health fairs; facilitating community groups; enforcing health regulation; one to one advice and education; networking and liaising with other workers; instructing on specific techniques, such as self-administration of insulin; facilitating self help groups and enabling health promotion by the provision of support services such as childcare and interpreting facilities (Naidoo and Wills 2000c). Most of these methods can be adapted for use with smoking cessation.

The change strategies framework by Bennis (1976) can be applied to health behavioural change and is of particular relevance to anti- smoking legislation. It includes three strategies for bringing about change which are based on different assumptions about human behaviour, and which, when applied to health promotion, involve three distinctly different approaches. The first strategy (rational- empirical), is based on the supposition that ‘knowledge is power’. Within this strategy it is assumed that an individual will modify their health- related behaviour in response to receiving reliable and valid information. For example, if the government or a health professional issues advice about the dangers of smoking, the individual should reduce or cease their smoking habit. It is well- known that this often does not happen; even some health professionals smoke, despite their level of knowledge about the dangers (McKenna 2001). The reasons for this are usually related to dependence. It is also possible that human beings adopt Freudian mental defence mechanisms, which are maladaptive coping strategies used (in this instance) to circumvent evidence of the negative consequences of a health- related behaviour, such as smoking. These include denial, intellectualisation (which involves citing contradictory evidence), or rationalisation, among others (Lupton 1995). Resorting to these defences can undermine the power of knowledge and evidence, however valid and reliable it is.

The second strategy (power- coercive) involves the use of legislation and policy change in order to enforce health- related change. A good example of this is the anti- smoking legislation referred to in paragraph 1, page 1. There is some evidence to demonstrate that no- smoking policies do have the effect of reducing smoking behaviour (Brigham et al 1994). There has been criticism of the legislation as it is seen by some as an infringement of the individual’s right to choose. However this view is countered by the argument that the health of non- smokers can be adversely affected by cigarette smoke, and these people have the right to be protected (HM Treasury 2004). It appears that many non- smokers feel that they should be safeguarded from the effects of passive smoking (Pilkington et al 2006).

The first two strategies adopt a ‘top- down’ approach whereas the third strategy (normative- re-educative) is based on the assumption that an individual is more likely to change their health- related behaviour if they have had involvement in bringing about the change; if they feel empowered. This approach underpins some of the health promotion strategies referred to in para. 1 of this page; for example facilitating community groups. However as discussed earlier (para. 2, p.3), it seems likely that community participation and empowerment might be of limited value within certain groups, such as people who are disadvantaged or marginalised.

In conclusion, it appears that a multi- faceted approach needs to be adopted in order to address health- behaviours which are harmful to health, in this instance smoking. The starting point is that there is incontrovertible evidence that smoking is harmful to health, and can lead to premature death, as cited in para.1, p.1. The question of whether we have the right to choose to smoke can be challenged because of the evidence- base that demonstrates that smoking can affect the health of others (para. 3, p. 4). However it is important to recognise that people who smoke need adequate support and resources in order to be able to stop. There is existing evidence that legislative and policy change can reduce smoking behaviours (para. 3, p.4) and it will be interesting to see the outcomes of the current legislation (para. 1, p. 1). However, smokers also need clear, unambiguous messages about the effects of smoking, consistent support from health professionals and accessible information about smoking cessation services (Kerr et al 2006).

References

Acheson D. Independent Inquiry into Inequalities in Health: Report. London Stationery Office 1988.

Action on Smoking and Health Factsheet No. 2. Smoking Statistics: Illness and Death. ASH 2005.

Bennis et al The Planning of Change Holt Rinehart and Winston 1976

Brigham J, Gross J, Stitzer M and Felch L Effects of a restricted work-site smoking policy on employees who smoke.

Am J Public Health

. 84(5): 1994 pp. 773–778.

Department of Health. Health Act 2006. Part 1 Chapter 1. 2006.

Erben R, Franzkowiak


P and Wenzel E. People empowerment vs. social capital: from health promotion to social marketing.



Health Promotion Journal of


Australia

. 9(3) 2000 pp. 179-182

Gommans J, Bunton J and MacDonald G. Health Promotion: 2nd Edition. Routledge. 2005. p.189.

Gulliford M, Sedgwick J and Pearce A. Cigarette smoking, health status, socio-economic status and access to health care in diabetes mellitus: a cross-sectional survey.

BMC Health Service Research

2003 pp. 3: 4.

Hanson Hoffman. Recovery from Smoking – Second Edition: Quitting with the 12 Step Process – Revised Second Edition. Hazelden. P.1

Kerr S, Watson H, Tolson D, Lough M and Brown M. Smoking after the age of 65 years: a qualitative exploration of older current and former smokers’ views on smoking, stopping smoking, and smoking cessation resources and services.

Health


and Social Care in the Community

. 14(6) 2006 pp. 572-582,

Laverack G. Health Promotion Practice: Building Empowered Communities. Sage publications. 2004. pp. 21, 22, 44.

Lupton D. The Imperative of Health: public health and the regulated body. Sage Publications. 1995. p. 111.

Mckenna H, Slater P, McCance T, Bunting B, Spiers A and McElwee G. Qualified nurses’ smoking prevalence: their reasons for smoking and desire to quit.

Journal of Advanced Nursing.

35(5). 2001. pp.769-75

McPherson K. Public health does not need to be led by doctors: for.

BMJ

. 30; 322(7302) 2001 p.3–1596.

Measor L, Tiffin C and Miller K. Young People’s Views on Sex Education: Education, Attitudes and Behaviour. Routledge 2000. p.4.

Moonie N (Ed.) GCE AS Level Health and Social Care Double Award Book. Harcourt Heinemann. 2005. p.29

Naidoo J. & Wills J. Health Promotion: foundations for practice (2nd edition). London, Baillière Tindall 2000. pp. 113

Pilkington P, Gray S. Gilmore and A. Daykin N. Attitudes towards second hand smoke amongst a highly exposed workforce: survey of London casino workers.

Journal of Public Health.

28(2) 2006 pp.104-110

Royal College of Physicians. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal College of Physicians. RCP 2000.

Seedhouse D. Ethics: the heart of healthcare. Second Edition. John Wiley and Sons.. 2002. Chapter 2

Tannahill A What is Health Promotion?

Health Education Journal

44(4) 1985 pp. 167-8

Tones K and Green J Health Promotion: Planning and Strategies. Sage Publications. 2004. p. 16.

Tones K and Tilford S. Health Promotion: effectiveness, efficiency and equity. Nelson Thornes. 2001. p. 28.

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In 2015-2016, the CDC found 71.6% of the American adult population exceed healthy weight standards. More of the population was considered obese at 39.3% compared to 31.8% for the overweight population (Center for Disease Control and Prevention, 2019b). Overweight is defined as having a body mass index (BMI) of 25 or greater and obesity as a BMI of 30 or greater (Center for Disease Control and Prevention, 2019a). The pandemic of overweight and obesity has not eluded the pregnant population as 58.5% of women are overweight or obese in their childbearing years (20-39) and have the potential to enter pregnancy obese (Catalano & Koutrouvelis, 2015). The obesity crisis is also prevalent in the military population as 44% of TRICARE beneficiaries exceed the recommended gestational weight guidelines (Fahey et al, 2018). Obesity has many complications in the nonpregnant adult population that progress to further complications in pregnancy. Being overweight or obese can contribute to infertility, a difficult pregnancy, and a difficult recovery which can then affect the readiness of our active duty military population. Nurse practitioners must be cognizant of each step that obesity plays in family planning and educate patients accordingly.

Roles in Family Planning

When compared to women of normal BMI (equal to or greater than 18.5 and less than 25), women with a BMI that puts them into the overweight or obese category are shown to experience delays in becoming pregnant (Dodd & Briley, 2017). Obese women are disproportionally represented in infertility treatment clinics and have a higher rate of abnormal menstruation as well as miscarriage (Coad & Dunstall, 2011). Women in these categories are also more likely to be diagnosed with polycystic ovarian syndrome (PCOS) which compromises rates of fertility. While not all women with PCOS are obese, the symptoms associated with PCOS increase in severity as body weight increases (Coad, Dunstall, 2011). However, it appears that difficulty becoming pregnant is not strictly related to the weight of the female, but also that of the male partner. It is believed that lower rates of successful assisted reproduction in couples with an obese male can be contributed to imbalanced hormone levels, impaired spermatogenesis, impaired DNA integrity, and reduced sperm counts (Dodd & Briley, 2017; Palmer, Bakos, Fullston, Lane, 2012). Prenatal care of obese women is extremely important as they are at increased risk for congenital anomalies to include neural tube defects as folic acid appears to lose its protective effect in pregnancies complicated by increased body habitus (Coad & Dunstall, 2011). Military providers cannot dismiss the role obesity plays in infertility difficulties as the psychological component infertility places onto the couple can impact military readiness greatly. The active duty member can experience increased stress which can impede focus on their duties as well as increase the likelihood of experiencing depression effecting work production (Catalano & Koutrouvelis, 2015).

Roles in Pregnancy

Maternal obesity complicates pregnancy in almost every risk category. These include pregnancy specific complications (complications that arise in pregnancy only), but also the fact that the woman is entering pregnancy with an increased chance of having pre-existing diagnoses that can be further complicated by pregnancy (Dodd & Briley, 2017). Complications include increased risk for the development of gestational diabetes, gestational hypertension, preterm labor, infection, thromboembolic events, perinatal death, impaired recovery, and recent research has shown the development of cerebral palsy (CP) (Dodd & Briley, 2017; Villamore et al., 2017). Maternal obesity is also correlated with poorer labor outcomes including induction of labor, prolonged labor course, increased risk for cesarean delivery (C/S), and instrumented delivery to include forceps/vacuum (Coad & Dunstall, 2011). Obese women who are undergoing a trial of labor after C/S delivery are almost two times the risk for maternal morbidity and at five times the risk for neonatal injury (Catalano & Koutrouvelis, 2015). There are also increased risks to the fetus as obese women are more likely to have a marcrosomic fetus or an infant that is large for gestational age. Villamor et al. (2017) found a statistically significant association among Swedish mothers between cerebral palsy and the mother’s early BMI they believed to be partly mediated through asphyxia-related neonatal complications. Villamore et al. (2017) found mothers with a BMI of 25-29.9 had a 22% increased risk, mothers with a BMI of 30-34.9 had a 28% increased risk, mothers with a BMI of 35-39.9 had a 54% increased risk and mothers with a BMI greater than 40 had a 202% increased risk of having an infant develop cerebral palsy.

Finally, monitoring an overweight or obese woman can be difficult, especially regarding fetal size. With increasing BMI, it becomes difficult to estimate fetal size with palpation alone and ultrasound (US) is needed for accurate assessment. However, maternal obesity can still hinder accurate US assessment with the most error reported at the highest maternal BMIs and the extremes of fetal weight resulting in poorer assessment of fetal status (Dodd & Briley, 2017). Maternal obesity is one most important modifiable risk factors in stillbirth prevention that is not linked to genetic or shared familial environmental factors across developed nations (Dodd & Briley, 2017). According to Catalano & Koutrouvelis (2015) obese pregnant woman are 40% more likely to experience a stillbirth and that risk increases with BMI.

Roles in the Postpartum Period

Increased complications in the labor course leads to increased complications in the postpartum course for both mother and infant. A mother may experience a difficult recovery from C/S delivery, increased risk for wound infection or dehiscence, difficulty moving and adjusting to a new role as a caregiver while trying to recover from surgery, and increased risk of thromboembolism development (Dodd &Briley, 2017). Obese women are found to have decreased initial breastfeeding rates and decreased rates for prolonged breastfeeding which can partly be contributed to the increased risk of medical complications and C/S delivery (Dodd &Briley, 2017). This could potentially impact maternal and newborn bonding as well as the newborn needing supplementation or admitted to the neonatal intensive care unit for hypoglycemia protocol (Dodd & Briley, 2017). Obese mothers are also at risk for future metabolic dysfunction as excess gestational weight gain is a significant factor in postpartum weight retention which could have an impact on any future additional pregnancies (Catalano & Koutrouvelis, 2015).

The Effect on Military Readiness

Obesity has a large and detrimental impact on military readiness. TRICARE spends one billion dollars annually on health processes contributed to obesity (Fahey et al., 2018). At a time when congress is looking to decrease the healthcare budget with large healthcare system reorganization and downsizing, a one-billion-dollar expenditure will not be tolerated going forward. TRICARE spends more on pregnancy and delivery care than any other type of hospital admission at 782 million dollars (Fahey et al., 2018). High risk pregnancies are at the center of this cost. High risk pregnancies mean more missed work days for appointments as they require more appointments than an uncomplicated pregnancy. Many complicated pregnancies require nonstress testing two days a week with more frequent US once a certain stage in the pregnancy is reached. This equates to more missed time at work as well as more burden on the healthcare system (Fahey, et al., 2018).

Secondly, readiness is affected because the active duty woman may not be ready to deploy. While the pregnant woman is non-deployable up until the first year postpartum, being overweight or obese has an extreme effect on readiness. The woman must be ready to pass a physical fitness test at the year end mark (per Air Force regulations) and as a new mother with difficulty losing weight and other life challenges, this goal can be exceeding difficult especially if there happens to be excessive weight to lose. Among all active duty personnel who are women, postpartum females had significantly lower fitness test scores six months after delivery compared to their pre-pregnancy scores (Fahey et al., 2018). If her delivery and postpartum course was complicated by C/S delivery making recovery difficult or other complications like needing an episiotomy to deliver a large infant, then she may have even more difficulty getting back into testing shape. If the active duty member went into her pregnancy overweight or obese, she now has more weight to lose. The risk of not passing physical fitness tests can be drastic with potential discharge from the military and thus, the end of a career. This not only affects the woman’s livelihood but costs the military money. Recruiting and training new personnel can be as much as 50,000 dollars or more per individual (Fahey et al., 2018).

Patient Education

Prior to pregnancy is the ideal time to lose weight as even small decreases in weight prior to pregnancy have shown to have improved outcomes, however it is not too late to intervene once a woman becomes pregnant (Catalano & Koutrouvelis, 2015). Basic education should be provided to the patient regarding definitions of overweight and obesity as well as the ideal amount of weight the woman should gain during her pregnancy based on her BMI. The Center for Disease Control and Prevention (2019c) states the appropriate weight gain per BMI are as follows: underweight or BMI of less than 18.5 should gain 28-40 pounds, normal weight or BMI of 18.5- 24.9 should gain 25-35 pounds, overweight or BMI 25- 29.9 should gain 15-25, and obese or BMI 30 or greater should gain 11-20 pounds. Education has shown to be successful regarding nutrition as well as light exercise plans to include walking and measuring steps with a pedometer (Maturi, Afshary, & Abedi, 2011). The patient must be educated on the complications and potential negative outcomes that being obese during pregnancy can have on both her and her fetus/baby. Obese mothers are more likely to have their children grow up to be obese, increased risk of asthma development, altered behavior to include autism spectrum disorders, developmental delay and attention-deficit/hyperactivity disorder (Fahey et al., 2018; Catalano & Koutrouvelis, 2015). Education on future family planning to include spacing should not be forgotten. Short interval pregnancies pose risks to an uncomplicated pregnancy, but those that are complicated by excess weight and potential other complications like prior C/S delivery should be cautioned about short interval pregnancies and the risk they pose to include uterine rupture and preterm labor. As mentioned above, a woman is at increased risk of postpartum weight retention with excess weight gain in pregnancy and have an increased likelihood of entering the next pregnancy above healthy weight standards.

The provider may utilize motivational interviewing techniques in order to help patients change their unhealthy habits to include diet and exercise changes (Catalano & Koutrouvelis, 2015). Spieker et al. (2015) found the ideal environment to conduct education regarding diet and exercise was during prenatal and well-child visits which could potentially lessen the weight gain in both the mother and infant. Spieker et al. (2015) utilized dissonance-based health promotion, ideal for this time period of transition, as this method consists of interventions that capitalize on the basic human desire to have one’s words and actions remain congruent. This program specifically discusses the high-risk behaviors of poor diet, sedentary lifestyle and how the effects of obesity can lead to adverse outcomes in pregnancy and encourages mindful behavior rather than focusing on weight loss (Spieker, et al., 2015). Many women view pregnancy as an alternative health state and try adjusting their behaviors to better suit the pregnancy (reduction in smoking and alcohol consumption) which dissonance-based counseling appeals to (Spieker, et al., 2015).

Conclusion

Obesity is a modifiable disease with far reaching arms into every aspect of American lives to include pregnancy and the military. While obesity has great health effects prior to pregnancy, obesity complicates current medical diagnoses and can make a normal healthy pregnancy an unhealthy one. Obesity has very concerning implications to the mother, fetus and infant to include preconceptionally, during pregnancy and postpartum. Military readiness is greatly affected by this diagnosis. Some ways the nurse practitioner can intervene is to encourage a healthy lifestyle prior to pregnancy, continue to encourage healthy eating, and prescribe daily exercise routines suited to the individual pregnancy. With education and cheerleading, the nurse practitioner can have a large impact on the mother, her infant, and the expanding family.

References

• Dodd, J.M., & Briley, A.L. (2017). Managing obesity in pregnancy- An obstetric and midwifery              perspective.
  
  Midwifery, 49,
  
  7-12. http://dx.doi.org/10.1016/j.midw.2017.03.001
• Catalano, P.M., & Koutrouvelis, G.O. (2015). Practice Bulletin No 156: Obesity in pregnancy.
  
  Obstertrics & Gynecology, 126(
  
  6), 112-126. doi:10.1097/AOG.0000000000001211
• Center for Disease Control and Prevention. (2019a). Defining adult overweight and obesity. Retrieved from https://www.cdc.gov/obesity/adult/defining.html
• Centers for Disease Control and Prevention. (2019b). Obesity and Overweight. Retrieved from
  
  https://www.cdc.gov/nchs/fastats/obesity-overweight.htm
  
• Center for Disease Control and Prevention. (2019c). Weight gain during Pregnancy. Retrieved from
  
  https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-
  
  gain.htm
• Coad, J., & Dunstall, M. (2011).
  
  Anatomy and physiology for midwives.
  
  Great Britain: Elsevier
• Fahey, M.C., Talcott, G.W., Cox Bauer, C.M., Bursac, Z., Gladney, L., Hare, M.E…. Krukoski,              R.,A. (2018). Moms fit 2 fight: Rationale, design, and analysis plan of a behavioral              weight management intervention for pregnant and postpartum women in the U.S. military.
  
  Contemporary Clinical Trials, 74,
  
  46-54.
  
  https://doi.org/10.1016/j.cct.2018.09.012
  
• Maturi, M.S., Afshary, P., & Abedi, P. (2011). Effect of physical activity intervention based on a pedometer on physical activity level and anthropometric measures after childbirth: a randomized controlled trial.
  
  BMC Pregnancy and Childbirth, 11
  
  (103), 1-8. http://www.biomedcentral.com/1471-2393/11/103
• Palmer, N.O., Bakos, H.W., Fullston, T., & Lane, M. (2012). Impact of obesity on male fertility, sperm function and molecular composition.
  
  Spermatogenesis,
  
  
  2
  
  , 253–263.
• Spieker, E.A., Sbrocco, T., Theim, K.R., Maurer, D., Johnson, D., Bryant, E., . . . Stephens, M.B. (2015). Preventing obesity in the military community (POMC): The development of a clinical trials research network.
  
  International Journal of Environmental Research and
  
  
  
  
  Public Health, 12,
  
  1174-1195. doi:10.3390/ijerph120201174
• Villamor, E., Tedroff, K., Peterson, M., Johansson, S., Neovius, M., Petersson, G., & Cnattingius, S. (2017). Association between maternal body mass index in early pregnancy and incidence of cerebral palsy.
  
  JAMA, 317
  
  (9), 925-936. doi:10.1001/jama.2017.0945