Abstract
Objectives:
Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and mortality. While a healthy diet may reduce the risk of HDP, dietary counseling at obstetric visits is rare. The goal of this study was to evaluate provider perspectives and rates of dietary counseling among obstetric patients with HDP and related conditions such as obesity.
Study design:
A survey study involving the distribution of surveys to obstetric care providers at an academic medical center and affiliated hospitals. Surveys evaluated rates of dietary counseling among obstetric patients with HDP and obesity, and used Five-point Likert scales to assess the likelihood and perceived importance of dietary counseling by disease state, as well as the weight of barriers and enabling factors to dietary counseling.
Main outcome measures:
Primary outcome measures were rates of dietary counseling among obstetric patients with HDP and obesity, and the likelihood and perceived importance of dietary counseling. Additional measures of interest included the weight of barriers/enabling factors to dietary counseling, provider confidence in providing dietary counseling, and rates of patient referral to dieticians/nutritionists.
Results:
Only 31 % of providers reported counseling patients with HDP on diet. Providers were significantly more likely to counsel patients with obesity compared to patients with HDP (p < 0.001). Lack of time and competing demands were the most frequently reported barriers to counseling.
Conclusions:
Providers are unlikely to offer dietary counseling to patients with HDP compared to those with obesity. These data highlight an important gap in preventative care for patients with HDP.
1. Introduction
Hypertensive disorders of pregnancy (HDP) are increasing and represent a leading cause of maternal morbidity and mortality in the US and worldwide [1,2]. Importantly, HDP are associated with adverse effects in the maternal-child dyad including cardiometabolic events later in life [3-6]. Current guidelines for gestational hypertension and preeclampsia focus on prevention of preeclampsia in at-risk patients with the use of low-dose aspirin initiated between 12 to 28 weeks of gestation (optimally before 16 weeks of gestation) [7,8], optimization of delivery timing, and treatment of acute-onset severe hypertension (systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg or both) [9]. For patients with chronic hypertension, initiation of low-dose aspirin is also recommended for preeclampsia prevention, though treatment targets for blood pressures during pregnancy remain controversial and vary by country [10,11].
In pregnancy, multiple antihypertensive medications are contraindicated, poorly studied, or have controversial safety profiles [10,12]. For these reasons, many pregnant patients with chronic hypertension discontinue anti-hypertensive medications out of concerns of fetal harm, placing them at risk of developing elevated or severe-range blood pressures [13,14]. One lifestyle strategy known to reduce blood pressure in adults is the Dietary Approaches to Stop Hypertension (DASH) diet, which is high in fruits, vegetables, whole grains, and low-fat dairy [15]. Studies in both healthy and hypertensive adults have shown that a diet rich in fruits and vegetables during pregnancy may reduce the risk of gestational hypertension and preeclampsia [16-26]. Additionally, prepregnancy adherence to the DASH diet is associated with lower risk of preeclampsia, and higher DASH adherence scores during pregnancy is associated with lower mid-pregnancy diastolic blood pressure and mid- and late- pregnancy fetoplacental vascular function [27,28]. For these reasons, along with support of the American College of Obstetricians and Gynecologists (ACOG) and the European Society of Cardiology (ESC) guidelines, lifestyle interventions should be considered an important strategy for reducing or maintaining blood pressure in pregnant patients and those of child-bearing age. Despite the recognized benefits of healthy diet in pregnancy, few patients at risk for HDP follow the DASH diet or receive counseling on diet and exercise in pregnancy [29,30].
To our knowledge, no studies to date have assessed obstetric provider perspectives on dietary counseling among pregnant patients with HDP. Thus, the goals of this study were to 1) determine rates of dietary counseling among pregnant patients with or at risk of developing HDP, 2) quantify the perceived importance of dietary counseling and the likelihood of providing dietary counseling to obstetric patients with different comorbidities, and 3) determine the weight of barriers and enabling factors to dietary counseling among obstetric patients with or at risk of developing HDP.
2. Methods
2.1. Study procedures
All methods were approved by the University of Massachusetts (UMass) Chan School of Medicine Institutional Review Board. Inclusion criteria for survey participation comprised: attending physicians, fellows, residents, nurse practitioners, and physician assistants currently treating obstetric patients and working in an Obstetrics and Gynecology, Maternal and Fetal Medicine, or Family Medicine practice at UMass Memorial Medical Center or a UMass-affiliated hospital.
2.2. Survey distribution
Obstetric providers were identified through department queries. Surveys were distributed to eligible providers through REDCap, a secure system [31], or through emails distributed by administrative staff who were not directly involved with the research study. Providers consented to participate through REDCap and completed surveys between June and September 2020. Incomplete surveys were excluded from the final analysis.
2.3. Exposures and outcomes of interest
Surveys assessed provider characteristics including provider type and demographic factors such as self-reported gender, race, and ethnicity. Surveys evaluated rates of dietary counseling and referral rates to a dietician or nutritionist among obstetric patients with the following conditions: chronic hypertension, gestational hypertension, pre-eclampsia, history of a HDP, abnormal laboratory values (e.g., elevated cholesterol), and those with an overweight (25–29.9 kg/m2) or obese (>30 kg/m2) body mass index (BMI).
Five-point Likert scales were used to assess the likelihood and perceived importance of dietary counseling or patient referral to a dietician or nutritionist among obstetric patients with different comorbidities (overweight or obese BMI, HDP, history of HDP). Likert scales included the following options: Not at all important/Very Unlikely (score of 0), Low importance/Not Likely (score of 1), Neutral (score of 2), Important/Likely (score of 3), Very important/Very Likely (score of 4), and Unsure/do not know.
Five-point Likert scales were also used to assess the extent to which different factors served as barriers (e.g., time availability) or enabling factors (e.g., patient motivation) to dietary counseling and referral to dieticians/nutritionists during pregnancy. Likert scales included the following options: Not at all (score of 0), To a small extent (score of 1), To some extent (score of 2), To a moderate extent (score of 3), and To a great extent (score of 4). Provider confidence in providing dietary counseling was also assessed using a five-point Likert scale ranging from No confidence at all (score of 0) to Very confident (score of 4).
2.4. Statistical analysis
The percentage of providers offering dietary counseling in different clinical scenarios was quantified and compared using Chi-square tests. Rates of dietary counseling by disease state were then further stratified and compared between attending and non-attending (e.g., resident physician, nurse practitioner) providers using Chi-square tests.
For evaluating the perceived importance and likelihood of dietary counseling or referral to a dietician/nutritionist in different clinical scenarios, the 5-point Likert scale responses ranging from 0 to 4 were assigned as described above. Mean Likert values were then established for each disease state or clinical scenario. Responses of “Unsure” were excluded from mean calculations. A pooled mean Likert value was established for HDP, which comprised gestational hypertension, chronic hypertension, preeclampsia, and a history of HDP. Comparisons were made using Student’s T-Tests. Results were then stratified and compared between attending and non-attending providers. This process was also used to evaluate and compare provider confidence in providing dietary counseling to patients between attending and non-attending groups, as well the weight of barriers and enabling factors to dietary counseling and to referral to dieticians/nutritionists.
3. Results
3.1. Study demographics
The survey completion rate was 18 %, with a total of 26 respondents. Among study respondents, 96 % were female and identified as Non-Hispanic White. In total, 46.2 % of study respondents were attending physicians, with 53.8 % non-attending providers (residents, fellows, and nurse practitioners).
3.2. Rates of dietary counseling
In total, 100 % of providers reported ever counseling obstetric patients on healthy eating habits. While nearly all providers (92 %) reported ever counseling obstetric patients with overweight or obese BMIs on healthy diet, only 31 % reported counseling patients with HDP or a history of a HDP on diet, with no difference between attending and non-attending providers. Other scenarios in which providers reported offering dietary counseling included patient inquiry (77 %), abnormal laboratory values (e.g., elevated cholesterol, 42 %), and “other” (42 %), which was primarily reported as counseling for pre-gestational or gestational diabetes mellitus (Table 1).
Table 1.
Rates of obstetric provider dietary counseling by disease state.
| Disease state | % Providers (n = 26) |
|---|---|
| Overweight or obese | 92 |
| Patient inquiry | 77 |
| Chronic hypertension | 27 |
| Gestational hypertension | 15 |
| History of hypertensive disorder of pregnancy | 15 |
| Preeclampsia | 12 |
| Family history chronic illness | 8 |
| Laboratory values (e.g., elevated cholesterol) | 42 |
| Other* | 42 |
Other reported reasons included gestational and pre-gestational diabetes.
3.3. Perceived importance of dietary counseling
While 73 % of providers felt that it was very important to counsel patients with obesity on dietary habits, few respondents felt that it was very important to counsel patients with HDP a history of HDP on diet (Table 2). The mean Likert value for the perceived importance of counseling patients with obesity was 3.8 (representing important to very important), while for patients with HDP or a history of HDP it was 2.2 (representing neutral) (p < 0.001, 95 % CI 1.1 – 2.0). There was no difference in the perceived importance of counseling patients with obesity or those with HDP/history of HDP between attending and non-attending providers.
Table 2.
Providers’ perceived importance of dietary counseling by disease state.
| Disease state | Very important (%) | Important (%) | Neutral (%) |
Low importance (%) |
Not at all important (%) |
|---|---|---|---|---|---|
| Obese | 73.0 | 23.1 | 0.0 | 0.0 | 0.0 |
| Overweight | 50.0 | 38.5 | 3.8 | 3.8 | 0.0 |
| Chronic hypertension | 23.1 | 27.0 | 27.0 | 15.4 | 3.8 |
| Gestational hypertension | 15.4 | 11.5 | 38.5 | 19.2 | 3.8 |
| Preeclampsia | 15.4 | 7.7 | 42.3 | 19.2 | 3.8 |
| History of hypertensive disorder of pregnancy | 15.4 | 15.4 | 38.5 | 19.2 | 3.8 |
3.4. Likelihood of counseling by disease state
The mean Likert value for the likelihood of offering dietary counseling to obstetric patients with obesity was 3.4 (representing likely), while for patients with HDP or a history of HDP it was 1.8 (representing not likely to neutral) (p < 0.001, 95 % CI 1.0–2.1).
3.5. Barriers and enabling factors to counseling
Competing demands (95 %) and lack of time (92 %) were the most frequently reported barriers to counseling at least to a moderate extent, each with a mean Likert value of 3.2 (Table 3). Insufficient training was reported as a barrier to counseling at least to a moderate extent by 58% of providers. Time availability (92 %) and patient motivation (88 %) were the most frequently reported enabling factors to dietary counseling at least to a moderate extent, with mean Likert values of 3.6 and 3.4, respectively (Table 4). There was no difference in the weight of barriers or enabling factors to dietary counseling between attending and non-attending providers.
Table 3.
Extent to which each factor served as a barrier to dietary counseling.
| Mean Likert Value |
Qualitative value | |
|---|---|---|
| Time availability | 3.6 | Moderate to great extent |
| Competing demands | 3.6 | Moderate to great extent |
| Insufficient training | 2.6 | Some to moderate extent |
| Insufficient guidelines | 2.2 | Some extent |
| Lack of rapport with patient | 2.1 | Some extent |
| Low comfort level addressing topic | 2.0 | Some extent |
| Use of interpreters during visits | 1.7 | Small to some extent |
| Prior failed attempts with this patient | 1.6 | Small to some extent |
| Prior failed attempts with others | 1.4 | Small extent |
| Uncertainty of benefit to patient | 1.1 | Small extent |
Table 4.
Extent to which each factor served as motivating/enabling factor to dietary counseling.
| Mean Likert Value |
Qualitative value | |
|---|---|---|
| Time during appointment | 3.6 | Moderate to great extent |
| Patient motivation | 3.4 | Moderate to great extent |
| Patient is obese | 3.0 | Moderate extent |
| Patient is overweight | 2.4 | Some to moderate extent |
| Patient has chronic hypertension | 1.6 | Small to some extent |
| Patient has gestational hypertension | 1.4 | Small extent |
| Patient has preeclampsia | 1.3 | Small extent |
| Patient has history of hypertensive disorder of pregnancy | 1.2 | Small extent |
3.6. Provider confidence
In total, 81 % of survey respondents reported having no to low confidence in their ability to provide dietary counseling to obstetric patients. There was no significant difference in the mean confidence level between attending and non-attending providers, and both groups, on average, reported low confidence levels (2.3 vs. 2.0, p = 0.30).
3.7. Referral to dieticians or nutritionists
In total, 85 % of providers felt that obstetric patients would benefit from dietary counseling by a dietician or nutritionist, and 92 % reported ever referring obstetric patients to a dietician or nutritionist. There was no difference in the frequency of referrals between attending and non-attending providers. The most frequently reported reasons for ever referring a patient to a dietician/nutritionist included overweight or obese BMI, chronic hypertension, and “other,” which included referral for gestational diabetes mellitus or type 2 diabetes mellitus (Table 5).
Table 5.
Rates of patient referral to a dietician or nutritionist by disease state.
| % Providers (n = 26) |
|
|---|---|
| Overweight or obese | 62 |
| Chronic hypertension | 62 |
| Patient inquiry | 46 |
| Laboratory values (e.g., elevated cholesterol) | 23 |
| Gestational hypertension | 4 |
| Preeclampsia | 4 |
| History of hypertensive disorder of pregnancy | 4 |
| Family history of chronic illness | 4 |
| Other* | 69 |
Other reported reasons included gestational and pre-gestational diabetes.
Only 8 % of providers reported being likely or very likely to refer patients with gestational hypertension or preeclampsia to a dietician/nutritionist (Supplemental Table 1). There was a significant difference in the likelihood of referral for patients with obesity (mean Likert value 2.9, representing likely) compared to those with HDP or a history of HDP (mean Likert value 1.5, representing not likely to neutral) [p < 0.01, 95 % CI −2.4 – −0.5] (Supplemental Table 2). There was no difference in the likelihood of referral between attending and non-attending providers. The greatest enabling factor to referral to a dietician/nutritionist was the patient showing readiness or motivation to change, and the greatest barriers to referral were competing demands and patient lack of interest (Supplemental Tables 3-4).
4. Discussion
4.1. Main findings
This study elucidates several important aspects of dietary counseling and referral patterns in obstetric patients with HDP and obesity. While 100 % of study respondents reported ever providing dietary counseling to obstetric patients, only 31 % reported counseling patients with HDP or a history of HDP on diet. Additionally, while 73 % of providers felt that it was very important to counsel patients with obesity on dietary habits, only 15 % felt that it was very important to counsel those with HDP or a history of HDP on diet. These data are consistent with a prior study by Yamamoto et al., which found that, in a nationally-representative sample, only 17.9 % of outpatient preventative care visits in pregnant patients included counseling on diet and exercise [30].
The greatest reported barriers to counseling were time constraints and competing demands, and the greatest enabling factors were time availability and patient motivation. Of note, the majority of survey respondents reported low confidence levels in their ability to provider dietary counseling to obstetric patients. While 85 % of providers felt that obstetric patients would benefit from dietary counseling by a dietician, few providers reported being likely to refer patients with HDP to dieticians for counseling, despite their own lack of confidence in counseling. However, half of providers reported being likely to refer patients with obesity to a dietician or nutritionist. The greatest barriers to referral were competing demands and patient lack of interest.
The ACOG and ESC recommend lifestyle modification (e.g., diet, exercise, maintaining a healthy weight) for patients with HDP to prevent future cardiovascular disease [9,32]. Indeed, maintaining a healthy diet and weight, and limiting excessive gestational weight gain in pregnancy are important for reducing adverse patient outcomes [33,45]. Despite the recognized benefit of dietary modification during pregnancy and evidence that dietary counseling is effective in promoting lifestyle change and potentially reducing rates of HDP [34-41], few survey respondents reported counseling obstetric patients with HDP or a history of HDP on diet.
4.2. Implications
Numerous studies have demonstrated that a diet rich in fruits and vegetables may reduce one’s risk of developing HDP [16-26]. Additionally, maintaining a healthy lifestyle postpartum is important for maintaining cardiovascular health after delivery [42]. Thus, dietary counseling serves an important role in obstetric care. Here, we showed that few obstetric providers report counseling patients with HDP on diet, and that providers are significantly more likely to counsel patients with obesity on diet. This suggests a clear gap in preventative care for obstetric patients with HDP, as dietary counseling, either by an obstetric provider or a dietician/nutritionist in these patients, may reduce the risk of pregnancy-related complications.
Given that the majority of providers reported little confidence in their ability to provide dietary counseling to obstetric patients, this highlights an area for improvement in training for obstetricians and gynecologists. Additionally, the difference in counseling between patients with obesity and HDP is also concerning, and potentially related to weight bias and stigma [43]. Because a lack of time and competing demands serve as major barriers to dietary counseling, providers may benefit from referring patients with HDP or those at risk of developing HDP to dieticians/nutritionists, and may benefit from standardized guidelines for when and how to refer patients to dieticians for dietary counseling in pregnancy.
5. Strengths and limitations
The strengths of this study include its novelty, as no studies to date have evaluated rates of dietary counseling among obstetric patients with HDP. Additionally, this study included providers at multiple training levels, increasing the generalizability of the results. This study had several limitations, including the small sample size and low survey completion rate at 18 %, likely in part related to the timing of the survey distribution during the COVID-19 pandemic. Though this response rate is comparable to physician response rates in other studies [44], this low response rate could impose nonresponse bias on the study. Another major limitation of this study was the use of a non-validated survey, as no validated questionnaire was available.
6. Conclusion
Obstetric providers were more likely to offer dietary counseling to obese patients than to those with HDP. These data highlight an important gap in preventative care for women with HDP. Given that time constraints are a common barrier to dietary counseling, obstetric providers should consider nutrition referrals for at-risk patients. Future studies should seek to determine the effect of incorporating obstetrician- or dietician-led dietary counseling into preconception and prenatal care visits on reducing rates of HDP and improving maternal and fetal outcomes.
Supplementary Material
Funding
Lara C. Kovell is supported by the National Heart, Lung, and Blood Institute (Bethesda, MD) through K23HL163450. Gianna L. Wilkie is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, through grant K23HD111526.
Angela Essa reports no funding.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.preghy.2025.101273.
Footnotes
Ethical approval
All study procedures were approved by the University of Massachusetts Chan Medical School Institutional Review Board.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Data availability statement
The data and statistical tools used for this research study will be made available upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data and statistical tools used for this research study will be made available upon request.