Effects of Physical Activity on Quality of Life of Pregnant Women with Overweight or Obesity: A Systematic Review

Round 1

Reviewer 1 Report

It's a good idea to review a new topic. But what sets the author’s research apart? This occurs when a person who was originally obese becomes pregnant. So what is the difference between obese people and pregnant obese people?

Because the pregnancy period is long, there will be a big difference depending on when the measurement was taken.

The number of studies finally analyzed is very small. The conclusion is too definitive. Since there are many areas that have not yet been studied, more flexible expressions are required.

I don't have any related comment.

Author Response

Dear reviewer,
Thank you very much for your review, I hope I have met your comments

Author Response File: Author Response.pdf

Reviewer 2 Report

This manuscript provides an informative systematic review of literature related to the topic of overweight/obesity, pregnancy, physical activity, and quality of life.  The authors have clearly outlined the process they used and the resulting findings.  Additional expansion on their exclusion criteria/reasons what be useful to clarify what deemed the articles unsuitable.  Finally, no reasons were given for only including research articles in their review.  As well, further expansion on the opportunities for policy/research would be useful in the discussion section.  

The manuscript and systematic review is very well-written with only very minor editing required.  The risk table as well could be increased in size to improve readability. 

Author Response

Dear reviewer, thank you very much for your review. I enclose the answers point by point 

Author Response File: Author Response.pdf

Reviewer 3 Report

This systematic review investigated whether physical activity for pregnant women with obesity have beneficial effect on the quality of life and mental status reviewing 6 randomized control trials. In the results, physical activity interventions had no significant effect. The authors previously reported a similar systematic review regarding gestational weight gain in Ref. 16, and there are several systematic reviews from other authors with the subjects not limited to obesity. Based on the context, the Discussion section should be deliberated in depth.

1.        The authors described the results of previous systematic reviews in the Discussion section but did not examine the quality of the systematic reviews. For example, in Lines 303–312, the opposite results were presented, but it is hard to understand the reason of the difference. For example, selection criteria, methods, used database, etc.

2.        The time of assessment was various (Line 241), and depressive symptoms changed during pregnancy and in the postpartum period in Lines 325–333. It is unknown when is the target to prevent the comorbidity (Lines 70–79) in the hypothesis? Clarify this, select and analyze the literature, and discuss it.

3.        The heterogeneity was little discussed. “However, it was not possible to obtain quantitative results from this systematic review due to the heterogeneity of the interventions. In this area, there is a need to develop rigorous clinical trials to establish the direct impact of physical activity and exercise interventions on the quality of life and mental health of this population.” In addition to discussion about heterogeneity, suggest the direction of the future study in terms of uniformity or consistency.

4.        Supplementary files are not available for the reviewers (Lines 116–124). Additionally, the title of supplementary files should be presented at the backmatter according to the guidelines.

Minor points

Title

5.        Several authors have no country names.

Abstract

6.        Delete the subheadings according to the Instructions.

7.        Instead of the description, “Methodological quality was assessed using the Cochrane RoB2 tool and a narrative synthesis of the results was performed,” the results of quality should be described.

Methods

8.        Lines 128, 207, and 208. Superscript.

Results

9.        Lines 162–165. Repetition.

10.     Figure 1. “Reports sought for retrieval (n = 15)” is unknown. The number before it is 181, and the number after it is 88.

11.     Figure 1. “Reason 1 to 6” is not explained in the main text or the caption.

12.     Lines 169–173. Could you add a sentence that there were not selected Portuguese literature? Most readers cannot read Portuguese.

13.     Table 1. The abbreviations should be defined the first time they appear in each of three sections according to the guidelines. In the same way, the abbreviations in the Table should be defined in the cells or the foot note: EG, CG, nEG1, nEG2, nCG, MGA, QoL, GPG, MOS, GDM, SMART, BREF, etc.

14.     Figure 2. The font size is too small, and the resolution is too low.

15.     Lines 213–219. Is there information about how many times of delivery before. Did the pregnant women experience physical exercise during previous pregnancy or comorbidity with pregnancy before? If this factor influences the results, discuss it.

16.     Line 266. It is unknown whether adverse effect of physical activity is reported. If not, describe there is no. If present, report the prevalence.

17.     Lines 313, 325, and 338. The reference number should appear at the first sentence.

18.     Line 336. Ref. 32 is not the selected literature. Is it correct?

19.     Line 361. “From a public health perspective, this should be enhanced….” It is hard to understand what “this” indicate.

20.     Line 383. Period.

Author Response

Dear reviewer, thank you very much for your review. I enclose the answers point by point 

Author Response File: Author Response.pdf

Reviewer 4 Report

Methodologically, the SR is well done.  The interpretation can/must be improved, however.

Introduction: I challenge the thesis that all forms of overweight and obesity are " a medical condition" (page 2/20).  Clearly, there is a difference between a BMI of 26 and 44.  Overweight and obesity as a whole constitute a risk factor for a number of health conditions.  These effects are gradual with the level of obesity.  We do not call poverty a medical condition, or alcohol/cannabis/nicotine use: yet again, these are risk factors for developing a number of health conditions.  We should avoid medicalizing everything.  In the process, we stigmatize unfairly.

Figure 1 is unclear, we go from n = 181 tot n = 15 to n = 88 to n =6.

Table 1 is extensive, which is good on the one hand, but loses the succinctness of a real table.  It will be difficult to print and remain readable.  The authors might try to make the table more succinct and add information in the text body.

Methodological quality, page 14/20.  The authors are quite "severe", eg a "High-risk" of bias for the Poston et al trial.  The authors tend to "punish" honest writing.  I find the judgment in the Abstract "no solid results" and "more rigorous clinical trials" misplaced.  We know on the other hand that many authors are keen to conceal the weaknesses in the design of their trial.  Surely, we should be critical of THOSE trials.

Narrative synthesis.  Perhaps this is not the focus of the study, but the authors do well to point out the increase in fitness/physical quality of life in overweight gravidas through physical actvity.  Perhaps they should transfer these positive messages to the Abstract and Discussion.  The question, then, is: why does increased fitness not translate into better overall quality of life in the short term?  Maybe the 'inhibitors' mentioned in the Discussion on page 16/20 (pain, poor sleep, anxiety, etc.) are too dominant.

The Discussion is difficult to follow, and needs rewriting.  The authors relate to studies in "pregnant women", by which they probably mean non-obese women.  Therefore, the authors should be more specific about the population they are discussing at that moment. 

Can be improved, poorly written Discussion for example.

Author Response

Dear reviewer,
Thank you very much for your review, I hope I have met your comments

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thank you for your faithful revision.

I do not have any comment.

Author Response

Thank you

Reviewer 3 Report

Thank you for your revision, which improves the manuscript clear. Additional Several concerns remain.

1.     In the Abstract (Line 29), six databases included “BVS”, but in the Methods, Virtual Health Library (VHL), and in the Results, the Virtual health Library (BVS). In the supplementary file, “BVS”. The abbreviation should be consistent.

2.     Lines 67–69. Ref. 11, the guideline, has been retired. Replace it with a recent one. Ref. 12, and 13 do not mention type 1 diabetes. Type 1 diabetes may be considered unrelated to overweight, obesity, or insulin resistance. Is this sentence correct?

3.     Line 117. Supplementary Table S1 should be self-explanatory. “DS”, and “IF” is not explained in the footnote.

4.     Line 123. Period

5.     Line 125. Although Supplementary Table S1 is accessible, but Supplementary Table S2 is inaccessible. It should be also self-explanatory.

6.     Half of “quality of life” have definite article “the”, but the remains have not.

7.     Line 105, 121, 213, 214, 215, Table 1, kg/m2, plain fonts, but Line 60, and 61, kg/m², superscript.

mentioned above.

Author Response

1. In the Abstract (Line 29), six databases included “BVS”, but in the Methods, Virtual Health Library (VHL), and in the Results, the Virtual health Library (BVS). In the supplementary file, “BVS”. The abbreviation should be consistent.

Thank you very much for the correction. We've changed it in the main text.

2. Lines 67–69. Ref. 11, the guideline, has been retired. Replace it with a recent one. Ref. 12, and 13 do not mention type 1 diabetes. Type 1 diabetes may be considered unrelated to overweight, obesity, or insulin resistance. Is this sentence correct?

Thank you very much for your reminder. I have now removed the reference to "Davies, 2018" from the main text and replaced it with the most recent one. With regard to diabetes, we have changed “risk of developing metabolic dysregulation with increased insulin resistance”.

3. Line 117. Supplementary Table S1 should be self-explanatory. “DS”, and “IF” is not explained in the footnote.

I've already changed it in the supplementary material. thank you very much.

4. Line 123. Period

Done

5. Line 125. Although Supplementary Table S1 is accessible, but Supplementary Table S2 is inaccessible. It should be also self-explanatory.

We have removed supplementary material 2 because we have placed the reasons for exclusion between lines 166-169

6. Half of “quality of life” have definite article “the”, but the remains have not.

Done

7. Line 105, 121, 213, 214, 215, Table 1, kg/m2, plain fonts, but Line 60, and 61, kg/m², superscript.

Done

Reviewer 4 Report

I still feel that the harshly negative tone of the Abstract should be reduced:

see Results, page 16: "greater adherence to the protocol was associated with a better post-intrevention physical quality of life", "positive results in weight control", "positive effects in relation to the aerobic fitness and maximum workload of the participants".

The quality of the trials may have limitations, but the Abstract is too harsh: "does not appear to have an effect", "no solid results", "more rigorous trials".

The authors should focus in the Discussion on factors that might render physical activity more effective during pregnancy.

Author Response

The quality of the trials may have limitations, but the Abstract is too harsh: "does not appear to have an effect", "no solid results", "more rigorous trials".

Thank you very much for your comments. We have changed the conclusions of the abstract "The effects of physical activity during pregnancy for women with obesity or overweight are varied due to the diversity of interventions implemented. Nonetheless, a discernible positive association emerges between stringent adherence to the prescribed physical activity regimen and enhanced physical well-being, weight management, and heightened aerobic capacity. In order to ascertain more definitive conclusions, rigorous clinical trials are needed, that take into account the heterogeneity of interventions and ensure adequate adherence to the protocol.”

The authors should focus in the Discussion on factors that might render physical activity more effective during pregnancy.

Thank you very much for your comment. I've added content to the discussion “, the use of digital media to prescribe exercise for obese pregnant women appears to have a favorable impact on physical activity levels and may reduce the barriers to physical inactivity during pregnancy [35].”