New Debate: Is It Time for Infertility Weight-loss Programmes to be Couple-based?

Damian Best; Alison Avenell; Siladitya Bhattacharya; Gertraud Stadler


Hum Reprod. 2017;32(12):2359-2365. 

In This Article

The Rationale for a Couple-based Intervention

Partner support in everyday life may facilitate behaviour change and continuation in programmes. Infertility clinics are relatively unique in medicine, as they accommodate the needs of couples rather than individuals. Partners support each other during treatment and the emotional upheavals engendered by it. Where weight loss is required as part of their management, it is reasonable to expect that this support would be useful, particularly in facilitating programme continuation. Perhaps it is time to consider the development of weight-loss programmes targeting couples, rather than individuals.

Couples May Have Similar Weight and Eating and Activity Patterns

Couples tend to have similar body mass indices, and weight change in one partner can go hand in hand with weight change in the other. A systematic review (Di Castelnuovo et al., 2009) found correlations between partners with regards to BMI (r = 0.15 across 34 582 couples in 19 studies) and weight (r = 0.11 across 6765 couples in 9 studies). A representative study of 11 979 Dutch couples replicated correlations for BMI between partners (r = 0.23) (Monden, 2007). A study including 3356 expectant couples attending antenatal clinics (Edvardsson et al., 2013) found a positive partner correlation for BMI (r = 0.21). A woman's odds of being obese were more than six times higher if their partner was also obese, in comparison with women whose partner was of normal weight (OR 6.2, 95% CI 4.2–9.3). More than one-third (37.8%, P < 0.001) of couples in a study investigating semen parameters were concordant for obesity (Polotsky et al., 2015). A Danish population cohort study reported that couples presenting for IVF resembled each other in BMI, though they did not supply supportive data (Petersen et al., 2013). In a study of weight change in 3722 older couples, the probability of weight loss in women was 36% when the partner also lost weight compared to 15% if the partner's weight was static (Jackson et al., 2015).

Weight correlations between partners may be attributed to similar eating and activity patterns. For example, an 18-month home-based weight-loss trial with 132 couples found concordance in daily caloric intake, food intake, including that outside the home, physical activity and sedentary behaviours between partners (Scherr and Gorin, 2011). Prior epidemiological studies have found concordance in many health behaviours in couples, including physical activity and diet (Simonen et al., 2002; Wilson, 2002; Meyler et al., 2007; Brummett et al., 2008; Homish and Leonard, 2008; Pachucki et al., 2011) The main barriers to exercise reported by women in another study (Banting et al., 2014) were lack of time and fatigue, and their main physical activity supports were their partners (Banting et al., 2014). This compels us to consider whether couple-based interventions might in fact be more useful than individual interventions.

Partner Involvement May Facilitate Behaviour Change, Programme Continuation and Prove Cost-effective

Social support from close others has been a long-standing treatment recommendation for weight-loss interventions (Brownell, 1984; Kalodner and Lucia, 1990; Look AHEAD Research Group et al., 2006; Perri et al., 2008). Existing trials involving partners often show greater weight-loss effects with interventions involving persons participating with family members rather than individually (Rosenthal et al., 1980; Pearce et al., 1981; Murphy et al., 1982; Black and Lantz, 1984; Wing et al., 1991; Cousins et al., 1992; McLean et al., 2003; Avenell et al., 2004). Involving support partners proved beneficial, particularly if the partners actively participated in the programme (Kumanyika et al., 2009) and if they also lost weight (Gorin et al., 2005). Couple-based interventions may be an effective and cost-effective public health approach, as two individuals could lose weight as inexpensively as one (Black and Threlfall, 1989).

Trial data illustrate the fact that partners may facilitate behaviour change and weight loss. A meta-analysis in 1990 compared behavioural weight-control programmes involving partners to individual programmes (Black et al., 1990). The programmes contained couples with both concordant and discordant need for weight loss. The authors concluded that couple-based programmes were superior to individual interventions immediately post treatment (estimated effect size = 0.331, 95% CI 0.13, 0.54; P < 0.05), and at 2–3-months' follow-up (estimated effect size = 0.279, 95% CI 0.008, 0.566; P = 0.06), though the latter did not reach statistical significance. Participants in a small weight-loss trial (N = 23) lost more weight when their partners had normal weight than when their partners were overweight (at 12 months: 12.7 kg vs. 9.2 kg; at 15 months: 13.4 kg vs. 7.9 kg) (Black and Threlfall, 1989), supporting the argument for couple enrolment, even when one partner has no excess weight to lose.

Another small trial (N = 29) of overweight men and women found greater weight loss at 6 months when the partner was cooperative and participated in the programme (13.4 kg) than when the programme was delivered individually, either with a cooperative partner (8.8 kg) or a non-cooperative partner (6.9 kg) (Brownell et al., 1978). Participants in this couple intervention reported that mutual monitoring was key in the early weeks of the programme, and subsequent support and encouragement from their partner enabled them to adhere (Brownell et al., 1978). One further small trial (N = 49) found that overweight women, but not men, with diabetes lost more weight when enroled with their spouses (Wing et al., 1991). Lastly, 393 UK council employees were enroled in a large trial to reduce the levels of saturated fat in their diets, either individually or with their partner (Prestwich et al., 2014). Participants receiving the partner-based intervention increased the ratio of 'good' fats to 'bad' fats at 3 and 6 months, and also managed to decrease their waist circumference more than those receiving the individual intervention (effect size not given; P = 0.04).

Preparation for Parenthood as a Teachable Moment for Adopting a Healthier Lifestyle With Long-term Benefits for Both Partners and Their Baby

A successful weight-loss intervention could improve the chances of achieving pregnancy and delivering a healthy baby (Best et al., 2017) via higher spontaneous pregnancy rates (Duval et al., 2015; Mutsaerts et al., 2016; Lan et al., 2017) and possibly better IVF treatment outcomes (Clark et al., 1998; Sim et al., 2014a), including fewer pregnancy complications (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2011) and more live births (Kort et al., 2014). In the longer run, both partners in addition to their baby could benefit from maintained behaviour change with better health across the lifespan. A healthy weight is related to lower risk for cardiovascular disease, Type 2 diabetes and all-cause mortality (National Clinical Guideline Centre, 2014). Weight loss is related to reduced incidence of Type 2 diabetes in women and men (Avenell et al., 2004; Robertson et al., 2014) and erectile dysfunction in men (Robertson et al., 2014). The point at which couples experience fertility problems could thus become a teachable moment for long-term changes towards a healthier lifestyle, with benefits to the couple and their family over their life course (Cohen et al., 2011).