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662 Asia Pac J Clin Nutr 2021;30(4):662-674
Original Article
Nutrition and physical activity interventions to
ameliorate postpartum depression: A scoping review
1 1
Noor Fairuzi Suhana Yahya MSc , Nur Islami Mohd Fahmi Teng PhD , Srijit Das MBBS,
2 3
MS , Norsham Juliana PhD
1
Faculty of Health Sciences, Universiti Teknologi MARA, Selangor, Malaysia
2
Sultan Qaboos University, Muscat, Oman
3
Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Negeri Sembilan, Malaysia
Background and Objectives: Globally, there is a high prevalence of postpartum depression (17.7%) reported in
a recent study among mothers during the postpartum period. It contributes to poor health and well-being among
newly delivered women. We reviewed the published effect of nutrition and physical activity interventions on im-
proving and treating postpartum depression. Methods and Study Design: The scoping review was performed us-
ing Arksey and O'Malley's methodological framework. The systematic search was conducted using Scopus, Pub-
med, EBSCOHost and Google Scholar in April 2020, updated in March 2021. Only literature published between
January 2010 until February 2021 was searched. Results: A total of 25 articles were included, of which 23 were
randomised controlled trials , and 2 were quasi-experimental studies. Some of studies found improvements in de-
pression (76% out of all studies). On this basis, nutrition or physical activity intervention probably improves
postpartum depression. Moreover, the integration of nutrition and physical activity appears to improve depression
in the more thorough follow-up of participants . Active involvement of the participant in the interventions was
contributory to effectiveness. Conclusions: Nutrition and physical activity interventions with appropriate strategy
and delivery are promising options for the management of postpartum maternal mental health. More definitive
investigation of non-pharmacological interventions to ameliorate depression among postpartum women is war-
ranted.
Key Words: depression, postpartum, diet therapy, exercise therapy, exercise movement techniques
9
INTRODUCTION modifiable intervention. Nutritional factors play an es-
The postpartum period is crucial for a women's current sential role in complex brain function and in metabolic
and future wellbeing, as maternal physiology returns to pathways impinging on mental health. For example, es-
its pre-pregnancy status. The changes include uterine in- sential fatty acids (particularly omega-3), iron, folate and
volution, postpartum wound healing, and increased ab- vitamin B-12 are critical to brain function through enzy-
1
dominal muscle strength. This takes about six to eight matic activity, cellular and oxidative processes, and neu-
9
weeks, beginning with the birth of the fetus and placen- rotransmisssion. Nutrient deficiencies of pregnancy may
tal expulsion . The postpartum period predisposes women persist postpartum and require attention for optimal men-
8,9
to major hormonal change affecting emotional lability tal health . Nutrition intervention is an appealing strate-
2
with potential depression. Postpartum depression is a gy to reduce postpartum depression being cost-effective,
9
serious psychiatric illness that occurs within one month of stigma-free, and generally acceptable. The integration of
3
childbirth. A meta-analysis of the global prevalence of nutrition and other preventive strategies may more effec-
8
postpartum depression in 56 countries, revealed a global tively ameliorate depressive disorder.
pooled prevalence of 17.7%, ranging from 3% in Singa- Physical activity has been shown to be an effective way
4 10
pore to 38% in Chile. Symptoms of postpartum depres- to improve a mother's psychosocial well-being. Reduced
sion include passivity with behaviors such as depressed physical activity is associated with more depressive sym-
mood (sad, hopeless), lack of interest in the child or its
5
care, and inappropriate fatigue, continuously over some Corresponding Author: Dr Nur Islami Mohd Fahmi Teng,
two-weeks. It may affect infant development physically Centre for Dietetics Studies, MiCHILD (Maternal, Infant and
Young Child) research group, Faculty of Health Sciences, Uni-
and in motor, cognitive and emotional development, as
versiti Teknologi MARA. Puncak Alam Campus, 42300, Selan-
well as impair maternal-infant interaction, with poor
6 gor, Malaysia.
bonding, and infant insecurity.
7 Tel: +03-32584540
According to Jasimah et al, women with severe de-
Email: nurislami@uitm.edu.my
pression had a high consumption of unhealthy foods. De-
Manuscript received 08 June 2021. Initial review completed 08
pressive disorders may be associated with macro and mi-
August 2021. Revision accepted 25 September 2021.
8
cronutrient deficiencies. In this event, nutrition may be a
doi: 10.6133/apjcn.202112_30(4).0013
Interventions on postpartum depression 663
ptoms among women who adhere to traditional confine- search was performed in electronic databases using
11
ment practices. Several studies underscore that seden- standardised search terms specific to the needs of each
tary behaviour is linked to postpartum depressive symp- respective database and revised by the research team. The
10,12
toms, whereas physically active women have less. databases selected were Scopus, Pubmed, EBSCOHost
More than increased muscle strength and flexibility, and Google Scholar, and performed in April 2020 with
physical activity can favour other health dimensions such update in March 2021. The search was conducted with
as satisfaction and awareness of self-ability in coping MeSH (Medical Subject Headings in PubMed) terms in-
with motherhood and its impact on livelihood, so im- cluding “depression”, “postpartum”, “postpartum de-
13
proving psychosocial well-being. pression”, “diet”, “nutrition”, “exercise”, “exercise
Women’s preferences for pharmacological (such as an- therapy” and “exercise movement techniques”. Table 1
tidepressants and hormonal therapy) or non- lists the initial keywords and search terms generated.
pharmacological approaches to postpartum depression Boolean operators (AND, OR, AND NOT) were used to
14
management may be ambiguous and affect adherence. combine search terms within related keywords. If search
That nutrition and physical activity interventions can be terms were incomplete, an additional search was per-
cost-effective in improving mental health become rele- formed using modified search terms. Table 2 shows the
9,12
vant. Evidence for the effectiveness of integrated nu- search strings generated.
trition and physical activity in postpartum depression risk
9,10,12,15,16
reduction has been inconclusive. The current Stage 3: Selecting studies
scoping review of references works, including literary For this review, articles that were duplicated among da-
resources through to 2021 adds perspective to systematic tabases were removed. Articles were screened according
reviews focused on publications through to 2019 or to years included (January 2010 to March 2021), and re-
8,10
2020. The present scoping review is guided by the stricted to English publications . Screening for article
main research question, namely, ‘Whether and how effec- eligibility was in two stages: a title and abstract/summary
tively do physical activity and nutrition interventions and full-text screening. Finally, an article was included if
ameliorate postpartum depression?’ It focuses on inter- it fulfilled the following criteria:
vention strategy and its effectiveness. Population: primiparous or multiparous postpartum
adult women.
METHODS Intervention: nutrition or dietary modification, nutri-
Protocol development tion improvement, and exercise-based (supervised, unsu-
The interpretive scoping review methodology used is pervised, coaching-based, or motivational), started only
adapted from that of Arksey & O'Malley.17 The frame- after childbirth.
work has five stages: 1) identifying the research questions; Outcome: Depression symptoms according to a vali-
2) identifying relevant studies; 3) study selection; 4) dated assessment tool.
charting the and collating data, 5) summarising and re- Age of participant: from 18 to 50 years
17
porting information. This scoping review follows the All the articles selected were full papers for reference,
Preferred Reporting Items for Systematic Reviews and and excluded if they were:
Meta-Analyses Extension for Scoping Reviews (PRIS- Non-human or animal studies;
MA-ScR). As a scoping review, registration with the In- Only abstracts, case reports, protocols or focussed on
ternational Prospective Register of Systematic Reviews unrelated topics.
was not required. The selection process is shown in Figure 1.
Stage 1: Identifying the research question Stage 4: Charting the data
17
According to Arksey & O'Malley, defining the relevant To confirm study relevance and extract its characteristics,
research question is a vital initial step since it guides the a framework was developed, referred to as data charting.
way search strategies are designed. In this review, we This method uses both a narrative and analytic approach
used general format of a PICO question that is P (popula- to extract data that best addresses the research objectives.
tion): postpartum women, I (intervention): nutrition and It is a process which synthesises and interprets data by
physical activity, C (comparison intervention): control or sifting, charting, and sorting information based on key
17
alternative to the intervention group, and O (outcome): issues and themes. Each selected article was categorised
postpartum depression or maternal mental health. There- by authors, publication year, country, aim, de-
fore, we identified one overarching research question to sign/methods, participants/ sample size, type of interven-
lead our systematic search strategy and reporting of re- tion and allocation to a scoping table. This is overviewed
sults: "What is the effect of nutrition and physical activity in Table 1-3.
interventions on postpartum depression among postpar-
tum women compared with a control or non-intervention Stage 5: Collating, summarising and reporting results
group?" The main characteristics of studies included were sum-
marised qualitatively and tabulated based on data extrac-
Stage 2: Identifying the relevant studies tion, and findings presented in narrative form. Content
Our research team developed the search strategy collabo- analysis was conducted to identify themes regarding sam-
ratively A time frame for publication access was set to ple size, type, duration, frequency, and intervention effec-
focus on recent interventions in postpartum depression tiveness for improving depressive disorder among post-
(from January 2010 to February 2021). The systematic partum women. Knowledge gaps were identified. Emer-
664 NFS Yahya, NI Mohd Fahmi Teng, S Das and N Juliana
Table 1. List of keywords and synonyms generated as search terms
Postpartum depression Nutrition intervention Physical activity intervention
“postpartum” AND “depression” “diet” “exercise” OR “fitness” OR “sport” OR
Aerobic
“postpartum depression” “nutrition” “physical activity”
“maternal mental health” “nutrition intervention” “motor activity”
“postnatal” AND “depression” “diet intervention” “exercise therapy”
“well-being” AND “postpartum” “nutri*” OR “food” “exercise test”
“vitamin” OR “mineral” OR “supplement” “physical activity intervention” OR “lifestyle
OR “micronutrients” intervention
Table 2. List of search strings
Search string 1: ( “postpartum depression” OR ( “postpartum” AND “depression” ) OR “maternal mental health” OR
(“well*being” AND postpartum) )
AND
( “diet” OR “nutrition” OR “nutrition intervention” OR “diet intervention” OR “nutri*” OR “food” OR
“vitamin” OR “mineral” OR “dietary supplements” OR “supplement*” OR “micronutrients” )
AND
( “exercise” OR “fitness” OR ( “physical” AND “activity” ) OR “physical activity” OR “exercise test”
OR “aerobic” OR “physical exercise” OR “motor activity” OR “exercise therapy” OR “exercise move-
ment techniques” OR “sport” OR “ physical activity intervention*” OR “lifestyle intervention*” )
Search string 2: ( “postpartum depression” OR ( “postpartum” AND “depression” ) OR “maternal mental health” OR
(“well*being” AND postpartum) )
AND
( “diet” OR “nutrition” OR “nutrition intervention” OR “diet intervention” OR “nutri*” OR “food” OR
“vitamin” OR “mineral” OR “dietary supplements” OR “supplement*” OR “micronutrients” )
Search string 3: ( “postpartum depression” OR ( “postpartum” AND “depression” ) OR “maternal mental health” OR
(“well*being” AND postpartum) )
AND
( “exercise” OR “fitness” OR ( “physical” AND “activity” ) OR “physical activity” OR “exercise test”
OR “aerobic” OR “physical exercise” OR “motor activity” OR “exercise therapy” OR “exercise move-
ment techniques” OR “sport” OR “ physical activity intervention*” OR “lifestyle intervention*” )
gent themes could then be considered. 2 days until 12 months postpartum. Most studies (n=19)
18-21,24-32,34,37,40-43
used the Edinburgh Postnatal Depression
44 22,33,39
RESULTS Scale (EPDS), while three studies used the Beck
45 23,36
Study selection Depression Inventory (BDI), two studies the Center
46
The search protocol identified 2425 potentially relevant for Epidemiological Studies Depression Scale (CES-D),
35
articles, and three additional articles were found by scan- and one used the Zung Self-Rating Depression Scale to
ning article reference lists, making 2428 initial titles in assess depressive symptoms. Eight studies included
all. After removal of duplicates, 2265 articles remained. women who fulfilled the depressive symptoms crite-
25,26,28-32,35
These were screened for inclusion years, English lan- ria, while the remaining studies included wom-
guage and document type, where only journal articles en who did not follow these criteria.
were accepted. Some 509 articles with title, abstract, and This review is about two main interventions, nutrition
full text or equivalent and which fulfilled inclusion crite- and physical activity, to ameliorate postpartum depres-
ria were reviewed . Those articles that did not describe sion. Eight studies focused only on nutrition interven-
18,30-33,41,43 19,20,36,37,40,42,21,25-
interventions to ameliorate postpartum depression were tions, 14 on physical activity,
29,34,35 23,24,39
excluded. There were 32 articles where intervention rele- , and three studies were designed to combine
vancy was not in doubt. Finally, 25 publications met the nutrition and physical interventions to improve maternal
criteria for inclusion in this scoping review. mental health. Almost all studies (n=23) were random-
ised controlled trial studies, except for two quasi-
25,36
Study characteristics experimental studies.
Study characteristics are summarised in the Table 3. The
total sample was 3352 women [control n =1549 and in- Nutrition interventions characteristics
tervention n=1803] and international [United States There was a wide variety of nutrition and physical activi-
18–24 25–27
(n=7), Australia (n=3), United Kingdom ty interventions . For nutrition, there were three main cat-
28,29 30–33 34 35
(n=2), Iran (n=4), Turkey (n=1), Egypt (n=1), egories: 1) overall diet, 2) on specific micronutrients and
36–39 40 41
Taiwan (n=4), Japan (n=1), China (n=1) and India 3) specific food type. For overall diet modification in-
42
(n=1) ]. All were apparently healthy postpartum women terventions, two were targetted for maternal weight-loss
39
without any childbirth complication, recruited as early as by individualised dietary with either education plans or
Interventions on postpartum depression 665
65
Figure 1. Summary of the selection of publications.
24
social cognitive theory-based internet intervention, with groups; 1) coaching and motivational health promotion
19,23,24,28,29,39
depressive symptoms as a secondary outcome. On the techniques; 2) relaxation and breathing exer-
23 35 21,25,26
other hand, Surkan et al, with a primary focus on de- cises; 3) walking; 4) aerobic and/or yoga and/or
36,37,40 27,42
pressive symptoms, incorporated key messages such as Pilates; 5) cardiovascular and strength and; 6)
limiting red meat to three or fewer servings per week. resistance or more intense exercise following the postpar-
20,34
Intervention with specific micronutrients has been vari- tum period. Intervention durations varied between 1 to
30 20,25-27,34-37,40,42
ously with supplementary vitamin D, vitamin D and 4 months for most studies (n=10), 6 months
31 22 19,28,39
calcium, tryptophan and tyrosine and zinc and magne- in three studies, and up to 12 months in four stud-
18 21,23,24,29
sium targetting depressive symptoms. Interventions ies. Meanwhile, the session time duration was
22
lasted from three days (n=1), to two to three weeks reciprocal with session frequency in a week, where short-
41,43 18,31-33 19,34
(n=2), one to two months in most studies (n=4), er sessions were more frequent and longer sessions
30,39 24,47 27,36,42
six months (n=2) and as long as 12 months (n=2). were less frequent. This was evident with session
27,36,42
The supplement dosage average about 1 capsule per frequency from one session for 60 minutes, to two
18,22,30,32 31 21,29,35,37
day, or fortnightly. Specific foods used have sessions for 15 to 45 minutes, four sessions for 90
43 41 33 40
included chamomile tea, magnolia tea and saffron to minutes each and five sessions for at least 30 minutes
19,34,47 28
enhance mood and prevent depressive symptoms. The each. However, Forsyth et al recommended 150
chamomile and magnolia teas were prescribed as one cup min/week of moderate-intensity exercise without guid-
28,30 25,26
per day, whereas the saffron capsule was consumed ance about frequency. Similarly, Teychenne et al
33
twice daily. encouraged participants to set a self achievable goal and
gradually increase it according to progress, without refer-
Physical activity interventions characteristics ence to duration or frequency.
Physical activity interventions were classified into six
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