Effectiveness of Lifestyle Modification on Reproductive Health among Young Women: An Integrative Review

Background: The present review focuses on the effectiveness of lifestyle modification on reproductive health among young women. Obesity causes various physical and psychological health risks in women’s reproductive health and overweight, obesity are increasing and have become an epidemic worldwide. 
Objective: This article investigated the outcome of a lifestyle modification package on the reproductive health of young obese and overweight women. 
Methods: The literature published in English from 2010 to 2020 was reviewed using PRISMA guidelines. Scientific articles were searched in the electronic data base (Scopus, Medline, Google scholar, and PubMed central) on the lifestyle modification on reproductive health. 
Results: After reviewing the literature, it showed that the outcome of lifestyle modification had improved the reproductive health of women in infertile women in many ways. 
Conclusion: The review highlights the need for specific interventional studies on reproductive health which can improve the health of young women. 


INTRODUCTION
Obesity, a serious health problem, is a widespread affliction among women of reproductive age. Obesity and overweight refer to an abnormal and excessive fat deposition that harms the body's health. The World Health Organization (WHO) defines overweight as having a body mass index (BMI) of equal to or more than 25 kg/m2, while obesity is defined as having a BMI of equal to or greater than 30 kg/m2 [1].
Obesity causes a slew of issues, including social, psychological, demographic, and health issues.
It has been associated with elevate health risks like diabetes, hypertension, coronary heart disease, and osteoarthritis, as well as numerous cancers like endometrial, breast, and colon cancers. Obesity has also been linked to reproductive issues, particularly in women. It's linked to anovulation, menstrual irregularities, infertility, assisted reproduction issues, miscarriage, and poor pregnancy outcomes [1].
Fedorcsák, P., Storeng, et al., 2000 discovered that greater peripheral aromatization of androgens to estrogens affects gonadotropin production in obese women. Hyperandrogenemia is caused by insulin resistance and hyperinsulinemia in obese women. Leptin levels rise while sex hormone-binding globulin (SHBG), growth hormone (GH), and insulin-like growth factor binding proteins (IGFBP) levels fall. As a result, the hypothalamic-pituitary-gonadal (HPG) axis' neuro-regulation deteriorates. Impaired ovulatory function and, as a result, reproductive health could be explained by these changes [2].
Lifestyle factors are changeable aspects of one's life that can have an impact on one's general health and well-being. Lifestyle factors such as age at which a woman starts a family, weight, nutrition, exercise, stress, occupational and environmental exposure can all have a significant impact on a woman's reproductive health. Other factors that have a negative impact on reproductive health include illicit drug usage, cigarette smoking, caffeine consumption, and alcohol consumption Sharma, Biedenharn, Fedor, & Agarwal [3].  [5].
Another advised lifestyle change technique is a portion regulated diet with a defined portion of protein and a liquid diet. Obesity treatment has been found to be particularly effective when using a glycemic load diet with meal replacements such as liquid shakes and meal bars.
Physical activity, which is another way to change your lifestyle, appears to be linked to significant weight loss and long-term weight management. Physical activity lowers blood pressure and cholesterol levels while also improving glucose tolerance. Another significant aspect of lifestyle change is behavior therapy, which assists obese people in developing ideas and procedures for changing their eating, physical activity, and thinking behaviors that contribute to their weight gain. Self-monitoring is a critical component of weight loss. Frequent monitoring is a key predictor of both short and long-term weight loss Wadden, Webb, Moran, & Bailer [4].
The fact that there is evidence to support the benefits of lifestyle adjustment in the treatment of obesity and overweight, As a result, the goal of this integrative review is to assess the impact of lifestyle changes on reproductive health in young overweight and obese women. This literature will be an added value to the evidence based literature which will help in improving the best health care practice of overweight and obese women in the reproductive age group.

METHODS
Integrative review of literature was done through a systematic process in an attempt to understand the outcome of the lifestyle modification package on reproductive health among obese young women. With the help of existing available qualitative and quantitative literature, an integrative review method was adopted. A search of the databases Scopus , Pubmed, Google Scholar, MedLine was done. The most effective data on lifestyle modification was selected. The following keywords: Life style modification, Obesity, Overweight, Menstrual cycle, PCOD, Reproductive health, Sexual function, Fertility rates, Weight management, Exercise, Activity, and Diet were used in different combinations to identify the eligible article.
A total of 533 articles were obtained through electronic search engines. After removing the duplicates, 176 articles were available for further screening. Of these, 146 articles were removed because they did not meet the eligible population. After screening the full text of the remaining 30 articles, although lifestyle modification studies apart from reproductive health were in many articles, those were rejected to conserve the main focus of lifestyle modification on reproductive health. Finally, a total of 8 articles were included in the review.
These articles were hand searched and those with general information, commentary, speech/lecture, biography and instructional material/guideline were excluded. Although non relevant articles were rejected. The article which provided complete information was excluded. The use of limiters such as the timeframe from January 2010 to December 30, 2020. Articles published before 2010 were excluded. English language, peer-reviewed journals, and nursing reduced the number to 8. All articles were further analyzed based on the availability of keywords Life style modification, Obesity, Overweight, Menstrual cycle, PCOD, Reproductive health, Sexual function, Fertility rates, Weight management, Exercise, Activity, and Diet. This resulted in 8 articles for the analysis. [Table 1] Through the whole process, the authors screened the titles and the abstract of each relevant review at the first stage after the rejection of copying and in the second stage, the author assessed the full relevant texted articles for eligibility and disagreement was settled by agreement. The author independently carried out the data extraction. In the third stage, the author screened out the relevant data from the articles and mingled it into an article review matrix.
The narrative analysis was done to interpret the text in this article as only limited literature was available to generate the evidence of a lifestyle modification package on reproductive health in obesity.

RESULT
The detailed information of the articles analyzed through narrative analysis is appended in table -1, Article Review Matrix. The outcome variables analyzed in this article included were sexual function, fertility rate improvement in irregular menstrual cycle and weight management. The most common intervention in lifestyle modification was diet and exercise for all the studies. In the review matrix, a total of 8 articles were taken.

Sexual Function
Wekker et al. conducted a study on lifestyle intervention which shows improvement in sexual function of women with obesity and infertility. The total time was 6 months and the intervention targeted physical activity, diet and behavior modification. As a result, women reduced 5-10% in weight or a reduction in BMI below 29 kg/m 2 within the intervention period. The result showed the total 'sexual function' score (96.514.2 vs. 91.412.8; 95% CI 0.84 to 9.35) compared to the control group (n = 72) indicated that lifestyle interventions can contribute to better long-term sexual function in women who are at greater risk of sexual problems [6].

Fertility Rate
Van Elten TM, Karsten MDA et al., 2019 conducted a study for 6 months to see the effect of a preconception lifestyle in obese infertile women on diet and physical activity. In another study, a 6 month lifestyle intervention program combined with diet, physical activity and behavioral modification plan resulted in weight loss and reduced energy intake [7]. (Karsten et al., 2019) conducted a study, on 6 month lifestyle intervention program combined with diet, physical activity and behavioral modification plan was implemented aiming at 5-10% weight loss. Women with previous dietetic support lost weight during the intervention period and women with higher self-efficacy reduced energy intake. The higher levels of physical activity were associated with a higher number of daily steps and on completion of the lifestyle intervention program; the weight loss could be noticed [8]. Secondary analysis of a multicenter RCT reported that anovulatory women after receiving lif intervention had more natural conceptions than ovulatory women Van Oers et al.
[9]. 216 behavioral modification plan resulted in weight loss and reduced energy intake [7]. (Karsten et conducted a study, on 6 month lifestyle intervention program combined with diet, physical activity and behavioral modification plan 10% weight loss. Women with previous dietetic support lost weight during the intervention period and women with efficacy reduced energy intake. The physical activity were associated with a higher number of daily steps and on completion of the lifestyle intervention program; the weight loss could be noticed [8]. Secondary analysis of a multicenter RCT reported that anovulatory women after receiving lifestyle intervention had more natural conceptions than

Improvement In Irregular Menstrual
A lifestyle modification program implemented for one year among women with PCOS resulted in an increased number of regular menstrual cycles in women of the study group. In addition, 58.5% ing regularly compared to none in p (Marzouk, Nabil, & Senna either a 12-week intervention (n = 27); or a control group (n = 22) who received recommendations for weight loss and the same printed material as the intervention. Anthropometric and reproductive parameters were measured at baseline and at 12 weeks. location : setting : Design: randomized controlled trial Duration: 12 weeks Sample: Forty-nine obese women, aged ≤37 years, intervention (n = 27) consisting of a very-low-energy diet for the initial 6 weeks followed by a hypocaloric diet, combined with a weekly group multidisciplinary programme; control group (n = 22) who received recommendations for weight loss and the same printed material as the intervention initial 6 weeks followed by a hypocaloric diet, combined with a weekly group multidisciplinary programme of exercise and behavioural components.

DISCUSSION
The Author identified various lifestyle modifications and their effect on reproductive health. In which five of the included studies were Multicenter randomized controlled trials, one quasi experimental design and two used randomized controlled trials. The participants were young women (18-39year) whose reproductive health in terms of PCOS, infertility and menstrual cycle was assessed before and after lifestyle modification intervention. Sample sizes varied. The participants were exposed to life style modification interventions in which dietary modification, exercises and behavior therapy were primarily used interventions. The time period of interventions varied in all studies, but in 7 studies the time period was 6 month and in one study the time period was 1 year. The Self-Administered scale, Rotterdam Scale for PCOS and likert type scales were used to evaluate reproductive health. None of the investigators has mentioned any specific exercises which could yield the best possible results in terms of improvement of reproductive health. Most of the evidence shows that lifestyle modification interventions, both dietary modification and physical exercises, proved to be effective in improving the overall reproductive health of young women.
Our search is limited to examining the studies relevant to only young women and adolescents below 18 years were not studied. The finding of this study cannot be generalized to all women population. Also, the search was restricted to studies published in the English language, and we have excluded 3 of the similar studies in other languages; therefore, it is possible that additional studies might present different findings. Also, there is a big challenge to finding similar studies because of very limited studies available on lifestyle modification on reproductive health. We included all the best possible studies to the best of our knowledge. We have included the studies from 2010 onwards in the review, but there were many similar studies which may have been overlooked. We could not conduct a meta analysis because the optional statistical analysis differed across the studies. Studies in this review analysis showed that lifestyle modification is the best and cost-effective treatment in all group women. Therefore, the authors recommend that lifestyle intervention should be a part of the nurses' role while caring for overweight and obese women. In addition, adolescent girls must be targeted at an early stage to prevent them from developing obesity to have better reproductive health.

CONCLUSION
The literature has clearly identified a series of advantages of the lifestyle modification package and its impact on young women's reproductive health. Lifestyle modification has the potential to improve reproductive health, which raises a number of health issues in young women and for young women it's a good opportunity for primary prevention to protect themselves from reproductive health problems. This will help and minimize young women from costly and invasive treatment.

LIMITATION
The investigator reviewed and summarized the literature pertaining to the effectiveness of lifestyle modification interventions on reproductive health among young women, although the results would vary as very limited literature is available.

PRIORITIES FOR FUTURE RESEARCH
Therefore, the authors would recommend a study on structured lifestyle modification for obesity and reproductive health. Future research could be directed towards reproductive health.

CONSENT
It's not applicable.

ETHICAL APPROVAL
It's not applicable.