A lifestyle intervention of weight-gain restriction: diet and exercise in obese women with gestational diabetes mellitus

A Primary Care-Based Early Childhood Nutrition Intervention: Evaluation of a Pilot Program Serving Low-Income Hispanic Women

Nutrition in early childhood can significantly impact physical and mental health outcomes for children. However, research on broadly defined pre/postnatal nutrition interventions is sparse. The present study is a process and outcome evaluation of a primary care-based nutrition intervention targeting low-income Hispanic women. Pregnant women enrolled in the program were in their first trimester and received services through their 6-month well child check. The program provided vouchers for fruits and vegetables from the local farmers' market, nutrition classes, cooking classes, and lactation counseling. We conducted a prospective study of program participants (n = 32) and a comparable group of women for whom the program was not available (n = 29). Panel survey data measured maternal diet, exercise, stress, depression, social support, infant feeding practices, and demographics. Outcome measures obtained from medical records included pregnancy weight gain, infant weight at 6 and 12 months, and infant development at 9 months. Findings reveal that the program was not associated with infant weights. However, despite similar profiles at baseline, women in the intervention group were more likely than women in the comparison group to have significant improvements in diet, exercise, and depression (p ≤ .05). In addition, participants were more likely to breastfeed (p = .07) and their infants were more likely to pass the ages and stages developmental screen (p = .06) than women in the comparison group. The study was limited by a lack of random assignment and small samples. However, the breadth and size of the effects suggest pre/postnatal nutrition interventions integrated into primary care warrant additional investigation.

Exercise in pregnancies complicated by obesity: achieving benefits and overcoming barriers

An increasing number of women are entering pregnancy in an overweight or obese state. Obese women and their offspring are at increased risk of adverse perinatal outcomes, which may be improved by regular moderate-intensity antenatal exercise. Current guidelines recommend that all pregnant women without contraindications engage in ≥30 minutes of moderate-intensity exercise on a daily basis. However, obese women are usually less physically active and tend to further reduce activity levels during pregnancy. This commentary summarizes the potential short- and long-term benefits of antenatal exercise in obese pregnant women, highlights the challenges they face, and discusses means of improving their exercise levels. In addition, we make recommendations on exercise prescription for pregnancies complicated by obesity.

'Fit Moms/Mamás Activas' internet-based weight control program with group support to reduce postpartum weight retention in low-income women: study protocol for a randomized controlled trial

BACKGROUND

High postpartum weight retention is a strong independent risk factor for lifetime obesity, cardiovascular disease, and type 2 diabetes in women. Interventions to promote postpartum weight loss have met with some success but have been limited by high attrition. Internet-based treatment has the potential to overcome this barrier and reduce postpartum weight retention, but no study has evaluated the effects of an internet-based program to prevent high postpartum weight retention in women.

METHODS/DESIGN

Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m(2) or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures.

DISCUSSION

Fit Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (identifier: NCT01408147 ) on 29 July 2011.

Treating diabetes during pregnancy

INTRODUCTION

Gestational diabetes mellitus (GDM), defined as glucose intolerance with first recognition or onset during pregnancy, is steadily rising in prevalence. GDM affects ∼ 3 - 5% of pregnancies in the US and is associated with significant adverse perinatal and maternal outcomes. Diagnosing and treating GDM early in pregnancy is of utmost importance as it can prevent poor outcomes such as macrosomia, shoulder dystocia and obstetric complications.

AREAS COVERED

This review describes the importance of treating GDM and the various available interventions for glycemic control in women with GDM, including the latest evidence regarding pharmacological treatments and specifically anti-hyperglycemic agents. It deals with timing of pharmacological treatments, recommended doses and what pharmacological agent should be used.

EXPERT OPINION

Unless diagnosed late during pregnancy, a stepwise approach is the best way to treat GDM, beginning with diet and exercise and proceeding to pharmacological interventions if failure occurred. Although insulin is the dominant treatment, the use of anti-hyperglycemic agents such as glyburide and metformin in treating GDM has gained popularity and consideration should be made using these agents as first-line pharmacological treatment. Anti-hyperglycemic agents do not require frequent monitoring or injections and may therefore appeal more to patients. Further studies are needed regarding long-acting insulin and other anti-hyperglycemic agents such as thiazolidinediones, as well as identifying treatment options more specific to an individual based on risk factors and other variables predicting treatment outcomes in GDM.

Simple lifestyle recommendations and the outcomes of gestational diabetes. A 2 × 2 factorial randomized trial

The benefits of exercise and behavioural recommendations in gestational diabetes mellitus (GDM) are controversial. In a randomized trial with a 2 × 2 factorial design, we examined the effect of exercise and behavioural recommendations on metabolic variables, and maternal/neonatal outcomes in 200 GDM patients. All women were given the same diet: group D received dietary recommendations only; group E was advised to briskly walk 20-min/day; group B received behavioural dietary recommendations; group BE was prescribed the same as B + E. Dietary habits improved in all groups. In a multivariable regression model, fasting glucose did not change. Exercise, but not behavioural recommendations, was associated with the reduction of postprandial glucose (p < 0001), glycated haemoglobin (HbA1c; p < 0.001), triglycerides (p = 0.02) and C-reactive protein (CRP; p < 0.001) and reduced any maternal/neonatal complications (OR = 0.50; 95%CI=0.28-0.89;p = 0.02). In GDM patients a simple exercise programme reduced maternal postprandial glucose, HbA1c, CRP, triglycerides and any maternal/neonatal complications, but not fasting glucose values.

The role of exercise in reducing the risks of gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy and is particularly prevalent among obese women. Both GDM and obesity confer significant comorbidities for the mother and her offspring, including perinatal complications, excessive fetal growth and long-term risks for maternal and offspring obesity and diabetes. Exercise has well-documented health benefits and reduces peripheral insulin resistance in nonpregnant individuals, a major risk factor for the development of diabetes. Observational studies conducted in large population-based cohorts suggest that women who are the most active before pregnancy are less insulin-resistant in late pregnancy and have lower rates of GDM. This article will review the evidence supporting a role for exercise in the prevention of GDM, the management of glycemic control in women with established GDM, and the reduction of GDM-associated maternal and offspring health consequences. Wherever possible, the discussion will focus on studies carried out on obese women. However, there are many areas where strong evidence is lacking in obese populations, and it may be inferred from similar studies performed in normal weight pregnant women.

The potential value of sleep hygiene for a healthy pregnancy: a brief review

The quality of the intrauterine environment influences maternal-fetal health and also offspring predisposition to obesity and cardiometabolic disease later in life. Several determinants, including but not limited to pregravid obesity and excessive gestational weight gain, alter the developmental milieu, fetal growth, and child obesity risk. However, the role of sleep and its relationship to healthy pregnancy is not fully established. Given the host of psychosocial and physiological complications associated with childhood obesity, targeting the gestational period is purported to be an opportune time for preventive intervention. Many longitudinal studies suggest that short sleep duration is a risk factor for the development of impaired glycemia and obesity. However, there is a dearth of information concerning the role of sleep hygiene and its role in a healthy pregnancy. Reports note disrupted and poorer quality of sleep during gestation and highlight an association between reduced sleep and risk of gestational diabetes mellitus. Given the lack of well-designed human trials assessing the value of sleep and healthy pregnancy outcomes, this review summarizes current evidence which suggests that incorporating sleep recommendations and utilizing time management strategies that encourage a healthful night 's sleep may improve the health of the mom and the baby.

Supervised exercise-based intervention to prevent excessive gestational weight gain: a randomized controlled trial

OBJECTIVE

To study the effect on maternal weight gain of a supervised light- to moderate-intensity exercise-based intervention performed from the ninth week of pregnancy.

PARTICIPANTS AND METHODS

A total of 962 healthy pregnant women were randomly assigned to a standard care or exercise intervention group conducted between September 1, 2007, and January 31, 2011. The intervention included light- to moderate-intensity aerobic and resistance exercises performed 3 days a week (50-55 minutes per session). Excessive gestational weight gain was calculated on the basis of the 2009 Institute of Medicine (IOM) recommendations. Gestational body weight gain was calculated on the basis of the weight measured at the first prenatal visit (fifth to sixth weeks of gestation) and weight measured at the last visit to the clinic before delivery. Women were categorized into normal weight or overweight or obese.

RESULTS

Women in the intervention group gained less weight (adjusted mean difference, 1.039 kg; 95% CI, 0.534-1.545 kg; P<.001) and were less likely to gain weight above the IOM recommendations (odds ratio, 0.625; 95% CI, 0.461-0.847) compared with those in the standard care group. The main treatment effects according to body mass index category were that normal weight women in the intervention group gained less weight (adjusted mean difference, 1.393 kg; 95% CI, 0.813-1.972 kg; P<.001) and were less likely to gain weight above the IOM recommendations (odds ratio, 0.508; 95% CI, 0.334-0.774) than normal weight women who received standard care. No significant treatment effect was observed in overweight or obese women.

CONCLUSION

Supervised exercise of light to moderate intensity can be used to prevent excessive gestational weight gain, especially in normal weight women.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01790347.

Diet and carbohydrate food knowledge of multi-ethnic women: a comparative analysis of pregnant women with and without Gestational Diabetes Mellitus

Background

Diet therapy is the cornerstone for the management of gestational diabetes mellitus (GDM). Carbohydrate is the primary nutrient affecting postprandial blood glucose levels. Hence, knowledge of food containing carbohydrates can assist women with GDM optimize glycemic control. Despite that, there is a paucity of research on carbohydrate-related knowledge of women with GDM. The United Arab Emirates (UAE) has one of the highest prevalence of diabetes (19.2%) in the world. This study compared diet and knowledge of carbohydrate-containing foods among pregnant women with and without GDM in the UAE.

Methods

The sample consisted of multi-ethnic women with GDM (n = 94) and a control group of healthy pregnant women (n = 90) attending prenatal clinics in three hospitals in Al Ain, UAE. Data were collected using a questionnaire and a 24-hour recall. Knowledge of food sources of carbohydrate, dietary patterns, and nutrient intakes of the two groups were compared.

Results

There were no significant differences in the mean knowledge score of food sources of carbohydrate between women with GDM and that of pregnant women without GDM. Similarly, there were no significant differences in energy and nutrient intakes between the two groups with the exception of percent energy from protein. Women with GDM reported significantly lower intake of fruits and fruit juices (P = 0.012) and higher consumption of milk and yogurt (P = 0.004) compared to that of women without GDM. Twenty-two percent of women with GDM indicated they never visited a dietitian for counseling while 65% reported they visited a dietitian only once or twice during the pregnancy. Predictors of carbohydrate knowledge score were perceived knowledge of diet and GDM and parity among women with GDM and parity and educational level among those without GDM.

Conclusion

The results of the study highlight the urgent need to provide nutrition education for women with GDM in the UAE.

The important role of physical activity in the prevention and management of gestational diabetes mellitus

The actual pathophysiology behind gestational diabetes mellitus (GDM) is still unclear, but a deterioration in insulin resistance beyond that induced by pregnancy, combined with beta cell dysfunction, plays a key role. Interventions that help improve glucose tolerance by attenuating pregnancy-induced insulin resistance or achieve glycaemic control may therefore help in preventing and managing GDM. In non-pregnant populations, physical activity has been associated with an improvement in glucose homeostasis and insulin sensitivity and a risk reduction for type 2 diabetes mellitus (T2DM) and is a cornerstone for T2DM treatment. However, there is still controversy regarding the benefits of physical activity in preventing and managing GDM. The objective of this review is therefore to provide a comprehensive overview of the effect of prenatal physical activity-based interventions on (1) glucose tolerance, insulin sensitivity and GDM prevention and (2) glycaemic control and insulin use in GDM women. On the basis of the available literature, there is a lack of consistent evidence regarding the benefits of physical activity on improving glucose tolerance and insulin sensitivity and preventing GDM. However, it appears that physical activity may help to achieve good glycaemic control and limit insulin use in GDM women. Compliance appears to be a major problem in physical activity-based intervention studies aimed at GDM prevention. Rigorous scientific research is still required to make an informed decision about the role of physical activity in the prevention and management of GDM and to develop evidence-based physical activity guidelines for GDM prevention and management.

Effects of a weight-gain restriction programme for obese pregnant women on sickness absence and pregnancy benefits

OBJECTIVE

To evaluate the effect of a weight-gain restriction programme for obese pregnant women on sickness absence days and pregnancy benefit days during pregnancy and postpartum.

DESIGN

A prospective, controlled intervention study. The Swedish Social Security Agency's records were utilized to compile sickness absence and pregnancy benefit information.

SETTING

Antenatal care clinics in the south-east of Sweden.

SUBJECTS

One hundred fifty-five obese pregnant women who participated in a weight restriction program with weekly structured motivational and behavioural talks combined with aqua-aerobics during pregnancy. A total of 193 obese pregnant women with no intervention served as controls.

MAIN OUTCOME MEASURES

Sickness absence benefits and pregnancy benefits expressed as a percentage.

RESULTS

On average women in the intervention group had 76.68 total full days of sickness absence benefit compared with 53.09 days in the control group. Total full days of pregnancy benefits were 39.66% days and 41.41% for the intervention and control groups respectively. For the women who were on sick leave there were no differences between the groups in the amount of days taken.

CONCLUSIONS

Given the complexity of factors that have an influence on sickness absence leave, it is possible that programmes that do not address the influence of social aspects and attitudes towards sickness absence have limited effect.

Guidelines and interventions for obesity during pregnancy

BACKGROUND

Obesity is a growing worldwide epidemic among women of reproductive age, including pregnant women. The increased prevalence of obesity has been accompanied by an increase in gestational weight gain. Maternal obesity has deleterious consequences for both mother and child.

OBJECTIVE

To review the recent guidelines from the National Institute for Health and Clinical Excellence and the Institute of Medicine regarding gestational weight gain and interventions to treat obesity during pregnancy.

METHODS

Guidelines on gestational weight gain from these organizations, as well as reports of gestational weight gain in the published literature, are summarized.

RESULTS

Many normal and overweight parturients exceed the recommendations in the guidelines, which may contribute to postpartum obesity.

CONCLUSION

Lifestyle changes, including dieting and increased activity, may help to limit excessive gestational weight gain but the optimal strategy remains unclear.

The potential impact of physical activity during pregnancy on maternal and neonatal outcomes

INTRODUCTION

Pregnancy is a critical period of body weight regulation. Maternal obesity and excessive gestational weight gain have become increasingly common and contribute to poor obstetrical outcomes for mother and baby. Regular participation in physical activity may improve risk profiles in pregnant women.

PURPOSE AND METHODS

Our objectives were to provide an overview of maternal-fetal exercise physiology, summarize current evidence on the effects of physical activity during pregnancy on maternal-fetal outcomes, and review the most recent clinical practice guidelines. In addition, we summarize the findings in the context of the current obesity epidemic and discuss implications for clinical practice. A literature review was completed in which we queried OVID (Medline), EMBASE, and PSYCHINFO databases with title words "exercise or physical activity" and "pregnancy or gestation" from 1950 to March 1, 2010. A total of 212 articles were selected for review.

RECOMMENDATIONS

Care providers should recommend physical activity to most pregnant women (i.e., those without contraindications) and view participation as a safe and beneficial component of a healthy pregnancy.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After participating in this CME activity, physicians should be better able to classify the potential impact of physical activity on maternal glycemic control and fetal growth outcomes. Assess maternal lifestyle and provide recommendations on appropriate gestational weight gain, evaluate pregnant women for contraindications to physical activity participation, make individualized recommendations for exercise participation, and educate patients on the merits of physical activity for health benefit.

Feasibility and acceptability of a midwife-led intervention programme called 'Eat Well Keep Active' to encourage a healthy lifestyle in pregnancy

BACKGROUND

Eating a diet that is high in fat and sugar and having a sedentary lifestyle during pregnancy is understood to increase the risk of excessive gestational weight gain and obesity following the birth of the baby. However, there are no clinical guidelines in the UK on what is considered to be appropriate gestational weight gain. Indeed, clinical recommendations discourage the routine re-weighing of pregnant women, stating instead that women should be advised regarding their diet and activity levels, in order to prevent excessive weight gain. Pregnancy is seen as a time when many women may have an increased motivation to improve their lifestyle behaviours for the benefit of the fetus. However, it is evident that many women have difficulty in both maintaining a healthy balanced diet and remaining active through pregnancy. It would seem that midwives may be ideally placed to assist women to make and maintain healthier lifestyle choices during pregnancy.

METHODS/DESIGN

This study will look at the feasibility and acceptability of a newly devised intervention programme called 'Eat Well Keep Active'. Participants will complete a questionnaire prior to the programme to obtain baseline data on food frequency, physical activity and to gauge their perception of personal ability to improve/maintain healthy lifestyle. The programme comprises client centred techniques; motivational interviewing and goal setting delivered early in pregnancy (12-16 weeks) with the aim of supporting a healthy well balanced diet and either continuing or commencing appropriate levels of physical activity. Participants will then be followed up six weeks following the intervention with a one-to-one interview, and a further brief questionnaire. The interview will provide preliminary data regarding perceived effectiveness and acceptability of the 'Eat Well Keep Active' programme whilst the questionnaire will provide data regarding changes in the confidence of participants to lead a healthy lifestyle.

DISCUSSION

There is an identified need for effective interventions that assist pregnant women in managing their diet and activity levels. Results from this study will demonstrate whether women find this programme of intervention, designed to elicit healthy behaviours in pregnancy, acceptable and whether they perceive it to be effective.

Addressing obesity in pregnancy: what do obstetric providers recommend?

OBJECTIVE

Maternal obesity is associated with adverse pregnancy outcomes. To improve outcomes, obstetric providers must effectively evaluate and manage their obese pregnant patients. We sought to determine the knowledge, attitudes, and practice patterns of obstetric providers regarding obesity in pregnancy.

METHODS

In 2007-2008, we surveyed 58 practicing obstetricians, nurse practitioners, and certified nurse-midwives at a multispecialty practice in Massachusetts. We administered a 26-item questionnaire that included provider self-reported weight, sociodemographic characteristics, knowledge, attitudes, and management practices. We created an 8-point score for adherence to 8 practices recommended by the American College of Obstetricians and Gynecologists (ACOG) for the management of obese pregnant women.

RESULTS

Among the respondents, 37% did not correctly report the minimum body mass index (BMI) for diagnosing obesity, and most reported advising gestational weight gains that were discordant with 1990 Institute of Medicine (IOM) guidelines, especially for obese women (71%). The majority of respondents almost always recommended a range of weight gain (74%), advised regular physical activity (74%), or discussed diet (64%) with obese mothers, but few routinely ordered glucose tolerance testing during the first trimester (26%), planned anesthesia referrals (3%), or referred patients to a nutritionist (14%). Mean guideline adherence score was 3.4 (SD 1.9, range 0-8). Provider confidence (beta = 1.0, p = 0.05) and body satisfaction (beta = 1.5, p = 0.02) were independent predictors of higher guideline adherence scores.

CONCLUSIONS

Few obstetric providers were fully compliant with clinical practice recommendations, defined obesity correctly, or recommended weight gains concordant with IOM guidelines. Provider personal factors were the strongest correlates of self-reported management practices. Our findings suggest a need for more education around BMI definitions and weight gain guidelines, along with strategies to address provider personal factors, such as confidence and body satisfaction, that may be important predictors of adherence to recommendations for managing obese pregnant women.

Can we modify the intrauterine environment to halt the intergenerational cycle of obesity?

Child obesity is a global epidemic whose development is rooted in complex and multi-factorial interactions. Once established, obesity is difficult to reverse and epidemiological, animal model, and experimental studies have provided strong evidence implicating the intrauterine environment in downstream obesity. This review focuses on the interplay between maternal obesity, gestational weight gain and lifestyle behaviours, which may act independently or in combination, to perpetuate the intergenerational cycle of obesity. The gestational period, is a crucial time of growth, development and physiological change in mother and child. This provides a window of opportunity for intervention via maternal nutrition and/or physical activity that may induce beneficial physiological alternations in the fetus that are mediated through favourable adaptations to in utero environmental stimuli. Evidence in the emerging field of epigenetics suggests that chronic, sub-clinical perturbations during pregnancy may affect fetal phenotype and long-term human data from ongoing randomized controlled trials will further aid in establishing the science behind ones predisposition to positive energy balance.

Reducing excessive gestational weight gain: lessons from the weight control literature and avenues for future research

Excessive gestational weight gain is a prevalent problem and an independent predictor of future obesity in both mothers and offspring. Intervention research to prevent excessive gestational weight gain is still in its infancy but results to date have been quite modest. Research in weight control outside of pregnancy over the past 30 years has been more robust and identified several key components of effective programs, including use of caloric restriction, daily diet self-monitoring, self-weighing, behavior therapy and ongoing patient-provider contact. The aim of this article is to summarize intervention components shown to be effective in promoting successful weight control outside of pregnancy and explore potential applications in pregnancy. Available evidence suggests that the strategies shown to be effective for weight control outside of pregnancy may also promote better weight control in pregnancy, but several lines for future investigation remain.

Gestational Diabetes

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and is strongly related to subsequent risk of type 2 diabetes. The epidemics of obesity and diabetes and the increasing incidence of GDM in recent years highlight the importance of preventing GDM among women at high risk to avoid the associated short- and long-term adverse health outcomes for both mothers and their offspring. Indeed, women may be more likely to adopt healthy lifestyle habits during pregnancy and maintain these habits into the postpartum period. Although there is substantial evidence that targeting at-risk groups for type 2 diabetes prevention is effective if lifestyle changes are made, relatively little attention has been paid to the prevention of GDM. Therefore, the objective of this article is to review the scientific evidence regarding the association between modifiable risk factors and GDM; discuss how lifestyle interventions, including weight management through diet and exercise could be successful in reducing the risk for GDM; and provide recommendations for future lifestyle intervention programs with a focus on translation and dissemination of research findings.

[Physical exercise, weight gain, and perinatal outcomes in overweight and obese pregnant women: a systematic review of clinical trials]

This study aimed to evaluate the effects of exercise on weight gain and perinatal outcomes among overweight and obese pregnant women, through a systematic review in MEDLINE/PubMed, EMBASE, LILACS, and SciELO. We included ten clinical trials that evaluated the effectiveness of exercise with or without combined diet in the control of gestational weight gain. Three studies were randomized, and methodological quality was assessed using the CONSORT 2010 Checklist, but none met all the criteria. Four studies showed weight gain differences between groups. The majority (60%) of studies showed no differences in perinatal outcomes (mode of delivery, gestational age at birth, birth weight). In conclusion, few studies confirmed the positive effect of exercise in controlling weight gain during pregnancy, thus requiring more research in this direction. Regarding perinatal outcomes, mild to moderate exercise does not appear to be decisive for perinatal outcomes, and is safe for pregnant women with overweight and obesity.

Intergenerational cycle of obesity and diabetes: how can we reduce the burdens of these conditions on the health of future generations?

Prepregnancy overweight or obesity and excessive gestational weight gain have been associated with increased risk of maternal and neonatal complications. Moreover, offspring from obese women are more likely to develop obesity, diabetes mellitus, and cardiovascular diseases in their lifetime. Gestational diabetes mellitus (GDM) is one of the most common complications associated with obesity and appears to have a direct impact on the future metabolic health of the child. Fetal programming of metabolic function induced by obesity and GDM may have intergenerational effect and thus perpetuate the epidemic of cardiometabolic conditions. The present paper thus aims at discussing the impact of maternal obesity and GDM on the developmental programming of obesity and metabolic disorders in the offspring. The main interventions designed to reduce maternal obesity and GDM and their ability to break the vicious circle that perpetuates the transmission of obesity and metabolic conditions to the next generations are also addressed.

Diabetes gestacional: um algoritmo de tratamento multidisciplinar

O tratamento do diabetes gestacional é importante para evitar a morbimortalidade materno-fetal. O objetivo deste artigo é descrever o tratamento atualmente disponível para o manejo otimizado da hiperglicemia na gestação e sugerir um algoritmo de tratamento multidisciplinar. A terapia nutricional é a primeira opção de tratamento para as gestantes, e a prática de exercício físico leve a moderado deve ser estimulada na ausência de contraindicações obstétricas. O tratamento medicamentoso está recomendado quando os alvos glicêmicos não são atingidos ou na presença de crescimento fetal excessivo à ultrassonografia. O tratamento tradicional do diabetes gestacional é a insulinoterapia, embora mais recentemente a metformina venha sendo considerada uma opção segura e eficaz. A monitorização do tratamento é realizada com aferição da glicemia capilar e com avaliação da circunferência abdominal fetal por meio de ultrassonografia obstétrica a partir da 28ª semana de gestação.

Optimization of gestational weight gain in the obese gravida: a review

Because of the consistent association between gestational weight gain and birth weight (along with other maternal and child outcomes such as postpartum weight retention and child obesity), helping women avoid excessive weight gain during pregnancy should be an important objective of prenatal and preconceptional care. This article focuses on the updated Institute of Medicine gestational weight gain recommendations and measures directed at maintaining those guidelines and improving pregnancy outcome.

The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomised clinical trial

OBJECTIVE

To evaluate the effectiveness and safety of physical exercise in terms of maternal/perinatal outcomes and the perception of quality of life (QoL) in pregnant obese and overweight women.

DESIGN

A randomised controlled clinical trial.

SETTING

The Prenatal Outpatient Clinic of the Women's Integral Healthcare Centre (CAISM-UNICAMP) at the University of Campinas, Campinas, Brazil.

POPULATION

Eighty-two pregnant women (age ≥ 18 years; pre-gestational body mass index ≥ 26 kg/m(2) ; gestational age 14-24 weeks).

METHODS

Women were randomised into two groups: women in one group exercised under supervision and received home exercise counselling (the 'study group'; n = 40) and women in the other group followed the routine prenatal care programme (the 'control group'; n = 42).

MAIN OUTCOME MEASURES

Primary outcomes were gestational weight gain during the programme and excessive maternal weight gain. Secondary outcomes were increased arterial blood pressure, perinatal outcomes and QoL (WHOQOL-BREF).

RESULTS

In the study group, 47% of pregnant women had weight gains above the recommended limit, compared with 57% of women in the control group (P = 0.43). There was no difference in gestational weight gain between the groups. Overweight pregnant women who exercised gained less weight during the entire pregnancy (10.0 ± 1.7 kg versus 16.4 ± 3.9 kg, respectively; P = 0.001) and after entry into the study (5.9 ± 4.3 kg versus 11.9 ± 1.5 kg, respectively; P = 0.021) compared with women in the control group. Arterial blood pressure was similar between the groups over time. There was no difference in perinatal outcome or QoL.

CONCLUSIONS

The exercise programme was not associated with control of gestational weight gain in our sample as a whole, but was beneficial for lower gestational weight gain in overweight women. Exercise was not associated with adverse perinatal outcomes and did not affect variation in arterial blood pressure or the perception of QoL.

The association between gestational diabetes mellitus and recreational physical activity

We aimed to investigate the association of recreational physical activity before pregnancy with gestational diabetes mellitus (GDM). A cross-sectional study was performed using self-reported data from the Pregnancy Risk Assessment and Monitoring System. The study population included 1,052 self-reported GDM cases and 10,351 non-GDM controls. Recreational physical activity in the 3 months before pregnancy was recalled in postpartum structured interviews. Compared to women exercising less than 1 day per week, women who exercised >5 days per week in the 3 months before pregnancy had a 31% lower odds of GDM (adjusted odds ratio [aOR]: 0.69; 95% confidence interval [CI]: 0.46, 1.03). Women who exercised 1-4 days per week had a 7% lower odds of GDM (aOR: 0.93; 95%CI: 0.72, 1.19). We did not observe statistically significant associations between pre-pregnancy physical activity and GDM risk. However, the magnitude and direction of association are consistent with previous observational studies. These studies collectively suggest a role of physical activity in GDM prevention.

PPAR Action in Human Placental Development and Pregnancy and Its Complications

During pregnancy crucial anatomic, physiologic, and metabolic changes challenge the mother and the fetus. The placenta is a remarkable organ that allows the mother and the fetus to adapt to the new metabolic, immunologic, and angiogenic environment imposed by gestation. One of the physiologic systems that appears to have evolved to sustain this metabolic regulation is mediated by peroxisome proliferator-activated receptors (PPARs). In clinical pregnancy-specific disorders, including preeclampsia, gestational diabetes, and intrauterine growth restriction, aberrant regulation of components of the PPAR system parallels dysregulation of metabolism, inflammation and angiogenesis. This review summarizes current knowledge on the role of PPARs in regulating human trophoblast invasion, early placental development, and also in the physiology of clinical pregnancy and its complications. As increasingly indicated in the literature, pregnancy disorders, such as preeclampsia and gestational diabetes, represent potential targets for treatment with PPAR ligands. With the advent of more specific PPAR agonists that exhibit efficacy in ameliorating metabolic, inflammatory, and angiogenic disturbances, further studies of their application in pregnancy-related diseases are warranted.

An assessment of patient information channels and knowledge of physical activity and nutrition during pregnancy

BACKGROUND

Excessive weight gain during pregnancy increases the risk for obesity in mother and child. Healthy eating and physical activity may help prevent excessive gestational weight gain and minimize offspring risk of developing obesity, diabetes and cardiovascular disease. Our goal was to determine the information channels used by pregnant women to obtain information on nutrition and exercise.

METHODS

We collected information about their knowledge of physical activity and nutrition during pregnancy and assessed their satisfaction with this information to identify factors that may be improved upon when designing a behavioural intervention. An anonymous, voluntary questionnaire was completed by 147 pregnant women to identify the proportion who are currently receiving information about exercise from their care provider.

RESULTS

The primarily Caucasian sample (age: 30.9 ± 4.2, weeks gestation: 21.4 ± 9.4) completed the survey. A total of 86% are willing to participate in a lifestyle intervention trial. Personal health and the health of their child were cited as top reasons for participation. Most women were not informed as to the importance of appropriate pregnancy-specific energy intake or made aware of their own personal healthy gestational weight gain targets. A total of 63% report receiving some form of information on physical activity during pregnancy. Of those who do not, almost all (93%) would like to receive this information from a care provider. Overall, 88% of women consider it safe to exercise when pregnant.

DISCUSSION

Given their responses, nutrition and exercise information offered through a lifestyle intervention during pregnancy may increase healthy behaviours and warrants clinical investigation.

Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study

BACKGROUND

Excessive weight gain during pregnancy is a major risk factor for postpartum weight retention and future weight gain and obesity in women, but few adequately powered randomized controlled trials have examined the efficacy of a behavioral weight-control intervention during pregnancy.

OBJECTIVE

This study examined whether a behavioral intervention during pregnancy could decrease the proportion of women who exceeded the 1990 Institute of Medicine (IOM) recommendations for gestational weight gains and increase the proportion of women who returned to pregravid weights by 6 mo postpartum.

DESIGN

This study was a randomized, assessor-blind, controlled trial. Participants were pregnant (13.5 wk gestation), normal-weight (NW; n = 201) and overweight or obese (OW/OB; n = 200) women whose average age was 28.8 y. Participants were randomly assigned within the 1990 IOM weight category (NW compared with OW/OB) to standard care (n = 200) or to a behavioral intervention to prevent excessive gestational weight gain (n = 201). The intervention included one face-to-face visit; weekly mailed materials that promoted an appropriate weight gain, healthy eating, and exercise; individual graphs of weight gain; and telephone-based feedback. The retention at the 6-mo postpartum assessment was 82%.

RESULTS

Intent-to-treat analyses showed that the intervention, compared with standard care, decreased the percentage of NW women who exceeded IOM recommendations (40.2% compared with 52.1%; P = 0.003) and increased the percentages of NW and OW/OB women who returned to their pregravid weights or below by 6 mo postpartum (30.7% compared with 18.7%; P = 0.005).

CONCLUSION

A low-intensity behavioral intervention during pregnancy reduced excessive gestational weight gains in NW women and prevented postpartum weight retention in NW and OW/OB women. This trial was registered at clinicaltrials.gov as NCT01117961.

Practitioner advice and gestational weight gain

BACKGROUND

The purpose of this study was to investigate receipt of gestational weight gain advice in prenatal care and ideal and expected gestational weight gain outcomes for normal weight and overweight/obese women.

METHODS

This was a cross-sectional study of normal weight (n = 203) and overweight/obese (n = 198) women in early (<16 weeks) pregnancy.

RESULTS

Less than half of participants (41.7%) reported receiving weight gain advice from a practitioner. In multivariate models, pregravid weight status was not significantly related to receiving advice. However, women with lower income (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.77, p = 0.01), younger age (OR 0.93, 95% CI 0.87-0.99, p = 0.02), and multiparity (OR 0.49, 95% CI 0.28-0.87, p = 0.02) were least likely to report receiving advice. Among those receiving advice, most (85%) received accurate advice; however, overweight/obese women were more likely to be advised to overgain compared with normal weight women (22.2% vs. 2.3%, p = 0.0001). Overweight/obese women were also more likely than normal weight women to report ideal (OR 7.2, 95% CI 2.3-22.7, p = 0.001) and expected (OR 4.7, 95% CI 2.6-8.4, p = 0.0001) pregnancy weight gains above Institute of Medicine guidelines. Further, a consistent relationship was observed between higher ideal and expected weight gains and greater first trimester weight gain (p < 0.03).

CONCLUSIONS

Clinicians should be encouraged to provide timely and accurate advice to women about gestational weight gain. Interventions to promote healthy gestational weight gain may benefit from targeting women's beliefs about ideal and expected gestational weight gain.

Compliance with leisure-time physical activity recommendations in pregnant women

OBJECTIVE

The aim of this study was to identify the prevalence and factors associated with the performance of minimal beneficial leisure-time physical activity in the first half of pregnancy according to the criteria of the American College of Sport and Medicine (ACSM) and the American College of Obstetricians and Gynecologists (ACOG).

MATERIAL AND METHODS

This was a cross-sectional study carried out at the Maternal and Neonatal University Hospital in Granada, which services the whole population of the hospital reference area. We studied 1,175 healthy pregnant women aged over 18 years. Information about sociodemographics, lifestyles, obstetric antecedents and anthropometric variables were collected. The amount of leisure-time physical activity was quantified by assigning metabolic equivalents to each activity. The ACSM and ACOG criteria were used to define optimal physical activity in the first half of pregnancy. The frequency of compliance for both criteria was estimated. Multiple logistic regression models were fitted to study the factors associated with the recommendations.

RESULTS

Only 20.3% (95% confidence interval 15.50-26.10) of the women complied with ACOG criteria. More women complied with ACSM recommendations (70.8%, 95% confidence interval 67.5-73.8), which are less restrictive criteria. Women aged 30 years old or older and those with a university degree tended to devote more time to exercising according to both recommendations.

CONCLUSION

The prevalence of pregnant women who performed minimal beneficial leisure-time physical activity was lower with the dominant and more accepted criteria. It is necessary to encourage physical activity, mainly among those who are younger, and those with lower levels of educational attainment.

Interventions during pregnancy to reduce excessive gestational weight gain: a systematic review assessing current clinical evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system

BACKGROUND

  Excessive weight gain during pregnancy is common in developed countries and increases the risk of complications during pregnancy, delivery and the postpartum period, which can affect both maternal and fetal outcome. Interventions to reduce excessive gestational weight gain have previously not been systematically evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

OBJECTIVES

  To determine whether published trials of interventions to reduce excessive gestational weight gain are of sufficient quality and provide sufficient data to enable evidence-based recommendations to be developed for clinical practice in antenatal care.

SEARCH STRATEGY

  A literature search was conducted in the scientific databases PubMed, Cochrane Library, Cinhal and Pedro, and the reference lists of relevant articles were reviewed. The literature search was concluded on 15 August 2009.

SELECTION CRITERIA

  All randomised controlled trials (RCTs) were considered for inclusion. As the number of published RCTs was limited, we also considered for inclusion all nonrandomised intervention studies that included a control group. Systematic reviews were examined to identify additional original studies.

DATA COLLECTION AND ANALYSIS

  Two reviewers independently assessed the quality of the methods and results of all included articles. Extracted data were classified using the GRADE system.

MAIN RESULTS

  Four intervention studies with a randomised controlled design and four intervention trials with a nonrandomised controlled design met the inclusion criteria. As a consequence of important limitations in study design, inconsistency and lack of directness, the overall quality of evidence was judged to be very low using the GRADE system.

AUTHORS' CONCLUSIONS

  The results of published intervention trials are of insufficient quality to enable evidence-based recommendations to be developed for clinical practice in antenatal care.

Physical activity and gestational weight gain: a meta-analysis of intervention trials

BACKGROUND

high gestational weight gain (GWG) has been found to be associated with a number of adverse perinatal and long-term outcomes.

OBJECTIVES

we aimed to perform a systematic review and meta-analysis to find out whether physical activity in pregnancy might help avoid high GWG.

SEARCH STRATEGY

a literature search in relevant databases and an additional search by hand through bibliographies of various publications were performed.

SELECTION CRITERIA

we included randomised controlled trials on healthy women, with increased physical activity as the only intervention. GWG had to be documented for the intervention and control group separately.

DATA COLLECTION AND ANALYSIS

two reviewers independently extracted data and performed quality assessment. Data from the included trials were combined using a random-effects model. The effect size was expressed as mean difference (MD).

MAIN RESULTS

of 1380 studies identified, 12 trials met the inclusion criteria. In seven trials, GWG was lower in the exercise group compared with the control group, whereas five trials showed a lower GWG in the control groups. The meta-analysis resulted in an MD of GWG of -0.61 (95% CI: -1.17, -0.06), suggesting less GWG in the intervention groups compared with the control groups. We found no indication for publication bias or dose effects.

AUTHOR'S CONCLUSIONS

in summary, our analyses suggest that physical activity during pregnancy might be successful in restricting GWG.

Does exercise have a role in the management of gestational diabetes mellitus?

Gestational diabetes mellitus (GDM) is associated with a marked increase in the long-term risk of type 2 diabetes and adverse pregnancy outcomes. Engaging in vigorous recreational physical activity prior to and during pregnancy significantly reduces the risk of developing GDM. In contrast, evidence of a therapeutic effect from participation in a structured exercise training regimen, although promising, is limited and requires further more substantial investigation. This paper briefly reviews the pathophysiology of GDM, the evidence related to physical activity participation and exercise regimen intervention on GDM, and the clinical considerations required for prescribing exercise.

Gestational diabetes: risks, management, and treatment options

Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.

Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials

BACKGROUND

Excessive gestational weight gain (GWG) increases the risk of a number of adverse pregnancy outcomes and was recently identified as a potential risk factor for childhood obesity. It is therefore of interest whether GWG can be modified by an intervention combining dietary counseling and physical activity.

OBJECTIVE

The objective was to review published data on interventions to reduce GWG by modulating diet and physical activity during pregnancy.

DESIGN

We systematically reviewed 4 databases and bibliographies of various publications supplemented by a hand-search for relevant articles published in English or German and performed a meta-analysis to quantify the effect estimate by a random-effects model.

RESULTS

Four randomized controlled trials and 5 nonrandomized trials with a total of 1549 women enrolled were identified as being relevant. Meta-analyses of all 9 trials indicated a lower GWG in the intervention groups, with a standardized mean difference of -0.22 units (95% CI: -0.38, -0.05 units). We observed no indication for publication bias.

CONCLUSIONS

Interventions based on physical activity and dietary counseling, usually combined with supplementary weight monitoring, appear to be successful in reducing GWG. The results are of particular interest with respect to the objective of preventing excessive GWG.

Gestational diabetes: risk factors and recent advances in its genetics and treatment

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study of over 23000 diabetes-free pregnancies has shown that at a population level an unequivocal linear relationship exists between maternal glucose concentrations around the beginning of the third trimester of pregnancy and the risk of their baby being born above the ninetieth centile for weight. With the rising incidence of gestational diabetes (GDM) across the developed world, largely paralleling the increased prevalence of obesity, there has been a sharp increase in the risk of pregnancy complications developing related to the birth of macrosomic babies. The associated additional long-term complications of GDM pregnancies means that in the future there is likely to be a large increase in the incidence of type 2 diabetes and associated conditions in both the mothers and their affected offspring. The present review seeks to highlight recent advances and remaining gaps in knowledge about GDM in terms of its genetics (where some of the recently discovered polymorphic risk factors for type 2 diabetes have also proved to be risk factors for GDM) and its treatment by diet, exercise and drugs.