Dietary Approaches to Stop Hypertension Diet and Activity to Limit Gestational Weight: Maternal Offspring Metabolics Family Intervention Trial, a Technology Enhanced Randomized Trial

Investigating discrepancies in findings between rigorous randomized trials and meta-analyses evaluating pregnancy interventions to limit gestational weight gain

INTRODUCTION

Robust randomized trials consistently demonstrate little impact from diet and physical activity interventions on gestational weight gain (GWG) and clinical outcomes, although meta-analyses report some benefit. Our aim was to evaluate the effect of trial quality on treatment effect estimates and review conclusions.

METHODS

We conducted a systematic review of dietary and/or physical activity interventions for pregnant women with a body mass index ≥18.5 kg/m2. We assessed studies for risk of bias and methodological features impacting reliability. Outcomes included GWG; gestational diabetes mellitus (GDM); pre-eclampsia; caesarean birth; and birth weight measures. For each outcome, a sequence of meta-analyses was performed based on intervention group and level of potential bias in the effect estimate.

RESULTS

We identified 128 eligible studies. The most robust estimate from a combined diet and physical activity behavioral intervention, with only studies at negligible risk of bias, was a difference in GWG of 1.10 kg (95% CI -1.62 to -0.58; 17,755 women). There was no evidence of an effect on any clinical outcomes.

CONCLUSIONS

Our findings highlight discrepancies produced by the indiscriminate inclusion of studies with methodological flaws in previous systematic reviews. Regular weighing of pregnant women is futile in the absence of clinical benefit.

Gestational weight gain below recommendations and adverse maternal and child health outcomes for pregnancies with overweight or obesity: a United States cohort study

BACKGROUND

The current Institute of Medicine (IOM) pregnancy weight gain guidelines were developed using the best available evidence but were limited by substantial knowledge gaps. Some have raised concern that the guidelines for individuals affected by overweight or obesity are too high and contribute to short- and long-term complications for the mother and child.

OBJECTIVES

To determine the association between pregnancy weight gain below the lower limit of the current IOM recommendations and risk of 10 adverse maternal and child health outcomes among individuals with overweight and obesity.

METHODS

We used data from a prospective cohort study of United States nulliparae with prepregnancy overweight (n = 955) or obesity (n = 897) followed from the first trimester to 2-7 y postpartum. We used multivariable Poisson regression to relate pregnancy weight gain z-scores with a severity-weighted composite outcome consisting of ≥1 of 10 adverse outcomes (gestational diabetes, preeclampsia, unplanned cesarean delivery, maternal postpartum weight increase >10 kg, maternal postpartum metabolic syndrome, infant death, stillbirth, preterm birth, small-for-gestational age birth, and childhood obesity).

RESULTS

Pregnancy weight gain z-scores below, within, and above the IOM-recommended ranges occurred in 5%, 13%, and 80% of pregnancies with overweight and 17%, 13%, and 70% of pregnancies with obesity. There was a positive association between pregnancy weight gain z-scores and all adverse maternal outcomes, childhood obesity, and the composite outcome. Pregnancy weight gain z-scores below the lower limit of the recommended ranges (<6.8 kg for overweight, <5 kg for obesity) were not associated with the severity-weighted composite outcome. For example, compared with the lower limit, adjusted rate ratios (95% confidence interval) for z-scores of -2 standard deviations in pregnancies with overweight (equivalent to 3.6 kg at 40 wk) and obesity (-2.8 kg at 40 wk) were 0.99 (95% confidence interval [CI]: 0.91, 1.06) and 0.97 (95% CI: 0.87, 1.07).

CONCLUSIONS

These findings support arguments to decrease the lower limit of recommended weight gain ranges in these prepregnancy body mass index groups.

Effect of a lifestyle intervention among pregnant women with overweight on neonatal adiposity: A randomized controlled clinical trial

BACKGROUND

The excess neonatal adiposity is considered a risk factor for the development of childhood obesity and the birth weight is a marker of health throughout life.

AIMS

To evaluate the effect of a lifestyle intervention conducted among pregnant women with overweight on neonatal adiposity and birth weight.

METHODS

A total of 350 pregnant women were recruited and randomly allocated into the control (CG) and intervention (IG) groups. Pregnant women in the IG were invited to participate in three nutritional counselling sessions based on encouraging the consumption of unprocessed and minimally processed foods, rather than ultra-processed foods, following the NOVA food classification system, which categorizes foods according to the extent and purpose of industrial processing, and the regular practice of physical activity. Neonatal adiposity was estimated using a previously validated anthropometric model. Adjusted linear regression models were used to measure the effect.

RESULTS

Adopting the modified intention-to-treat principle, data from 256 neonates were analyzed for birth weight, and data from 163 for body composition estimation. The treatment had no effect on the proportion of fat mass [β 0.52 (95 % CI -1.03, 2.06); p = .51], fat-free mass [β -0.50 (95 % CI -2.45, 1.45); p = .61] or birth weight [β 53.23 (95 % CI -87.19, 193.64); p = .46].

CONCLUSIONS

In the present study, the lifestyle counselling used had no effect on neonatal adiposity or birth weight. Future studies should investigate the effect of more intensive interventions.

Maternal 24-h movement patterns across pregnancy and postpartum: The LIFE-Moms consortium

Objective

Time spent among the 24-h movement behaviors (physical activity [PA], sleep, sedentary behavior [SB]) in the perinatal period is important for maternal and child health. We described changes to 24-h movement behaviors and behavior guideline attainment during pregnancy and postpartum and identified correlates of behavior changes.

Methods

This secondary data analysis included the standard of care group (n = 439) from the U.S.-based Lifestyle Interventions For Expectant Moms (LIFE-Moms) consortium, including persons with overweight and obesity. Wrist-worn accelerometry was used to measure movement behaviors early (9-15 weeks) and late (35-36 weeks) pregnancy, and ∼ 1-year postpartum. Sleep and moderate-to-vigorous PA (MVPA) were compared to adult and pregnancy-specific guidelines, respectively. SB was classified into quartiles. PA and SB context were quantified using questionnaires. Mixed models were used to examine changes in behaviors and guidelines and identify correlates.

Results

Participants were 31.3 ± 3.5 years, 53.5 % were Black or Hispanic, and 45.1 % had overweight. Sleep duration decreased across time, but participants consistently met the guideline (range: 85.0-93.6 %). SB increased during pregnancy and decreased postpartum, while light PA and MVPA followed the inverse pattern. Participants met slightly fewer guidelines late pregnancy (1.2 ± 0.7 guidelines) but more postpartum (1.7 ± 0.8 guidelines) than early pregnancy (1.4 ± 0.8 guidelines). Black or Hispanic race/ethnicity, higher pregravid body mass index, and non-day work-shift (e.g., night-shift) were identified correlates of lower guideline adherence and varying PA and SB context.

Conclusion

Perinatal interventions should consider strategies to prevent SB increase and sustain MVPA to promote guideline adherence.

Nutrition Interventions for Lowering Cardiovascular Risk After Hypertensive Disorders of Pregnancy: A Systematic Review

Background

Hypertension is one of the most common medical problems during pregnancy. Hypertensive disorders of pregnancy (HDP) increase the risk of premature cardiovascular disease (CVD) 2- to 4-fold within 10 years after delivery. Early health behaviour modifications may prevent or manage several cardiovascular risk factors. Importantly, compared with women without HDP, fewer women with HDP achieve national dietary guidelines to prevent CVD. This highlights an opportunity for programs tailored for women post-HDP to support their nutritional behaviours as a key component of postpartum CVD preventive care. This systematic review investigated the impacts of nutrition modifications on lowering measures of CVD risk after HDP.

Methods

Four electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) were searched in October 2022 with a search strategy focused on nutrition programs/interventions and women post-HDP. Additional inclusion criteria were original research and reported outcome of CVD risk or cardiovascular risk factors.

Results

Six studies were included: 4 experimental trials and 2 prospective cohort studies. Of the nutrition interventions, 4 were embedded within comprehensive health behaviour intervention programs. Outcome measures varied, but all studies reported blood pressure. A narrative synthesis found that the range of changes in blood pressure varied from no change to clinically meaningful change.

Conclusions

This review found statistically nonsignificant yet clinically important improvements in measures of cardiovascular risk across a range of nutritional interventions in women after HDP. Further high-quality evidence is needed to inform the design and implementation of nutritional preventive cardiovascular care targeting this high CVD-risk population.

Interventions in preconception and pregnant women at risk of gestational diabetes; a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Women at risk of gestational diabetes mellitus (GDM) need preventative interventions.

OBJECTIVE

To evaluate targeted interventions before and during pregnancy for women identified as being at risk of developing GDM.

METHODS

Systematic review and meta-analysis conducted following PRISMA guidelines. MEDLINE, EMBASE and the Cochrane Library in addition to reference and citation lists were searched to identify eligible randomised controlled trials (RCTs) utilising risk stratification during the preconception period or in the first/early second trimester. Screening and data extraction were carried out by the authors independently. Quality assessment was conducted based on the Cochrane risk-of-bias tool. Random effects meta-analysis and narrative synthesis were performed.

RESULTS

Eighty-four RCTs were included: two during preconception and 82 in pregnancy, with a pooled sample of 22,568 women. Interventions were behavioural (n = 54), dietary supplementation (n = 19) and pharmacological (n = 11). Predictive factors for risk assessment varied; only one study utilised a validated prediction model. Gestational diabetes was reduced in diet and physical activity interventions (risk difference - 0.03, 95% CI 0.06, - 0.01; I2 58.69%), inositol (risk difference - 0.19, 95% CI 0.33, - 0.06; I2 92.19%), and vitamin D supplements (risk difference - 0.16, 95% CI 0.25, - 0.06; I2 32.27%). Subgroup analysis showed that diet and physical activity interventions were beneficial in women with ≥ 2 GDM risk factors (risk difference - 0.16, 95% CI 0.25, - 0.07; I2 11.23%) while inositol supplementation was effective in women with overweight or obesity (risk difference - 0.17, 95% CI 0.22, - 0.11; I2 0.01%). Effectiveness of all other interventions were not statistically significant.

CONCLUSIONS

This review provides evidence that interventions targeted at women at risk of GDM may be an effective strategy for prevention. Further studies using validated prediction tools or multiple risk factors to target high-risk women for intervention before and during pregnancy are warranted.

App-Supported Lifestyle Interventions in Pregnancy to Manage Gestational Weight Gain and Prevent Gestational Diabetes: Scoping Review

BACKGROUND

Excessive gestational weight gain (GWG) and gestational diabetes mellitus (GDM) are common pregnancy complications that have been shown to be preventable through the use of lifestyle interventions. However, a significant gap exists between research on pregnancy lifestyle interventions and translation into clinical practice. App-supported interventions might aid in overcoming previous implementation barriers. The current status in this emerging research area is unknown.

OBJECTIVE

This scoping review aims to provide a comprehensive overview of planned, ongoing, and completed studies on eHealth and mobile health (mHealth) app-supported lifestyle interventions in pregnancy to manage GWG and prevent GDM. The review assesses the scope of the literature in the field; describes the population, intervention, control, outcomes, and study design (PICOS) characteristics of included studies as well as the findings on GWG and GDM outcomes; and examines app functionalities.

METHODS

The scoping review was conducted according to a preregistered protocol and followed established frameworks. Four electronic databases and 2 clinical trial registers were systematically searched. All randomized and quasi-randomized controlled trials (RCTs) of app-supported lifestyle interventions in pregnancy and related qualitative and quantitative research across the different study phases were considered for inclusion. Eligible studies and reports of studies were included until June 2022. Extracted data were compiled in descriptive analyses and reported in narrative, tabular, and graphical formats.

RESULTS

This review included 97 reports from 43 lifestyle intervention studies. The number of published reports has steadily increased in recent years; of the 97 included reports, 38 (39%) were trial register entries. Of the 39 identified RCTs, 10 efficacy or effectiveness trials and 8 pilot trials had published results on GWG (18/39, 46%); of these 18 trials, 7 (39%) trials observed significant intervention effects on GWG outcomes. Of all 39 RCTs, 5 (13%) efficacy or effectiveness trials reported GDM results, but none observed significant intervention effects on GDM. The RCTs included in the review were heterogeneous in terms of their PICOS characteristics. Most of the RCTs were conducted in high-income countries, included women with overweight or obesity and from all BMI categories, delivered multicomponent interventions, delivered interventions during pregnancy only, and focused on diet and physical activity. The apps used in the studies were mostly mHealth apps that included features for self-monitoring, feedback, goal setting, prompts, and educational content. Self-monitoring was often supported by wearable activity monitors and Bluetooth-connected weight scales.

CONCLUSIONS

Research in this field is nascent, and the effectiveness and implementability of app-supported interventions have yet to be determined. The complexity and heterogeneity of intervention approaches pose challenges in identifying the most beneficial app features and intervention components and call for consistent and comprehensive intervention and outcome reporting.

Influence of the DASH Diet on Gestational Weight Gain and Perinatal Outcomes in Women with Pre-Existing Diabetes Mellitus: A Randomized, Single-Blind, Controlled Clinical Trial

BACKGROUND

This study aimed to investigate the influence of the dietary approaches to stop hypertension (DASH) diet on gestational weight gain and perinatal outcomes in pregnant women with pre-existing diabetes mellitus (PDM).

METHODS

A randomized, single-blind, controlled clinical trial was conducted with 68 pregnant women with PDM throughout prenatal care until delivery (18 weeks) at a public maternity hospital in Rio de Janeiro, Brazil (2016-2020). The standard diet adopted by the control group (standard diet group-SDG) contained 45-55% carbohydrates, 15-20% protein, and 25-30% lipids of the total energy intake. An adapted DASH diet, with a similar macronutrient composition, but with higher calcium, potassium, magnesium, fiber, and reduced saturated fat, was prescribed for the intervention group (DASH diet group-DDG). Student's t- or Mann-Whitney U tests were used to compare outcomes between groups. To assess the trajectory of gestational weight gain throughout the intervention between the study groups, linear mixed-effects regression models were used.

RESULTS

The DDG had lower gestational weight gain at the fifth (p = 0.03) and seventh appointment (p = 0.04), with no difference in average total gestational weight gain (SDG: 10 kg [SD = 4]; DDG: 9 kg [SD = 5], p = 0.23). There was a trend for a lower length of stay of the newborns (p = 0.08) in the DDG without differences for other perinatal outcomes.

CONCLUSIONS

The DASH diet promoted less variation in gestational weight gain without promoting a difference in total gestational weight gain, and there was no difference between the study groups for perinatal outcomes.

Association of a Lifestyle Intervention with Blood Pressure Trajectories During Pregnancy and Postpartum in Women with Pre-pregnancy Overweight and Obesity

OBJECTIVES

Healthy lifestyle, including healthy diet and physical activity, has been associated with lower blood pressure (BP). We hypothesized that overweight/obese women randomized to a lifestyle intervention beginning in early pregnancy would be less likely to have a higher BP trajectory.

METHODS

The Health in Pregnancy and Postpartum study promoted a healthy lifestyle in pregnant and postpartum women with pre-pregnancy overweight or obesity. BP was measured at study visits at ≤ 16 and 32 weeks of pregnancy and 6 and 12 months postpartum. Latent class trajectories were constructed to identify groups of participants with similar BP patterns throughout the study period. Odds of being assigned to the higher BP trajectories between the intervention and control group were determined with logistic regression, adjusted for age, race, pre-pregnancy BMI, gestational weight gain, smoking during the study period, and household income.

RESULTS

Of the 219 participants enrolled (44.3% Black participants, 55.7% White participants, mean age = 29.7 ± 0.3 years), 112 (51.1%) were randomized to the intervention. Two systolic and diastolic BP trajectory groups were identified (Low-Stable, Moderate-Increasing). Randomization to the lifestyle intervention was not associated with odds of Moderate-Increasing systolic (OR 0.83, 95%CI 0.4, 1.6) or diastolic (OR 0.67, 95%CI 0.3, 1.3) BP trajectory assignment. Those in the Moderate-Increasing BP groups had higher BMI and were more likely to have an adverse pregnancy outcome.

CONCLUSIONS

A lifestyle intervention initiated in early pregnancy to help prevent excessive gestational weight gain was not associated with odds of specific BP patterns through pregnancy and postpartum.

Effect of the Dietary Approaches to Stop Hypertension (DASH) diet on the development of preeclampsia and metabolic outcomes in pregnant women with pre-existing diabetes mellitus: a randomised, controlled, single-blind trial

Preeclampsia (PE) affects up to five times more women with pre-existing diabetes mellitus (PDM) than women without it. The present study aimed to identify the effect of the DASH diet on PE incidence (primary outcome) and blood pressure, glycated haemoglobin (GH), serum lipids, glutathione peroxidase (GP), C-reactive protein (CRP - secondary outcomes) in pregnant with PDM. This randomised, controlled, single-blind trial studied sixty-eight pregnant women with PDM throughout prenatal care until delivery (18 weeks) at a public maternity hospital, Brazil. The standard diet group (SDG) received a diet containing 45-65 % carbohydrates, 15-20 % protein and 25-30 % lipids. The DASH diet group (DDG) received the adapted DASH diet with a similar macronutrient distribution, but with a higher concentration of fibres, unsaturated fats, calcium, magnesium and potassium as well as lower saturated fat. Student's t, Mann-Whitney U and the Chi-square tests were used to compare outcomes. PE incidence was 22⋅9 % in the SDG and 12⋅1 % in the DDG (P = 0⋅25). GP levels significantly increased in the DDG (intra-group analysis; mean difference = 1588 [CI 181, 2994], P = 0⋅03) and tended to be different from the variation in the SDG (mean difference = -29⋅5 [CI -1305; 1⋅365]; v. DDG: 1588 [CI 181; 2994], P = 0⋅09). GH levels decreased significantly and similarly between groups (SDG: -0⋅61 [CI -0⋅26, -0⋅96], P = 0⋅00) v. DDG: -1⋅1 [CI -0⋅57, -1⋅62], P = 0⋅00). There was no evidence of a difference in PE incidence at the end of the intervention between the two diets. The DASH diet seems to favour PE-related biochemical markers.

Early Growth and Cognitive Development in Children Born Preterm: Relevance of Maternal Body Mass Index

OBJECTIVE

Maternal prepregnancy body mass index (BMI) represents a surrogate marker of fetal exposures to the maternal metabolism during pregnancy. Yet, it remains poorly understood whether this marker indicates risk of altered trajectories in postnatal growth and development in children born preterm. This study aimed to determine whether maternal prepregnancy BMI is associated with altered growth and development in children born preterm.

STUDY DESIGN

A retrospective cohort study evaluated prepregnancy BMI as the exposure for childhood outcomes using linear regression and mixed effects models. The 38 children included in this follow-up evaluation originally participated in a prospective, observational cohort study to determine longitudinal levels of lipid species in preterm human milk expressed by women who delivered prior to 32 weeks. Childhood outcomes in this study were anthropometric measures during hospitalization (n = 38), after discharge through 36 months (n = 34) and Bayley-III developmental scores through 18 months corrected age (n = 26).

RESULTS

In 38 children born prior to 32 weeks, higher maternal prepregnancy BMI was independently associated with higher preterm infant growth velocity during hospitalization, but not associated with in-hospital change in length or head circumference and/or postdischarge growth. In univariate linear regression models, higher maternal BMI was associated with lower cognitive scores at 18 months corrected age. This significant association remained in an adjusted model accounting for relevant influences on early childhood development.

CONCLUSION

Increasing maternal prepregnancy BMI may reflect risk of altered growth and cognitive development in children born preterm.

KEY POINTS

· Maternal BMI was associated with early preterm infant weight gain.. · Maternal BMI was not associated with postdischarge growth.. · Increased maternal BMI may be associated with lower cognitive function scores in offspring..

Telehealth Strategies for the Delivery of Maternal Health Care : A Rapid Review

BACKGROUND

Telehealth strategies to supplement or replace in-person maternity care may affect maternal health outcomes.

PURPOSE

To conduct a rapid review of the effectiveness and harms of telehealth strategies for maternal health care given the recent expansion of telehealth arising from the COVID-19 pandemic, and to produce an evidence map.

DATA SOURCES

Systematic searches of MEDLINE, the Cochrane Library, CINAHL, Embase, and Scopus for English-language studies (January 2015 to April 2022).

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies of maternal care telehealth strategies versus usual care.

DATA EXTRACTION

Dual data extraction and risk-of-bias assessment of studies, with disagreements resolved through consensus.

DATA SYNTHESIS

28 RCTs and 14 observational studies (n = 44 894) were included. Maternal telehealth interventions supplemented in-person care for most studies of mental health and diabetes during pregnancy, primarily resulting in similar, and sometimes better, clinical and patient-reported outcomes versus usual care. Supplementing in-person mental health care with phone- or web-based platforms or mobile applications resulted in similar or better mental health outcomes versus in-person care. A reduced-visit prenatal care schedule using telehealth to replace in-person general maternity care for low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction versus usual care. Overall, telehealth strategies were heterogeneous and resulted in similar obstetric and patient satisfaction outcomes. Few studies addressed disparities, health equity, or harms.

LIMITATIONS

Interventions varied, and evidence was inadequate for some clinical outcomes.

CONCLUSION

Replacing or supplementing in-person maternal care with telehealth generally results in similar, and sometimes better, clinical outcomes and patient satisfaction compared with in-person care. The effect on access to care, health equity, and harms is unclear.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42021276347).

The effects of a lifestyle intervention (the HealthyMoms app) during pregnancy on infant body composition: Secondary outcome analysis from a randomized controlled trial

BACKGROUND

Pregnancy has been identified as a window for childhood obesity prevention. Although lifestyle interventions in pregnancy can prevent excessive gestational weight gain (GWG), little is known whether such interventions also affect infant growth and body composition.

OBJECTIVES

To investigate (i) the effects of a 6-month lifestyle intervention (the HealthyMoms app) on infant body composition 1-2 weeks postpartum, and (ii) whether a potential intervention effect on infant body composition is mediated through maternal GWG.

METHODS

This is a secondary outcome analysis of the HealthyMoms randomized controlled trial. Air-displacement plethysmography was used to measure body composition in 305 healthy full-term infants.

RESULTS

We observed no statistically significant effect on infant weight (β = -0.004, p = 0.94), length (β = -0.19, p = 0.46), body fat percentage (β = 0.17, p = 0.72), or any of the other body composition variables in the multiple regression models (all p ≥ 0.27). Moreover, we observed no mediation effect through GWG on infant body composition.

CONCLUSIONS

Our findings support that HealthyMoms may be implemented in healthcare to promote a healthy lifestyle in pregnant women without compromising offspring growth. Further research is required to elucidate whether lifestyle interventions in pregnancy also may result in beneficial effects on infant body composition and impact future obesity risk.

FTO and ADRB2 Genetic Polymorphisms Are Risk Factors for Earlier Excessive Gestational Weight Gain in Pregnant Women with Pregestational Diabetes Mellitus: Results of a Randomized Nutrigenetic Trial

Excessive gestational weight gain (GWG) is associated with increased risk of maternal and neonatal complications. We investigated obesity-related polymorphisms in the FTO gene (rs9939609, rs17817449) and ADRB2 (rs1042713, rs1042714) as candidate risk factors concerning excessive GWG in pregnant women with pregestational diabetes. This nutrigenetic trial, conducted in Brazil, randomly assigned 70 pregnant women to one of the groups: traditional diet (n = 41) or DASH diet (n = 29). Excessive GWG was the total weight gain above the upper limit of the recommendation, according to the Institute of Medicine guidelines. Genotyping was performed using real-time PCR. Time-to-event analysis was performed to investigate risk factors for progression to excessive GWG. Regardless the type of diet, AT carriers of rs9939609 (FTO) and AA carriers of rs1042713 (ADRB2) had higher risk of earlier exceeding GWG compared to TT (aHR 2.44; CI 95% 1.03-5.78; p = 0.04) and GG (aHR 3.91; CI 95% 1.12-13.70; p = 0.03) genotypes, respectively, as the AG carriers for FTO haplotype rs9939609:rs17817449 compared to TT carriers (aHR 1.79; CI 95% 1.04-3.06; p = 0.02).

A Comparison of the Cost-Effectiveness of Lifestyle Interventions in Pregnancy

OBJECTIVES

Lifestyle interventions during pregnancy improve maternal and infant outcomes. We aimed to compare the cost-effectiveness of 4 antenatal lifestyle intervention types with standard care.

METHODS

A decision tree model was constructed to compare lifestyle intervention effects from a novel meta-analysis. The target population was women with singleton pregnancies and births at more than 20 weeks' gestation. Interventions were categorized as diet, diet with physical activity, physical activity, and mixed (lacking structured diet and, or, physical activity components). The outcome of interest was cost per case prevented (gestational diabetes, hypertensive disorders in pregnancy, cesarean birth) expressed as an incremental cost-effectiveness ratio (ICER) from the Australian public healthcare perspective. Scenario analyses were included for all structured interventions combined and by adding neonatal intensive care unit costs. Costs were estimated from published data and consultations with experts and updated to 2019 values. Discounting was not applied owing to the short time horizon.

RESULTS

Physical activity interventions reduced adverse maternal events by 4.2% in the intervention group compared with standard care and could be cost saving. Diet and diet with physical activity interventions reduced events by 3.5% (ICER = A$4882) and 2.9% (ICER = A$2020), respectively. Mixed interventions did not reduce events and were dominated by standard care. In scenario analysis, all structured interventions combined and all interventions when including neonatal intensive care unit costs (except mixed) may be cost saving. Probabilistic sensitivity analysis showed that for physical activity and all structured interventions combined, the probability of being cost saving was 58% and 41%, respectively.

CONCLUSIONS

Governments can expect a good return on investment and cost savings when implementing effective lifestyle interventions population-wide.

Mobile Phone App Use Among Pregnant Women in China and Associations Between App Use and Perinatal Outcomes: Retrospective Study

BACKGROUND

Maternal and child health (MCH)-related mobile apps are becoming increasingly popular among pregnant women; however, few apps have demonstrated that they lead to improvements in pregnancy outcomes.

OBJECTIVE

This study aims to investigate the use of MCH apps among pregnant women in China and explore associations with pregnancy outcomes.

METHODS

A retrospective study was conducted at 6 MCH hospitals in northern China. Women who delivered a singleton baby at >28 weeks' gestation at the study hospitals were sequentially recruited from postnatal wards from October 2017 to January 2018. Information was collected on the women's self-reported MCH app use during their pregnancy, along with clinical outcomes. Women were categorized as nonusers of MCH apps and users (further divided into intermittent users and continuous users). The primary outcome was a composite adverse pregnancy outcome (CAPO) comprising preterm birth, birth weight <2500 g, birth defects, stillbirth, and neonatal asphyxia. The association between app use and CAPO was explored using multivariable logistic analysis.

RESULTS

The 1850 participants reported using 127 different MCH apps during pregnancy. App use frequency was reported as never, 24.7% (457/1850); intermittent, 47.4% (876/1850); and continuous, 27.9% (517/1850). Among app users, the most common reasons for app use were health education (1393/1393, 100%), self-monitoring (755/1393, 54.2%), and antenatal appointment reminders (602/1393, 43.2%). Nonusers were older, with fewer years of education, lower incomes, and higher parity (P<.01). No association was found between any app use and CAPO (6.8% in nonusers compared with 6.3% in any app users; odds ratio 0.77, 95% CI 0.48-1.25).

CONCLUSIONS

Women in China access a large number of different MCH apps, with social disparities in access and frequency of use. Any app use was not found to be associated with improved pregnancy outcomes, highlighting the need for rigorous development and testing of apps before recommendation for use in clinical settings.

Maternal Diet During Pregnancy and Lactation and Child Food Preferences, Dietary Patterns, and Weight Outcomes: a Review of Recent Research

PURPOSE OF REVIEW

Efforts to promote children's preferences for healthy foods hold much potential for improving diet quality and preventing obesity. The purpose of this review was to summarize recent evidence for associations between maternal diet during pregnancy and lactation and child food preferences, dietary patterns, and weight outcomes.

RECENT FINDINGS

Recent research illustrates greater maternal vegetable intakes during pregnancy and lactation predict greater child preferences for and intakes of vegetables. Recent randomized clinical trials to improve maternal weight outcomes during the perinatal period via behavioral lifestyle interventions that included dietary components have yielded mixed findings for effects on child weight outcomes. There is strong evidence that maternal diet during pregnancy and lactation shapes flavor preferences during infancy; more research is needed to understand factors that facilitate versus hinder the translation of these preferences to later dietary patterns and weight outcomes.

The role of maternal diet on offspring hyperinsulinaemia and adiposity after birth: a systematic review of randomised controlled trials

In utero diet may be directly related to the risk of fetal hyperinsulinaemia and offspring metabolic health. This review examines the relationship between maternal dietary exposures and sub-clinical fetal hyperinsulinaemia and neonatal adiposity. Articles were identified in MEDLINE, Web of Science, Cochrane Controlled Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, SCOPUS, and SPORTDiscus (September 2019-March 2021) using the preferred reporting items for systematic reviews and meta-analyses guidelines. PROSPERO registration ID CRD42020146453. Studies were selected by two independent reviewers. Randomised controlled trials (RCT) involving a dietary intervention with pregnant women (healthy pregnancy, gestational diabetes mellitus and obesity) and reporting fetal cord-blood insulin, c-peptide, glucose or adiposity estimates were included. One author extracted all information on main study characteristics and outcomes. Risk of bias was assessed using the Cochrane Collaboration's bias risk assessment tool. A total of 733 articles were identified. Fourteen articles from 11 RCTs (3614 participants) were included. Studies reviewed showed no specific effect of maternal diet on neonatal cord blood insulin, c-peptide or glucose levels. Infants born to mothers who followed a low glycaemic load (GL) had lower skin fold thickness compared to controls. Interventions that provided individualised nutrition counselling to women with obesity or previous infant born > 4 kg were also associated with lower adiposity. The studies reviewed suggest that lifestyle-based dietary interventions to improve glycaemia (low GL) have a protective effect against excess adiposity. Future studies should incorporate multi-modal interventions with dietary counselling to support lifestyle changes throughout gestation and include assessments of maternal insulin resistance at recruitment.

Quality improvement strategies enhance primary care dietetics: A systematic review and meta-analysis

BACKGROUND

Quality improvement strategies have been widely applied in health care; however, little is known about their use in primary care dietetics. This review aims to describe and evaluate the effectiveness of quality improvement strategies that seek to improve patient outcomes by enhancing dietetic care compared to standard dietetic care.

METHODS

The study employed a systematic review and meta-analysis design following PRISMA guidelines and included studies up to March 2021. Studies were included if they used a randomised controlled trial (RCT) design to evaluate the effect of a quality improvement strategy applied to care delivered by a dietitian on patient outcomes. A meta-analysis was conducted where there were sufficient studies with homogeneous populations and outcome measures.

RESULTS

Twelve RCTs (n = 1604) met the inclusion criteria for review and five studies (n = 511) were eligible for meta-analysis for glycated haemoglobin in patients with type 2 diabetes. The most frequently reported quality improvement strategies addressed disease management programs (58%), patient education (67%), group care (42%) and patient self-management (42%). A positive intervention effect was reported in 50% of the included studies. A low grade of evidence supported a positive intervention effect for quality improvement intervention by a dietitian for glycated haemoglobin (pooled mean difference = -0.39% with 95% confidence interval = -0.70 to -0.08, p = 0.01) in n = 511 patients with type 2 diabetes mellitus.

CONCLUSIONS

Interventions aimed at enhancing quality in primary care dietetic practice support improvements in patient outcomes. Further research on quality improvement interventions for patient outcomes is required to strengthen the evidence base in this important topic.

Maternal Dietary Quality and Dietary Inflammation Associations with Offspring Growth, Placental Development, and DNA Methylation

The ‘Developmental Origins of Health and Diseases’ hypothesis posits that prenatal maternal diet influences offspring growth and later life health outcomes. Dietary assessment has focused on selected nutrients. However, this approach does not consider the complex interactions between foods and nutrients. To provide a more comprehensive approach to public health, dietary indices have been developed to assess dietary quality, dietary inflammation and risk factors for non-communicable diseases. Thus far, their use in the context of placental development is limited and associations with offspring outcomes have been inconsistent. Although epidemiological studies have focused on the role of maternal diet on foetal programming, the underlying mechanisms are still poorly understood. Some evidence suggests these associations may be driven by placental and epigenetic changes. In this narrative review, we examine the current literature regarding relationships between key validated diet quality scores (Dietary Inflammatory Index [DII], Mediterranean diet [MD], Healthy Eating Index [HEI], Alternative Healthy Eating Index [AHEI], Dietary Approaches to Stop Hypertension [DASH], Glycaemic Index [GI] and Glycaemic Load [GL]) in pregnancy and birth and long-term offspring outcomes. We summarise findings, discuss potential underlying placental and epigenetic mechanisms, in particular DNA methylation, and highlight the need for further research and public health strategies that incorporate diet quality and epigenetics.

Maternal periconceptional nutrition matters. A scoping review of the current literature

BACKGROUND

The importance of nutrition in reproductive health is widely acknowledged with special emphasis given to periconceptional maternal diet and its implications on embryo-fetal development, pregnancy complications, and the health of the offspring.

METHODS

Following the PRISMA guidelines, we searched for literature in PubMed, CINAHL, and WoS to gather newer information on how diet composition influences the concepts from the very early stages of pregnancy and how maternal health may be affected as well. Fifty-six studies published up to June 2020 met the inclusion criteria.

RESULTS

With its proportioned and diversified macronutrient composition, the Mediterranean Diet prevents congenital anomalies, preterm birth, hypertensive disorders, and gestational diabetes. Similar dietary patterns rich in vegetables, nuts, fish, and cereals increase the likelihood of conception and have a protective action, mediated by their antioxidant properties, against orofacial clefts, congenital heart and limb defects in the progeny. Conversely, the pro-inflammatory features of western diets, rich in processed foods and low in fruit content, diminish fertility, increase miscarriage rates, and enhance the risk of neural tube defects regardless of folate supplementation.

CONCLUSIONS

It may be concluded that within the multiple dietary options, some of them are soundly associated with beneficial effects for the mother and the newborn.Implications for practiceAn appropriate counseling must be offered to the woman of fertile age to make her aware of how periconceptional nutrition may help fulfill her reproductive expectations.

Do Lifestyle Interventions in Pregnant Women with Overweight or Obesity Have an Effect on Neonatal Adiposity? A Systematic Review with Meta-Analysis

Excessive body fat at birth is a risk factor for the development of childhood obesity. The aim of the present systematic review with meta-analysis was to evaluate the effect of lifestyle interventions in pregnant women with overweight or obesity on neonatal adiposity. The PubMed, Embase, Web of Science, Scopus, and LILACS databases were used as information sources. Original articles from randomized clinical trials of lifestyle intervention studies on pregnant women with excessive body weight and the effect on neonatal adiposity were considered eligible. The risk of bias was assessed using Cochrane criteria. The meta-analysis was calculated using the inverse variance for continuous data expressed as mean difference (MD), using the random effect model with a 95% confidence interval (CI). The outcomes were submitted to the GRADE evaluation. Of 2877 studies, four were included in the qualitative and quantitative synthesis (n = 1494). All studies were conducted in developed countries, with three including pregnant women with overweight or obesity, and one only pregnant women with obesity. The interventions had no effect on neonatal adiposity [Heterogeneity = 56%, MD = −0.21, CI = (−0.92, 0.50)] with low confidence in the evidence, according to GRADE. Studies are needed in low- and medium-developed countries with different ethnic-racial populations. PROSPERO (CRD42020152489).

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

OBJECTIVE

To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

DATA SOURCES

Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

STUDY SELECTION

Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating with dual review.

MAIN OUTCOMES AND MEASURES

Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms.

RESULTS

Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited.

CONCLUSIONS AND RELEVANCE

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

A Behavioral Lifestyle Intervention to Limit Gestational Weight Gain in Pregnant Women with Overweight and Obesity

OBJECTIVE

This study aimed to evaluate the effects of an antenatal behavioral lifestyle intervention on total gestational weight gain (GWG) and perinatal outcomes.

METHODS

Pregnant women with overweight and obesity in South Carolina were recruited into a theory-based randomized controlled trial (n = 112 intervention, n = 105 standard care), which was designed to target weight self-monitoring, increased physical activity, and improved dietary practices.

RESULTS

Participants were racially/ethnically diverse (44% African American). Intervention and standard care participants had similar total GWG at delivery (12.9 ± 6.9 vs. 12.4 ± 8.3 kg, respectively), but intervention participants had a smaller standard deviation (P = 0.04) in total GWG. The treatment effects were moderated by race/ethnicity and prepregnancy BMI. Among African American participants with overweight, intervention participants gained 4.5 kg less, whereas, among African American women with obesity, intervention participants gained 4.1 kg more than standard care participants. Total GWG among White participants was similar regardless of weight status and group assignment. Fewer intervention participants than standard care participants had adverse pregnancy outcomes (P ≤ 0.01).

CONCLUSIONS

The behavioral lifestyle intervention favorably impacted GWG in African American participants with overweight but not African American participants with obesity. The intervention's overall favorable impact on perinatal outcomes suggests that the mechanisms beyond total GWG may drive these outcomes.

Attenuated early pregnancy weight gain by prenatal lifestyle interventions does not prevent gestational diabetes in the LIFE-Moms consortium

AIMS

To examine the effect of lifestyle (diet and physical activity) interventions on the prevalence of GDM, considering the method of GDM ascertainment and its association with early pregnancy characteristics and maternal and neonatal outcomes in the LIFE-Moms consortium.

METHODS

LIFE-Moms evaluated the effects of lifestyle interventions to optimize gestational weight gain in 1148 pregnant women with BMI ≥ 25 kg/m2 and without known diabetes at enrollment, compared with standard care. GDM was assessed between 24 and 31-weeks gestation by a 2-hour, 75-gram OGTT or by local clinical practice standards.

RESULTS

Lifestyle interventions initiated prior to 16 weeks reduced early excess GWG compared with standard care (0.35 ± 0.24 vs 0.43 ± 0.26 kg per week, p=<0.0001) but did not affect GDM diagnosis (11.1% vs 11.6%, p = 0.91). Using the 75-gram, 2-hour OGTT, 13. 0% of standard care and 11.0% of the intervention group had GDM by the IADPSG criteria (p = 0.45). The 'type of diagnostic test' did not change the result (p = 0.86). Women who developed GDM were significantly heavier, more likely to have obesity, and more likely to have dysglycemia at baseline.

CONCLUSION

Moderate-to-high intensity lifestyle interventions grounded in behavior change theory initiated between 9 and 16-weeks gestation did not affect the prevalence of GDM despite reducing early GWG. CLINICALTRIALS.GOV: NCT01545934, NCT01616147, NCT01771133, NCT01631747, NCT01768793, NCT01610752, NCT01812694.

Metabolic Signatures of Gestational Weight Gain and Postpartum Weight Loss in a Lifestyle Intervention Study of Overweight and Obese Women

Background: Overweight and obesity amongst women of reproductive age are increasingly common in developed economies and are shown to adversely affect birth outcomes and both childhood and adulthood health risks in the offspring. Metabolic profiling in conditions of overweight and obesity in pregnancy could potentially be applied to elucidate the molecular basis of the adverse effects of gestational weight gain (GWG) and postpartum weight loss (WL) on future risks for cardiovascular disease (CVD) and other chronic diseases. Methods: Biofluid samples were collected from 114 ethnically diverse pregnant women with body mass index (BMI) between 25 and 40 kg/m² from Chicago (US), as part of a randomized lifestyle intervention trial (Maternal Offspring Metabolics: Family Intervention Trial; NCT01631747). At 15 weeks, 35 weeks of gestation, and at 1 year postpartum, the blood plasma lipidome and metabolic profile of urine samples were analyzed by liquid chromatography mass spectrometry (LC-MS) and ¹H nuclear magnetic resonance spectroscopy (¹H NMR) respectively. Results: Urinary 4-deoxyerythronic acid and 4-deoxythreonic acid were found to be positively correlated to BMI. Seventeen plasma lipids were found to be associated with GWG and 16 lipids were found to be associated with WL, which included phosphatidylinositols (PI), phosphatidylcholines (PC), lysophospholipids (lyso-), sphingomyelins (SM) and ether phosphatidylcholine (PC-O). Three phospholipids found to be positively associated with GWG all contained palmitate side-chains, and amongst the 14 lipids that were negatively associated with GWG, seven were PC-O. Six of eight lipids found to be negatively associated with WL contained an 18:2 fatty acid side-chain. Conclusions: Maternal obesity was associated with characteristic urine and plasma metabolic phenotypes, and phospholipid profile was found to be associated with both GWG and postpartum WL in metabolically healthy pregnant women with overweight/obesity. Postpartum WL may be linked to the reduction in the intake of linoleic acid/conjugated linoleic acid food sources in our study population.

Preventing Excess Gestational Weight Gain and Obesity in Pregnancy: the Potential of Targeting Psychological Mechanisms

PURPOSE OF REVIEW

Overweight and obesity are now the most common high-risk conditions in pregnancy in the United States and increase risk of adverse outcomes during pregnancy, delivery, and the postpartum. Importantly, excess gestational weight gain is highly predictive of maternal postpartum weight retention and risk of overweight and obesity in mothers and their children later in life. This makes pregnancy a unique window of opportunity in the fight against obesity across the lifespan. This narrative review critically evaluates research on the efficacy of interventions targeting excess gestational weight gain, highlighting the potential of targeting psychological mechanisms to facilitate positive weight-related behavior change specifically in pregnancy. The PUBMED and PsycInfo databases were searched for relevant articles, including meta-analyses, systematic reviews, and randomized controlled trials with the primary or secondary aim of reducing gestational weight gain.

RECENT FINDINGS

There is currently no gold standard for preventing excess gestational weight gain, especially in women with pre-pregnancy overweight and obesity. Existing interventions primarily target diet and physical activity but lack broad empirical support and typically have only modest effects on weight gain in pregnancy, with few successfully preventing excess weight gain. Furthermore, interventions that successfully target gestational weight gain have minimal positive impact on weight- and diet-related maternal and fetal health outcomes. A growing evidence points to the utility of targeting psychological mechanisms in the prevention of excess gestational weight gain, including cognitive and affective factors, food cravings, and self-efficacy. Given the lack of broad evidence to support the efficacy of interventions targeting diet and physical activity, there is a notable need for research to develop and evaluate interventions targeting psychological factors that could positively impact diet- and weight-related behavioral change in pregnancy.

Preterm human milk at lactation weeks 1 and 4 categorized by maternal pre-pregnancy body mass index: Metabolomics and lipidomics datasets

Human milk samples were prospectively obtained from women who delivered prior to the 32nd week of gestation [1]. The 36 preterm human milk samples analysed in this dataset were collected at week 1 and week 4 of lactation. Samples were categorized as being from women with normal pre-pregnancy body mass index (BMI 18–24.9 kg/m²) versus overweight/obese (BMI ≥25). Whole milk samples were frozen at −80 Celsius without prior processing and shipped for analysis on dry ice. Untargeted metabolomic and lipidomic platforms using UPLC-MS/MS and infusion-MS analysis for select lipids were performed by Metabolon. Lipidomic analysis included detection of complex lipids found in the milk fat globule membrane. Data were categorized by maternal BMI, week of lactation as well as gestational age at delivery. Data sheets are separated based on whether they report metabolomics versus lipidomics, as well as whether they report output from samples collected at week 1 versus week 4 of lactation. These data allow calculating relationships between clinical variables and human milk components. As an illustrative example, correlations between pre-pregnancy BMI and total milk fatty acids were calculated for this report using the Spearman correlation. These data will inform scientists of variability in milk composition attributable to maternal pre-pregnancy BMI as well as changes in milk composition as milk matures during lactation from week 1 to week 4. These data may best be used for generating hypotheses and justification of future work investigating whether maternal pre-pregnancy body mass index impacts preterm human milk composition.

Feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain

INTRODUCTION

Gestational weight gain (GWG) and postpartum weight retention (PPWR) are significant, potentially modifiable, contributors to women's future weight and health trajectories. There is a need for feasible and patient-centered (i.e., convenient, remotely-delivered, technology-enhanced, and accessible through the prenatal care setting) behavioural interventions that limit GWG and PPWR. This study tests the feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain and postpartum weight retention.

METHODS

Pregnant women (11-16 weeks gestation) were recruited from two prenatal clinics and randomized to the active intervention or health education comparison group. Completion of the program was monitored and perceived helpfulness was rated (0-100).

RESULTS

Twenty-six women were randomized (n = 13 per arm; mean age = 31.6 years, SD = 3.6; mean BMI = 26.7 kg/m2, SD = 7.4). Participants completed a median of 18 coaching calls and 16/19 learning activities during pregnancy, and a median of 6 calls and 5/6 learning activities postpartum. They logged weights at least once/week for a median of 36/38 expected weeks and tracked daily calories and exercise for a median of 154/266 days and 72/266 days, respectively. Median (Q1, Q3) helpfulness ratings of the program during pregnancy were 80 (64, 91) and 62 (50, 81) postpartum; helpfulness ratings of coaching calls were 85 (58, 98). At 37 weeks gestation, 77% of participants achieved IOM weight gain recommendations compared to 54% in the comparison group.

CONCLUSIONS

This study provides evidence for the feasibility and acceptability of a remotely-delivered behavioural weight control intervention in pregnancy and postpartum.

Association of the First 1,000 Days Systems-Change Intervention on Maternal Gestational Weight Gain

OBJECTIVE

To examine the associations of a clinical and public health systems-change intervention on the prevalence of excess gestational weight gain among high-risk, low-income women.

METHODS

In a quasi-experimental trial, we compared the prevalence of excess gestational weight gain among women before (n=643) and after (n=928) implementation of the First 1,000 Days program in two community health centers in Massachusetts. First 1,000 Days is a systematic program starting in early pregnancy and lasting through the first 24 months of childhood to prevent obesity among mother-child pairs. The program includes enhanced gestational weight gain tracking and counseling, screening for adverse health behaviors and sociocontextual factors, patient navigation and educational materials to support behavior change and social needs, and individualized health coaching for women at high risk for excess gestational weight gain based on their prepregnancy body mass index (BMI) or excess first-trimester weight gain. The primary outcome was gestational weight gain greater than the 2009 Institute of Medicine (now known as the National Academy of Medicine) guidelines according to prepregnancy BMI.

RESULTS

Among 1,571 women in the analytic sample, mean (SD) age was 30.0 (5.9) years and prepregnancy BMI was 28.1 (6.1); 65.8% of women started pregnancy with BMIs of 25 or higher, and 53.2% were Hispanic. We observed a lower prevalence (55.8-46.4%; unadjusted odds ratio [OR] 0.69, 95% CI 0.49-0.97), similar to results in a multivariable analysis (adjusted OR 0.69, 95% CI 0.49-0.99), of excess gestational weight gain among women with prepregnancy BMIs between 25 and 29.9. Among women who were overweight at the start of pregnancy, the lowest odds of excess gestational weight gain were observed among those with the most interaction with the program's components. Program enrollment was not associated with reduced excess gestational weight gain among women with prepregnancy BMIs of 30 or higher.

CONCLUSIONS

Implementation of a systems-change intervention was associated with modest reduction in excess gestational weight gain among women who were overweight but not obese at the start of pregnancy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03191591.

Effects of the Dietary Approaches to Stop Hypertension (DASH) on Pregnancy/Neonatal Outcomes and Maternal Glycemic Control: A Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND & OBJECTIVE

No systematic review to date has appraised the impact of the Dietary Approaches to Stop Hypertension (DASH) eating plan on maternal glycemic control and pregnancy outcomes. Thus, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) to ascertain whether the DASH diet in pregnant women ameliorates their glycemic control and neonatal outcomes when compared to standard diets.

METHODS

We performed a comprehensive systematic review and meta-analysis of RCTs on PubMed/MEDLINE, Web of Science, SCOPUS, and Embase from the inception until October 2019.

RESULTS

Six studies met the eligibility criteria and were included in the quantitative meta-analysis. The pregnant women had cardiometabolic disorders such as gestational diabetes, obesity, and hypertension. The meta-analysis suggested a significant effect of DASH diet on fasting plasma levels of glucose (WMD = -6.239 mg/dl; 95% CI: -11.915, -0.563, p = 0.031), but not for the homeostasis model assessment of insulin resistance (WMD = -1.038; 95% CI: -2.704, 0.627, p = 0.22). Following the DASH diet during pregnancy decreased the risk of gestational preeclampsia (RR = 0.667; 95% CI: 0.451, 0.987, p = 0.043), macrosomia (birth weight >4000 g) (RR = 0.294; 95% CI: 0.120, 0.721, p = 0.043), and large for gestational age (RR = 0.452; 95% CI: 0.211, 0.969, p = 0.041). Consuming DASH diet during pregnancy neither increased nor decreased the risk of cesarean section, polyhydramnios, preterm birth (<37 weeks), and small for gestational age. The mean newborn head circumference (cm) (WMD = -0.807; 95% CI: -1.283, -0.331, p = 0.001) and ponderal index (kg/m³) (RR = -0.396; 95% CI: -0.441, -0.350, p = 0.000) in the group receiving the DASH diet were lower than in the control group.

CONCLUSION

The adherence of pregnant women with cardiometabolic disorders to DASH eating pattern has a significant effect on decreasing fasting plasma glucose levels, ponderal index, incidence of preeclampsia, fetal macrosomia, large for gestational age, and newborn head circumference.

Effectiveness of physical activity interventions for overweight and obesity during pregnancy: a systematic review of the content of behaviour change interventions

BACKGROUND

Behaviour change techniques (BCTs) employed within PA intervention for pregnant women with a healthy body mass index (BMI) have been previously identified, however, these BCTS may differ for other weight profiles during pregnancy. The aim of this current review was to identify and summarise the evidence for effectiveness of PA interventions on PA levels for pregnant women with overweight and obesity, with an emphasis on the BCTs employed.

METHODS

A systematic review and meta-analysis of PA intervention studies using the PRISMA statement was conducted. Searches were conducted of eight databases in January 2019. Strict inclusion/exclusion criteria were employed. The validity of each included study was assessed using the Cochrane Collaboration's tool for assessing risk of bias. The primary outcome measure was change in PA levels, subjectively or objectively measured, with physical fitness as a secondary outcome. All intervention descriptions were double coded by two authors using Michie's et al's BCT taxonomy V1. Meta-analyses using random effect models assessed the intervention effects on PA. Other PA outcomes were summarised in a narrative synthesis.

RESULTS

From 8389 studies, 19 met the inclusion criteria 13 of which were suitable for inclusion in a meta-analysis. The remaining 6 studies were described narratively due to insufficient data and different outcome measures reported. In the meta-analysis, comparing interventions to a control group, significant increases were found in the intervention group for metabolic equivalent (SMD 0.39 [0.14, 0.64], Z = 3.08 P = 0.002) and physical fitness (VO2 max) (SMD 0.55 [0.34, 0.75], Z = 5.20 P = < 0.001). Of the other six, five studies reported an increase in PA for the intervention group versus the control with the other study reporting a significant decrease for women in their 3rd trimester (p = 0.002). 'Self-monitoring of behaviour' was the most frequently used BCTs (76.5%), with 'social support' being newly identified for this pregnant population with overweight or obesity.

CONCLUSIONS

This review identified a slight increase in PA for pregnant women with overweight and obesity participating in interventions. However, due to the high risk of bias of the included studies, the results should be interpreted with caution. PA measures should be carefully selected so that studies can be meaningfully compared and standardised taxonomies should be used so that BCTs can be accurately assessed.

The relationship between body mass index before pregnancy and the amount of weight that should be gained during pregnancy: A cross-sectional study

Objective:

To investigate the adaptation of pregnant women to the recommended weight gain range according to body mass index (BMI) and to determine the factors affecting them.

Methods:

This cross-sectional study was performed in a university hospital’s obstetrics and gynecology unit (tertiary center) in Turkey. This study was conducted between March 2018 and August 2018 (6 months) in pregnant women. Pregnant women with chronic disease and receiving treatment during antenatal follow-up, with twin pregnancy, with a fetus with a congenital abnormality, and nutritional disturbance were excluded from the study. Eight hundred twelve pregnant women with normal antenatal follow-up and who volunteered to participate were included in the study.

Results:

The mean age of the participants was 27.66 ± 5.05 years. The mean weight and BMI before pregnancy were near standard in all participants. The group with the highest rate of recommended weight gain according to BMI before pregnancy was the group with low weight pregnant women. The ideal weight gain rate in all groups was 32%.

Conclusions:

The groups with overweight and obese pregnant women according to BMI before pregnancy had the highest rates of weight gain, above the recommended limits. BMI before pregnancy directly affects weight gain during pregnancy and the importance of pre-pregnancy counseling and weight loss is emphasized once again.

Evidence-based recommendations for energy intake in pregnant women with obesity

BACKGROUND

In women with obesity, excess gestational weight gain (≥270 g/week) occurs in two out of three pregnancies and contributes to metabolic impairments in both mother and baby. To improve obstetrical care, objectively assessed information on energy balance is urgently needed. The objective of this study was to characterize determinants of gestational weight gain in women with obesity.

METHODS

This was a prospective, observational study of pregnant women with obesity. The primary outcome was energy intake calculated by the energy intake-balance method. Energy expenditure was measured by doubly-labeled water and whole-room indirect calorimetry and body composition as 3-compartment model by air displacement plethysmography and isotope dilution in early (13-16 weeks) and late pregnancy (35-37 weeks).

RESULTS

In pregnant women with obesity (n=54), recommended weight gain (n=8, 15%) during the second and third trimesters was achieved when energy intake was 125±52 kcal/d less than energy expenditure. In contrast, women with excess weight gain (67%) consumed 186±29 kcal/d more than they expended (P<0.001). Energy balance affected maternal adiposity (recommended: -2.5±0.8 kg fat mass, excess: +2.2±0.5, inadequate: -4.5±0.5, P<0.001), but not fetal growth. Weight gain was not related to demographics, activity, metabolic biomarkers, or diet quality. We estimated that energy intake requirements for recommended weight gain during the second and third trimesters were not increased as compared to energy requirements early in pregnancy (34±53 kcal/d, P=0.83).

CONCLUSIONS

We here provide the first evidence-based recommendations for energy intake in pregnant women with obesity. Contrary to current recommendations, energy intake should not exceed energy expenditure.

FUNDING

This study was funded by the National Institutes of Health (R01DK099175; Redman, U54GM104940 and P30DK072476; Core support).

TRIAL REGISTRATION

clinicaltrials.gov: NCT01954342.

One-year postpartum anthropometric outcomes in mothers and children in the LIFE-Moms lifestyle intervention clinical trials

BACKGROUND/OBJECTIVES

Excess gestational weight gain (GWG) is a risk factor for maternal postpartum weight retention and excessive neonatal adiposity, especially in women with overweight or obesity. Whether lifestyle interventions to reduce excess GWG also reduce 12-month maternal postpartum weight retention and infant weight-for-length z score is unknown. Randomized controlled trials from the LIFE-Moms consortium investigated lifestyle interventions that began in pregnancy and tested whether there was benefit through 12 months on maternal postpartum weight retention (i.e., the difference in weight from early pregnancy to 12 months) and infant-weight-for-length z scores.

SUBJECTS/METHODS

In LIFE-Moms, women (N = 1150; 14.1 weeks gestation at enrollment) with overweight or obesity were randomized within each of seven trials to lifestyle intervention or standard care. Individual participant data were combined and analyzed using generalized linear mixed models with trial entered as a random effect. The 12-month assessment was completed by 83% (959/1150) of women and 84% (961/1150) of infants.

RESULTS

Compared with standard care, lifestyle intervention reduced postpartum weight retention (2.2 ± 7.0 vs. 0.7 ± 6.2 kg, respectively; difference of -1.6 kg (95% CI -2.5, -0.7; p = 0.0003); the intervention effect was mediated by reduction in excess GWG, which explained 22% of the effect on postpartum weight retention. Lifestyle intervention also significantly increased the odds (OR = 1.68 (95% CI, 1.26, 2.24)) and percentage of mothers (48.2% vs. 36.2%) at or below baseline weight at 12 months postpartum (yes/no) compared with standard care. There was no statistically significant treatment group effect on infant anthropometric outcomes at 12 months.

CONCLUSIONS

Compared with standard care, lifestyle interventions initiated in pregnancy and focused on healthy eating, increased physical activity, and other behavioral strategies resulted in significantly less weight retention but similar infant anthropometric outcomes at 12 months postpartum in a large, diverse US population of women with overweight and obesity.

[Blood pressure levels and associated factors among pregnant women of the MINA-Brazil Study]

The scope of this study was to investigate the factors associated with blood pressure levels among pregnant women participating in the MINA-Brazil Study, registered in the Family Health Strategy in Cruzeiro do Sul in the Western Brazilian Amazon. Multiple linear regression models were used, adopting a level of significance of 5%. The majority of pregnant participants were less than 24 years of age, 44% were primigravidae, and 59.1% had excessive weekly gestational weight gain. The frequency of hypertension was 0.7%. Factors positively associated with systolic blood pressure levels in pregnancy were pre-pregnancy body mass index (β = 0.984, CI95%: 0.768-1.200), and weekly gestational weight gain (β = 6.816, CI95%: 3.368-10.264). Diastolic blood pressure levels in pregnancy were positively associated with maternal age (β = 0.111, CI95%: 0.002-0.221), maternal schooling (β = 2.194, CI95%: 0.779-3.609), pre-pregnancy body mass index (β = 0.589, CI95%: 0.427-0.751), and weekly gestational weight gain (β = 3.066, CI95%: 0.483-5.650). These findings stress the importance of the role of antenatal care to prevent hypertensive disorders during pregnancy.

Nutrition and Exercise Strategies to Prevent Excessive Pregnancy Weight Gain: A Meta-analysis

Objective  To evaluate nutrition-only, exercise-only, and nutrition-plus-exercise interventions for optimizing gestational weight gain (GWG) based on the 2009 Institute of Medicine (IOM) guidelines. Study  PubMed, Google Scholar, and 2015 Cochrane Review were searched. Analysis of variance was used to determine if significant GWG differences exist between strategies, with additional subanalyses on overweight (OV) or obese women based on 2009 IOM guidelines. Results  Of 66 identified studies, 31 contributed data ( n  = 8,558). Compared with routine prenatal care, nutrition-only interventions were significantly associated with reduced GWG and are most likely to produce weight gain within IOM recommendations ( p  = 0.013). Exercise-only ( p  = 0.069) and nutrition-plus-exercise ( p  = 0.056) interventions trended toward GWG within IOM guidelines, but did not reach statistical significance. Supervised ( p  = 0.61) and unsupervised ( p  = 0.494) exercise programs had similar effectiveness. Subanalyses on OV or obese women produced similar results to studies that did not differentiate results based on body mass index: nutrition only ( p  = 0.011), exercise only ( p  = 0.308), and nutrition plus exercise ( p  = 0.129). Conclusion  Preventing excessive GWG is crucial, especially for OV or obese women. In the current study, nutrition-based intervention is the health system strategy that showed significant impact on preventing excessive GWG compared with routine prenatal care. Among women who are OV or have obesity, nutrition-only interventions hold the most promise compared with routine prenatal care.