The Maternal Obesity Management (MOM) Trial Protocol: a lifestyle intervention during pregnancy to minimize downstream obesity

Population characteristics associated with adherence to prenatal group-based exercise programs

Community-based supervised group exercise may be an effective option to increase activity levels throughout pregnancy. Previous studies that have explored predictors of low adherence to exercise during pregnancy have not examined group-based settings. We analysed an international cohort of 347 pregnant women who participated in group-based prenatal exercise interventions (from <20 weeks to 34-36 weeks pregnant). Probable adherence predictors informed by previous literature that were assessed included: pre-pregnancy physical activity level and body mass index (BMI) classification, age, number of previous pregnancies, and education level. Adherence was measured by attendance. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated to explore the relationship between the selected predictors and high adherence (≥70%). Post-secondary education level versus only secondary (aOR 5.28; CI 1.67; 16.72) or primary level (aOR 13.82; CI 4.30; 44.45) presented greater likelihood to have high adherence to the exercise intervention than low adherence. Future research and public health initiatives should consider implementing strategies to overcome education-related barriers to improve accessibility to prenatal exercise.

Current Researches, Rationale, Plausibility, and Evidence Gaps on Metformin for the Management of Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) are a group of morbid pregnancy complications, with preeclampsia (PE) being the most common subclassification among them. PE affects 2%–8% of pregnancies globally and threatens maternal and fetal health seriously. However, the only effective treatment of PE to date is the timely termination of pregnancy, albeit with increased perinatal risks. Hence, more emerging therapies for PE management are in urgent need. Originally introduced as the first-line therapy for type 2 diabetes mellitus, metformin (MET) has now been found in clinical trials to significantly reduce the incidence of gestational hypertension and PE in pregnant women with PE-related risks, including but not limited to pregestational diabetes mellitus, gestational diabetes mellitus, polycystic ovary syndrome, or obesity. Additionally, existing clinical data have preliminarily ensured the safety of taking MET during human pregnancies. Relevant lab studies have indicated that the underlying mechanism includes angiogenesis promotion, endothelial protection, anti-inflammatory effects, and particularly protective effects on trophoblast cells against the risk factors, which are beneficial to placental development. Together with its global availability, easy administration, and low cost, MET is expected to be a promising option for the prevention and treatment of PE. Nevertheless, there are still some limitations in current studies, and the design of the relevant research scheme is supposed to be further improved in the future. Herein, we summarize the relevant clinical and experimental researches to discuss the rationale, safety, and feasibility of MET for the management of HDP. At the end of the article, gaps in current researches are proposed. Concretely, experimental MET concentration and PE models should be chosen cautiously. Besides, the clinical trial protocol should be further optimized to evaluate the reduction in the prevalence of PE as a primary endpoint. All of those evidence gaps may be of guiding significance to improve the design of relevant experiments and clinical trials in the future.

Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

O impacto do uso da metformina para gestantes obesas na prevenção da pré-eclâmpsia

Objetivos: o artigo objetiva avaliar o uso de metformina em gestantes obesas na prevenção da pré-eclâmpsia.Métodos: trata-se de um ensaio clínico randomizado com mulheres grávidas obesas com índice de massa corporal superior ou igual a 30 kg/m2 divididos em dois grupos – um grupo de estudo, que utilizou metformina, e um grupo controle, que seguiu a rotina de pré-natal. As gestantes entraram no estudo com idade gestacional menor que 20 semanas e foram acompanhadas durante todo o período pré-natal. O diagnóstico de pré-eclâmpsia foi feito de acordo com os critérios da Organização Mundial de Saúde.Resultados: verificou-se a redução de risco absoluto e o número necessário para tratar em um intervalo de confiança de 95% para o resultado pré-eclâmpsia. Nos resultados, 272 gestantes foram avaliadas. No grupo de estudo (n = 127), oito (6,3%) desenvolveram pré-eclâmpsia. No grupo controle (n = 145), 31 (21,4%) tiveram a doença (p <0,01).Conclusão: o estudo apontou uma redução de risco absoluto de 15,1 vezes (IC95%: 7,1-22,9) e número necessário para tratar de sete (IC95%: 4,4-13,9). O uso de 1000 miligramas diárias de metformina indicou uma redução de 15,1 vezes no risco absoluto de pré-eclâmpsia na população estudada, com a necessidade de tratar sete gestantes para evitar um desfecho.

Stunting and overweight among children in Northeast Brazil: prevalence, trends (1992-2005-2015) and associated risk factors from repeated cross-sectional surveys

Background

A study involving children from Alagoas (Northeast Brazil) revealed that, as a consequence of a drastic reduction in the prevalence of stunting between 1992 to 2005, (22.5 to 11.4%) combined with an increase in overweight prevalence (6.7 to 9.3%), the prevalence of these two conditions in 2005 was very close. If these trends were maintained, it is very likely that, at this time, the childhood overweight prevalence has already exceeded that of the stunting. However, no study is available to confirm this hypothesis. The identification of these changes is relevant to the planning and evaluation of public policies. This study aimed to investigate the prevalence, time trends and associated factors with stunting and overweight in children from Alagoas.

Methods

Independent cross-sectional household surveys were conducted in 1992 (n = 1231), 2005 (n = 1381) and 2015 (n = 988). Data were collected from probabilistic samples of children aged 0–60 months. Stunting was defined by stature-for-age < − 2 sd and overweight by weight-for-stature > 2 sd.

Results

Between 1992, 2005 and 2015, the stunting prevalence was 22.6, 11.2 and 3.2% (reduction of 85.8%), while the overweight prevalence was 6.9, 7.5 and 14.9% (increase of 115.9%), respectively. After multivariate analysis, the following positive associations with stunting were observed in 1992: age group > 24 months (28.3% vs 14.5%), mother with ≥2 children (28.8% vs 12.8%), low birth weight (28.3% vs 15.7%) and mother with low schooling (29.3% vs 7.2%). In 2015 there was a higher prevalence of stunting in males (4.2% vs 2.2%), in children < 24 months (4.6% vs 2.2%), with low birth weight (8.6% vs 3.0%) and in those who had mothers with low schooling (7.0% vs 2.6%). Regarding overweight, in 1992 there was higher prevalence for male (9.1% vs 4.7%) and in children whose mothers had ≤2 children (8.9% vs 5.8%), while in 2015 only birth weight >  4 kg was associated to overweight (27.3% vs 14.2%).

Conclusions

During the analyzed period, there was a significant decrease in stunting prevalence. At the same time, a substantial increase was observed in the overweight prevalence. Currently, stunting is a problem of low magnitude, while overweight has become a worrying public health problem.

Supporting women of childbearing age in the prevention and treatment of overweight and obesity: a scoping review of randomized control trials of behavioral interventions

BACKGROUND

Women of childbearing age are vulnerable to weight gain. This scoping review examines the extent and range of research undertaken to evaluate behavioral interventions to support women of childbearing age to prevent and treat overweight and obesity.

METHODS

Eight electronic databases were searched for randomized controlled trials (RCT) or systematic reviews of RCTs until 31st January 2018. Eligible studies included women of childbearing age (aged 15-44 years), evaluated interventions promoting behavior change related to diet or physical activity to achieve weight gain prevention, weight loss or maintenance and reported weight-related outcomes.

RESULTS

Ninety studies met the inclusion criteria (87 RCTs, 3 systematic reviews). Included studies were published from 1998 to 2018. The studies primarily focused on preventing excessive gestational weight gain (n = 46 RCTs, n = 2 systematic reviews), preventing postpartum weight retention (n = 18 RCTs) or a combination of the two (n = 14 RCTs, n = 1 systematic review). The RCTs predominantly evaluated interventions that aimed to change both diet and physical activity behaviors (n = 84) and were delivered in-person (n = 85).

CONCLUSIONS

This scoping review identified an increasing volume of research over time undertaken to support women of childbearing age to prevent and treat overweight and obesity. It highlights, however, that little research is being undertaken to support the young adult female population unrelated to pregnancy or preconception.

Comparison of adequacy of birth weight for gestational age according to different intrauterine growth curves

Abstract Objectives: to compare the assessment of the adequacy of birth weight for gestational age according to different intrauterine growth curves. Methods: across-sectional study, which analyzed gestational and neonatal information from 344 mother-newborn binomials. Birth weight data were analyzed using the International Fetal and New Born Growth Consortium for the 21st Century (INTERGROWTH-21st) and compared with the growth curves proposed by Alexander et al. and Fenton & Kim. Newborns were classified as small for gestational age (SGA), suitablefor gestational age (SUGA) or large for gestational age (LGA). Results: among the newborns, 51.2% were male, and 93.0% were born at term. Higher prevalence of SUGA and LGA and lower SGA was found by the INTERGROWTH-21st curves when compared to the references of Fenton & Kim and Alexander et al. Moderate agreement was observed in detecting birth weight by different growth curves. Conclusions: there was a lower detection of SGA infants and a higher screening, especially of LGA infants, in the INTERGROWTH-21st evaluation, when compared to the growth curves of Fenton & Kim and Alexander et al.

Using the theoretical domains framework to explore primary health care practitioner's perspectives and experiences of preconception physical activity guidance and promotion

Preconception physical activity is one of the main predictors of continued engagement in physical activity during and after pregnancy and subsequently, improves the health of women and their child. In the UK, guidance states that Primary Care health Professionals (PCPs) should assess and discuss the lifestyle of preconception women, in routine appointments, in order to address potentially modifiable risk factors. However, knowledge and provision of this guidance in the UK is unknown. It is not clear if individuals actively seek preconception guidance from PCPs, what guidance they request, and whether PCPs have the knowledge and skills to provide this support in line with current guidelines. This research aimed to explore current practice and the perspectives of PCPs in delivering physical activity guidance to preconception patients. Fifteen semi-structured interviews were conducted with PCPs (GPs and community pharmacists) in the UK. Data was analysed using the Theoretical Domains Framework (TDF). Our findings showed patients did not frequently present solely for preconception physical activity guidance, but occasionally enquired when consulting about another issue. PCPs lacked motivation to implement physical activity guidance due to the perception that their advice would have no impact on behaviour change. There were a number of perceived opportunities to implement preconception physical activity guidance. These findings illustrate the need for consistent and specific preconception lifestyle and PA guidance for PCPs.

Women's recall of health care provider counselling on gestational weight gain (GWG): a prospective, population-based study

BACKGROUND

Prenatal care has been validated to provide medical and educational counselling intended to reduce the risk of adverse pregnancy conditions and improve the maternal and fetal outcomes. Prenatal targeted information regarding nutrition, lifestyle, and weight gain is predictive of meeting Institute of Medicine (IOM) 2009 gestational weight gain (GWG) guidelines. There is limited information about women's experiences with these prenatal counselling domains, particularly in women who do not meet GWG recommendations. The objective of this study was to evaluate the impact of women's recall of prenatal counselling and its effect on meeting their GWG within guidelines in a prospective, community-based pregnancy cohort.

METHODS

A sample of 2909 women with singleton pregnancies was drawn from the prospective community-based pregnancy cohort All Our Families from Alberta, Canada. Women were stratified into three GWG groups, adequate, inadequate, and excessive GWG, based on pre-pregnancy BMI and the adherence to the Institute of Medicine weight gain in pregnancy guidelines. At less than 25 and 34 to 36 weeks' gestation, maternal socio-demographic information and women's recall of prenatal counselling experiences was collected through self-administered questionnaires. Multivariate logistic regression analyses tested GWG strata impact on women's recall of the prenatal counselling advice in eight domains of nutrition, lifestyle, and weight management during pregnancy.

RESULTS

Adequate GWG was reached by 35.9% of women, 46.5% gained excessive and 17.6% gained inadequate weight. Women who were overweight and obese prior to pregnancy were more likely to gain excessive weight than women who were normal weight (OR 3.3, 95% CI 2.6-4.1; and OR 2.9, 95% CI 2.1-3.9, respectively). Most women reported having no difficulties in finding prenatal care, felt comfortable with their health care provider and were satisfied with the answers received. There was no difference in the recall of prenatal advice received in any of the eight domains of prenatal counselling assessed among women with appropriate and non-optimal GWG.

CONCLUSION

Women with adequate and non-optimal GWG received comparable prenatal counselling on nutrition, weight gain, and lifestyle modifications. There remain missed opportunities in targeting prenatal counselling advice to women at risk for suboptimal or excessive GWG.

Appropriate Interventions for Pregnant Women with Indicators of Metabolic Syndrome on Pregnancy Outcomes: A Systematic Review

Metabolic syndrome (MetS), a series of symptoms, including abdominal obesity, impaired glucose tolerance and insulin metabolism, hypertension, and dyslipidemia, is considered as the risk of developing cardiovascular disease and diabetes that can predispose a pregnant women to serious health problem, women in the developed as well as the developing countries. This study was aimed to investigate the effects of appropriate interventions on pregnant women with indicators of MetS to further improve the outcome of pregnancy. This systematic review was performed to extract articles of randomized controlled trials (RCT) on pregnant women with indicators of (MetS) and focusing on physical activity, dietary or lifestyle interventions on maternal health or perinatal outcomes, with searching in the Web of Science, PubMed, CDSR, Scopus, and Google Scholar were investigated. Two researchers independently evaluated the quality of the studies, being presented in all the articles and ranked the studies as high/low quality; the level of evidence was based on the number of high-quality studies and the coordination of the obtained results. Then, 17 articles, which met the inclusion criteria, were selected; among these, 7 articles studied the physical activity, 3 articles reviewed diets, 6 probed the lifestyle interventions, and 1 article was on counseling. In general, evidence suggested how the physical activity and proper diet impacts on proper weight gain during pregnancy, prevents maternal complications, and improves the outcome of pregnancy. According to the results of this systematic review, proper interventions during pregnancy can have a positive effect on maternal weight gain and the general health condition of pregnant women with indicators of MetS.

Development and pilot evaluation of a pregnancy-specific mobile health tool: a qualitative investigation of SmartMoms Canada

Background

Mobile technology is ubiquitous. Women of childbearing age have embraced health information technology for pregnancy-related counsel as prenatal care provider communication is increasingly scarce and brief. Pregnant women and new mothers place high value in the use of online sources to support their pregnancy information needs. In Canada, over 300,000 women are pregnant annually, with approximately 60% exceeding evidence-based weight gain recommendations. Mobile health (mHealth) tools, such as mobile applications (app), have the potential to reduce excessive gestational weight gain, offering pregnant women trustworthy guidance, ultimately improving the health outcomes of mothers and infants. Therefore, the primary aim of this study was to implement a qualitative, descriptive research design to assess the receptiveness, functionality, and future prospective of the SmartMoms Canada mHealth app.

Methods

Two focus groups (n = 13) involving both currently pregnant and recently postpartum women were organized on the same day. Focus groups were transcribed verbatim and thematic analysis was undertaken using manual coding and NVivo software. Participants who took part in the focus groups (n = 13) and those who could not attend (n = 4) were asked to complete a Likert-scale survey. All survey responses (n = 17) were analyzed using simple tabulation and percentage analysis.

Results

Participants were technologically proficient and interacted with several mHealth tools prior to testing the SmartMoms Canada app. Six major themes emerged from thematic analysis: knowledge of pregnancy-specific mHealth services, knowledge and attitudes of weight gain guidelines, weight tracking, strengths of the app, critique and lastly, future suggestions for the app.

Conclusions

Our thematic analysis found that women positively viewed the future potential of our app and offered constructive feedback to improve the next version. Participants sought more personalization and enhanced app interactivity, along with promotion of overall maternal health including nutrition and mental health, in addition to weight tracking.

Neurodevelopment in 3-4 year old children exposed to maternal hyperglycemia or adiposity in utero

BACKGROUND

Prenatal exposure to maternal metabolic complications has been linked to offspring neurodevelopmental problems. However, no studies investigating these links have examined the role of maternal prenatal diet.

AIMS

To determine if prenatal exposure to maternal adiposity or hyperglycemia is associated with neurodevelopmental problems in 3-4 year old children, and if links persist following adjustment for confounding variables, including prenatal diet.

METHOD

808 mother-child pairs from the Maternal-Infant Research on Environmental Chemicals-Child Development Plus cohort were used to examine associations between pre-pregnancy body mass index (BMI), hyperglycemia and offspring verbal, performance and full-scale IQ scores, as well as internalizing and externalizing problems. Associations were examined before and after adjustment for prenatal diet along with home environment, maternal depression, education and prenatal smoking. Semi-partial correlations were examined post-hoc to assess the impact of each confounder in the adjusted models.

RESULTS

In the unadjusted models, BMI and hyperglycemia predicted lower verbal and full-scale IQ. BMI was also linked to externalizing problems. However, associations were not significant after adjustment. In adjusted models, post-hoc analysis revealed that prenatal diet and home environment accounted for significant variance in verbal and full-scale IQ. The home environment and maternal depression accounted for significant variance in externalizing problems.

CONCLUSION

In the adjusted models, maternal metabolic complications were not associated with offspring neurodevelopment. Even while adjusting for well-known risk factors for adverse offspring cognition (home environment, maternal depression), we show for the first time that maternal prenatal diet is an important confounder of the links between maternal metabolic complications and offspring cognition.

Estado nutricional materno e sua associação com o peso ao nascer em gestações de alto risco

Resumo O estado clínico e o nutricional da gestante representam importantes variáveis para o risco de inadequações de peso ao nascer. Assim, o presente estudo visou avaliar o estado nutricional de gestantes de alto risco e sua associação com o peso ao nascer de seus conceptos. Estudo transversal com gestantes de alto risco assistidas no Hospital Universitário de Maceió-AL e seus recém-nascidos. O estado nutricional das gestantes e de seus conceptos foi avaliado segundo o Índice de Massa Corporal para a idade gestacional e o peso ao nascer, respectivamente. A associação entre fatores maternos (comorbidades e estado nutricional) e o peso ao nascer foram realizadas pelos testes de qui-quadrado e correlação de Pearson, adotando um nível de confiança de 95% (α = 0,05). Foram estudadas 149 gestantes, com 19,7% delas com baixo peso; 32,0% eutróficas e 48,3% com excesso de peso. Entre os recém-nascidos, 39,6% eram pequenos para idade gestacional (PIG); 26,8% adequados para a idade gestacional (AIG) e 33,6% grandes para a idade gestacional (GIG). O excesso de peso gestacional e a presença de comorbidades metabólicas se associaram com o nascimento de recém-nascidos GIG e o ganho ponderal gestacional insuficiente com o nascimento de recém-nascidos PIG, sendo fundamentais intervenções para redução desses desfechos.

Dyslipidemia and maternal obesity: Prematurity and neonatal prognosis

Summary Objective: To identify the changes caused by dyslipidemia and obesity in pregnancy suggesting causes for premature birth, and the prognosis for the newborn. Method: Systematic review based on the Medline, Lilacs, Embase and Cochrane library databases between 1996 and 2016. The search for studies included the following keywords: “dyslipidemia, pregnancy, obesity, preterm birth.” A protocol was programmed and a protocol for inclusion/exclusion of studies was implemented. Results: Of the 5,789 articles initially selected between March 1996 and July 2016, only 32 were in accordance with the established criteria. Of these, 28.12% discussed risk factors of prematurity; 37.50%, metabolic alterations and gestational dyslipidemia; 21.87%, dyslipidemic complications in preterm birth; and 12,50%, lipid metabolism, glycemic and placental transfer. Conclusion: There is a reduced adaptation of obese pregnant women to the metabolic changes of gestation. This favors dyslipidemic intercurrences in the mother, which, directly or indirectly, suggests the occurrence of premature births and high lipid transfer to the fetus. Therefore, preterm newborns, whose mothers were dyslipidemic during pregnancy, have greater risk of epicardial fat, both in early (first year of life) and in later (adult) phases of life.

Psychosocial predictors of gestational weight gain and the role of mindfulness

OBJECTIVE

To identify the psychosocial factors (i.e., stress, anxiety, depression, social support) that are associated with gestational weight gain (GWG) and the relationship of mindfulness with GWG during each trimester of pregnancy.

DESIGN

In this cross-sectional study, an online survey that assessed physical and mental health and wellness practices was administered to pregnant women.

PARTICIPANTS

Pregnant women ≥8 weeks gestation, ≥18 years old, and could read and write in English.

MEASUREMENT AND FINDINGS

Women who responded to the survey (N=1,073) were on average 28.7±4.6 years old. Findings from a regression analysis suggest that increased levels of depression may be predictive of increased GWG in the second trimester and decreased levels of mindfulness may be predictive of increased GWG in the first trimester. Anxiety, stress, and overall social support were not associated with GWG in any trimester.

KEY CONCLUSIONS

Mindfulness-based strategies (e.g., yoga) may have the potential to manage both depression and excessive GWG and may beneficial for and preferred by pregnant women. More research is warranted to determine clear relationships between psychosocial health, mindfulness, and GWG.

IMPLICATIONS FOR PRACTICE

Health care providers are encouraged to screen for depression in early pregnancy (i.e., first or second trimester) and provide resources to manage symptoms of depression and GWG to promote optimal birth outcomes. Health care providers may want to counsel patients on how to manage depression and/or GWG by suggesting mindfulness-based approaches.

Perceptions, Uses of, and Interests in Complementary Health Care Approaches in Depressed Pregnant Women: The PAW Survey

Depression affects up to 23% of pregnant women and is associated with adverse physical/mental health outcomes for both the mother and baby. Depressed pregnant women may be more likely to engage in unhealthy lifestyle behaviors that contribute to an increased risk for chronic disease. Little is known regarding depressed pregnant women's perceptions, uses of, and interests in complementary health approaches. Study participants (mean age 28.7 ± 6.8; n = 1032) included pregnant women ≥8 weeks gestation who responded to a survey assessing physical and mental health and wellness practices. Of those completing the survey, depressed pregnant women (n = 272) had significantly higher levels of anxiety (P < .001) and stress (P < .001) and had poorer sleep quality (P < .001), mindfulness (P < .001), and social support (P < .001) compared to nondepressed pregnant women (n = 760). A majority (84%) of depressed pregnant women would consider using a complementary health approach for weight and/or stress management during pregnancy, and more than 50% were interested in yoga.

Effect of simple, targeted diet in pregnant women with metabolic risk factors on maternal and fetal outcomes (ESTEEM): study protocol for a pragmatic multicentre randomised trial

INTRODUCTION

Women with metabolic risk factors are at higher risk of adverse pregnancy outcomes. Mediterranean-based dietary interventions have the potential to minimise these risks. We aim to evaluate the effectiveness of a simple, targeted intervention modelled on Mediterranean diet in preventing maternal and fetal complications in pregnant women with metabolic risk factors.

METHODS AND ANALYSIS

Pregnant women with a singleton pregnancy <18 weeks gestation, and without pre-existing diabetes, chronic renal disease and autoimmune diseases will be recruited. Women with metabolic risk factors will be randomised to receive a dietary intervention based on a Mediterranean pattern, supplemented with extra virgin olive oil and mixed nuts until delivery. The intervention will be delivered through a series of one to one and group sessions. The primary outcome is a composite maternal outcome of pre-eclampsia or gestational diabetes and a composite fetal outcome of stillbirth, small for gestational age fetus or admission to the neonatal intensive care unit. Secondary outcomes include maternal, fetal, dietary and laboratory outcomes. We aim to randomise 1230 eligible women with metabolic risk factors. We will also compare the outcomes in women with and without these risk factors. The sample size will provide us with 80% power at 5% significance, assuming a 20% loss to follow-up to detect a 30% reduction in maternal and fetal complications.

ETHICS AND DISSEMINATION

The ESTEEM trial is designed to provide a definitive estimate of the effects of Mediterranean dietary pattern in pregnancy on maternal and fetal outcomes. The pragmatic nature of ESTEEM ensures the applicability of its findings into clinical practice. The findings of the study will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the NHS Research Ethics Committees (14/EE/1048).

TRIAL REGISTRATION NUMBER

NCT02218931; Pre-results.

Just DO(HaD) It! Testing the clinical potential of the DOHaD hypothesis to prevent mental disorders using experimental study designs

Optimal early cognitive and emotional development are vital to reaching one's full potential and represent our best chance to improve the mental health of the population. The developmental origins of health and disease (DOHaD) hypothesis posits that adverse perinatal exposures can alter physiology and increase disease risk. As physiological plasticity decreases with age, interventions applied during gestation may hold the most promise for reducing the impact of mental disorders across the lifespan. However, this vast clinical potential remains largely unrealized as the majority of human DOHaD research is observational in nature. The application of more rigorous experimental designs [e.g. Randomized Controlled Trials (RCTs)] not only represents a major step toward unlocking this potential, but are required to fully test the scientific validity of the DOHaD hypothesis as it pertains to mental illness. Here, we argue that the optimization of maternal diet and exercise during pregnancy represents our best chance to improve offspring neurodevelopment and reduce the burden of mental disorders. Follow-up studies of the offspring of pregnant women enrolled in new and existing RCTs of maternal gestational nutrition+exercise interventions are required to determine if acting during pregnancy can prevent and/or meaningfully reduce the prevalence and severity of mental disorders in the population.

Excess weight and dyslipidemia and their complications during pregnancy: a systematic review

Abstract Objectives: to identify bibliographically disorders related to excess weight, dyslipidemia and their complication during pregnancy and in the fetus and newborn. Methods: a systematic review including observational and interventional studies and reviews, based on MEDLINE, LILACS, Embase and the Cochrane Library between 2000 and 2015. The key-words "lipids, pregnancy, obesity and newborn" were used to establish a selective stage for inclusion/exclusion of titles, repeated studies, key-words, abstracts, methodological incompatibility and correlation with objectives. Results: 58 studies were selected, of which 36 (62%) addressed prevention and the risk in pregnancy of excess weight and lipid disorders and 19 (32.7%) suggestions and/or consequences for the fetus and newborn. Conclusions: excess weight and lipidemic disorders in pregnancy are causes for concern in scientific studies, posing risks both for the mother and the newborn. Higher prevalence of caesarian and pre-eclampsia were the two most noteworthy complications for gestational outcomes. In short, the impact on care of maternal habits and excess weight during pregnancy is highly significant, owing to the different degrees of complication in obstetric outcomes and their influence on the clinical characteristics of the newborn.

Certified Nurse-Midwives' Experiences with Gestational Weight Management

Excessive gestational weight gain is associated with fetal metabolic reprogramming and subsequent childhood obesity, as well as maternal recalcitrant obesity and its successive morbidities. We conducted a review of the literature and an explorative, descriptive study of the techniques and strategies used by a subset of certified nurse-midwives to help women achieve optimal gestational weight gain. We also identified barriers to this outcome. With more effective management approaches to gestational weight gain, adverse maternal and neonatal health outcomes could potentially be prevented. http://dx.doi.org/10.1016/j.nwh.2015.12.007.

The early origins of obesity and insulin resistance: timing, programming and mechanisms

Maternal obesity is associated with an increased risk of developing gestational diabetes mellitus and it also results in an increased risk of giving birth to a large baby with increased fat mass. Furthermore, it is also contributes to an increased risk of obesity and insulin resistance in the offspring in childhood, adolescence and adult life. It has been proposed that exposure to maternal obesity may therefore result in an 'intergenerational cycle' of obesity and insulin resistance. There is significant interest in whether exposure to maternal obesity around the time of conception alone contributes directly to poor metabolic outcomes in the offspring and whether dieting in the obese mother before pregnancy or around the time of conception has metabolic benefits for the offspring. This review focusses on experimental and clinical studies that have investigated the specific impact of exposure to maternal obesity during the periconceptional period alone or extending beyond conception on adipogenesis, lipogenesis and on insulin signalling pathways in the fat, liver and muscle of the offspring. Findings from these studies highlight the need for a better evidence base for the development of dietary interventions in obese women before pregnancy and around the time of conception to maximize the metabolic benefits and minimize the metabolic costs for the next generation.

Maternal Factors and Adverse Perinatal Outcomes in Women with Preeclampsia in Maceió, Alagoas

Background

Preeclampsia has been associated with several risk factors and events. However, it still deserves further investigation, considering the multitude of related factors that affect different populations.

Objective

To evaluate the maternal factors and adverse perinatal outcomes in a cohort of pregnant women with preeclampsia receiving care in the public health network of the city of Maceió.

Methods

Prospective cohort study carried out in 2014 in the public health network of the city with a sample of pregnant women calculated based on a prevalence of preeclampsia of 17%, confidence level of 90%, power of 80%, and ratio of 1:1. We applied a questionnaire to collect socioeconomic, personal, and anthropometric data, and retrieved perinatal variables from medical records and certificates of live birth. The analysis was performed with Poisson regression and chi-square test considering p values < 0.05 as significant.

Results

We evaluated 90 pregnant women with preeclampsia (PWP) and 90 pregnant women without preeclampsia (PWoP). A previous history of preeclampsia (prevalence ratio [PR] = 1.57, 95% confidence interval [95% CI] 1.47 - 1.67, p = 0.000) and black skin color (PR = 1.15, 95% CI 1.00 - 1.33, p = 0.040) were associated with the occurrence of preeclampsia. Among the newborns of PWP and PWoP, respectively, 12.5% and 13.1% (p = 0.907) were small for gestational age and 25.0% and 23.2% (p = 0.994) were large for gestational age. There was a predominance of cesarean delivery.

Conclusion

Personal history of preeclampsia and black skin color were associated with the occurrence of preeclampsia. There was a high frequency of birth weight deviations and cesarean deliveries.

Systematic review of antenatal dietary and lifestyle interventions in women with a normal body mass index

INTRODUCTION

Women who commence pregnancy with a normal body mass index (BMI) are at the greatest risk of excessive gestational weight gain, impacting on infant birthweight, pregnancy-related complications and postpartum weight retention. Our aim was to review systematically the effect of antenatal dietary and lifestyle interventions in pregnant women with a normal BMI on maternal and infant outcomes.

MATERIAL AND METHODS

We searched the Cochrane Controlled Trials Register, PubMed, Medline, and the Australian and International Clinical Trials Registry with the date of the last search in July 2015. We included all published, unpublished and ongoing randomized trials recruiting women of a normal BMI, comparing dietary and/or lifestyle interventions with standard antenatal care.

RESULTS

Twelve randomized controlled trials were identified, involving a total of 2713 pregnant women, with five studies reporting clinical data for 714 women with a normal BMI. Women who received a dietary and lifestyle intervention were less likely to experience gestational weight gain [four studies, 446 women; mean difference -1.25 kg; 95% confidence interval (CI) -2.39 to -0.11], weight gain above the Institute of Medicine guidelines (four studies, 446 women; risk ratio 0.66; 95% CI 0.53-0.83) and hypertension (two studies; 243 women; risk ratio 0.34; 95% CI 0.13-0.91). There were no statistically significant differences in the occurrence of gestational diabetes, cesarean section or birthweight greater than 4 kg.

CONCLUSIONS

While providing an antenatal dietary and lifestyle intervention for pregnant women of normal BMI appears to reduce gestational weight gain, the review was limited by the relatively small available sample size. Further well-designed randomized controlled trials are required.

Mindfulness Meditation to Promote Wellness and Manage Chronic Disease

Lifestyle medicine is a patient-engaged field that has grown in tandem with our increasing knowledge of the importance of lifestyle factors and modifiable health behaviors for disease prevention, health promotion, and the management of chronic illness. Stress is at the epicenter of many negative behaviors that contribute to unhealthy lives, such as smoking, overeating, and unhealthy diets, and lack of activity. Mindfulness meditation is a stress reduction practice that teaches awareness, appreciation, and nonjudgmental acceptance of one’s present experience, thereby short-circuiting reactive, automatic stress reactions. Our systematic review and meta-analysis focuses on the application of randomized controlled mindfulness intervention studies across a broad range of populations and conditions that are relevant to lifestyle medicine. In addition to organizing and highlighting mindfulness research studies that are relevant to the field of lifestyle medicine, we also empirically examine the impact of study design issues (eg, use of different controls, intervention length and duration, sample size, primary outcomes) on the magnitude of effect of mindfulness interventions in lifestyle medicine. Overall, this systematic review and meta-analysis found partial evidence for mindfulness-based interventions to provide short-term benefits across a wide range of lifestyle medicine–relevant populations and study outcomes, particularly focusing on the areas of diet and weight management and symptom burden. Numerous outcome measures were used; however, the most common were the Perceived Stress Scale and the State Trait Anxiety Inventory. This analysis also provides evidence for mindfulness-based interventions that have fewer than 20 individuals per group, as well as partial support for interventions that are less than the standard 8 weeks in duration.

Programming of fetal insulin resistance in pregnancies with maternal obesity by ER stress and inflammation

The global epidemics of obesity during pregnancy and excessive gestational weight gain (GWG) are major public health problems worldwide. Obesity and excessive GWG are related to several maternal and fetal complications, including diabetes (pregestational and gestational diabetes) and intrauterine programming of insulin resistance (IR). Maternal obesity (MO) and neonatal IR are associated with long-term development of obesity, diabetes mellitus, and increased global cardiovascular risk in the offspring. Multiple mechanisms of insulin signaling pathway impairment have been described in obese individuals, involving complex interactions of chronically elevated inflammatory mediators, adipokines, and the critical role of the endoplasmic reticulum (ER) stress-dependent unfolded protein response (UPR). However, the underlying cellular processes linking MO and IR in the offspring have not been fully elucidated. Here, we summarize the state-of-the-art evidence supporting the possibility that adverse metabolic postnatal outcomes such as IR in the offspring of pregnancies with MO and/or excessive GWG may be related to intrauterine activation of ER stress response.

Obesity Prevention from Conception: A Workshop to Guide the Development of a Pan-Canadian Trial Targeting the Gestational Period

This report summarizes a meeting, Obesity Prevention from Conception, held in Ottawa in 2012. This planning workshop was funded by the Canadian Institutes of Health Research (CIHR) to bring together researchers with expertise in the area of maternal obesity (OB) and weight gain in pregnancy and pregnancy-related disease to attend a one-day workshop and symposium to discuss the development of a cross-Canada lifestyle intervention trial for targeting pregnant women. This future intervention will aim to reduce downstream OB in children through encouraging appropriate weight gain during the mother’s pregnancy. The workshop served to (i) inform the development of a lifestyle intervention for women with a high pre-pregnancy body mass index (BMI), (ii) identify site investigators across Canada, and (iii) guide the development of a grant proposal focusing on the health of mom and baby. A brief summary of the presentations as well as the focus groups is presented for use in planning future research.

Anthropometrics and body composition by dual energy X-ray in children of obese women: a follow-up of a randomized controlled trial (the Lifestyle in Pregnancy and Offspring [LiPO] study)

OBJECTIVE

In obese women, 1) to assess whether lower gestational weight gain (GWG) during pregnancy in the lifestyle intervention group of a randomized controlled trial (RCT) resulted in differences in offspring anthropometrics and body composition, and 2) to compare offspring outcomes to a reference group of children born to women with a normal Body Mass Index (BMI).

RESEARCH DESIGN AND METHODS

The LiPO (Lifestyle in Pregnancy and Offspring) study was an offspring follow-up of a RCT with 360 obese pregnant women with a lifestyle intervention during pregnancy including dietary advice, coaching and exercise. The trial was completed by 301 women who were eligible for follow-up. In addition, to the children from the RCT, a group of children born to women with a normal BMI were included as a reference group. At 2.8 (range 2.5-3.2) years, anthropometrics were measured in 157 children of the RCT mothers and in 97 reference group children with Body Mass Index (BMI) Z-score as a primary outcome. Body composition was estimated by Dual Energy X-ray (DEXA) in 123 successful scans out of 147 (84%).

RESULTS

No differences between randomized groups were seen in mean (95% C.I.) BMI Z-score (intervention group 0.06 [-0.17; 0.29] vs. controls -0.18 [-0.43; 0.05]), in the percentage of overweight or obese children (10.9% vs. 6.7%), in other anthropometrics, or in body composition values by DEXA. Outcomes between children from the RCT and the reference group children were not significantly different.

CONCLUSIONS

The RCT with lifestyle intervention in obese pregnant women did not result in any detectable effect on offspring anthropometrics or body composition by DEXA at 2.8 years of age. This may reflect the limited difference in GWG between intervention and control groups. Offspring of obese mothers from the RCT were comparable to offspring of mothers with a normal BMI.

Perinatal factors in neonatal and pediatric lung diseases

Wheezing and asthma are significant clinical problems for infants and young children, particularly following premature birth. Recurrent wheezing in infants can progress to persistent asthma. As in adults, altered airway structure (remodeling) and function (increased bronchoconstriction) are also important in neonatal and pediatric airway diseases. Accumulating evidence suggests that airway disease in children is influenced by perinatal factors including perturbations in normal fetal lung development, postnatal interventions in the intensive care unit (ICU) and environmental and other insults in the neonatal period. Here, in addition to genetics, maternal health, environmental processes, innate immunity and impaired lung development/function can all influence pathogenesis of airway disease in children. We summarize current understanding of how prenatal and postnatal factors can contribute to development of airway diseases in neonates and children. Understanding these mechanisms will help identify and develop novel therapies for childhood airway diseases.

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.