The effect of a personalized intervention on weight gain and physical activity among pregnant women in China

The association between dietary, physical activity and the DNA methylation of PPARGC1A, HLA-DQA1 and ADCY3 in pregnant women with gestational diabetes mellitus: a nest case-control study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with DNA methylation and lifestyle. The effects of DNA methylation on GDM, and the interaction between DNA methylation and lifestyle factors are not well elucidated. The objective of this study was to explore the association between GDM, DNA methylation and lifestyle factors.

METHODS

A nest case-control design was performed. Sociodemographic data, dietary intake and daily physical activity information of pregnant women were collected. Bisulfate pyrosequencing was used to detect the DNA methylation level of PPARGC1A, HLA-DQA1, and ADCY3 genes. The differences of DNA methylation levels between the GDM group and the control group were compared. The correlation between clinical characteristics, dietary, physical activity and DNA methylation level was analyzed.

RESULTS

A total of 253 pregnant women were enrolled, of which, 60 participants (GDM: 30; control: 30) were included in the final analysis. There were no significant differences in DNA methylation levels of six methylated sites between the two groups in this study (P > 0.05). Daily intake of potato and poultry were associated with DNA methylation level of the CpG 1 site of the ADCY3 gene in all participants and the control group (P < 0.05). Duration of folic acid intake before pregnancy was correlated with the methylation level of the CpG 1 site of the ADCY3 gene in all participants (r = 0.341, P = 0.04) and the control group (r = 0.431, P = 0.025). Daily oil intake was correlated with the methylation level of CpG 2 (r = 0.627, P = 0.016) and CpG 3 (r = 0.563, P = 0.036) of PPARGC1A in the GDM group.

CONCLUSION

The association between the DNA methylation levels and GDM wasn't validated. There were associations between dietary and DNA methylation in pregnant women. A large-sample-sized and longitudinal study is warranted to further investigate the impacts of lifestyle on DNA methylation.

Theory-based interventions aimed at promoting physical activity in pregnant women: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

The objectives were to assess (i) the quality of theory implementation, (ii) the application of behavior change techniques, and (iii) the effectiveness of theory-based interventions in promoting physical activity in pregnant women and improving maternal and neonatal outcomes.

METHODS

A systematic search was conducted across 8 databases (Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, EMBASE, MEDLINE, APA PsycINFO, PubMed, SPORTDiscus, and Web of Science) to identify randomized controlled trials published from database inception to 8 July 2023. The Cochrane risk-of-bias 2.0 tool was used to evaluate the quality of the included studies. The theory coding scheme was used to measure the quality of theory implementation, and behavior change techniques were coded according to behavior change taxonomy (version 1). The meta-analysis was performed using RevMan 5.3. The Grading of Recommendations, Assessment, Development, and Evaluation Approach was used to assess the certainty of evidence.

RESULTS

Eleven studies met the study criteria. Nine studies were based on one theory, while two studies were based on a combination of two theories. The quality of theory implementation was generally moderate. A total of 24 unique behavior change techniques were extracted. The most commonly used types of behavior change techniques were 'instruction on how to perform the behavior' (n = 9), 'goal setting' (behavior) (n = 8), 'action planning' (n = 7), and 'information about health consequences' (n = 7). Theory-based interventions significantly improved moderate-to-vigorous physical activity (standardized mean difference (SMD) = 0.17, 95 % confidence interval (CI) [0.04, 0.30], P = 0.01; moderate certainty of evidence), reduced the average gestational weight gain per week (mean difference (MD) = -0.06, 95 % CI [-0.11, -0.01], P = 0.02; moderate certainty of evidence), and decreased the incidence of gestational diabetes mellitus (risk ratio (RR) = 0.64, 95 % CI [0.46, 0.89], P = 0.008; high certainty of evidence). However, the effects of theory-based interventions on total physical activity, total gestational weight gain and the incidence of gestational hypertension and preterm delivery were unclear (P > 0.05).

CONCLUSIONS

(i) Most of the studies exhibited a moderate level of theory implementation quality. (ii) The use of theories varies, but common behavior change techniques were found across studies. (iii) Theory-based interventions can improve physical activity and maternal and neonatal outcomes and appear to be safe. Appropriate health behavior theories and behavior change techniques should be fully utilized in future interventions.

REGISTRATION

PROSPERO: CRD42023440886.

TWEETABLE ABSTRACT

Theory-based interventions can improve physical activity and maternal and neonatal outcomes and appear to be safe. Appropriate health behavior theories and behavior change techniques should be fully utilized in the development of future interventions.

Prenatal prednisone exposure impacts liver development and function in fetal mice and its characteristics

Prednisone, a widely used glucocorticoid drug in human and veterinary medicine, has been reported to cause developmental toxicity. However, systematic studies about the effect of prednisone on fetal liver development are still unclear. We investigated the potential effects of maternal exposure to clinically equivalent doses of prednisone during different gestational stages on cell proliferation and apoptosis, cell differentiation, glucose and lipid metabolism, and hematopoiesis in the liver of fetal mice, and explored the potential mechanisms. Results showed that prenatal prednisone exposure (PPE) could suppress cell proliferation, inhibit hepatocyte differentiation, and promote cholangiocyte differentiation in the fetal liver. Meanwhile, PPE could result in the enhancement of glyconeogenesis and bile acid synthesis and the inhibition of fatty acid β-oxidation and hematopoiesis in the fetal liver. Further analysis found that PPE-induced alterations in liver development had obvious stage and sex differences. Overall, the alteration in fetal liver development and function induced by PPE was most pronounced during the whole pregnancy (GD0-18), and the males were relatively more affected than the females. Additionally, fetal hepatic insulin-like growth factor 1 (IGF1) signaling pathway was inhibited by PPE. In conclusion, PPE could impact fetal liver development and multiple functions, and these alterations might be partially related to the inhibition of IGF1 signaling pathway.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review

Background

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s.

Objectives

We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes.

Search Methods

We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search.

Selection Criteria

We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs.

Data Collection and Analysis

Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately.

Main Results

Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment).

Authors’ Conclusions

Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Association between physical activity education and prescription during prenatal care and maternal and fetal health outcomes: a quasi-experimental study

BACKGROUND

Physical activity (PA) during pregnancy is associated with healthy gestational weight gain (GWG) and a reduced risk of developing gestational diabetes (GD), gestational hypertension (GHT) and fetal macrosomia. However, in Canada, less than 20% of pregnant women meet PA recommendations. This study assessed associations between an intervention including PA education by prenatal nurses and a PA prescription delivered by physicians and fetal and maternal outcomes.

METHODS

This is a quasi-experimental study. Two groups of women who received their prenatal care at the obstetrics clinic of a university hospital were created. In the first group, 394 pregnant women followed at the clinic received standard care. In the second group, 422 women followed at the clinic received standard care supplemented with education on the relevance of PA during pregnancy and a prescription for PA. Data for both study groups were obtained from the medical records of the mothers and their newborns. Logistic regressions were used to compare the odds of developing excessive GWG, GD, GHT, and fetal macrosomia between the two study groups.

RESULTS

The addition of PA education and PA prescription to prenatal care was associated with 29% lower odds of developing excessive GWG (adjusted odds ratios (OR) 0.71, 95% confidence intervals (CI) 0.51-0.99), 73% lower odds of developing GHT (0.27, 0.14-0.53), 44% lower odds of fetal macrosomia (> 4 kg) (0.56, 0.34-0.93), and 40% lower odds of being large for gestational age (0.60, 0.36-0.99). The intervention was not associated with a difference in odds of developing GD (0.48, 0.12-1.94).

CONCLUSIONS

The inclusion of education and prescription of PA as part of routine prenatal care was associated with improvements in maternal and fetal health outcomes, including significantly lower odds of GWG, GHT and macrosomia.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review

Importance

Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified.

Objective

To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care.

Data Sources

Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020.

Study Selection

Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included.

Data Extraction and Synthesis

Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers.

Main Outcomes and Measures

The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care).

Results

Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG.

Conclusions and Relevance

These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

Implementation of Antenatal Lifestyle Interventions Into Routine Care: Secondary Analysis of a Systematic Review

IMPORTANCE

Lifestyle interventions in pregnancy optimize gestational weight gain and improve pregnancy outcomes, with implementation recommended by the US Preventive Services Task Force. Yet, implementation research taking these efficacy trials into pragmatic translation remains limited.

OBJECTIVE

To evaluate success factors for implementing pregnancy lifestyle interventions into antenatal care settings in a meta-analysis, using the penetration, implementation, participation, and effectiveness (PIPE) impact metric.

DATA SOURCES

Data from a previous systematic review that searched across 9 databases, including MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database, were obtained, in 2 stages, up to May 6, 2020.

STUDY SELECTION

Randomized clinical trials reporting gestational weight gain in singleton pregnancies.

DATA EXTRACTION AND SYNTHESIS

The association of penetration, implementation, and participation with effectiveness of antenatal lifestyle interventions in optimizing gestational weight gain was estimated using random-effects meta-analyses. The Cochrane risk of bias tool, version 1.0, was used to assess risk of bias.

MAIN OUTCOMES AND MEASURES

Penetration (reach), implementation (fidelity), participation, and effectiveness of randomized clinical trials of lifestyle interventions in pregnancy.

RESULTS

Ninety-nine studies with 34 546 participants were included. Only 14 studies reported penetration of target populations. Overall, 38 studies (38.4%) had moderate fidelity, 25 (25.2%) had high fidelity, and 36 (36.4%) had unclear fidelity. Participation was reported in 84 studies (84.8%). Lifestyle interventions were associated with reducing gestational weight gain by 1.15 kg (95% CI, -1.40 to -0.91 kg).

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that, despite the large body of evidence on efficacy of lifestyle interventions during pregnancy in optimizing gestational weight gain, little guidance is available to inform implementation of this evidence into practice. There is a need to better elucidate implementation outcomes in trial design alongside pragmatic implementation research to improve the health of women who are pregnant and the next generation.

Effect of individualized weight management intervention on excessive gestational weight gain and perinatal outcomes: a randomized controlled trial

It is unclear whether weight management is still effective for pregnant women with excessive weight gain in the second or third trimester in China. This study adopted individualized weight management intervention for pregnant women with abnormal weight gain in the second or third trimester, to analyze the effect of intervention by observing the gestational weight gain and perinatal outcomes. This randomized controlled trial was performed at Aerospace Center Hospital. The obstetrician determined whether the pregnant women gained too much weight in the second or third trimester according to the Institute of Medicine guidelines, and randomly divided the pregnant women who gained too much weight in the second or third trimester into the intervention group or the control group according to the inclusion and exclusion criteria. The pregnant women in the intervention group and in the control group all received routine prenatal examination and diet nutrition education by the doctors in the Department of Obstetrics and Gynecology. The intervention group underwent individualized weight management, including individualized diet, exercise, psychological assessment, cognitive intervention and continuous communication, the whole process is tracked and managed by professional nutritionists. The obstetrician collected the prenatal examination data and pregnancy outcome data of all enrolled pregnant women. The primary outcome measure was weight gain during pregnancy. A generalized linear model and a logistic regression model were used to compare the outcomes between the two groups. In total, 348 pregnant women participated in this study with 203 in the intervention group and 145 in the control group. The whole gestational weight gain in the intervention group (15.8 ± 5.4 Kg) was lower than that in the control group (17.5 ± 3.6 Kg; adjusted β =  - 1.644; 95% CI [-2.660--0.627]; P = 0.002). The percent of pregnant women with excessive weight gainbefore delivery was 54.2% (110/203) in the intervention group, which was lower than 69.7% (101/145) in the control group (adjusted RR = 0.468; 95% CI [0.284-0.769] P = 0.003). The pregnant women given the individualized weight management intervention from the second to the third trimester experienced less weight gain than that from the third trimester (15.5 ± 5.6 Kg vs. 16.2 ± 5.2 Kg), but without significant difference (P = 0.338). Lower rates of GDM, preeclampsia and gestational hypertension, higher rates of fetal distress and puerperal infection were observed in the intervention group than in the control group (all P < 0.05). Individualized weight management during the second or third trimesters is still beneficial for pregnant women who gain excessive weight and can decrease the associated adverse outcomes.

Application of Mobile Technology for Disease and Treatment Monitoring of Gestational Diabetes Mellitus Among Pregnant Women: A Systematic Review

BACKGROUND

Gestational diabetes mellitus (GDM) is an increasing health issue among pregnant women worldwide. Treatment of hyperglycemia during pregnancy improves outcomes for both mothers and infants. Effectively performing and reviewing self-monitoring of blood glucose is time-consuming for patients and care providers. In the modern era, most people having access to smartphones create opportunities for use of phone-based technologies to improve patient care in chronic diseases. This review aims to investigate the awareness and use of the smartphone application (app) with respect to management of GDM among pregnant women.

MATERIALS AND METHODS

Various relevant studies (n = 522) from 3 databases named Pub Med, Cochrane Library, and Google Scholar were included. For this, the study involved designing of a 5-stage review framework, which included research question identification, identification of articles, article selection, data collection, and result reporting.

RESULTS

Initial search criteria used a combination of keywords, by which we found out 522 literatures from 3 databases. After screening the titles and abstracts, 249 articles were excluded due to duplicate literatures and 252 articles were excluded due to the following reasons: not relevant (n = 172), editorial (n = 43), not in English (n = 7), and abstract only (n = 30). Furthermore, 10 articles were excluded because apps such as MobiGuide, pregnant + app, and GDm health were not mentioned in these articles. A total of 11 articles were included for the final analysis.

CONCLUSION

The mobile apps described in the present study (pregnant +, MobiGuide, and GDm health) provided personalized health care services, patient care improvement, and enhanced patient's compliance toward blood glucose monitoring and treatment.

Trends in the Number of Behavioural Theory-Based Healthy Eating Interventions Inclusive of Dietitians/Nutritionists in 2000-2020

Nutrition interventions developed using behaviour theory may be more effective than those without theoretical underpinnings. This study aimed to document the number of theory-based healthy eating interventions, the involvement of dietitians/nutritionists and the behaviour theories employed from 2000 to 2020. We conducted a review of publications related to healthy eating interventions that used behaviour change theories. Interventional studies published in English between 2000 and 2020 were retrieved from searching Medline, Cinahl, Embase, Psycinfo and Cochrane Central. Citation, country of origin, presence or absence of dietitian/nutritionist authors, participants, dietary behaviours, outcomes, theories and any behaviour change techniques (BCTs) stated were extracted. The publication trends on a yearly basis were recorded. A total of 266 articles were included. The number of theory-based interventions increased over the two decades. The number of studies conducted by dietitians/nutritionists increased, but since 2012, increases have been driven by other researchers. Social cognitive theory was the most used behaviour theory. Dietitians/nutritionists contributed to growth in publication of theory-based healthy eating interventions, but the proportion of researchers from other professions engaged in this field increased markedly. The reasons for this growth in publications from other professions is unknown but conjectured to result from greater prominence of dietary behaviours within the context of an obesity epidemic.

The association between soy intake and risk of gestational diabetes mellitus: a prospective cohort study

BACKGROUND

The association between soy intake and adverse pregnancy outcomes remains unclear. The objectives of this study were to investigate the soy consumption of pregnant women in the second trimester and explore the prospective association between soy intake and the risk of adverse pregnancy outcomes.

METHODS

Pregnant women between 13 and 24 weeks of gestation were recruited at a women's and children's hospital in southwest China from June to December 2019. Dietary intakes in the middle trimester were assessed by a semi-quantitative food frequency questionnaire. Participants were divided into the insufficient group (< 40 g/day) and the control group (≥40 g/day) according to daily soy consumption. Participants were followed up until delivery. Pregnancy outcomes including gestational diabetes mellitus (GDM), cesarean section, and macrosomia were obtained. Multiple logistic regression was used to analyze the association between soy intake and risk of adverse pregnancy outcomes. Sociodemographic information, histories of diseases, and duration of physical activities were obtained and used for covariate adjustments.

RESULTS

A total of 224 participants were included in this study, of which identified 36 (16.1%) cases of GDM, and 120 (53.6%) cases of cesarean section. More than half (125, 55.8%) pregnant women consumed less soy than 40 g/day. Daily soy intake less than 40 g was associated with the increased risk of GDM (OR = 2.755 95%CI 1.230-6.174, P = 0.014) and cesarean section (OR = 1.792 95%CI 1.035-3.101, P = 0.037) without adjustment for confounders such as age, pre-pregnancy body mass index, parity, daily intake of vegetables, fruits, seafood and, nuts. After adjusting for these factors, daily soy intake of less than 40 g increased 2.116-fold risk of GDM (95%CI 1.228-7.907, P = 0.017), but not with the significantly increased risk of cesarean section.

CONCLUSION

Insufficient soy intake may increase the risk of GDM, suggesting adequate soy intake may have a beneficial role in the prevention of GDM.

TRIAL REGISTRATION

Registration number: ChiCTR1900023721 . Date of registration: June 9, 2019.

Effectiveness of an intervention focusing on diet and walking during pregnancy in the primary health care service

Interventions during prenatal care can mitigate negative outcomes of a sedentary lifestyle and unhealthy diet during pregnancy. We aimed to evaluate the effectiveness of an intervention that promoted healthy diet and leisure-time walking during antenatal care in a pragmatic, controlled, non-randomized intervention study. Physicians and nurses from all health care units of the Family Health Strategy model of health assistance participated in educational training to promote leisure-time walking and healthy diet during antenatal care visits. Pregnant women who received health care from these professionals constituted the intervention group (n = 181). The control group (n = 172) included pregnant women who received routine antenatal care, in health care units of the traditional model of health assistance. Data were collected in each trimester of pregnancy. Diet was investigated using a food frequency questionnaire adapted from Risk and Protective Factors Surveillance System for Chronic Non-Comunicable Diseases Through Telephone Interview (Vigitel). Leisure-time walking in a typical week was assessed using questions from the Physical Activity in Pregnancy Questionnaire. There were positive effects on leisure-time walking during the second trimester and the third trimester of pregnancy and on the women who achieved 150 minutes per week of walking during the third trimester. The intervention reduced the risk of pregnant women consuming soft drinks and/or commercially prepared cookies in the third trimester. This lifestyle intervention was partially effective, tripling the proportion of pregnant women who achieved the recommended walking time and reducing by half the proportion of women who had a high weekly consumption of soft drinks and industrially processed cookies.

Do patients with gestational diabetes mellitus and their own blood glucose meter have better pregnancy outcomes than those not using a glucose meter?

ABSTRACT

To compare pregnancy outcomes between patients with gestational diabetes mellitus (GDM) with and without their own blood glucose meter.We conducted a retrospective-cohort study of 835 women with GDM at the Second Hospital of Tianjin Medical University, Tianjin, China from 1 January 2016 to 31 December 2018. Perinatal outcomes of these patients were monitored and collected in the Tianjin Maternal and Child Health System. Each patient was advised by a certified clinical nutritionist regarding dietary analysis and lifestyle recommendations. All pregnant women with GDM were divided into the following 2 groups according to whether they had their own blood glucose meter: women with self-measured blood glucose levels with a routine obstetric examination in the study group (n = 424); and those with non-self-measured blood glucose levels with a double obstetric examination in the control group (n = 411). Maternal and fetal pregnancy outcomes were compared between these 2 groups. According to different self-management modes, the women were also divided into eight subgroups to compare blood sugar control and compliance with recommended insulin therapy.The cesarean section rate was significantly lower in the study group than in the control group (P < .05). The prevalence of large-for-gestational age (P < .05) and macrosomia was significantly lower in the study group than in the control group (both P < .05). The prevalence of appropriate-for-gestational age was significantly higher in the study group than in the control group (P < .05). Birth weight was significantly lower in the study group than in the control group (P < .05). The mean times for blood sugar control and from the doctor recommendation for insulin treatment to the patient compliance in the study group were significantly shorter than those in the control group (both P < .05). The proportion of insulin required in the study group was significantly lower than that in the control group (P < .05). There were no significant differences in the time of controlling blood sugar and compliance among the 4 subgroups of the study group. However, subgroups with a dietary diary in the control group were better.Self-monitoring blood sugar plus a routine obstetric examination can help patients with GDM control blood sugar, even without dietary diaries and treadmills. In addition to increasing the number of obstetric examinations, recording dietary diaries is helpful for controlling blood sugar in patients with GDM who are unwilling to measure blood sugar by themselves.

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.

Effects of a Lifestyle Intervention in Routine Care on Prenatal Dietary Behavior-Findings from the Cluster-Randomized GeliS Trial

The antenatal lifestyle and excessive gestational weight gain (GWG) modify the risk of obstetric complications, maternal weight retention, and the risk of obesity for the next generation. The cluster-randomized controlled "Healthy living in pregnancy" (GeliS) study, recruiting 2286 women, was designed to examine whether a lifestyle intervention reduced the proportion of women with excessive GWG. Trained healthcare providers gave four counseling sessions covering a healthy diet, regular physical activity, and self-monitoring of GWG in the intervention group. In this secondary analysis, the effect on maternal dietary behavior was analyzed. Dietary behavior was assessed by means of a 58-item food frequency questionnaire in early and late pregnancy. The intervention resulted in a significant reduction in soft drink intake (p < 0.001) and an increase in the consumption of fish (p = 0.002) and vegetables (p = 0.023). With the exception of higher percentage energy from protein (p = 0.018), no effects of the intervention on energy and macronutrient intake were observed. There was no evidence for an overall effect on dietary quality measured with a healthy eating index. Some dietary variables were shown to be associated with GWG. In a routine prenatal care setting in Germany, lifestyle advice modified single aspects of dietary behavior, but not energy intake or overall dietary quality.

Improving the effectiveness of lifestyle interventions for gestational diabetes prevention: a meta-analysis and meta-regression

BACKGROUND

Diet and exercise during pregnancy have been used to prevent gestational diabetes mellitus (GDM) with some success.

OBJECTIVE

To examine the effectiveness of lifestyle intervention on GDM prevention and to identify key effectiveness moderators to improve the prevention strategy.

SEARCH STRATEGY

Pubmed, Scopus, Cochrane, and cross-references were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating lifestyle interventions during pregnancy for GDM prevention.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data. A random-effects model was used to analyse the relative risk (RR) and 95% confidence interval (95% CI). Meta-regressions and subgroup analyses were used to investigate important moderators of effectiveness.

MAIN RESULTS

Forty-seven RCTs involving 15 745 participants showed that diet and exercise during pregnancy were preventive of GDM (RR 0.77, 95% CI 0.69-0.87). Four key aspects were identified to improve the preventive effect: targeting the high-risk population; an early initiation of the intervention; the correct intensity and frequency of exercise; and gestational weight gain management. Although 24 RCTs targeted women who were overweight or obese, body mass index (BMI) failed to predict the effectiveness of an intervention. Instead, interventions are most effective in high-incidence populations rather than simply in women who are overweight or obese. Furthermore, exercise of moderate intensity for 50-60 minutes twice a week could lead to an approximately 24% reduction in GDM.

CONCLUSION

The best strategy to prevent GDM is to target the high-risk population predicted by risk evaluation models and to control the gestational weight gain of women through intensified diet and exercise modifications early in their pregnancy.

TWEETABLE ABSTRACT

Four key effectiveness moderators of lifestyle interventions for GDM prevention.

Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis

Objective

Gestational diabetes mellitus (GDM), gestational hypertension (GH) and pre-eclampsia (PE) are associated with short and long-term health issues for mother and child; prevention of these complications is critically important. This study aimed to perform a systematic review and meta-analysis of the relationships between prenatal exercise and GDM, GH and PE.

Design

Systematic review with random effects meta-analysis and meta-regression.

Data sources

Online databases were searched up to 6 January 2017.

Study eligibility criteria

Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone [“exercise-only”] or in combination with other intervention components [e.g., dietary; “exercise + co-intervention”]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcomes (GDM, GH, PE).

Results

A total of 106 studies (n=273 182) were included. ‘Moderate’ to ‘high’-quality evidence from randomised controlled trials revealed that exercise-only interventions, but not exercise+cointerventions, reduced odds of GDM (n=6934; OR 0.62, 95% CI 0.52 to 0.75), GH (n=5316; OR 0.61, 95% CI 0.43 to 0.85) and PE (n=3322; OR 0.59, 95% CI 0.37 to 0.9) compared with no exercise. To achieve at least a 25% reduction in the odds of developing GDM, PE and GH, pregnant women need to accumulate at least 600 MET-min/week of moderate-intensity exercise (eg, 140 min of brisk walking, water aerobics, stationary cycling or resistance training).

Summary/conclusions

In conclusion, exercise-only interventions were effective at lowering the odds of developing GDM, GH and PE.

Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review of the relationship between prenatal exercise and fetal or newborn death.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Online databases were searched up to 6 January 2017.

STUDY ELIGIBILITY CRITERIA

Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (miscarriage or perinatal mortality).

RESULTS

Forty-six studies (n=2 66 778) were included. There was 'very low' quality evidence suggesting no increased odds of miscarriage (23 studies, n=7125 women; OR 0.88, 95% CI 0.63 to 1.21, I²=0%) or perinatal mortality (13 studies, n=6837 women, OR 0.86, 95% CI 0.49 to 1.52, I²=0%) in pregnant women who exercised compared with those who did not. Stratification by subgroups did not affect odds of miscarriage or perinatal mortality. The meta-regressions identified no associations between volume, intensity or frequency of exercise and fetal or newborn death. As the majority of included studies examined the impact of moderate intensity exercise to a maximum duration of 60 min, we cannot comment on the effect of longer periods of exercise.

SUMMARY/CONCLUSIONS

Although the evidence in this field is of 'very low' quality, it suggests that prenatal exercise is not associated with increased odds of miscarriage or perinatal mortality. In plain terms, this suggests that generally speaking exercise is 'safe' with respect to miscarriage and perinatal mortality.

Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis

Objective

Gestational weight gain (GWG) has been identified as a critical modifier of maternal and fetal health. This systematic review and meta-analysis aimed to examine the relationship between prenatal exercise, GWG and postpartum weight retention (PPWR).

Design

Systematic review with random effects meta-analysis and meta-regression. Online databases were searched up to 6 January 2017.

Study eligibility criteria

Studies of all designs in English, Spanish or French were eligible (except case studies and reviews) if they contained information on the population (pregnant women without contraindication to exercise), intervention (frequency, intensity, duration, volume or type of exercise, alone [“exercise-only”] or in combination with other intervention components [eg, dietary; “exercise + co-intervention”]), comparator (no exercise or different frequency, intensity, duration, volume or type of exercise) and outcomes (GWG, excessive GWG (EGWG), inadequate GWG (IGWG) or PPWR).

Results

Eighty-four unique studies (n=21 530) were included. ‘Low’ to ‘moderate’ quality evidence from randomised controlled trials (RCTs) showed that exercise-only interventions decreased total GWG (n=5819; −0.9 kg, 95% CI −1.23 to –0.57 kg, I2=52%) and PPWR (n=420; −0.92 kg, 95% CI −1.84 to 0.00 kg, I2=0%) and reduced the odds of EGWG (n=3519; OR 0.68, 95% CI 0.57 to 0.80, I2=12%) compared with no exercise. ‘High’ quality evidence indicated higher odds of IGWG with prenatal exercise-only (n=1628; OR 1.32, 95% CI 1.04 to 1.67, I2=0%) compared with no exercise.

Conclusions

Prenatal exercise reduced the odds of EGWG and PPWR but increased the risk of IGWG. However, the latter result should be interpreted with caution because it was based on a limited number of studies (five RCTs).

Attenuating Pregnancy Weight Gain-What Works and Why: A Systematic Review and Meta-Analysis

Excessive maternal gestational weight gain (GWG) contributes to generational obesity. Our aim was to explore efficacy and intervention characteristics (trimester, duration, frequency, intensity, and delivery method) of interventions to prevent excessive GWG. CINAHL, Cochrane, EMBASE, LILACS, MEDLINE, PsycINFO, and Scopus were searched up to May 2018 (no date or language restrictions). Keywords and MeSH terms for diet, GWG, intervention, lifestyle, maternal, physical activity, and pregnancy were used to locate randomized-controlled trials (RCTs). The Cochrane Collaboration tool for assessing risk of bias was applied. Eighty-nine RCTs were included. Meta-analysis (60 trials) estimated that women in diet only (WMD: -3.27; 95% CI: -4.96, -1.58, p < 0.01), physical activity (PA) (WMD: -1.02; 95% CI: -1.56, -0.49, p < 0.01), and lifestyle interventions (combining diet and PA) (WMD: -0.84; 95% CI: -1.29, -0.39, p < 0.01) gained significantly less weight than controls. The three eHealth interventions favored neither intervention nor control (WMD: -1.06; 95% CI: -4.13, 2.00, p = 0.50). Meta-regression demonstrated no optimal duration, frequency, intensity, setting, or diet type. Traditional face to face delivery of weight management interventions during pregnancy can be successful. Delivery via eHealth has potential to extend its reach to younger women but needs further evaluation of its success.

Interventions designed to reduce excessive gestational weight gain can reduce the incidence of gestational diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials

AIMS

To (i) evaluate the global impact of interventions designed to prevent excessive gestational weight gain (eGWG) on the incidence of gestational diabetes (GDM), and (ii) examine whether the effects differ by pre-conception body mass index (BMI) or ethnicity.

METHODS

A systematic search of randomised controlled trials (RCTs) with a primary or secondary aim to reduce eGWG was conducted in seven international and three Chinese databases without date limits. Meta-analysis data are reported as relative risk (RR) for GDM incidence for interventions including: diet, physical activity (PA), and lifestyle (diet and PA).

RESULTS

Forty-five studies were included, 37 in the meta-analyses. Diet and PA interventions reduced GDM risk by 44% (RR: 0.56, 95% CI: 0.36-0.87) and 38% (RR: 0.62, 95% CI: 0.50-0.78), respectively. Lifestyle interventions and BMI didn't significantly alter GDM risk. PA interventions from Southern-Europe reduced GDM risk by 37% (RR: 0.63, 95% CI: 0.50-0.80). Whereas, diet and lifestyle interventions conducted in Asia reduced GDM risk by 62% (RR: 0.38, 95% CI: 0.24-0.59) and 32% (RR: 0.68, 95% CI: 0.54-0.86), respectively.

CONCLUSION

Diet and PA interventions designed to reduce GWG are more effective than standard care in reducing the incidence of GDM, although the effect varies by region and BMI. The 'one size fits all' approach is not supported.

Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation

BACKGROUND

Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.

OBJECTIVES

To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).

REVIEW METHODS

Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.

RESULTS

Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI -0.92 to -0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate -0.10 kg, 95% CI -0.14 to -0.06 kg) and multiparity (summary estimate -0.73 kg, 95% CI -1.24 to -0.23 kg).

LIMITATIONS

The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.

CONCLUSION

Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.

FUTURE WORK

The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003804.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Conduct and reporting of acceptability, attitudes, beliefs and experiences of pregnant women in randomised trials on diet and lifestyle interventions: A systematic review

OBJECTIVE

To evaluate the conduct and reporting of views of pregnant women on the acceptability, attitudes, beliefs and their experiences in randomised trials on diet and lifestyle interventions.

STUDY DESIGN

We undertook a systematic review of literature of randomised trials identified from our previous search in major electronic databases (until February 2017) without language restrictions. We included trials on diet and lifestyle interventions that reported acceptability, attitudes, beliefs and experiences of pregnant women. The quality of papers was evaluated using the Critical Skills Appraisal Programme (CASP) framework. Data were extracted for the following domains: acceptability, intention, behaviour, attitudes and factors influencing participation. The proportion of studies that reported the various components in each domain was reported in percentages.

RESULTS

Of the 110 trials on diet and lifestyle in pregnancy, 24 reported on views of pregnant women. Acceptability of the provided information to the woman was reported in 84% (20/24), compared to 12% (3/24) on acceptability to partner or to family. Mother's intention to adhere to intervention in pregnancy was reported in 68% (17/24) of studies vs.only 16% (4/24) on family's intentions to support adherence. Changes in mother's behaviour were reported for consuming specific components of diet such as nuts (8%, 2/24), olive oil (12%, 3/24) and fruit (40%, 10/24) vs. 16% (4/24) of trials reporting changes in family's behaviour. While knowledge of food ingredients (72%, 18/24), and attitude to gestational weight gain were commonly reported (66%, 16/24) in over two-thirds of studies, only half assessed attitude to participation in research (45%, 11/24). All studies reported facilitators for uptake of intervention such as personalised support (100%, 24/24), with half (52%, 13/24) on beliefs about weight, and less than 10% (2/24) about baby's health.

CONCLUSION

The focus on studies is mainly on the mother, and less on family. Further studies are needed with a holistic approach to ensure that such interventions when implemented are accepted by women and their families.

Combined diet and exercise interventions for preventing gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with a wide range of adverse health consequences for women and their infants in the short and long term. With an increasing prevalence of GDM worldwide, there is an urgent need to assess strategies for GDM prevention, such as combined diet and exercise interventions. This is an update of a Cochrane review that was first published in 2015.

OBJECTIVES

To assess the effects of diet interventions in combination with exercise interventions for pregnant women for preventing GDM, and associated adverse health consequences for the mother and her infant/child.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs, comparing combined diet and exercise interventions with no intervention (i.e. standard care), that reported on GDM diagnosis as an outcome. Quasi-RCTs were excluded. Cross-over trials were not eligible for inclusion. We planned to include RCTs comparing two or more different diet/exercise interventions, however none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed the risk of bias of the included trials and assessed quality of evidence for selected maternal and infant/child outcomes using the GRADE approach. We checked data for accuracy.

MAIN RESULTS

In this update, we included 23 RCTs (involving 8918 women and 8709 infants) that compared combined diet and exercise interventions with no intervention (standard care). The studies varied in the diet and exercise programs evaluated and health outcomes reported. None reported receiving funding from a drug manufacturer or agency with interests in the results. Overall risk of bias was judged to be unclear due to the lack of methodological detail reported. Most studies were undertaken in high-income countries.For our primary review outcomes, there was a possible reduced risk of GDM in the diet and exercise intervention group compared with the standard care group (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.01; 6633 women; 19 RCTs; Tau² = 0.05; I² = 42%; P = 0.07; moderate-quality evidence). There was also a possible reduced risk of caesarean section (RR 0.95, 95% CI 0.88 to 1.02; 6089 women; 14 RCTs; moderate-quality evidence). No clear differences were seen between groups for pre-eclampsia (RR 0.98, 95% CI 0.79 to 1.22; 5366 participants; 8 RCTs; low-quality evidence), pregnancy-induced hypertension and/or hypertension (average RR 0.78, 95% CI 0.47 to 1.27; 3073 participants; 6 RCTs; Tau² = 0.19; I² = 62%; very low-quality evidence), perinatal mortality (RR 0.82, 95% CI 0.42 to 1.63; 3757 participants; 2 RCTs; low-quality evidence) or large-for-gestational age (RR 0.93, 95% CI 0.81 to 1.07; 5353 participants; 11 RCTs; low-quality evidence). No data were reported for infant mortality or morbidity composite.Subgroup analyses (based on trial design, maternal body mass index (BMI) and ethnicity) revealed no clear differential treatment effects. We were unable to assess the impact of maternal age, parity and specific features of the diet and exercise interventions. Findings from sensitivity analyses (based on RCT quality) generally supported those observed in the main analyses. We were not able to perform subgroup analyses based on maternal age, parity or nature of the exercise/dietary interventions due to the paucity of information/data on these characteristics and the inability to meaningfully group intervention characteristics.For most of the secondary review outcomes assessed using GRADE, there were no clear differences between groups, including for perineal trauma (RR 1.27, 95% CI 0.78 to 2.05; 2733 participants; 2 RCTs; moderate-quality evidence), neonatal hypoglycaemia (average RR 1.42, 95% CI 0.67 to 2.98; 3653 participants; 2 RCTs; Tau² = 0.23; I² = 77%; low quality evidence); and childhood adiposity (BMI z score) (MD 0.05, 95% CI -0.29 to 0.40; 794 participants; 2 RCTs; Tau² = 0.04; I² = 59%; low-quality evidence). However, there was evidence of less gestational weight gain in the diet and exercise intervention group compared with the control group (mean difference (MD) -0.89 kg, 95% CI -1.39 to -0.40; 5052 women; 16 RCTs; Tau² = 0.37; I² = 43%;moderate-quality evidence). No data were reported for maternal postnatal depression or type 2 diabetes; childhood/adulthood type 2 diabetes, or neurosensory disability.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests reduced risks of GDM and caesarean section with combined diet and exercise interventions during pregnancy as well as reductions in gestational weight gain, compared with standard care. There were no clear differences in hypertensive disorders of pregnancy, perinatal mortality, large-for-gestational age, perineal trauma, neonatal hypoglycaemia, and childhood adiposity (moderate- tovery low-quality evidence).Using GRADE methodology, the evidence was assessed as moderate to very low quality. Downgrading decisions were predominantly due to design limitations (risk of bias), and imprecision (uncertain effect estimates, and at times, small sample sizes and low event rates), however two outcomes (pregnancy-induced hypertension/hypertension and neonatal hypoglycaemia), were also downgraded for unexplained inconsistency (statistical heterogeneity).Due to the variability of the diet and exercise components tested in the included studies, the evidence in this review has limited ability to inform practice. Future studies could describe the interventions used in more detail, if and how these influenced behaviour change and ideally be standardised between studies. Studies could also consider using existing core outcome sets to facilitate more standardised reporting.

Functionality, Implementation, Impact, and the Role of Health Literacy in Mobile Phone Apps for Gestational Diabetes: Scoping Review

BACKGROUND

The increasing ownership of mobile phones and advances in hardware and software position these devices as cost-effective personalized tools for health promotion and management among women with gestational diabetes mellitus (GDM). Numerous mobile phone apps are available online; however, to our knowledge, no review has documented how these apps are developed and evaluated in relation to GDM.

OBJECTIVE

The objective of our review was to answer the following 2 research questions: (1) What is known from the existing literature about the availability, functionality, and effectiveness of mobile phone apps on GDM prevention and management? (2) What is the role of health literacy in these apps?

METHODS

We searched 7 relevant electronic databases for original research documents using terms related to mobile phone apps, GDM, and health literacy. We thematically categorized selected articles using a framework adapted from Arksey and O'Malley.

RESULTS

We included 12 articles related to 7 apps or systems in the final analysis. We classified articles around 2 themes: (1) description of the development, feasibility, or usability of the apps or systems, and (2) trial protocols. The degree of personalization varied among the apps for GDM, and decision support systems can be used to generate time-efficient personalized feedback for both patients and health care providers. Health literacy was considered during the development or measured as an outcome by some apps.

CONCLUSIONS

There is a limited body of research on mobile phone apps in relation to GDM prevention and management. Mobile phone apps can provide time- and cost-efficient personalized interventions for GDM. Several randomized controlled trials have been launched recently to evaluate the effectiveness of the apps. Consideration of health literacy should be improved when developing features of the apps.

Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials

Objective To synthesise the evidence on the overall and differential effects of interventions based on diet and physical activity during pregnancy, primarily on gestational weight gain and maternal and offspring composite outcomes, according to women's body mass index, age, parity, ethnicity, and pre-existing medical condition; and secondarily on individual complications.Design Systematic review and meta-analysis of individual participant data (IPD). Data sources Major electronic databases from inception to February 2017 without language restrictions.Eligibility criteria for selecting studies Randomised trials on diet and physical activity based interventions in pregnancy.Data synthesis Statistical models accounted for clustering of participants within trials and heterogeneity across trials leading to summary mean differences or odds ratios with 95% confidence intervals for the effects overall, and in subgroups (interactions).Results IPD were obtained from 36 randomised trials (12 526 women). Less weight gain occurred in the intervention group than control group (mean difference -0.70 kg, 95% confidence interval -0.92 to -0.48 kg, I²=14.1%; 33 studies, 9320 women). Although summary effect estimates favoured the intervention, the reductions in maternal (odds ratio 0.90, 95% confidence interval 0.79 to 1.03, I²=26.7%; 24 studies, 8852 women) and offspring (0.94, 0.83 to 1.08, I²=0%; 18 studies, 7981 women) composite outcomes were not statistically significant. No evidence was found of differential intervention effects across subgroups, for either gestational weight gain or composite outcomes. There was strong evidence that interventions reduced the odds of caesarean section (0.91, 0.83 to 0.99, I²=0%; 32 studies, 11 410 women), but not for other individual complications in IPD meta-analysis. When IPD were supplemented with study level data from studies that did not provide IPD, the overall effect was similar, with stronger evidence of benefit for gestational diabetes (0.76, 0.65 to 0.89, I²=36.8%; 59 studies, 16 885 women).Conclusion Diet and physical activity based interventions during pregnancy reduce gestational weight gain and lower the odds of caesarean section. There is no evidence that effects differ across subgroups of women.

Effect of diet and exercise intervention in Chinese pregnant women on gestational weight gain and perinatal outcomes: A quasi-experimental study

Aim To determine the effect of a diet and exercise intervention in pregnant women on total gestational weight gain, weekly weight gain, 42-days postpartum weight retention, mode of delivery, and infant birth weight.

METHODS

One hundred and one eligible Chinese pregnant women whose pre-pregnancy body mass index ranged from 18.5 to 24.9 were recruited between June 2013 and June 2014 from a tertiary hospital. Ninety participants, 45 in each group, completed the study. Intervention women received three face-to-face interventions and three follow-up phone calls which were developed based on the Transtheoretical Model. Gestational weight was measured at each prenatal check. Mode of delivery and infant birth weight were collected from the medical record. The 42-days postpartum weight was measured during the postpartum visits.

RESULTS

(1) The total gestational weight gain and mean weight gain per week in the intervention group were significantly less than the control group (P=0.045 and P=0.008 respectively). (2) Infant birth weight was significantly lower in the intervention group (P=0.012). (3) Postpartum weight retention was significantly less in the intervention group (P=0.001). 4) There were not significant differences in mode of delivery. 5) Infant birth weight was significantly less than the control group (P=0.012).

CONCLUSIONS

The lifestyle intervention significantly reduced gestational weight gain, optimized infant weight and lowered postpartum weight retention. Promotion of gestational weight management is needed and cultural health beliefs about pregnancy and postpartum practices should be considered when developing the intervention plan.

Is improvement in the Healthy Food Intake Index (HFII) related to a lower risk for gestational diabetes?

The aim was to analyse whether changes in the Healthy Food Intake Index (HFII) during pregnancy are related to gestational diabetes (GDM) risk. The 251 pregnant women participating had a pre-pregnancy BMI≥30 kg/m2 and/or a history of GDM. A 75 g oral glucose tolerance test (OGTT) was performed during the first and second trimesters of pregnancy for assessment of GDM. A normal OGTT result at first trimester was an inclusion criterion for the study. FFQ collected at first and second trimesters served for calculating the HFII. A higher HFII score reflects higher adherence to the Nordic Nutrition Recommendations (NNR) (score range 0-17). Statistical methods included Student's t test, Mann-Whitney U test, Fisher's exact test and linear and logistic regression analyses. The mean HFII at first trimester was 10·1 (95 % CI 9·7, 10·4) points, and the mean change from the first to the second trimester was 0·35 (95 % CI 0·09, 0·62) points. The range of the HFII changes varied from -7 to 7. The odds for GDM decreased with higher HFII change (adjusted OR 0·83 per one unit increase in HFII; 95 % CI 0·69, 0·99; P=0·043). In the analysis of the association between HFII-sub-indices and GDM, odds for GDM decreased with higher HFII-Fat change (fat percentage of milk and cheese, type of spread and cooking fats) but it was not significant in a fully adjusted model (P=0·058). Dietary changes towards the NNR during pregnancy seem to be related to a lower risk for GDM.

Interventions to improve physical activity during pregnancy: a systematic review on issues of internal and external validity using the RE-AIM framework

BACKGROUND

Physical activity (PA) during pregnancy has significant health benefits for the mother and her child; however, many women reduce their activity levels during pregnancy and most are not sufficiently active. Given the important health benefits of PA during pregnancy, evidence that supports research translation is vital.

OBJECTIVES

To determine the extent to which physical activity interventions for pregnant women report on internal and external validity factors using the RE-AIM framework (reach, efficacy/effectiveness, adoption, implementation, and maintenance).

SEARCH STRATEGY

Ten databases were searched up to 1 June 2015. Eligible published papers and unpublished/grey literature were identified using relevant search terms.

SELECTION CRITERIA

Studies had to report on physical activity interventions during pregnancy, including measures of physical activity during pregnancy at baseline and at least one point post-intervention. Randomised controlled trials and quasi-experimental studies that had a comparator group were included.

DATA COLLECTION AND ANALYSIS

Reporting of RE-AIM dimensions were summarised and synthesised across studies.

MAIN RESULTS

The reach (72.1%) and efficacy/effectiveness (71.8%) dimensions were commonly reported; however, the implementation (28.9%) and adoption (23.2%) dimensions were less commonly reported and no studies reported on maintenance.

CONCLUSIONS

This review highlights the under-reporting of issues of contextual factors in studies of physical activity during pregnancy. The translation of physical activity interventions during pregnancy could be improved through reporting of representativeness of participants, clearer reporting of outcomes, more detail on the setting and staff who deliver interventions, costing of interventions and the inclusion of process evaluations and qualitative data.

TWEETABLE ABSTRACT

The systematic review highlights the under-reporting of contextual factors in studies of physical activity during pregnancy.

Risk factors for gestational diabetes: is prevention possible?

Gestational diabetes mellitus (GDM), a common pregnancy complication, continues to be a significant public health and clinical problem. It carries significant short-term and long-term adverse health outcomes for both mother and offspring, which reinforces the significance of understanding risk factors, in particular modifiable factors, for GDM and of preventing the condition. Research in the past decade from observational studies has identified a few diet and lifestyle factors that are associated with GDM risk and demonstrated that time frames both before and during pregnancy may be relevant to the development of GDM. Findings from intervention studies on the effect of diet and lifestyle on the prevention of GDM have been largely controversial and inconsistent. Variations in study population, types of intervention, timing and duration of intervention and diagnostic criteria for GDM may all at least partly account for the large heterogeneity in the findings from these intervention studies. This review provides an overview of emerging diet, lifestyle, and other factors that may help to prevent GDM, and the challenges associated with prevention. It also discusses major methodological concerns about the available epidemiological studies on GDM risk factors. Findings from both observational and intervention studies are discussed. This review summarises a presentation given at the 'Gestational diabetes: what's up?' symposium at the 2015 annual meeting of the EASD. It is accompanied by two other reviews on topics from this symposium (by Peter Damm and Colleagues, DOI: 10.1007/s00125-016-3985-5 , and by Marja Vääräsmäki, DOI: 10.1007/s00125-016-3976-6 ) and an overview by the Session Chair, Kerstin Berntorp (DOI: 10.1007/s00125-016-3975-7 ).

Pre-pregnancy body mass index, height and physical activity are associated with rate of gestational weight gain among Malaysian mothers

AIM

Both inadequate and excessive weight gain during pregnancy can have immediate and long-term health risks for women and infants. This study investigated rate of gestational weight gain (GWG) and its associated factors in Malaysian pregnant women.

METHODS

This cross-sectional study was conducted at maternal and child health clinics in Selangor and Negeri Sembilan between November 2010 and April 2012. A pre-tested questionnaire was used to obtain sociodemographic, obstetric, dietary intake and physical activity information. Current weight and height were measured using standard procedures. GWG rate was calculated as the average weekly weight gain in that particular trimester of pregnancy and further categorized according to the Institute of Medicine (IOM) recommendations.

RESULTS

Mean GWG rate for all pre-pregnancy BMI categories in the second and third trimesters was higher than the IOM recommendations. Overweight women (adjusted OR, 4.26; 95%CI: 1.92-9.44) and women <153 cm tall (adjusted OR, 1.96; 95%CI: 1.21-3.18) tend to have inadequate GWG rate. Women with high pre-pregnancy body mass index (BMI; ≥25.0 kg/m(2) ; overweight: adjusted OR, 3.88; 95%CI: 2.12-7.09; obese: adjusted OR, 2.34; 95%CI: 1.28-4.29) and low physical activity (adjusted OR, 1.74; 95%CI: 0.77-3.97) were two-threefold more likely to have excessive GWG.

CONCLUSION

Both inadequate and excessive GWG can have detrimental effects on the health of mothers and infants. Pre-pregnancy BMI, height and physical activity should be emphasized in prenatal care to ensure that women have adequate GWG rate.